Need to re-look Vitamin A supplement programme

Mumbai: Scientists and nutrition experts have sought a review of the Vitamin A supplementation programme in the country, saying the number of children suffering from the deficiency have decreased over the years.

"The prevalence of Vitamin A deficiency is less than one per cent and is limited to selected geographical pockets in the country. Keratomalacia and nutritional blindness have disappeared," the scientists said.

The current evidence suggests that the supplement cannot be justified as a public health intervention for prevention of xerophthalmic blindness or childhood mortality in India and, therefore, needs a re-look, the experts said.

"The continuation and intensification of Universal Vitamin A Supplementation Programme (UVAS), despite consistent opposition from Indian scientists, is proving detrimental for our public health needs, Dr Umesh Kapil, Department of Gasteroenterology and Human Nutrition of AIIMS and Dr H P S Sachdev, Department of Paediatrics and clinical epidemiology of Sitaram Bhartia Institute of science and Research said.

"We suggest a dispassionate, national evidence-based process to examine an appropriate shift in the vitamin A supplementation policy," they said.

"It is unfortunate but true that the agencies are trying to implement interventions for prevention and control of micronutrients disorders according to their mandate rather
than the magnitude and health consequences," they said.

Vitamin A is an essential nutrient needed in small amounts for normal functioning of the visual system, growth and development, maintenance of epithelial cellular integrity,
immune function and reproduction. Severe deficiency of Vitamin A is known to produce corneal xerophthalmia or keratomalacia and blindness in children.

According to the Annual Report of Micronutrients Initiatives India, an International NGO, out of 32 million US dollar available in the Annual Budget 2009-2010, more than 20 million US dollars were spent on Vitamin A Procurement and Interventions. A meagre sum of 2.5 million US dollars were spent on iron interventions.

Anaemia is the most common nutritional deficiency disorder in the country.

The National Prophylaxis Programme against Nutritional Blindness was initiated in 1970 as an urgent remedial measure to eliminate unacceptably high magnitude of xerophthalmic blindness.

All one to five-year-old children were to be administered 2,00,000 international unit of Vitamin A orally once in six months.

During the early 1990s this intervention was restricted to children between nine months and three years as clinical deficiency was almost exclusively restricted to this age range.

An expert group, in the year 2005, endorsed 9 months to 3 years as the target age group for universal vitamin A supplementation (UVAS) but in 2006, the age group 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.

"The stated objective of the UVAS programme in India remains unaltered since inception; however, the current advocacy for intensification and increase in age range
primarily pertains to child survival benefit," Kapil said.

"In under-5 children, clinical vitamin A deficiency including severe xerophthalmia was a major public health problem in the early 1960s. However, in the past four decades,
keratomalacia has almost disappeared and there is a sharp decline in the prevalence of Bitot`s spots," the scientists said.

Recent surveys indicate that the prevalence of Bitot`s spots is less than 0.5 per cent (conventional cut-off to define public health problem) in a few isolated geographical
pockets, which are socio-economically backward with poor health infrastructure.

This observed decline is largely due to the implementation of relevant developmental and health initiatives in the country.

"The available evidence indicates that this decline cannot be attributed to the UVAS programme. The latest national survey revealed that only 18 per cent of eligible children received Vitamin A supplementation," they said.

However, Sachdev said allegedly due to pressure by the `Vitamin A lobby` the results have not been published even 6 years after completion of the study.

Systematic reviews show that vitamin A supplementation results in an increased risk of developing acute respiratory infection, which violates the public health principle of
causing no harm and Vitamin A in large doses causes hypercalcaemia due to a direct effect on bone.

"It intensifies the severity of bone demineralization and inhibits the ability of vitamin D to prevent such demineralisation. Excessive dietary intake of vitamin A in adults is associated with reduced bone mineral density and increased risk for hip fracture," they said.