IDD NEWSLETTER AUGUST 2016 15

Children and pregnant women in Abkhazia are iodine deficient

Gregory Gerasimov IGN Regional Coordinator for Eastern Europe and Central Asia; Andrei Tulisov UNICEF and Northern Medical University, Arkhangelsk, ; Andrei Tuzhba Polyclinic of the Region, Abkhazia; Alla Belyaeva Center of Public Health, Sukhumi, Abkhazia; Sergei Petrenko International Ecological Institute, Minsk, Belarus

Abkhazia is a partially recognized state at the crossroads of Western Asia and Eastern Europe, on the eastern coast of the , south of Russia and northwest of . It covers 8,660 sq. km and has a population of around 240,000. Its capital is Sukhumi. While Georgia exerts no control over its former Autonomous Republic, the Georgian government, the and the majority of the world's govern- ments (with the exception of Russia and few other countries) consider Abkhazia part of Georgia. Like in other parts of the former USSR, iodine deficiency in the Caucasus Republics (Georgia, Armenia, and Azerbaijan) was virtually eliminated in the 1950s to 1980s, which helped to significant- ly reduce the prevalence of endemic goiter and eliminate the most severe manifestations Main street in Abkhazia’s capital and largest city, Sukhumi. of IDD, such as cretinism. While many of the other newly independent states managed to successful- from Sukhumi and were from coastal ly revive their IDD prevention programs towns. Spot urine samples as well as samples in the mid 1990s, and went on to achieve of household kitchen salt were collected at significant improvements in iodine nutrition each survey site. All salt samples were tested status by 2010, Abkhazia lagged significantly for iodine content using qualitative rapid test behind. It was only recently (in May 2016) kits (RTKs: MBI Kits, India). Quantitative that the Ministry of Health, with technical testing of the salt was not carried out, as support from the IGN and UNICEF, con- only very few salt samples were found to ducted the first ever survey of iodine nutri- contain any iodine. The urinary iodine tion and use of iodized salt in Abkhazia. concentration (UIC) was measured at the The survey recruited 212 participants laboratory of A.D. Sakharov Environmental Institute of the Belarus State University in from three administrative districts: Gagra, Map of Abkhazia. The numbers represent the three Sukhumi and (see map). Among them Minsk. Districts (Gagra, Sukumi, and Gali) selected for the The survey findings are concerning: assessment of iodine nutrition and use of iodized were 151 school-age children (SAC, 8–12 salt in Abkhazia. year-old), recruited from schools, and 61 the median urinary UIC in school-age pregnant women aged 18–39 years mostly children is only 29 µg/L (optimal range: in the 2nd and 3rd trimester of pregnancy, 100–299 µg/L), while the median UIC in recruited from prenatal clinics. Of the 151 pregnant women is 27 µg/L (optimal range: SAC 67 were living in urban and 84 in rural 150–499 µg/L), which suggests that both areas. The two urban sites (Sukhumi and population groups may be iodine deficient Gagra) are located on the Black Sea coast, (see Table 1). In SAC, the median UIC while the rural schools are all inland. The was higher in urban compared to rural areas women attending the prenatal clinic in Gali (36.3 µg/L vs 24.1 µg/L). No such diffe- were mainly from rural inland villages; those rence was observed in pregnant women. IDD NEWSLETTER AUGUST 2016 ABKHAZIA 16

The proportion of SAC with urinary iodine priced variety would become available on including pregnant women, which puts levels below 100 µg/L was very high at the market. When asked about the bene- their babies at risk of cretinism, impaired 97%, with 30.5% of values below 20 µg/L. fits of iodized salt, only a relatively small cognitive development and intelligence, In pregnant women, the median UIC was proportion of respondents (17%) knew that as well as goiter. To eliminate the risk of alarmingly low at all three surveyed sites, it prevents goiter. Recent experience of iodine deficiency disorders and achieve but it was particularly low (below 20 µg/L, similar questionnaires in Georgia (in 2016) optimal iodine nutrition, Abkhazia should indicating severe iodine deficiency) in the and Tajikistan (in 2015) shows that this is urgently implement appropriate legislative/ capital city of Sukhumi. Only 3.4% of rather low: in the other two surveys, more regulatory measures to restrict the import, pregnant women had UICs within the opti- than 90% of respondents recognized goiter sale, and use of non-iodized salt. There is no mal range of 150–499 µg/L, while 37.9% prevention as the main beneficial effect of local salt production in Abkhazia that would UICs were below 20 µg/L. iodized salt. On the other hand, a relatively require time and resources in order to start iodization. Fortunately, all salt in Abkhazia is imported from Russia by a very limited TABLE 1 Median urinary iodine concentrations (µg/L) in school-age children number of wholesale companies and, in the- (SAC) and pregnant women by place of residence, in Abkhazia. ory, switching from import of mainly non- Place of Residence Urban SAC Rural SAC Pregnant women iodized to exclusively iodized salt should not (District) (n=67) (n=84) (n=61) pose a problem. Sukhumi 42.3 (n=33) 22.5 (n=30) 18.0 (n=23) The survey report submitted to the Gagra 31.4 (n=34) 30.0 (n=30) 33.0 (n=19) Government of Abkhazia calls for the adop- Gali - 19.5 (n=24) 32.5 (n=19) Total for Abkhazia 29.1 (n=151) 26.5 (n=61) tion of legislation that would ban all import, wholesale and retail trade of common salt, as well as the use of non-iodized salt in Why are children and pregnant high proportion of respondents recognized the catering and food processing (baking) women iodine deficient? that iodized salt plays a beneficial role in industry. Similar laws completely ban- Although Abkhazia is on the Black Sea, children’s mental development (15%) and in ning non-iodized salt were adopted 10–15 fish and seafood are mostly imported and fetal development (27%). At the same time, years ago in Armenia, Azerbaijan, Georgia, quite expensive; for this reason they are it is troubling is that over 40% of pregnant Turkmenistan, Uzbekistan, Kazakhstan and not widely consumed by the population. women in Abkazia could not list a single other post-Soviet states, which have subse- Despite local beliefs, that persimmon, feijoa benefit of iodized salt. quently achieved optimal iodine nutrition at (Acca sellowiana), and walnuts are rich sour- the national level. ces of iodine, in fact, there are almost no What is next for Abkhazia? local natural, rich sources of dietary iodine The survey results are alarming, as they Technical and logistical support for this study in in Abkhazia. At the same time, household point to the presence of moderate-to-severe Abkhazia was provided by UNICEF and the coverage of iodized salt appears to be very iodine deficiency in the Abkhaz population, IGN thanks to a generous grant from GiveWell. low: only five out of the 150 tested salt samples were iodized (3.3%). While iodized salt (premium brands only) was available in urban supermarkets, it was not commonly sold in the rural shops or markets. In additi- on, a considerable price difference between the premium (iodized) salt and non-iodized salt in economy packaging prevents most customers from buying it. In the survey, only a few participants reported buying iodized salt to season food. There is no cur- rently no legislation in Abkhazia to limit the import or use of non-iodized salt. A questionnaire on the use of iodized salt suggests that the vast majority of pregnant women (88%) are aware of the existence of iodized salt, but only 5% declare a strong preference for purchasing iodized salt. The reported purchasing habits

(preference given to salt in its original Salt and urine samples are being collected for analysis of iodine content packaging with a label, buying salt in smaller volumes, and buying from preferred shops) suggest that it might be possible to incre- ase the sales of iodized salt if a reasonably