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Bulletin of the World Health Organization

Print version ISSN 0042-9686

Bull World Health Organ vol.78 n.3 Genebra Mar. 2000

http://dx.doi.org/10.1590/S0042-96862000000300005 

THEME PAPERS

 

Polio as a platform: using national immunization days to deliver vitamin A supplements

 

La poliomyélite comme plate-forme : utilisation des journées nationales de vaccination contre la poliomyélite pour administrer des suppléments de vitamine A

 

La poliomielitis como plataforma: utilización de los días nacionales de inmunización contra la poliomielitis para distribuir suplementos de vitamina A

 

 

Tracey GoodmanI; Nita DalmiyaII; Bruno de BenoistIII; Werner SchultinkIV

ITechnical Officer, Department of Vaccines and Biologicals, World Health Organization, 1211 Geneva 27, Switzerland
IIProject Officer, Nutrition Section, UNICEF, New York, NY, USA
IIIMedical Officer, Department of Nutrition for Health and Development, World Health Organization, Geneva, Switzerland
IVSenior Adviser, Nutrition Section, UNICEF, New York, NY, USA

 

 


ABSTRACT

In 1988 the 41st World Health Assembly committed WHO to the goal of global eradication of poliomyelitis by 2000 “in ways which strengthen national immunization programmes and health infrastructure”. The successful use of polio National Immunization Days (NIDs) to deliver vitamin A is an example of how polio eradication can serve as a platform to address other problems of child health. Importantly, this integration is helping to achieve the World Summit for Children goal of eliminating vitamin A deficiency by the year 2000. It is estimated that between 140 million and 250 million preschool children are at risk of subclinical vitamin A deficiency. In 1998 more than 60 million children at risk received vitamin A supplements during polio national immunization days (NIDs). While food fortification and dietary approaches are fundamental to combating vitamin A deficiency, the administration of vitamin A supplements during NIDs helps raise awareness, enhance technical capacity, improve assessment and establish a reporting system. Moreover, polio NIDs provide an entry point for the sustainable provision of vitamin A supplements with routine immunization services and demonstrate how immunization campaigns can be used for the delivery of other preventive health services.

Keywords: cost of illness; delivery of health care, integrated; dietary supplements; immunization programmes; vitamin A deficiency, prevention and control; vitamin A, therapeutic use.


RÉSUMÉ

En 1988, la Quarante et unième Assemblée mondiale de la Santé a invité l’OMS à s’engager en faveur de l’éradication mondiale de la poliomyélite à l’horizon 2000 d’une façon qui renforce les programmes nationaux de vaccination et les infrastructures sanitaires nationales. Le succès de l’utilisation des journées nationales de vaccination contre la poliomyélite pour administrer des suppléments de vitamine A constitue un exemple de la façon dont l’éradication de la poliomyélite peut être utilisée comme plate-forme pour la lutte contre d’autres problèmes de santé de l’enfant. En même temps, cette initiative contribue à la réalisation de l’objectif du Sommet mondial pour les enfants, à savoir l’élimination de l’avitaminose A et de toutes ses conséquences, y compris la cécité, à l’horizon 2000.

L’avitaminose A est un problème de santé publique connu ou présumé dans 118 pays, tous dans le monde en développement. On évalue à 140-250 millions le nombre d’enfants d’âge préscolaire à risque de carence infraclinique en vitamine A. Ces enfants courent un risque sensiblement accru de maladie et de décès, en particulier par rougeole et diarrhée. L’avitaminose A, connue depuis longtemps en tant que principal facteur de cécité chez l’enfant et responsable de 250 000 à 500 000 cas chaque année, est maintenant reconnue comme facteur majeur de mortalité, à l’origine de 1 à 3 millions de décès d’enfants par an.

