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Week of Nov. 11, 2006; Vol. 170, No. 20 , p. 312

The Antibiotic Vitamin

Deficiency in vitamin D may predispose people to infection

Janet Raloff

In April 2005, a virulent strain of influenza hit a maximum-security forensic psychiatric hospital for men that's midway between San Francisco and Los Angeles. John J. Cannell, a psychiatrist there, observed with increasing curiosity as one infected ward after another was quarantined to limit the outbreak. Although 10 percent of the facility's 1,200 patients ultimately developed the flu's fever and debilitating muscle aches, none did in the ward that he supervised.


WINTER WOES. Cold-weather wear and the sun's angle in the winter sky limit how much ultraviolet light reaches the skin. This can add up to a deficiency in production of vitamin D, which might explain why respiratory infections are common and severe in winter.

"First, the ward below mine was quarantined, then the wards on my right, left, and across the hall," Cannell recalls. However, although the 32 men on his ward at Atascadero (Calif.) State Hospital had mingled with patients from infected wards before their quarantine, none developed the illness.

Cannell's ward was the only heavily exposed ward left unaffected. Was it by mere chance, Cannell wondered, that his patients dodged the sickness?

A few months later, Cannell ran across a possible answer in the scientific literature. In the July 2005 FASEB Journal, Adrian F. Gombart of the University of California, Los Angeles (UCLA) and his colleagues reported that vitamin D boosts production in white blood cells of one of the antimicrobial compounds that defends the body against germs.

Immediately, Cannell says, the proverbial lightbulb went on in his head: Maybe the high doses of vitamin D that he had been prescribing to virtually all the men on his ward had boosted their natural arsenal of the antimicrobial, called cathelicidin, and protected them from flu. Cannell had been administering the vitamin D because his patients, like many other people in the industrial world, had shown a deficiency.

The FASEB Journal article also triggered Cannell's recollection that children with rickets, a hallmark of vitamin D deficiency, tend to experience more infections than do kids without the bone disease. He shared his flu data with some well-known vitamin D researchers, and they urged him to investigate further.

On the basis of more than 100 articles that he collected, Cannell and seven other researchers now propose that vitamin D deficiency may underlie a vulnerability to infections by the microbes that cathelicidin targets. These include bacteria, viruses, and fungi, the group notes in a report available online for the December Epidemiology and Infection.

This is only a hypothesis, "but a very credible one" that deserves testing, says immunologist Michael Zasloff of Georgetown University in Washington, D.C.

Behind the hypothesis are recent studies that link vitamin D intake to revved-up cathelicidin production. These investigations point to an infection-fighting role for vitamin D, which is produced in skin exposed to sunlight but is present in few foods.

A study published earlier this year that investigated the relationship between vitamin D and susceptibility to tuberculosis also bolsters the idea proposed by Cannell's team. Scientists have already planned a handful of clinical trials to evaluate the antimicrobial benefits of vitamin D supplementation.

Zasloff argues that if studies support the hypothesis, "we can imagine one day treating infections not by giving somebody a drug, but by giving them safe and simple substanceslike a vitamin."

Innate protection

Legions of germs come into contact with our bodies every day. Each microbe seeks a host in which it can multiply. Most would-be invaders, however, don't succeed; if not barred entry outright, they're destroyed by cellular recruits called up to participate in local immune militias.

Scientists hadn't been sure what serves as the call to arms for these immune cells and what triggers the production of their antibiotic arsenal, which includes several chemical weapons.

Over the past 5 years, a spate of studies began to shed light on the rollout of one of those munitionscathelicidin. Dermatologist and immunologist Richard L. Gallo of the University of California, San Diego, a coauthor of many of these studies, explains that cathelicidin "targets the bad guys." It kills invaders by punching holes in the external membrane of a microbe, permitting its innards to leak out.

Molecular geneticist John H. White of McGill University in Montreal and his colleagues were the first to observe that cathelicidin production is ramped up by vitamin Dor, more specifically, by the hormone 1,25-D, the vitamin's active form (SN: 10/9/04, p. 232: http://www.sciencenews.org/articles/20041009/bob8.asp). Through a cascade of events, vitamin D transforms into a compound, called a prehormone, that circulates in blood and then is converted locally, as needed, into 1,25-D.

In the nucleus of cells, 1,25-D binds to short sequences of DNA. Known as response elements, these sequences switch on the activity of adjacent genes. "We wanted to find out what genes were next to the vitamin D response elements," White recalls.

