INTERNATIONAL COUNCIL FOR CONTROL OF IODINE DEFICIENCY DISORDERS NEWSLETTER ICCIDDIDD VOLUME 23 NUMBER 2 MAY 2006

In this Issue: Togo’s successful Meetings and IDD control pro- Australia 2 Announcements 18 gram protects United States 4 Abstracts 20 newborns against brain Ghana 7 Belarus 14 damage from Togo 10 iodine deficiency. (see page 10)

Chernobyl 20th Anniversary: Adequate iodine could have helped to spare many children from thyroid cancer

On the 20th anniversary of the still iodine deficient today. Despite Chernobyl nuclear plant disaster, it many efforts to get legislation passed is important to remember that the on universal salt iodization (USI) in number of children who subsequent- Belarus, the Russian Federation and ly developed thyroid cancer from Ukraine, the issue is still being deba- radiation exposure could have been ted. Even mild iodine deficiency significantly lower if they had been during pregnancy can affect fetal consuming iodized salt in their daily brain development and, as a result, up diet at the time of the accident. to 2.4 million babies are born each Considering the increasing use of year in Central and Eastern Europe nuclear power worldwide, this is and the Commonwealth of another good reason to ensure ade- Independent States with mental quate iodine intake for all children. impairment. UNICEF is urging the Calling for universal salt iodization in governments of Belarus, the Russian an April 2006 press release, Maria Federation and Ukraine to legislate Calivis, UNICEF Regional Director for universal salt iodization and is for CEE/CIS noted: “For the 4,000 working with salt producers and the children in question, iodized salt general public to raise awareness of could have made all the difference. the importance of iodine. Damaged Chernobyl nuclear reactor, 1986 Many would have been spared from Current IDD control efforts in Belarus thyroid cancer. And amid all the tarian aid - it is too easy to overlook are covered on pages 14-18 of this issue other vast numbers - 400,000 people what is small: a drop of iodine of the Newsletter. uprooted from their homes; five mil- costing just a few cents.” The areas lion still living in contaminated areas; affected by Chernobyl were iodine 100,000 still dependent on humani- deficient before the disaster, and are

THE INTERNATIONAL COUNCIL FOR CONTROL OF IODINE DEFICIENCY DISORDERS (ICCIDD) is a nonprofit, nongovernmental organization dedicated to sustained optimal iodine nutrition and the elimination of iodine deficiency throughout the world. Its activities have been supported by the international aid programs of Australia, Canada, Netherlands, USA, and also by funds from UNICEF, the World Bank and others. 2 IDD NEWSLETTER MAY 2006 AUSTRALIA

The re-emergence of iodine deficiency in Australia A national study confirms the existence of inadequate iodine intake in the Australian population, prompting calls for the urgent implementation of mandatory iodization of all edible salt.

Mu Li and Creswell Eastman ICCIDD Office for South East Asia and the Pacific In 1992, the Australian Centre for volumes were measured by ultra- derline iodine deficient, with a natio- Control of Iodine Deficiency sound. For much of the survey, data nal median UI of 104 µg/L (Table 1). Disorders (ACCIDD) reported were collected by a purpose-built On a state basis, NSW and Victorian median urinary iodine (UI) levels in vehicle known as a “ThyroMobil” children are mildly iodine deficient, the Australian population were >200 (Merck, Darmstadt, Germany), which with median UI levels of 89 µg/L µg/L, consistent with iodine suffi- had been used for studies of iodine and 74 µg/L, respectively. South ciency. However, in recent years nutrition in other countries. Australian children are borderline several studies from Victoria, New iodine deficient, with a median of South Wales, and Tasmania have The study found that, overall, chil- 101 µg/L. Both Queensland and found median UI levels <100 µg/L. dren in mainland Australia are bor- Western Australian children are iodi- In surveys of pregnant women, median UIs have also been found to Table 1: Distribution of urinary iodine excretion (UI) levels in Australian school- be well below 100 µg/L. Concerned children in 2003-2004 by state by these data,ACCIDD conducted a national survey in 2003-2004 to State n M : F Age (y)1 Median UI (µg/L) (interquartile range) document the population iodine ratio nutritional status of schoolchildren NSW 427 1 : 1 9.3 ± 0.6 89.0 (65.0–123.5) in Australia. VIC 348 1 : 0.8 9.7 ± 0.5 73.5 (53.0–104.3) SA 317 1 : 0.9 9.0 ± 0.5 101.0 (74.0–130.0) A cross-sectional survey of 8-10 y- old schoolchildren was done, based WA 323 1 : 0.8 8.9 ± 0.6 142.5 (103.5–214.0) on a one-stage random cluster sam- QLD 294 1 : 1.3 9.1 ± 0.4 136.5 (104.3–183.8) ple drawn from all year 4 school clas- Total 1709 1 : 0.9 9.2 ± 0.6 104.0 (71.0–147.0) ses in government and non-govern- ment schools in the five mainland 1 Mean (SD). Iodine replete, UI >_ 100 µg/L; mild iodine deficiency, UI 50–99 µg/L Australian states of New South Wales (NSW),Victoria, South Australia, Table 2: Percentage of Australian children in 2003-2004 with thyroid volumes Western Australia and Queensland. by ultrasound greater than the WHO 97th percentile1, by state and gender Tasmania was excluded from the Based on body-surface area Based on age study because a voluntary iodine for- (BSA (95% CI) (95% CI) tification program, using iodised salt in bread, is ongoing in that state; the Boys Girls Boys Girls Northern Territory was excluded for NSW 3.9 (1.3–6.6) 7.1 (3.7–10.6) 6.4 (3.0–9.7) 10.0 (5.9–14.1) logistical reasons.The sample inclu- VIC 0 0 0 0.7 (0–1.9) ded 1709 students from 88 schools SA 4.8 (1.6–8.1) 10.1 (5.2–14.9) 6.6 (2.8–10.3) 10.7 (5.8–15.7) (881 boys and 828 girls). UI was QLD 2.3 (0–4.9) 3.1 (0.4–5.8) 3.1 (0.1–6.0) 5.6 (2.1–9.2) measured in spot samples and thyroid Total 4.4 (3.0–5.8) 7.0 (5.2–8.7) 5.6 (4.0–7.1) 9.3(7.3–11.3)

1 From reference: Am J Clin Nutr 2004; 79: 231-237. IDD NEWSLETTER MAY 2006 AUSTRALIA 3

ne sufficient, with medians of 137 in the Food Standards Code in 1982. Authors note: In the wake of the µg/L and 143 µg/L, respectively. Chlorine-containing sanitisers have publication of results of Australian Thyroid volumes in Australian gradually been replacing iodine-con- National Iodine Nutrition Study, the schoolchildren are slightly increased taining sanitizers in the industry. authors would like to pay tribute to compared with WHO reference the late Professor John Dunn, former values from children living in iodine As a result, surveys of the iodine Executive Director of ICCIDD who sufficient countries (Table 2).There content of milk samples from super- helped initiate the study.At the 12th was no significant association bet- markets around metropolitan Sydney International Thyroid Congress in ween UI and thyroid volume. in 2001 and 2004 showed lower Kyoto, Japan October 2000, Dr. Mu levels, and iodine concentrations Li presented data on UI from metro- Children living in Western Australia were highly variable. Median con- politan Sydney, and, in discussions and Queensland are clearly ingesting centrations were 140 µg/L in 1991 with Dr. Dunn, a national study to more iodine than their counterparts (range, 60-220 µg/L) and 195 µg/L investigate the national iodine nutri- living elsewhere in Australia.The in 2001 (range, 66-412 µg/L). lodine tion status was planned. Professor most likely explanations include: 1) concentrations varied between sam- Dunn suggested using the Thyro- possible differences in the proportion ples of the same brand and type by Mobil, considering the size of of the population using iodized salt; up to 100 µg/L. Many samples con- Australia, and started the negotiation 2) variations in regional milk iodine tained <200 µg/L (10/13 in 2001 with Merck to bring the ThyroMobil content; and 3) drinking water iodi- and 7/13 in 2004). to Australia to conduct the study. ne levels.These possibilities are cur- rently being investigated. For exam- Thus, the perception that Australian ple, drinking water samples collected milk is a rich source of iodine is no References during the survey showed relatively longer always true.A cup (250 ml) Li M, Eastman CJ,Waite KV,et al.Are high iodine levels in water and milk per day would provide at most 50-60 Australian children iodine deficient? Results in northern and central Queensland, µg, approximately 1/3rd of the daily of the Australian National Iodine Nutrition which could explain why the UI requirement of an adult. Despite Study. MJA 2006;184(4):165-169. levels indicated iodine sufficiency in these changes, dairy milk remains an Li M,Waite KV,Ma G, Eastman CJ. this state. important source of dietary iodine, Declining iodine content of milk and re- and its content should continue to emergence of iodine deficiency in Australia. The decline in iodine intake in be monitored. MJA 2006;184(6):307. Australia appears to be due to changes within the dairy industry. Another contributory factor to the In Australia, the major sources of re-emergence of iodine deficiency in dietary iodine are milk and dairy Australia has been the decreasing products, seafood and iodized salt. consumption of iodized salt. Few if Except in Tasmania, the food industry any food manufacturers use iodised does not use iodized salt in the pro- salt in the preparation and manufac- duction and preparation of food. For ture of foods. It is alarming that mild decades, milk containing iodine resi- iodine deficiency is extensive in dues from sanitising solutions (iodo- Australian children and no action has phors) used in the dairy industry has yet been taken by public health aut- probably been the largest source of horities to increase iodine intake in iodine in the Australian diet. the population. It is reasonable to assume that pregnant women and A 1975 survey of iodine concentrati- breastfeeding mothers are also iodine on in milk conducted by the deficient, putting the next generation Australian Consumers' Association of children born in Australia at risk found mean concentrations of 593 of the neuropsychological conse- µg/L and 583 µg/L. Because of con- quences of iodine deficiency.The cerns about iodine toxicity, Food implementation of mandatory fortifi- Standards Australia and New Zealand cation of all edible salt for human specified an iodine limit of 500 µg/L consumption is long overdue. 4 IDD NEWSLETTER MAY 2006 UNITED STATES

