PUBLIC HEALTH NUTRITION

ETIOLOGY AND PUBLIC HEALTH

IMPLICATION OF VITAMIN A DEFICIENCY
(VAD)

CONTRIBUTED BY:
KANISHKA UPADHYAY
PGDDPHN
LADY IRWIN COLLEGE
ETIOLOGY AND PUBLIC HEALTH IMPLICATION
OF VITAMIN A DEFICIENCY (VAD)
1.INTRODUCTION

VITAMIN A
DISCOVERY
Vitamin A is a fat soluble vitamin. There are two different types of
Vitamin A: Preformed Vitamin A and Provitamin A. Preformed Mc Collum, Simmonds and Kennedy
Vitamin A is also known as retinol and it can be used up directly isolated vitamin A in 1916.
by the body. Meanwhile, Provitamin A is also known as Richard Kuhn(Nobel Prize,1938) identified
carotenoids, which, after being consumed, are converted to carotenes. Paul Karrer in 1931 elucidated
retinol in the body. the structure of vitamin A (Nobel Prize,
The active form is present only in animal tissues. The pro-vitamin 1937).
beta-carotene is present in plant tissues. All the compounds with
vit A activity are referred to as retinoids: retinol (vit A alcohol), retinal (vit A aldehyde) and
retinoic acid (vitamin A acid).
Vitamin A is an essential nutrient required for maintaining immune function, eye health, vision,
growth and survival in human beings.
METABOLISM:

Vitamin A is required for the formation of rhodopsin, a photoreceptor pigment in the retina.
It helps maintain epithelial tissues and is important for lysosome stability and glycoprotein
synthesis.
Normally, the liver stores 80 to 90% of the body’s vitamin A. To use vitamin A, the body releases it
into the circulation bound to prealbumin (transthyretin) and retinol-binding protein.
Retinol activity equivalents (RAE) were developed because provitamin A carotenoids have
less vitamin A activity than preformed vitamin A; 1 μg retinol = 3.33 units
Dietary sources: Dairy products and poultry like eggs, milk, chicken, are rich in retinol.
Meanwhile, carotenoids are present in vegetables and fruits.

The Recommended Dietary Allowance (RDA) for men and women is 900 and 700 μg retinol
activity equivalents (RAE)/day, respectively. The Tolerable Upper Intake Level (UL) for
adults is set at 3,000 μg/day of preformed vitamin A.

2. VITAMIN A DEFICIENCY

2.1 ETIOLOGY
According to WHO, vitamin A deficiency is a common form of micronutrient malnutrition
affecting 21.1% of preschool-age children and 5.6% of pregnant women worldwide.
Primary vitamin A deficiency is usually caused by:
 Prolonged dietary deprivation
It is endemic in areas such as southern and eastern Asia, where rice, devoid of beta-carotene,
is the staple food. Xerophthalmia due to primary deficiency is a common cause of blindness
among young children in developing countries.
 Disease, including parasitic infections, diarrhoeal disease, or other infections such as
measles.
Secondary vitamin A deficiency maybe due to:
 Decreased bioavailability of provitamin A carotenoids

 Interference with absorption, storage, or transport of vitamin A

Interference with absorption or storage is likely in celiac disease, chronic diarrhea, bile duct
obstruction, giardiasis, and cirrhosis. Vitamin A deficiency is common in prolonged protein-
energy undernutrition not only because the diet is deficient but also because vitamin
A storage and transport is defective.
Factors such as household food insecurity (due to poverty or other reasons), inadequate care
and feeding practices, unhealthy household environments and inadequate health services.

