United Nations System
Standing Committee on Nutrition

Report of the Sub-Committee on Nutrition at its Twenty-Fifth Session

II.  Work in Progress:  Summary of Discussion and Conclusions

C. Reports of decisions taken in Working Groups

C.8  Vitamin A Deficiency -- Summary Report of the Working Group

54.  The Working Group expressed caution in citing the global estimates of subclinical vitamin A deficiency (VAD) due to methodological difficulties and recommended that WHO and UNICEF work together to update prevalence estimates, using a new methodology.  Updated estimates could be disseminated through SCN publications and in other ways.

55.  Some principal conclusions of the discussion were highlighted.

• The Bangladesh national vitamin A deficiency survey results were presented. Xerophthalmia is no longer a problem of public health significance, and sub-clinical VAD is greatly reduced. These results showed that access to home gardens played a role in addition to supplementation in reducing VAD over time.
• USAID-funded research in Nepal on supplementation during pregnancy and maternal mortality was noted. The challenge is to continue to undertake studies of the mortality reduction benefit of improved vitamin A status during pregnancy. WHO has organized a meeting in May to discuss vitamin A and maternal mortality.
• A near crisis in Guatemala where the government was considering revoking a law requiring vitamin A fortification of sugar was highlighted. UNICEF with PAHO collaboration will write and disseminate lessons learned.
• All donors and agencies are invited to be part of a global initiative by UNICEF, USAID, MI and CIDA to secure greater commitment to achieving the goal of elimination of VAD as a public health problem. Vitamin A programmes are not yet an integral part of child survival strategies.

56.  A need for field-friendly assessment tools was highlighted. It was agreed that the interrelationships between iron and VAD should be considered at the next meeting.  An informal technical consultation on Vitamin A was held in New York in December 1997.  This group concluded that while assessment is important in countries likely to have a VAD problem, programmes should not necessarily await completion of serum surveys.

Full Report of the Meeting of the Working Group on Vitamin A Deficiency

Sunday 29 March 1998, Oslo, Norway

Chair: Dr Joanne Csete, UNICEF
Rapporteur: Dr Martin W. Bloem, HKI

Theme: 1988 – The Year of Vitamin A

1. Challenge in determining the global prevalence of vitamin A deficiency

Joanne Csete (UNICEF) presented issues related to determining the global prevalence of vitamin A deficiency, which are highlighted in a recent report by UNICEF/MI/Tulane University, which summarizes the current status and trends in eliminating vitamin A deficiency. This report revealed the need to re-estimate the global prevalence of vitamin A deficiency from estimates presented in WHO/UNICEF MDIS report on the Global Prevalence of Vitamin A Deficiency (1995). The WHO/UNICEF MDIS report estimated the global prevalence of pre-school children affected by clinical VAD to be 3.3 million and by sub-clinical VAD to be 251 million. These estimates were based on prevalence surveys available up until around 1990. Since more data are now available on the prevalence of sub-clinical VAD, the methodology to estimate the prevalence of VAD can be improved to be more accurate. Following a group discussion, it was recommended that WHO and UNICEF would come up with a new report on the global prevalence of vitamin A deficiency using a new methodology.

• The group recommended using caution in citing the global sub-clinical prevalence of 251 million until new estimates are available.

• A new methodology should be used in the new update of the global prevalence of VAD.

Martin Bloem (HKI) presented the results of the Bangladesh national Vitamin A Deficiency Survey, carried out between September and December 1997. Figure 1 shows that prevalence of xerophthalmia for both the national survey of 1982/83 and the survey of 1997. The data shows that xerophthalmia is not any more a problem of public health significance. The question is what are the causes of this dramatic decline in the prevalence of xerophthalmia compared with the survey of 1982/83.

Why?

• VAC-program (cumulative effect)
• Home gardening
• Immunization
• Water and sanitation
• others

Table 1. Prevalence of Xerophthalmia among children aged 6-59 months, Bangladesh National Vitamin A Survey 1997 (n=27,496) Kiess L., et al. (in prep)

Martin Bloem (HKI) presented several data, which made it very plausible that, the VAC-program and the Homegardening activities both contributed to the success story of Bangladesh. The data also showed that homegardens and the intake of plant foods contributed to the vitamin A status of women and their children (De Pee et al, in prep).

• The prevalence of xerophthalmia is not anymore a problem of public health significance
• VAC is an effective (even SUSTAINABLE) strategy to combat VAD
• However, it is not very plausible that VAC was responsible for the long-term improvement of the vitamin A status in Bangladesh.
• Homegardens play an important role as a short term vitamin A source in Bangladesh
• Homegardens play an important role as a long-term vitamin A source in Bangladesh.
• Homegardens play an important role as a vitamin A source of all hh members in rural Bangladesh.
• It is very plausible that both the VAC-program and the improvement of dietary intake of vitamin A foods through home gardens were responsible for the dramatic improvement of the vitamin A status in Bangladesh.

