Combating Vitamin A Deficiency - A Rational Public Health ... · Combating Vitamin A Deficiency - A...
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Reviews And Comments Combating Vitamin A Deficiency - A Rational Public Health Approach Shanti Ghosh All paediatricians, ophthalmolo- gists and, in fact, most public health scientists have been witness to the serious aftermath of vitamin A defi- ciency, leading to Keratomalacia and blindness in earlier years. Fortunately that event has become a rarity today. However, milder manifestations such as night blindness and Bitot's spots are still seen even though the preva- lence is markedly reduced. These vary between one state and another and within districts as well, as shown by a recent ICMR study on 18 district nutri- tion profiles. Night blindness is diffi- cult to judge in young children. How- ever, there are reports of night blind- ness during pregnancy, which disap- pear spontaneously after delivery. When energy intake is half of what it should be, naturally micronutrient intake will also be less. This applies to .ill1 micro- nutrients, iron being by far the lead- ing one. From the data available, one would conclude, therefore, that the problem of vitamin A deficiency is markedly reduced though not entirely eliminated. We also know that deficiency signs are the end points of deficiency and a child could be biochemically deficient without showing any physical signs. Unfortunately, assessing blood lev- els, etc, is not simple (or of indisput- able significance) and so one would have to depend on general levels of nutrition and deficiency signs to as- sess prevalence of the problem. The prevalence of deficiency could also vary from one season to another, de- pending on availability of ~-carotene- rich foods, drought situation, etc. The oft quoted justification for synthetic vitamin A administration is reduction in mortality - in some mor- bidity and not in others, and overall prevention or reduction in severity of the infection. For the former (reduc- tion in mortality) there are conflicting reports, some in favour and others against. As for reducing the serious- ness of the infection, there are sev- eral factors which could contribute to that - the level of malnutrition being the most important one. In severely malnourished children, infections are more severe and mortality high but to infer that these children need syn- thetic vitamin A to deal with the prob- lem would be like Marie Antoinette asking the people of France to eat cake if bread was not available. There is also much talk of specific beneficial effect in measles but the way to deal with that is to immunise the child against measles, which is part of the immu- nisation programme, and prevent the disease rather than identify the child after he has developed measles and then administer vitamin A. The same health machinery that identifyies the case of measles should also be able to immunise the child. However, if the child is hospitalised for complications, pneumonia being the most common one, he can cer- tainly be administered one dose of vitamin A. India being a large and diverse country, no survey, however well sup- ported in the field and statistically, can find out the true extent of the problem. We are told about areas where vitamin A deficiency signs are still a problem. The answer to this is that we should do district mapping for vita- min A deficiency signs all over the country. It should be decentralised and the states should take responsi- bility for it. Senior school children can be easily trained to do this and it will be educative for them too. Further programme management would de- pend on the result of such a survey, which again should be decentralised. Ad hocism is the death knell of any programme. When one programme, however good and relevant, is pushed, other programmes suffer. While elimi- nating polio is a lofty aim, coverage of other immunisations has fallen drasti- cally and we have witnessed the re- emergence of diphtheria and worsen- ing of the situation regarding other immunisation for preventable diseases. The aim of eliminating neonatal tetanus too has been given the go by because of reduction of tetanus tox- oid in pregnant women. If Delhi has four pulses of polio vaccine this win- ter, one can imagine what will happen to the other programmes. Administering vitamin A with polio immunisation is again controversial and the Indian Academy of Paediat- rics is against it. Recording of vitamin A administration is non-existent in field operations and the child could end up receiving vitamin A with each pulse. Besides very young infants too could receive it resulting in increased intra- cranial tension, however temporary. To do it effectively, it needs to be done in a project mode and not programme mode, which is short-lived and extremely expensive, and hence difficult to replicate - and again the programme suffers in the long run. The most important thing is to make sure that the existing health programmes are carried out as planned. the Government of India has a programme for vitamin A administra- tion along with measles vaccine, DPT booster, etc, for the first three years. Most of the serious infections and maximum malnutrition occur during this period. It can be debated whether it should be extended to five years depending on the deficiency signs data. This means that the health ser- vices have to be made accountable and supplies assured. We should not accept the reported figures but should have other means of monitoring and evaluation. Reported figures for immunisation coverage are near 100 per cent while survey reports are less than half. Survey of a programme has to be built into the programme itself. Another suggestion is one of administering vitamin A to pregnant women after the first trimester to in- crease vitamin A in breast milk. If pregnant women cannot be contacted during pregnancy for antenatal care and at the time of child birth, how will they be contacted during pregnancy at the appropriate time for vitamin A? How many women remember their date of LMP? This policy could result in teratogenic effect on the foetus. Besides, it has been reported from Sudan that large doses of vitamin A can lead to bone depletion. Another proposal is to give vita- min A after delivery to increase vita- min A levels in breast milk. Several reports state that vitamin A levels in breast milk fall quite rapidly. So the gain is not worth the effort and we will face more problems than benefits. It certainly is not feasible or necessary in our programme situation.
