Progress to date

As supplementation is currently the primary vitamin A deficiency control strategy and a key strategy for child survival, discussions of progress focus largely on coverage with that intervention. It should be noted that a number of countries, particularly in Latin America and the Caribbean, are successfully fortifying staple foods with vitamin A. However, coverage of fortification programmes has not been systematically assessed and will not be addressed in this section. Summary information on the scale of food fortification efforts in priority countries is included under country data on vitamin A deficiency control.

Vitamin A supplementation coverage

By the mid-1990s, limited efforts had been undertaken in the area of vitamin A deficiency control, primarily concentrated in areas affected by severe and clinically apparent deficiency and targeted to children less than two years of age through routine immunization contacts. To expedite progress, various concerned organizations, donors and leading technical experts met in an informal consultation in December 1997. The group stressed the importance of vitamin A supplementation as a reliable and effective way to combat vitamin A deficiency and to achieve rapid progress for child survival. The informal consultation also advised all countries with under-five mortality greater than or equal to 70 deaths per 1,000 live births to begin the distribution of vitamin A supplements immediately, regardless of whether the nation's vitamin A problem had been assessed, thus removing a constraint to progress.

 

 

In April 2007, UNICEF launched the Vitamin A Supplementation: A Decade of Progress report, which is a review of global advocacy efforts dated back to 1997.

 

 

 

 

 

 

 

 

 

30 PRIORITY COUNTRIES REACH 80 PER CENT OF CHILDREN WITH TWO DOSES ANNUALLY: Vitamin A supplementation coverage levels: two doses (2005)

Since then, rapid progress has been achieved. Past reports on progress have considered the total number of countries providing at least one round of vitamin A supplementation, achieving at least 70% coverage. In 1999, delivery of vitamin A capsules during National Immunization Days for polio eradication enabled 44 countries to attain this threshold - up from only seven countries achieving comparable coverage in 1995. Progress has been sustained through the present reporting year (2005), despite the phasing out of large-scale polio immunization campaigns in most areas of the world and other programmatic challenges.

Considering the official indicator for vitamin A supplementation - the proportion of children who have received at least one high dose supplement in the past six months - coverage levels have increased slightly at the global level, from 50% in 1999 to 75% in the most recent reporting year (2005). Global and regional coverage for 2005 are illustrated above, with the greatest proportion of children in the East Asia and Pacific region. Coverage in the least developed countries of the world is also quite impressive, at 77% on average. Many of these countries have far surpassed the minimal 70% coverage threshold and have been sustaining high coverage through model programmes for the past several years. Coverage estimates could not be calculated for other areas of the world due to unavailable data.

LEAST-DEVELOPED COUNTRIES LEAD THE WAY ON TWO-DOSE COVERAGE: 81 million children in these countries were reached in 2005 Percentage of children (age 6–59 months) receiving two doses of vitamin A, by region (2005)

 

 

Four-fold increase in the number of countries that are providing effective coverage

While the current supplementation indicator measures coverage with at least one dose, effective protection from deficiency and its consequences will require supplementation on a four to six month schedule. Ideally, coverage achieved in the second half of the year (as reported in UNICEF's The State of the World's Children report) would be comparable to that achieved earlier in the year and therefore truly representative of progress. However, coverage levels often vary widely from round to round due to changes in distribution mechanisms, or countries are unable to deliver a second annual dose at all. Examining the trends in countries delivering two rounds of supplementation (which more than doubled from 18 in 1999 to 69 in 2005), both reaching at least 70% coverage - considered "effective coverage" - reveals significant progress. Over the period 1999 to 2005, the number of priority countries providing effective levels of coverage has quadrupled.

MORE THAN A FOURFOLD INCREASE IN THE PROPORTION OF CHILDREN FULLY PROTECTED WITH TWO DOSES OF VITAMIN A: Global trends in vitamin A supplementation coverage (1999–2005)

While current monitoring tools cannot directly measure what proportion of those children covered are receiving both annual doses, we can approximate effective two-dose coverage using the series of assumptions described under "Monitoring Progress." Analysis of trends shows that although progress in augmenting coverage with one dose may be slow at the global scale, tremendous strides have been achieved in fully protecting children with the recommended two annual doses.

 

Vitamin A supplementation programmes have historically relied on National Immunization Days for polio eradication as a mechanism for delivering capsules to targeted children. Reliance on this linkage led to concern about programme sustainability as polio eradication goals were met and national immunization days for polio no longer needed in most areas. Interestingly, even as the phase-out of immunization days is nearly complete, countries are actually guaranteeing more delivery efforts for vitamin A capsules than in 2000, when immunization days were at their peaks. Considering all distributions carried out during the period of 1999 to 2004 in the 103 priority countries and the coverage achieved by those distributions, we are able to estimate mean coverage by delivery mechanism. This analysis clearly illustrates that the integrated delivery of vitamin A capsules with other child survival interventions has the greatest potential to reach the most at-risk children. While delivery of vitamin A through routine health services may be an effective strategy to reach children up to one year of age (i.e., in conjunction with immunization activities), distinct outreach events for delivering vitamin A and other child survival interventions will likely be necessary to ensure that all targeted children are protected from deficiency and its consequences.

Disparities in coverage

Although standardized monitoring surveys do not provide accurate coverage estimates - maternal recall is questionable as surveys are not conducted immediately following distribution of the vitamin - they are useful to explore any systematic differences in which children were reached. An analysis of disparity in vitamin A supplementation based on data from 22 countries with the latest MICS (2005 – 2006) survey results showed that there is no evidence of differential coverage between boys and girls.

Children in rural and poor families are more likely to be missed by supplementation

However, slight differences in coverage exist between children living in urban and rural areas. Rural children were more likely to have never received a vitamin A supplement than their counterparts in urban areas. A similar pattern appeared for wealth: children from poorer families were more likely never to have received vitamin A as compared to children from wealthier families.