Progress of IDD Elimination

through Universal Salt Iodization and Strengthening of IDD/USI Monitoring System in Azerbaijan

MISSION REPORT

By Gregory Gerasimov, MD, Dr.Sci.(Med)

UNICEF Consultant

Regional Coordinator

of International Council for Control of Iodine Deficiency Disorders (ICCIDD) for Eastern Europe and Central Asia

BAKU

JUNE 2002

Content

Executive summary 3

Background 7

1. Situation analysis of the status of IDD elimination through universal salt iodization and monitoring of iodine deficiency disorders in Azerbaijan 9

1.1. Iodized salt production and import 9

1.2. Iodized salt consumption at household level 10

1.3. Current status of IDD/USI monitoring system 11

2. Meetings with stakeholders of national IDD elimination program through USI 12

3. Recommendations for creation and strengthening of IDD/USI monitoring system in Azerbaijan 14

4. Asian Development Bank (ADB) micronutrient project in Azerbaijan: a need for closer cooperation in program monitoring 16

Persons met during the mission to Azerbaijan, June 10-15, 2002 18

Executive summary in Russian language 19

Attachment 1 23

EXECUTIVE SUMMARY

In 2001, the Parliament of the Republic of Azerbaijan passed the law on Prevention of Iodine Deficiency Disorders (IDD). This law gives a legal basis for introduction of nationwide system of IDD elimination through universal salt iodization (USI). Articles of this Law (effective of January 2003) stipulate that import, sale and production of non-iodized salt for nutrition and fodder purposes to the territory of the Republic of Azerbaijan shall be prohibited.

The implementation of legislation on IDD elimination through USI requires strengthening of the existing monitoring system for tracking both progress indicators (related to production, distribution and quality of iodized salt) and impact indicators (relating to biological effects of iodine supplementation). However, present status of IDD/USI monitoring system in Azerbaijan, current practices of measuring progress indicators relating mostly to quality control of iodized salt from production/import points to the retail trade (or food industry), and of measuring impact indicators were not well defined. The main purposes of the mission were:

· To provide situation analysis on the status of IDD elimination through universal salt iodization and monitoring of iodine deficiency in Azerbaijan;

· To assist the Government of Azerbaijan and UNICEF in the development and strengthening of IDD/USI monitoring system;

· To draft recommendations/proposals on further project development;

Ample historic knowledge and recent surveys prove that IDD are very prevalent in almost all regions of Azerbaijan. The survey of 942 schoolchildren (aged 8-14 years) from 13 regions showed high prevalence of goiter (86%) especially in the mountainous regions of Caucasus. The median urinary iodine excretion (UIE) was 54 mcg/L, with even lower levels (25-39 mcg/L) in the mountainous regions.

Before 1991 Azerbaijan had limited capacity for salt production and iodized salt was imported from other regions of the Soviet Union. Estimated annual demand for iodized salt for Azerbaijan population is 30-40 thousand tones. In addition to local production, significant amount of iodized salt is imported from Ukraine, Russia, Iran and Turkey. However, official information on import and production of salt, including iodized salt, at this time is neither full, nor reliable. According to most recent information from the custom and state statistics authorities, production, importation and trade of iodized salt is currently monitored, but the quality of information must be significantly improved.

The 2000 Azerbaijan Multiple Indicator Cluster Survey (MICS) provided a nationally representative data of households and status of women in children. According to MICS, 99% of households had salt, which was tested for iodine with rapid field tests. Among the households in which salt was tested, 41,3% had adequately iodized salt. Recent community based survey involving schoolchildren showed that on average from 20 to 50% of households in different regions of Azerbaijan have access to iodized salt. Community based survey of iodized salt consumption on household level is planned by UNICEF in 2002 to update 2000 MICS. The consultant has prepared project proposal, terms of reference and other technical documentation for the NGO that will be selected to conduct the survey.

Currently IDD/USI monitoring system in Azerbaijan is on early stages of development and needs serious improvements. Only one laboratory in the capital city is currently testing iodine in salt. On the production level iodine is tested in salt mainly by qualitative rapid field tests without necessary quantitative backup. There are no facilities for biological monitoring (e.g. measuring of iodine in urine).

