Memo no: H/SFWB/8B-01-2014/868 Date: 12/05/2016

Guideline on Bi-annual Vitamin A Supplementation

Importance of Vitamin A Supplementation

Vitamin A deficiency does its worst damage during childhood and is a major
contributor to childhood mortality and illness. The most commonly known effect of
Vitamin A deficiency is blindness. Less well known is that Vitamin A is also essential for
functioning of the immune system. Even before blindness occurs, vitamin- A deficient
children are at increased risk of dying from diseases such as measles, diarrhea, and
malaria. Vitamin A supplementation among vitamin-A deficient populations can reduce
child mortality (The Lancet, Vol 361, June 2003).

Doses and Schedule of vitamin A oil supplementation

Dose of vitamin A supplementation should be given to all children between 9-59

months, who have not received the megadose of vitamin A in the last one month. Dosage
of Vitamin A oil for children under 1 year is 1, 00,000 I.U. (1 lakh I.U. / 1ml) & for
children 1 - 5 years of age the dose is 2, 00,000 I.U. (2 lakh I.U. / 2ml).
Vitamin A supplementation will be done twice a year, at an interval of 6 months, i.e. June
and December.
Henceforth, first two dose of vitamin A oil will be administered with measles
vaccine at 9 & 16 months of age (measles 1st dose and booster dose) and 3rd dose
onwards all mega dose of vitamin A supplementation will be administered during
bi-annual round.

The 1st dose 1, 00,000 I.U (1ml) shall be given with routine measles immunization
(9 months of completed age).
The 2nd dose 2, 00,000 I.U (2ml) shall be given with routine 2nd dose measles
vaccination as early as possible after 16 months of age. Thereafter the child will be
 covered under bi-annual strategy. A gap of at least one month must be maintained
between consecutive two doses unless otherwise recommended.
The next 7 dose (each dose 2 ml) shall be administered during bi-annual round (in
every 6 months). A gap of at least one month is recommended between subsequent
doses to avoid toxicity.
All children 12-59 months age will be given one full spoon (2 ml/2, 00,000IU) of
Vitamin-A oil, provided the child hasnt been received megadose of vitamin A oil
within1 month prior to the round.
This activity will be carried out by ANM or any other trained health worker with the
support of Anganwadi Worker and ASHA.
Vitamin A supplementation (VAS) will be provided to all children aged 18 - 60
months (including drop-outs) during the bi-annual scheduled month.

Estimation of supplies

District will estimate the requirement of 100 ml Vitamin A bottles. Further session wise
estimation of supplies will be done by using micro-plans prepared by ANMs/AWWs of
respected areas. Population based figures of under 5 children should be calculated to
estimate the requirement of drugs and other logistics.
Need Assessment of Vitamin A 100 ml bottles:
A B C D E F G H I
Name
For VAD children (with
Total population (As per

Actual Requirement of
No. of children between

No. of children between

of
Vitamin A bottle (100
Total no. of children (9

visible sign & symptom)

of
requirement
Vitamin

Wastage calculation

district
months to 5 yr.)
9 months to 1yr
census 2011)

ml, oil based)

1 year to 5 yr

ml
bottles

Total
100

C= D= E= F= G= H= I=
B *1% B *11% (C + D) (C/100) + F*1% F*10% (F+G+H)
(D/50)

District has to ensure the availability of Vitamin A oil with spoon (marked in 1ml and
2ml) atleast two weeks prior the round.
 Planning and Implementation

For effective planning and implementation of the bi-annual rounds, following critical
areas need to be addressed:

1. Intersectoral coordination and convergence:

Involvement and support from other line departments including ICDS, Panchyat, and
development partners like UNICEF, local NGOs, Medical colleges and hospitals (Dept.
of Paediatrics and & Community Medicine) shall improve visibility and coverage of
the bi-annual round.
Active participation of counterparts required in planning meeting of bi-annual
round. These meetings are to be held on a pre-scheduled date at state, district and
block levels with involvement of functionaries from H&FW, ICDS, PRI members,
members from local NGO & development partners.
Faculties from Medical colleges (Dept. of Paediatrics and & Community Medicine),
urban health bodies (for urban municipal areas in districts and Kolkata) may also be
involved along with the other stake holders at state and distrct level planning
meeting for yielding more dividend in terms of improved bi-annual coverage
specially at urban area.