Iodine nutrition in the U.S.

Although iodine intakes have decreased by 50% since the early 1970s, the U.S. remains iodine sufficient.

Elizabeth Pearce Boston University School of Medicine Endemic goiter was eliminated in median UI was 173 µg/L for the 126 of 302 Atlanta children was 282 µg/L the U.S. following the initiation of pregnant women sampled, with 7.3% (5); that in a 2002 sample of 565 salt iodization in the 1920s.The first having UIs <50 µg/L (2). In a recent Boston-area children was 289 µg/L U.S. National Health and Nutrition survey of 100 healthy pregnant (6); and that in the most recent Examination Survey (NHANES I), women in the Boston area, the medi- NHANES survey (2001-2002; n = conducted from 1971-1974, reported an UI was 149 µg/L, with UIs ran- 374) was 249 µg/L. UI values in a median urinary iodine (UI) for the ging from 13 - 1200 µg/L (3). school-age children are consistently U.S population of 320 µg/L, reflec- Current data regarding iodine suffi- higher than those of adults, and UI ting adequate to excessive dietary ciency among lactating women are values are consistently higher in boys iodine intake (1). By the time of very limited. Breast milk iodine con- than in girls. NHANES III in 1988-1994, howe- tent was measu- ver, the median urinary iodine had red in a sample 25 fallen to 145 µg/L.The reasons for of 27 lactating 1988-94 UI Females this decrease in U.S. dietary iodine women in the 20 intake are not clear, although some Boston area in possible explanations are discussed 2002; the median 15 below. Fears that this trend would value was 157 1988-94 continue have prompted further µg/L (E. Pearce, UI Males monitoring, but the most recent unpublished 10

NHANES survey, conducted from data). In contrast, 1971-74 2001-2002, found that the median a small study 5 UI Females UI has stabilized at 168 µg/L (2). found a median breast milk iodi- 0 1971-74 UI Males Between the NHANES I and NHA- ne value of 33.5 0-11,9 12-19,9 20-29,9 30-39,9 40-49,9 50-59,9 60-69,9 70-79,9 NES III surveys, the risk for iodine µg/L in a sample deficiency increased most among of 23 women Figure 1: women of childbearing age (15-44 recruited via the U.S. population with urinary iodine <50 µg/L: NHANES I and NHANES III years) (Figure 1). In particular, the internet (4). median UI in pregnant women (n = 208) from NHANES I was 327 Several studies have reported UI µg/L, with 1% of the women sam- levels in school-age children over the pled having UIs < 50 µg/L.The past several decades.At the time of median UI among pregnant women NHANES I, the median UI for chil- from NHANES III (n = 348) was dren aged 6-11 was 421 µg/L; this 141 µg/L, with 6.9% having UIs <50 value had fallen to 237 µg/L by the µg/L.The most recent NHANES time of NHANES III. Since then, survey, conducted in 2000-2001, UI in U.S. children, as for other demonstrated that UIs in pregnant groups, appears to have stabilized. women appear to have stabilized: the The median UI in a 1996 sample IDD NEWSLETTER MAY 2006 UNITED STATES 5

Sources of Iodine in the iodine content of cows’ milk, another 17 brands was 10 µg iodine/slice. U.S. Diet probable reason for the decrease in The labeling of bread packages did Sources of iodine in the diet of U.S. US dietary iodine intake between not accurately predict their iodine adults have been difficult to identify, the 1970s and 1990s. Iodine is also content. in part because there are a wide introduced into cows’ milk by the variety of potential sources and food use of iodophor disinfectant, pre- The iodine content of eight varieties iodine content is not listed on packa- and post-milking teat dips and udder of infant formula sold in the Boston ging.Approximately 70% of salt sold washes.The iodine content of 18 area was recently measured, and valu- varieties of cows’ es ranged from 16 µg to 57 µg iodi-

400 milk from ne per 5 oz. serving (9).Thus, infants Boston-area who are exclusively formula-fed like- 350 supermarkets was ly consume adequate iodine. Other 300 320 recently measu- sources of iodine in the diet are eggs, 250 red, and the ave- meat, and poultry. Erythrosine dye 200 rage iodine con- (FDC Red #3) is sometimes descri- 150 tent of milk in bed as a major contributor to U.S. 161 this sample was dietary iodine intake, but this is pro- 100 145 464 µg/L (9). bably not the case because this colo- 50 rant is no longer widely used in U.S. 0 Commercially- foods, and the iodine contained in NHANES I NHANES III NHANES baked breads erythrosine is not readily bioavailable 1971-1974 1998- 1994 2001-2002 may have been (12). Total Males Females another major source of iodine Figure 2: Median urinary iodine concentration in the U.S. 1971-2002 in the U.S. diet. Conditioners are for household use is currently forti- added to store-bought bread to fied with 100 ppm potassium iodide. maintain freshness and prolong shelf However, it is estimated that house- life. In the 1960s, iodate bread condi- hold table salt accounts for only tioners were widely used. London et about 15% of daily salt intake, and al in 1965 reported that bread was a the salt used in manufacturing of source of large quantities of dietary many processed foods may not be iodine (10).This was considered to iodized. Possible reasons for the be a contributing cause to decreasing decrease in iodine consumption bet- radioactive iodine uptake in the U.S. ween the early 1970s and the 1990s during the 1960s (11). Because of include recommendations for redu- concerns about high bread iodine ced salt intake for blood pressure content, commercial bakeries now control, and increasing use of non- less commonly use iodate bread con- In 1924, Morton Salt, the leading U.S. salt producer, introduced iodized table salt to iodized salt in manufactured or “pre- ditioners.The decreasing use of ioda- help prevent goiter, a widespread health made” convenience foods (7). te bread conditioners is thought to problem in the U.S. at that time. have contributed to the reduction in The iodine content of milk in the dietary iodine levels between the U.S. increased by 300-500% over the 1970s and the early 1990s. In 2002 period from 1965 to 1980, largely the iodine content of 18 different due to changes in cattle feeds (8).A breads from Boston-area supermar- limitation of the allowable amount of kets was measured (9).Three varieties organic iodine ethylenediamine of bread contained >300 µg iodine dihydroiodine (EDDI) in cattle feed per slice (316 to 587 µg), while the in 1986 resulted in decreases in the average iodine content in the other 6 IDD NEWSLETTER MAY 2006 UNITED STATES

