Antecedent Risk Factors of Xerophthalmia Among Indian Rural Preschool Children

High prevalence of xerophthalmia linked to socio-demographic and nutritional factors among vitamin A-deficient rural primary schoolchildren in Malaysia

Vitamin A deficiency (VAD) remains a major health issue in developing nations, contributing to preventable childhood blindness. However, there is lack of recent data on xerophthalmia, especially among school-aged children in Malaysia. We hypothesized that xerophthalmia persists among rural schoolchildren in Malaysia and potentially associated with socio-demographic status and malnutrition. We conducted a cross-sectional study on 596 schoolchildren (8-12 years) from ten rural primary schools located in five states across Malaysia. Children meeting the criteria for xerophthalmia assessment included those diagnosed with vitamin A deficiency (VAD) (plasma retinol < 0.70 µmol/L) and marginal VAD (plasma retinol 0.70 to < 1.05 µmol/L). The overall prevalence of xerophthalmia was 48.8%, with the most common ocular sign being conjunctival xerosis (38.9%). The occurrence of xerophthalmia was negatively associated with retinol-binding protein 4 (RPB4) (P=0.003), alpha-carotene (P=0.04), hemoglobin (P=0.004), weight (P=0.02), body mass index (BMI) (P=0.04) and WAZ (weight-for-age z-score) (P=0.04) status. Based on multivariate logistic regression analysis, a higher risk of xerophthalmia was observed in boys (Adjusted odd ratio [AOR]: 1.7, 95% confidence interval [CI]: 1.2-2.5) and Orang Asli (OA, indigenous) schoolchildren (AOR: 2.0, 95% CI: 1.3-3.0), while schoolchildren with overweight/obesity status (AOR: 0.5, 95% CI: 0.3-0.8) were associated with a reduced risk of xerophthalmia. The present study unveils a high prevalence of xerophthalmia among vitamin A-deficient primary schoolchildren in rural areas of Malaysia, especially among the indigenous community. The identified socio-demographic and nutritional factors associated to xerophthalmia would facilitate the implementation of more targeted interventions in addressing these issues.

Corneal blindness in the developing world: The role of prevention strategies

Corneal blindness is an important contributor to the burden of global blindness and has a greater prevalence in low-income countries of the developing world where resources and infrastructure are limited. The causes of corneal blindness too are different from high-income countries and include infectious keratitis, ocular trauma, and xerophthalmia. Persons with these indications tend to have unfavourable outcomes after corneal transplantation, limiting their chances of benefitting from this sight-saving procedure. However, most causes of corneal blindness in the developing world are preventable. This highlights the importance of understanding the unique challenges in these regions and the need for targeted interventions. This article discusses various prevention strategies, including primordial, primary, and secondary prevention, aimed at reducing the burden of corneal blindness in low-income countries. These include capacity building, training, and awareness campaigns to reduce the risk factors of ocular trauma, infectious keratitis, and to improve access to first aid. It is also important to promote safe eye practices and tackle nutritional deficiencies through public health interventions and policy changes. Providing the required training to general ophthalmologists in the management of basic corneal surgeries and diseases and enhancing the accessibility of eye care services in rural areas will ensure early treatment and prevent sequelae. Current treatment modalities belong to the tertiary level of prevention and are largely limited to corneal transplantation. In developing nations, there is a scarcity of donor corneal tissue necessitating an urgent expansion of eye banking services. Alternative approaches to corneal transplantation such as 3D printed corneas, cultured stem cells, and biomaterials should also be explored to meet this demand. Thus, there is a need for collaborative efforts between healthcare professionals, policymakers, and communities to implement effective prevention strategies and reduce the prevalence of corneal blindness in the developing world.

