Factors affecting low coverage of the vitamin A supplementation program among young children admitted in an urban diarrheal treatment facility in Bangladesh.

BACKGROUND: Vitamin A deficiency (VAD) is one of the most prevalent micronutrient deficiencies in the world. About 2% of all deaths among children under five years of age (U-5) are attributable to VAD. Currently evidence-based knowledge is grossly lacking about the factors associated with low coverage of VAS. OBJECTIVE: This study aims to determine the factors affecting low coverage of the vitamin A supplementation program among the young children admitted to a diarrheal hospital. METHODS: We extracted data from the Diarrhoeal Diseases Surveillance System (DDSS) on children aged 12-59 months admitted to the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh, from 1996 to 2014. A logistic regression model was constructed to identify the factors that were significantly associated with non-compliance to vitamin A supplementation (VAS). Strength of association was determined by calculating adjusted odds ratios (aORs) and their 95% confidence intervals. RESULTS: A total of 8649 children were enrolled and comprised the analyzable sample. Their mean ± SD age was 25.2 ± 12.8 months and 40% were female. Around 68% of them had received VAS in the previous 6 months. In the logistic regression analysis, older (>24 months) children (aOR: 1.38; 95% CI: 1.24-1.53), having an illiterate mother (aOR: 1.43; 95% CI: 1.27-1.64), having an illiterate father (aOR: 1.3; 95% CI: 1.16-1.50), coming from the two lowest wealth quintiles (aOR:1.13; 95% CI: 1.02-1.27), with an average monthly household income <10,000 BDT, (1 USD = 60 BDT) and children who had not received the measles vaccine (aOR: 1.87; 95% CI: 1.63-2.19) were more likely not to have received VAS in the preceding six months. We also observed an increase in coverage of VAS from 61% to 76% over the last 18 years (p < 0.001). CONCLUSIONS: Non-compliance to VAS was found to be associated with older children, parents without formal schooling, family with greater poverty, low family income, and lack of measles vaccination. Specific programmatic approaches including prioritizing vulnerable children may enhance vitamin A coverage.

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.

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.

Vitamin A Supplementation for Prevention of Bronchopulmonary Dysplasia: Cornerstone of Care or Futile Therapy?

OBJECTIVE: To review the evidence on vitamin A supplementation (VAS) and bronchopulmonary dysplasia (BPD) in extremely-low-birth-weight infants. We also discuss the impact of a vitamin A shortage on BPD rates. DATA SOURCES: A PubMed search inclusive of dates 1946 to March 2016 was performed using the search terms bronchopulmonary dysplasia, chronic lung disease (CLD), and vitamin A STUDY SELECTION AND DATA EXTRACTION: All English-language studies were evaluated. Only those investigating VAS by intramuscular administration were included. DATA SYNTHESIS: A total of 6 studies were evaluated. Additionally, a report on the incidence of BPD during a national shortage was reviewed. Investigators found mixed results with VAS and incidence of CLD or death in a varying number of neonates. In the largest evaluation, investigators found a statistically significant decrease in the rate of death or BPD: 55% in the VAS group versus 62% in the placebo group. The number needed to treat to prevent 1 case of BPD was 15 infants. Few studies found an increased incidence of adverse events following VAS. A report over a 2-year shortage period found that whereas the rate of VAS declined dramatically, BPD rates remained stable. This large observational evaluation calls into question the place of vitamin A in BPD prevention. CONCLUSIONS: VAS has been identified as a strategy to decrease the incidence of BPD. Initial large-scale prospective evaluations have shown clear benefit of VAS in reducing the incidence of CLD or death. However, changing definitions of BPD and implementation of noninvasive ventilation strategies limit the application of early studies. During a drug shortage, VAS declined dramatically, but BPD rates remained stable. With concerns of sepsis and necrotizing enterocolitis in small-scale studies, and in light of the recent shortage evidence, further evaluations are necessary before VAS can be recommended as a cornerstone of BPD prevention.

The effect of the national shortage of vitamin A on death or chronic lung disease in extremely low-birth-weight infants.

