Sunlight for COVID-19: real-time meta analysis of 5 studies
Abstract
Statistically significant lower risk is seen for mortality, hospitalization, recovery, and cases. 5 studies from 5 independent teams in 4 countries show significant
improvements.
Meta analysis using the most serious outcome reported shows
37% [22‑50%] lower risk. Results are similar for Randomized Controlled Trials.
No treatment or intervention
is 100% effective. All practical, effective, and safe means should be used
based on risk/benefit analysis.
Multiple treatments are typically used
in combination, and other treatments
may be more effective.
There has been no early treatment studies to date.
All data to reproduce this paper and
sources are in the appendix.
Sunlight for COVID-19 — Highlights
Sunlight reduces
risk with very high confidence for pooled analysis, high confidence for cases, and low confidence for mortality, hospitalization, and recovery.
32nd treatment shown effective with ≥3 clinical studies in
December 2021, now with p = 0.000052 from 5 studies.
Outcome specific analyses and combined evidence from all
studies, incorporating treatment delay, a primary confounding factor.
Real-time updates and corrections,
transparent analysis with all results in the same format, consistent protocol
for 109
treatments.
Figure 1.
A. Random effects
meta-analysis. This plot shows pooled effects,
see the specific outcome analyses for individual outcomes.
Analysis validating pooled outcomes for
COVID-19 can be found below.
Effect extraction is pre-specified, using the most serious outcome reported.
For details see the appendix.
B. Timeline of results in sunlight studies. The marked dates indicate the time when efficacy was known with a statistically significant improvement of ≥10% from ≥3 studies for pooled outcomes and one or more specific outcome. Efficacy based on specific outcomes was delayed by 3.8 months, compared to using pooled outcomes.
Sunlight increases nitric oxide and vitamin D, and helps regulate the circadian rhythm which is important for immune health and may increase melatonin production at night. Sunlight may also directly inactivate SARS-CoV-2 in the environment1.
We analyze all significant
studies reporting COVID-19 outcomes as a function of sunlight exposure.
Search methods, inclusion criteria, effect extraction criteria (more serious
outcomes have priority), all individual study data, PRISMA answers, and
statistical methods are detailed in Appendix 1. We present random
effects meta-analysis results for all studies, studies within each treatment stage, individual outcomes, and Randomized Controlled Trials (RCTs).
Preclinical research is an important part of the development of
treatments, however results may be very different in clinical trials.
Preclinical results are not used in this paper.
Table 1 summarizes the results for all studies, for Randomized Controlled Trials, and for specific outcomes.
Figure 2 plots individual results by treatment stage.
Figure 3, 4, 5, 6, and 7
show forest plots for random effects meta-analysis of
all studies with pooled effects, mortality results, hospitalization, recovery, and cases.
| Improvement | Studies | Patients | Authors | |
|---|---|---|---|---|
| All studies | 37% [22‑50%] **** | 5 | 19,665 | 36 |
| Randomized Controlled TrialsRCTs | 32% [6‑50%] * | 1 | 30 | 5 |
| Cases | 48% [11‑70%] * | 3 | 19,635 | 24 |
Figure 2. Scatter plot showing the most serious outcome in all studies. The diamond shows the results of random effects meta-analysis.
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Figure 3. Random effects meta-analysis for all studies.
This plot shows pooled effects,
see the specific outcome analyses for individual outcomes.
Analysis validating pooled outcomes for
COVID-19 can be found below.
Effect extraction is pre-specified, using the most serious outcome reported.
For details see the appendix.
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Figure 4. Random effects meta-analysis for mortality results.
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Figure 5. Random effects meta-analysis for hospitalization.
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Figure 6. Random effects meta-analysis for recovery.
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Figure 7. Random effects meta-analysis for cases.
Figure 8 shows a forest plot for random
effects meta-analysis of all Randomized Controlled Trials.
RCT results are included in Table 1.
Currently there is only one RCT.
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Figure 8. Random effects meta-analysis for all Randomized Controlled Trials.
This plot shows pooled effects,
see the specific outcome analyses for individual outcomes.
Analysis validating pooled outcomes for
COVID-19 can be found below.
Effect extraction is pre-specified, using the most serious outcome reported.
For details see the appendix.
