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ZEBA A N, Bationo J F, Sombié O O, Diendéré J. Vitamin A Deficiency among Rural Primary School Children, A still Neglected Group for Vitamin A Supplementation Strategies. JNFS 2021; 6 (3) :246-254
URL: http://jnfs.ssu.ac.ir/article-1-362-en.html
Vitamin A Deficiency among Rural Primary School Children, A still Neglected Group for Vitamin A Supplementation Strategies
Augustin Nawidimbasba ZEBA * , Jean Fidèle Bationo , Olivier Ouahamin Sombié , Jeoffray Diendéré
Institut de Recherche en Sciences de la Santé/Direction Régionale de l’Ouest (IRSS/DRO), Post Office Box 545 Bobo Dioulasso 01, Burkina Faso
Keywords: Vitamin A deficiency, Primary school children, Burkina Faso
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Vitamin A Deficiency among Rural Primary School Children, A still Neglected Group for Vitamin A Supplementation Strategies

Augustin Nawidimbasba ZEBA; MD, PhD *1, Jean Fidèle Bationo; PharmD, MSc.2,
Olivier Ouahamin Sombié; MD, MSc 1.3 & Jeoffray Diendéré; MD, PhD1

1 Institut de Recherche en Sciences de la Santé/Direction Régionale de l’Ouest (IRSS/DRO), Post Office Box 545 Bobo Dioulasso 01, Burkina Faso.

2 Centre Muraz, Post Office Box 390, Bobo Dioulasso 01, Burkina Faso.

3 Department of Public Health and Primary Care, Ghent University, 9000 Belgium.

ARTICLE INFO

 

ABSTRACT

ORIGINAL ARTICLE

 

Background: Vitamin A deficiency (VAD) is still a public health problem across the globe and also in Burkina Faso, especially for under-five-years-old children. Since less information is available about the prevalence of VAD among the primary school children, this study aimed to study this area. Methods: A randomised double-blind placebo-controlled trial was conducted to assess the effect of high dose of vitamin A (VA) and daily zinc versus high dose of VA and daily zinc placebo (6 days per week) during four months among the primary school children. Of the total number of 200 school children, 100 were allocated to two random groups. Participants’ gender, age, weight, and height were measured, a blood smear was performed for malaria diagnosis, stool samples were collected for intestine parasites’ assessment, and blood samples were collected for haemoglobin and serum retinol measurement. Results: Baseline data of 183 school children were analysed and the findings showed that 20.6% of the school children were underweight (23.2% in girls vs. 16.5% in boys; P = 0.043). Anemia affected 36.2%, 39% had Plasmodium Falciparum, and 37.6% had intestine parasites. Furthermore, VAD prevalence was 46.1% (51.0% in boys vs. 41.2% in girls; P = 0,072). Conclusion: Among primary school children in the Western part of Burkina Faso, VAD is not only higher than other regions of the country, but also twice the critical level and defined as a severe public health problem by WHO. This result calls for action among the primary school children and recalls the importance of taking strategies against VAD among under-five-year-old children.

 

Key Word: Vitamin A deficiency; Primary school children; Burkina Faso

Article history:

Received:3 Nov 2020

Revised: 13 Mar 2021

Accepted:13 Mar 2021

 

*Corresponding author:

nawidzeba@gmail.com

Institut de Recherche en Sciences de la Santé. 399 Avenue de la Liberté, Bobo Dioulasso, Burkina Faso.

