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4570Improving child survival through vitamin A supplementation EDITORIAL BMJ 3 OCTOBER 2013

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  • Prof. Umesh Kapil
    Oct 9, 2013

      DEAR ALL 



      Improving child survival through vitamin A supplementation
      BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d5294 (Published 25 August 2011)
      Cite this as: BMJ 2011;343:d5294
      3 October 2013
      The editorial by Thorne-Lyman and Fawzi in 2011, (1) referring to the meta-analysis of the impact of vitamin A supplements by Mayo-Wilson, Imdad and others, (2,3) has now become more important than ever. The DEVTA results, only informally available in 2011, have now been published, (4) with extensive implications; indeed, as the editorial (1) says: ‘… the null findings have left lingering questions. Is vitamin A supplementation effective?’. These results have been the subject of conflicting comments recently in the Lancet, e.g. (5,6). But a number of inferences that should be drawn from the compilation and analysis of the evidence from trials prior to DEVTA (2,3) help answer this lingering question, and have not received adequate attention. There are three key related points, which now point to the need to seriously consider concrete steps to move beyond 6-monthly vitamin A supplementation at unphysiological levels.
      First, the trend through time in reported impact on mortality of high dose vitamin A 6-monthly supplements (usually 200,000 IUs) is informative, but some important inferences are not being drawn. The original meta-analyses by Beaton et al (7) in 1993 drew upon the 8 studies available at that time, to estimate an average mortality reduction (in 12-59 month children) of 23%. The recent meta-analyses (2,3) drew on seven of these, and added a further nine. They concluded that the weighted average mortality finding (without DEVTA) was essentially unchanged. What they did not point out is that 89% of the weight in this average came from the seven pre 1993 trials; the remaining 9 trials, with 11% weight, not surprisingly had little effect on the calculation.
      Further, it was not pointed out that of the 16 results, 8 showed no significant impact; since 1993, only two of 9 showed impact. Thus what is being confirmed is that the early trials showed efficacy; but there is sparse evidence in the past 20 years for this still being so, and none for large scale effectiveness. It seems disingenuous to imply that these new analyses confirm the continuing efficacy of VAC supplements.
      Second, by not including the possibility of changing impact through time, the effect of major changes in disease patterns is ignored. The impact on mortality was estimated in the original trials as resulting from reducing deaths from measles and diarrhea; no other causes were significant. (7, p50) Measles has been greatly reduced, by successful immunization programs, since the 1990’s; and diarrhea deaths have fallen, with improved living conditions, use of health services, and of ORT.
       Although the mechanism for intermittent high-dose VACs to reduce mortality is not known, it is only established as being relevant in these two diseases (7). Thus it is to be expected that mortality impact, if still present, would be reduced. The negative results of DEVTA, and of the study referred to by Benn et al, (8) are thus also not surprising. Both of these investigations, refuting conventional wisdom, suffered extraordinarily long delays in publication, in the DEVTA case causing speculation that ‘undoubtedly, the fact that there was no apparent effect detected delayed publication’. (5) Benn et al have a similar view about their unpublished results.(8) It is also seems disingenuous to assert that VACs are ‘a proven life-saving intervention’, (9) as if this necessarily continues under changing conditions, and in countries where measles has been controlled and diarrhea prevention and treatment improved.
      Third, vitamin A deficiency (VAD) is measured by serum retinol, as recommended by WHO. (10) The prevalence of VAD is around 30% in poor countries and falling only slowly.(11) However, it is clear that 6-monthly high dose VAD has only a limited and transient impact on serum retinol, (12, refs 6-20) which is how vitamin A gets to target tissues. There are established effective methods for reducing VAD: frequent physiological intakes of vitamin A or precursors through improved diets, fortification, and/or low dose supplements; (12, refs 22-35) moreover this is considered safe in pregnancy, in contrast to VACs.
      So the question becomes: why has most of the attention been on VACs (13) (over 7 billion so far distributed), (14) of unproven effectiveness in operational programmes, when employing these other approaches would have a wider range of benefits, including addressing any residual impact on child mortality that VACs 6-monthly may be having?
