Acta Pædiatrica ISSN 0803–5253

REGULAR ARTICLE

Vitamin D status and acute lower respiratory infection in early childhood in

Sylhet, Bangladesh
DE Roth1, R Shah1,2, RE Black1, AH Baqui (abaqui@jhsph.edu)1
1.Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
2.PROJAHNMO, Sylhet, Bangladesh

Keywords
Case–control study, Developing countries,
Pneumonia, Respiratory infections, Vitamin D
Correspondence
Dr Abdullah H. Baqui, Professor,
Department of International Health, Bloomberg
School of Public Health, The Johns Hopkins
University, 615 North Wolfe Street, Room E8138,
Baltimore, MD 21205, USA.
Tel: 410-955-3850 |
Fax: 410-614-1419 |
Email: abaqui@jhsph.edu
Received
15 June 2009; revised 19 September 2009;
accepted 16 October 2009.
DOI:10.1111/j.1651-2227.2009.01594.x
Abstract
Aim: Acute lower respiratory tract infection (ALRI) is the most important global cause of
childhood death. Micronutrient deficiencies may increase the risk of ALRI. A case–control study was
conducted to assess the association between vitamin D status and ALRI in rural Bangladesh.
Methods: Children aged 1–18 months hospitalized with ALRI (cases) were individually matched
to controls on age, sex, and village (N = 25 pairs). The mean serum 25-hydroxyvitamin D concentra-
tion [25(OH)D] in cases and controls was compared using paired t-test. The unadjusted and adjusted
odds of ALRI were assessed by multivariate conditional logistic regression.
Results: Mean [25(OH)D] was significantly lower among ALRI cases than controls (29.1 nmol ⁄ L
vs. 39.1 nmol ⁄ L; p = 0.015). The unadjusted odds of ALRI was halved for each 10 nmol ⁄ L increase
in [25(OH)D] (OR 0.53, 95% CI 0.30–0.96). Adjustment for confounders increased the magnitude
of the association.
Conclusion: Vitamin D status was associated with early childhood ALRI in a matched case–control study in rural
Bangladesh. Randomized trials may establish whether interventions to improve vitamin D status can reduce the
burden of ALRI in early childhood.

INTRODUCTION Despite South Asia’s low latitude and abundant sunshine,

Acute lower respiratory tract infection (ALRI) is the most
common cause of global child mortality, accounting for
approximately 2 million under-five deaths every year (1). In
Bangladesh, ALRI has been estimated to be responsible for
28% of deaths of infants aged 1–11 months of age (2).
Nutritional status is a well-recognized determinant of early
childhood susceptibility to ALRI (3). Although it is
unknown whether vitamin D status plays a role, rickets
caused by severe vitamin D and ⁄ or calcium deficiency has
been noted to be a condition predisposing to pneumonia
(4,5). Recently, associations between ALRI risk and serum
concentrations of 25-hydroxyvitamin D (25(OH)D), the cir-
culating biomarker of vitamin D status, were found in
Indian children (6) and Turkish neonates (7), but not in
Canadian infants and children (8,9). The biological ratio-
nale for an association is based principally on laboratory
evidence that the activated hormonal form of vitamin D,
1,25-dihydroxyvitamin D [1,25(OH)2D], is a potent immu-
nomodulator (10,11).
Abbreviations
ALRI, acute lower respiratory tract infection; [25(OH)D], 25-hy-
droxyvitamin D concentration; 1,25(OH)2D, 1,25-dihydroxyvita-
min D; WA, weight-for-age; LA, length-for-age; SD, standard
deviation; OR, odds ratio; CI, confidence interval.
low [25(OH)D] has been reported in infants in India
(12,13) and Pakistan (14), and among pregnant women in
India (15), Nepal (16) and Bangladesh (17), suggesting that
the contribution of vitamin D status to ALRI risk might be
prominent in this region. In this case–control study, we
aimed to assess whether serum [25(OH)D] was associated
with the risk of ALRI in children aged from 1 month to
2 years in rural Sylhet, Bangladesh.
METHODS
Setting and participants
In January–February 2008, we conducted a matched case–
control study in Zakiganj sub-district of Sylhet, in north-
eastern Bangladesh. Nursing staff at the sub-district hospital
assisted research personnel in identifying patients aged 1–
23 months, who were admitted to the ward with a respira-
tory illness within the past 24 h, 6 days ⁄ week during the
study period. ALRI was defined according to the following
case definition: (i) caregiver report of cough and ⁄ or diffi-
culty breathing for less than 2 weeks; (ii) rapid respiratory
rate for age by WHO criteria (‡50 breaths per minute for
participants <12 months of age; ‡40 for participants
‡12 months of age) and ⁄ or intercostal or lower chest wall
indrawing that was persistent throughout the examination;
and (iii) central cyanosis and ⁄ or inspiratory pulmonary
crackles heard on auscultation by the study physician. The

