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J Nutr Sci Vitaminol, 67, 1–12, 2021
Review
Assessment of Vitamin A Supplementation Practices in Countries of the Eastern Mediterranean Region: Evidence to Implementation
Farah SAAD1, Lisa ROGERS2, Radhouene DOGGUI3,4 and Ayoub AL-JAWALDEH1,*
1 Regional Offi ce for the Eastern Mediterranean (EMRO), World Health Organization (WHO), Monazamet El Seha El Alamia Str, Extension of Abdel Razak El Sanhouri Street,
P.O. Box 7608, Nasr City, Cairo 11371, Egypt2 Department of Nutrition for Health and Development, World Health Organization, Geneva, Switzerland
3 Department of Family Medicine, Université de Sherbrooke, Sherbrooke, Québec, Canada4 Centre de Formation Médicale du Nouveau-Brunswick, Moncton, New Brunswick, Canada
(Received June 21, 2020)
Summary Vitamin A is an essential nutrient necessary for human growth and develop-ment, with critical roles in vision, immune function reproduction and maintenance of epi-thelial cellular integrity. Inadequate intake of vitamin A places populations at risk of devel-oping diseases associated with vitamin A defi ciency (VAD). VAD is highly prevalent across the Eastern Mediterranean Region (EMR) in children under 5 y and women of childbearing age. Therefore, infants and young children, pregnant women and postpartum women are commonly targeted by supplementation programs. Although, vitamin A supplementation has been shown to decrease preventable childhood diseases and deaths related to VAD, supplementation of vitamin A has been greatly misused in several countries within the EMR raising concern around the process of supplementing the target population. Countries across the EMR have reported different supplementation practices depending on the income level of the country, the availability of vitamin A and the prevalence rates of VAD. Although some countries had higher supplementation rates than others, the concern lies in the mid-dle-income countries and their supplementation practices. Some of the countries across the region do not follow the World Health Organization’s (WHO) guidelines for vitamin A sup-plementation for the recommended age groups. The objective of this study is to assess the vitamin A supplementation practices across the countries in the EMR, determine the gaps in the supplementation practices and the issue with supplementing to healthy populations where VAD is not a public health concern, and provide recommendations for proper vita-min A supplementation within the region.Key Words Retinol defi ciency, supplementation, fortifi cation programs, supplementation, Eastern Mediterranean Region.
Vitamin A is an essential nutrient necessary for human growth and development, with critical roles in vision, immune function, reproduction, and mainte-nance of epithelial cellular integrity (1). Essential nutri-ents cannot be synthesized by the body and must there-fore be provided by the diet. Vitamin A may be con-sumed as either preformed vitamin A or provitamin A carotenoids. Preformed vitamin A is found in animal source foods such as human and animal milk and other dairy products; glandular meats, including liver; fi sh liver oils; and egg yolks. Provitamin A carotenoids are found in plant sources such as green leafy vegetables, yellow vegetables, yellow and orange non-citrus fruits, red palm oil, and other indigenous plants like palm fruit found in Brazil (1). Although provitamin A carotenoids have lower amounts of biologically available vitamin A, they are more affordable than animal source foods in
the Eastern Mediterranean Region (EMR). Animal prod-ucts may be widely available in the region, but their high cost makes it challenging for low-income popula-tions to consume suffi cient amounts of preformed vita-min A (1). Most countries in the EMR region, are classi-fi ed as low- to middle-income and their populations showed a relatively low vitamin A intakes and food sources diversity.
Young children and pregnant women are the most vulnerable to vitamin A defi ciency (VAD). VAD is the main cause of preventable maternal and childhood blindness and increases the risk of mortality from com-mon childhood diseases such as diarrhea (2). In 2013, it was estimated that 29% of children �5 y of age in low- and middle-income countries globally were vita-min A defi cient (3). The prevalence of VAD varies between countries within the EMR with several being classifi ed as having VAD of severe public health signifi -cance, defi ned as a �20% prevalence of serum retinol concentrations �0.70 �mol/L or �5% prevalence of
* To whom correspondence should be addressed.E-mail: [email protected]
SAAD F et al.2
Tabl
e 1
. Su
mm
ary
of W
HO
rec
omm
enda
tion
s fo
r vi
tam
in A
su
pple
men
tati
on a
nd
the
prev
alen
ce o
f vi
tam
in A
defi
cie
ncy
by
popu
lati
on g
rou
p in
cou
ntr
ies
of t
he
WH
O E
aste
rn M
edi-
terr
anea
n R
egio
n. (
11
, 16
, 22
–26
).
