Volume 11 Number 1, February 1995
IN THIS ISSUE
James P. Grant, Executive Director of the U.N. Children's Fund (UNICEF) and Under-Secretary General of the United Nations from 1980 to 1995, died in January 1995. Under his vigorous leadership, UNICEF became one of the largest multilateral development agencies. His enormous capacity in getting leaders and governments to focus on the needs of children had earned him, in the words of U.N. Secretary General Boutros Boutros Ghali, the title of "An Extraordinary Champion of Children."
Beginning in 1980 when he joined UNICEF, Mr. Grant called for action to tackle a "silent emergency," the needless death of some 40,000 children each day. Subsequently, he mobilized the international community to launch the Child Survival and Development Revolution, which consisted of simple, inexpensive measures to fight infectious diseases, malnutrition, and child neglect. The efforts he led have saved the lives of millions of children in the last 15 years through immunization, oral rehydration therapy, breastfeeding, growth monitoring and safe motherhood.
His vision of and commitment to a world where each child has an even chance to grow up to be a productive citizen led him to organize the largest gathering of heads of state and government in September 1990 for the World Summit for Children. More than 70 kings, presidents, and prime ministers, and subsequently more than 150 countries, signed the U.N. Convention of the Rights of the Child and committed themselves to an agenda of specific programs designed to improve the status and conditions of children around the world.
Mr. Grant was born in Beijing in 1922 and was educated at the University of California and Harvard University. Before coming to UNICEF, he worked with the United Nations Relief and Rehabilitation Administration in China, the United States Agency for International Development and the U.S. Department of State. His achievements for children were recognized by numerous public awards, most recently the U.S. Medal of Freedom, the nation's highest civilian honor, by President Clinton last year. At a memorial service in New York, the First Lady, Hillary Rodham Clinton, called him "one of the greatest Americans of this century."
Mr. Grant was a special friend and supporter of ICCIDD. He recognized the damage that iodine deficiency does to children, and the feasibility of its prevention. Under his leadership, UNICEF provided the first funding to inaugurate ICCIDD, and he followed the progress towards the goal of IDD elimination with particular interest. He was an indefatigable champion of universal salt iodization, and his address at the Quito meeting in May 1994 (IDD Newsletter, vol. 10, page 14) entitled "Iodine Deficiency Disorders on the Run" contained all the hallmarks of his remarkable leadership - optimism, enthusiasm, pragmatism, and a passion to improve the lot of children.
ICCIDD will miss this great champion of those who suffer from iodine deficiency. His example will continue to provide stimulation for all of his fellow soldiers in the fight to eliminate IDD.
The World Summit for Children in 1990 pledged the virtual elimination of IDD by the year 2000. This theme has been endorsed by other international conferences, including the World Health Assembly, the International Conference on Nutrition. The mid-decade goal, due in 1995, is universal iodization of salt.
Monitoring progress towards a goal is an essential component of any project, particularly one involving so many different countries, agencies, and individuals as the elimination of IDD. Accordingly, in 1993, a small ad hoc group already present in Geneva at the meeting of the Subcommittee on Nutrition of the Administrative Coordinating Committee of the United Nations (ACC/SCN) met to discuss development of a database for tracking progress towards the goal. The group included David Alnwick (UNICEF), Ken Bailey (WHO), Graeme Clugston (WHO), John Dunn (ICCIDD), Jonathan Gorstein (Community Systems Foundation), Rainer Gutekunst (ICCIDD), Venkatesh Mannar (ICCIDD), and Kevin Sullivan (Emory University). The group agreed that such a database should be rapidly assembled, be easily disseminated, contain a summary of essential information rather than be encyclopedic, and be easily updated. A particular goal was to make it compatible with any existing databases on related topics, to facilitate exchange of information. Dr. Jonathan Gorstein, Community Systems Foundation, developed the format, and kept it compatible with the MDIS system that he was simultaneously developing for the World Health Organization. ICCIDD through John Dunn was to be responsible for providing data on countries, and the Office of Health and Nutrition of USAID agreed to fund the first phase through ISTI/IMPACT. The database has been designated as "CIDDS," an acronym for "Current IDD Status." The first phase was devoted chiefly to establishing the database and entering immediately available information. It was reasoned that detailed enquiry for new information would delay establishment of initial data and that the project should begin with baseline information. This approach would initiate the process and provide a background for identifying gaps in information and designing strategy for obtaining missing data.
Information in the CIDDS database includes the following categories: (1) assessment information, including goiter prevalence and laboratory data; (2) legislation on salt iodization; (3) identification of government or other authorities responsible for IDD control, and a description of the program; (4) current efforts at information, education, and communication; (5) a summary of the sources, production, iodization, cost, marketing, and transportation of salt; (6) supplementation with measures other than iodized salt; (7) monitoring, including indicators and information; (8) other control program notes, including comments on impending developments, random notes from observers, sources for further information, etc. For most countries the printout amounts to 4-6 pages, but many items will be blank because the compilers did not have readily available information.
Phase 1 and support from USAID ended in December 1994. The product was a disk with information arranged by each country. Since then, ICCIDD has been obtaining further information from countries as it becomes available, and is in the process of entering it into the database. The intent is for an ongoing process of updating, with periodic issuance of disks, perhaps every three or six months. Developing on-line availability through e-mail or other electronic transfer is being actively pursued. The objective is to have an easily accessible rapid summary of relevant information about IDD status that is freely available to global workers in IDD elimination. A crucial ingredient for this project will be the continued supply of information from countries to correct errors or omissions and document new developments. The major purposes, again, are to assess how well the world is living up to its commitment towards IDD elimination, and to identify ways that the effort can be enhanced and accelerated.
Further information about CIDDS can be obtained from Dr. Dunn at the IDD Newsletter, Dr. Jonathan Gorstein at Community Systems Foundation, Dr. Bruce Cogill, ISTI/IMPACT, or Dr. Frances Davidson, Office of Nutrition, USAID.
Another database is the WHO Micronutrient Deficiency Information System (MDIS), described in a previous issue of the IDD Newsletter (vol. 9, no. 3, page 28, August 1993). This system plans to develop a comprehensive updated database of IDD prevalence information and to monitor the state and progress of control programs. Its first publication, entitled Global Prevalence of Iodine Deficiency Disorders, appeared in 1993. Similar publications on deficiencies of vitamin A and of iron are in progress. Material for the MDIS is obtained from country governments through WHO representatives and is compiled by the Nutrition Unit at WHO headquarters in Geneva, and entered into the database after verification of sources. Further information can be obtained from Dr. Barbara Underwood in the Nutrition Unit, WHO, Geneva.
