The present cross-sectional descriptive study was undertaken between January and July 2009. The study population comprised all the under-five children (0-60 months) residing in these areas (n=3679). Of these, 108 could not be included because of various reasons; 3571 children formed the study subjects. Ethical clearance was obtained from the Institutional ethics committee.

A house-to-house survey was carried out and information was obtained as per a predesigned proforma that included the identification data, and sociodemographic and environmental profile of the child’s family. The social class of the child’s family was determined using the Modified Prasad Scale [4]. Social classes I, II and III of the modified Prasad’s classification are categorized as upper class and IV and V as lower classes. A precise history of dietary intake and vitamin A containing foods was elicited from the mother (recall of food items consumed in last 24 hours). Appropriate breastfeeding was defined as exclusive breastfeeding for six months of age and continued up to two years along with semi solids. Complementary feeds given in recommended amount and frequency as per WHO guidelines [5] was labelled as appropriate feeding. Second part of the proforma consisted of anthropometry and general physical examination of the child including signs of xerophthalmia. One pediatrician and eight post-graduate students from the Departments of community medicine and ophthalmology comprised of the field unit. All children with positive clinical findings and a systematic sample of 1 in 50 of those with a negative clinical finding were examined by a senior pediatrician. If any positives were detected from the negatives, then all the negatives of that day were re-examined by the senior pediatrician. The first four questions of the WHO algorithm listed below [6] for assessment of night blindness were enquired from mothers of children above two years of age, viz (i) Do you/does your child have any problem seeing in the daytime? (ii) Do you/does your child have any problem seeing in the evening or in low levels of light?, (iii) If (2)=yes: Is this problem different from most other children/women in your community?, (iv) Do you/Does your child have ‘Rataundhi’ ? (The local term for XN).

Proxy reports from mothers were used for children. All participants (including mothers) who complained of having a problem seeing in low levels of light but no problem seeing during the day; and which were different from most other children/women in their community were considered to be having night blindness. They were asked to give examples of the problem (spontaneous complaints). If no spontaneous complaints were reported, they were asked whether, in low levels of light, they were able to see something (eg food) that had been put in front of them, were able to play or work, or were prone to walk into or to trip over objects (prompted complaints). Standard methods and procedures for ophthalmic examination were used to detect signs of xerophthalmia [7]. Ocular examination was done with the help of a bright illuminant torch. WHO classification [8] was adopted to grade the severity of xerophthalmia. Conjunctival xerosis in isolation was not included as a marker but was considered when accompanied with Bitot’s spots or a positive Kajal sign [9]. Kajal is a formulation of lamp black mixed with oil used as an ocular cosmetic. It stains the xerotic areas in the eye black which makes XIA and XIB lesions stand out. Nutritional assessment was done using CDC 2000 reference standards. Age and sex specific –2 Z-scores were followed to define wasting and stunting. Statistical analysis was carried out by chi-square test and odds ratio with its 95% confidence interval. Binary logistic regression was used to do the multivariate analysis.

Age and sex distribution of the study population is shown in Table I. Mean age of the participants was 36±21 months. The urban and rural sex ratios were 0.83 each. Prevalence of xerophthalmia in the present study was 9.1%. There was a rising trend in the prevalence and severity of xerophthalmia with increasing age (Table II). The difference in xerophthalmia prevalence among under two and over two years age groups was statistically signi-ficant (P<0.001). Table III depicts the socio demographic and maternal factors in relation with xerophthalmia. Univariate analysis revealed lower socioeconomic status, rural status, illiterate or working mother, incomplete immunization and inappropriate care seeking behavior to be signi-ficantly associated with xerophthalmia. A large number of children were underweight (32%), stunted (65%) and wasted (72%) but xerophthalmia was significantly associated with wasting alone (Table IV). Other risk factors associated with xerophthalmia are also depicted in Table IV. Multivariate binary logistic analysis obviated the potential confounding factors that were statistically significant on univariate analysis. An inadequate intake of proteins and vitamin A containing foods as well as predominant maize diet emerged significant dietary factors.

TABLE I  Age and Sex Distribution of the Study Population

We conclude that the undisputed long-term solution to prevent this nutrition-related, avoidable blindness lies in changing the dietary habits of the rural Indian population through behavior change communication by nutritional education, nutritional supplementation, and nutritional rehabilitation. Fortification of staple cereals like maize through innovative food engineering technologies can go a long way towards alleviation of the problem. Routine screening of ‘at risk’ children for signs of xerophthalmia by peripheral health workers will help in early detection and treatment. Prompt prophylaxis of contacts of affected children would address the potential subclinical cases. Research is required into factors responsible for clustering of cases in specific areas.

Contributors: All authors were involved in all aspects of the study and manuscript preparation.

Funding: Department of Community Medicine, JN Medical College, AMU, Aligarh.

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