Popu
lati
on
grou
pW
HO
rec
omm
enda
tion
Sett
ings
Dos
e an
d fr
equ
ency
Pre
vale
nce
of
vita
min
A
defi c
ien
cyA
pplic
able
cou
ntr
ies
Neo
nat
e (fi
rst
2
8 d
aft
er
birt
h
Not
rec
omm
ende
d as
a p
ubl
ic h
ealt
h
inte
rven
tion
to
redu
ce in
fan
t m
orbi
d-it
y an
d m
orta
lity
N/A
N/A
Non
eN
/A
Infa
nts
1
–5 m
o of
ag
e
Not
rec
omm
ende
d as
a p
ubl
ic h
ealt
h
inte
rven
tion
for
the
redu
ctio
n o
f m
orbi
dity
an
d m
orta
lity
N/A
N/A
Non
eN
/A
Infa
nts
an
d ch
ildre
n
6–5
9 m
o of
ag
e
Rec
omm
ende
d in
set
tin
gs w
her
e vi
tam
in A
defi
cie
ncy
is a
pu
blic
h
ealt
h p
robl
em
Popu
lati
ons
wh
ere
the
prev
alen
ce
of n
igh
t bl
indn
ess
is 1
% o
r h
igh
er
in c
hild
ren
24
–59
mo
of a
ge o
r w
her
e th
e pr
eval
ence
of
seru
m
reti
nol
�0
.70
�m
ol/L
is 2
0%
or
hig
her
in in
fan
ts a
nd
child
ren
6
–59
mo
of a
ge
Infa
nts
6–1
1 m
o (i
ncl
udi
ng
HIV
�):
1
00
,00
0 I
U (
30
mg
RE)
vit
amin
A o
nce
O
man
: 9.5
%Eg
ypt:
12
%Ir
an: 1
8.3
%Jo
rdan
: 18
.3%
Mor
occo
: 9.3
%Pa
lest
ine:
72
.9%
Afg
han
ista
n: 5
0.4
%Pa
kist
an: 3
9.4
%So
mal
ia: 3
3.3
%
Iran
Jo
rdan
Pa
lest
ine
Syri
a A
fgh
anis
tan
Paki
stan
So
mal
ia
Ch
ildre
n 1
2–5
9 m
o (i
ncl
udi
ng
HIV
�):
2
00
,00
0 I
U (
60
mg
RE)
vit
amin
A e
very
4
–6 m
o
Infa
nts
an
d ch
ildre
n w
ith
m
easl
es
Rec
omm
ende
d fo
r al
l ch
ildre
n w
ith
m
easl
esA
ll co
un
trie
s, a
ll se
ttin
gsIn
fan
ts u
nde
r 6
mo:
imm
edia
tely
on
dia
gnos
is
50
,00
0 IU
N
ext
day:
50
,00
0 I
U
2–4
wk
late
r (i
f ey
e si
gns)
50
,00
0 I
U
N/A
Iraq
Le
ban
onPa
kist
an
Som
alia
Su
dan
Tu
nis
ia
Yem
en
Infa
nts
6–1
1 m
o: im
med
iate
ly o
n d
iagn
osis
1
00
,00
0 IU
N
ext
day:
10
0,0
00
IU
2
–4 w
k la
ter
(if
eye
sign
s) 1
00
,00
0 I
U
Ch
ildre
n a
ged
12
mo
and
over
: im
med
iate
ly
on d
iagn
osis
20
0,0
00
IU
N
ext
day:
20
0,0
00
IU
2
–4 w
k la
ter
(if
eye
sign
s) 2
00
,00
0 I
U
Pre
gnan
t w
omen
Not
rec
omm
ende
d du
rin
g pr
egn
ancy
as
par
t of
rou
tin
e an
ten
atal
car
e fo
r th
e pr
even
tion
of
mat
ern
al a
nd
infa
nt
mor
bidi
ty a
nd
mor
talit
y
N/A
N/A
Iran
: 14
.1%
Pa
lest
ine:
54
.8%
A
fgh
anis
tan
Egyp
t Ir
an
Jord
an
Paki
stan
Pa
lest
ine
Som
alia
In a
reas
wh
ere
VAD
is a
sev
ere
publ
ic
hea
lth
pro
blem
, Vit
amin
A s
upp
le-
men
tati
on is
rec
omm
ende
d fo
r th
e pr
even
tion
of
nig
ht
blin
dnes
s
Popu
lati
ons
wh
ere
the
prev
alen
ce
of n
igh
t bl
indn
ess
is 5
% o
r h
igh
er
in p
regn
ant
wom
en o
r 5
% o
r h
igh
er in
ch
ildre
n 2
4–5
9 m
o of
age
Up
to 1
0,0
00
IU
dai
ly
Up
to 2
5,0
00
IU
wee
kly
for
a m
inim
um
of
12
wk
duri
ng
preg
nan
cy u
nti
l del
iver
y
Vitamin A Status in EMR 3
night blindness (4). Between 2004 and 2007, the prev-alence of sub-clinical vitamin A defi ciency was reported to be 10% in Egypt and the Syrian Arab Republic, 17% in Jordan, 20% in Morocco, 20–30% in Oman, and over 60% in Yemen, but only 2.3% in Tunisia (4). Between 2011 and 2015, the prevalence of VAD (�0.70 �mol/L retinol) among children 15–23 mo of age and 14% in pregnant women in Iran (5), 50% �0.70 �mol/L reti-nol among children 6–59 mo in Afghanistan in 2013 (6), and 56% �0.70 �mol/L retinol in children 0–59 mo and 43% in women of reproductive age in Pakistan in 2011 (7).
There are several interventions being implemented in areas where vitamin A defi ciency is of concern. High dose vitamin A supplementation is currently one of the most widely implemented vitamin A interventions in low- and middle-income countries. It is estimated that 62% of children 6–59 mo of age in the 82 high priority countries targeted by UNICEF received the recommend-ed two doses of high dose vitamin A supplementation in 2017 (8). Since the early 1990’s, high dose vitamin A supplementation has been recommended by WHO for children 6–59 mo of age in settings where VAD is a public health problem for the reduction of morbidity and mortality related to preventable childhood diseases (9, 10). However, a more recent large study of high dose vitamin A supplementation in preschool age chil-dren in India (11) did not fi nd a signifi cant effect on child morbidity and mortality and some feel this inter-vention is no longer relevant due to reductions in the prevalence of diarrhea and diarrhea and their associat-ed morbidity and mortality (12). An updated Cochrane systematic review of vitamin A supplementation for the prevention of morbidity and mortality in children from 6–59 mo of age reported a lower, but still signifi cant, reduction in all-cause mortality [risk ratio (RR) 0.88; 95% confi dence interval (CI) 0.83 to 0.93], mortality due to diarrhea (RR 0.88; 95% CI 0.79 to 0.98), diar-rhea incidence (rate ratio 0.85; 95% CI 0.82 to 0.87), measles incidence (rate ratio 0.50; 95% CI 0.37 to 0.67), incidence of Bitots spots (RR 0.42; 95% CI 0.33 to 0.53) and incidence of night blindness (RR 0.32; 95% CI 0.21 to 0.50) (13). As of 2011, WHO no longer recommends the use of high dose vitamin A supple-mentation for postpartum women or infants 1–5 mo of age (14, 15).
