Universal Salt Iodization in Central and Eastern Europe and the Commonwealth of Independent States

UNIVERSAL SALT IODIZATION IN CENTRAL AND EASTERN EUROPE AND THE COMMONWEALTH OF INDEPENDENT STATES

Experiences, achievements and lessons learned during the decade 2000-2009

SUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORTSUMMARY REPORT

Cover pages photos credits: Giacomo Pirozzi

Design:

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UNIVERSAL SALT IODIZATION IN CENTRAL AND EASTERN EUROPE AND THE COMMONWEALTH OF INDEPENDENT STATESExperiences, achievements and lessons learned during the decade 2000-2009

INTRODUCTIONWhen in 1994 UNICEF and WHO reached agreement to recommend Universal Salt Iodization (USI) as the preferred strategy for eliminating Iodine Defi ciency Disorders (IDD), the countries in Central and Eastern Europe and The Commonwealth of Independent States were undergoing or entering a period of political turmoil and economic transition. After President Tito’s death, the Federal Republic of Yugoslavia had started to fall apart, a process that lasted into 2006 with the peaceful separation of Serbia and Montenegro. And after the Union of Soviet Socialist Republics (USSR) split up in 1991, the newly independent states began a transition toward autonomous, market-based decisions. UNICEF established country offi ces throughout the region during the 1990s and started increasing its support for the national efforts to reach for USI.

Iodine defi ciency is the world’s single greatest cause of preventable mental retardation. A diet low in iodine affects populations that consume grains, vegetables and animal foods grown on soils depleted in iodine due to erosion, heavy rainfall or intensive agriculture. Iodine defi ciency is especially damaging during early pregnancy, infancy and young childhood, and it can lead to increased miscarriages, stillbirths and infant mortality. The uppermost concerning consequence of iodine defi ciency in a population is the damage of the fetal brain before birth. Even a mild defi ciency in expectant

mothers can lead to an average loss in learning ability of 13.5 IQ points in each newborn generation, who are projected to earn less when they reach adulthood, thus preventing children, communities and nations from achieving their full development potential.

USI PROGRESSThis summary presents an analysis of the lessons learned from national USI strategies in 20 countries of the UNICEF region Central-Eastern Europe and Commonwealth of Independent States (CEE/CIS) during the decade 2000-2009. Global tracking data maintained by UNICEF show that in 2000, adequately iodized salt was used in 50% or more of the households in only seven countries in this study. This had increased to 85% by 2009 – a quantum leap compared to a decade ago but still below the targets. Figure 1 illustrates the count of countries by their USI achievements during the decade.

© UNICEF Kyrgyzstan

© UNICEF Albania

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FIGURE 1: IMPROVEMENTS IN NATIONAL USI STRATEGIES DURING THE PAST DECADE

Obviously, more needs to be done to close the remaining margins. Nevertheless, the key important lesson learned from a decade of action is that despite the unique socio-cultural environment and the signifi cant political and economic transitions that lasted into the decade, the USI strategy was readily adopted, pursued and carried forward in most countries of the region. The fi ndings of this study support the evidence that the public health problem of iodine defi ciency can be effectively overcome by USI, and they add to the growing global confi dence that IDD can be eliminated by establishing salt iodization as the universal norm.

STUDY METHODAn analysis of public health research and practice reveals that USI strategies make progress from the planned simultaneous actions in four key strategic areas, namely: salt iodization, communication, monitoring and evaluation, and joint collaborative oversight (Figure 2). The actions taken in these areas were analyzed for their inputs and resources, and their outcomes and impact obtained with the specifi c USI strategy in each country. The fi ndings of these analyses were put in the typical time-sequence of a Logical Framework Analysis.

The full report includes a detailed summary of the national USI strategy in each of the 20 countries during the past decade, which helped informing the overall conclusions and lessons learned. The criteria used for assessing the outcomes and impacts followed the international expert recommendations of the World Health Organization, UNICEF and the International Council for Control of Iodine Defi ciency Disorders (ICCIDD). This summary presents the important conclusions and lessons learned from the analysis of a decade of action on USI.

