EPIDEMIOLOGI KVA(Vitamin A Deficiency Epidemiology)

Nutritional Epidemiology LectureTopic 8

Epidemiology)

Azrimaidaliza, SKM, MKM Public Health Science Program Study-Majoring Nutrition Public HealthMedical Faculty Andalas University Padang - West Sumatera

PREFACEn Kurang Vitamin A (KVA) merupakan salah

satu masalah gizi kurang yang masih dihadapi oleh negara-negara berkembang termasuk Indonesiatermasuk Indonesia

n KVA à suatu keadaan, ditandai rendahnya kadar Vitamin A dalam jaringan penyimpanan (hati) & melemahnya kemampuan adaptasi terhadap gelap & sangat rendahnya konsumsi/masukkan karotin dari Vitamin A (WHO, 1976)

MAP OF VITAMIN A DEFICIENCY (VAD) IN THE WORLD.1

Figure 1. Countries categorized by degree of public health importance of Vitamin A deficiency, April 1995, WHO

MAP OF VITAMIN A DEFICIENCY IN THE WORLD.2

Source : KP West J Nutr. 2002 in Keith P. West, Jr., Professor Center for Human Nutrition Johns HopkinsBloomberg School of Public Health Baltimore, Maryland, April 16th, 2007

DATA WHO

n Setiap tahun à 3-10 juta anak menderita xeroftalmia dan 250.000 – 500.000 anak menjadi butaà menyebabkan dediferensiasi;

keratinisasi sel epitel, perubahan nafsu makan; xerofthalmia

Source : KP West J Nutr. 2002 in Keith P. West, Jr., Professor Center for Human Nutrition Johns HopkinsBloomberg School of Public Health Baltimore, Maryland, April 16th, 2007

Source : KP West J Nutr. 2002 in Keith P. West, Jr., Professor Center for Human Nutrition Johns HopkinsBloomberg School of Public Health Baltimore, Maryland, April 16th, 2007

BESARAN MASALAH KVA DI DUNIA

MATERNAL VITAMIN A DEFICIENCY IN THE WORLD

n Maternal Vitamin A Deficiency : ~10% of women develop develop night blindness in latter half of pregnancy in poorly nourished South Asian populations

Maternal night blindness = VA Deficiency(that can directly affect mother & infant)

n 40-day male India infant with keratomalacia (X3B), unable to open eyes~3 days after birth. Eyes responded to VA treatment. Mother had history of night blindness throughout pregnancy.

Source : M Gupta et al Indian J Pediatr 2005;72:881 Keith P. West, Jr., Professor Center for Human Nutrition JohnsHopkins Bloomberg School of Public Health Baltimore, Maryland, April 16th, 2007

PERKEMBANGAN KVA DI INDONESIA

n A nutrition survey conducted in Indonesia in early 1970s à the prevalence of VAD was very high.Indonesia à one of the first developing n Indonesia à one of the first developing countries to identify that high levels of severe VAD constituted a serious public health problem & began to implement programs to eliminate the problem since the 1970s (HKI, 2000).

CONTINUED…n Since 1970s-1990s, Indonesia embarked

on a nation-wide vitamin A intervention program by providing high-dose vitamin A capsule twice a year to almost all under-five children. five children.

n Within 2 decades, the program àsuccessfully reduced the clinical prevalence of VAD (xeropthalmia) to 0,33% in 1992, a level in which VAD was no longer considered as a public health problem.

PREVALENSI KVA DI INDONESIA

No. Klasifikasi Tahun

1978 1992

1. X1B = Bercak bitot2. X2/X3 = Xerosis kornea/keratomalasia3. XS = Parut kornea

1,3 0,3327,7 018,0 0

ØSejak tahun 1992 à Indonesia bebas xeropthalmia à 60 ribu anak balita disertai gejala

CONTINUED…

à 60 ribu anak balita disertai gejala bercak bitot (X-1b : Prevalensi 0,33%) (SUVITA,1992)Tidak merupakan masalah kesmas

à Namun masih dijumpai 10 juta anak balita menderita KVA sub klinis (50% balita : serum retinol

CONTINUED…

klinis (50% balita : serum retinol <20 µg/100 ml)

n > 1992 à Tidak ada data nasionalprevalensi KVA

n Tingginya proporsi balita dengan serum retinol <20 mcg/100 ml àberisiko tinggi u/ terjadinya xeropthalmia & me↓ tingkat

CONTINUED…

xeropthalmia & me↓ tingkat kekebalan tubuh à mudah terserang penyakit infeksi

kapsul vitamin A dosis tinggi

n Tahun 1998 à Survei HKI daerah kumuh

perkotaan à masalah KVA

CONTINUED…

perkotaan à masalah KVA muncul kembali

n What is the current magnitude of VAD prevalence in Indonesia is difficult to speculate.

n Di Indonesia à ada laporan lisan dari beberapa propinsi à timbul kembali kasus-kasus

CONTINUED…

à timbul kembali kasus-kasus xerophthalmia

à di NTB ditemukan kasus stadium X3 à anak menjadi buta

KLASIFIKASI KVA (Xeroftalmia)