UNICEF maintains databases for specific aspects of IDD and its elimination. One deals with funding and resources available for countries. Another collects data annually from field offices on monitoring the mid-decade and year 2000 goals of the World Summit of Children. This activity monitors all of the goals established at the Summit, of which IDD elimination is one. The specific indicators requested from countries are the percentage of schoolchildren with goiter, the percentage with urinary iodine below 10 mg/dl, and the percentage of households consuming adequate iodized salt. Additionally, UNICEF collects data on salt iodization, and compiles periodic reports. For further information, contact Mr. David Alnwick, Senior Nutrition Adviser, UNICEF, New York.
A conference in late February 1995 was convened by the Micronutrient Initiative in Ottawa. It provided an opportunity to report on the existing database efforts in IDD and other micronutrients, particularly CIDDS, the MDIS, and UNICEF. Dr. Mashid Lotfi of the Micronutrient Initiative prepared a useful background document that reviewed not only the three databases described above, but listed additional efforts including: a PAHO nutrition database; a file at the University of Pernambuco in Brazil on vitamin A and micronutrient deficiencies; the ACC/SCN databases on projects dealing with world nutrition and women's nutrition; the FAO computerized databases of food consumption; the United Nations University's NFOODS database of food composition; IFAN, the international food and nutrition database; APHA, with information about programs and research on health and nutrition of women; and the TEKRAN database of the US Department of Agriculture, which compiles studies on agriculture, food, and human nutrition. Dr. Lotfi's document also considered means for exchanging information including routine mail, telephone, fax, and Internet, and reviewed different search approaches and software.
The objectives of the conference were: (a) to share information about currently available databases; (b) to identify needs and gaps in information necessary for implementing micronutrient control programs; (c) to promote cooperation among different database activities; (d) to facilitate exchange of data among appropriate stakeholders; and (e) to improve the accessibility and availability of databases and information. The 30 attendees at the conference included epidemiologists, technical experts on databases, public health professionals, and representatives of several international agencies. ICCIDD Board members or Senior Advisers present included John Dunn, Festo Kavishe, Venkatesh Mannar, C. Pandav, and Frederick Trowbridge. Plenary sessions described existing databases and technical capabilities currently available. Group discussions considered the place of database activities, advocacy, and implementation at the global, regional, and national levels.
Some of the major outcomes were: (1) representatives of the existing databases on IDD (ICCIDD, WHO, UNICEF) agreed to work closely with each other and share information freely; (2) the group recognized the value of developing a database of technical information that would be readily accessible to workers both in the field and at central levels, for information about various aspects of micronutrient deficiency and its correction; (3) all emphasized the importance of harmonizing existing and future efforts in micronutrient databases, to achieve the greatest efficiency and accessibility for users; one approach to this effort would be the designation of one agency or center, or a closely coordinated network, to facilitate entry, maintenance, and dissemination of data; defining the requirements for such a facility, or group of facilities, is an urgent next step to follow this meeting; and (4) while this conference focussed on global databases, all recognized that the most important goal for databases is to promote correction of micronutrient deficiencies at the country level, and that further efforts with databases should always have the specific benefit of country programs firmly in mind; means to develop database capacity in countries need to be studied urgently, and such country-based systems should be fully compatible with any international systems.
A final report of the conference is being drafted by Dr. Lotfi, and should become available from her at the Micronutrient Initiative. The next steps will be to develop a concrete modus operandi for harmonizing existing and future database efforts, including a technical database. ICCIDD recognizes the importance of such databases as a monitoring tool in tracking progress, and will continue to spearhead activities in these areas.
Widespread public ignorance of IDD effects
What is iodine deficiency? If this is a $100 question, readers of the Newsletter will, of course, have the quiz money in the bank. For you, IDD is not only a familiar subject but a commitment - a commitment to its virtual elimination. But pose the question to the man and woman in the street, you will certainly get a blank look.
Thanks to the extraordinary work of medical scientists and development specialists, many of them active in ICCIDD, IDD has been recognized at the highest international policy level. The decision at the 1990 World Summit for Children to achieve virtual elimination of IDD by the year 2000 is concrete evidence of such recognition. Yet, there exists a vacuum of public awareness and knowledge about IDD and its devastating effects on the mental development of children, an impairment that spells the reduction of up to 10 to 15 I.Q. points. Even among health professionals, IDD is largely equated with goiter, an unsightly swelling of the neck, and cretinism. Medical scientists have clearly shown that goiter and cretinism are just more visible signs of a much larger pool of victims, especially women and children.
Most preventable cause of mental retardation
The fact that IDD is the most preventable cause of mental retardation in children is not widely known. It is not addressed in many of the general medical text books or in most health education materials. Iodized salt has been available for a long time as an effective measure to fight goiter, as have other iodine supplements; yet in many endemic areas they have not resulted in any significant reduction of IDD incidence - proof that the availability of iodized salt itself is not enough to ensure consumption. Surveys have shown that IDD are no longer a problem confined solely to the endemic areas but occur in all areas of many developing countries as well as in some industrialized countries; thus in these countries IDD control work must aim at nationwide coverage. Moreover, the goal of virtual elimination is only five years away and its success depends ultimately upon the behavior of individuals, based on the awareness of IDD risks, to ingest small quantities of iodine on a regular basis. Sustaining virtual elimination calls for the establishment of using iodized salt as the social norm.
This situation calls for purposeful communication and education efforts to accompany the current and critical thrust of universal salt iodization. Increased awareness can also create and stimulate market demand for iodized salt and generate action on other fronts in fighting IDD.
Need for action
In response to these concerns, Dr. Basil Hetzel, Executive Director of ICCIDD, invited Professor Jack C. Ling of Tulane University, an ICCIDD Board member, to submit a communication plan for inclusion in ICCIDD's global strategy. At its 1994 annual meeting, ICCIDD's Board decided to designate Tulane University's International Communication Center (ICEC) as its Communication Focal Point to facilitate the exchange of information and to encourage action in the field of communication and education related to IDD elimination, including the drive toward universal salt iodization, the recognized principal instrument for IDD elimination.
