IDD prevention program in Bulgaria-IDD prevention program in Bulgaria-Progress of Universal Salt IodizationProgress of Universal Salt Iodization

Ludmila Ivanova, MD, PhDSofia, Bulgaria

The main purpose of the presentationThe main purpose of the presentation

To share Bulgarian experience in USI as most effective strategy for sustainable

Elimination of IDD

Iodine deficiency – an age old problem Iodine deficiency – an age old problem Bulgarian icons with goiterBulgarian icons with goiter

Bulgaria is a country with 1/3 of the territory being Bulgaria is a country with 1/3 of the territory being

endemicendemic

For the first time a Regulation on IDD prevention was introduced in 1958

The strategies were focused on endemic regions only.

Salt iodization and iodine supplementation with tablets

of target groups (children, pregnant women) was

implemented

The outcome was reduction of goiter from 55.9% to

12.1% in the following 15 years.

In 1994 the new Legislation was introduced based on:In 1994 the new Legislation was introduced based on:

Lessons learned by the previous National Regulation – lack of sustainability

Focused on endemic regions only Irregular production and distribution of iodine tablets High costs and low coverage rate of iodine tablets Lack of intersectorial co-operation

IDD situation in Bulgaria – increased incidence of goiter International Recommendations – Universal salt iodization

(ICCIDD/UNICEF/WHO)

National Legislation on IDD ControlNational Legislation on IDD Control

Government Decree 96/17.05.1994 of the Council of Ministers (State Gazette 43/27.05.1994)

Order N RD-09-244/14.06.1994. of the Chief State Sanitary Inspector of the Republic of Bulgaria (State Gazette 52/26.06.1994)

Amendment N 7/01.07.1996 to Bulgarian State Standard 628-77 “Table salt”

Ordinance for Requirements to the composition and characteristics of food grade salt (State Gazette 11/06.02.12001)

Government Decree 96/17.05.1994 was developed to set Government Decree 96/17.05.1994 was developed to set the foundational of the IDD Elimination Program the foundational of the IDD Elimination Program Main Principles/Activities

Universal salt iodization covering all salt for human consumption, food industry and cattle breeding

Short term additional prophylaxis of risk groups-(schoolchildren and pregnant women) in the “endemic regions” with iodine tablets for the first 2 years of the program ( high goiter grade over 30% )

Trade policy stimulating the import of iodized table salt

Establishment of National Monitoring System-capacity building, training ect.

National Program for Control of IDD - Multisectoral National Program for Control of IDD - Multisectoral EffortsEfforts

Institutional support / Intersectoral Co-ordination

National Coordinating Committee for IDD Control

(MOH,- Industry, -Trade, Salt Producers, Finances,

Agriculture, Committee of Standardization,

Thyroidologists, Nutritionists, NGO,s) Expert Council on IDD at Ministry of Health

Order N RD-09-244/14.06.1994. of the Chief State Order N RD-09-244/14.06.1994. of the Chief State

Sanitary Inspector of the Republic of BulgariaSanitary Inspector of the Republic of Bulgaria

Prohibition of placing non-iodized table salt at the market

Definition of a system and methods for control of the quality of iodized salt

Creation of a database for recording results of iodized salt at the market through the Ministry of Health

Amendment N 7/01.07.1996 to Bulgarian State Standard Amendment N 7/01.07.1996 to Bulgarian State Standard 628-77 “Table salt”628-77 “Table salt”

Salt iodization with potassium iodate at level 28-55 ppm KJO3 (16.6-32 ppm I).

Ordinance for Requirements to the composition and Ordinance for Requirements to the composition and characteristics of food grade salt characteristics of food grade salt (State Gazette 11/06.02.2001)(State Gazette 11/06.02.2001)

Definition “For food purposes only salt iodized with KJO3 at level 28-55 ppm must be used;

Expiry time, not longer than 12 months after iodization

Specification of storage condition (clean, closed and dry rooms)

Specification of Package material Labeling (Ordinance for food labeling, Decree

136/2000(SG, 62/2000)

Requirements to Laboratory control

Sampling procedure (Ordinance 2/1997, SG

10/97) Methods-Bulgarian State Standard methods-

8840-71, BSS 2/92),

Ordinance for Requirements to the composition and Ordinance for Requirements to the composition and characteristics of food grade salt characteristics of food grade salt (State Gazette 11/06.02.2001)(State Gazette 11/06.02.2001)

As a result of effective implementation of enacted As a result of effective implementation of enacted legislationlegislation

First National Survey on IDD Situation in Bulgaria two years after implementation

universal salt iodization

1996

Optimistic resultsOptimistic results

Based on the Results of the National survey the strategies Based on the Results of the National survey the strategies

were revisedwere revised

The supplementation with tablets was discontinued because High cost taken by the budget of MOH –

3 USD/capita/per year Relatively low coverage rate (50%) - distribution

problems Low actual usage Perception by population as a drug Concern of side effect by health specialists

Based on the Results of the National survey the strategies Based on the Results of the National survey the strategies were revisedwere revised

Universal salt iodization was recognized as the only strategy for control of IDD in Bulgaria Low cost covered by Producers/consumers

1.25 USD/capita/year for iodized salt

Universal coverage rate No risk of toxicity/overdosing Perception by people as “ food” Health specialists are aware of long-term

consequences of Iodine Deficiency (TSH congenital screening) and need of prevention, not treatment

