Food and Nutrition Research Institute Department of Science and Technology Corazon VC. Barba, Ph.D. Director The Philippines’ Vitamin A Supplementation Program: Supplementation Program: Indicative Impact, Policy and Program Implications

Year NID b + Vit A (%) (first dose) NMD/ASAP c (%) e (second dose) (GP d ) 2000(GP d ) e 76 e a from HKI A briefer on the Philippine vitamin A supplementation program: accomplishments and challenges supplementation program: accomplishments and challenges b National Immunization Day c National Micronutrient Day/Araw ng Sangkap Pinoy d Garantisadong Pambata e based on FETP cluster survey a

Reasons for lack of a smooth transfer of program ownership to LGU’s Low public response due to inability of the program to provide supplies on time at the LGU level Lack of promotion and social mobilization at the implementation level Low awareness of mothers and the community Lack of priority for the nutrition program among LGUs Low number of volunteers Waning enthusiasm among health workers because of lack of support by local executives; and Inadequate knowledge about the benefits and importance of micronutrients among health workers.

Socio-economic indicators Samar n = 432 Albay n = 414 Monthly household income equal to or more than P2,000 equal to or more than P2,000 less than P2,000 less than P2,000 Household electricity present present absent absent Household gas or electric stove or electric stove present present absent absent (1.12, 3.52) (1.13, 2.18) (1.16, 2.03) a Klemm RDW et al, 1997 b probability of receiving VAC among 1-4 years old children Probability of ASAP participation by 1-4 years old children by selected household socio-economic indicators, 1996: bi-variate analysis OR (95% CI) nsnsns

Household refrigerator present present absent absent Type of house wood or concrete house wood or concrete house nipa hut or shanty nipa hut or shanty (1.07, 2.11) b 2.53 (1.49, 4.30) 2.27(1.17,4.42) b a Klemm RDW et al, 1997 b probability of receiving VAC among 1-4 years old children (1.02, 2.01) ns Socio-economic indicators Samar n = 432 Albay n = 414 Probability of ASAP participation by 1-4 years old children by selected household socio-economic indicators, 1996: bi-variate analysis indicators, 1996: bi-variate analysis OR (95% CI)

Age (Year) 1993 b Deficient (PR:<10  g/dL) Low (PR:10- <20  g/dL) Deficient + low <20  gL) Deficient (PR:<10  g/dL) Low (PR:10- <20  g/dL) Deficient + low <20  gL) 1998 c < Total a 1993 and 1998 National Nutrition Survey, FNRI-DOST b 15% of sample received vitamin A capsules c 85% of sample received vitamin A capsules Proportion (%) of 0-5 years old children with deficient to low plasma retinol (PR:<20  g/dL), 1993 and 1998 a

Plasma retinol (ug/dL) FREQUENCY DISTRIBUTION OF PLASMA RETINOL FREQUENCY DISTRIBUTION OF PLASMA RETINOL AMONG PRESCHOOL CHILDREN IN 1993 AND 1998 AMONG PRESCHOOL CHILDREN IN 1993 AND 1998 NATIONAL NUTRITION SURVEY:PHILIPPINES NATIONAL NUTRITION SURVEY:PHILIPPINES %

FREQUENCY DISTRIBUTION OF PLASMA RETINOL OF PRESCHOOL CHILDREN BY ASAP PARTICIPATION IN 1993, 1993 NNS SURVEY, PHILIPPINES Plasma Retinol (µg/dL) %

FREQUENCY DISTRIBUTION OF PLASMA RETINOL OF PRESCHOOL CHILDREN BY ASAP PARTICIPATION IN 1998, 1998 NNS SURVEY, PHILIPPINES Plasma Retinol (µg/dL) %

Proportion (%) of 1-5 years old children with deficient to low serum retinol by ASAP participation, 1993 and 1998 Plasma retinol level with ASAP without ASAP with ASAP without ASAP DeficientLow Deficient + low

