Prospective Clinical Study to Find out Epidemiology of Xerophthalmia in Children in a Tertiary Care Centre in India

Objective: To study the epidemiology of xerophthalmia in children 2-6 years of age in North India. Methods: A prospective clinical study was done at two tertiary care centers of North India between 2010 to 2016, Cases were selected from routine OPD and children less than 6 years of age were examined by an ophthalmologist. Diagnosis and classifi cation of Xerophthalmia was done according to WHO classifi cation. All the data recording demographic profi le, socioeconomic status, other health problems etc were recorded in a fi xed proforma. Data was analyzed by SPSS version 16. Findings: Two thousand nine hundred forty six cases were included in the study after satisfying inclusion and exclusion criteria. The prevalence of night blindness was estimated to be 2.93% (95% Confi dence Interval [CI]: 2.53-3.33) among children between 2 and 6 years of age. Xerophthalmia prevalence was 4.43% (95% CI: 4.19-4.67). Prevalence was more in girls than boys and higher in low socioeconomic status. Conclusion: Vitamin A defi ciency is recognized to be a severe public health problem leading to corneal opacity and childhood blindness in most of the areas of North India. Research Article Prospective Clinical Study to Find out Epidemiology of Xerophthalmia in Children in a Tertiary Care Centre in India Deepak Mishra1*, Megha Gulati2, Prashant Bhushan1, Nilesh Mohan2 and Bibhuti Sinha P2 1Department of Ophthalmology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP, India 2Regional Institute of Ophthalmology, IGIMS, Patna, Bihar, India *Address for Correspondence: Dr. Deepak Mishra, Assistant Professor in Ophthalmology, Department of Ophthalmology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, UP, India, Tel: 91-9415360338; Email: drdmishra12@yahoo.com Submitted: 24 November 2017 Approved: 28 December 2017 Published: 29 December 2017 Copyright: 2017 Mishra D, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited


Introduction
Xerophthalmia/ dry eye refers to all ocular manifestations ranging from night blindness to corneal melting due to vitamin A de iciency. Recognition of symptoms and signs of Xerophthalmia and prompt treatment according to the International classi ication is the mainstay of the therapy. Children & pregnant women are primarily at risk. Xerophthalmia is the most common, most devastating ocular disease attributing to nutritional de iciency. Although xerophthalmia literally means "dry eye," it denotes the entire spectrum of ocular abnormalities arising from vitamin A de iciency. These include night blindness, retinopathy, conjunctival and corneal xerosis, corneal ulceration and melting, and less obvious alterations in the epithelial structure of the eye and several other organs.
The importance of vitamin A for normal host resistance and survival has become increasingly evident. Even children with mild, subclinical de iciency are at increased risk of respiratory disease and diarrhea, anemia, growth retardation, and death [1]. Although the ocular complications of de iciency are best known and clinically evident, they represent only one facet of this multisystemic disorder.
Some 250 million preschool children are at risk of vitamin A de iciency, mainly in developing countries because of insuf iciently varied diets, poor maternal education and inadequate hygiene [2]. Vitamin A Prophylaxis Programme was launched in 1970 with the objective of reducing the disease and preventing blindness due to Vitamin A de iciency. It was initially started in 7 states with severe problems. Later it was extended to the entire country. Under the programme, children aged 6 months to 6 years were to be administered a mega dose of vitamin A at 6 monthly intervals. To prioritize Vitamin A administration, the programme was revised to give 5 mega doses at 6 months intervals to children 9 months to 3 years of age. In view of adequate supplies of Vitamin A, the target group has been revised to cover children 9 months-5 years, since 2007.Shervin et al reported that the prevalence of Xerophthalmia has been declining, because of widespread vitamin A supplementation and measles immunisation in at-risk populations [3]. Bahreynian et al also reported reduction in disability-adjusted life years due to vitamin a de iciency in Iranian population aged less than 5 years [4]. The objective of the present study was to determine the epidemiology of vitamin A de iciency in children aged 2-6 years in north India.

