Volume 12 Number 1, February 1996
IN THIS ISSUE
The Executive Board of the World Health Organization passed on January 23, 1996, a resolution concerned with monitoring the sustainability of the elimination of the iodine deficiency disorders. A resolution was submitted by Australia, supported by Vietnam, Bhutan, Nepal, Pakistan, and Israel. Time did not permit more speakers. After minor amendments, the final resolution was passed unanimously. The Board first considered a progress report by the WHO Director General that made the following points:
"1. In 1990, the World Health Assembly was the first world body to challenge the international community to eliminate iodine deficiency disorders (IDD) by the year 2000. Globally, a significant acceleration of national and international action had already begun by the mid-1980's when WHO, UNICEF, and the International Council for the Control of Iodine Deficiency Disorders (ICCIDD) convened meetings for this purpose in all regions. Following the Assembly's call for action in 1990, global awareness and action was substantially strengthened by endorsement of the end-of-decade goal by the World Summit for Children (1990) and the Montreal Policy Conference on Micronutrient Malnutrition (1991).
2. The World Declaration and Plan of Action, which was adopted by the International Conference on Nutrition (1992) and endorsed in its entirety by the Forty-sixth World Health Assembly (1993), reaffirmed this IDD goal. It also provided strategic guidance, including emphasis on salt iodization. Recognizing the nutritional triumph that achieving the goal would constitute, WHO, in collaboration with UNICEF and ICCIDD, has vigorously striven to provide up-to-date technical guidance and programmatic support to member states and the international community, including comprehensive technical documentation.
3. Knowledge of the global magnitude of IDD, and thus its real significance for health and socioeconomic development, has improved considerably since 1990. In 1993, at least 1,572 million people worldwide were at risk of IDD, i.e., living in areas where goiter rates are above 5%. At least 655 million of this number are affected by goiter, 13% in Africa, 10% in Latin America, 27% in Southeast Asia, 14% in the Eastern Mediterranean, 15% in Europe, and 22% in the Western Pacific. However, the chief motivation behind the current worldwide drive to eliminate IDD as a significant public health problem is the estimated 43 million people who are affected by some degree of IDD-related brain damage. There is encouraging evidence from countries in Africa, Latin America, Southeast Asia, and the Western Pacific that goiter prevalence rates and the incidence of cretinism are failing, particularly as iodized salt programs are established.
4. Iodine deficiency disorders are known to be a significant public health problem in 118 countries. While only 46 had national salt iodization programs in 1990, their number had increased to 83 by 1995. The majority of the remaining 35 countries are in the process of determining the magnitude and public health significance of IDD. Since 1990, 72 countries have conducted IDD surveys or re-assessments and many have established national IDD monitoring systems.
5. Frequently, despite the availability of iodized salt, consumption remains widely variable, partly due to differential pricing, insufficient communication and understanding by the public, health professionals and policy makers, and inadequate or non-existent legislation. By December 1994, 20 countries - mostly in West Africa and Eastern Europe - had no iodized salt legislation. However, from a regional and global perspective, significant progress has been achieved. Data suggest that in over 30 African countries the population consuming iodized salt has increased from less than 5% in 1992 to more than 50% in 1995. The proportion of salt that is iodized in Latin America and Southeast Asia is over 70% and about 50%, respectively.
6. Despite progress achieved, a major acceleration of action and support is needed, particularly in countries in West and Central Africa, South Asia and Eastern Europe. Furthermore, sustainability of IDD control requires major national infrastructure development to ensure continual monitoring, training, and legislation. Only with these critical elements in place can the goal of eliminating IDD by the year 2000 be achieved."
Dr. Francois Delange, Executive Director, presented the position of ICCIDD, stating:
"ICCIDD fully supports the proposal of resolution because it is logical within the framework of an action aiming at the virtual elimination of IDD by the year 2000 and because it is essential in order to reach this objective.
The progress report by the Director General has reminded this audience of the magnitude of the problem. Iodine deficiency is the main cause of potentially preventable mental retardation. The Director General has underlined the major progress achieved during the past five years through a network starting from the National IDD Committees and including UN agencies (essentially WHO and UNICEF), NGO's (essentially ICCIDD), and bilaterals. ACC/SCN harmonizes the process.
The Director General has also underlined that, despite progress achieved, a major acceleration of action and support is needed.
A new dimension of the problem which is underlined both in the report of the Director General and in the project of resolution, is the absolute necessity to ensure sustainability of the elimination of IDD by continued monitoring of the programs. Correction of iodine deficiency does not escape the universal rule in preventive and curative medicine that the effects of any intervention have to be evaluated and their sustainability monitored on a short and long term basis. Establishing legislation and implementing procedures, essentially plants for salt iodization, are prerequisites but are not sufficient to guarantee the efficiency, safety and benefit of the programs, especially if our deadline for success is within five years. As a matter of fact, we know that the risk of side effects induced by iodine supplementation such as transient thyrotoxicosis is directly related to the time interval elapsed between the initiation and the completion of the correction of iodine deficiency. There are examples in the world today where the optimal efficiency of programs of iodine supplementation is not achieved because of insufficient components of evaluation and monitoring.
ICCIDD is recognized by WHO as the expert international body on iodine deficiency disorders. It is a comprehensive consultancy resource, ready to provide services to countries and agencies, including and especially for evaluation and monitoring. The methodology has been carefully elaborated and the main power is available within ICCIDD, which is presently involved, at the request and in collaboration with governments and UN agencies, in programs of independent evaluation in about 25 countries in Europe, Africa, Asia and South America.
The ultimate goal is almost achieved. It can be achieved very quickly at a reasonable cost. IDD virtual elimination could be used as a model for other similar programs. However, the official support of this assembly is essential to help the national health authorities and the competent professional bodies to collaborate towards the achievements of the goal."
In commenting on the approval of this resolution, Dr. Basil Hetzel, Chairman of ICCIDD, noted: "The resolution provides the necessary mandate for the role of the ICCIDD in monitoring and independent evaluation of national programs in cooperation with governments and international agencies. It is also significant that a further reporting date (1999) is included in the resolution. In view of the strong support evident at the Executive Board level, the passage of the resolution by the World Health Assembly (attended by 180 countries) can be confidently expected."
In October 1995 ICCIDD accepted an invitation from the Government of Paraguay to consult on its IDD program. Dr. Eduardo Pretell, ICCIDD Regional Coordinator of the Americas, and Dr. John Dunn, ICCIDD Secretary, visited Paraguay, met with officials in the Ministry of Health and the IDD Control Program, inspected several of the major salt processing plants, and conducted a field trip to Misiones. They heard presentations from each of the Health Regions of the country, and offered comments and suggestions to the Ministry. The following report highlights some of their findings and recommendations. ICCIDD is indebted to the Ministry of Public Health and Social Welfare, and particularly Ms. Griselda Miranda, for sharing information with ICCIDD.
Background
IDD has long been present in Paraguay. Details have been previously reported in the IDD Newsletter (most recently vol. 10, page 20, May 1994 and vol. 11, page 8, February 1995). The last national survey conducted in all the Regions showed a goiter prevalence of 49% and urinary iodine levels correspondingly low, with a median value of 7.0 mg/dl and 30% below 5 mg/dl.
A control program was created in the Ministry of Health and Social Welfare in 1992, with the name Programa Nacional de Prevención y Control de DDI (PRONACDDI), through Resolution RG 23, which established that all salt sold in the country for human or animal consumption should contain potassium iodate in the proportion of 67-100 ppm of salt (equivalent to 40-60 ppm of iodine) and mandated annual registration of importers and processors. This Resolution was later reinforced through Presidential Decree #5401 on September 5, 1994. At the same time the Compromiso de Asunción of September 15, 1994 declared that all the people have a right to receive adequate quantities of iodine in their food, and urged the Government and all involved to cooperate towards this objective to achieve the goal of universal salt iodization in 1995.
