Ensuring Maximum Public Health Benefits of USI: the Role of Monitoring

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Ensuring Maximum Public Health Benefits of USI
the Role of Monitoring

• Prof. Gregory Gerasimov
• UNICEF Consultant
• Central and Eastern Europe, CIS and Baltic States

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Global success in salt iodization
of households that consume iodized
salt Globally - 73 CEE/CIS/BS - from 5 to 90
Baltic States - up to 10 UNICEF 98 Report
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Definitions - MONITORING

• Monitoring is the process of collecting and
  analysing on a regular basis information about
  the program for the purpose of identifying
  problems such as non-compliance, and taking
  corrective actions so as to fulfill stated
  objectives

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Definitions - INDICATOR

• An indicator is used to help describe a situation
  that exists, and can be used to track changes in
  the situation over time.
• Indicators are usually quantitave, but may also
  be qualitative.
• Indicators may be direct and indirect.

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Indicators of IDD Control Program

• Process Indicators - for monitoring of salt
  iodization
• Impact (Outcome) Indicators - for biological
  monitoring

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Process Indicators

• Is all imported salt iodized to the countrys
  requirement?
• Is adequately iodized salt reaching the target
  population?

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Biological (Impact) Indicators

• Is there a significant IDD problem?
• What is the prevalence of IDD in a given
  population?
• What impact salt iodization has on iodine status
  of the population?
• Have IDD been eliminated as a public health
  problem?

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PROCESS INDICATORS
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Factors That Determine Iodine Content in Salt

• Variability in the amount of added iodine
• Uneven distribution of iodine in the iodized salt
• The extent of iodine loss during storage and
  distribution
• Loss of iodine due to cooking and food processing

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Industry Standards for Iodized Salt

• Former USSR GOST 13830-91 required
• use of instable potassium IODIDE (KI)
• level of iodization 23/-11 ppm
• shelf life 3 months

• UNICEF/WHO recommendations
• use of stable potassium IODATE (KIO3)
• level of iodization 20-40 ppm
• shelf life more than 12 months

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MOST OF SALT PRODUCERS IN THE REGION THAT SUPPLY
IODIZED SALT TO THE BALTIC STATES COMPLY WITH
ABOVE RECOMMENDATIONS
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Determining Salt Iodine Levels

• Titration method
• Rapid test kits
• Semi-quantitative measurement kits

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MONITORING SYSTEM

• Government (External) Monitoring System
• The Producers Distributors (Internal)
  Monitoring System
• Household Level Monitoring
• Cross-sectional surveys
• Community based monitoring

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IMPACT INDICATORS
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Biological Indicators

• Goiter rate in school children (by palpation and
  ultrasonography)
• lt5 - no iodine deficiency
• Urinary Iodine
• gt100 mcg/l - no iodine deficiency
• Neonatal TSH screening
• samples with TSH level gt 5 mU/L - less than 3

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Goiter (Thyroid Size) Assessment

• Easy to perform
• Little training needed (for palpation)

• Reflects remote rather than present iodine status
• Observers variations
• Low sensitivity
• Expensive equipment (for ultrasonography)

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Urinary Iodine Assessment

• Reflects current iodine status of population
• Samples easy to collect
• Sensitive and reliable indicator

• Trained lab staff needed
• External and internal quality control required
• Rather expensive equipment

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Neonatal TSH

• No additional investments in impact (biological)
  monitoring

• It is not recommended to set up neonatal TSH
  screening program solely for purpose of IDD
  monitoring

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SURVEY METHODS

• School surveys
• goiter rate (palpation ultrasonography)
• urinary iodine
• samples of salt from households
• Household surveys
• goiter rate (palpation)
• urinary iodine
• checking of iodine in salt

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WHO/UNICEF/ICCIDD criteria for monitoring
progress towards elimination of IDD as a public
health problem
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Universal Salt Iodization in Baltic States

• Legislation, Regulations, Standards
• Implementation Enforcement
• Monitoring and Impact Assessment

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ACHIEVABLE GOAL

• ELIMINATION OF IDD AS A PUBLIC HEALTH PROBLEM IN
  THE BALTIC STATES IN THE NEXT 1-2 YEARS

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