RCTs help to make study groups more similar and can provide a higher level of
evidence, however they are subject to many biases7, and
analysis of double-blind RCTs has identified extreme levels of bias8.
For COVID-19, the overhead may delay treatment, dramatically compromising
efficacy; they may encourage monotherapy for simplicity at the cost of
efficacy which may rely on combined or synergistic effects; the participants
that sign up may not reflect real world usage or the population that benefits
most in terms of age, comorbidities, severity of illness, or other factors;
standard of care may be compromised and unable to evolve quickly based on
emerging research for new diseases; errors may be made in randomization and
medication delivery; and investigators may have hidden agendas or vested
interests influencing design, operation, analysis, reporting, and the
potential for fraud. All of these biases have been observed with COVID-19
RCTs. There is no guarantee that a specific RCT provides a higher level of
evidence.
RCTs are expensive and many RCTs are funded
by pharmaceutical companies or interests closely aligned with pharmaceutical
companies. For COVID-19, this creates an incentive to show efficacy for
patented commercial products, and an incentive to show a lack of efficacy for
inexpensive treatments. The bias is expected to be significant, for example
Als-Nielsen et al. analyzed 370 RCTs from Cochrane reviews, showing that
trials funded by for-profit organizations were 5 times more likely to
recommend the experimental drug compared with those funded by nonprofit
organizations. For COVID-19, some major philanthropic organizations are
largely funded by investments with extreme conflicts of interest for and
against specific COVID-19 interventions.
High quality RCTs for novel acute diseases are more challenging, with
increased ethical issues due to the urgency of treatment, increased risk due
to enrollment delays, and more difficult design with a rapidly evolving
evidence base. For COVID-19, the most common site of initial infection is the
upper respiratory tract. Immediate treatment is likely to be most successful
and may prevent or slow progression to other parts of the body. For a
non-prophylaxis RCT, it makes sense to provide treatment in advance and
instruct patients to use it immediately on symptoms, just as some governments
have done by providing medication kits in advance. Unfortunately, no RCTs have
been done in this way. Every treatment RCT to date involves delayed treatment.
Among the 109 treatments we have analyzed,
65% of RCTs involve very late treatment 5+ days after
onset. No non-prophylaxis COVID-19 RCTs match the potential real-world use of
early treatments. They may more accurately represent results for treatments
that require visiting a medical facility, e.g., those requiring intravenous
administration.
RCTs have a bias against finding an
effect for interventions that are widely available — patients that
believe they need the intervention are more likely to decline participation
and take the intervention. RCTs for sunlight are more likely to
enroll low-risk participants that do not need treatment to recover, making the
results less applicable to clinical practice. This bias is likely to be
greater for widely known treatments, and may be greater when the risk of a
serious outcome is overstated. This bias does not apply to the typical
pharmaceutical trial of a new drug that is otherwise unavailable.
For COVID-19, observational study results do not systematically
differ from RCTs, RR 1.00 [0.92‑1.08]
across 109 treatments10.
Evidence shows that observational studies
can also provide reliable results. Concato et al. found that well-designed
observational studies do not systematically overestimate the magnitude of the
effects of treatment compared to RCTs. Anglemyer et al. analyzed reviews
comparing RCTs to observational studies and found little evidence for
significant differences in effect estimates.
We performed a similar analysis across the 109 treatments
we cover, showing no significant difference in the results of RCTs compared to
observational studies, RR 1.00 [0.92‑1.08]. Similar results are found for all low-cost treatments, RR
1.02 [0.92‑1.12]. High-cost treatments
show a non-significant trend towards RCTs showing greater efficacy,
RR 0.92 [0.82‑1.03].
Details can be found in the
supplementary data.
Lee et al. showed that only 14% of the guidelines of the Infectious
Diseases Society of America were based on RCTs. Evaluation of studies relies
on an understanding of the study and potential biases. Limitations in an RCT
can outweigh the benefits, for example excessive dosages, excessive treatment
delays, or remote survey bias may have a greater effect on results. Ethical
issues may also prevent running RCTs for known effective treatments. For more
on issues with RCTs see14,15.
