Iodine deficiency disorders (IDD) have long been a major public health problem in Bhutan. The main components of IDDCP are salt iodisation and distribution (introduced in April, 1985); iodised oil injections (if necessary); monitoring iodine content of salt; evaluation of the programme and community-level education. A nation-wide internal programme evaluation of IDDCP was carried out in 1991-92. The results showed that compared to 1983, there was a considerable reduction in the prevalence of goitre and cretinism, and improvement in the urinary iodine status of the population. They also recognise that there are many constraints that can adversely influence the effectiveness of such a public health programme. Indeed, elsewhere many promising country programmes to control IDD that began in a satisfactory manner have not been sustainable.
Four years after the completion of the internal evaluation, the Royal Government of Bhutan expressed interest in a study by an external team so as to receive an independent feedback on the current status of the programme and recommendations thereof. The present study was, therefore, undertaken to address this goal.
Purpose / Objective
To review the porcess of effective salt iodisation at Salt Iodisation Plant (SIP), Phuntsholing, covering procurement, transportation and storage of common salt, quality assurance at salt iodisaton plant inclusive of equipment inventory and maintenance, iodisation level, packaging, labelling, storage and price of iodised salt and its distribution.
Informatin was collected by conducting interviews with key officials of Bhutan Salt Enterprises (Proprietor and Manager cum Officier-in-charge), Idonie Monitoirng Laboratory at SIP in Phuntsholing; and officials of Food Corporation of Bhutan in Phuntsholing. A site visit to SIP, Phuntsholing was made for observing the present status of all activities related to salt iodisation. Additionally, a review of exsting documents both published and unpublished was completed.
Key Findings and Conclusions
The results of the present study show that the total goitre rate was 14 percent, which indicates mild iodine deficiency, in accordance with the recommended criteria of WHOIUNICEF/ICCIDD.
The median urinary iodine excretion was 230 mg/l indicating no iodine deficiency. It is important to note here that frequency distribution curves are necessary for full interpretation of urinary iodine data. The distribution of urinary iodine levels was as follows: 3 percent children had less than or equal to 20 mg/l; 9.9 percent between 21 and 50 mg/l and 11.1 percent between 51 and 100 mg/l. Thus, 24 percent of the mg/l urine samples analysed showed values less than 100 mg/l. The urinary iodine levels of ³100 mg/l is the accepted cut-off point that indicates adequate iodine intake.
The observed TGR and UIE pattern could be explained on the basis of findings of process indicators, i.e. iodine content of salt. A total of 18 percent of the salt samples analysed from households had iodine content less than 15 PPM, the desired level of iodine in salt. About 9 per cent of the salt samples showed high values of iodine (above 70 PPM) and an equal number showed low values (5 to 10 PPM), indicating non-uniformity of iodine levels in the salt available at the community level. Thus, at the community level, a significant proportion of the salt available had inadequate as well as non-uniform iodine levels.
All the salt samples from household and retailers contained iodine. However, adequate levels of iodine were observed in 82 percent of salt samples from households (³15 PPM) and 74 percent salt samples collected from retailers ( ³ 25 PPM). The low levels of iodine in salt at household level, in the present study, could also explain the observation that 24 percent of school children had urinary iodine excretion less than 100 mg/l as compared to only 13 percent to 16 percent in the 1991-92 study.
From the reported TGR in 1991-92 study i.e. 18.4 percent (northern Bhutan), and 32.5 percent (southern Bhutan), the TGR in the present study had declined to 14 percent. It is pertinent to point out the results of the first pilot study on the effectiveness of salt iodisation in Kangra Valley, (Himachal Pradesh, India) which was implemented from 1957 to 1972. With adequate iodine levels in the salt, TGR in this study showed a reduction by 50 percent every five years. As referred above, the initial TGR in Bhutan in 1983 was 64.5 percent. It showed approximately 50 percent reduction in the 1991-1992 study, after 6 years of continuous and adequate iodised salt supply. However, though the present study (1996) showed a trend in decline, the expected 50 percent reduction was not observed. It would have been achieved if the population had continued to receive adequate amounts of iodine during the period 1991-92 to 1996.
A visit to the Salt lodisation Plant (SIP), Phuntsholing, showed that since 1994, there was a breakdown in the monitoring of the iodine content of salt at the production level. The laboratory located at SIP had been shifted away and records of analysis were inadequate and incomplete. In addition, the salt crusher was also not functioning. These factors together probably resulted in having salt with inadequate and non-uniform iodine content as observed in the community.
There was also a breakdown in the monitoring of iodised salt at the community level. The total number of salt samples analysed per district were less than the recommended targets. This finding was corroborated in the present study. Only 25 percent of the retailers responded that a salt sample was collected from their premises, for monitoring by health authorities in the previous six months. The quarterly salt monitoring reports sent from the district to PHL, Thimpu were incomplete and irregular. There was no system of providing feedback on salt monitoring to the District Administration, Health Department, Bhutan Salt Enterprise (BSE), Phuntsholing I and other stakeholders for necessary corrective action.
Moreover, since 1994, there had also been consistent breakdowns in the regular procurement of common salt by BSE, Phuntsholing resulting in retailers buying salt from across the Indo-Bhutan border directly, thereby having no control over the iodine content of salt.
All the salt available in the retail shop was observed to be packaged. However, many of the packaging materials were not up to the standard. As a result, 34 percent of retailers repacked their salt in small plastic packets to increase the shelf-life of iodised salt. The HOPE bags of 37.5 kg, though labelled as iodised, did not have the date and level of iodisation. The repacked small packets were not labelled. The storage of salt at retailer level as well as household level (stakeholders), however, was found to be satisfactory.
The results of KAPB survey of retailers showed that 74 percent heard about iodised salt and only 54 percent knew about the benefits of iodised salt. While 40 percent reported correctly about the ill effects of IDD, only 46 percent of the retailers were aware about the regulation on the sale of iodised salt.
In view of the observations made in the present evaluation, it is, therefore, vital to take immediate steps to ensure timely and adequate procurement of salt by BSE, Phuntsholing, and to ensure its proper iodisation with strict quality control measures at SIP. In addition, the introduction of cyclic monitoring of IDCP, covering every district once in five years, for goitre prevalence and urinary iodine in school children and iodine content of salt at household level using the " 30 cluster method", would be the other step. These two measures would reverse the present trend and be the mainstay of ensuring progress towards sustainable elimination of IDD by and beyond the year 2000 AD.
Past experience has taught us that for any IDDCP to succeed, the people need to be convinced about the benefits of consuming adequately iodised. To have greater involvement of the people in sustaining the activities of IDCP by and beyond 2000 AD, the IEC on IDD should be strengthened to cover different target groups i.e. consumers, retailers, stakeholders. In the monitoring and evaluation of the IDDCP, the IEC component should be made an integral part for finding out the current status and, subsequently, recommend mid-course corrections. salt These efforts can be complemented and sustained by involving primary and junior school teachers in the monitoring process. This will serve a dual purpose; that of creating awareness of 100 and its intervention among an important group of stakeholders, and also encourage social participation in a public health programme.
It is essential to maintain political commitment that can be strengthened by broad public understanding of the issues. Policy needs to include quality assurance, with specific focus on the availability of a good product (i.e. iodised salt with appropriate iodine levels), forever. Equally important is the need to further involve the stakeholders in sustaining the elimination of IDD, for it is an undertaking that requires action by all at all times. These efforts should be complemented by periodic evaluation of the programme by an external agency.
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Health - Micronutrients IDD
Royal Government of Bhutan, WHO-SEARO