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close this bookDelivery of Oral Doses of Vitamin A Deficiency and Nutritional Blindness: A State-of-the-art Review - Nutrition policy discussion paper No. 2 (UNSSCN, 1987, 120 p.)
View the document(introduction...)
View the documentUNITED NATIONS - ADMINISTRATIVE COMMITTEE ON COORDINATION - SUBCOMMITTEE ON NUTRITION (ACC/SCN)
View the documentACKNOWLEDGEMENTS
View the documentFOREWORD
View the documentINTRODUCTION AND POLICY IMPLICATIONS
View the documentCONCLUSIONS AND SUMMARY
Open this folder and view contents1. INTRODUCTION
Open this folder and view contents2. EFFICACY OF ORAL VITAMIN A
Open this folder and view contents3. VITAMIN A DELIVERY SYSTEMS
Open this folder and view contents4. MEASURES OF DELIVERY PROGRAMME EFFECTIVENESS
Open this folder and view contents5. POPULATION COVERAGE
Open this folder and view contents6. PROGRAMME CHARACTERISTICS
Open this folder and view contents7. PROGRAMME ECONOMICS
View the documentREFERENCES AND NOTES
View the documentALTERNATIVE STRATEGIES WITH EMPHASIS ON FOOD FORTIFICATION
View the documentCOMMENTS ON VITAMIN A SUPPLEMENTATION
View the documentCURRENTLY AVAILABLE TECHNOLOGIES IN INDIA TO COMBAT VITAMIN A MALNUTRITION
View the documentPROGRAMMATIC ISSUES IN VITAMIN A DOSE DELIVERY
View the documentDELIVERY OF LARGE DOSES OF VITAMIN A

COMMENTS ON VITAMIN A SUPPLEMENTATION

E.M. DeMaeyer

Dr. Edouard M. DeMaeyer is with the Nutrition Unit, World Health Organization, Geneva, Switzerland

Xerophthalmia has disappeared from industrialized countries during the 20th century in the absence of any special programme to control the disease. This is undoubtedly due to the improvement in the socioeconomic status of the population, accompanied by an increased dietary intake of vitamins, including vitamin A. Better sanitation, lover incidence of childhood diseases and gastrointestinal infections have certainly contributed to the disappearance by reducing the overall requirements for vitamin A and preventing a reduced intake during infectious episodes. The same trends are clearly occurring in a number of developing countries: this is the case, for instance, of such countries as Singapore and South Korea, where xerophthalmia has disappeared over the last thirty years. It is interesting to note that while xerophthalmia has disappeared, many of these countries are still fortifying some of their foods with vitamin A: margarine is typical of this practice. While carotenoids are added for aesthetic reasons, there is no doubt that the addition of retinol is motivated by nutritional objectives.

Xerophthalmia is still highly prevalent in a number of developing countries; most of them are located in Asia and in Africa, a few pockets remaining in Latin America and the Caribbean. In most of these countries, the socioeconomic situation will not improve at a sufficiently fast rate for the disease to disappear spontaneously within an acceptable length of time. Given the present tools available to correct the situation, action must be taken immediately. There is no doubt that the distribution of large oral doses of vitamin A constitutes at the present time the most effective answer to the problem. A programme of distribution can be organized relatively rapidly, using the health and social structures existing in the country. This type of programme has often been called an emergency or short-term programme. This appellation is somewhat misleading as it gives the impression that the programme will be terminated relatively quickly, say within a few years. However, even if this is true in some countries approaching a fair level of development, many others distribution of Vitamin A, especially targeted or medical distribution may be needed for many years to come if the population, and particularly children, are to be fully protected against vitamin A deficiency. A good example of this situation is the prevention of rickets in Europe which was achieved during this century by the administration of cod liver oil at weekly intervals or, more recently, using large doses of pure vitamin D once or twice a year. Although living habits have changed considerably over the last sixty years and children are commonly exposed to sunlight and provided, therefore, with sufficient vitamin D, the administration of a vitamin D supplement before and in the middle of winter is still widely recommended by the paediatricians and practised by mothers. It seems, therefore, that once a practice has been recognized as useful by doctors and parents alike, it may take a long time before it is discontinued, even if it is little or no more justified.

