EPIDEMIOLOGY

OF VITAMIN A
DEFICIENCY
 The vitamin A deficiency disorders
(VADD) cycle

Adults Pregnancy
Reliance on leaves and fruits Increased needs
Food taboos
Low pre-formed vitamin A
Low foetal stores
Low fat
Low vitamin E
Low vitamin A status
Young child
Increased needs for growth
Breast: Bottle:
Protective Hazardous
immunisation infections
VADD
Mother care Parasites
Neglect

EP07
 Estimated number of preschool children affected
by clinical and subclinical vitamin A deficiency

Estimate WHO/UNICEF MI/UNICEF/Tulane

(million) (million)
Clinical 2.80 3.30

Subclinical 251 75,140

Note:
Prevalence peaks in children between the age of 2
and 4 years.
Boys are at higher risk than girls.
 Estimated number of preschool children affected by
clinical and subclinical vitamin A deficiency by region

Region Clinical Sub-clinical

% #million % #million
s s
South Asia 0.95 1.58 19.2 32.3
East Asia/Pacific 0.25 0.40 9.1 15.8
Latin America/Caribbean 0.24 0.12 9.0 4.7
East/Southern Africa 1.06 0.53 20.0 10.0
West/Central Africa 0.87 0.45 18.1 9.4
Middle East/North Africa 0.27 0.12 9.8 4.2
TOTAL 0.63 3.30 14.6 75.4
 Vitamin A deficiency problem in women of
reproductive age

Night blindness in 5 millions

pregnancy
Persistent risk of various 5 – 10 million
morbidity after night
blindness
Vitamin A deficiency in 10 millions
pregnancy
 Maternal night blindness
Nepal, national 18%
Nepal, Terai 11-16%
Nepal, Jumla 54%
Bangladesh, national 13%
India, national 12%
Indonesia, Central Java 0.4%
Philippines, national 10%
Laos, national 7%
Laos, regional 11%
Zambia, national 12%
El Salvador, local 10%
 Vitamin A Deficiency (VAD)

• A nutrition survey conducted in Indonesia in early

1970s revealed that the prevalence of VAD was
very high.. Indonesia was one of the first developing
countries to identify that high levels of severe VAD
constituted a serious public health problem and
began to implement programs to eliminate the
problem since the 1970s (HKI, 2000)

.
 Vitamin A Deficiency (VAD)

• . Since 1970s to 1990s, Indonesia embarked on a

nation-wide vitamin A intervention program by
providing high-dose vitamin A capsule twice a
year to almost all under-five children.

• Within two decades, the program successfully

reduced the clinical prevalence of VAD
(Xeropthalmia) to 0.33% in 1992, a level in which
VAD was no longer considered as a public health
problem.
 Vitamin A Deficiency (VAD)
• .However, at the sub-clinical level, 50% of the
children under fives still had low serum retinol (<20
μg/dl).

• Unfortunately, there is no national data available

beyond 1992 on VAD prevalence in Indonesia,
except scattered small studies by HKI in recent
years.

• What is the current magnitude of VAD prevalence

in Indonesia is difficult to speculate.
 VADD risk factors
Age and sex
1100
1000 Male Female
900
Number of cases

800
700
600
500
400
300
200
100
0
1 2 3 4 5 6 7 8
Oomen, 1961 Age (years)
EP01
 VADD risk factors
Age and sex
30
Male
Bitot‘s spot rate per 1000

Female

20

10

0
0 1 2 3 4 5 6
Age (years)
Sommer, 1982

EP02
 Relationship of age to degree of
severity of corneal involvement

70

60
Cases below age 2 (%)

50 n= 25

40 n= 34

30

20
n= 50
n= 53
10
0
1–3 4–5 6 7–8
Clinical severity (corneal
Sommer, 1982
file)
EP15
 Age distribution of consecutive cases
with corneal xerophthalmia (X2 or X3)
Percentage of corneal cases (X2 / X3)

40 Bandung, Indonesia, 1978 – 1979

Lahan, Nepal, 1986 – 1988

30

20

10

0
<1 1 2 3 4 5 >6
Sommer and West, 1996 Age (years)
E09
 Age distribution of mild xerophthalmia
in selected countries in Asia and Africa
4 Nepal 4 Zambia
XN
3 3
X1B

2 2
XN

1 1 X1B
Prevalence (%)

0 0
<1 1 2 3 4 <1 1 2 3 4 5
14 XN 4
India Indonesia
X1B
1
2 3
10
8
2 X1B 1978
6
XN 1978
4 1 X1B 1992
2
XN 1992
0 0
1 2 3 4 5 <1 1 2 3 4 5
Sommer and West, 1996 Age (years)

EP10
 VADD risk factors
Physiological status

Relative frequency of occurrence of eye signs

XN X1B X2+3

Pre-school + + ++
School ++ ++ +
Pregnancy +++ +
Lactation +++ +

EP06
 VADD risk factors
Infectious diseases

70 n = 53
Respiratory disease (%)

60
50
40 n = 50
30
n = 53
20 n = 50
10
0
X1B X2 X3A X3B
Clinical classification of cases
Sommer, 1982

EP04
 Mild xerophthalmia (XN, X1B),
weight/height, and mortality

(per 1000 child intervals) Wt for ht

<90% standard
90-99% standard
Mortality

Normal XN X1B XN, X1B

Ocular status

Sommer, 1983

EP12
 VADD risk factors
Season
16
Night blindness and Bitot‘s spot

Male
14 Female

12
10

8
6
2
4
0
4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72 Weeks
r

v
n

n
v
c

g
p

n
r

l
t

t
Ap

Ju
Oc

Oc
Ma

Ma

No
No
De

De
Ja

Ju

Au
Se
Fe

Ja
Sinha and Bang, 1973

EP03
 Relative risk of mild xerophthalmia
and type of food consumed

12

10

8
Odds ratio

0
Dark Yellow Egg Meat / fish Milk Rice Sugar
green fruit / banana rice
Aceh Study leaves vegetable mix water
Group, 1991
EP13
 Prevalence of sub-clinical vitamin A deficiency
among pre-school children (1993 and 1998)

40 38.0
35.8
1993
Percent prevelence

30 1998

20
10.4
10 8.2

0
<0.35µmol/l <0.70µmol/l
serum retinol level

EP20
 Breast feeding and mild xerophthalmia
(XN, X1B)
100 A. West Java, Indonesia 100 B. Sarlahi, Nepal
80 80
Percent of children breastfed

60 60
40 40
20 20
0 0
6 18 30 42 54 6 18 30 42 54
100 100 D. Lower Shire Valley,
C. Dhaka, Bangladesh
80 80 Malawi

60 60
40 40
20 20
0 0
6 18 30 42 54 6 12 18 24 30 36
Sommer and West, 1996
EP14 Age (months)
 Comparison of breast feeding in X1B cases,
matched controls and a random sample

n=2
100
n=5674 Bitot‘s spot cases
Presently breast fed (%)

Control
80
n=24 Random sample
n=5670

60

40
n=64 n=5723
n=25
20 n=70
n=5793
n=1 n=94 n=85 n=70 n=67 n=5338
0
0 1 2 3 4
Age (years)
Sommer, 1982

EP16