WHO Cont'erence Ball Thursda.y, 22 SeptenWer 1966 at 2.30 p.m. CHAIRMAN:
Dr S.R. Sayanqllmathan
CONTENTS 1 2 The epidemiology of filariasis in the
Western Pacific Reg10n
••.••••••••••••••.•••••••••••••••••••• ..••••••••••••••••.•••.••.•••.••••
The epidemiology of endemic goitre in
the Western Pacific Region
187
"
-175-
1.76
RmIONAL COMMI'l'l'EE: SEVENTEENTH SESSIClf
Fourth Meet1zlg Thursday. 22 September
1966
at 2.30 p.m.
r
I.
Representatives of Member states AUSTRALIA
Dr. H.E. Downes Dr R. Taureka Dr Thor Peng Thong Dr C.K. Chang Dr T.C. Hsu Medecin-General M. Orsini Dr M. Matsuo Mr K. Watanabe Mr Y. Matsuda Dr Koukeo Saycocie Dr Dr Dr Mr L.W. Jayesuria R. Dickie C.H. James Abdul Aziz bin Mohamed
CAMBODIA CHINA
FRANCE
JAPAN
LAOS
MALAYSIA
NEW ZEALAND
Dr C.N.D. Taylor Dr A.H. Cruz Mr J .M. Morales Dr A.N. Acosta Mr V. Buencamino Mr W. !lustre Mr J. Alvarez Mr I. Bantug Mr B. Hizon Mr D. Gonzales Mr P. Viray Mr A. Asuncion Mr I. Nicanor Mr R. Austria Dr Nuno Campelo de Andrade Dr Manuel Florentino Matias Mr Carlos da Luz Nunes
PHILIPPINES
PORTUGAL
REPUBLIC OF KOREA SINGAPORE UNITED KINGIX1'\1
z.mnJrEB OF THE FotJRl'H MIml'ING
Dr Y.K. Cha Nlr J.H. Suh Mr N.J. Choi
Dr S.R. Sayampanathan Dr P.H. Teng Dr C.H. Gurd Dr R.K.C. Lee Dr H. De Lien Mr M.K. Koizumi Dr ~-Nhful-Thuful Dr J .C. Thieme inter~overn~ental
UNITED STATES OF AMERICA
VIEl'-NAM
WESTERN SAMOA II. --r--
ReEresentatives of other SOUTH PACIFIC COMMISSION
organizations
Dr G. LOison
" III. ReEresentatives of non-governmental organizations DlTERNATIONAL COMl'1lTTEE OF CATHOLIC ~~SES DlTERNATIONAL COUNCIL OF NURSES """" ;
..
Mrs M. Ordonez Mrs R. S. Diamante Professor Han Su Shin Dr J
r
INTERNATIONAL PLANNED PARENTHOOD FEDERATION THE WORIJ) MEDICAL ASSOCIATION
.C. Denoga
IV. ;L
WHO Secretariat REPRESEln'ATIVE OF THE Director-GENERAL SECRETARY Dr P.M. Kaul
Assistant Director-General Dr
.
Francisco J. Dy Regional Director
118
Sl5Vl!i'ltE/lil.t.tH S!ESICif
At this meeting Dr SAYAMPII1I.A5AB (Si!lgapore) I Vice-c::ba1rIIBzl, took the Cbair.
1
THE EPmEMIOLOOY <F FILARIASIS IN THE WES!I.'ERN PACIFIC Rl!XlICB: ITEM PROPOSED BY THE GOV'ERNMEN'.r Ci' PORl'OOAL: Item 15 of the Agellda (Document WPB/BCl7/8) The CHAIRMAN invited tbe Chief Bepresentat1ve of Portugal to
introduce this item. Dr AlIDBADE (Portugal) reterred to document WPB/RCJ.1/8 prepared by the
Secretariat, which summar1zed the s1tuat10n in various countries wbere the disease prevailed. The Representative of Western Sam:>a had conveyed to
the Committee earlier some important 1Dformation on the progress ot activities in his country. Bis delegat10n considered it opportWJe tor tbe
Committee to review tbe problem and be boped that representatives would report on the situation in their own coWItries. Filariasis was toUDd in Portuguese Timor and tbe incidence varied from 5 per cent. to more thaD 20 per cent. from 1.9 per cent. to 5.7 per cent. and 8IlOtber type I sim:1lar to Brugia ~edema
appeared in rates
Wucbereria bancrotti was present,
ma.lap
but with some peclillar cha.rac-
teristics, had been found recently. Similar to
Pathologically, it had a pattern
!t. bancrofti but
only rarely had it been 1'ound to produce lesions
on the genitals. of this DeW
Its periodicity was 1'oUDd to be DOCturaaJ..
