Eggs Are Cost-Efficient in Delivering Several Shortfall Nutrients in the American Diet: A Cost-Analysis in Children and Adults.

The purpose of the current study was to examine the cost of eggs in relation to nutrient delivery in children and adults. The present analysis used dietary intake data from the National Health and Nutrition Examination Survey 2013-2016 (egg consumers: 2-18 years-old, N = 956; 19+ years-old, N = 2424). Inflation adjusted food cost and the cost of nutrients were obtained from the Center for Nutrition Promotion and Policy food cost database. Cost and nutrient profiles for What We Eat in America food categories were compared to whole eggs. Of the 15 main food groups examined, whole eggs ranked third for lowest cost per 100 g (excluding beverages), such that eggs cost 0.35 USD per 100 g, with dairy and grains representing the first and second most cost-efficient foods, at 0.23 USD and 0.27 USD per 100 g, respectively. In children and adults, eggs represented a cost-efficient food for protein delivery, such that eggs provided nearly 2.7% and 3.7% of all protein in the diet, respectively, at a cost of about 0.03 USD per g of protein. Eggs contributed 3.8% and 6.0% of all vitamin A in the diet of children and adults, at a cost of approximately 0.002 USD and 0.003 USD per RAE mcg of vitamin A, respectively. In children 2-18 years-old, nearly 12% of all choline in the diet is delivered from eggs, at a cost of approximately 0.002 USD per mg of choline. Similarly, in adults 19-years-old+, eggs provide nearly 15% of all dietary choline in the diet, at a cost of approximately 0.002 USD per mg of choline. Eggs provide nearly 5% and 9.5% of all vitamin D in the diet of children and adults, at a cost of approximately 0.21 USD and 0.22 USD per mcg of vitamin D, respectively. Overall, eggs ranked as the most cost-efficient food for delivering protein, choline, and vitamin A, second for vitamin E, and third for vitamin D in children. In adults, eggs ranked as the most cost-efficient food for delivering protein and choline, second for vitamin A, and third for vitamin D and vitamin E. In summary, eggs represent an economical food choice for the delivery of protein and several shortfall nutrients (choline, vitamin A, and vitamin D) in the American diet.

Cost-effectiveness of sunflower oil fortification with vitamin A in Tanzania by scale.

In 2011, Tanzania mandated the fortification of edible oil with vitamin A to help address its vitamin A deficiency (VAD) public health problem. By 2015, only 16% of edible oil met the standards for adequate fortification. There is no evidence on the cost-effectiveness of the fortification of edible oil by small- and medium-scale (SMS) producers in preventing VAD. The MASAVA project initiated the production of sunflower oil fortified with vitamin A by SMS producers in the Manyara and Shinyanga regions of Tanzania. A quasi-experimental nonequivalent control-group research trial and an economic evaluation were conducted. The household survey included mother and child pairs from a sample of 568 households before the intervention and 18 months later. From the social perspective, the incremental cost of fortification of sunflower oil could be as low as $0.13, $0.06, and $0.02 per litre for small-, medium-, and large-scale producers, respectively, compared with unfortified sunflower oil. The SMS intervention increased access to fortified oil for some vulnerable groups but did not have a significant effect on the prevention of VAD due to insufficient coverage. Fortification of vegetable oil by large-scale producers was associated with a significant reduction of VAD in children from Shinyanga. The estimated cost per disability-adjusted life year averted for fortified sunflower oil was $281 for large-scale and could be as low as $626 for medium-scale and $1,507 for small-scale producers under ideal conditions. According to the World Health Organization thresholds, this intervention is very cost-effective for large- and medium-scale producers and cost-effective for small-scale producers.

Availability and affordability of priority life-saving medicines for under-five children in health facilities of Tigray region, northern Ethiopia.

