Vitamin D as Supplementary Treatment for Tuberculosis
A Double-blind, Randomized, Placebo-controlled Trial
Christian Wejse1,2, Victor F. Gomes1, Paulo Rabna1, Per Gustafson1,3, Peter Aaby1, Ida M. Lisse4,
Paul L. Andersen2, Henning Glerup5, and Morten Sodemann1,6
1Bandim Health Project, INDEPTH Network, Statens Serum Institute, Bissau, Guinea-Bissau;2Infectious Disease Research Unit, Aarhus University
Hospital, Skejby, Denmark;3Infectious Diseases Research Group, Department of Clinical Sciences, Lund University, Malmo ¨, Sweden;4Department of
Pathology, Herlev University Hospital, Copenhagen, Denmark;5Department of Internal Medicine, Aarhus University Hospital, Silkeborg, Denmark;
and6Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
Rationale: Vitamin D has been shown to be involved in the host
immune response toward Mycobacterium tuberculosis.
Objectives: To test whether vitamin D supplementation of patients
with tuberculosis (TB) improved clinical outcome and reduced
Methods: We conducted a randomized, double-blind, placebo-
controlled trial in TB clinics at a demographic surveillance site in
Guinea-Bissau. We included 365 adult patients with TB starting
antituberculosis treatment; 281 completed the 12-month follow-
up. The intervention was 100,000 IU of cholecalciferol or placebo at
inclusion and again 5 and 8 months after the start of treatment.
Measurements and Main Results: The primary outcome was reduction
in a clinical severity score (TBscore) for all patients with pulmonary
TB. The secondary outcome was 12-month mortality. No serious
adverse effects were reported; mild hypercalcemia was rare and
present in both arms. Reduction in TBscore and sputum smear
conversion rates did not differ among patients treated with vitamin
D or placebo. Overall mortality was 15% (54 of 365) at 1 year of
follow-up and similar in both arms (30 of 187 for vitamin D treated
and 24 of 178 for placebo; relative risk, 1.19 [0.58–1.95]). HIV
infection was seen in 36% (131 of 359): 21% (76 of 359) HIV-1,
10% (36 of 359) HIV-2, and 5% (19 of 357) HIV-112.
Conclusions: Vitamin D does not improve clinical outcome among
patients with TB; it is possible that the dose used was insufficient.
Clinical trial registered with www.controlled-trials.com/isrctn
Keywords: vitamin D; tuberculosis; randomized clinical trial; clinical
Vitamin D was used for treatment of tuberculosis (TB) in the
preantibiotic era (1–3) and before then cod liver oil, rich in
vitamin D, was used as well as sun exposure (4). Vitamin D has
found evidence of an association with vitamin D deficiency
(VDD) and active tuberculosis (7–10). Vitamin D is a low-cost
intervention that is easy to administer in resource-poor settings,
and has been suggested as prophylaxis in TB household contacts
mechanism of vitamin D–mediated effect on TB treatment
antimycobacterial activity in macrophages in vitro, to upregulate
protective innate host responses, and to trigger antimicrobial
peptides such as cathelicidin (5). No data are available on dose-
dependent effects of vitamin D on mycobacterial activity, but it
has been speculated that pharmacologic doses of vitamin D may
elevate serum 25-hydroxyvitamin D [25(OH)D] concentrations
to levels saturating the ability of vitamin D–binding protein to
bind vitamin D metabolites, leading to an increase in biological
availability of 1,25-dihydroxyvitamin D in infected tissues (13).
Two small randomized studies (14, 15) have suggested beneficial
effects on weight gain and time to sputum conversion without an
initial screening for VDD. One review concluded there is
evidence that vitamin D modulates antimycobacterial immunity
and called for double-blind, randomized, placebo-controlled
trials in patients with active TB (13).
We aimed to test whether vitamin D supplementation could
patients with TB. Vitamin A is known to be a beneficial in-
tervention to children irrespective of vitamin A status (16), and
therefore we hypothesized that vitamin D, regardless of initial
vitamin D status, would improve immunologic capacities against
M. tuberculosis. We report the findings from a community-based
trial (the VDTB Trial) testing vitamin D supplementation for
Centennial Conference in London, September 2007 (17).
AT A GLANCE COMMENTARY
Scientific Knowledge on the Subject
Vitamin D insufficiency is associated with impaired immune
function and increased risk of active tuberculosis (TB).
Vitamin D has been used in the preantibiotic era in the
treatment of TB. It has also been suggested as a supplemen-
tary/prophylactic treatment for TB, but only two small trials
have assessed this.
