Population 1

Population:  81.377 millions
Population annual growth rate:   1.6%
Population < 18 years:  30,594 thousands; <5 yrs: 7,685 thousands
Crude birth rate:   20 per 1000
Life expectancy at birth:  69 years

Current Iodine Nutrition Situation

Median urinary iodine: 146 µg/L (2003).

Coverage rate for adequately iodized salt was 82.5% (National survey, 2003) which was increased from the 2000 level of 77.6%. Of the 61 provinces in Vietnam, 31 have coverage rates of 90% or above and 50 have rates above 70%. 11 have rates below 70%. This is an improvement since 2000 when only 27 had rates above 90%, 43 had rates above 70% and 18 had rates below 70%.

The MICS 2000 national survey found a household coverage rate of only 39.5% adequately iodized salt, which contrasts significantly with the results of the 2000 national household based survey which was 77.6%. The school based survey that was done the same year found that 71.7% of all the samples tested in the schools (brought in by the school children) were adequately iodized. Both the national survey and the MICS survey were nationally representative. However, the national survey used results from titration, a sub-sample of which were verified by an external laboratory (de Lange) whereas the MICS survey used the MBI kit. One possible explanation is that there are reports that the color from rapid tests kits may be slow to appear and so positive samples were recorded as negative.

Salt Situation Analysis 

Production 3

According to the National IDD Control Committee (NIDDC Committee), the total quantity of iodised salt produced in 2003 was 206,500 MT, based on the amount of KIO 3 distributed to producers. Registered producers are 75. However, it is important to note that the current legislation does not extend to non iodised salt, and as such the NIDDC does not maintain data on the supply and availability of non-iodised salt in the country.

• The Viet Nam salt industry appears to be protected. Imports are only allowed under a quota system and only high-grade industrial salt, which cannot be produced locally is permitted to be imported. Imports of food grade salt are not allowed.
• Iodization is undertaken by facilities controlled by NSC or provincial authorities or privately. All facilities wanting to iodize salt must be certified by NIDDC so they have a list - there are 75 in total, only 26 are under the NSC. NSC does not know who or where the others are and although we asked NSC to coordinate with NIDDC to get a complete list, this was apparently not possible.
• Non-iodized salt remains readily available, even, contrary to reports, in subsidy areas. There are also reports of non-iodized imported salt eg. from Thailand. Households frequently purchase both kinds of salt - for different uses in the house eg. while iodized salt may be used for cooking and on the table, non-iodized salt is frequently used for pickling and eating with 'green fruit', boiled chicken etc. It is also used for agricultural purposes. When buying salt, the public have to choose between iodized and non-iodized salt and although the awareness of the benefits of iodized salt appears to be high, they have to judge whether the extra cost is worth it.

Iodine Procurement and Utilization 3

The Committee for Ethnic Minorities controls a budget of about 70 billion Dong for the administration of the subsidy. This covers labour, packaging and KIO 3 for iodization and 48 billion for transportation of the salt. The vast majority of money is thus allocated to distributing the salt to subsidy areas. The purpose of the subsidy is to ensure availability of this important public health commodity in poor and remote communities.

Universal Salt Iodization Program

Information, Education, C ommunication (IE C ) Activities 5

Significant amounts of IEC on IDD and iodised salt have been undertaken at all levels. All health workers we spoke with talked of IEC activities such as radio spots, posters, loudspeaker messages. Much of this IEC seems to focus on goitre. Often the message is "eat iodised salt to prevent goitre" and the 2000 national survey found that 99% of people knew that iodine deficiency caused goitre. Only 21% knew that it caused mental retardation, however. The provincial committee of Can Tho found that people responded better to messages about goitre than about mental retardation because goitre is visible. Retailers, and school teachers to a lesser extent, seemed to have been involved in IEC activities.

Legislation

In 1999, the government issued Decree No. 19 on the Production and Supply of Iodized Salt for Human Consumption. This decree stipulates that all salt for direct human consumption and salt used for food preparation must be mixed with iodine. The decree then goes on to detail criteria and conditions for edible salt production, quality control, examination, inspection and handling of violations and provisions for implementation. This decree was followed by an interministerial circular of 10 November 1999 with Guidelines on the Implementation of Government Decree 19/1999/ND-CP.

Based on the legislative framework of Decree No 19 and subsequent implementation guidelines, all manufactures or distributors of iodised salt must receive a certificate by the MOH confirming that the enterprises have sufficient conditions and standards to produce iodised salt for human consumption and are subject to specific regulations. In spite of this, there are many producers who have only received operating permits from provincial departments of planning and investment as there is some misunderstanding of the legal and programme requirement 3 .

It has been recognised that Decree 19 is narrow in scope and steps have already been taken to revise the regulation with an emphasis on ensuring that common, non-iodised salt be included as the current regulations only state that only "salt for direct human consumption and food preparation" should be iodised 3 .