BACKGROUND: In developing countries, child health outcomes are influenced by the non-availability of priority life-saving medicines at public sector health facilities and non-affordability of medicines at private medicine outlets. This study aimed to assess availability, price components and affordability of priority life-saving medicines for under-five children in Tigray region, Northern Ethiopia. METHODS: A cross-sectional study was conducted in Tigray region from December 2015 to July 2016 using a standard method developed by the World Health Organization and Health Action International (WHO/HAI). Data on the availability and price of 27 priority life-saving medicines were collected from 31 public and 10 private sectors. Availability and prices were expressed in percent and median price ratios (MPRs), respectively. Affordability was reported in terms of the daily wage of the lowest-paid unskilled government worker. RESULTS: The overall availability of priority life-saving drugs in this study was low (34.1%). The average availabilities of all surveyed medicines in public and private sectors were 41.9 and 31.5%, respectively. The overall availability of medicines for malaria was found to be poor with average values of 29.3% for artemisinin combination therapy tablet, 19.5% for artesunate injection and 0% for rectal artesunate. Whereas, the availability of oral rehydration salt (ORS) and zinc sulphate dispersible tablets for the treatment of diarrhea was moderately high (90% for ORS and 82% for zinc sulphate). Medicines for pneumonia showed an overall percent availability in the range of 0% (ampicillin 250 mg and 1 g powder for injection and oxygen medicinal gas) to 100% (amoxicillin 500 mg capsule). The MPRs of 12 lowest price generic medicines were 1.5 and 2.7 times higher than the international reference prices (IRPs) for the private and public sectors, respectively. About 30% of priority life-saving medicines in the public sector and 50% of them in the private sector demanded above a single daily wages to purchase the standard treatment of the prevalent diseases of children. CONCLUSIONS: The lower availability, high price and low affordability of lowest price generic priority life-saving medicines in public and private sectors reflect a failure to implement the health policy on priority life-saving medicines in the region.

Vitamins for Cardiovascular Diseases: Is the Expense Justified?

Despite the knowledge that a well-balanced diet provides most of the nutritional requirements, the use of supplemental vitamins is widespread among adults in the United States. Evidence from large randomized controlled trials over the last 2 decades does not support vitamin supplementation for the reduction of cardiovascular risk factors or clinical outcomes. Many of the vitamins used in common practice likely are safe when consumed in small doses, but long-term consumption of megadoses is not only expensive but has the potential to cause adverse effects. Therefore, a need exists to revisit this issue, reminding the public and healthcare providers about the data supporting the use of vitamins for cardiovascular disease, and the potential for harm and the expense associated with their unnecessary use. In this review, we highlight the scientific evidence from randomized controlled studies regarding the efficacy and safety of vitamin supplementation for primary and secondary prevention of cardiovascular diseases and outcomes. We also draw attention to issues related to widespread and indiscriminate use of vitamin supplements and the need to educate the public to curtail unnecessary consumption and expense by limiting their use based on strong scientific evidence.

Delivering Vitamin A Supplements to Children Aged 6 to 59 Months: Comparing Delivery Through Mass Campaign and Through Routine Health Services in Ethiopia.

BACKGROUND: The delivery of vitamin A supplements in Ethiopia has been shifting from Child Health Days (campaigns) to routine delivery via the community health services. OBJECTIVE: The objective of this study was to compare the cost and effectiveness of these 2 delivery methods. No previous studies have done this. METHODS: A mixed method approach was used. Quantitative data on costs were collected from interviews with key staff and coverage data from health facility records. Qualitative data on the 2 modalities were collected from key informants and community members from purposefully sampled communities using the 2 modalities. RESULTS: Communities appreciated the provision of vitamin A supplements to their under 5-year-old children. The small drop in coverage that occurred as a result of the change in modality can be attributed to normal changes that occur with any system change. Advantages of campaigns included greater ease of mobilization and better coverage of older children from more remote communities. Advantages of routine delivery included not omitting children who happened to miss the 1 day per round that supplementation occurred and not disrupting the availability of other health services for the 5 to 6 days each campaign requires. The cost of routine delivery is not easy to measure nor is the cost of disruption to normal services entailed by campaigns. CONCLUSION: Cost-effectiveness likely depends more on effectiveness than on cost. Overall, the routine approach can achieve good coverage and is sustainable in the long run, as long as the transition is well planned and implemented.

Should we still use vitamin A to prevent bronchopulmonary dysplasia?

Bronchopulmonary dysplasia (BPD) is associated with significant short- and long-term morbidity in preterm infants, and it can be prevented in some infants with vitamin A prophylaxis. Vitamin A, once widely used in neonatal intensive care, was scarce for the last few years, but has become available again at a much higher price, leading to dilemmas about its routine use. In this review we discuss experimental, clinical and socioeconomic evidence related to BPD, and provide a framework for clinicians and policy-makers to evaluate the value of vitamin A treatment and make decisions about its use for prevention of BPD.

[Cost-effectiveness analysis (CEA) regarding vitamin A in children aged less than 5 years-old in Colombia]. / Análisis de costo efectividad de la vitamina A en niños menores de 5 años en Colombia.

