Population

Population:  8,808 millions

Population annual growth rate:  2.1%

Population < 18 years:  3.967 millions; <5 yrs: 1.194 millions

Crude b irth rate:   29 per 1000
Life expectancy at birth:   64 years

Current Iodine Nutrition Situation

Prevalence of Goitre/ Urinary Iodine Concentration

Total goitre rate was 4.5% (National survey, 1994)

The information on iodine concentration the country disposes of comes from sentinel sites, dating from 2000; unfortunately continuity was broken owing to various problems. This information shows that iodine in urine in school children reaches 68 ug/L, less than the recommended level under the ICCIDD norm of over 100 ug/l. The lowest levels are found in the valley region with 43.5 ug/L and the highest level was found in the high plateau with 77 ug/L versus 69 ug/L in the valleys.

Iodized salt C overage

Household iodized salt use 1 : 90% (2003)

The National Health Survey ENDSA which carried out every 4 to 5 years in the country demonstrated that adequately iodated salt consumption in households reached 96% in 1998. However after 1998 Ministry of Health support for control of iodized salt production diminished noticeably. The first alert signal was generated by the Multiple Indicators Survey (MICs 2000) which showed that only 65% of salt was being adequately iodated. The recent ENDSA survey (2003) indicated an increase coverage of iodized salt consumption to 90%.

Salt Situation Analysis

Production 5

Iodized salt production is 31,000 MT per year, production capacity is 57,000 MT per year, and consumer demand is 27,000 MT per year. 39 plants are regularly working; one plant has improved the quality of iodized salt produced and low tech characteristics were maintained in the same 25 plants evaluated the previous year, making a total of 26 plants.

Information, Education, Communication (IEC) Activities

Based on the study carried out, the Coordinator of the National Nutrition Programme (PRONAN) with support from UNICEF, has developed an Information, Communication and Social Mobilization Strategy, so as to promote the adequate production, sale, monitoring and consumption of iodized salt. Materials for these four groups have been identified and production of printed and sound materials has been completed. The initiation of a campaign is planned in October in coordination with National Nutrition Council ( CONAN) and the Ministry of Health, once that iodized salt with the new seal of guarantee is available for sale in the market.

PRONAN continues to inform the population through the press on salt brands that are being correctly iodated, and this contributes to improve the quality of iodized salt.

Legislation

The Fortified Foods Law is pending promulgation by Congress and once this is achieved will lead to the updating of legal aspects of the norms on iodation.

Various coordination meetings have been held and normative functions have been agreed upon with SENASAG under the Ministry of Agriculture and the Direction for the Monitoring of Foods and Drinks under the Ministry of Health. This agreement will lead to the initiation of the re-registration of salt iodation plants so as to accede to the new seal of guarantee.

Salt iodation for animal consumption is still pending, owing to changes of authorities within the Ministry of Agriculture.

Program Monitoring and Evaluation

The National Nutrition Programme of the Ministry of Health has established the need to continuously evaluate progress in the elimination of the IDD (household iodized salt consumption and urinary iodine concentration) through Surveys, and the National

Monitoring of progress in IDD is maintained by means of annual progress reports generated by the National Monitoring System of Quality in Fortified Foods, however, the system must be consolidated in a decentralization process through the SEDES and with participation from grass root organizations, schools and municipalities, and principally with the alter a very slow process was experienced.

Laboratory network

This has continued to be run under the coordination at national level of Nutrition/Micronutrients Laboratory of the National Institute for Health Laboratories (INLASA) in the city of La Paz .. Regional laboratories within the network have begun the process of quality gradually, under coordination with INLASA.

National Monitoring System for Fortified Foods

The system has been redesigned and put into force in coordination with SENASAG and the municipalities and with an early alert system put into effect maintains a defined information flow, participation of the civil population in quality control as well as recognition by departmental authorities of companies and organizations who have worked best over the year.