Program Monitoring and Evaluation

The IDD control programme is managed by the National IDD Control Committee (NIDDC Committee) based in the Endocrinology Hospital and administered by the Ministry of Health. The NIDDC coordinates all activities of the programme, including monitoring of salt iodisation at all different levels of the salt distribution system. There are 75 registered producers of iodised salt in the country, with 26 under responsibility of the National Salt Corporation of the Ministry of Agriculture and Rural Development (MARD) and the rest being either private concerns or operate under coordination of Provincial Government authority, e.g., People's Committee 3 .

An elaborate monitoring system has been developed by the NIDDC using principles of Lot Quality Assurance Sampling (LQAS) in which salt producers aren asked to analise 16 salt samples for each 'batch' of salt. Of these 16 samples, no more than 2 can have values either below 35 ppm or above 45 ppm, or else the 'batch' is rejected and needs to be re-iodised. For external monitoring, provincial health inspectors visit each salt producer in their area, with a frequency that ranges from weekly to bi-weekly to monthly, and essentially replicate the internal QC, following similar procedures to assess the adequacy of salt.

There is a very well organised and efficient national IDD committee that oversees monitoring of the IDD elimination programme 2 .

• The Monitoring system consists of surveys undertaken by provincial IDD committees three times per year - in April, July and October.
• Provincial authorities visit salt iodization facilities twice a month (or more often) to take random samples of salt to assess iodization levels. The samples are tested in the provincial salt laboratory (every province has a salt laboratory).
• There are also reports of checking salt iodization levels at retail level by both provincial and commune authorities to ensure that iodized salt is adequately iodized. However in many cases, little can be done if salt is found to be non-adequately iodized, unless it has come from a factory within that province. Some communes also seem to collect data on how much iodized salt is sold.
• In addition, national surveys at household and school level are undertaken every three years. Household surveys have been undertaken in 1997, 1998, 2000 and 2003. School surveys have been undertaken in 1993, 1998 and 2000 and 2003. The surveys all collect iodized salt household coverage and urinary iodine data and the school based surveys also collect total goitre rate. In the household coverage survey the UI data is from women with children under 5 and in the school based survey it is from children in school.
• The central urinary iodine and salt iodine laboratories in the Hospital of Endocrinology in Hanoi supervises quality assurance of regional and provincial laboratories in addition of UI analyses.
• Vietnam has developed its own rapid test kit. The kit is labeled to differentiate between 7ppm and 20ppm which is the level of iodization that the law has stipulated must be available at household level.

National Committee

Intersectoral collaboration is not yet officially established. The program is managed by the National IDD Committee which is situated within the Ministry of Health. At provincial level, the IDD program is the responsibility of the Provincial People's Committee. The Provincial Primary Health Care Committee functions as the IDD Committee, which is often chaired by the Vice Chairman of the Provincial People's Committee. The IDD department is housed in the Provincial Preventive Health Centre and operates as the focal point for IDDC program of the province.

Other Interventions

Oral supplementation with iodized oil capsules was used from 1984 to 1995 but it's no longer used. 

Challenges and Constraints 3

•  Lot quality assurance sampling (LQAS) may not be capturing the variations in iodine levels of salt. Salt producers maintain 'QA' records which are reviewed by provincial health authorities when they visit factories. In addition, while there has been extensive external monitoring, with some producers visited once a week, the exercise is seen as being redundant which has essentially repeated the very same activities that the producers themselves implement.

•  Decree 19 states that all edible salt and salt for food preparation must be iodized. However there has been a difference of opinion as to whether this includes salt for food processing. Currently many of the salty condiments industry (including fish sauce) and home food processing is using non-iodized salt.

Future Plans for Sustained IDD Elimination

The followings activities are being planned/considered by key stakeholders:

•  Modify and Improve Existing Legislation

•  Ensure sustainability of the programme through intersectoral collaboration

•  Streamline Monitoring and Quality Assurance Systems

•  Re-focus Communication Activities from goitre prevention and reduction to assuring optimal iodine nutrition to protect the brains of newborn babies from intellectual impairment.

•  Rationalize Salt Industry including Salt Iodization. Within existing plans to upgrade and rationalize the salt industry in move to market-oriented economy, ensure iodization is included as basic requirement.

References

1) UNICEF. The State of the World's Children. 2005

2) Eastman, C.J. Reports from the Regions and the Countries by ICCIDD Regional Coordinators: Vietnam in Towards the Global Elimination of Brain Damage due to Iodine Deficiency. Oxford University Press, 2004.

3) Gorstein, J. Tracking Progress towards IDD Elimination in Viet Nam. UNICEF consultant report. 2004.

4) UNICEF, ICCIDD and WHO. Report of Inter-Agency Visit to Review Viet Nam Universal Salt Iodisation Programme. 2004.