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

MonitoringMonitoring

Prof. Gregory GerasimovProf. Gregory GerasimovUNICEF Consultant

Central and Eastern Europe, CIS and Baltic States

Global success in salt iodization Global success in salt iodization

% of households% of households that consumethat consumeiodized saltiodized salt

Globally - 73%Globally - 73%CEE/CIS/BS - CEE/CIS/BS - from 5 to 90% from 5 to 90% Baltic States - Baltic States - up to 10% up to 10%

UNICEF 98 Report

Definitions - MONITORINGDefinitions - MONITORING

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

Definitions - INDICATORDefinitions - INDICATOR

• An An indicatorindicator is used to help describe a is used to help describe a situation that exists, and can be used to situation that exists, and can be used to track changes in the situation over time.track changes in the situation over time.

• Indicators are usually Indicators are usually quantitavequantitave, but , but may also be may also be qualitativequalitative..

• Indicators may be Indicators may be directdirect and and indirectindirect..

Indicators of IDD Control Indicators of IDD Control ProgramProgram

• Process Indicators Process Indicators - - for monitoring of for monitoring of salt iodizationsalt iodization

• Impact (Outcome) Impact (Outcome) IndicatorsIndicators - for - for biological biological monitoringmonitoring

Process Indicators Process Indicators

• Is all imported salt iodized to the Is all imported salt iodized to the country’s requirement?country’s requirement?

• Is adequately iodized salt reaching Is adequately iodized salt reaching the target population?the target population?

Biological (Impact) IndicatorsBiological (Impact) Indicators

• Is there a significant IDD problem?Is there a significant IDD problem?

• What is the prevalence of IDD in a given What is the prevalence of IDD in a given population?population?

• What impact salt iodization has on iodine What impact salt iodization has on iodine status of the population?status of the population?

• Have IDD been eliminated as a public Have IDD been eliminated as a public health problem?health problem?

PROCESS PROCESS INDICATORSINDICATORS

Factors That Determine Iodine Factors That Determine Iodine Content in SaltContent in Salt

• Variability in the amount of added iodineVariability in the amount of added iodine

• Uneven distribution of iodine in the Uneven distribution of iodine in the iodized saltiodized salt

• The extent of iodine loss during storage The extent of iodine loss during storage and distributionand distribution

• Loss of iodine due to cooking and food Loss of iodine due to cooking and food processingprocessing

Industry Standards for Iodized Industry Standards for Iodized SaltSalt

• Former USSR GOST Former USSR GOST 13830-91 required:13830-91 required:– use of instable use of instable

potassium potassium IODIDE (KI)IODIDE (KI)

– level of iodization level of iodization 23+/-11 ppm23+/-11 ppm

– shelf life 3 monthsshelf life 3 months

• UNICEF/WHO UNICEF/WHO recommendations:recommendations:– use of stable use of stable

potassium potassium IODATE (KIO3)IODATE (KIO3)

– level of iodization level of iodization 20-40 ppm20-40 ppm

– shelf life more shelf life more than 12 monthsthan 12 months

MOST OF SALT MOST OF SALT PRODUCERS IN THE PRODUCERS IN THE

REGION THAT SUPPLY REGION THAT SUPPLY IODIZED SALT TO THE IODIZED SALT TO THE

BALTIC STATES COMPLY BALTIC STATES COMPLY WITH ABOVE WITH ABOVE

RECOMMENDATIONSRECOMMENDATIONS

Determining Salt Iodine LevelsDetermining Salt Iodine Levels

• Titration methodTitration method

• Rapid test kitsRapid test kits

• Semi-quantitative Semi-quantitative measurement kitsmeasurement kits

MONITORING SYSTEMMONITORING SYSTEM

• Government (External) Monitoring Government (External) Monitoring SystemSystem

• The Producers’ & Distributors’ The Producers’ & Distributors’ (Internal) Monitoring System(Internal) Monitoring System

• Household Level MonitoringHousehold Level Monitoring– Cross-sectional surveysCross-sectional surveys– Community based monitoring Community based monitoring

IMPACT IMPACT INDICATORSINDICATORS

Biological IndicatorsBiological Indicators• Goiter rate in school Goiter rate in school

children (by palpation children (by palpation and ultrasonography)and ultrasonography)– <5% - no iodine

deficiency• Urinary IodineUrinary Iodine

– >100 mcg/l - no iodine deficiency

• Neonatal TSH Neonatal TSH screeningscreening – samples with TSH

level > 5 mU/L - less than 3%

Goiter (Thyroid Size) Goiter (Thyroid Size) AssessmentAssessment

• Easy to performEasy to perform• Little training needed Little training needed

(for palpation)(for palpation)

• Reflects remote rather Reflects remote rather than present iodine than present iodine statusstatus

• Observers’ variationsObservers’ variations• Low sensitivityLow sensitivity• Expensive equipment Expensive equipment

(for ultrasonography)(for ultrasonography)

Urinary Iodine AssessmentUrinary Iodine Assessment

• Reflects current Reflects current iodine status of iodine status of populationpopulation

• Samples easy to Samples easy to collectcollect

• Sensitive and reliable Sensitive and reliable indicatorindicator

• Trained lab staff Trained lab staff neededneeded

• External and internal External and internal quality control quality control requiredrequired

• Rather expensive Rather expensive equipmentequipment

Neonatal TSH Neonatal TSH

• No additional No additional investments in impact investments in impact (biological) (biological) monitoringmonitoring

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

SURVEY METHODSSURVEY METHODS

• School surveysSchool surveys– goiter rate (palpation & ultrasonography)goiter rate (palpation & ultrasonography)– urinary iodine urinary iodine – samples of salt from householdssamples of salt from households

• Household surveysHousehold surveys– goiter rate (palpation)goiter rate (palpation)– urinary iodineurinary iodine– checking of iodine in saltchecking of iodine in salt

WHO/UNICEF/ICCIDD criteria for monitoring progress towards elimination of

IDD as a public health problem

Indicator Goal1. Salt iodizationPercentage of householdsconsuming adequately iodized salt

> 90%

2. Thyroid sizeProportion of school children withgoiter

< 5%

3. Urinary iodine (reflects actualiodine consumption with food)Median level (mcg/L)

100-200

Universal Salt Iodization in Universal Salt Iodization in Baltic StatesBaltic States

• Legislation, Legislation, Regulations, Regulations, StandardsStandards

• Implementation & Implementation & EnforcementEnforcement

• Monitoring and Monitoring and Impact AssessmentImpact Assessment

ACHIEVABLE GOAL:ACHIEVABLE GOAL:

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