IMPORTANCE: Prophylactic vitamin A supplementation has been shown to reduce the incidence of chronic lung disease or death in extremely low-birth-weight infants. Beginning in 2010, a national shortage reduced the supply of vitamin A available. OBJECTIVE: To estimate the association between vitamin A supplementation and death or chronic lung disease in the context of the recent drug shortage. Intercenter variability in vitamin A use was assessed secondarily. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 7925 infants with birth weights between 401 and 1000 g who were cared for in US neonatal intensive care units managed by the Pediatrix Medical Group. Infants were discharged between January 1, 2010, and June 30, 2012, and data were collected from the Pediatrix Clinical Data Warehouse. Infants who had major congenital anomalies, died during the first 3 days of life, or had missing data were excluded from the analysis. EXPOSURES: Vitamin A supplementation. MAIN OUTCOMES AND MEASURES: The primary outcome was either death before hospital discharge or chronic lung disease, defined as receiving any respiratory support at 36 weeks' corrected gestational age. RESULTS: Of the 6210 eligible infants, 3011 (48.5%) experienced the primary outcome. Those who received vitamin A were more immature and more likely to receive mechanical ventilation during the first 3 days of life. During the study period, vitamin A supplementation significantly decreased (27.2% to 2.1%); however, the primary outcome was similar (48.4% to 49.5%; P = .40). Vitamin A was unrelated to death or chronic lung disease in unadjusted or multivariable analyses (relative risk [RR], 0.97; 95% CI, 0.91-1.03; P = .32) when demographic and clinical information were considered. After classifying centers by vitamin A use, the center of birth was significantly associated with the outcome, with birth in low- and medium-use centers related to a reduced likelihood of death or chronic lung disease. CONCLUSIONS AND RELEVANCE: The occurrence of death or chronic lung disease appears unaffected by the recent shortage of vitamin A. However, the center of birth appears to be an important risk factor for these infants' outcomes.

Vitamin a metabolism, action, and role in skeletal homeostasis.

Vitamin A (retinol) is ingested as either retinyl esters or carotenoids and metabolized to active compounds such as 11-cis-retinal, which is important for vision, and all-trans-retinoic acid, which is the primary mediator of biological actions of vitamin A. All-trans-retinoic acid binds to retinoic acid receptors (RARs), which heterodimerize with retinoid X receptors. RAR-retinoid X receptor heterodimers function as transcription factors, binding RAR-responsive elements in promoters of different genes. Numerous cellular functions, including bone cell functions, are mediated by vitamin A; however, it has long been recognized that increased levels of vitamin A can have deleterious effects on bone, resulting in increased skeletal fragility. Bone mass is dependent on the balance between bone resorption and bone formation. A decrease in bone mass may be caused by either an excess of resorption or decreased bone formation. Early studies indicated that the primary skeletal effect of vitamin A was to increase bone resorption, but later studies have shown that vitamin A can not only stimulate the formation of bone-resorbing osteoclasts but also inhibit their formation. Effects of vitamin A on bone formation have not been studied in as great a detail and are not as well characterized as effects on bone resorption. Several epidemiological studies have shown an association between vitamin A, decreased bone mass, and osteoporotic fractures, but the data are not conclusive because other studies have found no associations, and some studies have suggested that vitamin A primarily promotes skeletal health. In this presentation, we have summarized how vitamin A is absorbed and metabolized and how it functions intracellularly. Vitamin A deficiency and excess are introduced, and detailed descriptions of clinical and preclinical studies of the effects of vitamin A on the skeleton are presented.

Nepal's vitamin A supplementation programme, 15 years on: Sustained growth in coverage and equity and children still missed.

Nepal's national vitamin A programme, that started in a few districts in 1993, was incrementally and systematically expanded to cover the targeted population - children ages 6-59 months - in all the 75 districts of the country over a decade. By 2001, four-fifths of the eligible children had received vitamin A supplementation. Based on data from the 2006 Nepal Demographic and Health Survey, this paper analyses the extent to which the levels and patterns of the programme's coverage have continued to sustain over time, and identifies the children who are still missed by the programme. The overall coverage in 2006 increased to 87.5% nationally, ranging between 80 and 93% (except for two population subgroups), indicating that the programme has been effective in eliminating large inequities in access and utilisation of programme services. The children still missed by the programme (12.5%) have been found to disproportionately represent the poorest of the poor families, mothers with no education, and residents of rural areas and certain ecological and development subregions. The programme is most likely to sustain its achievements thus far, assuming that programme support ingredients and inputs are not interrupted or affected adversely in any way. Emerging policy and programmatic issues are discussed.

The cost of Child Health Days: a case study of Ethiopia's Enhanced Outreach Strategy (EOS).

Child Health Days (CHDs) are twice-annual campaign-style events designed to increase the coverage of vitamin A and one or more other child health services. Although more than two dozen countries have had a CHD, little has been published about them. This paper presents an activity-based costing study of Ethiopia's version of CHDs, the Enhanced Outreach Strategy (EOS). The December 2006 round reached more than 10 million beneficiaries at an average cost per beneficiary of US$0.56. When measles is added, the cost of the package doubles. Given the way the distribution day delivery system and the service package are structured, there are economies of scope. Because most of the costs are determined by the number of delivery sites and are independent of the number of beneficiaries, other things equal, increasing the beneficiaries would reduce the average cost per beneficiary. Taking into account only the mortality impact of vitamin A, EOS saved 20,200 lives and averted 230,000 DALYs of children 6-59 months. The average cost per life saved was US$228 and the cost per DALY averted was equivalent to 6% of per capita GDP (US$9), making the EOS cost-effective, according to WHO criteria. While CHDs are generally construed as a temporary strategy for improving coverage of supply-constrained systems, inadequate attention has been paid to demand-side considerations that suggest CHDs have an important role to play in changing care-seeking behaviour, in increasing community organization and participation, and in promoting district autonomy and capacity. Recognition of these effects suggests the need for decisions about where and when to introduce, and when to end, a CHD to take into account more than 'just' health sector considerations: they are more broadly about community development. UNICEF played a key role in initiating the EOS and finances 68% of costs, raising concern about the programme's long-term sustainability.

