European Journal of Clinical Nutrition (2004) 58, 13421349

& 2004 Nature Publishing Group All rights reserved 0954-3007/04 $30.00
www.nature.com/ejcn

ORIGINAL COMMUNICATION
Vitamin A deficiency and xerophthalmia among
school-aged children in Southeastern Asia
V Singh1 and KP West, Jr1*
1

Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore,
MD, USA

Objective: To determine provisional estimates of the extent of vitamin A (VA) deficiency and xerophthalmia among school-aged
children.
Design: Literature search of published, unpublished and website-based population survey and study reports, with countryspecific imputation of prevalence rates and numbers of children affected by: (1) VA deficiency based on measured or imputed
distributions of serum retinol concentration o0.70 mmol/l (equivalent to o20 mg/dl) and (2) xerophthalmia, by country.
Setting: Countries within the WHO South-East Asian Region.
Subjects: The target group for estimation was children 515 y of age.
Interventions: None.
Results: The estimated prevalence of VA deficiency is 23.4%, suggesting that there are B83 million VA-deficient school-aged
children in the region, of whom 10.9% (9 million, at an overall prevalence of 2.6%) have mild xerophthalmia (night blindness or
Bitots spot). Potentially blinding corneal xerophthalmia appears to be negligible at this age.
Conclusions: VA deficiency, including mild xerophthalmia, appears to affect large numbers of school-aged children in SouthEast Asia. However, nationally representative data on the prevalence, risk factors and health consequences of VA deficiency
among school-aged children are lacking within the region and globally, representing a future public health research priority.

European Journal of Clinical Nutrition (2004) 58, 13421349. doi:10.1038/sj.ejcn.1601973

Published online 31 March 2004
Keywords: vitamin A deficiency; xerophthalmia; night blindness; Bitots spots; school-aged children; South-East Asia

Introduction
Vitamin A (VA) deficiency exists as a public health nutrition
problem among preschool-aged children in 118 developing
countries around the globe, with the South-East Asian
Region (defined by WHO to include Bangladesh, Bhutan,
India, Indonesia, Democratic Peoples Republic of Korea,
Maldives, Myanmar, Nepal, Sri Lanka and Thailand) harboring the maximum number of cases (West, 2002). Health
consequences of VA deficiency, termed VA deficiency
disorders or VADD, early in life include all active clinical

*Correspondence: KP West, Jr, Department of International Health, Johns

Hopkins Bloomberg School of Public Health, Center for Human Nutrition,
Room W2505, 615 N. Wolfe Street, Baltimore, MD 21205, USA.
E-mail: kwest@jhsph.edu
Guarantor: KP West Jr.
Contributors: VS studied the literature, calculated estimates and wrote
the paper. KPW conceptualized the problems, guided the analyses and
contributed to writing the paper.
Received 18 July 2003; revised 10 November 2003; accepted 1 December
2003; published online 31 March 2004

stages of xerophthalmia including corneal xerophthalmia

and its potentially blinding sequelae, impaired mechanisms
of host resistance, increased severity of infection, anemia,
poor growth and mortality (Sommer & West, 1996). We have
previously estimated that, globally, B127 million preschoolaged children under 5 y of age are VA deficient (serum retinol
o0.7 mmol/l or having abnormal impression cytology), of
whom 4.4 million have xerophthalmia (West, 2002). There
are also an estimated 7.2 million pregnant women with VA
deficiency (serum retinol o0.7 mmol/l) at any one time in
the developing world, of whom B6 million are night blind
(West, 2002), a condition attributable to VA deficiency
(Christian, 2002). Gestational and postpartum VA deficiency
may increase the risk of maternal morbidity (Christian et al,
1998, 2000a) and mortality (West et al, 1999; Christian et al,
200b) and infant mortality (Christian et al, 2001). A high
maternal prevalence of low VA status (based on serum retinol
o1.05 mmol/l) during pregnancy (eg, 22.0% in Africa and
24.3% in South Asia) (West, 2002), coupled with evidence of
recurrent night blindness in repeated pregnancies, suggests

VA deficiency and xerophthalmia among school-aged children

V Singh and KP West

1343
that the nutritional problem is likely to be chronic, with
antecedent risk possibly starting earlier in childhood and
pubescence; that is, 515 y of age. However, populationbased data on the prevalence of VA deficiency and the extent
and severity of accompanying VADD are lacking for schoolaged children throughout most of the developing world.
The original intent of the present study was to estimate the
prevalence of VA deficiency and xerophthalmia, and numbers of children affected, between the ages of 5 and 15 y by
country and region of the developing world. However, due to
scarcity of data at this age for most countries, provisional
estimates could only be made for the WHO South-East Asian
Region, with merely a few observations possible at this time
related to the extent of this problem in sub-Saharan Africa.
Still, we hope that resulting provisional estimates for this
region will motivate action toward more school-aged assessment of VADD.

