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RF_DIS_9_SUDHA
Original Article
Indian J Pediatr 1995; 62 : 545-555;
Towards the Elimination of Iodine Deficiency
Disorders in India
S.
C.
Pandav and K. Anand
Centrefor Community Medicine, All Indin Institute of Medical Sciences, New Delhi
Abstract. Iodine deficiency disorders (IDO) are an Important public health problem In India with an
estimated 270 million people at risk of IDD. India has adopled the strategy of salt iodisation for
control of IDD and has the goal of "Universal iodisation of salt by 1995 and elimination of IDD by
2000”. There Is a high degree of political commitment which need to continue If the goal Is to be
achieved. Currently the ban on alo of unlodlsod salt Is only applicable to salt on human
consumption. There Is a need for extending tho ban to Include salt for animal consumption as IDD
affects livestock as well. India has the Installed capacity Io produce Its requirement of 5 million
tonnes iodised salt. Communication strategies have to be strengthened especially to educate
people who have concerns about of iodine toxicity. The success to a large extent depends on the
quality control and monitoring of Iodine content of salt at all stages from production to
consumption. NGO's and the community have to be encouraged to participate in this process. To
sustain the elimination of IDD, a partnership of various stakeholders IDD elimination is essential.
(Indian J Pediatr 1995; 62 : 545-554)
Key words : Iodine deficiency disorders; Lamination; India
This paper describes the current progress
Assessment of the Problem
towards the elimination of Iodine Defi
Current status
ciency Disorders (IDD) in India. It is cov
ered under subheadings which trace the India is the second most populous country
path of "assessment - analysis - action - as in the world with a population of 834 mil
sessment "cycle, tinder each subheading, lion (1991 census). High prevalence of
first, the current status is described fol goitre and cretinism exists in a broad 1 li
lowed by the agenda for the future. Unlike malayan and sub-Ilimalayan goitre-belt
communicable diseases like smallpox, IDD from Jammu and Kashmir in tiic North to
can not be eradicated once and for ewer. Arunach.il Pradesh in the East and along
The control efforts like salt iodisation will this entire length extending at least 500
have to be sustained perpetually. The con kms south of the Himalayas into the flat
cluding part of the paper raises the issues sub-I limalayan terai (plains). In addition to
of sustainability and the partnership that the well-known "Himalayan endemic
needs to be built between the stakeholders belt", iodine deficiency has been reported
to achieve the sustained elimination of from many other states in the country. In
1989, Indian Council of Medical Research
IDD.
(1CMR) carried out a multicentric IDD
Reprint requests : Dr C.S. Pandav, Associate Professor, prevalence study. Nine states outside the
Centre for Community Medicine, All India Institute of traditional "goitre-belt" were studied for
the prevalence of goitre and cretinism. A
Medical Sciences, New Delhi - 110 029.
546
THE INDIAN JOURNAL OF PEDIATRICS
1995; Vol. 62. No. 5
Table 1. Status of IDD Endemicity and Ban Notification in States/UTs of India
State/UT
Status
of Ban
Total
Dist.
Dist.'
surveyed
Dist.
endemic
Andhra Pradesh
Arunachal Pradesh
A tSc N Islands
*
Assam
Bihar
Delhi
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu & Kashmir
Karanataka
Kerala
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagland
Orissa
Punjab
Rajasthan
Sikkim
Tamil Nadu
Tripura
Uttar Pradesh
West Bengal
Chandigarh
Dadra & Nagar Haveli
Daman and Diu
Full
Full
Full
Full
Full
Full
No ban
Full
Full
Full
Full
Partial
23
12
2
IB
38
1
1
19
14
12
15
20
14
45
31
8
54
7
13
12
27
4
21
3
62
18
1
1
1
1
4
7
10
1
6
10
1
18
20
1
1
9
2
10
14
5
4
16
10
6
2
3
7
2
3
3
4
1
3
29
5
1
1
1
-
Lakhswadeep
Pondicherry
Total No. of Dist.
No ban
Full
Partial
Full
Full
Full
Full
Partial
Full
Full
Full
Full
Full
Full
Full
Full
Full
Full
Full
No ban
457
18
21
1
1
11
3
10
14
17
5
16
28
6
2
3
7
2
3
3
4
2
3
34
5
1
1
1
-
239
% dist.
endemic
85.7
100
100
100
95
100
100
82
67
100
100
29
80
100
36
100
100
100
100
100
100
100
100
50
100
85
100
100
100
100
-
-
197
[Source (3)]
* Survey done by Centre for Community Medicine, All India Institute of Medical Sciences, New
Delhi.
1995; Vol. 62. No. 5
THE INDIAN IOURNAL OF PEDIATRICS
total of 409, 923 individual were examined
and the overall goitre prevalence observed
was 21.1 percent, whereas the overall cre
tinism prevalence was 0.7 percent.'
In India, it is estimated that 270 million
people are at risk and 79 million are af"fected by IDD which includes, 2.2 million
and 6.6 million with mild neurological dis
orders.2 Out of the total 457 districts, 239
districts have been surveyed by the Gov
ernment of India and State Governments.
Of these, 197 districts arc endemic for
goitre (Table 1). No single stale in the
country is free from IDD as a public health
problem on the basis of these surveys.1
Thus the strategy for IDD elimination
should be applied to the whole country.
Tire incidence of neonatal hypothyroid
ism (NH) in a severely endemic area of In
dia (like Uttar Pradesh) is 2400 per 100,000
births which is 50 to 200 times more than
the reported average incidence of Nil in
non-endemic areas. This means that on.an
average, with every passing hour, 10 chil
dren are born in the country who will not
attain their optimal mental and physical
potential as a result of neonatal hypothy
547
roidism due to environmental iodine defi
ciency.'1 It has also been observed that the
Intelligence Quotient (IQ) of school chil
dren in areas with iodine deficiency is
about 13 points lower than the children liv
ing in iodine sufficient areas.5 The total IQ
points thus lost to the country is formidable.
All this makes India as one of the major
endemic iodine deficiency country in the
world. Immediate steps are therefore, re
quired to ensure that iodine supplementa
tion, in some form, reaches the population,
at the earliest.
Agenda for future
As there is great variability among the dif
ferent districts in the country, it may not be
right to extrapolate the prevalence rates to'
the rest of the country. It is essential that
all the districts are surveyed at the earliest
using epidemiologically sound techniques.
The recently recommended use of EPI
Cluster sampling technique for this pur
pose by a consultative committee of
VVIIO/UNICEF/ICC1DD is easy to carry
out and can be done in a short span of
lime.'' This committee also recommended
Tabui 2. Grading of Goitre by Palpation Method
Grade
Description
0
No palpable or visible goitre
1
A mass in the neck that is consistent with an enlarged thyroid
that is palpable but not visible when the neck is in the normal
position. Il moves upward in the neck as the subject swallows.
Nodular alteration (s) can occur even when the thyroid is not
enlarged.
2
A swelling in the neck that is visible when the neck is normal posi
tion and is consistent with an enlarged thyroid when the neck is
palpated.
[Source (6)1
548
1995; Vol. 62. No. 5
TI IE INDIAN JOURNAL OF PEDIATRICS
Table 3. Summary of IDD Prevalence Indicators and Criteria for a Significant Public Health
Problem
Severity of public health
problem (prevalence)
Indicator
Target
population
Mild
Moderate
Severe
Goitre Grade > 0
SAC'
5.019.9%
20.029.9%
>30.0%
Thyroid volume > 97th
centile by ultrasound
SAC
5.019 9%
20.029.9%
>30.0%
Median urinary iodine
level (ug/1)
SAC
50-99
20-49
<20
TSH > 5mU/l'whole
blood
Neonates
3.019.9%
20.039.9%
> 40.0%
Median Tg (ng/ml serum)
C/A"
10.019.9
20.039.9
> 40.0
* SAC = school-age children
** C/A = children and adults
[Sources (6)]
the use of simplified classification of goitre
and indicators for assessing the severity of
IDD as public health problem. These have
been shown in Table 2 and 3 respectively.
It is vital that a complete survey of the
country is undertaken using this method at
the earliest. However, this should not de
lay the immediate implementation of salt
iodisation programme in these areas.
Strategies Available
Current status
All the methods of prevention of IDD are
based on supplementation of iodine in dif
ferent ways. This includes fortification of
different food stuffs like salt, bread, milk
etc. with iodine or use of iodised oil. Of the
two most common methods of iodine
supplementation - iodized salt and iodized
oil injection, the former is widely prac
tised. This was one of the strategy adopted
by India when it launched the National
Goitre Control Programme (NGCP) in
1962.
Agenda for future
l
Though iodised salt is undoubtedly the
strategy for the country, there is still a
scope for complementary strategy in the
form of iodised oil. This should, however,
be limited to high endemic areas where
there is high prevalence of cretinism. Other
factors which further compound the prob
lem in these areas are the distance from the
salt producing centres, difficulty in trans
port and communication due to hilly ter
rain and annual or semi-annual salt-pur
chasing habits of people. The state of
Sikkim with high prevalence of goitre
199^;Vol.«.No.5
THE INDIAN JOURNAL OF PEDIATRICS
(56.9%) and cretinism (2.9%) among school
children is one such example.7 It should,
however, be clear that the iodised oil
should only be a short term strategy and
all efforts to strengthen the supply of
iodised salt should be made. Fortification
of salt has also been tried for controlling
iron deficiency anemia. With the availabil
ity of technology for double fortification, it
is likely that this strategy may be adopted
in the near future. This has important im
plications for the quality of common ilalt
produced in the country.
India to universalize iodisation of salt by
1995 and elimination of IDD by the year
2000 was reflected in the second SAARC
Conference on children in South Asia, held
in Colombo, Sri Lanka, in September 1992."
(v) The National Plan of Action for Chil
dren (NPA) of the Government of India
also includes "Universal iodisation of salt
for reduction of IDD to 10% by 2000".’
Political Commitment
Current status
The efforts of the Government of India to
achieve universal iodisation have been af
firmed at many important national and in
ternational events : (i) In May 1990, the
43rd World Health Assembly passed a
resolution commending the governments,
inter-govemmental and non-governmental
organisations for their efforts to prevent
and control IDD as a major health problem
in all the countries by the year 2000. (ii) In
September 1990, the historic world summit
for children, convened by the United Na
tional, adopted a plant of action setting out
the goals one of which was "Virtual Elimi
nation of IDD". India was one of the signa
tories of this summit.7 (iii) Historically,
Goitre and IDD elimination was a part of
the 20-point programme of the Prime Min
ister of India, late Mrs. Gandhi. The adop
tion of the resolution of International Con
ference of Nutrition held in 1992 at Rome
and the National Nutritional Policy, both
of which have reference to IDD by the gov
ernment in 1993, reflect the strengthening
of government's resolve to eliminate IDD.
(iv) The commitment of the Government of
549
Agenda for future
In 1996, A report has to be placed before
the World Health Assembly on the
progress achieved in the global efforts to
wards IDD elimination. India can seize this
opportunity to moye/sponsor the resolu
tion in view of its significant achievements.
Advocacy
Current status
Though there has been sufficient political
commitment for elimination of IDD in
India, there is a need for different national
and state level discussions. A meeting of
the 'Policy and Advocacy on IDD' was
held for high level health officials on 17
January 1994 at Delhi. It was chaired by
the Health Secretary and 47 officials from
central government, state governments
and representatives from national and
international agencies participated in the
meeting.
Agenda for future
There is a need to continue the exercise on
an ongoing basis as the political and the
administrative leadership keeps on chang
ing. The advocacy efforts should focus on
the potential aspect for success of this
programme among the different national
health programmes.
550
1995; Vol. 62. No. 5
THE INDIAN JOURNAL OI: PEDIATRICS
Legislation
Current status
The sale of uniodised salt has been banned
by issuing notifications under Section 7
(clause iv) of Prevention of Food Adultera
tion (PFA) Act by the state governments
within their territories either fully or par
tially. The qualities of iodised salt have
been specified under the provision of item
A.15.01 of Appendix B of PFA Rules, 1954.’
The ban is applicable only to tire salt meant
for human consumption and not appli
cable to salt for animal consumption. Strict
ban enforcement is as important and es
sential as the ban notification. The PFA Act
is implemented by Food and Drugs Ad
ministration of the concerned states. The
food inspectors are empowered to draw
samples in accordance with the procedure
laid down in the rules and get them
analysed in the designated laboratories. If
a salt sample fails to meet the specifica
tions, either in terms of iodine content or
other characteristics, the food inspectors
are empowered to launch prosecutions
against the manufacturer/producer/re
tailer/seller of such substandard iodised
salt. A successful prosecution could mean
imprisonment which shall not be less than
six months, but may be extended upto
three years and a fine of not less than Rs.
1000.’
The full ban notification has been in
force in 21 states and 5 union territories
(Table 1). Gujarat and Tamil Nadu have re
cently issued full ban notification with ef
fect from 1st January 1995. Kerala, Goa,
and Pondicherry have not issued any ban
notification
whereas
Karanataka,
Maharashtra and Orissa have issued par
tial ban notification.’
Agenda for future
Necessary efforts to ban uniodised salt in
all states and union territories should be
made. At present ban is only on salt meant
for human consumption and not on salt
meant for animal consumption. This im
plies that both the types of salt are avail
able in the market and the uniodised salt
being cheap is more likely to be bought by
a not so knowledgeable consumer. There
fore, it is necessary that ban is extended to
Table 4. Criteria for Monitoring Progress Towards Eliminating IDD as a Public Health Problem
Indicator
Goal
1.
Salt iodisation
Proportion of Households consuming effectively iodized salt
> 90%
2.
Urinary iodine
Proportion below 100 Jlg/1
Proportion below 50 pg/1
< 50%
< 20%
3.
Thyroid size
In school children 6-12 years of age :
Proportion with enlarged thyroid, by plapation or ultrasound
<5%
4.
Neonatal TSH
Proportion with levels > 5mU/l whole blood
<3%
[Source (6)1
1995; Vol 62 No. 5
THE INDIAN JOURNAL OF PEDIATRICS
all salts. It is also important to note that
IDD affects livestock as well and causes
abortions, still births, decreased yield of
meat, milk, egg, wool etc. and a decreased
capacity to work.'"
salt requirement for the country is around
5 million tonnes whereas the rest can be
exported. The production and demand for
iodised salt can be raised substantially
once all the states notify ban of uniodised
salt and strictly enforce it.
To facilitate easy and speedier distribu
tion of salt, the Salt Commissioners Office
and the Ministry of Railways have devel
oped a railway zonal scheme linking pro
duction centres and sources with the near
est distribution points.2
Capacity Buildinc/Training
Current stuatus
All India Institute of Medical Sciences, Na
tional institute of Communicable disease al
New Delhi and All India Institute of Hy
giene and Public Health at Calcutta have
been identified as nodal training centres
for both medical and non-medical person
nels also and.monitoring salt urinary io
dine.
551
Agenda for future
A good proportion of the salt is produced
by medium and small scale producers.
They find it difficult and uneconomical to
iodise their salt. Designing and production
Agenda for future
of hand-operated iodistation plants with a
Training on IDD should also be a part of capacity to iodise about 100 Kg salt/hour
the general training of the health workers at low cost (Rs. 15,000 per plant) is being
at all state Health and Family Welfare developed by an Indian firm. The trans
Training Centres. Sufficient emphasis on portation by road is increasingly being
IDD should also be a part of the medical used and a need for proper channelistion
undergraduates curriculum.
of routes is needed.
To prevent iodine losses during storage
Issues Related to Salt Iodisation
and transport, there is a need for use of
safe and protective packing by HDPE or
Current status
The total annual production of salt in India LDPE bags. In places where buying is an
is 13.5 million tonnes, out of which 5.2 mil nual/semi-annual, one should advocate
lion is used for human and animal con large LDPE bags rather than small packets.
sumption and the rest for industrial pur With the increasing concern of environ
poses. The three major salt producing mentalist about the use of plastic bags,
there is need for research to look for a bio
states are Gujarat (68%), Tamil Nadu (15%)
and Rajasthan (12%).2 There area present degradable yet protective material that
meets the packaging requirements of con
about 6,450 medium and large scale pro
sumers.
ducers who account for 92% of the total
salt produced in the country, the rest 8%
Information Education and
being accounted for by about 3,000 small
Communication
scale producers."
Current status
Of the total installed capacity of 6.6 mil
lion tonnes of salt iodisation only about 3 Television and Radio spots addressing dif
million tonnes are being produced. The ferent issues in IDD have been agreed
552
THE INDIAN JOURNAL OP PEDIATRICS
upon and are being broadcast. These mate
rials have been prepared after extensive
Knowledge Altitude Practice (KAP) sur
veys in the affected areas. These messages
are primarily aimed at the general public
and are meant to create a demand for
iodised salt.
As a policy decision in 1989, the Gov
ernment of India has decided to promote
the national logo of "smiling sun" for an
easy identification of iodised salt by the
public. If properly enforced, this not only
ensures a quality product but also gives
the public value for their money.
Agenda for future
There have been repeated concerns about
the toxicity of iodised salt and tire need for
universal iodisation. Issues related to the
safety of universal salt iodisation have
been carefully examined by WI IO which
recommends that daily intakes of upto
Img (1000 pg) appear to be entirely safe.12
At the current recommended levels in In
dia, the daily intake is likely to be in the
range of 150 pg to 300 pg. The benefits to
be derived from universal salt iodisation
by the affected, and the absence of signifi
cant adverse effects among others in the
same area who are not iodine deficient, far
outweigh any risk of excess intake for a
small minority.12
IEC efforts aimed at doctors, nutrition
ists and decision-makers are necessary to
remove the misconceptions regarding io
dine toxicity. Various professional bodies
of doctors, pediatricians, nutritionists, en
docrinologists like Indian Medical Associa
tion should include this in their agenda.
Monitorinc
Current status
The success of the National IDD Control
1995; Vol. 62. No. 5
Programme depends primarily on the io
dine level in salt at tire retailer level, and fi
nally at the consumer level. For an effec
tive salt iodisation programme, monitoring
the levels of iodine at various stages and
under various circumstances in one of the
most important factors.
Every iodized salt manufacturer has to
maintain a process control laboratory to
ensure proper level of iodisation. A second
check is carried out by the Salt Department
before the dispatch ofsalt by rail or road.
Quality control at the retail level is done
by the State Governments through the
Health Directorates. The Food Inspectors
of the concerned State Governments main
tain the quality of iodized salt. In order to
strengthen the monitoring system. Govern
ment of India with UNICEF assistance has
finalised a project for intensive IDD activi
ties in four endemic states of Assam,
Madhya Pradesh, Himachal Pradesh and
Uttar Pradesh.
Though the government has a system
for monitoring, it is necessary to supple
ment it by external agencies. Non-govern
mental organizations (NGOs) have an im
portant role to play in this and its success
has been proven by a recent study under
taken in U.P. The study was done in six
teen
districts
around
Dehradun,
Gorakhpur and Varanasi. Three NGOs
were selected which further identified
more peripheral NGOs who collected salt
from the households and retailers. It re
vealed that out of 10,153 salt samples col
lected, 60.9% of the salt samples had iodine
levels below the recommended 15 ppm.
The iodine level was especially low in
Gorakhpur and Varanasi zones where 72%
to 73% of samples had iodine level below
15 ppm compared to 50% in Dehradun. A
total of 5.3% salt samples had no iodine.13
1995; Vol. 62. No. 5
THE INDIAN JOURNAL OF PEDIATRICS
Agenda for future
century. It is absolutely essential that all
tire impediments arc Yemoved in its path.
If necessary the Consumer Forums and
NGO's should be encouraged to file Public
interest litigation on behalf of cretins and
children of India It is indeed paradoxical
that at present some people/organisations
are questioning universal salt iodisation.
Though the above study proved the
feasibility of NGOs' for this purpose, more
NGOs in different parts of the country
have to take up this challenge. With the
availability of spot testing kits monitoring
can be done in schools and even the
general public can be asked to participate
in this activity. The criteria for monitoring
progress towards elimination of IDD as
a public health problem is given in
Table 4.
Community Participation
Current status
Modest efforts have been made by some
NGOs in this field using their existing
network. However, much needs to be
done. With the promulgation of Panchayati
Raj Act, community participation can
actually be demonstrated in practice.
Madhya Pradesh, which is the first state of
the country to implement this Act, has
already demonstrated the immense
potentiality of this scheme, hi conjunction
with the high level political commitment,
Madhya Pradesh has forged ahead with an
action programme to eliminate IDD form
the state by 1997.14
555
Building a Partnership
There are a number of contributors to the
successful elimination of IDD. Each will
need to understand the potential of other.
These stakeholders include government,
food processing industry, nutritionists,
educationists, agriculture and animal hus
bandry, communication professionals and
people working with mentally disabled.
Commitment to and ownership of the so
lution to the IDD problem by this wider
network of stakeholders will be essential to
ensure the elimination of IDD by the year
2OOO.15
This agenda of involving and building
alliances with a large and diverse range of
aWrs is ambitious but not impossible. The
first step in this direction was taken in
April 1995 when delegates for six South
Asian countries - Bangladesh, Bhutan, In
dia, Nepal, Pakistan, Sri Lanka came to
gether to decide the strategy for the sub
continent.
Agenda for future
Sustainability
In the continuing process of empowerment
of people to take their own decisions, IDD
should feature as an important issue. The
impact of iodine deficiency on intelligence
and educability of children is an important
impediment for the development of a com
munity. It also seriously handicaps our ef
forts for education for all by the end of this
As said earlier, unlike the communicable
diseases, eliminating IDD is not a one time
effort. The main effort is to sustain the
achievements. Many countries have suf
fered setbacks in their programme of IDD
elimination, when the success induced a
sense of complacency.
555
oc-
on
nc
liu
Tl IE INDIAN JOURNAL OF PEDIATRICS
1995; Vol. 62. No. 5
The iodistation of salt, while undoubtedly
a simple technique for an immeasurably
important social benefit, is, nevertheless,
only the first step in the goal of elimination
of IDD. Many other steps will be needed
before IDD can be prevented from ever
making a comeback. The strategy for man
agement of sustained IDD elimination
should, therefore, focus on continuous po
litical and financial commitment, clear
communication strategy, persistent quality
control, regular monitoring and responsive
administration."
Deficiency Disorders in school children of
Sikkim. Indian Pediatr 1994; 61 : 407-414.
8. Ministry of Industry. Universalization of
access to iodised salt-A mid-decade goal.
Produced by the Salt Department,
Ministry of Industry with support from
UNICEF, 1994.
9. Ministry of Human Resource Develop
ment. National Plan of Action on Nutri
tion. Food and Nutrition Board, Depart
ment of Women and Child Development,
Ministry of Human Resource Develop
ment, Government of India, New Delhi,
1995.
10. Interrnalional Council for Control of Io
dine Deficiency Disorders (SEARO). Pro
ceedings of Technical review meeting on
iodine deficiency disorders in liverstock
populations, G.B. Pant University for Ag
riculture and Technology, Pantnagar,
Dist. Nainital, Uttar Pradesh, India; 2728th January 1995. (In Press).
11. UNICEF Progress towards Universal salt
Iodisation : An update on the current
status of universal salt iodisation in
countries
where
UNICEF
has
programmes. Nutrition section, UNICEF,
New York, December 1994.
12 World Health Organization : Iodine and
i lealth : Eliminating iodine deficiency
disorders safely through salt iodisation A statement by the WHO, WHO/NUT/
94.4; Geneva, August 1994.
13. Citizens' report on Iodine content in salt
at consumer level in Uttar Pradesh.
Published by Centre for Community
Medicine, All India Institute of Medical
Sciences, New Delhi - 110029.
14. Department of Health and Family Wel
fare, Government of Madhya Pradesh.
Rajiv Gandhi Mission for elimination of
Iodine Deficency Disorders: Mission Doc
ument; Bhopal, 1995.
15. Pandav CS, Vishwanathan FI, Haxton
DP. Sustaining elimination of iodine
deficiency disorders. National Med J India
(editorial), 1995; 8 (2) : 49-50.
554
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Sciences, New Delhi - 110029.
14. Department of Health and Family Wel
fare, Government of Madhya Pradesh.
Rajiv Gandhi Mission for elimination of
TI IE INDIAN JOURNAL OF PEDIATRICS
555
Iodine Deficency Disorders: Mission Doc
ument; Bhopal, 1995.
15. Pandav CS, Vishwanathan H, Haxton
DP. Sustaining elimination of iodine
deficiency disorders. National Med J India
(editorial), 1995; 8 (2) : 49-50.
FORTY-NINTH WORLD HEALTH ASSEMBLY
Agenda item 17
WHA49.13
25 May 1996
Prevention and control of iodine
deficiency disorders
The Forty-ninth World Health Assembly,
Having considered the report of the Director-General regarding the progress achieved in preventing and
controlling iodine deficiency disorders;1
Recalling resolutions WHA39.3I and WHA43.2 on the prevention and control of iodine deficiency
disorders,
1.
COMMENDS governments, international organizations, bilateral agencies, and nongovernmental
organizations, in particular the International Council for Control of Iodine Deficiency Disorders:
(I) on their efforts to prevent and control iodine deficiency disorders and to support related national,
regional and global initiatives;
(2) on the progress achieved since 1990, through joint activities in many countries, towards the
elimination of iodine deficiency disorders as a major public health problem throughout the world;
2.
REAFFIRMS the goal of eliminating iodine deficiency disorders as a major public health problem in
all countries by the year 2000:
3.
URGES Member States:
(I) to give high priority to the prevention and control of iodine deficiency disorders wherever they
exist through appropriate nutritional programmes as part of primary health care;
(2) to increase efforts for the sustainability of the elimination of iodine deficiency disorders by
continued monitoring, training and technical support, including advice on appropriate health legislation,
and social communication in cooperation with the International Council for Control of Iodine
Deficiency Disorders, other nongovernmental organizations and UNICEF, as required;
' Document A49/4, pan VII.
WHA49.13
4.
REQUESTS the Director-General:
(I)
to continue to monitor the incidence and prevalence of iodine deficiency disorders;
(2) to reinforce the technical support provided to Member States, on request, for monitoring progress
towards the elimination of iodine deficiency disorders with the help of the International Council for
Control of Iodine Deficiency Disorders, other nongovernmental organizations and UNICEF, as required;
(3) to mobilize additional technical and financial resources to permit those Member States in which
iodine deficiency disorders are still a significant problem, for training health and development workers
in the early identification and treatment of iodine deficiency disorders and develop or expand their
appropriate public health preventive programmes for the elimination of these disorders;
(4)
to establish a mechanism for verifying the elimination of iodine deficiency disorders in the world;
(5) to report to the Health Assembly by 1999 on progress achieved in the elimination of iodine
deficiency disorders.
Sixth plenary meeting, 25 May 1996
A49/VR/6
2
Special Article
Indian J Pediatr 1995; 62 : 381-393
Review of Experiences with Iodized Oil in National
Programmes for Control of Iodine Deficiency Disorders
R. Sankar1, C.S. Pandav2, F.U. Ahmed3, Pralhad Rao4, M.P. Dwivedi5, V.Desai6,
M.G. Karmarkar2* and L.M. Nath2
7 Department of Thyroidology, Institute of Nuclear Medicine and Allied Sciences (RS),
-Department of Community Medicine, All India Institute of Medical Sciences (CSP, MGK
and LMN), New Delhi and ^Department of Community Medicine, Assam Medical
College,Dibrugarh (FUA), 4'5National Institute of Nutrition, Hyderabad (PR),
6Department of Community Medicine, Government Medical College, Surat (VD)
Iodine deficiency is a world wide problem
that leads to goitre and the syndrome of
endemic cretinism together with clinical
and subclinical deficits of motor and
cognitive function. This spectrum of
defects haye been collectively labelled as
iodine deficiency disorders.1 About one
billion people world wide are at risk for
iodine deficiency.2
In India, iodine deficiency exists in the
Himalayan/sub-Himalayan belt, some
2500 kms in length from Jammu and Kash
mir in the west to Arunachal Pradesh in
the east, and along this entire length ex
tending at least 500 kms south of Himala
yas into the flat sub-Himalayan Terai.3 In
addition iodine deficiency exists in many
pockets spread throughout the country.4'5
Current estimates indicate that, there are
54 million people with goitre, 2.2 million
suffer from endemic cretinism and an ad
ditional 6.6 million have milder neurologi
cal deficit attributable to environmental io
dine deficiency.6 In severely iodine defi
cient regions of the country, the incidence
Reprint requests: Lt. Col. R. Sankar, Gasified Spe
cialist in Medicine Department of Thyroidology,
Institute of Nuclear Medcine and Allied Sciences,
Timarpur, Delhi-110 054.
of neonatal chemical hypothyroidism
has been found to be between 7.5% and
13.3%.7
There is an overwhelming evidence to
indicate that IDD can be effectively pre
vented by simply providing an adequate
intake of iodine. Iodine supplementation is
available in several forms. Interventional
measures designed to cover an entire
population include: iodized salt, iodized
oil and iodized water.
There exists a clear choice of strategies
for the control of IDD. They are comple
mentary to each other. Probably not all
strategies will be appropriate for all condi
tions. Some will be more relevant than oth
ers in a given situation. In some, a combi
nation of strategies may appear advisable.
In India, iodized oil was used in a pilot
study in Uttar Pradesh. Although the re
sults were encouraging, on the basis of
(unpublished) observations in a subset of
recipients of iodized oil, concern has been
expressed over the theoretical possibility
that iodine supplementation during preg
nancy may adversely affect foetal develop
ment as a result of maternal thyroid inhibi
tion from Wolff-Chaikoff effect. This led to
a set back to the IDD control programme
in the country. It is with this background a
1995; Vol. 62. No. 4
in the treated group (children whose moth
ers had received iodized oil) 7 of 412 chil
dren (1.7%) were cretins (pcO.OOl). It is no
table that of the mothers of cretinous chil
dren, 6 of 7 mothers in the treated group
were already pregnant at the time of injec
tions. Therefore, of the children conceived
after their mothers were injected only one
cretin was born of the treated group. The
study, therefore, concluded that iodized
oil is effective in preventing endemic cre
tinism provided it is given prior to concep
tion. Children born into the trial between
1966 and 1972 were followed up until 1982.
The follow up of children born into the
trial population was limited to five villages
for logistic reasons, and the cohort of chil
dren born into the trial were further exam
ined in 1974, 1976, 1978'and 1982.15,16 Sev
eral measures of motor and cognitive func
tions were studied, hi 1978, when the chil
dren were aged 6-12 years, the tests ap
plied were of grip strength, speed of move
ment (by tapping or dotting with a pencil),
unimanual accuracy (by screwing nuts
onto bolts or by inserting pegs into a peg
board), and bimanual accuracy by bead
threading. The iodine-supplemented
group performed significantly better on
the tasks of uni and bimanual accuracy,
but the scores on the other tasks did not
differ significantly. In 1982, when the chil
dren were aged 10-12 years, the pegboard
and bead-threading tests were repeated
and the intellectual performance was as
sessed by Pacific Design Construction Test
(PDCT). The results showed that, a greater
proportion of children in the control than
in the supplemented group performed
poorly.
A field trial of iodized oil was initiated
in few villages of Andean Ecuador in 1966.
The recipients of iodized oil injections have
THE INDIAN JOURNAL OF PEDIATRICS
383
been followed most carefully upto the
present time-1992.17,18,19 In the two villages
studied, the mean urinary iodine excretion
was below 20 ug/gm of creatinine. Prior to
intervention, the overall prevalence of
goitre w'as between 50% and 70%, and
from 6% to 8% of the subjects w'ere cretins.
Administration of intramuscular iodized
oil in one dose lead to a goitre reduction of
36% within 2 years, a decrease of the 24
hour radio iodine uptake from 79% to 38%,
and increase in the serum PBI from 2.8 to
7.1, and an increase in the urinary iodine
excretion to 87 ug/gm of creatinine. The
only toxic effect of oil administration was
the identification of three subjects with
thyrotoxicosis a few months following oil
administration. They were identified in the
follow up. A particularly salutary effect of
this programme was improvement of the
long term performance of the children
born of mothers who received iodized oil.
Improvement was measured in terms of
school attainments and in results of
neuromotor and psychological testing.20,21
No cretin was identified among the prog
eny of iodized oil recipients.
In Peru, a trial of iodized oil prophylaxis
was started in 1966 by Pretell et al.22,23
They showed that 18 months after iodized
oil injection the prevalence of grade I
goitre fell from 58% to 16%. No
hypothyroidism or Jod-Basedow was en
countered. This study also showed that
thyroxine levels of pregnant women under
prophylaxis improved and adequate quan
tity of iodine were present in breast milk of
lactating mothers who had received io
dized oil.
In the severely endemic region of Zaire
in Central Africa, iodized oil injection
programme was begun in early 1970s and
has continued much more extensively in
THE INDIAN JOURNAL OF PEDIATRICS
1995; Vol. 62. No. 4
the Ubangi region where severe iodine de
ficiency has existed. Two longitudinal
studies from this region are important as
they address the efficacy of iodized oil and
its safety in pregnancy. In the first trial24
the short and long term effects of iodized
oil was investigated. In a village of 1181/
the subjects were injected with iodized oil,
goiter prevalence fell dramatically from
48% before treatment to 16% one year
later; remained at this level after 2.5 years,
then increased to 26%, five years after io
dized oil. The daily urinary iodine which
was 15 ug/day was accompanied by high
thyroidal uptake and serum TSH. Eighteen
months after the injection of iodized oil,
the daily urinary iodine excretion was 640
ug/day. The thyroidal uptake and serum
TSH were low. Even five years after the in
jection of iodized oil, the serum thyroxine
was well within the normal range. Along
with this study, 2000 inhabitants of two
villages treated with iodized oil were fol
lowed up and no case of Jod-Basedow was
observed.24'25-26
The second study was conducted in the
Ubangi region in north western Zaire.24 It
was a hospital based randomized trial with
concurrent controls. Iodized oil injections
were given to women attending antenatal
clinic. Prenatal consultations took place be
tween the 20th and 36th weeks of preg
nancy. Immediately after the prenatal con
sultation, one women out of every two, se
lected randomly in a double blind design,
received iodized oil or saline. The outcome
measures were birth weight, perinatal and
infant mortality rates and development
quotient. Outcome assessment was blind.
The results obtained from the untreated
mothers (control group) and newborns
were compared with those obtained from
treated group (iodized oil group). The re
sults are shown in Table 2. In the treated
group improvement in all the parameters
studied were observed. Mean birth weight
was 200 grams higher. Perinatal mortality
was down to almost half the value in the
treated group, while infant mortality was
25% and 17% respectively. No goitre was
observed in the newborns of treated moth
ers, who had a mean daily iodine excretion
of 576 ug/day at delivery. The psychomo
tor development quotient in infants, 4 to 25
months of age was 104 in the untreated
group and 115 in the treated one. The dif
ferences were statistically significant.
The other most important observation
of this Ubangi study was the observation
of serum T-4 concentration in children
bom into the trial. In the untreated group
there was extreme variability and very low
serum T-4 values and they were main
tained throughout the study period. In the
384
Table 2. Effect of Injection of Iodized Oil Given During Pregnancy
Not treated
Treated
2634 +/- 552 (98)
2837+/- 542 (112)
Perinatal mortality/1000
188(123)
98 (129)
Infant mortality/1000
250 (263)
167(252)
Development quotient
104 +/- 24 (66)
115 +/-16 (72)
Birth weight
Number of subjects in parentheses
1995; Vol. 62. No. 4
THE INDIAN JOURNAL OF PEDIATRICS
untreated group the mothers iodine defi
ciency was matched by a low mean value
for cord serum thyroxine in the new bom
and by definitely elevated serum TSH.
These findings indicated very high fre
quency of severe infantile hypothyroidism
in the untreated group. In the children
born of treated mothers from birth to two
years, there was only one unexplained but
definite case of both biological and clinical
hypothyroidism out of 132 children. In the
age period from two to four years, there
was a gradual decrease in individual T-4
values and above 4 years of age, the fre
quency distribution of T-4 values was back
to the severely low levels observed in the
untreated group. The result of this work
show that the injection of pregnant women
with iodized oil, is an emergency measure
that dramatically prevents thyroid failure,
improve the somatic and intellectual de
velopment and the very survival of neo
nates bom to mothers treated during preg
nancy.
Watanabe et al27 compared the results of
iodized oil by the oral and parental routes
in two districts of Western-Argentina.
Their results show satisfactory reduction
in goitre size by both the routes. Serum
thyroxine concentration and thyroidal ra
dioactive iodine uptake were found nor
mal after two years (both routes). Among
250 in one province who received iodized
oil, three developed Jod-Basedow. All
these three had large nodular goitres.
Maberly et al28 studied the effect of io
dized oil on goitre size, thyroid function
and the development of Jod-Basedow phe
nomenon in the Lobuk Antu district of
Sarawak, Malaysia. 240 subjects were stud
ied before and at intervals of one and two
years following iodized oil injection. After
one year, the goitre prevalence decreased
from 75 to 33%. There was normalization
of thyroid function. Of the 240 subjects
studied, eight were suspected clinically of
being thyrotoxic and the diagnosis was
confirmed in four subjects by biochemical
assessment. Two of these four were 50
years of age and older which is the predi
cated age of Jod-Basedow.29-30
In a longitudinal study in Western Su
dan,31 2316 school children received single
dose of 400 mg of iodized oil in capsule
and 1161 children received 1 ml of oil as in
jection; 2393 children served as controls.
One year after treatment, goitre prevalence
was reduced from 67% to 36% among chil
dren who received iodized oil orally, and
from 71 to 42% in those who received it as
injection. The goitre prevalence in the con
trol group did not change. Urinary iodine
levels increased after iodized oil and re
mained significantly higher than the initial
values during the trial. TSH and the thy
roid hormone levels normalized. During
the trial iodized oil was also given to 841
individuals covering a wider age range
with comparable results. Similar results
were obtained in a previous study from
Sudan.32
A community based controlled trial
comparing the oral and intramuscular io
dized oil has been carried out in 23 se
verely iodine deficient villages in Eastern
Zaire.33 All adults in these villages were di
vided into five groups including a placebo
group. The effectiveness was assessed by
size of goitre and thyroxine concentration.
Iodized oil produced large and statistically
significant rise in thyroxine levels at four
and eight months after supplementation
and the effectiveness of oral iodized oil
was comparable to intramuscular prepara
tion. The study also showed yearly admin
istration of iodized oil would be effective
385
THE INDIAN JOURNAL OF PEDIATRICS
1995; Vol. 62 No 4
in correcting iodine deficiency in commu
nities and that large scale supplementation
with oral iodized oil was feasible in remote
areas with untrained people.
A follow up34 of the recipients of io
dized oil showed that blood spot thyroxine
remained normal throughout the period of
two years follow up. The other most im
portant finding was that thyroxine levels
in the infants bom to mothers treated injec
tion or oral iodized oil were higher than
that observed in the control group. TSH
levels were not raised in any of the infants
in the group who had received iodized oil
injection but was observed in one of 87 in
fants in the orally treated group. Tonglet et
al35 have reported on the efficacy of low
doses of iodized oil in the control of iodine
deficiency. This trial from Zaire demon
strated that oral administration of one
small dose of iodized oil (0.1 ml or 0.25 ml)
can correct severe iodine deficiency for
about one year. The efficacy of the inter
vention was demonstrated by the normal
ization of serum thyroxine and TSH con
centrations and reduction in goitre size in
the subjects who received oil.
Watcher et al36 in Southern Highlands
of Tanzania have shown beneficial effects
of iodized oil injection on thyroid function
in children. This study also noted that
mothers who received iodized oil injection
during pregnancy had sufficient iodine in
breast milk for upto three years.
In Nepal iodized salt programme was
initiated in 1973 and a mass iodized oil in
jection programme was initiated in 1979.
The impact of the programme was as
sessed between May 1985 and June 1986. A
total of 33,808 individuals were examined
for various indicators of IDD in 15 dis
tricts. There were seven districts which
had been covered by iodized oil and
three which were under iodized salt
programme. A total of 3,894 children be
tween 5-14 years were examined in the oil
intervention districts. There were six cre
tins in this age group. Similarly a total of
8,158 children were examined in seven
other districts and 20 cretins were found.
Urinary iodine excretion was higher in the
iodized oil recipients and the thyroid hor
mone concentration was also found to
have normalized in the recipients.
In India the efficacy of iodized oil was
studied in a pilot study in some PHCs of
Deoria and Gonda districts of Uttar
Pradesh in 1983.37 Children and women in
the reproductive age group including
pregnant women were the major target
population. One ml of Lipiodol was given
intramuscularly. A total of over 12,000 in
jections were given. Follow up studies of a
sub-set of these groups showed that major
ity of injected subjects excreted satisfactory
levels of urinary iodine upto 45 months
post-injection. The breast milk iodine con
tent in mothers who received iodized oil
during pregnancy was upto four fold
*
higher than non-injected control mothers
from the same area. No untoward results
of this programme was noted, except that
attention was called to the fact that iodized
oil given in the last trimester of pregnancy
does not reduce the incidence of neonatal
hypothyroidism.37
A total of 154 babies born to mothers
who had received iodized oil during preg
nancy were studied for their cord blood
thyroxine and TSH levels. Sixteen of these
newborns had neonatal hypothyroidism
(16/154). The mean duration before deliv
ery when iodized oil injection was given to
these women was 3.5 weeks. It is pertinent
to point out that a study from the same re
gion had revealed the incidence of neona-
386
1995; Vol. 62. No. 4
THE INDIAN JOURNAL OF PEDIATRICS
tai chemical hypothyroidism to range from
4% to 14%. This indicates that the inci
dence of neonatal chemical hypo
thyroidism does not change if iodized oil is
given in the last month of pregnancy.
However the authors have concluded that
iodized oil injection given during preg
nancy is harmful and causes neonatal
chemical hypothyroidism.
foetal neurological development if it leads
to maternal thyroid inhibition by the
Wolff-Chaikoff effect. This fear may be al
layed by the data available from many
endemias on the beneficial effects of io
dized oil given to pregnant women.
Pharoah ct al have clearly shown the safety
of iodized oil administration in pregnancy
by following up children born to these
women who received iodized oil during
pregnancy for fifteen years. Thilly et al
have demonstrated in a study of very strict
design, that in the neonates bom to women
who have received iodized oil, complete
thyroid function normalization goes hand
in hand with a remarkable decrease in
perinatal mortality as well as an increase in
the birth weights and the somatic and in
tellectual development of the children.
These studies have demonstrated that the
injection of pregnant women with iodized
oil rather than having adverse effects is an
emergency measure that dramatically pre
vents thyroid failure in the foetuses, with
its consequences on brain maturation and
perinatal mortality for a period of 2 to 4
years. No case of iodide goitre has been
described following injection of iodized oil
to women of child bearing age.
On the contrary the data from India37
showed that iodized oil when given to
pregnant women, 3.5 weeks prior to deliv
ery did not decrease the incidence of neo
natal hypothyroidism. But unfortunately
this data has been mispresented to show
that iodized oil has no role in IDD prophy
laxis.41 The results and interpretation of the
said study are questionable. Many possible
confounders have been carefully con
cealed. Birth weight and maturity of the in
fants with neonatal hypothyroidism is not
given. The absence of neonatal goitre in
any of these 16 infants goes against the
Safety of Iodized Oil
In the context of National Iodine Supple
mentation programmes concern has been
expressed over the theoretical possibility
of two adverse effects of large doses of io
dine to whole population, viz., (a) iodine
induced hyperthyroidism or Jod-Basedow;
(b) Wolff-Chaikoff effect.
Thyrotoxicosis is a rare complication of
prophylactic programmes both with io
dized salt and oil. Jod-Basedow has been
described in different studies including
three among 960 subjects in Ecuador,38 one
among 2025 in Peru,39 three among 94 in
Argentina,27 and four among 240 in
Sarawak.28 Many of these cases were ob
served
in
elderly
women
with
multinodular goitre and all were either
transient or easily treated. Jod-Basedow
has ben extremely rare or non-existent in
the several million injections given in sev
eral endemias.40 It is possible that reported
cases of Jod-Basedow reflect pre-existing
underlying thyroid disease, rather than
new pathology. However, epidemiologial
surveillance is recommended three to six
months after iodized oil injections
programmes.
Another concern with iodized oil and
that is potentially more important is the
theoretical possibility that administration
of iodine during pregnancy may affect
387
388
THE INDIAN JOURNAL OF PEDIATRICS
1995; Vol. 62. No. 4
theory that the neonatal hypothyroidism in
them was due to Wolff-Chaikoff effect.
There is no follow up reported. It is well
known that the incidence of transient neo
natal hypothyroidism is high in the iodine
deficient regions.
It is pertinent to point out that WolffChaikoff effect was demonstrated in iodine
deficient rats; that a similar inhibition of
thyroid gland follow iodine administration
to an iodine deficient human population
has not been demonstrated.42 A recent well
designed study from China43 has clearly
shown that upto the end of the second
trimester, iodine treatment protects the
fetal brain from the effects of iodine
deficiency. Treatment later in pregnancy or
after delivery may improve brain growth
and developmental achievement slightly,
but it does not improve neurologic status.
One of the important observation in this
study was that there was no harm to the
foetus from large doses of iodine late in the
third trimester.
Iodized oil given to pregnant women
also increases the breast milk iodine con
tent which is a distinct advantage in many
endemias in the under developed world
where ihfants are by and large on breast
milk for most of their infancy. It has been
suggested that the inability of iodized oil
injection given in pregnancy to prevent
cretinism is a total contra-indication to its
use.41 This ignores the benefit to the whole
iodine deficient population, only some of
whom are pregnant.
On the balance of risk between on the
one hand very rare cases of iodide goitre in
the new bom together with Jod-Basedow
in the eldest adults and on the other hand
the clear evidence that maternal iodine
deficiency may severely compromise the
development of the foetus, it is quite
clear that the iodized oil prophylaxis has
a highly advantageous benefit to risk
ratio.
Table 3. World Experience with Iodized Oil
(million doses)
Beneficiary population
Continent
Oral Intramuscular
Total
Asia
16.05
41.98
58.03
Africa
1.05
1.80
3.30
Latin America
1.50
0.80
2.30
Total
19.05
44.58
63.63
Use of Iodized Oil in National IDD
Control Programmes
Iodized oil has a definite place in a public
health programme for the correction of
severe iodine deficiency and prevention of
cretinism. The greatest advantage with
iodized oil is that iodine supplementation
can begin almost immediately. This will
provide iodine to the high risk population
for two to five years while organising more
complicated schemes of salt iodization.
This is most important in circumstances
where salt iodization is delayed due to
various factors such as remoteness of a
region and difficulties in a market
situation.
It is for this reason that iodized oil has
been used on massive scale in many coun
tries and has been found to be extremely
satisfactory. In excess of 60 million doses
have been given since the original intro
duction in Papua New Guinea, Table 3. In
Asia alone more than 50 million doses
have been given (Indonesia-11.4 million
doses; China-37 million doses; Nepal-4
million doses).
THE ENDIAN JOURNAL OF PEDIATRICS
1995; Vol. 62. No. 4
theory that the neonatal hypothyroidism in
them was due to Wolff-Chaikoff effect.
There is no follow up reported. It is well
known that the incidence of transient neo
natal hypothyroidism is high in the iodine
deficient regions.
It is pertinent to point out that WolffChaikoff effect was demonstrated in iodine
deficient rats; that a similar inhibition of
thyroid gland follow iodine administration
to an iodine deficient human population
has not been demonstrated.42 A recent well
designed study from China43 has clearly
shown that upto the end of the second
trimester, iodine treatment protects the
fetal brain from the effects of iodine
deficiency. Treatment later in pregnancy or
after delivery may improve brain growth
and developmental achievement slightly,
but it does not improve neurologic status.
One of the important observation in this
study was that there was no harm to the
foetus from large doses of iodine late in the
third trimester.
Iodized oil given to pregnant women
also increases the breast milk iodine con
tent which is a distinct advantage in many
endemias in the under developed world
where ihfants are by and large on breast
milk for most of their infancy. It has been
suggested that the inability of iodized oil
injection given in pregnancy to prevent
cretinism is a total contra-indication to its
use.41 This ignores the benefit to the whole
iodine deficient population, only some of
whom are pregnant.
On the balance of risk between on the
one hand very rare cases of iodide goitre in
the new born together with Jod-Basedow
in the eldest adults and on the other hand
the clear evidence that maternal iodine
deficiency may severely compromise the
development of the foetus, it is quite
clear that the iodized oil prophylaxis has
a highly advantageous benefit to risk
ratio.
388
Table 3. World Experience with Iodized Oil
(million doses)
Continent
Beneficiary population
Oral Intramuscular
Total
Asia
16.05
41.98
58.03
Africa
1.05
1.80
3.30
Latin America
1.50
0.80
2.30
Total
19.05
44.58
63.63
Use of Iodized Oil in National IDD
Control Programmes
Iodized oil has a definite place in a public
health programme for the correction of
severe iodine deficiency and prevention of
cretinism. The greatest advantage with
iodized oil is that iodine supplementation
can begin almost immediately. This will
provide iodine to the high risk population
for two to five years while organising more
complicated schemes of salt iodization.
This is most important in circumstances
where salt iodization is delayed due to
various factors such as remoteness of a
region and difficulties in a market
situation.
It is for this reason that iodized oil has
been used on massive scale in many coun
tries and has been found to be extremely
satisfactory. In excess of 60 million doses
have been given since the original intro
duction in Papua New Guinea, Table 3. In
Asia alone more than 50 million doses
have been given (Indonesia-11.4 million
doses; China-37 million doses; Nepal-4
million doses).
1995; Vol. 62. No. 4
IDD Elimination in India
THE INDIAN JOURNAL OF PEDIATRICS
389
efficient alternative producing the follow
ing results over iodised salt programme:
The National Goitre Control Programme Rs. 1600 per case averted of endemic cre
was launched in 1962, with iodized salt as tinism, Rs. 500 per case averted of mild
the preferred approach for IDD elimina- IDD, and Rs. 600 per IDD attributable
tion.y After three decades of the death averted. The cost benefit ratio of
programme IDD continues to be a major IDD control in this study, which is a con
public health problem for the country. IDD servative estimate (for it did not include
is a classic example of "place disease". benefits as a result of improved educability
There is a striking difference in the preva and benefits to live stock) was also found
lence of IDD in different regions of the to be favourable at 1 : 3.44 In this context,
country. The severe goitre endemias are all the attempts of Indian scientists to produce
in the Himalayan and sub-Himalayan re iodized oil indigenously using sun flower
gions. In these regions iodized oil is the oil are quite relevant45 and needs immedi
preferred approach until iodized salt suc ate consideration.
The question of outreach is common to
cessfully covers these regions. The long
term solution should still be iodized salt. all public health programmes, be it infec
Iodized oil and salt programmes are not tion control or prevention of malnutrition.
mutually exclusive. They are complimen Given the experience of country's health
tary to each other. In many countries a and welfare departments in the implemen
combined strategy with iodized oil and io tation of vitamin A (frequency of adminis
dized salt has been successfully used; In tration—6 monthly) and UIP (frequency of
donesia, China and Nepal are few ex contact-monthly), the programme of io
dized oil administration; oral-frequency
amples from our region.
There is little justification at this stage of once in two years and injection—once in
development and technical know-how to five years; should pose minimal opera
withhold iodized oil, an effective interven tional difficulties.
Any public health intervention has its
tion, from hyperendemic areas and thus
deny the benefits of science to the poor. own risks and benefits and the applicabil
Amongst the objections put forth are cost, ity of the said intervention depends on the
spread
of
infection
(HIV)
and benefits accrued over the risks. Needle
unapproachability. The cost of iodized oil transmitted is a risk in any programme
intervention is important. However, a re where injection programmes are used, but
cent comprehensive analysis done by it has to be weighed against the benefits. In
Pandav et al on "Economic evaluation of UIP (universal immunization programme)
iodine deficiency disorder control children below one year are given five in
programme in Sikkim" has demonstrated jections (BCG, DPT x 3 and Measles). Total
the cost effectiveness of iodized oil inter of 3 per cent of the population of the coun
vention for the "high risk" population cov try are below one year of age which means
ering women in reproductive age group there are nearly 25 million infants in our
(15 to 44 years) and children under 15 country. Assuming a UIP coverage of 80
years of age. The incremental analysis per cent, hundred million injections are
showed iodized oil programme as a more given in the UIP for primary vaccination
THE INDIAN JOURNAL OF PEDIATRICS
1995; Vol. 62. No. 4
alone. Can we do away with this on the
theoretical possibility of needle transmit
ted infections? The right step is to take ad
equate precautions to ensure strict aseptic
and sterilization procedures.
There is an urgent need for the nutrition
scientists and health planners of the coun
try to give a serious thought to the iodized
oil programme as a complementary mea
sure to the iodised salt programme in
hyper-endemic areas to halt the relentless
march of the physically crippled and men
tally retarded children into our society.
The total population of the states of
Jammu and Kashmir, Himachal Pradesh,
Uttar Pradesh, Madhya Pradesh, Bihar,
West Bengal, and the eight North Eastern
States is 378 million (1991 census). All
these states are in the severely iodine defi
cient zone. Assuming a conservating esti
mate of 30 per cent of the population in the
states of UP, MP and Bihar to have severe
iodine deficiency and the entire population
in the states of Jammu and Kashmir,
Himachal Pradesh, West Bengal and North
Eastern states to have severe iodine defi
ciency then together approximately 200
million people live in severe iodine defi
cient areas. The crude birth rate is 30 per
thousand, which means 6 million children
are bom in the regions with severe iodine
deficiency in these states every year. Let us
assume the incidence of neonatal chemical
hypothyroidism (NCH) in these severely
iodine deficient regions as 7% (reported in
cidence of NCH in UP is 7% to 13%).
Therefore, 4,20,000 children with NCH are
bom in these states alone every year. These
children are being denied the opportunity
to obtain the optimum mental and physical
development and yet all this is totally ^pre
ventable. The picture is similar in many of
the developing countries in the world. All
that is required is to bridge the gap be
tween a policy based on scientific knowl
edge and its immediate application in
these severely iodine deficient areas.
390
References
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2. Tonglet R, Bourdoux P, Minga T and
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B.
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11. Buttfield IH, Hetzel BS. Endemic goitre
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12. Buttfield IH, Hetzel BS and Odell WD.
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13. Pharoah POD, Buttifield IH and Hetzel
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14. Pharoah POD, Buttifield IH and Hetzel
BS. Neurological damage to the foetus
resulting from severe iodine deficiency
during pregnancy. Lancet 1971; i : 308310.
15. Pharoah POD and Connolly KJ. A
controlled trial of iodinated oil for the
prevention of endemic cretinism. A
long term follow up. Int J Epidemiol
1987; 16 : 68-73.
16. Pharoah POD and Connolly KJ. Effects
of maternal iodine supplementation
during pregnancy. Arch Dis Child 1991;
66 : 145-147.
17. Stanbury JB. The effect of goitre
prophylaxis with iodized oil on the
prevention of endemic cretinism. In :
Fellinger K. and Hofer R. Eds. Further
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Akademie 1971; 61-77.
18. Fierro-Benitez R, Ramirez I and Suarez
J. Effect of iodine deficiency correction
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Quotient. In : Stanbury JB and Kroc RI
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Gland: Relations to Endemic Cretinism.
New York, Plenum Press, 1972; 239-247.
19. Fierro-Benitez R, Ramirez I, Estrella E
and Stanbury JB. The role of iodine in
intellectual development in an area of
endemic goitre. In : Dunn JT and
Mederios-Neto GA eds. Endemic Goitre
and Cretinism: Continuing Threats to
World
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20. Fierro-Benitez R, Cesar R, Stanbury JB.
Long term effects of correction of iodine
deficiency on psychomotor and
intellectual development. In : Dunn JT,
Pretell EA, Daza CH, Viteri FE eds.
Towards the Eradication of Endemic Goitre
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21. Fierro-Benitez R, Cesar R, Stanbury JB,
Rodrigouez P, Garces F, Fierro-Renoz F.
and Esterlla E. Effects on school
children of prophylaxis of mothers with
iodized oil in an area of iodine
deficiency. / Endocrinol Inv 1988; 11 :
327-335.
22. Pretell EA. The optimal programme for
prophylaxis of endemic goitre with
iodized oil. Adv Exp Med Biol 1972; 30 :
267-288.
23. Pretell EA, Moncloa F, Salinas R et al.
Prophylaxis and treatment of endemic
goitre in Peru with iodized oil. J Clin
Endocrinol Metab 1969; 29 : 1586-1591.
24. Thilly CH, Lagasse R, Bourdoux P and
Ermans AM. High dose iodine
prophylaxis in serve endemic goitre. A
balance of risks. J Mol Med 1980; 4 : 191197.
25. Thilly CH, Delange F, Ramioul L et al.
Strategy of goitre and cretinism control
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6:43.
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Thilly CH, Delange F, Goldstein GJ and
Ermans
AM.
Endemic
Goitre
prevention
by
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A
reassessment. J Clin Endocrinol Metab
1973; 36: 1196-1204.
27. Watanabe T, Moran D, El Tamer E. et al.
Iodized oil in the prophylaxis of
endemic goitre in Argetina. In : Dunn JT
and Mediros-Neto GA eds. Endemic
Goitre and Cretinism: Continuing Threats
to World Health. Washington, Pan
American Health Organization Sci Pub
no. 292, 1974; 231.
28. Maberly GF, Corcoran JM and Eastman
CJ. The effect of iodized oil on Goitre
size, Thyroid function and the
development
of
Jod-Basedow
phenomenon. Clin Endocrinol 1982; 17 :
253-259.
29. Hetzel BS, Thilly CH, Fiero-Benitez R et
al. Iodized Oil in the Prevention of
Endemic Goitre and Cretinism. In :
Stanbury JB and Hetzel BS eds. Endemic
Goitre and Endemic Cretinism. Wiley
Eastern Ltd., New Delhi, 1985; pp. 513532.
30. Matovinovic J. Complications of Goitre
Prophylaxis. In : Stanbury JB and Hetzel
BS eds. Endemic Goitre and Endemic
Cretinism. Wiley Eastern Ltd., New
Delhi, 1985; 533-549.
31. Eltom M> Karlson FA, Kamal AM et al.
The effectiveness of oral iodized oil in
the treatment and prophylaxis of
endemic goitre. / Clin Endocrinol Metab
1985; 61 :1112-1117.
32. Abdel Wahab M., Eltom M., Omer MIA
et al. Prophylaxis and treatment of
endemic goitre in western Sudan with
intramuscular iodized oil. Ann Trop
Paediatr 1984; 4 : 159-163.
33. Philips DW, Lusty TD, Clive Osmond
and Church D. Iodine supplementation:
Comparison of oral or intramuscular
iodized oil with oral potassium iodide.
A controlled . trial in Zaire. Int J
Epidemiol 1988; 17 : 142-147.
34. Philips DIW and Clive Osmond. Iodine
supplementation
with
oral
or
intramuscular iodized oil. Two year
follow-up of a comparative trial. Int ]
Epidemiol 1989; 18 : 907-910.
Tonglet R, Bourdoux P, Mingo T and
Ermans AM. Efficacy of low oral doses
of iodized oil in the control of iodine
deficiency in Zaire. New Engl J Med
1992; 326 : 236-241.
Wachter W, Mvungi M, Konig A et al.
Prevalence
of
goitre
and
hypothyroidism in Southern Tanzania:
effect of iodized oil on thyroid hormone
deficiency. I Epidemiol Comm Health
1986; 40 : 86-91.
Kochupillai N and Godbole MM.
Iodized oil injections in Goitre
Prophylaxis. Possible impact on the
newborn.
Bull
NFl
(Nutrition
Foundation of India) 1986; 7 : 4.
Fierro-Benitez R, Ramirez I, Estrella E et
al. Iodized oil in the prevention of
endemic goitre and associated defects in
the Andean Region of Ecuador. In :
Stanbury JB ed. Endemic Goitre. Pan
American Health Organization Sci Pub
193, Washington 1969.
Pretell EA, Moncloa F, Salina R et al.
Endemic goitre in rural Peru: Effect of
iodized oil on prevalence and size of
goitre and
on
thyroid
iodine
metabolism in known endemic goitrous
population. In : Stanbury JB ed. Endemic
Goitre.
Pan
American
Health
Organization Sci Pub nd. 193,
Washington, 1969; 419-437.
Hetzel BS. The Story of Iodine Deficiency.
Oxford University Press, New Delhi,
1989.
Kochupillai N. Prevention and Control
of Goitre: Demerits of iodized oil
injections. Bull NFI1991; 12.
Wolff J. Transport of iodide and other
anions in the thyroid gland. Physiol Rev
1964; 44 : 45.
Cao Xue-Yi, Jiang Xin-Min, Dou ZhiHong et al. Timing of vulnerability of
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Sikkim, India. An analysis. Thesis
submitted to the School of Graduate
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X>t-S <1-3
WHO/HUT/94.4
Distr.: Gerwd
Original: English
A statement by the World Health Organization
World Health Organization
Geneva
August 1994
The World Health Organization
gratefully acknowledges the financial support
of the United Nations Children's Fund,
which has enabled it to reproduce this document.
© World Health Organization, 1994
This document is not o formol publication of the World Health Organization (WHO),
and oil rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted,
reproduced ond translated, in port or in whole, but not for sole nor
for use in conjunction with commercial purposes.
The views expressed in documents by named authors ore solely the responsibility of those authors.
IODINE AND HEALTH
eliminating iodine deficiency disorders safely through salt iodization
p
A deficiency of iodine, which is among the body’s essential trace ele
ments, is both easy and inexpensive to prevent. Iodine deficiency nevertheless continues to be a significant public health problem in many
countries. Iodine deficiency not only causes goitre; it may also result in
irreversible brain damage in the fetus and infant, and retarded psycho
motor development in the child. Iodine deficiency is the most common
cause ofpreventable mental retardation. It also affects reproductive func
tions and impedes children’s learning ability. The cumulative consequences
in iodine-deficient populations spell diminished performance for the en
tire economy of affected nations.
Iodine deficiency disorders (IDD) are currently a significant public health
problem in 118 countries (1). An estimated 1571 million people world
wide live in iodinc-deficent environments and are thus at risk of IDD;
20 million of these are believed to be significantly mentally handicapped
as a result. A large proportion of the severely deficient are women in
their reproductive years whose babies are at high risk of irreversible men
tal retardation unless they receive adequate amounts of iodine.
"
In the last 50 years, many countries in the Americas, Asia, Europe and
Oceania have successfully eliminated IDD, or made substantial progress
in their control, largely as a result of salt iodization with potassium iodide or potassium iodate and through dietary diversification. For ex
ample, in Switzerland, where salt iodization began in 1922, cretinism
has been eliminated and goitre has disappeared, while there has been
negligible evidence of any adverse effects from iodine intake.
Universal salt iodization3 has been endorsed in numerous international
forums'1 by heads of state, senior government officials, and representa
tives of international intergovernmental and nongovernmental organi
zations. Nevertheless, WHO continues to receive queries from national
« Universol solt iodization is defined os fortification of oil soil for humon ond onimol consumption.
k The most important of these ore the World Health Assembly, in resolutions WHA39.31 (1986) ond WHA43.2 (1990), the World Summit
for Children (New York, 1990), the Policy Conference on Ending Hidden Hunger (Montreal, 1991), ond the International Conference on
Nutrition (Rome, 1992)
2
IODINE AND HEALTH: eliminating iodine deficiency disorders solely through salt iodization
health authorities and others seeking reassurance about the safety of pro
viding iodized salt to non-deficient populations. As with all preventive
public health measures, the decision to ensure universal salt iodization
will be made by weighing the potential risk of excess intake for the few
(see pages 3-5) against the well-documented risk of mental and physi
ological impairment for the many if a deficiency is uncorrected.
In response to concerns expressed, and to facilitate decision-making it
countries, this statement summarizes the cumulative scientific and epi '
demiological evidence in this regard.
Physiological need for iodine
Based on studies of balance and excretion over a 24-hour period, a safe
daily intake of iodine has been estimated to be between a minimum of
50 pg and a maximum of at least 1000 pg (2, 3). A generally accepted
desirable adult intake is 100-300 pg/day. At all intake levels, a propor
tionate amount of iodine is excreted in the urine, which is the biochemi
cal basis for assessing iodine statug(4).
Usual food sources of iodine
Sea fish, other sea food, and seaweed are rich sources of iodine suitable
for human consumption. Iodine is also found in vegetables grown in
soils containing adequate amounts of this trace element, and in milk
products, eggs, poultry and meat from animals whose diet contained'
sufficient iodine.
Usual salt intakes
Average daily salt intakes vary from country to country. Usually, con
sumption levels are within the 5-15 g/day range for children and adults.
No increase in salt consumption is called for. Rather, the recommended
level of salt iodization should be adjusted to provide approximately 150
pg of iodine/day actually consumed, taking into account usual climatic
factors like heat and humidity, which can affect retention of this element.
The recommended quantities of iodate to be added to salt under differ
ent conditions are provided in Table 1(5). Although potassium iodide
was first used in salt iodization, the use of iodate is now recommended
3
IODINE AND HEALTH: eliminating iodine deficiency disorders safely through soft iodization
since it is more stable than iodide under varying climatic conditions.
Because iodate, on ingestion, is very rapidly reduced to iodide, its use in
iodinated salt is equivalent to iodide.
Table 1: KCIDD-UUKEf-WHO recommended levels of iodine in salt
Samples of desirable overage levels ot vorioos points in the solt distribution chain, depending on climate, salt
(intake, ond conditions affecting packaging and distribution
Ports of iodine per million ports of solt, i.e. micrograms per gram, milligrams per kilogram or grams per tonne
Climate ond
Requirement of
Requirement al
Requirement al
Requirement ot
doily soil consump
factory ootside
factory inside
retail sole
household
tion (g/person)
ths country
the country
(shop/markel)
level
Packaging
Bulk
Retoil
Bulk
Refoil
Bulk
(sock)
pock
(sock)
pock
(sock)
(<2 kg)
(<2kg)
Retoil
pock
(< 2 kg)
Warm moist
5g
100
80
90
70
80
60
50
10g
50
40
45
35
40
30
25
5g
90
70
80
60
70
50
45
10g
45
35
40
30
35
25
22.5
5g
80
60
70
50
60
45
40
10g
40
30
35
25
30
22.5
20
Worm dry or
cool moist
9 TTj
Cool dry
Source: Adopted from World Summit hr Children - mid-decode god: iodine deficiency disorders. Genew, 1994.
UNICEF-WHO Joint Committee on Health Policy, document JCHPSS/94/2.7 ond reference 5.
N.8.168.6 mg of KIO3 contains 100 mg of iodine.
N.B. These are indicative initial levels, which should be adjusted in the light of urinary iodine measurement.
Adverse effects associated with high nutritional intakes of iodine
Since iodine, when ingested in large amounts, is easily excreted through
the kidneys into the urine, iodine intakes even at very high levels (milli
gram amounts) can be consumed safely. However, the following adverse
affects, though rare, have been reported.
4
IODINE AND HEALTH: eliminating iodine deficiency disorders safely through salt iodization
Allergic reactions to iodine in food. Skin rashes and acne have occasion
ally been attributed to iodized salt. Such reports are extremely rare, how
ever, and thus these conditions are unlikely to occur following salt
iodization. For example, among 20 000 children in the USA suffering
from allergy during the period 1935-1974, not a single case was re
ported of allergic hypersensitivity to iodine in food. Following publica
tion in Annals ofAllergy of a request for notification of allergy to iodine.
not a single report was recorded between 1974 and 1980 (3).
High intakes of dietary iodine and thyroid diseases. Through adaptive
mechanisms, normal people exposed to excess iodine remain euthyroid
and free of goitre. In certain susceptible individuals, iodide goitre and
Hashimoto thyroiditis with hypothyroidism have been observed after
iodine intakes of 500-3000 pg/day. The prevalence of susceptible indi
viduals in different countries is not fully known. It has been suggested
that high nutritional intake of iodine substantiated by urinary iodine of
1000-10 000 pg/litre—as observed in one country in up to 2% of the
population—could have an adverse effect in susceptible individuals and
in patients with pre-existing abnormalities of the thyroid gland (3). In
this small proportion of the population, chronic excess intake might con
tribute to the development of Hashimoto thyroiditis, iodide and colloid
goitre, and thyroid carcinoma. However, the incidence of follicular thy
roid cancer, a more severe form of cancer, is lower in iodine-sufficient
than in iodine-deficient areas. There is little indication that iodine in the
amounts noted influences the development of any of these thyroid diseases.
n
In Japan, where dietary iodine intakes are high, it has been shown that:
■ normal people who are not iodine-deficient can maintain normal thy
roid function states even at intakes of several milligrams of dietary
iodine/day;
■ the incidence of non-toxic diffuse goitre and toxic nodular goitre is
markedly decreased by high dietary iodine intake;
■ the incidence of Graves disease and Hashimoto disease does not ap
pear to be affected by high intakes of dietary iodine.
