Xerophtalmia and scurvy    
Xerophtalmia and scurvy Pierre Nabeth 06.09.98
Re: Xerophtalmia and scurvy Penny Nestel 06.09.98
Re: Xerophtalmia and scurvy Helen Young 07.09.98
Re: Xerophtalmia and scurvy Remi Sogunro 07.09.98
update: Xerophtalmia and Scrurvy Pierre Nabeth 10.09.98
Xerophtalmia and scurvy David Alnwick 11.09.98

Date: Sun, 06 Sep 1998 07:52:48 +0100
From: pnabethattoptechnology.mr (pnabeth)
Subject: Xerophtalmia and scurvy

Last week I went to a remote region of Mauritania. In a health centre, I was very surprised to learn that every year, from June to august, a number of people are treated for vitamin deficiencies, mainly vit.A and vit.C.

The region is very poor. 3000 inhabitants live at less than 5 km from the health centre (the whole population benefiting from the health centre activities is unknown, probably less than 10,000).

My visit was very short and I have not seen any patient but I had a look at the registration book. According to it, from June 1, 1997 to August, 3, 1998, 123 people were treated for xerophthalmia and 32 were treated for scurvy.

>From August 1, 1997 to July 31, 1998, the incidence rates in the population living at less than 5 km from the centre were as follows:

Xerophtalmia: 2.0 % / year
Highest rates were seen, as in 1997, in June and July:
June 98: 6.4 p.thousand/month
July 98: 6.8 p.thousand/month 85% of patients were adults (over 15). 76% of adults were females.

Scurvy: 0.2 % / year (but 70% of the cases were living at a distance over 10 km)
Highest rate in June, as in 1997: 1.1 p.thousand/month 89% of patients were adults. all adults were females.

I wrote a small report (in french) and showed it to people working at the Ministry of Health in Nouakchott. They didn't seems worried at all.
Do you think that it is a "normal" situation in a poor unassisted rural population or should something be done (or both) ?


Pierre Nabeth

Date: Sun, 06 Sep 1998 14:47:03 +0100
From: pnestelaterols.com
Subject: Re: Ngonut: [Fwd: Xerophtalmia and scurvy]

Dear Pierre,

Vitamin A deficiency can be seasonal as vitamin A intakes levels fall in the dry season when fruit and vegetables are not available and milk production declines. The 'peak' in cases is not unexpected.

Pregnant women are known to be at increased risk of nightblindness and there are studies showing lactating women are subclinically deficient (based on retinol levels). There are few studies on vitamin A deficiency among non-pregnant non lactating women, which does not mean they too are not at risk of VAD. WHO is advocating that pregnant women be given vitamin A post partum as the risk of conception during this period is low, but this is not yet policy in Mauritania. Women can be given vitamin A BUT only if they are not pregnant or the likelihood of them not being pregnant is known with reasonable certainity, i.e. you would have to cautious about having a mass program for women of reproductive age.

It is interesting that you did not find records of VAD in children....
This suggests that perhaps children were not being checked or the women had some other eye problem that is being called VAD. It would be worth following up on this. That said, it would not be surprising if the children were at risk of VAD, especially in the dry season, in which case it would be important to have a preventative as well as a therapeutic program in place. One of the doses of vitamin A should be given just before the season that clinical signs become very noticeable.

A recent document produced by the MI/UNICEF on 'Progress in controlling VAD' states that Mauritania provides vitamin A capsules during national immunization days or other mass campaigns. It might be a good idea to see whether the capsules are getting to and being distributed in this area through the existing health system and if not what can be done to improve the availabilty of the caspules.... it may be a supply problem.

Yes, something should be done!

Penny Nestel

Date: Mon, 07 Sep 1998 17:02:23 +0100
From: Helen Young <h.youngatodi.org.uk>
Subject: Re: Ngonut: [Fwd: Xerophtalmia and scurvy]

Dear all,
Outbreaks of scurvy in non refugee populations - how common is this? I used to think that scurvy was one of those deficiency diseases that had been all but eradicated except for those unfortunate refugees dependent on food rations in an area where they were unable to find other sources of vitamin C rich foods. But since then I too have come across, or heard of population groups, that have reported occurrences of scurvy and levels of other micronutrient deficiencies, particularly vitamin A deficiency and iron deficiency anemia that were almost unbelievable.

