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					Indian Journal for the Practising Doctor
Ethical Issues in Vitamin A Supplementation in
Author(s): Kapil, U

Vol. 4, No. 4 (2008-09 - 2008-10)

Review Article

Kapil, U

Dr Umesh Kapil, MD, PhD, Professor, Department of Human Nutrition, All India Institute of Medical
Sciences, New Delhi

Correspondence: Prof Umesh Kapil, Department of Human Nutrition, All India Institute of Medical
Sciences, Ansari Nagar, New Delhi-110029 (India). [E-mail: umeshkapil (at)]

In India, Vitamin A deficiency (VAD) was a major public health problem during the 50‘s and the 60‘s.
Presently, it remains a public health problem only in selected geographical pockets of the country. Although,
VAD can occur in any age-group but the most serious effects are usually seen in children 6-36 months of
age, as this is a fast growing period and the dietary intake of VA is low. Also, illnesses such as diarrhea,
acute respiratory tract infection and measles, which deplete vitamin A reserves, are more frequent. The
severe deficiency of vitamin A with corneal involvement leading to blindness in children is now rarely seen
as the precipitating diseases like diarrhea, ARI and measles are now more effectively prevented and
controlled because of the improved coverage of primary health care services in the country. This paper
describes the VAS activities undertaken during recent years for prevention and control of VAD in India and
the possible reasons of episode of VA-related deaths in the Assam state of India and other related public
health concerns

Current situation of VAD?

Clinical deficiency: Severe deficiency of vitamin A is known to produce corneal xeropthalmia/ keratomalacia
and blindness in children. Such cases are rarely seen in a community survey and require a large sample
size for accurate estimates of prevalence. Hospital records show a significant decline in keratomalacia
                               1                                     2
cases in the last two decades and clinicians report similar trends . However, clinical signs of mild
xeropthalmia, like Bitot‘s spots and night blindness, are still seen among children in deprived communities.
The first repeat survey of the National Nutrition Monitoring Bureau (NNMB) conducted during 1988–1990, in
the same villages as those surveyed earlier during 1975–1979, showed that the prevalence of Bitot‘s spots
had declined from 1.8% to 0.7%3. Yet, the 2nd repeat survey conducted in 1996–1997 showed no further
improvement4 and the prevalence is still above 0.5% (Table I) – the WHO cut-off level for labeling VAD a
public health problem. The national averages do not give a full picture because the prevalence rates vary
widely, not only between the states but also within a given state.
Table 1: Percent Prevalence of Bitot‘s Spots in Preschool Children

                         1975-79 1988-90
                         n=12775) (n=11535)
Andhra Pradesh           3.1             1.0
Gujarat                  0.9             0.5
Karnataka                2.3             1.1
Kerala                   0.1             0.5
Madhya Pradesh 0.4                       NA
Maharashtra              0.4             0.3
Orissa                   1.5             1.1
Tamil Nadu               2.9             0.6
Pooled data              1.8             0.7

Source: National Nutrition Monitoring Bureau, Report of Repeat Surveys (1988-90)

India Nutrition Profile (1999) is often quoted to show low prevalence of clinical deficiency in the population .
In a few states like Haryana, Assam and Orissa, for which the data on preschool children are given
separately, the prevalence is relatively higher. A survey in five north-eastern states (Assam, Bihar, Orissa,
West Bengal and Tripura) showed the prevalence of Bitot‘s spots to be 0.7–2.2% and that of night blindness
1.2– 4.0%, indicating VAD to be a public health problem in all the five states . The survey also showed high
prevalence of night blindness among pregnant women (3.2– 16%). The district-wise data collected in Uttar
Pradesh showed Bitot‘s spots in 5.6% of children . There was a wide variation in the prevalence between
the districts and even within a district from cluster to cluster, ranging from 0.2% to 13.7%.

A survey of the Indian Council of Medical Research (ICMR, 1998) covering 16 districts, mostly in northern
and eastern regions, showed that the prevalence of Bitot‘s spots ranged from 0–4.7% and that of night
blindness from 0.4–4.8% Table II. All the available clinical and biochemical indicators are subject to
limitations and therefore WHO has recommended that at least 2 indicators should be used for assessing the
vitamin A status of a population .