2.1.1 MALNUTRITION AND VAD

Malnutrition is a complex phenomenon. Broadly defined, malnutrition refers to the condition of
inappropriate nutrition. In recent years, various vitamin and mineral deficiencies, including
vitamin A, iron, iodine and zinc have been recognized as discrete types of malnutrition that
adversely affect human health and contribute to disease and mortality. Some of these nutrients
affect closely related biological systems; for example both vitamin A and zinc play important
roles in maintaining different aspects of immune function.
RISK GROUPS:
1. Pre-school children: The primary cause of widespread VAD in preschool children is low
dietary intake of vit A and carotenoids by infants and children. The average intake of
vit A by preschool children is reported to range between 106 and 214 mg with almost
80% have intakes less than 50% of the RDA.
2. Measles and other high-risk group infections:
Severe infectious episodes, particularly measles but also malaria and chickenpox, can
cause acute decompensation in vitamin A status. If vitamin A status is marginal to begin
with, the resultant deficiency greatly increases the risk of blindness, systemic
complications and death.
Children suffering severe protein—energy malnutrition or illness (chronic or recurrent
diarrhoea, lower respiratory disease, acute otitis) and coming from communities in which
vitamin A deficiency occurs are also at increased risk of clinically significant deficiency
and its consequences.
3. Pregnant women: Maternal VAD is reported to be common in India. Studies from
National Institute of Nutrition indicated 4% of pregnant women belonging to low socio-
economic status had night blindness during the third trimester while the pregnant women
surveyed had low serum retinol levels <30g/dl.
3.DEFICIENCY MANIFESTATIONS
Impaired dark adaptation of the eyes, which can lead to night blindness, is an early symptom of
vitamin A deficiency.

 Xerophthalmia results from keratinization of the eyes. It involves drying (xerosis)

and thickening of the conjunctivae and corneas. Superficial foamy patches composed
of epithelial debris and secretions on the exposed bulbar conjunctiva (Bitot spots)
develop. In advanced deficiency, the cornea becomes hazy and can develop erosions,
which can lead to its destruction (keratomalacia). Keratinization of the skin and of the
mucous membranes in the respiratory, gastrointestinal, and urinary tracts can occur.
Drying, scaling, and follicular thickening of the skin and respiratory infections can
result.

 Night Blindness
Retinol is essential for the elaboration of rhodopsin (visual purple) by the rods, the
sensory receptors of the retina responsible for vision under low levels of illumination
Vitamin A deficiency can therefore interfere with rhodopsin production, impair rod
function, and result in night blindness. The presence of night blindness is not always
recognized, especially among children who have not yet begun to crawl or toddle.
 Conjunctival xerosis and Bitot’s spot
The epithelium of the conjunctiva in vitamin A deficiency is transformed from the normal
columnar to the stratified squamous type, with a resultant loss of goblet cells, formation of a
granular cell layer , and keratinization of the surface. This is the histopathological picture of
conjunctival xerosis.
The affected individuals are usually of school age or older and may have a history of previous
bouts of night blindness or xerophthalmia. The abnormalities are often overlooked or, in
apparent overcompensation, over-diagnosed Thus they are not, by themselves, an accurate
basis for establishing the prevalence of clinical xerophthalmia, and conjunctival xerosis cannot
be regarded as an acceptable criterion for determining whether vitamin A deficiency is a
significant public health problem.
  Corneal xerosis:
Corneal changes begin early in vitamin A deficiency, long before they can be seen with the
naked eye Many children with night blindness (without clinically evident conjunctival xerosis)
have characteristic superficial punctate lesions of the inferior—nasal aspects of the cornea.
Clinically, the cornea develops classical xerosis, with a hazy, lustreless, dry appearance, first
observable near the inferior limbus.
 Corneal ulceration/keratomalacia:
Ulceration/keratomalacia indicates permanent destruction of a part or all of the corneal stroma,
resulting in permanent structural alteration. The surrounding cornea is generally xerotic but
otherwise clear, and typically lacks the grey, infiltrated appearance of ulcers of bacterial origin.
Localized keratomalacia is a rapidly progressive condition affecting the full thickness of the
cornea It first appears as an opaque, grey to yellow mound or outpouching of the corneal
surface.

