LAUSR

Correspondence to Dr Andreas Hasman; ahasman@ unicef. org © Author(s) (or their employer(s)) 2021. Reuse permitted under CC BYNC. No commercial reuse. See rights and permissions. Published by BMJ. In efforts to restrict the spread of SARSCoV2, many lowincome and middleincome countries suspended communitybased public health and nutrition programmes in early 2020. At the time, the expectation was that disruptions due to the COVID19 response would cause significant declines in programme coverage of key services, and eventually increase preventable morbidity and mortality among the most vulnerable children. The magnitude of the pandemic’s impact on preventive vitamin A supplementation (VAS) programmes is now made visible in UNICEF’s annual programme coverage data. Regular administration of highdose VAS to children 6–59 months old every 4–6 months reduces the risk of child mortality by 12%–24% in communities where vitamin A deficiency is prevalent. Prior to the pandemic, the global VAS programme reached over 200 million children annually with the recommended two VAS doses in countries with high child mortality. Between 2016 and 2019, coverage had been hovering at around 65% of eligible children. In the year prior to the COVID19 outbreak, about 200 million eligible children benefited from the two annual doses of VAS, while 134 million missed out on at least one of the doses and therefore the full benefits of supplementation. The situation deteriorated sharply following the March COVID19 outbreak, primarily due to service delivery disruptions caused by pandemic containment measures. Based on administrative data analysed by UNICEF, there was a 19 percentage point decline in twodose VAS coverage from 2019 (from 60% to 41%; figure 1), with 62 million fewer children (ie, onethird) receiving both VAS doses in 2020. The steepest drops in coverage occurred in the first half of the year (figure 2) following recommendations to suspend mass public health and nutrition campaigns. Global VAS coverage thus fell from 72% in the first half of 2019 to 49% in the first half of 2020, while the number of children covered fell from 239 million in the first half of 2019 to 165 million in the first half of 2020 (ie, a drop of almost a quarter). In the second half of 2020, when suspensions were rescinded, 57% or 192 million eligible children were reached compared with 63% or 211 million children in the second half of 2019 (a drop of only six percentage points). Eight countries drove the sharp decline in twodose coverage in 2020: Afghanistan, Cameroon, Chad, Niger, Nigeria, Pakistan, Sudan and Tanzania. In these countries, 85 million children were missed (ie, 43% of the total number of missed children). If the eight countries were to regain the coverage achieved in 2019, global VAS coverage would be 61%. Arguably, they should be given priority attention to shore up the coverage of the global VAS programme. It is also clear that countries with the greatest need for supplementation, that is, highest child mortality, had the lowest coverage in 2020. Out of the 48 countries from which we have data, 23 have under5 Summary box