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1.
Rev Endocr Metab Disord ; 23(2): 293-297, 2022 04.
Article in English | MEDLINE | ID: covidwho-1718863

ABSTRACT

Patients with pre-existing cardiovascular disease (CVD) are at high risk for adverse outcomes with coronavirus disease 2019 (COVID-19). Further, COVID-19 infection is associated with numerous cardiovascular (CV) complications including arrhythmia, myocardial injury, cardiomyopathy, and thrombotic events. Increased susceptibility to COVID-19 and CV complications related to COVID-19 may be in part related to immune dysregulation and inflammation associated with CV disease which is exacerbated with viral infection. Vitamin D plays a major role in immune function and exerts anti-inflammatory effects, which may prove important in the context of CVD and COVID-19. To date, studies have shown minimal benefit for vitamin D supplementation in patients with COVID-19, though there are no studies specific to patients with CVD and related complications. Further, given that vitamin D has important protective effects on the CV system, including augmentation of myocardial contractility and anti-thrombotic effects, it is unknown if supplementation with vitamin D can mitigate CVD complications associated with COVID-19.


Subject(s)
COVID-19 , Cardiovascular Diseases , Vitamin D Deficiency , COVID-19/complications , COVID-19/drug therapy , Cardiovascular Diseases/etiology , Cardiovascular Diseases/prevention & control , Humans , Vitamin D/physiology , Vitamin D/therapeutic use , Vitamin D Deficiency/complications , Vitamin D Deficiency/drug therapy , Vitamins/therapeutic use
2.
Mol Cell Biochem ; 476(12): 4351-4362, 2021 Dec.
Article in English | MEDLINE | ID: covidwho-1375667

ABSTRACT

Vitamin D is an immunomodulatory hormone with an established role in calcium and phosphate metabolism and skeletal mineralization. Evidence showing its immunological benefits by regulating essential components of the innate and adaptive immune system is prevalent. Vitamin D deficiency is reported worldwide and is thereby found to be associated with various immune-related diseases. Rheumatoid Arthritis and COVID-19 are two such diseases, sharing a similar hyperinflammatory response. Various studies have found an association of lower Vitamin D levels to be associated with both these diseases. However, contrasting data is also reported. We review here the available scientific data on risk factor association and supplementation benefits of Vitamin D in Rheumatoid Arthritis and COVID-19, intending to critically evaluate the literature.


Subject(s)
Arthritis, Rheumatoid/diet therapy , COVID-19/etiology , Vitamin D Deficiency/complications , Vitamin D/physiology , Arthritis, Rheumatoid/etiology , Humans , Risk Factors , Vitamin D/immunology , Vitamin D/therapeutic use , Vitamin D Deficiency/diet therapy
3.
Ital J Dermatol Venerol ; 156(3): 366-373, 2021 Jun.
Article in English | MEDLINE | ID: covidwho-1207967

ABSTRACT

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19), has become pandemic on March 11th, 2020. COVID-19 has a range of symptoms that includes fever, fatigue, dry cough, aches, and labored breathing to acute respiratory distress and possibly death. Health systems and hospitals have been completely rearranged since March 2020 in order to limit the high rate of virus spreading. Hence, a great debate on deferrable visits and treatments including phototherapy for skin diseases is developing. In particular, as regards phototherapy very few data are currently available regarding the chance to continue it, even if it may be a useful resource for treating numerous dermatological patients. However, phototherapy has an immunosuppressive action possibly facilitating virus infection. In the context of COVID-19 infection risk it is important to pointed out whether sunlight, phototherapy and in particular ultraviolet radiation (UV-R) constitute or not a risk for patients. In this review we aimed to focus on the relationship between UV-R, sunlight, phototherapy, and viral infections particularly focusing on COVID-19.