UNICEF made significant efforts to improve IDD/USI monitoring in Azerbaijan. Salt producers and Center for Hygiene and Epidemiology received technical support and were provided with laboratories for testing of iodine in salt. In May 2002 UNICEF supported laboratory training of 3 local specialists in Bulgarian national IDD laboratory in Sofia. Participants refreshed their skills in iodine salt testing and were also trained in urinary iodine determination. UNICEF is currently ordering necessary equipment and reagents for the national urinary iodine laboratory.

Meetings with main stakeholders, including Head of Parliamentary Commission for Social Policy, Deputy Minister of Health, other ministerial officials, salt producers, health and nutrition specialists, representatives of civic organizations, showed high level of commitment to implement national legislation of IDD prevention and attain the goal of virtual IDD elimination in coming years.

In the past three years Azerbaijan made a big progress and significantly increased supply of iodized salt to its population (from almost zero in 1998 to 41% in 2000). Presently this country is only few steps away from reaching the World Summit for Children goal of virtual IDD elimination.

Successful implementation of national legislation on the prevention of IDD requires creation of rigorous government monitoring system to track production, import and distribution of iodized salt as well as its impact on health of population. Civic groups and organizations (women and consumer’s NGO, schoolchildren and their families) should be also involved in monitoring of USI on the community level (schools, households). The backbone of IDD/USI monitoring system should be created by the end of 2002. The following recommendation to UNICEF and the Government of Azerbaijan were made based on the results of the mission:

1. Introduction and enforcement of 2001 Azerbaijan Law on Prevention of IDD require development of regulatory basis, including official decrees, executive orders and/or resolutions of several government agencies. Issues of IDD/USI monitoring require special attention from the Ministry of Health, State statistics, Custom and other authorities.

2. The monitoring systems for iodized salt should have three main levels:

- Internal monitoring systems by salt producers and importers/distributors;

- External monitoring systems by the government (Ministry of Health and other agencies);

- Monitoring at the household level (through cross-sectional surveys and community based monitoring).

3. Current gap in normative values of iodine in salt, in the guidelines and officially approved methods for iodine testing in salt should be cleared by the executive order of the Ministry of Health and/or by resolution(s) of Chief State Sanitary Physician.

Based on positive experience of several CIS countries (Ukraine. Russia, Belarus, Kazakhstan and others), as well as on WHO/UNICEF/ICCIDD guidelines “Recommended Iodine Levels in Salt and Guidelines for Monitoring their Adequacy and Effectiveness” it is recommended to the Azerbaijan government to set for the following requirements for iodized salt:

- The level of iodine in salt shall be 40 +/- 15 mg/kg (parts per million, ppm),

- The use of both potassium iodate (KIO3) and potassium iodide (KI) for salt fortification shall be permitted. However, preference should be given to the use of potassium iodate as this substance is more stable and increases stability and shelf-life of iodized salt,

- Provisional 12 months shelf life period for iodized salt fortified with potassium iodate and 6 months for iodized salt fortified with potassium iodide should be established. These periods could be subsequently increased based on results of stability studies. After the expiry of 6 or 12 months of shelf life, iodized salt may not be traded and must be utilized for technical purposes only.

- The following requirements must be set for labeling of iodized salt: the package must have a clear sign “Iodized Salt”, date of production, iodine content, compound used for iodization (potassium iodate or iodide), shelf life. Information about benefits of the consumption of iodized salt should be also recommended on salt packages.

4. The government should also develop and implement a procedure for licensing producers of iodized salt (per article 8.2. of the Law on IDD Prevention) and procedures for warning, publicizing, fining and banning for the non-compliance to the rules and regulations regarding quality of iodized salt.

5. Support should be provided to constant monitoring of iodized salt on the household level. Community based monitoring may be organized in the communities through the schools, by providing rapid test kits to community midwives and doctors, school teachers, environmental activists and members of youth and women civic organizations.

