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VITAMIN A
SUPPLEMENTS
A guide to their
use in the treatment
and prevention of
vitamin A deficiency and
xerophthalmia
Prepared by a WHO/UNICEF/IVACG Task Force
WORLD HEALTH ORGANIZATION
GENEVA
The World Health Organization is a specialized agency of the United Nations with primary
responsibility for international health matters and public health. Through this organization,
which was created in 1948, the health professions of some 165 countries exchange their
knowledge and experience with the aim of making possible the attainment by all citizens of the
world by the year 2000 of a level of health that will permit them to lead a socially and
economically productive life.
By means of direct technical cooperation with its Member States, and by stimulating such
cooperation among them, WHO promotes the development of comprehensive health services,
the prevention and control of diseases, the improvement of environmental conditions, the
development of health manpower, the coordination and development of biomedical and health
services research, and the planning and implementation of health programmes.
These broad fields of endeavour encompass a wide variety of activities, such as developing
systems of primary health care that reach the whole population of Member countries;
promoting the health of mothers and children; combating malnutrition; controlling malaria and
other communicable diseases including tuberculosis and leprosy; having achieved the eradication
of smallpox, promoting mass immunization against a number of other preventable diseases;
improving mental health; providing safe water supplies; and training health personnel of all
categories.
Progress towards better health throughout the world also demands international cooperation in
such matters as establishing international standards for biological substances, pesticides and
pharmaceuticals; formulating environmental health criteria; recommending international
nonproprietary names for drugs; administering the International Health Regulations; revising
the International Classification of Diseases, Injuries, and Causes of Death; and collecting and
disseminating health statistical information.
Further information on many aspects of WHO’s work is presented in the Organization’s
publications.
COMMUNITY HEALTH CELL
r -i- - -
,r<ir
VITAMIN A
SUPPLEMENTS
A guide to their use
in the treatment
and prevention of
vitamin A deficiency
and xerophthalmia
Prepared by a WHO/UNICEF/IVACG Task Force
World Health Organization, Geneva, 1988
The publication of this guide was supported financially by the
Government of Italy, through the WHO/UNICEF Joint Nutrition
Support Programme.
Reprinted 1990
Reprinted, with permission, by courtesy of UNICEF
COMMUNITY HEALTH CEU
326. V Main, I Block
Koram<>nga'a
Bengal*-56003*
Indi*
ISBN 92 4 154236 5
© World Health Organization, 1988
Publications of the World Health Organization enjoy copyright protection in accordance with
the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction
or translation of WHO publications, in part or in toto, application should be made to the
Office of Publications, World Health Organization, Geneva, Switzerland. The World Health
Organization welcomes such applications.
The designations employed and the presentation of the material in this publication do not imply
the expression of any opinion whatsoever on the part of the Secretariat of the World Health
Organization concerning the legal status of any country, territory, city or area or of its
authorities, or concerning the delimitation of its frontiers or boundaries.
The mention of specific companies or of certain manufacturers’ products does not imply that
they are endorsed or recommended by the World Health Organization in preference to others of
a similar nature that are not mentioned. Errors and omissions excepted, the names of
proprietary products are distinguished by initial capital letters.
PRINTED IN SWITZERLAND
88/7668-IAM-6000
89/8319-IAM-5000 (R)
Contents
Preface........................................................................................
1. Introduction.............................................................................
5
7
2.
Treatment of xerophthalmia.................................................
Children under 6 years old..........................................................
Children aged 6 years or over, adolescents, and adults.............
Women of reproductive age, pregnant or not............................
8
8
9
9
3.
Prevention of vitamin A deficiency, xerophthalmia, and
nutritional blindness in children........................................... 10
Rationale....... ............................................................................. 10
Safety.......................................................................................... 10
Disease-targeted distribution...................................................... 10
Universal distribution.................................................................. 11
4.
Operational matters................................................................ 13
Vitamin A preparations............................................................... 13
Logistics...................................................................................... 14
Training....................................................................................... 17
Monitoring and evaluation.......................................................... 18
Selected bibliography............................................................. 19
Annex 1. Participants in the WHO/UNICEF/IVACG Task
Force.......................................................................... 21
Annex 2. Countries categorized by degree of public health
significance of vitamin A deficiency, xerophthalmia,
and nutritional blindness.............................................22
Annex 3. Data on the stability of commonly supplied vitamin
A preparations............................................................ 24
Preface
The Thirty-seventh World Health Assembly, in 1984, adopted a
resolution requesting the Director-General of the World Health
Organization to give all possible support to Member States in the
prevention and control of vitamin A deficiency and xerophthalmia and to
coordinate the launching and management of action programmes for this
purpose with other intergovernmental organizations and appropriate
nongovernmental organizations.