What This Study Adds to the Field
Vitamin D can be given safely to patients with TB. Our
study suggests no overall effect on clinical outcome or
mortality with the doses used. The study raises the question
of whether vitamin D has a differential effect depending on
(Received in original form April 16, 2008; accepted in final form January 23, 2009)
Supported by Aarhus University Hospital (Ph.D. scholarship); the Danish Research
Council for Developmental Research; the SSAC; and the Skejby Hospital, Segel,
and Beckett Foundations. The funding sources and the provider of cholecalciferol
had no role in study design, data collection, data analysis, data interpretation, or
writing of the report. The principal investigator (corresponding author) had full
access to all the data and had final responsibility for the decision to submit for
Correspondence and requests for reprints should be addressed to Christian
Wejse, M.D., Ph.D., Infectious Disease Research Unit, Aarhus University Hospital,
Skejby, Brendstrupgaardsvej, 8200 Aarhus N, Denmark. E-mail: wejse@
Am J Respir Crit Care Med
Originally Published in Press as DOI: 10.1164/rccm.200804-567OC on January 29, 2009
Internet address: www.atsjournals.org
Vol 179. pp 843–850, 2009
The Bandim Health Project, a disease surveillance site located in
Guinea-Bissau, West Africa. A poor, urban population of 92,000 is
under continued epidemiologic surveillance, and we have previously
reported a high TB incidence of 470 per 100,000 in this area (18).
We conducted a randomized, double-blind, placebo-controlled trial.
Trial inclusion criteria included either a diagnosis of TB by sputum
examination (smear microscopy; no culture was available) or by World
Health Organization(WHO,Geneva, Switzerland)clinical criteria (19),
age 15 years or more, and residence in the study area. There were no
Field assistants daily identified new patients with TB initiating tubercu-
losis chemotherapy at the three health centers and at the national TB
hospital situated in the study area, inviting patients to be included in the
trial the next day. All received antituberculosis treatment consisting of
rifampicin (R) and pyrazinamide (Z) followed by 6 months of H1E
collected by the patient twice per month. Adherence to daily observed
referred to sputum examinations after 2, 4, and 6 weeks of treatment in
addition to the regular sputum examinations provided by the national
tuberculosis program at 2, 5, and 8 months of treatment.
Patients were randomized to either 100,000 IU of cholecalciferol or
identical placebo ampoules at inclusion. Cholecalciferol and placebo
(vegetable oil without cholecalciferol) were given in ampoules with
ciferol or placebo, and this was repeated 5 and 8 months after inclusion.
Hence patients completing treatment received in total 300,000 IU of
dosage and time points was a concern that vitamin D might induce hy-
seen at 2 months; instead, samples were collected for calcium measure-
ment and hypercalcemia was assessed at the first interim analysis. We
substantial pill burden on the patients and because it was a simple
intervention applicable to low-resource settings. A single large dose has
been shown as effective as daily administration, and the half-life is
2 months (20). The dosage was known to be efficient for treatment of
vitamin D deficiency and also safe to give with no deficiency present and
even in pregnancy (21).
Patients were invited to clinical examinations after 2, 5, and 8 months
of treatment, followed by a household visit 12 months after initiation of
treatment, or until death or moving out of the study area.
The random allocation sequence was computer generated; a list of
continuous study numbers was generated with a random allocation to
treatment 1 or 2. Study numbers were consecutive and given to patients
by the field assistant at inclusion, and patients were recorded in a book
with prewritten study numbers and allocation sequence numbers 1 or 2.
Study medicine was provided in identical containers labeled lot 204
A physician gave the trial information, obtained patient’s consent, and
conducted the clinical examination; a trial nurse administered study
medicine according to sequence number.
Patients, staff, and researchers assessing outcome were blinded. Trial
medicine was available in two lots and for logistical reasons it was not
concealed whether a patient was on lot 1 or lot 2 during the trial.
Blinding was not assessed among patients, but we assessed blinding
among 10 field assistants and investigators through tasting both lots.
Five voted in favor of lot 204 being vitamin D, five voted in favor of lot
205. The randomization code was broken by the primary investigator in
December 2006 on completion of data analysis.
We questioned the patients for the following adverse effects related to
kidney stones, and confusion. We measured calcium concentrations in
treatment. After the first interim analysis of calcium concentrations in
control samples taken at 2 months, we proceeded to give vitamin D at 5
and 8 months.
To determine the body mass index, we used the following formula: body
mass index 5 weight/(height)2. Height was measured with a meter scale;
weight was measured in kilograms, using the same weight scale at each
patient visit. Mid–upper arm circumference was measured at the mid-
point between the acromion and olecranon over the biceps of the non-
UK) to the nearest 0.2 cm (22).
Severity of TB disease was assessed by the TBscore, which counts
has been validated in another cohort and has been grouped in severity
but there was a high frequency of HIV-2-infected patients as shown in
2–infected than HIV-1–infected individuals (24, 25), HIV-2 patients
were more comparable to HIV-1 patients than to uninfected patients:
79% (22 of 28) of HIV-2 patients had a CD41T-lymphocyte count less
than 500 cells/ml and 12-month mortality was 17% (6 of 36).
