Volume 16 Number 3 August 2000

IN THIS ISSUE:

SALT2000: MARKING AND SUSTAINING GLOBAL PROGRESS IN UNIVERSAL SALT IODIZATION. Frits van der Haar, Justus M. de Jong, David P. Haxton and M. G. Venkatesh Mannar, The Rollins School of Public Health of Emory University, Atlanta; Akzo Nobel Salt, Hengelo (Ov), The Netherlands; Retired UNICEF Official, Board Member ICCIDD, Greensboro; and The Micronutrient Initiative, Ottawa, Canada

More than 1,000 people involved with the salt industry and universal salt iodization from 75 countries worldwide gathered for the 8th World Salt Symposium on 7-11 May 2000 in The Hague, The Netherlands. Its theme, ASalt, life depends on it@, focussed on the outstanding achievements in combating iodine deficiency during recent years. The welcome speech by the Chairman of the Salt2000 Foundation, Mr. Floris Bierman, at the Opening Ceremony signaled a turning point in global progress against iodine deficiency. For the first time since political world leaders at the World Summit on Children in 1990 pledged the global elimination of iodine deficiency, captains of the salt industry publicly accepted their specific role and responsibility in delivering the product and services necessary for achieving and sustaining this goal.

The Salt2000 Symposium completed two years of preparations by a loose alliance of organizations involved in supporting the universal salt iodization (USI) strategy. In Europe, America, Asia and Africa, "run-up" regional salt producers= meetings brought out issues of concern to the industry and initiated mutually supportive actions among national entities not previously accustomed to work together. At the Symposium, this alliance contributed a report on the global state of USI, a partnership booth in the Salt2000 Exhibition Hall, a video clip to highlight special situations, and lessons learned in national applications of USI, and a CD-Rom based USI Resource Kit. Movie actor Roger Moore, UNICEF Goodwill Ambassador and Kiwanis Special Spokesperson on IDD, spoke to a highly appreciative audience at the Symposium gala dinner.

In addition to Mr. Bierman, the Opening Ceremony included remarks by Ms. Carol Bellamy, Executive Director of UNICEF, and by Ms. Evelyne Herfkens, Dutch Minister for Development Cooperation. The speakers recalled the many efforts and accomplishments toward the global conquest of IDD procided by national governments, the salt industry, the UN and donor agencies, Kiwanis= World Service Project, ICCIDD, MI, PAMM and others. Four days of scientific sessions reviewed results and lessons from national programs based on salt iodization and a special plenary session on iodine, moderated by Dr. Basil Hetzel, ICCIDD Chairman, and Mr. Nettles Brown, President of Kiwanis International, featured a keynote speech by Professor V. Ramalingaswami of India, ICCIDD member and former Vice-Chairman. Posters of global and national IDD programs were shown in the Exhibition Hall.

The Salt2000 Chairman and Mr. Venkatesh Manner, MI Executive Director, jointly hosted a high-level Round Table to explore continued collaboration among the partner organizations. Participants included CEO=s of several leading salt industries, salt producers from China, India and the Russian Federation, the Executive Director of UNICEF, and representatives from WHO, the World Bank, Kiwanis International, ICCIDD, PAMM, the major iodine industries, and the Dutch bilateral agency. The group agreed that the productive salt sector would take a stronger role in achieving and sustaining global success, and the communication and collaboration among the partner organizations would be formalized and strengthened.

BACKGROUND

An historical perspective - In January 1994, UNICEF and WHO recommended USI as the prime approach to correcting iodine deficiency in countries where it is a public health problem. This step developed from a succession of meetings, beginning with the World Summit on Children in New York (1990), which pledged the Avirtual elimination of IDD@. From this, guidelines for policy action were reviewed at the Policy Conference on Hidden Hunger in Montreal (1991) and frameworks for national action were formulated at the International Conference on Nutrition in Rome (1992). A scientific conference (the Damaged Brain of Iodine Deficiency) organized by Dr. John B. Stanbury, then ICCIDD Chairman, in May 1993 at the Franklin Institute in Philadelphia, USA, emphasized that in countries where IDD is a public health problem, the population is iodine deficient even if the clinical burden is not perceived or demonstrable in all individuals. These meetings set the stage for full application of USI, defined as Aiodization of all salt for human and animal consumption, including salt for food processing@.

These global political and scientific events, and the clear commitment by political, agency and scientific leaders to a goal and an affordable and proven method of achieving it, enhanced the actions that followed in most countries. National IDD programs started budding, leading to better organization, and convening the national talents and resources. Support from bilateral donors, including Australia, Belgium, Canada, Germany, Japan, the Netherlands, Sweden and the United States increased. The UN led the global thrust through UNICEF and WHO, with some major loans by the World Bank. Most manpower and resources came from within the countries. The MI estimated that by early 1998, for each dollar of public policy, programming and surveillance, the salt industry invested up to US$ 10 for production, iodization, packaging and marketing.

Beginning in 1993, Kiwanis International became a very important contributor. The IDD Newsletter (13:49-53, 1997) reported in detail on the Kiwanis World Service Project. The Kiwanis= financial contribution, pledged at US$ 75 million channeled through UNICEF, has been enhanced by the public and political support of Kiwanis members for maintaining national progress. UNICEF's AState of the World=s Children 1998@ report acknowledges the strength of civic partner contributions to the global progress, and they remain a most important factor in the overall effort.

In 1995, UNICEF reported that most countries with recognized IDD were implementing national plans for salt iodization and were either on track or close to meeting the goal of USI by the mid decade. The State of the World=s Children 1998 report, based on ongoing data collection through 1997, estimated that almost 60% of the world's edible salt was being iodized.

Leading to Salt2000 - The 7th World Salt Symposium in Kyoto, Japan, in 1992, introduced the global elimination goal in a special session presentated by ICCIDD Board members. The discussion focused on policy advocacy, mobilization of the salt productive sector, the need for partnership arrangements, and the special urgency of addressing the problem in China. Working relationships with salt industry organizations such as the European Salt Producers Association (ESPA) and the Salt Institute continued, for example by keeping a roster of contacts with salt industry-based technical experts and through support by private salt companies in Europe and USA for training of salt iodization consultants by UNICEF, MI, PAMM and others. UNICEF and some bilateral aid programs continued calling on the salt industry for technical expertise in iodization and marketing of iodized salt. But participation by the salt industry in the international meetings on IDD elimination remained limited.

In the 1992 Kyoto meeting, Akzo Nobel Salt, a business unit of the Dutch Akzo Nobel holding company, in cooperation with European salt producing colleagues, accepted responsibility for organizing the next World Salt Symposium in the year 2000 through a newly formed foundation with board members of Akzo Nobel Salt and other European Salt producing companies. Leaders from global research organizations and trade organizations served on the Advisory Council. The Symposium took the name Salt2000 to reflect the change of millennium, and the theme, ASalt, life depends on it@, to emphasize the many ways that salt interacts with society.

PREPARATIONS

A planning meeting in the Hague at the invitation of the Netherlands government, in November 1998 brought together Akzo Nobel Salt, the German Salt Producers= Association, ESPA, ICCIDD Board members, and officers from UNICEF, WHO, MI and PAMM. An informal alliance of these groups plus Kiwanis International began an ambitious plan of collaborative work. It chose the theme ASalt2000: Iodine inside.@ This alliance drew strength from the coordinated support of the 8th World Salt Symposium, and from a series of associated Regional Salt Producers= Meetings in the Arun-up@ period to the global session in The Hague. Its aims were to consolidate the global progress already achieved in USI, to elaborate more explicitly the responsibility of salt producers in national elimination programs, and to jointly celebrate the impending success at Salt2000 while expanding the alliance into the future. The overall coordination became focused at PAMM. The March 1999 ICCIDD Board re-confirmed PAMM=s Operations Director, Dr. Frits van der Haar, as its contact person, and the Salt2000 Foundation nominated him as liaison member on the Salt2000 Scientific Advisory Committee. From December 1998, PAMM started reporting on the plans and activities of the group by a dedicated internet website. Announcements of the Symposium were sent in large numbers through the regular distribution channels of UNICEF, WHO and the other partners, to invite colleagues in IDD programs, technical support positions and private productive enterprises to submit papers and register their intent to participate. The MI became the leader of advocacy and press publicity on behalf of the group, in close contact with Salt2000 organizers and, later, the Dutch UNICEF Committee. Professor Ling, the Chairman of ICCIDD=s Communications Committee participated in the teleconferences, which were held regularly from mid 1999, as did Mr. Hanneman, the President of the Salt Institute and ICCIDD Board member. UNICEF sent repeated messages through its Regional Offices to encourage participation in the Salt2000 Symposium and the associated meetings for the salt industry. Both the Director-General of WHO and the Executive Director of UNICEF were invited to speak at the Salt2000 opening session in May 2000.

Regional Salt Producers= Meetings - Regional salt producers' meetings took place from mid 1999 onwards. The Regional Directors of UNICEF and their staffs in many regions played key roles in their preparation and follow-up, while all the organizations in the alliance made valuable contributions. In most instances, selected salt producers from the region helped set the agenda and implement particular sections. The meeting in Kiev, Ukraine, attracted close to 100 persons from the salt industry and national governments of 23 countries in the Eastern Europe/Central Asia region, an area that lags behind others in progress towards USI. The meeting established a pattern repeated later, of identifying experts from industry and through Kiwanis to handle specific technical issues of interest to the assembled producers. For the meeting in Latin America, UNICEF and PAHO jointly led the organization and conduct of the meeting. Meetings in Africa were held on the initiative from the UNICEF regional nutrition officers, with African technical consultants making the arrangements. WHO was the lead organization in the Middle East, in collaboration with the existing Regional Iodized Salt Producers Association. Financial contributions came from Kiwanis, MI, UNICEF, the Dutch government and salt producers, as well as from the private sector. In all, the meetings engaged more than 500 participants, most of them from the private trading and productive sector.