Dry eye disease in the young: A narrative review

Dry eye disease (DED), a multifactorial ocular disease that significantly impacts quality of life, is most commonly reported in adults. This review describes the prevalence, risk factors, diagnosis and management of DED in children. A literature search, conducted from January 2000-December 2022, identified 54 relevant publications. Using similar diagnostic criteria to those reported in adults, namely standardized questionnaires and evaluation of tear film homeostatic signs, the prevalence of DED in children ranged from 5.5% to 23.1 %. There was limited evidence for the influence of ethnicity in children, however some studies reported an effect of sex in older children. Factors independently associated with DED included digital device use, duration of digital device use, outdoor time and urban living, Rates of DED were higher in children with ocular allergy and underlying systemic diseases. Compared with similar studies in adults, the prevalence of a prior DED diagnosis or a diagnosis based on signs and symptoms was lower in children, but symptoms were commonly reported. Treatment options were similar to those in adults, including lifestyle modifications, blinking, management of lid disease and unpreserved lubricants in mild disease with escalating treatment with severity. Management requires careful exploration of symptoms, medical history and the diagnosis and management of ocular comorbidities such as allergy and anterior blepharitis. Appropriately powered population-based studies are required to understand the prevalence of and risk factors for DED in children. Development of age-appropriate thresholds for signs and symptoms of DED would support better diagnosis of disease and understanding of natural history.

Dry eye syndrome: comprehensive etiologies and recent clinical trials

Dry eye syndrome (DES) is multifactorial and likely to be a cause of concern more so than ever given the rapid pace of modernization, which is directly associated with many of the extrinsic causative factors. Additionally, recent studies have also postulated novel etiologies that may provide the basis for alternative treatment methods clinically. Such insights are especially important given that current approaches to tackle DES remains suboptimal. This review will primarily cover a comprehensive list of causes that lead to DES, summarize all the upcoming and ongoing clinical trials that focuses on treating this disease as well as discuss future potential treatments that can improve inclusivity.

Dry eye syndrome risk factors: A systemic review

Dry eye disease has been recognized to be a global public health problem, as it has many consequences starting from daily life activities restrictions to economical costs of management. At present, there is a lack of knowledge regarding the most important risk factors for eye dryness. This problem is becoming important worldwide especially with the increase use of technology, smartphones, computers, and contact lenses. The aim of this systematic review is to determine the most relevant factors associated with dry eye symptoms to help in its early recognition, prevention and reduce its subsequent implications. PRIMSA 2009 checklist was used to conduct this systematic review. The inclusion and exclusion criteria were implemented first. Then, PubMed Database was explored for articles. The data extraction was based on three categories: Sociodemographic, diseases, and medications in the form of odds ratios. Predictive values, confidence intervals, and prevalence were recorded when the data were sufficient. This systematic review included 6 Articles and 48 evaluated variables. Female gender, contact lenses, use of computers, thyroid abnormalities, hypertension, antidepressant, and antihistamine were identified to be the strongest and the most common risk factors for dry eye syndrome.

Species-Specific Associations Between Soil-Transmitted Helminths and Micronutrients in Vietnamese Schoolchildren

Soil-transmitted helminth (STH) infections and micronutrient deficiencies are closely related and often coexist among low-income populations. We studied the association between infections with specific STH species and micronutrient status in rural Vietnamese schoolchildren. Children (N = 510) aged 6-9 years were recruited from two primary schools. STH infections were determined in stool samples. Hemoglobin, ferritin, retinol, and zinc were measured in blood samples, as well as C-reactive protein to control for inflammation. Iodine excretion was measured in urine. Associations of single and multiple infections with Ascaris lumbricoides, Trichuris trichiura, and hookworm with micronutrient status (hemoglobin, plasma ferritin, retinol, zinc, and urinary iodine) were estimated by multiple regression analysis. Ascaris infections showed a specific and intensity-dependent negative association with vitamin A. Trichuris and hookworm infections were associated with lower hemoglobin concentration, but not with plasma ferritin. Trichuris-infected children had zinc deficiency less often than uninfected children. In conclusion, our study shows species-specific associations between STH infections and micronutrient status in children. The different life cycles of STH species might have specific effects on the absorption or loss of specific micronutrients. Tailor-made combinations of deworming and nutritional interventions may be needed to improve child health and nutrition.

Helminth infections and micronutrients in school-age children: a systematic review and meta-analysis

BACKGROUND

Helminth infections and micronutrient deficiencies are highly prevalent in developing countries. Neither condition typically causes overt disease, but they do lead to indirect morbidity such as impaired physical and cognitive development.

OBJECTIVE

We aimed to systematically review current evidence on the relation of helminth infections with micronutrient status in school-age children worldwide.

DESIGN

We included both observational studies and randomized controlled trials (RCTs). We applied a random-effects meta-analysis to estimate 1) cross-sectional associations between helminths and micronutrient status, 2) effects of anthelminthic treatment on micronutrient status, and 3) effects of micronutrient supplementation on helminth infection and reinfection.