Two of these response elements proved to be neighbors of genes that make antimicrobial peptides, cathelicidin and beta-defensin 2, the researchers reported in 2004. When the researchers administered 1,25-D to a variety of cells, production of beta-defensin 2 increased "modestly," White told Science News. In contrast, he says, the gene for making cathelicidin "went boom! Its induction was very, very strong."

Almost a year later, while hunting for triggers for cathelicidin production, Gombart confirmed the McGill finding. His group had been administering various natural signaling agents to white blood cells, which the immune system sends out to vanquish germs.

In these cells, "nothing turned on the cathelicidin gene to any degree except vitamin D. And it really turned that gene onjust cranked it up," Gombart says. "I was completely surprised."

Independently, dermatologist Mona Sthle of the Karolinska Institute in Stockholm reached a similar conclusion when she realized that both vitamin D and several antimicrobials, including cathelicidin, are produced in the skin. She says, "It just came to mean intuitive thoughtthat maybe the sun, through vitamin D production, might help regulate the skin's antimicrobial response."

So, her team administered an ointment containing a drug mimic of 1,25-D to the skin of four healthy people. The salve hit "the jackpot, right away," Sthle says. In the May 2005 Journal of Investigative Dermatology, her team reported that where the ointment had been applied, cathelicidin-gene activity skyrocketed as much as 100-fold. The team also found evidence of a localized increase in the concentration of cathelicidin.

Tackling TB and more

Those studies, though suggestive, didn't reveal whether vitamin D directly reduced infection risk in people. Together with Gallo, microbial immunologist Robert Modlin of UCLA and his colleagues moved closer to that goal: They evaluated the vitamin's role in fending off the tuberculosis (TB) germ Mycobacterium tuberculosis.

This group, working independently of Gombart's team, had been focusing on macrophages, a type of white blood cell deployed by the immune system to gobble up and destroy germs. These defense cells have features, called toll-like receptors, that identify biochemical patterns characteristic of invading microbes. If the receptors sense an invader, they can trigger cathelicidin production.

Modlin's team showed that before making that antibiotic, those cells briefly boosted their production of vitamin D receptors and of an enzyme that converts the vitamin D prehormone into 1,25-D. However, the data suggested that significant concentrations of 1,25-D would develop only in the presence of the TB bacteria. This indicated that the microbe, and perhaps other germs, must be present for the enzyme to maximize its production of 1,25-D, Modlin says.

His group then tested whether people's blood concentrations of the prehormone are high enough to drive the production of germ-killing concentrations of cathelicidin. Black people, because of the sun-filtering effect of dark pigments in their skin, are far more likely than whites to be vitamin D deficient (SN: 10/16/04, p. 248: http://www.sciencenews.org/articles/20041016/bob9.asp). Furthermore, blacks tend to be more susceptible to TB than whites and to develop a more severe illness when infected.

The team collected blood serum from white people and from blacks. When the researchers added TB bacteria, macrophages in the serum from black participants produced 63 percent less cathelicidinand were less likely to kill the germsthan were macrophages incubated in serum from whites.

The scientists then added vitamin D to the serum from blacks until concentrations of the prehormone matched those in the serum from whites. This boosted the macrophages' cathelicidin production and rates of TB-microbe killing to those seen when such cells were incubated in serum from whites. Modlin's group reported its findings in the March 24 Science.

The new data may explain the difference between blacks and whites in TB susceptibility. Modlin says, "We showed that serum from African American individuals did not support the production of the antibiotic by immune cells, until the serum received supplemental vitamin D."

"We're now planning to do a clinical trial and treat African Americans who are deficient with vitamin D to correct their serum levels [of the prehormone] and see if this will change their antimicrobial response," Modlin says.

Gallo is also planning a new trial. His group will compare the effectiveness of supplemental vitamin D in elevating cathelicidin concentrations when administered as oral supplements or as a skin treatment.

The team expects to see the biggest benefit in skin wounds. However, Gallo predicts that even healthy skin will exhibit somewhat elevated antimicrobial concentrations, signaling an improved resistance to infection.

Sun exposurein moderationmight also prove therapeutic, Sthle's team suggested in the November 2005 Journal of Investigative Dermatology. The scientists showed that in eight fair-skinned people, a single dose of ultraviolet-B radiationjust enough to evoke some skin reddening the next dayactivated the vitamin D receptor and the cathelicidin gene in the exposed skin.

Sthle is now beginning a trial of people with skin infections. A drug analog of 1,25-D will be applied to see whether it speeds wound healing.

Flu too?

