Iodine Deficiency Disorders (IDD) in the Russian Federation:

A Review of Policies towards IDD Prevention and Control and Trends in IDD Epidemiology (1950-2002)

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

ICCIDD Regional Coordinator for Eastern Europe and Central Asia

UNICEF Consultant

Moscow - 2002

Content

Executive Summary……………………………….

1. Introduction………………………………………...

2. Experience of Soviet Program of Endemic Goiter Prevention in Russia

2.1. Pioneer studies (end of 19^th – first part of 20^th Century)

2.2. Start of endemic goiter control programs in Russia (1933-1955)

2.3. Success of endemic goiter control program in the former USSR (1956-1970)

2.4. Production and supply of iodized salt in the USSR (1948-1966)

2.5. Other methods of EG control in 1950s-1980s

2.6. Abandoned child: endemic goiter control in 1970-1990

2.7. International Symposium “The Elimination of Iodine Deficiency Disorders”, Tashkent, November 1991

2.8. Production and supply of iodized salt in the USSR (1970-1990)

2.9. Achievements and gaps in EG control in the USSR (1930 – 1990)

3. Current progress of IDD control and prevention in the Russian Federation

3.1. From endemic goiter to iodine deficiency disorders

3.2. New epidemiological criteria used in IDD surveys (1991-2000)

3.3. Earlier IDD surveys in Chernobyl - affected regions of Russia.

3.4. Earlier surveys in Moscow and Moscow district

3.5. Surveys in Western and Eastern Siberia

3.6. Synopsis of epidemiological studies of iodine deficiency in Russia in 1991-2000

3.7. Iodized salt production in Russia (1997-2002)

3.8. Other methods of iodine supplementation

3.9. Development of legislative and regulative framework

3.10. Recent trends in iodine nutrition of the Russian population

3.11. Role of bilateral and international agencies in resuming of IDD prevention program in Russia (1997-2002)

4. Conclusion and recommendations

References

Acknowledgements

Annex 1

Executive Summary

Extensive review of the scientific literature revealed that during 1955-1970 iodine deficiency in Russia was virtually eliminated (as evidenced in significant reduction of endemic goiter prevalence and elimination of most severe manifestations of IDD, such as cretinism. This was accomplished by a mix of measures, including significant production of iodized salt (up to 1 million tones annually, or 4.5-5 kg per capita of population), iodine tablets distributed in specific target populations, principally women and children in critical areas; and careful monitoring.

The main shortcoming of IDD/endemic goiter control in the USSR was its limitation only to “endemic goiter” areas. There was no legislation for universal salt iodization and IDD prevention was regulated by administrative mechanisms of fully centralized Soviet economy. Iodized salt was supplied to endemic goiter areas as identified on the list provided by the Ministry of Health. However, iodization of all edible salt was not mandated for the salt industry. In 1970s-1980s iodine deficiency gradually returned when supervision waned, and when regular effective monitoring reduced. Because of broader economic and political problems, the system of IDD/endemic goiter control started deteriorating and finally collapsed with the break up of the country in 1991.

Reinstitution of IDD program in Russia requires high level advocacy based on scientific evidence of the existence of significant iodine deficiency nationwide. Results of extensive epidemiological studies carried out in Russia in 1991-2001 revealed that population in all surveyed areas is exposed to some degree of iodine deficiency. Iodine deficiency is present in big cities and industrially developed areas, it is generally more severe in rural than in urban regions, and in eastern (Asian) part compared to western (European) part of the country. Iodine deficiency is also present in districts that have not been earlier considered as “endemic for goiter”. Results of these surveys provided solid background for high level advocacy, also on the part of international and bi-lateral organizations and donors.

The whole concept of IDD prevention in the Soviet Union was meant for an extremely centralized state management system for iodized salt production and distribution. In early 1990s, many salt enterprises and almost the entire wholesale and retail trade system were privatized. After the collapse of the Soviet Union, there was essentially no legislative framework left in Russia for conducting IDD prevention program under the conditions of a market economy. As a result, this program was practically curtailed, and production of iodized salt was almost non-existent. However, by 2002, Russian salt producers have built up sufficient production capacities for iodized salt (up to 700,000 tones annually), refurbished the production facilities, drawn up and introduced new advanced quality standards based on international experience, and improved iodization, quality assurance and the packaging of iodized salt. The supply of iodized salt to Russian population increased from less than 20,000 tones in 1997 to nearly 140,000 in 2001. It is safe to state now that there are no longer any real obstacles in the Russian salt industry to fully meeting the county’s demand for iodized salt. However, presently production of iodized salt covers less than 30% of potential demand.