Keratomalacia

Bitot’s spot
4.PREVALENCE

Global burden of vitamin A deficiency

An estimated 4 million children under the age of 5 years are affected by xerophthalmia, a
serious eye disorder that can be caused by moderate to severe deficiency and can lead to
blindness. Far greater numbers of children show no external signs of VAD but live with
dangerously low vitamin A stores, leaving them vulnerable to infection and with reduced
immunity to fight common childhood diseases. Because of technical and financial constraints,
such as the limited ability to transport and store biological samples, or lack of laboratory
facilities, many countries have not been able to assess the true level of deficiency. It is
estimated that 127 million preschool children may be affected globally, and most of this burden
is concentrated in South Asia and sub-Saharan Africa.

VITAMIN A DEFICIENCY STATUS IN INDIA

Vitamin A deficiency (VAD) has been recognized to be a major
controllable public health and nutritional problem. An estimated 5.7%
children in India suffer from eye signs of Vit A deficiency. Recent
evidence suggests that even mild VAD probably increases morbidity
and mortality in children, emphasizing the public health importance of
this disorder.
Studies of the past two decade indicate a substantial reduction in
severe VAD problem and a reduction in ocular signs caused due to
deficiency of vit A. Such a decreasing trend observed in the
prevalence of VAD coincides with the implementation of the National
Vitamin A Prophylaxis Programme in the entire country in the early
1970s under the Fourth Five Year Plan.
The Ministry of Human Resource, however, has compiled data of
three major surveys and developed a national database on clinical
signs of xerophthalmia. The emerging national profile on prevalence of VAD indicates a wide
variation in VAD prevalence in 26 states/ union territories.
Despite reduction in clinical signs of VAD, subclinical deficiency of vitamin A continues to be
widespread. This is evident from the data presented in table below. Subclinical VAD as
measured by serum retinol levels, below 0.7microg/dl, in children below6 years is reported to be
between 34% and 60%. These survey findings confirm vitamin A deficiency disorders (VADD) is
a public health problem in India.
5. PREVENTION OF VITAMIN A DEFICIENCY
1)CONSUMPTION OF VITAMIN A RICH FOOD:

Regular dietary intake of vitamin A rich foods by pregnant and lactating women and by children
under 5 years of age.
The mothers attending antenatal clinics and immunization sessions as well as mothers and
children enrolled in the ICDS Programme are to be made aware of the importance of preventing
VAD.
Breastfeeding, including feeding of colostrums, to be encouraged.
Feeding of locally available B-carotene (precursor of vit A) rich food such as green leafy
vegetables and yellow and orange vegetables and fruits like pumpkins, carrots, papaya, mango
along with cereals and pulse to a weaning childto be promoted widely.
For increasing availability of vitamin A rich food, growing of vit A rich foods in home gardens and
consumption of these must be promoted.
2) VITAMIN A SUPPLEMENTATION PROGRAMME
In India VAS programme commenced in 1970 and it was the first country to launch the VAS
administration programme. The evolvement of the VAS programme in the last three decades
can be broadly divided into the following three phases:
A) Phase 1- National Prophylaxis Programme for Prevention of Blindness Due to Vitamin A
Deficiency (NPPVAD), 1971
In India, the National Programme for Prevention of Vitamin A Deficiency was launched by the
Ministry of Health and Family Welfare in 1970 as nutritional blindness prevention programme
under the Fourth Five Year Plan. Under this scheme all children between ages of one and three
years were to be administered 200,000 IU of Vitamin A orally once in six months.
In an attempt to improve the coverage, especially of the first two doses, it was decided to link
Vitamin A administration to the ongoing immunization programme during the Eighth Plan period.
Finally, in the 2006, the age group of eligible children was broadened to include children between
6 months and 5 years after reconsidering recommendations of the WHO, UNICEF and Ministry
of Women and Child Development. from all as 9 months to 5 yr. of age (oral prophylactic dose).
Objectives:

1. Prevention of vitamin A deficiency

i. Promoting consumption of Vitamin A rich food –promotion of regular dietary
intake of Vitamin A rich foods by all pregnant and lactating women and by children
under 5 years of age by increasing local production and consumption of green
leafy vegetables and other plant foods those are rich sources of carotenoids.
ii. Creating awareness about the importance of preventing Vitamin A
deficiency– among the women’s attending Antenatal clinics, immunization
session, as well as women and children registered under ICDS programme.
iii. Prophylactic Vitamin A as per the following dosage schedule:

100000 IU at 9 months with measles immunization

200000 IU at 16-18 months, with DPT booster
200000 IU every 6 months, up to the age of 5 years.
Thus, a total of 9 mega doses are to be given from 9 months of age up to 5 years.
Treatment of Vitamin A deficient children

i. All children with xerophthalmia are to be treated at health facilities.

ii. All children having measles, to be given 1 dose of Vitamin A if they have not received it in
the previous month.
iii. All cases of severe malnutrition to be given one additional dose of Vitamin A.
B)Phase II- Revision of Policy in 1991 and Integration of Vitamin A Supplement Programme
with the child survival efforts.
Vitamin A supplementation – a specific, targeted intervention delivered by health workers –
remains an important and effective strategy for reducing vitamin A deficiency.
VAS in infants and children 6-59 months of age.
WHO recommendations
In settings where vitamin A deficiency is a public health problem (prevalence of night blindness
is 1% or higher in children 24–59 months of age or where the prevalence of vitamin A deficiency
(serum retinol 0.70 µmol/l or lower) is 20% or higher in infants and children 6–59 months of
age), high-dose vitamin A supplementation is recommended in infants and children 6–59
months of age.

Source: World Health Organisation

IU, international units; RE, retinol equivalent
 Unlike, most other micronutrients, vitamin A is stored in the body for prolonged periods
and hence periodic administration of massive dose ensures adequate vit A.
 In 1992, the Policy guidelines for the administration of VAS to preschool children,
including infants at nine months, were incorporated as one of the major activities of the
Child Survival and Safe Motherhood (CSSM) Programme.
 Administration of supplemental dose of vit A to pre-school children at periodic intervals is
a simple, effective and most direct intervention strategy. This is a short term strategy.
 Under this strategy, every infant 6-11 months and children 1-5 years is to be
administered vit A every 6 months. The recommended schedule is as follows:
6-11 months: 1 dose of 100,000 IU
1-5 years : 200,000 IU/6 months
A child must receive a total of 9 oral doses of vit A by its fifth birthday.
 The contact with an infant during administration of measles vaccine between the age of
9-12 months is considered a practical time for administering the vit A supplement-
100,000 IU for infants.
 A biannual approach maybe used for administering vitamin A to children 1-3 years and
3-5n years. However, the DPT/OPV booster in mid-second year to a child is a suitable
time for the second dose of vitamin A (200,000 IU). Wherever, ICDS programme is
 functioning, Anganwadi Women (AWW) should be involved in the distributon and
administration of Vitamin A.

The Tenth Five Year Plan recommended that the practice of administering 100,000 IU dose of
Vitamin A at nine months along with the measles vaccine and administering MDVAS with
200,000 IU at 18, 24, 30 and 36 months of age may be continued. In order to improve coverage
without too many logistical problems, these four doses are to be administered during April and
October each year (pre-summer/pre-winter period).
In addition:
 all children with xerophthalmia should be given two doses of synthetic Vitamin A as per
the present schedule of the Government under the RCH programme;
 all children suffering from measles should also be given one dose of Vitamin A, if they
have not received it during the previous one month;
 and all cases of severe CED (based on weight-for-age criteria or clinical signs) should
be given one additional dose of Vitamin A.

