1. food and drink
2. food
3. fruits and vegetables

Guidelines for Administration of
Vitamin A Supplements
In Universal Distribution Projects
Our Mission.
Our mission is to mobilize and deploy private sector resources to advance availability, access and use of
micronutrients, especially vitamin A, by newborns, infants and children in need.
ii
Preface
Vitamin Angels is a leading partner for global elimination of death and disease associated with micronutrient deficiency, especially vitamin A deficiency
among neonates, infants and children. We mobilize and deploy private sector resources to advance availability, access and use of micronutrients,
especially vitamin A, by newborns, infants, and children in need.
Vitamin Angels works to support “universal distribution” and “targeted distribution” of vitamin A in countries defined by the World Health Organization
(WHO) as experiencing moderate to severe vitamin A deficiency. This manual is designed for personnel responsible for managing and delivering health
care services who seek to incorporate distribution of vitamin A into regular activities associated with community or facility-based health care services.
This manual provides information that is essential to be considered when planning and implementing effective universal/targeted distribution of vitamin
A supplements. The focus of this manual is guidelines and technical information to aide in activation of universal distribution of vitamin A supplements.
To a limited extent this manual also provides guidance pertaining to large scale, targeted distribution of vitamin A to high-risk groups. This manual is
designed so that each section may be removed for individual use, and may be reproduced in whole or in part according to user needs.
In initiatives for either universal or targeted distribution of vitamin A supplements, it is likely that those who distribute vitamin A will, inevitably,
encounter infants, children and pregnant mothers who are in need of treatment with vitamin A for measles and xerophthalmia (or more serious ocular
conditions). Information contained herein is NOT intended as a guide to the diagnosis and treatment of these or other conditions. However, some
simple guidance is provided for non-health care workers to help them better understand if an infant, child or pregnant mother should be referred to a
qualified health care practitioner for evaluation for conditions that might require treatment with vitamin A. As a convenience, we have inserted current
treatment schedules for certain common conditions that require treatment with vitamin A; but in all circumstances, seek and follow the advice of local
health care practitioners.
Vitamin Angels would like to acknowledge our use and adaptation of materials from the Pan American Health Organization (PAHO), the Micronutrient
Initiative (MI), and the WHO for inclusion in these guidelines – the use of which is encouraged, in part or in whole, as long as use is not for
commercial purposes. These sources are:
1. Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59
months and women up to 6 weeks postpartum: A guide for health workers, Second edition.
2. Micronutrient Initiative (2007). Vitamin A in child health weeks: A toolkit for planning, implementing, and monitoring.
3. WHO (1998). Distribution of Vitamin A during national immunization days: WHO/EPI/GEN/98.06.
iii
CONTENTS
1. Introduction to vitamin A
1.a. What is vitamin A
1.b. What are dietary sources of vitamin A
1.c. Who needs vitamin A and why
1.d. Vitamin A deficiency (VAD)
1.e. Vitamin A supplements
6
6
6
6
7
2. How to ship, transport, and store vitamin A supplements
2.a. General guidance
2.b. International and onward shipping & warehousing guidance
2.c. Local, point of distribution storage
8
8
9
3. When to give vitamin A supplements
3.a. Universal distribution
3.b. Targeted distribution
3.c. Treatment for night-blindness and xerophthalmia
3.d. Calculating amount of vitamin A needed for a universal distribution program
10
10
10
11
4. Opportunities for distribution of vitamin A supplements
4.a. General
4.b. Child health weeks or days
4.c. Micronutrient days
4.d. Community-based outreach approaches
4.e. Regular deworming programs
12
13
13
13
13
5. How to give vitamin A supplements using capsules
5.a. General instructions for using vitamin A capsules
5.b. Cutting open a vitamin A capsule
5.c. Dispensing vitamin A from a capsule
5.d. Infection prevention in universal vitamin A distribution programs
5.e. Respiratory hygiene / cough etiquette
5.f. Hand hygiene
5.g. Indications for hand hygiene
6. Vitamin A supplements for infants and children 6-59 months
6.a. Screening
6.b. Dosing
6.c. Route of administration of vitamin A supplements
6.d. Follow-up
6.e. How often should vitamin A supplements be given
6.f. Labeling of vitamin A supplements
6.g. Contraindications to giving vitamin A supplements
6.h. Side effects
7. Vitamin A supplements for mothers postpartum
7.a. Screening
7.b. Dosing
iv
14-15
15
15
16
17
17
17
18
18
19
19
19
19
19
19
20
20-21
8. Vitamin A and infants less than 6 months: breastfeeding and supplementation
8.a. Breastfeeding to deliver vitamin A
8.b. Breastfeeding recommendations
8.c. When to begin vitamin A supplementation for infants less than 6 months of age
8.d. Screening
8.e. Dosing
8.f. Follow-up
22
22
23
23
23
23
9. Administration of vitamin A supplements to children who present with selected health conditions
9.a. General
24
9.b. Children with measles
24-25
9.c. Dosing children sick with measles
25
9.d. Children with protein-energy malnutrition
25
9.e. Dosing children with protein-energy malnutrition
26
9.f. Women with eye conditions (Bitot’s spots, xerophthalmia, etc.)
26
9.g. Dosing women with eye conditions
26
9.h. Dosing infants and children with eye conditions
27
10. How to arrange your work station for administration of vitamin A supplementation
28-29
11. Training and public awareness promotion for vitamin A distribution
11.a. Training needed before each distribution
11.b. Creating public awareness communications
11.c. Key promotion messages
11.d. Ways to promote vitamin A distribution
30-31
31
31
31
12. Requirements for vitamin A distribution points
12.a. Supplies needed at each distribution location
12.b. Physical facilities/processes needed at each location at which distribution of vitamin A is to occur
13. Record-keeping in conjunction with distribution of vitamin A
13.a. Recording on a form that anticipates distribution of vitamin A
13.b. Recording on a form that does not anticipate distribution of vitamin A
13.c. Tally Sheet for higher governmental authorities (where required)
13.d. For those completing the tally sheet
13.e. For onsite supervisors who receive tally sheets
13.f. For offsite supervisors and/or health authorities receiving tally sheets
14. Maximizing vitamin A intake
14.a. Sources of vitamin A in ordinary foods
14.b. How to prepare foods to increase vitamin A intake
14.c. Common sources of food with vitamin A and their estimated vitamin A concentration
32
33
34-35
36
36
37
37
37-39
40
40
41
15. References
42-47
16. Appendices
16.a. Appendix A: VAS Priority Countries
16.b. Appendix B: How to Administer Vitamin A
16.c. Appendix C: Instructions for Distribution Supervisors
48-51
52
53
v
01
chapter
Introduction to Vitamin A
What is Vitamin A?
Vitamin A (retinol) is an essential, fat-soluble nutrient stored in body organs, mainly the liver. It is
released, as needed, into the bloodstream, becoming available for use by cells throughout the body.
body11.
The human body does not make vitamin A, so intake of vitamin A from external sources is necessary.
What are Dietary Sources of Vitamin A?
Vitamin A is naturally present in some foods such as milk fat, breast milk, butter, cheese, liver, and fish liver oils. Because
breast milk is a good source of vitamin A, breastfeeding is an important source of vitamin A for newborns and infants.
Vitamin A is also added to many foods known as “fortified” foods, such as ready-to-eat cereals, snack foods, margarine,
and processed dairy products. These foods provide a major dietary source of preformed vitamin A where available and
when accessible by individuals.
Carotenoids, generally found in plants, are converted into vitamin A in the body. Carotenoids are found in dark green leafy
vegetables, deeply colored yellow and orange fruits and vegetables, and egg yolk.2,3 However, conversion of carotenoids
to vitamin A in the body is not very efficient; and it is virtually impossible for most young children of poorer families in the
developing world, to meet their vitamin A requirements just from eating vegetables and fruits.4
Who Needs Vitamin A and Why?
Vitamin A is an essential nutrient required for maintaining eye health and vision, growth, immune function, and survival.5
Everybody needs vitamin A to protect and promote their health, but it is especially critical for growing infants and children
and lactating women. Women who breastfeed need vitamin A to help them stay healthy, and to pass on vitamin A to their
infants through breast milk. Young children need vitamin A after they are weaned to help them to grow, develop normally,
and stay healthy.
Vitamin A Deficiency (VAD)
The body cannot make vitamin A, so all the vitamin A that we need must come from what we eat. However, the body can
store any extra vitamin A we eat for up to 4 to 6 months so that there is a reserve for times of need. When the reserve
supplies in the body are low, and we do not eat enough foods containing vitamin A to meet our body’s needs, vitamin A
deficiency occurs. When an individual experiences vitamin A deficiency, we can experience many adverse health effects,
and some problems, including infections are more severe.16
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Chapter 1: Introduction to Vitamin A
Vitamin A deficiency remains a significant public health problem with an estimated 190 million preschool children and 19
million pregnant women affected globally.17 Intensive efforts remain critically important to prevent and control vitamin A
deficiency.
Vitamin A deficiency is a major contributor to child mortality—its reduction is an essential element of child survival
programs. Likewise, ensuring adequate vitamin A intake by pregnant women is as an essential element of maternal health
and survival programs where deficiency is likely.18
Vitamin A Supplements
Infants, young children and women not eating foods of sufficient quality and quantity to provide the amount of vitamin A
they need, can be given a high-dose form of vitamin A by mouth. Administering vitamin A in this manner is referred to as
vitamin A supplementation.19 Because vitamin A is stored in the liver, high-dose vitamin A supplements need to be given
only once every four to six months to prevent vitamin A deficiency in children.20
Supplementation is a low-cost, highly effective way to improve vitamin A status of children and other population groups,
and is a relatively easy intervention to implement, rapidly, on a national scale.21 In addition, where fortification of foodstuffs
is not yet established, or where population sub-groups don’t have access to fortified foods, supplementation with vitamin A
is an efficient and cost-effective way to ensure adequate intake of vitamin A among vulnerable populations even if it needs
to be continued for a number of years.
There are no health conditions or illnesses that prevent an individual from being given vitamin A. However, children who
are sick, especially with measles or xerophthalmia, who appear for vitamin A supplementation should be given vitamin A
immediately, but also referred to a health facility for further evaluation and possible additional treatment.22,23
Vitamin A is typically available in the form of a capsule that contains a single dose of vitamin A in an oil form. Each capsule
has a narrow end that can be cut off, allowing the contents of the capsule to be “squirted” into the mouth of the intended
recipient. In a very few countries, vitamin A supplementation is available as a syrup.
6
Vitamin A Helps to Protect Our Health in Several Ways:
INCREASES CHANCE OF SURVIVAL
When young children up to 6 years old intake adequate amounts of vitamin A, they are considerably more likely to survive an infection.
Risk of death from measles is reduced by about 50%, from diarrhea by about 40%, and overall mortality by 23-30%.8,9,10
REDUCES SEVERITY OF INFECTIONS
Vitamin A plays a very important role in the immune system and is critical in helping the body resist infection and disease. It also helps
to decrease the severity of many childhood infections, like diarrhea and measles.11
PROMOTES GROWTH
Vitamin A is necessary for growth. Young children have a special need for vitamin A because they are growing rapidly. Pregnant
women need vitamin A to help the growth of their unborn child; women also need vitamin A after birth to protect themselves and to
help their growing infant.12
PROTECTS EYE SIGHT AND THE EYES
Vitamin A is vital for the proper functioning of the eye. The transparent part of the eye, the cornea through which one sees, is
protected by vitamin A. If there is shortage of vitamin A, it may be difficult to see in dim light. A severe shortage of vitamin A may result
in blindness.13 Vitamin A deficiency is the leading cause of preventable blindness in children.14
PREVENTS ANEMIA
Vitamin A works to reduce anemia by facilitating the transport and use of iron. Interventions that control vitamin A deficiency have the
potential to help control anemia induced by either malnutrition or infection.15
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How to Ship, Transport and Store
Vitamin A Supplements
General Guidance
24
Vitamin A supplements are more stable than vaccines. Vitamin A supplements DO NOT need a cold chain and
DO NOT need to be stored in a refrigerator. However, air and sunlight reduces potency of vitamin A. Vitamin A
supplements should:
•
•
•
•
Be kept out of direct sunlight
Be kept cool
Be kept dry
NOT be frozen
International and Onward Shipping &
Warehousing Guidance
Vitamin A supplements provided by Vitamin Angels are factory packed and prepared for international shipment according
to manufacturer specifications consistent with international best practices. The integrity of manufacturer packing should be
maintained throughout international shipment.
Once Vitamin A supplement shipments arrive at the port of entry, shipping agents should maintain packaging and temporary
storage according to shipper’s instructions; however, consignees should take possession of bulk shipments as soon as
practical. Arrangements should be made to clear vitamin A from customs in advance if feasible. Vitamin Angels provides
relevant documentation required by a consignee to prepare and arrange for the release of vitamin A from customs. The
packaging of bulk shipments should be maintained to the maximum extent possible and broken only to the extent required
to inspect quantities and verify labeling. At no time should the seal of any individual container containing vitamin A be
broken until it is to be dispensed to the person intended to take it.
