1. TURKEY IODINE DEFICIENCY DISORDERS AND SALT IODISATION PROGRAMME

2. SITUATION IODINE DEFICIENCY DISORDERS TURKEY

3. TOTAL THYROID HYPERPLASIA % 30.5 (When it is evaluated with all grades) 2. GRADE PREVALANCE% 4.3 3. GRADE PREVALANCE% 1.8 4. GRADE PREVALANCE% 0.5 BIG GOITRE PREVALANCE % 2.4 (TOTAL OF 3. VE 4. LEVELS) THYROID NODULE PREVALANCE % 2.8  Prof. Urgancıoğlu, Hatemi and his friends 1980 - 1987 WHO indicators, 73.757 persons IDD SITUATION: IDD SITUATION: ENDEMIC GOITRE IN TURKEY ENDEMIC GOITRE IN TURKEY

4. SCREENED REGIONS (1997-1999 ) (1997-1999 )

5. IODINE SITUATION AND GOITRE PREVALANCE OF SCHOOL AGED CHILDREN IN HIGH RISK PROVINCES 1997-1999 RESULTS: GOITRE PREVALENCE FOR CHILDREN IS % 31.8 30% AND HIGHER PROVINCES ARE; KASTAMONU, BAYBURT, TRABZON, ERZURUM MALATYA, SAMSUN, EDİRNE, AYDIN, KAYSERI THROUGH THE URINARY IODINE MEASUREMENTS : 14 PROVINCES ARE MIDDLE/HIGH, 6 PROVINCES HAVE LOW LEVEL OF IODINE DEFICIENCIES.

6. Burdur ÇorumBolu IODINE DEFICIENCIES WITH SONOGRAPHIC PREVALANCE PROVINCES AT RISK 1997-1999 HIGH (9), MIDDLE (4), LOW(7) 5-19.9 % Low level 20-29.9 % Middle level 30 % + High level

7. IODINE SITUATION AND GOITRE PREVALANCE IN 20 PROVINCES SCHOOL AGED CHILDREN RESULTS: GOITRE PREVELANCE OF SCHOOL CHILDREN IN 20 PROVINCES IS 31.8 %. WITH GOITRE PREVALANCE; THERE ARE 9 PROVINCES HIGHER THAN 30% ( KASTAMONU, BAYBURT, TRABZON, ERZURUM MALATYA, SAMSUN, EDİRNE, AYDIN VE KAYSERI)

8. ÇorumBolu HIGH (3), MIDDLE(11), LOW(6) Burdur IODINE DEFICIENCIES WITH URINARY IODINE MEASUREMENTS PROVINCES AT RISK 1997- 1999 50-100 mcg/lt Low level 20-49 mcg/lt Middle level 0-19 mcg/lt High level

9. LEGISLATION SITUATION TURKISH FOOD CODEX TABLE SALT CIRCULAR (09 JULY 1998 NUMBER: 23397 ) EDIBLE SALT EDIBLE SALT A) Table salt (directly goes to consumers, fortified with iodine, refined or unrefined edible salt ) B) Salt used in food Industry ****INTO TABLE SALTS 50-70 mg/kg. POTASSIUM IODIDE 25-40 mg/kg. POTASSIUM IODATE MUST BE ADDED. SALT USED IN FOOD INDUSTRY NEED NOT BE FORTIFIED

10. IODISED SALT HOUSEHOLD CONSUMPTION RATES BY REGIONS-1995 18.6 16.5 18.3 23.6 15.6 URBAN:23.6 RURAL: 9.6 AVERAGE: 18.2

11. IODISED SALT CONSUMPTION SURVEY 2002

12. URBAN/VILLAGE Iodised Salt Consumption -2002 ( % )

13. %80-9620 PROVINCE %60-7818 PROVINCE %50-5913 PROVINCE %35-4913 İL %0-3114 PROVINCE IODISED SALT CONSUMPTION IN PROVINCES- 2002 Siirt0 Kırşehir5.7 Hakkari8 Batman12

14. IODISED SALT CONSUMPTION OF HOUSEHOLDS BY REGIONS-2002

17. Urinary Iodine Level in Kapuzbaşı Village -2002 (6 – 15 Years old 91 children) İyotlu tuz kullanımından önceİyotlu tuz kullanımından sonra

18. PROBLEMS n 1-High prevalance rate of iodine deficiency disorders -total goiter rate: 30,5% (1987) -total goiter rate: 30,5% (1987) -school children goiter rate: 31,8 % (at risk provinces, 1997-1999 ) -school children goiter rate: 31,8 % (at risk provinces, 1997-1999 ) n 2-- While consumption of iodised salt have been increasing still a sizeable segment of population is not using iodised salt due to lack of awareness of the population n 3- High number of small producers of non iodized salt (around 200) n 4- Difference between the prices of iodized and non iodized salt for food industry