Preparation for these meetings included salt situation assessments and market-based salt supply analyses in selected countries. The instruments for the assessments were adapted from an AIodized Salt Program Assessment Tool@ which had been jointly published by the global lead organizations. This process yielded new data and information from over 30 countries on the gatekeepers in trade and production of edible salt for human and animal consumption, and on the amount of salt being iodized. These data generally complemented the information being gathered by WHO for a progress report to the 1999 World Health Assembly. At all meetings, ICCIDD Regional Coordinators spoke in the introductory sessions on progress towards IDD elimination.

These gatherings witnessed the initiation of regional salt producer/trader associations. In Central/Eastern Europe and the Commonwealth of Independent States, key interested salt producers from Russia, Ukraine, Kazakhstan and Belarus made contact, and some later joined the European Salt Producers Association. In Central and Latin America, the existing Mexican Salt Producers Association volunteered to coordinate the budding regional association. Similarly, the Kenya Salt Manufacturers Association and the Botash Company, Botswana agreed to lead efforts to start an East and Southern Africa Association, and the major producer from Ghana accepted a similar role for West Africa.

The concerns and interests of salt industry participants were the main focus of these meetings. Participants from Government and other collaborating national organizations were asked how they could help their efforts. This was a role reversal from the meetings dominated by the public sector earlier in the decade. Each meeting produced regional action plans to accelerate USI through collaborative efforts of national coalitions of public, private and civic sectors. Specific obstacles to progress were identified, and ideas for their correction formulated. For example, UNICEF in the Central/Eastern Europe and Commonwealth of Independent States region urged large catering institutions to use only iodized salt, to raise the demand. That region, which is lagging in the global USI efforts, began collecting data semi-annually to monitor changes in iodized salt production and supply. In East and Southern Africa, UNICEF provided technical support and coordinated with the ICCIDD Sub-regional Coordinator in efforts to harmonize standards in national iodization laws. In the Middle-East and North Africa region, the Regional Directors of WHO and UNICEF wrote letters to Ministers of Health urging them to adopt harmonized iodization levels, to exempt potassium iodate and salt iodization equipment from import tax and duties, and to minimize value-added tax on iodized salt for consumers.

In summary, the meetings in Kiev, Ukraine (September 1999), Bogota, Colombia (November 1999), Mombasa, Kenya (February 2000), Accra, Ghana and Dubai, UAE (both in April 2000) represented pioneering opportunities for salt producers and traders to discuss mutual issues with public sector officials, representatives from civic groups, UN and bilateral agencies, and international experts. Reports of these meetings, where available, have been posted on the internet as part of the Salt2000 proceedings, at http://www.sph.emory.edu/PAMM, and summarized in the IDD Newsletter.

Developing the Salt2000 agenda - Meanwhile, the alliance made proposals for the scientific program of Salt2000. These were endorsed at the Scientific Program Committee's meeting in June 1999 and by the Salt2000 Board in September 1999. The plan included speeches at the Opening Ceremony by the UN leaders, a multimedia presentation and a printed AGlobal State of USI@ report. A plenary session would hear presentations on history, achievements, the salt industry=s role, and ideas on sustaining the success. Five parallel sessions for scientific presentations would consider technical issues in iodization, salt markets and distribution, other fortification efforts, and national program and policy issues. An exhibition booth would highlight the efforts and achievements of nations, to commend all people who contributed to the progress.

The alliance members followed this plan up by reviewing 51 submissions of manuscripts or intent-to-speak for the AIodized Salt for Eliminating Iodine Deficiency@ section. In collaboration with the Editor of the Salt2000 Proceedings, presenters were constantly encouraged and assisted in the timely submission of full manuscripts. Session moderators were invited from the broader community of organizations involved in the global efforts.

Other aspects of the Salt2000 program also demanded attention. UNICEF developed a video on global progress for the opening ceremony and the joint exhibition booth organized and donated by the MI. Footage for the video came from the regional salt producer meetings, and from a special trip to China to showcase its extraordinary progress. UNICEF and the MI backed the media briefings associated with the salt producer meetings, and developed media advisories and text proposals for the speeches by leaders at the Opening Ceremony. Professor Ling, the ICCIDD Communications Focal Point, worked closely with Kiwanis International to provide ideas and proposals for these communications elements and for the dinner speech by Mr Moore. The MI commissioned and supervised the development of a CD-Rom-based collection of publications and resources for national salt iodization programs. The contents of the various speeches, video, booth materials, and media advisories were coordinated with the Salt2000 secretariat, in collaboration with the Dutch UNICEF Committee and Foreign Ministry. UNICEF and WHO worked together on a report of the global state of USI. From the development of messages and content for the joint booth, an effort coordinated by MI, the overriding message for communications emerged. In January 2000, the alliance decided that Salt2000 offered a unique opportunity to engage the participating leaders at the Symposium in a high-level discussion about future collaboration and issued invitations, jointly signed by the Chairman of the Salt2000 Foundation and the Executive Director of MI.

HIGHLIGHTS FROM THE SYMPOSIUM

Opening ceremony - The opening ceremony in the Netherlands Congress Center in The Hague, included speeches and cultural, musical and theatrical displays. The many uses and applications of salt for life were emphasized with the theme ASalt, Life depends on it.@ A highlight of the ceremony was the ongoing struggle against global iodine deficiency.

The issue of salt and health, and the role of the salt industry in fighting iodine deficiency disorders, became the central theme of the Symposium. The attitude of the salt industry clearly had changed. Mr. Bierman emphasized this change in the collaboration among partners by stating: "Some 10 years ago, when our cooperation was called upon, we pointed at the respective governments saying: Alet them come up with the laws and regulations, and we will supply the product@. We thought that all problems would be then solved. We now know and do better; we go out and promote, we convey the message and we supply the technology.@

Ms. Carol Bellamy, Executive Director of UNICEF, in her speech responded: AThe broad representation of government, industry, health, and international organizations is a confirmation of the value of this Symposium. I am confident that next year, at the Special Session of the UN Generally Assembly, we will be able to report that we have achieved, or are on the very brink of achieving, that crucial Summit goal. Distinguished delegates, the elimination of iodine deficiency disorders is a shining success story that will have grown directly as the result of your work and your commitment to improving the lives of children everywhere.@

Plenary and break-out Sessions - The plenary session, entitled AAn IDD-free world: how to keep it that way!@ was chaired by the ICCIDD Chairman, Dr. Basil S. Hetzel, and the Kiwanis International President, Mr. L. Nettles Brown. The keynote speech by Dr. V. Ramalingaswami, introduced by Dr Hetzel as an eminent public health scientist with experience that covers over a half century, described the cost to the world from continued iodine deficiency. Long ignored and initially ill-understood for only its health impact, iodine deficiency now has dawned upon the world as the largest preventable cause of diminished cognitive ability as well as of countless losses from impaired health status, reduced work performance and, ultimately, stunted development of individuals, communities and nations.

The papers in the plenary session provided the basic ingredients for a comprehensive approach to ensure attaining as well as sustaining victory over IDD. Mr. David Alnwick, Senior Health Advisor of UNICEF, recounted the development of the global alliance of partners that aims at applying available science. Mr. Venkatesh Mannar reviewed global trends, developments and prospects for universal salt iodization. Mr. David Haxton presented a forward-looking view of the new attitudes and operational styles as well as the modern tools for sustaining the elimination of iodine deficiency into our world=s future.

A total of 56 oral and poster presentations testified that the technical, financial and managerial obstacles to global elimination of iodine deficiency disorders can be overcome. Bold political statements and vigorous follow-up actions of the past decade had started to yield results. USI, the essential part of the policy to eliminate IDD, is steadfastly being pursued in virtually all countries having iodine deficiency disorders as a public health problem. A session entitled AExamples from National Programs" included perspectives from China (by the President of the National Salt Industry), and from South Africa, the Russian Federation, Zimbabwe and Indonesia, to demonstrate the progress occurring in countries.

A session on AMarkets of Iodized Salt@ featured salt producers and investigators from countries as diverse as Bangladesh, Croatia, France, Bulgaria and Nigeria to present and discuss barriers and opportunities in delivering the product to consumers. Another session on AQuality of Iodized Salt@ offered a scientific debate on the usefulness of on-the-spot testing of iodized salt for iodine, followed by contributions about stability of potassium iodate in packed iodized salt, and assessment of human iodine status after its consumption. The successful application of edible salt as carrier of iodine suggested using salt for other beneficial purposes, i.e., fluoride for caries prevention, iron to combat iron deficiency anemia and diethylcarbamazine (DEC) for eradicating lymphatic filariasis. The technologies, programmatic approaches and scientific investigations were presented in a session entitled ASalt as Vehicle for Other Public Health Efforts@. Reports from the recent regional Salt Producers Meetings formed the key elements of the session ASustaining the Success of Universal Salt Iodization@ which focused on ideas for institutionalizing salt iodization, quality assurance of iodized salt from producer to consumer, and continued effective surveillance - in short, to make the purchase and consumption of iodized salt the new norm.

Round Table of Leaders - Following the opening ceremony, the Round Table of Leaders discussed the need and ways to accomplish the global elimination goal and to sustain it in all countries of the world through mutually supportive action by interested organizations. A detailed report of the discussion appears on the Salt2000 website. The global progress so far provides a strong rationale to further consolidate the achievements and to accelerate action toward completing the elimination goal in all countries. The group recognized that national oversight coalitions need continued support to ensure that success of elimination, once achieved, is sustained in a country. The participants further advised that the ongoing partnership should continue, and agreed that a small working group should hold the coalition together and recommend actions not currently handled by one or more of the allies.

The Roundtable also made a number of points that could form the basis for a future work plan. There was strong support for imaginative consumer education, to bolster demand for the product but also for public understanding of the dangers of iodine deficiency and the benefit from using iodized salt. Transfers to small producers of appropriate technologies and training in modern management techniques were proposed, particularly in iodine deficient countries with many producers. The group endorsed the need for examination of trends in iodine consumption also in industrialized countries, and called for reporting on the progress of USI in all countries of the world. The discussion gave priority to: advancing those countries that are close to goal achievement; addressing the issues that delay progress where USI is lagging; re-examining tactics in such situations; and promoting stronger and more pervasive education efforts for sustaining the interest in assured iodine nutrition.

