Vitamin A policies need rethinking

Abstract

The prevalence of vitamin A (VA) deficiency, which affects about one-third of children in developing countries, is falling only slowly. This is despite extensive distribution and administration of periodic (4- to 6-monthly) high-dose VA capsules over the past 20 years, now covering a reported 80% of children in developing countries. This massive programme was motivated largely by an expectation of reducing child mortality, stemming from findings in the 1980s and early 90s. Efficacy trials since 1994 have in most cases not confirmed a mortality impact of VA capsules. Only one large scale programme evaluation has ever been published, which showed no impact on 1-6-year-old mortality (the DEVTA trial, ending in 2003, in Uttar Pradesh, India). Periodic high-dose VA capsules may have less relevance now with changing disease patterns (notably, reductions in measles and diarrhoea). High-dose VA 6-monthly does not reduce prevalence of the deficiency itself, estimated by low serum retinol. It is proposed that: (i) there is no longer any evidence that intermittent high-dose VA programmes are having any substantial mortality effect, perhaps due to changing disease patterns; (ii) frequent intakes of vitamin A in physiological doses -e.g. through food-based approaches, including fortification, and through regular low-dose supplementation-are highly effective in increasing serum retinol (SR) and reducing vitamin A deficiency; (iii) therefore a policy shift is needed, based on consideration of current evidence. A prudent phase-over is needed towards increasing frequent regular intakes of VA at physiological levels, daily or weekly, replacing the high-dose periodic capsule distribution programmes. Moving resources in this direction must happen sooner or later: it should be sooner.

High dose vitamin A capsules – Rusty bullets?

“…However, the impact on serum retinol is small and its effects are always transient, raising serum retinol above deficient levels for only 1-3 months (Mason, et al, 2015).…”

“…When the estimates of the mortality impact for the individual trials are plotted over time, the impact has clearly declined (Mason, et al, 2015). Including the two recent trials in the meta-analysis with the pre-1995-trials, may therefore not answer the question about what effect from HDVACs can be expected today.…”

Transgenic Pro-Vitamin A Biofortified Crops for Improving Vitamin A Deficiency and Their Challenges

“…Despite extensive distribution of periodic VAS over the past 20 years, decrease in VAD has been stagnant; Mason et al (2014) estimated an annual global improvement rate of VAD as 0.3 percentage points since 1990, and at this rate the authors argued it would take another 100 years to eliminate VAD [33]. While criticizing VAS, Greiner (2013) endorsed food-based approaches for their reachability and safety to all community members, and promotion of selfsufficiency and food security [34].…”

Vitamin A and the eye: an old tale for modern times

“…It is present in rural areas and the peripheries of large cities in South Asia, Africa, and Latin America, and the poor communities of large cities of developed countries (14)(15)(16)(17) . The most vulnerable individuals are children and pregnant women.…”

“…The issue of vitamin A deficiency in these populations, distributed in more than 45 countries, has been the target of international preventive programs of vitamin A supplementation and periodic evaluation (16,18,19) . Individuals suffering from food deprivation and malabsorption are often infected with intestinal parasite diseases, such as Ascaris lumbricoides and Ancilostomides, Giardia lamblia, which may aggravate the inflammatory background and the signs and symptoms of hypovitaminosis A (21)(22)(23)(24) .…”