In 1985, therefore, WHO proposed a coordinated 10-year plan of action
for the prevention and control of vitamin A deficiency and
xerophthalmia. The overall strategy includes long-, medium- and short
term measures. Long-term measures are designed to increase the
availability and the consumption of foods rich in vitamin A. Medium
term measures include the fortification of food. The administration of
high-dose vitamin A supplements to groups at risk constitutes the short
term measure, which can be initiated when urgent and immediate action
must be taken.
Programmes for the distribution of vitamin A supplements have
expanded steadily over the past three years, so much so that WHO
requested the International Vitamin A Consultative Group (IVACG),
which provides technical advice on matters related to vitamin A
deficiency, to assist in preparing guidelines that could be used by health
administrators and programme managers in the development of national
or regional programmes for the prevention and control of vitamin A
deficiency and xerophthalmia in areas where xerophthalmia constitutes a
significant public health problem.
The guidelines presented here have been drawn up by a
WHO/UNICEF/IVACG Task Force that considered drafts at meetings
held in Brasilia in October 1986 and New York in April 1987 and
finalized them in the light of the most recent findings in January 1988 in
Washington, DC. They are based on the best scientific evidence available
at the present time; nevertheless, it is probable that, with accumulating
experience, some changes may need to be introduced in future years.
It is suggested that health administrators and programme managers
consider and adapt these guidelines, as they judge appropriate, to their
own local conditions and carefully monitor their application. The effects
of supplementation programmes on the morbidity and mortality of
vitamin-A-deficient persons—children particularly—need further study;
national or regional prevention and control programmes offer an
excellent opportunity for this.
5
1. Introduction
Vitamin A supplementation—that is, the periodic administration to
vitamin-A-deficient persons of high doses of the vitamin (200 000 HJ,1 or
less for special groups)—is effective in controlling vitamin A deficiency
and xerophthalmia and in preventing nutritional blindness. To ensure
that the vitamin A status of a population becomes and remains adequate
requires, of course, more comprehensive, long-term measures that
include nutrition education, the fortification with vitamin A of food
products such as dried skim milk and sugar, and the production and
regular consumption of foods that are naturally rich in vitamin A or
provitamin A, such as fish-liver oil and green leafy vegetables. However,
high-dose vitamin A supplementation is usually the most effective short
term measure, provided that a sufficient and regular coverage of the
population at risk can be achieved. It can be organized relatively quickly
at a reasonable cost, and it has an immediate effect in improving the
body reserves of vitamin A in the target population. This improvement is
important not only for controlling the specific vitamin deficiency, but
also for lessening childhood morbidity and mortality due to other
causes—diarrhoea and lower respiratory infections, for example. Later,
as the more permanent control measures mentioned above take effect,
the high-dose supplementation can be phased out.
In areas where vitamin A deficiency and xerophthalmia are known to
constitute a significant public health problem (see Annex 2), a sufficient
and regular supply of vitamin A preparations should be made available,
through the health services system, for distribution at the peripheral level
to the local populations at risk. All the personnel at the primary health
care level, and community health workers in particular, should be trained
in the prevention, recognition, and treatment of xerophthalmia as part of
their regular duties.
1 Dosages are expressed in this publication in IU (international units) for the sake of
simplicity; see Section 4 for the equivalents in milligrams of retinol.
7
2. Treatment of
xerophthalmia
The treatment schedules given below apply to all stages of active
xerophthalmia, including night blindness, conjunctival xerosis, Bitot’s
spot, corneal xerosis, and keratomalacia. The oral administration of
large doses of vitamin A is the recommended method of treatment. The
first dose should be given immediately xerophthalmia is recognized.
Patients with acute corneal lesions should be referred, whenever this is
possible, directly to a hospital for treatment of their general condition as
well as of their eye disease.
Children under 6 years old
Children over 1 year and under 6 years old
Treat as shown in Table 1.
Table 1.
XEROPHTHALMIA TREATMENT SCHEDULE
for children over 1 year and under 6 years old
Immediately on diagnosis
200 000 IU vitamin A orally
(see Note)
The following day
200 000 IU vitamin A orally
4 weeks later
200 000 IU vitamin A orally
Note: If there is persistent vomiting or profuse diarrhoea, an intramuscular injection of 100 000
IU of water-miscible vitamin A ( but not an oil-based preparation) may be substituted for the
first dose. The use of sterile syringes and needles is, of course, essential.
Children under 1 year old and children of any age
who weigh less than 8 kg
Treat with half the doses shown in Table 1.
Notes on the treatment of young children
Children with diarrhoea may absorb rather less of the vitamin A than
other children, but if the doses recommended above are used they should
still absorb enough for the treatment to be adequate. Xerophthalmic
8
Treatment of xerophthalmia
children with severe protein-energy malnutrition need to be carefully
monitored because their vitamin A status is unstable and may rapidly
worsen, even when they are treated with the doses recommended.
Additional doses may then be required for them.
