title: A Changing Landscape for Vitamin A Programs: Implications for Optimal Intervention Packages, Program Monitoring, and Safety.
abstract: Vitamin A deficiency (VAD) remains a widespread public health problem in the developing world, despite changes in under-5 mortality rates, morbidity patterns, and intervention options.
  
  
  
  This article considers the implications of a changing epidemiologic and programmatic landscape for vitamin A (VA) programs.
  
  
  
  We review progress to prevent VAD and its health consequences, assess gaps in VA status and intervention coverage data, and assess data needed to guide decisions regarding the optimal mix, targeting, and dose of VA interventions to maximize benefit and minimize risk.
  
  
  
  Vitamin A supplementation programs have contributed to the reduction in under-5 mortality rates, but alone, do not address the underlying problem of inadequate dietary VA intakes and VAD among preschool-aged children in the developing world. A combination of VA interventions (eg, supplementation, fortified foods, multiple micronutrient powders, and lipid-based nutrient supplements) will be required to achieve VA adequacy in most settings. Current efforts to measure the coverage of multiple VA interventions, as well as whether and how much VA children are receiving, are few and fragmented.
  
  
  
  Where intervention overlap exists, further effort is needed to monitor VA intakes, ensuring that targeted groups are consuming adequate amounts but not exceeding the tolerable upper intake level. Vitamin A status data will also be critical for navigating the changing landscape of VA programs. Data from these monitoring efforts will help to guide decisions on the optimal mix, targeting, and exposure to VA interventions to maximize public health benefit while minimizing any potential risk.
authors.affiliation: Helen Keller International, New York, NY, USA Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA rklemm@hki.org.
authors.forename: Rolf D W
authors.initials: RD
authors.lastname: Klemm
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Amanda C
authors.initials: AC
authors.lastname: Palmer
authors.affiliation: Micronutrient Initiative, Ottawa, Ontario, Canada.
authors.forename: Alison
authors.initials: A
authors.lastname: Greig
authors.affiliation: University of California, Davis, CA, USA.
authors.forename: Reina
authors.initials: R
authors.lastname: Engle-Stone
authors.affiliation: UNICEF, West and Central Africa Regional Office, Dakar, Senegal, Africa.
authors.forename: Nita
authors.initials: N
authors.lastname: Dalmiya
mesh_terms: D016907:Adverse Drug Reaction Reporting Systems; D019985:Benchmarking; D002662:Child Health Services; D002675:Child, Preschool; D005527:Food, Fortified; D014943:Global Health; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D009313:National Health Programs / Q000592:standards*; D015995:Prevalence; D012449:Safety; D014801:Vitamin A / Q000008:administration & dosage* / Q000009:adverse effects; D014802:Vitamin A Deficiency / Q000453:epidemiology / Q000517:prevention & control*
chemical_list: D014801:Vitamin A
keywords: assessment; fortification; supplementation; toxicity; vitamin A deficiency