6. Efforts from both the government and UNICEF should be made to strengthen the system of biological (impact) monitoring. This may include procurement of equipment and training of laboratory staff in urinary iodine measurement (supply list for urinary iodine laboratory has been developed), organization of pilot regional surveys in most affected regions of the country in 2002-2003, and preparation for national IDD survey for program evaluation in 2004.

Additionally, on the meeting with Dr. Tahmina Taghi, Country Coordinator for Asian Development Bank (ADB) Regional Project “Improving Nutrition for Poor mothers and Children” it was recommended to request a visit of international consultant to iodized salt production sites in Azerbaijan to develop recommendations for upgrading iodized salt production with ADB funds. $800,000 grant has been provided to the government of Azerbaijan to improve nutrition of poor mothers and children through fortification of salt with iodine and flour with iron. Specifically this would be extremely beneficial for Naxcivan salt plant that supplies iodized salt to population of this enclave that has restricted direct communication with the rest of Azerbaijan territory. Results of 2000 MICS showed that this regions has the lowest level of household iodized salt consumption – only 11%.

These recommendations were delivered on one-day refreshment training and supported by membership of Intersectoral National Committee on Nutrition and Micronutrients.

Background

In 2001, the Parliament of the Republic of Azerbaijan passed the law on Prevention of Iodine Deficiency Disorders (IDD). This law gives a legal basis for introduction of nationwide system of IDD elimination through universal salt iodization (USI). An Article 8.3 of the above-mentioned Law (effective of January 2003) defines that “import, sale and production of non-iodized salt for nutrition and fodder purposes to the territory of the Republic of Azerbaijan shall be prohibited”. The IDD Law proves the government commitment to eliminate IDD through USI in Azerbaijan in the coming years.

The implementation of legislation on IDD elimination through USI requires strengthening of existing monitoring system for tracking both progress indicators (related to production, distribution and quality of iodized salt) and impact indicators (relating to biological effects of iodine supplementation).

Article 5.0.1. of the Law requires regular monitoring, on the annual basis, of IDD and the efficiency of preventive measures as well as reporting of the results to the concerned bodies. Another Article (6.2.) stipulates quality and safety monitoring of iodized salt.

Articles of Azerbaijan Law “On Prevention of Iodine Deficiency Disorders” related to monitoring of IDD and quality control of iodized salt

(translation by UNICEF Office).

5.1.1. For monitoring purposes annual assessment of the dynamics of Iodine deficiency disorders and the efficiency of preventive measures taken and reporting the results to the concerned bodies;

6.2. To identify the compliance of quality and safety indicators of iodized salt with the standards and requirements the examination of samples taken from salt shall be made by the appropriate executive power agency.

7.1. The amount of iodine in the structure of salt shall be identified by the appropriate executive authority.

7.3. The processing, packaging, labeling, storage, transportation and sale of the iodized salt imported into the Republic of Azerbaijan and produced in the Republic shall be implemented complying with appropriate standards and requirements.

7.4. The rules for the use of the salt with expired date, its’ reprocessing, and reiodization shall be specified by the appropriate executive power agency.

8.1. The iodized salt produced in the territory of the Republic of Azerbaijan shall be certified according to the procedures stipulated in the legislation of the Republic of Azerbaijan for the purposes of identifying the compliance of quality and security indicators of iodized salt with the appropriate standards and requirements.

However, the present status on IDD/USI monitoring system in Azerbaijan, current practices of measuring progress indicators relating mostly to quality control of iodized salt from production/import points to the retail trade (or food industry), and of measuring impact indicators relating is not well defined. For this reason, UNICEF Office in Azerbaijan requested the assistance of an international consultant to perform situation analysis on the status of IDD elimination through USI and monitoring of iodine deficiency in Azerbaijan and provide assistance in the development and strengthening of IDD/USI monitoring system.