Onward shipment within a country of vitamin A packaged in bulk should be completed as quickly as possible while
maintaining the original package to the extent possible – while minimizing exposure to light and heat, preventing freezing,
and maintaining dry conditions.
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Chapter 2: How to Ship, Transport, and Store Vitamin A Supplements
Capsules: Normally, vitamin A comes in the form of a “gelatin capsule.” Each capsule corresponds to a single dose, and
capsules are transported in bulk in sealed, opaque, containers with 100, 500 or 1000 capsules to a container. Where vitamin
A in capsule form is temporarily warehoused in bulk, a quantity of 10,000 capsules – a volume sufficient to meet the needs
of 5,000 children for one year – will require approximately one cubic meter of space in a dry, cool area out of direct sunlight
without possibility of freezing temperatures.
Syrup: In some, very limited circumstances, vitamin A is prepared by the manufacturer as syrup and packed in sealed
bottles – each bottle contains a number of doses. Where vitamin A is provided as syrup packaged in bottles, it will require a
larger space for storage that is dependent upon the volume of syrup in each bottle.
Whether the vitamin A supplement is in the form of capsules or a syrup preparation, individual bulk containers should not be
opened at central or regional warehouses, but kept intact until received at the point of distribution to individuals.
Steps should be taken by those managing the supply and distribution of vitamin A to monitor expiry dates to ensure use
before expiration
Local, Point of Distribution Storage
• Vitamin A can be stored locally in a secured room or cabinet that ensures containers remain out of direct sunlight, cool, dry and not subject to
freezing. Care should be taken to ensure containers are secure from insects and pests. Do not store vitamin A in the same place as poisonous/
toxic substances or chemicals as kerosene and petrol.
• If unopened and stored in a sealed, bulk container, vitamin A in capsule or syrup forms will retain their potency, under good conditions of
storage, for at least 2 years.25,26,27,28
Capsules:
Once the seal on a bulk container is opened, individual capsules should be used within 1 year.
Syrup:
Vitamin A preparations in syrup form, if properly stored in their original container, should be used within
6-8 weeks of opening the bottle.29
• Write the date on the label once a bulk container of capsules or a glass bottle of vitamin A syrup is opened so that you will know when to
stop using it.
• Always check the expiry date printed on the label. Although preparations stored beyond the
designated periods are less potent, they are nevertheless safe and often contain enough
vitamin A for therapeutic use.30,31
• Storage of 100,000 IU and 200,000 IU capsules (generally different colors) should be
separate and clearly marked, so the two different doses do not get mixed up.32,33
• All vitamin A supplements should be stored in opaque containers—aluminum containers
are frequently used—for protection against light.34
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When to Give
Vitamin A Supplements
The importance of vitamin A to infant and child health has prompted WHO/UNICEF to recommend
administration of vitamin A in three ways35: universal distribution, targeted distribution, and treatment.
Each is summarized here.
Universal Distribution
Technical advisory groups recommend universal distribution within a given geographical region to all infants and children
6 – 59 months of age as well as to lactating women, including lactating women who are not breastfeeding36; it is an effective
way to prevent vitamin A deficiency among infants, children, and women.
Universal distribution is recommended in all countries identified by WHO/UNICEF as priority countries for vitamin A
supplementation;37 these countries have vitamin A deficiency that is classified as a moderate or severe public health
problem. The current 122 priority countries are highlighted in the table in Appendix A [page 48].
While supplementation programs are often viewed as an interim solution until fortified foods are in widespread use, vitamin
A supplementation programs are increasingly viewed as a viable long-term solution for combating vitamin A deficiency.
Targeted Distribution
Vitamin A supplementation is an effective way to prevent vitamin A deficiency among high-risk groups. Groups with an
increased risk of vitamin A deficiency include children suffering from protein-energy malnutrition or a childhood infection
(such as measles, diarrhea, respiratory disease, and chickenpox), siblings of children with protein-energy malnutrition or
a childhood infection, siblings of children with xerophthalmia, children living in the same village or community as children
suffering from protein-energy malnutrition, a childhood infection, or xerophthalmia, and certain very high-risk groups such
as refugees or other populations suddenly cut off from regular food supplies or experiencing famine conditions.
Treatment for Night-Blindness and Xerophthalmia
Although beyond the scope of this document, vitamin A supplementation is recommended for treatment of specific medical
conditions, including but not limited to those with night-blindness or xerophthalmia.
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Chapter 3: When to Give Vitamin A Supplements
Calculating the Amount of Vitamin A Needed for a
Universal Distribution Program
38
The calculations below provide a method for computing an estimate of the amount of vitamin A supplies that should be
on hand based on the assumption that all children 6 – 59 months of age in an administrative jurisdiction (e.g., a district or
province) will be dosed with vitamin A.
For Every 1,000 Population,
Assume that:
1.5% are infants under 6 months of age - 15
Approximate Annual Procurement for
Every 1,000 People Translates Into:
Number of 50,000 IU capsules needed = 15 capsules
(15 person x 1 capsule = 15 capsules)
1.5% are infants 6 months to 1 year of age - 15
Number of 100,000 IU capsules needed = 15 capsules
(15 persons x 1 capsule = 15 capsules)
5% are children 1-3 years of age - 50
9% are children 3-5 years of age - 90
3% are lactating women - 30
Number of 200,000 IU capsules = 310 capsules/year
(50 persons x 2 capsules/year) + (90 persons x 2 capsules/year) +
(30 person x 1 capsule) = 100 + 180 + 30 = 310 capsules/
1,000 population
Note: for programs where distribution anticipates inclusion of sufficient vitamin A to treat for Bitot’s spots and active
xerophthalmia, the following references are handy as a guide for computing the additional quantities of vitamin A (200,000 IU
formulation) needed per 1,000 population:
• 25% of the general population, or 250 are women of reproductive age; one should assume that 4% of these will
have Bitot’s spots = 10 persons. Assume each will be treated with one dose, so that an additional 10 capsules of
200,000 IU vitamin A capsules should be on hand for every 1,000 population.
• 5% of children 1-5 years of age, or 8 children will have one episode of xerophthalmia per year. Assume each will
be treated with one dose immediately, so that an additional 8 capsules of 200,000 IU vitamin A capsules should
be on hand for every 1,000 population.
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Opportunities for Distribution of
Vitamin A Supplements
General
Distribution of vitamin A supplements is traditionally undertaken in the context of a variety of health systems related
initiatives (e.g., MCH services at health centers and community outreach services conducted under the auspices of a
ministry or department of health – often in collaboration with a ministry or department of education).
Increasingly, experience shows that initiatives to distribute vitamin A through programs and projects affiliated with the health
system are nearing their potential, yet large numbers of infants and children who do not have access to the formal health
system are not reached by traditional distribution systems. Consequently, large scale demonstration projects are being
undertaken to distribute vitamin A through innovative distribution schemes coordinated with, but operated entirely outside
the health system. For example, large, community-based micro-finance associations are undertaking vitamin A distribution.
The focus of this section is the opportunities for vitamin A distribution in the context of health programs. As a basic premise,
all health systems operating in countries experiencing vitamin A deficiency should take the opportunity to increase coverage
of vitamin A supplementation by adding supplementation services to all basic health services irrespective of whether
distribution takes place within a health care facility or through community health outreach services.
Vitamin A Distribution Can be Integrated Into Any Number of Existing Health
39,40
Service Interventions Including:
• As a part of regular services at facility based health care centers as a part of:
• Expanded program for immunization (EPI) activities 39,41
• Integrated management of childhood illness (IMCI)
• Maternal and child health (MCH) services,
• Maternal and child survival services, and
• Other postnatal care services;
• During specially planning “Child Health” or “immunization days or weeks”,
• During specially organized “micronutrient” distribution events,
• Through community-based outreach and distribution, and
• During regularly scheduled “deworming” programs.
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Chapter 4: Opportunities for Distribution of Vitamin A Supplements
All health workers should always ask the parents if the child is in need of the next dose of vitamin A supplement, or check
the immunization or health card of the child and the health card of the mother for the last date of vitamin A supplementation.
Every immunization contact, postpartum contact of the mother, and well-baby or sick-child consultation should be
used to check and treat children with vitamin A deficiency. Mothers should be screened and administered vitamin A
supplementation at delivery, during postpartum contacts, and during immunization contacts for her child within the first six
weeks postpartum.
Child Health Weeks or Days
Child Health Weeks (CHW) are regular events organized to deliver an integrated
package of preventive services known to be highly cost-effective for improving child
health and survival that are run in conjunction with routine services at health facilities.
CHWs aim to reach all children under the age of 5 years at least every 6 months during
a limited time period (i.e., a day, week or month). The package of essential preventive
health services is defined by local circumstances and needs and can include vitamin
A supplementation, deworming, insecticide-treated bed nets (ITN’s) or other services
as deemed appropriate.
For a more in-depth discussion
of ways to organize vitamin A
supplementation programs around
other health activities, see the
Micronutrient Initiative’s manual:
Vitamin A in child health weeks: A
toolkit for planning, implementing,
and monitoring (2007).
Micronutrient Days
In many countries, vitamin A has been distributed successfully during National
Immunization Days, providing one vitamin A supplement per year. Micronutrient
Days were developed to provide the second distribution per year. Typically,
specific dates during the year are identified as the focus for distributing vitamin
A supplements and other micronutrients such as iron and folic acid tablets.
Community-Based Outreach Approaches
This approach is usually administered through the government health infrastructure
and is based upon massive social mobilization. Supplements are distributed to
the district health office, then on to health posts, and then through village workers.
One successful example of this approach comes from Nepal where a program
was initiated to have female community health volunteers distribute capsules on
the same 4 days every year (two days for the first distribution and two for the
second).
Regular De-Worming Programs
About two-thirds of countries experiencing vitamin A deficiency also are classified
by WHO as being endemic with soil-transmitted helminths (STHs) or “worms.” STHs
compete for available micronutrients ingested by infants and children. In countries
with regular deworming programs, treatment of STH is a perfect opportunity to
provide vitamin A supplements as the distribution schedule for both a deworming
agent and vitamin A are similar.
page 13
For more information about
when and how to appropriately
integrate regular deworming, see
the WHO/UNICEF manual: How
to add deworming to vitamin A
distribution (2004).
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How to Give Vitamin A Supplements
Using Capsules
Administering vitamin A is a simple act that can be performed by skilled health workers or virtually any
level of community worker with nominal training, including community volunteers trained to distribute
vitamin A.42
General Instructions for Using Vitamin A Capsules
43,44,45
Step 1
Check that you know what dose of vitamin A to administer to individuals of a given age group. Vitamin A typically comes in
color coded capsules containing either 50,000 IUs, 100,000 IUs or 200,000 IUs of vitamin A. Check the label of the bottles
to make sure you know which capsules are available during any given distribution. Also, check the expiration date on the
label.
Step 2
Before administering vitamin A to infants and children, it is important for those administering vitamin A to wash their hands
with soap and preferably clean water. If while administering vitamin A, a sick infant or child is encountered, the person
administering vitamin A should wash his/her hands between each child.
Step 3
As each child arrives, check the child’s age and decide what dose of vitamin A should be given. This can be done by asking
the child’s age of an accompanying caregiver or by observing the child – children who walk are likely to be at least 12
months old.
Step 4
Ask if the child has received vitamin A capsule in the last one month. If the answer is yes, confirm and do not
administer. If no, continue.
(NB. If you are using only 200,000 IU capsules you need to calculate the number of drops for a half-dose (100,000 IU) for infants age 6 – 12
months of age; or calculate the number of drops for a quarter dose (50,000 IU) for infants under 6 months of age. To do this, open a few
capsules with scissors, squeeze out the contents and count the number of drops per capsule. Calculate the average number of drops, and
divide by 2 for the number of drops for a half dose (100,000 IU), or divide by 4 for the number of drops for a quarter dose (50,000 IU). If there
are an odd number of drops, round up. Similarly, if you have access only to 100,000 IU capsules, you will need to use two capsules where
200,000 IUs are required; or alternatively use half the amount in the capsule for use where only 50,000 IUs are required).
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Chapter 5: How to Give Vitamin A Supplements Using Capsules
Step 5
Ask the caretaker to hold the child, make sure the child is calm. Select the appropriate dose of vitamin A
for the infant or child:
• 50,000 IU to an infant less than 6 months of age
• 100,000 IU to an infant 6 - 11 months of age
• 200,000 IU to children more than 12 months of age
Step 6
Cut open the narrow end of each capsule with scissors and squeeze the correct amount of vitamin A into the child’s mouth.
•
DO NOT give the capsule to the child
•
DO NOT ask a child to swallow the capsule
•
DO NOT give the capsule to the mother to administer vitamin A at later time
Step 7
Place each used capsule in a plastic bag or container and wipe hands to clean off oil. To avoid accidental ingestion by
children or animals, safe disposal can be achieved by burying or if possible, burning used capsules.
Step 8
Place one tally mark on the tally sheet for each child given a dose of vitamin A; also record the dose on the child health
card, if available. DO NOT record the number of capsules or the age of the child.
Step 9
At the conclusion of distribution of vitamin A each day, be sure to close the bottle from which you took the vitamin A
capsules to ensure that the remaining capsules stay protected from light and moisture.