ª2009 The Author(s)/Journal Compilation ª2009 Foundation Acta Pædiatrica/Acta Pædiatrica 2010 99, pp. 389–393 389
Vitamin D and ALRI in Bangladesh
latter criterion was incorporated to increase the specificity
of the case definition for moderate–severe ALRI rather than
viral upper respiratory tract infection or mild bronchiolitis.
Exclusion criteria were as follows: pulmonary tuberculosis,
aspiration pneumonia, symptomatic cardiac anomaly ⁄ fail-
ure, or an inability to obtain a blood specimen after a maxi-
mum of two venipuncture attempts.
Control participants were selected by population-based
sampling. After successful collection of data and specimens
from a case participant, field personnel conducted a focused
household census in the village in which the case partici-
pant resided, listing all eligible children aged 1–23 months,
and matched to cases on age (±2 months) and sex. Controls
participants met the following criteria aimed at identifying
children unlikely to have had a recent or severe ALRI: (i)
no caregiver reported history of ‘fast or difficult breathing’
or ‘lower chest wall indrawing’ (using a local term) of
>1 day duration, or a diagnosis of ‘pneumonia’ at a health
centre, during the past 1 month; (ii) no caregiver-reported
history of hospitalization for ‘pneumonia’ or ‘fast or difficult
breathing’ in the past year; and (iii) no signs of tachypnoea
or lower chest wall indrawing at the time of study recruit-
ment or assessment. Field personnel generated a list of all
provisionally eligible children. In an order based on age
proximity to the case, personnel consecutively approached
caregivers of listed children until a control participant was
recruited. If an eligible control was not enrolled, the census
and eligible control identification process was repeated in
the nearest neighbouring village.
Procedures
All cases and controls underwent the following procedures
performed by trained personnel: (i) caregiver questionnaire
related to risk factors for ALRI and vitamin D deficiency
including mother’s clothing practices, swaddling during
infancy, dietary history, indicators of socio-economic status,
cigarette smoke exposure and cooking fuel use; (ii) physical
examination by a physician; (iii) infant weight (the average
of at least two measurements, to the nearest 0.1 kg; Seca
354 infant scale) and length (the average of at least two
measurements, to the nearest 0.5 cm; Seca 210 measuring
mat); and (iv) collection of a venous blood specimen by
standard methods, separated into serum aliquots and stored
at )20C or colder. At study completion, sera were shipped
to the laboratory of Dr Bruce Hollis (Medical University of
South Carolina, Charleston, USA) for measurement of the
total serum 25(OH)D concentration by radioimmunoassay
(18).
Substantial efforts were undertaken to obtain case–con-
trol pairs with non-haemolyzed blood specimens of suffi-
cient volume. For each case, control selection was initiated
only if the case participant specimen had an appropriate
non-haemolyzed colour and amount based on qualitative
visual inspection by field staff. To minimize the burden on
any individual child, only one specimen was collected from
each child. Using the lists of eligible controls generated from
the village census, repeat control recruitment was attempted
if the first control participant specimen was of low quality.
390 ª2009 The Author(s)/Journal Compilation ª2009 Foundation Acta Pædiatrica/Acta Pædiatrica 2010 99, pp. 389–393
Roth et al.
Iterative quality control feedback was used to improve spec-
imen quality throughout the study.
Caregivers provided signed permission prior to enrol-
ment. The study was approved by The Johns Hopkins
Bloomberg School of Public Health Institutional Review
Board and the ethics committee of the Bangladesh Institute
for Child Health at the Dhaka Shishu Hospital, Bangladesh.
Statistical analysis
The case and control groups were compared with respect to
demographic characteristics, suspected ALRI risk factors
and possible determinants of vitamin D status using paired
t-tests (continuous variables) and McNemar’s chi-square
test (dichotomous variables). The primary comparison was
the mean case–control difference in [25(OH)D], analysed
by paired t-test. The odds of ALRI as a function of
[25(OH)D] was assessed using conditional logistic regres-
sion. To adjust for confounding by other putative ALRI risk
factors, categorical covariates that changed the odds ratio
(OR) for the [25(OH)D]-ALRI association by >10% (a pri-
ori criterion for substantial confounding) were included in a
multivariate conditional logistic regression model. Gender-
specific weight-for-age (WA) and length-for-age (LA) z-
scores were calculated according to WHO growth standards
(19); according to convention, ‘stunting’ was defined as <)2
z-score for LA and ‘underweight’ was defined as <)2 z-score
for WA. Analysis was performed using STATA version 10.1
(Stata Corporation, College Station, TX, USA).
With 80% power, a type I error risk of 5%, and conserva-
tively assuming a standard deviation (SD) of 25 nmol ⁄ L, we
had estimated that 25 case–control pairs would permit
detection of a mean difference in 25(OH)D concentration
of 15 nmol ⁄ L between matched pairs, recognizing that
a smaller SD would permit detection of a smaller mean
difference.
RESULTS
Twenty-five case–control pairs (N = 50) with adequate
blood specimens were enrolled. Cases and controls were
similar according to most baseline descriptors, but cases
tended to have lower socioeconomic status, younger moth-
ers and worse nutritional status (Table S1). Age ranged from
1 to 18 months; controls were an average of 10 days (SD
39) older than cases.
Case ALRIs were characterized by tachypnoea (100%),
inspiratory crackles (100%), lower chest-wall indrawing
(84%), wheezes (64%), intercostal indrawing (48%) and
rhinorrhoea (8%). None of the infants had visible cyano-
sis or other danger signs (e.g. inability to feed, severe
lethargy). Temperature and pulse oximetry were not rou-
tinely measured. All cases were treated with standard par-
enteral antibiotics at the discretion of the attending
physician and discharged home on oral antibiotics when
improving clinically.
Serum [25(OH)D] ranged from 9.5 to 73.9 nmol ⁄ L. The
mean [25(OH)D] was significantly lower among ALRI
cases (29.1 nmol ⁄ L, SD 17.2) compared with matched
Roth et al. Vitamin D and ALRI in Bangladesh