Oil-based preparations are the preferred formulation for oral
administration of vitamin A, but water-miscible preparations may be
used if the oily solution is not available. If large-dose capsules or
concentrated syrup is not available, vitamin A in an equivalent dosage
may be given by mouth in other forms, such as fish-liver oil. Oil-based
preparations are normally well absorbed by the body when they are
administered orally, but they should never be injected since oil-based
vitamin A is liberated extremely slowly from the injection site. The only
preparation suitable for injection, intramuscularly, is water-miscible
vitamin A.
Involvement of the cornea in xerophthalmia is a medical emergency.
Vitamin A must be administered immediately according to the three-dose
schedule in Table 1. In order to treat or reduce the risk of secondary
bacterial or viral (measles) infection of the eye, which would compound
the damage to the cornea, the topical application of an antibiotic eye
ointment, such as tetracycline or chloramphenicol, is recommended.
Ophthalmic ointment containing steroids should never be used in this
situation. To prevent trauma to a cornea already weakened by xerosis or
ulceration, the eye should be protected by an eye shield (not occlusive),
and it may be necessary to restrain the arm movements of young children
by light bandaging.
Children aged 6 years or over, adolescents,
and adults (except women of reproductive age)
Treat with the same dosages as those for children 1 - 6 years old (see
Table 1).
Women of reproductive age, pregnant or not
For night blindness or Bitot’s spot, treat with a daily dose of 10 000 IU
of vitamin A orally (1 sugar-coated tablet) for 2 weeks.
When active corneal lesions of xerophthalmia occur in a woman of
reproductive age, one has to balance the possible teratogenic or other
risk to the fetus (should she be pregnant) of a large dose of vitamin A
against the serious consequences for her of vitamin A deficiency if she is
not given a large dose. It would appear reasonable, in these exceptional
circumstances, to administer the full treatment for corneal xerophthalmia,
as described above for young children.
9
3. Prevention of vitamin A
deficiency, xerophthalmia,
and nutritional blindness in
children
Rationale
Vitamin A (retinol) is a fat-soluble substance that is stored in the human
body, principally in the liver, and released as needed into the
bloodstream, from which it is drawn for utilization by epithelial cells
throughout the body, including those of the eye, and by the
photoreceptor cells of the eye. Periodic supplementation with large doses
of vitamin A is intended to protect the individual against vitamin A
deficiency and its serious consequences over a certain period of time by
building up a buffer stock of the vitamin in the liver. Administration of
200 000 IU of vitamin A to a child will give protection for from 3 to
6 months depending on the vitamin A content of the diet and the rate at
which the body utilizes it.
Safety
Vitamin A supplementation programmes are known to be effective and
safe. When the vitamin A is administered in the doses recommended,
there are rarely any adverse effects. Such side-effects as may occur (for
instance, headache or vomiting) are minor and transitory and do not
require specific treatment.
Disease-targeted distribution
A disease-targeted distribution involves the administration of a high dose
of vitamin A to individuals at special risk of developing vitamin A
deficiency. Infants and children with infections such as acute or
prolonged1 diarrhoea, acute lower respiratory infections, or severe
protein—energy malnutrition who present for treatment at a health1
1 Prolonged diarrhoea means diarrhoea lasting 14 days or more.
10
Prevention of vitamin A deficiency
centre are the most important groups requiring vitamin A ;
supplementation in any targeted programme. The disease-targeted
prevention schedule is given in Table 2.
Table 2.
DISEASE-TARGETED PREVENTION SCHEDULE
for preschool children at high risk (e.g., those presenting at a
health centre with measles (see Note 7), severe protein-energy
malnutrition, acute or prolonged diarrhoea, or acute lower res
piratory infections)
Children over 1 year and under
6 years old
200 000 IU of vitamin A orally at time of first
contact with health worker for each episode
of illness (see Note 2)
Infants under 1 year old and
children of any age who weigh
less than 8 kg
100 000 IU of vitamin A orally at time of first
contact with health worker for each episode
of illness (see Note 2)
Note 1: In areas where measles is a particularly severe disease, with a high mortality and a high
risk of blindness, as in Africa, it is appropriate to apply the full treatment for xerophthalmia
described in Section 2, page 8.
Note 2: This dose should not be given to children who have already received a high-dose vita
min A supplement within the preceding month.
Universal distribution
Universal distribution for prevention in childhood involves the periodic
administration of large doses of vitamin A to all children under 6 years
old in communities at risk of vitamin A deficiency and a large dose to
lactating mothers during the first 2 months after delivery. The prevention
schedule is shown in Table 3.
How the doses are spaced in time (from 3 to 6 months apart) will depend
upon the amount of vitamin A in the usual diet of the population; it
may also be influenced by logistic considerations.
The timing of the distribution of large doses of vitamin A should take
account of seasonal factors. Universal-distribution schemes should make
vitamin A available to the population before the onset of a season in
which there is a special risk of vitamin A deficiency—for instance,
seasons when diarrhoea or measles are most frequent or when foods rich
in vitamin A are scarce.
