Vitamin A program deficiency highlights primary care needs

“The great Vitamin A fiasco,” by Michael Latham in World Nutrition, the Journal of the World Public Health Nutrition Association (www.wphna.org), Volume 1, Number 1, May, 2010

In his commentary, Michael Latham addresses the evolution since the 1970s of vitamin A capsule administration in public health policy as funded by international governing bodies including the U.S. Agency for International Development (USAID), United Nations Children’s Fund (UNICEF), and World Health Organization (WHO) such that it influences the processes put in motion to serve under- and malnourished children in developing countries. Latham, recognized leader in nutrition science, states that current policy can be seen as incorrect method of administration of vitamin A in the field on the local level, given what more and more amounts to non-thorough follow-through based on actual child need statistics. He says the global funding may near a ‘donor fatigue’ situation before long, so that the Vitamin A program will cease altogether, and that what is needed is a change in program administration, rather than death of the program. He describes the importance of correct implementation of the vitamin A program worldwide.

Latham was a founding member of the International Vitamin A Consultative Group (IVACG) in 1975, funded by USAID. Together with the UN’s Standing Committee on Nutrition (SCN), vitamin A and other food and nutrition policies are implemented. This Vitamin A administration group originally worked to prevent vitamin A deficiency and, more generally, childhood mortality and morbidity. Capsules were acknowledged by nutrition experts to be a temporary measure in reducing xerophthalmia, or dry eye, and keratomalacia, or night blindness, in young children, conditions which can lead to total blindness, and not as a superior method for treating underlying causes on a sustainable basis, according to Latham. Vitamin A is an essential micronutrient found in retinol and carotenoid units found naturally in breast milk, animal foods (including liver, poultry, and fish), dairy products, eggs, green leafy vegetables, fruits, and yellow and orange vegetables and tubers, hence, carrots. It is also found in great concentration in tropical palm and other plant oils. Vitamin A deficiency is also seen in measles infections, and the best method for treating measles is vaccination, not capsules.

In an important study in Indonesia, published in The Lancet in 1986, 24 years ago, vitamin A massive dosage administration was credited with a 34 percent reduction in child mortality from all causes. This study, and succeeding ones, failed to exclude measles mortality. Based on Latham’s years of field experience in Africa, he concluded that as causes of death were not reported, more thorough data-gathering techniques would reveal measles as the probable culprit where children had symptoms of respiratory infection, diarrhea, or fever, according to family members’ “verbal autopsies.”

Latham’s World Nutrition article argues that these decision-making organizations, USAID, UNICEF, and WHO, should revise priorities so they will be closer to their original objectives, so that the underlying hunger issue is addressed and food availability is placed ahead of medicinal dosing, with respect to vitamin A availability. Instead of massive twice-yearly doses of capsules per infant, age six to twelve months, and child, age four to five years, as the first answer to supply a body vitamin A, the retinol and carotenoid intake in children’s diets can best be met through adequate vitamin A in the food supply. Specifically, the massive dose set at 200,000 IU for babies is just under the food equivalent on a daily basis of 600 IU, and for children one to five years 400,000. The daily food equivalent is given as 900 IU for children ages four to five. What about the daily food equivalent for children ages one to four? The article does not give to the reader the same basis for comparison between food and medicinal dose for ages one to four—a typo, perhaps? Adjusting for age, one can assume that the two-year-old is receiving the same dose as the five-year-old.

In 1992, WHO and the Food and Agriculture Organization (FAO) determined that vitamin A supplementation intervention was most needed in Africa, Southeast Asia, and the Western Pacific. Tanzania implemented a disease-based approach through its essential drugs program in addition to improvement on a country-wide basis of production and marketing of red palm oil, and growing and selling tropical fruit seedlings from schools, which proved to be sustainable. Until the mid-1990s, governments usually attempted to integrate capsule delivery into primary health care delivery, according to Latham.

The Beaton report, published by the Swedish International Development Cooperation Agency (SIDA) found that the universal vitamin A capsule program in Bangladesh was found to be wanting by 1989, in that recordkeeping was inadequate as to what age group was receiving the capsules, showing that they were being used as a ‘magic bullet’ drug. Importantly, the report found that infants under six months were receiving almost as much supplementation as older babies and children, when infants weren’t supposed to receive any capsule supplementation at all. Although Worldview International, an NGO, followed up on a district-by-district basis, the universal VAC policy had begun to dominate. Supplementation was seen as the answer to vitamin A deficiency, as a cure all, in the agenda, and some UN and national aid agencies were complicit, with pharmaceutical giants standing to benefit.

Latham says that vitamin A programs at the local and national level can benefit from actual accurate recordkeeping leading to improved morbidity and mortality statistics at the international committee level as reported from the field. Keratomalacia should be addressed before it progresses to blindness on an individual basis, not a universal one, and symptoms correctly diagnosed as they progress or regress, with childrens’ health and diet being more closely monitored. Measles vaccinations should be administered, rather than relying solely on capsule administration to prevent deficiency, so that individuals are more well protected. In the case of advanced disease, cause of death can more accurately be determined in those who have been immunized. Latham suggests that protection and development of healthy, affordable, and appropriate food systems and supplies are needed, which lead to protection against other diseases, sustainability, enhancement of well-being, and social, cultural, economic, and environmental benefits. In this article, Latham explains how we may allow ourselves to think that it is not necessary to dose individuals without any symptoms of vitamin A deficiency. With a return to a natural sustainability base using a trickle-up approach at the local level, which melds food based programs with supplementary capsule programs, there is no reason to sound a death knell for the SCN or other vitamin A programs due to donor fatigue. Latham suggests that revision of policy with regard to vitamin A deficiency is what is needed, based on monitoring in local field situations over time as they evolve.