Vitamin A Program In Bangladesh

Vitamin A deficiency is the leading cause of blindness among children and women. It is also associated with increased risk of morbidity and mortality. Several national nutrition surveys and focused studies during the last four decades indicate that though the situation has improved, Vitamin A Deficiency (VAD) continues to be a public health problem in Bangladesh . Prevalence of severe VAD, based on night blindness, in pre-school children decreased from 3.7% in 1982-83 to 0.2% in 2002 (Table 1). However, there is still a high level of sub-clinical VAD in pre-school children based on the serum retinol levels. The 1997 survey showed that 22% of pre-school children had serum retinol levels. The below the cut off level of 20ug and more than 2.7% of pregnant women, 2.4% of lactating mothers and 1.7% of non-pregnant non-lactating mothers were found to be f=night blind. Only a limited number of studies in limited geographic areas and/ or socio-economic groups are available where serum retinol levels heave been reported for school-age children, adolescents and pregnant women. However, night blindness and Bitot`s spots continue to be detected in school age children and night blindness reported in o.33% of non-pregnant women in rural Bangladesh in 2004.

Table 1: Prevalence of Night Blindness (XN) Among Children 12-59 months

Following WHO report in 1972, the Government of Bangladesh (GoB) adopted a multi-pronged approach to address the problem of VAD. In 1973, the GoB launched the Nutritional Blindness Prevention Program. The interventions included the Vitamin A Capsule (VAD) supplementation to children 6 to 72 months twice a year through domiciliary visits by the health staff and Vitamin A capsules (200.000 IU) were provided to all children aged 12-72 months twice a year through domiciliary visits by the health staff and Vitamin A capsules (100,000 IU) provided to all children aged 9 months at the EPI centers. In 1981, the responsibility of distributing Vitamin A Capsules (VAC) was shifted from the Director preventive of Primary Health Care & Disease Control to the Institute of Public Health Nutrition (IPHN). However, the VAC coverage rate in the rural areas did not improve significantly. It was 45% (a range of 16-85%) in 1982-83, 37% in 1987-88 and 35% in 1989.

It is important to recognize that the strategy for addressing vitamin A deficiency was not limited to only vitamin A supplementation. The agricultural, health and nutrition related policies and programs, such as, home gardening, homestead

• 1 .WHO. Vitamin and Mineral Nutrition Information System. 2006.
• 2 .IPHN/HKI. Annual Report of the Nutrition Surveillance Project, 2005.
• 3 .HKI. Vitamin A distribution; trends in Bangladesh. 1996
• 4 .IPHN/UNICEF. Nutritional Blindness Prevention. Evaluation Report. 1989

poultry, nutrition education, promoting breastfeeding, fortification of edible oil with vitamin A, etc. also contributed to reduced prevalence of VAD in the population.

In mid-1990s, the GoB launched the Bangladesh Integrated Nutrition Project (BINP). An evaluation of this project indicated that ~BINP improved the delivery and use of micronutrients (iron/folate, vitamin A, and iodized salt) to a greater extent than that seen in non-project areas. Data from most studies showed a 10 to 30 percentage point higher uptake of vitamin A capsules among children under 2 years old. Around the same time, vitamin A supplementation to children under 12 months of age was integrated into the outreach clinics of the Expanded Program on Immunization (EPI) and vitamin A supplementation to children 12-72 months of age was integrated with the National Immunization Day (NID. The coverage rates improved significantly.

The current National Nutrition Project (NNP) builds on the success of the BINP. Under the NNP, vitamin A supplements will be distributed to (1) infants aged 9-11 months with the measles vaccination (2) children aged 12-59 months every 6 months during Vitamin A Plus Campaigns (3) postpartum women within 6 weeks of delivery, and (4) children with vitamin A deficiency, measles, persistent diarrhea or severe malnutrition. The National Food Policy, 2006 provides further support for addressing VAD through a clearly articulated strategy on ``Balanced diet containing adequate micronutrients” which includes bio-fortification, food fortification, nutrition education and dietary diversification.

However, quantifying the impact of all these measures to reduce VAD is difficult. What is clear is that the coverage rates for vitamin A supplementation have been steadily rising since the mid-1990 from 50% to 85% due to changing strategy of center based supplementation instead of distributing capsules domiciliary visit. International organizations, particularly UNICEF, MI and CIDD also came forward to support this implementation strategy. An attempt has been made to capture this success story in this document.

The high coverage of Vitamin A supplementation to children has resulted in a reduction in the prevalence of vitamin A deficiency. Since 1997, the prevalence of night blindness, an early indicator of vitamin A deficiency, has been maintained below the 1 per cent threshold that indicates a public health problem. However, it mist be emphasized that vitamin A deficiency is being controlled by the Vitamin A supplementation program rather than being eliminated, because infants and young children still consume diets that are lacking in Vitamin A. For this reason, the vitamin A supplementation program must continue until production and consumption of Vitamin A rich foods are increased.

