National Iodine Deficiency Disorders Control

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Historical Background/Periodical Development
Prof V.Ramlingaswami surveyed the Kangra district in Himachal pradesh during the period, 1956–1972, Wherein 1 lack school children were surveyed. Intervention was planned and the area was distributed in zones. Zone A was supplied with ordinary salt. Zone B received salt + potassium iodide. The results showed that the goiter rate dropped from 40% in 1956 to 19% in 1962, in zone B.

This study is well known as Kangra Valley study. Government of India realised the magnitude of the problem and launched a 100% Centrally Sponsored Programme called National Goiter Control Programme in 1962. In August 1992 this programme was renamed as National Iodine Deficiency Disorders Control Programme with a view to conver the wide spectrum of Iodine Deficiency Disorders like mental and physical retardation, Deaf – mutism, cretinism, still births, abortions.

Gandhiji picking up salt at Dandi Gandhiji picking up salt at Dandi
International focus on elimination of Iodine Deficiency Disorders reflected in passing resolutions in world summit for children held at New York in September 1990, 43 rd world health assembly held at Geneva in may 1990, SAARC conference on children of South Asia held at Colombo in Sept,1992. India as a signatory to these resolutions reiterated its commitment to eliminate IDD.

Now, from 2 lacs tonnes of annual production, more than 40 lacs of annual production has been achieved. India is second largest manufacturer of Iodized Salt in the world after China. Presently 4.00 million tones of Iodized Salt in produced.

In last 50 years many countries in North America, Asia, Europe have eliminated IDD with Salt Iodization. For example, cretinism, Goiter have been eliminated in Switzerland due to salt Iodization since 1922.

As per WHO estimate about 30 % of world population is reported to have IDD.

As a Public Health Problem IDD is reported from 110 countries which account for 46% world population.

Elimination of IDD from the world is receiving highest priority from WHO, which is a reflected in the subject selected for discussion at 97 th session of the executive board and 49 th world health assembly held in may 1996. In 1995, a inter country conference was organized by international council for control of IDD, UNICEF, Canadian international Development, micronutrient agency Govt. of Bangladesh at Dhaka. The main theme of this meeting was commitment to the goal of eliminating IDD.

There are series of declarations at the following events So, lastly to sum up the IDD has a solid historical background for commitment to eliminate IDD.

Objectives
  1. Surveys to assess the magniutde of the Iodine Deficiency Disorders.
  2. Supply of Iodated salt in place of common salt.
  3. Resurvey after every 5 Years to assess the extent of Iodine Deficiency Disorders and the impact of iodated salt.
  4. Laboratory monitoring of iodated salt in urinary iodine excretion.
  5. Health education.

Strategy of National Iodine Deficiency Disorders Control
Intervention strategies in prevention and control of IDD
Method for iodine supplementation and associated difficulties Of the above mentioned methods, iodination of salt of a proven intervention, salt being a common food item used by a vast majority of population. Therefore, to ensure success of a national iodine deficiency disorders programme, it is mandatory to check that the salt being used by humans is adequately iodized.
  1. The highly volatile nature of iodine in all forms, potassium iodide ( ki) being the most volatile and potassium iodate ( KIO3) the least, makes production and quality assurance of iodinated salt quite difficult.
  2. The problem may be compounded due to fragile distribution network and faulty preservation system, e.g. salt may be left uncovered or exposed to heat. Addition of salt after cooking to reduce loss of iodine is advocated.
  3. The last but not the least difficult task is to ensure actual consumption of salt. Though the addition of iodine makes no differences in the taste of the salt, but the introduction of a new variety of salt, where a familiar one is already available, is likely to be resisted. Thus it is quality important to create a high demand and preference for iodized salt to be used in households.
Steps towards prevention of IDD
In order to make the national programme of IDD elimination possible, it is important to take up effective steps in the following directions
  1. Advocacy efforts create awareness – The impact of iodine deficiency on the next generation and its potential economic impact need to be highlighted.
  2. Education of the masses through IEC materials will assure a demand for iodized salt.
  3. Formulation of legalization that only salt with specific iodine content should be produced or imported, guarantees that only iodized salt is available in the market.
  4. Quality assurance procedures should be opted for production, distribution and marketing of salt.
  5. A strategy needs top be established to verify the extent and nature of the IDD problem.
Activities
District level
Guidance to medical officer, team at district training Centre and review in monthly meeting about spot testing of salt sample and Collection of Urine Sample.