Table II: Prevalence of Vitamin A Deficiency Disorders in Children (<6 Years)

REGION Name of district Number of children Bitot’s spot No (%)
              Mandi                     10589                           NIL
              Dehradun                  8912                            NIL
              Badaun                    10782                           NIL
              Mainpuri                  5562                            1 (0.02)
              Baramulla                 10766                           3 (0.03)
              Srinagar                  9713                            4 (0.04)
              Lakhimpur Kheri 11026                                   51 (0.46)
              Bikaner                  10730                          118(1.10)
              Bishnupur                11068                          7 (0.06)
              Kohima                   11079                          27 (0.24)
              Dibrugarh                10754                          32 (0.30)
              Nagaon                   10696                          32 (0.30)
              Patna                    10739                          334 (3.11)
              Gaya                     10711                          505 (4.71)
SOUTH         Mehboob Nagar            10343                          38(0.37)
WEST          Raigarh                  11042                          3 (0.03)
ALL DISTRICTS                          164512                         1155(0.70)

Sub-clinical deficiency: In communities where clinical signs of VAD are seen, subclinical deficiency can be
expected to be more common. Large-scale data on serum retinol levels are not available to assess the
                                                                                           9            10
extent of biochemical deficiency. But the community studies carried out in Andhra Pradesh , Tamilnadu
and Uttar Pradesh indicate that 30–50% of children have retinol levels below 20 μg/dl – the WHO cut-off
indicating a public health problem. These observations are corroborated by the dietary data. Green leafy
vegetables, milk and milk products are the major sources of vitamin A in Indian diets. Surveys carried out in
different parts of the country show a low consumption of these foods . The average intake of vitamin A is
around 300 μg in women and 120 μg in children, and more than 80% have intakes less than 50% of the
recommended dietary allowance (RDA) .

Thus, the available data show that, although the severe forms of blinding malnutrition have declined in the
last two decades, milder grades of VAD still exist in many parts of India.

Reasons of Decline in VAD – During the last 40 years indicators of child health have registered significant
positive gains in India. The prevalence of severe protein energy malnutrition has come down from 15%
(1975) to less than 2% in (2000). Also, the immunization coverage for measles and other vaccine
preventable diseases has improved from 5-7% in early 70s to 80-90% currently. Similarly, there has been a
significant improvement in the dietary intake of vitamin A rich foods. The health infrastructure has improved,
leading to better treatment facilities and a decrease in the overall burden of morbidity among children. The
percentage of population below poverty level has also reduced.

The GOI has addressed the issue of food insecurity quite diligently. The Integrated Child Development
Program, which covers 90 per cent of the rural India, provides nutritional supplements to children less than
six years of age, nutrition education to mothers and vitamin A supplements.

Evolution of VA supplementation in India

The National Programme for Prevention of Nutritional Blindness was started in 1970 with the specific aim of
preventing nutritional blindness caused by vitamin A deficiency leading to keratomalacia . To begin with,
this programme was initiated in 11 states of the country. The evaluation studies conducted by the National
Institute of Nutrition, Hyderabad (NIN) in 1976 in 2 states showed positive results of the programme,
however, a subsequent evaluation in 1978 in 13 states by NIN revealed that the programme had many
deficiencies in its implementation. The NIN study documented that, in areas where the vitamin A
administration was carried out, the prevalence of eye signs of vitamin A deficiency were reduced. In
subsequent years, the programme was extended to all states in the country .
In 1994, under the National Child Survival and Safe Motherhood Programme (CSSM), the Vitamin A
Prophylaxis Programme was modified keeping in view of the vulnerability of young children. It was
recommended that priority should be given to children in the age group of 9 months to 3 years, and that
each child should receive 5 doses of vit A before her 3rd birthday16.

