See TIH/VA screens 14-17

Table 1. Prevalence of clinical vitamin A deficiency among children by region (0-72 months), 1990-2000. Region Percent Vitamin A

Deficient Numbers Vitamin A

Deficient (Millions)

Trend (pp/yr)

1990 1995 2000 1990 1995 2000 1990-1995 1995-2000 Sub-Saharan Africa 1.57 1.4 1.39 1.564 1.508 1.541 -0.034 -0.002 Middle East and North Africa

1.03 0.76 0.69 .387 .312 .266 -0.054 -0.014

South Asia 1.44 1.45 1.58 .721 .735 .792 0.002 0.026 Southeast Asia 0.76 0.43 0.64 .442 .256 .365 -0.066 0.042 China 0.43 0.24 0.42 .483 .252 .406 -0.038 0.036 India 0.93 1.05 1.85 1.064 1.233 2.15 0.024 0.160 Middle America and the Caribbean

0.89 0.84 0.28 .176 .171 .055 -0.010 -0.112

South America 0.67 0.69 0.23 .228 .224 .070 0.004 -0.092 Eastern Europe and Central Asia

---- 0.46 0.39 ---- .076 .053 ---- -0.014

Total 1.23 1.10 1.37 5.065 4.767 5.698 -0.026 0.054 Total 0-4 Population 411.63 433.05 416.89

Trends in the preva lence o f sub -c lin ica l vitam in -A defic ient ch ildren , 1990 -2000.

0

10

20

30

40

50

60

70

1990 1995 2000

Y ear

Prev

alen

ce

S ub-S aharan A frica M idd le E ast and N orth A fricaS outh A s ia S outheast A s iaC h ina Ind iaM idd le A m erica and the C aribbean S outh A m ericaE aste rn E urope and C entra l A s ia

Supplementation with Vitamin A Capsules (V AC)

4 -- 8 weeks post partum: 300,000 I Us to mother, for breast feeding -in health center, clinic, or home visit

6 or 9 months on: 200,000 I Us every 6 months (check) - with NationalImmunization Day (but annual), Micronutrient Day or Week, or otherspecial event; case management in clinics

Low dose supplementation during pregnancy: 5,000 I Us /week(check)

Supplementation with Vitamin A Capsules (V AC)

Fortification

Commodity fortified (= 'vehicle') must be regularly consumedin predictable quantities by the target group; must not beliable to large fluctuations in intake (e.g. staples,seasonings, are suitable)

Nutrient (= 'fortificant') must be stable and retained in foodpreparation; must not decrease appeal of food (colour,taste, price, texture, etc.)

For vitamin A, vegetable oils/margarine are potentiallysuitable as vitamin A is fat- soluble, but may not reachall groups; sugar is OK (vit A in water-dispersible form,e.g. palmitate) but intakes vary

For iodine, salt clearly the method of choice

For iron, wheat is fine, where it is the staple; for rice-staplepopulations, there remains an unsolved problem (especiallyas iron compounds wash out in cooking)

Multiple fortification (including sprinkles) becomes easierand more effective with urbanization, development, andincreased use of processed foods.

UNICEF Region

A

Total Number of Vitamin A Capsules Procured in Millions

B

200,000 IU Vitamin A Need for

Children 12-59mo in Countries with Reported Capsule Procurement for

1998*

C

Estimated Adequacy of Capsule Supply for Children 12-

59mo in Countries Receiving UNICEF Vitamin A Capsules

D

Median Value for 1998 Reported

Vitamin A Program Coverage

of Children 6-59mo*

E 1993 1994 1995 1996 1998

Regional Annual

Average (1993-1996, 1998)

1998 (in millions)

1998 (%)

1998 (median %) (n)

South Asia

5.36 46.50 48.06 2.40 6.73 21.81 62.73 9.1 87 (5)

East Asia & Pacific

3.95 13.70 12.64 26.00 31.31 17.52 36.32 66.6 80 (8)

Latin America & Caribbean

8.90 26.80 25.56 4.30 23.32 17.78 62.05 30.0 60 (9)

East & Southern Africa

14.13 51.40 38.95 11.80 31.08 29.47 33.85 67.8 83 (13)

West & Central Africa

3.92 6.02 9.40 5.15 36.33 12.16 73.15 36.2 90 (11)

Middle East & North Africa

8.68 17.40 0.32 17.40 24.73 13.71 21.32 57.6 85 (6)

Total 44.94 161.82 134.93 67.05 153.5 112.45 289.42 38.1 80 (52)

VAC distribution 1993-1998

VAC coverage -- 1993-98

Table 2. Changes in indicators of vitamin A deficiency (VAD) after 200,000 IU doses in children of 12-42 months (India) and 6-60 months (Philippines)

VAD indicator Study Baseline

prevalence Prevalence 1 month after VAC

Prevalence 4 months after VAC

Bitot’s spots Orissa 2.9% 1.9% 3.6%

Andhra Pradesh 5.5% 6.1% 5.3%

Orissa 63.8% 46.1% 86.4%

Andhra Pradesh 52.3% 63.9% 71.2%

Philippines, 1993 38.0% 22.9% NA

Serum retinol, <0.7 mcm/l or <20 mcg/dl

Philippines, 1998 43.5% 36.5% 39.2% (a)

Orissa 20.4% 5.0% 21.4%

Andhra Pradesh 5.7% 6.9% 9.7%

Philippines, 1993 11.2% 4.5% NA

Serum retinol, <0.35 mcm/l or < 10 mcg/dl

Philippines, 1998 10.3% 5.7% 9.3% (a)

Notes. Results from Orissa and Andhra Pradesh, from NIN (India)/MI, draft June 2001, survey dates April and July 2000. Reported coverage of VAC was 93% in Orissa and 35% in Andhra Pradesh, for children 12-48 months. Philippine results from FNRI, Madriaga et al, 1998; children 6-60 months, coverage 80-90%; baseline represents no dose group assessed at same time as +dose group; (a) from Tulane/FNRI/UPLB analyses of the same data.

Prevalence of SR < 10 ug/dL among 1-5y old children in Visayas, high and low prevalence areas, without and with VAC (1-2, 3-4, 5-6 mo after dose)

0

5

10

15

20

25

30

35

40

no VAC VAC 1-2 VAC 3-4 VAC 5-6

%

High prev

Low prev

All HUCs

High prev: Prev10(%) = 38.3 + 61.7(dVAC1-2)* - 17.7(dVAC3-4) - 7.6(dVAC5-6)*

All HUC: Prev10 (%) = 27 - 18(dVAC1-2) - 11(dVAC3-4) - 2(dVAC5-6)* - 2(dstunting)* + 2(dinfection)*

VAC evaluation results -- Philippines

POLICY IMPLICATIONS-- Philippines

Shift in policy or resource allocation:

•Change in dosing schedule from twice a year to three times a year

• Universal distribution of VAC in high prevalence areas and targeted distribution where prevalence of VAD is low

• Stunting may be a criterion for screening program targets in low prevalence areas

Future Policy

• VAC’s in high prevalence (<10 mcg/dl) areas

• VAC’s ? Targetted to stunted children

• post partum to ma’s

• low dose supplementation in pregnancy (where?)

• fortify widely -- oils, sugar, flour, weaning foods …

• in ‘sprinkles’

But now … see ‘Vitamin A strategies need rethinking’