Xerophthalmia in the state of Paraiba, northeast

of Brazil: clinical findings3

Leonor MP Santos, PhD, Jean M Dricot, DrSc, Luiza S Asciutti, BS, and
Christiane Dricot-d’Ans, MD, DrSc

ABSTRACT An epidemiological survey of the prevalence of xerophthalmia was conducted in

the state of Paraiba through 10,922 clinical examinations of 0 to 12 yr old children from six
localities representative ofthe three different ecological regions of Panaiba. The regional distribution
of clinical signs of vitamin A deficiency was markedly different, and in the semiarid region (Sent#{227}o)
the prevalence reached levels suggesting that it was a public health problem in that area. Seasonal
variations were observed and were specially significant in the “Serto,” with xerophthalmia signs
appearing more frequently during the interhanvest period. This seems to be the first report with

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documented active cases ofxerophthalmia in this region of Brazil. Am J Clin Nuir 1983;38:139-
144.

KEY WORDS Xerophthalmia, Northeast Brazil, children, regional distribution, seasonal var-
iation

Introduction the coastal region (Litoral), with high rainfall,

completely dominated by large sugar cane
The Northeast of Brazil is one of its least plantations and related activities; a transi-
developed regions and it can be considered tional region (Brejo/Agreste) of moderate al-
as the largest and most populated poverty titude and more temperate climate, where
area of Latin American. The occurrence of cultivation of staple foodstuffs is done in
vitamin A deficiency in the Northeast of Bra- small and mid-size rural properties; and the
zil has been suspected for some time; dietary Sert#{227}o,a semiarid zone with very irregular
and/or biochemical surveys and clinical ob- rainfalls and sparse vegetation, where cattle
servations have already suggested the exist- raising and cotton production are the main
ence of hypovitaminosis A in the area (1-9). activities.
In only one study (9) were clinical signs of In all three regions it is possible to separate
xerophthaLmia reported in significant levels; two distinct phases ofthe agroindustrial cycle:
it should be pointed out, however, that it was the harvest and the interharvest seasons. The
a retrospective survey, compiling information interharvest period brings more hardship to
furnished by local hospitals, ophthalmology the people, due to decreased food stocks, less
clinics, and ophthalmologists. None of these job opportunities, and higher food prices.
studies has surveyed the clinical signs of xc-
rophthalmia with a systematic, standardized Methods
epidemiological methodology and with a suf-
ficient sample size. Six towns ranging from small to mid-size and repre-
sentative of their ecological zones, were selected accord-
As a part of a broader epidcmiological
ing to criteria such as: economic activities, land tenure,
study of nutrition in the state of Paraiba (a agricultural crops, demography, etc. In the coastal area,
state very representative of the ecological
conditions of the Northeast region), a direct 1 From the Departamento de PromocAo de Sa#{252}de,
epidemiological survey of xerophthalmia was Universidade Federal da Panalba, JoAo Pessoa-Pb, Bra-
conducted to assess its prevalence in children, sil.
2 Supported by CNPq, SEPLAN-Pb, INAN, UFPb,
as well as its possible geographical and/or
and local city governments.
seasonal variations. :i Reprints not available.
It is possible to differentiate, in the state of Received October 21, 1982.
Paraiba, three very distinct ecological zones: Accepted for publication January 18, 1983.

The American Journal ofClinical Nutrition 38: JULY 1983, pp 139-144. Printed in USA I 39
© 1983 American Society for Clinical Nutrition
140 SANTOS ET AL
tables ( 1 1), as well as information regarding the child’s
one town (Mamanguape) was drawn from the sugar cane
region, whereas the other (Bayeux) represents the poorest immunization status and recent history of illness.
suburban area of the largest city, the state capital. In the
transitional area the town selected was Esperan#{231}a, and Results
in the Sert#{226}o three towns were studied: Itaporanga,
Conceic#{227}o, and Pianc#{243}. The results presented in Table I refer to
In the smallest localities, all children from 0 to 12 yr observations made during the harvest season
old were examined in door-to-door visits; in the other
and show clear regional clustering of xer-
towns a systematic, quasi random sampling of house-
holds was done in a proportion varying from one-half to
ophthalmia in the state of Paraiba; the scm-
one-fourth, depending of the size of the town. iarid region, the Sert#{227}o,is the only one where
During a first phase, localities were studied during clinical signs of vitamin A deficiency were
the harvest season, and in a second round of observations found during that period. The difference in
(about 6 months later) data were collected during the
distribution of conjunctival xerosis with Bitot
interharvest season for only one town in each ecological
region; the data collection corresponded to the period
spot (X1B) between the Sert#{227}oand the other
from July of 1981 to March of 1982. two areas presented a very high statistical
The eye examination was performed in daylight by significance (p < 0.001). In the Scrt#{227}o,the
previously trained health professionals (from the ne- distribution of xerophthalmia in children was
search team); the suspected cases were reexamined by a
rather homogeneous among the three locali-