Methods
We reviewed findings related to xerophthalmia and VA
deficiency in school-aged children from published and
unpublished and web-based sources. Major sources of data
included Multiple Indicator Cluster Surveys (MICS) for enddecade assessment in 55 countries submitted to United
Nations Childrens Fund (UNICEF) in the year 2001 (UNICEF,
2001a); survey reports in the Micronutrient Deficiency
Information System (MDIS) of the World Health Organization (WHO) in year 1995 (World Health Organization, 1995);
summaries of surveys compiled by the Micronutrient
Initiative (MI), United Nations Childrens Fund (UNICEF)
and Tulane University in year 1998 (The Micronutrient
Initiative); and findings of surveys, observational studies and
intervention trials reported in the scientific literature.
Prevalence data were also obtained from professional society
newsletters, periodicals, reports published by governmental
and nongovernmental organizations, correspondence with
principal investigators and abstracts from International
Vitamin A Consultative Group (IVACG) meeting reports
over the past 15 y.
Wherever possible, prevalence data were abstracted for the
relevant age range of this study, 515 y. However, prevalence
rates covering narrower age ranges (eg, 69 y among Thai
children (Bloem et al, 1989)) or ranges that only partly
included the target group (eg, 1317 y old among Nepali
children (KP West Jr et al, unpublished data, 2003) were
assumed to represent the entire target age.
Estimates of numbers of children 515 y in each country
were derived for most countries from two sources: the
UNICEF Year 2001 State of the Worlds Children Report,
which provides estimates of the total population and
numbers of preschool children (o5 y) for the year 1999
(UNICEF, 2001b), and the 2001 World Population Data Sheet
of the Population Reference Bureau to obtain the percentage
of children less than 15 y of age in each country (Population

Reference Bureau, 2001). This percentage was applied to the

total population reported by UNICEF to obtain the number
of children o15 y, from which was deducted the number
o5 y to estimate the number of children 515 y in each
country. This latter number served as the number
at-risk against which prevalence estimates were multiplied
to obtain numbers of VA-deficient and xerophthalmic
children.
Reports on the prevalence of VA deficiency were based on
biochemical and cytological indicators. VA-deficient status
was primarily defined as a serum (or plasma) retinol
concentration o0.70 mmol/l (o20 mg/dl) (IVACG, 1993). If
serological data were reported only as a mean concentration
with standard deviation (s.d.), or standard error with sample
size, a prevalence rate was calculated under an assumption of
normality of serum retinol concentration, as frequently
observed in population reports (West, 2002; Ballew et al,
2001). This allowed us to derive a standard normal deviate
(Z-score) from a reported mean and s.d. The probability
associated with the area under the left tail of the distribution, below the cut-point of 0.70 mmol/l, was adopted as an
estimate of prevalence of deficiency, as previously carried out
for preschoolers (West, 2002). In one country, the prevalence
of abnormal conjunctival impression cytology, a comparable
population indicator of VA deficiency (Natadisastra et al,
1988; Reddy et al, 1989; Sommer, 1995), was also used from
one study for modeling an estimate of VA deficiency for
school-aged children (ie, Indonesia) (Natadisastra et al,
1988).
Estimation of the prevalence of xerophthalmia and
consequent numbers of school-aged cases was based on
reports of WHO-defined clinical stages of night blindness
(XN), Bitots spot (XlB) and active corneal disease (X2 and
X3) (Sommer, 1995; Sommer & West, 1996). Conjunctival
xerosis (XlA) was not used as a clinical indicator due to
unreliability of diagnosis (Sommer, 1995). A single prevalence of active xerophthalmia was calculated as done
previously for preschool children (World Health Organization, 1995; The Micronutrient Initiative, 1998; West, 2002).
Thus, aggregate prevalences were adopted as reported.
Where only stage-specific rates were reported, an aggregate
rate was calculated by summing rates of X3, X2, XlB and half
of the reported rate of XN, under a conservative assumption
that half of the children reported as having night blindness
also had Bitots spots, as assumed in previous estimates for
preschoolers (West, 2002). When only one eye sign was
reported, we assumed that other ocular manifestations of
xerophthalmia were absent (West, 2002).

Estimation of prevalence and numbers affected in the

South-East Asian region
Although relevant data were most widely available in SouthEast Asia, studies of school age VA status remain sparse, and
vary considerably in design and representativeness. Such
diversity of evidence led us to adopt country-specific
European Journal of Clinical Nutrition

VA deficiency and xerophthalmia among school-aged children

V Singh and KP West

1344
approaches to impute the prevalence of VA deficiency and
xerophthalmia in an attempt to optimize the use of available
data.
Bangladesh. No rural serological data on VA status were
available for children 515 y of age. However, data on
biochemical VA deficiency were available from four urban/
periurban studies. An unweighted mean prevalence of 21.2%
was computed from serum retinol concentrations from two
studies of nonschool-attending adolescent female garment
factory workers in Dhaka (Ahmed et al, 1997, 2001). Given
that more than 90% of urban adolescents throughout the
country do not attend school (Bangladesh Bureau of
Statistics, 1999), a weight of 0.9 was assigned to this
estimate. An unweighted mean prevalence rate of 3.5% was
also calculated from two studies of school-attending adolescent children in Dhaka (Ahmed et al, 1996, 1998). As less
than 10% of urban children attend school (Bangladesh
Bureau of Statistics, 1999), a weight of 0.1 was assigned to
this estimate. The weighted percentages were summed to
obtain an urban prevalence of 19.4%. Two further assumptions were made to scale this percentage up to a provisional
national estimate: (a) Since all four studies were in girls,
males were assumed to have a prevalence of VA deficiency
comparable to females, based on data suggesting males to be
as or more VA deficient than females in the preschool years
(Sommer & West, 1996). This allowed the above percentage
to be applied to school-aged boys. (b) The urban:rural
prevalence ratio for VA deficiency was assumed to be 1.0
based on an observed national rural:urban prevalence ratio
of B1.0 for the clinical symptom of XN (UNICEF, 1998).
Based on this apparent comparability in risk, a provisional
prevalence of 19.4% was applied to the school-aged children
throughout the country.
For xerophthalmia, a national prevalence of 3.7% for night
blindness (UNICEF, 1998), among children 611 y of age, was
applied to the entire 5- to 15-y-old population. As a
conservative measure, we assumed that other clinical stages
of xerophthalmia were either solely exhibited by children
with night blindness or absent in the population.
Bhutan. No VA status data were available for school-aged
children. However, data from a 1985 national survey, as
summarized in the WHO MDIS in 1995 (World Health
Organization, 1995), indicated that 14% of Bhutanese
children 04 y had a serum retinol concentration o10 mg/dl
(o0.35 mmol/l). Under an assumption of normality and an
associated s.d. 9.3 mg/dl, this percentage would suggest a
prevalence close to 50% o20 mg/dl. Rather, the prevalence of
14% o10 mg/dl among preschoolers was doubled to 28%,
despite the lack of VA programs for this older group, in order
to impute a conservative prevalence of VA deficiency
(o20 mg/dl) for children 515 y of age.
A national prevalence of xerophthalmia among 612 y
Bhutanese children was reported in 1976 to be 1.3% (Tilden,
European Journal of Clinical Nutrition

