Peter Bergman, Gal Dubnov-Raz, Susanna Esposito, Davaasambuu Ganmaa, Adit A Ginde,Emma C Goodall, Cameron C Grant, Christopher J Griffiths, Wim Janssens, Ilkka Laaksi, Semira Manaseki-Holland, David Mauger, David R Murdoch, Rachel Neale, Judy R Rees, Steve Simpson,Jr Iwona Stelmach, Geeta Trilok Kumar, Mitsuyoshi Urashima, Carlos A Camargo Jr
To assess the overall effect of vitamin D supplementation on risk of acute respiratory tract infection, and to identify factors modifying this effect.
Systematic review and meta-analysis of individual participant data (IPD) from randomised controlled trials.
Medline, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, ClinicalTrials.gov, and the International Standard Randomised Controlled Trials Number registry from inception to December 2015.
Eligibility criteria for study selection
Randomised, double blind, placebo controlled trials of supplementation with vitamin D3 or vitamin D2 of any duration were eligible for inclusion if they had been approved by a research ethics committee and if data on incidence of acute respiratory tract infection were collected prospectively and prespecified as an efficacy outcome.
25 eligible randomised controlled trials (total 11321 participants, aged 0 to 95 years) were identified. IPD were obtained for 10933 (96.6%) participants. Vitamin D supplementation reduced the risk of acute respiratory tract infection among all participants (adjusted odds ratio 0.88, 95% confidence interval 0.81 to 0.96; P for heterogeneity <0.001). In subgroup analysis, protective effects were seen in those receiving daily or weekly vitamin D without additional bolus doses (adjusted odds ratio 0.81, 0.72 to 0.91) but not in those receiving one or more bolus doses (adjusted odds ratio 0.97, 0.86 to 1.10; P for interaction=0.05). Among those receiving daily or weekly vitamin D, protective effects were stronger in those with baseline 25-hydroxyvitamin D levels <25 nmol/L (adjusted odds ratio 0.30, 0.17 to 0.53) than in those with baseline 25-hydroxyvitamin D levels ≥25 nmol/L (adjusted odds ratio 0.75, 0.60 to 0.95; P for interaction=0.006). Vitamin D did not influence the proportion of participants experiencing at least one serious adverse event (adjusted odds ratio 0.98, 0.80 to 1.20, P=0.83). The body of evidence contributing to these analyses was assessed as being of high quality.
Vitamin D supplementation was safe and it protected against acute respiratory tract infection overall. Patients who were very vitamin D deficient and those not receiving bolus doses experienced the most benefit.
Acute respiratory tract infections are a major cause of global morbidity and mortality with an estimated 2.65 million deaths worldwide in 2013. Observational studies report consistent independent associations between low serum concentrations of 25-hydroxyvitamin D and susceptibility to acute respiratory tract infection. 25-hydroxyvitamin D supports induction of antimicrobial peptides in response to both viral and bacterial stimuli, suggesting a potential mechanism by which vitamin D inducible protection against respiratory pathogens might be mediated. Vitamin D metabolites have also been reported to induce other innate antimicrobial effector mechanisms, including induction of autophagy and synthesis of reactive nitrogen intermediates and reactive oxygen intermediates.
These epidemiological and in vitro data for numbered affiliations see end of article have prompted numerous randomised controlled trials to determine whether vitamin D supplementation can decrease the risk of acute respiratory tract infection. A total of five aggregate data meta-analyses incorporating data from up to 15 primary trials have been conducted to date, of which two report statistically significant protective effects 9 10 and three report no statistically significant effects. All but one of these aggregate data meta-analyses reported statistically significant heterogeneity of effect between primary trials. This heterogeneity might have arisen as a result of variation in participant characteristics and dosing regimens between trials, either of which may modify the effects of vitamin D supplementation on immunity to respiratory pathogens.
People with chronic obstructive pulmonary disease who have lower baseline vitamin D status have been reported to derive greater clinical benefit from supplementation than those with higher baseline status,and participant characteristics such as age and body mass index have been reported to modify the 25-hydroxyvitamin D response to vitamin D supplementation. Treatment with large boluses of vitamin D has been associated with reduced efficacy for non-classic effects, and in some cases an increased risk of adverse outcomes. While study level factors are amenable to exploration through aggregate data meta-analysis of published data, potential effect modifiers operating at an individual level, such as baseline vitamin D status, can only be explored using individual participant data (IPD) meta-analysis. This is because subgroups are not consistently disaggregated in trial reports, and adjustments for potential confounders cannot be applied similarly across trials.
