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*
Department of International Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322 and
Institute of Human Nutrition, Columbia University, New York
2To whom correspondence should be addressed. E-mail: uramakr{at}sph.emory.edu.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONPROGRAMMATIC THEMESANNECY ACCORDSOTHER ISSUES: BIOLOGIC...LITERATURE CITED |
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KEY WORDS: • vitamin A deficiency • vitamin A deficiency disorders • programs • indicators • intervention strategies
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONPROGRAMMATIC THEMESANNECY ACCORDSOTHER ISSUES: BIOLOGIC...LITERATURE CITED |
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).
It was fitting that this landmark meeting for IVACG was held in Hanoi, Vietnam. Vietnam has been a success story in reducing VAD and xerophthalmia to below WHO cut-off points constituting a public health problem (2
). Moreover, it was able to do it at a time when resource constraints were very real (3
). As in several other countries that have achieved the same status, such as Bangladesh, Indonesia, and the Philippines, nonxerophthalmic VAD, as measured by serum retinol, remains a public health problem, but the successful model remains. The appropriateness of Vietnam as the venue was mirrored in the opening remarks of Deputy Prime Minister H. E. Pham Gia Khiem and by the welcoming address by Professor Do Nguyen Phuong, Minister of Health, Vietnam. Adding their congratulations, support and wishes for further success were the U.S. Ambassador and senior representatives of WHO, the World Bank, Food and Agriculture Organization of the United Nations (FAO) and UNICEF.4
Subsequent contextual presentations described the magnitude of VADD (1
) and the appeal of VADD prevention as a significant intervention for support by donors, including the U.S. Agency for International Development (USAID). A regional overview by UNICEF (4
) was supplemented by specific examples of Cambodia and the Philippines, complementing the Vietnamese, and other, experience.
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PROGRAMMATIC THEMES |
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TOPABSTRACTINTRODUCTIONPROGRAMMATIC THEMESANNECY ACCORDSOTHER ISSUES: BIOLOGIC...LITERATURE CITED |
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Two other broad topics received attention. First was the surprisingly large number of countries still quantifying or identifying that they have a VAD public health problem, e.g., Angola, parts of Brazil, Cameroon, Cape Verde, parts of China, Federated States of Micronesia, Ghana, Haiti, Iran, Jordan, Myanmar, Pakistan and Zimbabwe. Although not newly identified, of the 16 Economic Cooperation of West African States countries in western Africa, 14 are known to have a problem of VADD, and two are presumed to have a public health problem. Consequently, one could say all 16 of these countries have evidence or likely evidence of VADD. An estimate of lives saved by vitamin A intervention programs in those countries was around 60,000 young children and infants. The countries concerned and the cost of surveys in such countries suggested the potential usefulness of a surrogate measure for measuring a public health problem of VAD, and under-five mortality rate (U5MR) was discussed in this context.
The second main topic was the clear and compelling evidence of success in many countries classified as having a past problem of public health significance by WHO xerophthalmia criteria. Some countries can now describe how success has been achieved; as indicated, the host country, Vietnam, is one of the most compelling in this respect. A large measure of their success has been attributed to appropriate strategies integrated with the primary health care system, a successful social mobilization action, and a strong monitoring and supervision network (3
). Others that can claim to no longer have a public health problem of xerophthalmia include Bangladesh, parts of India, Indonesia and the Philippines. However, most still suffer from significant VADD, and none of the countries with an identified VAD problem can afford not to sustain and advance their programs.
