KEY BIBLIOGRAPHY || GENERAL BIBLIOGRAPHY

1. Iodine supplementation: benefits outweigh risks
- by Delange F, Lecomte P: Drug Saf 2000 Feb;22(2):89-95; International Council for Control of Iodine Deficiency Disorders, Brussels, Belgium. fdelange@ulb.ac.be.

In 1990, iodine deficiency affected almost one-third of the world population and was the greatest single cause of preventable brain damage and mental retardation. Following a resolution adopted by the World Summit for Children in 1990. major programmes of iodine supplementation were implemented by the governments of the affected countries with the support of major donors. Iodisation of salt was recognised as the method of choice. Nine years later, by April 1999, 75% of the affected countries had legislation on salt iodisation and 68% of the affected populations had access to iodised salt. The prevalence of iodine deficiency disorders decreased drastically in most countries and the deficiency disappeared completely in some such as Peru. This result constitutes a public heath success unprecedented with a non-infectious disease. However, occasional adverse effects occurred. The principle effect is iodine-induced hyperthyroidism which occurs essentially in older people with autonomous nodular goitres, especially following iodine intake that is too rapid and of too massive an increment. The incidence of the disorder is usually low and reverts spontaneously to the background rate of hyperthyroidism or even below this rate after 1 to 10 years of iodine supplementation. The possible occurrence of iodine-induced thyroiditis in susceptible individuals has not been clearly demonstrated by large epidemiological surveys. Iodine supplementation is followed by an increased prevalence of occult papillary carcinoma of the thyroid discovered at autopsy but the prognosis of thyroid cancer is improved due to a shift towards differentiated forms of thyroid cancer that are diagnosed at earlier stages. Iodine-induced hyperthyroidism and other adverse effects can be almost entirely avoided by adequate and sustained quality control and monitoring of iodine supplementation which should also confirm adequate iodine intake. Available evidence clearly confirms that the benefits of correcting iodine deficiency far outweigh the risks of iodine supplementation.

2. S.O.S. for a Billion: The Conquest of Iodine Deficiency Disorders
- by Basil S. Hetzel & C.S. Pandav; Oxford University Press: Delhi, India. Second Edition, ISBN 0195640020, 1996. Paperback, 466 pages, 24 chapters which are as follows:

PART I The Conquest of Iodine Deficiency Disorders - The Global Picture 1. S.O.S. for A Billion - The Nature and Magnitude of the Iodine Deficiency Disorders; 2. Recent Progress in the Elimination of Iodine Deficiency Disorders; 3. The Conquest of Iodine Deficiency through a Global Partnership of People, Governments, International Agencies, the Salt Industry, Kiwanis International and Micronutrient Initiative;

PART II National Programmes for the Elimination of IDD 4. Measurement of Iodine Deficiency Disorders; 5. The Iodization of Salt for the Elimination of Iodine Deficiency Disorders 6. The Use of Iodized Oil and Other Alternatives for the Elimination of Iodine Deficiency Disorders; 7. The Economic Benefits of the Elimination of IDD; 8. From Knowledge to Policy to Practice 9. The Progress of Communicating the Message; 10. Planning and Managing National Programmes for Elimination of Iodine Deficiency Disorders; 11. The Role of the International Agencies; 12. The Role of Kiwanis International;

PART III Stories from the Countries 13. IDD in Africa; 14. IDD in Central Asia; 15. IDD in South-east Asia; 16. IDD in China; 17. IDD in Europe; 18. IDD in Latin America; 19. IDD in the Middle East PART IV Sustaining Elimination of IDD 20. Monitoring and Verification of Progress towards the Elimination of IDD by the Year 2000 and Beyond;

PART V Statement on Safety of Iodized Salt and Iodized Oil 21. Statement on Safety of Iodized Salt and Iodized Oil PART VI New Alliances and Progress Towards Elimination of IDD 22. IDD in Livestock Populations 23. Partnership to End Hidden Hunger - Collaboration of Stockholders in Sustaining the Elimination of IDD 24. Progress Towards Elimination of IDD - Excerpts from Publication of International Agencies (UNICEF, WHO, World Bank) and International conference on Nutrition (ICN) INDEX

3. The Economics of Iodine
7th Edition, May 1998, published by Roskill Information Services, Ltd., 2 Clapham Road, London SW9 0JA, England; fax 44 171 793 0008; e-mail: info@roskill.co.uk; cost: $1200. To order,esmee@roskill.co.uk, ref:ICCIDD.

This book provides detailed information on the world distribution and marketing of iodine. Its chapters present a summary, background information on iodine, data on reserves in geographical regions, production processes, world output and production capacity, production and supply by country and company, international trade, consumption, end uses, and prices. The material has special interest for countries and organizations involved with obtaining iodine for correction of iodine deficiency.

