1. 1 Dr Kunal Bagchi Regional Adviser – Nutrition & Food Safety WHO South-East Asia Regional Office Kathmandu, Nepal November 2011

2. 2  Essential nutrient required by humans for the normal functioning of the visual system, maintenance of cell function for growth, epithelial cellular integrity, immune function and reproduction  Dietary requirements for vitamin A are from : mixture of preformed vitamin A (retinol) present in animal source foods provitamin A carotenoids, derived from foods of vegetable origin and which have to be converted into retinol by tissues such as the intestinal mucosa and the liver in order to be utilized by cells  Aside from the clinical ocular signs of night blindness and xerophthalmia, symptoms of vitamin A deficiency (VAD) are largely non-specific  Biochemical measures of vitamin A status are essential in order to attribute non-ocular symptoms to VAD Vitamin A

3. Prevalence (%) No. affected (in millions) South- East Asia 49.9%91.5 (45.1 – 54.8)(82.6 – 100) Prevalence of serum retinol (<0.70 µmol/l and number of individuals affected among pre-school age children in South-East Asia Vitamin A deficiency: prevalence in pre-school age children Vitamin A deficiency: prevalence in pre-school age children Global Prevalence of vitamin A deficiency in populations at risk 1995 – 2005 – WHO Global Database (2009) Country Age group Estimate (%) Public health problem Bangladesh0.5 – 4.99 years 21.7 [18.5 – 25.3] Severe Bhutan1.00 – 4.99 years 22.0 [18.4 – 26.0] Severe DPR KoreaNA 27.5 Severe India1.00 – 4.99 62.0 [59.8 – 64.1] Severe IndonesiaNA 19.6 [ 2.2 – 72.3] Moderate Maldives2.00- 2.99 9.4 [6.7 – 13.1] Mild MyanmarNA 36.7 [5.1 – 86.2] Severe Nepal0.5 – 4.99 32.3 [28.0 – 36.9] Severe Sri Lanka0.5 – 5.99 35.3 [32.3 – 38.5] Severe ThailandNA 15.7 [1.7 – 66.5] Moderate Timor LesteNA 45.8 [6.9 – 90.6] Severe Vitamin A deficiency: Prevalence of in pre-school age children (Serum retinol < 0.70 µmol /l)

4. Basis for the Guidelines on Vitamin A Supplementation Member States request for guidance on the effects and safety of vitamin A supplementation Global, evidence-informed recommendation on the use of vitamin A supplements Informed decisions on appropriate nutrition actions to achieve MDG 4 [reduction in child mortality] Intended for: policy-makers, technical experts and programme managers 4

5. To prepare evidence profiles related to pre- selected topics, based on up-to- date systematic reviews GRADE: Grading of Recommendations Assessment, Development and Evaluation methodology was followed 1.Identification of priority questions and outcomes 2.Retrieval of the evidence 3.Assessment and synthesis of the evidence 4.Formulating of recommendations, including future research priorities 5.Planning for dissemination, implementation, impact evaluation and updating of the guideline WHO Handbook for Guideline Development 5

6. Neonatal Vitamin A supplementation  Systematic reviews to evaluate the effects and safety of neonatal vitamin A supplementation  Analysis of data showed no significant reduction in the relative risk of mortality during infancy  No evidence of a reduced risk of morbidity or mortality related specifically to diarrhoea or acute respiratory infection  Meta-analysis assessing the survival effect of vitamin A given to neonates found no significant effect all-cause mortality and no differential effect of the intervention between genders 6

7. Neonatal Vitamin A Supplementation Recommendation At present time, neonatal vitamin A supplementation (supplementation within the first 28 days after birth) is not recommended as a public health intervention to reduce infant morbidity and mortality [strong recommendation] 7

8. 8 Systematic review to evaluate the effects and safety of vitamin A supplementation in infants 6 months of age or less No significant effect on the risk of mortality or morbidity in the first year of life No effect on all-cause mortality, when given as a cumulative dose, regardless of the status of maternal postpartum vitamin A supplementation Vitamin A supplementation in infants 1 – 5 months of age