Innovative programs
Of the five identified themes, it was clear that there is already considerable experience in post-NID interventions. This is important, as the addition of vitamin A capsules to the polio immunization national campaigns has been an important factor in the current high rates of vitamin A capsule coverage. The global program to eliminate polio has covered all countries, except where internal war has made such campaigns impossible. With such impressive coverage (consistently over 95% of the target young child population), the opportunity was seized to also distribute vitamin A capsules at least once a year. Coverage, as demonstrated in a number of posters, has been over 85–95% even in countries where access is difficult, as in much of western Africa. However, the polio campaign is scheduled to last only 5 y and has already come to an end in much of the world. The challenge being addressed is how to maintain such high coverage in the absence of NID. Some of the experience presented, such as in the Philippines, western Africa and Zambia, dated back to innovative programs that addressed the need to give a second dose after the first dose had been given with the annual polio immunization round. Countries that successfully reached children with supplements after their NID programs were completed included Bangladesh, Cambodia, Myanmar, the western African countries and the Philippines. Latin America did not use the NID approach much, partly because of earlier completion of their polio campaign. Many of the countries are using one of three approaches: vitamin A weeks, addition of vitamin A to routine immunization schedules (in some cases using outreach as in Cambodia), and Child Health Weeks twice a year where a range of child health interventions are offered. In addition to vitamin A capsules, these can include iron/folate supplements, immunizations, perhaps iodized salt and deworming (the Philippines also includes information on safe toys and oral hygiene) (5
). There are already some real successes with coverage around 85%. The recommended new guidelines for supplementation, especially with routine immunization contacts, will be helpful, as this becomes part of more country programs, such as Cambodia (6
). Another example of innovative supplementation was the promising Bolivian experience of promoting multivitamin and mineral supplements among women of reproductive age by using social marketing techniques (7
).
Integration of different strategies
One of the aspects of success that was identified was integration of different strategies (supplementation, food-based approaches of fortification and dietary diversification, public health interventions, education and empowerment and poverty alleviation). Although supplementation clearly is critically important, especially in countries with poor-quality diets and high rates of infectious disease, complementary activities are also frequently adopted. This may include Child Health Weeks; deworming and other primary health care efforts at regular health centers; and community interventions such as nutrition education, home gardening, and integrated small-scale ecosystems at a household level. An example of an integrated small-scale ecosystem is the improved VACVINA—i.e., the Vietnam Association of V (vuòn/garden), A (ao/pond), C (chuông/cattleshed) participants initiative in Vietnam (8
). Bangladesh, with input from Helen Keller International (HKI) and over 40 national nongovernmental organizations (NGO), now has home gardens feeding 700,000 families (9
). Although the low bioavailability of plant sources means it is unlikely that poor households can obtain all their vitamin A needs in this way, home gardens may play an important role in helping build some measure of household food security, reasonable nutritional status and empowered communities. This appears to be especially so for poor women. For example, evaluation of the HKI home gardening efforts showed increased intakes among women and children in program households in Nepal compared with nonprogram households (9
), whereas in Bangladesh improved vitamin A status based on biochemical measures was seen among women but not young children, even though the children also received high dose supplements (10
). Use of traditional foods as sources of ß-carotene may well have been underestimated—e.g., in Micronesia (11
) and Vietnam (12
).
Fortification of foods, such as flour in the Philippines and processed foods in countries throughout Asia, is becoming more common. Fortification strategies will be much informed by the programmatic and political experience and success of sugar fortification in Central America. It was also clear that the private sector will have a critical role in fortification and that public-private collaboration continues to be strengthened.
There is early experience with supplementation with multimicronutrients, particularly iron, folate and zinc. It is likely that by the time of the next IVACG meeting, results from operational research currently under way will be ready for presentation. Although staples may be fortified with just vitamin A (e.g., oil, sugar), most food vehicles are likely to be fortified with more than one micronutrient. Positive results were presented from efficacy trials that tested fortified products such as a multinutrient fortified beverage in Tanzania (13
), biscuits fortified with red palm oil in South Africa (14
) and sugar and oil in Central America (15
,16
). The results of stability trials with fortified sugar and vegetable oils were also encouraging (17
,18
).
Women’s risk of VAD
It was clear that women’s risk of VAD is now well recognized, especially their high rates of night blindness. This was proposed as a useful community-level indicator, but its use as a monitoring indicator is more limited. The question of whether improvement of women’s vitamin A status will reduce maternal mortality in deficient populations will receive attention as major national replications of the Nepal studies are completed in Bangladesh, Ghana and elsewhere. Programmatic experience with the recommendation to double the postpartum dose to two supplements of 200,000 IU of vitamin A will be reported at the next meeting. Increased experience with postpartum supplementation, and better calculation of the needs of women and their breast milk vitamin A levels will help elucidate the relationship between vitamin A status and maternal mortality.
