Micronutrient Deficiency Control Strategies in Vietnam ppsx

The prevalence of xerophthalmia, or clinical vitamin A deficiency VAD, is now lower than the cut-off point established by the World Health Organization WHO to indicate a significant publ

Vietnam

N.X Ninh, N.C Khan, N.D Vinh and H.H Khoi

Introduction

Micronutrient deficiencies affect the

majority of the population in Asia Though

somewhat lower than in other countries in

the region, micronutrient deficiencies

remain prevalent in Vietnam The

prevalence of xerophthalmia, or clinical

vitamin A deficiency (VAD), is now lower

than the cut-off point established by the

World Health Organization (WHO) to

indicate a significant public health problem

However, the prevalence of sub-clinical

VAD as measured by low serum retinol

exceeds 10% for children under five and

pregnant women It is well established that

sub-clinical VAD may contribute to high

mortality, morbidity and growth retardation

among young children The success of the

VAD control program in Vietnam is

attributed mainly to the effectiveness of

high dose vitamin A supplementation, as the

fortification program has not yet been

established

Control of iodine deficiency disorders (IDD)

has been achieved with remarkable results

This was facilitated by government approval

of universal salt iodization in 1999 Iron

deficiency anemia (IDA) affects over half of

all women of childbearing age, infants, and

young children in Vietnam Iron deficiency

worsens during periods of growth and

pregnancy, or with parasitic infections (e.g.,

malaria, hookworm) Other nutritional

deficiencies such as folic acid and vitamin C

can also contribute to anemia and poor iron

absorption Iron deficiency, before the onset

of anemia, may have adverse effects on

function such as work performance For

every 10% deficit in hemoglobin

concentration, there is a 10-20% deficit in work performance Once anemia occurs, there can also be impairment of cognitive performance and behavior, lowered immunity, and pregnancy complications Anemia is devastating not only to the individual, but also to the economic and intellectual capacity of the whole nation The current strategy of combating iron deficiency in Vietnam is through iron supplementation, covering about 15-20% of the communities

in the country The iron fortification program has just started with a pilot study Zinc deficiency is likely to be as widespread

as iron deficiency anemia Vitamin B1

deficiencies are additional deficiencies of potential public health importance Clearly, micronutrient deficiencies must be controlled and prevented

Correcting iodine, vitamin A and iron deficiencies can improve the population-wide IQ by 10-15 IQ points, reduce maternal deaths by one-third, decrease infant and childhood mortality by 40%, and increase strength and work capacity by almost 50% Investment into the elimination of these deficiencies will result in reduced health care costs and education expenditures, improved work capacity and productivity, equity, increased economic growth and national development

The Vietnamese diet, disproportionately comprised of staple foods at the expense of dietary diversity, places the population at risk for micronutrient deficiencies Diets with high consumption of rice and low consumption of animal products may provide inadequate amounts of micronutrients as well as inhibit their absorption Recent years have seen improvements in dietary quality and diversity, with higher consumption of

The authors are affiliated with the National

Institute of Nutrition, Hanoi, Vietnam

protein rich foods and lower consumption of

staple foods However, to ensure the population-level

consumption of the RDA of micronutrients, national

nutritional programs are needed Previous program

approaches based upon dietary diversification and

supplementation have contributed to the

reduction of micronutrient malnutrition, but

the progress has not reached national

objectives For this reason, a more

cost-effective and sustainable strategy is sought

to overcome the problem of micronutrient

malnutrition

Vitamin A deficiency (VAD)

Initiation of the program

The national vitamin A supplementation

program was launched in 1988 with an

orientation workshop to raise awareness

among policy makers and mass media

organizations regarding VAD Steering and

technical committees were then established

to run the program The key collaborators

were the National Institute of Nutrition

(NIN) and the Institute of Ophthalmology

The program was started as a pilot project

funded by UNICEF in seven districts, and

was expanded in 1993 to a nationwide level

Program implementation

The core elements of the program included

the following:

ƒ Universal distribution of high dose

vitamin A capsules (VAC) to

children 6-36 months of age twice

annually, in collaboration with National

Immunization Days (NIDs); distribution of

VAC to women after delivery; and

targeted distribution of VAC to

individuals at high risk for VAD

such as malnourished children, and

children with diarrhea, measles, or

respiratory infections The high dose

vitamin A capsules are distributed

through the primary health care

system and health care facilities

ƒ Promotion of nutrition education

with emphasis on breastfeeding,

complementary feeding practices,

dietary diversity and growth monitoring

ƒ Promotion of the production and consumption of a diverse diet to increase vitamin A intake at the household level, through activities such as gardening, aquaculture and animal husbandry

ƒ Establishment of a program implementation network from community to central levels, based on a strong preventive health structure with the active participation of mass organizations like the Vietnam Women’s Union (VWU), the education sector and other groups

ƒ Development and dissemination of IEC materials such as posters, booklets and videotapes, combined with employment of mass media channels to implement regular education and communication activities

ƒ Provision of training and information on micronutrient deficiencies to program staff to improve staff’s knowledge, attitudes and practices

Program coverage

It was expected that with the strong health system in place, Vietnam should be able to achieve a high coverage rate of VAC distribution to target groups However, a survey conducted in 2000 shows the mean distribution of high dose vitamin A for children 6-36 months of age to be 77%, and for women post-partum to be 52% (Figures

1, 2) The variation in coverage rates among regions can be explained, in part, by constraints to the quantity and quality of the health services at the local level, as well as

by the accessibility of health centers (e.g., road conditions) This is demonstrated in difficult to access areas, including isolated mountain areas such as the Central Highlands and the Northern Highlands, where the coverage rates for post-partum women are lowest (23.5% and 42.2% respectively) (Figure 2)

Prevalence and trends

The prevalence of xerophthalmia (X2/X3) in children under five years of age appears to

have declined since 1988, based upon data

from national nutrition surveys (Table 1)

The national survey completed in 1988

reports a xerophthalmia (X2/X3) prevalence

seven times higher than the cut-off point

established by WHO as a public health

problem (i.e., 0.07% vs 0.01%) However,

by 1994 a national survey reported a

prevalence of 0.005% The data in the 1998

survey also show clinical symptoms of

xerophthalmia that were lower than the

WHO criteria for a public health problem

National trends in night blindness in

children under five years of age suggest that

significant improvements were gained from

1988 to 1994 (i.e., a reduction of approximately 86%)

Though rates increased from 1994 to 1998,

the national prevalence remains relatively

low at 0.20% Similarly, maternal night

blindness increased from 0.58% to 0.9%

from 1994 to 1998, remaining lower than

the reference threshold of 10%

In terms of sub-clinical VAD, serum retinol

data has only been collected on the

national level The prevalence of

sub-clinical vitamin A deficiency (serum retinol

<0.70 µmol/L) in children under five years

of age was estimated for the Red River

Delta Region at 11% The survey detected

zero cases of very low serum retinol

(<0.35µmol/L) Sub-clinical VAD was

found to be more prevalent among children

below one year of age There has been a

decreasing trend of low serum retinol levels

in children in the Red River Delta Region

From 1999 to 2000, prevalence decreased

by 5.5 percentage points, while for previous

years the decrease ranged from 0.3 to 3.0

percentage points In 1998, the prevalence

of low breast milk retinol concentration

(<1.05µmol/L) among lactating women was

58% (Figure 3) The trend of low retinol in

breast milk cannot be assessed, although

there is a large reduction from 1998 to 2000

(15.2 %)

These studies show a close association between vitamin A deficiency and protein-energy malnutrition (PEM) In fact, the nutritional status of the population suffering from xerophthalmia is generally poor, and active corneal lesions were frequently observed in the populations with severe PEM A close relationship was also found between xerophthalmia and breastfeeding, weaning practices, and the inclusion of green vegetables in children’s diets

Program effectiveness and impact

As a rule, the prevalence of VAD has declined substantially over the last 15 years

in terms of clinical and sub-clinical symptoms For clinical symptoms, Vietnam has achieved its mid-decade goal (1995) of virtual elimination of xerophthalmia The project appears to have had a great impact

on reduction of the prevalence of clinical xerophthalmia at the national level (Table 1) However, the sub-clinical VAD is still high at the national level (12.4% low serum vitamin A <0.7 µmol/L and 53.8% of low vitamin A in breast milk) The question raised here is whether the reduction in VAD

is attributable to the program, to the success

of other program interventions, or to a secular trend due to socio-economic development With this in mind, future research needs to be carefully designed so that program impact can be assessed However, available data collected to date seems may explain part of the impact of the program The trend of low serum retinol levels in children in the Red River Delta from 1995 to 2000 is a case in point Moreover, after five years in which one pilot project combined IDA and VAD interventions, the prevalence of low serum retinol decreased remarkably from 14.7% to 6.2% (Figure 4)

FIGURE 1 Coverage of high dose vitamin A distribution to children aged 6-36 months by region, 2000

Mean Mekong River Delta

South East

Central Highlands

Southern Central Coast

Northern Central Coast

Red River Delta

Northern Highlands

FIGURE 2 Coverage of high dose vitamin A distribution to post partum women by region, 2000

Mekong River delta

South east Central Highlands

Southern Central Coast

Northern Central Coast

Red River Delta

Northern Highlands

Mean

Lessons for strengthening sustainable

and effective programs

The strengths of the program include the

following:

ƒ The project was successfully implemented

through the provincial preventive health

system, with the implementing facility

network well established from the

central to community levels

ƒ There was a high level of community participation

ƒ There is strong support and assistance from universities and other international agencies including the Micronutrient Initiative (MI), the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF)

ƒ Project strategies are clear, there is

a high level of awareness among

project leaders, cross-sectoral involvement is

closely integrated, and high commitment from

authorities has been expressed at

all levels

The limitations of the program include the

following:

ƒ A regular government budget has

not been established to support

project sustainability

ƒ The monitoring and evaluation

system is based at the central level

at the National Institute of

Nutrition, and the capacity of this

system is still limited The data

reported from provincial levels is

therefore of questionable accuracy

ƒ UNICEF currently purchases the

entire supply of vitamin A capsules

distributed in Vietnam The

financial sustainability of the

program rests in part upon

continued UNICEF funding

Several conclusions can be drawn about lessons learned:

ƒ A baseline survey to assess the current situation is important to demonstrate need for the project as well as to serve as a foundation for monitoring and evaluation systems

ƒ Projects should begin with an orientation workshop to raise awareness among government, media and the public regarding VAD

ƒ The commitment from all government levels to the project is crucial to ensure the success and stability of the program

ƒ Support from international agencies is necessary

ƒ Implementation through the existing health care network, along with a high level of community participation, are important

ƒ Monitoring and evaluation activities should take place regularly

ƒ Appropriate IEC and social mobilization are key components of the program

ƒ Collaboration with NIDs to distribute the vitamin A capsule improves program coverage

TABLE 1 Prevalence of clinical VAD and xerophthalmia in Vietnam, 1988-1998

Clinical symptoms 1985-1988*

n=34,214

1994 **

n= 37,920

1998 ***

n=12,900 Night blindness (XN)

Children under 5 years

Pregnant/lactating mothers 0.37 Not available 0.05 0.58 0.20 0.90

Bitot’s spot (X1B) 0.16 0.045 Not available

Corneal ulceration/ Keratomalacia

X2/X3A/X3B)

Corneal scar (XS) 0.12 0.048 Not available

* National Survey on Vitamin A Deficiency, NIN 1988

** National VAD/PEM Survey, NIN/HKI/UNICEF 1994

*** National VAD/PEM Survey, NIN/UNICEF 1998

FIGURE 3 Prevalence of low vitamin A in breast milk in the Red River Delta Region,

