Giving Children a Smart Start NETWORK FOR SUSTAINED ELIMINATION OF IODINE DEFICIENCY 180 Elgin Street, Suite 1000, Ottawa, ON Canada K2P 2K3 T 1 (613) F 1 (613) Achieving Universal Salt Iodization: Lessons learned and Emerging Issues by Venkatesh Mannar and Lucie Bohac

Giving Children a Smart Start 180 Elgin Street, Suite 1000, Ottawa, ON Canada K2P 2K3 T 1 (613) F 1 (613) Presentation outline Introduction Taking Universal Salt Iodization to Scale : Lessons Learned Emerging issues Conclusions

Giving Children a Smart Start 180 Elgin Street, Suite 1000, Ottawa, ON Canada K2P 2K3 T 1 (613) F 1 (613) Introduction Iodine Deficiency Disorders are widespread in the world affecting millions of people with a range of physical and mental abnormalities. Universal Salt Iodization (USI) of all human and animal salt is the global strategy for elimination of iodine deficiency. This paper outlines the progress and experiences in taking USI to scale and lessons learned, emerging issues and the key needs to achieve USI.

Giving Children a Smart Start 180 Elgin Street, Suite 1000, Ottawa, ON Canada K2P 2K3 T 1 (613) F 1 (613) The Iodine Network A global coalition of public, private, international and civic organizations is championing the sustained elimination of IDD through USI. Current Members of the Network are: China National Salt Industry Corporation EU Salt Emory University Global Alliance for Improved Nutrition (GAIN) International Council for Control of Iodine Deficiency Disorders (ICCIDD) Kiwanis International Salt Commissioner to the Government of India Micronutrient Initiative Salt Institute Tata Chemicals US Centers for Disease Control UNICEF World Health Organization World Food Programme

Giving Children a Smart Start 180 Elgin Street, Suite 1000, Ottawa, ON Canada K2P 2K3 T 1 (613) F 1 (613) Taking Universal Salt iodization to Scale Overview of Global Progress (UNICEF, May 2008) Globally, 70% of households are consuming adequately iodized salt. 34 countries have achieved USI and another 28 are close to the goal. More than 120 countries are implementing USI programmes. 84 million infants are protected annually from the risk of IDD. The number of countries where IDD remains a problem has dropped to 47.

Giving Children a Smart Start 180 Elgin Street, Suite 1000, Ottawa, ON Canada K2P 2K3 T 1 (613) F 1 (613) Taking Universal Salt iodization to Scale Lessons Learned: National Commitment High level advocacy, policy and planning commitments, legislation, national coalition and administrative oversight India Rapid progress Lifting of ban on sale of non iodized salt in 2000 led to significant drop in production of iodized salt – subsequently recouped when ban was reinstituted. Russia Began iodization efforts in 1950s and achieved success Dissolution of USSR: fragmentation and collapse of iodization program Small progress recently but household consumption still very low. China Premier committed to goal of IDD elimination 1991 High level advocacy meeting 1993 launched USI programme Over 90% coverage within a decade

Giving Children a Smart Start 180 Elgin Street, Suite 1000, Ottawa, ON Canada K2P 2K3 T 1 (613) F 1 (613) Taking Universal Salt iodization to Scale Impact of National Commitment

Giving Children a Smart Start 180 Elgin Street, Suite 1000, Ottawa, ON Canada K2P 2K3 T 1 (613) F 1 (613) Taking Universal Salt iodization to Scale Lessons Learned: Salt iodization as a Norm In large salt processing plants iodization is a simple step. Iodization in small/medium operations is more challenging. Recently there have been significant investments in salt refining capacity in several countries. (China, India, Bangladesh) New strategies needed to address bottlenecks through advocacy, technical support, monitoring and enforcement To address multiple levels of iodization and packaging, encourage raw salt producers to iodize at source (including purchases from cottage units) A strong working relationship between regulatory bodies and the salt industry is key (e.g. Nigeria)