Currently, 48 of the treatments we analyze show statistically significant efficacy or harm, defined as ≥10% decreased risk or >0% increased risk from ≥3 studies. Of these, 60% have been confirmed in RCTs, with a mean delay of 7.1 months (68% with 8.2 months delay for low-cost treatments). The remaining treatments either have no RCTs, or the point estimate is consistent.
We need to
evaluate each trial on its own merits. RCTs for a given medication and disease
may be more reliable, however they may also be less reliable. For off-patent
medications, very high conflict of interest trials may be more likely to be
RCTs, and more likely to be large trials that dominate meta analyses.
Heterogeneity in COVID-19 studies arises from many factors including:
Details of the patient population including age and comorbidities may
critically affect how well a treatment works. For example, many COVID-19
studies with relatively young low-comorbidity patients show all patients
recovering quickly with or without treatment. In such cases, there is little
room for an effective treatment to improve results, for example as in
LĂłpez-Medina et al.
Efficacy may
depend critically on the distribution of SARS-CoV-2 variants encountered by
patients. Risk varies significantly across variants17, for
example the Gamma variant shows significantly different characteristics18-21. Different mechanisms of action may be
more or less effective depending on variants, for example the degree to which
TMPRSS2 contributes to viral entry can differ across variants22,23.
The use
of other treatments may significantly affect outcomes, including supplements,
other medications, or other interventions such as prone positioning.
Treatments may be synergistic24-35, therefore
efficacy may depend strongly on combined treatments.
Across all
studies there is a strong association between different outcomes, for example
improved recovery is strongly associated with lower mortality. However,
efficacy may differ depending on the effect measured, for example a treatment
may be more effective against secondary complications and have minimal effect
on viral clearance.
The
distribution of studies will alter the outcome of a meta analysis. Consider a
simplified example where everything is equal except for the treatment delay,
and effectiveness decreases to zero or below with increasing delay. If there
are many studies using very late treatment, the outcome may be negative, even
though early treatment is very effective.
All meta analyses combine heterogeneous studies, varying in population,
variants, and potentially all factors above, and therefore may obscure
efficacy by including studies where treatment is less effective. Generally, we
expect the estimated effect size from meta analysis to be less than that for
the optimal case.
Looking at all studies is valuable for providing an overview of all research,
important to avoid cherry-picking, and informative when a positive result is
found despite combining less-optimal situations. However, the resulting
estimate does not apply to specific cases such as
early treatment in high-risk populations.
While we present results for all studies, we also present treatment time and
individual outcome analyses, which may be more informative for specific use
cases.
This section validates the use of pooled effects for COVID-19, which enables
earlier detection of efficacy, however note that pooled effects are no longer
required for sunlight as of April 2022.
Efficacy is now known based on specific outcomes. Efficacy based on specific outcomes was delayed by 3.8 months, compared to using pooled outcomes.
For COVID-19, delay in clinical results translates into
additional death and morbidity, as well as additional economic and societal
damage. Combining the results of studies reporting different outcomes is
required.
There may be no mortality in a trial with low-risk patients,
however a reduction in severity or improved viral clearance may translate
into lower mortality in a high-risk population.
Different studies may report lower severity, improved recovery, and lower mortality,
and the significance may be very high when combining the results.
"The studies reported different outcomes"
is not a good reason for disregarding results.
We present both specific outcome and pooled analyses.
In order to combine the results of studies reporting different outcomes we use
the most serious outcome reported in each study, based on the thesis that
improvement in the most serious outcome provides comparable measures of
efficacy for a treatment. A critical advantage of this approach is
simplicity and transparency.
There are many other ways to combine evidence for different outcomes, along
with additional evidence such as dose-response relationships, however these
increase complexity.
Another way to view pooled analysis is that we are using more of
the available information. Logically we should, and do, use additional
information. For example dose-response and
treatment delay-response relationships provide significant additional evidence
of efficacy that is considered when reviewing the evidence for a
treatment.
Trials with high-risk patients may be restricted due to ethics for treatments
that are known or expected to be effective, and they increase difficulty for
recruiting. Using less severe outcomes as a proxy for more serious outcomes
allows faster collection of evidence.
For many COVID-19 treatments, a reduction in mortality logically
follows from a reduction in hospitalization, which follows from a reduction in
symptomatic cases, which follows from a reduction in PCR positivity. We can
directly test this for COVID-19.
