NATIONAL IODINE NATIONAL IODINE DEFICIENCY DISORDER DEFICIENCY DISORDER CONTROL PROGRAMMECONTROL PROGRAMME

DR BAGDI , JT.DIRECTORDR BAGDI , JT.DIRECTORDR. S.D.KULKARNI , DY.DIRECTORDR. S.D.KULKARNI , DY.DIRECTOR

DIRECTORATE OF HEALTH SERVICESDIRECTORATE OF HEALTH SERVICESMUMBAIMUMBAI

Salt : Freedom

Platinum jubilee of Dandi March(12th March – 6th April 1930-2005)

• Iodine is essential dietary element-required for Iodine is essential dietary element-required for THYROID HORMONES T3, T4. THYROID HORMONES T3, T4.

• Its iodinated molecule of Es-Am-Acid Tyrosine.Its iodinated molecule of Es-Am-Acid Tyrosine.

• Iodine - essential micronutrient. Requirement - Iodine - essential micronutrient. Requirement - 100-150 microgms/day for normal human growth 100-150 microgms/day for normal human growth and development.and development.

– Thyroxin is essential for – Calorigensesis, , Thyroxin is essential for – Calorigensesis, ,

Thermoreguration, Protein SynthesisThermoreguration, Protein Synthesis

– Promotion of Nitrogen, Promotion of Nitrogen,

Retention, Glycogenolysis, intestinal Retention, Glycogenolysis, intestinal

absorption absorption of glucose , Lipolysvis , of glucose , Lipolysvis ,

Uptake of glucoseUptake of glucose

IDD Problem PyramidIDD Problem Pyramid• It's worldwide It's worldwide

major public major public health problem. health problem. Globally 1.5 Globally 1.5 billion- risk of billion- risk of Iodine deficiency Iodine deficiency disorders.disorders.

• The pyramid The pyramid shows the visible shows the visible effects of Iodine effects of Iodine Deficiency Deficiency Disorders (IDD) Disorders (IDD) Goitre and Goitre and Cretinism Cretinism account only for account only for 1--10% of 1--10% of these, these,

• Whereas 90% of Whereas 90% of the effects the effects remain hidden. remain hidden.

1%-10%

5% -30%

30% - 70%

Goitre & Cretinism

Some brain damage

Less active population due to decreased thyroid

function (hypothyroidism)

19621962Commenced Goiter control programmeCommenced Goiter control programme 1972 N I D D C P1972 N I D D C P

A) Problem is not restricted to Goiter A) Problem is not restricted to Goiter belt but extremely prevalent all belt but extremely prevalent all

over over the country. No state it is free.the country. No state it is free.b) So also Iodine deficiency is not b) So also Iodine deficiency is not limited to Goiter; Cretinism but wide limited to Goiter; Cretinism but wide

spectrum -------Deaf Mutism spectrum -------Deaf Mutism M.R.M.R.

Impairment of intellectual function.Impairment of intellectual function.54 million Goiter54 million Goiter2.2 million Cretium2.2 million Cretium

6.6 million mild neuro 6.6 million mild neuro deficiency.deficiency.

Spectrum of Iodine Spectrum of Iodine Deficiency DisordersDeficiency Disorders

•FoetusFoetus Abortion

Still births

Congenital Anomalies

Increased Perinatal Mortality

Increased Infant Mortality

Spectrum of Iodine Spectrum of Iodine Deficiency DisordersDeficiency Disorders

Neurological Cretinism

–Mental Deficiency

–Deaf Mutism

–Spastic Diplegia

–Squint

•FoetusFoetus

Spectrum of Iodine Spectrum of Iodine Deficiency DisordersDeficiency Disorders

•FoetusFoetus Myxedematolous Cretinism

– Dwarfism

– Mental Deficiency

Psychomotor defects

Spectrum of Iodine Spectrum of Iodine Deficiency DisordersDeficiency Disorders•NeonaNeona

teteNeonatal Goitre

Neonatal Hypothyroidism

Child and Adolescent

Goitre

Juvenile Hypothyroidism

Impaired Mental Function

Retarded Physical Development

Spectrum of Iodine Spectrum of Iodine Deficiency DisordersDeficiency Disorders•AdultAdult Goitre with its complications

Hypothyroidism

Impaired Mental Function

• Iodine deficiency disorders is Iodine deficiency disorders is

Public Health problem.Public Health problem.

