Saskatchewan Disease Control Laboratory Newsletter February 2016 Volume 3, Number1
Contents Highlights of this Newsletter
Highlights 1
Urine Samples for Endocrinology Need to be Preserved
Urine Samples for Endocrinology Need to be Preserved 1
Zika Testing Update on page 2
Celiac Testing and ANA Testing on page 4
Change in Call Back Services for Needle Stick & Exanthem Testing on page 5
On page 6 HIV Viral Load Testing on Infants < 18 Months of Age.
Change in Emergency Numbers on page 9.
Update on Zika Testing from SDCL
2
Celiac Disease
4
Change in Call Back Services for Needle Stick & Exanthem Testing
5
Chlamydia Culturing Testing
5
Urine Samples for Endocrinology Need to be Preserved
About Nucleic Acid Amplification (NAAT)
6
HIV Viral Load Testing on Infants < 18 Months of Age
6
Vitamin D Testing
7
Contact Information for TDG
7
Recently, there has been an increase in the number of urine samples submitted to the Endocrinology section which have not been adequately preserved. To ensure that results for your patient are accurate, we ask you to take the following precautions:
ANA Testing
8
•
Contacts/ Emergency Numbers
9
Requests for Add-on Tests or Lab Results
9
Attachments: Viral Infections 2014-15 Vitamin D Package
SDCL 5 Research Drive Regina, SK S4S 0A4 (306) 787-3131 ISSN 1913-3138
• • •
Catecholamine Panel, Metanephrine Panel, HVA, VMA and 5HIAA Panel, Oxalate: Acidify to a pH between 2 and 4 with 6 N HCl or freeze if acid is not available. Citrate: Add 10 g boric acid as preservative at start of collection. Urinary Free Cortisol: Do not add preservative, store and send frozen. Methyl-malonic acid. Do not add preservative, store and send frozen.
Please refer to the Saskatchewan Disease Control Laboratory’s online compendium (http://sdcl-testviewer.ehealthsask.ca/) to review acceptable preservation for such tests. In most cases, this involves either acidifying or freezing the sample.
.
The SDCL Compendium of Tests, requisition pdfs and shipping instructions are available on-line at http://sdcl-testviewer.ehealthsask.ca
February, 2016
Saskatchewan Disease Control Laboratory Newsletter
❚Update on Zika Testing from SDCL Zika virus infection is caused by a flavivirus
•
Random urine can be added as a secondary
transmitted through the bite of an infected Aedes
sample, 20 ml in sterile container, submitted on
mosquito, mainly Aedes aegypti. Although infections
an ice pack, collected within 10 days of onset of
in humans were documented in the 1950s, Zika
symptoms
virus has only recently emerged as a disease of significant public health concern. At the time of writing, a large outbreak in the Americas has affected more than 20 countries. Before these outbreaks, known areas of endemic transmission were limited to Asia and Africa. It is likely the virus will continue to spread because the principal vectors are found in many tropical and subtropical regions as well as in some warmer temperate regions. Currently, the significant and emerging concern about Zika virus is the spatial and temporal clustering of the Zika virus outbreak in Brazil with the increase in the incidence of children born with microcephaly. This association has been supported
The samples are submitted to the National Microbiology Laboratory for Zika virus PCR. IgM serology will be performed on all PCR-negative serum samples. Zika virus serology cross reacts with West Nile virus, dengue and yellow fever, therefore positive results will be resolved by further evaluation using PRNT (plaque-reduction neutralization test). The PRNT is a technically complicated test which requires at least one week incubation. Confirmation of Zika virus infection by serology often requires a convalescent sample taken 2-4 weeks after the acute illness.
