BOGOTA REGIONAL MEETING

Professor Frits van der Haar
Mr. Nicolas Febres Cordero
Dr. Erick Boy
Dr. Jes™s Toledo Tito
Dr. Omar Dary M
Eng. Diego AvendaÒo
Eng. Hans Vanhassel
Dr. Dora LucÌa
Mr. Jose Vicente Puert
Dr. Eduardo A. Pretell
Mr. Rafael Molina GarcÌa
Mr. Francisco Fern·ndez
Case Studies
Quality Assurance


Antecedents

The food supply of more than 1.6 billion people is lacking in adequate levels of iodine, resulting in the widespread prevalence of a spectrum of Iodine Deficiency Disorders (IDD). This public health problem can be corrected by the regular delivery of small doses of iodine to the population through commonly eaten foods or condiments. Salt is an excellent carrier for iodine and other nutrients as it is consumed at relatively constant, well-definable levels by all people within a society, independently of economic status.

In 1990, seventy Heads of State gathered at the World Summit for Children in New York and pledged to eliminate Iodine Deficiency Disorders (IDD) as one of the health and social development goals to reach by the year 2000. Salt iodization was identified as the main intervention to deliver iodine on a continuous and self-sustaining basis to populations around the world. Governments working with the salt industry and supported by international agencies and expert groups then set to plan and implement programmes that would enable this measure. Over the past decade, as part of the Universal Salt Iodization (USI) initiative, a large number of developing countries have taken steps to ensure that all salt produced for human and livestock consumption is iodised. Once established in a country, salt iodization is a permanent and long-term solution to the problem. It eliminates iodine deficiency and continues to provide each individual with his/her daily iodine needs and prevents recurrence. Within one year of iodised salt containing the required iodine being widely available and consumed in a community, there will be no further birth of cretins or children with subnormal mental and physical development attributable to iodine deficiency. Goitres in primary school children and adults will have started to shrink and even disappear altogether. Children will be more active and perform better at school.

Achievements The following achievements in IDD elimination over the past decade are noteworthy:

By 1998, more than 170 countries had committed themselves to universal iodization of salt. Many countries have provided resources for IDD elimination in their national financial budgets and are progressing toward the goal of Universal Salt Iodization.

Salt iodization has witnessed a remarkable growth in application. According to UNICEF reports a significant proportion of the populations in more than 87 countries - at least 68% of the world's population - already have access to iodised salt. Forty-five countries have achieved more than 75% coverage. 1 2

Investment (Public & Private) in the iodised salt industry over the past decade exceeds one billion dollars and continues to grow 3.

More than 12 million cases of mental retardation in infants are being prevented annually.

There is now potential for eliminating the ancient scourge of iodine deficiency disorders. Success with salt iodization has given governments a new confidence to address other more complex micro nutrient problems using salt as well as other food carriers to deliver essential micronutrients to their populations. In many developing countries, salt iodization is the first large-scale experience in national fortification of a commodity to eliminate a public health problem. It has taught valuable lessons in collaboration between government, industry, non-governmental organisations, the media, the community at large and other sectors. It has also offered insights into building and sustaining an intervention politically, technically, managerially, financially, and culturally.

Status of National Salt Iodization Programs

Most countries already have all, or most, of the necessary programmed components in place. Producers are clearly supporting increased production and sale of iodised salt. In the majority of countries, iodised salt is already available, public awareness and knowledge is high, IDD rates are being monitored and regulations or laws are in place or being developed. Universal Salt Iodization (USI) seems to be in reach, yet we are not yet there.

The need therefore is to fine-tune activities. Countries of this region need to identify constraints and weakness and develop corrective actions. Monitoring is key since time and again, we have seen the re-emergence of IDD when monitoring slackens. A well-functioning, appropriate monitoring system is needed to provide information for decision-making, targeting, focusing attention, raising awareness, and garnering resources.

The key role of the Salt Industry in iodization programs

The specific objective is to dovetail iodization into the prevailing salt production and distribution system in a country at minimum cost and disruption. The Salt Industry has obviously been a key player in enabling this major public health achievement. However, the production process and scale vary over a wide range in this most ancient of industries. Salt manufacturing techniques and product quality vary over a wide range from cottage scale units producing a few hundred tons a year to very large fully automated plants producing several million tons. Some countries depend entirely on mining of underground rock salt deposits. Others on the extraction of salt from sea water or saline lake/underground brine by solar drying. In a few countries both forms are produced. For units with production > 10,000 tons per year that are well organised with quality control systems, the integration of iodization has been relatively easy. Such large producers account for nearly 75% of all salt for edible consumption in these countries. However, a small but significant proportion of the salt is produced along coastlines or lake shores as a semi-agricultural operation by many small producers. The smaller units often operate with a minimum of organisation and little or no quality control. They are scattered along the coast or lakes shores and do not lend themselves to regulation by the government. Very often precise figures regarding event their location, extent of holdings and production statistics are not available. The producers have limited financial means and lack access to technical or financial assistance to institute quality iodization processes and to monitor quality. As a result, the salt produced in these units is of poor quality. This has complicated USI programs. Additionally, they have poor packaging practices or do not package the salt at all. Yet they are often the main salt supplies to the communities most at risk of IDD.



As a second phase of USI implementation, support needs to be provided to small producers. The producers often have to first be convinced that they have a role to play in the USI program and that they are capable of doing it. Benefits to them, including economic returns, have to be illustrated. Their limitations and constraints need to be recognised. They cannot and should not be expected to participate for the good of the country, although this should be developed as a motivating factor. At the end of the day, the production of iodised salt must benefit them economically in order for their contribution to be sustainable. As a long-term aim, they should also be supported to upgrade their facilities in general. In order to remain economically viable, small salt producers will have to change with the times. The trend will inevitably be towards better quality, iodised salt. To work towards, they may need to form co-operatives with other producers. A shared iodization machine may be the starting point for such a co-operative. The next step may be a packing machine. Alternatively, they could be facilitated to supply their salt to a larger producer, who undertakes the task of iodization and packaging and perhaps purification.

Technical training and assistance is often needed, for example in establishing production, quality control sampling and analytical procedures. In some cases, appropriate technology for salt purification needs to be provided. Simpler quality control and analytical techniques, such as test kits, may also be needed.

A further problem experienced in some countries, is multiple levels of iodization and packaging. In this situation, raw salt producers supply their un-iodized salt to multiple small re-packagers who take on the task of iodization and packing the salt into consumer-size bags. As with small salt-producers, these facilities often do not have the capacity to consistently produce good quality iodized salt and to monitor its quality. Where this practice occurs, governments should encourage raw salt producers, especially if they are large, to iodize the salt at source. These raw salt producers can thereafter supply large sacks of iodized salt to re-packers for packing into small bags. By encouraging iodization at source, the number of facilities that need to be monitored is reduced and large producers can take advantage of economies of scale to implement more dependable and uniform iodization techniques.

The stability of iodine in salt and levels of iodization are questions of crucial importance to national planners and salt producers as they have implications for programmed effectiveness, safety, and cost. High humidity results in rapid loss of iodine from iodised salt, ranging anywhere from 30% to 98% of the original iodine content 4. By refining and packaging salt in a good moisture barrier, such as low density polyethylene bags, iodine losses can be significantly reduced, during storage periods of over six months. Over the past decade, there have been significant investments in salt refining capacity in several countries. This augurs well for iodization since refined salt in watertight packing retains up to 80% of iodine for 12 months.



The significant lessons learned

As significant as the achievements to date are and as exciting as their potential might be, there is much to be done. The goal of universal iodization of all salt for human and animal salt is close to being achieved. The challenge however, does not end there. There is evidence of declining IDD prevalence but the goal of elimination has not yet been achieved. Experience over the past decade has provided several valuable lessons, which point to future strategies to expand and sustain the universal iodization of salt.