Subject(s)
COVID-19/epidemiology , Pandemics , SARS-CoV-2/radiation effects , Sunlight , Ultraviolet Rays , Vitamin D/physiology , Adaptive Immunity/radiation effects , Animals , Antimicrobial Cationic Peptides/biosynthesis , Antimicrobial Cationic Peptides/physiology , Cytokines/metabolism , Disease Models, Animal , Disease Susceptibility , Humans , Immunity, Innate/radiation effects , Interleukin-6/blood , Pathogen-Associated Molecular Pattern Molecules , SARS-CoV-2/genetics , SARS-CoV-2/pathogenicity , Skin Diseases/radiotherapy , Sunlight/adverse effects , Toll-Like Receptors/physiology , Ultraviolet Rays/adverse effects , Ultraviolet Therapy/adverse effects , Viruses/radiation effects , Vitamin D/biosynthesis , Vitamin D/therapeutic use
4.
Front Endocrinol (Lausanne) ; 12: 644298, 2021.
Article in English | MEDLINE | ID: covidwho-1191681

ABSTRACT

Vitamin D is a potent steroid hormone that induces widespread changes in gene expression and controls key biological pathways. Here we review pathophysiology of vitamin D with particular reference to COVID-19 and pancreatic cancer. Utility as a therapeutic agent is limited by hypercalcemic effects and attempts to circumvent this problem have used vitamin D superagonists, with increased efficacy and reduced calcemic effect. A further caveat is that vitamin D mediates multiple diverse effects. Some of these (anti-fibrosis) are likely beneficial in patients with COVID-19 and pancreatic cancer, whereas others (reduced immunity), may be beneficial through attenuation of the cytokine storm in patients with advanced COVID-19, but detrimental in pancreatic cancer. Vitamin D superagonists represent an untapped resource for development of effective therapeutic agents. However, to be successful this approach will require agonists with high cell-tissue specificity.


Subject(s)
COVID-19/drug therapy , Carcinoma, Pancreatic Ductal/drug therapy , Pancreatic Neoplasms/drug therapy , Vitamin D/agonists , Vitamins/agonists , Cytokine Release Syndrome/drug therapy , Humans , Vitamin D/physiology
5.
Metabolism ; 119: 154753, 2021 06.
Article in English | MEDLINE | ID: covidwho-1152589

ABSTRACT

BACKGROUND: Disease severity and mortality rates due to COVID-19 infection are greater in the elderly and chronically ill patients, populations at high risk for vitamin D deficiency. Vitamin D plays an important role in immune function and inflammation. This systematic review and meta-analysis assesses the impact of vitamin D status and supplementation on COVID-19 related mortality and health outcomes. METHODS: We searched four databases until December 18th 2020, and trial registries until January 20th 2021. Two reviewers screened the studies, collected data, assessed the risk of bias, and graded the evidence for each outcome across studies, independently and in duplicate. Pre-specified outcomes of interest were mortality, ICU admission, invasive and non-invasive ventilation, hospitalization, time of hospital stay, disease severity and SARS-CoV-2 positivity. We only included data from peer-reviewed articles in our primary analyses. RESULTS: We identified 31 peer-reviewed observational studies. In our primary analysis, there was a positive trend between serum 25(OH)D level <20 ng/ml and an increased risk of mortality, ICU admission, invasive ventilation, non-invasive ventilation or SARS-CoV-2 positivity. However, these associations were not statistically significant. Mean 25(OH)D levels was 5.9 ng/ml (95% CI [-9.5, -2.3]) significantly lower in COVID-19 positive, compared to negative patients. The certainty of the evidence was very low. We identified 32 clinical trial protocols, but only three have published results to-date. The trials administer vitamin D doses of 357 to 60,000 IU/day, from one week to 12 months. Eight megatrials investigate the efficacy of vitamin D in outpatient populations. A pilot trial revealed a significant decrease in ICU admission with calcifediol, compared to placebo (OR = 0.003), but the certainty of the evidence was unclear. Another small trial showed that supplementation with cholecalciferol, 60,000 IU/day, decreased fibrinogen levels, but did not have an effect on D-dimer, procalcitonin and CRP levels, compared to placebo. The third trial did not find any effect of vitamin D supplementation on COVID-19 related health outcomes. CONCLUSION: While the available evidence to-date, from largely poor-quality observational studies, may be viewed as showing a trend for an association between low serum 25(OH)D levels and COVID-19 related health outcomes, this relationship was not found to be statistically significant. Calcifediol supplementation may have a protective effect on COVID-19 related ICU admissions. The current use of high doses of vitamin D in COVID-19 patients is not based on solid evidence. It awaits results from ongoing trials to determine the efficacy, desirable doses, and safety, of vitamin D supplementation to prevent and treat COVID-19 related health outcomes.


