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Transcript of Vitamin a Deficiency in Populations at Risk
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Global prevalence
o vitamin A defciencyin populations at risk19952005
WHO Global Database
on Vitamin A Defciency
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WHO Library Cataloguing-in-Publication Data
Global prevalence o vitamin A defciency in populations at risk 19952005: WHO global database on
vitamin A defciency.
1.Vitamin A defciency epidemiology. 2.Vitamin A defciency etiology. 3.Vitamin A defciency complications.
4.Child. 5.Eye maniestations. 6.Databases as topic. I.World Health Organization.
ISBN 978 92 4 159801 9 (NLM classifcation: WD 110)
World Health Organization 2009
All rights reserved. Publications o the World Health Organization can be obtained rom WHO Press, World Health Organization, 20 Avenue Appia,
1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; ax : +41 22 791 4857; e-mail: [email protected]). Requests or permission to reproduce or t ranslate
WHO publ ications whether or sale or or noncommercia l di stribution should be addressed to WHO Press, at the above address (ax: +41 22 7914806; e-mail: [email protected]).
Te designations employed and the presentation o the material in this publication do not imply the expression o any opinion whatsoever on the part o
the World Health Organization concerning the legal status o any country, territory, city or area or o its authorities, or concerning the delimitation o its
rontiers or boundaries. Dotted lines on maps represent approximate border lines or which there may not yet be ull agreement.
Te mention o specifc companies or o certain manuacturers products does not imply that they are endorsed or recommended by the World Health
Organization in preerence to others o a similar nature that are not mentioned. Errors and omissions excepted, the names o proprietary products are
distinguished by initial capital letters.
All reasonable precautions have been taken by the World Health Organization to veriy the inormation contained in this publication. However, the
published material is being distributed without warranty o any kind, either expressed or implied. Te responsibility or the interpretation and use o the
material lies with the reader. In no event shall the World Health Organization be liable or damages a rising rom its use.
Cover photographs by WHO/P. Virot, L. Rogers, and . Stanley
Designed by minimum graphicsPrinted in France
Suggested citation: WHO. Global prevalence o vitamin A defciency in populations at risk 19952005. WHO Global Database
on Vitamin A Defciency. Geneva, World Health Organization, 2009.
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iii
Contents
Preace vii
Acknowledgements ix
Abbreviations x
1. Introduction 1
1.1 Vitamin A deciency: a public health problem 1
1.1.1 Etiology 11.1.2 Health consequences 1
1.1.3 Assessing vitamin A status and deciency 2
1.2 Control o vitamin A deciency 2
2. Methods 4
2.1 Data sources Te WHO Global Database on Vitamin A Deciency 4
2.2 Selection o survey data 4
2.2.1 Administrative level 4
2.2.2 Population groups 5
2.3 Dening vitamin A deciency 5
2.3.1 Serum or plasma retinol threshold 5
2.3.2 Estimated prevalence o night blindness and biochemical vitamin A deciency or countrieswith no survey data 6
2.3.3 Uncertainty o estimates 6
2.3.4 Combining national estimates 7
2.3.5 Global prevalence o vitamin A deciency in populations at risk 7
2.3.6 Classication o vitamin A deciency as a problem o public health signicance 7
2.4 Population covered by survey data, proportion o population, and the number o individuals with
vitamin A deciency in populations at risk 8
2.4.1 Population covered 8
2.4.2 Proportion o population and the number o individuals afected in countries at risk or
vitamin A deciency 8
3. Results and Discussion 9
3.1 Results 9
3.1.1 Population covered 9
3.1.2 Proportion o population and number o individuals with vitamin A deciency in populations at risk 10
3.1.3 Public health signicance o vitamin A deciency 11
3.2 Discussion 16
3.2.1 Population covered 16
3.2.2 Strengths o estimates 16
3.2.3 Proportion o population and the number o individuals with vitamin A deciency in populations at risk 16
3.2.4 Classication o countries by degree o public health signicance o vitamin A deciency 16
3.2.5 Comparison to previous estimates 16
3.2.6 Limitations o estimates 17
3.3 Conclusions 18
COntents
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GlObAl preVAlenCe Of VitAmin A DefiCienCy in pOpulAtiOns At risk 19952005iv
References 19
Annexes
Annex 1 WHO Member States grouped by WHO region and UN region as o 2007 21
Table A1.1 WHO Member States grouped by WHO region 21
Table A1.2 WHO Member States grouped by UN region and subregion 22
Annex 2 Results by UN region 24
Table A2.1 Percentage o population at risk o vitamin A deciency covered by night blindness
and serum retinol prevalence surveys (national or subnational) conducted between
1995 and 2005, by UN region 24
Table A2.2 Prevalence o night blindness and numbers o afected preschool-age children and
pregnant women in countries at risk o vitamin A deciency in each UN region 24
Table A2.3 Prevalence o serum retinol
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v
Figures
Figure 1 Night blindness as a public health problem by country 19952005: Preschool-age children 12
Figure 2 Biochemical vitamin A defciency (retinol) as a public health problem by country 19952005:
Preschool-age children 13
Figure 3 Night blindness as a public health problem by country 19952005: Pregnant women 14
Figure 4 Biochemical vitamin A defciency (retinol) as a public health problem by country 19952005:
Pregnant women 15
COntents
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vii
Preface
Part o the World Health Organizations mandate is to pro-
vide inormation on the health status o the population at
the global level. In this respect, since 1991, the Department
o Nutrition or Health and Development (NHD) has been
maintaining the Vitamin and Mineral Nutrition Inor-
mation System (VMNIS), which includes three databasesrelated to three micronutrient disorders o public health
signicance globally: iodine deciency, iron deciency
and anaemia, and vitamin A deciency. Te objectives o
VMNIS are to assess the status o the population at the
global level in order to increase the awareness o the public
health community and policy makers, evaluate the impact
o interventions and measure progress towards the goals en-
dorsed by the international community, to compare data
between countries, track changes over time, and increase
the capacity o countries to manage health data related to
micronutrients.
