IDDNEWSLETTERIn this Issue:

VOLUME 22 NUMBER 4 NOVEMBER 2006

INTERNATIONAL COUNCIL FOR CONTROL OF IODINE DEFICIENCY DISORDERS

THE INTERNATIONAL COUNCIL FOR CONTROL OF IODINE DEFICIENCY DISORDERS (ICCIDD) is a nonprofit, nongovernmental organizationdedicated to sustained optimal iodine nutrition and the elimination of iodine deficiency throughout the world. Its activities have been supported bythe international aid programs of Australia, Canada, Netherlands, USA, and also by funds from UNICEF, the World Bank and others.

ICCIDD

Steady progressagainst IDD in thePhilippines

Through universal salt iodization(USI) and use of iodized oil, enor-mous progress has been made in Asiain reducing iodine deficiency overthe last decade (1).

In the Philippines, Republic Act No.8172 promoting salt iodization nati-onwide, otherwise known as theASIN Law (2), was passed in 1995.This law requires the addition of

iodine to all salt intended for animaland human consumption. But achie-ving USI in the Philippines has beena challenge: by 2003, only 56% ofhousehold salt was iodized.

Focus on South Asiaand the Pacific

Indonesia

7New Zealand

8Papua New Guinea11

Philippines

1 Vietnam

17

Meetings andAnnouncements

Abstracts

19Sri Lanka

14

Many young women in Southeast Asia need more iodine: in the Philippines andIndonesia over 3 million children each year are born “unprotected” from the damageof iodine deficiency

LA Perlas, JA Desnacido, JM Marcos, RL Cheong, andMRA Pedro The Food and Nutrition Research Institute (FNRI) of the Department of Science and Technology (DOST) and A2Z,Academy for Educational Development (AED), Philippines

The Philippines conducts NationalNutrition Surveys (NNS) every 5years, and in the NNS in 1987, thetotal goiter rate was reported to be3.5% among Filipinos 7 years andolder (3).The goiter rate increased to6.7% in the 1993 NNS (4). In bothNNS, goiter was determined by pal-pation. In the succeeding surveys of1998 and 2003, goiter prevalence wasnot determined, but urinary iodineconcentration (UI) was measured.

Both the 1998 and 2003 NNS useda stratified multistage sampling designthat covered all regions of the coun-try. Included in the 1998 survey were10,616 children aged 6-12 years,while the 2003 survey included4,665 children aged 6-12 years, 583pregnant women and 1,184 lactatingmothers. Sample size for the 1998survey was adequate for provincialestimates, while that of the 2003 sur-vey was for national estimates only.Spot urine samples were collected

from survey participants and UI forboth surveys was determined by theacid digestion method as recommen-ded by ICCIDD (5) and interpretedusing ICCIDD criteria (6).To assessthe accuracy of the UI assay, theFNRI’s Nutritional BiochemistryLaboratory participated in theEQUIP Program (Ensuring theQuality of Iodine Procedures) of theCenters for Disease Control andPrevention (CDC) in Atlanta, GA,USA (7).

In 1998, IDD in the Philippines wasconsidered mild based on a nationalmedian UI in children 6-12 years of71 µg/L, with 35.8% of values below50 µg/L; only 2 regions of the coun-try had median UI >100 µg/L (8). Inthe 2003 survey, the median UIamong children 6-12 years dramati-cally increased to 201 µg/L, withonly 11.4% having values <50 µg/L(Table 1).While the 1998 median of71 µg/L corresponded to an iodineintake that was insufficient, themedian value of 201 µg/L in 2003indicated intake that was “more thanadequate” (as defined by a medianUI >200 µg/L).This high level ofintake may increase risk, in suscepti-ble individuals, of iodine-inducedhyperthyroidism within 5-10 yearsfollowing introduction of iodized salt (6).

Pregnant women and lactatingmothers are both nutritionally vulne-rable groups whose nutritional healthsignificantly determines the nutritio-nal status of their infant. In 2003,

among pregnant and lactatingwomen, the median UI and propor-tion of UI values below 50 µg/Lwere 142 µg/L and 18%, and 111µg/L and 23.7%, respectively (Table 1).

The median UI for pregnant andlactating women was not determinedin the 1998 NNS. However an ECD(Early Child Development) SpecialNutrition Survey conducted in 2000in 3 regions (Western Visayas, CentralVisayas, and Central Mindanao)obtained median UI values of 86µg/L and 71 µg/L for pregnant andlactating women respectively; UIvalues below 50 µg/L were presentin 28.4% and 35.2%, respectively (8).Thus, median UIs from the 2000ECD report were lower than the2003 national estimates.While themedian UI for pregnant women andlactating mothers in the 2003 surveysuggested adequate iodine intakes,the IDD problem may have not beenentirely eliminated, since the propor-tion of UI values less than 50 µg/Lamong lactating women was still over20%.

The full distribution of UI values forchildren, pregnant women and lacta-ting mothers are presented in Figures1-3.The distribution of UI valuesamong children in the 1998 surveywas skewed towards low values, whe-reas the distribution of values in the2003 survey has shifted towards hig-her values (Figure 1). Figure 1 alsoshows that among the children,23.5% had moderate iodine deficien-

2 IDD NEWSLETTER NOVEMBER 2006 PHILIPPINES

Table 1 Urinary iodine (UI) concentrations in the 2003 national study in the Philippines, including children andpregnant and lactating women

Population group Median UI (µg/L) Percentage with UI < 50 µg/L

Children, 6-12 y 201 11.4

Pregnant women 142 18.0

Lactating mothers 111 22.7

Table 2 Progress in the Philippines towards the eliminationof IDD, 1998-2003

Indicator Goal Achievements1998 2003

Proportion of house- >90% 9.7% 56%holds using iodized salt

Median urinary iodine 100-200 ug/L 71 ug/L 201 ug/L(µg/L)

Proportion <100ug/L <50% 65.4% 23.8%

Proportion <50 ug/L <20% 35.8% 11.4%

IDD NEWSLETTER NOVEMBER 2006 PHILIPPINES 3

cy in the 1998 survey, but only 7.4%were below this level in the 2003survey. Severe iodine deficiency (UI<20 µg/L) also decreased from12.3% in 1998 to 4.0% in 2003.Among pregnant women (Figure 2),10.8% and 7.2% had spot UI valuesindicating moderate and severe IDD,respectively.Among lactating women(Figure 3), 14.4% and 9.3% had spotUI values indicating moderate andsevere iodine deficiency, respectively.

On the other hand, among childrenin the present survey, 14.3% had UIlevels >_ 300 µg/L corresponding toan excessive iodine intake.This valuewas only 0.1% in the 1998 survey.Among pregnant and lactatingwomen, 9.8% and 3.6% had UIs>300µg/L.

Although the median UI obtainedfor 6-12 year old children in the2003 survey was 201 µg/L, the samesurvey showed that only 56% (Table2) of salt from the households sur-veyed tested positive for iodine (10).This is far from the goal recommen-ded by ICCIDD that access to iodi-zed salt at the household level be>_90 %. However, there has beensignificant progress towards the eli-mination of IDD in the countrysince the 1998 survey, when only

9.7% of households tested positivefor iodized salt (11). While informa-tion directly linking salt consumptionto UI is not available, it may be safeto assume that the dramatic increasein UI between 1998 and 2003 is aresult of the progress made towardsuniversal salt iodization (USI).

The 2003 survey also found percapita intake of salt is 6 g/day, whichtheoretically translates to a per capitaiodine intake of 240 µg/day fromsalt, considering the mandated iodineconcentration in household salt iodi-ne is 40 ppm (2).This calculatedintake is higher than the iodinerequirement for Filipinos in someage groups (e.g., 90 µg/day for chil-dren from birth to 6 yrs, 120 µg/dayfor 7-9 yr old children and 200µg/day for pregnant women and lac-tating mothers) (12).This intake doesnot include iodine from processedfoods with iodized salt. It is possiblethat the children, compared to preg-nant women and lactating mothersmay be taking in more iodine fromthese foods (e.g. mami noodles).Usually, it is virtually impossible toreach excess levels of iodine wheneating a varied diet without fortifiedfoods or supplements.This may nolonger be true with the increasedarray of fortified foods and increased

use of supplements.

There are indications of increasingavailability of processed foods thatuse iodized salt, based onDepartment of Health (DOH) regi-strations by food manufacturers withthe Sangkap Pinoy Seal (SPS) (13).Considering this, it would be usefulto look into current levels of iodinein salt at the household level, and totrack iodine levels in iodized salt atproduction and retail sites.

While the national medians in 2003survey were >100 µg/L for all popu-lation groups studied, iodine nutriti-on within regions and provinces mayvary.The 1998 survey found theregions of ARMM and CentralLuzon had iodine intakes that wereadequate based on median UI. Butintakes appeared to be low in otherprovinces as indicated by a medianUI <100 µg/L (8).The Philippinescan only be considered iodine suffi-cient if at least 90% of householdshave access to iodized salt and medi-an UI is >_100 µg/L in all regionsand provinces. This highlights theimportance of assessing IDD at sub-national levels.

There has been a dramatic improve-ment in iodine status in thePhilippines from 1998 to 2003.Theincrease in iodine intakes between1998 and 2003 is likely due to steadyprogress made towards USI.There isa need for careful monitoring toavoid the reemergence of IDD, aswell as to avoid iodine excess. IDDsurveys at sub-national levels are nee-ded to monitor progress towards eli-mination of IDD in all regions.

For long-term sustainability, a highlevel of political awareness, a strongmotivation for enforcement of theASIN law and involvement of saltproducers as full partners will be needed.The government should pro-

Filipino children need adequate iodine to learn well at school

vide training courses on salt iodizati-on technology and quality assurancein laboratories in all regions formonitoring level of iodine in salt.Funds should be given to conductresearch on stability of iodine in iodi-zed salt, tracking of iodine from pro-duction to retail to household levels,and association of UI and salt use,among others.

References1. de Benoist B,Andersson M,Takkouche B,Egli I. 2003 Prevalence of iodine deficiencyworldwide. Lancet 362:1859-60 2. Republic Act No. 8172.An ActPromulgating Salt Iodization Nationwide andfor Related Purposes (ASIN LAW) and itsImplementing Rules and Regulations.Republic of the Philippines.3. Tanchoco CC, Cilindro PA, Pingol MC, etal.Third National Nutrition Survey. Clinicaland Anthropometric Phase. JPMA. 199066(1): 33-49.4.Velandria FV, Magbitang JA,Tanchoco CCet al. Fourth National Nutrition Survey,Philippines, 1993. Part C. Clinical NutritionSurvey. PJN 1997 XLIV(1&2):49-65.5. Dunn JT, Crutchfield HE, Gutekunst R,Dunn AD. 1993. Methods for measuringiodine in urine. ICCIDD/UNICEF/WHO.6. WHO, UNICEF, ICCIDD.Assessment ofiodine deficiency disorders and monitoringtheir elimination. Geneva,World Healthorganization, 2001 (WHO/NDH/01.1).7. Environmental Health, Centers for DiseaseControl and prevention (CDC),Atlanta GA.Ensuring the Quality of Urinary IodineProcedures (EQUIP).8. Madriaga JR, Cheong RL, Desnacido JAet al. Prevalence of Iodine Deficiency in thePhilippines. PJN. 2001 48 (1-2): 59-68.9. FNRI-DOST. Baseline Survey and DataGeneration on Nutritional Status,Psychosocial Development and Care of 0-6Year-Old Children in ECD provinces. Oct.2001.10. Pedro MRA, Sario SS, Cerdeña CM, etal. Awareness and Usage of Fortified Foods.Presented during the Media Forum, PearlManila Hotel, Dec. 200411.Villavieja GM, Sario IS, Laña RD,Cerdeña CM,Tarayo ER, and Nones CA.Awareness and usage of fortified foods in thePhilippines. PJN 2001, 48(3-6): 147-162.12. Food and Nutrition Research Institute,Department of Science and Technology(FNRI DOST), 2002. Recommended Energyand Nutrient Intakes. Philippines, 2002Edition.13. DOH/USAID/MOST. Sangkap PinoySeal approved products as of March 2005.

4 IDD NEWSLETTER NOVEMBER 2006 PHILIPPINES

Figure 2 Distribution of urinary iodine concentrations (µg/L) in pregnant women inthe Philippines in 2003.

%35

30

25

20

15

10

5

0<20 20-49 50-99 100-149 150-199 200-249 250-299 300-399 400-499

7.210.8

18.4

15.613.1 12.3 12.7

9.4

0.4

Figure 1 Distribution of urinary iodine concentrations (µg/L) in schoolchildren inthe Philippines in 1998 and 2003.

%40

35

30

25

20

15

10

5

0<20 20-49 50-99 100-149 150-199 200-249 250-299 300-399 400-499

12.3

4.0

23.5

7.4

29.6

12.4

17.3

12.7 11.913.2

4.5

16.2

0.9

20.8

0.1

13.7

0.6

NNS 1998

NNS 2003

Figure 3 Distribution of urinary iodine concentrations (µg/L) in lactating women inthe Philippines in 2003.

%40

35

30

25

20

15

10

5

0<20 20-49 50-99 100-149 150-199 200-249 250-299 300-399 400-499

9.3

14.4

22.7

16

13.110.8 10.3

3.50.1

IDD NEWSLETTER NOVEMBER 2006 PHILIPPINES 5

Davao City makes a breakthrough in their saltiodization programDavao City, nestled in Mindanao in southeastern Philippines, is now making greatstrides in its salt iodization program. The achievements of the city – 84% householdusage of iodized salt and 99% of salt iodization in public markets – is a far cry fromseveral years ago. In 1998-99, 34% of children in the province suffered from mode-rate-to-severe iodine deficiency, and only 23% of households used iodized salt.

Theo San Luis ICCIDD, the Philippines

The Big Turnaround

Davao City adopted a FoodFortification Program as early as1993 but it was not until 1999 when the program gained significantmomentum. In May 1999, the UnitedStates Agency for InternationalDevelopment (USAID) chose toassist Davao under its “EndingHidden Hunger Project”, a projectsupporting Universal Salt Iodization(USI).

The launch of the Ending HiddenHunger program at the First CitySummit on Salt Iodization in March2000 marked the turning point inthe city’s iodization program.Theevent brought together the key sec-tors: government, private businessand civil society to forge agreementsfor the program.The following fivekey agreements were made:

1. Food processors, salt manufactu-rers and academia were included asmembers of the City NutritionCommittee

2. Food fortification education andtraining to be given to food manu-facturers

3. Incentives such as tax rebates andacquisition of Sangkap Pinoy (foodfortification seal from the Depart-ment of Health) for manufacturerswho comply with requirements

4. Massive information campaign onfood fortification to create demandfor iodized salt and fortified foods

5. Create and monitor implementa-tion of ordinances for the promotionof USI

The local government passed LocalOrdinance No. 95 in October 2000,mobilizing all sectors to ensure saltiodization in the city.The ordinanceprovides for the use of iodized salt inthe preparation of food and its wideravailability to customers. In 2001, thelocal government created an ad hoc

group to ensure the effective imple-mentation of the salt iodization pro-gram. The ad hoc group was com-prised of the City Mayor’s office, theCity Health Office, trade depart-ment, ports authority, Kiwanis Clubof Davao City and the Davao CityChamber of Commerce andIndustry.

A year later, Davao City MayorRodrigo Duterte created the DavaoCity Task Force on Salt Iodization(formerly the ad hoc group) toboost, sustain and ensure implemen-tation of salt iodization and food for-tification programs in the city.Thetask force consists of the followingagencies and organizations:

• Office of the City Mayor –Chairperson• Kiwanis Club of Davao City – Co-chairperson• City Health Office – Secretariat • Members: City Legal Office, CityCooperative Development Office,Bureau of Customs, City EconomicEnterprise, City Information Office,Department of Health, Departmentof Education, Department of Tradeand Industry, Davao City Chamberof Commerce and Industry

Davao City

6 IDD NEWSLETTER NOVEMBER 2006 PHILIPPINES

Significant achievements

The 12-person task force achievedthe goals of the project sooner thanexpected due to overwhelming sup-port from the city government,donors and key sectors.

A. Increase in usage of iodized saltBased on the survey conducted bythe Manila Office of Helen KellerInternational for the Department ofHealth, household use of iodized saltjumped from 40% in 2001 to 84% in2003. Moreover, 99% of salt in mar-kets contains iodine.

This can be attributed to the lowe-ring of iodized salt prices from Php12/kg (equivalent to US$ 0.23) in2001 to Php 4-6/kg (US$ 0.07-0.11cents) in 2003. The Task Force faci-litated the price decrease of iodizedsalt after it purchased 50 sacks ofiodized salt and commissioned baran-gay (village) health workers to repackand sell the salt at a lower price.Since then, warehouses significantlyreduced prices from Php 168 (US$3.23)/sack to Php 88 (US$1.69)/sack of salt.

B. Increased awareness on foodfortification and salt iodizationThe effective information campaignhas created a paradigm shift amongconsumers and businesses in DavaoCity. Food fortification/Iodizationseminars, information education andcommunication materials and inte-

gration of salt iodization in school curricula and health workers’ educa-tion has generated more support and increased demand for iodine-fortifiedfoods.The food industry was thencompelled to fortify their food pro-ducts. Big corporations such asUniversal Robina, Pilmico Maurifoods, bakeshops and other foodmanufacturers agreed to use iodizedsalt in their production.

C. Formation of other SaltIodization Task Forces in the countryThe Davao City Task Force helpedestablish task forces in five othercities in the Philippines namely:Cagayan de Oro, General Santos,Cebu, Bacolod, Zamboanga, andIligan.Advocacy was conductedduring meetings with local leaders ofKiwanis International in these areas.They highlighted the program as aWorld Service Project of Kiwanisand encouraged them to emulate theDavao City Task Force as model.Ajoint meeting was held including amajority of these leaders to formallyinitiate the establishment of theirrespective task forces.

Looking forward

Even though Davao City has madestrides towards achieving UniversalSalt Iodization, there is a lot to bedone.The Task Force is now focusingits efforts on capacity building oflocal salt cooperatives, intensifyingthe information campaign on saltiodization and food fortificationthrough radio, and promotion of vit-amin A and iron fortification to fullyimplement the “Ending HiddenHunger Project”.

It is hoped that with the conti-nued support and increasedcooperation from all sectors,100% iodization of salt willsoon be a reality in Davao City.

Iodized salt available in a local market

The Davao City ASIN Task Force

Background

Manual iodization offers a cheap andsimple alternative for small farmersand salt traders to iodize salt, withouthaving to first invest in expensiveequipment and upgrade the qualityof their salt.This would be a meansto capture and iodize raw salt whichwould normally go directly from thefarmer to the market without iodiza-tion.Therefore, UNICEF commis-sioned a study to determine the levelof contaminants in raw salt and deve-lop parameters for effective iodizati-on of salt with hand sprays.

Objectives

The targeted outcome was a set ofguidelines to be used for training far-mers and salt collectors on manualiodization. For this purpose, theSEAMEO-TROPMED and theMinistry of Industry conducted afeasibility study of hand spray iodiza-tion.The overall study consisted oftwo components:(1) A stability study to determine sta-

bility of iodine in raw salt iodizedusing hand spraying under experi-mental conditions(2) Potential Health Risk Study todetermine iodine status of workersexposed to iodine during handspraying and the potential health riskexposure

Design

Component 1 included a cross-sec-tional study of raw salt assessment,followed by laboratory simulationand field verification. Raw salt sam-ples (n=70) stratified by salt quality(K2 and K3) were obtained fromSampang, Pati and Jenepontodistricts.This is a major salt produ-cing area with a high number of saltworkers, and household consumptionof iodized salt ranges from <40% to<80%. SNI requirement was used asthe standard for determining raw saltquality. Iodine stability was observedduring a 12-week storage trial in thelaboratory, and a 4-week storage trialin farms, markets and households.

Component 2 was conducted in Patidistrict as a comparative cross-sectio-nal study during the peak period ofsalt harvest, a high iodine exposureperiod. Hand-sprayer workers (n=42)and non-workers (n=41) living in

the same area were assessed for theirhealth, nutritional and iodine status.Goiter, thyroid stimulating hormone(TSH), urinary iodine concentration(UI) and iodine intake was measured.Data on variables related to iodineexposure among the workers, such aslength of exposure and use of safetyequipment, was also collected.

IDD NEWSLETTER NOVEMBER 2006 INDONESIA 7

Study Report:Salt Iodization Using HandSpraying in Indonesia A Feasibility Study Report submitted to UNICEF by the Ministry of Industry and SEAMEO-TROPMED RCCN University of Indonesia, April 2006

Tony Tanduk, Sigit Dwi Wahjono, Bambang Hernanto, Marihati The Ministry of Industry of IndonesiaUmi Fahmida, Rina Agustina SEAMEO-TROPMED RCCN University of Indonesia

8 IDD NEWSLETTER NOVEMBER 2006 NEW ZEALAND

Results

Approximately 54% of iodized saltsamples met the requirement forminimum NaCl content of 97.4%(the range of NaCl concentrationwas 90-97%). Moisture content ofalmost all raw salt samples exceededthe allowed maximum of 7%, becau-se the samples were 3-day old, freshlyharvested salts. Most of the salt sam-ples (95%) met requirements forinsoluble matter, and all samples metrequirements for heavy metal andarsenic concentrations.

Potassium iodate content assesseddirectly after spraying met therecommended minimum level of30ppm (>33ppm for volumetricbottle hand sprayer; >40ppm forpressure tank hand sprayer).This levelwas obtained regardless of salt qualityor salt pile thickness (either 1/4 or1/2 m). Moreover, the iodine con-

tent remained above 30ppm after 12weeks of storage in the laboratoryand 4 weeks of storage at the farm,market and household.The observedloss of 20-30% of the iodine contentduring 4 months of storage suggeststhat the initial iodine content shouldbe above 40ppm to meet the recom-mended minimum level after prolon-ged storage.The use of pressure tankhand-spray is recommended.Production capacity is 8 tons/day ofiodized salt (packed) using bothequipment types. Estimated cost foriodization by hand-spraying usingrecommended packaging is approxi-mately Rp 162.000/ton, includingpackaging material.

Findings from Component 2 studyindicate higher TSH and UI levelsamong the spraying workers is likelyto be associated with iodine exposu-re using hand spraying. However, the

effect appears reversible. However,two cases of hypo- and hyperthyroi-dism in female workers, attributed tothe combination of both high iodineintake and iodization, warrants furt-her investigation.The use of handspraying for iodization can berecommended with preference tomale operators, exposure as a handspray operator of no more than fouryears, and safety precautions to mini-mize iodine exposure. Further studiesto assess implementation of the gui-delines at farmer level are needed toserve as a model of hand sprayerimplementation.

There is a need to communica-te results of this study to localgovernments in salt-producingareas without underminingmore rigorous effort to iodizesalt (e.g. using a screw convey-or machine).

IDD re-emerges in New Zealand Sheila A. Skeaff and Christine D. Thomson Dept of Human Nutrition, University of Otago, New Zealand

The low iodine content of NewZealand soils predisposes the popula-tion to inadequate iodine intakes.There are anecdotal reports that theindigenous people of New Zealand,the Maori, had goiter prior to colo-nization in the 1800s. Studies in theearly 1920s found endemic goiterthroughout New Zealand (1). In1924 Hercus recommended salt beiodized at 5 ppm; assuming dailyintakes of 10g of salt, this wouldincrease iodine intake by =40 µg/day(2).Thus, after Switzerland, New

Zealand was the second country inthe world to introduce iodized salt.

In 1927 it was estimated that theconsumption of salt was closer to 5-6g/day and =50% of the iodine iniodized salt was lost between produc-tion in England or Canada, and salein New Zealand (3).The work ofPurves in the mid 1930s, comparing24-hour urinary iodine excretion(UI) from several parts of NewZealand,Australia, and two Pacificislands, showed an increase in UI of

100 µg/day would be needed to raiseNew Zealand levels to those of regi-ons that were iodine sufficient (4).

In 1939, the Department of Healthincreased the level of iodization insalt to 50 ppm.Although no publici-ty accompanied this legislation andthe choice of using iodized salt wasleft up to the consumer or manufac-turer, consumers generally preferredprepackaged iodized salt to non-iodi-zed salt sold loose in a brown paperbag (2). By 1953, surveys of school-

IDD NEWSLETTER NOVEMBER 2006 NEW ZEALAND 9

children reported that goiter rateshad fallen to =1% (5).

The use of iodized salt in cookingand at the table, together with theintroduction of iodophors by the

dairy industry in the 1960s, providedsufficient dietary iodine until theearly 1990s (5). Food manufacturersin New Zealand did not use iodizedsalt in processed foods, despite thisoption being available to them.Furthermore, because there was noformal system of national nutritionsurveillance in New Zealand, theiodine status of the population wasnot monitored during this period.

In the 1990s,Thomson began toinvestigate the interaction betweenselenium and iodine, and inadver-tently discovered that UI had fallento low levels; iodine deficiency hadre-emerged in New Zealand.Thereare two likely explanations: a) adecline in the use of table salt inresponse to public health recommen-dations to decrease sodium; and b)the replacement of iodophors by lessexpensive, detergent-based sanitizersin the dairy industry.

Over the past 15 years, studies asses-sing iodine status in New Zealandhave reported mild-to-moderateiodine deficiency.Thomson et al. (6)reported a mean UI of 57 µg/day inadults living in Otago (South Island)

between 1992-93. Similarly, in a lar-ger study conducted the followingyear in adult blood donors living inOtago and Waikato (North Island)reported a median UI of 60 µg/Land 76 µg/L, respectively (7). In1997-98,Thomson et al. (8) reportedlower UIs wereassociated withincreased thyroidvolume (TV) andthyroglobulin(Tg).

Three studieshave assessediodine status inrandom samplesof New Zealandchildren. Skeaff etal (9) reported amedian UI of 66µg/L in 8-10year old schoolchildren. Moreover, analysis of TV

data from the children using themost recent reference values showed30% had goiter (9). Confirmation ofmild iodine deficiency was obtainedwhen a similar median UI (67 µg/L)was reported in the first nationalChildren’s Nutrition Survey in 2002(10); the median Tg concentration ofa sub-sample of children was 12.8ng/mL (11). In a study of 6-24month-old children, those currentlybreast-fed had a median UI of 44µg/L while those weaned (i.e. todd-lers) had a median UI of 59 µg/L(12).

Of concern are reports of moderateiodine deficiency in pregnantwomen; this finding is not surprisinggiven the high iodine requirementsduring pregnancy.Two small studiesof pregnant women living in Otagoconducted between 1995-99 repor-ted a median UI ranging from 32-52µg/L during the course of pregnancy(13,14), similar to the median UI of42 µg/L recently found in women intheir last month of pregnancy (15).In 2005, the ThyroMobil and Iodinein Pregnancy (TRIP) survey, the firststudy to assess iodine status in preg-nant women living throughout NewZealand, found a median UI of 38µg/L with 7% of women having aTV>18 mL.

The Minister of Health, Dr Pete Hodgson, watching the ThyroMobilsurvey of iodine status of pregnant women in Wellington

Despite being surrounded by ocean, most New Zealand children are iodine deficient

What can be done about iodine defi-ciency in New Zealand? It would beprudent for pregnant and lactatingwomen in New Zealand to consumea supplement containing 150-200 µgof iodine each day.Recommendations for people toincrease their intake of foods that arerich sources of iodine, such as fishand seafood, are not likely to be fol-lowed. Despite being surrounded bythe sea, New Zealanders eat relativelysmall amounts of these foods prima-rily because they are expensive (16).An education campaign aimed at rai-sing awareness about iodine deficien-cy would be beneficial.At the pre-sent time, the public is largely una-ware that the New Zealand diet con-tains sub-optimal levels of iodine.The visit of the ThyroMobil to NewZealand in 2005 generated limitedpublicity among pregnant women,midwives and a handful of govern-ment ministers in the capital city ofWellington.

A new food standard for mandatoryfortification of the food supply withiodine has been recently proposed(17).The draft proposal would repla-ce non-iodized salt with iodized saltin breads, breakfast cereals, and bis-cuits. Changing the current AustraliaNew Zealand Food Standards Codeis not a simple process, requiring thepreparation of three AssessmentReports (i.e. initial, draft, final) andtwo rounds of public consultation byFood Standard Australia NewZealand.The Australia and NewZealand Food Regulation MinisterialCouncil is then notified of the final

report, which they can choose toadopt, amend, reject or they mayrequest review. If the new food stan-dard is accepted, the regulation isgazetted and comes into effect after aset transition period (usually 12months); at the writing of this article,mandatory iodine fortification mightbe in place by 2008.

In the early part of the 20thcentury, it took 15 years forthe New Zealand governmentto introduce measures toimprove iodine status, in theearly part of the 21st century,it appears that history mayrepeat itself. Sadly, the adverseeffects are greatest on thesmallest New Zealanders.1. Hercus CE, Benson WN, Carter CL.Endemic goitre in New Zealand and its rela-tion to the soil-iodine. Journal of Hygiene1925;24:321-402.2. Purves HD.The aetiology and prophylaxisof endemic goitre and cretinism. NewZealand Medical Journal 1974;80:477-479.3. Hercus C, Roberts K.The iodine contentof foods, manures, and animal products inrelation to the prophylaxis of endemic goitrein New Zealand. Journal of Hygiene1927;26:49-83.4. Hercus C, Purves HD. Studies on endemicand experimental goitre. Journal of Hygiene1936;36:182-203.5. Mann J,Aitken E.The re-emergence ofiodine deficiency in New Zealand? NewZealand Medical Journal 2003;116(1170):1-5.6. Thomson CD, Smith TE, Butler KA,Packer MA.An evaluation of urinary measu-res of iodine and selenium status. Journal ofTrace Elements in Medicine & Biology1996;10:214-222.7. Thomson CD, Colls AJ, Conaglen JV,Macormack M, Stiles M, Mann J. Iodine sta-tus of New Zealand residents as assessed by

urinary iodide excretion and thyroid hormo-nes. British Journal of Nutrition1997;78(6):901-12.8. Thomson CD,Woodruffe S, Colls AJ,Joseph J, Doyle TC. Urinary iodine and thy-roid status of New Zealand residents.European Journal of Clinical Nutrition2001;55(5):387-92.9. Skeaff SA,Thomson CD, Gibson RS. Mildiodine deficiency in a sample of NewZealand schoolchildren. European Journal ofClinical Nutrition 2002;56:1169-1175.10. Wilson N, Scragg R, Fitzgerald E, et al.Serum zinc, serum cholesterol and urinaryiodine. NZ Food NZ Children: Key results ofthe 2002 Children's Nutrition Survey.Wellington: Ministry of Health, 2003.11. Skeaff SA,Thomson CD, McLachlan S,Morgen A.Thyroglobulin as an index of mildiodine deficiency.Asia Pacific Journal ofClinical Nutrition 2005;14 (Suppl):S42.12. Skeaff S, Ferguson E, McKenzie J,ValeixP, Gibson R,Thomson CD.Are breast-fedinfants and toddlers in New Zealand at riskof iodine deficiency? Nutrition:TheInternational Journal of Applied and BasicNutritional Sciences 2005;21:325-331.13. Thomson CD, Packer MA, Butler JA,Duffield AJ, O'Donaghue KL,Whanger PD.Urinary selenium and iodine during preg-nancy and lactation. Journal of TraceElements in Medicine & Biology2001;14(4):210-7.14. Skeaff SA.The iodine status of vulnerablegroups in New Zealand. PhD: University ofOtago, 2004.15. Mulrine HM, Skeaff SA, Ferguson EL,Valeix P. Iodine status of Dunedin mothersand their breastfed infants.Asia PacificJournal of Clinical Nutrition 2005;14(Suppl):S41.16. Russell DG, Parnell WR,Wilson NC, etal. NZ Food: NZ People. Key results of the1997 National Nutrition Survey. Ministry ofHealth:Wellington 199917. Food Standards Australia New Zealand.Proposal P230: consideration of mandatoryfortification with iodine. Canberra,Australia.Wellington, New Zealand, 2006.

10 IDD NEWSLETTER NOVEMBER 2006 NEW ZEALAND

Background

The Government of Papua NewGuinea (PNG) made a commitmentto work towards the elimination ofiodine deficiency as a public healthproblem by the year 2000 by signingthe relevant World Summit forChildren declarations in 1990.Initiatives, taken by the Governmenttowards achieving this goal, includeintroduction of policies for theimplementation of universal salt iodi-zation (USI) as the main strategy forthe elimination of IDD.The amend-ment of the Pure Food Act of 1970was published in the GovernmentGazette in June 1995, promulgatingthe PNG Salt Legislation as the legalinstrument for implementation ofthe USI policy (1).The USI policywas consolidated by its inclusion inthe National Health Plan 1996 –2000 (2).

In November 1999, the NutritionProgram, Department of Health,released a paper on “SituationAnalysis: Iodine Deficiency Disordersin PNG” (3).The document ack-nowledged the public health signifi-cance of IDD in PNG, and conclu-ded that IDD could not be elimina-ted by the end of the year 2000. It

called for urgent action to ensurethat IDD is eliminated by 2010. Inthe light of the WHO/UNICEF/ICCIDD (4) programmatic indica-tors for sustainable elimination ofIDD as a public health problem, tre-mendous progress has been made inthe implementation of USI in PNG.

A multidisciplinary national commit-tee, responsible to the Governmentfor the elimination of IDD, has beenestablished as a sub-committee underthe Food Sanitation Council.Thestakeholders and members in thecommittee include the NationalDepartment of Health (NDOH), theNational Department of Education(NDOE), UNICEF, the IndependentConsumer and CompetitionCommission (ICCC), the NationalAgriculture Quarantine andInspection Authority (NAQIA), theUniversity of Technology, Lae andthe School of Medicine and HealthSciences (SMHS) University ofPapua New Guinea (UPNG).

Current Situation

Political commitment to the imple-mentation of USI policy is evidentin the Nutritional Objectives ofHealth Vision 2010, the NationalHealth Plan 2001 – 2010 (5).Amajor objective of this policy is theelimination of IDD as a public healthproblem by 2010.The IDD programhas also been integrated into theFamily Health program for resourceallocation.

A senior executive in NDOH coor-dinates the USI policy implementati-

on process. Environmental HealthOfficers at the national and commu-nity levels are mandated to enforcethe USI policy and to promote theuse of iodized salt. NDOH SeniorExecutives regularly participate inIodized Salt Monitoring workshopsin various provinces organized, incollaboration with UNICEF, for trai-ning of quarantine officers and foodinspectors.They were also activelyinvolved in the recently concludedNational Micronutrient Survey(NMS 2005).

Iodized salt

The PNG Salt Legislation of June1995 banned the importation andsale of non-iodised salt in PNG (1).According to the Legislation,“Salt,other than Table Salt, shall containpotassium iodate in proportion ofnot less than 50 ppm and Iodinecontent shall be not less than 30ppm. … Table Salt shall contain

IDD NEWSLETTER NOVEMBER 2006 PAPUA NEW GUINEA 11

Progress towards eliminationof IDD in Papua New GuineaVictor J. Temple School of Medicine and Health Sciences, University of Papua New Guinea

Potassium Iodate in a proportion notless than 70 ppm and Iodine contentshall be not less than 40 ppm (1).”However, no distinction was madebetween iodine content in salt atproduction, importation and house-hold levels, and the daily per capitasalt consumption was not stated.

The setting up of a new Micro-nutrient Laboratory in SMHS(MNL-SMHS) UPNG demon-strated further commitment to theelimination of IDD. Prior to 2002,there was only one functional micro-nutrient laboratory in the country(University of Technology, Lae).TheMNL-SMHS, set up in 2003, is aregistered member of the Inter-national Resource Laboratories forIodine (IRLI) Network.Appropriatefunding, however, is necessary toensure that the standards, alreadyachieved by the MNL-SMHS, aremaintained.

NDOH, in collaboration withNDOE and UNICEF, have develo-ped programs for public educationand social mobilization on the issue

of IDD and the importance of iodi-zed salt consumption.The electronicand mass media, well-baby clinics,susu-mama haus, schools, churches,community leaders and women’sgroups are all involved in this aware-ness campaign, which gained evengreater momentum during the NMS2005. Specific proposals have beenmade for these programs to be incor-porated into the health and educati-on networks.This is vital for ensu-ring sustainability and greater successof the USI policy.

However, there are few regular dataon salt iodine concentration at thefactory, wholesale, retail and house-hold levels. Over 80% of salt sold in

PNG is imported. Quarantineofficers are authorized to regularlymonitor all imported salt con-signments, using rapid test kits.Environmental health officers andfood inspectors also use these kits tomonitor salt at the wholesale andretail levels. Salt samples with sub-standard iodine content are sent tothe MNL-PNG for further testing.Monitoring at the household level islimited.Available data indicate thatfrom 1996 to 1997 there was a73.5% to 87.1% increase in adequa-tely iodized (> 30ppm) salt, sold inretail shops in Lae City (6). In thesame period, the proportion of ade-quately iodized salt in wholesaleshops increased from 61.5% to

12 IDD NEWSLETTER NOVEMBER 2006 PAPUA NEW GUINEA

Table 1 Per capita consumption of salt and iodine content in salt samples fromhouseholds (HH) and retail shops in Hella Region Southern Highlands Province(SHP), NCD and three areas in Central Province Papua New Guinea. (Data fromreferences 7 and 9).

Per salt capita Iodine content in salt samples Iodine contentconsumption (>

¯30ppm) (>

¯15 ppm)

g/day % HH % Retail shops % HH

Hella region 2.6 ± 1.3 95 100 100SHP (9)

NCD (7) 6.8 ± 1.8 90 95 100

Rural hilly area 7.8 ± 3.7 50 90 75(Tauruba village) (7)

Rural costal area 6.2 ± 2.0 68 80 100(Papa village) (7)

Urban area (Five 6.5 ± 2.4 70 80 96mile settlement) (7)

Table 2 Recent data on urinary iodine (UI) concentrations in women and childrenin regions of Papua New Guinea. (Data from references 8-10).

Median UI (µg/L) % with UI level <50µg/L

Pregnant women (Lae City) (8) 231 3.3

Children age 6 – 12yrs 48 52.8(Hella Region SHP) (9)

Male children age 6 – 12yrs 67 46.7(Hella Region SHP) (9)

Female children age 6 – 12yrs 44 59.8(Hella Region SHP) (9)

Non-pregnant women (NCD) (10) 163 7.2

Lactating women (NCD) (10) 134 17.5

Pregnant women (NCD) (10) 180 6.6

IDD NEWSLETTER NOVEMBER 2006 PAPUA NEW GUINEA 13

90.9% (6).Analysis of salt from twoschools in Lae City indicated ade-quate iodine content in 98% and48% of salt samples, respectively (5).

Urinary iodine

Data on UI concentration in school-age children, with appropriate sam-pling for higher risk areas, are alsoscanty.Table 2 shows some recentdata obtained by limited surveys inLae City (8), Hella Region SouthernHighlands Province (9) and NCD(10).The NMS 2005, conductedfrom May to October 2005, repre-sents a significant development in theassessment of the status of iodine andother micronutrients.The NMS2005 was organized and supervisedby the National Nutrition SurveyTask Force with representation fromNDOH, SMHS UPNG andUNICEF. The International Micro-nutrient Malnutrition Prevention andControl (IMMPaCt) Programme, USCenters for Disease Control andPrevention (CDC),Atlanta, providedtechnical support and partial fundingfor the project.Additional technicalsupport was provided by the Instituteof Nutrition, Mahidol University(INMU) Bangkok,Thailand.Thedraft summary report of NMS 2005was presented and extensively discus-sed at various forums, including aspecial Public Health Symposium forinvited specialists, recently held inPort Moresby (October 11-12,2006).The final NMS 2005 report,outlining the remaining practicalsteps towards elimination of IDD by2010 is expected to be published inJune 2007.

The Nutrition section in NDOH isin constant contact with theDepartment of Trade and Industry toensure that salt importers, producersand refiners maintain up-to-datequality control records and makethem accessible for verification byinspectors. Importers are encouraged

to implement the First-In-First Out(FIFO) principle, in order to mini-mise loss of iodine in salt over time.However, random unannouncedexternal monitoring procedures arenot being implemented. Packagingprocedures do not always guaranteeclear labelling of salt with accurateinformation on its iodine content (asrequired by law).A database of resultson monitoring of salt iodine and uri-nary iodine in PNG is available inthe Division of Basic MedicalSciences (BMS), SMHS UPNG.TheChairman of BMS coordinates thedatabase. Greater emphasis on moni-toring iodine content in salt at alllevels is a prerequisite for achievingthe goal of eliminating IDD in PNGby 2010.

Conclusions

The current status of the salt iodiza-tion program in PNG can be charac-terized as “existent but needingstrengthening.” Further progressrequires periodic reviews of the pro-gram, to ensure that its tempo ismaintained (4, 11). Consolidation ofthe current monitoring and imple-mentation systems for salt iodizationin the country is necessary to achievethe objective of elimination of IDDin PNG by 2010.

References1. Barter P. Pure Food Act, amendment ofPure Food Standards. Papua New GuineaGovt. National Gazette. Port Moresby 1995;G 47.2. National Health Plan 1996 – 2000,Chapter 7, Section 5, Policy No. 3, PortMoresby: Papua New Guinea, Ministry ofHealth,August 1995, pp 44 3. Nutrition Program Department of Health:Situation Analysis Iodine DeficiencyDisorders. Department of Health PortMoresby Papua New Guinea, Nov. 1999, 2 –23.4. WHO, UNICEF, ICCIDD.Assessment ofIDD and monitoring their elimination:Aguide for programme mangers, 2nd Edition.WHO/NHD/01.1, 2001 5. National Health Plan 2001-2010, HealthVision 2010, Provincial and District HealthProfiles.Vol. 3 Part 2; 1st edn. Port Moresby:Papua New Guinea Ministry of Health,August 2000; 38 – 44.6. Amoa B, Pikire T,Tine P. Iodine contentof salt in Lae city of PNG.Asian Pacific J.Clin Nutr (1998) 7 (2): 128 – 130.7. Temple VJ and Ian D. Per capita consump-tion of salt and iodine content of salt inNCD and Central Province, PNG.(Manuscript submitted to PNG MedicalJournal).8. Amoa B, Rubiang L, Iodine status of preg-nant women in Lae.Asia Pac J Clin Nutr2000, 9, 1: 33 – 35.9. Temple VJ, Mapira P,Adeniyi KO, Sims P.Iodine deficiency in Papua New Guinea(Sub-clinical iodine deficiency and salt iodi-zation in the highlands of Papua NewGuinea). Journal of Public Health, 2005,Vol.27 (1): 45 – 4810. Temple VJ, Haindapa B,Turare R, MastaA,Amoa AB and Ripa P. Status of iodinenutrition in pregnant and lactating women inNCD, PNG.Asia Pac J Clin Nutr, 2006; 15(4) (in Press).11. Manner VMG, Dunn JT. Salt iodizationfor the elimination of iodine deficiency.ICCIDD, Netherlands, 1995.

Background

Iodine deficiency was recognized as apublic health problem in Sri Lankafollowing the 1986 national surveythat documented a total goiter preva-lence of 18.2%. In 1995, theGovernment of Sri Lanka launcheduniversal salt iodization (USI) as themainstay of iodine deficiency con-trol.With strong private-public part-nership and financial and technicalsupport from external developmentpartners, the Ministry of Healthcareand Nutrition intensified effortstoward USI.A recent national IDDsurvey was conducted to assess thestatus of iodine nutrition.

The 2005 National Survey

A cross sectional study of childrenfrom 60 primary schools in SriLanka was carried out in 2005.Thirty schools were randomly selec-ted from districts that demonstratedurine iodine (UI) levels between100-200 µg/L.Thirty children wererandomly selected from each schoolfor the study.Thyroid glands of chil-dren aged 6-9 years were measuredby palpation and graded according tothe WHO/UNICEF/ICCIDD crite-ria. Iodine content of household saltsamples was analyzed. Casual urinesamples were analyzed for urinaryiodine.A total of 1900 children werestudied. Prevalence of goiter (3.8%)was higher in girls than boys andranged from 0.5% to 10.3% in thedifferent provinces. Median UI in1,879 samples was 154 µg/L, with arange of 6-1754 µg/L.The results ofthe study in 1,594 samples found91% of households consume iodizedsalt.The frequency distribution of UIshows that 35% of the children hadUI in the ‘adequate’ range, with 29%having low values (< 100 µg/L) and36% having high values (> 200µg/L). Only 0.1% of children hadvery low UI values < 20 µg/L.

In comparison with a 2000 nationalstudy, there was a reduction in thegoiter rate from 20.1% to 3.8%, anincrease in median UI from 145µg/L to 154 µg/L and increasedhousehold consumption of iodizedsalt, up from 49.5% to 91.2%.Thesenew data indicate Sri Lanka hasachieved its goals of eliminating iodi-ne deficiency as a public health pro-blem.The challenge ahead is sustai-ning the gains and achievements

made through the IDD eliminationprogram.

Colombo Meeting, September2006

To this end, the Ministry ofHealthcare and Nutrition, Sri Lankaorganized a Consultative Meeting atColombo on 5th September 2006 to“Review and Develop NewStrategies of the Salt IodizationProgram in Sri Lanka.” Presentationsincluded the recent survey report ofthe Medical Research Institute,Department of Healthcare andNutrition, work related to iodizedsalt in the food control unit ofMinistry of Health, research on thy-roid antibodies in school childrenand experiences of IDD eliminationin other countries.The objective wasto critically review the strategies andmake recommendations to streng-then the salt iodization program so asto achieve the final goal of eliminati-on of iodine deficiency disorders inSri Lanka.

14 IDD NEWSLETTER NOVEMBER 2006 SRI LANKA

Renuka Jayatissa Medical Research Institute, Colombo, Sri LankaMahinda Gunawardena ICCIDD Sri LankaAberra BekeleUNICEF, Sri LankaChandra PandavICCIDD Regional Coordinator, South Asia

Sri Lanka eliminates IDDStrong private-public partnerships have helped Sri Lanka achieve the goal ofeliminating iodine deficiency as a public health problem

A total of 80 participants from fivesectors (Health,Academia, SaltIndustry, Bilateral and InternationalAgencies, Other Sectors) attendedthe meeting.The meeting wasaddressed by Dr.Athula Kahandali-yanage, Director General of HealthServices.The program overview andobjectives were explained by Dr.C.K. Shanmugarajah, DirectorEnvironmental and OccupationalHealth. Dr. Shanmugarajah said thatsubstantial progress has been achievedin Sri Lanka but one should not for-get that “IDD can reemerge.Therefore, sustained vigilance is need-ed in its elimination”. He reiteratedthe commitment of the Governmentof Sri Lanka to achieve USI by 2001and elimination of IDD by 2005 inresponse to the goals set at the WorldSummit for Children in 1990.

A presentation by Dr. RenukaJayatissa was made on the findings ofMedical Research Institute (MRI)on “Iodine Nutrition in Sri Lanka,2005.” In her presentation Dr.Renuka reported Sri Lanka has eli-minated IDD as a public health pro-blem on a national scale. However,the prevalence of goiter remains ele-vated in the Western, Central andUva provinces.There is also a pro-blem of availability of adequatelyiodized salt at household level inNorthern Province.Though SriLanka has attained adequate iodinenutrition status, it needs to continueto pay special attention to IDD inendemic areas to avoid re-emergenceof IDD as a public health problem.On the other hand, a significant pro-portion of urine samples in North

Central and Northern Provincesshowed iodine contents that werehigh, indicating the need for streng-thening the quality assurance systemsat different levels. She made the fol-lowing recommendations:

1. To reinvigorate the intersectoralNational Iodine Committee coveringall the involved institutions.

2. To maintain the provision of tech-nical and logistical capacities for theassessment of iodine in salt and urineat National Reference Laboratory soas to facilitate the sustainability.

3. To integrate indicators of IDD eli-mination into the national system ofhealth information, in particular thehousehold coverage of iodized salt.

4. To conduct nationwide IDD surveys using the principle of

Annual Cyclic Monitoring.

5. To support operational research in the field of eliminating IDD.

6.Verification by salt producers ofsalt quality prior to purchase fromsalterns.

7. Registration of all salt producersunder the Ministry of Health foreasy follow up.

The Micronutrient Initiative-ICCIDD Program in Sri Lanka

A joint Micronutrient Initiative(MI)-ICCIDD project addresses amajor concern area in Sri Lankan saltiodization. Of the salt produced bythe two major salt producers, LankaSalt Ltd and Puttalam Salt Ltd., only30% is iodized at the factory accor-

ding to legal health/trade standards.The balance of 70% is iodized by thecottage industry, whose process isneither monitored nor controlled.This leads to a mismatch in the qua-lity of iodized salt.The objective ofthe MI-ICCIDD program is to eli-minate this shortcoming throughenabling the two main salt producersto iodize their entire content.This isthrough a donor grant by MI-ICCIDD for two new factoriesincluding salt washeries, crushers,centrifuges and iodization plants.Thiswill ensure that all the salt leavingthe two factories will fall within thelegal parameters of USI. Machineryis in fabrication in India for installati-on and commissioning at both facto-ries, scheduled for January 2007.

Status of ProgrammaticIndicators met in Sri Lanka

I. An effective functional nationalbody (council or committee) respon-sible to government for the nationalprogram.

National Iodine Committee esta- blished under the Ministry of Healthcare and Nutrition

II. Evidence of political commit-ment to USI & elimination of IDD

Strong political commitment by H.E.The President of Sri Lanka and the Minister of Health to make proper iodization standards and ensure the program is a success

III. Appointment of a responsibleexecutive officer for IDD eliminationprogram

Director Environmental and Occupational Health appointed as a responsible focal point for the IDD Elimination Program by the Director General Health Services

IV. Legislation or regulations forUSI, ideally covering both human & agricultural salt

In place since 1995, but only for human consumption

IDD NEWSLETTER NOVEMBER 2006 SRI LANKA 15

Table 1 Status of Criteria for Monitoring Progress against IDD in Sri Lanka

Status Goals Current status

Proportion of households >90% 91.2%using adequately iodized salt

Urinary Iodine Proportion below 100 µg/l<50% 29.9%

Proportion below 50 µg/l<20% 7.5%

Programmatic Indicators Attainment of at least 8 of 10 9of the indicators

16 IDD NEWSLETTER NOVEMBER 2006 SRI LANKA

V. Commitment to assessment &reassessment of progress towards eli-mination with access to laboratoriesable to provide accurate data on salt& urinary iodineYes, in place.

VI. A program of public education& social mobilization on importanceof IDD & consumption of iodizedsaltYes, in place through Health Educa- tion Bureau, Ministry of Healthcare and Nutrition

VII. Regular data on salt iodine atthe factory retail & household levelsYes, by public health inspectors through quarterly returns

VIII. Regular laboratory data onUIE in school age children withappropriate sampling for higher riskareasYes, with the cyclic monitoring data from MRI

IX. Cooperation from the salt indu-stry in maintenance of quality con-trolYes, regular meetings are held

X. A database for recording of resultsof regular monitoring proceduresparticularly for salt iodine and UIEYes, MRI maintains a data base for salt iodine and UIE

XI. If available neonatal TSH moni-toring with mandatory public repor-ting

Pilot study conducted and method was established at MRI. Not done on routine manner due to cost.

Excerpts from an article by Francis Mead, UNICEF Sri Lanka

The two women stand close toget-her, and together they step forward,each holding a long-handled pole, alittle like a wooden rake, except the-re’s a flat piece of wood at the endinstead of prongs.The women areboth wearing white rubber bootsand they are standing in a shallowbasin, about 30 yards across, which isfilled with a few inches of filmywater. In perfect synchronization,they dip their rakes into the waterand drag back the white crystals thatare hidden just beneath the surface.As they move, a shelf of crystalsbuilds up against their rakes, and theyfinally sweep their catch into a pile at the edge of the basin.

The women work at a salt factory atPuttalam midway up Sri Lanka’s eastcoast. Puttalam Salt Ltd stands onland that was formerly owned by theking of Sri Lanka in the eighteenthcentury.A salt road used to wend itsway across to the ancient seat of thethrone at Kandy.Today the PuttalamSalt plant occupies 700 acres at theedge of a lagoon and supplies about

a third of the country’s salt.

In July this year, UNICEF handedover a new iodization machine toPuttalam Salt Ltd. Major financialbacking for this project has comefrom the governments of Norwayand Canada, as well as KiwanisInternational, ensuring that the driveto protect children continues.

Despite the advances, there are stilldifficulties to be faced in Sri Lanka,not least the existence of over 300small salt producers around theisland, some of them producing non-iodized salt.And yet here too therehas been progress. Just a few kilome-tres north of Puttalam Salt Ltd liesPuttalam Salt Production WelfareSociety Ltd: across the flat terrain,hundreds of small, privately ownedsalt beds are visible, with narrow cau-

seways running between them. Hereand there are little pyramids of har-vested salt set out in rows. Each smallbed requires 20 people to work thesalt, and women, once again, carryout much of the labor, balancing bas-kets of fresh salt on their heads asthey walk back to collection points.The Society has 500 members and5000 people in total work in the saltbeds. Until recently, the Societywasn’t using its salt iodization machi-ne, which was a also supplied byUNICEF. But after a new govern-ment drive on food regulation, theSociety began using the machine,and now bag after bag, marked“Iodated Salt”, is stacked on the con-crete floor at the producers’ salt pro-duction plant.

“It’s difficult to get across to ordinarypeople the problem of IDD becauseit’s not very visible,” says D.P.Adikari,UNICEF’s project officer for nutriti-on in Sri Lanka. He has monitoredIDD for ten years, and has been acti-vely engaged in the campaign to eli-minate it for the last five.“Iodizationcan make a big difference to people’shealth. But convincing people hasbeen a real challenge.”

The salt of life – how iodized salt protects a generation of Sri Lanka’s children

BackgroundHistorically, cretinism rates of up to 8%were reported in remote mountainousareas in Vietnam. Data from a 1985-86national prevalence survey indicated that29 of 53 provinces had a significant IDDproblem with an overall TGR of 39.7%,with a higher prevalence in females andchildren.A 1993 survey found 84% ofurine samples had low iodine levels.A1995 southern delta cluster survey(n=300) found a mean urinary iodine(UI) concentration of 32 µg/L.A 1995survey in the southern delta, among 30clusters per province (3,000 children,aged 8-12 years old), showed goiter pre-valences ranging from 8.7 to 27.8, with a mean of 18.2%. No differences werenoted between the prevalence of IDD in the lowland areas as compared withhighland regions. In 2000, a survey bythe national IDD control program wascarried out in households in 61 provin-ces; the subjects were mothers of chil-dren under five.The median UI was 123µg/L, and 43% were <100 µg/L.Thegoiter prevalence among 8,712 school-children was 10.2%.

Legislation on iodized saltThe Law of Health Protection in 1989required Ministry of Health and authori-

ties at all levels to take all necessary mea-sures to control IDD in endemic goiterareas.This was followed by the PrimeMinister's decision in 1994 for universalsalt iodization.There was a declarationby the government in 1995 to eradicategoiter and all IDD by the year 2005,with the two main indicators being goiter prevalence among schoolchildren 8-12 years old < 5% and median UI>100 µg/L. In 1999, the governmentissued Decree No. 19 on the Productionand Supply of Iodized Salt for HumanConsumption.This decree stipulates thatall salt for direct human consumptionand salt used for food preparation mustbe mixed with iodine.The decree provi-des detailed criteria and conditions foredible salt production, quality control,examination, inspection and handling ofviolations and provisions for implemen-tation.This decree was followed by aninterministerial circular of 10 November1999 with Guidelines on the Imple-mentation of Government Decree19/1999/ND-CP.

Based on the legislative framework ofDecree No 19 and subsequent imple-mentation guidelines, all manufacturersor distributors of iodized salt must recei-ve a certificate by the MOH confirmingthat the enterprises have sufficient con-ditions and standards to produce iodizedsalt for human consumption and are sub-ject to specific regulations. It has beenrecognized that Decree 19 is narrow inscope and steps have already been takento revise the regulation with an emphasison ensuring that common, non-iodizedsalt be included.The current regulationsstate that only "salt for direct humanconsumption and food preparation"should be iodized.Virtually all salt islocal and none is imported, and legislati-on requires 50 ppm iodine be added tosalt as potassium iodate.Vietnam hasdeveloped its own rapid test kit.The kitis labeled to differentiate between 7 ppmand 20 ppm which is the level of iodiza-tion that the law has stipulated must beavailable at household level.

Program Monitoring andEvaluationThe IDD control program is managedby the National IDD ControlCommittee (NIDDC Committee) basedin the Endocrinology Hospital in Hanoiand administered by the Ministry ofHealth.The NIDDC coordinates all acti-vities of the program, including monito-ring of salt iodization at all differentlevels of the salt distribution system.There are 75 registered producers ofiodized salt in the country, with 26under responsibility of the National Salt Corporation of the Ministry ofAgriculture and Rural Development(MARD) and the rest being either pri-vate concerns or operate under coordi-nation of Provincial Government autho-rity, e.g., People's Committee.An elabo-rate monitoring system has been develo-ped by the NIDDC using principles ofLot Quality Assurance Sampling (LQAS)in which salt producers are asked to ana-lyze 16 salt samples for each 'batch' ofsalt. Of these 16 samples, no more than 2 can have values either below 35 ppmor above 45 ppm, or else the 'batch' isrejected and needs to be re-iodized. Forexternal monitoring, provincial healthinspectors visit each salt producer intheir area, with a frequency that rangesfrom weekly to bi-weekly to monthly,and essentially replicate the internal QC,following similar procedures to assess theadequacy of salt.

There is a very well organized and effi-cient monitoring of the IDD eliminationprogram.The Monitoring system consistsof surveys undertaken by provincial IDDcommittees three times per year - inApril, July and October. Provincial aut-horities visit salt iodization facilitiestwice a month (or more often) to takerandom samples of salt to assess iodizati-on levels.The samples are tested in theprovincial salt laboratory (every provincehas a salt laboratory).There are alsoreports of checking salt iodization levelsat retail level by both provincial andcommune authorities to ensure that

IDD NEWSLETTER NOVEMBER 2006 VIETNAM 17

Elimination of IDD in VietnamData from ICCIDD and the Network for Sustained Elimination of Iodine Deficiency

18 IDD NEWSLETTER NOVEMBER 2006 VIETNAM

iodized salt is adequately iodized. Inaddition, national surveys at householdand school level are undertaken everythree years. Household surveys havebeen undertaken in 1997, 1998, 2000and 2003. School surveys have beenundertaken in 1993, 1998 and 2000 and2003.The surveys collect iodized salthousehold coverage and urinary iodinedata, and the school based surveys alsocollect the total goiter rate. In the house-hold coverage survey, the UI data is fromwomen with children under 5 and in theschool based survey it is from children inschool.The central urinary iodine andsalt iodine laboratories in the Hospital ofEndocrinology in Hanoi supervises qua-lity assurance of regional and provinciallaboratories in addition to UI analyses.

National CommitteeThe program is managed by theNational IDD Committee which issituated within the Ministry of Health.At provincial level, the IDD program isthe responsibility of the ProvincialPeople's Committee.The ProvincialPrimary Health Care Committee functi-ons as the IDD Committee, which isoften chaired by the Vice Chairman ofthe Provincial People's Committee.TheIDD department is housed in theProvincial Preventive Health Centre andoperates as the focal point for IDDCprogram of the province.

Current statusVietnam’s National Iodine DeficiencyDisorders Control (NIDDC) Programhas been made enormous progress

against IDD.The latest data from theNIDDC indicate IDD has been elimina-ted from the country.This remarkableachievement is documented in the indi-cators described below.

Iodine status indicators1. Goiter rate in 8-12 year old children=3.6%Target achieved:Yes

2. Median UI level in children andwomen =122 µg/L

<50% below 100 µg/L = 38.8%<20% below 50 µg/L =14.7%Target achieved:Yes

Salt indicators1. Proportion of households using ade-quately iodized salt = 93.2%

Target achieved:Yes

Program indicators1. Effective functional and multidiscipli-nary national body for IDD elimination,responsible to the Government.

a. Coordinating body is the Central Steering Committee for the National IDD Control Program of the Ministry of Health (MoH), with membership from different MoH departments and the Hospital of Endocrinology.b. The Program collaborates with other Ministries.c. The establishment of a multisecto ral body is under discussion.Target achieved: Not yet met (in dis cussion)

2. Evidence of political commitment toUSI and the elimination of IDD

a. Government budget for the NIDDC Programb. Subsidies for iodized salt in poor areasc. National IDD Day (1 November) celebrated annuallyTarget achieved:Yes

3. Appointment of a responsible executi-ve officer for the IDD elimination pro-gram

a. Prof. Le Ngoc Trong,Vice Minister of Healthb. Dr. Luong Ngoc Khue, Chair,Central Steering Committee, NIDDClTarget achieved:Yes

4. Legislation or regulation on universalsalt iodization

a. National Decree # 19 regulates the

production and distribution of iodized salt, but does not cover all aspects rela-ted to USI.Target achieved: Not yet met

5. Commitment to assessment and reas-sessment of progress in the eliminationof IDD with access to laboratories ableto provide accurate data on iodized saltand urinary iodine

a. A national monitoring system and laboratory network for iodized salt and urinary iodine are in place.b. National surveys were done in 1993, 1998, 2000 and 2003Target achieved:Yes

6. A program of public education andsocial mobilization on the importance of IDD and the consumption of iodizedsalt

a. Information, Education and Communication (IEC) activities are carried out but mostly as fragmented and local activities.b. A Behavior Change Communi-cation Program and a communication strategy do not exist.Target achieved: Not yet met

7. Regular data on salt iodine at the fac-tory, retail and household level

a. Data are available through the natio-nal monitoring system and national surveysTarget achieved:Yes

8. Regular laboratory data on urinaryiodine in school–age children, withappropriate sampling for higher riskareas

a. Data are available through the natio-nal monitoring system and national surveysTarget achieved:Yes

9. Co-operation from salt industry inmaintenance of quality control

a. Laboratories functioning in all salt iodization plants and regular monito-ring by laboratory networkTarget achieved:Yes

10. A database for recording of resultsor regular monitoring procedures, espe-cially for salt iodine, urine iodine and ifavailable, neonatal TSH, with mandatorypublic reporting

a. Database at the MoH and data published annually during National IDD DayTarget achieved:Yes

Goiter was endemic in many regions ofVietnam until recently

In memory of Rainer Gross, a tirelessadvocate for child nutrition

UNICEF Chief of Nutrition, Dr. RainerGross, 61, died on 30 September. Dr. Gross, aGerman national, joined UNICEF in April2002 at the organization’s New York head-quarters. His leadership was the key in deve-loping UNICEF’s global health and nutritionstrategy.Widely respected as an authority inhis field, Dr. Gross specialized in a number ofareas, including undernutrition in emergen-cies and the delivery of micronutrients. Hewas known as a tireless advocate who wouldnot let the world forget about the ongoing‘silent emergency’ of undernutrition and itscomplex causes – including not only foodshortages but also access to education, healthcare and economic opportunity.Last May, in what would be one of his lastmajor projects, Dr. Gross was the movingforce behind the landmark UNICEF report,‘Progress for Children:A Report Card onNutrition’. Despite some gains in child nutri-

tion since 1990, the report found, more thanone child in four in the developing world isundernourished.

Before joining UNICEF, Dr. Gross was asenior nutrition adviser for the GermanGovernment. In a career spanning threedecades, he also worked as a researcher, advi-sor and leader at health and nutrition pro-grams around the world. He served stints inthe field in Indonesia, Brazil and Peru, andwas going to retire to the latter country fol-lowing his planned retirement next year. Dr.Gross is survived by his wife Ulla, his sonPatrick, his daughter Kerstin and three grand-children.

The Network for Sustained Eliminationof Iodine Deficiency is moving

The new address as of November 4th,2006 is:180 Elgin Street, Suite 1000, Ottawa, ONCanada K2P 2K3 Telephone: +1 (613) 782- 6812 Fax: +1 (613) 782-6838 E-mail: info@iodinenetwork.net

Iodine Network Welcomes NewCoordinator, Lucie Bohac

The Network for the Sustained Eliminationof Iodine Deficiency is pleased to announce

the appointment of Lucie Bohac as the newCoordinator of the Iodine Network. Luciehas taken up the position as of October 18,2006 and brings with her over 13 years expe-rience in executive management, programdesign, policy and partnership development aswell as public relations in youth orientedorganizations.As the former executive direc-tor of the Canadian Youth Foundation(CYF), Lucie managed organizational restruc-turing, edited research publications, affectedpublic policy campaigns, spearheaded privatesector partnerships and developed majorinitiatives. Previous to her position at CYF,she was the director of the Youth InitiativesProgram at CIDA. Lucie has been active onthe Board of Directors of a variety of not-for-profit organizations such as the CanadianYouth Business Foundation,AIESECInternational and the Collegium for Workand Learning. In her role as the Coordinatorof the Iodine Network, Lucie will be respon-sible for the Network’s secretariat. She willmanage the Network’s programs and Boardactivities, as well as implement the advocacyand communications initiatives; network andcollaborate with the international communityof organizations working to eliminate iodinedeficiency; and, along with the Network’schair, develop and broker financial assistanceto support the Network. Lucie is based inOttawa, Canada at the MicronutrientInitiative offices which host the Secretariat.

IDD NEWSLETTER NOVEMBER 2006 MEETINGS AND ANNOUNCEMENTS ABSTRACTS 19

Meetings and Announcements

AbstractsEffect of concurrent vitamin A and iodine deficiencies on the thyroid-pituitary axis in rats.Biebinger R, et al.Thyroid. 2006;16(10):961-5

Deficiencies of vitamin A and iodine arecommon in many developing countries.Vitamin A deficiency (VAD) may adverselyaffect thyroid metabolism.The study aim wasto investigate the effects of concurrent vit-amin A and iodine deficiencies on the thy-roid-pituitary axis in rats.Weanling rats (n =56) were fed diets deficient in vitamin A(VAD group), iodine (ID group), vitamin Aand iodine (VAD + ID group), or sufficient

in both vitamin A and iodine (control) for 30days in a pair-fed design. Serum retinol (SR),thyroid hormones (FT(4),TT(4), FT(3), andTT(3)), serum TSH, pituitary TSHbetamRNA expression levels, and thyroid weightswere determined at the end of the depletionperiod. Compared to the control and IDgroups, SR concentrations were about 35%lower in the VAD and VAD + ID groups (p< 0.001), indicating moderate VA deficiency.Comparing the VAD and control groups,there were no significant differences in TSH,TSHbeta mRNA, thyroid weight, or thyroidhormone levels. Compared to the controlgroup, serum TSH,TSHbeta mRNA, andthyroid weight were higher (p < 0.05), and

FT4 and TT4 were lower (p < 0.001), in theVAD + ID and ID groups. Compared to theID group,TSH,TSHbeta mRNA, and thy-roid weight were higher (p < 0.01) and FT4and TT4 were lower (p < 0.001) in the VAD+ ID group.There were no significant diffe-rences in TT3 or FT3 concentrations amonggroups. In conclusion, moderate VAD alonehas no measurable effect on the pituitary-thyroid axis. Concurrent ID and VAD produ-ce more severe primary hypothyroidism thanID alone.

Iodine deficiency and goiter prevalence in Turkey after mandatory iodization.Cetin H et al. J Endocrinol Invest. 2006;29(8):714-8

The prevalence of iodine deficiency, and itsrelation to iodized salt consumption, was stu-died in the Isparta province of Turkey. Fivehundred students between 6-11 yr of agewere evaluated.With a questionnaire, the sub-jects were asked whether they were usingiodized salt.After their body weight andheight were measured, thyroid glands wereexamined with palpation, thyroid volumeswere determined with ultrasonography, andurinary iodine (UI) concentration was analy-zed.The results showed the median UI was70 µg/L, suggesting Isparta is a region withmild iodine deficiency.The total goiter preva-lence was 30.4% with palpation and 26% byultrasound (14.2% for urban and 36.2% forrural areas).The rate of total iodized salt con-sumption was 68%, with consumption ofiodized salt in the urban areas was significant-ly higher than that in rural areas (74 vs 62%).

Thyroid hormone synthesis and secre-tion in man following 80 mg iodine for15 days and subsequent withdrawal. Theodoropoulou A, et al. J Clin EndocrinolMetab. 2006 Oct 17; [Epub ahead of print]

The intrathyroidal non-hormonal and hor-monal iodine concentration after exposure tolarge doses of iodine for a relatively longperiod of time is not known.The aim of thisGreek study was to determine if administrati-on of large doses of iodine for a long periodalters intrathyroidal hormonal (HI),T4 andT3 and total iodine (TI) content, as well asserum concentrations of thyroid hormonesand TSH. In 33 euthyroid patients with a sin-gle thyroid nodule or hyperparathyroidism,Lugol solution (80 mg iodine) was administe-red for fifteen days before operation. Groupsof six to eight patients were operated the day0, 5, 10 and 15 after iodine withdrawal.TI,HI in a sample of thyroid tissue, and serumconcentrations of T4,T3 and TSH were mea-sured. In twenty-one normal euthyroid sub-

jects who were not operated, a similar proto-col was employed and serial blood measure-ments were done. HI content and serum T4and T3 were unchanged during and afteriodine discontinuation.TI was increasedduring iodine administration and returned tocontrol values 5 days after discontinuation ofiodine.The ratio of HI/TI was decreased andreturned to control values 15 days after theiodine was discontinued. Serum TSH wasincreased during iodine administration andreturned to control values 10 days after iodinewithdrawal. In conclusion, administration ofiodine was accompanied by increased intra-thyroidal iodine, but no changes in HI nordemonstrable increases of serum T4 and T3.

Iodine supplementation for pregnancyand lactation - United States andCanada: recommendations of theAmerican Thyroid Association.Becker DV et al.Thyroid. 2006;16(10):949-51

The fetus is totally dependent in early preg-nancy on maternal thyroxine for normalbrain development.Adequate maternal dieta-ry intake of iodine during pregnancy isessential for maternal thyroxine productionand later for thyroid function in the fetus. Ifiodine insufficiency leads to inadequate pro-duction of thyroid hormones and hypothy-roidism during pregnancy, then irreversiblefetal brain damage can result. In the UnitedStates, the median urinary iodine (UI) was168 µg/L in 2001-2002, well within therange of normal established by the WorldHealth Organization (WHO), but whereasthe UI of pregnant women (173 µg/L; 95%CI 75-229 µg//L) was within the rangerecommended by WHO (150-249 µg/L), thelower 95% CI was less than 150 µg/L.Therefore, until additional physiologic dataare available to make a better judgment, theAmerican Thyroid Association recommendsthat women receive 150 µg iodine supple-ments daily during pregnancy and lactationand that all prenatal vitamin/mineral prepara-tions contain 150 µg of iodine.

Hypothyroidism in a breast-fed preterm infant resulting from maternaltopical iodine exposure. Smith VC et al. J Pediatr. 2006;149(4):566-7

Hypothyroidism developed in a preterminfant, whose initial screening thyroid functi-on test results were normal, at 2 weeks of life.The infant's mother was packing herCaesarian incision with iodine soaked gauze,resulting in a markedly increased breast milkiodine concentration.Treatment with oralthyroxine normalized thyroid function testsin the infant.

Endemic goiter and iodine deficiency:Are they still a reality in Spain? Peris Roig B et al.An Pediatr (Barc).2006;65(3):234-40

The study aim was to estimate the prevalenceof goiter and iodine deficiency in a healthdistrict in Valencia. In students aged 6 to 14years, thyroid examination was performed bymeans of palpation and inspection, and urina-ry iodine (UI) was analyzed in a spot urinesample. Sociodemographic and anthropome-tric data, as well as nutritional iodine status,were recorded in a standardized survey. Inchildren with goiter, thyroid-stimulating hor-mone (TSH), free T4, and antithyroid antibo-dies were determined.The sample included928 children (478 boys and 450 girls).Theprevalence of goiter was 34%.There were nosignificant differences in the prevalence ofgoiter by age or sex, but an inverse correlati-on was detected between the prevalence ofgoiter and parental socioeconomic position.Mean UI was 155 µg/l and there was nosignificant correlation of UI with goiter. Inchildren with goiter, 13 had positive antithy-roid antibodies, 18 had high TSH (subclinicalhypothyroidism), and one had suppressedTSH (subclinical hyperthyroidism). In con-clusion, there is endemic goiter in this regi-on, while mean UI is in the normal range.This could be interpreted as indicating atransition phase to an improvement in iodinedeficiency.Autoimmune diseases explained4% of the cases of goiter.

THE IDD NEWSLETTER is published quarterly by ICCIDD and distributed free of charge in bulk by international agencies and by individual mailing.The Newsletter also appears on ICCIDD’s website (www.iccidd.org). The Newsletter welcomes comments, new information, and relevant manuscriptson all aspects of iodine nutrition, as well as human interest stories on IDD elimination in countries.

For further details about the IDD Newsletter, please contact:Michael B. Zimmermann, M.D., the editor of the Newsletter, at the Human Nutrition Laboratory, Swiss Federal Institute of Technology Zürich, ETHZentrum, Schmelzbergstrasse 7, LFW E19, CH-8092 Zürich, Switzerland, phone: +41 44 632 8657, fax: +41 44 632 1470,iccidd.newsletter@ilw.agrl.ethz.ch.

ICCIDD gratefully acknowledges the support of UNICEF and the Swiss Federal Institute of Technology Zürich for the IDD Newsletter.

© Copyright 2006 by International Council for Control of Iodine Deficiency Disorders

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20 IDD NEWSLETTER NOVEMBER 2006