Volume 13 Number 4, November 1997

IN THIS ISSUE

KIWANIS INTERNATIONAL COMBATS IDD EFFECTS OF SALT IODIZATION IN SEVEN AFRICAN COUNTRIES TOWARDS IMPROVED SALT IODIZATION IN ENUGU STATE NORMAL THYROID VOLUME OF YOUNG ADULTS IN TURKEY EMBRYOTOXICITY STUDIES IN THE RAT AND RABBIT IODINE DEFICIENCY AWARENESS CAMPAIGN IN KASHMIR ABSTRACTS

Maternal iodine status and thyroid volume during pregnancy: correlation with neonatal iodine intake

The relation of transient hypothyroxinemia in preterm infants to neurologic development at two years of age

Aliment re jodaufnahme bei jugendlichen in mecklenburg-vorpommernzwischen 1993 and 1996 gestiegen IN BRIEF IDD activities in East/Southern Africa ALGEPA AWARD 1996 GAETANO SALVATORE KIWANIS INTERNATIONAL COMBATS IDD. Constance S. Pittman, ICCIDD Board member and Chair, Worldwide Service Project-IDD Committee, Kiwanis Club of Birmingham, Alabama, U.S.A.

All at once everyone is talking about Kiwanis. The name of Kiwanis is mentioned by the governments trying to implement their national programs for the control of iodine deficiency disorder (IDD). Kiwanis is acknowledged by the representatives of the United Nations Children's Emergency Fund at public forums (UNICEF). However, Kiwanis is not easy to define, being a large organiza tion with a constant physical and intellectual growth. It is a loose network of ordi nary people who aspire to promote the spiritual values of life, to live and conduct thems elves by a code of tolerance, service, and charity, and to foster the necessary attitudes and skills for service among young people by precept and example Their motto is " We Build." This article is a brief account of Kiwanis, its growth, its strengths and limitations and its major role in the international effort to eliminate IDD. A fuller h istory of the early years of Kiwanis is available, (Dimensions of Service; The Kiwanis Story by L. A. Hapgood, reprinted by Kiwanis International in 1989). The monthly magazi ne, Kiwanis is a major publication of Kiwanis International for membership education, and a rich source on the launching and progress of the Kiwanis Worldwide Service Pro ject-Iodine Deficiency Disorders (WSP-IDD). Brief history of Kiwanis

Kiwanis International has been an active service club in the United States for eight decades. The name, Kiwanis, is derived from an Otchipew Indian word. The original word has several possible translations including: "we have a good time," "we make a noise," or "we trade." During the years leading to the World War I, the Midwest of the United States was experiencing a rapid economic rise driven by the automobile industry and radio communication. The local merchants, concerned by public unease over business ethics and practices, cast about for leadership and association that might provide the means to address such concerns. The Kiwanis Club was first organized in the last days of 1914, by 35 businessmen and professional people at the Edelweiss Cafe in Detroit, with the stated aim to be an association for men to exchange ideas and promote business opportunities. Led by Allen Simpson Browne and Joseph G. Prance and armed with an application bearing sixty signatures, the club was first incorporated in the State of Michigan on January 21, 1915. The membership grew rapidly to 250 after six months and continued to increase to approximately 10,000 by 1918. By then, Kiwanis clubs were established in most major areas of the United States and Canada.

In its early years, Kiwanis was under the influence of Browne, its national organizer and recruiter. He was able to attract many new members of similar mind who saw the club as a business for self interest and looked upon the club membership only as an opportunity to forge social relationships and business patronage. However, a few club founders persisted in the belief that the club could prosper only if it also offered philanthropic services to the local community. Slowly the idea of service gained ascendancy as many club members became more energized and fulfilled when they gave themselves in the national war efforts and in their service to others in the communities. The struggle to redirect the club objective and reform the club governance caused a lot of intramural conflict. The frictions ceased finally only after the club purchased the ownership of Kiwanis from Browne. At the 1919 Kiwanis convention in Birmingham, Alabama the club officially adopted service as its central tenet and launched a program to change the club culture away from the original commercial emphasis of "we trade" to that of community service of " we build." This laid the ground work for a new Kiwanis, allowing it to evolve later into a major player in the service club movement.

Through the following decades Kiwanis held steady to its central tenet of service while it adapted continuously to meet the challenges of a changing world. In recognition of the already integrated clubs in the United States and Canada, the parent organization changed its name from The National Kiwanis Club to Kiwanis International in 1918. Still later, at its 1961 convention in Toronto, after the experience of another World War and facing a slow growth of membership, Kiwanis resolved to establish clubs in other countries beyond North America.

Kiwanis International has sponsored youth service clubs since 1925, when Key Club International was first established for high school students. Later, Circle K International was established for college students, followed by Builders Club, for children in the middle schools. Each youth club is sponsored by a Kiwanis club, which provides financial help and preceptors. Together they perform campus and community services and foster leadership and personal development. Many sponsor clubs are able to augment their experience in sports and travels, and to provide scholarships for higher education. Unburdened by tradition, these youth service clubs are more energetic and innovative in their choice of service projects and, not surprisingly, more liberal and international in their social outlook than the parent organization. Circle K International began to accept girls in 1973. Key Club International accepted girls in 1977, while Kiwanis International itself did not have women members until 1987. The youth service clubs have elected women and African-Americans as their club presidents and experimented with telecommunication to hold joint meetings with their counterparts overseas. They also have embraced the Kiwanis Worldwide Service Project-IDD with ready enthusiasm and startling generosity. Their leaders are invited to go on Kiwanis field trips abroad to visit IDD on site. Organization and activities

Kiwanis International in 1997 has clubs in 82 countries. It has a total membership of more than 600,000, including over 315,000 regular Kiwanis club members. Circle K International alone has 10,000 members on 560 university and college campuses. Key Club International has 194,000 members in 4,560 high schools, while Builders Club has active organizations in 2,000 middle schools. The membership growth rate has been highest in the developing countries, especially in Asia. The 1995-96 Kiwanis census shows 45,000 women members in Kiwanis International and they hold 15.6% of all offices of club president. This year, Walter G. Sellers, an African-American college administrator, is the elected Kiwanis International president of 1997-1998. The program brochures of the 1997 Kiwanis annual convention in Nashville were printed in four languages including English, French, Spanish and Chinese Simultaneous translation in these languages was available during the meetings and the announcements on the meeting floor were given in these four languages as well.

In accordance with its by-laws, Kiwanis International each year elects a new president and a Board of Trustees who are vested with full authority to oversee all the activities of this far flung organization. The administrative staff is housed in the headquarters building in Indianapolis, Indiana. The incumbent International President, by tradition, committed his year in office to promote a personal theme of service programs. The themes change, for example, from citizenship, to faith, to reading, to children, from one year to the next, with limited impact. As the leadership struggled in the past to give Kiwanis International a more clearly defined public image, it came to appreciate the promise of a focused service program for the entire organization. That recognition eventually led to its taking on the elimination of iodine deficiency disorders as its Worldwide Service Project in 1992, as discussed below.

The administration of Kiwanis International is organized into more than 40 districts. A new governor is elected in each district every year. The numbers and the geographic boundaries of these districts change from time to time, in response to their membership growth or service opportunity. The recent expansion of Kiwanis in Eastern Europe, the former Soviet Union, Africa and Asia has made it necessary to devote a lot of attention and resources to build new clubs, train new leaders and educate the new members on stewardship and service disciplines. A Kiwanis club is chartered only after it meets the requirements of membership size, scheduledmeetings, dues structure and service programs. The chief executive officer is the club president who is also elected yearly. Each Kiwanis club is expected to be self-reliant in meeting the cost of its service projects from member contributions, community support and fund raising projects. By tradition, the clubs enjoy a high degree of autonomy and innovation. They vary in size, financial resources and skill, and promote different service projects according to the interests of club leadership, the community needs and local culture. While nearly all clubs take on some child-oriented service, their approaches are often different and unique. Each club may choose to work on a project by itself or in alliance with other clubs sharing similar interests. Together, the Kiwanis clubs form a heterogeneous and dynamic grassroots organization with an immense potential to render service to others.

An active member pays dues to his own Kiwanis club and to Kiwanis International as well as contributing to special projects according to his ability and conscience. The members band together to raise money, for example, by selling peanuts and raffles, cooking pancakes and barbecue or sponsoring sport events and other entertainments. They often receive large contributions from their communities and local businesses because of their services. Through team work, they are able to collect hundreds and thousands of dollars to pay for their projects, and have a long tradition of raising money for projects through voluntary donations, not by taxation.

The magazine, Kiwanis, a monthly publication of Kiwanis International and its main vehicle of communication and education, carries many stories of projects of special interest. For example, the Kiwanis Club of Little Havana, Miami, Florida, teamed up with several major league baseball greats to provide medical supplies and food to the detained refugees at Guantanamo Bay, Cuba (Kiwanis 81:2,21, 1 996). The Kiwanis of Rhinelander, Wisconsin raised the equivalent of $225,000 in funds, materials and labor to refurbish a kitchen designed to teach and serve persons with disabilities (Kiwanis Ibid). The Kiwanis Club of Reykjavik-Videy, Iceland assisted local businesses and trade groups to build an outdoor swimming pool for the Mosfellsbaer Summer Camp (Kiwanis 81:5,10, 1996). The Kiwanis Club of Montreal-St. George, Quebec donates $75,000 annually to help feed 2,000 children through several food agencies in their community, while the Kiwanis Club of Owen Sound, Ontario supports the food drive of the local Salvation Army by sponsoring an annual Santa Claus Parade (Kiwanis 82:10,7, 1997).

