Mortality associated with mild, untreated xerophthalmia

The high mortality rate among children with severe corneal xerophthalmia is well recognized. The present study investigates, for the first time, mortality among the very much larger number of otherwise healthy free-living children with mild xerophthalmia (night blindness and Bitot's spots). An average of 3481 children (under 6 years of age) living in six Indonesian villages were reexamined by an ophthalmologist, pediatrician, and nutritionist every 3 months for 18 months. The overall prevalence of mild xerophthalmia was 4.9%. During the 18 months of observation, 132 children died. Of these, 24 had mild xerophthalmia and 108 had normal eyes at the 3-monthly examination preceding their death. Mortality rates were calculated for each 3-month interval by classifying all children by their ocular status at the start of the interval, and then dividing the number of deaths within the interval by the number of children of the same ocular status followed up for that interval. Mortality rates for the six 3-month intervals were then added together, and the results expressed as deaths per 1000 "child-intervals" of follow-up. Overall mortality rates for children with mild xerophthalmia and for children with normal eyes were 23.3 and 5.3, respectively, a ratio of 4 to 1. Excess mortality among the mildly xerophthalmic children increased with the severity of their xerophthalmia. Mortality rates for children with night blindness, with Bitot's spots, and with the two conditions concurrently were 2.7, 6.6, and 8.6 times the mortality rate of non-xerophthalmic children. This direct, almost linear relation between mortality and the severity of mild xerophthalmia was still present after standardizing for age and for the presence or absence of respiratory infection and protein-energy malnutrition. In the population studied, 16% of all deaths in children 1 to 6 years of age were directly related to vitamin A deficiency identified by the presence of mild xerophthalmia. These results suggest: that the existence of mild vitamin A deficiency in a community justifies initiation of vigorous intervention measures to reduce mortality, as much as to prevent the rarer cases of blindness; that night blindness and Bitot's spots should be accorded the same respect as is low "weight for height" in identifying those children in urgent need of medical attention; that ocular criteria used for determining the existence and severity of a vitamin A problem be reevaluated; and that the ophthalmic community, which has long been responsible for managing xerophthalmia, must now re-alert nutritionists, pediatricians, and public health workers to the serious systemic consequences accompanying even mild