Dans la situation actuelle, l’objectif fixé par le Sommet mondial pour les enfants, à savoir l’élimination de l’avitaminose A, ne sera vraisemblablement atteint à temps que par 35 pays. Si les stratégies alimentaires et celles portant sur l’enrichissement des aliments doivent faire partie de la lutte globale contre l’avitaminose A, il est souvent impossible, dans de nombreux pays en développement, de les appliquer rapidement ou à grande échelle. Les efforts visant à accélérer l’élimination de l’avitaminose A reposent maintenant sur la supplémentation en tant que moyen bon marché et efficace d’améliorer rapidement et durablement le bilan vitaminique A des populations à risque.

La fourniture de suppléments fortement dosés en vitamine A tous les 4 à 6 mois a non seulement pour effet de protéger contre la cécité, mais elle a aussi un impact considérable sur la santé des enfants de 6 à 59 mois, réduisant le risque de mortalité par toutes causes de 23% (35% en Asie), le risque de mortalité par rougeole de 50% et celui par diarrhée de 33% environ. La vitamine A est indispensable au fonctionnement du système immunitaire ainsi qu’à la croissance et au développement de l’enfant. Globalement, la baisse de mortalité chez l’enfant imputable à la supplémentation en vitamine A est comparable, sinon supérieure, à celle conférée par n’importe quel vaccin de l’enfance.

Les journées nationales de vaccination offrent à la fois une infrastructure de dispensation et une couverture sans égale, dont peut bénéficier l’administration de suppléments de vitamine A. En 1997, plus de 450 millions d’enfants, soit près des deux tiers des enfants de moins de 5 ans dans le monde, ont été vaccinés lors de journées nationales de vaccination contre la poliomyélite. La supplémentation en vitamine A pendant ces journées est logique: la population cible, les enfants de moins de cinq ans, est la même, les campagnes nationales atteignent les régions les plus reculées et les personnes les plus à risque d’avitaminose A, les ressources financières et humaines limitées sont utilisées plus efficacement, et le rapport coût/efficacité ainsi que l’impact sont améliorés. A US $0,02 par dose, la supplémentation en vitamine A est l’une des interventions les plus rentables en matière de santé de l’enfant. De plus, sur le plan logistique c’est l’intervention la plus facile à mettre en œuvre pendant les journées nationales de vaccination car les capsules ne nécessitent ni réfrigération ni stockage particulier et elles peuvent être administrées avec une formation et un matériel relativement limités.

En 1998, 75% des 118 pays dans lesquels l’avitaminose A est un problème de santé publique connu ou présumé ont mis en œuvre des journées nationales de vaccination (89/118), et 40 d’entre eux (45 %) y ont inclus une supplémentation en vitamine A. Au total, plus de 60 millions d’enfants ont ainsi reçu de la vitamine A et ont bénéficié de ses effets protecteurs. En 1998, 22 pays d’Afrique ont distribué de la vitamine A au cours de leurs journées nationales de vaccination. Il a été prévu que 12 autres pays introduisent la supplémentation en vitamine A dans leurs journées nationales de vaccination en 1999.

L’administration de vitamine A au cours des journées nationales de vaccination contribue à la lutte contre l’avitaminose A grâce à une meilleure sensibilisation, au développement des capacités techniques, à l’amélioration de l’évaluation et à l’établissement d’un système de notification. De plus, ces journées constituent un point de départ pour la dispensation durable de suppléments de vitamine A dans le cadre des services de vaccination courants et montrent comment peuvent être utilisées les campagnes de vaccination pour la mise en œuvre d’autres mesures préventives.


RESUMEN

En 1988, la 41a Asamblea Mundial de la Salud comprometió a la OMS a perseguir la meta de la erradicación mundial de la poliomielitis para 2000 con «métodos que fortalecieran los programas de inmunización y las infraestructuras sanitarias nacionales». El éxito de la utilización de los días nacionales de inmunización contra la poliomielitis para distribuir suplementos de vitamina A es un ejemplo de cómo la erradicación de la poliomielitis puede servir de plataforma para abordar otros problemas de salud infantil. Al mismo tiempo, esta iniciativa contribuye a alcanzar la meta de la Cumbre Mundial en favor de la Infancia de acabar con la carencia de vitamina A y todas sus consecuencias, incluida la ceguera, para el año 2000.