Analysis of the the association between different outcomes across studies from
all 109
treatments we cover confirms the validity of pooled outcome analysis for COVID-19.
Figure 9 shows that lower hospitalization is very strongly associated
with lower mortality (p < 0.000000000001).
Similarly, Figure 10 shows that improved recovery is very strongly associated
with lower mortality (p < 0.000000000001).
Considering the extremes, Singh et al. show an association between viral clearance and
hospitalization or death, with p = 0.003 after excluding one large
outlier from a mutagenic treatment, and based on 44 RCTs including 52,384
patients.
Figure 11 shows that improved viral clearance is strongly associated
with fewer serious outcomes. The association is very similar to
Singh et al., with higher confidence due to the larger number of
studies. As with Singh et al., the confidence increases
when excluding the outlier treatment, from p = 0.00000042 to p = 0.00000002.
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Figure 9. Lower hospitalization is associated with lower mortality, supporting pooled outcome analysis.
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Figure 10. Improved recovery is associated with lower mortality, supporting pooled outcome analysis.
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Figure 9. Improved viral clearance is associated with fewer serious outcomes, supporting pooled outcome analysis.
Currently, 48 of the treatments we analyze show statistically significant efficacy or harm, defined as ≥10% decreased risk or >0% increased risk from ≥3 studies. 89% of these have been confirmed with one or more specific outcomes, with a mean delay of 5.1 months. When restricting to RCTs only, 56% of treatments showing statistically significant efficacy/harm with pooled effects have been confirmed with one or more specific outcomes, with a mean delay of 6.4 months.
Figure 12 shows when treatments were found effective during the
pandemic. Pooled outcomes often resulted in earlier detection of efficacy.
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Figure 12. The time when studies showed that
treatments were effective, defined as statistically significant improvement of
≥10% from ≥3 studies.
Pooled results typically show efficacy earlier than specific
outcome results. Results from all studies often shows efficacy much earlier
than when restricting to RCTs.
Results reflect conditions as used in trials to date, these depend on the
population treated, treatment delay, and treatment regimen.
Pooled analysis could hide efficacy, for example a treatment that is
beneficial for late stage patients but has no effect on viral clearance may
show no efficacy if most studies only examine viral clearance. In practice, it
is rare for a non-antiviral treatment to report viral clearance and to not
report clinical outcomes; and in practice other sources of heterogeneity such
as difference in treatment delay is more likely to hide efficacy.
Analysis validates the use of pooled effects and shows significantly faster
detection of efficacy on average.
However, as with all meta analyses, it is important to review the different
studies included. We also present individual outcome analyses, which may be
more informative for specific use cases.
SARS-CoV-2 infection and replication involves a complex interplay of 50+ host
and viral proteins and other factors42-47,
providing many therapeutic targets.
Over 8,000 compounds have been predicted to reduce COVID-19
risk48, either by directly
minimizing infection or replication, by supporting immune system function, or
by minimizing secondary complications.
Sunlight increases nitric oxide and vitamin D, and helps regulate the circadian rhythm which is important for immune health and may increase melatonin production at night. Sunlight may also directly inactivate SARS-CoV-2 in the environment1.
Figure 13 shows an overview of the results for sunlight
in the context of multiple COVID-19 treatments, and Figure 14 shows a plot
of efficacy vs. cost for COVID-19 treatments.
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Figure 13.
Scatter plot showing results within the context of multiple COVID-19 treatments.
Diamonds shows the results of random effects meta-analysis.
0.6% of 8,000+ proposed treatments show efficacy49.
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Figure 14. Efficacy vs. cost for COVID-19 treatments.
Sunlight increases nitric oxide and vitamin D, and helps regulate the circadian rhythm which is important for immune health and may increase melatonin production at night. Sunlight may also directly inactivate SARS-CoV-2 in the environment1.
Increased sun exposure reduces risk for COVID-19.
Statistically significant lower risk is seen for mortality, hospitalization, recovery, and cases. 5 studies from 5 independent teams in 4 countries show significant
improvements.
Meta analysis using the most serious outcome reported shows
37% [22‑50%] lower risk. Results are similar for Randomized Controlled Trials.