High-dose vitamin A supplementation has contrib-uted to reducing child mortality rates in low- and mid-dle-income countries but does not address the underly-ing problem of inadequate vitamin A intakes. Nutrition interventions such as the fortifi cation of staple foods with vitamin A and the use of multiple micronutrient powders containing vitamin A are recommended in these settings (16, 17). Because the prevalence of VAD varies greatly with the EMR and is still a problem of public health signifi cance in some countries, decisions to scale back or shift from universal high dose vitamin A supplementation should be based on information that verifi es that vulnerable populations have adequate vita-min A status and access to suffi cient dietary sources of
Popu
lati
on
grou
pW
HO
rec
omm
enda
tion
Sett
ings
Dos
e an
d fr
equ
ency
Pre
vale
nce
of
vita
min
A
defi c
ien
cyA
pplic
able
cou
ntr
ies
HIV
- po
sitiv
e pr
egn
ant
wom
en
Not
rec
omm
ende
d as
a p
ubl
ic h
ealt
h
inte
rven
tion
for
redu
cin
g ri
sk o
f m
oth
er-t
o-ch
ild t
ran
smis
sion
of
HIV
N/A
N/A
N/A
N/A
Post
part
um
w
omen
Not
rec
omm
ende
d fo
r th
e pr
even
tion
of
mat
ern
al a
nd
infa
nt
mor
bidi
ty
and
mor
talit
y
N/A
N/A
A
fgh
anis
tan
: 11
.3%
Egyp
t: 0
.4%
Jo
rdan
: 4.8
%O
man
: 0.2
%Pa
kist
an: 2
2.4
%Pa
lest
ine:
28
.7%
So
mal
ia: 5
4.4
%
Supp
lem
ent
wit
h
vita
min
A t
o in
divi
du-
als
suffe
rin
g fr
om
defi c
ien
cy, n
igh
t bl
indn
ess,
Bit
ot’s
spo
t an
d xe
roph
thal
mia
Tabl
e 1
. C
onti
nu
ed
SAAD F et al.4
Tabl
e 2
. VA
D p
reva
len
ce r
ates
an
d vi
tam
in A
su
pple
men
tati
on p
ract
ices
by
cou
ntr
y (i
nfo
rmat
ion
wer
e ob
tain
ed fr
om c
oun
try
repr
esen
tativ
e of
fi ces
wit
hin
WH
O E
MR
).
Cou
ntr
y in
com
e le
vel
Cou
ntr
yT
ype
of
surv
eyY
ear
Pre
vale
nce
of
VAD
Vit
amin
A c
ut-
offs
Supp
lem
enta
tion
pr
ogra
m p
rese
nt?
Vit
amin
A s
upp
lem
enta
tion
do
se, f
requ
ency
an
d m
eth
odW
HO
gu
idel
ines
fo
llow
ed?
Fort
ifi ca
tion
Nat
ure
Vect
orLe
vel (
mg
per
kg)
Hig
h
inco
me
leve
l
Ku
wai
tN
/AN
/A6
–9 y
: M
ales
20
.52
%Fe
mal
es 1
6.3
8%
�0
.9 �
mol
/LN
oN
/A
10
–19
y:
Mal
es 8
.36
%
Fem
ales
9.9
4%
�0
.9 �
mol
/L (
10
–17
y)
�1
.04
�m
ol/L
(1
8–1
9 y
)
20
–49
y:
Mal
es 2
.53
%
Fem
ales
9.0
5%
�1
.04
�m
ol/L
�5
0 y
: M
ales
4.4
5%
Fem
ales
3.8
5%
�1
.04
�m
ol/L
Om
anO
man
N
atio
nal
Su
rvey
20
17
Ch
ildre
n 6
–59
mo:
9
.5%
Defi
cie
ncy
: �0
.7 �
mol
/L
for
child
ren
6–5
9 m
o Y
es, t
hro
ugh
imm
un
iza-
tion
pro
gram
s fo
r ch
ildre
n a
t 1
2 a
nd
18
mo
(not
affi
liate
d w
ith
UN
ICEF
)
Th
ere
is s
upp
lem
enta
tion
for
child
ren
at
12
mo
wit
h a
dos
e of
1
00
,00
0 I
U a
nd
18
mo
wit
h a
do
se o
f 2
00
,00
0 I
U
Mod
e: o
ral (
caps
ule
) Fr
equ
ency
: on
e ti
me
at 1
2 m
o an
d on
e ti
me
at 1
8 m
o
Supp
lem
enta
tion
re
com
men
ded
in
Al-
Shar
qyah
gov
ern
orat
e (1
8.9
%)
and
Al W
ust
a go
vern
orat
e (3
1.9
%)
Man
dato
ryO
il1
8
Wom
en 1
5–4
9 y
: 0
.2%
Defi
cie
ncy
: �0
.7 �
mol
/L
Insu
ffi ci
ency
: �1
.05
�
mol
/L
An
ten
atal
an
d po
stn
atal
ca
re p
rogr
ams
N/A
Bah
rain
, Q
atar
, Sau
di
Ara
bia,
U
nit
ed A
rab
Emir
ates
N/A
N/A
No
data
on
VA
D
and
supp
lem
enta
-ti
on b
ecau
se it
is
not
a p
ubl
ic h
ealt
h
prob
lem
N/A
No
supp
lem
enta
tion
N/A
Mid
dle
inco
me
Egyp
tN
utr
itio
n
Cou
ntr
y P
rofi l
e (F
AO
)
20
03
Ch
ildre
n 6
–71
mo:
Se
vere
0.6
%Lo
w 1
2%
Seve
re: �
0.3
�m
ol/L
Mar
gin
al: 0
.3 t
o �
0.7
�
mol
/LLo
w: �
0.7
�m
ol/L
Yes
, th
rou
gh v
acci
nat
ion
pr
ogra
ms
2 d
oses
: 1
. Fir
st d
ose,
1 v
it A
cap
sule
, at
9 m
o w
ith
mea
sles
vac
cin
e 1
00
,00
0 IU
2
. 2 v
it A
cap
sule
s 2
00
,00
0 I
U
tota
l at
18
mo
for
child
ren
wit
h
activ
ated
pol
io
——
——
Wom
en o
f ch
ild
bear
ing
age:
Se
vere
0.4
%
Mar
gin
al 1
0%
Vit
amin
A c
apsu
le:
20
0,0
00
IU
wit
hin
28
d a
fter
de
liver
y
Iraq
15
%D
efi c
ien
cy: �
0.7
�m
ol/L
Yes
, th
rou
gh v
acci
nat
ion
pr
ogra
ms
10
0,0
00
IU
wit
h m
easl
es2
00
,00
0 I
U w
ith
pen
ta2
00
,00
0 I
U p
resc
hoo
l
——
—
Vitamin A Status in EMR 5
Cou
ntr
y in
com
e le
vel
Cou
ntr
yT
ype
of
surv
eyY
ear
Pre
vale
nce
of
VAD
Vit
amin
A c
ut-
offs
Supp
lem
enta
tion
pr
ogra
m p
rese
nt?