1986; Task Force for Child Survival and Development, 1991).

Given the age and poor description of methods associated
with this survey, the prevalence was down-weighted by 0.5
to yield a conservative prevalence estimate of 0.65%.
Democratic Peoples Republic of Korea. There was no
estimate available in the literature on VA deficiency in North
Korea. Although likely to exist as a result of famine during
the past 5 y, in the absence of data no prevalence for either
VA deficiency or xerophthalmia was estimated for North
Korea, leaving the North Korean child population to be
excluded from the WHO regional denominator.
India. Population-based serum retinol data among schoolaged children are lacking in India. Three (Pant & Gopaldas,
1987; Pratinidhi et al, 1987; Reddy et al, 1989) biochemical
studies, among schoolers living in high-risk, urban slums
yielded an unweighted estimate of 69.3% for children with
serum retinol concentrations o0.70 mmol/l. In the absence
of other data, a weight of 0.3 was arbitrarily applied to this
value in an attempt to account for both uncertainty and lack
of representativeness. The resulting prevalence of 23.1% was
applied to the school-aged population of the country. This
provisional estimate seems reasonably conservative given
widespread reports of poor diet (Pratinidhi et al, 1987;
Ramakrishnan et al, 1999), persistent xerophthalmia (Khandait et al, 1999) and undernutrition (Pratinidhi et al, 1987;
Department of Women and Child Development, 1998)
amidst a lack of any VA deficiency prevention programs for
school-aged children throughout India.
For xerophthalmia, national, population-based data on
XN were available for Indian children 514 y of age based on
UNICEF Multiple Indicator Cluster Surveys (MICS) carried
out in recent years in each state (Department of Women and
Child Development, 1998). Prevalence rates of mild X1B for
eight states were also available from the National Nutrition
Monitoring Bureau (2000) and from five other survey reports
in four states (Rahmathullah et al, 1990; Gupta et al, 1998;
Aravind Comprehensive Eye Survey, 1999; Nambiar &
Kosambia, 2003; Singh & Sharma, 2003) covering children
whose ages ranged from 5 to 16 y (Rahmathullah et al, 1990;
Gupta et al, 1998; Aravind Comprehensive Eye Survey, 1999;
Nambiar & Kosambia, 2003; Singh & Sharma, 2003). As these
latter rates were not considered to be statewide, they were
weighted by a factor of 0.75, to account for the lack of
representativeness, and averaged with each statewide MICS
prevalence rate for XN. Rates for all states were summed and
averaged (unweighted) to obtain a national prevalence for
India (2.8%), which was then multiplied by the estimated
number of school-aged children in the country.
Indonesia. We could locate no data on serum retinol levels
among school-aged Indonesian children. However, serum
retinol concentration data do exist from three studies of
preschool-aged children and five studies of pregnant and

VA deficiency and xerophthalmia among school-aged children

V Singh and KP West

1345
lactating women in Indonesia. These data provided an
opportunity to interpolate a prevalence rate for the 5- to
15-y-old age group, at the mid-interval age of 10 y, by
entering age-specific prevalence rates from the above eight
studies into a least-squares linear regression model. The
resulting equation was: Y 49.421.52X, where Y is the
estimated prevalence of VA deficiency (serum retinol
o0.70 mmol/l) per 100 and X is the age in y. Given
prevalences of 58.4, 39.4 and 35.6% at average ages of 2.4,
2.5 and 4.5 y among preschoolers (Natadisastra et al, 1988;
Kjolhede et al, 1995; Muhilal, 1995), and 10.417.0% among
pregnant and lactating women of ages 1540 y (Stoltzfus et al,
1992, 1993; Suharno et al, 1993; Muhilal, 1995; Tanumihardjo et al, 1996), we estimated a prevalence among 10-yold children of 34.2%, which was applied to the combinedsex population of 5- to 15-y-old children in Indonesia.
No prevalence data could be located on xerophthalmia in
school-aged Indonesian children. Thus, a xerophthalmia
prevalence of 0.4% among preschoolers from a national
survey in 1992 (Muhilal et al, 1994) was adopted for
schoolers. This estimate is likely to be conservative, given a
well-known trend for the prevalence of mild xerophthalmia
to rise with age at least into the early school years (Sommer,
1982; Djunaedi et al, 1988; Muhilal et al, 1994), a lack of any
VA supplementation program for this age group, and
probably adverse nutritional effects from a national economic crises during the past decade.
Maldives. No report of VA status exists in this country,
leading to its exclusion from present regional estimates of VA
deficiency and xerophthalmia.
Myanmar. A mean, unweighted VA deficiency prevalence
of 27.5%, based on serum retinol values o0.70 mmol/l,
among 2- to 14-y-old children in three surveyed districts
reported in 1989 (Sunn et al, 1989) was still considered to be
a valid estimate for school-aged children in the country.
For xerophthalmia, a prevalence rate of 4.04% obtained for
XlB in a population-based survey of 614 y children in four
regions as reported in 1989 (Thein & Myint, 1989) was also
considered valid for the present exercise. Other stages of
xerophthalmia were not reported and inferred, conservatively, to be absent.
Nepal. In Nepal, amidst lack of nationally representative
biochemical data on VA deficiency in school-aged Nepalese
children, unpublished baseline or control group serum
retinol data were available in 1992 first trimester pregnant
girls 1417 y of age living in the southern plains of the
country and participating in two maternal supplementation
trials (KP West Jr and P Christian, unpublished data, 2003).
The resulting prevalence of 14.2% o0.70 mmol/l was unlikely
to have been affected by plasma expansion because it was
based on phlebotomy in the first trimester of pregnancy. The
value is lower than values obtained during a 1998 national