COMMUNITY HEALTH CEL4
O^os-
326. V Main, I Block
Koramongala
Bangalore-560034
India
11
Vitamin A supplements
Table 3.
UNIVERSAL-DISTRIBUTION PREVENTION SCHEDULE
for preschool children and lactating mothers
Children over 1 year and
under 6 years old
200 000 ID of vitamin A orally every 3-6 months
Infants 6-12 months old
and any older children
who weigh less than 8 kg
100 000 III of vitamin A orally every 3-6 months.
Immunization against measles provides a good
opportunity to give one of these doses (see Note}
Lactating mothers
200 000 IU of vitamin A orally once: at delivery
or during the next 2 months. This will raise the
concentration of vitamin A in the breast milk and
therefore help to protect the breast-fed infant
l
Note: When infants less than 6 months old are not being breast-fed, supplementation with
50 000 III of vitamin A before they reach 6 months should be considered.
12
4. Operational matters
Vitamin A preparations
Although the international unit (IU)—an expression of biological activity
rather than of chemical quantity—was officially discontinued as long ago
as 1954 for vitamin A (which chemically is retinol), vitamin A
preparations are still usually labelled in IU as well as, increasingly, in
milligrams (mg) or micrograms (ug) of retinol or its esters. Preparations
for vitamin A supplementation may be supplied as retinol palmitate or
retinol acetate. Two hundred thousand international units (200 000 IU)
are equivalent to 60 mg of retinol, or 110 mg of retinol palmitate, or
69 mg of retinol acetate. In these preparations the vitamin A is usually
diluted in a vegetable oil, generally high quality peanut oil, with vitamin
E often included as an antioxidant to stabilize the product and to
enhance the absorption and storage of vitamin A by the body (e.g.,
40 mg (or 40 IU) of vitamin E as rfZ-alpha-tocopherol for 200 000 IU of
vitamin A).
The chemical stability and therefore the biological activity of vitamin A
are affected by temperature and sunlight; nevertheless, a cold chain is
not required in the distribution system. The shelf-life of an oily solution
of vitamin A in a properly stored, unopened, opaque container is
estimated to be at least 2 years.
Once a container has been opened, however, there is a gradual reduction
in the vitamin’s biological activity. Partial protection against this is
afforded by formulating the oily solution in capsules. Vitamin A,
especially in liquid form, should be stored in a dark bottle (or an
aluminium container) to shield it from the light. Liquid preparations
from properly stored containers should be used within 6-8 weeks of
opening the container. In general, it is recommended that containers for
liquid vitamin A for use in the field or by peripheral health units should
be limited in size (e.g., 100 doses) to minimize the loss of potency that
may occur once the bottle has been opened. Further information on the
stability of vitamin A preparations under various conditions is given in
Annex 3.
For the treatment and prevention schedules given in Sections 2 and 3, the
following preparations are recommended; they are those contained in the
fifth WHO Model List of Essential Drugs (see No. 3 in the Selected
Bibliography, page 19):
Capsules containing 200 000 IU of vitamin A (110 mg of retinol
palmitate) in oily solution.
13
Vitamin A supplements
•
•
•
Oily solution in liquid form for use with dropper or multi-dose
dispenser, dispensing a measured dose of vitamin A (e.g., 50 000 IU,
or 100 000 IU, or 200 000 IU).
Sugar-coated tablets, each containing 10 000 IU of vitamin A (5.5 mg
of retinol palmitate).
Ampoules of 2 ml, each containing 100 000 IU of water-miscible
vitamin A (55 mg of retinol palmitate) for intramuscular injection.
Logistics
The coverage and continuity of a supplementation programme depend
greatly upon supplies being available at the peripheral level when they are
needed. At least two factors significantly affect this availability:
procurement and distribution.
Procurement
Procurement involves the timely and appropriate purchase of supplies
according to the size of the population, its age distribution, and the
conditions to be treated. In countries where xerophthalmia is a
significant public health problem, for example, vitamin A should be
provided'for preventive purposes to all preschool children and to mothers
after delivery as well as for treating xerophthalmia and other forms of
vitamin A deficiency.
To illustrate the type of planning required to determine procurement
needs, calculations have been made in the following example for a
universal-distribution preventive programme that extends to the treatment
of xerophthalmia.
Example
(a) Assume a population of 1000 people with the following characteristics:
3 % are infants less than 1 year old................................................................ 30 infants
3 Vo are children between 1 and 2 years old................................................... 30 children
• 11 Vo are children over 2 and under 6 years old............................................... 110 children
3 Vo are lactating mothers............................................................................... 30 women
• 25 Vo are women of reproductive age (250 women), of whom 4 Vo have night
blindness or Bitot’s spot ......................................................................... 10 women
5 Vo of the 140 children between 1 and 6 years old have one episode of
xerophthalmia per year ...........................................................................