We measured serum 25-hydroxy metabolites of vitamins D2and D3
[25(OH)D213] simultaneously by isotope-dilution liquid chromatography–
tandem mass spectrometry on an API 3000 mass spectrometer (Ap-
plied Biosystems, Foster City, CA), according to a method adapted
from Maunsell and colleagues (26). The inter- and intraassay coefficients
of variation were 9.4 and 9.7%. We defined VDD as serum 25(OH)D3
not exceeding 50 nmol/L and vitamin D insufficiency (VDI) as 25(OH)D3
not exceeding 75 nmol/L, according to Vieth (27).
Serum calcium and albumin were measured by absorbance (COBAS
Integra; Roche Diagnostics, Mannheim, Germany). We corrected total
serum calcium for individual variations in albumin by the following
equation: adjusted serum calcium (mmol/L) 5 serum calcium total
(mmol/L) 3 0.00086 3 (650 2 serum albumin [mmol/L]).
Laboratory, Bissau, by flow cytometry (FACStrak; Becton Dickinson,
San Jose, CA) with the use of three two-color immunofluorescence
reagents, CD45/CD14, CD3/CD4, and CD3/CD8 (Simultest; Becton
Dickinson). Leukocyte and differential counts were performed manually.
counts were available only from 276 patients at inclusion and from 187
patients at 8 months.
investigatedwhether vitaminD increasedserum calciumconcentrations
significantly. A significant change in serum calcium was defined as
albumin-corrected serum calcium increasing to a concentration greater
than 2.75 mmol/L in a patient with no hypercalcemia before vitamin D
supplementation. Estimating no hypercalcemia before vitamin D sup-
plementation and hypercalcemia in 15% afterward, 60 patients in each
and a 5% significance level.
For vitamin D supplementation we used the clinical end point of
weight increase and mortality for sample size assessment; the primary
calculation, but weight was known to be a major component. We
estimated that a weight increase of more than 10% would be seen for
70% of the patients, and with intervention 80–85% (relative risk,
844 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINEVOL 1792009
a power of 80% and a 5% significance level. For the mortality outcome
we stipulated case fatality to be 27% (24), and relative risk after
intervention to be 0.6, demanding a sample size of 286 patients in each
arm. We estimated enrollment of 300 patients per year, and the planned
and funded inclusion period was 2 years, but the incidence estimates we
had based this on proved to be too high. After 2 years we had enrolled
only 365 patients and the interim analysis showed no difference in
mortality or any trends for any of the arms being superior, and hence we
decided not to prolong the trial.
The primary outcome was clinical improvement as assessed by TBscore
in clinical state in patients with TB. It is based on points assigned to signs
and symptoms, including cough, hemoptysis, dyspnea, chest pain, night
sweating, anemia, tachycardia, lung auscultation finding, fever, low body
from 0 to 13. Change in TBscore has been shown to detect clinical change
well; a high TBscore correlates well with mortality and low TBscores
correlate with favorable outcomes, cure, and completed treatment.
The secondary outcome was all-cause mortality at 12 months of
follow-up.A verbal autopsy wasconductedonall deaths,with a physician
using a standardized questionnaire to obtain information from the
nearest relative. No traumatic deaths were recorded; all died of causes
that may be related to TB or HIV.
We further assessed sputum conversion in smear-positive patients,
weight gain and changes in immunologic response by changes in CD41
T-lymphocyte count. The primary end point was available only for the
patients completing 8 months of treatment. Mortality was analyzed by
‘‘intention to treat,’’ that is, for all included patients regardless of number
of follow-ups and study drug treatments.
or range. The Pearson chi-square (x2) was used to assess statistical
differences in proportions between groups (P , 0.05); the Student t test
to assess differences in means between two groups when a normal
distribution was present; and the Wilcoxon rank-sum test when non-
parametric analysis was needed. Linear and logistic regression analyses
were used as multivariate models to adjust clinical outcomes for effects of
other factors. Cox regression and the Wilcoxon-Breslow-Gehan log-rank
test for equality of survivor functions were used to analyze mortality, and
Kaplan-Meier survival graphswereusedtoestimate the survivalfunction.
A two-sidedP , 0.05 was considered significantforthe primaryoutcome,
for mortality P , 0.03 was considered significant because of interim
P value 5 [(no.oftests 1 1)/(23 no.oftests)] 3 crudeP value, hencefor
exploratory subgroup analyses a P value of 0.03 were considered signifi-
cant. Therefore 97% confidence intervals were used in estimates in all
subgroup analysis. Statistical analyses were performed with STATA
version 9 software (StataCorp, College Station, TX).
A data and safety monitoring board was established to monitor the study.
Interim safety analyses were done at 5 and 16 months for calcium
concentrations and mortality, and were blinded to treatment group. No
clinical outcomes were analyzed, only safety;the predefined stoppingrule
was a difference in mortality between the two treatment arms at the 5%
Pretest and posttest counseling was provided for HIV testing; HIV-
infected patients with TB were referred for cotrimoxazole treatment,
social support and retesting at a nongovernmental organization volun-
tary counseling and testing center in Bissau. No antiretroviral treatment
was available in Bissau during the study period. Written informed
consent was obtained before enrollment. The study was permitted by
the Health Ministry of Guinea-Bissau and approved by the National
on Biomedical Research Ethics.