Salt iodization strategies and programs need to keep adjust to a changing environment

Globalisation and free trade are having significant impacts on salt production, import, refining, and distribution patterns and need to be monitored. Adequate inputs (material, financial, trained human resources) need to be ensured. Public demand for a balanced iodine intake should be expanded and sustained.

IDD elimination should not remain a vertical program

Communications and monitoring of USI and IDD elimination should be integrated within existing health/education/agricultural extension structures and procedures in imaginative ways. Knowledge of the value of iodine could be introduced into the curricula of primary and secondary schools and health service training. Process and impact monitoring could be included in household surveys, census, and other ancillary information-gathering efforts on a permanent basis.

Quality assurance of the product, the process, and the progress is key

Quality Assurance and Quality Control systems are crucial to the success of IDD programs.
These should cover:

The Product (clean products, quality standards, appropriate iodine levels, fair prices);

The Process (access to raw materials, iodate, packaging, labelling, quality assurance mechanisms in place, systematic and regular training, public communication, social marketing, management, accountability);

The Progress (impact measurement in humans and animals to confirm success and shows its positive consequences in health, well-being, productivity, and progress of the nation).

Apply modern technology and management tools rapidly to streamline IDD elimination programs

We need to look at ways in which modern technology can be more rapidly applied to essentials of programmed in IDD elimination. Some immediate ways are through rapid field test and assessment techniques, electronic communications tools and reporting techniques, management information systems, training, orientation and motivation.

Key Requirements to achieve and sustain USI

In addition to programs being in place, the key needs to achieve and sustain USI include:

Continued and strong government commitment and industry motivation are essential to eliminate IDD. We have not yet adequately addressed the hard question of "how to sustain progress when foreign aid leaves". Programs should continue after external inputs are withdrawn with more national resources in firm and permanent budgets to sustain progress. Political commitment to IDD elimination needs constant renewal. The economics of the salt industry and the food processing industry need to be more fully understood by the health and scientific community in order that recommendation for national consideration makes good business sense as well as good public policy. Elimination of IDD will reduce preventable mental retardation annually, but this must be made into socially positive political good.

A clear communications strategy should be implemented to expand and sustain consumer awareness and demand for iodised salt. The rationale should be that children have the right to reach their genetic potential and people have the right to demand fortified products like salt at convenient locations, in appropriate packages, at fair pricesÖ and forever.

There is immediate need to cover those who don't receive iodised salt. A managerial overview of national resources dedicated to this effort required priority attention. In so doing we must avoid the danger of thinking of IDD as a problem mainly for rural or mountain populations. It is a major urban problem, as well. Countries with limited resources, or smaller problems need more help; others need support to accelerate existing plans.

The Salt industry should have the mandate and resources to ensure effective iodization. Producer compliance, quality assurance, logistic problems and bottlenecks need to be addressed through effective advocacy and social communications.

Sustained management inputs and quality assurance of product, process and progress.

Training of personnel is vital, continuing component. The need in every country is for constant vigilance to assure that (a) the producers are fully up to date and have good personnel in packaging, monitoring, reporting and analysis; (b) the country is inserting knowledge about iodine into learning channels, training courses, public communications and schools; (c) the responsible agents like Ministries of Health have adequate trained personnel for their vital role of surveillance and assessment of progress in human nutrition, including laboratories and other support measures.

Monitoring systems should be in place to ensure specified salt iodine levels and co-ordinated with effective regulation and enforcement.

National training schemes in micro nutrient malnutrition are priority needs. The need for constant attention to this aspect cannot be overstated. These need to be multidisciplinary in composition and scope. All stakeholders in success must be kept up to date.

The final proof of impact and successful elimination of iodine deficiency is reflected in the reduction in prevalence of Iodine Deficiency Disorders. These need to be monitor and tracked at periodic intervals.



New frontiers

Over the past decade there has been a world-wide movement by consumer groups to raise private sector consciousness to participate in tackling social and environmental problems. Viewed from this angle, IDD control presents an opportunity for the salt industry to derive economic and social benefit for itself while simultaneously providing a social benefit to the community by fortifying the salt they produce and sell.

Salt enjoys unique advantages as a carrier of nutrients in most parts of the world in terms of universal coverage, uniformity of consumption and low cost of fortification. Encouraged by the progress made in several countries in implementing successful salt iodization programs, efforts have been directed at examining the feasibility of fortifying salt with iron and other nutrients such as fluorine along with iodine. With production, surveillance and monitoring infrastructure for iodization programmed already in place, such an integration and co-ordination would enable resource savings and maximum efficiency. The commercial application of large-scale multiple fortification programs would be a major breakthrough in establishing a cost effective delivery system for these nutrients to cover large populations.

The salt industry and trade can play an important role at the global, regional and country level in terms of social advocacy and by providing the vitally needed technical and financial inputs to eliminate several nutrient deficiencies from the face of the earth.

REFERENCES

1. The State of the World's Children. UNICEF (1998).

2. Progress Towards the Elimination of Iodine Deficiency Disorders. UNICEF, World Health Organisation, ICCIDD, 1999.

3. Venkatesh Mannar M.G. Toward Universal Salt Iodization: What have we learnt in the last 10 years? Paper presented at the Workshop on Monitoring of Iodised Salt Programs in Asia, April 1999.

4. Diosady, L., Alberti, Mannar, M.G., V. Stone, T. Stability of Iodine in Iodized Salt Used for the Correction of IDD, Food and Nutrition Bulletin Vol. 18 (4) (1997), p. 388.

5. Proceedings of the International Workshop for IDD Elimination in China. Ministry of Health & ACAD, Beijing, October 1998.



Dr. Eduardo A. Pretell. Regional Coordinator for America, ICCIDD

This joint meeting brings together health officers in charge of national programs to control iodine deficiency disorders (IDD) in the Americas, the producers and distributors of iodised salt and representatives of international agencies, all committed to eradicate iodine deficiency as a public health hazard. This is a unique opportunity to reaffirm this commitment, not just to attain the target around the year 2000 but also to guarantee that the achievements will be sustained.

I am grateful for the opportunity to deliver this lecture in which I will briefly review basic concepts on iodine deficiency and its consequences, reaffirm the justification of the commitments undertaken, report on progress and achievements in the Region and comment on what still remains to be done.

IMPORTANCE OF IODINE AND THYROID HORMONES

Iodine is essential for normal growth and development and for the survival of mankind and animals. The biological importance of iodine is that it is the main component of thyroid hormones. Iodine needs vary with age: a daily intake of 50 µg is recommended for babies aged 1-12 months; 90 µg for the 2-6 year group ; 120 µg for 7-12 years, and 150 µg for children over 12 and adults. Pregnancy calls for an intake of 200 µg to offset a greater iodine loss in urine, the increase in peripheral connection of the thyroid hormones and iodine being transferred to the foetus through the placenta, the same is true during nursing.

These needs must be met in order to assure normal secretion and synthesis of thyroid hormones, since it has been fully established they play a crucial role in the development of the central nervous system. Thyroid hormones are present from early pregnancy and are necessary for brain development. The normal maturity of the brain depends largely on a fine integration of development centres; likewise hormone supplements determine a child's behaviour pattern.

The human brain starts to develop during foetal life and terminates around the age of 4. During the early months of pregnancy, the mother provides thyroid hormones through the placenta, thereafter the foetus is able to produce them itself and must also meet its own iodine needs.

