Wed, 09 Jul 2003

Indonesia steps up Vitamin A supplementation

Tantri Yuliandini, The Jakarta Post, Jakarta

What can equal the joy of seeing dew drops sparkling in the morning sun, or witnessing a rainbow across a lake of blue?

Such things may be trivial to the sighted, but some 10 million under-fives in Indonesia may never get to see them and experience such joy. According to the latest data from the Ministry of Health, more than 50 percent of children under five in Indonesia suffer from vitamin A deficiency (VAD), which, if untreated, can cause blindness.

About 66,000 of these are already showing clinical signs of xerophthalmia -- a dry and thickened, lusterless condition of the eyeball.

Indonesia was once known as the "home of xerophthalmia", Muhilal from the Research and Development Center for Nutrition in Bogor, West Java, said.

He explained that government efforts in the late 1980s in providing vitamin A capsule supplementation for children aged one to five years, and its nationwide effort to increase consumption of vitamin A-rich foods, had succeeded in lowering the level of severe VAD, so that it was no longer considered a public health problem.

But the crisis in 1998 meant far more than a near-collapse of the country's economy. With reduced buying power, people could no longer afford to buy food rich in micronutrients, such as eggs, meat and milk.

"This decrease in the dietary intake of vitamin A correlates with an increase in the prevalence of nightblindness among children up to 35 months old," Helen Keller International said in its Indonesia Crisis Bulletin.

"Since xerophthalmia had become rare in Indonesia in the last 10 years, its reemergence had not immediately become known," Ministry of Health public nutrition director Rachmi Untoro said. The threat of severe VAD once again loomed, especially in poor areas.

Based on Ministry of Health research that only 10 percent of children aged six to 11 months were receiving vitamin A supplements in 1999, compared with 60 percent of children aged one to five years, a new target group was officially added for routine supplementation.

Since then, coverage rates increased to around 60 percent for six- to 11-month-old children and around 70 percent for children aged one to five years.

The government's vitamin A program consists of providing free vitamin A capsules twice a year, in February and August, to children six months to five years of age.

"We give out vitamin A capsules to under-fives at all puskesmas and posyandu," Ministry of Health director for nutritional health Rachmi Untoro said, adding that about 7,000 puskesmas (community health centers) and 240,000 posyandu (integrated health service posts) existed across Indonesia.

A blue capsule contains 100,000 IU (immunizing units) of vitamin A for children six to 11 months old, and a red capsule 200,000 IU for children one to five years old.

Hellen Keller International noted that the ingredients for a successful supplementation program in Indonesia included community awareness about the routine program, children's attendance at designated distribution points, heath worker knowledge about current supplementation guidelines and procedures, a well-functioning distribution system for capsules and timely procurement of adequate stocks for children.

The Ministry of Health, together with Helen Keller International, recently launched a booklet, Early Detection of Xerophthalmia, to help train health workers in detecting the early signs of xerophthalmia due to severe VAD, as well as how to treat them.

Vitamin A is a family of fat-soluble vitamins. Retinol is one of the most active, or usable, forms, and can found in eggs, milk and liver. Provitamin A caretenoids, found in dark-colored fruit and vegetables, can also be converted to vitamin A.

Stored normally in the liver, vitamin A is crucial for effective immune-system functioning, protecting the integrity of epithelial cells lining the skin, the surface of the eyes, the inside of the mouth and the alimentary and respiratory tracts, Helen Keller International said.

Depending on the degree of deficiency, a range of abnormalities appear in the eyes of vitamin A-deficient children. The condition begins with night blindness and conjunctival xerosis (dryness of the eye membranes), progresses to corneal xerosis (dryness of the cornea), and, in the late stages, to keratomalacia (softening of the cornea).

According to the booklet, children at risk of xerophthalmia include babies with a birth weight of less than 2.5 kilograms, those who did not receive breastmilk exclusively or who did not receive it until the age of two, undernourished children, and children with infections such as diarrhea, tuberculosis or pneumonia, or who suffer from intestinal worms.

Children from poor families, who might be living in refugee camps, are also at risk of xerophthalmia.