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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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