Cutting Open a
Vitamin A Capsule
Dispensing Vitamin A
from a Capsule
• Open the capsule by cutting across the narrow end with a
clean pair of scissors (see photo below).
• Squeeze the sides of the capsule firmly, and carefully
drop all the contents of the capsule into the mouth of the
recipient (see photo below).
• To avoid finger pricks, do not use pins to open the
capsules. Also, do not open capsules with your teeth.
• DO NOT place the capsule in the mouth of the
infant or child.
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Infection Prevention in Universal Vitamin A
Distribution Programs
Without proper precautions, universal distribution of vitamin A may risk the spread of infectious diseases. The nature of
universal distribution programs makes this risk small, nonetheless, simple steps can be taken to lower the risks or even
prevent the transmission of infections and diseases.
Broadly speaking, universal distribution of vitamin A usually takes place in one of two settings: a community-based setting
outside a health care facility (e.g., a school, community center or some other local gathering place), or in an out-patient
health care clinic. In community-based settings, the risk of spreading infectious diseases is generally no greater than the
risk when any large group of children gather with one an other in a public setting. In health care settings, the risk may
actually be increased because of several reasons:
• Many of the people seeking health care services are already sick,
• Invasive procedures are routinely performed in health care facilities which can provide more opportunities for anyone else in the
facility to be at greater risk to exposure to micro-organisms,
• Service providers and other staff are constantly exposed to potentially infectious materials as a part of their work, and without
proper precautions can inadvertently spread infectious materials to other persons with whom they have contact, and
• Services are sometimes provided to many clients in a limited physical space, often during a short period of time, and can lead to
increased exposure of all clients.
Infection prevention practices should be adapted and applied, routinely, in any setting in which universal distribution of
vitamin A is undertaken46 in order to protect clients (infants, children, etc. who are intended to receive vitamin A), health
care workers and other staff and volunteers. As a starting point, those considering a universal distribution program should
consider how to address the underlying need that is implied by generally accepted or “standard” precautions.
These include:47
• Hand washing and antisepsis (hand hygiene),
• Use of personal protective equipment (e.g., gloves, mask, goggles, apron, gown, shoe cover, hair cover) when handling blood,
body substances, excretions and secretions,
• Appropriate handling of patient care equipment and soiled linen,
• Prevention of needle stick / sharp injuries,
• Environmental cleaning and spills-management, and
• Appropriate handling of waste.
For universal distribution of vitamin A that is to take place at very busy ambulatory
health care centers, these centers should already rigorously employ standard
infection prevention practices before introducing programs for universal distribution
of vitamin A – especially if the facility can’t easily segregate those receiving vitamin A
from those generally coming to receive care as sick patients.48
For a more in-depth discussion
about these issues, see
EngenderHealth (2001), Infection
prevention: A reference booklet for
health care providers.
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Chapter 5: How to Give Vitamin A Supplements Using Capsules
Respiratory Hygiene/Cough Etiquette
52
Controlling the spread of pathogens from infected individuals is key to avoid transmission to unprotected contacts. For
diseases transmitted through large droplets and/or droplet nuclei, respiratory hygiene/cough etiquette should be applied by
all individuals with respiratory symptoms. All individuals (health workers, children, mothers, volunteers and visitors) with signs
and symptoms of a respiratory infection should:
• Cover their mouth and nose when coughing/sneezing,
• Use tissues, handkerchiefs, cloth masks or medical masks if available, as source control to contain respiratory secretions, and
dispose of them into the waste containers,
• Use a medical mask on a coughing/sneezing person when tolerated and appropriate, and
• Perform hand hygiene.
Vitamin A distribution management should promote respiratory hygiene/cough etiquette:
• Promote the use of respiratory hygiene/cough etiquette by all health care workers, children, and family members with acute
febrile respiratory illness,
• Educate health care workers, children, mothers, and visitors on the importance of containing respiratory aerosols and secretions
to help prevent the transmission of respiratory diseases, and
• Consider providing resources for hand hygiene (e.g. dispensers of alcohol-based hand rubs, hand-washing supplies) and
respiratory hygiene (e.g. tissues); areas of gathering, such as waiting rooms, should be prioritized.
Hand Hygiene
49
Hand hygiene is one of the most important measures to prevent
and control spread of disease and is a major component of
Standard Precautions. The main points are:
Indications for Hand Hygiene
Perform hand hygiene:
• Before and after touching each child or mother,
• Use of an alcohol-based hand rub is the preferred
means for routine hand hygiene if hands are not visibly
soiled. If alcohol-based hand rub is not available, wash
hands with soap and water, using a single-use towel for
drying hands.
• If hands are visibly dirty or soiled with blood or other
body fluids, or if broken skin might have been exposed
to potentially infectious material, or after using the
toilet, hands should be washed thoroughly with soap
and water.
Alcohol-based hand rubs with optimal antimicrobial efficacy
usually contain 75 to 85% ethanol, isopropanol, or n-propanol,
or a combination of these products. The WHO-recommended
formulations contain either 75% v/v isopropanol, or 80% v/v
ethanol.50
51
• After contact with body fluids or excretions, mucous
membranes, and
• After contact with inanimate surfaces and objects (including
medical equipment) in the immediate vicinity of each child
or mother.
Before handling vitamin A supplements or de-worming medication,
perform hand hygiene using an alcohol-based hand rub or wash
hands with either plain or antimicrobial soap and water.
Soap and alcohol-based hand rub should not
be used at the same time.
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Vitamin A Supplements for
Children 6-59 Months
Screening
• There are no conditions or illnesses that prevent a child from being given vitamin A; however, children who come for
supplementation who are sick with measles or xerophthalmia should be given vitamin A and then referred to a health facility
for treatment.53,54
• From the age of 6 months, children should be screened to determine eligibility for a dose of vitamin A at all immunization and
other health contacts. Eligibility can be determined by checking the immunization or child health card for the last date of
vitamin A supplementation.
• Vitamin A supplements can be safely given at the same time as vaccines55,56 and with deworming medications.57
• Advantage should be taken of all opportunities when a child comes in contact with health services to screen and provide
vitamin A supplements to children.
Dosing
In the table below, you will find the correct dosing and schedule of administration for vitamin A supplementation in universal
distribution programs for children 6-59 months of age in order to prevent vitamin A deficiency.58,59
Ascertain (or estimate) the age of the child to ensure that you are providing the correct dose for the age of the child.60,61
Vitamin A Dosing Schedule for Universal Distribution of Vitamin A:
Children 6-59 Months of Age
TARGET GROUP
DOSE
HOW OFTEN
Infants 6-11 months of age
100,000 IU, administered orally
Every 4-6 months
Children 12-59 months of age
200,000 IU, administered orally
Every 4-6 months
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Chapter 6: Vitamin A Supplements for Children 6-59 Months
Route of Administration of Vitamin A Supplements
Vitamin A supplements for prevention of vitamin A deficiency are given by mouth (orally). Vitamin A supplements presented
in capsules should never be given by injection.
Follow-up
• Immediately after administering the proper dose of vitamin A, instruct the parent when to return with the child for its next dose
of vitamin A.
• The person administering vitamin A should communicate to the parent, in a manner appropriate for the parent to remember, the
next date of vitamin A supplementation.
How Often Should Vitamin A Supplements be Given
Vitamin A supplements give protection against vitamin deficiency for a period of 4 to 6 months. Therefore, it is
recommended to give a vitamin A supplement every 4 to 6 months to young children who do not receive the amount they
need from their food.
Labeling of Vitamin A Supplements
Preparations of vitamin A supplements are labeled in international units (IU). Preparations also may be labeled in milligrams
(mg) or micrograms (mcg, µg). Always check the manufacturer’s instructions.
Contraindications to Giving Vitamin A Supplements
There are no contraindications to giving vitamin A supplements to children. However, children with respiratory infections
unable to breath properly, or any child who has already received a preventive dose of vitamin A within the last one month
should not be supplemented with vitamin A.62,63
Side Effects
At the doses that vitamin A is given for universal distribution programs, the dosage has a wide margin of safety.
Consequently, side effects are very rare. Nonetheless, some side effects may occur, including that a child may eat less
for a day, or there could be some vomiting or headache. Advise the adult that accompanies the child for vitamin A
supplementation that there is a small risk for side effects, that these side effects are normal, that the symptoms will pass
and that no specific treatment is necessary.64,65
A Note for Trainers on the Side Effects and Safety of Vitamin A Capsules
56
When training service providers, this topic is best dealt with when discussing “how to give vitamin A.” It is important
for all trainers to be confident about the safety of vitamin A, how to communicate the safety of vitamin A to those who
bring their child for vitamin A supplementation, and how to communicate what side effects may occur – even if very
rare – and how these side effects should be dealt with. When the protocol and techniques for administration of vitamin
A are properly followed, vitamin A is safe.
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Vitamin A Supplements for
Mothers Postpartum
Screening
Pregnant women and women of child-bearing age:66,67
Pregnant women, or women of childbearing age who may be in the early stages of pregnancy without knowing it, should NOT be given
large dose vitamin A supplements (over 10,000 IU). A large dose of vitamin A given early in pregnancy may damage the unborn child.
Women up to 6 weeks after delivery:68,69,70
It is only safe to give large dose vitamin A supplements (over 10,000 IU) to women of childbearing age within 6 weeks after delivery.
At this time, there is almost no chance that the mother is pregnant.
Vitamin A supplementation of the lactating mother increases her own body reserves of vitamin A (which is important for
keeping the mother healthy), and potentially, can increase vitamin A in her breast milk to the benefit of the infant and its
vitamin A status through the first few months of life. The earlier vitamin A supplementation is given to the lactating mother,
the sooner the mother’s vitamin A status is raised.
Dosing
In the table on the next page, you will find the correct dosing and schedule
of administration for vitamin A supplementation in universal distribution
programs for lactating mothers in order to prevent vitamin A deficiency.
Mothers should receive vitamin A supplementation within 6 weeks of
delivery.
Supplements may also be given daily or weekly in low doses during the first
6 months after delivery.
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Chapter 7: Vitamin A Supplements for Mothers Postpartum
Vitamin A Dosing Schedule for Universal Distribution of Vitamin A:
Women up to 6 Weeks Postpartum
TARGET GROUP
DOSE
HOW OFTEN
Women immediate after delivery
200,000 IU, administered orally
Once
OR
Women immediately after delivery
10,000 IU, administered orally
Daily for six weeks after delivery
OR
Women immediately after delivery
25,000 IU, administered orally
page 21
Weekly for six weeks after delivery
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Vitamin A and Infants Less Than 6
Months of Age: Breastfeeding and
Supplementation
Breastfeeding to Deliver Vitamin A
71
There is considerable evidence that newborn infants are born with limited reserves of vitamin A, particularly in countries with
high rates of vitamin A deficiency. When a lactating mother has sufficient vitamin A stores, she passes vitamin A through
breast milk to her child and ensures its adequate vitamin A status. So, the promotion and support of breastfeeding should
be an important part of any strategy to prevent vitamin A deficiency.72
A mother should breastfeed her infant for its first 6 months of life without other foods or liquids. After 6 months, the mother
should introduce complementary foods and keep breastfeeding – generally until the child is 2 years of age.
Those who administer vitamin A supplementation should always: i) encourage a mother to feed their infant using
breastfeeding exclusively until the infant is 6 months of age, and where possible, ii) advise mothers on the benefits of
breastfeeding, and how to breastfeed adequately.
Breastfeeding Recommendations
73
• Mothers should start breastfeeding shortly after delivery (within the first hour).
• Mothers should be instructed on the proper attachment of the child to the breast.
• The child should be breastfed as often and as long as the child wants, day and night, up to every 2½ to 3 hours or
between 8 to 12 times a day.
• Mothers should not give her child food or drink, including water, other than breast milk during the first 6 months;
and feeding bottles and pacifiers should not be used.
• Mothers should consume a balanced diet and drink sufficient liquids in order to ensure a good milk supply.
• Frequent breastfeeding should be promoted since it stimulates adequate breast milk production to meet the daily
requirements of the child.
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Chapter 8: Vitamin A and Infants Less Than 6 Months of Age:
Breastfeeding and Supplementation
When to Begin Vitamin A Supplementation for Infants
Less than 6 Months of Age
74
For infants who are not breast-fed or for breast-fed infants whose mothers have not received a vitamin A supplement, the
current recommendation is for these infants to receive a 50,000 IU vitamin A supplementation one time before the age of 6
months.
Screening
• There are no conditions or illnesses that would prevent a infant from being given vitamin A; however, children who come for
supplementation who are sick with measles should be referred to the health facility for treatment.75,76
• From birth, an infant’s eligibility for a dose of vitamin A should be determined at all immunization and other health contacts. A
child is eligible for vitamin A if they have not received vitamin A supplementation within the past 4 months.
• Vitamin A supplements can be safely given at the same time as vaccines.77,78
• Advantage should be taken of all opportunities when an infant comes in contact with health services to screen and provide
vitamin A supplements to children.