OBJECTIVE: Evaluating the relative cost-effectiveness of using vitamin A in children aged less than 5-years-old regarding the reduction of events involving diarrhoea, malaria and mortality from the Colombian health-related social security system (CHSSS). MATERIALS AND METHODS: A decision tree was constructed, using deaths averted as outcome. Probabilities were taken from the pertinent literature and costs from official sources. The cost-effectiveness threshold was three times greater than the per capita Colombian gross domestic product (GDP) in 2012. Probabilistic and deterministic sensitivity analyses were made and cost effectiveness acceptability curves were drawn. RESULTS: Providing a cohort of 100,000 children with vitamin A (as opposed to not doing so) would represent a saving regarding medical attention costs of $ 340,306,917 due to the number of events involving diarrhea (4,268) and malaria (76), having become reduced, as well as cases requiring hospitalization. A saving for the CHSSS was consistently obtained in sensitivity analysis. CONCLUSION: Providing vitamin supplements for children aged less than 5 years-old would seem to be the least costly and most effective (dominant) strategy for the CHSSS, i.e. compared to not doing so).

An analysis of the costs of Uganda's Child Days Plus: do low costs reveal an efficient program or an underfinanced one?

BACKGROUND: Twice annually, Uganda implements Child Days Plus (CDP), a month-long outreach activity that distributes vitamin A capsules to preschool children and deworms children 6 months to 14 years old. Introduced initially as a temporary, interim strategy, CDP is now a decade old. OBJECTIVE: To assess how well CDP is implemented using an activity-based cost analysis. METHODS: In the absence of a cost-accounting system for CDP, we defined the six major CDP activities as cost centers and identified five important subactivities required to implement a round of CDP. Based on a purposive sample, we conducted a structured interview survey of 59 Ministry of Health facilities, 9 district offices, and national-level CDP staff. RESULTS: Only one-third of the facilities implemented all 11 CDP core activities. The survey revealed that Ministry of Health staff and volunteers are frequently paid substantially less in allowances than they are entitled to for their CDP outreach activities. Viewing these two practices--nonimplementation and less-than-full-reimbursement--as indicators of CDP's underfinancing, we estimate the program is underfinanced by the equivalent of 37% of its 'full implementation" costs. Two-thirds of underfinancing is manifested in nonimplementation and one-third as less-than full-reimbursement. CDP exploits economies of scale and scope and has an average cost per child served of US$0.22. We estimate that it annually saves 367,000 disability-adjusted life-years (DALYs) at an average cost of US$12.5, making it--despite its underfinancing--highly cost-effective. CONCLUSIONS AND RECOMMENDATIONS: Increased CDP funding would enable its vitamin A coverage rate of 58% and its deworming coverage rate of 62% to be increased, thereby increasing its effectiveness and efficiency. CDP should be "relaunched," as part of an effort to improve the structure of the program, set expectations about it, and earmark a minimum of resources for CDP. The Ministry of Health should demonstrate its new, greater commitment to CDP by introducing a program-specific budget line item, increasing CDP's budget allocation, and developing and implementing a training program that identifies the minimum uniform activities required to implement CDP.

Managing the vitamin A program portfolio: a case study of Zambia, 2013-2042.

BACKGROUND: Micronutrient deficiencies continue to constitute a major burden of disease, particularly in Africa and South Asia. Programs to address micronutrient deficiencies have been increasing in number, type, and scale in recent years, creating an ever-growing need to understand their combined coverage levels, costs, and impacts so as to more effectively combat deficiencies, avoid putting individuals at risk for excess intakes, and ensure the efficient use of public health resources. OBJECTIVE: To analyze combinations of the two current programs--sugar fortification and Child Health Week (CHW)--together with four prospective programs--vegetable oil fortification, wheat flour fortification, maize meal fortification, and biofortified vitamin A maize--to identify Zambia's optimal vitamin A portfolio. METHODS: Combining program cost estimates and 30-year Zambian food demand projections, together with the Zambian 2005 Living Conditions Monitoring Survey, the annual costs, coverage, impact, and cost-effectiveness of 62 Zambian portfolios were modeled for the period from 2013 to 2042. RESULTS: Optimal portfolios are identified for each of five alternative criteria: average cost-effectiveness, incremental cost-effectiveness, coverage maximization, health impact maximization, and affordability. The most likely scenario is identified to be one that starts with the current portfolio and takes into account all five criteria. Starting with CHW and sugar fortification, it phases in vitamin A maize, oil, wheat flour, and maize meal (in that order) to eventually include all six individual interventions. CONCLUSIONS: Combining cost and Household Consumption and Expenditure Survey (HCES) data provides a powerful evidence-generating tool with which to understand how individual micronutrient programs interact and to quantify the tradeoffs involved in selecting alternative program portfolios.