survey of 19.8% in a stratum of 41 women o20 y of age and

23.7% in a stratum of 122 4-y-old children of both sexes
(Nepal Micronutrient Status Survey, 1998). Based on assumptions of uniform risk across earlier school-aged years and
gender, as observed in the national sample (Nepal Micronutrient Status Survey, 1998), a prevalence of 14.2% was
applied to the Nepalese school-aged population.
The xerophthalmia rate for school-aged children was
obtained from a 1998 national survey of XN and XlB (Nepal
Micronutrient Status Survey, 1998). An aggregate prevalence
for all active stages of xerophthalmia was not reported;
therefore, assuming that half of the children with XN also
had XlB (Sommer, 1982), an aggregate prevalence of 2.6%
was obtained by adding half of the prevalence rate of XN
(0.5  1.33%) to that of XlB (1.91%).
Sri Lanka. No data were found on VA deficiency in
children 515 y of age in Sri Lanka, forcing our estimate to
be derived from a 1979 national survey prevalence of 6.0%
among 4- to 6-y-old children (Brink et al, 1979). Under
assumptions of little improvement in general socioeconomic, health and nutritional status in Sri Lanka, as reflected
by a relatively constant infant mortality rate over the past
two decades (United Nations Development Programme,
1999), coupled with what appeared to have been a general
lack of VA programming activity during this time period, a
VA deficiency prevalence estimate of 6% among children 4
6 y of age dating to 1979 (Brink et al, 1979) was applied to the
515 y age range.
Similarly, 1979 data on the prevalence of XN (1.4%) and
XlB (2.1%) (Brink et al, 1979) were used to estimate the
present burden of xerophthalmia in schoolers. To obtain a
single estimate for xerophthalmia, half of the XN prevalence
rate was added to that of XlB, under an assumption that half
of the children reporting to have had XN also had XlB and
thus were included in the X1B rate.
Thailand. The northeastern region of Thailand historically
represents the only major locus of undernutrition with VA
deficiency in the country. An unweighted mean prevalence
for VA deficiency of 41.83% was obtained from two surveys
of children aged 69 y and 18 y undertaken in Northeastern
Thailand between 1985 and 1990 (Bloem et al, 1989, 1990).
This prevalence was down-weighted by two factors: (a) As
Northeastern Thailand was assumed to represent only 25%
of the country, a weight of 0.25 was applied to this
prevalence. (b) Since the prevalence was assumed to have
been measured during the high-risk dry part of the year, an
additional weight of 0.5 was also applied to account for
seasonal variation. These adjustments led us to estimate a
school-aged VA deficiency prevalence of 5.2%. In order to
estimate a single prevalence of xerophthalmia where both
XN and X1B had been reported (Bloem et al, 1989), half of
the XN prevalence rate was added to XlB, under the
assumption that half of the children reported as having
European Journal of Clinical Nutrition

VA deficiency and xerophthalmia among school-aged children

V Singh and KP West

1346
night blindness also had Bitots spots, as assumed previously
(West, 2002). To account for the lack of national representation, this value was down-weighted by a factor of 0.25. An
additional weight of 0.5 was applied to the estimate to
account for seasonal variation as the data appeared to apply
only to the higher risk dry season. These adjustments
rendered a national xerophthalmia prevalence of 0.15%,
which was applied to the 5- to 15-y-old population of the
country.

Results
Provisional estimates of the prevalence of VA deficiency and
numbers of affected children between 5 and 15 y of age for
each country in the WHO South-East Asian Region are
shown in Table 1. The overall prevalence estimate for VA
deficiency is 23.4%, with individual country estimates
ranging from a low of 5.2% in Thailand to a high of 34.2%
in Indonesia. This overall prevalence leads to an estimate of
B82.7 m VA-deficient school-aged children in the region.
While not having the highest apparent prevalence (23.1%),
India has the largest number of VA-deficient schoolers,
estimated at 56.4 m, representing 68% of all deficient
children at this age in the region. If one were to apply the
minimum VA deficiency prevalence of 15%, as recently
revised by the IVACG (Sommer & Davidson, 2002) for
determining public health significance in preschoolers, the
countries of Bangladesh, Bhutan, India, Indonesia and
Myanmar would appear to have a VA deficiency problem of
public health importance among school-aged children.
Table 1 also displays provisional estimates of the prevalence and numbers of cases of mild xerophthalmia (XN and
X1B) between 5 and 15 y of age for each country in the WHO
South-East Asian Region. At an imputed overall prevalence of
2.6%, there are B9.0 m children with night blindness and/or
Bitots spots in the Region. The maximum prevalence