Dosing
In the table below, you will find the correct dosing and schedule of administration for vitamin A supplementation in universal
distribution programs for infants less than 6 months of age to prevent vitamin A deficiency.79
Vitamin A Dosing Schedule for Universal Distribution of Vitamin A:
Children 0-6 Months of Age
TARGET GROUP
DOSE
HOW OFTEN
Infants <6 months of age who
are not breast-fed
50,000 IU, administered orally
Once
Infants <6 months of age who are
breast-fed whose mothers have not
received a vitamin A supplement
50,000 IU, administered orally
Once
Follow-up
• Immediately after administering the proper dose of vitamin A, instruct the parent when to return with the infant for its next dose
of vitamin A.
• The person administering vitamin A should communicate to the parent, in a manner appropriate for the parent to remember, the
next date of vitamin A supplementation.
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Administering Vitamin A Supplements
to Children Who Present with
Selected Health Conditions
General
In general, any infant or child who is sick and otherwise eligible to receive vitamin A should be
given vitamin A. Although it is beyond the scope of this manual to give guidance on diagnosis and
comprehensive treatment of children sick with any condition, for convenience of those operating a
universal distribution program – who are likely to see children who are sick – instructions for handling
and dosing children with certain common conditions are provided here. In all circumstances, sick
infants and children should be immediately referred to a health care provider for further evaluation and
treatment immediately after dosing with vitamin A unless dosing is specifically contraindicated.
Children with Measles
All children with the measles infection should be provided high dose vitamin A supplementation. Administration of vitamin
A to children at the time of measles diagnosis decreases both the severity of disease and the case fatality rate. Children
who live in areas where measles is a common infection should also receive vitamin A supplementation as a preventative
measure.80
Children who come for supplementation who are sick with measles should be segregated from other children if possible,
supplemented with vitamin A, and immediately referred to a health care professional for further evaluation and treatment.
Persons administering vitamin A who come in contact with a sick child should immediately wash their hands with soap and,
preferably, clean water.
Dosing Children Sick with Measles
81,82
• The first dose of vitamin A should be administered on the day of measles diagnosis, with the exact dosage depending on age.
The second dose should be administered the following day.
• When the mother is not able to return for the second dose, she should be given the vitamin A supplement to administer at home.
• The age-specific dosing schedule for giving vitamin A supplements to children with measles is on the next page.
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Chapter 9: Administering Vitamin A Supplements to
Children who Present with Selected Health Conditions
Vitamin A Supplementation Schedule During Measles:
Children 0-59 months of Age
TARGET GROUP
HOW OFTEN
DOSE
Immediately upon presentation/diagnosis:
Infants < 6 months of age
50,000 IU, administered orally
Once
Infants 6-11 months of age
100,000 IU, administered orally
Once
Children > 12 months of age
200,000 IU, administered orally
Once
Next Day:
As Above
Same age-specific doses as above
Once
At Least Two Weeks Later:
As Above
Same age-specific doses as above
Children with Protein-Energy Malnutrition
Once
83
Children with severe protein-energy malnutrition (PEM) are at increased risk of having or developing vitamin A deficiency.
Any child with severe malnutrition, showing visible wasting or edema of both feet, should be given a high dose of vitamin A
supplement immediately on diagnosis and referred to the hospital for treatment.
High dose vitamin A supplements should only be administered to children who have not already received vitamin A
supplementation within the last 4 weeks.
Dosing Children with Protein-Energy Malnutrition
84
• A single high dose of vitamin A supplement, according to age, should be given to children with severe malnutrition immediately
on diagnosis.
• The age-specific dosing schedule for giving vitamin A supplements to children with severe PEM is indicated below.
Vitamin A Treatment Schedule During Severe Protein-Energy Malnutrition:
Children 0-59 months of Age
TARGET GROUP
DOSE
HOW OFTEN
Immediately upon presentation/diagnosis:
Infants < 6 months of age
50,000 IU, administered orally
Once
Infants 6-11 months of age
100,000 IU, administered orally
Once
Children > 12 months of age
200,000 IU, administered orally
Once
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Women with Eye Conditions (Bitot’s spots, xerophthalmia, etc.)
According to the WHO, women of reproductive age, infants and children with night blindness or Bitot’s spots should be
treated; and community campaigns provide an opportunity to provide such treatment.
Dosing of Women with Eye Conditions
Women of reproductive age with night blindness or Bitot’s spots should be
treated with a daily dose of 5,000 - 10,000 International Units of vitamin A for
at least 4 weeks. Such a daily dose should never exceed 10,000 IU, although
a weekly dose not exceeding 25,000 IU may be substituted. When severe
signs of active xerophthalmia (i.e., acute corneal lesions) occur in women of
reproductive age, the WHO recommends, whether the women is pregnant or
not, it is necessary to balance the possible teratogenic effect or other risks
of a high dose of vitamin A to the fetus (should she be pregnant) against the
serious consequences (for her and the fetus) of VAD. In these circumstances,
the high dose treatment for corneal xerophthalmia as described below can be
administered.85
Vitamin A Supplementation Schedule for Treatment of Corneal Xerophthalmia
in Women of Reproductive Age
TARGET GROUP
DOSE
HOW OFTEN
Immediately upon presentation/diagnosis:
Women of reproductive age
200,000 IU, administered orally
Once
Next Day:
As Above
Same doses as above
Once
At Least Two Weeks Later:
As Above
Same doses as above
Once
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Chapter 9: Administering Vitamin A Supplements to
Children who Present with Selected Health Conditions
Dosing of Infants and Children with Eye Conditions
85
(Bitot’s spots, xerophthalmia, etc.)
Vitamin A Supplementation Schedule for Treatment of Xerophthalmia in
Infants and Children all Ages
TARGET GROUP
DOSE
HOW OFTEN
Immediately upon presentation/diagnosis:
Infants < 6 months of age
50,000 IU, administered orally
Once
Infants 6-11 months of age
100,000 IU, administered orally
Once
Infants > 12 months of age
200,000 IU, administered orally
Once
Next Day:
As Above
Same age-specific doses as above
Once
At Least Two Weeks Later:
As Above
Same age-specific doses as above
Once
Notes:
1.
"Next day” dosing and subsequent doses can be administered by the child’s mother at home.
2.
The WHO recommends that all children with measles be treated with the same schedule of vitamin A supplementation
for xerophthalmia,
3.
Children with severe measles should be treated with vitamin A according to the following schedule: 200,000 IU on day
1 and followed by a second 200,000 IU dose on day 2.
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How to Arrange a Work Station
for Administration of Vitamin A
Supplementation
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Chapter 10:
How to Arrange a Work Station for Administration of Vitamin A Supplementation to Ensure a Smooth Flow of Clients
How to Arrange a Workstation for Administration of
Vitamin A Supplementation to Ensure a Smooth Flow of
Clients
87,88,89
1. Vaccinate the child.
2. Ensure procedure saftey.
3. Monitor and respond to
reactions.
3
2
Vitamin A &
Deworming Table
IMMUNIZATION
TEAM
Immunization
Table
(includes the provision of deworming agents and immunizations)
TALLY TEAM
2. Record the dose given on the
attendance card.
Tally
Table
1. Check that child is in the target
age group.
4
1
Register
Table
2. Tally the number of deworming
doses given by age group.
1. Check the age of the child and
give vitamin A +/- deworming
tablet according to protocol.
REGISTRATION TEAM
Using each child’s attendance
card, record on tally sheet each
treatment receieved.
1. Tally the number of vitamin A
doses given by age group.
VITAMIN A &
DEWORMING TEAM
2. Give the caretaker one
attendance card for each child.
3. Write the child’s age on the
back of the card.
3. Tally the number of
immunization doses given by age
group.
HEALTH EDUCATION
Health
Education
Waiting
Area
1. Instruct caretaker when to
return with their children for the
next appropriate dose of vitamin
A supplement.
2. Provide caretaker with a paper
reminder of the next dosing case.
Enter/Exit
CROWD CONTROL TEAM
» Assist in setting up the post each day
» Maintain order in the waiting zones
» Inform the crowd of any delays
» Keep flow of people moving
» Mobilize the community
• This is one way of organizing the flow of children & mothers coming for health care.
• If you are giving immunizations, vitamin A should be given first so the child is not upset & crying when trying to swallow
the drops from vitamin A capsule.
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Training and Public Awareness
Promotion for Vitamin A Distribution
Whether vitamin A is distributed at one or multiple locations, the manager of operations should ensure
that training or re-fresher training for proper distribution of vitamin A takes place, and actions be taken
that create public awareness and information about vitamin A distribution. Key points regarding training
and public awareness communications are provided in this section. For a more in-depth discussion
about these issues, see the MOST/USAID (2001) Twice-yearly vitamin A supplementation: A guide for
program managers and the Micronutrient Initiative (2007) Vitamin A in child health weeks: A toolkit for
planning, implementing, and monitoring.
Training Needed Before Each Distribution
90
As many health providers and/or community leaders are not informed about vitamin A and its important role in preserving
child health, appropriate training should be undertaken that addresses the benefits of vitamin A as well as all aspects of
organizing and implementing distribution.
Training should be tailored to account for whether this is the first time vitamin A distribution is being undertaken and
whether it is a routine activity using the same staff or new staff. Training may be quite intensive at the start of a new
program; however, as vitamin A distribution becomes more routine, refresher or even just-in-time on-the-job training may be
more appropriate.
The training should take place in advance of the vitamin A distribution so that each team / location has time to complete
training and preparations needed for a distribution event.
During training, the health worker should practice telling the caregiver that the child is receiving vitamin A, say something
positive to the caregiver about participation (“vitamin A will help your child resist disease/ grow well/be strong/stay
healthy”), and remind the caregiver when to come back for the next capsule.
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Chapter 11:
Training and Public Awareness Promotion for Vitamin A Distribution
Training Should Focus On:
• Information on benefits/basic facts about vitamin A. Health workers need to know the benefits associated with vitamin A capsules
as well as other basic facts about vitamin A (see Appendix B).
• Skill development for capsule providers. Health workers need to be competent in proper administration of vitamin A capsules—
knowing proper dosage, estimating age, cutting capsules, tallying, etc. Training that gives the workers an opportunity to solve
problems in a simulation of the distribution event will be more effective than relying only on lectures. Demonstration with practice
works best; for example, workers should be asked to demonstrate how to use a 200,000 IU capsule for a child under one.
Creating Public Awareness Communications
The advantage of periodic supplementation lies in the ability to promote participation actively by mothers for relatively little
expense, as the promotion occurs only twice each year. Over time, a well-conceived strategy to promote public awareness
of vitamin A as a means to preserve the health of children will result in the creation of demand throughout the community for
initial and ongoing vitamin A distribution programs.91
Key Promotion Messages:
For promotion of vitamin A distribution in communities, minimum information containing key messages should be
provided, about a month before the distribution, to all parents and caregivers, including:92
• Dates of vitamin A distribution
• Where and when to go (times and locations for the nearest services)
• What services will be given
• Instructions to bring all children age 6 to 59 months (with their child health card)
• Health benefits of the services (i.e. that this is important for the health of every child)
Ways to Promote Vitamin A Distribution
There are many ways of communicating to the community, and it is up to each manager to prioritize which methods work
best in their community. Using more than one method will increase the chances of messages reaching the target group.
For example, there are a number of promotional methods that are effective for spreading the word about distributions.
Evaluations of Vitamin A and Polio Eradication programs consistently find that different approaches work best in urban and
rural settings:93
• In urban settings, use of radio and communications through religious organizations
(mosques, churches) and their leaders (priests, imams) are found to be effective
• In towns and villages, use of “town criers,” with microphones, meetings led by
community leaders and women’s organizations are most effective
• Inter-personal communication is particularly important in hard-to-reach and
rural settings, and involvement of trusted leaders is strongly recommended.
page 31
Note that experience suggests
that use of print materials and
newspapers has not been found
to be effective for creating a
demand for vitamin A. One report
stated that neither print materials
(posters, banners, billboards)
nor newspapers were found to
be effective although they could
be useful to address specific
advocacy needs.94
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Requirements for Vitamin A
Distribution Points
Supplies Needed at Each Distribution Location
• Vitamin A capsules in sufficient quantities for each child and mother expected.
• Child Health Cards for recording vitamin A administration, if used, should be in adequate numbers for all children receiving
vitamin A supplementation (see example on page 35).
• 1 pair of scissors to open the capsules for each person distributing the vitamin A.
• Wipes or towels for each person distributing vitamin A to clean oil off their hands.
• A plastic bag or box to in which to dispose of used capsules.
• Tally Sheets for each person supplying vitamin A in sufficient number to cover the number of children expected. For example,
since a tally sheet usually covers 100 children in 6-59 months of age, the number of tally sheets needed would be equal to
the number of children in this age group expected to be seen divided by 100, plus an additional 10% as back-up
(see Tally Sheet example on pages 39).
• Training materials for health workers and volunteers.
• Educational materials for parents / caretakers.
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Chapter 12: Requirements for Vitamin A Distribution Points
Physical Facilities/Processes Needed at Each Location at
Which Distribution of Vitamin A is to Occur
• Adequate storage area for all vitamin A supplies should be available to ensure that vitamin A is able to be stored in a
secure, dry cool place and away from direct sunlight.
• A method for disposing of used vitamin A capsules.
