1. Assessment and perspectives of the iodized salt program in Lao PDR Universal Iodized salt program in Lao PDR: current situation, development and perspectives 25 – 26 JUNE 2015 Bounthom PHENGDY Director of Nutrition Center, Department of Hygiene and Health Promotion Ministry of Health

2. Outline of the presentation  Background of the IDD in Lao PDR : Evidence based data of IDD and salt consumption by HH  National Health Survey, 2000  School Survey, 2005  MICs III, 2006  School Survey, 2014  Indicators for program achievement  Some recommendations for future direction on IDD eradication

3. Background zIDD was identified as main public health problem since 1993 yEvidence showed: Π95% of school age children 6- to 12 years old had urine iodine excretion < 100 mcg/l Π65% had urine iodine excretion < 60mcg/l

4. Background zIn 1995, then the Universal Salt iodization (USI) program was announced and implemented under the PM decree number 42

5.  After five year of USI was implemented, the NHS2000 showed  Mean urine iodine excretion among school children was 155.30mcg/l and  only 27% had urine iodine excretion < 100mcg/l (68%drop from 1993)  Coverage of adequate Iodized salt at household level was 76%  9% of school children were identified as goiter grade 1-+2 Progress of USI

6.  In 2005, the school based survey was conducted nation wide And MICS survey also provided data on its coverage, 2006 Can IDD eradicate in LAO PDR?

7. National coverage of iodized salt at household level: School based survey 2005 Average coverage 85% iodized salt consumption nation wide Vietnam Thailand Myanmar China Cambodia Source: Recently School Based Survey 2005 by MOH, MOEH < 70% 70 – 90% > 90% Missing data

8. Salt iodization (MICS 2006) 83.8% 58.3% 87.2% Mics and Nutrition survey 2006

9. zSince 2005, Eradication of IDD from this country was discussed and planned z…However,

10. Survey in the target 5 provinces in 2008

11. In the year 2008: ©ë ®÷­«ö´ Á²¤©ó ¹ö¸Îɾ²½Á­¡¦‰¤À¦ó´¦÷¢½²¾® ¡ö´º½­¾Ä´Œ¡ñ­²½¨¾©, ¡½§¸¤¦¾ê¾ì½­½¦÷¡ Xiengkhouang province

12. ©ë ®÷­«ö´ Á²¤©ó ¹ö¸Îɾ²½Á­¡¦‰¤À¦ó´¦÷¢½²¾® ¡ö´º½­¾Ä´Œ¡ñ­²½¨¾©, ¡½§¸¤¦¾ê¾ì½­½¦÷¡ Houaphanh Province 2008

13. Sources of salt (XiengKuang province, 2008) 37% 62.7% 0.3%

14. Sources of salt (Huaphanh province, 2008) 53.5% 42% 4.5%

15. Sources of salt Phongsaly province, 2008 40.8% 18.4%

16. Sources of salt Khammouane province, 2008 60.7% 33.3% 4.1% 1.6%

17. Soures of salt Attapeu province, 2008 92.4% 6.7% 0.8%

18. Salt producer, 2008 48% 23.5% 7.7% 4.1% 4.4%

19. Quality of salt testing by WYD test 2008 42.2% 55.2% 2.2%0.4%

20. Getting to Zero of the IDD: Challenges for Lao PDR School Survey 2013-2014

21. 2013-2014 School survey zThe median urinary iodine concentration (UIC) =103 µg/L(95% CI 96-114) z89.1% of the salt was “iodized” based on RTK tests (compared to 85% in 2005 and 79.5% in 2011-12), zOnly 37% of the salt samples had actually a measured iodine level >15 mg/kg (compared to 68.3% in 2005). zCompared to the results of the 2006 NNS (median UIC was 205.4 µg/L), the median UIC nationwide has decreased by almost 2 times from optimal to borderline due to suspension of iodized salt production.

22. zThe underlying causes for the failing, or poorly executed, salt iodization strategy in Lao PDR were the lack or temporary shortage of essential supplies (potassium iodate and/or WYD solutions) zThis was combined with temporary weakened official enforcement and oversight and led to failures in the salt factory’s commitments to continually adhere to the national USI mandate. Challenges, and Why?

23. zTo secure the potassium iodate supply, consolidate all the required supplies for USI though a newly established Lao USI Secretariat/PIRF, zEfforts to ensure QA measurements and required reporting in all salt factories zCreation of a central QA data analysis and information capacity. What to do next?

24. 10 Indicators to measure Progress for USI program achievement 1. Iodized salt coverage > 90% Urine iodine excretion Œ < 50% Urine iodine excretion <100 mcg/l Œ < 20% Urine iodine excretion < 50 mcg/l É Quality of salt with adequate iodine (90%): Œ HH level 20Œ40 ppm, Œ Factory level 40Œ60 ppm 2. Existing of National Committee from multi-sectors for IDD eradication 3. Existing clear policy and strategy for USI and IDD eradication 4. Existing Committee secretariat for IDD eradication 5. Existing regulations on control and management of IDD, Existing regular monitoring system for the progress of the USI with good laboratory for testing iodine in salt and urinary iodine excretion

25. 10 Indicators to measure Progress for USI program achievement (continue) 6. Existing IEC program for the community on IDD and iodized salt consumption 7. Existing regular data on iodine at factory level, household level, and retail shop 8. Existing data from laboratory regularly on urinary iodine excretion for school children with focus on high risk areas 9. Existing good collaboration among salt producers in management and quality control 10. Existing data collection and record system with regular monitoring

26. Some recommendations for future direction on IDD eradication to Concerned bodies zControl measurement/enforcement to monitor factory salt production and imported salt from neighboring countries ySalt for human and animal consumption should fortified with iodine yControl check point at the border for imported salt and allow only salt with adequate iodine level xTest kit should be available at Control check point

27. Some recommendations for future direction on IDD eradication  To salt factory  Quality Control at factory level on salt production with adequate iodine yRegular improvement internal and external production system zTo Community yEducating community to understand the importance of IDD and the use of salt iodization for IDD prevention yEducated community on how to store and use iodine salt properly

28. There is a need for multi- sectoral collaboration to work together MOH, MOIC, MOE, Mass organization

29. Conclusion Iodized salt Status in Lao PDR 84 79 89 58 37 percent

30. Where we are in the Region? Unicef: Sustainable Elimination of Iodine Deficiency

31. Where we are in the Region? Unicef: Sustainable Elimination of Iodine Deficiency koreaPhillipineMyanmaNepal CambodiaIndonesiaLao PDRChinaThailandVietnam New data 2012 for Thailand

32. Thank you for your kind attention