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Published ahead of print on April 26, 2007, doi:10.1164/rccm.200701-007OC
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American Journal of Respiratory and Critical Care Medicine Vol 176. pp. 208-213, (2007)
© 2007 American Thoracic Society
doi: 10.1164/rccm.200701-007OC

Original Article

A Single Dose of Vitamin D Enhances Immunity to Mycobacteria

Adrian R. Martineau1,2,3,*, Robert J. Wilkinson3,4,5,*, Katalin A. Wilkinson3,4, Sandra M. Newton3, Beate Kampmann3,4, Bridget M. Hall1, Geoffrey E. Packe2, Robert N. Davidson5, Sandra M. Eldridge1, Zoë J. Maunsell6, Sandra J. Rainbow6, Jacqueline L. Berry7 and Christopher J. Griffiths1

1 Centre for Health Sciences, Queen Mary's School of Medicine and Dentistry, Barts and The London, London, United Kingdom; Newham Chest Clinic, London, United Kingdom; 3 Wellcome Trust Center for Research in Clinical Tropical Medicine, Division of Medicine, Wright Fleming Institute, Imperial College London, London, United Kingdom; 4 Institute of Infectious Diseases and Molecular Medicine and Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; 5 Tuberculosis Clinic and 6 Department of Clinical Biochemistry, North West London Hospitals NHS Trust, Northwick Park Hospital, Harrow, United Kingdom; and 7 Vitamin D Research Group, University School of Medicine, Manchester Royal Infirmary, Manchester, United Kingdom

Correspondence and requests for reprints should be addressed to Adrian R. Martineau, M.R.C.P., Centre for Health Sciences, Queen Mary's School of Medicine and Dentistry, Barts and The London, London E1 2AT, UK. E-mail: a.martineau{at}qmul.ac.uk


   ABSTRACT
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 ABSTRACT
AT A GLANCE COMMENTARY
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Rationale: Vitamin D was used to treat tuberculosis (TB) in the preantibiotic era. Prospective studies to evaluate the effect of vitamin D supplementation on antimycobacterial immunity have not previously been performed.

Objectives: To determine the effect of vitamin D supplementation on antimycobacterial immunity and vitamin D status.

Methods: A double-blind randomized controlled trial was conducted in 192 healthy adult TB contacts in London, United Kingdom. Participants were randomized to receive a single oral dose of 2.5 mg vitamin D or placebo and followed up at 6 weeks.

Measurements and Main Results: The primary outcome measure was assessed with a functional whole blood assay (BCG-lux assay), which measures the ability of whole blood to restrict luminescence, and thus growth, of recombinant reporter mycobacteria in vitro; the readout is expressed as a luminescence ratio (luminescence postinfection/baseline luminescence). IFN-{gamma} responses to the Mycobacterium tuberculosis antigens early secretory antigenic target-6 and culture filtrate protein 10 were determined with a second whole blood assay. Vitamin D supplementation significantly enhanced the ability of participants' whole blood to restrict BCG-lux luminescence in vitro compared with placebo (mean luminescence ratio at follow-up, 0.57, vs. 0.71, respectively; 95% confidence interval for difference, 0.01–0.25; p = 0.03) but did not affect antigen-stimulated IFN-{gamma} secretion.

Conclusions: A single oral dose of 2.5 mg vitamin D significantly enhanced the ability of participants' whole blood to restrict BCG-lux luminescence in vitro without affecting antigen-stimulated IFN-{gamma} responses. Clinical trials should be performed to determine whether vitamin D supplementation prevents reactivation of latent TB infection. Clinical trial registered with www.clinicaltrials.gov (NCT 00157066).

Key Words: human • vitamin D • innate immunity • mycobacteria



   AT A GLANCE COMMENTARY
TOP
 ABSTRACT
 AT A GLANCE COMMENTARY
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Scientific Knowledge on the Subject
Vitamin D was used to treat tuberculosis in the preantibiotic era, and 25-hydroxyvitamin D supports induction of antimycobacterial immunity in vitro. Studies to evaluate the effect of vitamin D supplementation on antimycobacterial immunity have not been performed.