Cherrie:
Analysis of UVA exposure and COVID-19 mortality in the USA, England, and Italy, showing increased UVA exposure associated with lower mortality.
Jabbar:
Analysis of 120 COVID-19 and 120 control patients in Iraq, showing lower risk of cases with regular sunlight exposure (3 times/week).
Kalichuran:
Prospective study of 100 COVID-19 patients in South Africa, 50 with COVID-19 pneumonia and 50 asymptomatic, showing higher risk of symptomatic COVID-19 with lower exposure to sunlight, and with vitamin D deficiency. Sunlight exposure may be correlated with physical activity and may have additional benefits independent of vitamin D53.
Ma:
Analysis of 39,915 patients with 1,768 COVID+ cases based on surveys in the Nurses' Health Study II, showing higher UVA/UVB exposure associated with lower risk of COVID-19 cases.
Pereira:
RCT 30 hospitalized COVID-19 patients investigating the effectiveness of photobiomodulation (PBM) using a vest with near-infrared LEDs (simulating part of the sunlight spectrum). The treatment group showed shorter hospitalization, significant improvement in cardiopulmonary function, and improvements in leukocyte, neutrophil, and lymphocyte counts post-treatment. The treatment group had higher pneumonia severity at baseline.
For more discussion see56.
For more discussion see56.
We perform ongoing searches of PubMed, medRxiv, Europe PMC,
ClinicalTrials.gov, The Cochrane Library, Google Scholar, Research
Square, ScienceDirect, Oxford University Press, the reference lists of other
studies and meta-analyses, and submissions to the site c19early.org.
Search terms are sunlight and COVID-19 or SARS-CoV-2. Automated searches are performed twice daily, with all matches reviewed for inclusion.
All studies regarding the use of sunlight for COVID-19 that report
a comparison with a control group are included in the main analysis.
This is a living analysis and is updated regularly.
We extracted effect sizes and associated data from all studies.
If studies report multiple kinds of effects then the most serious
outcome is used in pooled analysis, while other outcomes are included in the
outcome specific analyses. For example, if effects for mortality and cases are
both reported, the effect for mortality is used, this may be different to the
effect that a study focused on.
If symptomatic
results are reported at multiple times, we used the latest time, for example
if mortality results are provided at 14 days and 28 days, the results at 28
days have preference. Mortality alone is preferred over combined outcomes.
Outcomes with zero events in both arms are not used, the next most serious
outcome with one or more events is used. For example, in low-risk populations
with no mortality, a reduction in mortality with treatment is not possible,
however a reduction in hospitalization, for example, is still valuable.
Clinical outcomes are considered more important than viral test status. When
basically all patients recover in both treatment and control groups,
preference for viral clearance and recovery is given to results mid-recovery
where available. After most or all patients have recovered there is little or
no room for an effective treatment to do better, however faster recovery is
valuable.
If only individual symptom data is available, the most serious symptom has
priority, for example difficulty breathing or low SpO2 is more
important than cough.
When results provide an odds ratio, we compute the relative risk when
possible, or convert to a relative risk according to57.
Reported confidence intervals and p-values were used when available,
using adjusted values when provided. If multiple types of adjustments are
reported propensity score matching and multivariable regression has preference
over propensity score matching or weighting, which has preference over
multivariable regression. Adjusted results have preference over unadjusted
results for a more serious outcome when the adjustments significantly alter
results. When needed, conversion between reported p-values and
confidence intervals followed Altman, Altman (B), and Fisher's exact
test was used to calculate p-values for event data. If continuity
correction for zero values is required, we use the reciprocal of the opposite
arm with the sum of the correction factors equal to 160.
Results are expressed with RR < 1.0 favoring treatment, and using the risk of
a negative outcome when applicable (for example, the risk of death rather than
the risk of survival). If studies only report relative continuous values such
as relative times, the ratio of the time for the treatment group versus the
time for the control group is used. Calculations are done in Python
(3.13.0) with
scipy (1.14.1), pythonmeta (1.26), numpy (1.26.4), statsmodels (0.14.4), and plotly (5.24.1).
Forest plots are computed using PythonMeta61
with the DerSimonian and Laird random effects model (the fixed effect
assumption is not plausible in this case) and inverse variance weighting.
