ACC/SCN statement: The control of vitamin A deficiency

The following statement was agreed upon by participants in the ACC/SCN Consultative Group meeting on Strategies for the Control of Vitamin A Deficiency held at the Micronutrient Initiative, in Ottawa, Canada, 28-30 July 1993, and supported by the Canadian International Development Agency and the Micronutrient Initiative.

The elimination of vitamin A deficiency as a public health problem has been identified as a high priority in international nutrition and health by the International Conference on Nutrition, the World Summit for Children, and the World Health Assembly. Control of vitamin A deficiency in many areas of the world will lead to substantial and lasting improvement in childhood survival as well as preventing the scandal of irreversible blindness due to malnutrition.

The cause of vitamin A deficiency is a lack of preformed vitamin A, carotene, and sometimes fat and oil in the diet. The year-round availability and adequate consumption of vitamin A-/carotene-rich foods and dietary fat will be required to eradicate the deficiency. Because prevention of vitamin A deficiency is an integral part of the overall strategy to improve nutritional wellbeing and child health, and to conserve limited resources, vitamin A programmes should be integrated with other programmes concerned with health and development. Efforts to identify, advocate, plan, implement, evaluate, and monitor the control of vitamin A deficiency should, as far as possible, be combined with the control of other coexisting nutritional deficiencies. The following specific points concerning vitamin A deficiency control were agreed:

1. A combination of interventions is usually needed to prevent vitamin A deficiency; these include dietary modification (including the production, processing, marketing, and consumption of vitamin A-/carotenerich foods), breast-feeding promotion, food fortification, and supplementation. The appropriate combination of interventions may change over time, depending on trends in the level of deficiency, programme outreach to vulnerable population groups, availability of technical inputs, and administrative and political priorities.
2. Periodic situation analyses and the evaluation of programme cost-effectiveness provide a basis for adjusting strategies, especially in relation to population responses to intervention activities, and provide the opportunity for phasing out programme components, as appropriate.
3. In all circumstances, the promotion and protection of breast-feeding is a fundamental aspect of preventing deficiency of vitamin A. Promotion should include attention to initiation, optimal breast-feeding practices, and duration, as required by local situations. Enhancing the nutrition status of the mother is a valuable component of such breastfeeding promotion activities.
4. Nutrition education is an essential component of programmes aimed at preventing vitamin A deficiency. Dietary modification can also be supported by other means, such as social marketing and promotion of home production.
5. If dietary sources of vitamin A are not readily available to those at risk of deficiency, intervention activities should include improving their availability. Efforts may be needed to improve the production, processing, preservation, pricing, and marketing of such foods. Bioavailability of the vitamin A should be increased by ensuring that diets contain sufficient fat and that intestinal parasites are controlled.
6. Dietary modifications that increase vitamin A intake will often improve the status of other micronutrients, particularly iron and vitamin C. For example, many foods that promote iron absorption (especially green leafy vegetables, animal products, and some fruits) are also good sources of vitamin A. Furthermore, improving vitamin A status can also improve iron status through an interaction between these two nutrients. Therefore, a combined food-based approach to deficiencies of vitamin A and of iron should be pursued.
7. Where feasible, food fortification is a highly recommended intervention for the prevention of vitamin A deficiency. Consumption of processed foods by the target population, food technology expertise, and multi-sectoral commitment are requisites for successful food-fortification programmes. Social marketing may also have an important role in increasing awareness of the problem and creating demand for action. Early participation of the food industry in this process and an effective food control system are essential.
8. In situations where vitamin A deficiency is endemic in the population, certain opportunities may be taken to provide high-dose preparations of vitamin A. The first of these is with immunization contacts from six months of age, especially the nine-months measles contact.* Secondly, if the mother is in contact with health services (e.g., attended delivery or postnatal visit), provision of a single large dose of vitamin A within the first four weeks after birth can improve the vitamin A content of breast milk and hence offer protection for the breast-fed infant. Thirdly, for children between one and five years, other contacts with health services may also be appropriate for providing supplements; in this case adequate record-keeping is necessary to reduce the dangers of excess supplementation and to ensure that potency of preparations is maintained by regular turnover of stocks.
9. Case management of measles and of severe protein-energy malnutrition requires the therapeutic use of high-dose preparations of vitamin A where there is a risk of sub-clinical deficiency; this use should not be limited to children with clinical vitamin A deficiency. The goal here is an immediate effect on the course of morbidity and on reduction of case fatality rates. Such case management is complementary and additional to approaches for controlling vitamin A deficiency at a population level.
10. Political support and sustained allocation of government resources are needed for the development, implementation, and maintenance of vitamin A programmes. Support from international organizations (multilateral, bilateral, and non-governmental) is important in fostering political commitment, and often in providing financial support in line with local priorities.
11. Linking research and human resource development with intervention activities continues to be important in initiating, maintaining, and building on vitamin A interventions.
12. Effective management is essential to the success of any type of vitamin A programme. Experience has shown that the success of vitamin A programmes is limited more by management problems than by lack of appropriate intervention technologies. Development of an effective management system will usually require as much attention as the choice of intervention. Similarly, evaluation of vitamin A programmes should involve management aspects as well as impact.