Micronutrient Deficiency Control Strategies in Vietnam ppsx

Micronutrient Deficiency Control Strategies in
Vietnam




N.X. Ninh, N.C. Khan, N.D. Vinh and H.H. Khoi

Introduction

Micronutrient deficiencies affect the
majority of the population in Asia. Though
somewhat lower than in other countries in
the region, micronutrient deficiencies
remain prevalent in Vietnam. The
prevalence of xerophthalmia, or clinical
vitamin A deficiency (VAD), is now lower
than the cut-off point established by the
World Health Organization (WHO) to
indicate a significant public health problem.
However, the prevalence of sub-clinical
VAD as measured by low serum retinol
exceeds 10% for children under five and
pregnant women. It is well established that
sub-clinical VAD may contribute to high
mortality, morbidity and growth retardation
among young children. The success of the
VAD control program in Vietnam is
attributed mainly to the effectiveness of
high dose vitamin A supplementation, as the
fortification program has not yet been

established.

Control of iodine deficiency disorders (IDD)
has been achieved with remarkable results.
This was facilitated by government approval
of universal salt iodization in 1999. Iron
deficiency anemia (IDA) affects over half of
all women of childbearing age, infants, and
young children in Vietnam. Iron deficiency
worsens during periods of growth and
pregnancy, or with parasitic infections (e.g.,
malaria, hookworm). Other nutritional
deficiencies such as folic acid and vitamin C
can also contribute to anemia and poor iron
absorption. Iron deficiency, before the onset
of anemia, may have adverse effects on
function such as work performance. For
every 10% deficit in hemoglobin
concentration, there is a 10-20% deficit in
work performance. Once anemia occurs,
there can also be impairment of cognitive
performance and behavior, lowered im munity, an d
pregnancy complications. Anemia is
devastating not only to the individual, but
also to the economic and intellectual
capacity of the whole nation. The current
strategy of combating iron deficiency in
Vietnam is through iron supplementation,
covering about 15-20% of the communities
in the country. The iron fortification

program has just started with a pilot study.
Zinc deficiency is likely to be as widespread
as iron deficiency anemia. Vitamin B
1

deficiencies are additional deficiencies of
po tential public health importance. Clearly,
micronutrient deficiencies must be controlled and
prevented.

Correcting iodine, vitamin A and iron
deficiencies can improve the population-
wide IQ by 10-15 IQ points, reduce
maternal deaths by one-third, decrease
infant and childhood mortality by 40%, and
in cr ea se strength and work capacity by almost 50%.
Investment into the elimination of these
deficiencies will result in reduced health
care costs and education expenditures,
improved work capacity and productivity,
equity, increased economic growth and
national development.

The Vietnamese diet, disproportionately
comprised of staple foods at the expense of
dietary diversity, places the population at
risk for micronutrient deficiencies. Diets with high
consumption of rice and low consumption of animal
products may provide inadequate amounts of
micronutrients as well as inhibit their absorption. Recent

years have seen improvements in dietary quality
and diversity, with higher consumption of
The authors are affiliated with the National
Institute of Nutrition, Hanoi, Vi
etnam
N.X. Ninh et al.
protein rich foods and lower consumption of
st ap le foods. However, to ensure the population-level
consumption of the RDA of micronutrients, national
nutritional programs are needed. Previous program
approaches based upon dietary diversification and
supplementation hav e con tr ib uted to th e
reduction of micronutrient malnutrition, but
the progress has not reached national
objectives. For this reason, a more cost-
effective and sustainable strategy is sought
to overcome the problem of micronutrient
malnutrition.


Vitamin A deficiency (VAD)

Initiation of the program

The national vitamin A supplementation
program was launched in 1988 with an
orientation workshop to raise awareness
among policy makers and mass media
organizations regarding VAD. Steering and
technical committees were then established

to run the program. The key collaborators
were the National Institute of Nutrition
(NIN) and the Institute of Ophthalmology.
The program was started as a pilot project
funded by UNICEF in seven districts, and
was expanded in 1993 to a nationwide level.