WHO estimates o the global prevalence o vitamin A
deciency were rst published through its Micronutrient
Deciency Inormation System in 1995. Since then, large
programmes on vitamin A deciency control have been
implemented in several countries where vitamin A de-
ciency was a public health problem many o these pro-
grammes involved vitamin A supplementation and were
strengthened by being combined with polio eradication
campaigns. Additionally, vitamin A status indicators, espe-
cially symptomatic reporting o night blindness and serum
retinol concentrations, have been assessed in many more
national surveys than reported or previous estimates. As aresult, most data collected in the present report are based
on reported histories o night blindness and serum retinol
concentrations.
Vitamin A deciency is one o the most important causes
o preventable childhood blindness and is a major contribu-
tor to morbidity and mortality rom inections, especially
in children and pregnant women, aecting the poorest seg-
ments o populations, particularly those in low and middle
income countries. Te primary cause o vitamin A decien-
cy is lack o an adequate intake o vitamin A, and may be
exacerbated by high rates o inection, especially diarrhoeaand measles. Its consequence is most apparent during stag-
es o lie o high nutritional demand (e.g. early childhood,
pregnancy and lactation). A variety o interventions are be-
ing used to improve the vitamin A status o populations:
dietary diversication, vitamin A supplementation and or-
tication.
In 1987, WHO estimated that vitamin A deciency wasendemic in 39 countries based on the ocular maniestations
o xerophthalmia or decient serum (plasma) retinol con-
centrations (
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GlObAl preVAlenCe Of VitAmin A DefiCienCy in pOpulAtiOns At risk 19952005viii
Tis document is divided into three chapters. Te rst
provides an overview o vitamin A deciency, the second
describes the criteria used to identiy, revise, select, and in-
terpret the ndings o the surveys, and the methodology
developed to generate national, regional, and global esti-
mates, while the third discusses the results.
Tis report is written or public health ofcials, nutri-
tionists, and researchers. We hope that readers nd it useul
and eel ree to share any comments with us (micronutri-
[email protected]). We also hope that this inormation will
contribute to our common goal to eliminate vitamin A de-
ciency as a public health problem.
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ix
Acknowledgements
Tis report utilized data rom the WHO Global Database
on Vitamin A Deciency, which is part o the WHO Vita-
min and Mineral Nutrition Inormation System (VMNIS),
developed by the Reduction o Micronutrient Malnutrition
Unit in the Department o Nutrition or Health and De-
velopment.
Tis report is the result o the hard work and collaboration
o several individuals. We would especially like to thank
Lisa M. Rogers, who took the lead on the development o
this report, Daniel Wojdyla o the Universidad Nacional de
Rosario, Argentina or perorming the statistical analyses,
Keith P. West Jr o Johns Hopkins Bloomberg School o
Public Health or his extremely valuable scientic input on
vitamin A, and Bruno de Benoist or his technical expertise
in this area. Grace Rob and Ann-Beth Moller also provid-
ACknOWleDGements
ed valuable assistance in data management. Additionally,
WHO wishes to thank the numerous individuals, institu-
tions, governments, nongovernmental, and international
organizations or providing data or the database. Without
continual international collaboration in keeping the data-
base up-to-date, this compilation on the global situationand trends in the prevalence o vitamin A deciency would
not have been possible. Special thanks are due to ministries
o health o the WHO Member States, WHO regional o-
ces, and WHO country ofces.
Tis report was made possible by the nancial support o
the Micronutrient Initiative, the Government o Luxem-
bourg, the Centers or Disease Control and Prevention, and
Sight and Lie.
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x GlObAl preVAlenCe Of VitAmin A DefiCienCy in pOpulAtiOns At risk 19952005
Abbreviations
GDP Gross domestic product
HDI Human Development Index: a composite indicator o wealth, lie expectancy and education developed by
the United Nations Development Programme.
MDIS Micronutrient Defciency Inormation System
PreSAC Preschool-age children
PW Pregnant womenSD Standard deviation
UN United Nations
VAD Vitamin A defciency
VADD Vitamin A defciency disorders
VMNIS Vitamin and Mineral Nutrition Inormation System
WHO World Health Organization
XN Night blindness
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1
1. Introduction
1. intrODuCtiOn
1.1 Vitamin A defciency: a public healthproblem
Vitamin A deciency (VAD) is a major nutritional concern
in poor societies, especially in lower income countries. Its
presence as a public health problem is assessed by measuring
the prevalence o deciency in a population, represented byspecic biochemical and clinical indicators o status. Te
main underlying cause o VAD as a public health problem
is a diet that is chronically insufcient in vitamin A that can
lead to lower body stores and ail to meet physiologic needs
(e.g. support tissue growth, normal metabolism, resistance
to inection). Deciency o sufcient duration or severity
can lead to disorders that are common in vitamin A de-
cient populations such as xerophthalmia (xeros = dryness;
-ophthalmia = pertaining to the eye), the leading cause o
preventable childhood blindness, anaemia, and weakened
host resistance to inection, which can increase the severityo inectious diseases and risk o death. A poor diet and in-
ection requently coexist and interact in populations where
VAD is widespread. In such settings, VAD can increase the
severity o inection which, in turn, can reduce intake and
accelerate body losses o vitamin A to exacerbate deciency.