Transcript of Combating Vitamin A Deficiency - A Rational Public Health ... · Combating Vitamin A Deficiency - A...
Reviews And Comments
Combating Vitamin A Deficiency - A RationalPublic Health Approach
Shanti Ghosh
All paediatricians, ophthalmologists and, in fact, most public healthscientists have been witness to theserious aftermath of vitamin A deficiency, leading to Keratomalacia andblindness in earlier years. Fortunatelythat event has become a rarity today.However, milder manifestations suchas night blindness and Bitot's spotsare still seen even though the prevalence is markedly reduced. These varybetween one state and another andwithin districts as well, as shown by arecent ICMR study on 18 district nutrition profiles. Night blindness is difficult to judge in young children. However, there are reports of night blindness during pregnancy, which disappear spontaneously after delivery. Whenenergy intake is half of what it shouldbe, naturally micronutrient intake willalso be less. This applies to .ill1 micronutrients, iron being by far the leading one.
From the data available, one wouldconclude, therefore, that the problemof vitamin A deficiency is markedlyreduced though not entirely eliminated.We also know that deficiency signsare the end points of deficiency and achild could be biochemically deficientwithout showing any physical signs.Unfortunately, assessing blood levels, etc, is not simple (or of indisputable significance) and so one wouldhave to depend on general levels ofnutrition and deficiency signs to assess prevalence of the problem. Theprevalence of deficiency could alsovary from one season to another, depending on availability of ~-carotenerich foods, drought situation, etc.
The oft quoted justification forsynthetic vitamin A administration isreduction in mortality - in some morbidity and not in others, and overallprevention or reduction in severity ofthe infection. For the former (reduction in mortality) there are conflictingreports, some in favour and othersagainst. As for reducing the seriousness of the infection, there are several factors which could contribute tothat - the level of malnutrition beingthe most important one. In severelymalnourished children, infections are
more severe and mortality high but toinfer that these children need synthetic vitamin A to deal with the problem would be like Marie Antoinetteasking the people of France to eatcake if bread was not available. Thereis also much talk of specific beneficialeffect in measles but the way to dealwith that is to immunise the child againstmeasles, which is part of the immunisation programme, and prevent thedisease rather than identify the childafter he has developed measles andthen administer vitamin A.
The same health machinery thatidentifyies the case of measles shouldalso be able to immunise the child.However, if the child is hospitalisedfor complications, pneumonia beingthe most common one, he can certainly be administered one dose ofvitamin A.
India being a large and diversecountry, no survey, however well supported in the field and statistically,can find out the true extent of theproblem. We are told about areas wherevitamin A deficiency signs are still aproblem. The answer to this is that weshould do district mapping for vitamin A deficiency signs all over thecountry. It should be decentralisedand the states should take responsibility for it. Senior school children canbe easily trained to do this and it willbe educative for them too. Furtherprogramme management would depend on the result of such a survey,which again should be decentralised.