Chair, Joanne Csete (UNICEF) presented the recent, significant research findings of the Nepal study carried out by the Johns Hopkins School of Public Health, and the National Society for Eye Health and Blindness Prevention in Nepal, supported by USAID and the Task Force Sight and Life, on the effect of vitamin A supplementation on reducing maternal mortality. Approximately 44,000 young married women, nearly half of whom became pregnant during the study, where given either vitamin A supplements or placebos. The supplements were in the form of either pure vitamin A or beta-carotene.

Among the women receiving pure vitamin A there were 38 per cent fewer deaths and among those receiving beta-carotene there were 50 per cent fewer deaths, during pregnancy and three months following childbirth, than among women receiving no supplements. However, Frances Davidson (USAID) stressed the fact that there is a need for replication of this study in Africa and South Asia. She invited other donors to support these efforts. Bruno de Benoist (WHO) mentioned that a follow-up meeting will be held in the end of May in Geneva.

• This study highlights the urgent need to improve the nutrition of girls and women as part of a multi-pronged approach to reduce the tragedy of maternal mortality in the developing world.
• There is a need for replication of this study in Africa and South Asia.
• More donor support is needed to accomplish this effort
• WHO Geneva has organized a meeting for May 1998 that will review the Nepal results and related scientific issues.

Venkatesh Mannar of the Micronutrient Initiative summarized current efforts to fortify staple foods with vitamin A. Progress has been made in some regions to accelerate efforts as a result of collaboration between UNICEF, MI/CIDA, USAID and PAHO/WHO. But it was recognized that additional work is required in the area of vitamin A fortification.

Concern was expressed about relying on one single strategy to eliminate VAD. The recent crisis in Guatemala whereby the Govt. was considering revoking a law to fortify sugar with vitamin A illustrated this point. Wilma Freire (PAHO) explained that the crisis arose due to the fact that imported non-fortified sugar was cheaper than domestic sugar fortified with vitamin A. Concern was expressed regarding the impact of growing trade liberalization on efforts to fortify staple foods. The group recommended that efforts be made for fortified foods to not be subject to tariff barriers. Bill Clay (FAO) pointed out that a country has to specify the same level of fortification for imports and domestic products or commodities.

• Additional work is required in the area of vitamin A fortification
• Need for all of us to be educated on trade concept of fortification.
• Danger of relying only on one strategy.

Global vitamin A Initiative. Frances Davidson of USAID provided the group with a background on the global initiative to accelerate progress towards the elimination of VAD being supported by UNICEF/MI/CIDA and USAID. The 1990 World Summit for Children set the goal of elimination of vitamin A deficiency by the year 2000. Many countries are working hard to reach that goal. But while some progress is being made, there is irrefutable evidence that vitamin A deficiency is widespread among children in the world. A key element in ending vitamin A deficiency in the short time that remains before the dawn of a new millenium is reaching policy makers with the message about this simple, safe and effective child survival tool, and about how to use that tool quickly, efficiently and cost effectively.

To this end, USAID, UNICEF, CIDA and the Micronutrient Initiative have started a global initiative to secure commitment to achieving the Year 2000 goal of elimination of vitamin A deficiency and to set benchmarks for countries unable to reach that goal. The following targets were set at an informal expert meeting in December 1997:

• By end 2000: All countries where populations are affected by VAD or likely to be affected (based on infant and child mortality criteria) should at a minimum have a detailed plan of action for elimination of VAD as a public health problem, with a budget and a plan for resource mobilization to support actions.
• By mid-year 2002: All of these countries should have data on process indicators corresponding to key program strategies.
• By end of 2005: All affected countries should have assessed or re-assessed VAD through nationally representative surveys using serum retinol or other more convenient criteria that may be better established at that time.

Urban Jonsson (UNICEF) mentioned that the lack of attention to vitamin A in developing countries is a matter of global embarrassment and of the need to question policy makers why they chose to allow millions of children to die. He said that policy makers don’t change their opinion based on scientific arguments but policy arguments. No governments are too poor. Era of politeness should be over. Children’s rights should be the focus of advocacy.

Nevin Scrimshaw (UNU) – highlighted importance of mentioning interaction of vitamin A with other micronutrient deficiencies such as iron. Agencies working on iron or vitamin A should use this link more effectively to promote progress on iron concomitant with progress on vitamin A.

It was mentioned that there is a need to present vitamin A initiative as part of comprehensive child survival package as opposed to a single freestanding intervention.

