8 IDD NEWSLETTER AUGUST 2017 ETHIOPIA

BackgroundIn Ethiopia, iodine deficiency has been recognized as a major public health pro-blem for the past six decades, and the threat it poses to the health and development of the population still looms large (1). The Ethiopian government, together with its development partners, has shown unfaltering commitment to combating malnutrition in general, and iodine deficiency in particular. A multi-sectoral National Nutrition Strategy (NNS) was adopted in 2008, implemen-ted through 5-year National Nutrition Programmes (NNP). In December 2016, the government launched the second NNP cycle focusing on the first 1,000 days of life to eradicate chronic malnutrition by 2030. Control of micronutrient deficiencies in the most vulnerable populations––children under five and pregnant/lactating women––is one of the program’s key targets. Since its inception, the NNP has stressed the need for multi-sectoral coordi-nation to tackle undernutrition. A dedicated implementation guideline was developed to facilitate this process between various sectors. The agriculture sector has been pro-moting diversified food production, whereas the education sector works to improve awareness and school feeding programs. The Ministry of Industry has taken important strides to ensure progress towards universal salt iodization (USI) including calling for mandatory use and sale of iodized salt. But a lack of up-to-date national and regional esti-mates of iodine intake has stood in the way of successful program implementation across the sectors.

2015 Micronutrient Survey confirms tremendous progressBetween March and July 2015, the Ethiopian Public Health Institute conducted a cross-sectional micronutrient survey with financial support from the Government

of Ethiopia and development partners (UNICEF, Micronutrient Initiative, World Bank, USAID/ENGINE, WFP, FAO, GAIN, and World Vision). The goal of this ambitious project was to estimate the natio-nal prevalence of vitamin and micronutrient deficiencies, including iodine deficiency, and assess the access to adequately iodized salt in Ethiopia. A nationally-representative sample was drawn from nine regions and two administrations (Addis Ababa and Dire Dawa) in Ethiopia. Ninety-five percent (n=3’805) of eligible households participated in the survey. The median urinary iodine con-centration (UIC), measured in spot urine samples collected from schoolchildren aged 5–14 years (n=1’663) was 104 µg/L with an interquartile range (IQR) of 63–197 µg/L, indicating iodine sufficiency at the natio-nal level. In non-pregnant women aged 15–49 years (n=1’751), the median UIC was 97 µg/L (IQR, 57–171 µg/L), closely

mirroring the iodine intakes in school-age children. Variations in iodine intakes were reported across regions and between the rural and urban areas, with the rural popula-tions more prone to iodine deficiency than their urban counterparts. Rural residence had been identified as a factor in iodine deficiency by previous studies in Ethiopia (2) and in other regions.

Knowledge of IDD and iodized saltAround two-thirds of the surveyed women had heard about goiter, but this proporti-on varied from 46% in Somali to 86% in Amhara. Knowledge about the causes of goiter was the highest in the cities of Addis Ababa and Dire Dawa, and in the north-eastern region of Tigray. Women in those regions were the most likely to associate goiter with a lack of iodine (consumed eit-her as iodized salt or in food). However, nationally, 52% of Ethiopian women could not identify any causes of goiter. This pro-

Data excerpted from: Andinet Hailu. Ethiopian National Micronutrient Survey Report: September 2016. Ethiopian Public Health Institute, Ministry of Health. 2016

Remarkable progress against iodine deficiency in Ethiopia

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Women in Ethiopia have borderline insufficient iodine intakes, even though awareness of iodine deficiency prevention is increasing in some areas.

IDD NEWSLETTER AUGUST 2017 ETHIOPIA 9

portion was even higher (>65% of women) in the Afar, Somali, Amhara, and SNNP regions. Although the awareness of goiter prevention appears to be increasing in someregions compared with past surveys (3), in others it remains low. More than a half of the women in Tigray and Addis Ababa knew that eating iodized salt could pre-vent goiter, but most women in Amhara, Oromia, Afar, Somali and Gambela had poor knowledge. In previous studies, poor maternal knowledge about iodized salt had been associated with lower iodine status (4). More health promotion efforts are needed to improve awareness across all sections of the population and increase the demand for iodized salt.