XN : Buta SenjaX1A : Xerosis konjungtivaX1B : Bercak bitotX2 : Xerosis korneaX2 : Xerosis korneaX3A : Ulkus kornea dengan xerosisX3B : KeratomalasiaXS : Xeroftalmia scarsXF : Xeroftalmia fundus

Sumber : Depkes RI & HKI, 2002

WHO Xerophthalmia Classification (1982)(Sommer & Davidson. J Nutr 2002)

n XN Night blindness (>1%) *n X1B Bitot’s spots (> 0.5%)n X2 Corneal xerosis orn X2 Corneal xerosis orn X3 Corneal ulceration/

Keratomalacia (> 0.01%)n XS Corneal scarring (> 0.05%)

Serum retinol (>15%)(<.70 umol/L/20 ug/dL)

*WHO minimum criteria for public health significance

Continued…

n Plasma Vit.A < 0,35 µmol/l (10 µg/dl) : > 5%Plasma Vit.A < 20 µg/dl Plasma Vit.A < 20 µg/dl à rawan terhadap

penyakit infeksi & me↑ mortalitas

n Liver Vit.A < 5 µg/g : > 5%

Sumber : Depkes RI & HKI, 2002

CAUSES OF NIGHTBLIND WOMEN

Source : Christian et al: Int J Epidemiol 1998; Eur J Clin Nutr 1998; Am J Clin Nutr 1998; Soc Sci Med 1998; Am J Epidemiol 2000; J Nutr 2002; Katz et al, J Nutr 1995; Semba et al 2003

PENYEBAB KVA

ASUPAN KVA

EXPOSURE OUTCOME

ASUPAN VITAMIN A ↓ KVA

PENYEBAB KVA :

KURANG PENGETAHUAN &

KEPERCAYAAN

KEADAAN EKONOMI

NAFSU MAKAN HILANG

ASUPAN VIT. A RENDAH

KVAHILANG

PELARUT VIT. A RENDAH

KEP

PENYAKIT INFEKSI

ABSORBSI & UTILISASI VIT. A

KVA

PENYEBAB TIDAK LANGSUNG

PENYEBAB LANGSUNG

CONTINUED…

n Deplesi Vitamin A dalam tubuh àproses lama

n Dimulai dengan persediaan Vit. A dalam hati habis à kadar Vit. A plasma me↓ à disfungsi retina à perubahan jaringan epitel

Source : KP West in Semba & Bloem 2007, Johns Hopkins Bloomberg School of Public Health Baltimore, Maryland, April 16th, 2007

Sumber : Depkes RI & HKI, 2002

Sumber : Depkes RI & HKI, 2002

CONTINUED…

n Bayi prematur à Cadangan Vit.A dalam hati rendah

n Konsumsi alkohol & m’derita sakit n Konsumsi alkohol & m’derita sakit liver à hati rusak à tidak mampu menyimpan banyak Vit. A

n Obat-2an yang merubah absorpsi lemak menghambat absorpsi Vit. A

n Penderita diare kronik, Chron’s disease atau tidak cukup pankreas & kondisi malabsorpsi lemak

n Di USA à KVA terjadi pada penderita

CONTINUED…

n Di USA à KVA terjadi pada penderita sindrom malabsorpsi lemak/diet ketat spt anorexia nervosa

n Intake Zn tidak adekuat à simptom KVA krn Zn dibutuhkan u/ p’gunaan Vit.A secara efisien

PENENTUAN KADAR VIT.A

n Apabila terdapat kelainan mata àkadar vitamin A serum (< 5 µg/100 ml) & kadar RBP (< 20 µg/100 ml) sudah sangat rendahsudah sangat rendah

n Konsentrasi Vit.A dalam hati àindikasi yang baik u/ menentukan status Vit.A

n Biopsi hati à tindakan yang mengandung risiko bahaya

n Penentuan kadar Vit. A jaringan

CONTINUED…

tidak mudah dilakukan n Konsentrasi Vit.A penderita KEP

rendah < 15 µg/gram jaringan hepar (Pujiadji, 1989)

BATASAN & INTERPRETASI PEMERIKSAAN KADAR VITAMIN A DALAM DARAH

UMUR (TAHUN) DEFISIENSI MARGIN CUKUP

Semua Umur < 10 µg/dl 10-20 µg/dl >20 µg/dl

DAMPAK KVA PADA BALITA

n 1 diantara 2 (48,1%) dari balita yg menderita KVA à menderita anemia kurang zat besi (SKRT, 2001)(SKRT, 2001)

n Anak-2 yang KVA pada derajat sedang berisiko tinggi untuk mengalami gangguan pertumbuhan (Hadi et. al., 2000),

n Di samping itu à menderita beberapa penyakit infeksi seperti campak & diare

CONTINUED…

seperti campak & diare n KVA bertanggung-jawab

terhadap 23% kematian anak balita di seluruh dunia (Beaton, 1997)

EVALUASI PROGRAM PENANGGULANGAN KVA

n Konsumsi sayur & buah berwarna à sangat penting, agar tidak tergantung pada kapsul Vitamin Atergantung pada kapsul Vitamin A

n Kasus xeropthalmia à p’yuluhan kons. sayur & buah tidak efektif & cakupan kapsul Vitamin < 80% àlaporan bbrp propinsi (NTB, Sumsel) th 2000 & me↑ morbiditas pada balita

Vitamin A Intake of Children 12-59 months of age in Rural West Sumatera (Survey HKI, 2003)

n Dietary intake of vitamin A àimportant indicator of whether or not a chronic problem of VAD is likely to exist & indicates the need for exist & indicates the need for interventions to control VAD.

n The severest forms of VAD à in terms of clinical symptoms, which include night blindness, ulceration of the cornea & full blindness.

