Indian Journal for the Practising Doctor Ethical Issues in Vitamin A Supplementation in India 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) yahoo.com] Introduction 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 States 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) 4 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 5 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 6 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%. 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 8 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 NORTH 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) EAST 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 11 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 12 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 13 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 14 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 15 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 17 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 18-22 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 23 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 24 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 25 negligence led to the death of many children . 26 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 government? 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 27 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 28,29 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 documented. vii) Research studies have also documented that massive doses of vitamin A in children could lead to 30 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 31,32 pointed out in Indian study. The scientific validity of ―meta analysis‖ exercises on benefits of VA 33,34 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 35 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 promoted 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 community. References 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. 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