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Should universal distribution of high dose vitamin A to children cease?

BMJ 2018; 360 doi: (Published 01 March 2018) Cite this as: BMJ 2018;360:k927
  1. JB Mason, professor emeritus1,
  2. CS Benn, professor2,
  3. HPS Sachdev, professor3,
  4. Keith P West Jr, George G Graham professor of infant and child nutrition4,
  5. Amanda C Palmer, assistant professor4,
  6. Alfred Sommer, professor4
  1. 1Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
  2. 2Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
  3. 3Pediatrics and Clinical Epidemiology, Sitaram Bhartia Institute of Science and Research, New Delhi, India
  4. 4Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  1. Correspondence to: JB Mason johnbmason2{at}, KP West Jr kwest1{at}

Up to $500m a year could be put to better use by stopping ineffective and potentially harmful supplementation programmes in poorer countries, say JB Mason, CS Benn, and HPS Sachdev; but Keith P West Jr, Amanda C Palmer, and Alfred Sommer disagree, saying that such programmes have been proved to save millions of lives and should be withdrawn only when robust evidence permits

Yes—JB Mason, CS Benn, HPS Sachdev

Some 270 million children aged 6 to 59 months, in 60 to 80 low and middle income countries, receive high dose vitamin A capsules (200 000 IU, about 100 times the daily recommended intake) twice a year, according to reports from Unicef1 and Nutrition International.2

These programmes, intended to reduce child mortality, are no longer effective, are wasteful, and are of doubtful safety. But this is disputed. Two key questions emphasise the main disagreements.

Programmes don’t reduce deaths

The first key question is: what impact do these programmes have on child mortality today? Deaths prevented by intermittent high dose vitamin A supplements in the 1980s and 90s were primarily from measles and diarrhoea3; measles now has low incidence, with high vaccination coverage, and diarrhoea is better managed.4 Re-analysis of a Ghanaian study showed that only unvaccinated children benefited.5

Even if programmes did have the same impact today, with as much as a 23% reduction in mortality among 6 to 59 month old children, we could expect only a 2% reduction in the 0 to 59 month mortality rate.678

In addition, the two studies reported since 2000910 showed these programmes had no impact on mortality. Meta-analyses of data in systematic reviews are being misinterpreted when assessing current impact on mortality. Results of trials done after 2000 are pooled with those from before 2000, which make up around 80% …

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