The study
type of microf'ilariae had been started by David and meson
and was being continued by Pratessor Crul: Ferreira. of the National School of Public Health and Tropical Medic1ne.
Anopheles barbirostris was
considered to be tbe vector.
The routine treatment adopted was betrazan gIllS.
(diethylcarbamazine) - six tablets 01' O.a:;
a day per month tor a year.
-~
179 Several bloOd ljanml 'hnd ~ es ~ after treatment.
been found to
be negative four to five months
Prophylactically, hetrazan had been used in doses of Blood
three tablets, also once a day per month, in hyperendemic areas. was checked every six months. tinuing. Dr DOWNES (Australia) stated that filariasis in Australia was interesting for two reasons:
Trials bad started in 1965 and were con-
the worm was first discovered. by Joseph Microf':Llariae were
Bancroft in Brisbane, Queensland in December 1876.
foUXld to be endemic from northern New South Wales to the north-east of Australia. Endemicity was mainly concentrated in the Brisbane area and Clinical manifestations of' the In 1909-
the vector was Q. pipiens fatiga.ns.
disease included lymphangitis, hydrocele and elephantiasis.
..
1910, 11.10 per cent. of' the admissions to the Brisbane Hospital bad m!crofilariae. In 1922-1924 tbe incidence had ~one do'WIl to 5 per cent. known, all
Dr TAUREKA. (Austral.1a) stated that, as f'ar as
,TaS
filariasis in the Territory of Papua and New Guinea was due to nocturnal. periodic
.!!.
bancroft!.
The disease was endemic in the coastal areas up
to 1500 feet, but in some localized areas transmission occurred at higher altitudes. In general, about 30 per cent. of' the population might be
infected, but clinical mani:festations were relatively low; for example, hydrocele was 5 per cent., elephantiasis was 1-2 per cent. In this
general distribution, there were localized areas in which the disease was much more highly endemic and where the infection rate was 50 per cent. and the elephantiasis rate as high as 12-13 per cent.
These hyperendemic The main
areas were aSSOCiated with a higher index of transmission. vectors were members of Anopheles pupctulatus.
Culex J2.. fat!gans was
].80
'.
•
not susceptible to infection, but -was perhaps a vector of secondary
importance.
A small-scale control proJect (this was not eradication)
had been carried on for over seventeen years by the School of Public
Health aIld Tropical M:=diciJ:le of Sydney.
Hetrazan was show. to have
reduced the microfilariae endemicity but did not bring it down to zero. Residual insectic1des partially interrupted transmission because of the longevity of the lii'e of the worm which was up to twenty years. Control
measures had been applied for long periods even though residual insecticides did not bring the percentage down to zero. Dr THIEME (Western Samoa) said that a d1f:f'erent type of bancrofti
was foUlld in Western Samoa.
This was diurnal sub-periodic. !I8l!!QPZlUS
The vectors The elldemi-
were Aedes P<?l.yDesiensis, Aedes
and Aedes upolensis.
city in rural areas -was from 16 to
38
per cent.
The town area -was less
infected, the endemicity being only
16 per cent. A campaign
had been
started in lolly last year in which ten million tablets of hetrazan bad been distributed. of 120 000 people.
This bad been thought sufficient for the population later on, it had been found tha~
the population had
increased to 135 000 aIld the tablets had, therefore, been increased to twelve million. Distribution had been made by the district medical The tablets bad been given weekly all
officers to the women I s committees.
for six weeks aIld twelve doses had been given every lOOnth, me.k1ng eighteen-dose regimen.
!rhere had been good. support on the part of the
people aIld only a few had refused to co-operate, although some had forgotten to take the tablets aIld tberefore the percentage of infection had risen. Preliminary
results bad revealed a definite reduction in cases
in some areas wbere the incidence had gone down from cent.
