United Nations System
Standing Committee on Nutrition

Report of the Meeting of the Working Group on Vitamin A and Iron

Saturday, 10 April 1999, UNHCHR, Geneva
Chairperson: Roger Shrimpton, UNICEF
Rapporteur: Martin W. Bloem, Helen Keller International

1.  Vitamin A Global Initiative

The 1990 World Summit for Children set the goal of elimination of vitamin A deficiency (VAD) by the year 2000. While some progress is being made, there is irrefutable evidence that vitamin A deficiency is still widespread among children in the developing world. This is why USAID, UNICEF, CIDA, and MI created a Global Initiative to secure commitment to achieving the year 2000 goal and to set benchmarks for countries unable to reach that goal by December 1997. The targets were set in an informal meeting in December 1997.

This technical consultation recognized the importance of multiple strategies to control vitamin A deficiency. However, in view of the remarkable benefits of vitamin A and the savings that accrue from a reduced burden on health services associated with improved vitamin A status, policy makers and programme managers should focus on proven, rapid and effective strategies to combat vitamin A deficiency. Vitamin A supplementation is a low-cost, sustainable strategy that has been in place and effective for decades in some developing countries. Policy makers should be advised that vitamin A supplementation is not necessarily a short-term measure.

Roger Shrimpton reported on the progress of the Vitamin A Global Initiative:

• 43 of 64 countries with VAD added vitamin A to National Immunization Days (NIDs).

• About 60% of children in sub-Saharan Africa received at least one dose of vitamin A in the last six months of 1998, doubling coverage from two years ago.

• Globally, 34 countries report over 80% coverage, mostly through NIDs.

• Almost 400 million capsules provided by CIDA.

• Significant new funding available from CIDA for implementation of VAD programmes.

Main points discussed:

• There was extensive discussion on the importance of strategies other than supplementation to combat vitamin A deficiency. There was a lot of concern that the Vitamin A Global Initiative put too much emphasis on the distribution of vitamin A capsules. The cost of the capsules is a critical point. It was argued that vitamin A capsule distribution programmes are at least as effective as immunization or oral rehydration programmes in mortality prevention. The long-term costs of those programmes are not questioned in a similar way. The Indonesian case is a good example of how eventually a government can assume the costs of a vitamin A capsule distribution programme. It was suggested that targeting can also reduce the cost of the capsule programme.

• The Bangladesh case study showed that both the vitamin A capsule programme and the increase of intake of vitamin A-rich foods through homegardens resulted in a dramatic reduction in vitamin A deficiency. There are several studies ongoing to identify various ways to improve the bioavailability of plant foods. Furthermore, IFPRI, in close collaboration with others, is developing high beta-carotene foods.

• Helen Keller International’s 24-hour Vitamin A Semi-Quantitative method could be a useful tool to monitor food based strategies. This method is based on a 24-hour recall questionnaire and estimates vitamin A intake semi-quantitatively, but distinguishes four different sources of vitamin A – vegetables, fruits, animal foods and fortified foods – and estimates vitamin A content per ingredient instead of per dish.

• In Central and South America food fortification programmes have been successful in at least six countries.

• Since the start of the Vitamin A Global Initiative in 1997, DFID has become part of the coalition. There was a request from USAID to other donors to join the initiative.

• The human right approach could play an important role in setting out model legislation.

• As NIDs phase out there is a need to find other opportunities for vitamin A supplementation.

2.  Vitamin A Assessment and Reference Laboratories Project

Biochemical assessment of populations at risk is one of the methods to monitor the progress of the Vitamin A Global Initiative. Serum surveys cannot be repeated frequently but are necessary in addition to coverage data and process indicators to ensure that activities are having an impact on VAD. Information on carotenoid and retinol content of foods is also required for developing and monitoring food approaches to controlling vitamin A deficiency. Proficiency (capability, precision, and accuracy) in determining retinol/carotenoids in serum and foods has increased markedly in industrialized countries in the last 10 years through activities of agencies both in the USA and Europe. Such proficiency needs to be extended to countries where vitamin A deficiency is a public health problem. The aim of the project is to investigate proficiency of selected laboratories in measuring retinol and carotenoids in serum and foods, and where appropriate to improve the measurements in terms of precision and accuracy by providing support and training. The selection of the participating laboratories will be based on potential capability and need with respect to surveys which are likely to be carried out. In 1998 a survey was carried out by WHO to identify potential laboratories in Africa. Phase one of the project will entail preparing reference materials and then measuring reference materials by participating laboratories to estimate within/between laboratory variation and accuracy, and analysis and reporting of results. The second phase will involve taking an inventory of protocols and facilities such as lab facilities, electricity, etc. Lastly, on-site visits to the participating laboratories will lead to the identification of further requirements and will be the basis for training and follow-up. Barbara Underwood, IUNS, informed the group of the U.S. National Institute of Standards and Technology programme which supports laboratories globally.

