1. IDD Elimination: Global and Regional Achievements
Achieving Universal Salt Iodisation for Optimal Iodine Nutrition
UNICEF, IGN, GAIN, MI EAP Regional Meeting
12-14 October, Bangkok
#commit2USI
IDD Elimination: Global and Regional Achievements
Christiane Rudert
Regional Nutrition Advisor, UNICEF EAPRO

2. Global achievements: household iodised salt coverage
Some experts believe universal salt iodization may be the most successful public health effort of the past two decades, in which enormous strides have been made.
However, progress has stalled in recent years
75% Globally
 <20%
 20-49%
 50-69%
 70-89%
 ≥ 90%
 Data not presented as most recent estimate is not in accordance to the standard definition and earlier data <2009
 no data
Source: UNICEF Database, 2015

3. An estimated 35 million newborns were at risk of iodine deficiency disorders in 2013
Damage related to iodine deficiency greatest and irreversible in the growing fetus.
Protecting pregnant women priority. Unfortunatley, still some 35 million newborns are born every year unprotected against IDD
Coverage of adequately iodized salt has plateaued–and fallen in some countries
A new sense of urgency, opportunity, and vigor around iodine needs to be created

4. Decline in the number of iodine deficient countries
Ref: Iodine Global Network
EAP Regional Workshop on
ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

5. Estimated median UIC 1993 (μg/L)
113 COUNTRIES IODINE DEFICIENT IN 1993
Country
by region
AFRO
AMRO
EMRO
EURO
SEARO
WPRO
The size of the bubbles = population of each country,
The color of the bubbles six WHO regions.
The number of countries for which data are available has increased over this same time period from 121 to 155, further demonstrating the impact.
Goiter rate 1993 (%)
Estimated median UIC 1993 (μg/L)

6. Estimated goiter rate 2015 (%)
25 COUNTRIES IODINE DEFICIENT IN 2015
Country
by region
AFRO
AMRO
EMRO
EURO
SEARO
WPRO
Global focus is now on sustaining the achievements while accelerating efforts to improve the iodine status in these 25 countries. As such, we are on the verge of a major public health success.
Estimated goiter rate 2015 (%)
Median UIC 2015 (μg/L)

7. Regional achievements: household iodised salt coverage by region 2008-2012
Ref: UNICEF State of the Worlds Children 2015
EAP Regional Workshop on
ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

8. Household iodized salt coverage
Inequities between the richest and poorest quintiles in consumption of iodized salt are evident in about two Thirds of countries
Coverage lowest quintile <<
Coverage highest quintile
Coverage lowest quintile=
Coverage highest quintile
data for 44 countries: the richest quintile was at least twice as likely as the poorest quintile to consume adequately iodized salt (red circles). In another third of countries, the rich were more likely to consume iodized salt.
However, over one third of countries showed that the richest and poorest 20 per cent of the population were roughly equal in terms of their consumption of  iodized salt (the green circles) The data also show that countries with higher overall coverage (circles in the top right quadrant) tend to have more equitable distribution of coverage.
Household iodized salt coverage
Highest quintile
Household iodized salt coverage
Lowest quintile

9. Regional achievements: household iodised salt coverage
Ref: National surveys such as DHS, MICS, Living Standards, National Nutrition or IDD. Surveys assessing adequately of iodine with a quantitative methodology, such as titration, shown with an asterix *
EAP Regional Workshop on
ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

10. Iodine status in the region (median urinary iodine)
SAC WRA PW

11. Regional achievements: china case study
China achieved IDD elimination in 2005:
HH iodised salt coverage >95% and adequately iodised salt coverage >90%
Elimination of goitre (<5%)
Adequate iodine status in school age children
Also achieved IDD elimination in 28 out of 31 provinces
Facilitating factors:
High political commitment
Mandatory legislation
State-owned salt monopoly
Surveillance and evaluation system
EAP Regional Workshop on
ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

12. However back-sliding in some countries……. Cambodia
Preliminary DHS/Micronutrient Survey 2014 results: urinary iodine status is inadequate
Ref: 2008 CSIN, 2011 CSIN, 2014 Market Monitoring (WYD).