IODINE DEFICIENCY - CAUSES AND CONSEQUENCES

Today iodine deficiency is accepted as being the main cause of preventable brain damage and mental backwardness. The World Health Organisation, UNICEF and the International Council for Control of Iodine Deficiency Disorders ICCIDD) estimate that even in the early 90s at least 1,500 million people world-wide were exposed to the risk of iodine deficiency, at least 655 million suffered from goitre, 43 million were mentally handicapped to some degree and 11 million had patent endemic cretinism. Iodine deficiency is a permanent geochemical occurrence in some areas of the globe, particularly mountain chains such as the Andes, the Sierra Madre, and places subject to flooding and erosion such as the Amazon. Consequently, food and drinking water has a low iodine content and intake does not meet the daily needs of the inhabitants The iodine content of mother's milk is insufficient to cover the needs of the baby.

Endemic cretinism and goitre have been known since biblical times and treatment was empirical (Fig. 1). It was only in 1811 when Curtois isolated iodine from seaweed that they were related with an iodine deficiency. Later, in the early XX century, the importance of iodine in thyroid physiology was confirmed by separating thyroid hormones. There has been outstanding progress in research on these two illnesses in the last 200 years, and hundreds of epidemiological studies have correlated their prevalence with geographical areas and environmental factors. The first world map of endemic goitre was published in 1960 and showed that iodine deficiency was widely present in the earth's crust and involved almost all countries in the world.

But studies on iodine deficiency reached a peak in the second half of the XX century and revealed other consequences that affect survival and quality of life. Both the studies run in our laboratory and those of other authors showed that iodine deficiency causes low levels of T4 and T3 serum in pregnant women; more miscarriages; and a transitory congenital hypothyroidism rate of more than 20%. When an iodine deficiency is present in foetal life and continues after birth because the mother's milk is deficient, this damages neurofunctional and mental development, the children have a intelligence quotient well below those whose mothers received an iodine supplement (74.4 vs. 85.6, p < 002), likewise hearing and language problems are more frequent.

Abortions in China provided material for a human foetus study that confirmed the existence of foetal hypothyroidism and goitre. More recently, De Long listed the three main features of endemic cretinism as being deaf-muteness, mental deficiency and motor disorders and established the existence of different types of endemic cretinism with different neurological patterns. Likewise, a large-scale analysis of studies made by different authors confirmed that the average intelligence quotient of the iodine-deficient population is 13.5 points below that of the rest of the population. It is important to stress that furnishing an iodine supplement during the critical stages of foetal life can prevent such damage.

IDD: METHODS OF PREVENTION AND CONTROL

Prevention of IDD and treating those cases that are reversible, such as goitre, can be achieved by administering a suitable amount of iodine. A French chemist, Boussingault, working in Colombia in 1825 was the first person to propose such a treatment and tried to persuade the authorities to use it. This was only done a hundred years later.

Iodine can be administered in different ways: by fortifying food, supplements or diet diversification. The aim is to guarantee an average intake of 150 µg per day.

IMPORTANCE OF IODIZED SALT AND EXPERIENCES IN THE AMERICAS

Iodised salt is the most cost/efficient method, it is user-friendly and easy to implement. Because salt is an item of mass consumption, an average of 10 grams a day, it is easy to calculate the iodization level for each country or region, taking into account the risk of iodine loss between the production centre and the home and thus guaranteeing the required intake. Also, the iodising process is fairly simple and very inexpensive.

Using salt to prevent endemic goitre was prompted by two pioneering studies made almost simultaneously in the early XX century. Marine and Kimball started to iodise salt on a very small scale in 1917 and distributed it among school children in Akron, Ohio, USA, achieving a spectacular success in the reduction and eradication of goitre.

At the same time, Bayard y Hunziker were doing the same in the Zermatt Valley of Valais, Switzerland. In the following years, this method gained ground in Europe and North America but with some restrictions because medical-scientific groups feared it could result in hyperthyroidism and also there was little knowledge on daily iodine needs. At present iodised salt should be viewed as a medical-pharmaceutical product since it is used for IDD control and treatment. Therefore, its production, quality, marketing, consumption and impact on health call for permanent monitoring by government agencies and the producers, with participation of health personnel as shown in

Chart 1

In Latin America, legislation and effective compliance with salt iodization took place mainly between the 50s and 70s and in many countries there was a considerable time lapse between one and the other. Established iodine levels varied considerably and, in the light of current information were unsuitable. In some cases this is because they failed to guarantee the normal iodine intake and have been corrected recently, and in other cases the intake was very high with the risk of producing another thyroid pathology. Most countries use potassium iodate, this being the compound recommended by international organisms because of its greater stability. Nevertheless, this strategy did not achieve the desired effect in most countries. As shown in Chart 2, only Costa Rica managed to normalise the prevalence of goitre, this being the main indicator used at that time. In other countries, this indicator remained stable or showed some reduction in the 20 to 30-year period after salt iodization was introduced. In some countries such as Guatemala, Colombia, Uruguay, endemic goitre was eradicated and later reappeared. Two statements explain this unfortunate experience: failure to grasp the problem and absence of national programs to guarantee monitoring and sustain achievements.

Table 2 LANDMARKS IN IODINE DEFICIENCY

Scientific evidence gathered in the 60s and 70s, which showed that iodine deficiency caused brain damage became the major factor in prompting a new attitude to this scourge that severely affects the quality of life. When ICCIDD was founded in 1986, it gave further impetus to the struggle to control iodine deficiencies that had been initiated many years before. The immediate aim of ICCIDD was to act as a top-level consulting group for the countries and United Nations agencies, and to bridge the gap between knowledge and action undertaken to attain the goal of IDD eradication. It restated the problem of iodine deficiency, placing less emphasis on goitre and focusing on a wider range of disorders that appear at different stages of development and are grouped under the term iodine deficiency disorders (Chart 3).

Chart 3 Iodine Deficiency Disorders (IDD)

Thus, the permanent eradication of iodine deficiency disorders is a pressing matter. The use of iodised oil has appeared as an immediate option while efforts continue to rapidly seek the goal of universal iodization of salt for human consumption. Subsequently, the UNO World Summit for Children held in 1990, assumed the universal commitment to eradicate iodine deficiency as a public health problem by the year 2000, this was endorsed by 71 heads of state and 80 representatives of other governments. The World Health Meeting had previously approved this target for WHO, as had a resolution from the UNICEF Managing Committee. Subsequently, an earlier target of 1995 was set for universal iodization of salt for human consumption and the final goal was to sustain IDD eradication.

IDD CONTROL IN LATIN AMERICA - STATUS

Natives in the Americas used the word "ccotto" to refer to goitre, proof that it existed prior to the arrival of Colon. Most countries acknowledge that iodine deficiency is a public health problem, one that still prevailed in 19 countries around 1990.

All Latin American countries have reassessed IDD over the last 15 years, boosting the government commitment to design and perform control programs. Achievements to date have been remarkable and indicate that the Americas will be the first regions to attain the2000 goal.

The commitment undertaken by governments at the World Summit for Children and support offered by UNICEF, ICCIDD and PHO/WHO, together with other organisms and countries, have been instrumental in the success of these programs. However, it should be noted that some countries need to work harder at setting up an organism to handle programs, as well as monitoring, education, social mobilisation, and collaboration with the salt industry.

Chart 4 Iodised salt: supply, consumption and quality

The latest polls run by international agencies, external assessment of programs in 5 countries and the Mobile Thyroid project in Latin America handled by ICCIDD, shows the following: that in 12 of 14 countries (86%) having up-dated information, iodised salt fully satisfies the need of the population, based on average annual consumption of 4-5 kilos. of salt per person. Furthermore, data furnished by 20 countries shows that 12 of them (60%) iodised salt was being used in 90% of the homes. Seventeen countries are monitoring quality and results show that in nine of them (53%) over 90% of the salt in homes or retail outlets contain 15 ppm of iodine (Chart 5).

