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1
t.
TRACKING PROGRESS TOWARDS
SUSTAINABLE ELIMINATION OF
IODINE DEFICIENCY DISORDERS IN BHUTAN
By
Nutrition Section, Directorate of Health Services,Royal Government of Bhutan
International Council for Control of Iodine Deficiency Disorders(ICCIDD), New Delhi (India)
Clinical Epidemiology Unit, All India Institute of Medical Sciences,New Delhi, India
UNICEF, Thimpu (Bhutan)
WHO, Thimpu (Bhutan) & WHO-SEARO, New Delhi (India)
The Micronutrient Initiative, Ottawa (Canada)
August, 1996
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TRACKING PROGRESS TOWARDS SUSTAINABLE ELIMINATION OF
IODINE DEFICIENCY DISORDERS IN BHUTAN
CONTENTS
Acknowledgement
Abbreviations
Executive Summary
1 ) Introduction
2) Goals and Objectives
3) Review of IDD ControlProgramme activities in Bhutan
4) Monitoring of Salt lodisationin Bhutan
5) Current status of IodineDeficiency Disorders in Bhutan
6) Summary of Recommendations
Bibliography
Annexures
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2
3
8
15
17
18
31
74
76
78
A
Acknowledgement
We would like to express our sincere thanks to the Royal Government of Bhutan forgiving us this opportunity for," Tracking Progress Towards Sustainable Elimination ofIodine Deficiency Disorders in Bhutan."
Thanks are also due to school students, teachers, members of the community, BhutanSalt Enterprises, retailers and wholesalers, officials of District Administration, Health,Education, Food Corporation of Bhutan, Ministry of Trade, Agriculture and Livestockfor their co-operation and support which enabled us to complete the field componentof the survey in two weeks time.
Technical and financial support of the Royal Government of Bhutan (RGB), UnitedNations Children's Fund (UNICEF), International Council for Control of IodineDeficiency Disorders (ICCIDD), World Health Organisation (WHO) and TheMicronutrient Initiative (Ml) is gratefully acknowledged.
\Abbreviations
BHU Basic Health Unit
BSE Bhutan Salt Enterprises
FCB Food Corporation of Bhutan
ICCIDD International Council for Controlof Iodine Deficiency Disorders
IDD Iodine Deficiency Disorders
IDDCP Iodine Deficiency Disorders Control Programme
IML Iodine Monitoring Laboratory
Ml The Micronutrient Initiative
Nu Nultrum (currency in Bhutan)
PHL Public Health Laboratory
RGB Royal Government of Bhutan
SIP Salt lodisation Plant
DIE Urinary Iodine Excretion
UNICEF United Nations Children's Fund
WHO World Health Organisation
/Executive Summary
Iodine deficiency disorders (IDD) have long been a major public health problem inBhutan. A nationwide study in 1983 reported a mean goitre prevalence of 64.5 percent; a high prevalence of cretinism and low urinary iodine concentration in themajority of the population.
Based upon the findings of the 1983 study, the Royal Government of Bhutan, in 1984,formulated and introduced a coordinated multi-sectoral Iodine Deficiency DisordersControl Programme (IDDCP). The main components of IDDCP are salt iodisation anddistribution (introduced in April,1985); iodised oil injections (if necessary); monitoringiodine content of salt; evaluation of the programme and community level education.
A nation wide internal programme evaluation of IDDCP was carried out in 1991-92.The results showed that as compared to 1 983, there was a considerable reduction inthe prevalence of goitre and cretinism and improvement in the urinary iodine status ofthe population. This could be attributed to the successful salt iodisation programmeas reflected in over 95 per cent salt samples at household level having adequateamount of iodine. A report of this survey,"Iodine Deficiency Disorders-The BhutanStory" published by the Directorate of Health Services, Ministry of Social Services,Royal Government of Bhutan in 1992, observed that it is possible for a country withdesired political commitment and appropriate administrative support, to implement ascientifically sound intervention programme, so as to make a significant impact incontrolling IDD. Bhutan now has a programme which envisages providing adequatelyiodised salt throughout the country, and building awareness among a populationwhose understanding of IDD is slowly but steadily growing.
"To establish a programme such as this (IDDCP in Bhutan), is of course a major task.To maintain the programme and constantly improve it, is an even greater'one". Thishas been well recognised by the Government and stated in the 1992 Report referredto above. They also recognise that there are many constraints which can adverselyinfluence the effectiveness of such a public health programme. Indeed, elsewheremany promising country programmes to control IDD which began well have not beensustainable.