CONCLUSIONS

The USI strategy for global elimination of iodine deficiency matured into a central theme at the Salt2000 Symposium. Many inputs from the global partnership of public, private, civic, agency and scientific sectors made the Salt2000 event a major milestone in the progress to protect humankind against iodine deficiency. The participation of chief executive officers of leading salt industries publicly demonstrated how these corporations have embraced the global goal by applying the USI strategy.

The process of collaborative work in preparation for Salt2000 and the many consequent contributions at the Symposium by the organizations involved should influence the ongoing tactics of support to achieving the global IDD elimination goal. The balanced collaboration to jointly pursue the common vision was impressive. The results obtained from working by alliance demonstrated the key principles for success of the new paradigm in global health development, often spoken about in policy statements. Driven by the common goal, a results-oriented coalition of public-private-civic-scientific groups allowed each partner to deliver what it knows and does best. For the first time in the history of IDD elimination, members of a broad alliance had worked as equal partners.

At the Salt2000 Round Table, leaders of salt industry spoke and the leaders of global organizations responded. Those among the leaders who grasped the power of initiative, have followed through by proposing a permanent collaborative arrangement that allows all willing organizations to jointly support the achievement and sustainability of the global elimination goal. This is the future challenge that arose from the Salt2000 experience. From a name, Salt2000 became a concept, which started out as a millennium meeting, and then mushroomed into a movement.

REPORTS FROM THE REGIONS

This section is taken from annual reports of ICCIDD Regional Coordinators and other sources.

EUROPE AND CENTRAL ASIA

Dr. Delange, ICCIDD Regional Coordinator, has noted that from the WHO/UNICEF/ICCIDD report for 1999 (IDD Newsletter 15(2):17-19, 1999), only 27% of the populations of countries affected by IDD had access to iodized salt. This is attributed to difficulties in re-implementing USI in some Eastern European countries, and to an absence of national commitment and enforced legislation, despite the presence of IDD in some Western European countries such as France, Spain, Italy, and Belgium. He proposed an action plan to include the following elements:

1. maintenance and re-enforcement of advocacy and training on IDD at local, national, regional, and global levels;

2. ongoing detailed reviewuation and registration of the extent of IDD in Europe, in follow-up to data from a series of meetings on IDD in Europe over the past several years (previously reported in the IDD Newsletter).

3. more vigorous efforts at implementation of USI in areas where it has not yet been achieved; this would include coordination between producers and importers of iodized salt at national levels, standardization of techniques, and regulations on salt iodization in terms of the compounds used, levels of iodization, regulations on trade, importation, and taxes, and implementation of quality assurance programs for iodized salt;

4. administration of iodized oil if necessary, at least to women of childbearing age, in "hard to reach" areas with severe iodine deficiency;

5. iodine supplementation by tablets of potassium iodide at physiologic levels during gestation, lactation, infancy, and early childhood in areas with mild or moderate iodine deficiency;

6. organization of quality control and monitoring of programs of iodine supplementation from producers to consumers; this would include: agreement on indicators, epidemiology, clinical and biochemical tests; availability of a network of national and regional reference iodine laboratories; development and support for national IDD committees; organization of partnership reviewuations of country programs; and operational research, e.g., simplified kits for measurement of iodine in urine, and salt, use of neonatal TSH as monitoring tool, and reviewuation of consequences of moderate and mild iodine deficiency on neurointellectual development;

7. reviewuation of side effects of iodine, especially iodine-induced hyperthyroidism, development of thyroid autoimmunity and change in pattern of thyroid cancer; and

8. monitoring of salt intake; the promotion of iodized salt should not result in an overall increased salt intake; monitoring of iodized salt intake is a unique opportunity to reviewuate and monitor salt nutrition and to respect and support WHO recommendations to maintain or decrease the salt intake in healthy individuals.

Dr. Gerasimov, Subregional Coordinator for Central and Eastern Europe and Central Asian Subregions, reviewed activities there. The meeting for salt producers in Kiev in September 1999 was already reported (IDD Newsletter 16:16, 2000).

Late 1999 saw two workshops to support creation of national and regional IDD assessment and monitoring systems. One in Tashkent was attended by eight participants from four Central Asian countries, with support from UNICEF and facilitated by Dr. Gerasimov and Professor B. Mishchenko. The objectives were to train participants in basic epidemiologic principles of IDD surveys, to provide additional training in methodology of urinary iodine determinations, and to assist in developing provisional plans for national IDD surveys in each country. One participant from each country was responsible for the national IDD control program and another was the laboratory manager for urinary iodine (UI) determinations. Equipment and material for measuring UI had been supplied by UNICEF, personnel were trained, and each country now has its own laboratory. The second workshop was held in Ashgabat, Turkmenistan, for its national team. To advance these activities, Dr. Gerasimov completed a syllabus "A Guideline for Biological Monitoring of Iodine Deficiency" in Russian, partly based on the manual "Urinary Iodine Assessment: A Manual on Survey and Laboratory Methods" by K. Sullivan and S. May for UNICEF. The syllabus, available in electronic form from Dr. Gerasimov's office, covers the following topics: overview of iodine deficiency and urinary iodine assessments; planning and preparation for IDD surveys; sample size and selection of survey sites; survey performance; and analysis.

A training workshop for medical educators "Education of Educators on IDD" in June 1999 in Moscow, with financial support from the US Center for Disease Control, discussed training of medical students and postgraduate medical doctors about IDD elimination. It also focussed on communication with the general public and how best to facilitate efforts of health care providers to increase consumer acceptance of iodized salt and use of fortified foods. Attendees included professors of endocrinology, nutrition and public health from Russian medical schools. The workshop provided the participants with a broader understanding of IDD to help them conduct educational sessions on IDD and to inform consumers about the importance of iodized salt.

Dr. Gerasimov, with UNICEF support, developed a communication package for health care providers. Its contents include a brochure "What You Always Wanted to Know About Iodine Deficiency: Information, Questions and Answers," containing basic information on IDD. It also included selection of key articles from ICCIDD's "The Damaged Brain of Iodine Deficiency" and its workshop on iodine-induced hyperthyroidism, both translated into Russian. These efforts were in response to a generally insufficient level of awareness on IDD and its health impact among physicians and the general public. A special survey showed that the majority of physicians interviewed did not fully understand iodine deficiency. Some thought IDD brain damage was genetic and not preventable, few knew the benefits of iodized salt, half thought that individual urinary iodine levels needed to be established before recommending iodized salt, and some did not advise their patients to consume iodized salt, from concern about possible hyperthyroidism. IDD was not being discussed among colleagues, and IDD was not being covered in medical school curricula or training courses.

The training workshop for medical educators led to the development of a Russian national consensus paper on prophylaxis and treatment of nontoxic goiter. This document, drafted by Dr. Gerasimov, seeks to provide a clear understanding of IDD and the methods for its control and prevention. It was officially adopted by the Russian Congress of Pediatric Endocrinologists in October 1999.

CENTRAL ASIAN REPUBLICS

The June 2000 issue of WHO CAR NEWS information bulletin (in Russian), published by the WHO Information Center for Central Asian Republics, contains articles by policy leaders and scientists working in the field of IDD in these countries. Dr. Gerasimov provides the following brief English summaries of these articles:

Kazakhstan (by T. Sharmanov and F. Ospanova) - DHS performed in 1999 with support of Macro International and USAID showed that 29% of 5,844 surveyed households consume iodized salt, 31.3% in urban and 26.2% in rural areas. In most iodine deficient areas in the east and south of the country, only 21.6% to 24.5% of households consumed iodized salt. Urinary iodine was tested in 494 women of childbearing age: 52-65% of samples were "iodine deficient" but the article did not give specific numbers. The level of salt iodization at the Aral salt plant increased to 40 ppm, and potassium iodate has replaced iodide.

Kyrgyzstan (by R. Sultanalieva and S. Mamutova) - A survey performed in 1999 showed low urinary iodine levels: 

Bishkek
(capital city)

Osh district
(Ferghana valley)

Naryn distric
(Mountains)
Urinary iodine media, mcg/L
30
45
37
Percent of samples with urinary iodine
< 100 mcg/L
92
100
94


   All salt is imported. Local private ventures are producing small amounts of iodized salt. In January 2000, the Kyrgyz Parliament adopted an Act, "On IDD prophylaxis," signed by the President, that mandates iodization of all salt for human and animal consumption.

Tajikistan (by S. Kasymova) - A significant increase in the incidence of endemic goiter was recorded in the 1990's: from 56-60 cases per 100,000 population in 1980's to 5,915 cases per 100,000 in 1999. Local surveys showed that goiter occurred in 33-90% of schoolchildren. Monitoring in 1999 also revealed that the Asht and Javan salt factories iodize up to 80% of all edible salt, while the Vose salt factory flooded the market with cheap non-iodized salt. It was estimated that up to 40% of households now consume iodized salt.

Turkmenistan (by G. Akmuradova) - By the President's decree all edible salt must be iodized. Turkmenistan is producing its own potassium iodate for salt iodization (iodine concentration in salt is 23+/-11 mg/kg). In 1999, 90% of the salt produced for the market was iodized. A urinary iodine laboratory was installed in the Mother and Child Institute, and technical personnel trained. A small survey performed in 1999 in Ashgabat, with support of Dr. Gerasimov as UNICEF consultant, showed that 90% of households consume iodized salt. However, urinary iodine levels revealed mild IDD (median - 67 mcg/L). It was suggested that the level of salt iodization be increased to the internationally recommended level of 40 ppm. Turkmenistan may soon become the first IDD-free country in the CARK region.

Uzbekistan (by S. Ismailov) - An IDD survey showed that 40-50% of schoolchildren have goiter and that urinary iodine levels were below 100 mcg/L in almost all samples, as tested by the Merck kit. Iodization equipment and potassium iodate were supplied to salt factories, but many salt samples collected in the market contain no iodine. A law prohibiting production and import of non-iodized salt and strengthening monitoring systems, is essential.

SOUTHEAST ASIA

In India, Dr. Pandav, Regional Coordinator, participated in more than 12 meetings, conferences, and workshops on various aspects of IDD. He visited Nepal and Bangladesh to discuss salt producers meetings and iodine monitoring laboratories. The first Asian salt producers meeting was held in Sri Lanka in October 1999. A review of IDD in South Asian countries took place in December 1999. Other conferences took place in Tokyo, Manilla, Geneva, Tehran, Bangkok, and Mauritius.