Age Dose

6-11 months One dose of one Lakh International Unit
1- <3 years One dose of Two Lakh International Unit every six months

Under the new strategy a component of therapeutic administration of vitamin A was added to the
programme possibly because many scientific studies reported positive role of vitamin A supplementation in
reducing the risk of mortality particularly in children suffering from measles, diarrheoa and ARI. Accordingly,
the therapeutic doses of Vitamin A were included to be given to the following children: i) Those with eye
signs of VAD ii) Those suffering from night blindness and iii) those suffering from diarrhoea, measles and
ARI with eye signs of VAD

Presently, Vitamin A Supplementation (VAS) is done through the existing network of primary health centres
and sub-centres. The female multipurpose worker and other paramedics at the village level sub-health
centres are responsible for administering Vitamin A solution. The services of ICDS functionaries are utilized
for the implementation of the programme. Monthly intensive drives are undertaken every six months to have
coverage of the children which could not be covered during the routine health care visits of the health
functionaries, to have a 100% coverage. Under the Reproductive Child Health (RCH) programme, six bottles
of vitamin A concentrate are provided every six months to cover all children in 5,000 population.

In the year 2000, Ministry of Health and Family Welfare, Government of India, decided that

   i.    synthetic Vitamin A supplementation should not be linked with Pulse Polio Immunization,
  ii.    the screening of children for clinical symptoms and signs of VAD in children should become part of
         the primary health care,
  iii.   all children with clinical VAD should be treated as per the schedule recommended under the
         Reproductive and Child Health Program (All children suffering from measles should be given one
         dose of Vitamin A if she/he has not received it during the preceding 1 month,
  iv.    all children with severe protein energy malnutrition, based on weight for age criteria or clinical
         nutritional signs should be given one additional dose of vitamin A and
  v.     no additional dose of Vitamin A is required for children suffering from diarrhea or respiratory tract
         infections .

VA Supplementation in Assam, India in 2001

The GOI recommendation state that VAS should be done in children in the age group of 6 – 36 months,
should be fed as part of the routine primary health care, and the campaign mode should not be utilised for
VA distribution. However, in the Assam state of India, on a single day, (11 November 2001), health workers
administered VA to 3.2 million children. The mass administration of syrup was part of the UNICEF‘s vitamin
A campaign, to reduce VAD among children. On the same day, about 1,000 children who were administered
the syrup fell ill, showing symptoms of vitamin A toxicity, including vomiting, nausea and headache. Children
in the more remote villages were unable to access medical care in time. There were fatalities; according to
the GOI report, 15 of these were in the 1-3 year age group. Significantly, two cases were outside the target
group – seven-month-old infant and a five-and-a-half year old child         .

Geo- Climatic and demographic Profile of Assam – Assam is situated in the far, North-Eastern corner of
India. The total geographical area accounts for about 2.4 per cent of the country‘s total land. The State has
two distinct natural regions, viz., the Brahmaputra Valley (comprising of 18 plain districts and two hill
districts) and the and the Barak Valley (comprising of three plain districts). According the 2001 Census, the
population of Assam stood at 26,638,407 with the decadal growth being 18.85 per cent during the preceding
decade. During the year 2002, the birth rates, death rates and infant mortality rates of Assam have been
26.6, 9.2 and 70 per 1000. Assam produces some of the finest and the most expensive teas in the world.
Assam also produces crude oil and natural gas.
VAD situation in Assam – The state level data is not available, however, the Indian Council of Medical
Research, in 1999, conducted a survey in two districts (Dibrugarh and Nagaon) and found that VAD was not
a public health problem. Only 0.3% of children had Bitot‘s spot – a marker of vitamin A deficiency.

Deviations made during VA supplementation campaign in Assam –

i) In 2000, the GOI made specific recommendations that the VA should be administered to children (9 to 36
months) as a part of the routine health care services and campaign mode should not be adopted. Contrary
to these recommendations, in Assam, the VA supplementation was done in a campaign mode and given to
all children in the age group of 6 – 60 months as if there was an acute outbreak of VAD in the state.