Materials and Methods
A prospective clinical study was done at two tertiary care centers of North India between 2010 to 2016, Cases were selected from routine OPD and children less than 6 years of age were examined by an ophthalmologist. Diagnosis and classi ication of Xerophthalmia was done according to WHO classi ication. All the data recording demographic pro ile, socioeconomic status, other health problems etc were recorded in a ixed proforma. Seeing the prevalence of disease, we use a 99% con idence level, a 50% standard of deviation, and a 5% margin of error to calculate the sample size. Data was analyzed by SPSS version 16.
A pretested questionnaire was administered to mothers or female caregivers, in order to collect demographic and health information on the children studied and on socioeconomic and environmental factors of relevance to the households. The child's dietary vitamin A intake was assessed with the help of a semi quantitative food frequency questionnaire. Anthropometric measurements, ocular examinations and vitamin a status estimation was done.
Height and weight were measured without footwear. Children were classi ied as underweight, stunted and wasted if the calculated weight-for-age, height-for-age and weight-for-height Z-scores respectively were below -2.0 standard deviations. Ocular examinations were conducted by an ophthalmologist. The various stages of xerophthlamia were identi ied and information on night blindness was collected. Diagnosis, classi ication & treatment of Xerophthalmia was done according to WHO classi ication & guidelines.

Results
Two thousand nine hundred and forty-six childrens were included in the study with higher prevalence in girls than boys. Female children's were predominated in the study, ifty-nine percent were female whereas forty-one percent were male. Higher number of participants were from in low socioeconomic status (According to Kuppuswamy scale) the prevalence of night blindness was estimated to be 2.93% (95% Con idence Interval [CI]: 2.53-3.33) .Overall Xerophthalmia prevalence was 4.43% (95% CI: 4.19-4.67).In 46% cases more than one child was affected in the family. Our study also found that 63.7% children received no treatment because of lack of knowledge & awareness. However 27.8 % were taking treatment from local doctor or health worker which did not contain Vitamin A Supplement. Stool microscopic examination of children showed 23% children were suffering from worm infestations (Figures 1,2 Table 1).

Discussion
Vitamin A de iciency has been long recognized as a major cause of blindness and an important public health problem among children in India. The current study observed 4.43 % prevalence of xerophthalmia in children 2-6 years of age. The earlier-conducted studies have reported a prevalence of xerophthalmia in the range of 1.1 % to 22.3 % in different population groups and in different parts of the country [4][5][6][7][8][9][10][11].
The observed association between various the sociodemographic factors (lower socio-economic status, girl preponderance, more than one child of same family) and xerophthalmia was also endorsed by the results of previous studies [5,6]. Prevalence of night blindness, estimated to be 2.93 % is far above the minimum prevalence to determine its public health signi icance (1%), suggesting moderate degree of public health problem. A high prevalence of night blindness can serve as a mapping tool in developing targeted programmes, and as a method for the community to monitor its population's vitamin A status, particularly in response to an intervention. Prevalence criteria for determining the public health signi icance of xerophthalmia and vitamin A de iciency in children aged 6 months to 6 years [12].   Prevalence of night blindness to de ine a public health problem and its level of importance among children aged 24-71 months [13] .
Degree of public health problem, % Prevalence of night blindness Mild 0.01-0.99 Moderate 1.0-4.9 Severe 5.0 or more Efforts to reduce vitamin A de iciency in younger children to a level not considered to be of public health signi icance are encouraging but a challenging task remains in countries where the number of children affected is larger than previously expected. Organizations committed to eliminating vitamin A de iciency need to re-evaluate policies for reducing vitamin A de iciency in populations similar to those covered by the present study. Xeropthalmia is common in rice eating states in India e.g. Bihar, West Bengal, Tamil Nadu, Andhra Pradesh, Orissa, because rice is devoid of Carotene [14,15].

Conclusion
Vitamin A de iciency is recognized to be a severe public health problem leading to corneal opacity and childhood blindness in most of the areas of North India.
Health education is needed for dietary diversi ication to include vegetables and fruits for long-term sustainability in improving the vitamin A status of children of all age groups. Such an approach will improve the intake of vitamin A and other micronutrients in a balanced manner.