Objectives of the mission:

· To provide situation analysis on the status of IDD elimination through universal salt iodization and monitoring of iodine deficiency in Azerbaijan;

· To assist the Government of Azerbaijan and UNICEF in the development and strengthening of IDD/USI monitoring system;

· To draft recommendations/proposals on further project development;

Work assignment

a) To review, in collaboration with national counterparts, current status of IDD elimination program in Azerbaijan;

b) To review the status of IDD/USI monitoring system and make recommendations for its strengthening

c) To assess the technical conditions of laboratory(ies) for determination of iodine in salt and urine, including needs for training for personnel and procurement of necessary equipment and reagents;

d) 1-2 days refreshment training for the personnel on implementation of a plan on monitoring and elimination of iodine deficiency disorders.

e) Draft recommendations/proposals on further project development, including the feasibility of launching national progress review to support implementation of legislation on IDD elimination through USI.

f) Review and draft recommendations on IDD/USI National Program including plan of actions

1. Situation analysis of the status of IDD elimination through universal salt iodization and monitoring of iodine deficiency disorders in Azerbaijan

Iodine Deficiency Disorders (IDD) remain the major health and socio-economical problem in Azerbaijan. Recent publication by researchers from Greece and Azerbaijan “Iodine Deficiency in Azerbaijan after the discontinuation of iodine prophylaxis program: reassessment of iodine intake and goiter prevalence in schoolchildren” by K.Markou et al (Thyroid, 2001, v.11, N2, p.1141-1146) outlines the current status of the problem. The survey of 942 schoolchildren (aged 8-14 years) from 13 regions showed high prevalence of goiter (86%) especially in the mountainous regions of Caucasus. The median urinary iodine excretion (UIE) was 54 mcg/L, with even lower levels (25-39 mcg/L) in the mountainous regions. These data emphasize the need for urgent measures to combat iodine deficiency nation-wide.

1.1. Iodized salt production and import.

Information on production and import of iodized salt in Azerbaijan is very limited. Annual requirement for salt for human consumption for Azerbaijan (based on population of 8,5 million and mean per capita consumption of 3,5 kg of salt per year) is close to 30,000 tones (the Salt Situation Analysis performed in 1999 gives the requirement for iodized salt for Azerbaijan in the amount 40,000 tones).

Before 1991, production of salt in Azerbaijan was limited to Naxcivan State Salt Factory, while most of salt was imported from other regions of the Soviet Union. Still, major part of salt for human consumption is imported from Ukraine, Russia, Iran and Turkey and from Turkmenistan for industry purposes. There are more than 80 companies that import salt to Azerbaijan.

In 1999-2000 the country UNICEF office collected information on iodized salt production and import from individual salt producers and from custom authorities. Based on official information of custom office, during first 9 months of 2000 import of salt (by 84 companies) to Azerbaijan amounted to 37,084 tones, while export (127 tones) was almost negligible. There is no information on what proportion of imported salt was used for human consumption and what part of this edible salt has being iodized.

According to information collected by UNICEF office, production of edible salt by 6 salt producers in 2000 reached 4,873 tones; 3,345 tones (67%) were iodized. Almost all iodized salt was produced by company “Dilek” (2,950 tones).

Recent official information on production and import of salt in Azerbaijan is rather confusing. Production of salt in 2001 was 3,734 tones, while 535 tones (14,3%) were iodized. In 2001 the retail outlets traded 17,048 tones of salt (about 50% of calculated requirements), including 1,695 tones (less than 10%) of iodized salt. Custom reported importation of 3,680 tones of salt in the Q1 of 2002 with only 7% (256 tones) of iodized salt. These data contradicts with data of MICS (2000) and subsequent independent reports showing much higher consumption of iodized salt on the household level (table 1). Clearly, official information on import and production of edible salt and iodized salt at this time is neither full, nor reliable. Significant part of salt could be traded through the “gray market” to avoid VAT and other taxes (a common practice in many countries of the former USSR with transition economies). Additionally, there are local small (cottage type) salt producers that are difficult to control and monitor.

According to most recent information from the custom and state statistics authorities, production, importation and trade of iodized salt is currently monitored, but the quality of information must be significantly improved.

1.2. Iodized salt consumption at household level.

The 2000 Azerbaijan Multiple Indicator Cluster Survey (MICS) provided a nationally representative data of households and status of women in children. According to MICS, 99% of households had salt, which was tested for iodine with rapid field tests. Among the households in which salt was tested, 41,3% had adequately iodized (containing > 15 mg of iodine per kg of salt). The percentage of households with adequately iodized salt ranges from 11% in Naxcivan to almost half of households in other provinces. Urban households are more likely and poor households are less likely to use iodized salt.