Te prevalence and severity o xerophthalmia, anaemia and
the (less-measurable) vicious cycle between VAD and in-
ection in vulnerable groups (notably young children and
pregnant or lactating mothers) represent the most compel-
ling consequences o VAD and underlie its signicance as a
public health problem around the world.
1.1.1 Etiology
Vitamin A is an essential nutrient needed in small amounts
or the normal unctioning o the visual system, and main-
tenance o cell unction or growth, epithelial integrity, red
blood cell production, immunity and reproduction. Essen-
tial nutrients cannot be synthesized by the body and there-
ore must be provided through diet. When dietary intake
is chronically low, there will be insufcient vitamin A to
support vision and cellular processes, leading to impaired
tissue unction. Low vitamin A intake during nutrition-
ally demanding periods in lie, such as inancy, childhood,pregnancy and lactation, greatly raises the risk o health
consequences, or vitamin A deciency disorders (VADD).
Dietary deciency can begin early in lie, with colostrum
being discarded or breasteeding being inadequate, thereby
denying inants o their rst, critical source o vitamin A
(1). Tereater, into adulthood, a diet decient in vitamin
A lacks oods containing either preormed vitamin A esters,such as liver, milk, cheese, eggs or ood products ortied
with vitamin A or lacking its carotenoid precursors (mainly
beta-carotene), such as green leaves, carrots, ripe mangos,
eggs, and other orange-yellow vegetables and ruits. Where
animal source or ortied oods are minimally consumed,
dietary adequacy must rely heavily on oods providing
beta-carotene. However, while nutritious in many ways, a
diet with modest amounts o vegetables and ruits as the
sole source o vitamin A may not deliver adequate amounts,
based on an intestinal carotenoid-to-retinol conversion ra-
tio o 12:1 (2). Tis ratio reects a conversion efciency that
is about hal that previously thought, leading to greater ap-
preciation or why VAD may coexist in cultures that heav-
ily depend on vegetables and ruits as their sole or main
dietary source o vitamin A.
Usually, VAD develops in an environment o ecological,
social and economical deprivation, in which a chronically
decient dietary intake o vitamin A coexists with severe
inections, such as measles, and requent inections caus-
ing diarrhoea and respiratory diseases that can lower intake
through depressed appetite and absorption, and deplete
body stores o vitamin A through excessive metabolism and
excretion (3, 4). Te consequent synergism can result inthe bodys liver stores becoming depleted and peripheral tis-
sue and serum retinol concentrations decreasing to decient
levels, raising the risks o xerophthalmia, urther inection,
other VADD and mortality.
1.1.2 Health consequences
Vitamin A deciency impairs numerous unctions and, as
a result, can lead to many health consequences, to which
inants, young children and pregnant women appear to be
at greatest risk. Xerophthalmia is the most specic VADD,
and is the leading preventable cause o blindness in childrenthroughout the world (5). Night blindness oten appears
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GlObAl preVAlenCe Of VitAmin A DefiCienCy in pOpulAtiOns At risk 199520052
during pregnancy, a likely consequence o preexisting,
marginal maternal vitamin A status superimposed by nu-
tritional demands o pregnancy and intercurrent inections
(6). Anaemia can result rom VAD in children and women,
likely due to multiple apparent roles o vitamin A in sup-
porting iron mobilization and transport, and hematopoiesis
(7). Preexisting VAD appears to worsen inection (8) and
vitamin A supplementation has been shown to reduce the
risk o death in 659 month old children by about 2330%
(911). Tree trials rom southern Asia have reported that
neonatal vitamin A supplementation reduced mortality by
21% in the rst six months o lie (12) while two other stud-
ies conducted in Arica showed no impact o this interven-
tion (13, 14). One study has reported an approximate 40%
reduction in maternal mortality ollowing routine dietary
supplementation with vitamin A during pregnancy (15).
1.1.3 Assessing vitamin A status and defciencyTe main objective o assessing vitamin A status is to deter-
mine the magnitude, severity and distribution o VAD in
a population. Most surveys assess its prevalence in young
children and, with increasing requency, in pregnant or lac-
tating women, as reported here. Although VAD is likely to
be widespread ollowing the preschool years, ew data exist
to reveal the extent o VAD in school-age and young ado-
lescent children (16). Estimating the national prevalence
is to be encouraged as such data aids in targeting regions
or interventions, and provides baseline values or monitor-
ing population trends and intervention programme impact
over time.
wo sets o indicators o VAD are commonly used or
population surveys: clinically assessed eye signs and bio-
chemically determined concentrations o retinol in plasma
or serum. Te term xerophthalmia encompasses the clini-
cal spectrum o ocular maniestations o VAD, rom milder
stages o night blindness and Bitots spots, to potentially
blinding stages o corneal xerosis, ulceration and necro-
sis (keratomalacia) (17), as listed in Table 1. Te stages o
xerophthalmia are regarded both as disorders and clinical
indicators o VAD, and thus can be used to estimate an im-
portant aspect o morbidity and blinding disability as wellas the prevalence o deciency. As corneal disease is rare,
the most commonly assessed stages are night blindness,
obtainable by history, and Bitots spots, observable by han-
dlight examination o the conjunctival surace. Standard
procedures exist or assessing xerophthalmia (17). Although
night blindness and Bitots spots are considered mild stages
o eye disease, both represent moderate-to-severe systemic
VAD, as evidenced by low serum retinol concentrations
(19), and increased severity o inectious morbidity (i.e. di-
arrhoea and respiratory inections) and mortality in chil-
dren (5) and pregnant women (6, 20).
