Letters to the Editor
Indian Pediatrics 2001; 38: 103-107
Linking Vitamin A Distribution to the Pulse Polio Program
Keeping in view the magnitude of problem in slum of Chandigarh, we did an operational research project supported by UNICEF to deliver vitamin A solution to about 27,642 children (1-5 years old) in all 26 slums of Chandigarh by using National Immunization Day (23rd January, 2000) and could achieve a coverage rate of 98.7%. The delivery of vitamin A with Pulse Polio Immunization (PPI) was found to be operationally feasible without any major problem. A follow up study being undertaken by us had showed significant reduction in VAD after mass distribution and no case of toxicity has been found so far and not even reported by health institutions of intervention area. As per WHO, even if a dose is given closer than 4 weeks apart, the danger of transient undersirable effect is low, and of serious adverse effect is negligible(5). It is worthwhile to mention here that the routine vitamin A distribution under the RCH Program is being done as usual in Chandigarh. It appears that while giving recommendation, the IAP Subspeciality Chapter on Nutrition, has overlooked that the primary concern of vitamin A prophylaxis program is to prevent childhood blindness and the recommendations focussed mainly on effect on morbidity and mortality(6).
In out opinion, the linking of vitamin A solution with PPI appears to be an appro- priate step becaue of poor dietary intake of vitamin A, still high prevalence of VAD, malnutrition and childhood blindness due to VAD and poor coverage by national program. The recommendation of IAP Subspeciality Chapter on Nutrition on this issue needs reconsideration.
We are grateful to Dr. Swami and Dr. Thakur to allow us to re-examine the benefits, safety and feasibility of linking megadose vitamin A prophylaxis (VAP) with Pulse Polio Immunization (PPI), particularly in relation to the current estimates of vitamin A deficiency (VAD) in the country. In India, VAP was started in 1970 as a program with the specific aim of preventing nutritional blindness due to vitamin A deficiency. The current policy is to administer vitamin A to all children between 9 months to 3 years, and for logistical reason VAP has been linked to measles and 1st booster dose of DPT immunization(1).
The study done by Swami et al. in slum area of Chandigarh involving 1300 children in 1999 (unpublished, non-peer reviewed) cites various estimates of the magnitude of VAD. Invariably for programmatic decision, preva-lence of Bitotís spot (the most specific indicator) is considered. We shall therefore restrict further discussion to Bitotís spot prevalence only. In their study, the prevalence of Bitotís spot is mentioned as 0.6%. The 95% CI with this sample size would be 0.2% to 1%, indicating that the observed prevalence could have been as low as 0.2%. The current prevalence of Bitotís spot in the country is just 0.21% (pooled data), though disparities exist between various states(2). This figure is well below the WHO cut-off level of 0.5% to determine public health significance. The District Nutrition Project of Indian Council of Medical Research recently carried out a survey on status of VAD in 16 districts in India. Only 4 districts located in relatively underprivileged regions of Bihar, Uttar Pradesh and Rajasthan had prevalence of Bitotís spots above 0.5% level(3).
Dr. Swami and Dr. Thakur carried out the study amongst the most disadvantaged population in a small area only. The result of their study, therefore, cannot be extrapolated for the whole country. The study by Singh et al.(4), referred to by them relates to subclinical VAD only, control of which is not really the stated objective of the VAP program. In fact the attempt to equate clinical and subclinical VAD (mentioned as 23-34.8%) would be inappropriate for programmatic decisions.
The study by Rahi et al.(5) referred to by them was done in blind children and in no way indicates that VAD leading to keratomalacia/blindness is a public health problem. A careful scrutiny of the results reveals that VAD as a cause of blindness was attributed in 18.6% and not 26.4% as mentioned by Dr. Swami and Dr. Thakur. The latter estimate relates to corneal diseases due to all causes and not only VAD. In another recent study(6), the associa-tions and indications for pediatric keratoplasty were analyzed. Corneal opacification was found to be due to infectious keratitis in 51.08% cases, whereas keratomalacia and trauma were responsible for the same in 19.50% and 5.54% cases, respectively. Infectious keratitis is considered the major cause of corneal opacification. A nationwide survey conducted by the ICMR during 1971-74 showed that 2% cases of blindness were attributable to corneal disease caused by vitamin A deficiency(7). In the subsequent (1985) national survey of blindness, carried out under the auspices of the Government of India and the World Health Organization (WHO), this figure declined to 0.04%(7).