in a small number of cases, through detection of
For each sample you must include:
Zika virus genome in amniotic fluid, placenta and
•
Symptoms, and date of onset of symptoms
tissues of affected fetuses and neonates. In addition,
•
Date sample taken
an apparent increase in Guillain-Barré syndrome
•
Travel history, including travel dates to known
has been noted in Zika virus affected areas of Brazil, and El Salvador, and previously in French Polynesia. The recommended screening for women with two or more symptoms consistent with Zika virus (including acute onset of fever, maculopapular rash, arthralgia or conjunctivitis) who have returned from a Zika virus endemic area is: •
Serum as primary specimen, 5 ml collected in a serum separator vacutainer (SST), centrifuged, within 10 days of onset of symptoms
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dengue- and Zika-affected areas Testing for Zika virus should be considered in the diagnosis of any ill traveler: •
With compatible epidemiological and clinical history
•
Who visited a country where Zika virus transmission is ongoing or widespread and has symptom onset:
Within three days after arrival up to 14 days after departing the endemic area
Saskatchewan Disease Control Laboratory Newsletter
February, 2016
Zika Continued. Testing for other similar viral infections and for
In summary, consider testing pregnant women
malaria, dengue or chikungunya should also be
(symptomatic and asymptomatic) who have
done as appropriate.
returned from an area where Zika virus is known or
The performance characteristics of the Zika virus serologic assay are not known; that is, at this time we do not know what the sensitivity and specificity of the test means with respect to risk for sequelae such as microcephaly. Testing is generally not warranted for returned travelers: •
whose clinically compatible illness has resolved
•
who have travelled and remain asymptomatic
Because of the limitations on interpreting serology, clinicians should consider serial ultrasounds (every 3-4 weeks) to follow pregnant women with confirmed or suspected (if testing results are pending) Zika virus infection in pregnancy or for
suspected to be circulating. Also consider Zika virus when investigating Guillian-Barré syndrome, fetal loss or sickle cell crisis if there is a compatible travel history. For additional information on Zika virus for health please see CATMAT guidance on PHAC website: http://healthycanadians.gc.ca/publications/diseasesconditions-maladies-affections/committeestatement-treatment-prevention-zika-declarationcomite-traitement-prevention/indexeng.php?id=zika_virus_16_phac_catmat If you require further information on Zika virus testing please call SDCL microbiologist on-call at 306-798-1234.
asymptomatic pregnant travelers returning from Zika virus infected areas. Any results that are concerning should prompt consultation with a specialist such as a Maternal Fetal Medicine Specialist to help define risk and counsel the mother.
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February, 2016
Saskatchewan Disease Control Laboratory Newsletter
❚Celiac Testing In September 2015, SDCL moved to a new platform for celiac testing. The assays on the new platform have increased sensitivity such as, for some patients, it may offer an alternative to invasive procedures such as biopsies, especially when diagnosing younger patients. The new test method is a chemiluminescent immunoassay. Celiac testing will continue to be run as a panel which includes anti-tissue transglutaminase (anti-tTG) IgA, and antideamidated gliadin peptide (anti-DGP) IgA and IgG. The new method has greater specificity than the previous method. The reportable range of the three assays is also considerably larger than the previous test method which may be more useful in monitoring compliance with a gluten free diet. The reportable range for anti-tTD IgA is now < 1.9 to > 4965.5 CU; the reportable range for anti-DGP IgA is now < 5.2 to > 2367.3 CU; and the reportable range for anti-DGP IgG is 1936.7 CU. A quantitative IgA test is provided as part of the panel when the anti-DGP IgG is elevated but the anti-DGP IgA and anti- tTG IgA are normal, to detect subjects with either primary or secondary humoral IgA deficiency, which occurs in about 2-3% of the time in celiac disease and can lead to false negative results. If the patient has IgA deficiency the anti-tTG IgG result is available to direct follow up. The serology tests in the celiac panel are used to identify those individuals with high probability of having celiac disease. The clinical relevance of positive tests in the panel should be confirmed by a biopsy of the small intestine examined to detect damage to the intestinal villi. Occasionally further testing includes anti-endomysial antibody to make a diagnosis without a biopsy.
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Requirements for diagnosing CD without duodenal biopsy: Patients at risk of complications from biopsy, including young children, are often candidates to avoid biopsy, especially in the presence of genetic predisposition markers such as HLA DQ2 /DQ8, due to high negative predictive value, and high-risk serological results. Recent studies have suggested that symptomatic patients with high anti-tTG titers greater than 10 times the upper limit of normal could be reliably diagnosed without histological confirmation. Non-invasive monitoring of celiac disease: Non-invasive monitoring is about monitoring the patient every six months looking for a decline in antibody level. Given that antibody levels typically decrease over time with the removal of gluten from the diet, levels of anti-tTG or anti-DGP antibodies will often be followed to ensure that they decline or turn negative altogether. For the purpose of monitoring, anti-DGP antibodies have been shown to be more sensitive in unveiling compliance to a gluten free diet compared to anti-tTG antibodies, even though antibodies to tTG have enhanced sensitivity for diagnosis. Consider using non-invasive monitoring for the diagnosis, and follow up of possible celiac patients.