The advanced monitoring system for iodized salt (production and quality control) has been introduced in Russia from 2000. Preliminary results of monitoring showed significant improvement of iodized salt quality. Hence, 10% of salt tested in 2001 did not meet requirements in iodine content. Biological monitoring system is gradually strengthening with network of urinary iodine laboratories established in 1998. Recent surveys showed that with introduction of iodized salt iodine deficiency in some regions was reduced, but not eliminated.

Policies of IDD prevention are currently stipulated by the Resolution of the Government (1999) that set for voluntary model of IDD prophylaxis. In the absence of mandatory legislation, the supply of iodized salt to households and food industry depends on demand by the retail traders, and hence, large and small consumers. Efforts to increase “public demand” will unlikely be sufficient enough to achieve 90% of households consuming iodized salt in the next few years. A comprehensive legislative framework with a strong enforcement system is needed that requires mandatory iodization of all food-grade salt (table salt and salt for food processing). This requires high level advocacy, including concerted efforts from international (UNICEF, WHO, FAO) and bi-lateral organizations and donors.

1. Introduction

Earlier data on IDD in Russia are sparse with most of original papers published in Russian language in national journals and proceedings of local scientific meetings. Since endemic goiter (EG) in the Soviet Union have been considered to have been under control, or eliminated, this problem (until very recent time) attracted little attention of medical doctors and scientists. In 1986, the European Commission on IDD failed to receive any information on IDD in the USSR [1].

Indeed, at some time (in 1950s – 1970s) the Soviet Union made a significant progress in IDD prevention through the mix of measures, including mass production of iodized salt and iodine supplementation of risk groups. However, as in some other countries, IDD returned when supervision waned (in 1970 monitoring of EG in USSR was abrogated), public interest decreased and resources reallocated. By end of 1980s, IDD was a forgotten problem and, when the last remaining pillar of IDD prevention, production of iodized salt, collapsed in 1991-92, the consequences of emerging iodine deficiency were not fully realized until very recent time.

The history of IDD control and prevention in Russia could be divided into several stages:

· First stage - pioneer studies (end of 19^th – first part of 20^th century) showed high prevalence and significance of IDD/EG and efficacy of their control with iodized salt and iodine supplements,

· Second stage – in 1950s – 1970s IDD/EG were put under strict control through expanded production of iodized salt and medical iodine supplementation of risk groups. These resulted in significant reduction of IDD, while severe manifestations of iodine deficiency, such as cretinism and giant goiters, were virtually eliminated.

· Third stage - earlier success turned into the period of complacency (1970 – 1990) when the system of IDD/EG control started to deteriorate and finally collapsed with break down of the Soviet Union,

· Fourth stage (1991-1997) - extensive studies using modern assessment techniques (urinary iodine determination, thyroid ultrasonography) proved that IDD are significant national problem and require serious attention,

· Current fifth stage - the problem of IDD in Russia has been recognized and substantial progress has been achieved in addressing this micronutrient deficiency. However, the magnitude and significance of IDD in Russia need more effective strategy, specifically on the part of the government.

The main objective of this review is to facilitate attention of decision makers to five decades of experience of IDD control and prevention in Russia.

This review is based on published and unpublished information from mainly Russian sources that are going back up to 1950s. Based on these existing data, an attempt was made to identify trends in IDD incidence and prevalence in 1950s – 1960s, 1970s -1980s and in 1991 – 2002, to review official documents, related to IDD/EG control and prevention programs in past and in present time, to estimate production volumes and patterns of distribution of iodized salt, to provide brief description of other IDD control methods, and to develop recommendation for further actions to strengthen IDD elimination program in Russia based on national and international experience.