Assessment of a public health problem and measurement of impact
Many countries have now achieved coverage rates of over 80% through NID and less impressive, but still high, rates through using other distribution methods—e.g., through health clinics (Posyandus) in Indonesia (19
). Not surprisingly, attempts to assess the magnitude of the impacts of programs have begun. Although it is understood that many childhood factors (e.g., disease, care, environment, and poverty) are all involved in high levels of U5MR, an early study from the Philippines has shown a distinct improvement (shift to the right in the frequency distribution) of plasma retinol values of those reached by the government program after 5 y of mass supplementation (20
). This is apart from the generally recognized role supplementation and other allied interventions have played in reducing the more florid expressions of VADD such as blinding xerophthalmia. In measuring impact, it is important to use appropriate sampling to measure activities that contribute to this improvement. At the local government level, there is also evidence of a positive impact [e.g., Nepal (21
), Philippines (5
,22
), and Vietnam (3
)]. It is also important that measurement of impact has a strong programmatic content so that results can be used to capture programmatic lessons learned, identify continuing pockets or larger areas of deficiency, and help governments and NGO partners target programs more effectively. Although coverage rates were often impressive, there was discussion about the need to agree on definitions of success (e.g., is one capsule in the past year a measure of success?).
Sustainability of VADD programs
One of the most important and recurring themes of the meeting was sustainability of VADD programs. With some of the lessons already learned, such as involvement of the community [e.g., local government units in the Philippines (5
,22
), female community health volunteers in Nepal (21
), and the women’s union in Vietnam (3
)], targeting hard-to-reach groups will become an important aspect of programs, as will the increasing role of fortification. It was also clear that supplementation will be a critical part of countries’ strategies over the coming years. Several key factors were identified: the need for governments to include community involvement in VADD programs, including procurement of capsules in national and local budgets, increased alliances with the private sector, specific attention to decentralized distribution systems and local government units, continued attention to logistics and distribution problems, and the role of partnerships with NGOs and academia.
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ANNECY ACCORDS |
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TOPABSTRACTINTRODUCTIONPROGRAMMATIC THEMESANNECY ACCORDSOTHER ISSUES: BIOLOGIC...LITERATURE CITED |
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). The results from this meeting were discussed at the Annecy meeting. Immediately before the IVACG meeting, participants from the Annecy meeting, with several others, met to review the suggestions that arose from that meeting. The resulting conclusions and recommendations for assessment and interventions were then discussed in open forum at the IVACG meeting. The salient features of the recommendations and discussion are presented in the following sections. Indicators of VADD
Revisiting and updating current knowledge and recommendations for indicators of VADD in public health programs was a major theme of this meeting. This was timely, because the last comprehensive agreement concerning these indicators was reached in 1982 (2
). Special attention was given to the presentation of innovative, less invasive and inexpensive methods, which are suited to field settings and are better measures of the spectrum of VADD. Some key characteristics of the indicators that were presented are improved measures of physiologic function, more practical and field based, simplified yet sophisticated and more comprehensive. Another contribution was discussion of the suitability of indicators based on their purpose—namely, for baseline assessment versus monitoring and evaluation.
Assessment of the magnitude of VADD. The following indicators were reviewed and discussed during the XX IVACG Meeting in the context of assessing the magnitude of VADD.
), the most important being that it was a proxy for various other nutrition and health conditions and lacked specificity. Many viewed it as one of several potential surrogate indicators. After discussion, the recommendation was made to use U5MR >50 as an easy tool for screening at the national level and to serve primarily as a trigger for advocacy and action.
). It is noninvasive, portable, quick (about 15 min per subject but requires smaller sample sizes than some other assessments) and does not require handling of biologic specimens. More importantly, it correlates well with other indicators of VADD such as serum retinol and night blindness; there is also evidence of response to treatment. However, it was noted that it may not be suitable for young children (<2 y) and that more work was needed to validate the proposed cut-off values (>-1.11 log cd/m2) for purposes of screening and evaluation.
). Christian presented data indicating that VADD is a public health problem if >5% of pregnant women reported having night blindness during their last completed pregnancy. Data from South Asia indicated a strong correlation between maternal night blindness and child xerophthalmia at subnational and household levels and with other indicators such as serum retinol and dark adaptation as well. A key advantage of this method is the smaller sample size requirements; however, it cannot be used for evaluating child-based intervention programs.
