Vitamin A supplementation programmes are missing children from scheduled castes and scheduled tribes. New evidence from India

Background: Surveys have indicated that 62 % of preschool-age Indian children suffer from sub-clinical vitamin A deficiency (VAD), with a threefold higher prevalence of severe forms of VAD among children from schedule castes (SC) or schedule tribes (ST). The objective of this analysis is to assess whether India’s national vitamin A supplementation (VAS) programme is reaching the districts with higher concentration of SC/ST children in the seven states with the largest burden of under-five mortality (74 % of India’s under-five deaths). Methods: Disaggregated analyses of trends in and outcome VAS coverage and full VAS coverage were conducted between 2006 and 2011 by state and SC/ST concentration quintile using three data sources—India’s national VAS programme, Office of the Registrar General and Census Commissioner, and District-Level Household Survey—to compute exposure (SC and/or ST concentration) and outcome (VAS coverage and full VAS coverage) were conducted. Results: Between 2006 and 2011, all SC/ST concentration quintiles reported significant increases in full VAS coverage (two doses/child/year). The mean full VAS coverage over the 6-year period was positively correlated with the SC/ST concentration quintile: the district quintile with the highest concentration of SC/ST households reported the highest full VAS coverage (62.5 %), while the district quintile with the lowest concentration of SC/ST households reported the lowest coverage (47.9 %). The estimated number of children not fully covered by the VAS programme decreased by 39.0 % among children from SC/ST households and by 51.7 % among children from non-SC/ST households. The mean annual number of SC/ST children not fully covered was similar across SC/ST concentration quintiles (1.1 to 1.3 million). Conclusions: Indian states have achieved significant progress in expanding the coverage of the VAS programme. However, a large proportion of children are not benefitting from this child survival intervention, particularly among SC/ST children. These children are potentially among the most vulnerable to VAD and its consequences. India’s national VAS programme needs to be strengthened in sub-district-level units (i.e. blocks and villages) with higher concentrations of SC/ST children, with particular emphasis on SC children. Background Several population-based intervention trials have assessed the contribution of vitamin A deficiency (VAD) to child mortality [1–8]. Independent meta-analyses of these trials have indicated that in areas where VAD is prevalent, child mortality is reduced by 23–34 % following vitamin A interventions [9–12]. This significant improvement in child survival has been largely attributed to a reduction in * Correspondence: [email protected] United Nations Children’s Fund (UNICEF) Regional Office for South Asia, Lekhnath Marg, P.O. Box 5815, Kathmandu, Nepal Full list of author information is available at the end of the article © 2015 Aguayo et al. Open Access This arti International License (http://creativecommo reproduction in any medium, provided you link to the Creative Commons license, and Dedication waiver (http://creativecommons article, unless otherwise stated. mortality from measles, severe diarrhoea, dysentery, and possibly falciparum malaria [7, 13–15]. A recent Cochrane review has concluded that vitamin A supplementation (VAS) should be given to all children at risk of deficiency, particularly in low and middle income countries [16, 17]. In light of this compelling evidence, WHO recommends that in settings where VAD is a public health problem, children 6–59 months old be provided vitamin A supplements to reduce child morbidity and mortality [18]. In India, VAD has long been recognized as a public health problem [19–21]. Surveys carried out between cle is distributed under the terms of the Creative Commons Attribution 4.0 ns.org/licenses/by/4.0/), which permits unrestricted use, distribution, and give appropriate credit to the original author(s) and the source, provide a indicate if changes were made. The Creative Commons Public Domain .org/publicdomain/zero/1.0/) applies to the data made available in this Aguayo et al. BMC Nutrition (2015) 1:15 Page 2 of 7 2002 and 2005 found that 62 % of preschool-age children had sub-clinical VAD (serum retinol < 20 μg/dl). These surveys indicated that the prevalence of more severe forms of VAD was three times higher among children from schedule caste (SC) or schedule tribe (ST) households [22, 23]. Furthermore, India’s 2006 National Family Health Survey indicated that the proportion of SC/ST children 6–59 months who had received vitamin A supplements in the 6 months preceding the survey was a mere 17 % [24]. Since 2006, the Government of India and India’s State Governments have made a concerted effort to increase the coverage of the VAS programme by strengthening the implementation of bi-annual VAS rounds as part of the national VAS programme, managed by the Ministry of Health and Family Welfare. The programme aims at delivering preventive VAS to children 6–59 months old. For programmatic convenience, the first VAS dose (100,000 IU) is administered with the measles vaccination at ~9 months, while the subsequent eight doses (200,000 IU each) are administered every 6 months