Z7.6
to 1.7 per
In another area with a higber rate of 38.1 per cent., the
~8~
incidence bad fallen to 5. 1 per cent.,; in one area it bad been reduced from 32.2 per cent. to 7.3 per cent. Of particular significance was the
reduction in the density of the carriers of microfilariae, generally to 1-2 per cent. In SOIOO
areas it was now below 1 per cent.
'!'be positive
cases were being fol.l.owed up and treated. Dr JAYESURIA (MUaysia) stated that the examination of slides by
workers attached to malaria teams bad revealed that f1l.ariasis did in fact exist in Sabah and Sarawak. on the extent of the disease. In West M>.l.aysia hUlDElll filariasis was due to two species - Wuchereria
No intormation -was, however, available
bancroft! and Brugia mal.ayi.
Infection by W. bancroft! was first regarded
as rare but recent work during the past decade bad shown that this intection was more widely distributed than original.l.y suspected, especial.l.y in the rural areas wbere it affected the M:U..ays and the aborigines. urban vector of '!'be
.!:!.
bancroft! was Culex pipiens tatis!;ps. to~.
In the rural ~.
areas transmission bad been attributed
wharton! and
ma.cul.a.tus.
Brugia malaY! occurred in swampy areas around the mouths of rivers and in paddy fields in the northwest. It also occurred in other scattered areas
of the country, although the people there were not so heavUy intected.
'!'be vectors in the hil.l.y regions were not definitely know. but Mmsonia
dives,
!!. donaldi
and
~
chryso.l1naetus might be involved.
~.
mal.ayi
occurred in two forms - the periodic form. where the microf1l.ariae exhibited
..
nocturnal per1odlc1ty,and the semi-periodic one in which the microf1l.ariae were found by day as well. vectors. The periodic form. was characteristic of the coastal paddy fiel.ds '!'be two forms were transmitted by different
and swampy areas of' South Kedah, Penang (mainland), Penang Island and
182
...
North Perak.
Transmission was attributed to
A.
cOlI!Pestris (:!01"IIIerlY
laIown as the dar.k.-'W1nged ~.barb1rostr1s) aZId
to a l.esser extent by·
t!-
1.ll!.itormis,
MA.J:!
1lId1a:oa 8ZId
M-
amlulit'!fa.
This type of terrain bad no
reservoir of
1 ma 1
iDf'ection.··
The semi-periodic form was characteristic of swampy forest areas 8ZId had 8.!I:lmA] reservoirs of 1rI:f.'ect1on, particularly the dusky l.eaf-lIIODkey
(PresbUb obseurus) which had a mtural intection rate of 70 per cent. ~ss1on
was by various species of azmulata 8ZId
l:tm A9P1 a,
particularly
!f. bomleae,
M-
dives,
M-
M-
1.ll!.itormis.
lie
baD.crofti 1rI:f.'ection was not heavy 8ZId the cl1n1cal t'eatures were OccasiODal cases of ~g:it1s,
relatively rare.
hyOrocel.e and chyluria
had been noted in assoc1s.tion with II1crof1lariaemia.
There was no sig)liticant ditference in the cl1n1cal ma.nitestation between the two forms of ~.
DIAl.a.y1.
Infected huDIf!.ns developed enlarge-
DlAnt ot lymph glands, a retrograde lympbangitis and transient awelllDg of the aft'ected 11mb with slight eosinoph:l]1a, or a marked leucocytosis 8ZId eosinoph1l1a assoc1s.ted with preliminary chsnges. generally passed unnoticed by the population. These early stages
Attacks of ad.eno-
lymphaDg1tis, lasting three to five days often associated with fever, occurred at irregular intervals. legs below the knee in 'J!be aft'ected limbs, Dearly always the
I.
mAley! iDf'ection, might show transient swelling Sometimes
during the attacks and ult1DlA.tely lead. to elephantiasis. abscesses were associated with the attack.
Recent work suggested that
eos:I.Dophilic lungs or tropical eos:I.Dophilia in M:Ll.aya. might have a t'1lar1al aetiology. It was esti!DA.ted that 5 per cent. of the total population had. :!1lariasis .inly due
to!.
DIAl.a.y1, about half ot them living in the
183
more heavily infected areas or the banks of the larGe rivers as they flowed into the sea. In such areas, up to 45 per cent. of the people had
microfilariaemia and 5-6 per cent. elepbantiasis of the legs. The control. programme was divided into two phases.
