EPIDEMIOLOGI

KVA
TOPIK 8
PREFACE
 Kurang Vitamin A (KVA) merupakan salah
satu masalah gizi kurang yang masih
dihadapi oleh negara-negara berkembang
termasuk Indonesia
 KVA  suatu keadaan, ditandai
rendahnya kadar Vitamin A dalam jaringan
penyimpanan (hati) & melemahnya
kemampuan adaptasi terhadap gelap &
sangat rendahnya konsumsi/masukkan
karotin dari Vitamin A (WHO, 1976)
 MAP OF VITAMIN A DEFICIENCY (VAD)
IN THE WORLD.1

Figure 1. Countries categorized by degree of public health importance of Vitamin A deficiency,

April 1995, WHO
 MAP OF VITAMIN A DEFICIENCY
IN THE WORLD.2

Source : KP West J Nutr. 2002 in Keith P. West, Jr., Professor Center for Human Nutrition Johns Hopkins
Bloomberg School of Public Health Baltimore, Maryland, April 16th, 2007
DATA WHO
 Setiaptahun  3-10 juta anak
menderita xeroftalmia dan 250.000
– 500.000 anak menjadi buta
 menyebabkan dediferensiasi;
keratinisasi sel epitel, perubahan
nafsu makan; xerofthalmia
Source : KP West J Nutr. 2002 in Keith P. West, Jr., Professor Center for Human Nutrition Johns Hopkins
Bloomberg School of Public Health Baltimore, Maryland, April 16th, 2007
Source : KP West J Nutr. 2002 in Keith P. West, Jr., Professor Center for Human Nutrition Johns Hopkins
Bloomberg School of Public Health Baltimore, Maryland, April 16th, 2007
BESARAN MASALAH KVA DI DUNIA
MATERNAL VITAMIN A
DEFICIENCY IN THE WORLD
 Maternal Vitamin A
Deficiency :
~10% of women
develop
night blindness in
latter half of
pregnancy in poorly
nourished South
Asian populations
Maternal night blindness = VA Deficiency
(that can directly affect mother & infant)

 40-day male India infant with keratomalacia (X3B),

unable to open eyes~3 days after birth. Eyes responded
to VA treatment. Mother had history of night blindness
throughout pregnancy.
Source : M Gupta et al Indian J Pediatr 2005;72:881 Keith P. West, Jr., Professor Center for Human Nutrition Johns
Hopkins Bloomberg School of Public Health Baltimore, Maryland, April 16th, 2007
 PERKEMBANGAN KVA
DI INDONESIA
 A nutrition survey conducted in Indonesia
in early 1970s  the prevalence of VAD
was very high.
 Indonesia  one of the first developing
countries to identify that high levels of
severe VAD constituted a serious public
health problem & began to implement
programs to eliminate the problem since
the 1970s (HKI, 2000).
CONTINUED…
 Since 1970s-1990s, Indonesia embarked
on a nation-wide vitamin A intervention
program by providing high-dose vitamin A
capsule twice a year to almost all under-
five children.
 Within 2 decades, the program 
successfully reduced the clinical
prevalence of VAD (xeropthalmia) to
0,33% in 1992, a level in which VAD was
no longer considered as a public health
problem.
PREVALENSI KVA DI
INDONESIA

No. Klasifikasi Tahun

1978 1992
1. X1B = Bercak bitot 1,3 0,33
2. X2/X3 = Xerosis kornea/keratomalasia 27,7 0
3. XS = Parut kornea 18,0 0

Sumber : Kodyat, B.A, dkk dalam Almatsier, 2002

CONTINUED…
 Sejak
tahun 1992
 Indonesia bebas xeropthalmia
 60 ribu anak balita disertai gejala
bercak bitot
(X-1b : Prevalensi 0,33%)
(SUVITA,1992)
Tidak merupakan masalah kesmas
CONTINUED…
 Namun masih dijumpai 10 juta
anak balita menderita KVA sub
klinis (50% balita : serum retinol
<20 µg/100 ml)
 > 1992  Tidak ada data nasional
prevalensi KVA
CONTINUED…
 Tingginya proporsi balita dengan
serum retinol <20 mcg/100 ml 
berisiko tinggi u/ terjadinya
xeropthalmia & me↓ tingkat
kekebalan tubuh  mudah terserang
penyakit infeksi
kapsul vitamin A dosis tinggi
CONTINUED…
 Tahun 1998
 Survei HKI daerah kumuh
perkotaan  masalah KVA
muncul kembali
 What is the current magnitude of VAD
prevalence in Indonesia is difficult to
speculate.
CONTINUED…
Indonesia  ada laporan lisan dari
 Di
beberapa propinsi
 timbul kembali kasus-kasus
xerophthalmia
 di NTB ditemukan kasus stadium
X3  anak menjadi buta
XEROFTHALMIA
 Istilah
yg menerangkan gangguan
kekurangan vitamin A pada mata,
termasuk kelainan anatomi bola
mata & gangguan fungsi sel retina
yg berakibat kebutaan
 Berasal dari Bahasa Latin : ‘Mata
Kering’
KLASIFIKASI KVA (Xeroftalmia)
XN : Buta Senja
X1A : Xerosis konjungtiva
X1B : Bercak bitot
X2 : Xerosis kornea
X3A : Ulkus kornea dengan xerosis
X3B : Keratomalasia
XS : Xeroftalmia scars
XF : Xeroftalmia fundus
Sumber : Depkes RI & HKI, 2002
WHO Xerophthalmia Classification (1982)
(Sommer & Davidson. J Nutr 2002)

