Malnutrition and morbidity among children not reached by the national vitamin A capsule programme in urban slum areas of Indonesia

Summary

Objective

To determine whether vitamin A capsule programmes fail to reach children who are at higher risk of malnutrition and morbidity. Although it has been suggested that there are health disparities between children who are reached or not reached by these programmes, little quantitative work has been undertaken to characterize this relationship.

Study design

As part of a national surveillance system, nutritional status and other factors were compared in 138,956 children, aged 12–59 months, who had and had not received vitamin A supplementation in urban slum areas in Indonesia.

Results

In total, 63.1% of children had received a vitamin A capsule within the previous 6 months. Among children who had and had not received vitamin A supplementation, respectively, the proportion with weight-for-age and height-for-age Z scores <−3 were 7.8% vs 8.6% (P<0.0001) and 9.4% vs 10.7% (P<0.0001), and with a history of diarrhoea in the previous week was 8.1% vs 10.7% (P<0.0001). In families where a child had or had not received vitamin A supplementation, the proportion with a history of infant death <12 months was 5.2% vs 7.2% (P<0.0001) and child death <5 years was 6.7% vs 9.2%, respectively (P<0.0001). Children who had not received vitamin A supplementation were also significantly more likely to be anaemic and have diarrhoea or fever on the survey day compared with children who had received supplementation.

Conclusions

In the urban slums of Indonesia, children who do not receive vitamin A supplementation tend to be slightly more malnourished and ill, and are more likely to come from families with higher child mortality than children who receive vitamin A. Higher rates of child mortality in non-participating households suggest that reaching preschoolers could yield a disproportionate survival benefit. Importantly, children who are not reached by the vitamin A programme are also unlikely to be reached by vaccination and other services, emphasizing the need to identify and extend efforts to reach non-participants.

Introduction

It is estimated that vitamin A deficiency affects 140 million children in the developing world¹ and is a leading cause of child morbidity, mortality and paediatric blindness.² Vitamin A is essential for normal cell differentiation, growth, maintenance of mucosal surfaces, reproduction, immunity and vision. Periodic high-dose vitamin A supplementation programmes have been established over the last 25 years in many developing countries in order to increase child survival and decrease the incidence of paediatric blindness. Vitamin A supplementation has proven to be a very cost-effective intervention,³ reducing all-cause mortality among 6–59-month-old children by 23%.⁴ It is estimated that if vitamin A coverage reached 99% of children in the 42 countries with the greatest burden of child mortality, 225,000 child deaths could be prevented annually.⁵

Vitamin A deficiency has been highly prevalent in Indonesia since at least the early 20th Century. In the 1970s, the prevalence of xerophthalmia was recorded at 1.33% and acute corneal disease affected one in 1000 infants and preschool children each year.⁶ In the early 1970s, with the introduction of vitamin A capsule pilot programmes, and later in the 1980s, with the initiation of a national programme, the prevalence of severe vitamin A deficiency began to decrease. By 1992, the prevalence of xerophthalmia had fallen by approximately 75–0.34% and acute corneal disease to 0.05 per 1000 among infants and preschool children.⁶ However, subclinical vitamin A deficiency is still common.⁷

Periodic high-dose vitamin A capsule distribution has been identified by the World Bank as one of the most cost-effective interventions to reduce child mortality in developing countries.⁸ In addition, the Copenhagen Consensus included vitamin A capsule distribution as one of the most effective measures to improve global health.⁹ Indonesia has had one of the strongest vitamin A capsule distribution programmes for child survival in the world,¹⁰ and the intended coverage is for all infants aged 6–12 months and all preschool children aged 12–59 months. The programme consists of biannual distribution of oral vitamin A, 60 mg retinol equivalents, to children aged 12–59 months and half the dose for infants aged 6–12 months.¹¹ The main site for distribution of vitamin A capsules to children is the subvillage health post (‘posyandu’).

The effectiveness of vitamin A capsule distribution programmes for child survival is likely to be related to the extent of programme coverage. It has been suggested that vitamin A supplementation in developing countries may fail to reach the children who are at highest risk,¹² but there are few recent quantitative data on the characteristics of children who do not receive vitamin A supplementation.¹³ It is not known whether children who are missed may actually be at greater risk of morbidity and mortality. To gain further insight into this issue, this study sought to characterize the demographic and health characteristics of preschool children who are reached and not reached by the national vitamin A capsule distribution programme in Indonesia. It was hypothesized that children who did not receive vitamin A supplementation were more likely: (i) to be stunted, wasted and underweight; (ii) to be at higher risk of diarrhoea, fever and anaemia; (iii) to have lower childhood immunization coverage; and (iv) to come from families with higher rates of infant and under-5 child mortality than children who received vitamin A. In order to address these hypotheses, the characteristics of children who did and did not receive vitamin A supplementation in urban slum areas of Indonesia were examined.