Field prophylactic trial with a single annual oral massive dose of vitamin A

National control programme against nutritional blindness due to vitamin A deficiency: Current status & future strategy

Vitamin A deficiency (VAD) among 1-5 yr old children is reported to be widely prevalent in Southeast Asia and some parts of Africa. It is the leading cause of preventable blindness in young children in the low-income countries in the world. Children even with milder signs of VAD have higher risk of morbidity and mortality. Inadequate dietary intakes of vitamin A with poor bioavailability associated with frequent infections are the primary contributory factors. Currently available approaches to control VAD are ensuring adequate intakes of vitamin A in daily diets, fortification of foods consumed regularly particularly among the low-income communities and periodic administration of massive dose of vitamin A supported by public health interventions and reinforced by behaviour change communication. Under the National Programme in India, six monthly administration of mega dose of vitamin A to 6-59 month old children has been implemented since 1970, to prevent particularly blindness due to VAD and control hypovitaminosis A. Despite inadequate coverage and poor implementation of the programme, blindness due to VAD in children has almost disappeared, though subclinical VAD is still widely prevalent. Based on the results of meta-analysis of eight trials, which indicated that vitamin A supplementation to children aged 6-59 months reduced child mortality rates by about 23 per cent, the World Health Organization made a strong recommendation that in areas with VAD as a public health problem, vitamin A supplementation should be given to infants and children of 6-59 months of age as a public health intervention to reduce child morbidity and improve child survival. At present, in India, there is a need for change in policy with respect to the national programme to opt for targeted instead of universal distribution. However, NITI (National Institution for Transforming India) Aayog, which formulates policies and provides technical support to the Government of India, recommends strengthening of the National Programme for control of VAD through six monthly vitamin A supplementation along with health interventions. Eventually, the goal is to implement food based and horticulture-based interventions harmonizing with public health measures, food fortification and capacity building of functionaries for elimination of VAD.

Potential Use of Red Palm Oil in Combating Vitamin A Deficiency in India

Vitamin A deficiency is widespread among pre-school children in India. Severe forms of vitamin A deficiency lead to nutritional blindness. Massive-dose vitamin A prophylaxis has been in operation in India since the early 1970s to prevent nutritional blindness. with a decline in the severe forms of vitamin A deficiency, the emphasis has shifted to a food-based approach to control the still widespread mild to moderate forms of vitamin A deficiency by promoting consumption of carotene-rich foods such as fruits and vegetables, especially green leafy vegetables. Compared with these sources, red palm oil is a richer source of carotenes, with 500–600 μg of carotenes per gram of oil. Further, the carotenes in red palm oil may be better absorbed than carotenes from other plant sources because they are in an oil medium. the value of red palm oil as a rich source of carotenes to cure and prevent vitamin A deficiency was recognized and studied in India as far back as the mid-1930s. Later, during the 1980s, systematic studies in both animals and humans established the safety, acceptability, and nutritional potential of crude red palm oil as a rich source of provitamin A. During the early 1990s, community studies were carried out with edible-grade crude palm oil to improve the vitamin A status of children and mothers. with the current availability of highly refined edible-grade red palm oil, its use as a source of provitamin A at home and in feeding programmes for children should pose no problem, because it is more acceptable than crude palm oil. It can indeed prove to be a potential source of carotene to eradicate vitamin A deficiency in the country.

Controversies Continue: Universal Supplementation of Megadose of Vitamin A to Young Children in India

The universal megadose of vitamin A (MDVA) supplementation program was started in the year 1970. The program is presently in continuation for the prevention of nutritional blindness and possibly reduction in under-five mortality rate (U5MR). Presently, blindness due to vitamin A deficiency (VAD) has disappeared and the difference between U5MR and infant mortality rate (IMR) is less than 10 thus MDVA is unlikely to have any impact on mortality. The continuation of universal MDVA needs to be modified based on the current scientific evidence.

Liver intake in 24-59-month-old children from an impoverished South African community provides enough vitamin A to meet requirements

OBJECTIVE

To assess the contribution of liver to the vitamin A intake of 24-59-month-old children from an impoverished South African community where liver is frequently consumed and vitamin A deficiency previously shown to be absent.

