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EPIDEMIOLOGICAL DATA
     
Clinical Vitamin A Deficiency
Most Recent Clinical VAD Survey
Date: 1993 - Fourth National Nutrition Survey
Groups Surveyed: Children 1-5 yrs
Sample Size: 5073 children; 21,629 all age groups
Sampling Method: Stratified two-stage design.  Nationwide, 76 provinces in all regions of the Philippines, including 8 clusters of cities and municipalities in Metro Manila.
Sampling Strategy: Sample households were drawn using a stratified two-stage sampling design.  Stratification was done by region, province and urban/rural classification.  The barangay (village)  and household served as primary and secondary units. 
Estimated Prevalence of VAD: Presence of at least one of the following clinical indicators
1.  Conjunctival xeroxes with bitots spot
2.  Corneal xeroxes/ ulceration/ keratomalacia
3.  Corneal scar

                             Prevalence of clinical VAD in preschool children by sex and age in years.                                         

Country/Sex and Age Group

Sample Size

Prevalence (%)

(Night-blindness, XN) 

Prevalence (%)

Bitot’s spot (X1B)

Philippines

5,073

0.4

0.1

Males

2,626

0.3 

0.1

<1 y

242

0.2

-

1 y

422

-

-

2 y

440

0.7

-

3 y

424

0.2

-

4 y

392

0.5

-

5 y

359

0.9

0.6

6 y

347

1.6

0.3

Females

2,447

0.3

0.1

<1 y

209

-

-

1 y

405

-

-

2 y

425

0.2

-

3 y

358

0.3

0.3

4 y

363

-

-

5 y

373

0.3

-

6 y

314

0.3

-

 

Prevalence of clinical VAD (4th NNS, 1993); including pregnant and lactating women.

Area/Location: 

 

Sample Size

Prevalence (%)

(Night-blindness, XN) 

Prevalence (%)

 Bitot’s spot (X1B)

Philippines

21,629

1.1 

0.1

Ilocos

1,043

1.5 

-

Cagayan

1,185

0.4 

-

Central Luzon

1,471

3.1 

0.1

Southern Tagalog

2,810

2.1 

0.5

Bicol

1,157

0.3 

-

Western Visayas

1,677

0.1 

-

Central Visayas

1,061

0.7 

-

Eastern Visayas

1,560

2.3 

0.6

Western Mindanao

767

0.7 

-

Northern Mindanao

1,931

0.1 

-

Southern Mindanao

1,555

1.3 

0.3

Central Mindanao

798

0.3 

-

CARAGA*

 

 

 

National  Capital Region (NCR)

2,145

0.5 

0.1

Cordillera Autonomous Region (CAR )

1,243

0.8 

-

Autonomous Region of Muslim Mindanao (ARMM)

826

- 

0.4

 
 
Sub-clinical Vitamin A Deficiency
Most Recent Sub-clinical VAD Survey
Date:
Groups Surveyed: Children 6 months to 5 years, pregnant and lactating women.
Sample Size: Children 6 mos- 5 yrs: 14,291
Pregnant women: 2963
Lactating women: 3165
Sampling Method: The survey followed a two-stage sampling design, with the barangays as the primary stage and the individuals as the secondary units
Estimated Prevalence of VAD:  Indicator is serum retinol <0.35mm/L
 

Prevalence of Sub-clinical VAD among children 6 months to 5 years of age by Region.

Area/Location

Sample Size

Prevalence of Deficient and Low Plasma Retinol:

(< 20 mg/dL)

Philippines

14,291

38.0

Ilocos Region

612

25.9

Cagayan

675

27.8

Central Luzon

1,024

45.4

Southern Tagalog

1,797

37.9

Bicol

883

34.5

Western Visayas

1,165

40.9

Central Visayas

1,027

50.8

Eastern Visayas

839

36.5

Western Mindanao

454

54.6

Northern Mindanao

647

30.7

Southern Mindanao

1,227

35.6

Central Mindanao

522

35.4

CARAGA

557

33.8

National Capital Region (NCR)

1,572

31.1

Cordillera Autonomous Region (CAR )

867

30.4

Autonomous Region of Muslim Mindanao (ARMM)

423

40.5

 

Prevalence of Sub-Clinical VAD among Pregnant Women by Region, 1998 NNS.

