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Progress of IDD
Elimination through Universal Salt Iodization in
and
Strengthening of National IDD/USI Monitoring System
REPORT
by
Gregory Gerasimov, MD
ICCIDD
Regional Coordinator for
UNICEF
Consultant
March,
2002
TERMS OF REFERENCE
Objectives:
·
To assist
the Government and UNICEF in development and strengthening of monitoring tools
·
To draft
recommendations/proposals on further project development
·
To provide
situation analysis on the status of universal salt iodization and monitoring of
iodine deficiency disorders in
Work assignment
1. The specific tasks of the contractor will
include, but not be limited to the following:
a)
To
review, in collaboration with national counterparts, current status of IDD
elimination program in
b)
To review the status of
IDD/USI monitoring system and make recommendations for its
strengthening (assessment of
technical conditions of the laboratory for
determination of iodine in urine including needs for training for personnel and
procurement of necessary equipment and reagents, Scientific and Clinical MCH
Centre, Ashgabat).
c)
1-2 days
refreshment training for the personnel on implementation
of a plan on monitoring and elimination of iodine deficiency disorders.
d) Draft recommendations/proposals on
supplementary funds utilization (US$ 50,000, provided by USAID) and further
fund raising needs.
e)
Draft
recommendations/proposals on further project development, including legislative
issues, communication strategy and the feasibility of
launching national progress review in
f) Provide situation analysis on the status of
universal salt iodization and IDD monitoring to be used during preparation of
the Mid-term review.
ACKNOWLEDGEMENTS
This mission would not be possible without
extensive support of Dr. Anatoly Abramov, Assistant Health and Nutrition
Officer, UNICEF Office in
CONTENT
BACKGROUND 4
CURRENT
STATUS OF IDD ELIMINATION PROGRAM IN
a. Production and distribution of iodized salt 7
b. Improvement of iodized salt quality 7
c. Recommendations 8
CURRENT STATUS OF IDD/USI
MONITORING SYSTEM AND RECOMMENDATION FOR ITS STRENGTHENING 9
a. Iodized salt production:
strengthening of a quality control system 9
b. Iodized salt
distribution: quality control on transport, wholesale and retail
levels 9
c. Impact of salt
iodization: strengthening of biological monitoring 10
FURTHER PROJECT
DEVELOPMENT 11
a. Review of Progress towards
Optimum Iodine Nutrition 11
b. Scientific and
c. Recommendations on supplementary funds utilization
and further fund raising needs 13
REFRESHMENT
TRAINING AND BRIEFING OF NATIONAL AUTHORITIES 14
ANNEXES 16
BACKGROUND
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. 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. WHO,
UNICEF and ICCIDD developed indicators and criteria for tracking severity of
IDD and progress of their elimination.
TABLE 1. IMPACT INDICATORS AND SEVERITY OF IODINE DEFICIENCY
[WHO, UNICEF, ICCIDD. Assessment of Iodine Deficiency
Disorders and Monitoring their Elimination,
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Severity of public health problem |
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Indicator |
None |
Mild |
Moderate |
Severe |
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Median urinary
iodine concent-ration (mcg/L) |
> 100 |
50-99 |
20-49 |
< 20 |
|
Goiter prevalence |
< 5% |
5.0 - 19.9% |
20 – 20.9% |
> 30% |
IDD is an important public health
problem in
TABLE 2. GOITER PREVALENCE AND
THYROID VOLUME IN 9-YEARS OLD CHILDREN IN
(G.Gerasimov, D.Haxton: IDD in Central Asia, In: SOS for a Billion, Dehli, Oxford University Press, 1996)
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ASHGABAD |
TASHAUZ |
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Goiter rate (%) |
20 |
64 |
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Urinary iodine
concentration (mcg/L) |
75 |
37 |
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Sample size |
100 |
100 |
Following
UNICEF/ECO International Conference on the Elimination of Iodine Deficiency
Disorders (Ashgabad, 1994) President of a
In 1996 the
Government approved the usage of potassium iodate (instead of less stable
iodide) for salt iodization at the level of 23+/-11 mg/kg. Iodization
technology was updated with new equipment supplied by UNICEF that resulted in
better technology of fortification. The first batch of improved iodized salt
was produced at "Guvlyduz" salt plant in 1996. The neighboring
Cheleken chemical plant started production of potassium iodate, analytical grade,
for local needs. Hence, there is no problem with acquisition and supply of the
fortificant for salt iodization in
Production capacity of
"Guvlyduz" salt plant allows production of up to 70 - 80 thousand
tons of iodized food salt per year. Actual demand (and production) of edible
salt for
In order to
establish monitoring system for IDD elimination UNICEF procured and assisted in
installation of the laboratory for urinary iodine determination at the
Scientific and Clinical Mother and
In 2000,
Thus, currently
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Quality of iodized salt (low concentration of iodine
in salt);
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Product monitoring (quality control of iodized salt
from producer to end consumer);
-
Impact monitoring (biological monitoring of the
impact of USI).