The Kiwanis clubs sponsor projects to help children, senior citizens, disabled persons, disadvantaged people, law enforcement, schools, hospitals and clinics, day-care centers, family shelters and other causes. Some clubs have continuously promoted over decades specific projects that enjoy very strong loyalty am ong the members. The Kiwanis International Worldwide Service Project-Iodine Deficiency disorders, (WSP-IDD), is only one among numerous service projects that must compete for the interests and donations of the Kiwanians. It has taken nearly three years of forceful leadership and focused membership education to promote WSP-IDD as a project for the entire Kiwanis International. That process has changed the very culture of Kiwanis from being a community based service club to become a major international service organization. This story in itself is worth telling. Development of the International Service Project Against IDD

By late 1990 the leaders of Kiwanis International recognized that the traditional annual promotion of a service theme of different emphasis was both ineffective and cost inefficient. This led to the development of a pilot service program named Young Children: Priority One, focusing on early interventions for children from birth to five years of age. The program also proposed to develop partnership with those organizations sharing similar overall objectives in service. The proposal to initiate a service program for the entire Kiwanis International was received by the clubs with such enthusiasm that Kiwanis International decided to adopt Young Children: Priority One as its primary worldwide service project without time limitation. The new outlook also brought Kiwanis International into contact with other service organizations interested in children's issues, UNICEF among them. With startling speed andmomentum, Kiwanis International gained a broadening vision of service and potential influence as a major service provider,never to retreat again.

Through the pioneering efforts of ICCIDD, along with UNICEF, WHO, and others, the World Health Assembly and the World Summit for Children, both in 1990, had pledged the virtual elimination of iodine deficiency by the year 2000 (IDD Newsletter 6(2):1, 1990 and 6(4):1, 1990). In October, 1991 Kiwanis International attended two follow-up meetings with the representatives of many governments and international service organizations in Montreal, Protecting the World's Children: Keeping the Promise and Ending Hidden Hunger (IDD Newsletter 7(4):29, 1991). The agreed objectives announced at these meetings, to promote children's health and nutrition, have since been endorsed by the governments of most nations. The new contacts made at these meetings allowed Kiwanis International to develop a close relationship with UNICEF. Later by request, UNICEF prepared for Kiwanis a list of programs in which Kiwanis might be interested. After months of evaluation, discussions with Dr. Peter Greaves (then UNICEF Senior Nutrition Officer and ICCIDD Board member) and urging from the then International President of 1990-1991, Dr. WilBlechman, the Kiwanis International Board of Trustees chose to join UNICEF in the effort to eradicate iodine deficiency disorders, to prevent mental retardation and facilitate economic development in the world by year 2000. The program known as the Kiwanis International Worldwide Service Project-Iodine Deficiency Disorders (WSP-IDD) was adopted during the Kiwanis International convention held in Nice, France on June 30, 1993 (IDD Newsletter 9(3):31, 1993).

From the beginning, the agreed role for Kiwanis was primarily to raise funds to promote iodized salt as the main vehicle to eliminate IDD through the Kiwanis-UNICEF partnership. Kiwanis proposed to build large salt plants in areas affected by iodine deficiency. The estimated building cost was in the range 70,000 each. Allowing some additional funds for IDD education and to pay for the start-up cost of manufacturing iodized salt, Kiwanis International pledged to raise $75 million dollars to fund its Worldwide Service Project IDD. The original proposal had the appeal of sounding neatly quantitative and finite. But before long the Kiwanis leadership came to realize that IDD is usually most severe in those countries that lack s ocio-political stability, technical expertise and transportation. Very few of these countries can operate a large, modern salt plant or have the means to distribute the salt after iodization. It is obvious that these countries should have more flexible national IDD programs in order to better meet their different needs and take better advantage of their unique resources, as they generally have a greater need for improved salt quality than for salt production, and for iodine than for big salt plants. Legal advice has turned out to be the most cost-effective way to help these countries in organizing their salt industry and in passing legislation to mandate salt iodization. This experience has been one of learning for Kiwanis. Its lessons have helped to amend its allocation of IDD funds in more cost-effective and innovative ways towards those IDD projects with greater promise of program sustainability.

Kiwanis International also had other problems to address in the early stages of WSP-IDD. Progress was frustratingly slow after the initial launching, for several possible reasons. Before beginning an unprecedented large fund drive of $75 millions, Kiwanis International first had to strengthen the Kiwanis International Foundation, its fund raising arm. It also had to appoint a Worldwide Service Project All location Committee of senior leadership to oversee dispensing of IDD funds. Also, a new relationship had to be nurtured, new responsibilities defined, and new guidelines established to ensure the proper function of the Kiwanis-UNICEF partnership to service all participants well for years to come.

By a contractual arrangement, Kiwanis International agreed to fund all its IDD projects through UNICEF. The agreement stipulates that the government of a recipient country or geo-political entity prepares an application for assistance to initiate and implement a national IDD program. The application is first submitted to UNICEF for review of its feasibility and need. If rated favorably, the application is advanced to a second review by the Kiwanis Worldwide Service Project Allocation Committee, which has the final authority to release the approved funds to UNICEF. The Allocation Committee meets whenever several applications are received, in order to expedite the review process. The funding by the Kiwanis International Foundation of national IDD programs in 50 countries since 1995 shows the success of this partnership. It is worth noting that Kiwanis does not provide overhead or administrative costs, wh ich must becovered from the UNICEF budget. At this stage of the Kiwanis-UNICEF partnership, Kiwanis defers to UNICEF on most programmatic matters and funding decisions. However, Kiwanis may be expected to become more knowledgeable and more independent during the review process in the future.

The rapid double clutching, changing the programmatic emphasis of Kiwanis from Young Children: Priority One to World Service Project-Iodine Deficiency Disorders, caused some bewilderment and resistance among Kiwanians. Each Kiwanian pays an annual dues to Kiwanis International, which was only $18 until increased recently to $27 during the 1997 Kiwanis annual convention. It was apparent from the onset, that the large sum of money needed to fund the Worldwide Service Project-IDD must come from the members as additional voluntary pledges and donations. Kiwanis International must meet this financial obligation by moral persuasion, a prospect eased only by the fact that the Kiwanians are anything but cynical people. They believe in their slogan, "We Build." To win them over, Kiwanis International mounted an arduous IDD education program for leaders and members alike in some 8,600 Kiwanis clubs, providing them with speakers, literature, audio and videotapes on IDD and the need for iodized salt to control them. The Board and members of ICCIDD were active participants in this effort.

The Kiwanians learned and responded. They began to forge alliances with celebrities, businesses and other philanthropic organizations. They recruited Roger Moore, the movie actor, to be the Honorary Chairman of the Worldwide Service Project-IDD. The name of Morton Salt, and its logo of a young girl under an umbrella advertising the fact that Morton Salt pours easily, appeared on the collection cans for IDD donations. The Joseph P. Kennedy, Jr. Foundation and Kiwanis International jointly funded a research program for water iodization, a first award to China for an IDD project. Sponsored by UNICEF, the Kiwanians also organized field trips to visit many remote areas to learn about IDD and salt iodization. The IDD education of the membership lasted nearly three years before money ear-marked for Worldwide Service Project-IDD began to flow into the Kiwanis International Foundation. A few trickles of dollars started to grow, in crescendo, into millions of dollars in pledges and cash contributions in the past year. Current status of the project

The progress of the World Service Project-IDD can be gleaned from the magazine, Kiwanis. Again for examples, the Builder Club of the middle school in Venice, Florida had a trick-or-treat fund raiser and collected $260 for IDD (Kiwanis 81:3,10, 1996). In May, 1995, Eyjolfur Sigurdsson, then Kiwanis International President-Elect, traveled to Nepal to learn about their national IDD program. He was accompanied by Leo Wise, the 1994-95 Key Club International President, Denise Sisk, the 1994-95 Circle K International Secretary and Jeanne Moose, the 1995-96 Circle K's New York District Secretary (Kiwanis 81:3,26, 1996). The Eastern Canada and Caribbean District collected more than $1.7 million in pledges and cash donations for IDD toward its goal of raising $3 million in five years (Kiwanis 82:3,8, 1997).

In December, 1996, Kiwanis International announced the release of $110,000 to UNICEF to fund a research project on iodization of water in Xinjiang Autonomous Region, China which was started by Dr. Robert Delong, ICCIDD Board member, with the prior support of the Thrasher Research Fund. The preliminary results showed that iodization of irrigation water increased the daily urinary iodine excretion of women to levels that meet the iodization standard of China. The results also suggested improvements in infant mortality and livestock production (IDD Newsletter 12(2):25,1996). The current grant, a first Kiwanis award to China, includes a gift of $10,000 from the Joseph P. Kennedy, Jr. Foundation. The new project proposes to iodize the canals of 200 villages, which have a population of 4 million people. The estimated iodization cost per person per year is less than $0.20 (Kiwanis 82:3,11, 1997).

By August, 1997, when Kiwanis International reached the midpoint of its Worldwide Service Project-IDD, it had collected $25 million dollars in pledges and cash designated for IDD. By prior agreement, the IDD money may be released to UNICEF when it can certify certain progress or completion of a national IDD program. According to the available data of September, 1997, Kiwanis has released $7.5 million dollars of its IDD fund to UNICEF. The IDD fund has to date been allocated to 50 countries all over the world. The regional distributions are shown below:

19 African nations received $3,386,960 3D 47.1% of total;

8 Asian nations received $1,553,758 3D 21.6%;

7 Latin American nations received $1,073,680 3D 14.9%;

7 European nations received $790,663 3D 11.1%;

3 Middle East nations received $350,850 3D 4.9%.

The most recent data now show more than $10 million distributed to over 55 countries. The trend of regional allocations has remained unchanged during 1996 and 1997. Not in the above calculation are three national IDD programs which were funded later, including one sizable grant to Russia, to upgrade a salt pl ant. The expressed aim is to utilize the debilitated, existent Russian plant and the ready availability of Russian technology and expertise to provide iodized salt to Mongolia just across the border. The UNICEF-Kiwanis partnership has encouraged the national IDD programs to consider the use of regional planning and regional pooling of resources, technology and manpower, which can reduce both the start-up time and the project cost.

