Association of Vitamin A Status With Under-Five Mortality in India

Objective: To re-estimate the survival benefit from Vitamin A supplementation (VAS) in India using meta-analysis and to correlate mortality and vitamin A deficiency (VAD) in children aged 6 month to 5 year. Methods: Pooled risk ratio (fixed effects model) for mortality reduction with VAS was calculated from available Indian studies. Computed mortality rates in 6 months to 5 years children in Indian states were regressed on VAD prevalence estimates of the states. Results: There was no reduction in risk of all-cause mortality with VAS (RR=0.96; 95% CI: 0.89, 1.03). When regressing mortality on VAD in high or low VAD prevalence states, the regression coefficients were discordant. Conclusion: No survival benefit was observed for VAS in India from the available literature. The targeting of VAS programs should be given serious consideration.

Iodine Deficiency in School Children in Aligarh District, India.

We carried out this study to assess iodine deficiency disorders among school children of 6-12 years age group in Aligarh district of India. The prevalence of goiter was 5.2%. Median Urinary Iodine Excretion level was 150 µg/L; 22.5% of students had biochemical iodine deficiency. 50.4% households were consuming adequately iodized salt.

Low-quality scientific evidence for the continuation of universal Vitamin A supplementation among under 5 children in India.

Vitamin A supplementation (VAS) is presently being undertaken in India among under 5 (U5) children for two possible benefits (i) to prevent nutritional blindness due to Vitamin A deficiency (VAD) and (ii) to reduce U5 mortality. The existing scientific evidence suggests that nutritional blindness due to VAD has been virtually eliminated and also the difference between U5 mortality rate and infant mortality rate is very low for VAS to have any meaningful impact. On the contrary, scientific evidence indicates that there could be side effects of the administration of mega dose of Vitamin A (MDVA). These side effects of MDVA have not been systematically investigated. The universal VAS should be discontinued immediately as there are no likely benefits to U5 children.

Iodine Deficiency amongst School Age Children in Pauri District of Uttarakhand, India.

Objectives: To assess the status of iodine deficiency amongst school age children (6-12 years) in district Pauri, Uttarakhand. Methods: Thirty clusters were selected by utilizing the population proportionate to size (PPS) cluster sampling methodology. A total of 2067 children in the age group of 6-12 years were included. The clinical examination of the thyroid of each child was conducted. “On the spot” urine and salt samples were collected from children. Results: The Total Goiter Rate (TGR) was found to be 16.8%. The proportion of children with Urinary Iodine Concentration (UIC) level <20, 20-49, 50-99, 100-199 and ≥200 μg/l was found to be nil, 25.3, 17.2, 34.0 and 23.5 percent, respectively. The median UIC level was 115 μg/l. Only 40.4% of the salt samples had stipulated level of iodine of 15 ppm and more. Conclusions: Findings of the present study indicates that the population is possibly in transition phase from iodine deficient as revealed by TGR of 16.8% to iodine sufficient as revealed by median UIC level of 115 μg/l. There is a need to further strengthen the existing monitoring system for the quality of iodized salt in the district in order to achieve the elimination of IDD.

Resolution of Bitot's Spots Following Mega-Dose Vitamin a Supplementation in Children between 1 and 5 Years of Age.

Objectives: To evaluate the responsiveness of BS over one year to MVAS administered as per national program in rural India. Methods: Prospective community based follow-up of a cohort of 262 children with BS, aged between 1 and 5 years. Resolution or cure was defined if there was no discernible BS in either eye. Results: During one year, only three children were lost to follow-up. At six months of follow-up (MVAS at baseline and 1 month later), 51.1% (95% CI 45.3% to 57.3%) were classified as cured. The corresponding figures at one year (additional MVAS at 6 months) were 59.9% (95% CI 54.1% to 65.9%). Amongst those cured at six months, about half and three-fourths had resolved at two and three months, respectively. There were no significant socio-demographic or clinical predictors of response. Conclusions: Substantial non-response to MVAS at six months (49%) and one year (40%) of follow-up suggests that presently in the Indian subcontinent, Bitot's spot is a relatively crude indicator of severe current vitamin A deficiency. Thus for programmatic decisions and evaluation, public health burden of VAD should not be solely assessed through BS.