Current Status
PRONACDDI exists within the Department of Nutrition of the Ministry of Public Heath and Social Welfare. Its regional activities are carried out by health personnel of each Region, who also have other responsibilities. The program has technical support from the central laboratory for determination of iodine in salt and urine.
The strategies of the program include the following: (1) extension of coverage with iodized salt throughout the country; (2) community participation through organized groups; (3) multisectoral coordination; (4) institutional strengthening; (5) intersectoral coordination among the Ministry of Health, other government institutions, and private industries; (6) distribution of laboratory results to authorities at all levels; (7) design and implementation of a system for surveillance, monitoring, and program evaluation; (8) intensive education, communication, and social marketing; and (9) establishment of a team for technical standards at the central level.
Salt
All salt is imported, most from Argentina, some from Brazil. The major importer sells both iodized and noniodized salt to the three major packagers/iodizers/distributors, all in the Asunción area. The major importer is currently purchasing a large modern plant with high capacity for salt iodization. The three major packagers use simple iodization technology, one a spray and the other two a dry mix of potassium iodate. Quality control is by occasional testing with a kit.
The Ministry of Health estimates an annual need of 22,500 metric tons of salt for human use, 67,700 for animals, 3,420 for industry, and 580 for other uses, a total of 94,200. The salt actually registered as imported through normal channels represents only about 20% of the country's total need, suggesting that much of the remainder is contraband.
Potassium iodate is the iodizing compound. It is purchased from Chile, apparently by the Government through UNICEF, and then resold to the producers at rates variously described as from $15 to $26 per kilogram. As noted above, the law specifies potassium iodate at 67-100 ppm, which translates to approximately 40-60 ppm as iodine; there is occasional confusion as to which form (iodine or iodate) is being discussed.
The estimated per capita consumption is 15 grams per day, of which about 50% is iodized. The cost of iodized salt in major urban areas is US $0.60/kg, whereas the price of the noniodized product is US $0.38. Of 529 salt samples collected from the country, 37% had no iodine, 30% had 1-19 ppm (as iodine), 21% had 22-49 ppm, and 39% had 50 or more ppm. Of these salt samples, 24% were coarse, the rest fine or semi-fine. In general these data did not vary greatly among different parts of the country.
A system of education and monitoring for iodized salt was being established in 1995 in the 13 departments of the country. This system uses inspectors from the Servicio Nacional Saneamiento Ambiental (SENASA), distributed throughout the country, to collect samples of salt from consumption centers as well as from the producers and importers. The personnel for monitoring include 12 inspectors from SENASA, a laboratory technician for salt control, a technical assessor for industries, and a biochemist for the laboratory.
Biological Monitoring
Several studies of goiter prevalence in the Regions in 1994 have been reported. These include estimates of 34% in Misiones and 48% in Cordillera. Samples for urinary iodine have been collected, and most still await laboratory determination. Recent figures were that 52% of the urines from Misiones and 78% of those from Caazapa had more than 5 mg of iodine/dl urine.
Education
This has been a vigorous activity at all levels and for all targets. The Ministry has conducted programs for health personal, teachers, and students. In turn, at the provincial level some teams, particularly those in Misiones, Cordillera, and Guiara, have been active in schools and with teachers; most children in Paraguay attend school (approximately 80% by one estimate), at least for the elementary grades. The enthusiasm and innovation in these educational efforts have been impressive. Some examples are included in the accompanying photographs. The programs for students include plays, songs, contests, and dances. At the provincial level special efforts have been made to involve the press and municipal governments in learning about IDD. The Ministry of Health in Asunción has vigorously supported these regional efforts. UNICEF has also been a major supporter towards the goal of universal salt iodization.
Summary
Paraguay has shown commendable vigor in its attack on iodine deficiency during the past five years. The program is growing, thanks to the hard work of central and regional government officials as well as the general population. The educational efforts have been particularly impressive. However, all recognize that there is much to be done with further implementation of salt iodization and effective monitoring. A continuation at the current level of effort offers optimism for success in eliminating IDD from Paraguay.
The Newsletter thanks Dr. Andrés Vidovich, Minister of Health, Dr. Rafael Figueredo, Director, Department of Nutrition, Lic. Griselda Miranda, Chief of PRONACDDI, Dr. Miguel Ugalde, UNICEF Representative, and Dr. José Fiusa Lima, OPS Representative, and many other health workers in Paraguay, for providing information for this article.
In mid-1995, Dr. C. S. Pandav, ICCIDD Regional Coordinator for Southeast Asia, led a team to investigate the status of iodine nutrition in the Maldives, in conjunction with the Department of Public Health, Government of the Republic of Maldives, with support from UNICEF. The following is an abstract from his report.
The Republic of Maldives is an 820 km archipelago in the Indian Ocean, to the southwest of Sri Lanka and India. It comprises a group of 1190 small coral islands forming 26 atolls. About 200 of the islands are inhabited. They are small, rarely exceeding 1 sq. km, and low-lying, with an average elevation of 1.6 meters above sea level. The country's total population is 235,000, of which about one-quarter live in Male', the center of administration.
A survey for goiter was carried out in a total of 30 schools, from which 2834 children were examined from seven atolls. About 2/3 of the children were age 8-10, the remainder were 6-8 or 10-12, with equal distribution between boys and girls. All examinations were carried out by Dr. Pandav.
The total goiter rate of the 2834 children was 23.6%. It was slightly higher (29.4%) in the 10-12 year olds, 23.4% in the 8-10 year olds, and 21.5% in the 6-8 year olds. The rate for females was 26.6% and 20.7 for males.
A total of 316 urine samples were analyzed for iodine content. The median was 6.7 mg/dl, with 65.5% being below the recommended level of 10 mg/dl.
Iodine was also measured in a few sources of drinking water. Of ten samples of rain water, the mean iodine content was 1.65 mg/l; five samples of well water, 38.8 mg/l; three samples of ground water, 6.2 mg/l, and one sample of desalinated drinking water, 2.9 mg/l.
A total of 39 salt samples from three different producing companies were measured for iodine content. Samples from two of them (Siem Trading Company and Moon Star) had no iodine. Twenty-eight samples from Flying Man showed three with an iodine content greater than 15 ppm, 19 with less than 15 ppm and six with no iodine. A rapid assessment from a few families suggested an average salt consumption of 10-15 grams per person per day. Salt is stored in covered plastic containers. In most households it was kept near the fireplace. Salt labeled as "iodized salt" was rarely available.
The staple diet was rice and tuna fish. In many places the head of the tuna fish, which by virtue of containing the thyroid gland is rich in iodine, is not eaten. Also, fish were usually cooked in open pots, possibly leading to the loss of iodine by evaporation. In general, people did not eat reef fish, which are known to consume seaweeds rich in iodine.
The survey team conducted discussion sessions with community members to sensitize them on the importance of IDD as a public health problem. None of the communities were aware of goiter and the problems associated with it, or of iodized salt. Table salts, imported from Singapore and Thailand, were not tested for iodine content. The data above on kitchen salt were brands imported from India.
Dr. Pandav's team made several recommendations. They recognized the existence of mild iodine deficiency in the Maldives, and recommended universal salt iodization to combat it. They noted the need for effective monitoring of the iodine content of salt. They also propose a need for education and communication activities, directed at policy makers, doctors and health professionals, traders, teachers, and the community itself. They also proposed a follow-up survey in three years.
