E-drug: Vitamin A and child deaths in India (cont)
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[With reference to previous postings, 25 November 2001, 6 February 2002, a
letter and an electronic response from BMJ this week. Copied as fair use.
KM]
[Report provided by Moderator Kirsten Myhr - Thank you Kirsten. BS]
BMJ 2002;324:791 ( 30 March )
Letters
Vitamin A programme in Assam probably caused hysteria
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 weekfar 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 effectsfar 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.
Keith P West Jr, professor.
kwest@jhsph.edu
Alfred Sommer, professor.
Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD,
21205, USA
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1. Mudur G. BMJ.com news roundup. Deaths trigger fresh controversy over
vitamin A programme in India. BMJ 2001; 323: 1206[Full Text]. (24 November.)
2. Sommer A, West Jr KP. Vitamin A deficiency: health, survival and vision.
Oxford: Oxford University Press, 1996.
3. Unicef. The state of the world's children 2001early childhood. New York
City: Unicef, 2000.
4. Florentino R, Tanchoco CC, Ramos AC, Mendoza TS, Natividad EP, Tangco
JB, et al. Tolerance of preschoolers to two dosage strengths of vitamin A
preparation. Am J Clin Nutr 1990; 52: 694-700[Abstract].
5. Agoestina T, Humphrey JH, Taylor GA, Usman A, Subardja D, Hidayat S, et
al. Safety of one 52-mumol (50,000 IU) oral dose of vitamin A administered
to neonates. Bull WHO 1994; 72: 859-868[Medline].
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Can Mass Hysteria Kill? 29 March 2002
Prabir K Chatterjee,
Surveillance Medical Officer
Godda-814133 India
Email: godda@vsnl.net
While one accepts that Vitamin A may not have caused even one death in
Assam, it is obvious that the public no longer accept the programme. Even
the doctor-professor who heads the Union Ministry was not willing to stand
up for the huge mass Vitamin A administration campaign. There were deaths.
Was any investigating team able to state what caused the deaths? No child
death is "natural" surely. The question that goes begging an answer is: If
there are so many deaths in a few days, shouldn't the donors and the
government be addressing the current causes of death. public health
programmes can be piggy backed on a good health service. But should a lot of
money be spent in forcing Hospital Staff to leave their curative work?
[Report provided by Moderator Kirsten Myhr - Thank you Kirsten. BS]
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