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Vitamin - A Deficiency
A Manageable Health Problem
About Dr
Zahid Masood Khan
Vitamin-A deficiency is a major cause of child mortality and morbidity,
affecting under five years children of developing countries. The prevalence of
clinical signs of Vitamin-A deficiency (eye signs-xerophthalmia etc) in
developing countries is estimated to be about 0.6 percent in pre-school
children. The same is about one percent in the less than five years old children
of south Asia and sub-Saharan Africa. Out of 3.3 million children affected, 2
million are in Asia. Clinical Vitamin-A deficiency is only the tip of the
ice-berg. It is an indicator of wide-spread sub-clinical Vitamin-A deficiency,
where ocular signs are not present, but risk of ill health and death is
increased. Prevalence of sub clinical Vitamin-A deficiency in developing
countries, based on serum retinal levels, are estimated in the range of 15-27 %.
A number of studies have confirmed the fact that Pakistan has a substantial
degree of sun-clinical deficiency of Vitamin-A. It is estimated that more than
30 % of Pakistani children in this group suffer from sub clinical Vitamin-A
deficiency. it is particularly important, as approximately 40 % of our less than
five children are malnourished. Besides, diarrhea an pneumonia are still the
major cause of death in young children.
The increased risk of death associated with Vitamin-A deficiency occurs well
before eye signs appear and is much more widespread than clinical Vitamin-A
deficiency, threatening the health of as many as one third of the world's
children. Proxy indicators for Vitamin-A deficiency in the community are
widespread in Pakistan. These include infant mortality rate of more than 70 per
1000 and under five mortality of more than 100 per 1000, high prevalence rates
of low birth weight and protein energy malnutrition.
In an ideal world, provision of a diet rich in Vitamin-A should be the right
strategy. however, until that becomes a reality, alternative of food
fortifications and supplementation with Vitamin-A are the right solution.
Government of Pakistan/UNICEF have adopted the strategy of supplementation, in
response to high prevalence of sub-clinical Vitamin-A deficiency amongst our
young children. It involve the use of high dose Vitamin-A capsule (drops),
ideally twice a year. It would involve the usage of Vitamin-A as per following
guidelines:-
AGE FOR VITAMIN-A
6-12 months 100,000 Units
12-59 months 200,000 Units.
Ideally Vitamin-A should be administered every six months.
Paediatricians can play a leading role in advocacy, promotion and implementation
of this program. Family physicians have an opportunity to inform and educate
families and community about Vitamin-A deficiency. health workers need to be
aware of the Vitamin-A deficiency being a public health problem in Pakistan and
help in esuring that all less than five years children get an approximate dose
of Vitamin-A twice a year.
VITAMIN-A
Vitamin-A are organic substances in food, which are required in small amount,
but can not be synthesized by the body in adequate quantities. Vitamin-A
deficiency is one the common cause of blindness, especially amongst young
children. Vitamin-A or retinol is found in green vegetables and leaves etc. The
conversion of beta carotene into retinol in the humans is only 30 % efficient.
Dietary retinol ester is hydrolyzed to retinol in the intestine. Retinol is
esterified in the mucosal cell with palmitic acid and is stored in the liver as
retinol palmitate. This in turn is hydrolyzed to free retinol for transport to
its site of action.
DAILY REQUIREMENTS
Recommended daily intakes of retinol are 300 ug for infants and young children,
500-750 ug for children of 9 to 15 years, 750 ug for adolescents and adults and
1200 ug for lactating women (1 ug retinol = 3 of old i.u.). In many parts of the
world most or all of the requirements are obtained from carotenoids in vegetable
foods.
FUNCTIONS OF VITAMIN-A
Vitamin-A acts on a number of areas in the human body to facilitate certain
processes:
a. Maintaining the integrity of epithelial surface,
b. Ensuring adequate structure and function of visual system,
c. Strengthening the immune system,
d. Ensuring adequate growth and development, and
e. Helping in efficient utilization of iron for haemoglobin production.
