IDD Elimination & Universal Salt Iodization Policy in Georgia Current Trends and Challenges

UNICEF

PARTNERSHIP FOR IDD ELIMINATION IN GEORGIA

IDD Elimination & Universal Salt Iodization Policy in Georgia

Current Trends and Challenges

Ms. Mariam JashiAPO Health – UNICEF Georgia

Mr. Zurab SekhniashviliDirector, National Center for Nutrition

National Conference “Enhancing Partnership for IDD Elimination in Georgia”25-28 June 2004 - Tbilisi Georgia

UNICEF

PARTNERSHIP FOR IDD/USI IN GEORGIA

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%

UNICEF


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

UNICEF


Samtskhe-Javakheti

Imereti

Adjara

Guria

Abkhazia

Samegrelo-Zemo SvanetiRacha-Lechkhumi & Kvemo Svaneti

Kvemo Kartli

Kakheti

Shida Kartli

Tbilisi

Mtskheta-Mtianeti

No Single District in Georgia Free of Goiter Age group >15 years old - 2003

Per cent

5.0 - 25.0

25.1 - 50.0

50.1 - 70.0

> 70.1

Missing Data

UNICEF


Samtskhe-Javakheti

Imereti

Adjara

Guria

Abkhazia

Samegrelo-Zemo SvanetiRacha-Lechkhumi & Kvemo Svaneti

Kvemo Kartli

Kakheti

Shida Kartli

Tbilisi

Mtskheta-MtianetiPer cent

< 25.0

25.1 - 50.0

50.1 – 70.0

> 70.1

Missing Data

No Single District in Georgia Free of Goiter -

UNICEF


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

UNICEF



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)

UNICEF



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

UNICEF


Membership of National IDD Council

1996State 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

2002State 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 ResourcesRoles & Responsibilities too GeneralPrivate Sector not officially included

UNICEF


Policy and Strategic Framework Guiding National Programmes

Government CommitmentWorld Summit For Children - 1990World Fit For Children - 2002Millennium Development Goals - 2000 National Health Policy & Strategy

What is the Goal? Sustainable Elimination of IDD by 2005Universal Salt Iodization (USI) by 2005All Salt for Human and Animal Consumption to be Iodized

What Indicators? Household Consumption of Iodized Salt >90%Goiter Prevalence < 5% of the populationAdequate Iodine Status - Urine Iodine Excretion > 100 mcg/dl

UNICEF


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

UNICEF


Progress and Status

Findings from

Salt Situation Analysis in Georgia

2003

Institute for Polling and Marketing

UNICEF


Salt Import in TonsGeorgia 1999-2002

20175042

19041

32742

0

5000

10000

15000

20000

25000

30000

35000

1999 2000 2001 2002

Non-iodizedIodizedIndustrial

Source: Salt Situation Analysis 2003 - IPM/UNICEF

Customs Data - 2002

UNICEF


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 manufacturer’s 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

UNICEF


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;

UNICEF


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

UNICEF


Iodized Salt Prices Range 0.25 to 7.57 GEL

Price

Name of Salt Producer Min Max AverageRock Salt (“SOL’ Kamennaya”) “Artyomsol” 0.25 0.50 0.33Kalas Golden (500gr) Kalas Group 1.20 1.50 1.27Kalas Classic (400gr) Kalas Group 0.60 1.00 0.77Kalas Master (250gr) Kalas Group 0.55 0.80 0.64Kalas HPA (500 gr) Kalas Group 0.45 0.80 0.53Iodized Salt "S" Akzo Nobel Salz 3.65 3.65 3.65Picnic Salt (Dansk "S") Akzo Nobel Salz 3.10 3.10 3.10Salzina (Speise Salz, 1 kg) Akzo Nobel Salz 1.90 1.90 1.90Salzina (Speise Salz, 500 gr) Akzo Nobel Salz 1.00 1.00 1.00Salzina (Jod Salz) Akzo Nobel Salz 1.00 1.00 1.00Die Sparsamen (Speise-salz) Akzo Nobel Salz 1.00 1.00 1.00Die Sparsamen (Jodsalz) Akzo Nobel Salz 0.75 1.00 0.83Salina Iyotlu (Plastic bottle) Cihan-Kur A.S. 0.80 1.00 0.93Salina Iyotlu (Plastic bag) Cihan-Kur A.S. 0.60 0.80 0.68Sea Salt Droga 5.75 5.75 5.75Morska Sol Droga 5.60 5.60 5.60Alkyon Perla 0.50 0.50 0.50Unknown (in Iranian) N/A 0.30 0.30 0.30Salt Iran N/A 0.50 0.50 0.50Extra “Avanski Solekombinat” 0.60 0.70 0.65White Salt “Valetek Prodimpeks” 1.00 1.00 1.00Salt Iodized Extra “Enterprise MS” 1.00 1.50 1.25Salt Iodized JSC “Bassol” 2.50 2.50 2.50Salt extra “Monarkh” Ltd 2.50 2.50 2.50Marino Fino Spera and Company 1.00 1.00 1.00

Affordability issueis a

lesser concern

UNICEF


Household Consumption of Iodized Salt >90%?

