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Vitamin A Deficiency
Dr. Dipesh Tamrakar MBBS MD
Community Medicine and Tropical Diseases Department of Community Medicine KUSMS Scope of Problem • Vitamin A deficiency affects approximately 21 percent (250 million) of the developing world's preschool-aged children and leads to the deaths of over 800,000 women and children each year. • Vitamin A deficiency is estimated to be responsible for nearly one-fourth of global child mortality from measles, diarrhea and malaria and for a fifth of all-cause maternal mortality. • In the 1990s: 2-8 percent of preschool-aged Nepali children experienced severe vitamin A deficiency, or xerophthalmia, associated with blindness and risk of child death. • This silent syndrome compromises immune system function, leaving young children unable to fight common childhood infections such as measles or diarrhea
• Vitamin A deficiency is also the leading cause of
preventable childhood blindness in developing countries, with up to 500,000 children going blind because of it each year
• In addition, half of these children will die within a
year of losing their sight. Vitamin A Essential nutrient required by humans for the normal functioning of the visual system, maintenance of cell function for growth, epithelial cellular integrity, immune function and reproduction Dietary requirements for vitamin A are from : mixture of preformed vitamin A (retinol) present in animal source foods provitamin A carotenoids, derived from foods of vegetable origin and which have to be converted into retinol by tissues such as the intestinal mucosa and the liver in order to be utilized by cells Aside from the clinical ocular signs of night blindness and xerophthalmia, symptoms of vitamin A deficiency (VAD) are largely non-specific Biochemical measures of vitamin A status are essential in order to attribute non-ocular symptoms to VAD
4 Vitamin A deficiency: Vitamin A deficiency: Prevalence of in prevalence in pre-school pre-school age children (Serum retinol < 0.70 µmol /l) age children Public Age group Country Estimate (%) health (yrs) problem Prevalence of serum retinol (<0.70 µmol/l) and number of Bangladesh 0.5 – 4.99 21.7 [18.5 – 25.3] Severe years individuals affected among pre-school age children in Bhutan 1.00 – 22.0 [18.4 – 26.0] Severe South-East Asia 4.99 years DPR Korea NA 27.5 Severe Prevalence No. affected India 1.00 – 62.0 [59.8 – 64.1] Severe (%) (in millions) 4.99 Indonesia NA 19.6 [ 2.2 – 72.3] Moderate South- 49.9% 91.5 Maldives 2.00- 2.99 9.4 [6.7 – 13.1] Mild East (45.1 – 54.8) (82.6 – 100) Myanmar NA 36.7 [5.1 – 86.2] Severe Asia Nepal 0.5 – 4.99 32.3 [28.0 – 36.9] Severe Sri Lanka 0.5 – 5.99 35.3 [32.3 – 38.5] Severe Thailand NA 15.7 [1.7 – 66.5] Moderate Global Prevalence of vitamin A deficiency in populations at Timor Leste NA 45.8 [6.9 – 90.6] Severe risk 1995 – 2005 – WHO Global Database (2009) Causes of Deficiency • Poor Diet • Diarrhoea • Measles • Roundworms infestation aggravate Vit A deficiency Deficiency Features • Xerophthalmia: main feature • Nightblindness: initial feature Difficult to detect in children who are not mobile yet • Bitot’s spot: dry, muddy wrinkled conjunctiva followed by grayish, silvery or foamy patches on the temporal side of the cornea • Photophobia WHO Classification of Xerophthalmia
Primary Secondary
X1A Conjuctival Xerosis XN Night Blindness
X1B Bitot’s Spots XF Fundal Changes
X2 Corneal Xerosis XS Corneal Scarring
X3A Corneal Ulceration (<1/3 of Cornea) X3B Corneal Ulceration (>1/3 of Cornea) Prevention • Health education to consume- green leafy vegetables, deep yellow fruits and vegetables. Liver, egg yolk. Fat necessary for absorption of vit A • 6 monthly supplementation of vitamin A to all children from 6 months- 5 years Schedule of Vitamin A Supplementation in Nepal Subject Vitamin A supplementation Infants 6-12 months of age 100, 000 IU of Vitamin A and older children weighing every six months. less than 8 kg Immunization against measles Children from 1 to 5 years of 200, 000 IU of vitamin A age every six months Lactating mothers 200,000 IU of Vitamin A at the time of delivery or within 2 months Vitamin A supplementation in pregnant women
Suggested vitamin A supplementation scheme in pregnant women for
the prevention of night-blindness in areas with severe public health problem related to vitamin A Target Group Pregnant Women Up to 10 000 IU vitamin A (daily dose) OR Dose Up to 25 000 IU vitamin A (weekly dose) Frequency Daily or weekly Routes of Oral liquid, oil-based preparation of retinyl administration palmitate or retinyl acetate A minimum of 12 weeks during pregnancy until Duration delivery Population where the prevalence of night-blindness Settings is 5% or higher in pregnant women or 5% or higher in children 24 – 59 months of age Treatment • Xerophthalmia: Vit A given in the following doses.
- Children < 1yr or wt < 8kg (3 doses): 1 lac i.u once daily for 2 days and after 14days to 1 month starting treatment - Children > 1yr (3 doses): 2 laks i.u once daily for 2 days and after 14 days to 1 month starting treatment
• On diagnosis of Measles: Vit A for 2 days as above
• Severely malnourished child/ child with persistent diarrhoea without features of xerophthalmia: Vit A as recommended for 1 day. NEPAL NATIONAL VITAMIN A PROGRAM History of Vit. A Supplementation Program in Nepal • In 1993: the government of Nepal initiated the National Vitamin A Programme (NVAP) with the support of UNICEF, USAID, and local researchers and NGOs. • NVAP aimed to reduce child mortality and morbidity related to vitamin A deficiency by providing twice-yearly supplements of vitamin A capsules to children in priority districts. • A large cadre of women who served as community-based volunteers was integral to the rapid expansion of the program to Nepal’s 75 districts. Nepal Vitamin A Program Objectives
• Reduce child mortality and prevent
xerophthalmia through supplementation of children 6-60 months of age with high-dose vitamin A capsules
• Reduce vitamin A deficiency to a level that
no longer constitutes a public health problem. Outcomes • Impact: NVAP prevented blindness in approximately 2,000 children each year, and was found to reduce under-five mortality in Nepal by about half between 1995 and 2000. • Cost and Cost-Effectiveness: The cost of delivering two rounds of vitamin A per year was approximately $1.25 per child covered. With an estimated cost of $327 –$397 per death averted and $11-12 per disability-adjusted life year (DALY) gained, NVAP is considered highly cost-effective. Nepal Vitamin A Program Implementation Strategy
• twice yearly supplementation
• community-based • female volunteers (FCHVs) • vit A and health education • monitoring and evaluation Nepal Vitamin A Program All 75 Districts are covered now
NVAP Initiated Districts
Child Deaths Averted by Vitamin A Supplementation 50000 100 90 90 92 96 96 86 86 92 40000 80 35,329 Number of Deaths Averted
Coverage (6-59 months) Nepal Vitamin A Program Elements of Success
• Community-based, female community health
volunteers • Slow, consistent, gradual expansion • GON ownership, enabling policy environment • Donor coordination • Community empowerment and ownership • Support systems strengthened National Nutrition Program • Target Eliminate vitamin A deficiency and sustain elimination by 2017 Thank you
