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 week—far 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 effects—far 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.
References
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