[e-drug] T-shirts and hypervitaminosis-A

["Vijay Thawani" <vijaythawani@rediffmail.com>]

E-DRUG: T-shirts and hypervitaminosis-A
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[A nasty side-effect of T-shirts... WB]

Dear E-druggers,

In the city of Nagpur, in central India, couple of days back >60 children from a slum in Indira Nagar, who received oral Vitamin-A supplement, took seriously ill and had to be admitted in a Govt Hospital. Some of the children are still reported to be in hospital. Media reports that the tragedy occured as a result of overdose of Vitamin-A, because the children were offered inducement of T-shirt by Rotary club for taking the oral dose of vitamin-A. Some children repeatedly went, took two caps(sic)(cap of the bottle) full of oral vitamin-A every time, and collected a T-shirt every time. An activist doctor of the area, where this programme was carried out, has gone on record to state that he knew of children who went >6 times in couple of hours!

The Network for Rational Use of Medicines (NetRUM) fact sheet on the topic states:

Vitamin-A preparations should be stored <15 degree Celsius. After opening the bottle it should be used at once.(British Pharmacopeia. University Press, Cambridge, London. 1980, Vol 1: P 474 - 475).

Vitamin-A is lipophilic and therefore rapidly absorbed from GIT. Acute toxicity results in severe headache, vomiting, drowsiness, irritability, papilledema. After 24 hours there is generalized peeling of the outer layer of skin. The hypervitaminosis-A is characterized by dry purpuric skin, dermatitis, skin desquamation, pain and tenderness of bones, anorexia, fatigue, ecchymosis, anemia, hepato spleenomegaly.(Kamal Kishore, Seth SD, Seth Vimlesh. The vitamins. in Text Book of Pharmacology. Ed S D Seth. 2nd edition, Chapter 21, P 780-781).

Vitamin-A is very cummulative because it is stored in liver and fat. Hence the effects take weeks to wear off. It is also teratogenic. The Teratology Society advices that supplementation should not exceed 8000 IU (2400 µg) per day. (Bennett P N, Brown M J.  Eds.  Vitamins. calcium, bone.  in Clinical Pharmacology. 9th edition, 2003. Churchill Livingstone. Chapter 38. P 735-736.)

The severe headache is due to raised intra cranial tension. The risk of hypervitaminosis increases with protein malnutrition.  Retinol > 100 µg/dl (3.5 µ M) in plasma is diagnostic of hypervitaminosis-A. Most signs and symptoms disappear within a week. Desquamation and hyperostosis remain evident several months after recovery and in rare cases bone malformations may be permanent. Long term and irreversible damage to liver may also occur.(Markus R, Coulston A M. Fat soluble vitamins: vitamin A, K and E. in Goodman and Gillman?s The Pharmacological Basis of Therapeutics. Eds J G Hardman, L E Limbird.10th International edition. 2001. McGraw Hill. Chapter 64).

In Assam,India, in 2001 death of a two year old child after consumption of Vitamin-A triggered mass concern and thousands of people rushed their children with complaints of fever, vomiting and diarrhea to nearest health centre after prophylaxis with vitamin-A. All deaths and illnesses that occurred in children during the subsequent weeks were attributed to vitamin-A.(Kishore J. National program for prophylaxis against blindness in children caused due to vitamin-A deficiency. in National Health programs of India: National policies and legislations related to health. 5th edition 2005. Century Publications, New Delhi. Chapter 13 D, P 207).

What lessons do we learn from the Nagpur accident? Should inducements be offered for mass vaccinations or nutrition supplementation programmes? Can children be blamed for the repeat visits and called greedy of the inducement? Should not the recipients of dose be physically marked with some indeliable ink on visible, fixed spot of the body for easy identification so that they can be identified easily if they visit again? Who should be held responsible for such inducible problems? 

regards from India,

Dr Vijay Thawani

Dr Vijay Thawani,
14-A, Jeevan Jyoti, Clarke Town,
Nagpur-440 004, India.
Net group: http://health.groups.yahoo.com/group/netrum
Blog: http://vijaythawani.blogspot.com
Land line:(Res)+91-712-2522977
Cell: +91-9970195474
vijaythawani@rediffmail.com