However, high intakes of dietary iodine may induce hypothyroidism in
auto-immune thyroid diseases and may inhibit the effects of thionamide
drugs (6).
IODINE AND HEALTH: eliminating iodine deficiency disorders safely through salt iodization
f
w
5
There are well-documented reports of iodine-induced hyperthyroidism
(Jod-Basedow phenomenon) where iodine, sometimes in norma! quan
tities, was introduced among iodine-deficient populations. Administra
tion of ordinary amounts of iodine has also been reported to induce
hyperthyroidism in people with nodular thyroids, and in other individu
als who have no apparent underlying thyroid disease. However, these are
transient phenomena, which cease after correction of iodine deficiency;
they do not occur in populations with sufficient (i.e. normal) iodine in
take.
Current estimates of daily iodine intakes in Canada and the USA are
substantially above physiological need—in the range of 460 pg/day
among 9-16-year-old children, to greater than 1 mg among as many as
10-20% of adults (7). With a level of iodization that provides these popu
lations approximately 260 pg/day of iodine from salt, it is thus apparent
that much of the intake comes from non-salt sources (see below). A
survey conducted in 1968-1970 in ten states (USA) showed that where
total goitre prevalence was greater than 3.5%, the percentage of indi
viduals with high iodine-excretion values, i.e. more than 800 pg/litre,
was 16% compared with 6% in states with lower total goitre prevalence
(8).
Other sources of iodine
of,
'
In industrialized countries there are many adventitious sources of iodine
which increase daily intake levels far above the physiological amount pro
vided through iodized salt, for example (3):
■ poultry and eggs from animals that consume fish flour as part of their
feed and iodoform in water that is used as a disinfectant;
■ cow’s milk and dairy products from animals fed seaweed, producing
an iodine content of milk as high as 694 pg/litre, or that come into
contact with iodophors used to clean milking apparatus or as teat
dips and udder washes;
■ bread and baked goods through the iodates used as oxidants in dough
conditioners and cleaning agents for bakery equipment (reports of
the iodine content of bread in the USA range from 0 to 268 pg/
slice);
6
IODINE AND HEALTH: eliminating iodine deficiency disorders safely through salt iodization
□ the iodine-containing colouring agents added to some drugs (includ
ing many multivitamins, minerals, and antacids as a coating or
colouring agent), beverages, foods (including some brands of dry
cereal that contain as much as 850 Jig of iodine per 20g of product)
and cosmetics.
Iodine availability
The iodine content of food actually consumed is not necessarily equiva
lent to that of raw food since some iodine is lost during cooking. For
example, losses of about 20% occur in the iodine content offish by fry
ing or grilling and as much as 58% by boiling. Iodine consumed in food
is generally well absorbed, with the possible exception of people suffer
ing from protein-energy malnutrition, which is of particular concern in
high-prevalence, endemic-goitre areas of developing countries.
The uptake of radioactive iodine by an individual thyroid is dependent
on the amount of stable, i.e. non-radioactive, iodine in the diet. This is
the basis for using radioactive iodine to evaluate thyroid function. Stud
ies from Chernobyl following the nuclear reactor accident in 1986 indi
cate high thyroid cancer rates, especially among young children. It is
postulated that the thyroids of children in this iodine-deficient area ex
perienced an unusual uptake of radioactive iodine released into the at
mosphere following the accident. It has been estimated that, in general,
iodine prophylaxis, e.g. use of iodized salt, should reduce by twofold ro
threefold the risk of thyroid irradiation resulting from a nuclear accidi
(9).
Conclusion
Issues relating to the safety of universal salt iodization have been care
fully examined by WHO and by joint FAO/WHO, ICCIDD/UNICEF/
WHO and WHO/FAO/IAEA expert groups in the process of prepar
ing recommendations (1, 2, 5, 6). All concerned agree that universal salt
iodization is the principal public health measure for eliminating IDD.
Daily iodine intakes of up to 1 mg, i.e. 1000 pg, appear to be entirely
safe. Iodization of salt at a level that assures an intake of 150-300 pg/
day thus keeps intakes well within a safe daily range for all populations,
IODINE AND HEALTH: eliminating iodine deficiency disorders safely through salt iodization
7
irrespective of their iodine status. Dail)' consumption of 10 g of salt
containing 50 parts per million of iodine would add a maximum of only
500 pg of iodine. Thus the likelihood of exceeding an iodine intake of
1 mg/day from iodized salt is quite small.
In susceptible individuals—a minority of adults, usually over 45 years of
age, who may or may not have nodular goitres—transient side-effects
have been reported at usual intakes exceeding 500-3000 pg/day. The
benefits to be derived from universal salt iodization by the more than
1500 million people estimated to be at risk or deficient, and the absence
of significant adverse effects among others in the same areas who are not
iodine-deficient, far outweigh any risk of excess intake for a small minority.
References
1.
ICCIDD/UNICEF/WHO. Mol prevalence of iodine deficiency disorders. MDIS Working paper fl. Micronutrient Deficiency
Information System, Geneva, World Health Organization, 1993 (unpublished document ovoiloble on request from the
Nutrition unit, WHO, Geneva).
2.
Evaluation of certain food additives and contaminants. Thirty-seventh report of o Joint FAO/WHO Expert Committee on
Food Additives. Geneva, World Health Organization, 1991:49 (WHO lechnical Report Series No. 806).
3( Jbnbury IB, Hetzel BS. Endemic goitre and endemic cretinism. Iodine nutrition in health and disease. New York, John
Wiley 8, Sons, Inc., 1980.
4.
Dunn JI, Crutchfield HE, Gutekunst R, Dunn A. Methods for measuring iodine in urine. ICCIDD/UNICEF/WHO, 1993
(unpublished document available on request from the Nutrition Unit, WHO, Geneva).
5.
ICCIDD/UNICEF/WHO. Indicators for assessing iodine deficiency disorders and their control programmes. Report of a
consultation (review version). Geneva, World Health Organization, 1993 (unpublished document WHO/NUT/93.1;
available on request from the Nutrition Unit, WHO, Geneva).
6.
7.
Trace elements in human nutrition and health. Geneva, World Health Organization (in preparation).
Borsono CP. Environmental factors altering thyroid function and their assessment. Environmental Health Perspectives,
1981, 38:71-82.
8.
Trowbridge FL Hand DA, Nichaman Ml. Findings relating to goitre and iodine in the ten-state nutrition survey. American
Journal of Clinical Nutrition, 1975,28:712-716.
9.
Rubery El, Sarnies E. eds. Iodine prophylaxis following nuclear Occidents. Proceedings of a joint WHO/CEE workshop,
July, 1988. New York, Pergomon Press, 1990.
Iodine deficiency disorders are both easy
. and inexpensive to prevent, yet.they continue to
be a significant public health problem in 118 countries.
Despite the endorsement of universal salt iodization
in numerous international forums as an^effective means
of preventing these disorders, queries are still made
about the safety of providing iodized salt to
non-deficient populations. In response to
concerns expressed, and to facilitate
decision-making by responsible authorities,
this statement summarizes the cumulative
evidence in this regard.
-£>i-S q-if
IODINE DEFICIENCY DISORDERS
AND CONTROL MEASURES
IN INDIA - CURRENT STATUS
This Public Information Guide is brought to you with the assistance
from UNICEF-ROSCA, New Delhi and International Council For
Control of Iodine Deficiency Disorders (ICCIDD),
South-east Asia Region, New Delhi.
IODINE DEFICIENCY DISORDERS
AND CONTROL MEASURES
IN INDIA - CURRENT STATUS
BY
S.
C.
PANDAV. *
M.D.
N. KOCHUPILIAI. M.D.
""Centre for Community Medicine
&
Department of Endocrinology & Metabolism
All India Institute of Medical Sciences
New Delehi —110 029
abstract
Goitre has been an age old health problem in the Indian sub-continent. According to the
latest available estimate, about 120 million people live in known iodine deficient areas of India
of which one-third are goitrous. Environmental iodine deficiency has been established as the
dominant cause of endemic goitre in the sub-Himalayan region as well as in several other areas
in the interior of the peninsula. A carefully designed prospective study conducted for a period
of over 18 years in 100,000 persons of Kangra Valley of Himachal Pradesh has clearly de
monstrated the efficacy of iodine fortified common salt in the control of endemic goitre. Sub
sequent to this study, a National Goitre Control Programme was launched by the Government
of India towards the end of Second Five Year Plan, in 1962. In this article the detailed informa
tion on goitre prevalence and current status of control measures in different parts of the country
is presented.
IODINE DEFICIENCY DISORDERS AND CONTROL MEASURES
IN INDIA - CURRENT STATUS
INTRODUCTION
Goitre, an age old health problem, has been a subject of public health and scientific interest
for over eight decades in the Indian sub-continent. Though its cause was discovered and cure
prescribed over two decades back, it still continues to afflict over 40 million people in India and
its control still eludes the National Goitre Control Programme. In this communication we
briefly review the goitre scene in India and update the current status of control measures in dif
ferent parts of the country.
GOITRE - AN AGE OLD HEALTH PROBLEM
Endemic goitre has been an age old health problem in the southern slopes of the Himalaya.
Reference to goitre is found in vedic literature ‘ATHARVA VEDA’ dated to a period around
2000 B.C. ‘Galganda’ was the name given to goitre by the early Hindu physicians Susruta and
Charaka, about 500 B.C.1 In ‘Nidana Sthana’ the Xlth Chapter of the ‘Sushruta Samhita’ the
definition of ‘Galaganda’ (Goitre) reads as:
“The deranged and aggravated Yayu in combination with the deranged and augmented
Kapham and fat of the locality affects the two tendons of the neck (Manyas) and gradually
gives rise to a swelling about that part of the neck characterised by the specific symptoms of
the deranged Doshas (Vayu or Kapham) and principles involved in the case. The swelling
is called ‘Galganda"’ (Goitre)2
The term ‘Galganda’ is used even today in India to denote goitre.
PREVALENCE OF ENDEMIC GOITRE AND CRETINISM
Though goitre is recognised to be a health problem in the Indian sub-continent for over 2000
years, it still continues to be a major public health problem not only in India but most of the
countries of south and south-east Asia. In point of fact, endemic goitre, along with anemia,
kwashiorkor, marasmus and xerophthalmia constitute the five principal deficiency diseases in
the world today.3. In Asia alone, an estimated 436 million people lives in areas with environ
mental iodine deficiency of which 176 million are goitrous. The countries most affected by en
demic goitre and endemic cretinism are India, Pakistan, Nepal, Bhutan, Bangladesh, Burma,
Indonesia, China, Phillipines and Vietnam.4
Endemic goitre and endemic cretinism are widely prevalent in the Indian sub-continent. The
world’s most intense endemic belt runs along the slopes, foothills and adjacent plains to the
south of the Himalaya, extending over 2,400 kms from Kashmir in the west to the Naga hills in
the east. The Himalayan endemic belt involves the northern states of Jammu & Kashmir,
Himachal Pradesh, Punjab, Haryana, Uttar Pradesh, Bihar, West Bengal, Sikkim, Assam,
Mizoram, Meghalaya, Tripura, Manipur, Nagaland and Arunachal Pradesh.5
In addition more and more pockets of goitre are being reported
Tndud^ the
rest of India, now referred to as ‘extra-Himalayan foci of endem g
•
shadhol Sar
hilly states of Central India particularly along the Chotta Nagpur Plateau,!Sidhi, Shadhol Sar
guja and Raigarh districts in the sub-Vindhya belt of Madhya Pradesh the travail ranges m
Rajasthan, along the Narmada valley in Gujarat, the city of Bom ay,
ura S'
pracjesh
distrticts of Maharashtra, some tribal areas of the Visakhapatnam is nc
where the
and the tea estates of Kerala. A recent addition to this is the Union Tern ory
states and
capital of India is located6. Thus, endemic goitre has been reported from 16 of the 22 States and
4 of the 9 Union Territories of India (Figure — 1). The range of endemic goitre preva ence varies
from 10.2 percent in Ranchi district of Bihar to 69 percent in U.T. of Mizoram with an average
goitre prevalence rate of 32 percent.
According to the latest available estimate about 120 million people in India live in know
iodine deficiency regions. Of these, the actual number of persons afflicted with goitre is esti
mated to be about 40 million.5.
ETIOLOGY OF ENDEMIC GOITRE
Primacy of environmental iodine deficiency in the causation of Himalayan endemic goitre
was first established by a series of investigative efforts, spanning over a decade by Ramalingaswami et al 7,8,9,I0,1! . The level of iodine in the drinking water is extremely low in the endemic
zone, no value being higher than 3 ugm/L and most values considerably below this figure.
Marked elevation of 24 hours thyroidal1311 uptake coupled with low urinary iodide excretion of
less than 50 micrograms per gram of creatinine ceearly demonstrate iodine deficiency state in
the goitrous individuals. The plasma inorganic iodine (PH) estimated by the isotope dilution
technique was low while PB131 I at 48 hours was markedly elevated, thus demonstrating a rapid
turnover rate of intrathyroidal iodine pool of these goitrous individuals from the endemic
zones.
The glands at histology showed marked acinar proliferation with tall columnar epithelium
and scanty colloid, thus substantiating histologically the rapid turnover rate observed indirectly
as the elevated PB 131I. The small intrathyroidal pool is turned over rapidly in an effort to com
pensate for environmental iodine deficiency, thus maintaining euthyroid state despite the se
vere environmental iodine deficiency. A majority of the goitrous patients studied showed suppressibility of raised I3II uptake by extraneous triiodothyronine (T3), thus demonstrating an in
tact pituitary-thyroid interrelationship. Since most of these goitre, in response to thyroidstimulating hormone (TSH) did not show any further enhancement of 13II uptake, maximum
endogenous stimulation by TSH is surmised. Studies designed to demonstrate iodine organifi
cation defects of partial or complete degrees did not yield any positive results.
IODINE PROPHYLAXIS: KANGRA VALLEY EXPERIMENT
The efficacy of iodisation of common salt as a prophylactic measure was established early
in the century by experiences in the United States of America and Switzerland.12,13 In order to
substantiate the role of iodine deficiency as the causative factor of endemic goitre in the
Himalayan belt and study the effectiveness of iodine prophylaxis, a prospective study was or
ganised in 1954 in a population of approximately 100,000 persons in the Kangra valley of
Himachal Pradesh. 8- 11 The study area was divided into three zones, A, B and C After a
baseline survey in 1956, the salt distributed to zones A and C was fortified with potassium
iodide and potassium iodate respectively while zone B was supplied with unfortified salt The
salt fortification was such as to supply approximately 200 micrograms of iodine per capita per
day. After 6 years of iodisation, i.e., in 1962, a striking decrease in the prevalence of goitre was
observable in zones A (from 38 per cent to 19 per cent) and C (from 38 per cent to 15 per cent)
when compared to uniodised zone B (from 38 per cent to 40 per cent). Six years later a systema
tic survey of goitre prevalence showed further reduction in the prevalence rates for zone A and
zone C (8-5 percent and 9.1 percent respectively). In 1972, spot checks on goitre prevaFe£ce"n
the iodised areas by an independent group of physicians showed negligible prevalence of goitre
among school children and *1 uptake and urinary excretion of iodide had become normal.
national goitre control programme
Subsequent to the classical demonstration of the efficacy of the iodated salt prophylaxis in
e control of endemic goitre in the Kangra valley of Himachal Pradesh by Ramalingaswami
and associates, a National Goitre Control Programme (N.G.C.P.) was launched by the Gov
ernment of India towards the end of the Second Five Year Plan, in 1962, to identify the goitre
endemic regions of the country and supplement intake of iodine to the entire population of the
endemic regions in order to prevent endemic goitre and its grave consequences.5.
N.G.C.P. has three main components:
(i)
Initial survey to identify endemic areas.
(ii)
Production and supply of iodised salt to the endemic regions.
(iii)
Resurvey in goitre endemic regions after 5 years continuous supply of iodised salt to
assess the impact of the control programme.
N.G.C.P. is a purely central plan scheme and entire expenditure incurred in the produc
tion of iodised salt is met by the Ministry of Health and Family Welfare (Department of Public
Health) which is released as grant-in-aid to the three units currently engaged in manufacturing
iodised salt.
The administrative structure of NGCP, is given in Figure 2.14 As is evident NGCP was con
ceived to be executed by a multiplicity of agencies comprising of Health, Industry and Railway
Ministries of the Central (Federal) Governemnt, Health & Civil Supplies Ministries of the
State Governement with State Salt Nominees (private traders) responsible for procurement,
transportation and supply of iodated salt to the population living in endemic goitrous'regions.
The detailed information on goitre prevalence and control measures in different parts of
the country is given in Annexure I.
1.
REFERENCES
Langer P. Endemic Goitre, Monograph Series No. 44 World Health Organisation.
2.
Geneva (1960) 10.
Kaviraj Kunjalal Bishagratna The Sushruta Samhita Vol. II English Translation Published
by the author No. 10 Kashi Ghose’s Lane, Calcutta. (1911)77.
3. The five principal deficiency diseases in the World today. World Health. May (1977) 16.
4.
Carriere Rolf C. Personal Cummunication. ROSCA, UNICEF. New Delhi, (1984)
5.
National Worshop on Goitre Control and Nutrition, Goitre Control Cell, Directorate
General of Health Services, New Delhi, December (1985).
6.
Pandav, C.S. Kochupillai, N. Endemic Goitre in India, Prevalence, etiology, attendant
disabilities and control measures. Indian J. Pediat 49 (1982) 259.
7.
Ramalingaswami, V., Subramanyam, T. A. V., Deo, M.G. The etiology of Himalayan en
demic goitre. Lancet (1961) 791.
8.
Sooch. S.S., Deo, M.G. Karmarkar, M.G., Kochupillai, N., Ramachandran, K.,
Ramalingaswami, V. Prevention of endemic goitre with iodized salt. Bull WHO 49 (1973)
307.
9.
Ramlingaswami, V. Endemic goitre in South East Asia — New clothes on an old body. Ann
Int Med 78 (1973) 277.
10.
Karmarkar, M.G., Deo, M.G., Kochupillai, N., Ramalingaswami, V. Pathophysiology of
Himalayan endemic goitre. Am J. Clin Nutr 27 (1974) 96.
11.
Sooch, S., Ramalingaswami, V. Preliminary report of an experiment in the Kangra valley
for the prevention of Himalayan endemic goitre with iodinated salt. Bull WHO 32 (1965)
22.
12.
Stanbury, J.B., Ermans, A.M., Hetzel, B.S., Pretell, E.H. Querido, A. Endemic goitre
and cretinism-Public health significance and prevention. WHO Chronicle 28 (1974) 220.
13.
Lowenstein, F.W. Iodized salt in the prevention of endemic goitre. A world wide survey of
present programs. Am J Pub Hlth 57 (1967) 1815.
14.
Kochupillai, N., Pandav, C.S. How not to control Goitre: Some lessons that could lead to
National Policy in India. ‘Future’ Fourth Quarter 5 (1982) 23.
Indian J Paediat 51: 53-54, 1984
RECOMMENDED LEVELS OF SALT IODATION IN INDIA
C. S. Pandav
*
M.D., M. G. Karmarkar Ph.D. and N. Kochupillai M.E>.
A programme of goitre prophylaxis based on iodated salt should aim at providing between
150 and 250 microgram of supplemental iodine per head per day.*
1 In India, the average daily
consumption of salt per head is 10 gm.2 Therefore to achieve the above level of supplemental
iodine at consumption, the salt should have 15 to 25 parts per million (ppm) concentration of
iodine.
It has been reported from a tropical country that iodated salt stored in stitched plastic bags
at room temperature for three months retained upto 75 percent of its iodine. After nine
month’s storage, the iodine dropped to 50 percent . Experience with salt packed in stitched jute
bags has been less satisfactory. In extremely adverse conditions of packaging, storage and
handling, the amount of iodine remaining after 9 months may be as little as 10 percent.3 Assum
ing that there is 50 percent loss of iodine between production and consumption level, the salt
should have 30 to 50 ppm concentration of iodine at the source of production.
In India, at all the three units of production (Sambhar Lake, Howrah and Khargoda) the
salt is fortified with Potassium Iodate (KIO3)4 Quantitatively 1.685 mg of K1O3 contain 1 mg of
iodine. Therefore, the concentration of iodate in salt, in order to have 30 to 50 ppm of iodine,
should be standardized at 51 to 84 ppm, at the production level.
There have been reports in the literature about complications of goitre prophylaxis. These
have arisen, in the words of David Marine as result of ‘abuse of iodine’. Amongst these rare
complications, the common ones which have been mentioned are allergic reactions to iodide in
food, iodine induced hyperthyroidism, iodism and iodine goitre. Iodized salt has often been
blamed for skin rashes and acne. Today such reports are extremely rare. From 1935 to 1974,
among 20,000 children in United States suffering from allergy, not a single case of allergic
hypersensitivity to iodine in the food was reported.5 A request for notification of allergy to
iodine in the Annual Allergy in 1974 has not yet yielded a single report so far.5 These are re
ported to occur exclusively in situations where iodine is administered as a therapeutic agent in
pharmacological doses (gm) and therefore irrelevant in situations like iodine prophylaxis for
goitre, where iodine consumed is in microgram quantity per head per day.
* From the Centre for Community Medicine and Department of Endocrinology and
Metabolism, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029
REFERENCES
1.
“Level of lodation of Salt” in Report of Seminar on Goitre Control. WHO, SEARO, New
Delhi, SEA/NUT/22:17, 1967.
2.
Gopalan C, Rama Sastri BV, Balasubramaniam SB, Nutritive value of Indian foods. Na
tional Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India P. 23,
1982.
3.
DeMaeyer EM, Lowenstein FW, Thilly CH. The control of endemic goitre. WHO,
Geneva, P.33,1979.
4.
Country Programme People, National Goitre Control Programme, Ministry of Health and
Family Welfare, Government of India, New Delhi, September 1980.
5.
Matovinovic J: Complications of Goitre Prophylaxis, in Endemic goitre and endemic cre
tinism, Stanbury JB, Hetzel BS, (ed) A Willey Medical Publication, New York, P. 533,
1980.
Reprinted from :
Indian Journal of
Pediatrics
Published Bimonthly at :
DEPARTMENT OF PEDIATRICS
ALL-INDIA INSTITUTE OF MEDICAL SCIENCES
NEW DELHI-110 029
This Public Information Guide is brought to you with the assistance
from UNICEF-ROSCA, New Delhi and International Council For
Control of Iodine Deficiency Disorders (ICCIDD),
South-east Asia Region, New Delhi.
ANNEXURE- 1
NATIONAL GOITRE CONTROL POGRAMME - CURRENT STATUS
Statement showing baseline survery year and goitre prevalence, year of commencement of
lodated salt supply, year of re-survey and goitre prevalence in endemic districts (D), Union
Territories (UT) and state (S).
[Arranged in alphabetical order]
State (S) Union
Territory (UT)
District (D)
Arunachal
Pradesh (UT)
Assam (S)
Districts (D)
1. Cachar
2. Darang
3. Dibrugarh
4. Goalpara
5. Kamrup
6. Lakhimpur
7. Nowgong
8. Sibasagar
9. United Mikir&
H.C. Hills
Base line
Survey Year
1960
Goitre
preva
lence %
Commencement of
lodated salt supply
(year)
Resurvey
(year)
Goitre
Preva
lence %
38.0
1965
1982
26.8
15.0
31.5
19.0
40.2
26.5
30.1
20.5
13.2
12.9
Not yet begun
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
1979
1979
—
—
—
—
—
—
—
•-s-- “
—
64.5
51.2
—
—
—
--- -
1959-70
Bihar (S)
Districts (D)
1. Champaran East
2. Champaran West
3. Darbhanga
4. Hazaribagh
5. Muzaffarpur
6. Palamau
7. Purnea
8. Ranchi
9. Saharsa
10. Santhal Paragana
11. Saran
1960
1960
1962
1964
1964
1964
1962
1964
1962
1964
1961
40.3
40.3
23.2
32.0
41.7
20.9
26.5
10.2
20.5
23.5
35.5
1964
1964
Not yet begun
Chandigarh (UT)
1969
11.2
1968
1977
45.9
Delhi (UT)
1975-78
29.0
1984
—
—
Gujarat (S)
Districts (D)
1. Bharuch
2. Valsad
1977
1983
31.7
36.6
1982
1984
Not done
—
—
Haryana '(S)
Districts (D)
1. Ambala
2. Gurgaon
1972
1976
26.0
6.5
1969
Not done
—
—
-- -
—
—
--- .
—
—
Himachal Pradesh (S)
Districts (D)
1. Bilaspur
2. Chamba
3. Hamirpur
4. Kangra
5. Kinnaur
6. Kullu
7. Mahasu
8. Mandi
9. Simla
10. Sirmor
1959
——
1956
1956
—
1956
1959
1959
1974
1959
25.7
—
41.2
41.2
—
41.2
39.9
20.7
41.6
1963
1963
1963
1957
1963
1964
1963
1963
1964
Madhya Pradesh (S)
Districts (D)
1. Raigarh
2. Sarguja
3. Shahdol
4. Sidhi
1980
1981
1976
1979
34.4
41.8
55.6
37.8
1984
1984
1984
1984
Maharashtra (S)
Districts (D)
1. Aurangabad
2. Jalna
3. Amravati
4. Wardha
5. Buldhana
Manipur (S)
1973
1983
1983
1983
1984
1970
35.0
35.0
46.2
54.9
49.5
32.0
1982
1982
—
—
—
1965
Not done
—
—
—
—
—
__
__
—
Meghalaya (S)
Districts (D)
1. Garo Hills
1966
23.0
Not Yet
begun
__
__
2. United Khasi &
Jaintia Hills
1966
7.0
—
—
Mizoram (UT)
1976
69.0
»
—
—
Nagaland (S)
Districts (D)
1. Khomia
2. Mokochung
3. Twen-song
1960
1960
1960
32.5
26.1
50.2
1965
1965
1965
Not done
»»
Punjab (S)
Districts (D)
1. Gurdaspur
2. Hoshiarpur
3. Ropar
1961
1961
1969
52.3
40.3
9.3
1964
1964
1964
1969
1969
1982
42.3
23.6
45.8
Sikkim (S)
1976
37.8
1984
—
—
Tripura (S)
1970
17.0
Not yet begun
—
Not done
—
—
1962 & 1968 32.1 &9.9
—
Not done
—
—
34.5
1981
—
Not done
—
—
—
—
—
Uttar Pradesh (S)
Districts (D)
1- Almora
2. B'adaun
3. Bareilly
4. Basti
5. Bahraich
6. Bijnore
7. Chamoli
8. Dehradun
9. Deoria
10. Garhwal
11. Gonda
12. Gorakhpur
13. Kheri
14. Nainital
15. Pilibhit
16. Pithoragarh
17. Rampur
18. Shahjahanpur
19. Tehri Garhwal
20. Uttar Kashi
1930
1956
1974
1930
1930
1960
1930
1965
1973
1930
1978
1930
1962
1964
1975
1930
1974
1974
1954
1930
40.0
55.0
64.0
37.0
37.0
23.2
40.0
39.7
65.9
40.0
65.9
37.0
20.0
30.0
41.3
40.0
35.8
44.7
35.0
40.0
West Bengal (S)
Districts (D)
1. Cooch-Bihar
2. Darjeeling
3. Jalpaiguri
4. Maida
5. WestDinajpur
1965
1963
1965
1965
1965
21.7
34.5
33.2
10.3
14.8
Source: National Goitre Control Programme,
Ministry of Health and Family Welfare
Government of India (1985).
1966
Not yet begun
1974
—
25.4
—
> •>
—
—
1969
—
1969
—
1974
—
—
—
—
—
1974
—
—
1974
1974
—
—
1966
Not yet begun
1966
Not yet begun
1966
Not yet begun
»>
1966
Not yet begun
1966
Not yet begun
1966
1966
1973
1967
1973
1973
1973
Not done
1975-76
Not done
16.9
—
16.9
—
25.4
—
—
—
—
—
25.4
—
—
25.4
25.4
—
35.6
—
—
—
(F
UNION
TECHNICAL GOITRE
REVIEW COMMITTEE
GOVERNMENT
MINISTRY OF HEALTH
I
____________ 1______________
_______________ FUNCTION__________________
1.
REVIEW
2.
3.
MONITOR
SUGGEST REMEDIAL MEASURES
j
I
MEMBERS
1.
CHAIRMAN- HEALTH SECRETARY
MEMBERS-
2.
ADDITIONAL SECRETARY, HEALTH
3.
D.G.H S
4.
ADGHS.
5.
DIRECTOR (PUBLIC HEALTH )
6.
ADVISOR
7.
DADG (GOITRE) FROM MIN. OF
HEALTH JEW GOVT OF INDIA
8.
JOINT SECRETARY, MIN. OF SOCIAL
WELFARE GOVT. OF INDIA
9.
I NUTRITION)
UNDER SECRETARY MIN OF INDUSTRIAL
DEVELOPMENT GOVT. OF INDIA
10.
DEPUTY DIRECTOR (TT)
RAILWAY BOARD
NEW DELHI
11.
SALT COMMISSIONER.
12.
CHAIRMAN-CUM-MANAGING DIRECT
HINDUSTAN SALT LTD JAIPUR
JAIPUR
13.
HEALTH SECRETARIES AND
14.
D.G.H S. FROM GOITRE AFFECTED
STATES
NEW DELHI
15.
D.GIC.MR
16.
MEDICAL EXPERTS FROM A I I M.S
17.
W. H.O
18.
UNICEF
SPECIAL INVITEES
ADMINISTRATIVE STRUCTURE CF NATIONAL GOITRE CONTROL PROGRAMME
MINISTRY OF INDUSTRY
MINISTRY GF RAILWAYS
ICCIDD INTERNATIONAL COUNCIL FOR CONTROL OF IODINE DEFICIENCY DISORDERS
SLETTER
VOLUME 12
NUMBER 2
MAY 1996
Progresses Towards BOD Elimmation
T
he government of Peru requested an external evalua
tion of achievements made under the National
Program for 1DD Eradication (PRONEDDI). The
consultation took place in late March 1996 with Dr. Eduardo A.
Pretell, ICCIDD Regional Coordinator for the Americas, Dr.
Gianfranco Fenzi, Professor of Endocrinology in Naples and
ICCIDD Senior Advisor, Dr. Mauro Rivadeneira, ICCIDD
Board member and representative for PSADD1 (the Andean
Regional Program) and UNICEF, Dr. Carlos Zamalloa,
Regional Consultant in Nutrition-for PAHO/WHO, and Dr.
Juan C. Arraya, of the Unit of Nutrition (UPAN) of Bolivia.
Before meeting with the government, Drs. Prcteli and Fenzi vis
ited seven parts of rhe country to obtain information on pro
duction and quality of iodized salt, goiter prevalence, urinary
iodine levels, and knowledge about IDD in the population. The
evaluation meeting was assisted by local representatives of the
Medical College of Peru, the College of Nutrition, the Peruvian
Endocrine Society, the National Center of Nutrition, the
National Institute of Statistics and Information, the Project of
Health and Basic Nutrition of rhe World Bank, the Embassy of
Canada, PAHO/WHO, UNICEF, and rhe Ministry of Health.
This article is based on the report submitted by Drs. Pretcll and
Fenzi.
COURTESY G-F. FENZI.
Children clutching their packages of iodized salt parade in support
ofIDD control in Chachapoyas.
Background
The sierra and jungle regions of Peru have long been known
as areas of severe iodine deficiency. Historical details have been
documented frequently in the IDD Newsletter, most recently in
1995 (11(1):6). For baseline status, rhe 1986 survey gave a
median goiter prevalence of 36% in rhe Sierra and Selva, and a
median urinary iodine of 7.1 pg/dl, with 37% of samples below
5 pg/dl. The population at risk was estimated at six million. Ar
that rime the production of iodized salt was inadequate.
Production by the state salt monopoly covered only 50% of the
population’s needs, and 40% of homes consumed salt without
iodine. Iodine deficiency was not widely appreciated as a prob
lem of public health.
In 1986 the Program established as its objectives the provi
sion of adequate iodine to all rhe population as quickly as pos-
Continued on page 18
IN THIS ISSUE
PERU PROGRESSES TOWARDS IDD ELIMINATION ■ REPORTS FROM THE REGIONS
IODIZATION OF IRRIGATION WATER SUCCESSFUL IN WESTERN CHINA ■ IODIZED SALT IN PESHAWAR. PAKISTAN ■
EFFECTS OF STORAGE AND COMMONLY USED SPICES ON STABILITY OF IODIZED SALT IN INDONESIA E
GOITER PREVALENCE AND USE OF IODIZED KITCHEN SALT IN TANZANIA
NIGERIA ADVANCES TOWARDS IDD ELIMINATION ■ IN BRIEF: CONFERENCE ON ELIMINATION OF IDD IN AFRICA.
US/JAPAN COMMON AGENDA INCLUDES IDD CONTROL. WORLD HEALTH ASSEMBLY 1996.
PAMM AND SISTER CITIES INTERNATIONAL ■ ABSTRACTS ■ RECENT PUBLICATIONS
IDD NEWSLETTER □ MAY 1996
COURTESY G-F FENZI.
A fiesta in the Sierra, supporting iodized salt, the salt ofilife.
The level of risk and the prevalence of IDD are now con
trolled in the greater part of the country and have been signifi
cantly reduced in the remainder, as demonstrated by the fol
lowing indicators:
Iodized salt - Peru has achieved the intermediate goal of uni
versal iodization of salt for human consumption. The estimated
volume of production of iodized salt in 1995, 132,000 metric
tons, covers 112% of the potential demand, double that avail
able in 1986. Now 60% of the production comes from the two
large major producers, EMS AL and QUIMPAC, and 40% from
57 medium-sized and small producers who have become
involved recently.
The quality of iodized salt has improved considerably. At the
plant level, the mean iodine content is 40.5 ppm, with 64% of
samples greater than 30 ppm (the legal requirements are 30-40
ppm). At the levels of shops and homes, the percentage of sam
ples adequately iodized (greater than 20 ppm) has increased
from 36% in 1992 to 75% in 1995, and the iodine content was
greater than 10 ppm in 92% of samples. Correspondingly, the
proportion of samples without iodine has been reduced from
32% to a current 3.2%.
Studies of salt consumption show an important change in the
attitude of the population. Now 81.1% of housewives state that
they use iodized salt, an increase of 20% over 1986, at which
time only 69% of the salt was adequate iodized (i.c., greater than
15 ppm). 1 he consumption was less in rural areas (64.4%) than
sible, and rhe eventual achievement of IDD elimination.
Between 1986 and 1995 the strategy changed as the program
evolved. Education has been a major emphasis throughout.
Iodized oil was extensively administered as a short-term solution
in the earlier phases but recently has been used less frequently.
In contrast, production and commercialization of iodized salt
took years to put into place, but has been increasingly relied on
in the last several years. Also, monitoring and surveillance have
become much more prominent in the Program’s organization.
Iodized oil was given initially to about two million people in
66 provinces of the Sierra, the population at greatest risk. In
recent years, iodized salt has become rhe mainstay for iodine
supplementation in those regions. For reasons of logistics and
economic limitations, the greatest support for the increase in
distribution of iodized salt has taken place primarily in the
northern sierra area, and more recently this step has been intro
duced in the south.
Current Status
At the meeting, Dr. Pretell and Dr. Fenzi, and the other
external experts reviewed information supplied by rhe Ministry
of Health, and discussed their own findings. They concluded
that despite economic, political, and social difficulties that the
country had between 1985 and 1995, PRONEDDI had made
significant advances towards the goal of IDD elimination.
18
IDD NEWSLETTER a MAY 1996
of regions and subregions, in addition to 156 focal points at the
primary level of health. This highly motivated and well educat
ed network has developed among health personnel who work in
the regions. The work of PRONEDDI is supported also by
other national government organizations such as the Ministries
of Education, Industry, and Agriculture, the National Program
of Food Assistance, the Peruvian universities, and local govern
ments.
2. Political and economic backing - The pledge by the country
in supporting the World’s Summit for Children and the
National Plan of Action for Children, 1992/1995 includes the
control of IDD as a high priority. This political decision has
been reinforced with economic support from the public trea
sury, which for the period 1992-1995 contributed 42% of the
total costs, and in addition, paid the salaries of those responsible
for the Program at different levels of management. The Program
also received economic and technical support from UNICEF
Peru, OPS/OMS, ICCIDD, and the European Union. In the
last three years, most of the external economic support has been
channeled through UNICEF.
3. Awareness among different sectors of the population Knowledge of rhe problem of IDD has spread extensively as a
multisectoral activity through mass communication, schools,
and community participation. The educational effort has
included creative and innovative action at the community level.
Drs. Prerell and Fenzi appreciated this important aspect during
their field work when they talked with children in the streets on
the problem of IDD, and evaluated the knowledge of salt plant
workers on the importance of iodine deficiency and the contri
bution of iodized salt to health. (The accompanying illustrations
show several aspects of community participation). Many educa
tional programs for health workers and students have included
regular training on IDD.
4. Commitment of the private salt industry and other institu
tions- Although legal instruments require iodization of salt, it is
evident that, in addition, strong motivation exists among all lev
els of salt producers, and this fact is reflected in the increased
output and better quality of their product in the last three years.
Moreover, the great majority of the small and medium produc
ers have complied with the regulations. The venture into the
production of iodized salt for animals has led to demonstration
farm projects for the benefit of the agricultural industry. The
participation of the private sector and of the universities has also
contributed to the technological development of local produc
tion of kits for quality control, machines for iodizing the salt,
and salt drying sheds.
5. Availability ofiodine for salt iodization - Currently, impor
tation and distribution of KIO3 is guaranteed through a rotat
ing fund regulated by the Program, and also through direct
importation of iodine by large and medium producers. It is
expected that in the future, potassium iodate will be obtained
directly by private industry.
6. Availability of appropriate laboratory facilities - The pro
gram has 14 laboratories distributed throughout the country for
determining iodine in salt. This network permits an efficient
and affordable system of surveillance and monitoring of iodized
salt that corresponds with the national decentralization into
existing 28 subregions of health. At the same time the program
has access to the supporting facilities of the Laboratory of
Endocrinology of the Universidad Peruana Cayetano Heredia
for determining urinary iodine and hormone levels at low cost.
This laboratory also supports programs of IDD control in other
countries.
Achievement ofsustainable elimination of
IDD in the country is promising.
urban (74.4%) and varied in the different zones of the country,
85.9% in the Selva, 81.8% in the North Sierra, 69.9% in the
Central Sierra, and 55.7% in the Southern Sierra.
Iodization of salt for animal consumption has begun. Two
private companies have produced iodized block salt on a small
scale. 1 he Program has encouraged these trials and has estab
lished demonstrations in 64 farm centers.
Urinary excretion ofiodine - This has been the principal indi
cator for the Program. Serial values clearly demonstrate the
progress achieved in all zones of the country. In Sierra Norte,
one of the rwo zones most severely affected, the deficiency is
practically controlled, as shown by the progressive increase in
median UI levels from 5.7 pg/dl (44.8% < 5) in 1986 to 12.8
pg/dl (20% < 5) in 1993 and to 13.8 pg/dl (15.9% < 5) in 1995.
In the Sierra Centro and the Selva, zones with less severe defi
ciency. the median has also increased to normal levels, from a
basal value of 9.5 pg/dl to 11.0 in 1993 and 15.2 in 1995 in
Sierra Centro. In the Selva, initial values were 11.9 pg/dl and
now are 18.8 pg/dl. Only in Sierra Sur has the change been
more gradual, from 5.6 pg/dl (46.3% < 5) in 1986 to 10.0 pg/dl
(34% < 5) in 1995. The overall level for rhe Sierra and Selva is
13-9 pg/dl, twice higher than the value recorded in 1986; 24%
of samples were less than 5 pg/dl.
Goiter prevalence in sentinel sites - Thyroid size assessment by
palpation in schoolchildren 6-14 years was carried out in each of
eight communities studied in the basal survey of 1986, rwo each
in Sierra Norte, Sierra Centro, Sierra Sur, and one in the Selva.
Drs. Pretell and Fenzi made the evaluation in five of these. The
results by zones show that the prevalence has diminished from
62.4 to 13.9% in Sierra Norte, from 41.7 to 5.7% in Sierra
Centro, from 43 to 19.9% in Sierra Sur, and from 32.3 to 3.0%
in the Selva. The median goiter prevalence in these eight locali
ties has changed from 47.7 to 10.8%. In rwo zones these figures
have already reached normal levels even though in Sierra Sur rhe
change has been smaller.
Based on these three indicators, in accord with the criteria
proposed by ICCIDD, the Sierra Norte and the Selva zones can
be considered as free of IDD risk, although some small isolated
foci persist and require attention. The Central zone is very close
to meeting these standards for iodine sufficiency. In Sierra Sur
the distribution and quality of iodized salt have increased con
siderably in the last year, and these intensified activities of pro
motion, surveillance and monitoring may result in control of
rhe deficiency in a very short time.
Ar the national level, it is esrimared that the population at
risk has been reduced from 6 to 1.2 million people.
Sustainability
Achievement of sustainable elimination of IDD in the coun
try is promising. The creation of PRONEDDI and its develop
ment over rhe past ten years has been highly effective. The
Program satisfies the following criteria:
1. Organization - PRONEDDI is a unit under the Director
General of Health in the Ministry of Health, with a central
director and functional organization including 29 coordinators
19
IDD NEWSLETTER
MAY 1996
COURTESY G-F FF.NZI
Drs. Fenzi (left) and Pretell palpate necks ofchildren for goiter in
Ollantaitambo.
Conclusions
Since its creation PRONEDDI has had two important fea
tures, a strong technical component and political support from
the government. These factors have permitted the design and
implementation of strategies and activities to achieve and sus
tain its objectives. The cost-benefit ratio of the program is one
of the lowest in America and more than 50% of expenses have
been covered from the country’s own resources.
COURTESY G-F FENZI
Recommendations
The external expens commended rhe program for notable
advances in the control of IDD, but noted the persistence of risk
in a small part of rhe population. To assure eradication of the
problem and its sustainability, the group recommended that
PRONEDDI be maintained in its current structure and opera
tional scheme, with the following recommendations for its
greater success:
1. Strengthen the central team of the Program, to assure its
technical resources. Economic and technical support for
this should be sought from external cooperation agencies,
PAHO, UNICEF, ICCIDD, the Micronutrient
Initiative, and bilaterals.
2. Improve the salt industry, particularly the small and
medium producers, to gain more experience in the
process of iodization and in salt drying, and thus to better
the quality of local artisanal iodization. Maintain the
rotating fund for purchase of KIOj.
3. Give priority to technical assistance and management of
the iodization plants in Sierra Sur, particularly the Maras
plant in Cuzco and San Juan de Salinas in Puna, because
of their strategic importance.
Since its creation PRONEDDI has had two
important features, a strong technical
component and political supportfrom the
government.
20
Iodized salt in Morrope, Chiclayo, waitingfor distribution. The
slogan states that the vendor is carrying out his responsibility by
selling only iodized salt.
Ensure that 100% of the iodized salt from plants produc
ing salt for human consumption comply with the legally
established requirements (30-40 ppm) and that iodization
in artisanal plants arc adjusted to the required limits. Also,
stimulate production and use of iodized salt for animals.
5. Expedite new legal instruments in accord with free mar
ket economics to permit more effective control of iodized
salt quality.
6. Reinforce and promote alliances within and among dif
ferent sectors in order to strengthen the program, partic
ularly the sections dealing with education, farming, salt
producers, and communication media.
7. Integrate the epidemiologic surveillance of the program
with that of other micronutrients.
8. Establish an effective monitoring system in the supple
mented population for the detection and management of
cases of iodine-induced hyperthyroidism.
9. Offer immediate protection with iodized oil to the small
population groups that cannot have adequate access to
iodized salt.
10. Give appropriate publicity to the findings and results of
this evaluation, for the benefit of other programs in other
countries.
11. Maintain a follow-up of these recommendations and the
previous advances of the program. ■
4.
IDD NEWSLETTER a MAY 1996
Reports from the Regions
This article offers highlights from the reports of the 1CCIDD
cgioual Coordinators for the year 1995.
omit news that has
already been presented in the Newsletter.
Values for urinary thiocyanate levels were respectively, 2.27,
2.74, and 2.95 mg/dl, with a national median of 2.48 mg/dl.
These values are high when compared, for example, to Brussels,
with a mean of 0.5 mg/dl. A salt survey found that 31% of the
population was already consuming iodized salt, from 25% in the
Sahel and 30% in the Sudan to 50% in Ndjamena. Millet of
various species is widely7 consumed as a staple food, including
the pennisetum species. Cassava is consumed either raw, boiled,
or after soaking to prepare dishes. Thus two goitrogens - millet
and cassava - are in the Chad diet. A national IDD seminar
workshop took place in June 1994, followed by a short-term
plan of action. Iodized salt continues to be imported from
Nigeria, Cameroon, and Senegal.
Rwanda - A goiter survey carried out in 1990 showed that
several districts were highly endemic, with an average total goi
ter rate of 50%, and a plan of action for 1990-1995 was devel
oped. Since then, high risk groups in two sanitary regions,
Gitarama and Gikongoro have received iodine supplementation
with Lipiodol. A ministerial order required that only iodized salt
should be sold. Also occurring during this five year period were
training activities on monitoring, seminars to raise awareness of
salt dealers, distribution of rapid field test kits, and establish
ment of a laboratory for analyzing iodine in salt. Since 1992 the
IDD Control Program has been integrated into the
Micronutrient Control Program in two pilot regions, with plans
to extend this organization to the rest of the national territory7.
A short-term plan of action was developed and included the dis
tribution of vitamin A capsules, iron tablets, and Lipiodol. Civil
strife beginning in April 1994 abruptly halted the program.
Currently, a new team is gradually trying to reintroduce the
control of micronutrient deficiency7.
AFRICA
Dr. Benmiloud, Regional Coordinator, reviewed the many
activities in Africa. Most have already been presented in rhe
Newsletter. Dr. Delange organized a multicenter study in sever
al African countries, assessing thyroid size, iodized salt intake,
and urinary iodine levels. The assessment has been completed,
the data arc being analyzed and a full report is expected soon.
Dr. Lantum. Subregional Coordinator for Central Africa
and Madagascar, reported his participation in seminars for small
salt producers in Dakar, rhe African Task Force on
Micronutrients, evaluation of the Cameroon National IDD
Program, the African Task Force in Micronutrients held in
Ethiopia, the development of a plan of action for IDD elimina
tion in rhe Central African Republic, and the multicenter study
of the impact of iodized salt on iodine status in Cameroon and
Nigeria. Some country' data follow.
Central African Republic - A plan of action had been devel
oped, with Dr. Lantum's help several years ago, but was delayed
during testing of water iodization with the Rhodiftise system.
The latter method was found effective and interesting but could
not surpass universal salt iodization in terms of cost benefit and
feasibility. Renewed effort is now raking place by implementing
the previous plan. UNICEF, the World Bank, and
Micronutrient Initiative have expressed interest in supporting
the new program. IDD is severe in rhe CAR, with national
median urinary7 iodine concentration of 2.1 pg/dl.
Cameroon - The independent verification by the
ICCIDD/WHO/UNICEF team has shown a reduction in total
goiter rate from 29.4% in 1990 to 10.4% in 1995. Further
results of the multicenter study will appear shortly. The
Cameroon Minister of Health has authorized the creation of a
national committee in charge of micronutrients.
Equatorial Guinea - An IDD baseline survey was conducted
by Dr. John Ogbuta of Nigeria, and Dr. Lantum reports that an
IDD problem was identified.
Madagascar - Universal salt iodization consumption was
anticipated to be in effect beginning in December 1995.
Sao Tome and Principe - A masters thesis by Luis Ruiz
(1993) for the University7 of London Institute of Child Health
reported a cross sectional survey of 2,01 1 schoolchildren, 6-12
years old, that showed a total goiter rate of 50% and a visible
exo iter rate of 3%. The south district of Caue had a prevalence
of 60%. The mean urinary7 iodine level in goitrous children was
6.7 pg/dl, and 9.5 pg/dl in nongoitrous. The amount of dietary
fish correlated with urinary7 iodine levels. One myxedematous
and five neurological cretins were described, and the island had
a deafness prevalence of 1.9%. Iodized salt is nor available in the
marker.
Chad - A national IDD survey was carried out between 1993
and 1994, revealing a total goiter rate of 64% for the Sahelian
zone, 70% for the Sudanese zone and 25% for Ndjamena, giv
ing a national average of 63%. The median urinary iodine con
centration for these three zones was respectively, 3.7 pg/dl, 2.3
pg/dl, and 4.7 pg/dl, with a national median of 2.9 pg/dl.
CHINA AND EAST ASIA
The Regional Coordinator, Dr. Chen Zu-pei, reviewed
progress in his region. In China he cited 1994 data from the
Ministry of Public Health as follows: population at risk for
iodine deficiency, 727 million (out of the country’s total 1.2 bil
lion persons); 29 of the country’s 31 provinces are endemic for
iodine deficiency; eight million persons are recognized to have
endemic goiter; and 187,000 are cretinous; and adults have a
total goiter rate in of 1.79%, while children age 7-14 years have
13.01%.
The annual meeting of the National Leading and
Coordination Group for IDD Control was held in Beijing in
November 1995, and reaffirmed the importance of increasing
awareness of IDD, especially for top leaders and policy makers,
multisectoral coordination, reinforcing the function of the pro
fessional ream or sector, universal salt iodization and the exclu
sion of non-iodized salt. The Annual Working Meeting for
Endemic Disease Control in March 1995 drafted two major
objectives, universal salt iodization by the end of 1995 or 1996,
and implementation of a national monitoring plan. A follow-up
workshop in September strengthened these efforts. At that time
80% of rhe provinces had universal salt iodization in place and
the remaining 20% had made plans for its implementation by
the end of 1996. Two problems were recognized: the proportion
of households consuming effectively7 iodized salt (> 20 ppm) was
only 50%; and rhe total need of iodized salt is about 7.8 million
21
IDD NEWSLETTER
MAY 1996
and of eastern Siberia (Republic of Sakha-Yakutia) had moder
ate iodine deficiency, with some pockets more severe (median
urinary iodine 2.5 pg/dl, ultrasound goiter rate 40-60% . Rural
areas of Central European Russia also showed moderate levels of
IDD (goiter rate 40-50%, median urinary iodine 2.9 pg/dl).
This new information is important because only mild iodine
deficiency had previously been thought to exist m Russia.
An IDD control program in Russia was adopted by the
President’s decree in 1994, bur not implemented due to lack of
funds. In other republics, programs are being developed in
Kazakstan and Kirgizstan following rhe Ashkabad meeting
(IDD Newsletter I0(4):44, 1994). Salt iodized with KI (25 ± 10
ppm salt) is being produced in Russia, Ukraine, Byelarus, and
Kazakstan, but is of rather low quality. No legislation on USI
has been adopted in the countries of this subregion, and there is
no information on the amount of iodized salt produced.
Iodized oil has been used to a limited degree in Tadjikistan.
I.ipiodol capsules were also delivered by the International Red
Cross to some regions of Russia and Ukraine that were exposed
to radioactive fallout by rhe Chernobyl disaster.
The bread iodization project was described in an abstract in
a recent IDD Newsletter (12(1):15. 1996). The Ministry of /*)
Public Health has expressed considerable interest towards
implementing bread iodization in regions of severe and moder
ate iodine deficiency where iodized salt is nor available.
tons, bur the current production capacity is only 6 million tons,
leaving a deficit of 1.8 million tons. An implementation project
supported by the World Bank may relieve this deficiency.
Using the WHO/UNICEF/1CC1DD recommended criteria
lor monitoring progress towards elimination of IDD, Dr. Chen
concludes the following regarding IDD prevalence: Beijing and
Shanghaino have no iodine deficiency (total goiter rate less than
5%); five provinces have severe IDD (TGR greater than 30%);
eight provinces have moderate IDD (TGR 20-30%); and 14
provinces have mild IDD (TGR 5-20%). He also noted that
about 50% of salt ar the consumer level was effectively iodized
(> 20 ppm), with a range of 12-79%, except in Jiangsu, with
95%.
An investigation of ten big cities showed that most had a
total goiter rate above 5% and urinary iodine below 10 pg/dl,
indicating that iodine deficiency is not restricted to remote or
rural areas.
Regarding international cooperation, the IDD program has
been jointly assisted by UNDP, WHO, and UNICEF in ten
provinces. The World Bank developed an important project of
support for light industry to improve the capacity, quality and
distribution of iodized salt. A Sino-Swedish project on preven
tion and rehabilitation of iodine deficiency-related mental retar
dation will cover 14 counties with IDD in eight provinces.
Dr. Chen advised rhe Ministry of Public Health, on behalf of
the National IDD Advisory Committee, on rhe use of iodinerich food or tablets, a topic that was confusing some officials and
health workers. The results were statements that iodized salt is a
major intervention for IDD elimination in China, that iodized
oil is a supplementary means for the national program, that both
iodized salt and iodized oil arc officially sanctioned, and that
iodine-rich foods or tablets as competition to iodized salt, arc
not advocated.
MIDDLE-EAST
Dr. Anna Verster, WHO Regional Advisor in Nutrition,
reported.
Country activities
Afghanistan - Although rhe country still suffers civil unrest,
the severe problem of IDD has been recognized. Efforts are
underway ro start salt iodization locally at the various sites where
salt is produced. WHO has provided iodized oil for distribution
ro children and women during the second and third round of
rhe immunization campaign. Iodized salt from Iran is available
in Heart and Kandahar.
Cyprus - Reports to WHO on the neonatal screening for
1 SH suggest that no IDD problem exists in the country.
Egypt has taken the political decision to iodize all salt, x
Discussion on technical issues, especially iodide/iodate and the '■
possibility of iodization of “kitchen salt” took a long time.
WHO and UNICEF assisted the government in making a suit
able decision.
UNICEF carried our one round of iodized oil in the worst
affected area, with WHO technical input. Iodized salt is report
edly under production starting May 1, 1996 after the standards
were adjusted to allow for iodization. Salt comes from the sea,
and is iodized with KIO3 through spraying. The total annual
production is 2 million kg. All edible salt will be iodized, either
as coarse salt or refined.
Iran reports reaching 87% consumer coverage with iodized
salt. Fifty-two small-to-medium producers all over the country
produce excellent quality iodized salt, which is also exported to
some parts of Afghanistan. Iran has a comprehensive monitor
ing system, and IDD is included in rhe primary health care sys
tem. Iodized salt was given to all families during the polio cam
paign (IDD Newsletter 10(4):48, 1994). The salt in Iran is from
different sources, sea salt, rock salt, and lake salt. All edible salt
is iodized by spraying with KIO3 using country-specific tech
nology. An excellent monitoring system is in place.
EUROPE
Dr. Delange, Regional Coordinator, reported. A major activ
ity was the ThyroMobil project (IDD Newsletter, 11(3):33,
1995). Its methods were thyroid volume by ultrasound and uri
nary iodine determinations in school-age children in selected
sites in 12 European countries. The final results arc being tabu
lated. So far they show that iodine nutrition is markedly
improved in many countries compared co the situation reported
in 1992. However, iodine deficiency persists unchanged in some
countries such as Belgium.
In other news, Bulgaria, has decreed mandatory iodization of
household salt at a level of 20 ppm. Strict quality control has
been organized and export of iodized salt produced in Bulgaria
is no longer allowed. Beginning in February 1995, pregnant and
lactating women and children to the age of 7 years are supple
mented with tablets of iodide. The goiter prevalence in school
children has decreased from 65 to 17% and urinary iodine
increased from 3 pg/dl ro 14 pg/dl.
In Belgium, a National IDD Committee of the Ministry of
Health chaired by Dr. Delange, organized a consensus confer
ence and made unanimous recommendations for advocacy pro
grams, universal salt iodization and iodine supplementation of
pregnant and lactating and young infants. The Minister of
Health committed formally to implementation of these mea
sures, bur changes in the political scene delayed this action.
Dr. Gerasimov, Subregional Coordinator for Eastern Europe
and Central Asia, reported. Surveys in several remote regions of
Russia showed that parts of western Siberia (Tyumen province)
22
IDD NEWSLETTER h MAY 1996
aq n 1993 a national survey of 3,004 school-age children
o- , 'eC °?jlCr rarfs 01 24-44%. The salt included in rhe ration
? Iraqis is now iodized. A 1995 survey showed that 49O . 0 or families use iodized salt. Salt legislation exists.
Jordan in 1993 carried out a national survey that showed a
moderate/severe problem. The biggest salt manufacturer (Al
zraq) was using iodide in a process which involved heating of
the iodized salt in a drying tunnel with iodine losses. On the
advice of WHO and UNICEF consultants, iodate has been sub
stituted for iodide, UNICEF now provides the iodate, and the
salt is adequately iodized. The second manufacturer, Al Amra,
has just started iodizing all salt for human consumption. Dr.
Verster assisted in rhe development of a monitoring system for
iodized salt integrated into the existing food control system with
links to the National IDD Committee. She recommended
expanding the standard for iodized table salt to include all edi
ble salt. WHO has funded a small study to assess iodized salt in
pickles. 7 he salt used is either from wells in the desert (Al Azraq)
or from potash in rhe Dead Sea. The compound used is KIO3,
which is sprayed onto the salt.
Kuwait - Although there are no date yet on IDD prevalence,
the main salt producers in Kuwait have agreed to start iodizing
their salt.
Lebanon has carried out a national survey. IDD is moder
ate/severe. The country' has a decree stating that all salt import
ed or produced must be iodized. The two factories in rhe coun
try both use iodate to iodize all edible salt (50,000 kg). The sea
is rhe source of salt and it is iodized by spraying. A survey of salt
consumption was carried out by a MSc student for UNICEF,
looking at 30 clusters of 15 households each. Of 461 samples,
84% were adequately iodized with iodate (334 samples) or
iodide (54 samples). In Beirut and its suburbs, over 90% of salt
samples were adequately iodized. The cut-off used for deciding
adequacy was high, > 50 ppm of iodine. The legislation is
Lebanon requires 50-100 ppm, a rather high value in view of
current experiences with losses.
Libya has been assisted by WHO in setting up or improving
the laboratory' capacity for IDD. All is now set for a national
survey to evaluate the effect of the salt iodization program,
which has been ongoing, particularly in remote areas where
IDD is a problem. WHO will provide technical support. All
edible salt (120,000 kg) is presently iodized with KIO3 at 26
ppm. The salt is from salt lakes. Recommendations to increase
the iodization level and to change to iodate have been made.
Morocco has carried out a national IDD survey that showed
IDD to be a problem of public health significance in the coun
try', with highest goiter prevalences in the mountains (44%) and
lowest on the coast (19%), with a national average of 22%.
In March 1995, the government held a one-day national
seminar to present the data and discuss strategies. WHO partic
ipated actively. Iodized oil was distributed in Azal, Taza,
Chefchaoun, Ouarzazate, while other hyper-endemic areas will
be targeted in 1995/96. A salt situation study was done and a
meeting held with producers. Seventeen iodization plants pro
vided by UNICEF are now functioning. Several salt producers
have formed cooperatives or produce under the same label. A
logo has been adopted (a tajine). Legislation was adopted by the
Ministries of Health, Agriculture, Commerce and Industry, and
Energy' and Mines, to iodize all edible salt at 80 ppm ± 10 ppm
(Ministerial decree of October 1994). A KAP study was done
which will assist in I EC.
In September 1995, Morocco planned to begin a neonatal
screening program using TSH and T4 in neonates coming for
BCG (day 7-30 days postpartum) to detect congenital hypothy
roidism. This will start in Rabat, initially, in collaboration with
the IDD control program.
Oman has carried out its national IDD survey and found
mild IDD nationally, with higher prevalences in some areas.
The country both imports salt and produces it locally. A
Ministerial decree has been issued to ensure that only iodized
salt is imported. Also, the only local producer is iodizing his salt
after receiving technical advice from WHO/EMRO. On a
recent visit to the Dutch salt producer AKZO, Dr. Verster was
informed that Oman has changed its order from non-iodized to
iodized salt.
Pakistan has recently taken up iodized salt with renewed
vigor and extensive support from UNICEF and the World
Bank. Access to iodized salt has been increased through support
to rhe private sector provided by the Iodized Salt Support
Facility (ISSF). Advocacy for iodized salt legislation is under
way. Most salt is rock salt and dry mixing is rhe technique cho
sen. Further derails on the program in Pakistan are provided
elsewhere in this issue of the Newsletter.
Qatar - A preliminary study' on iodine deficiency disorders
was carried out in January 1996. Urine specimens from 59 chil
dren (30 boys and 29 girls, 6-15 years) randomly selected from
10 primary' schools in Doha showed an average iodine content
of 23.37 pg/dl with 70% of rhe samples above 10 pg/dl. A
national study was proposed.
Saudi Arabia informed WHO about the results of its neona
tal screening program. IDD is prevalent in some areas of the
country'. Iodized sale is available although no legislation as yet
regulates USI. The first ever national IDD survey was recently
completed. It showed a mild-moderate prevalence, with severe
IDD in rhe south, based on goiter prevalence in 8-10 year old
schoolchildren. However, the urinary iodine levels were not
congruent with this. Median urinary iodine excretion varies
from 11 pg/dl in the south to 24 in the west, with a national
mean of 17 ± 8 pg/dl and a median of 18. In the south, 45%
had an excretion below 10 pg/dl, compared with 19% in the
north and 15% in the east. The report’s authors, who include
the Assistant Deputy Minister of Health for Preventive Affairs,
recommended universal salt iodization, a view supported by
WHO and UNICEF. There is now need for a decree and stan
dards. A new regional association of iodized salt producers has
been created, and the salt producers need to be informed of its
existence.
Sudan has made the political decision to iodize all salt.
WHO and UNICEF are actively involved as advisors. A
National IDD Committee has been formed, and iodization
plants have arrived. Legislation endorsing salt iodization was
passed by a Ministerial decree. A proposal for a monitoring sys
tem was recently' prepared and WHO technical support was
given through a short-term consultant.
Syria has recently received and installed new iodization
plants. The main mine was already producing some iodized salt
but only 20% of the national need. The new plants have
increased the capacity to 100% of the national need. Syria’s salt
comes from a deep mine with a capacity of 80,000 tons per year.
Most is iodized by spraying KIO3 while some is dry mixed in an
automatic mixing drum.
Tunisia reviewed its targeted iodized salt program in 199293 and found that the iodization level was too low, and showed
IDD occurred in several parts of the country. Tunisia has, with
support from WHO and UNICEF, taken the decision to rein
state universal salt iodization with adequate iodine (40 ppm).
23
IDD NEWSLETTER
MAY 1996
been developed there in collaboration with the National
Agrarian University La Molina (Lima) and the National
University Hermilio Valdizan (Huanuco m the Andes).
Preliminary results demonstrate significantly low concentration
of iodine in milk of cattle from the Sierra (2 9 ± 1.9 pg I/dl) in
comparison with those from rhe coast (21.6 ± 19.9 pg/dl).
These results are quite similar to previous observations in
humans and are being used for advocacy among farmers. .
Dr. Prctell summarizes rhe current situation of countries as
Yemen - A decree to enforce iodization of salt in the whole
country was accepted by the Council of Ministers. Some iodized
salt is presently produced in Yemen and UNICEF has provided
additional iodization equipment. An IDD committee was
formed. WHO assisted technically in setting up the salt moni
toring system, by providing a consultant who has carried out
training of laboratory staff and by provision of equipment.
Regional Activities
WHO/EMRO has provided technical support to a number
of countries (notably Jordan, Yemen. Sudan) in the area of
monitoring of salt iodization programs and their impact on
IDD. Technical support and training in laboratory techniques
for IDD control was given to Iran. Yemen, and Libya. WHO
supported a study in Jordan on the possible effect o( iodized salt
on pickles which showed no effect on taste, appearance or con
sistency of locally made pickles from several different types ol
vegetables.
A joint regional WHO/UNICEF meeting on universal salt
iodization for salt producers was held in Amman and at the Al
Azraq Salt Works in Jordan. The meeting resulted in rhe for
mation of a Regional Association of Iodized Salt Producers,
which is already actively networking. On the basis of the expe
riences of the salt producers attending, rhe participants recom
mended that:
1. All countries of the region affected by iodine deficiency
should have effective legislation and standards for iodized salt.
2. The use of iodized salt must be made universal.
3. Evenr country should have an IDD committee which
monitors process and impact of salt iodization and gives feed
back to the producers.
4. Potassium iodate should be the compound of choice for all
salt iodization in the region.
5. Potassium iodate should be exempted from taxes and/or
customs duties.
6. The school education system should be used for monitor
ing at rhe household level and for social marketing.
7. For marketing purposes and to promote iodized salt,
videos and other promotional materials should be produced by
governments and salt producers in collaboration with WHO
and UNICEF.
8. The newly formed Association of Iodized Salt Producers
should look into development of one or more logos for iodized
salt.
9. WHO and UNICEF were requested to continue to sup
port the salt iodization program.
AMERICAS
Dr. Pretell reported. Many activities in the Americas have
already been reported in this and previous issues of the IDD
Newsletter, particularly on Peru and Paraguay.
In December, Dr. Pretell participated in the 5th Annual
Meeting of the Andean Subregional IDD Project, in Caracas. In
all of the five Andean countries the production of iodized salt for
humans is more than sufficient to cover rhe potential demand.
The five countries have carried out national surveys on goiter,
urinary iodine, and consumption and quality of iodized salt.
Results on iodized salt production, consumption, and quality
are encouraging. Iodization of salt for animal consumption has
not been implemented yet, except in Peru (see this issue, IDD
Newsletter). Two projects on iodine deficiency in animals have
follows:
. . ... ... .
.
IDD nearly eliminated and sustainability likely - 1 his group
includes Costa Rica, Nicaragua, Ecuador, Bolivia, Chile, Peru,
Venezuela, Colombia, and Brazil. In each, the amount of
iodized salt available for human consumption is greater than the
potential demand. All but one of these countries have active
national IDD control programs. Each has governmental and
private salt industry support. Seven of the nine have laboratory
facilities for urinary iodine analysis. All have a strong education
program. All have conducted recent national surveys. External
evaluation is needed and should be the next step.
Some IDD still exists - In these countries, Mexico and
Argentina, there is little governmental concern about IDD as a J
health problem and no recent evaluations have taken place.
Iodized salt available but no recent evaluation - These coun
tries include Guatemala, Honduras, Salvador, and Panama.
They need evaluations on impact of iodized salt and may need
technical assistance.
Countries without USI - These include Uruguay and
Paraguay. The latter was reviewed in a recent IDD Newsletter
(12(1):3, 1996), and considerable progress is being made. In
Uruguay, promising efforts are talcing place to implement US1,
and IDD elimination is expected fairly soon.
Dr. Prctell proposed the following activities for 1996: (1)
external evaluation of the IDD programs in Bolivia, Chile, and
Peru, each of which has expressed the need. (Since the report
was submitted, the Peru evaluation has already occurred, see this
issue of IDD Newsletter). Colombia and Venezuela have also
made significant progress, and external evaluation needs to be
considered. (2) Brazil has completed data collection from a
national survey of goiter prevalence, urinary iodine concentra
tion, and the iodine content of salt. Analysis is in progress and
Dr. Pretell has been invited to a workshop in Brasilia to review A
the results and a plan of action for the future. (3) Technical
assistance is needed for reassessment of their remaining IDD
areas in Argentina and Mexico and development of intervention
piograms as necessary; the governments of these two countries
are generally unaware of their IDD status. (4) Despite apparent
progicss of salt iodization in Central America, recent data on
production and quality control are not available nor are impact
evaluations. These need attention.
SOUTHEAST ASIA AND PACIFIC
Dr. Pandav has already provided derailed reports on various
aspeers of IDD in Southeast Asia in recent issues of the IDD
Neiusletter (11(4):45, 1995). His report to ICCIDD for 1995
includes valuable country profiles for each country, with data on
salt iodization, utilization of iodized salt at the household level.
and biological markers (urinary iodine, goiter, neonatal TSH),
when available. New information from these data sheets is being
tabulated in ICCIDD’s C1DDS database. ■
24
IDO NEWSLETTER n MAY 1996
Iodization of Irrigation Water Proves
Successful in Western China
A
ddition of iodine to irrigation water was reported to
Iodine helped humans and also
be a successful means for improving human iodine
nutrition in western China (Lancet 1994, 334:107110, abstracted in IDD Newsletter, 10(4):51, 1994). The same
research group has continued their observations and Dr.
