REGIONAL OFFICE FOR CENTRAL AND EASTERN EUROPE,

COMMONWEALTH OF INDEPENDENT STATES AND

THE BALTIC STATES

Progress of IDD Elimination through Universal Salt Iodization

in the Czech Republic, Slovakia, Hungary and Poland

OVERVIEW REPORT

by Gregory Gerasimov, MD

ICCIDD Regional Coordinator for Eastern Europe and Central Asia

UNICEF Consultant

March, 2002

TERMS OF REFERENCE

Work Assignment

The Consultant will prepare 4 overview reports (one per country) on the progress of IDD elimination through USI in Poland, Czech Republic, Slovakia and Hungary. This will include:

- Collection and collating available information on IDD in the 4 countries (including data on recent surveys of goiter prevalence and urinary iodine excretion) and make a conclusion on whether iodine nutrition is sufficient;

- Review existing data on production, import and distribution of iodized salt in relation to expected demand;

- Make recommendations to the Regional Office on future activities in these countries, including expediency of partnership evaluation of IDD elimination through USI.

CONTENT

EXECUTIVE SUMMARY 3

INTRODUCTION 6

Issues of Universal Salt Iodization 7

Indicators of Iodine Nutrition 7

COUNTRY REPORTS

1. THE CZECH REPUBLIC

1.1. Legislative environment and national IDD/USI program 11

1.2. Status of iodine nutrition of population 11

1.3. Production and distribution of iodized salt 12

1.4. Conclusion 12

1.5. Recommendations 13

1.6. Literature 13

2. SLOVAKIA

2.1. Current status of iodine nutrition of population 14

2.2. Conclusion 14

2.3. Recommendations 14

2.4. Literature 15

3. HUNGARY

3.1. Current status of iodine nutrition of population 16

3.2. Conclusion 16

3.3 Recommendations 16

3.4. Literature 17

4. POLAND

4.1. Legislative environment and national IDD/USI program 18

4.2. Status of iodine nutrition of population 18

4.3. Production and distribution of iodized salt 19

4.4. Poland IDD Review 19

4.5. Conclusion 20

4.6. Recommendations 20

4.7. Literature 20

EXECUTIVE SUMMARY

The UNICEF-WHO Joint Committee on Health Policy in 1993 agreed upon recommending universal salt iodization (USI) in countries where iodine deficiency disorders (IDD) are a public health problem. Universal iodization of all salt for human and animal consumption, including the salt used in food processing, is feasible, cheap, safe, rapidly effective and widely accepted.

The problem of iodine deficiency in European countries has been greatly underestimated for several decades. After initial successful efforts to combat endemic goiter in 1940s-1950s with iodized salt, IDD were generally considered no longer a significant health problem in Europe. Situation has been re-evaluated in early 1990s with the development of more sensitive methods to assess IDD (urinary iodine determination and goiter assessment by ultrasonography method). WHO, UNICEF and ICCIDD agreed upon the following criteria of IDD elimination through USI in affected countries: proportion of households using adequately iodized salt must be more than 90% nationwide; median urinary iodine level must be above 100 mcg/L while values below 50 mcg/L should be limited to less than 20%.

After World Summit for Children (1990) and several important European meetings several countries of Central Europe pledged elimination of IDD. This Report provides an overview of the progress of IDD elimination through USI in the Czech Republic, Slovakia, Hungary and Poland. The amount and quality of information on IDD control in these countries is different: situation is much better studied in Poland and the Czech Republic while data on iodine nutrition and especially iodized salt production are very scarce in Slovakia and Hungary.

In spite of the significant progress achieved over the past decade, iodine nutrition of population in the Czech Republic is not fully adequate and mild iodine deficiency is still persisting. USI is this country is limited to household (table) salt. However iodized table salt constitutes only relatively small part of integral salt consumption by population. In developed countries of Western and Central Europe about 80% of salt is consumed in processed foods such as bread, sausage, canned and other ready-to-eat foods (so called “hidden salt”). Only insignificant part of this “hidden salt” in the Czech Republic is iodized. The use of iodized salt and premixes in agriculture are also limited leading to iodine deficiency of cattle and, hence, of milk and dairy products. Expanded use of iodized salt in food industry (especially in baking and for meat procession) and in public catering may further increase proportion of iodized salt and lead to normalization of iodine nutrition.