The salt industry has been an important factor in this progress, providing more assistance as it comes to better understand its role.

• Information furnished by national programs Iodine concentration in urine and prevalence of goitre

While not all countries are supplying top-quality iodised salt for domestic use, urinary iodine which is the main indicator for appraising impact, is normal in 16 of the 17 countries (95%) appraised, that is, the mean is *100 µg/l and less than 20% has a concentration <50 µg/l is below 20% (chart 6).

Less and less emphasis is placed on appraising the prevalence of goitre because palpation data is unreliable. Recently, schoolchildren at sentry posts in 11 countries were submitted to ultrasonic appraisal and results showed prevalence <5% in each one, using WHO standards. This is the same as in Costa Rica where appraisal uses palpation (chart 6).

Chart 6. Iodine concentration in urine and prevalence of goitre

• Ultrasound following WHO standards Achieving and sustaining targets.

The above information is clear proof that the Region has made considerable progress in IDD control, while admitting there are some cases where the intermediate target of universal salt iodization has not been achieved. Also, a matter of concern is that some countries cannot yet guarantee that the target will be sustained.

We list some matters that need to addressed if the whole Region is to meet the target of sustainable IDD eradication.

1. Current legislation in the different countries establishes varying levels of iodization. These should be reviewed with the aim of reaching a tentative standard of 20-40 ppm.

2. 86% f the countries produce/import sufficient iodised salt to meet the needs of the population. However, only 60% of the countries are using iodised salt in over 90% of homes, and the supply of properly iodised salt (* 15 ppm) at retail points and homes has only been confirmed in 53%.

3. Only some countries have external and internal monitoring of iodised salt and the results show 40-70% compliance with national standards. Most countries monitor retail sales points but not on a regular basis.

4. The use of urinary iodine as the main indicator to measure monitoring impact has been gaining ground in all countries. However, it is recommended that such control be made systematically on a representative sample of the population at risk and not sporadically.

5. There is sufficient evidence that 7 countries: Bolivia, Chile, Colombia, Costa Rica, Ecuador, Peru y Venezuela have reached the goal of eradicating IDD as a public health problem. In five of them, members of the Andean Sub-Regional Group, this has been confirmed by external assessments. Another 8 countries have made considerable progress and only three countries need to work harder to attain the goal.

6. It is essential that all countries reach the goal and assure that it is sustained. Recently, a few isolated cases have shown there is a risk of weakening or regression. It is also very important to avoid an excessive iodine intake, as has been the case in one or perhaps three countries.

Bibliography

1. Towards The Eradication of Endemic Goiter, Cretinism, and Iodine Deficiency (J T Dunn, E A Pretell, C H Daza & F E Viteri, Eds). PAHO Sc Pub N† 502, Washington, D C, 1986.
2. The Prevention and Control of Iodine Deficiency Disorders (B S Hetzel, J T Dunn & J B Stanbury, Eds). Elsevier, Amsterdam, 1987.
3. Pretell E A & Dunn J T: Iodine deficiency disorders in the Americas. En : The Prevention and Control of Iodine Deficiency Disorders (B S Hetzel, J T Dunn & J B Stanbury, Eds). Elsevier, Amsterdam, 1987, p. 237.

4. Noguera A & Gueri M: An·lisis de la situaciÛn de deficiencia de iodo en AmÈrica Latina: Sus tendencias y estrategias de acciÛn. OPS, HPP/HPN/27/94, INCAP DCE/016, Washington, DC, 1994.
5. Salt iodization for the elimination of iodine deficiency (M G Vencatesh Mannar & J T Dunn, Eds). MI-ICCIDD-UNICEF-WHO. Ottawa, Canada, 1995.

6. Niveles de yodo recomendados en la sal y directrices para vigilar su adecuaciÛn y eficacia. OPS/OMS-UNICEF-ICCIDD. WHO/NUT/96.13. Ginebra, 1996.

7. Pretell E A (Presidente), Cevallos J L, Degrossi O, Del Soler G, Escobar I D, Fierro BenÌtez, GÛmez V, G¸el R, Higa A M, Magos C, MartÌnez L, Medeiros G, Musso S, Salveraglio C, Torres J E, Vera J, Verduzco C : Concenso sobre los DDY en LatinoamÈrica. Criterios de evaluaciÛn y monitoreo para su erradicaciÛn sostenida. FederaciÛn Panamericana de Sociedades de EndocrinologÌa. Rev. Arg. Endocrinol. Metab. 35:239, 1998

8. Progress towards the elimination of iodine deficiency disorders (IDD). WHO/NHD/99.4. Geneva, 1999.

9. Indicator for assessing the iodine deficiency disorders and their elimination. Report on a consultation held in WHO, Geneva, May 4-6, 1999 (en prensa).



Frits Van der Haar. Professor Frits van der Haar, Technical Director, PAMM

Your Excellency, Esteemed Dignitaries, Colleagues, Friends, Ladies and Gentlemen, Good Evening.

On behalf of the Salt 2000 organisers, I'd like to thank you for this great opportunity given to explain the detailed plans for an extraordinary event that will take place at the 8th World Salt Symposium which will be held in The Hague, the seat of Government of The Netherlands, from 7 till 11 May of the Year 2000.

In November 1997, the Salt 2000 Foundation first announced the 8th World Salt Symposium. It did so under the banner "Salt, Life depends on it." The announcement explained that the scope of planned events include the following:

• A Scientific Programme
  
• A Technical Exhibition
  
• A Public Exhibition
  
• Technical Visits
  
• Social/Partner Programme

The invitation is extended to all persons involved in salt and its uses:

• General and functional management,
  
• Scientists, engineers and technologists
  
• Expert advisors and consultants
  Regulatory and governmental authorities

Encouraged by the challenge in this announcement, a group of concerned organisations started a joint effort of working with the Salt 2000 organisers to "Put Iodine Inside" and assure an appropriate place in the planned events for the ongoing efforts at universal salt iodization for the global elimination of IDD. These organisations include UNICEF, WHO, The Dutch Development Directorate, Kiwanis International, ICCIDD, MI, PAMM, and others added in time.

The over-riding goal of the work plan would be to give special meaning to the motto of the 8th World Salt Symposium. By putting Iodine Inside, these actions would support the motto by the added quality of life from the production and supplies of IODIZED SALT.

At the invitation of the Dutch Development Agency this group met in November 1998 with the Salt2000 organisers and the Europe-based salt producer associations with the aim to develop a work plan of action. The coalition, from its meeting in November 1998, developed the following objectives:

• Celebrate and consolidate the extraordinary achievements already obtained in universal salt iodization;

• Congratulate salt producers everywhere with their continued contribution to the solution of a global public nutrition problem;
  

• Sustain the success into the next century by putting in place the requirement of balanced responsibilities and approaches, from:

• Quality Assurance of iodised salt;

• Surveillance of iodised salt supplies and iodine status in the population;

• Vigilance in society against re-occurrence of iodine deficiency as a public nutrition problem.

The work plan of the coalition includes the following actions:

• A comprehensive communications effort;
  
• Reporting on the World USI Status at the end of the millennium;
  
• Holding Salt Producers Meetings in various regions of the world.

These "Run-up" meetings are proceeding according to the formula shown:

• In the region, identify key significant salt producers and traders, to,
  
• Obtain a consensus on the promotion and implementation of USI, and
  
• Improve mutually supportive actions among producers as a group,
  
• Obtain inputs for the agenda of the Salt2000 Symposium,
  
• Carry out national assessments for the World USI Status report, and
  
• Create ongoing communications to enhance "Freedom from IDD forever".