RESULTS

Meta-analyses of observational studies showed an association between helminth infections and serum retinol [standardized mean difference (SMD): -0.30; 95% CI: -0.48, -0.13] but not serum ferritin (SMD: 0.00; 95% CI: -0.7, 0.7). Conversely, meta-analyses of anthelminthic treatment RCTs showed a positive effect on ferritin (SMD: 0.16; 95% CI: 0.09, 0.22) but not retinol (SMD: 0.04; 95% CI: -0.06, 0.14). The number of studies on micronutrients other than ferritin and retinol was not sufficient for pooling. Meta-analyses of micronutrient-supplementation RCTs showed only a modest protective effect for multimicronutrient interventions on helminth infection and reinfection rates (OR: 0.77; 95% CI: 0.61, 0.97).

CONCLUSIONS

In this review, we show evidence of distinct associations between helminth infections and micronutrients in school-age children. More studies are needed on micronutrients other than iron and vitamin A and on possible helminth species-specific effects. A thorough comprehension of the interplay between helminth infections and micronutrients will help guide integrated and sustainable intervention strategies in affected children worldwide.

Prevalence and risk factors of dry eye disease in Japan: Koumi study

OBJECTIVE

To estimate the prevalence and risk factors of dry eye disease (DED) in a rural setting in Japan.

DESIGN

Cross-sectional study.

PARTICIPANTS

We included 3294 subjects, aged ≥ 40 years who were in the residential registry for Koumi town.

INTERVENTION

Subjects in a rural mountain area, Koumi town, completed questionnaires designed to detect dry eye diagnosis and risk factors.

MAIN OUTCOME MEASURES

Clinically diagnosed DED was defined as the presence of a previous clinical diagnosis of DED by ophthalmologists or severe symptoms of DED (both dryness and irritation constantly or often). Current symptoms of DED and possible risk factors such as age, gender, educational history, smoking history, alcohol drinking history, height and weight, visual display terminal (VDT) use, and contact lens (CL) wear, and past/current history of certain common systemic diseases were the main outcome measures. We used logistic regression analysis to examine associations between DED and other demographic factors.

RESULTS

Of the 3294 eligible residents, 2791 residents (85%) completed the questionnaire. The percentage of women with a composite outcome of clinically diagnosed DED or severe symptoms (21.6%; 95% confidence interval [CI], 19.5-23.9) was higher than that of men (12.5%; 95% CI, 10.7-14.5; P<0.001). A low body mass index (BMI; odds ratio [OR], 2.07; 95% CI, 0.98-4.39), CL use (OR, 3.84; 95% CI, 1.46-10.10), and hypertension (HT) (OR, 1.39; 95% CI, 0.94-2.06) were risk factors for DED in men. Use of a VDT (OR, 2.33; 95% CI, 1.12-4.85), CL use (OR, 3.61; 95% CI, 2.13-6.10), and myocardial infarction or angina were the risk factors (OR, 2.64; 95% CI, 1.51-4.62), whereas high BMI was a preventive factor (OR, 0.69; 95% CI, 0.48-1.01) for DED in women.

CONCLUSIONS

Among a Japanese cohort, DED leading to a clinical diagnosis or severe symptoms is prevalent. Use of CLs was a common dry eye risk factor in both genders. The condition is more prevalent in men with low BMI, HT, and in women with myocardial infarction or angina and VDT use. Relevant measures directed against the modifiable risks may provide a positive impact on public health and quality of life of Japanese.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Determinants of vitamin A deficiency amongst children in Aligarh District, Uttar Pradesh

OBJECTIVES

To determine the prevalence and determinants of xerophthalmia among children aged 0-60 months .

METHODS

This cross-sectional study included 3571 children under 5 years of age from six villages and four periurban areas. Children with xerophthalmia were identified and severity graded using the WHO classification. The main outcome measures were socio-demographic, nutritional and comorbidity related risk factors of xerophthalmia. A pretested questionnaire carrying information on the above factors was administered to the caregivers. Univariate and multivariate binary logistic regression analyses were performed to examine the association of each of these factors with xerophthalmia.