The book is full of interesting facts. The iodine market was in over-supply in 1990, and prices fell to a low of about US $9.00/kg by 1993, but rose again to around US $20.00/kg by 1998. World consumption is about 18,000 metric tons. Over 80% is used in North America, Western Europe and Japan. Major applications include photography, nylon manufacture, catalysis (e.g., in synthetic rubber), X-ray contrast media, disinfectants, and supplements in humans and animals. The world's largest producer is SQM in Chile, with a capacity of 8,000 tons. Several other Chilean companies bring the country's total to about 15,000 tons, slightly over half of the world's production. Three major companies in Japan provide an additional 9,000 tons. Other iodine reserves are in Azerbaijan, China, Indonesia, Turkmenistan, the USA, and Russia. Many other countries have companies manufacturing various iodine derivatives from imported iodine.

The book details the many uses of iodine, including for iodized salt. It quotes ICCIDD and UNICEF on country data and iodized salt usage for the correction of iodine deficiency. It calculates that at 1998 prices (US $12-16/kg for iodine), the iodization of one ton of salt at 40 ppm increases the cost by US $1.00. Thus, addition of iodine represents between 7 and 15% of the cost of bulk salt. The world's consumption of salt in 1996 was estimated at 44 million tons. The total amount of iodine for salt iodization is less than 1,000 tons per year, but is increasing. Animal feeds also include iodine, in the forms of potassium iodide, calcium iodate, ethylenediamide dihydriodate and ethylenediamine dihydriodide. Recommended levels have been 120 mcg/kg of dry matter for calves and 0.0076% iodine in iodized salt licks for pregnant cows. In the United Kingdom, the maximal level permitted in whole feeding stuff is 40 mg/kg. Other applications of iodine that may impact on humans are antiseptics and disinfectants, water purification, pharmaceuticals, X-ray contrast media, and protection from radioactive iodine fallout. Increased use of iodine in disinfectants and animal feeds, as well as for correction of iodine deficiency, is anticipated. Prices of crude iodine ranged from US $5.00 in 1973 to about US $20.00 in the late 1980's and again recently. The price has fluctuated with demand and general economic prosperity. Crude iodide costs about the same as crude iodine. The book is clearly written and has a wealth of detail. The information about IDD is a bit out of date, but valuable information about utilization, and marketing of iodine remains. This is a valuable reference work that will interest agencies and governments involved in obtaining iodine for human use.

4. Progress Towards the Elimination of Iodine Deficiency Disorders (IDD)
Publ. By the Dept. Of Nutrition for Health and Development, World Health Organisation WHO / NHD / 99.4

Following its introduction to the successes and gains towards universal salt iodisation and reference to the World Health Assembly's 1996 Resolution on the topic, the report outlines the history and major symptoms of IDD and the means variously available to correct dietary deficiences. The significant roles of the international agencies, WHO, UNICEF,ICCIDD,PAMM, MI ; national and legislative bodies ; and the salt industry itself are all acknowledged. Global statistics are given on the goals of the elimination programme; on populations at risk of IDD ( 38% ), and on the changes in total goitre rate between 1990 and 1998 (+1%). Data is also given on the the regional activities in control activities (78% ), household consumption of iodised salt( 68%), and the prevalence of monitoring systems (65%).The progress in each WHO region is reviewed with case history notes specific to Zimbabwe,Peru, India, Iran, Poland and China. The final chapters of the paper list the problems and constraints remaining to be addressed and note that while good progress has been made in Africa, the Americas, East Asia and the Eastern Mediterranean, much remains to be done in Eastern Europe and Central Asia.

5. Urinary Iodine Assessment:
A Manual on Survey and Laboratory Methods - by Kevin M. Sullivan and Sandra May, July 26, 1999. Program Against Micronutrient Malnutrition (PAMM) Department of International Health, Rollins School of Public Health at Emory University, 1518 Clifton Road NE , Atlanta GA 30322 USA

This manual was developed by PAMM at the request of UNICEF to assist countries in assessing the prevalence of IDD, an important issue for the end of the decade in which the global community committed to virtually eliminate IDD. It must be realized that IDD can remain eliminated in most countries only if all edible salt is appropriately iodized. There will be an important ongoing need for national assessments after the year 2000 and that these assessments assist in building infrastructure that will remain well into the next century. These types of assessments will need to be repeated at regular intervals forever. Recent experience in some developed countries, where the intake of iodine has declined in recent years, emphasizes the importance of an ongoing national monitoring system. The contents of the manual are given in chapters on : 1. Overview of Iodine Deficiency and Urinary Iodine Assessment :2. Planning and Preparing for the Survey :3. Selection of Survey Sites 4. Performing the Survey : 5. Laboratory Methods : and 6. Data Entry and Analysis of the Survey. We wish to acknowledge the valuable resources and technical inputs from key people from PAMM, UNICEF, ICCIDD, the Dutch Government, the All India Institute, KIWANIS, WHO, the Micronutrient Initiative, ICPMR (Australia), and National Programs who have contributed their perspective to this manual. In particular we would like to recognize Glen Maberly, Frits van der Haar, Werner Schultink, Nita Dalmiya, Roger Shrimpton, Robin Houston, Warwick May, Jonathan Gorstein, Chandra Pandav, John Dunn, M. G. Karmarkar, Gary Ma, and Charles Todd. We recognize that many countries may have already developed approaches to assessing IDD and we encourage you to send comments about this manual to the authors. We will maintain an active web site http://www.sph.emory.edu/PAMM where additional information will be provided and we would welcome placing your information on this site to share with others.