± 2000 ± 2009

USI Progress in Central and Eastern Europe and the Commonwealth of Independent States, 2000-2009

100%

90% 4 more countries attained USI

2 more are close to the goal

4 more have coverage of 50-69%

The number of countries withcoverage <50% fell by 8

80%

Coverage� >90� 70-89� 50-69� 20-49� <20

70%

60%

50%

40%

30%

20%

10%

0%

Pro

po

rtio

n o

f co

un

trie

s

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FIGURE 2: MAIN ACTION AREAS FOR THE EXECUTION OF A NATIONAL USI STRATEGY

HISTORY OF IODINE DEFICIENCY AND SALT IODIZATION IN THE REGIONPublications from the countries in this study before 2000 show abundant and widespread problems of goiter and cretinism. In the Balkans, voluntary iodization of household salt was fi rst introduced during the 1950s in former Yugoslavia, Romania and Bulgaria. When surveys during the 1960s showed only small decreases in the burden of goiter, mandatory iodization of all the salt destined for use in the food industry and the households became enacted in Bulgaria and Yugoslavia, which in each case was followed by a drastic decline of goiter prevalence within a decade. The turmoil with the breakup of the Yugoslav Federation prevented the swift adoption of modern assessment methods, yet population-representative surveys carried out near the turn of the century demonstrated optimum iodine nutrition in the populations of Macedonia FRY and the Federation of Serbia and Montenegro. In Romania meanwhile, the iodization of food industry salt became prohibited and the iodization of table salt remained voluntary. Studies in 30 counties of Romania showed that iodine defi ciency persisted beyond the year 2000. Two surveys dated from before 2000 in Albania had demonstrated 30-40% goiter prevalence plus the existence of endemic cretinism – equivalent to moderate-to-severe iodine defi ciency.

In the former USSR, the iodization of salt was governed for a long time by a 1956 ordinance from the Ministry of Health in Moscow that defi ned the administrative divisions with a high burden of goiter to which iodized salt should be supplied. While the list of IDD-affected regions increased toward the majority of regions throughout the Soviet Union, iodized salt was practically made mandatory and the trade in common salt became ever more restricted. A tremendous increase took place in the production of iodized salt, from ±100,000 tons in 1950 to almost 1 million tons in 1965. Consequently, population surveys undertaken during 1965-1969 across the vast expanse of the USSR demonstrated that endemic goiter had virtually been eliminated and that new cretinism cases were no longer observed. As a result, the Ministry of Health declared that the problem had been overcome and it abandoned its central oversight and monitoring.

Key Components in IDD Elimination Programming

Salt lodization

StrategyOversight

Evaluation &Surveillance

Advocacy &Social Mobilization

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The end of oversight by the Ministry of Health did not cause the salt industry to abandon the practice of iodizing salt, however. The Ministry of Food Industry issued directions on annual production quota, including iodized salt. But with the passage of time, the aging technologies and QA methods in the salt enterprises became increasingly less capable to meet the industry’s iodization standards and in combination with the poor paper packaging and the long railway supply lines, the quality of iodized salt in retail outlets started to decline. The deterioration of the Soviet economy during the 1980s also affected the production volumes of iodized salt and by 1990, the total realized iodized salt supply in the USSR reached only half of the planned 1.4 million tons. It is therefore not surprising that IDD was making a comeback. In November 1991, at an international symposium organized by ICCIDD, UNICEF and WHO in Tashkent, Uzbekistan, reputed scientists from 10 Soviet Republics presented evidence dating from the 1980s that IDD had re-occurred in various regions and population groups across the USSR. Evidence of the comeback of IDD as a major public health problem was confirmed from rapid IDD assessments carried out in six newly independent states during 1994.