Se sabe o se sospecha que la carencia de vitamina A es un problema de salud pública en 118 países, todos ellos del mundo en desarrollo. Se estima que de 140 a 250 millones de niños en edad preescolar están expuestos a una carencia subclínica de vitamina A. Esos niños corren mucho más riesgo de enfermar y morir, en particular de sarampión y diarrea. Se sabe desde hace tiempo que la carencia de vitamina A, una de las principales causas de ceguera infantil, provoca la pérdida de la visión a 250 000-500 000 niños al año, y ahora se reconoce que es un importante factor de mortalidad, responsable de la defunción de entre uno y tres millones de niños.

Tal como están las cosas, probablemente sólo 35 países cumplan a tiempo el objetivo de eliminar la carencia de vitamina A que fijó la Cumbre Mundial en favor de la Infancia. Aunque las estrategias de enriquecimiento del régimen alimenticio y de los alimentos deben formar parte del control global de la carencia de vitamina A, en muchos países en desarrollo a menudo es imposible ponerlas en práctica rápidamente o de una manera generalizada. En el empeño de acelerar la eliminación de la carencia de vitamina A se ha recurrido a la suplementación como medio barato y muy eficaz de mejorar de manera rápida y duradera el estado en cuanto a la vitamina A de las poblaciones en riesgo.

La administración de suplementos de altas dosis de vitamina A cada cuatro o seis meses no sólo protege contra la ceguera sino que tiene múltiples repercusiones en la salud de los niños de entre seis y 59 meses de edad, reduciendo el riesgo de mortalidad por todas las causas en cerca del 23% (35% en Asia), el de la mortalidad por sarampión en un 50% y el de la mortalidad por enfermedad diarreica en cerca del 33%. La vitamina A es esencial para el funcionamiento del sistema inmunitario y para el crecimiento y el desarrollo saludables del niño. En términos generales, la reducción de la mortalidad infantil atribuible a la suplementación de vitamina A es comparable, si no mayor, que la de cualquiera de las vacunas infantiles.

Los días nacionales de inmunización cuentan con una infraestructura de distribución y un alcance únicos a los que se puede asociar la administración de suplementos de vitamina A. En 1997, durante los días nacionales de inmunización contra la poliomielitis, se inmunizó a más de 450 millones de niños, casi dos tercios de los niños menores de cinco años de todo el mundo. Es lógico proceder a la suplementación de vitamina A en los días nacionales de inmunización: la población destinataria de niños menores de cinco años de edad es la misma; las campañas nacionales alcanzan a quienes más aislados están y a quienes corren más riesgo de sufrir carencia de vitamina A; se usan de manera más eficaz los recursos financieros y humanos limitados y se gana en eficacia respecto del costo y en repercusión. A un precio de US$ 0,02 por dosis, la suplementación de vitamina A es una de las intervenciones de salud infantil más eficientes. Además, desde un punto de vista logístico, es la intervención más fácil de introducir en los días nacionales de inmunización porque las cápsulas no necesitan refrigeración ni almacenamiento especial y porque para administrarlas no se requiere excesira preparación y material.

En 1998, el 75% de los 118 países donde la carencia de vitamina A es un problema real o presunto de salud pública organizaron días nacionales de inmunización (89/118). De estos últimos, 40 (45%) incluyeron suplementación de vitamina A. En total, más de 60 millones de niños en riesgo recibieron vitamina A y se beneficiaron de sus efectos protectores. En 1998, 22 países africanos administraron vitamina A durante sus días nacionales de inmunización. Se espera que, en 1999, 12 países más introduzcan la suplementación de vitamina A durante sus días nacionales de inmunización.

