1. National Iodine Deficiency Disorder Control Programme
Moderator: Prof. P.R.Deshmoukh
Presenter: Rohan R Patil

2. Defination
Iodine deficiency disorders (IDD) refer to all of the consequences of iodine deficiency in a population that can be prevented by ensuring that the population has an adequate intake of iodine.
- World Health Organization

3. Spectrum of Iodine Deficiency Disorders
Foetus
Abortion
Still-birth
Congenital anomalies
Neonatal cretinism
Mental deficiency
Diplegia Squint
Myxedamotous cretinism
Dwarfism
Hypothyroidism
Psychomotor Defects
Neonate
Neonatal hypothyroidism
Child and Adolescent
Retarded mental and physical development
Adult
Goitre and its complication
Impaired mental function
Iodine induced hypothyroidism
All Ages
Physical Sluggishness

4. Iceberg of IDD

5. The hourglass of IDD Historic view 1962-1983 Current view 1984 onwards
Iodine Deficiency = Goiter =
Visible Swelling
No Pain, Cosmetic problem
Cretinism: A rare event
= LOW PRIORITY
Brain Damage
Lack of Energy - hypothyroidism
Learning Disability, ↑Deaths
 Child Development & Child Survival
 Human Resource Development
= HIGH PRIORITY
Historic view
Current view 1984 onwards

6. Defination of Iodine Deficiency Disorder as Public Health problem
Epidemiological criteria for assessing the severity of IDD based on the prevalence of goitre in school-aged children
None
Mild
moderate
Severe
Total Goitre Rate %
5-19.9% %
> =30%

7. Defination of Iodine Deficiency Disorder as Public Health problem
Epidemiological criteria for assessing iodine nutrition based on
median iodine concentrations of school age children ( 6 years)
Median UI
Iodine Intake
Iodine Status
<20
Insufficient
Severe Iodine Deficiency
20-49
Moderate Iodine Deficiency
50-99
Mild Iodine Deficiency
Adequate
Adequate Iodine Nutrition
Above requirements
Likely to provide adequate intake for pregnant/ lactating women
>300
Excessive
Risk of hypothyroidism/ Autoimmune thyroid dsease

8. Defination of Iodine Deficiency Disorder as Public Health problem
Epidemiological criteria for assessing iodine nutrition based on median
or range in urinary iodine concentrations of PREGNANT WOMEN
Median UI(Ug/dL)
Iodine Intake
<150
Insufficient
Adequate
Above requirements
>500
Excessive
IDD could be defined as a public health problem if
Total goitre prevalence
> 5%
MUI (In more than 50% of population)
<100 ug/L
MUI ( In more than 20% of the population)
<50 ug/L

9. Cause of Iodine Deficiency:
Iodine Deficiency: How’s Affected
CAUSE
Effect on People
Effect on Animals
Low Availability of Iodine
Soil Erosion
Who’ s Affected
Humans
Livestock
Plants
Water, Soil
How Affected
Health and Socio-economic Impact
Clinical and reproductive Disorders, Decreased Productivity
Iodine poor feeds and fodder,
Goitrogens
Environmental Iodine deficiency

10. Magnitude of the problem among Indian states: (NIN study in 2003)
Region
% prevalence of goitre
% P of other signs of IDD
Salt Iodine (>15PPM)
By spot Test
Northern
13.4
0.67
63.3%
Eastern
27.5
0.61
44.8%
North Eastern
6.1
0.03
77.9%
Central
10.7
0.62
29.7%
Southern
10.2
0.76
17.9%

11. Magnitude of problem across Maharashtra:
S.N.
District
No. of goiter (1000 population) 1
Ahmednagar
11.06 2
Nanded
1.42 3
Nagpur
11.72 4
Wardha
10.3 5
Nashik
15.00 6
Hingoli
12.08 7
Aurangabad
14.04

12. Estimated % of household consuming adequately iodized salt:
Country
% of household
Bhutan 95
China 93
Vietnam 77
Bangladesh 70
Indonesia 65
Nepal 63
India 50
Myanmar 48

13. Use of iodized salt in households:
NFHS II
NFHS III
>15 ppm
49.3
51.1
<15 ppm 28 25
0 ppm
22.7
23.9

14. Use of iodized salt in households: (NFHS III)r

15. PIONEER STUDY CONDUCTED IN KANGRA DISTRICT OF HIMACHAL PRADESH (1956-68)
Location: Kangra Valley, Himachal Pradesh.
Divided into 3 zones –A , B , C
Type of study: Community based
Study Period: 1956 – 1968
Outcome variable: Goiter prevalence among school age children

16. STUDY DESIGN Baseline survey in 1956 Salt distributed to three zones
Zone A : Salt + Potassium iodide
Zone B : Plain salt
Zone C : Salt + Potassium iodate
15 gms of salt/person/day
So as to ensure 200 µg of iodine/person/day

17. Prevalence of Goitre in Zone A (KI Salt)
Prevalence of Goitre in Zone B (Plain salt till 1962, then KI salt)
Prevalence of Goitre in Zone A (KIO3 Salt)

18. Kangra Valley Study Conclusion:
Iodine supplementation in the form of adequately iodized salt on a regular and continuous basis reduces goiter prevalence
Recommendation:
To establish National Goiter Control Programme.