) concluded that serum retinol reflects the vitamin A status of the individual, especially when stores are limited. However, serum retinol is affected by infection and protein energy malnutrition (28
). A recommendation was made to simplify the earlier definition of VADD to "VADD is a public health problem if the prevalence of low serum retinol (<0.7 µmol/L) is >15%." High pressure liquid chromatography (HPLC) was recognized as the method of choice for serum retinol estimation, but issues remain such as the need for quality control and external controls for laboratories in developing countries. The description of the physiological functions of retinol-binding protein (RBP) with a mouse model (29
) clearly demonstrated the central role of this protein in the uptake and transport of retinol. Although RBP is much easier to measure because it requires less blood and has lower costs, it is also affected by protein energy malnutrition and infection. Differences in the level of RBP saturation with retinol lead to difficulty in recommending a cut-off value in assessment of VAD. The importance of assessing infection, especially subclinical infection, in obtaining valid estimates of VAD was demonstrated by Thurnham (28
), who conducted a meta-analysis of data from several studies with various levels of infection. Reductions of nearly 33 and 10–15% in serum retinol levels were attributed to current and recent subclinical infections, respectively.
Progress in the field testing and validation of blood spot methods for the assessment of retinol and RBP was promising (30
). Several posters displayed recent developments on the use of dried blood spots as a field-friendly method to assess the vitamin A status of populations by retinol and RBP (30
–32
) and monitoring vitamin A content of fortified foods (33
). Although the actual methods of assay still rely on traditional methods such as HPLC, these approaches are promising at least in the collection and transport of samples. Presenters also highlighted the need for quality control and monitoring the proficiency of laboratories in many developing countries (34
).
Monitoring and evaluation of VADD programs.
The role of both process and outcome indicators in monitoring and evaluating VADD programs was addressed. The selected outcome indicators include the traditional measures of xerophthalmia in young children, maternal night blindness, measurement of pupillary threshold and the biochemical indicators—namely, serum and breast milk retinol. Examples of their use both in research studies and, more importantly, in programs (for example, the fortification experience in Central America, Indonesia and the Philippines) were presented (35
). A major feature of these revised recommendations is the shift from clinical indicators that are increasingly rare and require large sample sizes to obtain valid estimates to the use of more functional indicators, which can be done with smaller sample sizes and, more importantly, capture the full spectrum of VADD. Presenters emphasized the value of examining shifts in serum retinol distributions, especially to track progress and monitor ongoing efforts in the prevention and control of VADD. In the case of process indicators, the roles of providers and consumers were discussed (36
). The importance of creating demand for the various interventions and integrating with other issues in the development agenda was emphasized.
Interventions for the prevention and control of VADD
Existing recommendations for supplementation and food-based approaches, including fortification and dietary diversification, were reexamined and critically evaluated. Presenters raised the scientific issues associated with human requirements of vitamin A and safety related to the proposed recommendations for high dose vitamin A supplements for infants and lactating women (37
). The need for combining various strategies to combat VADD was identified as a way to improve vitamin A intakes and minimize losses. The contribution of supplementation and fortification as public health approaches was examined and specific recommendations for future action were presented (38
,39
). The role of other food-based approaches was more controversial and generated much debate and discussion. Reexamination of bioavailability of vitamin A from plant sources (40
,41
) raised concerns about the adequacy of relying only on the promotion of provitamin A–rich foods, especially dark-green leafy vegetables, as a strategy. Key recommendations for the various intervention strategies are summarized in the following sections.
Supplementation.
Recommendations for prophylactic and therapeutic use of vitamin A supplements in the prevention and control of VADD are summarized by Ross (38
). IVACG endorsed recommendations made at the WHO meeting in Yverdon-les-Bains in 2000 (23
)—namely, to double the existing dose of prophylactic supplementation for i) infants < 6 mo of age (from 25,000 to 50,000 IU at the three routine Expanded Programme on Immunization contacts at 4, 10 and 14 wk) and ii) lactating women (from a single dose of 200,000 IU at delivery to two doses of 200,000 IU within 6 wk after delivery and 24 h apart).
The topic of routine prophylactic supplementation for pregnant women in deficient populations was also raised. Although existing data from a few research trials and kinetic calculations indicate that doses of <10,000 IU per day and <25,000 IU per week are safe and potentially beneficial (37
), IVACG decided it was still premature to make recommendations for pregnant women and to await the results of ongoing efficacy trials.