Saskatchewan Disease Control Laboratory Newsletter
February, 2016
❚Change in Call back Services for Needle Stick and Exanthem Testing As of March 31, 2016 the Saskatchewan Disease Control Laboratory ( SDCL) is changing the needle stick work up and exanthem screening (measles, rubella, mumps) call backs. The needle stick testing is available through the Core Lab while screening for measles, rubella, or mumps are available through the Immunoserology Section. These services are available seven days a week from 8 a.m. to 4 p.m. Samples should be submitted in totes flagged with a yellow closure as per STAT protocol. To request a STAT test from Monday to Friday phone 306-787-3131 - for needle sticks ask for the Core Lab, or for measles, rubella, and mumps, ask for Immunoserology, and provide information on the samples, such as how they are being shipped, the expected time of arrival and the phone number of person to whom the results will be provided. STAT samples that have been received at the SDCL by 4 p.m. Monday to Sunday will be processed that day. On the weekend the Core lab will be carrying a cell phone from 4 p.m. on Friday to 4 p.m. on Sunday. Use the number, 306-529-4304, to access the needle
stick service and to communicate on the progress of the sample being transported to the SDCL. For call back on weekends for exanthem screen tests (measles, rubella, mumps), or vasculitis screen tests, that are performed in the Immunoserology Section, please call the microbiologist-on-call number: 306-798-1234. In addition, as of March 31, 2016 the SDCL will be discontinuing the look-up of results after regular business hours. However, prenatal results such as HIV and group B strep testing done at SDCL are available to hospitals electronically. For example, staff on maternity wards with access to the SDCL portal can use this to obtain results, and other hospitals can call the Emergency Room in their institution to access prenatal testing results through the eHealth viewer, and eventually consider obtaining the information via the “Sunrise Clinical Manager” once it is connected to SLRR. SDCL laboratory results are available Monday to Friday from 8 a.m. to 5 p.m. and Saturday from 7:30 a.m. to 4 p.m., by phoning 306-787-3131.
❚Chlamydia Culture Testing Due to the low sensitivity compared to molecular detection, chlamydia culture testing is no longer available. It has been replaced by Chlamydia trachomatis nucleic acid amplification testing. (NAAT). Please use the following APTIMA collection kits (available from SDCL Materials Management): •
•
Cervix, Urethra or Eye – Use APTIMA Unisex Swab Collection Kit (White labeled tube) For more information, please refer to Doc 140055 SDCL 001R V3.1 Microbiology Requisition Effective Date March 2015 (see SDCL Compendium).
Vagina, Rectum or Throat – APTIMA Vaginal Swab Collection Kit (Orange labeled tube)
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February, 2016
Saskatchewan Disease Control Laboratory Newsletter
❚About Nucleic Acid Amplification (NAAT) There are various terms used to describe the detection of virus particles in the blood – PCR, NAAT and viral load testing. Nucleic-acid amplification tests, or NAATs, refers to the use of a series of repeated reactions to make numerous copies of the target DNA or RNA sequence, so that they are easier to identify.
The HIV viral load assay done at the SDCL is a reverse transcription-polymerase chain reaction (RTPCR) assay for the quantitation of human immunodeficiency virus type 1 (HIV-1) in human plasma from HIV-1 infected individuals over the range of 40 to 10,000,000 copies/mL.