Divisional level
Dy. Director of Health Services (IDD) is responsible for the implementation of National Iodine Deficiency Disorders Control Programme by CME about IDD, functional status of various district Public Health Lab and Regional Public Health Lab, Co-ordination in various sectors like Food and Drug Administration (FDA), Civil Supplies Department, Tribal Development Department, ICDS wing of Women & Child Department, Workshop in various medical collages involvement of Municipal Corporation.

Services to Common People
The anganwadi workers. MPW’s at PHC, ANM’s at Sub–centre can have Spot – testing of salt and also estimation of Iodine content salt in Public Health Laboratories can be done free of charge for a common man directly or through health workers.

Urinary Iodine estimation is done at Aurangabad, Nasik, Nagpur, Pune regional public health laboratories at no charges.

Medical Officer at PHC, Sub–district hospital, Rural Hospital, examines for the diagnosis of goitre in out patient department and treatment can be obtained free of charge.
Service Centers Available in each District ANM/MPW at sub – Centre/PHC can accept salt sample and sent to district Public Health Lab for estimation Iodine content.

In some high risk pregnancies the Urinary Iodine Estimation can be done by sending the sample to public health laboratory at Pune, Nasik, Nagpur, Aurangabad.

The medical Officers at PHC, Rural Hospital, District Hospital examine the patient for any swelling in the neck and give free treatment.

Performance – District Wise
Survey is done in various districts the results are as follows

Sr.No District Survey year Goiter cases in surveyed % population
1 Aurangabad 1970–71 54.53
2 Jalna 1973–74 51.05
3 Wardha 1983–84 54.29
4 Amravati 1983–84 46.16
5 Dhule 1984–85 30.03
6 Buldhana 1984–85 49.53
7 Satara 1985–86 20.29
8 Thane 1989–90 0.29
9 Nasik 1989–90 3.53
10 Jalgaon 1989–90 2.65
11 Pune 1989–90 0.41
12 Latur 1989–90 11.81
13 Beed 1989–90 0.02
14 Nanded 1989–90 0.02
15 Osmanabad 1989–90 11.18
16 Nagpur 1989–90 2.68
17 Bhandara 1989–90 0.7
18 Gadchiroli 1989–90 0.05
19 Chandrapur 1989–90 0.03
20 Akola 1989–90 0.01
21 Yeotmal 1989–90 0.12
22 Raigad 1990–91 0.11
23 Ahmednagar 1990–91 0.34
24 Solapur 1990–91 3.16
25 Kolhapur 1990–91 3.16
26 Sangli 1990–91 0.05
27 Mumbai Corporation 1997–98 3.34