Finally, multivitamins may be another foods, and the iodine content of women from the Boston, Massachusetts area. important source of iodine in the foods is not well-presented on pac- Thyroid. 2004;14:327-8. U.S. Of the various formulations on kage labels. 4. Kirk AB, Martinelango PK,Tian K, Dutta the market, 51% of adult multivit- A, Smith EE, Dasgupta PK. Perchlorate and iodine in dairy and breast milk. Environ Sci amins contain iodine; most of those Recommendations Technol 2005;39:2011-7. include 150 µg daily (13). Forty five There needs to be increased awa- 5. Xu F,Sullivan K, Houston R, Zhao J, May percent of children’s multivitamin reness of the importance of adequate W,Maberly G.Thyroid volumes in US and formulations contain iodine, while iodine nutrition, particularly during Bangladeshi schoolchildren: comparison with pregnancy and European schoolchildren. Eur J Endocrinol 450 lactation, among 1999;140:498-504. 6. Zimmermann MB, Hess SY,Molinari L, et 400 the U.S. public. 421 al. New reference values for thyroid volume 350 Accurately by ultrasound in iodine-sufficient schoolchil- 300 identifying iodi- dren: a World Health Organization/Nutrition ne content on for Health and Development Iodine 250 282 289 food package Deficiency Study Group Report.Am J Clin 249 200 237 labels would Nutr 2004;79:231-7. 150 facilitate this 7. Lee K, Bradley R, Dwyer J, Lee SL.Too process. much versus too little: the implications of 100 current iodine intake in the United States. Women of 50 Nutr Rev 1999;57:177-81. childbearing age 8. Hemken RW.Milk and meat iodine con- 0 should be NHANES NHANES Atlanta Chelsea NHANES tent: relation to human health. J Am Vet Med I II 1999 2001 2002 encouraged to Assoc 1980;176:1119-21. use iodine-con- 9. Pearce EN, Pino S, He X, Bazrafshan HR, Figure 3: taining multivit- Lee SL, Braverman LE. Sources of dietary Median urinary iodine (µg/L) in U.S. school children in recent studies amins. iodine: bread, cows' milk, and infant formula Finally, there is in the Boston area. J Clin Endocrinol Metab 2004;89:3421-4. none of the infant liquid multivit- a need for larger and more systematic 10. London WT,Vought VL, Brown F.Bread: amin formulations contain iodine studies of iodine nutrition in diffe- a dietary source of large quantities of iodine. (13). Currently, only 44 of 69 (64%) rent U.S. populations and for routine N Engl J Med 1966;223:338. types of prenatal multivitamins mar- monitoring of food iodine content. 11. Sachs BA, Siegel E, Horwitt BN. Bread keted in the U.S. contain any iodine; iodine content and thyroid radioiodine upta- of those, 85% contain 150 µg. Based (Adapted from E. Pearce, Iodine ke: a tale of two cities. Br Med J 1972;1:79- on concerns about adequate iodine Health in the United States in 2005, 81. 12. Ingbar SH, Garber J, Burrows BA. intake in the perinatal period, the in the Clinical Endocrine Update Unpublished report submitted to WHO by National Academy of Sciences Syllabus, Endocrine Society Press, the Certified Color Manufacturers recently recommended that conside- 2005, with permission) Association, Inc.,Washington, DC, 2004.. ration be given to adding iodine to 13. Lee SL, Roper J. Inadequate iodine sup- all prenatal vitamins (14). plementation in American multivitamins. References Endocr Pract 2004;10 (Suppl 1):46 (abstract). 1. Hollowell JG, Staehling NW,Hannon 14. Committee to Assess the Health Conclusions WH, et al. Iodine nutrition in the United Implications of Perchlorate Ingestion, States:Trends and public health implications: National Research Council. Health Although iodine intakes appear to Implications of Perchlorate Ingestion. have decreased by 50% since the Iodine excretion data from the National Health and Nutrition Surveys I and III National Academies Press,Washington, DC, early 1970s, the U.S. remains iodine (1971-1974 and 1988-1994). J Clin 2005. sufficient. Endocrinol Metab 1998; 83:3401-8. There are concerns about the 2. Caldwell K L, Jones RL, Hollowell JG. increased prevalence of low urinary Urinary iodine concentrations – United iodine values among women of States NHANES (2001-2002).Thyroid childbearing age. 2005;15:692-9. There is wide variation in the 3. Pearce EN, Bazrafshan HR, He X, Pino S, Braverman LE. Dietary iodine in pregnant iodine content of some common IDD NEWSLETTER MAY 2006 GHANA 7

Combating IDD in Ghana

Ebenezer Asibey-Berko, Rebecca Ahun, Tamar Schrofer and Ernestina Agyepong ICCIDD Ghana Following the Dakar consultations Republic, laun- on USI for West Africa in October ched Ghana’s 2004, the following objectives were USI program at set for progress on USI in Ghana: the national level on February 9, 1. Secure high-level political 2005. It was well commitment to USI attended by the 2. Ensure all salt produced in Ghana public, media is effectively iodised and interest 3. Monitor and enforce the salt groups.This was iodisation law followed by 4. Increase national awareness of launches in four the benefits of iodised salt regions that had 5. Strengthen partnerships low rates of USI in a 2003 survey. Two more regio- nal launches fol- Figure 1: Officers from the Ghana Food Research Institute teaching lowed in the methods of salt iodization to producers Upper East and was a threat to progress, but arrange- Northern regions in October 2005. ments were made for Mina The UNICEF representative, Chemicals, a private chemical dealer, Dorothy Rozga, and Prof. Badu to import KI into the country. Akosa, Chairman of the National UNICEF also procured KI for a trai- Iodisation Committee and Director ning program, run by the National General of the Ghana Health Salt Iodization Committee, to iodize Services, visited the office of the Vice heaps of salt that had accumulated in President of Ghana to update him of parts of the country. Salt producers progress towards USI. and National Disaster Mobilisation Organisation coordinators were trai- ned in simple manual iodization Ensuring the iodisation of all methods in six regions, using accu- Ghanaian salt mulated stocks of uniodised salt. The Food and Drugs Board (FDB) is After training, a free portable sprayer, Securing high level political to lead in this activity with the sup- iodised salt spot test kits, potassium commitment port of the Ministry of Trade and iodate and other supplies were given In this effort,The Ministry of Health Industries, Presidential Special to the trainees to allow them to go and Ghana Health Services, worked Initiative on Salt, Ghana Standards and iodize their heaps of salt.The in collaboration with the National Board and the Food Research free supplies were provided by Salt Producers Association, the office Institute.The Food and Drugs Board UNICEF. Plans were also put in of the Presidential Special Initiative developed and distributed a Code of place to locate and iodise non-iodi- on Salt, UNICEF,the Ministry of Practice to all salt producers, traders, zed salt awaiting sale at the markets. Local Government and Rural transporters and stakeholders in Development, the Ghana Education November 2005.This spelled out the Service and the Ministry of standards expected of all in the indu- Environment and Science.Aliu stry.A shortage of potassium iodate Mahama, the Vice President of the (KI) in the country in January 2005 8 IDD NEWSLETTER MAY 2006 GHANA

Monitoring and enforcing the the iodization status of salt with School Health Officers on the salt iodization law spot-test kits and identify the move- importance of salt iodisation at over The Food and Drugs Board was to ment of iodized and non-iodized 1500 schools in 4 regions. lead this activity with the collaborati- salt.A ceremonial handing-over of on of the Ghana Health Services, the 5000 salt spot-test kits to enforce- Customs and Excise Prevention ment personnel took place in Strengthening partnerships October, 2005. The National Salt Iodization com- mittee, with members from various Checks at pro- stakeholder groups, held nine mee- duction/refining tings in 2005.To ensure smooth run- plants. In ning of salt committees around the December 2005, country, guidelines for salt commit- the Food and tees have been developed by the Drugs Board Ghana Health Services and the started visiting Nutrition Unit.A reorganisation of salt production the National Salt Producers plants to see Association of Ghana is underway their facilities. through the office of the Presidential Samples of their Special Initiatives on Salt.This should salt was collected increase government recognition of and sent to the group and make it easier for the accredited labo- group to import KI for its members. ratories for ana- Figure 2: Promoting iodized salt to women salt traders at a market in the lysis of iodine Volta Region of Ghana. Ghana was represented in July 2005 content by titra- at a consultative meeting with ECO- tion. Services, the Ministry of Local WAS partners in Burkina Faso.The Government and rural Development, Increasing awareness and meeting discussed standardization of and the Micronutrient Initiative mobilising for positive behavior salt, quality control, trade and taxati- (MI). change on within the framework of USI in The Ministry of Health led this West Africa.The meeting agreed on Salt sampler distribution.Two hun- activity, assisted by the Ghana Health the following: dred and forty salt samplers were Services, UNICEF and the Ghana To apply the standards of the procured for enforcement.They will Education Service. Economic and Monetary Union of be used to collect salt samples from French West African Countries salt sacks at road checkpoints to be KAP study.To identify knowledge (UEMOA) for iodated salt, and use tested for iodine. gaps to target for public education, a the same methods for assessing salt KAP (Knowledge,Attitudes and iodine content. Factory inspections. In December Practices) study was conducted on To identify four laboratories in the 2005, the Food and Drugs Board the “Salt Habits of Ghanaians”, sub-region (Ghana, Cote d’Ivoire, began factory inspections to ensure sponsored by Unilever Ghana. Nigeria and Senegal), and strengthen adequate salt iodization at the facto- their capacities to serve the subregi- ries. Developing a communication strate- on.The office of the Ghana gy. Prototype campaign materials Presidential Special Initiative on Salt Permit for raw salt movement and have been pre-tested, mass produced is to strengthen the capacity of the checking of salt at road check points. and distributed.The Food and Drugs Ghana Reference Laboratory. The Food and Drugs Board develo- Board is developing a documentary To adopt the fiscal provisions of ped a permit that must be completed on USI for TV,and vans from the UEMOA in relation to iodised salt, to transport raw salt, and the quantity Ministry of Information will visit KI, and salt iodisation equipment. and final destination of the salt must Ghanaian communities to show the UEMOA should in turn modify its be on the permit. Several large natio- documentary and educate the public. tariff and suppress its taxes to facilita- nal salt producers are already com- te iodated salt trade in the region. plying. Over 500 customs and police IDD / USI education in schools.The officers have been trained to check Ministry of Education is training IDD NEWSLETTER MAY 2006 GHANA 9

Other Activities The Micronutrient Initiative helped appoint for UNICEF a USI program officer, Rebecca Ahun, in Accra.A journalist has been engaged by UNICEF to report on the USI pro- gramme and prepare press releases.