Vit
amin
A s
upp
lem
enta
tion
do
se, f
requ
ency
an
d m
eth
odW
HO
gu
idel
ines
fo
llow
ed?
Fort
ifi ca
tion
Nat
ure
Vect
orLe
vel (
mg
per
kg)
Isla
mic
R
epu
blic
of
Iran
Seco
nd
Inte
grat
ed
Mic
ron
u-
trie
nt
Surv
ey
20
12
Ch
ildre
n 1
5–2
3
mo:
19
.1%
Defi
cie
ncy
: �0
.7 �
mol
/LSe
vere
defi
cie
ncy
: �0
.35
�
mol
/L
Yes
, wit
h s
upp
ort
from
U
NIC
EFN
atio
nal
Su
pple
men
tati
on o
f vi
t A
an
d D
from
3–5
d u
nti
l th
e en
d of
24
mo.
Th
eref
ore,
su
pple
men
tati
on w
ith
Meg
ados
e ap
plie
s on
ly fo
r ch
ildre
n
24
–59
mo.
Vit
amin
A M
egad
ose:
In
fan
ts (
0–6
mo)
: 60
,00
0 I
U
once
In
fan
ts (
6–1
2 m
o): 1
00
,00
0 I
U
ever
y 4
–6 m
o C
hild
ren
�1
-y-o
ld: 2
00
,00
0 I
U
ever
y 4
–6 m
o P
regn
ant
wom
en/w
omen
of
child
bear
ing
age:
up
to
10
,00
0 I
U d
aily
La
ctat
ing
wom
en: 2
00
,00
0 I
U
once
in t
he
fi rst
8 w
k af
ter
deliv
ery
Not
rec
omm
ende
d fo
r pr
egn
ant
and
wom
en o
f ch
ildbe
arin
g ag
e u
nle
ss
defi c
ien
cy is
pre
sen
t or
pr
eval
ence
of
VAD
is
�5
% in
ch
ildre
n
24
–59
mo
——
—
Pre
gnan
t w
omen
: 1
4.1
%
Jord
anN
atio
nal
M
icro
nu
-tr
ien
t Su
rvey
20
10
Ch
ildre
n 1
2–5
9 m
o:
12
–23
: 19
.7%
24
–35
: 17
.7%
3
6–4
7: 1
6.5
%
48
–59
: 2.5
%
Tota
l defi
cie
ncy
: 1
8.3
%To
tal s
ever
e: 0
.3%
Defi
cie
ncy
: �0
.7 �
mol
/L
Seve
re: 0
.35
�m
ol/L
Y
es, t
hro
ugh
UN
ICEF
for
Jord
ania
n a
nd
Syri
an
refu
gees
. 2 h
igh
dos
es o
f su
pple
men
tati
on t
o yo
un
g ch
ildre
n fi
rst
wit
h
mea
sles
vac
cin
atio
n a
nd
seco
nd
wit
h M
MR
Firs
t do
se 1
00
,00
0 I
U a
t 1
0 m
o w
ith
mea
sles
vac
cin
e Se
con
d sh
oot
dose
giv
en a
t 1
8 m
o w
ith
MM
R
——
—
Non
-pre
gnan
t w
omen
(y)
: 1
5–1
9: 6
.3%
20
–29
: 7.6
%3
0–3
9: 3
.2%
40
–49
: 2.5
%
Tota
l defi
cie
ncy
: 4
.8%
No
supp
lem
enta
tion
N/A
Leba
non
N/A
N/A
N/A
N/A
Vit
amin
A s
upp
lem
enta
-ti
on p
rovi
ded
by M
oPH
to
en
han
ce t
he
effe
ct o
f m
easl
es c
onta
inin
g va
ccin
es p
rovi
ded
by t
he
Expa
nde
d P
rogr
am o
n
Imm
un
izat
ion
(EP
I)
N/A
Not
rec
omm
ende
d to
en
han
ce m
easl
es v
acci
ne
but
to d
ecre
ase
activ
e m
easl
es in
fect
ion
——
—
Tabl
e 2
. C
onti
nu
ed
SAAD F et al.6
Cou
ntr
y in
com
e le
vel
Cou
ntr
yT
ype
of
surv
eyY
ear
Pre
vale
nce
of
VAD
Vit
amin
A c
ut-
offs
Supp
lem
enta
tion
pr
ogra
m p
rese
nt?
Vit
amin
A s
upp
lem
enta
tion
do
se, f
requ
ency
an
d m
eth
odW
HO
gu
idel
ines
fo
llow
ed?