6. Hyperthyroidism and Other Thyroid Disorders: A Practical Handbook for Recognition and Management
- by Charles H. Todd

This joint publication (1998) of World Health Organization and ICCIDD is a short practical guide by Dr. Todd, ICCIDD Interim Regional Coordinator for Africa and Senior Lecturer in the University of Zimbabwe Medical School, written principally to aid in the recognition of iodine-induced hyperthyroidism and other thyroid illnesses in developing countries. Its chapters include: an overview of iodine metabolism and thyroid physiology, with special emphasis on the importance of iodine; how normal thyroid function can be disturbed and its consequences; a clinical approach to patients with suspected thyroid disease; thyroid function tests in diagnosis; the choice among treatments for hyperthyroidism; the treatment of hypothyroidism; the management of goiter and thyroid nodules; and case examples. The principal target audience is physicians and other health workers in developing countries who need to be ready for iodine-induced hyperthyroidism as iodine deficiency is corrected. The writing is concise, the points are made clearly, and the focus is always on the realities of practicing medicine in developing countries. The booklet should help in the early diagnosis and treatment of hyperthyroidism. Further information can be obtained from the Nutrition Unit at WHO, Dr. Todd, or others in ICCIDD.

7. STABILITY OF IODINE IN IODIZED SALT USED FOR CORRECTION OF IODINE-DEFICIENCY DISORDERS
- by L. L. Diosady, J. O. Alberti, M. G. Vankatesh Mannar, and T. G. Stone, University of Toronto and Micronutrient Initiative, Toronto and Ottawa, Canada.

Food and Nutrition Bulletin 18:388-396, 1997.
Samples of noniodized salt consumed by low-income population from eight countries were fortified under standardized experimental conditions to contain about 50 ppm iodine with KIO3. The iodized salt from each sample was packaged in either (a) solid low density polyethylene bags, 0.07 mm thick, (b) in open plastic containers, or (c) in woven high-density polyethylene bags, 0.15 mm thick. Packages were then stored at about 40 degrees centigrade at either high humidity (100%) or medium humidity (60%). Samples from each package were taken after 0, 1, 2, 3, 6, and 12 months of storage and measured for iodine content by titration or neutron activation, and for moisture content. The results showed that all salt samples lost iodine over the 12 months period, but the amount lost varied widely, from 10% to 100% of the original iodine value. In the low-density polyethylene bags at 60% humidity, samples retained from 83-100% iodine at six months and 68-88% after 12 months, at 100% humidity with low-density polyethylene bags, retention at six months was 67-92% and at 12 months, 17-66%. For the high-density polyethylene bags, retention at 60% humidity at six months was 89-99%, and at 12 months 69-81%; at 100% humidity, these ranges were 1-61% (six months) and 0-3% (12 months). Salt stored in open containers at 60% humidity for six months retained 81-98% iodine and at 12 months 69-80%; but at 100% humidity, 17-36% at six months and 8-26% at 12 months. These results emphasize the importance of humidity and the packaging material. At 60% relative humidity, all samples retained at least 80% of their iodine, and at 12 months at least 68%, under all conditions of storage. At 100% humidity there was wide variation depending on the packaging. An additional factor was the purity of the salt obtained from different countries. Canadian salt of high purity and little moisture or other impurities lost less than 10% after six months of storage at low humidity, but lost almost all the iodine at high humidity unless packaged in the low-density polyethylene bags. Some salt retained iodine effectively for several months but then dropped sharply afterwards. This careful study shows the importance of moisture and stability of iodine in salt. Highly purified salt will improve stability, but effective packaging is a more practical approach for most countries. The authors point out that the solid low-density polyethylene packaging can retain about 90% of the iodine for up to six months. However, the woven high-density polyethylene bags are necessary for bulk packaging of salt because of their increased mechanical strength. For choice of optimal salt iodization, countries need to consider the local conditions and then determine the best level of salt iodization and the most appropriate packaging and distribution.

8. Iodine Deficiency Disorders in Livestock: Ecology and Economics
by C.S. Pandav and A.R. Rao; University Press, New Delhi,.1997.

Livestock health and productivity are affected by environmental iodine deficiency in much the same way as their human owners, so that in those rural regions where IDD is a problem for the people, it is also a problem for the domesticated animals on which the population depends for its survival. The assembled papers in this book present a holistic approach in examining how IDD affects both humans and animals through the food chain, and represents the proceedings of a multidisciplinary review of the topic conducted in India in 1995. The seven sections of the book cover:- an overview of IDD : livestock and the Indian economy : IDD in livestock : feeds and fodders - iodine status : animal studies in India : control measures for IDD in kivestock : and recommendations for intervention.

9. Guia Para La Produccion De Sal Yodada De Alta Calidad (Guide to the Production of High Quality Iodized Salt)
- Produced through the OMNI Project, with the assistance of OSMOSIS and PATH. 1997.