Cost of childhood diarrhoea in rural South Africa: exploring cost-effectiveness of universal zinc supplementation.

OBJECTIVE: To describe the cost of diarrhoeal illness in children aged 6-24 months in a rural South African community and to determine the threshold prevalence of stunting at which universal Zn plus vitamin A supplementation (VAZ) would be more cost-effective than vitamin A alone (VA) in preventing diarrhoea. DESIGN: We conducted a cost analysis using primary and secondary data sources. Using simulations we examined incremental costs of VAZ relative to VA while varying stunting prevalence. SETTING: Data on efficacy and societal costs were largely from a South African trial. Secondary data were from local and international published sources. SUBJECTS: The trial included children aged 6-24 months. The secondary data sources were a South African health economics survey and the WHO-CHOICE (CHOosing Interventions that are Cost Effective) database. RESULTS: In the trial, stunted children supplemented with VAZ had 2·04 episodes (95 % CI 1·37, 3·05) of diarrhoea per child-year compared with 3·92 episodes (95 % CI 3·02, 5·09) in the VA arm. Average cost of illness was $Int 7·80 per episode (10th, 90th centile: $Int 0·28, $Int 15·63), assuming a minimum standard of care (oral rehydration and 14 d of therapeutic Zn). In simulation scenarios universal VAZ had low incremental costs or became cost-saving relative to VA when the prevalence of stunting was close to 20 %. Incremental cost-effectiveness ratios were sensitive to the cost of intervention and coverage levels. CONCLUSIONS: This simulation suggests that universal VAZ would be cost-effective at current levels of stunting in parts of South Africa. This requires further validation under actual programmatic conditions.

Impact of supplemental immunisation activity (SIA) campaigns on health systems: findings from South Africa.

BACKGROUND: Supplemental immunisation activity (SIA) campaigns provide children with an additional dose of measles vaccine and deliver other child health interventions including vitamin A supplements, deworming medications and oral polio vaccines. They also require the mobilisation of a large health workforce. We assess the impact of the implementation of SIA campaigns on selected routine child and maternal health services in South Africa (SA). METHODS: We use district-level monthly headcount data for 52 South African districts for the period 2001-2010, sourced from the District Health Information System, SA. The data include 12 child and maternal health headcount indicators including routine immunisation, and maternal and reproductive health indicators. We analyse the association between the implementation of the 2010 SIA campaign and the change (decrease/increase) in headcounts, using a linear regression model. RESULTS: We find a significant decrease for eight indicators. The total number of fully immunised children before age 1 decreased by 29% (95% CI 23% to 35%, p<0.001) during the month of SIA implementation; contraceptive use and antenatal visits decreased by 7-17% (p ≤ 0.02) and about 10% (p<0.001), respectively. CONCLUSIONS: SIA campaigns may negatively impact health systems during the period of implementation by disrupting regular functioning and diverting resources from other activities, including routine child and maternal health services. SIA campaigns present multidimensional costs that need to be explicitly considered in benefit-cost assessments.

Supplementary immunization activities (SIAs) in South Africa: comprehensive economic evaluation of an integrated child health delivery platform.

BACKGROUND: Supplementary immunization activity (SIA) campaigns provide children with an additional dose of measles vaccine and deliver other interventions, including vitamin A supplements, deworming medications, and oral polio vaccines. OBJECTIVE: To assess the cost-effectiveness of the full SIA delivery platform in South Africa (SA). DESIGN: We used an epidemiologic cost model to estimate the cost-effectiveness of the 2010 SIA campaign. We used province-level campaign data sourced from the District Health Information System, SA, and from planning records of provincial coordinators of the Expanded Programme on Immunization. The data included the number of children immunized with measles and polio vaccines, the number of children given vitamin A supplements and Albendazole tablets, and costs. RESULTS: The campaign cost $37 million and averted a total of 1,150 deaths (95% uncertainty range: 990-1,360). This ranged from 380 deaths averted in KwaZulu-Natal to 20 deaths averted in the Northern Cape. Vitamin A supplementation alone averted 820 deaths (95% UR: 670-1,040); measles vaccination alone averted 330 deaths (95% UR: 280-370). Incremental cost-effectiveness was $27,100 (95% UR: $18,500-34,400) per death averted nationally, ranging from $11,300 per death averted in the Free State to $91,300 per death averted in the Eastern Cape. CONCLUSIONS: Cost-effectiveness of the SIA child health delivery platform varies substantially across SA provinces, and it is substantially more cost-effective when vitamin A supplementation is included in the interventions administered. Cost-effectiveness assessments should consider health system delivery platforms that integrate multiple interventions, and they should be conducted at the sub-national level.