National vitamin A supplementation coverage survey among 6-59 months old children in Guinea (West Africa).

BACKGROUND: Vitamin A deficiency (VAD) is a major contributor to child mortality in sub-Saharan Africa. Sustained control of VAD is essential to meet the Millennium Development Goal (MDG) for reduction of child mortality in Guinea. Since, twice yearly vitamin A supplementation (VAS), either coupled with National Immunization Days or stand-alone has been adopted as a key strategy to combat VAD in 6-59 months old children. OBJECTIVES: The objectives of this survey were to describe national VAS coverage rates and related factors affecting VAS coverage among 6-59 months old Guinean children. METHODS: In July 2003, a VAS coverage survey was implemented in Guinea. A cross-sectional random cluster survey was conducted to select Guinean children (n = 1950, 390 mother-child pairs per zone) aged 6-59 months. The country was divided into four agro-ecological zones with 30 clusters chosen per zone. Within each cluster, a random selection of 13 households with at least one child was carried out with random selection of one child per household. Data on characteristics of children, receipt of VAS, caregivers' socio-economic characteristics, vitamin A knowledge and practices of caregivers were collected by questionnaire. RESULTS: The national coverage rate of 68% is much lower than the official coverage rate of 93%. Middle Guinea, the region most affected by VAD, had the lowest coverage rate (58%). CONCLUSION: In order to increase overall VAS coverage and reduce regional disparities, it is suggested that mass VAS be organized on a regional level, prioritizing rural regions (Middle and Upper Guinea) and the city of Conakry.

Review: Genetically modified plants for the promotion of human health.

Plants are attractive biological resources because of their ability to produce a huge variety of chemical compounds, and the familiarity of production in even the most rural settings. Genetic engineering gives plants additional characteristics and value for cultivation and post-harvest. Genetically modified (GM) plants of the "first generation" were conferred with traits beneficial to producers, whereas GM plants in subsequent "generations" are intended to provide beneficial traits for consumers. Golden Rice is a promising example of a GM plant in the second generation, and has overcome a number of obstacles for practical use. Furthermore, consumer-acceptable plants with health-promoting properties that are genetically modified using native genes are being developed. The emerging technology of metabolomics will also support the commercial realization of GM plants by providing comprehensive analyzes of plant biochemical components.

Socioeconomic differentials in supplementation of vitamin A: evidence from the Philippines.

The efficacy of supplementation of vitamin A in child survival has been well-demonstrated. However, the effectiveness of a programme of vitamin A supplementation at the population level has been rarely examined. Understanding how programmes reach disadvantaged children can help improve the design of initiatives of vitamin A supplementation. The differentials in receipt of vitamin A by socioeconomic status were assessed using data from the Philippines. Factors associated with receipt of vitamin A during the last six months were examined using the Philippines Demographic and Health Surveys conducted in 1993 and 1998. In total, 6,970 and 6,118 children aged 12-59 months were included in 1993 and 1998 respectively. Logistic regression was used for identifying associations between the outcome and the household socioeconomic variables. The coverage of national-level vitamin A supplementation increased from 27% in 1993 to 79% in 1998. However, children whose mothers did not complete primary education and children living in poor households were less likely to receive supplementation. This disparity increased between the surveys: the adjusted odds of vitamin A intake by poor households compared to middle-class households declined from 0.73 [95% confidence interval (CI) 0.61-0.87) in 1993 to 0.52 (95% CI 0.42-0.63)] in 1998, resulting in an increased health inequity. The vitamin A programme in the Philippines was not uniformly successful in reaching the most vulnerable children. Approaches targeting vulnerable households or approaches not requiring mothers to travel to distribution centres may be more promising.

The impact of vitamin A supplementation on mortality inequalities among children in Nepal.