Four years after completion of internal evaluation, the Royal Government of Bhutanexpressed interest in, "Tracking Progress Towards Sustainable Elimination of IDD inBhutan" by an external team so as to receive an independent feedback on the currentstatus of th-e programme and recommendations thereof.The present study was,therefore undertaken to address this goal.
\To track progress towards sustainable elimination of IDD in Bhutan, the present studywas designed to evaluate the following components of the programme :
1) Product
1.1) To review the process of effective salt iodisation at Salt lodisation Plant (SIP),Phuntsholing covering procurement, transportation and storage of common salt;quality assurance at salt iodisation plant inclusive of equipment inventory &maintenance, iodisation level, packaging, labelling & storage; price of iodised salt andits distribution in the country.
2) Process
2.1) To review IDD Control Programme activities related to assessment, intervention(salt iodisation & iodised oil injections), Information, Education & Communication(IEC), training, experience-exchange, documentation and programme management.
2.2) To review the monitoring of iodised salt at community level.
2.3) To study the Knowledge, Attitude, Practice and Behaviour (KAPB) on IodineDeficiency Disorders (IDD) of stakeholders from key sectors namely health, salt B(producer, distributors and retailers), education, agriculture & livestock, trade, |administrators, consumers etc in sustainable elimination of IDD. |
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3) Progress |
To carry out quantitative assessment of process and outcome indicators for trackingbiological progress with respect to IDD status of the population.
3.1) Outcome indicators : total goitre rate (clinical) and urinary iodine excretion(biochemical) in school children aged 6 to 11 years.
3.2) Process indicator : iodine content of salt at household and retail level bytitremetric method.
These three indicators assess different aspects of the biological progress towardselimination of IDD. For example, total goitre rates show long term effect of bio-availability of iodine. Urinary iodine excretion pattern reflects body iodine stores andexisting level of iodine intake. The iodine content of salt indicates present level ofiodine in salt, but gives no information about the variations occurring in the past. Tounderstand the impact of IDDCP in a population, the results of these indicators shouldbe viewed in totality.
The results of the present study show that the total goitre rate was 14 per cent whichindicates mild iodine deficiency, as per the recommended criteria of WHO / UNICEF/ ICCIDD.
The median urinary iodine excretion was 230 jug/I indicating NO iodine deficiency. Itis important to note here that frequency distribution curves are necessary for fullinterpretation of urinary iodine data. The distribution of urinary iodine levels was asfollows : 3 per cent children had less than or equal to 20/yg/l; 9.9. per cent between21 and 50/vg/l and 11.1 per cent between 51 and 100 j j g / \ . Thus, 24 per cent of theurine samples analysed showed values less than 100 fjg/\. The urinary iodine levels of>_ 100 fjg/\, is the accepted cut-off point that indicates adequate iodine intake.
All the salt samples from household and retailers contained iodine. However, adequatelevels of iodine were observed in 82 per cent of salt samples from households (_>_ 15PPM) and 74 per cent salt samples collected from retailers ( >_ 25 PPM).
The observed TGR and UIE pattern could be explained on the basis of findings ofprocess indicator, i.e. iodine content of salt. A total of 1 8 per cent of the salt samplesanalysed from households had iodine content less than 15 PPM, the desired level ofiodine in salt. About 9 per cent of the salt samples showed high values of iodine(above 70 PPM! and an equal number showed low values (5 to 10 PPM), indicatingnon-uniformity of iodine levels in the salt available at the community level. Thus, atthe community level, a significant proportion of the salt available had inadequate aswell as non-uniform iodine levels.
As referred to earlier, in the present study only 82 per cent of salt samples athousehold level had adequate iodine as compared to 95 per cent to 96.5 per cent ofsalt samples in the 1991-92 study. The low levels of iodine in salt at household levelin the present study could also explain the observation that 24 per cent of schoolchildren had urinary iodine excretion less than 100/;g/l as compared to only 13 percent to 16 per cent in 1991-92 study.