This guide contains illustrations and simple messages on the key aspects of salt production for improving the quality of the salt and ensuring its effective iodization. The guide, written in Spanish and intended for use by salt producers, includes all of the stages of production, from the pre-production preparation and care of the salt, to its storage and iodization. The guide was developed in Guatemala, where a system of solar evaporation of sea water with black polyethylene is used to produce salt. However, many of the technical principles and procedures that are included in the guide can be applied or adapted to other systems of salt production used in other countries.

10. Produce, Procure, Stock and Sell only Iodized Salt- A handbook for traders
by R. Prakash, S. Sundersan, R. Mohan, S. Mukherjee, S. Vir & U. Kapil. The Salt Department Ministry of Industry and UNICEF-India.

A 16 page, full-color brochure produced by The Salt Department, Ministry of Industry with the support from UNICEF with the following table of contents: Intoduction p.1-3 Production of Iodised salt p.4 Ban on sale of iodised salt p.5 How to procure Iodised salt p.6 Packing p.7 Labeling p.8 Storage p.8 Quality control and the PFA Act p.9 Producers/Manufacture's Responsibility p.12 Trader's responsibility p.14 Repacker's responsibility p.13 Conclusion p.14 Annexure I p.16.

11. The Micronutrient Education Activity Kit for Children
- by A. L. Corneli The Rollins School of Public Health: Emory University; Atlanta, Georgia. (Draft) June 1996.

Through this manual, children will learn the importance of consuming micronutrient-rich foods through a series of exciting and fun learning activities. This project is in coordination with PAMM and SCP.

12. Micronutrient Laboratory Equipment Manual
- by Warwick A. May. Rollins School of Public Health: Emory University, Atlanta, Georgia. March 1, 1996.

This manual is a valuable resource to both micronutrient program managers and laboratory managers. The laboratory assessment of micronutrient status in populations and individuals is a critically important component of successful micronutrient intervention strategies. This manual includes a detailed section on iodine laboratory.

13. Iodine Deficiency Disorders in Bangladesh: A Data-Base
- by Quazi Salamatullah, H.K.M. Yusuf & C.S. Pandav. publ. by ICCIDD, UNICEF - Bangladesh, Dhaka University. January 1995.

This is a 36-page booklet, glossy, full-color cover with B&W text. It is a compilation of data available in Bangladesh on IDD with the following table of contents: 1. Articles on IDD in Journals 2. Articles on IDD in Proceedings 3. Study reports on IDD 4. Articles on IDD published in Newspaper 5. Articles on IDD published in Magazines 6. Booklets/leaflets/posters on IDD 7. Audiovisual materials on IDD 8. Workshops/seminars/events held on IDD 9. Members of the National Salt Committee 10. Persons involved in IDD 11. Perform for IDD data-base 12. Acknowledgements.

14. IDD Elimination Strategy in Pakistan - Focus on Communication
- publ. by PO, Nutrition, UNICEF - Pakistan in Islamabad, Pakistan, 1995.

A 31-page full-color booklet on IDD Elimination Strategy in Pakistan with focus on communication with the following table of Contents:
I. The Problem II. The solution III. Communication Strategy A. Interpersonal Communication B. Advocacy Events C. Advertising Campaign D. Distribution of Printed Materials E. Collaborations F. Implementation 1) Consumers 2) Television 3) Radio 4) Print 5) Outdoor 6) The Distribution Network 7) Community leaders and NGOs 8) Health Care Providers 9) Children 10) Religious Leaders 11) Other Activities.

15. Seven Deadly Sins in Confronting Endemic Iodine Deficiency, and How to Avoid Them
- by John T. Dunn. Journal of Clinical Endocrinology and Metabolism , 1332, 1996.

A useful personal view and up-date from Dr. John Dunn, who has provided technical advice and assistance to many UNICEF offices on IDD. The fact that the article was published in the Journal of Clinical Endocrinology and Metabolism and therefore presumable reaches many endocrinologists is noteworthy. The article should be of interest to everyone who is concerned with monitoring progress towards IDD elimination and sustaining the progress achieved.

16. Lack of Simple Elements Puts Millions at Risk
- by Brown, David in The Washington Post {Science/Nutrition} Mar 17, 1995.

An article in full-color with a picture, diagram (of the thryoid gland) and global map (of IDD prevalence). The article has several sections: -Tackling a little-known epidemic -Iodine can't be synthesized -Effort to cost $ 75 million.

17. An Agricultural Approach to Preventing Iodine Deficiency Disorders: effects of iodination of irrigation water on crop and animal production in China
- by G. R. Delong, X.M. Jiang, M.A. Rakeman, & et al. Food-Based Approaches to Preventing Micronutrient Malnutrition ,p.35, 1996.

In 1992, iodination by dripping an aqueous solution of potassium iodate into irrigation water was instituted for the control of severe IDD in four rural villages. Results indicate that iodine-treatment of irrigation water increased iodine availability levels in crops and livestock.

