Perspective: Integration to Implementation (I-to-I) and the Micronutrient Forum—Addressing the Safety and Effectiveness of Vitamin A Supplementation

Abstract

An ongoing challenge to our ability to address the role of food and nutrition in health promotion and disease prevention is how to design and implement context-specific interventions and guidance that are safe, efficacious, and avoid unintended consequences. The integration to effective implementation (I-to-I) concept is intended to address the complexities of the global health context through engagement of the continuum of stakeholders involved in the generation, translation, and implementation of evidence to public health guidance/programs. The I-to-I approach was developed under the auspices of the Micronutrient Forum and has been previously applied to the question of safety and effectiveness of interventions to prevent and treat nutritional iron deficiency. The present article applies the I-to-I approach to questions regarding the safety and utility of large-dose vitamin A supplementation programs, and presents the authors’ perspective on key aspects of the topic, including coverage of the basic and applied biology of vitamin A nutrition and assessment, clinical implications, and an overview of the extant data with regard to both the justification for and utility of available intervention strategies. The article includes some practical considerations based on specific country experiences regarding the challenges of implementing vitamin A–related programs. This is followed by an overview of some challenges associated with engagement of the enabling communities that play a critical role in the implementation of these types of public health interventions. The article concludes with suggestions for potential approaches to move this important agenda forward.

Public Health Aspects in the Prevention and Control of Vitamin Deficiencies

“…This is, perhaps, because measles and diarrhoa are, globally, less of a problem due to immunization and health interventions such as oral rehydration supplements and zinc for diarrhea. The true impact is a continuing source of debate at present (49, 50) and has practical considerations in terms of what interventions countries should be using and how to know when it is appropriate to shift, for example, from supplementation to dietary interventions, including fortification, or to some mixture of approaches. In the meantime, coverage with vitamin A supplements, twice a year, is stagnant or even dropping (51), before anything has come to take their place on the same scale.…”

“…These factors made vertical programs 1 such as supplementation attractive, not least because of their cost-effectiveness (the Copenhagen Consensus concluded a benefit:cost ratio of 9.5:1) (27). To international, bilateral donors, such programs also appeared to offer potential solutions with a clear problem, a clear solution, and clear outcomes; with their funding and support, there were considerable successes in at-risk countries (47, 50).…”

“…There was also a lack of proper national evaluations (48). Nevertheless, many millions of lives were, and continue to be, saved by the programs (48, 50, 65).…”

“…Since 2000, these global efforts to scale up VAS programs have yielded dramatic improvements in coverage from a decade before, contributing to a decline in child mortality (49, 81). But these efforts peaked at 78% (290 million children) in 2009 due to a loss of delivery platforms, weak health systems, and fragile states (50), leading to a shocking 6-year low. In 2016, 64% of children in need in priority countries were reached, but more than 140 million children were not, leaving them vulnerable to increased risks of disease and death (50).…”

“…But these efforts peaked at 78% (290 million children) in 2009 due to a loss of delivery platforms, weak health systems, and fragile states (50), leading to a shocking 6-year low. In 2016, 64% of children in need in priority countries were reached, but more than 140 million children were not, leaving them vulnerable to increased risks of disease and death (50).…”