Massive dose vitamin A programme in India - Need for a targeted approach

The National Prophylaxis Programme against Nutritional Blindness due to vitamin A deficiency (NPPNB due to VAD) was started in 1970 with the specific aim of preventing nutritional blindness due to keratomalacia. The Programme was launched as an urgent remedial measure to combat the unacceptably high magnitude of xerophthalmic blindness in the country seen in the 1950s and 1960s. Clinical VAD has declined drastically during the last 40 years. Also, indicators of child health have shown substantial gains in different States in the country. The prevalence of severe undernutrition has come down significantly. Immunization coverage for measles and other vaccine preventable diseases has improved from 5-7 per cent in early seventies to currently 60-90 per cent, in different States. Similarly, there has been a significant improvement in the overall dietary intake of young children. There has been virtual disappearance of keratomalacia, and a sharp decline in the prevalence of Bitot spots. Prophylactic mega dose administration of vitamin A is primarily advocated because of the claim of 23 per cent reduction in childhood mortality. However, benefits on this scale have been found only in areas with rudimentary health care facilities where clinical deficiency is common, and there is substantial heterogeneity, especially with inclusion of all trials. There is an urgent need for adopting a targeted rather than universal prophylactic mega dose vitamin A supplementation in preschool children. This approach is justified on the basis of currently available evidence documenting a substantial decline in VAD prevalence, substantial heterogeneity and uncertainty about mortality effects in present era with improved health care, and resource constraints with competing priorities.