In tbe f'irst
phase a.ll persons (a.bout 155 000) l1ving in the ~re heavily infected areas were treated. In the second, the work was to be extended to the
less heavily infected areas and at the same time resurveys would be carried out in the area covered Ilecessary. officer. ~'eviously
and retreatment given where
A four-man team worked Ullder the supervision of a health It was estimated that the team should be able to treat 3000
to 4000 people a year at an a.ll-in cost of M\i25 000 (about US$83OO) per annum, i.e., around M\i6.50 (US$2.1S) per person treated. Mus treatment of an area w.s indicated when the microfilaria rate in the community was above 10 per cent. and there was reappearance of
clinical f'ilariasis.
The drug used was citrate of sal.t of dietby--
carbamazine (a piperazine der1vati ve) g1ven orally in a standard dosage of' 5 mg. per kg. body weight in weekly doses for six weeks. Pregna.nt
women, the sick and infirm, and infants under four months were excluded from treatment. House visits were made for two or three days a.t'ter
treatment to provide pal.l1atives, in the form of aspirin, fomentations, etc. During these visits, previous absentees might be found and treated.
IQrmphatic reactions due to the effect of' the drug on the adult worms occurred in up to 4 per cent. of the people treated, commonly after the second or third dose. ease day.
Depending on the density of' the population and
or
access to the area, a team could deal. with 300 to 400 people a
A systematic 1'1lar1asis control campaign was instituted in 1961 with six trained teams operating in areas of high endemicity. Mariam area ot Central Kedah, a low-lying s~y
In the llukit
area 01' about twenty
square miles with a population ot about 4000, some 322"( people had been exam;fned in 1959. The microt1laria rate had been 25 per cent. and the C.IIIIl.
mean number of micro1'ilariae per 20
ot blood was 2.6.
Ninety-one
per cent. of the people had been treated.
In a re ...exam;fnation, some
seven to twelve IllOnths later, it had been foUlld that the microi'ilaria rate had declined from 26 per cent. to 1.5 per cent. 8.IId the mean number
ot micro1'ilariae in 20
C.IIIII1.
ot blood from 2.6 to 0.18. In 1962, a blood A total of 2972 people were examined
survey was carried out in the area.
and it was foUlld that the microtilar1a rate was 0.58 8.IId the mean number
ot microf1lariae in 20 c.mm.ot blood was 0.058. An exam:Jnation ot 324 children born in the area since the control campaign started showed that none of them had contracted the infection. In areas where a reservoir of animal infection was present and where control ot vectors was not a practical proposition like the Pahang Tua area ot East Pahang, it would appear that retreatment ot all positive cases every two years alone would not be sufficient but mass treatment should be carried out, in addition, once in every six years t;Tr
so.
Dr CHA (Republic of Korea) said that :filariasis was not a majt;Tr
public health problem in his country. reported.
Several endemic areas bad been
1!-
malayi was the only lmown specie of human filaria.
The
clinical pattern was quite similar to that of filariasis bancrofti. Recently, from 1965 to the early part of made on Cheju Do Island.
1966,
a small survey had been
The two villages concerned were located in
the southern coastal area of the isl.a.nd, about thirty miles apart.
185
The mierof1lariae incidence in one vil.J.a.ge was 16 cases out of 228 people,
or about 7 per cent., and in the other, 79 cases out of' 336 people, or 22.2 per cent. The findings in the survey iDdicated that the principal.
clinical manifestation was e1ephantiasis which showed sex and age differences. Eighty-four cases had been observed in the two vi11ages - 30 were A higber incidence of' e1ephantiasis had. been The cuticuJ.ar hypotrophic
males and 54 females.
observed among people over twenty years oll.
changes (elephantiasis) appeared I/rjre often in the l.ower extremities, 77 per cent. more otten than in the upper part of the body. Mlcro-
fi1ariae had been found in the bl.ood in 4.7 per cent. of 84 cases, and 19 per cent. of the cases bad cOJlil1ained of occasional high fever; 2.4 per ·cent. had 1YJ1ilhangitis on1y in the 10wer extremities. cby1uria were observed in CheJu Do. Dr BSU (China) said that fUariasis was a serious public health
No
problem in on1y a small part of the province and in Pescador, which was located between Taiwan Is1and. and Mainland China. present and Q. pipiens fatigans was the sole vector. }:!. bancrofti was ~. malayi
had
never been found among the local people, but on1y in people cOming from Mainland China or Chinese students cOming from South-East Asia.