The Government has shown keen interest in developing legislation regulating the importation of iodized salt, as the preferred measure to control IDD. Meetings with selected traders have been organized by the government for briefing about IDD. Many of the traders have already committed themselves to import iodized salt even without formal legislation. The report notes the need for some modifications in trade policies to monitor and control the arrival of goods such as salt.
This article is extracted from a report by David Haxton, ICCIDD Board member and UNICEF consultant
"Aji khiivek duustal, davs khiiel uustal." This Mongolian proverb, "Do work until the end, if you have started it; stir the salt until it melts, if you have added it to the soup," describes the persistence of the leaders of the Mongolian government in addressing elimination of IDD in the country. Mongolia has an average elevation of 1600 meters, a temperature range from +20· C in summer to -25· C in winter, an area of 604,670 square miles (about half the size of India), and a population of just over 2.2 million people, of which 600,000 live in the capital city and Aimag, Ulaan Baator (Aimag is a political subdivision headed by an elected governor).
Discussions about IDD began just after the political changes and election of a government in 1990. An interministerial team drafted a National Program of Action for Children in Mongolia that was officially released by the Government in May 1993. This program was a direct response to the challenge of the 1990 Global Summit on Children that called for the elimination of IDD by the year 2000. Endemic goiter had been recognized in most parts of Mongolia, and in late 1993 the Government, with assistance from UNICEF, began a national survey to describe its extent. To carry out the survey, 20 national physicians were trained in survey techniques. Each Aimag was prepared by orientation sessions for school leaders and health centers. The survey used the cluster sampling approach, focussing on women and children aged 7-14 who had lived in the same place for more than five years, to adjust for a significant nomadic population. Data included names, location, sex, age, and estimation of thyroid size by palpation, using the ICCIDD/WHO/UNICEF criteria. A complete report has been published in Mongolian, and is currently undergoing English translation.
A total of 36,836 children aged 7-14 were examined. The overall goiter prevalence was 28%, of which 26.4% were grade 1 (palpable goiter) and 1.6% grade 2 (visible goiter). The range, by Aimag, was from 6.0% for Umnegobi to 55.6% for Darhan-uul. Of the 22 Aimag's and other political divisions in the country, 20 had a goiter prevalence greater than 10%, 16 greater than 20%, and 6 greater than 30%, including Ulaan Baatar, with 41.8%. Figures for women were quite similar. Of 10,900 examined, the total goiter rate was 31.2%, of which 28.4% was grade 1, and 2.8% grade 2. The distribution by Aimag was almost identical to that found in children.
These results were evidence enough for the central government to propose a national effort to iodize all alimentary salt for humans and animals. They showed that a public health problem existed and that it was of national significance and priority. Foreign aid was suggested for technical assistance, supplies, equipment, and training. Some scientists remained unconvinced. Most of their resistance sprang directly from the relative absence of up-to-date information on iodine deficiency and on the progress of science to prove the value of appropriate iodine consumption for nutritional well being.
The next step was a salt survey, undertaken in early 1995. It clearly showed that domestic salt could easily be iodized. The major producer and packager located in the capital Aimag handled most of the product including imports. Smaller producers were also approached and were willing to iodize their limited production, but required assistance for the equipment, raw materials and technical guidance. Imported salt would be iodized on arrival in the country until adequate quality assurance procedures were in place in the country of purchase. Until recently all production facilities were state owned and managed, but now they are gradually being turned over to private owners. A long absence from market techniques and strategies creates difficulties in management, pricing, and sales approaches.
The Minister of Health, while recognizing IDD as a serious public health issue, was concerned that such a national endeavor needed the full support of all sectors of society to provide a political foundation for the preparation of new laws on food fortification in general and salt iodization in particular. He called for a full national debate on salt iodization, including the views from the scientific groups not yet convinced that a national IDD problem existed. To facilitate this review, the government requested technical assistance to plan and execute a National Advocacy Event. David Haxton was recruited as consultant to help prepare the meeting, plan discussions, orient participants and assist drafting of a national plan. His work with the team in Mongolia led to meetings in July 1995 in Ulaan Baator with senior government officials and other interested groups. By that time there was considerable progress in drafting a national plan and in stimulating additional interest and commitment. Salt from one major plant was already iodized and supplies and equipment for smaller units had been ordered. However, there was still resistance by some scientists and some concern about political repercussions.
The Minister of Health was firmly behind the achievement of the goal of elimination of IDD, but needed public resolution of relevant issues before announcing an official policy. The Minister of Trade and Industry gave immediate and full concurrence with the concept of salt iodization. He accepted the idea that he could encourage all industries associated with his ministry to purchase only iodized salt and agreed to work directly with the small producers as well. He could also press for regulations that all imported food be appropriately fortified.
A meeting with about 30 scientists from various disciplines revealed no outright opposition to IDD elimination. Some expressed doubts about the needs to iodize all salt, to iodize salt for animals, or to provide iodized salt to populations "not at risk." Although references were made to studies showing iodine in the water or soil in various places, supporting documentation could not be obtained.
Several important issues that are being defined and addressed in a new plan, currently under preparation, include limitations of resources, equipment, laboratories, and packaging. Particularly important are human resources, and these require training across a range of tasks and services. In addition, plans will be outlined for experience exchanges with other countries and institutions, and for training at internationally recognized centers like PAMM. Priority attention will be paid to train people in quality assurance and salt iodization.
It was agreed that a communication strategy is vital to successful development. It will fill the information gaps in science and technology and create advocacy to sustain the political will achieved. In addition, it will create a strategy for alliance building and for creating and sustaining public demand. UNICEF agreed to translate essential documents and manuals for broad distribution.
It was agreed that financial resources will be planned in one comprehensive design, tabulating national resources from the Ministries of Health, Agriculture, Education, Trade and Industry, and outlining foreign aid requirements. It was proposed that the National Advocacy Meeting required the following essential agreements: (1) the highest political commitment and participation; (2) a location of political and national significance; (3) multi-professional composition, not limited to science and medicine, and multisectoral; (4) a national plan for review; (5) a specific set of commitments from each sector; (6) participation by consumers, producers, and all elements of society; and (7) a highly significant role for the governors.
Support from the Prime Minister's office was sought, because the program was national in scope, and the National Development Secretariat was made responsible for coordination of development and of foreign aid. The National UNICEF Committee of Japan agreed in principle to support the scheme, once it had received an official and official request to UNICEF. A national plan was prepared in draft for the agreement of the National Advocacy Meeting. Meanwhile training of Mongolian nationals in China and Thailand took place, accompanied by technical visits of consultants from India and Japan.
The communications strategy was drafted with the three major objectives of creating a more enlightened political commitment, creating a permanent method of communication and information exchange among professional and civic groups to sustain alliances, and creating a sustainable public demand for iodized salt.
As an aside, the extensive network of health services in Mongolia, reaching over 90% of the country's population, provides attendance at more than 90% of births. This offers an opportunity to determine whether a nationwide neonatal screening program is feasible at the present time, and such a study was recommended to the authorities and to UNICEF.
As a gesture to initiate national plans of action, UNICEF has offered to donate potassium iodate. While this is a good step, it should be accompanied by a long-range plan by which there is a gradual assumption of responsibility within the country for this activity. One could consider an offer to the Government to buy the potassium iodate by reimbursable procurement with payment in local currency.
The President announced the National Advocacy Meeting for November 3, 1995 in the Government House. In preparation for the meeting, each ministry was approached with specific suggestions for actions it could take, and also for ideas to propose to the meeting. In addition, each Minister was briefed about the consequences of IDD on activities in his area of charge; e.g., the loss of learning capacity on education, the loss of reproductive capacity on agriculture, and loss of productivity of citizens. UNICEF assisted by translating into Mongolian various documents, including several booklets and manuals developed by ICCIDD, PAMM, the MI, and WHO.