Iodine Deficiency Status Amongst School Children in Pauri, Uttarakhand.

Objective: To assess the iodine deficiency status amongst school age children in district Pauri, Uttarakhand. Methods: 2067 children (age of 6-12 years) were included. Clinical examination of thyroid gland of each child was conducted. On-the-spot urine and salt samples were collected from children. Results: Total Goitre Rate was found to be 16.8% and median Urinary Iodine Concentration level was 115 μg/L. Only 40.4% of salt samples had e 15 ppm of iodine. Conclusion: There is a mild degree of iodine deficiency in school age children in district Pauri. There is a need of strengthening the National Iodine Deficiency Disorder Control Program.

Variability of Thinness and its Relation to Cardio-metabolic Risk Factors using Four Body Mass Index References in School-children from Delhi, India.

Objectives: To compare: (i) prevalences of thinness in schoolchildren by four body mass index references in common use viz., Centre for Disease Control (CDC); Cole; Indian Academy of Pediatrics (IAP); World Health Organization (WHO); and (ii) relationship of thinness with absence of cardio-metabolic risk factors in these BMI references. Design: Cross-sectional. Setting: Schools in Delhi. Participants: Anthropometry and blood pressure were measured in 16,245 school children aged 5 to 18 years. Fasting lipids and blood sugar were estimated in 2796 subjects. Outcome measures: Age and sex-specific prevalences of thinness and predictive ability of reference cut-off for detecting any cardio-metabolic risk factor were compared. Results: Prevalence of thinness varied with the reference employed; more so for boys. Overall prevalence of thinness was least with IAP reference and highest with CDC cut-offs (6.6% to 16.9% in boys, 6.5% to 10.3% in girls). Children identified as thin by any reference had comparable, significantly lower risks (OR 0.59 to 0.73) of associated cardio-metabolic aberrations. In subjects with any cardio-metabolic or blood pressure aberration, the prevalence of thinness was highest with CDC and least with IAP definition. Conclusion: Prevalence of thinness varies considerably with the reference employed. Thin children, identified by any reference, have a lower risk of associated cardio-metabolic aberrations; however, thinness is a poor diagnostic test for this purpose. In populations undergoing nutrition transition, there is a need to link cardio-metabolic risk factors with recommended anthropometric criteria to define undernutrition.

Iodine Deficiency Disorders in School Age Children in Kullu District, Himachal Pradesh.

Iodine deficiency disorder is a major public health problem in Himachal Pradesh. A study was conducted in district Kullu to assess the prevalence of IDD in school age children. Clinical examination of the thyroid of 1986 children was conducted. On the spot urine and salt samples were collected. The Total Goiter Rate was found to be 23.4% and median urinary iodine excretion was 175μg/L. The population is possibly in transition phase from iodine deficient to iodine sufficient nutrition.

Massive dose vitamin A programme in India - Need for a targeted approach.

The National Prophylaxis Programme against Nutritional Blindness due to vitamin A deficiency (NPPNB due to VAD) was started in 1970 with the specific aim of preventing nutritional blindness due to keratomalacia . The Programme was launched as an urgent remedial measure to combat the unacceptably high magnitude of xerophthalmic blindness in the country seen in the 1950s and 1960s. Clinical VAD has declined drastically during the last 40 years. Also, indicators of child health have shown substantial gains in different States in the country. The prevalence of severe undernutrition has come down significantly. Immunization coverage for measles and other vaccine preventable diseases has improved from 5-7 per cent in early seventies to currently 60-90 per cent, in different States. Similarly, there has been a significant improvement in the overall dietary intake of young children. There has been virtual disappearance of keratomalacia, and a sharp decline in the prevalence of Bitot spots. Prophylactic mega dose administration of vitamin A is primarily advocated because of the claim of 23 per cent reduction in childhood mortality. However, benefits on this scale have been found only in areas with rudimentary health care facilities where clinical deficiency is common, and there is substantial heterogeneity, especially with inclusion of all trials. There is an urgent need for adopting a targeted rather than universal prophylactic mega dose vitamin A supplementation in preschool children. This approach is justified on the basis of currently available evidence documenting a substantial decline in VAD prevalence, substantial heterogeneity and uncertainty about mortality effects in present era with improved health care, and resource constraints with competing priorities.