RESULTS

The overall prevalence of xerophthalmia was of serious public health importance at 9.1%. Prevalence of both mild (night blindness, and Bitots spots) and severe forms (corneal changes) of xerophthalmia increased with age. Bitots spots and night blindness were the commonest manifestations. Rural dwelling, lower social class, maternal illiteracy and occupation outside home were significant antecedent socio-demographic risk factors on univariate analysis. Multivariate analysis revealed low intake of proteins and vitamin A containing foods as well as predominant maize diet to be significant dietary factors. Nutritional wasting and a preceding history of measles were significant comorbid determinants (P<0.05). None of the socio-demographic variables emerged significant on multivariate analysis.

CONCLUSIONS

Vitamin A deficiency remains a significant public health problem in Aligarh district. The proximal factors in a child's milieu viz nutrition and comorbidities were more significantly associated with xerophthalmia than the distal socio-demographic factors, thereby making a case for their cost effective prevention. The high magnitude of the problem calls for intensification of existing prophylactic measures in these areas.

Optimal vitamin A and suboptimal vitamin D status are common in Iranian infants

AIM

Investigation of serum concentrations of vitamins A and D in Iranian infants.

METHODS

A descriptive cross-sectional study, investigating 7112 infants (15-23 months of age) from all regions of Iran, who attended health care centres from May 25 to June 2, 2001. Unequal clusters with unequal household sizes were sampled. Vitamin A and D levels were analysed with high-performance liquid chromatography.

RESULTS

The mean (SD) concentration of vitamin A was 2.09 (0.83) μmol/L. At a national level, 0.7% of the infants had a level indicating deficiency, and 0.5% of the infants had insufficient concentrations of vitamin A, defined as serum concentrations <0.35 and <0.7 μmol/L retinol, respectively. A total of 88% of infants had optimal concentrations (>1.4 μmol/L). The mean (SD) concentration of vitamin D was 61.3 (31.4) nmol/L. Deficiency was found in 2.8% of infants (<25 nmol/L), and insufficiency in 32.9% (<50 nmol/L). Suboptimal and optimal concentrations were found in 44% and 20%, representing 50-75 and >75 nmol/L, respectively. Girls had lower vitamin D concentrations than boys (p = 0.006).

CONCLUSION

As in developed countries, vitamin A deficiency was rare in Iranian infants. Vitamin D deficiency was also rare, but 33% of infants had insufficient levels; this was more common in girls than boys.

Concurrent micronutrient deficiencies are prevalent in nonpregnant rural and tribal women from central India

OBJECTIVE

The existence of concurrent micronutrient deficiencies in Indian women of reproductive age has received little attention. This study aimed to comprehensively assess the micronutrient status of nonpregnant rural and tribal women 18-30 y from central India.

METHODS

Participants (n = 109) were randomly selected using a stratified (rural-tribal) proportionate-to-population size cluster sampling method from 12 subcenters in Ramtek block, Nagpur. Sociodemographic, anthropometric, dietary, and biochemical data, including blood and urine samples, were obtained.

RESULTS

Tribal and rural women had similar sociodemographic characteristics and anthropometric status; 63% of women had a body mass index <18.5 kg/m(2). The median urinary iodine concentration was 215 μg/L (IQR: 127, 319). The mean (SD) concentration of hemoglobin, serum zinc, retinol, and folate was 112 (13) g/L, 10.8 (1.6) μmol/L, 1.2 (0.3) μmol/L, 18.4 (8.4) nmol/L, respectively, with a geometric mean serum vitamin B(12) concentration of 186 pmol/L. The percentage of women with low values for hemoglobin (<120 g/L), serum zinc (<10.7 μmol/L), vitamin B(12) (<148 pmol/L), retinol (<0.7 μmol/L), and folate (<6.8 nmol/L) was 66%, 52%, 34%, 4%, and 2%, respectively. Tribal women had a higher prevalence of zinc deficiency (58% versus 39%, P = 0.054) and concurrent deficiency of any two micronutrients (46% versus 26%; P = 0.034), including zinc and anemia (38% versus 21%, P = 0.024).

CONCLUSION

Zinc, vitamin B(12), and iron constitute the principal micronutrient deficiencies in these women. Existing supplementation programs should be extended to include 18- to 30-y-old nonpregnant women as the majority of childbearing occurs within this timeframe.