❚HIV Viral Load Testing on Infants < 18 months of Age The Canadian case definition (PHAC, 2009)1 for HIV infection in children under 18 months requires the demonstration of HIV in the infant, by the detection of viral nucleic acid or p24 antigen, or by isolation of HIV in culture, in two separate samples collected at different times. In practice, the most sensitive test for a timely result is the HIV viral load. In infants less than 18 months of age born to HIVpositive women, nucleic acid testing should be done within two weeks after birth and, if negative, repeated at 1 to 2 months and at 3 to 4 months of age. Any positive results should be repeated with a second specimen for confirmation. For children who are born to HIV-positive women and who have negative nucleic acid results, antibody testing should be done at 12 and 18 months of age to ensure that they have lost
6
maternally derived antibodies. Infants receiving antiviral prophylaxis or treatment need not be tested while receiving antivirals, but should be tested three to four weeks after cessation of therapy. For HIV viral load testing on infants or adults order the test on the Chemistry / Immunoserology requisition. Refer to the SDCL Compendium for specimen collection procedure. Public Health Agency of Canada (2009) Case Definitions for Communicable Diseases under National Surveillance. CCDR 35S2: 86-87 at
1
http://www.phac-aspc.gc.ca/publicat/ccdrrmtc/09vol35/35s2/index-eng.php
Saskatchewan Disease Control Laboratory Newsletter
February, 2016
❚ Vitamin D Testing Saskatoon Health Region and the Saskatchewan Disease Control Laboratory provide Vitamin D testing for the province. In reviewing the data from our information systems, we have identified an opportunity to better manage vitamin D testing in the province. In this regard, Drs. A. Lyon (SHR), B. Mali (RQHR) and J. Eichhorst (SDCL) have reviewed the data from our laboratories and the clinical best practice guidelines for this laboratory testing. This analysis suggests that most physicians and nurse practitioners are good stewards of resources in the care of their patients. We recognize and appreciate that the majority of providers order vitamin D tests on selected patients where it is clinically indicated (typically far fewer than 50 vitamin D tests per year per provider). However, we have noted that a small number of providers order the majority of testing.
As a result, we are providing information to practitioners regarding the issue. We ask all practitioners to limit orders for vitamin D tests to patients where the test is clinically indicated and to avoid routine screening. We are also distributing a patient information package on vitamin D testing so that physicians and nurse practitioners have a document to provide to patients who have questions about vitamin D testing. The literature supports the concept that, in most cases, it is wise to “treat – not test” and suggest patients supplement their diet with vitamin D (testing not generally required prior to or following supplementation). Over the next number of months, the Saskatoon Health Region and SDCL will be monitoring the use of this test among healthcare providers to ensure it is used appropriately.
❚Contact information for Transportation of Dangerous Goods If you have any inquiries regarding packaging or shipping diagnostic samples, please check with Transport Canada. Please find coordinates below.
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February, 2016
Saskatchewan Disease Control Laboratory Newsletter
❚ANA Testing The SDCL testing platform for the detection of antinuclear antibodies (ANA) uses an indirect immunofluorescence test method. Each sample is tested at an initial dilution of 1:80. If a sample result is either Negative or a Weak Positive (dilution of 1:80) then the following comment will be added, “Only ANA screen positive samples with a titre of 1:160 or greater are reflexed for a Double-Stranded DNA Antibody (dsDNA) and Antibodies against Extractable Nuclear Antigens (ENA)”. If the sample result is positive at 1:160 it is repeated at an 1:80 and 1:640 dilution. The reportable positive dilutions are
1:160, 1:320, 1:640, 1:1280 and 1:2560. The four most common reportable patterns are homogeneous, speckled, centromere and nucleolar. Samples that are ANA Positive (dilution of 1:160 or greater) will be tested for dsDNA and ENA. The ENA panel includes Anti-SSA, Anti-SSB, AntiSmith, Anti-nRNP/Sm, Anti-Jo-1 and Anti-Scl-70. Please note that all requests for dsDNA and ENA testing will first have an ANA performed and will only be tested for dsDNA and ENA if the ANA is positive.
Reminder: A complete mailing address or validated fax number is required for all copy-to requests. Failure to submit this information will delay in you receiving results for your patient.
To receive future copies of the SDCL Newsletter electronically and to save trees, please email: Janette Romanuik at
[email protected] with your email address, organization, address and phone number.
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Saskatchewan Disease Control Laboratory Newsletter
February 2016
The Saskatchewan Disease Control Laboratory (SDCL) phone tree (306) 787-3131 has been created to help assist with timely response to client inquiries. Provided is a list of the tree numbers and information that clients will access when choosing a number. Hours of operation
Monday to Friday 8:00 AM to 5:00 PM. On Saturdays limited services 7:30 AM to 4:00 PM.