CSSM/RCH Programme
Under the CSSM and later under the RCH programme, six bottles of vitamin A supplement
(VAS) syrup of 100cc were supplied for a population of 5000, as part of ‘’drug kit A’’ of the
government. This was supplied every six months i.e., a total of 100 cc per 5000 population
per year.
The VAS supply projection was based on the assumption that a subcenter would have an
average population of 5000. The supply estimated was inadequate since the population
covered by the subcenter was often as high as 7000-8000 for the high population states of
Uttar Pradesh, Bihar, Madhya Pradesh, Orissa etc.
The strategy of linking first dose of VAS with measles vaccine administration proved
practical. Sixteen states reported the coverage of over 55% for both measles vaccine and vit
A administration indicating that the linkage of administrating VAS with measles vaccine was
effective in reaching children 6-12 months of age.

CONCENTRATED VITAMIN A SOLUTION – IMPORTANT GUIDELINES

  Vitamin A concentrate is available at primary health centers and sub health centers in
the form of flavored syrup at a concentration of 100,000 IU/capsule.
 Vit A syrup should be administered using the 2ml spoon/dispenser provided with each
bottle of vit A. It should be kept away from direct sunlight. It should be stored in a cold
dark room temperature and is stable for a minimum of 1 year.

Vitamin A supplementation status in India

Presently in India, vitamin A supplementation is done through the existing network of primary
health centers and subcenters. The female multipurpose worker and other paramedics of the
health centers are responsible for administering vitamin A concentrates to children in the 9-35-
months age group. The services of the Integrated Child Development Scheme (ICDS)
functionaries are also utilized for the implementation of the program. Vitamin A is supplied in
Drug Kit A to subcenters. Each kit, supplied every 6 months, contains six bottles of 100 ml, i.e.,
1200 ml per year. The supplies are adequate to cover all the eligible children who are under the
jurisdiction of the subcenters.

Overall, only one-quarter of children age 12-35 months were given any vitamin A supplements
in the six months preceding the NFHS-3 survey.  There is no state in which more than half of
children were given vitamin A supplements in the last six months. The states with the most
successful supplementation programmes are West Bengal, Mizoram, and Kerala.  In 9 states,
less than 20 percent of children were given vitamin A supplements. In Uttar Pradesh and
Nagaland, not even 1 out of every 10 children received vitamin A supplementation during the
last six months.
EXAMPLE OF A STATE-
In Assam State, the vitamin A administration was linked with pulse polio immunization campaign
with an aim to further improve the coverage. During the campaign, a few deaths of children who
had received the vitamin A concentrate were attributed to mega dose of vitamin A causing
considerable concern among the public and contributing to extensive adverse publicity which
almost derailed the national programme. It is relevant to know that under the Indian National
Vitamin A Prophylaxis Programme, since its inception in 1970, vitamin A concentrate is
administered in syrup form and dispensed with a 2 ml spoon, unlike vitamin A capsule
distribution in most other countries. For the Assam programme, the sponsoring agency had
replaced the 2 ml spoons with 5 ml cups. Thus, the workers, who were, perhaps, not adequately
trained, might have administered more than 2 ml of vitamin A to such children. High-potency
vitamin A has been known to cause transient side effects such as nausea, vomiting and
headache in a small proportion of 1-4 yr old children.

GLOBAL SCENARIO: For children living in countries where under-five mortality is high and
vitamin A deficiency is a public health problem, vitamin A supplementation (VAS) provides vital
protection from blindness and decreases their risk of dying from preventable causes such as
measles and diarrhoea. During much of early childhood – from 6 months to 5 years of age – two
high-dose supplements of vitamin A per year, spaced four to six months apart, can strengthen
the immune systems and improve chances of survival.

Source- :
UNICEF

Since the year 2000, global efforts to scale up VAS programmes have yielded dramatic
improvements in coverage, contributing to drops in child mortality. Yet today, VAS programmes
are in crisis.
Global coverage of vitamin A supplementation has dropped to a shocking six-year low, leaving
more than one third of children unprotected from the devastating effects of vitamin A deficiency
– and stark inequities remain in reaching the children most in need. As VAS delivery shifts and
countries lose platforms that they have relied on to successfully deliver vitamin A in the past, the
need to chart new directions for the future of VAS programmes has never been more urgent.