The control programme bad been started in 1958 and since then
US$130 000 had been spent on it.
ALthough it was nearing a successful
conclusion, to eliminate the disease would require continued efforts for a considerable length of time. InPescador, the entire seventy-
four vil1ages had been examined and it had been found that the inci-
..
dence of filariasiS ranged from 0.5 to 17.5 per cent., averaging about 8.3 per cent. In Taiwan proper, an island-vide survey had been
made and 180 vil1ages vith a total population of 300 000 bad been found
186
.to be a.f'fected.
Tbe incidence in these 180 v1lla.ges ran f'rom 0.2 to ~O contro~
per cent.
Tbe
progra.Dllle was carried out by means of' 8I!.ti-parasite b~od
measures, that ws, detection of mierof1l.ariae carriers by mass survey and drug treatment of carriers detected. a year in tbe endemic area.
This was repeated once
The objective ws to reduce the mierof'ilariae
rate in every endemic village down to a level below ment bad aao been given in some tbe period ~960 to 15163. been applied. relative~
0.5.
*8S drug treat-
highly endemic v1lla.ges during
Insecticide house spraying with RCR had also
In all of' the 74 villages in Pescador, the microfilarial In 1963, mass resurvey and At
rate had been brought down to 0.7 per cent.
treatment had been carried out in all. the villages in Taiwn proper.
the end of JUlIe 1966, tbere were only five villages recorded with a microfilarial rate of over 0.5 per cent. for both 'l'a.iwn proper a.nd Pescador. Dr OllSIIfI (France) referred to the filariasis contro~ progra.Jlllle
carried out in French Polynesia by the Institute of M!dica.l. Research. This ws based on drug treatment of carriers and. control of mosquito larvae.
Carriers were detected through blood surveys.
In 'l'a.h1ti, 6.8
per cent. carriers of microf1l.aria had been tound.
Studies were being The drug
carried out to find the JOOst suitable treatment regimen.
(diethylcarbamazine) ws prescribed for oral application once every two months, at a dosage of 6 mg. per kilogra.mme body l{eight. In 1965,
19 000 blood examinations had been made, 10 000 for drug treatment; 2 per cent. of Aegypti polynesiensis were found positive for filarial larvae. The RmICliAL DIRECTOR drew attention to the Inter..regional Seminar
on F1l.ariasis which bad. been convened in Minila last year.
Copies of
l87
the report bad been distributed to governments in the Region, as well as to those in other regions which bad participated. available. The Regional Director then referred to the various statements made
Further copies were
by the Representatives and asked if the Rapporteurs had now sufficient material to draft a resolution. Dr HSU suggested that the resol.ution might contain reference to the
•
importance of continuing efforts to control the disease. shown tbat it could be controlled. bad been reduced from
Ex;perience had
In Taiwan, for example, the incidence
8 per cent. to 0.5 per cent.
Dr ANDRADE supported this proposal.
Dr THIEME suggested that it might be useful to ask for UNICEF's continued support to such cauq>aigns. The CHAIRMAN
believed that nobody woul.d disagree with this sugges-
tion.
He then asked the Rapporteurs concerned to draft an appropriate
resol.ution.
(For consideration of draft resolution, see minutes of the
fifth meeting, section l.)
2
THE EPIDEMIOIDGY OF lllIDEMIC GOITRE IN THE WESTERN PACIFIC RmION: ITEM PROPOSED BY THE GOVERNMENT OF PORTOOAL: Item 16 of the Agenda. (Document WPB/RCl7/9 and Add.l) The CHAIRMAN invited the Chief Representative of Portugal to
introduce this item. Dr AlIDRADE (Portugal) stated that eJldemic goitre OCCUlTed in varying
intenSity in the Western Pacific Region, but was a :public health problem
188
in some countries.
In Portuguese Timor, tbe rate ws 4.9 per cent., i.e.,
2597 cases in a population of a little more thaD. 55 000; 63.6 per cent. of tbe cases examined belonged to Type 1, 25.9 per cent. to Type 2 and 10.4. per cent. to Type 3. So far, tbere was no evidence of related dea.tlless, The :bardness of water and its iodine -<
/
dumbness or intellectual deficiency.
contents had been checked in water sam;ples trom twenty-eight sources in one of tbe endemic areas. Both had been found to be low.