INDIA

On May 11, the Ministry of Health and Family Welfare, Department of Health, issued a press notice "withdrawal of restriction on sale of common salt for direct human consumption." This reversed a decision made by the Government in 1984 to implement universal salt iodization in India. The stated reason for the new notice was that such a public health measure should be enforced by widespread publicity and dissemination of information rather than through statutory provision, and "compulsion in such matters of individual choice is undesirable." The preliminary notification described a period of 45 days for receipt of views and the Government would then make a final decision. A group of prominent members of ICCIDD, including Professors Ramalingaswami, Karmarkar, Kochupillai, Godbole, Pandav, Kapil, and Colonel Sankar, protested this action. Their statement emphasized: (1) the severity of the consequences of IDD and the previous widespread iodine deficiency in India; (2) that the small increase in the cost of iodized salt is amply justified by the enormous benefits; (3) the impracticality of leaving the choice to individuals; (4) the safety of consuming iodized salt in an iodine-sufficient community; (5) that India has made remarkable progress towards eliminating iodine deficiency, with 70% of the population now having access to adequately iodized salt, but the Government's press note could send wrong signals about its interest in eliminating iodine deficiency, leading to severe disruption of progress made so far; (6) that if public health policy is not to be forced upon people against their free will, what about universal immunization, purification of drinking water, etc?; (7) that if the issue is loss of employment of small-scale producers, other solutions that do not require halting salt iodization exist; and (8) the overwhelming importance of iodized salt as a preventive measure to ensure proper brain development of children.

Dr. Pandav listed a series of measures he and his colleagues were taking: (1) continuing dialogue with the Prime Minister's office at all levels; (2) the National Human Rights Commission summoned the Ministry of Health to provide an explanation, on the basis of this representation; (3) contacting: all members of parliament, NGO's, and consumer organizations; all recipients of National Civil Honors; all health officials and environmental organizations; and all apex industrial institutions; (4) regular coverage in the electronic and print media was taking place; (5) public interest litigation was being filed in the Supreme Court.

After a period of national discussion, the Union Health Minister finally announced the Government's decision to lift the ban on noniodized salt production and asked in a written order that all state governments and union territories carry out this action by October 1. The ban applies to 22 states and 7 union territories, based on provisions of the Prevention of Food Adulteration act of 1954. ICCIDD's Indian members continue to actively fight this decision. Public interest litigation is being filed with the country's Supreme Court and ICCIDD members and colleagues are active in providing technical and scientific guidance to the filing organizations. Common Cause made the point that withdrawal of the ban would not affect the rich, who will continue to buy iodized salt, but the poor, who will now be susceptible to goiter and mental deficiency because they are not aware of the risk they take in purchasing the lower priced salt. This action of the Government has provoked widespread criticism, particularly in the scientific and health community. Dr. V. Ramalingaswami, former ICCIDD Vice-Chair, stated "it is a great tragedy for India to have come such a long way, and now, this has happened." Dr. Pandav and colleagues continue to actively work to avert this setback to USI.

SRI LANKA

Mahinda Gunawardena has forwarded information on accomplishments related to USI and IDD. UNICEF has assisted small-scale operators to acquire raw salt processing plants. The Sri Lanka Standards Institute has endorsed Lanka Salt Limited for its large investments in upgrading processing, packing and storage, and most importantly, testing facilities. Puttalam Salt (the second largest producer in the country), is improving quality and upgrading its laboratory. UNICEF has granted facilities and testing equipment to salt producers. The two large producers, along with the small-scale producers, are working to achieve the national annual edible requirement of 75,000 metric tons of iodized salt this year. Legislation was passed in 1995 mandating iodized salt for human consumption, but some products are still falsely labeled. The Ministry of Health has given public health inspectors a monthly reporting form to assess and record levels of iodine in the iodized salt at the retail and household levels. Schoolchildren, shop owners, and community groups, especially in areas with UNICEF nutrition intervention projects, participate in testing salt for iodine. A Subcommittee on IDD Control was formed in 1998 under the National Nutrition Coordinating Committee of the Ministry of Planning, Implementation and Parliamentary Affairs. It meets bimonthly to discuss achievements, problems, and remedial measures in salt iodization programs; Lanka Salt Limited is a member. Small-scale producers are being re-registered, based on their capacity and facilities to produce iodized salt. The State Pharmaceutical Corporation and Lanka Salt have been requested to procure potassium iodate in bulk and retail it to the re-registered small-scale producers, who have complained that the potassium iodate in the market is of poor quality.

The country has carried out educational programs and distributed relevant materials. General awareness of IDD has increased to approximately 80%, but non-availability of iodized salt in some markets has produced lower consumption figures. The two new iodized salt plants are expected to increase and achieve the national requirements. Lanka Salt Limited is currently co-sponsoring with UNICEF an island-wide iodated salt awareness program among medical officers of health and public health inspectors. The Medical Research Institute of the Ministry of Health, with UNICEF assistance, is planning a national survey in September 2000 to assess iodine levels in urine.

The success of the salt iodization program depends on the performance of the two major salt producers. Currently, no back-up system exists to support production during unforeseen problems. Continuous advocacy and information education programs are necessary to overcome false labeling of salt packages and to prevent undesirable practices, such as washing salt in the rural areas. Currently, iodized salt is more expensive than raw salt, and consumers need to be encouraged to use iodized salt because its benefits outweigh the cost difference.

WORKSHOP ON IDD IN ASIA

The Third Workshop on Measures against Iodine Deficiency Disorders in Asia was held in Tokyo, Japan, from February 15-17, 2000. This was the last workshop in the series, the earlier two having occurred in December, 1997 and February, 1999. Professor M. Irie, ICCIDD Senior Advisor, was Advisor to the Workshop, and ICCIDD was featured along with the Ministry of Health and Welfare (MHW) of Japan and the Japan International Corporation of Welfare Services (JICWELS) as organizers. Professor Madhu Karmarkar, ICCIDD Senior Advisor, and Dr. Pandav were consultants and speakers, and Dr. Sangsom Sinawat, ICCIDD Board member, presented data from Thailand.

The objective of the Workshop was to contribute to development of human resources in planning and administration of measures against IDD in Asian countries. It also provided an opportunity for information and experience exchange on progress towards sustainable elimination of IDD. Over 40 participants attended the workshop, including senior program managers from Bangladesh, Cambodia, Indonesia, Nepal, Philippines and Thailand. Additional participants were governmental representatives (Ministry of Health and Welfare, Ministry of Foreign Affairs of Japan and JICA (Japan International Cooperation Agency)), UNICEF, several leading faculty members from medical institutions in Japan, and members from the private sector covering areas related to IDD and thyroid disorders. Laboratory methods for blood spot TSH (Bayer Medical) and urinary iodine (Hitachi method, Ohashi et al.) were demonstrated.

The workshop publication included information on five countries given below. The sixth, Thailand, was reported extensively in a recent IDD Newsletter (16:1, 2000) and is not repeated here.

BANGLADESH

The 1993 national survey showed 69% of urinary iodine samples below 100 mcg/L and a goiter prreviewence of 47%. A repeat survey was underway at the time of the conference and the results are not immediately available. The report notes that of 753,000 tons of edible salt per year, 612,000 are iodized. Two hundred sixty-seven producers sell iodized salt individually to wholesalers. No salt is imported or exported. Information is not available on a price differential between iodized and noniodized salt, because the latter is not supposed to be available for human consumption. Each producer receives kits for testing iodine in salt, and is expected to use them for each batch (7 tons). The government has laboratories for measuring iodine levels in salt. Salt samples are collected every two weeks from each country by government inspectors. The Secretary of the Ministry of Health and Family Welfare chairs a National Salt Committee with members from relevant Ministries and the private sector. UNICEF has supported IDD control in collaboration with the Bangladesh Small and Cottage Industries Cooperation of the Ministry of Industry, the Ministry of Health and Family Welfare (particularly the Institute of Public Health), and the Bangladesh country branch of ICCIDD.

The program continues to promote advocacy meetings and extensive communication activities to the mass media to increase awareness of the importance of iodized salt use. Messages about IDD have been incorporated into communication activities of the primary health care service and national school health programs.

(Presented by Mr. MD Rezaul Hoque, Bangladesh Small and Cottage Industries, Ministry of Industry.)

CAMBODIA

Background - Previously, endemic goiter was thought confined to mountainous areas in the northeast, but more recently, has been found throughout the country, even along the Mekong River, the coast, and surrounding the capital city.

IDD status - Regional goiter surveys in 1990 showed a prreviewence of 19% in the northeast. A 1995 study found goiter of 20% in the Phnom Penh suburb and 2% on the coast. A 1996 survey found goiter rates of 20% in schoolchildren of Kratie, along the Mekong River, and 50% in Stung Treng, in the northeast. A survey in 1996-97 of all provinces, except three, found an overall goiter prreviewence of 17% in 1800 schoolchildren, aged 8 to 12, selected randomly to be representative of each province (total sample of 35,418). No urinary iodines or other further impact studies were done.

Iodized salt - Seven salt iodization plants have been commissioned for iodized salt producers in Phnom Penh (IDD Newsletter 15:46, 1999). Current estimates are production of 75,000 to 80,000 tons per year locally, with unknown amounts imported. Humans use an estimated 35,000 to 40,000 metric tons of uniodized salt. Salt production is by solar evaporation of seawater in the southwest coastal area. Plant capacity has been less than expected, due to the poor quality of the salt. Wholesale traders distribute salt by rail or truck. Uniodized salt costs from 300 to 800 riels, compared with 500 to 1000 riels (approximately US $0.30/kg) for iodized salt. Iodized salt imported from Thailand for urban markets costs about US $0.90/kg. The estimated per capita salt consumption is 7-10 grams. A study on salt marketing by Helen Keller International is expected later this year.

Control program - In 1997, a National Subcommittee for the Control of Iodine Deficiency Disorders in Cambodia was established within the National Nutrition Committee. It includes representatives from eight ministries, and constitutes three working groups, on salt iodization, communication, and monitoring. Salt iodization legislation has been drafted and considered by the National Subcommittee.