Two drops for survival

Vitamin A supplements offer powerful lifesaving protection: they can reduce child mortality by at
least 12 per cent.

In 2016, 64 per cent of children in need in priority countries were reached with two doses of
vitamin A – but more than 141 million children were left behind, leaving them vulnerable to
disease and death. The situation is most alarming in West and Central Africa, where two-dose
coverage was the lowest of all regions in 2016, reaching just more than half of children in need.

.Global coverage dropped to a six-year low in 2016. At the same time, wide fluctuations in
coverage in short time spans are apparent in a number of regions, particularly those with weak
routine health systems, such as West and Central Africa, South Asia and Eastern and Southern
Africa, leaving vulnerable lives unprotected.

More than a decade of data show dramatic programme scale-up – yet, alarming dips
in coverage are leaving vulnerable young lives at risk.
 Adverse effects of MDVAS (Massive Dose VAS ):

Bulging fontanelle:
Nearly 12% of infants developed bulging fontanellae, when administered 100,000 IU of
vitamin A. A significant proportion of brain development takes place in children below the
age of three 16 years. Data from NFHS 4 indicate that in India, 38.4 % of children have
under-nutrition (HAZ below minus 2 SD). Subjecting these under-nourished children to
repeated episodes of increased intracranial tension could contribute to retarded brain
development.
Potential for aggravation of zinc deficiency There is a possibility that zinc deficiency,
which is already present in under-nourished children, could be aggravated by massive
doses of vitamin A. The administration of massive doses of vitamin A to children who
may be deficient in multiple nutrients including vitamin D and zinc could aggravate
growth retardation. The potential role of massive-dose vitamin A prophylaxis in the
persistence of stunting in poor children has to be carefully investigated.

C)Phase III: Acceleration of vitamin A programme- establishing effective biannual VAS

Delivery Model, 2000
In the mid 1990s, there was a global level effort to revive the VAS programme by linking
VAS administration with polio NIDs (National Immunisation Days)

1. In July 1998, a Joint WHO/UNICEF statement encouraged all countries where VAD
was a public health problem to include policy of administration of age appropriate VAS
 dosage to children during NIDs- an integration of ‘’two powerful child survival
tools’’.
2. In early 2000, a number of delivery strategies were experimented for Vitamin A
supplement (VAS) administration such as intensive campaign approach as well as the
biannual delivery strategy.
3. A number of states launched the biannual strategy with modifications introduced by
the state governments in the operational plan. Between 2001 and 2008, the fixed
month biannual strategy programme was reported to have been established in atleast
10 states- Assam, Bihar, Chattisgarh, Gujarat,Jharkhand, Karnataka, Madhya
Pradesh, Orissa, Tamil Nadu, Uttar Pradesh.
4. The biannual strategy of Vitamin A programme emphasizes on the organization of six
-monthly VAS administration sections in fixed period of the
year along with community mobilization. As per the
biannual strategy, two months, six months apart are
identified as VAS months, when vitamin A doses are to be
administered.
5. The Tenth Plan recommendations that the two months
(pre-summer/pre-winter period) in a year, 6 months apart
should be taken up for VAS distribution for coverage of
children has resulted in accelerating the adoption of the
biannual strategy.
ESTABLISHMENT OF THE BIANNUAL FIXED MONTH STRATEGY
The biannual strategy was viewed as an opportunity to deliver a package of the
following set of interventions for improving child health and nutrition:
 Management of severely malnourished children (grade III and grade IV)
 Promotion of Infant and Young Child Feeding (IYCF)
 Promotion of consumption of iodised salt and organizing salt testing events at
community level.