DeLong (ICCIDD Board member) provides a recent summary
for the IDD Newsletter. His co-authors are Jiang Xin-min, Cao
Xue-yi, Jiang Jiung, Ma Tai, David W. James, Murdone abdul
Rakeman, Dou Zhi-hong, Mahmud Mamette, Kareem
Arnette, and Zhang Ming-Ii, from rhe Xinjiang Endemic
Diseases Research Institute, Urumchi; rhe Xixjiang Health and
Anti-Epidemic Station, Urumchi; Tianjin Medical College,
Tianjin; LItah State University, Logan, Utah, and Duke
L'niversny Medical School, Durham, NC. I he present article
summarizes some of their major findings to date. Full publica
tion will follow.
Iodine addition technique - From a 200 liter rank, placed on
a platform over an irrigation canal, a solution of 5% potassium
iodate was dripped into the water flowing beneath, to produce
iodine concentrations of 10-80 pg/1 in rhe canal water. Dripping
occurred over two to four week periods in May to July. The
administrations included 30 kg of iodine to an area of four vil
lages with a total population of 5600 in Long Ru in 1992, and
another 80 kg to the same area in 1993. Also, in 1993, 80 kg
iodine were added in an area of eight villages with a population
of 15,600 in Bakechi, and in 1994, 80 kg were administered to
an area of 15 villages, total population of 25,000, in Tusala.
Iodine in water and soil - A surprising finding was that the
content of iodine in the soil, expressed as pg/kg, was regularly
about three times that in rhe water, expressed as pg/1. The
authors suggest that this increase in water-soluble soil iodine
reflects an action of KIO, in solubilizing soil iodine that was
previously insoluble. This result is being further explored.
Iodine uptake by plants - The iodine content in wheat and
cabbage increased several fold in the two years after initiating
the iodization, beginning within several weeks and persisting for
at least two years. The effects on major grain crops were uncer
tain.
Rice productivity increased markedly in 1994 and 1995 in
the test villages only, raising the possibility' of a beneficial effect
of iodine on rice production. Corn yields in the test villages rose,
but did also in control villages. Mean productivity of wheat
remained constant.
Effects on animals - The uptake of iodine by the thyroid
increased two to three fold in sheep and chickens, rhe two
species in which it was measured. In Long Ru this effect persist
ed for at least three years, but in Bakcchi, values returned to
baseline in two years. The iodine content of mutton, chicken,
and eggs also increased markedly, rising about six fold in chick
ens after two years, for example. Egg iodine content increased
two to three fold, and remained high even after rhe second year.
Effects on animal health - The relative number of sheep
improved animal health.
increased by 10% in the test villages, and the total number by
6.9%, compared to controls, in Long Ru. Similarly, in Bakcchi,
the relative increase was 10.1% and in Tusala, 5-1%. The sur
vival of newborn lambs increased significantly in all three test
areas. For example, in Long Ru, the increases over the prerreatment years for the three years 1993, 1994, and 1995, were
respectively 42%, 63%, and 35%, while similar figures for the
control villages were -1.2%, +20%, and +15% for the same
three year period, compared to the three previous years.
Hnman urinary iodine excretion - In Long Ru, the median
rose From 14 pg/1 before dripping to 49 pg/1 one year later, and
then decreased to 18 and 21 pg/1 for the respective next two
years. For women, the median urinary iodine excretion was 51
pg/1 in 1994, one year after the last dripping, and 29 pg/1 in
1995. In Bakcchi, initial levels were about 40 pg/1, and two
years after the last dripping, the median was 78 pg/1 for women
and 58 pg/1 for children.
Effects on children - Measurements of height, weight, and
head circumference of children aged 2-6 years were compared
between iodinated and control villages. For each, the mean val
ues for the treated children were greater than the controls, but
not always significantly so. Further studies are being planned.
Cost ofintervention - The authors calculate that for Long Ru
the cost was about US $0.10 per person. The principal expense
was the iodate, which was available only at the Chinese com
mercial price, about twice the UNICEF price; if rhe UNICEF
price had been available, the cost would have been almost half.
For Bakcchi, the estimate was considerably lower. These calcu
lations include only cost on a human per capita basis. The ben
efits for livestock are significant. For example, in Long Ru, rhe
value of the increased sheep production was estimated to reach
88,000 yuan in 1995 alone, compared to the total cost of
applied iodine of 14,000 yuan. Chicken productivity would also
increase the benefit cost ratio.
COMMENT
These results are exciting from at least several vantage points.
First, they show that iodization of irrigation water is a practical,
cost-effective means of iodine supplementation under rhe cir
cumstances existing in this area of western China. Secondly,
they offer valuable preliminary data on the great benefits iodiza
tion has for human and animal development. Further data and
conclusions from this research will be awaited with much
interest.
25
IDD NEWSLETTER b MAY 1996
Iodized Salt in [Peshawar, Pakistan: Its Iodine
Content, Price, andl Use hy the People
(The following article was submitted to the IDD Newsletter by
Dr. Matt til Haq. Thyroid Laboratory, Institute of Radiotherapy
and Nuclear Medicine, Peshawar, Pakistan. Co-authors included
Dr. Iftikhar Ahmad, Dr. Salarzai. and Dr. Sher M. Khan. The
article has been shortened, edited, and adaptedfor the Newsletter/
bout 20 million people live in iodine-deficient areas of
A
Pakistan. Of these, 8 million show some manifesta
tion of iodine deficiency, and at least a million show
some degree of mental retardation. Goiter prevalence reaches
20% in children of age 0-19 years in the Northwest Frontier
Province. The government of Pakistan is committed to virtual
elimination of IDD through universal salt iodization by the year
2000. The recommended concentration of iodine is 70 ppm, at
a price of rs 2.50/kg and packing size of 800 grams in polyeth
ylene bags (1,2).
The purpose of the present work is to evaluate rhe iodine
content in the available iodized salt to address the following
questions: (1) is the iodine content constant among batches?; (2)
are salts sold according to the recommendations of
UNICEF/WHO and the Planning and Development
Department of the government?; (3) what percentage of people
use iodized salt?; and (4) why do some people not use iodized
salt?
To carry out the study, we collected at retail points 21 sam
ples of iodized salt from different manufacturers, for assessment
of iodine. Exactly two months later different batches of the
available brands were collected from the same shops. We ran
domly chose 1244 families to interview for their attitudes
towards iodized salt. The iodine content of salt was determined
by standard iodometric titration (3-5).
Of the 21 brands, only five contained adequate amounts of
iodine (70 ppm). An additional five brands contained 30 ppm
or above. The remaining 11, (52%) had less than 30 ppm. The
overall range was 7 to 153 ppm. Three brands had levels greater
than 125 ppm.
On repeat sampling of 11 brands two months later, some
showed only minor differences, but in others the differences
were huge. Examples of some differences are given as follows,
comparing the first and the second determination: (a) 75.5 vs.
27.1 ppm; (b) 14.1 vs. 49.4; (c) 55.7 vs. 42.8; (d) 37.6 vs. 25.0;
(e) 19.4 vs. 29.5; (f) 69.5 vs. 131.5; (g) 52.9 vs. 35.4. Repeat
sampling for the remainder of the 12 brands corresponded more
closely to the initial values.
All manufacturers offered their salt in plastic bags, according
to national and international recommendations. Thirteen
(62%) of these supplied rhe recommended 800 gram packages,
the remainder supplied salt either in larger or smaller containers.
The price range was rs 2.7 to 8.75 per kg of salt. Most manu
facturers sell iodized salt ar two to three times the recommend
ed price. The retail price shows no correlation with the iodine
content.
The survey of 1244 families showed that only 241 (19%)
used iodized salt. An additional 10% occasionally use it, while
the remaining 70% never do. When questioned about why they
did not use iodized salt, 44% answered chat it causes failure of
"Hand and Pot” symbolfor iodized salt in Pakistan.
the reproductive system, 26% stated that it was too expensive
compared to non-iodized salt, and the remaining 30% felt that
the iodized product had no advantage.
These results show that most of the iodized salt available to
the consumer at retail points does not have an adequate or con
stant supply of iodine. The price is considerably higher, and for
this reason, 26% feel they cannot afford it. Additionally, 70%
do not use iodized salt because of misunderstanding or igno
rance of its benefits. The authors recommend an effective
nation-wide IDD commission, with rhe following responsibili
ties:
1. To improve awareness ar all levels about rhe importance of
IDD and the use of iodized salt. Consumers need to know that
iodized salt is beneficial for the reproductive process and the y
physical and mental development of infants and children and
that it has no adverse effects.
2. To have regular monitoring of the iodine content of salt at
the plant, retail and consumer levels.
3. To ensure an adequate and cheap supply of potassium
iodate or potassium iodide for rhe salt industry.
4. To educate consumers to demand and use only iodized
salt.
REFERENCES
l. Report on the National Consultation on Elimination of IDD from
Pakistan by UNICEF and Nutrition Cell and Planning Commission, 1994.
2. Report of a Mission for World Bank to Pakistan, June 29-JuIy 11, 1993.
3. Karmarkar MG, Pandav CS, Krishnamachari KAVR 1986 Principles and
Procedures of Iodine Estimation - A Laboratory Manual. New Delhi.
4. Bloedal WJ, Meloche VW 1964 Elementary Quantitative Analysis Theory and Practice, p 458, 2nd edition.
5. Tyabji R 1985 1 he use of iodated salt in the prevention of iodine defi
ciency disorders.
26
IDD NEWSLETTER ■ MAY 1996
Effects on Storage and Commonly Used Spices
on Stability of Iodized Salt in Indonesia
paper and abstract were kindly made available to the IDD
Newsletter by Professor Dr. I. N. Arbya, Department of
Biochemistry, Udayana University, School of Medicine, Bali,
Indonesia. The following abstract summarizes his findings.
boiling KIO3 for five minutes in water or meatbail stew at a neu
tral pH did not affect its concentration appreciably.
The author also investigated the effects of many spices com
mon used in Indonesian cooking. The spices use for this
research were: aqua (as control), garlic (allium sativum), candle
nut (aleurites moluccaua), galingale (keampfieria galanga), red
onion (allium cepd), ginger (zingiber officinale), galangalc
(alpinia galanga), turmeric (curcuma domestied), tomato
(solatium lycopersicum), chili (capsicum annuum), fermented
shrimp paste (terasi), coriander (coriandrum sativum), pepper
(piper nigrum), complete spice mixture (bumbu lengkap), sour
vegetable spice (bumbu sayur aseni), mixture of spices with
coconut milk (bumbu iodeh), and hot mixed spices (bumbupiec
ing. Most spices when mixed with iodized salt lowered its
iodine concentration, but not below 40 ppm. Tumeric and
tomato lowered it to levels between 30 and 35 ppm. Mixture
with chili led to the almost immediate disappearance of its
iodine. The author suggests that this might be caused by the
high vitamin C found in tomato and particularly in chili, which
he attributes to the mixing of KIO3 with an acid to release free
iodine, which then volatilizes. The other foods such as shrimp
paste, tumeric, and pepper also produced acid. Most of rhe
iodine content was also lost when iodized salt was mixed with a
complete spice mixture, sour vegetable spice, some species of
coconut milk, or hot mixed spices.
Dr. Arhya concludes that the government’s effort to control
IDD by iodizing table salt will be futile if cooking habits are not
modified. However, modifying such habits is difficult to carry
out in practice, and he proposes an alternative program, such as
capsules of iodized oil, supplying iodine in domestic animal
foods to provide iodine-rich meat, or perhaps processing sea
weed to produce fertilizers for agriculture.
is fortified with KIO3 in Indonesia at 40 ppm.
■ ^is study examined its stability under different
conditions.
The first experiments evaluated the effects of open-air expo
sure in six brands of iodized salt, each claiming to have 40 ppm
iodine. After three months, the water content of five of the
brands increased but stayed within the standard requirement,
less than 5% moisture. The sixth brand started with a moisture
content of 5.2%, and reached 6.9% three months later. Initial
iodine contents oi the six brands were respectively, 60, 53. 50,
2/, 9, and 4 ppm. After three months, the same brands had 53,
44, 43. 22, 5, and 2 ppm. respectively. After an additional two
months, rhe levels were 31, 24. 24, 12, 0, and 0 ppm, respec
tively. The approximate losses in rhe first three months for each
brand were 17%, 14%. 19%, 39%, and 53%, respectively.
1 hus, for the first three brands, the levels remained above 40
ppm after three months of storage. For the other three brands,
the iodine content was insufficient even when freshly produced,
and much greater losses occurred during rhe ensuing three
months. These three inadequate brands had a generally lower
quality and a much lower price than rhe other three.
From these results, rhe Indonesian practice of keeping salt in
open containers has little effect on water or iodine content of
iodized salt. Most Balinese families require an average 350 g
(range 50-500 g), salt per week, so a 500 g package will usually
last for one month or less. While one to two months may elapse
between production and purchase, consumption still rakes place
within three months of production. It may be concluded that
for quality control purposes, measuring the iodine content of
iodized salt in the factory alone will be sufficient. The conclu
sions about KIO} stability were supported by finding that even
[Ed note: These results raise serious questions about losses of
iodine in spice mixtures. More investigation is needed to character
ize this effectfurther and to assess its practical consequences.]
Nigeria Advances Towards HDD Elimination
This article is adapted front a report entitled "Status of Iodine
Deficiency Disorders in Nigeria 1993-1995 ' by Egbuta and
Hettiaratchy, presented by Dr. John Egbuta. Dr. Egbuta, recently
elected to the 1CCIDD Board, is currently a Project Officer for
micronutrients with UNICEF Lagos, and has been a senior
research fellow, Department of Chemical Pathology at the
University of Jos. Dr. Nimal Hettiaratchy is Chief of the
Nutrition Section of UNICEF in Lagos.
iodized salt (IDD Newsletter, 11(2):31, 1995). Dr. Ekpechi,
ICCIDD Senior Adviser and former Board Member, produced
a map in 1986 showing a significant goiter prevalence in many
parts of the south, central and western regions, but reliable
information was not available for most of the country. In 1992,
Dr. Bailey and Mr. Mannar, both ICCIDD Board members,
summarized goiter prevalence information for seven hyper
endemic local government areas, ranging from a 16% goiter
prevalence in Bassa (Plateau State) to 36% in Enugu State.
BACKGROUND
IDD STATUS
Previous reports have clearly established a significant pres
ence for IDD in Nigeria (/£>£> Newsletter, 7(1):2, 1991), and
more recently, have described the efforts to correct it through
Because there was insufficient information about the extent
of IDD in Nigeria, Egbuta and Hettiaratchy carried our a rapid
comprehensive goiter survey in 1993. They examined 17,500
27
IDD NEWSLETTER □ MAY 1996
The importation and processing of salt in Nigeria is handled
by the private sector. The salt industries were mobilized through
high-level advocacy and workshops and seminars. Several visits
and meetings were held with the salt importers on a bilateral
basis and as a group, for the purpose of advocacy and monitor
ing. As a preliminary step UNICEF sponsored the attendance of
some key officials of the salt companies at the West African
Regional Meeting on salt iodization held in Dhaka, Senegal in
1992. After intensive promotional efforts, the Standards
Organization of Nigeria developed a memorandum of under
standing with the salt importers, and by the beginning of 1993
the salt industries had become partners with the Standards
Organization and UNICEF in salt iodization.
With evidence that the former approach was
not working, it became necessary to explore
other directions including private sector
involvement, strong media mobilization and
legislation.
children from rhe entire 30 scares of the country, and collected
3500 urine samples. Sampling was by palpation in 50 boys and
50 girls, usually age 9, in each school, the latter selected to be
representative of their districts. Ultrasonography was also used
for assessing thyroid size in two regions.
The report gives data for each state. The national average for
goiter prevalence, defined as thyroid enlargement in over 5% of
children, was 20%. By zone, the prevalences were 37.2% in the
southeast, 28.7% in the southwest, 12.5% in the northwest, and
13.4% in the northeast. This 1993 survey found a higher goiter
prevalence than had been estimated before. The authors suggest
that this apparent worsening may be due to increased dietary
cassava, whose thiocyanate is goitrogenic. In the 1970’s when
the economy was better, people could vary their menu with
non-cassava-based diets. However, with a poorer economy in
the 1990’s, cassava was again the major dietary staple. Thus, rhe
combination of iodine deficiency' and increased reliance on cas
sava may have worsened rhe goirer prevalence.
Program Operation
Legal provision (or mandatory salt iodization was a key fac
tor in negotiations with the salt companies. The strategy for this
developed late in 1992 during rhe consultancy visits of Dr.
Bailey and Mr. Mannar, leading to agreement by the Federal
Ministry of Health and the Standards Organization to jointly
develop mandatory iodization of all food-grade salts in the t)
country. The Standards Organization then decreed that non
iodized salt would no longer be allowed to be imported or pro
duced in Nigeria after January 1, 1994.
Media mobilization was another important ingredient.
Previously there had been almost no knowledge of IDD, but the
involvement of the media was enlisted through workshops, con
ferences, and seminars. In 1993 alone, IDD was featured 11
times on national television and radio prime time news, beamed
to 30 million TV viewers and 60 million radio listeners. An
IDD documentary and jingles were produced for constant air
ing on television and radio, and a national IDD logo was pre
pared and is embossed on every salt bag sold in the country.
Following the introduction of universal salt iodization, a
form was designed and circulated to all field offices of UNICEF,
the Standards Organization of Nigeria, the National Agency for
Food, Drugs Administration and Control, and the National
Primary Health Care Development Agency. These field offices
were given several vials of the field test kits for the measurement
of iodine in salt, and charged with monitoring and evaluating
the progress of USI through monthly assessment of all the salt <,
available and circulated in all parts of Nigeria.
Results from these tests have been impressive. By December
1994, 97% of households were consuming iodized salt.
STRATEGY DEVELOPMENT
This survey was parr of a new operational strategy for IDD
in Nigeria. For more than 15 years the plan to control IDD had
been largely unsuccessful because planners and researchers had
embarked on a unidirectional strategy, expecting the govern
ment to be the key player. With evidence that this approach was
not achieving satisfactory results, it became necessary to explore
other directions including private sector involvement, strong
media mobilization and legislation. In addition, an assessment
of the current status of the salt industry was undertaken. This
included a systematic listing of importers of salt, through the
Ministry of Trade of Commerce.
IODIZED SALT
CONCLUSIONS
Nigeria has only three major salt companies (Dicon, Nascon,
and the New Nigerian Salt PLC). (The role of Dicon in salt
iodization was described in the IDD Newsletter 11 (2):31, 1995.
All of the country’s 630,000 metric tons processed annually are
imported. Of this amount, Dicon processes 500,000 metric
tons, Nascon 50,000, and New Nigeria 80,000. In addition, the
three companies produce non-iodized industrial grade salt,
respectively, at 60,000, 10,000, and 40,000 metric tons per
year, for a total of 110,000. At an estimated consumption of 57 grams per day' per person, Nigeria’s annual requirement is
450,000-550,000 metric tons. Dicon iodizes its salt at source in
Australia before shipment to Nigeria; rhe other two companies
have iodization plants in Nigeria.
The apparent figure of 97% iodized salt consumption is
extremely impressive. The authors make several suggestions for
its sustainability. One is adherence to the regional agreement on
universal salt iodization for West African countries of 1994, to
prevent introduction of non-iodized salt across the country’s
borders. The authors also suggest strong emphasis on awareness
creation and greater social marketing about the benefits of
iodized salt. It is important to develop a reliable monitoring and
evaluation system in which the services of regulatory agencies,
including the Standards Organization, Food and Drug
Administration, and universities, can be applied. Finally, the
current regulations must be enforced in order to protect rhe
consumer.
28
IDD NEWSLETTER □ MAY 1996
Goiter Prevalence and Use of Iodized Kitchen
Salt in Iringa Rural District (Tanzania)
P. FRANCESCONI, B.S. KIB1KI, V. PISANI. CUAMM COLLEGE FOR HEALTH COOPERATION, IRINGA AND IRINGA
DISTRICT IDD CONTROL COORDINATION
odine deficiency disorders affect an estimated 25% of the
I
The recent regulation on salt production
population in Tanzania. A law effective in early 1995 pro
hibited manufacture of non-iodized salt. Iringa Rural, a
northern district of the southern region of Iringa, is inhabited by
an estimated population of 413,504 people. Visible goiter has
been said to be 3.1%, but may be much higher in the sur
rounding mountainous areas; for example, a routine school sur
vey in 1994 suggested 7% visible goiter.
1 he present study was conducted to survey the prevalence of
goiter and rhe circumstances under which it occurs, and also to
assess the proponions of households and retail shops using
iodized salt, and knowledge about iodized salt in the population.
is having a good impact. Iodized salt is
present in all the villages.
15.7% were 18-24 ppm, and 13.2% were less than 18 ppm.
Extrapolating these results to the total number of households
visited, we find that 60.5% of the households use salt with an
iodine content of 25 ppm or higher.
Of 99 salt samples taken from retail shops, only 12 were not
iodized. Overall, 61.6% had an iodine content equal or higher
than the threshold level of 25 ppm, and 31.3% contained more
than 40 ppm.
Practice and knowledge about kitchen salt - Of the households
visited, 90.9% had salt available. The average consumption,
estimated through interview, was 9.2 grams/person/day. We
found that 81.8% of the households use salt only for cooking;
the remainder use it also at the table. Salt was variously stored in
closed tins (42.6%), in a packet (28.6%), in an open container
(19.7%), or in a bottle (9.2%). A few households (4.6%)
washed the salt before use. Most of the salt (81.9%) is bought
within the village, at an average price of 240 Tsh/kg, most fre
quently in half kilogram packages (61.4%).
Fifty-one percent of the interviewees had heard about iodized
salt, but only 18.6% knew the type that they had purchased and
only 9.6% were aware of precautions to be taken during storage
of iodized salt.
Methods
Goiter survey - 45 primary schools were randomly selected in
each geographical zone, and three classes selected from each, to
give a total of 5,573 children for survey by examination for vis
ible goiter (grade 2 and 3 by the old WHO system, grade 2 by
the new system) (see IDD Newsletter 10(4), 1994), and also for
visible goiter when the neck is fully extended (grade 1B, old sys
tem, would be included in grade I in the new classification).
Additional data were obtained on age, shoe-wearing, and shirt
condition, the latter two as indices of socioeconomic status.
Household surveys - Health officers or assistants visited house
holds or shops, and in each, collected a sample of salt and ques
tioned the household members or shop keepers to test knowl
edge and learn abut use of iodized salt. Also, the iodine content
of salt was first screened by kits, and positive samples then col
lected for quantitative measurement by iodometric titration.
The field workers were previously trained during a three-day
workshop that included a pretest of procedures and tools in a
sample village. In analyzing the data, analyses from three villages
were excluded because of inconsistencies on repeat examination.
Conclusions
The overall goiter prevalence in Iringa Rural was higher than
had been previously reported. This may be due to previous
underestimation or possibly to a recent increase. At least three of
the nine divisions of the district (Kilolo, Kiponzelo, and Mlolo),
with a population of 203,248 people, have a prevalence severe
enough to consider the use of iodized oil.
The recent regulation on salt production is having a good
impact. Iodized salt is present in all the villages and its content
generally indicates limited loss of iodine before reaching the
household. If we accept a daily consumption of 9.2 grams salt
per capita, and assume a 30% average loss of iodine during rhe
cooking process (unpublished document, Tanzanian Food and
Nutrition Center), we can calculate that 62.5% of the Iringa
Rural population ingests more than the recommended 150 pg of
iodine per day.
Further research is needed to properly evaluate the average
consumption of salt ar the household level, and more
importantly, the average intake of particular groups at risk
(pregnant women and infants), which may well be well below
the average).
Results
Goiter prevalence - The overall prevalence of visible goiter for
the district was 12.0%, varying from 3.0% in the lowlands to
18.6% in rhe mountains. The prevalence of IB goiter was con
siderably greater in each zone, so that the total goiter prevalence,
measured as the sum of grades 1B, 2, and 3, was 54%, with a
range from 44.5% in the lowlands to 63.9% in the highlands.
The overall prevalence was 46.2% in males and 61.7% in
females. The difference among age groups from 6 to 20 years
was small. Children who were barefoot had a slightly higher goi
ter prevalence (57.7%) than those with shoes (48.9%).
Iodized salt use at household and retail level- Iodized salt was
available in 264 of the 309 households visited (85-5%). In 17 of
the 309, non-iodized salt was present, while no salt was found
in the remaining 28 households. Of the 264 positive samples
from the field rests, 159 were randomly selected and examined
with titration to quantitate the level of iodine. Of these, 38.8%
had more than 40 ppm, 32.3% were between 25 and 40 ppm,
29
IDD NEWSLETTER
MAY 1996
ABSTRACTS
seeing that iodized salt be purchased; (2) technical assistance ISSF provides advice on equipment, KIO3 purchase, and testing;
and (3) marketing - the first step was new packaging, brand
names, and incorporation of national logo. The additional costs
of iodization are low, therefore, the slight increase in price is usu
ally acceptable if accompanied by a general education campaign
on the benefits of iodized salt. For communication, the logo of
“Hand and Pot” shows salt being dropped into a cooking pot by
a woman’s hand, with the words “iodized salt” in Urdu. The
national slogan translates “health from generation to genera
tion,” to appeal to sentiments of family and long-term use.
Additional parts of the campaign have included advocacy
with government officials, religious leaders, NGO’s, and the salt
sector. Events include public gatherings, seminars, training ses
sions, and conferences. An advertising campaign was beamed to
consumers and the retail distributing network and included all
media. Important partnerships were established with govern
ment and NGO officials, salt marketers, teachers, and advertis
ing agencies. A retailer’s kit was developed to help retailers promote the benefits of iodized salt, and include trade promotion
brochures, calendars, mobiles, stickers, posters, and a rapid test
kit. Other groups targeted in the communication efforts were
community leaders and NGO’s, to include iodized salt in their
health-related activities; health-care providers, for example, by
distributing prescription pads with iodized salt logos, slogans
and messages to 25,000 doctors across the country; children,
targeted through a master’s training program for teachers and by
providing story books about IDD issues; and religious leaders,
because of their enormous influence in communities.
IODINE DEFICIENCY. A NATIONAL PROBLEM.
MEDICAL SPECTRUM, 16, (21-22), NOVEMBER
1995
These issues of the Journal of the Pakistan Medical
Association are devoted to IDD, principally in English, but with
summaries in Urdu. They include general information about
IDD and the means for its correction, some of it adapted from
ICCIDD publications. It also describes a study of TSH levels in
cord blood from 884 infants born in hospitals in Islamabad,
Lahore, Karachi, and Quetta, showing that 72% had high TSH
levels. Further details are not given, such as cutoff for this deter
mination, but this result presumably reflects transient neonatal
hypothyroidism, a well recognized consequence of iodine defi
ciency. These data include Karachi,a city not previously regard
ed as iodine deficient, and more details on methodology are nec
essary, bur the findings imply that much more of Pakistan is
iodine deficient than previously recognized.
The Spectrum also describes the Pakistan Iodized Salt Project,
which works with the salt industry to promote iodized salt.
When it began in 1994, about 5% of salt consumed in Pakistan
was iodized, while by late 1995, that number was over 40%.
Initially, only three salt processors were iodizing salt, but that
number had increased to over 400 less than two years later.
Pakistan has about 600 salt processors, most of them using sim
ple technolog}- on a small scale. The Project has been offering
them technical support to incorporate iodization into their pro
cessing. Simultaneously, a campaign to sensitize consumers to
the need for iodized salt was developed. A key component has
been the cooperation and enthusiasm of the salt industry. The
article summarizes some key lessons from experience so far: (1)
the efforts to stimulate demand should occur simultaneously
with efforts to increase the availability of iodized salt; (2) to
make the program effective, rhe private sector salt producers
need to be convinced to invest their own funds and they will
then be committed to iodization in order to protect and advance
their own investments; (3) legislation should be developed along
with programs that work with the private sector, rather than
being promulgated in a vacuum; and (4) nonprofit social mar
keting organizations can provide a critical link between the pub
lic and private sector, because international donors and govern
ments are often not structured to work directly with the private
sector.
The article describes organization of the current program in
some detail. Severe iodine deficiency has been long recognized in
Pakistan, particularly in the north, as described previously in the
IDD Newsletter. Efforts during the last decade with iodized oil
and iodized salt met with limited success. In 1994 a new strate
gy was developed, based on (1) government commitment for
IDD elimination with USI; (2) involvement of the private sec
tor to make iodized salt available; and (3) effective education.
Supporting legislation has been developed, approved by the
Federal Cabinet, and awaiting National Assembly ratification.
A major development was the Iodized Salt Support Facility
(ISSF), a division of Social Marketing Pakistan, an NGO. Its
goals are to motivate salt processors to iodize salt, and to create
demand for it. The ISSF provides: (1) motivation - this includes
education, appeal to patriotic and humanitarian spirit, and the
likelihood of higher profits; ISSF regarded it as crucial that the
salt producer invest his own resources into necessary technolog
ical improvement, because it insured his personal involvement in
IODINE NUTRITION IN POLAND, AN EXAMPLE
OF PROGRESS. ,Z. Szybinski, F. Delange, M. Gembicki, I.
Kinalska, A. Lewinski, J. Nauman, J. Podoba, M. Rybakova, L.
Szewczyk, R. Wasikowa, Z. Zdebski, The Thyroid and Iodine,
edited by J. Nauman, D. Glinoer, L. E. Braverman, U. Hostalek,
published by Schattauer, Stuttgart. Merck European Thyroid
Symposium, Warsaw, May 16-18, 1996, page 43.
This article reports progress in Poland since the 1993 report
(summarized in IDD Newsletter 11 (3):38, 1995). Based on new
ultrasound criteria for goiter, the previous data were recalculat
ed, and reported for the country, subdivided into seven major
geographical areas. The prevalence of goiter, by ultrasound,
ranged from a low of 9.6% in areas bordering the sea to 43% in
the Sudeten; median urinary iodine excretions ranged from 57-5
pg/1 in rhe eastern plains to 91.6 pg/1 near the sea. The
ThyroMobil project (IDD Newsletter 11(3):33, 1995) covered
four areas, not evaluated in the previous survey. The mean goi
ter prevalence, by ultrasound criteria, was 32% (range 14.255.4%) and the median urinary iodine excretion was 63.8 pg/1
(range 32.0-93.1 pg/1). In preliminary results from a study of
102 pregnant women, median urinary iodines were 59 pg/1 both
in the first trimester and at the end of pregnancy, with respec
tive thyroid volumes of 14.2 and 20.8 ml. Twenty women were
given 1 50 pg iodine per day; by the end of pregnancy their uri
nary iodine levels were 96.7 pg/1 and their thyroid volume had
increased only slightly (from 15.6 ml to 16.8). The one and the
hve-mmute Apgar Scales for newborn infants of die 20 suppie^nte i oTc" Were
an<^ 9-?> respectively, compared with
J mV? °r the unsuPPlemented. The Ballard Scale score
was 38.7 for supplemented versus 37.3 for unsupplemented.
30
IDD NEWSLETTER n MAY 1996
r“U*rS' the Polish Council for Control of
e ciency Disorders recommends urgent implementaion or mandatory iodine prophylaxis with iodization of kitchen
S' t at .->0 ppm and an additional supplementation of 150-200
Pg todine/day for pregnant women.
to be addressed, particularly extensive changes in salt production
and marketing; other measures including iodized oil, iodized
water, and iodine drops arc occasionally useful, but the longrange solution should usually be iodized salt; (3) exclusion ofrel
evant stakeholders - all groups with a stake in rhe problem of
iodine deficiency or its solution should be included in develop
ing a program; these groups include health authorities, other
branches of the government including education, agriculture,
and standards, the salt industry, health professionals and the
iodine deficiency community itself; (4) inadequate education - all
levels, from government to affected population, need to under
stand the effects of iodine deficiency, the importance of its cor
rection, and the means for doing so; (5) insufficient monitoring the best instruments are urinary iodine levels, iodized salt use
and thyroid size measured in representative groups at regular
intervals with public reporting of results; (6) inattention to costs
- iodization increases the cost of salt production, and this
increase needs to be recognized and distributed fairly; and (7)
nonsustainability - the program must be fair to all relevant par
ries and accompanied by a regular system of appropriate moni
toring; otherwise, it will not be sustained.
SEVEN DEADLY SINS IN CONFRONTING
ENDEMIC IODINE DEFICIENCY, AND HOW TO
AVOID I HEM. J. 7. Dunn, University of Virginia Health
Sciences Center, Charlottesville, V4, USA J Clin Endocrinol
Metab 81:1332, 1996.
1 he author noting that iodine deficiency has major conse
quences and its treatment is straightforward, muses on why it
continues to exist as a public health problem. Citing examples,
he lists seven errors that frequently occur in iodine supplemen
tation programs, with suggestions for their avoidance. The seven
are: (1) unreliable assessment ofiodine deficiency - the best indica
tors arc urinary iodine concentration, thyroid size (preferably by
ultrasound), blood spot thyroglobulin levels and neonatal TSH
determinations, and the best group for surveys is schoolchildren;
(2) poor iodine supplementation plan - iodized salt is the preferred
supplement, but potential problems in its implementation need
BRIEF , . .
Conference on Sustainable Elimination of IDD in Africa Held in Harare, Zimbabwe, April 22-24, hosted by the govern
ment
of Zimbabwe
and
jointly
sponsored
by
ICCIDD/UNICEF/WHO and the government of Zimbabwe.
Dr. Judith Mutamba, ICCIDD Subregional Coordinator for
Eastern and Southern Africa, played a key role in the organiza
tion of rhe meeting. Opening statements were made by Ms. J.
Tagwireyi, Director, National Nutritional Unit, Ministry of
Health, David Alnwick (UNICEF), L. Arcvsharian (WHO),
and Dr. Hetzel (Chairman, ICCIDD). An opening address was
given by the Honorable Dr. T. J. Stamps, Minister of Health of
Zimbabwe. Dr. Delange (ICCIDD, Executive Director) deliv
ered the keynote address. The attendees included about 250 del
egates from 45 African countries, included 7 ministers of health
and industry. Major support was provided by WHO, UNICEF,
and the national governments. ICCIDD, WHO, UNICEF,
MI, and the government of Zimbabwe, as well as private indus
try, contributed to the core budget. Conference objectives
included assessing progress in Africa towards IDD elimination,
continuing political commitment, identifying necessary mea
sures for sustainability, particularly monitoring, and strengthen
ing information exchange. The conference report has been pre
pared in draft form, and will be published shortly. The program
included regional reports, country case studies and working
group sessions on monitoring, evaluation, and training, meeting
the challenge in the sustainable elimination of iodine deficiency,
integrating micronutrient control programs, food fortification
and control of micronutrient deficiency, and a final panel dis
cussion chaired by Dr. Hetzel. The principal outcome of the
meeting was evidence of major progress towards rhe goal in
most countries; Mr. Alnwick proposed a figure of 12 million
infants saved from brain damage. Also achieved was the integra
tion of IDD within the African Task Force for Micronutrient
Deficiency, chaired by Dr. Benmiloud, Vice-Chair of ICCIDD.
The question of iodine-induced hyperthyroidism (IIH) was dis
cussed extensively; Minister Stamps insisted that this serious
problem should not question the major benefits from USI pro
grams. Dr. Delange reviewed rhe multicenter study of 7 African
countries in assessing the impact of salt iodization level on
iodine status. Iodine deficiency has been eliminated from all of
the sites investigated in these countries, a major achievement.
Although iodine overload was evident in many of them, no
additional cases of IIH were found in the survey. The major
problems identified were in the salt network, including the level
of production of iodized salt in some salt plants, unreliability of
test kits, and the need for reconsidering figures for rhe stability
of iodine in iodized salt. ICCIDD representatives at the confer
ence included Hetzel, Benmiloud, Delange, Mannar, Mutamba,
Pandav, Ling, Asuquo, Bailey, Kavishe, Lantum, Ntambue,
Siandwazi, and van der Haar.
United States/Japan Common Agenda Includes IDD
Control - This two-country Common Agenda is part of a
framework for a new economic partnership in addressing criti
cal global challenges in areas including health, population, envi
ronment, technology, and economic development. In a recent
meeting between Prime Minister Hashimoto and President
Clinton, over 20 projects in 5 broad categories were listed.
Among those for health and human development, it was stated
“we will explore cooperation on the control of iodine deficiency
disorders and support of micronutrient programs in developing
countries.” Several members of ICCIDD, including Dr. Irie,
Mr. Flaxton, and others were active in coordination with
UNICEF in placing IDD on this agenda.
World Health Assembly 1996 - This organization officially
passed rhe resolution on IDD, previously approved by its
Executive Council, and reported in the last issue of the IDD
Newsletter. This action reaffirms the commitment to achieve rhe
sustainable elimination of IDD.
31
IDD NEWSLETTER
B PAMM and Sistcr Cities International - Sister Cities
International is a nonprofit, nongovernmental organization that
seeks to develop partnerships between US and foreign cities to
increase global understanding and cooperation at the municipal
level. Currently, over 1,000 US communities are linked with
more than 1600 communities in 120 nations worldwide. The
program fosters exchanges of ideas, expertise, and cultural
understanding. PAMM (Program Against Micronutrient
MAY 1996
Malnutrition) is well known to readers of the Newsletters a col
laborative effort between Emory University and the US Center
for Disease Control working towards the elimination of
micronutrient deficiencies, particularly iodine, vitamin A, and
iron. It acts in close coordination with ICCIDD on the preven
tion of iodine deficiency. More information on the partnership
with Sister Cities International can be obtained from PAMM,
1518 Clifton Road, N.E., Atlanta, Georgia 30322, USA.
RECENT PUBLICATIONS
The Thyroid and Iodine, edited by J. Nauman, D. Glinoer, L.
E. Braverman, U. Hostalek, published by Schattauer, Stuttgart,
New York - This book consists of papers from the Merck
European Thyroid Symposium in Warsaw, May 16-18, 1996.
Many papers relate to iodine deficiency and its correction, and
some are being abstracted in this or other issues of the IDD
Newsletter.
Iodine Supplementation in a Goitre Endemic Area, with
Special Reference to Pregnancy and the Neonatal Period, by
Babikir Elnagar, Uppsala Universit}', 1996 - This dissertation
summary reports several clinical studies on iodine deficiency and
its treatment, particularly in Sudan; some are being abstracted in
the IDD Newsletter.
USI Update - This periodic summary by UNICEF reports
progress in universal salt iodization with short paragraphs on
many countries. It is available from USI Update, Nutrition
Section, H-10F, Program Division, UNICEF, 3 UN Plaza,
New York, NY 10017, USA; fax (212) 326-7336; E-mail
ndalmiya@unicef.org.
The State of the World’s Children 1996 - This annual publi
cation reports issues and progress for children. It has useful
ICCIDD
tables on development trends by country. Available from
UNICEF, New York.
Micronutrient Fortifcation ofFoods - This book, a joint pub
lication of rhe Micronutrient Initiative and International
Agricultural Centre in Wagcningen, provides background infor
mation and techniques of food fortification with vitamin A,
iron, and iodine. Major sections include: developing a food for
tification program; food vehicles and fortificants; food fortifica
tion techniques; quality assurance and control; legislations and
regulations; review of research and current practices; opportuni
ties for multiple fortification; and implementation issues and
research needs. It is available by contacting Dr. Mahshid Lotfi
at the MI, BP 8500, 250 rue Albert, Ottawa, Canada K1G
3H9.
Bangladesh IDD Newsletter - Initial issues of this publication
were in January and April 1996, in English and Bengali. It con
tains general information on IDD, with particular emphasis on
Bangladesh, and is published by the National Coordinator
Office for ICCIDD in Bangladesh, c/o Institute of Nutrition
and Food Science, University of Dhaka, Dhaka 1000,
Bangladesh; fax 880-2-865583; E-mail QStullah@Agni.Com.
INTERNATIONAL COUNCIL FOR CONTROL OF IODINE DEFICIENCY DISORDERS
The International Council for the Control of Iodine
Deficiency Disorders (ICCIDD) is a nonprofit nongovern
mental organization dedicated to the sustainable elimination
of iodine deficiency throughout rhe world. Its activities arc
supported by donations from CIDA, UNICEF, rhe World
Bank, SIDA, AIDAB, the Netherlands Ministry for
Development Cooperation, USAID, rhe World Health
Organization, and others. Inquiries about membership in rhe
ICCIDD should be directed to the Executive Director, Dr.
Delange.
Editor, Dr. Dunn. Communications about different
geographical regions can also be directed to the respective
Regional Coordinators.
The IDD Newsletter is published quarterly by ICCIDD
and distributed free of charge in bulk by international agen
cies and also by individual mailing. The Newsletter welcomes
comments, new information, and relevant manuscripts.
Inquiries and subscription requests should be sent to the
IDD NEWSLETTER
SECRETARIAT
Dr. Francois Delange,
Executive Director, ICCIDD
Avenue de la Fauconnerie 153
1170 Brussels, Belgium
Fax: 32-2-675-1898
Edited by Dr. J. T. Dunn, Box 511,
University of Virginia Medical Center,
Charlottesville, VA 22908, U.S.A.
Fax: 1-804-296-9275
°i.&
I0CID5 INTERNATIONAL COUNCIL FOR CONTROL OF IODINE DEFICIENCY DISORDERS
VOLUME 12
NUMBER 3
AUGUST 1996
st 1 years Bolivia has conducted a determined
against its severe endemic iodine deficiency, with
progress. In August 1996, the Government
invited a term of external consultants to assess its progress, with
particular reference to the criteria and guidelines for sustainable
1DD elimination recommended by ICCIDD {IDD Newsletter
11(2):19, May, 1995). The ream consisted of four ICCIDD
Board members, Dr. Eduardo Pretell, Dr. Mauro Rivadeneira,
Dr. Frits van der Haar and Dr. John Dunn, as well as Mr.
David Alnwick (LTNICEF/New York), Dr. Aaron Lechtig
(UNICEF/Bogota), and Dr. Wilma Friere (PAHO/Washington).
The group met over three days, conducted a field trip to Oruru,
COURTESY E. SCHOFFEL1N/UNICEF
COURTESY E. SCHOFFELIN7UNICEF
Continued on page 34
Stages in iodized salt production, Bolivia. (Left) Harvesting saltfrom the vast Uyuni salar. (Right) Packaging iodized salt into blocks.
IN THIS ISSUE
BOUVIA CONQUERS IODINE DEFICIENCY ■ ELEVENTH ANNUAL ICCIDD BOARD MEETING ■
THE CONTROL OF IDD IN ZIMBABWE ■ PATTERN OF SALT CONSUMPTION AND AWARENESS ABOUT IODINE
DEFICIENCY DISORDERS IN KASHMIR VALLEY ■ SUCCESS OF USI IN MADHYA PRADESH - A FOLLOW-UP HI ABSTRACTS
■ IN BRIEF: ICCIDD ON THE INTERNET, DALAI U\MA STATEMENT ON IDD, WHO PRESS RELEASE ON USI
■ RECENT PUBLICATIONS .
IDD NEWSLETTER d AUGUST 1996
and discussed the program extensively with national personnel,
including Dr. Juan Carlos Arraya. Dr. Carmen Daroca, Dr.
Javier Torres Goita. Lie. Jose Rivero, and others. A summary of
the group’s findings follows.
Background
IDD has long been a major problem throughout Bolivia. A
survey in 1983 reported a country-wide goiter prevalence of
65%. with 59% in the least affected department. The course of
IDD over the last ten years has been chronicled extensively in
previous issues of the Newsletter (4(4): 1, November 1988,
7(2):9, May 1991, 8(2): 16, May 1992, 10(2): 16, May 1994,
and 11(1):6, February 1995).
The initial strategy' was to develop a national salt iodization
program (PRONALCOBO), administer about 1.7 million
doses of iodized oil orally as a temporary' measure, and conduct
intensive education campaigns. A semi-autonomous corpora
tion, EMCOSAL, developed iodizing cooperatives among
groups of small producers and aggressively promoted proper
packaging and distribution of iodized salt throughout rhe coun
try. EMCOSAL was dissolved in 1994, having completed its
purpose, and salt iodization was left in the hands of the coun
try’s approximately' 52 private salt producers.
Other forms of iodine supplementation were used in the
early' stages of the Program. In 1985 Lugol’s iodine, one drop
each day', was distributed to pregnant woman and preschool
children throughout the country-, but the coverage was not fur
ther evaluated. Approximately 225.000 people received some
iodine in this form. Several campaigns with iodized oil took
place, the first in 1983, a second in 1986 and the third in 1988.
The latter provided iodine to about 1,200,000 inhabitants in
4,800 communities {IDD Newsletter 4(4): 1, November, 1988).
Subsequently, another 196,000 doses have been given, with
only several thousand each year recently.
A major part of the campaign has been education and social
communication. These activities have been described previously
in rhe Newsletter. The Program aimed materials about IDD and
rhe benefits of its treatment to all levels, facilitated by' many col
laborators both in governmental and nongovernmental organi
zations and in all regions. By' the current year, evaluations in the
most deprived zones of the country' demonstrated that knowl
edge of iodized salt was greater than 95%.
Initially, epidemiologic surveillance was based solely on thy
roid size. The 1981 survey reported a national goiter prevalence
of 61%, and a repeat survey' in 1983 found 65%. In both, all
departments of the country' had extensive goiter, rhe lowest
prevalence in 1983 being 56%. A survey in 1989 of 25,830 chil
dren, six to eight years old, reported an overall goiter prevalence
of 20.6%, ranging from 11.3% in Potosi to 38.9 in Beni. In
1994, a survey' confined to 30 clusters with a sample of 360
reported a national goiter prevalence of 4.5%. However, because
of uncertainties in accuracy of palpation in these small thyroids
in children, a further review comparing palpation among sever
al endocrinologists and ultrasonography left the matter unset
tled. All agreed that the goiter prevalence had greatly decreased
from that reported in previous surveys.
Education has been a key component of the program. The
previous articles document the extent and innovation of this
activity. Examples included brochures and other literature
directed at many different levels, fiestas, radio shows, videos,
and numerous oral presentations.
A brief survey of a small number of students taken from each
COURTESY E. SCHOFFEUN/UNICEF
Salt iodization by simple technology on site in Bolivia.
parr of the country' reported a goiter prevalence of 4.5% in 1994
and a median urinary iodine excretion of 19.4 pg/dl, with ade
quately iodized salt in 90% of samples taken at the consumer
level.
Current Status
In preparation for the external evaluation, PRONALCOBO
conducted a national survey (the Multiple Indicators Study),
completed in August 1996, on the consumption of iodine and
the content of iodine in urine in 100 clusters, 70 in urban zones
and 30 in rural zones. Twenty-five households in each cluster
were sampled, a total of 2500 households nationwide. The sur
vey found that consumption of iodized salt was 92% overall in
the country, 85% in rural areas and 98% in urban. This was an
increase from the Demographic and Health Survey of 1994
(DHS/94), which showed an iodized salt consumption of 64%
in rural areas and 91% in the urban.
The current survey measured urinary iodine in five samples
from each cluster, for a total of 500 samples. The results showed
a median urinary' iodine excretion of 25.2 pg iodine/dl, and an
average of 20 pg iodine/dl. In urban and rural regions, 98% of
the values were over 10 pg/dl. Nationally, 81% of the urinary
34
IDD NEWSLETTER □ AUGUST 1996
iodine levels were greater than 10 pg/dl. and only 9.2% were
Delow 5 pg/dl. In distribution among the departments,
Chuquisaca had 70% oi the households using iodized salt, and
a median urinaiy iodine excretion of 16.8 pg/dl. All other medi
an urinaiy iodine excretions were above 20 pg/dl.
Current data indicate that approximately 70,000 metric tons
or salt are produced per year. Of this, iodized salt comprised
^3,5/9 metric tons in 1995. This amount provides enough for
19 grams iodized salt per person per day and makes the country
more than sufficient in availability of iodized salt for the average
salt consumption. Beginning with 14 iodization plants in 1986,
the number has grown steadily to rhe present 54, all of them pri
vate and independent. By department these are distributed
among La Paz (11), Oruro (31), Uyuni (4), Cochabamba (6)
and Sucre (2). Of the 17,000 metric tons per year of non
iodized “common salt,” 20% is block salt, another 20% granu
lar salt, and the remaining 60% rock salt. Iodization of block
salt has been a long interest in the Bolivian program, and large
scale iodization of blocks has begun in Uyuni and Coipasa.
Consumption of block salt by humans has decreased notably in
the past five years and its use is confined mainly to animals.
2.
3.
4.
5.
Application of Guidelines for HDD
Elimination
The Guidelines for Assessment of Progress towards IDD
Elimination, proposed by ICCIDD {IDD Newsletter 11(2): 19,
May 1995) recommended that at least two of three criteria
should be met to establish current iodine sufficiency. One, that
adequately iodized salt is available and consumed by more than
90% of rhe population, appears to be met in Bolivia. Another,
that the median urinary iodine excretion be greater than 10
pg/dl, is also satisfied. These two conditions establish iodine suf
ficiency by the ICCIDD guidelines. A third criterion, that goi
ter prevalence is less than 5%, is nor clearly established in
Bolivia, although the decrease in thyroid size by palpation has
diminished dramatically during the course of the program.
ICCIDD has also offered guidelines for assessing sustainabil
ity. We can apply these to Bolivia as follows:
1. Existence ofan effective national IDD program - Continued
monitoring of iodine content of salt is in place. The DBS
study is a recurring international program that is next
scheduled for Bolivia in 1997-98. It carries out careful
household surveys, and in the most recent effort included
raking of salt samples and information on salt use. It is rec
6.
ommended that urinaiy iodines also be incorporated in this
or other surveys, to provide a biological marker for contin
uous follow-up. This guideline called for continuous mon
itoring including mandatory public reporting at regular
intervals. If properly implemented, the DBS survey can
satisfy this recommendation; otherwise, specific periodic
surveys should be undertaken.
Awareness - Currently rhe Government, private sector, and
consumers in Bolivia have a high awareness of iodine defi
ciency and appear committed to its sustained elimination.
Salt industry - The guideline called for the industry’s com
mitment, technical resources, and responsibility to rhe sus
tained and effective iodization of salt. Currently, the indus
try is doing this. Improvement in quality control and tech
nology were recommended by the external evaluators,
because much of the current methodology is fairly primi
tive, and the iodization, while adequate, is nor well con
trolled.
Iodine supply - This appears satisfactory under current con
ditions.
Cost and benefits - A key feature in any successful program
is that consumers are motivated to prefer iodized salt. This
recommendation is probably met currently in Bolivia.
Non-iodized salt is more difficult to obtain, and its price is
only slightly less than the iodized product ($0.18 compared
to $0.20). '
Laboratory access - Current lab facilities in La Paz are satis
factory for urinaiy iodine determination, and probably
adequate for salt iodine measurement both in La Paz and
elsewhere in the country.
Conclusion
The external evaluating committee commended Bolivia for
its dramatic progress from severe iodine deficiency to its current
level of iodine sufficiency. The country has met the ICCIDD
guidelines for iodine sufficiency and the prospects for sustain
ability appear good. Areas for improvement include better qual
ity control and technology of the salt iodization. Also, while ani
mals are probably receiving iodized salt, and iodized salt is prob
ably part of food processing, both of these areas deserve more
attention. As with all countries, monitoring must take place reg
ularly in future years to ensure permanence of IDD elimination.
“I encourage all people to demand iodized salt in the marketplace;
all governments to assure that iodized salt is regularly available to all people;
all salt producers to support efforts to eliminate iodine deficiency in this manner.
This ivill help to ensure a bright future for the health
and development ofyour future generations. ”
— DALAI LAMA
(Full statement on page 49)
35
IDD NEWSLETTER ■ AUGUST 1996
Eleventh Annual ICCUDD Board Heeting
he 1996 meeting took place in several stages. Fifteen
technically independent in managing their IDD programs.
ICCIDD recognizes that die biggest push will be towards
achieving sustainable IDD elimination by the year 2000, and
continues to dedicate all its efforts to this goal. It also recognizes
that the sustainability will require constant monitoring and
availability of technical support, both for countries that still have
not attained that goal and for others that having attained it, need
regular monitoring to prevent recurrence of iodine deficiency.
For rhe next three years ICCIDD, in coordination with
agencies, wants to intensify its action in its specific fields, par
ticularly technical and scientific expertise and research, focussing
on monitoring at all levels to ensure sustainable elimination, as
well as information, communication, and education, and liaison
with other agencies involved in the same process. ICCIDD
plans to expand its already close links with its collaborative
allies, particularly the Micronutrient Initiative and PAMM. The
directors of both of these groups were early members of the
ICCIDD Board, and have remained on it after rhe subsequent ▼
creation of their respective organizations. ICCIDD recognizes
the importance of these links in achieving the common goal of
sustainable elimination of IDD.
Dr. Delange outlined some key components of ICCIDD’s
proposed global program for the next three years. These
included:
1. Identification of countries with IDD and inadequate pro
grams - This has been a major activity of ICCIDD since its
inception, in collaboration with WHO, UNICEF, and
other partners. New information continues to appear and
progress is being constantly updated.
2. -/independent evaluation - ICCIDD has prepared a short
bulletin with recommendations on steps to be taken for
independent evaluation of country progress towards IDD
elimination. Components of this statement have already
been published in the IDD Newsletter (11 (2): 19, May,
1995). ICCIDD has already been invited to participate in
independent external evaluations of country programs in
Paraguay, Bolivia, Peru, the African multicenter study and
several countries in Southeast Asia, among others. With the
rapid progress in IDD programs during the past five years,
and the approach of the year 2000, this will be one of the
most important activities for ICCIDD in the next several
years. Equally important is the provision of a framework for
continued monitoring by countries in the years following
2000. Veterans of the IDD scene will ruefully recall the
promising initial achievements in IDD control a generation
ago that subsequently lapsed because methods for perma
nent monitoring were not installed.
ICCIDD is continuing its efforts to coordinate data on
progress in countries and technical issues. The CIDDS
(Current IDD Status) database project has been described
in earlier Newsletters. It was developed by ICCIDD in coor
dination with WHO and UNICEF, by Dr. Jonathan
Gorstein and Dr. John Dunn, with extensive input from
regional coordinators in ICCIDD and agencies, particular
ly UNICEF and WHO. Financial support has come from
USAID, initially through its IMPACT program and cur
rently through OMNI. Dr. Gorstein has also been respon
sible for developing databases for the MDIS of WHO in
T
Board members met in Harare, Zimbabwe, April 2527 in conjunction with the Conference on
Sustainable Elimination of IDD in Africa by the year 2000
(reported in previous issue of the Newsletter), including Asuquo,
Bailey, Benmiloud, Delange, Egbuta, Hetzel, Lan cum, Ling,
Mannar, Mutamba, Ntambue, Pandav, Siandwazi, Thilly, and
van der Haar. Special observers and guests were B. Underwood
(WHO), A. Verster (WHO/EMRO), and C. Ciupek (Guerbet).
A follow-up teleconference was held shortly afterwards, hosted
by PAMM in Atlanta, with Delange, Maberly, Dunn, Pretell,
and Stanbury, as a step towards making communication among
Board members more efficient. Improved methods of telecom
munication make this approach feasible, and it has the great
advantage of saving both money and time that would be
required for a full Board meeting. The Executive group of
ICCIDD will continue to meet annually in the fall, this year
scheduled for Ottawa in late October. Additionally, the increas
ing availability of electronic communications through e-mail
and the Internet greatly facilitate information exchange.
Activities in this direction are discussed elsewhere in this issue.
Dr. Hetzel, ICCIDD Board Chairman, presided at the
Harare meeting and Dr. Delange, Executive Director, at the
later teleconference. Items on the agenda included: reports of
activities of the Executive during the past year, considerations
for future activities; reviews of regional activities; reports of spe
cial advisory committees on science and technology, salt tech
nology, communication, and liaison; publications; future meet
ings; reports of the nominating committee; and review of finan
cial status.
Many of these items have already been addressed in previous
issues of the IDD Newsletter and are not repeated here. Others
will be described in further reports in a forthcoming issue. The
following paragraphs present additional highlights.
Reports of Executive Directors - Dr. Hetzel and Dr.
Delange reported that the transition of office of the Executive
Director in mid 1995 from Australia to Belgium had proceeded
smoothly, and they are working closely together in their current
roles, as Chairman and Executive Director, respectively. Dr.
Delange reviewed his activities including production of docu
ments, letters to Regional Coordinators, publications, indepen
dent evaluations, the multicenter study in Africa, statements on
iodine-induced hyperthyroidism, field work in Europe and
Africa, the ThyroMobil project, and visits and contacts with the
European Union, UNICEF and WHO (both at their respective
headquarters and many regional and country offices), the SCN
of the ACC, private industry, particularly Guerbet and Merck,
Kiwanis in France, Belgium, Monaco, and approach to bilater
als in Belgium, Germany, and Switzerland.
Discussion of ICCIDD orientation for next three
years - ICCIDD noted the remarkable progress that has been
made towards the goal of sustainable elimination of IDD. It has
contributed to the success by its network of over 400 profession
als in 82 countries, by its technical and scientific support to gov
ernments, professional bodies and agencies, and by its transfer of
technology to affected countries, thus enabling them to become
36
IDD NEWSLETTER ■ AUGUST 1996
4.
Geneva and databases for vitamin A and iron for the
Micronutrient Initiative. Currently CIDDS IV is available via
the Internet of the MI (http://www.idrc.ca/mi/mnnet.htm)
with last updating in June 1996. Drs. Gorsrein and Dunn
are currently updating this (CIDDS V) under contract with
OMNI, in close collaboration with the ML ICCIDD is
establishing its own home page on the Internet (see
announcement elsewhere in this issue). This will house
CIDDS V, a techn ical database with text from the IDD
Newsletter (IDDTECH), and information about ICCIDD
and IDD in general.
Operational research - An independent evaluation of water
iodination as a means for correcting iodine deficiency is
underway, headed by Dr. Benmiloud, ICCIDD Vice
Chairman. His group has completed a review of existing
water iodination reports from Malaysia, Italy, Thailand,
Mali, China, rhe Central Africa Republic, and Sudan.
Interviews are being conducted with some producers of
iodinators, and field studies are being undertaken in two
African countries and two Asian countries where iodized
water has been used. In each, information will be obtained
about: rhe population coverage with iodized water; rhe
iodine intake and goiter prevalence of the target popula
tion; technical information on various iodinators including
their availability, installation, maintenance, cost to the
community and the household; reliability of iodine supply
under field conditions; capacity of the community to main
tain water iodization systems; rhe acceptability of the
iodized water and its cost by rhe community; and the acces
sibility of iodized salt. The review and data will permit Dr.
Benmiloud’s group to compare water iodization with other
preventive measures, particularly iodized salt, for efficiency,
cost, acceptability, maintenance, monitoring and sustain
ability. This study is being funded by the Canadian
International Development Agency through the
Micronutrient Initiative.
b. Evaluation ofthe impact ofIDD correction on intellectual
and socioeconomic development - Development of such a
study is being considered, and funding sought.
c. Development of a screening test for field urinary iodine
determination - As has been pointed out before, urinary
iodine is the major laboratory indicator for iodine nutri
tion. While simple quantitative laboratory methods exist
and have been evaluated and modified by ICCIDD
{IDD Newsletter 9(4):40, November, 1993), semiquantitative methods that are faster, cheaper, and applicable
in the field are needed. Several groups are actively inter
ested in pursuing this technical development, which
ICCIDD strongly encourages.
d. Further integration of neonatal thyroid screening as an
index of adequacy of iodine deficiency correction - This
project is being pursued by several Board members
including Maberly, Thilly, van der Haar, Benmiloud,
and Delange.
e. Technical evaluation oftest kits for determination ofiodine
levels in salt - The roles of pH, alkalinity, and type of
starch are being investigated. Mr. Mannar, the MI,
PAMM, and ICCIDD, in close collaboration with
UNICEF, are pursuing this project.
Collaborative projects - The following are identified as
joint projects for collaboration with others, particularly
PAMM, the MI, and WHO, as well as other agencies.
a. Identification of countries with IDD projects but with
37
out current implementation and equipment.
Identification and implementation of regional reference
laboratories.
c. Joint publications on technology and policy guidelines.
d. Training and capacity building, and reinforcement of
regulations with the salt industry.
e. Networking on micronutrients.
5. Communication and education - Dr. Ling reviewed activ
ities during the past year. In advocacy/promotional activi
ties, these included launching the first IDD Day with MI,
UNICEF, and Kiwanis, the ICCIDD/Animation Award
entries with results sent to UNICEF, and promotion of a
global iodized salt logo. In rhe area of the communicarion/education clearing house, the Focal Point produced
and distributed rhe second version of Clearinghouse Notes,
put in a bibliographic database. It also produced the con
sultant flyer in English, French, and Spanish, the IDD Fact
Card, and proposed an IDD progress information presen
tation service.
Future actions were discussed at the meeting. They include:
(a) contribution to the next IDD Day; (b) art competition on
I DD themes involving schoolchildren as an effective method of
public participation and education; Dr. Ling will pursue this
possibility with groups such as UNESCO; (c) a proposed pub
lication “Countdown 2000” which will have country spotlights;
Dr. Ling will pursue this project with Regional Coordinators
and relate it to existing information Systems within ICCIDD,
such as the CIDDS database, and develop proposals for fund
ing; and (d) development of an IDD module for school health
curricula in countries. The programs should include school
health education that involves training of teachers and the incor
poration of sections on IDD in curricula.
b.
Regional activities - The annual reports of the Regional
Coordinators were reviewed. Information from these has been
given in previous issues of the IDD Newsletter. Additionally, Dr.
Ntambue noted that in Zaire, rhe Ministry of Trade in 1995
adopted the regulation that all imported salt should be iodized,
with inspection by rhe National Office of Quality Control ar rhe
port of entity. During the Multicenter Study, four sites were vis
ited, of which three had more than 94% of the salt iodized and
urinary iodine levels above 10 pg/dl. Additional urine samples
are being analyzed.
Publications and reports
1.
2.
3.
4.
SOS for a Billion - The Conquest of Iodine Deficiency
Disorders, Second edition, edited by Hetzel and Pandav is
now available for $20 individual copy or $15 per copy for
bulk orders. Drs. Hetzel or Pandav can be contacted for
ordering information. A French translation is being planned.
Introduction to the ICCIDD - This recent update was
printed, and some 1600 copies already distributed. It is
planned to make this also available on the ICCIDD home
page on the Internet.
Iodine Nutrition in Pregnancy - Most manuscripts have
been gathered for this publication, to be edited by Drs.
Stanbuty, Delange, Dunn, and Pandav, and printed by the
Oxford University Press in Delhi, the latter by negotiation
with Dr. Pandav.
Social Mobilization for IDD - The Board recognizes the
need for a handbook on the social mobilization aspects of
IDD programs, including advocacy at the sub-national
level, public education, and stimulating demand for iodized
IDD NEWSLETTER nAUGUST 1996
IDD NEWSLETTER bAUGUST 1996
salt at the community level. Dr.s. Ling and Lantum, with
PAMM, will explore this need.
5. IDD Newsletter - The editor, Dr. Dunn, filed a report.
Four issues appear each year, for a total of 60-64 pages.
Approximately 4200 copies are printed, distributed either
in bulk or by individual subscription. Approximately 80%
go to developing countries. Funding currently comes from
the ICCIDD core budget. The OMNI program of USAID
has offered to contribute and this is being negotiated. Issues
for the last five years are being introduced onto ICCIDD’s
website on the Internet and may become available by disk
as well.
6. ICCIDD Monthly Update - This sheet of 1-3 pages is
issued at rhe end of each month by the Secretary, Dr.
Dunn, and distributed by e-mail, fax, or mail to Board
members and others who have expressed interest. More
than half of the Board members can be accessed via e-mail,
and the list grows steadily. While developed initially as a
means for steady communication among Board members,
it is also sent to key agency officials and others with an
interest in 1DD who have requested receiving it. It will also
be included on ICCIDD’s website.
7. ICCIDD manual series - Some 50,000 copies of The
Practical Guide to Iodine Deficiency were printed in English
in 1990 and most supplies have been exhausted. The
Spanish and French translations are also nearly exhausted.
Copies are still available in Portuguese. This manual, has
been widely distributed by direct mail and through inter
national agencies. The manual Salt Iodization for the
Elimination of Iodine Deficiency, by Mannar and Dunn, is
available for distribution from the MI, the ICCIDD
Secretary’s office, WHO, or UNICEF. The manual
Methods for Measuring Iodine in Urine is also available.
0 996
I.
BOARD
A.
EXECUTIVE COMMITTEE
Dr. B. S. Hetzel
Chairman
Cl- Health Development Foundation
Sth Floor. Samuel Way Building
Women’s and Children’s Hospital
72 King William Road
North Adelaide 5006, Australia
Telephone: 61-8-204 7021
Fax: 61-8-204 7221
E-mail: iccidd@a011 .aonc.net.au
Dr. M. Benmiloud
Vice Chairman
c/oANDRS
P. O. Box 1008
Oran, Algeria
Fax: 213-6-347934
"
Dr. F. Delange
Executive Director
Avenue de la Fauconnerie, 153
1170 Brussels, Belgium
Telephone: 32 2 675 85 43
Fax: 32 2 675 18 98
E-mail: fdelange@ulb.ac.be
Liaison activities - The Board reviewed its extensive contacts
with other groups, particularly those by Dr. Delange, Dr.
Hetzel, Mr. Haxton, and Dr. Benmiloud, with World Health
Organization, the Subcommittee on Nutrition of the United
Nations Administrative Coordinating Committee, the World
Bank, Kiwanis, UNICEF, OMNI, bilateral donors, and many
other organizations. Regional Coordinators also pursued local
contacts with agencies and nationals involved in IDD or its cor
rection. The Board re-emphasized its strong commitment to
coordinating its activities with all relevant groups.
Dr. J. T. Dunn
Secretary
University of Virginia Health Sciences
Center
Box 511
Charlottesville, VA 22908, USA
Telephone: 804-924-5929
Fax: 804-296-9275
E-mail: jtd@virginia.edu
Mr. M. G. Venkatesh Mannar
Executive Director, The Micronutrient
Initiative, IDRC
BP 8500
250 Albert Street
Ottawa K1G 3H0, Canada
Telephone: 613-236-6163
Fax: 613-567-4349
E-mail: tguay@idrc.ca
Election of Board members and Senior Advisors - The
accompanying list gives the composition of the new Board. New
members of the Board for 1996 include: J. Egbuta, public health
scientist (Nigeria); L. Locatelli-Rossi, salt consultant (South
Africa); L. Meftah, salt consultant (Algeria); Sangsom Sinawat,
government nutrition physician (Thailand). The following
Board members with expiring terms were renominated: Bailey,
Djokomoeljanto, Medeiros-Neto, Mutamba, Ntambue,
Pinchera, van der Haar. New Senior Advisors include R.
Aquaron, scientist (France); R. Carriere, UNICEF (Bangladesh);
N. Chawla, communications specialist (India); O. L. Ekpechi,
endocrinologist (Nigeria); G-F. Fenzi, endocrinologist (Italy); G.
Gebre-Medhin, pediatrician (Sweden); R. Hanneman, Salt
Institute (USA); S. Ouais, physician (Syria); R. Prakash, Salt
Commissioner (India); R. Trowbridge, CDC/PAMM, nutri
tion physician (USA); B. Underwood, nutritional scientist
(WHO); P. Vitti, endocrinologist (Italy); R. Volpe, endocrinol
ogist (Canada). ■
Ms. J. Mutamba
Ministry’ of Health
P. O. Box 8204
Causeway
Harare, Zimbabwe
Telephone: 263-4-792 454
Fax: 263-4-791 169
38
Dr. C. S. Pandav
Center for Community Medicine
All India Institute of Medical Sciences
Ansari Nagar
New Delhi 110 029, India
Telephone: 91-11-686 35 22
Fax: 91-11-686 3522
Dr. D. Lin turn. Subregional Coordinator for
Central Africa
University Centre for Health Sciences
CISS BP 1364
Yaounde, Cameroon
Telephone: 237-31 -5105 or 5178
Fax: 237-23-0296 (WHO)
B.
SUBCOMMITTEE HEADS
Dr. J. Mutamba, Subregional Coordinator
for Eastern and Southern Africa
(Also Executive Committee)
Dr. J. B. Stan bury, Science and Technology
43 Circuit Road
Chestnut Hill, MA 02167, USA
Telephone: 617-277-3545
Fax: 617-277-3545
E- m a i L j s ta n b u r@warrc n .med. h a rva rd. ed u
Dr. C. S. Pandav, Regional Coordinatorfor
Southern Asia
(Also Executive Committee)
Dr. j. Ling, Communication
School of International Health
Tulane University
1430 Tulane A venue. Room 1310
New Orleans, LA 70112
Telephone: 504-584-3655
Fax: 504-584-3653
E-mail: ihoepis@music.ics.rulane.cdu
Mr. D. P. Haxton, Political and Industrial
Liaison
909 Elizabethan Drive
Greensboro, NC 27410
Telephone: 910-855-7886
Fax: 910-855-7886
E-mail: DPHaxton@aol.com
Mr. M. G. Venkatesh Mannar, Salt
Industry
(also Executive Committee)
t
C.