2. Experience of Soviet Program of Endemic Goiter Prevention in Russia

2.1. Pioneer studies (end of 19^th – first part of 20^th Century)

First studies of EG in Russia have started in the end of 19^th century and pockets of EG have been found in many governorships (administrative district in the pre-revolutionary Russia) such as Perm, Kazan, Vyatka, Orenburg, Ufa, Olonetsk, Novgorod, Vladimir in the European part of Russia, in Eniseysk, Tomsk, Irkutsk, Zabaikalsk governorships in Siberia, and in other areas of the country that currently do not any more belong to the Russian Federation [3].

These pioneer studies in Russia were linked primarily with the names of two physicians who made enormous efforts to study this disease. Nikolay Kashin (who also described a disorder presently known as Kashin-Beck disease, attributed to selenium deficiency) made his studies in Eastern Siberia. He found that EG is dominant on virtually all territory of Irkutsk governorship (near the Baikal Lake). In 1868 N.Kashin surveyed 73,669 persons in this governorship and found 154 patients with endemic cretinism (0.2% of the whole population). In some villages the proportion of persons with cretinism to patients with goiter amounted to 4.4-67.7%. [3]

Another prominent medical scientist who researched EG primarily in Perm governorship (North-East of European Russia) was Nikolay Lezhnev who in 1904 published a first book on endemic goiter in Russia. N.Lezhnev surveyed many townships and villages in this part of the country and found that up to 25-50% of population in some villages suffered from EG. N.Lezhnev found that patients with goiter usually had delayed physical and mental development and decreased intellectual capacity as well as that they were predisposed to infections diseases, such as tuberculosis. He also found that out of 60 children who entered primary school only 10-12 children were able to complete 3 year course of basic studies. In his pioneer book “Goiter in Russia” he wrote that “goiter has an important national significance and that fighting goiter becomes of vital importance” [3].

Cases of endemic cretinism (EC) were also found in other areas of Russia. M.Kandratsky found that up to 5% of population in some villages of Tsarevokokshaysk (present – name Yoshkar-Ola) and Cheboksary counties of Kazan governorship were cretins [4]. Unfortunately, after 1904 studies of EG in Russia were virtually seized and continued only in the middle of 20^th century.

2.2. Start of endemic goiter control programs in Russia (1933-1955)

Initial studies of EG in the USSR started in 1930s and are linked with the name of Oleg Nikolaev, a prominent Russian endocrine surgeon and enthusiast of goiter prophylaxis. In one of his first publications on the subject “Etiology of Endemic Goiter” published in 1932 he defined importance of EG and suggested methods of iodine supplementation, including supply of population in affected areas exclusively with iodized salt. He called iodized salt “full-value salt” as it contains vital micronutrient – iodine [5].

In 1933 O.Nikolaev and his colleagues started a pilot project aimed at investigation and control of EG in the North Caucasus republic of the Russian Federation - Kabardino-Balkaria. The field survey showed that goiter prevalence amounted to 26% in men and to 69% in women. For the first time this pilot project introduced mandatory iodine supplementation with iodized salt and distribution of iodine tablets to patients with goiter. By 1940, the prevalence of EG in this region has decreased to 0.9%. The Second World War (1941-1945) interrupted iodine supplementation and EG prevalence in 1945 again increased to 4.1%. [6]. Reinstitution of the prophylactic program with iodized salt resulted in another decrease of EG prevalence to 1.1% in 1948. [2].

In his book “Endemic goiter” [2], O.Nikolaev wrote that control of EG must encompass the following approaches:

- iodization of common salt for consumption by population and also use of iodized salt by food industry, especially for bread baking,

- distribution of iodine tablets to risk groups (pregnant and breastfeeding women, children and adolescents),

- organization of special medical units for diagnosis and treatment of goiter (antigoiter dispensaries),

- screening of population in affected regions and active treatment (including surgery) of patients with goiter.

It should be noticed that in all the surveys before 1991, goiter prevalence in Russian studies was estimated by palpation, using classification developed by O. Nikolaev [2] (Table 1).