Program implementation

The core elements of the program included
the following:

 Universal distribution of high dose
vitamin A capsules (VAC) to
children 6-36 months of age twice
an nua ll y, in collaboration with National
Immunization Days (NIDs); distribution of
VAC to women after delivery; and
targeted distribution of VAC to
individuals at high risk for VAD
such as malnourished children, and
children with diarrhea, measles, or
respiratory infections. The high dose
vitamin A capsules are distributed
through the primary health care
system and health care facilities.
 Promotion of nutrition education
with emphasis on breastfeeding,
complementary feeding practices,
dietary diversity and growth

monitoring.
 Promotion of the production and
consumption of a diverse diet to
increase vitamin A intake at the
household level, through activities
such as gardening, aquaculture and
animal husbandry.
 Establishment of a program implementation
network from community to central levels,
based on a strong preventive health structure
with the active par ti cip at ion o f ma ss
organizations like the Vietnam
Women’s Union (VWU), the
education sector and other groups.
 Development and dissemination of
IEC materials such as posters,
booklets and videotapes, combined
with employment of mass media
channels to implement regular
education and communication
activities.
 Provision of training and information on
micronutrient deficiencies to program staff to
improve staff’s knowledge, attitudes and
practices.

Program coverage

It was expected that with the strong health
system in place, Vietnam should be able to

achieve a high coverage rate of VAC
distribution to target groups. However, a
survey conducted in 2000 shows the mean
distribution of high dose vitamin A for
children 6-36 months of age to be 77%, and
for women post-partum to be 52% (Figures
1, 2). The variation in coverage rates among
regions can be explained, in part, by
constraints to the quantity and quality of the
health services at the local level, as well as
by the accessibility of health centers (e.g.,
road conditions). This is demonstrated in
difficult to access areas, including isolated
mountain areas such as the Central
Highlands and the Northern Highlands,
where the coverage rates for post-partum
women are lowest (23.5% and 42.2%
respectively) (Figure 2).

Prevalence and trends

The prevalence of xerophthalmia (X2/X3) in
children under five years of age appears to
Micronutrient Deficiency Control Strategies in Vietnam

have declined since 1988, based upon data
from national nutrition surveys (Table 1).
The national survey completed in 1988
reports a xerophthalmia (X2/X3) prevalence
seven times higher than the cut-off point

established by WHO as a public health
problem (i.e., 0.07% vs. 0.01%). However,
by 1994 a national survey reported a
prevalence of 0.005%. The data in the 1998
survey also show clinical symptoms of
xerophthalmia that were lower than the
WHO criteria for a public health problem.
National trends in night blindness in
children under five years of age suggest that
significant improvements were gained from
19 88 to 1994 (i.e., a reduction of approximately 86%).
Though rates incr eased fro m 1 994 t o 1 99 8,
the national prevalence remains relatively
low at 0.20%. Similarly, maternal night
blindness increased from 0.58% to 0.9%
from 1994 to 1998, remaining lower than
the reference threshold of 10%.
In terms of sub-clinical VAD, serum retinol
data has only been collected on the sub-
national level. The prevalence of sub-
clinical vitamin A deficiency (serum retinol
<0.70 µmol/L) in children under five years
of age was estimated for the Red River
Delta Region at 11%. The survey detected
zero cases of very low serum retinol
(<0.35µmol/L). Sub-clinical VAD was
found to be more prevalent among children
below one year of age. There has been a
decreasing trend of low serum retinol levels
in children in the Red River Delta Region.

From 1999 to 2000, prevalence decreased
by 5.5 percentage points, while for previous
years the decrease ranged from 0.3 to 3.0
percentage points. In 1998, the prevalence
of low breast milk retinol concentration
(<1.05µmol/L) among lactating women was
58% (Figure 3). The trend of low retinol in
breast milk cannot be assessed, although
there is a large reduction from 1998 to 2000
(15.2 %).
These studies show a close association
between vitamin A deficiency and protein-
energy malnutrition (PEM). In fact, the
nutritional status of the population suffering
from xerophthalmia is generally poor, and
active corneal lesions were frequently
observed in the populations with severe
PEM. A close relationship was also found
between xerophthalmia and breastfeeding,
weaning practices, and the inclusion of
green vegetables in children’s diets.