• A simple program for training those administering vitamin A that includes instruction on administering vitamin A, how to
recognize sick children, and a way to refer sick children.
• A method, systematically applied, for informing the parent/caretaker of each infant or child when to bring the infant or child
back for the next dose of vitamin A.
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Record-Keeping in Conjunction
with Distribution of Vitamin A
95
Record-keeping is an important part of any health service activity. It is recommended that a record of
vitamin A administration be included with existing record systems, like immunization records, growth
charts, health center records, and home-based health records. It is important to recognize that existing
health records may or may not have a specific place for entering information about administration of
vitamin A and associated follow-up appointments.
Recording Information Pertaining to Administration of
Vitamin A (for a specific individual) on an Immunization/
Health Card or Other Form that Anticipates Distribution of
Vitamin A
If the form (see sample form on next page) to be used at your vitamin A distribution site provides space for entering
information relevant to vitamin A distribution for a specific child, the critical information to be included comprises:
• Child information: Name of the child, whether the child is female or male, birth date of child (if available) or age,
name of mother and father, and child’s address.
• Information pertaining to vitamin A administered: Date and dose of vitamin A given (eg., November 5, 2009;
vitamin A capsule; 200,000 IU).
• Information pertaining to deworming agent administered (as appropriate): Whether a deworming agent such as albendazole is
given at the same time; indicate the date and dose of deworming agent given (eg., November 5, 2009; Albendazole; 400 mg).
• Next Appointment date(s): Write the date of the next time this individual should receive their next dose of vitamin A and a
deworming agent (if appropriate)
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Chapter 13: Record-keeping in Conjunction with Distribution of Vitamin A
Sample Immunization/Child Health Card that Anticipates Vitamin A Distribution
Name of Child
Female or Male
Birth Date of Child
Day:
Month:
Year:
Name of Mother
Name of Father
Address
VITAMIN A:
DOSE AND DATE GIVEN
ALBENDAZOLE (400 MG):
DATE GIVEN
0-5 months
50,000 IU:
DO NOT GIVE
6-11 Months
100,000 IU:
DO NOT GIVE
12-17 Months
200,000 IU:
1/2 Tablet:
18-23 Months
200,000 IU:
1/2 Tablet:
24-29 Months
200,000 IU:
1 Tablet:
30-35 Months
200,000 IU:
1 Tablet:
36-41 Months
200,000 IU:
1 Tablet:
42-47 Months
200,000 IU:
1 Tablet:
48-53 Months
200,000 IU:
1 Tablet:
54- 59 Months
200,000 IU:
1 Tablet:
CHILD’S AGE
VACCINES
NEXT APPOINTMENT:
(DATE)
Date Given
NEXT APPOINTMENT:
(DATE)
Date Given
NEXT APPOINTMENT:
(DATE)
BCG
DTP1
DTP2
DTP3
OPV0
OPV1
OPV2
OPV3
MEASLES
HepB0
HepB1
HepB2
HepB3
OTHER SERVICES
INSECTICIDE-TREATED
BEDNET
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13
chapter
Recording Information Pertaining to Administration
of Vitamin A (for a specific individual) that Does Not
Anticipate Distribution of Vitamin A
If the form to be used at your vitamin A distribution site does not provide space for entering information relevant to vitamin
A distribution for a specific child, you should:
• Locate an appropriate space (eg., in one of the corners, or near the space used for recording information about vaccinations) on
the form in which you can record information.
• Write a capital “A” on the form to indicate that vitamin A supplementation information is recorded on the form.
For example, see below:
A June 6, 2009
(note: express the date so that it is clearly understood and consistent with the usual convention for
writing a date in your country).
• Insert all the same information that is listed above (i.e., for forms that anticipate vitamin A distribution).
Tally Sheet for Higher Governmental Authorities
(where required)
Generally where vitamin A distribution is recorded on an immunization or heath card, the local health authority requires
tabulation of summary data on the individuals to whom vitamin A has been distributed on “tally” sheet. Some things to
remember about tally sheets:
• A tally sheet is a quick and simple report of coverage for your supervisor and for other higher-level authorities (where required).
• Generally, tally sheets are marked with information after each individual receives his/her dose of vitamin A.
• The tally sheet is the first level of data collection, so accurate and timely completion of tally sheets is very important.
• A supply of new tally sheets need to be available at the start of each day on which a vitamin A distribution is to be completed;
use a separate tally sheet every day.
• An example of a tally sheet for vitamin A and deworming is given on pages 38-39. Tally sheets can also be designed to record
distribution of other actions, such as immunizations and bednet distribution.
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Chapter 13: Record-keeping in Conjunction with Distribution of Vitamin A
For Those Completing the Tally Sheet:
• Be sure to enter information on the tally sheet that helps others to identify the location at which the distribution of vitamin A
took place, and the date of the distribution – at the top of the sheet.
• Each time you give a dose of vitamin A (or a de-worming agent such as albendazole), make a “tick” mark in the appropriate area
corresponding to the correct dose and age group of the child or mother.
• At the end of the day, add up all the tick marks that have been drawn for each of the age groups. Write the TOTAL number of tick
marks for each of the groups separately in the space provided in the SUMMARY section.
• Submit your completed tally sheet to your supervisor.
• Complete the Child Health Card / Immunization card with information about the specific individual to whom you give vitamin A
and mark the tally sheet at the same time – immediately after giving a dose of vitamin A. If you don’t do this,
you may forget to do it.
For Onsite Supervisors Who Receive Tally Sheets:
• Review tally sheet with the health worker before leaving the distribution site.
• Deliver the tally sheet to the local health authorities as required, but also leave a summary sheet of the total persons that
received vitamin A supplements with the health authority sponsoring the distribution at that specific site for their records
and future use.
• Make a note in the boxes of “Any adverse effect” that were observed, “Action taken,” and the “Outcome.”
Use a separate page if needed.
For Offsite Supervisors Who Receive Tally Sheets:
• Tally sheets can be used for preparation of a report to the person responsible for the distribution program.
• Tally sheets can be useful for reviewing the amount of vitamin A stock levels available and determining the amount of vitamin A
to re-order vitamin A distribution under your authority.
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13
chapter
Example of Daily Tally Sheet Form during Vitamin A and
Deworming (albendazole) Distribution
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Chapter 13: Record-keeping in Conjunction with Distribution of Vitamin A
page 39
vitaminangels.org
Any Adverse Effects:
Albendazole Tablets
Vitamin A Capsules
0-5 Months
Supply
0 - 5 Months
(50,000 IU)
12 - 59 Months
(200,000 IU)
6-11 Months
Action Taken:
Women 6 Weeks Postpartum
Used
Summary
Total All Age Groups
Outcome:
24 - 59 Months
(400 mg, 1 Tablet)
24-59 Months
Remark
Total 12-59 Months
TOTAL NUMBER OF CHILDREN DEWORMED
Returned Unused
12-23 Months
12 - 23 Months
(200 mg, 1/2 Tablet)
*This document was developed using Vitamin A in Child Health Weeks: A Toolkit for Planning, Implementing and Monitoring, prepared
by the Micronutrient Initiative and available through their website at www.micronutrient.org.
Received
12-59 Months
TOTAL NUMBER OF CHILDREN SUPPLEMENTED WITH VITAMIN A
6 - 11 Months
(100,000 IU)
Deworming Children
12-59 Months
EXAMPLE OF TALLY RECORDING:
**USE A SEPARATE TALLY SHEET EVERY DAY**
Women to 6 Weeks
Post partum
(200,000 IU)
HEALTH CENTRE
DATE
Vitamin A supplementation
Infants 0-5 months, Children 6-59 months, Women to 6 weeks postpartum
DISTRICT
REGION/PROVINCE
Daily Tally Sheet
14
chapter
Maximizing Vitamin A Intake
Sources of Vitamin A in Ordinary Foods
To increase the amount of vitamin A in the diet, a variety of foods should be eaten every day. Vitamin A
can be derived from meat, fish, milk and dairy products and plant foods. Carotenoids, precursors that
change into vitamin A in the body, are present in dark green vegetables and orange-colored fruits and
vegetables.
Vitamin A from animal sources and breast milk is better utilized by the body than carotenoids from plant
sources. Introduce the use of animal sources of vitamin A (e.g., eggs) into the diet, if possible.96
Consider introduction of home fruit and vegetable gardens to ensure having better access to a variety
of vitamin A-rich foods. Consume preserved, dried and fortified foods when fresh fruits and vegetables
are temporarily unavailable in order to assure a diverse diet year round.
How to Prepare Foods to Increase Vitamin A Intake
97
• Cut, shred or grind vegetables into small pieces,
• Add a small amount of oil or fat to the meal (½ to 1 teaspoon), preferably canola oil, corn oil or sunflower oil,
during mixing and preparation,
• Boil or steam vegetables for a short period of time, preferably with a lid on the pot,
• Avoid cooking vegetables for long cooking times under high temperatures,
• Consume foods immediately after preparation; don’t allow cooked food to sit for extended periods of time,
• Store fresh fruits and vegetables in a cool and dry place without exposure to sunlight, and
• Sun dry fruits and vegetables as a method for storing/preserving.
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Chapter 14: Maximizing Vitamin A Intake
Common Sources of Food with Vitamin A and
Their Estimated Vitamin A Concentration
97
FOOD
Weight(g)
Mature breast milk (≥ 21 days postpartum)99
Common
Measure
µg RE
—
—
500 µg RE/L
226.66
1 Cup
17,552
Chicken, broilers or fryers, giblets, cooked
145
1 Cup
2,542
Sweet potato, cooked, baked in skin
146
1 Potato
1,403
Sweet potato, cooked, boiled, without skin
156
1 Potato
1,228
Spinach, cooked, boiled, drained
180
1 Cup
943
Carrots, raw
110
1 Cup
919
Cantaloupe, raw
160
1 Cup
270
Romaine or cos lettuce, raw
56
1 Cup
244
Sweet red pepper, raw
149
1 Cup
234
Egg, whole, cooked, fried
92
2 Large
182
Papaya, raw
304
1 Papaya
167
Whole milk, raw
244
1 Cup
112
Mango, raw
207
1 Mango
79
Red tomato, raw
180
1 Cup
76
Apricot, raw
70
2 Apricots
68
Avocado, raw
226.8
1 Cup
16
Cucumber, with peel, raw
301
1 Large
15
Oranges, raw
131
1 Orange
14
Beef liver, cooked, pan-fried
page 41
vitaminangels.org
REFERENCES
REFERENCES - IN ORDER BY CHAPTER
1. INTRODUCTION TO VITAMIN A
1. WHO/UNICEF/IVACG Task Force (1997). Vitamin A supplements: A guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia,
Second edition, p. 3.
2. Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, pp. 7-8.
3. West KPW, Jr. and Darnton-Hill I (2009). Vitamin A deficiency. From: Nutrition and Health: Nutrition and Health in Developing Countries, Second edition. pp 377433. Edited by: R. D. Semba & M. W. Bloem, Humana Press, Totowa, NJ.
4. West KPW, Jr. and Darnton-Hill I (2009). Vitamin A deficiency. From: Nutrition and Health: Nutrition and Health in Developing Countries, Second edition. pp 377433. Edited by: R. D. Semba & M. W. Bloem, Humana Press, Totowa, NJ.
5. Sommer A, West KP, Jr (1996). Vitamin A deficiency: health, survival and vision. New York: Oxford University Press.
6. Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, pp. 7-8.
7. Sommer A, West KP, Jr (1996). Vitamin A deficiency: health, survival and vision. New York: Oxford University Press.
8. Beaton GH, Martorell R, Aronson KJ, Edmonston B, McCabe G, Ross AC, and Harvey B (1993). Effectiveness of vitamin A supplementation in the control of young
child morbidity and mortality in developing countries. United Nations (UN) Administrative Committee on Coordination, Sub-committee on Nutrition State-of-the-Art
Series: Nutrition Policy Discussion Paper No. 13.
9. Glasziou PP, Mackerras DE (1993). Vitamin A supplementation in infectious diseases: A meta-analysis. British Medical Journal, 306: 366–370.
10. Fawzi WW et al (1993). Vitamin A supplementation and child mortality: A meta-analysis. Journal of the American Medical Association, 269: 898–903.
11. UNICEF (1997, December). Vitamin A global initiative: A strategy for acceleration of progress in combating vitamin A deficiency. Consensus of an informal
technical consultation convened by UNICEF in association with The Micronutrient Initiative, WHO, CIDA, and USAID.
12. Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, p. 7.
13. West KPW, Jr. and Darnton-Hill I (2009). Vitamin A deficiency. From: Nutrition and Health: Nutrition and Health in Developing Countries, Second edition. pp 377433. Edited by: R. D. Semba & M. W. Bloem, Humana Press, Totowa, NJ.
14.
WHO (2002). The World Health Report 2002: Reducing risks, promoting healthy life.
15. West KP Jr, Gernand A, Sommer A (2007). Vitamin A in nutritional anemia. In: Kraemer K, Zimmermann MB, eds. Nutritional anemia. Basel, Sight and Life Press,
pp. 133–153.
16. Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, pp. 7-8.
17.
WHO (2009). Global prevalence of vitamin A deficiency in populations at risk 1995-2005.