What This Study Adds to the Field
A single oral dose of vitamin D significantly enhanced tuberculosis contacts' antimycobacterial immunity in vitro.

 
Tuberculosis (TB) is a global emergency: in 2004, there were an estimated 8.9 million new cases and 1.7 million deaths due to the disease (1). One-third of the global population has latent TB infection (2), providing a reservoir for future reactivation disease well into the present century. An understanding of the factors causing reactivation is therefore of considerable public health significance.

Clinical studies suggest that vitamin D enhances antimycobacterial immunity, and that deficiency is associated with susceptibility to active disease. High doses of vitamin D were widely used to treat active TB in the preantibiotic era (3); more recently, case-control studies have demonstrated that a vegetarian diet (low in vitamin D) is an independent risk factor for active TB in South Asians (4) and that patients with TB who are of Gujarati Hindu ethnic origin have significantly higher rates of vitamin D deficiency than ethnically matched tuberculin-positive TB contacts (5).

Vitamin D is synthesized in the skin during exposure to ultraviolet light and is also available in the diet, principally from oily fish. It is readily metabolized in the liver to form 25-hydroxyvitamin D (25[OH]D), the accepted measure of vitamin D status (6). 25(OH)D is then further metabolized by the 1-{alpha}-hydroxylase enzyme Cyp27B1 to its biologically active metabolite, the steroid hormone 1-{alpha}, 25-hydroxyvitamin D (1{alpha},25[OH]2D) (7).

1{alpha},25(OH)2D has no direct antimycobacterial action, but it does induce antituberculous activity in vitro in both monocytes (8) and macrophages (9). Several mechanisms of action have been proposed. Exogenous 1{alpha},25(OH)2D induces a superoxide burst (10) and enhances phagolysosome fusion (11) in Mycobacterium tuberculosis–infected macrophages; both phenomena are mediated by phosphatidylinositol 3-kinase, suggesting that this response is initiated by binding membrane vitamin D receptor (VDR) (12). 1{alpha},25(OH)2D also modulates immune responses by binding nuclear VDR, where it up-regulates protective innate host responses, including induction of nitric oxide synthase (13). Recently, 25(OH)D has also been shown to support messenger RNA induction of the antimicrobial peptide cathelicidin LL-37, which possesses antituberculous activity (14).

Randomized controlled trials evaluating the effect of vitamin D supplementation on antimycobacterial host response have yet to be performed. Placebo-controlled prospective studies in tuberculin-positive individuals with the development of active TB as primary outcome measure would require very large sample sizes to detect clinically significant effects. We therefore adopted an alternative approach, conducting a double-blind randomized controlled trial of vitamin D supplementation in a large cohort of TB contacts in London, United Kingdom, using a surrogate primary outcome measure: the BCG-lux assay (15). In this assay, whole blood is cultured with a recombinant Mycobacterium bovis bacille Calmette-Guérin (BCG) expressing luciferase, an enzyme that catalyzes the conversion of aldehyde substrate to produce light detectable in a luminometer. Because this reaction is ATP dependent, light production relates to bacillary metabolic activity and colony forming units (cfu) (16). The ability of whole blood to suppress BCG-lux bioluminescence is determined at both 24 and 96 hours postinfection, to assay innate and acquired components of host response, respectively. This model has yielded intuitive correlates of protection in several previous studies (15, 17, 18).

We combined BCG-lux analysis with a whole blood interferon (IFN)-{gamma} release assay (IFNGRA) that quantifies IFN-{gamma} response to the M. tuberculosis antigens early secretory antigenic target-6 (ESAT-6) and culture filtrate protein 10 (CFP-10) (19). Antigen-stimulated IFN-{gamma} production is an often-used correlate of protective immunity to M. tuberculosis infection (20), and this assay therefore served as a second indicator of the acquired host response. We also determined 25(OH)D concentrations in serum of all subjects at baseline and follow-up, and in BCG-lux assay supernatants of a randomly selected subgroup of participants allocated to the area of the study.

Some of the results of this study have been previously reported in the form of an abstract (21).