7 children
(b) Assume that the following vitamin A preparations are available:
• Capsules containing 200 000 IU of vitamin A in oily solution
■ Oily solution in liquid form containing 100 000 IU of vitamin A per 1-ml dose in a
multi-dose dispenser
■ Sugar-coated tablets containing 10 000 IU of vitamin A
14
Operational matters
(c) Assume that infants and children under 2 years old will receive the oily solution
from a dispenser and that those 2 years or older will receive a capsule.
(</) The requirements will be as follows:
Infants:
Children 1 -2
years old:
100 000 IU (1 ml) twice between 6 and 12 months
of age for 30 infants................................................... 2 ml x 30
200 000 IU twice a year for 30 children.................... 4 ml x 30
Children 2-6
years old:
Children with
xerophthalmia:
1 capsule of 200 000 IU twice a year
for 110 children ................................................... 220 capsules
Lactating women:
1 capsule of 200 000 IU for 30 women.................. 30 capsules
Women of reproductive
age with night blindness
or Bitot’s spot:
1 sugar-coated tablet of 10 000 IU per day for
14 days for 10 women.............................................. 140 tablets
Total per year:
3 capsules of 200 000 IU for 7 children ................ 21 capsules
Liquid preparation of vitamin A in dispenser containing
lOOOOOIU/ml:
(2 ml x 30) + (4 ml x 30) = 180 ml
Capsules of 200 000 IU:
Tablets of 10 000 IU:
220 + 21 + 30 = 271 capsules
140 tablets
Cost
Owing to the limited market, very few companies manufacture high-dose
vitamin A capsules, and UNICEF is the major global supplier. (In India,
however, vitamin A is produced locally and administered to children in
the form of a syrup.) The cost per capsule of 200 000 IU of vitamin A
(known as retinol high potency in UNICEF essential drugs listings) is less
than USS 0.02 when obtained through UNICEF procurement services.
The capsules are available in bottles containing 100 or 500. The cost in
other currencies fluctuates according to variations in exchange rates. A
handling fee of 4% and a freight charge of 15% by sea are additional.
Distribution
The most important target for vitamin A distribution is the
xerophthalmic child. Another vulnerable group that requires immediate
attention includes children with infections such as measles, acute or
prolonged diarrhoea, and acute lower respiratory infections, or suffering
from severe protein-energy malnutrition. Hence any distribution strategy
must give priority to the treatment of sick children, whether in a hospital
or medical centre or living in their own communities. These, however,
represent only a small proportion of all those who would benefit from
preventive supplementation with vitamin A.
15
Vitamin A supplements
The timely distribution of a stock of vitamin A preparations from central
warehouse to provincial and district stores and thence to field clinics will
depend on the existing medical supply system. It will also depend on the
perceived need for a supplementation programme, on the resources
available, and on the mechanisms at hand for implementing the
programme. When universal vitamin A distribution originated, special
teams were often formed solely for that purpose, and these were the
mainstay of the fledgling programmes of 10- 15 years ago. Under the
influence of new strategies and with the need for economy, however,
vitamin A distribution is now being integrated into existing primary
health care structures. Although special teams may still be used on
occasion, it is generally a routine procedure undertaken within the local
health care system.
It is obviously not possible to set out in detail how measures for
distributing vitamin A preparations can be incorporated into specific
programmes within the health systems of different countries.
Nevertheless, programme managers may consider some of the following
possibilities, bearing in mind the need to suit measures to the specific
situation in each country.
Primary health care/maternal and child health services
Since the adoption in 1978 of the Declaration of Alma-Ata, emphasizing
the importance of community outreach in meeting the demands for
health care, there has been a move to strengthen and upgrade the
primary health care and maternal and child health services. The
community health worker is of particular importance here as a critical
link between the individual and the health services. The primary health
care system being intended to treat the sick and at the same time to
monitor the healthy children, it is potentially an effective mechanism into
which to integrate vitamin A interventions for both the treatment and the
prevention of xerophthalmia and vitamin A deficiency. Some countries
have included vitamin A preparations in their essential drugs programmes
and thus in the kits of essential drugs supplied to primary health care
centres as well as to centres at other levels. This procedure, which
facilitates both procurement and distribution, should be adopted in all
countries in which xerophthalmia constitutes a significant public health
problem.
Programmes for the prevention of blindness
Such programmes exist in an increasing number of developing countries,
focusing on action against the major causes of avoidable blindness,
which include xerophthalmia. These programmes are usually linked to, or
part of, primary health care and include a component of eye care at the
community level. This may be utilized for the regular delivery of
vitamin A to children and mothers, particularly as they are anyhow often
being examined for trachoma in endemic areas or being treated for
16
Operational matters
conjunctivitis or other eye disorders. Furthermore, nutrition education
should form part of general education for eye health.