Recruitment began in November 2003 and ended in December
2005. Follow-up was completed in December 2006. Three hun-
dred and sixty-seven patients were enrolled and received study
drug at inclusion. Two patients were excluded as a revision of
chest X-rays showed no infiltrations, they were smear negative,
and therefore did not meet the WHO criteria for tuberculosis.
Hence 365 patients were analyzed by intention to treat. One
patient was mistaken for another patient and wrongly received
censored at that date. Two hundred and thirty-three patients
came for 8-month follow-up; 9 of these had not received the
second dose at 5 months but all were analyzed for the primary
outcome. Fifty-seven patients were monitored (found alive at
home visit) but were not seen at the final follow-up, 47 patients
died during the first 8 months, and 24 patients abandoned
treatment or transferred out (they were censored). The flow of
participants is outlined in Figure 1.
Baseline characteristics, including median age, body mass
index, type of TB, prevalence of HIV, baseline CD41T-lympho-
cyte (CD4) counts, baseline vitamin D concentrations, and TB
severity score were similar between the vitamin D supplementa-
tion and placebo groups (Table 1). Baseline characteristics for
from those with complete follow-up (data not shown).
The symptoms asked for as adverse effects were reported most
frequently at inclusion, at which time 103 of 365 reported any of
the symptoms before receiving the study drug. At 2 months only
24 reported any symptom, most frequently excessive thirst: 10 of
157 (6%) reporting adverseeffects in the vitamin Dgroup and 14
of 147 (9%) in the placebo group (P 5 0.31).
At 2 months of follow-up mean albumin-corrected serum
the reference range in the vitamin D group with an albumin-
corrected serum calcium of 2.93 mmol/L and two patients in the
placebo group with serum calcium at 2.92–3.02 mmol/L. At
8 months the mean serum calcium values were slightly higher
Changes in TBscore and time to clinical improvement (progres-
week, but sputum conversion rates were not different in the two
groups among the 247 initially smear-positive patients (data not
shown); smear positivity over time is presented in Figure 3.
We further analyzed weight gain and change in CD4 counts as
(70 of 124) gained more than 10% in weight, and in the placebo
Weight gain did not differ by HIV status (data not shown).
The mean CD4 count at 8 months was higher than at
inclusion, but did not differ in the two treatment arms. In the
vitamin D–treated group 97 patients had a mean CD4 count of
592 cells/ml (95% CI, 513–671) and in the placebo group
90 patients had a mean CD4 count of 635 cells/ml (95% CI,
556–714). Paired CD4 counts at both inclusion and 8 months
Wejse, Gomes, Rabna, et al.: Vitamin D TB Trial 845
were available from 133 patients. Among the 70 vitamin D–
treated patients there was a mean rise in CD4 count of 50 cells/ml
(95% CI, 257 to 158) and in the placebo group a mean fall of
7 cells/ml (95% CI, 2109 to 95). Results differed when stratified
by HIV status: Among 41 HIV-infected individuals the vitamin
D–treated patients had a fall in CD4 count of 3 cells/ml (95%
CI, 282 to 76) versus a mean rise of 19 cells/ml (95% CI, 278 to
117) in placebo-treated patients (P 5 0.71). In contrast, 92 HIV-
uninfected individuals had a mean rise in CD4 count of 78 cells/ml
(95% CI, 282 to 238) in the vitamin D–treated group and
a mean fall of 17 cells/ml (95% CI, 2153 to 120) in the placebo
group (P 5 0.37). However, this shift in change in CD4 count
was not significant (test of homogeneity, P 5 0.47).
The Secondary Outcome: Mortality
Fifty-four all-cause deaths were recorded during the 12-month
follow-up period, 30 of 187 (16%) in the vitamin D group and 24
of 178 (13%) in the placebo group (Table 2) (Kaplan-Meier
estimate shown in Figure 4, log-rank test P 5 0.45). In univariate
analyses, the only variables affecting the estimate were the
presence of VDI (increasing the hazard ratio [HZ] by 14%) and
HIV-1 infection (decreasing the HZ by 8%), and for HIV-1 we
noted a tendency for interaction (test of interaction, P 5 0.08).
When adjusting for both HIV-1 and VDI in a logistic regression
model, the estimate was only moderately increased, HZ 5 1.3
(95% CI, 0.7–2.3).