18. UNICEF (1997, December). Vitamin A global initiative: A strategy for acceleration of progress in combating vitamin A deficiency. Consensus of an informal
technical consultation convened by UNICEF in association with The Micronutrient Initiative, WHO, CIDA, and USAID.
19. Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, pp. 7-8.
20. WHO (1998). Distribution of vitamin A during national immunization days: WHO/EPI/GEN/98.06., p. 9.
21. UNICEF (1997, December). Vitamin A global initiative: A strategy for acceleration of progress in combating vitamin A deficiency. Consensus of an informal
technical consultation convened by UNICEF in association with The Micronutrient Initiative, WHO, CIDA, and USAID.
22. Micronutrient Initiative (2007). Vitamin A in child health weeks: A toolkit for planning, implementing, and monitoring, p. 47.
23. MOST/USAID (2001). Twice-yearly vitamin A supplementation: A guide for programme managers, p.14.
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » References
2. HOW TO SHIP, TRANSPORT, AND STORE VITAMIN A SUPPLEMENTS
24.
WHO (1998). Distribution of Vitamin A during national immunization days: WHO/EPI/GEN/98.06., p. 14.
25.
WHO/UNICEF/IVACG Task Force (1997). Vitamin A supplements: A guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia,
Second edition, pp. 10-11.
26.
WHO (1998). Distribution of Vitamin A during national immunization days: WHO/EPI/GEN/98.06., p. 14.
27.
Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, p. 9.
28.
Micronutrient Initiative (2007). Vitamin A in child health weeks: A toolkit for planning, implementing, and monitoring, p. 49
29.
WHO/UNICEF/IVACG Task Force (1997). Vitamin A supplements: A guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia,
Second edition, pp. 10-11.
30.
WHO/UNICEF/IVACG Task Force (1997). Vitamin A supplements: A guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia,
Second edition, pp. 10-11.
31.
Freig, A, Page, M & Sullivan, KM (2009). Quality assessment of high dose vitamin A capsules used in global vitamin A supplementation programs. Abstract
presented at the Micronutrient Forum, China.
32.
WHO (1998). Distribution of Vitamin A during national immunization days: WHO/EPI/GEN/98.06., p. 14.
33.
Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, p. 9.
34.
WHO/UNICEF/IVACG Task Force (1997). Vitamin A supplements: A guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia,
Second edition, pp. 10-11.
3. WHEN TO GIVE VITAMIN A SUPPLEMENTS
35.
WHO/UNICEF/IVACG Task Force (1997). Vitamin A supplements: A guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia,
Second edition.
36.
UNICEF (1997, December). Vitamin A global initiative: A strategy for acceleration of progress in combating vitamin A deficiency. Consensus of an informal technical consultation convened by UNICEF in association with The Micronutrient Initiative, WHO, CIDA, and USAID.
37.
High priority countries are generally defined as having: i) child mortality equal or greater than 70 deaths/1000 live births – currently 62 countries, ii) child mortality less than 70 deaths/1000 live births but showing evidence of VAD derived from national assessments – currently 32 countries, or iii) 9 other countries with a
history of programming where the national government recognizes VAD as a problem and has a demonstrated commitment to programming to redress VAD. See
UNICEF 2009: http://www.childinfo.org/vitamina_priority.html
38.
WHO/UNICEF/IVACG Task Force (1997). Vitamin A supplements: A guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia,
Second edition, p. 14.
4. ORGANIZING MASS DISTRIBUTION OF VITAMIN A
39.
MOST/USAID (2001). Vitamin A facts for health workers, p. 7.
40.
Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, p. 30.
41.
WHO (1998). Distribution of vitamin A during national immunization days: A generic addendum to the Field guide for supplementary activities aimed at achieving
polio eradication, 1996 revision.
5. HOW TO GIVE VITAMIN A SUPPLEMENTS USING CAPSULES
42.
MOST/USAID (2001). Twice-yearly vitamin A supplementation: A guide for programme managers, p.11.
43.
WHO (1998). Distribution of vitamin A during national immunization days: A generic addendum to the Field guide for supplementary activities aimed at achieving
polio eradication, 1996 revision.
44.
Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, p. 14.
page 43
vitaminangels.org
REFERENCES
45.
46.
Micronutrient Initiative (2007). Vitamin A in child health weeks: A toolkit for planning, implementing, and monitoring, p. 49
WHO (June 2007). Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care: WHO Interim Guidelines, pp. 10-11.
47.
WHO (2004). Practical Guidelines for Infection Control in Health Care Facilities, pp. 10-15
48.
EngenderHealth (2001). Infection prevention: A reference booklet for health care providers, pp. 1-6
49.
WHO (June 2007). Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care: WHO Interim Guidelines, pp. 53-54.
50.
WHO (2009). Guidelines on hand hygiene in health care: A summary, p. 29.
51.
WHO (2009). Guidelines on hand hygiene in health care: A summary, p. 12.
52.
WHO (June 2007). Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care: WHO Interim Guidelines, pp. 54-55.
6. VITAMIN A SUPPLEMENTS FOR CHILDREN 6-59 MONTHS
53.
Micronutrient Initiative (2007). Vitamin A in child health weeks: A toolkit for planning, implementing, and monitoring, p. 47
54.
MOST/USAID (2001). Twice-yearly vitamin A supplementation: A guide for programme managers, p.14.
55.
Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition.
56.
WHO (1998). Distribution of Vitamin A during national immunization days: WHO/EPI/GEN/98.06.
57.
WHO/UNICEF (2004). How to add deworming to vitamin A distribution.
58.
WHO/UNICEF/IVACG Task Force (1997). Vitamin A supplements: A guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia,
Second edition.
59.
IVACG Statement (2002). The annecy accords to assess and control vitamin a deficiency: Summary of recommendations and clarifications.
60.
WHO (1998). Distribution of vitamin A during national immunization days: A generic addendum to the Field guide for supplementary activities aimed at achieving
polio eradication, 1996 revision, p. 31.
61.
Micronutrient Initiative (2007). Vitamin A in child health weeks: A toolkit for planning, implementing, and monitoring, p. 47.
62.
Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, p.14.
63.
Micronutrient Initiative (2007). Vitamin A in child health weeks: A toolkit for planning, implementing, and monitoring, p. 49.
64.
Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, p.14.
65.
Micronutrient Initiative (2007). Vitamin A in child health weeks: A toolkit for planning, implementing, and monitoring, p. 49.
7. VITAMIN A SUPPLEMENTS FOR MOTHERS POSTPARTUM
66.
WHO (1998). Distribution of vitamin A during national immunization days: A generic addendum to the Field guide for supplementary activities aimed at achieving
polio eradication, 1996 revision, p. 9.
67.
Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, p.15.
68.
WHO/UNICEF/IVACG Task Force (1997). Vitamin A supplements: A guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia,
Second edition, pp. 3-4.
69.
WHO (1998). Distribution of vitamin A during national immunization days: A generic addendum to the Field guide for supplementary activities aimed at achieving
polio eradication, 1996 revision, p. 9.
70.
Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, p.15.
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » References
8. VITAMIN A AND INFANTS LESS THAN 6 MONTHS: BREASTFEEDING
AND SUPPLEMENTATION
71.
Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, p. 18.
72.
WHO/UNICEF/IVACG Task Force (1997). Vitamin A supplements: A guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia,
Second edition, p. 24.
73.
Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, p. 18.
74.
WHO/UNICEF/IVACG Task Force (1997). Vitamin A supplements: A guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia,
Second edition, p. 4.
75.
Micronutrient Initiative (2007). Vitamin A in child health weeks: A toolkit for planning, implementing, and monitoring, p. 47.
76.
MOST/USAID (2001). Twice-yearly vitamin A supplementation: A guide for program managers, p.14.
77.
Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition.
78.
WHO (1998). Distribution of Vitamin A during national immunization days: WHO/EPI/GEN/98.06.
79.
WHO/UNICEF/IVACG Task Force (1997). Vitamin A supplements: A guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia,
Second edition, p. 4.
9. ADMINISTRATION OF VITAMIN A SUPPLEMENTS TO CHILDREN
PRESENTING WITH SELECTED HEALTH CONDITIONS
80.
WHO/UNICEF/IVACG Task Force (1997). Vitamin A supplements: A guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia,
Second edition, pp. 5-8.
81.
WHO/UNICEF/IVACG Task Force (1997). Vitamin A supplements: A guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia,
Second edition, pp. 6,8.
82.
Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, p. 20.
83.
Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, p. 22.
84.
Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, p. 22.
85.
WHO/UNICEF/IVACG Task Force (1997). Vitamin A supplements: A guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia,
Second edition, pp. 6,7.
86.
WHO/UNICEF/IVACG Task Force (1997). Vitamin A supplements: A guide to their use in the treatment and prevention of vitamin A deficiency and xerophthalmia,
Second edition, pp. 6,7.
10. HOW TO ARRANGE A WORK STATION FOR ADMINISTERING VITAMIN A
SUPPLEMENTS TO ENSURE A SMOOTH FLOW OF CLIENTS
87.
Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, p. 24.
88.
WHO (1998). Distribution of Vitamin A during national immunization days: WHO/EPI/GEN/98.06, p. 33.
89.
Micronutrient Initiative (2007). Vitamin A in child health weeks: A toolkit for planning, implementing, and monitoring, p. 49.
page 45
vitaminangels.org
REFERENCES
11. TRAINING AND PUBLIC AWARENESS FOR VITAMIN A DISTRIBUTION
90.
MOST/USAID (2001). Twice-yearly vitamin A supplementation: A guide for program managers, pp.13-16.
91.
MOST/USAID (2001). Twice-yearly vitamin A supplementation: A guide for program managers, pp.17-19.
92.
Micronutrient Initiative (2007). Vitamin A in child health weeks: A toolkit for planning, implementing, and monitoring, p. 52.
93.
Micronutrient Initiative (2007). Vitamin A in child health weeks: A toolkit for planning, implementing, and monitoring, p. 52.
94.
21 Waisbord, S (April 2004). Assessment of communication programmes in support of polio eradication: Global trends and case studies, The Change Project, AED, p.6.
12. REQUIREMENTS FOR VITAMIN A DISTRIBUTION POINTS
13. RECORDKEEPING IN CONJUNCTIONS WITH DISTRIBUTION
OF VITAMIN A
95.
Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, pp. 26, 27.
14. MAXIMIZING VITAMIN A INTAKE
96.
Sommer A (2001). Vitamin A deficiency disorders: Origins of the problem and approaches to control. From: http://biotech-info.net/disorders.html.
97.
Pan American Health Organization (2001). Providing vitamin A supplements through immunization and other health contacts for children 6-59 months and women
up to 6 weeks postpartum: A guide for health workers, Second edition, p. 34.
98.
U.S. Department of Agriculture, Agricultural Research Service. 2009. USDA National Nutrient Database for Standard Reference, Release 22. Nutrient Data Laboratory Home Page, http://www.ars.usda.gov/ba/bhnrc/ndl (accessed February 1, 2010).
99.
Underwood, BA (1994). Maternal vitamin A status and its importance in infancy and early childhood, American Journal of Clinical Nutrition 59(suppl):517S-524S.
