Fact Sheet Expert Opinion Photo Essay


Eliminating Vitamin A deficiency

Archana Dwivedi, UNICEF Project Officer, Maternal Nutrition

Q: What role does vitamin A play in a child’s health and development?

A: Vitamin A is a fat-soluble vitamin found in meats, livers, dairy products and eggs, fruit, carrots, green leafy vegetables and red palm oil. Many people are familiar with the relationship between vitamin A and blindness, but the micronutrient also plays a critical role in boosting the immune system. If children have insufficient vitamin A, their ability to resist diseases such as diarrhoea, measles and acute respiratory infections is greatly hampered. Increasing the vitamin A intake of populations with vitamin A deficiency (VAD) can decrease childhood deaths from such illnesses by 23 per cent, or nearly a quarter of childhood deaths. Not to mention the number of children who avoid hospital stays and missed school days.

Q: What are UNICEF’s short- and long-term goals in combating VAD?

A: The short-term goal (by 2005) is to double the number of countries that have achieved two annual rounds of Vitamin A supplementation with more than 70 per cent coverage of children between the ages of six months and 59 months. Our baseline is 1999, when there were 10 countries that achieved this coverage. By 2005, we hope to increase that number to 20 countries that have sustainable vitamin A programmes. The long-term goal is to eliminate vitamin A deficiency by 2010.

Q: How will UNICEF reach these goals?

A: There are three strategies: diversifying foods, fortifying foods and vitamin A supplements. Breastfeeding is included in the category of diversifying foods, because this is where infants get a lot of vitamin A. In fortification and vitamin A supplementation, we focus on children six months to five years old and also pregnant and breastfeeding mothers.

The impact of vitamin A is most profound during the first three years of life and then with pregnant women who need more vitamins and minerals, both for themselves and the foetus. So we look at different approaches to increase the vitamin A intake of these two groups. Vitamin A supplementation is the basis of the vitamin A ‘programming’: we look at the foods they eat that are rich in vitamin A and try to start a programme to fortify or enrich the vitamin A content of various foods.

A successful fortification programme identifies a staple that most of the population eats and that is produced in a way that will accommodate fortification. Commonly-fortified foods include flour, oils and sugar.

Q: What is UNICEF’s role in vitamin A supplementation?

A: At just a few cents a capsule, Vitamin A is an extremely cost-effective, efficient method for addressing VAD. UNICEF has been supporting Vitamin A supplementation for a long time, but in 1997 we expanded our programme to a much larger scale after receiving a donation from the Canadian-based Micronutrient Initiative that supplied all the capsules we need. We’ve already seen a great deal of progress in the programme.

Today, UNICEF supports 95 per cent of the world’s vitamin A supplements for developing countries, with the bulk of the funding coming from the Micronutrient Initiative. The Canadian International Development Agency (CIDA) also provides funds for Vitamin A supplementation programmes.

Q: How does vitamin A supplementation work?

A: Vitamin A capsules have a little nib at the end that you cut with scissors and then drop the vitamin A into the children’s mouths. The World Health Organization (WHO) has established dosage guidelines: each child between six and 11 months is to receive 100,000 international units (IU) of vitamin A. This increases to 200,000 IU every six months from 12 to 59 months of age.

Prevention is what we are aiming at with the dose every six months, but we do have specific regimens for children who have measles or who are severely malnourished. With measles, for example, the child receives 200,000 IU as soon as he or she is diagnosed and then the same dosage the next day. We are also supporting women postpartum (the period shortly after childbirth) and they receive 200,000 IU after giving birth.

Q: What is vitamin A fortification?

A: Populations in industrialized countries get an abundant supply of vitamin A, not just in the natural diet, but also through fortification of foods such as margarines and vegetable or canola oil. Many countries in Central America, such as Guatemala and Honduras, have had great success with sugar fortification. Other commonly-fortified foods are flour and oils.

To have a successful fortification programme, you have to identify a staple that most of the population eats and one that is produced in a way that will accommodate fortification. Before any fortified staple is introduced into the community, rigorous tests are performed to make certain that fortification is not changing the basic nature of the food: its flavour, colour or cooking properties. 

Q: How does UNICEF determine that a population has a VAD problem?

A: There are clinical signs such as xerophthalmia, or eye damage, and night blindness in pregnant women and children. WHO has decided that if there is greater than two per cent night blindness among pregnant women, then there is a public health problem in the population. Another evaluation is biochemical – we can look at serum-retinol levels in the blood. When serum retinol is collected, it provides specific identifying information for the early stages of VAD. There are established levels of serum retinol for healthy individuals, so the out of range values of those suffering from VAD can easily be identified. We use all of these indicators to determine whether or not to begin a vitamin A supplementation program.

Doing countrywide surveys can be expensive and time-consuming, so we often use a much broader, but telling, indicator – the under-five mortality rate (U5MR). We know through past experience as well as data, that any country with an U5MR over 70 (or more than 70 deaths per 1,000 live births) should be assumed to have Vitamin A deficiency as a public health problem and action needs to be taken.

Q: How does UNICEF work with governments to implement vitamin A programmes?

A: Usually each country will have a policy on micronutrients that includes all three strategies. UNICEF helps make it operational. For supplementation, we look at what the delivery strategies could be, such as combining the programme with a National Immunization Day, an integrated Child Health Day, or a Micronutrient Day. In some cases, it may be possible to incorporate it into routine health services. We support the logistical planning, provide the supplements and then assist in monitoring and evaluating the whole system.

Q: What are some of the success stories?

A: Tanzania is a good example of an integrated programme. That country holds Child Health Days where they address malaria, hookworm, vitamin A and growth monitoring. The vitamin A component has been highly successful – Tanzania achieved over 80 per cent in both rounds in 2002. The programme is community-based: they don’t do everything on one day, but over a one- or two-week period. Each district picks when they want to hold their days within that time frame.

Nepal and Viet Nam have had successful vitamin A supplementation programmes for years. In West Africa, Niger has been doing Micronutrient Days where, in addition to providing vitamin A supplements, they also test the salt for iodine (iodine deficiency can cause brain damage and learning disabilities, stunt children’s growth, cause goitre and can also significantly raise the risk of stillbirth and miscarriage for pregnant women) and look at iron folate (a lack of iron or iron deficiency anaemia, greatly heightens women’s risk of death during childbirth and their newborns face a high risk of low birth weight, as well as poor growth and physical development).

Q: What are some of the obstacles to implementing vitamin A programmes?

A: One of our challenges is to educate governments, health professionals, policymakers and the public about vitamin and mineral deficiencies, which are often hidden. With vitamin A, we must explain all the benefits of supplementation. VAD is not just about blindness, but also about levels of disease and death.

We also need to dispel fears and misinformation among the public that vitamin A is dangerous for children. It is possible to get too much vitamin A and experience side effects such as wooziness or loose stools, however, there has been no documented case, ever, of any child dying from too much vitamin A.

Q: Who are UNICEF’s key partners in the vitamin A programming?

A: UNICEF works with an informal network of donors and international organizations in the Vitamin A Global Initiative. Partners include the Micronutrient Initiative (MI), the Canadian International Development Agency (CIDA), the World Health Organization (WHO) and the United States Agency for International Development (USAID). There is also the UK Department for International Development (DfID) and the Dutch government.

Within this group, we discuss and coordinate where to direct programming, advocacy and fundraising. We also rely on a lot of other organizations, such as Helen Keller International, which is a huge partner in terms of implementing vitamin A programmes, and researchers at Johns Hopkins and Cornell Universities, for expert advice.