In late 1990s Slovakia has reached optimal iodine nutrition of its population through USI. The data on the production and distribution of iodized salt is not complete, but available information suggests that normalization of iodine nutrition has been reached through iodization of salt both for household consumption and for food industry. Thus, Slovakia could be a priority country for partnership review of IDD elimination through USI.

Iodine nutrition in Hungarian population is still not optimal with large variations of iodine supply across the country. USI is not introduced in this country: production and import of iodized salt is voluntary. There is no information on the proportion of iodized salt on retail market in relation to common salt; iodized salt is also not used in food industry.

In the decade of 1990s Poland made a huge step towards elimination of IDD in its population and implemented rather efficient model of iodine prophylaxis based on mandatory production and distribution of household iodized salt. However, the goal of optimal iodine nutrition has not been met and additional measures to improve iodine supply to population are needed, including upgrading the quality of iodized salt and iodization of salt for animal nutrition and for the food industry.

Table 1 summarizes progress achieved by four countries in relation to WHO/UNICEF/ICCIDD criteria for sustainable IDD elimination.

Table 1. Progress of IDD control through USI in the Czech Republic, Slovakia, Poland and Hungary in relation to WHO/UNICEF/ICCIDD criteria for sustainable IDD elimination

CRITERIA	THE CZECH REPUBLIC	SLOVAKIA	POLAND	HUNGARY
Urinary Iodine Values (mcg/L)	85-87	130-143	Below 100	52-115
The proportion of households consuming effectively iodized salt	N/A	N/A	N/A	N/A
IDD/USI monitoring system in place	Yes	Yes	Yes	Yes
Recent monitoring data (within 2 years)	Yes	Yes	Yes	Yes
Availability/access to laboratories for iodine in salt and urine	Yes	Yes	Yes	Yes
Legislation or regulations on USI	Mandatory iodization of household salt only	Mandatory iodization of all salt for human consumption	Mandatory iodization of household salt only	Voluntary salt iodization
National IDD committee or council	Yes	Yes	Yes	Yes
Evidence of political commitment to the elimination of IDD and USI	Yes	Yes	Yes	+/-
A program of public education on IDD/USI	Yes	N/A	Yes	N/A

NA – Data Not Available; +/- Difficult to Estimate

In terms of iodine supply though iodized salt only Slovakia has published data revealing optimal iodine supply to population. However, this information is based on several small-scale and regional assessments, rather than on a nationwide survey. In other three countries iodine nutrition remains marginally low. Information on iodized salt production and consumption (if available at all) in the Czech Republic, Slovakia, Poland and Hungary is based on production/supply figures, data on the proportion of households consuming effectively iodized salt are lacking. All four countries have IDD monitoring system in place with laboratories for measurement of iodine in salt and urine.

All countries, except Hungary, have legislation/regulation on USI; however only in Slovakia this regulation covers all salt for human consumption (and effectively results in optimal iodine supply). In Poland and the Czech Republic USI is limited to household (table) salt only. In Hungary the use of iodized salt is still voluntary. All countries have National IDD Committees (or Councils) and are committed to the elimination of IDD and USI (situation is not clear in Hungary where decision on USI has not been reached).

Recommendations

· Partnership Review of IDD elimination through USI may be considered in Slovakia. However, a nationwide assessment of the proportion of households consuming effectively iodized salt and evaluation of iodine nutrition (based on urinary iodine levels in representative sample of population) should be conducted in this country prior to Partnership Review. Partnership review of IDD elimination through USI is currently NOT expedient in Poland, the Czech Republic and Hungary (median urinary iodine levels are below 100 mcg/L, at least in some regions of these countries).

· Taking into account relatively high consumption of household salt by Polish population (about 6 g per day), mandatory iodization of all table salt should result in more adequate iodine nutrition of population. Polish national authorities should consider increasing the level of salt iodization (to internationally recommended level of 40 ppm) and shifting to more stable KIO3. These measures could increase the quality of iodized salt (currently only 47% of salt contains the recommended iodine content) and elevate iodine supply. Lifting a ban over the use of iodized salt by food industry should be also considered.