Until now, no
known goitrogenic f'actors had been detected.
In the meantime, tbe Health
Services were prepared to implement a control scheme based on mass application of iodine 011 injections such as was being dcme in Hew Guinea. As documentation on the control of' goitre was incomplete, it was considered useful to bring this to the attention of tbe Coum1ttee f'or discussion and
advice. Tbe
It would be interesting to hear of the experiences in Hew Guinea. RmICIlAL DIRECroR referred to document W!!R/RCl7/9, which sumHe also drew
marized the information available in the Regional Oi'fice.
attention to the addendum to this document which contained the IIX)st recent information secured from Papua and Hew Guinea. Dr JAYESURIA (!tU..aysia) aclm1tted that no systematic surveyor study had been made of' endemic goitre in West 1elaysia, although there had been
a number of'
~
!!e£
studies, observations and investigations, which proPolunin,
vided a f'airly good picture of its epidemiology and prevalence.
in a study of the disease among aborigines, had shown that tbyroid enlargement occurred in about 40 per cent. of those under study and that there had been little d1f'f'erence in the incidence of' goitre between aborigineS and MUays living in the remote '!1 la
no. districts.
He had also observed that tbyroid enlargement was coDllllOner in temales
. age.
189 in whom the gland tended to enl.e.rge and become more nodular with increasing Endemic goitre bad also been fOUlld by Po1unin in the hills and valleys
of Kedah and Upper Perak and in the interior of' Kel.a.ntan and Trengganu. other goitre areas in Ml.l.aya bad been discovered on the western slopes of the main DK)untain range in Se1angor and in Negri Selllbil.an.
Subsequent
investigation in 1959 by a medical team in a district in Kedah bad confirmed Po1unin IS filldings. In a study carried out by Ng Cheuk Bing, Surgical Specialist of' the
District lfospital, Klang, it bad been observed that about 5 per cent. of the cases in the surgical outpatients I department complained of thyroid swellings, and it was obvious that there were many more milder cases which never turned up in the hospital. The enlargement tended to be un1torm in He believed that
the younger age grouJ? and nodular in the older one.
the lack of iodine lias not the onl.y cause for goitre, as the diet of the poorer people 11ving along the sea coast contained enough and the cases bad been sho'WIl to have normal. serum-bOUlld iodine levels. possible that auto-immunity might be an important factor. It was
These cases
had been sho'WIl to be positive to the Zinc Flocculation and Thymol
Turbidity tests. to be hypothyrOid.
It had also been noted that the older age group tended The high pregnancy rate in Ml.l.aysia, with its
increasing demand on the thyroid, might also be a contributing factor. Cases among children under fifteen years were rare and this further confirmed that the lack of iodine was not the only cause. The incidence
started about puberty, cOincid.ing with the increasing demand on the thyroid. The enlargement was uniform. The incidence would rise up ~~
to the age of thirty-five when the goitre became nodular and ~
thyroid and did not seem to subside without treatment. was much more common in females.
The disease
190
. Although the admission of goitre cases in the hospitals showed a
rising trend, this did not Jlecessarily mean an increase in 1Dcidence. The rise might be attributed to the increasing knowledge of the population
and overel.l admissions into doubled.
hospi~over
the past decade 'Wb1ch bad almost
From the various studies and observations available, it appeared
that MU.ayan waters were usually soft and their iodine contents exceedingly low, ranging 1'rom 0.2 to 0.5 parts 01' iodine per thousand. million. The
higher percentage in the tropics of run-of1' water, which had not had the opportunity to leach iodides out 01' the soil, might lower the river water iodine concentration. For an area to be goitre-1'ree the water should
contain 3-5 parts 01' iodine per thousand million. Goitre occurred especially in remote inland areas where transport was di1'1'icult aDd where there was an adequate supply of local river 1'ish with a low iodine content.
In JD:)re accessible areas dried sea fish was
the impOrtant item of the diet aJld the analysis 01' four of the principal dried sea foodstuffs gave iodine contents from
36
to
134
parts iodine per
hundred thousand.
On the other hand, observations of cases among popula-
tion-groups living nearer the sea coast tended to show that, even though their diet might contain ~no~
iodine, auto-iDJDJmity
~
high prep.ncy
rates with their increased demand. on the thyroid might be a contributing 1'actor. Dr DICKIE (M3.laysia) stated that no systematic study had been made
as yet in Sarawak. or Sabah.
