Volume 17 Number 4, November 2001
IN THIS ISSUE:
About 1/6 of the world's population lives in India, where iodine deficiency has been recognized for years. Its effects are most visible in the north, along the Himalayas and the Terai, but they have become increasingly apparent in other parts as well. In fact, virtually all the states in India are affected to some degree. This article, drawn largely from the reports of Dr. C. S. Pandav, ICCIDD Regional Coordinator for Southeast Asia, summarizes current progress.
Iodine nutrition
Most available data rely on goiter prevalence. A survey by the Ministry of Health and Family Welfare, Government of India, of 283 of the country's 587 districts in 29 states and 6 union territories classified 247 districts (87%) as endemic. All states/UT's, except two, had at least one endemic district. Urinary iodine concentrations have generally been low and correspond with areas of goiter and known iodine deficiency. Localized surveys have shown high neonatal TSH levels in deficient areas. Many of the data on goiter prevalence are from the 1970's, and comprehensive information on iodine nutrition from urinary iodine concentrations is not available. Overall, an estimated 167 million people in India are at risk of developing iodine deficiency disorders, 54 million have goiter, and 2.2 million are cretins.
Iodized salt
About 20 years ago it was apparent that the entire country risked iodine deficiency and a policy of nationwide salt iodization was announced in 1984. In 1988, the Prevention of Food Adulteration Act was changed to require that iodized salt contain at least 30 ppm as iodine at production and 15 ppm iodine at the point of consumption.
India has 926 iodization plants, with a total installed capacity of 13.9 million tons, much more than the requirement of 5 million tons annually for human consumption. Over 75% of iodized salt comes from Gujarat and Rajasthan. Production in the year 2000 was 4.7 million tons. Of this, 1.2 million came from salt refineries, the rest from small and medium producers. About 2/3 of the edible salt travels by rail, including all of the supply for the northeastern states, West Bengal, and Bihar. Depending on packing, a kilogram of iodized salt sells for Rs 2-4.5, but refined salt, some 25% the country's production, costs Rs 5 or more per kilogram.
In quality monitoring by Salt Department Laboratories at production, 61% of samples contained at least 30 ppm iodine, and 90% of samples measured by spot testing kit at the consumer level contained at least the minimum 15 ppm iodine.
A summary issued by the Salt Department in October 2001 reviewed each state and union territory in terms of IDD prevalence, status of the ban notification, presence of IDD cells, requirements and supply of iodized salt, monitoring information, and suggested actions. A 1998/1999 survey in 25 states showed that 70% of the population consumed some iodized salt, and its iodization was adequate in 49%. Iodized salt consumption was higher in urban areas (67%), associated with a higher standard of living (78%) than a lower (36%), and greater in the northeastern states than in the south.
The Salt Department notes the following constraints: inadequate awareness, difficulty in monitoring transported salt, use of noniodized industrial and cattle salt for human consumption, withdrawal of ban orders in Gujarat and Orissa (later restored in Orissa), partial ban in Andhra Pradesh and Maharashtra, and absence of a ban in Kerala, poor enforcement of ban orders in some states, and private interest lobbying against iodized salt.
IDD control program
The national program is overseen by the Ministries of Health and Family Welfare, in collaboration with the Salt Commissioner and the Ministry of Industry, to ensure the production, distribution, and quality control of iodized salt. The Directorate General of Health Services has a Central IDD Cell, and in addition, each state has its own IDD control cell, usually in the Department of Health. State health departments are responsible for quality control of salt within the state, creating consumer demand, monitoring iodized salt consumption, and conducting training and IEC.
Monitoring of iodine nutrition has been limited. Earlier studies assessed goiter by palpation with occasional localized studies of urinary iodine. Drs. Karmarkar and Pandav, of the All India Institute of Medical Science and ICCIDD, have long experience in the technology of urinary iodine, and have conducted surveys in many neighboring countries as well as parts of India.
Education and communication
As would be expected in the world's largest democracy, national issues such as salt iodization attract considerable public discussion, so advocacy continues to be a crucial part of the campaign against IDD. Dr. Pandav and many colleagues have devoted much time to emphasizing the damaging effects of iodine deficiency, especially on mental development and child survival. This advocacy has been especially important as states first decided to institute a ban against noniodized salt, and later considered whether to rescind the ban. For example, the state of Orissa rescinded the ban, but was persuaded to reinstitute it by an active coalition of NGO's and sympathetic political leaders from Orissa. In urging this action, Drs. Pandav and Karmarkar pointed out to the local authorities that the IDD prevalence rate in this state showed moderate iodine deficiency, and also that Orissa was among the country's leaders in infant mortality (110 per 1000 live births), poverty, and household index. They also stressed the right of every child in Orissa to have equal opportunity for development. Following these arguments, the Orissa government reinstated the ban.
ICCIDD, UNICEF, the government, and many other groups have been active at both national and state levels in communication efforts. These have taken the form of public discussions, printed material, and training at all levels. Many sectors have come together for this effort, including national and local health authorities, NGO's like ICCIDD, international aid agencies, the salt industry, and concerned citizens.
India celebrated Global IDD Day on October 21, 2001. The event was organized by the Union Ministry of Health and Family Welfare. A commemorative postage stamp (see figure) was released by Mr. Pramod Mahajan, Union Minister of Parliamentary Affairs, Information Technology and Communication. Other speakers were Dr. C. P. Thakur, Union Minister of Health and Family Welfare, Mr. Tapan Sikdar, Minister of State for Communication, Dr. Raman Singh, Minister of State for Commerce and Industry, and Ms. Maria Calivis, UNICEF Representative for India. Their messages urged the people to use only iodized salt, to rid the nation of iodine deficiency, and to sustain the progress already made.
The Kerala Study
The state of Kerala, with a population of 31 million people, lies on India's southwest coast. Different studies had reported the goiter prevalence to range from 4.7% to 27.3%. Kerala was the only state in the country that did not ban the sale of noniodized salt. A new study to assess the current IDD status and also the attitudes towards IDD and iodized salt was proposed, to help develop recommendations for sustainable IDD elimination in the state. The study was performed by a coalition including Drs. Pandav, Karmarkar, Moorthy, and Sankar from ICCIDD in New Delhi, in collaboration with the government's medical colleges in Kerala and UNICEF. The subjects were 35 children, 6-12 years old, from each of 30 clusters. The total goiter rate was 16.6% by palpation. The median iodine concentration of 990 urine samples, was 123 mcg/L, and 8% were below 50 mcg/L. Of 1066 salt samples from households and 59 from retail shops analyzed by titration, 48.9% from households, and 61% at the retail level had > 15 ppm iodine.
In focus group discussions, most of the women recognized different brands of salt and their prices. Most bought powdered salt but only those in urban areas preferred the iodized salt. The quality of the product and price, not health benefits, were the major factors influencing choice of salt in the market. About half of those interviewed did not know the advantages of iodized salt and those who were aware knew little about IDD other than goiter. Most stated they would choose health over price in selection of salt, if those benefits were clearly established.
The study team recommended a more vigorous campaign for use of adequately iodized salt. Legislation and/or appropriate regulatory mechanisms should increase the accessibility and availability of iodized salt, possibly through the Public Distribution System to make the price affordable, especially for lower socioeconomic groups. The goal is that the family have consumption of adequately iodized salt as their normal behavior. Most salt samples had some iodine, but only half were adequately iodized, suggesting that some labeling and marketing are inaccurate, and regulations to adjust this lapse are needed. The team also proposed annual cyclic monitoring among the State's districts, so that all are covered to ensure availability of adequately iodized salt. Finally, they recommended a State-level IDD committee, with representatives of all stakeholders, to track progress.
Dr. Pandav presented these findings to the Chief Minister of Kerala and to one of its members of Parliament. These and other political officials were impressed with the findings of the report, and promised further action.
Summary
The size and diversity of its population set India apart from all other nations. While the effects of iodine deficiency have been most apparent in the north, they occur throughout the country. Great progress has been made with iodized salt, but continuing efforts are needed to reach the goal of optimal iodine nutrition. Major activities are quality control of iodized salt, nutritional monitoring, advocacy, and increased awareness.
IODIZED SALT IN RURAL INDIA: THE HUMAN SIDE OF ITS IMPACT
by Anindita Ramaswamy
Gonda (Uttar Pradesh): A few years ago, the gently echoing voices of children reciting the alphabet were almost an anachronism in this district of Uttar Pradesh=s Terai region. Most of the schools in the villages of Gonda district were deserted. Doctors who have studied the area say that there was no will to learn. The few who attended class, did so in a daze of confusion, imbibing little, asking less.
