Case -Study on IDD/USI Program in Lao P.D.R. August 2001

Demographic/Economic Profile Population - 5,2 M (2000) Population Density p/sq.km Population Growth Rate - 2.4% Fertility Rate - 6.4% Rural Population - 85% Life Expectancy - 59 (F: 60; M: 56) GDP per Capita - US$ 350 Area - 236,800 sq. km

IMR : 82 per 1,000 live birth Under 5 MR : 106 per1,000 live birth MMR : 530 per 100,000 live birth DPT3 Immunization : 52.8 % Measles Immunization : 65% Rate of unattended birth : 65% Main causes Morbidity& : Malaria, ARI & Mortality in Under 5. Diarrhea Disease Health Indicators : (2000)

Water Sanitation Access to safe drinking water - 52 % of population (2000) Acess to latrines - 32 % of population Education Literacy Rate - 65% (overall) - 60% (female)

I. Extent, Distribution and Causality of IDD in Lao Resource-scarce country with mountainous areas Soil erosion contribute to the poor quality of Iodine in the soil Vegetable and rice growth do not contain sufficient Iodine : Assessment of goiter rate - 10% living in the plains - 30% living in accessible plateau areas

II. Initiation of USI Program A. Short-Term strategy : NGO administered a single injection of iodised oil (lipoidol) - 10,000 Residents in VT, LPB 1993 : 10,000 doses of oil (08 provinces) - not feasible or cost effective approach - only be justification for its use in high-risk population (women of child bearing; children in very isolated areas)

B. National Survey on IDD (1993) - Analysis of the iodine content of urine of 2454 school age children in 31 villages  95% of children affected with IDD (urinary iodine < 100  g/l)  65% be classified with Severe Iodine Deficiency (urinary iodine < 20  g/l)

C. USI Program in lao PDR USI was identified as the most appropriate and sustainable strategy to tackle the problem of IDD USI was initiated in 1995 The Prime Minister’s Degree on USI was signed in May 1995 Salt standard was issued and quality of standard issued are level of iodine in salt : - > 30 ppm at the producer level - > 15ppm at consumer level 08 salt factories and  20 small scale producers

III. USI Program Implementation A. Equipment,Potassium iodate & spare parts supported by UNICEF - SIP provided to 08 large salt factories - Hand mixers provided to  20 small scale salt producers - Potassium Iodate  1,500 kg/years - Laboratory equipment and reagents for UI - Rapid test kits

B. Monitoring / Assessment of IDD program The community Health/Safe Motherhood Project in two districts of Luang Prabang Province: - in 1996, just 5 months after the introduction of USI, 72% of 2511 household were utilising iodized salt months later (1997/1998), 96% of 2,270 household were consuming adequate iodised salt.

IV. Success of the USI Program MCHI-GTZ study in the North. Prov. (Luangprabang) investigating changes in indicators of IDD from Aug. 95 to Aug 97 year HH utilisation Prev.of goiter UI(<100  g/l) 1995 (n=219)  9% 97%  1% 1997 (n=271) 99% 44%  80% CEMUBAC Survey in 1996 on One northern and two southern province of Lao: Region Median Urine Total goiter Adequately Iodised iodine(  g/l) prevalence household salt North 85*(n=83) 37%(n=180) 75%(n=76) South 195*(n=142) 28%(n=629) 86%(n=239)

Iodized Salt Coverage (years 1995,1996,2000) Source MCHI - GTZ Study in the northern Province of Luangprabang (1995) MICS Survey 1996 and National Survey 2000

Total Goiter Rate results from National Surveys (1993 and 2000) %

Urinary Iodine results from National Survey (years 1993, 2000) Median  g/l

Table for Severe, Moderate, Mild Optimal level of Iodine in UIE from years 1993 to 2000 Indicators 1993(n=2454) 2000(n=900) Severe <20  g/l 65% 0.4% Moderate <50  g/l 23% 7% Mild <100  g/l 7% 20% Optimal 5% 73% Prevalence of severe and optimal level of Iodine in UIE from 1993 to 2000

The efficiency of iodized salt distribution in hard to access areas The lack of compliance among small scale producers The stability of iodine under different storage conditions Quality assurance of iodine measurements Sustainability of program (Phase out free supply of Potassium Iodate and spare parts) V. Future Challenges for the USI Program

VI. Lessons from Universal Salt Iodination Signing of Prime Minister Decree (provided power to implement the program) Multi-sector Collaboration - USI program is managed by inter-sectoral committee Geography and size of Lao (landlocked not prone to sea salt commercialization) - 08 large-scale salt producers Feedback of Monitoring System - routine monitoring and a number of small surveys