Second National Survey on IDDSecond National Survey on IDD Situation in Situation in Bulgaria after implementation universal Bulgaria after implementation universal

salt iodizationsalt iodization

spring 2003spring 2003

National Survey on IDD Situation in Bulgaria - Spring National Survey on IDD Situation in Bulgaria - Spring 2003-Results based on USI2003-Results based on USI

Indicators Salt iodization

Prevalence (%)

Proportion of households using adequately iodized salt, 28-55 ppm KJO3 ( Bulgarian State Standard) Iodine over 15 ppm

86.2

97.8

Proportion of households using iodized salt below 28 ppm KJO3

Proportion of households using iodized salt below 15 ppm J

4.2

2.2

Proportion of households using iodized salt above 55 ppm KJO3

9.6

Box plot of results from salt analyses from household Box plot of results from salt analyses from household survey conducted in 2003 in ten regions of Bulgariasurvey conducted in 2003 in ten regions of Bulgaria

 

1 2 3 4 5 6 7 8 9 10

region HEI

20

40

60

80

Results of salt monitoring at market levelResults of salt monitoring at market level in the period in the period 1996-20031996-2003

LABORATORY RESULTS OF IODIZED SALT SAMPLES BY TYPE OF THE REGIONS FOR THE PERIOD 1995-

2003

0

10

20

30

40

50

60

70

80

90

100

1995 1996 1997 1998 1999 2000 2001 2002 2003

BG ER PER NER

National Survey on iodine nutrition of schoolchildren, National Survey on iodine nutrition of schoolchildren, aged 6-11 years, Spring 2003aged 6-11 years, Spring 2003

Urinary iodine (ioduria)

Median (mg/L) 198.0

Proportion below 100 mg/L 6.9 %

Proportion below 50 mg/L 0.8 %

National Survey on IDD Situation in Bulgaria -Spring National Survey on IDD Situation in Bulgaria -Spring 20032003

Goiter grade (ultrasonography)

Proportion above P97 (WHO, 1997) 4.3%

Comparison of individual values of ioduria from two Comparison of individual values of ioduria from two

National surveys of shshoolchildren 1996 – 2003National surveys of shshoolchildren 1996 – 2003

0

10

20

30

40

50

60

70

80

брой л

ица

50 90 130 170 210 250 290 330 370 410 450

йодурия (mcg/l)

Разпределение на индивидуалните стойности на йодурия при деца 6-14 години след въвеждане на йодната профилактика в

България

0

10

20

30

40

50

60

70

80

брой л

ица

50 90 130 170 210 250 290 330 370 410 450

йодурия (mcg/l)

Разпределение на индивидуалните стойности на йодурия при деца 6-14 години след въвеждане на йодната профилактика в

България

Разпределение на индивидуалните стойности на йодурия при деца 7-11 години, Национално

проучване 2003 година

0

10

20

30

40

50

60

70

80

10 50 70 90110130150170190210230250270290310330350370390410430450500550700

бр

ой

ли

ца

Distribution of individual values of ioduria from two Distribution of individual values of ioduria from two National surveys of schoolchildren 1996 – 2003 according National surveys of schoolchildren 1996 – 2003 according

the the ICCIDD/UNICEF/WHO criteriaICCIDD/UNICEF/WHO criteria

42.2

9.56.9

0.8

0

5

10

15

20

25

30

35

40

45

< 100 < 50

19962003

Ioduria of pregnant women, National survey 2003Ioduria of pregnant women, National survey 2003

Total group 355Age ( years)

26 (21-31)Median ioduria (mcg/L)

165Minimum (mcg/L) 40Maximum (mcg/L)

6000.8

15.2

72.4

11.5

0

10

20

30

40

50

60

70

80

<50 <100 100-300 300

Percentile distribution (PPercentile distribution (P2525, P, P5050,P,P7575) of ioduria from ) of ioduria from

schoolchildren for the period 1994-2003schoolchildren for the period 1994-2003

72.4

102.25

149.7

65.4

111.4

146

101.9

158

218

260

38.5

198

0

50

100

150

200

250

300

1994 1996 2001 2003

Iodur

ia m

cg/L

ААassessment/Monitoring/Evaluationassessment/Monitoring/Evaluation

Monitoring plan of IDD status

Indicators Proportion of adequately iodized salt at the Proportion of adequately iodized salt at the

market market Annual plan prepared by the MOH Sampling – monthly-Hygiene Inspectorates, Analyses – HEI Laboratories Reporting-every three months to MOH

Assessment/Monitoring/Evaluation

Biological monitoring Ioduria/biomarker of intakeIoduria/biomarker of intake

Nat. surveys – school aged children/every 5 years

Total Goiter RateTotal Goiter Rate: palpation; ultrasound

Neonatal TSH program screeningNeonatal TSH program screening (separate)

Conclusions

The iodine nutrition of the Bulgarian population was substantially improved after the implementation of universal salt iodination in 1994

The legislation and the establishment of effective monitoring system builds up an fundamental of the National IDD Elimination Program

Bulgaria is already achieving the final goal – elimination of IDD trough the most cost effective and adequate strategy Universal Salt Iodization

Thank you