Information at national and departmental levels is available on the plants (sample A and B) and on the market (sample C). The norm in Bolivia is 40-80 parts per million, as established from the beginning of the programme. It has not been considered convenient yet to present the ICCIDD recommendations of 15 parts or more per million, as the results of the study to determine areas of risk are still pending.

National Coordination for IDD Elimination

The Committee responsible under the National Program for IDD Elimination must be multidisciplinary, including the components of nutrition, education, salt producers, communication media and others, under the coordination of the Ministry of Health.

Although working irregularly the National Nutrition Council (CONAN) has been maintained, created by Supreme Decree No. 27029 in May 2003, and includes representatives from various Ministries, the Senate, private industry, food producers and processors (oil, salt and milk producers and flour millers), grass root organizations and the Bolivian Workers Union. It was created as an organism responsible for promoting and coordinating interinstitutional and intersectoral coordination in the formulation and follow up of national policies for Nutrition.

Departmental Nutrition Councils (CODAN) is regularly functioning in Santa Cruz and Cochabamba, and has drawn up and presented Departmental Nutrition Plans, which include IDD control. CONAN and the CODANs are considered a coalition at national and departmental levels for monitoring IDD control, as well as alliances established in the other departments.

Other Interventions

Iodized oil and solution distributed to communities not yet reached with iodized salt has achieved 45% coverage in rural areas. IDD control has been supported by a major public education program--using mass media and interpersonal communications--to increase awareness of IDD and stimulate demand for iodized salt and iodized oil in severely iodine deficient areas..

Key Lessons Learned

The entire country had severe iodine deficiency with goitre prevalence in the 60% range and frequent cretinism. An impressive programme with iodized salt and iodized oil led to iodine sufficiency by 1996, with median urinary iodine of 252 µg/L and household consumption of iodized salt reached 92%. The situation is improving mainly through salt iodization at 35 regulated and monitored, commercial plants. Strong political commitment, generated in part by a growing awareness within the Bolivian medical community of the severe effects of iodine deficiency, led the government to create the National Program to Fight Against Goiter (PRONALCOBO) in 1983. An external review committee then concluded that the country was iodine sufficient. Subsequently the situation deteriorated. Changes in government and personnel led to decreased monitoring and a general lost of interest. By 2000, household use of iodized salt was down to 62%, and the median urinary iodine was in the deficient range (ICCIDD 2001).

This reduction following achievements up to 1998 was due to the following problems:

•  Complexity of salt producers, a majority of which are low-tech

•  Less political support for the Program by Ministry of Health authorities following certification in 1996

•  Continuous changing of persons in charge of the Program at central and departmental level

•  Lack of full institutionalization of the quality control system for fortified foods and of the epidemiological surveillance system

Faced with this situation, PAHO/WHO and UNICEF have increased efforts through advocacy, technical assistance and strategic activities at both political and technical levels with the Ministry of Health, municipalities, producers and civil society. Activities implemented have led to improved iodized salt consumption within the norm from 65%, (MICs 2000) to 85% (ECIN 2002) and, according to the latest information provided by ENDSA 2003, Bolivia has once more achieved 90% of adequately iodated salt.

Challenges and Constraints 5

•  Social and political instability in the country was aggravated by the total paralysis of the country in May and June this year.

•  Various salt producers still elude iodation norms and the corresponding sanctions are not fully carried out.

•  Delay in promulgation of the Fortified Foods Law to provide legal support for improved control.

Future Plans for Sustained IDD Elimination 5

The following activities are currently pending for implementation:

•  Dissemination of the Information, Communication and Social Mobilization Strategy

•  A new seal of guarantee planned for the month of October

•  The conclusion of the study to Determine IDD Areas of Risk planned for January 2006

References

•  UNICEF. The State of the World's Children. 2005

•  IDD NL 20(2):19, 2004

•  Dunn, John T. Sustaining Optimal Iodine Nutrition in Towards the Global Elimination of Brain Damage Due to Iodine Deficiency. Oxford University Press, 2004.

•  UNICEF. " Second Progress Report on USI". UNICEF-La Paz. July 2005.