The President attended the first two hours of the session in the company of five Cabinet ministers, all of whom spoke on specific actions each element of the Government could undertake. The President stressed the multisectoral aspects of the national plan. He was particularly concerned about the problem of mental retardation and the consequences for children, and also for investments in learning. He pressed for immediate submission of the appropriate documentation to the Great Hural (the national parliament).
As a follow-up of the National Advocacy Meeting on IDD, the Government of Mongolia adopted the National Plan of Action on IDD Elimination in Mongolia on January 13, 1996. The National Council for IDD Control established by the Government is headed by the Deputy Chairman of the National Development Board, who is the Vice Minister of Health. The National Council is committed by regulation to report on implementation of the program to the Government every year.
The meeting included 150 people from all political parties, all Aimags, consumer groups, scientific societies, relevant Government ministries (including Finance), and the press. For its current status, Mongolia now joins the expanding list of countries with a national plan to eliminate IDD that is comprehensive and multisectoral. The political commitment now achieved must be sustained. The importance of iodine to human development must be included in all learning materials and shared through all learning channels. A national quality assurance system is in its infancy and requires considerable investment to assure permanence and high professional standards. Training plans are in place and require annual renovation and stimulation. A communications strategy has been designed, and a logo for the program and for the product is approved. Following the meeting, the National UNICEF Committee of Japan pledged to support the full cost of the program for the initial three years.
This experience supports the contention that to move from policy to practice, we must make it good politics. Creating national endeavors requires the creation of sustainable alliances of national interests, both public and private. Communication is more than a message from time to time; it is a process that requires professional design and professional implementation to assure that government officials and private producers understand each other, that scientists and producers share knowledge with one another, and that the public is informed and stimulated to demand good quality service at a fair price.
The following article is adapted from a manuscript by Drs. Abdul Rahman Al-Nuaim, Yagob Al-Mazrou, Mohammed Kamel, Omer Al-Attas, Nasser Al-Daghari, and Riyad Sulimani, and kindly made available to the Newsletter by Dr. Rahman Al-Nuaim.
Little data have been available on iodine nutrition in the Arabian peninsula. In this paper the authors included 4,638 Saudi schoolchildren, aged 8-10 years old, randomly selected from different regions of the country and examined for thyroid size by palpation, using the WHO criteria. Urine samples were collected, taken to the central laboratory at the College of Science in King Saud University Riyadh, and the concentration determined after chloric acid digestion by the ceric ammonium sulfate-arsenious acid reduction method. A further examination of a random sample of 1,357 schoolchildren from areas with different geographical nature were examined by neck palpation and classified by the WHO standards.
Of the study population, 51% were males and 49% females. The mean urinary iodine concentration was 18 mg/dl for males and 17 for females. Median values for both were 17 mg/dl. Twenty-two percent had urinary iodine concentrations below 10 mg/dl. In the southern province, 44% of students had urinary iodine concentrations below 10 mg/dl, compared with 17% for the northern province, and 8% for the central and western provinces.
Of the students surveyed, 69% lived in urban communities and 31% in rural communities. There was little difference in mean and median urinary iodine concentrations between urban and rural subjects. The median urinary iodine concentration of those in high altitudes was 11 mg/dl, and 20 for low altitudes.
From the study group, 1,357 subjects in different geographical areas were examined by neck palpation. For Riyadh, in the Central Province in the desert, the goiter prevalence was 8% and the median urinary iodine 19 mg/dl. For Gizan, in the Southern Province (coastal, nonmountainous region), the goiter prevalence was 4% and medium urinary iodine 23 mg/dl. Fifa, in the Southern Province (coastal mountains), had a goiter prevalence of 25% and a median urinary iodine of 11 mg/dl. Assir, representing the Southern Province (high altitude) had a goiter prevalence of 30% and a median urinary iodine of 10 mg/dl. These data show the expected inverse relationship between goiter prevalence and urinary iodine concentration.
In reviewing these geographical differences, the authors note that the Southern Province, with the lowest urinary iodine concentration, has a high altitude, low-to-medium income and poor access to high iodine-containing foods such as fish. By contrast the Western Province had a median urinary iodine concentration of 24 mg/dl, and only 8% were less than 10. The Western Province has a low altitude, medium to high income, and easy access to fish. In other comparisons, the medium urinary iodine concentration was slightly higher in males than in females, in rural communities than in urban communities, and in low altitudes relative to high.
In separate food studies, the majority of Saudis consume food with adequate iodine concentrations. In another study, all water samples had fairly low iodine concentrations.
In conclusion, the authors note that iodine status is satisfactory in all provinces except the Southern Province, where some regions have adequate iodine status but others have mild deficiency. They recommend an iodization program for that region. In review of the official Saudi standards for salt manufacture, salt iodization is neither mandatory nor recommended. The authors propose that universal salt iodization be instituted in the country.
Several organizations including ICCIDD, UNICEF, and Kiwanis, sponsored the first annual IDD Day, on October 21, 1995 in New York. Alternate dates were chosen in some countries to better fit national schedules.
UNICEF distributed a press release to all UNICEF National Committees and field offices. It included statements by Carol Bellamy, Executive Director of UNICEF, Basil Hetzel, Chairman of ICCIDD, Kyjolfur Sigurdsson, President of Kiwanis International, Roger Moore, UNICEF Special Representative and Honorary Chairman of the Kiwanis/UNICEF Campaign to Combat IDD, and Sir Edmund Hillary, UNICEF Special Representative for the Children of the Himalayas.
The goal of IDD Day was to highlight current progress towards the elimination of IDD and to identify the problems that remain. The UNICEF announcement provided background information about IDD and the means for its correction. Ms. Bellamy noted, "During the last five years an unprecedented global assault on this nutritional problem has been made. In over 100 countries the importance of the problem of iodine deficiency was brought out of the medical service and textbooks and onto the agendas of the leaders and legislators of nations. This [IDD Day] is a good opportunity to take stock of progress and to remind ourselves that more work needs to be done. In many countries further support and effort is still required to ensure that all salt is effectively iodized. In countries that have already achieved a high level of salt iodization, efforts must be focussed on ensuring that these achievements are sustained - for without continuous vigilance, this scourge will return."
Dr. Hetzel stated "When an expectant mother suffers from severe deficiency of iodine, her child may suffer brain damage and become a cretin. If we can get everyone to use only iodized salt, we can eliminate this scourge."
Mr. Sigurdsson said, "Kiwanis Clubs have pledged to raise the $75 million needed to achieve adequate salt iodization around the world, monitor production and quality, provide remedial treatment to people already harmed by IDD, and educate populations at risk about the importance of using iodized salt."
In addition, the press release included a package of information with photos, brochures, and videos about IDD.
An example of IDD Day at the regional level is provided by Dr. C. S. Pandav, ICCIDD Regional Representative for Southeast Asia. In New Delhi on October 30, children from 30 city schools gathered to mark the nation's progress. They brought salt samples from their homes to test the iodine content. An on-the-spot painting and slogan-writing competition was organized for the children's participation. The venue was at Mothers International School, which was decorated with banners announcing the event. Student volunteers directed visitors to the exhibition and salt testing demonstration. The exhibition, consisting of a varied display of charts, posters, pamphlets and other educational material, proved to be of great interest to children from the participating schools. Students performed salt titration experiments to demonstrate to others how to test for iodine content. The painting and slogan competition produced several winners who received awards and display of their efforts.
The chief guest, Professor L. M. Nath, Director, AIIMS, toured the exhibits and salt testing demonstrations. ICCIDD was represented by Dr. Pandav, Dr. M. G. Karmarkar, and Ms. Nilima Chawla, and other ICCIDD staff. Dr. Pandav and Dr. Karmarkar spoke to the audience of participating students, teachers and others. Professor Nath also addressed the gathering and presided over presentation of awards.