controls (39.1 nmol ⁄ L SD 9.4); the mean case–control dif-
ference was 10.0 nmol ⁄ L (standard error, 3.68 nmol ⁄ L;
p = 0.0146). The unadjusted conditional odds of ALRI was
approximately halved for each 10 nmol ⁄ L increase in serum
[25(OH)D] (OR 0.53, 95% CI 0.30–0.96; p = 0.037). Vita-
min D status was marginally better among infants born to
younger mothers and those at higher socioeconomic status
(Table S1).
Among several covariates considered as potential con-
founders of the vitamin D – ALRI association (categorical
variables listed in Table S1), only three factors met the a pri-
ori definition for substantial confounding (Table 1): under-
weight and two markers of low socioeconomic status (not
owning a home and living in a house with walls made of
natural rather than manufactured materials). Adjustment
for these confounders (Model D) increased the magnitude
of the ALRI-[25(OH)D] association (OR 0.23, 95% CI
0.06–0.81; p = 0.022). Further adjustment for exact age (in
days) did not substantially affect the magnitude of the asso-
ciation, but decreased its precision (OR 0.25, 95% CI 0.06–
1.05; p = 0.059).
DISCUSSION
In rural north-eastern Bangladesh, we found a significant
association between vitamin D status and hospitalization
for ALRI in a group of infants and young children aged 1–
18 months. The sample size was small but adequately pow-
ered for the primary analysis based on a continuous mea-
sure of exposure (25(OH)D), and an efficient design using
age, sex and community matching that yielded reasonably
similar case and control groups. Although few covariates
met the criterion for confounding, multivariate adjustment
did not qualitatively alter the inference that lower
[25(OH)D] was associated with ALRI. If causal, the
observed association suggests that a modest upward shift in
the [25(OH)D] distribution could have a meaningful impact
on ALRI susceptibility in this setting. An increase of at least
10 nmol ⁄ L in the population mean [25(OH)D] would be a
feasible public health aim, as it could be readily attained by
routine use of the standard oral vitamin D supplement that
is recommended for infants in Canada and the US
(400 IU ⁄ day) (20).
A causal role of vitamin D status in ALRI susceptibility is
biologically plausible given the well-established involve-
ment of vitamin D in immune function observed in cell cul-
ture and animal models (10,11). In particular, the
endogenous synthesis of a host antimicrobial peptide (LL-
37) is stimulated by the activation of the vitamin D receptor
by 1,25(OH)2D in monocytes (21) and respiratory epithelial
cells (22). Upregulation of LL-37 in tracheal secretions dur-
ing lower respiratory tract infections in infants further sug-
gests its potential role in innate defences against ALRI (23).
This study aimed to determine whether previous observa-
tions in India (6) and Turkey (7) could be corroborated in
rural Bangladesh, where the burden of ALRI mortality is
high (2) but knowledge of vitamin D status was previously
limited. Findings in these three case–control studies were
reasonably consistent with respect to the average
[25(OH)D] in controls and the difference in [25(OH)D]
between cases and controls (Table 2), despite distinct set-
tings and characteristics of case and control groups. In two
separate studies from a western country (Canada), vitamin
D status was not associated with the risk of hospitalization
for ALRI (8,9); however, a key distinguishing feature was
that the [25(OH)D] distributions in the Canadian study
populations were substantially higher than in the other
studies (Table 2), likely because most of the Canadian

