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Vitamin A deficiency and xerophthalmia among school-aged children in

Southeastern Asia

Article  in  European Journal of Clinical Nutrition · October 2004

DOI: 10.1038/sj.ejcn.1601973 · Source: PubMed

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 European Journal of Clinical Nutrition (2004) 58, 1342–1349
& 2004 Nature Publishing Group All rights reserved 0954-3007/04 $30.00
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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Design: Literature search of published, unpublished and website-based population survey and study reports, with country-
specific 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 5–15 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
Bitot’s 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 South-
East 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, 1342–1349. doi:10.1038/sj.ejcn.1601973
Published online 31 March 2004

Keywords: vitamin A deficiency; xerophthalmia; night blindness; Bitot’s spots; school-aged children; South-East Asia

Introduction stages of xerophthalmia including corneal xerophthalmia

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 People’s Republic of Korea,
Maldives, Myanmar, Nepal, Sri Lanka and Thailand) harbor-
ing 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
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 preschool-
aged 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

that the nutritional problem is likely to be chronic, with
antecedent risk possibly starting earlier in childhood and
pubescence; that is, 5–15 y of age. However, population-
based data on the prevalence of VA deficiency and the extent
and severity of accompanying VADD are lacking for school-
aged 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 num-
bers 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 assess-
ment 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 end-
decade assessment in 55 countries submitted to United
Nations Children’s Fund (UNICEF) in the year 2001 (UNICEF,
2001a); survey reports in the Micronutrient Deficiency
Information System (MDIS) of the World Health Organiza-
tion (WHO) in year 1995 (World Health Organization, 1995);
summaries of surveys compiled by the Micronutrient
Initiative (MI), United Nations Children’s 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, 5–15 y. However, prevalence
rates covering narrower age ranges (eg, 6–9 y among Thai
children (Bloem et al, 1989)) or ranges that only partly
included the target group (eg, 13–17 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 5–15 y in each country
were derived for most countries from two sources: the
UNICEF Year 2001 State of the World’s 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
VA deficiency and xerophthalmia among school-aged children
V Singh and KP West
1343
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 5–15 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 distribu-
tion, 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), Bitot’s 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 preva-
lence of ‘active xerophthalmia’ was calculated as done
previously for preschool children (World Health Organiza-
tion, 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 Bitot’s 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 South-
East 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 5–15 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 adoles-
cent 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 assump-
tions 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 6–11 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 0–4 y had a serum retinol concentration o10 mg/dl
(o0.35 mmol/l). Under an assumption of normality and an
associated s.d. ¼ 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 5–15 y of age.
A national prevalence of xerophthalmia among 6–12 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 People’s 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 school-
aged 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 (Khan-
dait 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 5–14 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

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 ¼ 49.42–1.52X, 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 10.4–17.0% among
pregnant and lactating women of ages 15–40 y (Stoltzfus et al,
1992, 1993; Suharno et al, 1993; Muhilal, 1995; Tanumi-
hardjo et al, 1996), we estimated a prevalence among 10-y-
old children of 34.2%, which was applied to the combined-
sex 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 eco-
nomic 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 6–14 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, conserva-
tively, 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 14–17 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
VA deficiency and xerophthalmia among school-aged children
V Singh and KP West
1345
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 assump-
tions of uniform risk across earlier school-aged years and
gender, as observed in the national sample (Nepal Micro-
nutrient 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 5–15 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 socioeco-
nomic, health and nutritional status in Sri Lanka, as reflected
by a relatively constant infant mortality rate over the past
two decades (United Nation’s 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
5–15 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 6–9 y and 1–8 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 Bitot’s spots, as assumed previously
(West, 2002). To account for the lack of national representa-
tion, 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 preva-
lence 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
Bitot’s spots in the Region. The maximum prevalence
appears to be in Bangladesh (3.7%); the minimum preva-
lence 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 through-
out 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 preva-
lence, 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 (5–15 y) with estimated numbers of cases in the WHO South-East
Asian Regiona

VADb Xerophthalmia

South/South-East Asia Population, 5–15 y Percentage (%) Number Percentage (%) Number

Bangladesh 35 658 800 19.4 6 917 807 3.7 1 319 376

Bhutan 527 880 28.0 147 806 0.7 3695
India 244 324 160 23.1 56 438 881 2.8 6 841 076
Indonesia 42 863 050 34.2 14 659 163 0.4 171 452
Myanmar 10 643 470 27.5 2 926 954 4.0 425 739
Nepal 6 102 850 14.2 866 605 2.6 158 674
Sri Lanka 3 621 920 6.0 217 315 2.8 101 414
Thailand 9 774 440 5.2 508 271 0.2 14 662

Total 353 516 570 23.4 82 682 802 2.6 9 036 088
a
Countries in the WHO South-East Asian region excluded in the above table are Democratic People’s 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


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 5–15 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 xerophthal-
mia, remain largely unknown. While blinding xerophthal-
mia 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.
VA deficiency and xerophthalmia among school-aged children
V Singh and KP West
1347
In this report, we provide provisional estimates of the
prevalence of VA deficiency and xerophthalmia, and the
numbers affected, among children 5–15 years of age in the
WHO South-East Asian Region. After reviewing the litera-
ture, 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 Bitot’s
spots), equivalent to an overall prevalence of 2.6%. Un-
known in this estimate is the population of potentially
unresponsive Bitot’s 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 5–15 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 community-
based 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 0.5–6% for
xerophthalmia and 13–60% for VA deficiency (o0.70 mmol/
l). Recently, a prevalence of 34% was reported among school-
attending 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 sub-
Saharan 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-00-97-00015-
00 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.
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