Ad hocism is the death knell ofany programme. When one programme,however good and relevant, is pushed,other programmes suffer. While eliminating polio is a lofty aim, coverage ofother immunisations has fallen drastically and we have witnessed the reemergence of diphtheria and worsening of the situation regarding otherimmunisation for preventable diseases.
The aim of eliminating neonataltetanus too has been given the go bybecause of reduction of tetanus toxoid in pregnant women. If Delhi hasfour pulses of polio vaccine this winter, one can imagine what will happen
to the other programmes.
Administering vitamin A with polioimmunisation is again controversialand the Indian Academy of Paediatrics is against it. Recording of vitaminA administration is non-existent in fieldoperations and the child could endup receiving vitamin A with each pulse.Besides very young infants too couldreceive it resulting in increased intracranial tension, however temporary.To do it effectively, it needs to bedone in a project mode and notprogramme mode, which is short-livedand extremely expensive, and hencedifficult to replicate - and again theprogramme suffers in the long run.
The most important thing is tomake sure that the existing healthprogrammes are carried out as planned.the Government of India has aprogramme for vitamin A administration along with measles vaccine, DPTbooster, etc, for the first three years.Most of the serious infections and
maximum malnutrition occur duringthis period. It can be debated whetherit should be extended to five yearsdepending on the deficiency signsdata. This means that the health services have to be made accountableand supplies assured. We should notaccept the reported figures but shouldhave other means of monitoring andevaluation. Reported figures forimmunisation coverage are near 100per cent while survey reports are lessthan half. Survey of a programme hasto be built into the programme itself.
Another suggestion is one ofadministering vitamin A to pregnantwomen after the first trimester to increase vitamin A in breast milk. Ifpregnant women cannot be contactedduring pregnancy for antenatal careand at the time of child birth, how willthey be contacted during pregnancyat the appropriate time for vitamin A?How many women remember theirdate of LMP? This policy could resultin teratogenic effect on the foetus.Besides, it has been reported fromSudan that large doses of vitamin Acan lead to bone depletion.
Another proposal is to give vitamin A after delivery to increase vitamin A levels in breast milk. Severalreports state that vitamin A levels inbreast milk fall quite rapidly. So thegain is not worth the effort and we willface more problems than benefits. Itcertainly is not feasible or necessaryin our programme situation.
The existing programme shouldbe properly implemented and monitored. There are no short cuts to healthcare.
Dietary diversification too shouldbe built into the programme emphasising on sprouted grains, dais, vegetable, fruits, etc. Sprouted grains willnot only provide ~-carotene, but willreduce phytates and help absorptionof iron. Some of the old customs regarding this are dying out because ofchanged life styles, women's workload and changing dietary practices.We need to get the community involved to revive the good practices inthe interest of better health.
Keynote address at the National Consultation
on vitamin A held in New Delhi in September 2000.
The author is Consultant, Maternal and Child Health,New Delhi.
NUTRITIONNEWS
• The 32nd Annual Conferenl;e ofthe Nutrition Society of India washeld at the National Institute of Nutrition, Hyderabad, on December 1 and2. There were two symposia on 'Current status and future prospects ofgenetically modified foods in India'and 'Implementation of nationalprogrammes - a way ahead'.
The Gopalan Oration by DrGurudev S. Khush, Principal PlantBreeder at the International Rice Research Institute, Philippines, was on'Strategies to meet the global foodand nutrient needs in the new millennium'. The Srikantia Memorial Lecture was delivered by Dr S. Rajagopalan,Distinguished Fellow, M.S.Swaminathan Research Foundation,Chennai, on 'Perspective planning forhuman development'.
There was also Young Scientists Award series - both in the senior
and junior categories and free presentations. The NSI Best Poster Awardwas given to Ms Shailee Saran of theCentre for Research on Nutrition Support Systems for the poster on 'Efficacy of probiotics in control of diarrhoea and undernutrition in poor chil-
dren in urban slums' by Dr SarathGopalan, Shailee Saran, Promila Gahlot(CRNSS) and Dr T. Prasanna Krishna,NIN.
