Vitamin A Supplementation

The use of supplements to eliminate vitamin A deficiency is a notable success, with remarkable advances achieved within the past decade. Although the elimination of vitamin A deficiency by year 2000 was one of the goals set at the World Summit for Children in 1990, little progress was evident at mid-decade. Clinical vitamin A deficiency was estimated to affect approximately 3.3 million children younger than the age of 5 years in 1995, with an additional 100 million subject to subclinical deficiency. The periodic distribution of high-dose vitamin A supplements, originally employed in Indonesia during the 1970s for the prevention of blindness in children, was shown in the 1980s to also impact young child mortality. The supplements have the advantage of ensuring requirements for 4-6 months after administration, such that two or three capsules per year can meet vitamin A requirement of preschool children.

The lack of perception of vitamin A deficiency as a problem was a substantial barrier to establishing large-scale preventive supplementation programs. The prevalence of clinical signs of frank vitamin A deficiency, such a Bitot's spot and corneal lesions, that make it a 'public health problem' is very small at just 0.5%. Since clinical signs are often more common in rural populations, a significant vitamin A deficiency problem can easily go undetected. National representative surveys were thus a prerequisite for taking action. Another barrier is the voice of those who advocate for food-based approaches and view supplements as technical fixes or golden bullets that are of questionable sustainability promoted by the pharmaceutical sector. In reality, of course, these are not either/or options.

Convincing proof of the efficacy of vitamin A capsules for child mortality reduction in the early 1990s helped to create increased momentum for populationwide preventive supplementation programs. The turning point for increasing the coverage of vitamin A supplements was undoubtedly the publication of a meta-analysis of the efficacy trials of massive-dose vitamin A capsules. The analysis of eight mortality trials indicated that improving the vitamin A status of children aged 6 months to 5 years by massive-dose capsule distribution reduced child mortality rates by approximately 23%. The important conclusion of the meta-analysis was that increased risk of mortality from vitamin A deficiency was not just limited to those portions of the population with severe vitamin A deficiency problems but was present across the whole population distribution.

What consisted of 'the justification' for carrying out vitamin A supplementation programs evolved rapidly during the latter half of the 1990s. Many of these discussions were held at the meetings of the International Vitamin A Consultative Group and the working group on vitamin A of the Standing Committee on Nutrition of the United Nations. A broad technical consensus was finally accepted that even in the absence of survey data, it was highly likely that the benefits of vitamin A supplements would be evident in populations in which the mortality rates for those younger than 5 years old were higher than 70 per 1000. Prior to this, vitamin A supplements were targeted to those children with illnesses such as measles and diarrhea. The most recent programmatic recommendations are that if mortality for those younger than 5 years old is higher than 50 per 1000, then supplements should be employed routinely as a preventive measure for all young children. Subsequent to this consensus, a global policy to integrate vitamin A capsule distribution into regular immunization schedules, and also to incorporate vitamin A capsules into the national immunization campaign days being promoted to achieve the eradication of polio, was rapidly adopted.

Programmatic vitamin A interventions received considerable impetus from the Vitamin A Global Initiative, an informal interagency advocacy group that worked to promote the adoption of vitamin A supplementation programs. The initiative included WHO and UNICEF, together with CIDA from Canada, DIFID from the United Kingdom, USAID from the United States, and the Micronutrient Initiative (MI). Through their networks, these various organizations worked together to convince governments with high mortality rates for children younger than age 5 years to introduce periodic vitamin A capsule distribution programs. Vitamin A capsules were made available by CIDA through UNICEF to any developing country that wanted them, and UNICEF and MI with USAID and DIFID funds developed a global communication campaign.

By the end of the 1990s, vitamin A supplementation programs had seen a remarkable expansion. Most countries with high mortality rates for children younger than 5 years old adopted vitamin A supplementation programs, with the most notable exception being India. The number of countries with vitamin A programs increased from 10 in 1995 to 72 in 2000. The ways in which the vitamin A capsule programs were developed and implemented varied by country, but the most common strategy was to use national immunization days for polio eradication to piggyback vitamin A supplements. The use of this approach doubled from 30 countries in 1997 to 60 in 1999. Because the polio eradication strategy requires two nationwide campaigns not more than 2 months apart, some countries also promoted separate micronutrient days, or child health days, so that children would get at least two capsules during the course of a year, 6 months apart. UNICEF procured through its central warehouse in Copenhagen and supplied through its country programs an average of 289 million capsules per year from 1993 to 1998, which was estimated to be only 38% of the worldwide need.

Estimates of the coverage of vitamin A capsules indicate a remarkably high coverage of supplements by the turn of the century, with remarkable saving of life. Based on multiple sources, UNICEF estimates that in 1999 half of all children aged 6-59 months in developing countries outside of China, and 80% of such children in the least developed countries, received a vitamin A capsule within the past 6 months. Coverage was highest in sub-Saharan Africa, where 70% of children aged 6-59 months received a capsule in the past 6 months. Extrapolation of the protective effect of a 23% reduction in child mortality shown by the meta-analysis to the increased coverage of capsules achieved between 1998 and 2000 suggests that 1 million lives were saved in this short period.

The challenge that remains for vitamin A supplementation is one of sustainability. Although supplements are traditionally viewed as a short-term solution, in reality they need to be maintained during at least the medium term if continued gains in mortality reduction are to be realised. Increases in other sources of vitamin A, be it through diet and/or fortification, are unlikely to be achieved in the short term. The eventual phasing out of national immunization days, as polio eradication becomes a reality, will cause problems for maintaining the high coverage of vitamin A capsules. Alternate strategies are needed and are being put in place in many countries. Bangladesh and Nepal are two examples of countries that successfully promote biannual micronutri-ent days with large-scale social mobilisation efforts. Sustaining the provision of the vitamin A capsules is also likely to become a problem. Until now, supplements have predominantly been provided by the Canadian government and supplied through UNICEF, and how long this will be sustained is not known. The costs for individual governments to take on are small, however, and the benefits in terms of lives saved will likely remain enormous for many decades.

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