DIETARY FORTIFICATION:

Fortification is the addition of selected nutrients to common dietary constituents, is a long-

accepted and successful means of protecting nutritional status in countries with suitable food
distribution systems. It provides a method of delivering vitamin A to children without having to
seek them out individually. As fortification provides supplementary vitamin A more frequently
and at lower dosage than does periodic mass dosing, it is more likely to result in sustained
increases in liver stores. It is also an effective means of increasing the vitamin A intake of
pregnant and lactating
women (and hence of their newborn and breast-fed infants) without the risk of teratogenic
effects.
Milk is one of the most nutritious foods. Vitamins A and D though important for various bodily
functions and naturally present in milk are removed along with fat when the milk is processed to
produce toned, double-toned and skimmed milk.

At the processing level, four types of fluid milk are commonly produced in India: Fortifying
standardized (Fat - 4.5%), toned (Fat - 3%), double toned (Fat - 1.5%) and skimmed milk (Fat <
0.5%) with vitamin A and vitamin D will ensure that these will also reach consumers who purchase
low-fat milk and provide them with significant amounts of their daily needs of these vitamins.

Reasons for decline in VAD in India:

I. Health infrastructure: There is now better access to health care for mothers and
children. The doctor/population ratio and the ANM/population ratio have vastly
improved. Health care delivery has improved. The availability of effective antibiotics
has reduced the duration of acute respiratory infections and other infection-induced
morbidities. Also, the improvement in literacy has led to better utilization of health
care facilities. Immunization coverage for measles and other vaccine preventable
diseases has improved from 5-7% in the early 1970s to 80-90% currently.
II. Food availability: With policies in place to make subsidised food grains available
and accessible to poor households, there has been a significant improvement in the
overall dietary intake of young children. The ICDS covers more than 90% of rural
India, providing nutritional supplements to children under the age of six years and
nutrition education to mothers. The prevalence of 18 severe under-nutrition has
come down significantly
III. Infrastructure: Roads, communication facilities, electricity supply, water supply and
social security have improved. significantly. All these factors have indirectly
contributed to better health care and lower prevalence of vitamin A deficiency in
children.
 Elimination of vitamin A deficiency- future direction
VAS programme is an integral part of the RCH-2 Programme of the National Rural
Health Mission (NRHM) 2005-2011. The biannual strategy for improving coverage of
VAS is a sustainable model which can be effectively taken to scale. Reaching pre-school
children in both rural as well as urban regions is crucial and a suitable sustainable VAS
programme design needs to evolve to reach the unreached urban regions, streamlining
of the procurement of adequate quantity of VAS supply remains a challenge. Higher
priority and political commitment for implementation of the vitamin A supplementation
programme, along with commitment to improve production and access to vitamin A
fortified foods is essential to eliminate vitamin A deficiency in India and making a
significant difference in survival rate and quality of life of children in the country.

More work is needed to make programmes sustainable

A sustainable VAS programme maintains consistently high VAS coverage over time, even as
funding sources and delivery platforms shift, change or cease.

Globally, VAS programme sustainability is fragile, with wide variability in the coverage levels
achieved by individual countries over time. Less than one third of priority countries were able to
achieve high coverage in at least 8 of the previous 10 semesters.

Coverage variability highlights the need to ensure that VAS programmes are a part of the
broader health systems approach and well-integrated into the planning, financing and delivery of
health and nutrition services.

The way forward..

A world without vitamin A deficiency is possible. Yet until nutritious diets are a reality for every
child, VAS is a powerful solution for saving lives. Since 2000, the dramatic scale-up of VAS
programmes has protected millions of children from the devastating consequences of vitamin A
deficiency. Yet today, progress in reaching all targeted children has halted and risks
backsliding.

It is not too late to re-chart the future of VAS programmes. But if we fail to act now, we will lose
our hard-won progress and jeopardize the lives of millions of children. As the world mobilizes
towards the 2030 Agenda for Sustainable Development – and particularly the target of ending
preventable deaths in children under age 5 – there has never been a better time to reprioritize
this safe, cost-effective and evidence-based intervention.
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