Current Situation In November 2005, a UNICEF con- sultancy reviewed the Ghana’s USI strategy. It noted a high (85%) popu- lation awareness of salt iodisation, but only limited (50%) access to iodised salt.Their main recommendation was Figure 3: A demonstration of spraying iodine on salt at Bawku, Upper East Region of Ghana. for Ghana to quickly maximize pro- duction and market supply of iodized salt.To check the extent of house- hold coverage at the end of 2005, a national survey was done by the Ministry of Health and Ghana Health Services.The survey covered all regions of Ghana, and its results will be available soon.

Figure 4: Mixing salt sprayed with iodine in central Ghana.

Figure 5: Promotion of iodized salt in Ghana 10 IDD NEWSLETTER MAY 2006 TOGO

Elimination of IDD in Togo Recent data suggest Togo has eliminated of IDD as a public health problem in the year 2005.

Théophile Ntambwe Kibambe Sub-regional Coordinator for ICCIDD in Francophone Africa

Background goiter rate in 6-12 y-old children. A national screening in 1986 repor- The results suggested a significant ted a goiter prevalence of 18.4% in reduction of IDD in the formerly the general population of Togo, indi- endemic areas, but the study was cating mild-to-moderate IDD nati- done in sites that were relatively onwide. However, several regions accessible and thus not nationally suffered from moderate and severe representative.The 2000 MICS II goiter, especially in the Savannah survey found 67% of household salt regions, Plateau and Kara.The fight was iodized at a level >25ppm on a against IDD began with the admini- national level, up from 1% coverage stration of Lugol solution (potassium just 5 years earlier. iodide) to goitrous subjects in 1986- 89.This was followed by distribution In 2001, the Ministry of Health did a of Lipiodol capsules to vulnerable national survey to evaluate progress groups in severely endemic regions in IDD control.The study found from 1990-1995. In 1995, a nation- 75% of household salt was adequately wide multiple indicator study (MICS iodized, and the prevalence of goiter I) found only 1% of household salt was 7.2%, indicating mild IDD in was iodized. the population. On the regional coalition of experts to accomplish level, IDD was mild in the Savannah the study.The committee included The strategy of USI in Togo was region, the Kara, and the Plateau, the Ministries of Health and adopted on May 1996, based on an with goiter rates 7-14%, and was Education, the faculty of sciences of interministry decree, with regulations absent in the Maritime and Central Lomé University, the General on importation, production, distribu- regions with goiter rates <4%. In National Directorate of Statistics and tion and utilization of food grade July 2003, a national revision of Accounting, UNICEF and WHO. salt.The strategy was supported by regulations on monitoring of iodized This president of the technical com- awareness campaigns, education of salt was done, and a reemphasis mittee was T Ntambwe, the Sub- salt controllers, and other measures. placed on sustaining efforts to elimi- regional Coordinator of ICCIDD in In 1998, the demography and health nate IDD. Francophone Africa. survey in Togo found 73% of house- hold salt was iodized, but with great The general aims of the study were disparities on a regional level, e.g., The 2005 to determine: coverage was 81% in Kara, but only National Study the coverage of iodized salt at the 22% in the Savannah region. A comprehensive study to evaluate household level and its content progress against IDD, coordinated by the median urinary iodine and the In October 1999, a survey was done the General Health Director and goiter prevalence in the population as part of the ThyroMobil project in supported financially by UNICEF, the level of awareness in the popu- 4 West African countries (Benin, was incorporated into the action plan lation on iodine deficiency Burkina Faso, Mali, and Togo). of the National Nutrition Service of the establishment of a monitoring Ultrasound was used to measure thy- Togo for 2005.A technical commit- system for iodized salt roid volume for determination of tee was responsible for organizing a IDD NEWSLETTER MAY 2006 TOGO 11

Challenges Urinary iodine indicating iodine sufficiency. By encountered levels region,Table 4 shows that 40-58% The poor quality of many roads Tables 3 and 4 show the UI concen- of samples contained higher than made access by car to remote sites in trations in 1339 samples from recommended levels of iodine (>200 rural areas difficult. Because 4-wheel schoolchildren aged 6-12 y.The µg/L) on the east and west coast and drive vehicles were not available, national median UI is 171 µg/L, in the Lomé community. access to some sites was accomplis- hed by motorcycles. Table 1: Mean iodine content of household salt in different regions of Togo In many provinces in the rural in 2005 zones, the exact age of children was Geographical area Mean iodine content in salt (ppm) unclear.The age of the child was Dry Savannah 64 estimated based on information from teachers and the fact that children Dry Atakora 58 are enrolled into the educational Humid Atakora 42 system at age 7 y. As a consequence, Humid Savannah 71 children’s ages were likely underesti- Humid Forest 37 mated. Coastal East 49 Several schools selected from school lists available in Lomé could Coastal West 31 not be located and were replaced by Lomé community 39 other schools in the same province. Total 49.7

Coverage Table 2: Proportion of household salt by concentration in different regions of Togo of iodized salt in 2005 Tables 1 and 2 show the iodine con- Geographical area < 15 ppm 15-100 ppm > 100 ppm tent in household salt based on titra- Dry Savannah 3,3 % 82,5 % 14,2 % tion of 900 samples. Over 92% of Dry Atakora 1,1 % 88,9 % 10,0 % households had access to adequately iodized salt. The mean iodine con- Humid Atakora 6,7 % 87,8 % 5,6 % tent in household salt was 49.7 ppm, Humid Savannah 9,2 % 70,8 % 20,0 % at the upper limit of the UEMOA/ Humid Forest 5,8 % 92,5 % 1,7 % WAHO norms adopted in July 2005 Coastal East 2,7 % 94,7 % 2,7 % in Ouagadougou, where it was Coastal West 15,0 % 83,3 % 1,7 % recommended that the iodine con- tent of household salt be in the range Lomé community 14,0 % 81,3 % 4,7 % of 30-50 ppm. However, there are Total 7,0% 85,3% 7,7% regional variations. Inadequately for- tified salt (<15 ppm) was found mainly in the coastal western area Table 3: Median UI (µg/L) in school children by region in Togo in 2005 and the Lomé community, whereas in the dry and humid Savannah Geographical area UI median zones, levels of iodine were too high Dry Savannah 164,7 (>100ppm). Dry Atakora 157,3 Humid Atakora 152,5 Humid Savannah 188,1 Humid Forest 157,5 Coastal East 215,8 Coastal West 192,7 Lomé community 182,7 Total 171,4 12 IDD NEWSLETTER MAY 2006 TOGO

Table 4: Proportion (%) of UI by concentration (µg/L) in school children in Togo, Table 5: Goiter prevalence by geographic by region, in 2005

Geographical area < 50 50-99 100-199 200-300 300 Geographical area Number children Dry Savannah1,7 7,8 63,9 23,3 3,3 Dry Atakora 0,0 5,2 81,5 13,3 0,0 Dry Savannah 924 Humid Atakora 0,0 3,0 83,0 13,3 0,7 Dry Atakora 693 Humid Savannah0 ,0 2,2 57,3 33,1 7,3 Humid Atakora 693 Humid Forest 0,0 1,7 81,8 16,6 0,0 Humid Savannah 924 Coastal East5,0 4,1 33,2 40,6 17,1 Humid Forest 924 Coastal West 2,2 1,1 48,9 37,8 10,0 Coastal East 1155 Lomé community0,8 10,3 48,4 28,3 12,1 Coastal West 462 Total 1,3 4,9 60,6 26,3 6,9 Lomé community 1155 Total 6930