The campaign approach for distribution of vitamin A is not recommended as it creates the culture of
perpetual dependence on the health infrastructure for receipt of vitamin A for control of VAD. Also, all the
efforts of the health functionaries are more on delivery of vitamin A doses to achieve the targets allotted to
them rather than giving health and nutritional education to mothers of the beneficiaries for consumption of
vitamin A rich foods .

All types of village level functionaries (trained/untrained) participate in the campaign approach for
administration of VA. In a mass campaign where the object is to ―capture‖ as many children (and to push in
as much vitamin A) as possible, the common precautions cannot be adhered to. Also, in a campaign
approach of administration of VA, the routine health care activities of the workers get disrupted, and the
mothers are not usually counseled for improving the dietary intake of vitamin A in their children, which is the
`main stay‘ of the National Programme.

Traditional Bottle and spoon

                                            New cup and Bottle

A study conducted in the Orissa State, India earlier documented that wherever VA was linked with pulse
polio immunization, with large resources and inputs from an International organization, more than 52% of the
mothers did not know that the solution administered to their children was vitamin A, indicating poor health
education activities undertaken in a campaign mode. The same study reported that despite a well-organized
campaign approach, about 21.4% infants who were ―not‖ the eligible beneficiaries, received vitamin A7.

iii) UNICEF replaced the traditional 2 milliliter spoons with 5 milliliter cups to pour out vitamin A for the
campaign. The 2 ml spoon was being used by health workers for the last 30 years in the programme. This 5
ml cup was introduced by the UNICEF (India) without concurrence of the GOI. The workers were not trained
about the use of these 5 ml cup. This, theoretically, allowed delivery of up to 500, 000 IU (275 mg retinyl
palmitate) of vitamin A in a single dose, to a child (if the 5-ml cup was filled and administered to the child).
This constituted the administration of the largest single dose of vitamin A to children unprecedented in the
annals of human health-care .

The Judicial Enquiry of VA- related deaths – The deaths of children in Assam related to VA in 2001 were
referred to the judiciary. The Guwahati High Court of Assam, India, ruled that both the United Nations
Children‘s Fund (UNICEF) and the government of Assam are to be blamed for the death of more than 20
children who were given vitamin A in the State. A 2-judge bench of the High Court pronounced its verdict in
a PIL filed by 2 Assam residents against the state government and the UNICEF. The court ordered the state
government to pay compensation to the families of the children who died, at the rate of 20,000 rupees
(US$400) in addition to the paltry 5000 rupees (US$100) that each family had already been paid. The Chief
Justice, PP Navlekar, and Justice AH Saikia, said in their judgment that UNICEF had introduced stronger
doses of vitamin A by replacing the traditional 2-ml dosing spoon with 5-ml medicine cups. The Court
observed that the health workers involved were not properly trained and briefed and had administered
higher doses than many of the sick children could tolerate. The judgment mentioned that there was an
element of negligence in the way the Assam health department had administered the vitamin A, and that the
negligence led to the death of many children .

Investigation the Assam Human Right commission (AHRC) – The Assam Human Rights Commission
(AHRC) investigated the VA-related deaths in Assam and considered two questions: One was whether the
deaths were coincident with vitamin A administration, and not due to vitamin A – a view expressed by some
experts, given the high under five mortality rate (U5MR) in Assam. The second question was whether there
was any violation of human rights by any public servant, and if so what steps should be taken by the

In order to substantiate the theory of coincidence, in his submission to the Commission, the Director of
Health Services, Assam, had provided a statement detailing the cases of 31 children who died in the first
week after the day of the campaign. Of these eight had not received vitamin A. After considering the causes
of death from a medico-legal perspective, the Commission rejected this premise on the grounds that the
signs and symptoms preceding the deaths of several children were attributable to vitamin A toxicity or
allergy, and distinct from other causes of common poisoning.

Further, a forensic examination of the viscera (stomach, kidney and liver) of two cases (aged 2 and 3 years
respectively) was positive for vitamin A poisoning. The Commission also said that the opinions of the experts
were too theoretical and could not be accepted in the context of the case. Based on these considerations,
the Commission‘s Report argued that there exists a strong prima facie case that some of the children died
owing to vitamin A administration.

