Public health strategies

Globally, it is estimated that 140–250 million children under five years of age are affected by vitamin A deficiency. These children suffer a dramatically increased risk of death, blindness and illness, especially from measles and diarrhoea. As part of the global call to action, the UN Special Session on Children in 2002 set as one of its goals the elimination of vitamin A deficiency and its consequences by the year 2010. The strategy to achieve this goal is to ensure that young children living in areas where the intake of vitamin A is inadequate receive the vitamin through a combination of breast feeding, dietary improvement, food fortification, and supplementation.

Combining the administration of vitamin A supplements with immunization is an important part of this effort. Since 1987, WHO has advocated the routine administration of vitamin A with measles vaccine in countries where vitamin A deficiency is a problem. Great success and many millions of children have been reached by including vitamin A with National Immunization Days (NIDs) to eradicate polio. Providing immunization-linked high-dose supplementation to new mothers soon after delivery has provided a further benefit to young infants through enriched breast milk.

Provision of vitamin A supplements every four to six months is an inexpensive, quick, and effective way to improve vitamin A status and save children's lives. The Beaton Report concluded that all-cause mortality among children aged 6–59 months was reduced by 23% through vitamin A supplementation in areas where vitamin A deficiency was a public health problem. However, comprehensive control of vitamin A deficiency must include dietary improvement and food fortification in the long term.

WHO perspective

Vitamin A is essential for the functioning of the immune system and the healthy growth and development of children. Immunization contacts offer unrivalled opportunities for delivering vitamin A to children who suffer from deficiency. Studies show that vitamin A does not have any negative effect on seroconversion of childhood vaccines.

As well as routine immunization services, national immunization days for polio eradication, measles, and multi-antigen campaigns have been used safely and successfully to provide vitamin A to a wide age range of children at risk.

High-dose vitamin A should be avoided during pregnancy because of the theoretical risk of teratogenisis (birth defects). From a programmatic perspective, high-dose vitamin A supplementation must occur during the safe infertile period immediately after delivery. Accordingly, high-dose vitamin A supplementation can be provided safely to all postpartum mothers within six weeks of delivery, when the chance of pregnancy is remote. For breastfeeding mothers, the safe infertile period extends up to eight weeks after delivery. The first contact with the infant immunization services provides an excellent opportunity to supplement postpartum mothers and improve the vitamin A content of their breast milk.

There is a well-established scientific basis for the treatment of measles cases with vitamin A supplementation that is recommended by WHO as part of the integrated management of childhood illness.

The recommended doses of vitamin A supplementation for the prevention of vitamin A deficiency are indicated in the following table.

Special issues

Field trials are in progress with a view to confirming the suitability of administering vitamin A with the DTP doses during infancy.

Table

Potential target groups and immunization contacts in countries with vitamin A deficiency

* The optimal interval between doses is four to six months. A dose should not be given too soon after a previous dose of vitamin A supplement: the minimum recommended interval between doses for the prevention of vitamin A deficiency is one month (the interval can be reduced in order to treat clinical vitamin A deficiency and measles cases).

Key references

Beaton GH, Martorell R, L'Abbé, et al. Effectiveness of vitamin A supplementation in the control of young child morbidity and mortality in developing countries. UN, ACC/SCN State-of-the-art Series, Nutrition policy Discussion Paper No. 13, 1993.

Ching P, Birmingham M, et al. Childhood mortality impact and costs of integrating vitamin A supplementation into immunization campaigns. American Journal of Public Health, 2000, 90(10):1526–1529.

Distribution of vitamin A during national immunization days. A generic addendum to the Field guide for supplementary activities aimed at achieving polio eradication, 1996 revision. Geneva, 1998 (unpublished document WHO/EPI/GEN/98.06; available from Vaccines and Biologicals, World Health Organization, 1211 Geneva 27, Switzerland and on the Internet at www.who.int/vaccines-documents/DocsPDF/www9836.pdf).

Goodman T, Dalmiya N, et al. Polio as a platform: using national immunization days to deliver vitamin A supplements. Bulletin of the World Health Organization, 2000, 78(3):
305–314.

Helen Keller International and WHO. Integrating vitamin A with immunization: An information and training package (CD-ROM) 2000.

Integrated management of childhood illness: a WHO initiative. Bulletin of the World Health Organization, 1997, 75 (Suppl 1: 119–128).

Integration of vitamin A supplementation with immunization. Weekly Epidemiological Record, 1999, 74:1–6 and on the Internet at http://www.who.int/wer/pdf/1999/wer7401.pdf.

Integration of vitamin A supplementation with immunization: policy and programme implications. Report of a meeting, 12-13 January 1998, UNICEF, New York. Geneva, 1998 (unpublished document WHO/EPI/GEN/98.07; available from Vaccines and Biologicals, World Health Organization, 1211 Geneva 27, Switzerland and on the Internet at www.who.int/vaccines-documents/DocsPDF/www9837.pdf).

WHO/UNICEF/IVACG. Vitamin A supplements: a guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia (2^nd edition.) Geneva: World Health Organization; 1997.

Useful links

BASICS

Helen Keller Worldwide

IVACG

PATH

CDC

Micronutrient Initiative

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