The document discusses about xerophthalmia and its present situation in global and National level (Nepal). It also focusing on how school based intervention work against Xerophthalmia along with intervention from government of Nepal.

1. School-based Programs to Prevent
Xerophthalmia
Bishal Poudel, Shweta Karn
Students of Bachelor of Public Health (2nd
Batch, 6th
semester)
Madan Bhandari Academy of Health Sciences, Hetauda, Nepal

2. Xeropthalmia
• Xerophthalmia refers to the constellation of ocular (related to eye) signs and
symptoms associated with Vitamin A deficiency.
• It includes conjunctival and corneal xerosis, Bitot's spots, keratomalacia,
nyctalopia, and retinopathy.
• There are two causes of Xerophthalmia. First, it may be caused by reduced
dietary intake of Vitamin A, which is more often seen in developing countries.
• The second cause includes cases of Xerophthalmia unrelated to dietary
Vitamin A intake. It is seen sporadically and may be caused by various defects
in Vitamin A metabolism and storage and include chronic liver disease
(alcoholism, upper gastrointestinal surgery, inflammatory bowel disease,
pancreatitis).

3. • A plasma or serum retinol concentration <0.70 μmol/L indicates subclinical vitamin A deficiency in children
and adults, and a concentration of <0.35 µmol/L indicates severe vitamin A deficiency. (Source: WHO)
• An estimated 250 000–500 000 children who are vitamin A-deficient become blind every year, and half of
them die within 12 months of losing their sight.
• Deficiency of vitamin A is associated with significant morbidity and mortality from common childhood
infections, and is the world’s leading preventable cause of childhood blindness. ( Source: WHO)
• In 1981, Nepal Blindness Survey shows that the prevalence of Bitot's spots and night blindness, forms of
xeropthalmia, exceed WHO cut-offs for a public health problem
• The Government of Nepal initiated the National Vitamin A Program (NVAP) in 1993 to improve the vitamin
A status of children age 6–59 months.
• The 1998 National Micronutrient Status Survey suggested that nearly 17% of children aged 6–59 months
had subclinical vitamin A deficiency, as measured using serum retinol.
• By 2016, the prevalence of children with deficiency was assessed at 8.5%, as measured using retinol
binding protein and 4.2% according to the modified relative dose response assay (National Micronutrient
Survey 2016).

4. Cut-off values for public health
significance
Indicator Prevalence public health significance
Serum or plasma retinol
<0.70 μmol/L in preschool-age
children
< 2%:
2-9%:
10-19%:
≥ 20%:
No public health problem
Mild public health problem
Moderate public health problem
Severe public health problem
Night blindness (XN) in pregnant
women
≥ 5%: Moderate public health problem
Source: WHO, 2009

5. School based programs to prevent
Xerophthalmia
• Schools are frequently the focal point of nutrition interventions because most children
spend a substantial proportion of their day in school. Furthermore, schools offer a
natural setting for education, with the potential to reach parents as well as children,
and teachers are often seen as role models. Hence, school-based interventions have
the ability to reach many children and families.
Role of schools:
• Nutrition education + behavior change
• Provision of Vitamin-A-rich (fortified foods) through schools meals or snacks
• Catchup measles vaccination through school health days
• School-based deworming
• Screening and referral services

6. • Nutrition education: School/community gardening and education
programs increase fruit/vegetable intake—useful for promoting provitamin
A foods (dark-green leaves, orange/yellow veg, eggs, dairy), especially
when paired with school meals and take-home messaging.
• Provision of Vitamin-A-rich (fortified foods) through schools' meals
or snacks:
• Fortified biscuits / snacks for primary schoolchildren improved serum
retinol and other micronutrients, and reduced deficiency markers
• Vitamin A–fortified foods (oils, flours, rice, dairy) reduce deficiency and
thus can be integrated into school feeding

7. • Catch-up measles vaccination through school health days: Measles
worsens vitamin A deficiency and is linked to corneal blindness; high-
coverage measles vaccination prevents measles and its eye complications.
Schools are effective venues for catch-up campaigns
• School-based deworming: Deworming (where helminths are endemic)
supports nutritional absorption and is commonly bundled with school
feeding/fortification or micronutrient snacks.
• Screening & referral via School Eye Health: Training teachers/school
nurses to spot night blindness history and Bitot’s spots and refer for
treatment. In Nepal, we can utilize school health nurses for these
interventions.

8. Community based interventions
Nepal Government has initiated National Vitamin A Program (NVAP) in 1993 to improve
Vitamin A status of the children aged 6 59 months
‐ and reduce child mortality. Under this
program, FCHVs (at the community level) distribute the vit. A capsule to the targeted
children twice a year, which takes place nationally in every ward on first week of Baisakh
and Kartik each year to the children between 6- and 59-month age through a campaign-
style activity.
Dosage of vitamin A supplementation
 200,000 IU for postpartum mother
 200,000 IU for children 1-5 years
 100,000 IU for < 1 years

9. Sources
• Feroze KB, Kaufman EJ. Xerophthalmia. [Updated 2023 Apr 17]. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431094/
• Vitamin A deficiency, https://www.who.int/data/nutrition/nlis/info/vitamin-a-deficiency (accessed 25 August
2025).
• Imdad, A., Herzer, K., Mayo-Wilson, E., Yakoob, M. Y., & Bhutta, Z. A. (2010). Fortification of staple foods
with vitamin A for vitamin A deficiency. Cochrane Database of Systematic Reviews, 12, CD010068.
https://doi.org/10.1002/14651858.CD010068.pub2
• Tee, E. S., Kandiah, M., Awin, N., Chong, S. M., Satgunasingam, N., Kamarudin, L., & Hussein, R. (1999).
School-administered fortified biscuits improve micronutrient status of Malaysian primary school
children. The American Journal of Clinical Nutrition, 69(6), 1240S–1247S.
https://pubmed.ncbi.nlm.nih.gov/10075336/
• Bere, E., Veierød, M. B., Skare, Ø., & Klepp, K. I. (2014). The impact of a school gardening intervention
on fruit and vegetable intake among children: A cluster randomized controlled trial. International Journal
of Behavioral Nutrition and Physical Activity, 11, 99. https://doi.org/10.1186/s12966-014-0099-7
• World Health Organization. (2022). Vitamin A supplementation and integration with child health services.
WHO.
https://www.who.int/teams/immunization-vaccines-and-biologicals/essential-programme-on-immunization/int
egration/linking-with-other-health-interventions/vitamin-a