Vitamin-A has long been known as anti-infective vitamin, which is important for
normal immune function and the integrity of epithelium of ocular, respiratory
and intestinal tissues. A newly emerging hypothesis suggests that Vitamin-A
deficiency may be an underlying cause of iron deficiency, and that zinc
deficiency may cause immobilization of hepatic Vitamin=A stores. This hypothesis
has generated among researchers and public health policy makers further interest
in exploring the mechanisms of nutrient-nutrient interaction and evolving new
strategies to control and prevent micro-nutrient deficiencies.
CAUSES OF VITAMIN-A DEFICIENCY
a. Habitually low intake of Vitamin-A as compared to the requirements,
b. Economic, social and environmental factors that limit access to the use of
Vitamin-A containing food. The underlying cause of the above situation is mostly
poverty.
c. Situations, where physiological needs are high:
Period of rapid growth and development i.e. infancy and early childhood
Pregnancy and lactation: and frequent infection such as diarrhoea, febrile
illness, measles.
MALNUTRITION AND VITAMIN-A DEFICIENCY
Malnutrition means bad or inappropriate nutrition situation. Most of the
deprivation occurs in the poor and under privileged. In the context of
developing countries the same child is likely to have more one form of
deficiency i.e. PEM, Vitamin-A, Iron deficiency. Listed below are common forms
of malnutrition.
1 PROTEIN ENERGY MALNUTRITION (PEM)
This is the most well known form of malnutrition and it means that the young
children has not received adequate amount of food. It is reflected in the weight
for age, height for age and weight for height parameters. In simple terms, that
is referred to as under weight, stunting and wasting, respectively. High
prevalence of low birth rate and protein energy malnutrition is accepted as an
indicator for Vitamin-A deficiency being a problem in the community.
2 FLUID AND ELECTROLITE MALNUTRITION (Dehydration)
Here children with diarrhea loose water and salts from their body and become
deficient in these elements. it leads to a state of dehydration. Diarrheal
diseases causes deaths due to dehydration. It may also be termed as a form of
malnutrition. Diarrheal disease is particularly lethal in the presence of
Vitamin-A deficiency.
3 MICRO NUTRIENT NUTRITION (Hidden Hunger)
Micronutrients are elements, usually minerals or vitamins, rich facilitate
various metabolic processes in the human body, leading to adequate growth and
development. The most important micronutrients investigate so far are Iodine,
Vitamin-A, Iron, Folic Acid and Zinc. Although these elements are needed in
micro quantities, the effect of their deficiency can be devastating on both
growth and development.
4 MULTIPLE MICRO-NUTRIENT DEFICIENCIES.
Many population in the developing world suffer from multiple micro-nutrient
deficiencies. Moreover, deficiencies often interact. Vitamin-A supplementation
at appropriate level has been found to improve not only Vitamin_A status, but
also iron motabolism in pregnant women and pre school/school age children. Such
an approach should be considered in country like Pakistan, where iron deficiency
is common. A combination of iron and Vitamin-A supplementation has been found to
be more than 40 % effective in reducing anaemia than an iron supplement alone.
Given which a frequent overlap, multiple micro-nutrient supplementation hold
clean potential to address micro-nutrient deficiencies in a cost effective
manner.
INFECTIONS AND VITAMIN-A DEFICIENCY
Vitamin_A deficiency is well known as an anti-infective vitamin. It has a
positive impact on mortality and morbidity diarrhoea and measles. This is
achieved through an augmenting effect on immunity. Cellular differentiation,
maintenance of epithelial surface, growth, reproduction and vision. Serum
retinol levels may drop during infections because of decreased mobilization of
hepatic reserves of retinol during acute phase response, accelerated utilization
of Vitamin_A by target organs and increased urinary loss. An episode of
infection seems to hasten the deletion of Vitamin-A stores. Low serum levels of
Vitamin_A during infection may have detrimental effects on the immune response,
given the close relationship between immune cell function and availability of
Vitamin-A.