Re–Survey is done in various districts the results are as follows

Sr.No. District Year of Re–Survey Goiter cases in surveyed % population
1 Aurangabad 1989–90 17.53
2 Jalna 1989–90 12.12
3 Thane 1990–91 28.22
4 Dhule 1991–92 43
5 Wardha 1991–92 34.6
6 Amravati 1991–92 30.1
7 Satara 1992–93 22.02
8 Kolhapur 1992–93 27.03
9 Buldhana 1992–93 16.09
10 Raigad 1993–94 25.04
11 Sangli 1993–94 20.03
12 Parbhani 1993–94 21
13 Akola 1993–94 24.01
14 Pune 1994–95 32.05
15 Chandrapur 1994–95 20.05
16 Ratnagiri 1996–97 2.83
17 Nasik 1996–97 16.04
18 Latur 1996–97 7.33
19 Nanded 1996–97 15.08
20 Nagpur 1996–97 14.04
21 Bhandara 1996–97 12.97
22 Jalgaon 1997–98 10.02
23 Aurangabad 1997–98 10.06
24 Beed 1997–98 10.01
25 Yeotmal 1997–98 10.02
26 Satara 1998–99 4.08
27 Jalna 1998–99 11.07
28 Wardha 1998–99 10.45
29 Gadchiroli 1998–99 9.69
30 Buldhana 1998–99 12.02
31 Kolhapur 1990–00 6.41
32 Parbhani 1990–00 15.01
33 Washim 1990–00 16.35
34 Amravati 1990–00 16.35
35 Raigad 2000–01 1.42
36 Ahmednagar 2000–01 11.06
37 Dhule 2000–01 15.05
38 Solapur 2000–01 1.85
39 Sindhudurg 2000–01 40.09
40 Sangli 2000–01 5.95
41 Osmanabad 2000–01 12.06
42 Nagpur 2000–01 11.72
43 Thane 2001–02 7.02
44 Ratnagiri 2001–02 6.5
45 Nasik 2001–02 15
46 Pune 2001–02 5.28
47 Aurangabad 2001–02 14.04
48 Parbhani 2001–02 12.08
49 Ratnagiri 2002–03 10.89
50 Latur 2002–03 11.91
51 Wardha 2002–03 10.03
52 Gadchiroli 2002–03 7.09
53 Jalgaon 2003–04 2.97
54 Dhule 2003–04 20.03
55 Bhandara 2003–04 11.87
56 Sindhudurg 2004–05 11.22
57 Yeotmal 2004–05 10.23
58 Satara 2004–05 3.83
59 Amravati 2005–06 22.04
60 Buldhana 2005–06 11.87
61 Kolhapur 2006–07 0.81
62 Osmanabad 2006–07 18.79
63 Jalna 2006–07 16.63
64 Sangli 2006–07 0.64
65 Akola 2006–07 19


Field staff working under District Health Officer & Civil Surgeon collects salt sample

Sr.No Year Total Samples Sun–standred Percentage
1 2002 5394 1632 40.64
2 2003 4423 1476 36.26
3 2004 7319 2221 32.51
4 2005 13774 3347 24.00
5 2006 20172 3405 17.00

Urinary Iodine Estimation is done at Pune & Nagpur Public Health Lab, Results are as follows

Year Total Sample 50–99 micrograms 20–50 micrograms Below 20 micrograms
2002 1084 170 68 118
2003 1241 383 102 24
2004 1725 212 45 26
2005 2615 403 154 59
2006 1880 424 380 76

Special Features of Programme
The role of micronutrients is increasingly getting appreciated. Iodine is one of the important micronutrient. It is required to the extent of 150 microgram per day.

Iodine requirement
0–5 yrs: 10 Micrograms
6–12 yrs: 120 Micrograms
above 12 yrs: 150 Micrograms
pregnancy: 200 Micrograms

Normally, to the source of iodine is the plants Vegetables, animal products.

About 4 lack tones of Iodine is evaporated from Sea and by rains it is available in upper layer of soil.

The plants absorb iodine from the soil. But due to industrialization, tree felling etc, there is erosion of soil. Due to erosion the upper layer of sail is lost and so, also the iodine content is lowered.

Due to deficiency of Iodine there is wide spectrum Disorders called Iodine Deficiency Disorders.

Spectrum of Iodine Deficiency Disorders

Fetus Abortions
Stillbirths
Congenital Anomalies
Increased Prenatal Mortality
Neurological Cretinism Mental deficiency
Deaf–mutism
Spastic diplegia
Squnit
Myxedematous cretinism dwarfism
Mental Deficiency
Psychomotor defects
Neonate Neonatal goiter
Neonatal hypothyroidism
Child and Adolescent Goiter
Juvenile hypothyroidism
Impaired mental function
Retarded physical developement
Adult Goiter with this complications
Hypothyroidism
Impaired mental function


Due to loss of IQ by 10–15 points and decrease in the activity of all members of society due to deficiency of iodine results in adverse effect on economy. The IDD is a problem of all the states in the country. Sample survey conducted in 28 states and 6 UT has revealed that IDD endemic 254 district out 0f 312 districts.