This is the list of Regional Salt Producer Meetings:

• End September this year, a total of 120 people met in Kiev, the capital of Ukraine, coming from 24 countries in Central Eastern Europe, the Commonwealth of Independent States and the Baltic's;
  
  
• Today in Bogota, the capital of Colombia, we celebrate the opening of the Latin America and Caribbean regional meeting of salt producers with the public sector on USI for the elimination of IDD. It is very heartening for us to see the strong turn-out, and to notice the keen anticipation of all participants;
  
  
• In the 2nd week of February, 2000, a salt producer meeting will be held for All-Africa in Mombassa, on the Indian Ocean Coast of Kenya; and
  
  
• Prelimi
  nary plans are being made for a meeting for South Asia to be held in Colombo, the capital city of Sri Lanka.

Each of these meetings and the associated assessments contributes valuable information on the role of the salt production and supply sector in achieving USI for IDD elimination around the globe.

We now return to the Salt 2000 Symposium, with "Iodine Inside". The scope of the Scientific Programme includes the entire spectrum of salt occurrences and uses. A significant part of the action addresses the theme of "Iodised Salt for Sustained IDD Elimination".

The theme is given its format from the following activities:

• A plenary session entitled "An IDD Free World: How to keep it that way". We are excited and grateful that we have obtained acceptance for a keynote presentation by Professor V. Ramalingaswami of the All India Institute of Medical Sciences in New Delhi, India. Professor Ramalingaswami is an eminent scientist with early and continued interest in IDD and its global control. He is a special advisor to both the Director-General of WHO and the Executive Director of UNICEF.
  
  
• There will be 5 parallel sessions all focusing on technical issues and the benefits for public nutrition of iodised and otherwise fortified salt;
  
  
• Top UN officials will speak at the Festive Opening Ceremony; o The coalition will provide a booth at the technical exhibition; and
  
  
• It is likely that the UNICEF/Kiwanis Ambassador and Spokesperson on IDD, Mr. Roger Moore whom most of you will remember as James Bond, will give the speech at the gala dinner.

The "Iodine Inside" coalition provides one of the two plenary sessions. Parallel sessions are provided almost throughout the duration of the scientific programme. The coalition will provide a stand at the technical exhibition, which runs continuously. Poster presentations will be made at the two poster sessions. And Ms. Carol Bellamy, Executive Director of UNICEF and Dr. Gro H. Brundtland, the Director-General of WHO have both committed to speak at the festive Opening Ceremony.

In the Salt 2000 Exhibition and with leadership of the Micronutrient Initiative, the coalition will provide an exhibit, composed of a balanced representation of the work done by all members in the global elimination of IDD through universal salt iodization.

I wish to remind you that in the year 2000 in The Hague, the 8th World Salt Symposium, organised by the salt industry, is a special occasion that offers much more than what I could present to you in this short time.

The efforts by the coalition, in positive collaboration with the responsible salt industry, will lead to a clearly visible range of offerings on USI for the global elimination of IDD at the Symposium, to really make the Salt2000 motto come true: Salt, Life Depends on It. Please join us in these efforts. Please, participate in Salt 2000.

On behalf of the Salt 2000 organisers, jointly with the Salt 2000 coalition, for the privilege of speaking to you tonight, I say thank you.



Mr. Nicolas Febres Cordero, Administrative Manager Of Ecuatoriana De Sal Y Productos Quimicos. E C U A S A L, Ecuador

We are very pleased to be a part of an international gathering, this time, at the level of Latin America and the Caribbean Nations, where the experiences, achievements and definitive solutions to the problem of the struggle against all the terrible diseases originated from iodine deficiency in the nourishment of our nations will be discussed in depth.

As on previous occasions, I am here in a dual capacity: on the one hand, I am honoured to be the representative of a private salt producing company, in general, and, on the other hand, as Directive of ECUASAL, a company which, being a pioneer in the preparation of iodised salt for human consumption and, at the same time, the main salt producer in
Ecuador, has played a major role over the past four decades in the difficult struggle to eliminate endemic goitre, cretinism, congenital malformation and other disorders derived from iodine deficiency in the daily diet.

Ecuador's achievement, specially in the struggle against endemic goitre, constitutes without a doubt, a faithful reflection on the efficiency of a commitment, when responsible governments and honest entrepreneurs work hand-in-hand to overcome hurdles in favour of a peoples health, specially in those most forsaken areas of a population. In this manner, governments fulfil the obligation imposed upon them by their mandate and modern entrepreneurs, with a social sense, also comply with their inescapable obligation to serve, within their means, the society where their companies develop their activities.

With respect to the Ecuadorian example, we must emphasise the speed at which such results have been obtained, since over a period of only 30 years and with few resources, specially in the beginning, the fight against goitre shows significant numbers, and, I must mention that around the 1960's, disorders such as goitre and other related diseases affected, in average, about 33% of the population in Ecuador, and in certain areas of the Ecuadorian Mountain Range, this number exceeded 80% of the population. Currently, at the end of the century, the latest official numbers recently revealed in the last research submitted by Quito, show that such diseases affect very few communities, while the iodised salt already reaches more than 95% of the population in Ecuador.

We feel very proud to have been and to continue to be, as a private company and together with a high level public sector, a fundamental factor in such achievement in our country, Ecuador, where, I repeat, the existence of endemic goitre in the risk areas is discarded. However, we will continue supporting the Operational Program to struggle against Endemic Goitre and Cretinism, so as to guarantee sustainability of the aforementioned program and thus, achieve total and definitive eradication of the referred diseases. Likewise, we offer our Latin American and Caribbean brothers our experiences of over 30 years, so they may avoid making our mistakes and, if possible, improve our successes.

We must publicly acknowledge the team of officials and technical personnel, among others, Dr. Mauro Rivadeneira and Dr. Paco Canelos, who, from the very beginning of this struggle, have arduously worked, feeling assured that their perseverance and mystique have been transferred, with similar intensity, to the task being recently carried out by many other public health professionals. But, above all, and to be very fair, we must acknowledge that without the help of the Government of the Kingdom of Belgium, we wouldn't have been able to implement, with such efficiency, the Program for the Struggle against Goitre and Endemic Cretinism, a cooperation that over the past fifteen years has unquestionably resulted invaluable; and all this, with the constant support of international organisations such as UNICEF and the Pan-American Health Organisation.

Co-ordination between public and private entities, on the specific subject of salt iodization that we are dealing with today, is really simple when both parties so desire it. This co-ordination must be founded on the common wish and total conviction that this process leads to collective welfare, above and beyond any particular, economic or political interest. If a country or region obtains this support or basis as occurred and occurs in Ecuador, the rest follows smoothly and, over a relatively short period of time, results are perceived that further feed the desire to continue towards the final goal without being hindered by mean interests.

My participation would not be complete unless I make certain comments that could be considered as suggestions, and which might help for current or future campaigns in our countries.

First of all, recommend authorities to give preferential treatment, mainly with respect to taxes, to production and sale of human consumption products, such as iodised and fluorinated salt, because it seems incongruent, to say the least, that the State raises prices on basic products which, in turn, are vital instruments to preserve the health of the people. In Ecuador, like in other countries, the serious mistake is being made of taxing the raw material that lead to a final product, such as iodide or potassium iodine, and now fluorine, which are added to salt by law, and that, in our case, increase the cost by approximately 30% when entering the country, as well as other materials and packing imported or acquired in the national market. We definitely cannot speak of "universalising" consumption of iodised salt if the product is not kept at a more accessible economic level.

Secondly, we must respectfully request Health Authorities to exercise stricter controls on the different salt preparation, transfer and commercialisation levels, as, unfortunately, there will always be irresponsible producers who operate clandestinely and who violate the laws, specially the health-related laws, releasing harmful products in certain market sectors, which are usually the most affected, from the health standpoint.

