Rapid Assessment and Delivery of Vitamin A to Slum Children by Using National Immunization Day in Chandigarh H.M. Swami, J.S. Thakur, S.ES. Bhatia and Ramnik Ahuja
Department of Community Medicine, Government Medical College & Hospital, Chandigarh-160047, India Abstract. This study was done with the objective to see the feasibility of using National Immunization Days (NIDs) for rapid assessment, and delivery of Vitamin A solution to about 27,600 children dwelling in 26 slums in Union Territory of Chandigarh. The assessment of Vitamin A deficiency (VAD) was done in a stratified random sample of 1304 children during third round of Intensified Pulse Polio Immunization (IPPI) and delivery of Vitamin A solution was done during fourth round of IPPI in 1999-2000 covering 27642 children in the age group of 1-5 years. An additional team of two persons per centre delivered age specific doses of Vitamin A solution through 72 centres and operational problems were recorded. IPPI staff provided supervision and same tally sheets as of IPPI were used. The prevalence rate of VAD was 24.6%, with conjunctival xerosis, bitot's spot and corneal xerosis as 23.7%, 0.6% and 0.2% respectively. 27275 (98.7%) children out of 27642 were administered Vitamin A solution, with no major operational problem. Only five parents (0.01%) refused Vitamin A solution. No case of side effect or toxicity due to Vitamin-A was reported. The strategy to assess and deliver Vitamin A during NID's was found to be feasible and successful and could be a basis for launching similar initiatives in other areas of India and other countries where VAD is a public health problem. [Indian J Pediatr 2001; 68 (8) : 719-723]
Key words : National Immunization Day; Vitamin-A deficiency; Prevalence; Supplementation Vitamin-A deficiency (VAD) in an important public health problem in approximately 118 countries including India. It contributes to about 2% of cases of total blindness in the country, which is preventable. According to an estimate, 30,000-40,000 children may lose their eyesight due to VAD in India each year with another 50,000-100,000 becoming partially blind (UNICEF, 1986). Nearly 8% of the children in India show an apparent occular sign and s y m p t o m s of xerophthalmia. A recent estimation of the magnitude of the problem world wide reveals that 25-50 million children may be suffering from physiological consequences of Vitamin-A deficiency with 0.5 million of them developing xerophthalmia annually. R e d u c i n g VAD r e q u i r e s a mix of strategies. Although Vitamin-A supplementation is a short term strategy, b u t still has an immense impact. This is further enhanced by the fact that in VAD endemic areas, 23-24% reduction in young child mortality 1and
50% in measles mortality is expected when Vitamin-A status is raised to normal. 2 Each year r o u t i n e immunization programme reaches about 80% of the world children, offering one of the best opportunities for distributing Vitamin-A s u p p l e m e n t . With the global effort to eradicate polio, National Immunization Days (NIDs) provide an additional opportunity to reach children with Vitamin-A. As it is k n o w n , Vitamin-A supplementation is one of the most costeffective health interventions. A single Vitamin-A supplement given during NIDs has the potential to improve substantially the Vitamin-A status of children. When the correct dosage is given, Vitamin-A is safe and has negative effect on seroconversion rates for OPV. 3 With this background, the present study was u n d e r t a k e n to use NIDs to screen and assess the Vitamin-A status of the underfive children and to d e l i v e r Vitamin-A s o l u t i o n to them in s l u m s of Chandigarh.
Reprint requests : Dr. HM Swami, Prof. and Head Deptt. of Community Medicine Govt. Medical College and Hospital, Chandigarh - 160047. Fax No. 0172-609360.