Press 1: For general medical laboratory information, test results and to arrange for Stat testing Customer Services staff provides information to callers and responds to requests for lab test results. If all lines are busy, you may leave a message (provide details) for a return call or to have lab test results faxed (validated fax number only). For lab test results, provide the patient HSN, test, collection date, validated fax number, who is calling and return phone number. Note for STAT testing or requests for technical information, your call will be transferred to the appropriate lab section. Press 2: Compendium Information - To access the on-line compendium go to
http://sdcl-testviewer.ehealthsask.ca Press 3: Out of Province or Country Referrals - For information on tests referred out-of-province or country. Press 4: Exceptions to Provide Missing Information from requisitions sent to SDCL - To provide missing sample information that has been requested by SDCL staff. Press 5: Maternal Serum Screening - For results on maternal serum screening samples submitted. Press 6: Water Samples - For results on water samples submitted. Press 7: Shipping and Supplies - For example, requests for requisitions or transport media such as SAF, Cary Blair or viral for samples submitted to the Saskatchewan Disease Control Laboratory. Press 8: Emergency and After Hours Service (Evenings and Weekend) - (listen only) STAT Toxicology (306) 536-4653 STAT weekend needle stick services from 8 a.m. to 4 p.m. (306) 529-4304 STAT for measles, mumps, rubella call microbiologist-on-call (306) 798-1234 Note for Call backs: Provide the patient’s HSN, test required, name of physician requesting the STAT testing. Or stay on the line to repeat the menu. Requests for Add-on Tests or Laboratory Results (Outside “Circle of Care”): 1. SDCL does not accept verbal requests for testing and requires a faxed (or hard copy) request (or requisition be submitted for add-on test requests. If a request for laboratory results for a patient is made by someone not obviously identified as in the "circle of care", before release of results can occur, SDCL requires a "signed release of medical information form" to be faxed to (306) 787-9122. For a copy of the release form, contact SDCL at (306) 787-3131.
9
282
8
490 10 25 88
1 2 1 1 1 1
2 2 2 1 1 3 2 6 6
1 1 1
0
3
1
61 79 91 106 157 176 142 128 259 285
1
14 85 18 9 58 15 16 74 22 7 83 11 5 109 16 9 141 18 11 91 12 8 81 25 8 98 25 4 121 11
1484
8
91 941 173 407 178
2 3 1
73 45 46 67 37 29 17 30 32 31
19 13 17 12 22 22 10 24 18 21
* Possible vaccine induced cases have not been removed
662 43 23 11 2
2 1 3 1
50 6 2
9 160 3 35 16 174 68 67 50 19 3 5 1
1
3
6 33 75 107 56 16 1 1
0
2 7 17 29 31 38 12 11 3 3
484 50 295 153
93 71 44 58 38 24 12 20 14 20
3 8 7 5 6 2
188 331 244 79 17 2
1 3 2
1 1
1 1
26 20 42 31 15 7 10 6 1 2
4 4
1
12 7 7 3 3 3 5
4
50 160 394 27
1
5 2 2 3 3 1 3
1 21 91 734 21 6 10 22 20 14 10
37 863 82
WNV
5 5
4 5 1 1 1 1
4 3 1 8 5
Varicella zoster
81 26 255 179 63 15 2
Rubella*
110 7 9 16 2 7 30 3 18 28 1 9 67 2 15 56 2 6 33 3 6 21 2 7 20 8 3 21 15 6 39 3 6 76 7 10 517 55 102
RSV
4 12 2 12 7 23 3 31 10 43 4 10 4 2 6 1 2 2 4 4 52 134
Rotavirus
Parvovirus
Parechovirus
Parainfluenza
5 1
1 3 21 1 3 512 26 2 1 742 541 85 158 460 20 403 36 81 8 3
Norovirus
17 19 17 22 30 17 15 17 17 16 13 19 219
MPV
65 20 53 51 25 29 20 29 22 33 32 64 443
Influenza B
14 7 19 14 9 11 14 17 16 17 13 11 162
Influenza A - not subtyped
62 68 67 65 82 51 58 65 67 58 59 60 762
Influenza A(H3N2)
6 18 12 9 10 7 15 14 9 6 9 21 136
Influenza A(H1N1)pdm09
HSV-2
HAV
Entero/Rhino
Enterovirus NT
90 2 19 122 2 116 3 129 4 1 108 5 5 90 4 88 5 267 1 249 98 103 1 27 1479 17
Mumps*
1
128 198 95 48 5 8 1 4 1 1 3 6 1 1
70
1 2 3 5
HSV-1
6 13 7 11 1 8 7 9 13 13
29 33 40 38 21 34 19 17 25 26
2 1 3 4 2 4 11 15 14 12 2
HIV-1
11 7 6 12 7 10 7 10 2 18 9 14 113
Echovirus
EBV
CMV
4 2 2 67 1 1 30 1 3 8 1 3 2 1 3 2 1 3 2 1 1 1 3 1 23 1 392 12 24
HCV
1
2
2014 to 2015
HBV
1
Coxsackie virus
Coronavirus 213 45
Number of Positive Findings
Measles*
Jan-15 Feb Mar Apr May June July Aug Sept Oct Nov Dec Totals
59 19 52 40 49 29 29 15 22 25 30 28 397
Astro/Calicivirus
