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Recent estimates from the world health organization (who) indicate that 190 million preschool aged children, approximately one third of the world`s preschool age population, are vitamin a deficient
Vitamin A Supplementation in DEVTA (Deworming and Enhanced Vitamin A)
Vitamin A is a cost effective strategy for reducing child mortality
Recent estimates from the World Health Organization (WHO) indicate that 190 million preschool aged
children, approximately one third of the world`s preschool age population, are vitamin A deficient.
Vitamin A deficiency increases the risk of disease and death from severe infections, and is the leading
cause of preventable blindness in children.
Well controlled randomized trials in different regions with a high prevalence of vitamin A deficiency
have conclusively demonstrated that vitamin A supplementation to children every four to six months
under the age of five years is an efficient and cost-effective strategy for reducing child mortality.
Specifically, a 2011 Cochrane review of 17 randomized controlled trials conducted in 9
countries concluded that vitamin A supplementation results in a 24 percent reduction in
under-five child mortality
. This reduction in all-cause mortality confirmed an earlier meta-analysis
in 1993 on which vitamin A supplementation guidelines of the World Health Organizations (WHO) were
based and adopted by some 100 countries. There is also strong evidence from both community and
clinical trials that vitamin A prophylaxis and treatment can reduce the severity and fatality from
measles, diarrhoea, and reduce risk of hearing loss following middle ear infections.
Findings of a recently published program evaluation in the state of Uttar Pradesh, India
were not consistent with the established all-cause mortality reduction from vitamin A.
The ‘DEVTA study’ was an attempt to evaluate a large supplementation program providing high-dose
vitamin A every six months through routine services. One to two million preschool children were said
to have been enrolled through the Aganwadi centers of the Integrated Child Development Service
(ICDS), and comparisons were made between usual care, 6-monthly vitamin A supplementation, 6-
monthly albendazole (for deworming) or both. The intervention continued for 5 years and concluded
that vitamin A supplementation did not have a significant effect on reducing child mortality.
The DEVTA Study had limitations, primarily in the program design and evaluation
The research activity was vastly under-staffed with only 18 monitors overseeing the work of over
8300 Anganwadi workers and the participation of one to two million children. This shortage required
the number of children and their levels of compliance to be determined only from a mid-study census
which represented the number of ‘compliers’ at the time of the census rather than the numbers of
participants and capsules taken during the intervention. The authors report an overall compliance of
86%, raising questions about accuracy of record-keeping. The DEVTA trial also did not include
younger children between 6-12 months, who normally account for one-third of the deaths in children
While the DEVTA study represented an earnest attempt to evaluate a large, Government of
India program delivering vitamin A to children every six months, an intervention that is
well established in the scientific literature for its ability to reduce child mortality, the
results showed only a non-significant reduction in child mortality. The study was expected
to have revealed a greater program impact.
The reasons for this lack of effect are likely to be
found in how the program was run and evaluated, problems that commonly afflict most large
intervention strategies. There are many lessons to be learned from this undertaking, both with
respect to vitamin A delivery and the design, implementation and resources needed for evaluating
programs. We encourage the global scientific community to resist combining the DEVTA findings with
those of previous, rigorously conducted trials to reset the overall “efficacy” of vitamin A in reducing
child mortality. Doing so could send a wrong message that mixing program evaluation results with
those of well-controlled randomized human trials is an acceptable strategy, when it is not, especially
when the potential to continue saving millions of children’s’ lives are at stake.
Shally Awasthi, Richard Peto, Simon Read, Sarah Clark, Vinod Pande, Donald Bundy, and the DEVTA (Deworming and Enhanced
Vitamin A) team. Vitamin A supplementation every 6 months with retinol in 1 million pre-school children in north India: DEVTA, a cluster-randomised trial. Lancet
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