DESIGN

Cross-sectional.

SETTING

Northern Cape Province, South Africa.

SUBJECTS

Children aged 24-59 months (n 150). Vitamin A intake from liver was assessed using a single 24 h recall and a quantified liver frequency questionnaire. In addition, information on vitamin A intake via the national fortification programme was obtained from the 24 h recall and information on vitamin A supplementation from the Road-to-Health Chart. Height, weight and socio-economic data were also collected.

RESULTS

Stunting, underweight and wasting were prevalent in 36·9 %, 25·5 % and 12·1 % of children. Mean daily vitamin A intake from liver was 537 and 325 μg retinol equivalents measured by the 24 h recall and liver frequency questionnaire, respectively. Liver was consumed in 92·7 % of households and by 84·7 % of children; liver intake was inversely related to socio-economic status (P < 0·05). The food fortification programme contributed 80 μg retinol equivalents and the vitamin A supplementation programme 122 μg retinol equivalents to daily vitamin A intake.

CONCLUSIONS

The study showed that liver alone provided more than 100 % of the Estimated Average Requirement of the pre-school children in this impoverished community. The results also challenge the notion generally held by international health bodies that vitamin A deficiency, poor anthropometric status and poverty go together, and reinforces the fact that South Africa is a culturally diverse society for which targeted interventions are required.

Cost-effectiveness of "golden mustard" for treating vitamin A deficiency in India

BACKGROUND

Vitamin A deficiency (VAD) is an important nutritional problem in India, resulting in an increased risk of severe morbidity and mortality. Periodic, high-dose vitamin A supplementation is the WHO-recommended method to prevent VAD, since a single dose can compensate for reduced dietary intake or increased need over a period of several months. However, in India only 34 percent of targeted children currently receive the two doses per year, and new strategies are urgently needed.

METHODOLOGY

Recent advancements in biotechnology permit alternative strategies for increasing the vitamin A content of common foods. Mustard (Brassica juncea), which is consumed widely in the form of oil by VAD populations, can be genetically modified to express high levels of beta-carotene, a precursor to vitamin A. Using estimates for consumption, we compare predicted costs and benefits of genetically modified (GM) fortification of mustard seed with high-dose vitamin A supplementation and industrial fortification of mustard oil during processing to alleviate VAD by calculating the avertable health burden in terms of disability-adjusted life years (DALY).

PRINCIPAL FINDINGS

We found that all three interventions potentially avert significant numbers of DALYs and deaths. Expanding vitamin A supplementation to all areas was the least costly intervention, at $23-$50 per DALY averted and $1,000-$6,100 per death averted, though cost-effectiveness varied with prevailing health subcenter coverage. GM fortification could avert 5 million-6 million more DALYs and 8,000-46,000 more deaths, mainly because it would benefit the entire population and not just children. However, the costs associated with GM fortification were nearly five times those of supplementation. Industrial fortification was dominated by both GM fortification and supplementation. The cost-effectiveness ratio of each intervention decreased with the prevalence of VAD and was sensitive to the efficacy rate of averted mortality.

CONCLUSIONS

Although supplementation is the least costly intervention, our findings also indicate that GM fortification could reduce the VAD disease burden to a substantially greater degree because of its wider reach. Given the difficulties in expanding supplementation to areas without health subcenters, GM fortification of mustard seed is an attractive alternative, and further exploration of this technology is warranted.

Measles blindness

Measles remains a major problem in developing countries, where it affects an estimated 30 million children a year and causes up to one million deaths annually. Measles blindness is the single leading cause of blindness among children in low income countries, accounting for an estimated 15,000 to 60,000 cases of blindness per year. There is a close synergism between measles and vitamin A deficiency that can result in xerophthalmia, with corneal ulceration, keratomalacia, and subsequent corneal scarring or phthisis bulbi. High-dose oral vitamin A supplementation is recommended for all children with measles in developing countries. Higher measles immunization coverage to interrupt measles transmission and interventions aimed at improving vitamin A nutriture of children are the main strategies to prevent measles blindness.