Stratified Analysis 1: Vitamin D Insufficiency
Because the effect of vitamin D supplementation may be seen
only among patients with vitamin D deficiency or insufficiency,
we assessed the outcomes in these two groups separately in an
exploratory, not prespecified, analysis. At treatment initiation,
mean TBscores differed according to vitamin D status, although
not significantly. The 181 patients with pulmonary TB with
Figure 1. Flowchart of partici-
846 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINEVOL 1792009
6.8) compared with 157 patients with pulmonary TB with VDI
having a mean TBscore of 6.8 (95% CI, 6.5–7.1), and the
29 patients with pulmonary TB with VDD had a mean TBscore
significantly by vitamin D status at treatment start. Among the
220 patients with pulmonary TB seen at 8 months with an initial
vitamin D measurement, the 117 with normal vitamin D status
had a mean TBscore of 0.7 (95% CI, 0.5–0.9) compared with 1.3
(95% CI, 1.0–1.6) among 103 patients with initial VDI. Among
these VDI patients, the TBscore was insignificantly lower at
8 months: among 55 vitamin D–treated the mean score was 1.1
(95% CI, 0.8–1.4) compared with 1.4 (95% CI, 1.0–1.9) among 48
placebo-treated (P 5 0.21).
For the secondary outcome, mortality, the crude mortality
ratio of 1.2 changed moderately when looking at the 163
patients with initial VDI, HZ 5 1.4 (95% CI, 0.5–3.7). But
when looking at the 30 patients with VDD, HZ for death among
vitamin D–treated patients was 0.7 (95% CI, 0.1–6.4). Adjusting
for HIV and background factors did not change these estimates.
Stratified Analysis 2: The Role of HIV
Because HIV infection may modify the effect of health inter-
ventions, for example, vitamin A, we examined the impact of
vitamin D among both HIV-infected and HIV-uninfected indi-
viduals in an exploratory, not prespecified, analysis. As demon-
strated in Table 3, the data suggest a tendency after the first dose
HIV-uninfected patients treated with vitamin D and a more slow
decrease in HIV-infected patients treated with vitamin D,
TBscores being significantly different by HIV status in the
vitamin D–treated group (P 5 0.008) after 2 months of follow-
up but not in the placebo group (P 5 0.45). This pattern was
similar at 5 and 8 months with significant differences by HIV
status in the vitamin D–treated group, although TBscores at
inclusion did not differ significantly. Table 3 also shows a lower
TBscore at the end of treatment in the HIV-uninfected group;
however, this difference was not significant.
In addition, we analyzed whether mortality differed when
stratified for HIV status. Among the 131 HIV-infected patients,
12-month mortality was high, as shown in Table 2. In a Cox
regression model we examined mortality separately for both
HIV-1–infected patients and for all HIV-infected patients. HZ
estimates were not changed when looking at all HIV-infected
risk was not significantly higher in the vitamin D–treated arm,
HZ 5 1.8 (95% CI, 0.8–4.1) or significantly lower among the 228
HIV-uninfected patients, HZ 5 0.9 (95% CI, 0.3–2.8). This
TABLE 1. BASELINE CHARACTERISTICS AT ENROLLMENT
(n 5 187)
(n 5 178) Parameter
Age, years, mean (SD)
Extrapulmonary TB, no.
count, cells/ml (range)
, 200/ml, no. (%)
Weight, kg, mean (SD)
Mean BMI (range)
MUAC, cm, mean (range)
TBscore* (95% CI)
Distribution of severity class
No. with s-25(OH)D3
, 50 nmol/L (%)
No. with s-25(OH)D3
, 75 nmol/L (%)
calcium, mmol/L, mean (SD)
30/138 (22%)23/138 (17%)
86 (48%) 77 (45%)
2.03 (0.26) 2.03 (0.24)
Definition of abbreviations: BMI 5 body mass index; CI 5 confidence interval;
MUAC 5 mid–upper arm circumference; s-25(OH)D35 serum 25-hydroxyvitamin
D3; TB 5 tuberculosis; TBscore 5 clinical scoring system for tuberculosis.
Data are presented as number (%) unless otherwise stated.
* Only patients with pulmonary TB.
Figure 2. TBscore (clinical scoring system for tuberculosis) at various
time points for the two treatment arms.
Figure 3. Proportion of patients with positive acid-fast bacteria sputum
Wejse, Gomes, Rabna, et al.: Vitamin D TB Trial847
showed indications of effect modification of HIV on vitamin D
treatment (test of interaction, P 5 0.08). By adjusting for the
presence of VDI the mortality risk for HIV-1–infected individ-
uals was 2.4 (95% CI, 0.95–6.5).
Vitamin D Status at 2 and 8 Months
and 3 months after the first and second doses were given at in-
clusion and at 5 months. At 2 months 270 samples were available
rise was seen in serum 25(OH)D3concentrations, in 203 patients
with paired samples at inclusion, 2 months, and 8 months (Figure
(95% CI, 75–81) to 103 nmol/L (95% CI, 99–108) at 2 months of
follow-up and 98 nmol/L (95% CI, 94–102) at 8 months. The
increase was also present in the placebo group: Mean 25(OH)D3
increased to 105 nmol/L (95% CI, 99–110) in the treatment arm
and 103 nmol/L(95% CI, 96–110) in the placebo armat 2 months
and to 102 nmol/L (95% CI, 96–107) in the treatment arm and
95 nmol/L (95% CI, 89–102) in the placebo arm at 8 months.