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second person in order to confirm or reject the diagnosis.
No specialized ophthalmohogical technique or instru- ties, and no significant difference was found.
ment was used. Xenosis of conjunctiva not accompanied The distribution ofthe xerophthalmia cases
by Bitot spot was not recorded. Night blindness was by age group is shown in Table 2. The prey-
assessed from information furnished by the mother or
alence of Bitot spot was higher for the school
child’s guardian and in all cases recorded, the description
was of striking loss of eyesight at twilight. Corneal scans children (1%) than for the preschoolers
due to trauma or with a history not compatible with (0.3%), the difference being statistically sig-
ceratomalacia were not included. All the clinical signs of nificant (p < 0.005).
xerophthalmia were classified according to the recom-
Tables 3 and 4 compare the results ob-
mendations of the International Vitamin A Consultative
Group (IVACG) (10) as follows: XN, night blindness;
tamed in the harvest season (already pre-
Xl B, conjunctival xerosis with Bitot spot(s); X2, conical sented in Tables 1 and 2), with data collected
xerosis; XS, conical scars. for some of the same localities during the
The active cases of xerophthalmia were treated with interharvest period. The results suggest the
initial doses varying from 75,000 to 200,000 IU of vi-
existence of a seasonal variation, with more
tamin A orally, and most of them were reexamined 2 to
cases of xerophthalmia found in the interhar-
10 wk later with the purpose of confirming the clinical
diagnosis by a therapeutic test; at this time a second dose vest period in both age groups. For preschool
adding up to no more than 300,000 IU was given. The children the difference between the two sea-
siblings of the affected children also received vitamin A sons was statistically significant considering
as a preventive measure.
all the three ecological regions together (p <
As part of the broader nutritional survey already
mentioned, anthropometric parameters were recorded 0.01), and even more significant when we
and classified by comparison with national reference analyze only the Sert#{227}o(p < 0.005). For

TABLE 1
Regional Distribution of xerophthalmia in
0- to 12-yr old children

. No ofclinical signs
Region No of
locality children
XN XIB X2 XS

Coastal
Mamanguape 751 0 1 0 0
Bayeux 689 0 0 0 0
Total 1440 0 1 0 0
Transitional
Esperan#{231}a 1431 0 0 0 0
Sert#{227}o
Itaporanga 1566 2 6 0 1
Conceic#{226}o 1831 3 13 1 1
Pianc#{243} 1594 4 10 0 3
Total 4991 9 29 1 5
 XEROPHTHALMIA IN NORTHEAST BRAZIL 141

TABLE 2
Age distribution of xerophthalmia
cases-SertAo area

No of clinical signs
No of
Age group children
XN XIB X2 XS

Preschool 2802 5 8 0 3
(0-59 mo)
Schoolage 2189 4 21 1 2
(60-143 mo)
Total 4991 9 29 1 5

TABLE 3
Seasonal variation of xerophthalmia in
preschool children

No of clinical signs
No of
Region/period children
XN XIB X2 XS

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Coastal (Mamanguape)
Harvest 751 0 1 0 0
Interharvest 1011 0 0 0 0
Transitional (Esperanca)
Harvest 770 0 0 0 0
Interharvest 720 0 1 0 0
SertAo (Itaporanga)
Harvest 917 2 4 0 0
Interharvest 570 0 11 0 1