At this point, I would like to state my concern when I notice that in certain areas the opinion prevails that to iodise salt is difficult for small producers. Frankly, I disagree with such opinions, because as we all know that the industrial process of iodising salt is neither technically difficult nor economically expensive. The core of the problem lies in the need to have the corresponding authorities exert the necessary control and follow-up, in order to achieve the universality we all hope for.

Finally, it is necessary for the private entrepreneur to pay more attention to his own control processes, with the systems and laboratory equipment that modern science places at our disposal, in order to guarantee regular and correct doses of iodine and, as an endorsement to his goodwill, establish his own external controls to allow timely correction of mistakes or involuntary deficiencies, beyond the producer's control. All this, naturally in addition to the regular and essential official controls.

Unfortunately, in the case of our country, Ecuador, only two or three salt industries have complied with our obligations throughout our entire operation, and we have, at the same time, always showed the most decided support to all that has been required from us. Our participation has been recognised by organisations such as UNICEF, when our National Government, presided by Architect Sixto Dur·n-BallÈn, was bestowed a decoration. Also, when ECUASAL was celebrating its first 25 years of industrial operations, it was formally said that notable achievements in our country were due, in good measure, to the decided cooperation from serious and reliable producers.

Distinguished Authorities here present: if the economic and administrative means are not found to allow total and permanent control and follow-up, let me be very frank when I state our sincere concern in the sense that all efforts thus far made and all new initiatives will have served no purpose, even worse, they will become a mere mockery, not only to you who are deploying enormous efforts with the best intentions, and to us, producers, who are complying with the law at a very high price, but mainly, to our populations, who are, in definitive, the ones to whom we must explain our acts.

As private entrepreneurs, we reiterate our indeclinable position to continue co-operating in all causes that, one way or another, lead to improving the standard of living of the Ecuadorian people. We were pioneers in salt iodising and subsequently in its fluorination, reason why now, as ECUASAL, we once again ratify our indeclinable commitment of permanent social service, expressing at the same time, the enormous satisfaction derived from a totally fulfilled duty.




Dr. Erick Boy. Senior Programmes Specialist. The Micronutrient Initiative

Double fortified salt (DFS) is a highly purified salt which has been fortified withmicro-encapsulated ("spray-dried") KIO3 and ferrous fumarate. Iodate is encapsulated using dextrin. Ferrous fumarate is available at commercial level. The capsule prevents iodine (a stable alkali) and iron (a stable acid) to react with each other (iodine sublimation) in the presence of humidity.

Double fortification of Salt with Iodine and Iron is a unique opportunity since well established salt iodization programs around the world, the Infrastructure to refine, iodise, pack, and distribute installed iodised salt could be used. The addition of stable and bio-available iron can be made at a minimal marginal cost to attend another public health problem: iron deficiency anemia.

Studies carried out

• Stability
  
• Acceptability by the consumer
  
• Bangladesh
  
• Guatemala
  
• Ghana
  
• Absorption in mice
  
• Absorption in vitro and in vivo
  
• Efficiency studies in Ghana

Conclusion of the efficiency study in Ghana: 23% reduction in the anemia prevalence in children after an 8-month period consumption of DFS compared with the group receiving iodized salt. There was a decrease in over 50% of iodine deficiency in women and children (effect of the iodized salt only).

Components of the DFS:

The National Institute of Nutrition in India used Ferrous sulphate, Sodium hexametaphosphate and Potassium iodide/iodate. The process at Toronto University used ferrous fumarate and Potassium iodide/iodate encapsulated

Processing

• It requires additional washing/grinding/drying
  
• Fortification
  
• Additional packing

Cost

• Refining
  
• Fortifying agents and additives
  
• Packing

The cost of DFS with Fe and I depends on whether there are facilities to refine salt, capacity and number of fortification units, a roofed physical area for the salt plant, warehouses for grinded/refined salt and other needed equipment.



Dr. Jes™s Toledo Tito, General Director, Public Health Department, Ministry of Health.

Introduction

It is widely known that iodine deficiency is the main preventable cause of mental and physical disabilities. This deficiency is responsible for the loss of at least 15 points in the intelligence quotient. Minute quantities of iodine consumed daily through iodised salt or sea products define the quality of life of people living in iodine deficient areas around the world. This is the case of the sierra and forest areas in Peru, where approximately 11 million people live.

Peru, a country of geographic, climatic and cultural mega-diversity, with a total population of 24.8 million, suffered the effects of iodine deficiency for many years. This problem was recognised more than a century ago, and the first efforts to control it appeared in 1940, with a legislation to make the supply of iodised salt mandatory in goitre areas. In 1969 this legislation was modified to include the obligation to produce and consume iodised salt. Unfortunately, both laws were only partially implemented. It was not until the 80s that a control policy was defined.

In 1990, the Government committed itself to eliminate Iodine Deficiency Disorders (IDDs) as a public health problem before the year 2000, considering it one of the priorities within the Health Policy Outlines, the National Action Plan for Children, and the Feeding and Nutrition National Plan.

Program Development

The base-line study carried out during 1986-87 showed that iron deficiency had reached an important dimension in 60% of the population living in the sierra and the forest. A severe deficiency was found in both north and south sierras, with a goitre prevalence of 36%. Likewise, the study detected that the production of iodised salt only covered 57% of the population, and its consumption in the sierra and the forest was less than 60%. Knowledge about IDDs was scant.

Given this situation, the National Program established the following goals:

To guarantee the supply of iodine to the population in the short and medium terms, and
To establish as a final objective the total elimination of iron deficiency disorders through the universal consumption of iodised salt for the year 2000.

After a sustained program, which has been implemented for more than a decade, it has been possible to control IDDs. The strategic plan included a combination of supplementation interventions for high-risk populations, and support to the production and commercialisation of iodised salt. Unfortunately, this support was only partially given due to the crisis situation of the 90s, as well as the new free-market context. Progressively, a national working network was built through training and sensitising programs, as well as information, education, and communication activities, and epidemiological surveillance and monitoring.

The frequency of the interventions was planned according to the present situation and resources, which initially came from International Cooperation through PAHO and UNICEF. After that, the Government assigned a budget, which became a regular activity in the Annual Plan of the Ministry of Health.

In 1992 the salt iodization control system was implemented. It allowed to identify medium and small iodised salt producers, which began to multiply in the context of the free-market. In order to promote and strengthen universal salt iodization, a project was developed jointly with UNICEF, based on social marketing strategies, and applying public segmentation and benefits exchange. This project was addressed to everyone involved in products demand and supply, such as salt producers, dealers, authorities, health staff, opinion leaders, etc. The strengthening of the surveillance system was also taken into consideration.

Attention to small producers became a priority through training programs, the creation of a potassium iodate revolving fund, technical consultancy, development of a salt iodization control system in salt plants, non-iodised salt commercialisation control, and information, communication and education actions.

Despite the economic, political and social difficulties, the first independent evaluation requested in 1996 by the Ministry of Health came to the conclusion that the country had managed to achieve significant steps towards the goal of IDDs elimination, and that the medium-term goal of the universal salt iodization had been reached.

Current situation

In 1998, an international committee of experts, gathered to conduct a second evaluation, verified that the country meets the criteria set forth by WHO, ICCIDD and UNICEF to be considered as a country free of IDD:

Universal iodization of salt for human consumption 100% coverage has been achieved and sustained since 1995, of which 70% is produced by the largest salt plants and 30% by medium and small salt industries. Ninety four per cent of all plants have complied with the salt iodization regulation, and the quality of salt iodization in the market has improved from 43% in 1992, to 91% in 1999 (the iodization level is over 15 ppm).