The existing recommendations for prophylactic supplementation of 100,000 IU and 200,000 IU every 4–6 mo for infants aged 6–11 mo and children aged 12–59 mo remain unaltered. Treatment regimens for infants, children, women of reproductive age and other groups have not changed. Finally, the need for prophylactic supplementation of refugees and internally displaced populations was also emphasized. Delivery channels for supplementation were discussed briefly and encouraging experiences with innovative approaches both within and outside the public health sector were presented at this meeting (38
).
Food-based approaches: fortification.
A major outcome of this meeting was the endorsement of fortification as a valid and much needed strategy to combat VADD in many developing countries. The advantages of food fortification as a highly cost-effective and safe intervention were presented through examples from various parts of the world with different staple foods (e.g., sugar, oil and flour) and food products (e.g., complementary foods, biscuits and margarine) (39
). A poster presented by Ash (13
) featured the additional benefits of simultaneous fortification with several micronutrients; the benefits included reduced anemia and improved child growth. The key conclusions were as follows: i) the need is to scale up from field projects to national programs, ii) the main barriers to successful fortification programs are human rather than technological, and iii) effective public–private collaboration is central to success in the prevention and control of VADD. Such collaboration recognizes that although each of these sectors has different objectives, they have common ground and their relationship must be based on trust. Specific recommendations were also made for increasing efforts toward developing international, regional and country agendas to foster food fortification in countries with VAD.
Food-based approaches: dietary diversification.
The adequacy of the dietary supply of vitamin A in developed and developing countries was examined in terms of patterns of consumption and of estimates of the bioefficacy of conversion of provitamin A compounds, especially ß-carotene to retinol. In developed countries, where VADD are uncommon, >60% of vitamin A intake comes from preformed retinol in animal-based food products, fortified foods and pharmaceutical supplements (37
,40
). This is not the case, however, in many developing countries, where plant foods are the primary sources of vitamin A. Furthermore, recent data from Wageningen, The Netherlands; Bogor, Indonesia; and Hanoi, Vietnam (40
) demonstrate the inaccuracy of the previously accepted conversion factor of 6:1 (6 µg of dietary ß-carotene = 1 µg of retinol or retinol activity equivalent, RAE) used in the FAO/WHO 1988 recommendations. This conversion led to gross overestimation of the available dietary vitamin A supply, especially in developing countries. The revised conversion factors presented were 26:1 and 12:1 for ß-carotene from dark-green leafy vegetables and from fruits and tubers, respectively, and 21:1 for a mixed diet with a 4:1 ratio of vegetables to fruits (40
). Even in the United States, where VADD is not a problem, the Institute of Medicine revised the conversion factor for dietary ß-carotene from 6 to 12 in 2001, based on studies conducted in healthy and nutritionally adequate individuals. Thus, "average" vitamin A intakes in developing countries in Africa (528 RAE), South America (440 RAE) and Asia (381 RAE) are clearly inadequate because they fall below the recommended level of 600 RAE/d when the conservative revised conversion factor of 12 µg of ß-carotene for 1 µg of retinol is used.
Miller et al. (41
) reviewed vitamin A requirements and concluded that young children in developing countries become vitamin A deficient primarily because their mothers are deficient, their dietary intakes are low in available vitamin A, and they are sick frequently. Young children in many developing countries are likely to have zero vitamin A stores by 4–5 mo of age, as all children are born with low stores (1700 µg), suffer considerable losses due to being ill at least 10% of the time and receive low levels of vitamin A from breast milk because their mothers are deficient. To overcome deficiency and maintain minimum adequate levels of liver vitamin A (20 µg/g) with fruits and vegetables alone, the young child would have to consume almost 10 times the normal portion of fruits and vegetables, particularly for seasonal foods like mangoes.
Based on the above findings, promotion of plant-based foods alone will not suffice for the prevention and control of VADD in young children. Therefore, recommendations for dietary diversification include promoting and supporting breast-feeding, because breast milk is an excellent source of preformed retinol (assuming maternal adequacy); promoting the consumption of animal foods if feasible; increasing the carotenoid content of staples; and combining dietary improvement with other approaches such as fortification and supplementation. The suggestion that dietary approaches alone are inadequate in the prevention and control of VADD in developing countries generated considerable discussion. Participants discussed the evidence of successful intervention strategies that have used dietary approaches such as home gardening. However, the final consensus was that dietary approaches are not being discarded as an intervention approach for VADD; instead, there is a recognition of the limitation of promoting intake of only plant-based sources of vitamin A in overcoming VADD. Therefore, there is a need for a well-integrated mix of intervention strategies that include food-based approaches to improve overall dietary quality, food fortification, supplementation and public health measures as appropriate.