Measuring serum retinol concentrations in a population
constitutes the second major approach to assessing vitamin
A status in a population, with values below a cut-o o
0.70 mol/l representing VAD (21), and below 0.35 mol/l
representing severe VAD. Although there is not yet interna-
tional consensus, a serum retinol concentration below a cut-
o o 1.05 mol/l has been proposed to refect low vitamin
A status among pregnant and lactating women (22). Whilethe distribution o serum retinol concentrations below ap-
propriate cut-os are considered to refect inadequate states
o vitamin A nutriture, a low biochemical concentration o
retinol in circulation is not considered a VADD. Also, while
an inadequate dietary intake o vitamin A or beta-carotene
likely reveals an important and preventable cause o VAD
in a population, it is not an indicator o vitamin A status.
1.2 Control o vitamin A defciencyTree types o community interventions can reduce VAD
in aected populations. Improving the availability and in-
take o vitamin A through dietary diversication should be
viewed as an activity or all communities in order to en-
hance the overall nutritional status o the population. Tis
requires nutrition education to change dietary habits, as
well as providing better access to vitamin A or provitamin
A-rich oods, such as mangoes, papaya, or dark green leay
vegetables. Encouraging home gardening or local coopera-
tives to grow such oods may be necessary in regions where
they are not locally available or are too expensive.
A second approach to increasing the dietary intake o
vitamin A is through ortication o a staple ood or condi-
ment with vitamin A. Tis has been the primary strategy orreducing VAD in Central and South America, where sugar
began to be ortied with vitamin A three decades ago (23).
Although many ood items such as ats, oils, margarine and
cereal products have long been ortied with vitamin A in
high income countries, ew other vitamin A ortication
programmes with national reach currently exist in lower
income countries. It can be expected that this approach will
gain momentum as increasing numbers o potentially orti-
able oods become centrally produced or processed under
controlled conditions and penetrate markets o the poor in
many countries (24
).Tirdly, the most widely practiced approach to control-
Table 1 Classifcation o xerophthalmia
Xn ngh d
X1A Cojcva xo
X1b bo o
X2 Coa xo
X3A Coa cao/aoaaca (< 1/3 coa ac)
X3b Coa cao/aoaaca (1/3 coa ac)
Xs Coa ca
Xf Xohhac d
soc: c (18)
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31. intrODuCtiOn
ling VAD in most high risk countries is the periodic deliv-
ery o high-potency supplements, containing 200 000 IU
o vitamin A, to preschool-age children (
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4 GlObAl preVAlenCe Of VitAmin A DefiCienCy in pOpulAtiOns At risk 19952005
2. Methods
conducted between 1995 and 2006. Most surveys assessed
nutritional status in women or preschool-age children.
2.2 Selection o survey data
Te time rame or the current estimates is 19952005 and
survey data or WHOs Member States were extracted romthe database. Available data on both biochemical (serum/
plasma retinol) and clinical (current or history o night
blindness) VAD were selected or each country based on the
administrative level or which the survey was representative
and on the population group surveyed.
All countries with a 2005 gross domestic product (GDP)
US$ 15 000 were assumed to be ree rom VAD o a pub-
lic health signicance and were thereore excluded. None
o these 37 countries had retinol or night blindness data
reported or either preschool-age children or pregnant
women.
2.2.1 Administrative level
Surveys were rst selected according to the administrative
level they represented. Surveys were considered as national
when they were based on a nationally representative sam-
ple o the population surveyed. Subnational surveys were
selected only i a nationally representative survey was not
available or the years 19952005. Subnational surveys are
classied based on the population they represent: regional
(multiple states), state (representative o the rst adminis-
trative level boundary), district (representative o the sec-
ond administrative level boundary), or local surveys.Seven surveys were included as national even though
some areas within the country had been let out or security
or other concerns. In one o these surveys, data available
rom an originally missing area was pooled with the na-
tional data and weighted by the areas general population
estimate to provide a national estimate or that country.
Tis proportion was determined by using the most recent
census data. Tree additional surveys were accepted as na-
tional even though they were only representative o either
the rural (Bangladesh, Cambodia) or urban (Cuba) popula-
tions.For the majority o countries with subnational data,
2.1 Data sources The WHO Global Databaseon Vitamin A Defciency
Te current estimates are based on data available in the
WHO Global Database on Vitamin A Deciency (27); a
part o the Vitamin and Mineral Nutrition Inormation
System (VMNIS), maintained at WHO Headquarters inGeneva, Switzerland. Tis database compiles inormation
on the prevalence o night blindness, other ocular signs o
VAD, and blood retinol concentrations, regularly collect-
ed rom the scientic literature and through collaborators,
including WHO regional and country ofces, United Na-
tions organizations, ministries o health, research and aca-
demic institutions, and nongovernmental organizations.
MEDLINE and WHO regional databases (Arican Index
Medicus, Index Medicus or the WHO Eastern Mediter-
ranean Region, Latin American and Caribbean Center on
Health Sciences Inormation, Index Medicus or South-East Asia Region) were systematically searched. Tese
resources were augmented by manual searching o arti-
cles published in non-indexed medical and proessional
journals. Data were extracted rom reports written in any
language.