(reported by Dr. Hong Rathmony, Vice-Chief, Communicable Disease Control Department, Ministry of Health.)

INDONESIA

Background - The IDD Newsletter has carried frequent reports on IDD in Indonesia (15:16, 46, 1999). Surveys showed a total goiter rate of 60-90% in 1973 and of 27% in 1990.

IDD status - A repeat survey in 1998 assessed a representative 300 schoolchildren aged 6 to 12 years old from each subdistrict, and about 50% of pregnant women from each district. The total sample was 1.2 million schoolchildren, 90,000 pregnant women and 40,000 urine specimens. The results showed a national goiter prreviewence of 9.8%; 67% of districts were no longer endemic, while IDD was moderately severe in 12%. An estimated 53.8 million people are still iodine deficient. The total goiter rate of pregnant women was 16.0% and their median urinary iodine was 147 mcg/L, with 13% between 50-99 mcg/L. The median serum TSH of pregnant women was 4.0 mU/L, and 30% had values greater than 5 mU/ml. Adequately iodized salt (greater than 30 ppm) was consumed in 64% of households. The total goiter rate of pregnant women correlated closely with iodized salt consumption.

Iodized salt - In 1999, 64% of the salt consumed was adequately iodized (greater than 30 ppm), slightly down from 65% in 1998. The level varied greatly among provinces, from 12% in west Nusa Tenggara to 95% in Jambi. The type of salt was 42% crystal/rough, 35% powdered, and 23% brick salt. Increased price and concern about the taste led the reasons for not using iodized salt.

Program - The Government has recognized the need to accelerate the program, and the World Bank has supported this effort through the Intensified Iodine Deficiency Control Project. Key components are monitoring the iodine status of the community, increasing consumption of iodized salt, increasing the supply of iodized salt, targeted distribution of iodized oil capsules, and inter-ministerial policy and program coordination. Iodized oil capsules, produced by the National Industrial Pharmacy, are distributed primarily to women of childbearing age and elementary schoolchildren in severely endemic areas. Distribution has been through local governments, religious or women's organization, and teachers.

The program is making increased efforts to promote awareness on IDD. Messages are "iodized salt for an intelligent child" and family planning programs add "healthy" to the slogan "two children are enough." The ThyroMobil project in 1997 to 1998 carried out by ICCIDD with financial and organizational support from Merck Indonesia brought national attention to IDD. Other measures to increase awareness include educational programs in schools and in mass media. The program is also emphasizing capacity building among health workers.

The goals are to eliminate births of new cretins by the year 2001, and to reduce goiter among schoolchildren to below 5% by the year 2010. Particular constraints have been in the operative management at the district and subdistrict level. Recommendations for USI include increased iodized salt production, special attention to salt producing areas, mandatory iodization of salt before importation, and local regulations allowing only iodized salt in the market; for goiter reduction, improving supplies to the district level, mobilizing partners for distribution, and better recording and reporting. Further research is needed on the presence of IDD in the coastal areas, on the relation between iodine nutrition and the autoimmune response, and on the loss of iodine during cooking. As decentralization progresses, local government involvement is essential in supporting successful IDD programs.

(This report combines the Tokyo presentation by Ms. Cornelia SKM and Dr. Anie Kurniawan, Directors of Community Nutrition, Ministry of Health, with data from "Iodine Deficiency Disorders in Indonesia" by Robert Djokomoeljanto, Dini Latief, and Muhilal, presented at the International Symposium on Iodine Deficiency as a Cause of Brain Damage in Asia, Adelaide, Australia, March 2000.)

NEPAL

Background - Nepal has a long history of extreme iodine deficiency, with frequent cretinism and a high goiter prreviewence reviewed over the years in the IDD Newsletter (most recently vol. 15(3):46, 1999). Iodized oil campaigns were conducted in the 1970's and 1980's on a five-year cycle. In the last decade a vigorous effort with iodized salt has shown considerable success.

IDD status - The most recent survey (source: National Micronutrient Status Survey, 1998, draft report) describes a total goiter rate of 50% in women and 40% in school-age children, with urinary iodines of < 100 mcg/L in these two groups as 16% and 13.9%, respectively.

Iodized salt - Virtually all the country's salt is imported, 90% from India. The Salt Trading Corporation (STC), a government-sponsored agency, is the single largest entity, obtaining all its salt from India. Some Tibetan salt enters by traditional trading routes, especially in the western mountain districts, accounting for about 1,250 metric tons in Humla and Mustang annually. Three types of salt come from India: phoda (large crystals), extracted from subsoil brine underground (64%); kurkutch, crude salt mainly from the sea, as small crystals (17%); and fine sea salt (18%). The STC has strategic warehouses at the five entry points. Most iodization (85-90%) occurs at the point of dispatch in India, the remainder by six STC iodization plants at the major entry points. To reach Nepal, imported salt must travel about 300 km from production site under sun and rain and sometimes in open wagons, with considerable iodine loss, so, some salt needs re-iodization before distribution. STC distributes salt through a country-wide network of offices and dealers. The transport cost as well as 50% of the cost of the salt is subsidized by the government in the remote inaccessible mountain areas. This subsidized salt meets only part of the total requirement, the rest is purchased from local markets. The phoda salt is packed in 75 kg HDPE bags, the other types in smaller bags - 5 and 10 kg packages are encouraged. Costs of the phoda and kurkutch salt are considerably higher in the mountainous areas; approximate retail prices of a kg of phoda or kurkutch salt are 2.9-4.3 US cents in the Terai, 4.3-7.2 US cents in the hills, and 22-84 US cents in the remote mountains. Prices of other salt, including that from Tibet, are also higher in the mountains. However, subsidized packaged salt in some remote areas is available for about 2-7 US cents/kg. Satisfactory data are not available on national salt consumption; the National Micronutrient Status Survey in 1998 suggested about 14 grams per capita per day, but this may include salt purchased for livestock.

IDD program - The Government launched a salt iodization program in 1973 with the STC responsible for its implementation. The Ministry of Health began an iodized oil injection program in 1979, covering 40 hill and mountainous districts, which was phased out in 1994, supplanted by oral iodized oil capsules distributed to women and children in 15 remote mountainous districts. In 1997, the Ministry of Health prepared a five-year (1997-2002) national plan of action for IDD elimination, adopting USI for a long-term strategy and iodized oil capsule supplementation as a short-term.

The previous agreement with the Government of India expired in March 1998 and the STC has since continued the USI program under the Nepalese Ministry of Supplies. Parliament enacted legislation on the production, sale, and distribution of iodized salt in 1998, approved by the King and published in January 1999. It has not yet been effective, pending bylaws and regulations for implementation and enforcement. It provides for registration and licensing of salt trade, quality control, record keeping, government inspections, and enforcement. The Ministry of Health is the key organization responsible for implementing and monitoring the prevention program. It interacts with the National Planning Commission, the Policy Dialogue committee, the Ministry of Agriculture, Ministry of Supplies, NGO's, international agencies, and research institutes, including the BP Koirala Institute of Health Sciences, which has facilities for urinary iodine analysis.

The Government has recently launched a massive iodized salt social marketing campaign, using radio, TV, and merchandizing materials to create awareness. With technical assistance from UNICEF and the MI, a systematic salt iodine internal monitoring mechanism was introduced at STC in 1996. This tracks the iodine level in salt from import to repackaging in Nepal, using the semiquantitative test kits. Only lots with the required 50 ppm are sold to dealers. This monitoring system has been computerized and a central database established at STC headquarters, with regular monthly entry. Iodine monitoring in households is being incorporated as part of the National Vitamin A Program of the Ministry of Health. A current study is exploring iodization of the Tibetan salt used in Humla, Mustang, and Manang districts.

Some current issues and strategies: (1) increased warehouse facility is planned for proper storage; (2) packaging more salt in 1 kg plastic bags is being encouraged; (3) the social marketing campaign is trying to shift consumer demand from phoda salt to crushed iodized salt; iodine loss is highest in phoda salt, so options to improve its iodization are being explored; (4) noniodized or inadequately iodized salt still comes from India, without regulations on iodized salt, imports, and distribution; enforcement of the iodized salt act and provision of necessary regulations are essential; and (5) the country has a 40% literacy rate and social taboos and superstitions are widely prreviewent; these factors emphasize the compelling importance of an adequate communications program in the country.

(presented by Mr. Joshi Ram Prasad, Chief Executive Officer, Salt Trading Corporation Ltd.)

PHILIPPINES

Background - Iodine deficiency has been well documented in the Philippines for years (see IDD Newsletter 9(3):25-27, 1993). Other important nutritional deficiencies are of protein/energy, vitamin A, and iron. About 60-70% of Philippine children are malnourished. Infant mortality is 48.9 per 105 live births, and maternal mortality rate was 197 per 105 in 1995.

IDD status - Data on previous surveys have appeared in the Newsletter. A 1998 survey conducted by the Food and Nutrition Research Institute showed the national median urinary iodine was 71 mcg/L. Thirty-six percent of samples were in the moderate to severe deficient range, and only two regions (Central Luzon and ARMM) had a median urinary iodine above 100 mcg/L; even these areas had > 20% of children with values less than 50 mcg/L.

Iodized salt - The report contains extensive data on the salt industry, some of it summarized in the 1993 IDD Newsletter article. The total production then was 233,000 MT, of which 203,000 MT were reportedly for human consumption and only 30,000 MT for industrial use. A partial survey in 1999 of big salt manufacturers in seven regions showed that the total amount of iodized salt, from local production and importation, amounted to 110,625 MT, while noniodized salt was 12,196 MT. Most of the producers are listed as fish pond owners and not as salt producers. Only recently have salt producers been required to have a license. The most common method of salt production is by solar evaporation, and 98% is in large coarse grains. The production season is December to May. Packaging is in either woven high density polyethylene or woven propylene. Data on importation for 1994 reported 24,000 MT table salt, 92,000 MT industrial salt, and 8,000 MT common salt. In 1999, India, with 12,500 MT, was the major country of origin for imported salt.