Goiter salt) and think that grey salt contains Iodized salt prevalence more iodine. By region, in the dry monitoring system Table 5 shows the goiter prevalence Savannah and dry and humid In a survey of custom offices nation- assessed by palpation and inspection Atakora, IDD awareness is generally wide, most did not control iodine in 6930 children aged 6-12 y.The higher than in the humid Savannah, levels in imported salt. Only a few national prevalence of goiter in this humid forest and the Lomé commu- had received training to control iodi- age group is 2%, indicating iodine nity. Men appeared to have better zed salt according to established stan- sufficiency. knowledge of IDD than women. dards and most did not have the appropriate testing materials.The When asked about the attitude of the Services of Hygiene and Sanitation IDD Awareness population to IDD, goitrous persons were also contacted.Although hygie- Interviews on IDD awareness in the are often stigmatized, and treated ne service agents are responsible for adult population were done in villa- with pity or mockery. Some keep performing the controls at the mar- ges in each of the 30 provinces in their distance from goiters in fear of ket level, most did not have enough the survey, in men and women in being infected. Men generally had a valid fast-check kits, and complained both urban and rural areas. In gene- more positive attitude toward goit- of a lack of available transport, skilled ral, the interviewed subjects recogni- rous people than women.The majo- personnel and harmonized support zed goiter, but were uncertain on its rity of the interviewed persons for the data collection.There was a cause; often, the water of the responded that there was no locally clear lack of regular collaboration neighboring river or the rain was available remedy to treat goiter. between different public services in blamed, or certain foods (e.g., egg Several recommended the use of tra- charge of iodized salt monitoring. plant), or bacteria or parasites, or the ditional medicine: neck massage, general environment. Generally, application of herbal mixtures on the knowledge of the cause of goiter was goiter, wearing of special collars, etc. poor. Similarly, awareness of iodized Regarding the storage conditions of salt was low in the population. Its household salt, women generally sto- benefits for health and its sources for red it in the kitchen or the sleeping purchasing were unknown by the room, in various containers of plastic, majority, many who were not even glass or metal (bottles, cans, canisters, aware that iodized was available on cups) or in well-closed plastic bags, the local market.Women did not away from the fireplace. express a clear preference for certain salt types, except for some who are guided by the color (grey vs. white IDD NEWSLETTER MAY 2006 TOGO 13

area in Togo in 2005. Table 6: Progress in the elimination of IDD of Number of Goiter Indicator Aims Achievements goiters prevalence (%) Iodized salt Percentage of households > 90 % 92,1 % 62 6,7 using iodized salt 22 3,2 Urinary iodine 2 0,3 Median UI 100 – 200 µg/L 171,4 µg/l Proportion < 100 µg/l < 50 % 6,2 % 13 1,4 Proportion < 50 µg/l < 20 % 1,3 % 21 2,3 Goiter 15 1,3 Goiter prevalence in children < 5 % 2,0 % aged 6-12 y 0 0,0 5 0,4 140 2,0

Recommendations to reinforce the regulatory control To the salt importers: Togo has eliminated IDD as a public of iodized salt at borders and on the to verify iodized salt quality prior health problem on a national scale. market by the custom and health ser- to purchase from industrial or small- However, there remains the problem vices, including rigorous legal enfor- scale plants of non-iodized salt and persistence of cement to organize themselves in decen- mild endemic goiter in the dry to provide the National Reference tralized associations around the Savannah region of Togo. Special Laboratory (National Institute of country efforts to stop the importation of Hygiene) with technical and logisti- to sell solely iodized salt on the non-iodized salt need to be made. cal capacities for the assessment of national markets On the other hand, a significant pro- iodine in salt and urine portion of salt and urine samples in a to increase awareness of the bene- To the media, NGO’s, consumers, few provinces showed iodine con- fits of iodized salt through sensitizati- and opinion leaders: tents that were too high, emphasizing on campaigns in the media to participate in the promotion of the need for careful regular monito- to integrate the message of IDD iodized salt nationwide, in collabora- ring of IDD nationwide. control into the curricula of the pri- tion with the health services and mary and secondary schools other involved sectors To the government of Togo: to integrate indicators of IDD eli- to organize an intersectoral moni- mination into the national system of toring committee covering all the health information, in particular the involved institutions and to free the household coverage of iodized salt resources needed for its functioning to ensure annual surveys of iodine on a central, regional and provincial status in risk-prone regions level to report every third year on nati- to adopt the interministry decree onwide IDD status proposed in 2003 to regulate the to support operational research in production, importation and utilizati- the field of eliminating IDD on of iodized salt 14 IDD NEWSLETTER MAY 2006 BELARUS Progress against IDD in Belarus

S. Sivuha and A. Lyashkevich Consultants, UNICEF Office Belarus Background and endocrinologists, with the sup- higher for private companies. The Government Program for port of WHO and UNICEF.The Iodine Deficiency Prevention in program, supported by the Ministry Although iodized salt is included in Belarus was suspended in the early of Health, was used as a basis for the the mandatory list of goods which 1990s after the break-up of the resolution adopted by the Belarusian should be available in all retail out- Soviet Union.The output of iodized Government in April 2001.The reso- lets, several districts have low availa- salt produced by Belarusian compa- lution stipulated iodized salt should bility of iodized salt in the retail net- nies at that time could satisfy <14% be used in food production (except work; e.g. in 2003, only 12% of of the country’s needs, and salt quali- for ocean fish and seafood proces- shops in three districts of the Vitebsk ty was generally poor.A comprehen- sing) and catering, as well as be avai- region had iodized salt available. sive survey of iodine deficiency was lable in all retail outlets.The resoluti- Spot-check inspections of retail out- conducted in 1997-1999 including on did not ban import and sales of lets conducted in 2004 found <1% twelve thousand children and adoles- non-iodized salt.Although salt iodi- of salt samples produced by cents with the support of WHO. zation in the food industry was made Belarusian companies did not meet The median urinary iodine (UI) was mandatory, because of strong opposi- the salt composition requirements, only 44 µg/L, and in some regions, it tion in some government bodies, but for salt imported from Ukraine, was as low as 27 µg/L.The conse- table salt iodization was made volun- 8.6% of samples failed to meet the quences of iodine deficiency were tary.Another important aspect of the norms. Fines are imposed for a failu- especially acute for Belarus as many program was an advocacy campaign re to implement the Government people were affected by radiation in the media, health facilities and Resolution. In 2003, administrative exposure as a result of the Chernobyl educational institutions. penalties were imposed on 62 food accident (see separate article in this enterprise managers, and this has hel- issue of the Newsletter). Low iodine The Ministry of Health was designa- ped ensure compliance at the enter- intakes in a population increase the ted as responsible for regular monito- prise level, but at the district level, risk of radioactivity damaging the ring of all components of the IDD the changes are fairly slow.The thyroid gland and causing thyroid control program, including monito- Government and local authorities are cancer. Public interest in iodine ring of the quality of salt.The iodine informed quarterly on the results of increased during the first few years fortification level (40±15 ppm as monitoring program. after the Chernobyl accident, as potassium iodate) was approved in people became aware of this connec- 2000 by a resolution of the Senior tion, and there was widespread use of Sanitary Doctor of Belarus.The sani- Salt production prophylactic pharmaceutical iodine. tary and epidemiological services of and iodization Humanitarian aid programs distribu- Belarus supervise iodized salt pro- In Belarus salt is produced by two ted potassium iodide capsules in duction, storage and distribution companies:“MozyrSalt” and schools and day-care centers.At the conditions and its use in food pro- “BelarusKaliy”.Their potential pro- same time, many housewives did not duction.This control is already in duction capacity is six times higher purchase salt iodized with potassium place during approval of technologi- than the country’s needs and practi- iodate, as they incorrectly believed cal specifications for food producti- cally all salt can be iodized, if nee- that it worsened the taste of food. on. District sanitary doctors are ded.The “MozyrSalt” Company instructed to inspect each food pro- employs modern technologies for salt ducer and catering facility at least production using iodization and pac- The program for once a year. In 2003, it was estimated kaging facilities supplied by UNI- IDD elimination that only 40-70% of food producers CEF and TACIS.The production, A comprehensive program for com- used iodized salt in districts of the packaging and laboratory control of bating IDD was developed in 2000 Brest region, and the percentage was quality meet the international by a team of public health officials lower for state-run enterprises and standard ISO 9002-03. In contrast, IDD NEWSLETTER MAY 2006 BELARUS 15