Bolivia is reported to have adequately iodized 90% of its table salt at this time (IDD Newsletter 12(4):33, 1996). As an increasing number of national IDD programs are implemented, the list of countries waiting for monitoring and certification can be expected to lengthen, while some countries may continue to need help for their efforts to sustain IDD control. At the moment it is not clear what role the Kiwanis-UNICEF partnership will play in the global IDD control and monitoring for the long term beyond the year 2000. It can be expected that any decision of an international IDD monitoring program will be influenced to some degree by the design of the protocol, the assignment of responsibilities and the estimated cost. Conclusions

"Kiwanis has helped to save over 2.5 million children from mental retardation," reads the UNICEF Statement on Impact of Kiwanis Fund for Prevention of Mental Retardation through Salt Iodization of arch 7, 1997. The complete text of the UNICEF report is available on Kiwanis International's World Wide Web site at http://www.kiwanis.org/wasp/unresult.htm. This judgement reflects the experience that Kiwanis International has been a loyal partner of UNICEF. The Kiwanians and the members of the K family have contributed their labor of love and their treasure to help UNICEF to continue many on-going national IDD programs and to initiate new ones in fifty countries. One may expect that before the end of WSP-IDD, the donations given by Kiwanis and the K family will have benefitted nearly all countries in need of iodine deficiency control, a contribution of startling dimension that was unimaginable even to the Kiwanians themselves five years ago. Meanwhile, from adaptations in response to the needs of Worldwide Service Project-IDD, Kiwanis International has gained a common purpose and pride and forged greater cohesion among its clubs in the K family. Its members are energized. They have become more knowledgeable of the world around them and more aware of their own immense potential to serve others. This once quaint, neighborhood club has emerged as a major international service organization. ICCIDD SALUTES KIWANIS

The accompanying article by Dr. Constance Pittman documents the strong role being played by Kiwanis International in the struggle to correct iodine deficiency worldwide. ICCIDD was founded in 1986 to achieve sustainable IDD elimination and is recognized by WHO as the expert technical and professional group in the field. We welcome the recent involvement of Kiwanis and other donors and service organizations in this effort. Kiwanians, including Dr. Pittman, Dr. Blechman, and Mr. Sigurdsson, have served on the ICCIDD Board, and ICCIDD through its members makes presentations and provides technical support to local Kiwanis clubs and their national and international governing bodies. The battle against iodine d eficiency is still not won, and the most difficult part - sustaining the achievement once at tained - lies ahead. ICCIDD continues to emphasize that contributions to salt iodization and other interventions will not have a lasting impact unless the donors also demand a monitoring plan that will ensure sustainability in each country. In general, most countries and international groups are not giving sufficient attention to monitoring, and this inadequacy, unless remedied, may jeopardize the long-range effects of current efforts. This concern does not, however, prevent recognizing the remarkable progress in iodization so far. ICCIDD congratulates the members of Kiwanis for their dedication, hard work, and sizable contribution, and looks forward to a continuing collaboration towards the common goal of sustainable elimination of IDD. 0CEFFECTS OF SALT IODIZATION IN SEVEN AFRICAN COUNTRIES

This article summarizes the report of a conference at WHO in Geneva in July 1996. It had been preceded by field visits and review of the effects of salt iodization in seven African countries, the "Multicenter Study." The objectives of the conference were to assess results from the study on levels of salt iodization and their biological impact on iodine status, including iodine-induced hyperthyroidism, to review levels of iodization for salt under varying conditions, and to make recommendations on optimal levels of salt iodization to achieve iodine sufficiency while minimizing the risk of iodine-induced hyperthyroidism. Participants from ICCIDD included Dr. M. Benmiloud, Dr. L. Braverman, Dr. H. Burgi, Dr. F. Delange, Dr. B. Hetzel, Mr. L. Locatelli-Rossi, Mr. L. Meftah, Dr. D. Lantum, Dr. T. Ntambwe-Kibambe, Dr. C. Pandav, Dr. M. Rivadeneira, Dr. C. Todd, and Dr. P. Vitti. Others present were Mr. D. Alnwick, UNICEF: Dr. D.Benbouzid, Dr. B. de Benoist, and Dr. B. Underwood, WHO; and Mr. T. Stone , PATH Canada. THE AFRICAN MULTICENTER STUDY

The objective of the study was to examine populations with previously severe iodine deficiency who have recently been exposed to salt iodization, with attention to present iodine intake and the possibility of iodine-induced hyperthyroidism. The seven countries included Cameroon, Democratic Republic of Congo, Kenya, Nigeria, Tanzania, Zaire, Zambia, and Zimbabwe. Botswana was also considered because it is a major exporter of salt in southern Africa. For each country, background information included climate, history of iodine deficiency, and details of the salt iodization program. A study team of several experts visited two or three areas in each country, particularly those with a known previous high prevalence of iodine deficiency and likely to have older adults with nodular goiter. Two or three primary schools were selected in each area, casual urine samples were collected from 50 to 100 schoolchildren, and the children were asked to bring about 20 g salt from home for analysis. Additionally, salt samples were collected from the market, and household surveys on salt consumption were conducted. All salt and urine samples were analyzed at one laboratory in Brussels.

The following paragraphs report summaries from individual countries. Some of these data were reported at the 1996 Harare conference and summarized previously in the IDD Newsletter (13(2):17-27, 1997) and are not repeated here. Data from this report have also been entered in ICCIDD's CIDDS database and are available there for review (http://avery.med.virginia.edu/~jtd/iccidd/).

Cameroon - The team studied two areas, one in East Province, at Betare-Oya and another in Northwestern Province at Oshie. In the former, the goiter prevalence was 22.7% (n 3D 353) and the urinary iodine concentration (UI) was 122 E6 g/L (n 3D 98). In Oshie, the goiter prevalence was 21.1% (394) and the UI 104 E6g/L (n 3D 153). Of 308 salt samples, iodine content was distributed as follows: 0 ppm, 7%; 7-15 ppm, 14%; 15-30 ppm, 9%; > 50 ppm, 70%. The 1991 legislation specifies 100 ppm iodine in salt. Visits to hospitals in these communities and in Yaounde revealed no increase in hyperthyroidism.

Democratic Republic of Congo (former Zaire) - Four areas were studied, Rutshuru and Uvira in the Kivu region, 2000 km east of Kinshasa, and Kalemie and Likasi in Shaba region, 2000 km southeast of Kinshasa. Three primary schools were surveyed in each region. Goiter prevalences for these four regions were respectively, 32%, 16%, 35%, and 31%, for 75-83 samples per area. Urinary iodine concentrations were: Rutshuru, 368 E6g/L; Uvira, 303 E6g/L; and Shaba, 160 E6g/L (75-150 samples per area). Frequency distribution of 355 salt samples, by iodine content were: 0 ppm, 18%; 25-50 ppm, 11%; 50-75 ppm, 63%; > 75 ppm, 9%. Salt samples from all but one community had an acceptable iodine content. Despite a previous report of iodine- induced hyperthyroidism in Kivu, the survey team found no further evidence for hyperthyroidism in that region.

Kenya - The study took place in Kericho (200 km northwest of Nairobi), Kiambu (50 km north of Nairobi), and in Nairobi itself. The goiter prevalence ranged from 9.5- 14%. The UI (approximately 110 samples each) in the three regions were: Kericho, 125 E6g/L; Kiambu, 378 E6g/L; and Nairobi, 580 E6g/L. Iodine content of the salt in these three at the household level were, respectively, 63 F1 35 ppm, 47 F1 33 ppm, and 68 F1 31 ppm. Hospital visits revealed no increase in hyperthyroidism.

Nigeria - The study took place in Igara (Edo State), and in Uzo-Uwani (Enugu State). The goiter prevalences in these two were respectively, 26 and 40%, and UI's were 260 E6g/L and 369 E6g/L. Frequency distributions of iodine content of salt, combining household, retail, and production data, were: 0 ppm, 7%; 7-15 ppm, 6%; 15-30 ppm, 23%; > 50 ppm, 64%. The reports notes "a questionable increase in incidence of hyperthyroidism among patients attending the Department of Surgery in the hospital of Enugu City."

Tanzania - Study sites were Iringa and Mbeya. Goiter prevalences were, respectively, 61% and 31%, and UI's were, respectively, 161 E6g/L and 160 E6g/L. Frequency of iodine in salt, by test kits, for Iringa, were: 0 ppm, 23%; 25 ppm, 28%; and 50-75 ppm, 48%; and for Mbeya: 0 ppm, 4%; 25 ppm, 9%, and 50-75 ppm, 87%. By titration of samples collected from households, 49% had less than 18 ppm iodine, 36% had 18-36 ppm, and 19% had from 37 to 74 ppm. No cases of iodine-induced hyperthyroidism were reported in the two study regions. A hyperthyroidism rate of 13- 30% is suggested from laboratory tests in hospitals in Dar-Es-Salaam, a rate frequency unchanged from that before universal salt iodization was implemented.

Zambia - The study took place in Choma and Livingstone in Southern Province and in Katete in Eastern Province. The team found the goiter prevalence to be from 4-16% in Southern Province, and 4% in Eastern Province. Urinary samples showed iodine concentrations, respectively, of 184-264 E6g/L and 175 E6g/L. Test kits showed that 94% of salt samples collected from households had more than 25 ppm iodine, and 100% of those collected at retail level were iodized. The number of cases of hyperthyroidism did not change between 1985 and 1995, indicating no increase associated with salt iodization.

Zimbabwe - The country has already been reviewed in the IDD Newsletter (13(2):23, 1997 and 12(3):40, 1996), and comments on its iodine-induced hyperthyroidism are given there and below.