 

Postal code : 01 BP 545 Bobo Dioulasso 01

Tel: +226-72168697

 

Introduction
Vitamin A deficiency (VAD) is a public health concern worldwide and especially in the developing countries. According to the World Health Organisation (WHO), around 190 million preschool children are affected by VAD with or without clinical manifestation. It is also known to contribute to childhood mortality and morbidity (Stevens et al., 2015, World health organization, 2009). In sub-Saharan African, almost all the data available on VAD, whether in term of VAD prevalence or its adverse effects, are referring to the under-five-year-old children or pregnant or lactating women (Bishai et al., 2005, Imdad et al., 2017, Sahile et al., 2020, Schmitz et al., 2012). In the developing countries, the common strategy against VAD has been vitamin A supplementation among under-five-years-old children and indeed many studies have proven its efficacy previously (Fawzi et al., 1993, Glasziou and Mackerras, 1993).
In Burkina Faso, for instance, it is accepted that VAD is a public health concern for under-five-years-old children even though data at the national level are not available yet. Report from a study in some part of the country suggested that more than 60% of this group of children are affected by VAD (Zagré et al., 2003). One of the national strategies against this deficiency, presented since 2005 is a biannual supplementation of under-five-years-old children with vitamin A capsules.
Apparently under-five-years-old children are not the only individuals at concern with regards to VAD in Burkina Faso. In fact, data showed that more than 40% of the school children in the Eastern and Norden rural settings of Burkina Faso (Zeba et al., 2006) and even in the capital city (Daboné et al., 2011) are affected by VAD.
The current study aimed to assess the impact of double supplementation of vitamin A and zinc versus vitamin A and zinc placebo. Moreover, we targeted at assessing the baseline vitamin A status among school children living in a Western rural setting of Burkina Faso. The findings can be used to provide more insight on this matter in the rural Western part of the country.