When the present decade started, salt iodization strategies had already progressed signifi cantly in the Balkan area and in the CIS countries, the former Soviet guidance of iodized salt supplies to areas with endemic goiter formed part of public memory. The need for iodizing salt to tackle a health development issue was, therefore, not new in the countries of this study but after the demise of central command, a Government-led health development objective could no longer become imposed on the private industry. This made it necessary to adopt joint collaborative decisions for the planning and management of a public health program of national importance. And the fi rst critical challenge, as borne out by global experience, was to ensure the enactment of a law on salt iodization.

NATIONAL DECISIONS ON USI LEGISLATONThe number of countries with a principle statutory law that mandates salt iodization increased during the decade from fi ve (25%) to 18 (90%). In 14 countries, the law comprises the “true” USI strategy, namely compulsory iodization of the salt supply for the food processing industries as well as the households. The law was focused on the fraction of household salt in three countries, and it mandated the food industry salt fraction in one country. A national law on salt iodization was not enacted in the Russian Federation and Ukraine, but the regulations in each of these countries prescribe the iodine levels in case household salt is iodized. The convening power of UNICEF at executive level has been a major factor in mobilizing multi-sector, public-private collaboration to create common, persuasive testimony by the stakeholder organizations in favor of the USI legislation.

In the 18 countries with a law enacted, fully adequate iodized salt supply in combination with adequate iodine nutrition in the population had been achieved by the end of the decade in 9 countries, while in 6 other countries the target was tantalizingly close and population iodine nutrition indicators were showing only minor imperfections. The major reasons for these accomplishments were the conscientious quality assurance practices in the salt factories and the due diligence in salt industry regulations by a State agency for Standardization and Metrology, together with dependable salt inspection and release procedures, practiced by a Food Authority in particular in those countries that depend on salt import. The progress in the 18 countries and their underlying reasons validate the global knowledge that IDD legislation brings success when the stakeholders faithfully carry out their respective duties.

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SITUATION AT THE END OF THE DECADEIn the countries of this study, the end-decade situation of sustainable IDD elimination through USI can be characterized as follows:

• USI and optimum iodine nutrition achieved in Armenia, Belarus, Bosnia and Herzegovina, Bulgaria, Georgia, Kazakhstan, Kosovo, Macedonia and Turkmenistan

• USI and optimum iodine nutrition close in Azerbaijan, Kyrgyzstan, Moldova, Montenegro, Romania and Serbia

• Operational challenges in progressing toward USI in Albania, Tajikistan and Uzbekistan, and

• Political challenges have prevented a national decision on USI legislation in Russia and Ukraine.

True USI was made mandatory in all the Balkan countries except Romania. The two “near successful” countries, Serbia and Montenegro, had inherited their USI laws from the former Yugoslav Federation at comparatively low iodine standards (12-18mg iodine/kg), which was the major underlying reason why the national, p o p u l a t i o n - r e p r e s e n t a t i v e iodine surveys in 2007 showed persistent iodine defi ciency among pregnant women in each case. The population survey data from Bosnia and Herzegovina, Kosovo and Macedonia show that successful USI and adequate population iodine nutrition were attained after a modest raise of the salt iodization standards in each country (Table 1). The salt iodine levels in Bulgaria (17-33mg/kg, mandatory) and Romania (15-

25mg/kg, voluntary for table salt only) are also modestly higher. Bulgaria has reached USI and produced evidence of adequate iodine nutrition among school children, while the progress in Romania was impressive but as yet not successful with a focus on only the salt used in the households. The true USI law in Albania dates of 2008, which left a too short period to expect accomplishments at this time. The comparisons of progress in this area indicate that the achievements toward USI and optimum population iodine nutrition depend on the type of USI laws and the adequacy of standard setting.