Botswana - A review of salt iodization at Sua Pan was made, because its Botswana Soda Ash Plant is a major salt supplier for Botswana, Malawi, South Africa, Congo, and Zambia. Titration of 22 samples at the production site showed values ranging from 0-200 ppm, with a mean of 90 ppm. Testing by kit on 22 other samples gave values between 25 and 75 ppm, and two samples had no iodine.

Conclusions of the multicenter study - All areas investigated showed median urinary iodine concentrations above 100 E6g/L and dramatic decreases in goiter prevalence, demonstrating current iodine sufficiency. All the areas investigated were previously iodine deficient, so salt iodization has been highly successful in correcting iodine deficiency. However, 5 out of the 7 countries had some areas with highly elevated median urinary iodine levels, from 300-580 E6g/L. These amounts indicate a potential risk of iodine-induced hyperthyroidism, particularly in areas where previously severe iodine deficiency was rapidly reversed, such as in Zambia and Zimbabwe. Despite this risk, the iodine-induced hyperthyroidism noted in Zimbabwe was not observed elsewhere. In countries such as Kenya, iodized salt has been used for more than 20 years, and this fact may partly explain the lack of observed hyperthyroidism. Nonetheless, without more screening, the possibility of biochemical iodine-induced hyperthyroidism without clinical manifestations remains. When iodine overload was found, it was clearly the result of an excessive level of iodine in the salt, in turn most likely due to excess iodine added at production and also to a lower loss between producer and consumer than was predicted. STABILITY OF IODINE IN IODIZED SALT

Results were presented from a study of sea salt from Ghana, Indonesia, Philippines, Senegal, and Tanzania, lake salt from Bolivia, and rock salt from an additional unspecified country. Samples of uniodized salt were taken during production from local producers, and shipped to Toronto in airtight containers. Two kg of each sample were fortified with potassium iodate to achieve 50 ppm as iodine. Five hundred gram samples of each were packaged in either low density polyethylene bags, open plastic containers, or woven high density polypropylene bags. Samples were then stored for six months at either 100% or 60% humidity, in an oven of controlled temperature (40F8 C) with air saturated by exposure to a water tray. Iodine content was measured by neutron activation analysis after 0, 3, and 6 months of storage.

The samples varied greatly in size (15-100 mm) and homogeneity of salt particles, as well as in color (bright, white, dark, gray, rusty, and brown). Over the six month period, salt samples lost from 0-100% of the original content of iodine. At six months, from 0-20% iodine was lost at 60% humidity and 98% was lost at 100% humidity. The best results were obtained with low density polyethylene bags. The open plastic container permitted moisture to remain in the sample and contributed to iodine instability. The woven high density polypropylene bags behaved similarly to open containers, and retained significantly less iodine generally. Impurities and the degree of processing markedly affected salt stability. The samples from country A were well controlled in color and size but had a 95% loss of iodine in one month. At medium humidity, the salt from Ghana lost very little iodine, but at high humidity, the iodine content remained satisfactory for three months but then dropped sharply afterwards. Samples from Canada, India, Philippines, and Senegal lost less than 15% iodine even at 100% relative humidity when in low density polyethylene bags. The Canadian salt, which was of high purity with little moisture, was quite stable.

These results show that moisture is critically important in the stability of iodine in salt, particularly at high temperature. Stability is improved by increased refinement of salt. Well-sealed bags of low density polyethylene keep losses below 10% for at least six months. Woven high density polypropylene when used should be fitted with a liner of low density polyethylene or one that is laminated.

These results so far show that packaging is more important for iodized salt stability than is salt quality or environmental conditions. The 10-20% losses were smaller than the expected 50%, a conclusion similar to that from field data in Guatemala and Ecuador. Improvement of salt quality is still important because artisanal salt may be of much poorer quality than some of the samples tested in this study. Salt should be properly washed and dried and large open containers should be avoided. IODINE-INDUCED HYPERTHYROIDISM IN ZIMBABWE

This issue has been discussed elsewhere in the IDD Newsletter (13(2):23, 1997 and 12(3):40, 1996). Iodine-induced hyperthyroidism occurred in Zimbabwe and was due to a rapid improvement in previously severe iodine deficiency with the implementation of salt iodization. Iodine intake is now more than sufficient and this may contribute to an increase in thyrotoxicosis. The iodine content of the salt should be reduced, and it requires strict monitoring. RECOMMENDATIONS

The group confirmed the importance of universal salt iodization as the recommended intervention for preventing and correcting iodine deficiency. It noted the marked progress made towards iodine sufficiency with salt iodization. At the same time it found that some people in some countries now have iodine intakes that are unnecessarily high and that may occasionally be associated with iodine-induced hyperthyroidism.

The detailed recommendations have been published (IDD Newsletter 13(1):10, 1997. The key points are as follows:

1. The current recommended daily iodine intakes are: 50 E6g for infants (first 12 months of age); 90 E6g for children (2-6 years of age); 120 E6g for schoolchildren (7-12 years of age); 150 E6g for adults (beyond 12 years of age); and 200 E6g for pregnant and lactating women. 0C

2. Iodine-induced hyperthyroidism should be recognized as an iodine deficiency disorder that may occur, primarily in older people, when previously iodine deficient populations increase their iodine intake, even when the total amount is within the usually accepted range.

3. To provide 150 E6g/day of iodine in iodized salt, the iodine concentration in salt at the point of production should generally be within the range of 20-40 mg iodine depending on salt quality, packaging, and consumption habits.

4. In areas where severe iodine deficiency has been present for a long time, the iodine levels in salt should be set at the lowest level that will prevent all manifestations of iodine deficiency while minimizing the risk of iodine-induced hyperthyroidism.

5. It is essential to have an effective national program that monitors both iodine levels in salt and iodine nutrition in people. 0CTOWARDS IMPROVED SALT IODIZATION IN ENUGU STATE. E. C. Okeke, D. O. Nnanyelugo, and C. Awa, Department of Home Science and Nutrition, University of Nigeria, Nsukka, Nigeria.

Nigeria has a long history of significant iodine deficiency. The current decade has shown considerable progress towards its elimination with iodized salt (1,2). This article examines how the system is working in Enugu, where we studied marketing channels, transport and storage methods for salt, the level of knowledge and awareness of the benefits of iodized salt, and the level of iodine in salt samples consumed and sold in the state. METHODS

The iodine-deficient state of Enugu is situated on much of the highlands of the Awgu, Udi, and Nsukka hills and the rolling lowlands of the Eboyi River Basin to the east and the Oji River Basin to the west. The mean temperature in the hottest periods of February and April is about 87F8 F. Rain is seasonal, most of it falling between July and September. Using rapid rural appraisals technique, a team of human nutritionists and dieticians undertook the study. Two questionnaires were developed and administered through purposive sampling procedure to salt traders and people responsible for meal preparation in households in three local government areas, Enugu, Nsukka, and Awgu. The study group consisted of a total of 200 salt traders, who were also heads of household, and included 3 distributors, 48 wholesalers, 114 retailers, and 35 hawkers. They were interviewed using a pretested questionnaire. We also asked 100 schoolchildren, aged 7-13 years to bring in samples of salt consumed in their homes for testing. In addition, 66 g of iodized salt was assigned to each household sampled to determine the level of usage by the people. We selected households for interview from the listing used during a previous Bench Mark survey on food fortification in Nigeria. RESULTS Background Information

Ninety-five percent of the respondents were traders while the others were part- time farmers (4%) or civil servants (1%). Their monthly income varied from 1000 Naira (US $12.5) to above N10,000 (US $125.00) per month. Seventeen percent had no formal education, 43% had some, and 40% had secondary education. Most traders (44%) purchased salt weekly, chiefly those who purchased 10-15 bags of 25kg at a time. The reasons given for procurement were: low demand for salt (55%), finish of consignment (42%); limited working capital (37%), and no credit facility (1%). Forty-two percent of the traders, including distributors, transported salt in closed trucks, the remainder moved in open trucks.

The quantity of salt bought at a time depended on the purchaser. Distributors bought between 1,000-6,000 or more bags of 25 kg at once, depending on the time of new allocations. Wholesalers bought 100-500 bags and retailers bought 10-50 bags of both iodized and noniodized salt at a time. Sources for salt (with quantities in stock on day of survey) were: Port Harcourt and Enugu for distributors (372 bags), the same plus Onitsha for retailers (200 bags) and Enugu, Nsukka, and Orba for retailers (7 bags), and hawkers (3 bags). The amount of iodized salt sold in any one day by retailers and hawkers ranged from 1-8 bags of 25 kg, while noniodized salt ranged from 0.5-5 bags. Ninety-eight percent of the respondents had a maximum storage period of one month, of which 52% was stored for one or two weeks and only 1% stored for above one month. Knowledge and Awareness of Benefits of Iodized Salt

Iodized salt was preferred by 100% of distributors, 86% of wholesalers, 73% of retailers, and 91% of hawkers. About 6% of retailers and hawkers preferred buying rock salt. All three of the distributors knew the benefits of iodized salt, compared with poorer knowledge among wholesalers (26%), retailers (15%), and hawkers (9%). The usage pattern among these traders was not related to knowledge of the benefits of iodized salt. The majority of all dealers (above 85%) used iodized salt, but only 25% knew its benefits. The percentage that knew about the iodized salt program was 94%, while 6% knew about noniodized and rock salt. Eighty percent preferred iodized salt to other salt types. Twelve percent preferred noniodized salt while 8% preferred rock salt. Salt Utilization in the State

Salt consumption patters were investigated in 20 households, 6 with an income level of N1000-5000, 10 with N5000-10,000, and 4 above N10,000. One hundred percent of the respondents used salt in cooking, 64% for food preservation, 26% for washing fruits and vegetables, 20% for washing clothes and 3% for preparing oral rehydration therapy. The use of salt in the three income levels and different educational backgrounds did not vary significantly. The number of days taken by a household to consume the 66 grams of salt ranged from 1.5 in the above N10,000 income level to 2.5 in the middle income range. From this we estimate consumption of 5-8 grams per person per day, in line with the report by Egbuta and Hettiaratchy (1), who calculated consumption of 5-7 g per person per day.