Eight students made presentations on IDD. Each spoke with feeling and eloquence and demonstrated an unusually sound grasp of both the problem and its solution. Some had written rhymes and jingles about iodized salt, which they recited with great gusto. Other children also participated, asking pertinent questions which were answered by the panel. Many children volunteered to test the salt in their neighborhoods if provided with a salt testing kit. Participants and organizers pronounced the event a success in highlighting the importance of IDD and its prevention.
(Information for this report came from Dr. C. S. Pandav, and Ms. Saroja Narayanan, UNICEF Project Officer).
Joseph Benotti died in January. He was a major contributor both to thyroid research and to the international campaign against IDD.
He was born and lived most of his life in Weston, Massachusetts, USA. After receiving degrees in chemistry at the College of the Holy Cross in Worcester, Massachusetts, he worked for years as Director of the Clinical Chemical Laboratories at the New England Medical Center in Boston with Dr. Siegfried Thanhauser, carrying out significant research on lipid metabolism.
In 1953 he became co-director, with his brother Norbert, of the Boston Medical Laboratory, where he remained until retirement. There he developed methods for measuring protein-bound iodine in blood and iodine in urine. He automated these methods so that they became indispensable tools for the study of thyroid disease in the individual patients and for surveys of iodine deficiency in many countries around the world, especially Latin America and Europe. He visited many laboratories in order to help establish these methods. His techniques and his name became by-words among investigators in the iodine field everywhere. He made many important contributions to the scientific and medical literature. Everyone knew Joseph Benotti by name and reputation and many were privileged to be his friends.
At the personal level, he was warm and supportive. No one every saw him ruffled or angry, and he always had a good and complimentary word for everyone with whom he had professional or personal contact. In the larger arena of the international efforts towards elimination of IDD, those who are involved owe him a great debt. His skillful investigations and technical developments opened the way to an understanding of the pathophysiology of the iodine deficiency state, its epidemiology and its prevention.
We all extend our warmest sympathy to his wife, Louise, and to his two children.
- John B. Stanbury
Multicenter Study to Assess Impact of Salt Iodization on Iodine Status - The first phase of the study took place in November and December 1995. It included a briefing session in Yaounde and field visits with collection of urine samples in Cameroon, Kenya, Nigeria, and Zaire, currently being analyzed in Brussels. Preparation of national reports is in progress. The second phase takes place in February 1996. A briefing session for the members of the national teams and the international consultants has been scheduled for Harare on February 8-9, and includes representatives of WHO (Dr. DeBenoist), UNICEF (Dr. Kavishe), and ICCIDD (Dr. Delange). Field visits will take place immediately thereafter in Tanzania (consultants: Pandav, Locatelli-Rossi); Zambia (Todd), and Botswana (Locatelli-Rossi). In Zimbabwe the national team, including Todd and Mutamba (ICCIDD Subregional Coordinator and Chairperson of the National IDD Committee), have already collected appropriate data that will be included in the final global report.
Eritrea Inaugurates Iodization Plants - On December 21, 1995, Mr. Ogpre Abreha, the Minister of Trade and Industry, formally inaugurated the public and private salt facilities in Assab in the presence of several ministers of the Government and a delegation from Ethiopia including the Minister of Trade and Industry and the Vice Minister of Health. The industry at Assab now has a combined estimated capacity of up to 300,000 mt iodized salt annually. In Massawa, the Regional Governor, Mr. Idris Totil, inaugurated the public salt plant, with capacity of up to 100,000 mt iodized salt per year. In both ceremonies, representatives from UNICEF and several other agencies were represented. These inaugurations were the culmination of two years of continued collaboration between the governments of Eritrea and Ethiopia and UNICEF, with funding from CIDA and USAID. Frits van der Haar (ICCIDD Board member) participated in these activities on behalf of OMNI/USAID. Iodized salt from Eritrea is expected to contribute to elimination of IDD in Eritrea and Ethiopia, having a combined population of almost 60 million and a major IDD problem in both.
Independent Evaluation of Water Iodization - A proposal has been submitted by ICCIDD to the Micronutrient Initiative, in response to a request from CIDA. Dr. Benmiloud will be principal investigator for ICCIDD. Planned activities include: a review of existing information as to technology, cost, operation, results, feasibility, and comparison with other measures; interviews with providers as necessary; visits to selected sites in developing countries where water iodization is being used; and preparation of conclusions and a report. The team being assembled by Dr. Benmiloud will include specific expertise in water engineering and socioeconomic assessment, as well as in IDD. Others from the ICCIDD Board assisting Dr. Benmiloud include Bailey, Delange, Dunn, Lantum, and Pandav.
Technical Review of Iodine-induced Hyperthyroidism (IIH) - A two-day ICCIDD meeting of technical experts representing diverse aspects of the IIH issue and its solution is scheduled for early March in Boston, chaired by Dr. John Stanbury. Topics include the following: comprehensive review of literature and some key recent examples; rapid update on iodine physiology and its alterations in iodine deficiency; human iodine requirements; laboratory assessment; clinical assessment; treatment of individuals; and prevention. Sponsorship and organization is by ICCIDD, with financial support from several industrial sources and foundations. The assembled information and discussion will be published and provide a technical foundation for policy decisions by international groups, including ICCIDD.
A.L.G.E.P.A. (Association pour la Lutte contre le Goitre Endémique et les Pathologies Associées; Association for the fight against endemic goiter and associated pathologies) - This nonprofit organization has set up an award to promote research and prevention in the field of iodine deficiency disorders (IDD). The award is of FF 30,000 (US $6,000). There are no limits of age for the candidates. The application may vary from focused research by young scientists to broad overview of lifelong actions by senior investigators. The evaluation of the proposals will be made by an international jury of 14 known experts in the field of IDD chaired by Professor F. Delange. Applications forms can be obtained from: A.L.G.E.P.A., 55, Boulevard Pereire, 75017 Paris, France; telephone (33-1) 45 91 76 18, fax (33-1) 45 91 51 99. The deadline of the applications is May 31, 1996.
THE AMOUNTS OF IODIZED SALT NECESSARY FOR INDIA TO ACHIEVE UNIVERSAL SALT IODIZATION. U. Kapil, K.S. Sohal, T.D. Sharma, D. Nayar, M. Goel, Department of Human Nutrition, All India Institute of Medical Sciences, New Delhi.
Iodine deficiency has ill effects on domestic animals as well as on humans. In general, iodine deficiency in animals decreases production of milk, meat, eggs, and wool, and increases the rate of stillbirths and miscarriages (1-3).
The Government of India has formulated a policy of universal salt iodization, setting as its goal the production of 5.2 million tons per year iodized salt, originally projected for the year 1995. The requirement for iodized salt is presently calculated on the basis of 6 kg/person/year (1), to cover both human and animal consumption. This calculation assumes a per capita salt consumption of 10-15 g/day for humans. Thus, of the 6 kg/person/year in the overall calculation, humans require about 3.6 kg, leaving only 2.4 kg/year for animal consumption. The present paper addresses the type and amount of salt for domestic animals in India, because no previous investigation has provided these data.
METHODOLOGY
This study was carried out in three districts, two in Himachal Pradesh and one in the National Capital Territory of Delhi, by assessing one block in each district and two villages in each block. A total of 501 households were studied. In each the person responsible for animals was interviewed with a structured questionnaire to obtain information on number of animals, type and amount of salt given to animals, and frequency of salt purchased for animal consumption.