· Nationwide surveys to assess the proportion of households that are currently consuming adequately iodized salt should be considered in Poland, the Czech Republic, Slovakia and Hungary;

· IDD/USI Program Review (using ISPAT tool) may be conducted in Poland, the Czech Republic and Hungary to outline ongoing problems and to decide on future steps to reach sustainable IDD elimination in these countries. UNICEF may provide external support for the Program Review, if requested.

· Representatives of Poland, the Czech Republic, Slovakia and Hungary should be invited to all future European IDD/USI Advocacy meetings.

INTRODUCTION

The problem of iodine deficiency in European countries has been greatly underestimated for several decades. Initial efforts to combat endemic goiter were launched in several western and central European countries in late 1940s and early 1950s. After remarkable studies on the effects of iodine deficiency and their prevention through salt iodization, iodine deficiency disorders (IDD) were generally considered no longer a significant health problem in Europe.

However, surveys carried out in 1980’s under the auspices of the European Thyroid Association (ETA), clearly demonstrated the persistence of iodine deficiency in many countries, including Czechoslovakia, Poland and Hungary [R.Gutekunst and P.Scriba, 1989]. Moreover, several European countries were affected by large radioactive contamination (mainly with radioactive iodine) which has occurred after the Chernobyl accident in 1986. The uptake of radioactive iodine by the thyroid gland increases in the situation of environmental iodine deficiency. Important reason to introduce iodine prophylaxis in many countries is an increased risk for the development of thyroid tumors from an insufficient iodine supply in the case of radioactive fallout.

An International Workshop “Iodine Deficiency in Europe: a Continuing Concern” held in Brussels, Belgium, on April 24-28, 1992 was an important milestone in the process of revitalization of IDD control programs in Europe. Based on results on this meeting, the European office of the WHO recommended all European governments to establish, support and fund a multisectoral national committee in charge of iodine deficiency and introduce legislation to ensure availability of iodized salt.

Numerous IDD surveys have been conducted before and after the Brussels meeting in several parts of Europe hitherto almost unexplored. In 1995-1996 a standardized study of iodine deficiency (“ThyroMobil Project”) was conducted in 12 European countries, including Poland, Czech Republic, Slovakia and Hungary under the auspices of ICCIDD, WHO and UNICEF. The mobile unit (“ThyroMobil” van) visited schools is all sites of the countries under investigation. Results of this study published in 1997 [F.Delange et al. 1997] provided an important update on iodine nutrition in Europe. In general, apart from regions with optimal iodine supply, mild and even moderate iodine deficiency was persisting in surveyed countries.

In 1997 three international agencies charged with leading fight against IDD (UNICEF, WHO and ICCIDD) have organized a Regional Conference on elimination of IDD in Central and Eastern Europe, the CIS and the Baltic States (Munich, September 3-6, 1997).One of the objectives of the conference has been a review of the current status of iodine nutrition in CEE/CIS/BS region. The Proceedings of this meeting provided another important update of situation in 4 Central European Countries.

Regional Salt Producers’ Meeting for Central and Eastern Europe, CIS and the Baltic Region (29 September – 1^st October 1999, Kiev, Ukraine) provided another piece of important information on production and supply of iodized salt and current status of iodine nutrition in several European countries.

This Report is based on the analysis of available scientific information on status of iodine nutrition, progress in IDD elimination, production and supply of iodized salt in Poland, the Czech Republic, Slovakia and Hungary. The amount and quality of information on IDD control in these countries is different. Situation is much better studied in Poland and the Czech Republic while data on iodine nutrition and especially iodized salt production are very scarce in Slovakia and Hungary.

Issues of Universal Salt Iodization

The UNICEF-WHO Joint Committee on Health Policy in 1993 agreed upon recommending universal salt iodization (USI) in countries where iodine deficiency disorders are a public health problem. Universal iodization of all salt for human and animal consumption, including the salt used in food processing, is feasible, cheap, safe, rapidly effective and widely accepted. During the remainder of the decade, USI became the essential strategy for the elimination of iodine deficiency in all countries that have formulated national action plans. In 1990, less than 10% of the edible salt was being iodized. Prompted by a commitment made at the World Summit for Children, a significant increase occurred in the production and supply of iodized salt in most countries of the world. By the end of 1999, the proportion of households having access to iodized salt had improved to more than 70%, providing additional iodine to nearly 4 billion people worldwide, with the result that goiter rates are falling and that the intellectual promise for newborns and young children is improved.