© Frits vander Haar

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TAB

LE 1

: M

AIN

CH

AR

AC

TE

RIS

TIC

S O

F T

HE

US

I L

AW

S A

ND

IO

DIZ

ED

SA

LT S

UP

PLY

OU

TC

OM

ES

BA

LKA

N A

RE

A

Le

gis

lati

on

on

sa

lt i

od

iza

tio

nS

alt

su

pp

ly o

utc

om

es

Ye

ar

Co

un

try

Ch

ara

cte

r o

f th

e la

wS

tan

da

rdFo

rtifi

can

tY

ea

rC

ou

ntr

yFo

od

in

du

stry

Ho

use

ho

lds

200

8A

LBTr

ue

US

I25

On

ly K

IO3

200

6A

LBN

o d

ata

60

% c

ove

rag

e (r

apid

te

st)

2001

/5B

iHTr

ue

US

I20

– 3

0K

IO3

and

KI

200

8B

iHY

es,

bu

t n

o d

ata

Mea

n c

on

ten

t 26

.5 m

g/k

g

2001

BU

LTr

ue

US

I17

– 3

3O

nly

KIO

320

03

BU

LY

es,

bu

t n

o d

ata

Un

iver

sal (

rap

id t

est

)

200

8K

OS

Tru

e U

SI

18 –

23

On

ly K

IO3

200

9K

OS

Mea

n c

on

ten

t o

f th

e n

ati

on

al s

up

ply

28

.5m

g/k

g

199

9M

AC

Tru

e U

SI

20 –

30

On

ly K

IO3

200

5M

AC

Ye

s, b

ut

no

da

ta9

4%

≥ 2

0m

g/k

g

1974

MO

NTr

ue

US

I 1

2 –

18

KIO

3 an

d K

I20

07M

ON

Ye

s, b

ut

no

da

taM

ean

co

nte

nt

12.4

mg

/kg

2002

RO

MO

nly

ho

use

ho

ld s

alt

15 –

25

KIO

3 an

d K

I20

04

RO

MN

on

e74

% ≥

15m

g/k

g

1974

SE

RTr

ue

US

I 1

2 –

18

KIO

3 an

d K

I20

07S

ER

Ye

s, b

ut

no

da

taM

ean

co

nte

nt

13.9

mg

/kg

CO

MM

ON

WE

ALT

H O

F IN

DE

PE

ND

EN

T S

TAT

ES

200

4A

RM

Tru

e U

SI

50

± 1

0O

nly

KIO

320

05

AR

MY

es,

bu

t n

o d

ata

97%

co

vera

ge

(rap

id t

est

)

2001

AZ

ETr

ue

US

I4

0 ±

15

On

ly K

IO3

2007

AZ

EY

es,

bu

t n

o d

ata

Mea

n c

on

ten

t 22

mg

/kg

2001

BE

LO

nly

fo

od

in

du

stry

sal

t4

0 ±

15

On

ly K

IO3

200

6B

EL

Un

iver

sal

94

% c

ove

rag

e (r

apid

te

st)

200

5G

EO

Tru

e U

SI

40

± 1

5O

nly

KIO

320

05

GE

OY

es,

bu

t n

o d

ata

91%

co

vera

ge

(rap

id t

est

)

200

3K

AZ

Tru

e U

SI

40

± 1

5O

nly

KIO

320

06

KA

ZY

es,

bu

t n

o d

ata

92%

co

vera

ge

(rap

id t

est

)

2001

KY

RTr

ue

US

I4

0 ±

15

On

ly K

IO3

2007

KY

RP

rob

ably

Mea

n c

on

ten

t 11

.2m

g/k

g

1997

MO

LO

nly

ho

use

ho

ld s

alt

25

– 3

5 K

IO3

and

KI

200

6M

OL

No

ne

66

% c

ove

rag

e (r

apid

te

st)

RU

SN

o U

SI l

aw4

0 ±

15

On

ly K

IO3

R

US

No

ne

a3

5%

est

ima

te

2002

TAJ

Tru

e U

SI

40

± 1

5O

nly

KIO

320

09

TAJ

Pro

bab

ly5

8%

co

vera

ge

(rap

id t

est

)

200

3T

UR

Tru

e U

SI

40

± 1

5O

nly

KIO

320

06

TU

RY

es,

bu

t n

o d

ata

87%

co

vera

ge

(rap

id t

est

)