Generalised acceptance and consumption of iodised salt for human consumption. This aspect has had a sustained increment in high-risk areas since 1994 -from 61% to 97% in 1998. Likewise, the utilisation of iodised salt for animal consumption has been encouraged.

Normalisation of the urinary iodine level, the main biologic impact indicator Between 1986 and 1997, a sustained increment of 71 µg/L to 250 µg/L, together with a drop of urinary iodine from 36% to 5% have been achieved.

Reduction of goitre prevalence in school-age children from 36% to 11% between 1986 and 1995 The most recent thyroid gland ultrasound evaluation carried out in November 1998 by the ICCIDD, showed a goitre prevalence under 1%.

Following these results, the United Nations granted Peru with the International Certification for the virtual elimination of IDDs, based on the report generated by the Evaluating Committee which established that "Iodine deficiency has been virtually eliminated in Peru; we can foresee excellent perspectives if the Program is capable of maintaining the current situation". UNICEF, PAHO and ICCIDD in Lima, Peru signed this declaration, on November 1998.

Key aspects for success and sustainability
1. Strengthening of Institutional Capacity

• There is a political commitment from the Government to consider the sustainability of IDDs control as one of its national health priorities.
  
• There is a technically sustained national program whose activities are included in the regular program of the Ministry of Health, with a specific budget.
  
• The legislation for mandatory production, commercialisation, and consumption of iodised salt for human and animal consumption is in place and applied.
  
• There are trained and highly motivated human resources to maintain the goals already achieved.
  
• Technical and financial support has been received from International Organisations during the different stages of the process (UNICEF, PAHO/WHO, USAID, Cooperation of the governments of Belgium, through the Andean Sub-regional Program of IDDs Control, Canada and the European Union, as well as the permanent technical consultancy of ICCIDD).

2. Commitment of the salt industry to keep quality and sufficient production volumes of iodised salt. The largest industries keep an optimal level of iodization, while the medium and small industries are making efforts to overcome the 80%. A permanent relationship between the program and the salt producers is being maintained. …

3. Permanent availability of iodine to produce iodised salt through the potassium iodate revolving fund. The Fund is available in those departments where production centres work. In those areas where a private importer exists, the Fund serves as a regulating agent. A key aspect is that the Fund keeps a quantity of 1,000 kilograms of iodate in reserve, which can only be used, in emergency situations and to avoid interruptions in the salt iodization process. …

4. A surveillance and monitoring system for all process indicators (iodization quality and iodised salt availability), outcomes (iodised salt consumption prevalence), and impact factors (urinary iodine), with decentralised laboratories for controlling salt iodization and a large-scale field qualitative instrument. And as a national reference system, there is also the national nutritional indicators monitoring system of the Feeding and Nutrition National Centre. …

5. Training is delivered regularly to all social agents involved in the salt production, commercialisation, consumption, control and surveillance chain, as well as educational contents incorporated in all health actions.

6. A permanent communication plan addressed to the public, using the interpersonal, group and mass media channels. Joint production strategies with local radio stations and the participation of local actors will allow the use of such resources. …

7. Involvement of the community and local authorities in the surveillance of iodised salt. The use of the qualitative kit has been an instrument that has promoted general participation. …

8. A multisectorial strategy based on the interchange of benefits between all social actors.

9. The ultimate challenge:

To keep the achieved goals, for which it is necessary to continue with the salt monitoring system, the joint work with all iodised salt producers, surveillance of the population, maintenance of the revolving fund, sensitisation of the Community, and general awareness of the situation.

To carry out technological improvements for medium and small producers, taking into account that the double fortification of salt with iodine and fluorine must be started. The Ministry of Health will expand the monitoring system of iodine and fluorine content in salt.

To maintain sustainability of the goals achieved is everyone's task. We must be conscious that access to iodised salt is a right for all Peruvians and that it can be taken as a basis for social development.



q CASES STUDIES IN BRAZIL, GUATEMALA AND DOMINICAN REPUBLIC

q SITUATION OF SALT IODISATION IN BRAZIL.

• The Micronutrient Initiative (Agide Gorgatti Netto). November 1999

BACKGROUND OF IDD CONTROL

• 1953: Law # 1.994, August 14 of 1953.
  
• 1974: new Law # 6.150 - all salt for human consumption,10-30 ppm. Obligation for purchasing KIO3 = the salt industry. Sates, territories and municipalities should carry out control.
  
• 1974: sub-program of salt iodization adopted the strategy to give it free ß 1975 - Decree # 75.697: Standards of Quality and Identity of salt for human consumption.
  
• 1977 - Decree # 80.563, established salt for animal consumption should be iodized.
  
• 1978 - creation of the Program to Combat Endemic Goiter ß
  
• 1982 - creation of monitoring of salt and epidemiological surveillance sub-programs.
  
• 1984 - "sentinel" areas selected in 15 municipalities: Par·, Maranh“o, Bahia, Minas Gerais, Goi·s (and subsequently Tocantins). Children between 9 to 14 years old.
  
• 1994 - Resolution # 1.806: new fortification levels (40 to 60 ppm).
  
• 1995 - Law # 9.005 "Ö. the Ministry of Health will provide ...iodine to the salt industries".
  
• 1999 - MoH resolution # 218: new fortification levels (40-100 ppm).
  MH no longer responsible to provide free iodine to salt industries.

RECENT LEGISLATION SITUATION ON SALT FORTIFICATION WITH IODINE LAW 6.150/74 established the responsibility of salt industries to buy potassium iodate (government provided it from 1993 - April, 1999)

LAW 9.005/95 established from 1995 until 1999 the responsibility of the Federal Government to provide potassium iodate to salt industries.

REGULATION # 1.806/94/MH establishes the iodine content in salt for human consumption: 40-60 ppm

REGULATION # 218 - March 25/99/MH establishes a new range for iodine content of salt for human consumption: 40 - 100 ppm

PROVISIONAL RULE 1.814/23-04.99 established the obligation of Federal Government to provide iodine salt to industries.

PRESENT SITUATION: the Federal Government at the present moment decided not to provide iodine to salt industries and concentrate efforts on Inspection and IEC activities. The Brazilian Legislation requires that both salts for human and animal consumption must be iodized. The Brazilian Government bought in 1998, 270 t. of potassium iodate, to be distributed among salt industries.

GOITER PREVALENCE

• 1955: survey by MoH - 20.7% of 86.217 school children presented signs of goiter.
  
  
• 1974-1976 - MoH Survey: (n=421.752 school children) a decrease of 33% in 20 years (15 million Brazilians with goiter)
  
  
• 1995 survey: Goiter confined to some States (Mato Grosso do Sul, Mato Grosso, RondÙnia, Tocantins, Amazonas y Acre. But also salt producer States like Rio Grande do Norte, show signs of having IDD.
  
  
• National prevalence in 1995: 1.3% o It seems that in cattle grower States (Mato Grosso, Mato Grosso do Sul , Goi·s, RondÙnia, Tocantins) part of the rural population is using salt for animal consumption
• 1995: In zones of risk of 35 municipalities with mean values above 10mg/dl, 10% showed iodine below 2,5mg/dl, which indicates that a reasonable part of these population has a deficient consumption of iodine.

During November, 1999: Sanitary Control of the Ministry of Health, collected 147 salt samples showing that 82% of the salt samples were iodized > 40 ppm (1.36% = 0 ppm).

QUICK MARKET SURVEY

There are approximately 169 establishments involved in salt, both for human and animal consumption. However we may say that about 17 establishments, responsible for production of 90 to 95% of salt (both refined and grinded) for human consumption (i.e.grinded salt brand "MIRAMAR", responsible for 1/3 of all salt destined for human consumption). The production of refined and milled salt in 1998 was of 2,464,201 TM

The two most important results of the quick market survey by interviewing CEO and other salt executives are:

• Even big salt companies feel a need of a better QC/QA program for their industries
  
  
• There is a general complain that the State Control Services do not exert their full obligation in relation to inspection duties. This is being currently reinforced.