Fort
ifi ca
tion
Nat
ure
Vect
orLe
vel (
mg
per
kg)
Mor
occo
Th
e R
egio
nal
Su
rvey
on
VA
D:
Min
istr
y of
Hea
lth
19
99
3.1
% o
f ch
ildre
n
aged
from
6 t
o 7
2
mo
hav
e a
seru
m
reti
nol
rat
e �
0.3
�
mol
/L3
7.8
% h
ave
a se
rum
ret
inol
rat
e be
twee
n 0
.3 a
nd
0.7
�m
ol/L
Insu
ffi ci
ent:
�
0.3
�m
ol/L
Low
: 0
.3–0
.7 �
mol
/L
Nor
mal
: �0
.7 �
mol
/L
Yes
, a m
icro
nu
trie
nt
supp
lem
enta
tion
pro
-gr
am fo
r ch
ildre
n a
nd
wom
en a
ccor
din
g to
a
nat
ion
al s
ched
ule
. Th
is
inte
rven
tion
is in
te-
grat
ed in
to t
he
nat
ion
al
nu
trit
ion
pro
gram
3 d
oses
for
child
ren
un
der
fi ve:
1
.Fir
st d
ose
at 6
mo
(10
0,0
00
IU)
2.S
econ
d do
se a
t 1
2 m
o (2
00
,00
0 IU
) 3
.Th
ird
dose
at
18
mo
(20
0,0
00
IU)
——
—
Mic
ron
u-
trie
nt
Surv
ey
20
19
Ch
ildre
n a
ged
6 m
o to
12
y s
how
ed t
hat
9
.3%
of
child
ren
h
ave
a lo
w s
eru
m
vita
min
A le
vel
(�0
.7 �
mol
/L)
incl
udi
ng
2.1
%
hav
e in
suffi
cien
t se
rum
leve
ls
(�0
.35
�m
ol/L
)
Insu
ffi ci
ent:
�
0.3
5 �
mol
/LLo
w:
�0
.70
�m
ol/L
Nor
mal
: �
0.7
0 �
mol
/L
Pale
stin
eP
regn
ant
wom
en:
54
.8%
Indi
vidu
al c
ut-
off
poin
ts:
�1
.05
�m
ol/L
Mar
kedl
y lo
w: �
0.7
�
mol
/LLo
w: �
1.0
5 �
mol
/L
Yes
, on
ly fo
r ch
ildre
n
0–1
2 m
o ol
dT
wo
drop
s pe
r da
y of
vit
amin
A
and
D e
ach
dro
p co
nta
inin
g 5
00
IU
vit
amin
A a
nd
20
0 I
U
vita
min
D
Not
rec
omm
ende
d fo
r 0
–5 m
o—
——
Lact
atin
g m
oth
ers:
2
8.7
%In
divi
dual
cu
t-of
f po
ints
: �
1.0
5 �
mol
/LM
arke
dly
low
:�0
.7
�m
ol/L
Low
: �1
.05
�m
ol/L
Ch
ildre
n 6
–59
mo:
7
2.9
%In
divi
dual
cu
t-of
f po
ints
: �
1.0
5 �
mol
/LM
arke
dly
low
:�0
.7
�m
ol/L
Low
: � 0
.7 �
mol
/L a
nd
�1
.05
�m
ol/L
Ado
lesc
ent
mal
es:
42
.6%
Indi
vidu
al c
ut-
off
poin
ts:
�1
.05
�m
ol/L
Mar
kedl
y lo
w: �
0.7
�
mol
/LLo
w: �
0.7
�m
ol/L
an
d �
1.0
5 �
mol
/L
Ado
lesc
ent
fem
ales
: 5
7%
Indi
vidu
al C
ut
–off
Po
ints
: �1
.05
�m
ol/L
Mar
kedl
y lo
w: �
0.7
�
mol
/LLo
w: �
0.7
�m
ol/L
an
d �
1.0
5 �
mol
/L
Tabl
e 2
. C
onti
nu
ed
Vitamin A Status in EMR 7
Cou
ntr
y in
com
e le
vel
Cou
ntr
yT
ype
of
surv
eyY
ear
Pre
vale
nce
of
VAD
Vit
amin
A c
ut-
offs
Supp
lem
enta
tion
pr
ogra
m p
rese
nt?
Vit
amin
A s
upp
lem
enta
tion
do
se, f
requ
ency
an
d m
eth
odW
HO
gu
idel
ines
fo
llow
ed?
Fort
ifi ca
tion
Nat
ure
Vect
orLe
vel (
mg
per
kg)
Tun
isia
Popu
lati
on
base
d st
udy
: C
entr
e w
e of
Tu
nis
ia
20
10
Ch
ildre
n a
ged
5–7
: Se
vere
defi
cien
cy:
0.0
%M
ild d
efici
ency
: 2
.3%
Low
sta
tus:
17
.0%
Suffi
cien
t st
atu
s:
79
.7%
Pla
sma
vita
min
A
(mm
ol/L
)Se
vere
: �0
.35
�m
ol/L
Mild
: �0
.35
an
d �
0.7
0
�m
ol/L
Low
: �0
.70
an
d �
1.0
5
�m
ol/L
Suffi
cien
t: �
1.0
5
�m
ol/L
No,
acc
ordi
ng
to t
he
resu
lts
of t
he
surv
ey
con
duct
ed in
th
e po
ores
t re
gion
of
the
cou
ntr
y, it
is
pre
sum
ed t
hat
VA
D is
n
ot a
pu
blic
hea
lth
pr
oble
m
No
——
—
Syri
an A
rab
Rep
ubl
icN
/AN
/AN
/AN
/AY
es, t
hro
ugh
vac
cin
atio
n
prog
ram
s at
age
s 6
, 12
an
d 1
8 m
o ol
d
2 d
oses
of
vita
min
A:
20
0,0
00
IU
from
2–5
y o
ld
3 d
oses
of
vita
min
A:
10
0,0
00
IU
at
6 m
o,
20
0,0
00
IU
at
12
mo
and
20
0,0
00
at
18
mo
Emer
gen
cy s
etti
ng
——
—
Low
in
com
eA
fgh
anis
tan
Nat
ion
al
Nu
trit
ion
Su
rvey
20
13
Ch
ildre
n 6
–59
mo:
5
0.4
%4
5.8
% m
ild V
AD
4.6
% s
ever
e VA
D
�0
.70
�m
ol/L
Cu
t of
f fo
r m
ild V
it A
de
fi cie
ncy
(0
.35
–0.7
0
�m
ol/L
)C
ut
off
for
seve
re V
it A
de
fi cie
ncy
(�
0.3
5
�m
ol/L
)* T
he
prev
alen
ce o
f vi
tam
in A
in c
hild
ren
6
–59
mo
of a
ge in
A
fgh
anis
tan
is a
sev
ere
publ
ic h
ealt
h p
robl
em
Yes
, th
rou
gh v
acci
nat
ion
pr
ogra
m, o
nly
for
child
ren
not
cov
ered
/m
isse
d du
rin
g N
atio
nal
Im
mu
niz
atio
n D
ay (
NID
)
Yes
, th
rou
gh N
ID° 6
–12
mo
age,
10
0,0
00
IU
ev
ery
6 m
o° 1
2 m
o-5
y a
ge, 2
00
,00
0 I
U
ever
y 6
mo
Ch
ildre
n w
ith
mea
sles
:° 6
–12
mo
age,
10
0,0
00
IU
on
da
y on
e, t
wo
and
14
.° �
12
mo
age,
20
0,0
00
IU
on
da
y on
e, t
wo
and
14
Volu
nta
ryO
il9
Wom
en 1
5–4
9 y
: 1
1.3
%
10
.8%
mild
VA
D
0.5
% s
ever
e VA
D
�0
.70
�m
ol/L
Cu
t of
f fo
r m
ild V
it A
de
fi cie
ncy
(0
.35
–0.7
0
�m
ol/L
)C
ut
off
for
seve
re V
it A
de
fi cie
ncy
(�
0.3
5
�m
ol/L
No
N/A
Paki
stan
Nat
ion
al
Nu
trit
ion
Su
rvey
20
18
Ch
ildre
n 6
–59
mo:
Seve
re d
efi c
ien
cy:
12
.1%
Mod
erat
e de
fi -ci
ency
: 39
.4%
Non
-defi
cie
nt:
4
8.5
%
Seru
m r
etin
ol le
vel
Seve
re d
efi c
ien
cy is
�
0.3
5 �
mol
/LM
oder
ate
defi c
ien
cy is
0
.35
to
0.7
0 �
mol
/LN
on-d
efi c
ien
t �
0.7
0
�m
ol/L
Yes
For
child
ren
6 t
o 5
9 m
o,
twic
e a
year
at
6
mon
thly
inte
rval
s al
ong
wit
h p
olio
SIA
s.N
o ot
her
su
pple
men
tati
on.