UK

RN

o U

SI l

aw4

0 ±

15

On

ly K

IO3

200

5U

KR

No

ne

18%

co

vera

ge

(rap

id t

est

)

2007

UZ

BO

nly

ho

use

ho

ld s

alt

40

± 1

5O

nly

KIO

320

06

UZ

BN

on

e5

3%

co

vera

ge

(rap

id t

est

)

a O

nly

a f

ew

bre

ad f

act

ori

es

in R

uss

ia h

ave

star

ted

usi

ng

io

diz

ed

sal

t in

bre

ad b

akin

g

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In the CIS area, the agreement of 2001 in Minsk among the Prime Ministers on mutual collaboration and a common salt iodization standard of 40±15 mg iodine/kg for cross-border trade has highly facilitated the progress made by State members. Noteworthy, the standards in Armenia were set at an even higher level, namely 50±10mg/kg, and Belarus elected to make the law binding on only the salt for the food processing industry while promoting the iodization of household salt. During the decade, fi ve CIS countries attained the USI target and demonstrated adequate population iodine nutrition: Armenia, Belarus, Georgia, Kazakhstan and Turkmenistan; three countries are tantalizingly close: Azerbaijan, Kyrgyz Republic and Moldova; the progress in Tajikistan is critically challenged, and in one other CIS country (Uzbekistan) the strategy is pursued with a focus on household salt. As noted above, no principle law has been enacted in the Russian Federation or Ukraine.

THE IMPORTANCE OF PARTNERSHIP COLLABORATIONIn exploring the reasons for success or failure, information from the successful countries in this study support the global experience about the importance of strong partnership collaboration, which was a new concept especially in the ex-Soviet societies. An interconnected lesson is that this collaboration can be seriously delayed from the infl uential role that Government advisors may exploit in arriving at a national decision. Their objections in lagging countries are mostly of socio-normative nature, although fi nancial gain may be suspected. Underlying their objections is the poor embrace of public health principles, which explains the continual preference for a mainly clinical prophylaxis approach which was typical in former times.

For a timely national decision on enacting a USI strategy, national stakeholders should provide positive and common testimony of the need and feasibility of a mandatory USI law that ideally encompasses the salt supply channels to the food industry as well as the households. Focusing the strategy and decision-making on the household salt fraction only – the publicly visible “vehicle” – has not been adequate.

© UNICEF/SWZK00152/ Giacomo Pirozzi

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TAB

LE 2

: L

AR

GE

-SC

ALE

SA

LT C

OM

PAN

IES

IN

TH

E R

EG

ION

Co

un

try

Pro

du

cer

So

urc

e o

f sa

ltTo

tal s

alt

sup

ply

e

stim

ate

(1,0

00

MT/

y)

Foo

d-g

rad

e sa

lt

est

imat

e (1

,00

0 M

T/y)

Io

diz

ed

sa

lt e

stim

ate

(1

,00

0 M

T/y

)

Arm

enia

Ava

nR

ock

sal

t an

d

solu

tio

n m

inin

g4

0 15

15

Bel

aru

sM

ozy

rso

lS

olu

tio

n m

inin

g3

50

280

100

Bo

snia

an

d H

erze

go

vin

aH

emij

ski K

om

bin

at

«So

das

o»