Subject(s)
COVID-19/complications , Vitamin D Deficiency/complications , Vitamin D/physiology , COVID-19/mortality , COVID-19/physiopathology , Dietary Supplements , Humans , Nutritional Status , Vitamin D/therapeutic use , Vitamin D Deficiency/physiopathology , Vitamins/therapeutic use
6.
Mol Cell Biochem ; 476(6): 2421-2427, 2021 Jun.
Article in English | MEDLINE | ID: covidwho-1092035

ABSTRACT

Aggressive inflammatory response leading to hypercoagulability has been found to be associated with disease severity in COVID-19 patients and portends bad treatment outcome. A state of acute disseminated intravascular coagulation (DIC), along with pulmonary embolism and/or deep vein thrombosis, has been observed in critically ill ICU patients. Autopsy reports of COVID-19 patients demonstrated microthrombi in lungs and in other organs, as well as marked inflammatory changes, characteristic clinicopathological features that exacerbate disease severity. Vitamin D supplementation was recommended by many clinicians across the globe to improve clinical symptoms of COVID-19 patients, mainly because of its immunomodulatory roles on immune cells. Furthermore, vitamin D and its associated molecules are also known to directly or indirectly regulate various thrombotic pathways. We propose that vitamin D supplementation not only attenuates the risk of Acute Respiratory Disease Syndrome (ARDS) but it also may have a role in reducing coagulation abnormalities in critically ill COVID-19 patients. The overarching goal of this review is to discuss the effects of vitamin D on coagulation pathways and other intertwined processes leading to thrombosis. Many clinical trials are currently investigating the efficacy of vitamin D supplementation in reducing the risk of COVID-19 infection. However, randomized placebo control clinical trials are also necessary to ascertain the effect of vitamin D supplementation on reducing the risk of coagulopathy in COVID-19 patients.


Subject(s)
COVID-19/drug therapy , COVID-19/etiology , Vitamin D/pharmacology , Vitamin D/physiology , Blood Coagulation Disorders/virology , COVID-19/complications , Humans , Urachal Cyst/etiology , Vitamin D Deficiency/virology
7.
Horm Mol Biol Clin Investig ; 42(1): 77-85, 2021 Feb 04.
Article in English | MEDLINE | ID: covidwho-1067449

ABSTRACT

COVID-19 has resulted in an ongoing global pandemic, which spread largely among people who have had close contact with the infected person. The immunopathology of the SARS-CoV-2 virus includes the production of an excess amount of pro-inflammatory cytokines "a cytokine-storm". The respiratory system (main), cardiovascular system and the gastrointestinal tract are the most affected body systems during viral infection. It has been found that most of the patients who require admission to hospital are elderly or have chronic underlying diseases. Higher cases of malnutrition and co-morbidities like diabetes mellitus and cardiovascular diseases are reported in elderly patients due to which, the immune system weakens and hence, the response to the virus is diminished in magnitude. A deficiency of micronutrients results in impaired immune responses leading to improper secretion of cytokines, alterations in secretory antibody response and antibody affinity which increases susceptibility to viral infection. The deficiency of various micronutrients in COVID-19 patient can be treated by appropriate nutritional supplements, prescribed after evaluating the patients' nutritional status. Here we aim to highlight the role of a few particular nutrients namely Vitamin D, Vitamin C, Omega-3 fatty acids, Zinc and Magnesium along with the synergistic roles they play in enhancing immunity and thus, maintaining homeostasis.


Subject(s)
COVID-19/epidemiology , Malnutrition/epidemiology , Ascorbic Acid/physiology , COVID-19/complications , COVID-19/immunology , COVID-19/therapy , Dietary Supplements , Fatty Acids, Omega-3/physiology , Humans , Immune System/physiology , Magnesium/physiology , Malnutrition/complications , Malnutrition/immunology , Malnutrition/therapy , Micronutrients/physiology , Nutritional Status/physiology , Pandemics , SARS-CoV-2/physiology , Vitamin D/physiology , Zinc/physiology
8.
Am J Physiol Endocrinol Metab ; 320(3): E520-E526, 2021 03 01.
Article in English | MEDLINE | ID: covidwho-1011022