Expanded programmes on immunization
In the many countries in which they have been established, these
programmes aim to provide immunization to a target group of young
children and to institutionalize the mechanisms for such immunization.
They can therefore provide an efficient channel for the distribution of
vitamin A to an age group crucial for the control of vitamin A
deficiency, though they might miss the 2-3-year-old weanlings and
severely malnourished children. It would nevertheless be useful to take
advantage of a delivery system that reaches such a large proportion of
the critical group.
Diarrhoea control activities
The child who suffers from acute or prolonged diarrhoea also runs a
special risk of vitamin A deficiency. Oral rehydration therapy at a health
centre provides a mechanism by which children who may need
supplemental vitamin A can be identified and given it.
Other channels
Channels outside the usual scope of the health care system have also
been used for vitamin A supplementation. Among these are the school
system, agricultural extension schemes, mothers’ groups, and
nongovernmental organizations and voluntary agencies. Indeed, several
nongovernmental organizations have been, and still are, actively
supporting vitamin A supplementation schemes as part of their
contribution to development work.
Training
In order to ensure the maximum coverage of vulnerable population
groups, the entire health system must be involved and its personnel must
be proficient in recognizing the signs and symptoms of vitamin A
deficiency and in its treatment and prevention. The medical staff needs
to be able to recognize and treat the condition and to deal with patients
referred to them from other points in the system. The community health
workers need instruction in identification, prevention, treatment, and
referral. The specific schedules for treatment and prevention must be
known to the staff at all levels of the health system as well as to any
other persons involved in the work for the control of vitamin A
deficiency.
The most efficient way to ensure the regular provision of the required
training is to integrate a vitamin A component into the existing curricula
17
Vitamin A supplements
for health workers at all levels. Teaching materials have been developed
by WHO' and by other organizations such as Helen Keller International
Incorporated,12 which can easily be inserted into formal training sessions.
Monitoring and evaluation
Monitoring
Monitoring in this context is essentially a means of determining whether
or not vitamin A is being appropriately delivered, where, and to whom.
It is a useful supervisory tool for programme management and invaluable
for indicating problems of supply and logistics as they occur. For this
purpose it is recommended to include a record of vitamin A
administration in existing record forms, such as growth charts, mothers’
cards, and health centre records. This is particularly important if several
channels are being used for the delivery of vitamin A as it helps to avoid
duplication while ensuring safety and full coverage.
Evaluation
A simple type of evaluation is to measure whether or not a
supplementation programme has reached its goals in terms of vitamin A
distribution. It initially involves identifying a target population and the
intended level of coverage, then following through to determine whether
the vitamin A is reaching that population at the intended level. Existing
record systems can be used, and surveillance teams can gather additional
information to supplement the data from those records. Evaluation of
programme impact (i.e., whether or not the incidence and prevalence of
vitamin A deficiency have declined since the start of a programme’s
activities) is more complex; it requires greater resources but is invaluable
in motivating politicians, health administrators, and the public to support
the programme. It will also help to determine whether further
operational research is necessary to adjust the distribution strategy to
local conditions; this is especially true for disease-targeted programmes,
which deal with a spectrum of pathological conditions whose frequency
and severity vary from place to place.
1 For information write to: Nutrition, Division of Family Health, World Health
Organization, 1211 Geneva 27, Switzerland.
2 For information write to: Helen Keller International Incorporated, 15 West 16th Street,
New York, NY 10011, USA.
18
Selected bibliography
Publications of the World Health Organization'
1.
WHO Technical Report Series, No. 590, 1976 {Vitamin A deficiency and
xerophthalmia: report of a Joint WHO/USAID Meeting).
2.
WHO Technical Report Series, No. 672, 1982 {Control of vitamin A deficiency and
xerophthalmia: report of a Joint WHO/UNICEF/USAID/Helen Keller
International/IVACG Meeting).
3.
WHO Technical Report Series, No. 770, 1988 {The use of essential drugs: third report
of the WHO Expert Committee).
4.
Sommer, A. Field guide to the detection and control of xerophthalmia, 2nd ed.
Geneva, World Health Organization, 1982.
5.
Weekly epidemiological record, 62 (19): 133-134 (1987) (Joint WHO/UNICEF
statement on vitamin A for measles).
6.
World Health Organization. Prevention and control of vitamin A deficiency,
xerophthalmia and nutritional blindness: proposal for a ten-year programme of
support to countries. Unpublished document NUT/84.5 Rev. 1 (Available upon request
from Nutrition, Division of Family Health, WHO, 1211 Geneva 27, Switzerland).
Publications of the United Nations Administrative
Committee on Coordination/Sub-Committee on
Nutrition1
2
7.
West, K. W. & Sommer, A. Delivery of oral doses of vitamin A to prevent vitamin A
deficiency and nutritional blindness. 1987 (Nutrition Policy Discussion Paper No. 2).
Publications of the United Nations Children's
Fund3
8.
9.