Communication focal point
The IDD Communication Focal Point is located at Tulane University's School of Public Health and Tropical Medicine and operated by ICEC in New Orleans, Louisiana, USA. Given the limited resources and largely voluntary nature of ICCIDD, the Focal Point aims to stimulate and facilitate action by other organizations and serve as a resource. Staffed by part-time graduate student workers, it has three functions: IDD promotion, resource collection, and limited material production.
IDD promotion
One of the first actions of the Focal Point was to find a well-known personage to speak for IDD globally, to generate public attention and command the support of the media. It turned to UNICEF with its stable of goodwill ambassadors and spokespersons. UNICEF has responded by designating Roger Moore its IDD spokesman. Concurrently, Mr. Moore has also been appointed Honorary Chairman of the Worldwide Service Project for IDD of the Kiwanis International, an international service organization committed to raise $75 million for IDD work.
The launching of an Annual IDD Day, approved by the ICCIDD Board in 1994, was the Focal Point's second promotional initiative. The Focal Point is working with UNICEF and Kiwanis International to make IDD Day a reality during the month of October, 1995. Concrete plans are being developed to make it an international day, around which various government units and non-governmental organizations concerned with IDD will undertake promotional and educational activities. UNICEF, with help from the Focal Point and the Micronutrient Initiative, is expected to prepare a media kit for distribution to interested groups. A guide on IDD Day activities will also be prepared.
The Focal Point also hopes to introduce a worldwide IDD Poster Competition involving schoolchildren in conjunction with the IDD Day. The competition will present an opportunity for children and their parents and teachers to learn about IDD. If properly developed, the poster competition could involve principals, mayors and governors and national leaders, generating media coverage at various levels.
To stimulate animated video productions on IDD, a joint ICCIDD/UNICEF $10,000 prize for the best video was announced during the recent Animation for Development Summit held at the Walt Disney Studios in Orlando. The prize will be administered by UNICEF's Radio and Television Section in New York and should attract a number of IDD productions.
IDD Clearinghouse
Because many countries around the world have carried out IDD work and produced various communication and education materials, the Clearinghouse hopes to serve as a repository of such material in order to assist others in developing their own materials. Collection of material has begun and by the end of January, 120 items have been received. They have been classified in the following categories: books, journals, reports, videos, brochures, pamphlets, posters, newsletters, policy papers, flipcharts, slide sets, and miscellaneous.
As there is clear need for information on IDD's cost-benefit at the community level, the Focal Point has initiated steps to develop a project to collect data and produce information to show the benefit of IDD intervention in terms of economic productivity. Such information will be critical for advocacy purposes at the sub-national levels.
Also, a guide to gather information about iodized salt at point-of-purchase has been prepared in order to get IDD information directly to food preparers, a most critical group for effecting iodized salt use. If funded, an institution in a developing country will be invited to undertake the inquiry. When communicators and educators know the circumstances of point-of-purchase, they can tailor their educational efforts accordingly and design appropriate IDD messages to encourage the purchase of iodized salt and to facilitate its proper use,
Material production
A number of logos for iodized salt were produced for use by salt manufacturers. A fact card about IDD for use by lay speakers for educational and fund raising purposes and a leaflet about ICCIDD's consulting services in English, French, and Spanish are in production.
Future productions include a periodic Clearinghouse Notes which will indicate what materials are available and, if additional funding is available, Countdown 2000, a brief report on IDD progress and problems designed for decision and policy makers.
A call for collaboration
Though a good start has been made, the Focal Point needs support from all IDD workers. As the countdown toward 2000 has begun, all of us concerned with IDD must pool our resources to deliver the commitment before the next millennium, on behalf of the future generations.
All IDD Newsletter readers are urged to send appropriate communication and education materials, reports, and studies to:
Mr. Tom Scialfa/Ms. Kim Seifert
ICCIDD Communication Focal Point
ICEC, Tulane School of Public Health and Tropical Medicine
1501 Canal Street, Suite 1300
New Orleans, LA 70112, USA
Telephone: 504-587-7393; Fax: 504-585-4090
The Andean Subregional Project, a network of several countries including Venezuela, Colombia, Ecuador, Peru, Bolivia, and Paraguay, is headquartered in Quito, administered by UNICEF, and funded in part by the Belgian government. Activities and progress of the organization and the countries were described at a regional meeting on IDD in Quito in April 1994 (IDD Newsletter, 10(2):13, May 1994). A December meeting in Lima heard details of recent progress and plans for IDD in Peru, as well as reports on other countries in the region.
Peru
Factors that make the correction of IDD in Peru complex include severity of iodine deficiency in the mountains, difficulty of access to isolated areas with severe IDD, frequent scattered sources of salt that make iodization difficult to control, and recent adverse economic conditions. Thus, a program that had made promising progress in the previous decade has had lapses in the last several years. Now, it is being revitalized, and a new thrust is targeted particularly to iodized salt.
Within the Ministry of Health general themes are equity in distribution of services, decentralization, comprehensive health care, greater efficiency and better investment of available financial resources. Strengthening at the central level is needed to provide better models. Health posts are being expanded. The IDD strategy is now based on promoting the production and consumption of iodized salt. Monitoring of salt iodization levels and an annual survey of salt consumption patterns will be the process indicators, and urinary iodines will be used as impact indicator. The program is multisectoral. Strengthening of laws and improved communication are necessary. Process indicators for animals are also needed.
Plans for the current year (1995) include more vigorous communication efforts, iodization of rock salt, establishing demonstration projects, monitoring systems, impact evaluation, strengthening institutions and expanding the program to other micronutrients. The national program also recommends dietary diversification, particularly fish, for long range sustainability. The iodine content of salt is monitored in the laboratory, and reports of the volume of production are routinely examined. Test kits for measuring iodine levels in salt have been produced locally and are being widely distributed for monitoring. Schoolchildren are surveyed for their salt use and the salt they bring from home is checked with kits. In 1994 70% of the samples were adequately iodized, and it is anticipated that this figure will be at least 80% in 1995. There are 83 different brands of salt, many from the north. Data from 1994 show that 86% of samples in the north had satisfactory iodine content (at least 20 ppm iodine), 44% in the central area, and 78% in the south. Iodine is sold by a rotating fund, which greatly lowers the price to producers.
