Khan, Mohammad Aman; (2002) Vitamin A deficiency in children in the North West Frontier Province of Pakistan. Masters thesis (M.Phil), UCL (University College London).

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Abstract

BACKGROUND: Vitamin A deficiency (VAD) is single commonest cause of childhood blindness in developing countries, and contributes significantly (even at sub-clinical levels) to morbidity and mortality from childhood infections. The World Health Organization (WHO) lists Pakistan as having severe sub-clinical VAD, but few reliable population based studies have been undertaken to ascertain the severity and distribution of VAD in children. It was a commonly held belief among health professionals that VAD was not a problem, and prior to 1999 there were no programs of control in Pakistan. Between July 1992 and January 1996, 154 children aged 0-15 years presented to Lady Reading Hospital, Peshawar, with xerophthalmia. More than 60% had blinding xerophthalmia, and 123 (78%) were 0-6 years of age. We thought that if clinical cases of VAD were presenting to a teaching hospital in Peshawar, that children with blinding xerophthalmia might be presenting in other districts in the Province. AIMS: A. To develop a surveillance system for documenting the occurrence and geographical distribution of blinding xerophthalmia in children presenting to eye departments at district level in North West Frontier Province (NWFP) B. To conduct a population based survey of children aged 0-6 years in the same region to validate the surveillance system, and to determine possible risk factors with a view to developing appropriate control measures. METHODS: A: Surveillance system: All district level ophthalmologists in the Province were invited to a one-day workshop where the study was explained. They were asked to complete and return a simple recording form for all children aged 0-72 months who presented with blinding xerophthalmia over a 12 month period. Information recorded included findings of a brief interview with the mothers of affected children. B: Selection of study districts for population based survey: To validate the surveillance system, two districts in NWFP were selected; one district was selected which had a participating ophthalmologist who did not report any cases (district with “no reported cases, NRC”). The other district was the one with the highest estimated prevalence of blinding xerophthalmia (this was District Swabi - the district with “reported cases, RC”). In each district 4 villages were selected, and 200 children aged 0-6 years who lived in the poorest parts of the village were examined for xerophthalmia according to the WHO criteria. Information was also collected on potential risk factors at village, household and individual level. RESULTS: A Surveillance system: District of residence: Cases of blinding xerophthalmia were reported from 19 districts of the 31 districts in the region. Twenty-one participating ophthalmologists recorded 80 cases of blinding xerophthalmia between 1/11/1996 and 31/10/1997. Four were excluded from the analysis. Fifty-three children (69.7%) were recorded from outpatients, 20 (26.3%) from eye wards, and 3 children (3.9%) had been admitted to children's ward. The highest number of reported cases came from Peshawar District (12 children). District Swabi had the highest estimated prevalence of VAD (80 per million children aged 0-6 years). Age, sex and seasonalitv: The commonest age at presentation was 25 - 48 months for boys and girls. Four children were less than 6 months and all were males. Thirty-nine children were male (51%). Fifty children (65%) presented during summer and autumn months. Findings on interview: The majority of mothers of affected children had received no education, and almost half of households had a monthly income of <1,200Rs (<29 US $). Precipitating illnesses included diarrhoea (63%) and fever with cough (56%). One-third of children aged >9 months had not been immunized against measles, and a quarter of all children had not been adequately breast-fed. Seven children (9%) had never been breastfed. B Population based study Study population: A total of 1,680 children aged 0-72 months were examined in the 8 study villages. In the “affected” district 393 households were visited and 861 children were examined. In the “NRC” district 327 households were visited and 819 children examined. Proportion of children with xerophthalmia: Clinical signs of VAD were present in 53 children (3.2%); 37 (69.8%) had night blindness and 16 (30.2%) had Bitot's spots. In the “RC” district 39 children (4.5%) had VAD, compared with 14 (1.7%) in the “NRC” district (MH Chi sq. = 11, p=<0.001). The proportion of children with VAD varied from 1.0% in two “NRC” villages, to 7.1% in a village in the “RC” district. Factors associated with xerophthalmia (univariate analysis): Out of 53 children with VAD, 29 were males and 24 were females. Children with VAD were significantly older than unaffected children (p<0.001), were more likely to have had measles recently (p<0.013), and were more likely to live in large households (p<0.001). CONCLUSIONS: This study shows that the surveillance system employed was a reasonably reliable means of identifying communities of children with clinical VAD, as well as indicating high-risk seasons. The system could also be used to monitor the effectiveness of control programmes in the future. Xerophthalmia seems to be more prevalent in villages identified by the surveillance system. However, even in villages where no child was reported during surveillance, cases of xerophthalmia were detected.

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