      This would free up scarce resources now being used for VAC campaigns, which have considerable opportunity costs.(15) Improved diets, fortified foods, and multiple micronutrient provision would surely bring broader improvements in nutrition to more people, including reproductive aged women who are now largely excluded.
      John Mason, PhD[1], David Sanders MD[2], Roger Shrimpton PhD[1], Ted Greiner PhD[3].
      1) School of Public Health and Tropical Medicine, Tulane University, New Orleans
      2) School of Public Health, University of the Western Cape, South Africa
      3) Department of Nutrition, Hanyang University, South Korea.
      1 Thorne-Lyman A, Fawzi WW. Improving child survival through vitamin A supplementation. BMJ. 2011 Aug 25;343:d5294. doi: 10.1136/bmj.d5294. PubMed PMID: 21868480
      2 Mayo-Wilson E, Imdad A, Herzer K, Yakoob MY, Bhutta ZA. Vitamin A supplements for preventing mortality, illness, and blindness in children aged under 5: systematic review and meta-analysis. BMJ. 2011 Aug 25;343:d5094. doi: 10.1136/bmj.d5094. Review. PubMed PMID: 21868478; PubMed Central PMCID: PMC3162042
      3 Imdad A, Herzer K, Mayo-Wilson E, Yakoob MY, Bhutta ZA. Vitamin A supplementation for preventing morbidity and mortality in children from 6 months to 5 years of age.Cochrane Database Syst Rev. 2010 Dec 8;(12):CD008524. doi: 10.1002/14651858.CD008524.pub2. Review. PubMed PMID: 21154399
      4 Awasthi S, Peto R, Read S, Richards SM, Pande V, Bundy D; DEVTA (Deworming and Enhanced Vitamin A) team. Population deworming every 6 months with albendazole in 1 million pre-school children in north India: DEVTA, a cluster-randomised trial.Lancet. 2013 Apr 27;381(9876):1478-86. doi: 10.1016/S0140-6736(12)62126-6. Epub 2013 Mar 14. PubMed PMID: 23498850; PubMed Central PMCID: PMC3647147.
      5 Garner P, Taylor-Robinson D, Sachdev HS. DEVTA: results from the biggest clinical trial ever. Lancet. 2013 Apr 27;381(9876):1439-41. doi: 10.1016/S0140-6736(13)60600-5. Epub 2013 Mar 14. PubMed PMID: 23498851
      6 Sommer A, West KP Jr, Martorell R. Vitamin A supplementation in Indian children.Lancet. 2013 Aug 17;382(9892):591. doi: 10.1016/S0140-6736(13)60645-5. Epub 2013 Mar 22. PubMed PMID: 23528188
      7 Beaton, G., Martorell, R., Aronson, K., Edmonston, B., McCabe, G., Ross, A. & Harvey, B. (1993) Effectiveness of Vitamin A Supplementation in the Control of Young Child Morbidity and Mortality in Developing Countries. ACC/SCN State-of-the-Art Series, Nutrition Policy Discussion Paper No. 13. ACC/SCN, Geneva.http://www.unscn.org/layout/modules/resources/files/Policy_paper_No_13.pdf
      8 Benn CS, Fisker AB, Aaby P. Vitamin A supplementation in Indian children. Lancet. 2013 Aug 17;382(9892):593. doi: 10.1016/S0140-6736(13)61737-7. PubMed PMID: 23953380
      9 Mannar V, Schultink W, Spahn K. Vitamin A supplementation in Indian children.Lancet. 2013 Aug 17;382(9892):591-2. PubMed PMID: 23961552.
      10 Sommer A, Davidson FR; Annecy Accords. Assessment and control of vitamin A deficiency: the Annecy Accords. J Nutr. 2002 Sep;132(9 Suppl):2845S-2850S. PubMed PMID: 12221259
      11 UN Standing Committee on Nutrition. Progress in Nutrition. 6th Report on the World Nutrition Situation. UN-SCN, Geneva. 2010.http://www.unscn.org/files/Publications/RWNS6/html/index.html
      12 Mason JB, Ramirez MA, Fernandez CM, Pedro R, Lloren T, Saldanha L, Deitchler M, Eisele T. Effects on vitamin A deficiency in children of periodic high-dose supplements and of fortified oil promotion in a deficient area of the Philippines. Int J Vitam Nutr Res. 2011 Sep;81(5):295-305. doi: 10.1024/0300-9831/a000077. PubMed PMID: 22419200
      13 UNICEF. Vitamin A Supplementation: a Decade of Progress. 2007, New York.
      14 Micronutrient Initiative. 20 Years of Progress. 2011/12 Annual Report. Ottawa.
      15 Doherty T, Chopra M, Tomlinson M, Oliphant N, Nsibande D, Mason J. Moving from vertical to integrated child health programmes: experiences from a multi-country assessment of the Child Health Days approach in Africa. Trop Med Int Health. 2010 Mar;15(3):296-305.
      Competing interests: None declared
      John B Mason, Professor
      David Sanders, Roger Shrimpton, Ted Greiner
      Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Ste 2300, New Orleans, LA 70112, USA Orleans
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      © 2013 BMJ Publishing Group Ltd
      Dr. Umesh Kapil 
      Professor Public Health Nutrition 
      Room Number 118; 
      Human Nutrition Unit,
      Old OT Block,
      All India Institute of Medical Sciences 
      New Delhi,  India ,110029
      Mobile 91-9810609340