Vit
amin
A fo
rtifi
cati
on
of E
dibl
e O
il an
d G
hee
Vit
amin
A c
apsu
les
are
give
n t
o al
l ch
ildre
n 6
to
59
mo
of a
ge.
Tw
ice
a ye
ar a
t 6
mon
thly
in
terv
als
alon
g w
ith
Pol
io S
IAs
6–1
1 m
o 1
00
,00
0 I
U1
2–5
9 m
o 2
00
,00
0 I
U
Man
dato
ryO
il1
1.7
Wom
en o
f re
pro-
duct
ive
age:
Seve
re d
efi c
ien
cy:
4.9
%M
oder
ate
defi -
cien
cy: 2
2.4
%N
on-d
efi c
ien
t:
72
.7%
Tabl
e 2
. C
onti
nu
ed
SAAD F et al.8
Cou
ntr
y in
com
e le
vel
Cou
ntr
yT
ype
of
surv
eyY
ear
Pre
vale
nce
of
VAD
Vit
amin
A c
ut-
offs
Supp
lem
enta
tion
pr
ogra
m p
rese
nt?
Vit
amin
A s
upp
lem
enta
tion
do
se, f
requ
ency
an
d m
eth
odW
HO
gu
idel
ines
fo
llow
ed?
Fort
ifi ca
tion
Nat
ure
Vect
orLe
vel (
mg
per
kg)
Som
alia
Nat
ion
al
Mic
ron
u-
trie
nt
and
An
thro
po-
met
ric
Nu
trit
ion
Su
rvey
20
09
Ch
ildre
n 6
–59
mo:
3
3.3
%D
efi c
ien
cy: �
0.8
25
�
mol
/LY
es, t
hro
ugh
su
pple
men
-ta
tion
pro
gram
sIn
fan
ts 6
–11
mo
and
child
ren
1
2–5
9 m
o: s
ingl
e do
se e
very
4
–6 m
o at
10
0,0
00
IU
an
d 2
00
,00
0 I
U r
espe
ctiv
ely
——
—
Sch
ool-
aged
ch
ildre
n: 3
1.9
%N
/A
Wom
en o
f re
pro-
duct
ive
age
(15
–49
y)
: 54
.4%
Defi
cie
ncy
: �1
.24
�
mol
/LN
/ASi
ngl
e do
se o
f 2
00
,00
0 I
U
wit
hin
th
e fi r
st 6
wk
of d
eliv
ery
Suda
nPo
st-p
artu
m
wom
en: 1
3.5
%�
1%
Yes
, th
rou
gh N
IDS
vacc
inat
ion
cam
paig
ns
twic
e a
year
. V
itam
in A
su
pple
men
ta-
tion
th
rou
gh p
olio
er
adic
atio
n p
rogr
ams.
Infa
nts
an
d ch
ildre
n (
6–1
1 m
o):
10
0,0
00
IU
tw
ice
a ye
ar
Ch
ildre
n 1
2–5
9 m
o: 2
00
,00
0 I
U
twic
e a
year
P
regn
ant
wom
en: n
o su
pple
-m
enta
tion
un
less
VA
D t
hen
5
0,0
00
IU
or
as p
resc
ribe
d by
do
ctor
Po
stpa
rtu
m w
omen
: 20
0,0
00
IU
w
ith
in fo
rty
days
aft
er d
eliv
ery;
fr
equ
ency
dep
ends
on
rep
etit
ion
of
th
e pr
egn
ancy
.
Ch
ildre
n u
nde
r 5
y:
N/A
Yem
enN
/AN
/AY
es. T
ypes
: R
outi
ne
supp
lem
enta
-ti
on: a
lon
g w
ith
rou
tin
e EP
I w
ith
MR
dos
es a
t th
e ag
e of
9 a
nd
18
mo
old.
C
ampa
ign
sty
le s
upp
le-
men
tati
on: a
lon
g w
ith
po
lio/m
easl
es c
am-
paig
ns.
Usu
ally
for
two
dose
s a
year
if t
he
cam
paig
ns
are
impl
e-m
ente
d as
pla
nn
ed.
Ch
ildre
n 6
–11
mo:
10
0,0
00
IU
C
hild
ren
12
–59
mo:
2
00
,00
0 IU
. T
he
mod
e an
d fr
equ
ency
are
as
expl
ain
ed e
arlie
r.
Man
dato
ryO
il1
8
Tabl
e 2
. C
onti
nu
ed
Vitamin A Status in EMR 9
vitamin A. The Global Alliance for Vitamin A (18) has developed a process for helping countries to gather and evaluate the necessary evidence to aid countries in adapting the WHO guidelines on high dose vitamin A supplementation in infants and children 6–59 mo of age.
The aim of this paper is to review the WHO guide-lines on vitamin A interventions and assess the current vitamin A supplementation practices across the EMR. As supplementation practices and the prevalence of VAD across the region is inconsistent, this review high-lights that high dose supplementation is being provided to populations where VAD is not of public health con-cern. Gaps in supplementation practices are also identi-fi ed to improve programmes within the region in com-pliance with WHO recommendations.