MATERIALS AND METHODS
Indian Journal of Pediatrics, Volume 68---August, 2001
Chandigarh is a city of most modern architectural splendour and has acquired the enviable reputation 719
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of being the "City Beautiful" with a population of 9 lakhs. The city has been conceived as a living organism with close parallelism of functions. It became a Union Territory in 1966 and has over the years been an epicentre of business, education and job opportunities. As a result of which, last few years has seen influx of migrant population from other parts of the country. These people have settled d o w n in mushroom settlements giving rise to slums in Chandigarh, which are n u m b e r e d 26 and still increasing. These slums have minimal basic amenities and health status of the people residing there is very poor. Assessment of Vitamin-A status was done during third round of Intensified Pulse Polio Immunization (IPPI) (19 December, 1999) in a stratified random sample of 1300 children selected randomly from nine slums of Chandigarh and from each slum, one IPPI booth was selected randomly. After administration of OPV drops, every third child was examined and assessed for Vitamin-A status by using a simple predesigned and pretested proforma containing data about age, sex, Vitamin-A status and episodes of ARI, diarrhoea in the last one month. An additional team consisting of at least one doctor and one medical social worker was used for data collection, which was specifically trained for the purpose through lectures, audiovisual aids by showing slides on various stages of VAD besides practical demonstration on 3-4 cases. Vitamin-A deficiency was assessed as per W H O classification. 4 M a s s d i s t r i b u t i o n of V i t a m i n - A s o l u t i o n w a s organized during fourth round of IPPI starting from 23 January, 2000 and all 27642 children in the age group of 1-5 years in 26 slums of Chandigarh were included, hence no need of sampling. Children below one year were excluded as decided in a high level meeting including UNICEF representatives before launching of initiative, because of operational considerations since this activity was being organised for the first time in India. Information Education and Communication (IEC) activities were started one month in advance in the area along with IPPI in a fully intergrated manner. P a r e n t s w e r e i n f o r m e d a b o u t VAD (Rataundi in Vernacular) as a p u b l i c health p r o b l e m , its consequence and therefore, the need for undertaking this activity. Hence the parents were made fully aware, consented and volunteered for Vitamin-A solution to their children. All these children w e r e then given Vitamin-A solution (200,000 IU) through 72 IPPI centres b y an additional team of two trained persons per IPPI centre, of these two persons, one was an MBBS student from local medical college and other volunteers from local 720
degree college. First day was a booth-based activity and on second and third days, house to house visits were undertaken. Any child who spitted out VitaminA solution was again administered OPV drops but was not given Vitamin-A solution again. Supervision during the campaign was provided b y routine IPPI staff besides the investigators. A simple tally sheet was used to record the total number of doses of Vitamin-A administered. Another p r e d e s i g n e d and pretested proforma was used and filled up at the end of day by medical students about the operational problems and side effect due to Vitamin-A, encountered b y them. The health institutions of the intervention area were requested to report any case of side effects/toxicity due to Vitamin-A through passive reporting and verified by project team and for this purpose doctors, health w o r k e r s and anganwari w o r k e r s of the area w e r e trained before launching of the initiative. RESULTS
A total of 1304 children were examined for Vitamin-A status, out of which 321 cases of VAD were found giving a prevalence rate of 24.6%. Conjuctival xerosis was the most common sign in 23.7% of the children, with bitot's spots (XIB) and corneal xerosis (X2) in 0.6% and 0.2% children respectively (Table 1). It was observed that VAD was a public health problem amongst the preschool slum children of Chandigarh as per W H O criteria. There were 27642 beneficiary children in 1-5 years age g r o u p , 27275 of t h e m w e r e given Vitamin A solution giving coverage rate of 98.7% with 82.8%, 13.8% and 2.1% children respectively covered on first, second & third days of IPPI. The operational problems expressed by staff in Vitamin-A distribution were : ten per cent of the staff told that it takes a lot of time and there was a problem of long queues. Only five (0.01%) parents refused Vitamin-A solution to the children with three due to non-awareness and one each did not feel the need and in one already given. Many (85.0%) co-ordinators told that children were not accompanied b y parents, instead were with neighbours. Only 91 (0.3%) children sp~tted out Vitamin-A solution which w e r e again g i v e n OPV drops. N o n e of the child vomited out and reported any side effects or toxicity such as fever, nausea and vomitting due to Vitamin-A. During supervisory visit on first day, it was observed that the surface of tables and hands of the staff had become oily which was rectified by providing paper napkins. The problem of disposal of partially used Vitamin-A solution bottles, and collection and cleaning of plastic spoons were also observed.
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Rapid Assessment and Delivery of Vitamin A to Slum Children TABLE1. Distribution of Xerophthalmia Among Preschool Children in Different Slums of Chandigarh
SI. No.
1. 2. 3. 4. 5. 6. 7. 8. 9.
Area
No of Preschool Children Screened
Madrasi Colony Palsora Colony Janta Colony Peer Colony Hallo Majra Pandit Colony Kumhar Colony Indira Avas Colony Colony No. 4 Total
Record of all Abnormalities Present
Total
XN
136 80 142 48 246 196 188 100 168 1304
0 0 0 0 0 0 0 0 0 0
Figures in Parenthesis are Percentages.
