E-drug: Controversy over vitamin A programme in India
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[I am not going to suggest that confusion of strengths of vitamin A
preparations or bad quality is the problem here, but I have been to
countries where poorly labelled preparations with different strengths were
sold 'side by side'. And could cause capsules intended to be taken every
six months to be taken more frequently. Regulatory authorities and others
should be aware of the different products available both in public and
private sector and the confusion caused by this as well as by inconsistent
labelling of strengths and lack of package insert or dosage information on
labels. KM]
BMJ 2001;323:1206 ( 24 November )
Deaths trigger fresh controversy over vitamin A programme in India
Ganapati Mudur New Delhi
Indian doctors have renewed their accusation that international agencies
are
needlessly promoting the administration of vitamin A across India to all
children aged below 5 years.
Paediatricians and nutritionists launched a barrage of criticism after 14
children died and thousands fell ill last week in the north eastern state
of
Assam following a vitamin A campaign supported by Unicef. Health officials
are investigating the deaths and illness amid suspicions that health
workers
might have given overdoses to children during the state-wide campaign to
deliver vitamin A to three million children aged 1 to 5 years.
Unicef had replaced the traditional 2 millilitre spoons with 5 millilitre
cups to pour out vitamin A for the campaign. Health officials suspect that
this switch in the method of measuring the vitamin and the inadequate
training of health workers might have led to overdoses, but they have not
ruled out contamination or other causes. Unicef officials in New Delhi said
that the cups had been introduced because they were considered more
efficient and hygienic. They said the cups were now being withdrawn, but
they added that it was unlikely that overdoses had caused the deaths and
illness. "Even a full 5 millilitre cup of vitamin A would not be lethal," a
Unicef official said.
Some Indian doctors have questioned the benefits and safety of the
administration of vitamin A through the "pulse campaign" promoted by
Unicef.
The campaign involves delivering the supplement to all children aged 1 to 5
years across a state on a single day. The Indian health ministry has had a
vitamin A programme running for more than three decades that covers
children
aged 9 months to 3 years and is linked to immunisation. However, less than
30% of target children in India receive even one dose of vitamin A.
Paediatricians are urging more selective use of vitamin A because child
nutrition has improved and clinical signs of vitamin A deficiency, such as
symptoms of eye disease, are becoming less common. However, Unicef
maintains
that symptoms of eye disease are associated with advanced vitamin A
deficiency and that children might be needlessly put at risk of impaired
immune function and fatal infections long before such symptoms appear.
Paediatricians reject that argument. "There is no clinching evidence to
show
reduction in mortality through vitamin A among children with subclinical
vitamin A deficiency," said Dr Harsh Pal Singh Sachdev, professor of
paediatrics and clinical epidemiology at the Maulana Azad Medical College,
New Delhi, and editor of the journal Indian Pediatrics.
A technical consultation initiated by the health ministry last year
concluded that existing data were not sufficiently robust to recommend
vitamin A supplementation to reduce mortality in children aged 1 to 5
years.
"The promotion of the universal distribution of vitamin A is a glaring
example of the commercial exploitation of malnutrition in developing
countries by pharmaceutical companies," said Dr Umesh Kapil, additional
professor of human nutrition, All India Institute of Medical Sciences, New
Delhi.
The Nutrition Society of India has warned that the Assam episode will lead
to an erosion of public confidence in government healthcare programmes and
might even cause a serious setback to the pulse poliomyelitis campaign.
--
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