Program effectiveness and impact

As a rule, the prevalence of VAD has
declined substantially over the last 15 years
in terms of clinical and sub-clinical
symptoms. For clinical symptoms, Vietnam
has achieved its mid-decade goal (1995) of
virtual elimination of xerophthalmia. The

project appears to have had a great impact
on reduction of the prevalence of clinical
xerophthalmia at the national level (Table
1). However, the sub-clinical VAD is still
high at the national level (12.4% low serum
vitamin A <0.7 µmol/L and 53.8% of low
vitamin A in breast milk). The question
raised here is whether the reduction in VAD
is attributable to the program, to the success
of other program interventions, or to a
secular trend due to socio-economic
development. With this in mind, future
research needs to be carefully designed so
that program impact can be assessed.
However, available data collected to date
seems may explain part of the impact of the
program. The trend of low serum retinol
levels in children in the Red River Delta
from 1995 to 2000 is a case in point.
Moreover, after five years in which one
pilot project combined IDA and VAD
interventions, the prevalence of low serum
retinol decreased remarkably from 14.7% to
6.2% (Figure 4).

N.X. Ninh et al.
FIGURE 1. Coverage of high dose vitamin A distribution to children aged 6-36 months by region, 2000
0% 20% 40% 60% 80% 100%
Mean
Mekong River Delta
South East
Central Highlands
Southern Central Coast
Northern Central Coast
Red River Delta
Northern Highlands

FIGURE 2. Coverage of high dose vitamin A distribution to post partum women by region, 2000
0% 20% 40% 60% 80%
Mekong River delta
So ut h ea st
Central Highlands
Southern Central Coast
Northern Central Coast
Red River Delt a
Northern Highlands
Mean



Lessons for strengthening sustainable

and effective programs

The strengths of the program include the
following:

 The project was successfully implemented
through the provincial preventive health
system, with the implementing facility
network well established from the
central to community levels.
 There was a high level of
community participation.
 There is strong support and assistance from
universities and other international agencies
including the Micronutrient Initiative (MI),
the World Health Organization (WHO) and
the United Nations Children’s Fund
(UNICEF).




Micronutrient Deficiency Control Strategies in Vietnam


 Project strategies are clear, there is
a high level of awareness among
project leaders, cross-sectoral involvement is
closely integrated, and high commitment from
authorities has been expressed at

all levels.

The limitations of the program include the
following:

 A regular government budget has
not been established to support
project sustainability.
 The monitoring and evaluation
system is based at the central level
at the National Institute of
Nutrition, and the capacity of this
system is still limited. The data
reported from provincial levels is
therefore of questionable accuracy.
 UNICEF currently purchases the
entire supply of vitamin A capsules
distributed in Vietnam. The
financial sustainability of the
program rests in part upon
continued UNICEF funding.

Several conclusions can be drawn about
lessons learned:

 A baseline survey to assess the
current situation is important to
demonstrate need for the project as
well as to serve as a foundation for
monitoring and evaluation systems.

 Projects should begin with an orientation
workshop to raise awareness among
government, me dia a nd th e public
regarding VAD.
 The commitment from all government
levels to the project is crucial to
ensure the success and stability of
the program.
 Support from international ag en cies is
necessary.
 Implementation through the existing health
care network, along with a high level of
community participation, are important.
 Monitoring and evaluation activities should
take place regularly.
 Appropriate IEC and social mobilization are
key components of t he pr og ra m.
 Collaboration with NIDs to
distribute the vitamin A capsule
improves program coverage




TABLE 1. Prevalence of clinical VAD and xerophthalmia in Vietnam, 1988-1998

Clinical symptoms 1985-1988
*

n=34,214

1994
**

n= 37,920
1998
***

n=12,900
Night blindness (XN)
Children under 5 years
Pregnant/lactating mothers

0.37
Not available

0.05
0.58


0.20
0.90
Bitot’s spot (X1B) 0.16 0.045 Not available
Corneal ulceration/ Keratomalacia
X2/X3A/X3B)
0.07 0.005 Not available
Corneal scar (XS) 0.12 0.048 Not available
*
National Survey on Vitamin A Deficiency, NIN 1988
**
National VAD/PEM Survey, NIN/HKI/UNICEF 1994

***
National VAD/PEM Survey, NIN/UNICEF 1998






N.X. Ninh et al.

FIGURE 3. Prevalence of low vitamin A in breast milk in the Red River Delta Region,
1995-2000





FIGURE 4. Percentage of low serum vitamin A levels (<0.7 umol/L) in Thanh Mien
District, 1995-2000

0%
2%
4%
6%
8%
10%
12%
14%
16%
1995 1997 1998 1999 2000

Year
Prevalence
0
10
20
30
40
50
60
70
1995 1997 1998 2000
Year
Prevalence (%)
Micronutrient Deficiency Control Strategies in Vietnam

Iron deficiency anemia (IDA)

Initiation of the program

The national iron deficiency anemia control
program was launched in 1995 following
the national anemia and nutrition risk survey
(U NIC EF /N IN, Institute of M ala ria, Pa rasit e,
and Entomology -IMPE, Institute of
Hematology and Blood Transfusion-IHBT).
Orientation workshops and mass media
campaigns pertaining to the serious
consequences of anemia in Vietnam were
carried out. The NIN was appointed to run
the project with support from UNICEF.