While data of MICS provides with most recent official information on household iodized salt consumption, there are other reports from community surveys performed independently in schools (data collected by the Ministry of Education) by teachers and schoolchildren using rapid tests. Data of these independent studies are generally in good agreement with MICS, showing that 20-50% of households used iodized salt (Table 1).

Currently, UNICEF is arranging another community survey in 30 districts of the country through consumers’ rights protection NGO that will give an estimate of current use of iodized salt in different regions of the country. This is certainly an important study and UNICEF should continue to support IDD/USI monitoring activities on community level. The consultant prepared project proposal, terms of reference and other technical documentation for the NGO that will be selected to conduct the survey.

Table 1. Proportion of households consuming iodized salt in Azerbaijan (January-April, 2002) according to data of community based surveys in schools (Report of the Ministry of Education to UNICEF)

Districts	% of iodized salt	Districts	% of iodized salt
1. Qebele	59,8	Oguz	14
2. Sabirabad	13,6	Berde	22,3
3. Ismaylii	19,3	Astara	15,6
4. Qax	51,6	Qusar	13,3
5. Deveci	20,3	Zagatali	14
6. Ali-Bayramli	12,6	Samahi	23,6
7. Celilabad	18,6	Ucar	31
8. Agdash	24,3	Sheki	27
9. Qobustan	33,3	Salvan	27,3
10. Saatli	13,6	Bilasuvar	40
11. Goycay	20,6	Lenkeran	60
12. Masalli	22,6	Quba	33,3
13. Xacmaz	30,6	Ter-Ter	44,6
14. Siazan	10,6	Agsu	47,3
15. Imishli	29	Kurdamir	36

1.3. Current status of IDD/USI monitoring system

Efficient IDD/USI monitoring system should cover production (import), distribution and trade of iodized salt using indicator to monitor and evaluate the salt iodization process (process indicators). These indicators involve iodine content in salt at the production site, point of packaging (if different from the production site), wholesale and retail levels, and in households. Impact indicators are used to assess baseline IDD status and to monitor and evaluate the impact of salt iodization on the target population. Impact indicators are used for the biological monitoring. The principal impact indicator recommended by WHO/UNICEF/ICCIDD involves urinary iodine levels. Changes in goiter prevalence lag behind changes in iodine status and therefore cannot be relied upon to reflect accurately current iodine intake, although they may be use useful in following trends[1].

Currently IDD/USI monitoring system in Azerbaijan is on early stages of development and needs serious improvements. Only one laboratory in the Center for Hygiene and Epidemiology in Baku is currently testing iodine in salt. However, in 2001 this laboratory made only 15 quantitative tests for iodine in salt. Even on production level iodine is tested in salt mainly by qualitative rapid field tests without necessary quantitative backup. There are no facilities for biological monitoring (e.g. measuring of iodine in urine).

UNICEF made significant efforts to improve IDD/USI monitoring in Azerbaijan. Salt producers and Center for Hygiene and Epidemilogy received technical support and were provided with laboratories for testing of iodine in salt. In 2001 UNICEF organized a workshop on IDD/USI monitoring in Baku and invited international consultant (Dr. L.Ivanova from Bulgaria) to train laboratory staff in iodine salt testing. In 2002 UNICEF supported laboratory training of 3 local specialists in Bulgarian national IDD laboratory in Sofia. Participants refreshed their skills in salt iodine testing and were also trained in urinary iodine determination. UNICEF is currently ordering necessary equipment and reagents for the national urinary iodine laboratory.

2. Meetings with stakeholders of national IDD elimination program through USI.

In the Ministry of Health of Azerbaijan I had a privilege to meet with Dr. Abas Velibeyov, First Deputy Minister of Health, Chief State Sanitary Physician of Azerbaijan, Dr. Victor Gasimov, Chief of Hygiene and Nutrition Department of the Ministry, Dr. Rosa Huseinova, National Coordinator of IDD/USI program, Dr. Alexandr Umnyashkin, Chief of