19. TURKEY IODINE DEFICIENCY DISORDERS AND SALT IODISATION PROGRAMME

20. ELIMINATION OF IDD IN TURKEY GOAL OF THE PROGRAMME

21. MPO OBJECTIVES   Elimination of IDD of children until 2005   Reduction of IDD of adults 1/3 until 2005   To iodise 100% of table salt in the country   Raise3 awareness of all related organizations, salt producersand the community on the importance of iodisied salt   To establish effective monitoring and evaluation system for the whole programme in Turkey

22. IMPLEMENTATION ON 1994-2002 1. TRAINING 2. ON LEGISLATION 3.WITH SALT PRODUCERS ON HOW TO IODISE THE SALT 4.DEVELOPMENT OF MATERIALS 5-MONITORING AND EVALUATION

23.   FOR HEALTH PERSONNEL ( 81 PROVINCES)  FOR MINISTRY OF AGRICULTURE PERSONNEL  FOR MINISTRY OF AGRICULTURE PERSONNEL (81 PROVINCES)   SALT PRODUCERS (220 FACTORIES)   MARKET REPRESENTATIVES   NGOS   MUNICIPALITIES   PROVINCIAL DIRECTORS   UNIVERSITIES 1. TRAINING ACTIVITIES

24. n n Providing iodisation machines and on the job training for usage, n n Providing Potasium Iodate to the producers, n n Training of salt producers on how to produce iodised salt, 1994 4 Firma 2001 15 Firma (KI) 7 Firma (KIO3) 7 Firma (KIO3) 3. ACTIVITIES WITH SALT PRODUCERS FOR SALT IODISATION IMPLEMENTATION

25. 4. DEVELOPMENT OF MATERIALS n n For health personnel and community n n Audio and visual materials training materials developed

26. A. MONITORING OF IODISATION LEVEL IN SALT B. MONITORING IODISATION IN URINARY LEVEL OF THE PEOPLE C. CHECKINGS AT THE FIELD LEVEL NATIONAL MONITORING LEVELS OF THE PROGRAMME

27. A ) MONITORING OF IODISATION LEVEL IN THE SALT 1.QUALITATIVE (WITH TEST KITS (KIO3 and KI)) 2.QUANTITATIVE ANALYSIS (IN THE LABAROTORIES PRODUCTION STAGE 81 PROVINCIAL PUBLIC HEALTH LABORATORIES 1 REFİK SAYDAM GENERAL HYGIENE CENTRAL ADMIN. 7 REGION R.S. 8 REGION R.S. MINISTRY OF HEALTH MINISTRY OF AGRICULTURE 38 PROVINCIAL AGRICULTURE LABORATORIES FROM PRODCUTION TO CONSUMPTION WHO IS RESPONSIBLE FROM WHICH MONITORING ? RANDOM ANALYSIS IN 3. MONTH

28. B) IODINE CONSUMPTION LEVEL IN URINARY LEVEL OF PERSONS WITH SURVEYS; 1.A) Goitre prevelance surveys, B) Iodine level in urinary, C) Neonatal – TSH, 2. HOUSEHOLD IODISED SALT CONSUMPTION ( Cluster survey )

30. PRODUCTION OF IODISED AND NON-IODISED SALT SITUATION ( Kg.) -171.000.0002001 -85.128.0002000 35.943.19862.104.8931999 73.872.43223.751.7021998 83.970.86120.773.5271997 NON- IODISED IODISED SALT YEARS 22 ÜRETİCİDEN ALINAN VERİLER

31. OBJECTIVES n n To encourge and support the small salt producers in all regions to produce iodised salt in order to expand the consumption of iodised table salt in rural areas; n n To ensure the use of potassium iodate instead of iodide in iodised salts at the national level in order to introduce a standard in quality as well as monitoring; n n To establish quality control laboratories, fully equipped with the necessary tools and trained personnel, that can conduct iodine analysis in the 22 centres identified for the purposes of monitoring- assessment activities on the national scale by the end of 2001; n n To promote nationwide use of iodised salt through community leaders, mass media, schools, the military, community groups etc; n n To ensure that the consumption of iodised salt reaches 95% by the year 2005. n n To conduct cross-sectional surveys within the framework of monitoring activities with the aim of providing guidance for the programme activities.

32. STRATEGİES n Increase demand for iodized salt in the community through innovative approaches in advocacy and social marketing n Strengthen collaboration with the school system as channel for promotion of iodized salt n Intensify support to salt producers

33. THE PROGRAMME ACTIVITIES TRAINING: – Health Personnel (Health Managers of 81 Provinces ) – Representatives of Provincial Agriculture Directors – Salt Producers – Market representatives, teachers –Production of training materials ADVOCACY AND SOCIAL MOBILIZATION : Through the school system: - Training of teacher trainers, students -Development and production of education material -Training of Community leaders, military, media etc.

34. THE PROGRAMME ACTIVITIES IODISATION OF SALT: –On the job training of salt producers –Legislation change –Ttechnical material support –Potassium iodate support MONITORING AND EVALUATION: MONITORING AND EVALUATION: –Situation Analysis, Household consumption and School based surveys –Establishment of monitoring system –Annual Evaluation meetings