From the reported TGR in 1991-92 study i.e. 18.4 per cent (northern Bhutan), and32.5 per cent (southern Bhutan), the TGR in the present study had declined to 14 percent. It is pertinent to point out the results of the first pilot study on effectiveness ofsalt iodisation in Kangra Valley,(Himachal Pradesh, India) that was implemented from1957 to 1972. With adequate iodine levels in the salt, TGR in this study showed areduction by 50 per cent every five years. As referred above, the initial TGR in Bhutanin 1983 was 64.5 per cent. It showed approximately 50 per cent reduction in 1991-1992 study, after 6 years of continuous and adequate iodised salt supply. However,though the present study in 1996, showed a trend in decline, the expected 50 percent reduction was not observed. It would have been achieved if the population hadcontinued to receive adequate amounts of iodine during the period 1991-92 to 1996.
A visit to the Salt lodisation Plant (SIP), Phuntsholing, showed that since 1 994, therewas a breakdown in monitoring of iodine content of salt at the production level. Thelaboratory located at SIP had been shifted away and records of analysis wereinadequate and incomplete. In addition, the salt crusher was also not functioning.These factors together probably resulted in having salt with inadequate and non-uniform iodine content as observed in the community.
There was also a breakdown in the monitoring of iodised salt at the community level.The total number of salt samples analysed per district were less than therecommended targets. This finding was corroborated in the present study. Only 25 percent of the retailers responded that a salt sample was collected from their premises,for monitoring by health authorities in the previous six months. The quarterly saltmonitoring reports sent from the district to PHL, Thimpu were incomplete andirregular. There was no system of providing feed back on salt monitoring to theDistrict Administration, Health Department, Bhutan Salt Enterprise (BSE), Phuntsholingand other stakeholders for necessary corrective action.
Moreover, since 1994, there had also been consistent breakdowns in the regularprocurement of common salt by BSE, Phuntsholing resulting in retailers buying saltfrom across the Indo-Bhutan border directly, thereby having no control over iodinecontent of salt.
All the salt available in the retail shop was observed to be packaged. However, manyof the packaging materials was not up to the standard. As a result, 34 per cent ofretailers repacked their salt in small plastic packets to increase the shelf-life of iodised Isalt. The HDPE bags of 37.5 kg, though labelled as iodised, did not have the date andlevel of iodisation. The repacked small packets were not labelled. The storage of saltat retailer level as well as household level (stakeholders), however, was found to besatisfactory.
The results of KAPB survey of retailers showed that 74 per cent heard about iodisedsalt and only 54 per cent knew about the benefits of iodised salt. While 40 per centreported correctly about the ill effects of IDD. Only 46 per cent of the retailers wereaware about the regulation on the sale of iodised salt.
The KAPB survey of the enlightened segment of the society, represented by thestakeholders showed that 92 per cent heard about iodised salt and 83 per cent knewabout the benefits of iodised salt. While 67 per cent reported correctly about the illeffects of IDD. Only 42 per cent of the stakeholders were aware about the regulationon the sale of iodised salt.
In view of the observations made in the present evaluation,it is .therefore, vital to takeimmediate steps to ensure timely and adequate procurement of salt by BSE,Phuntsholing, and to ensure its proper iodisation with strict quality control measures
at SIP. In addition, the introduction of cyclic monitoring of IDDCP, covering everydistrict once in five years, for goitre prevalence and urinary iodine in school childrenand iodine content of salt at household level using ," 30 cluster method", would bethe other step. These two measures would reverse the present trend and be themainstay of ensuring progress towards sustainable elimination of IDD by and beyondthe year 2000 AD.
Past experience have taught us that for any IDDCP to succeed, the people need to beconvinced about the benefits of consuming adequately iodised salt. In Bhutan, a largenumber of people have heard about iodised salt. However, the benefits of iodised saltspecially in preventing mental retardation, improving scholastic performance andlivestock productivity should be emphasised. Together these have importantimplications in social, economic and human resource development in Bhutan. Theseefforts can be complemented and sustained by involving primary and junior schoolteachers by involving them in the monitoring process. This will serve dual purpose ;that of creating awareness of IDD and its intervention among an important group ofstakeholders and also encourage social participation in a public health programme.
To have greater involvement of the people in sustaining the activities of IDDCP by andbeyond 2000 A.D., the IEC on IDD should be strengthened to cover different targetgroups i.e. consumers, retailers, stakeholders. In the monitoring and evaluation of theIDDCP, the IEC component should be made an integral part for finding out the currentstatus and subsequently recommend mid-course corrections.