Two examples, are the rural population of Red Sea Hills in North Sudan, and the ethnic Tibetans in South West China. In Red Sea Hills the nutritional status of adult women (BMI) was very poor indeed, for an apparently stable situation, and I was in little doubt that micronutrient deficiencies were in part responsible for high rates of maternal and under five mortality. Anthropometric and some mortality data are available from Oxfam surveys. No data is available on maternal mortality, but in anthropometric surveys it was even noticeable how many mothers were absent as they had died in childbirth or shortly after.

These areas share in common a dependence on livestock as the basis of their livelihood, which for one reason or another had become more and more marginalised as a means of livelihood. I couldn't help wondering about the Mauritanians in question - what is their source of livelihood, and ask myself what is the long-term answer for addressing micronutrient deficiencies in such vulnerable populations (once their major nutritious food source has been reduced severely or removed altogether, and few alternatives are available)? Perhaps the first step is to acknowledge that such pockets of extreme deficiency diseases do exist among pastoral groups in semi-arid areas, and are found in contexts that do not necessarily qualify as an 'emergency', or for emergency relief.
The magic bullet of vitamin A supplementation would obviously help, and indeed Oxfam and the Ministry of Health organized a programme that included children and adolescents, but much more is needed to address the more widespread deficiencies of both type l and type ll nutrients. However, little will be done until the problem is more widely recognized and understood.

Helen Young

Date: Mon, 07 Sep 1998 09:43:40 +0100
From: Remi Sogunro <rembascsatzamnet.zm>
Subject: RE: Ngonut: [Fwd: Xerophtalmia and scurvy]

Hi Pierre,

Yes, for 2 years, Zambia has been providing vitamina along with the NID as well as sub-national vitammin A distribution 6 months following the NID.

What about fortifying commonly consumed food products? Zambia recently fortified sugar with vitamin A. The country is also actively looking at fortifying mealie meal, the staple maize flour comsumed at household by all.

Remi Sogunro

Date: Thu, 10 Sep 1998 08:44:29 +0100
From: pnabethattoptechnology.mr (pnabeth)
Subject: Ngonut: update: Xerophtalmia and Scrurvy

Dear All

Thank you for all the well documented answers on Scurvy and Xerophtalmia you have posted.

The area where the data collected (Mounguel Moughataa in Gorgol Wilaya for those who know Mauritania) is a desert area (40 mm of rain in 1997 according to local authorities). People grow mainly sorgho, beans, and watermelon; some receive food assistance from the Government (corn); they have very little access to fresh fruit and vegetable.

As I told you, the incidence rates were calculated with data collected from the registration book of a health centre.
I wouldn't swear that the cases reported were rightly scurvy and xerophtalmia. But in case they were, I wanted to know if actions had do be taken.
The answer is clearly Yes: health staff have to be trained for the recognition of the diseases, a reliable surveillance system must be implemented, and may be a survey should be conducted. Then, control measures will have to be taken if the cases are confirmed.
In addition, as many of you wrote, vitamin deficiencies are indicative of a major problem in the population and an investigation could point out the poor health status of the people living in this area.

The low proportion of children with xerophtalmia might be explained by the administration of vitamin A caps to under 5 children during immunisation campaigns . I don't know the vitamin A coverage in the area where the data were collected but I am very sceptical about the impact of campaigns in remote areas, in countries where human and logistics means are not available. More probably, children have a lower access to health facilities than adults.

Anyway, thank you very much for your assistance. I will let you know how things progress.


Pierre Nabeth

Date: Fri, 11 Sep 1998 17:50:10 -0400
From: dalnwickatunicef.org (David Alnwick)
Subject: Re[2]: Ngonut: [Fwd: Xerophtalmia and scurvy]

A short answer to the earlier question raised on the network about the proportion of children in Mauritania receiving vitamin A supplements:

"According to survey results from Mauritania available to UNICEF New York, Mauritania included vitamin A and measles in their 1997 (March) National Immunisation Days (NIDS) as well as in 1998 (March) NIDS for which UNICEF provided assistance. Coverage for Oral Polio Vaccine in the NIDS was 90% in 1997 for the round which included vitamin A. The vitamin A coverage in 1997 was around 82% (based on calculations from data available on OPV coverage and number of children immunized and children receiving vitamin A). Figures for 1998 not yet available but likely to be comparable."

David Alnwick
Chief, Health Section
Programme Division
UNICEF Headquarters
New York