13. What happened in Cambodia?
No external regulatory monitoring and enforcement of national legislation
End of UNICEF subsidy of KIO3 and rise in price following Fukoshima
Industry did not maintain its commitment to take over purchase of KIO3
EAP Regional Workshop on
ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

14. However back-sliding in some countries……. myanmar
Ref: Availability of Iodised Salt at HH Level in Myanmar 2011: Report of a School Based Survey 2011
EAP Regional Workshop on
ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

15. However back-sliding in some countries……
However back-sliding in some countries……. Vietnam – household use of iodised salt
Ref: National IDD Surveys and Multiple Cluster Indicator Survey in 2011
EAP Regional Workshop on
ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

16. However back-sliding in some countries……
However back-sliding in some countries……. Vietnam – urinary iodine of women
Optimal range for UIC of reproductive age women
Ref: Report on IDD Survey 2008/9, HoE

17. And little/no progress in others…….. indonesia
Ref: Riskesdas 2007 and Non-iodized: <5ppm iodine; Inadequately iodized: iodine; Adequately iodised: ≥15ppm iodine.

18. And little/no progress in others…….. Philippines
EAP Regional Workshop on
ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

19. Philippines: inequity in iodine status
EAP Regional Workshop on
ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

20. Global Nutridash performance score for USI (2013/2014)
Policy environment – existence of legislation and scope of legislation
National ownership and programme governance
Communication
Monitoring and evaluation and quality assurance
Total programme performance score
Policy environment : which types of salt is iodization mandatory under the law; whether regulations are in line with the law; integration of USI in national policies, plans and budgets; and inclusion of iodized salt in national food standards.
National ownership and programme governance: whether IDD a funded budget line; whether potassium iodate procurement was maintained without external funds; existence of national coordination mechanism and its functioning; and percentage of salt from large and medium size producers
Communication
Whether iodized salt is clearly recognizable as iodized to the consumer; whether a communication strategy in place that addresses
identified bottlenecks from production/import of iodized salt to reaching the population; whether education about IDD and iodized salt included in health system, schools, etc;
Monitoring and evaluation and quality assurance
i) Assesses whether there is a national monitoring system exist that tracks programme activities (e.g., policy implementation, production, supply, communication); ii) whether any monitoring data reported and used for corrective action/programme adjustments; iii) rules and operating procedures for external QC (inspections and sample taking at the production/import and the commercial levels) by national authorities are clearly established; iv) the rules and procedures for external QC actually been applied by national authorities in the past calendar year; v) standards and responsibilities for internal QA at the production level clearly established; vi) iodized salt production sites complied with the standards for internal QA in the past calendar year; vii) any examples of punitive or rewarding actions (including public recognition) relating to the compliance of salt producers with QA standards for iodized salt; viii) the salt iodization programme in your country been evaluated by external independent evaluators in the past 5 years?
Total programme performance score
Policy, governance/ownership and M&E/QA = 30% weighting and communication 10%. In 2014 the categories, questions and weighting shifted a little.
Ref: UNICEF Nutridash
EAP Regional Workshop on
ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

21. Regional nutridash performance scorE: policy environment

22. Regional nutridash performance score:
national ownership and programme governance
Score (%)

23. Regional nutridash performance score: communication

24. Regional nutridash performance score: monitoring, evaluation and QA/QC

25. Regional nutridash performance score: TotaL

26. Issues hindering progress in the region
Reduced political commitment
Inadequate coordination structures for intersectoral collaboration
Lack of regulatory monitoring and weak enforcement of national legislation
Insufficient use of iodised salt in processed foods
Insufficient data on iodine status of reproductive age or pregnant women
National data on household iodised salt and median urinary iodine likely hiding sub-national disparities
Poor quality data on household use of iodised salt – reliance on rapid test kits
EAP Regional Workshop on
ACHIEVING UNIVERSAL SALT IODISATION FOR OPTIMAL IODINE NUTRITION

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