Análisis de costo efectividad de la vitamina A en niños menores de 5 años en Colombia / Cost-effectiveness analysis (CEA) regarding vitamin A in children aged less than 5 years-old in Colombia

Objetivo evaluar la costo-efectividad relativa del uso de vitamina a en los niños menores de 5 años en la disminución de eventos de diarrea, malaria y la mortalidad, bajo la perspectiva del sistema de salud colombiano (SGSSS). Materiales y Métodos se construyó unárbol de decisión con muertes evitadas como desenlace. Las probabilidades se extrajeron de la literatura y los costos de fuentes oficiales. El umbral de costo-efectividad fue tres veces el producto interno bruto (PIB) per cápita colombiano de 2012. Se realizaron análisis de sensibilidad determinísticos, probabilísticos y curva de aceptabilidad. Resultados En una cohorte de cien mil niños, la administración de vitamina a, frente no hacerlo, representaría un ahorro en costos de atención médica de $ 340.306.917, debido a que reduce el número de eventos de diarrea (4.268) y de malaria (76), así como los casos en los que se requiere hospitalización. En todos los análisis de sensibilidad se obtuvo un ahorro para el sistema. Conclusión Dentro del sistema de salud colombiano, la suplementación con vitamina a para niños menores de 5 años, comparado con no hacerlo, es la estrategia menos costosa y más efectiva (dominante).

Objective Evaluating the relative cost-effectiveness of using vitamin A in children aged less than 5-years-old regarding the reduction of events involving diarrhoea, malaria and mortality from the Colombian health-related social security system (CHSSS). Materials and Methods A decision tree was constructed, using deaths averted as outcome. Probabilities were taken from the pertinent literature and costs from official sources. The cost-effectiveness threshold was three times greater than the per capita Colombian gross domestic product (GDP) in 2012. Probabilistic and deterministic sensitivity analyses were made and cost effectiveness acceptability curves were drawn. Results Providing a cohort of 100,000 children with vitamin A (as opposed to not doing so) would represent a saving regarding medical attention costs of $ 340,306,917 due to the number of events involving diarrhea (4,268) and malaria (76), having become reduced, as well as cases requiring hospitalization. A saving for the CHSSS was consistently obtained in sensitivity analysis. Conclusion Providing vitamin supplements for children aged less than 5 years-old would seem to be the least costly and most effective (dominant) strategy for the CHSSS, i.e. compared to not doing so).

Cost-effectiveness of "golden mustard" for treating vitamin A deficiency in India.

BACKGROUND: Vitamin A deficiency (VAD) is an important nutritional problem in India, resulting in an increased risk of severe morbidity and mortality. Periodic, high-dose vitamin A supplementation is the WHO-recommended method to prevent VAD, since a single dose can compensate for reduced dietary intake or increased need over a period of several months. However, in India only 34 percent of targeted children currently receive the two doses per year, and new strategies are urgently needed. METHODOLOGY: Recent advancements in biotechnology permit alternative strategies for increasing the vitamin A content of common foods. Mustard (Brassica juncea), which is consumed widely in the form of oil by VAD populations, can be genetically modified to express high levels of beta-carotene, a precursor to vitamin A. Using estimates for consumption, we compare predicted costs and benefits of genetically modified (GM) fortification of mustard seed with high-dose vitamin A supplementation and industrial fortification of mustard oil during processing to alleviate VAD by calculating the avertable health burden in terms of disability-adjusted life years (DALY). PRINCIPAL FINDINGS: We found that all three interventions potentially avert significant numbers of DALYs and deaths. Expanding vitamin A supplementation to all areas was the least costly intervention, at $23-$50 per DALY averted and $1,000-$6,100 per death averted, though cost-effectiveness varied with prevailing health subcenter coverage. GM fortification could avert 5 million-6 million more DALYs and 8,000-46,000 more deaths, mainly because it would benefit the entire population and not just children. However, the costs associated with GM fortification were nearly five times those of supplementation. Industrial fortification was dominated by both GM fortification and supplementation. The cost-effectiveness ratio of each intervention decreased with the prevalence of VAD and was sensitive to the efficacy rate of averted mortality. CONCLUSIONS: Although supplementation is the least costly intervention, our findings also indicate that GM fortification could reduce the VAD disease burden to a substantially greater degree because of its wider reach. Given the difficulties in expanding supplementation to areas without health subcenters, GM fortification of mustard seed is an attractive alternative, and further exploration of this technology is warranted.