table salt is a by-product in producti- Managers of a number of bread- A technologist at one of the on of potassium fertilizers at the baking plants were very cautious Minsk-based bread-baking “BelarusKaliy” Company.The com- about the Government Resolution plants, when asked to describe pany iodizes salt depending on the on mandatory salt iodization. In his company’s response to the needs of the domestic market. 2001 a number of complaints were Government resolution on manda- forwarded to the Council of tory iodized salt, responded as In 2003 both enterprises produced Ministers. Producers of bread and follows: about 65,000 tons of iodized salt and canned food were concerned that “We were not very enthusiastic more than 50% was exported. their products could become less about the Government Resolution. Foreign market requirements influ- tasty and could go up in price. Our concern was that we would enced the commitment of top mana- Therefore, sanitary services conduc- have to change recipes and the gers of the Belarusian salt-mining ted frequent inspections and at the technological process as a whole. companies to implement the pro- same time made a special emphasis We were also concerned about a gram of salt iodization.The main on advocacy work.Tests of iodine harsh increase of costs. As we importers are Russia, Bulgaria and content in bread in different regions are not allowed to raise bread Hungary. Potassium iodate is supplied in 2003-2004 found an average of prices, losses are inevitable.” from Russia. In 2001, the two salt 25 ppm (Figure 1).The estimated “But we avoided changes of reci- producers satisfied 75% of the coun- share of bread-baking plants that pes and there were only minor try’s needs; in 2003 this increased to regularly use iodized salt is 90%. cost increases. The cost of salt 80%. Household testing suggested Resistance of producers was addres- makes up only 3% in the total 55% of households use iodized table sed through the traditionally high cost of the product and our com- salt (Table 1), while 82% of those sur- extent of government control in this pany survived the cost increases veyed declared the use of iodized sector, as the Government keeps fairly easily. We were also con- salt. bread prices under control. cerned whether iodine was still present in bread because the According to the data of the Public It is also mandatory to use iodized temperature of baking is 220 (F) Coordinating Council for Iodine salt in production of sausages, but degrees. Medical doctors assured Deficiency Prevention, at the most recipes do not require much us that it’s OK. If this is so, we Russian market, the price of iodized salt (except for liver sausage and support the use of iodized salt in salt produced by the Belarusian com- black pudding). Monitoring is con- bakery products.” panies is 2-4-fold lower than the ducted by the Republican Center for price offered by the Russian produ- Hygiene, Epidemiology and Public “We all have children, we cers.At the domestic market the Health, and by the Ministry of Trade. all survived Chernobyl, retail price of the Belarusian iodized Production managers and technolo- and we realize the impor- salt is 6-10% higher than the price of gists of meat processing factories in tance of iodization”. ordinary salt. interviews by phone confirmed the use of iodized salt in produc- tion of sausages, smoked Ordinary black bread Iodization foods, and prepared foods. of food products Senior officials from the Bread baked on maple leaves As Belarus has not adopted USI, the Belarusian Research Institute Cherkizovsky bread main method of ensuring iodine for Technology in Meat and intake is its mandatory use in food Dairy Industry confirmed White bread production.The emphasis has been that all the recipes for meat Dobrushsky bread on the use of iodized salt in bread products included iodized production. Bread is a traditional salt.The Ukrainian- Prybuzhsky bread component of a daily diet of the Belarusian preparation “iodis- majority of the Belarusian house- concentrate” is used in pro- Rye-bread holds. Its daily per capita consumpti- duction of some brands of Black formed bread on is about 200-300 grams. bottled water, eggs and dairy 0 10 20 30 40 Therefore, the use of iodized salt in products (iodcaseine is also baking may provide 40-70% of the used in production of sour-milk pro- With IS daily needs of an individual.This ducts). Unlike bread, the market seg- W/o IS product was chosen due to the sim- ment of these products is narrower. Figure 1: Iodine content (µg/100g) in plicity of baking technologies and This iodine concentrate is also used different breads in Belarus baked with and the same recipes for the main varie- by one of the leaders of dairy indu- without iodized salt ties of bread. 16 IDD NEWSLETTER MAY 2006 BELARUS

stry – the Brest factory of dairy pro- training workshops involving hun- salt. Some experts have expressed ducts, famous for its brand ‘Savushkin dreds of teachers from all regions of concern that availability of compe- Product’. Interviews by phone with the country have been held. ting products at the market can dis- cheese factories showed that none of courage potential buyers of iodized them used iodized salt.The reason is It is not easy for a Belarus customer salt. a negative recommendation from the to get a clear understanding of the Belarusian Research Institute for often conflicting advertising messages A 2003 national survey including Technology in Meat and Dairy on products containing iodine and 5000 respondents reported 74% of Industry, based, on publications of other micronutrients. One can see the population was aware of the pro- the Russian Research Institute for customers in shops trying to deci- blem of iodine deficiency, and 87% Cheese and Butter Production.A pher labels on salt packages and of respondents had seen the adverti- common misperception is that iodi- other products. For example, the sing of iodized salt on TV.People zation changes both taste and color “Darida” company produces drin- with incomplete secondary educati- of cheese. king water containing selenium, iodi- on, living in rural areas, the elderly, ne and other elements.The “Mozyr and men were less informed about Salt” company produces iodized, the problem. Rural people are parti- Raising awareness fluorinated and iodized-fluorinated cularly biased against iodized salt and about IDD Due to cultural, historic and econo- mic reasons, administrative control of iodized salt production in the coun- try has proved to be fairly efficient. The Ministry of Health and UNICEF have done their best to encourage “MozyrSalt” and “BelarusKaliy” to implement the Government Program. Representatives of the two salt pro- ducers have been invited to partici- pate in meetings with health sector and food industry professionals, and have received technical assistance.As a result,“MozyrSalt” now benefits A key task for successful imple- about the benfits of iodized salt from sales of iodized products in mentation of the IDD control pro- from the TV message “A pinch of foreign countries. gram in Belarus is advocacy salt is a way to health”. campaigns aimed at consumers. An important task is to organize trai- UNICEF has recently prepared a The power of this TV message is ning for health professionals and number of radio and video mes- illustrated by a story from a school teachers. In the 1990s, in the sages about the benefits of iodi- Belarusian village. On wake of the Chernobyl accident, zed salt. They are regularly Remembrance Day (the second pediatricians and teachers were active shown on the national TV channel, Tuesday after Easter), people go advocates, and iodine was distributed and are targeted mainly at chil- to cemeteries to commemorate in many schools, but efforts have dren and their families and con- their ancestors. By tradition the waned somewhat since then. From vey positive messages. The most requiem matins are held and discussions in focus-groups on food popular one includes a child say- people leave food on the graves supplements and micronutrients, it is ing “a pinch of salt is sufficient!”, as a symbolic meal for the apparent that many rural health care and has been shown since July deceased such as Easter eggs, practitioners rely on outdated infor- 2001. This phrase was incorpora- Easter cakes, boiled rice with rai- mation about the properties of iodi- ted in the popular theatrical per- sins and honey, and bread with zed salt and the impact of IDD.To formance “A Kid and Karlson” salt. An elderly woman preparing increase awareness, the UNICEF based on a fairy tale by A. such a traditional meal for the Office in Belarus has supported the Lindgren, and in performances dead requested some salt to pre- production and distribution of infor- around the country children easi- pare the meal, and a chorus of mation brochures and leaflets on ly picked up the key phrase about voices responded to her with the IDD, with a circulation of >500,000 “one pinch of salt”. Semi-structu- phrase: “A pinch of iodized salt is copies, and published articles in red interviews have found that sufficient!”. newspapers and in a magazine for many adults have also learned primary school teachers. Dozens of IDD NEWSLETTER MAY 2006 BELARUS 17