   METHODS
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 ABSTRACT
 AT A GLANCE COMMENTARY
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Participants
Study participants were recruited from TB contact clinics at Newham and Northwick Park Hospitals, London, United Kingdom. All people over 17 years of age who had been exposed to a patient with active TB were assessed. Individuals were excluded if they had symptoms, clinical signs, or radiographic evidence of active TB; if they had HIV infection, renal failure, sarcoidosis, or hyperparathyroidism; if they were taking corticosteroids, thiazide diuretics, or supplementary vitamin D (either alone or as part of a multivitamin preparation); or if they were breastfeeding or pregnant. Sociodemographic and dietary details were recorded on case report forms. Participants self-classified ethnicity into one of the following five categories (22): black African, South Asian, white, mixed, or other. A blood sample was drawn for baseline assays, a tuberculin skin test was performed according to national guidelines (23), and a urine sample was collected from women of childbearing age for pregnancy testing. TB contacts were reviewed at 1 week, and the grade of the tuberculin reaction was recorded. The study nurse then allocated a study ID number to eligible participants, and administered study medication from a container labeled with that number. These containers had previously been filled with either a single oral dose of 2.5 mg ergocalciferol or lactose placebo of identical appearance, according to a computer-generated sequence of random numbers in blocks of 10. Participants were reviewed at 6 weeks postrandomization, when a second blood sample was drawn for follow-up assays. The study research nurse and all participants and individuals performing laboratory assays were blinded to allocation. The study was approved by the research ethics committees of North East London and Harrow (REC refs. P/02/146 and EC 2759, respectively), and written, informed consent to participate was obtained from all participants.

Whole Blood Assays
The primary outcome measure was BCG-lux assay luminescence ratio. This assay has been described elsewhere (15). Briefly, M. bovis–BCG transformed with a replicating vector containing the luciferase (lux) gene of Vibrio harveyi was prepared as previously described (16). Frozen aliquots of BCG-lux bacilli were grown to midlog phase in Middlebrook 7H9 broth supplemented with 10% albumin dextrose catalase enrichment (BD; Franklin Lakes, NJ) and 15 µg/ml hygromycin (Roche, Lewes, UK). Triplicate samples of 0.5 ml venous blood of each participant diluted with an equal volume of RPMI 1640/2 mM glutamine/25 mM HEPES (N-2-hydoxyethylpiperazine-N'-ethane sulfonic acid) buffer (Sigma, Poole, UK) were infected with 3 x 105 cfu of log-phase bacilli corresponding to a multiplicity of infection (mononuclear phagocyte to bacillus) of approximately 1:1 and incubated at 37°C on a rocking platform. Mycobacterial luminescence was measured after harvesting of assay supernatants in triplicate samples at baseline and 24 and 96 hours, and a luminescence ratio was calculated by division of the 24- or 96-hour luminescence value by the baseline value.

The IFNGRA used in this study has also been described elsewhere (19). Triplicate samples of venous blood diluted 1:10 with RPMI 1640 (Sigma) were cultured with 2.5 µg/ml recombinant ESAT-6 (24), 5 µg/ml CFP-10 (Lionex, Braunschweig, Germany), or no stimulus at 37°C in 5% CO2. Supernatants were aspirated at 96 hours for determination of IFN-{gamma} concentration by ELISA using an antibody pair from BD (assay sensitivity < 10 pg/ml).

Determination of 25(OH)D Concentration
Concentrations of 25(OH)D2 and 25(OH)D3 were determined by isotope-dilution liquid chromatography–tandem mass spectrometry (25) and summed to give values for total 25(OH)D. Assays were performed in a clinical biochemistry laboratory that participates in the international Vitamin D External Quality Assessment Program (http://www.deqas.org/). Positive standards of known concentration were run for both 25(OH)D2 and 25(OH)D3. Total 25(OH)D was determined in serum of all participants and in BCG-lux assay supernatants of a randomly selected subgroup of 32 participants allocated to the intervention arm of the trial.