Project activities involved other institutions
and agencies such as the education sector,
Vietnam Women’s Union, Youth Union,
and mass media organizations.

Organizations responsible for the program
are the NIN and the Ministry of Health
(MOH). Collaborators in program management
and control are the Institute of Hematology
and Blood Transfusion; the Institute of
Malaria, Parasitology and Entomology; the
Institute of Protection of Children's Health
(IPCH); the Institute of Protection of
Mother and Newborn; the Ministry of
Health Preventive Health Department; the
Maternal and Child Health/Family Planning
Department (MCH/FP); and the Youth
Union, along with mass media agencies.

The vertical management structure is based
on preventive health and MCH/FP systems.

 Central Level: National Steering
Committee (9 members)
 Provincial Level: Preventive health
center, MCH/FP centers, and social
organizations
 District Level: District health center (Hygiene-
Epidemiology an d MC H/FP t ea ms )
 Community Level: CHC are

responsible for the project. Iron distribution
takes place in health centers during antenatal
visits (ANC services) or through collaborator
visits. Teachers distribute the pills and IEC
materials to girls under he al th worke r
supervision.

The project runs under the existing
preventive health system. In each
community one or two staff members are
responsible for the project. There is
community participation in the management
system at each level: health, p op ulation/f amil y
planning service, VWU, school teachers,
Youth Union are the key members of
management boards under the co-ordination
of local People's Committees.

Program implementation

The core elements of the program include
the following:

 Universal supplementation of pregnant
women from the beginning of pregnancy
through on e mon th po st-p artum, w it h
one tablet daily (60 mg iron and
0.25 mg folate).
 Weekly supplementation of children 6-15
years of age. Through the school system,

teachers distribute iron tablets under the
supervision of a health worker.
 Supplementation of non-pregnant
women of 15-35 years of age. The
program is carried out by local
organizations including the
Women's Union and the Youth
Union. This program is currently in
the research phase.
 Iron or multi-micronutrient supplementation of
infants and children is also under
research in several studies with
support from UNICEF.
 IEC is one of the highest priorities
in the IDA program. Awareness of
the important roles of iron for fetal
growth, perinatal mortality, child
growth and development, in physical activity
and work performance, and intellectual
performance and productivity are
all addressed. IEC is focused on the
objective of increased consumption
of iron-rich foods.
 In Vietnam, iron deficiency is
closely associated with the high
prevalence of hookworm. A dewor ming
program through yearly campaigns
for children and non-pregnant
women will be applied (PCD
project).

N.X. Ninh et al.
 In addition, a project for f or ti fi ca ti on o f
biscuits with iron and vitamin A
along with a project for
fortification of biscuits with iron,
zinc and calcium are being
conducted with pregnant women
and researched at the National
Research program (KHCN-l1-09).
FeNaEDTA fortified fish sauce is
also being studied in collaboration
with International and Japan ILSI.
The efficacy of iron-fortified fish
sauce was evaluated and the
effectiveness will be assessed in
the year 2002. Multi-micronutrient
fortification of weaning foods is
also being researched as a pilot
study, which will be expanded in
the future. The survey in the year
2000 shows potential food sources
 for fortification. It was determined
that noodles (44.7gr/capita/day)
and fish sauce (24.8ml/capita/day)
are among the most popular foods
(Figure 5).

Program coverage

The program started in 1995 and has been

expanded to cover 15-20% of the whole
country (Table 2). The low coverage is due
to lack of supplies as well as the low
utilization of CHC in terms of staff quality
and quantity. In terms of intensity, the price
estimated for iron tablets is approximately
7680 VND (US$0.50) (32 VND/ 1 tablet x
240 tablet/ pregnancy = 7,680VND per
pregnancy)



FIGURE 5. Average food consumption, 2000 (G or ml/capita/day)
















TABLE 2. Number of potential beneficiaries that received services, 1995-2000

1995 1996 2000
Pregnant women targeted 425,000 40,000 46,200*
No of province benefited 46 10 17
No of district benefited 158 10 20
No of commune benefited 2186 100 264
* The figure was estimated based on the percentage of women per population in a commune (2.5%).