For inclusion in the database, a complete and original
survey report providing details o the sampling method
used is necessary. Serum or plasma retinol levels measured
in capillary, venous, or umbilical cord blood using quan-
titative methods are reported, usually together with the
prevalence o VAD. Measures o clinical VAD may have
included the prevalence o current night blindness (XN),history o maternal night blindness during a previous
pregnancy (pXN), conjunctival xerosis (X1A), Bitots spot
(X1B), corneal xerosis (X2), corneal ulceration/keratoma-
lacia aecting
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5
surveys were representative o at least the rst (state) level
boundary. Exceptions to this were second (district) level
boundary surveys used or Sao ome and Principe, and
Ghana. Most countries that used subnational surveys were
represented by at least two states (rst level boundaries).
Exceptions to this principle were the surveys or ajikistan
and Uzbekistan, or which only one state was covered by
the survey. When two or more surveys at the subnational
level were available or the population group and country
concerned within the acceptable time rame, the results
were pooled into a single summary measure and weighted
by the total population that the survey represented. Te
most recent population census data available between 1995
and 2005 was used or this. No local level surveys and most
district level surveys were used in these estimates to reduce
potential bias in the estimates.
In general, surveys with prevalence data based on a
sample size o less than 100 subjects were excluded. Tissample size, along with a condence level o 95%, would
result in an error 10% i the prevalence estimate was 50%
and the design efect was 1.0. I the sample size was less
than 100, a larger error would result. However, a ew excep-
tions were made. National surveys with a sample size o less
than 100, but greater than 50, were considered as nation-
ally representative only when the results were being applied
to a total population o less than 500 000 people (n=1 in
preschool-age children), or to pregnant women (n=3) since
the numbers in this group are requently small, especially
in populations with a lower rate o reproduction. One na-
tional survey (Mexico) o pregnant women was excluded
because the sample size was less than 50. One survey or
retinol in pregnant women (Zimbabwe) and three surveys
or night blindness in preschool-age children (Gambia, In-
dia, Sri Lanka) did not report a sample size. In these cases,
a sample size o 100 was used only to approximate variances
and derive condence intervals.
2.2.2 Population groups
wo population groups were evaluated: preschool-age chil-
dren (
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GlObAl preVAlenCe Of VitAmin A DefiCienCy in pOpulAtiOns At risk 199520056
taken as slightly conservative. For only two o the 71 val-
ues in children, the predicted prevalence overestimated
the observed prevalence o retinol
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7
95% prediction interval were computed by using the logit
transormations in the regression models and then back-
transorming them to the original scale (37, 38).
2.3.4 Combining national estimates
Country estimates or the 156 Member States with a 2005
GDP
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2.4 Population covered by survey data,proportion o population, and the numbero individuals with vitamin A defciency in
populations at risk
2.4.1 Population covered
Te population covered by survey data at the regional and
global level was calculated by summing the number o in-
dividuals in the population group in countries with sur-
vey data divided by the total number o individuals in the
population group in the countries identifed at risk o VAD
in the entire region or globally or each population group.
2.4.2 Proportion o population and the number o
individuals aected in countries at risk or
vitamin A defciency
Te number o individuals with VAD was estimated in
both population groups or both indicators (night blind-
ness and retinol) or each country considered to be at risko VAD, each WHO and UN region, and global ly based on
each countrys proportion o the population with VAD. Te
proportion o the population group with VAD was mul-
tiplied by the national population o those considered to
be at risk o VAD to provide the number o subjects with
VAD at the country level, and the 95% confdence inter-
val was used as a measure o uncertainty. Te population
fgures are or the 2006 projection rom the 2006 revision
o the United Nations population estimates (40). Popula-
tion fgures or pregnant women were derived rom the
annual total number o births (time period 20052010).For 14 countries with a small total population (0.01% o
all women), birth data were not provided in tabulations o
the UN population division, and the number o pregnant
women was estimated by applying a WHO regional average
o births per reproductive-age woman (15 to 49 years) to the
total number o reproductive-age women.
Table 4 Prevalence criteria or defning night blindness
o public health signifcance
Public health Night blindness (XN)importance(degree o Childrena Pregnantseverity) (2471 mo o age) womenb
md >0%
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9
3. Results and Discussion
proportion o preschool-age children and pregnant women
covered by night blindness survey data was 54% and 55%,
respectively, and by serum retinol survey data, 76% and
19%, respectively. By WHO region, the coverage varied
drastically depending on the population group assessed
and the indicator used. For night blindness in preschool-age children, data coverage was highest in South-East Asia
(82.4%) and the Western Pacifc (87.3%) and very low in
Europe (1%) and nil in the Americas (0%). Survey cover-
age or night blindness in pregnant women was the high-
est in South-East Asia (96.8%) and the lowest in Europe
3. results AnD DisCussiOn
3.1 Results
3.1.1 Population covered
Only the 156 Member States which have a 2005 GDP
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GlObAl preVAlenCe O VitAmin A DeiCienCy in pOpul AtiOns At risk 1995200510
(1.3%). Survey coverage or serum retinol was the highest
in the Western Pacic (99.8%) and the lowest in Europe
(17.8%) or preschool-age children; however, or pregnant
women, coverage was the highest in the Eastern Mediter-
ranean (39.8%) and virtually nil or both Europe (0%) and
the Americas (0.6%).