CONSUMPTION OF SALT AND COSTS OF IODIZATION ASSUMPTIONS

Direct consumption: 12 g/person/day
Indirect consumption: 4 g/person/day
Total: 16 g/person/day

* 5,84 kg/person/year × 166 million inhabitants
* 970.000 t./salt/year

The salt industries estimate that 870.000 t. Is consumed in the form of refined salt and 100.000 t. is consumed in the form of grinded salt.

Estimates also says that:

About 86% of refined salt, i.e. * 750.000 t, is produced by large salt industries.

About 14% of refined salt, i.e. * 120.000 t, is produced by medium and small salt industries.

Another 1.500.000 t of grinded salt is sold in bulk or in 25-kg plastic bags for animal consumption.

Grinded salt is mostly consumed in the Northeast area of Brazil, particularly in rural areas.

Lately it is presumed that at least part of salt for animal consumption is consumed by humans in cattle growers states such as Mato Grosso, Mato Grosso do Sul, Par·, RondÙnia, Tocantins, etc.

Outstanding facts from field notes:

Large producers agree to non-subsidized provision of iodate conditionally.

As a counter part they require the government to be more effective in the inspection process

Small producers still demand the government to provide free iodine, saying that the burden to buy potassium iodide is too heavy.

Insterinstitutional commission created to reach a concensus (Insterinstitutional Commission for IDD Control, Nov. 1999) on several issues.

CURRENT ACTIVITIES UNDERTAKEN IN MICRONUTRIENTS:

The Ministry of Health is trying very hard to organize the system, and is under way a "National Program to Control Micronutrient Malnutrition in Brazil", that gives strong priority for food fortification, including the fortification of salt with iodine. This Program is receiving financial support by both Federal Government and International Organizations. National Monitoring of Salt Quality and reinforced inspection at the industry and retail levels (as result of recent salt analysis): training, manual of good production practices, market sampling, etc.

IEC activities being reinforced through community health workers.



q SITUATION OF SALT IODISATION IN GUATEMALA ARCHIVO EN PPT (DISQUETTE). FAVOR INSERTAR AQUI LAS GRAFICAS 1, 2, 3 Y 4

q SITUATION OF SALT IODISATION IN DOMINICAN REPUBLIC ARCHIVO EN PPT (EN DISQUETTE) FAVOR INSERTAR AQUI LOS CUADROS No 1, 2

y 3. ADEMAS LAS GRAFICAS No 1 Y 2

v SUMMARY OF THE KEY ASPECTS OF THE SESSION

Positive experiences were presented that demonstrated the growing incidence of salt iodization and the important decline in problems associated with iodine deficiencies -- accomplishments made possible thanks to the decided commitment of salt producers and to the complementary work by the public sector responsible for IDD control programmes. The efforts by small producers are very valuable, but technical and financial support is needed for them to be able to join together and have solid industries that are capable of maintaining an optimal quality of iodized salt.

A call was issued to governments to maintain permanent surveillance of salt iodization, so that the companies that are correctly carrying out the task of iodization do not find themselves at a disadvantage vis-ý-vis those that are not following the norms.

Both dry and wet iodine application techniques were reviewed, as well as the use of iodide and iodate. Neither technique was rated as preferable to the other, but rather, they both were considered valid according to the reality of each company and each country. However, it was clear that the application of iodine should be accomplished as closely as possible to the end of the refining process in order to prevent the losses that can take place during the process itself.

The issue of Quality Assurance was touched on, mentioning the importance of using ISO 9000 norms, which facilitate both the control of iodine application in the companies' process of salt refining, and external surveillance and control by the State.

On the topic of double fortification of salt, there is no disagreement about salt being a good vehicle for fortification with one or several micronutrients, as is being done successfully with iodine and fluoride. There was an exchange of interesting experiences in salt fortification with iron, and although the outcomes have been heartening from both the technological and nutritional perspectives, research continues in the effort to define the best vehicle for incorporating iron. Under the current conditions of Latin America and the Caribbean, for the time being it is not considered to be a proposal that can be transferred to the salt industry, and instead there is a preference for continuing experiences in fortifying flour with iron.

Finally, it is recognized that the proper iodization of salt and the elimination of iodine deficiencies must be a permanent job for all sectors and actors, including the entire community, so as to consolidate the successes and avoid the slippage that has occurred in some countries because of a lack of commitment by government and industry to make their achievements sustainable.



v CONCEPTUAL FRAMEWORK OF A QUALITY GUARANTEE SYSTEM FOR SALT IODIZING PROGRAMS.

Dr. Omar Dary M. Nutritional Institute of Central America and Panama INCAP/OPS Guatemala, Central America.

INTRODUCTION

I would like to begin this presentation with an anecdote. A few years ago I had the opportunity to visit Switzerland. As I was walking down a street, I noticed that there were piles of newspapers in the corners and an open basket so buyers could deposit the price of the newspaper. Now let me ask you a question: If we wanted to repeat this experience in any city of Latin America, what would happen? Evidently, the results wouldn't be the same. This example leads us to a conclusion: processes and solutions must be adapted to the idiosyncrasy and conditions of each region or country. What is positive in one place does not necessary produce the same results in another. This conclusion is also applicable to control and monitoring systems on food fortifying practices and, in the specific case of this event, on salt iodising.

Our current globalized world, with an ever increasing trend to open trade markets between countries, will force production companies in every country to improve and introduce control and monitoring systems to guarantee products that meet technical specifications. In our countries we already see certain industries that have certificates of good manufacturing practices issued by the International Standards Organisation (ISO). This means that sooner or later, we will have quality companies - if they survive - producing goods and services, and among them, that of iodised salt. That however is the theory, current reality is something else. The salt industry in the Latin American region is very heterogeneous, going from rudimentary artisan production to the most sophisticated state-of-the-arts processes in the world. From the public health standpoint, we require that products from all those companies, regardless of how developed they are, produce correctly iodised salt. The challenge is then to have an effective and efficient Quality Assurance System for all. The challenge acquires further importance with artisan industries. This is our situation in Central America, and I would like to share with you our experiences and conclusions.

WHEN INTERFERENCE DOES NOT WORK

In Guatemala, a national survey was undertaken in 1995 on micronutrients including iodine content determination in home obtained salt samples. Taking advantage of this activity, a salt iodising surveillance program was simultaneously started in public schools as part of a UNICEF promoted and financed program, with INCAP technical support. Encountered situation was moderately acceptable, 88% of the samples showed iodine with a level equal to or exceeding 15 ppm. That very same year, a series of training program began to improve marine salt product. Part of this training included the use of a qualitative kit to determine iodine presence. One year later we discovered that the percentage of iodised salt, of at least 15 ppm, had reduced to 49%. This means that the measure led to program deterioration. This however was not the only factor that changed. Supervision of salt producers by the food control authorities has also been reduced. This case serves as an example that State inspection is vital to maintain the iodise program and that, in Guatemala's case, this role can not be replaced by simply introducing a qualitative kit to artisan salt producers.

In 1996, when we compared Guatemala's case with that of neighbouring countries, Honduras and El Salvador, the contrast was more remarkable. In those two countries, although program quality was not optimum, it was much better. Three years later, Guatemala's conditions remain unsatisfactory, while in the two other countries, the quality of iodised salt has remained stable or even improved. An important issue here is that producers in neither country have correct quality practices. The question is then; why the difference?

Both in El Salvador and in Honduras, like in Guatemala, there are hundreds of small marine salt extractor artisans. Howev