"There was no life in the children, as they were all suffering from hypothyroidism (slowing of the metabolic rate due to deficiency in the production of thyroid hormones). They were lethargic and apathetic. Most of them had a dazed expression on their faces, even their eyes looked glassy," the chief medical officer of Gonda district, Dr. A.B. Shukla, said.
It is a little past 7 a.m. and Dr. Shukla is standing in the center of the local market in Bahalpur village. In the midst of trucks being unloaded and shutters going up for the day's business, animated groups of school children walk past, holding hands, swinging their bags. A cycle rickshaw whirls past. Wooden planks have been added to it, to accommodate more children. This one has eight students, the driver carefully maneuvering his way through garbage heaps while simultaneously holding onto straps of multi-colored water bottles. Another contingent of six children soldiers past. These have neither uniforms nor shoes. Their clothes are faded and dirty, but they clutch their slates and chatter away to the school gates.
Images like this never cease to amaze Dr. Shukla, who has been witness to a very different time. They also astound Dr. N. Kochupillai, head of the department of endocrinology and metabolism at the All India Institute of Medical Sciences (AIIMS) in New Delhi, who remembers a time when the classrooms were empty.
Dr. Kochupillai said, "This is the impact of salt iodization. It has made all the difference here. A few years back you couldn't get these children to go to school. Now the demand has gone up so much, that there isn't enough space to accommodate all of them."
Surendra Singh understands the impact of iodization. A school teacher, he has been principal of the Surajmal Munim Saraswati Shishu Mandir in Colonel Ganj for two years. "This entire area is very backward. After iodization most of the goiter in the region is gone and more children are coming to school now. With education, many of the myths associated with goiter have also gone. We have a well here in our primary school. Many years ago, because the few school children were mentally so slow, people in the village would say that if you drank water from our well, you got goiter. Now, goiter has vanished and there are more children in the school."
There are now 400 children in this school. Talking about the impact of a sustained iodization program, the principal says, "If there is continuity then there will be change."
Mr. Singh also recognizes the fact that teachers play an extremely important role in health education, as they are respected, reliable and credible. "It is through the teachers that we can reach out to the parents B especially mothers, as they are trusted and well known in their communities. It is important to spread the importance of iodine through them, otherwise the iodization program will be in trouble."
Health education is a regular part of the routine at the Saraswati Shishu Mandir, where messages related to health are disseminated during the morning prayer time. "Our teachers also visit children's houses to check the living conditions, and now, to check if they are consuming iodized salt," the principal said.
Omresh Mishra, a teacher in the same school, said, "The doctors came last year to conduct some tests. Previously, we were not open to intelligence tests. Now we want to know how they can do better.... we want to know the results of the tests. It is good for our health. We were all told about the effects of iodization."
Irfan, a Class IV student, is excited about the ongoing examinations. "I am trying to come first in my class. I have studied very hard. But there are many other good students also, so it is a little difficult." His brother Arshad, in Class VII, said, "It is exam time and I need the additional lessons, because my mathematics is weak. But I know I will perform better in these tests."
While the Saraswati Shishu Mandir is housed in a two-story permanent structure, where the students have notebooks and pencils and work on wooden desks, the local school in Katra Shahbazpur village is set in a more bucolic environment.
The school has room for only 53 students. Earlier, the two-room, dingy school was perennially deserted. Now, teacher Amresh Bahadur Singh, says he has 183 students and constant demands from more. "The children would refuse to come to school. They would waste away at home, doing nothing. Now we have only two teachers, more children than we can handle and no place to seat them."
The classes continue, nonetheless. The courtyard outside the school has been converted into a makeshift classroom, where children of all ages sit in orderly rows, chalk in hand and slate on lap. The overhead banyan trees provide adequate shade.
Amresh Bahadur said, "Apart from the children, we also educate the parents. There are around 1,000 people in this village, and we spread information about health through the children. We especially tell them not to wash the salt, as the iodine will be lost."
The new generation of children seems free from both the physical deformities and mental handicaps characteristic of IDD. Husna Khatum should know. This nurse at the community medical center in Colonel Ganj has three children studying at the Saraswati Shishu Mandir. "I read somewhere that UNICEF provides salt testing kits for children to experiment with in India, China and Bangladesh. If the salt turns purple, it contains iodine. I thought that was an effective way of getting the message across to children, and through them to their parents," she said.
For Ms. Khatum, the statistical results of the test are not important. "What matters is that the children learn about the value of iodine, they understand why iodine is so important and they realize that iodine deficiency would completely ruin their future."
CONTINUING PROGRESS AGAINST IDD IN
MACEDONIA
by B. Karanfilski, V. Bogdanova, O. Vaskova, S. Loparska, S. Miceva-Ristevska,
Gj. Sestakov, S. Kuzmanovska, Institute of Pathophysiology and Nuclear Medicine,
Medical Faculty, Skopje, Macedonia.
[Ed note: This article builds on previous reports in the IDD Newsletter (most recently 16(4):55, 2000) in chronicalling the country's dedicated efforts, led by Professor Karanfilski (ICCIDD National Focal Point for Macedonia and Senior Adviser) and colleagues, to sustain iodine sufficiency in their country.]
Background
Much past information has confirmed a high incidence of goiter in Macedonia, endemic in some areas. Ramzin et al. (1) reported in the 1950's that Macedonia had approximately 200,000 goitrous inhabitants, more than 20% of the population. Legislation in 1956 mandated iodization of salt with potassium iodide at 10 mg/kg (7 mg/kg as iodine). Subsequent reports showed that the goiter prevalence had decreased, but remained at the endemic level (2).
In a complete national survey in 1995/96 that included all 30 districts of the country (a total of 115 schools selected randomly, with minimum one rural and one urban school for each district), 18.7% of 11,486 children had goiter, ranging from 7.8-29.8% among different districts. In a 20% subsample from all ages in that study, thyroid volume determined by ultrasonography was significantly larger than that described for iodine sufficient areas of Europe and the median urinary iodine concentration was 117 mcg/L, ranging from 79-190 mcg/L; 8 of the 30 districts had a median < 100 mcg/L.
These results showed that mild to moderate iodine deficiency continued to exist in Macedonia according to the criteria of WHO, UNICEF and ICCIDD (3), and that the preventive measures so far were not sufficient. We concluded that a new law should be introduced, requiring iodization of salt at a much higher concentration.
While awaiting regulatory action, we carried out in 1999 a new survey in 1,142 children, 7-15 years old, from 30 primary schools, selected randomly. The national median urinary iodine was 116 mcg/L, confirming the findings of the l995/96 survey.
New regulations effective in October 1999, stipulated that all salt for human consumption, including that in the food industry, should contain 20-30 mg iodine/kg salt, as potassium iodate. A national survey in September 2000, one year after the application of new regulations, measured urinary iodine excretion in 1,211 children, 8-10 years old, from 30 primary schools, selected using the PPS method, and found a median iodine concentration of 154 mcg/L (4,5).
Iodine nutrition in children
A new national survey, September-October 2001, measured urinary iodine excretion in 929 schoolchildren, 8-10 years old, selected by the PPS method, and found a national median of 164.5 mcg/L. Table 1 compares this result with the several other studies of urinary iodine level in recent years.
Table 1. Urinary iodine excretion (mcg/L), 1995-2001.
1995/96 1999 2000 2001
Number of children 2,380 1,142 1,211 929
Median UI 117 116.7 154.1 164.5
Mean UI 132±78.7 131.9±76.9 169±97.1 182.7±91.4
> 100 mcg/L 1,413 (59%)696 (61%) 976 (81%) 784 (84%)
< or = 100 mcg/L 967 (41%)446 (39%) 235 (19%)145 (16%)
< 50 mcg/L 250 (11%)130 (11%) 46 (3.8%) 28 (3%)
The mean and median urinary iodine concentrations were significantly higher after application of the new regulations, showing that the new law for salt iodization was highly effective. Thus, Macedonia has progressed from mild/moderate iodine deficiency to its present sufficiency.
Iodine nutrition during pregnancy and lactation
In the period May-June 2001, we conducted a survey to assess the effects of the new iodization levels on women during pregnancy and lactation, when the need for iodine is greater. Urinary iodine excretion was determined in a total of 382 pregnant women and 109 lactating women, from 10 cities countrywide.
Our results (Table 2) showed normal median values for urinary iodine excretion in the group of pregnant and lactating women. The distribution of individual values however, shows that 25% of pregnant women and 26% of lactating women had values < 100 mcg iodine/L. Thus, even though the iodine supply has increased with the new levels of salt iodization, it does not yet completely cover the higher requirements during pregnancy and lactation, and these should be met by an additional iodine supplement of 100 mcg iodine daily.