Biotechnology.
Conference participants also addressed the emerging role of biotechnology as an innovative and cost-effective solution to increase dietary vitamin A intakes (42
). An applied example is golden rice. This genetically modified staple has high ß-carotene content, and its use is considered a potential way to combat VADD in India. Simulations with existing data on food consumption patterns indicated that, although golden rice may meet almost 60% of the recommended daily allowance of ß-carotene for adults, it will be much lower (6–12%) in infants and young children who consume small quantities of rice. It does however have the potential to increase levels of vitamin A in breast milk. Plant breeders are developing other transgenic crops, but more research is needed in the areas of biodiversity, biosafety and efficacy. Other issues raised by participants include intellectual rights, political support, regulations, impact on farmers and the need for collaboration between nutrition scientists and plant breeders.
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) presented preliminary results from a mortality trial in southern India. To date, this trial indicates a 20% reduction in infant mortality after dosing newborns with 50,000 IU of vitamin A on the first 2 d of life. Results from the Nepal intervention trial, which found dramatic reductions in maternal mortality, also showed that the response to vitamin A supplementation during gestation was modified by maternal anemia for low neonatal weight. In the Nepal intervention trial, improvements were seen only among nonanemic women (44
); nonpregnancy-related mortality was also reduced among younger (<20 y) and older (>40 y) women (45
). A study by Brabin (46
) demonstrated the increased vulnerability of adolescent girls to VAD. This was related to variations in estrogen and other sex hormones.
Several posters examined the relationship between vitamin A and human immunodeficiency virus (HIV). Results from an antenatal vitamin A supplementation trial among HIV-positive women in South Africa found that, although there were no improvements in maternal or infant vitamin A status, HIV-positive infants in the vitamin A group had a reduced inflammatory response compared with those who received a placebo (47
,48
). A study among Ugandan adults found no evidence to support the hypothesis that vitamin A supplements early in HIV disease decrease the rate of disease progression (49
).
In the final session, Paul Arthur reviewed research priorities for addressing VADD. These priorities were suggested during the meeting through a questionnaire completed by the meeting participants, including researchers (41%), people working on programs (39%), people representing U.N. agencies or bilateral organizations (16%) and funders (4%). Over half those who completed the questionnaire identified the following areas as needing more research:
Research priorities raised by program people also included post-NID strategies for supplementation, sustainability of supplementation programs, toxicity when several programs are concurrent, simpler assessment methods and program monitoring. Researchers expressed interest in understanding interactions between vitamin A status and infections, including helminths and vitamin A related to the health of women. Donors were interested in questions about whether it is best to supplement all women of reproductive age or to target pregnant women, post-NID strategies for supplementation and tackling poverty alleviation.
Carol Bellamy, Executive Director of UNICEF, addressed the closing plenary session, assuring the audience of a continued commitment to eliminating VAD as a public health problem by UNICEF and other international agencies. She further reminded participants of the dramatic progress that has been made, paid tribute to donor governments and called on all governments and their citizens, communities, civil society organizations and the private sector to join in this and other efforts to give every child a better future.
In his closing remarks, Alfred Sommer thanked the speakers and participants for a rich discussion of the progress made in controlling VADD. Sommer said the XX IVACG Meeting provided an opportunity to "scrape the barnacles clean" from the vitamin A recommendations of the past 25 y and "build the vitamin A agenda anew focusing on what works." The overall message of the meeting was of real progress in programs with considerable experience on which to draw, but there is a continuing need for innovation and attention to sustainable programs. It was clear that these programs need to integrate community food-based approaches and other poverty-alleviating measures with supplementation and other public health interventions directed not only to young children but also to women. Interventions, both locally and nationally, need to continue using public and private partnerships that have proved successful. The big challenge is choosing the optimal mix of interventions most suitable to the current and future needs of individual countries. In terms of research, the significance of VADD for maternal and neonatal health, biologic interactions with other nutrients and infections, evaluation of integrated approaches and further refinement and validation of better indicators of vitamin A status all require urgent attention.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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3 Abbreviations used: FAO, Food and Agriculture Organization of the United Nations; HIV, human immunodeficiency virus; HKI, Helen Keller International; HPLC, high pressure liquid chromatography; IU, international units; NGO, nongovernmental organization; NID, national immunization days; RAE, retinol activity equivalent; RBP, retinol-binding protein; U5MR, under-five mortality rate; UNICEF, United Nations Children’s Fund; USAID, U.S. Agency for International Development; VACVINA, The Vietnam Association of V (vuòn/garden), A (ao/pond), C (chuông/cattleshed); VAD, vitamin A deficiency; VADD, VAD disorders; WHO, World Health Organization.