 XN Night blindness (>1%) *

 X1B Bitot’s spots (> 0.5%)
 X2 Corneal xerosis or
 X3 Corneal ulceration/
Keratomalacia (> 0.01%)
 XS Corneal scarring (> 0.05%)
Serum retinol (>15%)
(<.70 umol/L/20 ug/dL)
*WHO minimum criteria for public health significance
Continued…
 Plasma Vit.A
< 0,35 µmol/l (10 µg/dl) : > 5%
Plasma Vit.A < 20 µg/dl
 rawan terhadap
penyakit infeksi & me↑
mortalitas
 Liver Vit.A < 5 µg/g : > 5%
Sumber : Depkes RI & HKI, 2002
PENYEBAB KVA

EXPOSURE OUTCOME

ASUPAN
VITAMIN A ↓ KVA
PENYEBAB KVA :
KURANG
PENGETAHUAN &
KEPERCAYAAN

KEADAAN ASUPAN VIT. A

EKONOMI RENDAH

NAFSU MAKAN
HILANG
KVA

PELARUT VIT. A
RENDAH
ABSORBSI &
KEP UTILISASI VIT. A

PENYAKIT INFEKSI

PENYEBAB TIDAK PENYEBAB

LANGSUNG LANGSUNG
CONTINUED…
 Deplesi Vitamin A dalam tubuh 
proses lama
 Dimulai dengan persediaan Vit. A
dalam hati habis  kadar Vit. A
plasma me↓  disfungsi retina
 perubahan jaringan epitel
Source : KP West in Semba & Bloem 2007, Johns Hopkins Bloomberg School of Public Health Baltimore, Maryland, April
16th, 2007
Sumber : Depkes RI & HKI, 2002
Sumber : Depkes RI & HKI, 2002
CONTINUED…
 Bayi prematur  Cadangan Vit.A
dalam hati rendah
 Konsumsi alkohol & m’derita sakit
liver  hati rusak  tidak mampu
menyimpan banyak Vit. A
 Obat-2an yang merubah absorpsi
lemak menghambat absorpsi Vit. A
CONTINUED…
 Penderita diare kronik, Chron’s
disease atau tidak cukup pankreas &
kondisi malabsorpsi lemak
 Di USA  KVA terjadi pada penderita
sindrom malabsorpsi lemak/diet ketat
spt anorexia nervosa
 Intake Zn tidak adekuat  simptom
KVA krn Zn dibutuhkan u/ p’gunaan
Vit.A secara efisien
PENENTUAN KADAR VIT.A
 Apabila terdapat kelainan mata 
kadar vitamin A serum (< 5 µg/100
ml) & kadar RBP (< 20 µg/100 ml)
sudah sangat rendah
 Konsentrasi Vit.A dalam hati 
indikasi yang baik u/ menentukan
status Vit.A
CONTINUED…
 Biopsi hati  tindakan yang
mengandung risiko bahaya
 Penentuan kadar Vit. A jaringan
tidak mudah dilakukan
 Konsentrasi Vit.A penderita KEP
rendah < 15 µg/gram jaringan
hepar (Pujiadji, 1989)
BATASAN & INTERPRETASI PEMERIKSAAN
KADAR VITAMIN A DALAM DARAH

UMUR (TAHUN) DEFISIENSI MARGIN CUKUP

Semua Umur < 10 µg/dl 10-20 µg/dl >20 µg/dl
DAMPAK KVA PADA BALITA
1 diantara 2 (48,1%) dari balita yg
menderita KVA  menderita anemia
kurang zat besi
(SKRT, 2001)
 Anak-2 yang KVA pada derajat
sedang berisiko tinggi untuk
mengalami gangguan pertumbuhan
(Hadi et. al., 2000),
CONTINUED…
 Di samping itu  menderita
beberapa penyakit infeksi
seperti campak & diare
 KVA bertanggung-jawab
terhadap 23% kematian anak
balita di seluruh dunia
(Beaton, 1997)
Source : Keith P. West, Jr., Professor Center for Human Nutrition Johns Hopkins
Bloomberg School of Public Health Baltimore, Maryland, April 16th, 2007
EVALUASI PROGRAM
PENANGGULANGAN KVA
 Konsumsi sayur & buah berwarna
 sangat penting, agar tidak
tergantung pada kapsul Vitamin A
 Kasus xeropthalmia  p’yuluhan
kons. sayur & buah tidak efektif &
cakupan kapsul Vitamin < 80% 
laporan bbrp propinsi (NTB, Sumsel) th
2000 & me↑ morbiditas pada balita
Vitamin A Intake of Children 12-59 months of
age in Rural West Sumatera (Survey HKI, 2003)