Fractions of patients with VDD/VDI were not lower to at in-
clusion but were lower in the treatment arm at 2 and 8 months,
although not significantly different (data not shown); crude data
levels was noted among vitamin D–insufficient patients at baseline:
Patients with 25(OH)D3concentrations less than 75 nmol/L in-
creased from 60 nmol/L (95% CI, 57–63) to 102 nmol/L (95% CI,
(95% CI, 57–63) to only 95 nmol/L (95% CI, 85–106).
Vitamin D supplementation of patients with TB in Guinea-
Bissau did not result in serious adverse events, and we showed
no effect on the chosen outcomes in the entire group of patients.
The data show no significant differential effects of vitamin D
supplementation in either HIV-infected or vitamin D–insufficient
subjects. We may, however, speculate that there is a trend
toward positive effects for HIV-uninfected and vitamin D–
insufficient subjects and a trend toward higher mortality among
HIV-infected patients treated with vitamin D.
treatment although 53 of 273 (19%) had CD41T-lymphocyte
counts indicating a need for such treatment, which unfortunately
findings cannot be generalized to HIV-positive patients treated
with antiretroviral therapy.
with TB in the study area, but severe vitamin D deficiency was
rare. Our findings indicate a slightly beneficial effect among
patients with TB with low vitamin D, but the study was not
sufficiently powered or designed to determine this. Furthermore,
patients with TB will be routine in resource-poor settings. Our
whether vitamin D is of value for patients with TB in resource-
Our study addresses the controversy of hypercalcemia in
patients with TB (29). We found no evidence of TB-associated
in calcium concentrations during antituberculosis treatment
irrespective of vitamin D treatment arm. This observation is in
line with Fuss and colleagues, who did not find that vitamin D
supplementation of patients with TB resulted in hypercalcemia
(30). In 1969 Brincourt reported the result of repeated oral
supplementation with 15 mg (600,000 IU) of vitamin D2(3) as
supplementary treatment to antibiotics in 150 patients in a study
with no control group and noted an effect on dissolving cavities;
Brincourt observed no hypercalcemia.
have reported. However, they all used much higher dosages than
in this trial, and all of these studies were uncontrolled (31–33). In
modern times we know of only two small randomized trials
enrolling 24 children with TB in Egypt (15) and 67 adults in
Indonesia (14). They used oral vitamin D at 1,000 and 10,000 IU/
day, respectively, or placebo. They reported a more evident
clinical and radiographic improvement in the treated group in
Egypt (although not statistically significant), and improved
sputum conversion rates in the Indonesian study. These studies
were small and HIV status was not reported; however, it is
unlikely that these studies included many HIV-infected individ-
Figure 4. Kaplan-Meier plot of cumulative incidence proportion (1 –
survival) for the two groups.
TABLE 3. TBscore IN TREATMENT GROUPS BY TIME
AND HIV STATUS
Mean TBscore (NVitamin D/NPlacebo) Vitamin D (SD)Placebo (SD)P Value
* HIV infected (HIV-1 and HIV-2 and HIV-112 combined).
TABLE 2. MORTALITY BY HIV STATUS
InfectionVitamin D PlaceboMortality Ratio
HIV-1 and HIV-112 infected
HIV-2 only infected
HIV-1 and HIV-2 uninfected
HIV status unknown
848 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINEVOL 179 2009
uals. It is worth noting that the Indonesian study showed benefit
with a combined dose 1 log higher than the present study; the
reason for this trial not showing effect may therefore be that the
dose was insufficient. We based our choice of dose on what has
been shown effective toward osteomalacia, but the optimal dose
for an antituberculous effect is not known and it may well be
higher. As shown in Figure 5, the doses of vitamin D used did not
have a lasting effect on vitamin D levels in the patients who
receivedvitaminDandthe lackof effectmaythereforebedueto
The finding that vitamin D levels were higher at 2 months of
follow-up in both treatment arm and placebo arm is curious and
been present right after vitamin D supplementation. A large
intervention, and if the dose given was suboptimal even for
nondeficient patients no difference between groups would be
expected 2 months later. There are no previous data on repeated
treatment, and therefore a rise in vitamin D levels at 2 months
may be a normal phenomenon. It is likely that patients with a TB
diagnosis in the intensive phase of treatment are allowed a better
share of food by the family to compensate for their illness; in our
experience the patients with TB are focused on obtaining a rich
diet with meat and eggs if possible and may therefore have
increased their dietary vitamin D intake. A change in sun
exposure may also explain the increased vitamin D levels, but
we have no knowledge of this being the case. Activated macro-
phages have been shown to hydroxylate 25(OH)D (34) to 1,25-
dihydroxyvitamin D [1,25(OH)2D]; active synthesis of 25(OH)D
from nonhydroxylated vitamin D by macrophages no longer
occupied bymycobacteria may thereforebea possible additional
mechanism for increased vitamin D in the placebo group.