A major thrust has been in communication, at all levels. The salt industry is actively involved in communication efforts. The program also recognizes the need for outcome monitoring with urinary iodines.
Several aspects of the salt iodization and communications are presented in the accompanying photographs.
Bolivia
The IDD program has been reorganized administratively, as part of a general government restructuring. Now there is a program against micronutrient malnutrition as part of the national secretariat of health within the Ministry of Human Development. A small sampling of 360 students, selected strictly proportional to the distribution of the national population, was carried out in June 1994. The country-wide goiter prevalence was 4.5% in schoolchildren, the median urinary iodine excretion was 19.4 mg/dl, and iodine in salt at the consumer level was adequate in 90% of samples. While this study is useful as a strictly national figure, such a small sample could easily overlook significant local areas with IDD. Nevertheless, progress continues to be promising.
EMCOSAL, the semiautonomous government salt program originally set up under the national program against iodine deficiency, has been dissolved. Meanwhile private plants have been more active and 44 of these are currently iodizing salt. Concern was expressed at the meeting as to whether the remote areas would continue to receive adequately iodized salt, but presenters of the program felt that this would be achieved by the private producers.
The program maintains a rotating fund for supplying iodate to producers and will continue monitoring. As part of a "final push," kits to test iodine levels in salt are being used in schools, and communication is being increased through many local means.
Colombia
Some data presented indicate that despite marketing efforts, only about one-third of the salt has adequate amounts of iodine, and only 12% of the poorer part of the population receive iodized salt. The distribution system involves repackaging, and the knowledge levels and sanitary conditions in repackaging plants are low. A survey of three Andean provinces in 1994 showed goiter prevalences of 21%, 16%, and 17%; 88% of urinary iodines were < 10 mg/dl and 33% were < 5. A plan for a much larger study to involve about 10,000 children and 4,050 urinary iodines were described. The program proposes improved monitoring of the salt industry, more advocacy and information within the government and development of communications and education activities. The current program specifies KI rather than KIO3 for iodization. It also requires addition of fluoride, a double fortification.
Ecuador
Currently, kit monitoring in schools show that 97% of students are consuming effectively iodized salt. Median urinary iodines continue well above the 10 mg/dl cutoff for adequate iodine intake. In the next phase Ecuador is proposing an extension of its cooperative agreement with the Belgian government and additional funding through the year 2000. Part of this agreement will include components for control of deficiencies of vitamin A and iron.
Paraguay
A presidential decree dating from September 5, 1994 requires iodization of all salt sold in the country for human or animal consumption. It specifies potassium iodate in the range of 67-100 ppm salt, to ensure a minimal ingestion of 400-600 mg of iodine per day. It mandates an annual registration of importers and processors of salt destined for human or animal consumption, and places responsibility for the program in the hands of the Ministry of Public Health and Social Welfare.
A consultation on universal salt iodization for elimination of IDD met in Asuncion on September 15 and issued a declaration that: (1) all people have a right to receive adequate amounts of iodine in their food; (2) the government has the obligation to support this right through laws and regulations that assure the protection of the population in consumption of iodized salt; (3) to follow this, it is necessary that all salt for human and animal consumption, including that used in food processing, contains adequate amounts of iodine; (4) the support of the private sector dedicated to the production and distribution of salt is fundamental in achieving this objective; (5) the government will work by establishing legal, technical, and administrative norms and take whatever other measures are necessary to assure that all the salt consumed is adequately iodized, and will also implement appropriate strategies of information to promote iodized salt through the relevant ministries and other institutions public and private; and (6) the country should achieve universal iodization of salt in the year 1995 as a step in the eradication and virtual elimination of the iodine deficiency disorders before the end of this century.
The action plan includes establishing a monitoring system for salt consumed in the country. Strategies include training multipliers, educational campaigns, setting up techniques for urinary iodines, developing a plan for sampling of salt, advocacy with local authorities and inter-institutional coordination.
Results from the pilot program in Misiones in south, were reviewed. In that area 34% of the people have visible goiter and 84% use coarse salt. The program has shown great progress, and more complete data should be available in early 1995. Venezuela
The conference heard available information about IDD in Venezuela, particularly in the state of Merida, where 65% of students have goiter and 59% have a median urinary iodine below 10 mg/dl. Iodized oil was given there to about 27,000 people. An intensive education campaign is planned imminently. In 1994 71% of salt samples had more than 15 ppm iodine. Daily salt consumption for humans is said to be 6.8 grams.
The program's activities include prevalence surveys, communication campaigns, a study of salt marketing, analysis of salt samples at the nutrition units, monitoring of urinary iodine, review of the laws, epidemiologic monitoring, and reorganization of inter-institutional committees dealing with IDD. It appears that the law will include salt for animals.
Future plans
The conference summarized plans for the region. Universal salt iodization is the goal. The Subregional Program provides technical advice, coordination, and seed money. In addition, it has prepared technical manuals, performed consultancies in other parts of Latin American and has been particularly active in training. Common requests from the countries to the program were experience exchange, technical training, technical assistance, communication, surveillance, monitoring, standardization, demonstration farms, means of verifying compliance with universal salt iodization, equipment and supplies, and integration with vitamin A and iron. Standardization of legal instruments among countries was also discussed but was regarded as too complex.
An international jury selected Professor Dang Tran Due as the winner of the first ALGEPA Award for his work in fighting endemic goiter and iodine deficiency disorders in Vietnam. Professor Dang is an endocrinologist who created, under the direction of the Ministry of Health, the Hanoi Endocrinologic Institute, which has been in charge of the country's program against IDD since 1970. Over the years he has conducted many epidemiologic studies on IDD in various regions of Vietnam, and started programs to control it. With his colleagues Dr. Lemy and Dr. Thai, he initiated new techniques for IDD control such as manual salt iodization and injection of iodized oil, and later oral iodized oil, as part of the national program. He has collaborated extensively with many international experts, including Drs. Polonin, Hershman, Ermans, Bourdoux, Thilly, Mannar, Buttfield, and Ling.
The awards jury, chaired by Dr. Hetzel and co-chaired by Dr. Thilly, selected Professor Dang for his achievements, dedication, persistence, and ability to adapt preventive measures to socioeconomic conditions in his country. The awards ceremony took place in Paris on November 9, 1994 in the presence of Dr. Michel Guerbet, Chairman of ALGEPA. Others present were Dr. Thilly, Dr. Ciupek, Dr. Chastin, and Dr. Delange.