the majority of them prefer to use further communication campaign, Current situation for cooking, and especially for pick- but it may be difficult to address this Within the short period after the ling, non-iodized coarse rock salt problem without mandatory iodizati- adoption of the National Program imported from Ukraine. Changes of on of salt. (2001), the Republic of Belarus has these habits should be a focus of the achieved a considerable progress in combating iodine deficiency. Table 1: Iodine content in table salt (%) in Belarus, by region and nationally, in 2003 However, it appears that in order to Iodine Minsk Minsk Brest Gomel Grodno Vitebsk Mogilev Belarus eliminate IDD, USI may be necessa- ppm region ry. In the third quarter of 2004 the No iodine 50 50 46 39 32 45 51 45 share of iodized salt in retail network was 66,4%, and in the first quarter 1-14 21 28 19 21 13 17 12 19 was 70%.This is nearly double the 15-25 29 20 36 40 56 37 38 36 level compared to 2001 (36%).The 26-40 2 1 0.4 best situation is reported in the capi- tal city (up to 95%). However, in a number of rural areas the share of Table 2: Household consumption of iodized salt by type of settlement (%) iodized salt available in retail network Area of residence No iodine 1-14 ppm 15-25 ppm 25-40 ppm is 20%, mainly in border regions Capital city 50 21 29 where non-iodized salt is supplied from Ukraine and Russia. Recently Big city 34 22 44 there has been a considerable slow- Medium-size city 42 21 36 1 down in salt promotion at the mar- Small town 46 16 38 1 ket despite penalties and advocacy Rural areas 49 18 34 0.3 efforts. Total 45 19 36 0.4 Control measurements of iodine content in food offered by canteens and cafes in Minsk in 2002-2003 80 suggested that a standard lunch can 70 provide 25-75% of the required daily 60 dose of iodine.A survey of children 50 and teenagers conducted in Minsk in 2002-2003 found a median UI was 40 >180 µg/L, and normal thyroid 30 function. Iodine was found in 75% of 20 salt samples in the households of the 10 surveyed children.A more recent study in Minsk by the Center for 0 Hygiene, Epidemiology and Public 2001 2002 2003 Q1 2004 Q2 2004 Health found a median UI in school Figure 2: Share of iodized salt on the Belarusian market (%); Q=quarter children of 210 µg/L.The current share of iodized salt available in Minsk in the retail network is esti- Urinary iodine (mcg/L) mated to be 55-57%. 100

80 Medical workers

60 Newspapers, magazines TV, Radio 40 Friends, relatives, 20 colleagues 0 10 20 30 40 50 60 70 80 0 2001 <20 20-50 51-100 >100 2003 Figure 3: Urinary iodine excretion (%), in 9-17 y-old children in Belarus Figure 4: Information sources in Belarus on iodized salt, (n=282) in 2003, the overall median was 192 µg/L surveys 2001-2003 (%) 18 IDD NEWSLETTER MAY 2006 MEETINGS AND ANNOUNCEMENTS Meetings and announc

Future perspectives ICCIDD Board Meeting the 23 Member States, 21 attended, 18 at the IDD experts now feel the next step The 2006 ICCIDD Board Meeting was held Ministerial level. Mr. Haxton presented a needs to be mandatory iodization of in New Delhi, India, on April 20-21. It was statement on IDD and prepared an extract of salt, including the iodization of all attended by: Jack Ling (Chair), Jerry Burrow the Global IDD Data Base in Arabic. It poin- ted out that no AL Member has yet achieved table salt, as advocacy efforts have not (Vice-Chair), Basil Hetzel (Ex-emeritus Chair), Fereidoun Azizi, Harry Black, Hans coverage of 90% of households with adequa- been able to change the attitude of Bürgi, Chen Zu-Pei, Dong Zhihua, Cres tely iodized salt, and few countries had for- many rural populations.Attitudes of Eastman, Gregory Gerasimov, Richard med national IDD coalitions. Part of the Belarusian government officials may Hanneman, David Haxton, Izzeldin Hussein, presentation was covered by Egyptian TV. change following the recent CIS Pieter Jooste, Dan Lantum, Daniel Levac, Mu Overall, the visit was meant to encourage the agreement to promote iodized salt. Li, Lorenzo Locatelli-Rossi,Venkatesh Arab League and Member States to renew At the end of 2003, the Belarusian Mannar, Chandrakant Pandav, Eduardo the priority for USI and elimination of IDD. Ministry of Health with support Pretell,Aldo Pinchera, Claude Thilly, Paolo from UNICEF elaborated the strate- Vitti,Yan Yuqin, Michael Zimmerman, Judith gy for elimination of IDD in 2004- Mutamba and Theo Ntambwe. David Nune Mangasaryan: New Senior 2007.This year it is expected to draft Haxton, Executive Director, emphasized that Advisor for Nutrition and Child Growth & Development, Nutrition Unit, and adopt the government resolution the recent nomination of 15 ‘priority coun- tries’ for IDD control by UNICEF,endorsed UNICEF NY. prohibiting import of non-iodized by the IDD Network Board, should focus UNICEF recently announced the appoint- salt; by 2007 it is expected to ban the ICCIDD attention on these countries; ment of Dr. Nune Mangasaryan as a senior use of non-iodized salt in livestock Regional Coordinators should cooperate clo- advisor for Nutrition and Child Growth & sector. But many health sector top sely with the relevant UNICEF offices in Development, in the Nutrition Section, of officials are still cautious about these these countries. Daniel Levac, from the UNICEF New York (effective February measures. Resolutions have twice Treasurer’s Office, reported that the annual 2006). Prior to this appointment, Dr Manga- been rejected by the Ministry of expenses decreased from $687,325 in 2004 to saryan served as a Fortification Officer in the Health, a stand likely influenced by $606,333 in 2005. Cres Eastman submitted a Nutrition Section and as a Nutrition officer resistance from the part of food pro- working document on the revision of the in the CEE/CIS Region. Dr Mangasaryan ducers, intensive promotion of By-law, governance and operations of trained as a public health physician and held several leadership positions in the Armenian organic compounds of iodine produ- ICCIDD.The Nominations Committee pro- posed Gerry Burrow as new Chairman, Cres Ministry of Health, including position of ced in Russia and the Government’s Eastman as new Vice-Chairman and Daniel Deputy Minister of Health prior to joining interest to maintain good economic Levac as Treasurer for a 3 year term.All these UNICEF.Her contact information at the relations with Ukraine, which conti- proposals were seconded and unanimously UNICEF Nutrition Section is + 1 212 326 nues to supply non-iodized salt. accepted. David Haxton’s term as executive 71 59, E-mail: [email protected] However, if the government decides director was extended to 3 years. Jack Ling, as to only import iodized salt, the pro- outgoing Chair, emphasized that ICCIDD’s ducer from Ukraine could meet this future focus should be in areas such as expan- Moldovan food producers visit requirement. Further success of the sion of programmatic activities at country Switzerland to discuss iodized salt program largely depends on effective level, greater accountability, follow up to the On March 27-30, 2006, UNICEF invited lobbying at the Ministry. WHA resolution, more regional collaborative delegates from the Republic of Moldova to meetings, broadening the funding base of visit Swiss food factories and learn from their ICCIDD, revision of the ICCIDD By-laws, experience of using iodized salt in food pro- promotion of greater participation of duction.Among the delegates were govern- References Directors and members, reaching out to ment officials and major Moldovan food pro- Filonov V., Kolomiets H., Mochart T. Reports other professional organizations, recruiting ducers. In Gruyeres, cheese producers explai- of the Belarusian Republican Center for younger Directors, and launching an aggressi- ned that using iodized salt in the famous Hygiene, Epidemiology and Public Health. ve effort to form national coalitions. Swiss cheese does not change the taste of it. Minsk, 2002, 2003. The family company Baer, largest soft cheese producer in the country, stated that they have Prevention of Iodine Deficiency Disorders in ICCIDD attends the Arab League been using iodized salt as long as they can the Republic of Belarus. Minsk, UNICEF, Meeting of Ministers of Health remember, without any negative effect on the 2003. David Haxton, Executive Director of quality.The delegation members themselves ICCIDD, attended the Arab League Meeting could verify this by tasting the many cheeses of Ministers of Health at invitation of the that are produced here.A tour at the Pouly Secretary General on March 13-19, 2006. Of Industrial Bread factory in Geneva once IDD NEWSLETTER MAY 2006 MEETINGS AND ANNOUNCEMENTS 19 ements