Table 1 Unadjusted and adjusted conditional associations between vitamin D status and acute lower respiratory tract infection among infants and young children in
rural Sylhet, Bangladesh
Multivariate models

Unadjusted models Model A Model B Model C Model D

Risk factor OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

Increase in [25(OH)D] of 10 nmol ⁄ L 0.53 (0.30–0.96) 0.45 (0.23–0.89) 0.43 (0.20–0.91) 0.43 (0.21–0.89) 0.23 (0.06–0.81)
Underweight 2.00 (0.50–8.00) 4.41 (0.72–26.9) – – 4.55 (0.53–38.79)
No household ownership 2.5 (0.49–12.89) – 6.56 (0.66–65.5) – 8.91 (0.35–224.65)
House walls made of natural materials 2.5 (0.49–12.89) – – 6.39 (0.75–54.4) 14.1 (0.68–292.41)

Table 2 Summary of published case–control studies on the association between vitamin D status and acute lower respiratory infection in early childhood
Average 25(OH)D concentration (nmol ⁄ L)

Study Country N Average age (months) ALRI cases Controls Difference (Controls ) Cases)

Wayse 2004 (6) India 150 23.9 22.8 38.4 15.6

Karatekin 2009 (7) Turkey 40 0.3 22.8 40.8 18
Roth 2009 (8) Canada 129 13.3 77.2 77.0 )0.2
McNally 2009 (9) Canada 175 13.6 81 83 2
Roth 2009 Bangladesh 50 4.2 29.2 39.2 10.0