Giving Children a Smart Start 180 Elgin Street, Suite 1000, Ottawa, ON Canada K2P 2K3 T 1 (613) F 1 (613) Taking Universal Salt iodization to Scale Lessons Learned: Monitoring & Evaluation Household surveys (UNICEF MICS/DHS) useful to assess coverage and consumption of iodized salt. Progress towards IDD elimination is confirmed by accurate data on urinary iodine excretion (UIE)in school children. Database on results of regular monitoring of salt, UIE and thyroid hormone levels with mandatory public reporting is essential. Standardization and quality assurance of laboratory procedures is critical: International Resource Laboratories for Iodine Network (IRLI)formed by US CDC to strengthen laboratory capacity in different parts of the world.

Giving Children a Smart Start 180 Elgin Street, Suite 1000, Ottawa, ON Canada K2P 2K3 T 1 (613) F 1 (613) Taking Universal Salt iodization to Scale Lessons Learned: Education & Social Mobilization As visible forms of iodine deficiency (goitre/cretinism) regress the focus is on less visible impacts especially brain damage. Ongoing communication efforts are essential. Tailor messages to different audiences with specific calls to action Understand common wisdoms & correct misinformation and educate public Integrating up-dated IDD info into technical & education materials of food inspection, health and education curriculums Public education serves to solidify support for IDD elimination and create a demand for iodized salt

Giving Children a Smart Start 180 Elgin Street, Suite 1000, Ottawa, ON Canada K2P 2K3 T 1 (613) F 1 (613) Emerging Issues: IDD in Europe

Giving Children a Smart Start 180 Elgin Street, Suite 1000, Ottawa, ON Canada K2P 2K3 T 1 (613) F 1 (613) Emerging Issue: Role of Small Producers A significant proportion of salt is produced by many small producers with limited financial means or access to technical assistance. Two recent programs by Micronutrient Imitative to expand iodization of salt by small producers: Senegal, India Senegal: Nearly 10,000 producers encouraged to join associations provided with material and technical assistance and enable to improve salt quality and productivity India: In Rajasthan State formation of cooperatives; provision of technical inputs, establishment of revolving fund and training in quality assurance have enabled substantial expansion in production.

Giving Children a Smart Start 180 Elgin Street, Suite 1000, Ottawa, ON Canada K2P 2K3 T 1 (613) F 1 (613) Emerging Issue: Processed Foods USI efforts do not always include salt used in processed foods Food processors reluctant to use iodized salt – unfounded concerns about effects on organoleptic properties of foods/ trade barriers Given expanded consumption of process foods, programs relying upon fortification of table salt alone may not be adequate. Iodine intake may also be reducing due to other changes e.g. decreased use of iodophors in the dairy industry Trade harmonization to mandate use of iodized salt in processed foods to address inter-country variations in micronutrient recommendations may offer a solution.

Giving Children a Smart Start 180 Elgin Street, Suite 1000, Ottawa, ON Canada K2P 2K3 T 1 (613) F 1 (613) Emerging Issue: Monitoring, Data & Analysis UIE trends in school-aged children to be complemented with iodine status of pregnant and lactating women. Monitoring of iodine status should not only check for deficiency but also highlight excess e.g. Kenya, parts of China. However risks in excess much smaller than those of deficiency WHOI 2007 Resolution: Efforts to eliminate IDD require continuous monitoring and oversight and require Member States to establish mechanisms for monitoring iodine nutrition and reporting on their progress.

Giving Children a Smart Start 180 Elgin Street, Suite 1000, Ottawa, ON Canada K2P 2K3 T 1 (613) F 1 (613) Conclusions While tremendous progress has been made to make salt iodization universal, 2 billion people are still at risk in the world Government Commitment is key for USI Document and review models of engaging small producers sector holding significant marker share IDD knowledge needs to be embedded into health sector infrastructure New advocacy efforts directed at Europe needed Expand iodization to include salt used in processed foods Improved monitoring and reporting to the World Health Assembly in 2010 is an opportunity to take action and address gaps. Address remaining technical issues