Impacts of Vitamin A Degradation on the Effectiveness and Cost-Effectiveness of Vitamin A Fortification Programs: Modeled Evidence for Preschool Children in Nigeria

Dietary vitamin A inadequacy remains a serious public health problem, especially among young children. Food and condiment fortification programs and policies are in place in many countries to address this issue, but degradation of the vitamin A added via fortification can reduce the quantity of vitamin A reaching consumers. We modeled the impacts of vitamin A degradation on program effectiveness and cost-effectiveness in fortified wheat flour, sugar, and (hypothetical) bouillon cubes in Nigeria. We used secondary data to estimate the prevalence of vitamin A inadequacy among young children (6-59 months), and the programs' modeled contributions to reducing vitamin A inadequacy at selected levels of vitamin A degradation. The Lives Saved Tool was used to estimate child-lives saved. Program costs were estimated using activity-based models. Vitamin A degradation had a large negative impact on program effectiveness. Over the 0% to 80% vitamin A degradation range, accounting for other existing programs, fortification of sugar (7.5 mg/kg), wheat flour (2 mg/kg), and bouillon cubes (96 mg/kg) would reduce inadequacies among children by 2.9 to 0.7 percentage points, 3.9 to 0.7 percentage points, and 20.6 to 9.6 percentage points, respectively. Over the same vitamin A degradation range, average annual child-lives saved ranged from 3984 to 769 (sugar), 3036 to 739 (wheat flour), and 15 301 to 7153 (bouillon cubes); estimated cost/child-life saved ranged from US$ 550 to US$ 2848 (sugar), US$ 1039 to US$ 4271 (wheat flour), and US$ 944 to US$ 2018 (bouillon cubes). Vitamin A fortificant selection, technological innovations in vitamin A fortificants, and/or changes in premix and fortified food handling and storage could reduce degradation; these options could increase program costs, but merit consideration.