Premature abandonment of global vitamin A supplementation programmes is not prudent

Mason et al. provide an overview of vitamin A supplementation (VAS) programmes globally and conclude that the current strategy for biannual supplementation with vitamin A between 6 and 59 months of age has outlived its utility. They base their conclusions on the following main arguments. First, despite VAS programmes, global prevalence of vitamin A deficiency has not changed; second, the evidence on the effectiveness of VAS in terms of child mortality was drawn from studies undertaken over two decades ago and may not be relevant any more in the current context of reduced child mortality especially in deaths related to diarrhoea and measles. They cite heavily the decade-old but recently published Deworming and Enhanced Vitamin A (DEVTA) study in India, where a lower effect size on under5 mortality was seen. Mason et al. conclude by suggesting that dietary diversification and fortification strategies may offer a more effective set of interventions. We concur with the notion that eventually appropriate diets and interventions to reduce poverty and food insecurity may offer the best options to improve health and nutrition status across populations. However, are we at a stage when a well-established and accepted global programme should be abandoned without due attention to the feasibility, current effective coverage and cost-effectiveness of alternative strategies? We strongly believe that such a course could seriously jeopardize gains in child health and survival. There are several arguments to support our contention. First, it is important to note that twice-yearly high-dose vitamin A supplementation is not an intervention to sustainably control vitamin A deficiency, but rather an immediate, life-saving intervention to improve child survival. In the latter context, it is also incorrect to relate VAS programmes to child mortality alone. Whereas admittedly the programme was initiated three decades ago with child mortality impact in mind, it was always meant to improve morbidity outcomes as well. There is ample indirect evidence that this has indeed been achieved in many regions of the world. The current rate of reduction in diarrhoea mortality globally is disproportionate to the change in coverage of Oral Rehydration Solution (ORS) and zinc usage or indeed breastfeeding rates, and has also largely taken place in the very regions (Latin America and South East Asia excluding India) where the rate of progress in reducing child mortality and VAS programme coverage has been highest. Figure 1 shows some of the trends in vitamin A deficiency in countries of the region where population-level vitamin A deficiency and VAS coverage data over the past two decades are available. It is also notable that in contrast to the statement that rates of global vitamin A deficiency have not changed, severe deficiency has indeed disappeared in many regions. Severe xerophthalmia and childhood blindness related to this have significantly reduced and this reduction has been attributed to a combination of success of measles immunization and VAS. Similarly, diarrhoea burden, especially rates of severe and persistent diarrhoea have reduced significantly over the last two decades. The benefits of VAS may thus extend well beyond mere mortality impact. Caution must be exercised in using the results from the DEVTA study to make the case that the programme effectiveness is questionable. Numerous concerns have been expressed about the completeness of data capture in that