      On Tuesday, February 9, 2010 10:49 PM, surendernikhil gupta <drsurendernikhil@...> wrote:
      Sending the link once again. It is working here with me.

      Thank you very much.
      Dr. Surender N. Gupta,
      FAIMS;FIMS;MA (Phil);MAE (Epidemiology)
      Faculty, Regional Health and Family Welfare Training Centre,
      CHHEB, Kangra-Himachal Pradesh, India.
      01892-265472 (Fax); 01892-263472 (Office)
      Mobile: 094181-28634.
                        drnikhilsurender@ gmail.com

      --- On Wed, 2/10/10, Rakesh Biswas <rakesh7biswas@ gmail.com> wrote:

      From: Rakesh Biswas <rakesh7biswas@ gmail.com>
      Subject: Re: [iapsm_youthmembers ] Hepatitis B in health care workers: Indian scenario-J Lab Physicians
      To: iapsm_youthmembers@ yahoogroups. com
      Date: Wednesday, February 10, 2010, 11:51 AM

      The link says page not found.
      Does this article say that the the incidence of HBV infection in HCWs has decreased in India? Could you mention the figures?

      On Wed, Feb 10, 2010 at 11:12 AM, surendernikhil gupta <drsurendernikhil@ yahoo.com> wrote:
      The risk of hepatitis B infection is well documented among healthcare workers. Although with the use of hepatitis B vaccine the incidence of HBV infection in HCWs has decreased, there is still substantial scope for improvement, as many healthcare workers are unvaccinated. Therefore, there is a need for well-planned and clear policies for HBV screening and vaccination in healthcare workers, especially those who are at a greater risk of exposure to blood or other potentially infectious material.
      Dr. Surender N. Gupta,
      FAIMS;FIMS;MA (Phil);MAE (Epidemiology)
      Faculty, Regional Health and Family Welfare Training Centre,
      CHHEB, Kangra-Himachal Pradesh, India.
      01892-265472 (Fax); 01892-263472 (Office)
      Mobile: 094181-28634.
                        drnikhilsurender@ gmail.com

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