The next ALGEPA Award will be presented in 1996. Further details can be obtained from Dr. Claude Ciupek, ALGEPA, 55 Boulevard Pereire, 75017 Paris, France.
by Abdul Hamid Zargar, Javid Amin Shah, Mohammad Muzaffar Mir, Bashir Ahmad Laway, Shariq Rashid Masoodi, Nissar Ahmad Shah, Departments of Endocrinology and Biochemistry, Institute of Medical Sciences, Srinagar, Kashmir, India.
We studied a total student population of 10,196 in the age group of 5-15, which included 5,676 boys and 4,520 girls in 210 randomized villages of the Kashmir valley in the Indian sub-continent. Thyroid size was assessed as recommended by Stanbury et al. (1). Of these, 4,609 (45.2%) had thyroid enlargement (Table 1). Only two children had grade 3 goiter and none had grade 4. The overall goiter prevalence increased with age, from 30% in the age group 5-12 years to 51% in those more than 12 years old.
We collected 202 urine samples randomly from the surveyed population, irrespective of sex or thyroid size, and processed them for creatinine and iodine estimation as recommended by Karmarker et al. (2), obtaining a value of 49.6 ± 3.6 (mean ± SEM) mg I/g creatinine (range 6.3-103.6).
Iodine deficiency goiter continues to be a significant public health problem throughout the world, including Europe (3) and various parts of India (4). The prevalence of goiter among schoolchildren in pockets in the goiter belt of Himalayan and sub-Himalayan regions varies from 55% to nearly 100% (5). The mean urinary iodine excretion in our study shows that the Kashmir valley has moderate iodine deficiency and needs prompt measures to correct this major public health problem.
ACKNOWLEDGEMENTS
We are grateful to Professor M. S. Khuroo, Director of Institute of Medical Sciences, Srinagar, Kashmir (India) for providing the necessary facilities to carry out this study. We also acknowledge with gratitude the technical help of Professor M. G. Karmarkar, All India Institute of Medical Sciences, New Delhi, in carrying out urinary iodine estimations.
REFERENCES
Table 1. Prevalence of different grades of goiter among 10,196 children.
| Grade of Goiter | Number | Prevalence (%) |
| OB | 1,640 | 16.1 |
| I | 2,208 | 21.7 |
| II | 759 | 7.4 |
| III | 2 | 0.0 |
| Total | 4,609 | 45.2 |
[Ed. note: for conversion to the most recent recommended system of goiter staging (IDD Newsletter 10:39, Nov. 1994) Grades OB and I (as above) are now Grade 1 (palpable goiter), and Grades II and III are now Grade 2 (visible goiter)].
A recent article in the IDD Newsletter, (Vol. 9, page 26, August 1993) described the current aggressive push for the prevention of IDD in the Philippines. In 1992, Ms. Catherine V. Bersamira and Dr. Charles Cheng of Baguio City in northern Luzon, an area of severe iodine deficiency, carefully studied the knowledge, attitudes, and practices (KAP) of inhabitants in that area. Their results are contained in a manuscript kindly shared with the IDD Newsletter by Dr. Cheng. We here abstract some of their findings, with an eye particularly to the perceptions held by many people in iodine deficient areas. Recognizing these attitudes provides the opportunity to mount more effective information campaigns.
The study took place in Benguet Province, part of the Cordillera Administrative Region (CAR) in northern Luzon. The terrain is mountainous and hilly with narrow plateaus and valleys. Baguio City, the largest municipality, is 5,000 feet above sea level. Mount Pulag, the second highest mountain in the Philippines, is on Benguet's eastern border. Two tribes, the Ibalois and Kankana-eys, inhabit the area. Farming includes vegetables, cattle, horses, and hogs and is the important industry. Major crops are rice, corn, gabi, cassava, fruits, leafy vegetables, and tiger grass. A household survey conducted by the Regional Health Office in 1990 found an overall goiter prevalence rate of 23% for the CAR.
Four communities were studied. One, the municipality of Kapangan, had a goiter prevalence rate of 64%, reaching 92% in school children and adolescent girls. Tuba, another town studied, had a prevalence of 4%. The main dietary constituents in these areas were rice, corn, gabi, camote, cassava, and local vegetables including cabbages, beans and womboc. Access to seafood was low. Iodized salt was made available through the provincial health office. Another study site, Baguio City, had a goiter prevalence of less that 1%. The general diet was similar to that of Kapangan and Tuba, but seafood and seaweed were available.
A total of 400 subjects were studied, 100 each in Kapangan, Tuba, and 2 barangays (smaller municipal districts) in Baguio City. In overall terms, Kapangan and Tuba, relative to the barangays in Baguio City, had higher prevalences of goiter, larger family sizes, a predominance of Kankana-ey, and lower educational attainments, and were largely agricultural. The investigation used a questionnaire to obtain a socio-demographic profile, dietary preferences, knowledge of IDD and its treatment, attitudes towards it, and practices related to its treatment and prevention. This questionnaire was translated into the local dialects, and pretested in neighboring communities.
KNOWLEDGE
The majority of the respondents readily identify the term goiter, but not iodine deficiency disorders. (For aficionados of words for goiter [see IDD Newsletter 6(1), p 6, 1990], the report describes the following local terms: biskel, akak, biscog, biscong, bekkak, bintuka, and biyol). In Kapangan and Tuba, most of the respondents recognize the word goiter, since most have seen it or heard about it from midwives or older residents. In the city, most had heard about it, but only 2% recognized ever having seen a goiter. Sources of information were from readings in health subjects for 68%, and from older residents, friends and neighbors for 28%.