The main purpose of this
visit to
CURRENT
STATUS OF IDD ELIMINATION PROGRAM IN
a. Production and distribution of iodized salt.
Salt for human consumption and for industry use in
During the visit we made a small survey of local shops
and markets and tested iodine in salt with rapid test kit. All salt appeared to
be iodized. This personal observation is well correlated with government
reports on universal salt iodization in
b. Improvement of iodized salt quality.
The issue of iodine level in salt produced in
At the request of UNICEF during this visit I have
prepared a Memo for the Ministry of Health with justification for the increase
of iodine level in salt to internationally recommended level of 40 mg/kg (Annex 1, in Russian). The main
reasons for increasing the level of salt iodization presented in this Memo are:
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Quality of iodized salt
will be improved as more iodine will be retained in salt at the consumer level;
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As a result, iodine supply
to population through iodized salt will be more optimal and sustained without
any risk of over supplementation;
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Almost all other
neighboring countries and main trade partners of Turkmenistan (Russia,
Kazakhstan, Uzbekistan, Azerbaijan and others) have already increased level of
salt iodization to 40+/-15 mg/kg;
There is an ample chance that this Memo will help
Ministry of Health to adopt internationally recommended level of salt
iodization and make an important step in elimination of iodine deficiency in
At the same time, the issue of improvement of
packaging of iodized salt should be better studied. Most of salt is supplied to
consumers (including retail trade) in 20 kg bags. These bulk size bags are not
tightly sealed (simply tied), they lack clearly
labeled product name “Iodized salt”, as well as dates of production and/or
expiry. Only small proportion of iodized salt is packaged in plastic shakers
and containers (that cost 10-20 times more than “regular” salt). Low quality of
packaging is one of the factors for high losses of iodine from salt during
distribution and storage and may have unfavorable impact on sustainability of
USI.
c. Recommendations:
·
UNICEF Office should continue advocacy process
with the Ministry of Health for the regulation that will increase iodine content
in salt to internationally recommended level of 40 (+/- 15) mg/kg;
·
Additional measures should be taken to increase
quality of packaging of most popular brand of iodized salt supplied to
population. These may include upgrading quality of bulk size containers (bags),
their sealing (introduction of heat sealing or sewing process), and labeling. A
visit of international consultant to "Guvlyduz"
salt plant to develop recommendations on improvement of packaging and labeling
of iodized salt is quite feasible.