RESULTS
The 501 households had a total of 1,037 animals, including buffalo, ox, Jersey cows, sheep, local cows, goats, and a few dogs and horses. Salt was provided either as common salt or in crystalline form, in approximately equal amounts. About 67% of the households purchased salt separately for animal consumption, while the remainder purchased it along with that for the human occupants. About 65% of the families purchased salt on a monthly basis.
Most animals received salt either daily or at least weekly. Most households (65%) gave more salt in the winter, and some gave further additions in the rainy season (23%) and summer (12%). The following are mean daily amounts of salt provided, by species: buffalo, 31.1 g ± 39; local cow, 33.9 g ± 50; Jersey cow, 50.1 g ± 60; cattle (ox), 33.8 g ± 59; goats, 11.5 g ± 13; and sheep, 16.6 g ± 29.
The annual report of the Division of Animal Husbandry, Government of India, 1993, records the following total numbers for domestic animals in the country in millions: buffalo, 76.77; cattle, 195.87; cows, 62.15; sheep, 44.84; and goats, 99.41 (4). Even if only 25% of domestic animals are to be provided with iodized salt, the annual requirement of iodized salt would be about 12 million tons, using projections from the current study. This figure is 7 million tons more than the present government target of 5.2 million tons for human and animal consumption. Thus, the total requirements to achieve universal salt iodization, for the entire human population and 25% of the domestic animal population, is about 15.3 million tons.
CONCLUSION
Projections from this study show that effective universal salt iodization in India, to cover all of the human population and 25% of the domestic animal population, will require about 15.3 million tons of iodized salt. This figure is about three times that of the 5.2 million tons currently targeted by the Government. The targets for iodized salt production need to be revised upward if universal salt iodization sufficient for all human and at least 25% of the animal population is to be achieved.
REFERENCES
SOME FACTORS INFLUENCING LOSS OF IODINE FROM IODIZED SALT. U. Kapil, S. Prakash, A.D. Shah, D. Nayar, Department of Human Nutrition, All India Institute of Medical Sciences, New Delhi.
Iodine can evaporate from iodized salt. Conditions increasing such losses include use of potassium iodide rather than iodate, impurities in the salt, high humidity, porous packaging material, exposure to heat and sunlight, and long intervals between production and consumption. This study assesses the effects of temperature and sunlight on loss of iodine from salt in India. All salt was obtained from reputable producers, iodized with potassium iodate, and packed in LDPE bags.
In the first experiment, salt was kept in an open tray in the laboratory in an incubator at a constant temperature of 40·C for 40 days. The initial iodine level was 53 ppm, decreasing to 50 ppm by 40 days, a loss of 5.6%.
A second experiment was similar except that the temperature was 60·, leading to steady losses of iodine, reaching 31% loss at 30 days.
In a third experiment, salt was kept in an open tray in sunlight every day for six hours (10:00 a.m. through 4:00 p.m.) and afterwards placed in an incubator at constant temperature of 40· until the next day, for a period of 22 days in the month of June. During the period, the day temperature varied from 40·C to 45·C. The initial iodine content was 53 ppm. After 22 days, the content was 29 ppm, a loss of 42% of the starting iodine. The rate of loss was roughly proportional to the duration of exposure.
This study shows significant losses of iodine from salt when exposed either to sunlight and/or to temperatures of 60·. Salt traders should be educated to store iodized salt in covered shade, particularly in the summer season when the day temperature is high. Also, health workers should educate housewives to keep salt away from the cooking fire in the kitchen to avoid iodine losses.
REVIEW OF EXPERIENCES WITH IODIZED OIL IN NATIONAL PROGRAMMES FOR CONTROL OF IDD. R. Sankar, C.S. Pandav, F.U. Ahmed, P. Rao, M.P. Dwivedi, V. Desai, M.G. Karmarkar, L.M. Nath, New Delhi, India. Indian J Pediatr 1995 62:381-393
This review was undertaken to address concern of some in India that iodine supplementation during pregnancy might have adverse effects on fetal development. It reviews 14 field trials using iodized oil and various national programs. Most of these have been reviewed in previous issues of the IDD Newsletter. These studies included administration with either oral or intramuscular iodized oil. The review particularly addresses a pilot study in Uttar Pradesh in 1983 (Kochupillai and Godbole 1986 Bull NFI, 7:4). Of about 12,000 women given 1 ml of Lipidol intramuscularly, most had satisfactory levels of urinary iodine almost four years after injection, and iodine in breast milk of mothers who received iodized oil in pregnancy was about four times higher than that of non-injected mothers. However, iodized oil given in the last trimester did not appear to reduce the incidence of neonatal hypothyroidism. Cord blood thyroxine and TSH levels were studied in 154 children born to mothers who had received iodized oil during pregnancy. Sixteen of these had neonatal hypothyroidism; the mean time of iodized oil administration to the mothers in this subset was 3.5 weeks before delivery. In a comparable group that did not receive iodine supplementation, the incidence of neonatal chemical hypothyroidism ranged from 4 to 14%, essentially the same as in the ones whose mothers received iodized oil late in pregnancy. The reviewers conclude that the incidence of neonatal hypothyroidism does not change if iodized oil is given in the last month of pregnancy. However, that study does not justify a conclusion, drawn by others, that iodized oil injection during pregnancy is harmful and causes neonatal chemical hypothyroidism.
The authors note that Jodbasedow (iodine-induced hyperthyroidism) has been a rare complication among the published studies, less than 0.4% for series totally 3,319 subjects. Most of the cases were in elderly women with multinodular goiter.
The authors conclude that iodized oil is safe, and decry the hesitation in India to administer iodized oil to areas in need while awaiting effective penetration of iodized salt. They note that the northern and eastern states of India that are severely iodine deficient have a total of 378 million people, and extrapolating from available indicators of IDD severity, they calculate that approximately 200 million people live in areas of severe iodine deficiency, and from a crude birth rate of 30 per 1000, they estimate that 6 million children in the severely iodine-deficient regions are born each year. They make a strong plea for immediate intervention with iodized oil in these areas while awaiting the effective penetration of iodized salt.
TOWARDS THE ELIMINATION OF IODINE DEFICIENCY DISORDERS IN INDIA. C.S. Pandav and K. Anand, All India Institute of Medical Sciences, New Delhi. Indian J Pediatr 1995 62:545-554.
This paper provides a concise and comprehensive summary of the current state of IDD in India. Much of the information has been presented elsewhere in the Newsletter, particularly vol. 11, no. 4, November 1995. The authors note that while a ban on the sale of non-iodized salt has been in force in 21 states and 5 union territories, salt for animal consumption is not included at present. As is common elsewhere, the presence of both non-iodized and iodized salt in the market, the former somewhat cheaper and ostensibly for animal use, poses a major loophole to universal salt iodization effectiveness. Other major needs include increased training, education on the importance and safety of iodized salt, more vigorous monitoring, more extensive community participation, and the need for a continuous political and financial commitment.
CHILDHOOD IQ MEASUREMENT IN INFANTS WITH TRANSIENT CONGENITAL HYPOTHYROIDISM. F. Calaciura, G. Mendorla, M. Distefano, S. Castorina, T. Fazio, R.M. Motta, L. Sava, F. Delange, R. Vigneri. Cattedra di Psicologia, Università di Catania, Catania, Italy; Université Libre de Bruxelles, Brussels, Belgium. Clin Endocrinol 43:473-477, 1995.
This paper provides long range follow-up (6.1-9.6 years) of nine infants identified with transient congenital hypothyroidism by an elevated TSH on pilot screen for congenital hypothyroidism in an area of iodine deficiency in Sicily. In each the cord serum TSH and T4 indicated hypothyroidism but these reverted spontaneously to normal within a few weeks, and they were not treated with thyroid hormones. These nine children were compared with a control group of the same age born in the same area at approximately the same time but having normal thyroid function at birth.