The Commission‘s conclusion with regard to the second question pointed out that the pamphlet (in
Assamese) distributed to the health workers as part of the training did not contain any warning to the
workers and the parents or guardians of the children about the possible side effects of high dose vitamin A.
Also, the training did not give any consideration to the health status of the child and the pamphlet did not
caution workers against giving vitamin A to sick or ailing children. Nor did it indicate whether vitamin A
should be administered to a child suffering from chronic vitamin A toxicity, as even 2 ml may be a mega
dose in such a case. Vitamin A may have precipitated the death of children already suffering from
gastroenteritis, viral fever and other childhood diseases, the report said.

The Commission (AHRC) pointed out that, significantly, the leaflet also did not warn the workers against
exceeding the 2 ml limit while measuring out with a 5 ml cup. The supervision provided, in the form of one
doctor for 10 booths, was also not sufficient to ensure safe administration.

One of the suspected causes for the deaths was the unilateral switch by UNICEF to the use of a 5 ml
dispenser. The Government of India‘s stated norm is a 2 ml dose. The dispensing health workers were
reportedly not warned of this or trained adequately. The Report, took cognizance of the fact that a change in
methods of dispensing in some areas might have resulted in the administration of a higher dose and that
some children may have suffered side effects due to the plastic cup measuring out a mega dose.
The deaths of children after administration of VA in Assam raised many concerns in the delivery of public
health services in the country:

i) The episode of VA-related deaths in Assam led to an erosion of public confidence in government
healthcare programmes and caused a serious setback to the pulse polio campaign for 2-3 years. The
parents refused the OPV immunization during the PPI campaigns due to fear of adverse effects.

ii) Many years following the Assam episode, many public health care activities in the country got curtailed.

iii) The health functionaries stopped administering the VA doses in the country.

iv) UNICEF withdrew the 5 ml cup for distribution of VA from the states where the UNICEF- sponsored
supply of VA were made. The 5 ml cup had been introduced first in Assam for campaign mode.

Current Issues on Vitamin A supplementation
Limitations of the Current VAS Strategy- The following are the major limitations of the VAS strategy
practiced in India

i) Universal supplementation of VA to children is being undertaken irrespective of the socioeconomic
considerations. Although, there is limited justification for universalisation of VAS, as the data collected in
various national surveys indicate that the VAD was limited to isolated geographical pockets in the country.
The highly exaggerated reports of the magnitude of ―nutritional blindness‖ in the country suggesting that
blindness due to vitamin A deficiency is a major public health ―emergency‖ needing immediate drastic
solutions has never been substantiated by the scientific evidence. Also, the adequate data on the functional
benefits of the VAS (with massive dose of VA) to young children who are not suffering from clinical VAD is
not available.

ii) The mega dose of vitamin A (200,000 IU) is 165 times higher than the daily recommended dose of 400
International Unit for a child. The data on therapeutic trials of high-dose vitamin A in children hospitalized for
acute infectious diseases have revealed that those with low vitamin A status on admission tended to benefit,
but that no gains and even adverse effects were observed in those with adequate pre-admission vitamin A
status. Hence, it is scientifically inappropriate to administer a pharmacological dose of vitamin A to a child
who is not suffering from vitamin A deficiency.

iii) VA can not be administered to all children unlike oral polio vaccine, which when given to near 100%
children, helps to develops herd immunity and eliminates wild poliovirus transmission. VA supplementation
does not provide a similar herd protection. Infections can not be predicted while in case of VAD, the cases
can be predicted, diagnosed and treated much before the clinical manifestations. Hence, comparison of
universal VA supplementation with universal polio Immunization is scientifically incorrect.

iv) In India, health is a state subject and the Government of India policies are not followed by all the states
due to state-specific health situation and or due to resource constraints. When the donation of VA supplies is
received by a state from an International agency of high reputate, the recommended age group is modified
and children in the age group of 6 to 60 months are covered. The philanthropic reputation of the international
agency convinces the state government to accept the advice.

v) After administration of a mega dose of VA, the side effects like bulging of anterior fontanels has been
documented in up to 16% of young children        .