Iodine levels in salt
Macedonia does not produce salt, and all the iodine needs are covered by imports of iodized salt. An exception is SOLBIT, a producer in Bitola, which imports noniodized salt and iodizes it in its factory.
The state sanitary inspection, with almost a hundred inspectors in the country, is responsible for the quality control of salt. All the imported salt is held back by the customs authorities until a certificate of adequate iodine content is obtained. Unsatisfactory salt is returned to the country of production. Sanitary inspectors send samples to the central facility or to any of the 10 regional Institutes of Public Health, which are responsible for testing the iodine content of salt by the titration method.
In addition to this regular control, we tested four collections of salt samples from consumers 6, 12, 18 and 24 months after the implementation of the new law for salt iodization (Table 3). The results show significant progress in the use of iodized salt. During the 24 months after implementation of the new law, the fraction of salt samples that contained the optimal concentration of iodine (between 20 and 30 mg/kg) increased from 42% to 69%, and the fraction of samples with inadequate iodine concentrations (lower than 20 mg per kg) decreased from 46% to 6%. We also found that 12-25% of samples had more than 30 mg iodine per kg salt, and some samples contained iodide instead of iodate.
We matched the values for urinary iodine excretion in school children and women with the iodine concentration in salt samples brought from home (Figure 1), dividing results from 427 salt/urine pairs into 7 groups of 61 each and calculating the median for each group. A good linear correlation exists between the iodine concentrations in urine and salt in these groups.
IDD control program
The National Committee for IDD successfully coordinates the activities for elimination of iodine deficiency and its consequences in Macedonia. Its members represent all relevant sectors in the country that can contribute to that aim. The Committee supports all initiatives in this area and successfully implements the program, which has realized full correction of iodine deficiency in Macedonia.
Summary
Macedonia had mild to moderate iodine deficiency before raising the levels of iodine in salt from 7 mg/kg to 20-30 mg/kg, effective in October 1999. The new law also required iodization of salt used in the food industry. A follow-up survey two years later, in late 2001, found a median urinary iodine of 164 mcg/L, indicating achievement of iodine sufficiency. A survey of pregnant and lactating women showed normal median urinary iodine levels (140 mcg/L) but 25% were below 100 mcg/L, and additional iodine supplements of 100 mcg iodine daily are recommended for these conditions. Data in the latter part of 2001, two years after the change in salt regulations, showed that 69% of samples contained between 20 and 30 mg iodine/kg the legal range), while 6% were less than 20 mcg/kg and 25% greater than 30 mcg/kg.
We found a good correlation between the iodine concentrations in urine and that in salt from the individual's home. Macedonia has a national committee for IDD that represents relevant sectors and successfully coordinates the program.
References:
1. Ramzin S 1959 Endemic goiter in Yugoslavia. 1st Yugoslav symposium for endemic goiter, Belgrade, pp 27-60.
2. Kicic M, Djordjevic S, Janic M, et al 1985 Iodine prophylaxis and new data for endemic goiter in Yugoslavia. 5th Yugoslav Symposium for Thyroid Gland, Zlatibor, pp 1-18.
3. Karanfilski B, Bogdanova V, Vaskova O, Loparska S, Miceva-Ristevska S, Sestakov Gj 1997 Iodine deficiency in Macedonia. Mak Med Pregl 1-2:5-10.
4. Karanfilski B, Bogdanova V, Vaskova O, Loparska S, Miceva-Ristevska S, Sestakov Gj, Kuzmanovska S 2000 Macedonia Achieves Iodine Sufficiency. IDD Newsletter 16(4):55-56.
5. Karanfilski B, Bogdanova V, Vaskova O, Loparska S, Miceva-Ristevska S, Sestakov Gj, Kuzmanovska S 2001 Current status of iodine deficiency in Macedonia. Mak Med Pregl 3-4:101-104.
Table 2. Urinary iodine during pregnancy and lactation
Number Median UI Distribution_____
UI 0-100 100-199 > 199
Pregnancy (mcg/L) mcg/L mcg/L mcg/L
First trimester 78 149.7 21.8% 60.2% 18.0%
Second trimester 140 157.6 23.5% 49.3% 27.2%
Third trimester 164 130.4 28.1% 53.0% 18.9%
All 382 140.7 25.1% 53.2% 21.7%
Lactation 108 139.2 26.9% 47.2% 25.9%
All (pregnancy and
lactation) 490 140.4 25.5% 51.8% 22.7%
Table 3. Effect of new law on salt iodine levels, implemented in November 1999
Distribution among iodine
Period from Number of levels (mg/kg)
implementation of law samples < 20 mg/kg 20-30 mg/kg > 30 mg/kg
6 months 1,218 46% 42% 12%
12 months 540 26% 52% 22%
18 months 437 14% 66% 20%
24 months 378 6% 69% 25%
SYMPOSIUM REPORT, IODINE DEFICIENCY IN BOSNIA/HERZEGOVINA, SLOVENIA, AND CROATIA
This symposium was held in Sarajevo, November 2000, and has been published by the Academy of Sciences and Arts of Bosnia and Herzegovina. The editors are Dr. Husref Tahirovic and Dr. Faruk Konjhodzic. The publication is in Serbo Croatian, with abstracts in English, from which this summary is drawn.
Dr. Francois Delange, then ICCIDD Executive Director and Regional Coordinator for Europe, discussed sustainable elimination of iodine deficiency in Europe, its achievements, pitfalls, and strategy. He reviewed the remarkable progress in combatting iodine deficiency during the 1990's, largely due to iodized salt. However, only 27% of the European population affected by iodine deficiency has access to iodized salt, attributable to a striking relapse in some eastern European countries and the absence of national commitments in large western European countries with mild to moderate IDD. He reviewed progress and proposed action for achieving sustainable elimination of IDD in Europe, through iodized salt.
Bosnia and Herzegovina - This paper by Dr. H. Tahirovic and A. Lolic reviewed a recent survey of 5,523 schoolchildren, aged 7-14, in Bosnia and Herzegovina, and 3,660 in Republic Srpska. Salt in Bosnia and Herzegovina comes mainly from a plant in Tuzla, iodized at 5-15 mg KI/kg salt, and from Pag, at 10-20 mg KI/kg salt. The Srpska population use Tuzla salt and salt from Yugoslavia.
In Bosnia/Herzegovina the goiter prevalence was 27%, ranging from 12.9% in West Herzegovina Canton to 51.2% in Bosnia Podrinje Canton. The median urinary iodine excretion was 77.6 mcg/L, ranging from 1 to 208 mcg/L. The median was < 100 mcg/L in 70% and < 50 mcg/L in 34%. Household salt samples varied in iodine content from 3 to 29.8 mg/kg, at an average of 14.4 " 5.9 mg/kg. In Srpska, the goiter prevalence was 23.5%, ranging from 10% in Trebinje to 31% in Doboj. The urinary iodine excretion was 127 mcg/L; 24% were < 100 mcg/L and 3% < 50 mcg/L. Of household salt samples, 54% were < 20 mg/kg, and 7% < 10 mg/kg.
The authors conclude that Bosnia and Herzegovina continue to have mild to moderate iodine deficiency and the present iodine prophylaxis is not adequate.
Croatia - The current status of iodine deficiency was summarized by Drs. Zvonko Kusic, Stanislav Lechpammer, and Nina Dabelic. In the mid 20th century, the goiter prevalence ranged from 80% in Slavonia and Lika to 46% in Zagreb, and cretinism was found in Rude near Zagreb. A 1953 law required iodization of all salt, for both human and animal use, with 10 mg KI/kg salt. Within 10 years, the goiter prevalence had decreased three-fold and endemic cretinism disappeared. By 1990, endemic goiter was considered to be mainly eliminated. A national committee, formed in 1992, found that mild iodine deficiency persisted, with a prevalence of goiter by palpation among schoolchildren of 8-35%. In some areas, 14-30% of schoolchildren had urinary iodine excretions < 50 mcg/L, and 66-83% were < 100 mcg/L. Thyroid volumes by ultrasound of schoolchildren in Zagreb were above standards for iodine sufficiency in 5-13%. The average iodide value in the largest salt plant, in Pag, was 8.3 mg/kg. In 1996, the Ministry of Health raised the level to 25 mg KI/kg salt. Data from 1997 showed that 5.2-22.1% of schoolchildren had urinary iodine excretion < 50 mcg/L, and 30-58.6% < 100 mcg/L. Salt samples taken from households in 1999 showed that 14% had < 20 mg KI/kg salt. In a survey of schoolchildren in Rude, 10.7% had urinary iodine excretions < 50 mcg/L, and 41.7% were < 100 mcg/L. Thyroid volumes in schoolchildren in Zagreb and in Rude in 1999 appeared to be in the normal range by the then-existing criteria. Progress three years after implementing the increased levels of iodine in the salt has been encouraging. Regular monitoring of both iodine nutrition and salt is recommended.
