2Kellogg Eye Center, University of Michigan, Ann Arbor, USA
3,4Royal Hobart Hospital, Hobart, Australia
Methods: A cross-sectional, community-based study was conducted among 89 children (6 to 72 months old) at two refugee camps in Dili, East Timor. We evaluated socio-economic, demographic, nutrition intake of vitamin A, and examined clinically for xerophthalmia. The World Health Organization (WHO) criterion was used to classify the populations' VAD risk and status.
Results: Of 89 children, 80.9% received vitamin A supplementation and full immunization, but 5.6% suffered from night blindness, without xerophthalmia. As recommended by WHO, all children consumed fruits/vegetables containing vitamin A sources more than three times per week. 69.7% had been regularly breast fed. Yet almost 30% of the children suffered from moderate to severe malnutrition.
Conclusions: Despite social unrest, no evidence of clinical VAD was found among the refugee children in East Timor. However, subclinical VAD occurred at a level of mild-moderate public health importance, with concurrent malnourishment; consequently, this situation warrants further attention.
Keywords: Vitamin A Deficiency; Children; Refugee; Night blindness; Malnutrition
Countries with social underdevelopment have limited access to healthcare, social services, and education; moreover, they tend to follow traditional beliefs [3, 13, 14]. Populations who are physically isolated from health and social services are often more prone to VAD, partly because of their low socioeconomic status, but also because of the frequent or severe infections resulting from low immunization rates and inadequate treatment [15- 17]. Concomitant acute respiratory infections and diarrhoeal morbidity may contribute towards morbidity and mortality from VAD [2, 18-20]. Refugees are believed to be at special risk of developing subclinical VAD as well as acute and chronic malnutrition . Inadequate living conditions among refugees, particularly those living in poverty following armed conflict and social displacement has been associated with high mortality in children and infants from VAD [21-24].
The aim of the current study is to examine the risk factors for VAD in children 6 to 72 months old at the refugee camps in Dili, East Timor. To date, the effect of war, civil unrest, and hostile environments in East Timor and their impact on VAD among the refugee population remain poorly understood.
Ethics approval was obtained from the Ministry of Health, Timor Leste prior to study commencement and the study conformed to the provisions of the Declaration in Helsinki. Parental consent was obtained for all children before enrolment. and their anonymity was preserved. Both the interviewer and mother of the household, completed a household questionnaire in the local language; the form, based on the International Vitamin A Consultative Group and WHO guidelines for assessment of VAD, focused on demographics, maternal educational level, and socioeconomic factors as well as immunization, vitamin A supplementation, dietary intake, and breast-feeding practices .
Night blindness, a symptom of xerophthalmia, is often present with other ocular VAD signs [29, 30]. Poor adaptation to the dark is the result of a reduced rate of regeneration of rhodopsin in the outer segments of the rods following exposure to light. Assessment of night blindness through interviews, as used in our study, has been validated by several other studies [31-33]. Currently, objective assessment measurements for night blindness such as the portable dark field adaptometer, Vision Restoration Time and pupillary and vision thresholds are being developed, although they have not yet been standardised [34-36]. History of night blindness has been shown to have sensitivity, specificity and positive predictive value of 47.2, 98.1 and 96.2%, respectively, compared with the standard diagnosis procedure using luxometer readings . Due to financial and logistical constraints, we did not measure serum retinol levels or perform conjunctival impression cytology.
In our study, almost 30% of the children suffered from moderate to severe malnutrition. Families are often fraught with social poverty, including under-education, poor environmental sanitation, and personal hygiene, all of which can contribute toward malnutrition in children with VAD [3, 4, 13, 38, 39]. Although vitamin A is an important factor for normal growth, several factors (e.g., micronutrient deficiency, infections, and goitre) may decelerate muscle growth [4, 40]. A child with borderline/marginal vitamin A intake will have very limited vitamin A stores, and dietary problems such as impaired absorption (e.g., gastroenteritis) or a sudden increase in metabolic demand (e.g., growth spurt) may result in the rapid depletion of their already limited reserves [3, 39, 41]. Intestinal worm infections may also directly compete for the intake of vitamin A in addition to appetite suppression [4, 42]. Infectious diseases decrease children's appetites; infections are especially devastating for the weaned child.
In a previously published study in Timor and Rote Islands, Indonesia, VAD had been associated with severe tuberculosis; MUAC was applied as a measure of tuberculosis severity . Although the reproducibility of MUAC is fair , a single measurement of MUAC as in our survey is of less value compared to serial measurements in assessing the nutritional status of a child. A single MUAC measurement indicates the cumulative growth, not whether growth is proceeding or not. All anthropometric indices have their limitations since growth is a multi factorial process, and specific nutrient deficiency (e.g., iron, thiamine, zinc) cannot be differentiated. The weight for age index, although easy to measure, has some disadvantages: The precise age of young children is not known in some communities. Healthy children of the same age may have different growth patterns prior to being weighed. Weight is much more labile than height and is, to some extent, a reflection of body composition: Weight gain may occur from tissue fluid increase as well as from increases in muscle or fat. In future studies, somatic measurements should be repeated to estimate the linear growth of this population.
Community healthcare providers and policymakers need to tailor specific comprehensive strategies to improve vitamin A status in at-risk communities, recognising that it is a long-term haul. In order to develop cost-effective VAD programmes, it is helpful to examine possible collaborations with other community health or developmental programmes, such as breast feeding, immunization, primary healthcare, family planning, literacy, and local-level political parties as well as school, church, and other religious and non-governmental organizations. These organizations can be a focal point for promoting vitamin A-rich foods through agricultural gardens and their educational curriculum. Additionally, it is important to ensure that primary and secondary school teachers as well as other community leaders have sufficient knowledge about vitamin A, the consequences of VAD, and knowledge of local foods containing vitamin A. The simplified dietary assessment is a simple and rapid assessment tool to detect population groups at risk for VAD [44, 45]. Parental education should encourage family planning to space children, resulting in improved care. Pregnant women should be encouraged to increase their vitamin A intake in their diet [28, 30]. They should not receive large doses of vitamin A as it may be teratogenic, but a daily supplemental dose of 10 000 IU over 2 weeks is deemed safe. In addition, mothers should be encouraged to vaccinate children again measles and other diseases as well as increase the rates of exclusive breast feeding to infants younger than 6 months old.
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