La administración de vitamina A durante los días nacionales de inmunización ayuda a combatir la carencia de esa vitamina, concienciando, creando capacidad técnica, mejorando la evaluación y estableciendo un sistema de notificación. Además, los días nacionales de inmunización ofrecen un punto de acceso para la administración sostenible de suplementos de vitamina A junto con los servicios de inmunización sistemática y demuestran cómo pueden utilizarse las campañas de inmunización para poner en práctica otras medidas preventivas.


 

 

Introduction

In 1988 the 41st World Health Assembly committed WHO to the goal of global eradication of poliomyelitis by 2000 in ways “which strengthen national immunization programmes and health infrastructure” (1). It is believed that efforts to achieve polio eradication can be a platform for the delivery of other health interventions and for strengthening health systems overall. The successful use of national immunization days (NIDs) to deliver vitamin A clearly shows how this can be done.

The present article reviews the disease burden caused by vitamin A deficiency (VAD), explains how polio NIDs have been used to accelerate progress towards the goal of eliminating VAD, and highlights the critical factors for success, the benefits obtained and the constraints encountered. The platform components provided by NIDs for other preventive child health interventions, and future prospects are outlined.

 

Disease burden attributable to vitamin A deficiency

The disease burden associated with micronutrient deficiency, or hidden hunger as it is sometimes called, is widely recognized. The World Summit for Children in 1990 and the International Nutrition Conference in 1992 laid down goals and timelines for protecting the world’s children from such deficiency. Among the goals was the elimination of vitamin A deficiency and its consequences, including blindness, by the year 2000 (2, 3).

It is considered that VAD exists as a problem of public health significance in varying degrees in 118 countries (Table 1) (4). The highest prevalence of clinical VAD occurs in Africa, while South-East Asia has the highest number of children affected. Clinical VAD, involving signs and symptoms of eye damage and xerophthalmia, affects 3 million children globally. However, the full magnitude of VAD often remains hidden: it is estimated that 140–250 million children under 5 years of age are at risk of subclinical VAD (4, 5); they show none of the ocular signs or symptoms, but have a markedly increased risk of illness and death, particularly from measles and diarrhoea. Annually, VAD causes blindness in 250 000–500 000 children (6) and is a major factor contributing to 1–3 million child deaths (7).

Progress against VAD has been made in many countries through a combination of strategies including food fortification, dietary approaches (eating foods rich in vitamin A, e.g. liver, eggs, leafy green vegetables, orange fruits such as papaya and mango) and supplementation (capsules or liquid). However, as matters stand, the goal set by the World Summit for Children for the elimination of VAD by the year 2000 is likely to be achieved on time by only 35 countries (8). While dietary and food fortification strategies are essential, it is often impossible to implement them quickly or widely in those developing countries where VAD is most severe. Consequently, efforts to accelerate the elimination of VAD have turned to supplementation as a low-cost, highly effective means of rapidly and sustainably improving the vitamin A status and health of children.

The provision of high-dose vitamin A supplements every 4–6 months not only protects against blindness but also has a dramatic multiple impact on the health of children aged 6–59 months, reducing the risk of mortality from all causes by about 23% (35% in Asia) (913), that of measles mortality by 50% (9, 10, 13, 14), and that of diarrhoeal disease mortality by about 33% (9, 10, 1315). Vitamin A is essential for the functioning of the immune system and the healthy growth and development of children. Overall, the reduction in child mortality attributable to vitamin A supplementation is comparable to, if not greater than, that of any single childhood vaccine (8).

 

Using NIDs to accelerate progress towards the elimination of VAD

Despite years of evidence that vitamin A supplementation is a key child survival intervention the challenge has been to establish a reliable delivery mechanism. Since 1994 it has been the policy of WHO and UNICEF to integrate the administration of vitamin A supplements with immunization services, which have contact with 80% of the world’s children under 1 year of age. Whereas the uptake of vitamin A supplementation with routine immunization services has been slow and somewhat limited, the inclusion of vitamin A administration in polio vaccination campaigns has been adopted rapidly and is proving to be one of the most successful ways of reaching large numbers of children at risk of VAD.