dards. Referring to a recently conducted pro- the remaining urgency to reach sustainable gram by the Health care and Nutrition quality salt iodization in Central Asia and Ministry in Colombo to provide assistance to Mongolia.The meeting was organized by countrywide salt producers to iodise the salt Asian Development Bank, United Nations they manufacture, Minister Silva thanked Children Fund and Kazakhstan Academy of ICCIDD and the MI (Asia) for granting a Nutrition as part of the Sustainable Food sum of Rs. 80 million to modernize the Fortification in Central Asia and Mongolia Hambantota and Puttalam salterns. It is project.The participants of the meeting con- reported that under this novel program, these firmed their support for the goal of universal two organizations are expected to provide salt iodization (USI) in order to protect technical assistance and the know-how to newborns from brain damage and reduce more convinced the delegation members that these two major salt manufacturers in order national economic loss, and agreed on the iodized salt use is, in fact, standard business to produce at least 75,000 metric tons of following actions: practice in food production in Switzerland. iodized salt which is the national requirement a. Upholding the principle that salt producti- “The visit convinced us that iodine has no of the country. Minister Silva further said that on companies are responsible for achieving effects on the taste and consistency of the as the country was not self-sufficient in salt, USI by ensuring: food,” said Ion Cretu, Head of the around 10,000 metric tonnes were being ongoing improvements in quality iodized Department of the Food Industry and imported from India annually and the health salt production Regulations, Ministry of Agriculture and authorities had already been directed to make promotion of iodized salt to the customers Food Industry of the Republic of Moldova. a thorough investigation into the iodization and the public “We saw that all the famous products of standards of such imported salt. un-interrupted adequate potassium iodate Switzerland are produced with iodized salt. In supplies, requesting UNICEF assistance Moldova, we have wasted a lot of time.We where appropriate should have started using it a lot earlier!” It is ICCIDD visit to Tanzania Food and b. Strengthen the authority of the Salt hoped the visit will spur Moldovan food pro- Nutrition Centre Iodine Laboratory Producer Associations in their collaboration ducers to start following the Swiss example The ICCIDD Regional Coordinator for as full partner in national salt iodization pro- of using iodized salt in processed food. Africa, Prof. D. Lantum recently assessed the grams in each country by: urinary iodine laboratory of the Tanzania promoting membership by all salt produc- Food and Nutrition Centre (TFNC) as part tion companies in the country Rehabilitation of salt plants to accele- of monitoring and evaluation of the national membership of the Chairpersons in natio- rate salt iodization in Sri Lanka. Universal Salt Iodization and Iodine nal Food Fortification Alliances As part of the post-tsunami initiatives, the MI Deficiency Disorders Programmes (USI/ engagement by the Associations as a full Asia just signed a memorandum of under- IDD).The findings of the assessment were: 1) participant in the processes of standing with the government of Sri Lanka TFNC has the necessary technical equipment regulation/legislation. for a project amount of CAD 779,000. and capacity to analyze 500-750 samples per c. Strengthen the collaboration of Salt The project was initiated in collaboration day and therefore it can accelerate the urina- Producer Associations with the Governments with the local ICCIDD representative. ry iodine assessment for the National and other national partners by: During the project launching, the Healthcare Surveys; and 2) the urinary iodine assessed by facilitation of cross-border trade and and Nutrition Minister Nimal Siripala de TFNC meets international standards and it reduction of transport costs, tariffs and value- Silva on Friday said that he was disappointed inter-calibrated with the CDC in Atlanta, add taxes by the consumption of non-iodized salt by a U.S., and other world laboratories. Based on improving border control against illegal large percentage of people in the country these findings, ICCIDD recommends that imports and exports of non-iodized salt due to lack of understanding on the risk of TFNC can be utilized by other countries in continuous improvements of quality brain damages and other related disorders. In East, Central and Southern Africa Region for monitoring systems an interview with the local newspaper, the USI/IDD monitoring and reporting. regular reporting to the Food Fortification Sunday Observer, Minister de Silva said that Alliance about the status of iodized salt sup- from the huge bulk of salt, currently produ- plies ced by large and small scale salt manufactu- Second Regional Meeting of Salt submit proposals on how to improve the rers in Sri Lanka, only 30 per cent accurately Producers in Central Asia and supply. maintains the accepted iodization standards. Mongolia For more information about the project plea- The Minister is also of the view that some Representatives from salt production compa- se visit: http://caffproject.net/index.html. salt manufacturers are in the habit of mixing nies and Salt Producer Associations of colours in their manufactured salt and decei- Kazakhstan, Kyrgyz Republic, Mongolia, ve consumers, saying that they are properly Tajikistan and Uzbekistan, met in Tashkent, manufactured according to the accepted stan- on November 22-24 to discuss progress and IDD NEWSLETTER MAY 2006

schoolchildren aged 11-15 yr, resident in Messina M, Redmond G. Effects of soy protein Piedmont region for more than 5 yr, to assess and soybean isoflavones on thyroid function in Abstracts both goiter prevalence and iodine intake.The healthy adults and hypothyroid patients: a review median urinary iodine concentration was 116 of the relevant literature.Thyroid. µg/L and the prevalence of goiter was 3.1%, 2006;16(3):249-58 indicating this area is iodine-sufficient. No Soy foods are a traditional staple of Asian differences in goiter prevalence and median diets but because of their purported health urinary iodine excretion were observed bet- benefits they have become popular in recent Aloumanis K, Mavroudis K,Vassiliou I, et al. ween urban and rural/ mountain populati- years among non-Asians, especially postme- Urgent thyroidectomy for acute airway obstruction ons. In conclusion, Piedmont is now an iodi- nopausal women. One concern is that soy caused by a goiter in a euthyroid pregnant ne-sufficient region. may adversely affect thyroid function and woman.Thyroid. 2006;16(1):85-8 interfere with the absorption of synthetic Pregnancy can contribute to thyroid enlarge- thyroid hormone. In this review, 14 trials ment. However, acute respiratory failure as a Matalon S, Sheiner E, Levy A, et al. were identified in which the effect of soy result of airway obstruction from an enlarged Relationship of treated maternal hypothyroidism foods or isoflavones on at least one measure thyroid gland is an unusual incident.The case and perinatal outcome. J Reprod Med. of thyroid function was assessed in presuma- presented here concerns a 27-year-old 2006;51(1): 59-63 bly healthy subjects.With only one excepti- woman in her 20th gestational week who The objective of the study was to investigate on, either no effects or only very modest underwent an urgent operation for removal pregnancy outcome in women with hypo- changes were noted in these trials.Thus, col- of a nontoxic, multinodular goiter that was thyroidism.A population-based study was lectively the findings provide little evidence causing severe upper airway obstruction lead- performed comparing all singleton pregnan- that in euthyroid, iodine-replete individuals, ing to acute life-threatening respiratory failu- cies of patients with and without hypothyroi- soy foods, or isoflavones adversely affect thy- re. Diagnosis of extrathoracic tracheal stenosis dism. Hypothyroidism was diagnosed and roid function. Some evidence suggests that was based on spirometry with analysis of the treated before pregnancy. Deliveries occurred soy foods, by inhibiting absorption, may flow volume curve and was confirmed by between the years 1998 and 2002 in a tertia- increase the dose of thyroid hormone requi- magnetic resonance imaging of the neck. ry medical center. During the study period red by hypothyroid patients. In addition, Despite operational risks to the mother as 139,168 singleton deliveries occurred, and of there remains a theoretical concern based on well as the fetus during gestation, an urgent those, 0.8% (n = 1,102) were in patients with in vitro and animal data that in individuals thyroidectomy was carried out successfully. hypothyroidism.The following risk factors with compromised thyroid function and/or The postoperative period progressed normal- were significantly associated with hypothyroi- whose iodine intake is marginal soy foods ly and the patient completed her pregnancy dism: fertility treatments, recurrent abortions, may increase risk of developing clinical hypo- with no further respiratory symptoms. diabetes mellitus, previous cesarean section thyroidism.Therefore, it is important for soy and advanced maternal age. No significant food consumers to make sure their intake of differences regarding pregnancy complicati- iodine is adequate. Saggiorato E,Arecco F,Mussa A, et al. Goiter ons, such as placental abruption, preterm prevalence and urinary iodine status in urban deliveries or postpartum hemorrhage, were and rural/mountain areas of Piedmont region. noted between the groups. However, patients J Endocrinol Invest. 2006;29(1):67-73 with hypothyroidism had higher rates of Piedmont region was reported in the 1970s cesarean deliveries (20.1% vs. 11.5%, p < to be a mildly iodine-deficient area with a 0.001). Perinatal outcomes, including birth goiter prevalence > 10%.This study aimed at weight < 2,500 g, Apgar score < 7 at 5 characterizing the current status of iodine minutes and perinatal mortality did not differ deficiency in Piedmont, with special attenti- between the groups. In conclusion, treated on to differences between urban and maternal hypothyroidism is not associated rural/mountain areas. In a cross-sectional with adverse perinatal outcome. However, 8706 Feldmeilen, Switzerland study, ultrasound thyroid volumes and urinary hypothyroidism is an independent risk factor

iodine concentration were measured in 2178 for cesarean section. Urs Imholz Design:

THE IDD NEWSLETTER is published quarterly by ICCIDD and distributed free of charge in bulk by international agencies and by individual mailing. The Newsletter also appears on ICCIDD’s website (www.iccidd.org). The Newsletter welcomes comments, new information, and relevant manuscripts on all aspects of iodine nutrition, as well as human interest stories on IDD elimination in countries.

For further details about the IDD Newsletter, please contact: Michael B. Zimmermann, M.D., the editor of the Newsletter, at the Human Nutrition Laboratory, Swiss Federal Institute of Technology Zürich, ETH Zentrum, Schmelzbergstrasse 7, LFW E19, CH-8092 Zürich, Switzerland, phone: +41 44 632 8657, fax: +41 44 632 1470, [email protected].

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