9. 9 Recommendation Vitamin A supplementation in infants 1–5 months of age is not recommended as a public health intervention for the reduction of morbidity and mortality [strong recommendation] Vitamin A supplementation in infants 1 – 5 months of age

10. 10 Vitamin A supplementation in children 6–59 months of age is associated with reduced risk of all-cause mortality and reduced incidence of diarrhoea Improvement of gut integrity, decrease severity of diarrhoeal episodes and reduced susceptibility to infections Many countries have integrated strategies to deliver vitamin A supplements to infants and children in their national health policies. Vitamin A supplementation in infants and children 6 – 59 months of age

11. 11 Vitamin A supplementation in infants and children 6 – 59 months of age High-dose vitamin A supplementation is recommended in infants and children 6–59 months of age in settings where vitamin A deficiency is a public health problem [strong recommendation] Recommendation

12. 12 Vitamin A supplementation in infants and children 6 – 59 months of age Vitamin A supplementation should be used along with other strategies to improve vitamin A intakes [e.g. dietary diversification and food fortification] Supplements should be delivered to children 6– 59 months of age twice yearly during health system contacts and integrated into other public health programmes Recommendation can be applied in populations where infants and children may be infected with HIV

13. 13 Vitamin A supplementation in infants and children 6 – 59 months of age Suggested vitamin A supplementation scheme for infants children 6–59 months of age Target Group Infants 6 – 11 months of age (including HIV+) Children 12-59 months of age (including HIV+) Dose 100,000 IU (30 mg RE) vitamin A 200,000 IU (60 mg RE) vitamin A FrequencyOnceEvery 4 – 6 months Route of administration Oral liquid, oil-based preparation of retinyl palmitate or retinyl acetate Settings Populations where the prevalence of night blindness is 1% or higher in children 24–59 months of age or where the prevalence of vitamin A deficiency (serum retinol 0.70 μmol/l or lower) is 20% or higher in infants and children 6–59 months of age

14. Vitamin A supplementation in pregnant women 14 Public health problem affecting a large number of pregnant women - increased need for vitamin A during pregnancy, most common during third trimester Essential for the health of the mother as well as for the health and development of the fetus Guideline provides global, evidence-informed recommendations on the use of vitamin A supplements in pregnant women – achieving the improvement of maternal health [MDG 5] Intended for: policy-makers, technical experts, programme managers

15. Vitamin A supplementation in pregnant women 15 Vitamin A supplementation is not recommended during pregnancy as part of routine antenatal care for the prevention of maternal and infant morbidity and mortality (strong recommendation) In areas where there is a severe public health problem related to vitamin A deficiency, vitamin A supplementation during pregnancy is recommended for the prevention of night blindness (strong recommendation) Recommendation

16. Vitamin A supplementation in pregnant women 16 Suggested vitamin A supplementation scheme in pregnant women for the prevention of night-blindness in areas with severe public health problem related to vitamin A Target GroupPregnant Women Dose Up to 10 000 IU vitamin A (daily dose) OR Up to 25 000 IU vitamin A (weekly dose) Frequency Daily or weekly Routes of administration Oral liquid, oil-based preparation of retinyl palmitate or retinyl acetate Duration A minimum of 12 weeks during pregnancy until delivery Settings Population where the prevalence of night-blindness is 5% or higher in pregnant women or 5% or higher in children 24 – 59 months of age

17. Vitamin A supplementation in postpartum women 17 Vitamin A supplementation in postpartum women is not recommended for the prevention of maternal and infant morbidity and mortality (strong recommendation) Recommendation

18. Vitamin A supplementation in pregnancy for reducing the risk of mother-to-child transmission of HIV 18 Vitamin A supplementation in HIV- positive pregnant women is not recommended as a public health intervention for reducing the risk of mother-to-child transmission of HIV [strong recommendation] Recommendation

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