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » References
page 47
vitaminangels.org
A
APPENDIX
VAS Priority Countries
Estimated
population
UNICEF
w/ VAD
Population
WHO
VAS
(number of
under 5
VAD as a
Priority
(number of children) public health Countries
(000)
children)
problem (122)
(103)
2009
2007
(000) (2008)
(2009)
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Congo, Democratic
Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Holy See
Honduras
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
UNICEF
HighImpact
Country
(60)
2006
USAID
MCH
Priority
Country
(30)
2008
x
x
4,907
217
3,328
4
3,170
4
3,361
221
1,327
391
738
28
69
16,710
14
472
590
36
1,450
71
1,245
172
221
16,125
37
349
2,934
1,155
1,611
3,016
1,753
59
656
1,985
1,238
86,881
4,485
97
551
3,109
47
505
N/A
1,982
1
478
1
N/A
N/A
176
N/A
N/A
4,112
1
79
N/A
4
1,052
13
271
26
57
2,405
N/A
62
1,415
408
377
1,106
N/A
1
455
973
97
7,877
262
28
144
Severe
Moderate
Moderate
None
Severe
Mild
Moderate
None
None
None
Severe
None
None
Severe
Mild
Moderate
None
Moderate
Severe
Severe
Severe
Moderate
Severe
Moderate
None
Moderate
Severe
Severe
Severe
Severe
None
Mild
Severe
Severe
Mild
Mild
Mild
Severe
Severe
x
x
x
x
x
11,829
2
376
3,139
208
613
49
519
320
108
3
1,086
1,392
9,447
608
103
811
73
13,323
87
291
3,870
182
267
241
3,446
3,319
532
9
2,118
1,635
265
69
1,252
N/A
958
486
22
126,642
20,891
6,402
4,450
7,236
0
35
1,633
19
23
N/A
27
N/A
38
0
152
208
1,027
113
11
173
6
6,195
12
N/A
N/A
27
167
73
N/A
2,422
N/A
1
326
707
176
3
398
N/A
130
33
N/A
78,643
4,261
31
1,256
Severe
Moderate
Mild
Severe
Mild
Mild
None
Mild
None
Severe
Mild
Moderate
Moderate
Moderate
Moderate
Moderate
Severe
Mild
Severe
Moderate
None
None
Moderate
Severe
Severe
None
Severe
None
Moderate
Moderate
Severe
Severe
Mild
Severe
x
x
x
x
x
Moderate
Mild
None
Severe
Moderate
None
Severe
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x*
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x*
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
VAS
Coverage
Rate (6-59
months)
2008 full
coverage
(%)
Under 5 mortality rate
Infant mortality rate (under 1)
1960
1980
2000 2008 Rank 1960
1980
2000
96
360
280
257 257
1
245
185
165
-151
72
25
14 127
105
55
22
-261
134
44
41 67
166
94
37
-4
4 179.5
3
82
345
265
260 220
2
208
158
154
90w
15
12 136
13
-73
41
19
16 117.5
61
36
17
-76
36
23 98
62
32
-24
13
6
6 162
20
11
5
-43
17
6
4 179.5
37
14
5
-123
93
36 74
95
77
-68
35
19
13 132.5
51
28
15
-150
30
12
12 138
94
23
10
97
248
205
92
54 58.5
149
129
66
-90
29
13
11 142.5
74
22
12
-26
17
13 132.5
22
15
-35
15
6
5 169
31
12
5
-71
23
19 107.5
54
20
52
296
214
160 121 23
176
127
95
-300
227
100
81 44
175
135
77
45
255
175
84
54 58.5
152
115
63
-160
39
17
15 122
105
31
14
-173
84
101
31 84
118
62
74
-176
91
30
22 100.5
115
70
27
-87
22
9
7 155
63
19
8
-70
24
16
11 142.5
49
20
14
100
308
241
194 169 11
183
143
116
80
238
191
181 168 12
141
114
109
88
153
104
90 41
104
78
-255
173
151 131 19
151
105
88
-33
13
6
6 162
28
11
5
-80
42
29 88
61
31
68
349
189
186 173 10
198
121
120
0
228
205 209
3
135
122
-155
45
11
9 147.5
118
35
10
-60
37
21 103
47
30
-122
51
26
20 105.5
77
37
20
20
265
165
84 105 32
200
120
62
10
198
102
117 127 22
118
66
74
85
---90
----86
---68w
--49
-88
---0
28
--24
--20
94
66
------53
86
---
302
123
98
54
36
25
25
149
178
278
191
52
273
28
34
360
40
212
64
202
247
204
57
22
236
216
281
158
210
37
31
169
23
22
20
19
10
205
92
98
176
118
192
24
212
41
9
13
115
214
57
16
150
23
139
282
106
200
102
26
8
156
125
130
80
205
24
14
136
8
9
6
5
6
147
17
40
32
51
35
200
97
11
151
18
4
5
91
132
37
5
113
7
26
53
184
218
70
109
40
11
3
89
48
44
48
199
15
11
114
6
6
4
4
4
95
11
33
25
23
18
148
58
6
109
18
3
4
77
106
30
4
76
4
15
35
146
195
61
72
–
31
7
3
69
41
32
44
5
122
142.5
25
162
162
179.5
179.5
179.5
39
142.5
79.5
95
98
110
14.5
56
162
27.5
110
190
179.5
46
30.5
86.5
179.5
47
179.5
122
77.5
16
6
54.5
48
194.5
84
155
190
50
67
81.5
64
174
87
70
37
30
22
22
102
107
185
129
40
162
22
29
204
34
126
53
136
165
137
51
17
158
128
164
109
133
28
26
115
20
22
18
17
9
134
71
64
119
84
116
20
126
33
8
10
73
133
48
13
92
20
97
167
77
134
74
24
8
107
79
92
60
129
20
13
95
7
7
5
4
5
97
15
33
27
40
29
120
61
9
92
16
4
4
60
94
32
4
72
6
21
39
111
129
52
79
32
9
3
66
36
36
38
Soil-transmitted
helminthisasis
(Ascariasis,
trichuriasis, hookworm
disease)
Drug(s) used:
ALB or MBD
2007
165
13
33
3
116
10
15
22
5
4
34
12
9
47
11
12
4
22
78
56
48
13
33
20
8
10
104
108
70
87
5
24
113
124
8
19
17
49
79
Rank
1
122
73
181
4
141
125
98
159
168
39
128
145
56
137
132
169
126
24
44
58
129
21
107
148
133
9
14
43
25
160
90
12
7
149
103
113
57
28
108
16
10
89
5
5
3
3
4
84
9
31
20
30
21
124
46
4
75
16
3
4
60
82
27
4
73
4
15
29
93
118
45
57
–
20
6
2
54
25
29
36
6
117
138
22
161
162
182
183
170
26
130
91
99
80
97
8
60
163
33
118
184
171
47
27
84
172
34
173
119
76
18
10
63
48
195
95
156
193
51
85
78
69
✓
No info
✓
No info
✓
✓
No info
No info
No info
No info
No info
✓
not prevalent
✓
✓
No info
No info
✓
✓
✓
✓
No info
✓
✓
not prevalent
No info
✓
✓
✓
✓
No info
✓
✓
✓
No info
✓
✓
✓
✓
✓
✓
✓
✓
No info
✓
No info
No info
No info
✓
✓
✓
✓
✓
✓
✓
✓
No info
✓
✓
No info
No info
✓
✓
No info
No info
✓
No info
✓
✓
✓
✓
✓
✓
No info
✓
No info
No info
✓
✓
✓
✓
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Appendix A: VAS Priority Countries
Estimated
population
UNICEF
w/ VAD
Population
WHO
VAS
(number of
under 5
VAD as a
Priority
(number of children) public health Countries
(000)
children)
problem (122)
(103)
2009
2007
(000) (2008)
(2009)
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's
Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic
Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macedonia, The former
Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia (Federated
States of)
Moldova, Republic of
Monaco
Mongolia
Montenegro‡
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norway
Oman
Pakistan
Palau
Palestine--Occupied
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and
Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia‡
Seychelles
Sierra Leone
Singapore
335
693
2,892
255
5,400
750
1,384
6,540
10
N/A
N/A
N/A
81
N/A
108
340
5,200
2
None
None
None
Severe
None
Moderate
Severe
Severe
Severe
1,575
2,292
249
547
441
N/A
N/A
133
Severe
None
None
Severe
x
776
109
323
272
619
700
2
151
27
320
13
40
89
365
54
N/A
17
N/A
Severe
Moderate
Moderate
Severe
Severe
Mild
x
112
3,060
2,591
2,732
27
2,207
19
6
475
91
10,281
35
1,323
1,436
97
3
1,317
1
4
217
9
2,799
Severe
Severe
Severe
Mild
Mild
Severe
Mild
Severe
Severe
Mild
Severe
14
200
2
229
38
3,041
3,820
4629
277
1
3,535
958
288
675
3,121
25,020
0
293
293
23,778
2
8
55
N/A
46
7
1,203
2,525
1,523
43
0
1,171
N/A
N/A
21
1,819
7,228
0
N/A
15
2,377
0
Severe
Severe
None
Moderate
Moderate
Severe
Severe
Severe
Moderate
Moderate
Severe
None
None
Mild
Severe
Severe
Moderate
None
Mild
Moderate
Mild
697
345
950
736
2,975
10,701
1,810
538
77
1,059
7,389
1,646
2
15
32
100
103
419
4,422
164
N/A
N/A
173
1,017
103
0
2
Mild
Moderate
Moderate
Moderate
Severe
Mild
None
None
Moderate
Moderate
Mild
Mild
Moderate
9
22
2
23
2,859
2,046
576
14
947
200
0
4
N/A
22
104
707
104
1
747
N/A
Mild
Moderate
None
Severe
Mild
Severe
Moderate
Mild
Severe
None
UNICEF
HighImpact
Country
(60)
2006
USAID
MCH
Priority
Country
(30)
2008
x
x
x
x
x
x
x
x
x
x
x
x
Moderate
None
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
VAS
Coverage
Rate (6-59
months)
2008 full
coverage
(%)
Under 5 mortality rate
Infant mortality rate (under 1)
1960
1980
2000 2008 Rank 1960
1980
2000
-36
14
7
4 179.5
31
12
6
-39
19
7
5 169
32
16
6
-50
17
5
4 179.5
44
15
5
-75
46
32
31 84
56
36
26
-40
11
5
4 179.5
31
8
3
-139
65
30
20 105.5
97
52
25
-73
43
30 86.5
60
37
27
205
115
117 128 21
122
73
77
-70
48 61.5
52
98
--99
120
127
128
-
43
18
35
110
55
5
11
51
----------
235
44
85
203
288
270
70
41
200
26
44
130
235
70
22
16
101
13
32
108
235
22
6
11
5
61
9
13
79
145
17
2
7
3
-97
95
--97
--87
---
177
186
362
113
500
42
310
92
133
70
175
266
42
168
300
17
170
42
77
16
137
155
14
54
224
7
68
125
18
39
------83
94
--93
---92
74
---97
--
211
313
252
168
292
22
26
193
354
290
23
280
227
-
65
51
128
144
230
134
108
193
11
16
113
320
228
11
95
153
32
-----86
---------
88
212
94
239
110
70
112
140
82
206
-
---23
-90
--12
--
131
109
250
311
83
390
40
page 49
55 57
5 169
11 142.5
38 70.5
Soil-transmitted
helminthisasis
(Ascariasis,
trichuriasis, hookworm
disease)
Drug(s) used:
ALB or MBD
2007
4
4
3
26
3
21
28
80
46
Rank
174
175
176
86
185
100
87
29
61
85
90
89
-
32
16
29
90
42
5
9
44
42
4
9
34
67
164
146
70
54.5
147.5
132.5
45
17
113.5
193.5
155
190
155
35
65
151
190
159
52
33
135
21
38
101
157
55
19
12
77
11
28
86
157
20
5
8
4
56
7
26
68
93
17
2
7
2
50
150
88
15
3
114
186
152
177
11
106
100
6
28
194
6
36
118
17
17
142.5
30.5
34
162
89.5
7.5
162
74
24
113.5
113.5
120
112
218
72
285
37
182
67
93
52
106
158
31
110
176
14
108
33
58
14
84
95
11
43
124
6
55
79
16
32
15
70
71
10
26
117
4
49
75
13
29
123
40
35
142
89
11
165
59
30
131
81
47
24
6
62
13
54
178
110
69
30
86
6
8
43
270
207
5
15
108
14
39
17
4
41
8
36
130
98
42
45
51
5
6
27
167
186
–
4
12
89
15
69
113.5
179.5
67
150.5
74
20
36
65
63
60
169
162
92
13
9
194.5
179.5
138
42
122
132
183
169
102
195
18
22
130
211
165
19
164
139
-
50
41
90
99
149
94
71
130
9
13
82
191
117
9
73
110
27
37
21
5
48
11
45
122
78
50
25
64
5
6
34
159
107
4
12
85
13
33
16
3
35
9
32
115
74
47
25
43
4
5
28
83
97
–
3
11
73
9
74
120
187
71
147
72
20
37
65
92
64
178
166
82
5
17
196
188
143
31
144
65
46
118
61
121
81
24
31
32
36
33
213
-
27
26
80
27
41
40
9
8
23
22
24
183
25
16
27
23
69
28
24
32
7
4
10
14
13
112
16
13
92
98
50
89.5
96
81.5
155
179.5
146
127
132.5
26
117.5
132.5
58
142
68
160
69
62
81
94
69
122
-
55
34
84
46
86
50
21
25
25
29
27
126
-
24
20
60
23
33
30
8
6
19
19
20
110
21
14
24
18
50
24
17
23
6
3
12
13
13
109
16
14
104
110
55
108
101
93
157
189
111
121
127
19
115
134
74
103
85
213
32
319
13
23
34
6
97
29
133
13
15
277
4
13 132.5
26 94
2 193.5
98 36
21 103
108 29
7 155
12 138
194 7.5
3 190
92
69
150
124
62
221
31
56
66
65
94
27
183
11
19
28
6
64
23
66
11
13
162
3
17
22
4
64
20
59
7
12
155
2
116
96
190
45
102
49
153
135
2
194
No info
No info
No info
✓
No info
not prevalent
No info
✓
✓
✓
not prevalent
No info
No info
✓
No info
No info
✓
✓
not prevalent
No info
No info
No info
No info
✓
✓
✓
✓
✓
No info
✓
✓
✓
✓
✓
No info
No info
No info
No info
not prevalent
✓
✓
✓
✓
✓
No info
No info
✓
✓
✓
✓
No info
not prevalent
✓
✓
✓
✓
✓
✓
✓
✓
No info
No info
not prevalent
No info
No info
✓
✓
✓
✓
✓
No info
✓
not prevalent
✓
No info
✓
✓
not prevalent
vitaminangels.org
A
APPENDIX
VAS Priority Countries
Estimated
population
UNICEF
w/ VAD
Population
WHO
VAS
(number of
under 5
VAD as a
Priority
(number of children) public health Countries
(000)
children)
problem (122)
(103)
2009
2007
(000) (2008)
(2009)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Tajikistan
Tanzania, United Republic
of
Thailand
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Venezuela (Bolivarian Rep.