appears to be in Bangladesh (3.7%); the minimum prevalence is in Thailand (0.15%). As with VA deficiency, due to a
substantial estimated prevalence (2.8%) combined with its
large population size, the largest number of school-aged
children with xerophthalmia lives in India (B6.8 m),
representing B76% of all cases throughout the Region.
Countries of Bangladesh, India, Myanmar, Nepal and Sri
Lanka exceed a minimum prevalence criterion of 1.5% for all
active stages of xerophthalmia, a minimum public health
criterion that has been recently proposed for preschool-aged
children (West, 2002).
Figure 1 displays a map of the joint distribution of
prevalences of VA deficiency above or below 15% and
xerophthalmia above or below 1.5% in each country of the
Region, as recently reported for preschool children throughout the world (West, 2002). Countries with the darkest shade
that, based on this exercise, appear to exceed both cutoffs are
Bangladesh, India and Myanmar. Nepal is on the borderline
between the highest and second highest risk classification.

Discussion
Although there exists substantial documentation of prevalence, severity and health consequences of VA deficiency in
preschool-aged children (Sommer & West, 1996), and rapidly
emerging evidence about this nutritional problem in
pregnant and lactating women (West, 2002), little has been
done to evaluate systematically the extent of VA deficiency
in the preadolescent and adolescent years. Underlying the
current global emphasis on preschoolers and pregnant
women are the multiple, known health disorders of VA
deficiency and the urgent and continuing need to launch,
expand and sustain preventive efforts in these high-risk
groups (Sommer & West, 1996; Christian et al, 1998;
Christian et al, 2000a, b; Christian, 2002). In contrast,
preadolescent school-aged individuals, as a demographic

Table 1 Prevalence of VA deficiency and xerophthalmia among school-aged children (515 y) with estimated numbers of cases in the WHO South-East
Asian Regiona
VADb
South/South-East Asia

Xerophthalmia

Population, 515 y

Percentage (%)

Number

Percentage (%)

Number

Bangladesh
Bhutan
India
Indonesia
Myanmar
Nepal
Sri Lanka
Thailand

35 658 800
527 880
244 324 160
42 863 050
10 643 470
6 102 850
3 621 920
9 774 440

19.4
28.0
23.1
34.2
27.5
14.2
6.0
5.2

6 917 807
147 806
56 438 881
14 659 163
2 926 954
866 605
217 315
508 271

3.7
0.7
2.8
0.4
4.0
2.6
2.8
0.2

1 319 376
3695
6 841 076
171 452
425 739
158 674
101 414
14 662

Total

353 516 570

23.4

82 682 802

2.6

9 036 088

Countries in the WHO South-East Asian region excluded in the above table are Democratic Peoples Republic of Korea and Maldives, due to a lack of prevalence data
on VA deficiency and xerophthalmia among school-aged children.
b
Based on measured or imputed serum retinol concentration o0.7 mmol/l (Sommer, 1995).

European Journal of Clinical Nutrition

VA deficiency and xerophthalmia among school-aged children

V Singh and KP West

1347

Figure 1 Countries in the WHO South-East Region stratified by joint prevalence of VAD, defined by serum retinol concentration o0.7 mmol/l
and/or xerophthalmia (X), all active stages combined, among children 515 y of age.

group, are widely regarded as having relatively lower health

and nutritional risks. This lower risk profile has likely
depressed motivation historically to assess the prevalence
of VA deficiency and its disorders or to implement VA
deficiency prevention programs in school-aged children.
Indeed, the public health consequences of periadolescent VA
deficiency, other than mild manifestations of xerophthalmia, remain largely unknown. While blinding xerophthalmia seems to be exceedingly rare, other less apparent or
specific health consequences of VA deficiency known to exist
in younger children, such as increased severity of diarrhea
(Sommer & West, 1996), could contribute to the burden of
disease in this age group and should not be assumed to be
absent. Furthermore, beyond plausible risk of comorbidity,
given that maternal night blindness recurs with repeated
pregnancy during the reproductive years in high-risk
populations (Katz et al, 1995), it is possible that adolescent
VA deficiency antecedes and predicts chronic maternal
VA deficiency and its apparent health consequences
(Christian et al, 1998, 2000a, b, 2001; West et al, 1999).
This latter possibility would confer far greater importance to
the need to quantify the prevalence and severity, and
understand the epidemiology of VA deficiency in early
adolescence.

In this report, we provide provisional estimates of the

prevalence of VA deficiency and xerophthalmia, and the
numbers affected, among children 515 years of age in the
WHO South-East Asian Region. After reviewing the literature, this was the only region of the world for which we
could locate a minimum set of published and unpublished
population data on the problem at this age from which such
estimates could be made. The exercise suggests that at least
one-quarter of all school-aged children, or nearly 83 million
in the region are VA deficient, defined as having a serum
retinol concentration below 0.70 mmol/l (20 mg/dl). We
further estimate that 10.9%, or 9 million, of deficient
children have mild xerophthalmia (night blindness or Bitots
spots), equivalent to an overall prevalence of 2.6%. Unknown in this estimate is the population of potentially
unresponsive Bitots spot cases as has been reported in some
populations of preschool children (Emran & Tjakrasudjatma,
1980; Semba et al, 1990). Interestingly, both prevalence
estimates for VA deficiency and xerophthalmia exceed public
health minima of 15% and 1.5%, respectively (Sommer &
Davidson, 2002; Ross, 2002; West, 2002), as established by
the WHO and the International Vitamin A Consultative
Group (IVACG) for identifying VA deficiency as a public
health problem in preschool-aged children. We propose that,
European Journal of Clinical Nutrition