Many other findings also suggested to Cannell's team that flu vulnerability might be tempered by adequate vitamin D intake. The researchers have marshaled data, gleaned from 120 or so reports over the past 70 years, suggesting a link between vitamin D and resistance to infections.

For instance, the researchers point to studies showing that in winter, colds, flu, and other respiratory diseases are more common and more likely to be deadly than they are in summer. During winter, ultraviolet-light exposure tends to be low because people spend more time indoors and the atmosphere filters out more of the sun's rays, especially at mid and high latitudes.

Cannell's group cites a 1997 study showing that the rate of pneumonia in Ethiopian children with rickets, and therefore a likely vitamin D deficiency, was 13 times as high as in children without that disease. The researchers also point to five studies since the 1930s that have linked reduced risks of infectious disease to dietary supplementation with cod liver oil, a rich source of vitamin D.

Although the arguments in the paper by Cannell's group "are provocative," White says, "I find them believable."

So does Gallo. "There are many microbes out there that rarely-to-never cause disease in immunocompetent individuals. It's not because the microbes don't choose to infect us," he notes. "It's because the body's immune defense against the microbes is sufficient to control their proliferation."

It's possible, he says, that a shortfall in vitamin D might seriously compromise that defense.

Gombart's group is developing rodents in which vitamin D modulates cathelicidin.

Until such lab animals are available, vitamin D's impacteven on flu risk"should be explored in clinical trials," Zasloff says, because the treatment poses little risk to people.

Moreover, he argues, the payoff from any positive finding "would be amazing. Imagine being able to block the spread of epidemic flu with appropriate doses of this vitamin."


This article reminds me that in preantibiotic days, tuberculosis patients were put on a fresh-air-and-sunshine regimen. Could the vitamin D so acquired account for the cures this system sometimes produced?

Nancy Axford
Sacramento, Calif.

Researcher John J. Cannell points to TB sanitariums as anecdotal evidence that sunlight fights infections.J. Raloff

Does the vitamin D in milk help protect against infection?

Graeme McRae
Palmdale, Calif.

Probably not, according to Michael Holick of Boston University, who has measured the vitamin's content in milk. Far better, he says, would be cod-liver oil, with "a whopping 1,360 [international units of vitamin D] per tablespoon."J. Raloff

If you have a comment on this article that you would like considered for publication in Science News, send it to editors@sciencenews.org. Please include your name and location.

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Braff, M.H. . . . and R.L. Gallo. 2005. Cutaneous defense mechanisms by antimicrobial peptides. Journal of Investigative Dermatology 125(July):9-13. Available at http://dx.doi.org/10.1111/j.0022-202X.2004.23587.x.

Cannell, J.J., et al. 2006. Epidemic influenza and vitamin D. Epidemiology and Infection 136(December):1129-1140. Abstract and preprint available at http://dx.doi.org/10.1017/S0950268806007175.

Chromek, M. . . . R.L. Gallo, et al. 2006. The antimicrobial cathelicidin protects the urinary tract against invasive bacterial infection. Nature Medicine 12(June):636-641. Available at http://dx.doi.org/10.1038/nm1407.

Gombart, A.F., Q.T. Luong, and H.P. Koefler. 2006. Vitamin D compounds: Activity against microbes and cancer. Anticancer Research 26(July-August):2531-2542. Abstract available at http://www.iiar-anticancer.org/research/level3.php?

Gombart, A.F., N. Borregaard, and H.P. Koeffler. 2005. Human cathelicidin antimicrobial peptide (CAMP) gene is a direct target of the vitamin D receptor and is strongly upregulated in myeloid cells by 1,25-dihydroxyvitamin D3. FASEB Journal 19(July):1067-1077. Available at http://www.fasebj.org/cgi/content/full/19/9/1067.

Howell, M.D. . . . R.L. Gallo, et al. 2004. Selective killing of vaccinia virus by LL-37: Implications for eczema vaccinatum. Journal of Immunology 172(Feb. 1):1763-1767. Available at http://www.jimmunol.org/cgi/content/full/172/3/1763.

Liu, P.T., et al. 2006. Toll-like receptor triggering of a vitamin D-mediated human antimicrobial response. Science 311(March 24):1770-1773. Abstract available at http://www.sciencemag.org/cgi/content/abstract/311/5768/1770.

Lpez-Garca, B., P.H.A. Lee, and R.L. Gallo. 2006. Expression and potential function of cathelicidin antimicrobial peptides in dermatophytosis and tinea versicolor. Journal of Antimicrobial Chemotherapy 57(May):877-882. Abstract available at http://dx.doi.org/10.1093/jac/dkl078.