TABLE 4
Seasonal variation of xerophthalmia in
school children

No of clinical signs
No of
Region/period children
XN XIB X2 XS

Sert#{227}o(Itaporanga)
Harvest 649 1 2 0 1
Interharvest 759 2 13 0 0

school children the difference was also sig- TABLE 5

nificant (p < 0.02). PEM and xerophthalmia in preschool children
(Itaporanga 1981 and 1982)
The relationship between protein-energy
malnutrition (PEM) (as evaluated by anthro- Xerophthalmia
PEM criteria Total
pometric measurements) and xerophthalmia
Absent Present
in preschool children in the town of Itapor-
Wt for age
anga is shown in Table 5. Although the num-
>75% 1182 10* 1192
ber of cases is small, statistical analysis was Between 75 and 60% 260 6 266
performed and did not point to a clear trend; <60% 29 0 29
the difference in prevalence of xerophthalmia Ht for age
in children with height for age (h/a) below >90% 1088 6t 1094
<90% 383 10 393
90% as compared to the normal children was
Wt for ht
highly significant (p < 0.001). On the other >90% 1100 12* 1112
hand, if we analyze children with insufficient Between 90 and 80% 344 4 348
weight for age (w/a) or insufficient weight <80% 27 0 27
Total 1471 16 1487
for height (w/h) in comparison with normal
children, the difference in the occurrence of a NS.

xerophthalmia is not statistically significant, 1 p <0.001.

142 SANTOS ET AL

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 XEROPHTHALMIA IN NORTHEAST BRAZIL 143

TABLE 7 clinical signs of xerophthalmia. This may be

Prevalence of xerophthalmia in
due to two facts: first, the mortality rate
the SertAo
among this group is very high and probably
Observed prevalence in even higher if the PEM is associated with the
. . preschoolers WHO
Clinical
.
.
minimum lack of vitamin A; and second, the clinical
sign
Harvest Interharvesi prevalences
signs of xerophthalmia found in the field,
(n 2.802) (n 570)
mainly Bitot spots with conjunctival xerosis,
% % q
correspond to the initial stage of the disease.
XN 0.2 0.0 1
X1B 0.3 1.9 0.5 Although the results presented in Table 4
X2 0.0 0.0 0.01 indicate xerophthalmia to occur more fre-
XS 0.1 0.2 0.05 quently in the cronically malnourished chil-
dren (inadequate height/age), ifother criteria
were used to evaluate PEM such as weight
and none of the severely malnourished by
these criteria (w/a below 60% or w/h below for age (w/a) or weight for height (w/h) no
80%) had clinical signs of xerophthalmia. statistical difference was found. In addition,
All active cases of xerophthalmia were many cases ofBitot spots and night blindness,
which were reversible with vitamin A ther-