Figure 1 shows main pathways for use of salt in the modern society. In developed countries, industrial requirements are several times the edible consumption. In the USA and Western Europe, for instance, nearly 97% of the total production of salt is used for technical (non-edible) purposes. In the developing countries, the trend towards increased industrial demand is becoming apparent only during past two decades and up to 90% of salt is used for human consumption, mainly as household (table) salt.

A high intake of salt is a factor contributing to the development of hypertension and cerebrovascular disease, therefore it is recommended that the consumption of salt be limited to 5-6 g a day. In Western and Central Europe about 80 % of salt is consumed in processed foods such as bread, sausage, canned and other ready-to-eat foods. However, the use of iodized salt for food processing is not mandatory in most European countries. Moreover, some European countries (France, Great Britain, Poland) are even prohibiting the use of iodized salt in food industry. Taking into the account that many Central European countries (Poland, Hungary and others) are exporting significant amounts of their agriculture products, the use of iodized salt in food industry in these countries is also restricted. Unfortunately, the European Unions lacks agreed upon policy on the control of iodine deficiency and on universal salt iodization.

Indicators of Iodine Nutrition

There are two main impact indicators to assess severity of iodine deficiency and track progress of its elimination.

IMPACT INDICATORS AND SEVERITY OF IODINE DEFICIENCY

[WHO, UNICEF, ICCIDD. Assessment of Iodine Deficiency Disorders and Monitoring their Elimination, Geneva, WHO. WHO/NHD/01.1, 2001]

	Severity of public health problem
Indicator	None	Mild	Moderate	Severe
Median urinary iodine concent-ration (mcg/L)	> 100	50-99	20-49	< 20
Goiter prevalence	< 5%	5.0 - 19.9%	20 – 20.9%	> 30%

More recently, WHO, UNICEF and ICCIDD have adopted the iodine concentration in urine as the primary indicator for tracking progress in IDD control programs. Because most of ingested iodine is excreted in the urine, the measurement of iodine in urine is highly sensitive indicator of the iodine content in diet. In the individual, the amount of iodine in the urine can be quite variable depending on the number of factors. However, at the population level, the median level of urinary iodine from a representative sample of the population provides an estimate of the average amount of iodine in the diets. If iodine concentration of the population is adequate, then one can feel assured that the brains of newborns are being protected from IQ loss because of iodine deficiency [J.Gorstein, 2001].

In 2001 WHO, UNICEF and ICCIDD developed comprehensive Criteria for Sustainable Elimination of IDD [WHO, UNICEF, ICCIDD. Assessment of Iodine Deficiency Disorders and Monitoring their Elimination, Geneva, WHO. WHO/NHD/01.1, 2001]. A prerequisite of the sustainable elimination of iodine deficiency as public health problem is normal iodine nutrition confirmed by urinary iodine determination when median urinary iodine level in nationally representative sample of population is equal or above 100 mcg/L. If iodized salt is the vehicle for eliminating iodine deficiency, as in almost all countries, the proportion of households consuming effectively iodized salt must be more than 90%. Several other criteria must guarantee availability and sustainability of consumption of adequately iodized salt by population (see below).

These criteria are used to assess progress in IDD control in Poland, Czech Republic, Slovakia and Hungary and for preparation of recommendations to the Regional UNICEF Office on future activities in these countries, including expediency of partnership evaluation of IDD elimination through USI.

Literature

1. R.Gutekunst, P.Scriba. Goiter and iodine deficiency in Europe. The European Thyroid Association Report as updated in 1988. J.Endocrinol. Invest. 1989, v. 12, p.209-220

2. Iodine Deficiency in Europe: a Continuing Concern. F.Delange, J.Dunn and D.Glinoer, eds. Plenum Press, NY and London, 1993, p.377-382

3. F.Delange et al. Thyroid volume and urinary iodine in European schoolchildren: standardization of values for assessment of iodine deficiency. European J. of Endocrinology, 1997, v.136, p.180-187

4. Elimination of IDD in Central and Eastern Europe, the CIS and the Baltic States. Proceedings of a Conference held in Munich, <