The safety of using vitamin A supplementation as a public health intervention has been confirmed (1618), even when administered to young children in populations or areas with subclinical deficiency (19). This approach is further justified on the basis of cost-effectiveness — not only is it safe, but it is significantly cheaper to deliver vitamin A supplements through a universal approach, rather than narrow targeting (20).

NIDs offer a delivery infrastructure and an unparalleled reach to which the provision of vitamin A supplements can be attached. In 1997 more than 450 million children, almost two-thirds of those under 5 years of age, were immunized during polio NIDs. Vitamin A supplementation during NIDs makes good sense: the target population of children under 5 years of age is the same; nationwide campaigns reach the unreached and those most at risk of VAD; limited financial and human resources are used more efficiently; and cost-effectiveness and impact are increased. At US$ 0.02 per dose, vitamin A supplementation is one of the most cost-effective child health interventions available (21). Furthermore, it is logistically the easiest to introduce during NIDs because the capsules require no refrigeration or special storage and because relatively little training and equipment are needed for them to be administered.

In 1998, 75% of the 118 countries where VAD is a known or suspected public health problem conducted NIDs (89/118). Of these, 40 (45%) included vitamin A supplementation in their NIDs (Table 2). Over 60 million children received vitamin A and benefited from its protective effects. In 1998, a total of 22 African countries administered vitamin A during their NIDs (Fig. 1), and 60% of children under 5 years of age in Africa received at least one high-dose vitamin A capsule through either NIDs, special vitamin A campaigns, or other strategies (22).

 

 

 

 

The outlook for 1999 looks promising with 12 new countries, including some of those with the most serious VAD problems, e.g. Angola, India (Orissa State), Pakistan, and Senegal, are planning to give vitamin A during their NIDs for the first time (23).

 

Factors needed for success

The rapid and widespread success of using NIDs to deliver vitamin A is attributable to a coordinated strategic effort by WHO, UNICEF, major international donors, nongovernmental organizations and academic institutions (23). The critical factors for success have included:

Advocacy. WHO and UNICEF jointly recommended vitamin A supplementation during NIDs to governments and other partners. Donors such as the Canadian International Development Agency (CIDA) and the US Agency for International Development (USAID) played a key leadership role and urged governments to use NIDs as a means of rapidly increasing the coverage of vitamin A supplementation. Particular efforts to engage the private sector were also pursued by USAID’s Vitamin A (VITA) Initiative, which has received the high-profile support of US First Lady, Hillary Rodham Clinton.

Policy development. In July 1998 a joint WHO/ UNICEF statement (24) on the policy and operational questions relating to vitamin A and NIDs pledged the support of both agencies and encouraged all countries where VAD was a public health problem to include age-appropriate vitamin A supplementation for children during polio NIDs.

Technical support and training. An international meeting was held in January 1998 to clarify technical, logistic and monitoring issues related to the integration of vitamin A supplementation with NIDs. Subsequently, with the help of BASICS1 these matters were dealt with in a new field guide entitled “Distribution of vitamin A supplements with NIDs” (25). In 1998, technical discussion and experience sharing of vitamin A supplementation was included in the agendas of all WHO and UNICEF regional planning and management meetings on polio eradication and immunization.

Social mobilization. Intensive efforts were made at the country level to inform and educate the public and all levels of staff about the importance of vitamin A and its provision during polio NIDs.