Macedonia - Its IDD status was reviewed by Dr. Karanfilski and colleagues. A more recent report by these same authors appears elsewhere in this issue of the Newsletter.
Slovenia - Drs. Katja Zaletel and Sergej Hojker summarized the status. As with the rest of the former Yugoslavia, Slovenia introduced iodine prophylaxis with 10 mg KI/kg salt in 1953. Data within the last 15 years reported that 79% of 13 year old schoolchildren had goiter, 11% of them severe. The average urinary iodine excretion was < 100 mcg/L and the average concentration of iodine in breast milk was 43.2 mcg/L. Slovenia does not produce sufficient salt for its own needs, and began importing salt with a higher iodine content from Bosnia, Croatia, Austria, and Slovakia. An iodine level of 25 mg KI or 32 mg KIO3/kg salt was recommended in 1999. As of late 2000, there were no new data on iodine nutrition, but increased incidences of hyperthyroidism were being reported. A new epidemiologic study was planned for 2001.
INDONESIA INAUGURATES CENTER FOR IDD CONTROL
The Directorate of Nutrition in the Ministry of Health and Diponegoro University have joined to form a Center of Excellence for Control of IDD at the University in Semarang. Professor Eko Boedihardjo, Rector of the University, and Professor Dr. Azrul Azwar, Director-General of Community Health, Ministry of Health, presided at the opening ceremony, on November 4, 2001. A following two-day session reviewed general aspects of IDD and its control, with particular attention to Indonesia and plans for the future.
Background
Iodine nutrition - IDD has been known in Indonesia for many years. A national survey of primary schoolchildren from 1980-1982 in 26 provinces described a goiter prevalence of > 10% in 68% of subdistricts and a > 30% prevalence in 40% of the subdistricts. Some villages had more than 80% goiter. The 1980-1982 survey estimated 75,000 cretins in the country as well as 3.5 million additional subjects with lesser mental impairment, and the incidence of cretins reached 10-15% of the population in some areas. In a 1988 follow-up, the total goiter prevalence had decreased by 37%.
A large 1998 survey reported a total goiter rate of 9.8% in elementary schoolchildren at the provincial level. About 45% of the subdistricts were categorized as still having IDD: severe in 334, moderate in 278, and mild in 1,167.
In 2000, the ThyroMobil assessed 7,447 children aged 6-12 in five provinces - four in Java, plus sites in Sumatra and Bali. The median urinary iodine was 195 mcg/L. Of these, 34% were between 100 and 200 mcg/L, 17% were < 100 mcg/L, and 49% > 200 mcg/L, including 18% > 300 mcg/L and 0.7% > 1,000 mcg/L. The median in Bali was 81 mcg/L. The goiter prevalence by palpation was 9.0%, and by ultrasound also 9%, using Indonesian normative values from children in a known iodine sufficient area in Java. Thus, most of the sites sampled, except Bali, appeared to be iodine sufficient.
Salt iodization - Indonesia has some 25,000-30,000 small salt farmers who produce 75% of the country's annual 1.2 million tons. The estimated need for human consumption is 600,000 tons, of which PT Garam, a state-owned company, supplies half. The production technology is primitive and salt must be washed extensively to remove impurities. Iodization takes place in more than 300 processing plants distributed over 24 provinces. A 1995 Ministerial Decree requires standards that would upgrade both refining and local iodization. The "people's salt" (from small farmers), is of poor quality, needs extensive washing to remove impurities, and is not well suited to direct iodization. All registered manufacturers are legally bound to iodize the salt but many do not. The staple in rural villages is raw salt, favored for its low price and availability. Noniodized raw salt, available for fertilizers and fish curing, is frequently diverted to human use. Regulations specify 30-80 mg KIO3/kg. At the production level, 86% of the salt contains sufficient iodine, decreasing to 68% at the market level and 64% at households.
IDD program - A National IDD Committee is chaired by the National Development Planning Agency, coordinating four ministries including Health. Local governments carry out coordination at the provincial level. Salt is monitored at production by the Ministry of Industry and Trade, which visits plants monthly at random to test all brands and offer technical advice to producers. It also monitors salt at the market level in districts where iodine levels in household salt are low. Qualitative monitoring takes place in schools on samples brought from home.
Supplementation with iodized oil is prescribed for women of reproductive age, (including pregnant and lactating mothers), in severe and moderate endemias, and for elementary schoolchildren in severe endemias. However, the coverage for the target group remains fairly low, around 20-30% for women. Pregnant women are supposed to receive vitamin preparations that include iron and other nutrients but not iodine, and coverage is not extensive. The Ministry of Community Health is responsible for nutrition, but the Ministry of Industry is responsible for salt. Interaction between the two has not always been close. The Ministry of Community Health is pleased with the decrease in total goiter rate and the increased use of iodized sat. Continuing issues are sustainability, especially under conditions of general decentralization, and the problems inherent with so many small salt producers. The Ministry has decided to concentrate on 17 districts with significant IDD, to include strengthening of small salt farms, social mobilization, and law enforcement. Decentralization also means that localities themselves now need to purchase iodized oil capsules. An initiative - "healthy Indonesian coalition" - is a local community effort to promote health and provide advocacy to local governments; this approach will be tried in the 17 districts. A national coordinating group for IDD exists, but barely functions.
Indonesia's "health development plan towards healthy Indonesia 2010" has been presented and appears on the internet (www.gizi.net), published by the Indonesian Nutrition Network. Section 3.7, the Nutrition Improvement Program, targets a reduction of total goiter rate from 18% to 13% and no new cretins. Of the 10 prioritized health programs, the Nutrition Improvement Program is listed as #2. The general strategy of the Health Ministry emphasizes cross-sectoral involvement.
The Center
The Center of Excellence for IDD Control in Indonesia is being managed by the Faculty of Medicine of Diponegoro University (UNDIP) in a close relationship with the Ministry of Health. Professor R. Djokomoeljanto, ICCIDD Senior Advisor, is Chair of the Center, and Professor Satoto is the Secretary. The Center will help develop an IDD network, the Indonesian Forum for Control of IDD, to consist of experts from institutions in many parts of the country. Coordination among the Center, the Forum, and the Ministry of Health will be very close.
The following are key activities planned for the Center:
1. Updating the IDD Laboratory - The laboratory at UNDIP has been operating for 10 years, following training at the CDC/PAMM course in the early 1990's. It has facilities for measuring urinary iodine and has been steadily active in this field.
2. Fellowship for postgraduate training - The Center plans to implement a fellowship program for postgraduate education in IDD, to build up capacity for the country. It will also develop courses in IDD management for the staffs of relevant institutions in the country.
3. Library and clearing house - Access to recent publications has been difficult for developing countries like Indonesia, and the Center plans to provide library services to meet this need. It will serve as a resource for literature, and has already developed a website for diffusion of knowledge (www.gaky.net).
4. Publications - The Center is developing two; the first is a program-based publication, under the responsibility of the Director of Health Promotion at the Ministry of Health. The second, the Indonesian IDD Review, is bilingual (Bahas Indonesia and English), planned for three issues per year, edited by the Center with a board of international and national experts, and integrated by the Secretary of the Center. The first issue, in November 2001, has 79 pages of text, drawn principally from the presentations at the November symposium (see below).
5. Annual seminar on IDD in Indonesia - This activity has been organized as a forum among experts and interested individuals to share updated information and experiences in dealing with the IDD program in Indonesia and elsewhere, organized by the Faculty of Medicine at UNDIP in collaboration with the Director of Nutrition at the Ministry of Health.
6. Operational research on IDD control in Indonesia - The Center will develop terms of reference and facilitate implementation of operational research. Examples of issues are: (a) salt iodization on salt farms; (b) village-based iodized salt distribution and marketing systems; (c) community-based iodized salt monitoring systems; and (d) pattern of effects of IDD on child growth and development disorders.