Consensus Statement of the Indian Academy of Pediatrics on Integrated Management of Severe Acute Malnutrition.

Justification: Severe acute malnutrition (SAM) is a major public health issue. It afflicts an estimated 8.1 million under-five children in India causing nearly 0.6 million deaths. The improved understanding of pathophysiology of SAM as well as new internationally accepted growth charts and newer modalities of integrated intervention have necessitated a relook at IAP recommendations. Process: A National Consultative Meeting on Integrated Management of Severe Acute Malnutrition was held in Mumbai on 16th and 17th October, 2010. It was attended by the invited experts in the field. Extensive discussions were held as per the program. The participants were then divided into six groups for detailed discussions. The groups deliberated on various issues pertaining to the task assigned and presented recommendations of the groups in a plenary session. The participants made a list of recommendations after extensive discussions. A Writing Committee was formed and was entrusted with the task of drawing a Consensus Statement on the basis of these Recommendations. After multiple deliberations, the following Consensus Statement was adopted. Objectives: To critically evaluate the current global evidence to formulate a consensus among stakeholders regarding diagnosis and management of SAM. Recommendations: An integrated management of malnutrition is likely to yield more dividends. Thus, management of SAM should constitute an important component of Integrated Management of Neonatal and Childhood Illnesses (IMNCI) program. Determination of SAM on the basis of Z-scores using WHO Growth charts is considered statistically more appropriate than cut-offs based on percentage weight deficit of the median. Considering the fact that many children with SAM can be successfully managed on outpatient basis and even in the community, it is no more considered necessary to advise admission of all children with SAM to a healthcare facility. Management of SAM should not be a stand-alone program. It should integrate with community management therapeutic programs and linkages with child treatment center, district hospitals and tertiary level centers offering inpatient management for SAM and include judicious use of ready-to-use-therapeutic Food (RUTF). All sections of healthcare providers need to be trained in the integrated management of SAM.

State of globe: mitigating measles menace in era of MMR/V

In non vaccination ancient era, multiple epidemics of measles/german measles/variola used to occur in the cyclical trend of two to three years during spring months. Outbreaks in Faroe Islands in 1846 and in Fizi Island in 1875 are examples of this type of transmission where virgin epidemics took the highest mortality toll. According to WHO report, in the absence of immunization, 90% of the persons can be expected to develop clinical measles sometimes in their life time as noted in Greenland in 1951 epidemic and german measles in 2012 in Kangra. But the epidemiology of communicable diseases underwent tremendous change not only in the developed countries, viz America and European countries but also in the developing countries like India, Pakistan and African countries with the introduction of vaccination and thereby mortality and morbidity on account of vaccine preventable diseases in all the age groups around the world nose dived. This provided a big relief to the suffering humanity across the world. Different countries have various sets of immunization programme running in the countries; be it single dose of measles at the age of 270 days or second shot of measles or other vaccinations. Round the globe, MMR or MMRV or pentavalent vaccination with their pluses or minuses, still is the right choice to mitigate the menace of measles

Zinc Deficiency Amongst Adolescents in Delhi.

A cross sectional study was conducted in 260 adolescent schoolchildren (114 males) in the age group of 11-18 years to estimate the prevalence of zinc deficiency in the National Capital Territory of Delhi. Serum zinc was estimated using Inductively coupled plasma mass spectrometer. Overall, 49.4% children (50.8% males, 48.2% females) were found to have a deficient zinc nutriture.