19. National Goiter Control Programme
Launched at the end of second five year plan (1962)
Aims:
Initial survey to identify endemic areas
Production & Supply of iodized salt to endemic areas
Impact assessment surveys after five year

20. NGCP activities ( )
Goiter is a painless disorder which less liable to cause mortality.
NGCP received low priority from the view point of government as a national public health programme and also from the population
Salt Iodization plants established in public sector
Rajasthan 5
Gujrat:3
West Bengal :4
Estimated need/year
1 million tons
Production capacity/Year
0.38 million tons
Actual Production/year
0.15 million tons

21. Universal Salt Iodization: (1983)
GOI policy decision to iodize all salt meant for human consumption – Universal Salt Iodization (USI)
Private sector was permitted and encouraged to produce iodized salt
“Elimination of goiter” was included in Prime Minister’s 20-point National Development Program

22. National Salt Iodization
Decision Phase:
Enable a decision supported by mobilization of industry, setting of standards and regulation
Implementation Phase:
Ensure infrastructure for iodization and packaging of all human and livestock salt. Support with quality assurance and communications.
Consolidation Phase:
Once the goal of USI achieved, it needs to be sustained through ongoing external evolution monitoring and periodic evolution.

23. Changing Status of legislation (1968-2005):
1968: Iodized salt brought under PFA Act
1983: Policy decision taken for Universal Salt Iodization
1983: Iodized Salt brought under revised PFA Act
1997: Sale & storage of non-iodized salt banned
2000(May): GOI decided to lift ban on sale of non-iodized salt.
2000 (Sept): Ban on sale of non- iodized salt was lifted.

24. An ICMR task force study, 1989
Location: 14 districts of 9 states
Type of study: Community Based
Type of Population: Rural (all age groups, both sexes)
Study Design: Multistage random sampling
Sample Size: 4,09,923
Year of data collection:

25. PREVALENCE OF GOITRE & CRETINISM IN STUDY DISTRICTS
PERCENTAGE (%)
GOITRE
CRETINISM
Vishakhapatnam
15.8
0.2
Dibrugarh
65.8
2.2
Muzaffarpur
33.7
1.7
Sitamari
31.8
1.1
Surat
22.7
0.4
Mandla
34.4
2.1
Dhule
16.5
0.1
Central Manipur
10.4
3.0
West Manipur
19.8
6.1
Nilgiri
6.9
Baharaich
20.2
Basti
20.0
Gorakhpur
18.6
Mirzapur
6.2
0.3
TOTAL
21.1
0.7

26. National Iodine Deficiency Disorders Control Programme (NIDDCP)
Objectives and components
Surveys to assess the magnitude of the Iodine Deficiency Disorders.
Supply of iodated salt in place of common salt.
Resurvey after every 5 years to asses the extent of Iodine Deficiency Disorders and the Impact of iodated salt.
Laboratory monitoring of iodated salt and urinary Iodine excretion.
Health education. & Publicity

27. National Iodine Deficiency Disorders Control Programme (NIDDCP)
GOAL:
To reduce the prevalence of iodine deficiency disorders below 10 percent in the entire country by 2012 A.D.

28. National Iodine Deficiency Disorders Control Programme (NIDDCP)
POLICY
To iodate the entire edible salt in the country by The programme commenced in April 1986 in a phased manner
To enhance the production, demand and supply of iodated salt
banning the sale of non-iodated salt for direct human consumption in the entire country with effect from 17th May, 2006 under the Prevention of Food Adulteration Act 1954

29. National Iodine Deficiency Disorders Control Programme (NIDDCP)
Nodal Ministry: MOHFW r
IDD Cell Central Level: DGHS
STATES/UNITON TERRITORY IDD CELL
State Health Directorate

30. National Iodine Deficiency Disorders Control Programme (NIDDCP)
Achievements:
The policy regarding production of iodated salt has been liberalized, permitting production by the private sector.
The annual production of iodated salt was raised from 5 lakh MT in to lakh MT in expected to further rise to 50 lakh MT in the near future.
The Salt Commissioner, in consultation with the Ministry of Railways:-under priority category ‘B’; a priority second to that of Defence.

31. National Iodine Deficiency Disorders Control Programme (NIDDCP)
PFA, 1954: stipulate that the iodine content of salt at the production and consumption levels should be at least 30 and 15 ppm respectively.
Banning the sale of non iodated salt for direct human consumption in the country with effect from 17th May, 2006
NIDDCP has been included in the 20 Point Programme of the Prime Minister.