0
10
20
30
40
50
Noodle Fishsauce Sugar Cooking oil Seasoning
G or ml consumed/capita/da
y
Micronutrient Deficiency Control Strategies in Vietnam

Prevalence and trends

The 1995 survey found that anemia
prevalence was a problem of major public
health significance in Vietnam: 52.7% of
pregnant women, 40.2% of non-pregnant
women and 45.3% of children are anemic
(Table 3). The groups at highest risk for

anemia are children under two years of age
and pregnant women (Figures 6 and 7,
Tables 3 and 4). The data of the national
survey in 2000 show a substantial decrease
of anemia prevalence in all groups and
across all ecological regions in Vietnam.
Even so, anemia prevalence is still
remarkably high (Tables 3 and 4). Figure 8
shows that anemia prevalence is more
prevalent in rural areas than in urban areas.

The majority of anemia is most likely
attributable to iron deficiency. Low serum
ferritin was associated with hemoglobin
levels. In addition, dietary meat
consumption was correlated with anemia
levels. The survey in 2000 determined that
the prevalence of anemia decreased with the
increase of weekly meat consumption
(Table 5). Moreover, there is a trend of
increase in meat consumption and iron
intake over the past decade (Table 6).

In Vietnam, IUD use is the most popular
among contraceptive methods (57.6%) and
the survey data showed that women who use
IUD are greater risk for anemia than those
who did not. This relation is stronger among
women living in rural areas (OR 1.62 in
rural versus OR 1.08 in urban area) (Table

7).

Parasitic infections, such as hookworm and
malaria, also contribute significantly to
anemia in Vietnam. It has been known that
in the North Central Coast, the Central
Highlands and the Southeast regions of the
country, where hookworm is more common,
prevalence of anemia seems to be higher
than in other regions. There was not any
research to demonstrate the role of malaria.
But, it is widely accepted that in areas with
high prevalence of malaria, prevalence of
anemia is also high. Due to high prevalence
and incidence of malaria in Vietnam, a
carefully designed study will be needed to
explore its role as a risk factor.

TABLE 3. Anemia prevalence among children, non-pregnant women, pregnant
women and men, 1995-2000



TABLE 4. Anemia prevalence (%) by zone of residence

Survey 1995 Survey 2000
Demographic group
% CI 95% % CI 95%
Children 0-60 months 45.3 42.9 - 47.6 34.1 31.4 - 36.9
Non-pregnant women 40.2 37.5 - 42.9 24.3 22.1 - 26.6

Pregnant women 52.7 49.9 - 55.5 32.2 29.5 - 35.1
Men 15.7 13.5-17.8 9.4 7.8-11.4

Children <5 years Pregnant Women
1995 2000 1995 2000
Northern Highlands 44.1 37.7 51.3 33.2
Red River Delta 36.7 23.7 51.9 23.7
Northern Central Coast 43.0 40.6 58.6 34.9
Southern Central Coast 49.2 33.2 54.8 38.3
Central Highlands 61.4 45.1 49.2 30.7
South East 45.7 43.4 50.3 34.3
Mekong River Delta 52.2 35.2 51.4 36.9
National Average 45.3 34.1 52.7 32.2
N.X. Ninh et al.


TABLE 5. Association between frequency of eating meat and anemia

Mothers (non-pregnant women) Children
Time per
week meat
eaten
Anemic (%) OR Anemic (%) OR
0 33.0 2.19**
(1.68<OR<2.86)
49.2 1.83**
(1.44<OR<2.33)
1-3 25.6 1.53**
(1.30<OR<1.81)
38.5 1.18*

(1.03<OR<1.36)
4-7 18.3 Ref. 34.6 Ref.
* Significant at p<0.05
** Significant at p< 0.001


TABLE 6. Country average of meat intake (g/capita/day) and iron intake (mg/capita/day),
1990-2000

1990 (Means & SD) 2000 (Means & SD)
Meat consumption (g/capita/day) 24.4 14.4 51.0 69.2
Iron intake (mg/capita/day) 9.53 1.17 11.16 4.26