VA deficiency and xerophthalmia among school-aged children

V Singh and KP West

1348
until modification is warranted, these cutoffs also be
considered applicable to children 515 y of age.
Although very few data were available to estimate the
prevalence or burden of school-aged VA deficiency in other
regions of the world, population surveys or communitybased studies carried out in the Cameroon (Gouado et al,
1996), Ethiopia (Kassaye et al, 2001), Ghana (Ghana VAST
Study Team, et al, 1993), Malawi (Brabin et al, 1999), Senegal
(Carlier et al, 1993) and Tanzania (Ash et al, 2003) over the
past decade have revealed prevalences of 0.56% for
xerophthalmia and 1360% for VA deficiency (o0.70 mmol/
l). Recently, a prevalence of 34% was reported among schoolattending adolescents in Nigeria (Ene-Obong et al, 2003).
These ranges suggest that VA deficiency could be a
significant public health problem, while raising the need
for more representative population data, throughout subSaharan Africa.
These provisional estimates suggest that school-aged VA
deficiency could be an important public health problem in
the South-East Asian region due to the numbers of children
likely affected, the potential for associated but largely
ignored (and unknown) health consequences at this age
and because of the potential for deficiency in early
adolescence to predispose women to chronic VADD during
the reproductive years, especially during and following
pregnancy.

Acknowledgements
We thank Parul Christian for sharing early, unpublished
tables on vitamin A deficiency in India. This study was
funded by Cooperative Agreement No. HRN-A-00-97-0001500 between the Office of Health and Nutrition, US Agency
for International Development (USAID), Washington, DC,
USA and the Center for Human Nutrition, Department of
International Health, The Bloomberg School of Public
Health, Johns Hopkins University, Baltimore, MD, USA with
additional support from The Bill and Melinda Gates
Foundation, Seattle, WA, USA and the Sight and Life
Research Institute, Baltimore, MD, USA.

References
Ahmed F (1998): Vitamin A deficiency in Bangladesh: a review and
recommendation for improvement. Pub. Health Nutr. 1, 115.
Ahmed F, Hasan N & Kabir Y (1997): Vitamin A deficiency among
adolescent female garment factory workers in Bangladesh. Eur. J.
Clin. Nutr. 51, 698702.
Ahmed F, Khan MR & Jackson AA (2001): Concomitant supplemental
vitamin A enhances the response to weekly supplemental iron and
folic acid in anemic teenagers in urban Bangladesh. Am. J. Clin.
Nutr. 74, 108115.
Ahmed F, Khan MR, Karim R, Taj S, Hyderi T, Faruque MO, Margetts
BM & Jackson AA (1996): Serum retinal and biochemical measures
of iron status in adolescent schoolgirls in urban Bangladesh. Eur. J.
Clin. Nutr. 50, 346351.
Aravind Comprehensive Eye Survey (ACES) (1999): The Prevalence of
Xerophthalmia in Children as a Function of Age, Gender and
Socioeconomic Status: Data from the Aravind Comprehensive Eye

European Journal of Clinical Nutrition

Survey (ACES). Tamil Nadu, India: Aravind Eye Hospital. (unpublished).