of)
Viet Nam
Yemen
Zambia
Zimbabwe
SUMMARY INDICATORS
Sub-Saharan Africa
Eastern and Southern Africa
West and Central Africa
Middle East and North
Africa
South Asia
East Asia and Pacific
Latin America and
Caribbean
CEE/CIS
Industrialized countries
Developing countries
Least developed countries
World
266
94
73
1,611
5,200
2,373
1,784
5,836
49
159
527
364
2,807
871
21
N/A
9
930
890
N/A
524
1,523
8
66
N/A
N/A
302
230
Mild
None
Moderate
Severe
Moderate
None
Severe
Severe
Moderate
Severe
None
None
Moderate
Severe
7,566
4,843
185
947
14
94
780
6,543
518
1
6,182
2,132
307
3,601
21,624
249
2,576
33
1,683
708
87
366
2
7
120
824
137
0
1,629
476
N/A
N/A
N/A
30
1,519
5
Severe
Moderate
Severe
Severe
Moderate
Mild
Moderate
Moderate
Severe
Severe
Severe
Severe
None
None
None
Moderate
Severe
Moderate
2,911
7,316
3,733
2,282
1,707
271
972
984
1,089
610
Mild
Moderate
Severe
Severe
Severe
UNICEF
HighImpact
Country
(60)
2006
x
x
x
x
x
x
x
x
x
x
x
USAID
MCH
Priority
Country
(30)
2008
x
x
x
x
x
x
x
x
x
x
x
x
x
VAS
Coverage
Rate (6-59
months)
2008 full
coverage
(%)
Under 5 mortality rate
Infant mortality rate (under 1)
1960
1980
2000 2008 Rank 1960
1980
2000
-40
23
10
8 150.5
33
20
8
-45
18
6
4 179.5
37
16
5
-88
36 74
65
100
250
165 200
4
148
100
39
91
63
67 52
64
50
-57
16
6
4 179.5
46
13
4
-133
48
19
15 122
83
36
16
67
208
142
97 109 27.5
123
86
65
-56
41
27 92
40
31
44
225
143
142
83 43
150
99
98
-20
9
4
3 190
16
7
3
-27
11
6
5 169
22
9
5
-200
74
20
16 117.5 134
56
17
87
127
93
64 53
99
75
Soil-transmitted
helminthisasis
(Ascariasis,
trichuriasis, hookworm
disease)
Drug(s) used:
ALB or MBD
2007
7
3
53
88
46
4
17
69
27
66
3
4
15
57
Rank
154
191
54
23
52
179
139
46
83
13
192
180
136
53
93
--64
------67
-----38
--
241
148
264
65
71
254
219
224
222
27
30
61
209
175
59
177
39
41
100
133
126
67
185
30
33
14
15
42
108
107
141
13
107
124
26
34
31
44
71
43
145
23
10
6
9
16
62
48
104
14
93
98
19
35
21
22
48
36
135
16
8
6
8
14
38
33
33
127
40
36
107.5
77.5
103
100.5
61.5
74
18
117.5
150.5
162
150.5
127
70.5
79.5
142
103
156
50
59
170
163
133
149
23
26
51
141
106
46
100
32
36
72
103
105
51
107
25
27
12
13
37
86
77
88
11
85
78
22
30
25
38
59
35
85
19
9
6
7
14
52
38
73
6
77
65
19
31
18
21
45
30
82
20
7
5
7
12
36
28
38
155
62
41
105
75
109
94
66
77
32
106
151
167
158
140
68
79
-98w
-96
20
79
112
340
213
158
46
66
205
155
108
25
30
110
182
105
18 110
14 127
69 50
148 14.5
96 38
59
70
225
126
96
37
44
135
90
70
21
23
81
102
68
17
13
55
103
59
112
124
36
16
42
134,534
1960
277
1980
200
1960
161
1980
117
2000
101
2007
89
61,795
66,795
252
300
179
220
145
193
120
169
150
171
109
125
91
111
80
97
46,256
177,453
146,114
248
238
-
133
163
74
55
96
40
43
76
28
157
157
-
91
111
53
42
70
32
36
59
22
53,618
26,561
56,038
566,411
122,674
634,631
154
39
219
276
184
84
70
15
128
207
115
35
39
7
88
154
80
23
23
6
72
129
65
103
32
140
168
120
63
56
13
86
128
77
29
33
6
60
98
55
22
22
5
51
84
47
x
x
x
x
x
x
x
x
x
x
x
2000 2008
170 144
No info
No info
✓
✓
✓
No info
✓
✓
✓
✓
No info
No info
not prevalent
No info
✓
✓
✓
✓
✓
✓
not prevalent
No info
No info
✓
✓
No info
No info
No info
No info
No info
No info
✓
✓
✓
✓
✓
✓
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Appendix A: VAS Priority Countries
Column B--Population under 5 (number of children) (000). From State of the World's Children Special Edition (2009). UNICEF.
Table 6 Demographic Indicators - Population (thousands) (2008)
Column C--Estimated population w/ VAD (number of children) (000). From Global prevalence of vitamin A deficiency in populations at risk 1995–2005: WHO global database on vitamin A
deficiency (2009).
Table A3.3 Country estimates of the prevalence of serum retinol <0.70 mol/l in preschool-age children 1995-2005
Colunm D--WHO 2009--(122) countries are classified as having a moderate to severe public health problem based on biochemical VAD in preschool-age children. From Global prevalence
of vitamin A deficiency in populations at risk 1995–2005: WHO global database on vitamin A deficiency.
Table 5 Prevalence cut-offs to define vitamin A deficiency in a population and its level of public health significance (Biochemical)
Public health
Serum or plasma retinol
importance
<0.70 μmol/l in preschool-age
(degree of severity)
children or pregnant women
Mild
2%–<10%
Moderate
10%–<20%b
Severe
20%
Column E--VAS Priority Countries (103)
Based on: 1. U5MR > 70
2. VAD prevalence
3. History of Programming
Source: Vitamin A Supplementation--A Decade of Progress (UNICEF) 2007
Column F--UNICEF High-Impact Countries (60)
* Brazil and China are not priority countries for vitamin A supplementation. Brazil has a subnational programme in north-eastern regions. China has a subnational programme for children
aged 6–36 months in select provinces with poor health and nutrition indicators.
Sources: For number of under-five deaths annually, SOWC 2006, pp. 98-101; UNICEF Vitamin A Supplementation Database.
Colunm G--USAID MCH Priority Country (30)
Source: Working Toward the Goal of Reducing Maternal and Child Mortality: USAID Programming and Response to FY08 Appropriations (USAID) 2008
Column H -- VAS Coverage Rate (6-59 months) 2008 full coverage (%)
Notes:
-- Data not available
w Identifies countries with national vitamin A supplementation programs targeted towards a reduced age range. Coverage figure is reported as targeted.
Sources: Table 3 Infant Feeding practices and micronutrient indicators, pp. 108-111; Tracking Progress on Child and Maternal Nutrition: A survival and development priority, UNICEF Nov
2009.
Column V -- Occurrence of lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminthiasis, and loiasis in countries and territories where preventive chemotherapy
interventions may need to be implemented
STH Prevalence: ✓ Endemic; No Info; or Not Prevalent
Source: WHO (2006)--Preventive chemotherapy in human helminthiasis : coordinated use of anthelminthic drugs in control interventions : a manual for health professionals and
programme managers. Pages 6, 36-39.
Column V:
This is a provisional list.
Mapping activities for Loa
loa are still in progress and
other countries may prove
to be endemic.
STH
Prevalence
✓ Endemic
No Info
Not Prevalent
Countries/Territories
Not listed
STH Prevalence
WHO VAD as a
public health problem
2009
Puerto Rico
Tokelau
American Samoa
French Polynesia
New Caledonia
Wallis and Futuna
✓ Endemic
✓ Endemic
✓ Endemic
✓ Endemic
✓ Endemic
✓ Endemic
No Information
No Information
No Information
No Information
No Information
No Information
WHO--VAD as a
public health problem (122) 2009
None
Mild
Moderate
Severe
2
21
31
62
32
8
15
10
3
3
3
1
page 51
vitaminangels.org
B
APPENDIX
How to Administer Vitamin A to Children
Vitamin A deficiency is a major contributor to child mortality—its
reduction is an essential element of child survival programs.
Vitamin A helps to protect
our health in several ways:1
» Increases chance of survival among children under age 5
» Reduces severity of infections
» Promotes growth, protects eye sight and the eyes, prevents anemia
Dosing Instructions:
Vitamin A Dosing Schedule for Universal Distribution of Vitamin A: Children 6-59 Months of Age
•
•
•
•
•
•
•
•
•
TARGET GROUP
DOSE
HOW OFTEN
Infants 6-11 months of age
100,000 IU, administered orally
Every 4-6 months
Children 12-59 months of age
200,000 IU, administered orally
Every 4-6 months
Wash hands with soap and water.
water
Ask the child or caretaker his or her age.
Ask if the child has received a vitamin A capsule in the last one month. If yes, do not administer. If no, continue.
Ask the caretaker to hold the child, and make sure the child is calm.
Select the appropriate dose of vitamin A for the infant or child:
50,000 IU to an infant less than 6 months of age,
100,000 IU to an infant 6 - 11 months of age,
200,000 IU to children 12 months of age and older
Cut open the narrow end of each capsule with scissors and squeeze the correct amount of vitamin A into the child’s mouth.
Make sure that the infant or child swallows the content of the capsule and does not spit out any drops. Check if the child is
comfortable after swallowing the drops.
Place each used capsule in a plastic bag or container and clean hands with sanitizer.
Place one tally mark on the tally sheet for each child given a dose of vitamin A; also record the dose on the child health card
if available.2
Albendazole/Mebendazole Dosing Schedule in Combination with
Universal Distribution of Vitamin A: Children 6-59 Months of Age
1. Pan American Health
Organization (2001).
Providing vitamin A
supplements through
immunization and other
health contacts for
children 6-59 months
and women up to 6
weeks postpartum: A
guide for health
workers, Second
Edition, pp. 7-8.
2. Source: Micronutrient Initiative (2007).
Vitamin A in child
health weeks: A
toolkit for planning,
implementing, and
monitoring, p. 47
TARGET GROUP
Albendazole 400 mg
Mebendazole 500 mg
Infants 6-11 months of age
Do Not Give
Do Not Give
Children 12-23 months of age
1/2 Tablet
1 Tablet
Children 2-5 Years
1 Tablet
1 Tablet
Albendazole can be chewed without water. If Mebendazole is used, provide clean drinking water for children.
Remember to Tell the Child's Parent/Caretaker:
• This is vitamin A
• Vitamin A helps keep your child strong and healthy
• Bring your child for another dose of vitamin A in _____________________ (name of month)
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Appendix B: How to Administer Vitamin A to Children
C
Vitamin A deficiency is a major contributor to child mortality—its reduction is an essential element
of child survival programs.
Vitamin A helps to protect our health in several ways:1
» Increases chance of survival among children under age 5 (child mortality from all causes is reduced by 23-30%)
» Reduces severity of infections, including measles, malaria, diarrhea and respiratory infections
» Promotes growth, protects eye sight and the eyes, prevents anemia
APPENDIX
Instructions for Distribution Supervisors
Distribution Checklist:
 Are there enough vitamin A capsules?
 Scissors to cut tip off of capsule
 A plastic bag or box to throw away used capsules
 Sanitizer or wipes to clean hands between children
 Child health card to give to parent or caretaker
(if the child doesn’t already have one)
 Tally sheet to record number of doses given
Supervisors need to know:1
•
•
•
•
•
•
•
•
•
Why give vitamin A?
The effectiveness of vitamin A
Possible side effects/safety of vitamin A
How to identify target groups that need to receive vitamin A and de-worming
How to distinguish between 100,000 iu and 200,000 iu capsules
How to handle and store vitamin A capsules
How to give 1/2 a capsule of 200,000 iu vitamin A to a child 6-11 months of age
Important information to share with the parent/caretaker of the child
How to record vitamin A on child health card and tally sheet
Training for Health Workers: 3
•
•
•
•
•
•
Know how to determine the age of the child
Know the appropriate dose of vitamin A and de-worming medicine to give to the child
Know how to open, administer, and dispose of vitamin A capsules correctly
Keep unused capsules out of direct sunlight
Make sure the child is calm before receiving vitamin A or de-worming medicine
Make sure the child swallows all vitamin A drops and is comfortable after receiving vitamin A
and de-worming medicine
• Know how to record the dose given on the child’s health card and tally sheet
Guidelines for Administration of Vitamin A Supplements | In Universal Distribution Projects » Appendix C: Instructions for Distribution Supervisors
1. Pan American Health
Organization (2001).
Providing vitamin A
supplements through
immunization and other
health contacts for
children 6-59 months
and women up to 6
weeks postpartum: A
guide for health
workers, Second
Edition, pp. 7-8.
2,3. Source: Micronutrient Initiative (2007).
Vitamin A in child
health weeks: A
toolkit for planning,
implementing, and
monitoring, p. 47
page 53
NOTES
vitaminangels.org
54
NOTES
vitaminangels.org
55
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