Essential drugs: Price list. Copenhagen, UNICEF (published twice yearly).
Eastman, S. J. Vitamin A deficiency and xerophthalmia. Recent findings and some
programme implications. New York, UNICEF, 1987.
Publications of the International Vitamin A
Consultative Group4
10.
International Vitamin A Consultative Group. Guidelines for the eradication of
vitamin A deficiency and xerophthalmia. Washington, DC, IVACG, 1977.
11.
De Luca, L. M. et al. Recent advances in the metabolism and function of vitamin A
and their relationship to applied nutrition. Washington, DC, IVACG, 1979.
1 References 1-5 are available from Distribution and Sales, World Health Organization, 1211 Geneva 27, Switzerland.
2 Available from ACC/SCN, c/o World Health Organization. 1211 Geneva 27, Switzerland.
3 Available from UNICEF, UNICEF House, 3 United Nations Plaza. New York. NY 10017, USA.
4 Available from International Life Sciences Institute- Nutrition Foundation, 1126 Sixteenth Street NW. Washington, DC
20036, USA.
19
Vitamin A supplements
12.
Bauernfeind, J.C. The safe use of vitamin A. Washington, DC. IVACG, 1980.
13.
McLaren, D.S. et al. The symptoms and signs of vitamin A deficiency and their
relationship to applied nutrition. Washington, DC, IVACG, 1981.
14.
International Vitamin A Consultative Group. Biochemical methodology for the
assessment of vitamin A status. Washington, DC, IVACG, 1982.
15.
West, K.P. & Sommer, A. Periodic large ora! doses of vitamin A for the prevention
of vitamin A deficiency and xerophthalmia: a summary of experiences. Washington,
DC, IVACG, 1984.
16.
Underwood, B. A. The safe use of vitamin A by women during the reproductive years.
Washington, DC, IVACG, 1986.
Publications from the International Center for
Epidemiologic and Preventive Ophthalmology'
17.
Sommer, A. et al. Oral versus intramuscular vitamin A in the treatment of
xerophthalmia. Lancet, 1: 557-559 (1980).
18.
Sommer, A. Nutritional blindness: xerophthalmia and keratomalacia. New York,
Oxford University Press, 1982.
19.
Sommer, A. et al. Increased mortality in children with mild vitamin A deficiency.
Lancet, 2: 585-588 (1983).
20.
Sommer, A. et al. Increased risk of respiratory' disease and diarrhoea in children with
pre-existing mild vitamin A deficiency. American journal of clinical nutrition, 40:
1090-1095 (1984).
21.
Sommer A. et al. Impact of vitamin A supplementation on childhood mortality.
Lancet, 1: 1169-1173 (1986).
1 Address: Dana Cenier, Wilmer Institute, Johns Hopkins Hospital, 600 North Wolfe Street. Baltimore, MD 21205, USA.
20
Annex 1
Participants in the WHO/UNICEF/IVACG Task
Force
Dr C.O. Chichester, International Vitamin A Consultative Group, Washington,
DC, USA
Dr N. Cohen, Geneva, Switzerland (WHO Consultant)
Dr F. Davidson, Office of Nutrition, United States Agency for International
Development, Washington, DC, USA
Dr E.M. DeMaeyer, Geneva, Switzerland (WHO Consultant) (Chairman)
Ms S.J. Eastman, Helen Keller International Incorporated, New York, NY, USA
Dr J.P. Greaves, United Nations Children’s Fund, New York, NY, USA
Dr R. Leavell, Helen Keller International Incorporated, New York, NY, USA
Dr D.S. McLaren, University of Edinburgh, Edinburgh, Scotland
Dr L.H. Pacheco-Santos, Federal University of Paraiba Joao Pessoa, Paraiba,
Brazil
Dr F. Solon, Nutrition Centre of the Philippines, Manila, Philippines
Dr A. Sommer, International Center for Epidemiologic and Preventive
Ophthalmology, Wilmer Institute, Johns Hopkins Hospital, Baltimore, MD,
USA
Dr L. J. Teply, International Vitamin A Consultative Group, Washington, DC,
USA
Dr B.A. Underwood, National Eye Institute, National Institutes of Health,
Bethesda, MD, USA
Dr K.P. West, Jr, International Center for Epidemiologic and Preventive
Ophthalmology, Wilmer Institute, Johns Hopkins Hospital, Baltimore, MD,
USA
COMMUNITY HEALTH CELl
326. V Main, I Block
Koram»ngala
Bangaiora-560034
India
21
Annex 2
Countries categorized by degree of public health
significance of vitamin A deficiency,
xerophthalmia, and nutritional blindness
(From information available to WHO in January 1988)
WHO Region
Category 1s
Category 2 6
Category 3 c
Africa
Benin
Burkina Faso
Chad
Ethiopia
Ghana
Malawi
Mali
Mauritania
Niger
Nigeria
United Republic
of Tanzania
Zambia
Angola
Kenya
Mozambique
Uganda
Rwanda
Burundi
Algeria
Botswana
Lesotho
Madagascar
Senegal
Zaire
Zimbabwe
Americas
Brazil
Haiti
El Salvador
Guatemala
Honduras
Bolivia
Ecuador
Jamaica
Mexico
Peru
South-East Asia
Bangladesh
India
Indonesia
Nepal
Sri Lanka
Burma
Bhutan
Thailand
Europe
Turkey
‘ Category 1: Significant public health problem in part or whole of country.
b Category 2: Insufficient information but high probability of significant public health problem
in part or whole of country.
c Category 3: Sporadic cases but prevalence not such that it constitutes a significant public
health problem.