National meeting on IDD
The keynote speech on November 4 was by Professor Azrul Azwar, Director General of Community Health, Ministry of Health. He noted that IDD remains a public health problem in many areas of the country. Since 1997, the Government of Indonesia, supported by the World Bank, has developed a new strategy with increased reliance on iodized salt and the targeted use of iodized oil capsules for women of reproductive age in vulnerable areas. He noted that national iodized salt use has remained at about 64% for the last several years, and that iodized oil coverage was low, at 55% in nonpregnant women, 88% in pregnant women, 57% in lactating mothers, and 84% in school-age children.
The seminar reviewed issues in implementation and included a lively and constructive discussion among members from the different sectors. Some of the themes that emerged were:
· Problems facing small farmers are low quality of seawater, poor design of crystallization beds, short harvest season, small areas, no warehouse, limited funds and labor, low productivity due to season and rainfall, and weak bargaining power in a free market.
· Issues in the production sector include illegal salt producers, difficulty obtaining potassium iodate, producers who knowingly add less than the prescribed amount of iodine, unhealthy competition, ignorance in the community on the benefits of iodized salt, difficulty of distinguishing iodized and noniodized salt, administrative problems at the government level, failure of programs to touch the real issues, frequent duplication and overlap in programs, weak intersectoral coordination and poor enforcement of laws. A motivation-oriented approach was suggested, along with a guarantee that all salt be iodized. One speaker noted that the law to support enforcement is still too weak and a more comprehensive approach is needed. All of these points were discussed openly with the attendees from the Ministry of Health.
In addition to updates on the IDD status and issues of implementation, the seminar included reviews on various aspects of IDD, including the global challenge, neonatal hypothyroidism, maternal thyroid function during pregnancy, fetal neurological development related to iodine nutrition, iodine in the environment, relation of iodine nutrition to the autoimmune response, the combined effect of selenium and iodine deficiencies, sociocultural aspects of IDD control programs, iodine excess, and review of the ThyroMobil experience in Indonesia. The Indonesian IDD Review offers details from these presentations.
IODINE GIVES CRETIN COUPLE NORMAL CHILDREN
When I came to Sengi for the first time in 1973, the village was so quiet, there were no activities seen or observed by visitors, everyone looked lethargic and gave the impression of being lazy. Not a single child played in front of his or her house. Nowadays we know that this must be the consequences of hypothyroidism, since 87% of this population had low serum thyroid hormone levels. Many also showed signs of clinical or subclinical hypothyroidism, and 9% were cretins. Nobody finished the six years of elementary school, and the drop-out rate was tremendously high. This was due to "central hypothyroidism" - they were anergic. On April 17, 1973, villagers received an injection of iodized oil Dramatic changes were seen within a year. The children were now lively, playing happily in front of their houses, group activities like badminton, volley ball, and chess playing were organized. All were amazed when, at the end of 1974, Sengi received the honor for the best volley ball and chess player in the subdistrict competition among villages. In subsequent years, the school drop-out rate fell dramatically. Many students passed primary, secondary, and then high school, and some of them followed with a university education. Public activities increased. Fishing and farming boomed, and the community now exports fish and vegetables regularly. The socioeconomic condition has improved accordingly.
Cretins improved physically, but not mentally. Mr. P. A. (above, far right) was a hypothyroid cretin, but felt himself healthy enough to marry. His wife (far left) was a neurological cretin. By that time the iodine deficiency of everyone in the village had been corrected by the injection of iodized oil. This couple had three healthy sons. They grew and developed normally, both physically and mentally. One of the three was well until he died in a vehicle accident. The other two, pictured above, include Rame (second from right), who ranked first when finishing the high school in Semarang, and now (2001) has almost finished his BSc in chemistry at Diponegoro University. His younger brother, Ramidi (second from left), born in 1983, ranked first of 49 pupils in his high school class; he is now also in Semarang and plans to become a physician.
What a difference the iodine in a single injection made in the fate of this family!
- R. Djokomoeljanto, 2001
GOITER AND EVIL IN BALI PUPPETS
Goiter from iodine deficiency has been endemic in Bali for many years, and local culture often associates it with undesirable character traits. In the traditional puppet play, there are four royal servants. Two, Tualen and his son, Merdan, are always on the side of good. The other two are the brothers Delem, the elder, and Sangut, the younger; they always side with evil. Delem (this statue and puppet), is short and has reddish skin, protruding eyes, large goiter, husky voice, big ears, short fingers, hyper-extended gait, and large protruding belly. His character: easily offended, sensitive, suspicious, tricky. Sangut, the younger brother, is pale, has normal eyes, small goiter, high voice, and an athletic form with slight belly protrusion. He is more tricky, agitated, "swaying with the wind." (From interview by Prof. R. Djokomoeljanto with a puppeteer at Pejeng Village, Bali.)
KAZAKHSTAN PROGRESSES TOWARDS IDD ELIMINATION.
T. S. Sharmanov, F. E. Ospanova, Z. T. Tolysbaeva, Institute of Nutrition, Kazakhstan.
Environmental iodine deficiency (in soils, waters, and domestic foods) is present in half of Kazakhstan's territory, and endemic goiter occurs in 11 of its 14 provinces (M. E. Zeltser, et al, 1979). Studies from the 1960's and 1970's resulted in maps of the distribution of iodine in the soils and waters and of its effects, dividing the country into areas of either iodine sufficiency or severe, moderate, or mild deficiency. Most endemic goiter regions were in the south and east, and about two-thirds of the overall population has been estimated at increased risk for IDD.
The major causative factor of IDD is the low iodine content in the food. Negative changes in the nutrition structure and life conditions of the majority of the population in association with new socio-economic conditions, and the rapid decrease of production and availability of adequately iodized salt, are exacerbating the situation. In recent years the consumption of locally grown foods has increased, especially in rural regions. The supply of iodized salt to the endemic regions has decreased significantly. Also, the quality of iodized salt has required considerable improvement to conform to international recommendations.
Some recent progress has occurred. The Institute of Nutrition is a center that collaborates with WHO and UNICEF on micronutrient deficiency, in the republics of Central Asia and Kazakhstan (CARK). It supports universal salt iodization (USI) as one of the principal means for IDD elimination. A reference laboratory set up at the Institute coordinates Kazakhstan's iodine deficiency control program. Work with the large salt producer "Araltuz" has recently led to the substitution of potassium iodate for the previously used potassium iodide, and the level of salt iodization was increased to 40 ppm. A handbook of monitoring and quality control - "How to provide quality assurance of salt iodization" - has been developed for salt producers and for the surveillance system, offering detailed directions for determining potassium iodate in salt. The joint work of the Institute of Nutrition with salt producers has emphasized protection of the population's health and the intellectual potential of the future generations, and recognition of these benefits led the salt producers to introduce changes in the salt iodization process even without a resolution from the government. A draft resolution and national program are under consideration by the government, but meanwhile enactments of ministry and department heads are important, because the preparation and promotion of legislation to regulate iodized salt production can be a lengthy process. The State Chief Sanitary Inspector's Resolution "On IDD prophylaxis," #9 of September 27, 1999 was developed and approved. It states that only iodized salt can be produced and traded, and sale of non-iodized salt is prohibited.
With UNICEF and CARK technical support in 2000, "Pavlodarsol," the second largest salt producer, received an iodization machine, and both major salt producers were given 400 tons of potassium iodate free. Thus, in 2000 the two major salt plants produced 82,440 tons of salt, of which 37,560 were of edible salt, and 87.4% of the edible salt was iodized. However, non-iodized salt is still reaching the country by importation and from small salt producers.
To expand the variety of foods fortified with iodine, iodized yeast and iodized drinking water have been developed. In rural regions of Kazakhstan, home baking of bread is widespread, especially in families with many children. Iodized yeast provides a supplementary source of iodine, with 300 grams of bread providing the average recommended daily iodine ration.
An integral part of the IDD elimination program is information and education aimed at the general population and special target groups. The Institute of Nutrition conducts communicative work among different groups. A press conference on the necessity of strengthening IDD control was conducted for all mass media together with surveillance system officers in 1999, and another press conference for all mass media took place in 2000 at the national press club. A number of articles and papers have been published in different newspapers and magazines, including booklets with information on IDD prevalence and prevention. Further activities, including results on urinary iodine excretion, iodized salt consumption and population awareness, will be forthcoming.
THE
CURRENT STATUS OF IODINE DEFICIENCY DISORDERS IN TYVA REPUBLIC,
RUSSIAN FEDERATION.
I. Osokina*, R. Mongush, N. Kuular, E. Ondar**
*Institute for Medical Problems of the North, Krasnoyarsk, Russia
** Ministry of Public Health in Tyva Republic, Kyzil, Russia.
The Republic of Tyva is one of 89 administrative territories of the Russian Federation. It lies in the geographical center of Asia bordering Mongolia. Mountains cover almost 80% of its territory. Of its 308,600 people, 98,9% are indigenous Tyvinians. Tyva is one of the Russian Federation's least developed territories and has the highest levels of child mortality (31.9 per 1000), and of tuberculosis and syphilis morbidities.