XIA 49 21 62 4 42 25 52 25 30 310 (23.7)
XN = Night blindness XIA = Conjunctival xerosis
DISCUSSION Vitamin-A supplementation is the easiest intervention to add to NIDs and requires a m i n i m u m of training and equipment, s As per WHO, Vitarnin-A delivery and NID's can be combined because the target population of under five-year-olds are same; nation wide campaign reached the "unreached" and those most at risk; limited human and financial resources were used efficiently and cost effectiveness and impact were increased, s The strategy of using NIDs to assess and deliver Vitamin-A in the slum areas of Chandigarh was found to be feasible as the programme could achieve a coverage of 98.7%, setting up an example of good coordination between health services and an academic institution to fight a public health problem. Similarly, NID (January 18, 1997) had been successfully utilized by the authors in the past to assess the nutritional status of underfive children in Chandigarh 6 and prevalence of malnutrition was found to be very high (42%). Project was well received at every level including grass root level health workers as neither Vitamin-A staff reported non-cooperation by IPPI staff nor IPPI staff reported hampering of their activity anyway. As per our experience, inclusion of VitaminA to NIDs has no adverse effect on polio eradication effort. Supervisory and IEC activities were fully integrated with IPPI and were effectively utilized for delivery of Vitamin-A solution. The programme got excellent media coverage and social mobilization. Vitamin-A solution was well accepted by children as no child vomitted out and low spit out (0.3%) rate. Since polio drops were administered first, followed by Vitamin-A solution, hence no problem in acceptance of Indian Journal of Pediatrics, Volume 68---August, 2001
XIB
X2
X3
1 0 2 0 2 1 2 0 0 8 (0.6)
0 1 2 0 0 0 0 0 0 3 (0.2)
0 0 0 0 0 0 0 0 0 0
Total 50 22 66 4 44 26 54 25 30 321
(36.7) (27.5) (46.5) (8.3) (17.8) (13.2) (28.7) (25.0) (17.8) (24.8)
X1B = Bitot's spots; X2=Corneal xerosis X3=Corneal ulceration
polio drops. The polio drops were administered again if child spitted out but no Vitamin-A solution was given. No case of side effects/toxicity was found and not even reported by doctors, health workers and anganwari workers working in health institutions of intervention area in first round. Similarly neither any case of toxicity was r e p o r t e d in a s a m p l e of 101 children nor through passive reporting during second round held on 10th December, 2000. We could not encounter any study which could show the previous experience with this strategy in the world. However, linking of Vitamin-A with IPPI provided different experiences in the states of Orissa and Uttar Pradesh with high coverage rates for the former because of proper planning and support and poor coverage for the latter where it was lacking. In Orissa, risk of i m m e d i a t e side effects attributable to Vitamin-A administration, such as fever, nausea and vomitting, was similar in children who received Vitamin-A with oral polio vaccine with those who did not (about 3%) (Ministry of Health and Family Welfare, Govt. of India, unpublished data). However, unequivocal evidence does not exist on possible long term consequences of increased intra cranial pressure (presenting as bulging fontanel). With experience, the time taken to administer Vitamin-A reduced as told by staff. Long queues at some places were observed but may be due to behavioural pattern in slums as people generally come out in groups. Based on our experience it is recommended that provision of paper napkin to clean spillage which had occurred at some of the booths, reuse of plastic spoons after proper cleaning in CSSD of hospitals and provision of large disposable polythene bags should be made in subsequent rounds. 721
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Expecting that addition of Vitamin-A to NIDs may increase the workload at an immunization post, so we have made arrangements for extra workers per team to ensure smooth flow and avoid delays. However, with o u r experience, it w a s f o u n d that V i t a m i n - A distribution can be undertaken b y IPPI staff only, without any additional staff with proper training. We did not face any logistics problem as supplies were made available by UNICEF well in time. It is also worthwhile to mention here that routine Vitamin-A distribution under national programme is being done as usual in Chandigrah. However, good planning and co-ordination with local health services is essential for the successful integration of Vitamin-A s u p p l e m e n t a t i o n in NIDs. It is not necessary that p r o g r a m m e is taken up at national scale. Rather it should be area, region