Access to iodized salt remains lowThanks to ongoing multilateral efforts, the household use of adequately iodized salt has gradually improved. In 2015, the national coverage was 89.2%; however, only about 26% of the surveyed households had salt that was adequately iodized (at ≥15 ppm, measured using a quantitative titration method). The highest coverage of adequa-tely iodized salt was in Tigray (55.2%) and

Somali (49.4%) regions, and the lowest in the regions of Gambela (9.5%), SNNPR (13.7%), and Amhara (15%). This is lower than the national coverage reported in the 2014 national micronutrient survey (43% iodized at ≥15 ppm), but it is unclear whether the earlier estimate was weighted and therefore fully representative of the national situation (5).

The importance of USI in tackling child malnutrition A USI program in Ethiopia was initiated in 1989, but it suffered a setback in the 2000s due to the Ethiopian-Eritrean war, which closed the borders to imports from the Red Sea for many products, including iodized salt (1). As a consequence, as recently as in 2005, school-age children were severely iodine deficient, with a population median UIC of only 24.5 µg/L (6). In the same year, the government adopted a strategy for the virtual elimination of IDD by the year 2015 through universal salt iodization (7). A law was passed in early 2011 requiring that all salt for human consumption should be iodized (8). At the time, the iodization capacity among Ethiopia’s 400 small-scale producers was estimated at only 15% of the national requirements (9). Since the enactment of the law, wide-ranging efforts have been made to incre-ase the monitoring capacity of regulatory agencies, promote the consolidation of the fragmented salt industry, build salt iodization capacity through improved QA/QC proto-cols and a sustainable supply of KIO3, and raise awareness of IDD among salt produ-cers, local governments, and consumers.

Despite the regional variation in household coverage with adequately iodized salt and iodine intake, the latest results demonstrate the extent of progress that could be achieved in just a few years with sufficient political will, committed invest-ment, and multi-sectoral collaboration, and they validate the tremendous importance of USI in tackling child malnutrition in Ethiopia.

References1. Girma K et al. The status of iodine nutrition and iodine deficiency disorders among school children in Metekel Zone, Northwest Ethiopia. Ethiop J Health Sci. 2014;(23)1:109-1162. Abebe Z et al. Poor dietary diversity, wealth status and use of un-iodized salt are associated with goiter among school children: a cross-sectional study in Ethiopia. BMC Public Health. 2017;17:443. Ersino G et al. Clinical assessment of goiter and low urinary iodine concentration depict presence of severe iodine deficiency in pregnant Ethiopian women: a cross-sectional study in rural Sidama, southern Ethiopia. Ethiop Med J. 2013 Apr;51(2):133-414. Gidey B et al. Availability of Adequate Iodized Salt at Household Level and Associated Factors in Rural Communities in Laelay Maychew District, Northern Ethiopia: A Cross Sectional Study. J Nutr Health Sci. 2015;2(1):15. Zerfu D. National salt iodization coverage toward prevention of Iodine Deficiency Disorder in Ethiopia. Ethiopian Public Health Institute. 20146. Abuye C, et al. Prevalence of goiter in children 6 to 12 years of age in Ethiopia. Food and Nutr Bull 2007; 8(4): 391-98.7. Adish A et al. Ethiopia breaking through with new iodized salt. MI, UNICEF-Ethiopia, GAIN, ICCIDD, FoH, Ethiopia. 20138. Federal Democratic Republic of Ethiopia. Regulation No.204/2011 Salt Iodization Council of Ministers Regulation. Fed Negarit Gaz FDRE 2011; 17(28):5785-869. GAIN-UNICEF Partnership Project: Country Final Report – Ethiopia. GAIN, UNICEF. 2016

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Women living in rural areas tend to have lower iodine intakes and poorer knowledge of iodine deficiency, which makes them more vulnerable to iodine deficiency disorders.

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