'GIONAL COORDINATORS
Dr. F. Delange, Regional Coordinator for
Europe
(also Executive Director)
Dr. G. Gerasimov, Subregional Coordinator
for Russia and Central Asia Rep)
Flead, Department of Therapy
Russian Endocrinology Research Centre
Institute of Clinical Endocrinology
D. Uljanova, 11
117036 Moscow, Russia
Telephone: 7 095 124 35 02
Fax: 7 095 124 35 02
E-mail: gerasim@gerasim.msk.su
Dr. M. Benmiloud, Senior Coordinator for
Africa
(Also Vice Chair)
Dr. Zu-pei Chen, Regional Coordinatorfor
China and Eastern Asia
Vice Director, Institute of Endocrinology
Tianjin Medical University
Tianjin .300070, People’s Republic of
China
Dr. E. A. Pretell, Regional Coordinatorfor
the Americas
Av. Cuba 523
Apartado Postal 110388
Lima 11. Peru
Telephone: 51-14-335-772
Fax: 51-14-716-320
D.
OTHER BOARD MEMBERS
Mrs. M. N. Asuquo (Nigeria)
Dr. K. Bailey (WFIO, Geneva)
Dr. W. J. Blechman (Kiwanis, USA)
Dr. H. Delisle (Canada)
Dr. G. R. DcLong (USA)
Dr. R. Djokomoeljanto (Indonesia)
Dr. J. O. Egbuta (Nigeria)
Mr. M. Girard (Canada)
Dr. F. P. Kavishe (UNICEF, Kenya)
Dr. B. Kodyat (Indonesia)
Dr. L. Locatelli-Rossi (South Africa)
Dr. G. Maberly (USA)
Dr. G. Medeiros-Neto (Brazil)
Mr. L. Meftah (Algeria)
Mr. R. Mohan (India)
Dr. M. Ntambue-Kibambc (Zaire)
Dr. A. Pinchera (Italy)
Dr. C. Pittman (USA)
Dr. M. Rivadeneira (Ecuador)
Dr. Sangsom Sinawat (Thailand)
Ms. C. Siandwazi (Tanzania)
Dr. C. Thilly (Belgium)
Dr. F. van der Haar (USA)
Ms. H. Viswanathan (India)
39
11 SENIOR ADVISORS
Dr. R. /\quaron (France)
Dr. K. Bagchi (WHO/EMRO)
Dr. K. Bauch (Germany)
Dr. C. Beckers (Belgium)
Dr. A. Berg (World Bank)
Dr. L. E. Braverman (USA)
Dr. FL Burgi (Switzerland)
Mr. R. Carriere (UNICEF, Bangladesh)
Dr. B. A. Charania (Pakistan)
Dr. I. Chastin (France)
Ms. N. Chawla (India)
Dr. G. A. Clugston (WHO, Geneva)
Dr. C. H. Daza (Colombia)
Dr. M.C. de Blanco (Venezuela)
Dr. C. J. Eastman (Australia)
Dr. O. L. Ekpechi (Nigeria)
Dr. F. Escobar del Rey (Spain)
Dr. G-F. Fenzi (Italy)
Dr. R. Fierro-Benitez (Ecuador)
Dr. M. H. Gabr (Egypt)
Dr. E. Gaitan (USA)
Dr. M. Gebre-Medhin (Sweden)
Dr. M. Gembicki (Poland)
Dr. J. P. Greaves (UK)
Mr. R. Hanneman (USA)
Dr. M. Iric (Japan)
Dr. D. T. Jamison (USA)
Dr. M. G. Karmarkar (India)
Dr. D. A. Koutras (Greece)
Dr. B. A. Lamberg (Finland)
Dr. J. Q. Li (China)
Dr. T. Z. Lu (China)
Dr. T. Ma (China)
Mr. R. ManofF(USA)
Dr. J. Matovinovic (USA)
Dr. S. Nagataki (Japan)
Dr. C. Nwokolo (Nigeria)
Mr. FL Oost (The Netherlands)
Dr. S. Ouais (Syria)
Dr. A. Pardo (Bolivia)
Dr. J. A. Pittman (USA)
Dr. A. Pradilla (Colombia)
Mr. R. Prakash (India)
Dr. Q. Qian (China)
Dr. A. Querido (The Netherlands)
Dr. V. Ramalingaswani (India)
Dr. G. Riccabona (Austria)
Dr. N. Salvatore (Italy)
Dr. P. Scriba (Germany)
Dr. Zhong-fu Shi (China)
Dr. FI. Stacpoole (Mexico)
Mr. P. Subramanian (India)
Dr. R. Suwanik (Thailand)
Dr. F. L. Trowbridge (USA)
Dr. B. Underwood (WHO, Geneva)
Dr. L. S. Villadolid (Philippines)
Dr. P. Vitti (Italy)
Dr. R. Volpe (Canada)
IDD NEWSLETTER □ AUGUST 1996
The Control of IDD in Zimbabwe
CHARLES TODD
Senior Lecturer. University of Zimbabwe Medical School
JUDITH MUTAMBA
National IDD Control Coordinator, Ministry of Health and Child Welfare
imbabwe is a landlocked sub-Saharan African country
Z
situated between the Zambezi and Limpopo rivers (see
map, Figure 1). It is thus south of the Equator and
entirely within the Tropic of Capricorn. Zimbabwe's neighbors
are Zambia to the north, Mozambique to rhe east, South Africa
to the south and Botswana to the west. Most of rhe country is
on rhe Central African plateau at altitudes of 900 meters or
more above sea level. Granite, schists and igneous rocks make up
more than 70% of the country’s area.
The total surface area of Zimbabwe is 390,757 km2, and
population around 11.5 million. Around one third of the pop
ulation live in urban areas. Greatest population densities (apart
from cities) are found in the east and north, and lowest in the
west. The country' is divided into 8 provinces plus the two main
cities.
Zimbabwe is classified as a lower middle income country
(1994 per capita GDP was US$438). It has a well developed
infrastructural network of roads and railways. The principle
sources of national wealth are agriculture, mining and tourism.
Tobacco is the single biggest foreign exchange earner, but hor
ticulture is of growing importance. In recent years Zimbabwe
has been a net importer of maize, the main staple food, after a
succession of poor seasons. In 1996, after good rains, the coun
try is expecting to once again start exporting maize. Many dif
ferent minerals are mined: among the most important are gold,
chrome, iron, copper, asbestos and platinum. There are no sub
stantial salt deposits in Zimbabwe and all salt is imported.
IDD in Zimbabwe
Map ofZimbabwe to show provinces.
A variety of words for goiter exist in rhe local languages of
Zimbabwe, suggesting that it has long been recognized by
indigenous African people. Published accounts of goiter first
appeared in the 1960s. In the most derailed of these, Dent and
co-workers reported finding a total goiter rate of 76% amongst
356 subjects of all ages, with a high frequency of clinical nodu
larity.! Prevalence was highest in the 6-10 and 10-20 year age
groups. One subject was suspected of being hypothyroid and no
cretinism was observed. Water in a local well and stream was
analyzed for iodide levels: these were 1.13pg/L and 0.90pg/L
respectively. Although these levels were recognized as being very
low, the authors suggested that goitrogens, particularly from the
Brassica family, may also be playing an important role.
Political events during the 1970s overshadowed any attempts
to tackle endemic goiter, bur after Independence in 1980 inter
est in the problem was rekindled. Grave and Mills reviewed the
notes of all admissions with a principal diagnosis of thyroid dis
ease to Mpilo Hospital, Bulawayo for the years 1969-77.2 They
concluded that in 64% of the 418 cases dietary iodine deficien
cy was the main cause of the disease, and made a strong plea for
legislation on the iodization of domestic salt.
A study in Goromonzi District reported a goiter prevalence
of 29%, although this may have been an underestimate.3 Urine
iodine results were probably misleadingly high, but no role for
goitrogens was suggested. Eight of 229 subjects tested were
hypothyroid and two hyperthyroid. One hundred infants under
one year old had TSH estimation carried out on filter paper
whole blood samples: all were in the normal range. A study in
Hwedza district found a total goiter rate of 73% overall - very
similar to the figure found in the same schools 18 years earlier.4
Despite this very high figure, a community survey of 7,000 peo
ple in the same area revealed only five (0.07%) who had lesions
consistent with cretinism.5
A decisive role for iodine deficiency in rhe etiology of endem
ic goiter in Zimbabwe was only recently established.6 Median
urine iodine concentrations in Hwedza and Chiweshe districts
were lOpg/L and 16.5pg/L respectively: results consistent with
severe iodine deficiency. Goitrogens that are metabolized to
thiocyanate were found to have no significant effect. Figures 2
and 3 show respectively subjects with goiter and a cretin from
these two districts.
As part of a later study in Goromonzi district, thyroid func
tion testing was performed on schoolchildren, showing raised
40
IDD NEWSLETTER □ AUGUST 1996
ex els in 35% of the 188 children tested.7 Audiometry on
c ns same group showed that all but one of the 121 children tcstCC la normal hearing indicating an absence of subclinical cre
tinism. despite the high frequency of hypothyroidism.8
By the beginning of the current decade, the picture had
ecome fairly clear. Endemic goiter occurred in many parts of
Zimbabwe, and was severe in some localities. Iodine deficiency
lad been established as the main etiological factor, with little
apparent role for goitrogens.
Zimbabwe has achieved virtual
elimination of iodine deficiency within
a very short period.
province summary of the results is shown in Table 1 - these data
have been weighted by population size utilizing the results of the
1992 census.9 The survey confirmed that endemic goiter affect
ed the whole of Zimbabwe to a greater or lesser extent: no dis
trict had a total goiter rare of less than 10%. In other words, the
whole of Zimbabwe was affected by some degree of iodine defi
ciency. Twenty of the surveyed districts were judged as being
severe endemia on the basis of total goiter rates (TGR) above
50%. The most severely affected province was Mashonaland
East: it includes the worst affected district, Murehwa, where
total and visible goiter rates were 79% and 23% respectively.
The least affected provinces were Matebeleland South and the
two major cities, Harare and Bulawayo. Overall, 6.4 million
people - more than half the total population of Zimbabwe were at risk of moderate or severe IDD.
1988 National Goiter Survey
Despite the evidence from some parts of rhe country that
severe IDD did occur, its importance as a public health problem
was disputed. In order to resolve this question, and to determine
whether a national IDD control program was justified, in 1988
the Ministry of Health carried out a national goiter survey. With
the support of the Swedish International Development Agency
(SI DA), teams from all provinces were trained in goiter survey
techniques and surveys took place in all provinces towards rhe
end that year.
Thyroid size was estimated according to standard methods as
recommended by WHO. Surveys took place in primary schools
with the aim of covering 1% of the total population of each dis
trict. Schools were selected according to a locally developed
method of sampling on a population proportionate-to-size basis,
similar to that described in “Monitoring Salt Iodization
Programs. " 10 Total and visible goiter rates were derived on a
district-by-district basis.
Altogether 53 districts were surveyed. A province-by-
Establishment of a National IDD
Control Program
In 1989, following the national goiter survey, the Ministry of
Health called a national consultative meeting of all the interest-
Table I: Summary of results of 1988 national goiter survey: Weighted data by providence
Providence
Population (1992)
Total Examined
TGR%
VGR%
Severity of IDD
Manicaland
1,537,224
22,373
42.7
2.8
Moderate
Mashonaland Central
856,736
17,133
51.9
5.0
Severe
Mashonaland East
1,034,342
14,144
59.5
10.3
Extreme
Harare
1,485,615
9,824
10.8
0.2
Mild
Mashonaland West
l.l 12,955
20,727
41.4
13
Moderate
Masvingo
1,222,581
24,549
51.2
5.4
Severe
Matebeleland North
641.186
16,263
38.8
1.6
Moderate
Bulawayo
621,742
4,663
19.3
0.4
Mild
Matebeleland South
592,398
14,834
16.6
0.7
Mild
Midlands
1.307.769
19,586
42.5
3.6
Modeiate
10,412,548
164,096
38.3
3.3
Moderate
Zimbabwe overall
TGR = Total goiter rate
VGR = Visible goiter rate
41
IDD NEWSLETTER a AUGUST 1996
TERMS OF REFERENCE OF THE ZIMBABWE INTERSECTORAL COMMITTEE ON IDD CONTROL
I.
To define the plan of action for the IDD control program.
2.
To assign tasks to the various Ministries and sectors.
3.
To monitor rhe implementation of the IDD plan of action.
4.
To assist in the distribution of iodized oil capsules as a short term strategy for the control of IDD in severely
affected areas.
5.
To ensure rhe availability of iodized salr as a long term strategy for the control of IDD.
6.
To formulate mechanisms lor monitoring and evaluation.
7.
To identify relevant research areas.
8.
To draw up a project proposal for the Zimbabwe IDD control program.
9.
To suggest effective mechanisms to sensitize communities on IDD and foster meaningful community participation
c
in the control program.
10.
To facilitate rhe enacting of appropriate legislation for the control of IDD.
II.
To work out mechanisms for involving NGOs and the international agencies in the IDD program in Zimbabwe.
ed parties to discuss the results and to plan strategies for the
elimination of IDD in Zimbabwe. The meeting recommended
that a national intersectoral committee be established to oversee
IDD control, with representation from a variety of Ministries including Health, Trade and Commerce, Finance, Agriculture,
Information and Justice; the University of Zimbabwe, and the
bilateral agencies. The terms of reference for this committee are
given in the Box.
The committee is chaired by rhe director of rhe Maternal and
Child Health (MCH) unit within the Ministry of Health. The
secretariat is located in the Departmental of National Nutrition,
and the Deputy Director of Nutrition is the coordinator of the
national IDD control program.
In addition to rhe main committee and the secretariat, three
subcommittees were established as working parties. These are:
(a) monitoring and research; (b) salt iodization, and (c) social
mobilization.
The national consultative meeting set a variety of objectives
for IDD control. These were later refined by rhe national inter
sectoral committee and incorporated into the national plan of
action which was adopted in 1991. The overall goal of rhe
national IDD control program, as stated in the plan of action is
“to eliminate iodine deficiency disorders in Zimbabwe by ensuring
normal iodine nutrition ofthe entire population by the year 2000
The main method recommended was universal salt iodiza
tion, with iodized oil capsule distribution as an interim measure
for severely affected areas. A broad intersectoral and interminis-
42
tcrial approach to addressing the IDD problem was recom
mended, through the following strategies: intersectoral collabo
ration; advocacy; social marketing; strategic intervention; sur
veillance, monitoring and evaluation; research and evaluation;
and human and organizational development.
Three major achievements of the Zimbabwe IDD control
program are highlighted: the attainment of USI, the creation of y
a partnership with the private sector; and the establishment of a
comprehensive monitoring program.
Universal salt iodization (USI)
USI always appeared the best option for IDD control in
Zimbabwe. Salt, prepackaged into 500g to 2kg bags, is distrib
uted throughout the country by traders, who sell it through
retail outlets. All but a tiny amount of salt is imported, and
packaged locally. In the late 1980s, four companies handled
80% of all salt imports.
Sensitization on the need for iodization of salt commenced
after the formation of the national intersectoral committee, with
local politicians and the salt traders particularly targeted. (Figure
4 shows a poster used in efforts to raise the awareness of the gen
eral public on the issue.) International pressure for action was
also growing, particularly following the World Summit for
Children in 1990. Included in the plan of action adopted by
heads of state was rhe virtual elimination of IDD by the year
2000. The President of the Republic of Zimbabwe, Robert
IDD NEWSLETTER
(Above) Women with visible goiter. (Right) Cretin, left, with
normal woman and her child.
Mugabe, was present at the United Nations for this summit.
The importance of the Sua Pan project in Botswana was real
ized at an early stage. Sua Pan is a large salt pan which was devel
oped for the large scale commercial production of soda and salt.
In early 1991, at a meeting of rhe Africa IDD Task Force in Dat
es Salaam, a resolution was passed urging the managing compa
ny to produce iodized salt. This was followed up with a salt pro
ducers’ workshop held in Botswana in 199.3.
As a result of all these and other efforts, increasing quantities
of iodized salt were produced and imported into Zimbabwe
from 1992 onwards. The law governing salt in Zimbabwe was
finally amended in early 1995. The new regulations specify that:
“all salt that is manufactured or soldfor human consumption,
whether as crude salt, table salt, favored salt or otherwise...
shall be iodated with potassium or sodium iodate and contain
the equivalent ofnot less than thirty milligrams or more than
ninety milligrams ofiodine per kilogram ofsalt."
Recent data shows that nearly all of Zimbabwe’s salt is now
iodized to some degree, with only 2% of 335 samples collected
in 1996 having less titan 10 ppm iodine. However, 33% of sam
ples still did nor meet the lower legal limit of 30 ppm. (1986
sentinel surveillance data - see below).
Partnership with the private sector
Private and non-governmental organizations have participat
ed in rhe Zimbabwe IDD control program from its inception,
particularly the salt importers (all private companies) and the
Consumer Council of Zimbabwe. These organizations were
43
AUGUST 1996
IDD NEWSLETTER □ AUGUST 1996
a mechanism to monitor rhe biological effects of iodine supple
mentation, and to make recommendations to the main com
mittee on any changes needed. To this end, 12 sentinel districts
were chosen. These represent a cross section of urban and rural,
remote and proximal, and previously severe and mild IDD
areas. In each of these districts, three schools are randomly
selected for annual visits by the survey team. The main method
selected for monitoring has been urine iodine analysis on spot
samples collected from school children. At least 50 samples are
collected in each school from children who are selected by sys
tematic random sampling from the total enrollment of the
school. Goiter surveys arc carried out ar the same time. Survey
teams in the provinces were originally trained for the national
goiter survey in 1988, and follow up training workshops have
been held since.
Urine iodine assays are established at the Government
Analyst Laboratory' (GAL) and the University of Zimbabwe
Department of Biochemistry. The GAL has the main responsi
bility for routine analysis of urine iodine. Staff there attended
one of the training courses held at the Program Against
Micronutrient Malnutrition (PAMM) in Atlanta, and the labo
ratory participates in the PAMM quality' control scheme.
Facilities for TSH monitoring on filter paper samples are
available, and neonatal testing is being carried out on a trial basis
in selected districts. However, due to staffing difficulties and the
expense of the method, measurement of TSH has yet to become
established as a routine part of Zimbabwe’s monitoring system.
Salt monitoring, which is carried out countrywide, also
forms a major component of the Zimbabwe IDD control pro
gram. Environmental health officers from all provinces have
now been trained in the use of rapid test kits for monitoring salt
at household, retail and wholesale level, and a reporting system
for results has also been established. According to available
records, around 5,000 salt samples were tested in 1995. When a
batch of salt is found to be inadequately iodized on kit resting,
samples are sent to the GAL for formal analysis by' titration
before action is taken. In addition, salt monitoring with analy
sis by titration has now been incorporated into the program for
monitoring the effects of the social dimensions of the economic
structural adjustment program, providing a regular countrywide
snapshot of the quality' of salt on sale.
IDD poster - The caption, in Shona, translates “goiter is
preventable; always use iodized salt. "
actively involved in policy formulation and the implementation
ofUSI. Once the need for importation of iodized salt had been
recognized, traders started to import it well in advance of any
legal requirement to do so. Recognizing rhe health benefits of
iodized salt, traders put it on sale at little or no extra cost to the
consumer (less than 5% more than non-iodized salt). The major
supplier of iodized salt, SodaAsh (Botswana), realizing the
potential commercial advantages, agreed to sell iodized salt at
the same price as the equivalent type of non-iodized salt. This
partnership with the private sector, which has helped to provide
iodized salt at affordable prices, should also greatly strengthen
rhe prospect of sustaining US1 in the future.
Changes in iodine status
Local assays for iodine levels in urine were established in
Zimbabwe by 1990. Early' results confirmed the findings
(reported above) from outside laboratories, and underlined how
severe and widespread iodine deficiency was in Zimbabwe. Prior
to the implementation of USi, in 1990-92, typical median urine
iodine (UI) levels amongst primary schoolchildren were around
20-50pg/L. For example, in Chimanimani district (Manicaland)
median Ul was 19.5pg/L, Murehwa (Mashonaland East)
22pg/L, Centenary (Mashonaland Central) 24pg/L, Binga
(Matebcleland North) 51pg/L, Bikira (Masvingo) 31pg/L.
Gokwe (Midlands) 59pg/L, Matobo (Matebeleland South)
37pg/L and Harare City 5O.5pg/L. Such results broadly con
firmed the findings of rhe 1988 goiter survey - and indicated
that moderate to severe iodine deficiency occurred throughout
the country, even in cities.
By' 1993, obvious change in urine iodine was already appar
ent. For example, in that year Chimanimani and Centenary' dis
tricts had median UIs of 283pg/L and 228pg/L respectively.
Extensive urine collection under rhe monitoring program took
Monitoring
As indicated above, monitoring was identified as a key ele
ment of Zimbabwe IDD control program ar an early stage, and
the subcommittee on monitoring and research has met regularIv since its formation in March 1990. The committee’s mem
bership includes representatives from rhe Ministry of Health
and Child Welfare (Nutrition, Epidemiology Environmental
Health, Government Analyst and Biair Research Laboratory);
the Ministry of Agriculture (Veterinary Services); the University
of Zimbabwe (Biochemistry, Chemical Pathology and
Community Medicine), and UNICEF.
The main function of this committee has been to set in place
44
IDD NEWSLETTER a AUGUST 1996
and manpower are required to sustain the existing surveil
lance system.
omi!
Typical changes in iodine status which have
sind | 9^0" 4 Previously severeaffected district
Conclusion
Year
Zimbabwe has achieved virtual elimination of IDD within a
very short period, an achievement of which we are justifiably
proud, and a testament to the efforts of many people in govern
ment, the University, the international agencies and the salt
trade. Some fine tuning is required, particularly with regard to
rhe amount of iodine in salt, and continuing monitoring is
essential. Indeed, a well established monitoring system is essen
tial for rhe sustainability of the program, along with the contin
uing commitment of all the key players: politicians, salt traders,
government ministries, non-governmental organizations and
consumers. The benefits for future generations - in terms of
increased school performance, increased work capacity,
decreased goiter and so on - are likely to be enormous. ■
Median urine iodine (pg/L)
1991
20
1993
280
1995
430
place in 1995. The overall median UI on all samples collected
from 6 districts was 430pg/L (range of medians: 290-560pg/L)
and mean 490pg/L. What is remarkable is that of all 966 sam
ples analyzed, only 16 (1.7%) had values below 50pg/L and 48
(5.0%) below lOpg/L. These results indicate that all the chil
dren surveyed were receiving an adequate amount of iodine.
While it is indisputable that most of the change in iodine sta
tus is due to the implementation of US1, there have also been
some dietary changes over the same period. In recent years there
has been a considerable increase in intake of sea fish, notably
mackerel, following the signing of a trade agreement with
Namibia. Annual per capita fish consumption rose from 2.66kg
in 1992 to 6.35kg in 1994.11 This probably equates to an aver
age daily intake of about 15pg iodine per day. However, since
fish consumption is variable, some individuals may be getting as
much as lOOpg of iodine from this source.
Table 2 summarizes the typical changes in iodine status
which have occurred, in previously severely affected districts,
during the current decade.
Little data on the changes in the occurrence of the manifes
tations of IDD, such as goiter, are available, but a small study in
one locality showed a drop in total goiter rate from 44% to 9%.
References
1. Dent RJ, Lewis B, Nelms J D, Stover AE. A study of thyroid disease in the
Chikwaka region of Rhodesia. Cent Afr J Med, 1968; 14: 67-72.
2. Grave GF, Mills AE. A clinico-pathological study of thyroid disease
patients admitted to Mpilo Hospital: a nine year survey. Cent Afr J Med, 1980;
26: 251-53.
3. Chinamora Research Team. Endemic goiter in Chinamora, Zimbabwe.
Lancer 1986; i: 1198-1200
4. Todd CH, Laing R, Marangwanda CS, Mushonga N. Iodine deficiency
disorders in Zimbabwe. No change in prevalence of endemic goiter in Wedza
district, as shown by school surveys carried out 18 years apart. Cent Afr J Med
1989; 35: 304-306.
5. Todd CH, Arthur G, Keeley D. A survey of endemic cretinism in Wedza
District. Cent Afr J Med 1988; 34: 233-234 (abstract).
6. Todd CH, Bourdoux P. Severe iodine deficiency in two endemic goiter
areas of Zimbabwe. Cent Afr J Med 1991; 37: 237-241.
7. Todd CH, Sanders D. A high prevalence of hypothyroidism in associa
tion with endemic goitcr in Zimbabwean schoolchildren. J Trop Pacd 1991; 37:
199-201.
8. Todd CH, Sanders D, Chimanyiwa T. Hearing in primary school chil
dren in an iodine deficient population in Chinamhora, Zimbabwe. Trop Geogr
Med 1988; 40: 223-225.
9. Census 1992, Zimbabwe national report. CSO, Harare, Zimbabwe.
1994.
10. Sullivan KM, Houston R, Gorstein J, Cervinskas J (eds). Monitoring
universal salt iodization programs. PAMM, MI, ICCIDD, 1995.
11. Sen S. The market for fish and fish products in Zimbabwe.
FAO/ALCOM, 1995.
12. Todd CH, Allain T, Gomo ZAR, Hasler JA, Ndiwcni M, Okcn E.
Increase in thyrotoxicosis associated with iodine supplements in Zimbabwe.
Lancet 1995; 346: 1563-64.
Current challenges
These results are a testament to the success of USI, and sug
gest that IDD has already been eliminated in Zimbabwe.
However, program managers still face a number of important
and related challenges, notably:
(a) A rise in the incidence of hyperthyroidism since USI was
implemented. Todd et al 12 described a threefold increase
in the number of cases of hyperthyroidism seen at the cen
tral hospital in Harare between 1991 and 1994. Such an
increase has been described in many countries in associa
tion with programs of iodine supplementation, and may to
some extent be unavoidable. Although hyperthyroidism is a
readily treatable condition, adequate facilities for this are
required.
(b) From a state of iodine deficiency, Zimbabwe’s population
is now exposed to more iodine than needed to guarantee
normal thyroid function. This may magnify any increase in
hyperthyroidism and is therefore undesirable. The reasons
for this state of over abundant supply are probably that salt
consumption was underestimated and losses of iodine from
salt were overestimated. Furthermore, there is enormous
variability in the amount of iodine in the salt.
(c) Continuing to monitor iodine status. These experiences
indicate the importance of an on-going program of moni
toring as part of overall IDD control. While a salt moni
toring manual is being developed for local use, resources
Acknowledgements
We wish to acknowledge all the members of the National
Intersectoral Committee on IDD control and all its various sub
committees. In particular we wish to thank Mrs. Theodora
Nyamandi from the Government Analyst Laboratory, Prof.
Julia Hasler of die University of Zimbabwe, and Ms. Laura
Maclehose and Dr. Peggy Henderson of UNICEF, Harare. This
report contains some data prepared by the authors for the recent
WHO seven country study on iodine status in Africa. Finally we
wish wc to thank the Secretary for Health and Child Welfare for
permission to publish.
45
IDO NEWSLETTER a AUGUST 1996
Pattern of Salt Consumption and Awareness About
Iodine Deficiency Disorders in Kashmir Valley
A. H. ZAR.GAR, F. A. SOFI, S. R. MASOODI, B. A LAWAY, N. S. SHAH. A. I. WANI,M. I. f^OODI,
Department of Endocrinology, Institute of Medical Sciences, Soura, Srinagar as
Address correspondence to: Dr. A. H. Zargar, Associate Professor and Head, Department of Endocnno ogy.
’
.
_ nlMpdical Srin
f
nces.
Soura. Srinagar, GPO Post Bag No. 27, Kashmir 190 011, India.
Introduction
I he commitment of the South Asia Association for Regional
Cooperation (SAARC) to eliminate 1DD by the year 2000 is
reflected in the declaration of “Universal Access to Iodized Sait
by 1995” at the second SAARC Conference held in Colombo,
Sri Lanka in September, 1992. Recently an extensive survey has
revealed that Kashmir valley is an iodine deficient area with a
very high goiter prevalence in schoolchildren (1). The present
study assesses the pattern of salt consumption and awareness of
iodine deficiency disorders by different socioeconomic groups in
Kashmir valley.
Study Population and Methods
We investigated 999 subjects from different socio-economicstrata and from various areas of Kashmir valley (urban and
rural). They were interviewed using a pre-planned question
naire on salt consumption and on awareness of various aspects
of iodine deficiency disorders. The study population included
teachers, doctors, college students, businessmen and housewives
chosen randomly from various areas of Kashmir valley. Literacy,
socioeconomic status and urban/rural status of the study popu
lation was determined by Pareck’s scale and modified
Kuppuswamy scale (2).
1DD awareness was assessed by asking about goiter, its rela
tionship to iodine deficiency, utility of iodized salt, etc. Salt
consumption pattern was determined by asking about the type
of salt consumed, source of salt, and storage of salt. We also vis
ited various markets to assess the availability of different types of
salt (coarse salt, rock salt, iodized salt, etc.).
Results
Table I gives the details of IDD awareness in 999 subjects
surveyed. From this table it is clear that; (I) most subjects had
seen someone with goiter; (2) goiter was seen more frequently
by subjects who were either rural, illiterate, or lower class; (3)
only a small percentage of upper class literate and urban subjects
replied that we should use iodized salt; and (4) a significant per
centage of urban, literate, middle-upper class subjects knew the
companies manufacturing iodized salt, primarily through televi
sion advertisements.
Table 2 has details of the types of salt consumed in rural and
urban areas, and shows that: (I) most of the people in rural
areas consume non-iodized salt; (2) only one-third of urban sub
jects preferentially and invariably use iodized salt; (3) a small
percentage prefer rock salt; (4) one-third of urbanites do not
seem to care about the type of salt they should use; and (5) peo
ple from rural areas seem to prefer coarse salt.
Table 3 records the pattern of salt consumption in various
socio-economic classes, and shows that: (1) most of the people
from rhe lower class consume coarse salt;’ (2) only one-fourth of
the upper class take iodized salt; and (3) collectively, all classes
predominantly consume coarse salt.
Continued on page 48
An elderly hukka-smoking Kashmir shopkeeper dealing with non
iodized salt.
d young businessman selling non-iodized salt in the main market
of Srinagar, the capital city.
46
IDD NEWSLETTER a AUGUST 1996
TABLE 1
AWARENESS OF IODINE DEFICIENCY DISORDERS (IDD) IN 999 SUBJECTS SURVEYED
Variable
Males
n=639
Females
n=360
Urban
n=375
Rural
n=624
Literate
n = 645
Illiterate
n=354
Lower class
n=258
Middle class
n=579
Upper class
n=162
1. Have you seen a person
with goiter?
540
(84.5)
282
(78.33)
354
(94.4)
510
(8173)
579
(89.76)
285
(80.50)
228
(88.37)
504
(87.04)
132
(81.48)
2. Is it seen in your
area?
291
(45.53)
159
(44.16)
111
(293)
339
(54.32)
228
(35.34)
222
(62.71)
120
(46.51)
303
(52.33)
33
(20.37)
3. Do you know its
cause?
75
(11.73)
15
(4.16)
60
(16)
30
(4.80)
90
(13.95)
0
(0)
12
(4.65)
45
(7.77)
33
(20.37)
4 What is iodized salt?
36
(5.63)
9
(2.5)
30
(8)
15
(2.40)
45
(6.97)
0
(0)
6
(2.32)
24
(4.14)
15
(9.25)
5. What salt should we
use?
168
(26.29)
42
(11.66)
162
(43.2)
48
(7.69)
210
(32.55)
0
(0)
33
(12.79)
123
(21.24)
54
(33.33)
6. If. iodized why?
30
(4.69)
6
(1.66)
24
(64)
12
(1.92)
36
(5.58)
0
(0)
6
(232)
18
(3.1)
12
(7 40)
7. What is iodine
content of salt?
3
(0.469)
0
(0)
3
(0.8)
0
(0)
3
(0.46)
0
(0)
0
(0)
3
(0 51)
0
(0)
8. Companies that
manufacture iodized
salt?
165
(25 82)
30
(8.33)
102
(27.2)
93
(14.90)
195
(30.23)
0
(0)
18
(6.97)
129
(22.27)
48
(29.62)
Table entries show numbers of positive or correct responses (Z in parentheses).
Table 3. Pattern of salt consumption in various
socio-economic classes
Table 2. Pattern of salt consumption in rural versus
urban population
Type of salt
Urban Population
Rural Population
Total population
used
n = 375
n = 624
n = 999
Coarse
Rock
Iodized
81 (21.6)
39 (104)
114 (30.4)
564 (90.4)
12(1.9)
6(1.0)
Socio-economic Class
141 (37.6)
42 (6.7)
Lower Class
Middle Class
Upper Class
used
n = 258
n = 579
n = 162
Coarse
210(814)
381 (65.8)
54 (33.3)
Rock
15(5.8)
27 (4.7)
9 (5.6)
Iodized
9 (3.5)
69 (11.9)
42 (259)
Both iodized
and
non-iodized
24 (9.3)
102 (17.6)
57 (35.2)
645 (64 6)
51 (5 1)
120(12.0)
Both iodized
and
non-iodized
Type of salt
183 (18.3)
Table entries are numbers of people, with percent of total in parentheses.
Table entries are numbers of people, with percent of total in parentheses.
47
IDD NEWSLETTER □AUGUST 1996
Discussion
Lack of awareness in a dual market leads
the population (especially the rural poor)
to choose non-iodized salt even if it is only
marginally cheaper.
This study has shown that there is little awareness about
IDD in the general population in this valley, although the area
has significant manifestations of iodine deficiency. In order to
eliminate IDD, iodine needs to be introduced into the daily
diet. Items regularly consumed include salt, bread, sweets, milk,
sugar, and water. Among these, salt has been universally accept
ed for iodization because almost all sections of a community
consume it irrespective of economic level. Salt intake is partic
ularly high in this valley because people use it instead of sugar
with tea. There is supposed to be a total ban on the sale of non
iodized salt in Jammu and Kashmir (3). However, market sur
vey revealed non-iodized salt is freely available throughout
Kashmir valley (Figures 1 and 2). In fact, there are businessmen
exclusively engaged in the sale of non-iodized salt. Some grocers
also offer iodized salt, particularly in Srinagar, the capital city,
and in some major towns. However, the amount of this salt that
is actually sold seems quire small because of the common man’s
preference for the coarse non-iodized salt.
From this study we conclude that we are far from achieving
IDD elimination by the year 2000. The official agencies appear
to have no will to implement the already existing total ban on
non-iodized salt, and this lack is compounded by inadequate
awareness regarding the magnitude of the IDD and its allevia
tion through salt iodization at the levels of policy making and
implementing, medical professionals, rhe salt sector and general
public. Lack of awareness in a dual market where both iodized
and non-iodized salt compete leads the population (especially
the rural poor) understandably to choose non-iodized salt even
if it is only marginally cheaper. Correcting this situation requires
strong political commitment and industry motivation support
ed by effective and continuous monitoring to make only iodized
salt available. However, at present it appears unlikely that we
are anywhere near elimination of IDD in this valley.
References
1. Zargar AH. Shah JA, Mir MM, Laway BA, Masoodi SR, Shah NA 1995
Prevalence of goiter in schoolchildren in Kashmir valley. Am J Clin Nutr
62:1020-1021.
2. Mahajan BK, Gupia MC 1991 Social environment. In: Mahajan BK,
Gupta MC (eds), Textbook of Preventive and Social Medicine, first edition. Jay
Pec Brothers Medical Publishers Pvt. Ltd., New Delhi, pp 82-87.
3. Ministry of Industry. Banning sale of edible non-iodized salt - n urgent
measure. Produced by The Salt Department, Ministry of Industry with support
from UNICEF. 1995.
Success of USI in Madhya Pradesh
- A Follow-Up
A
n article in the IDD Newsletter (11(4), 46, Nov.
As a result of the Mission, almost all homes
used iodized salt.
1995) on Madhya Pradesh's (MP) program to sus
tain IDD elimination, based on reports from Dr. C.
S. Pandav, ICCIDD Regional Coordinator, and Ms. Nilima
Chawla, ICCIDD Board member, described the “Mission
Approach," for an all-out push against IDD. This approach has
clear objectives and strategies to handle a public issue, within a
defined time frame by a committed team. The Rajiv Gandhi
Mission for Elimination of Iodine Deficiency Disorders,
launched in August 1994, was one of seven in Madhya Pradesh.
Its objectives were to ensure availability of adequately iodized
salt in all villages and towns of the State by the end of 1997 and
to increase awareness of the population on the importance of
iodine and IDD.
The previous article described the program and the intensive
effort to assess IDD and test salt for iodine content. After the
first year, the Mission reported that more than 84% of rhe salt
consumed in the State was iodized. Since the Mission appeared
to be successful in its goal, a date in 1996 for its closure was set
by the Chief Minister, who also stated that “the closure will be
preceded by an independent evaluation to be conducted by a
reputed nongovernment evaluation agency." This led to an invi
tation to ICCIDD to provide this independent evaluation. For
this, Dr. Pandav headed a large team for planning and coordi
nation, laboratory assessment, field survey, data management,
and report preparation.
The evaluation focussed on the proportion of urban and
rural households in MP consuming adequately iodized salt, and
the availability of iodized salt at the retail level in rural and
urban areas. In addition, it assessed the awareness of the popu
lation about iodized salt and IDD. The field survey in
November 1995, conducted by 20 physicians representing 12
national institutions and two international organizations,
assessed 30 clusters from rural and urban populations. The
teams collected salt samples from households and retail shops,
and interviewed household members and shop keepers to assess
their knowledge, attitude, practice and behavior about iodine
deficiency and iodized salt.
48
IDD NEWSLETTER □ AUGUST 1996
'v.L
The results showed that 98.4% of salt samples at the house
hold level, were iodized. Their iodine content was adequate in
69/o urban households, and 61% from rural ones. The inade
quate levels of these samples might come from insufficient
iodization at production level, and/or problems with packaging,
storage, transportation, and repacking.
Awareness of issues about IDD and iodized salt was consid
ered positive in 65% of urban households and 44% of rural
ones. Major sources of information were health workers and
television. The survey also noted that 88% of urban households
consumed powdered salt while 32% of rural households used
crystalline salt. Of the powdered salt samples, about 30% were
inadequately iodized. Thirty-eight percent of the crystalline
samples in rural households were adequately iodized, contrary to
popular impressions. The retail shops in the sampled areas sold
only iodized salt (> 97%). The levels of adequately iodized salt
in shops was similar to that in households.
The evaluation team concluded that the Mission had been
successful, and noted these specific achievements:
1. Involvement of the salt traders in implementing the uni
versal salt iodization program. The “Bhopal Declaration”
by the salt traders, in which they agreed to sell only iodized
salt, was an important boost.
2. Forging partnerships between program managers and key
stakeholders to understand the viewpoints of different
sectors.
3. The involvement of Nagarik Apoorti Nigram, a service
group, to make adequately iodized salt available, particular
ly in the remote areas.
The involvement of the district administration, health
department, and education department to create awareness
and promote monitoring.
The team emphasized the importance of a smooth transition
to a “system approach,” to gather rhe critical momentum need
ed for the program to progress on its own and achieve sustain
ability. In addition, they recommended that: (1) the program
should continue to receive the same level of priority and urgency
that it did during the Mission; (2) intersectoral coordination
should be retained and preferably enhanced; (3) the efforts to
obtain community participation must be continued and
strengthened; (4) the Mission Director’s role should be assumed
by a responsible officer from one of the participating depart
ments, which would then be responsible for further implemen
tation of rhe program; and (5) the monitoring system should
include social, regulatory, and health functions; social monitor
ing should be carried out in schools, communities, and con
sumer organizations, with spot testing of iodized salt and
recording its price; the Directorate of Food and Drug Control
should enforce existing regulations; health monitoring should
include goiter prevalence and urinary iodine levels measured in
school-age children eveiy five years.
The evaluation team recommended that the success of this
program should be widely publicized in the State and nation, as
a model for implementing other health-related social develop
ment issues. The report concludes by emphasizing the need to
sustain political statement that is bolstered by broad public
understanding of issues. Key components are quality assurance
and continued involvement of all relevant stakeholders. ■
4.
IN BRIEF . . .
“It is the right of children to grow and develop to their fill
genetic potential. This requires that each receive appropriate
amounts of micronutrients for the body and the brain to develop
harmoniously. It is especially important to understand- that minute
amounts ofiodine are vital to the normal growth and development
ofchildren. The absence ofthose amounts denies appropriate oppor
tunity for growth of the brain. Children born to parents living in
iodine deficient areas ofthe world, many millions in Central, East,
and South Asia, are at risk of preventable mental retardation.
Scientific studies reveal that iodine deficiency also is a cause ofpoor
educational ability of children, as those living in iodine deficient
areas have an IQ level about 13 points lower than that ofchildren
living in iodine sufficient areas. This can be prevented by the regu
lar consumption of iodized salt in the daily diet in cooking, food
preservation and food savoring. I encourage all people to demand
iodized salt in the marketplace; all governments to assure that
iodized salt is regularly available to all people; all salt producers to
support efforts to eliminate iodine deficiency in this manner. This
will help to ensure a bright future for the health and development
ofyourfuture generations. ”
■ ICC1DD on the Internet - A home page is being set up
through the server at the University of Virginia. Components
include: general information about ICCIDD, the Current IDD
Status (CIDDS) database, and an IDD technical database
(IDDTECH). The present address is “http://avery.med.virginia.edu/-jtd/iccidd/”; this may change. The CIDDS database
contains summary information on IDD in each country. It has
been available on disk and through the MI server for the past
two years with periodic updating. The current edition, CIDDS
4 was completed in mid 1996, and the next, CIDDS 5, is sched
uled for late 1996. IDDTECH is a technical database initially
composed of the last five years of the IDD Newsletter, by flat text
with indexing by country and subject. Dr. Jonathan Gorstein
and Dr. John Dunn are carrying out this project, with financial
support from the USAID-sponsored OMNI program and in
coordination with the Micronutrient Initiative. Maintenance of
entries will be carried out by ICCIDD with new information as
it appears. For those without web access, these databases can be
distributed by disk. Coordination of these activities with the MI
and others will be discussed at die forthcoming Executive meet
ing in Ottawa.
WHO Press Release on USI - Following rhe review in
Geneva in July of the multicenter study in Africa, attended by a
number of ICCIDD members including Delange, Benmiloud,
Braverman, Lan turn, Todd, Vitti, and others, WHO released a
statement, beginning with “..... the benefits of salt iodization by
far outstrip potential adverse effects.” Special attention was
given to the cases of iodine-induced hyperthyroidism in Zaire
B
■ Dalai Lama Statement on IDD - This statement, signed by
the Dalai Lama, was issued on August 16, 1996. David Haxton,
ICCIDD Board member, and others were instrumental in
obtaining it, with particular reference to its usefulness in accel
erating efforts to control IDD in Mongolia. The text is as fol
lows:
49
IDD NEWSLETTER □ AUGUST 1996
some batches of iodized salt containing levels of iodine higher
than prescribed. Recommendations for better monitoring and
quality control were made. The release also noted that some
countries could safely lower salt iodine levels without reducing
effectiveness. The statement called on governments to work
closely with salt producers to further improve the quality of
iodized salt. A report with the actual data is expected once its
release is authorized by WHO. ■
and Zimbabwe. The reporc comments on the decrease in goiter
and other beneficial effects of USI. It also noted that cases of
hyperthyroidism had occurred in Zaire and Zimbabwe, but had
not clearly been shown in Cameroon, Kenya, Nigeria, Tanzania,
and Zambia, the other countries in the study. The press release
attributed the cases of hyperthyroidism to unnecessarily high
levels of iodization in the salt, partly due to lower losses and
higher consumption than previously assumed, and partly to
ABSTRACTS
IS THERE A CASE FOR A PROTECTIVE “TREAT
MENT” OF IODINE DEFICIENCY GOITERS
WHEN LARGE DOSES OF IODINE HAVE TO BE
ADMINISTERED? G. Hintze, O. Blombach, E. Scharf-
RELATION BETWEEN SERUM THYROTROPIN
AND THYROGLOBULIN WITH URINARY IODINE
EXCRETION. U7 Buchinger, O. Lorenz-Wawschinek, G.
Bimer, U'< Langsteger, R. Bonelli, O. Eber, Graz-Eggenberg,
Austria. The Thyroid and Iodine, edited by J. Nauman, D.
Glinocr, L. E. Braverman, U. Hostalek, published by Schattauer,
Stuttgart. Merck European Thyroid Symposium, Warsaw, May
16-IS, 1996, page IS9.
Styria has historically been iodine deficient. Iodized salt
was introduced in Austria at 10 ppm KI and increased to 20
ppm in 1990. Between 1984 and 1990, the percentage of sub
jects with urinary iodines below 100 pg/dl dropped from 83 to
37%, probably because of improved education on the benefits
of adequate iodine nutrition. No significant changes occurred
after 1991. Six hundred eighty-two euthyroid patients on
no thyroid medications were assessed by urinary iodine levels,
TSH, and serum thyroglobulin. From the accompanying graph,
TSH was at its lowest (1.25 pU/ml) with a urinary iodine
between 200 and 300 pg/1 and slightly higher, but still within
the normal range, when the urinary iodine level was either
greater or less. Serum thyroglobulin levels decreased progres
sively with increased iodine in urine. Assuming that low TSH
and Tg values correspond with optimal iodine intake, the
authors conclude such an intake should be approximately
250 pg/day.
Bornhofen, J. Kobberling, Germany. The Thyroid and Iodine,
edited by J. Nauman, D. Glinoer, L. E. Braverman, U. Hostalek,
published by Schattauer, Stuttgart. Merck European Thyroid
Symposium, Warsaw, May 16-18, 1996, page 192.
A frequent clinical concern is whether large doses of iodine,
such as in radiocontrast media, affect thyroid function in sub
jects from iodine-deficient areas. The authors performed thyroid
function studies in 710 subjects undergoing coronary angiogra
phy. Two patients developed hyperthyroidism, as defined by a
low TSH and increased T4. About 2% of subjects developed
overt hypothyroidism, and up to 14% had transient subclinical
hypothyroidism. The authors conclude that development of
iodine-induced hyperthyroidism is an uncommon event follow
ing iodine loads in areas of moderate iodine deficiency.
ALIMENTARY SUPPLY OF IODINE IN GERMANY.
R, Hampel, T. Ktihlberg, H. Zbllner, d. Klinke, K. Klein, E.-G.
Pichmann, A. Kramer. Milnch med Wschr 138:78, 1996 (in
German).
This study reports urinary iodine values from 5,932 volun
teers with normal thyroids from 32 regions of Germany. The
median value was 72.4 pg/g creatinine; 76.9 pg/g in children
and 71.9 pg/g in adults. Nine percent were over 150 pg/day,
17% were between 100 and 150; 55% were between 50 and
100; 17% between 25 and 50; and 2% were below 25 pg. There
were no significant differences between the former East
Germany and West Germany, nor among different regions of
the country. The authors conclude that despite voluntary mea
sures that include evolution of trade barriers within Europe,
information campaigns, and removal of restrictive laws, iodine
deficiency continues in Germany. They recommend laws for
iodine prophylaxis.
THE EFFECTS OF DIFFERENT DOSES OF ORAL
IODIZED OIL ON GOITER SIZE, URINARY
IODINE, AND THYROID-RELATED HORMONES.
B. Elnagar, M. Eltom, F. A. Karlsson, A. M. Ermans, M. GebreMedhin, P. P. Bourdoux, University Hospital, Uppsala, Sweden. J
Clin Endocrinol Mctab 80:891-897, 1995.
The authors gave single oral doses of iodinated oil (Lipiodol)
containing either 200, 400, or 800 mg iodine to 117 adults with
goiter in the Darfur region of western Sudan, an area of severe
iodine deficiency, with an overall goiter prevalence of 80%, vis
ible goiter 28%, and median urinary iodine 2 pg/dl. After 12
months, 13.8% of the 200 mg group had a urinary iodine con
centration above 10 pg/dl compared with 27.3% of the 400 mg
group and 35% of the 800 mg group. About 60% of the subjects
in each group showed a reduction in thyroid size, by palpation.
The median TSH for all subjects was normal before treatment
and decreased in all groups. A few subjects had an increase in
TSH about one week after oil administration. Four subjects, all
females, three with thyroid nodules, showed evidence of hyper
thyroidism, mostly in rhe first two months. The authors con
clude that rhe dose of 200 mg iodine provides satisfactory con
trol of iodine deficiency for one year, basing this conclusion on
TSH response. This dose applies to adults and is lower than that
recommended by Benmiloud, et al., for children.
THE USE OF SUGAR AS A VEHICLE FOR IODINE
FORTIFICATION IN ENDEMIC IODINE DEFI
CIENCY. M Eltom, B. Elnagar, E. A. Sulieman, F. A. Karlsson,
H V. van Thi P. Bourdoux, M. Gebre-Medhin, University
Hospital, Uppsala, Sweden, hit J Food Sci Nutr 46:281-289.
The authors first surveyed sugar production and consump
tion in Sudan, noting the presence of five major plants, four
government owned They concluded that sugar consumption
was uniformly distributed throughout the country' without difnnT77m°/g0 socl°economic groups. The mean daily intake
ranged from 48 to 78 grams. They assessed several techniques
for iodization of sugar including addition as a solution before
SO
IDD NEWSLETTER ■ AUGUST 1996
ctystalhzation or by spraying before drying . They gave iodinated sugar
to
in--------------Kh.nrrnnmv«*»f,„;„
.
. 125 subiects
,
..ary iodine 4.9 pg/dl)
Jn
ost* (--6 Pg/dl), rhe latter an area of severe iodine defi
ciency with a goiter prevalence of 55%. Eighty-two percent of
t ie goitrous subjects showed a decrease in thyroid size. Urinary
!O ines increased to 14.4 pg/dl in Khartoum and 9.8 in Kosti
a er
months consumption of iodized sugar. No cases of
iodine-induced hyperthyroidism were found. The authors note
several advantages for iodization of sugar in Sudan, including
economic feasibility, availability of plants and factories already
in operation, a low initial cost for iodization, and a well-orga
nized sugar distribution system. They conclude that iodized
sugar deserves further study as an alternative approach in cir
cumstances where sugar is widely available and salt iodization
programs are still not well developed.
and motivation. The severely iodine-deficient children scored
significantly lower (p < 0.01) than the mildly deficient children.
The authors interpreted these results as showing neural impair
ment as well as poor sociopsychologic stimulation resulting in
learning disability and lowered motivation for achievement.
They further concluded that unless iodine nutrition is
improved, children such as these from iodine-deficient areas will
not achieve their full potential even with adequate schooling
opportunities.
IODINE SUPPLEMENTATION IN SWEDEN AND
REGIONAL TRENDS IN THYROID CANCER INCI
DENCE BY HISTOPATHOLOGIC TYPE. B. Pettersson,
M. P. Coleman, E. Ron, H. O. Adami, University Hospital
Uppsala. Sweden, hitJ Cancer 65:13-19, 1996.
The authors analyzed 5,838 cases of thyroid cancer in
Sweden diagnosed between 1958 and 1981 to assess its possible
relationship to iodine status. They found that iodine-deficient
areas had a relative risk for developing thyroid cancer of 0.92 for
all types, 0.80 for papillary cancer, and 0.87 for anaplastic can
cer. The relative risk of follicular thyroid cancer in iodine-defi
cient regions was 1.98 in men and 1.17 in women. When exam
ined by health care region, there was little variation among these
six geographical areas in Sweden, leading the authors to con
clude that iodization of rhe food supply was not associated with
adverse trends in the occurrence of thyroid cancer.
SEMI-ANNUAL
REPORT,
IODIZED
SALT
SUPPORT FACILITY (ISSF), GOVERNMENT OF
PAKISTAN
IDD
ELIMINATION
PROJECT,
JANUARY-JUNE, 1996. I. Zafar, Islamabad, Pakistan.
IDD in Pakistan has been reviewed many times in the IDD
Newsletter, most recently in May 1996. The initial goal of 80%
of salt being iodized by the end of 1996 has been pushed back
to the end of 1998. However, one goal of Salt Marketing
Pakistan (SMP), that at least 75% of salt processors initiate salt
iodization, was achieved in 1995. In addition, household con
sumption of iodized salt increased from 2% in 1994 to 19% by
August 1995, and to an estimated 30% by the end of 1995.
The report notes some stalling of the program during the
first half of 1996. Contributing factors included the high price
of iodized salt and its low availability in rural areas, inadequate
funding for SMP, and rumors linking family planning to
iodized salt. Also, achieving federal legislation for iodized salt
has been delayed, and the iodized salt logo has nor yet been reg
istered. However, there has been progress. Currently, over 80%
of salt producers are iodizing at least part of their output.
Iodized salt sales in June 1996 showed an upward trend over
those in May.
In the salt industry, rhe first half of 1996 showed a decrease
in the number of salt producers by about 100, to approximate
ly 520 currently. Noniodized salt continues to be available. Salt
producers have recently been more willing to accept the subsi
dized price for KlOj. The report identifies lack of enforcement
and low market demand as principal issues and suggests that
these need increased emphasis for the remainder of the year.
Education and communication activities also decreased,
again attributed to nonavailability of funds and revision of the
communication strategy. However, there has been increasing
emphasis on local activity, particularly in rural areas. Recently,
messages on iodine deficiency and the importance of iodized salt
have been initiated for inclusion in the teaching in public pri
mary schools.
J. Linseisen, C. C. Merges, S. Schwarz, G. Wolfram, Universitat
Munchen. Zeitschrift fur Ernahrungswissenschaft 34:240-242,
1995.
The authors compared two university canteens differing only
in that one used iodized salt for food preparation and rhe other
did not. The relative iodine content of meals in the first canteen
was 56.5 pg compared with 17 pg in the one without iodized
salt, assuming a similar sodium chloride intake. They conclude
that the use of iodized salt in eating establishments may play a
more important role than previously recognized.
LEARNING DISABILITIES AND POOR MOTIVA
TION TO ACHIEVE DUE TO PROLONGED
IODINE DEFICIENCY. B. D. Tiwari, M. M. Godbole, N.
THE EFFICACY OF IODINE PROPHYLAXIS IN
THE PREVENTION OF ENDEMIC GOITER IN THE
SOUTHWESTERN AREA OF ASTURIAS. A. Engttix,
Chattopadhyay, A. Mandal, A. Mithal, Varanasi, India. Am J
Clin Nutr 63:782-786, 1996.
The authors compared 100 male children from a severely
iodine deficient village to those from mildly deficient villages
(mean urinary iodine concentration 2.8 pg/dl versus 5.7, I 4 7.0
versus 9 6, and TSH 6.2 versus 4.9). Both groups were given
psychological tests including maze, verbal, and pictorial learning
I. Riano. 0. Larrubia, R. Gomez de la Torre, C. Rey. J. Otero, I.
Pinto, Hospital Narcea, Asturias, Spain. Anales de Medicina
Interna 12:182-186, 1995.
Iodized salt was introduced into this Spanish region 10 years
ago. The authors studied 317 school age children chosen ran
domly. The goiter prevalence was now 16.4%, compared with
63% previously. The mean urinary iodine excretion increased
URINARY IODINE EXCRETION IN THE NORTH
EAST OF PENINSULAR MALAYSIA. M. Mafauzy, W.
B. Mohamad, M. Y. Anmn, M. Musalniah, Universiti Sains
Malaysia, Kelantan, Malaysia. Southeast Asian Journal of
Tropical Medicine and Public Health 26:138-142, 1995.
The authors examined 2,034 adults (over 15 years old) in the
state of Kelantan. They compared regions near the coast with
those more inland, with rhe former having a goiter prevalence of
31 % and the latter 45%. The mean urinary iodine excretion was
the same in the two regions (57 pg iodine/g creatinine). The
authors concluded, on the basis of the goiter prevalence and uri
nary iodine, that this area of Malaysia is iodine deficient.
IODINE CONCENTRATION IN CANTEEN MEALS
PREPARED WITH OR WITHOUT IODIZED SALT.
51
IDD NEWSLETTER ■ AUGUST 1996
from 53 pg iodine/g creatinine co 106. However, while sale
iodization has been generally effective, pockets of iodine defi
ciency remain.
DECREASE OF INCIDENCE OF TOXIC NODULAR
GOITER IN A REGION OF SWITZERLAND AFTER
FULL CORRECTION OF MILD IODINE DEFICIEN
CY. B. L Baltisberger, C. E. Minder, H. Burgi, Bttrgerspital,
THE INSTABILITY OF DIETARY IODINE SUPPLY
OVER TIME IN AN AFFLUENT SOCIETY. C Als, K
Solothurn, Switzerland. Ear J Endocrinol 132:546-549, 1995.
Switzerland has gradually raised rhe levels of iodine in.the.salt
over decades. In 1980 rhe iodine content was increased from 7.5.
to 15 ppm, with an accompanying increase in mean urinary
iodine excretion from 90 to 1 50pg/g creatinine. The authors
reviewed rhe incidence of hyperthyroidism during these years,
and found a 27% rise in the first year but thereafter a steady
decrease to reach a level in 1988 that was only 44% of that in
1980. The decrease was principally in toxic nodular goiter
(down 73%) rather than in Graves’ disease (down 33%). The
authors conclude that except for a brief initial increase in hyper
thyroidism, correction of mild iodine deficiency gives a long
range decrease in the incidence of hyperthyroidism.
Lauber, L. Brander, D. Luscher, H. Rosier, University of Bern,
Switzerland. Expcrientia 51:623-633, 1995.
The authors studied several groups of adult subjects in Bern,
Switzerland. The mean urinary iodine excretion in healthy vol
unteers was 87pg/g creatinine. Previous estimates in rhe 1980’s
had indicated urinary iodine levels greater than 100 pg iodine/g
creatinine. The authors conclude that iodine intake in this afflu
ent society has been unstable and attribute it to modifications of
eating habits including a reduction in total salt consumption.
They also note the increased consumption of foods from other
countries, prepared with salt containing little or no iodine.
RECENT PUBLICATIONS
/. SOS for a Billion - The Conquest of Iodine Deficiency
Disorders, 2nd edition, Oxford Press, Delhi, 1996, edited by B.
S. Hetzel and C. S. Pandav - A nontechnical overview by
ICCIDD of current information on IDD and the efforts to
eliminate it. Available from rhe Oxford Press or from ICCIDD.
2. Micronutrient Laboratory-Equipment Manual, by Warwick
May, PAMM - Contains specific derails on supplies for setting
up laboratory' methods for micronutrients, including iodine in
urine and salt. Available by writing PAMM, Emory University,
1518 Clifton Road, N.E., Atlanta, GA 30322, USA.
3. Sharing Risk and Reward: Public-Private Collaboration to
Elimination Micronutrient Malnutrition, sponsored by PAMM,
ICCIDD
MI, OMNI - Reports on conference in Ottawa, December
1995. Available from MI or PAMM.
4. Desordenes por Deficiencia de Yodo (D.D.Y.). Una Vision
Contemporanea, by Julio Cesar Carrillo, Facultad de Medicina,
Universidad Nacional de Colombia, Bogota, 1995 - A very brief
overview of IDD, with particular reference to Colombia. In
Spanish.
5. Elimination de Desordenes por Deficiencia de Yodo
(D.D.Y.). Plan de Capacitacion y Divulgation, by Julio Cesar
Carillo, Universidad Nacional de Colombia, Bogota, 1996 - A
summary of the national plan for education and dissemination
of information about IDD in Colombia. In Spanish.
INTERNATIONAL COUNCIL FOR CONTROL OF IODINE DEFICIENCY DISORDERS
The International Council for the Control of lotline
Deficiency Disorders (ICCIDD) is a nonprofit nongovern
mental organization dedicated to the sustainable elimination
of iodine deficiency throughout the world. Its activities are
supported by donations from CIDA, UNICEF, the World
Bank, SIDA, AIDAB, the Netherlands Ministry for
Development Cooperation, USAID, rhe World Health
Organization, and others. Inquiries about membership in the
ICCIDD should be directed to the Executive Director, Dr.
Delange.
Editor, Dr. Dunn. Communications about different
geographical regions can also be directed to the respective
Regional Coordinators.
The IDD Newsletter is published quarterly by ICCIDD
and distributed free of charge in bulk by international agen
cies and also by individual mailing. The Newsletter welcomes
comments, new information, and relevant manuscripts.
Inquiries and subscription requests should be sent to the
IDD NEWSLETTER
SECRETARIAT
Dr. Francois Delange,
Executive Director, ICCIDD
Avenue de la Fauconnerie 153
1170 Brussels, Belgium
Fax 32-2-675-1898
Edited by Dr. J. T. Dunn. Box 511,
University of Virginia Medical Center,
Charlottesville, VA 22908, U.S.A.
Fax: 1-804-296-9275
©Copyright 1996 by International Councilfor Control of Iodine Deficiency Disorders
Sustaining Elimination of
iodine Deficiency Disorders
m
South Asian Countries
he
Dr Chandrakant S. Pandav
28th Annual PHA Conference
29 September - 2 October 1996
Perth, Western Australia
PUBLIC HEALTH ASSOCIATION OF AUSTRALIA INC
AR BN. 06 2 8 94 4 73
Sustaining Elimination of
Iodine Deficiency Disorders
in
South Asian Countries
Dr Chandrakant S. Pandav
28th Annual PH A Conference
29 September - 2 October 1996
Perth, Western Australia
PUBLIC HEALTH ASSOCIATION OF AUSTRALIA INC
The International Council for Control of
Iodine Deficiency Disorders (ICCIDD) is a non-profit
non governmental organization dedicated to the
sustainable elimination of Iodine Deficiency Disorders
(IDD) throughout the world. The ICCIDD was granted
an official status as an International NGO at the 47th
World Health Assembly held in Geneva in 1994. It's
activities are supported by donations/grants from the
Australian Agency for International Development
(AusAID), the Canadian International Development
Agency (CIDA), the Micronutrient Initiative (MI), the
Netherlands Ministry for Development Cooperation,
the Swedish International Development Agency (SIDA),
the United Nations Children's Fund (UNICEF), the
United States Agency for International Development
(USAID), the World Bank, the World Health
Organization (WHO), and others.
TO THE GLOBAL PARTNERSHIP
DEDICATED TO THE ELIMINATION OF
IODINE DEFICIENCY DISORDERS
An Ancient Scourge of Mankind
The People of the affected countries
The Governments of the affected countries
The Salt Producers of each country
The International Agencies-especially
The World Health Organization
The United Nations Children’s Fund
The World Bank
The Micronutrient Initiative
Program Against Micronutrient Malnutrition
Kiwanis International
The International Expert Network of
International Council for Control of
Iodine Deficiency Disorders
(ICCIDD)
The Bilateral Agencies especially
The Australian Agency for International Development
The Canadian International Development Agency
The Netherlands Ministry for Development Cooperation
The Swedish International Development Agency
The United States Agency for International Development
Dr. Chandrakant S. Pandav
Additional Professor,
Centre for Community Medicine
All India Institute of Medical Sciences
New Delhi - 110 029, India.
&
Regional Co-ordinator, South Asia & Pacific
International Council for Control of Iodine Deficiency Disorders
(ICCIDD)
ISBN 81-86813-06-3
Printed at Sona Printers Pvt. Ltd. B-181 Okhla Ph-1, New Delhi - 20.
Contents
Acknowledgements
Abstract
Context and Perspective of Iodine
Deficiency Disorders (IDD)
1
Current Status of IDD Elimination
Programmes
6
Future Strategy for Sustaining
Elimination of IDD
9
4.
Conclusion
17
5.
PostScript
19
6.
References
20
7.
Biodata
24
1.
2.
3.
Acknowledgements
A major portion of this paper constituted a
Background Note prepared for the,"Third SAARC
Ministerial Conference on Children of South Asia"
held at Rawalpindi, Pakistan in August 1 986. I would
like to thank UNICEF-ROSA, Kathmandu for giving
me the opportunity to prepare this note.
I am grateful tothe Director, All India Institute
of Medical Sciences (AllMS), New Delhi for the con
stant encouragement and unstinted support given for
all activitiesrelated to IDD elimination for the last 1 8
years. My thanks to all Faculty colleaguesand staff of
Centre for Community Medicine, AllMS particularly
Dr K. Anand, for their support for the work on IDD.
I gratefully acknowledge the support provided
by the International Council for Control of Iodine
Deficiency Disorders (ICCIDD) for carrying out IDD
activities related to IDD elimination programmes in
the Region. I am also thankful to Dr. Basil S. Hetzel,
Chairman, ICCIDD and Dr. Francois Delange, Execu
tive Director, ICCIDD and Board Membersof ICCIDD
for their inputs from time to time.
I was trained as an International Clinical
Epidemiology Network (INCLEN) Fellow (Health
Economics; Level - II), at the Department of Clinical
Epidemiology and Biostatisticsand Centre for Health
Economics and Policy Analysis (CHEPA), atMcMaster
University, Hamiltion, Ontario, Canada. I would like
to place on record my acknowledgement to the
INCLEN Programme.
Finally, I would like to express my most sincere
thanks to the Public Health Education and Research
Trust of the Public Health Association of Australia Inc
for inviting me to be the International Health Orator
for 1 996, atthe28th Annual Conference of the Public
Health Association, Perth, Australia. I consider myself
very fortunate for the opportunity given to contribute
to the conference theme on "Threats to Public Health:
Challenges and Strategies."
Abstract
Sustaining elimination of Iodine deficiency disorders
in South Asian countries
Iodine deficiency is the world's single most
significant cause of preventable brain damage and
mental retardation.
The clinical and subclinical
manifestations of iodine deficiency are collectively
included in the term Iodine Deficiency Disorders (IDD)
and affect al I stages of human growth and devel opment,
from foetus to adult.
Regional cooperation in South Asian countries i n
IDD Control dates back to 1985. Since then Joint Inter
country Consultations and Workshops have been
regularly held (1985, 1989, 1990, 1991, 1995).
The commitment of the South Asian Association
for Regional Cooperation (SAARC) toeliminate IDD by
the year 2000 is reflected in the declaration of Universal
Access to Iodised Salt by 1995 at the second SAARC
conference held in Colombo, Sri Lanka in September
1992.
Considerable progress has been made in the
SAARC countries towards the elimination of IDD.
Based on the experience so far, it is now time for
member countries to consolidate the progress made so
far, share the experiences amongst one another and
together draw out a future strategy focusingon sustaining
theelimination ofIDD in their respective countries and
in the SAARC Region.
Hi story teaches us that the sustai ned el imi nati on
of IDD requires constant vigilance of a range of
professional and public interests. It is particularly
important to understand this as we have crossed the
target of universal iodisation of edible salt by the end
of 1995. Too many of us may diminish our efforts when
we reach the first plateau. The long climb to eliminate
the stealthy scourge of IDD from the globe begins with
achievement of universal iodisation of salt.
The future agenda for sustainable elimination of
IDD should include continuous political and financial
commitment, clear communication strategy, quality
control measures, monitoring and tracking biological
progress; and ensuringthatthe management process is
in place to carry out these activities.
1
Context and Perspective of
Iodine Deficiency Disorders (IDD)
IDD - A major public health problem
Iodine deficiency is the world's single most
significant cause of preventable brain damage and
mental retardation1. Theclinical and subclinical man
ifestations of iodine deficiency are collectively in
cluded in theterm Iodine Deficiency Disorders (IDD)
and affect all stages of human growth and develop
ment, the fetus, the neonate, the child and adoles
cent, and the adult in the whole population. The
adoption of the term IDD which was suggested by
Hetzel in 1983 reflects a new dimension of under
standing the full spectrum of the effects of iodine
deficiency2. All these effects can be prevented by
correction of iodine deficiency.
IDD and the girl child
It is a well known that IDD and goitre are more
common in females, specially during puberty, preg
nancy and lactation1. Lack of iodine can cause irrep
arable harm even before birth. Mothers who are
deficient in iodine may have frequent abortions and
give birth to stillborn babies. The children born to
such mothers are at a greater risk of dying during the
first year of life. Those who survive can be perma
1
nently crippled with varyingdegrees of mental hand
icap and physical deformity commonly referred to
as endemic cretinism3.
IDD and educability
Iodine deficient children suffer from tardy con
centration, impaired co-ordination and sluggishness,
which results in poor school performance. In addi
tion, their energy and productivity are also adversely
affected. It has been estimated that, on an average,
school children living in iodine deficient areas have
an IQ level, about 1 3 points lower than the children
living in iodine sufficient areas4. Thus, the total
accumulated loss to each country is formidable.
International commitments for IDD elimination
On the occasion of the World Summit for Chil
dren at the United Nations in New York in 1990,
attended by 71 Heads of State and 1 59 Governments,
one of the specific goals adopted by the governments
was the virtual elimination of IDD by the year 2000.
To achieve that goal, it was subsequently agreed that
all countries would iodise at Ieast95% of salt supplies
for each country by the end of 1 995s.