Vitamin A fortification in Uganda: comparing the feasibility, coverage, costs, and cost-effectiveness of fortifying vegetable oil and sugar.

BACKGROUND: Twenty-eight percent of Ugandan preschool children suffer from vitamin A deficiency. With vitamin A supplementation covering only a third of children under 5 years of age, fortification is essential to reduce their vitamin A deficiency-related disease burden. At present, the only widely consumed food in Uganda that is fortified with vitamin A is vegetable oil. OBJECTIVE: To compare the feasibility, coverage, costs, and cost-effectiveness of fortifying vegetable oil and sugar with vitamin A in order to assess, from a public health policy perspective, whether sugar should also be fortified. METHODS: The 2005/6 Uganda Household Budget Survey was used to analyze households' apparent consumption levels of sugar and vegetable oil and to model the additional intake of vitamin A, assuming the sugar and oil fortification levels are those set by the Uganda Bureau of Standards. RESULTS: The annual incremental private sector cost of vitamin fortification is US $555,668 for oil and US $2,644,765 for sugar. Assuming that oil and sugar fortification are both effective in reducing vitamin A deficiency by 30% among those who consume these foods, the estimated cost per disability-adjusted life year (DALY) averted is US $82 for sugar and US $18 for oil. Vitamin Afortification of vegetable oil is 4.6 times more cost-effective than vitamin A fortification of sugar. If sugar were to be fortified, the 17% of Ugandans who purchase sugar but do not purchase oil would become new beneficiaries of vitamin A fortification. This would increase the coverage of vitamin A-fortified foods by 31% and reduce the percentage of Ugandans without any coverage to 25%. Those most at risk for vitamin A deficiency-members of rural, poor households-would benefit disproportionately from the introduction of sugar fortification. CONCLUSIONS: Although the lack of information on the vitamin A deficiency status of consumers of oil and sugar precludes making definitive conclusions, the increased coverage and cost per DALY averted due to sugar fortification suggests-based on World Health Organization guidelines-that the Government of Uganda should pursue sugar fortification.

The role of expanded coverage of the national vitamin A program in preventing morbidity and mortality among preschool children in India.

Higher food prices increase the risk of vitamin A deficiency among preschool children in poor families, because a larger part of the household food budget is spent on grain foods and less on vitamin A-rich foods. Vitamin A supplementation is an important source of vitamin A for children. Our objective was to characterize coverage of the India national vitamin A program for preschool children and identify risk factors for not receiving vitamin A. Anthropometric and demographic data were examined in 23,008 children aged 12-59 mo in the India National Family Health Survey, 2005-2006. Within the last 6 mo, 20.2% of children received vitamin A supplementation. The prevalence of stunting, severe stunting, underweight, and severe underweight was higher among children who did not receive vitamin A compared with those who received vitamin A (P < 0.0001). In families with a child who did and did not receive vitamin A, respectively, the proportion with a history of under-5 child mortality was 8.4 vs. 11.4% (P < 0.0001). By state, vitamin A program coverage was inversely proportional to the under-5 child mortality rate (r = -0.51; P = 0.004). Maternal education of > or =10 y [odds ratio (OR) 2.22; 95% CI 1.69-2.91], 7-9 y (OR 1.99; 95% CI 1.57-2.53), or 1-6 y (OR 1.65; 95% CI 1.28-2.13) compared with no education was an important factor related to receipt of vitamin A. Poor coverage of the vitamin A supplementation program in India has serious implications in the face of rising food prices. Expanded coverage of the vitamin A program in India will help protect children from morbidity, mortality, and blindness.

Vitamin A intake and status in populations facing economic stress.