18. The Mineral Fortification of Foods
- Richard Hurrell (Ed.) Pub. by Leatherhead International,Randalls Rd., Leatherhead, Surrey,UK KT22 7RY, 1999

The book is intended as an essential guide to food manufacturers and fortified food developers,to assist them in selecting the best fortification compound and vehicle for their products. Its 13 chapters cover the concepts of fortification, giving as examples, salt iodisation and addition of iron and calcium to foodstuffs, and follows this with separate chapters on the mironutrient elements calcium, iron, iodine, selenium, copper, zinc, and magnesium. There is special focus on fortification in developing countries,in conventional foods, and in iron fortification of cereals. The text concludes with a review of quality control including sampling and analytical techniques, and a summary of global fortification legislation.

19. An evaluation of salt intake and iodine nutrition in a rural and urban area of the Cote d'Ivoire
- Hess SY, Zimmermann MB, Staubli-Asobayire F, Tebi A, Hurrell RF; Eur. J. Clin. Nutr. 1999 Sep;53(9):680-6

OBJECTIVE: To evaluate the habitual salt intake of individuals living in the Cote d'Ivoire, and to monitor the iodine nutrition of adults, schoolchildren and pregnant women one year after implementation of a universal salt iodisation programme.
DESIGN: A three day weighed food records with estimation of food intake from a shared bowl based on changes on body weight, determination of sodium and iodine concentrations in 24 h (24 h) urine samples from adults, and determination of urinary iodine in spot urines from schoolchildren and pregnant women.
SETTING: A large coastal city (Abidjan) and a cluster of inland villages in the northern savannah region of the Cote d'Ivoire.
SUBJECTS: For the food records: 188 subjects (children and adults) in the northern villages; for the 24 h urine collections: 52 adults in Abidjan and 51 adults in the northern villages; for the spot urine collections: 110 children and 72 pregnant women in Abidjan and 104 children and 66 pregnant women in the north.
MAIN RESULTS: From the food survey data in the north, the total mean salt intake (s.d.) of all age groups and the adults was estimated to be 5.7 g/d (+/- 3.0), and 6.8 g/d (+/- 3.2), respectively. In the 24 h urine samples from adults, the mean sodium excretion was 2.9 g/d (+/- 1.9) in the north and 3.0 g/d (+/- 1.3) in Abidjan, corresponding to an intake of 7.3-7.5 g/d of sodium chloride. In the north the median 24 h urinary iodine excretion in adults was 163 microg/d, and the median urinary iodine in spot urines from children and pregnant women was 263 microg/l and 133 microg/l, respectively. In contrast, in Abidjan the median 24 h urinary iodine was 442 microg/d, with 40% of the subjects excreting > 500 microg/d, and the median urinary iodine in spot urines from children and pregnant women was 488 microg/l and 364 microg/l, respectively. Nearly half of the children in Abidjan and 32% of the pregnant women were excreting > 500 microg/l.
CONCLUSION: Based on the estimates of salt intake in this study, an optimal iodine level for salt (at the point of consumption) would be 30 ppm. Therefore the current goals for the iodised salt programme--30-50 ppm iodine appear to be appropriate. However, in adults, children and pregnant women from Abidjan, high urinary iodine levels, levels potentially associated with increased risk of iodine-induced hyperthyroidism, are common. These results suggest an urgent need for improved monitoring and surveillance of the current salt iodisation programme in the Cote d'Ivoire.

20. Impact after 1 year of compulsory iodisation on the iodine content of table salt at retailer level in South Africa
- Jooste PL, Weight MJ, Locatelli-Rossi L, Lombard CJ; Int. J. Food Sci. Nutr. 1999 Jan;50(1):7-12

The short-term effectiveness of introducing compulsory iodisation through revised health legislation, evaluated in terms of the iodine content of iodised table salt, was investigated in three of the nine provinces in South Africa. Shortly before the introduction of compulsory iodisation of table salt in December 1995, iodised at a higher level than before, 187 iodised salt samples were purchased at retailers in 48 magisterial districts situated in the three provinces of Western and Eastern Cape and Mpumalanga for analysis of the iodine content using the titration method. In a follow-up 1 year later 287 iodised salt samples were obtained from the same retailers for iodine determination. The mean iodine content of iodised salt increased significantly from 14 to 33 ppm. However, large variation in the iodine content of iodised table salt among and within salt brands existed at follow-up, and the mean iodine content was lower than the legal specification of 40 to 60 ppm. Only 24% of the samples were found within the range required by the law at follow-up compared to 42% before revising the salt legislation. Despite the introduction of compulsory salt iodisation, the mean retail price of iodised salt remained the same between 1995 and 1996 for a 500 g package of salt. Further refinement of the iodisation processis necessary to improve the accuracy of iodisation and decrease the variation in iodine content. This study nevertheless showed that the introduction of compulsory iodisation and elevating the legally specified iodine level of table salt resulted in a significantly elevated mean iodine level of iodised salt within 1 year, without any additional cost to the consumer.