Protocol and registration
The methods were prespecified in a protocol that was registered with the PROSPERO International Prospective Register of Systematic Reviews. Approval by a research ethics committee to conduct this meta-analysis was not required in the UK; local ethical
permission to contribute deidentified IPD from primary trials was required and obtained for studies by Camargo et al21 (the ethics review committee of the Mongolian Ministry of Health), Murdoch et al22 (Southern Health and Disability Ethics Committee, reference URB/09/10/050/ AM02), Rees et al23 (Committee for the Protection of Human Subjects, Dartmouth College, USA; protocol No 24381), Tachimoto et al24 (ethics committee of the Jikei University School of Medicine, reference 26-333: 7839), Tran et al25 (QIMR Berghofer Medical Research Institute human research ethics committee, P1570), and Urashima et al 26 27 (ethics committee of the Jikei University School of Medicine, reference 26-333: 7839).
Patient and public involvement
Two patient and public involvement representatives were involved in development of the research questions and the choice of outcome measures specified in the study protocol. They were not involved in patient recruitment, since this is a meta-analysis of completed studies. Data relating to the burden of the intervention on participants’ quality of life and health were not meta-analysed. Where possible, results of this systematic review and meta-analysis will be disseminated to individual participants through the principal investigators of each trial.
Randomised, double blind, placebo controlled trials of supplementation with vitamin D3 or vitamin D2 of any duration were eligible for inclusion if they had been approved by a research ethics committee and if data on incidence of acute respiratory tract infection were collected prospectively and prespecified as an efficacy outcome. The last requirement was imposed to minimise misclassification bias (prospectively designed instruments to capture acute respiratory tract infection events were deemed more likely to be sensitive and specific for this outcome). We excluded studies reporting results of long term follow-up of primary randomised controlled trials.
Data collection processes
IPD were requested from the principal investigator for each eligible trial, and the terms of collaboration were specified in a data transfer agreement, signed by representatives of the data provider and the recipient (Queen Mary University of London). Data was identified at source before transfer by email. On receipt, three investigators (DAJ, RLH, and LG) assessed data integrity by performing internal consistency checks and by attempting to replicate results of the analysis for incidence of acute respiratory tract infection where this was published in the trial report. Study authors were contacted to provide missing data and to resolve queries arising from these integrity checks. Once queries had been resolved, clean data were uploaded to the main study database, which was held in STATA IC v12 (College Station, TX).
Data relating to study characteristics were extracted for the following variables: setting, eligibility criteria, details of intervention and control regimens, study duration, and case definitions for acute respiratory tract infection. IPD were extracted for the following variables, where available: baseline data were requested for age, sex, cluster identifier (cluster ran domised trials only), racial or ethnic origin, influenza vaccination status, history of asthma, history of chronic obstructive pulmonary disease, body weight, height (adults and children able to stand) or length (infants), serum 25-hydroxyvitamin D concentration, study allocation (vitamin D versus placebo), and details of any stratification or minimisation variables. Follow-up data were requested for total number of acute respiratory tract infections (upper or lower), upper respiratory tract infections, and lower respiratory tract infections experienced during the trial; time from first dose of study drug to first acute respiratory tract infection (upper or lower), upper respiratory tract infection, or lower respiratory tract infection if applicable; total number of courses of antibiotics taken for acute respiratory tract infection during the trial; total number of days off work or school due to symptoms of acute respiratory tract infection during the trial; serum 25-hydroxyvitamin D concentration at final follow-up; duration of follow-up; number and nature of serious adverse events; number of potential adverse reactions (incident hypercalcaemia or renal stones); and participant status at end of the trial (completed, withdrew, lost to follow-up, died).
Definition of outcomes
The primary outcome of the meta-analysis was incidence of acute respiratory tract infection, incorporating events classified as upper respiratory tract infection, lower respiratory tract infection, and acute respiratory tract infection of unclassified location (ie, infection of the upper respiratory tract or lower respiratory tract, or both). Secondary outcomes were incidence of upper and lower respiratory tract infections, analysed separately; incidence of emergency department attendance or hospital admission, or both for acute respiratory tract infection; use of antimicrobials for treatment of acute respiratory tract infection; absence from work or school due to acute respiratory tract infection; incidence and nature of serious adverse events; incidence of potential adverse reactions to vitamin D (hypercalcaemia or renal stones); and mortality (acute respiratory tract infection related and all cause).