Statistical Analysis
We calculated that 198 participants would need to be recruited to detect a 20% difference in luminescence ratio between intervention and control groups with 80% power at the 5% significance level. Analysis of potential correlates of vitamin D deficiency was conducted using {chi}2 tests for univariate analysis and binary logistic regression analysis for multivariate analysis. Effect of allocation on whole blood assay outcomes was evaluated using analysis of covariance. Mean concentrations of 25(OH)D pre- versus postsupplementation were compared with paired t tests. We analyzed data using SPSS (version 12.0.1, 2003; SPSS, Inc., Chicago, IL) and GraphPad Prism (version 4.03, 2005; GraphPad, Inc., San Diego, CA) software packages.


   RESULTS
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 RESULTS
DISCUSSION
 REFERENCES
 
We assessed 364 TB contacts for eligibility between December 16, 2002, and January 31, 2005; 39 were ineligible, and 133 declined randomization (Figure 1). The group of 133 TB contacts who declined randomization had similar sex ratio, age range, and ethnic composition to the 192 participants who were randomized to receive vitamin D or placebo. All received the intended treatment; 43 participants (22 in the placebo group and 21 in the intervention group) were lost to follow-up, and a further 18 (10 in the placebo group and 8 in the intervention group) were excluded from the analysis in the absence of a valid BCG-lux assay result at either baseline or follow-up. Analysis of primary outcome was conducted on the remaining 131 participants, of whom 64 received placebo and 67 received vitamin D.


Figure 1
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  		Figure 1. Study recruitment profile. *Concentrations of 25-hydroxyvitamin D were determined in BCG-lux assay supernatants performed at baseline and follow-up in a randomly selected subset of 32 participants allocated to the intervention arm of the study.

 
Baseline characteristics of these 131 participants are compared in Table 1. Control and intervention groups did not differ significantly with respect to age, sex ratio, ethnic composition, BCG immunization rate, tuberculin reactivity, nature of TB exposure, vitamin D status, BCG-lux assay luminescence ratios, or ESAT-6–stimulated IFN-{gamma} concentration. The median CFP-10–stimulated IFN-{gamma} concentration at baseline was higher in the placebo group than in the intervention group (median, 40 vs. 0 pg/ml; p = 0.03).


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  		TABLE 1. BASELINE CHARACTERISTICS OF RANDOMIZED PARTICIPANTS INCLUDED IN ANALYSIS (n = 131)

 
At follow-up, the mean 24-hour luminescence ratio was 20.4% lower for individuals allocated to vitamin D compared with those allocated to placebo (0.57 vs. 0.71 respectively; 95% confidence interval [CI] for difference, 0.01 to 0.25; p = 0.03; Figure 2). Mean 96-hour luminescence ratio at follow-up was not significantly different for individuals allocated to vitamin D compared with those allocated to placebo (1.34 vs. 1.30, respectively; 95% CI for difference, –0.27 to 0.25; p = 0.94). The median antigen-stimulated whole blood IFN-{gamma} secretion at follow-up was not significantly different for individuals allocated to vitamin D compared with those allocated to placebo (for ESAT-6: 88 vs. 54 pg/ml, respectively; p = 0.13; for CFP-10: 45 vs. 26 pg/ml; p = 0.23).


Figure 2
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  		Figure 2. Influence of vitamin D supplementation on BCG-lux assay luminescence ratio. Mean BCG-lux assay 24-hour luminescence ratio at follow-up was 20% lower for individuals allocated to vitamin D compared with those allocated to placebo (0.57 vs. 0.71, respectively; 95% confidence interval for difference, 0.01 to 0.25; p = 0.03).

 
Baseline serum 25(OH)D concentrations were determined for all 192 randomized participants plus an additional 10 TB contacts who gave a baseline blood sample but subsequently declined randomization (n = 9) or were found to be ineligible for randomization (n = 1) (Figure 1). Of these 202 TB contacts, 84 (42%) were vitamin D deficient (serum 25[OH]D < 20 nmol/L) (26) and 189 (94%) were vitamin D insufficient (serum 25[OH]D < 75 nmol/L) (27) at baseline. Vitamin D deficiency was associated with black African and South Asian ethnicity, lack of fish in the diet, and enrollment from November to April on univariate analysis (Table 2). Multivariate analysis revealed each of these factors to be independent correlates of risk of vitamin D deficiency (for black African ethnic origin: exp[B] [estimated odds ratio] = 0.16; 95% CI, 0.04 to 0.67; p = 0.01; for South Asian ethnic origin: exp[B] = 0.20; 95% CI, 0.06 to 0.73; p = 0.02; for absence of fish in the diet: exp[B] = 0.42; 95% CI, 0.22 to 0.84; p = 0.01; for enrollment from November to April: exp[B] = 0.45; 95% CI, 0.24 to 0.84; p = 0.01).