Protein energy malnutrition, vitamin A deficiency and night blindness in Bangladeshi children

The occurrence of night blindness and serum vitamin A concentrations among children in rural Bangladesh were studied in relation to protein energy malnutrition, dietary habits and intake of vitamin A capsules. In 1992, 124 night-blind children were registered in a cross-sectional survey in the northern part of Bangladesh, and age-, sex- and neighbourhood-matched controls were selected. Of these, the first reported night-blind child from a household (n = 105) and their controls were included in the analyses. Our results showed that night blindness was associated with protein energy malnutrition when using the mid-upper arm circumference (MUAC) as a measure of nutritional status. The odds ratio for a confirmed diagnosis of night blindness among children with a MUAC < 80% of the reference versus normal children was 5.4 (CI 1.9-15.5). Low MUAC was associated with low intake of beta-carotene-rich and vitamin A-containing foods as well as with low serum vitamin A in the total series of cases and controls. This may indicate that night blindness is only one aspect of the general protein energy malnutrition problems in this population. We therefore suggest that measures to prevent vitamin A-related morbidity and mortality should include improvement of the general diet with increased consumption of dietary vitamin A.

Vitamin A supplementation and child survival

Previous studies of the effect of 6-monthly vitamin A supplementation on child mortality have given conflicting results. In other trials, more frequent doses of vitamin A have significantly reduced mortality among children at risk of vitamin A deficiency. We have done a double-blind, placebo-controlled trial of vitamin A supplementation in the Sudan among 28,753 children aged 9-72 months at risk of vitamin A deficiency. Children were assigned to receive either 200,000 IU vitamin A and 40 IU vitamin E every 6 months (vitamin A group) or 40 IU vitamin E alone (placebo group). During the 18 months of follow-up, there were 120 deaths (8.4/1000) in the vitamin A group and 112 (7.9/1000) in the placebo group (relative risk 1.06, 95% confidence interval 0.82-1.37). Controlling for geographic site, round of observation, anthropometry, morbidity, dietary intake of vitamin A, sex, and all baseline differences between the two groups did not change the results. Children living in poor and unsanitary environments, younger children, and those sick, stunted, wasted, or consuming diets low in vitamin A were at a significantly higher risk of dying. The lack of an effect of large-dose vitamin A supplementation on mortality, despite a clear association between dietary vitamin A and mortality, underscores the need to identify factors that modify the efficacy of vitamin A supplements as a public-health measure. Reducing poverty, improvements in sanitation, and access to adequate diets should remain the main goals to improve child survival.

Xerophthalmia clinics in rural eye camps

Even though the primary prevention of many eye diseases can be effectively incorporated into the existing pattern of rural eye camps, efforts in this direction are restrained and insubstantial. We describe our technique and experience in the prevention of xerophthalmia by organising a distinct entity called a xerophthalmia clinic in our eye camps. The clinic consists of an Ophthalmologist or an Ophthalmic assistant who will exclusively examine children who come to the eye camp. This is perhaps, the first report on rural xerophthalmia clinics, in ophthalmic literature. Over a seven year period from 1984 to 1990 we have conducted 71 xerophthalmia clinics amongst the ninty eye camps organised. A total of 11,370 children were examined in the xerophthalmia clinic out of which 18.9% were afflicted with the disease. Therapeutic doses of Vitamin A were administered on the spot to the afflicted and prophylactic doses were administered to the rest. Intensive health education efforts are made through clinics to effectuate change in dietry habits towards consumption of locally grown DGLV (Dark Green Leafy Vegetables) like Anthenum, chenopodium and Amaranthus. A bipronged offensive consisting of mega-dosing and health education is, for the present and the foreseeable future, the best strategy to combat xerophthalmia in this desert region. A year by year breakdown of prevalence rates in the present study shows that in years of severe drought the prevalence of xerophthalmia increases three fold over the non-drought or mild drought years, thereby demonstrating that drought is a substantial risk factor in developing countries leading to vitamin A deficiency and xerophthalmia.

