Determinants of vitamin a deficiency in children between 6 months and 2 years of age in Guinea-Bissau

Niels Danneskiold-Samsøe, Ane Bærent Fisker, Mathias Jul Jørgensen, Henrik Ravn, Andreas Andersen, Ibraima Djogo Balde, Christian Leo-Hansen, Amabelia Rodrigues, Peter Aaby, Christine Stabell Benn, Niels Danneskiold-Samsøe, Ane Bærent Fisker, Mathias Jul Jørgensen, Henrik Ravn, Andreas Andersen, Ibraima Djogo Balde, Christian Leo-Hansen, Amabelia Rodrigues, Peter Aaby, Christine Stabell Benn

Abstract

Background: The World Health Organization (WHO) classifies Guinea-Bissau as having severe vitamin A deficiency (VAD). To date, no national survey has been conducted. We assessed vitamin A status among children in rural Guinea-Bissau to assess status and identify risk factors for VAD.

Methods: In a vitamin A supplementation trial in rural Guinea-Bissau, children aged 6 months to 2 years who were missing one or more vaccines were enrolled, vaccinated and randomized to vitamin A or placebo. Provided consent, a dried blood spot (DBS) sample was obtained from a subgroup of participants prior to supplementation. Vitamin A status and current infection was assessed by an ELISA measuring retinol-binding protein (RBP) and C-reactive protein (CRP). VAD was defined as RBP concentrations equivalent to plasma retinol <0.7 μmol/L; infection was defined as CRP >5 ml/L. In Poisson regression models providing prevalence ratios (PR), we investigated putative risk factors for VAD including sex, age, child factors, maternal factors, season (rainy: June-November; dry: December-May), geography, and use of health services.

Results: Based on DBS from 1102 children, the VAD prevalence was 65.7% (95% confidence interval 62.9-68.5), 11% higher than the WHO estimate of 54.7% (9.9-93.0). If children with infection were excluded, the prevalence was 60.2% (56.7-63.7). In the age group 9-11 months, there was no difference in prevalence of VAD among children who had received previous vaccines in a timely fashion and those who had not. Controlled for infection and other determinants of VAD, the prevalence of VAD was 1.64 (1.49-1.81) times higher in the rainy season compared to the dry, and varied up to 2-fold between ethnic groups and regions. Compared with having an inactivated vaccine as the most recent vaccine, having a live vaccine as the most recent vaccination was associated with lower prevalence of VAD (PR=0.84 (0.74-0.96)).

Conclusions: The prevalence of VAD was high in rural Guinea-Bissau. VAD varied significantly with season, ethnicity, region, and vaccination status.

Trial registration: Clinicaltrials.gov NCT00514891.

Figures

Figure 1
Figure 1
Map of regions in Guinea-Bissau. Villages included in the study marked as dots.
Figure 2
Figure 2
Vaccine schedule in Guinea-Bissau. Consisting of BCG vaccine, oral polio vaccine (OPV), diphtheria-tetanus-pertussis (DTP), and measles vaccine (MV). In September 2008 DTP was exchanged for diphtheria-tetanus-pertussis-Hepatitis B-H. Influenzae (Pentavalent) vaccine and yellow fever vaccine was introduced to be given together with MV. wk: weeks, mo: months.
Figure 3
Figure 3
Prevalence of VAD by month in Guinea-Bissau. Number of samples tested indicated in the lower part of each bar.

