REGIONAL COMMITTEE Fifty-seventh Session Kurumba Resort, Maldives 7-9 September 2004
Provisional Agenda item 11.1 SEA/RC57/Inf.3 (Rev.1)
2 September 2004
REVIEW OF IODINE DEFICIENCY DISORDERS IN THE SOUTH-EAST ASIA REGION *
*
Originally issued as document No. SEA/ HSM/Meet.9/6 dated 22 June 2004
CONTENTS
1. INTRODUCTION 2. MAGNITUDE OF THE PROBLEM AND SITUATION ANALYSIS 3. PROGRESS TOWARDS SUSTAINABLE ELIMINATION OF IDD IN THE SEA REGION 4. WAY FORWARD 4.1 4.2 4.3 4.4 Policy Formulation and Programme Management Salt Iodisation Health Information, Communication and Community Participation Quality Assurance and Monitoring Progress
1 2
2 4
5 5 5 6 6
5. WHO EFFORTS IN THE ELIMINATION OF IDD 5.1 5.2 5.3 5.4 Advocacy for Policy and Programme Development Setting Norms Capacity Building Measuring Progress
6 7 7 7
Annexes 1. The Spectrum of Iodine Deficiency Disorders (IDD) 2. Indicators of Sustainable Elimination of IDD 8 9
1.
INTRODUCTION Iodine deficiency has been known to exist for centuries, and even now, iodine deficiency disorders (IDD) pose a significant public health challenge in the South-East Asia Region (SEAR). In addition, they have an impact on social and economic development. Elimination of iodine deficiency and its devastating consequences is achievable. While Member States in the Region have made significant progress in this regard, a lot remains to be done. What is required, among other things, is a strong partnership between WHO, national governments, UN agencies, NGOs, leading institutions and donors to achieve the set targets. Iodine is naturally present in the soil and in water. Crops grown on iodine-deficient soil or water are also deficient in this micronutrient. Iodine is required for the production of thyroid hormones which are essential for normal physical and mental development of humans. A very small amount is required daily. e.g. only 150 micrograms per day for an adult. Iodine deficiency disorders (IDD) refer to the wide spectrum of effects on growth and development (Annex 1). These include not only goitre with impaired thyroid function but also decreased fertility, increased perinatal mortality and retarded growth. Iodine deficiency is the leading cause of preventable mental retardation, and remains a major threat to the health and development of populations, particularly in low-income countries. Iodine deficiency at critical stages during pregnancy and early childhood results in impaired development of the brain, and consequently, in impaired mental function. Severe iodine deficiency causes cretinism. Thus, the most important global and economic significance of iodine deficiency is the mental impairment that lowers intellectual prowess of children at home, at school and at work, and ultimately affects productivity in adult life, reducing the potential of whole communities. The Thirty-ninth World Health Assembly, in 1986, called for prevention and control of IDD. The Forty-third World Health Assembly, in 1990, adopted a resolution to eliminate iodine deficiency as a public health problem. Soon after, 70 heads of state gathered at the World Summit for Children and pledged to make elimination of IDD as one of the health and social development goals to be achieved by 2000. Universal salt iodization (USI) was identified as the main intervention for achieving this goal. The global target now is for the elimination of IDD by 2005, as set in the United Nation General Assembly Special Session (UNGASS) on Children, held in 2002. So far, only Bhutan has achieved this goal. In other SEAR countries, however, progress towards achieving this goal seems to have slowed down. There are several reasons, important amongst them being complacency and a false sense of having achieved USI with a decrease in visible signs of iodine deficiency, e.g. goitre. The focus of this paper, therefore, is on the status of IDD control programmes in the South-East Asia (SEA) Region and the areas which would need urgent attention if the goal of IDD elimination is to be attained.
SEA/RC57/Inf.3 (Rev.1) Page 2
2.
MAGNITUDE OF THE PROBLEM AND SITUATION ANALYSIS Across the world, countries are trying to increase the coverage of iodized salt. The position of South Asia in this respect is shown in Figure 1. Figure 1. Worldwide consumption of iodized salt 86 40
100 80 60 40 20 0
Percent
62
61
67
79 53 48
S E/
ics alt /B IS /C ro Eu E. ica er m ic tA cif La Pa & ia As E ia As a S ric Af N E/ id. M a ric Af /C W a ric Af
Source: UNICEF End Decade Database, Feb 2004
Current estimates show that there are 172 million people with goitre in the SEA Region and another 600 million are at risk. Nearly 20 million newborns are unprotected, constituting nearly 35% of the world’s unprotected newborns. (The number of unprotected newborns is derived from the number of pregnant women who do not consume adequately iodized salt).
ld or W
vg /A
3.
PROGRESS TOWARDS SUSTAINABLE ELIMINATION OF IDD IN THE SEA REGION Goitre rates have decreased remarkably over the last two decades. However, goitres may persist even though current iodine status is optimal. Therefore, information collected on goitre prevalence requires careful interpretation. Urinary iodine excretion, on the other hand, provides a better picture of the current iodine intake of an individual. However, it is equally important to carry out regular monitoring of iodized salt at the production level and periodic monitoring at the household level. The sustainable elimination of IDD requires that the following ICCIDD/UNICEF/WHO indicators are met. Details are provided in Annex 2. • Proportions of households using adequately iodized salt (with an iodine content of 15 parts per million (ppm) or more– coverage should be more than 90%. Median urinary iodine excretion (UIE) should be at least 100 ug/l with less than 20% of values below 50 ug/l. Programmatic indicators - At least 8 out of the 10 specified indicators should be met.
• •
SEA/RC57/Inf.3 (Rev.1) Page 3
In addition to eliminating IDD, acceptable iodine nutrition will be sustained in the population if the median urinary iodine is maintained within the range of 100-300 ug/l. Most countries in the Region have attempted to implement effective IDD elimination programmes over the past few years. Because of the large population in this Region, success here will contribute significantly to the global elimination of IDD. Nine of the 11 Member States are operating universal salt iodization programmes and have most key programme components in place. Many countries have national action plans for IDD control. While eight countries have a national inter-sectoral coordinating body, seven have salt iodization legislation in place as well as laboratory facilities for salt quality and programme monitoring. The requirement of iodized salt in the 11 countries is about 8.5 million metric tons. This includes the requirement for livestock. With the exception of India and Thailand, all other countries import salt. Bhutan, Nepal and Maldives do not produce any salt and depend totally on imports. In this Region, nearly 66% of households have access to iodized salt but only Bhutan has reached over 90% coverage. Figure 2 shows the percentage of households in each of these countries that consume adequately iodized salt. However, if some areas do not have sufficient access to iodized salt, or iodine deficiency is severe, supplementation with iodized oil may be required (as was being done recently in the case of pregnant women in parts of Indonesia, Myanmar and Nepal). Also, in many parts of Thailand, condiments such as fish sauce are used commonly for flavouring, and initiatives to iodize fish sauce have been taken. More studies would be required, however, to show whether this would be feasible (with regard to quality control and monitoring) and cost-effective before it can be considered as a possible complement to iodized salt in some countries. Figure 2. Adequately iodized salt coverage in the SEA Region 95 70 49 72 63 44 63 73
100 90 80 70 60 50 40 30 20 10 0
65
67
Percent
BAN BHU IND INO MAL MMR NEP SRL THA TLS Countries
Source: UNICEF End Decade Database, Feb 2004, and country reports
(No information is available on DPR Korea).
SEA/RC57/Inf.3 (Rev.1) Page 4
The most recently reported figures for urinary iodine excretion data are shown in Figure 3. Although the median values are within the acceptable range, what is worrying is that the proportion of population with urinary iodine excretion below 100 microgram/l range from about one quarter to two thirds. Figure 3. Urinary iodine excretion in the SEA Region 350 Percent of UIE and Median 300 250 200 150 100 50 0 BAN (1999) BHU (2001) IND (2001)* INO (1996) MAL (2002) MMR (2001) NEP (1998) SRL (2003) THA (2000) 43 12 33 123 123 65 64 115 43 136 144
298
205 150
38
35
22
35
Country and year of survey Median UI (ug/l) Propotion of population with UI < 100 ug/l
Source: Country survey data. Data from DPR Korea and Timor-Leste are not available * Data from Kerala
4.
WAY FORWARD Unlike some diseases (smallpox), IDD cannot be eradicated, and may recur if iodine intake becomes inadequate. Continuous efforts will thus be required to ensure the effective functioning of IDD control programmes. As mentioned earlier, universal salt iodization has been identified as the simplest way to achieve optimal iodine nutrition. Although considerable progress has been made in improving the availability and accessibility of iodized salt, about 66% of the households in the Region are currently using adequately iodized salt. The infrastructure to produce the required quantity of iodized salt exists in most countries, so the proportion of population consuming iodized salt could reach or exceed 90%. To achieve this, accelerated efforts are needed. Some of the areas which need attention in the countries are given below: • • • • Policy formulation and programme management Universal Salt iodization (USI) Health information, communication and community participation Quality assurance and monitoring progress
SEA/RC57/Inf.3 (Rev.1) Page 5
4.1 Policy Formulation and Programme Management Although all countries in the Region are committed to eliminating IDD, the decrease in goitre rates has led to a false sense of complacency. IDD programmes will need to be revitalised if the goal of sustainable IDD elimination is to be reached. In this context, the following actions may be considered. • • • • • • Increasing the importance and priority given to IDD prevention on the national health and development agenda. Developing or revising the strategy for IDD prevention and optimal iodine nutrition, linked to the national plan. Establishment of an inter-sectoral technical working group with clearly-defined goals, authority and responsibilities for implementation of the strategy. Prioritization of reproductive age women to ensure that their newborn babies – the future generation - are protected from IDD. Usage of data from monitoring surveys on UIE to re-prioritise and track the IDD programme. Strengthening existing legislation to cover all salt for human and animal consumption (including for food processing) and defining upper and lower limits for iodine content. Legislation should have implementing guidelines (e.g. monitoring the iodine content at production and import sites), and be legally enforceable.
4.2 Universal Salt Iodization (USI) The production and marketing of adequately iodized salt needs to be accelerated until all households and individuals have access to it. Inadequate coverage of iodized salt could be ascribed to a variety of factors, the important ones being: (a) absence of appropriate legislation, (b) lack of national IDD committee or coalition, (c) inadequate salt iodization, (d) insufficient knowledge of IDD among salt producers, (e) small informal rural salt production, (f) household use of non-iodized salt meant for other purposes, (g) informal repackaging, (h) lack of monitoring, (i) price differential between iodized and non-iodized salt, and (j) lack of awareness of the implications of IDD among consumers and health providers. It would thus be important to: • • • work with the salt industry and the ministry of industries; develop/review the action plans for salt iodization, and support small producers to form cooperatives to enable them to compete, iodize their salt production, and meet standards.
4.3 Health Information, Communication and Community Participation Consumption of iodized salt should become the norm. For this to occur, the focus has to shift to the consumer so that the problem and the solution can be reappraised in terms of consumer perceptions and attitudes.
SEA/RC57/Inf.3 (Rev.1) Page 6
The focus of the consequences of iodine deficiency also needs to shift from goitre to its damaging effect on brain development and cognitive losses. Development of a communication strategy to expand and sustain consumer awareness and demand for iodized salt would be very useful. All channels available should be used to disseminate the benefits of eating iodized salt. For social mobilization, salt testing kits could be used as a tool in schools and communities. Nongovernmental organizations and the community would need to get involved in this process. 4.4 Quality Assurance and Monitoring Progress The objective of assessment of iodine status is not only to iodize the salt, but to ensure that the population has a normal iodine status, and normal thyroid function. Monitoring iodized salt production is thus an essential requirement for eliminating and preventing IDD. Producers must implement a system of internal monitoring and quality control to consistently achieve the required iodine concentration in their salt. An effective internal monitoring system, coupled with external independent monitoring, increases the chances of successfully eliminating IDD. In this context, networking of laboratories, with quality assurance protocols, would be helpful for the countries. For this reason, the International Resource Laboratory for Iodine Network has been set up by the Center for Disease Control (CDC) Atlanta, WHO, UNICEF, the International Council for Control of Iodine Deficiency Disorders (ICCIDD) and the Micronutrient Initiative (MI). In the SEA Region, Bhutan, Indonesia and Myanmar have strong monitoring systems with inbuilt mechanisms for problem solving. The Bhutan and Indonesian models have complex plans and involve many small laboratories. They are also expensive and the high cost of implementation reduces sustainability. Therefore there is a need to establish reference laboratories, and develop and implement simple sampling systems that are effective and provide producer and consumer protection. Potassium iodate availability (and cost), and facilitating easy procurement for small producers, are issues which would require further discussion. Most countries in the Region import salt. In these countries regular monitoring should be done at the entry point to ensure that only salt iodized according to the prescribed specifications is imported. There is an urgent need to harmonize the iodine content standards across the Region. India exports salt to Nepal and Bhutan, but as the standards in these countries are quite different, there are cost implications for the importing country as they have to add additional iodine for their consumers.
5.
WHO EFFORTS IN THE ELIMINATION OF IDD WHO is working with countries and its partners for IDD elimination and in sustaining optimal iodine nutrition. The focus will be mainly on the following areas:
5.1 Advocacy for Policy and Programme Development Necessary measures have been taken to highlight why prevention of IDD requires urgent attention. WHO provides necessary evidence-based information to countries to facilitate political commitment, policy formulation and programme amendment, and to the partners and donors for their active involvement and increased support.
SEA/RC57/Inf.3 (Rev.1) Page 7
5.2 Setting Norms • Research support and generation of evidence: The South-East Asia Nutrition Research-cum-Action Network, launched by the Regional Office, is carrying out research in generating clinical and programmatic evidence. While increasing interaction with the concerned WHO collaborating centres, efforts are being made to expand the Network. Countries are being assisted to disseminate evidence and bring about changes in policies and practices for improving iodine nutrition. Development of region-specific norms and guidelines: Region-specific technical policy and programme guidelines, as well as norms and standards need to be developed in consultation with experts in the field. Dissemination of norms and standards: The Regional Office is focusing on the dissemination, adaptation (when required), and utilization of guidelines and tools in collaboration with UNICEF and ICCIDD.
•
•
5.3 Capacity Building • Strengthening national institutions and WHO collaborating centres: WHO is working with countries and partners in strengthening institutional capacity for technical support, programme implementation, programme planning, surveillance and monitoring. WHO-SEARO has already supported two training workshops. Development of a pool of experts: Training and fellowships are being provided to develop a pool of multidisciplinary experts to build regional capacity to support programmes in countries. Providing technical support to countries: The Regional Office is providing technical support to enable countries develop strategies and priorities; conduct effective programme planning, mobilize resources and monitor and evaluate programme implementation. Partnerships: Partnerships with the salt industry, various global and national initiatives, UN partners, particularly UNICEF, Micronutrient Initiative, ICCIDD, USAID and other development partners, leading institutions, donor agencies and NGOs are being actively pursued. A Global IDD network for Sustainable Elimination of IDD already exists, and WHO is making efforts to strengthen this Network and play a leading role in it.
•
•
•
5.4 Measuring Progress WHO is working with countries and partners for country-specific surveillance including indicators on IDD, improving the quality of data collection, analysis and monitoring capacity, and their utilization for measuring progress and programme planning. Feedback from the Member States will help to maintain the database on regional progress in the IDD, facilitate sharing of information and reporting to governing bodies. Along with UN partners and other agencies (UNICEF, MI, ICCIDD), WHO is organizing and undertaking reviews of IDD control programmes in Member States. This is to determine the status of the programmes and to provide positive feedback for improvement, as well as for assessing whether they have achieved optimal iodine nutrition for their populations.
SEA/HSM/Meet.9/6 Page 8
Annex 1 THE SPECTRUM OF IODINE DEFICIENCY DISORDERS (IDD)
FOETUS
Abortions Stillbirths Congenital anomalies Increased perinatal mortality Increased infant mortality Neurological cretinism: mental deficiency, deaf mutism, spastic diplegia squint Myxoedematous cretinism: mental deficiency, dwarfism, hypothyroidism Psychomotor defects Neonatal hypothyroidism Retarded mental and physical development
NEONATE CHILD AND ADOLESCENT ADULT
Goitre and its complications Iodine-induced hyperthyroidism (IIH) Goitre Hyperthyroidism Impaired mental function Increased susceptibility to nuclear radiation
ALL AGES
Ref: ICCIDD/UNICEF/WHO Assessment of Iodine Deficiency Disorders and Monitoring their Elimination. A guide for programme managers, 2001.
SEA/HSM/Meet.9/6 Page 9
Annex 2 INDICATORS OF SUSTAINABLE ELIMINATION OF IDD
In considering whether the sustainable elimination of iodine deficiency as a public health problem has been achieved, the following criteria should be met. With regard to salt iodization , availability and consumption of adequately iodized salt (>15 ppm iodine) must be guaranteed. This is demonstrated by its use by more than 90% of households. Preconditions for the use of this vehicle for eliminating IDD are: • • • • local production and/or importation of iodized salt in a quantity that is sufficient to satisfy the potential human demand (about 4-5 kg/person/year); 95% of salt for human consumption must be iodized according to government standards for iodine content, at the production or importation level; the percentage of food-grade salt with iodine content of at least 15 ppm, in a representative sample of households must be equal to or greater than 90%, and iodine estimation at the point of production or importation, and at the wholesale and retail levels, must be determined by titration. At the household level, it may be determined by either titration or certified kits.
With regard to the population’s iodine status: • • the median urinary concentration should be at least 100 micrograms/liter, with less than 20% of values below 50 micrograms/liter; and the most recent monitoring data (national or regional) should have been collected in the last two years.
At least eight out of the following ten programmatic indicators should occur: • an effective, functional national body (council or committee) responsible to the government for the national programme for the elimination of IDD (this council should be multidisciplinary, involving the relevant fields of nutrition, medicine, education, the salt industry, the media and consumers, with a chairman appointed by the Minister of Health); evidence of political commitment to universal salt iodization and elimination of IDD; appointment of a responsible executive officer for the IDD elimination programme; legislation or regulations on universal salt iodization (while ideally regulations should cover both human and agricultural salt, if the latter is not covered this does not necessarily preclude a country from being certified as IDD-free); commitment to assessment and reassessment of progress in the elimination of IDD, with access to laboratories able to provide accurate data on salt and urinary iodine; a programme of public education and social mobilization on the importance of IDD and the consumption of iodized salt; regular data on salt iodine content at the factory, retail and household levels;
• • •
• • •
SEA/RC57/Inf.3 (Rev.1) Page 10
• • •
regular laboratory data on urinary iodine in school-aged children, with appropriate sampling for higher risk areas; cooperation from the salt industry in the maintenance of quality control, and a database for recording of results or regular monitoring procedures, particularly for salt and urinary iodine content, and if available, neonatal TSH, with mandatory public reporting.
Ref: ICCIDD/UNICEF/WHO Assessment of Iodine Deficiency Disorders and Monitoring their Elimination. A guide for programme managers, 2001