Of the salt samples brought in by children from home, 58% contained 50 ppm iodine, 33% contained 7-50 ppm, and 9% had no iodine. When salt sold in the local market was tested, it was found that the Dicon and John Holt brands of salt contained 50 ppm iodine, while the rest had varying levels. DISCUSSION

Ninety-five percent of salt marketing in Enugu State is by traders. The remainder is sold by part-time marketers, including students and farmers. The distributors are businessmen who purchase salt in trailer loads at a time for distribution to wholesalers, who in turn sell to retailers and hawkers. The distributors earned above N10,000 ($125.00) per month and bought just the quantity allocated from Port Harcourt. This town is the source of most state salt dealers. Other dealers earned less than N10,000 ($125.00) per month. Very few salt marketers (2%) sold only salt. Other foods were sold along side, e.g., the ingredients used in baking.

Salt marketing in Enugu State goes through a number of channels from the distributors to the hawkers before it reaches the consumer. This important observation has implications for the handling of iodized salt. A new marketing channel may have to be established to reduce deterioration of the product due to the number of times it changed hands.

The main reasons for the delayed salt procurement from weekly to fortnightly to monthly included limited working capital, limited and inelastic demand for salt, lack of credit facilities, and seasonal price fluctuations. The price of a 25 kg bag of salt varied greatly, ranging from N350 to N500 and was independent of type. The retailers and hawkers sold smaller packages, which the consumers preferred. Almost all hawkers interviewed packaged salt before sale, using either polypropylene or polyethylene bags. These materials were readily available and have gained customer acceptance by their constant use. It was observed that half of the traders interviewed purchased their salt from retail outlets. Consequently, packaging at the factory should be in units required at retail level, and we recommend 500 g bags instead of the current 25 kg bags.

The educational background of the salt traders affected their knowledge of the benefits of iodized salt. Those with higher education, secondary school and above, (48%) knew about iodized salt, while the rest (52%), who had elementary (35%) and no formal education (12%), did not. Different brands of salt, some iodized and some not, were sold in the markets. Effort should be made to educate consumers on the importance of iodized salt and the adverse consequences of buying and consuming noniodized salt. This need calls for developing a public education campaign to increase awareness of iodized salt. This strategy is an important consideration in achieving effective iodization in the country.

There appeared to be no formal association embracing all the salt traders in Enugu State, but 26% of them were members of other trade associations. It might be necessary to form a nationwide salt traders association in the urban areas by using identified major operators in the trade. Such an association can assist with the maintenance of iodized salt quality. There is also need for closer monitoring and systematic evaluation of procurement, marketing, distribution, and consumption of iodized salts. We also recommend further studies to establish the rate of iodine loss between possible iodization points and various other locations, bearing in mind established methods of feasible distribution and handling (3). SUMMARY

A team of human nutritionists and dieticians has used a Rapid Appraisal Technique to evaluate the impact of the salt iodization in Enugu State. Results in three markets revealed that most traders and consumers (94%) have increased knowledge of the iodized salt program of Nigeria. Fifty-eight percent of families in Nsukka used salts containing 50 ppm of iodine, 33% used salt between 7 and 50 ppm iodine and 9% used noniodized salts. About 23% traders have little knowledge about iodized salt, and careless handling occurs during transportation, storage and sale of salts. Most consumers bought salt according to brand name and cost, although some salt did not contain iodine. There is need for closer monitoring, increased consumer awareness, systematic evaluation of procurement, marketing, distribution and consumption, and follow-up of the effects on IDD. REFERENCES

1. Egbuta J, Hettiaratchy N 1996 Nigeria advances towards IDD elimination. IDD Newsletter 12(2):27-28.

2. Asuquo MN 1995 How salt companies can take the lead in iodization: an example from Nigeria. IDD Newsletter 11(2):31.

3. Kwadzo GTM 1995 Salt production and marketing in Ghana. In: Asibey Berko E, Orraca-Tetteh R (eds). Proceedings of the National Workshop in Iodine Deficiency Disorders in Ghana, p 70. 0CNORMAL THYROID VOLUME OF YOUNG ADULTS IN TURKEY. G. Erdogan, S. G81ll81, M. Erdogan, H. Sav, Y. Yavuz, N. Baskal, Departments of Endocrinology and Metabolic Diseases and Biostatistics, Ankara University Medical School, Ankara, Turkey.

To determine the existence and prevalence of goiter in a given geographical area is very important. The clinical diagnosis of goiter is usually made by inspection and palpation, but the neck anatomy of the subject and the experience of the examiner can influence its accuracy. Estimation of thyroid size by inspection and palpation may be only poorly related to the real thyroid volume, and thyroid palpation is often of limited value for epidemiological studies. Although the sensitivity of palpation in adults is acceptable, the specificity is low. In contrast, many investigators have shown ultrasonographic scanning to be accurate and precise in the estimation of thyroid size (1-8).

Differences in daily iodine intake, genetic background and environmental factors can contribute to variation in mean thyroid volume among different areas. Therefore, establishment of a reference range for the normal thyroid gland is essential both for the examination of patients referred for evaluation of the thyroid gland and for the determination of goiter prevalence in a given area. In Turkey epidemiological studies on endemic goiter was first started by Atay and Onat (9,10). Neck palpation was used for all recent studies (11-13) except one from the Kayseri region in which ultrasonography was used to determine thyroid volume in children (13).

In the present study, we attempted to establish normal values for the thyroid gland volume of young adults by performing thyroid sonography in 380 healthy medical school studies. We excluded subjects with clinical goiter and/or history of thyroid disease and another 28 subjects because the ultrasound showed either nodules or heterogeneous echo patterns. The final group for statistical evaluation consisted of 352 individuals (204 females, 148 males), aged 18-24 years, mean 20.5 years. Thyroid volumes were estimated by real-time B-mode high resolution ultrasonography with a 7.5 MHz transducer, and calculated by multiplying the long axis diameter (A), short axis diameter (B) and thickness (C) by 0.52 for each lobe, then adding the volumes of the two lobes.

The mean thyroid volume as determined by ultrasonography was 12.1 F1 3.5 ml (mean F1 SD), 11.1 F1 3.2 ml for females, 13.7 F1 3.4 ml for males (p < 0.05). The upper limit of normal (97th percentile) was 22.4 ml for males and 20.2 ml for women.

Sonographically-determined volumes are increasingly used for comparative studies of goiter incidence. Palpation is particularly unsuitable for differentiating between normal and small goiters. While volumetry of the thyroid gland appears to be simple, the reported range of normal values was enormously wide and varied from country to country with differences of more than 100% (1,3-6,8, Table 1). Daily iodineintake is the most important of several factors known to affect thyroid growth in both children and adults, so establishing volumetric standards for a population living in a given geographic area is essential to prevent overestimation of goiter prevalence.

With the results of the present study, we suggest that thyroids greater than 20.2 ml for women and 22.4 ml for men should be considered goiters. We have established reference values for normal thyroid volume that provide a reference point for mapping of goiter prevalence and iodine deficiency in adults in Turkey. REFERENCES

1. Gutjahr G, Storkel S, Kraus W, Albert G, Thelen M 1984 Sonography of the thyroid gland: volume determination and morphologic correlation of echo and tissue structure. ROFO Fortschr Geb Rontgenstr Nuklearmed 141:297-303 (German).

2. Gutekunst R, Scriba PC 1986 Application of sonography in epidemiological studies. IDD Newsletter 2(1):4.

3. Berghout A, Wiersinga WM, Smits NJ, Touber JL 1988 The value of thyroid volume measured by ultrasonography in the diagnosis of goiter. Clin Endocrinol 28:409-414.

4. Heged81s L, Perrild H, Poulsen LR, Andersen JR, Holm B, Schnohr P, Jensen G, Hansen JM 1983 The determination of thyroid volume by ultrasound and its relationship to body weight, age, and sex in normal subjects. J Clin Endocrinol Metab 56:260-263.

5. Gutekunst R, Smolarek H, Hasenpusch U, Stubbe P, Friedrich HJ, Wood WG, Scriba PC 1986 Goiter epidemiology: thyroid volume, iodine excretion, thyroglobulin and thyrotropin in Germany and Sweden. Acta Endocrinol 112 :494-501.

6. Olbricht T, Schmitka T, Mellinghoff U, Benker G, Reinwein D 1983 Sonographic determination of thyroid volume in subjects with healthy thyroids. Deutsche Medizinische Wochen 108:1355-1358.

7. Berghout A, Wiersinga WM, Smits NJ, Touber JL 1987 Determinants of thyroid volume as measured by ultrasonography in healthy adults in a non-iodine deficient area. Clin Endocrinol 26:273-280.

8. Oberhofer R, Ober A, Oberkofler F, Amor H 1989 Thyroid gland volumes of healthy adults in an area with endemic goiter. Acta Medica Austriaca 16:38-41.

9. Atay K 1935 Ulusal Cerrahi Kurultayina Rapor. Kader Basimevi, Istanbul (3rd National Congress of Surgery, Istanbul, 1935).

10. Onat AR 1948 X Milli T81rk Tip Kongresi Ankara, Kader Basimevi Istanbul (10th National Congress of Medicine, Ankara, 1948).

11. Kologlu S, Kologlu LB 1977 T81rkiyede endemik guvatrin etyopatogenezi. Istanbul Tip Kurultayi Tutanaklari Istanbul, 63.