TABLE 7. Association between IUD used and anemia among non-pregnant women

All Rural Urban
Use of contraceptive
method
Anemic Non-anemic Anemic Non-anemic Anemic Non-anemic
IUD users 568 1651 498 1296 70 355
Non-IUD users 292 1339 206 869 86 470
OR OR=1.58**
(1.34<OR<1.85)
OR=1.62**
(1.34<OR<1.96)
OR=1.08
(0.75<OR<1.54)
P P <0.0001 P<0.0001 P >0.05

FIGURE 6. Anemia among children <5 years of age (National Survey 2000)


Micronutrient Deficiency Control Strategies in Vietnam


FIGURE 7. Trends in anemia prevalence by group, 1995-2000


















FIGURE 8. Anemia prevalence by rural and urban areas
Program effectiveness and impact

Information on the program’s impact on
coverage and behavior is available through a
report from the provincial center. The
survey done in 2000 also found that there is
a difference in anemia prevalence between
those people who are exposed and not
exposed to IEC messages (Table 8).

In the areas receiving iron supplementation,
the prevalence of anemia decreased about
10 to12 percentage points (Table 9).
Anemia prevalence data from national
surveys in the years 1995 and 2000 showed
the greatest effect in reducing anemia
prevalence, in pregnant women (20.5%
reduction) and non-pregnant women (16%
reduction). However, the extent to which the
decrease of anemia prevalence was
attributable to the program needs a more in-
depth analysis. We can conclude that despite
the low program coverage, the prevalence of
anemia in Vietnam has decreased
remarkably in all groups, particularly in
pregnant women, non-pregnant women and
0
5
10
15
20

25
30
35
40
Children<5 Non-Pregnant Women Pregnant Women Men
Prevalence
Rural
Urban
0
10
20
30
40
50
60
Children<5 Non-Pregnant Women Pregnant Women Men
Prevalence
1995
2000
N.X. Ninh et al.
children. The program has been running
successfully, and to some extent it
contributes to the large reduction of anemia
prevalence. The impact of the program
should be further analyzed and future
programs need to be designed so that
program impacts can be assessed separate
from socio-economic development impacts.

Lessons for Strengthening Sustainable

and Effective Programs

The strengths of the program include the
following:

 The project is implemented through
the primary health care system at
the community level, that also
provides ANC services for pregnant women
and growth mon itor ing for ch ildr en
under five years of age.
 Health workers’ knowledge of
anemia has improved through
training and retraining courses.
 Collaboration with universities and
international organizations (e.g.
UNICEF, WHO, ILSI, and IRD)
has taken place.

The limitations of the program include the
following:

 Some difficulties have arisen in
monitoring the actual consumption
of iron tablets.
 Due to lack of supplies, the project
currently covers only 15-20% of
the country.
 Monitoring, supervision and reporting systems
are weak, especially at the community level.

 Dietary sources of iron have improved since
1990. However, dietary intak e o f i ro n
still does not meet the required
needs, especially in rural areas
where anemia is most prevalent.



TABLE 8. Impact of IEC on the prevalence of anemia

Exposed to IEC messages
No Yes
Total
Anemic 925 493 1418
Non-anemic 2454 1888 4342
Total 3379 2381 5760
P <0.001 1.44 (1.27 <OR <1.64



TABLE 9. Prevalence of anemia in the iron supplemented and non-supplemented areas

Non-Pregnant Women Pregnant Women Children <5 y

n % & CI 95% n % & CI 95% n % & CI 95%
Iron
supplementation
areas
4187 21.4
18.6-24.2

1697 28.9
25.7-32.4

4136
29.7
26.8-32.8
Non-iron
supplementation
areas
2948 29.3
25.7-33.2
1047 38.8
34.1-43.7

2888
42.1
36.9-47.4
P <0.0001 <0.0001 <0.0001




Micronutrient Deficiency Control Strategies in Vietnam

Iodine deficiency disorders (IDD)

Program implementation

The core elements of the program include
the following:

 Production and distribution of
iodized salt.
 Training of health and education personnel,
along with tho se in vo lv ed in the salt
iodization process.
 IEC activities, legislation, monitoring
and evaluation.
 Universal salt iodization approved
by the Prime Minister in April
1999.

Program objectives for 1996-2000 in
mountainous regions were:

 Distribution of 6 kg/capita/year of
iodized salt.
 Attainment of 100% coverage for
iodized salt use.
 Ensuring that iodized salt has a
sufficient prophylactic dose of
iodine (≥20ppm at HH).
 Reduction of goiter prevalence
among children 8-12 years of age
by two percentage points.