Several delivery systems for vitamin A supplementation have evolved. The selection of the most appropriate one is largely based on the strength of the health infrastructure and financial considerations. The “universal” distribution is, in principle, the most attractive and the most effective one. It is very difficult to cover 100% of the child population, and those who are left out are usually those at greatest risk. Compliance also decreases with time. The difficulty of reaching all children is illustrated by the distribution programme in Indonesia. The Nutrition Directorate of Community Health in the Indonesian Ministry of Health is the authority responsible for the vitamin A capsule distribution. The latter is carried out through four types of community outreach programmes, as follows:

1. The Special Vitamin A Distribution Programme is a vertical activity where single-purpose volunteers distribute capsules twice a year to children aged 1-6 years, under the supervision of district health centres (Puskesmas).

2. The Usaha Perbaikan Gizi Keluarga (UPGK), which stands for Family Nutrition Improvement Effort, is a programme that includes the weighing of children, distribution of oral rehydration salts and iron tablets, nutrition education, and help with home and village gardens. Vitamin A capsules are distributed twice a year.

3. The Nutrition Intervention Project (NIP), which has broadly-based nutrition activities, includes the distribution of first aid packages to selected primary health workers in several districts in four provinces. These packages include vitamin A capsules for distribution every six months.

4. The BKKBN, a family planning programme, includes a “nutrition package”, one of the components of which is the distribution of vitamin A capsules.

These four distribution systems operate in different parts of the country, and attempts are being made to test them for efficiency and results. In Lombok(1), for example, a survey conducted in 1977 revealed a high prevalence of ocular signs of vitamin A deficiency. The area was subsequently identified as a priority high-risk area and a massive dose vitamin A distribution programme was initiated. Vitamin A capsules were distributed using three systems: the Special Programme, UPGK, and NIP. A particular effort was made in 1982 to coordinate the activities of the various programmes in order to make them more effective. Capsule distribution was backed up by radio messages in order to increase public awareness of the significance of night blindness as an early sign of nutritional blindness and the importance of giving vitamin A capsules to children. Information concerning capsule distribution in Lombok is presented in Table 1.

TABLE 1

VITAMIN A CAPSULE DISTRIBUTION IN LOMBOK, INDONESIA, 1977-1982
(number of capsules in thousands)

1978

1979

1980

1981

1982

Special Programme

0

0

88.9

270.7

456.0

UPGK

0

27

68.4

--

--

NIP

5.4

16.2

16.2

36

36

BKKBN

0

0

0

0

0

Total number of capsules

5.4

43.2

173.5

306.7

492.0

Average number of children covered (in 000's)

2.7

21.6

86.7

153.3

246.0

Total number of children covered (percentage)

0.8%

6.8%

27.1%

47.9%

76.9%

The results of the Lombok evaluation indicate that the prevalence of xerophthalmia decreased dramatically during the period 1977-1982. The prevalence of Bitot's spots decreased from 1.6% in 1977 to 0.24% in 1983 (p < 0.01) (See Figure 1). The prevalence of corneal xerophthalmia decreased from 0.21% in 1977 to 0.04% in 1983 (p < 0.01). While the prevalence of corneal scars remained about the same - 0.21% in 1977 compared with 0.2% in 1983 - it should be noted that the majority of scars detected in 1983 were more than two years old.

All data indicate that there is a marked decrease in the prevalence of xerophthalmia in Lombok since 1977. In the absence of a control group it is not possible to attribute the decline to the vitamin A distribution programme alone; other factors such as changes in the socioeconomic status of the population may also have contributed to the improved situation. One thing is certain, however: in those areas throughout Indonesia where distribution programmes have been pursued with diligence, the prevalence of xerophthalmia has decreased, and in those areas where there are no control programmes, prevalence has remained stable, or even increased.