Date Jan-14 Feb Mar Apr May June July Aug Sept Oct Nov Dec Totals
Adenovirus
Laboratory Evidence of Human Viral Infections -
3 2 2
6 8 7 11 1 10 2 11 6 1 5 2 9 3 17 9 13 102 0 1 2 1 2
1 1
8
10 11 18 11 7 12 18 9 12 11
119 0
February 18, 2016 All Physicians and Nurse Practitioners
Dear Doctor or Healthcare Provider: RE: Vitamin D Testing In Saskatchewan Currently in Saskatchewan, only the Saskatoon Health Region (SHR) and the Saskatchewan Disease Control Laboratory (SDCL) maintain the infrastructure to deliver vitamin D testing. Both SDCL and SHR are committed to supporting good patient care through high quality vitamin D testing in those cases where it is required. In reviewing the data from our information systems, we have identified an opportunity to better manage vitamin D testing in the province. In this regard, Drs. A. Lyon (SHR), B. Mali (RQHR) and J. Eichhorst (SDCL) have reviewed the data from our laboratories and the clinical best practice guidelines for this laboratory testing. This analysis suggests that most physicians and nurse practitioners are good stewards of resources in the care of their patients. We recognize and appreciate that the majority of providers order vitamin D tests on selected patients where it is clinically indicated (typically far fewer than 50 vitamin D tests per year per provider). However, we have noted that a small number of providers order the majority of testing. As a result, we are providing information to practitioners regarding the issue. We ask all practitioners to limit orders for vitamin D tests to patients where the test is clinically indicated and to avoid routine screening. We are also distributing a patient information package on vitamin D testing so that physicians and nurse practitioners have a document to provide to patients who have questions about vitamin D testing. The literature supports the concept that, in most cases, it is wise to “treat – not test” and suggest patients supplement their diet with vitamin D (testing not generally required prior to or following supplementation). We are confident that with the support of health care providers, we will be able to manage the delivery of this test in a manner that provides the maximum clinical benefit to our patients.
Letter To Healthcare Providers Regarding Vitamin D Testing Page 2 February 18, 2016
The Saskatchewan Medical Association (SMA) Board and Representative Assembly have endorsed the recommendations of Choosing Wisely Canada. This work is part of our first efforts to improve the appropriate use of all laboratory resources. This work is consistent with both the Choosing Wisely Canada campaign and the Appropriateness of Care Framework that was developed in Saskatchewan. If you have questions regarding this testing, please feel free to call either Dr. Jeff Eichhorst (SDCL) or Dr. Andrew Lyon (Saskatoon Health Region). Dr. Eichhorst can be reached at (306) 787 3284 or by email at
[email protected] Dr. Lyon can be reached at (306) 655 5164 or by email at
[email protected] . Copies of both the clinical recommendation and the Patient Information Package are available online in the SDCL compendium at http://sdcl-testviewer.ehealthsask.ca/ in the What Is New at SDCL section. This document will also be posted on the public website Saskatchewan.ca . We thank you for your consideration of this information and your support. Sincerely,
Dr. Brian Laursen Chair, Senior Medical Officers Committee
Saskatchewan Clinical Practice Recommendation For Appropriate Use of Vitamin D Testing January 2016
General Population: • There is no clinical benefit to test for serum vitamin D levels in the general population. • Saskatchewan residents are likely at risk of low vitamin D levels from autumn to spring, however, supplementation should be recommended without a need to screen or monitor vitamin D levels. (Health Canada Dietary Reference Intakes - http://www.hc-sc.gc.ca/fnan/nutrition/vitamin/vita-d-eng.php) Recommendations: • Do not routinely measure Vitamin D in the general population who may be at risk from low dietary intake and/or low exposure to sunlight. Vitamin D supplementation is appropriate for this general population without the need to screen or monitor Vitamin D levels.