Operational support and provision of supplies. Through the Micronutrient Initiative (MI), since 1997 the Government of Canada has donated more than 800 million vitamin A capsules to support vitamin A supplementation activities (these capsules have been used for NIDs, but also for special “micronutrient days”, treatment, postpartum maternal supplementation, and routine delivery to children with health services). The provision of free-of-charge supplies has made it easier for governments to consider the addition of vitamin A to NIDs. Operational costs for the inclusion of vitamin A with NIDs have also been covered in many countries through Government of Canada/MI grants to WHO and UNICEF. These grants assisted countries to cover the costs related to freight, internal distribution, additional volunteers, and other supplies such as scissors, training and advocacy, revision of tally forms, and monitoring. With the free supply of vitamin A capsules, the incremental costs of integrating the delivery vitamin A with NIDs have been kept low. Yearly rounds of polio NIDs are on average estimated to cost US$1 per child. Based on WHO/UNICEF country experiences, the additional cost of adding vitamin A has ranged from 2% to 10% depending on the size of the country (generally higher costs in smaller countries), with an average incremental cost of about 5%.

Monitoring and reporting. Tally sheets for recording the delivery of oral polio vaccine have been revised to include the monitoring of vitamin A supplementation during NIDs. National reporting of vitamin A supplementation during NIDs and routine immunization services has been included in WHO’s global immunization information system and databases, and will be published annually. The collection of the information is facilitated by a joint UNICEF/WHO reporting form on vaccine-preventable diseases, which for the first time in 1998 made it possible to collect data on vitamin A supplementation. A more detailed effort to collect data is being undertaken by UNICEF through a multiple indicator cluster survey in about 70 countries during 1999 and 2000.

 

Benefits and constraints of integrating polio vaccination and vitamin A supplementation

Integration has attracted new international donors and resources, and there has been broader collaboration at the country level as national immunization and nutrition programmes have worked together to plan and implement polio NIDs that include vitamin A supplementation. The polio experience is helping to drive research on vitamin A. Planning is in progress for studies on assessing immune responses to the simultaneous administration of vitamin A and various childhood vaccines. Positive results could allow vitamin A to be given in conjunction with immunization campaigns directed against other diseases, e.g. yellow fever. Operational research on simplifying the age-specific dosage and making the administration of vitamin A easier is also under discussion.

As polio eradication draws nearer and the disease is seen less often, support and commitment become harder to obtain. In many instances where countries need to conduct intensified and additional rounds of NIDs to ensure polio eradication, the inclusion of vitamin A serves as a useful inducement for maintaining momentum, guarding against fatigue, and completing the task. On the one hand, governments are pleased to do something more to reduce child morbidity and mortality. On the other, the availability of vitamin A increases attendance during NIDs (26). Vitamins are highly valued in most developing countries, and the offer of vitamin A alongside polio vaccination acts as an incentive to mothers and care-givers to take children to immunization posts.

On balance, the impact of administering vitamin A during NIDs has more positive than negative effects. There are, however, logistic and managerial implications. Extra supplies have to be ordered and distributed, additional training and volunteers are needed, the organization and client flow of the vaccination post have to be adapted, and a system of additional screening and integrated tallying needs to be introduced. The added complexities are manageable, but where there is weak and already stressed management it is essential to have careful planning and organization, and extra technical support is often necessary in order to avoid compromising the performance of polio NIDs.

The administration of vitamin A supplements during polio NIDs cannot wholly solve the problem of VAD. Because NIDs are normally held annually they only provide an opportunity for one dose of vitamin A to be given each year. This raises the vitamin A status and liver stores of children and provides the associated protective health benefits for 4–6 months. However, children with vitamin A deficiency should receive a supplement at least twice a year (i.e. every 4–6 months). In order to provide a second dose of vitamin A, some countries, including Bangladesh, Nepal, Niger, and the Philippines, have organized “micronutrient or vitamin A days” six months after the annual NIDs. Providing vitamin A with routine immunization services offers a longer-term solution.

 

A platform for what?