Data for selected variables follow, the controls first, then the transient hypothyroids; significant differences (p < 0.05 or less) are noted by an asterisk: weight at birth (g), 3090 vs 3120; cord serum TSH (mU/ml), 8.0 vs 132*; cord serum T4 (nMol/l), 117 vs 48*; age at follow-up (years), 8.2 vs 7.4; thyroid volume (ml), 5.2 vs 6.1; serum TSH (mU/ml), 2.4 vs 4.3; T4 (nmol/l), 120 vs 108; T3 (nmol/l), 2.67 vs 2.54; Tg (mg/l), 132 vs 268; performance IQ, 89.2 vs 75.0*; verbal IQ, 96.2 vs 84.4; global IQ, 90.0 vs 78.3*.
The more hypothyroid at birth, the more severe the intellectual impairment on follow-up. Four children with elevated TSH's and low cord serum T4's had average IQ scores approximately 10 points lower than those of less severely affected children.
The authors conclude that even the transient deficit of thyroid function in the neonatal period of children born in an area of endemic goiter leads to an IQ significantly lower than that of matched controls with normal thyroid function at birth. Thus, even short-term hypothyroidism in the neonatal period can damage intellectual potential of the infant.
CARENCES NUTRITIONNELLES EN IODE. C. Jaffiol, J.C. Manderscheid, F. de Boisvilliers, L. Baldet, J. Bringer, L. Rouard. Service d'Endocrinologie, Hôpital Lapeyronie, 34000 Montpellier, France. Cah Nutr Diét 30(3):176-182, 1995.
This concise review in French summarizes the causes and consequences of iodine deficiency, daily needs and sources, clinical and laboratory markers and geographical distribution. It concludes with a description of iodine prophylaxis.
IODINE DEFICIENCY IN SCHOOLCHILDREN OF THE DOMINICAN REPUBLIC. This national study was prepared by the Centro Nacional de Investigaciones en Salud Meterno Infantil, Santo Domingo Republic of Dominicana, 1995. A summary has been transmitted to the IDD Newsletter by Ms. Patricia Garcia, Communication and Information Officer, UNICEF, Dominican Republic.
These data were part of a general survey for micronutrient nutrition in the Dominican Republic schoolchildren. The study population of 4,033 schoolchildren, aged 6-14, were assessed for goiter, and of these 837 had urinary iodine measured. The overall prevalence of goiter was 5.3%, higher in age group 10-14 (7%), urban areas, students of public schools and in the regions of Azua (12%) and La Vega (7%), particularly in higher elevations. For the purposes of this study, a urinary iodine of less than 7 mg/dl was taken as deficient. By this criterion, 74% of the schoolchildren had low urinary iodine levels, and 42% were described as having a severe deficit, reaching 89% in some areas. Only 5% of the salt consumed in the children's homes was iodized.
The report makes a number of general recommendations about micronutrient deficiency in the country. Some that apply particularly to iodine are as follows: (1) improve family's economy; (2) improve education, particularly, those components aimed at better nutrition and feeding; (3) improve food production in the family in the community; (4) ensure iodized salt for human and animal consumption; and (5) promote community activities in organizing and participating in feeding and nutrition activities.
ABSTRACTS PRESENTED AT 11TH INTERNATIONAL THYROID CONGRESS, TORONTO, SEPTEMBER 19, 1995, published in Thyroid 5, Suppl 1, September 1995. The following are abstracts prepared by the IDD Newsletter from the printed abstracts and presentations.
CONGENITAL HYPOTHYROIDISM SCREENING PROGRAMS PROVIDE A SENSITIVE METHOD FOR THE IDENTIFICATION OF POPULATIONS AT RISK FOR ENDEMIC GOITER. G. Costante, O. Ludovico, M. Nocera, G. Parlato, E. Schifino, M.F. Marasco, U. Crocetti, C. Capula, S. Filetti. Cantanzaro, Italy, page S-21.
This study reports data from the congenital hypothyroidism screening program in Calabria, Italy, where the mean urinary iodine level ranges from 47 to 75 mg/g creatinine in some areas. Of those TSH levels on whole blood of 21,674 infants tested at day 5 of life in 1993, 0.9% of TSH levels were greater than 20 mU/ml, the established cutoff for neonatal hypothyroidism. Of these 14 had permanent congenital hypothyroidism. The median neonatal TSH was 2 mU/ml, with a 95% cutoff at 20 mU/ml. A highly significant correlation was observed between neonatal TSH values between 10 and 20 mU/ml and the prevalence of goiter in schoolchildren in the same area. The authors conclude that congenital hypothyroidism screening programs are useful indicators of the degree of iodine deficiency in the region.
INCIDENCE OF CONGENITAL HYPOTHYROIDISM (CH): AN INDICATOR OF IODINE DEFICIENT AREAS IN ITALY. M. Sorcini, A. Oliveri, C. Fazzini, E. Medda, M.E. Grandolfo, F. Aghini-Lombardi, P. Balestrazzi, G. Giovannelli, S. Carta. Rome, Pisa, and Parma, Italy, page S-37.
The National Registry of Congenital Hypothyroid Infants established in Italy in 1987 currently covers 99% of live births and reports a mean CH incidence of 1:3200. Of these 20% had normal glands (i.e., were not athyreotic), a percentage that increased to 31% in areas with a CH incidence greater than 1:2000. When compared to infants with agenesis or ectopia, the infants with normal glands had a significantly lower mean gestational age, lower weight and length at birth, and higher incidence of prematurity and respiratory distress syndrome. On recall this group with normal thyroids had less severe hypothyroidism by T4 and TSH values. The areas with a CH incidence greater than 1:2000 showed that 75% of the recalls had transient hypothyroidism. In some, an association with iodine deficiency has been documented. The authors conclude that neonatal screening is a particularly sensitive indicator of population iodine status and can help identify even mild iodine-deficient areas.
LONGITUDINAL STUDY OF IODINE DEFICIENCY IN NEWBORNS OF THE REUNIFIED PARTS OF THE CITY OF BERLIN. A. Grüters, K.P. Liesenkötter, B. Stach, H. Willgerodt, H. Helge. Berlin and Leipzig, Germany, page S-37.
East Berlin previously had an effective national iodine supplementation program, not found in West Berlin. Screening with TSH between 1991 and 1993 in the reunified Germany showed that urinary iodine concentrations were still higher in newborns from East Berlin than from the West, and their TSH levels were lower (0.8 versus 1.8 mU/ml in 1991, 0.94 verus 1.9 mU/ml in 1993). There were no differences in T4 serum levels. The authors point to the value of TSH screening for monitoring iodine deficiency, and underline the need for effective iodine supplementation in this area of Germany.
EXPERIENCE WITH ORAL IODIZED OIL IN THE REGION OF RUSSIA WITH MILD IODINE DEFICIENCY. N. Sviridenko, N. Mayorova, B. Mishenko, M. Arbusova. Moscow, Russia, page S-29.
A total of 837 schoolchildren in an iodine-deficient area near Moscow received a single dose of 200 mg iodine orally as Lipiodol. The goiter prevalence by ultrasonography ranged from 31 to 61%, and median urinary iodine levels from 2.5 to 8.8 mg/dl. Median urinary iodine levels after iodized oil administration were (mg/dl): one week, 38.8; two weeks, 30; three months, 16; and 9 months, 11.3. Goiter prevalence decreased to a range of 18 to 42%, while a control group of children who did not receive iodized oil had no change. Nine months after iodized oil, the mean TSH level had significantly decreased. The authors conclude that iodized oil is a useful alternative to other methods for iodine supplementation, particularly in areas close to nuclear reactors, to prevent excessive radioiodine uptake in case of an accident when iodized salt is not currently available.