The adolescent growth spurt of height among rural Indian boys in relation to childhood nutritional background: an 18 year longitudinal study

The Adolescent Growth Spurt (AGS) was studied in rural Hyderabad boys of 5+ years of age with known childhood nutritional background. Longitudinal data on height measurements of pre-school children available for 13 to 16 points of follow-up, during an 18 year period of study (i.e., from 1965-66 to 1983-84) were utilized for this purpose. A Preece and Baines model 1 (PB 1) function was fitted for height measurements of 323 boys aged 19-24 years in 1984. The boys were classified into three groups according to degree of under-nutrition at the age of 5+ years, using Boston reference values for height. Boys with severe height deficit at age 5+ were considered to have had a background of severe undernutrition and were referred as Group III. Boys with normal range height measurements at age 5+ were considered to have a normal nutritional background and were referred to as Group I. Group II boys had height deficits in between the above two groups and were considered to have milk to moderate undernutrition backgrounds. Group I boys had similar timing, intensity, duration of Adolescent Growth Spurt Period (AGSP) and gained a similar amount of height during puberty as did British boys. Group III boys differed significantly from British boys for AGS. They entered late into puberty, with significantly depressed intensity, but gained a similar amount of height, as a result of prolonged AGSP, which continued till 19.2 years. Thus a childhood background of undernutrition did not lead to any additional deficit in height during puberty. However, pre-pubertal height deficits were carried into adult height. The growth curves of rural Hyderabad children were parallel to the British distance height curve after 12 years of age. The mean constant height velocity curve of group I boys was superimposable on the British curve during puberty.

Impact of massive doses of vitamin A on incidence of nutritional blindness

In a longitudinal study designed to assess the impact of a massive-dose vitamin A programme on the incidence of keratomalacia, 50 000 preschool children in 450 slum areas in Hyderabad city (India) were given 200 000 IU of vitamin A once every 6 months. During the study period, the incidence of keratomalacia in areas covered by the programme decreased by about 80%, while in control areas the reduction was of the order of 20%. To test whether large doses of vitamin A supplements prevented keratomalacia, a case-control analysis was done, with patients with severe protein-energy malnutrition being used as controls. The high odds ratio clearly indicated that keratomalacia was more likely to occur in children not receiving supplements.

Nutritional ocular diseases and their association with diarrhoea in Matlab, Bangladesh

The prevalence of visual defects, especially from causes associated with nutritional deficiencies, and their relation to diarrhoea in rural Bangladesh have been studied. A trained physician and a team of health workers examined visual defects in 149 villages, with a total population of 182 976. According to WHO classification, night blindness (XN) was found in only 0.03 persons/1000 population and 0.04 were found to have conjunctival xerosis (XIA) and Bitot's spot (XIB). Corneal xerosis (X2, X3A, X3B) also was found in 0.04 persons/1000. Night blindness combined with conjunctival xerosis and Bitot's spot (XN + XIA + XIB) was present in 1.69 persons/1000 and all combined stages of active xerophthalmia were seen in 0.06 persons/1000. Xerophthalmia prevailed up to age 19 years. Males had a significantly higher (2.9) incidence/1000 than did females (1.2). The total rate of keratomalacial scar for all ages was 0.31 persons/1000, while corneal opacity from other causes was seen in 2.25 persons/1000 population. More than 2.06 persons/1000 had ocular manifestations of one or more vitamin A deficiencies, while 4.47 persons/1000 had other ocular diseases, except for cataracts. Only 12.0% of all the corneal scars (XS) were due to keratomalacia. History of night blindness is a good indicator of vitamin A deficiency. In 96% of cases, night blindness was associated with conjunctival xerosis and Bitot's spot (XN + XIA + XIB). The onset of approximately 86% of cases of corneal xerosis (X2, X3A, X3B) and night blindness associated with conjunctival xerosis and Bitot's spot (XN + XIA + XIB) was related to diarrhoea.