The argument that polio NIDs can serve as a platform for other preventive child health interventions implies that a foundation for something more is being created. Polio NIDs and subnational immunization days are expected to provide opportunities for delivering vitamin A until 2002 or 2003. Subsequently, measles vaccination campaigns and perhaps other immunization campaigns can be expected to continue providing opportunities for delivering vitamin A, although not with the same frequency as polio NIDs. This does not mean that the platform of polio NIDs will be dismantled once the job is complete. The administration of vitamin A during NIDs has led to the following effects (Fig. 2) that can be expected to continue far beyond the termination of polio NIDs.

 

 

Increased awareness and advocacy of VAD. NIDs require political commitment at a high level and coordinated donor support. In many countries, NIDs are the most prominent health events of the year, gaining the attention of the entire population. The inclusion of vitamin A supplementation has sensitized and raised the awareness of governments, the donor community and local communities to the significance of VAD. The ability to deliver vitamin A supplementation on a national scale has alerted decision-makers to the public health significance of VAD beyond blindness. It is now understood that improving vitamin A status is a way to increase child survival. This serves to build a culture of prevention, a necessary precondition for the introduction of other VAD control strategies. In particular, food fortification often requires collaboration between government and industry. As fortified foods and dietary change are introduced, the VAD awareness primed through NIDs should help to generate interest and demand among consumers.

Strengthened technical capacity. Many health workers at all levels have learnt about VAD and have been trained in the use of vitamin A supplements. In 1998 the administration of millions of doses of vitamin A was achieved by people with the knowledge and skill to understand why it was important and how to perform the task properly. After the NIDs these health workers returned to their regular jobs, carrying their learning and experience with them. They can be expected to include VAD in health education activities, to give vitamin A supplements for the treatment of children with severe measles or clinical VAD and as part of the integrated management of childhood illness, and to seize opportunities to administer vitamin A supplements preventively in conjunction with routine immunization services.

Sharing laboratory network learning. The eradication of polio requires a strong laboratory component to guide strategy and the certification of polio-free status. This has led to the creation of a polio laboratory network with regional reference laboratories and to the strengthening of the capacities of national laboratories. The elimination of VAD also requires a laboratory component but at present the capacity for assessment of VAD is very limited in many developing regions. Guidance for developing and strengthening laboratory capacity in this field can be obtained by examining the lessons learnt from the polio laboratory network.

Integrated reporting. Before the introduction of vitamin A supplementation during NIDs there were only ad hoc and informal systems for collecting data on coverage with vitamin A supplements. Now, however, it is possible to adapt immunization reporting systems and databases to include information on this matter. This provides data that can be used to improve performance, for example through the identification of low-coverage districts that may have problems with supply or training. Furthermore, progress towards the goal of eliminating VAD can be monitored and the annual publication of data in ranked form can be used to prompt certain countries to take action. The adaptation of the routine immunization reporting system to include vitamin A coverage also signals that vitamin A is not linked to NIDs alone. By asking for data on this matter the message is given that there are longer-term opportunities for vitamin A supplementation and that they should be utilized.

Entry point for linking vitamin A with routine immunization services. By raising awareness, building technical capacity, improving assessment and creating a reporting system, NIDs provide an entry point and the necessary components for the sustainable delivery of vitamin A supplements with routine immunization services. In areas of vitamin A deficiency there are several recommended opportunities for providing vitamin A supplementation with these services. New mothers can receive it at the first infant immunization contact (e.g. BCG or diphtheria–tetanus–pertussis 1 (DTP1)) if this occurs within 6–8 weeks of delivery (the safe infertile period) and if they did not receive vitamin A at the time of birth. Supplements given to postpartum mothers increase the vitamin A content of their breast milk and improves the vitamin A status of their young infants. For children, a dose of vitamin A should be provided with the measles immunization contact at 9 months of age. Many experts believe that vitamin A supplements could also be safely administered during earlier immunization contacts (i.e. to children under the age of 6 months), and research on this subject is in progress. It is to be hoped that the outcome will be a policy supporting the provision of at least two doses of vitamin A during immunization contacts within the first year of life.

