title: Safety and Mortality Benefits of Delivering Vitamin A Supplementation at 6 Months of Age in Sub-Saharan Africa.
abstract: BACKGROUND
  Vitamin A supplementation (VAS) among children 6 to 59 months of age reduces vitamin A deficiency (VAD)-related mortality. Child health days (CHDs) only reach an estimated 16.7% of children at exactly 6 months, leaving uncovered children at risk of VAD-related mortality; similarly, VAS provided at 9 months of age with measles-containing vaccine leaves infants unprotected for 3 months.
  
  
  OBJECTIVE
  Using data from sub-Saharan Africa, we estimated the mortality benefits and safety of providing VAS at age 6 months, compared to delivery through CHDs and at 9 months.
  
  
  METHODS
  We modeled VAS-preventable mortality benefits at 6 months as a function of published VAS effect sizes, intervention coverage, and proportion of infant deaths occurring between 6 and 11 months. To evaluate safety, we modeled the effect of different VAS coverage scenarios on maximum hepatic vitamin A concentrations (HVACs).
  
  
  RESULTS
  VAS linked to a 6-month visit could reduce infant mortality by an additional 1.95 (95% confidence interval [CI]: 1.38-2.52) and 1.63 (95% CI: 1.15-2.11) percentage points compared to VAS through CHDs and at 9 months, respectively. The HVAC models indicate that VAS at 6 months is safe even in the presence of a second VAS dose 1 month later and other food-based vitamin A control strategies.
  
  
  CONCLUSIONS
  Advancing the first VAS dose to 6 months should be considered in settings where VAS is currently given first at 9 months. A 6-month VAS dose should also be considered in settings where VAS is delivered through CHDs. VAS delivery at 6 months could also serve as a platform to deliver other high-impact interventions.
authors.affiliation: 1 UNICEF Headquarters, New York, NY, USA.
authors.forename: Roland
authors.initials: R
authors.lastname: Kupka
authors.affiliation: 2 Helen Keller International Headquarters, New York, NY, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Nielsen
authors.affiliation: 3 Helen Keller International Tanzania Country Office, Dar es Salaam, Tanzania.
authors.forename: Christina
authors.initials: C
authors.lastname: Nyhus Dhillon
authors.affiliation: 4 Helen Keller International Africa Regional Office, Nairobi, Kenya.
authors.forename: Jessica
authors.initials: J
authors.lastname: Blankenship
authors.affiliation: 5 Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, CA, USA.
authors.forename: Marjorie J
authors.initials: MJ
authors.lastname: Haskell
authors.affiliation: 6 Helen Keller International Africa Regional Office, Dakar, Senegal.|7 Bill & Melinda Gates Foundation, Seattle, WA, USA.
authors.forename: Shawn K
authors.initials: SK
authors.lastname: Baker
authors.affiliation: 6 Helen Keller International Africa Regional Office, Dakar, Senegal.|7 Bill & Melinda Gates Foundation, Seattle, WA, USA.
authors.forename: Kenneth H
authors.initials: KH
authors.lastname: Brown
keywords: Africa South of the Sahara; deficiency; immunization; supplementation; vitamin A