Materials and Methods

Study design and participants: The study was carried out between March and July 2014 in the “Vallée du Kou” primary school in Bama village. It is a rural area located in the “Dandé” health district, at around 30 km away in the Western part of the city of Bobo Dioulasso. Bama is a village where fishing activity is dominant and many households are in good food security status, whether in term of food availability or food accessibility. In this regard, this village is in a better condition than other areas in the Eastern or Northern parts of the country (MAAHA, 2020).
A randomized double-blind placebo-controlled trial was conducted, assessing the effect of a combined supplementation of a high dose (200 000 UI) of vitamin A in addition to a daily zinc supplementation (six days per week). The results were compared with the effect of a high dose (200 000 UI) of vitamin A plus daily zinc placebo (six days per week) in the primary school children of 7 to 12 years old. The baseline data were collected form the selected children at the inclusion and a daily follow-up were conducted with the same children for zinc vs. zinc placebo intake during a four-month period. At the end of the fourth months, the study ended with an end line data collection.
The primary outcomes of the study included decrease of intestine parasites prevalence among the primary school children by 50% and the decrease of anemia by 25% as an effect of the combined supplementation of vitamin A and zinc compared to the supplementation of vitamin A and zinc placebo. Initially, the sample size of 180 school children was considered using the 80% power and α = 0.05). In order to take into account the drop-out during the follow-up, 10% was added to this initial sample size. A total number of 200 school children were selected and 100 were allocated to each of the two random groups for the study. The first random group (AG) received a high dose of vitamin A in addition to the daily zinc supplementation and the second group received a high dose of vitamin A in addition to daily zinc placebo (PG).
The supplements and placebos were provided by U-Pharma unit of the National Health Science Research Institute of Burkina Faso (IRSS). Zinc powder was included in capsules containing 10 mg Zn in the form of zinc gluconate and placebo was a zinc-free capsule with maize powder, having colour, taste, and appearance similar to those of zinc gluconate. All capsules were coded based on the two groups and investigators, clinical staff, field workers, and parents were blind to the codes. The children in the AG received one high dosage of vitamin A and a daily dosage (except Sunday) of zinc gluconate, while the children in the PG received one high dose of vitamin A and a daily dose of zinc gluconate placebo.
Study participants and follow up process: The study inclusion criteria were: studying at “Vallée du Kou” school, being within the age range of 7 to 12 years, having no clinical sign of VAD, planning to remain at the selected school till the end of the school year, submitting a signed informed consent form by the legal representative of the selected child. Before the enrolment day, village meetings were held in the local language to explain the purpose, methods, and risks of the study.
At the enrolment, children were individually allocated into the AG or PG in two blocks using computer-generated randomly permutated codes. Children were then visited at home every day, six days per week during four months of follow-up from March to July 2014 by the trained village-based field workers to distribute zinc or zinc placebo supplements.
The above-mentioned flowchart describes the study profile and the data collection process from the selection to the end line of the data collection. After the selection, only children for whom a blood sample was collected at the baseline were enrolled and followed-up.
Study variables laboratory procedures: Part of the study variables and laboratory processing are described in an already published paper (Bationo et al., 2018). Variables such as gender, age, weight, and height were measured, blood smear was performed for malaria diagnosis, stool samples were collected for intestine parasites assessment, and blood samples were collected at the baseline and at the end line.
Age, gender, weight, and height were computed into body mass index for age used for children from 5 to 19 years old. A z-score was derived from it with a z-scores < -2 SD indicating underweight children and z-scores > 1 SD, indicating overweight children.
At the end of each data collection session, the blood samples were brought to the IRSS Laboratory and centrifuged the same day. The serum samples were then collected, frozen, and kept at -20°C until analysed. The serum samples were shipped to the University of Wisconsin-Madison, USA, in dry ice and subsequently stored at -80°C before being analysed by Gas Chromatography-combustion-isotope ratio mass spectrometry (GC-C-IRMS) technics as published for vitamin A body store determination and HPLC for serum retinol (Gannon et al., 2014). With serum retinol, case of VAD and a severe case of vitamin A deficiency was defined with serum retinol <0.7 μmol/l and < 0.35 μmol/l, respectively as recommended by WHO.
Haemoglobin (Hb) was directly measured in the field with a drop of whole blood using a HemoCue_R (Hemocue HB 2011, Angelholm, Sweden), so that anemia was defined as Hb <11,5 g/dl for children < 12 years and Hb < 12 g/dl for children ≥ 12 years (World health organization, 2004) .
The same blood drop was used to perform a blood smear for malaria diagnosis. Thick and thin giemsa-stained blood films were collected and analysed for the plasmodium species-specific density per 200 white blood cells. Each film was examined by a technician in the field, re-examined by an experienced laboratory technician, and checked by a third investigator in cases of discrepancy. The total parasite count per µL was quantified and a thick was declared negative if no parasites were seen on the film.
Data processing and analysis: Data were analysed with “IBM-SPSS” version 26.0 (IBM Corp, Armonk, NY, USA). Quantitative variables were expressed as mean ± standard deviation (SD) and categorical variables as percentages with 95% confidence intervals (CI). Differences between quantitative variables were assessed using the independent t-test and the Analysis of variance (ANOVA) test for comparison of more than two groups followed by the Bonferroni post hoc test. Differences between categorical variables were assessed by χ2 test.
Ethical aspects: An ethical approval of the study protocol was received from the ethical committee of Centre Muraz (011-2014/CE-CM). The trial was registered at Pan African Clinical Trials Registry (PACTR201702001947398). The study was also explained to the “Dandé” health district authorities, the villagers, and the head of each participating compound individuals. Written informed consent was obtained from parents or guardians of all included children before enrolment. Children who got sick during the surveys or visits by the supervisors were treated in the village or referred to Bobo Dioulasso hospital free of charge.
Results
From the original 200 school children included in the study, we were able to have enough blood samples from 183 in order to carry out the vitamin A assessment. A total number of 17 children were excluded from the study because it was impossible after two to three attempts to draw a blood sample from them. The baseline characteristics in Table 1 shows that 20.6% of the school children were underweight and girls were more affected than boys even though the difference was not significant (23.2% in girls vs. 16.5% in boys; P = 0.185).
Mean haemoglobin was 12.24 g/dl, which was significantly higher in girls than in boys marginally (12.38 g/dl vs. 12.09 g/dl; P = 0.057). Anemia affected 36.2% of the school children with no difference between boys and girls. Plasmodium falciparum was found in the blood of 39% of the children, which was in a similar proportion between boys and girls, with a geometric mean parasite density of 542.43 Plasmodium falciparum positive /ml. Alongside with plasmodium falciparum, intestine parasites were found among the school children, so that 37.6% of them were affected in a similar proportion for boys and girls. The mean serum retinol level was 0.8 μmol/l (0,75 in boys vs. 0.85 in girls; P = 0.059) and 46.1% of the school children had VAD, which was higher in boys than in girls, although it was not statistically significant (51.0% vs. 41.2%; P = 0,072).
In considering Table 2, we can see that the mean serum retinol remained almost similar between girls and in boys despite the nutritional variety of the infectious status. Despite these conditions, the mean serum retinol levels were above the threshold of 0.70 μmol/l determining the deficiency status.
The odds of VAD, as shown in Table 3 were not significant for school children with underweight, anemia, intestine parasite, plasmodium falciparum, or both parasites. Even children with these conditions exhibited more deficiencies.