References

    1. WHO. Global prevalence of vitamin A deficiency in populations at risk 1995–2005. Geneva; 2009. .
    1. Humphrey JH, West KP Jr, Sommer A. Vitamin A deficiency and attributable mortality among under-5-year-olds. Bull World Health Organ. 1992;70:225–232. .
    1. Sommer A, Davidson FR. Assessment and control of vitamin A deficiency: the Annecy Accords. J Nutr. 2002;132:2845–2850. .
    1. WHO. Indicators for assessing vitamin A deficiency and their application in monitoring and evaluating intervention programmes. Geneva; 1996. .
    1. Benn CS, Aaby P, Balé C, Olsen J, Michaelsen KF, George E, Whittle H. Randomised trial of effect of vitamin A supplementation on antibody response to measles vaccine in Guinea-Bissau, west Africa. Lancet. 1997;350:101–105. doi: 10.1016/S0140-6736(96)12019-5. .
    1. Fujita M, Brindle E, Shofer J, Ndemwa P, Kombe Y, Shell-Duncan B, O'Connor KA. Retinol-binding protein stability in dried blood spots. Clin Chem. 2007;53:1972–1975. doi: 10.1373/clinchem.2007.093104. .
    1. Erhardt JG, Estes JE, Pfeiffer CM, Biesalski HK, Craft NE. Combined measurement of ferritin, soluble transferrin receptor, retinol binding protein, and C-reactive protein by an inexpensive, sensitive, and simple sandwich enzyme-linked immunosorbent assay technique. J Nutr. 2004;134:3127–3132. .
    1. Thurnham DI, Northrop-Clewes CA. Optimal nutrition: vitamin A and the carotenoids. P Nutr Soc. 1999;58:449–457. doi: 10.1017/S0029665199000592. .
    1. Fisker AB, Lisse IM, Aaby P, Erhardt JG, Rodrigues A, Bibby BM, Benn CS. Effect of vitamin A supplementation with BCG vaccine at birth on vitamin A status at 6 wk and 4 mo of age. Am J Clin Nutrit. 2007;86:1032–1039. .
    1. Gamble MV, Ramakrishnan R, Palafox NA, Briand K, Berglund L, Blaner WS. Retinol binding protein as a surrogate measure for serum retinol: studies in vitamin A-deficient children from the Republic of the Marshall Islands. Am J Clin Nutrit. 2001;73:594–601. .
    1. Semba RD, Yuniar Y, Natadisastra G, Muhilal, Gamble MV. Assessment of vitamin A status of preschool children in Indonesia using plasma retinol-binding protein. J Trop Pediatr. 2002;48:84–87. doi: 10.1093/tropej/48.2.84. .
    1. Gorstein JL, Dary O, Pongtorn, Shell-Duncan B, Quick T, Wasanwisut E. Feasibility of using retinol-binding protein from capillary blood specimens to estimate serum retinol concentrations and the prevalence of vitamin A deficiency in low-resource settings. Public Health Nutr. 2008;11:513–520. .
    1. Thurnham DI, McCabe GP, Northrop-Clewes CA, Nestel P. Effects of subclinical infection on plasma retinol concentrations and assessment of prevalence of vitamin A deficiency: meta-analysis. Lancet. 2003;362:2052–2058. doi: 10.1016/S0140-6736(03)15099-4. .
    1. Schisterman EF, Perkins NJ, Liu A, Bondell H. Optimal cut-point and its corresponding Youden Index to discriminate individuals using pooled blood samples. Epidemiology. 2005;16:73–81. doi: 10.1097/. .
    1. WHO Multicentre Growth Reference Study Group: WHO Child Growth Standards. Length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age. Geneva: Methods and development; 2006.
    1. WHO. WHO Anthro for personal computers version 3.2.2. Geneva; 2010.
    1. Barros AJ, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol. 2003;3:1–13. doi: 10.1186/1471-2288-3-1. .
    1. Demissie T, Ali A, Mekonnen Y, Haider J, Umeta M. Demographic and health-related risk factors of subclinical vitamin A deficiency in Ethiopia. J Health Popul Nutr. 2009;27:666–673. .
    1. Hornshøj L, Benn CS, Fernandes M, Rodrigues A, Aaby P, Fisker AB. Vaccination coverage and out-of-sequence vaccinations in rural Guinea-Bissau: an observational cohort study. BMJ Open. 2012;2:e001509. doi: 10.1136/bmjopen-2012-001509. .
    1. Flores H, Campos F, Araujo RC, Underwood BA. Assessment of marginal vitamin A deficiency in Brazilian children using the relative dose response procedure. Am J Clin Nutr. 1984;40:1281–1289. .
    1. Benn CS, Diness BR, Roth A, Nante E, Fisker AB, Lisse IM, Yazdanbakhsh M, Whittle H, Rodrigues A, Aaby P. Effect of 50,000 IU vitamin A given with BCG vaccine on mortality in infants in Guinea-Bissau: randomised placebo controlled trial. BMJ. 2008;336:1416–1420. doi: 10.1136/. .