12. Urgancioglu I, Hatemi H, T81rkiyede endemik guvatr. Cerrahpasa Tip Fak81ltesi, N81kleer Tip Bilim Dali Yayini, 14.

13. Kurtoglu S, Covut IE, Kendirci M, 9Az81m K, Durak AC, Kiris A 1995 Normal thyroid volume of children in Turkey: pilot study in Kayseri Province. IDD Newsletter 11(3):41-42. Table 1. Mean normal thyroid volume values reported from different countries.

Mean Thyroid Volume (ml) Country

n

Women

Men

Total Germany (5)

1397

16.5

26.9

21.4 Germany (1)

100

17.8

22.1

19.8 Germany (6)

542

13.5

16.7

---- Austria (8)

500

12.09

14.94

13.35 Sweden (5)

303

7.7

11.1

10.1 Denmark (4)

271

17.5

19.6

18.6 Netherlands (3)

50

8.7

12.7

10.7 Present data

352

11.1

13.7

12.1 EMBRYOTOXICITY STUDIES WITH LIPIODOL ULTRA-FLUIDE IN THE RAT AND RABBIT. Paul C. Barrow and Jean-Marc Idee, Chrysalis, Les Oncins BP 118, 69593 L'Arbresle Cedex, France and Laboratoire Guerbet, B.P. 50400, 95943 Roissy Charles-De-Gaulle Cedex, France

Lipiodol Ultra Fluide, a very low viscosity mixture of ethyl esters of fatty acids obtained from poppy seed oil, has been proposed for the prevention of iodine deficiency disorders (IDD) in areas of the world where inclusion of iodized salt in the diet is not feasible. The available studies in humans do not appear to indicate any appreciable risk associated with the administration of Lipiodol or other iodized oils during pregnancy (1), but little or no relevant animal data are available in the literature. It was decided, therefore, to test Lipiodol Ultra Fluide for embryotoxic effects in laboratory animals according to the current international guidelines for medicinal products (2).

The anticipated human dose is 570 mg of iodine as a single annual treatment. The biodistribution and biodisposability of iodine following treatment with Lipiodol Ultra Fluide has been investigated in rats and farm animals (3). Rapid absorption of Lipiodol was demonstrated following oral administration, which resulted in a biodisposability five times greater than by intramuscular injection. No massive or prolonged uptake of iodine by the thyroid gland was observed, however, and the mechanism of long-term prevention of IDD remains poorly understood. Studies with radiolabelled Lipiodol given orally to pregnant rabbits demonstrated a transplacental passage of iodine with the degree of uptake by the fetus increasing with gestational age (Laboratoires Guerbet, unpublished data).

It could be argued that the ICH regulatory guidelines are unnecessarily stringent for a therapeutic agent that will be administered once, at most, during each pregnancy. It was considered necessary, however, to expose pregnant animals at all stages of organogenesis, since the treatment program will involve treating pregnant women once per year regardless of pregnancy. This constraint led to experimental complications in the rabbit, which did not tolerate repeated administration of the test article, and the study design had to be adapted accordingly.

Peanut oil, rather than non-iodized poppy seed oil, was used as the control vehicle in these experiments to allow a comparison of any potential toxic effects of the oil component of Lipiodol Ultra Fluide in addition to any effects of the iodine component. Methods and Results

Experiments were performed in the rat and rabbit, which are generally considered to be the two species of choice for the safety assessment ofembryotoxicity (2). Rat

Three groups of 25 Sprague Dawley rats were given undiluted Lipiodol Ultra Fluide (Laboratoires Guerbet, Roissy, France) by daily gavage from days 6 to 17 of gestation inclusive, at a dose volume of 0.104, 0.229 or 0.521 ml/kg/day. The corresponding dose levels of iodine were 50, 110, and 250 mg/kg/day. A control group was similarly treated with 0.521 ml/kg/day of peanut oil. Clinical condition, body weights and food consumption were monitored throughout gestation. A caesarean examination was performed on day 20 of gestation and litter parameters we rerecorded. The maternal organs were also examined for any treatment-related changes. All fetuses were weighed. Approximately half of the fetuses from each dam were given an external examination at necropsy and then preserved whole in HarrissonFEs fixative prior to soft tissue examination using a modification of the Barrow- Taylor method (4). The remaining fetuses were given an external and internal necropsy examination under low power magnification prior to staining for skeletal examination by a modification of the Wilson technique (5).

All rats survived to the end of the study. There were no adverse changes in clinical condition. Body weight gain in the high dose group was slightly reduced during the treatment period, statistical significance was attained for the first four days. The intermediate and low dose groups were not affected. There were no significant differences in maternal food consumption. One dam given the lowest dose level underwent total litter loss early in gestation, but this isolated occurrence did not suggest an effect of treatment. The caesarean data and fetal weight did not show any treatment-related influences. No significant lesions were found at necropsy examination of the dams and there were no malformed fetuses in any group. Fetal soft tissue findings were limited to renal pelvic dilatation and associated incidences of kinked and/or dilated ureters. The overall incidence of fetuses with one or more of these variations was slightly, but not statistically significantly, increased in the high dose group. The incidences of fetuses with skeletal abnormalities did not show any treatment-related trends. Rabbit

Initial experiments revealed a marked intolerance of the female rabbit to Lipiodol Ultra Fluide at daily dose level equivalent to 12.5 mg of iodine per day given on 13 consecutive days (unpublished data). The maternal reactions observed suggested a disturbance of gastrointestinal function, possibly due to a perturbation of the enteric flora. This type of influence is a common consequence of the oral administration of zenobiotics in the rabbit (2). The very low dose volumes used and the lack of effect with a comparable volume of peanut oil would suggested that the iodine component of Lipiodol Ultra Fluide was responsible for the observed maternal toxicity. Intermittent dosing, every three days, was well tolerated by the rabbits and allowed the assessment of all stages of organogenesis while minimizing the number of groups of animals required for the experiment.

Lipiodol Ultra Fluide was administered undiluted by gavage to groups of 22 NZW rabbits once every three days at a volume of 0.026 ml/kg. The treatment days were staggered to ensure treatment of one group on each day during the period of organogenesis (i.e., groups 2 to 4). The control group (group 1) was given a daily gavage of 0.26 ml/kg/day of peanut oil from day 6 to 18 of gestation. A caesarean examination was performed on day 29 of gestation and fetuses were weighed, killed by intraperitoneal injection of sodium pentobarbitone and then examined for external and visceral abnormalities. The heads of approximately half of the fetuses were fixed in Harrisson's fixative and later examined for internally abnormalities by serial sectioning. The thoracic and abdominal cavities of all fetuses were dissected and examined. The viscera were then removed prior to processing for skeletalexamination of the body and head as appropriate.

There was no mortality. Clinical condition, maternal food consumption and body weight gain were not adversely influenced by treatment. At least 20 out of 22 rabbits were pregnant in all groups and all pregnant females had viable fetuses at term. Litter data and fetal weight were not obviously influenced by treatment. No abnormalities were found at necropsy examination of the dams. External, internal and skeletal examination of the fetuses revealed a total of five malformed fetuses (from four litters) in the control group, five malformed fetuses (from five litters) in group 2, six (from five litters) in group 3 and two from a single litter in group 4. The overall combined incidences of malformed fetuses in the three treated groups was similar to that in the control group (i.e., 2.5% of fetuses from 18% of treated litters compared with 2.6% of fetuses from 18% of control litters). Conclusion

In conclusion, the experiments described herein did not reveal any suggestion of an embryotoxic potential of Lipiodol Ultra Fluide when given to pregnant animals at high doses with respect to the proposed human dose. The results provide some reassurance concerning the safety of the administration of iodized oils to pregnant women as part of an IDD prevention program. The relevance of our experiments, however, should not be overestimated, particularly in view of the marked differences in chemical composition among different iodized oil preparations. It could be hazardous, for instance, to extrapolate the results to cover the use of other iodized oils, or even of other Lipiodol formulations, which have not been manufactured to the same exact composition and iodine content as the Lipiodol Ultra Fluide used in our studies. REFERENCES

1. Delange F 1996 Administration of iodized oil during pregnancy: a summary of the published evidence. Bulletin W.H.O., 74(1):101-108.

2. ICH 1994 Step 4 Tripartite Harmonised Guidelines. Detection of toxicity to reproduction for medicinal products. In: D'Arcy PF, Harron DWG (eds). Proceedings of The Second International Conference on Harmonisation Orlando 1993. Queen's University, Belfast, pp 557-578.

3. Chambon IC, Chastin I 1993 Animal studies of iodized oils: iodine disposition and physiological effects. In: Delange F, Dunn JT, Glinoer D (eds). Iodine Deficiency in Europe, Plenum Press, New York, pp. 159-165.

4. Barrow MV, Taylor WJ 1967 A rapid method for detecting malformations of rat foetuses. J Morph 127:291-306.

5. Barrow P 1990 Technical procedures in reproduction toxicology. Laboratory Animals handbooks 11. Royal Society of Medicine, London. ALGEPA AWARD 1996

The prize for 1996 was awarded jointly to Professor Riccardo Vigneri of Catania, Italy and Professor Daniel Lantum of Yaounde, Cameroon. This biannual prize is given by the nonprofit organization ALGEPA (Association for the Fight Against Endemic Goiter and Associated Pathologies) to promote research and preventive work on endemic goiter and iodine deficiency disorders. The awards were presented in Paris on December 9, 1996 by Dr. Michel Guerbet, President of the Association. The winners were selected from 24 candidates, including senior thyroidologists and experts in IDD from all over the world. A jury of 13 members, chaired by F. Delange, Executive Director of ICCIDD, made the selection.