21. Status of salt iodisation and iodine deficiency in selected districts of different states of India
- by Kapil U, Nayar D; Indian J Public Health 1998 Jul-Sep;42(3):75-80

Iodine deficiency disorders (IDD) is a major public health problem. Surveys conducted by the National Goitre Survey team of the Directorate General of Health Services during the past three decades have revealed a high prevalence of endemic goitre in different states. Out of a total of 267 districts surveyed till date, 226 have been reported to be endemic to iodine deficiency. A successful measure for the prevention of IDD is salt iodisation. The Salt department, Government of India has taken an intensive programme of production of iodised salt in the country. The production has increased from 1.5 lakh metric tonnes in 1984 to 40 lakh metric tonnes in 1996. To assess the impact of increased production of iodised salt on the availability of iodised salt at the beneficiary and trader level and also on the status of iodine deficiency, surveys were undertaken in selected districts of 10 states and 2 union territories of the country. These studies have been presented and discussed here.

22. A determination of iodides in salts: a validation of methods
- by Drobnik M, Latour T; Rocz Panstw Zakl Hig 1998;49(2):169-76

The studies reported were aimed at finding a simple analytical method enabling quantitative determination of iodide in table iodised salt and in therapeutic iodide-bromide salts. The analytical procedure proposed is a modification of spectrophotometric method recommended in the Polish Standards. The method based on the reaction of iodide oxidation by sodium nitrite was validated by determining its precision, accuracy and linearity. Statistical analysis has shown that the coefficient of variation varies between 2.73 and 4.82%, recovery is from 91.7 to 101.83% and falls within the confidence interval for the mean recovery at the assumed level of significance. The method can be used for controlling the technology of table salt iodisation.

23. Control of efficiency and results, and adverse effects of excess iodine administration on thyroid function
- by Koutras DA; Ann Endocrinol (Paris) 1996;57(6):463-9

The control of the efficiency and the results of iodisation programs can be done clinically, biochemically and by monitoring the side-effects. Clinical improvement (disappearance of all the manifestations of iodine deficiency disease) is the most important end-point. However, some manifestations may persist for life, and so clinical improvement may require a long time interval before becoming apparent. For this reason, biochemical control, especially the urinary iodine excretion, is the most important early sign of the success (or not) of the iodisation programs. Side-effects of iodine in general include: 1. Iodine-induced hyperthyroidism. An increase in toxic nodular goitre is probably transient and eventually its incidence is expected to decrease. However, an increased incidence of autoimmune Graves' disease is probably permanent. 2. Iodine-induced hypothyroidism. 3. Iodine-induced autoimmunity, both of the Hashimoto and of the Graves types. 4. An increase in the incidence of papillary cancers, probably with a decrease in the more aggressive types. In any case, the benefits of iodisation programs far outweigh the risks, provided they are implemented and monitored carefully.

24. Persistence of goiter despite oral iodine supplementation in goitrous children with iron deficiency anemia in Cote d'Ivoire
- by Zimmermann M, Adou P, Torresani T, Zeder C, Hurrell R; Am J Clin Nutr 2000 Jan;71(1):88-93

BACKGROUND: In developing countries, many children are at high risk of goiter and iron deficiency anemia. Because iron deficiency can have adverse effects on thyroid metabolism, iron deficiency may influence the response to supplemental iodine in areas of endemic goiter.
OBJECTIVE: The aim of this study was to determine whether goitrous children with iron deficiency anemia would respond to oral iodine supplementation.
DESIGN: A trial of oral iodine supplementation was carried out in an area of endemic goiter in western Cote d'Ivoire in goitrous children (n = 109) aged 6-12 y. Group 1 (n = 53) consisted of goitrous children who were not anemic. Group 2 (n = 56) consisted of goitrous children who had iron deficiency anemia. At baseline, thyroid gland volume and urinary iodine, thyrotropin, and thyroxine were measured by using ultrasound. Each child received 200 mg I orally and was observed for 30 wk, during which urinary iodine, thyrotropin, thyroxine, hemoglobin, and thyroid gland volume were measured.
RESULTS: The prevalence of goiter at 30 wk was 12% in group 1 and 64% in group 2. The mean percentage change from baseline in thyroid volume 30 wk after administration of oral iodine was -45.1% in group 1 and -21.8% in group 2 (P < 0.001). Among the anemic children, there was a strong correlation between the percentage decrease in thyroid volume and hemoglobin concentration (r(2) = 0.65).
CONCLUSION: The therapeutic response to oral iodine was impaired in goitrous children with iron deficiency anemia, suggesting that the presence of iron deficiency anemia in children limits the effectiveness of iodine intervention programs.

25. Persistence of iodine deficiency 25 years after initial correction efforts in the Khumbu region of Nepal
- by Murdoch DR, Harding EG, Dunn JT; N Z Med J 1999 Jul 23;112(1092):266-8