MethodologyThe most current WHO guidelines for vitamin A sup-
plementation in different age groups were retrieved from the WHO e-Library of Evidence of Nutrition Actions (19). A literature search was conducted to iden-tify the most recent national nutrition surveys, as well as publications from UNICEF and the United Nations Food and Agriculture Organization (FAO) describing vitamin A supplementation practices in countries within WHO EMR. In addition, data on the vitamin A status of populations was retrieved using the Micronu-trients Database in the WHO Vitamin and Mineral Nutrition Information System (20). Representatives from all 22 countries within WHO EMR were contacted to complete a questionnaire regarding the vitamin A status of their population, whether or not vitamin A supplementation programmes were being implemented, and if so, at what the dose, frequency and method of supplementation.
Countries within WHO EMR were classifi ed by income. The categories include low, middle- and high-income countries. Afghanistan, Djibouti, Libya, Pakistan, Somalia, Sudan and Yemen are categorized as low-income countries. The middle-income countries in the region include Egypt, Iraq, Islamic Republic of Iran, Jordan, Lebanon, Morocco, Palestine, Syrian Arab Republic and Tunisia. High-income countries include Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and United Arab Emirates.
ResultsThe most recent guidance on vitamin A supplemen-
tation for different population groups was published in 2011. Recommendations are available by the following life stages: neonate (fi rst 28 d of life), infants aged 1–5 mo, infants and children aged 6–59 mo, pregnant women, pregnant women living with Human Immuno-defi ciency Virus (HIV), postpartum women, and infants and children with measles. Table 1 (10, 15, 21–25) summarizes the recommendations based on age group, settings, dose and frequency of supplementation and route of administration. In addition, the prevalence of VAD in each country in the EMR is added to each age
group with a column of the countries that are recom-mended to supplement with vitamin A.
Information from 20 out of the 22 countries was available and the practices were compared with the WHO guidelines to determine if countries were follow-ing the recommended guidelines.
Countries across the EMR have revealed different sup-plementation practices depending on the income level of the country, the availability of vitamin A and the prevalence rates of VAD (Table 2) (e.g. Islamic Republic of Iran (26)). Although some countries had higher sup-plementation rates than others, the concern lies in the middle-income countries and their supplementation practices. Some of the countries across the region do not comply with the WHO guidelines for vitamin A sup-plementation for all recommended age groups. Throughout the analysis of the data, it was witnessed that the cut-off points used across countries within the EMR are different. The majority diagnosed defi ciency when the serum retinol levels were �0.7 �mol/L, mar-ginal when levels were between 0.3 to �0.7 �mol/L, and classifi ed as severely defi cient when levels were �0.3 �mol/L. However, countries including Kuwait, Palestine and Somalia, diagnosed defi ciency when vita-min A levels were �1.05 �mol/L. This can create a dif-ferentiation between the data related to prevalence rates between countries since rates could be lower if different cut-offs are used.
High-income countries have little or no data related to VAD or supplementation practices because VAD is not a public health problem or non-existent in countries like Bahrain, Qatar, Saudi Arabia and United Arab Emir-ates. In this case, no supplementation programs are present in these countries. Kuwait has available data on the prevalence of VAD between the ages 6–50 y old in males and females. The prevalence among 10–19, 20–49, and �50 y old is minor with all rates �10%. The only age group that had higher levels of defi ciency was 6–9 y old where the prevalence of VAD in males is 20.25% and 16.38% in females. However, since it is not considered a public health problem, Kuwait does not have a supplementation program present meaning they are following the recommended WHO guidelines.
Oman is the only high-income country that raises questions when it comes to their vitamin A supplemen-tation practices. As a high-income country with access to high-quality diets rich in vitamin A foods, the preva-lence among children ages 6–59 mo (9.5%) and women 15–49 y old (0.2%) which is relatively low. Although rates are low, Oman supplements children at ages 12 (100,000 IU) and 18 (200,000 IU) mo through immu-nization programs, and women through antenatal and postnatal programs. This does not comply with the WHO guidelines since the prevalence of VAD among children is not �20%. After taking a deeper look into the current situation in Oman, it has been noticed that governorates like Al-Sharqyah and Al Wusta have high rates of defi ciency with rates of 18.9% and 31.9%, respectively.
Unlike high-income countries in the EMR, the mid-
SAAD F et al.10
dle-income countries face the greatest discrepancies in the rates of VAD and their supplementation practices. In most middle-income countries including Egypt, Islamic Republic of Iran, Jordan and Tunisia, VAD is considered to be a mild-to-moderate public health prob-lem. However, in Palestine and Morocco, VAD is classi-fi ed as a severe public health problem with prevalence rates of 72.9% and 37.8% among children 6–59 mo, respectively. The prevalence of VAD in Egypt is 12% for children 6–71 mo and are being supplemented with vitamin A at 9 mo when the measles vaccination is introduced, and then a second dose at 18 mo only for children with activated polio. However, there is no evi-dence that correlates vitamin A supplementation with treating polio. Since the 1990s vitamin A supplementa-tion has been linked with polio National Immunization Days (NIDs), as a vehicle to reach children (27). This reveals that Egypt is following older recommendations that link vitamin A supplementation with decreasing morbidity and mortality rate among children. Although the Islamic Republic of Iran (prevalence 19.1%) is fol-lowing the recommended guidelines for children (15–23 mo), they are supplementing pregnant women and women of childbearing age with 10,000 IU of vitamin A daily. This is not recommended unless there is a defi -ciency present or night blindness of children ages 24–59 mo is �5%. Another country that is following older recommendations related to decreasing morbidity and mortality is Lebanon. Although there is no avail-able data on the prevalence rates, Lebanon revealed that vitamin A supplementation is provided to enhance the effect of measles containing vaccines. However, this is not a recommendation in the WHO guidelines unless a child has an active measles infection. Other countries like Jordan, Morocco and Syria are implementing the WHO recommended guidelines properly by following the recommended dosage and setting.
Low-income countries have revealed the highest rates of VAD related to moderate acute or severe acute mal-nutrition. Due to higher rates of VAD, low-income countries including Afghanistan (children 6–59 mo: 50.4%), Pakistan (39.4%), Somalia (33.3%) and Sudan VAD is considered a severe public health problem that needs solutions to prevent night blindness in vulnerable populations. All countries have supplementation pro-grams in place that comply with the WHO guidelines. In addition, with higher VAD rates among pregnant women and women of child bearing age, supplementa-tion is provided to mothers within the fi rst 40 d after delivery as recommended by WHO in Somalia and Sudan.