 

Table 1. Baseline nutritional, clinical, and parasitological characteristics

 

Variables

All (n = 183)

Boys (n = 89)

Girls  (n = 94)

P-valuea

Age (y)

9.32 ± 1.56b

9.31 ± 1.53

9.33 ± 1.59

0.933

Weight (kg)

24.75 ± 5.37

24.94 ± 4.95

24.57 ± 5.76

0.626

Height (cm)

129.08 ± 12.42

128.08 ± 14.39

130.03 ± 10.19

0.274

Haemoglobin (g/dl)

12.24 ± 1.09

12.09 ± 1.12

12.38 ± 1.04

0.057

Body mass index (kg/m²)

14.91 ± 1.70

14.96 ± 1.46

14.86 ± 1.88

0,060

Serum retinol μmol/l

0.80 ± 0.35

0.75 ± 0.34

0.85 ± 0.35

0.059

Weight  status according to body mass index z-score

   Normal ((≥-2 and  ≤ +1)

151(78.40) c

(74) 83.5

(70) 74.7

0.185

   Underweight (< -2 Z)

40 (20.60)

(15) 16.5

(22) 23.2

 

   Overweight (> +1 to ≤ +2)

2(1.0)

0

(2) 2.0

 

Anemia

36.2

39.8

32.7

0.185

Positive Plasmodium falciparum

39.0

35.7

42.2

0.215

Geometric mean density Plasmodium  falciparum positive /ml ± SEd

542.43

596.67

516.01

193.25

565.58

1081.19

0.284

Positive intestine parasite

37.6

38.5

36.7

0.462

Serum retinol < 0.70 μmol/l (%)

46.1

51.0

41.2-

0.072

a: Qualitative variable  Student t-test  and quantitates X2 test; b: Mean ± SD; c:N (%); d: Geometric mean±  SE (Standar Error)

 

Table 2. Retinol concentration (μmol/l) according to nutritional and infection status

 

 

 

 

 

All (n = 183)

P-value

Boys (n = 89)

P-value

Girls  (n = 94)

P-value

Weight status according to body mass index z-score

   Normal (-2 - 1)

0.82 ± 0.34b

0.479 c

0.79 ± 0.34c

0.341 c

0.84 ±

0.34 c

0.618

   Underweight (< -2)

0.79 ± 0.33

 

0.70 ± 0.29

 

0.85 ±

0.35

 

   Overweight (1 - 2)

1.09 ± 0.46

 

-

 

1.09 ±

0.46

 

Anemia

   Yes

0.76 ± 0.35

0.225a

0.72 ± 0.35

0.483 a

0.81 ±

0.34

0.415 a

   No

0.82 ± 0.34

 

0.77 ± 0.33

 

0.87 ±

0.35

 

Intestine parasite

   Yes

0.85 ± 0.37

0.315 a

0.71 ± 0.35

0.704 a

0.96 ±

0.36

0.080 a

   No

0.78 ± 0.35

 

0.75 ± 0.37

 

0.80 ±

0.34

 

Presence of Plasmodium falciparum

   Yes

0.79 ± 0.35

0.902 a

0.73 ± 0.34

0.827 a

0.87 ±

0.37

0.784 a

  No

0.80 ± 0.36

 

0.74 ± 0.35

 

0.84 ±

0.36

 

a: Student t-test; b:Mean ± SD;  c: ANOVA with Bonferroni post hoc test.  