LG and RLH analysed the data. Our IPD meta-analysis approach followed published guidelines.20 Initially we reanalysed all studies separately; the original authors were asked to confirm the accuracy of this reanalysis where it had been performed previously, and any discrepancies were resolved. Then we performed both one step and two step IPD meta-analysis for each outcome separately using a random effects model adjusted for age, sex, and study duration to obtain the pooled intervention effect with a 95% confidence interval. We did not adjust for other covariates because missing values
for some participants would have led to their exclusion from statistical analyses. In the one step approach, we modelled IPD from all studies simultaneously while accounting for the clustering of participants within studies. In the two step approach we first analysed IPD for each separate study independently to produce an estimate of the treatment effect for that study; we then synthesised these data in a second step.20 For the one step IPD meta-analysis we assessed heterogeneity by calculation of the standard deviation of random effects; for the two step IPD meta-analysis we summarised heterogeneity using the I2 statistic. We calculated the number needed to treat to prevent one person from having any acute respiratory tract infection (NNT) using the Visual Rx NNT calculator, where meta-analysis of dichotomous outcomes revealed a statistically significant beneficial effect of allocation to vitamin D compared with placebo.
Exploration of variation in effects
To explore the causes of heterogeneity and identify factors modifying the effects of vitamin D supplementation, we performed prespecified subgroup analyses by extending the one step meta-analysis framework to include treatment-covariate interaction terms. Subgroups were defined according to baseline vitamin D status (serum 25-hydroxyvitamin D <25 v ≥25 nmol/L), vitamin D dosing regimen (daily or weekly without bolus dosing versus a regimen including at least one bolus dose of at least 30000 IU vitamin D), dose size (daily equivalent <800 IU, 800-1999 IU, ≥2000 IU), age (≤1 year, 1.1-15.9 years, 16-65 years, >65 years), body mass index (<25 v ≥25), and presence compared with absence of asthma, chronic obstructive pulmonary disease, and previous influenza vaccination. To ensure that reported subgroup effects were independent, we adjusted interaction analyses for potential confounders (age, sex, and study duration). The 25 nmol/L cut-off for baseline 25-hydroxyvitamin D concentration in subgroup analyses was selected on the grounds that it is the threshold for vitamin D deficiency defined by the UK Department of Health,29 and the level below which participants in clinical trials have experienced the most consistent benefits of supplementation.30 We also performed an exploratory analysis investigating effects in subgroups defined using the 50 nmol/L and 75 nmol/L cut-offs for baseline circulating 25-hydroxyvitamin D concentration, because observational studies have reported that less profound states of vitamin D deficiency may also associate independently with an increased risk of acute respiratory tract infection.31 32 To minimise the chance of type 1 error arising from multiple analyses, we inferred statistical significance for subgroup analyses only where P values for treatment-covariate interaction terms were <0.05.
We conducted sensitivity analyses excluding IPD from trials where acute respiratory tract infection was a secondary outcome (as opposed to a primary or co-primary outcome), and where risk of bias was assessed as being unclear. We also conducted a responder analysis in participants randomised to the intervention arm of included studies for whom end study data on 25-hydroxyvitamin D were available, comparing risk of acute respiratory tract infection in those who attained a serum level of 75 nmol/L or more compared with those who did not.
Study selection and IPD obtained Our search identified 532 unique studies that were assessed for eligibility; of these, 25 studies with a total of 11 321 randomised participants fulfilled the eligibility criteria. IPD were sought and obtained for all 25 studies. Outcome data for the primary analysis of proportion of participants experiencing at least one acute respiratory tract infection were obtained for 10 933 (96.6%) of the randomised participants.
Conclusions and Policy Implications
Our study reports a major new indication for vitamin D supplementation: the prevention of acute respiratory tract infection, both viral and bacterial. We also show that people who are very deficient in vitamin D and those receiving daily or weekly supplementation without additional bolus doses experienced particular benefit. Our results add to the body of evidence supporting the introduction of public health measures such as food fortification to improve vitamin D status, particularly in settings where profound vitamin D deficiency is common.
Full journal research copy available here.