Current Iodine Deficiency Disorder Situation

Population

Population:  1, 065 millions
Population annual growth rate:   1.8%
Population < 18 years:  414,965 thousands; <5 yrs: 118,568 thousands
Crude birth rate:   24 per 1000
Life expectancy at birth:  64 years

Current Iodine Nutrition Situation

Total goiter rate (TGR) from 24 states and districts surveys pooled at district level was 17.9%. There is no State or Union Territory in India is free from Iodine Deficiency Disorders. Goitre surveys conducted in 582 districts in 29 States and 6 Union Territories over a wide period of time (1960's to 1990's) have identified 247 districts as IDD endemic 4 .

Notwithstanding the above measures, representative surveys conducted between 2001 and 2002 in Bihar, Kerala, Orissa, and Tamil Nadu provided evidence of the inadequacy of the population's iodine status as indicated by the urinary iodine concentration.

Table 1 : Summary of findings from recent studies on iodine nutrition in India

For adequate iodine nutrition, WHO/ICCIDD/UNICEF cut-off value for the median is UIE > 100 µg/L, with no more than 20% of the population having a value below 50 µg/L.

Households that consumed adequately iodized salt 1 : 50 %.

Salt Situation Analysis

Production

India is the third largest producer of salt after China and USA . Annual production is 14 million tons. Gujarat , Tamil Nadu and Rajasthan are the major salt producing States accounting for about 70%, 15% and 10% respectively of the total production 4 .

Almost all iodized salt in the country is produced mainly in three states: Gujarat in west India , Rajasthan in northwest India and Tamil Nadu in South India . The salt is then transported from these production centres to the rest of the country by road and rail transport. For distances beyond 500 kilometres, it is economical to transport the salt by the rail route. Iodized salt is transported at a lesser rate 2 .

Consumption

•  Households iodized salt consumption was:   50% (1998-99).

•  A more recent national survey (RCH-2, 2002-03) which covered 1,000 households drawn from 50 percent of the total districts in each state, revealed wide variation among states in the consumption of adequately iodized salt. Its more disturbing finding was the decline in consumption levels from 49.3 percent (as per NFHS-2, 1998-1999) to 36.7 percent (RCH-2, 2002-03). The observed decline was substantial in such states as Assam, Gujarat, Maharashtra, and UP.

Iodine Procurement and Utilization

Universal Salt Iodization Program

Information, Education, C ommunication (IE C ) Activities

To address the core issues surrounding the acceleration of USI for eliminating IDD in India, an effective communication strategy targeting all the important stakeholders in the USI programme was devised and the relevant tools for its implementation are being developed. The strategy is geared to helping achieve by the end of 2007 two national objectives : (a) 90 percent of households are able to consume adequately iodized salt and (b) 100 percent of salt producing districts have mobilised producers/refiners to produce only iodised salt.

Relying on a basket of interventions including advocacy, social marketing of iodized salt as well as awareness creation at the community level, the communication strategy will target an audience composed of policy makers, programme managers and implementers, salt producers, traders, and retailers, and the community. For each sub-group of target audience a set of effective communication channels was identified.

3.2.4 Undertaking IEC and social mobilisation.

To promote the consumption of iodized salt at the household level, awareness generation activities were carried out in several states.

Legislation 2

In 1997, in a move to increase the sale and consumption of iodized salt, the government of India banned the storage and sale of common salt for human consumption. This move, though well intentioned may have been the cause for the protesting voices raised against USI, as the implementation of this order by the government raised the question of choice by the consumers.

On September 13, 2000 , the Government of India lifted the ban at the national level on the sale of non-iodized salt (India Gazette 2000). However, except for two states ( Gujarat and Orissa) the remaining states did not lift the Ban. (Later on Orissa introduced the ban again) The reason given was that, “When the question was of individual choice, compulsion is undesirable”.

Carol Bellamy (UNICEF) during her audience with the Prime Minister (April 7, 2005) asked the government to re-instate the central ban on the sale of non-iodised salt, which born fruit with its reinstatement 5 declared on 15 th June 2005.

Program Monitoring and Evaluation

Monitoring the quality, availability as well as consumption of iodized salt is an essential component of the USI strategy. For effective program monitoring, MOH has supported the establishment of IDD Control Cell. MOH also set up a National Reference Laboratory at the National Institute of Communicable Diseases (New Delhi) for training medical and para-medical personnel and monitoring the iodine content of salt and urine samples. Monitoring of iodized salt is carried out at both production and consumption levels. At retailer and consumption level, two types of monitoring currently exist:

(i). Monitoring carried out by the Prevention of Food Adulteration (PFA) authorities using titration method.

(ii). Monitoring using both the titration and spot testing kits by district health laboratories.