Salt producers sell to major distributors, who in turn sell to warehouses and to retail stores. Retailers typically purchase more of the coarse type, and store it for resale. The costs range from Php 3.75 (Philippine pesos) to Php 10 for noniodized salt, and from Php 10 to Php 26.5 for iodized salt.

Control program - The overall strategy is the Philippine Plan of Action for Nutrition. The Department of Health through its Nutrition Service and Bureau of Food and Drugs is responsible for leading micronutrient supplementation and food fortification efforts, in partnership with other governmental, nongovernmental, and international organizations, and the private sector. A National Micronutrient Action Team (NMAT), created in 1993 by the Secretary of Health, recommends policies and guidelines and provides overall direction for management of the program. The NMAT includes the following governmental departments: Health, Agriculture, Education, Culture and Sports, Interior and Local Government, Budget and Management, Trade and Industry, and Science and Technology; other participants are the Philippine Medical Association, the Philippine Information Agency, the Nutrition Center of the Philippines, UNICEF, and HKI. The IDD Experts Group has members from the Department of Health, and the Philippine Thyroid Association, among others. The regions have their own micronutrient action teams, with similar functions and organizational structure, chaired by the regional health directors. At the provincial, city, and municipal levels, local nutrition committees are responsible.

Law of the Republic #8172, an "Act promoting salt iodization nationwide" (known as the ASIN law), was signed in December 1995. Its purpose is to: promote the elimination of IDD through cost-effective measures of salt iodization; require all manufacturers of food grade salt to iodize their product; provide mechanisms for local industry in production, marketing, and distribution of iodized salt; and ensure the sustainability of the salt iodization program. The act applies to the entire salt industry, food outlet, restaurants, stores, food manufacturers, and processors, as well as to government and nongovernmental agencies. Sanctions and administrative penalties can be imposed and the offender's license can be withdrawn.

The ASIN law created a Salt Iodization Advisory Board for policy and coordination of the national salt iodization program. Its composition includes relevant ministries and agencies of the Government, as well as representatives from the medical and salt production sectors. Despite this legislation and efforts of the Government, only 10% of the salt was iodized by 1998, even though the awareness level was 84%. Iodized salt had only limited availability in the market and its price was high. In response, the Secretary of Health ordered that the law be enforced and fully implemented, to achieve 50% USI by 1999 and 100% by the end of the year 2000.

Iodized oil capsules were distributed between 1993 and 1997, but all current activities are towards iodized salt. The two major efforts are the salt iodization itself and social marketing. The former provides iodization machines with capacities ranging from 300 kg/hour to 500 tons/hour on a soft loan basis with an initial free supply of potassium iodate. The three components of this approach are:

1. community-based salt iodization, was undertaken in the five provinces of the CAR, the region with the highest prreviewence of goiter and no salt production; salt iodization facilities were installed in strategic areas in each of the provinces, and operate through the local government and its provincial health officers or federation of village health workers;

2. producer-based salt iodization, with particular attention to iodizing salt efficiently at production sites; a 5 ton/hour capacity machine was provided on soft loan term to the country's largest salt producer;

3. focus on other producers; the program has provided them with iodization machines; currently, 42 iodization machines are installed nationwide, with a combined capacity of producing at least 80% of the country's total requirement.

The social marketing strategy initiated in 1994, aims to encourage producers and traders to embrace salt iodization and to create demand among the general public through advocacy meetings, mass media, and interpersonal strategies. By 1997, 84% of the population knew about iodized salt, but only 18% used it. The implementing strategies include communication materials in print and broadcast, advocacy meetings among different sectors from government and the private sector, and wide publicity for activities such as salt testing in schools and communities. Despite these activities, utilization decreased in 1998.

Enabling mechanisms include legislation, training courses on salt iodization technology and quality assurance, titration laboratories in all regions for monitoring, introduction of lot quality assurance sampling, assessment and surveillance of the IDD problem, research on stability of iodine and iodized salt, and monitoring and reviewuation to track progress.

Another inducement is the Sangkap Pinoy Seal Program. Food manufacturers are authorized to carry this Department of Health seal of acceptance on products that meet standards for appropriate fortification with either vitamin A, iron, and/or iodine. So far, three of the 24 approved products that carry the seal are fortified with iodine - a chocolate drink, a snack food, and powdered milk. Some salt monitoring is taking place at production and trade levels during the current year, and routine monitoring at least twice yearly is proposed. The Government is also beginning to check imported salt on arrival, and local government units are testing for salt at public markets. A national titration laboratory exists. In 1997, UNICEF distributed equipment and reagents to establish titration laboratories in all regions except the National Capital Region. However, out of the six regions monitored, only two titration laboratories are functional. Problems include lack of laboratory space and insufficient reagents and glassware.

The technique for urinary iodine is available at the DOH Bureau of Research and Laboratory. It is used only on special surveys.

(Presented by Luz Santarromana-See, Nutritionist-Dietitian, Nutrition Service, Department of Health.)

BIOAVAILABILITY OF ORAL VERSUS INTRAMUSCULAR IODINATED OIL (LIPIODOL7 UF) IN HEALTHY SUBJECTS. R. Leverge, J.-F. Bergmann, G. Simoneau, Y. Tillet, and B. Bonnemain, Laboratoire de Toxicologie et de Pharmacologie Clinique, and Unite de Recherches Therapeutiques, Hopital Lariboisiere, Paris; and Guerbet, 50400, Roissy CDG Cedex, France.

Iodine deficiency is widespread throughout the world, especially in developing countries (1,2). Dietary iodine supplementation by iodized salt is the first-line measure, but to be effective, it must involve the entire food chain through universal salt iodization (USI). Many countries have been unable to overcome one or more of the following obstacles: difficulties in delivering or distributing iodized salt in isolated regions; poor storage conditions, inducing degradation of iodized salt; sociocultural habits that are resistant to information campaigns; occasional complications from goitrogenic factors (e.g., cassava); and irregular or low consumption of salt.

For these reasons, from 1960 onwards, several health organizations, including WHO, UNICEF, and ICCIDD, have complemented the distribution of iodized salt in endemic regions by medicinal iodine administration of Lipiodol UF injection, an iodinated oil registered in 1990 by WHO on its list of essential medicinal products. Lipiodol UF injections contain 480 mg of iodine per ml. The single active substance is mono- and diiodinated fatty acid ethyl esters (C16 and C18). Its iodine is bound to an organic substrate and is, therefore, slowly released following intramuscular administration (3-5). This delayed effect has been particular useful in the treatment of iodine-deficient populations.

The first studies conducted in New Guinea injected doses as high as 2 grams of iodine. Many subsequent studies, in New Guinea, Peru, Ecuador, Congo, Sudan, Tanzania, China, Iran, the Philippines, and others, showed that much lower doses were equally effective, and adverse effects were rarely reported (5). However, Lipiodol injection campaigns have two major disadvantages: (1) they require the presence of medical and health care infrastructure, ensuring the quality of injections but increasing the cost; and (2) injections under nonsterile conditions carry the risk of diseases transmitted by blood and blood products, such as hepatitis and HIV/AIDS. Concern for such contamination is particularly high in developing countries, where iodine deficiency is also more widespread. These considerations made oral administration more attractive. Clinical trials in adults, children, and pregnant women confirm the efficacy of this route of administration (5-11). Guerbet, therefore, developed a capsule form of Lipiodol that is easier to distribute and less expensive. Each capsule contains 190 mg of iodine as Lipiodol (ethyl esters of iodized fatty acids from poppyseed oil; 38% of Lipiodol's weight is iodine). The capsule shell includes gelatin, glycerol, sodium propylparahydroxybenzoate and sodium ethyl parahydroxybenzoate.

EXPERIMENTAL APPROACH

We studied 36 healthy volunteers, aged 18 to 40 years, at the Lariboisiere Hospital Therapeutic Research Unit in Paris, after obtaining informed consent and approval by relevant ethics committees. Subjects were divided randomly into two groups, each receiving either 1 ml of Lipiodol (480 mg of iodine) IM or a single oral dose of three Lipiodol capsules (total 570 mg of iodine) and followed for nine months. The two groups were similar in age (mean 27.5 years), body size, blood pressure, and heart rate, as well as thyroid tests (Table 1).

Follow-up included: general physical examination (cardiac and pulmonary auscultation, examination of the abdomen, nervous system, skin, locomotor apparatus, weight, blood pressure, heart rate, palpation of thyroid, exclusion of clinical signs of thyroid dysfunction, and measurement of neck circumference), at D30, D60, D90, D180, and D270; thyroid ultrasonography, routine blood and urine chemistry at D-21 and D90; serum thyroglobulin (Tg), TSH, FT3 (free T3), and FT4 (free T4) on D-21, D30, D60, and D90; and anti-TPO and anti-TRAK antibodies on D-21 and D90. Additional assessment in 18 volunteers (nine per group) measured thyroid hormone levels on D0 and D1, and, in three volunteers per group, also on D5, D11, and D15 in order to detect any signs of early thyroid dysfunction, such as the Wolff-Chaikoff effect.

Twenty-four hour urine iodine excretions were measured on D0, D1, D3, D5, D7, D9, D11, D13, D15, D30, D60, D90, D180, and D270, in the ICCIDD Urinary Iodine Laboratory in Brussels, using a Technicon Autoanalyzer and the Sandell-Kolthoff reaction (12).

We used the following software for calculations and determination of pharmacokinetic parameters: SIPHAR/BASE, SIPHAR/ABSORPTION, SIPHAR/URINARY, PHARM/STAT, IPHAR/WIN (SIMED SA, France). Urine excretion data were expressed as medians and means because they did not show a normal distribution. Statistical comparison was performed for mean values of D0 and those for D60, D90, D180, and D270, by the Student t test on paired data and by ANOVA. We used analysis of elimination profiles, in terms of rate of excretion as a function of time [log(DQu/dt)=log(ClrCo)-Kelt)], to determine the pharmacokinetic profile of absorption, distribution and elimination of iodine for each route of administration.