Area/Location

Sample Size

Prevalence of Deficient and Low Plasma Retinol:

(< 20 mg/dL)

Philippines

2963

22.2

Ilocos Region

132

8.1

Cagayan Valley

135

11.4

Central Luzon

223

24.7

Southern Tagalog

354

25.2

Bicol Region

173

14.6

Western Visayas

228

21.0

Central Visayas

190

33.8

Eastern Visayas

182

21.1

Western Mindanao*

97

41.4

Northern Mindanao

149

28.9

Southern Mindanao

258

21.3

Cental Mindanao**

106

16.6

CARAGA

136

25.5

NCR

349

18.1

CAR

166

19.4

ARMM

85

24.7

 
 
     
 

POLICY AND LEGISLATION
 

Legislation on VAD
    A law has been enacted by the Philippine Congress, Republic Act 8976, entitled "An Act establishing the Philippine Food Fortification Program and for other purposes". The law provides for the mandatory fortification of staple foods based on standards set by the Department of Health, and voluntary fortification of all processed foods or food products under the Sangkap Pinoy Seal Program.
    RA 8976, also known as the Food Fortification Act of 2000, was enacted into law on 07 November 2000. The Philippine Government has approved the Implementing Rules and Regulations (IRR) of the said law. This legislation focuses on fortification.
    The Department of Health also issued Administrative Order (AO) 3-A s.2000 on 10 January 2000 that specifies the implementing guidelines on vitamin A and iron supplementation. Included in this administrative order are priority targets, mechanics and schedule of supplementation, distribution, handling, and storage of vitamin A capsules, and implementation of a monitoring system.
    Vitamin A fortification is being promoted for wheat flour, refined sugar and cooking oil.  The fortification is mandated by RA 8976.
    There have been published documents stating the national policy regarding VAD.  The Department of Health issued Administrative 3-A Series 2000, which specifies the implementing guidelines on Vitamin A and Iron Supplementation. The guidelines have specific sections on therapeutic and preventive supplementation to address vitamin A deficiency
 

Government Agency to Address VAD

     The Department of Health has formed a National Micronutrient Action Team to address issues on micronutrient deficiency control programs.
     A National Food Fortification Steering Committee (NFFSC) has been formed to provide directions and goals and to coordinate food fortification activities.  The NFFSC, which is chaired by the DOH Undersecretary, includes representatives from government (including the Senate and House of Representatives),  non-government organizations, the academe, international funding agencies, and private industry. Other functions are: to recommend policies, guidelines, and standards for food fortification activities; facilitate the management and implementation of food fortification; to resolve issues in implementation of food fortification.
 
     

PROGRAM DATA
   
Supplementation
Program Description
     The vitamin A supplementation program in the Philippines started in the early 1980's as a targeted or high-risk approach. This was put into policy in the late 80's.
     The nationwide Vitamin A supplementation program (preventive universal approach) started in 1993 with Araw ng Sangkap Pinoy (ASAP) or National Micronutrient Day as the venue for distribution of vitamin A capsules. Since 1993 to the present, the Philippines has implemented a universal VAC supplementation with 200,000 IU twice a year (April and October) given to all preschoolers 9-59 months old (total number is approximately 7-9 million children.
     The targeted/therapeutic/medical approach is also a Dept of Health (DOH) policy. In accordance with AO No. 3-A s.2000, target groups for therapeutic supplementation are all VAD cases between 6-11 months old (using 100,000 IU x 4 doses); between 6 and 59 months old (200,000 IU x 4 doses); and pregnant women with nightblindness (10,000 IU daily x 4 weeks).  This is undertaken at government health facilities. However, a major obstacle to nationwide coverage is the limited supply of vitamin A capsules.
     Routine supplementation (started in 1989): Vitamin A capsules are given during routine supplementation activities at the rural health units or health centers and in hospitals in cases of measles, pneumonia and diarrhea; also targets pregnant and lactating women without signs and symptoms of VAD; high risk groups (mild, moderate, and severely underweight children with measles, ARI, diarrhea); postpartum women within one month of delivery; severely underweight children aged between 6-12 years
     Since 1993, VAC coverage has fluctuated between 75- 95 percent (1993-1996: >90 % coverage; 1997-2000: 76-85% coverage). Downward fluctuations in coverage were attributed to logistical problems, declining support for the campaign and changes in leadership and administration. (source: DOH, NNC, HKI responses).
     The VAC supplementation program will be strengthened in 2002 with the nationwide distribution of the Vitamin A supplementation policies to field health workers in combination with retraining and reorientation of health workers (Attached is the DOH Administrative Order on Vitamin A and Iron supplementation).
     There is a policy to address vitamin A supplementation for mothers within 8 weeks of delivery.  This in accordance with Administrative Order 3-A.  This started in 2002. Vitamin A supplementation of one capsule (200,000 IU) is given to mothers within one month after delivery, distributed as part of routine services in government health facilities.
 
Targeting

    

The DOH has targetted approximately 9 million children 12-59 months for every round of VAC distribution.

    

There are plans to include more than two million infants aged 6-11 months for VAC distribution.