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  		TABLE 2. CORRELATES OF VITAMIN D STATUS IN LONDON TUBERCULOSIS CONTACTS (n = 202)

 
Among randomized participants, administration of a single oral dose of 2.5 mg vitamin D induced a 91% increase in mean serum 25(OH)D (mean 25[OH]D pre- vs. postsupplementation, 35.2 vs. 67.4 nmol/L; 95% CI for difference, 26.3 to 38.7 nmol/l; p < 0.0001; Figure 3A) and corrected deficiency in all 23 participants in the intervention arm with baseline serum 25(OH)D < 20 nmol/L. No study participant experienced hypercalcemia or any other adverse event.


Figure 3
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  		Figure 3. Influence of vitamin D supplementation on serum and BCG-lux assay supernatant 25-hydroxyvitamin D (25[OH]D) concentrations A single oral dose of 2.5 mg vitamin D induced a 91% increase in mean serum 25(OH)D (mean 25(OH)D pre- vs. postsupplementation, 35.2 vs. 67.4 nmol/L; 95% confidence interval [CI] for difference, 26.3 to 38.7 nmol/L; p < 0.0001) and corrected deficiency in 23 of 23 participants with baseline 25(OH)D < 20 nmol/L allocated to the intervention arm of the trial (A). In a randomly selected subset of 32 participants allocated to the intervention arm of the trial, vitamin D supplementation induced a 95% increase in mean 24-hour BCG-lux assay supernatant 25(OH)D concentration (pre- vs. postsupplementation, 7.3 vs. 14.2 nmol/L; 95% CI for difference, 4.9 to 8.8 nmol/L; p < 0.0001) (B) and a 123% increase in mean 96-hour BCG-lux assay supernatant 25(OH)D concentration (pre- vs. postsupplementation, 6.5 vs. 14.5 nmol/L; 95% CI for difference, 5.4 to 11.8 nmol/L; p < 0.0001) (C).

 
Concentrations of 25(OH)D were also determined in BCG-lux assay supernatants performed at baseline and follow-up in a randomly selected subset of 32 participants allocated to the intervention arm of the study. Vitamin D supplementation induced a 95% increase in mean 24-hour supernatant 25(OH)D concentration (pre- vs. postsupplementation, 7.3 vs. 14.2 nmol/L; 95% CI for difference, 4.9 to 8.8 nmol/l; p < 0.0001; Figure 3B) and a 123% increase in mean 96-hour supernatant 25(OH)D concentration (pre- vs. postsupplementation, 6.5 vs. 14.5 nmol/L; 95% CI for difference, 5.4 to 11.8 nmol/L; p < 0.0001; Figure 3C).


   DISCUSSION
TOP
 ABSTRACT
 AT A GLANCE COMMENTARY
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
We have shown that a single oral dose of 2.5 mg vitamin D enhanced the ability of TB contacts' whole blood to restrict BCG-lux luminescence in vitro without affecting antigen-stimulated IFN-{gamma} responses. Profound vitamin D deficiency was found in more than 40% of this cohort, and was independently associated with absence of fish in the diet, South Asian and black African ethnic origin, and sampling in winter or spring. Supplementation induced a 91% increase in mean serum 25(OH)D concentration and corrected deficiency in all individuals with baseline 25(OH)D < 20 nmol/L for at least 6 weeks without inducing hypercalcemia in any participant.