• 200 million at risk of Iodine 200 million at risk of Iodine

deficiency disorders.deficiency disorders.

• 70 million suffer for goiter and 70 million suffer for goiter and

Iodine deficiency disorders.Iodine deficiency disorders.

Iodine DeficiencyIodine DeficiencyConsumption of crops/plants Consumption of crops/plants grown on iodine deficient soilgrown on iodine deficient soil leads leads to iodine deficiency in population.to iodine deficiency in population.Superficial layer of soil is important - Superficial layer of soil is important -

Heavy Rains Flooding DeforestationHeavy Rains Flooding DeforestationIodine RequirementIodine Requirement

0-5 yrs 10 micro g0-5 yrs 10 micro g6-12 yrs 120 micro g6-12 yrs 120 micro gabove 12 yrs 150 micro gabove 12 yrs 150 micro gPregnancy 200 micro gPregnancy 200 micro g

Effect of Iodine Effect of Iodine DeficiencyDeficiency

1) World’s single most 1) World’s single most significant cause of significant cause of preventable brain preventable brain damage and M.R. is damage and M.R. is Deficiency of Iodine.Deficiency of Iodine.

2) With every passing hour 2) With every passing hour 10 children are being 10 children are being born in our country, who born in our country, who will no attain their will no attain their optimum physical and optimum physical and mental potential due to mental potential due to iodine deficiency.iodine deficiency.

• Current Research indicates that Current Research indicates that iodine deficiency result in iodine deficiency result in lowering the average lowering the average intelligence of the entire school intelligence of the entire school age population by as much as age population by as much as 10 to 15. 12 points so 400 10 to 15. 12 points so 400 millions IQ points are missed by millions IQ points are missed by 40 million children.40 million children.

• So preventing deficiency raises So preventing deficiency raises the learning capacity of school the learning capacity of school children and improves school children and improves school performance.performance.

Iodine Deficiency Iodine Deficiency A Public Health ProblemA Public Health Problem

•Iodine deficiency Iodine deficiency in pregnant in pregnant woman may woman may cause cause miscarriages, miscarriages, stillbirths, and stillbirths, and birth defects.birth defects.

•Iodine deficiency Iodine deficiency impairs growth impairs growth and development and development of children.of children.

Iodine Deficiency Iodine Deficiency A Public Health ProblemA Public Health Problem• Children with iodine Children with iodine

deficiency may grow up deficiency may grow up stunted, less active, stunted, less active, mentally retarded with mentally retarded with impaired movements, impaired movements, speech or hearing.speech or hearing.

• Iodine deficiency also Iodine deficiency also causes goitrecauses goitre

• The majority of people in The majority of people in South-East Asia are at risk South-East Asia are at risk from iodine deficiency from iodine deficiency disorders.disorders.

Iodine deficiency disorders & Iodine deficiency disorders & HRDHRD

1)Iodine in pregnancy available to foetus.1)Iodine in pregnancy available to foetus.

Decreased synthesis of Thyroxin.Decreased synthesis of Thyroxin.

Prevents the normal development of foetal brain and bodyPrevents the normal development of foetal brain and body

Neonatal-chemical HypothyroidismNeonatal-chemical Hypothyroidism

Limits Intellectual growth Limits Intellectual growth

Fetal brain damage (irresponsible)Fetal brain damage (irresponsible)

Implications of Loss of IQImplications of Loss of IQ

• Poor scholastic performance Poor scholastic performance

Frequent failures/grade repetitions Frequent failures/grade repetitions

Absenteeism / Drop outsAbsenteeism / Drop outs

Reduced impact on economic and social Reduced impact on economic and social developmentdevelopment

Classification of GoiterClassification of Goiter

• As per World Health Organization As per World Health Organization Grade-0 No palpable or visibleGrade-0 No palpable or visible

Grade-1 Mass in the neck consistent with Grade-1 Mass in the neck consistent with enlarged thyroid enlarged thyroid

Palpable but not visible.Palpable but not visible. Moves upward in the neck as Moves upward in the neck as

the subject swallowsthe subject swallowsGrade -2 Swelling in the neck - visible Grade -2 Swelling in the neck - visible

Consistent with enlarged Consistent with enlarged thyroid when the neck is thyroid when the neck is palpated.palpated.