·
It also appeared that price tags for salt in the
shops did not have information that this salt is iodized. Random interviews
with market vendors and customers in Ashgabat revealed that they did not have
information that ALL salt in
CURRENT STATUS OF IDD/USI
MONITORING SYSTEM AND RECOMMENDATION FOR ITS STRENGTHENING
Current status and Recommendations for strengthening
of IDD/USI Monitoring System are outlined in the draft “National Plan for
Monitoring of IDD in
a. Iodized salt production:
strengthening of a quality control system
Currently, almost all edible
salt in
The following actions are recommended:
·
UNICEF, in collaboration with the Ministry of
Health, will supply and install the laboratory for measurement of iodine in salt
in the regional Sanitary-Epidemiological Inspection and support training of
personnel;
·
Regional Sanitary-Epidemiological Inspection and
salt producer should develop and implement Collaborative Plan for improvement
of internal and external quality control of iodized salt on the production
level. Results of iodized salt quality monitoring will be reported to the
Ministry of Health on the regular basis.
b. Iodized salt
distribution: quality control on transport, wholesale and retail levels
According to President’s
Decree all salt for human consumption is iodized and supplied to population
free of charge. Iodized salt is available in all retail shops. According to DHS
2000, 75% of households consume quality iodized salt. However, in 25% of the
households salt is not meeting requirements, possibly due to losses of iodine.
UNICEF us supplying rapid spot test kits for qualitative measurement of iodine
in salt to Sanitary Epidemiological Inspections; however, these Inspections
have no legal power to use these kits for salt testing due to lack of manuals
and guidelines adopted by the Ministry of Health.
The following actions are recommended:
·
Ministry of Trade, Association of Food Industry and
other concerned government bodies should improve ordering procedure for iodized
salt to prevent its excessive storage on wholesale and retail levels. FIFO
(First In – First Out) principle should be implemented to prevent losses of
iodine from salt;
·
Ministry of Health should develop and adopt manuals
and procedures for the use of rapid spot test kits (supplied by UNICEF) by
Sanitary-Epidemiological Inspections for control of iodine levels in salt on
wholesale and retail levels. Possibility of local production of rapid spot kits
should be carefully studied.
·
Ministry of Health should develop, adopt and
implement reporting system on iodized salt quality control.
c. Impact of salt
iodization: strengthening of biological monitoring
Once program of universal
salt iodization in
The following actions are recommended:
·
UNICEF, in collaboration with the Ministry of
Health, should supply the Scientific and
·
Ministry of Health, Scientific and
·
If national survey provides evidence of adequate
iodine nutrition of population, the Review of Progress towards Optimum Iodine
Nutrition should be initiated according to the guidelines of the Network for
Sustained Elimination of Iodine Deficiency in collaboration with UNICEF,
ICCIDD, WHO and other partners.
FURTHER PROJECT
DEVELOPMENT
a. Review of Progress towards
Optimum Iodine Nutrition
In 2001 WHO, UNICEF and
ICCIDD developed comprehensive Criteria for Sustainable Elimination of IDD
(Table 3). 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
(Table 3).
Currently, iodine nutrition
in
The following programmatic
indicators of sustainability of IDD elimination program in
·
An effectively functioning national multidisciplinary IDD committee has
been created since 1996.
·
President’s decree (1996) shows political commitment to the elimination
of IDD and universal salt iodization.
·
This Decree is the legal basis for USI;
·
Government is showing commitment to assessment and reassessment of
progress in the elimination of IDD.
·
The salt industry is willing to cooperate with health authorities in
the maintenance of quality control.
However, the following
programmatic indicators are not met.
·
IDD/USI Monitoring System should be strengthened (regular data on salt
iodine content on the factory, retail, and household levels; regular laboratory
data on urinary iodine in school-age children) according to recommendations
listed above.
·
A program of public education on the importance of IDD and the
consumption of iodized salt should be strengthened to ensure sustainability of
USI.
Recommendation:
Review of Progress towards
Optimum Iodine Nutrition in
TABLE 3. CRITERIA FOR SISTAINABLE ELIMINATION OF IDD
[WHO, UNICEF, ICCIDD. Assessment of Iodine Deficiency
Disorders and Monitoring their Elimination,
To declare the sustainable elimination of iodine deficiency as public health problem the following criteria should be met: