1. Ensuring Maximum Public Health Benefits of USI: the Role of Monitoring Prof. Gregory Gerasimov UNICEF Consultant Central and Eastern Europe, CIS and Baltic States

2. Global success in salt iodization % of households that consume that consume iodized salt Globally - 73% CEE/CIS/BS - from 5 to 90% Baltic States - up to 10% UNICEF 98 Report

3. Definitions - MONITORING Monitoring is the process of collecting and analysing on a regular basis information about the program for the purpose of identifying problems such as non-compliance, and taking corrective actions so as to fulfill stated objectivesMonitoring is the process of collecting and analysing on a regular basis information about the program for the purpose of identifying problems such as non-compliance, and taking corrective actions so as to fulfill stated objectives

4. Definitions - INDICATOR An indicator is used to help describe a situation that exists, and can be used to track changes in the situation over time.An indicator is used to help describe a situation that exists, and can be used to track changes in the situation over time. Indicators are usually quantitave, but may also be qualitative.Indicators are usually quantitave, but may also be qualitative. Indicators may be direct and indirect.Indicators may be direct and indirect.

5. Indicators of IDD Control Program Process Indicators - for monitoring of salt iodizationProcess Indicators - for monitoring of salt iodization Impact (Outcome) Indicators - for biological monitoringImpact (Outcome) Indicators - for biological monitoring

6. Process Indicators Is all imported salt iodized to the country’s requirement?Is all imported salt iodized to the country’s requirement? Is adequately iodized salt reaching the target population?Is adequately iodized salt reaching the target population?

7. Biological (Impact) Indicators Is there a significant IDD problem?Is there a significant IDD problem? What is the prevalence of IDD in a given population?What is the prevalence of IDD in a given population? What impact salt iodization has on iodine status of the population?What impact salt iodization has on iodine status of the population? Have IDD been eliminated as a public health problem?Have IDD been eliminated as a public health problem?

8. PROCESS INDICATORS

9. Factors That Determine Iodine Content in Salt Variability in the amount of added iodineVariability in the amount of added iodine Uneven distribution of iodine in the iodized saltUneven distribution of iodine in the iodized salt The extent of iodine loss during storage and distributionThe extent of iodine loss during storage and distribution Loss of iodine due to cooking and food processingLoss of iodine due to cooking and food processing

10. Industry Standards for Iodized Salt Former USSR GOST 13830-91 required:Former USSR GOST 13830-91 required: –use of instable potassium IODIDE (KI) –level of iodization 23+/-11 ppm –shelf life 3 months UNICEF/WHO recommendations:UNICEF/WHO recommendations: –use of stable potassium IODATE (KIO3) –level of iodization 20-40 ppm –shelf life more than 12 months

11. MOST OF SALT PRODUCERS IN THE REGION THAT SUPPLY IODIZED SALT TO THE BALTIC STATES COMPLY WITH ABOVE RECOMMENDATIONS

12. Determining Salt Iodine Levels Titration methodTitration method Rapid test kitsRapid test kits Semi-quantitative measurement kitsSemi-quantitative measurement kits

13. MONITORING SYSTEM Government (External) Monitoring SystemGovernment (External) Monitoring System The Producers’ & Distributors’ (Internal) Monitoring SystemThe Producers’ & Distributors’ (Internal) Monitoring System Household Level MonitoringHousehold Level Monitoring –Cross-sectional surveys –Community based monitoring

14. IMPACT INDICATORS

15. Biological Indicators Goiter rate in school children (by palpation and ultrasonography)Goiter rate in school children (by palpation and ultrasonography) –<5% - no iodine deficiency Urinary IodineUrinary Iodine –>100 mcg/l - no iodine deficiency Neonatal TSH screeningNeonatal TSH screening –samples with TSH level > 5 mU/L - less than 3%

16. Goiter (Thyroid Size) Assessment Easy to performEasy to perform Little training needed (for palpation)Little training needed (for palpation) Reflects remote rather than present iodine statusReflects remote rather than present iodine status Observers’ variationsObservers’ variations Low sensitivityLow sensitivity Expensive equipment (for ultrasonography)Expensive equipment (for ultrasonography)

17. Urinary Iodine Assessment Reflects current iodine status of populationReflects current iodine status of population Samples easy to collectSamples easy to collect Sensitive and reliable indicatorSensitive and reliable indicator Trained lab staff neededTrained lab staff needed External and internal quality control requiredExternal and internal quality control required Rather expensive equipmentRather expensive equipment

18. Neonatal TSH No additional investments in impact (biological) monitoringNo additional investments in impact (biological) monitoring It is not recommended to set up neonatal TSH screening program solely for purpose of IDD monitoringIt is not recommended to set up neonatal TSH screening program solely for purpose of IDD monitoring

19. SURVEY METHODS School surveysSchool surveys –goiter rate (palpation & ultrasonography) –urinary iodine –samples of salt from households Household surveysHousehold surveys –goiter rate (palpation) –urinary iodine –checking of iodine in salt

20. WHO/UNICEF/ICCIDD criteria for monitoring progress towards elimination of IDD as a public health problem

21. Universal Salt Iodization in Baltic States Legislation, Regulations, StandardsLegislation, Regulations, Standards Implementation & EnforcementImplementation & Enforcement Monitoring and Impact AssessmentMonitoring and Impact Assessment

22. ACHIEVABLE GOAL: ELIMINATION OF IDD AS A PUBLIC HEALTH PROBLEM IN THE BALTIC STATES IN THE NEXT 1-2 YEARSELIMINATION OF IDD AS A PUBLIC HEALTH PROBLEM IN THE BALTIC STATES IN THE NEXT 1-2 YEARS