3.1.2 Proportion o population and number o
individuals with vitamin A defciency in
populations at risk
Globally, night blindness afects 5.2 million preschool-
age children (95% CI: 2.08.4 million) and 9.8 million
pregnant women (95% CI: 8.710.8 million), which corre-
sponds to 0.9% and 7.8% o the population at risk o VAD,
respectively (Table 8). Low serum retinol concentration
(
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113. results AnD DisCussiOn
Table 11 Prevalence o serum retinol
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GlObAl preVAlenCe Of VitAmin A DefiCienCy in pOpulAtiOns At risk 1995200512
Figure 1 Night blindness as a public health problem by country 19952005: Preschool-age children
a) Countries and areas with survey data
Category of public healthsignificance (prevalence ofnight blindness)
None
Mild Mild (>0% 0%
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13
Figure 2 Biochemical vitamin A defciency (retinol) as a public health problem by country 19952005:
Preschool-age children
a) Countries and areas with survey data
b) Countries and areas with survey data and regression-based estimates
Category of public healthsignificance (prevalence ofserum retinol
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GlObAl preVAlenCe Of VitAmin A DefiCienCy in pOpulAtiOns At risk 1995200514
Figure 3 Night blindness as a public health problem by country 19952005: Pregnant women
a) Countries and areas with survey data
b) Countries and areas with survey data and regression-based estimates
Category of public healthsignificance (prevalence ofnight blindness)
No public healthproblem (
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15
Figure 4 Biochemical vitamin A defciency (retinol) as a public health problem by country 19952005: Pregnant women
a) Countries and areas with survey data
b) Countries and areas with survey data and regression-based estimates
Category of public healthsignificance (prevalence ofserum retinol
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GlObAl preVAlenCe Of VitAmin A DefiCienCy in pOpulAtiOns At risk 1995200516
3.2 Discussion
3.2.1 Population covered
Preschool-age children and pregnant women are consid-
ered to be populations most at-risk or VAD due to their
increased demands or vitamin A and the potential health
consequences associated with VAD during these lie stages.
Tus, the estimates presented here are specic to children
under 5 years o age and pregnant women. Tis report does
not address VAD as a public health problem in all other
age groups due to lack o adequate data and understanding
o the public health importance o VAD at other ages (a
research priority). We also assume that VAD is not a pub-
lic health problem or preschool-age children and pregnant
women residing in the 37 countries identied as having
a GDP US$ 15 000, who have been excluded rom this
analysis and consideration.
About hal o the global populations o both preschool-
age children and pregnant women considered to be at risko VAD were covered by survey data or this report. Cover-
age was considerably greater (76%) or serum retinol in pre-
school-age children than in pregnant women (19%) where,
however, it remains low.
3.2.2 Strengths o estimates
Tis report utilizes the most up-to-date data published as
o December 31, 2006 or the years 19952005. Tese es-
timates are based on the greatest number o VAD surveys
conducted in preschool-age children and pregnant women
to date. Where probabilistic, representative surveys havenot been conducted in the 10 year inclusion period, survey
estimates are complemented by regression-based estimates.
Use o GDP US$ 15 000 to classiy a country as high
income and assuming that they are not at risk o VAD o
public health signicance is arbitrary. Although there is lit-
tle survey data available in these countries to support this
assumption, the exclusion is supported by a usual tendency
or VAD risk to decline with rising socioeconomic status,
most clearly evident in its association with xerophthalmia
(4144). A second reason or excluding higher income
countries rom analysis was to improve the predictability
o the regression models and to help place ocus on areaswhere VAD is likely to be o public health signicance.
3.2.3 Proportion o population and the number
o individuals with vitamin A defciency in
populations at risk
Approximately one third o the worlds preschool-age popu-
lation is estimated to be vitamin A decient, with just less
than 1% being night blind at a given time. Te WHO re-
gions o Arica and South-East Asia have the highest burden
o VAD, reected by decient concentrations o the vitamin
in circulation, where 4450% o preschool-age children areaected. Most vitamin A decient children live in South-
East Asia, where 91.5 million preschool-age children have
serum retinol concentrations
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173. results AnD DisCussiOn
West estimated that 127 million preschool-age children are
vitamin A decient, dened as a serum retinol concentra-
tion
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GlObAl preVAlenCe Of VitAmin A DefiCienCy in pOpulAtiOns At risk 1995200518
A limitation o using serum (plasma) retinol concentra-
tion as an indicator o vitamin A status is that it is decreased
by acute and underlying chronic inections (8). Te major-
ity o surveys do not utilize an indicator o inection status
at the time in which retinol is assessed. Concurrent data
on inection status would not alter the indicator-based (i.e.
serum retinol) estimates o prevalence but could infuence
the interpretation o survey ndings with respect to cause
o apparent deciency (48).
In some cases, the prevalence o serum retinol concen-
trations
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19
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23. Arroyave G et al. Evaluation o sugar ortication withvitamin A at the nutritional level. Scientic PublicationNo. 384, Washington DC, PAHO, 1979.
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24. Dary O, Mora JO, International Vitamin A Consul-tative Group. Food ortication to reduce vitaminA deciency: International Vitamin A ConsultativeGroup recommendations. Journal o Nutrition, 2002,132:2927S2933S.
25. World Health Organization, UNICEF, IVACG ask
Force. Vitamin A supplements: a guide to their use in thetreatment o vitamin A defciency and xerophthalmia , 2nded. Geneva, World Health Organization, 1997 (http://whqlibdoc.who.int/publications/1997/9241545062.pd).
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42. Mele L et al. Nutritional and household risk actorsor xerophthalmia in Aceh, Indonesia: a case-controlstudy. Te Aceh Study Group. American Journal oClinical Nutrition, 1991, 53:14601465.
43. Khatry SK et al. Epidemiology o xerophthalmia in
Nepal. A pattern o household poverty, childhood ill-ness, and mortality. Te Sarlahi Study Group.Archiveso Ophthalmology, 1995, 113:425429.
44. World Health Organization. Te global prevalence ovitamin A defciency. Micronutrient Defciency Inorma-tion System (MDIS) Working Paper 2. Geneva, WorldHealth Organization, 1995 (WHO/NU/95.3).(http://www.who.int/nutrition/publications/vad_global_prevalence/en/index.html).
45. Micronutrient Initiative, UNICEF, ulane University.Progress in controlling vitamin A defciency. Ottawa,Micronutrient Initiative, 1998.
46. Micronutrient Initiative, United Nations Childrens
Fund. Vitamin and mineral defciency: a global prog-ress report. Ottawa, Micronutrient Initiative and NewYork, UNICEF, 2004 (http://www.micronutrient.org/pds/VMD.pd).
47. Mason J et al. Recent trends in malnutrition in devel-oping regions: vitamin A deciency, anemia, iodinedeciency, and child underweight. Food and NutritionBulletin, 2005, 26:59108.
48. Turnham DI et al. Efects o subclinical inection onplasma retinol concentrations and assessment o preva-lence o vitamin A deciency: meta-analysis. Lancet,2003, 362:20522058.
49. West KP Jr, Rice A, Sugimoto JD. ables on the global
burden o vitamin A defciency and xerophthalmia amongpreschool aged children and low vitamin A status, vita-min A defciency, and night blindness among pregnantwomen by WHO region (http://www.jhsph.edu/CHN/GlobalVAD.pd; updated August 2002).
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AnneX 1
WHO Member States grouped by WHO
region and UN region as of 2007
AnneX 1
Table A1.1 WHO Member States grouped by WHO region
AfricaAlgeria
Angola
BeninBotswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Congo
Cte dIvoire
Democratic Republic of
the Congo
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Guinea
Guinea-Bissau
Kenya
Lesotho
LiberiaMadagascar
Malawi
Mali
Mauritania
Mauritius
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao ome and Principe
Senegal
Seychelles
Sierra Leone
South Africa
Swazilandogo
Uganda
United Republic of
anzania
Zambia
Zimbabwe
AmericasAntigua and Barbuda
Argentina
Bahamas
BarbadosBelize
Bolivia (Plurinational State
of)
Brazil
Canada
Chile
Colombia
Costa Rica
Cuba
Dominica
Dominican RepublicEcuador
El Salvador
Grenada
Guatemala
Guyana
Haiti
Honduras
Jamaica
Mexico
Nicaragua
Panama
Paraguay
Peru
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and theGrenadines
Suriname
rinidad and obago
United States of America
Uruguay
Venezuela (Bolivarian
Republic of)
South-East Asia
Bangladesh
Bhutan
Democratic PeoplesRepublic of Korea
India
Indonesia
Maldives
Myanmar
Nepal
Sri Lanka
Tailand
imor-Leste
EuropeAlbaniaAndorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
FranceGeorgia
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Kazakhstan
Kyrgyzstan
Latvia
LithuaniaLuxembourg
Malta
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Republic of Moldova
Romania
Russian FederationSan Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
ajikistan
Te former Yugoslav
Republic of Macedonia
urkey
urkmenistan
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GlObAl preVAlenCe Of VitAmin A DefiCienCy in pOpulAtiOns At risk 1995200522
Ukraine
United Kingdom of Great
Britain and Northern
Ireland
Uzbekistan
Eastern Mediterranean
Afghanistan
Bahrain
Djibouti
Egypt
Iran (Islamic Republic of)
Iraq
Jordan
Kuwait
Lebanon
Libyan Arab Jamahiriya
Morocco
Oman
Pakistan
Qatar
Saudi Arabia
Somalia
Sudan
Syrian Arab Republic
unisia
United Arab Emirates
Yemen
Western Pacifc
Austra lia
Brunei Darussalam
Cambodia
China
Cook Islands
Fiji
Japan
Kiribati
Lao Peoples Democratic
Republic
Malaysia
Marshall Islands
Micronesia (Federated
States of)
Mongolia
Nauru
New Zealand
Niue
Palau
Papua New Guinea
Philippines
Republic of Korea
Samoa
Singapore
Solomon Islands
onga
uvalu
Vanuatu
Viet Nam
Table A1.2 WHO Member States grouped by UN region and subregion1
Arica
Eastern Africa
Burundi
Comoros
Djibouti
Eritrea
Ethiopia
Kenya
Madagascar
Malawi
Mauritius
Mozambique
Rwanda
Seychelles
Somalia
Uganda
United Republic of
anzania
Zambia
Zimbabwe
Middle AfricaAngola
Cameroon
Central African Republic
Chad
Congo
Democratic Republic of
the Congo
Equatorial Guinea
Gabon
Sao ome and Principe
Northern Africa
Algeria
Egypt
Libyan Arab Jamahiriya
Morocco
Sudan
unisia
Southern Africa
Botswana
Lesotho
Namibia
South Africa
Swaziland
Western Africa
Benin
Burkina Faso
Cape Verde
Cte dIvoire
Gambia
GhanaGuinea
Guinea-Bissau
Liberia
Mali
Mauritania
Niger
Nigeria
Senegal
Sierra Leone
ogo
Asia
Central Asia
Kazakhstan
Kyrgyzstan
ajikistan
urkmenistan
Uzbekistan
Eastern Asia
China
Democratic Peoples
Republic of Korea
Japan
Mongolia
Republic of Korea
Southern Asia
Afghanistan
Bangladesh
Bhutan
India
Iran (IslamicRepublic of )Maldives
Nepal
Pakistan
Sri Lanka
South-eastern Asia
Brunei Darussalam
Cambodia
Indonesia
Lao Peoples Democratic
Republic
Malaysia
Myanmar
Philippines
Singapore
Tailand
imor-Leste
Viet Nam
Western Asia
Armenia
AzerbaijanBahrain
Cyprus
Georgia
Iraq
Israel
Jordan
Kuwait
Lebanon
Oman
Qatar
Saudi ArabiaSyrian Arab Republic
urkey
United Arab Emirates
Yemen
1 http://unstats.un.org/unsd/
methods/m49/m49regin/htm,as of 31 January 2008.