Followingthe World Summit, a Policy Confer
ence on Micronutrient Malnutrition 'Ending Hidden
Hunger' was held in Montreal (10-1 2 October 1991),
with full participation by the Board of the Interna
tional Council for Control of Iodine Deficiency Disor
2
ders (ICCIDD)5. The goal of elimination was also
included in the Plan of Action adopted by the Interna
tional Conference on Nutrition (Rome 1 992)s.
At the recently concluded session of the World
Health Assembly in Geneva in May 1 996, the Resolu
tion of the Executive Board of the WHO on, " Preven
tion and control of iodine deficiency disorders", was
unanimously supported by the Member countries®.
Regional commitments for IDD elimination
Regional cooperation in IDD Control dates
back to 1985. Since then Joint WHO/UNICEF/
ICCIDD Intercountry Consultations and Workshops
have been regularly held in the South Asian Region in
the years 1 985, 1 989, 1 990, 1 991 and 1 9957.
The commitment of the South Asian Associa
tion for Regional Co-operation (SAARC) to eliminate
IDD by the year 2000 is reflected in the declaration of
'Universal Access to Iodised Salt by 1995 at the
second SAARC conference held in Colombo, Sri Lanka
in September 1 9927.
The targets for IDD control in the south-east
Asian region are that by 1 995, all countries with an
IDD problem will have ongoing national IDD
programmes and goitre rates will be below 20 per
cent. By the year 2000, the regional aim is to have
goitre rates no more than 5 per cent.
3
Benefits and risks of iodine supplementation
programmes
The benefits and risks of iodine supplementa
tion Programmes covering prevalence, population
groups involved, health consequences and severity
are presented in Table - 18.
The cost of salt iodisation is approximately 5
US cents per person per year - less than the price of a
cup of tea. Usingthe most conservative estimates, the
cost benefit ratio of IDD elimination programmes is
1:3®. If benefits related to education and livestock
populations are included, the ratio would be 1:8.
Thus, IDD elimination programmes provide a con
vincing opportunity of a worthwhile investment in
improving the health and nutrition of populations.
4
Table 1. Benefits and Risks of Iodine Supplementation Programmes
Description
Benefits of salt iodisation Programmes
Risks related to iodine
supplementation
Frequency of occurrence
globally (Prevalence)
- 1,570 million living in areas at risk of IDD
Toxicity : Iodine supplementation only
'unmasks' the subclinical stage of
hyperthyroidism and is not responsible
for its causation
Population groups
involved
- 655 million with goitre
- 43 million with preventable brain damage.
- commonest cause of preventable mental
retardation.
- fetus, neonates, children and adolescents
Health consequences
particularly girl child
- women in reproductive age group.
- irreversible and unbeatable
Severity
- reproductive failure-pregnancy wastage
- mental retardation
- incidence of it is very low
- allergy : No case of allergy has been'
reported since 1974
- toxicity : only people more than 45
years affected
- temporary
- reversible on stoppage of iodine
supplementation.
- minor symptoms (may even go
unnoticed)
2
Current status of
IDD Elimination Programmes
The total number of people and percentage of
regional population living in areas at risk of Iodine
Deficiency Disorders according to UNICEF Regions
is given in Table 2.
Table 2. Total number of people and percentage of regional
population living in areas at risk of Iodine Deficiency
Disorders.
UNICEF Regions
UNICEF Region
Population
(millions)
Population at risk % of
(millions)
Global
Total
East & Southern Africa
Central & Western Africa
Middle East & North Africa
East Asia & the Pacific
261
271
338
1,724
90
88
143
557
5.7
5.6
9.1
35.4
South Asia
1,183
410
26.1
Amencas & the Caribbean
Developed / Industrialized
444
1,217
168
116
10.7
7.4
Total
5.438
1,572
100.0
Source: WHO, Global Prevalence of Iodine Deficiency Disorders, published jointly by
WHO, UNICEF and ICCIDD, 1993.
6
The prevalence of goitre, based on recent
national surveys, current intervention strategy for IDD
programmes, status of legislation recommending
iodine content of salt at production and consumer
level, estimated production of iodised salt as a
proportion of total requirement and the estimated
proportion of households consuming adequately
iodised salt is given in Table -3. As is evident, consid
erable progress has been made in the SAARC coun
tries towards the elimination of IDD. Based on the
experience so far, it is now time for member countries
to consolidate the progress made so far, share the
experiences amongst one another and together draw
out a future strategy focusing on sustaining the elim
ination of IDD in their respective countries and in the
SAARC Region.
7
Table 3. Current status of IDD Elimination Programme in SAARC Countries
No.
1
2
3
4
5
6
7
Country
Goitre Prevalence
(Yr. of
survey/resurvey)
Current
intervention
strategy for
IDD Programme
Recommended
Iodine
Content of
salt in parts
per million
(PPM)
P = Production
C = Consumer
Bangladesh
(10,11,12]
Bhutan
[13]
India
[14,15]
47%
18% to 46% (1992)
Iodised salt/
Iodised oil
Iodised salt
>10%
(1994)
Iodised salt
P-50
c-N.A.
P-60
C-30-50
P-30
C- 15
Maldives
[16]
Nepal
[17, 18]
Pakistan
[19, 20]
Sri Lanka
24%
(1995)
55%
(1992)
> 10%
(1994)
Not yet
introduced
Iodised salt/
Iodised oil
Iodised salt
19%
(1989)
Iodised salt
(1993)
P = Not yet
C = Not yet
P-30
C-N.A.
P-50
C-15
P= > 50
C-25
Estimated
production/
availability
of iodised
salt as a
proportion
of total
requirement
Estimated
proportion
of
households
consuming
adequately
iodised salt
62%
34% (1995)#
95% to 97%
N.A.
60% to 70%
N.A.
61% to 69%
(Madhya
Pradesh)
8%
87%
50%
80%
30%
3
Future strategy for
Sustaining Elimination of IDD
The following is the suggested agenda to con
sider for sustaining elimination of IDD in SAARC
countries
Political and financial commitment
There has been considerable political commit
ment for the elimination of IDD in the Region as well
as in the Member countries. There is a need to
continue the exercise on an on-going basis as the
political and the administrative leadership keeps on
changing. The advocacy efforts should now focus on
the potential for achieving success in yet another
publichealth programmefollowingtheeradication of
small pox and near eradication of polio. Linked with
this is the issue of making the required resources
available to carry out the programme activities.
Role of salt industry and technology
Production and transportation of good quality com
mon salt
Bangladesh, India, Pakistan and Sri Lanka are
self sufficient in production of common salt. Bhutan,
Nepal and Maldives are importing common salt/
iodised salt primarily from India.
9
The following issues need attention so as to
ensure good quality iodised salt.
i)
Quality of common salt
In all the Member countries, there is a need to
improve the quality of common salt. Technical ca
pacity to do so exists in the Region.
ii) "High visibility" for bilateral agreements between
India and Bhutan, India and Nepal
Presently Bhutan and Nepal are importingcom
mon salt from India. The agreements are between the
a private salt trader from Bhutan and private traders
in India and between Salt Trading Corporation,
Kathmandu and private traders from India. There
have been delays in providing common salt to these
countries. There is a need to give "high visibility" to
these agreements so as to receive the desired atten
tion from the respective country representatives.
iii) High visibility for bilateral agreements between
India and Maldives
Maldives has yet to introduce legislation on
banning import of non-iodised salt. Maldives receives
most of its salt requirement from private traders in
Tamil Nadu, India. So far, no salt is produced in
Maldives. There is therefore need to have an agree
ment between these two countries to provide good
quality iodised salt to Maldives and, as in the case of
Bhutan and Nepal increase the visibility of this
agreement.
10
Issues, related to packaging and iodine retention in
salt
Packaging
To prevent iodine loss during storage and
transport, there is a need for use of safe and protective
packing by HOPE or LDPE bags weighing not more
than 50 kgs so as to be in conformity with the Interna
tional Labour Organization (ILO) recommendations.
In places where purchasingof iodised salt is annual/
semi-annual, one should advocate the use of large
LDPE bags rather than small packets. With the in
creasing concern of environmentalists about the use
of polyethylene bags, there is a need for research to
look for a bio-degradable yet protective material that
meets the packaging requirements of consumers.
Iodine retention in salt
Since there is no systematic and comprehen
sive information available on iodine retention in
iodised salt under different conditions of iodisation,
transportation and storage, there is an opportunity
for the Member countries to develop a common
protocol to answer this important operational research
question.
Legislation and enforcement
Except for Maldives, all the countries have
passed legislation on production of iodised salt.
1 1
Legislation to include salt for animal consumption
Since IDD also affects livestock causing abor
tions, still births, decreased yield of milk,meat, eggs,
wool etc., decreased capacity to work, there is a need
to extend the ban to cover sale of non-iodised salt
for animal consumption as well.
Enforcement
This is one of the weakest links in the
Programme. Based on the experience in European
countries, primarily of environmentalists, public in
terest litigations drawingthegovernment's attention
to availability of non-iodised salt in the market on a
regular basis will be an important opportunity for
community participation and involvement. Large scale
distribution and use of rapid salt test kits will facilitate
this involvement.
Recognition of role of private sector in IDD elimina
tion programme
It is quite obvious from the above list that the
private sector has played a key role in participating in
a major public health problem of national impor
tance. They are involved in production of common
salt, adequate iodisation, packaging, transportation
and marketing etc. The Member countries should
now be explicit in recognising their contribution and
have an on-going dialogue, not only to strengthen,
but build on this successful "Public-Private sector"
partnership for addressing micronutrient fortification
of foods.
12
Regional convention on common salt/iodised salt
As and when a member country requests for
common salt/iodised salt, there should be clear in
structions to mark the salt consignment as,"common
salt for iodisation in that country" or "iodised salt for
sale in that country". It is equally vital for the member
country exporting to pass on these instructions to the
concerned traders for strict compliance. The main
objective of this exercise i s to prevent sale of common
salt in the respective countries, specially along the
"soft" border areas.
Assessment & monitoring: Tracking progress towards
elimination of IDD
Different countries have at different times adopt
ed different protocols for assessment and monitoring
of IDD Programme. Asaresult it has not been possible
to compare in-country as well inter-country data to
assess the situation.
There is a need to sensitize the programme
managers for using the WHO/UNICEF/ICCIDD rec
ommended indicators of assessing IDD and its control
so as to ensure uniformity.
Community participation
No programme can be sustainable without
community participation. NGO's, schools and con
sumer forums have an important role in continuing
13
public pressure to ensure regular supply of good
quality iodised salt for all times to come. This should
therefore feature as a common agenda item. As
mentioned earlier, large scale distribution and use
of rapid salt test kits will facilitate this involvement.
Capacity enhancement and Regional Co-operation
There exists a network of institutions and
individuals with the required experience and exper
tise to address the sustainable elimination of IDD. The
key issue is of recognition of these and utilization of
these resources. The following is the list of expertise
which each country can contribute for capacity en
hancement and co-operation in the Region.
Bangladesh : Laboratory management and
Regional IDD Newsletter
Bhutan
: IDD assessment & Monitoring
India
: Salt industry and technology,
Laboratory Management
Nepal
: Programme integration experience
for iodised oil
Pakistan
: Social marketing
Maldives
: IDD assessment
Sri Lanka
: Community participation and NGO's
External evaluation
As the Member countries achieve elimination
of IDD there is a need for an external technical
agency to carry out an independent assessment of
14
progress towards sustainable elimination of IDD. Such
an exercise has been recently completed by the State
Government of Madhya Pradesh, India and Royal
Government of Bhutan.
The Forty-Ninth World Health Assembly in May
1 996 passed a resolution (WHA 49.1 3; Agenda item
17), unanimously adopting the resolution on the
"Prevention and Control of iodine deficiency disor
ders".
In the resolution, item 4,"REQUESTS the
Director-General:
(1)
to continue to monitor the incidence and
prevalence of iodine deficiency disorders;
(2)
to reinforce the technical support provided to
Member States, on request, for monitoring progress
towards the elimination of iodine deficiency disor
ders with the help of the International Council for
Control of Iodine Deficiency Disorders, other non
governmental organizationsand UNICEF, asrequired;
(3)
to mobilize additional technical and financial
resources to permit those Member States in which
iodine deficiency disorders are still a significant
problem, for training health and development
workers in the early identification and treatment of
iodine deficiency disorders and develop or expand
their appropriate public health preventive
programmes for the elimination of these disorders;
15
(4)
to establish a mechanism for verifying the
elimination of iodine deficiency disorders in the world;
(5)
to report to the Health Assembly by 1999
on progress achieved in the elimination of iodine
deficiency disorders.
16
4
Conclusion
History teaches us that the sustained elimina
tion of IDD requires constant vigilance of a range of
professional and public interests. It is particularly
important to understand this as we have crossed that
target of universal iodisation of edible salt by the end
of 1995. Too many of us may diminish our efforts
when we reach the first plateau. The long climb to
eliminate the stealthy scourge of IDD from the globe
begins with the achievement of universal iodisation
of salt24.
The strategy for management of sustained IDD
elimination should, therefore, focus on the following
essential elements:
•
Continuous political and financial commitment.
•
Clear communications strategy
professionals and the public.
•
Persistent quality control processes to assure a
high quality product, i.e. iodised salt with
appropriate iodine levels.
•
Monitoring and tracking biological progress
with respect to IDD status with requests for
independent assessment of the progress.
•
Ensuring that the management process is in
place to carry out these activites.
17
between
Basil Hetzel in his inaugural address at the
South Asian Country meeting on "Partnership to End
Hidden Hunger - Collaboration of stakeholders in
sustaining elimination of Iodine Deficiency Disorders
in Bangladesh", held at Dhaka, Bangladesh in April
1995 stated that, "The elimination of IDD will be a
great triumph in the field of public health, compara
ble to the eradication of smallpox". This is eminently
possible. For, there are few moments in time when
there is a clear fork in the path of major human
endeavour. As we battle against the ancient and
pervasive scourge of iodine deficiency, we are cer
tainly at a turning point. Never before has the way to
our goal been so clear or so near. Never before have
we been able to see so clearly or so far.
18
5
Post Script
At the request of U NICEF-ROSA, Kathmandu, a
background note was prepared for the "Third SAARC
Ministerial Conference on CHILDREN OF SOUTH
ASIA" which was held at Rawalpindi, Pakistan in
August 1 996. This paper constituted a major portion
of that note. The Rawalpindi Resolution on Children
of South Asia included the following statement on
IDD.
"For accelerating progress towards the goals,
WE AGREE TO : Launch a comprehensive nutrition
initiative in South Asia supported by measures such
as:
i)
adoption of the SAARC code on Breast Feed
ing and young child nutrition;fortification and sup
plementation of micronutrients like iron, iodine and
vitamin A;
ii)
salt.
adoption of a SAARC convention of iodised
19
6
References
1) Micronutrient Deficiency Information System,
World Health Organization, MDIS Working Paper #
1, Global Prevalence of Iodine Deficiency Disorders.
2) Hetzel B.S.: Iodine Deficiency Disorders (IDD) and
their eradication. Lancent 2:1 126-1 129, 1983.
3) Thilly, C.H., P. Bourdoux, B., Swennen, N., Bebe,
Due
D.
and A.M., Ermans, Assessment and planning
for IDD control programs in 'The Prevention and
Control of Iodine Deficiency Disorders'. Edited by
Basil S. Hetzel, John T. Dunn and John B. Stanbury,
Elsevier, 1987. p.p 181-94
4) Bleichrodt, N., M.Ph. Born, 1 994. 'A metaanalysis
of research on iodineand itsrelationship to cognitive
development'. In J. Stanbury eds. The damaged brain
of iodine deficiency: neuromotor, cognitive, behav
ioral, and educative aspects. Report of the Franklin
Institute Symposium, Publ. Cognizant Communica
tion Corporation.
5) "Progress towards elimination of IDD", in "S.O.S.
for a Billion - The conquest of Iodine Deficiency
Disorders", edited by Hetzel, B.S. and C.S. Pandav,
Second Edition, Oxford University Press, 1 996.
20
6) "Prevention and control of iodine deficiency disor
ders", Resolution of the World Health Assembly,
(WHA 49.13), Forty Ninth World Health Assembly,
Geneva, May 1 996.
7) Pandav, C.S. IDD in South-east Asia, in "SOS for a
Billion - The Conquest of Iodine Deficiency Disor
ders", second edition, Oxford Universtiy Press, 27191.
8) Pandav, C.S. Citizen's report on Iodine content in
Salt at Consumer level in Uttar Pradesh.
9) Pandav, C.S., J., Hurley. Economic evaluation of
iodine deficiency disorders control programme in
Sikkim. Thesis submitted for M.Sc (Health Sciences),
McMaster University, Hamilton, Canada, 1991.
10) Harun K.M. Yusaf, Salamatullah Quazi, Moududur
R. Khan, Mohammad Mohiduzzaman, Bardrun Nahar,
M. Mostafizur Rahman, M. Narul Islam, M.
Asaduzzaman Khan, Mohammad Shahidullah,
Tujammul Haque, Mohammad Baquer, Pandav C.S. Iodine Deficiency Disorders in Bangladesh, Indian
Journal of Pediatrics 1996; 63: 105-10.
11) Progotir Pathey, Progress Towards the Achieve
ment of the Goals for the 1 990's. Bangladesh Bureau
of statistics, Ministry of Planning Government of the
People's Republic of Bangladesh and U NICEF, 1 995.
1 2) IDD Newsletter, International Council for Control
of Iodine Deficiency Disorders in Bangladesh, Vol. 1,
No. 2, April 1 996.
21
13) Iodine Deficiency Disorders, The Bhutan Story.
Directorate of Health Services, Ministry of Social Ser
vices, Royal Government of Bhutan 1 992.
14) Towards the Elimination of Iodine Deficiency
Disorders in India, C.S. Pandav and K. Anand, Centre
for Community Medicine, All India Institute of Medi
cal Sciences, New Delhi, Indian J. Pediatr 1995: 62 :
545-555.
1 5) Pandav., C.S. et al : Independent Survey Evalua
tion of Universal Salt Iodisation in Madhya Pradesh,
1 5th January 1 996.
1 6) Pandav., C.S. et al : "Iodine Deficiency Disorders
in Maldives, UNICEF Male, Maldives, August 1995.
1 7) Nepal Multiple Indicator Surveillance, Major Indicators-Provisional Result, National PlanningCommission HMG/Nepal, Kathmandu, 1 995
1 8) Pandav., C.S. Iodine Deficiency Disorders Elim
ination in Nepal : Consultants Progress Report to the
Micronutrient Initiative. January 1996.
19) Iodized Salt Report, Government of Pakistan's
IDD Elimination Program, July 1996.
20) ISSF Semi Annual Overview January - June 1 996)
Government of Pakistan's IDD Elimination Program
June 1 996.
22
21) Partnership to End Hidden Hunger, Collaboration
of Stakeholders in Sustaining the Elimination of Io
dine Deficiency Disorders, Dhaka, Bangladesh 9-1 2
April 1995.
22) Iodine Deficiency Disorders in SAARC countries,
Draft act and rules for Import / Export of Iodised salt,
October, 1 994.
23) Indicators for assessing Iodine Deficiency Disor
ders and their control through salt iodization, WHO/
UNICEF/ICCIDD, 1994.
24) Editorial: Sustaining elimination of iodine defi
ciency disorders, C.S. Pandav, H. Viswanathan, D.P.
Haxton in The National Medical Journal of India,
Vol.8, No.2, 1995.
25) Personal Communications from UNICEF Offices
of SAARC member Countries, UNICEF Regional Of
fice, Kathmandu and H.Q. office New York and WHO
Regional Office, New Delhi and H.Q. Office, Geneva.
23
7
Biodata
Chandrakant S. Pandav
Chandrakant S. Pandav is a medical scientist;
epidemiologist & health economist and faculty mem
ber at the Centre for Community Medicine, All India
Institute of Medical Sciences (AllMS), New Delhi.
Dr Pandav is both a graduate and postgraduate of AllMS.
He has also done M.Sc. (Health Economics, Clinical
Epidemiology, Biostatistics) from McMaster Universi
ty, Canada. Dr. Pandavwas a member of a team at Al I MS
that showed the serious impact of iodine deficiency on
child development. He has published/presented over
150 papers in national and international journals/
conferences. He was Co-editor (With B.S. Hetzel) of
the book "S.O.S. for a billion - The conquest of Iodine
Deficiency Disorders" published by Oxford Universi
ty Press, New Delhi, April 1994. He has won many
awards for his academic and research activities.
Dr Pandav has worked as a consultant for WHO,
UNICEF, PAMM and Ml at the global, regional and
national level in India, China, Bangladesh, Nepal,
Bhutan, Indonesia, Philippines and in the Middle East.
He has played a major role in the policy &
advocacy, program development, monitoring & eval
24
uation, operational research and on economic & social
benefits of the elimination of iodine deficiency disor
ders. He is a member of Governing Board, Executive
Committee and since 1986 has been the Regional Co
ordinator, South Asia & Pacific of International Council
for Control of Iodine Deficiency Disorders (ICCIDD).
25
Sustaining Elimination of IDD
mro
ISBN 81-86813-06-3
International Council
for Control of
Iodine Deficiency Disorders
Universal Salt Iodisation
(USD
Independent Survey Evaluation
of
Universal Salt Iodisation (USI)
in
Madhya Pradesh
by
International Council for Control of
Iodine Deficiency Disorders
(ICCIDD)
Centre for Community Medicine
All India Institute of Medical Sciences
(AllMS)
New Delhi - 110 029, India
15 th January, 1996
The International Council for Control of
Iodine Deficiency Disorders (ICCIDD) is a non-profit
non governmental organization dedicated to the
sustainable elimination of Iodine Deficiency Disorders
(IDD) throughout the world. The ICCIDD was granted
an official status as an International NGO at the 47th
World Health Assembly held in Geneva in 1994. It's
activities are supported by donations/grants from the
Australian Agency for International Development
(AusAID), the Canadian International Development
Agency (CIDA), the Micronutrient Initiative (MI), the
Netherlands Ministry for Development Cooperation,
the Swedish International Development Agency
(SIDA), the United Nations Children's Fund (UNICEF),
the United States Agency for International
Development (USAID), the World Bank, the World
Health Organization (WHO), and others.
TO THE GLOBAL PARTNERSHIP
DEDICATED TO THE ELIMINATION OF
IODINE DEFICIENCY DISORDERS
An Ancient Scourge of Mankind
The People of the affected countries
The Governments of the affected countries
The Salt Producers of each country
The International Agencies-especially
The World Health Organization
The United Nations Children’s Fund
The World Bank
The Micronutrient Initiative
Program Against Micronutrient Malnutrition
Kiwanis International
The International Expert Network of
International Council for Control of
Iodine Deficiency Disorders
(ICCIDD)
The Bilateral Agencies especially
The Australian Agency for International Development
The Canadian International Development Agency
The Netherlands Ministry for Development Cooperation
The Swedish International Development Agency
The United States Agency for International Development
We would like to dedicate our efforts
to the memory of James P. Grant who was
Executive Director of UNICEF for 15 years
until his death in January, 1995
and
to the children of Madhya Pradesh.
They have
inspired
us
to continue working towards the goal of
sustaining the elimination of IDD
James P. Grant
12 May 1922-28 January 1995
ACKNOWLEDGMENTS
A sincere 'thank you'
To all those families who obliged with the survey
To all those who made this study possible and many more.
and
The Rajiv Gandhi Mission
for Elimination of
Iodine Deficiency Disorders
Government of Madhya Pradesh
UNICEF, Bhopal, (Madhya Pradesh)
All India Institute of Medical Sciences, Delhi
Centre for Community Medicine
Department of Human Nutrition
Department of Paediatrics
Indian Council of Medical Research (ICMR), Delhi
National Institute of Nutrition (NIN), Hyderabad
Institute of Nuclear Medicine and Allied Sciences (INMAS), Delhi
Sanjay Gandhi Post-Graduate Institute (SGPGI), Lucknow
Assam Medical College, Dibrugarh, Assam
ACP Medical College, Dhule, Maharashtra
Directorate of Health Services, Andaman and Nicobar
Directorate of Health Services, Sikkim
International Council for Control of Iodine Deficiency Disorders
(ICCIDD)
International Clinical Epidemiology Network (INCLEN)
Clinical Epidemiology Unit (CEU);
All India Institute of Medical Sciences, Delhi
Christian Medical College, Vellore
Government Medical College, Nagpur
King George Medical College, Lucknow
Independent Survey Evaluation of
Universal Salt Iodisation (USI) in
Madhya Pradesh
Planning & Co-ordination Team
Laboratory Team
Chandrakant S. Pandav
R. Sankar
N.K. Arora
F. Ahmed
M.C. Karmarkar
Rashid Ahmed
Smita Pandav
Shankar Chowdhury
Lalit M. Nath
M.C. Karmarkar
Bimal Rai
Smita Pandav
Sham Sunder
R.S. Solanki
Ranjana Satija
Field Survey Team
Lalit Kant
M.M. Codbole
K.V. Rameshwar Sarma
Vijay Gupta
Prashant Joshi
Y.K. Joshi
Dhananjay Deoskar
A.B. Sewarkar
N.K. Arora
Chandrakant S. Pandav
F. Ahmed
Kurien Thomas
Yogesh Jain
Bimal Rai
Rajiv Yadav
Girish Singh
S.B. Nagtilak
Rashid Ahmed
Arun Mallik
R. Sankar
Data Management &
Report Preparation
Office & Administrative
Support
R. Sankar
Rajesh Pandav
Rashid Ahmed
N.K. Arora
F. Ahmed
Chandrakant S. Pandav
Veena
D. Rajan
Ashok Negi
Saroja Narayan
Pritam Singh Tanwar
P. Ahuja
Binod Kumar
Edited by
Dr. Chandrakant S. Pandav
Regional Co-ordinator, South Asia & Pacific
International Council for Control of Iodine Deficiency Disorders
(ICCIDD)
&
Additional Professor,
Centre for Community Medicine
All India Institute of Medical Sciences
New Delhi - 110 029, India.
ISBN 81-86813-03-9
Cover design : Gouri Shankar Mukherjee
Photographs : Courtesy of UNICEF
Printed at Sona Printers Pvt. Ltd. B-181 Okhla Ph-1, New Delhi - 20.
Executive
Summary
Iodine deficiency disorders (IDD) continue to
threaten the health, well-being, social and economic
productivity, and advancement of several hundred
million people throughout the developing world.
Brain development and intelligence have been shown
to be adversely affected. Children living in iodine
deficient areas score significantly lower on I.Q. tests
by 1 3 points than those from-iodine sufficient areas.
Iodisation of salt is the preferred approach for iodine
supplementation in iodine deficient populations.
Universal Salt Iodisation Programmes are conceptually
very simple; however, the successful implementation
of an iodisation programme involves the complex
behavioral modification of the affected population
and changes in salt trade practices. Success of a salt
iodisation programme therefore, requires the active
support and commitment of all the key stakeholders.
Critical elements for sustaining a programme are
strong political will, supported by administrative
infrastructure and active community participation.
In India, the National Goitre Control Progamme
underthe Ministry of Health and Family Welfare has
helped to provide a policy and advocacy framework
from time to time. Some of the key events were the
introduction of IDD in Prime Minister Indira Gandhi's
"20 Point Progamme" in 1 983, adoption of Universal
Salt Iodisation (USI) in India by the Central Council of
ooco***
Health and Family Welfare in 1983, and participation
of the private salt traders in the supply of iodised salt.
Iodine Deficiency Disorders were first reported
as a public health problem in Madhya Pradesh as
early as 191 5. Remedial action, however, was initiated
only in 1 983 after the results of surveys carried out in
1978 and 1983, re-emphasised the gravity of the
problem. An iodized salt programme was introduced
in four districts of the state in 1983. Subsequently, all
the districts of the state were gradually covered by the
ban-notification banning the sale of non-iodised salt.
The programme was given a major thrust forward in
1988-1990, when during a span of two years, 33
districts were brought under the ban notification,
completing coverage of all the 45 districts of the state.
In addition to legislative measures, the need for
community participation and a fast-track approach to
achieve universal salt iodisation were considered
essential for attaining the goal of IDD elimination and
sustaining it thereafter.
The "Mission approach" has been adopted by
the highest political level, whenever a problem is
perceived as requiring urgent action for tangible
results. The Mission's approach entails clarity of
objectives and strategies to handle a public issue. The
plan of action is executed within a defined time-frame
by a committed team. Fast-track procedures and
collective action by an inter-sectoral effort are the
major strengths of this approach. Close monitoring
2
0
and transparent evaluation are also an integral part of
this approach.
The Government of Madhya Pradesh launched
seven missions to focus on the three basic needs of
the state's rural population: education, health
improvement, and employment. The Rajiv Gandhi
Mission for Elimination of Iodine Deficiency Disorders
is one of the seven missions. It was launched on 20th
August 1994. A blend of'scientific insight, social
commitment, and political will has given this age old
scourge a high priority on the human resource
development agenda of the governments of Madhya
Pradesh.
The objectives of the Mission were to ensure
availability of adequately iodised salt, in all villages
and towns of Madhya Pradesh, by the end of 1997
and, to increase the awareness of the population on
the importance of iodine and the disorders caused by
its deficiency. The strategy adopted by the Mission
has two clear components: 1) action on the demand
side to make communities aware of the need to use
adequately iodised salt and, 2) action on the supply
side, to ensure distribution and sale of adequately
iodised salt.
UNICEF has played a key role in givingtechnical
inputs and in providing support on a regular basis
demonstrating an excellent partnership with the
Government of Madhya Pradesh.
3
On completion of the first year of the Mission,
the Chief Minister presented a report entitled "Rajiv
Gandhi Mission: A Report to the People". The salient
achievement of the Mission as mentioned in the report
was the consumption of iodised salt was more than 84
per cent of all salt consumed in the state. Therefore,
it was proposed to announce the closure of this
Mission by 26th January 1996. The Chief Minister
also stated that "the closure will be preceded by an
independent evaluation to be conducted by a reputed
non government evaluation agency."
As a follow up, the International Council for
Control of Iodine Deficiency Disorders (ICCIDD), was
invited to independently evaluate the status of
Universal Salt Iodisation (USI), in Madhya Pradesh.
The primary objective of the evaluation was to
determine the proportion of urban and rural
households in Madhya Pradesh (MP), consuming
adequately iodised salt. The other objectives were to
determinetheavailability of iodised salt in the selected
clusters at the retail level in rural and urban areas and,
to determine the iodised awareness of the population
about iodised salt, IDD, salt use patterns, storage, and
cost at the households and retail level.
The field survey was carried out in November
1 995 by 20 senior physicians representing 1 2 premier
national institutions and two international
organizations. For the purpose of the survey, the state
was divided into urban and rural strata. Probability
4
Proportionate to Size (PPS) Cluster Sampling
Methodology was used to select 30 clusters in each of
the strata. Field activities included the collection of
salt samples from households and retail shops. In
addition, the Knowledge, Attitude, Practice and
Behaviour (KAPB), of household members and retail
shopkeepers was assessed through survey interviews.
Salt samples were analysed for iodine content
by iodometric titration - the internationally accepted
gold standard - at the All India Institute of Medical
Sciences (AllMS), New Delhi, under the technical
supervision of a senior ad visor to the ICCIDD. Ail data
collected were analysed by a specially designed
computer software package.
The results show that the state of Madhya
Pradesh has achieved universal availability of iodised
salt as 98.4 per cent of the salt samples were found to
be iodised at the household level (urban = 98.9 per
cent; rural = 98.3 per cent). With respect to adequate
iodine content, 69 per cent of urban households and
61 per cent of rural households were found to be
consuming adequately iodised salt. This truly
represents a remarkable achievement for a state that
imports all of its salt requirement.
The possible reasons for the inadequate level
of iodine in salt found in over 31 per cent of urban
and 39 per cent of rural households are: inadequate
iodisation at the production level, problems with
5
packaging, storage and transportation before it
reaches it's destination and, quality assurance issues
at the repacking units within the state.
In order to address these issues effectively,
there is a need for organizing continuous dialogue
with manufacturers, the salt commissioner's office,
railways and road transport agencies. Stringent
enforcement of P.F.A. rules is also necessary.
The positive awareness about iodised salt
among urban and rural households was 65 per cent
and 44 percent, respectively. Television programmes
and health workers were the major sources of
information to those who had heard about iodised
salt.
Other salient points revealed in the survey
include:
• most of the urban households (88 per cent) were
consuming powdered salt
• 32.1 per cent of rural households were using
crystalline salt
• about 30 per cent of powdered salt samples at
both urban and rural households levels were
inadequately iodised
• as many as 38 per cent of the crystalline salt
samples used in rural households were adequately
iodised, contrary to popular opinion that all powdered
salt is iodised and all crystalline salt is non-iodised
• the practice of salt purchase and storage was
found to be almost identical in both urban and rural
households
• retail shops catering to the households included in
the samples seem to sell only iodised salt both in
urban (99 per cent) and rural (97.9 per cent) areas
• it seems that 73 per cent of urban retail shop
samples and 66 per cent of rural retail shop samples
are adequately iodised. This was consistent with
observations made at the households level
The major achievement of the Mission was in
streamlining and strengthening the IDD elimination
measures that were already in place. The specific
achievements of the Mission as perceived by the
evaluation team were:
i) involvement of the salt traders in implementing the
Universal Salt Iodisation programme. "The Bhopal
Declaration" by the salt traders was an important
landmark in this respect.
ii) forgoing partnerships between the programme
managers and the key stakeholders to understand
each other's viewpoints and constraints
iii) Nagarik Apoorti Nigam (NAN) was involved as a
catalyst to ensure the availability of adequately
iodised salt, particularly in the remote tribal and hilly
areas. The NAN uses a social pricing strategy to
maintain the price of the packaged iodised salt.
7
iv) the district administration, the health department,
and the education department were involved on a
larger scale in creating awareness, and monitoring of,
the iodine content of salt.
In conclusion, the Mission approach has
succeeded in giving a thrust to the ongoing IDD
elimination programme. The achievements thus far
obtained have to be sustained. This is the most critical
period as complacency at this stage will lead to a
"sliding down effect". This transistional phase, from a
"Mission approach" to a "System approach", is
crucial, especially at a time when the whole IDD
programme has just taken off and has not yet gathered
the critical momentum needed to progress on it's
own.
To consolidate the achievements of the Mission
and sustain the elimination of IDD in Madhya Pradesh,
the following recommendations are proposed:
1. The IDD elimination programme should continue
to get the same level of priority and urgency in
implementation from political, administrative, and
social sectors.
2. The intersectoral co-ordination so far achieved
during the mission should be retained and preferably
enhanced at all levels.
3. The approach of ensuringcommunity participation
in the programme has to be sustained and made more
broad-based. The involvement of the educational
system, Panchayat system and consumer organisations
should be further strengthened for creating awareness
and participation in monitoring.
4. The Mission Director's role has to be taken over by
a responsible officer from any of the participating
departments, which would consequently be identified
as a nodal agency to implement the programme.
5. The monitoring system should include social
monitoring, regulatory monitoring and health
monitoring. Social monitoring should be done by
schools, communities, consumer organisations,
Panchayats and opinion leaders on the availability of
iodised salt, by testing it with a spot testing kit and by
recording its price.
6. With respect to regulatory monitoring, the
Directorate of Food and Drug Control, with the help
of active support of health agencies, should enforce
the P.F.A. Act.
7. In addition to monitoring the process indicators of
the IDD elimination progamme, health monitoring
should include the impact indicators, namely goitre
prevalence and urinary iodine in schoolage children
and should be measured every five years.
The success story of Madhya Pradesh in
operationalising the scientifically sound and costeffective programme of USl in eliminating IDD should
be widely communicated to the people of Madhya
9
Pradesh and the nation at large. This role model will
prove to be the guiding principle for implementing
many other health related social development issues.
A one time, or time bound salt iodization
programme cannot eliminate the spectrum of IDD
disorders, as the human body requires 1 00-1 50 //g of
iodine every day. There fore it is essential to sustain
the political commitment which can be strengthened
by broad public understanding of the issues. Policy
needs to include quality assurance to sustain
achievements towards IDD elimination. Equally
important is the need to further involve the various
groups that have a role to play in sustaining the
elimination of IDD namely the stakeholders, for it is a
venture that involves action by all, for all times.
10
A Glimpse at the History of Iodine Deficiency Disorders events in Madhya Pradesh
YEA«i (19-)
i
r
| J
| J
»
t
•
*
0
1
i
4
t
»
•
»
•
>
>
1
*
•
1) POLITICAL SUPPORT
PROGRAMME POLICY
2) INTERNATIONAL
ADVOCACY
3) ADMINISTRATIVE
INFRASTRUCTURE
4) ASSESSMENT OF SURVEYS
ON IDD PREVALENCE /
KAPB / SALT
S) LEGISLATION AND
ENFORCEMENT
6)
SALT INDUSTRY
7)
I EC
8)
TRAINING
9)
MONITORING
PROGRAMME: TRACKING
PROGRESS TOWARDS USI
10) EXTERNAL EVALUATION
YEAR (19-)
h h I: I: k h h h I: I: h |: I: I: |: h I: h I: I: I: I: |:
This timeline illustrates event (by a" •') that have taken place in the history of IDD programme in Madhya Pradesh
Inadequately Iodised Salt at Household & Retail Level in M.P.:
Probable Factors and Recommended Remedial Measures
Sustaining Elimination of IDD
ICCIDD
International Council
for Control of
Iodine Deficiency Disorders
ISBN 81-86813-03-9
Introduction to
International Council for
Control of
Me Deficiency Disorders
(ICCIDD)
The International Council for Control of Iodine Deficiency Disorders (ICCIDD) is
a non-profit non-governmental organisation dedicated to the sustainable elimina
tion of iodine deficiency disorders (IDD) throughout the world. The ICCIDD was
granted an official status as an International NGO at the 47th World Health
Assembly held in Geneva in 1994. It's activities are supported by donations/
grants from the Australian Agency for International Development (AusAID), the
Canadian International Development Agency (CIDA), the Micronutrient Initiative
(MI), the Netherlands Ministry for Development Cooperation, the Swedish Inter
national Development Agency (SIDA), the United Nations Children's Fund
(UNICEF), the United States Agency for International Development (USAID), the
World Bank, the World Health Organisation (WHO), and others.
TO THE GLOBAL PARTNERSHIP
DEDICATED TO THE ELIMINATION OF
IODINE DEFICIENCY DISORDERS
Ah Ancient Scourge of Mankind
The People of the affected countries
The Governments of the affected countries
The Salt Producers of each country
The International Agencies-especially
The World Health Organization
The United Nations Children's Fund
The World Bank
The Micronutrient Initiative
Program Against Micronutrient Malnutrition
Kiwanis International
The International Expert Network of
International Council for Control of
Iodine Deficiency Disorders
(ICCIDD)
The Bilateral Agencies especially
The Australian Agency for International Development
The Canadian International Development Agency
The Netherlands Ministry for Development Cooperation
The Swedish International Development Agency
The United States Agency for International Development
Edited by
Dr. Chandrakant S. Pandav
Regional Co-ordinator, South Asia & Pacific
International Council for Control of Iodine Deficiency Disorders
(ICCIDD)
ISBN 81-86813-04-7
Cover design by: Salim Meme
Printed at Sona Printers Pvt. Ltd. B-181 Okhla Ph-1, New Delhi - 20.
Contents
Preface
»
Introduction
1
ICCIDD
2
ICCIDD Mandate
3
ICCIDD Activities
5
ICCIDD Structure
6
ICCIDD Multidisciplinary Team of Experts
7
Collaboration
8
Research and Training
9
Monitoring
11
Communication & Publications
12
ICCIDD Consulting Services
14
ICCIDD Offices Bearers
15
Appendix
18
Preface
Iodine deficiency is the most common preventable cause of brain damage in the
world today.
This book introduces the Consulting Services of the International Council for the
Control of Iodine Deficiency Disorders (ICCIDD). It provides a brief account of the history
and function of the ICCIDD and its relation to the international agencies and to national
governments.
The ICCIDD now has a multidisciplinary network of 400 experts drawn from 82
different countries, who are committed to the development and monitoring of national
programs for the sustainable elimination of IDD.
In 1990 the goal of elimination of IDD as a public health problem by the year 2000
was adopted by the 43rd World Health Assembly for the World Health Organization. The
Executive Board of UNICEF passed a similar Resolution.
The World Summit for Children, attended by 71 Heads of State and 88 representa
tives of other governments meeting at the United Nations, New York, September'1990
approved a Plan of Action which included the virtual elimination of Iodine deficiency
disorders by the year 2000.
This book is designed to help achieve the goal of elimination by indicating the
available expertise of the members of the ICCIDD to all agencies and governments. The
ICCIDD provides technical assistance to governments and agencies on all aspects of
development and monitoring of national programs.
The ICCIDD welcomes contact by Agencies and Governments. Procedures for
Consultations are described.
The ICCIDD recognises that in order to sustain elimination of IDD a complex
network of activities of quality assurance of modern management in the national efforts is
required. This will take a good bit of effort by all concerned - the "stakeholders", - since it
involves management issues in nutrition, in health, in education, in agriculture, in salt
manufacture, in raw material provision, in human resource development, in public
education, and in sustained consumer demand.
The ICCIDD mandate is to promote collaboration with stakeholders in the spirit of
true partnership to end the hidden hunger of iodine deficiency.
The ICCIDD assures all concerned of its commitment to work with them in the
achievement of the great goal of elimination of the ancient scourge of iodine deficiency.
Basil S. Hetzel, MD
Chairman
ICCIDD
January, 1996
F. Delange, MD
Executive Director
ICCIDD
Introduction
Iodine Deficiency Disorders, or IDD, refers to a
variety of health problems caused by insufficient iodine
in the diet. Iodine is an essential nutrient for thyroid
function and through this for normal human growth and
development, particularly of the brain and intellectual
capacities. An estimated 1.6 billion people on earth in 110
countries live in areas where the soil is iodine deficient
and iodine-rich seafood is unavailable or not a part of the
local diet. This leads to devastating consequences caus
ing thyroid function abnormalities and where the defi
ciency is severe, endemic goitre and cretinism, mental
retardation, reduced fertility and increased perinatal and
infant mortality.
Advocacy by the ICCIDD
through UNICEF & WHO led
the 1990 United Nations
World Summit for Children to
commit itself to the goal of
virtual elimination of Iodine
Deficiency Disorders by the
year 2000.
Iodine deficiency was once considered a minor
problem, causing goitre, an unsightly but seemingly
benign cosmetic blemish. However, it is now known that
iodine deficiency is the most common preventable cause
of mental handicap in the world today, constituting a
threat to the social and economic development of many
countries of the world including European countries.
The industrialized world has made great strides
in combating iodine deficiency inspite of the persistence
of severely affected areas, particularly in the eastern parts
of Europe. A number of countries in Latin America have
achieved notable success, and in Asia, IDD elimination is
progressing in countries where national programs have
been launched. Finally, Africa has shown very significant
progress except in countries where major political insta
bility impaired the implementation of health programs.
The solution is relatively simple. A teaspoon of
iodine is all a person requires in a lifetime, but because
iodine cannot be stored for long-periods by the body, tiny
amounts are needed regularly. In areas of endemic iodine
deficiency, where soil and therefore crops and grazing
animals do not provide sufficient dietary iodine to the
populace, food fortification and supplementation have
proven highly successful and sustainable interventions.
Iodized salt programs and iodized oil supplements are
the most common tools in the fight against IDD.
ICCIDD
The International Council for Control of Iodine
Deficiency Disorders (ICCIDD) is the only international
organization specifically constituted to promote the
elimination of IDD. ICCIDD's multidisciplinary global
network of experts consists of some 400 specialists from
more than 82 countries. They include scientists in the
medical and nutrition fields, public health administra
tors, development managers, technologists, communi
cators, economists, salt technologists and other indus
try experts. All of them are committed to assisting
governments and international agencies in developing
national programs for the virtual elimination of IDD as
a public health problem.
ICCIDD was formed in 1986 with support from
UNICEF, WHO and the Australian government in
order to bridge the gap between available knowledge
and its application in solving the problem of IDD for the
millions at risk. ICCIDD has played a major role in
communicating the IDD threat to decision makers of
national governments and international agencies and to
a wide variety of health professionals and planners.
The UN mid-decade goal of
Universal Salt Iodization by
1995 is a critical step in the
virtual elimination of IDD.
ICCIDD multidisciplinary ex
perts can help make that goal
attainable and to sustain it
thereafter.
By participating in public policy development
and advocacy, program development, implementation
and training, ICCIDD consultants assist countries with
significant IDD problems to develop national IDD con
trol programs, in cooperation with:
•
national governments
institutions and individuals
private industries and welfare agencies
major international agencies
key bilateral aid giving agencies
ICCIDD is a non-profit, non governmental orga
nization (NGO) with official consultant status with WHO
and the UN system and an official participant in the
annual World Health Assembly.
e
ICCIDD Mandate
to promote awareness of the magnitude of IDD
and the fact that it can be eliminated at an
affordable cost;
to provide technical assistance in the assessment
of prevalence in countries and the development
of strategies for IDD elimination;
The goal of ICCIDD is to sup
port national efforts to virtu
ally eliminate IDD from the
globe by the year 2000.
To achieve 'Goal 2000',
ICCIDD works where IDD is
a problem, consulting with
governments and develop
ment agencies at the national
level to ensure that national
plans are in place to achieve
the goal and to sustain virtual
elimination once it is
achieved.
to provide technical assistance in monitoring the
application of these strategies and evaluate
their effectiveness;
to support training programs at national and
regional levels for survey design, program
management, monitoring and evaluation, social
communication and technical assistance to quality
assurance systems;
to encourage research on issues relating to the
virtual elimination of IDD.
Global Milestones in 1DD awareness
1960
The World Health Organization
(WHO) presents the first com
prehensive review of goitre on a
world scale, underlining the se
verity of the problem. However,
in spite of the successful elimina
tion of IDD in a number of indus
trialized countries, only very
slow progress is made in devel
oping countries during the next
15 years.
1974
The World Food Council is the
first of a number of international
organizations over the next de
cade to call for the elimination of
goitre.
1983
The concept of iodine deficiency
disorders (IDD) is introduced
with emphasis on the effects of
iodine deficiency on brain func
tion.
1985
With support from UNICEF,
WHO & Australian government,
the ICCIDD is founded in order
to bridge the gap between avail
able knowledge and its applica
tion.
1987
The United Nations Sub-Com
mittee on Nutrition establishes
an IDD Working Group to re
ceive an Annual Report on
Progress.
1990
The 43rd World Health Assem
bly in Geneva recognizes IDD
elimination as a major priority.
Photograph of Mother (with a goitre) holding a child
The UN World Summit for Chil
dren, attended by 71 Heads of
State and representatives of 159
governments, adopts a plan of
action that includes the virtual
elimination of IDD by the year
2000.
1991
Ending Hidden Hunger (A policy
conference on Micronutrient Mal
nutrition) Montreal, Canada.
1992
The 45th World Health Assem
bly and the WHO-FAO Interna
tional Conference on Nutrition.
Commitment confirmed.
ICCIDD Activities
Consulting services
Collaboration
Program Implementation
Research
Training
Monitoring
ICCIDD
Communication
Publications
The Logo of ICCIDD This shows the human brain within the
skull which emphasizes the importance of the brain in the
effects of iodine deficiency
The map shows the active progress of national 1DD Elimination programmes throughout the world Countries arc grouped into four categories (From WHO <!
*><>)
with permission)
ICCIDD Structure
The ICCIDD has a Governing Board of 38 members with more than
half from developing countries and the international agencies.
The Board meets annually, usually in conjunction with a regional
meeting or a special workshop.
ICCIDD has the executive of seven members which includes
Chairman, Vice-Chairman, Executive Director, Secretary & three
members.
Executive Director's position is full-time, the others being part time.
The Executive Director is responsible for the global secretariat in
Brussels, Belgium with a small & committed office staff.
The ICCIDD has Regional Coordinators for Latin America, South
Asia and Pacific, China and Eastern Asia, Europe, Eastern Europe
and Central Asia.
In Africa three Sub Regional Coordinators are responsible for
countries in the North and West (both anglophone and franco
phone), for Central (francophone) and East and South (anglophone)
areas.
Each Regional or Sub Regional Coordinator is the member of the
Board who makes an annual report on IDD activities in the region
and also takes appropriate initiative including consultancies to
individual countries.
ICCIDD has more than 400 members drawn from 82 countries from
many different disciplines.
ICCIDD Multidisciplinary Team of Experts
ICCIDD recruits consultants from over 82 coun
tries to provide culturally and politically sensitive ex
perts with the highest scientific, technical and managerial
capabilities. These consultants work in every aspect of
IDD elimination programme to help keep the wheel
turning (see figure),
•
•
•
•
•
•
•
•
•
Epidemiological, experimental & clinical studies;
endocrinology, obstetrics, paediatrics, public
health, radiology, clinical biochemistry, radio
immunology, nuclear medicine, pharmacology
and animal nutrition;
Assessment & program design;
Iodization of salt & other technologies;
Planning & training;
Management & program development;
Technical assistance to quality assurance systems;
Monitoring & evaluation;
Communication & education;
Advocacy & social marketing.
PROCESS
MODEL
FOR
NATIONAL
IDD
ICCIDD's multidisciplinary
teams of experts provide
comprehensive and cost
effective technical,
scientific and managerial
assistance.
ELIMINATION
PROGRAM
Collaboration
ICCIDD's principal strategic
allies for tire sustained elimination
of IDD are:
Governments of affected countries
The People of affected countries
Private Industry including:
• Saltindustry
• Food Industry
• Pharmaceutical Industry
National Governments and their
bilateral development agencies, in
cluding:
• Government of Australia and
AusAID
• GovernmentofBelgium
♦ Government of Canada and CIDA
• Governmentof the Federal
Republic of Germany
• Governmentof Japan
• Government of The Netherlands
• Government of Sweden
• Government of the United States of
America and USAID
Since 1986, ICCIDD regional coordinators have
collaborated with UNICEF and WHO regional represen
tatives and representatives from bilateral agencies and
NGOs in regional IDD working groups and task forces to
initiate and monitor elimination programs. There is now
a Task Force in place for Africa and IDD Working
Groups for Eastern Europe, Latin America, South East
Asia, China and Indonesia.
ICCIDD serves as the expert consultative body on
IDD issues in the support of elements of United Nations
system, and ICCIDD consultants are available to all inter
ested parties. Please refer to page 14 for client proce
dures to request and obtain consulting services.
United Nations
• United Nations Children's Fund
• World Bank
• World Health Organization
• The Subcommittee on Nutrition
of the Secretary General's Admi
nistrative Committee on Coord
ination. (ACC-SCN)
International and national NGOs:
• Kiwanis International
• Salt Institute of North America
• European Salt Producer's Associa
tion
• International Nutritional Anemia
Advisory Group
• International Advisory Group on
Vitamin A
Other Agencies
• Micronutrient Initiative
• Program Against Micronutrient
Malnutrition
1CCIDD maintains relations with
these organizations through design
ated board members who serve as
official liaison between ICCIDD and
each of the agencies and organiza
tions listed above.
Regional Working Groups
Generally: Include Countries, WHO, UNICEF, ICCIDD
Occasionally: Bilaterals, NGOs
Research and Training
Research
Because of its unique network of experts and close
connection with the academic world, ICCIDD is able to
initiate, stimulate, realize and support research activities
in all disciplines involved in the field of IDD. The results
of research are widely and rapidly disseminated and
applied directly through programs or incorporated in
technical guidelines.
The elimination of IDD has been
made possible by the significant
contributions of ICCIDD members
dating from the pioneering
research of John B. Stanbury
(Chairman Emeritus of ICCIDD)
and his colleagues who, first
For example, ICCIDD has determined optimal
dosage levels for iodized oil when given orally or by
intramuscular injection, including during pregnancy.
Other applied research includes simplifying methods for
measuring iodine in urine and standardization of thyroid
volume as a function of age in the absence of iodine
deficiency.
clearly demonstrated in the
Andean Region of South America
the mechanisms by which iodine
deficiency caused goitre.
Training
ICCIDD, in close collaboration with UN and bilat
eral agencies, organizes national and international meet
ings and short-term training programs for country pro
gram managers. The technical training includes proce
dures such as ultrasonography for measurement of thy
roid size, laboratory methods for the measurement of
urinary iodine, and methods for initiating neonatal thy
roid screening used as an index of IDD severity. Program
managers also visit the laboratories of senior ICCIDD
members for technical training.
Longer multidisciplinary training and ongoing
technical support is carried out by the Program Against
Micronutrient Malnutrition (PAMM) organized jointly
by the Centers for Disease Control (CDC), Emory Univer
sity, School of Public Health, the Task Force for Child
Survival and Development at the Carter Presidential
Center in Atlanta, USA and the International Agricultural
Centre and Wageningen Agricultural University in the
Netherlands. This includes management training in pro
gram implementation, social marketing, monitoring and
quality assurance, food fortification and laboratory
o
measurements and legal aspects of fortification. Senior
members of ICCIDD participate in PAMM teaching ac
tivities.
Social Mobilization (SOCMOB) training is con
ducted by Tulane University School of Public Health in
New Orleans, USA and through a network of institu
tions in Benin, Bolivia, Brazil, Ecuador, Ethiopia and the
Philippines.
Monitoring
ICCIDD is able to assist national governments and
agencies with an independent evaluation of progress
towards the goal of virtual eliminationofIDD at country
level. Experience indicates that this is important in
order to ensure sustainability of the elimination of IDD.
Following a request, ICCIDD will assist national govern
ments to review progress, exchange mutually support
ive information and results, and sustain elimination once
it is achieved, in order to sustain elimination of IDD a
complex network of activities of quality assurance of
modern management in the national efforts is required.
This will take a good bit of effort by all concerned - the
"stakeholders", - since it involves management issues in
nutrition, in health, in education, in agriculture, in salt
manufacture, in raw material provision, in human re
source development, in public education, and in sus
tained consumer demand.
Funding
ICCIDD was initially supported by UNICEF,
WHO and the Australian Government. Other
major donors for core funds include:
•
•
•
•
•
•
the Australian Agency for
International Development
(AusAID)
the Canadian International
Development Agency (CID A)
the
Dutch
Cooperation
Programme
the International Bank for
Reconstruction and Development(IBRD)
the Swedish International
Development Agency (SIDA)
the United States Agency for
International Development
(USAID)
In addition, individual project
grants
have come from USAID, the Micronutrient
Initiative, Thrasher Fund, private industry
and others for newsletters, databases and
research. Kiwanis International is raising
funds for UNICEF programs to substantially
support country programs aimed at the
virtual elimination of Iodine Deficiency Dis
orders.
Iodine Deficiency
Disorders are endemic
and the brain damage is
irreversible. However,
virtual elimination can be
attained through iodized
salt and ongoing
monitoring, iodized salt
promotion and program
evaluation.
Communication
& Publications
ICCIDD organizes and sponsors meetings, confer
ences and other gatherings designed to enhance knowl
edge about IDD, to accelerate national action towards its
elimination, and to create effective alliances with other
organizations for these purposes.
IDD Newsletter
1CC1DD publishes a quarterly
newsletter edited by Dr. John
Dunn at the University of
Virginia Medical Center. It
provides timely information
and
updates
on Iodine
Deficiency
Disorders and
related subjects. First pub
lished in 1985 and distributed
to individuals and institu
tions, the newsletter now has
a circulation of nearly 3,500
with approximately 80% copies
going to developing countries.
The newsletter plays a key role in
connecting all individuals and
organizations around
the
world interested in the topic
of IDD. It is available free of
charge from the editor.
ICCIDD has established a communication focal
point at the International Communication Enhancement
Center (ICEC) of Tulane University School of Public
Health to coordinate ICCIDD communication activities
and to promote special events and competitions that
increase public and institutional awareness of IDD. It is
also an information depository for IDD related materials,
such as reports, studies, photos, tapes, films, videos,
articles, training materials and posters for public educa
tion and information purposes and a point of referral for
inquiries.
Technical Manuals
ICCIDD currently has the following technical manu
als available:
•
A practical guide to the correction of iodine
deficiency, by J.T. Dunn and F. Van der
Haar, ICCIDD Publ., 1990.
Methods for measuring iodine in urine, by
J.T. Dunn, H.E. Crutchfied, R. Gutekunst
and A.D. Dunn, ICCIDD Publ., 1993.
'Indicators for Assessing Iodine Deficiency
Disorders and their Control through Salt
Iodization'. Report of a Joint WHO/
UNICEF/ICCIDD Consultation, 3-5
November,1992, WHO, Geneva. Document
WHO/NUT/94.6, Publ. 1994.
Technical Manuals (cont'd)
•
Monitoring Universal Salt Iodization
Programs edited by
Kevin M. Sullivan, Robin Houston,
Jonathan Gorstein, Jenny Cervinskas .
ICCIDD/ MI/ PAMM/UNICEF/ WHO.,
Publ.,1995
•
Salt Iodization for the Elimination of
Iodine Deficiency by
M. G. Venkatesh Mannar & John T. Dunn,
ICCIDD/ MI / UNICEF/ WHO Publ.,1995.
Other manuals are in preparation on:
•
laboratory testing for iodine deficiency
•
iodized oil and other alternatives to
iodized salt.
•
communication techniques
An appendix listing other IDD related publications that
are available from ICCIDD can be found on page 18.
ICCIDD Consulting Services
How to request ICCIDD consulting services.
1.
ICCIDD has prepared a roster of consultants indicating their areas of expertise
and previous consulting experience.
2.
Prospective requests by governments, institutions or individuals can be sent
directly to the ICCIDD or through a United Nations or Bilateral Agency.
If the requests are to be made directly to the ICCIDD, they can be forwarded
directly to the Executive Director or to any of the ICCIDD Office bearers given on
pages 15 to 17.
If the request to ICCIDD is through a United Nations Agency or a Bilateral
Development Agency, a discussion with the Representative of that Agency resident
in the country may reveal additional requirements and procedures.
3.
In any of the possibilities mentioned in point, no. 2 the request must contain
the following:
The official request for technical assistance.
The Terms of Reference for the assistance required.
The proposed duration of the work to be accomplished and the proposed
dates most suitable, with an alternative possibility.
The source of payment. It is preferable that formal statements of commitment
accompany the request.
The proposed budget for the consultant (s) including travel costs, services,
perdiem and miscellaneous, and other estimated costs.
The purpose of the assignment. The Terms of Reference will support this
statement. The end product expected must be stated, also (i.e. final report;
a document for planning purpose; an analysis including laboratory work,
etc.)
Special qualifications or specialized knowledge or skills deemed required.
Language in which the work will be undertaken; language in which product
is expected.
Name and title of supervisor or principal authority or individual to whom
the consultant reports in the Government of the concerned country.
NOTE: A special booklet is available from ICCIDD offices which provide further
details on the technical and advisory services available through ICCIDD.
ICCIDD Office Bearers
(as of January, 1996)
Executive Committee
Chairman
Executive Director
Basil S. Hetzel
Health Development Foundation
Women's and Children's Hospital
72 King William Road
North Adelaide 5006
AUSTRALIA
Fax
: 61-8-204-7221
Phone: 61-8-204-7021
F. Delange
Avenue de la Fauconnerie 153
B-1170 Brussels
BELGIUM
Fax
: 32-2-675-1898
Phone: 32-2-675-8543
Vice - Chairman
John T. Dunn
Box 511
University of Virginia
Medical Center
Charlottesville, VA 22908
U.S.A.
Fax
:1-804-296-9275
Phone: 1-804-924-1857
M. Benmiloud
University of Algiers
Service d'Endocrinoiogie
Centre Pierre et Marie Curie Avenue
Battandier, Algiers,
ALGERIA
Fax
: 213-2-742719
Phone: 213-2-742719
Secretary
Members
M. G. V. Mannar
Executive Director
Micronutrient Initiative
IDRC
P.O. Box BP 8500
250 rue Albert Street
Ottawa K1G 3H9
CANADA
Fax
: 1-613-236-9579
Phone: 1-613-236-6163
Judith Mutamba
Ministry of Health and
Child Welfare,
P.O. Box 8204,
Causeway,
Harare
ZIMBABWE
Fax
: 263-4-791-169
Phone : 263-4-792-454
Chandrakant. S. Pandav
Centre for Community
Medicine,
All India Institute of
Medical Sciences
New Delhi, 110029
INDIA
Fax
: 91-11-686-3522
Phone: 91-11-686-3522
ICCIDD Office Bearers
(as of January, 1996)
Regional Coordinators
Central Africa Sub Region
South Asia & Pacific
D. N. Lantum
University Center for
Health Sciences,
The University of Yaounde,
B.P. 1364,
Yaounde
CAMEROON
Fax
: 237-31-5178 OR 237-23-0296
Phone : 237-31-5104 OR 237-31-5178
Chandrakant. S. Pandav
Centre for Community Medicine,
All India Institute of
Medical Sciences
New Delhi, 110029
INDIA
Fax
: 91-11-686-3522
Phone: 91-11-686-3522
East/South Africa Sub Region
Z. P. Chen
Vice Director
Institute of Endocrinology
Tianjin Medical University
Tianjin 300070
PEOPLE'S REPUBLIC OF CHINA
Fax
: 86-22-335-9429
Phone : 86-22-334-1228 or 1234
Judith Mutamba
Ministry of Health and Child Welfare,
P.O. Box 8204;
Causeway,
Harare
ZIMBABWE
Fax
: 263-4-791-169
Phone: 263-4-792-454
West Africa Sub Region
- to be Appointed
Americas
E. A. Pretell
Av Cuba 523
Apartado Postal 110 388
Lima 11
PERU
Fax
: 51-14-716-320
Phone: 51-14-335-772
China & Eastern Asia
Europe
F. Delange
Avenue de la Fauconnerie 153
B-1170 Brussels
BELGIUM
Fax
: 32-2-675-1898
Phone: 32-2-675-8543
Eastern Europe & Central Asia
Gregory Gerasimov
Head of Therapy Department
Russian Endocrinology Research Centre
Institute of Clinical Endocrinology
Dm. Uljanova, 11.
Moscow 117036
RUSSIA
Fax
: 7095-124-3502
Phone: 7095-458-8372 (Home)
ICCIDD Office Bearers
(as of January, 1996)
Executive Committee Chairs
Science and Technology
Salt Industry
J. B. Stanbury
Chairman Emeritus, ICCIDD
43 Circuit Road
Chestnut Hill.
MASS 02167
U.S.A
Fax
: 1-617-277-3545
Phone: 1-617-277-3545
M. G. V. Mannar
Executive Director
Micronutrient Initiative
IDRC
P.O. Box BP 8500
250 Albert Street
Ottawa K1G 3H9
CANADA
Fax
: 1-613-236-9579
Phone: 1-613-236-6163
Summer Address
Isle Au Haut
MAIN 04645
U.S.A
Fax
: 1-207-335-2221
Phone: 1-207-335-2221
Political & Industrial Liasion
David P. Haxton
909 Elizabethan Drive
Greensboro, NC 27410
U.S.A.
Fax
: 1-910-855-7886
Phone: 1-910-852-9256
Communication
Jack C. S. Ling
School of International Health
Tulane University
1430, Tulane Avenue Room 1310,
New Orleans, LA 70112
U.S.A.
Fax
:1-504-584-3653
Phone: 1-504-588-3542
Chairman Emeritus
J. B. Stanbury
43 Circuit Road
Chestnut Hill.
MASS 02167
U.S.A
Fax
: 1-617-277-3545
Phone: 1-617-277-3545
Summer Address
Isle Au Haut
MAIN 04645
U.S.A
Fax
: 1-207-335-2221
Phone: 1-207-335-2221
Appendix
The following is a partial list of publications produced by ICCIDD members,
independently or in collaboration with national or international bodies and publishing
houses:
1.
Stanbury, J.B., G.L. Brownell., D.S. Riggs., H. Perinetti., J. Itoiz and E.B. Del
Castillo. Endemic goiter. The adaptation of man to iodine deficiency. Harvard
University Press, Cambridge, MA 1954.
2.
Stanbury, J.B. and B.S. Hetzel editors, Endemic goiter and endemic cretinism:
iodine nutrition in health and disease. Wiley Publications, New York 1980.
3.
Dunn, J.T., E. A. Pretell, C.H. Daza and F.E. Viteri. editors, Towards the eradica
tion of goiter, cretinism and iodine deficiency. PAHO Publ., Washington 1986.
4.
Kochupillai, N., M.G. Karmakar and V. Ramalingaswami editors, Iodine nu
trition, thyroxine and brain development. Tata McGraw Hill Publ., Delhi 1986.
5.
Medeiros-Neto, G., R.M.B. Maciel and A. Halpern editors, Iodine deficiency
disorders and congenital hypothyroidism. Sao Paolo 1986.
6.
Hetzel, B.S., J.T. Dunn and J.B. Stanbury editors, The prevention and control of
iodine deficiency disorders. Elsevier Publ., Amsterdam, 1987.
7.
Delong, R., J. Robbins and P. Condliffe editors, Iodine and the brain. Plenum
Press Publ., New York 1989.
8.
Hetzel, B.S., The story of iodine deficiency. An international challenge in
nutrition. Oxford University Press Publ., Oxford 1989.
(Also available in French, Spanish.,Chinese, Japanese and Russian.)
9.
Delange, F., D.A. Fisher., and D. Glinoer editors, Research in
hypothyroidism. Plenum Press Publ., New York 1989.
10.
Delange, F., J.T. Dunn., and D. Glinoer editors, Iodine deficiency in Europe. A
continuing concern. Plenum Press Publ., New York 1989.
11.
Hetzel, B.S., C.S. Pandav editors, SOS for a billion: the conquest of Iodine
Deficiency Disorders. Oxford University Press Publ., Delhi 1994.
12.
Stanbury, J.B editor, The damaged brain of iodine deficiency . Cognizant
Communications 1994.
13.
Maberly, G.F., F.L. Trowbridge., R. Yip., K.M. Sullivan., C.E. West. Programs
Against Micronutrient Malnutrition. Annu. Rev. Public Health. 50:259,1994.
14.
Rose Nathan, Food Fortification Legislation &: Regulations Manual, PAMM
1995
15.
Karmarkar, M.G., C.S. Pandav and M.M.S. Ahuja editors. Enviornment, Genetics
and Thyroid Disorders. Thyroid Association (India) Publ., 1990.
congenital
How to become a member of ICCIDD
1.
Contact any ICCIDD regional co-ordinator or any ICCIDD office bearers
listed on pages 15 to 17.
2.
Indicate your interest in IDD and submit brief details of your qualifications
and experience.
3.
Communication will be then sent from the ICCIDD office accepting the
membership
4.
No fees are required.
Printed at Sona Printers Pvt Ltd B-181 Okhfa Ph-1. N D 20 Ph. 6811313-4 5-6
ICCIDD
International Council
for Control of
Iodine Deficiency Disorders
ISBN 81-86813-04-7
DiS c) • I o
ICCIDD INTERNATIONAL COUNCIL FOR CONTROL OF IODINE DEFICIENCY DISORDERS
IDD
NEWSLETTER
VOLUME I I ■ NUMBER 4 ■ NOVEMBER 1995
India’s Fight Against IDD:
Reports from the Battlefield
India and China have more people affected by IDD
than any other countries in the world. Large goiters
and cretinism were recognized as commonplace in the
Himalayan foothills for many decades. More recent
information has shown that large parts of the rest of
India are also iodine deficient. A survey of23 9 ofthe
country’s 457 districts have shown 82% to be iodine
deficient
The government has tackled the problem by
promoting the use ofiodized salt and banning the use
of non-iodized salt. This massive undertaking has
been actively assisted by Dr. C.S. Pandav, ICCIDD
Regional Coordinator for Southeast Asia, his col
leagues at the All India Institute for Medical Science
in Delhi and many other ICCIDD members in India,
and by very strong support from UNICEF in Delhi,
where ICCIDD Board members David Haxton and
Rolf Carriere were formerly Regional Director and
Advisor for Nutrition, respectively. The following
pages present recent reports from the field.
Using the salt testsing kit a at Phut-talao
Primary School, M.P. “Look my salt sample
has turned blue! My young sister will now
get enough iodine from young age. "
Health worker explaining to the village
mother “buy and use only iodized salt. ”
Kalipura, M.P.
Madhya Pradesh’s Efforts
to Sustain IDD Elimination
Dr. C.S. Pandav, ICCIDD Regional Coordinator,
visited the Bhopal, Indore, and Jhabua districts of
Madhya Pradesh to report on progress against IDD.
This article and the accompanying photographs are
taken from the report prepared by Dr. Pandav and
Ms. Nilima Chawla, ICCIDD Board member and
ICCIDD s Communication Focal Point for South
Asia.