Table 1. Estimation of Thyroid Size by Palpation in the USSR and in Rest of the World

Goiter size classification in the USSR [2]	Estimation of thyroid size by palpation in other countries [Stanbury, 1987)
Grade 0 – thyroid is not palpable	Stage 0 – no goiter
Grade 1 – isthmus of the thyroid palpable	Stage 1A – goiter detectable only by palpation and not visible even when the neck is fully extended
Grade 2 – both of the thyroid lobes palpable	Stage 1B - goiter palpable but visible only when the neck is fully extended (this stage also includes nodular glands, even if not goitrous)
Grade 3 – thyroid visibly enlarged	Stage 2 – goiter visible with the neck in normal position; palpation not needed for diagnosis
Grade 4 – large thyroid with deformity of the neck	Stage 3 – very large goiter which can be recognized at a considerable distance
Grade 5 – a giant goiter	--

This classification has considerable differences with estimation of thyroid size by palpation used in other countries [7]. Specifically this refers to small size goiters. According to Soviet classification, goiter grades 1 and 2 were considered as “borderline state”. It is almost impossible to make correlations of these grades with stages 1A and 1B of international classification (Table 1). At the same time, definitions of visible goiters were almost the same. “True” goiter was considered when thyroid size is Grade 3 and more by Soviet classification. Since the rest of the world used international classification, comparison of earlier Russian data on goiter incidence and prevalence with like parameters in other parts of the world pose some difficulties.

2.3. Success of endemic goiter control program in the former USSR (1956-1970)

For more than 40 years EG control in the former USSR was regulated by the ordinance of the USSR Minister of Health No.37-M “On Improvement of Measures to Fight Endemic Goiter” (February 14, 1956). This document [8]:

- defined regions (republics and other administrative districts) of the former USSR with high prevalence on EG to which iodized salt must be supplied (Annex 1);

- gave legal basis for organization of special medical units (anti-goiter dispensaries), as well as Central Anti-Goiter Commission with the USSR Ministry of Health and similar committees in all regions affected by EG;

- promoted training of health care personnel (physicians and nurses) for anti-goiter dispensaries,

- defined EG control as a matter of concern of other government agencies (Ministries of Trade, Medical Industry, Food Industry, State Supply Committee, State Planning Committee and others),

- made sanitary-hygienic control units (stations) of the Ministry of Health responsible for quality control of iodized salt.

This ordinance, in fact, defined the strategy of EG control in the USSR for subsequent four decades. Coordination and planning of activities in EG control on the national level was the responsibility of Central Anti-Goiter Commission which was organized within the Ministry of Health in 1947. At the same time, on the regional level important role played Anti-Goiter Committees. These Committees were organized in every endemic goiter region under the local Executive Power Bodies and included representatives of regional departments of health, education, trade, etc. and helped to solve problems of EG prophylaxis locally on interagency level. Unfortunately both Central and Regional Anti-Goiter Commission and Committees seized to exist many years ago. However, they played quite important role in initial success of EG control program in the former USSR*.

In 1961 problems of EG were discussed on international conference of former socialist countries (USSR, Czechoslovakia, Romania, Hungary, Poland, Bulgaria and East Germany) in Sofia. The resolution of this meeting called the governments of these states to take extraordinary measures to eliminate EG and to coordinate efforts to fight EG on international level [9].

During 1960s the geochemical survey of the whole territory of the USSR was completed and resulted in the map of “provinces” with low iodine content in soil and water [10]. These areas were put under more strict control in terms of supply of iodized salt.

In 1965-1969 two national surveys of EG were carried out in the USSR. These surveys were performed primarily by teams from special medical units – anti-goiter dispensaries. By that time 63 dispensaries were organized in all endemic goiter regions of the country. Currently, it is almost impossible to obtain more detailed information about epidemiological design of these surveys. Most likely they were aimed at screening of huge population groups without specific selection. For example, it was reported that during the 1969 survey up to 1/5 of the whole population in EG regions were screened by medical teams from anti-goiter dispensaries [3].

The 1965 survey encompassed 13,238,428 persons. Cumulative prevalence of goiters grade 1 and 2 goiters nationwide was 5.9%, grades 3 to 5 – 0.34%, nodular goiter – 0.16%. Medical treatment was recommended to 1.08% of surveyed people. In 1969 even more significant amount of population were surveyed – 30,119,542 persons. Grades 1 and 2 goiters were found in 4.8%, grades 3-5 – in 0.18%, nodular goiter – in 0.07% of population. Medical treatment was recommended to 0.66% of surveyed persons [3].