2. Training:

State Level Video Conference with district involving ICDS and other development
partners both at state and district level- for guideline dissemination and planning
with districts and other departments.
District level orientation will be organized for Medical Officers, CDPO, BPHN, PHN,
ICDS & health supervisors from each block and other partners.
Further it is followed by orientation of ANM, ASHA during monthly meeting and
AWWs during sector meeting.
3. Developing microplans:
Micro-plans need to be revised and refined to include all villages/hamlets in a month
under a sub-center area. The primary unit for developing / revising micro-plans will
be at the sub-center level. Micro-plans shall include details of session site, date,
name of participating functionaries (ANM, ASHA, AWW, any other), due list status
with details of beneficiaries, etc. A sample micro-plan format is attached as annexure
1.
ANMs shall use the forum of 3rd Saturday meeting prior to the round to plan &
discuss the month long activities, share and firm up the micro plans including venue
of the sessions, mapping of hard-to-reach and unserved areas, review & finalize the
list of eligible beneficiaries including the dropouts, ensure availability of enough
stock of Vitamin A and vaccines and discuss the FAQs to clarify any questions that
may arise with all the AWWs & ASHA volunteers in her catchment area.
All AWWs, ASHA volunteers, village level functionaries and volunteers (PRI member,
NGO volunteers) & link workers should be involved in the planning and
implementation of this drive under the leadership of the ANM. The micro plans
prepared for each Sub Centre catchment should be shared with the next higher level
and is to be compiled at the BPHC tier.
Due list with information on eligible children's list and drop out children's list
should be available during each session. Before each bi-annual VAS + DW round
these micro-plans should be reviewed & according revised to cater to the local needs
& optimization of the outreach of services to all.

Health and ICDS supervisors will be responsible for ensuring development and
availability of micro-plans, due list and drop out list (during sessions) in their respective
sectors and render hand holding & supervisory support to the ANM in the planning &
implementation process, as and when required.

There is a need to inform the community prior to each round, thereby increasing
program visibility, encouraging & ensuring better community mobilization &
participation for effective & improved coverage. This should also be considered during
the planning process prior to each bi-annual round.
Compilation & sharing of micro plans and consensus among the BMOHs and CDPOs at
the block level is mandatory. The BMOH & CDPO will share compiled microplan to the
Dy. CMOH III/ DPHNO & DPO, ICDS respectively.

Logistics Planning and Management

The block and district officials shall ensure supply of Vitamin A Oil to reach the end-
users on time. All AWWs and ANMs must be instructed not to open a new bottle unless
one open bottle has been exhausted. An opened bottle has a shelf life of 6 - 8 weeks and
is to be kept away from sunlight. Apart from medicines and other consumable,s the
following materials should be available at the session site:

1. Reporting formats (Soft copy of reporting formats shall be shared with district from
child health section. Printing and distribution of reporting formats to be done as per
the micro plan.)
2. IEC materials: Banner, Poster, Pamphlet, FAQ, Guideline on Vitamin A should be
available for counseling during session. Poster, banner and other IEC materials
mentioning the date of forthcoming bi-annual round should be displayed at every
Office, health center, AWCs and public places.

Monitoring & Supervision

The month long programme shall be monitored and supervised at all levels of
implementation. Monitoring of the sessions will be ensured by block, district and state
officials. Monitoring formats will be supplied to the districts prior to the round.
Outreach sessions should be monitored on a priority basis along with sub-centre
sessions.
Monitoring schedule:

The district team (ADM, Dy. CMOH III, DMCHO, DPHNO, ACMOH - Dept. of H&FW,
SDO, DPO ICDS, any other member to be decided at the district level) will
monitor at least 10 sessions,
 Block team (BDO, BMOH, BPHN, PHN- Dept. of H&FW, CDPO ICDS, any other
member to be decided at the block level) will monitor at least 10 sessions and
GP level team (Health and ICDS supervisors and Panchyat representative) to
monitor at least 10 sessions during the month.
State officials will also monitor at least 10 sessions during the month.
50% of the sessions monitored, should be village outreach (not sub-centre
based) sessions.