However, a number of years ago, it had been
recognized that there was a considerable incidence of visible gOitre, especially in the upper reaches 01' rivers in el.l the five administrative divisioDS of Sarawak. Dr Dickie referred to the statement in paragraph
1.5 on page 3 01' the document which said, "Goitre is eJldem1c over a large
1.91.
area of Sabah." His colleague from Sabah had informed him that this was not quite correct, as visible goitre was restricted to three fairly circumscribed regions. In Sarawak, it was more widespread and was, in
fact, found in all the divisions.
Accurate figures of the incidence of ~ ~
the disease were not available but in some areas where
surveys bad
r.-
been made the figures were much the same as in lofest Mal.aysia, that is, between 20 and 40 per cent. In 1958, the Kapit and Kanowit Districts in
the Third Division of Sarawak had been particularly affected with a high incidence around the Rejang River and its tributaries. As a result, the
Government bad decided in 1958 to set up a salt iodization plant in Sibu, the divisional headquarters. Co-operation between the importers of the
salt and the Government was very good and it was lmo'Wll that nearly 100 per cent. of all the salt consumed in the up-river endemic areas of this Division was now iodized. In order to check whether the salt was, in
fact, reaching the upper reaches of the river and getting to the long houses, a simple process had been introduced at the iodization plant whereby a minute quantity of a green vegetable dye was put into it during the iodization process. people in these areas. This "green salt II was now well known to all the They were informed by means of posters and radio
propaganda and now demanded it. A second salt iodization plant had been set ~p
in Kuching, the capital
of Sarawak, where a large proportion of the salt destined for the ulu areas of the First and Second Divisions and also, to some extent, for the Fourth and Fifth Divisions, was imported. This plant was expected to come into
operation in January next year and arrangements bad already been made with the salt importers. It was hoped that by next year most of the salt going
to the goitre endemic areas of Sarawak would be iodized.
l.92
The REXlIONAL DIRECTOR pointed out that tbe working paper prepared by the Secretariat had been based on a lIIJuograph publisbed by WHO in l.960 and therefore tbe information it contained was not up-to-date. It was
espec1a.l.l.y inadequate in so far as New Zealand was concerned because an intensive programme of sal.t iodization over several deCades had succeeded in practical.ly eliminating goitre in New Zealand. Dr TAYLOR (New Zealand) confirmed tbe Regional Director I s statement
that goitre had virtually been eliminated in New Zealand. found that it occurred in both races.
It had been
In tbe I>aori race it was associated
to a l.arge extent with giving up tbeir seafood diet and taking to the European diet. The control of goitre had been brought about by having
under tbe Food and Drug Regul.ations a requirement that iodized salt shoul.d contain between 0.75 and 1.5 parts of iodine per 20 000 and tbe surveys that had been done from time to time showed that, in general, iodized salt was used almost exclusivel.y in the homes. Dr CRUZ (Philippines) stated that in l.965 questionnaires bad been
sent to the provincial and city bealth officers in tbe ditterent parts of tbe Philippines and tbe partial returns received showed that goitre
was widely distributed, cases having been reported especiall.y in the M:>untain Province and in Oriental and Occidental Mindoro. These findings
had been verified by mal.aria workers who distributed iodized salt to tbe native population of tbese provinces. The situation was now being assessed >
and it was hoped that more information woul.d soon be ava.il.ab1e.
Dr HSU (China) stated that goitre was a problem in Taiwan.
Salt
was iodized and tbe Government beld tbe monopoly for its production and sale.
A goitre control programme bad been started l.ast year and from
MINt71'&s
(F
THE FOURTH MEETING
193
October this year it would be expanded to cover the mole island.
Pilot
projects had been carried out from 1958 to 1969, during which the rate among schoolchildren in areas where goitre was most endemic had dropped from 44.9 to 2.8 per cent. among males, and from 58.6 to 5.3 per cent. among females. had
A survey had shown that in the younger age group the rate
dropped from 2l to 5.1 per cent. among males and from 41 to 21 per The male group seemed to have responded faster.
cent. among females.
These remarkable results had encouraged the start of a control project using iodized salt. This project, which had been carried out between
February 1965 and June 1966, had the support of both WHO and UNICEF which had. provided the machine and the potassium iodide. Forty town-
ships in forty counties where goitre was most prevalent had been chosen, covering about 1 000 000 inhabitants, and 20 000 tons of iodized salt had
been used.