RESULTS

Urinary iodine excretion - Figure 1 shows the curve for median values. The maximum for the intramuscular route was on day 13 (~5.5 mg/24 hours) and on day 1 for the oral route (> 77 mg/24 hours). Median daily excretion at 180 days was 149 mcg (oral) and 428 mcg (intramuscular) and at 270 days, 131 mcg (oral) and 338 mcg (intramuscular). The mean values for the intramuscular route were significantly higher than baseline until day 270 (p < 0.001). Mean values for the oral route were significantly higher than baseline until day 180 (p = 0.017) and close to the limit of significance on day 270 (p = 0.069). Distribution half-lives were about five days for the IM route and two days for the oral route, and elimination half-life was 80 days for the oral route and 75 days for intramuscular route.

Clinical effects - The general clinical examinations remained normal throughout the study. Six subjects (four for the IM route, two for the oral) had heart rates 20% higher than baseline values, but these differences were transient and not clinically significant. We found no changes in thyroid palpation, no clinical features of thyroid dysfunction, and no significant variations in neck circumference.

Ultrasonography - Thyroid ultrasound was recorded as normal in all subjects at the beginning of the study and in 32 of the 36 subjects at day 90. The remaining four subjects on day 90 had some microcysts and a small nodule reported, but this finding may reflect changes in examination technique between the two observations; the microcysts probably existed for some time before the study, because they were associated with calcifications.

Thyroid function tests - Table 1 gives mean values for Tg, TSH, FT3, and FT4. No significant changes occurred and all parameters remained within the normal range. Tests in several subjects on day 1, day 5, day 11, and day 15 also showed no change, in agreement with reports by Gerasimov (13).

DISCUSSION

The doses selected for the study correspond to those recommended by WHO, UNICEF, and ICCIDD for iodine-deficient adults, i.e., 400 and 960 mg oral for 12 months coverage, and 480 mg intramuscularly for 2-3 years (11).

At the doses we used, urinary iodine levels remained above baseline for over 12 months by the intramuscular route and for six months orally. The longer duration for intramuscular injection is explained by progressive release from the injection site. The difference between pharmacokinetic data and clinical activity kinetic data in iodine-deficient populations might result from a continuing release of iodine from storage tissues such as adipose even when urinary iodine excretion becomes lower than the baseline value but higher than the limit of iodine deficiency. An alternative explanation is the latent period between iodine deficiency and goiter formation. Several clinical studies and reviews (6,7,14,15) are consistent with the recommendations for dosing proposed by ICCIDD, WHO, and UNICEF.

This study also demonstrated the excellent safety of Lipiodol either by intramuscular or oral administration. We found no adverse clinical effects and no changes in thyroid function tests. This study obviously cannot reviewuate the long-term risk of iodine-induced hyperthyroidism nor the urinary iodine excretion in an iodine-deficient population, in whom inhibition of iodine organification has been observed after only 2 mg of free iodide administration (16). However, some authors regard the hyperthyroidism risk as lower than that observed after introduction of iodized salt into the diet (17,18). Delange, et al. (19) noted that a very high regular dietary intake could induce thyroid dysfunction, mainly in subjects with pre-existing thyroid abnormalities. In the present study, urinary iodine excretion values greater than 1 mg/24 hours were present for only three months with the intramuscular form and for only seven days orally. Other publications (11,14,20) confirm the safety and efficacy of Lipiodol in endemic goitrous populations, even during pregnancy.

Finally, the urinary iodine concentration returns to normal somewhat before the end of beneficial effects from the Lipiodol administration. This apparent discrepancy may be explained by Lipiodol's inducing an increase of iodine reserves in the thyroid gland, which can then function normally for several months on this reserve.

SUMMARY

We compared a single dose of three capsules (total of 570 mg of iodine) versus a single intramuscular injection of 1 ml Lipiodol UF (480 mg of iodine) in 36 healthy subjects followed for nine months in a randomized bioavailability study. The 24 hour urinary iodine values were above baseline for six months after oral administration and for > 12 months after intramuscular injection. Neither form of administration induced any undesirable effects or alterations in thyroid function tests. We conclude that the single dose of Lipiodol provides an effective and prolonged iodine supplement of one year's duration for oral administration and 2-3 years for the intramuscular. These results reconfirm the feasibility of protecting exposed populations by annual administration of an appropriate single oral dose.

Acknowledgement

The support of Professor F. Delange for the study is appreciated.

All correspondence concerning this article should be sent to:

B. Bonnemain

Guerbet

BP 50400

95943 Roissy CDG CEDEX, France

Telephone: 33 1 45 91 50 70

FAX: 33 1 45 91 51 99

E-mail: bonnemab@guerbet-group.com

References

1. Delange F, Ermans AM 1996 Iodine deficiency. In: Braverman LE, Utiger R, eds. The Thyroid. A fundamental and Clinical Text, 7th ed, Lippincott Raven Publishers, Philadelphia, pp 296-316.

2. WHO/UNICEF/ICCIDD. Indicators for assessing iodine deficiency disorders and their control through salt iodization, Document WHO/NUT/94.6.

3. Malamos B, Koutras DA, Mantzos J, et al 1970 Endemic goiter in Greece: effects of iodized oil injection. Metabolism 19:569-580.

4. Pretell EA 1972 The optimal program for prophylaxis of endemic goiter with iodized oil. Adv Exp Med Biol 30:267-288.

5. Dunn JT 1987 Iodized oil in the treatment and prophylaxis of IDD. In: Hetzel BS, Dunn JT, Stanbury, eds. The Prevention and Control of Iodine Deficiency Disorders, Elsevier, pp 127-134.

6. Furnee CA, Pfann GA, West CE, van der Haar F, van der Heide D, Hautvast JGAJ 1995 New model for describing urinary iodine excretion: its use for comparing different oral preparations of iodized oil. Am J Clin Nutr 61:1257-1262.

7. Benmiloud M, Chouaki ML, Gutekunst R, Teichert HM, Wood WG, Dunn JT 1994 Oral iodized oil for correcting iodine deficiency: optimal dosing and outcome indicator selection. J Clin Endocrinol Metab 79:20-24.

8. Lazarus JH, Parkes AB, John R, N'Diaye M, Prysor-Jones SG 1992 Endemic goitre in Senegal - thyroid function etiological factors and treatment with oral iodized oil. Acta Endocrinologica 126:149-154.

9. Chouaki ML, Benmiloud M 1994 Prevention of iodine deficiency disorders by oral administration of Lipiodol during pregnancy. Eur J Endocrinol 130:547-551.

10. Cao XY, Jiang XM, Dou ZH, Rakeman MA, Zhang ML, O'Donnell K, Ma T, Amette K, DeLong N, DeLong GR 1994 Timing of vulnerability of the brain to iodine deficiency in endemic cretinism. N Engl J Med 331:1739-1744.

11. Thilly CH, Delange F, goldstein-Golaire J, Ermans AM 1973 Endemic goiter prevention by iodized oil: a reassessment. J Clin Endocrinol Metab 36:1196-1204.

12. Sandell EB, Kolthoff IM 1937 Micro determination of iodine by a catalytic method. Microchemica Acta 1:9-25.

13. Gerasimov G, et al 1998 Acute effect of iodized oil on thyroid function in young adults. In: Stanbury JB, Delange F, Dunn JT, Pretell CS, eds. Iodine in Pregnancy, Oxford University Press, Delhi, pp 171-180.

14. Delange F 1996 Administration of iodized oil during pregnancy: a summary of the published evidence. Bull WHO 74:1-3.

15. Delange F 1994 The disorders induced by iodine deficiency. Thyroid 4:107-128.

16. Delange F, Ermans AM 1966 Inhibition of iodine organification by supplemental iodine in endemic goiter: therapeutic implications. Revue Europeene de'endocrinologie 3:331-335.

17. Stanbury J 1998 the pharmacology and toxicity of iodinated oil. In: Stanbury JB, Delange F, Dunn JT, Pretell CS, eds. Iodine in Pregnancy, Oxford University Press, Delhi, pp 103-129.

18. Todd CH, Allain T, Gomo ZAR, et al 1995 Increase in thyrotoxicosis associated with iodine supplements in Zimbabwe. Lancet 346:1563-1564.

19. Delange F, de Benoist B, Alnwick D 1999 Risks of iodine-induced hyperthyroidism after correction of iodine deficiency by iodized salt. Thyroid 9:545-556.

20. Pretell EA, Moncloa F, Salinas R, et al 1969 Endemic goiter in rural Peru: effect of iodized oil on prreviewence and size of goiter and on thyroid iodine metabolism in known endemic goitrous populations. In: Stanbury J, ed. Endemic Goiter, report of the meeting of the PAHO Scientific Group on Research in Endemic Goiter, held in Puebla, Mexico, June 27-28, 1968, PAHO/WHO document.   Table 1. Thyroid function (-)21 to 90 days after administration of Lipiodol either intramuscularly (IM) or orally (PO) to 18 subjects in each group. Table entries are means " SEM. None of the differences between baseline ((-)21 days) and the follow-up times was significant for any of the measures. Normal reference ranges: Tg, < 25 mcg/L; TSH, 0.2-4.0 mU/L; FT3, 3.4-7.2 pmol/L; FT4, 10.4-24.3 pmol/L. 


Days after administration


Tg
(mcg/L)
  


TSH
(mU/L)
  


FT3
(pmol/L)
  


FT4
(pmol/L)
 
IM
PO
  
IM
PO
  
IM
PO
  
IM
PO
(-)21
12.7±6.7
19.4±16.8
1.4±0.7
1.4±0.8
4.9±0.6
5.0±0.5
16.0±2.8
16.6±2.5
30
 17.6±12.9 18.3±16.5   2.6±1.4 1.8±1.2   5.0±0.8 5.5±0.9   14.6±3.0 15.6±3.5
60
 10.9±7.1 15.5±13.1   1.9±0.8 1.4±0.7   4.7±0.7 5.3±0.8   15.4±2.8  14.8±3.0
90
6.5±4.8
15.5±11.7
1.6±0.8
1.2±0.6
4.8±0.8
4.8±0.9
15.0±2.5
15.4±2.5

 

SUNA'S STORY: IDD IN AN ORANG ASLI VILLAGE CLOSE TO KUALA LUMPUR. C. C. Cuthbertson, B. Naemiratch, L. M. Thompson, A. Osman, J. H. Paterson, G. C. Marks, M. S. Hanafiah, and M. I. Zaleha, Nutrition Program, Australian Centre for International and Tropical Health and Nutrition, The University of Queensland, Brisbane, Australia; and Department of Community health, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia.