4 These remarks were made by Dr. Tran Trong Hai, Master of Ceremonies; Mr. Pham Gia Khiem, Vice-Prime Minister of Vietnam and Prof. Do Nguyen Phuong, Minister of Health of Vietnam on behalf of the local organizing committee; The Honorable Douglas B. Peterson, U.S. Ambassador to Vietnam; Dr. Linda Milan, WHO; Dr. Milla McLachlan, The World Bank; Dr. Biplab K. Nandi, Food and Agriculture Organization of the United Nations; and Mr. Morten Giersing, UNICEF.
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LITERATURE CITED |
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1. West, K. P., Jr. (2002) Extent of vitamin A deficiency among preschool children and women of reproductive age. J. Nutr. 132:2857S-2866S.
2. WHO (1982) Control of vitamin A deficiency and xerophthalmia: report of a joint WHO/UNICEF/USAID/HKI/IVACG Meeting. WHO Technical Report Series 672 1982 WHO Geneva, Switzerland. .
3. Khan, N. C. (2001) Vitamin A deficiency control program in Vietnam: situation, policy, and program. Presented at XX IVACG Meeting, Hanoi, Vietnam, Feb. 12, 2001 2001.
4. Atwood, S. (2001) Regional overview: vitamin A status and interventions. Presented at XX IVACG Meeting, Hanoi, Vietnam, Feb. 12, 2001 2001.
5. Paulino, L. S. (2001) Garantisadong pambata: the Philippine strategy of vitamin A supplementation to eliminate vitamin A deficiency. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
6. Panagides, D. (2001) Vitamin A deficiency in Cambodia: findings of the first national micronutrient survey. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
7. Warnick, E. (2001) Can social marketing of multivitamin/mineral supplements reach low income women? Lessons from Bolivia. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
8. Giay, T. (2001) VAC system in Vietnam—the solution to poverty alleviation, diet improvements, and the prevention of malnutrition and micronutrient deficiency. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
9. Talukder, A. (2001) Performance of NGO gardening programs in Bangladesh after withdrawal of HKI’s support. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
10. Fuchs, G. (2001) Impact of the HKI home gardening programme on VA status in Bangladesh. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
11. Englberger, L. (2001) Identification and promotion of new food sources of provitamin A in Micronesia. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
12. Vuong, L. T. (2001) A food-based approach to prevention of vitamin A deficiency: household production of ß-carotene rich oil from an indigenous fruit. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
13. Ash, D. (2001) Field trial of a micronutrient fortified beverage to improve the vitamin A status and micronutrient status of pregnant women in Tanzania. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
14. van Stuijvenberg, M. E. (2001) The effect of a biscuit with red palm oil as a source of ß-carotene on the vitamin A status of primary schoolchildren. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
15. Dary, O. (2001) Free-trade vs. public health: the history of fighting for sugar fortification program in Guatemala. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
16. Navas, G. (2001) Multisectorial efforts of the Nicaraguan society lead to sugar fortification with vitamin A. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
17. Kakuda, Y. (2001) Vitamin A stability in fortified vegetable oils. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
18. Sirohi, S. S. (2001) Fortification of sugar with vitamin A: an India experience. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
19. Hadju, V. (2001) Opportunities to improve the effectiveness of posyandu in Indonesia to deliver vitamin A supplementation, counsel mother and provide basic health services. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
20. Madriaga, J. R. (2001) Do pre-school children who have participated in the 1998 high-dose vitamin A supplementation program differ nutritionally from those who did not? XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
21. Shrestha, R. K. (2001) Sustaining a successful supplementation program: hidden factors in Nepal’s NVAP experience. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
22. Sandrino, C. B. (2001) Maintaining high vitamin A capsule coverage in a devolved health care system. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
23. WHO (2001) Vitamin A supplementation. Report of an informal consultation, March 1–3, 2000, Yverdon-les-Bains, Switzerland 2001 WHO Geneva, Switzerland. .
24. Schultink, W. (2002) Use of under-five mortality rate as an indicator for vitamin A deficiency in a population. J. Nutr. 132:2881S-2883S.
25. Congdon, N. G. & West, K. P., Jr. (2002) Physiologic indicators of vitamin status. J. Nutr. 132:2889S-2894S.
26. Christian, P. (2002) Recommendations for indicators: night blindness during pregnancy—a simple tool to assess vitamin A deficiency in a population. J. Nutr. 132:2884S-2888S.
27. de Pee, S. & Dary, O. (2002) Biochemical indicators of vitamin A deficiency: serum retinol and serum retinol binding protein. J. Nutr. 132:2895S-2901S.
28. Thurnham, D. I. (2001) A meta-analysis of data from 15 studies to quantify the effects of sub-clinical infection on plasma retinol. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
29. Blaner, W. S. (2001) Retinol binding protein (RBP): essential physiologic functions. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
30. Craft, N. E. (2001) Can dried blood spot retinol be used to assess vitamin A status? XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
31. Erhardt, J. G. (2001) Rapid and simple measurements of retinol in plasma from skin puncture blood and dried whole blood spots. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
32. Hix, J. (2001) Development of a rapid enzyme immunoassay for the detection of retinol binding protein (RBP-EIA). XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
33. Craft, N. E. (2001) Application of the CRAFTi portable fluorometer to the analysis of vitamin A in fortified foods. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
34. Brouwer, J. T. (2001) Proficiency test for laboratories measuring retinol and carotenoids in serum, 1999–2000. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
35. Wasantwisut, E. (2002) Recommendations for monitoring and evaluating vitamin A programs: outcome indicators. J. Nutr. 132:2940S-2942S.
36. Bloem, M. W., Kiess, L. & Moench-Pfanner, R. (2002) Process indicators for monitoring and evaluating vitamin A programs. J. Nutr. 132:2934S-2939S.
37. Allen, L. H. & Haskell, M. (2002) Estimating the potential for vitamin A toxicity in women and young children. J. Nutr. 132:2907S-2919S.
38. Ross, D. A. (2002) Recommendations for vitamin A supplementation. J. Nutr. 132:2902S-2906S.
39. Dary, O. & Mora, J. O. (2002) Food fortification to reduce vitamin A deficiency: IVACG recommendations. J. Nutr. 132:2927S-2933S.
40. West, C. E., Eilander, A. & van Lieshout, M. (2002) Consequences of revised estimates of carotenoid bioefficacy for dietary control of vitamin A deficiency in developing countries. J. Nutr. 132:2920S-2926S.
41. Miller, M., Humphrey, J., Johnson, E., Marinda, E., Brookmeyer, R. & Katz, J. (2002) Why do children become vitamin A deficient?. J. Nutr. 132:2867S-2880S.
42. Toenniessen, G. H. (2002) Crop genetic improvement for enhanced human nutrition. J. Nutr. 132:2943S-2946S.
43. Tielsch, J. M. (2001) Impact of vitamin A supplementation to newborns on early infant mortality: a community-based, randomized trial in South India. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
44. Dreyfuss, M. L. (2001) Vitamin A supplementation reduces the risk of low neonatal weight among non-anemic women in Nepal. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
45. Pradhan, E. K. (2001) Impact of vitamin A and beta carotene on non-pregnancy related, female mortality in rural Nepal. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
46. Brabin, L. (2001) Sex hormone patterns and serum retinol concentrations among Nigerian adolescents. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
47. Mburu, A. S. W. (2001) Acute phase proteins may be early predictors of seroconversion to human immunodeficiency in infants of HIV + women. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
48. Mburu, A. S. W. (2001) Efficacy of vitamin A (VA) supplements and plasma factors influencing maternal and infant VA status in human immunodeficiency virus positive (HIV +) women and their infants. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
49. Ross, D. A. (2001) Vitamin A status in early HIV infection and subsequent rate of HIV disease progression in Ugandan adults. XX IVACG Meeting poster, Hanoi, Vietnam, Feb. 12–15, 2001 2001.
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