32. National Iodine Deficiency Disorders Control Programme (NIDDCP)
To establish an IDD Control Cell in their State Health Directorates. Presently, 31 States/UTs have established such Cells.
A National Reference Laboratory for the monitoring of IDD has been set up
Four regional IDD monitoring laboratories has been set up

33. National Iodine Deficiency Disorders Control Programme (NIDDCP)
Cash grants are also provided by the Central Government for health education and publicity campaigns to promote the consumption of iodated salt.
For ensuring quality control of iodated salt at consumption level, testing kits for ‘on the spots’ qualitative testing have been distributed

34. National Iodine Deficiency Disorders Control Programme (NIDDCP)
FINANCIAL ASSISTANCE PATTERN TO STATES/UT
Financial assistance is being provided to all the states/UTs’s in form of quarterly advance release of funds from for various components under the programme.
IDD SURVEYS
Financial assistance of Rs per district is being provided to State/UT IDD Control Cells for conducting surveys for assessing the magnitude of goiter and other IDD.

35. The stakeholders in Iodine Deficiency Disorder control Programme (IDDCP):
Elected representatives
Government ministries
Salt producers, importers and distributors
Concerned civic groups, Professional organizations
Nutrition, food and medical scientists

36. National Iodine Deficiency Disorders Control Programme (NIDDCP)
Components
Political Support:
Primarily at governmental level, through the minister of health and the executive group of government.
Administrative arrangements:
A social model for a national IDD control programme

37. National Iodine Deficiency Disorders Control Programme (NIDDCP)
Indicators of IDD assessment:
Grade 0
No palpable or visible goitre.
Grade 1
A goitre that is palpable but not visible when the neck is in the normal position,
(i.e., the thyroid is not visibly enlarged). Thyroid nodules in a thyroid which is otherwise not enlarged fall into this category
Grade 2
A swelling in the neck that is clearly visible when the neck is in a normal position
and is consistent with an enlarged thyroid when the neck is palpated

38. National Iodine Deficiency Disorders Control Programme (NIDDCP)
Indicators of IDD assessment:
Indicators goal
Proportion of households consuming adequately iodized salt
>90%
Proportion of population with urinary iodine levels below 100 μg/l
<50%
Proportion of population with urinary iodine levels below 50 μg/l
<20%

39. Five year Plans TENTH Five Year Plan (2002-2007):
Effforts to reduce price differentials between iodised & non-iodised salt
More cost effective targeting of the PDS to address macro and micronutrient deficiencies
NIDDCP FOR THE 11TH PLAN:
To bring down prevalence of IDD below 10% in the entire country by 2012 AD.
To ensure 100% consumption of adequately iodated salt (15 PPM) at the household level.

40. Why consumption of adequately iodized salt was decreased?
Government of India lifts ban on sale of Non-iodized salt
Increase in Rail Tariff – 1st April 2002
Consequently increase in movement of iodized salt by road (especially from Rajasthan)
Currently, No mechanism in place for monitoring quality of iodized salt transported by road
Disappearance of most common visible effect of iodine deficiency i.e. goiter
Perception in people that : - iodized salt consumption is NOT required anymore
Communication strategy
DID NOT focus on mental handicap as a consequence of iodine deficiency
WAS NOT commensurate with seriousness of problem both in terms of scale & frequency

41. Action to be Taken
Supply– Salt Industry Support Small scale salt producers
Potassium iodate subsidy Initial assistance for repair and maintenance of salt iodization plants
Technical & training support

42. INFORMATION, EDUCATION AND COMMUNICATION (IEC)
Radio/TV spots have been prepared and their broadcast/telecast is being carried out.
A 10 minutes video film on IDD has been prepared and is being distributed to the States.
Pamphlets have been developed for distribution to States & UTs.
Posters depicting the various facets of IDD manifestation have also been prepared.
Salt Testing Kits for the qualitative testing of iodated salt to show presence of iodine are being used for creating awareness among people, including those living in remote, rural areas and urban slums.

43. INFORMATION, EDUCATION AND COMMUNICATION (IEC)
Discouraging the production of large crystals of Bargara salt for edible use which cannot be iodated uniformly.
Sensitizing iodated salt manufacturers about their role in quality monitoring.
IEC activities have also been intensified in coordination with the Song & Drama Division, Directorate of Field Publicity DAVP Doordarshan & AIR with a view to promote the consumption of iodated salt among the masses.

44. Communication Challenges to overcome
A) Penetrate the system with key messages
B) Communication Themes

45. References:
WHO, Iodine status worldwide WHO Global Database on Iodine Deficiency, WHO:2004.
WHO, UNICEF, ICCIDD Assessment of iodine deficiency disorders and monitoring their elimination, A guide for programme managers, WHO:3 ; 2007.
Umesh Kapil. Current status of salt iodization and level of iodine nutrient in India African Journal of Pharmacy and Pharmacology Vol. 2 (3). pp , May, 2008.
Pandav CS , Yadav K,Karmarkar MG. The Success story of Iodine Deficiency in India: Science, Statesman and Society Wisdom in Hindsight; ICCIDD New Delhi, Sept 2010.
ICMR task force study preliminary analysis of report 1989.
Revised Policy Guidelines On National Iodine Deficiency Disorders Control Programme October 2006