In August 1994 the government of Madhya
Pradesh (MP) established the Rajiv Gandhi Technol
ogy Mission for Eliminating Iodine Deficiency Disor
ders. Its purpose is to eliminate IDD by iodine supple
mentation for the entire 66 million people living in the
state. Other missions also established to meet basic
needs of rural people in the state include the Water
shed Development Mission, the Shiksha Mission, the
Mission for Control of Diarrheal Diseases, the
Mission for Development for Rural Industries, the
Mission for Development of Fisheries, and the
Mission for Development o f Advanced Technology.
These missions represent the MP government’s
effort to prioritize certain “thrust areas” in devel
opment and make them a collective endeavor.
Establishment of the missions received the strong
support of the chief minister.
Kalyanpur “hat" (weekly market) in M.P.,
“I only sell packaged iodized salt
The mission has two clear goals: (1) to make
communities aware ofthe need to use iodized salt, and
(2) to ensure adequate distribution and sale of iodized
salt. Community research had shown a very poor level
of IDD awareness. To counter this, in January 1995
an IDD Elimination Week took place in every devel
opment block. Its components included a major
information drive, house to house surveys to detect
cases of IDD, and spot testing ofall salt consumed by
the community. Mass rallies and meetings were
organized at 5,493 locations in 4,590 villages, with
1,543 exhibitions and films and 1,867 cultural shows.
Salt was tested in 2,234 schools, 353,941 households
were surveyed, detecting 10,362 IDD cases, and
255,360 salt samples were tested. After the IDD
elimination week, four Rath Y atras (information vans),
one each from Indore, Bhopal, Jamaipur, and Bilaspur,
covered all the blocks of the state to spread the
messages ofiodized salt and oral rehydration therapy.
With this highly visible and effective form ofcommu
nication, along with the other channels used, the
Mission successfully informed people that the addi
Kalyanpur “hat” (weekly market) in M.P., tional cost of four rupees per month per family was a
small price to pay to protect the family from iodine
“I only sell packaged iodized salt”.
deficiency.
With regard to supply ofiodized salt, communica
tion efforts convinced the salt traders to promote
iodized salt. By signing the Bhopal Declaration, they
agreed they would not sell salt that was not iodized.
The Nagarik Apoorti Nigam supplied iodized salt
through public distribution outlets, and thus was able to
quickly supplement the private salttrade. As a result,
iodized salt comprises 84% ofthe salt consumed in the
state. An independent evaluation will soon be con
ducted. The achievement in Jhabua is all the more
remarkable because it is one of the most backward
districts in Madhya Pradesh, with the lowest literacy
rate (19%) in the country, an infant mortality rate of
141 and severe economic and social deprivation. A
key feature in the success of iodized salt introduction
has been the extensive educational efforts, including
those in the schools. At the same ti me, the government
administration established a close link with salt pro
ducers and retailers, thus fostering greater under
standing and a sense ofsocial responsibility. This won
their partnership by cooperation rather than coercion.
ON INDEPENDENCE DAY: FREE AT LAST!
Jhabua District, Madhya Pradesh: It is dawn on the
16thofAugust 1995. In the soft light of could filled
monsoon morning, streams ofvillagechildren hurry to
their schools, each care fill ly carrying a fistful of salt.
For the first time inthe school atMindal, they are going
to test the salt to see if it contains iodine. As they settle
into their places, their faces reflecting theirsuspense,
young Kali, the class monitor lines up all the salt
samples in front ofher. From a small plastic bottle she
adds a drop of liquid to each pile of salt. Immediately
the salt changes color, one turning dark blue, another
becoming a light violet, while some stay the normal
white of edible salt. “This salt that didn’t turn blue is
bad salt”, she tells her classmates. “It doesn’t have
the iodine we need to keep our bodies strong and our
minds intelligent. So I’m going to throw away this bad
salt.”
. By throwing away the “bad” salt, Kali has
symbolically encapsulated a silent revolution that is
sweepingthe tribal districtofJhabua. A revolutionin
which all the uniodized salttraditionally available to the
people is being replaced with salt that contains iodine.
It is only when they get iodized salt that the iodinedeficient popu lation ofthis poor and underdeveloped
district will be spared themental retardation, stunting,
deaf-mutism and birth defects caused by iodine
deficiency.
— C.S. Pandav and N. Chawla
Kali, the class monitor throwing away the
non-iodized salt. “This salt that didn’t turn
blue is bad salt. ’’ Phut-talao Primary School
M.P.
o^?z
----- A
Reviews/Analyses
Administration of iodized oil during pregnancy:
a summary of the published evidence
*
F. Delange1
Tfiis brief review of the available studies confirms that the administration of iodized oil before or during
pregnancy prevents endemic cretinism and brain damage by correcting iodine deficiency and thyroid
function in pregnant women, fetuses, neonates, infants and children. The potential benefits derived from
using iodized oil immediately before or during pregnancy greatly outweigh the potential risks in areas of
moderate and severe prevalence of iodine-deficiency disorders, where iodized salt is not yet available.
Reprint No. 5679
(triiodothyronine) and a rise in serum TSH (thyroidstimulating hormone) concentrations over a period
of 4—10 days (mean.-6 days) in 8 subjects with small
goitres soon after receiving intramuscular (IM) in
jections of 400 mg of iodine in oil. which suggests an
acute inhibitory Wolff-Chaikoff effect. In addition.
three other subjects with large multinodular goitres
developed biochemical hyperthyroidism. These
findings in pilot studies are compatible with welldocumented iodine-induced thyrotoxicosis which
occurred in severely iodine-deficient populations fol
lowing the introduction of iodine prophylaxis by
iodized salt (41-46). There arc a few reports of iodiz
ed oil-induced hyper- or hypothyroidism in public
health programmes, sporadic cases of hyperthy
roidism having been reported from Ecuador (47).
Peru (48) and Argentina (49), but these were not
delected in large-scale programmes in New Guinea
(2.59). Zaire (6.9.12.51). Nepal (38.40.52). Algeria
(53). Indonesia (54. 55) and China (56. 57). Since
many of these interventions were conducted under
particularly difficult environmental conditions, ad
verse reactions to therapy could easily have escaped
detection (58).
In contrast, detailed studies have been carried
out on the effects of iodized oil administered to
women just before or during pregnancy with special
attention to the short- and long-term side-effects of
iodized oil on thyroid function in the mother,
neonate, infant and child (59). In carefully executed
studies in New Guinea on the effects of iodized oil
administered before or during pregnancy to prevent
endemic cretinism (4. //), biological tests examining
thyroid function were rarely available (20. 22) be
cause of particularly difficult environmental condi-
Bubetin ot the World Health Organization. 1996. 74 (1) 10 i 108
(Q World Health Organization 1996
The administration of iodized oil to entire popu
lations. and especially to women of childbearing age
and during pregnancy, has been proposed as an
emergency prophylactic and therapeutic approach in
areas with severe iodine deficiency complicated by
endemic cretinism where universal salt iodization
has not yet been successfully introduced (/). This
procedure prevents brain damage due to iodine defi
ciency in the fetus and the neonate.
Findings
Iodized oil programmes have conclusively been
shown to be effective in preventing and treating
endemic goitre, and also in preventing endemic
cretinism (2-/3) and the alterations of neuropsychointellectual development which are frequently en
countered in non-cretinous individuals (13-38).
However, adverse side-effects have been reported in
non-pregnanl adults due to the administration of
iodine far in excess of physiological need. For exam
ple. in a pilot study of 14 subjects in the Solu region
of the Nepalese Himalayas. Croxson and colleagues
(39. 40) reported a significant fall in serum T3
This article in based on material presented at a WHO Consulta
tion on the Safety of Iodized Oil for Pregnant Women, Geneva,
13-14 September 1994. See also: Safe use of iodized oil to
prevent iodine deficiency in pregnant women on pages 1-3 of this
issue. Requests for reprints should be sent to Nutrition Unit, World
Health Organization. 1211 Geneva 27, Switzerland.
' Department of Paediatrics, Hopital Saint-Pierre, Brussels.
Belgium.
101
F. Delange
102
Table 1: Effects of iodized oil; given just before or during gestation, on the thyroid function of mothers, neonates, infants and children." The results
are given as means ± SE except where otherwise indicated.
Region and
epidemiology
Protocol
Mothers at delivery
Neonates
Follow-up
North-eastern Algeria
Urinary iodine:
1.6 i 0.5pg/dl
Prevalence of goitre:
— global population: 53%
— pregnant women
(visible goitre
rate): 47%
Prevalence of cretinism: 1%
Placebo-controlled randomized study
(n= 1536)
Urinary iodine: 1.8 pg/dl
TSH 4.1mU/l
Placebo (n = 982) vs iodized oil
(n = 554)
Iodized oil 0.5 ml (240 mg I) orally
a) 1-3 months before conception
(n= 213)
b) During the first month bf
gestation (n = 190)
Urinary iodine. 9.4pg/dP
TSH. 2 1 mU/P
Urinary iodine: 10.1pg/dP
TSH: 2.1 mU/P
Urinary iodine: 9.8pg/dl°
TSH 1.9mU/P
d) During the third month of
gestation (n = 151)
TSH 12.4 (mU/l);
T4 6 7pg/dl
TSH: 4.9 (mU/l)6;
T4: 10.4pg/dP
TSH: 4.6 (mU/l)b;
T4: H.Opg/dP
TSH: 4.6 (mU/l)»;
T4: 10.8pg/dP
Ubangi area, northern Zaire
Infants:
The incidence of hypothyroidism was 2/982
in the untreated group and 0/554 in the
treated group
Hypothyroidism was only transient
Infants + children:
Untreated (n = 246)
WHO Bulletin QMS. Vol 74 1996
Urinary iodine: 15.5 ±
1.3jjg/day (n = 243)
Prevalence of goitre— global population: 51%
— pregnant women: 75%
Prevalence of cretinism:
1-10%
Cord serum TSH >50mU/l:
25%
Cord serum TSH >100mU/l
and T4 <4 pg/dl- 14%
Mothers:
The abortion, prematurity and stillbirth rates
were lower in the treated than in the
untreated group (P< 0 001)
None became hyperthyroid
At 6 months, urinary iodine remained twice
higher and TSH twice lower in the treated
lower in the treated group than in the
controls respectively
Placebo-controlled, longitudinal,
randomized study (n - 983)
Untreated (n = 195)
Urinary iodine (jig/dl).
3 63 (3.30-3.99)c
<5 65%
<2: 25%
Urinary iodine (pg/dl): 0-84 months: stable
1 5-3.6
Placebo (n = 484) vs iodized oil
(n= 499), 1 ml IM (480 mg I)
during the last two trimesters
of gestation (mean. 28th week)
Serum TSH (mU/l)
6.08 (5.64-6.56)c
T4: 9.1 ± 0.3pg/dl
T3; 187 ± 5ng/dl
Untreated
Serum TSH (mU/l):
18.45 (16.52-20 60)'
T4: 8.2 ± 0.3pg/dl
T3; 86 ± 5 ng/dl
Serum TSH >10mU/l:
0-36 months: 46-49%
36-84 months: 59%
Serum T4 (pg/dl), 0-84 months: low, stable
Overt clinical and severe biochemical hypo
thyroidism (endemic myxoedematous cretinism):
8.3%
Bulletin OMS Vol 74 199R
(Table 1: continued)
Treated (n = 256)
Urinary iodine (pg/dl)
56.6 (51.3-62.5)^
<5: 8%
>1000. 5%
Treated (n = 199)
Serum TSH (mU/l):
2 67 (2 49-2.86)fee
T4: 14.2 ± 0.3pg/dP
T3. 154 ± 3ng/dP
Serum TSH (mU/l);
7.19 (6.67-7 76)be
T4: 11.2 ±0.3pg/dl
*
T3 62 ± 3 ng/dl
*
Untreated (n = 404)
Urinary iodine: 3.3 pg/dl
Serum TSH 4.7mU/l
T.,. 10.5 ± 3.4pg/dl
T3: 216 ± 76 ng/dl
Untreated (n = 400)
Treated by iodized oil IM
Treated by iodized oil IM
(n = 146)
Treated
Urinary iodine (pg/dl):
0-12 months: 15.5
12-24 months: progressive decrease
>36 months: as low as in controls
Serum TSH >10mU/l:
0-24 months: 5%
24-36 months: 40%
>36 months as high as in controls
Serum T4 (pg/dl):
0-24 months: normal (except 1)
24-48 months: progiossive decrease
>48 months: as low as in controls
Endemic myxoedematous cretinism: 2.6%
Ntcheu district, Malawi
Urinary iodine: 3.3 ±
0.1 pg/dl
Prevalence of goitre59%
Prevalence of cretinism:
1%
Placebo-controlled randomized study
(n = 627)
Placebo (n = 404) vs iodized oil
0.5 ml (240 mg I) IM or orally during
the last trimester
Treated by iodized oil
orally (n = 76)
Urinary iodine- 12.3 pg/dl
*
Serum TSH: 2.6mU/l£’
T4: 12.5 ± 2.4 pg/dl
*
T3; 231 ± 70 ng/dl
*
Serum TSH: 5.9 mU/l
*
T4. 10.5 ± 2.7 pg/dl
*
T3: 66 ± 10 ng/dl
Treated by iodized oil
orally (n = 73)
Serum TSH: 5.6mU/l
*
T3- 9.7 ± 2.3 pg/dl
*
T4: 71 ± 16 ng/dl
*
4 Compiled from references 7-9, 12 and 61-68, and from J. Vanderpas & B. Swannen, personal communication.
b Significant difference compared with the untreated group (P < 0.001).
c These results are geometric means (-SEM; +SEM).
Adm inistration of iodized oil during pregnancy
(n = 147)
Urinary iodine: 28.5pg/dP
Serum TSH. 2.8mU/P
T4: 12.8 ± 3.1pg/dP
T3: 208 ± 87 ng/dl
Serum TSH: 11.1 mU/l
T.,; 8.6 ± 2 3 pg/dl
T3: 85 ± 54 ng/dl
F. Delange
lions. Pharoah (4) reported very low levels of serum
protein-bound iodine (PBI) in untreated mothers
who delivered eretins. whereas normal values were
still found in treated mothers who delivered normal
infants 3-4 years after receiving iodized oil injec
tions. Pretell and colleagues (60) reported that in an
area of severe iodine deficiency in the Peruvian An
des (daily urinary excretion of iodine. 25pg: preva
lence of visible goitre. 52-59%; and prevalence of
cretinism. 1.0—3.6%). umbilical cord scrum T4 (thy
roxine) and free T. levels were much lower, and TSH
levels higher, than in controls from an iodine-replete
area. The results for the same variables were normal
in neonates born to mothers injected with iodized oil
before or during early pregnancy. No adverse side
effects were observed either in mothers or neonates.
The most detailed studies of iodized oil given
during pregnancy have been conducted in Zaire (79.12.61-65). Algeria (66.67) and Malawi (65,68) in
areas of severe iodine deficiency and endemic goitre.
complicated by cretinism (Table I). The doses of
iodized oil were 1ml IM (480mg I) in Zaire, and
0.5ml IM or orally in Algeria and Malawi. Time of
administration varied from just before pregnancy in
Algeria to the third trimester of gestation in Zaire.
The result was a systematic and dramatic increase in
maternal iodine supply, with only occasional iodine
overload (5% of treated women in Zaire had urinary
iodine levels above 1000 pg/dl at the time of deliv
ery). Nevertheless, thyroid function in mothers.
which frequently indicates hypothyroidism in the
absence of therapy, was normal in all treated
mothers al delivery; their scrum TSH. T4 and T,
levels were similar to those observed tn mothers in
iodine-replete areas (69. 70). In addition, not a
single woman exhibited biochemical evidence of
hyperthyroidism and the prevalence of goitre
markedly decreased in those who had been treated.
In the absence of therapy for mothers, thyroid
function was severely impaired in a large number of
neonates (in the Ubangi area of Zaire, 14% of in
fants had cord serum TSH above 100 jtU/ml and T,
below 4 pg/dl). The extent of deviation from normal
values in infants was more severe than in mothers
and was directly related to the severity of the iodine
deficiency and hypothyroidism present in mothers.
Once again, iodized oil administered to mothers en
tirely normalized the thyroid function in neonates,
and the correction occurred regardless of the stage of
pregnancy — from the first month to late in the third
trimester — at the time of therapy.
In seven years of follow-up after treatment of
mothers with iodized oil. no case of hyperthyroidism
was reported in either mothers or children. Depend
ing on the dose and the stage of pregnancy at which
it was given, the status of iodine nutrition of infants
104
and children (evaluated by ascertaining urinary
iodine concentrations) progressively deteriorated
with age. reverting to the degree of iodine deficiency
foundin untreated individuals from the age of 2
years onwards. Nevertheless, clinical and biochemi
cal hypothyroidism was largely prevented in infants
born to treated women, and when they occurred.
they were frequently transient in nature. Finally,
treating pregnant women with iodized oil resulted in
decreased incidence of abortions, prematurity and
stillbirths, and an increased birth weight.
These positive results stand out in contrast to
the interpretation of the results of a single study.
which has frequently been reported in the literature
in the last decade (20. 71-74). The study was con
ducted in parts of Bhutan and India known for
severe iodine deficiency (more than 50% of the <
population with urinary iodine/creatinine ratio be
low 25 pg/g creatinine and goitre prevalence varying
from 60% to 80%). Iodized oil (I ml IM) was admin
istered to schoolchildren, women of reproductive
age. and pregnant women. Cord serum TSH and T4
w'crc measured in a group of 154 neonates born to
mothers who had been injected during the second
half of the third trimester of pregnancy (mean of 3.5
weeks before delivery). Selection criteria for
neonates and the range of the lime interval between
injection and delivery were not reported. Sixteen of
the 154 infants (10.4%) had cord serum TSH above
50mU/l and cord T4 below 3 pg/dl. indicating
neonatal biochemical hypothyroidism. The investi
gators concluded that the iodized oil administered
during pregnancy induced thyroid failure in the
neonates, and consequently that oil therapy should
be rejected as a prophylactic measure during preg
nancy.
This interpretation is seriously to be questioned
for two reasons. First, in the absence of results for
urinary iodine in mothers, there is no evidence that
the mothers were indeed injected and were iodine
overloaded. Second, and more important, the same
incidence of neonatal biochemical hypothyroidism
(7.5-13.3%) was reported in the study areas in the
absence of an iodized oil programme. Consequently.
the study provides no evidence that the iodized oil
administered to pregnant women had adverse effects
on the neonates.
Conclusion
Detailed studies provide conclusive evidence that
the administration of iodized oil prior to, or during.
pregnancy prevents endemic cretinism and brain
damage by correcting iodine deficiency and thyroid
function in pregnant women, fetuses, neonates, in
WHO Bulletin QMS. Vol 74 1996
Administration of iodized oil during pregnancy
tants and children. To prevent neurological damage.
it is crucial that iodine deficiency be corrected before
or during early gestation. Correction of maternal.
fetal and neonatal hypothyroidism can occur at any
time during pregnancy, including the last trimester.
1 he duration ol postnatal correction of thyroid func
tion depends on the dose of iodized oil administered
to the mother, e.g.. about two years for I ml iodized
oil administered orally or IM. but only 6 months for
half this dose. Despite the massive doses of iodine
administered, no iodine-induced thyroid function
abnormalities have ever been conclusively demon
strated at the time of delivery or in the short- or long
term follow-up of pregnant women and their
offspring. The potential benefits derived from using
iodized oil immediately before or during pregnancy
'greatly outweigh the potential risks in areas of mod
erate and severe prevalence of iodine-deficiency dis
orders. where iodized salt is not available or unlikely
to be available within 1-2 years.
Resume
Administration d’huile iodee pendant la
grossesse: resume des etudes publiees
Des etudes detaillees montrent de fagon concluante que I’administration d’huile iodee avant ou
pendant la grossesse contribue a prevenir le
cretinisme endemique et les lesions cerebrates
en corngeant la carence en iode et la fonction
thyroidienne chez la femme enceinte, le foetus, le
nouveau-ne, le nourrisson et I’enfant. Pour prevenir
les lesions neurologiques, il est essentiel de corriger la carence en iode avant la grossesse ou
au debut de celle-ci. La correction de I'hypothyroidisme maternel, foetal et neonatal peut se faire a
n'importe quel moment de la grossesse, meme au
~:Y:ours du dernier trimestre. La duree de la correction
post-natale de la fonction thyroidienne depend de la
dose d’huile iodee administree a la mere; elle est
par exemple d'environ deux ans apres administra
tion de 1 ml par voie orale ou intramusculaire, mais
seulement de six mois pour 0,5 ml. En depit des
doses massives d'lode qui ont ete administrees,
aucune anomalie de la fonction thyroidienne induite par cet element n’a ete demontree de fagon
concluante au moment de I’accouchement ou
ulterieurement chez les femmes enceintes et leurs
enfants qui ont fait I’objet d'un suivi a court ou a long
terme.
Les avantages potentiels de I’administration
d’huile iodee immediatement avant la grossesse
ou au cours de celle-ci compensent largement
les risques potentiels dans les regions oil la pre
WHO Bulletin OMS. Vol 74 1996
valence des troubles dus a une carence en iode est
moderee a forte et oil I’on ne prevoit pas de dis
tribution de sei iode avant un an ou deux.
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WHO Bulletin OMS. Vol 74 1996
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Original Article
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Indian J Pediatr 1996; 63 :105-110
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Iodine Deficiency v^t^^Sers in Bangladesh
Harun K.M. Yusuf,' " Salamatullah Quazi,2 Moududur R. Kahn,2 Mohammad
Mohiduzzaman,2 Bardrun Nahar,2 M. Mostafizur Rahman,2 M. Narul Islam,3 M.
Asaduzzaman Khan,3 Mohammad Shahidullah,4 Tujammul Hoque,5 Mohmand
Baquer,5 and Chandrakant S. Pandav3
'Department of Biochemistry, institute of Nutrition and Food Science, "Department of Statistics
and 'Insitute of Statistical Research and Training, University of Dhaka, 5UNICEF-Dhaka,
Bangladesh,6All India Institute of Medical Sciences, New Delhi
Abstract. An extensive iodine deficiency disorders survery was conducted in Bangladesh in 1993
to assess the latest iodine nutriture status of the country. The clinical variables of the survey were
goitre and cretinism, and the biochemical variable was urinary iodine. The “EPI-30 cluster"
sampling methoclology was followed for selecting the survey sites. In each survey site, the study
population consisted of boys and girls, aged 5-11 years, and men and women, aged 15-44 years,
in about equal populations, the total number of survey sites was 78 and the total number of
respondents was 30 072. The total number of urine samples was 4512 (15% sub-sample). The
current total goitre rate (grade 1 + grade 2) in Bangladesh is 47.1% (hilly, 44.4%; flood-prone,
50.7%; and plains, 45.6%). The prevalence of cretinism in the country is 0.5% (hilly, 0.8%; floodprone, 0.5%; and plains, 0.3%). Nearly 69% of Bangladeshi population have biochemical iodine
deficiency (urinary iodine excretion [UIE] < 10 mg/dl) (hilly, 84.4; flood-prone, 67.1%; and plains
60.4%). Women and children are more affected than men, in terms of both goitre prevalence and
UIE. The widespread severe iodine deficiency in all ecological zones indicates that the country as a
whole is an iodine-deficient region. Important recommendations of global interest are made from
the experience of the survey. (Indian J Pediatr 1996; 63 : 105-110]
Key words : lodine-deficiency disorders; Goitre; Cretinism; Urinary iodine.
I odine deficiency disorders (IDD) are
recognized as a major global public health
problem today. An estimated number of
1.57 billion people world wide are at risk
of IDD, 655 million are goitrous, and about
20 million suffer from varying degrees of
mental handicap related to iodine
deficiency.1,2 In fact, iodine deficiency is
the single most preventable cause of
neurological and intellectual impairment
(cretinism).3,4
Reprint requests: Professor of Biochemistry
(Human Nutrition), University of Dhaka,
Dhaka-1000, Banladesh.
Bangladesh is the largest delta in the
world. Three major rivers, the Padma
(downflow of the Ganges) flowing from
the west, the Jamuna (downflow of the
Brahmaputra) flowing from the north and
the Meghna, flowing from the north-east
form this huge delta. Ecologically, the
country has three different zones, namely
the hilly zone, the flood-prone zone and
the plain zone. Flooding is almost an
yearly phenomenon. Also, the country
experiences heavy rains; yearly rainfall
ranges from 1200 to 2400 mm.5
The annual flooding and heavy rains
constantly wash the soil off iodine. The
THE INDIAN JOURNAL OF PEDIATRICS
1996; Vol. 63. No. 1
cumulative yearly loss of iodine from the
soil makes the country extremely
vulnerable to the dangers of iodine
deficiency as is the case with other
countries in the valley plains of the
Himalayas-Bhutan, Nepal annd Northern
India.
The pioneering nutrition survey of the
then East Pakistan of 1962-646 and the
subsequent national goitre prevalence
study of 1981-827 showed prevalence of
goitre to the extent of 10.5 to 28.9%, with
highest prevalence rates being in the basin
areas of the above major rivers.
In view of repeated annual flooding,
heavy rains and continued deforestation,
all of which are likely to aggravate the risk
of IDD, a coomprehensive IDD survey was
done in the country in 1993. In this survey,
besides goitre, urinary iodine level was
measured arid cretinism was assessed for
the first time in this country 3 The present
paper describes the details of the key
findings'of the survey.
from the survey. In 39 "thanas" (of which 7
were of mixed type), UNICEF had been
carrying out a lipiodol injeection
programme for several years since 1986.
These thanas were excluded from the
present study. In addition, all 13 thanas of
the Chittagong Hill Tracts were also
excluded due to speciial circumstances
prevailing in these areas. Thus, in all, 151
thanas [106 + 32 (= 39-7) + 13] were
excluded from the study. The distribution
of the remaining 326 thanas was as follows
:-plains : 251 thanas; flood-prone : 69
thanas; and hilly : 6 thanas. All these 326
"thanas" from the respective ecological
zones thus constituted the universe for
sampling purpose.
Sampling
procedure.
The
study
population (respondents) consisted of
male and female children in the age group
of 5-11 years and male and female adults
in the age group of 15-44 years. Based on
the prevalence rate estimate (50%),
confidence interval (95%), relative error (±
5%) and appropriate design effect, it was
decided to examine 100 people in each of
the four groups mentioned above, i.e. 400
(100 x 4) respondents from each "niauza".
The
"EPI-30
cluster"
sampling
methodology as recommended by the Joint
WHO/ UNICEF/ICCIDD Consultation of
IDD Indicators9 was followed for selecting
the survey sites from the flood-prone and
the plain zoones. Thus 30 thanas were
selected each from these two zones, as the
primary sampling units, according to
probability proportional to population
size. From each thana, one "niauza"
(defined area generally equivalent to a
village) was selected randomly, as the
secondary sampling unit. In view of
limited accessibility, scarce population and
time consstraints, the small hilly zone was
106
Material and Methods
Study design. For the purpose of the survey,
the country was divided into three
ecological zones-the hilly, flood-prone, and
the plains. Flood-prone areas were those
which experience flood frequently, than at
least 5 times in last 10 years. Areas lying
more than 300 meters above the sea level
(Chittagong and Chittagong Hill Tracts)
were categorized as the hilly zone. The
remainder of the country was categorized
as plain land.
There are 477 "thanas" in Bangladesh
according to the 1981 census report. Of
these, a total number of 106 thanas were
identified to be of mixed type, i.e. floodprone/hilly/plains. These were excluded
1996; Vol. 63. No. 1
considered as a spcial area. From this zone,
18 mauzas were selected randomly. Thus
the total number of survey locations in the
whole country was 78.
Study population. In each mauza, the
study population consisted of four
different population groups (boys and
girls, aged 5-11 years and men and
women, aged 15-44 years) from 100
households (ultimate sampling units)
selected by a systematic random method.
The total number of respondents was
30072 (96.4% of target) in about equal
proportions. For collection of urine
samples, 15% of the households were
selected randomly from each mauza. The
total number of urine samples collected
was 4518 which met the estimated target
number.
Clinical examinations. The clinical
examinations for goitre and cretinism were
performed by MBBS doctors specially
recruited and trained for the survey.
Grading of goitre was done according to
the criteria recommended by the Joint
WHO/UNICEF/ICCIDD9 (grade 0, no
goitre; grade 1, thyroid palpable but not
visible; and grade 2, thyroid visible with
neck in normal position). When in doubt,
they were asked to record the immediate
lower grade. Intra and inter-observer
variation was controlled by repeated
training and random examinations of
goitre grades by the experts. In addition, a
validation exercise was carried out by
international experts. Cretin cases were
identified on the basis of history and
clinical manifestations of obvious mental
retardation, dwarfism, deaf-mutism,
squint and disturbed gait. The results were
recorded in a pre-designed questionnaire.
Biochemical investigation : iodine in urine.
On-the-spot urine samples were collected
THE INDIAN JOURNAL OF PEDIATRICS
107
from t he randomly selected respondents
in wide mouthed screw capped plastic
bottles. (One drop of toluene was added to
each sample to inhibit bacterial growth
and to minimize bad odour.) Iodine was
determined by the wet digestion method
adopted by Gutekunst.10 The results were
expressed as |ig iodine/dl urine. The data
was ' entered
into
the
relevant
questionnaires.
Validation of ttrinary iodine analysis.
Urinary iodine levels were determined by
expert faculty members. The validation of
these analyses was carried out by both
internal as well as external quality
assurance programmes. The PAMM/CDC
(Program
Against
Micronutrient
Malnutrition/Centre for Disease Control)
laboratory at Emory University, Atlanta,
GA, USA helped to conduct the external
assurance.
Data management and statistical analysis.
All questionnaires were manually edited
and coded. The data entry was done by
using a software dBase III + with range
checking and appropriate correction.
Significance of difference in values of
different groups was analysed by Chisquare, Mann-Whitney and other tests.
Results
Goitre Prevalence
The findings of the survey on goitre
prevalence in the three ecological zones are
given in Tables 1 to 3. In the plain zone
(Table 1), total goitre rates (TGR) (grade 1
+ grade 2) in the four population groups
(boys, girls, men and women) were found
to be 46.0%, 52.0%, 34.2% and 51.3%
respectively. Thus, the children and the
adult women were more affected than the
108
THE INDIAN JOURNAL OF PEDIATRICS
1996; Vol. 63. No. 1
adult males. The overall goitre prevalence flood-prone annd 60.4%5 in the plain zone
in this zone was 45.6% (36.2% palpable + were having biochemical iodine deficiency
9.4% visible). In the flood-prone zone (UIE < 10 pg/dl) (Table 4). The national
(Table 2), TGR in the four population figure for this stood at 68.9% (Fig. 1).
groups were found to be 50.5%, 55.8%,
36.7% and 59.8% respectively. Here also, Cretinism
the children and particularly the adult
women were worst affected. The overall Prevalence of cretinism in the country was
TGR in this zone was found to be 50.7% found to an extent of 0.5%. Zone-wise, the
cretinism rates were 0.8% in the hilly, 0.5%
(44.5% palpable + 6.2% visible).
The overall prevalence of goitre in the in the flood-prone and 0.3% in the plain
hilly zone is 44.7% (33.4% palpable + 11.3% zone (Table 5). There were more child
visible). In this zone, the prevalence of cretin cases than adult, and unlike goitre
both palpable and visible goitre in the prevalence, cretinism was more prevalent
adult females was double than that in the in the males than in the females.
adult males (Table 3).
Discussion
The overall goitre prevalence in the
country as a whole, calculated from total
population of Bangladesh and age and sex Results presented in the present paper are
distribution of the study populations was the summary of the key findings of the
found to be 47.1% (38.3% palpable + 8.8% National IDD Survey in Bangladesh—1993.
visiible) (Fig. 1). In many areas of each This is the first comprehensive IDD survey
zone, goitre prevalence was found to even conducted in this country, in which, in
exceed 90%. These are the worst affected addition to goitre assessment, urinary
'pocket' areas which warrant immediate iodine was also measured to ascertain
intervention.
biochemical iodine nutriture status of a
sub-sample of the study population.
Urinary Iodine Excretion
Cretinism was also assessed in the survey,
on the basis of obvious clinical symptoms,
The median urinary iodine excretion (UIE) as a second priority objective of the
in the study population was found to be survey.
the lowest in the hilly zone (3.4 pg/dl),
The application of the 'EPI-30 cluster'
followed by the flood-prone zone (5.1 pg/ methodology followed in the present
dl) and the plain zone (7.4 pg/dl) (Table 4). Naional IDD Survey for selection of
The median UIE was thherefore lower than suurvey sites may be considered as a
the accepted cut-off level of 10 pg/dl all pioneering effort. Goitre grading was
over the country.11 The females of both age validated by national and international
groups had significantly lower UIE than experts. The inter-team variations were
the males (Table 4), with more than one- minimal and agreement with respect to the
quarter of them having UIE less than 2 pg/ overall grading was 82.6%. The results of
dl
urinary iodine analysis were validated by
Distribution analysis shows that 84.4% satisfactory internal as well as external
of the population in the hilly, 67.1% in the quality assurance tests.
108
THE INDIAN JOURNAL OF PEDIATRICS
1996; Vol. 63. No. 1
adult males. The overall goitre prevalence flood-prone annd 60.4%5 in the plain zone
in this zone was 45.6% (36.2% palpable + were having biochemical iodine deficiency
9.4% visible). In the flood-prone zone (UIE < 10 pg/dl) (Table 4). The national
(Table 2), TGR in the four population figure for this stood at 68.9% (Fig. 1).
groups were found to be 50.5%, 55.8%,
36.7% and 59.8% respectively. Here also, Cretinism
the children and particularly the adult
women were worst affected. The overall Prevalence of cretinism in the country was
TGR in this zone was found to be 50.7% found to an extent of 0.5%. Zone-wise, the
cretinism rates were 0.8% in the hilly, 0.5%
(44.5% palpable + 6.2% visible).
The overall prevalence of goitre in the in the flood-prone and 0.3% in the plain
hilly zone is 44.7% (33.4% palpable + 11.3% zone (Table 5). There were more child
visible). In this zone, the prevalence of cretin cases than adult, and unlike goitre
both palpable and visible goitre in the prevalence, cretinism was more prevalent
adult females was double than that in the in the males than in the females.
adult males (Table 3).
Discussion
The overall goitre prevalence in the
country as a whole, calculated from total
population of Bangladesh and age and sex Results presented in the present paper are
distribution of the study populations was the summary of the key findings of the
found to be 47.1% (38.3% palpable + 8.8% National IDD Survey in Bangladesh—1993.
visiible) (Fig. 1). In many areas of each This is the first comprehensive IDD survey
zone, goitre prevalence was found to even conducted in this country, in which, in
exceed 90%. These are the worst affected addition to goitre assessment, urinary
'pocket' areas which warrant immediate iodine was also measured to ascertain
intervention.
biochemical iodine nutriture status of a
sub-sample of the study population.
Urinary Iodine Excretion
Cretinism was also assessed in the survey,
on the basis of obvious clinical symptoms,
The median urinary iodine excretion (UIE) as a second priority objective of the
in the study population was found to be survey.
the lowest in the hilly zone (3.4 pg/dl),
The application of the 'EPI-30 cluster'
followed by the flood-prone zone (5.1 pg/ methodology followed in the present
dl) and the plain zone (7.4 pg/dl) (Table 4). Naional IDD Survey for selection of
The median UIE was thherefore lower than suurvey sites may be considered as a
the accepted cut-off level of 10 pg/dl all pioneering effort. Goitre grading was
over the country.11 The females of both age validated by national and international
groups had significantly lower UIE than experts. The inter-team variations were
the males (Table 4), with more than one- minimal and agreement with respect to the
quarter of them having UIE less than 2 pg/ overall grading was 82.6%. The results of
dl.
urinary iodine analysis were validated by
Distribution analysis shows that 84.4% satisfactory internal as well as external
of the population in the hilly, 67.1% in the quality assurance tests.
1996; Vol. 63. No. 1
'"N
Since the survey was conducted on the
basis of ecological zones (hilly, flood-prone
and plains), the results are also presented
zone-wise. Contrary to our expectation,
results showed that total goitre rate (TGR)
was high in all three zones of the country
and clinically there was no significant
difference in TGR of these zones.
However, in terms of median urinary
iodine level, percent population having
biochemical iodine deficiency and also
prevalence rates of cretinism, the
ecological zones differed from each other
and could be presented in increading
degree of severity as plains < flood-prone
< hilly. This may indicate that IDD in the
hilly zone is old while that in the other
zones is relatively a more recent
phenomenon.
The results obtaiined from the present
survey show that IDD situation in
Bangladesh
is severe.
From the
widespread severe IDD in all three
ecological zones, we suspect that
Bangladesh as a whole is an iodinedeficient region and that 100% of its
population are at risk of iodine deficiency.
fortunately,
the
government
of
Bangladesh, with assistance from UNICEF,
has initiated a universal salt iodization
programme to solve the IDD problem.
One interesting observation emerged
from the present survey. In all the three
zones, the total goitre rate or urinary
iodine level in the children was
comparable to that in the adults, although
large variations existed among the adult
males and females. For example, in the
hilly zone, TGR (total goitre rate) in boys
and girls were 43.4% and 50.4%
respectively (overall 46.8%) and TGR in
men and women were 27.2% and 56.1%
respectively (overall 42.9%). Similar results
THE INDIAN JOURNAL OF PEDIATRICS
JOT
are seen in the other zones. Same is true for
median urinary iodine level and the
percent population having biochemical
iodine deficiency (see Results).
The above findings lead us to draw an
important conclusion-IDD surveys carried
out in children can be considered as
representative of the whole community.
Therefore, for future IDD surveys,
children aged 5-11 years should be
examined.
In the present survey, the school
attendance pattern of the school-aged
children was the same irrespective of
whether they had goitre or not (data not
shown). Thus, for countries where primary
schooling is universal, quick school-based
surveys (80-100 children per cluster) are
recommended instead of household
surveys. This would substantially reduce
the time and cost of an IDD survey.
Acknowledgements
This work was financial!}' supported by
the United Nations Children's Fund
(UNICEF) and the Canadian International
Development Agency (C1DA). We would
like to express our sincere thanks to
UNICEF
Country
Representative,
Bangladesh Mr Rolf C Carrier and his team
for their support. We are grateful to Dhaka
University authority, particularly its ViceChancellor Professor Emajuddin Ahamed,
for providing us with all administrative
and logistic support in conducting the
survey.
We would like to thank our field team
leaders Dr. M. Solyman, Dr. Moin Ahmed,
Dr. Syed I. A. F. Siddique, Dr. Shamsul
Muquarrabin, Dr. Tanvir Hossain, Dr. M.
Asad Hossain, Dr. Shariful Islam Mondol
annd Dr. Mamnunur Rahman Mamun for
no
1996; Vol. 63. No. 1
THE INDIAN JOURNAL OF PEDIATRICS
their hard work and sincere efforts in
assessing IDD status of the study
population. The invaluable assistance
provided by the field technicians
Humayun Kabir, Zulfikar Ali Bhutto,
Masud Shakil, Iqbal Hossain, Jahangir
Alam, Monowar Hossain, Ershadul
Hoque, Akhter Hossain and Mahbubul
Alam is acknowledged with utmost
appreciation. The expert technical
laboratory assistance of M. Omar Faruque,
M. Ayub Khan and Taslima Ferdausi is
also gratefully acknowledged.
We are grateful to Professor. M.G.
Karmarkar (Senior Advisor, ICCIDD) of
All India Institute of Medical Sciences,
New Delhi, India and Dr. G.F. Maberly of
the Centre for International Health at
Emory University School of Public Health,
Atlanta, GA, USA, for their assistance
respectively with internal and external
quality assurance of uriinary iodine
analysis. Special thanks are also due to Mr.
M. Yeakub Patwary, Consultant, UNICEFDhaka for his invaluable help in many
aspects of the survey.
References
Hetzel, BS. An overview of the preven
tion and control of iodine deficiency dis
orders, In : The Prevention and Ccontrol of
Iodine Deficiency Disorders, ed. by Hetzel
BS., Dunn, JT, and Stanbury, JB, Elsevier,
Amsterdam, 1989; 17.
2. Global Prevalence of Iodine Deficiency
Disorders-Micronutrient Deficiency' In
formation System (MDIS) Working Paper
No 1, WHO/UNICEF/ICCIDD, 1993 : 5.
1.
Pharoah, POD., Buttfield, IH, and Hetzel,
BS. Neurological damage to the fetus re
sulting from severe iodine deficiency
during pregnancy. Lancet, 1971; 1 : 308.
4. Bleichordt, N, Drcnth, PJD, and Querido,
A Effects of iodine deficiency on mental
and psychomotr abilities. Am J Physiol
Anthropol, 1980; 53 : 55-67.
5. Bangladesh Environmental DirectorateMinistry of Environment, Govt, of Bang
ladesh 1992; 17.
6. Nutrition Survey of East Pakistan (196264) : Department of Biochemistry,
University of Dhaka and the US
Department of Health Education and
Welfare, New York, 1966.
7. Report of National Goitre Prevalence
Study of Bangladesh (1981-82). Institute
of Public Health Nutrition, Ministry of
Health and Population. Control, Dhaka,
1983.
8. Yusuf HKM, Quazi S, Islam MN et al.
Current status of iodine-deficiency
disorders in Bangladesh. Lancet, 1994; 343
■ 1367-1368.
9. "Indicators
for
Assessing
Iodine
Deficiency Disorders-Report of the Joint
WHO/UNICEF/ICCIDD Consultation
on IDD Indicators, Geneva, November
1992." WHO/NUT/93.1, September,
1993.
10. Gutekunst, R. 1993 : Method A. In ;
Methods for Measuring Iodine in Urine, ed.
by Dunn, JT, Crutchfield, HE, Gutekunst,
R., and Dunn, A.D., ICCIDD/UNICEF/
WHO, The Netherlands, 18-27.
11. Stanbury JB, and Pinchera A 1994 .
Measuremenjt of iodine deficiency
disorders. In : SOS For A Billion; The
Conquest of Iodine Deficiency Disorders, ed.
by Hetzel BS, and Pandav CS, Oxford
University Press, Delhi, 73-88.
3.
c). >3
Update/Le point
---- <—---- a /■------------
Safe use of iodized oil to prevent iodinemeficiency
in pregnant women
*
A Statement by the World Health Organization1
The risks and expected benefits from iodized oil, given orally or by injection, to pregnant women in areas of
severe iodine deficiency where iodized salt is not available were evaluated. The conclusions, which were
approved by the International Council.for Control of Iodine Deficiency Disorders (ICCIDD), showed that for
'preventing and controlling moderate and severe iodine deficiency, the giving of iodized oil is safe at any time
during pregnancy. Maximum protection against endemic cretinism and neonatal hypothyroidism will be
achieved when iodized oil is given before conception. The potential benefits greatly outweigh the potential
risks in areas of moderate and severe iodine deficiency disorders, where iodized salt is not available and is
unlikely to be made available in the short term (1-2 years).
Introduction
Since salt iodization is the optimal way of correcting
iodine deficiency, it should continue to be the pri
mary focus, through sustainable programmes, for
preventing and controlling iodine deficiency disor
ders (IDD)? The level of iodization should be ad
justed to provide the recommended dietary intake
(RDI) of iodine in the quantity of salt usually con
sumed. For pregnant and lactating women the RDI
for iodine is 200pg/day (/).
Pending successful establishment of salt iodiza
tion in areas of moderate and severe iodine
deficiency? periodic large doses of iodine are fre
quently administered to all women of childbearing
age. orally or by injection, in the form of slowly
resorbable iodized oil. This intervention is an effec
tive short-term public health approach that prevents
• A French translation of this article will appear in a later issue of
the Bulletin.
’ Based on a WHO Consultation on the Safety of Iodized Oil for
Pregnant Women, Geneva, 13-14 September 1994. The partici
pants at this meeting were Dr M. Benmiloud (Chairman), Algiers,
Algeria, Dr F. Delange, Brussels, Belgium; Dr C.S Pittman, Bir
mingham, AL, USA, Dr S Yaffe, Bethesda, MD, USA; Dr C. Thilly,
Brussels, Belgium; Dr C. Voumard, United Nations Children's
Fund (UNICEF), Geneva, Switzerland. WHO Secretariat: Dr G
Clugston. Dr B Underwood, Dr K. Bailey, and Dr J. Zupan. Re
quests for reprints should be sent to the Nutrition Unit, World
Health Organization, 1211 Geneva 27, Switzerland.
goitre and iodine-related brain defects, including
endemic cretinism, in children. There are. however.
a number of doubts about the safety of using iodized
oil. or daily doses of iodine far in excess of normal
physiological need, to prevent 1DD. For example.
maternal iodine overload due to iodized oil during
the crucial period of pregnancy could inhibit mater
nal thyroid function through a Wolff-Chaikoff
effect? thereby decreasing the availability of thyrox
ine to the fetus. Iodized oil could also directly affect
fetal development. In addition, it has been suggested
that iodized oil administered during late gestation
could impair fetal and neonatal thyroid function.
also through a Wolff-Chaikoff effect (2).
Responding to these concerns, the World
Health Organization convened a group of experts to
review and evaluate the results of programmes pro
viding iodized oil to pregnant women. A careful re
view of the literature, and of experiences in several
countries where iodized oil has been given at various
stages of gestation, indicates that negative results
Iodine and health eliminating iodine deficiency disorders safely
through salt iodization, k statement by the World Health Organi
zation Unpublished WHO document WHO/NUT/94.4, 1994 (avail
able in English, French and Spanish).
c Moderate and severe iodine deficiency are defined in: Indicators
for assessing iodine deficiency disorders and their control through
salt iodization. Unpublished WHO document WHO/NUT/94.6,
Reprint No. 5665
1994 (available in English, French and Spanish).
c The Wolff-Chaikoff effect is the inhibitory effect exerted by ex
cess iodine on the iodization of tyrosines in hormone synthesis.
Bulletin of the World Health Organization, 1996, 74 (1): 1-3
©World Health Organization 1996
A Statement by the World Health Organization
have not been convincingly demonstrated? The
group concluded that, for purposes of preventing
and controlling moderate and severe iodine defi
ciency. as defined by WHO? the administration of
iodized oil is safe at any lime during pregnancy.
Maximum protection against endemic cretinism and
neonatal hypothyroidism will be achieved when
iodized oil is given before conception. During the
first trimester of pregnancy the supply of thyroid
hormone to the human fetus appears to be criti
cally dependent on maternal thyroid status. This
relationship has been conclusively demonstrated
in animals (3).
The group concluded that the available evi
dence conclusively demonstrates that iodized oil ad
ministered to women before, or at any time during.
gestation has no harmful side-effects. Moreover.
iodized oil not only prevents endemic cretinism
and menial retardation in infants due to iodine
deficiency, but also decreases fetal and perinatal
mortality and increases the birth weight.
dose that is compatible with the circumstances
should be selected, and repeated if necessary, to
ensure the desired degree of protection.
Prevention schedules and criteria
The reasons why iodized salt will not be avail
able within a year or two should be thoroughly inves
tigated before selecting iodized oil as a public health
intervention. Sometimes salt iodization programmes
in highly endemic areas cease functioning for un
avoidable reasons. Should they be unable to restart
soon, iodized oil may serve as a useful temporary
measure.
Dosage levels and frequency of administration, and
the duration of protection expected from each are
set out in Table 1. The dose selected and frequency
of administration should be the lowest that will en
sure protection throughout pregnancy, and during
lactation for at least the first year postpartum. The
Table 1: Dosage, frequency, and duration of effective
ness of administering iodized oil to fertile women of
childbearing age-'
Intramuscular0
*
Oral
*
Oral
Frequency.
based on
duration of effect
>1 year
12 months
6 months
Pregnant women
1 ml
300-480 mg
100-300 mg
Non-pregnant
fertile women
*
1 ml
400-960 mg
200-480 mg
J Adapted from the International Council for Control of Iodine
Deficiency Disorders (ICCIDD)
0 Lipiodol (ultra fluid) 1 ml contains about 480 mg iodine.
c Oriodol: 1 dose (0.57ml) contains about 300mg iodine. Lipiodol
(capsule): 1 capsule (0 4 ml) contains about 200 mg iodine.
- Available data indicate that a dose of 100-200 mg orally protects
for 3 months. No such data are available for pregnant women.
a See article on pages 99—106 of this issue of the Bulletin
(Delange F. Administration of iodized oil during pregnancy: a sum
mary of the published evidence).
2
Criteria for giving iodized oil to pregnant women
Programme planners should carefully review the cir
cumstances calling for the introduction or continua
tion of iodized oil supplementation programmes.
The use of iodized oil for pregnant women and
women of childbearing age should be considered
only in situations where:
— the prevalence of iodine deficiency disorders is
classified as moderate or severe;
— cretinism and neonatal hypothyroidism are
present: and
— universal salt iodization programmes will not
reach women of reproductive age within 1-2
years (which usually occurs in small areas within
countries or regions, thus requiring area-specific
interventions).
Monitoring
The decision to use iodized oil for women of
childbearing age should be made wherever the
above criteria are met. Assessment of these criteria
these requires baseline information on the distribution and severity of IDD, and on the availability of 0;
iodized salt throughout the area, country or region
concerned. Assuming that the necessary baseline in
formation is available, a monitoring system is re
quired to evaluate both the programme's efficiency
and its biological effectiveness. The system should
include sufficient numbers of pregnant women to
provide valid data for evaluation purposes and
should be established within the context of national
IDD control programmes.
Optimal biological and process indicators for
effective monitoring of programmes to prevent
fetal brain damage using iodized oil are given
below.
Biological indicators. These apply to infants and
mothers.
WHO Bulletin QMS. Vol M 1996
Safe use of iodized oil to prevent iodine deficiency
.• Infant
— birth weight:
— perinatal mortality rate;
— neonatal serum thyroid-stimulating hormone
(TSH).
• Mother
— urinary' iodine concentration;
— breast-milk iodine concentration.
At least one of the indicators should be neonatal
TSH or maternal urinary iodine.
Process indicators. These include the following:
— availability of iodized oil at distribution points;
f- system in place for registering and tracking the
doses given:
— proportion of a programme's eligible subjects
seen antenatally who have received iodized oil;
— system in place to determine pregnancy
outcomes.
Conclusion
Based on the available scientific and programmatic
evidence, the proposed iodized oil prevention sched
ule in this statement will lead to no detectable ad
verse effects on human health. The potential benefits
to be derived greatly outweigh the potential risks in
areas of moderate and severe IDD prevalence where
iodized salt is not available, and is unlikely to be
made available in the short term, i.e., within 1-2
years.
References
Trace elements in human nutrition and health. Geneva,
World Health Organization (in press).
2. Kochupillai N et al. Iodine deficiency and neonatal
hypothyroidism. Bulletin of the World Health Organiza
tion, 1986, 64 547-551.
3. Morreale de Escobar G et al. Hormone nurturing of
the developing brain, the rat model. In: Stanbury JB,
ed. The damaged brain of iodine deficiency. New York,
Cognizant Communication Corp., 1994.
1.
3
WHO Bulletin OMS Vol 74 1996
QUESTIONS ON
IODINE
• DEFICIENCY
PREFACE
It is now known that one
out of every five people
in India lives in identified
iodine-deficient areas
and is at a risk of being
affected by Iodine
^iciency Disorders.
These disorders, all
caused by a lack of
iodine in the diet, can
range from goitre,
mental retardation, and
physical subnormality to
cretinism. The majority
of these disorders are
permanent and
incurable. However,
each one of them is
completely preventable.
lodated salt, consumed
daily, offers complete
protection against all
iodine deficiency
disorders, at an annual
cost per person that is
less than the price of a
of tea.
To enable everyone to
include iodine in their
daily diet, a number of
salt iodation plants have
been set up, and in the
near future iodated salt
will be available in every
town and village of India.
This booklet answers
some common
questions about iodine
deficiency. If you have
any further questions,
please write to:
The Adviser (Nutrition)
DGHS
Ministry of Health &
Family Welfare,
Nirman Bhawan,
New Delhi-110011.
1
What is
lodated
(Iodised) Salt?
lodated or iodised
salt is used to
prevent iodine
deficiency
disorders. It is
common salt
containing traces of
an iodine
compound, lodated
salt looks, tastes
and smells exactly
like ordinary salt
and it should be
used in the same
way.
Common Salt
What is
Iodine?
e is a natural
ent which is
essential to human
life. Some of the
most vital functions
of the human body
depend upon a
steady supply of
iodine.
K
From where
do we
normally get
Iodine?
Iodine is present in
its natural state in
the soil and in water.
So our normal
requirement comes
from crops grown
on iodine-rich soil.
But when the soil of
any area lacks
iodine, the crops too
are deficient in this
essential nutrient.
Consequently, those
people who live on
iodine-deficient land
and eat its crops
regularly, do not get
their daily requirement
of this essential
element.
What happens
if a person
does not get
•nough
Iodine?
Goitre is only one of
the many conse
quences of iodine
deficiency. A
number of physical
and mental
abnormalities, some
serious, some mild,
result from iodine
deficiency.
What exactly
is a Goitre?
A goitre is a swelling of
the neck caused by an
enlarged thyroid gland.
When the body does not
get enough iodine, the
thyroid increases in size.
Not all goitres are visible.
Many of them, particularly
in the early stages, can be
detected only by an
experienced doctor. It is
only when a goitre grows
quite large that it can be
seen and recognised by
everyone. A person with a
goitre may also have other
hidden iodine deficiency
disorders.
What are
Iodine
Deficiency
[^orders
(IDD)?
Iodine Deficiency
Disorders (IDD)
form a spectrum of
abnormalities which
include goitre,
mental.retardation,
deaf mutism, squint,
difficulties in
standing or walking
normally and
stunting of the
limbs. Iodinedeficient women
frequently suffer
abortions and still
births. Their children
may be born
deformed, mentally
deficient or even
cretins. All these
problems are caused
by a simple lack of
iodine, and goitre is
the least tragic of
them.
10
Where does
IDD occur in
India?
Why does a
child become
a Cretin?
A baby growing in
the mother’s womb
needs a steady
supply of iodine for
the normal growth
and development of
its brain and body.
Only the mother’s
body can provide
this essential iodine.
But if the mother is
iodine-deficient, the
child too is deprived
of this much-needed
nutrient. If the
woman's deficiency
is severe, the child's
brain and body are
seriously and
permanently stunted,
and he becomes a
cretin, unable to
walk, talk or think .
areas of
Werest iodine
mother's deficiency
is minor, the child
will still be affected,
even though he may
look normal. The
damage to his brain
usually shows up
years later in poor
school performance
and an inability to
perform normal,
everyday tasks.
Millions in our
country suffer from
this form of iodine
deficiency and it
affects the social
and economic
progress of whole
regions.
deficiency lie in the
great sub-Himalayan
belt that extends
from Jammu and
Kashmir, all along
North India, to the
North East, covering
an area of 2500
square kms. But
IDD has also been
reported from
Maharashtra,
Gujarat, Madhya
Pradesh, Andhra
Pradesh, Orissa,
Karnataka, Kerala,
Tamil Nadu, Goa,
Rajasthan, West
Bengal and Delhi. In
fact, no state in India
is free from IDD and
new pockets of
iodine deficiency are
being discovered
every day.
11
12
Can the daily
consumption
of lodated Salt
cure Goitre,
Cretinism and
other Iodine
Deficiency
Disorders?
Cretinism is
permanent and
incurable. Like many
other iodine
deficiency disorders,
with the exception of
certain types of
goitre, it cannot be
cured but it can be
easily prevented
before it occurs. The
regular consumption
Are there any
special foods
that I can eat
Wiich are rich
in Iodine?
of iodated salt
provides protection
to present and future
generations against
the tragic
consequences of
iodine deficiency
disorders.
Except for certain
types of seaweed,
there are no foods
that are inherently
rich in iodine. All
food derives its
iodine from the soil
on which it grows. If
the soil is poor in
iodine all the food
grown on it will be
low in iodine.
Therefore in areas of
iodine deficiency,the
only way to ensure a
steady intake of
sential iodine is by
ding it to the diet
in the form of
iodated salt.
«
14
Why is Iodine
added to salt?
Can’t it be
taken
separately, like
medicines?
An important fact
about iodine is that
although it is needed
in tiny amounts, it is
needed regularly,
every day. While it
could be taken every
day like medicine or
a vitamin tablet, this
would involve taking
a tablet every day for
the rest of your life.
Salt, however, is
something that we
all use every day. All
of us eat roughly the
same amount of salt
— 10 to 15 grams a
day, and if it is
iodated, we
automatically get the
right amount of
iodine.
But if I live in
an area that is
not Iodinedeficient,
won’t the extra
Iodine in the
salt harm me?
No, it will not. All of
us need only a
certain amount of
iodine to function
normally. If this
iodine is already
available to the body,
it will simply reject
any additional
quantities and
excrete it unused
through the urine.
On the other hand, if
>u are deficient in
iodine, your thyroid
gland will use as
much iodine as it
needs and reject the
rest. This makes
iodated salt safe for
everyone.
Remember iodine is
.an essential nutrient
— not a medicine.
1©
Can lodated
Salt be used
by pregnant
women, very
young
children or
someone who
is ill? Is it like
ordinary salt?
Yes. Every person —
young, old, sick or
healthy — needs
iodine every day.
Pregnant women
and young children
need it even more
than others, so it is
not only safe but
also necessary for
them to use iodated
salt every day.
How can I tell
if salt contains
Iodine?
S^of non-iodated
slBias been
banned in U.P.,
Bihar, Himachal
Pradesh, J&K,
Punjab, Haryana,
Chandigarh, Delhi,
Sikkim, Assam,
Arunachal Pradesh,
Mizoram, Meghalaya,
Manipur, Nagaland,
Madhya Pradesh,
Tripura, West Bengal,
Daman & Dui, Dadra
& Nagar Haveli and
Lakshdweep, parts
of Maharashtra,
Andhra Pradesh,
Gujarat, Karnataka
and Orissa.
*w
Ag
cost testing kit
i^Failable which
allows you to test for
the iodine content of
the salt on the spot.
17
Is it possible
to use lodated
Salt for
livestock?
Yes. lodated salt
improves the health
and productivity of
animals and reduces
the number of still
births and
miscarriages. Also,
cattle who are fed
lodated salt produce
milk that is rich in
iodine.
18
Can lodated
Salt be stored
like normal
St?
Storing iodated salt
involves a few
precautions. The
iodine in the salt can
be destroyed by
prolonged exposure
to direct sunlight and
moisture. Therefore,
store the salt in an
airtight container
made of plastic,
wood, glass or clay,
with a well-fitting lid.
Make sure you
consume iodated
salt as early as
possible.
If salt is left exposed iodine is lost.
20
What should I
do if I cannot
find lodated
Salt in my
local market?
The Government of
India has decided to
make iodated salt
available in a phased
manner all over the
country. If your local
market does not
stock this salt, write
to the Civil Supplies
Department of your
State or UT or
to the nearest Salt
Commissioner's
Office, the address
of which is given on
the last page of this
booklet or to the IDD
Cell of Directorate
General of Health
Services,
Government of India.
How long will I
have to keep
using lodated
Bit?
If you live in an
iodine-deficient
environment, there is
no likelihood of the
deficiency being
corrected at the
source, namely, in
the soil. On the
contrary, the
increased degrada
tion of our environ
ment is making the
problem worse.
Largescale defores
tation, among other
things, has led to
increased flooding
and erosion of the
•soil, which
Salt Commissioner of
India
17, Shivaji Marg,
Sawai Ram Singh Road,
(Near Diggi House)
Jaipur-302 004.
RAJASTHAN
Dy. Salt Commissioner
11 Block, 11th Floor,
Shastri Bhawan,
Nungambakkam.
Post Box No. 706.
Madras-600 006.
TAMIL NADU.
Asst. Salt Commissioner
8 Lindsay Street, 4th Floor
Calcutta 700 087.
WEST BENGAL
Asst. Salt Commissioner
Salt Department BuMg
Near Haathi Colony,
Jamnagar-361 001.
GUJARAT
Asst. Salt Commissioner
East Godavri Distt.,
Kakinada-533 003.
ANDHRA PRADESH
Asst. Salt Commissioner
80 George Road,
Dy. Salt Commissioner
Ajanta Commercial Centre Tuticorin-628 001.
TAMIL NADU
B Block, 4th Floor,
Ashram Road,
Ahmedabad-380 014.
GUJARAT
Dy. Salt Commissioner
Exchange Building
Sprott Road, Ballard Estate
Post Box No. 1561.
Bombay-400001
MAHARASHTRA
Do’s
1.
Ensure strict quality control measures
at iodisation plants.
2.
Always pack iodised salt in moisture
proof sacks and seal these sacks
properly.
3.
Always shield iodised salt from
moisture, sunlight and high
temperature while storing.
4.
Make sure salt that has been iodised
first is also despatched first.
5.
Stamp the date of manufacture, the
name of the manufacturer, and the
level of iodisation on the salt packets.
This must be done because iodised
salt should be consumed within a
year of iodisation.
6.
Whenever you buy salt.insist on
iodised salt.
1.
Never use ordinary, unlined jute bags.
2.
Never store in the open or in a damp,
poorly ventilated godown.
3.
Avoid transporting in open trucks or in
open railway wagons.
4.
Never store iodated salt beyond six months.
Published by:
The Ministry of Health & Family
Welfare, Government of India
NDQ-1092/CDN/ENG-HIN/1 50/92/2903-2284/PS/ND
Don’ts
INTERNATIONAL COUNCIL FOR CONTROL OF IODINE DEFICIENCY DISORDERS (ICCIDD)
OFFICE OF THE REGIONAL CO-ORDINATOR, SOUTH ASIA & PACIFIC
IOCIDD
CENTRE FOR COMMUNITY MEDICINE
All India Institute of Medical Sciences, New Dethl-110,Q29, INDIA
Office: Tel.: 91 -11 -6863522, Fax:91-11 -6863522
Telex : 31-73042 AIMS-IN Grams : MEDINST
1st September, 1997
Dear friends and partners in IDD elimination,
The month of October is of special significance to all of us
Indians.
The Father of our Nation - Mahatma Gandhi - was born in
this month.
We would like to pay him a fitting tribute by
dedicating our efforts to eradicating the social and health
problems that continue to confront society.
This is especially
true of a health problem that affects all of us.
Iodine Deficiency Disorders are the single most common cause of
mental handicap in the world. An estimated 1.5 billion people are
at risk of iodine deficiency worldwide.
655 million people suffer
from goitre and 43 million people have brain damage caused by IDD,
which was preventable.
Based on different studies conducted
worldwide, it has been estimated that children living in iodine
deficient areas, have 13 IQ points lower, than children living in
iodine replete areas.
The social and economic loss caused by IDD
to any society is immense.
IDD has long been recognised as a major health problem in India.
Surveys have shown that IDD is endemic in all states and union
territories of the country.
Over 20 per cent of Indians, or an
estimated 217 million people are vulnerable to Iodine deficiency
and its spectrum of disorders, at all stages of development foetal, neonatal, childhood, adolescence and adulthood. 54 million
people have goitre, another 2.2 million have cretinism and 6.5
million have mild neurological disorders.
In order to over come
IDD, Universal Iodisation of Salt was implemented in India, with
the target of Universal Access to Iodised salt by 1995, so that IDD
could be eliminated by 2000 AD.
Ensuring legislation to iodize salt was one thing, monitoring its
availability and consumption by all was another.
Though some
surveys were conducted in different places, at different times in
the country, no countrywide survey has been attempted so far.
It
is difficult for an external independent agency to collect this
information from all over the country.
Only a network of non
governmental
organisations
can
accomplish
this
nationwide
assessment on the availability of iodised salt.
The Centre for Community Medicine (CCM), at the All India Institute
of Medical Sciences, has for many years been associated with
efforts to sustain elimination of IDD. In fact the department was
involved with the famous Kangra Valley Experiment.
This experiment demonstrated that iodine supplementation of salt in
the diet, reduced the incidence of IDD. Studies conducted in Delhi
and other parts of the country, by CCM, demolished the myth that
IDD was prevalent only in the Himalayan and sub-Himalayan regions.
We were also involved in highlighting the impact of maternal iodine
deficiency on new born babies.
We proved that neonatal chemical
hypothyroidism affects a child's intelligence.
Studies conducted among school children in Delhi have established
that despite the ban on sale on un-iodised salt, people still
continue to consume un-iodized salt.
This has underlined the
importance of monitoring not only production, but also the sale of
iodised salt.
Taking into account the magnitude of this survey, we are now
volunteering to carry out the task of monitoring the availability
of iodised salt at the national level, with the help of non
governmental organisations. Our previous endeavours with NGO's of
selected districts of UP was very successful. This has emboldened
us to take this step. The NGOs have been selected on the basis of
names suggested to us by the District Commissioner of each district
in India.
Some names have also been suggested by VHAI & CMAI.
We hope to bring out a joint report on the basis of this study
called the Citizens report on the availability of iodised salt in
India.
We seek your co-operation in making this venture a success.
It
will help us raise this issue at the national level, and develop
and suggest strategies to eliminate IDD from India.
Please feel free to contact any one of us in this regard:
Thanking you,
Yours sincerely.
(Dr. C.S. Pandav)
Additional Professor &
Regional Coordinator, ICCIDD
South Asia & Pacific Region
"vDr. K. Anand)
Assistant Professor
(Ms. S. Narayanan)
Project Officer, ICCIDD
WHAT DO WE WANT FROM YOU ?
1) Collect samples of salt from 10 shops in the area where you are
working.
2) If more than one type of salt, (not brand but in terms of
packed/loose
or powder/big crystals - see Proforma for shops,)
take a sample of each.
3)
Use the kit provided to test for iodine content of salt.
4) Fill the polythene packet and send them to ICCIDD Lab at Delhi
in the pre-paid envelop provided.
5)
Fill the details in the form provided.
PRE-PAID ENVELOPS
The pre-paid envelop is being provided to you so that the samples
can be sent to us conveniently. Do not put more than 4 packet of
salt per envelop.
HOW TO USE THE KIT ?
1)
2)
3)
4)
5)
Take one tea spoon of salt on a white paper.
Add a drop of the test solution on it.
Wait for 30 seconds.
Read the answer only as Yes / No.
It is yes, if the colour of the salt turns violet of any shade.
It is no, if there is no change in colour.
CHECK LIST
Pre-paid envelops
Zip lock polythene bag
Spot testing kit
Proforma
10
40 bags
1
10
Policy Makers
Sustaining Elimination of IDD
iacro
50 Years of Independence : Month of Mahatma Gandhi’s Birthday
Iodine Content of Salt in Retail Shops
:
Name of NGO
Name of Village/Town
Name of Shop
:
District
State
How long do you keep the salt (Stock)
Please Complete this Table-Thanks
S. No
Type of Salt
Label
Availability
(Yes / No)
Yes
1.
Company Packed
2.
Self Packed
3.
Loose Salt:
Kept in box / jute bags
/other containers
4.
Salt kept open on floor
5.
Salt for animals
If More than one variety of salt please mention it, Thank you
Name
Price / KG
(In Rs.)
Iodine
Yes/ No
Iodised
or Not
J
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50 Years of Independence : Month of Mahatma Gandhi’s Birthday
Iodine Content of Salt in Retail Shops
Name of NGO
:
Name of Village/Town
:
Name of Shop
District
State
How iong do you keep the salt (Stock)
Please Complete this Table-Thanks
S. No
Type of Salt
Label
Availability
(Yes / No)
Yes
1.
Company Packed
2.
Self Packed
3.
Loose Salt:
Kept in box/jute bags
/ other containers
4.
Salt kept open on floor
5.
Salt for animals
Name
Price/KG
(In Rs.)
Iodine
Yes/No
Iodised
or Not
_________________
If More than one variety of salt please mention it, Thank you
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50 Years of Independence : Month of Mahatma Gandhi’s Birthday
Iodine Content of Salt in Retail Shops
Name of NGO
:
Name of Village/Town
:
Name of Shop
:
District
State
How long do you keep the salt (Stock)
Please Complete this Table-Thanks
S. No
Type of Salt
Label
Availability
(Yes/No)
Yes
1.
Company Packed
2.
Self Packed
3.
Loose Salt:
Kept in box / jute bags
/other containers
4.
Salt kept open on floor
5.
Salt for animals
Name
Price I KG
(In Rs.)
Iodine
Yes / No
Iodised
or Not
__________________
If More than one variety of salt please mention it, Thank you
December 1987
Vol. II, No. 9
TECHNICAL LITERATURE UPDATE
A MONTHLY REPORT OF CURRENT LITERATURE ON ORT & RELATED HEALTH ISSUES
Technical Writer: ROBERT NORTHRUP, M.D.
Editor: WILLIAM AMT
These
monthly
bibliographical listings consist of selected
annotated articles and/or other information which our technical
editor,
Dr.
Robert
Northrup,
feels should be circulated to
individuals concerned about CRT and related health issues. Editor’s
coirenents, where appropriate, Eire appended in brackets.