Table 1. Causes of goiter as perceived by the respondents.
| Causes | Percent |
| Due to the drinking water | 31 |
| Ferns that grow near or around the spring | 8 |
| Constant shouting of a woman in labor | 10 |
| Drinking iced cold water and hot water alternately | 7 |
| Due to lack of iodine | 30 |
| Due to food eaten | 7 |
| It is a natural occurrence, everyone in the community has "Biscog" or "Biskel" | 3 |
| Do not know | 4 |
| All causes | 100 |
Table 1 summarizes responses to the question "What is the possible cause of this disease?" The most popular answer was that goiter came from drinking water, particularly from a spring coming from under big rocks, with white or crystalline rocks at its mouth. Others attribute it to the ferns that grow near or around the source of the water. Lack of iodine was recognized as a cause by less than one-third of respondents. Others suggested that goitrogens in cassava, sweet potatoes, lima beans, and vegetables like cabbages and eggplant might contribute. Those of Ibalois and Kankana-eys origin attribute goiter to the limestone-rich drinking water. Many of the respondents from specific areas in Kapangan and Tuba referred to the high calcium deposits left after boiling water in pots. Some older respondents expressed the belief that drinking from a spring that is not stirred first will cause goiter, but that stirring will drive or disperse the evil spirits caused by the passing of a snake or lizard in the spring. In another area, the respondents believe that the disorder is a natural occurrence, since almost everyone in the locality has goiter. Some of the respondents from Baguio City, particularly older ones, believe that the throat of women constantly shouting during labor becomes inflamed and will not return to its normal size. Another response was that sudden exposure to extreme hot or cold water will cause the veins in the neck to be inflamed, referred to as "pasma." Respondents in the rural areas believe that women were more likely to have goiter that men, and also thought that farmers were more prone to it.
Virtually none of the respondents knew much about iodine deficiency, and attributed whatever symptoms they recognize exclusively to thyroid enlargement. None felt a particular urgency to seek medical attention for goiter. About 85% thought that the disorder is best treated by medication and surgery. Since many felt that financial constraints limited their seeking medical care, they resorted to local herbs, including one called burburtak and Unwad. (Apparently earlier studies have suggested that in areas where burburtak is eaten as a vegetable, the incidence of goiter is much lower; however, a report from the Food and Nutrition Research Institute reports that the iodine levels of burburtak were high only in some plant samples from the mountain provinces, while burburtak from another area contained very little iodine.) Some of the older respondents believe that the goiter is best treated by using a heated wooden ladle pressed on the enlarged area.
The preventive measures to be undertaken to avoid IDD were also tallied. Avoiding springs where fern trees grow, or that originate from big rocks, or when water is not stirred first, accounted for 36% of responses, compared to 30% recognizing a need for iodine.
The investigators noted that the location of respondents shaped their level of scientific knowledge of IDD. The lower awareness in Tuba and Kapangan was attributed to lower educational attainment of respondents there, to the fact that goiter is so common that it is taken for granted, to the lower socio-economic status of the rural areas, and to the relative inaccessibility of health personnel.
ATTITUDES
In general, attitudes towards goiter were tolerant. The respondents said the disorder is not contagious, and thus, for instance, a mother with goiter can still breastfeed her baby. Those afflicted are not segregated or ridiculed. However, the younger respondents ages 15-28 years and single, feel embarrassed by their condition, particularly if it is grade 2 and 3, when they attend social gatherings. They also feel insecure when they go to Baguio City or away from their locality. One 28 year-old female factory worker claimed she had to wear clothes with turtlenecks to hide her goiter. The older respondents felt that since almost everyone has goiter, they usually do not see a need to seek medical assistance. In the rural areas, the person consulted would most likely be the midwife, because they are the most available health personnel. In the city, respondents preferred to consult a physician.
PRACTICES
There is a significant blending of traditional and modern practices for the treatment and prevention of biscog, or akak, or goiter. The traditional practices among the Ilocanos and Pangasinense are massage of the neck or medicinal plants. They attribute the goiter to frequent drinking of ice cold water or hot water, which causes the neck to be inflamed, or to phlegm accumulating during sudden coldness. To treat it, they may heat a wooden ladle and rub it on the enlarged neck. Another treatment uses a type of papaya fruit with a long fruit holder; this papaya is sliced thinly, heated over a stove until it becomes soft, and then wrapped around the neck for nine consecutive days. The process is repeated until the goiter decreases or disappears entirely. Others recommend ginger soaked in kerosene. The ginger is wrapped around the neck in the belief that ginger and kerosene will absorb the "pasma". Alternatively, rubbing alcohol or kerosene may be applied to the neck, in the belief that it will absorb the trapped coldness or the heat and decrease the enlarged area. Sometimes this massage is carried out by folk healers or by the goitrous person himself.
Unfortunately, the most afflicted are also the most economically deprived. The fear of medical intervention and its accompanying expenses create a barrier to proper medical care. Thus, particularly for those living near the boundaries of La Union and Kibungan, any folk healer's prescription becomes the most likely treatment, not only because it is more accessible but more significantly, also because the prescribed cure, usually herbs and particularly burburtak, is locally available and free. The leaves or tops of burburtak are gathered early in the morning, boiled for ten minutes, and then used as drinking water, or sauteed with meat, or cooked with anchovy. Some people boil it with tomatoes and salt and serve it as salad. The older respondents recommend using burburtak until the enlargement decreases or disappears. For this reason they prepare it in different ways, so they will not tire of it.
Three of the respondents advocated continuous praying to reduce goiter size. These were Santoala believers who reported that their type 3 goiters were cured through constant devotion and prayer to Santoala.
Of the 69 respondents who had goiter themselves, only 15 sought medical attention. One had had surgery, but the disorder recurred after two years. The 15 on medication had received iodine tablets, Lipoidal injections or iodized salt, as prescribed by physicians or midwives. Of those with goiter, 78% did not describe any particular symptoms when they noticed it, because goiter was a common occurrence in their communities. Of the remainder, 9% felt "insecure," 7% "frustrated," and another 6% "worried." These latter were all younger respondents, ages 17-35 years. While none felt they had been excluded from their community, many claimed that the goiter had an effect on their work. They became easily tired, sickly and irritable and felt that they could not perform as well. They said their physical capacity and labor productivity were reduced, with a corresponding decrease in their income.
SUGGESTED GUIDELINES FOR IDD PROGRAMS
The authors conclude from their study that the first step in a control and preventive program should be to gain entrance to this disease world as perceived by its inhabitants. Otherwise, costly programs and projects will continue to be ineffective. They offer the following guidelines:
1. Public information and technical training is essential. A well-informed population enhances the effectiveness of the program. The group targeted for special information should include leaders of the community, teachers, health providers, young members of the community, families, and religious leaders. Locally adapted messages should be prepared for the mass media and make the following points:
2. Schools should be involved in the educational program. Teachers should integrate teachings on IDD or goiter in their health and science education subjects. The Philippine Information Agency, (PIA) should also be tapped to set up an information drive in the dialect of the locality. Non-governmental organizations (NGO's) should also be involved in dissemination of information.
