IDD Elimination

1
IDD Elimination Universal Salt Iodization
Policy in Georgia Current Trends and Challenges
Ms. Mariam Jashi APO Health UNICEF Georgia Mr.
Zurab Sekhniashvili Director, National Center for
Nutrition

National Conference Enhancing Partnership for
IDD Elimination in Georgia 25-28 June 2004 -
Tbilisi Georgia
2
Iodine Deficiency in Georgia Traditional Concern

• 1745
• First source describing Goiter problem - writings
  by Vakhushti Bagrationi
• 1921
• Establishing Universal System for Combating
  Endemic Goiter - USSR
• 1935
• Republican Dispensary for Goiter Prevention in
  Tbilisi, Adjara Kutaisi
• 1939
• Iodized Salt Manufacturing in Kutaisi supplying
  Racha-Letchkhumi, Imereti, Svaneti and other
  High-Land areas
• 1938-1944
• Goiter prevalence in the High-Land regions
  reduced from 42.7 to 14

3
Lost Opportunity

• 1970s
• IDD Virtually Eliminated in Georgia
• 1980s
• Reducing efforts to sustain achievements -
  Illusion of IDD Liquidation
• 1990s
• Social-Economic Crisis, Disruption of Iodized
  Salt Import Distribution
• Mid-1990s
• Alarming Trend of IDD and Goiter Prevalence
  throughout the Country

4
No Single District in Georgia Free of Goiter Age
group gt15 years old - 2003
5
No Single District in Georgia Free of Goiter -
6
National Efforts to Combat IDD since 1990s

• 1996
• Presidential Decrees on State IDD Programme
  National Council on IDD
• 1997
• VAT (20) Exception Policy for Iodized Salt
  Import (0.15) and Sale
• Establishing district IDD committees in 71
  administrative units
• 1998
• State Standard for Iodized Salt
• Special Coding for Import of Iodized Salt vs.
  Non-iodized
• IDD Centres in Tbilisi, Kutaisi, Batumi, Telavi
  Zugdidi
• Lab Ultrasound Equipment provided by UNICEF
• Continuous Disease Surveillance and Database
  Formation

7
National Efforts to Combat IDD since 1990s

• 1997-2004
• Free consultation provided to 500,000 patients
• Medication (Levoxile) provided by ACTS Georgia
  for treatment of Goiter
• 2000-2001
• Distribution of Iodized Oil Capsule to 300,000
  children, pregnant lactating women in 35
  districts of 10 regions (UNICEF) - Emergency
  Interventions
• 1998-2001
• Information-Communication Campaign (TV/Radio,
  Printed Materials)

8
National Efforts to Combat IDD since 1990s

• 2002
• Presidential Decree overriding 1996 Decrees
• Renewing membership of National Council
• Drafting Law on Universal Salt Iodization
• 2003
• Draft Law Submitted to Parliament - Banning
  Import of Non-iodized salt except for Industry,
  Medical Purposes Re-Iodization

9
Membership of National IDD Council

• 2002
• State Chancellery - Chair of NCIDD
• Ministry of Labour, Health SA
• Ministry of Food and Agriculture
• Ministry of Justice
• Ministry of Economy, Trade Industry
• Ministry of Education
• Ministry of Finance
• Ministry of Transport Communication
• State Dept. for Standardization,
• Metrology Certification
• Ministry of Interior affairs
• Ministry of State Security
• Ministry of ENVR/Natural Resources

• 1996
• State Chancellery - Chair of NCIDD
• Ministry of Health
• Ministry of Food and Agriculture
• Ministry of Justice
• Ministry of Trade Foreign Econ. Relations
• Ministry of Education
• Ministry of Economy
• Ministry of Finance
• State Customs Department
• State Dept. for Standardization, Metrology
• Certification

Roles Responsibilities too General Private
Sector not officially included
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Policy and Strategic Framework Guiding National
Programmes

• Government Commitment
• World Summit For Children - 1990
• World Fit For Children - 2002
• Millennium Development Goals - 2000
• National Health Policy Strategy
• What is the Goal?
• Sustainable Elimination of IDD by 2005
• Universal Salt Iodization (USI) by 2005
• All Salt for Human and Animal Consumption to be
  Iodized
• What Indicators?
• Household Consumption of Iodized Salt gt90
• Goiter Prevalence lt 5 of the population
• Adequate Iodine Status - Urine Iodine Excretion gt
  100 mcg/dl

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How to Verify Progress What are Achievement?

