1. Vitamin A

2. Xerophthalmia Vernacular Terms
Matang Manok Mata Ajam Khwak Moan Gred Gradei Mager Aagh Korapothu
Chicken Eyes Chicken Eyes Dusk Blindness Scaly as Fish Fish Scales Scaly
Tagalog Indonesian Khmer Thai Bengali Singhalese

5. Impact of VADD on Public Health
250 million preschool-age children have subclinical vitamin A deficient
7.2 million pregnant women
3 million have clinical xerophthalmia
300, 000 are blind from xerophthalmia

6. Impact of Vitamin A Intervention on Child Survival
“Improvement of vitamin A status in young child populations… leads to a reduction in all-cause mortality rates of about 23%.”
United Nations, 1993
“Improved vitamin A nutriture would be expected to prevent approximately million deaths annually among children aged under 5 years.”
Bulletin of WHO, 1992
BUT Mechanisms involved are poorly understood

12. Functions Vision (night, day, colour)
Epithelial cell integrity against infections
Immune response
Haemopoiesis
Skeletal growth
Fertility (male and female)
Embryogenesis

17. Tests of Vitamin A Status
Subclinical
Relative dose-response test
Serum retinol
Retinal rod function
Conjunctival impression cytology (CIC)
Decreased Status
Clinical
Night blindness
Conjunctival and corneal eye signs

20. Factors that may Affect Plasma Vitamin A or Retinol Levels
Liver disease deacreases plasma retinal levels, probably as a result of a combination of decreased synthesis and secretion of RBP.
Stress decreases plasma retinol levels.
Protein-energy malnutrition decreases RBP production because of a limited supply of protein substrate. Consequently hepatic release of vitamin A is impaired resulting in decreased serum retinol levels.
Zinc deficiency decreases plasma retinol levels via its role in the synthesis of RBP.

21. Infections and parasitic infections lower plasma retinol levels.
Cystic fibrosis is associated with a defect in the transport of vitamin A from the hepatic stores to the periphery resulting in decreased levels of circulating retinol and RBP.
Low fat diets impair absorption of vitamin A, lowering plasma retinol concentrations.
Estrogens, either endogenous or those used in contraceptive agents, increase plasma retinol and RBP apparently as a result of incresed mobilization of Vitamin A from the liver.
Age, sex and race influence serum retinol levels, as indicated by the NHANES II survey results.

22. For the test, a baseline blood sample is taken immediately before the administration of a small oral dose (450µg) of vitamin A (as retinyl acetate or retinol palmitate); followed by a second blood sample, five hours later. The RDR (%) is calculated as:
Plasma retinol at 5 hr – Plasma retinol at 0hr
RDR(%) =
X 100
Plasma retinol at 5 hr
Vitamin-A-replete subjects have RDR values ranging from 0% to 14%. Relative dose response values greater than 14% to 20% are indicative of marginal vitamin A status in humans, the cutoff value depending on the coefficient of variation for the analytical method used to measure serum

23. Percentage of Children with Positive RDR Test Classified by Serum Retinol Levels
Serum Retinol (µg/dL) %
Number Tested
<20
100 12 86 21 26 19
>40 3 39
Total tested 91

27. Treatment Schedule (orally)
Immediately on diagnosis:
<6 months
50, 000 IU
6 months-12 months
100, 000 IU
> 12 months
200, 000 IU
Next day
Same age-specific dose
At least two weeks later
Same age-specific dose

39. Xerophthalmia ClassificationXN
Night Blindness
X1A
Conjunctival Xerosis
X1B
Bitot’s Spot with Conjunctival Xerosis X2
Corneal Xerosis
X3A
Corneal Xerosis with ulceration
X3B
Keratomalcia XF
Xerophthalmic Fundus XS
Corneal scars from Xerophthalmia

56. WHO criteria of a public health problem of xerophthalmia
Night Blindness
(XN)
In > 1%
Bitots spot
(X1B)
In > 0.5%
Corneal Xerosis/Ulceration/Keratomalacia
(X2, X3A, X3B)
In >0.01%
Corneal scar
(XS)
In > 0.05%
Plasma retinol of <0.35µmol/l (10 µg/dl)
In > 5%

61. Percent with Serum Vitamin A:
<10 µg/dL
10-19 µg/dL
>20 µg/dL
Normal Children
252 8 37 55
Children with night-blindness or Bitot’s spots
325 30 55 15
Children with corneal xerophthalmia 98 75 24 1
Serum vitamin A levels in a sample of Indonesian children with and without ocular lesions. Conversion factor SI units(µmol/L)= x 0.035