Dietary quality and diversity reflect adequacy of vitamin A. Both can deteriorate in response to economic crises. Although the nutritional consequences of the 2008 world food price crisis remain unclear, past studies of diet, status, and socioeconomic standing under usual (deprived) and unusually disruptive times suggest dietary quality and vitamin A status decline in mothers and young children. This is presumably the result of shifting diets to include less preformed vitamin A-rich animal source foods and, to a lesser extent, vegetables and fruits. Cross-sectional assessments of diet, deficiency, and socioeconomic status in a number of countries and surveillance data collected during the Indonesian economic crisis of 1997-8 indicate that the prevalence of vitamin A deficiency, night blindness, and other related disorders (e.g., anemia) may have increased during the 2008 crisis, and that it might not have necessarily recovered once food prices waned later in 2008. Lost employment may be a factor in slow nutritional recovery, despite some easing of food prices. Vitamin A deficiency should still be preventable amid economic instabilities through breast feeding promotion, vitamin A supplementation, fortification of foods targeted to the poor, and homestead food production that can bolster income and diversify the diet.

Estimating the global costs of vitamin A capsule supplementation: a review of the literature.

BACKGROUND: Vitamin A supplementation reduces child mortality. It is estimated that 500 million vitamin A capsules are distributed annually. Policy recommendations have assumed that the supplementation programs offer a proven technology at a relatively low cost of around US$0.10 per capsule. OBJECTIVES: To review data on costs of vitamin A supplementation to analyze the key factors that determine program costs, and to attempt to model these costs as a function of per capita income figures. METHODS: Using data from detailed cost studies in seven countries, this study generated comparable cost categories for analysis, and then used the correlation between national incomes and wage rates to postulate a simple model where costs of vitamin A supplementation are regressed on per capita incomes. RESULTS: Costs vary substantially by country and depend principally on the cost of labor, which is highly correlated with per capita income. Two other factors driving costs are whether the program is implemented in conjunction with other health programs, such as National Immunization Days (which lowers costs), and coverage in rural areas (which increases costs). Labor accounts for 70% of total costs, both for paid staff and for volunteers, while the capsules account for less than 5%. Marketing, training, and administration account for the remaining 25%. CONCLUSIONS: Total costs are lowest (roughly US$0.50 per capsule) in Africa, where wages and incomes are lowest, US$1 in developing countries in Asia, and US$1.50 in Latin America. Overall, this study derives a much higher global estimate of costs of around US$1 per capsule.

Vitamin A supplementation in Tanzania: the impact of a change in programmatic delivery strategy on coverage.

BACKGROUND: Efficient delivery strategies for health interventions are essential for high and sustainable coverage. We report impact of a change in programmatic delivery strategy from routine delivery through the Expanded Programme on Immunization (EPI+) approach to twice-yearly mass distribution campaigns on coverage of vitamin A supplementation in Tanzania METHODS: We investigated disparities in age, sex, socio-economic status, nutritional status and maternal education within vitamin A coverage in children between 1 and 2 years of age from two independent household level child health surveys conducted (1) during a continuous universal targeting scheme based on routine EPI contacts for children aged 9, 15 and 21 months (1999); and (2) three years later after the introduction of twice-yearly vitamin A supplementation campaigns for children aged 6 months to 5 years, a 6-monthly universal targeting scheme (2002). A representative cluster sample of approximately 2,400 rural households was obtained from Rufiji, Morogoro Rural, Kilombero and Ulanga districts. A modular questionnaire about the health of all children under the age of five was administered to consenting heads of households and caretakers of children. Information on the use of child health interventions including vitamin A was asked. RESULTS: Coverage of vitamin A supplementation among 1-2 year old children increased from 13% [95% CI 10-18%] in 1999 to 76% [95%CI 72-81%] in 2002. In 2002 knowledge of two or more child health danger signs was negatively associated with vitamin A supplementation coverage (80% versus 70%) (p = 0.04). Nevertheless, we did not find any disparities in coverage of vitamin A by district, gender, socio-economic status and DPT vaccinations. CONCLUSION: Change in programmatic delivery of vitamin A supplementation was associated with a major improvement in coverage in Tanzania that was been sustained by repeated campaigns for at least three years. There is a need to monitor the effect of such campaigns on the routine health system and on equity of coverage. Documentation of vitamin A supplementation campaign contacts on routine maternal and child health cards would be a simple step to facilitate this monitoring.