AIMS: To assess the current status of, and understanding about iodine deficiency disorders among Sherpa residents of the Khumbu region of Nepal, 25 years after the introduction of iodised oil injections.
METHODS: Several groups of Khumbu Sherpas were studied and goitre rate, urinary iodine level and cretinism prevalence were measured as indicators of iodine deficiency. Subjects were also questioned in detail about their food consumption, with particular reference to salt use, and about their understanding of the causes and treatment of iodine deficiency disorders.
RESULTS: The prevalences of goitre, deaf-mutism and cretinism were 21%, 1.3% and 0.5% respectively (compared to 92%, 4.7% and 5.9% in 1966). No cretins had been born since 1966. The median urine iodine concentration was 35 microg/L. Most people preferred uniodised Tibetan rock salt, although 44% regularly consumed iodised salt. All granulated salt tested from the local market contained adequate amounts of iodine. Only 11% of those surveyed knew that goitre was caused by iodine deficiency.
CONCLUSIONS: Although prevalences of iodine deficiency disorders are much less than 30 years ago, iodine deficiency continues to be a major problem in Khumbu and demands a clear control strategy, combining ongoing iodine supplementation and education. Iodised salt is usually the best approach to control of iodine deficiency disorders for most regions of the world but the Khumbu experience shows that local cultural and commercial factors can severely limit its impact. To be successful, control programme for iodine deficiency disorders also needs assessment of the salt trade, monitoring, education and occasional targeted interventions with iodised oil or other supplements.

26. Randomized clinical trial comparing different iodine interventions in school children
- by Zhao J, Xu F, Zhang Q, Shang L, Xu A, Gao Y, Chen Z, Sullivan KM, Maberly GF; Public Health Nutr 1999 Jun;2(2):173-8

OBJECTIVE: The purpose of this trial was to compare three different iodine interventions.
DESIGN: School children aged 8-10 years were randomized into one of three groups: group A was provided with iodized salt by researchers with an iodine concentration of 25 ppm; group B purchased iodized salt from the market; and group C was similar to group B with the exception that they were given iodized oil capsules containing 400 mg iodine at the beginning of the study. Salt iodine content was measured bimonthly for 18 months and indicators of iodine deficiency were measured at baseline and 6, 9, 12 and 18 months after randomization.
RESULTS: The prevalence of abnormal thyroid volumes, based on the World Health Organization (WHO) body surface area reference >97th percentile, was 18% at baseline and declined to less than 5% by 12 months in groups A and C, and to 9% after 18 months in group B. Results for goitre by palpation were similar. The median urinary iodine was 94 microg l(-1) at baseline and increased in all groups to > 200 microg l(-1) at the 6-month follow-up.
CONCLUSIONS: In this population of school children with initially a low to moderate level of iodine deficiency, the group receiving salt with 25 ppm (group A) was not iodine deficient on all indicators after 18 months of study. When the iodine content of the salt varied, such as in group B, by 18 months thyroid sizes had not yet achieved normal status.

27. Brassiodol, a new iodised oil for goitrous patients
- by Ingenbleek Y, Jung L, Ferard G; Coll Antropol 1998 Jun;22(1):51-62

A new iodised oil, called Brassiodol, is proposed to prevent or eradicate 127I-deficiency disorders. Its original synthesis utilises srapeseed oil as vehicle of iodination, allowing the covalent binding of 127I atoms to all olefin groups of fatty acids (FAs). The final product contains 376 mg 127I/mL, manifests high refractoriness to degradative processes and is well tolerated by goitrous patients. The proposed dosage is 1 mL/year in adults owing to the rapid deiodination and massive 127I leakage of larger amounts in the urinary output. About 300-350 mg 127I may undergo tissue sequestration, insuring appropriate iodine coverage during 9-12 months. Clinical follow-up, hormonal data, and 127I excretory kinetics point to the normalisation of thyroid function within 3 months is stages I and II of the goitrous disease. This iodised oil, characterised by low cost, easy handling and high nutritional efficiency, seems ideally suited to meet public health and economical problems in countries facing severe goitrous areas.

28. Intermittent oral administration of potassium iodide solution for the correction of iodine deficiency
- by Todd CH, Dunn JT; Am J Clin Nutr 1998 Jun;67(6):1279-83

Iodized salt and iodized oil are the main methods used to prevent iodine deficiency, but sometimes alternative approaches are needed. We tested the efficacy of various regimens for the intermittent administration of potassium iodide in Hwedza, Zimbabwe, an area of known severe iodine deficiency. We divided 304 schoolchildren aged 7-13 y into five equal groups that received iodine as a 10% solution of potassium iodide as follows: 8.7 mg every 2 wk (group A), 29.7 mg every month (group B), 148.2 mg every 3 mo (group C), 382 mg every 6 mo(group D), or 993 mg once (group E). The follow-up period was 13 mo. No adverse effects were encountered with any of these doses. After 6 mo, the median blood spot thyroglobulin concentration had decreased in all groups and had normalized in groups A and B to values found in iodine-sufficient populations. The number of children with elevated thyroid-stimulating hormone concentrations decreased in groups A-C, but the changes were not significant. Urine iodine concentration generally remained low in all groups but increased in group A. After 13 mo, mean thyroid volume measured by ultrasound had decreased in groups A and B to values comparable with those in iodine-sufficient areas, and was unchanged in the other groups. We conclude that oral potassium iodide is effective for the prophylaxis of iodine deficiency if given as a dose of 30 mg I monthly or 8 mg biweekly.