or state specific, where VAD is a public health problem. Some key steps before embarking on such strategy are : Check if your state or region has a VAD. Explain the importance of Vitamin-A to decision makers and get agreement to add Vitamin-A supplementation during NIDs. Engage partners for support if possible. Inform and educate the public and all level of staff. Check supplies and arrange logistics through national p r o g r a m m e or partners, which can be best handled by the same team that is managing the logistics for the vaccine supplies. Train health workers and volunteers, their supervisors, and others involved in NIDs how to give Vitamin-A along with training for NIDs. Evaluation of success can be achieved by calculating the Vitamin-A coverage achieved (from tally sheet) and assessing the quality of service achieved at each post by providing observers and supervisors with checklist during the campaign. The prevalence of VAD as 24.6% in this s t u d y is comparable to 23-34.8% reported from rural school children b y others. :,g Indian diet is also p o o r in Vitamin-A and one of study had reported adequate Vitamin-A in only 8-12% of the c h i l d r e n as p e r recommended level. 7 A study done in nine states of India to assess causes of childhood blindness had found that VAD deficiency was still responsible for 26.4% cases of childhood blindness. 9 Although there is a National p r o g r a m m e for Vitamin-A prophylaxis against blindness in children due to VAD in India w h i c h is a part of R e p r o d u c t i v e & Child H e a l t h Programme, b u t the r e p o r t e d Vitamin-A supplementation coverage rate (6-59 months) was only 25%. 1~Similar situation was prevailing in Chandigarh as about 42% children had received no dose, 30% had one and 23% had two doses respectively out of 735 children surveyed in 1996.11 According to WHO, if routine coverage with Vitamin-A supplements is less than 80%, then Vitamin-A supplements should be 722
included with supplementary immunization activities. 3 Therefore, due to poor dietary intake of Vitamin-A, still high p r e v a l e n c e of VAD, m a l n u t r i t i o n and c h i l d h o o d b l i n d n e s s d u e to VAD, b e s i d e s p o o r c o v e r a g e b y national p r o g r a m m e , the linking of Vitamin-A s o l u t i o n w i t h NIDs a p p e a r s to be an appropriate step as an alternative strategy and could be a basis for launching of similar initiative in other parts of India and in others countries where VAD is a public health problem. H o w e v e r , for sustainable elimination of VAD, production and consumption of Vitamin-A rich foods must be strongly promoted in the community and a holistic approach should be adopted for combating nutritional deficiencies as multiple nutritional problems coexist in the same population. This is a continuing study, where in children would be followed up for morbidity episodes till the second round, which will be held later this year in December, 2000.
Acknowledgement Authors express their heartfelt thanks to UNICEF, India country office for giving financial and logistic support to this initiative and Dr. K Suresh, Project Officer, Health Section UNICEF for his help and keen interest. We are grateful to Dr. VK Kak, Director Principal, Govt. Medical College and Hospital, Chandigarh for coordination for such a difficult and vast project. We are also thankful to Chandigarh Administration, health department, Union Territory Chandigarh and staff of department of Community Medicine for their help. We also acknowledge the contribution made by all supervisory and field staff of IPPI, NSS volunteers and local medical students.
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Rapid Assessment and Delivery of Vitamin A to Slum Children I m m u n i z a t i o n - U s i n g NID to deliver Vitamin A. EPI u p d a t e 33, 1998. 6. Swami HM et al. National Immunization Day to assess nutritional status of underfives in Chandigarh. Indian J Pediatr 2000; 67 (1) : 15-17, 7. Khamgaonakar MB et al. Vitamin-A intake and Vitamin A deficiency in rural children. Indian Pediatr 1990; 27 : 443-446. 8. Singh MC, Gagane N, Murthi GV et al. Evaluation of Vitamin A status by confuctival impression cytology
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among school age population. Indian Pediatr 1993; 30 : 1085-1089. 9. Rahi JS et al. Childhood blindness in India : Causes in 1318 blind school children in nine states. Eye 1995; 30 : 1085-1089. 10. Bellamy C. Nutrition Indicators. In The State of the World Children 2000. UNICEF; 2000 : 88-91. 11. Swami HM, Bhatia V, Bhatia SPS et al. Existing M C H services in rural area of Chandigarh. Indian J Corn Med 1997; 22 : 110-113.
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