 

Table 3. Odds of low retinol level related to nutritional and infection status

 

Variables

n

% Serum  retinol < 0.70 μmol/l

Odds

CI 95%

P-valuea

Weight status according to body mass index z-score

   Normal (-2-1)

145

43.4

1

 

 

   Underweight (< -2)

36

52.8

1.24

0.0-10.24

0.182

   Overweight (1 -2)

2

0

1.80

0.0-10.80

 

Anemia

 

 

 

 

 

   No

123

44.7

1

 

 

   Yes

69

47.8

1.03

0.56-1.91

0.903

Intestine parasite

 

 

 

 

 

   No

114

43.0

1

 

 

  Yes

69

52.2

0.70

0.38-1.29

0.261

Plasmodium falciparum

 

 

 

 

 

No

118

46.6

1

 

 

Yes

75

45.3%

1.09

0.59-1.99

0.771

a: Binary logistic regression
 

Discussion

The present study investigated the opportunity of assessing vitamin A status of 7-12 year-old school children in a rural setting of the western Burkina Faso. The western part of the country is richer in terms of food availability and household food security (MAAHA, 2020). Most families of the children were involved in fishing occupation. The prevalence of VAD is expected to be lower in such settings, that was found in the Central Norden part (47.2% in Kaya and 37.1% in Bogandé) (Zeba et al., 2006) and in the Capital city (40% in Ouagadougou) (Daboné et al., 2011) of the country. Unfortunately, we found that the prevalence of VAD was higher up to 46.1% in the western settings. Obviously, school children are not in a better condition than those of under five years with regards to VAD in Burkina Faso. According to WHO, VAD is a severe public health problem when its prevalence, measured as serum retinol <0.70 μmol/l reaches more than 20% (World health organization, 2011). In this study we found twice this threshold and yet little is done to mitigate the impact of this deficiency among this group of people. School children are at a particular stage of their development, through which they are in need of their optimum nutritional status to ensure the best conditions for learning abilities.
Vitamin A is known to contribute not only to immune system (Cantorna et al., 2019, Erkelens and Mebius, 2017, Mora et al., 2008) or to vision (Chiu et al., 2016, Saari, 2016, Wiseman et al., 2017) or else to the reduced morbidity or mortality (Darlow et al., 2016, Haider and Bhutta, 2011, Imdad et al., 2017, Neonatal Vitamin A Supplementation Evidence Group, 2019), but also to play an important role in iron metabolism (da Cunha et al., 2019). Iron deficiency is also known to be detrimental to children mental development, which can lead to impairment in school performance (Taras, 2005, Zimmermann and Hurrell, 2007). Indeed, a recent randomized double blinded trial over vitamin A supplementation suggested that children who received VA supplement had better performance in reading, spelling, and math computation than those who did not (Ali et al., 2017). Vitamin A strategies are commonly applied for under-five-year-old children and even for child bearing potential, pregnant, and breastfeeding women, but rare interventions focused on the primary school children. According to the present data, which corroborate those found in Central Northern and the capital city of Burkina Faso (Daboné et al., 2011, Zeba et al., 2006), more attention should be paid to this specific group, in which VAD is at the stage of severe public health problem in Burkina Faso (World health organization, 2011).
The study bears some limitations mainly due to its experimental design and limited sample size. Furthermore, the findings are neither generalizable to other regions nor to other parts of the country. However, the findings can provide a good insight into what might be the situation of the primary school children. To eliminate hidden hunger, providing enriched school meals to children is highly recommended.
Conclusion
The current study reported a high prevalence of VAD (twice the level permitted by WHO) among primary school children. The prevalence remained stable and high in children with or without intestine parasite, plasmodium falciparum, and underweight condition. However, no strategy at the national or regional or local level has ever responded to this situation. Most interventions against VAD deficiency have been focused on under-five-years-old children as well as pregnant and breastfeeding women, but the primary school children should not be neglected since they are at a particular stage of their development.
Acknowledgments
We gratefully acknowledge the technical and field support provided by IRSS. We also thank the population of the Bama and all the field workers involved in the study.This study was funded by the International Atomic Energy Agency under the project numbered RAF 6006.
Authors’ contribution
Augustin Nawidimbasba ZEBA: Developed the study, carried out data analysis and interpretation, as well as drafted the manuscript and its revision before submission. Jean Fidèle BATIONO: Carried out the field work, contributed to the data analysis and interpretation, and revised the manuscript before submission. Olivier Ouahamin SOMBIÉ and Jeoffray DIENDÉRÉ: Contributed to the data analysis and interpretation, and revised the final version of the manuscript before submission. All the authors read and approved the final manuscript.
Conflict of interests
The authors declare that they have no competing interests with regard to this paper.
 