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Vitamin D and ALRI in Bangladesh
infants and toddlers consumed either vitamin D-fortified
infant formula or milk, or received vitamin D supplements if
exclusively breast-fed (8). Therefore, there may be impor-
tant effect modifiers (e.g. infectious aetiology, host nutri-
tional status) and ⁄ or a [25(OH)D] threshold below which
ALRI risk begins to increase above baseline. Existing studies
do not permit demarcation of this threshold, but designing
future studies to do so would be an important step in the
much-needed development of functional paediatric defini-
tions of ‘vitamin D deficiency’ (24), a concept towards
which the present analysis was deliberately agnostic by con-
sidering case–control differences along a [25(OH)D] con-
tinuum.
The major limitation of this study was its small sample
size, which precluded extensive multivariate analysis or
detection of associations between ALRI and potentially
confounding risk factors. Notably, however, the direction of
non-significant associations between important ALRI risk
factors (e.g. stunting, lower socioeconomic status) and case
status were consistent with expectations. As we selected
community- rather than hospital-based controls, the lower
[25(OH)D] among cases may not be specific to ALRI, but
could be a general risk factor for poor health status predis-
posing to hospitalization. In addition to residual confound-
ing (i.e. the presence of factors that increase the risk of
ALRI and also lead to vitamin D deficiency), an alternative
explanation for the observed association in this and preced-
ing case–control studies is reverse causality (i.e. ALRI sup-
presses [25(OH)D]). Although [25(OH)D] was not
associated with the acute phase response in tuberculosis
patients (25) and did not vary over the course of malarial ill-
ness (26), it may be affected by pathogen- or organ system-
specific inflammatory responses.
In conclusion, there was a significant association between
vitamin D status and early childhood ALRI in rural Bangla-
desh. These findings strengthen the rationale for prospective
studies to establish the determinants of vitamin D status in
tropical regions and randomized controlled trials aimed at
determining whether feasible and safe interventions that
improve vitamin D status yield reductions in the burden of
childhood ALRI in resource-poor communities.
ACKNOWLEDGEMENTS
We would like to thank the participants and caregivers for
their kind cooperation, the study field staff, the PRO-
JAHNMO Sylhet team and personnel at the Zakiganj Sub-
district Hospital. In particular, we thank Mr Kazi Moksedur
Rahman (Deputy Executive Director, SHIMANTIK), Dr
Arun Kumar Roy (Project Research Physician, Projahnmo),
Dr Daniel Hossain (Project Research Manager, Pro-
jahnmo), Dr Sirajul Islam (Upazila Health and Family Plan-
ning officer), Dr Jonme Joy Dutta Shankar (Medical Officer,
Zakiganj sub-district hospital), Dr Samir K. Saha (Bangla-
desh Institute of Child Health, Dhaka Shishu Hospital,
Dhaka, Bangladesh), Dr Carole Wagner (Medical Univer-
sity of South Carolina, USA), and the Department of Inter-
national Health at The Johns Hopkins Bloomberg School of
392 ª2009 The Author(s)/Journal Compilation ª2009 Foundation Acta Pædiatrica/Acta Pædiatrica 2010 99, pp. 389–393
Roth et al.
Public Health for the support provided to us. We are grate-
ful to Dr Bruce Hollis (Medical University of South Caro-
lina, USA) for performing the 25-hydroxyvitamin D
analyses. D. Roth was funded by training grants from the
Canadian Institutes for Health Research and the Alberta
Heritage Foundation for Medical Research.
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SUPPORTING INFORMATION
Additional Supporting Information may be found in the
online version of this article:
Table S1 Characteristics and vitamin D status of infants and
young children hospitalized with acute lower respiratory
tract infections and age-, sex- and community-matched con-
trols
Please note: Wiley-Blackwell are not responsible for the
content or functionality of any supporting materials sup-
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rial) should be directed to the corresponding author for the
article
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