Incidence, prevalence, and scale of blinding malnutrition

4595 pre-school-age children in six villages of West Java were examined every 3 months. The incidence of active corneal xerophthalmia was 5 per 1000 per year (95% confidence limits, 2.6-7.5), and the average prevalence during each round of examinations was 12 per 10000. In a randomised, multistage cluster survey of 27084 rural children throughout Indonesia the population-weighted prevalence of active corneal disease among pre-school-age children was 6.4 per 10000 (95% confidence limits 3.2-9.6), 53% of that in the longitudinal study areas. At an adjusted incidence rate of 2.7 per 1000 per year, over 60000 Indonesian children become xerophthalmic every year. By extrapolation of these findings about 500000 new cases of xerophthalmia, half of which lead to blindness, occur each year in India, Bangladesh, the Philippines, and Indonesia combined.

Effect of intramuscular vitamin A injection on plasma levels of vitamin A and retinol-binding protein in malnourished children

1. Serum levels of retinol-binding protein (RBP), total vitamin A and retinyl ester were measured in twenty-four malnourished children with corneal lesions and nine normal children. 2. Initially, the RBP and vitamin A levels were significantly lower in malnourished children than in normal children. 3. After intramuscular injection of 30000 microgram of aqueous vitamin A, serum levels of total vitamin A were increased significantly at 24 h and tended to fall within 5 d of treatment in both groups. 4. Before treatment, retinyl ester accounted for less than 10% of the vitamin in circulation. After vitamin A injection, it increased to 30%, a level much lower than that reported in patients with hypervitaminosis A. 5. There was no significant difference between the two groups of children and none of them showed clinical signs of toxicity. These observations indicate that administration of massive doses of vitamin A over a short period will not produce toxic effects even in malnourished children.

Adolescent growth spurt among rural Indian boys in relation to their nutritional status in early childhood

The growth pattern of 677 rural Hyderabad boys aged between 13 and 18 years was studied over a year (1977-78) to obtain annual increments. These boys had earlier been studied over a four-year period (1965-69). Height for age at 5 years in relation to Boston standards was used to classify these subjects into four nutritional categories. The group that had experienced severe growth retardation in early life achieved a peak height velocity (6.9 cm/yr) similar to that of British boys (7.3 cm/yr), though the event was postponed by 2 years--from 14 years to 16 years. Height growth from 5 years to 17.5 years (62 cm) was comparable with that of Western boys (63 to 66 cm). However, increase in weight was lower (29 kg) than in Western boys (44 to 48 kg). Height deficits observed at age 5 continued into adolescence and weight deficits increased. As a consequence, the group that was shortest at age 5 continued to be shorter and lighter at 17-18 years of age.

Mass distribution of vitamin A and the prevention of keratomalacia

A retrospective review of 3,490 adminissions to the major pediatric facility in El Salvador was undertaken to determine whether biannual administration of massive doses of vitamin A (200,000 international units) to all availabel 1- to 4-year-old children was effective in preventing keratomalacia. During the 12 months preceding and following initiation of the program, the number of children admitted with presumed vitamin-A-related corneal destruction (33 vs. 31) and proportion of all malnourished admissions with such destruction (26 vs. 25 per 1,000) were similar. The seasonal distribution of these cases remained unchanged, the usual summer peak closely following the first distribution. Unexpectedly, 48% of the children had been ineligible for participation in the program, the vast majority being under 1 year of age. Only 80% of eligible children had actually received the vitamin. Corneal destruction was invariably accompanied by severe, generalized malnutition. Mortality among girls with corneal destruction (28 per 1,000) was almost three times that of boys, or malnourished patients as a whole.

Failure of a massive single oral dose of vitamin A to prevent deficiency

Preschool children maintained on low and moderate carotene diets were given a single oral dose of 50,000 μg vitamin A palmitate. On the low carotene diet, xerosis was observed in 8 weeks' time in the control group of children, and in 10 weeks' time in the children given the load of vitamin A. Statistical differences in serum vitamin A values between the groups were not of significance after 18 weeks. Children on a moderate carotene diet did not benefit from the loading dose of vitamin A.