Ro

ck s

alt

min

ing

50

50

45

Bu

lgar

iaTc

her

no

mo

rski

S

oln

itzy

Sea

sal

t ev

apo

rati

on

75

20

20

Kaz

akh

stan

Ara

ltu

zL

ake

salt

ev

apo

rati

on

35

0 9

0 70

Ro

man

iaS

alro

mR

ock

sal

t &

so

luti

on

min

ing

2,20

0 20

0 12

0

Ru

ssia

B

asso

lL

ake

salt

ev

apo

rati

on

1,25

0 4

50

125

Ru

ssia

S

ilvi

nit

By

pro

du

ct o

f ka

li m

inin

g9

00

90

30

Ru

ssia

Il

ets

kol

Ro

ck s

alt

min

ing

35

0 25

0 12

0

Ru

ssia

Ty

rets

kii s

ole

rud

nik

Ro

ck s

alt

min

ing

30

0 9

0 4

0

Taji

kist

anK

on

i Nam

akS

olu

tio

n m

inin

g4

5 3

0 20

Taji

kist

anN

amak

i Yo

von

So

luti

on

min

ing

15

15

10

Turk

men

ista

nG

uw

lyd

uz

Lak

e sa

lt

evap

ora

tio

n8

0 3

5 3

5

Ukr

ain

eA

rtem

sol

Ro

ck s

alt

min

ing

95

0 4

50

170

Uzb

ekis

tan

Kh

oji

ako

ntu

zS

urf

ace

min

ing

240

160

70

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MANAGING THE USI STRATEGYA National Coalition represents the national arrangement for joint collaborative decisions on the coordination of duties across stakeholders in the USI strategy. The main part of the study was directed at exploring the experiences and achievements managed by the partnership in the four main USI components salt iodization, communications, monitoring and evaluation, and national oversight. The fi ndings of these components led to the following conclusions.

Salt Iodization

Salt iodization takes place in the salt productive industry (Table 2). The CEE/CIS region is home to 15 large salt industries that produce the majority of the salt that humans consume, either directly as household salt or indirectly through the salt used in food industries. These companies are subject to rules for technology approval, production safety standards, fortifi cant authorization and product quality standards, upheld by a standardization and metrology authority typically under the Ministry of Industry and Trade. Management standards certifi ed by the International Standards Organization have been obtained by a number of these companies. The experience during the decade about a leadership role by salt company CEOs in the national partnerships illustrates a range from positive activism and support (for example in Armenia, Bosnia and Herzegovina, Kazakhstan and Serbia) to a lack of sincere interest.

Iodine sources for the fortifi cant supply in the region are located in the Russian Federation, Turkmenistan and Ukraine. In Russia, the Troitsky Iodine Plant in Krymsk, Krasnodar Territory, manufactures pure and analytical grade potassium iodate from iodine recovered from iodine-rich drilling water. A second Russian potassium iodate producer is the Uralsk Chemical Plant Verkhnyaia Pyshma in Sverdlovsk Region, which purchases the iodine ingredient from the Troitsky plant. The Cheleken Chemical Plant in Turkmenistan is another source of potassium iodate and in Ukraine, the fortifi cant is manufactured by the Iodobrom Company in the Crimean Peninsula. Since 2008, the Neftçala iodine factory in South-east Azerbaijan is being rehabilitated with a resumption of its production expected by 2009. Although some salt producers may base their actual purchases on long-established trade relationships with supply sources outside the region, these iodine production capacities can in theory provide for the entire fortifi cant needs of all the countries in CEE/CIS region.

A national salt industry association can potentially be useful, especially in countries – for example Azerbaijan, Kyrgyz Republic and Uzbekistan – with a sizable number of small salt enterprises who typically have cumbersome access to the fortifi cant at an affordable cost. The issues of iodized salt for livestock have not been a factor of importance for national progress, although the supply of non-iodized salt for animal husbandry can form a locally signifi cant impediment. No evidence was found in successful countries that the costs of salt iodization or the pricing by the producers were an obstacle. The evidence from surveys in Tajikistan and Albania, however, showed that household poverty can be an important reason for persistently low market shares of iodized salt in the economically disadvantaged areas.

Communication

The information from large, multi-channel communication campaigns was reviewed. The countries with these campaigns during the decade – nearly half of the countries in the study – typically included NGOs in the design and delivery, which added value by spreading the new information more readily and swiftly through more layers of society and may have helped turning potential gatekeepers into supporters. The number of large-scale campaigns was equally divided between the successful or near-successful countries and the countries that did not reach success. This suggests that an intensive public promotion effort did not make the difference for achieving success, and it does not lend support to the expectation that public demand would grow the supply of iodized salt. Therefore, public information campaigns in support of the USI strategy should not aim at changing the purchase behavior of the public. Messages aimed to strengthen the public’s acceptance are suffi cient.

