IDD%20prevention%20program%20in%20Bulgaria-Progress%20of%20Universal%20Salt%20Iodization

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IDD prevention program in Bulgaria-Progress of
Universal Salt Iodization

• Ludmila Ivanova, MD, PhD
• Sofia, Bulgaria

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The main purpose of the presentation

• To share Bulgarian experience in USI as most
  effective strategy for sustainable
• Elimination of IDD

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Iodine deficiency an age old problem Bulgarian
icons with goiter
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Bulgaria is a country with 1/3 of the territory
being endemic

• For the first time a Regulation on IDD
  prevention was introduced in 1958
• The strategies were focused on endemic regions
  only.
• Salt iodization and iodine supplementation with
  tablets of target groups (children, pregnant
  women) was implemented
• The outcome was reduction of goiter from 55.9 to
  12.1 in the following 15 years.

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In 1994 the new Legislation was introduced based
on

• Lessons learned by the previous National
  Regulation lack of sustainability
• Focused on endemic regions only
• Irregular production and distribution of iodine
  tablets
• High costs and low coverage rate of iodine
  tablets
• Lack of intersectorial co-operation
• IDD situation in Bulgaria increased incidence
  of goiter
• International Recommendations Universal salt
  iodization (ICCIDD/UNICEF/WHO)

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National Legislation on IDD Control

• Government Decree 96/17.05.1994 of the Council of
  Ministers (State Gazette 43/27.05.1994)
• Order N RD-09-244/14.06.1994. of the Chief State
  Sanitary Inspector of the Republic of Bulgaria
  (State Gazette 52/26.06.1994)
• Amendment N 7/01.07.1996 to Bulgarian State
  Standard 628-77 Table salt
• Ordinance for Requirements to the composition and
  characteristics of food grade salt (State Gazette
  11/06.02.12001)

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Government Decree 96/17.05.1994 was
developed to set the foundational of the IDD
Elimination Program Main Principles/Activities

• Universal salt iodization covering all salt for
  human consumption, food industry and cattle
  breeding
• Short term additional prophylaxis of risk
  groups-(schoolchildren and pregnant women) in the
  endemic regions with iodine tablets for the
  first 2 years of the program ( high goiter grade
  over 30 )
• Trade policy stimulating the import of iodized
  table salt
• Establishment of National Monitoring
  System-capacity building, training ect.

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National Program for Control of IDD -
Multisectoral Efforts

• Institutional support / Intersectoral
  Co-ordination
• National Coordinating Committee for IDD Control
  (MOH,- Industry, -Trade, Salt Producers,
  Finances, Agriculture, Committee of
  Standardization, Thyroidologists, Nutritionists,
  NGO,s)
• Expert Council on IDD at Ministry of Health

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Order N RD-09-244/14.06.1994. of the Chief State
Sanitary Inspector of the Republic of Bulgaria

• Prohibition of placing non-iodized table salt at
  the market
• Definition of a system and methods for control of
  the quality of iodized salt
• Creation of a database for recording results of
  iodized salt at the market through the Ministry
  of Health

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Amendment N 7/01.07.1996 to Bulgarian State
Standard 628-77 Table salt

• Salt iodization with potassium iodate at level
  28-55 ppm KJO3 (16.6-32 ppm I).

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Ordinance for Requirements to the composition and
characteristics of food grade salt (State
Gazette 11/06.02.2001)

• Definition For food purposes only salt iodized
  with KJO3 at level 28-55 ppm must be used
• Expiry time, not longer than 12 months after
  iodization
• Specification of storage condition (clean, closed
  and dry rooms)
• Specification of Package material
• Labeling (Ordinance for food labeling, Decree
  136/2000(SG, 62/2000)

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Ordinance for Requirements to the composition
and characteristics of food grade salt (State
Gazette 11/06.02.2001)

• Requirements to Laboratory control
• Sampling procedure (Ordinance 2/1997, SG 10/97)
• Methods-Bulgarian State Standard methods-8840-71,
  BSS 2/92),

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As a result of effective implementation of
enacted legislation

• First National Survey on IDD Situation in
  Bulgaria two years after implementation universal
  salt iodization
• 1996
• Optimistic results

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Based on the Results of the National survey the
strategies were revised

• The supplementation with tablets was
  discontinued because
• High cost taken by the budget of MOH
• 3 USD/capita/per year
• Relatively low coverage rate (50) - distribution
  problems
• Low actual usage
• Perception by population as a drug
• Concern of side effect by health specialists

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Based on the Results of the National survey the
strategies were revised

• Universal salt iodization was recognized as the
  only strategy for control of IDD in Bulgaria
• Low cost covered by Producers/consumers
• 1.25 USD/capita/year for iodized salt
• Universal coverage rate
• No risk of toxicity/overdosing
• Perception by people as food
• Health specialists are aware of long-term
  consequences of Iodine Deficiency (TSH congenital
  screening) and need of prevention, not treatment
  

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• Second National Survey on IDD Situation in
  Bulgaria after implementation universal salt
  iodization
• spring 2003

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National Survey on IDD Situation in Bulgaria -
Spring 2003-Results based on USI
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Box plot of results from salt analyses from
household survey conducted in 2003 in ten regions
of Bulgaria

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Results of salt monitoring at market level in
the period 1996-2003
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National Survey on iodine nutrition of
schoolchildren, aged 6-11 years, Spring 2003

• Urinary iodine (ioduria)
• Median (mg/L) 198.0
• Proportion below 100 mg/L 6.9
• Proportion below 50 mg/L 0.8

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National Survey on IDD Situation in Bulgaria
-Spring 2003

• Goiter grade (ultrasonography)
• Proportion above P97 (WHO, 1997) 4.3

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Comparison of individual values of ioduria from
two National surveys of shshoolchildren 1996
2003
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Distribution of individual values of ioduria from
two National surveys of schoolchildren 1996
2003 according the ICCIDD/UNICEF/WHO criteria
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Ioduria of pregnant women, National survey 2003

• Total group 355
• Age ( years)
• 26 (21-31)
• Median ioduria (mcg/L)
• 165
• Minimum (mcg/L)
• 40
• Maximum (mcg/L)
• 600

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Percentile distribution (P25, P50,P75) of ioduria
from schoolchildren for the period 1994-2003
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?assessment/Monitoring/Evaluation

• Monitoring plan of IDD status
• Indicators
• Proportion of adequately iodized salt at the
  market
• Annual plan prepared by the MOH
• Sampling monthly-Hygiene Inspectorates,
• Analyses HEI Laboratories
• Reporting-every three months to MOH

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Assessment/Monitoring/Evaluation

• Biological monitoring
• Ioduria/biomarker of intake
• Nat. surveys school aged children/every 5 years
• ? Total Goiter Rate palpation ultrasound
• Neonatal TSH program screening (separate)

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Conclusions

• The iodine nutrition of the Bulgarian population
  was substantially improved after the
  implementation of universal salt iodination in
  1994
• The legislation and the establishment of
  effective monitoring system builds up an
  fundamental of the National IDD Elimination
  Program
• Bulgaria is already achieving the final goal
  elimination of IDD trough the most cost effective
  and adequate strategy Universal Salt Iodization

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Thank you