Program objectives for 1996-2000 in the
midland and plains were:

 Distribution of 4 kg/capita/year of

iodized salt.
 Attainment of 60% coverage for
iodized salt use.
 Ensuring sufficient iodine content
in the salt.

Program targeting, coverage, intensity
and effectiveness

Since 1996, the program has covered 100%
of the communities in Vietnam. The
percentage of households using iodized salt
with standard iodine content (20 ppm) in
1998 is summarized in Table 10.
Consumption of iodized salt in 1998
increased significantly. However, this was
not the case in a few of the regions, namely
the Mekong River Delta Region. Twenty-
two provinces (36.1%) achieved the two
main objectives of the program: iodized salt
utilization of more than 90% and urinary
iodine levels at more than 10µg/dL. One
objective was achieved by 21 provinces
(34.4%), while 18 provinces (29.5%) had
not achieved either objective.

Prevalence and trends

Iodine deficiency disorders (IDD) have been
recognized as a public heath problem in the

mountainous regions of Vietnam since the
beginning of the 1970’s. The national
surveys (1993-1995, 1998) showed that IDD
was widespread in Vietnam. IDD is not only
limited to mountainous areas but is also
prevalent in other parts of the country, as
there is geographical variability in the
severity of IDD. However, the prevalence
of goiter and low urinary iodine in school
children decreased significantly from 1993
to 1998 (Tables 11 and 12, Figure 9).

Program effectiveness and impact

Monitoring and evaluation are performed
through the following activities:

 Monitoring iodized salt at
production site and at household
levels.
 Establishing a monitoring system
from the central level to the
community level and at all
factories.
 Evaluation of project progress in
1998.

Lessons for strengthening sustainable
and effective programs

The strengths of the program include the
following:

 An effective program and o perational
system have been established from
the central to the household level.
 High national iodized salt coverage
has been achieved (from 60.5 to
90%). The proportion of iodized
salt with standard iodine content is
high (i.e., 85.3% in households). A
N.X. Ninh et al.
part of this success is due to
government legislation.
 IEC activities have been implemented at a
nation-wide scale.
 An inter-sectoral approach complemented
with communication, production
and distribution of iodized salt has
been utilized.

The limitations of the program include the
following:

 The monitoring and supervision
system needs to be strengthened.
 There is a lack of adequate legislation
regulating the production and distribution of
iodized salt.
 The subsidized price of salt has to

be revised to have a maximum
impact on sustainable USI.


Conclusion and recommendations

 As a rule, micronutrient programs
have achieved the targets established by the
government. Th ere is currently a
decreasing trend of micronutrient
deficiencies, including a large
reduction of anemia in pregnant
and non-pregnant women in the last
five years. However, micron ut rient
deficiencies are still a serious
problem, particularly in the high-
risk groups: pregnant women,
women, and children. The
programs have succeeded with
strong support from the UN system
and the government at all levels.
Community participation as well as
NGOs and mass media agencies’
involvement are important key
factors. However, there are some
points that need to be addressed.
 It is clear that program success
depends upon the program
coverage. Since 1998, a national
nutrition program has been

transferred to the MOH and
primary health care has been
strengthened by promoting the
facilitator/mobilizer system, while
increasing personnel and quality.
This system will improve the ANC
service as well as nutrition
activities at the grass-root level.
Therefore, this system needs to be focused on
micronutrient def ic ie nc ie s.
 Financial supports should be
expanded and stabilized not only
from external resources but also
from government as well as
international and local NGOs, and
the private sector.
 Annual monitoring and evaluation
should be strengthened. At least
every 3 to 5 years a national survey
on micronutrient deficiencies (apart
from the national food consumption
survey) should be carried out,
paying attention to some risk
factors of anemia such as malaria,
hookworm, and IUD use.
 Capacity building through in-
service training as well as overseas
courses.

Strategies for Prevention and Control of

Micronutrient Deficiencies in Vietnam
(Period 2001-2010): Improving Mi cr onutri en t
Status is a part of the National Nutrition
Strategy issued by the Prime Minister on
February 22
nd
2001 (Decision No
21/2001/QD-TTg) for the period 2001-2010.
The objectives are as follows:

 Maintenance of a prevalence of
active corneal lesions due to VAD
below the level of public health
significance.
 Reduction of the prevalence of
under-five year olds with low
serum retinol to below 8% by
2005, and below 5% by 2010.
 In areas covered by the program,
reduction of prevalence of anemia
in pregnant women to 30% by
2005, and to 25% by 2010.
 Reduction of the goiter prevalence
among children aged 8-12 to below
5% by 2005. Universal salt
iodization is stabilized with more
than 90% of households using
iodized salt; urinary iodine level is
between 10-20 mcg/dl.