22
Annex 2
WHO Region
Category 1
Category 2
Category 3
Eastern
Mediterranean
Sudan
Afghanistan
Pakistan
Egypt
Iran, Islamic
Republic of
Iraq
Jordan
Morocco
Oman
Somalia
Syrian Arab
Republic
Yemen
Western Pacific
Philippines
Viet Nam
Democratic
Kampuchea
Lao People's
Democratic Republic
China
Fiji
Malaysia
23
.. Annex 3
Data on the stability of commonly supplied
vitamin A preparations
Vitamin A (as retinol palmitate) in oily solution, 10' lU/g; stabilized with
cf/-«-tocopherol
Storage conditions: 5 °C, room temperature, 35 °C; unopened container.
Retinol retention after:
Storage temperature
6 months
12 months
24 months
5°C
99%
98%
97%
Room temperature
99%
95%
92%
35°C
97%
92%
76%
Source: Hoffmann La Roche, Basle, Switzerland.
Vitamin A (as retinol palmitate) in edible oil contained in soft gelatine capsules
Storage conditions: 23 °C; closed containers.
Capsulation run
Initial retinol content
(lU/capsule)
Retinol retention
(after indicated storage time)
1
214 000
99% (20 months)
2
209 000
99% (29 months)
3
214 000
97% (31 months)
Source: Hoffmann La Roche. Nuttey, NJ, USA.
24
Teaching and training texts
from the World Health Organization
Education for Health
A Manual on Health Education In
Primary Health Care
1938, vlll + 261 pages
Sw.fr. 34-
A manual designed to give health workers
the insight and skills needed to help
individuals and communities learn how to
improve their own health.
Continuing the Education of
Health Workers
A Workshop Manual
by F.R. Abbanand A. Mejia
1988, x + 185 pages
Sw.fr. 35 -
A learning package that can help decision
makers and planners develop a wellconceived system for continuing the
education of health workers.
Educational Handbook for
Health Personnel
Sixth edition
by J.J. Guilbert
1987, 354 pages
Sw.fr. 34-
"... a standard work in medical education...
one of the best available texts for teacher
training..."
— Medical Teacher
On Being in Charge
1980 (reprinted 1984, 1985, 1986)
366 pages
Sw.fr. 12-
"... the best management training guide for
middle-level workers that we have seen...
extremely useful... "
— Development Communication Report
The Community Health
Worker
Working Guide. Guidelines for
Training. Guidelines for Adaptation
1987, 463 pages
Sw.tr. 22.-
"... an excellent guide ... ’
— British Medical Journal
"... an extraordinary book ..."
— Development and Cooperation
Teaching Health Statistics
Twenty Lesson and Seminar Outlines
edited by S.K. Lwanga and Cho-Yook Tye
1986, vlll + 243 pages
Sw.fr. 39.-
"... here, indeed, is a curriculum that
could be followed en masse or used
selectively to provide a respectable
foundation in the theory and application of
medical statistics ... Teachers who use
this book will significantly improve the
medical student's lot...'
— The Lancet
Guidelines for Training
Community Health Workers in
Nutrition
Second edition
1986,128 pages
Sw.fr. 16.-
"... could be read In its entirety with
benefit by all medical students, nurses,
and community health workers ...
excellent...'
— Tropical Diseases Bulletin
"... will be invaluable both to experts new
to the field and to those with established
training programs..."
— Food Technology
World Health Organization • Distribution and Sales -1211 Geneva 27 • Switzerland
The past few years have seen a steady increase in the num
ber of programmes for the distribution of high-dose vitamin
A supplements as an emergency measure to treat and pre
vent vitamin A deficiency and associated xerophthalmia.
Health administrators and programme managers in coun
tries in which these conditions constitute a significant pub
lic health problem are sometimes in doubt about just how
much vitamin A should be given to which age and population
groups, how often, and in what form. To help resolve these
doubts, WHO, UNICEFand the International Vitamin AConsultative Group (IVACG) have prepared the succinct guidelines
presented in this publication.
Treatment and prevention schedules are clearly stated, and
indications are given as to how vitamin A distribution can be
integrated into a variety of services forthe delivery of primary
health care.
ISBN 92 4154236 5
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