• A more aggressive global approach to vitamin A delivery will extend the CHILD SURVIVAL impact of vitamin A.
• Children’s Rights should be the focus of advocacy.
• Agencies working on iron or vitamin A should use this link more effectively to promote progress on iron concomitant with progress on vitamin A.
• There is a great need of more collaboration between donors to support these efforts.

Joanne Csete (UNICEF) presented the results of this informal meeting with participation from UNICEF, WHO, MI, USAID, CIDA, Johns Hopkins University, University of Wageningen, London School of Tropical Medicine, and HKI. The purpose of that meeting was to:

• Articulate a clear consensus on technical issues where lack of agreement may impede program progress in combating VAD
• Develop a strategy for accelerating of progress toward the elimination of VAD as a public health problem.

In the past, VAD was recognized solely as the leading cause of preventable child blindness, and program activities to reduce VAD are still often limited institutionally to blindness prevention programs. There is an urgent need to communicate the message that VAD is not just about blindness. In fact, ocular problems are an indicator of severe VAD. The child’s ability to resist illness is impaired long before blindness occurs. Although progress has been made, action is needed to accelerate progress. A factor that may be inhibiting progress is the need to conduct serum surveys to determine the vitamin A status of populations. The meeting proposed that countries with a high under five-mortality rate (U5MR) should take immediate action on VAD, as high U5MR is an indicator that VAD is a public health problem.

In many countries and communities, the belief exists that vitamin A supplements are unsafe, especially high-dose supplements for infants. There is a need to communicate that while there may be some side-effects in this age group, there is a transient, not life-threatening, and have no long term consequences for the child. In fact, the benefits to the infant far outweigh them.

Bruno De Benoist (WHO) mentioned that two booklets had been published on the safe use of vitamin A supplements to children and pregnant women.

• Vitamin A is an essential component of child survival programs; vitamin A is not just for blindness reduction
• Supplementation and fortification can be rapidly implemented to accelerate progress in VAD reduction while longer-term change is pursued.
• Assessment is important in countries likely to have a VAD problem, but programs should not necessarily await to completion of serum surveys.

The integration of vitamin A and EPI was brought up 10 years ago by USAID and in 1987, the Dutch Govt. had sponsored the EPI plus programs in WHO for five years. Recognizing the practicality of delivering vitamin A with EPI has led to a renewed interest on the part of CIDA/MI, which has recently given WHO’s EPI unit a large grant to pursue this integration. The operational challenges in integrating vitamin A into EPI were largely resolved at this recent technical meeting as presented by John Clement of WHO’s EPI Unit. He presented the group with an overview of a recently held meeting to discuss ways to improve vitamin A coverage by linkages to EPI programs. The vitamin A/EPI initiative focuses on improving vitamin A coverage by linking supplementation:

1. to regular EPI programs,
2. to national immunization days (NIDs) scheduled for most countries in Africa and Asia for polio eradication,
3. and with measles case management.

• Age-appropriate doses of vitamin A supplements should be linked to all immunization contacts where VAD is recognized as a public health problem.
• Where VAD is a public health problem, supplementation of women should be linked to BCG contacts.

MI presented the group with an update of new method to analyze retinol samples using Craft’smethodology (dried blood spots) and mentioned work on validation of this technique in Nepal. They also mentioned ongoing work to make interactive learning materials available on vitamin A and other micronutrients. MI also announced the availability of new publications on monitoring of vitamin A programs and on global progress in VAD progress (with UNICEF and Tulane University)

USAID accelerated vitamin A activities by supporting both programs and research. A call was made for abstracts for the upcoming IVACG meeting to be held in Durban, S Africa next year.

CIDA noted its support to vitamin initiatives through the MI but also mentioned support for ongoing research.

ODA is supporting British institutions to do research on vitamin issues and outlined a few.

FAO reported on continued support for a variety of vitamin A activities, including recent publications on food-based approaches to micronutrient deficiencies.

SIDA mentioned supporting research on a limited scale in Bangladesh.

PAHO outlined some of its ongoing activities in Latin America with a 6-country focus mainly on fortification.

WHO mentioned support for several vitamin A publications and their involvement in the various global initiatives to accelerate the elimination of VAD. (A publication on safe use of vitamin A supplements for pregnancy)

UNU with FAO is working on updating food tables since the vitamin A content of many food items is incorrect based on recent findings.

The Netherlands reported on support for vitamin A prevalence surveys in 8 countries through UNICEF.

Unicef: In addition to the global advocacy effort and other efforts noted above, UNICEF continued major support to vitamin A supplementation programs for children and post-partum women. A survey of country offices in 1997 indicated that about half the children in countries where VAD is a public health problem receive supplements, up significantly from 34% two years earlier.