Filled up monitoring formats should be submitted to the district along with the
coverage reports. Districts should compile and analyze the monitoring reports. These
analyzed monitoring reports and coverage reports should be reviewed and discussed in
the following month at GP, block, district and state level. NPSP Cell & WHO field
volunteers will play an active monitoring role in this bi annual round. A state level
review meeting will be held after the round to review coverage.

Reporting

Format A will be filled by ANM/ASHA/AWW after administering the dose of

Vitamin A to eligible children.
The ANMs will maintain coverage reports (Format B) of each and every session for
Vitamin A supplementation.
In addition, wherever available, the doses have to be marked both by ANMs and
AWWs in the MCP cards (immunization cards where MCPC not available) of the
beneficiary.
At the end of the round, AWWs will submit their report (Format A) to the respective
ANMs, who will compile all the session-wise reports held by her and reports
submitted by the AWWs of her sub-centre area and submit the same to the BMOHs.
The BMOH/BPMU will compile sub-centre-wise coverage reports of the particular
block (Format C) and submit the same to the CMOH/Dy CMOH III at the district
level.
The Dy CMOH III/ DPMU will compile reports of the district (Format D) for
submission to the CFW (Commissioner, Family Welfare)/ SFWO (State Family
Welfare Officer).
 Child Health section will ensure compilation of all district reports for the state and
share the findings with all concerned.
The PMU of NRHM/RCH will be fully involved in planning, implementation, monitoring
and reporting. Coverage reports should be sent to the next higher level as soon as the
round is completed, and report from each district should reach the state (along with the
HMIS reports) following the completion of the drive month. In addition, districts are
required to do a detailed session wise analysis of coverage and share it during the
review meeting, to be held about one month after completion of the round.

Key points to remember

The VAS drive will be taken up for all children aged 18 60 months in the
dedicated two months (June & December 2016).
Store vitamin A oil in cool and dark place.
Supervised administration of vitamin A oil is strongly recommended.
Dont administer vitamin A oil in empty stomach.
Vitamin A should not be administered to children suffering from diarrhoea and
vomiting or those who are acutely ill.
At least one month gap between two subsequent doses of vitamin A oil is safe. (acute
toxicity occurs at doses of 25,000 IU/Kg of body weight, with chronic toxicity
occurring at 4,000 IU/kg of body weight daily for 615 months. Ref: Rosenbloom,
Mark. "Toxicity, Vitamin". eMedicine)
When administered in recommended doses i.e. 1 ml. for children between 9 - 12
months and 2 ml. for children above 1 year to 5 yr, Vitamin A is effective and safe.
Adverse effects are rare, mild and transient. Experience across the world shows
that 5% to 7% of children given VAS can suffer from adverse effects that
disappear within 24 - 48 hours.
Counseling on schedule of VAS and the major dietary sources of Carotene
(Vitamin A) from locally available fruits and seasonal vegetables should be
included as part of NHE during these sessions (Please refer annexure for
reference material).
Immunization sessions at Sub Centers: Monday, Wednesday & Friday.
Extended out-reach sessions: Tuesday & Thursday.

Roles and responsibilities

Responsibilities of ANM: ANM should know about recommended doses for vitamin
A as per age groups.