1995-2000

FIGURE 4 Percentage of low serum vitamin A levels (<0.7 umol/L) in Thanh Mien

District, 1995-2000

0%

2%

4%

6%

8%

10%

12%

14%

16%

Year

0

10

20

30

40

50

60

70

Year

Iron deficiency anemia (IDA)

Initiation of the program

The national iron deficiency anemia control

program was launched in 1995 following

the national anemia and nutrition risk survey

(UNICEF/NIN, Institute of Malaria, Parasite,

and Entomology -IMPE, Institute of

Hematology and Blood Transfusion-IHBT)

Orientation workshops and mass media

campaigns pertaining to the serious

consequences of anemia in Vietnam were

carried out The NIN was appointed to run

the project with support from UNICEF

Project activities involved other institutions

and agencies such as the education sector,

Vietnam Women’s Union, Youth Union,

and mass media organizations

Organizations responsible for the program

are the NIN and the Ministry of Health

(MOH) Collaborators in program management

and control are the Institute of Hematology

and Blood Transfusion; the Institute of

Malaria, Parasitology and Entomology; the

Institute of Protection of Children's Health

(IPCH); the Institute of Protection of

Mother and Newborn; the Ministry of

Health Preventive Health Department; the

Maternal and Child Health/Family Planning

Department (MCH/FP); and the Youth

Union, along with mass media agencies

The vertical management structure is based

on preventive health and MCH/FP systems

ƒ Central Level: National Steering

Committee (9 members)

ƒ Provincial Level: Preventive health

center, MCH/FP centers, and social

organizations

ƒ District Level: District health center (Hygiene-

Epidemiology and MCH/FP teams)

ƒ Community Level: CHC are

responsible for the project Iron distribution

takes place in health centers during antenatal

visits (ANC services) or through collaborator

visits Teachers distribute the pills and IEC

materials to girls under health worker

supervision

The project runs under the existing preventive health system In each community one or two staff members are responsible for the project There is community participation in the management system at each level: health, population/family planning service, VWU, school teachers, Youth Union are the key members of management boards under the co-ordination

of local People's Committees

Program implementation

The core elements of the program include the following:

ƒ Universal supplementation of pregnant women from the beginning of pregnancy through one month post-partum, with one tablet daily (60 mg iron and 0.25 mg folate)

ƒ Weekly supplementation of children 6-15 years of age Through the school system, teachers distribute iron tablets under the supervision of a health worker

ƒ Supplementation of non-pregnant women of 15-35 years of age The program is carried out by local organizations including the Women's Union and the Youth Union This program is currently in the research phase

ƒ Iron or multi-micronutrient supplementation of infants and children is also under research in several studies with support from UNICEF

ƒ IEC is one of the highest priorities

in the IDA program Awareness of the important roles of iron for fetal growth, perinatal mortality, child growth and development, in physical activity and work performance, and intellectual performance and productivity are all addressed IEC is focused on the objective of increased consumption

of iron-rich foods

ƒ In Vietnam, iron deficiency is closely associated with the high prevalence of hookworm A deworming program through yearly campaigns for children and non-pregnant women will be applied (PCD

project)

ƒ In addition, a project for fortification of

biscuits with iron and vitamin A

along with a project for

fortification of biscuits with iron,

zinc and calcium are being

conducted with pregnant women

and researched at the National

Research program (KHCN-l1-09)

FeNaEDTA fortified fish sauce is

also being studied in collaboration

with International and Japan ILSI

The efficacy of iron-fortified fish

sauce was evaluated and the

effectiveness will be assessed in

the year 2002 Multi-micronutrient

fortification of weaning foods is

also being researched as a pilot

study, which will be expanded in

the future The survey in the year

2000 shows potential food sources

ƒ for fortification It was determined that noodles (44.7gr/capita/day) and fish sauce (24.8ml/capita/day) are among the most popular foods (Figure 5)

Program coverage

The program started in 1995 and has been expanded to cover 15-20% of the whole country (Table 2) The low coverage is due

to lack of supplies as well as the low utilization of CHC in terms of staff quality and quantity In terms of intensity, the price estimated for iron tablets is approximately