ABSTRACT

The immunomodulating role of vitamin D might play a role in COVID-19 disease. We studied the association between vitamin D and clinical outcomes in COVID-19 patients. This is a retrospective cohort study on COVID-19 patients with documented vitamin D levels within the last year. Vitamin D levels were grouped as ≥ 20 ng/mL or < 20 ng/mL. Main outcomes were mortality, need for mechanical ventilation, new DVT or pulmonary embolism, and ICU admission. A total of 270 patients (mean ± SD) age, 63.81 (14.69) years); 117 (43.3%) males; 216 (80%) Blacks; 139 (51.5%) in 65 and older age group were included. Vitamin D levels were less than 20 ng/mL in 95 (35.2%) patients. During admission, 72 patients (26.7%) died, 59 (21.9%) needed mechanical ventilation, and 87 (32.2%) required ICU. Vitamin D levels showed no significant association with mortality (OR = 0.69; 95% CI, 0.39-1.24; P = 0.21), need for mechanical ventilation (OR = 1.23; 95% CI, 0.68-2.24; P = 0.49), new DVT or PE(OR= 0.92; 95% CI, 0.16-5.11; P = 1.00) or ICU admission (OR = 1.38; 95% CI, 0.81-2.34; P = 0.23). We did not find any significant association of vitamin D levels with mortality, the need for mechanical ventilation, ICU admission and the development of thromboembolism in COVID-19 patients.NEW & NOTEWORTHY Low vitamin D has been associated with increased frequency and severity of respiratory tract infections in the past. Current literature linking clinical outcomes in COVID-19 with low vitamin D is debatable. This study evaluated the role of vitamin D in severe disease outcomes among COVID-19 patients and found no association of vitamin D levels with mortality, the need for mechanical ventilation, ICU admission, and thromboembolism in COVID-19.


Subject(s)
COVID-19/diagnosis , COVID-19/mortality , Vitamin D/blood , Aged , Aged, 80 and over , COVID-19/pathology , COVID-19/therapy , Cohort Studies , Female , Hospital Mortality , Hospitalization/statistics & numerical data , Humans , Intensive Care Units/statistics & numerical data , Male , Middle Aged , Mortality , Prognosis , Respiration, Artificial/statistics & numerical data , Retrospective Studies , SARS-CoV-2/immunology , SARS-CoV-2/pathogenicity , Severity of Illness Index , Vitamin D/physiology
9.
Nutrients ; 12(5)2020 Apr 27.
Article in English | MEDLINE | ID: covidwho-828212

ABSTRACT

The last couple of decades have seen an explosion in our interest and understanding of the role of vitamin D in the regulation of immunity. At the molecular level, the hormonal form of vitamin D signals through the nuclear vitamin D receptor (VDR), a ligand-regulated transcription factor. The VDR and vitamin D metabolic enzymes are expressed throughout the innate and adaptive arms of the immune system. The advent of genome-wide approaches to gene expression profiling have led to the identification of numerous VDR-regulated genes implicated in the regulation of innate and adaptive immunity. The molecular data infer that vitamin D signaling should boost innate immunity against pathogens of bacterial or viral origin. Vitamin D signaling also suppresses inflammatory immune responses that underlie autoimmunity and regulate allergic responses. These findings have been bolstered by clinical studies linking vitamin D deficiency to increased rates of infections, autoimmunity, and allergies. Our goals here are to provide an overview of the molecular basis for immune system regulation and to survey the clinical data from pediatric populations, using randomized placebo-controlled trials and meta-analyses where possible, linking vitamin D deficiency to increased rates of infections, autoimmune conditions, and allergies, and addressing the impact of supplementation on these conditions.


Subject(s)
Adaptive Immunity , Autoimmunity , Child Nutritional Physiological Phenomena/immunology , Dietary Supplements , Immunity, Innate , Immunologic Factors , Vitamin D/pharmacology , Vitamin D/physiology , Age Factors , Autoimmune Diseases/etiology , Child , Child, Preschool , Communicable Diseases/etiology , Female , Humans , Hypersensitivity/etiology , Infant , Male , Receptors, Calcitriol/metabolism , Receptors, Calcitriol/physiology , Signal Transduction/physiology , Vitamin D/metabolism , Vitamin D Deficiency/complications , Vitamin D Deficiency/immunology
10.
Virus Res ; 289: 198148, 2020 11.
Article in English | MEDLINE | ID: covidwho-733588