DiscussionAlthough some high-to-middle income countries
across the EMR consume relatively healthy diets, VAD remains a burden on most low-income countries and a few middle-income countries. Despite the burden and the efforts made to supplement with vitamin A in order to improve the status of those most vulnerable, coun-tries continue to misinterpret the recommended guide-
lines suggested by WHO. Previously, countries were advised to supplement with vitamin A to reduce mor-bidity and mortality rates among infants, children and pregnant women. UNICEF collaborated with several immunization programs to provide two high doses of vitamin A. By taking this initiative, it increased the cov-erage rates in low-income countries. Low-income coun-tries need access to vitamin A supplements. Although a lot of progress has been made over the past two decades, supplementation has recently become more diffi cult. This is because as the world works to eradicate polio, many countries have discontinued the implementation of polio immunization programmes. In low-income countries, these programmes are the vehicle for delivery of vitamin A supplements (28).
Since supplementation is not always available in low-income countries, it is important to consider other methods of preventing and treating VAD. One of the most common and effi cient methods includes fortifi ca-tion of staple foods. Vitamin A is one of many vitamins and minerals that is added to staple foods including veg-etable oil, wheat fl our, rice, sugar and many more. At the time of study only 3 countries (Afghanistan, Paki-stan and Yemen) have issued standards for the fortifi ca-tion of oil with vitamin A. Low compliance was reported in Afghanistan as low as 30% while it reaches 68% in Pakistan. Wheat fl our could be fortifi ed with vitamin A since it is stable in fl our and does not affect the smell, taste and appearance of the fl our. However, throughout the preparation of wheat fl our, the vitamin A content could be affected due to high humidity and tempera-tures (29). WHO has constructed recommendations on the average levels of nutrients to add to wheat fl our based on extraction, fortifi cation compound and per capita fl our availability (30). It is recommended to for-tify with vitamin A palmitate at different levels based on average per capita wheat fl our availability. The recom-mendations are based on population at risk of VAD. However, since vegetable oil is highly consumed in the EMR, fortifi cation of vegetable oil with vitamin A would be the most cost-effective technique to aid in the improvement of vitamin A status.
In addition to fortifi cation, efforts should be made to increase awareness on the importance of consuming a balanced and healthy diet that includes the intake of fruits, vegetables, protein, carbohydrates and fats. A healthy lifestyle starts off with breastfeeding. Mothers in low, middle- and high-income countries should be encouraged to breastfeed to support the needs of their infants. Breast milk is a rich source of vitamin A that adjusts to the amount an infant requires.
The current vitamin A situation and trend during the last three decades vary across the WHO regions. Indeed, the most affected ones by VAD are the African Region (47% (95% CI: 24–73) in 2013) and South East Asian Region (36% (95% CI: 9–67) in 2013) (3). The notice-able reduction in VAD was denoted in the Western Pacifi c Region from 40% (95% CI: 14–73) in 1991 to 6% (95% CI: 1–6) in 2013 while prevalence still consis-tently the same for the Eastern Mediterranean Region
Vitamin A Status in EMR 11
over the period of 1991–2013 or increased slightly in African Region (�4%) (3). The Regions of Americas VAD prevalence decreased by 10% since 1991 to reach 11% (95% CI: 4–23) in 2013. In 2017, the number of Disability-Adjusted Life Years (DALYs) reach more than one million in two regions, namely Africa Region and South-East Asia Region (Global Health Data Exchange, http://ghdx.healthdata.org/). However, the number of DALYs declined over the last three decades.
Some limitations to this study include the difference in the cut-off points of serum retinol used to identify VAD. With countries using different cut-offs it makes it diffi cult to compare VAD across the region. Some rates could potentially be higher or lower depending on the cut-offs used. In addition, the data on VAD has not been updated in all countries within the region. Each coun-try has information from different years, which could be another limitation when analyzing the data. The avail-able data across the EMR varies in the age groups stud-ied in countries. Most countries have studied infants and children ages 6–59 mo, pregnant women and women of childbearing age. However, some countries only have data available on older children and adoles-cents. This limits the analysis of the results as two age groups cannot be compared to one another.
In conclusion, to support Member States to appropri-ately follow and implement the WHO guidelines for vitamin A supplementation, there are a few recommen-dations to help the EMR. After investigating the current situation of VAD and supplementation practices in the region recommendations for countries with different income levels differ.
For high income countries, it is not recommended to supplement with vitamin A since defi ciency is extremely low or non-existent. However, in countries like Oman where VAD is not a public health problem but concern-ing levels of VAD are present in some governorates where nomads reside, it is recommended to only imple-ment supplementation programs that comply with the WHO guidelines in Al-Sharqyah and Al Wusta.
The fi rst step-in middle-income countries to change current practices is to identify if the country needs a supplementation program or not by looking at the prev-alence of defi ciency and matching it with the WHO rec-ommendations. There is a need to re-evaluate the target population that focus on targeted populations where VAD is a public health concern. Since the highest rates of defi ciency are among children 6–59 mo, middle income countries should focus on only supplementing children in populations where the prevalence of night blindness is �1% in children 24–59 mo of age or where the prevalence of VAD is �20% in infants and children 6–59 mo of age, using the cut-off �0.7 �mol/L. Dose, frequency and method should also comply with WHO guidelines. This applies to Eastern Mediterranean coun-tries including Iran, Jordan, Morocco, Palestine and Syria.
As for low income countries, since all Eastern Medi-terranean countries under this category comply with the WHO guidelines, it is recommended to continue to
supplement with vitamin A in parallel with the recom-mendations. If any improvements take place in low-in-come countries, it is recommended to re-evaluate sup-plementation practices to determine if supplementation is still needed in specifi c age groups or governorates.
As an overall recommendation for all countries in the EMR, countries should work towards increasing aware-ness on consuming a healthy diet rich in various vita-mins and mineral including vitamin A rich foods. In addition, it is highly recommended to improve the sta-tus of vitamin A through fortifi cation programs focused on fortifying wheat fl our, rice or vegetable oil.
AuthorshipReview concept and design: AA and FS, interpreta-
tion: FS, LR, RD and AA, writing manuscript: FS, RD, LR and AA.
Disclosure of state of COINo confl icts of interest to be declared.
AcknowledgmentsThis review is funded by the Eastern Mediterranean
Regional Offi ce of the World Health Organisation.
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