Recent evidence that vitamin A supplementation may save the lives - as well as the sight - of children affected by the eye disease xerophthalmia due to vitamin A deficiency has given new urgency to a 10-year United Nations programme aimed at the control and prevention of vitamin A deficiency. Launched by a UN interagency meeting in October 1985, the programme focuses on 34 developing countries known to have serious vitamin A deficiency problems. Despite unprecedented agreement on the need for the programme, however, the SCN annual session in February 1987 noted with concern that commitment of resources has been with few exceptions slow and requests for assistance from national governments limited in number and scope. A shortage of “start-up” funding is causing considerable problems for the programme. In 198 7 WHO transferred operational responsibility of the programme to its regional offices. Now, a study in Indonesia of the effectiveness of vitamin A capsule distribution in preventing eye damage has provided crucial evidence that the vitamin may have a direct effect in reducing mortality. After reviewing the study's findings in 1986, the SCN's Advisory Group on Nutrition said a difference of some 30 percent in pre-school child mortality between treated and control villages was “likely to be attributable” to vitamin A supplementation. The AGN statement continued: “It is appropriate to advise countries mounting high dose vitamin A programmes for the control of xerophthalmia that reduction of childhood mortality is a reasonable expectation and is a further justification for such programmes.”
The AGN statement adds weight to the SCN's call for concerted international action to reduce the worldwide prevalence and severity of vitamin A deficiency, xerophthalmia and nutritional blindness to a point where they are no longer significant public health problems. At present, the effects of vitamin A deficiency in the developing world are devastating, especially among children. Of an estimated 700,000 pre-school children who develop severe corneal xerophthalmia each year, as many as 400,000 die from the deficiency and accompanying factors such as protein-energy malnutrition, debilitating diarrhoea, respiratory tract infections and measles. About 25 percent of the survivors remain totally blind and 50 to 60 percent partially blind. Every year another eight to 10 million children are believed to develop milder, non-corneal xerophthalmia, leading to night blindness and associated with a higher risk of respiratory infections and diarrhoea. Research has also established that inadequate vitamin A causes damage to urinary and gastrointestinal tracts, impairs growth, bone formation and immune functions, and may cause anaemia. “At this point,” concluded an SCN study, “we should recognize that vitamin A deficiency may be as far-reaching in its pathological effects on the individual as proteinenergy malnutrition, and that prevention of the deficiency syndrome, even in its mild form, may have very important effects on child health, development and survival.”
[Source: WHO, 'Let There Be Sight']Nutritional Disease
Vitamin A deficiency is a nutritional disease, caused by inadequate dietary intake of the vitamin, or its plant-based precursors, and often aggravated by low absorption from the intestine. It has a primary, nutritional solution: improving vitamin A status to a physiologically acceptable level. In theory, this is as simple and inexpensive as administering to each affected child twice yearly a 200,000 IU vitamin A capsule costing two cents. But effective prevention and control of the disease depends on the correct choice of interventions and action to reach a much larger population than those immediately affected. This is because many more people are believed to be at risk than actually show signs of the deficiency and because preventive measures cannot be targeted only to those who would otherwise develop it. In practical terms, prevention depends on establishing national programmes employing various types of intervention, including mass distribution of oral doses of vitamin A, fortification of widely distributed food commodities and, in the longer term, dietary modification to increase the intake of the vitamin. The SCN reports that while national efforts are increasing, by 1987 only eight of the 34 countries known to be affected had such programmes and in most of these the coverage of preventative programmes was still very low.
Reaching the estimated 40 million pre-school children already suffering from mild or moderate vitamin A deficiency in the 34 target countries is a considerable challenge. Providing total coverage for these countries' pre-school child population of 280 million - and for children in a further 2 3 countries considered at risk - is an even more mammoth task. The 10-year UN programme aims to greatly accelerate the process of prevention and control of vitamin A deficiency by marshalling international assistance in five main areas: assessment of the prevalence and severity of the deficiency; prevention of the deficiency in high-prevalence areas; treatment of those suffering from vitamin A deficiency, xerophthalmia and nutritional blindness; training of health personnel and community workers; and investigation of technical, logistical and other problems affecting the implementation of programmes. An essential part of this process is the setting up, or strengthening, of national prevention and control programmes. This will involve a number of government sectors, particularly agriculture, health, education and the social services. Programme development will require assessment of the problem and of potential interventions, decisions on policy and resource commitments and, in many cases, external financial, material and technical assistance from UN agencies and donors.
Missions, Reviews
Since the programme's launch, several UN members and bilateral agencies have undertaken a variety of activities. WHO, the lead agency, has helped Bhutan, Burma, India and Sri Lanka assess their programme needs and prepare requests for assistance, while its regional offices for Africa and Southeast Asia have begun developing with concerned member states regional strategies for prevention and control of vitamin A deficiency. WHO has also prepared a technical review on the relationship between vitamin A and diarrhoea, explored the feasibility of distributing vitamin A through immunization schemes and distributed information on vitamin A deficiency to publishers in 40 countries. FAO has prepared and begun implementing a long-term plan for increasing the production and consumption of foods rich in the vitamin. It is conducting food consumption surveys of vitamin A and carotene intake in urban and rural areas, is planning nutrition education programmes and has sent experts to help a number of countries to assess their programme needs. It fielded missions with WHO to Bangladesh, Indonesia and Nepal. UNICEF, as part of its plan of action to complement the activities of WHO and FAO, has conferred with 10 countries of Africa and Asia to ascertain their needs and in 1986 provided a record number of vitamin A capsules - more than 80 million - to meet a growing demand from developing countries. WFP continues to provide skim milk fortified with vitamin A to vulnerable groups, particularly pre-school age children, while USAID has committed some $3 million to preventative programmes in six countries.
In a recent review of its efforts, WHO said “these steps are only the start of what must be, by definition, a sustained effort of an appropriate scale if the programme's primary objective is to be achieved”. It said further progress seemed to require greater efforts in developing countries to formulate and implement prevention/control strategies and to create mechanisms to harmonize and maximize the effectiveness of external support; greater support from donors; and sustained technical, managerial and financial assistance from UN agencies.
The SCN 14th Session recalled a statement by participants at the October 1985 interagency meeting which launched the programme: “It would be a terrible irony if, at a time when all the major ingredients of success are at hand - scientific knowledge, inexpensive and effective technology, and accumulated practical experience - the world community were prevented from taking concerted action for want of a modest shift in resources.” While discussions go on, vitamin A deficiency continues to kill or blind hundreds of thousands of children each year.
Costs and Benefits of Vitamin A Capsules
A single 200,000 I.U. dose of vitamin A, delivered every four to six months at a cost of less than 50 cents a year, may be enough to protect a young child against vitamin A deficiency and the threat of nutritional blindness and death. That is one conclusion of an SCN policy discussion paper on the prevention of vitamin A deficiency, published in June 1987. “Preliminary cost-benefit analysis shows that the benefits of preventing xerophthalmia calculated in monetary terms can far outweigh programme costs,” said the paper, “Delivery of Oral Doses of Vitamin A to prevent Vitamin A Deficiency and Nutritional Blindness.” What is more, “given the emerging evidence that vitamin A supplementation may reduce mortality among children with even mild deficiency, the benefit from improving vitamin A nutrition in a population may be even greater than those so far assessed”. However, the paper cautioned, while vitamin A supplementation programmes were conceptually simple, ensuring their adequacy and efficiency posed major challenges.
Capsules Containing Doses of Vitamin A are Given Six-Monthly by Mouth