Our findings also contrast with those of Range and colleagues
(35), who reported a 50% reduction in mortality among HIV-
infected patients with TB treated with multivitamin supplemen-
tation including vitamin D in a randomized clinical trial in
Tanzania. This was a subgroup analysis result, currently being
well as a variety of other micronutrients such as zinc, which was
shown to have a separate beneficial effect.
We observed trends in CD4 counts indicating an increase in
CD4 count in vitamin D–treated subjects who were not HIV
infected and a decrease in HIV-infected patients. We therefore
speculate that vitamin D has differential effects depending on
whether the immune system is intact.
We may hypothesize that a smallbeneficial effect is present in
HIV-uninfected patients with TB; vitamin D has been shown to
exert an effect in vitro on host immune response to Mycobacte-
rium tuberculosis (5). HIV-infected patients, on the other hand,
are known to suffer from further immune activation (36), which
may cause the slower clinical improvement and the nonsignifi-
infected patients. We may later analyze additional nonplanned
outcomes such as HIV viral load in this cohort to furnish more
data on this matter.
Indeed, vitamin D supplementation may have only a minor
effect on the outcome of TB treatment. Future studies may
therefore instead aim to evaluate vitamin D as an agent to
patients with TB with vitamin D at high doses.In this trial vitamin
D supplementation showed no beneficial effect for patients with
TB in general, but this may have been due to suboptimal dosage.
Further trials investigating larger, perhaps daily, vitamin D doses
for prevention of latent TB infection appear warranted.
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.
Acknowledgment: The authors thank the TB study team at the Bandim Health
Project; the staff at the Bandim, Belem, and Cuntum Health Centers and at Sant
D’Egidio TB Hospital; Henrik Friis and Søren Johnsen for useful suggestions early
in the study; and Lars Østergaard, Lars Pedersen, and Henrik Toft Sørensen for
serving on the Data and Safety Monitoring Board and Jesper Eugen-Olsen and
Jens Nielsen for advice on interpreting the data. The authors thank Crinex
Pharmaceuticals for providing the cholecalciferol and placebo ampules.
1. Dowling GB, Prosser Thomas EW. Treatment of lupus vulgaris with
calciferol. Lancet 1946;1:919–922.
2. Ellman P, Anderson K. Calciferol in tuberculosis peritonitis with
disseminated tuberculosis. BMJ 1948;1:394.
3. Brincourt J. Liquefying effect on suppurations of an oral dose of
calciferol. Presse Med 1969;77:467–470.
4. Bennett JH. The pathology and treatment of pulmonary tuberculosis, 1st
ed. Edinburgh: Sutherland and Knox; 1853. p. 138.
5. Liu PT, Stenger S, Li H, Wenzel L, Tan BH, Krutzik SR, Ochoa MT,
Schauber J, Wu K, Meinken C, et al. Toll-like receptor triggering of
a vitamin D–mediated human antimicrobial response. Science 2006;
6. Martineau AR, Wilkinson RJ, Wilkinson KA, Newton SM, Kampmann
B, Hall BM, Packe GE, Davidson RN, Eldridge SM, Maunsell ZJ,
et al. A single dose of vitamin D enhances immunity to mycobacteria.
Am J Respir Crit Care Med 2007;176:208–213.
7. 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;
8. Ustianowski A, Shaffer R, Collin S, Wilkinson RJ, Davidson RN.
Prevalence and associations of vitamin D deficiency in foreign-born
persons with tuberculosis in London. J Infect 2005;50:432–437.
9. Nnoaham KE, Clarke A. Low serum vitamin D levels and tuberculosis:
a systematic review and meta-analysis. Int J Epidemiol 2008;37:113–119.
10. Gibney KB, MacGregor L, Leder K, Torresi J, Marshall C, Ebeling PR,
Biggs BA. Vitamin D deficiency is associated with tuberculosis and
latent tuberculosis infection in immigrants from sub-Saharan Africa.
Clin Infect Dis 2008;46:443–446.
11. Bellamy R. Evidence of gene–environment interaction in development
of tuberculosis. Lancet 2000;355:588–589.
12. Zasloff M. Fighting infections with vitamin D. Nat Med 2006;12:388–390.
Figure 5. Vitamin D serum levels before and during study.
Wejse, Gomes, Rabna, et al.: Vitamin D TB Trial 849
13. Martineau AR, Honecker FU, Wilkinson RJ, Griffiths CJ. Vitamin D in Download full-text
the treatment of pulmonary tuberculosis. J Steroid Biochem Mol Biol
14. Nursyam EW, Amin Z, Rumende CM. The effect of vitamin D as
supplementary treatment in patients with moderately advanced
pulmonary tuberculous lesion. Acta Med Indones 2006;38:3–5.