Thus, despite rather low prevalence of EG found during first phase of monitoring survey (1965), in subsequent 4 years due to intensification of EG control the prevalence of EG (grades 1 and 2) decreased by 27%, grades 3-5 – by 47%, nodular goiter – by 53% [3, 10]. These positive changes were attributed to strengthening of measures aimed at control and prevention of EG, specifically – to significant increase of production and sales of iodized salt (see below).

Thus, at the beginning of 1970s, situation with EG in Russia and other parts of the USSR has significantly improved. Prevalence of small-size goiters (grades 1-2) decreased to almost sporadic level (less than 5% of the whole population), big-size goiters (grades 3-5) were almost totally eradicated, as well as cases of endemic cretinism. As a result, in early 1970s EG was officially declared as virtually eliminated. At the same time, from 1970 monitoring of EG was seized on the national and regional levels and special medical form for registration of EG cases was abolished [3]. It should be noted that anti-goiter dispensaries continued to control and monitor EG, but results of this monitoring were not reported to the Ministries of Health of the Soviet Republics and of the USSR. Thus, global national control of situation with EG was lost and subsequent changed in EG morbidity were not tracked.

2.4. Production and supply of iodized salt in the USSR (1948-1966)

Pilot production of iodized salt in Russia started in 1930s but was interrupted by the Second World War. Production of iodized salt was restored in 1948 with potassium iodide used as a fortificant at the level of 25 g of iodine per tone of salt. In the following years production of iodized salt significantly increased and by 1966 reached almost 1 million tones (Table 2). These data on the production of iodized salt in the USSR has never been published before and were generously provided by the Head of the Association of Russian Salt Producers B.Apansenko from his personal archive [11].

Table 2. Production of iodized salt in the USSR in 1948-1966 (thousand tones) [11]

Republics	Y E A R S
	1948	1950	1955	1958	1964	1965	1966
Russia	2.9	27.4	58.9	99.2	270.9	320	318
Ukraine	3.2	61.3	155.2	267.5	363.2	387.7	425
Kazakhstan	-	-	67.8	105.7	221.1	230	168
Other republics	-	2.4	10	1.9	7.4	7.5	9
TOTAL for the USSR	6.1	91.1	291.9	474.3	862.6	945.2	920

According to the ordinance of the USSR Ministry of Health [8] iodized salt must be supplied to EG areas that were defined by the Ministry Health. This list (Annex 1) included 14 of 15 Union Republics (all except Moldova), and most of administrative regions within these republics. Supply of iodized salt to these districts was mandatory and trade of non-iodized salt was generally restricted. The amount of salt supplied to each EG district was defined by the State Planning (Gosplan) and State Supply (Gossnab) Committees of the USSR Government based on requests from the Ministries of Trade of all Union Republics (for retail salt) and of other government agencies (Ministry of Food Industry, Ministry of Fisheries, etc.).

Every salt enterprise received annual plan for production and supply of iodized salt that had a power of law. However, even at that time, production of iodized salt did not fully meet the requirements of trade and food industry: in 1966 the demand for iodized salt amounted to 1,193,700 tones while 920,000 tones were produced (77% of the demand) [11].

Per capita production of iodized salt in the Soviet Union in 1960s - 70s was relative high – 4.5 – 5 kg/year. It should be noted that Russian salt industry at that time was not able to meet demand for iodized salt for population and food industry of the Russian Federation. In 1966 the demand for iodized salt for population and food industry of the Russian Federation was 691,000 tones compared to the production of only 318,000 tones. The balance was covered by salt enterprises from Ukraine where production of iodized salt (425,000 tones) exceeded domestic requirements (155,000 tones) [11].

Thus, significant increase of iodized salt production in 1950s - 1960s was the main factor for expressive reduction of EG prevalence observed over the same period. Before 1991 there was no price difference between iodized and non-iodized salt and usually population in EG regions was even unaware of consumption of exclusively iodized salt (which was still labeled as “iodized” according to existed regulation). Production and quality of iodized salt at that time was a matter of high government concern and vigorous control.