Interestingly, vitamin D supplementation suppressed BCG-lux bioluminescence at the 24-hour time point, but did not affect BCG-lux bioluminescence or whole blood antigen-stimulated IFN-{gamma} secretion at the 96-hour time point. Given that innate immune responses are mobilized more rapidly than acquired immune responses, 24- and 96-hour outcomes may be interpreted as indicators of innate and acquired responses, respectively. Our findings may therefore indicate that vitamin D supplementation primarily enhances innate responses to mycobacterial infection. This interpretation is in keeping with a recent report that 25(OH)D supports induction of innate antimycobacterial immune responses (14). An alternative potential explanation, given the borderline statistical significance of the effect of vitamin D supplementation on 24-hour luminescence ratio (p = 0.03), is that this result arose by chance. If, however, the effect is real, previous studies validating the assay (17, 18) suggest that suppression of BCG bioluminescence reflects a clinically meaningful enhancement of global antimycobacterial host response.

A large proportion of TB contacts assessed for eligibility declined randomization (Figure 1); however, the fact that this group did not differ significantly from participants in terms of median age, sex ratio, or ethnic composition suggests that the external validity of this study is unlikely to have been severely compromised by its low recruitment rate. The significant numbers of participants who were lost to follow-up or excluded from the analysis also represent a weakness of the study, primarily by increasing the potential for type II error.

The very high rates of profound vitamin D deficiency that we report in this group of otherwise healthy adults are higher than those documented in the institutionalized elderly (28) and are a cause for grave public health concern, given emerging evidence implicating vitamin D deficiency in the pathogenesis of a wide range of chronic diseases (29). The observation that black African and South Asian ethnicity are risk factors for vitamin D deficiency independently of diet may be explained by the effect of increased skin pigmentation in reducing cutaneous vitamin D synthesis (30); however, this possibility cannot be evaluated in the absence of data on participants' skin pigmentation. Our finding that a single oral dose of 2.5 mg vitamin D corrects profound vitamin D deficiency for at least 6 weeks without causing hypercalcemia underlines the potential use of this formulation as a safe, effective, and cheap ($1.20) public health intervention.

In conclusion, we have demonstrated that a single oral dose of vitamin D enhances TB contacts' immunity to mycobacteria. Prospective trials to determine the effect of vitamin D supplementation on TB incidence rates should be performed in deficient populations with high rates of latent TB infection.


   Acknowledgments
 
The authors thank Dr. Barbara Boucher for helpful discussions and review of the manuscript.


   FOOTNOTES
 
Supported by the Wellcome Trust (Refs. 064261, 066321, 072070, and 077273), the Department of Environmental Health, London Borough of Newham, Newham University Hospital NHS Trust Research Fund, and Northwick Park Hospital Tropical Research Fund. A.R.M. is supported by the British Lung Foundation.

* These authors contributed equally to this work. Back

Originally Published in Press as DOI: 10.1164/rccm.200701-007OC on April 26, 2007

Conflict of Interest Statement: None of the authors has a financial relationship with a commercial entity that has an interest in the subject of this manuscript.