OBJECTIVE: This paper examines gender, caste and economic differentials in child mortality in the context of a cluster-randomized trial of vitamin A distribution, in order to determine whether or not the intervention narrowed these differentials. DESIGN: The study involved secondary analysis of data from a placebo-controlled randomized field trial of vitamin A supplements. The study took place between 1989-1991 in rural Sarlahi District of Nepal, with 30,059 children age 6 to 60 months. The main outcome measures were differences in mortality between boys and girls, between highest Hindu castes and others, and between the poorest quintile and the four other quintiles. RESULTS: Without vitamin A, girls in rural Nepal experience 26.1 deaths per 1000, which is 8.3 deaths more than the comparison population of boys. With vitamin A the mortality disadvantage of girls is nearly completely attenuated, at only 1.41 additional deaths per 1000 relative to boys. Vitamin A supplementation also narrowed mortality differentials among Hindu castes, but did not lower the concentration of mortality across quintiles of asset ownership. The vitamin A-related attenuation in mortality disadvantage from gender and caste is statistically significant. CONCLUSIONS: We conclude that universal supplementation with vitamin A narrowed differentials in child death across gender and caste in rural Nepal. Assuring high-coverage vitamin A distribution throughout Nepal could help reduce inequalities in child survival in this population.

Mass supplementation of vitamin A linked to National Immunization Day.

OBJECTIVE: Main objectives were to assess the feasibility of linking vitamin A delivery with National Immunization Days (NIDs) and to see the impact on xerophthalmia. METHODS: An Intervention study of mass distribution of vitamin A solution was undertaken to control widespread xerophthalmia prevalent in children living in about 26 slums of Chandigarh in the year 2000. Two rounds of mass distribution of Vitamin A solution covering 27642 and 31762 children in 1-5 years of age in first and second rounds, respectively, were undertaken. The findings of second round and post evaluation after intervention are presented here. An additional team of two persons per pulse polio immunization (PPI) centre delivered age specific doses of vitamin A solution through 98 centres and operational problems were recorded. PPI staff provided the supervision and PPI tally sheets were used. RESULTS: The programme achieved a vitamin A coverage rate of 99% in first round and 88% in second round. Only two parents refused vitamin A solution. No side effect or cases of toxicity due to vitamin A were reported by health institutions in the area or in a stratified random sample of 101 children. There was a significant decline (13.4%) in xerophthalmia after two rounds of mass distribution (P < .001). The strategy to deliver vitamin A was successfully integrated into NID's and appeared to achieve a significant decline in xerophthalmia. CONCLUSION: Linking of vitamin A distribution with PPI could be a basis for launching similar initiatives in other areas of India and other countries where xerophthalmia is a public health problem.

Rapid assessment and delivery of Vitamin A to slum children by using National Immunization Day in Chandigarh.

This study was done with the objective to see the feasibility of using National Immunization Days (NIDs) for rapid assessment, and delivery of Vitamin A solution to about 27,600 children dwelling in 26 slums in Union Territory of Chandigarh. The assessment of Vitamin A deficiency (VAD) was done in a stratified random sample of 1304 children during third round of Intensified Pulse Polio Immunization (IPPI) and delivery of Vitamin A solution was done during fourth round of IPPI in 1999-2000 covering 27,642 children in the age group of 1-5 years. An additional team of two persons per centre delivered age specific doses of Vitamin A solution through 72 centres and operational problems were recorded. IPPI staff provided supervision and same tally sheets as of IPPI were used. The prevalence rate of VAD was 24.6%, with conjunctival xerosis, bitot's spot and corneal xerosis as 23.7%, 0.6% and 0.2% respectively. 27,275 (98.7%) children out of 27,642 were administered Vitamin A solution, with no major operational problem. Only five parents (0.01%) refused Vitamin A solution. No case of side effect or toxicity due to Vitamin-A was reported. The strategy to assess and deliver Vitamin A during NID's was found to be feasible and successful and could be a basis for launching similar initiatives in other areas of India and other countries where VAD is a public health problem.

Evaluation of vitamin A supplementation in Gulshan-e-Sikandarabad.

INTRODUCTION: Vitamin A deficiency (VAD) causes blindness of 250,000 to 500,000 children annually, around the world. It also increases the risk of morbidity and mortality due to other diseases. Pakistan is categorized in the 'Severe Sub-Clinical Deficiency' group. A mass supplementation program has been started in 1999. AIM: To determine the coverage of vitamin A supplements in children under five years of age, and to assess the incidence of symptoms related to hypervitaminosis A. SETTING: Block I-A of Gulshan-e-Sikanderabad. METHODOLOGY: A survey was conducted, using the fourth year MBBS students of Ziauddin Medical University (ZMU), under faculty supervision. A pre-tested structured questionnaire was used to assess coverage and symptoms of toxicity. RESULTS: Data was obtained on 489 children. The coverage of polio and vitamin A supplementation was 88% and 74.8%, respectively. In all 15 children (4.4%) experienced symptoms of toxicity related to vitamin A supplementation. CONCLUSION: Although vitamin A supplementation can save lives, it is only a short term measure. What is needed is a multi-strategy approach including short and long term strategies.