Mean plasma retinol and prevalence of deficient plasma retinol by interval after administration of VAC dose Time interval between receipt of VAC and data collection Mean plasma retinol a Deficient plasma retinol b (%) Deficient + low plasma retinol b (%) 1 month 2 months 3 months 4 months 5 months 6 months 25.0±10.7 (2371) 22.9±10.3 (1584) 23.6± 9.8 (1842) 22.3±10.8 (1858) 20.9±10.2 (1078) 23.1±20.0(1095) 5.9 (723) 6.1 (135) 5.3 (88) 8.9 (103) 12.6 (130) ns 12.6 (130) ns 8.1 (95) 30.8 (2371) 38.1 (1548) 33.7 (1842) 38.4 (1858) 44.8 (1078) ns 44.8 (1078) ns 37.4 (1095) Did not receive VAC 21.7  11.1 (1839) 12.0 (190)43.5 (1839) a mean differences (with VAC vs. no. VAC) are significant at 0.05 level b weighted prevalences among with VAC significantly different at level vs. no VAC ( ) number of subjects ns not significant

Logistic regression analysis: odds of having deficient plasma retinol, 1998 NNS Variables BS.E.Exp (B) VAC w/in 1-4 mos. No VAC W/o infection Non-anemic Normal-tall (h-a) VAC x non-stunting With supplement Operation Timbang Household size Age (y) Sex (male E Sig

Logistic regression analysis: odds of having deficient plasma retinol, 1998 NNS Variables BS.E.Exp (B) VAC w/in 1-4 mos. W/o infection Non-anemic Normal-tall (h-a) VAC x non-stunting With supplement Operation Timbang Household size Age (y) Sex (male Sig

Mean plasma retinol and % distribution by plasma retinol level by presence of infection during collection of blood samples n Mean PR (  g/dL) DeficientLowAcceptableHigh with VAC with infection with infection w/o infection w/o infection without VAC with infection with infection wo infection wo infectiontotal with infection with infection w/o infection w/o infection ± ± ± ± ± ± % Distribution Subjects

Prevalence of Deficient Plasma Retinol By Receipt of VAC and Month of Data Collection May June July Aug Sept Oct Nov Dec with VAC without VAC VAC Month of blood sample collection Subjects

Percent distribution by serum retinol level among children without infection Deficient not stunted with VAC with VAC w/o VAC w/o VACstunted with VAC with VAC w/o VAC w/o VAC 23.7± ± ± ±12.7 Serum retinol (% distribution) Mean plasma retinol (  g/dL) Deficient + Low Acceptable High 5.6 a 8.2 a 7.1 b 11.1 b 31.5 c 35.6 c 38.9 a 48.2 a a sig p < 0.05 b sig p <0.01 c ns Subjects

Vitamin A deficiency problem 38% of 0-5 y old 22% of pregnant women 16% of lactating mothers Increased health care cost & Economic losses Increased child morbidity & mortality Poor pregnancy outcome

VAS policy and program Progress and indicative impact Programmatic and policy recommendations

non-targeted or universal (all 0-5 y old non-targeted or universal (all 0-5 y old children) children) twice-yearly dosing (April and November) twice-yearly dosing (April and November) : centrally managed by DOH : centrally managed by DOH 1998-present: LGU-managed 1998-present: LGU-managed BHWs are at the core of distribution BHWs are at the core of distribution scheme: center-based/house-to-house scheme: center-based/house-to-house

Political leadership Advocacy and promotion Volunteerism Sustainability of supplies Access by the vitamin A deficient and at-risk

Strengthening of management capability of Local Government Units Motivation of Barangay Health Workers to reach and seek out target children esp. among the poor and at-risk Focus on the poor and at-risk Address R&D gaps plasma retinol and infection plasma retinol and infection efficiency of targeted vs. universal approach efficiency of targeted vs. universal approach efficiency of 2x vs 3x yearly efficiency of 2x vs 3x yearly sensitive, feasible, inexpensive: sensitive, feasible, inexpensive: indicators of vit A status for national surveys indicators of vit A status for national surveys è targeting or selection criteria

VAS appears to be effective in reducing the prevalence of VAD among 1-5 y old children The protective effect of VAS is evident particularly within four months after the dose VAS appears to affect not stunted and stunted children differently. Not stunted children are likely to benefit less significantly than stunted children, making a targeted approach a potentially more efficient policy option Urgent need to address research gaps