Beginning in 1997, several surveys by scientists from the Institute for Medical Problems of the North (Krasnoyarsk) revealed severe IDD in the west of the republic, characterized by a high goiter prevalence, endemic cretinism, congenital and non-congenital hypothyroidism, a very low UI (16 mcg/L), high serum thyroglobulin (86.1 " 19.3 ng/ml), and transient neonatal hypothyroidism on screening (1-5).
Status of the IDD control program in Tyva
In 1998, the Tyva Government and its Ministry of Public Health, in collaboration with scientists from the Institute for Medical Problems of the North (Krasnoyarsk), developed the Program for Eliminating Iodine Deficiency in Tyva Republic, which includes iodized salt consumption for the entire population and iodide pills (antistrumin) for high risk groups. Iodized salt is produced in Russia in sufficient quantities to meet the population's requirements; the nearest salt producing plant is located in the bordering Irkusk region. Since late 1998 iodized salt had been delivered to all the districts of the republic. However, as distribution and trade of iodized salt in the Russian Federation is not mandatory, and health authorities in Tyva do not promote it, consumption of iodized salt remains low. Only six of the 16 districts with severe iodine deficiency provide schoolchildren and pregnant women with iodized pills.
Most developing nations with iodine deficiency are largely rural. This compounds the difficulties of iodine distribution, whether by salt, capsules or other means, because "rural" inevitably equates with remote, scattered, difficult to communicate with, hard to reach, and usually poor. Reaching this rural target is the remaining challenge to the control of iodine deficiency, and suggests an agricultural approach for its solution.
Tyva is mainly pastoral, with large herds of sheep and of cattle, particularly in the western portion of the country, where the iodine deficiency is most severe. People there eat large amounts of meat, some at every meal, and of dairy products, so these constitute much of the diet. Animals do not receive iodine supplementation except minimally and sporadically. The possibility of supplementing iodine to animals immediately suggests itself (5).
In Tyva, the animal population can be targeted quite efficiently using iodized salt licks. These can be produced locally from deposits of rock salt. Iodizing animal salt directly affects a significant proportion of the rural population, because families in remote pastures often consume the same salt as their herds. Now the factory for iodizing animal salt in Tyva has already been constructed, thanks to Dr. Robert DeLong (Duke University and ICCIDD) and Jerry Brenner (Kiwanis Club of New Jersey), and this approach will be introduced in Tyva.
Results of Neonatal Thyroid Screening in Tyva
The regulations of the Russian Ministry of Health mandate screening for neonatal hypothyroidism. However, since costs of this screening are born by health budgets of each administrative territory and not by the federal government, the implementation of neonatal TSH screening depends largely on the availability of funds in regional budgets. In Tyva screening for neonatal hypothyroidism was initiated in 1995 and the laboratory was established by the Ministry of Health; it measures TSH in whole blood spots by the Delphia diagnostic system. A level above 5 mU/L suggests hypothyroidism. Of whole blood TSH levels from 8,427 newborns, collected between June 1, 1995 and September 1, 1998 (before the IDD control program), the TSH level was over 5 mU/L in 43.2% of samples, indicating severe iodine deficiency; moreover TSH levels in 5.36% of samples were greater than 25 mU/L showing biochemical transient hypothyroidism.
Figure 1 maps the country by neonatal TSH levels. Severe iodine deficiency (TSH > 5 mU/L in more than 40% samples) is typical for the Western part of the republic, in the valleys of the Khemchik and Yenisey rivers. Moderate iodine deficiency (TSH > 5 mU/L in 20 to 39.9% of samples) characterized the Central and Eastern parts of the country, and mild iodine deficiency (TSH > 5 mU/L in 3 to 19.9% of samples) occurred in 4 administrative districts in the South bordering Mongolia.
In 2000 we compared the yearly frequencies of TSH > 20 mU/L in neonatal screening over a three year period, to estimate the efficiency of the IDD control program. In 1997 the frequency of TSH > 20 mU/L was 8.43% (4,305 newborns). In 1998, 3.8% (5,306 newborns); and in 1999, only 1.9% (4,596 newborns). So, in the Republic of Tyva the preventive measures appeared to have a positive effect, reducing the frequency of TSH > 20 mU/L to one-fourth during this period.
The current status of IDD in Tyva
In January-March, 2000, we again evaluated IDD and the efficiency of preventive measures in Tyva, by examining 1,892 schoolchildren in four districts of the republic: (1) central - Kaa-Hemskiy; (2) eastern - Todginskiy; (3) western - Ulug-Hemskiy; and (4) southern - Ovyurskiy. The 1997 neonatal screening data indicated moderate iodine deficiency in the first two districts, severe in Ulug-Hemskiy, and mild in Ovyurskiy. Iodized salt was delivered to all of these districts, but only schoolchildren from Ulug-Hemskiy received antistrumin.
The assessment included clinical examination, measurement of weight and height, thyroid size by palpation and ultrasonography (by one examiner using "Aloka" SSD 210 Echo Camera with 5 mHz linear transducer), urine samples collected in the field and processed for iodine in the Biochemical Laboratory of Russian Endocrinology Research Center in the Russian Academy of Medical Sciences (Moscow), using conventional technique (1,3), and blood samples taken from 100 schoolchildren and analyzed for TSH, T4 and thyroglobulin.
In Todginskiy district we examined 260 schoolchildren in Toora-Chem village (iodized salt only). The total goiter prevalence in schoolchildren was 50.7% (Table 1); stage 2 (visible goiters) was 30.9%. Ultrasonography showed thyroid nodules in 1.9%. The median urinary iodine from children selected at random (Table 2) was 56.1 mcg/L; 70% were < 100 mcg/L, 40% < 50 mcg/L, and 13% < 20 mcg/L.
In Kaa-Hemskiy district, of 568 schoolchildren in five villages, the total goiter prevalence (Table 1) was 63.6% (28.9% - visible goiter), 33.3% in prepubertal children and 61.6% in pubertal children; stage 2 (visible goiters) in these groups of schoolchildren were, respectively, 14.6%, and 41.4%. Thyroid nodules were detected by ultrasonography in 5.8% of girls aged 15-16 years. Among schoolchildren in this district, two had features of congenital hypothyroidism and 18 were mentally retarded. The median urinary iodine was 38.2 mcg/L; 87,1% were < 100 mcg/L, 61.3% < 50 mcg/L, and 19.4% < 20 mcg/L.
Table 1. Goiter prevalence in schoolchildren in Tyva Republic
Districts Stage I goiter, % Stage II goiter, % Total goiter, %
Kaa-Hemskiy 34.7 28.9 63.6
Todginskiy 19.8 30.9 50.7
Ulug-Hemskiy 41.7 28.1 69.9
Ovyurskiy 27.1 3.8 30.9
In western Ulug-Hemskiy district, of 412 schoolchildren in the town of Schagonar (iodized salt and antistrumin pills), the total goiter prevalence (Table 1) was 62.3% (20.6% - visible goiter); 7.5% had thyroid nodules and the median urinary iodine (Table 2) was 59.2 mcg/L, with 71.4% < 100 mcg/L, 44.7% < 50 mcg/L, and 4.4% < 20 mcg/L.
In Ovyurskiy district, of 652 schoolchildren in the village of Chandagayty (salt iodization only), the total goiter prevalence (Table 1) was 30.9%, visible in 3.8%. The median urinary iodine was 89.6 mcg/L; 55% were < 100 mcg/L, 22.5% < 50 mcg/L, and none < 20 mcg/L.
Table 2. Urinary Iodine Levels in four districts
Urinary Iodine (UI), mcg/L
Districts 2 < 20 20-50 50-100 > 100 Median UI
Todginskiy 13.0% 27.0% 30.0% 30% 56.1
Kaa-Hemskiy 19.4% 41.9% 25.8 12.9% 38.2
Ulug-Hemskiy4.4% 40.3% 26.9% 28.6% 59.2
Ovurskiy ---- 22.5% 32.5% 45% 89.6
These results show that salt iodization, alone is not sufficient to prevent iodine deficiency in Tyva. In Ulug-Hemskiy district, receiving both iodized salt and antistrumin, we found considerable impact on urinary iodine levels. Therefore, distribution of iodized pills or iodized oil capsules is needed to provide an adequate iodine supply to the most vulnerable groups - pregnant and lactating women, children and adolescents. This campaign needs external funding because the local government is not likely to cover the costs of such intervention.
