Vitamin A Deficiency in Schoolchildren in Urban Central India: The Central India Children Eye Study

Vitamin A deficiency is a severe condition particularly in malnourished children and women in developing countries.^1,2 It has been estimated that approximately 250 000 to 500 000 malnourished children go blind each year from a deficiency of vitamin A, approximately half of whom die within a year of becoming blind. The most recent survey data obtained from 8 state surveys in 2003 suggest that 62% of preschoolers in India are vitamin A deficient, having serum retinol concentrations lower than 20 μg/dL (to convert to micromoles per liter, multiply by 0.0349).³ Against this background of rural deficiency, we conducted this study to assess the prevalence of symptoms of vitamin A deficiency in schoolchildren in urban central India.

The Central India Children Eye Study was performed in all government schools run by the local government authority in Nagpur, a city of about 3 million inhabitants in central India. Children attending government schools usually come from low to lower middle socioeconomic strata. The study included 11 829 schoolchildren. The mean (SD) age was 13.0 (1.9) years (range, 7-21 years). The Medical Ethics Committee of the Suraj Eye Institute in Nagpur approved the study. All examinations were carried out in the schools. Experienced social workers filled out a questionnaire including questions on the professions of the parents, presence of visual and ocular symptoms, and eating habits. Social workers particularly trained in refractometry measured uncorrected and corrected visual acuity. A trained ophthalmologist examined the ocular motility and searched for strabismus, performed slitlamp-based biomicroscopy of the external eye and anterior segment, and carried out an ophthalmoscopic examination. Ocular signs assessed for the presence and severity of vitamin A deficiency were xerosis of the conjunctiva, Bitot spots, corneal xerosis, and reported night blindness.

Data on the presence of ocular signs of xerophthalmia were available for 11 601 (98.1%) of the children (Table). The mean (SE) rate of xerophthalmia was 6.5% (0.2%) with the definition based on Bitot spots and/or night blindness and 13.4% (0.3%) with the definition based on any morphological parameter and/or night blindness (Table). In binary logistic regression analysis, xerophthalmia as defined by Bitot spots and/or night blindness was significantly associated with male sex (P < .001; odds ratio = 0.69; 95% confidence interval, 0.60-0.81), low intake of green vegetables (P = .003; odds ratio = 0.29; 95% confidence interval, 0.18-0.47), and presence of visual impairment or blindness (defined as visual acuity <20/60 in the better eye) (P < .001; odds ratio = 2.26; 95% confidence interval, 1.25-4.08).

The results suggest that in urban central India, the mean (SE) prevalence of xerophthalmia is about 6.5% (0.2%) based on Bitot spots and/or night blindness (Table). The data are in agreement with another study from Nagpur by Khandait et al,⁴ who reported a prevalence rate of 8.7% in children living in low-income regions in Nagpur. In another study performed in 2002 of rural populations in northern states of India,⁵ the prevalences of Bitot spots and night blindness were also relatively high (4.7% and 0.5%, respectively) and comparable with our results (Table). Because most other studies have usually focused on children aged 6 to 72 months, which is the young population most at risk, the finding of a high prevalence of vitamin A deficiency in older children in our study is of concern and warrants further investigation.

The study has some limitations. In some children, Bitot spots can persist after the vitamin A deficiency has been corrected, so one cannot accurately assume that the sign was indicative of current vitamin A deficiency. Also, data on systemic vitamin A supplementation were not collected.

In agreement with previous population estimates, our study indicates that xerophthalmia, a direct ocular consequence of vitamin A deficiency, remains a public health problem in urban children of low to lower middle socioeconomic strata in India.^4-6

Correspondence: Dr Nangia, Suraj Eye Institute, Plot 559 New Colony, Nagpur 440004, India (nagpursuraj@gmail.com).

Author Contributions: Drs Sinha and Jonas contributed equally to this work.

Funding/Support: This work was supported by an unrestricted grant from Om Drishti Trust Nagpur and by grants from Rotary Sight Saver Netherlands and Orbis India.