MAGNITUDE OF PROBLEM
Globally, over 250 million children under five years of age are at risk of
Vitamin-A deficiency. These children suffer a dramatically increased risk of
death and illness as consequence. Vitamin-A deficiency causes 250, 000 to
500,000 children o become blind and 50 % of these children dies with in an year
of loosing their sight. Our neighbors in South East Asia have the highest
prevalence of VAD in the world. Some three million children have clinical signs
of xerophthalmia. However, most of the children (90%) effected by VAD do not
have eye lesions but only sub-clinical deficiency.
Global trends in sub clinical prevalence estimates are less easily tacked than
clinical deficiency. Confounding disease-related factors that may vary in
intensity from country to country influence serum retinol levels. This makes
cross-country and regional comparisons difficult to evaluate. Overall 14.6 to
26.5% or 75 million to 140 million under five years children are afflicted with
sub-clinical deficiency.
VITAMIN-A DEFICIENCY IN PAKISTAN
based on the prevalence and severity of Vitamin-A deficiency in Pakistan, World
Health Organization (WHO) classified Pakistan as one with severe sub-clinical
Vitamin-A deficiency, which is considered to be a significant public health
problem. Clinical evidence of Vitamin-A deficiency in Pakistan is rare but cross
sectional studies conducted in different parts of the country suggest that
sublicnical Vitamin-A deficiency does exists among pre-school children at a
significant level. The following is a list of documents studies carried our in
Pakistan during 1961-1998, which is sufficient to prove that Vitamin-A
deficiency is a public health problem in Pakistan.
1 1961-1963 In a survey carried our in school children in Lahore, Bitot spots
were observed in 2-3 % of the children between 5-12 years
2 1965-1966. The nutrition survey of West Pakistan revealed that the dietary
intake of Vitamin-A containing foods was low in all income groups.
3 1975. A study conducted by Ali AM, et al nutrition survey of northern areas
reveled no cases of clinical Vitamin-A deficiency.
4 1977-78. In the micro-nutrient survey of Pakistan Vitamin-A status was
determined through dietary intake from 24 hours recall, and bio- chemical assay
plasma retinol levels were less than 0.7 micro mol/pl or 20 micro g/dl in 12.6%
of the samples.
5 1981-84. 50 hospitalized cases of night-blindness were studied for Vitamin-A
level. 28% had Vitamin-A levels less than 16 micro g/dl.
6 1985. National Institute of Health, Islamabad reported a prevalence of Bitot's
spot in children less than 5 years of age as 0.2%.
7 1987. A study conducted in the healthy population of Karachi revealed eye
changes in 2.7% of 0-3 years of age and 26% amongst 4-15 years age group.
8 1993. In a survey conducted at Karachi Molla et al found serum retinol levels
of less than 10 micro g/dl in 2% and less than 10-19 micro g/dl in 46% children
6-6 month old.
9 1997. A community based study in Peshawar revealed serum Retinol levels in
children less than 0.7 micro mol/1 (20 micro gr/dl) in 59% and less than 0.35
micro mol 10 micro g/dl in 7 %.
10 1998. A UNICEF sponsored survey in NWFP covering 2756 pre-school health y
children (6-60 months) showed retinol deficiency a. 3.3% less than 10 micro
g/dl, b. 31.8% less than 20 micro g/dl
11 1998 . An Opthalmological study conducted in Swat children, nightblindness,
xerosis of conjuctive and / or bitot's spots:
6-cases 1-3 years
4-cases 6-8 years
4-cases 10-14 years
1-case 25 years of age
12. 1993-95. King Edward Medical College (Community studies in rural areas and
urban slums). Children 9-36 months.