Also, on examination of schoolchildren and pregnant women in six districts with severe iodine deficiency, in the west of the republic the urinary iodine concentration in schoolchildren and pregnant women, receiving antistrumin, was 90 to 130 mcg/L.
Iodine Deficiency Cretinism in Tyva
Iodine deficient cretinism was not reported in Russia after the early 1950's, when the national control program began the large scale distribution of iodized salt and iodine tablets to populations of "endemic goiter regions" as defined by the Ministry of Health. Tyva is the first district of Russia where, after 40 years, new cases of iodine deficient cretinism are being discovered. These were predominantly of the myxedematous type, with an atypical clinical picture of congenital hypothyroidism. Although more than 5% of neonatal blood samples had TSH levels > 25 mU/L, most of these cases were thought to be transient and were not treated as permanently hypothyroid. Some recent cases of neurological cretinism (featured by tight hips and thighs, increased knee and adductor reflexes, slow facial movements and smile, flexed gait, shuffling; motor rigidity; spasticity with increased reflexes and ankle clonus, speech disorders and mental retardation) were described in the Newsletter (4).
These dramatic findings of cretinism confirm severe IDD, possible exacerbated by selenium deficiency in Tyva, and call for urgent implementation of control programs in this district.
Conclusions
Iodized salt alone has not been enough to prevent IDD in Tyva. In view of the republic's severe iodine deficiency, iodine supplements, as antistrumin or Lipiodol, should be distributed to high risk groups: pregnant and lactating women, children and adolescents.
References
1. Osokina IV, Manchouk VT 1998 IDD Newsletter 14(4):59-60.
2. Osokina IV, Manchouk VT 1999 Problemi Endokrinologii 4:24-27.
3. Osokina I 2000 Problemi Endokrinologii 1:7-9.
4. DeLong GR 1999 IDD Newsletter 15(4):59-61.
5. DeLong GR 1999 IDD Newsletter 15(4):61-62.
BOOK REVIEW:
IODINE. HIGH PERFORMANCE CHEMISTRY
This book from SQM, the large Chilean iodine provider, was prepared by their technical and sales staff led by Dr. Armin Lauterbach, Dr. Gustavo Ober, Mr. Sebastian Rios, Mr. William Basinger, and Mr. Alan Shipp. The preface states the book is "intended as reference for iodine consumers, R&D personnel, university researchers, and the industry in general." Its compact and attractive presentation provides a wealth of information about iodine. This IDD Newsletter article abstracts areas of greatest interest to our readers, along with occasional information from other sources. We thank SQM for making the book available and permission to quote from it.
Chemical features - The book begins with a general description of iodine's properties. [Ed note: the word "iodine" occasionally causes confusion, because it refers to iodine as an element (like oxygen or calcium) but also to molecular iodine (I2); the context should make the meaning clear.] The element was discovered by Curtois in 1812 on observing violet fumes rising when saltpeter pots were heated. It was named "iode" in French after the Greek word "ioeides," meaning violet-colored. It exists as shiny flakes that can be easily crushed. The boiling point 184.4° C, and it is only sparingly soluble in water: 0.16 grams dissolves in 1 kg water at 0°, and 4.48 grams at 100°. At low temperatures it is as the diatomic molecule, I2. It dissolves in many organic solvents, giving a brown to violet color. Its oxidation states are -1, +1, +3, +5, and +7. It forms stable compounds in all these states, and is mildly oxidizing at an acid pH. Its vapors can corrode metals, including stainless steel, but not titanium and molybdenum steels. Certain ferric, copper, chromium, and manganese salts, as well as chlorine, bromine, and nitrous acid can oxidize iodide (I-) in acid solution to release free iodine (I2). Chlorine oxidizes I2 to iodine monochloride. In alkaline solution, I2 is oxidized to iodate (IO3-) by sodium hypochloride.
Distribution - Iodine ranks 61st on the list of the 96 elements found in nature, making it one of the rarest. It is widely but thinly distributed in rocks, soil, water, plants, animal tissues, and foodstuffs. It almost never occurs in the free form, but is combined with other elements, usually as inorganic salts. The few sites where it is concentrated include seaweeds, occasional underground waters from deep oil well drilling, and some mineral springs. The largest concentration is in the natural deposits of sodium nitrate ("caliche") in northern Chile, but even there it is only one part in 500. The iodine in caliche is present as calcium iodate in two crystalline forms, called lautarite and dietzeite. The other large natural source is underground brines associated with oil and gas deposits in Japan, where iodine occurs most frequently as sodium iodide (NaI) at 50-150 ppm. Some seaweeds have iodine as sodium and potassium iodide salts (NaI and KI), reaching 950 ppm dry. Sea water contains < 0.05 ppm iodine, and although its total of 34.5 million tons is by far the world's largest deposit, it is not practical to extract because of its extreme dilution.
Extraction and production - Iodine is recovered from underground brines mainly by the so-called "blowout" process. The brines are first freed of impurities, then treated with chlorine, which converts hydrogen iodide (HI) to crystalline iodine (I2). An older method treats acidified brine with sodium nitrite, leaving soluble iodine (I2), which is then neutralized and extracted from activated carbon to produce an iodide-iodate solution and then iodine. Another approach removes iodine (I2) from oxidized brines using anion exchange resins.
Production from caliche ore in Chile begins with iodate reduction to iodine. Some iodine is also produced from seaweed, which is dried and burned, leaving iodine and salts of sodium and potassium.
World production - Chile is the world's leading producer, followed by Japan and the United States. Production distribution among countries in the year 2000 was: Chile, 52%; Japan, 37%; USA, 9%; and most of the remaining 2% from the CIS, China, and Indonesia. The world total is about 18,000 tons per year. All of the Japanese production - about 6500 tons per year - is from underground brines associated with natural gas, in wells about 1500 meters deep. In Chile, most iodine production is associated with nitrate plants. The annual output in Chile increased in the late 1990's and currently amounts to over 9000 tons. The United States annually extracts about 1600 tons iodine from deep brine wells, associated with oil and gas exploration. Extraction in the CIS countries is associated with oil production. Most of China's output is from seaweed, and is consumed domestically. Indonesia also produces some iodine.
Chemical forms of iodine - Salts, e.g., potassium iodide (KI) and potassium iodate (KIO3), are the most important commercial sources of iodine. The most common is KI, which is soluble in water, ethanol, and several other organic solvents. It is prepared by reacting potassium hydroxide with iodine (from HI and KHCO3) and by electrolytic processes. Sodium iodide is similarly produced by reacting iodine with sodium hydroxide or sodium carbonate. Hydrogen iodide (HI) is a gas, prepared by catalytic reduction of iodine in hydrogen, and marketed as an aqueous solution. Other commercially used iodide compounds are ICl, ICl3, IBr, IBr3, IF5, and IF7. All are formed by direct interaction of iodide with one of these other halogens.
The other common commercial inorganic derivative is iodate. Potassium iodate, produced by reacting I2 with potassium hydroxide, is a common example. This, with KI, is the most common form used to iodize salt. While safe to handle, metallic iodates (but not potassium iodate) can react with certain organic substances and become explosive.
The common organic iodine derivatives are: methyl iodide (CH3I) also called iodomethane; diiodomethane (CH2I2); iodoform (CHI3), also called triiodomethane; and ethyl iodide (C2H5I), called iodoethane. Some aromatic compounds of commercial interest are: thymol iodide (C20H24I2O2); iodobenzene (C6H5I), 4-iodophenol (C6H5IO) and 4-iodoanisole (C7H10IO).
Iodine usage - The distribution of iodines for various purposes is roughly as follows: X-ray contrast media, 23%; iodophors and biocides, 17%; chemicals, 17%; organic compounds, 12%; pharmaceuticals, 8%; human nutrition, 8%; nylon, 6%; animal feed, 5%; and herbicides, 4%.
Radiocontrast - Iodine compounds absorbs radiation more than does blood or soft tissues, and provide a dense shadow on X-ray-sensitive film, making the visualization of anatomical structures easier. Materials such as Lipiodol were developed and are still used for this purpose; their subsequent application to treatment of iodine deficiency has been a sideline.