It was intended to extend the control programme to the
whole island. A study of the epidemiology of goitre had also been made with the co-operation of the University. Random sampling had been used and. about
400 000 s~olchildren in 921 primary schools scattered allover the island had been examined. population. followed. This represented one-fifth of the total school
The criteria set up by the WHO Expert Committee had been The incidence among the pupils in Grade 1 was about 13 per cent.;
in the county of Nankow the incidence was 63 per cent. and in others the rate was as' high as 46 per cent. In Grade 2 the average was 1.2 per cent. A survey was
but in the highly endemic areas the rate was 18 per cent.
now being undertaken in the experimental control area and it was hoped that a report on the results would soon be available. Salt had been
originally prescribed to be iodized with 33 PPM potassium iodide.
194
SEVENTJ<Ei'mI SESSION
.According to the agreement drawn up with WHO and UNICEF, the iodine content of salt found in the checked periodically. PPM. who~esa~e
shops and in the homes bad to be
It bad been found tbat it came down to about 24
To improve this detect, it bad been necessary to check the moisture
of' the original salt, the mixing process in the machine and the storage of iodized salt while in transport. This situation -was now being studied.
Dr SAYCOCIE (raos) stated that, according to the statistics of his
Ministry of Health, endemic goitre -was frequent in the northern provinces. Forty-nine cases bad been found in Savanna.kllet and thirty-eight in Dampasak over the past six years. cases bad been reported in 1965. In the Vientiane Province eighty-four In High Mekong the incidence was 1.3
per cent. and in Southern raos and Vientiane 0.3 to 0.1 per cent.
Some
ot: the local doctors believed, however, that the incidence -was higber.
It had also been reported tbat in the northern part of' the country, goitre was more frequent in women than in men. years ot: age. Dr TAUREKA (Australia) said that goitre occurred in the remote parts
It appeared at about 30 to 40
of the Territory of Papua and New Guinea,
notab~y
in the Huon Peninsula.
It appeared in well defined regions where it tended to be nearly universal in the population, and of'ten spectacular goitres were seen.
UDdoubtedly,
this pattern was due to the subsistence econOlll\Y of the people who were dependent on the immediate environment for all food and water. If iodine
were deficient in this environment, the lack of trade in 'foodstuff meant that no outside traces of iodine would enter the area to mitigate the effects of' the deficiency. The mountainous terrain in the gOitrous area
•
MINUl'ES OF THE FOURTH MEEl'ING .
195
of New Guinea excluded any possibility of preventing goitre by conventional methods. Spectacular success with the control of yaws had been achieved by medical patrols making infrequent visits to remote areas and giving injections of penicillin. This had suggested to the Territory's Department of
Health that periodic injections of iodized oil into·the muscles might provide a depot of iodine that would last for months or years, and release small amounts of iodine to the general metabolism. McCuJlagb had followed
up this suggestion by injecting 1.0 to 4.0 ml. of iodized oil ("Neohydriol ", M3.y and Baker) into the deltoid area of 3934 individuals. No local or
general undesirable effects had been observed, and comparison with a
"
control group three years later had demonstrated significantly less gOitre in the injected group. The results were further assessed a1'ter a total
of five years by Hennessy who confirmed the observations, and obtained further evidence by serum protein bound iodine determination that, after five years, a single injection of iodized oil led to significantly higher levels than in control subjects. In this regard, it might be noted that
Clarke, lot:Cul1agh and Winnikoff had reported that depots of 0.5 ml. of iodized oil containing 40 per cent. iodine (wet w"eight) appeared ade(!uate for one to one-and-a-half years, and depots of 1.5 ml. for one-and-a-balf to two years, as judged by values of twenty-four hour percentage retentions of 1131 • Buttfield had measured radio-iodine uptake by the thyroid by means of a portable scaler, as well as iodine determinations in twenty-four hour urine samples of a group of 150 subjects. His findings were consistent
that iodine deficiency was the major cause of endemic goitre in the Huon area of New Guinea.
196 Tbere being no further discussions, tbe CHAIRMAN requested the Rapporteurs to prepare an appropriate resolution. (For consideration of
draft resolution, see minutes of the fifth meeting, section 1.)
Tbe meeting rose at
4.io p.m.