The development of the brain is not complete at birth, and the first twelve months are crucial from the point
of view of brain development. This is the time when billions of brain cell are multiplying and establishing
several thousands of inter neuronal synaptic connections. What effect does prolonged increased intra-
cranial tension have on brain development is not known.

vi) The effects of high doses of vitamin A on bone resorption and bone formation have been demonstrated in
animals. The scientific evidence of effect of supplementation of massive doses of vitamin A in young
undernourished children subsisting on low calcium intakes with respect to their bone health has not been

vii) Research studies have also documented that massive doses of vitamin A in children could lead to
increase in respiratory infections .

viii) The universal Vitamin A supplementation in India is advocated on the ground that it could bring about an
overall reduction in mortality by 23% . Although, this debatable scientific claim has been found only in
clinically VAD endemic areas with rudimentary health care facilities. The exact metabolic mechanisms
involved in bringing about this mortality reduction is not known, apart from conjectures. The claim of
mortality reduction largely rests on the findings of investigators belonging to the John Hopkins School.
However, the investigations from two other prestigious schools- Harvard School of Public Health and the
National Institute of Nutrition, India had failed to substantiate the mortality reduction claim. The possibility
that the mortality reduction observed could be an artefact being the result of the Hawthorne Effect had been
pointed out in Indian study.        The scientific validity of ―meta analysis‖ exercises on benefits of VA
supplementation on the mortality have been questioned.

The data for such meta analysis are derived from studies of different designs and from different regions, and
are of disparate quality, not all carrying the same weight. Moreover, since the majority of studies chosen for
a recent meta analysis were those gathered by more or less one and the same school, the analysis can be
considered ‗loaded‘. In all of these studies the estimation of vitamin A levels were either not done in the
recipient children, or a few children were subjected to investigation.

A recent meta-analysis of all the Indian studies on VA supplementation and reduction in the mortality has
documented that findings from vitamin A trials are not consistent , and there is no evidence as yet in favor
or against substantive benefit of universal vitamin A supplementation to children in India.

All the populations have different epidemiological characteristics. What is true in Indonesia may not be true
for Nigeria and similarly for India.(this has been demonstrated by results of randomized control studies taken
to assess the impact of VA supplementation on under five mortality conducted in different countries). It is
important that all the epidemiological characteristics of different countries a should be carefully considered
before advocating programme of universal coverage of children with VA.

4.2 Why Universal Administration of Synthetic Vitamin A is
International voluntary agencies receive funds from donors. The mechanism of donor support is as simple.
The agencies submit proposals to the donors mentioning specific activities to be carried out. The agencies
have to undertake the activities as approved by the donors. At present, the donor funds are available for
Vitamin A supplementation, hence agencies submit the proposals in this area and have to carry out the
project activities as approved by donors. The agencies have their limitations to do because of mandate of
donors (invariably who may at times have direct/indirect commercial interest). This is a vicious cycle in which
agencies have to work. The international agencies operate through scientists in government/semi-
government/ voluntary organizations in the concern country, to implement their project. The data is collected
by national scientists on a pre-designed protocol, questionnaire and tools, which often help agencies to
convince the administrators and planners in the country to promote VA supplementation.

5. What Needs to Done
The era of gross and rampant vitamin A deficiency leading to blindness is past in India. We should resist the
soft option of resorting to supplementation of mega dose of VA in order to escape the responsibilities of
improving the diets of young children. The children in poor communities need more ―food rather than pills /
tablets / sprays. The supplementation of mega dose of VA creates the culture of perpetual dependence on
the health infrastructure. The difference between the food-based approach and the synthetic VA supplement
based approach is somewhat like the difference between teaching a man to catch the fish that he needs
from his own local pond, on the one hand, or giving him instead (not a fish but) a ‗fish substitute‘ as a dole.
The former is ‗time consuming‘ while the latter may be ‗immediate‘, but the ‗beneficiary‘ will have to be
probably dependant on the substitutes, even assuming that the ‗substitute‘ is in fact as good as food itself.

Most projects seeking to change diets, however, ends with people returning to their old ways. If we wait for a
food-based approach alone to work, we will not solve the problem. The magnitude of the problem is such
that we can‘t wait (The implication here appears to be that diversification of diets in households ‗can wait‘ but
the business of synthetic micronutrient supplementation cannot wait but must be intensified!)

The states of Bihar, Rajasthan, Arunachal Pradesh, Uttar Pradesh, Madhya Pradesh in India where there is
poor intake of food, which provides all the micronutrients, may be given high priority and simultaneously the
states from where no cases of VAD have been reported and immunization status and food intake is high, the
vitamin A administration may be continued as a part of routine health care to have most cost effective
utilization of limited resources available in the health sector.

At present the VAS program is exclusively aiming only at universal synthetic vitamin A supplementation in all
states without consideration of prevalence / achievements of the state with respect to prevalence of VAD,
severe PEM, immunization status, under five mortality and Infant mortality rates, dietary intake of vitamin A
and prevalence of clinical VAD etc. Epidemiological characteristics of VAD and it‘s prevalence in the states
should be kept in mind before universal VA supplementation is carried out. For example, presently the state
of Kerala have same policy of Vitamin A supplementation as in Uttar Pradesh although the child health and
Nutrition parameters mentioned Kerala differs widely.

The sustainable solution of prevention and control of VAD is through promotion of the intake of green leafy
vegetables (GLV) and local available foods. The intake of GLV can be answer to more than the problem of
VAD. GLV are good sources of carotenes, folic acid, vitamin C, iron and calcium and can therefore
contribute improvement of the overall nutritional status of children. The micronutrient deficiencies are often
the result of lack of enough habitual food in the household rather than to the poor quality of such foods.
When overall food intake becomes adequate enough to provide basic energy needs, needs of other
nutrients would be met to a considerable extent even with the current diets. The food-based approach to
combat VAD in non-clinically deficient areas is the sustainable and cost effective solution. We should look to
our farms not pharmacies, for the nutritional improvement of our children. Solutions to the problem of VAD
must be ‗food-based‘ – not ‗drug-based‘.

In India, for cost effective utilization of limited resources available to the health sector, the `Triple A‘
approach for prevention and control of a disease i.e. Assessment, Analysis, Action‘ should be adopted i.e.
first assess the problem of VAD and then undertake the detail analysis of causes of VAD and then decide
the combination of approaches which should be adopted for prevention and control of VAD in the

    1.   Bhattacharya AK, Chatopadhyaya PS. Bulletin of the Calcutta School of Tropical Medicine 1986,
         34: 4447
    2.   National Nutrition Monitoring Bureau. Report of repeat survey (1989– 1990). National Institute of
         Nutrition, Hyderabad
    3.   Ghosh S. Combating vitamin A deficiency – A rational public health approach. NFI Bulletin. January
         2001, vol 22, No. 1
    4.   National Nutrition Monitoring Bureau. Report of second repeat survey – rural (1996-1997). National
         Institute of Nutrition, Hyderabad
    5.   India Nutrition Profile, Ministry of Human Resource Development. Government of India, 1998
    6.   Chakravarty I. Ghosh K. Micronutrient malnutrition – present status and future remedies. J Ind Med
         Assoc 2000, 98: 539
    7.   Vir SC. Linkage of vitamin A massive dose supplementation with pulse polio immunisation – an
         overview. A report on benefits and safety of administration of vitamin A to preschool children and
         pregnant and lactating women. Ed. Chapel U, Srivastava, New Delhi
    8.   Report of District Nutrition Project. Indian Council of Medical Research, 1999
    9.   Indicators for assessing vitamin A deficiency and their application in monitoring and evaluating
         intervention programmes. World Health Organization, Geneva, 1996
10. Bhaskaram P,Hemalatha P Kumar PA, Khan MM, Islam MA. et al. Effect of subclinical vitamin A
    deficiency and administration of vitamin A as a single dose on immune functions in children. Nutr
    Res 1989, 9: 1017
11. Rahmatullah L, Underwood BA, Thulasiraj RD, Milton RC, Ramaswamy K, Rahmatullah R, Babu G.
    Reduced mortality among children in southern India receiving a small weekly dose of vitamin A. N
    Engl J Med 1990, 323: 929-935
12. National Nutrition Monitoring Bureau. Report on food and nutrient intakes of individuals – rural.
    2000, National Institute of Nutrition, Hyderabad
13. Reddy V Vitamin A program in India – why the controversy? Sight and Life Newsletter 3 / 2002; 55
14. Maternal and child health scheme for prophylaxis against blindness in children caused by vitamin A
    deficiency. In: Family planning programme – Fourth five year plan. Technical Information: MCH No.
    2, Government press, New Delhi 1970.
15. Control of vitamin A deficiency. National Child Survival and Safe Motherhood Program, Ministry of
    Health and Family Welfare, Government of India, 1994.
16. Reproductive and Child Health Programme- Implementation Issues. Department of Family welfare,
    Ministry of Health and Family Welfare, Government of India, Government press, New Delhi 1998.
17. National consultation on benefits and safety of administration of Vitamin A to preschool children
    and pregnant and lactating mothers. Indian Pediatr 2001; 38: 37-42. Indian Journal for the
    Practising Doctor Vol V (4) September October 2008
18. India blames child deaths on Unicef 03-Sep-2003, Story from United Press International Copyright
    2003 by United Press International (via ClariNet)
19. Deaths trigger fresh controvery over vitamin A programme in India. Br Med J 2001; 323: 1206.
20. Sharma DC. UN Vitamin A campaign in India under fire. Lancet 2001; 358.
21. Probe ordered into vitamin A deaths. The Times of India, New Delhi, November 14, 2001.
22. Barman. Vitamin-A overdose likely. Assam Tribune, November 14, 2001.
23. Kapil U. Do we need campaign approach of vitamin A administration in non vitamin A deficient
    areas. Indian J Pediatr. 2002, 69:39-40.
24. Kapil U. Update on vitamin A-related deaths in Assam, India.Am J Clin Nutr. 2004 ; 80:1082-1083;
25. National consultation on benefits and safety of administration of Vitamin A to preschool children
    and pregnant and lactating mothers. Indian Pediatr 2001; 38: 37-42.
26. Court finds Unicef and government responsible for Assam child deaths Source:, September 3, 2003
27. Noel W Solomons and Klaus Schümann Update on vitamin A-related deaths in Assam, India. Am J
    Clin Nutr. 2004 ; 80:1083-1084.
28. de Francisco A, Chakraborty J, Chowdhury HR, Yunus M, Baqui AH, Siddique AK, Sack RB. Acute
    toxicity of vitamin A given with vaccines in infancy. Lancet. 1993;342 : 526-527 7
29. Gopalan C, Tamber B. Food-based approaches to prevent and control micronutrient malnutrition:
    scientific evidence and policy implications. World Rev Nutr Diet. 2003;91:76-131
30. Sempertegui F, Estrella B, Camaniero V, Betancourt V, Izurieta R, et al. The beneficial effects of
    weekly low dose vitamin A supplementation on acute lower respiratory infections and diarrhea in
    Ecuadorian children. Pediatrics 1999; 104: 29-38.
31. Reviews And Comments: Control of Vitamin A Deficiency—Priorities For Future Research In India :
    C. Gopalan, October 1988
32. Vijayraghavan K, Radhaiah G, Praksam BS, Sarma KVR, Reddy V. Effect of massive dose vitamin
    A on morbidity and mortality in Indian children. Lancet 1990; 336: 1342-1345.
33. Gopalan,C. Acute toxicity of vitamin A in infancy (Reviews and Comments), NFI Bulletin,15
34. Humphrey JH, Rice AL. Vitamin A supplementation of young infants. 1: Lancet. 2000;356:422-424
35. Gupta P, Indrayan A. Effect of vitamin A supplementation on childhood morbidity and mortality:
    Critical review of Indian studies. Indian Pediatr 2002; 39: 1099-1118.