Inclusion in a listing does not meem that we endorse or validate
the article cited; rather, that it is worthy of your attention and
further critical appraisal, particularly when it has alreEidy been
published in a well-known journal. The abstracts and commentaries
represent the opinions of the TLU editorial staff, and are not mesmt
to represent USAID policies or opinions. Comment or criticism is
welcome.
Buccimazza, S.; Hill, I.; Kibel, M. ; Bowie, M. THE COMPOSITION OF
HOME-MADE SUGAR/ELECTROLYTE SOLUTIONS FOR TREATING GASTROENTERITIS.
South African Medical Journal, 1986, Vol. 70, 728-730.
Five different instructions for preparing a sugar-salt
solution for early home treatment of diarrhea were tested
for
their effectiveness in communicating to low-income
mothers in Cape Town, South Africa, how to mix the solution
correctly.
The instructions compared use of a cup versus
use of a liter container as the volume measure for the
water, and pinches versus level teaspoons versus half-level
teaspoons versus 5 ml medicine-dispensing spoonfuls as the
measuring tools for the salt and sugar. Mothers were asked
to prepare solutions according to one of five sets of
instructions.
The sugar and sodium concentration, the
osmolality, and the volume of the measuring devices actually
used by the mothers in making the solutions were then
determined.
Technologies for Primary Health Care
PRITECH
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PH: 703-841-0680. Telex: 3792632—PARK PL. AID Supported Contract #DPE-5927-C-00-3083-00
December 1987
Vol. II, No. 9
TECHNICAL LITERATURE UPDATE
A MONTHLY REPORT OF CURRENT LITERATURE ON ORT & RELATED HEALTH ISSUES
Technical Writer: ROBERT NORTHROP, N.D.
Editor: WILLIAM AMT
These
monthly
bibliographical listings consist of selected
annotated articles and/or other information which our technical
editor,
Dr.
Robert
Northrup,
feels should be circulated to
individuals concerned about ORT and related health issues. Editor’s
coinnents, where appropriate, are appended in brackets.
Inclusion in a listing does not mean that we endorse or validate
the article cited; rather, that it is worthy of your attention and
further critical appraisal, particularly when it has already Deen
published in a well-known journal. The abstracts and commentaries
represent the opinions of the TLU editorial staff, and are not meant
to represent USAID policies or opinions. Comment or criticism is
welcome.
Buccimazza, S.; Hill, I.; Kibel, M. ; Bowie, M. THE COMPOSITION OF
HOME-MADE SUGAR/ELECTROLYTE SOLUTIONS FOR TREATING GASTRO-ENTERITIS.
South African Medical Journal, 1986, Vol. 70, 728-730.
Five different instructions for preparing a sugar-salt
solution for early home treatment of diarrhea were tested
for
their effectiveness in comnunicating to low-income
mothers in Cape Town, South Africa, how to mix the solution
correctly.
The instructions compared use of a cup versus
use of a liter container as the volume measure for the
water, and pinches versus level teaspoons versus half-level
teaspoons versus 5 ml medicine-dispensing spoonfuls as the
measuring tools for the salt and sugar. Mothers were asked
to prepare solutions according to one of five sets of
instructions.
The sugar and sodium concentration, the
osmolality, and the volume of the measuring devices actually
used by the mothers in making the solutions were then
determined.
PRI7ECH------Technologies for Primary Health Care
Request Articles from: Information Center, The PRITECH Project, 1655 N. Fort Myer Dr., #700. Arlington, VA. 22209
PH: 703-8414)680. Telex: 3792632—PARK PL. AID Supported Contract #DPE-5927-C-00-3083-00
The results showed that instructions for use of a
half-level teaspoon of table salt and eight level teaspoons
of cane sugar in one liter of water produced the safest,
most accurate solutions. The variation which resulted from
use of the cup measure, the level teaspoon of salt, and the
pinch of salt was so wide as to produce an unacceptably
large percentage of hyper- and hypo-osmolar solutions. The
5 ml dispensing spoon had greater volume than the teaspoons
provided by mothers (range of volume of the majority between
2.5 and 4 ml), and led to hyper-osmolar solutions. In the
taste
test,
16
of
25
mothers identified a sodium
concentration of 140 mmol/1 or more as tasting similar to
their own tears, with nine of the 16 choosing a solution
greater than 180 mmol/1. The authors concluded that using
taste could lead to the administration of excessively salty
solutions and should not be recommended.
[Editorial Comment:
This simple, but elegant, study is an
excellent example of the kind of study needed by most DDC
program managers to make decisions about messages on home
therapy.
In this environment, the liter measure was more
accurate; in another, the cup, glass, or other culturally
dependent measure may be more likely to be correct and
consistent.
That is why such studies are needed in each
different cultural setting.
The taste studies disappointed me. I had thought that
this very human and homely approach was probab1y useful.
This study shows that it is not, that most mothers in this
setting did not pick the correct solution. I might point
out that, in similar fashion, mothers in certain cultures
use home-available solutions to treat diarrhea which have
either too much or too little salt and/or sugar.
The sad conclusion must be that indigenous cultural
practices are not always appropriate physiologically, and
need careful study and, perhaps, modification. RSN]
Green, E.
DIARRHEA AND THE SOCIAL MARKETING OF ORAL REHYDRATION
SALTS IN BANGLADESH. Soc. Sci. Med., 1986, Vol. 23, No. 4, 357-366.
A national-level anthropological study of knowledge,
attitudes, and practices related to diarrhea was carried out
in Bangladesh to provide the basis for an effective program
to market ORS there.
The study used open-ended questions
and probing techniques to obtain a wider range of answers.
Four different types of diarrhea, each with a different
name, were identified by respondents: cholera-like, bloody,
greenish/yellowish
diarrhea
with
mucous, and "simple"
diarrhea.
Bloody diarrhea was often seen as more dangerous
than vomiting diarrhea (cholera).
Forty-two percent said
diarrhea might usefully purge bad elements from the body,
but purgatives do not seem to be used as treatment.
Although most (75%) recognized that diarrhea leads to
weakness and/or fatigue, the symptom of a sunken fontanelle
was virtually- unknown.
There was no term commonly used to
express the idea of dehydration.
2
Ninety-two percent of the respondents recognized ORS,
and 86% said ORS was used to cure or treat diarrhea; only
16% said ORS overcomes water loss. Fifty-nine percent had
used sugar-salt solution, 58% ORS. Some respondents said
ORS is too expensive for them.
Seventy-four percent said babies in their fami1ies
refuse
or
do
not like ORS, but 36% of this group
nevertheless forcefeed ORS to their children. Seventy-one
percent said ORS is as good or better than pills. Solid
foods
are
restricted
during diarrhea by 75% of the
respondents. Only 8% said they restrict breastfeeding.
Most
respondents
see
help
from
allopathic
practitioners, either trained or untrained, if diarrhea is
serious.
Radio is a source of information about diarrhea
for 60% of respondents.
[Editorial Comment:
Once again, it is precisely this kind
of anthropologically derived marketing study which is needed
by every diarrhea control program if its communication
efforts are to be successful. RSN]
Ichinose, Y.; Ehara, M.; Watanabe, S.; Shimodori, S.; et al. THE
CHARACTERIZATION OF VIBRIO CHOLERAE ISOLATED IN KENYA IN 1983.
Journal of Tropical Medicine and Hygiene, 1986, Vol. 89, 269-276.
Of the 245 strains of Vibrio cholerae El Tor isolated
in Kenya in 1983, 184 were resistant to tetracycline.,
streptomycin,
and
ampicillin.
All were sensitive to
chloramphenicol and nalidixic acid.
[Editorial Conment:
With the traditional treatment for
cholera being tetracycline, this finding is a problem.
Chloramphenicol has dangerous side effects, and nalidixic
acid is expensive.
Trimethoprim-sulfamethoxazole was not
tested and is a potential alternative.
The presence of drug resistance makes the availability
of effective rehydration facilities even more important.
Even with drug-sensitive cholera, the first priority in
preventing death is rehydration.
Feeding along with ORS
will reduce stool output and duration of cholera, just as
use of effective antibiotics will. RSN]
Kumar, V.; Monga, 0.; Walia, I.
KNOWLEDGE OF COMMUNITY HEALTH
VOLUNTEERS
REGARDING TREATMENT OF ACUTE DIARRHOEA IN CHILDREN.
Journal of Tropical Pediatrics, October 1986, Vol., 32, 214-217.
The knowledge and attitudes about ORT and diarrhea
management of community health volunteers in Haryana State,
India, was assessed with a questionnaire. Three groups of
30-34 CHVs had been trained differently. A fourth served as
the control group.
The results showed that almost none of the CHVs who
attended only a broad, three-month basic training course and
were not furnished.with ORS, could prepare ORS or home
3
solution correctly.
In fact, a majority of those CHVs who
were given refresher training three times in the year after
initial
training
prepared ORS incorrectly (only about
one-third knew how).
Those given repeated retraining and
furnished with ORS knew ORS preparation and use well, but
only one-third could prepare home solution.
Ability to
remember
signs of dehydration increased with refresher
training.
Despite even the maximum training, half of the
CHVs would restrict foods, compared with 80% in the control
group, and 29% to 58% of the trained CHVs would restrict
breastfeeding, 93% in the control group.
[Editorial Comment:
This is exactly the kind of practical,
operational study that diarrhea program managers need in
order to make informed decisions about how they do training,
and how much follow-up is needed. As might be expected, the
study
shows that a single training course has little
long-lasting impact.
Follow-up, either through refresher
training or monitoring, can make a real difference.
The study also shows that special attention is needed
for
certain
subjects
where widespread cultural norms
conflict with the desired lesson
in this case, feeding
during diarrhea.
It is interesting to note that Bentley’s study in India
showed
that
while mothers often said they restricted
feeding, observation of actual practice showed that almost
all
continued feeding, and all continued breastfeeding
during diarrhea. RSN]
Walker-Smith, J.
NUTRITIONAL MANAGEMENT OF ACUTE GASTROENTERITIS —
REHYDRATION AND REALIMENATION. Human Nutrition: Applied Nutrition,
1986, Vol. 40A, Suppl. 1, 39-43.
[Editorial Comment:
This review, dealing primarily with
developed-country patients, nicely emphasizes the importance
of high-solute feedings (high-lactose, for example) prior to
a diarrhea episode in leading to hypernatremic dehydration
when diarrhea occurs.
The kidneys are already overloaded
and cannot handle the extra burden of loss of hypotonic
diarrhea fluid, especially in children younger than six
months.
If such diarrhea patients then receive a hypertonic
rehydration fluid — as happened during the 1950s in the
U.S. with hytren (5% glucose), and with apple juice and Coca
Cola today (osmolarity +600, twice normal osmolarity, and no
sodium chloride) — their kidneys cannot compensate, and
they become hypernatremic.
WHO-standard ORS formula has
been used by Pizzaro in such hypernatremic and dehydrated
children with safety and food correction of hypernatremia.
We must consider carefully our recommendations to mothers so
that we do not push hyper-osmolar fluids (high in sugar,
usually) on children with diarrhea.
Walker-Smith goes on to point out that post-diarrhea
"lactose intolerance" may be more related to the use of
high-solute milks (i.e., iatrogenic) than to a functionally
commanding lactose deficiency. This corresponds to
4
experience in developing countries. But his assumption that
post-diarrhea
problems
are
due
to
a difference in
allergenicity of milk in the developed versus the developing
world, with diagrams blaming this on mucosal IgA deficiency,
seems overly imaginative, and no data are cited.
His
recommendation of cow’s miIk-free formulas for diarrhea
patients in the developing world is quite inappropriate.
Breastmilk should take first priority, and other simple
starchy
foods
second priority.
Pushing any formula,
implying the use of feeding bottles, is not a good idea, in
general.
These specific types of formulas are so expensive
as to make their use by other than the few rich children in
developing countries quite out of the question. RSN]
5
TECHNICAL
AMCL
\
fcRATURE UPDATE
T OF CURRENT LITERATURE ON ORT & RELATED HEALTH ISSUES
Technical Writer: Robert Northrup, M.D.
Editor: Hilliao Aot
NEW WHO ODD PROGRAM POSITION ON FLAVORING IN ORAL REHYDRATION SALTS
Until
recently,
the WHO ODD Program has actively discouraged
countries and ministries
of health from using flavored preparations
of oral
rehydration salts
(ORS), emphasizing in their interactions
with governments the desirability of using preparations with only the
four
basic
ingredients
(NaCl,
KC1,
NaHCOs,
and glucose).
In
addition
to the potential
for added flavor raising the price, the
strongest arguments against
the flavored preparations have been the
desirability of having a single preparation on the market (to reduce
confusion among purchasers
as well
as health workers),
and the
possibility that added flavor may lead to children drinking too much
of
the
solution and thereby developing hypernatremia.
Previous
issues of the TLU have discussed this subject.
Manufacturers of ORS,
however,
have almost uniformly wanted to add
flavoring,
based on their own assessment of the flavor of the plain
product,
and complaints
from parents either that they thought it
tasted bad,
or that
their child refused to drink it because of its
taste.
Many flavored preparations of ORS are already on the market.
In
the most recent issue of ODD Update, an occasional publication of
the ODD Programme,
we see for the fist time some relaxation of the
previous
position.
While continuing to recommend the simplest ORS
product,
the Programme has laid out clearly the potential advantages
of
flavoring in increasing acceptability and use of ORS.
It has also
declared publicly that there is no documented evidence that flavoring
will
either lead to overconsumption and consequent hypernatremia, or
lead to underconsumption.
Recognition that the slight additional
cost
may
bring
proportionate benefits by leading
to
greater
acceptability and increased use is also clearly stated.
•—
PRI7ECH-------
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This step opens the door to governments more freely allowing private
manufacturers
to distribute and sell
flavored products,
and
to
reconsidering whether they will promote officially both flavored and
unflavored products.
While we will all await evidence scheduled to
come
from
studies
of
the possibility of overconsumption or
underconsumption,
this gives
us
the possibility of responding more
positively at present to the wishes of consumers and producers of ORS
for flavored preparations.
In view
text of
1987) :
of the importance of this development, we quote the complete
the relevant portion of the CDD Update (No. 2, November
With the aim of making an essential drug available at a Ion
price, WHO and UNICEF have consistently recommended the use
of ORS compositions that contain the four basic ingredients
needed to yield an effective solution.
Many commercially
available products,
however, contain a flavouring agent, and
some a colouring agent.
The theoretical advantage of flavoured ORS
is greater
acceptability
(to
care
providers
and
children) and
consequently increased use.
The most important role of ORS
is to treat dehydrated diarrhoea cases.
In such cases taste
has not been found to be a problem
(and flavouring is thus
irrelevant).
In achieving widespread popular use of ORS,
however, particularly in the prevention of dehydration and in
post-rehydration maintenance
therapy, improved taste may be
an advantage.
These comments could apply equally well to
colouring of ORS.
The theoretical disadvantage of flavouring or colouring that
gives rise to the
greatest concern
is the
risk of
overconsumption and consequent hypernatremia; however, there
is no documented evidence that this is, in fact, a problem.
WHO is
supporting a study to investigate
this issue.
Additional studies would be welcome.
It is also possible
that flavoured
ORS could
in certain cases result in
underconsumption, as patients requiring large volumes of ORS,
particularly adults, may find flavoured ORS unpalatable after
ingesting large
amounts.
Again,
this
has not been
documented.
Colouring of ORS has lead (sic) to changes in stool or urine
colour and consequent confusion in diagnosis in a few cases.
The addition of flavouring and colouring agents adds
to the
cost of. ORS; however,
it is possible that it may bring
proportionate benefits. Any added substances should be shown
not to adversely affect the safety or the stability of the
product.
.
/
NATIONAL POLICY FOR UNIVERSAL
SALT IODISATION
A CRITIQUE
National Policy for Universal
Salt Iodisation
A Critique
Dr K P- Aravindan
Kerala Sastra Sahitya Parishad
English
National Policy for Universal Salt Iodisation.
A Critique
Dr. K. P. Aravindan
June 1989
First
Edition
Published by Kerala Sastra Sahitya Parishad
Parishad Bhavan, Trichur-680 002
Printed at GEO Printers,
Trivandrum
Cover :
Price
KSS?
:
Jayachandran
Rupees Three only
0408
IE Jun? 1989
-2 k
LL 6 IH-8?
National Policy For Universal
Salt Iodisation : A Critique
- ■ The ubiquitous common salt which once was the symbol of
our-, struggle for national liberation will soon be no more. The
lbw ebst-crystal-salt will be replaced by a higher priced, fine,’
iodised salt coming in sleek bags and carrying brand names’
made familiar by the electronic and other media. Another
item of mass consumption is going to be fully integrated into
the advanced capitalist market economy. The changeover will
be effected by suitable legislation by the Government of India,
buttressed by arguments put forth by a ‘neutral, disinterested’
scientific establishment. The monopoly sector of the Indian
industry will chipjn-with their might, guided, of course, by the
‘noble’ pursuit of .profit. Naturally, all these will be done in
the name of the poor suffering millions,- so that questioning it
would be made lq_ appear almost blasphemous. The object of
this article is to 'raise exactly a few of such blasphemous
questions.
- -•
The Background
Endemic goitre is enlargement of the thyroid gland seen in
\ a’significant number of people in a population. This has been
described in India from almost the vedic times. Charakasamhita
and. Susrutasamhita refer to neck swellings in what are most
likely cases of goitre. It is known from the early part of the
century that the inhabited valleys of the Himalayan massif is
one of the world’s largest contiguous areas of goitre preva
lence.1-!1
' The development of goitre or thyroid enlargement can be
due to various factors. Undoubtedly, deficient intake of iodine
is the' most important of these causes. Iodine is necessary in
minute quantities for the thyroid gland to synthesise its hormone
thyroxine. This iodine is usually made available through food
and water. In areas where iodine is deficient in water and soil,
goitre incidence increases. In some other areas substances
taken in the food can block the entry of iodine into the
6
hormone. Such substances, called goitrogens, are known to be
a cause of endemic goitre either acting alone or in consonance
with iodine deficiency.
It has been established beyond doubt that in the SubHimalayan belt extending from Kashmir to Assam (figure I)
iodine, deficiency is the cause of goitre.1 The water and the
food grown in rhe area is deficient in iodine and the people
consume little or no fish and meat, which are rich sources of
iodine, due to poverty and unavailability.
Fig. 1. Endemic goitre in Southeast Asia (Ref. 1)
In such areas of the world various ways have been thought
of by which iodine can be supplemented in the diet. The most
successful way this can be achieved is by iodising salt used for
human and animal consumption. This is done by adding a
specific amount of potassium iodide or iodate to the salt at the
point of manufacture.
Apart from the cosmetic problem caused by a greatly
enlarged thyroid gland, it is also found that in areas of high
endemicity of goitre, some children are born with gross mental
7
retardation, deaf-mutism and other physical abnormalities
(Cretinism). Prevention of this unfortunate disease is another
important aim of salt iodisation.2
Recognising the public health problem posed by the SubHimalayan endemic goitre, the Government of India initiated
the National Goitre Control Programme in 1962. The modus
operandi of this scheme was to (i) survey the suspected endemic
areas, (ii) supply of iodised salt to the areas, (iii) prohibit the
sale of non-iodised salt in those areas and (iv) resurvey after
periodic intervals to assess the impact of the programme. The
Government set up salt iodisation plants in the public sector in
Rajasthan, Gujarat, Assam, West Bengal and Himachal Pradesh.
The state owned Hindustan Salts was given the sole monopoly
for the production of iodated salt.3
Despite these measures, the National Goitre Control
Programme languished after a promising start. The “sad story”
of its mismanagement was sharply attacked by C. Gopaian,
former Director of I. C. M. R.4 This led to the setting up of a
working group by the G. O. I. to review the entire working of
the National Goitre Control Programme. It is the acceptance
of the suggestions made by the working group that Jed to the
policy of ‘Universal Iodisation of common salt’3.
Strange Recommendations of the Working Group
To any discerning observer the causes of the failure of the
programme in the endemic areas were obvious. The wo'king
group seems to have glossed over these entirely.
1. The public sector units which were entrusted with the
production of iodated salt were not able to produce the required
quantities. The fact was accepted tamely without going into
the reasons. The disinterest and lack of political will on the
part of the Government was not seen as the most important
factor. This was no doubt influenced by the urgings of the
private salt manufacturers. The fact that this is not due to the
innate inefficiency so often attributed to the public sector is
borne out by the efficient functioning of the untertakings in
which the Government is really interested — look at the compa
nies manufacturing condoms for the Government's pet family
planning project!
8
2. The failure of health education campaigns to make the
people in the endemic areas aware of the need to consume
iodised salt. Such an education campaign relating totheirdaily
life situation would have gone along way towards the success of
the programme. This lack of enthusiasm is again in striking
contrast to the missionary zeal of the F. P. propaganda.
3. Iodised salt was not made available in the endemic areas
at the same or lower prices as compared to uniodised salt. This
led to the smuggling and selling of cheaper non-iodised salt.
There was no administrative willingness to check this. In the
absence of a proper health campaign, people went in for cheaper
salt.
4. Some of the salt sold as iodised was, in fact, not so at
all. There were no proper quality control measures to detect
this.
5. Transport bottlenecks led further to non-availability in
areas where it is most required.
Instead of studying the causes of this failure and giving
suggestions for streamlining the existing production and distri
bution system, the working group seems to have arrived at
totally different and strange conclusions. It recommended that
the only solution is to go in for universal iodisation. The
reasons given were as follows.
I. It was administratively difficult to prevent the entry of
non-iodised salt in the goitre endemic areas.
2. The problem of goitre and IDDI was widely prevalent
throughout the country and new endemic areas were frequently
being identified.
3. The use of iodised salt by normal healthy individuals was
not a health hazard.3
Increased production is sought to be achieved by throwing
open the production of iodised salt to the private sector. As
regards distribution and quality control, despite platitudes, the
underlying hope seems to be that the market forces will take care
of everthing. As regards the second and third reasons, they
seem to be put in as afterthoughts based on ‘scientific evidence’
so conveniently supplied.
9
The working group recommendations and the Government
policy announced shortly thereafter are not based on a realistic
assessment of the causes of earlier failure. To quote Gopalan,
a supporter of the policy, “It will be a serious and naive miscal
culation to expect that by just extending'the salt iodation
programme to cover the entire country, implementation will be
simplified and current deficiencies will be automatically
overcome.”5
Socio Economic Cost of Universal Iodisation
Fate of small manufacturers
About 9 million tons of salt is produced in India annually.
Except for negligible amounts, it is mainly from sea water in the
states of Gujarat, Taruilnadu, Maharashtra and Andhra Pradesh.
About 10,000 manufacturers are involved in the production.
50% of the salt used for human consumption is produced by
small scale manufacturers with fields less than 40 hectares in
size.6
The process of iodisation can be done in different ways.
Spray mixing technology is the one favoured by the Govern
ment and the UNICEF. Moreover, only this technology can
iodate salt in large quantities (5 tonnes per hour) and ensure
uniform mixing of salt. The Government of india has decided
to supply potassium iodate free of cost to the manufacturers.
But the experience so far has been that the delivery is not
prompt.’ '
The real problem for the small manufacturer is that an
initial capital investment of 3-5 lakhs of rupees is needed for
one spray mixing unit, which most of them are in no position to
raise. Moreover, for those with smaller fields (a vast majority)
this technology is not cost effective. A further snag is that the
manufacturers have to set up and maintain a quality control
laboratory which adds to th: initial and recurring expenditure.
Newer regulations about packaging will also be disadvanta
geous to the small scale sector.
Adding to their woes is the competitive selling of iodised
salt under different brand names. In the resultant free market
warfare it will be a great wondci if the small scale sector
10
survives. In all likelihood the monopoly houses like the Tatas
who have now entered this field will make full use of the new
policy to drive the small manufacturers out of business with
their shrill advertising and aggressive marketing.
Cost to the consumer
Common salt sells in most areas of the country at a price
of approximately 50 ps per kg. The process of iodisation
which involves extra expenditure tends to increase the price
despite the subsidies. Apart from the capital costs involved,
there is a definite increase in the continuous operating costs.
It is claimed that the minimum operating costs work out at
about II paisc per kilogram, which is most probably an under
estimate. Of this, only about 2 paisc per kg is the Government
subsidy paid in the form of free supply of Potassium Iodate.
In fact, the increase in prices would be out of proportion
to the actual increase in expenses incurred. This is already
seen in the market where iodised salt sells for prices ranging
from Rs. 1.50 to Rs. 3 per kg. Only extreme naivete would
permit the hope that this will come down in future. The very
success of the current strategy depends on the co-operation of
the private sector and it would be unrealistic to hope that they
would be willing to forgo the current levels of profit in the
industry. As for the capability of the Government to force the
private sector to bring down the prices, past experience in the
different areas of industry should be an eloquent guide.
It is claimed that the costs of Rs. 1.5/kg and above is only
that of refined io.lated salt, and that iodated crystal salt would
sell cheaper as it already in the endemic areas. But the whole
point is that the new policy with emphasis on the private sector
and reliance of the market will help the big manufacturers
using the continuous spray mixing technology and sophisticated
packaging to prevail over the others. It is feared that the
crystal salt manufacturers (mostly small manufacturers and the
public sector) will be pushed out of production. There would
be an inexorable shift towards refined salt aided by the regula
tions and policies followed. UNICEF, the active partner of
the GOI in the implementation of the programme says in a
document, “A lot of the salt in India is in crystal form.
11
Historically consumers have bought only crystal salt. It Is
proposed that the common salt will be crushed before iodation.
This would be achieved in a phased manner and consumer
education will be undertaken to change consumer prefe
rences.”6
The final result would be that instead of salt now being
sold at 50 paise/kg, it would cost a minimum of Rs. 1.5/kg. This
would cost the consumer a minimum of Rs. 500 crores annually.
In other words, the Government would take Rs. 500 crores from
the poor citizens in whose name the policy is being pushed
through and pass it on to the monopoly sector of Indian private
industry.
Cost to the Government
The Government has comitted an estimated Rs. 210 million
for. the programme in the 7th plan.
further Rs. 125 million is
the projected cost for the 8th plan period excluding the recurrent
costs of the staff, subsidy and other inputs. Furthermore, all
the iodine required for the programme would have to be
imported and paid for in foreign exchange. It is only natural to
ask whether this kird of expenditure would not have been more
worthwhile if it was spent to make the already existing goitre
control programme in the endemic areas a success.
Fute of the endemic areas
If the proposed increase in iodised salt manufacture does
not keep up with the schedule, there is the real danger that the
supply to endemic areas will worsen. Previously, the flow of
iodised salt was .from the production centres to the endemic
areas. Now with the policy of universal iodisation, it would be
easier and more profitable for the private manufacturers to sell
the higher priced salt in the metropolitan and well developed
markets. We may sec a situation where people who really need
the product do not get it, while those who do not need it get
surfeit of the same. This situation already exists for several
products like drugs.
Perhaps, anticipating this, ft has been recommended that in
the interim period (ie. till iodised salt manufacture attains'
necessary levels) the people in the endemic area be covered by
12
injections of iodised oil.6 But it has been pointed out that this
would be prohibitively costly besides requiring large imports.
Moreover, it is strange to suggest that -'areas which are
’inaccessible’ to common salt would be easily accessible to
periodic massive injection programmes!3
The ‘Scientific’ Backbone of Universal Iodisation
The universal iodisation policy, if pushed through as it is,
will be done at tremendous social and economic cost. But the
bitter pill would have to be swallowed willingly, had the scienti
fic argument in its favour been so strong as to make it imperative.
Faced with any criticism of their policy, the authorities would
take cover behind the shield of ‘learned scientific opinion’. It
is worthwhile to examine how foolproof the scientific arguments
in support of universal iodisation really are.
Virtually all the studies forming the basis of the new policy
have been done by a handful of scientists-mostly in the All
India Institute of Medical Sciences. The claim is that they have
uncovered several new facts which challenge the conventional
wisdom.
The Conventional Wisdom
The conventional wisdom till the late seventies has been
that a programme for the prevention of endemic goitre can be
justified only in terms of health. If endemic goitre were merely
a cosmetic problem there could be little justification for govern
ment action. However large nodular thyroids may cause
obstructive symptoms and may be subject to malignant changes.
In addition, when endemic goitre is severe, endemic cretinism is
also found.
Leading from this question was posed as to what level of
endemic goitre or endemic cretinism justifies a prophylactic
programme. Obviously the criteria accepted would vary accor
ding to the socio-economic situation of a country. Methods for
grading goitres in surveys were developed whereby all goitres
were graded on a scale from 0 to 4.10 In general, it was sugges
ted that a 5% incidence of Grade I goitre in pre-or peri-adolescent
school children or a 30% incidence of goitre in the general
13
population would certainly warrant some action; the presence in
the populalion of 1% persons who could be classified as cretins
would demand early and urgent action.’
Challenge of ‘new evidence'
The bedrock of the new policy is the purported new evidence
unearthed by studies done in India. The main line of argument
is more or less as follows.
1. Previously it was thought that an adaptively enlarged
thyroid gland compensated for iodine deficiency by stretching
its capacity to put out enough thyroxine to meet bodily needs,
i.e., the patients are 'euthyroid’ (thyroid function normal). It is
now claimed that more than half the goitrous persons in the
severely endemic areas were ‘hypothyroid’ or that they had
thyroxine deficiency.11
2. Sub-cretinous brain damage occurs in endemic populations
in addition to overt cretinism.13 The argument is that even in
areas with no increase in the rate of cretinism, children have
subnormal intelligence and this can be detected by IQ tests. The-’
problem of mental retardation may be much more extensive than
was inferred originally from the observation that only less than
one percent of children in goitre endemic areas suffer from
cretinism. Recent studies reveal that 15% of children could be
suffering from varying degrees on mental retardation?
3. The risk for such subnormal intelligence can be assessed
by screening new borns for thyroxine deficiency. By such
methods, in the severe endemic areas, as much as one in six new
borne is found to be thyroxine deficient at birth.
4. Newer endemic areas in India are being found in surveys
and the cause for endemic goitre in these areas is also iodine
deficiency.11
5. Prophylaxis of endemic goitre is best done by iodising
salt. Excess intake of iodine will not be a problem given the
current levels of intake in any part of India.11
Each thread in this line of argument needs to be examined
in detail.
14
I. The claim of hypothyroidism in Himalayan endemic goitre
The most quoted study in support of this claim is one by
Kochupillai, et al., published in 1973.13 This article is cited
often and with an air of finality to the claim that as much as
60% of the goitrous individuals are decompensated and
subthyroid.14 13
In reality all that the study shows is that the mean levels of
TSH hormone is increased in the 26 goitrous subjects studied
when compared to controls in England. In fact, the mean
thyroxine (T4) levels were higher (significantly so in grade I
goitres) when compared to the same controls. In a classical
example of double talk, the authors try to dismiss this by saying
that it is possibly due to the fact that the controls were from
England! True, the authors find that the effective thyroxine
available (represented by the values of ETR) is slightly reduced.
But the most important point actually seen from the results but
only cursorily discussed is the fact that th; second type of
thyroid hormone called T3 is significautly elevated in the
subjects when compared to the controls.
Now, what happens is that the thyroid enlarges in response
to the increased secretion of the pituitary hormone TSH and
makes more economical use of the iodine available by prefer
ential secretion of triiodothyroxine (T3) which is metabolically
more active than thyroxine but contains less iodine (three atoms
per molecule as compared to four for thyroxine).l6,17 In these
persons the normal function of thyroid is thus maintained.
There is a tendency among some endocrinologists to use
the term ‘stibclinical hypothyroidism’ in subjects with normal
thyroxine and elevated T. S. H. But this is apparently a misno
mer. To quote an eminent endocrinologist, “I question the
wisdom of referring to patients with normal circulating thyroid
hormone, but elevated serum TSH values as suffering from
subclinicai hypothyroidism’. Hypothyroidism to my mind is a
state in which there is inadequate supply of thyroid hormone to
the tissues ..I would prefer the term inadequate thyroid reserve
in analogy to other endocrine axis ’’ 1B
15
The misnomer becomes positively misleading when used in
the lay press to whip up support for a policy as Kochupillai has
done.1
Some other attempts to present the above quoted study as
something of a landmark, again reveals a misleading propagan
dist streak out of place in a scientific article. For example, it
is said of the 1973 study, “this was indeed disturbing information
and lead to an editorial comment in Lancet about ‘Theory and
Practice of Endemic goitre.”14 A close reading of the said
Lancet editorial 16 finds the work mentioned among many
others. It was certainly not the sole inspiration, nor was the
main theme of the editorial the same.
2. The case for subclinical cretinism
In the mountainous terrain of the Himalayas there are
pockets where endemic cretinism is seen in 1-4% of the popular
tion. Even higher figures are reported from parts of Nepal.1
But elsewhere in the sub-Hiinalayan endemic areas the
incidence is uniformly below l%.3 In the supposedly new
endemic areas being uncovered, endemic cretinism is not seen at
all. But suppose iodine deficiency produces milder forms of
mental retardation (the so-called “subclinical cretinism” a la
sub-clinical hypothyroidism that we have just examined). It
then becomes a powerful and emotive argument for ramming
down the new policy (the unseen drain of brain power of our
future generations, etc.). So sub-clinical cretinism enters into
the vocabulary and if it did not exist, it had to be invented.
The methodology adopted for proving the new hypothesis
involves development and intelligence testing. This approach
is highly controversial and has been so riddled with a priori
assumptions, conscious fraud and politics, that its very value
and scientific objectivity has been seriously questioned.10,’1
In one such study, exactly 26 children of goitrous mothers
are compared with 20 controls by using the Gesscl development
score.11 It is then concluded that the development quotient and
language development are lower in children of goitrous
mothers. The mean DQ for the controls is 98.4 and that for
others is 94.4. Using a convenient statistical test tt-test) this
16
has been shown to be a significant difference and profound
conclusions drawn.
Apart from the conscious fraud resorted to by the likes of
the great Cyril Burt, which put mental testing into much disre
pute,” there are unconscious and theoretical errors which
nullify its scientific value. One such is ‘reification , ie., the
belief that anything given a name (like intelligence) is a thing
which can be measured on a metric scale, like height or weight
and can further be used for comparing people. The fault in
logic in the case of intelligence and developmental tests is clear.
The fact that it is possible to devise, tests on which individuals
score arbitrary points does not mean that the quality being
measured by the test is really metric. The illusion is provided
by the scale. The ordinal scale is ane arbitrary one and most
psychometric tests measure ordinals of this sort. A person with
an I.Q of 100 is not twice as intelligent as one with an I.Q of
50.24 Thus the statistical tests used to compare small differences
in scores are inappropriate.
A second criticism often levelled against these tests is that
strong a priori assumptions alter the result even in the absence
of a fraud. The tests do not represent the application of a neutral
instrument, a test, by an objective tester, to a testee whose per
formance is being measured. Rather, the results of a test are
themselves the products of a three way interaction between the
tester, the test and the testee. The tester’s expectations of the
testee’s performance may itself modify that performance.25 It is
seen that black children score better on IQ tests administered by
a black (or even by a computer!) than by a white.26 This tester
bias has led to such monumental errors as classifying the blacks
and Asians as less intelligent than whites, women as less intelli
gent than men, and so on.24
Another important source for error is the socio-cultural bias
of the tests themselves. In a country like India no single test
may be appropriate for all the regions. Yet using such a test
battery children in Gonda have been branded less intelligent than
those from the average Indian village.27 This is a slipshod work,
to say the least. No controls seem to have been tested at all.
Instead, the normal values provided by the tests’ designers
17
have been taken. Performance in intelligence tests especially
for those who score between 50 and 75 are strongly influenced
by factors like material deprivation, poor educational facilities,
family instability and lack of mnetal stimulation.” Yet we find
here supposedly serious scientists testing children from one of
the poorest regions of India without even bothering to set up a
control and branding them as subnormal. And to add to the
original errors they unquestioningly attribute low scores to iodine
deficiency without caring to look for other socio economic
variables which could have given the same result.
The claim for sub-cretinous mental retardation is not
supported by hard evidence. If indeed it is present in such high
proportions, it is indeed strange that it is not accompanied by a
concomitant increase in clinical cretinism. The studies done by
‘convinced’ scientists using faulty and careless methods seem
more like propaganda for- their pet theme rather than real
science.
As of now, the following comment by Clements in 1960
seems to be still valid. “Mental deficiency without the other
stigmata of cretinism has sometimes been considered to be a
sequel of endemic goitre. Most of those who have made this
claim have not had close association with endemic cretinism.... Extensive investigaiions of mental defectives in non-goitrous
areas have failed to show any connection between thyroid
function and mental deficiency. There seems to be no justifi
cation for the statement that one of the sequels of endemic
goitre in the progeny is uncomplicated mental dificiency.”
Neonatal chemical hypothyroidism
Proceeding from the assumption that milder forms of
mental retardation due to iodine deficiency exists, neonatal
screening for thyroid status was organised in selected areas to
detect those at risk.15,27
The indigenous development of
effective technology to accomplish this was a commendable
effort. But the conclusions drawn from the studies are open to
question.
In this study, the cord blood of newborns from the severely
endemic areas were examined for T4 and TSH and compared
with blood controls from Delhi and Kerala. Using standard
criteria, it was found that 7.5% in Gonda and 13.3% in Deoria
were hypothyroid, while there was no significant neonatal
chemical hypothyroidism in Delhi or Kerala.”
It is known that in iodine deficient areas, some children
may be born with what is called ‘transient neonatal hypothyroi
dism’. This abnormality is characterised by low serum T4 and
high TSH concentrations and spontaneously coirects itself over
five to six weeks.” In Europe, transient neonatal hypothyroi
dism has been related to iodine deficiency, since the incidence
seems higher in regions of endemic goitre.30,’1 In one series
of Belgian newborns, the prevalence of transient hypothyroidism
was I2%.” Most cases occurred in premature infants.” The
prevalence was 26% in infants under 32 weeks and about 5% in
term infants. Significant levels of transient neonatal hypo
thyroidism has been reported from Sicily.”
In the studies quoted from India no attempts have been
made to note the proportion of those with transient hypothyroi
dism.
There is further no attempt even to quantize the
proportion of premature infants Two of the articles published
in 1984 are clear examples of evasion of the issue.1'*, 13
Transient hypothyroidism is not even mentioned in the discus
sion. It is difficult to believe that the authors were unaware
of the condition which has been described as early as 1973.
However, in one of the articles13 the book containing a
discussion on the subject is quoted in the bibliography in
another context.30 This is an example of the kind of intelle
ctual dishonesty that is seen in much of the work on iodine
deficiency goitre in India.
The problem of transient hypothyroidism is acknowledged
in the discussion in a later paper by the same authors ”
(probably inserted after peer review). In it they admit that it
could be important in iodine deficient areas but that they did
not look for it because they considered it unethical to follow up
these babies without treatment. Again, it is unlikely that they
were unaware of the studies in which the babies were given T3
and followed up. In transient hypothyroidism the T4 gradually
rises under such conditions in a matter of weeks, whereas in
19
permanent hypothyroidism it does not.30 Thev could have easily
tried this in at least a subset of these cases, instead of starting
them on thyroxine.
;
Transient hypothyroidism should have been specifically
looked for especially in areas like Gonda and Deoria of eastern
UP where a higher proportion of birth complications and
prematurity is likely among the hospital deliveries. In the,
control areas of Delhi and Kerala this proportion would be much
less, because even most of the normal deliveries there take place
in hospitals.
Further, it is not a good policy to put babies with transient
hypothyroidism on prolonged thyroxine treatment becauseof the'
danger of neonatal hyperthyroidism.34 There is also some
evidence that in neonatal hypothyroxinemia (low T4, high TSH).
found in iodine deficiency environments, compensatory increase
in T3 is encountered and the babies are compensated.31
Undoubtedly, more studies need to be done in this area'
before firm conclusions and drawn. But one thing which has’
to de noted even at this juncture is that the control areas, among
which Delhi has been claimed to be a new endemic area, are
remarkably free from neonatal hypothyroidism, whether transientor otherwise.
The new endemic areas
Starting from the fifties and til! the seventies, the figures'quoted for goitre incidence in India were 40 million people
exposed, with 9 million having goitre.1. Then in the eighties, I
almost simultaneously with the beginnings of the new policy,’• we"see a quantum jump in the estimates. The newer estimateshave
the exposed population at 12C million with goitrous populationof 40 million.36 Even higher figures of 300 million exposed
and 60 million goitrous are sometimes bandied about.37
There is reason to believe that the new figures are part of a '
campaign based on gross exaggeration. It is gencraly part of '
an effort to impress’the decision makers—political and bureaucra
tic—and to gain public acceptance for the new policy. It is based
primarily on the surveys conducted in ditterent parts of the--
26
country followed by blind extrapolation of data using faulty
mathematical models.
It is now claimed that out of 132 districts studied, 122
provided evidence of iodine deficiency goitre. But there is no
indication that these 132 districts or the- areas surveyeci were
randomly selected, On the contrary, there is reasouTo~betievethat th ese areas were selected because they were- suspected to
be endemic for iodine deficiency. Extrapolation from these to
arrive at total figures would be highly fallacious. It has indeed
been claimed that the actual figures for the number of IDD in
South-East Asia (which includes India) have probably been
overestimated by a multiplicatory factor somewhere between
3 and 6 due to the bias in the mathematical models used.38*
Moreover the lay public including the decision makers are
misled in another more subtle way. They are told in an article
that there are 40 million goitrous people, often accomanied by
a photograph of a person with a large neck swelling. The
overall impression sought to be conveyed is that there are 40
million such people in the country. As a matter of fact the
vast majority of the supposed goitrous people have thyroids
which cannot even be seen. Even considering the figure of 40
million to be true, calculations made from the rates of various
grades of goitre in the [different surveys3’-*1 show that the
visible goitres will not exceed 4 million.
The clinically
significant cases causing cosmetic problems will not exceed 0.6
million. If there is a four fold overestimation in these figures,
the actual figures would be: total goitrous 10 million, visible
goitres 1 million and those producing clinical problems 0.15
million.
- ■.
These projections are made on the assumption that the
percentages of goitrous people obtained in the different surveys
are true. In reality, the surveys are liable to considerable bias
and variation.' It has been mentioned that the large majority
of goitres detected in such surveys are not visible but palpable
only. Any thyroid thought to be enlarged on palpation (a
swelling as big as the terminal phalanx ol the subject’s thumb)
is taken as a grade I goitre.43 This is highly subjective. When
the surveyors are convinced of a high prevalence in an area.
21
this leads to unconscious inflation of the percentages. Palpable
and visible goitres can be overestimated in individuals with thin
necks or poorly developed sterno-mastoid muscles.’ This it
another source of error in a poorly nourished population
like ours.
In the last few years one thrust of argument has been that
endemic goitre is no longer a problem of the sub-Himalayan
region alone and that it is widely prevalent in other parts of India
also. Surveys purporting to back this claim,are few in number
and subject to the same drawbacks mentioned above. The chance
of error is greater because in almost ail these surveys the results
indicate only mild or moderate endemicity (prevalence below
50%.. The fact that such studies are limited to few isolated
Fig. 2. Goitre endemic areas in India (Ref. 3)
22
pockets has not prevented fantastic clamis being made. Even
the maps have been redrawn to show the new found widespread
prevalence of endemic goitre in India (figure 2). These maps
are patently dishonest. For example, few isolated pockets in
Maharashtra have been surveyed. This has led to the whole
state to be shaded and shown as endemic goitrous.
'J' ' One way of checking the veracity of these survey results is
Sy reference to exacting biological data like that of iodine
Excretion in urine. Urinary excretion of iodine as a proportion
of the excretion of creatinine (iodine/gm of creatinine), when
properly done, is a good measure of iodine intake.42,44 Mean
values of less than 50 /'gms/gm of creatinine in a population is
indicative of moderate iodine deficiency. Values less than 25
/'gms indicate severe deficiency. This can be tested on casual
urine samples and is thus a relatively easy procedure.42 Yet
very few such studies are available from India. The occasional
study from areas outside the sub-Himalayan belt shows no
evidence of severe deficiency. The results of some studies
flatly contradict the results of the survey, thus casting doubts on
4he reliability of the survey results. For example, Krishnamachari
, reports severe endemia from Maharashtra, ie., a 52% prevalence.
But the urinary iodine/gm of creatinine in that population ranges
from 52 /'gins to 141 /'gms. Even the iodine content ofdrinking
water in the area is normal. Yet it is one of the surveys based
on which the whole of Maharashtra is shown as endemic goitrous!
Pandav, eb al. report a- goitre incidence of 55% from
Kalkaji and Chandui Chowkareas of Delhi. But this does not
correlate well with their finding of mean urinary iodine/
creatinine value of 48 gm/gm.4n They argue that this figure is
artificially high because of the probability of low creatinine
excretion by smaller Indian children. They say that the figure
of 50/'gm/gm as the cut off point for endemic iodine deficiency
was proposed for Western children and that this would exceed
by 20 30 percent the values appropriate for their Indian
counterparts Here they arc in error, for the value of 50 /'gm/
gm of creatinine was proposed by Follis, et al. based on their
findings in the Songkhla province of Thailand. There is no
reason to believe that it would be substantially different from
the Indian mean values.4’
23
There is, however, need to standardise the iodine excretion
values in the Indian population for getting comparative data.
Differential values for boys and girls may be calculated depen
ding upon their body weight.
*
’ It has been suggested that
measurement of iodine concentration alone in urine is sufficient
especially for monitoring control programmes.
*
’ Whatever it
is, iodine deficiency is best monitored and graded by measure
ment of urinary iodine excretion. Very little of such work has
been done in India especially outside the Himalayan belt. No
attempts have been made to standardise the values. Wherever
goitre really exists significantly and iodine excretion does not
reflect the degree of deficiency to account for it, goitrogens
have to be looked for. Such diverse things as contamination
of water by sewage, organochlorine pesticides, and thiocyanate
in tubers are blamed in this context.
*
’,50 Studies along these
lines from India are singularly marked by their absence. There
is reason to believe that blind extension of the studies done in
the sub-Himalayan endemic to the rest of India may prove
counterproductive in the long run.
The question of safety
The most hotly debated issue in the new policy concerns
the safety of iodine prophylaxis.
Two extreme views are
generally held. On the one hand, it is held that iodation of
salt can produce as many problems as it solves and should not
be resorted to at all. The supporters of the policy, on the
other hand, dismiss out of hand any reports regarding the
complications. Pandav, et al., mention allergic reactions to
iodine, iodine induced hyperthyroidism, iodism and iodide
goitre as the generally reported complications. They then
proceed to demolish the claim for allergic reactions without
discussing the others at all.31 Kochupillai in an article claims
that upto 400/' gms intake of iodine is not only sate but salu
brious.11 As with most extreme polemical views, the truth
resides somewhere in between.
It is absolutely true that allergic reactions to iodine and
iodism occur due to administration of pharmacologic doses of
iodine and is absent in the usual prophylactic programmes.
But the following complications need to be given serious
24
thought: a) Iodide goitre b) Iodine induced thyrotoxicosis
c) Sequelae of possible increase in salt intake.
a) Iodide goitre
It is well known that pharmacological excess of iodide can
produce goitre.31 Extremely high intakes of iodide can produce
endemic goitre as seen in the Hokkaido coast of Japan where
it is due to high intake of the seaweed ‘Kombu’ in soup.33
But can it also occur as the result of a prophylactic programme?
The answer seems to be a qualified ‘yes’. It appears that
milder forms of endemic goitre can be a result of prophylaxis
with iodised salt. A survey conducted in four areas of U. S.
in 7785 children showed an overall goitre prevalence of 6.8%.
In Michigan state the prevalence was 9.8%. These endemic
levels are seen many decades after the introduction of the salt
iodisation programme. In all these areas iodine intake was
more than adequate with a mean urinary iodine excretion of
452 jUgm/gm of creatinine. More interestingly it was found
that children with goitre and areas with high goitre prevalence
tended to have higher rather than lower iodine excretion.34 A
ten-state nutrition survey of 35,999 people in the US similarly
found a higher prevalence of goitre among persons excreting
high levels of iodine.33 The same study found an overal
prevalence of 3.1% wiih a high of 7-2% in Calilfornia.
It can however be argued that the overall incidence of
goitre in the U. S. was much higher prior to salt iodisation.
While this is no doubt true of the US, it is by no means the rule.
For example, there are reports that in Iran and Iraq the incidence
of goitre among school children increased after prophylactic
use of iodide.36 It is worth noting that such iodide goitres are
mainly reported from US and countries which have followed the
US in using high levels of iodide in their salt iodisation
programmes.
b) Iodine induced thyrotoxicosis
Mild iodide goitre produced by salt iodisation programmes,
if and when it occurs, is only a minor public health problem.
But thyrotoxicosis, ie , disease due to hyperfunctioning of the
thyroid gland is much more serious and caqnot be dismissed
lightly.'
25
Iodine induced hyperthyroidism, the so-called Jodbasedow
effect has been the subject of many reports since the beginning
of this century. Early reports noted the precipitation of
hyperthyroidism in goitrous patients who were administered
large doses of iodine. Iodisation of salt in parts of the U.S.
in the 1920s seems to have been followed by a temporary
increase in toxic nodular goitre (one form of hyperthyroidism).
•While the earlier reports were all in those receiving high doses
of iodine, it was convincingly shown that physiological doses
caq_also provoke toxic, goitre. This was done in a study from
Tasmania where a prophylactic programme based on iodation
of bread was initiated in 1966.5’ The incidence of thyrotoxicosis
in Tasmania showed a steep rise in 1966 and~tbis higher
incidence was maintained in 1967 and 1968. The increase was
evident after iodation of bread was begun.
In defence of iodation programmes, it is, however, pointed
out that the outbreak of thyrotoxicosis in Tasmania occurred
predominantly in old people with longstanding nodular goitres.
It is also known that the iodation of bread was effective in
bringing down the levels of goitre in the community5" so that
such forms of thyrotoxicosis disappeared along with endemic
goitre from the region eventually.
This argument is reasonable to a certain limit. In an are
*
where there are cases of endemic cretinism a few cases of thyro
toxicosis may seem a small price to pay for getting rid of a
graver problem. But what about areas of moderate or mild
deficiency where endemic cretinism is not seen at all?
It has also been stated that iodine induced hyperthyroidism
is not seen in the Indian endemic after initiation of prophylaxis.
This is assumed to be due to the younger age structure of the
population. But this claim cannot be accepted blindly. Has
the surveillance for thyrotoxicosis been conducted at all? Who
detects the random cases of toxic goitre occurring in far flung
backward areas?
Thyrotoxicosis occurring as a temporary phenomenon in
certain individuals in a goitrous population may be acceptable,
provided the prophylaxis that induced it finally gets rid of it.
26
This was the comfortable assumption till recently. But what
about the non-eudemic non-goitrous areas? Can there be an
increase in thyrotoxicosis in such a population as well? If so it
would be a definite point against introduction of iodistation of
salt in the non-endemic areas.
Recent studies in England show that the peak of onset of
thyrotoxicosis occurs in the winter months.” This has been
shown to correlate with winter peak in milk iodide concentr
ations which in turn correalates with the urinary iodine
excretion.60 Milk provides about half the adult iodine intake
in Britain in winter. The higher content of iodide in milk in
winter is because the cattle are fed solely on cattle feed enriched
with iodine and there is no grazing during the period. The
urinary iodine excretions are not (particularly high, with a
median of 106 /'gm/gm of creatiuine. The study expresses
concern that an excess of iodine may be harmful to some indivi
duals and asks whether an alteration of iodine levels in cattle
feed should be considered.60
The whole question of levels of iodisation is also likely to
be reopened by such findings.
High levels of iodisation as
practised in the USA and sought to be implemented in India
may not be so salubrious after all.
e) The possibility of increased salt intake
Problems like hypertension can be precipitated by increase
in the salt intake. In many Western nations the salt consumption
is coming down as a result of this awareness. In India, however,
the way iodised salt is sought to be popularised raises genuine
fears whether it will not lead to an increase in salt.consumption.
Iodised salt is presented almost as a restorative tonic with
wondrous powers. Companies advertise freely claiming that
anything from dullness to squint is due to iodine deficiency and
that iodised salt is the cure for it, A private company has
recently begun an advertising campaign presenting iodised salt
as a "healthy food”. There is no medical ethical justification
for this type of action.4’ Even the Government is made to join in
this unethical, unscientific marketing blitz. A comic book shows
a boy performing badly in school and dropping catches in
27
cricket. After consuming iodised salt he is transformed into a
brilliant student and a cricketing hero. After reading such stuff
how many mothers will be able to resist adding that little extra
salt to their children’s food? The most unfortunate bit is that
the said publication is by the Health and Family Welfare deparment of the GOI.61
Towards an Alternative Strategy
The present strategy of universal iodisation is one in which
the costs are borne by the consumers and the benefits accrue
to the monopolies. The real costs are likely to be higher than
envisaged. The costs presently calculated do not take .into
account the recurring expenditure for maintaining a vast net
work for quality control and underestimates the cost for
several items like import of iodine. Further more, the programme
is not likely to succeed because the focus has shifted from the
areas of severe endemicity. The whole programme is wasteful
of resources and unmindful of priorities facing the nation.
There is no appreciation for the opportunity cost of iodisation
ie., what other programmes with possible impacts on health,
such as immunisation or provision of safe drinking water, could
achieve with the same money. The scientific data presented in
support of the policy is open to question. Clearly an alter
native strategy is called for.
Scientists are often trapped in the quagmire of their own
reductionist thinking. This leads them to propose simple
‘technological fixes’ for problems of complex socio-economic
origin. The failure of National Nutrition Programme to solve
the problem of malnutrition and of National Blindness Eradi
cation Programme to solve the problem of Vitamin A deficiency
should have been eloquent pointers. But no lessons seem to have
been learnt. Waiting in the wings of future technological
fixes are fortification of salt with iron for anemia and a host of
other similar reductionist solutions.
Endemic goitre too is a problem with socio-economic,developmental and ecological causes. These have to be under
stood properly and solved sincerely. Iodine deficiency of soil
is related to flooding, deforestation and soil degradation possibly
related to the newer agricultural technologies. A programme
29
to combat iodine deficiency should essentially contain flood
control measures, checking deforestation, soil improvement,
proper use of pesticides and fertilisers and general eco-restoration. These measures will also help the people in more ways
than simply reducing the incidence of goitre.
It is also know that lack of food exchanges are important
in the causation of severe endemic goitre and endemic cretinism.
This is also a question of development. It has been noted in
Mexico that the simple measure of building a road in an inacce
ssible area resulted in more of food exchangesand disappearance
of endemic cretinism. Development and ecology are thus the
keystones of a permanent solution to the problem of IDD.
This is not to say that a salt iodation programme has no
role. In the severely endemic areas one cannot wait for the
general development to occur first. The birth of babies with
endemic cretinism is a tragic waste of human resources. In
fact this is the problem that needs to be tackled most urgently.
Areas of severe and moderate deficiency (which occurs in the
subr-Himalayan belt) can be tackled best by a program me limited
to those areas. In fact, focus should not be allowed to shift
from these areas by the imperatives of the free market economy.
This calls for revival and strengthening of the old National
Goitre Control Programme. The anomalies discussed earlier
need to be corrected and efficient implementation ensured.
Increased production of iodised salt throught the public sector,
vigorous quality control along with proper administrative
measures to check entry of iodised salt and a proper. public
health education campaign in those areas should be the corner
stones of such a programme. Subsidy may be given at the level
of the retailer or the consumer to bring the price of iodised salt
at par with that of ordinary salt. In the most severely affected
pockets with that high rates of endemic cretinism, provision of
iodised oil to expectant mothers could be considered. This can
be done through the PHCs and can be integrated with the
maternal and child health programmes.
Further studies to assess the problem in different parts of
the country accurately are needed. Such studies should be based
29
on the incidence of endemic cretinism and on urinary iodine
excretion parameters. The problem of goitrogens in natural
foods and in synthetic chemicals should also be subject of study.
The problem of IDD in India offers no easy solutions.
Rather than instant bravado and shotgun solutions, a mature
and realistic assessment of the whole problem is what is required.
A national debate involving scientists, social workers, econo
mists and politicians is called for.
REFERENCES
1
Ramalingaswamy V: Endemic goiter in Southeast Asia: Ann. Inter
Med: 78: 277, 1973.
’
Stanbury J B et al: Endemic goilre and cretinism: Public health
significance and prevention: IV/10 Chronicle, 28: 220, 1974.
J Subramanian P: National Goitre Control Programme—Current
Status. Bull NFI, July 1988.
• Gopalan C: The National Goitre Control Programme—A Sad Story.
Bull NFI, 2 (3) 1981.
5 Gopalan C: Prevention and control of endemic goitre.
(4) 1986.
Bull NFI,
6 UNICEF: Iodine deficiency disorders control programme India propo
sal fcr supplementary funding. 1988—92.
1 Kavadia PM in Economic Times, Bombay 25-2-1988.
8 UNICEF: Iodine deficiency disorders, (Booklet).
’ Stanbury J B: in Endemic Goitre, Geneva (WHO monograph series)
1960.
>0 Perez C et al: Technique of endemic goitre surveys.
Goitre, Geneva (WHO) p 369, 1960.
'*
Kochupillai N: National Policy to Iodise Salt.
Winter 1987—88.
In Endemic
Future.
22-23:39
13 Editorial: The National Med J of India, 1 (6), 1988.
13
Kochupillai N. et al: Pituitary thyroid axis in Himalayan endemic
goitre: Lancet, 1:1021, 1973.
14
Kochupillai N (Editorial): Ind Pcdiatr: 20: 467, 1983.
15
Kochupillai N, el al : Neonatal thyroid status in Iodine deficient
environments of the sub Himalayan region. Ind J Med Res: 80:293,
1984.
16
Editorial—Theory and Practice in Endemic Goitre: Lancet,
1975.
1:619,
*’ Editorial—Triiodothyronine: Lancet, 1: 898, 1971.
18 Editorial Comment in Year Book of Endocrinology,
Publishers, p, IJ9, 1986.
Year Book
t» Kochupillai N. in Mathrubhoomi, Malayalam daily, March 1989.
Karnin, L J: The Science and politics of IQ, Harmondswortb,
Penguin 1977,
31
Gould, S J :
1981.
The Mismeasure of Man, New York, W. W. Norton,
11 Upadhyay, S K, el al, : Developmental lag in pre-school children of
goitrous mothers. Ind Pediatr 20:259 1983.
33
Hernshaw L S, Cyril Burt—Psychologist
*.
Stoughton 1979.
London,
Hodder and
3* Rose S, in Not in Our Genes: Biology, Ideology and Human Nature,
Harmondswor-tb, Penguin 1983.
,s Rose S; in Designer Genes: Selangor: Indian, page 43.
26 Watson P, in Race, Culture and Intelligence.
27
Kochupillai, N, et al : Iodine Deficiency and Neonatal Hypothyroi
dism. Bull WHO. 64 (4) 547, 19 86.
28
Editorial—Inequalities revisited : Lancet, 1: 200, 1984.
29
Fisher D A, Klein A H : Thyroid development and disorders of
Thyroid function in the newborn. .Vrw. Eng. J. Med, 304:12, 1981.
30 Delange P, et al: in Neonatal Ihyroid Screening, Burrow
Dussault J H eds : New York, Raven Press, p 107, 1980.
31 Heidemann P, Stubbe P : J. Clin.
JN
Endocrinol. Metab, 47:189, 1978.
32
Delangc F, et al : Increased risk of primary hypothyroidism in
preterm infants : J. Paediatr. 105:462, 1984.
33
Sava L, et al: Transient impairment of Thyroid function in .new
borns from an area of endemic goitre : J. Clin. Endocrinol. Metab.,
59:90, 1984.
34
Editor’s column : Thyroid hormone replacement therapy in ■ the
perinatal period. Neurologic considerations. J. Paediatr, 92:1035
*
1978.
33 Clements, F W, in Endemic Goitre, Geneva (WHO), p 257, 1960.
36 Pandav, C S, Kochupillai, N ; Endemic goitre in India : Prevalence,
etiology and control measures : Ind. J. Pediatr, 50:259, 1982.
37 Guha A K, et al: Endemic Goitre in India, Swastha Hind, 25:37,
1981.
384 Glugston, G.. et al: Iodine deficiency disorders of Southeast Asia in
Prevention of Iodine deficiency disorders, Elsevier, Amsterdamp 49,1987.
38
39
Agarwal, D. K, Agarwal, K. N: Current status of endemic goitre in
some areas of sub-Himalayan belt. Ind. Pcdiatrt 20:471,1983.
Agarwal, D. K, et al. Current statu? of endemic goitre in District
Bharuch (Gujarat), Ind. Pediatr, 2P:I79, 1983.
32
40
Pandav, C. S, et al; Endemic goitre in Delhi, Ind. J. Med. Res. 72:81»
1980.
41
Dudani, T. G, Natu, M. N: Epidemiology of goitre in Ghodcgaon,
Ind. J. Med. Res. 13:980, 1978.
<42
Thilly, C, H: in Children in the tropics, Paris, International Child
ren’s Centre, p. 6.1988.
43 Edibam, H. H, et al\ Endemic Goitre in Narmada Valley in Broach
district Gujarat, Ind. J. Med. Sci, 26:218, 1972.
44 Dwivedi, M. P: Survey of sub-Vindhya belt of Endemic Goitre;
Swastha Hind, Aug: 186, 1978.
45
Trivedi, D. H, et al; Ind. J. Com Med, IV: 23, 1979.
46 Vought, R. L, et al: J Clin Endocrinol, 23:1218, 1963.
47 Krishanmachari, K. A: Endemic Goitre, A public health problem in
Maharashtra: Trop Geogr Med. 26:147, 1974.
4b Follis, R. H, et al; Studies on Iodine Nutrition in Thailand: J. Nutr,
76:159, 1962.
49 Jolin T, Rey, F. E: J Clin Endocrinol Metab. 25:540, 1965.
so Matovinovic J; Ann. Rey. Nutr, 3:34, 1983.
51
Pandav, C. S, et al: Recommended levels of salt iodisation in India.
Ind. J. Pediatr, 51:53, 1984.
52
Wolff J; Iodide goitre and pharmacological effects of ex cess iodide.
Am. J. Med, 47:101, 1969.
S3
Suzuki, H. T, et al; Endemic Coast Goitre in Hokkaido, Japan,
Acta Endocrinol, 40:161, 1965.
54
Trowbridge, F. L, et al;
56:82, 1975.
55
Trowbridge, F. L, et al; Findings relating to Goitre and Iodine in the
ten-state nutrition survey. Am. J. Clin Nutr, 28:712, 1975.
56
- Coghcy, J. E: The Spectrum of Iodine malnutrition and suggested
management, Acta Endocrinol, (Suppl.) 74:179:11, 1973.
Iodine and goitre in children, Pediatrics,
37 Conolly, R. J, et al; Increase in thyrotoxicosis in endemic goitre area
after iodation of bread. Lancet, 1:500, 1970.
5« Clements, D. W, el al: Lancet, 1:489, 1970.
59 Philips, D. W, et al; Iodine in milk and the incidence of thyrotoxi
cosis in England, Clin Endocrinol, 28:61, 1988
60 Nelson, M, et all Urinary iodine excretion correlates with milk iodine
content in seven British towns, J. Epidemiol. Comm. Health,
42:72, 1987.
•1 'Jugnu Aur Jadool'Namak'.
Welfare Dept. GOI,
Comic
book.
Health
and
Family
ACT NOW !!!
PARTICIPATE IN POLICY DECISION MAKING
*********
The Ministry of Health (GOI) has issued a preliminary notification on 10 May
2000 concerning a future withdrawal of the compulsory statutory iodisation
of salt and has invited views and suggestions from the general public
within 45 days.
No State in India is free of iodine deficiency. Protect the people of India
and its future generations from mental retardation by supporting universal
salt iodisation.
Write to the Secretary Health, Ministry of Health and Family Welfare,
Nirman Bhawan, New Delhi 110 011, before 23rd of June and express your
solidarity in support of the compulsory statutory iodisation of salt.
Thank you.
Universal Salt Iodisation (USI) in India :
Issues, Facts, Implications and Recommendations -1
Issues
Facts
Implications
Recommendations
I) Iodised Salt
1) Govt, own policy decision 1) A Retrograde step, sinking 1) Continue with Universal
Compulsory OR Choice? in 1984 taken by Central 50 years of research and Salt Iodisation
Should
we
have
compulsory
Universal Salt Iodisation
(USI)
OR we should leave the
choice to consumers?
1 '4 We- Scj
•J 5
•
;•
Council of Health
programme with one stroke
2) India is a signatory to
Convention on Rights of
Children and a party to
WHO/UNICEF/FAO
decisions on Universal Salt
Iodisation
2) Experience has shown
time and again in India and
elsewhere that withdrawal of
USI leads to re-occurrence of
Iodine Deficiency Disorders
and brain damage in children
3) As of now, Over 110 3) Those who are Below
; jU
countries in the world have Poverty Line and who suffer
compulsory USI
the most from brain damage
due to iodine deficiency do
not then purchase iodised jl
Ho rvobcfoflfr salt
4) India exports salt iodised
salt to SAARC countries and
many countries in Africa &
Asia
■;<
■
Universal Salt Iodisation (USI) in India :
Issues, Facts, Implications and Recommendations - 2
Issues
Facts
Implications
Recommendations
II) More employment OR 1) No ban on production of 1) NO ban on production of 1) Consolidation, expansion
unemployment ?
common salt. In fact, it is a common salt .Continue to and monitoring of existing
raw material for iodised salt
It is alleged that many
workers have been rendered
jobless as a result of USI
2) Salt Department has given
financial and technical
assistance to form co
operatives
3) USI has created NEW
jobs. Every salt iodisation
plant has created new
employment opportunities.
India has 850 salt iodisation
plants.
iodise salt as it has given rise policies for support to co
operatives
to more employment.
2) Provide marketing
facilities to small scale salt
producers
d
; "'
'
>be
Issues, Facts, Implications and Recommendations - 3
Issues
Facts
Implications
Recommendations
III) Iodised Salt:
1) Iodised salt is equally 1) People wrongly attribute 1) The misconception on
Refined & Packaged OR effective even if it is in crystal the rise in price of salt to price rise as a result of
Crystal and loose
form and sold in needed iodisation. In fact, the rise in iodisation should be cleared.
quantities from large 50 kg
There
is
a
general bags
misconception that only
refined and packaged
2) Only 17% of 42 lakh tons
iodised salt is effective
of iodised salt is refined and
available in polypacks.
price is a result of refining The price rise is due to refin
and its packaging in 1 kg poly ing of salt, packaging and ad
packs & advertising
vertising
2) A total of 83% of iodised
salt produced in the country
is crystal salt and is sold in
needed quantities from 50
kgs bags. The poor in the
country habitually consume
only this salt.
2) Initiate a major drive for
promoting use of crystal
iodised salt packed in 50 kg
bags and sold in needed
quantities.
;
kM MA kt
.
c.
V-'
TV) Iodisation & increase 1) Cost of iodisation per 1) People compare the price 1) Below Poverty Line
person per year is less than of common salt sold loose population should receive
in price of salt
the price of cup of tea!
with refined, packaged and
There is a mistaken notion (Only 50 paise per person per branded salt. Compare like
year)
that iodisation has led to
with like! The price of
increase in price of iodised 2) Major cost i.e. 70% of both packaged common salt and
common salt / iodised salt is packaged iodised salt are
salt
<
CloU'j0
for transportation and comparable.
packaging
J.......................
.
\S
ha-O-Kv/t’
loeUe-o*
iodised salt at subsidized
rates
2) Use Public Distribution
System specially in rural
areas for sale of iodised salt.
In fact ,over 13 states have
already done it.
........ c<
rvoxk £
j
f-U .o<ry>.
5o
Universal Salt Iodisation (USI) in India :
Issues, Facts, Implications and Recommendations - 4
Issues
Facts
V)
Universal
Salt
Iodisation OR Selective
area-specific______ salt
iodisation
1) Indian scientists have
shown that NOT even a
single state or UT is free from
iodine deficiency as a public
health problem
,
.
1ri
‘ '
U<r>
«-• I'M v
\Po
—__4---------- -----
Recommendations
1) When there are two types 1) Continue and expand
of salt available - common awareness programmes on
salt and iodised salt, people IDD to cover all sections of
mistakingly thinking it is society
cheap, buy the common salt.
Not buying iodised salt will
cost their life dearer than
buying common salt.
-i
2) Iodine deficiency is 2) Consumption of iodised 2) Continue with Universal
present NOT only in sub- salt even for those with no Salt Iodisation
Himalayan areas BUT in iodine
deficiency
is
pockets all over the country. TOTALLY SAFE
In fact, more areas are being
identified.
& U t. rt C.A3 iv<pl1 • 11 <.
\t -l - C
3)
Iodine
deficiency
disorders are EVEN present
in
Delhi,
Mumbai,
Chandigarh etc.
J'
'
f *
C. OvA F LG' ,
(
XJ
.
