EPIDEMIOLOGI KVA (Vitamin A Deficiency Epidemiology)

Nutritional Epidemiology Lecture Topic 8

EPIDEMIOLOGI KVA (Vitamin A Deficiency Epidemiology)

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

PREFACE Kurang Vitamin A (KVA) merupakan salah satu masalah gizi kurang yang masih dihadapi oleh negara-negara berkembang termasuk 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) n

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 Hopkins Bloomberg 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 buta à menyebabkan dediferensiasi; keratinisasi sel epitel, perubahan nafsu makan; xerofthalmia



BESARAN MASALAH KVA DI DUNIA

MATERNAL VITAMIN A DEFICIENCY IN THE WORLD n

Maternal Vitamin A Deficiency : ~10% of women 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 Johns Hopkins Bloomberg School of Public Health Baltimore, Maryland, April 16th, 2007

PERKEMBANGAN KVA DI INDONESIA A nutrition survey conducted in Indonesia in early 1970s à the prevalence of VAD was very high. 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). n

CONTINUED… 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 underfive children. n Within 2 decades, the program à successfully 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. n

PREVALENSI KVA DI INDONESIA No. Klasifikasi 1. 2. 3.

X1B = Bercak bitot X2/X3 = Xerosis kornea/keratomalasia XS = Parut kornea

Tahun 1978

1992

1,3 27,7 18,0

0,33 0 0

CONTINUED… Ø Sejak

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

CONTINUED… à Namun masih dijumpai 10 juta anak balita menderita KVA sub klinis (50% balita : serum retinol <20 µg/100 ml) n > 1992 à Tidak ada data nasional prevalensi KVA

CONTINUED… n Tingginya

proporsi balita dengan serum retinol <20 mcg/100 ml à berisiko tinggi u/ terjadinya xeropthalmia & me↓ tingkat kekebalan tubuh à mudah terserang penyakit infeksi kapsul vitamin A dosis tinggi

CONTINUED… n Tahun

1998 à Survei HKI daerah kumuh perkotaan à masalah KVA muncul kembali n What is the current magnitude of VAD prevalence in Indonesia is difficult to speculate.

CONTINUED… n Di

Indonesia à ada laporan lisan dari beberapa propinsi à timbul kembali kasus-kasus xerophthalmia à di NTB ditemukan kasus stadium X3 à anak menjadi buta

KLASIFIKASI KVA (Xeroftalmia) XN X1A X1B X2 X3A X3B XS XF

: Buta Senja : Xerosis konjungtiva : Bercak bitot : Xerosis kornea : Ulkus kornea dengan xerosis : Keratomalasia : Xeroftalmia scars : Xeroftalmia fundus

Sumber : Depkes RI & HKI, 2002

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

XN X1B X2 X3 XS

Night blindness Bitot’s spots Corneal xerosis or Corneal ulceration/ Keratomalacia Corneal scarring Serum retinol (<.70 umol/L/20 ug/dL)

*WHO minimum criteria for public health significance

(>1%) * (> 0.5%)

(> 0.01%) (> 0.05%) (>15%)

Continued… Plasma Vit.A < 0,35 µmol/l (10 µg/dl) Plasma Vit.A < 20 µg/dl à rawan terhadap penyakit infeksi & me↑ mortalitas n Liver Vit.A < 5 µg/g n

: > 5%

: > 5%


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 EXPOSURE

OUTCOME

ASUPAN VITAMIN A ↓

KVA

PENYEBAB KVA : KURANG PENGETAHUAN & KEPERCAYAAN KEADAAN EKONOMI

ASUPAN VIT. A RENDAH

NAFSU MAKAN HILANG

KVA

PELARUT VIT. A RENDAH KEP

ABSORBSI & UTILISASI VIT. A

PENYAKIT INFEKSI PENYEBAB TIDAK LANGSUNG

PENYEBAB LANGSUNG

CONTINUED… n Deplesi

Vitamin A dalam tubuh à proses 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



CONTINUED… n Bayi

prematur à Cadangan Vit.A dalam hati rendah 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

CONTINUED… n Penderita

diare kronik, Chron’s disease atau tidak cukup pankreas & kondisi malabsorpsi lemak 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 à kadar vitamin A serum (< 5 µg/100 ml) & kadar RBP (< 20 µg/100 ml) sudah sangat rendah n Konsentrasi Vit.A dalam hati à indikasi yang baik u/ menentukan status Vit.A

CONTINUED… n Biopsi

hati à tindakan yang mengandung risiko bahaya n Penentuan kadar Vit. A jaringan 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) Semua Umur

DEFISIENSI < 10 µg/dl

MARGIN 10-20 µg/dl

CUKUP >20 µg/dl

DAMPAK KVA PADA BALITA n1

diantara 2 (48,1%) dari balita yg menderita KVA à menderita anemia kurang zat besi (SKRT, 2001) n Anak-2 yang KVA pada derajat sedang berisiko tinggi untuk mengalami gangguan pertumbuhan (Hadi et. al., 2000),

CONTINUED… n Di

samping itu à menderita beberapa penyakit infeksi 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 A n Kasus xeropthalmia à p’yuluhan kons. sayur & buah tidak efektif & cakupan kapsul Vitamin < 80% à laporan 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 à important indicator of whether or not a chronic problem of VAD is likely to 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

CONTINUED…. n This

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

Data Collection Method n

n

n

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. Mothers were asked to recall everything their child ate or drank in the last 24 hours, & details about portion sizes & cooking methods were recorded. Vitamin A intake was estimated based on portion size and vitamin A content of the food.

Findings: - Vitamin A intake was well below the Indonesian Recommended Daily Intake and has improved little over time. n West Sumatra - Vitamin A intake in West Sumatra was no more than onethird of the Recommended Daily Intake for children n General

Gambar. Asupan Vitamin A Anak Usia 12-59 bln di Pedesaan Sumatera Barat Sumber : 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 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 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 blindness rates among children. In Indonesia, a 34% reduction in mortality was observed among children supplemented with VAC

CONTINUED….. nA

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

Findings: n

n n

General - Vitamin A capsule coverage has increased considerably, reaching the target of 80% coverage in August 02 and February 2003. West Sumatra - VAC coverage increased from August 1999 to February 2002, but modestly. 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 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

n

n

However, maternal deficiency has the added consequence of contributing to the poor health status of the newborn. One study in rural Nepal found an increased mortality rate of 63% among infants of night blind women. 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

n

n

The 24- hour Vitamin A Semi- Quantitative (VASQ) method was used to assess total VA intake for a 20% sub sample of households. 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. Vitamin A intake was estimated based on portion size and vitamin A content of the food

Findings: n

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 data collection. 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 [email protected] n [email protected]

EPIDEMIOLOGI KVA (Vitamin A Deficiency Epidemiology)

Recommend Documents