up to the age of 59 months using bi-annual VAS rounds as the main delivery platform [25]. The delivery of vitamin A supplements is ensured by the Auxiliary Nurse Midwife (ANM) of the Health Department, supported by the Accredited Social Health Activist (ASHA), the frontline worker of the National Rural Health Mission (NRHM), and the Anganwadi Worker, the frontline worker of Integrated Child Development Services (ICDS) programme, India’s flagship programmes for child health, nutrition and development. In 2006, the states of Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan and Uttar Pradesh—with 52 % of India’s under-five population (i.e. 59.4 million)—were home to 74 % of the under-five deaths in India, with a combined under-five mortality rate of 84 deaths for every 1000 live births (63 in India) [24, 26, 27]. Furthermore, 32.9 % of the combined population in these seven states survived below a minimum standard of living, with poverty levels as high as 47.3 % in the population quintile with the highest proportion of SC/ST households [28]. The objective of this analysis is to assess whether India’s national VAS programme is reaching the districts with a higher concentration of children who belong to SC/ST households in the seven states of India with the largest burden of under-five mortality. Methods We used the latest publicly available data by the Office of the Registrar General and Census Commissioner of India to determine the population size, population composition (including the proportion of SC/ST households), and the number of children 6–59 months (SC, ST, and non-SC/ST) in each of the seven states and 255 districts included in our analysis [29]. Data collection and collation procedures took into account the number of children 6–11 months old who received VAS through the routine immunization programme (measles vaccination at ~9 months) and the number of children 12–59 months old who received VAS through the bi-annual rounds. The number of children 6–59 months old who benefitted from the VAS programme in each district was determined using standardized bottom-up data collection and collation approach with data flowing up from the VAS supplementation sites in the village to the block, from the block to the district, and from the district to the state in each given calendar semester (semester 1: Jan 1–June 30; semester 2: Jul 1–Dec 31). Following international recommendations,VAS coverage was defined as the proportion of eligible children who received at least one VAS dose in a given calendar year while full VAS coverage was defined as the proportion of eligible children who received two VAS doses in a given calendar year. For any given district and calendar year, VAS coverage was computed as that of the semester with the highest VAS coverage whereas full VAS coverage was computed as that of the semester with the lowest VAS coverage, thus assuming that all children who benefitted from the VAS programme in the semester with the lowest VAS coverage also did in the semester with the highest VAS coverage [30]. STATA12 (StataCorp. 2009; Stata: Release 12. Statistical Software. College Station, TX: StataCorp LP) was used for all data analyses. Ethical approval was not sought as we analyse anonymous data that cannot be linked to individual children, caregivers, or household identity. Results The coverage and full coverage of the VAS programme was analysed by SC/ST concentration quintile, dividing the 255 districts into five quintiles (~51 districts per quintile): the lowest quintile comprising the 20 % districts with the lowest concentration of SC/ST households at one end and the highest quintile comprising the 20 % districts with the highest concentration of SC/ST households at the other end (Table 1). In 2006, the highest SC/ST quintile reported the highest full VAS coverage (52.6 %) while the two lower SC/ST quintiles reported the lowest full VAS coverage (~37.0 %). Between 2006 and 2011, the full VAS coverage increased in all SC/ST quintiles. This increase was inversely correlated with the SC/ST concentration quintile: highest (42.5 percentage points) in the lowest SC/ST quintile and lowest (8.6 percentage points) in the highest SC/ST quintile (Table 1). However, the mean full VAS coverage over the 6-year period (2006–2011) was positively correlated with the SC/ST concentration quintile: highest (62.5 %) in Table 1 Vitamin A supplementation coverage (at least one dose/child/year) and full VAS coverage (two doses/child/year) by SC/ST concentration quintile, India 2006–2011 SC/ST concentration quintile Year Lowest Lower Middle Higher Highest VAS coverage 2006 45.9 50.5 63.9 69.7 70.4 2007 71.6 74.6 74.4 83.6 86.4 2008 84.2 85.7 93.6 95.6 97.4 2009 93.0 96.3 98.1 94.7 96.8 2010 85.8 78.6 92.0 93.6 97.4 2011 95.1 96.9 90.1 89.2 88.1 2006–11 79.3 80.4 85.2 87.7 89.4 Full VAS coverage 2006 37.2 37.0 47.4 49.3 52.6 2007 10.5 40.8 44.7 57.5 56.1 2008 69.1 55.1 60.8 53.1 64.6 2009 84.5 85.1 77.7 66.8 65.4 2010 6.1 34.0 43.4 65.6 75.8 2011 79.7 70.3 65.4 60.0 61.2 2006–11 47.9 53.7 56.5 58.6 62.5 Note: Coverage figures are indicated as percentages Table 2 Vitamin A supplementation coverage (at least one dose/child/year) and full VAS coverage (two doses/child/year) by ST concentration quintile, India 2006–2011 ST concentration quintile Year Lowest Lower Middle Higher Highest VAS coverage 2006 26.5 55.9 77.3 71.5 70.