Pelletier et al: The Bangladesh Integrated Nutrition Project- Effectiveness and Lessons; Bangladesh Development Series, South Asia Human Development Unit, 2006. MoW&CA, GoB: National plan of action for children Bangladesh, 2005 UNICEF: EPI Coverage Evaluation Survey, 2005 CIDA/MI: Review of organizational options for delivery of nutrition services through the health, nutrtition and population sector program, 2006 UNICEF Country website.

History of success of Vitamin A Supplementation to different population groups

Large-scale Vitamin A supplementation (VAS) commenced in 1973, as a part of the Nutritional Blindness Prevention Program (NBPP). Vitamin A capsules (200,000IU) were provided to the children twice a year through domiciliary visits. The visits took place in April/May and October/November. In the rural areas, the village level multipurpose health care workers distributed the capsules while in the urban areas, the municipal staff and the NGO workers were involved in the distribution of VAC, From 1973 to 1981, the VAS program was managed by the Director of Primary Health Care & Disease Control. Since 1981, the Institute of Public Health Nutrition has been managing the program.

In the initial years, support for procuring vitamin A capsules was provided by the World Band (WB), UNICEF and the Swedish International Development Agency (SIDA). From 1997 to 2003, the Canadian Government through the Micronutrient Initiative supported the VAC under the World Band assisted National Nutrition Project.

In the initial years, the coverage rates were not very encouraging. These were reported as 45% ( 1982-83), 37% (1987-88) and 35& (1989). From June 1990 to April 1994, VAC coverage remained between 42-55% among children 6-72 months of age. In 1994, after the withdrawal of SIDA support (and before the commencement of WB support) the procurement of VAC was delayed. This resulted in one round being missed and the coverage dropped to 31%.

Concerned at the stagnant coverage rates, the IPHN modified the strategy and, in 1994, the GoB launched a mass public awareness campaign called the `Mother and Child Survival Fortnight’ The next round of VAS was coupled with the first National Immunization Day of the polio program. This resulted in coverage rate increasing to 85% (Table 3). Encouraged by these results, in 1995, `National Vitamin A Week was organized six months after the NID. Support was forthcoming from such agencies as World Health Organization, UNICEF, Canadian International Development Agency (CIDA), Micronutrient Initiative, Helen Keller International, etc. Since then, the VAC coverage rates have been reported to be above 80% for the two rounds of VAC, one paired with the NID and the other as stand alone (Table 3).

Considering that with the reduction in the incidence of poliomyelitis the NIDs were likely to be discontinued in the near future, the VAS strategy was reviewed. The GoB recognized that distributing multiple health and nutrition interventions in a more integrated manner would be more cost-effective than a stand alone VAS program. Accordingly, the `National Vitamin A Plus Campaign’ was planned with active technical and financial support from CIDA, Micronutrient Initiative and UNICEF.

In the first campaign, in October 2003, Vitamin A supplements were distributed to chidren aged 12-59 months, albendazole to choldren aged 24-59 months and children in primary and secondary schools tested salt for iodine. No less significant was the dissemination of health and nutrition messages. The reported coverage rate was 89% Consistently high coverage rates, over 80%, in the nest campaigns held in October 2004, June 2005 and December 2005 have validated this strategy. What is notable is that in the absence of a NID in 2005, the GoB implemented two National Vitamin A Plus Campaigns in 2005 signifying its commitment to this approach.

In each `National Vitamin A Plus Campaign, more than 18 million VAC are distributed to children 12-59 months of age through approximately 120,000 fixed and 40,000 non-fixed centers. More than 50,000 government staff and nearly 55,000 non-government workers and volunteers are involved in this bi-annual exercise. Several advocacy and planning meetings are held at the national divisional and city corporation levels.

Intersectoral coordination is achieved through the regular monthly meetings of the District Development Coordination Committee (DDCC) and the Upazila Development Coordination Committee (UDCC)

Intersectoral micro planning meetings are held at district (64 meetings) pourashavas (89 meetings) and upazila/sub-district (507 meetings) levels. In addition, orientation meetings are held at the union and ward levels for the health and family planning staff and NGO workers and volunteers.

In the urban/municipal areas, the program is coordinated by the City Corporations (under the Ministry of Local Government, Rural Development & Cooperatives) and implemented by NGOs. The City Corporations conduct the orientation for the NGO workers and volunteers at the zonal and ward levels prior to the campaign (figure).

IEC materials(folder and field guide) are distributed among field level managers and workers in the weeks leading to the campaign.