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National Vitamin A Supplementation Programme India schedule intervention 2024
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Department of Community Medicine - Case Study XVII: Gaurav, 6.5 years old
1. Provisional Diagnosis
Vitamin A Deficiency (VAD) - Night Blindness (Nyctalopia / XN stage of Xerophthalmia)
Clinical reasoning:
- Gaurav has difficulty walking during late evening - this is the classic symptom of night blindness (nyctalopia), where the child cannot see in dim light
- He walks with hands spread out - this is a compensatory behavior, as the child uses his arms to balance and feel his way around due to impaired vision in low light
- The mother noticed it herself (Park's notes: "The mother herself can detect this condition when her child cannot see in late evenings or find her in a darkened room")
- Age group (6.5 years) is within the high-risk preschool group for VAD
WHO Classification of Xerophthalmia (Wills Eye Manual):
| Grade | Description |
|---|---|
| XN | Night blindness (Gaurav's stage) |
| X1A | Conjunctival xerosis |
| X1B | Bitot's spots |
| X2 | Corneal xerosis |
| X3A | Corneal ulceration <1/3 cornea |
| X3B | Keratomalacia (>1/3 cornea) |
| XS | Corneal scar |
| XF | Xerophthalmic fundus |
Gaurav is at XN (Grade 1) - the earliest and most reversible stage. If untreated, this may progress to conjunctival xerosis, Bitot's spots, corneal ulceration, and ultimately keratomalacia leading to permanent blindness.
Additional non-ocular features to look for: Phrynoderma (toad skin - follicular hyperkeratosis), increased susceptibility to respiratory and GI infections, poor growth.
2. Management of the Child
A. Therapeutic Vitamin A (Treatment)
Vitamin A deficiency should be treated urgently. As per Park's Textbook:
"Nearly all of the early stages of xerophthalmia can be reversed by administration of a massive dose (200,000 IU or 110 mg of retinol palmitate) orally on two successive days."
Treatment schedule for Gaurav (6.5 years, night blindness):
- Day 1: 200,000 IU (2 ml) Vitamin A orally
- Day 2: 200,000 IU (2 ml) Vitamin A orally
- Day 14 (1-4 weeks later): Repeat 200,000 IU dose
B. Dietary Counseling
Advise the mother to increase dietary intake of:
- Animal sources (preformed Vitamin A / retinol): Liver, egg yolk, full-fat dairy, fish liver oil
- Plant sources (beta-carotene, provitamin A): Dark green leafy vegetables (spinach, drumstick leaves), yellow/orange fruits and vegetables (papaya, mango, carrot, pumpkin)
- Ensure adequate fat intake in diet (fat is needed for absorption of fat-soluble Vitamin A)
C. Treat Associated Conditions
- Screen and treat for Protein-Energy Malnutrition (PEM) - protein deficiency reduces retinol-binding protein production, worsening VAD
- Deworm (mebendazole if >1 year)
- Treat any intercurrent infections (diarrhoea, respiratory infections worsen VAD)
- Screen for measles - measles dramatically worsens Vitamin A status
D. Referral
Refer to CHC/District Hospital ophthalmology if corneal involvement develops. The ASHA has already correctly referred to CHC - appropriate action.
3. National Programme and Schedule for Intervention
National Programme: National Vitamin A Supplementation Programme (NVASP)
This comes under the Reproductive and Child Health (RCH) Programme / National Health Mission (NHM), Government of India.
Rationale: A large number of children in India suffer from sub-clinical VAD. The programme delivers preventive megadoses to all children under 5 years of age.
Dose & Schedule (as per Park's Textbook / NHM):
| Age | Dose | Route | Linked with |
|---|---|---|---|
| 9 months | 1,00,000 IU (1 ml) | Oral | Measles vaccination |
| 16-18 months | 2,00,000 IU (2 ml) | Oral | DPT Booster |
| 24 months | 2,00,000 IU (2 ml) | Oral | Every 6 months |
| 30 months | 2,00,000 IU (2 ml) | Oral | Every 6 months |
| 36 months | 2,00,000 IU (2 ml) | Oral | Every 6 months |
| 42 months | 2,00,000 IU (2 ml) | Oral | Every 6 months |
| 48 months | 2,00,000 IU (2 ml) | Oral | Every 6 months |
| 54 months | 2,00,000 IU (2 ml) | Oral | Every 6 months |
| 60 months | 2,00,000 IU (2 ml) | Oral | Every 6 months |
Total: 9 doses up to 5 years of age
- First dose (1 lakh IU) at 9 months with measles vaccine
- Second dose (2 lakh IU) after 9 months
- Subsequent doses (2 lakh IU each) at 6-month intervals up to 5 years
Additional rule: All cases of severe acute malnutrition receive one additional dose of Vitamin A.
Delivery platform: Biannual VAS rounds (twice a year) delivered through Anganwadi Centres (AWC), Primary Health Centres (PHC), Sub-Centres, and immunization clinics by ASHA workers, ANMs, and Anganwadi Workers (AWW).
Key Point for Gaurav's case: At 6.5 years, Gaurav is slightly outside the routine supplementation window (programme covers up to 5 years), which means he likely missed doses - reinforcing why screening and community outreach through ASHA workers is critical. His treatment now is therapeutic (not prophylactic), and dietary and socioeconomic factors should be addressed.
Sources: Park's Textbook of Preventive and Social Medicine, pp. 700, 712-714; Wills Eye Manual; NHM India (nhm.gov.in)
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