3. The rural health center staff should be trained to understand the uniqueness of the cognitive process of the people, their way of understanding the causation, the local terminology used, and the perceived symptoms of the deficiency. They should develop teaching materials consistent with the perceived gradient of the disease, stressing the early signs and symptoms. Since some places have not yet been reached by health personnel, interested members of the community and volunteers should be tapped and trained for the program, including older members and indigenous healers of the community.
SUMMARY
This article describes a detailed study of knowledge, attitudes, and practices about IDD in a severely iodine-deficient area in northern Luzon in the Philippines. Of the 400 subjects questioned, only 30% recognized that the goiter came from iodine deficiency. Thirty-one percent thought it came from drinking water. Other frequent responses attributed goiter to ferns growing near a spring, constant shouting of women in labor, drinking very cold or very hot water, or that it was a natural occurrence, since everyone had it. Respondents more likely to attribute the goiter to iodine deficiency were, in general, younger, urban, better educated, and more affluent. Folk medicine remedies were frequently applied, and included massage of the neck with a hot ladle, wrapping the neck with a particular fruit or occasionally kerosene, and local herbs, particularly burburtak. Lack of accessible orthodox medical care favored the folk treatments, particularly in isolated areas; these areas are also the ones in which iodine deficiency is most severe. The authors emphasize the importance of public information, involvement of schools in the educational program and transmitting messages about iodine deficiency in terms that will be understandable and acceptable to the target population. This study and its conclusions provide a valuable example of the problems involved in translating public will towards IDD correction into a sustainable reality at the grassroots level.
ECSA Salt Iodization Meeting - The first regional consultation on accelerating universal salt iodization in the Eastern and Southern African Region was held in Dar-Es-Salaam, Tanzania, November 29-December 1, 1994. The meeting was organized by UNICEF ESARO and hosted by the Government of Tanzania with UNICEF support. Over 80 high officials from 16 ESAR countries (Angola, Botswana, Burundi, Eritrea, Ethiopia, Kenya, Madagascar, Malawi, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe) met with representatives of the salt industry, ICCIDD, Commonwealth Regional Health Community (CRHC)/ECSA Nutrition Secretariat, donor agencies, staff from UNICEF ESAR country and Regional offices including the Regional Director Mr. Cole Dodge. Recommendations were adopted for setting coordinated strategies, policies, and procedures governing the production, trade, transport, storage, quality assurance, monitoring evaluation and verification, legislation, and other matters relating to sustained universal salt iodization in the region. Implementation of the Dar-Es-Salaam recommendations by all participating countries, with support from the appropriate regional bodies (e.g., OAU, SADC, PTA, CRHC), international agencies (WHO, UNICEF, ICCIDD, MI) and the donor community, is crucial to eliminating iodine deficiency in a region where more than 90 million people are at risk.
ICCIDD Meetings, Dhaka, Bangladesh - On April 10-12, 1995, two concurrent meetings will take place. The first is a management meeting entitled "Partnership to End Hidden Hunger: Sustaining Elimination of Iodine Deficiency Disorders." The format will be to involve stakeholders, distributed among groups of 8-10, and ICCIDD members, for discussions of ways to achieve and sustain IDD elimination. The second is a scientific meeting with the suggested theme: "IDD, Nutrition, and Human Resource Development," being organized by Professor Yusuf, the Chief of Investigation for the Bangladesh National IDD Prevalence Study. ICCIDD members will participate actively in presentations and discussions. The annual Board meeting will take place on April 8 and 9, also in Dhaka. Further details from Dr. Hetzel or Dr. Pandav at ICCIDD.
Eighth Annual Hunger Research Briefing and Exchange - This will occur at Brown University, Providence, RI, USA, April 5-7, 1995. This annual conference will discuss how governments and other groups can collaborate to make overcoming hunger part of the broader sustainable development goals of economic growth, positive political change, environmental protection, public health and education. For details, contact Dr. Ellen Messer, Box 1831, Brown University, Providence, RI 02912, USA.
Fifth International Course on Food Processing, Wageningen - Scheduled for August through November, 1995, two course programs are offered, one on quality assurance and marketing in food processing enterprises, the other on food fortification for the elimination of micronutrient malnutrition. Further details from the International Agricultural Center, P. O. Box 88, 6700 AB Wageningen, The Netherlands.
Report on Strengthening Medical Curriculum in IDD - Dr. R. R. Bharti, State IDD Program Officer, U.P., Lucknow, India, has made available a report on two workshops held in 1992 and 1993, one dealing with IDD in the clinical curriculum, the other in the preclinical studies. The workshops were held to make faculty aware of the importance of IDD, to consider how information on IDD could be included in physician training, and to learn the views of faculty and students on achieving this end. Further details are available from Dr. Bharti, K.G.'s Medical College Campus, Lucknow 226003, India.
Iodine content of infant formulas and iodine intake of premature babies: high risk of iodine deficiency. S. Ares, J. Quero, S. Durán, M. J. Presas, R. Herruzo, G. Morreale de Escobar, Hospital La Paz and Universidad Autónoma, Madrid, Spain. Arch Dis Child 1994; 71:F184-F191.
The authors measured the iodine content in samples of breast milk as well as in 32 infant feeding formulas from Spain and in another 127 from other countries. In Spain breast milk contained 10 mg iodine/dl. The paper gives data on individual commercial neonate formulas, follow-up formulas, and special formulas. The different brands showed rather wide variation, and all but one were lower than the range of maternal milk. The issue of optimal levels has been discussed before in the IDD Newsletter (vol. 8, no. 2, May 1992, page 17), reporting an international workshop that recommended a daily iodine intake of 90-120 mg in young infants, and proposed that the iodine content of formula milk be increased from previous recommendations of about 5 mg/dl milk, to 10 mg/dl for full term and 20 mg/dl for preterm infants. Data from this paper show that only one of the commercial formulas tested approaches these levels. The paper also gives useful information on consumption levels for infants, as follows: for small premature babies (27-30 weeks gestation) about 70 ml/kg six days after birth, 105 ml/kg three weeks post-natally, 150 ml/kg at two months and about 175 ml/kg by three months. The paper also summarized data on human breast milk from several different countries ranging from 1.5 mg I/dl in parts of Germany to 17.8 mg/dl in the United States. Of infant formulas collected from 15 countries, mostly from Europe but also from Japan, Canada, and the United States, the iodine content ranged from 3.3 to 17.0. Each of several large corporations sold preparations that differed considerably in iodine content in different countries. The authors note that the prevailing recommendation of 3.5 mg/dl, endorsed previously by several professional groups in the Europe and the United States, are considerably lower than found in breast milk, and lower than those proposed in 1992 by ICCIDD and others. The overall conclusion of the paper is that many infant formulas are clearly inadequate in the iodine they supply to neonates.