ABSTRACT

In late 2019, SARS-CoV-2 started to spread throughout the world causing the COVID-19 that has taken a considerable number of lives. Results obtained from several investigations have explained the virus origin, pathogenicity, and transmission. Similar to SARS coronavirus, the pulmonary angiotensin converting enzyme (ACE) 2 was introduced as the virus receptor for entering the cell. An increased body of epidemiological and clinical evidences has shown modulating effects of vitamin D in lung injuries through several mechanisms. Several clinical symptoms as well as molecular factors have shown to be related to the disease transmission and severity. In this study, vitamin D, ACE concentrations, and neutrophil to lymphocyte ratio (NLR) were measured in patients with confirmed COVID-19 in comparison with control group. Results demonstrated significant alterations in vitamin D and ACE levels as well as NLR in the patients' group. Contribution of those factors with the prognosis and severity of the disease has been shown.


Subject(s)
Betacoronavirus , Coronavirus Infections/complications , Pandemics , Pneumonia, Viral/complications , Vitamin D Deficiency/complications , Vitamin D/physiology , Adolescent , Adult , Aged , COVID-19 , Coronavirus Infections/blood , Disease Progression , Female , Humans , Leukocyte Count , Lymphocyte Count , Male , Middle Aged , Neutrophils , Peptidyl-Dipeptidase A/blood , Pneumonia, Viral/blood , SARS-CoV-2 , Vitamin D/blood , Young Adult
11.
Appl Microbiol Biotechnol ; 104(19): 8089-8104, 2020 Oct.
Article in English | MEDLINE | ID: covidwho-723331

ABSTRACT

Interspecies transmissions of viruses between animals and humans may result in unpredictable pathogenic potential and new transmissible diseases. This mechanism has recently been exemplified by the discovery of new pathogenic viruses, such as the novel severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) pandemic, Middle-East respiratory syndrome-coronavirus epidemic in Saudi Arabia, and the deadly outbreak of Ebola in West Africa. The. SARS-CoV-2 causes coronavirus disease-19 (COVID-19), which is having a massive global impact in terms of economic disruption, and, above all, human health. The disease is characterized by dry cough, fever, fatigue, myalgia, and dyspnea. Other symptoms include headache, sore throat, rhinorrhea, and gastrointestinal disorders. Pneumonia appears to be the most common and severe manifestation of the infection. Currently, there is no vaccine or specific drug for COVID-19. Further, the development of new antiviral requires a considerable length of time and effort for drug design and validation. Therefore, repurposing the use of natural compounds can provide alternatives and can support therapy against COVID-19. In this review, we comprehensively discuss the prophylactic and supportive therapeutic role of probiotics for the management of COVID-19. In addition, the unique role of probiotics to modulate the gut microbe and assert gut homeostasis and production of interferon as an antiviral mechanism is described. Further, the regulatory role of probiotics on gut-lung axis and mucosal immune system for the potential antiviral mechanisms is reviewed and discussed.Key points• Gut microbiota role in antiviral diseases• Factors influencing the antiviral mechanism• Probiotics and Covid-19.


Subject(s)
Betacoronavirus/physiology , Coronavirus Infections/therapy , Pneumonia, Viral/therapy , Probiotics/therapeutic use , Animals , COVID-19 , Coronavirus Infections/prevention & control , Coronavirus Infections/transmission , Gastrointestinal Tract/microbiology , Humans , Immunity, Mucosal , Lung/immunology , Lung/microbiology , Lung/virology , Pandemics/prevention & control , Pneumonia, Viral/prevention & control , Pneumonia, Viral/transmission , Probiotics/metabolism , Respiratory Tract Infections/microbiology , SARS-CoV-2 , Virus Diseases/prevention & control , Virus Diseases/therapy , Virus Diseases/transmission , Vitamin D/physiology , Zinc/metabolism
12.
J Endocrinol Invest ; 44(1): 27-35, 2021 Jan.
Article in English | MEDLINE | ID: covidwho-601171