Suna is 41-year-old Orang Asli woman who participated in a cross-sectional study conducted in her village.  The aim of the study was to determine the prreviewence of Iodine Deficiency Disorders (IDD) and associated factors in Suna's village. Suna and the villagers identify themselves as Orang Asli, the indigenous people of Malaysia.

There are no national prreviewence data for IDD in Malaysia. Various small studies have been conducted and the highest prreviewence rates have been found in remote inland areas. IDD studies in Orang Asli communities in Peninsular Malaysia have indicated a high palpable goiter prreviewence (26-45%), with the highest prreviewence found in remote and rural villages (1-3).

There are approximately 72,000 Orang Asli in Malaysia. They traditionally led a lifestyle of hunting and gathering food in the jungle. Many live in remote areas, although some have been relocated to the jungle fringe (4). Suna's village of 273 people is located on the jungle fringe, 46 km from Kuala Lumpur. However, it is within a 15-minute motorbike ride to the local health clinic and staff from the maternal child health clinic visit monthly.

Thyroid palpation and urinary iodine levels were used to determine the prreviewence of IDD. The prreviewence of goiter was determined by palpation using standard WHO protocol (5) and urine samples were analyzed for iodine content using the Sandell-Kolthoff reaction after applying the alkaline ashing method (6).

Demographic and dietary information were gathered using pre-tested questionnaires. Dietary data was collected with a food frequency questionnaire, which included a list of foods regarded as high in iodine content.

Women without children or who were not pregnant with their first child were excluded. Of the 45 women eligible, four did not participate, as they were absent from the village for the duration of the study.

Suna's story

A typical workday for Suna begins with preparing drink for the family, eating breakfast consisting of either tea or coffee and biscuit, and then going to work at a furniture factory.  Here she works with around ten other women from the village polishing furniture. Her workday starts at 8am and finishes at 7pm. Suna's dietary intake was recorded for three days. Her meals consisted of combinations of rice with fried cassava shoot, anchovy, cabbage and meat such as freshwater fish, beef or chicken curry.

Suna's childhood was spent at the dam area (approximately 20km away) where the land was flat and a variety of plants were grown. She did not attend school. She met her husband at the dam, when he came to work there with friends. She married him when she was 13 years old, and had her first child two years later.  Her husband's work involved finding and selling rattan from the jungle, and rubber tapping.

She remembers feeling hungry whilst she lived at the dam. At this time she didn't have any work, and she ate a lot of cassava root and freshwater fish.  She had eaten this diet for some time before she noticed the swelling on her neck, which she remembers occurred around the time of the birth of her second child. Suna's mother also noticed the swelling on Suna's neck and asked Suna why it was there. Suna did not know the answer.

A nutritional assessment of Suna indicates a Body Mass Index (BMI) of 16.9, which indicates she is underweight.  She only met 87% of her energy requirement according to the Malaysian Recommended Dietary Intake (7).  She was one of the eleven women who were found to have a goiter. She has a visible goiter of single nodule and soft consistency.

Of the 34 women who were examined by palpation (seven did not participate), eleven (32.4%) were found to have goiter. Of these, five (14.7%) had grade 1 and six (17.7%) had grade 2 goiter. The median urinary iodine level of these 34 women was 14.5 + 11.5 ug/L, and ranged from 0.32 ug/L to 43.72 ug/L, which classifies as severe iodine deficiency according to WHO classifications (5).

Suna and the women reported obtaining food from the following sources: their own home gardens, the jungle, the traveling fishmonger, the market, and two nearby shops. Iodine containing food identified included: seafish, freshwater fish (usually reported as Tilapia), sardines, freshwater prawns, and cockles. Freshwater fish was the most common iodine source, consumed by half of the participants once or twice daily.

Previous Malaysian and Orang Asli studies have identified possible factors contributing to IDD including: dependence on locally produced foods from potentially iodine deficient soils, frequent consumption of cassava, and low intake of seafood (1-3, 8). These factors were also reflected in this study.

Suna, like most of the women in the village, ate a staple diet of freshwater fish, cassava, rice, and green leafy vegetables. Most of the time the fish, cassava, and vegetables were collected at no cost in the surrounding jungle. Although seafood was eaten, it was eaten with much less frequency than freshwater fish.

A close examination of Suna's diet indicated that she consumed little iodine containing food. Her only source of iodine rich food, in the three days studied, was freshwater fish. This is readily available and obtained free by fishing.  Her average serving size was approximately the size of two matchboxes, around 60 grams cooked or 80 grams uncooked. 

Suna ate cassava, which is considered potentially goitrogenic due to its thiocyanate content. Thiocyanate levels vary in cassava and not all cassava is goitrogenic due to genetic and/or environmental factors (9). The thiocyanate in the cassava consumed by Suna and the participants may have exacerbated any iodine deficiency, however the extent of the exacerbation is not known. Suna ate cassava for two out of the three days studied.

Suna and the other women of the village were the main food preparers, and it was assumed dietary patterns of the family members would be similar, indicating the whole community may be at risk of severe iodine deficiency. Thus, other communities dependent on locally produced food sources potentially low in iodine due to environmental conditions, regardless of remoteness, may also be at risk.

Although this Orang Asli community was not remote, the IDD prreviewence was similar to remote communities reported in earlier studies (Osman 1-3, 8). This implies that Apockets@ of IDD in Peninsular Malaysia may be more widespread than previously thought and highlights the need to investigate other communities with similar characteristics to Suna's community.

To date, universal preventative IDD measures are not in place throughout Malaysia. Measures using iodization of water (gravity feed system), iodized salt and iodized oil capsules have been given to priority areas, especially in Sabah, Sarawak, Kedah, Kelantan, Pahang, and Perak.

These findings and Suna's story indicate there may be a need to look more closely at public health measures to prevent IDD in non-priority areas B so that women like Suna, and their families, are not at risk of goiter, and other damaging effects of the range of IDD.

Acknowledgements

This article derives from a thesis by the first three authors that was written in partial fulfillment for the requirements of the Master of Community Nutrition degree at the University of Queensland, Australia, in 1998. We thank the staff of the Community Health Department of University Kebangsaan Malaysia and the Nutrition Program of the University of Queensland for their supervision and assistance with the writing of the article. We thank the Australian Centre for International and Tropical Health and Nutrition (ACITHN) for a supporting scholarship to complete the journal article ADietary intake and iodine deficiency in women of childbearing age in an OrangAsli community close to Kuala Lumpur, Malaysia@, Asia Pacific Journal of Clinical Nutrition 2000; 9 (1):36-40; as well as this short article for the IDD Newsletter.

Corresponding author:

Jane Paterson, Nutrition Program, Australian Centre for International and Tropical Health and Nutrition, The University of Queensland, Level 3 Edith Cavell Building, Royal Brisbane Hospital, Herston, Queensland 4029, Australia.

Tel +61-7 3365 5400; Fax +61-7 3257 1253; Email jp@nutrition.uq.edu.au

References

1. Osman A, Zaleha MI, Iskandar ZA, Tan TT, Ali MM, Roslan I, Khalid BAK. Levels of thyroxine, TSH, thyroid volume and mental performance among Orang Asli in selected settlements in Malaysia. East African Medical Journal 1996; 73: 259-263.

2. Osman A, Zaleha MI, Letchumen R, Khalid BAK. The prreviewence of goitre in remote inland versus coastal areas. Med J Malaysia 1995; 50: 256-262.

3. Osman A, Khalid B, Tan TT, Wu LL, Ng ML. Protein energy malnutrition, thyroid hormones and goitre among Malaysian Aborigines and Malays. Asia Pacific J Clin Nutr 1992; 1:13-20.

4. Ibrahim Z. Regional development in rural Malaysia and the 'Tribal question'. Occasional Paper No. 28. Hull: Centre for South-East Asian Studies, 1995.

5. WHO/UNICEF/ICCIDD. Indicators for assessing iodine deficiency disorders and their control through salt iodisation. Geneva: World Health Organization, 1994.

6. Belling GB. Further studies on the recovery of iodine as iodine-125 after alkaline ashing prior to assay. Analyst 1983; 108: 763-765.

7. Tee ES. Nutrient composition of Malaysian foods, 4th edn. Kuala Lumpur: Institute of Medical Research, 1997.

8. Osman A, Muda K, Khalid BAK. Iodine content in urine samples among Malays and Aborigines. Acta Med Okayama 1994; 48: 289-292.

9. Delange F, Iteke FB, Ermans AM, eds. Nutritional factors involved in the goitrogenic action of cassava. Ottawa: International Development Research Centre, 1982.

In Brief.....

TIBET IDD ELIMINATION PROJECT - Formally inaugurated in Lhasa, May 18. This is a collaborative effort involving the Tibet Autonomous Region Government and the Tibetan Department of Health, the Central Chinese Ministry of Health and Ministry of Foreign Trade and Economic Cooperation, WHO, UNICEF, AusAid, and the University of Sydney Institute of Clinical Pathology and Medical Research (ICPMR). Dr. Cres Eastman (ICCIDD Board) prepared a feasibility study leading up to the project. AusAid is the major financial donor, and UNICEF and WHO will also contribute. WHO/WPRO is taking primary responsibility and is delegating to the ICPMR (Dr. Eastman and Dr. Mu Li) its management and coordination. The objective is to achieve iodine sufficiency in Tibet. Major components include: (1) development and construction of two iodized salt plants for people and animals; (2) an interim effort to give annual treatment with iodized oil to all infants and women of childbearing age; (3) health education and advocacy; (4) epidemiologic surveys for baseline and outcome data; (5) laboratories and clinical monitoring of progress; and (6) training of personnel. The project period is from May 2000 to 2003. Dr. Chen Zu-pei, ICCIDD Regional Coordinator and Chairman of the National Advisory Committee on IDD for China, will chair the Scientific Advisory Committee.