HORIZON INTERNATIONAL SOLUTIONS SITE

Summary:

Initially launched as a multi-faceted vision research project in the mid-1970s, data that became available indicated the value of developing an intervention program that would not only prevent blindness, but reduce childhood (and we now know maternal) morbidity and mortality in developing countries.

Effective interventions include long-term improvement in vitamin A status through periodic high dose supplementation and changes in dietary/consumption patterns, vitamin A fortification of staple products, and acute interventions, particularly for children with severe measles at high risk of micronutrient deficiency-related morbidity and mortality.

This has resulted in a UN worldwide initiative (WHO, UNICEF, FAO) to control vitamin A deficiency with programs at varying stages of development and implementation in over 65 countries. A number of nations, such as Indonesia (pre-Asian financial collapse), Vietnam, Guatemala and others have achieved virtual control of clinical xerophthalmia, if not subclinical vitamin A deficiency.

Problem Overview:

Nutrition

Increased child and maternal morbidity and mortality resulting from vitamin A deficiency

Background:

With the growing recognition (1983-1998) that vitamin A deficiency not only results in transient and permanent blindness but increased childhood morbidity and mortality (and most recently, maternal mortality as well), there has been a growing movement and consensus for controlling vitamin A deficiency worldwide. Indeed, observational and randomized controlled trials indicate that improving the vitamin A status of pre-school age children in developing countries can reduce childhood mortality by 20% to 56%; and most recently, that supplementation of women of child bearing age can reduce maternal mortality from 40% to 50%. In its 1993 annual report devoted to health, The World Bank estimated that vitamin A supplementation was one of the most cost-effective interventions available (less than US$1 per DALY [Disability-Adjusted Life Year]).

With increasing networking between NGOs, scientists and policy makers (principally through the periodic meetings of the International Vitamin A Consultative Group [IVACG]), orchestration of regional and global partnerships by WHO and UNICEF, and with the support of UNICEF and other donors (USAID, The World Bank, etc.), progress is being made in identifying locally appropriate approaches to improving vitamin A status amongst pre-school age children and, increasingly, women. These vary from dietary interventions to fortification of products consumed by the target population (MSG, sugar, wheat, instant noodles, and the like), to periodic supplementation with small (daily or weekly) or large (every one to six months) doses of vitamin A. Many countries have found that “micronutrient days,” at which time vitamin A is administered to all pre-school age children, or all children under 3 years of age, conducted once every 4 to 6 months (in the same way as polio immunization NIDs), is a very effective way for improving the general vitamin A status of the children at large. Supplementation by additional dosing of children at particularly high risk (those with diarrhea, measles or protein-energy malnutrition) has been effective in improving physiologic outcome. The costs and benefits of alternative approaches must be gauged to local opportunities and resources, and as much as possible implemented through broad-based integrated health and social welfare programs.

A critical component of every intervention is periodic evaluation of both process and outcome.

Status:

Over the past two decades, the number of countries that have formally embraced vitamin A control programs (of varying degrees of development and implementation) has risen from less than 5 to over 65. Countries with very effective and committed programs include Indonesia, Vietnam, Bangladesh, India (to varying degrees in the various states), Nepal, and Guatemala, amongst others. The entire status of the worldwide program, and the various components, continue to evolve. UNICEF has and continues to play a major role in stimulating these programs, providing assistance, offering financial support (usually in the form of large dose vitamin A capsules), and providing periodic global updates. The largest bilateral donor by far, and a key catalyst, has been the U.S. Agency for International Development (USAID).

Follow-up:

As a worldwide program, “follow-up” depends upon the regular, periodic exchange of information amongst the entire global partnership and national programs. Surveillance, monitoring, “lessons learned,” and regular meetings and policy statements organized by IVACG, often with its partners UNICEF and WHO, are important strategies for continuing to move the worldwide agenda forward, inform and strengthen programs at the national level, and refine interventions based upon experience and the latest research results.

NOTES: 

Resources on Public Health: Links with detailed information are available on the Horizon Solutions Site.

Weblinks:

Documentation:

Vitamin A control efforts and their impact are regularly documented through UNICEF, WHO, and IVACG programs.

Submitted by:

Alfred Sommer, MD, MHS
Asommer@jhsph.edu
Johns Hopkins University School of Public Health
615 North Wolfe Street
Baltimore, Maryland 21205-2179
USA
410-955-3540

Contact:

The control of vitamin A deficiency has moved from a purely research phase and focused intervention by one or two organizations and countries to a truly global effort. For further information one should contact specific ministries of health, UN agencies, and particular NGOs and academic institutions involved with these efforts. As a worldwide, multi-faceted effort, information is distributed throughout the web. Unlike other global health interventions, there is no single organizing body responsible for the results, but a multiplicity of initiatives stimulated, though not organized, by major institutions like UNICEF, USAID, and others.

Information Date: 1999-01-20
Information Source: A. Sommer, Johns Hopkins University; additional sources of information can be found at IVACG (http://www.ilsi.org/ivacg.html)