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Other important communication activities in many countries were stakeholder stimulation (including salt producers), infl uencing gatekeeper’s opinions and knowledge insertion into ongoing education curriculums. Stimulation of the salt industry could benefi t from more comprehensive in-depth analysis and on-the-job training of staff in the small salt enterprises to meet their specifi c needs in systemic capacity, especially better quality assurance procedures and more effective product promotion. The insertion of essential learning about the dangers of IDD and the benefi ts of USI in educational curriculums at secondary and graduate technical levels contributed to a foundation for sustained success in a number of countries.

In a broad area of Eastern Europe and Western CIS, the objections by technologists in the fruit and vegetable preservation industry became apparent during the decade as a barrier against the use of iodized salt in the food industry. This was, for example, the reason for prohibiting the use of iodized salt by the food industry in Romania. In Moldova, Ukraine and Russia, a bread bakery regulation from Soviet times is frequently quoted to justify objections against the use of iodized salt in bread bakeries. The underlying beliefs are that the use of iodized rather than common salt would affect the organoleptic characteristics of the industry’s products, a factor that has been dispelled by various model studies in Moldova, Russia and Romania. Moreover, the use of iodized salt use in food industries, especially in bread baking, is common practice in Western countries such as Denmark, Germany, the Netherlands, Switzerland, Australia and New Zealand.

Monitoring and Evaluation

The ability to manage national progress depends on the data and information from monitoring and evaluation, which is the third strategy area studied. Although an analysis of the national salt situation -typically with the amounts of national salt supplies included- were recognized early as an essential element for oversight, obligatory reporting of these supplies was achieved in only four countries. Little data is available from monitoring of the quality of salt used in the food manufacturing industries even though this fraction accounts for a major share of the total salt supplies in the countries of the region. Therefore, “watching over” the salt supply situation to verify the amount of national iodized salt provisioning in each of the salt supply channels cannot yet be reliably conducted in most of the region.

The review revealed that inspections by Food Authority offi cials in the consumer markets are typically strict in a number of countries. The quarterly reporting of salt inspection results to the national coalition has been made obligatory in Kazakhstan. The information about the use of iodized salt in the households is dependent on intermittent household surveys, which may have sizable time intervals. Universal use (>90% of households) of adequately iodized consumer salt was attained in 11 countries of the region, including Serbia and Montenegro where the salt iodine standard is below international convention.

For assessing the population iodine nutrition status (Figure 3), 14 countries have a national laboratory that can generate data of urinary iodine assays, eight of which are collaborating successfully in the CDC-provided external quality assurance program EQUIP. Surveys stratified by region and 30x30 population-proportional designs each constituted half of the surveys during the decade. School-age children were the target group in most national iodine surveys while the inclusion of pregnant women in iodine nutrition surveys was increasing. The time-lapse since the most recent survey is more than five years in six countries, while a nation-wide population-representative survey was not undertaken in two countries. The available reports from population surveys indicate that the approach of data analysis and interpretation is improving: Increasingly, UI distribution analysis is used for an index of optimum iodine nutrition and also the use of statistical techniques to analyze the relationship between indicators of iodine supply and those of iodine consumption and iodine nutrition status is improving.

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FIGURE 3: KEY RESULTS FROM NATIONAL POPULATION SURVEYS OF IODINE NUTRITION a

a Median urinary iodine concentrations in µg/L. Shaded areas indicate the normative range for each group. A national survey has not been conducted in Russia and Uzbekistan. *The 15-49 year old women surveyed in Ukraine (2002) and in Kazakhstan (2006) were not pregnant.

National Oversight

Finally, a review of the information, where available, of the forms and structures for national oversight suggests that both formal and informal interactions characterize the partnership arrangements in the region. The level of these interactions, and therefore the structure used, naturally depends on the issues arising and the importance being accorded to the decisions that need to be made. A national committee or commission tasked with IDD elimination exists at least on paper in most countries. Obligatory MOH reports and publicity of national progress made are typical accountability examples of national collaboration for USI progress.