Micronutrient Deficiency Control Strategies in Vietnam

To meet the Government requirements,
some strategic approaches have been
proposed:

 IE C activities: On the basis of
experiences to date, the IEC
component needs to be maintained
and improved. It plays a very
important role in the context of
existing socio-economic factors in
Vi et nam. The IEC activities shou ld
focus on government commitments
either at the central level or
community level, foster the
involvement of the community to
ensure the stability and sustainability of
the program, calling attention and
investment from external donors
such as UN agencies, ODA, NGOs
as well as the private sector.
Moreover, education that emphasizes
the consequences of micronutrient
deficiencies for the public should
be addressed, particularly the use
of locally available micronutrient
rich foods and dietary di vers if icatio n.

 Supplementation: Micronutrient supplement-

ation should be expanded nationwide,
especially to disadvantaged areas. The logistics
of the distribution of micronutrients should be
improved adequately and effectively.
Supplementation of single micronutrients
should be complemented by multiple nutrition
supplementation as soon as possib le .

 Implementation: Micronutrient
programs should be integrated into
primary health care facilities such
as EPI, ANC, ARI, hygiene/sanitation
and safe water. Monitoring
activities, reporting and a feedback
mechanism should be established
and maintained regularly to ensure
the effectiveness of the program.

 Fortification: Food fortification
with multi-micronutrients should
be applied as soon as possible and
utilization should cover all target
group s. Control of the quality of food
fortification, and the regulations of food
fortification should be addressed in the nea r
future.

Capacity building: improve the capacity
of the micronutrient research center at
NIN

A greater understanding of the importance
of micronutrient deficiencies to public
health in Vietnam led to the establishment
of the Micronutrient Research Center at
NIN with the following tasks:

 Support for techniques and guidelines on
implementation o f p rog rams .
 Monitoring and evaluation of the
micronutrient situation in the
whole country.
 Conducting and operating research
on micronutrients.

Lack of resources (manpower, equipment
etc) and limited capacity lead to difficulties
in the control of micronutrient deficiencies.
Hence, building the capacity of the center
should be prioritized in coming years.
Joining the multi-center initiative in this
project is a great chance to improve capacity
of the center in term of staff quality.

Further operational research on multi-
micronutrient food fortification should be
implemented

Based on recent research, children under 24
months of age are at a high risk for

micronutrient deficiencies. The content of
micronutrients in the dietary intake of
Vietnamese people is about 30 to 40%
deficient when compared with the RDA.
With the support from this project, we are
proposing operational research on
fortification with multi-micronutrients in
formula powder and several other foods for
children under 24 months of age.







N.X. Ninh et al.
TABLE 10. Percent of households using iodized salt by region, 1998 (National Survey in 1998)

Region % 95% CI N (Households)
Northern mountainous 97.2 96.0 – 98 4974
Northern low-land 77.3 74.7 – 79.7 3929
North-Central 74.0 68.9 – 78.4 2128
South-central 76.9 73.9 – 79.9 2829
West high-land 98.9 98.0 – 99.4 1436
South-East 61.7 57.1 – 66.0 2156
Mekong river delta 50.9 48.5 – 53.2 4269
Nationwide 72.8 71.6 – 74.0 21,721

TABLE 11. Goiter prevalence (%) in school children (8-12 years old)

1993-1995 1998
Goiter 27.1 14.9
1st degree 26.5 14.6
2nd degree 0.6 0.3


TABLE 12. Prevalence (%) of low urinary iodine content (<10 ug/dl) among children
(8 -12 years old)

1993-1995 1998
0-1.9 µ/dL (severe)
16 2.2
2-4.9µ/dL (moderate)
45 11.4
5-9.9 µ/dL (mild)
23 19.3
Total 84 32.9



FIGURE
9. Percentage of low urinary iodine content (<10mcg/dL) in school children
(Survey 2000)




0

5
10
15
20
25
30
5-9.9' 2-4.9' <2
Prevalence
( - ) IS
( + ) IS
Iodine levels (mcg/dL)
Micronutrient Deficiency Control Strategies in Vietnam


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