3.  Global Prevalence of Vitamin A Deficiency

At the previous ACC/SCN meeting in Oslo the Vitamin A Working Group discussed the conflicting estimates between the UNICEF/MI/Tulane University Report and the WHO/UNICEF/MDIS report #2. George Beaton was commissioned by WHO to critically review the estimates on vitamin A deficiency made in these reports. Dr Beaton concluded that there are no reliable quantitative estimates of the magnitude of subclinical vitamin A deficiency but independent attempts to estimate this from the fragmentary information available would suggest that numbers lie in the range of 140 to 250 million preschool children. These estimates do not take into account subclinical and clinical vitamin A deficiency occuring in older children and adults so the suggested magnitude is a serious underestimation of the total magnitude and importance of vitamin A deficiency.

4.  IDA Database and Assessment of IDA

Dr de Benoist described the WHO Global Database on Iron Deficiency Anaemia (MDIS-IDA). Using hemoglobin as the indicator the data include pre-school children, pregnant and lactating women. Prevalence is by age group, country and UN region. A brief background was given, including the currently used global prevalence figure of 2 billion people (30% of the world’s population). Dr de Benoist concluded that 80% of the world’s population are therefore likely to be suffering from iron deficiency. The prevalence of anaemia is much higher in developing than in developed countries.

Iron deficiency is likely to be the main cause of anaemia in the industrialized world. However, in developing countries, anaemia is the result of various factors including -- in addition to iron deficiency – intestinal hookworm infections, malaria, schistosomiasis, chronic infections in particular HIV and nutritional deficiencies such as PEM, folate, vitamin A and vitamin B deficiencies to mention only some of the major contributing factors. This implies that any intervention to control anaemia should look at the causes of anaemia, which may vary from one region to another. Dr Vinodinni Reddy (IUNS) mentioned findings from India in which anemic women assured of taking iron and folate daily, still had 30% of the group anemic after supplementation, presumably due to some other nutrient deficiency. In conclusion, anaemia is too often associated with iron deficiency; more focus should be put on the other causes of anaemia especially among poor segments of the populations.

A note of caution was offered by Abe Parvanta of CDC about obtaining reliable hemoglobin data from the field: efforts are frustrated because of the difficulty in collecting blood samples in a consistent and reproducable way.

The objectives of the MDIS-IDA Database are to support the assessment of the magnitude, severity and distribution of anemia, monitor trends, impacts of interventions and progress towards goals. An important outcome will be to encourage political commitment by increasing awareness of the problem. Constraints include the paucity and poor reliability of the data (often based on small, unrepresentative groups).

5.  Preventing Iron Deficiency in Women and Children: Consensus on Key Technical Issues

During the last ACC/SCN meeting in Oslo this Working Group called for a technical workshop to resolve issues using a practical, field-oriented, science-based approach, before the next meeting of the Working Group. Thirty specialists came together for the Technical Workshop at UNICEF headquarters in New York 7-9 October 1998. The proceedings of the meeting have been written up in a technical paper by Gary Gleason and Nevin Scrimshaw. It will take at least another month for this document to be finalized for distribution, but a semi-final draft for information only was distributed at the meeting.

Nevin Scrimshaw highlighted the important results of the technical workshop:

• Iron nutrition needs greater attention – it affects 3.5 billion people and has serious functional consequences that can include impaired cognition, decreased work capacity, reduced immunity and increased morbidity from infectious disease.

• Interventions and programme partners are available – recognition of the problem of iron deficiency and its consequences is seriously out of balance with the current availability of effective solutions to prevent it.

• Iron deficiency has massive economic costs – these have been hitherto almost totally unrecognized. The cost benefit ratio of preventive programmes for iron deficiency is recognized as one of the highest in public health.

• New programme actions are required – little progress has been made towards the global elimination of iron deficiency, in part because it is a hidden deficiency without overt symptoms. Advocacy and national programmes have been constrained by erroneous perceptions that effective, practical interventions are not available.

