IDD Elimination: Global and Regional Achievements Achieving Universal Salt Iodisation for Optimal Iodine Nutrition UNICEF, IGN, GAIN, MI EAP Regional Meeting 12-14 October, Bangkok #commit2USI IDD Elimination: Global and Regional Achievements Christiane Rudert Regional Nutrition Advisor, UNICEF EAPRO

Global achievements: household iodised salt coverage Some experts believe universal salt iodization may be the most successful public health effort of the past two decades, in which enormous strides have been made. However, progress has stalled in recent years 75% Globally  <20%  20-49%  50-69%  70-89%  ≥ 90%  Data not presented as most recent estimate is not in accordance to the standard definition and earlier data <2009  no data Source: UNICEF Database, 2015

An estimated 35 million newborns were at risk of iodine deficiency disorders in 2013 Damage related to iodine deficiency greatest and irreversible in the growing fetus. Protecting pregnant women priority. Unfortunatley, still some 35 million newborns are born every year unprotected against IDD Coverage of adequately iodized salt has plateaued–and fallen in some countries A new sense of urgency, opportunity, and vigor around iodine needs to be created www.data.unicef.org

Decline in the number of iodine deficient countries Ref: Iodine Global Network EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Estimated median UIC 1993 (μg/L) 113 COUNTRIES IODINE DEFICIENT IN 1993 Country by region AFRO AMRO EMRO EURO SEARO WPRO The size of the bubbles = population of each country, The color of the bubbles six WHO regions. The number of countries for which data are available has increased over this same time period from 121 to 155, further demonstrating the impact. Goiter rate 1993 (%) Estimated median UIC 1993 (μg/L)

Estimated goiter rate 2015 (%) 25 COUNTRIES IODINE DEFICIENT IN 2015 Country by region AFRO AMRO EMRO EURO SEARO WPRO Global focus is now on sustaining the achievements while accelerating efforts to improve the iodine status in these 25 countries. As such, we are on the verge of a major public health success. Estimated goiter rate 2015 (%) Median UIC 2015 (μg/L)

Regional achievements: household iodised salt coverage by region 2008-2012 Ref: UNICEF State of the Worlds Children 2015 EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Household iodized salt coverage Inequities between the richest and poorest quintiles in consumption of iodized salt are evident in about two Thirds of countries Coverage lowest quintile << Coverage highest quintile Coverage lowest quintile= Coverage highest quintile data for 44 countries: the richest quintile was at least twice as likely as the poorest quintile to consume adequately iodized salt (red circles). In another third of countries, the rich were more likely to consume iodized salt. However, over one third of countries showed that the richest and poorest 20 per cent of the population were roughly equal in terms of their consumption of  iodized salt (the green circles) The data also show that countries with higher overall coverage (circles in the top right quadrant) tend to have more equitable distribution of coverage. Household iodized salt coverage Highest quintile Household iodized salt coverage Lowest quintile

Regional achievements: household iodised salt coverage Ref: National surveys such as DHS, MICS, Living Standards, National Nutrition or IDD. Surveys assessing adequately of iodine with a quantitative methodology, such as titration, shown with an asterix * EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Iodine status in the region (median urinary iodine) SAC WRA PW

Regional achievements: china case study China achieved IDD elimination in 2005: HH iodised salt coverage >95% and adequately iodised salt coverage >90% Elimination of goitre (<5%) Adequate iodine status in school age children Also achieved IDD elimination in 28 out of 31 provinces Facilitating factors: High political commitment Mandatory legislation State-owned salt monopoly Surveillance and evaluation system EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

However back-sliding in some countries……. Cambodia Preliminary DHS/Micronutrient Survey 2014 results: urinary iodine status is inadequate Ref: 2008 CSIN, 2011 CSIN, 2014 Market Monitoring (WYD).

What happened in Cambodia? No external regulatory monitoring and enforcement of national legislation End of UNICEF subsidy of KIO3 and rise in price following Fukoshima Industry did not maintain its commitment to take over purchase of KIO3 EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

However back-sliding in some countries……. myanmar Ref: Availability of Iodised Salt at HH Level in Myanmar 2011: Report of a School Based Survey 2011 EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

However back-sliding in some countries…… However back-sliding in some countries……. Vietnam – household use of iodised salt Ref: National IDD Surveys and Multiple Cluster Indicator Survey in 2011 EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

However back-sliding in some countries…… However back-sliding in some countries……. Vietnam – urinary iodine of women Optimal range for UIC of reproductive age women Ref: Report on IDD Survey 2008/9, HoE

And little/no progress in others…….. indonesia Ref: Riskesdas 2007 and 2013. Non-iodized: <5ppm iodine; Inadequately iodized: 5-14.9 iodine; Adequately iodised: ≥15ppm iodine.

And little/no progress in others…….. Philippines EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Philippines: inequity in iodine status EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Global Nutridash performance score for USI (2013/2014) Policy environment – existence of legislation and scope of legislation National ownership and programme governance Communication Monitoring and evaluation and quality assurance Total programme performance score Policy environment : which types of salt is iodization mandatory under the law; whether regulations are in line with the law; integration of USI in national policies, plans and budgets; and inclusion of iodized salt in national food standards. National ownership and programme governance: whether IDD a funded budget line; whether potassium iodate procurement was maintained without external funds; existence of national coordination mechanism and its functioning; and percentage of salt from large and medium size producers Communication Whether iodized salt is clearly recognizable as iodized to the consumer; whether a communication strategy in place that addresses identified bottlenecks from production/import of iodized salt to reaching the population; whether education about IDD and iodized salt included in health system, schools, etc; Monitoring and evaluation and quality assurance i) Assesses whether there is a national monitoring system exist that tracks programme activities (e.g., policy implementation, production, supply, communication); ii) whether any monitoring data reported and used for corrective action/programme adjustments; iii) rules and operating procedures for external QC (inspections and sample taking at the production/import and the commercial levels) by national authorities are clearly established; iv) the rules and procedures for external QC actually been applied by national authorities in the past calendar year; v) standards and responsibilities for internal QA at the production level clearly established; vi) iodized salt production sites complied with the standards for internal QA in the past calendar year; vii) any examples of punitive or rewarding actions (including public recognition) relating to the compliance of salt producers with QA standards for iodized salt; viii) the salt iodization programme in your country been evaluated by external independent evaluators in the past 5 years? Total programme performance score Policy, governance/ownership and M&E/QA = 30% weighting and communication 10%. In 2014 the categories, questions and weighting shifted a little. Ref: UNICEF Nutridash EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

Regional nutridash performance scorE: policy environment

Regional nutridash performance score: national ownership and programme governance Score (%)

Regional nutridash performance score: communication

Regional nutridash performance score: monitoring, evaluation and QA/QC

Regional nutridash performance score: TotaL

Issues hindering progress in the region Reduced political commitment Inadequate coordination structures for intersectoral collaboration Lack of regulatory monitoring and weak enforcement of national legislation Insufficient use of iodised salt in processed foods Insufficient data on iodine status of reproductive age or pregnant women National data on household iodised salt and median urinary iodine likely hiding sub-national disparities Poor quality data on household use of iodised salt – reliance on rapid test kits EAP Regional Workshop on ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

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