Ash DM, Tatala SR, Frangillo Jr EA, Ndossi GD & Latham MC (2003):
Randomized efficacy trial of a micronutrient-fortified beverage in
primary school children in Tanzania. Am. J. Clin. Nutr. 77,
891898.
Ballew C, Bowman BA, Sowell AL & Gillespie C (2001): Serum retinol
distributions in residents of the United States: third National
Health and Nutritional Examination Survey, 198894. Am. J. Clin.
Nutr. 73, 586593.
Bangladesh Bureau of Statistics (1999): 1998 Statistical Yearbook of
Bangladesh, 19th Edition. Bangladesh Bureau of Statistics, Statistics
Division, Ministry of Planning, Government of the Peoples
Republic of Bangladesh, Dhaka, Bangladesh.
Bloem MW, Wedel M, Egger RJ, Speek AJ, Chusilp K, Soawakontha S
& Schreurs WHP (1989): A prevalence study of vitamin A
deficiency and xerophthalmia in northeastern Thailand. Am. J.
Epidemiol. 129, 10951103.
Bloem MW, Wedel M, Egger RJ, Speek AJ, Schrijver JK, Soawakontha S
& Schreurs WHP (1990): Mild vitamin A deficiency and risk of
respiratory tract diseases and diarrhoea in preschool and school
children in northeastern Thailand. Am. J. Epidemiol. 131, 332339.
Brabin L, Frazio-Tirrozzo G, Brabin B, Agbaje O, Harper G &
Broadhead R (1999): Vitamin A, vitamin E and anaemia status of
non-pregnant Malawian adolescents. XIX IVACG Meeting, Durban,
South Africa.
Brink EW, Davey W, Parera A, Broske SP, Cash RA, Smith JL,
Sauberlich HE & Bashor MM (1979): Vitamin A status of children
in Sri Lanka. Am. J. Clin. Nutr. 32, 8491.
Carlier C, Coste J, Etchepare M, Periquet B & Amedee-Manesme O
(1993): A randomized controlled trial to test equivalence between
retinyl palmitate and a carotene for vitamin A deficiency. BMJ 307,
11061110.
Christian P (2002): Recommendations for indicators: night blindness
during pregnancya simple tool to assess vitamin A deficiency in
a population. J. Nutr. 132, 2884S2888S.
Christian P, West Jr KP, Khatry SK, Katz J, LeClerq SC,
Kimbrough-Pradhan E, Dali SM & Shrestha SR (2000a):
Vitamin A or a-carotene supplementation reduces symptoms of
illness in pregnant and lactating Nepali women. J. Nutr. 130,
26752682.
Christian P, West Jr KP, Khatry SK, Katz J, Shrestha SR, KimbroughPradhan E, LeClerq SC & Pokhrel RP (1998): Night blindness of
pregnancy in rural Nepalnutritional and health risks. Int. J.
Epidemiol. 27, 231237.
Christian P, West Jr KP, Khatry SK, Kimbrough-Pradhan E, LeClerq
SC, Katz J, Shrestha SR, Dali SM & Sommer A (2000b): Night
blindness during pregnancy and subsequent mortality among
women in Nepal: effects of vitamin A and a-carotene supplementation. Am. J. Epidemiol. 152, 542547.
Christian P, West Jr KP, Khatry SK, LeClerq SC, Kimbrough-Pradhan
E, Katz J & Shrestha SR (2001): Maternal night blindness increases
risk of infant mortality in the first 6 months of life in Nepal. J.
Nutr. 131, 15101512.
Department of Women and Child Development (1998): India
Nutrition Profile. New Delhi, India: Ministry of Human Resource
Development, Government of India.
Djunaedi E, Sommer A, Pandji A, Kusdiono, Taylor HR & the Aceh
Study Group (1988): Impact of vitamin A supplementation on
xerophthalmia. Arch. Ophthalmol. 106, 218222.
Emran N & Tjakrasudjatma S (1980): Clinical characteristics of
vitamin A responsive and nonresponsive Bitots spot. Am. J.
Ophthalmol. 90, 160171.
Ene-Obong HN, Odoh IF & Ikwuagwu OE (2003): Plasma vitamin A
and C status of in-school adolescents and associated factors in
Enugu State, Nigeria. J. Health Popul. Nutr. 21, 1825.
Ghana VAST Study Team, Ross DA, Binka FN, Dollimore N, Smith PG,
Addy HA, Tomkins AM, Kirkwood BR, Arthur P, Morris SS &
Gyapong JO (1993): Vitamin A supplementation in northern

VA deficiency and xerophthalmia among school-aged children

V Singh and KP West

1349
Ghana: effects on clinic attendances, hospital admissions, and
child mortality. Lancet 342, 712.
Gouado I, Mbiapo TF, Moundipa FP & Teugwa MC (1996): Vitamin A
and E status of some rural populations in the north of Cameroon.
Int. J. Vit. Nutr. Res. 68, 2125.
Gupta SS, Aggarwal AK, Singh MMC, Ranjan, Kaur A & Kumar R
(1998): Vitamin A deficiency (VAD)still a major problem among
the underprivileged population. Sight Life Newslett. 1, 2326.
International Vitamin A Consultative Group (IVACG) (1993): A Brief
Guide to Current Methods of Assessing Vitamin A Status. Washington,
DC: IVACG.
Kassaye T, Receveur O, Johns T & Becklake MR (2001): Prevalence of
vitamin A deficiency in children aged 69 years in Wukro,
northern Ethiopia. Bull. WHO 79, 415422.
Katz J, Khatry SK, West Jr KP, Humphrey JH, LeClerq SC, Pradhan EK,
Pokhrel RP & Sommer A (1995): Night blindness is prevalent
during pregnancy and lactation in rural Nepal. J. Nutr. 125, 2122
2127.
Khandait DW, Vasudeo ND, Zodpey SP, Ambadekar NN & Koram MR
(1999): Vitamin A intake and xerophthalmia among Indian
children. Pub. Health 113, 6972.
Kjolhede CL, Stallings RY, Dibley MJ, Sadjimin T, Dawiesah S &
Padmawati S (1995): Serum retinal levels among preschool
children in Central Java: demographic and socioeconomic
determinants. Int. J. Epidemiol. 24, 399403.
Muhilal (1995): Noodle: a suitable fortification vehicle. Nutriview 2,
15.
Muhilal, Tarwotjo I, Kodyat B, Herman S, Permaesih D, Kharyadi D,
Wilber S & Tielsch JM (1994): Changing prevalence of xerophthalmia in Indonesia, 19771992. Eur. J. Clin. Nutr. 48, 708714.
Nambiar VS & Kosambia P (2003): Prevalence of vitamin A deficiency
in two urban slums of urban Vadodara, Gujarat, India. Improving
the Vitamin A Status of the Population. XXI IVACG Meeting,
Marrakech, Morocco.
Natadisastra G, Wittpenn JR, Muhilal, West Jr KP, Mele L & Sommer A
(1988): Impression cytology: a practical index of vitamin A status.
Am. J. Clin. Nutr. 48, 695701.
National Nutrition Monitoring Bureau, Government of India (2000):
Report on Nutritional Status of the Rural Population, 1996, Summarized in Background Document for the National Consultation on
Vitamin A, September 2930, 2000. New Delhi, India: National
Nutrition Monitoring Bureau, Government of India.
Nepal Micronutrient Status Survey (1998): Ministry of Health, Child
Health Division, His Majestys Government of Nepal; New ERA,
Micronutrient Initiative. Nepal and Kathmandu, Nepal: UNICEF
and WHO.
Pant I & Gopaldas T (1987): Effect of mega doses of vitamin A on the
vitamin A status of underprivileged school-age boys (715 years).
Indian J. Med. Res. 86, 196206.
Population Reference Bureau (2001): 2001 World Population Data
Sheet. Washington, DC: Population Reference Bureau.
Pratinidhi AK, Shah U & Bapat VS (1987): Screening tests for vitamin
A deficiency. Indian J. Pediatr. 54, 563570.
Rahmathullah L, Underwood BA, Thulasiraj RD, Milton RC,
Ramaswamy K, Rahmathullah R & Babu G (1990): Reduced
mortality among children in southern India receiving a small
weekly dose of vitamin A. N. Engl. J. Med. 323, 929935.
Ramakrishnan U, Martorell R, Latham MC & Abel R (1999): Dietary
vitamin A intakes of preschool children in South India. J. Nutr.
129, 20212027.
Reddy V, Rao V, Arunjyothi & Reddy M (1989): Conjunctival
impression cytology for assessment of vitamin A status. Am. J.
Clin. Nutr. 50, 814817.
Ross DA (2002): Recommendations for vitamin A supplementation.
J. Nutr. 132, 2902S2906S.
Semba RD, Wirasasmita S, Natadisastra G, Muhilal & Sommer A
(1990): Response of Bitots spots in preschool children to vitamin
A treatment. Am. J. Ophthalmol. 15, 416420.