2.5. Other methods of EG control in 1950s-1980s

Aforementioned ordinance of the USSR Ministry of Health (1956) [8] mandated distribution of iodine tablets to groups of high risks (pregnant, breastfeeding women, children and adolescents) in EG areas. Starting from early 1950s, the production of iodine tablets called “Antistrumin” (containing 1 mg of potassium iodide) was introduced on several pharmaceuticals factories. (It should be mentioned that “Antistrimin” is still producing and remaining the cheapest iodine supplement available on the Russian pharmaceutical market). This supplement was distributed free of charge (1 tablet weekly) in schools and kindergartens, and also provided through maternity units to pregnant and breastfeeding women.

2.6. Abandoned child: endemic goiter control in 1970-1990

Once EG has been proclaimed as “virtually eliminated disease” in 1970, it almost immediately caused significant decline in interest to this condition from physicians and medical scientists. What is the reason to investigate condition of no social and medical importance? Prof. M.Zeltser, prominent endocrinologist from Kazakhstan, told me once that for many years he had troubles with the local Ministry of Health defeating the need for control of ongoing program of iodine supplementation [12]. Even the use of medical term “endemic goiter” was not welcomed any more and in medical literature it was slowly replacing by another term – “thyroid hyperplasia”.

Review of scientific journals and other publications made by A.Nazarov and G.Gerasimov in 1992 found scarce publications on EG in 1970s-1980s [13]. This obviously reflected relatively low interest to the problem of EG since this condition have been considered to have been under control with ongoing prophylactic measures. However, some publications showed that situation with EG was not always under sufficient control and that lapses in iodine supplementation frequently occurred.

As survey performed in the city of Voronezh (Central European part) in 1969 showed EG of grades 1 and 2 in 9.5% of girls and 3.5% of boys aged 7-17 years. After improving of iodine prophylaxis with iodized salt the prevalence decreased to 3.86% and 0.78% respectively [14].

The Ural Mountains are known as the classic region of iodine deficiency. In Sverdlovsk (presently -Ekaterinburg), the biggest city in this area, lapses in iodine prophylaxis in 1970s led to increase in EG grades 1 and 2 from 23% to 26.3%, and in grade 3 and more from 0.79% to 0.94%. Field studies in the mountainous and sub mountainous regions of the south Ural region showed a substantial decrease of EG prevalence after salt iodization program was reinstituted. The prevalence of EG grades 1 and 2 decreased from 29.3% to 25.8% in the mountain region and from 36.9 to 29.1% in the sub mountain regions, the chief change occurring in children and adolescents. The prevalence did not change in persons over 40 years old. Overall, the prevalence of grades 3 to 5 decreased from 7.3% to 5.7% in the groups surveyed [15].

In Chelyabinsk region in the south Ural, the mean urinary iodine excretion was 127.4 +/- 10 mcg/day in urban areas and 80.7 +/- 3.7 mcg/day in rural ones. In Chelyabinsk, the biggest city in this area, the daily urinary iodine excretion in children aged 5-10 years was lower (45.7 +/- 3.8 mcg/day) than in children aged 11-15 years (82.3 +/- 3.9 mcg/day). It should be noticed that annual consumption of sea fish in this area increased 2.7 times between 1961-1978, while the prevalence of EG grade 3 and more decreased from 1.7 per 1000 residents to 0.6% per 1000 residents during the same period [16].

A special survey of 550 schoolchildren in Novokuznetsk and Tashtagol, towns in Ural Mountains region, showed the first town to have a goiter prevalence of 66.5% (grades 1 and 2) plus 7.6% (grade 3 and higher), and the second town to have 68.9% and 15% in the same two categories. All persons were clinically euthyroid, but the mean TSH level was in the upper normal range [17].

An iodine supplementation program with iodized salt in Tatarstan (a region between the Ural Mountains and Volga River) was conducted under control of local medical authorities during 1975-83, and achieved a decrease of EG grades 3 to 5 from 4.7% to 2.66% in adults, while in children the prevalence of EG declined from 36.5% to 1.8%. Later observations do not show further changes [18, 19].

Situation with EG the Asian part of Russia (Siberia and the Far East) in 1970-1980 was also rather controversial. Amursk region in the Far East of Russia (close to north Chinese border) was regarded as endemic for goiter. In 1971-75, 26,500 residents were examined and the prevalence of EG was estimated as 8.8 - 9.1% (for EG grades 3 to 5, 2.8% - 7.4%). After improving of iodine prophylaxis w