15. Morcos MM, Gabr AA, Samuel S, Kamel M, el Baz M, el Beshry M,
Michail RR. Vitamin D administration to tuberculous children and its
value. Boll Chim Farm 1998;137:157–164.
16. Benn CS, Bale C, Sommerfelt H, Friis H, Aaby P. Hypothesis: vitamin A
supplementation and childhood mortality: amplification of the non-
specific effects of vaccines? Int J Epidemiol 2003;32:822–828.
17. Wejse C, Gomes VF, Rabna P, Aaby P, Lisse I, Andersen PL, Glerup H,
Sodemann M. Vitamin D as supplementary treatment for tuberculo-
sis: a randomised double-blind placebo-controlled trial. Poster P2.106
presented at the Royal Society of Tropical Medicine and Hygiene
Centenary Conference. September 13–15, 2007, London.
18. Gustafson P, Gomes VF, Vieira CS, Rabna P, Seng R, Johansson P,
Sandstrom A, Norberg R, Lisse I, Samb B, et al. Tuberculosis in
Bissau: incidence and risk factors in an urban community in sub-
Saharan Africa. Int J Epidemiol 2004;33:163–158.
19. Harries AD, Maher D, Graham S. TB/HIV: a clinical manual, 2nd ed.
Geneva: WHO; 2004. WHO/HTM/TB/2004.329.
20. Vieth R. Vitamin D supplementation, 25-hydroxyvitamin D concen-
trations, and safety. Am J Clin Nutr 1999;69:842–856.
21. Trivedi DP, Doll R, Khaw KT. Effect of four monthly oral vitamin D3
(cholecalciferol) supplementation on fractures and mortality in men
and women living in the community: randomised double blind
controlled trial. BMJ 2003;326:469.
22. Powell-Tuck J, Hennessy EM. A comparison of mid upper arm
circumference, body mass index and weight loss as indices of under-
nutrition in acutely hospitalized patients. Clin Nutr 2003;22:307–312.
23. Wejse C, Gustafson P, Nielsen J, Gomes VF, Aaby P, Andersen PL,
Sodemann M. A clinical score system for monitoring tuberculosis in
a low-resource setting. Scand J Infect Dis 2008;40:111–120.
24. Seng R, Gustafson P, Gomes VF, Vieira CS, Rabna P, Larsen O,
Larouze B, Norberg R, Lisse IM, Samb B. Community study of the
relative impact of HIV-1 and HIV-2 on intrathoracic tuberculosis.
25. Gustafson P, Gomes VF, Naucler A, Vieira CS, Samb B, Aaby P, Lisse I.
Clinical predictors for death in HIV-positive and HIV-negative
tuberculosis patients in Guinea-Bissau. Infection 2007;35:69–80.
26. 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 D2and D3.
Clin Chem 2005;51:1683–1690.
27. Vieth R. What is the optimal vitamin D status for health? Prog Biophys
Mol Biol 2006;92:26–32.
28. Wejse C, Olesen R, Rabna P, Kaestel P, Gustafson P, Aaby P, Andersen
PL, Glerup H, Sodemann M. Serum 25-hydroxy-vitamin D in a West
African population of tuberculosis patients and un-matched healthy
controls. Am J Clin Nutr 2007;86:1376–1383.
29. Fuss M, Pepersack T, Gillet C, Karmali R, Corvilain J. Calcium and
vitamin D metabolism in granulomatous diseases. Clin Rheumatol
30. Fuss M, Karmali R, Pepersack T, Bergans A, Dierckx P, Prigogine T,
Bergmann P, Corvilain J. Are tuberculous patients at a great risk
from hypercalcemia? Q J Med 1988;69:869–878.
31. Winterberg H. Vigantol therapy in early tuberculous infections of the
lungs, and in exsudative pulmonary tuberculosis. Z Tuberk 1950;95:
32. Ghosh PK. Vitamin D2in tuberculosis. J Indian Med Assoc 1957;29:
33. Trautwein H, Stein E. Vitamin D2and pulmonary tuberculosis; effects
and therapeutic results. Beitr Klin Tuberk Spezif Tuberkuloseforsch
34. Adams JS, Ren SY. Autoregulation of 1,25-dihydroxyvitamin D synthe-
sis in macrophage mitochondria by nitric oxide. Endocrinology 1996;
35. Range N, Changalucha J, Krarup H, Magnussen P, Andersen AB, Friis
H. The effect of multi-vitamin/mineral supplementation on mortal-
ity during treatment of pulmonary tuberculosis: a randomised two-
by-two factorial trial in Mwanza, Tanzania. Br J Nutr 2006;95:
36. Brenchley JM, Price DA, Schacker TW, Asher TE, Silvestri G, Rao S,
Kazzaz Z, Bornstein E, Lambotte O, Altmann D, et al. Microbial
translocation is a cause of systemic immune activation in chronic HIV
infection. Nat Med 2006;12:1365–1371.
850 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINEVOL 1792009