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treated with vitamin A as previously de-
scnbed. In most cases where a second visit apy, were found in children whose anthro-
was possible, these signs had disappeared pometric measurements fell within the nor-
ma! range. Sommer (12) also reported Bitot
completely. An example is shown in Table 6,
with the therapeutic response ofthe preschool spots with conjunctival xerosis, responsive to
children in the town of Itaporanga. Occasion- vitamin A therapy, in groups of children with
ally nonresponsive cases were found, such as good general nutritional status compared to
that of a 9-yr-old boy with bilateral Bitot the population of Indonesian children.
spots (of the caseous type), totally unsensitive It can therefore be stated with a good
to vitamin A therapy. Other workers have degree of confidence that vitamin A defi-
already shown that nonresponsive Bitot spots ciency is occurring as a specific problem in
are more likely to occur in school age children the Scrt#{227}oarea; this semiarid region, how-
(12). ever, is rather large and extends through other
Table 7 shows a comparison of the preva- northeastern states in which it is reasonable
lence observed in the preschool children in to expect a similar xerophthalmia problem.
the Sert#{227}o,with the WHO minimum criteria There was an association between severe
for considering xerophthalmia as a public xerophthalmia and a history ofrecent measles
health problem; some of the prevalences infection; most of the cornea! scars (five of
found meet, and others exceed, the minimum six cases) were recalled by the families to
criteria and according to WHO, it is sufficient have followed a measles episode. In the case
that one of the criteria is met or surpassed to of night blindness and Bitot spots the associ-
consider xerophthalmia as a public health ation was doubtful, with three of 1 1 cases for
problem. XN and four of 50 cases for X1B related to
measles. It should be added that the vacci-
Discussion nation coverage for measles and other infec-
tious diseases was very low in that area (San-
The xerophthalmia cases clearly showed a tos et al, unpublished observations).
geographical pattern, occurring most fre- The results indicate that xerophthalmia oc-
quently in the Sert#{227}oarea. The first question curs more frequently during the interharvest
to be asked was whether this distribution season, the increase being of particular statis-
could be correlated directly to the distribution tical significance in the Sert#{226}oarea. This
of PEM. Other workers, in the northeast of observation should be interpreted taking into
Brazil, had shown this correlation to exist in account that in the year this survey was con-
the case of serum levels of retinol (5). ducted the harvest in the Sert#{228}owas unusu-
In the present report, however, none of the ally poor due to a drought. Throughout the
acutely malnourished children found in the period of this survey the “Emergency
field (w/a below 60% or w/h below 80%) had Drought-Relief Program” was in action and
144 SANTOS ET AL
small farmers in the Sert#{227}oof Paraiba were
DC; Government Printing Office, 1965.
2. Batista M. Considera#{231}#{244}essobne o problema de vi-
enlisted to receive the relief funds in cash.
tamina A no Nordeste Brasileiro. Hospital
l969;75:8 17-32.
Conclusions 3. Batista M, Gomes SMF. Niveis s#{233}ricosde vitamina
A e caroteno em diferentes grupos et#{225}nios.Hospital
1) Xerophthalmia seems to be a public
1969;76:73-8.
health problem in the Sert#{227}oof Paraiba. 4. Chopra JG, Kevany I. Hypovitaminosis A in the
2) In the intcrharvest period the occurrence Americas. Am I Clin Nutr 1970;23:23l-4l.
of xerophthalmia is higher. 5. Gomes FS, Batista M, Vanela RM, Baizante MO,
Salzano AC. Plasma retinol levels of pre-school chil-
3) A study of serum levels of vitamin A
dren in the sugar cane area of Northeast Brazil. Arch
seems justified. Lat Am Nutr l970;20:445-51.
4) In the Sert#{224}oit is necessary to study the 6. Varela RM, Teixeira SG, Batista M. Hypovitami-
dietary pattern of the population and its sea- nosis A in the sugar cane region of Southern Pen-
nambuco state, Northeast Brazil. Am I Clin Nutr
sona! variation.
l972;25:800-4.
5) It would be useful to conduct similar 7. Flores H, Araujo CR0. Liver stores of vitamin A in
clinical surveys in the semiarid zones of the infants and pre-school children deceased in Recife.
neighboring states. Abstr Int Congr Nutr, Rio de Janeiro, 1978;l97

Downloaded from www.ajcn.org by guest on December 1, 2010

(abstr).
6) The present information provides fur-
8. Olson JA. Liver vitamin A reserves of neonates, pre-
therjusti.fication for a vitamin A relief action school children and adults dying of various causes
presently under study by the Brazilian Na- in Salvador, Brazil. Arch Lat Am Nutr l979;29:521-
tional Institute of Nutrition and the state 42.
authorities of Paraiba. 9. Simmons WK. Xerophthalmia and blindness in
Northeast Brazil. Am I Clin Nutr 1976;29: 116-22.
The authors thank the nurses Miss Rejane Santana 10. IVACG. Control of vitamin A deficiency and xer-
and Miss Evelyne Mainbourg and Profs Maria Jos#{233}CN ophthalmia, technical report no 672. Geneva; World
Benigna, Elizabete P Lins, Cleide M Lima, Eug#{234}nio de Health Organization, 1982.
Carvalho Jr, and Lenice MR Costa, for their collabora- 1 1. Marques RM, Berqu#{243} E, Yunes J, Marcondes NE.
tion. We are specially grateful to Dr. Malaquias Batista Crecimiento de niiios bnisile#{241}os: peso y altura en
and Dr Ivan Beghin for their scientific advice and en- relaci#{243}n con la edade y el sexo y la influencia de
couragement. factores socio-economicos, publicaci#{243}n cientifIca
309, Washington, DC: Organizacion Panamericana
References de la Salud, 1975.
12. Sommer A, Emran N, Tjakrasudjatma S. Clinical
I. ICNND-Interdepartamental Comittee on Nutni- characteristics of vitamin A responsive and non-re-
tion for National Development. Northeast Brazil- sponsive Bitot spots. Am J Ophthalmol l980;90:160-
nutrition survey, March-May 1963. Washington, 71.