(Dr. Fahmida Jalil)Serum retinol levels less than 0.70 micromols/l in more than
80%
(Dr. Fahmida Jalil)
WHY ACTION IS NEEDED IN PAKISTAN?
Rationale for Improving Vitamin-A status in children.We need to improve
Vitamin-A status because it:
A. Increase chances of survival (Beaton et al - meta-analysis
Overall mortality reduced by 23%
Death from measles reduced by 50%
Death from diahrea reduced by 40%
B Reduces severity of childhood illness (measles and diahorea)
Fewer hospital admissionsContribute to well being of children and families
C Prevent Night blindness, xeropthalmia, corneal destruction and blindness
D it is cost effective and feasible
cost per capsule is only 2 US cents
Reduces health costs
easily integrated into existing public health/immunization programs (e.g. NID's
and SNIDs)
VITAMIN-A PROGRAM EXPERIENCE IN PAKISTAN
Govt of Pakistan- UNICEF
1- PILOT PHASE
Vitamin-A supplementation was integrated with Polio compaign in Karak, NWFP
(January, 1999). The aim was to demonstrate:
Acceptance,Safety and Operational and logistic feasibility.
2. NATIONAL STATEGY MEETING (MAY 1999) examined VAD data
(direct and indirect indicators).
looked at results of the pilot experience policy and strategy recommendations on
VAD prevention and control
3 ACHIEVEMENTS
Vitamin-A with NID's (Nov 1999)
Vitamin-A coverage 88%
High acceptance among families and communities
Vitamin-A with SNID's (April-July 2000(
Coverage 95% continued high level of acceptance.
4 STRATEGIES USED
a National and Provincial planning formulas
Ensure integration of Vitamin-A across all components:
Logistics and operational, microplanning, Training, IEC compaign and Monitoring
and supervision
b Training of health workers on polio and Vitamin-A Training undertaken at all
levels:
National training of master trainers, provincial, divisional and district
training of trainers and training of health workers and volunteers, and Training
guides, videos, demonstrations handouts used
c Advocacy and IEC compaign
National media summit and advocacy, seminars, held in all provinces involving
key stakeholders (Newspaper, TV, Radio Spots). This was followed by phased
implementation of district advocacy seminars.
Communities and health workers sensitized )mosque announcement, posters and
banners) 10 Million families received messages about advantages of Vitamin-A
supplementation (flyers and handbills)
d Monitoring and Supervision
Monitoring and supervision at provincial level (1999 and At divisional and
district level (2000)
PLAN FOR THE FUTURE
A Intensive National Planning Workshop in view of new strategy of house to house
(July, 2000)
B Re-training on microplanning, supervision and implementation of Vitamin-A and
Polio (august- October 2000)
C IEC compaign (Advocacy, Seminars, Posters, Brochures, flyers, TV, Radio Spots
Mosque announcements) on going
D Monitoring and supervision (focus on divisional and district level monitoring)
ongoing
LONG TERM APPROACHES
a Integration of Vitamin-A with routine EPI
b Breastfeeding (BF) BF protection (BF ordinance) Revive BFHI (Baby Friendly
Hospital Initiative)
c Vitamin-A Fortification Pure food acts law (1965)
Strengthen Quality Assurance and Enforcement.
ROLE OF PAEDIATRICS AND FAMILY PHYSICIANS
PLEASE:
A Beware that although clinical VAD is minimal in Pakistan , sub-clinical
deficiency is widely prevalent
b Inform your patient/families about VAD and its impact on young child health
c Promote exclusive breast feeding for about 6 months
d Use yourself and encourage others to use Vitamin-A drops, as being promoted
during the national immunization days (NIDS)
e Use your influence as a team leader to promote use of Vitamin-A drops in young
child
f Teach other health workers about VAD and use of Vitamin-A drops
g Encourage the use of Vitamin-A rich foods as a long term strategy such as
yellow fruits and vegetables
Courtesy
UNICEF
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