 

Prospects

NIDs are helping to build a sustainable platform for tackling VAD and other child health problems beyond the once-only provision of supplements. The experience of giving vitamin A during polio NIDs is leading to discussions on broadening them to become child health days or sustainable outreach services. Such periodic campaigns can be used to give vaccinations against diseases other than polio, to distribute vital micronutrients and anti-worm medicines, to provide health education and to promote the use of insecticide-treated bednets in malarial areas. Such activities have been undertaken in Latin America for many years with great success.

 

References

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11. Fawzi WW et al. Vitamin A supplementation and child mortality: a meta-analysis. Journal of the American Medical Association, 1993, 269: 898–903.         [ Links ]

12. Tonascia JA. Meta-analysis of published community trials of the impact of vitamin A on mortality. In: Proceedings of the Bellagio Meeting on Vitamin A Deficiency and Childhood Mortality. New York, Helen Keller International, 1993.         [ Links ]

13. Sommer A, West KP. Vitamin A deficiency: health, survival and vision. Oxford, Oxford University Press, 1996.         [ Links ]

14. IVACG Policy Statement on Vitamin A, Diarrhea and Measles. Washington, International Vitamin A Consultative Group, 1996.         [ Links ]

15. Huttly SRA, Morris SS, Pisani V. Prevention of diarrhoea in young children in developing countries. Bulletin of the World Health Organization, 1997, 75: 163–174.        [ Links ]

16. WHO/UNICEF/IVACG. Vitamin A supplements: a guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia, 2nd edition. Geneva, World Health Organization, 1997.         [ Links ]

17. Vitamin A and Pneumonia Working Group. Potential interventions for the prevention of childhood pneumonia in developing countries: a meta-analysis of data from field trials to assess the impact of vitamin A supplementation on pneumonia morbidity and mortality. Bulletin of the World Health Organization, 1995, 73: 609–619.         [ Links ]

18. Immunization safety: supplementary information on adverse events following immunization (contains summary review on safety of vitamin A administered with immunization). Geneva, World Health Organization, Department of Vaccines and Biologicals, Vaccines Assessment and Monitoring (unpublished document, in press).         [ Links ]

19. WHO/CHD Immunization-linked Vitamin A Study Group. Randomized trial to assess benefits and safety of vitamin A supplementation linked to immunization in early infancy. Lancet, 1998, 352: 1257–1263.         [ Links ]

20. Loevinsohn BP, Sutter RW, Costales MO. Using costeffectiveness analysis to evaluate targeting strategies: the case of vitamin A supplementation. Health Policy and Planning, 1997, 12: 29–37.         [ Links ]

21. World Bank. World development report 1993: investing in health. Oxford, Oxford University Press, 1993.         [ Links ]

22. UNICEF/WHO data, 1999.         [ Links ]

23. Vitamin A Global Initiative. A strategy for acceleration of progress in combating vitamin A deficiency: consensus of an informal technical consultation, New York, 18–19 December 1997. New York, UNICEF, 1998.         [ Links ]

24. Joint statement: policy and operational questions relating to vitamin A and EPI/NIDs. Geneva, WHO/UNICEF, 1998.         [ Links ]

25. Distribution of vitamin A during national immunization days: a ‘‘generic’’ addendum to the field guide for supplementary activities aimed at achieving polio eradication, 1996 revision. Geneva, World Health Organization, 1998 (available from Vaccines and Biologicals, World Health Organization, 1211 Geneva 27, Switzerland).         [ Links ]

26. Communications and reports from WHO and UNICEF Country Offices (unpublished).        [ Links ]

 

 

Requests for reprints
Tracey Goodman
Department of Vaccines and Biologicals, World Health Organization
1211 Geneva 27, Switzerland

 

 

1 BASICS (Basic Support for Institutionalizing Child Survival) is a five-year international public health project funded by the US Agency for International Development (USAID).