7680 VND (US$0.50) (32 VND/ 1 tablet x

240 tablet/ pregnancy = 7,680VND per pregnancy)

FIGURE 5 Average food consumption, 2000 (G or ml/capita/day)

TABLE 2 Number of potential beneficiaries that received services, 1995-2000

1995 1996 2000 Pregnant women targeted 425,000 40,000 46,200*

* The figure was estimated based on the percentage of women per population in a commune (2.5%)

0

10

20

30

40

50

Prevalence and trends

The 1995 survey found that anemia

prevalence was a problem of major public

health significance in Vietnam: 52.7% of

pregnant women, 40.2% of non-pregnant

women and 45.3% of children are anemic

(Table 3) The groups at highest risk for

anemia are children under two years of age

and pregnant women (Figures 6 and 7,

Tables 3 and 4) The data of the national

survey in 2000 show a substantial decrease

of anemia prevalence in all groups and

across all ecological regions in Vietnam

Even so, anemia prevalence is still

remarkably high (Tables 3 and 4) Figure 8

shows that anemia prevalence is more

prevalent in rural areas than in urban areas

The majority of anemia is most likely

attributable to iron deficiency Low serum

ferritin was associated with hemoglobin

levels In addition, dietary meat

consumption was correlated with anemia

levels The survey in 2000 determined that

the prevalence of anemia decreased with the

increase of weekly meat consumption

(Table 5) Moreover, there is a trend of

increase in meat consumption and iron intake over the past decade (Table 6)

In Vietnam, IUD use is the most popular among contraceptive methods (57.6%) and the survey data showed that women who use IUD are greater risk for anemia than those who did not This relation is stronger among women living in rural areas (OR 1.62 in rural versus OR 1.08 in urban area) (Table 7)

Parasitic infections, such as hookworm and malaria, also contribute significantly to anemia in Vietnam It has been known that

in the North Central Coast, the Central Highlands and the Southeast regions of the country, where hookworm is more common, prevalence of anemia seems to be higher than in other regions There was not any research to demonstrate the role of malaria

But, it is widely accepted that in areas with high prevalence of malaria, prevalence of anemia is also high Due to high prevalence and incidence of malaria in Vietnam, a carefully designed study will be needed to explore its role as a risk factor

TABLE 3 Anemia prevalence among children, non-pregnant women, pregnant

women and men, 1995-2000

TABLE 4 Anemia prevalence (%) by zone of residence

Demographic group

Children 0-60 months 45.3 42.9 - 47.6 34.1 31.4 - 36.9

Non-pregnant women 40.2 37.5 - 42.9 24.3 22.1 - 26.6

Pregnant women 52.7 49.9 - 55.5 32.2 29.5 - 35.1

Children <5 years Pregnant Women

Northern Central Coast 43.0 40.6 58.6 34.9

Southern Central Coast 49.2 33.2 54.8 38.3

TABLE 5 Association between frequency of eating meat and anemia

Mothers (non-pregnant women) Children Time per

week meat

(1.68<OR<2.86)

49.2 1.83**

(1.44<OR<2.33)

(1.30<OR<1.81)

38.5 1.18*

(1.03<OR<1.36)

* Significant at p<0.05

** Significant at p< 0.001

TABLE 6 Country average of meat intake (g/capita/day) and iron intake (mg/capita/day),

1990-2000

1990 (Means & SD) 2000 (Means & SD) Meat consumption (g/capita/day) 24.4 14.4 51.0 69.2 Iron intake (mg/capita/day) 9.53 1.17 11.16 4.26

TABLE 7 Association between IUD used and anemia among non-pregnant women

All Rural Urban Use of contraceptive

method Anemic Non-anemic Anemic Non-anemic Anemic Non-anemic

(1.34<OR<1.85)

OR=1.62**

(1.34<OR<1.96)

OR=1.08 (0.75<OR<1.54)

FIGURE 6 Anemia among children <5 years of age (National Survey 2000)