Dr Kunal Bagchi
Regional Adviser – Nutrition & Food Safety
WHO South-East Asia Regional Office
Kathmandu, Nepal
November 2011
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Vitamin A
 Essential nutrient required by humans for the normal functioning of
the visual system, maintenance of cell function for growth, epithelial
cellular integrity, immune function and reproduction
 Dietary requirements for vitamin A are from :
 mixture of preformed vitamin A (retinol) present in animal source
foods
 provitamin A carotenoids, derived from foods of vegetable origin
and which have to be converted into retinol by tissues such as
the intestinal mucosa and the liver in order to be utilized by cells
 Aside from the clinical ocular signs of night blindness and
xerophthalmia, symptoms of vitamin A deficiency (VAD) are largely
non-specific
 Biochemical measures of vitamin A status are essential in order to
attribute non-ocular symptoms to VAD
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Vitamin A deficiency:
prevalence in pre-school
age children
Vitamin A deficiency: Prevalence of in
pre-school age children
(Serum retinol < 0.70 µmol /l)
Country
Prevalence of serum retinol
(<0.70 µmol/l and number of
individuals affected among
pre-school age children in
South-East Asia
Prevalence
(%)
No.
affected (in
millions)
South49.9%
91.5
East
(45.1 – 54.8) (82.6 – 100)
Asia
Global Prevalence of vitamin A deficiency in populations at
risk 1995 – 2005 – WHO Global Database (2009)
Age
group
Estimate (%)
Public
health
problem
Bangladesh
0.5 – 4.99
years
21.7 [18.5 – 25.3]
Severe
Bhutan
1.00 –
4.99 years
22.0 [18.4 – 26.0]
Severe
NA
27.5
Severe
1.00 –
4.99
62.0 [59.8 – 64.1]
Severe
Indonesia
NA
19.6 [ 2.2 – 72.3]
Moderate
Maldives
2.00- 2.99
9.4 [6.7 – 13.1]
Mild
Myanmar
NA
36.7 [5.1 – 86.2]
Severe
Nepal
0.5 – 4.99
32.3 [28.0 – 36.9]
Severe
Sri Lanka
0.5 – 5.99
35.3 [32.3 – 38.5]
Severe
Thailand
NA
15.7 [1.7 – 66.5]
Moderate
Timor Leste
NA
45.8 [6.9 – 90.6]
Severe
DPR Korea
India
Basis for the Guidelines on Vitamin A
Supplementation
• Member States request for guidance on the
effects and safety of vitamin A
supplementation
• Global, evidence-informed recommendation
on the use of vitamin A supplements
• Informed decisions on appropriate nutrition
actions to achieve MDG 4 [reduction in child
mortality]
• Intended for: policy-makers, technical
experts and programme managers
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WHO Handbook for Guideline Development
1.
2.
3.
4.
Identification of priority questions and outcomes
Retrieval of the evidence
Assessment and synthesis of the evidence
Formulating of recommendations, including future research
priorities
5. Planning for dissemination, implementation, impact
evaluation and updating of the guideline
GRADE: Grading of
Recommendations
Assessment,
Development and
Evaluation methodology
was followed
To prepare
evidence profiles
related to preselected topics,
based on up-todate systematic
reviews
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Neonatal Vitamin A supplementation
 Systematic reviews to evaluate the effects and
safety of neonatal vitamin A supplementation
 Analysis of data showed no significant reduction in
the relative risk of mortality during infancy
 No evidence of a reduced risk of morbidity or
mortality related specifically to diarrhoea or acute
respiratory infection
 Meta-analysis assessing the survival effect of
vitamin A given to neonates found no significant
effect all-cause mortality and no differential effect of
the intervention between genders
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Neonatal Vitamin A Supplementation
Recommendation
At present time, neonatal vitamin A
supplementation (supplementation
within the first 28 days after birth) is not
recommended as a public health
intervention to reduce infant morbidity
and mortality
[strong recommendation]
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Vitamin A supplementation in infants 1 – 5
months of age
• Systematic review to evaluate the effects and
safety of vitamin A supplementation in infants 6
months of age or less
• No significant effect on the risk of mortality or
morbidity in the first year of life
• No effect on all-cause mortality, when given as a
cumulative dose, regardless of the status of
maternal postpartum vitamin A supplementation
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Vitamin A supplementation in infants 1 – 5
months of age
Recommendation
Vitamin A supplementation in infants
1–5 months of age is not
recommended as a public health
intervention for the reduction of
morbidity and mortality
[strong recommendation]
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Vitamin A supplementation in infants and children 6 –
59 months of age
• Vitamin A supplementation in children 6–59
months of age is associated with reduced risk of
all-cause mortality and reduced incidence of
diarrhoea
• Improvement of gut integrity, decrease severity
of diarrhoeal episodes and reduced
susceptibility to infections
• Many countries have integrated strategies to
deliver vitamin A supplements to infants and
children in their national health policies.