ABSTRACT

PURPOSE: Covid-19 is a pandemic of unprecedented proportion, whose understanding and management is still under way. In the emergency setting new or available therapies to contrast the spread of COVID-19 are urgently needed. Elderly males, especially those affected by previous diseases or with comorbidities, are more prone to develop interstitial pneumonia that can deteriorate evolving to ARDS (acute respiratory distress syndrome) that require hospitalization in Intensive Care Units (ICUs). Even children and young patients are not spared by SARS-CoV 2 infection, yet they seem to develop a milder form of disease. In this setting the immunomodulatory role of Vitamin D, should be further investigated. METHODS: We reviewed the literature about the immunomodulatory role of Vitamin D collecting data from the databases Medline and Embase. RESULTS: Vitamin D proved to interact both with the innate immune system, by activating Toll-like receptors (TLRs) or increasing the levels of cathelicidins and ß-defensins, and adaptive immune system, by reducing immunoglobulin secretion by plasma cells and pro-inflammatory cytokines production, thus modulating T cells function. Promising results have been extensively described as regards the supplementation of vitamin D in respiratory tract infections, autoimmune diseases and even pulmonary fibrosis. CONCLUSIONS: In this review, we suggest that vitamin D supplementation might play a role in the prevention and/or treatment to SARS-CoV-2 infection disease, by modulating the immune response to the virus both in the adult and pediatric population.


Subject(s)
COVID-19/epidemiology , COVID-19/immunology , COVID-19/therapy , Vitamin D/physiology , Adult , Age Factors , Age of Onset , Aged , Aged, 80 and over , COVID-19/pathology , Child , Dietary Supplements , Female , Humans , Immunomodulation/drug effects , Male , Pandemics , Pneumonia, Viral/epidemiology , Pneumonia, Viral/pathology , Pneumonia, Viral/prevention & control , SARS-CoV-2/drug effects , SARS-CoV-2/immunology , Vitamin D/administration & dosage , Vitamin D/blood
13.
Nutrients ; 12(4)2020 Apr 02.
Article in English | MEDLINE | ID: covidwho-26898

ABSTRACT

The world is in the grip of the COVID-19 pandemic. Public health measures that can reduce the risk of infection and death in addition to quarantines are desperately needed. This article reviews the roles of vitamin D in reducing the risk of respiratory tract infections, knowledge about the epidemiology of influenza and COVID-19, and how vitamin D supplementation might be a useful measure to reduce risk. Through several mechanisms, vitamin D can reduce risk of infections. Those mechanisms include inducing cathelicidins and defensins that can lower viral replication rates and reducing concentrations of pro-inflammatory cytokines that produce the inflammation that injures the lining of the lungs, leading to pneumonia, as well as increasing concentrations of anti-inflammatory cytokines. Several observational studies and clinical trials reported that vitamin D supplementation reduced the risk of influenza, whereas others did not. Evidence supporting the role of vitamin D in reducing risk of COVID-19 includes that the outbreak occurred in winter, a time when 25-hydroxyvitamin D (25(OH)D) concentrations are lowest; that the number of cases in the Southern Hemisphere near the end of summer are low; that vitamin D deficiency has been found to contribute to acute respiratory distress syndrome; and that case-fatality rates increase with age and with chronic disease comorbidity, both of which are associated with lower 25(OH)D concentration. To reduce the risk of infection, it is recommended that people at risk of influenza and/or COVID-19 consider taking 10,000 IU/d of vitamin D3 for a few weeks to rapidly raise 25(OH)D concentrations, followed by 5000 IU/d. The goal should be to raise 25(OH)D concentrations above 40-60 ng/mL (100-150 nmol/L). For treatment of people who become infected with COVID-19, higher vitamin D3 doses might be useful. Randomized controlled trials and large population studies should be conducted to evaluate these recommendations.


Subject(s)
Betacoronavirus , Coronavirus Infections/prevention & control , Nutrition Therapy , Pandemics/prevention & control , Pneumonia, Viral/prevention & control , Vitamin D/physiology , Vitamin D/therapeutic use , COVID-19 , Coronavirus Infections/epidemiology , Coronavirus Infections/mortality , Dietary Supplements , Humans , Influenza, Human/epidemiology , Influenza, Human/mortality , Influenza, Human/prevention & control , Pneumonia, Viral/epidemiology , Pneumonia, Viral/mortality , Risk Factors , SARS-CoV-2 , Seasons , Vitamin D Deficiency/epidemiology , Vitamin D Deficiency/prevention & control
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