So, this major public Health problem needs to addressed urgently by adopting various strategies like universal consumption of iodized salt, increased awareness at all levels, Surveillance etc.

Achievements of National Iodine Deficiency Disorders Control
Due to sustained support of GOI, UNICEF the iodized salt production has increased from 2 lacks tones in 1984 to 40 lacks tonnes currently. Initially only Government was the sole manufacturer of iodized salt. But with efforts of UNICEF & GOI, the private sector has taken a lead in this area.
The quality of iodized salt is also monitored and following table shows the betterment in this aspect.

Sr.No. Year Total Samples Sub–standred Percentage
1 2002–03 5394 1632 40.64
2 2003–04 4423 1476 36.26
3 2004–05 7319 2221 32.51
4 2005–06 13774 2247 24.00
5 2006–07 20172 3405 17.00

Urinary Iodine is good objective indicator of status of iodine. Till to 2003 only 2 laboratories were with the facility of estimation of Urinary iodine. But now this facility is available at 4 divisional place Aurangabad, Nashik Nagpur, Pune. Results of the investigations as follows:

This issue was discussed in state level meeting of Civil Surgeon, District Health Office, Dy. Director of Health Services. Every district level officer was given a CD about IDD.

At DGHS level meeting were held for sectoral co–ordination of FDA, Food & Civil Supplies, Women & Child health department, UNICEF, Dy. Salt commissioner etc.

Survey of the cases of Goiter is conducted in about five districts every year. The health worker visits houses and notes the cases of goiter. Cluster survey is uner taken in each taluka. One percent of the villages and 5% of school childern are surveyed.

During 2006–07 the state has proposed 23 districts goiter endemic district and tribal district. Painting of Slogans on 1500 S. T. Buses inside front panels for Iodine Deficiency.
Expected Community Participation
IDD is a sort of hidden problem, affecting almost all the members of society. IDD affects the economy of the state. Hence, the community participation is more important. The use of iodized salt by every person, will solve the problem to a large extent. The price difference between Crystal Salt and iodized salt will be less if large section of society uses iodized salt.

Every person takes about 10 gm Salt per day, so a family of 5 persons will need about 1.5 kg of salt per month. The expenses of Rs. 5 per month is too small and any family can bear it.

Quality of salt is also important 15 ppm is desired content. Members of society can have salt tested in district Public Health Laboratories free of charge.

Salt is a food item, if iodine is below 15 ppm, FDA can be contacted and the shopkeeper can be prosecuted for adulteration. The member of society can impress upon their representative for better policy like PDS & iodized salt.

Role of Other Sectors
IDD is a multi-sector involving problem. Food & Civil Supplies Department in 6 states in the country have taken up iodized salt in PDS. This can be followed by our state.

IDD affects the women & Children by lowering IQ, retardation of physical and mental growth, increased abortions, increase in congenital, abnormalities, the department may lead for PDS in iodized salt and health education by anganwadi workers & other means.

The prevalence of goitre is more in tribal regions. Therefor it is essential that at least in IDD prone areas iodised salt should be distributed by PDS.

The role of Food & Drugs Administration for preventing adulteration of salt is very important and the prosecutions may be launched against tthe culprits responsible for sub-standard quality of iodized salt.

Planning department can take initiative for the iodized salt in PDS as per GOI policy.

Department of Education can take active part by health education for the school children.

The rural development department and Social Welfare department can direct for only iodized salt in their hostels etc.

Impact
The deficiency of iodine results in loss of 10-15 points of Intelligence Quotient (IQ) in a school children. This is seen in the studies done in 22 countries.

so, also activity of all the members of society is affected. This all causes adversity foe economy. IDD also include decrease of birth weight, increase of infant mortality rate etc. Preventation of mental retardation, will help to reduce burden on society.

So, for smart, bright, healthy feature generation iodized salt consumption is so much required.