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Vitamin A supplementation in infants and
children 6 – 59 months of age
Recommendation
High-dose vitamin A supplementation
is recommended in infants and
children 6–59 months of age in
settings where vitamin A deficiency is
a public health problem
[strong recommendation]
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Vitamin A supplementation in infants and
children 6 – 59 months of age
• Vitamin A supplementation should be used
along with other strategies to improve vitamin
A intakes [e.g. dietary diversification and food
fortification]
• Supplements should be delivered to children 6–
59 months of age twice yearly during health
system contacts and integrated into other
public health programmes
• Recommendation can be applied in populations
where infants and children may be infected with
HIV
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Vitamin A supplementation in infants and children
6 – 59 months of age
Suggested vitamin A supplementation scheme for infants children 6–59 months of age
Target Group
Infants 6 – 11 months of
age (including HIV+)
Children 12-59 months of
age (including HIV+)
Dose
100,000 IU (30 mg RE)
vitamin A
200,000 IU (60 mg RE)
vitamin A
Frequency
Once
Every 4 – 6 months
Route of
administration
Oral liquid, oil-based preparation of retinyl palmitate or
retinyl acetate
Settings
Populations where the prevalence of night blindness is 1%
or higher in children 24–59 months of age or where the
prevalence of vitamin A deficiency (serum retinol 0.70
μmol/l or lower) is 20% or higher in infants and children
6–59 months of age
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Vitamin A supplementation in pregnant women
• Public health problem affecting a large number of
pregnant women - increased need for vitamin A
during pregnancy, most common during third
trimester
• Essential for the health of the mother as well as for
the health and development of the fetus
• Guideline provides global, evidence-informed
recommendations on the use of vitamin A
supplements in pregnant women – achieving the
improvement of maternal health [MDG 5]
• Intended for: policy-makers, technical experts,
programme managers
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Vitamin A supplementation in pregnant women
Recommendation
• Vitamin A supplementation is not
recommended during pregnancy as part of
routine antenatal care for the prevention of
maternal and infant morbidity and mortality
(strong recommendation)
• In areas where there is a severe public health
problem related to vitamin A deficiency,
vitamin A supplementation during pregnancy
is recommended for the prevention of night
blindness
(strong recommendation)
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Vitamin A supplementation in pregnant women
Suggested vitamin A supplementation scheme in pregnant women for
the prevention of night-blindness in areas with severe public health
problem related to vitamin A
Target Group
Dose
Frequency
Pregnant Women
Up to 10 000 IU vitamin A (daily dose) OR
Up to 25 000 IU vitamin A (weekly dose)
Daily or weekly
Routes of
administration
Oral liquid, oil-based preparation of retinyl palmitate or
retinyl acetate
Duration
A minimum of 12 weeks during pregnancy until delivery
Settings
Population where the prevalence of night-blindness is
5% or higher in pregnant women or 5% or higher in
children 24 – 59 months of age
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Vitamin A supplementation in postpartum
women
Recommendation
Vitamin A supplementation in
postpartum women is not recommended
for the prevention of maternal and
infant morbidity and mortality
(strong recommendation)
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Vitamin A supplementation in pregnancy for
reducing the risk of mother-to-child transmission of
HIV
Recommendation
Vitamin A supplementation in HIVpositive pregnant women is not
recommended as
a public health intervention for
reducing the risk of mother-to-child
transmission of HIV
[strong recommendation]
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