• The 27th Annual Kamala PuriSabharwal Lecture was delivered byDr V. Prakash, Director, Central FoodTechnological Research Institute,Mysore, on 'Value addition and byproduct utilisation in reaching macroand micro-nutrients through adaptable food processing', on December11, at the Lady Irwin College, NewDelhi.
• The First World Congress on 'TheFoetal Origins of Adult Disease' willbe held in Mumbai, India, from February 2 to 4, 2001. The Congress isbeing jointly organised by the Societyfor Natal Effects on Health in 'Adults(Sneha)-India and the InternationalCouncil for Research into the Foetal
Origins of Adult Disease. The .Congress will bring together, for the Firsttime, clinicians, epidemiologists, nutritionists and basic scientists working in this area and will describe theirclinical and epidemiological findingslinking size-at-birth with disease, thenutritional and endocrine control offoetal growth, the role of placentalfunction and maternal nutrition, andecological and evolutionary aspects.
• Indian Society for Parenteral andEnteral Nutrition (ISPEN): The 7thAnnual Conference of ISPEN will beheld in Ahmedabad on February 16and 17, 2001.
• Centre for Research on NutritionSupport Systems (CRNSS), in association with Apollo Centre for AdvancedPaediatrics (ACAP), IndraprasthaApolioHospital, is organising a three-daycourse on clinical nutrition, specialfeeds, enteral and parenteral nutrition and newer trends from April 6 to8,2001, attheAuditorium, IndraprasthaApollo Hospital.
• IX Asian Congress of Nutrition:Arrangements for the IX Asian Congress of Nutrition, to be held in NewDelhi in 2003, are now in progress.The Congress is scheduled for February 23 to 27, 2003, and will be held atHotel Ashok, New Delhi. Delhi enjoysa pleasant climate in February. HotelAshok, the venue of the Congress, isa leading hotel of Delhi and, in thepast, several international conferenceshave been held in its Convention Hall.
The Prime Minister of India hasgraciously agreed to be the Patron of
the Congress which will be held under the Presidentship of Dr C. Gopalan,President, Nutrition Foundation of India. Dr B.S. Narasinga Rao, President, Nutrition Society of India, will bethe Vice President. An Apex AdvisoryCommittee chaired by Dr Abdul KalamAzad, Scientific Advisor to the PrimeMinister, consisting of all senior Secretaries of the scientific departmentsof the Government of India and eminent scientists such as Dr Swami nathan,Dr Kurien, and Dr Rajammal P. Devdashas been constituted.
The Chairman of the OrganisingCommittee will be Dr S. Vardarajan,former Director General, CSIR, andPresident INSA. Dr Narasinga Rao andDr Kamala Krishnaswamy (Director,NIN), will jointly head the ScientificProgramme Committee. Leading nutrition scientists engaged in nutritionrelated studies will constitute the Executive Committee. Dr Umesh Kapil,Associate Professor, AIIMS, and DrKumud Khanna, Director, Institute ofHome Economics (University of Delhi),will be the Executive Secretaries.
The Scientific programme willinclude four Plenary Lectures, fourPlenary Panel Discussions, 35 Symposia, two Special Orations, 20 FreeCommunication Sessions and fourPoster Sessions. International agencies such the FAO, WHO, UNICEFand the International Atomic EnergyAgency have signified their willingness to cooperate in the organisationof the symposia. The First Announcement is expected to be released byMarch 31,2001. The participants willbe predominantly Asians, but theorganisers hope that as in the previous Asian Congresses of Nutrition, anumber of non-Asian scientists interested in Asian nutrition problems willalso participate.
• The National Family HealthSurvey-2 report is now available tothe public. Conducted in 1998-99, thesurvey provides a comprehensiveportrait of population, health and nutrition in India as well as of its states.The information was collected from arepresentative sample of approximately90,000 'ever-married' women in theage 15-49 years drawn from all thestates. The nutrition component included studies on food consumptionpatterns, anthropometry and haemoglobin in women and in about 25,000children under three years of age studiedover all states of the Indian Union.
Edited by Ms Bani Tamber for the Nutrition Foundation of India, C·13 Qutab Institutional Area, New Delhi 110 016.
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