29. There needs to be more than one way to skin the iodine deficiency disorders cat : novel insights from the field in Zimbabwe
- by Solomons NW; Am J Clin Nutr 1998 Jun;67(6):1104-5; Comment on: Am J Clin Nutr 1998 Jun;67(6):1279-83 ( see ref. above )

30. Prevention and control of iodine deficiency: a review of a study on the effectiveness of oral iodized oil in Malawi
- by Furnee CA; Eur J Clin Nutr 1997 Nov;51 Suppl 4:S9-10

Unfortunately there will always be groups of people who will not have access to iodized salt as a measure for iodine deficiency control. Iodized oil for oral use may be indispensable for them. The conclusions of a study in Malawi on the effectiveness of oral iodized are that the type of iodized oil, goitre, intestinal parasites, sex, adipose tissue, cassava consumption and seasonality are factors which influence the duration of effectiveness of this prophylaxis measure. The study in Malawi used urinary iodine concentration as a measure for iodine status and a hyperbolic function to describe the pattern of urinary iodine excretion after oral dosing. Cumulative frequency distributions of individually assessed durations of effectiveness very conveniently describe the prevalence rate of iodine deficiency after oral iodized oil administration. They are very useful for identifying factors which influence the effectiveness of oral iodized oil and may thus be a tool for optimizing iodized oil programmes.

31. Efficacy of different types of iodised oil
- by Untoro J, Schultink W, Gross R, West CE, Hautvast JG; Lancet 1998 Mar 7;351(9104):752-3

Randomized controlled trial . Comment on: Lancet 1997 Nov 22;350(9090):1542-5

32. Infant survival is improved by oral iodine supplementation
- by Cobra C, Muhilal, Rusmil K, Rustama D, Djatnika, Suwardi SS; J Nutr 1997 Apr; 127(4):574-8

Although reports suggest that infant mortality is increased during iodine deficiency, the effect of iodine supplementation on infant mortality is unknown. A double-masked, randomized, placebo-controlled, clinical trial of oral iodized oil was conducted in Subang, West Java, Indonesia to evaluate the effect of iodine supplementation on infant mortality. Infants were allocated to receive placebo or oral iodized oil (100 mg) at about 6 wk of age and were followed to 6 mo of age. Six hundred seventeen infants were enrolled in the study. Infant survival was apparently improved, as indicated by a 72% reduction in the risk of death during the first 2 mo of follow-up (P < 0.05) and a delay in the mean time to death among infants who died in the iodized oil group compared with infants who died in the placebo group (48 days vs. 17.5 d, P = 0.06). Other infant characteristics associated with reduced risk of death included weight-for-age at base line, consumption of solid foods, female gender and recent history of maternal iodine supplementation. Oral iodized oil supplementation had a stronger effect on the mortality of males compared with females. This study suggests that oral iodized oil supplementation of infants may reduce infant mortality in populations at risk for iodine deficiency.

34. Safe use of iodized oil to prevent iodine deficiency in pregnant women.
A statement by the World Health Organization - Bull. WHO 1996;74(1):1-3

The risks and expected benefits from iodized oil, given orally or by injection, to pregnant women in areas of severe iodine deficiency where iodized salt is not available were evaluated. The conclusions, which were approved by the ICCIDD, showed that for preventing and controlling moderate and severe iodine deficiency, the giving of iodized oil is safe at any time during pregnancy. Maximum protection against endemic cretinism and neonatal hypothyroidism will be achieved when iodized oil is given before conception. The potential benefits greatly outweigh the potential risks in areas of moderate and severe iodine deficiency disorders, where iodized salt is not available and is unlikely to be made available in the short term (1-2 years).

35. U.S. Centers for Disease Control and Prevention
Announcing The Opening Of The CDC Global Micronutrient Malnutrition Laboratory
A Global Micronutrient Malnutrition Laboratory has been established in the Division of Laboratory Sciences (DLS), National Center for Environmental Health (NCEH), Centers for Disease Control and Prevention (CDC), to help reduce morbidity and mortality caused by micronutrient malnutrition. The laboratory will provide the means to assess, intervene, evaluate, and control micronutrient status. The current focus of this laboratory will be on biochemical indicators of iodine, iron, vitamin A, and folate status.

A Global Micronutrient Malnutrition Laboratory has been established in the Division of Laboratory Sciences (DLS), National Center for Environmental Health (NCEH), Centers for Disease Control and Prevention (CDC), to help reduce morbidity and mortality caused by micronutrient malnutrition. The laboratory will provide the means to assess, intervene, evaluate, and control micronutrient status. The current focus of this laboratory will be on biochemical indicators of iodine, iron, vitamin A, and folate status.

Available features of this new laboratory related to IDD:

•	Reference method for urinary iodine by ICP-MS (mass spectrometry)
•	International Iodine Reference Laboratory services
	–	Reference materials for urinary iodine
	–	Reference materials for dried blood spot TSH
•	Laboratory analytical support
	–	For epidemiologic studies
	–	Health surveys
	–	And evaluation of nutrition interventions

Future features of the CDC Global Iodine Reference Laboratory (subject to funding):

For additional information please pick up our brochure or visit our website at http://www.cdc.gov/nceh/programs/ehls/newsann/micromal/newsmm.htm