In New Delhi, ICCIDD has established a system for regularly enlisting the schools in monitoring the programme:

Key Lessons Learned 2

An analysis of iodine deficiency disorders (IDD) elimination programmes all over the world show that the following four elements contribute to their success and India 's experience can be summed up as follows:

i) Political commitment. For the first 20 years of its existence, the National Goitre Control Programme (NGCP), launched in 1962 – iodized salt was a low priority renamed as the National Iodine Deficiency Disorders Control Programme (NIDDCP). The turning point was in 1983, when Prime Minister Indira Gandhi was briefed by top scientists on the consequences of IDD and the availability of a cheap and cost effective solution. She decided that this was not only a health problem but a national development problem.

Almost overnight, the programme underwent a sea change and the strategy of Universal Salt Iodization (USI) was adopted. Goitre control was on the Prime Minister's 20 Point Programme and the private sector was invited to produce iodized salt.

ii) Administrative infrastructure. For proper administration, it is essential to have a nodal point for the programme. For India this the Adviser (Nutrition) and Deputy Assistant Director General (Goitre). Each state also has an IDD cell to act as its nodal point.

iii) Scientific leadership. ICCIDD members have been involved in conducting research on different aspects of IDD for the last 40 years. The formation of an NGO in India as the National Chapter of ICCIDD as facilitated the creation of a ‘home base' located in the country's premier health institute, the All India Institute of Medical Science. This serves as the training and resource centre for field surveys, training in measuring iodine levels in salt and urine (to track progress toward IDD elimination), information dissemination, technical expertise and monitoring and evaluation of activities.

iv) Monitoring and evaluation. India has a system in which food inspectors collect salt samples and send them to laboratories for analysis. In New Delhi , ICCIDD has established a system for regularly enlisting the schools in monitoring the programme:

ICCIDD has also forged collaborative partnerships with a network of NGOs such as the Voluntary Health Association of India and the Bharat Scouts and Guides, which carry out activities all over the country. In addition to providing technical support, ICCIDD has conducted technical independent evaluations of the USI programme in New Delhi , Madhya Pradesh , Sikkim , Kerala, Tamil Nadu, Orissa, Bihar and Goa .

Challenges and Constraints

The foremost task is the collection of regular, reliable, representative, state level scientific data to convince the policy makers of the seriousness of the problem. In India , Public Interest Litigations (PIL) has been filed in the Supreme Court (the highest judicial body of the country), questioning the government decision to lift the ban. Be that as it may, the communication focus now should be towards the role of iodine and iodized salt in the optimum physical and mental development of the children of India 2 .

Other constraints include 6 :

•  Insufficient availability of adequately iodized salt, especially in rural areas

•  Low awareness about the need to use iodized salt (as the only means of protection against brain damage and subsequent loss of IQ points resulting in a decreased learning capability) often leading to a household's choice of cheaper non-iodized salt

•  Poor enforcement of legislation against the sale of non-iodized salt

Future Plans for Sustained IDD Elimination

Government of India and UNICEF developed a 5 year (2003-2007) plan of cooperation that covers the following 3 strategies 3 :

1. Increase the amount of iodised salt on the market through collaboration and dialogue with salt traders, wholesalers – medium and large producers. This group packages the largest part of the salt for human consumption and also has the capacity to iodise. They are motivated to do so at a reasonable price. The hindrances which they experience are now better understood and attempts be made to lift these, without influencing the normal trade practices. Small producers are being assisted in 2005 to improve production and marketing technique.
2. Continued advocacy at state and central level. State government and institutions should, where possible, monitor, demand and urge the production, import, and use of iodised salt. Only iodised salt should be used in mid-day meal schemes, ICDS, and iodised salt is made available through the Public Distribution System at low cost.
3. Create awareness among the general population about the need to use iodised salt. Focus of the message is on learning capability of children. These messages will go out through health and nutrition community workers (AWWs), Women Self Help Groups, and most importantly through schools. Testing of salt samples at schools and collaboration with consumers organisations are some of the powerful intervention mechanisms which were scaled up in 2005.

References

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

•  Moorthy D. and Pandav C.S. Reports from the Regions and the Countries by ICCIDD Regional Coordinators. 3.3 India in Towards the Global Elimination of Brain Damage Due to Iodine Deficiency. Oxford University Press, 2004.

•  UNICEF. Government of India – UNICEF Programme of Cooperation 2003-2007. Child Development & Nutrition Section. UNICEF India. 2005.

•  UNICEF. Note on iodine deficiency programmes in India supported by UNICEF. Child Development & Nutrition Section. UNICEF-India, 2004.

•  UNICEF. Iodine Deficiency Disorders Project in India . February-September 2004. UNICEF-India, November 2004.