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23
Europe
Eastern Europe
Belarus
Bulgaria
Czech Republic
Hungary
Poland
Republic of Moldova
Romania
Russian Federation
Slovakia
Ukraine
Northern Europe
Denmark
Estonia
Finland
IcelandIreland
Latvia
Lithuania
Norway
Sweden
United Kingdom of Great
Britain and Northern
Ireland
Southern Europe
AlbaniaAndorra
Bosnia and Herzegovina
Croatia
Greece
Italy
Malta
Montenegro
Portugal
San Marino
Serbia
Slovenia
Spain
Te former Yugoslav
Republic of Macedonia
Western Europe
Austria
Belgium
France
Germany
Luxembourg
MonacoNetherlands
Switzerland
Americas
Latin America and
the Caribbean
Caribbean
Antigua and Barbuda
Bahamas
Barbados
Cuba
Dominica
Dominican Republic
Grenada
Haiti
Jamaica
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the
Grenadines
rinidad and obago
Central America
Belize
Costa Rica
El Salvador
Guatemala
Honduras
Mexico
Nicaragua
Panama
South AmericaArgentina
Bolivia (Plurinational State
of)
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela (Bolivarian
Republic of)
Northern America
Canada
United States of America
Oceania
AustraliaNew Zealand
Austra lia
New Zealand
Melanesia
Fiji
Papua New Guinea
Solomon Islands
Vanuatu
Micronesia
Kiribati
Marshall IslandsMicronesia (Federated
States of)
Nauru
Palau
Polynesia
Cook Islands
Niue
Samoa
onga
uvalu
AnneX 1
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24 GlObAl preVAlenCe O VitAmin A DeiCienCy in pOpul AtiOns At risk 19952005
AnneX 2
Results by UN region
Table A2.1 Percentage o populationa at risk o vitamin A defciency covered by night blindness and serum retinol prevalence
surveys (national or subnational) conducted between 1995 and 2005, by UN region
UN region Preschool-age childrenb Pregnant women
Night blindness Retinol Night blindness Retinol
Aca (53)c 37.8 (17)d 75.9 (26) 62.9 (25) 27.0 (8)
Aa (37) 71.7 (12) 83.2 (21) 60.0 (13) 18.8 (7)eo (20) 0.7 (1) 0.7 (1) 1.3 (1) 0 (0)
la Aca ad
h Caa (32) 0 (0) 49.8 (16) 14.9 (6) 0.6 (4)
noh Aca (0) 0 (0) 0 (0) 0 (0) 0 (0)
Ocaa (14) 77.8 (2) 79.1 (3) 0 (0) 0 (0)
Global (156) 54.0 (32) 75.7 (67) 55.0 (45) 18.9 (19)
a excd co wh a 2005 GDp us$ 15 000. poao go: pchoo-ag chd (
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25
Table A2.3 Prevalence o serum retinol
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GlObAl preVAlenCe Of VitAmin A DefiCienCy in pOpulAtiOns At risk 1995200536
TableA3.2
Countryestimatesoftheprevalen
ceofnightblindnessinpregnantwomen
19952005
MemberState
Popu
lation2006a
Su
rve
yInformation
Proportionofthepopu
lation
Popu
lationw
ith
VAD
withnightbindness
(nu
mberofindividua
ls)(000)
Pregnantw
omen
General
Dateofsu
rvey
Lev
elof
Agerange
Sample
Pu
blichealth
(000)
(000)
(y
ears)
su
rvey
b
(y
ears)
Size
Referencec
Notes
Estimate
95%
CI
Estimate
9
5%
CI
problem
Veez
ea
598
27191
r
4.7
1.415.2
28
891
no
Vietn
am
1650
86206
r
4.1
1.213.2
67
19218
no
yeme
872
21732
r
9.8
3.027.8
85
26242
ye
Zamb
ia
473
11696
2003
n
15.0049.99
527
5098
5.7
1.717.5
27
883
ye
Zimba
bwe
374
13228
1999
n
15.0049.99
27704680,3331
4.6
3.46.1
17
1323
no
a
po
atiofgeaebaedothe2006ojectioomt
he2007eviioomt
heuitednatiopoatioDi
viio.
b
lev
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AnneX 4
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Measure DHS+. Micronutrient Update. Calverton, MD,
ORC Macro, 2002. Re 3331.