Thyroid volume and urinary iodine in school children and adolescents in Slovakia after 40 years of iodine prophylaxis. P. Langer, M. Tajtáková, J. Podoba, Jr., L'. Kost'álová, R. Gutekunst, Institute of Experimental Endocrinology, Slovak Academy of Sciences, Bratislava, Slovakia. Exp Clin Endocrinol 1994; 102:394-398.
Slovakia has historically been iodine deficient and endemic goiter was formerly common. A 1960 survey showed palpable goiter in 70% of adult women and median urinary iodines were below 50 mg/24 hours. Shortly afterwards, mandatory iodization of salt with KI was begun, and since 1965 has been at the level of 25 mg KI/kg salt. In this study the authors offer data on thyroid volume related to age in 4,254 schoolchildren aged 6-18 from 12 districts. For example, the median thyroid volume for 13 year olds of both sexes was 5.2 ml, a figure close to that of iodine-sufficient populations. The median urinary iodine was slightly less than 10 mg/dl; 51% were below 10 mg/dl, and 15% were less than 5 mg/dl. The authors concluded that the present level of iodization is nearly satisfactory for children, but higher levels may be necessary during the rapid growth of adolescence. They also note improvements in the program that should be considered, including use of KIO3, more frequent monitoring and better packing.
Timing of vulnerability of the brain to iodine deficiency in endemic cretinism. C. Xue-Yi, J. Xin-Min, D. Zhi-Hong, M. A. Rakeman, Z. Ming-Li, K. O'Donnell, M. Tai, K. Amette, N. DeLong, G. R. DeLong, Xinjiang Anti-Epidemic and Health Station, Institute of Endemic Diseases Research, Tianjin Medical College, China; and Duke University Medical Center, Durham, NC, USA. N Engl J Med 1994; 331:1739-1744.
This study took place in an area of western China with severe iodine deficiency, characterized by 54% visible goiter, median urinary excretions of 10-25 mg/l, and a cretinism prevalence of 2%. Pregnancy outcomes were evaluated in relation to the timing of treatment. Progeny were assessed by head circumference, neurological examination, and testing for cognitive and motor development, and results compared with untreated children who had been evaluated before the study began. The authors found that 2% of 120 infants whose mothers were treated in the first two trimesters had neurological abnormalities, compared with a figure of 9% for those treated during the third trimester or after delivery. Thus, treatment after the second trimester did not affect neurological outcome, but improved it if given earlier. Both head circumference and development quotient (DQ) at two years were improved in the treated children. Values for DQ were 83 (for all treated during pregnancy), 77 (first trimester), 90 (second trimester), 80 (third trimester), 79 (first three months postnatal), 80 (3-12 months postnatal), or 75 (untreated). Data from the first trimester were confounded because a change in the program for that group, the last one recruited, resulted in inadequate iodine supplementation. The authors conclude that iodine treatment before or during the first six months of pregnancy can prevent the damage of iodine deficiency to the developing brain. Later treatment improves brain growth and development score, but may not prevent brain damage.
An editorial appearing in the same issue of the New England Journal by Dr. Hetzel further reviewed international experience on the value of iodine supplementation in preventing neurological damage from iodine deficiency.
Thyroid volume measurement by ultrasound in children as a tool for the assessment of mild iodine deficiency. P. Vitti, E. Martino, F. Aghini-Lombardi, T. Rago, L. Antonangeli, D. Maccherini, P. Nanni, A. Loviselli, A. Balestrieri, G. Araneo, A. Pinchera, Istituto di Endocrinologia, University of Pisa, Pisa; Istituto di Clinica Medica, University of Cagliari, Cagliari, Assessorato Sanita, Comune di Pescopagano, Italy. J Clin Endocrinol Metab 1994; 79:600-603.
The authors compared thyroid size by ultrasound in 268 schoolchildren from an iodine-deficient area (median urinary iodine excretion 7.2 mg/dl) with 2,693 from iodine-sufficient areas (median urinary iodine excretion 110 mg/l). At all ages thyroid volume was statistically greater in the iodine-deficient areas. For example, for eight year olds the median in the controls was 3.3 ml versus 4.2 ml for iodine deficient, and for 13 year olds, 6.1 ml versus 8.1 ml. The prevalence of goiter by ultrasound, expressed as thyroid volume greater than two SD's of age-matched controls, was 25% in the iodine-deficient area compared to 3.9% in children from the sufficient area. The authors also compared findings on ultrasonography with neck palpation, and found discrepant data in more than 20% of the children in the iodine-deficient area. They conclude that mild iodine deficiency caused a significant increase in thyroid size in schoolchildren, and they also confirmed that field ultrasonography is much more accurate than neck palpation, particularly in areas of mild iodine deficiency.
Iodine in British foods and diets. S. M. Lee, J. Lewis, D. H. Buss, G. D. Holcombe, P. R. Lawrance, Ministry of Agriculture, Fisheries and Food, London; Laboratory of the Government Chemist, Middlesex, England. Brit J Nutr 1994; 72:435-446.
This paper offers detailed analysis of iodine levels in samples of the British "total diet." Milk remains a major source, with average concentrations of 150 mg/kg (1990-91), compared with 230 mg/kg twelve years before. A pronounced seasonal variation was noted, from 210 mg/kg in the winter to 90 in the summer. The paper analyzes the iodine in many other sources and offers detailed tables. The highest iodine contents were in fish products. The authors conclude that the current levels of iodine in the British diet are reasonable, and that the levels in British milk are not increasing. They note that certain population groups, such as those who avoid all animal products, may be exceptions and still may risk iodine deficiency. The tables are useful for comparison with data from other countries.