Received in original form January 2, 2007; accepted in final form April 26, 2007


   REFERENCES
TOP
 ABSTRACT
 AT A GLANCE COMMENTARY
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Dye C. Global epidemiology of tuberculosis. Lancet 2006;367:938–940.[CrossRef][Medline]
  2. Dye C, Scheele S, Dolin P, Pathania V, Raviglione MC. Global burden of tuberculosis: estimated incidence, prevalence, and mortality by country [consensus statement]. WHO Global Surveillance and Monitoring Project. JAMA 1999;282:677–686.[Abstract/Free Full Text]
  3. Martineau AR, Honecker F, Wilkinson RJ, Griffiths CJ. Vitamin D in the treatment of pulmonary tuberculosis. J Steroid Biochem Mol Biol 2007;103:793–798.[CrossRef][Medline]
  4. Strachan DP, Powell KJ, Thaker A, Millard FJ, Maxwell JD. Vegetarian diet as a risk factor for tuberculosis in immigrant south London Asians. Thorax 1995;50:175–180.[Abstract]
  5. Wilkinson RJ, Llewelyn M, Toossi Z, Patel P, Pasvol G, Lalvani A, Wright D, Latif M, Davidson RN. Influence of vitamin D deficiency and vitamin D receptor polymorphisms on tuberculosis among Gujarati Asians in west London: a case-control study. Lancet 2000;355:618–621.[CrossRef][Medline]
  6. Institute of Medicine. Dietary reference intakes for calcium, magnesium, phosphorus, vitamin D, and fluoride. Washington, DC: National Academy Press; 1997.
  7. Lips P. Vitamin D physiology. Prog Biophys Mol Biol 2006;92:4–8.[CrossRef][Medline]
  8. Rook GA, Steele J, Fraher L, Barker S, Karmali R, O'Riordan J, Stanford J. Vitamin D3, gamma interferon, and control of proliferation of Mycobacterium tuberculosis by human monocytes. Immunology 1986;57:159–163.[Medline]
  9. Crowle AJ, Ross EJ, May MH. Inhibition by 1,25(OH)2-vitamin D3 of the multiplication of virulent tubercle bacilli in cultured human macrophages. Infect Immun 1987;55:2945–2950.[Abstract/Free Full Text]
  10. Sly LM, Lopez M, Nauseef WM, Reiner NE. 1alpha, 25-dihydroxyvitamin D3-induced monocyte antimycobacterial activity is regulated by phosphatidylinositol 3-kinase and mediated by the NADPH-dependent phagocyte oxidase. J Biol Chem 2001;276:35482–35493.[Abstract/Free Full Text]
  11. Hmama Z, Sendide K, Talal A, Garcia R, Dobos K, Reiner NE. Quantitative analysis of phagolysosome fusion in intact cells: inhibition by mycobacterial lipoarabinomannan and rescue by an 1alpha,25-dihydroxyvitamin D3-phosphoinositide 3-kinase pathway. J Cell Sci 2004;117:2131–2140.[Abstract/Free Full Text]
  12. Norman AW, Mizwicki MT, Norman DP. Steroid-hormone rapid actions, membrane receptors and a conformational ensemble model. Nat Rev Drug Discov 2004;3:27–41.[CrossRef][Medline]
  13. Rockett KA, Brookes R, Udalova I, Vidal V, Hill AV, Kwiatkowski D. 1,25-dihydroxyvitamin D3 induces nitric oxide synthase and suppresses growth of mycobacterium tuberculosis in a human macrophage-like cell line. Infect Immun 1998;66:5314–5321.[Abstract/Free Full Text]
  14. Liu PT, Stenger S, Li H, Wenzel L, Tan BH, Krutzik S, Ochoa MT, Scauber J, Wu K, Meinken C, et al. Toll-like receptor triggering of a vitamin D-mediated human antimicrobial response. Science 2006;311:1770–1773.[Abstract/Free Full Text]
  15. Kampmann B, Gaora PO, Snewin VA, Gares MP, Young DB, Levin M. Evaluation of human antimycobacterial immunity using recombinant reporter mycobacteria. J Infect Dis 2000;182:895–901.[CrossRef][Medline]
  16. Snewin VA, Gares MP, Gaora PO, Hasan Z, Brown IN, Young DB. Assessment of immunity to mycobacterial infection with luciferase reporter constructs. Infect Immun 1999;67:4586–4593.[Abstract/Free Full Text]
  17. Tena GN, Young DB, Eley B, Henderson H, Nicol MP, Levin M, Kampmann B. Failure to control growth of mycobacteria in blood from children infected with human immunodeficiency virus and its relationship to T cell function. J Infect Dis 2003;187:1544–1551.[CrossRef][Medline]
  18. Kampmann B, Tena-Coki GN, Nicol MP, Eley B. Reconstitution of antimycobacterial immune responses in HIV-infected children receiving HAART. AIDS 2006;20:1011–1018.[Medline]
  19. Scholvinck E, Wilkinson KA, Whelan AO, Martineau AR, Levin M, Wilkinson RJ. Gamma interferon-based immunodiagnosis of tuberculosis: comparison between whole-blood and immunospot methods. J Clin Microbiol 2004;42:829–831.[Abstract/Free Full Text]
  20. Ellner JJ, Hirsch CS, Whalen CC. Correlates of protective immunity to mycobacterium tuberculosis in humans. Clin Infect Dis 2000;30:S279–S282.[CrossRef][Medline]
  21. Martineau AR, Hall BM, Maunsell ZJ, Newton SM, Davidson RN, Packe GE, Eldridge S, Wilkinson RJ, Griffiths CJ. Vitamin D induces antimycobacterial immunity in vivo and in vitro. Thorax 2005;60:ii43.
  22. Office for National Statistics. Ethnic group statistics: a guide for the collection and classification of ethnicity data. London: HMSO; 2003.
  23. British Thoracic Society. Control and prevention of tuberculosis in the UK: code of practice 2000. Thorax 2000;55:887–901.[Abstract/Free Full Text]
  24. Rhodes SG, Gavier-Widen D, Buddle BM, Whelan AO, Singh M, Hewinson RG, Vordermeier HM. Antigen specificity in experimental bovine tuberculosis. Infect Immun 2000;68:2573–2578.[Abstract/Free Full Text]
  25. Maunsell Z, Wright DJ, Rainbow SJ. Routine isotope-dilution liquid chromatography–tandem mass spectrometry assay for simultaneous measurement of the 25-hydroxy metabolites of vitamins D2 and D3. Clin Chem 2005;51:1683–1690.[Abstract/Free Full Text]
  26. Compston JE. Vitamin D deficiency: time for action: evidence supports routine supplementation for elderly people and others at risk. BMJ 1998;317:1466–1467.[Free Full Text]
  27. Dawson-Hughes B, Heaney RP, Holick MF, Lips P, Meunier PJ, Vieth R. Estimates of optimal vitamin D status. Osteoporos Int 2005;16:713–716.[CrossRef][Medline]
  28. Liu BA, Gordon M, Labranche JM, Murray TM, Vieth R, Shear NH. Seasonal prevalence of vitamin D deficiency in institutionalized older adults. J Am Geriatr Soc 1997;45:598–603.[Medline]
  29. Holick MF. High prevalence of vitamin D inadequacy and implications for health. Mayo Clin Proc 2006;81:353–373.[Medline]
  30. Clemens TL, Adams JS, Henderson SL, Holick MF. Increased skin pigment reduces the capacity of skin to synthesise vitamin D3. Lancet 1982;1:74–76.[CrossRef][Medline]