Microbicides - Iodine penetrates bacteria and other micro-organisms and splits bonds within the bacterial proteins, thus inactivating them. The term "iodophor" refers to a complex of iodine to a carrier molecule that increases iodine solubility in water and allows its gradual release. Many antiseptics use such iodophors. As an example, PVP-iodine (povidone iodine) is widely used as a skin cleanser. Its minimal effective range is as a 10% solution, which contains 1% free iodine. One application of a 10% PVP iodine solution reduces bacterial activity on skin in about 70-80% of instances, and six applications increase this to 96%, with a residual action of 6-8 hours. Iodophors are widely used to clean teats in agriculture, and to prevent mastitis. Some of this iodine appears in milk and can influence human iodine nutrition substantially. Iodophors are also used extensively in cosmetics, adhesives, paints, wood preservation, inks, and starches, to protect against particular micro-organisms.
Water purification - This is a major use for iodine. Concentrations up to 5 ppm do not have adverse effects for health, and 1 ppm sterilizes water at the high alkalinity found in many treated water sources. Travellers to areas with drinking water of uncertain purity frequently use tablets containing tetraglycine hydroperiodide to disinfect it. Commercial iodinators pass a side stream of water through an iodine-rich source to provide a 0.5 ppm iodine concentration in the water supply. Addition of iodine to drinking water is also an occasional alternative to iodized salt for correcting iodine deficiency (see IDD Newsletter 13(3):33-39, 1997), for this, iodine (I2) also purifies the water, but iodide (I-) and iodate (IO3-) do not.
Chemicals - Iodine has wide use in photography. Nearly all film depends on the light-sensitive properties of silver halide crystals, and silver iodide is one of the most common of these. Potassium iodide is the usual product for this application. Other roles in the chemical industry are as a catalyst in reactions for the production of synthetic rubber, in polymer production, for manufacture of acetic acid, for conversion of wood products, and for the synthesis of fluorinated chemicals, widely used in fire extinguishers and for treating textiles. Iodine is a major component of certain dyes, particularly erythrosine (tetraiodo fluorescein), also known as red #3. This is one of the most widely used dyes for cherries and candies. Other iodine-containing dyes are 4',5'-diiodo fluorescein, rose bengal, kriptocyanine, cyanine and pinachrome, used in printing ink, photographs, and textiles.
Drugs - The manufacture of pharmaceuticals, agrochemicals, and dyestuffs makes extensive use of iodine derivatives. Some examples are: diiodomethane for separations in ore analysis; 4-iodoanisole in preparation of ultraviolet B absorbers in cosmetics and sunscreen agents; and trifluoroethyl iodide for inhalation anesthetics, as well as in laser dyes and polymer or resin modifier. Preparations of iodine are active ingredients in numerous pharmaceuticals, covering most fields of medicine. They also serve as intermediate molecules in the synthesis of antibiotics, steroids, and other drugs.
Other uses - Iodide salts are used for heat stabilization in manufacturing nylon, for example, in achieving heat resistance in manufacture of tires. Silver iodide is used for seeding clouds to induce rainfall, because its crystalline structure is quite close to that of natural ice crystals. Isotopes of iodine are commonly used in nuclear medicine. Many herbicides contain iodine compounds, Iodomethanes are replacing methyl bromide (phased out because of its damage to the earth's protective ozone layer) for fumigating soil. Iodine is effective in production of perfluoroctylbromide, a blood substitute, and has various potential applications in conductive polymers, electroluminescence, lightweight batteries for cars, and electromagnetic shielding.
Safety - US national standards require that iodine be 99.8% pure. It is solid at room temperature and fairly safe to handle, but adequate ventilation is recommended. Exposure to concentrations of 0.1 ppm in the air for up to one hour is regarded as safe; higher concentrations for extended periods may irritate the eyes and respiratory tract. The mean lethal dose for adults is 2-4 g/kg body weight. Skin contact can also cause burns, which can be treated with a 5% solution of sodium thiosulfate. Iodine preparations can be neutralized by sodium thiosulfate and are quickly degraded. Iodine-consuming industries are now recycling iodine by recovering it in the waste from production processing.
Summary - This book offers much valuable information about iodine in a straightforward manner with many illustrations. Readers of the IDD Newsletter will find it helpful in understanding the production and distribution of iodine and how they impinge on iodine nutrition.
Further information about the book can be obtained directly from SQM at iodine@sqm.cl, or by visiting the SQM website at www.sqm.com.
IN BRIEF.....
RECOMMENDED NUTRIENT COMPOSITION FOR FORTIFIED COMPLEMENTARY FOODS
A technical consultation with this title was held October 4-5, 2001, sponsored by the Food and Nutrition Program, Division of Health Promotion and Protection, PAHO/WHO. Its objective was to review and make recommendations about nutrition supplements and the application to food fortification for children, especially in Latin America. Dr. Chessa Lutter led the meeting's organization and guided its objectives. Papers from the proceedings will be published in the Journal of Nutrition.
The conference considered many requirements and recommended levels for many nutrients, and explored feasible means of introducing them. Dr. John Dunn, ICCIDD Executive Director, spoke on iodine nutrition. The IDD Newsletter and many other publications have constantly documented the severe adverse effects of iodine deficiency and the minor complications from iodine excess. Despite great progress in the Americas during the past decade (IDD Newsletter 17(1):1-9, 2001), problems remain. Monitoring of iodine in people and salt is inadequate, fragile, or non-existent in most countries. Only five countries appear to have adequate monitoring by urinary iodine, and another six have limited monitoring. Only five monitor iodized salt effectively, while another 10 have partial assessment. Food programs should meet the guidelines for daily iodine intakes as recommended by WHO/ICCIDD: 90 mcg/day for age 0-9 years, 120 mcg/day for age 9-13 years, 150 mcg/day for adolescents and adults, and 200 mcg during pregnancy and lactation. These are similar to the recommendations of the Food and Nutrition Board, US National Academy of Sciences. The latter group set the upper tolerable level of daily iodine intake as 1100 mcg for adults, recognizing that this is a conservative figure and that much higher doses of iodine usually have no adverse effects. Salt intake is frequently restricted during pregnancy. Also, the median national urinary iodine concentration may not reflect the true status during pregnancy because of a changed renal threshold for iodine excretion and the additional needs of both mother and child. From these considerations, Dr. Dunn recommended that 90 mcg of iodine per day be added in a convenient form to complementary foods in the diets of children from birth onward, and 150 mcg iodine to the daily diet of women during pregnancy and lactation, achieved most simply as part of vitamin and mineral supplements. Finally, he emphasized the need to have effective monitoring by urinary iodine concentration in each country to permit adjustment of iodine nutrition to optimal intakes.
BANGLADESH - The Bangladesh IDD Newsletter from December 2000 provides updated information on the IDD status there. The first follow-up national IDD survey was carried out in late 1999, coordinated by the Institute of Nutrition and Food Science at the University of Dhaka. The study group included children 5-11 years old and adults, 15-44, a total of 20,978 subjects, and 3,790 urine samples, from 80 areas (including the 78 surveyed in 1993 plus two additional ones from the Chittagong Hill tracts). The total goiter prevalence was 17.8%, and the prevalence of cretinism in children was 0.4%. By geographical area, the median urinary iodine excretion was 63.8 mcg/L in the hilly zone, 139.3 mcg/L in the flood-prone zone, and 147.7 mcg/L in the plains. Forty-three percent of the population had a urinary iodine < 100 mcg/L. The hilly zone appears to still be iodine deficient, with a goiter prevalence of 19.8%. These survey results can be compared with the situation in 1993, when nearly 69% of the country's population had a urinary iodine excretion < 100 mcg/L. At that time, the median excretion in the hilly zone was 34.0% mcg/L, 51 mcg/L in the flood-prone zone and 74 mcg/L in the plain zone. Thus, the iodized salt program has led to major improvements in iodine nutrition, but deficiency still remains in some places.
A new program of monitoring salt began in 2000. In it, samples were collected every three months from all factories and their iodine content determined by titration at the IDD Laboratory at the Institute of Nutrition and Food Sciences in Dhaka. Surveyors collected samples, without prior notification, from unpacked salt and from already packed samples, both small and large. Of 1,541 samples from 182 factories, 20% had less than 30 ppm iodine, 33% were between 30 and 65 ppm and 47 were > 65 ppm. Thus, about one-third of the factories produced iodized salt within 15 ppm of the legal range (45-50 ppm).
The Newsletter also describes studies on cleaning salt by small producers. The country has some 37,500 farmers producing crude salt in about 51,444 acres located in 11 places of Cox's Bazaar and Chittagong. The salt of most of these farmers is black and must be washed several times to make it white. The Bangladesh Small and Cottage Industries Corporation conducted an experiment to produce salt on a pilot basis, including the addition of polythene to improve its quality. They found that this changed the appearance to white and the quantity of salt per unit was good. These studies were preliminary, and the Corporation has plans to do more extensive investigations.