Iodine Deficiency Disorders prevalence & Iodine Deficiency Disorders prevalence &

criteria for classificationcriteria for classification as a significantas a significant..

IndicatorIndicator Mild Mild Mod Mod Severe Severe

Goiter Goiter Grade >0Grade >0

10-10-19.9/19.9/10001000

20-21.1 20-21.1 //10001000

> 30 /> 30 /10001000

Median Median U.I.E. U.I.E. ((microgmsmicrogms/ltr.) /ltr.)

50-9950-99 20-4920-49 < 20 < 20

Loss of IQLoss of IQImplicationsImplications

• The intelligence The intelligence Quotient (IQ) score Quotient (IQ) score of children living in of children living in an iodine-deficient an iodine-deficient environment is environment is nearly 13 IQ points nearly 13 IQ points less than those less than those living in iodine-living in iodine-sufficient sufficient environment.environment.

Survey done in last 5 years.Survey done in last 5 years.

YearYear Name of the districtName of the district

1999-1999-20002000

Kolhapur, Sangli, Parbhani, Kolhapur, Sangli, Parbhani, Osmanabad, Akola, AmravatiOsmanabad, Akola, Amravati

2000-2000-20012001

Ahmednagar, Raigad, Solapur, Ahmednagar, Raigad, Solapur, Sindhudurg, Nanded, Nagpur, Sindhudurg, Nanded, Nagpur, ChandrapurChandrapur

2001-2001-20022002

Thane, Ratnagiri, Nasik, Pune, Thane, Ratnagiri, Nasik, Pune, Aurangabad, HingoliAurangabad, Hingoli

2002-2002-20032003

Ratnagiri, Latur,Beed, Wardha, Ratnagiri, Latur,Beed, Wardha, GadchiroliGadchiroli

2003-2003-20042004

Jalgaon, Nandurbar,GondiaJalgaon, Nandurbar,Gondia

ANAGAR11.6

222

2000-2001

NAGPUR11.72

NANDED1.42

CC,

C,PUR7.29

2001-2002

NASHIK15.00 Abad

14.4 HINGOLI12.8

2002-2003

RATNAGIRI

10.89

WARDHA

10.3

GADCHIROLI

7.9

2003-2004

NADURBAR20.3

GONDOA14.2

2004-2005SATARA

3.83S,DHURG11.22

YEOTMAL10.23

2000-20012000-2001Sr.NoSr.No..

Name of Name of DistrictDistrict

Year of Year of surveysurvey

No. of No. of Goitre Goitre (1000 (1000 population)population)

11 AhmednagarAhmednagar 2000-012000-01 11.0611.06

22 NandedNanded 2000-012000-01 1.421.42

33 NagpurNagpur 2000-012000-01 11.7211.72

44 ChandrapurChandrapur 2000-012000-01 7.297.29

2001-20022001-2002

Sr.NoSr.No..

Name of Name of DistrictDistrict

Year of Year of surveysurvey

No. of No. of Goitre Goitre (1000 (1000 population)population)

11 NashikNashik 2001-2001-0202

15.0015.00

22 AurangabadAurangabad 2000-2000-0101

14.0414.04

33 HingoliHingoli 2001-2001-0202

12.0812.08

2002-20032002-2003

Sr.NoSr.No..

Name of Name of DistrictDistrict

Year of Year of surveysurvey

No. of No. of Goitre Goitre (1000 (1000 population)population)

11 RatnagiriRatnagiri 2002-2002-0303

10.8910.89

22 WardhaWardha 2002-2002-0303

10.0310.03

33 GadchiroliGadchiroli 2002-2002-0303

7.097.09

2003-20042003-2004

Sr.NoSr.No..