    

Other target groups are pregnant women (comprising 3% of total population), children with measles, chronic diarrhea, pneumonia and those identified to have severe and moderate malnutrition (approximately 15 - 20% of the population.
Implementation
     The first dose of universal VAC distribution to preschoolers was given in October 1993 to coincide with World Food Day and was popularly known as Micronutrient Day or Araw ng Sangkap Pinoy (ASAP).
     Universal VAC supplementation for preschoolers is given twice a year in the Philippines (April and October). The first dose of vitamin A capsule was initially given through the National Immunization Day (every April 15) and the second dose during the National Micronutrient Day (every October 15) from 1993-1996.  The mass campaign for VAC distribution during the NID continued until 1998.  In 1999, NID was discontinued by the DOH, but a new delivery mechanism for VAC was conceptualized and implemented. This became known as the Garantisadong Pambata (Preschoolers Health Week) every second week of April. Garantisadong Pambata also includes the delivery of a package of health services such as immunization, iron supplementation for LBW, key messages for child health on breastfeeding, complementary feeding, dental health, use of fortified foods, etc.
     VAC are also distributed during the delivery of routine services in health facilities e.g. government hospitals and health centers.
   
Capsule Information
     An estimated number of 7-9 million million capsules were distributed per round of universal supplementation (twice a year).  (no specific information were given by respondents on importation, local production and actual distribution to other target groups.
 

Fortification
    

There are vitamin A fortification programs, as provided for in RA 8976 (Food Fortification Act) enacted into law by Congress, mandatory fortification of flour, cooking oil, and sugar should be achieved by November 2004.
    

Fortified Food

Approx. Percentage of Commodity Fortified

Fortification Level

mgs or Ius/kg

Retail Cost

Flour

5 our of 12 Millers fortifying, % of total supply unknown

3.0 mg/kg as retinol (minimum tolerable level)

6.5 mg/kg as retinal (maximum tolerable level)

NR*

Edible Oil

1 out of 36 Refineries fortifying, % of total supply unknown

12.0 mg/L (minimum acceptable level)

23 mg/L (maximum tolerable level)

NR

Refined Sugar

Pilot stage for premix production

Targeted at 5 mg RE/kg at retail distribution

NR

Other Processed Foods with Sangkap Pinoy Seal**

45 brands of different processed foods fortified

Labeled as containing at least 1/3 of RDA per serving

NR

* NR = Not Reported

**The Sangkap Pinoy Seal (SPS) Program of the Department of Health is a strategy that aims to encourage food manufacturers to voluntarily fortify processed foods or food products with essential nutrients at levels approved by the DOH. To date, 45 food products fortified under the SPS Program contain Vitamin A.
 
Other Programs
Dietary Change
     The Nutritional Guidelines for Filipinos (NGF), launched in 2000, are recommendations formulated to promote good health through proper nutrition. These recommendations aim to encourage the consumption of an adequate and well-balanced diet and to promote desirable food and nutrition practices as well as nutrition-related health habits in the general population. The NGF has specific recommendations that are intended to correct deficiencies in the current dietary pattern of Filipinos.
   

Mass Media Campaigns
     Media campaigns using television, radio, and print media are done to promote optimal vitamin A status during “Preschooler’s Week” (GP) conducted every April.

Community-Based Programs
     The National Nutrition Council, through the Philippine Plan of Action for Nutrition  (PPAN) as the blueprint for nutrition improvement in the country, has promoted 5 impact programs for implementation at the community level. Two of these are 1) home and community food production (home and school gardens) and  2) nutrition education (e.g. conduct of mother’s classes at the community level but has been done selected areas only). These impact programs are aimed at alleviating nutrition problems, including Vitamin A deficiency.
     
     
 
MONITORING
 

Clinical and Sub-clinical VAD
     The National Nutrition Survey is conducted every 5 years by the Food and Nutrition Research Institute. The survey includes clinical and biochemical methods for nutritional assessment, including vitamin A status.
     The indicators used for monitoring clinical VAD are nightblindness and signs of xerophthalmia (e.g Bitot’s spots); however, the last clinical survey for VAD was done in 1993 and was not done in 1998.
     The indicator used for monitoring sub-clinical VAD is serum retinol.
 
Supplementation
     The numbers of vitamin A capsules imported and/or produced are monitored.  The Department of Health is primarily responsible for procurement and monitoring of Vitamin A capsules.  UNICEF, as a source of vitamin A capsules,  also monitors the amount of VAC supplied to Country Program for Children (CPC) areas. Total cost provided by UNICEF in 2002 for VAC was valued at $ 124,983.00.
     VAC coverage is monitored through post cluster surveys and from routine reports submitted by government health facilities.
Fortification
     Not reported.
     
     
PROGRAM RESOURCES
   
Donor Agencies
     External Donor Agencies include UNICEF and HKI.
 
VAD Program Funding History and Projections
     External funds are being provided.  Funds are being used for provision of VAC, production of IEC materials, technical assistance in the development of policies/guidelines; conduct of workshops; social mobilization activities to increase awareness and coverage of VAC.
     The Food Fortification Project Strategic Plan 2000-2004 provides further information on funding needs for VAD control.

-  http://www.doh.gov.ph/food/FF1.html