The difficulty of reaching a significant percentage of children is veil illustrated in the case of Indonesia, where it was necessary to set up a special programme of distribution to achieve a significant coverage.

Dose of Vitamin A. So far, a dose of 200,000 IU of vitamin A has been used routinely. The vitamin A may be diluted in vegetable oil or presented in the form of capsules. In some instances, secondary effects such as nausea, vomiting and headaches, have been observed in a small percentage of children after administration of the vitamin. If the supplement is given for medical reasons such as measles, diarrhoea, pulmonary infections or protein energy malnutrition, there is always the possibility that the administration is repeated several times, causing eventually a state of hypervitaminosis A and the occurrence of signs of toxicity. It has, therefore, been suggested that a smaller dose, say 100,000 IU would be more appropriate when the supervision of the distribution system is weak. This obviously reduces the length of protection but insures a greater safety of the programme. These two factors must be carefully weighed; indeed, it is difficult to use simultaneously the two dosages for logistic reasons and also because of the danger of confusion among little trained personnel.

Nutrition education. There is no doubt that sensitization of the public and especially of the parents is essential for the success of a distribution programme. All types of media, including radio, TV, newspapers and posters, can and should be used to achieve this objective.

Another form of supplementation can be achieved through fortification of food with vitamin A. As mentioned above, this has been practiced for several decades in many industrialized countries. It can also be implemented in developing countries provided that the right food vehicle(s) is identified and that other necessary conditions are fulfilled. A well-designed food fortification programme has the great advantage of reaching almost automatically every individual; once the programme has been launched, the cost is very low in terms of expenses per caput per year. Preparing a fortification programme cannot be done on a crash basis. Identification of the food vehicle(s), development of the fortification technology, field testing, enactment of necessary legislation, setting up control laboratories, training supervisors and inspectors, are all steps that require some time, usually three to four years at minimum. Financially sound programmes can be continued over long periods of time without requiring great expenditures of time or effort. Over the medium term, fortification programmes whenever they are applicable constitute an effective alternative to the distribution of supplements.

A number of trials have been undertaken to test the feasibility and effectiveness of fortifying tea, cooking oil, monosodium glutamate and sugar with vitamin A. As a result of the studies, sugar has been fortified with vitamin A since 1976 in Costa Rica, Guatemala, Panama and Honduras. Fortification was still going on in 1985 in Guatemala and Honduras, whereas it had been discontinued in Costa Rica and Panama because vitamin A dietary intake had apparently improved sufficiently so as to make it unnecessary. The changes in the vitamin A status of the Guatemalan population have been assessed after one and two years of fortification; these were spectacular in terms of increased vitamin A concentrations in the blood, liver and breastmilk of almost all individuals and provide an excellent illustration of the effectiveness of a veil-designed fortification programme in correcting a nutrient deficiency.

Increasing the vitamin A dietary intake of the population and especially of young children is obviously the long-term solution. It is possible in certain cases to achieve this objective in the absence of major advances in socioeconomic development through nutrition education or through increased availability of vitamin A-rich foods. Development of horticulture, and of small husbandry schemes including fish culture can be done independently and can contribute significantly to the vitamin A intake of the population. Most of these schemes take a certain time to develop and require capital investment. There is no doubt that they should be undertaken but one must realize that their results will not become apparent before a certain time. The right combination of required measures will vary from country to country and, possibly, from region to region within countries.

In conclusion, periodic supplementation with large doses of vitamin A is an effective and possibly the only measure that can be taken on a crash basis to control xerophthalmia whenever it constitutes a public health problem. Primary health care can play a major role in facilitating the distribution of the vitamin A supplements. Once a supplementation programme has been established, medium- and long-term approaches should be developed which could lead to a permanent improvement of the vitamin A status of the population.

REFERENCE

(1) WHO Weekly Epidem. Rec. 17, 1984, pp. 129-130.