INCREASED THYROID VOLUME IN CHILDREN LIVING IN AN AREA SUBMITTED TO A RECENT IODINE PROPHYLAXIS: A CLUE TO PAST EXPOSURE TO IODINE DEFICIENCY.F. Aghini-Lombardi, L. Antonangeli, T. Rago, A.M. Bartolomei, P. Vitti. Pisa, Italy, page S-36.
The authors studied thyroid size by ultrasound in schoolchildren in an area of Tuscany that had previously been iodine deficient (urinary iodine 39 mg/l, median 22, in 1985) but subsequently had voluntary iodine prophylaxis (urinary iodine in 1993 was 98 mg/l, 88 median), and compared them with 2,693 children living in an iodine-sufficient area as controls. The following data are respectively for age in years, thyroid volume in ml in the iodine-deficient area, and volume in controls: 7, 3.1, 3.1; 8, 3.25, 3.3; 9, 3.8, 3.8; 10, 4.3, 4.3; 11, 5.1, 4.7; 12, 6.9, 5.2; 13, 7.8, 6.0; 14, 9.15, 6.4. When subjects with enlarged thyroid volumes were excluded, the median values from the previously iodine-deficient area were still higher than the controls: 12, 6.2, 5.2; 13, 7.5, 6.0; 14, 7.9, 6.4. All of the differences for ages 12, 13, and 14 years were highly significant. The authors conclude that a brief exposure to moderate iodine deficiency produces thyroid enlargement that persists even after correction of the iodine deficiency. This may account for an apparent discrepancy between a high goiter prevalence and a borderline normal iodine intake in other studies.
EARLIEST PREVENTION OF ENDEMIC GOITER BY IODINE SUPPLEMENTATION DURING PREGNANCY. K.P. Liesenkötter, H. Helge, W. Göpel, B. Stach, A. Grüters. Berlin and Leipzig, Germany, page S-38.
This study in a moderately iodine-deficient area of Germany compared 38 mothers who received 300 mg KI/day with 70 controls. The urinary iodine of the treated group increased from 53.2 mg/g creatinine (median) at the beginning of pregnancy, before iodine supplementation, to 104.5 mg/g creatinine postpartum. Iodine excretion of their newborns (77.0 mg/g creatinine), was significantly higher than that of the controls (55.6 mg/g). At birth, the newborns of the iodine-treated group had median thyroid volumes of 0.7 ± 0.3 ml median, significantly smaller than those of the control (1.5 ± 1.0). Three years after birth, 20 children from the iodine-treated group had a median thyroid volume of 1.4 ± 0.6 ml median, significantly below that of the control group, 2.3 ± 1.2 ml, although no special iodine supplementation had been given to either group after birth. The study showed that iodine supplementation during fetal life in this area of moderate iodine deficiency decreased thyroid size at birth, and that this effect persisted for at least three years.
THE EFFECT OF IODINE DEFICIENCY ON NEONATAL-MATERNAL THYROID RELATIONSHIP. R. Rajatanavin, L. Chailurkit, K. Suthivechvorakul, P. Winichakoon, P. Tananchai, S. Srinawat. Bangkok, Thailand, page S-38.
This study compared two groups of 300 women each, one in Bangkok (borderline iodine deficiency) and the other in Nan Province (severe iodine deficiency), with median urinary iodines of 6.4 mg/dl and 24-53 mg/g creatinine, respectively, and goiter rates in schoolchildren of 5% and 22-83%, respectively. Median serum neonatal levels, for Nan and Bangkok, respectively, were: TSH, 5.5 vs 3.5 mU/ml; free T4, 1.5 vs 1.7 ng/dl; T3, 44 vs 58 ng/dl; and Tg, 38 vs 44 ng/ml. The authors noted that neonatal serum TSH appeared to be a good index for assessment and surveillance of iodine deficiency in the neonates, and for this group the serum Tg was not as useful.
THE PATHOGENESIS OF ENDEMIC GOITER IN AN AFRICAN POPULATION. D.F. Smith. C. Darke, A.B. Parkes, A.M. Hetherton. Dublin, Ireland, and Cardiff, Wales, page S-39.
This study examined particularly HLA phenotypes in an area of moderately severe iodine deficiency in East Casamence province in Senegal. The mean urinary iodine excretion was 41 mg/g creatinine (71 subjects), and the mean thyroid volume 28.3 ml (195 subjects), elevated in 83% of females, 51% of males and 21% of children under 13. Of 154 subjects, 17.1% had antibodies against thyroglobulin and 7.2% against thyroperoxidase. HLA phenotype analysis showed a number of haplotypes not usually seen in Caucasion populations, but without significant association with thyroid enlargement or positive antibodies. The authors conclude that iodine deficiency is the major etiologic role, and that HLA associations do not appear involved in the development of goiter in this region.
BREAD IODIZATION FOR MICRONUTRIENT SUPPLEMENTATION IN IODINE DEFICIENT REGIONS OF RUSSIA. G. Gerasimov, A. Nazarov, N. Mayorova, A. Schischkina, M. Arbusova, B. Mischenko, I. Dedov. Moscow, Russia, page S-40.
Russia has significant iodine deficiency, and no effective control program. Bread production is centralized in large mechanical bakeries in various regions. Bread is traditionally a major dietary item in all Russian socioeconomic groups. In this study, 60 mg KI were added per 100 kg flour and the effects studied in 252 schoolchildren, aged 9-11 years, in a small town near Moscow. After three months of regular bread consumption (300-500 g/day), the median urinary iodine level increased from 4.8 to 12.6 mg/dl. Before bread iodization, 13% of the children had urinary iodine levels less than 2 mg/dl but after three months of iodization, none were below 2. Thyroid volume did not change during this period. The authors conclude that bread iodization is a simple, cheap, and effective method of supplementation for iodine deficient regions of Russia.
LOWERED LEARNING POTENTIAL AND ACHIEVEMENT MOTIVATION DUE TO PROLONGED IODINE DEFICIENCY. B.D. Tiwari, L.B. Tripathi, M.G. Karmarkar. Varanasi and Gorakhpur, India, page S-41.
One hundred male children from an iodine-deficient (mean urinary iodine 2.79 mg/dl) were matched by age, socioeconomic status, and education with a similar group from a non-iodine-deficient village (mean 5.7 mg/dl). The TSH concentrations of the two groups were, respectively, 6.23 mU/ml and 4.85, a highly significant difference. Tests included maze and verbal learning, and achievement motivation. The iodine deficient children were significantly slower in the maze learning and verbal learning and had lower scores in achievement motivation. The authors conclude that prolonged iodine deficiency produces subnormal mentation and reduced learning potential.
IODIZATION OF WATER FOR CORRECTING IODINE DEFICIENCY: A SIMPLE AND EFFICIENT TECHNIQUE. P. Bourdoux, D. Yazipo, L. Fio-Ngaindiro, L. Namboua, J. Ndoyo, L. Barrière-Constantin, E. Pichard. Brussels, Belgium, and Bangui, Central African Republic, page S-178.
This study applied the Rhodifuse water iodization system, in which NaI is slowly released from porous polymer cylinders into drinking water, to a severely iodine-deficient area of about 80,000 inhabitants in the Central African Republic. The median urinary iodine concentration before intervention was 2.1 mg/dl, and the goiter prevalence was 60.9%, 10.7% visible. The urinary iodine concentration was 28.9 mg/dl six months later and 17.4 at 12 months. The goiter prevalence dropped to 44% total and 2.5% visible. The authors conclude that water iodization by this technique is feasible and efficient, and offers an alternative to iodized salt that can be applied immediately where water supplies are available.