It is true that coverage of VAP is low in the country. The most comprehensive and recent data shows that only 30% children had received a dose of vitamin A(8). However, it is noteworthy that even without any significant intervention at National level the prevalence of VAD in India declined from 2% in 1975-79 to 0.7% in 1988-90 and 0.21% in 1998(2,9). This reaffirms that the appreciable decline in VAD in this country is probably not related to megadose VAP; therefore, the need for countrywide intensification of VAP program by linking it with PPI is questionable. As the current national prevalence of Bitotís spot (0.21%) is below the WHO cut-off level of 0.5% to determine public health significance, VAP may no longer be considered a national priority for blindness control program. It has now been suggested that megadose VAP as a measure for keratomalacia must be phased out, and efforts should be made to increase the intake of vitamin A through dietary improve-ment, which is most logical and sustain- able means of combating vitamin A deficiency(10).
The Nutrition Chapter, Indian Academy of Pediatrics has not agreed to linkage of megadose VAP with PPI primarily due to anticipated logistical issues. These fears were confirmed in the limited experience of linking of megadose VAP with PPI in 2 States of India (Orissa and Uttar Pradesh). In the State of Orissa, International Agencies (UNICEF and WHO) and National Institute of Nutrition collaborated. The staff gained the experience of administering vitamin A through an earlier round of campaign approach. Coverage for vitamin A distribution was reported as 92% for the target group; but a matter of concern is that despite a well-organized approach, 21.4% infants who were not the target population also received vitamin A during PPI(11). In Uttar Pradesh where external agencies did not provide similar support and the staff did not have prior experience of such linkage, only 39% children received vitamin A solution(12).
This just indicates the enormity of training requirements, commitment and probably involvement of multilateral agencies in meticulous planning even for a state level program. While there will be need to train pulse polio workers which include nonmedical personnel in many areas, health workers carrying out routine services will have to be instructed to discontinue routine vitamin A administration. In fact whether a succsessful National program like PPI could itself suffer due to additional objectives being introduced at this stage needs scrutiny. One should not lose sight of the fact that the country is on the threshold of achieving Ďzero polioí status and PPI will cease to exist within 3-4 years. Reinitiation of routine vitamin A administra-tion at that point of time would have obvious implications in terms of retraining, logistics and supplies.
The Nutrition Chapter of the Indian Academy of Pediatrics also considered the possibility of multiple dosing that might lead to toxicity, particularly in infancy. In fact Orissa experience mentioned above has shown that even after proper training, the possibility of multiple dosing in infancy remains real. No data is available on long-term effects of bulging fontanel and raised intracranial tension, which may follow multiple dosing in infancy. Another consideration for the Nutrition Chapter was that there is an appreciable decline of VAD in the country and this has already occurred despite a poor VAP coverage. The lack of evidence of benefits on mortality or morbidity in infancy(13) further supported the decision.
Cost benefit, often not taken into account, should also be an important issue for designing or continuing a National program. For a country of the size of India the cost of distributing vitamin A solution to all under five children in absolute terms is not a meager one. Though production of vitamin A has started in the country only recently, the raw material pseudo-ionone is still being imported. The justification for siphoning out scarce national funds for the anticipated quantum of benefit is a moot point in this context.
In the current scenario, a better option would be to provide mega-dose VAP only in areas having prevalence of Bitotís spot well above the level of 0.5% and high 1-4 year child mortality through existing health care services. Dietary diversification to include vegetables and fruits in the diet is advocated for long-term sustainability in improving vitamin A status. Such an approach will improve not only intake of vitamin A but also other micronutrients and essential phytonutrients as well in a balanced manner(14). It is worthwhile to note that the National Consultation on benefits and safety of administration of vitamin A to pre-school children, pregnant and lactat-ing mothers has specifically recommended that synthetic vitamin A supplimentation should not be linked to PPI(15),