The following selected consensus statements from the document were presented:

• The participants in the Technical Workshop shared endorsement of the recommendation of the ACC/SCN and many other groups that the most effective public health approach to prevent and control iron deficiency and iron deficiency anemia is a well-planned and monitored programme that employs multiple interventions and cross-sector strategies.

• The firm conclusion from several analyses is that iron deficiency anemia carries costs to all countries, but its effect on the economic productivity in developing countries is enormous. The estimate that iron deficiency is responsible for the loss of about one per cent of gross domestic product (GDP) does not include the burden of maternal death associated with severe anemia and the lowered effectiveness of funds spent on education. The costs to the health system for the treatment of anemia, and of an increase in infections are also substantial.

• Iron overload disorders and hemachromoatosis are rare, even in those populations of European origin most susceptible to them. Thus, the use of fortification and supplementation as public health interventions for preventing and controlling iron deficiency should not be constrained.

• Among all populations, including those in industrialized countries, a sizable percentage of women will become iron deficient during pregnancy unless they take iron supplements.

• Routine daily iron supplementation during pregnancy is now an essential part of public health efforts to prevent and control iron deficiency anemia, assure good maternal health during pregnancy and birth, and assure that infants begin life with good iron stores, until fortification approaches and/or pre-pregnancy supplementation succeeds in raising to healthy levels the iron stores of women when they enter pregnancy.

• The long-term goal of iron deficiency anemia control programmes should be to prevent iron deficiency in groups at risk including young children and women of childbearing age, the latter to ensure that they do not enter pregnancy in an anemic state. In developing countries, the majority of women do not have iron stores at levels needed to bring them through pregnancy without becoming iron deficient and are not able to maintain their stores when consuming only their usual diets.

If the prevalence of childhood anemia is less than 40 percent, the duration of supplementation should be from six months until 12 months of age for infants of normal birth weight (12.5mg of iron plus 50µg folic acid daily). If the prevalence is greater than 40 per cent, all children should be supplemented daily until 18 months of age.

• Conclusions of a cross-project analysis by George Beaton and colleagues of the efficacy of intermittent iron supplementation in the control of iron deficiency anemia in developing countries include:

• Both daily and weekly iron supplementation are efficacious. Weekly iron supplementation is likely to be less effective than daily administration except in situations where supervision is feasible with weekly regimens and not with daily supplementation.
• Weekly supplementation may be particularly disadvantageous during pregnancy and in situations where the baseline prevalence of anemia is very high.

• Unless ways are found to greatly improve "compliance" in comparison to that seen in existing programmes, neither daily nor weekly iron supplementation is likely to be an effective approach to preventing and controlling iron anemia in developing countries.

• Regardless of the degree of supervision that can be arranged, weekly, instead of daily, iron administration is not recommended for pregnancy.

• Future research priorities should be directed to development of other strategies either to effectively improve utilizable iron intakes (by altered food usage or fortification where this is feasible) or to greatly improve compliance in direct supplementation, daily or weekly.

• It is recommended also that the criteria for diagnosis of anemia and/or definition of public health problems be reviewed and revised as necessary with the specific goal of linking these to functional outcomes deemed to be of public health significance.

6.  Multiple Micronutrient Supplementation Formulation

This matter was the topic of a Workshop organized by SEAMEO, GTZ, and the Government of Indonesia (among others) in Singapore in November 1998 entitled "Micronutrient Supplementation and Safe Motherhood". The Workshop reviewed available evidence on possible benefits of micronutrient supplementation, discussed the composition of a possible supplement, evaluated determinants of programme effectiveness and addressed necessary advocacy needs. The high prevalence of deficiencies such as iron, vitamin A, zinc, folate etc. have been demonstrated and have a clear negative impact especially in pregnant women and young children. Dietary improvements are difficult to achieve in a short time span. While there is good evidence of benefits of multi-micronutrient supplementation based on efficacy trials, little is known about bioavailability and interaction among nutrients when combined in one tablet. Safety margins for larger intakes of the likely micronutrients to be included are wide, except for vitamin A. Current recommendations for vitamin A intakes are 10,000 IU/day or 25,000 IU/week. It was clear that programme effectiveness depends greatly on compliance, which was felt to be strongly influenced by factors such as perceived health benefits, shape and colour, and taste, of a tablet. While further research may be needed in some settings, much of this information already exists within the pharmaceutical industry.