Dr. Vigneri is currently Professor and Chairman of Endocrinology and Metabolism at the University Medical School at Catania, Sicily, and Head of the Division of Endocrinology at the Ospedale Garibaldi. He graduated in medicine, did postgraduate work in metabolism, nuclear medicine, and endocrinology. He started the university outpatient thyroid clinic in 1967. In the early 1970's he conducted field studies on endemic goiter in Sicily, and followed these with actions towards its prevention by providing information to public health authorities, health professionals, and the public. Since 1977, he has been a member of the IDD Committee in Italy. He has contributed to the implementation of a law on iodized salt and carried out important studies on water iodization, receiving the Italian Endocrine Society Award in 1988 for this work. He is presently coordinator for the region of Sicily of the Joint Project National Committee for Research, Italy and the European Community for goiter eradication in Southern Italy. He has created a prestigious school of endocrinology and nutrition in Catania, developed major international collaborations, and published 24 papers on IDD in major international and national journals.

Professor Lantum was born in Kumbo, Cameroon, studied at the University of Ibadan in Nigeria, graduated in medicine in London, England, and did post graduate work in medicine and hygiene and public health at the University of Liverpool and Tulane University. He has had vast field experience in IDD in Cameroon and other African countries. In Cameroon he has been an active contributor to the implementation of the national IDD program as a member of the IDD Committee, and provided a continuous relationship between the academic world, the Ministries of Health, Industry, and Commerce, the iodized salt industry, the local health authorities, and local communities. He played a major role in implementation of an ordinance by the Ministry of Health on mandatory salt iodization in 1991. He has been a member of ICCIDD since early in its history, and is presently a Board member and Subregional Coordinator for Central Africa. In that role he has participated in numerous field visits and consultations in other African countries, particularly Rwanda, the Central African Republic, Madagascar, and Nigeria. He is author of a number of publications on IDD, education, culture, and religion, as well as oral communications in Africa and abroad. Other awards include Grand Officer de l'Ordre National de la Valeur du Cameroon; Distinguished Afgrad Alumni Award designated by African American Institute; and the Albert Einstein International Academy Foundation Medal for Peace. THE IODINE DEFICIENCY AWARENESS CAMPAIGN IN KASHMIR. A. H. Zargar, A. I. Wani, B. A. Laway, S. R. Masoodi, and M. I. Bashir, Department of Endocrinology, SK Institute of Medical Sciences, Kashmir, India.

Awareness of iodine deficiency disorders (IDD) has increased globally over the last several decades. The 1991 Montreal conference "Ending Hidden Hunger: A Policy conference on Micronutrient Malnutrition" inspired many countries to initiate or reinforce IDD control programs as a national policy. ICCIDD gave a great impetus to quantitation, awareness, and eradication of IDD.

In an extensive goiter survey in schoolchildren in Kashmir valley carried out from 1993 to 1995, we found that 45.2% of children have thyroid enlargement and the urinary iodine excretion was low (1). Recently we found a relatively increased incidence of follicular carcinoma compared to papillary carcinoma among patients with thyroid cancer in Kashmir valley (2), and attributed this to iodine deficiency as suggested by earlier studies (3).

We also assessed the pattern of salt consumption and awareness about iodine deficiency disorders in different socio-economic groups in the valley, and to our dismay, found that awareness about IDD in the general population is very low and that most of the people continue to consume noniodized salt (4). Following that, Dr. Sheila Vir, UNICEF Project Officer (nutrition) contacted us with concern about the non- availability of iodized salt in some parts of the valley, and also wrote the Salt Commissioner of the Government of India. We requested UNICEF and the Salt Commissioner to initiate action because the sale of noniodized salt is banned in Jammu and Kashmir (5). Kashmir valley, all the districts of which are documented to be endemic for iodine deficiency, still does not have an "IDD cell," in contrast to most other states in India (6).

Here we report some of the initial measures we have taken to increase IDD awareness locally.

1. A circular was sent to the different schools of the valley briefly summarizing the goiter survey findings. The role of iodine deficiency in various disorders and its eradication by the consumption of iodized salt was emphasized.

2. Educational articles about IDD were written in the local vernacular newspapers, again emphasizing the role of iodized salt in eradicating IDD.

3. A statement was issued through the local television on the subject and the television authorities were requested to telecast the message on multiple occasions.

4. An editorial entitled "Eradication of iodine deficiency from Kashmir valley by the year 2000 AD - Is there any hope to achieve this goal?" was written in a locally published medical journal with a view to increase the awareness about IDD among the medical professionals and solicit their help to eradicate this problem (7 ).

Through this article, we request UNICEF and the Salt Commissioner to take due cognizance of this problem in Kashmir valley and to encourage the government of Jammu and Kashmir to create an "IDD cell" for effective monitoring of iodine deficiency elimination programs on a long term basis. We close with the words of James P. Grant, Executive Director UNICEF, Kathmandu 1986: "Iodine deficiency is a good example of a major nutritional disorder for which the techniques of treatment, control, and prevention are easily available and affordable. All it takes is a strong will, wider awareness, and cooperation among those who hold a key to the solution of the problem." References

1. Zargar AH, Shah JA, Mir MM, Laway BA, Masoodi SR, Shah NA 1995 Prevalence of goiter in schoolchildren in Kashmir valley. Am J Clin Nutr 62:1020- 1021.

2. Zargar AH, Laway BA, Masoodi SR, Wani NA, Peer GQ, Shah A, Jan GM 1997 Clinico-histopathological spectrum of thyroid malignancy from an iodine deficient are (Kashmir valley). Ind J Surg 197-204.

3. McConahey WM, Taylor WF, Gorman CA, Woolner LB 1981 Retrospective study of 820 patients treated for papillary carcinoma of the thyroid at the Mayo Clinic between 1946 and 1971. In: Advances in Thyroid Neoplasia, 245-262.

4. Zargar AH, Sofi FA, Masoodi SR, Laway BA, Shah NA, Wani AI, Masoodi MI 1996 Pattern of salt consumption and awareness about iodine deficiency disorders in Kashmir valley. IDD Newsletter 12(3):46-48.

5. Ministry of Industry. Banning sale of edible noniodized salt - an urgent measure. Produced by the Salt Department, Ministry of Industry, 1995.

6. GOI-UNICEF 1993-95 IDD project: Guidelines for implementation at State level.

7. Zargar AH, Wani AI, Laway BA, Masoodi SR 1997 Eradication of iodine deficiency from Kashmir valley by the year 2000 AD - is there any hope to achieve this goal? JK Practitioner 4:150-151. MATERNAL IODINE STATUS AND THYROID VOLUME DURING PREGNANCY: CORRELATION WITH NEONATAL IODINE INTAKE. P. P. A. Smyth, A. M. T. Hetherton, D. F. Smith, M. Radcliff, and C. O'Herlihy, University College Dublin and National Maternity Hospital, Dublin, Ireland. J Clin Endocrinol Metab 82:2840-2843, 1997.

The authors studied pregnant women and their offspring in Dublin, which has moderate iodine deficiency. Measures included thyroid volume by ultrasound and urinary iodine excretion (UI). The mean age of mothers was 28 years. Thyroid volume for nonpregnant controls was 11.3 ml. During pregnancy it rose from 13.9 ml in the first trimester to 16.0 ml in the third, and was still elevated above baseline 40 days after delivery. With 18 ml as an upper limit for normal, the number with goiters increased from 6.3% in the nonpregnant, through 19.5% in the first trimes ter to reach 32% in late pregnancy. The median UI in nonpregnant controls was 70 E6g/L, compared with 135 E6g/L in the first trimester. Three days after delivery, the median UI fell from 122 E6g/L to 76, the same value as in nonpregnant controls. In a subgroup of 108 mother/child pairs, the median UI of all mothers was 73 E6g/L but the mean UI excretion in breastfed babies was 100 E6g/L, in contrast to 43 E6g/L in bottle fed babies. The iodine content of the four formulas used for bottle feeding was 100-150 E6g/L. Sixty-two percent of the bottle feeders had UI's below 50 E6g/L, compared with 6% of the breastfeeding babies. The authors note that the increased UI excretion during pregnancy implies a negative iodine balance and probable diminished thyroidal iodine stores. They further noted the iodine loss was greater in those with multiple pregnancies. They note that despite mild iodine deficiency, the breast diverts iodine to the baby, as shown by differences in maternal and infant urinary iodine, and this benefit is lost on those fed with the formulas used in this study. (Ed. note: the data of this paper address several important issues, including: (1) why did urinary iodine concentration go up during pregnancy and if this is a general phenomenon, does it make the urinary iodine during pregnancy a less reliable indicator of iodine nutrition? (2) Does the breast of the lactating woman have priority over the thyroid for iodine concentration? Further study of the important questions raised by this paper are needed.)

ALIMENT8ERE JODAUFNAHME BEI JUGENDLICHEN IN MECKLENBURG- VORPOMMERN ZWISCHEN 1993 AND 1996 GESTIEGEN. R. Hampel, A. Gordalla, H. Z94llner, D. Klinke, and M. Demuth, Universitat Rostock, Rostock and Ernst-Moritz- Arndt Universitat, Griefswald, Germany. Z Ernahrungswiss 36:151-154, 1997.

The authors measured thyroid volume and urinary iodine excretion in 2,109 persons, aged 10-18 years old in Mecklenburg-Vorpommern, Germany in 1996, and compared the results with those from 1993. Using ultrasound, the goiter prevalence in 1996 was 18.5%, and 3.6% of subjects had one or more nodules. The urinary iodine excretion was 95 E6g, compared with 70 E6g in the 1993 study, without apparent changes in ingestion of iodine-containing foods or iodized salt. The authors attribute the increased iodine nutrition to a higher supply of iodine in commercial foodstuffs and animal products. THE RELATION OF TRANSIENT HYPOTHYROXINEMIA IN PRETERM INFANTS TO NEUROLOGIC DEVELOPMENT AT TWO YEARS OF AGE. M. L. Reuss, N. Paneth, J. A. Pinto-Martin, J. M. Lorenz, and M. Susser, Columbia University, New York, USA. N Engl J Med 334:821-827, 1996.