Name of Name of DistrictDistrict

Year of Year of surveysurvey

No. of No. of Goitre Goitre (1000 (1000 population)population)

11 NandurbarNandurbar 2003-2003-0404

20.0320.03

22 GondiaGondia 2003-2003-0404

14.0214.02

2004--20052004--2005

SR.NO.SR.NO. DISTRICTDISTRICT NO.OF NO.OF GOITRE/1000 GOITRE/1000 POPULATIONPOPULATION

11 SATARASATARA 3.833.83

22 SINDHUDURGSINDHUDURG 11.2211.22

33 YEOTMALYEOTMAL 10.2310.23

LABORATORY EXAMINATION OF LABORATORY EXAMINATION OF SALT SAMPLES SALT SAMPLES

YearYear SamplesSamples Below Below

15 Ppm15 PpmNil Nil Iodine Iodine ContentContent

% Of % Of Sub-Sub-standarstandard d SamplesSamples

2002--2002--0303

53945394 16321632 560560 40.6440.64

2003--2003--0404

44234423 14761476 128128 36.2636.26

2004--2004--0505

73197319 22212221 159159 32.5132.51

URINARY-IODINE ESTIMATIONURINARY-IODINE ESTIMATION PUB.HEALTH LAB. PUB.HEALTH LAB.

Year Total Samples 50-99 microgms 20-50 Below 20

2002 1084 170 68 118

2003 1241 383 102 24

20042005

1725 777

21285

4541

2627

IODISED SALT&P.F.A. IODISED SALT&P.F.A. ACT/RULESACT/RULES

• Essential Food item under provisions of Essential Food item under provisions of A.15.01 OF APPENDIX B OF Prevention of A.15.01 OF APPENDIX B OF Prevention of food Adulteration (PFA) Rules 1954food Adulteration (PFA) Rules 1954

• Food Inspectors –empowered to prosecute Food Inspectors –empowered to prosecute for sub-standard iodised saltfor sub-standard iodised salt

• Imprisonment not less than 6 months---Imprisonment not less than 6 months---3yrs3yrs

• FINE not less than rs.1000/FINE not less than rs.1000/

• notificationnotification

Burden Of I.D.D. IN INDIA& CHINA

CountrCountryy

Newborns Unprotected in Newborns Unprotected in millions(%) per yearmillions(%) per year

IndiaIndia 13.0(50%)13.0(50%)

ChinaChina 1.3(7%)1.3(7%)

Estimated % of huseholds consuming adequately iodised

salt:95 93

77 74 7065 63

50 48

BhutanChinaVietnamThailandBangladeshIndonesiaNepalIndiaMyanmar

Cost of Iodine for Salt Iodisation

Total annual requirement of iodised Total annual requirement of iodised salt in India for 1,000 million salt in India for 1,000 million population @ 5kg / person/ yearpopulation @ 5kg / person/ year

5 million tons5 million tons

Iodine required for Salt iodisation Iodine required for Salt iodisation @30ppm (30gm/ton)@30ppm (30gm/ton)

150,000kg150,000kg

(150 tons)(150 tons)

Price of iodine @Rs. 750/kg Price of iodine @Rs. 750/kg

Therefore total price for 150 tonsTherefore total price for 150 tonsRs. 11.25 Rs. 11.25 millionmillion

Cost of iodine/ person/yearCost of iodine/ person/year 11.25 paisa11.25 paisa

* Cost benefit ratio 1:10

Consumption of adquately iodised salt according to SE status in India (NFHS-II, 1998-99)

3650

7864

50

22

Adquate 36 50 78

Inadquate 64 50 22

Low SES Medium High SES

Supply (Push) - Government

• Effforts to reduce price differentials between iodised & non-iodised salt

• More cost effective targeting of the PDS to address macro and micronutrient deficiencies

… Iodised Salt

TENTHFive Year Plan(2002-2007)

Volume IISectoral Policies and Programmes

NUTRITION

PLANNING COMMISSIONGOVERNMENT OF INDIA, NEW DELHI

Actions expected fromActions expected from PUBLIC HEALTH EXPERTS PUBLIC HEALTH EXPERTS

• 1) Adequate samples-- 40 salt sample/ per 1) Adequate samples-- 40 salt sample/ per month.month.

• 2) Move the office of the Jt. 2) Move the office of the Jt. Commissioner/Asst. Commissioner FDA for Commissioner/Asst. Commissioner FDA for penal Action as per provision as per Act.penal Action as per provision as per Act.

• 3) Awareness in society about Iodine 3) Awareness in society about Iodine deficiency disorders by deficiency disorders by

• Newspaper write upNewspaper write up• WorkshopWorkshop• Advocacy in review meeting Advocacy in review meeting • Review of the progress in monthly meeting.Review of the progress in monthly meeting.• Mahila Melava Mahila Melava