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Type of article: orginal article | Subject: public specific
Received: 2020/11/3 | Published: 2021/08/17 | ePublished: 2021/08/17
References
1. Ali H, et al. 2017. Effect of maternal antenatal and newborn supplementation with vitamin A on cognitive development of school-aged children in rural Bangladesh: a follow-up of a placebo-controlled, randomized trial. American journal of clinical nutrition. 106 (1): 77-87.
2. Bationo JF, et al. 2018. Serum Carotenoids Reveal Poor Fruit and Vegetable Intake among Schoolchildren in Burkina Faso. Nutrients. 10 (10): 1422.
3. Bishai D, et al. 2005. The impact of vitamin A supplementation on mortality inequalities among children in Nepal. Health policy and planning. 20 (1): 60-66.
4. Cantorna MT, Snyder L & Arora J 2019. Vitamin A and vitamin D regulate the microbial complexity, barrier function, and the mucosal immune responses to ensure intestinal homeostasis. Critical reviews in biochemistry and molecular biology. 54 (2): 184-192.
5. Chiu M, Dillon A & Watson S 2016. Vitamin A deficiency and xerophthalmia in children of a developed country. Journal of paediatrics and child health. 52 (7): 699-703.
6. da Cunha MdSB, Campos Hankins NA & Arruda SF 2019. Effect of vitamin A supplementation on iron status in humans: A systematic review and meta-analysis. Critical reviews in food science and nutrition. 59 (11): 1767-1781.
7. Daboné C, Delisle HF & Receveur O 2011. Poor nutritional status of schoolchildren in urban and peri-urban areas of Ouagadougou (Burkina Faso). Nutrition journal. 10 (1): 34.
8. Darlow BA, Graham P & Rojas‐Reyes MX 2016. Vitamin A supplementation to prevent mortality and short‐and long‐term morbidity in very low birth weight infants. Cochrane database of systematic reviews.(8).
9. Erkelens MN & Mebius RE 2017. Retinoic acid and immune homeostasis: a balancing act. Trends in immunology. 38 (3): 168-180.
10. Fawzi WW, Chalmers TC, Herrera MG & Mosteller F 1993. Vitamin A supplementation and child mortality: a meta-analysis. Journal of the American medical association. 269 (7): 898-903.
11. Gannon B, et al. 2014. Biofortified orange maize is as efficacious as a vitamin A supplement in Zambian children even in the presence of high liver reserves of vitamin A: a community-based, randomized placebo-controlled trial. American journal of clinical nutrition. 100 (6): 1541-1550.
12. Glasziou P & Mackerras D 1993. Vitamin A supplementation in infectious diseases: a meta-analysis. British medical journal. 306 (6874): 366-370.
13. Haider BA & Bhutta ZA 2011. Neonatal vitamin A supplementation for the prevention of mortality and morbidity in term neonates in developing countries. Cochrane database of systematic reviews.(10).
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