CONTINUED….

n 70% of children was estimated blinded by VAD will die within the year, & mortality rates 3-26% have been observed among children with corneal disease.

n Long before eye damage can be observed, other body functions are impaired

n This includes immune function, which leads to increased morbidity & mortality, often even before the clinical eye signs of VAD have been

CONTINUED….

clinical eye signs of VAD have been observed.

Data Collection Methodn The 24-hour Vitamin A Semi-Quantitative

(VASQ) method developed by HKI was used to assess total VA intake for a 20% sub sample of households.

n Mothers were asked to recall everything their child ate or drank in the last 24 hours, & details about portion sizes & cooking methods were recorded.

n Vitamin A intake was estimated based on portionsize and vitamin A content of the food.

Findings:

nGeneral - Vitamin A intake was well below the Indonesian Recommended Daily Intake and has improved little over time. over time.

nWest Sumatra - Vitamin A intake in West Sumatra was no more than one-third of the Recommended Daily Intake for children

Gambar. Asupan Vitamin A Anak Usia 12-59 bln di Pedesaan Sumatera BaratSumber : HKI, 2003

Vitamin A Capsule Coverage among Children 6-59 Months of Age in Rural West Sumatra (Survey HKI, 2003)

n In recognition VAD as a public health problem, the government of Indonesia has set a target of 80% coverage with has set a target of 80% coverage with vitamin A capsules (VAC) among children 6-59 months of age12.

n All children in this group are to receive age appropriate doses of vitamin A twice a year.

CONTINUED….

n As there are two VA campaign distribution months each year (February & August), the achievement of this goal can be evaluated by estimating the level of evaluated by estimating the level of coverage for each

IMPORTANCE

n Supplementation with VAC has been shown to reduce clinical symptoms of VAD such as xeropthalmia and to reduce morbidity, mortality, and reduce morbidity, mortality, and blindness rates among children. In Indonesia, a 34% reduction in mortality was observed among children supplemented with VAC

CONTINUED…..

n A meta analysis of eight mortality trials indicated that improving VA status among children 6-59 monthsstatus among children 6-59 monthsof age reduces all-cause mortality by 23%

Findings:n General - Vitamin A capsule coverage has

increased considerably, reaching the target of 80% coverage in August 02 and February 2003.

n West Sumatra - VAC coverage increased from West Sumatra - VAC coverage increased from August 1999 to February 2002, but modestly.

n Highest coverage was still below 60% in both age groups, which is much below the target of 80%. No information is available for after February 2002.

Gambar. Pemberian Kapsul Vitamin A Anak Usia 6-59 bln di Pedesaan Sumatera Barat

Sumber : HKI, 2003

Total Vitamin A Intake among Non- Pregnant Mothers in Rural West Sumatera

n Low total dietary vitamin A (VA) intake among populations where food consumption is the predominant source of VA indicates that vitamin A deficiency is VA indicates that vitamin A deficiency is likely to exist.

Importance:

n Importance: VAD has the same consequences for the mother as the child.

n These include increased morbidity and severity of illness, exacerbated

n anemia, and blindness and death (refer to Total Vitamin A Intake among Children 12-59 Months).

CONTINUED….

n However, maternal deficiency has the added consequence of contributing to the poor health status of the newborn.

n One study in rural Nepal found an increased n One study in rural Nepal found an increased mortality rate of 63% among infants of night blind women.

n Furthermore, VAD among lactating women lowers the VA concentration of breast milk, which can lead to a VAD among breastfed infants.

Data Collection Method

n The 24- hour Vitamin A Semi- Quantitative (VASQ) method was used to assess total VA intake for a 20% sub sample of households.

n Mothers were asked to recall everything they ate Mothers were asked to recall everything they ate or drank in the last 24 hours, and details about portion sizes and cooking methods were recorded.

n Vitamin A intake was estimated based on portion size and vitamin A content of the food

Findings:n General - Vitamin A intake among nonpregnant

mothers was less than half of the Indonesian Recommended Daily Intake (even less for mother that are lactating since their RDI is higher) for every rural province in every round of higher) for every rural province in every round of data collection.

n West Sumatra – Vitamin A intake in West Sumatra was no more than 40% of the Recommended Daily Intake for non-pregnant, nonbreastfeeding women.

E-mail Contact :n Minda_azri@fk.unand.ac.idn uniminda@yahoo.com