 Dietary intake of vitamin A 

important indicator of whether or not
a chronic problem of VAD is likely to
exist & indicates the need for
interventions to control VAD.
 The severest forms of VAD  in
terms of clinical symptoms, which
include night blindness, ulceration of
the cornea & full blindness.
CONTINUED….
 70% of children was estimated
blinded by VAD will die within the
year, & mortality rates 3-26% have
been observed among children with
corneal disease.
 Long before eye damage can be
observed, other body functions are
impaired
CONTINUED….
 This includes immune function, which
leads to increased morbidity &
mortality, often even before the
clinical eye signs of VAD have been
observed.
Data Collection Method
 The 24-hour Vitamin A Semi-Quantitative
(VASQ) method developed by HKI was used to
assess total VA intake for a 20% sub sample of
households.
 Mothers were asked to recall everything their
child ate or drank in the last 24 hours, & details
about portion sizes & cooking methods were
recorded.
 Vitamin A intake was estimated based on portion
size and vitamin A content of the food.
Findings:
 General - Vitamin A intake was well
below the Indonesian Recommended
Daily Intake and has improved little
over time.
 West Sumatra - Vitamin A intake in
West Sumatra was no more than one-
third of the Recommended Daily
Intake for children
 Gambar. Asupan Vitamin A Anak Usia 12-59 bln
Sumber : HKI, 2003 di Pedesaan Sumatera Barat
Vitamin A Capsule Coverage among Children
6-59 Months of Age in Rural West Sumatra
(Survey HKI, 2003)

 In recognition VAD as a public health

problem, the government of Indonesia
has set a target of 80% coverage with
vitamin A capsules (VAC) among
children 6-59 months of age12.
 All children in this group are to
receive age appropriate doses of
vitamin A twice a year.
CONTINUED….
 As there are two VA campaign distribution
months each year (February & August),
the achievement of this goal can be
evaluated by estimating the level of
coverage for each
IMPORTANCE
 Supplementation with VAC has been
shown to reduce clinical symptoms of
VAD such as xeropthalmia and to
reduce morbidity, mortality, and
blindness rates among children. In
Indonesia, a 34% reduction in
mortality was observed among
children supplemented with VAC
CONTINUED…..
A meta analysis of eight mortality
trials indicated that improving VA
status among children 6-59 months
of age reduces all-cause mortality
by 23%
Findings:
 General - Vitamin A capsule coverage has
increased considerably, reaching the target of
80% coverage in August 02 and February 2003.
 West Sumatra - VAC coverage increased from
August 1999 to February 2002, but modestly.
 Highest coverage was still below 60% in both
age groups, which is much below the target of
80%. No information is available for after
February 2002.
 Gambar. Pemberian Kapsul Vitamin A Anak Usia 6-59 bln
di Pedesaan Sumatera Barat
Sumber : HKI, 2003
Total Vitamin A Intake among Non- Pregnant Mothers
in Rural West Sumatera (Survey HKI, 2003)

 Low total dietary vitamin A (VA) intake

among populations where food
consumption is the predominant source of
VA indicates that vitamin A deficiency is
likely to exist.
Importance:
 Importance: VAD has the same
consequences for the mother as the
child.
 These include increased morbidity
and severity of illness, exacerbated
 anemia, and blindness and death
(refer to Total Vitamin A Intake
among Children 12-59 Months).
CONTINUED….
 However, maternal deficiency has the added
consequence of contributing to the poor health
status of the newborn.
 One study in rural Nepal found an increased
mortality rate of 63% among infants of night
blind women.
 Furthermore, VAD among lactating women
lowers the VA concentration of breast milk,
which can lead to a VAD among breastfed
infants.
Data Collection Method
 The 24- hour Vitamin A Semi- Quantitative
(VASQ) method was used to assess total VA
intake for a 20% sub sample of households.
 Mothers were asked to recall everything they ate
or drank in the last 24 hours, and details about
portion sizes and cooking methods were
recorded.
 Vitamin A intake was estimated based on portion
size and vitamin A content of the food
Findings:
 General - Vitamin A intake among nonpregnant
mothers was less than half of the Indonesian
Recommended Daily Intake (even less for
mother that are lactating since their RDI is
higher) for every rural province in every round of
data collection.
 West Sumatra – Vitamin A intake in West
Sumatra was no more than 40% of the
Recommended Daily Intake for non-pregnant,
nonbreastfeeding women.
VA and mortality related to pregnancy 12 wks Post partum

Placebo VA b -carotene VA or b- C

# Pregnancies 7,241 7,747 7,201 14,948

# Deaths 51 33 26 59

Mortality 704 426 361 395

(per 100,000 pregnancies)

RR 1.0 0.60 0.51 0.56

(95%CI) (0.37-0.97) (0.30-0.86) (0.37-0.84)

Refs : West et al 1999