Vitamin A deficiency: policy implications of estimates of trends and mortality in children
Authors: John B Mason, David Sanders, Ted Greiner, Roger Shrimpton, Joshua Yukich
Journal: The Lancet Global Health (2015)

We welcome the Article by Gretchen Stevens and colleagues (September, 2015),1Stevens GA Bennett JE Hennocq Q et al.Trends and mortality effects of vitamin A deficiency in children in 138 low-income and middle-income countries between 1991 and 2013: a pooled analysis of population-based surveys.Lancet Glob Health. 2015; 3: e528-e536Summary Full Text Full Text PDF PubMed Scopus (286) Google Scholar although wish to correct a, no doubt, inadvertent misrepresentation of our views. Stevens and colleagues cite our paper2Mason J Greiner T Shrimpton R Sanders D Yukich J Vitamin A policies need rethinking.Int J Epidemiol. 2015; 44: 283-292Crossref PubMed Scopus (76) Google Scholar in support of their statement that “large scale or targeted supplementation or fortification strategies will probably have some beneficial effect on mortality in these regions [south Asia and sub-Saharan Africa]”. We advocated a prudent phase-over away from vitamin A capsules to more physiological and locally appropriate methods.2Mason J Greiner T Shrimpton R Sanders D Yukich J Vitamin A policies need rethinking.Int J Epidemiol. 2015; 44: 283-292Crossref PubMed Scopus (76) Google Scholar We did not advocate “large-scale or targeted supplementation”. In our paper, we suggested that no more than 2–3% of deaths in children younger than 5 years might be prevented by intermittent high-dose vitamin A. This is very similar to the estimate of 1·7% in the Article by Stevens and colleagues. There must be higher priorities than distributing enormous numbers of high-dose vitamin A capsules every 6 months (we estimate 8 billion to date!), which even if effective would have only a small effect on mortality in children younger than 5 years.2Mason J Greiner T Shrimpton R Sanders D Yukich J Vitamin A policies need rethinking.Int J Epidemiol. 2015; 44: 283-292Crossref PubMed Scopus (76) Google Scholar All now agree that vitamin A capsules given every 6 months have little or no effect on the prevalence of vitamin A deficiency, because their effect on serum retinol is small and transient. This information needs to be more widely disseminated, since many programme managers still believe that, even if the effect of vitamin A capsules on child mortality is in doubt, at least the capsules will help to reduce the extent of vitamin A deficiency; however, they will not. The continuation of present policies—that is, vitamin A supplementation with yet more capsules—is far from cost free to the recipient local health system. The usual route for delivery of capsules is at child health days every 6 months, which build on supplementary immunisation activities, and are now less needed and less common. The opportunity costs of these days have been documented in terms of weakened routine health services3Verguet S Jassat W Bertram MY et al.Impact of supplemental immunisation activity (SIA) campaigns on health systems: findings from South Africa.J Epidemiol Community Health. 2013; 67: 947-952Crossref PubMed Scopus (27) Google Scholar, 4Doherty T Chopra M Tomlinson M Oliphant N Nsibande D Mason J Moving from vertical to integrated child health programmes: experiences from a multi-country assessment of the Child Health Days approach in Africa.Trop Med Int Health. 2010; 15: 296-305Crossref PubMed Scopus (49) Google Scholar (likely to include lost opportunities to save children's lives). Moreover, the least developed health systems are the most weakened by child health days, for example in Cameroon and Ethiopia.5Hanvoravongchai P Mounier-Jack S Oliveira Cruz V et al.Impact of measles elimination activities on immunization services and health systems: findings from six countries.J Infect Dis. 2011; 204: S82-S89Crossref PubMed Scopus (42) Google Scholar The justification for distribution of vitamin A capsules, and indeed for child health days themselves, especially without supplementary immunisation activities, is in increasing doubt. We declare no competing interests. Vitamin A deficiency: policy implications of estimates of trends and mortality in children – Authors' replyOur reference1 to the work of Mason and colleagues2 was in a sentence that stated that “until this [an improvement in the overall nutrition of the population, including through dietary diversification and improved access to vitamin-rich foods, and improved access to treatment for infectious diseases] happens, large scale or targeted supplementation or fortification strategies will probably have some beneficial effect on mortality in these [south Asia and sub-Saharan Africa] regions”. This approach, whose ultimate aim is regular intake, largely through diet, is not inconsistent with the prudent phase-over approach outlined by Mason and colleagues. Full-Text PDF Open Access