Guideline for ordering serum 25-Hydroxy Vitamin D: Clinically Indicated Vitamin D testing: • Metabolic bone diseases • Malabsorption syndromes • Hypo or hypercalcemia • Prescribed medications that may interfere with Vitamin D metabolism such as anticonvulsants • Significant renal or liver disease Health Canada Recommended Daily Intake of Vitamin D for Patients: Age group Infants 0-6 months Infants 7-12 months Children 1-3 years Children 4-8 years Children and Adults 9 to 70 years Adults > 70 years Pregnancy & Lactation
Recommended Dietary Allowance (RDA) per day 400 IU (10 mcg) 400 IU (10 mcg) 600 IU (15 mcg) 600 IU (15 mcg)
Tolerable Upper Intake Level (UL) per day 1000 IU (25 mcg) 1500 IU (38 mcg) 2500 IU (63 mcg) 3000 IU (75 mcg)
600 IU (15 mcg)
4000 IU (100 mcg)
800 IU (20 mcg) 600 IU (15 mcg)
4000 IU (100 mcg) 4000 IU (100 mcg)
References: Choosing Wisely Canada / Family Medicine - October 29, 2014 Clinical Practice Guideline - Toward Optimized Practice www.topalbertadoctors.org August 2014 Vitamin D Testing Protocol- British Columbia Medical Association, June 2013 Health Canada Dietary Reference Intakes for Vitamin D - http://www.hc-sc.gc.ca/fnan/nutrition/vitamin/vita-d-eng.php#a15
Patient Information for Adults about Vitamin D Inadequacy Saskatchewan residents are at risk of low vitamin D levels from autumn to spring. Obtaining sufficient vitamin D from natural food sources alone is difficult. For many people, consuming vitamin D-fortified foods and being exposed to some sunlight are essential for maintaining a healthy vitamin D status. Older adults are at increased risk of developing vitamin D insufficiency in part because as they age, skin cannot synthesize vitamin D as efficiently, they are likely to spend more time indoors, and they may have inadequate intake of the vitamin. There is no clinical value in performing vitamin D tests on patients who are thought to be at risk for sub-optimal vitamin D levels and who would benefit from vitamin D supplementation. Testing for vitamin D is only recommended for certain medical conditions.
Do I need a blood test to check my vitamin D level? No, routine testing for vitamin D levels is only recommended for patients with certain medical conditions.
Which foods contain vitamin D? Foods with a higher amount of vitamin D include fish, liver, and egg yolk. Excellent sources of vitamin D are foods and beverages that have vitamin D added to them. Cow’s milk always has added vitamin D. Orange juice, margarine, and soy beverage usually have it added. For other foods, check the label. You know vitamin D has been added if you see ‘fortified’ or ‘enriched’ on the label.
Should I take a Vitamin D supplement? You might find it difficult to get enough vitamin D from food alone. You can take a single vitamin D supplement or a multivitamin with vitamin D in it.
Do I need vitamin D? Vitamin D is important for everyone. Vitamin D plays an important role in helping the body to absorb calcium through the small intestine. Our bodies need calcium to help make and maintain healthy bones, muscles and teeth. Too little vitamin D may be linked to a variety of common diseases.
Health Canada Dietary Reference Intakes for Vitamin D http://www.hc-sc.gc.ca/fn-an/nutrition/vitamin/vita-d-eng.php#a15