INTERNATIONAL RECOGNITIONDuring the decade, the guidelines and criteria developed by WHO/UNICEF/ICCIDD expert groups stimulated national assessments of USI strategies in a number of countries, followed in each case by an independent external review. The global Network for Sustained Elimination of Iodine Defi ciency has acknowledged that elimination of iodine defi ciency was achieved through USI in Macedonia (2003), Turkmenistan (2004), Armenia (2006), Bulgaria (2007) and Kazakhstan (2009) – the highest proportion of countries in any region of the world.

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CONCLUSIONS AND NEXT STEPS

The present study of 20 countries in the CEE/CIS region re-confi rmed the strong improvements of the iodine nutrition situation that took place during the past decade thanks to USI strategies. The analysis of the successful countries shows that a steadfast implementation of true USI laws successfully eliminates iodine defi ciency in the population within a short time. Strong public-private-civic partnerships were the underlying reason for the exemplary progress in each case. Most of the salt companies in the region have embraced quality iodized salt production as the universal norm and the due diligence in enforcing the salt iodine standards remains a critical factor for continued assurance of optimum iodine supplies. Communications have improved the prospects for sustained success in a number of countries, especially through stimulating the range of stakeholders, keeping the opinions of potential gatekeepers at bay, and inserting the essential learning into key educational curriculums. Finally, the capacity for surveillance of the population’s iodine nutrition situation has developed signifi cantly. Summing up, the experiences in USI strategies during a decade of action in the region revealed a tremendous improvement of the capacities for fi ghting iodine defi ciency at national scale.

In taking advantage of the experience of most of the countries in this study, the remaining challenges can be tackled by a combination of actions as follows:

• Establish a “National Salt Watch” for quantitative salt supply monitoring in each country

• Promote self-reliant input procurement and strengthen the quality assurance practices in small salt enterprises

• Insert essential IDD and USI knowledge in ongoing education curriculums in each country

• Promote diligent quality assurance of the salt imports in countries where progress is lagging (Albania, Kyrgyz Republic, Moldova, Romania and Uzbekistan)

• Professional training on public health principles-based analysis and action for current and future medical specialists

• Organize periodic re-advocacy and counter the political objections with the use of socio-normative principles from the Universal Declaration of Human Rights and the Convention of the Rights of the Child.

Even though USI is not specifi cally stated in the Millennium Development Goals, the success of IDD elimination contributes importantly to several fundamental values for society, such as the reduction of child mortality, improvement of maternal health, and effective primary education. In 2007, the World Health Assembly called on its States Members to establish national coalitions for monitoring the state of national iodine situation every three years. With the capacities that have been built and the excellent available experiences in many countries, the region is uniquely positioned to be the fi rst in the world where IDD may become completely and sustainably eliminated through USI.

Contact Information:

UNICEF Regional Offi ce for Central and Eastern Europe and the Commonwealth of Independent States Palais des Nations CH-1211 Geneva 10, Switzerland Telephone: +41 22 909 5543 Fax: +41 22 909 5909 www.unicef.org/ceecis

The printing of this summary has been made possible by funds contributed by the Global Alliance for Improved Nutrition (GAIN).The GAIN-UNICEF Universal Salt Iodization (USI) Partnership Project, funded by the Bill and Melinda Gates Foundation, contributes to global efforts to eliminate iodine defi ciency through salt iodization in 13 countries with the lowest coverage of iodized salt and the greatest burden of iodine defi ciency. By the end of the Project, the Partnership will have helped to reach more than 790 million people not yet covered by worldwide salt iodization programs, including more than 19 million newborn infants every year. The activities undertaken by GAIN and UNICEF will help to highlight key “success factors” which will enhance the design and implementation of sustainable USI programming.

Universal Salt Iodization in Central and Eastern Europe and the Commonwealth of Independent States

Health & Medicine

Transcript of Universal Salt Iodization in Central and Eastern Europe and the Commonwealth of Independent States