Results are presented with 95% confidence intervals. Heterogeneity among studies was
assessed using the I2 statistic.
Mixed-effects meta-regression results are computed with R (4.4.0) using the metafor
(4.6-0) and rms (6.8-0) packages, and using the most serious sufficiently powered outcome.
For all statistical tests, a p-value less than 0.05 was considered statistically significant.
Grobid 0.8.0 is used to parse PDF documents.
We have classified studies as early treatment if most patients
are not already at a severe stage at the time of treatment (for example based
on oxygen status or lung involvement), and treatment started within 5 days of
the onset of symptoms. If studies contain a mix of early treatment and late
treatment patients, we consider the treatment time of patients contributing
most to the events (for example, consider a study where most patients are
treated early but late treatment patients are included, and all mortality
events were observed with late treatment patients).
We note that a shorter time may be preferable. Antivirals are typically only
considered effective when used within a shorter timeframe, for example 0-36 or
0-48 hours for oseltamivir, with longer delays not being effective62,63.
We received no funding, this research is done in our spare
time. We have no affiliations with any pharmaceutical companies or political
parties.
A summary of study results is below. Please submit
updates and corrections at https://c19early.org/sunmeta.html.
Effect extraction follows pre-specified rules as detailed above
and gives priority to more serious outcomes.
For pooled analyses, the first (most serious) outcome is used, which may
differ from the effect a paper focuses on.
Other outcomes are used in outcome specific analyses.
| Pereira, 12/5/2022, Single Blind Randomized Controlled Trial, placebo-controlled, Brazil, peer-reviewed, 5 authors. | hospitalization time, 31.6% lower, relative time 0.68, p = 0.02, higher sunlight exposure 15, lower sunlight exposure 15. |
| pulmonary auscultation improvement time, 37.5% lower, relative time 0.62, p < 0.001, higher sunlight exposure 15, lower sunlight exposure 15. |
Effect extraction follows pre-specified rules as detailed above
and gives priority to more serious outcomes.
For pooled analyses, the first (most serious) outcome is used, which may
differ from the effect a paper focuses on.
Other outcomes are used in outcome specific analyses.
| Cherrie, 4/8/2021, retrospective, multiple countries, peer-reviewed, 7 authors, study period 22 January, 2020 - 30 April, 2020, per 100kJ m–2 increase. | risk of death, 32.0% lower, RR 0.68, p = 0.004, USA, England, Italy combined. |
| risk of death, 29.0% lower, RR 0.71, p < 0.001, USA. | |
| risk of death, 19.0% lower, RR 0.81, p = 0.002, Italy. | |
| risk of death, 49.0% lower, RR 0.51, p < 0.001, England. | |
| Jabbar, 12/31/2021, retrospective, Iraq, peer-reviewed, 4 authors. | risk of case, 62.8% lower, OR 0.37, p < 0.001, higher sunlight exposure 43 of 120 (35.8%) cases, 72 of 120 (60.0%) controls, NNT 4.1, case control OR. |
| Kalichuran, 4/26/2022, prospective, South Africa, peer-reviewed, survey, 4 authors, study period September 2020 - February 2021. | risk of symptomatic case, 58.2% lower, RR 0.42, p = 0.004, higher sunlight exposure 21, lower sunlight exposure 79, inverted to make RR<1 favor higher sunlight exposure, higher sunlight exposure vs. lower sunlight exposure. |
| Ma, 12/3/2021, retrospective, USA, peer-reviewed, 16 authors, study period May 2020 - March 2021. | risk of case, 23.0% lower, RR 0.77, p < 0.001, higher sunlight exposure 411 of 10,393 (4.0%), lower sunlight exposure 495 of 9,142 (5.4%), NNT 68, adjusted per study, odds ratio converted to relative risk, UVB, highest quartile vs. lowest quartile, model 3, table 3, multivariable. |
| risk of case, 23.1% lower, RR 0.77, p < 0.001, higher sunlight exposure 325 of 9,325 (3.5%), lower sunlight exposure 436 of 9,079 (4.8%), NNT 76, adjusted per study, odds ratio converted to relative risk, UVA, highest quartile vs. lowest quartile, model 3, table 3, multivariable. |
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