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EDITOR
Did
the recent campaign to distribute vitamin A in Assam, India, cause an epidemic
of illness or hysteria? The public health science underlying vitamin
A prophylaxis and the reports that emerged after the same-day dosing
of some 2.5 million preschool children point to hysteria.
Firstly, did vitamin A kill a child the day after dosing, and up to 13 children the next week, as claimed (overdosage by a new, larger delivery cup is being cited as the cause)?1 Almost certainly not. Even twice the prophylactic dose of 200 000 IU, had it been given (it is not clear that this routinely happened), is the recommended treatment for xerophthalmia.2
In blaming deaths on vitamin A critics have chosen to ignore the current
mortality among 1-4 year old children in India of about 7 deaths per
1000 children per year.3 Thus 17 500 of
these children would be expected to die over the coming year without
getting vitamin A, including 48 the next day, or over 325 within a
weekfar more than the
14 deaths claimed to have been caused by the campaign. The inference
to be drawn from this calculation suggests that vitamin A saved the
lives of children, not took them.
Was there an unexpected epidemic of illness? Not unexpected. High potency vitamin A causes transient nausea, vomiting, and headache in 3-9% of children.4 Ailments resolve within 48 hours, as reportedly occurred in Assam. In young infants a similar percentage may develop an isolated, bulging fontanelle that subsides within 72 hours.5 These consequences pose the "risk" of this programme.
At a rate of 5%, 125 000 dosed children would have been expected to develop
side effectsfar in
excess of the 15 000 cases reported by the media. Still, this number
presenting to health clinics on the same day in one state results in
a concentration of risk that could readily invite public scrutiny and
a media outcry. Educating functionaries of the programme and the
public that transient ailments may arise from receipt of vitamin A
may prevent such difficulties in the future.
A nutritious diet is undeniably preferred for preventing vitamin A
deficiency, but until such a goal is achieved periodic delivery of
vitamin A can prevent xerophthalmia, reduce severity of infection,
and improve children's survival.2 This is the
"benefit" side of the equation, which seems to have been ignored
in the hysteria surrounding the Assam programme.
Keith P West Jr
kwest@jhsph.edu
Alfred Sommer
Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD,
21205, USA
| 1. | Mudur G. BMJ.com news roundup. Deaths trigger fresh
controversy over vitamin A programme in India. BMJ 2001; 323: 1206 |
| 2. | Sommer A, West Jr KP. Vitamin A deficiency: health, survival and vision. Oxford: Oxford University Press, 1996. |
| 3. | Unicef. The state of the world's children 2001early
childhood. New York City: Unicef, 2000. |
| 4. | Florentino R, Tanchoco CC, Ramos AC, Mendoza TS, Natividad
EP, Tangco JB, et al. Tolerance of preschoolers to two dosage strengths of
vitamin A preparation. Am J Clin Nutr 1990; 52: 694-700 |
| 5. | Agoestina T, Humphrey JH, Taylor GA, Usman A, Subardja D,
Hidayat S, et al. Safety of one 52-mumol (50,000 IU) oral dose of vitamin A
administered to neonates. Bull WHO 1994; 72: 859-868 |
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