• Salt Situation Analysis in Georgia - 1999 2003
• Household Survey on Consumption of Iodized Salt -
  1999 2003
• Iodine Status among Children - 2000-2002
• Goiter Prevalence among Children and Adults -
  1997-2002
• Communication Assessment - 2003 John Hopkins
  University

12
Progress and Status

• Findings from
• Salt Situation Analysis in Georgia
• 2003
• Institute for Polling and Marketing

13
Salt Import in TonsGeorgia 1999-2002
Source Salt Situation
Analysis 2003 - IPM/UNICEF Customs Data - 2002
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Key Findings from 2003 Salt Situation Analysis

• 2002 - Iodized Salt mainly imported from Ukraine
  (96), also from Greece, Germany, Armenia,
  Azerbaijan, Turkey Italy
• Iodine content not tested at customs level
  customs-clearance registration based on
  manufacturers certificate or State Department of
  Standardization
• Wholesale/Retail Quality Control State Sanitary
  Inspection
• No clear articulation of administrative
  regulations sanctions for violating packaging,
  sorting, labeling, transportation storage
  standards for iodized salt

15
Key Findings from 2003 Salt Situation Analysis

• Some violation of State Standards for Storage of
  Iodized Salt observed at various distribution
  points. Salt Expiry Dates almost always followed.
  
• Quality Control systems at Import,
  Wholesale/Retail Sale needs refinement
• Lab equipment for salt titration at State
  Sanitary Department outdated
• Despite all efforts for legislative framework, no
  comprehensiveness achieved. Inadequacy of
  Legislative basis endorsement

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Communication on IDD/Iodized Salt

• IEC campaigns in 1998-2001 - NCN, Public Health
  Department, UNICEF
• No coordinated professional marketing
  communication efforts taken.
• Communication by salt importers not considered
  profitable given that salt import is no Big
  Business.
• Communication efforts needed at all levels -
  decision makers, importers, distributors,
  Households

17
Iodized Salt Prices Range 0.25 to 7.57 GEL
Affordability issue is a lesser concern
18
Household Consumption of Iodized Salt gt90?

• Findings from
• Household Survey
• 2003
• State Department for Statistics

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Availability of Iodized Salt at Household Level
Georgia (except Abkhazia and South Ossetia)1999
2003
Source MICS 1999 2003 HH
Survey/ UNICEF - SDS 1117 Households
20
Availability of the Iodized Salt at the Household
Level Georgia (except Abkhazia and South
Ossetia) 1999 - 2003
Source MICS 1999 2003 HH
Survey UNICEF - SDS
21
Awareness of Households on Iodine Deficiency
Republic of Georgia (except Abkhazia and South
Ossetia) 2003
From 67 in 1998
Source 2003 HH Survey UNICEF - SDS Georgia
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Main Source of Information on Iodine Deficiency
Republic of Georgia (except Abkhazia and South
Ossetia) 2003
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Some Other Findings

• What do you do to prevent Iodine Deficiency?

67.9 who knows about Iodized Salt can buy it in
areas where they live 61.2 households are buying
iodized salt monthly Each household spends
10-11GEL/year for purchasing salt.
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If you have a choice which salt would you buy?
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Motivation for choosing iodized vs. Non-IS
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IDD Prevalence Data

• Findings from National Center of Nutrition
• 1. Urine Iodine Excretion data among children
• 2001
• 2. Goiter Prevalence among children and adults
• 1997-2003

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Urine Iodine Excretion Children Aged 1-15
UIE Median Children 67 mcg/dl Tbilisi Data 2003
Source NCN, 2001
28
Goiter Prevalence Adult Population 1997-2003
Source National Center for
Nutrition, Georgia 2003 Data - Referral
29
Goiter Prevalence Child Population 1997-2003
Source National Center for
Nutrition, Georgia 2003 - Referral Data
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IDD Impact on Mental Development
IDD PROBLEM PYRAMID
IQ Reduction by 10-15 13.5 IQ Points in Average
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Future Challenges Summary of Recommendations
Political Commitment Re-establishment of
Effective Coordination Council/Committee/Task
Force Clear delineation of
roles/responsibilities mandates Commitment
from local governments - sub-national level
advocacy Legislation Endorsement by Parliament
Banning Import of Non-Iodized Salt
Articulating clearly administrative sanction
regulations
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Future Challenges Summary of Recommendations
Establishment of a strong monitoring system for
Quality Control of Iodized Salt at all levels
From Import to Household
Level Continuation of Communication Awareness
raising on IDD/USI Research-Based Strategy with
Experts - Refer to SitAn, HH Survey Intersectoral
Partnership Health, Education, Private, Youth,
NGOs Increase networking with main
Salt Importers Exploring school based IEC and
monitoring activities Identification Focus on
Pockets with high IDD prevalence
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Eliminating IDD in Georgia by 2005?
Reaching 38 of Children Adults
Affected by IDD 24 of Population
Not Aware on IDD 33 of Families
Not Using Iodized Salt
STILL