    1. Benn CS, Rodrigues A, Yazdanbakhsh M, Fisker AB, Ravn H, Whittle H, Aaby P. The effect of high-dose vitamin A supplementation administered with BCG vaccine at birth may be modified by subsequent DTP vaccination. Vaccine. 2009;27:2891–2898. doi: 10.1016/j.vaccine.2009.02.080. .
    1. Benn CS, Fisker AB, Napirna BM, Roth A, Diness BR, Lausch KR, Ravn H, Yazdanbakhsh M, Rodrigues A, Whittle H, Aaby P. Vitamin A supplementation and BCG vaccination at birth in low birthweight neonates: two by two factorial randomised controlled trial. BMJ. 2010;340:c1101. doi: 10.1136/bmj.c1101. .
    1. Arlappa N, Balakrishna N, Laxmaiah A, Raghu P, Rao VV, Nair KM, Brahmam GN. Prevalence of vitamin A deficiency and its determinants among the rural pre-school children of Madhya Pradesh, India. Ann Hum Biol. 2011;38:131–136. doi: 10.3109/03014460.2010.498794. .
    1. Rankins J, Green NR, Tremper W, Stacewitcz-Sapuntzakis M, Bowen P, Ndiaye M. Undernutrition and vitamin A deficiency in the Department of Linguere, Louga Region of Senegal. Am J Clin Nutr. 1993;58:91–97. .
    1. WHO/UNICEF/IVACG Task Force. Vitamin A supplements: a guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia. Geneva: ; 1997. .
    1. Pangaribuan R, Erhardt JG, Scherbaum V, Biesalski HK. Vitamin A capsule distribution to control vitamin A deficiency in Indonesia: effect of supplementation in pre-school children and compliance with the programme. Public Health Nutr. 2003;6:209–216. .
    1. Nathanail L, Powers HJ. Vitamin A status of young Gambian children: biochemical evaluation and conjunctival impression cytology. Ann Trop Paediatr. 1992;12:67–73. .
    1. Bates CJ, Villard L, Prentice AM, Paul AA, Whitehead RG. Seasonal variations in plasma retinol and carotenoid levels in rural Gambian women. Trans R Soc Trop Med Hyg. 1984;78:814–817. doi: 10.1016/0035-9203(84)90028-2. .
    1. Kæstel P, Martinussen T, Aaby P, Michaelsen KF, Friis H. Serum retinol is associated with stage of pregnancy and the acute phase response in pregnant women in Guinea-bissau. J Nutr. 2012;142:942–947. doi: 10.3945/jn.111.155937. .
    1. O'Neill ME, Carroll Y, Corridan B, Olmedilla B, Granado F, Blanco I, Van den Berg H, Hininger I, Rousell AM, Chopra M, Southon S, Thurnham DI. A European carotenoid database to assess carotenoid intakes and its use in a five-country comparative study. Br J Nutr. 2001;85:499–507. doi: 10.1079/BJN2000284. .
    1. Scrimshaw NS. Nutritional potential of red palm oil for combating vitamin A deficiency. Food Nutr Bull. 2000;21:195–201.
    1. You CS, Parker RS, Swanson JE. Bioavailability and vitamin A value of carotenes from red palm oil assessed by an extrinsic isotope reference method. Asia Pac J Clin Nutr. 2002;11(7):438–442. doi: 10.1046/j.1440-6047.11.s.7.1.x. .
    1. Blomhoff R, Blomhoff HK. Overview of retinoid metabolism and function. J Neurobiol. 2006;66:606–630. doi: 10.1002/neu.20242. .
    1. Bates CJ. Vitamin A in pregnancy and lactation. Proc Nutr Soc. 1983;42:65–79. doi: 10.1079/PNS19830008. .
    1. Fisker AB, Aaby P, Bale C, Balde I, Biering-Sørensen S, Agergaard J, Martins C, Bibby BM, Benn CS. Does the effect of vitamin A supplements depend on vaccination status? An observational study from Guinea-Bissau. BMJ Open. 2012;2:e000448–BMJ Open. doi: 10.1136/bmjopen-2011-000448. .
    1. Christiaensen L, Alderman H. Child Malnutrition in Ethiopia: Can Maternal Knowledge Augment The Role of Income. : The World Bank, Africa Region Working Paper Series; 2001. p. 22. .
    1. Aaby P, Martins CL, Garly ML, Balé C, Andersen A, Rodrigues A, Ravn H, Lisse IM, Benn CS, Whittle HC. Non-specific effects of standard measles vaccine at 4.5 and 9 months of age on childhood mortality: randomised controlled trial. BMJ. 2010;341:c6495. doi: 10.1136/bmj.c6495. .
    1. Aaby P, Roth A, Ravn H, Napirna BM, Rodrigues A, Lisse IM, Stensballe L, Diness BR, Lausch KR, Lund N, Biering-Sørensen S, Whittle H, Benn CS. Randomized trial of BCG vaccination at birth to low-birth-weight children: beneficial nonspecific effects in the neonatal period. J Infect Dis. 2011;204:245–252. doi: 10.1093/infdis/jir240. .

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