Singh K & Sharma S (2003): Vitamin A status of street and working

children in Delhi, India. Improving the Vitamin A Status of the
Population. XXI IVACG Meeting, Marrakech, Morocco.
Sommer A (1982): Nutritional Blindness: Xerophthalmia and Keratomalacia. New York: Oxford University Press.
Sommer A (1995): Vitamin A Deficiency and its Consequences. A Field
Guide to Detection and Control, 3rd Edition, Geneva: World Health
Organization.
Sommer A & Davidson FR (2002): Assessment and control of vitamin
A deficiency: the Annecy Accords. J. Nutr. 132, 2845S2851S.
Sommer A & West Jr KP (1996): Vitamin A Deficiency: Health, Survival
and Vision. New York: Oxford University Press.
Stoltzfus RJ, Habicht JP, Rasmussen KM & Hakimi M (1993):
Evaluation of indicators for use in vitamin A intervention trials
targeted at women. Int. J. Epidemiol. 22, 11111117.
Stoltzfus RJ, Hakimi M, Miller KW, Rasmussen KM, Dawiesah S,
Habicht JP & Dibley MJ (1992): High dose vitamin A supplementation of breast-feeding Indonesian mothers: effects on the
vitamin A status of mother and infant. J. Nutr. 123, 666675.
Suharno D, West CE, Muhilal, Kharyadi D & Hautvast JGA (1993):
Supplementation with vitamin A and iron for nutritional anemia
in pregnant women in West Java, Indonesia. Lancet 342, 1325
1327.
Sunn MM, Toe T & Naing KM (1989): Vitamin A status survey of
Myanmar children. International Vitamin A Consultative Group
Meeting, Kathmandu, Nepal.
Tanumihardjo SA, Muherdiyantiningsih, Permaesih D, Komala,
Muhilal, Kharyadi D & Olson JA (1996): Daily supplements of
vitamin A (8.4 mmol, 8000 IU) improve the vitamin A status of
lactating Indonesian women. Am. J. Clin. Nutr. 63, 3235.
Task Force for Child Survival and Development (1991): Conference
on ending hidden hunger. Proceeding of a Policy Conference on
Micronutrient Malnutrition, Montreal, October 1991. Presents data for
Indonesia, Bhutan and Ghana. Task Force for Child Survival and
Development, Atlanta.
The Micronutrient Initiative (1998): Progress in Controlling Vitamin A
Deficiency, Tulane University, Ottawa, Canada: The Micronutrient
Initiative, United Nations Childrens Fund.
Thein D & Myint T (1989): Vitamin A status of children in Myanmar.
Interdepartmental Workshop on Prevention and Control of Vitamin A
Deficiency, Myanmar, National Nutrition Center.
Tilden R (1986): Prevention and Control of Vitamin A Deficiency,
Xerophthalmia and Nutritional Blindness in Bhutan- Assignment
Report, 312 March 1986. New Delhi. (WHO Project ICP NUT
005).
UNICEF, Progotir Pathey (1998): Achieving the Goals for Children in
Bangladesh. Dhaka, Bangladesh: Bangladesh Bureau of Statistics,
Ministry of Planning, Government of the Peoples Republic of
Bangladesh, and UNICEF.
UNICEF (2001a): National Report-Multiple Indicator Cluster Survey-2.
Department of Women and Child Development, Government of
India and United Nations Childrens Fund (UNICEF), New Delhi.
UNICEF (2001b): The State of the Worlds Children 2001. New York:
United Nations Childrens Fund.
United Nations Development Programme (1999): Human Development Report 1999. New York, NY: UNDP.
West Jr KP (2002): Extent of vitamin A deficiency among pre-school
children and women of reproductive age. J. Nutr. 132, 2857S
2866S.
West Jr KP, Katz J, Khatry SK, LeClerq SC, Pradhan EK, Shrestha SR,
Connor PB, Dali SM, Christian P, Pokhrel RP & Sommer A (1999):
Double blind, cluster randomized trial of low dose supplementation with vitamin A or a-carotene on mortality related
to pregnancy in Nepal. The NNIPS-2 Study Group. BMJ 318,
570575.
World Health Organization (1995): The global prevalence of vitamin A
deficiency. Micronutrient deficiency information system (MDIS), Working Paper 2: WHO/NUT/95 3, Geneva: World Health Organization.

European Journal of Clinical Nutrition