The conclusions of the Workshop were that: the dietary intake of many micronutrients is often inadequate; micronutrient status needs improvement not only during pregnancy but also pre- and post-natally; and, that supplementation is the fastest option for improvement at critical stages in development.

Existing supplements are not felt to be useful. In response to a question from Tim Frankenberger of CARE it was explained that this was because they often had rather high vitamin A levels, relatively low iron of 27mg, and 0 or <10mg zinc. Nevertheless a ‘one-fit-for-all’ tablet would be needed and should contain at least, vitamins A, D, B₁, B₂, B₆, B₁₂, folate and zinc at RDA levels for pregnancy, and iron at 30-60mg. Tablets should be taken daily during pregnancy but could be taken once or twice a week before pregnancy. Compliance experience needs to be gathered and effectiveness studies using a common protocol (with the existing government distribution mechanism) for pregnant women should be the basis.

Remaining topics for research and further discussion include:

• Multi-micronutrient supplementation for infants and young children

• Further studies on optimal composition (e.g. iron and zinc levels)

• Effectiveness trials, with compliance receiving particular attention

In the meantime, some Working Group participants felt that governments could be encouraged to start multi-micronutrient supplementation during pregnancy and before, where possible. For now a supplement of the three examples given here could be used.

In response to a question about calcium, it was pointed out that to get anywhere close to the RDA required a very large tablet, which would almost certainly affect compliance. Mahshid Lotfi of the Micronutrient Initiative mentioned the interactions of such formulations, not only amongst themselves but also with other nutrients in the diet. Milla McLachlan of the World Bank foresaw possible difficulties in marketing such tablets because of different regulations of countries, requirements of national pharmacopoeias and so on. For these and other reasons (e.g. the perception of IDA as a disease in many parts of the world that only needed treatment when symptoms were experienced rather than a condition to be prevented -- Abe Parvanta, CDC), the Group noted that extensive information, education and communication (IEC) would be needed for successful implementation. Wilma Freire (PAHO/WHO) and Bill Clay (FAO) emphasized the need to consider fortification as a first priority where this might be more appropriate. Fortification has the advantage of requiring fewer new distribution channels and marketing than tablets. Fortification also allows for a fairly regular daily intake of nutrients and is particularly suitable for Latin America in complementary foods for young children.

7.  Report by Donor Agencies

USAID

During 1998, USAID continued and expanded its technical leadership in micronutrients, especially through the VITA effort. Under this initiative, USAID established partnership with 11 priority countries. The VITA effort has resulted in an active partnership with UNICEF and CIDA as mentioned above. The March 16 event as mentioned above was hosted by Mrs. Clinton and USAID. VITA has developed an active partnership with major private sector companies to expand and promote the availability of fortified foods and support other dietary behaviors.

USAID continues to identify and support research on important relationships of micronutrients to child health and survival and on the best ways to make these interventions available through high-impact policy and programme approaches. USAID leadership in research is combined with support to field programmes. USAID assistance also includes catalyzing public-private collaboration at the country level, evidenced by the initiation of a national sugar fortification programme in Zambia, the first such programme outside of Latin America.

In 1998 USAID also made substantial contributions to other aspects of child nutrition. These included demonstrating that implementation of the Minimum Package of Nutrition-Related Behaviors (Minpac) as part of the Integrated Management of Childhood Illness Progamme (IMCI) in Madagascar was associated with increased breastfeeding in the first hours after delivery from (22%-68%) and increased proportion of mothers receiving vitamin A supplements (from 2%- 32%).

USAID also reported that the Public Law 480 (food aid) now requires that all vegetable oil provided to 20 million recipients annually, shall be fortified with vitamin A (retinol palmitate at the level between 60 to 75 IU/gram). Most of this oil is included in non-emergency programmes -- much of which is given to children as complementary feeding.

CIDA

• CIDA is working with WHO and UNICEF to add vitamin A supplements to global immunization programmes.

• CIDA is working with UNICEF,USAID, MI, DFID and WHO on a global advocacy campaign in support of vitamin A. CIDA advocacy through the Canadian posts in a few countries has resulted in vitamin A being added to NIDs.

• CIDA is working to encourage other countries to make micronutrient programming a priority and to raise public awareness.

• In 1998, CIDA launched its "vitamin A plus" strategy with a new programme to improve vitamin A coverage. This includes increased collaboration with UNICEF to enhance the effectiveness and sustainability of vitamin A supplementation programmes. CIDA and the MI also promote food fortification by building partnerships among governments, food companies, NGOs and research centres.