Investigating South Africa’s Vitamin A ‘Dual Burden’

Researchers from The Child Health and Mortality Prevention Surveillance (CHAMPS) South Africa site are investigating an emerging public health challenge that could have important implications for child supplementation programmes: the coexistence of vitamin A deficiency and excessive vitamin A exposure among young children.

Vitamin A plays a vital role in children’s growth, vision, immune function, and overall development. South Africa has long implemented routine Vitamin A Supplementation (VAS) alongside mandatory fortification of staple foods to prevent deficiency. However, recent CHAMPS findings suggest that while these interventions have improved access to vitamin A, some children may be exposed to multiple overlapping sources of the nutrient. Postmortem liver tissue analysis from MITS showed that 62.3% of child deaths in the South African cohort had high or hypervitaminotic liver vitamin A stores. Among children aged 6 months and older with available liver results, all fell into the elevated categories. This pattern suggests the need for careful consideration of potential cumulative exposures.

To better understand these findings, the CHAMPS South Africa team conducted a household survey involving 722 children across the CHAMPS surveillance area. The assessment found that all eligible children had received routine vitamin A supplementation, while many were also consuming fortified staple foods and other dietary sources of vitamin A. Some 20.6% of the children met the criteria for possible excess supplementation (more doses than expected for their age), and 83.6% had three or more overlapping sources of vitamin A. This includes routine clinic doses alongside the frequent consumption of commercially fortified staples, such as mealie meal (consumed regularly by 96% of children in the sample) and staple porridge (consumed regularly by 69% of children in the sample).

A complementary qualitative study explored vitamin A supplementation practices across four primary healthcare clinics in Soweto. Interviews with healthcare professionals revealed that public health nurses consistently relied on the Road-to-Health Booklet and the Expanded Programme on Immunisation (EPI) schedule to determine eligibility and dosing. The study also identified several health system challenges that may contribute to both under- and over-supplementation, including incomplete documentation, movement of children between healthcare facilities, inconsistent management of missed doses, occasional stock shortages, and limited vitamin A-specific training for healthcare workers.

These findings are informing the next phase of the research, which will bring together experts and government stakeholders to review the evidence and identify opportunities to strengthen vitamin A programming. The goal is to ensure that children continue to benefit from vitamin A interventions while minimising the risk of excessive exposure through evidence-based, context-specific policy and programme improvements.

This work demonstrates how CHAMPS data can generate critical evidence to strengthen child health programmes and support informed public health decision-making and policy in South Africa and beyond. It highlights the value of established surveillance systems operating across multiple levels, which enable rapid research responses to emerging signals, allowing us to better understand and contextualise issues as they arise.

About CHAMPS: The Child Health and Mortality Prevention Surveillance (CHAMPS) network is a global collaboration funded by the Bill & Melinda Gates Foundation. It aims to provide accurate data on the causes of childhood death to inform policy and save lives in high-mortality regions.