Findings from

Household Survey

2003

State Department for Statistics

UNICEF


Availability of Iodized Salt at Household Level Georgia (except Abkhazia and South Ossetia)

1999 – 2003

77.2

30.4

8.1

67.5

0

10

20

30

40

50

60

70

80

%

0-15 ppm >= 15 ppm

1999

2003 field result/test kits

Source: MICS 1999

2003 HH Survey/

UNICEF - SDS

1117 Households

UNICEF


Availability of the Iodized Salt at the Household Level Georgia (except Abkhazia and South Ossetia)

1999 - 2003

70.5

21.8

96.9

58

12.3

75.9

2.7

58.1

0

10

20

30

40

50

60

70

80

90

100

%

0-15 ppm >= 15 ppm

Urban 1999

Urban 2003

Rural 1999

Rural 2003

Source:

MICS 1999 2003 HH Survey UNICEF - SDS

UNICEF


Awareness of Households on Iodine Deficiency Republic of Georgia (except Abkhazia and South Ossetia)

2003

63.8

36.2

89.2

10.8

76.8

23.2

0

10

20

30

40

50

60

70

80

90

Rural Urban Total (Country)

Have you heard about iodine deficiency?

Yes No

Source:

2003 HH Survey UNICEF - SDS Georgia

From 67% in 1998

UNICEF


Main Source of Information on Iodine Deficiency Republic of Georgia (except Abkhazia and South Ossetia)

2003

28.1 31

74

65.9

32 30.5 30.7

20.4

0

10

20

30

40

50

60

70

80

HealthWorker

Radio TV RelativeFriend

Children Journal paper

Other Do notknow

Urban

Rural

UNICEF


Some Other Findings

What do you do to prevent Iodine Deficiency?

Urban Rural Total

Buy iodised salt 58.8 51.3 55.7Buy product enriched with iodine 9.6 7.0 8.6Buy vitamins 9.4 4.4 7.4Buy sea products 4.5 0.0 2.7Do nothing 36.2 39.1 37.4Other 3.4 5.3 4.1Do not know 0.5 0.9 0.7

67.9% who knows about Iodized Salt can buy it in areas where they live61.2% households are buying iodized salt monthly

Each household spends 10-11GEL/year for purchasing salt.

UNICEF


If you have a choice which salt would you buy?

77.873.5 76.9

72.5 75.1

14.4 16.2 14.818.7 16.4

0

10

20

30

40

50

60

70

80

90

Big cities SmallCities

Cities, intotal

Villages Total

Iodized

Non Iodized

No preferences

Do not know

UNICEF


Motivation for choosing iodized vs. Non-IS

0

10

20

30

40

50

60

70

80

90

100

Iodized

Non-iodized

Iodized 98.1 1.1 1.6 1.1 2.5 0.6 0.2 0.5

Non-iodized 18.5 0 6.4 0 65.4 0 16 3.1

Useful for

healthCheaper

Sold in closest store

Only salt for sale

Tastes better

Smells better

Better for

canned

Do not know

UNICEF


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

UNICEF


Urine Iodine Excretion Children Aged 1-15

0.8 %

18%

62.3 %

18 %

0

10

20

30

40

50

60

70

< 20 mcg/dl 20-49

mcg/dl

50-

99mcg/dl

>100mcg/dlSource: NCN, 2001

UIE Median Children

67 mcg/dlTbilisi Data 2003

UNICEF


Goiter Prevalence – Adult Population 1997-2003

57.7 58.3

47.744.1

39.538.5

44*

0

10

20

30

40

50

60

1997 1998 1999 2000 2001 2002 2003

% of the TotalPopulation

Source: National Center for Nutrition, Georgia

* 2003 Data - Referral

UNICEF


Goiter Prevalence – Child Population 1997-2003

54 5552

4238 38

39*

0

10

20

30

40

50

60

1997 1998 1999 2000 2001 2002 2003

% of ChildPopulation

Source: National Center for Nutrition, Georgia

2003* - Referral Data

UNICEF


IDD Impact on Mental Development

IDD PROBLEM PYRAMID

IQ Reduction by

10-15%

13.5 IQ Points in Average

UNICEF


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

UNICEF


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

UNICEF


Eliminating IDD in Georgia by 2005?

ReachingReaching

38% of Children & Adults Affected by IDD

24% of Population Not Aware on IDD

33% of Families Not Using Iodized Salt

STILL

IDD Elimination & Universal Salt Iodization Policy in Georgia Current Trends and Challenges

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