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_________________________
I PUBLIC HEALTH
Dilemma over iodisation
As the Centre contemplates withdrawing the universal salt iodisation programme,
opinion is divided on the wisdom of the move.
the world since the 1920s. While iodine
can be added to bread, drinking and irri
HE Central government issued a gation water and cooking oil, the most
preliminary notification on May 10 effective and cheap way is by iodising salt.
announcing the withdrawal of the Specified amounts of potassium iodide or
Universal Salt Iodisation (USI) pro iodate is added to salt during its manu
gramme, 16 years after it was started. The facture.
USI is practised in 130 countries.
move has attracted sharp reactions, with
supporters and opponents of the USI India, which introduced the USI pro
squarely divided on scientific, ethical, gramme in May 1984, is a signatory to
several
international
conventions,
economic or legal grounds.
Essential for human survival and including the 43rd World Health
development right from the foetal stage, Assembly (Geneva, May 1990), rhe
iodine is used by the thyroid gland to syn World Summit for Children (New York,
thesise hormones. The average daily September 1990) and the South Asian
iodine requirement for an adult is 150 Association for Regional Cooperation
Conference
(Colombo,
micrograms and any excess iodine is (SAARC)
excreted by the kidney. No organ selec September 1992), all of which aimed to
tively stores iodine, nor is any plant rich eliminate IDD within a specified period.
in it as in the case of iron (drumstick
Supporters of the USI programme in
India quote studies by the Central and
leaves) or vitamins (mango).
Thyroid hormones play a crucial role State Health Directorates and the Indian
in the first two yean of life, when over 90 Council of Medical Research, which
per cent of brain development occurs. show that no State or Union Territory
Irreversible mental problems caused by (U.T.) is free from IDD. Sample surveys
iodine deficiency become apparent only in 26 States and six U.Ts reveal that the
after two yean of age. Iodine deficiency prevalence of IDD is above 10 per cent
at different stages - foetal, neonatal, ado in 241 of the 282 districts covered. But
lescent and adult - causes debilitating the opponents of USI argue that the sur
effects leading to a spectrum of problems,, veys are faulty. They say that the surverys
such as stillbirth, abortion, high inci-o are not based on a random sample but are
dence of neonatal and infant mortality, biased towards high IDD-prevalent areas,
congenital malfunction of organs, men and the figures obtained thus are extrap
tal retardauon, physical abnormalities olated for whole States.
(cretinism), deaf-mutism and. goitre.
Of all known nutritional-deficiency
These are collectively called iodine defi disorders, IDD are the easiest to prevent
ciency disorders (IDD). It is estimated yet, according to esumates available for
that the intelligence quotient (IQ) levels India, there are two million cases of cre
of schoolchildren in iodine-deficient tinism caused by iodine deficiency and 70
areas is at least 13 points lower than the million persons suffer various forms of
average.
IDD. Another 200 million fall in the
Iodine is primarily obtained from high-risk group.
food and water. IDD occur in areas where
Supporters of USI argue against con
iodine is deficient in water and soil. Also, ventional wisdom that only persons liv
in some cases substances in the food can ing in high-altitude areas, such as the
block iodine absorption, leading to IDD. Himalayan and sub-Himalayan regions,
Iodine is present in the topsoil and reach suffer from severe iodine deficiency as
es human beings through the soil-plant- heavy rain and glaciation wash away the
animal chain. It is present in plants in topsoil. They say that IDD were later
direct proportion to its content in the soil. found to be prevalent in the regions along
Iodine deficiency can be made up the Ganga and the Brahmaputra as well
through diet; this has been done all over because floods washed away the topsoil.
ASHA KRISHNAKUMAR
T
86
Further, it was found that deforestation
and intense agricultural practices also led
to severe iodine depletion of thesoil. Even
coastal Stares such as Tamil Nadu and
Kerala, which were thought to be iodinerich (sea is rich in iodine), are not free
from the problem. There are pockets of
iodine-deficient areas in every State.
Opponents of USI argue that even in
the mountainous terrain of the
Himalayas, where IDD are endemic,
there arc pockets where cretinism is found
in only a small segment of the popula
tion, between 1 and 4 per cent. In other
pans of the sub-Himalayan region, the
incidence is uniformly below 1 per cent.
Kerala Sastra Sahithya Parishad (KSSP)
member K.P. Aravindan said: “In the
supposedly new endemic areas...the
methodology adopted for proving the
incidence of IDD involves developmen
tal and intelligence testing, which is high
ly controversial and riddled with a priori
assumptions, conscious fraud and poli
tics, its very value of scientific objectivi
ty is in question.”
Recognising the severity of IDD in
the Himalayan region and the benefits of
iodine supplements from the study of the
Kangra valley conducted by former
Director of the All India Institute of
Medical Sciences (AIIMS) and the
ICMR, Prof. V. Ramalingaswamy, the
Centre initiated the National Goitre
Control Programme (NGCP) in 1962 to
identify endemic iodine-deficiency areas,
supply iodised salt to these areas and con
duct periodic resurveys to assess the
impact of the programme. After a promis
ing start, the programme fizzled out.
Even after nearly four decades of the
national programme, epidemiological
information on IDD is either not avail
able or, when available, is anecdotal or
insufficient to allow any meaningful
inference and planning. For example, of
the 132 districts surveyed by the NGCP,
122 were termed endemic goitre areas.
This conclusion, according to Aravindan,
is suspect as the sample (in Uttar Pradesh,
Bihar and West Bengal) was mostly from
the hills and foothills; the plains were not
FRONTLINE, JULY 7. 2000
m
id
in
id
ee
of
•n
ie
d
T
e
j
At a salt pan In Pondicherry. The cheapest and most effective way to counter Iodine deficiency Is Iodising salt.
•e
e
■e
included. But the results were extrapo
lated for the States as a whole..
However, following rhe setting up of
the NGCP, the Centre set up salt iodis
ation plants in Rajasthan and Gujarat.
The state-owned Hindustan Salts was
given the monopoly for the production
of iodised salt, bur its units were unable
to produce the required quantity. For
instance, in 1981, seven lakh tonnes of
iodised salt was needed to cover the
endemic areas, but the installed capacity
was only 3.76 lakh tonnes and the pro
duction only 1.3 lakh tonnes.
Critically reviewing the working of
the NGCP, a former Director of the
National Institute of Nutrition, Dr. C.
Gopalan, called for a working group to
look into the problem ofIDD. This com
mittee, along with the Central Council
for Health, recommended in 1984 USI
or a ban on the sale of non-iodised salt on
the grounds that it was difficult to pre
vent the entry of non-iodised salt in the
endemic goitre areas. The problem was
widely prevalent in the country. Besides,
the use of iodised salt by people without
iodine deficiency was nor considered
harmful. The recommendation was to be
implemented in phases from 1986, with
total salt iodisation by 1992. The iodine
content in salt was to be monitored by
the monitoring information system of the
Salt Department in various States.
The working group also suggested
n
■f
FRONTLINE. JULY 7. 2000
that production could be increased by
involving the private sector with some
subsidy (this was removed in 1992).
Following this, a number of big produc
ers, including some multinational cor
porations, entered the market and today
there are 848 iodised salt units, 70 per
cent of them big producers. Food being
a State subject, several States went to
court challenging the Centre’s decision.
All Stares except Kerala (no ban), Andhra
Pradesh (partial ban) and Maharashtra
(partial) have, however, banned the sale
of non-iodised salt. (Tamil Nadu
imposed a ban three years ago.)
However, realising that non-iodised salt
was still consumed by people in IDDendemic areas (as common salt was sold
for livestock's consumption), the Centre,
on November 27, 1997, issued a notifi
cation in “The Gazette of India
Extraordinary" to make the implemen
tation of the USI programme stringent.
Today 70 per cent of the population has
access to iodised salt and the country is
nearing the goal of complete elimination
ofIDD.
USI supporters say that India has
made substantial progress since the
launch of the programme. Fpr instance,
65 per cent of rhe population in Deorea,
Uttar Pradesh, suffered from some IDD
in 1973; rhe figure fell to 18 per cent in
1998. In Buldhana, Maharashtra, IDD
affected 49.5 per cent of rhe population
in 1984, but the figure came down to 16.9
per cent in 1991. In Sikkim, the inci
dence dropped from 54 per cent in 1990
to 16 per cent in early 2000. Since the
early 1990s, no cretin has been born in
the once-endemic Terai region.
Pending final notification of the
withdrawal of USI, the programme’s
proponents and opponents have been
vocal about their respective stand.
Several scientists have criticised the gov
ernment’s decision - among them are
Ramalingaswamy; Dr. Chandrakanr S.
Pandav, Regional Coordinator (South
Asia and Pacific) of the International
Council for Control of Iodine
Deficiency; Col. R. Sankar. Disorders
Special Medical Specialist ofthe Institute
of Nuclear Medicine and Allied Sciences
(INMAS); Prof. M.G. Karmarkar, pres
ident of the Thyroid Association of
India; Prof. N. Kochupillai. Head of
Endocrinology at the All India Institute
of Medical Sciences (AIIMS); Prof.
M.M. Godbole, Head of Endocrinology
at the Sanjay Gandhi Post Graduate
Institute (Lucknow); and Dr. Umesh
Kapil, Additional Professor of Human
Nutrition Unit at the AIIMS. President
of the Academy of Nutrition
Improvement Prof. Shantilal Kothari
(Nagpur), member of the All India Sarva
Seva Sangh Prof. Thakurdas Bang
(Wardha), member of the Vinoba
Ashram Dr. Jagdish Shah, and rhe
87
Sarvodaya leaders at the Gandhi Peace
Foundation have supported the move.
Broadly, the focus is on the following
issues:
Effects of excess iodine: USI’s oppo
nents argue that excess iodine would
cause hyperthyroidism, leading to iodide
goitre (goitre caused by high iodine
intake), iodine-induced thyrotoxicosis
(induced by hyper-functioning of the
thyroid gland) and sequelae of a possible
increase in salt intake (hypertension
caused by an increase in salt consumption
as iodised salt is presented by multina
tional corporations (MNCs) as a restora
tive tonic with powers to cure anything
from dullness to squint). Its supporters
say that salt iodisation in India is within
“safe limits". In India, common salt is
iodised with potassium iodate to 'an
iodine content level of 30 pans per mil
lion (ppm) so that at least 15 ppm of
iodine reaches the consumers after possi
ble transit loss. Even if there is no iodine
loss and the consumers take in 30 ppm
of iodine, scientists argue that it is with A Sikkimese woman In a region where
cretinism and goitre are endemic.
in safe limits.
Role of big corporations: Of the 44 salt
I
units, 31 per cent, accounting for 26
lakh tonnes of iodised salt, only 17 per per
] cent of the total production, is owned
cent is refined (powdered, bleached, by
I small producers.
packered and labelled) - branded or oth
Costlier salt: USI’s supporters argue
erwise. The rest is sold loose as crystal or ithat this is not because of salt iodisation,
powdered iodised salt. There is little iwhich has a nominal cost. It is estimated
doubt that companies such as the Tatas, that
i
iodising a kilogram of salt costs 10
Hindustan Lever and Nirma, which have paise.
|
Big companies, traders and retailers
entered the iodised salt market, make imake huge profits by buying iodised crys
huge profits. USI’s supporters argue that tal
t salt (at between Rs.1.50 and Rs. 2 a kg)
MNCs continue making huge profits from
I
small manufacturers and then after
with or without USI. The solution lies the
i powder-bleach-pack-labelling process
not in withdrawing the USI, but regular- !sell it (at between Rs.4 and Rs. 5.50 a kg).
ing the iodised salt market.
1
USI
’s supporters argue that this can be
Imported iodine cartel: USI’s sup- avoided
;
if the government buys iodised
porters argue that only Chile and Japan crystal
<
salt and sells it at a reasonable price
exportiodine-Theiodinerequiredforsalt to
i those who need it, or buys common salt
iodisation is a minuscule quantity com- from
I
small producers, iodises it in its iodi
pared to its need for the photo film, phar- sation
<
plants and then sells it. The traders,
maceutical
and food
processing who
i
procure common salt from small pro
industries, the primary sectors for which <ducers and iodise, bleach, pack and sell it
iodine is imported in India.
:
account
for 31 per cent of the total iodised
Marginalisation of the small-scale salt
< output in the country.
sector: This is true in some traditional
There is no administered price mech
salt-producing areas such as Gujarat and anism for iodised salt. Hence there is free
Tamil Nadu. According to USI’s sup trade and no price control. To make
porters, the solution to the problem of iodised salt available to the vulnerable sec
salt producers in the small-scale sector tions, which need it most, 20 States and
being marginalised by the major manu U.Ts sell it through the PDS, either wholfacturers is to help the small producers set ; ly or partially.
up iodisanon plants, organise them into
According to Dr. Shantilal Kothari,
cooperatives and help them market their\/who opposes USI, it is better to treat IDD
product. The government can also con-1' like any other medical problem and leave
sider buying iodised salt from the small it to the doctors to decide who needs addiproducers and sell it through the Public tional iodine and towhat extent. Anupam
Distribution System. Of the 848 iodised Mishra of the Gandhi Peace Foundation
88
says that USI is not advisable as iodine is
not totally benign and its excess con
sumption could lead to hyperthyroidism,
resulting in health complications. While
Dr. Jagdish Shah agrees that IDD is a
problem in India, he believes that USI is
not the way to address the problem.
A
supporter
of USI,
Dr.
Chandrakant S. Pandav, says: “The
Centre’s move is retrograde. There is no
scientific, legal, economic, social, educa
tional, moral or ethical justification for
it.” He argues that the cost-benefit ratio
of salt iodisation is 1:3; if the gains from
iodising livestock are also included, the
ratio rises to 1:8. “The annual cost of salt
iodisation per person is 50 paise, less than
that of a cup of tea,” he says.
According to him, the problems of
consuming iodine when you do not need
it is insignificant compared to the bene
fits derived from the USI programme.
Also, the people at risk are those who live
in isolated areas and who are a part of the
vicious cycle of poverty, ignorance and
disease. If both common salt and iodised
salt are available in the market, they
would buy only common salt as it may be
cheaper. Dr. Pandav asks, “if the govern
ment can push universal immunisation
and pulse polio, why not USI?”
According to Col. Sankar, if the gov
ernment withdraws the USI, the most
needy will suffer. The small manufactur
ers who sell iodised crystal salt, which the
poor and vulnerable in the rural areas buy,
would do away with iodisation and sell
only common salt, while refined brand
ed iodised salt will continue to be sold in
the urban markets. So, according to Col.
Sankar, even if the USI programme is
withdrawn, the government must ensure
that iodised salt reaches the people who
need it most and at a reasonable price. It
can be sold through the PDS and the gov
ernment must absorb the price differen
tial between common and iodised salt.
And, at the same time, the government
must initiate a study to map the incidence
of IDD in the country with a representa
tive sample. Reliable data so generated
would go a long way in dealing with the
problem of IDD.
It is not clear whether the govern
ment, which has given time until June
24 for the public response to the pre
liminary notification, has a pro
gramme for the endemic areas if it
withdraws the USI programme. The
reaction from the Ministry of Health
and Family Welfare, which put out the
notification, is that it would discuss its
plans after June 24.
FRONTLINE, JULY 7, 2000
NUTRITION PAPER OF THE MONTH
January 2000
Short-term Effectiveness of Mandatory Iodization of Table
Salt, at an elevated Iodine concentration, on the Iodine and Goiter Status of
Schoolchildren with Endemic Goiter
Jooste, P.L., Weight, M.J., & Lombard, CJ.
American Journal of Clinical Nutrition, 2000: 71:75-80
This study from South Africa shows the impact of salt iodization on iodine status
and goiter among schoolchildren Baseline goiter rates and urinary iodine
excretion were measured one month before iodization of salt was made mandatory
in 1995 in 565 children. Before 1995 salt iodization was optional, and it was
estimated that about 15% of the salt in the study area was iodized A follow-up
survey was conducted in 1996 among another cross-sectional sample of
schoolchildren using the same sampling and data-collection procedures In 1996,
82% of salt samples collected from children's households contained more than 20
ppm iodine, indicating the success of the salt iodization law. The goiter prevalence
in 1995 was about 26%, and was virtually unchanged in 1996 at about 28%.
However, the distribution curve of urinary iodine concentration shifted significantly
to the right. Median iodine concentration was 0.17 pmol/L in 1995 and was
increased to a value of 1 47pmol/L in 1996
Several points can be concluded Firstly, making iodization of salt mandatory lead
to a quick increase in the availability of iodized salt which had a clear impact on
iodine intake/status. Even with about 18% of the salt being inadequately iodized,
urinary iodine concentration increased significantly Secondly, in spite of the
clearly improved iodine intake goiter prevalence remained unchanged, indicating
that goiter prevalence is not a good indicator to monitor the impact of salt
iodization over a relatively short period of time. Once the large majority of
households use iodized salt, a representative survey of urinary iodine
concentration needs to be done to check whether iodine intake is sufficient. Other
studies showed that in iodine deficient areas such as this South African one, the
IQ point distribution of the whole population shifts to the left. In the South African
schools described in this study this IQ loss will now be prevented.
UNICEF NYHQ
Nutrition Section, PD
Short-term effectiveness of mandatory iodization of table salt, at
an elevated iodine concentration, on the iodine and goiter status
of schoolchildren with endemic goiter1’2
Pierer L Jooste, Michael J Weight, and Carl J Lombard
ABSTRACT
Background: Goiter rates and iodine deficiency usually show
marked improvement in efficacy studies of mandator}' iodization
of salt, but little is known about the short-term effectiveness of
mandator}' iodization.
Objective: The aim of the study was to evaluate, after 1 y, the
effectiveness of mandator}’ iodization of salt at an iodine con
centration higher than that occurring under optional iodization
on the goiter rates and iodine status of schoolchildren living in
an endemically goitrous area.
Design: Goiters, measured by palpation, and urinary iodine con
centrations of children in grades 4-7 in 4 schools in a known
goitrous area in South Africa were assessed before and 1 y after
the introduction of mandatory iodization at a higher iodine con
centration than occurred with optional iodization. Estimates of
the iodine concentration of iodized salt and the proportion of
households using iodized salt were also made
Results: Iodine concentration in table salt and household use of
iodized salt improved within 1 y. Goiter rates, which varied at
baseline from 14.3% to 30 2% in the 4 schools, remained
unchanged, with an overall mean (iSE) prevalence of 25.6 ± 2.5%
at baseline and of 27.5 ± 2.7% 1 y later. The distribution of urinary
iodine concentrations in the 4 schools improved substantially from
the baseline deficient range. The overall median urinary iodine
concentration increased from 0.17 to 1.47 p.mol/L.
Conclusions: Mandatory iodization of salt virtually eradicated
iodine deficiency within 1 y in South African schoolchildren, but
the goiter rate in these children did not decline. Measurement of
goiters by palpation may not be appropriate in short-term evalu
ations of mandatory iodization programs.
Am J Clin Nutr
2000:71:75-80.
Iodine deficiency, goiters, mandatory iodization.
urinary iodine excretion, iodized salt, short-term effectiveness.
South Africa, primary school children
KEY WORDS
INTRODUCTION
Iodization of salt is generally considered a first-line public health
measure for preventing and controlling endemic goiter induced by
iodine deficiency (1-3). Although considerable success in eliminat
ing or reducing endemic goiter has been achieved through national
salt-iodization programs, eg. in Switzerland (4), endemic goiter
persists in some countries with iodization programs and even in
some with mandatory iodization programs (5, 6). Mandatory
iodization of salt is therefore not an automatic guarantee of the
elimination or reduction of iodine deficiency and endemic goiter.
Mandatory iodization of household salt was introduced in South
Africa through revised legislation in December 1995. The saltrelated regulations of the Foodstuffs, Cosmetics and Disinfectants
Act No. 54 of 1972 were revised to make iodization mandatory
rather than optional and to increase the concentration of iodine in
the form of potassium iodate from 10-20 to 40-60 p.g/g. As a result
of this new regulation, the availability of iodized salt in food shops
was expected to increase from =30% (7) to >90% within 6 mo.
The introduction of mandator}' iodization has the potential to
produce a chain of effects from the production plant to the
household, including changes in iodine and goiter status of con
sumers. The success of such a program can be measured by mon
itoring key elements in this chain of events and evaluating the
effects on consumers (8). We previously showed that introducing
mandatory iodization in South Africa at a higher iodine concen
tration than that occurring with optional iodization resulted in a
significant increase in the mean iodine content of retail salt from
14 to 33 p.g/g within 1 y (9). Limited information is available on
the short-term effect on the iodine and goiter status of school
children of introducing mandatory iodization. The aim of this
study was to investigate the effects of mandator}' iodization after
1 y in schoolchildren in an endemically goitrous area.
SUBJECTS AND METHODS
Subjects
The study was carried out in the primary schools of 4 communi
ties [Haarlem (school 1), Louterwater (school 2), Krakeel (school 3),
and Joubertina (school 4)] in the Langkloof area, a I50-km-long
1 From ihc National Research Program for Nutritional Intervention and the
Biostatistics Division of the Center for Epidemiological Research in South
ern Africa of the Medical Research Council, Tygerberg, South Africa.
2 Reprints not available. Address correspondence to PL Jooste, National
Research Program for Nutritional Intervention, Medical Research Council,
PO Box 19070. Tygerberg, 7505, South Africa. E-mail: pjooste@mrc.ac.za.
Received March II, 1999
Accepted for publication June 4, 1999.
Am J Clin Nutr 2000:71:75-80. Printed in USA. O 2000 American Society for Clinical Nutrition
75
76
JOOSTE ET AL
fruit-producing valley =70 km inland from the southeastern coast
of South Africa. These 4 communities were chosen because the
Lanekloof area had been a focal point of studies on endemic goi
ter in the past (10). In addition, the socioeconomic status of the 4
communities ranged from low to high and there were sufficient
numbers of schoolchildren. Children in grades 4-7 (ie. with
4-7 years of schooling) attending primary schools in the 4 com
munities. situated over a distance of =100 km in the Langkloof
area, were used as subjects in both the baseline and follow-up stud
ies. In the 2 biggest schools, every second child on the alphabetic
class list was selected; in the remaining 2 schools, all the children
in these grades were recruited According to the headmasters of the
schools, school attendance rates exceeded 90%. Written consent
was obtained from parents or guardians of the children before each
phase of the study began. Permission to conduct the study was also
obtained from the headmasters and from the ethics committee of
the South African Medical Research Council.
Design
Baseline goiter rates, urinary iodine excretion, and related
variables were observed in the schoolchildren of the 4 study
communities in the month before the introduction of mandatory
iodization of household salt in South Africa (10). Measure
ments were repeated 1 y later in a follow-up study that used the
same sampling procedure (children in grades 4-7) to avoid age
effects on goiter rates.
Measurements
Identical sampling and data-collection procedures were used in
the 2 surveys, which were conducted in the same month of 2 con
secutive years. During each of these studies the size of the thyroid
gland of each child was visually inspected and palpated and was
graded according to the criteria of the World Health Organization,
the United Nanons Children’s Fund, and the International Coun
cil for Control of Iodine Deficiency Disorders (11) as not palpa
ble (grade 0). palpable but not visible (grade 1), or palpable and
visible (grade 2). Different observers were used in the 2 studies
but were standardized against each other. A urine sample (=20
mL) was obtained from each participating child during usual
school hours, corresponding to approximately the second urine
void of the day The urine samples were refrigerated at 4°C until
they were analyzed for iodine content by means of manual acid
digestion and spectrophotometric detection of iodine by ceric
ammonium reduction in the Sandell-Kolthoff reaction (12, 13).
Drinking-water samples were collected during baseline and fol
low-up from the municipal water supply in the 4 communities and
were similarly analyzed. The analysis of urinary iodine content
was standardized against the Centers for Disease Control in
Atlanta in an ongoing quality control program at the time of the
study. The CV of this analysis was 4.7% in our laboratory.
At baseline, when iodization was still optional, a short ques
tionnaire completed by the children’s parents was used to
estimate the proportion of households that used iodized salt. At
follow-up, to investigate the proportion of households using
iodized salt and the iodine content of iodized salt used, we asked
parents to put =15 g (3 tsp) of their table salt into iodine-free
polyethylene bags provided through the schools. The bags were
then tightly sealed until the samples were analyzed. Information
on indicators of the socioeconomic status of the head of the
household was generated by questionnaire. Several iodized salt
samples were purchased from grocers in the area at the time of
the baseline and follow-up studies and were subsequently ana
lyzed for iodine content. The retail and household salt samples
were analyzed quantitatively for iodine by using an iodometric
titration method (14). for which the CVs in our laboratory were
0.68 at 20 p.g/g and 1.05 at 60 p.g/g.
Data analysis
Follow-up data were not obtained for individual children, but
the same sampling procedure was used in the same study popu
lation at both sampling times. The overlap between the 2 samples
was therefore unknown and could have exceeded 50%. It can be
shown that considering the 2 samples as completely independent
in the statistical inference represented a conservative approach.
This was the result of not using the intrasubject correlation that
was present in the portion of the samples that overlapped. The
chi-square test was used to compare the prevalence of goiters,
and the median 2-sample test was used to compare the age and
urine iodine distributions of the baseline and follow-up observa
tions. Year-spccific prevalence was estimated, with adjustment
for the sampling design and realization.
RESULTS
In 1995, a total of 565 children (71-189 per school) partici
pated in the baseline phase of the study (Table 1). In 1996, a total
of 536 children (50-184 per school) were recruited into the study.
These numbers represented response rates ranging from 74.7% to
97.9% for the different schools in 1995 and from 51.5% to 94.4%
in 1996. giving overall response rates of 84.3% and 81.7%,
respectively. The low response rate at follow-up in school 4 was
due to a lack of motivation to participate. The mean age of the
total sample of children of 12.6 y in 1995 and 12.5 y in 1996 did
not differ significantly (median 2-sample test. P = 0.1238)
between the 2 study phases. Data on indicators of socioeconomic
status showed a higher level of education, fewer laborers, and
more professional people among the heads of households in the
school-4 community than in the other 3 communities (Table 1).
Total goiter rates, consisting of the sum of the palpable
(grade 1) and visible (grade 2) goiters, in the 4 communities
before and 1 y after the introduction of mandatory iodization are
shown in Figure 1. Al baseline, the severity of the prevalence of
goiters ranged from mild in school 4 (14.3%) to moderate in
schools 1 (26.3%) and 2 (25.0%) to severe in school 3 (30.2%).
The prevalence of goiters in these schools remained essentially
unchanged 1 y later, and the overall weighted prevalence of
25.6 ± 2.5% (x ± SE) in 1995, adjusted for the sampling effect
and response rate, did not differ significantly (chi-square test
for a difference in proportions) from the overall weighted preva
lence of 27.5 ± 2.7% 1 y later.
The distribution^ of urinary iodine excretion at baseline and
1 y after the introduction of mandatory iodization for each of the
4 schools are shown in Figure 2. Before mandatory iodization
came into effect, these distributions were skewed toward the low
urinary iodine concentrations, particularly in schools 1, 2, and 3,
all of which were of low socioeconomic status. In these 3 schools,
39.4%, 55.6%, and 76.6% of children had urinary iodine con
centrations in the severely low range (<0.16 p.mol/L) and very
few (<10%) had urinary iodine concentrations in the adequate
range (>0.79 pumol/L). In the fourth school, a low percentage of
children (1.5%) had severely low urinary iodine concentrations.
77
SHORT-TERM EFFECTIVENESS OF IODIZED SALT
TABLE 1
Characteristics ol the study population
School
School I
Characteristic
Response rate (Q)
Age (>■)'
Education2
<7 y (%)
>12y(%)
Occupation2
Laborer (%)
Professional (%)
School 2
School 4
School 3
Overall
1995
(n = 155)
1996
(n=156)
1995
(n = 1S9)
1996
(n= 184)
1995
(n = 150)
1996
(n = 146)
1995
(n = 71)
1996
(/j = 50)
1995
(n = 565)
1996
(w = 536)
92.8
12.7 ±1.8
92.3
12.4 ±1.8
97 9
12.5 i 1.8
94.4
12.6 ± 1.6
70.1
12.9 ±2.0
74.6
12.7 ±1.9
74.7
12.1 ± 1.0
51.5
12.0+1.0
84.3
12.6+1.9
81.7
12.5 ± 1.7
—
—
49.0
8.7
—
61.4
5.5
—
—
61.5
2 1
—
—
8.0
54.0
—
—
52.2
10.5
—
—
49.0
5.3
—
—
64.1
2.2
—
—
434
07
—
—
6.0
30.0
—
—
49.6
5.6
'x ± SD.
2 Refers to heads of households.
about a quarter had adequate urinary iodine concentrations, and
the rest were moderately deficient (0.16-0.39 p.mol/L) or mildly
deficient (0.4-0.78 pimol/L). One year after the introduction of
mandatory iodization, these urinary' iodine distributions shifted
substantially to the right toward higher, or adequate, concentrations
(median 2-sample test, P < 0.0001 for all 4 schools) (Figure 2).
In schools 1. 2, and 4, >80% of the children had urinary' iodine
concentrations >0.79 jxmol/L at follow-up: 78.5% of the samples
in school 3 were in this range.
Similarly, the median urinary iodine concentrations in the
4 schools increased markedly from concentrations indicating
severe (school 3). moderate (schools 1 and 2), and mild (school
4) iodine deficiency at baseline to concentrations well into the
replete range (0.79-1.58 p.mol/L) 1 y later (Table 2). During this
time the overall median urinary iodine concentration increased
from 0.17 to 1.47 p.mol/L (median 2-sample test, P < 0.0001).
The iodine content of 4 samples of retail iodized salt purchased
in the study area at the time of the baseline study ranged from 14
to 17 p-g/g (,v: 15 |xg/g). ie. within the range of 10-20 p-g/g that
was legally required before the introduction of mandatory
iodization. At follow-up 1 y later, 18 samples were purchased
from retailers in the area. The iodine content of these retail sam
ples increased to a mean of 25 p.g/g, somewhat below the revised
legal requirement of 40-60 p.g/g that came into effect with the
introduction of mandatory iodization. There was considerable
variation in the iodine content of these retail salt samples at fol
low-up, ranging from 0 to 56 p.g/g, resulting in a lower mean
value than expected. The higher salt iodine concentration in
community 4 than in the other communities was probably related
to the higher socioeconomic status of these communities, which
would have allowed them to purchase the more expensive brands
of salt that had higher iodine concentrations.
To assess the change in the proportion of households using
iodized salt as a result of the introduction of mandatory iodization,
we established the baseline percentage of households that used
iodized salt by questionnaire and used titrimetric analysis to
determine the iodine content of salt samples brought to school at
follow-up. At baseline, a low percentage of households (6.2% in
78
JOOSTE ET AL
FIGURE 2. Distribution of urinary iodine concentrations in schoolchildren before (■) and 1 y after (S) mandatory' iodization, at a higher concen
tration than occurred with optional iodization, began To convert values to pg/L, divide by 0.0079.
school 1,4.3% in school 2, 25% in school 3. and 45.7% in school
4) reported the use of iodized salt A year later, >70% of house
holds in each of the communities, for an overall percentage of
82.4% in the whole study area, were using salt iodized at a con
centration of >20 |xg/g (Table 2). Overall. 15.1% of households
had table salt with an iodine concentration within the legally
required range of 40-60 p.g/g (Table 2). although this required
range applies to the production site. In the 3 communities of lowest
socioeconomic status, the mean and median iodine concentra
tions of household salt were very similar, ranging from 24 to 34
p.g/g: in the community with the highest socioeconomic status
(school 4), mean and median concentrations were higher,
exceeding 40 p.g/g (Table 2). For the study area overall, the mean
(±SD) household iodine concentration was 31 ± 17 p,g/g and the
median was 29 p.g/g.
During both studies, the iodine concentrations of the drinkingwater samples taken in the 4 communities remained low,
between 0.0 and 0.12 pmol/L.
DISCUSSION
At baseline, rates of iodine deficiency and goiter ranged from
mild to severe in the 4 schools, despite the fact that optional
iodization had been in operation in South Africa since 1954.
The overall baseline prevalence of goiters of 25.6% (range:
14.3-30.2%) was, however, lower than the excessively high rates
of between 69% and 93% that prevailed in this area —60 y ago
(15, 16). Therefore, optional iodization at a concentration between
10 and 20 p.g/g and a 30% market share of iodized salt with
unequal accessibility (7). as was the case in South Africa for
4 decades before the introduction of mandatory iodization,
appeared to have had some beneficial effect but was ineffective in
eradicating iodine deficiency and endemic goiter in the study area.
Favorable changes were observed in the process indicators
between baseline and follow-up, such as the increase in the pro
portion of households that used iodized salt and the increase in
the iodine concentration of table salt. At baseline, the estimated
overall percentage of 15.5% of households using iodized salt
appeared to be lower than the national estimate of a 30% iodiza
tion rate of table salt before the introduction of mandatory'
iodization (7). These estimates were in striking contrast with
household use of iodized salt in the study area 1 y after manda
tory iodization was introduced, when 82.4% of households were
using salt with an iodine concentration >20 jig/g (and 90.9%
were using salt with an iodine concentration >10 p.g/g). More
over, the mean iodine concentration of retail salt samples collected
during this study increased from 15 p.g/g (range: 14-17) to 25
p.g/g (range: 0-56) 1 y after the introduction of mandatory
iodization. The latter mean value was lower than the mean value
of 31 p.g/g in household salt because of some very low concen
trations among the retail salt samples. In another study, con
ducted in 3 of the 9 provinces in South Africa at the same time
as the present study, we showed that the iodine concentration of
retail salt increased from a mean of 14 p.g/g before mandatory
iodization to 33 p-g/g 1 y after mandatory iodization was intro
duced (9). Although the iodine concentration was lower than the
legally required concentration of 40-60 p.g/g at the production
site, it nevertheless validated the observation of an increased
iodine concentration in iodized table salt over the study period.
On the basis of the improvement in these process indicators, a
short term effectiveness of iodized salt
79
TABLE 2
Iodine concentrations in the urine of schoolchildren at baseline and at 1-y follow-up and in salt used in the children's households (collected at 1-y
follow-up)
School
1995
1996
1995
1996
_ School 3
1995
1996
155
0.21
155
1.52
187
0.13
184
1.52
145
0.04
14-4
1 34
69
0.51
50
1.42
556
0.17
533
1.47
—
—
149
24 ± 17
24
—
—
—
182
33 ± 14
34
—
—
—
144
30 ± 12
28
—
—
—
48
43 + 26
47
—
—
—
523
31 ± 17
29
71.8
14.1
—
—
89.0
15.9
—
—
87.5
10.4
—
—
75.0
33.3
—
—
82.4
15.1
School 1
Iodine
Urinary' iodine
n
Median (p.mol/L)
Iodine in household salt
n
I ± SD (|ig/g)
Median (jig/g)
Percentage of salt samples with
>20 p.g/g
40-60 p.g/g
—
—.
__ School 2_
similar improvement was also expected in the associated out
come indicators, ie. higher urinary iodine concentrations and a
reduction in goiter rates.
Unlike the long-term successful reduction of goiter rates
resulting from salt-iodization programs in many countries (1-5),
the goiter rates in this study remained unchanged 1 y after
iodization became mandatory at a higher iodine concentration
than occurred with optional iodization. Although palpation of the
thyroid is subject to observer variation (17). the similarity in the
varying goiter rates of the children in the 4 schools before and
after the introduction of mandatory iodization suggests internal
consistency in the data, indicating a strong likelihood of a true
lack of change in goiter rales in the short term.
Short-term success in reducing goiter rates was achieved in
efficacy studies with iodized oil (IS) and low-dose iodine (0.2 mg/d)
(19) in adults but not in children receiving biscuits and cold
drinks fortified with iodine (20). Todd and Dunn (21) observed
reduced thyroid volumes, measured by ultrasound, in their effi
cacy study in 7-13-y-old children over a 13-mo period after the
administration of potassium iodide given at a dosage of 30 mg
monthly or 8 mg biweekly Administration of iodized oil to
schoolchildren aged 6-11 y as single iodine doses <480 mg did
not result in decreased thyroid volumes as measured by ultra
sonography over a period of 395 d (22). Only at a higher iodine
dose of 960 mg (administered orally; or 480 mg (administered
intramuscularly) did the goiter volume decrease significantly
after 395 d (22). In our evaluation of the short-term (1 y) effec
tiveness of mandatory iodization of table salt, the prevalence of
goiters in children in the 4 schools remained the same despite
the dramatically improved iodine status of these children. Rea
sons for the lack of change in the goiter races may be related to
insufficient time of exposure to mandatory iodization, the
insensitivity of thyroid palpation to small changes in thyroid
volume (17), a lesser effectiveness of lodized-salt prophylaxis
in reducing the size of goiters in children exposed to iodine
deficiency in the first years of life (23). or the possibility that
long-standing goiters may become autoimmune (24). This fail
ure of mandatory iodization to induce regression of goiters that
are mild-to-borderline severe in children suggests that assess
ment by palpation of the change in goiter rate may not be an
appropriate short-term indicator of the effectiveness of salt
iodization programs.
School 4
Overall
1995
1996
1995
1996
The dramatic shift toward higher values in the urinary iodine.
distributions and the similarly impressive increases in the
median urinary iodine concentration of children in the 4 schools
illustrate the short-term effect of mandatory iodization on an
outcome indicator such as urinary’ iodine excretion in school
children. It is unlikely that factors other than the introduction of
mandatory iodization at a higher concentration, which was asso
ciated with the favorable changes in process indicators previ
ously alluded to, were responsible for this marked improvement
in the iodine status of the children. The iodine concentration of
drinking water remained low throughout the study period and
sales of seafood, according to the managers of grocery stores in
the study area, also remained unchanged.
However. 10-19% of the urine samples from the different
communities still had iodine concentrations in the deficient
range. Further follow-up studies are required to determine
whether these results represent a steady state in urinary iodine
concentration or whether further improvement can be achieved
over a longer period of exposure to mandatory iodization.
Only table salt—and not salt used for agricultural purposes—is
being iodized in South Africa. Strictly speaking, this does not con
form to the definition of universal salt iodization, which extends to
iodization of salt for animals. However, the introduction of
mandatory iodization complied with part of the international mid
decade goal of universal salt iodization, resulting in a remarkable
reduction in iodine deficiency in schoolchildren within I y.
The generalizibility of these results depends to a large extent
on whether a national iodization program can be effectively
implemented, whether iodized salt can be distributed efficiently,
and whether consumers have unrestricted access to iodized salt.
Our data showed that introducing mandatory iodization at a
higher concentration than occurred with optional iodization
resulted in improved process indicators, ie, a significantly higher
mean iodine concentration of table salt and a markedly greater
percentage of households using iodized salt, within 1 y. In turn,
these changes in process indicators were responsible for the
increased dietary intake of iodine, which virtually eradicated the
mild-to-severe iodine deficiency in schoolchildren of 4 different
communities. However, the goiters in these children did not
regress within 1 y, leaving doubt about the appropriateness of
assessing goiter by palpation in short-term evaluations of the
effectiveness of iodization programs.
El
80
JOOSTE ET AL
REFERENCES
Hetzel BS. Pandax CS. eds. SOS lor a billion. New Delhi: Oxford
University Press. 199b
2. Delange F. The disorders induced by iodine deficiency. Thyroid
1994;4:107-28.
3. Lamberg B-A. Iodine deficiency disorders and endemic goitre. Eur J
Clin Nutr 1993;47:1-8.
4. Burgi H, Supersaxo Z. Selz B. Iodine deficiency diseases in Switzer
land one hundred years after Theodor Kocher's survey: a historical
review with some new goitre prevalence data. Acta Endocrinol
1990;123:577-90.
5. Report of the Subcommittee for the Study of Endemic Goitre and
Iodine Deficiency of the European Thyroid Association Goitre and
iodine deficiencx in Europe. Lancet 1986;1:1289-93.
6. Delange F. Burgi H Iodine deficiency disorders in Europe. Bull World
Health Organ 1989:67.317-25.
7. Jooste PL, Marks AS. Van Erkom Schurink C Factors influencing the
availability of iodised salt in South Africa S Afr J Food Sci Nutr
1995;7:49-52.
8. Mannar VMG. Control of iodine deficiency disorders by iodination of
salt- strategy for developing countries. In: Hetzel BS. Dunn JT, Stanbury JB. eds. The prevention and control of iodine deficiency disor
ders. Amsterdam: Elsevier Science Publishers. 1987:111-25.
9. Jooste PL, Weight MJ. Locatelli-Rossi L Lombard CJ. Impact after
one year of compulsory iodisation on the iodine content of table salt at
rerailer level in South Africa. Int J Food Sci Nutr 1999.50-7-12.
10. Jooste PL, Weight MJ. Kriek JA. Iodine deficiency and endemic goitre
in the Langkloof area of South Africa. S Afr Med J 1997;87:1374-9.
11 World Health Organization/United Nations Children’s Fund/Intemalional Council for Control of Iodine Deficiency Disorders. Indicators
for assessing iodine deficiency disorders and their control through salt
iodization. Geneva: World Health Organization. 1994.
12. Dunn JT. Crutchfield HE Gutekunst R. Dunn AD. Methods for meas
uring iodine in urine. The Hague: International Council for Control of
Iodine Deficiency Disorders. 1993.
13. Sandell EB. Kolthoff IM. Micro determination of iodine by a catalytic
method. Mikrochim Acta 1937:1 9-25.
I.
Mannar MGV. Dunn JT. Salt iodization foi the elimination of iodine
deficiency. The Hague: Internaiional Council for the Control of Iodine
Deficiency Disorders. 1995.
15 Blom 1JB The iodine cont’ni of foodstuffs in relation to the occur
rence of endemic goitre in the Langkloof Valley. Onderstepoort J Vet
Sci Anirn Ind 1934:11 131-8.
16. Buttner EE. Endemic goitre in the Langkloof Valley. S Air Med J
1935:9:187-9.
17. Tonglct R. Bourdoux P, Dramaix M. Kennan P. Errnans A-M Intcrobserver variation in the assessment of thyroid enlargement: a pitfall in
surveys of the prevalence of endemic goitre. Food Nutr Bull
1994.15:64-70.
18. Tonglct R. Bourdoux P. Minga T. Errnans A-M Efficacy of low oral
doses of iodized oil in the control of iodine deficiency in Zaire. N Engl
J Med 1992;326:236-41.
19. Kahaly G. Dienes HP. Beyer J. Homme! G. Randomized, double blind,
placebo-controlled trial of low dose iodide in endemic goitre. J Clin
Endocrinol Metab 1997:82:4049-53
20. Van Stuijvenberg ME. Kvalsvig JD. Faber M. Kruger M, Kenoyer DG,
Benade AJS. Effect of iron-, iodine-, and (B-carotene-fortified biscuits
on the micronutrient status of primary school children: a randomized
controlled trial. Am J Clin Nutr 1999.69.497-503.
21. Todd CH. Dunn JT. Intermittent oral administration of potassium
iodide solution for the correction of iodine deficiency. Am J Clin Nutr
1998.67.1279-83.
22 Benmiloud M. Chaouki AM. Gutekunst R. Teichert H, Wood WG,
Dunn JT. Oral iodised oil for correcting iodine deficiency: optimal
dosing and outcome indicator selection. J Clin Endocrinol Metab
1994;79:20-4.
23 Aghini-Lombardi F. Antonangeli L. Pinchera A. et al. Effect of iodized
salt on thyroid volume of children living in an area previously charac
terised by moderate iodine deficiency. J Clin Endocrinol Metab
1997:82-1136-9
24. Dremier S, Coppee F. Delange F. Vassart G. Dumont JE. Van Sande J.
Thyroid autonomy- mechanism and clinical effects J Clin Endocrinol
Metab 1996,81.4187-93.
14.
I
ould be
aid-hearted enough to let
SI
ie if you can tell
how to prevent others
from falling sick. 55
-
J
/ <7 / o 6
®
l-A s
w
I
—
*DeA-
is
;hat
'-J
capped
When you eat
iodised sail daily, you
prevent these disorders.
Brain
These disorders are
invisible and irreversible.
Goiter
WITHDRAWAL OF RESTRICTION ON SALE OF COMMON SALT
FOR DIRECT HUMAN CONSUMPTION
Ministry of Health & Family Welfare, Department of Health
New Delhi, May 11, 2000
“I would be hard-hearted enough to let the
sick die if you can tell me how to prevent
others from falling sick”.
-
Mahatma Gandhi
“Iodine deficiency is so easy to
prevent that it is a crime to let a
single child be born mentally
handicapped for that reason”.
H. Labouisse
Executive Director
UNICEF, 1978
\Ne are enclosing information on the relevance and importance of
Universal Salt Iodisation for the elimination of Iodine Deficiency
Disorders as a public health problem in our country.
The purpose of this communication is to assist you in taking informed
decision on the need for Universal Salt Iodisation in India. As
intimated in the Government Press release, you may wish to
communicate your considered opinion on whether you agree or
disagree with the Governments proposed amendment to the
Prevention of Food Adulteration Act. This has to be communicated
to the Secretary, Ministry of Health and Family Welfare,
Government of India, Nirman Bhavan, New Delhi 110 011 latest
by 24th June, 2000.
With best personal regards,
Yours sincerely,
Prof. V. Ftamaningaswami
Prof. M.G. Karmarkar
Prof. N. Kochupillai
National Research Professor President,
Prof. & Head
AllMS, New Delhi
Thyroid Association (India) Dept of Endocrinology &
New Delhi
Metabolism,
AllMS, New Delhi
. ''fy. .aaclSak.
Dr. C.S. Pandav
Additional Professor
Community Medicine
AllMS, New Delhi
Prof. M.M. Godbole
Prof. & Head
Dept, of Endocrinology
SGPGI, Lucknow
J
Col. R. Sankar
Special Medical Specialist
INMAS, Delhi
Dr. Umesh Kapil
'~T~^
Additional Professor
Human Nutrition Unit
AIIMS, New Delhi
2
WITHDRAWAL OF RESTRICTION ON SALE OF COMMON SALT
FOR DIRECT HUMAN CONSUMPTION
Ministry of Health & Family Welfare, Department of Health
__________________
New Delhi, May 11, 2000
1.
This statement concerns a PRESS NOTE issued by the
Ministry of Health & Family Welfare dated May 11, 2000, the
operative part of which says : “The Central Government has
issued a preliminary Notification proposing a future withdrawal
of the compulsory statutory iodisation of edible salt”.
2.
Tragically, this proposition, conceived by the Government in the
Department of Health, is unthinkable and anti-public health.
Iodine is an essential nutrient for human survival and
development. It is a constituent of the thyroid hormone which is
necessary for growth and development of humans from the
earliest stages of foetal life in the mother’s womb. The thyroid
hormone thyroxine (T4) and its effector metabolite tri-iodothyronine (T3) control normal body metabolic processes from
womb to tomb.
3.
Humans (and animals) are critically dependent on an external
supply of relatively small but adequate amounts of iodine
through food and water which, in turn, is dependent upon the
iodine content of the soil. Over the millennia the iodine in
surface soils in some parts of the world had been progressively
leached out by glaciacion at elevated altitudes, snow, rain, and
repeated flooding in reverine valleys and thus carried into the
sea. Most of the iodine on our planet exists in the sea. The
ecological profile of the Indian sub-continent with its hilly and
mountainous terrain and frequent floods in the reverine valley
systems makes it vulnerable to low iodine content of its soils
3
and thus to low nutritional iodine intakes by its inhabitants.
Iodine deficiency, in turn, leads to enlargement of thyroid gland
goitre, and to increased frequencies of cretinism, deaf-mutism
and other forms of developmental disorder. These in fact are
only the tip of the iceberg.
4.
Over the past five decades, Indian scientists have made
contributions, widely acknowledged, to our present state of
knowledge about iodine deficiency, which forms the basis of
current public health policy regarding iodine deficiency
throughout the world including India. These, in essence, are :
4.1
Brain damage is the most devastating component of
iodine deficiency in intrauterine and the first three years in
the life of the child leading to a global consensus on
iodine deficiency as the single most preventable cause of
brain damage in the population. Iodine deficiency is
among the most extensive obstacles to human
development. It results in lower intelligence and poor
school performance of children. It has been estimated
that, on an average, school children living in iodine
deficient areas have an IQ level lower by 13 IQ points
than those living in iodine abundant areas. Iodine
deficient children display poor concentration, impaired
coordination and sluggishness with diminished energy. A
special contribution of Indian scientists to this most
important feature of iodine deficiency relates to children
just born to iodine deficient mothers living in iodine
deficient area, showing an extremely high frequency of
neonatal hypothyroidism reflecting diminished function
of the thyroid at the very start of life itself. This is due
to no fault of the mother or child or indeed of the family.
Is it not the right of the child to receive adequate
iodine for its normal growth and development?
4.2
Recent estimates in India indicate that about 200 million
people are at risk of iodine deficiency while 70 million
manifest visible signs such as goitre. Out of 282 districts
surveyed so far, 241 are found to be endemic for iodine
4
deficiency. These surveys clearly demonstrate that no
State or Union Territory is totally free from iodine
deficiency. They include hitherto unsuspected areas
including the National Capital Territory of Delhi,
Mumbai and Chandigarh! Early in the course of these
Indian researches and due to a close connection between
research and public health action, the Government of
India launched a National Goitre Control Programme in
1962 through public distribution of iodised salt in iodine
deficient areas. But as the supply of iodised salt was
restricted only to those districts which had obvious
evidence of iodine deficiency and as the other
neighbouring districts were allowed to continue the use of
non-iodised salt which was freely available, the
Programme did not succeed due to logistic difficulties in
preventing non-iodised salt going into iodine deficient
areas.
The experience was similar in some other
developing countries. With further knowledge accruing in
later years and the realisation of the vast dimension of the
consequences of iodine deficiency not just restricted to
goitre and cretinism, thus revealing the true nature of the
problem as a form of hidden hunger, its bulk lying
beneath the surface, the concept of Universal Salt of
Iodisation (USI) in countries with iodine deficiency
became established.
The concept of USI implies
iodised salt for all people, at all times.
4.3
Iodine supplementation can be provided by adding iodine
to salt, oil (for oral consumption or intramuscular
injection), bread, drinking water, irrigation water, given as
iodine tablets or added to other edible items such as fish,
sauce, toffees, etc. In the Indian context, salt seems to
be the most appropriate vehicle for supplementation of
iodine. Salt is a commodity consumed in a fixed quantity
on a daily basis by rich and poor, as well as by urban and
rural populations.
5
4.4
4.5
If the area in question is iodine deficient (proven by
low urinary iodine levels), then there is no dispute that
iodine should be supplemented and there should be a
ban on the sale of non-iodized salt in that area. Even in
this area, if there are some people who are iodine
sufficient, extra daily consumption of 150 Dg of iodine by
these people is unlikely to cause them any harm. If the
area under question is iodine sufficient, then additional
iodine consumed because of salt iodization, would be
only 150 Dg/day which would again not cause any
medical problem.
Therefore, the only question to
consider here would be the increase in the cost of iodized
salt being consumed by the population.
There is also an apprehension that because of salt
iodisation, the price of salt has increased apparently
helping the big companies. This perception is not correct.
Only 17% of the iodised salt produced in our country is
refined salt. The remaining 83% is produced by the
medium and small manufacturers.
The economics of salt iodisation is given in Table - 1. The main cost
is contributed by transportation, wholesale and retailers margin and
the polypacks.
Table 1
|
: Economics of Salt Iodisation
1) Cost of iodine for salt iodisation
2) Cost of power, labour
3) Cost of loose crystal salt at production level
4) Cost of 1 kilo poly pack
5) Transport by rail / road
____
6
3.5 paise / kg
5.0 paise 1 kg
45.0 paise 1 kg
100 paise / kg
Rs. 1-3 / kg
The retail price of the iodised salt is given in Table - 2.
Table 2 : Retail prices of iodised salt
■
Type of salt
Price (Rs.)
Crystal iodised salt in loose
Powdered iodised salt in loose
Powdered iodised salt packed
Refined iodised salt (Branded)
Rs. 1.50-2.00/ kg
Rs. 2.00-2.50/kg
Rs. 2.50-4.00/kg
_______ Rs. 5.50 & above/kg_______
It is important to note here that most of the salt available
in rural areas is in the form of crystal iodised salt, sold
loose and is in the price range of Rs. 1.50 to Rs. 2.50 per
kg. As is evident from the above facts, this cost is not a
substantial issue considering the enormous benefits of
iodised salt for brain growth and development.
4.6
Recently from developed countries like U.S.A, and
Australia, reports are coming which indicates reemergence of iodine deficiency in these countries. When
iodine deficiency is present during pregnancy, even in
milder form, it may lead to neuro-pyschological deficits in
the children born to these women. The iodine intake in
these countries is going down because of change in
practice of washing milch animals udders with hot water
instead of iodine-containing compounds that contributed
to the extra iodine in the milk in the past. It is estimated
that in U.S.A., 15% of the women in the reproductive age
group have iodine excretion less than 50 pg/litre, which
according to the WHO indicates moderate iodine
deficiency. These countries, in view of the high literacy
rates and purchasing power, give option to the people for
buying iodised or non-iodised salt. The above recent
scientific information has prompted the USA government
7
to sanction US $ 5 million to update the iodine status in
USA. This experience should make us wiser and
therefore, we should continue Universal Salt Iodisation
even in those areas of India which are apparently, iodine
sufficient”.
4.7
In the present context it is not possible to leave the choice
of using iodized or non-iodized salt to individuals in the
community. To do so, would involve considerable inputs
from the point of view of public education and public
health. Therefore, considering the costbenefit ratio, it
would be better to have universal salt iodization for the
whole country. While discussing this, we have to keep in
mind the principles of public health according to which the
health of the overall community takes precedence over
the health of a few individuals or that of a small segment
of the population. Thus, if a segment of the population
living in an iodine-sufficient area is consuming salt
fortified with iodine which is unlikely to cause any major
medical problems, this itself should not prevent universal
salt iodization in our country.
4.8
The Kangra Valley experiment, considered a classic in
public health, clearly demonstrated that adding a small
physiological amount of iodine to common salt either in
the form of iodide or iodate protects all children against
the development of ill-effects of iodine deficiency. During
the past 30 years of the study, no adverse reactions of
significance have been observed in this population. Other
options such as iodised oil, bread, milk, sauce, water etc.
for delivery of iodine had been considered. But salt in
view of its obligatory daily consumption in fixed quantity,
and at low cost, has been accepted as the vehicle of
choice for delivering iodine to all iodine deficient
population groups in the world.
8
5.
Taking into account this large knowledge base about the illeffects iodine deficiency to which Indian scientists have made
significant contributions, the Central Council of Health, the
highest governmental body in the field of health in India,
consisting of Health Ministers from all the States of India
presided over by the Union Health Minister and usually
inaugurated by the Prime Minister took an informed and
historic decision in 1984 to universally iodinate all edible
salt in India by 1990 giving the highest priority to hyper
endemic areas.
The control of endemic goitre had been
included in the Prime Minister’s New 20-Point Programme.
Elimination of iodine deficiency on this planet of ours was
advocated by the World Health Assembly in 1990, by World
Summit for Children in the same year, by the International
Convention on the Rights of the Child and by the SAARC
conference for Children in 1992. India is a signatory to all these
resolutions. Since then, a sea change had been taking
place in the Indian scene. Salt industry had been mobilized
resulting in increased production of iodised salt from a mere
200,000 tonnes in 1983 to 40 lakh tonnes in 1998. All the
states with the exception of Kerala had issued Notification
prohibiting the sale of salt other than iodised salt for edible
purposes. Free trade prevails for iodised salt; however, with a
view to make iodised salt available to the most vulnerable
groups, 20 states and Union Territories have included iodised
salt in the Public Distribution System list fully or partially.
6.
India is making significant advances in the elimination of iodine
deficiency. Over 70% of the population now has access to
adequately iodised in India.
India and several other
developing
countries are
eliminating iodine deficiency.
almost on the brink of
The Director General of the
World Health Organization, Dr. Gro Harlem Brundtland,
addressing the World Health Assembly last year, said : “When
elimination of IDD is achieved, it will be a major and total
public health triumph ranking with small-pox and
poliomyelitis”. Soon India will be free from an age-old
scourge affecting millions upon millions of its people.
Throughout the millenniums behind us iodine deficiency had
been a stealthy drag on the physical, mental and social
9
development of its people. The present PRESS NOTE issued
by the Government has the potential of sending wrong
signals about the lack of interest of the government of
India in the elimination of iodine deficiency, thus leading to
disarray, disaster and dismantling of what had been achieved
so patiently, with mistakes made and corrected, and with
Science solidly behind policy. Now it would appear that
policy had forsaken scientific advance, humanism and
social development.
7.
If, as the Government Notification says no public health policy
should be forced upon people against their free will, then what
about universal immunisation of all children, chlorination of
drinking water supplies, and so many other public health
measures? Are we after Public Health or Health of the Public?
How does government know that iodised salt for prevention of
iodine deficiency is rejected by the people of India? For all we
know from our repeated visits to and studies in the iodine
deficient areas before and after the introduction of iodised salt,
a major transformation is taking place. The wide prevalence of
functional failure of the thyroid in different stages of the life
cycle of people in these villages with impairment of human skills
and learning abilities and productivity so characteristic of pre
iodisation scenario is yielding place now after iodisation to a
scenario of obvious improvement.
There is equally a
remarkable improvement in the laboratory parameters of thyroid
function - hypothyroidism at birth is significantly reduced, goitre
prevalence is going down and urinary iodine levels are rising to
normal.
If the issue is one of loss of employment of some small
scale producers of salt in some parts of the country, efforts are
being made to form salt co-operatives and give them free
equipment and other facilities for salt iodisation. The Salt
Commissioner of the Government of India says that, with
iodisation, employment opportunities had increased. In any
case the problem can be sorted out by mutual discussion of
concerned parties without halting a major national programme.
10
8.
Iodisation is essentially a preventive measure, it prevents future
generations of children from failing to reach their full genetic
potential in cognitive ability, learnability, in enhancing
productivity and in acting as members of society with dignity
and honour.
Won’t Gandhiji be delighted at the improved human
development being witnessed today through correction of
iodine deficiency by the provision of iodised salt? Indeed, he
wrote many years ago in the Harijan :
“I would be hard-hearted enough to let the
sick die, if you can tell me how to prevent
others from falling sick”.
-
11
Mahatma Gandhi
INDIAN MEDICAL ASSOCIATION (H.QS.)
IMA HOUSE INDRAPRASTHA MARG, NEW DELHI - 110 002
‘
'
Telephones : 331 8819,331 8680,331 8053,331 9009
Fax : 91-11-3316270, Telegram : “1NMEDICI” New Delhi
E-inail : inmedici@ndb.vsnl.net.in
DR. PREM AGGARWAL
Hony. General Secretary
Press Release
8th April, 2000
This is matter of deep concern that a statement on behalf of the Prime Minister of India has been
appeared in a newspaper recently that the compulsory iodization of the salt is going to be stoppe
in the country. It was also mentioned in the report that iodization of the salt is done on the behest
of certain multinationals or the lobbies with vested interest. It is also a matter of concern that
such an important socio-medical decision i.e. compulsory iodisation of salt or removing it has
been done by the Prime Minister only on sheer market forces. Indian Medical Association
strongly support of unique universal iodization of salt throughout the country and for the same I
am mentioning the following points :
The Problem: Iodine deficiency disorders are one of the most common public health problems
throughout India. Iodine Deficiency Disorders can be easily prevented by consuming iodized salt,
Iodine Deficiency not only cause Goitre, it can also result in implied brain development in the
fetus and infant and retarded physical and psychomotor development in the child. Even a small
amount of iodine deficiency can lower mental functioning. Iodine deficiency is the commonest
preventable cause of mental retardation in the world.
In the last 50 years, many countries in North America, Asia, Europe and Oceania have
successfully eliminated 1DD, or made substantial progress in its control, largely as a result of salt
iodisation with potassium iodine or potassium iodate and through dietary diversification. For
example, in Switzerland, where salt iodisation began in 1922, cretinism has been eliminated and
goitre has disappeared. There has been no evidence of any adverse effects from iodine intake in
countries with routine salt iodization.
Progress in India: Substantial progress has been made in India in the production of iodised salt
from 3 lakh Metric Tons in 1983 to nearly 42 Lakh Metric Tons in 1997. Similarly, recent IDD
surveys have revealed that more than 70 per cent of population is consuming iodised salt.
Concurrently, the total goitre prevalence and incidence of neonatal hypothyrodism have also
decreased. Estimations of urinary iodine exception levels amongst people indifferent states
indicate that they have adequate iodine intake with iodization of salt.
Most salt is currently iodised according to reports on iodine content of salt samples analysed and
received from different states through the Monitoring Information System (MIS) of the Salt
Department. The production of iodised salt is increasing. Assessment of Thyroid Marker among
goitre prone subjects countrywide show overall prevalence of thyrotoxicists of less than one per
ten thousand population which indicate no increase in the prevalence of hypothyroidism among
houtre zone subject to following salt iodisation.
These findings indicate successful
implementation of USI programme in India. Recently, the scientific journal "Nature" has
commended the Indian Salt iodisation Programme as one of the most successful preventive public
health programme amongst the developing countries.
Coitd.,2..
Res.: 72, Ansari Road, Daryaganj, New Delhi-110002 Tel.: 3283482. 3275831
[ 2 ]
Safety of Iodized Salt in 1970, the Food and Nutrition Board of the National Academy of
Sciences, USA, estimated that a daily intake of 1000 mcg of iodine is safe. In 1980, American
Medical Association noted that no adverse physiologic reactions were observed with iodine intake
up to 1000 mcg per day m healthy adults. Average daily intake of iodine in Japan has been
reported be 3000 micrograms which is 20 times more than the RD A value of 150 mcg in India.
From the average daily intake of 10 g iodine fortified salt, the estimated availability of iodine
would be 150 mcg of which about 30 per cent is lost during cooking. The remaining 105 mcg is
ingested and from this about 70 percent is absorbed by the body. This means approximately only
73.5 mcg is absorbed per day from iodine fortified salt. This quantity when added to the iodine
consumed daily through food will be broadly comparable to the daily physiological need of the
body. Indeed urinary iodine exception studies in the post iodisation phase show that all over the
county, the level achieved following salt iodisation is not more than 300 mcg per day. Thus the
level of iodine intake from iodised salt is safe in our county.
It is not correct to attribute skin reactions such as rashes and acne to iodised salt, Physiological
levels of iodine intake do not cause "lodism". For example, among 20,000 children in the USA
suffering from allergy during the period 1935-1974, not single case was reported of allergic
hypersenstivity to iodine in food. Following publication in Annals of Allergy of a request for
notification of allergy to iodine, not a single report was recorded between 1974 and 1980.
Daily iodine intake of upto 1 mg, i.e. 1000 mcg, appear to be entirely safe. Iodization of salt at a
level that assures an intake of 150-300mcg/day keeps iodine intakes well within daily
physiological needs for all population, regardless of their iodine status. In India, daily
consumption of 10 g of salt containing 15 parts per million of iodine would add a maximum of
only 150 mcg of iodine. Thus, the likelihood of exceeding an iodine intake of 1 mg/day from
iodized salt is quite small.
Whereas IDD is a public health problem in India;
Whereas it can be easily eliminated with the use of iodized salt;
Whereas it has been shown to be safe in India as in the rest of the world;
Whereas there have been objections raised by some ill informed groups on iodization of salt.
Indian Medical Association requests the Prime Minister and all the government agencies to take
this important socio-medical issue having enormous impact on the public health not lightly and
the compulsory iodization of salt should be the routine for the next century in the country which
has no ill effect and extremely beneficial to the masses.
Dr. Prem Aggarwal
Hony. General Secretary
With 70% of population having access to iodised salt, India, which adopted the
policy of Universal Salt Iodisation, is on the brink of elimination of IDD as a
public health problem. The decade of 90’s will be remembered how national
governments, the salt industry, UN agencies, non-governmental organizations,
scientists and practitioners from all sectors have collaborated in the global effort
to reach the common goal of IDD elimination. The experience gained from such
collaborative endeavour will open the door to new opportunities for accelerating
progress in public health.
Prof. V. Ramalingaswami
Keynote Plenary Lecture
8th World Salt Symposium
The Hague (Netherlands)
9th May’ 2000
PRESS INFORMATION BUREAU
GOVERNMENT OF INDIA
PRESS NOTE
WITHDRAWAL OF RESTRICTION ON SALE OF COMMON SALT FOR
DIRECT HUMAN CONSUMPTION
As a part of its drive to prevent iodine deficiency disorders amongst the
general public, the Central Government had issued a notification w.e.f. May 1998
making a mandatory for all manufacturers of edible salt to iodise their product.
However, over a period of time, a strong view has been expressed that such a
public health measure should not be enforced through statutory provisions. It
has been widely perceived that any initiative in this regard to beneficial
components of diet should be propagated through wide-spread publicity and
dissemination of information. It has been argued that, on a point of principle,
compulsion in such matters of individual choice, is undesirable. Taking such
perceptions into account, on 10.5.2000, the Central Government has issued a
preliminary notification proposing a future withdrawal of the compulsory statutory
iodisation of edible salt. The preliminary notification has prescribed a period of
45 days for receipt of views and suggestions of the general public in this regard.
After expiry of this period of 45 days, the Government will consider all the views
received and take a final decision in regard on this issue.
Ministry of Health & Family Welfare, (Department of Health)
New Delhi, Vaisakha 21, 1922, May 11, 2000
12
ISBN No.: 81-86813-11-X
NGOs
Policy Makers
riDD
International
Council for Control of
Iodine Deficiency Disorders
An International Iodine Lab
Network...
A Unique Conference...
W
The goal was to lay the foundation for an international
network, but at the same time addressed specific iodine
quality assessment techniques.
Much ground was covered in two days. One of the best
organized meetings
A Unique Conference...
■ Did not raise more questions than it answered
■ Interesting mix of policy, lab personnel and salt
industry
Hope to have greater participation from the salt
industry in the future
Why an International Network?
■ Concept has merit
■ Can bring “added value” to work at the
national level
An International Iodine Lab ■
Network Can...
■ Strengthen individual labs
■ Facilitate the establishment of regional labs
■ Develop capacity and provide training
■ Provide cost-effective technical assistance within the
region
■ Strengthen assessment, monitoring, and evaluation
An International Iodine Lab ■
Network Can...
Improve and standardize procedures and practices
Facilitate communication between members
Support members through advocacy
Play a role in securing resources
We Are Not Starting From
Ground Zero...
Some labs, with modest resources, can
become highly productive regional
resource labs
Build on the experiences of others
A Proposed Plan of Action
■
Recognized a need to create a simple plan of
action
Required by potential funding agencies
Demonstrates seriousness of our intent
Describes modest initial effort -both realistic
and achievable
A Proposed Plan of Action
■
■ Shows incremental growth of the initiative
■ Supplies potential funders with national
budget
■ Recognized that this is just a rough framework
that requires further refinement
Preparation for a
Global Network - Year 1
■
W
■ Form IDD Lab Network Secretariat, which will
J Define selection criteria for regional resource laboratories
J Select 1 laboratory per region (total of 6 regions) to be
used as core trainers for future regional resource
laboratories
■ Workshop of core trainers to harmonize training materials for
use in training of regional resource laboratories; explore
possibility of distance-based learning where appropriate
Development of Global Network ■
Year 2 and 3
W
■ Core trainers train regional resource laboratories preferably in
both, urinary iodine and salt iodine testing with support
from international agencies-TOT
J Monitoring and data analysis (program managers)
■J Laboratory methods and quality management (laboratory
managers)
J Statistical procedures (program and laboratory managers)
■ Core trainers identify needs for external funding for supplies
and equipment in regional resource laboratories
Development of Regional Networks ■
Year 4 and 5
W
■ Regional resource laboratories could build regional
networks where required or desired
^Provide training
JAgree on common standards
^Develop regional quality assurance programs
^Promote optimal use of existing equipment and
assess infrastructure needs
Financial Needs
- Yearl:
■
-
J Workshop for core trainers (12) - $50,000
■ Year 2 and 3:
J Each core trainer trains 2 regional resource laboratories in
their country (6 regions) - $80,000
J Equipment and supplies - $50,000
J Site visits - $50,000
■ Staff requirements for network activities
^2 at global level (secretariat) - $150,000/year
J 1 in each region (total of 6) - $450,000/year
Sustainability
■ No easy answers
■ Unable to come to grips with it in two days
■ Solutions will have to be based on
•S Local needs and acceptable practices
J Local political commitment
J Creativity of national government and international
organizations
J PAHO revolving fond
■ The initiation of the formation of the network should not wait
on the resolution of all the sustainability issues
Last But Not Least...
Special thanks to the CDC Team...
—Christine Pfeiffer
—Kathy Caldwell
—Mike Kinzer
for their tireless efforts, their endless
patience and their cheerful natures.
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