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[Abstract] [Full Text] [PDF]

Home page
 J. Nutr.Home page
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The Bioavailability of Vitamin D from Fortified Cheeses and Supplements Is Equivalent in Adults
J. Nutr., July 1, 2008; 138(7): 1365 - 1371.
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 PediatricsHome page
J. M. Mansbach and C. A. Camargo Jr
Bronchiolitis: Lingering Questions About Its Definition and the Potential Role of Vitamin D
Pediatrics, July 1, 2008; 122(1): 177 - 179.
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A. R. Martineau, R. J. Wilkinson, and C. J. Griffiths
Vitamin D and Tuberculosis Incidence in Spain
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E. Perez-Trallero, G. Cilla, A. Garcia-Zamalloa, and P. Idigoras
Vitamin D and Tuberculosis Incidence in Spain
Am. J. Respir. Crit. Care Med., April 1, 2008; 177(7): 798 - 798.
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 FASEB J.Home page
J. C. McCann and B. N. Ames
Is there convincing biological or behavioral evidence linking vitamin D deficiency to brain dysfunction?
FASEB J, April 1, 2008; 22(4): 982 - 1001.
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W. W. Yew and C. C. Leung
Update in Tuberculosis 2007
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[Full Text] [PDF]

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 Int J EpidemiolHome page
K. E Nnoaham and A. Clarke
Low serum vitamin D levels and tuberculosis: a systematic review and meta-analysis
Int. J. Epidemiol., February 1, 2008; 37(1): 113 - 119.
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M. Zasloff
Antimicrobial Peptides, Innate Immunity, and the Normally Sterile Urinary Tract
J. Am. Soc. Nephrol., November 1, 2007; 18(11): 2810 - 2816.
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