Mallbris, L. . . . and M.M. Sthle. 2005. UVB upregulates the antimicrobial protein hCAP18 mRNA in human skin. Journal of Investigative Dermatology 125(November):1072-1074. Available at http://www.nature.com/jid/journal/v125/n5/full/5603631a.html.

Muhe, L., et al. 1997. Case-control study of the role of nutritional rickets in the risk of developing pneumonia in Ethiopian children. Lancet 349(June 21):1801-1804. Abstract available at http://dx.doi.org/10.1016/S0140-6736(96)12098-5.

Murakami, M. . . . and R.L. Gallo. 2005. Expression and secretion of cathelicidin antimicrobial peptides in murine mammary glands and human milk. Pediatric Research 57(January):10-15. Available at http://www.pedresearch.org/cgi/content/full/57/1/10.

Wang, T.-T. . . . and J.H. White. 2004. Cutting edge: 1,25-dihydroxyvitamin D3 is a direct inducer of antimicrobial peptide gene expression. Journal of Immunology 173(Sept. 1):2909-2912. Available at http://jimmunol.org/cgi/content/full/173/5/2909.

Weber, G. . . . and M. Sthle. 2005. Vitamin D induces the antimicrobial protein hCAP18 in human skin. Journal of Investigative Dermatology 124(May):1080-1082. Available at http://dx.doi.org/10.1111/j.0022-202X.2005.23687.x.

Zasloff, M. 2006. Fighting infections with vitamin D. Nature Medicine 12(April):388-390. Abstract available at http://dx.doi.org/10.1038/nm0406-388.

Further Readings:

Diamond, T.H., et al. 2005. Annual intramuscular injection of a megadose of cholecalciferol for treatment of vitamin D deficiency: Efficacy and safety data. Medical Journal of Australia 183(July 4):10-12. Available at http://www.mja.com.au/public/issues/183_01_040705/

Germain, R.N. 2004. An innately interesting decade of research in immunology. Nature Medicine 10(December):1307-1320. Available at http://dx.doi.org/10.1038/nm1159.

Raloff, J. 2004. Vitamin D: What's enough? Science News 166(Oct. 16):248-249. Available at http://www.sciencenews.org/articles/20041016/bob9.asp.

______. 2004. Vitamin boost. Science News 166(Oct. 9):232-233. Available at http://www.sciencenews.org/articles/20041009/bob8.asp.

______. 2004. Should foods be fortified even more? Science News Online (Sept. 11). Available at http://www.sciencenews.org/articles/20040911/food.asp.

______. 1995. Defending us from our dirty mouths. Science News 147(March 18):166. Available at http://www.sciencenews.org/pages/pdfs/

Rogan, M.P., et al. 2006. Antimicrobial proteins and polypeptides in pulmonary innate defence. Respiratory Research 7(Feb. 17):29. Available at http://respiratory-research.com/content/7/1/29.

Wayse, V., et al. 2004. Association of subclinical vitamin D deficiency with severe acute lower respiratory infection in Indian children under 5 y. European Journal of Clinical Nutrition 58(April):563-567. Available at www.nature.com/ejcn/journal/v58/n4/full/1601845a.html.

Zasloff, M. 2006. Inducing endogenous antimicrobial peptides to battle infections. Proceedings of the National Academy of Sciences 103(June 13):8913-8914. Extract available at http://www.pnas.org/cgi/content/extract/103/24/8913.

______. 2005. Sunlight, vitamin D, and the innate immune defenses of the human skin. Journal of Investigative Dermatology 125(November):xvi-xvii. Abstract available at http://dx.doi.org/10.1111/j.0022-202X.2005.23924.x.


John J. Cannell
Atascadero State Hospital
10333 El Camino Real
Atascadero, CA 93422-2061

Adrian Gombart
David Geffen School of Medicine
Cedars-Sinai Medical Center
Davis 5019
Los Angeles, CA 90048

Robert L. Modlin
University of California, Los Angeles
Box 951750-1750

Mona Sthle
Department of Medicine
Karolinska Institutet

John H. White
Departments of Physiology and Medicine
McGill University
McIntyre Building, Room 1128
3655 Drummond Street
Montreal, QC H3G 1Y6

Michael Zasloff
Departments of Surgery and Pediatrics
Georgetown University School of Medicine
Washington, DC 20007

From Science NewsVol. 170, No. 20, Nov. 11, 2006, p. 312.

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