The authors studied the relationship between severe hypothyroxinemia and the risks for developing disabling cerebral palsy in central New Jersey. The population group included 882 newborns born at 33 or fewer weeks of gestation. Thyroxine levels on 536 were available, mostly tested on day 3. The subjects were evaluated for the presence or absence of cerebral palsy at two years of age by chart review, telephone interview; and mental development scores were available for 75% at two years of age. The results showed that the risk of disabling cerebral palsy was 11 times greater in infants with severe hypothyroxinemia than in those with normal thyroxine levels. The mean mental development score at age 2 was 15.4 points lower than that of children with normal neonatal blood T4 concentrations. The association of severe hypothyroxinemia and increased risk of disabling cerebral palsy remained after analyzing for a number of other variables. The authors conclude that severe hypothyroxinemia in preterm infants may contribute to problems of neurological and mental development. This study was done on premature infants in an iodine-sufficient area of the United States, so its relevance to iodine deficiency is not certain, but the results confirm the importance of adequate thyroid hormone function for the mental and physical development of the fetus. In Brief.......

IDD Activities in East/Southern Africa - A WHO intercountry workshop on micronutrient deficiency control for Anglophone Africa, organized in collaboration with ICCIDD, was held in Gaborone, Botswana on October 7-9, and opened by the Botswana Minister of Health. Attendees included representatives from the OAU and the Commonwealth Regional Health Secretariat, WHO staff, ICCIDD Board members (Benmiloud, Lantum, Mutamba, and Todd), and program managers from 17 different countries (Botswana, Eritrea, Gambia, Ghana, Kenya, Lesotho, Liberia, Malawi, Mozambique, Namibia, Nigeria, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe; Ethiopia, Mauritius, Seychelles and Sierra Leone were invited but did not attend). The purpose was to chart progress in implementation of micronutrient deficiency control programs, to examine national monitoring systems for salt iodization, and to review strategies for the control of vitamin A deficiency. The participating countries have made tremendous progress in implementing USI. Only four (Botswana, Gambia, Lesotho, Liberia) do not have legislation in place. Monitoring systems, however, remain weak, especially for biological indicators. Only Zimbabwe has reported iodine-induced hyperthyroidism. Progress in control of vitamin A and iron deficiencies has been much slower. Some countries have started vitamin A capsule distribution linked to national immunization days. Dr. John Clements fro m the EPI program at WHO/Geneva argued in favor of this approach. Trials of triple fortification of salt are ongoing in Ghana. The workshop recommended that countries adapt and harmonize legislation on human and animal salt iodization at the regional level, especially with regard to iodine concentration and salt at production site, on the basis of the 1996 ICCIDD/WHO/UNICEF recommendations, with regional bodies playing a more active role in the process. The participants supported sentinel sites as the most appropriate way for monitoring programs for micronutrient deficiency control, and recommended that the Task Force for Control of Micronutrient Deficiencies in Africa develop guidelines on criteria for selecting sentinel sites. The Task Force should also establish criteria for selection of regional reference labs to ensure validity and reliability of assay results, and should set up and maintain a list of laboratory facilities in the region. All countries should have independent officially designated control laboratories for measurement of iodine in salt by titration. In countries where facilities for measurements of iodine status (urinary iodine, thyroid hormones), vitamin A status (retinol), iron status (serum ferritin) are not available, intercountry cooperation should be encouraged and strengthened. The workshop recommended that strategy for vitamin A deficiency control should include a combination of supplementation, food diversification, fortification and public health measures, with more emphasis to a food- based approach. Surveys of anemia should investigate the relative importance of iron deficiency as a cause, and attempt to identify other important nutritional factors causing anemia.

Following the meeting, representatives from the governments of Botswana and Zimbabwe, ICCIDD, WHO, and UNICEF visited Sua Pan, home of Botswana Ash, Ltd., the major supplier of salt in the southern African region, particularly for Zimbabwe and Zambia, producing over 600,000 tons annually. The visit took place against a background of concern that some hyperthyroidism in Zimbabwe might be related to over-iodization of salt from this source. The company reported that their target level is 60 ppm, to meet the requirements of the various countries to which they export (except South Africa). The company urged harmonization of salt regulations between different countries. The visit also assessed control of the iodization process itself; a "master batch" is made by dry mixing potassium iodate with fine salt; this is then added to the salt being iodated (either coarse or fine) on a conveyer, from which it goes to a storage hopper prior to packing into 50 kg bags. Quality control comprises taking a sample from every 20th bag. Forty samples are collected in one plastic bag. This represents one wagon (800 bags). This batch sample is tested for alkalinity and iodine content, and once daily a sample is subjected to full chemical analysis. The delegation concluded that the mixing process and quality control were inadequate and made recommendations for improvement in both.

A meeting of the Task Force for Control of Micronutrient Deficiencies in Africa took place at the WHO offices in Gaborone, October 11, attended by de Benoist (WHO), Lantum, Benmiloud, Mutamba, Todd, Locatelli-Rossi, Siandwazi (ICCIDD), Addo (Ghana), and Ramarason (UNICEF Botswana representing Yambi). The discussion was wide ranging. Topics included the role and status of the Task Force; harmonization of salt legislation; follow-up on the Sua Pan visit; monitoring USI; the problem of small salt producers (the weak spot in USI); the need for an inventory of large-scale salt producers; selection of sentinel sites; combined surveys for the three deficiencies; the recent Nepal vitamin A food-based approach; the forthcoming UNICEF-sponsored meeting on iron deficiency anemia; lack of coordination in West Africa; and the proposed African micronutrient newsletter.

The Food and Nutrition Program of the Commonwealth Regional Health Community Secretariat for East, Central and Southern Africa (CRHCS/ECSA) has reported on the current status of salt iodization in six ECSA countries. Data were presented at the IDD meeting in Botswana in October 1997 and at the 26th ECSA Health Ministers conference in Mozambique in November. A short summary of progress in these countries was included in the last Update. A follow-up action plan will be developed at an ECSA meeting of the Food and Nutrition Experts Committee in February 1998 in the Seychelles. The CRHC is undertaking recommendations on harmonization of USI regulations in the ECSA, including reducing present iodine levels in some countries, promoting quality assurance, facilitating development of guidelines, advocacy, improving laboratory services, promoting regional capacity in research, and mobilizing resources for salt iodization. GAETANO SALVATORE

Gaetano Salvatore, known all over the world as "Nino," died on June 26, 1997. He was a Senior Advisor in ICCIDD, a world figure in academic thyroidology, and a leader in efforts to correct iodine deficiency in his native Italy. Nino was born in Naples, lived in Naples, and proudly manifested his attachment to the Neapolitan culture. His academic career was marked by a number of records. After his graduation in Medicine magna cum laude at the University of Naples, he became, in rapid sequence Assistant Professor, Full Professor, Chairman of the Department of Pathophysiology and Head of the Research Center of Endocrinology and Experimental Oncology, then Dean of the Medical School and finally President of the ancient and prestigious "Stazione Zoologica." All these positions were held in Naples and each of them was reached at an unusually early age. He was one of the youngest members entering the Accademia Nazionale dei Lincei.

His interest in thyroid research started as a medical student and was strengthened by postgraduate work in Paris and Bethesda. He published widely on thyroid physiology with particular regard to the molecular mechanisms of thyroid hormonogenesis. Despite the importance of his own investigations, perhaps his major contribution to medical science was the creation of an outstanding group of scientists working in the field of cellular and molecular biology as applied to thyroidology and endocrine oncology. He received extensive national and international recognition, including the Presidency of the European Thyroid Association, the Feltrinelli Award of the Accademia Nazionale dei Lincei, the Gold Medal for Merits in the School, Culture, and Arts from the Italian Government, and the Fogarty Scholarship in Residence from the USA Government.

As an educator, he was conscious of the function and responsibility of academic medicine in providing society with qualified physicians and medical scientists, and played a key role in promoting a controversial reform that revolutionized the entire curriculum of medical schools in Italy. He actively participated in a joint effort to coordinate national pre- and postgraduate medical curricula within the European Union. With regard to iodine deficiency, he recognized the obligation of the medical and academic sector to promote the health of the community. He was a champion of iodine prophylaxis as a means for improving health conditions as well as for promoting social and economic development in depressed endemic areas of Italy and elsewhere. He was a founder and Co-President of the National Committee for the Prevention of Endemic Goiter in Italy and a Senior Advisor in ICCIDD. Recently he launched a major project for extensive iodine prophylaxis in the most severely affected regions of southern and insular Italy.

Nino had an ebullient and warm personality. His remarkable talent for leadership generated enthusiasm and inspired immediate alliance. He had a strong character and strong opinions, and defended and imposed his views with vehemence and determination, but was also ready to admit and correct his errors. He liked power, but used his eminent positions for promoting culture rather than for personal advantage. He was a man of passion and curiosity; he liked science, but also was attracted to music, history, cookery, games and any new electronic gadget. He liked to discuss and to communicate orally rather than by writing, a propensity that was greatly facilitated by the advent of cellular phones, to which he was a virtual addict. He was generous, almost up to prodigality, as hundreds of taxi drivers and waiters in Naples and elsewhere were well aware. He was a hyperactive man with an enormous capacity for work and no distinction between night and daytime. He equally liked to give appointments at noon or at midnight. His home was an open house all year- round; students, scientists, friends, and relatives would be found at any time in his sitting room, mixed with senators and ministers.

He had a long and happy marriage to Marisa, a physician and scientist herself, who gave up her personal career to share his ebullient life. Although they had no children, any student or young scientist was sure to find in him a father who cared. He knew he was sick, but did not follow the advice of friends and colleagues to slow down his restless activity. He used to quote the aphorism of a great Neapolitan philosopher who said, "If I have to die, I wish to die at my working desk," and he did so.

ICCIDD joins the rest of his many friends, colleagues, and admirers in sharing the sorrow of Marisa and Nino's family and sends them its deepest condolences for his untimely death.

Aldo Pinchera, for ICCIDD