Planning:
Develop Micro plan/roster of sessions to include each AWC in SC catchment.
Sharing copy of Micro plan with ICDS- CDPO/Supervisors
Identify hard to reach areas and underserved population.
Cordinate home visits to educate parents for Vitamin A and immunization
Distribution of posters and other IEC materials to the AWW / ASHA for display.
Inform campaign days /dates to the AWW / ASHA for display the AWC / Public
places.
Ensure availability of supplies for each session, either at AWCs or other session
sites as per micro plan schedule.
Implementation:
Ensure all dropouts from previous sessions (as per the list from AWW /ASHA)
are included in due list for each current round.
Arrange suitable place for keeping the Vitamin A bottle and other drugs in the
shade.
Ensure sufficiency in stock of Vitamin A during each session.
Indent for buffer stock of Vitamin A bottles at the PHC, in case of excess demand.
Administer Vitamin A dose as per list developed by ASHA/AWW.
Organize outreach session as per the micro plan.
ANMs from the team of front line service providers are eligible to vaccinate the
eligible children as per national immunization schedule & guidelines.
Recording the dose of Vitamin A in her register, MCPC and Format-A for each
child.
Collection and compilation of Format A and prepare coverage report in Format B.
Submission of Format B to BMOH/BPHC of respective block.
 Inform the mother/caregiver of child regarding the schedule of next dose.
ANM shall be responsible for verification of the date of last receipt of vitamin A
oil by each child included in due list. At least one month gap between subsequent
two doses is recommended.
Nutrition Education and counseling to mothers.

Responsibilities of AWW:
Planning
Enumerate all U5 children in the village and share the list with ANM especially
the list drop outs / left out
Help ANM to identify hard to reach areas and unserved population
Conduct mothersmeeting on importance of Vitamin A supplementation and
follow up during home visits to enure participation of target beneficiaries during
the bi-annual rounds. Inform beneficiaries about the services and date, time and
place of bi-annual session.
Display poster and other IEC materials at AWC catchment, specially low coverage
hamlets.
Display session days/dates at AWCs and other prominent locations.
Conducting the session
Arrange suitable place for temporary storage of vitamin A bottles and other
supplies during & after sessions.
Ensure availability of the list of drop out/left out beneficiaries
Ensure all drop outs from previous session are brought for immunization
Ensure participation of all beneficiaries included in due list for the scheduled
session.
Nutrition Education / counseling to Mothers prior to and during session rounds
Assist ANM in conducting the bi-annual session
Support ANM to administer Vitamin A oil to children as per recommendation and
recording in register, MCPC and Format-A.
Submission of Format A to ANM for further compilation.

Responsibilities of ASHA:
 ASHA will be responsible for mobilizing the community/children to session site
i.e. SC/AWC/other.
Inform beneficiaries in her catchment regarding date, time and place of the
session site.
ASHA will support AWW in organising arrangements for biannual activities.
Conduct home visits to houses of drop-out children for follow-up & better
coverage.
Nutrition Education / counseling to mothers on exclusive breast feeding till 6
months age, Vitamin A supplementation & immunization

Responsibilities of Block level officials (BMOH/MO/BPHNO and CDPO):

Orientation of ANMs and ASHAs on biannual rounds (micronutrient

supplementation programme).
Conduct meetings with PHN/ANMs, ASHAs & AWWs to review implementation &
coverage status of bi-annual rounds.
Provide overall guidance and leadership.
Need assessement of Vitamin A for block
Ensure availability & supply of Vitamin A, IEC materials and other logistics.
Review and approve micro plans.
Monitoring bi-annual session (at least 10 session) and submission of monitoring
format at district level.
Compilation and analysis of Format B and prepare coverage report of block in
Format- C
Submission of Format C at the district level (to Dy. CMOH III/DPHNO)

Role of District level health and WCD officials:

Need assessement of Vitamin A for district
Compilation and analysis of Format C and prepare district coverage report in
Format- D
 Submission of Format D at the state level for further compilation and coverage
analysis
Monitoring bi-annual session (at least 10session/round).
Conduct regular meetings to review status of bi-annual rounds.
Provide overall guidance and leadership to the bi-annual activity.
Facilitate involvement and participation of relevant departments, NGOs, private
providers and other potential resources.
Review and approve the block / sub center micro plans.
Ensure supply of Vitamin A oil and logistic availability.
Data collation, analysis and timely submission to state.
Provide feedback to the blocks based on the monitoring and coverage data after
each round of session site.
Distribute IEC, reporting format etc to all facilities.