The results of the present study showed that Bhutan had achieved universal saltiodisation. However, it was observed that the proportion of adequately iodised salt atthe household level had declined from 95 per cent to 82 per cent during the period1992-96. For sustaining elimination of IDD, it is essential to maintain politicalcommitment which can be strengthened by broad public understanding of the issues.Policy needs to include quality assurance with specific focus on the availability of agood product (i.e iodised salt with appropriate iodine levels), forever. Equally importantis the need to further involve the stakeholders in sustaining the elimination of IDD, forit is a venture that requires action by all for all times. These efforts should becomplemented by periodic evaluation of the programme by an external agency.
TRACKING PROGRESS TOWARDS SUSTAINABLE ELIMINATION OF
IODINE DEFICIENCY DISORDERS IN BHUTAN
1) Introduction
1.1) Background
Bhutan is a small, landlocked country in the Eastern Himalayas. It is bordered by Indiain the East, West and South and by China in the North. Most of the population arescattered in farming communities through the small valleys.
The land area is 46,500 square kilometres and is almost entirely mountainous, withflat land limited to the broader river valleys and a band along the southern border. Theborder areas have a hot, humid climate, whilst the central and northern regions havetemperate to severe alpine climates. The present population is estimated atapproximately 650,000. The vast majority of the population are subsistence farmers,who have no formal education, with small numbers involved in the civil service andbusiness sector. |3
HBhutan is a monarchy. The present King, His Majesty King Jigme Singye Wangchuck, 1is the Head of State and also the Head of Government. He is assisted by the cabinet, 1which consists of His Majesty's Representatives, Ministers and senior civil |servants.The National Assembly, which meets twice a year, enacts legislation andadvises the Government on all matters of national importance.
•. The country is divided administratively into 20 districts, or Dzongkhags, eachcontaining a number of blocks, or gewogs. There are a total of 192 gewogs withnumerous villages in each gewpg.
1.2) Health care system in Bhutan
The health care system in Bhutan is under the Ministry of Social Services. TheDirectorate of Health Services has four divisions: Health Planning and Development;Public Health; Medi-care and Central Administration. At the Dzongkhag level, thehealth officials jointly responsible for planning, implementing and monitoringDzongkhag health programme are the District Medical Officer (DM0) and the DistrictHealth Supervisory Officer (DHSO). The DM0 looks after the hospital and health caredelivery and the DHSO primarily supervises the public health activities. The health caresystem in Bhuta; is depicted in Figure - 1.
8
ApexReferral
970 beds / HospitalSpecialised
servicesTraining insitution
Large OPD
NationalReferralHospital
Providesspecialised
services withsupport facility.
Acts as a referralhospital of the region
RegionalReferralHospital
Provides general healthservices, also has a community
health unit, which providesoutreach services
DzonkhagHospital
Two types - grade I physician with few bedsgrade II - no physician
provides comprehensive health caremainly through OPD,
minimal laboratory and essentialdrug supply
Ivlostly clinicpreventivepromotivehealth care
VHW VHW
Mostly conducte3^\N^by 1 or 2 HW >.
(HA,ANM,BHW) )+ local village health ;/
worker _—-^^
OutreachClinic
VHW
* ( ) number by the end of 7lh 5 year plan
Note:- These Health Service System also includes one indigenous hospital & indigenous dispensary
Fig.l. The Health Care System in Bhutan
1.2.1) Health manpower in Bhutan
The health manpower in Bhutan as per the latest information (1994) is given inTable 1.1.
Table 1.1 : Health manpower in Bhutan
Health manpower
Doctors in clinical practice(medical officers, DMO, specialists excludingadministrative physicians)
Nursing personnel(GNM, ANM, assistant nurses, junior nurses)
Public health personnel(DHSO, ANM, Health Assistant,Basic Health Worker)
Physicians of indigenous system (Drungtsho)
Indigenous compounders (Menpa)
TotalNo.
71
325
387
07
15
No. per 10,000population
1.1
5.0
6.0
-
-
1.2.2) Training facilities
Most of the physicians are trained in Indian health institutions. There are two nationallevel institutes in Bhutan.
i) Royal Institute of Health Sciences : It provides basic training for health workers ofall levels. This has the potential to be an institution for continued medical education.
ii) Institute of Traditional Medicine : It provides training to indigenous practitioners.
1.2.3) Health budget
The health service in Bhutan is presently free of charge to Bhutanese nationals. Thecurrent Health Sector budget for the fiscal year 1994-95 is Nu. 184 million.Government revenue meets about 70 per cent of the expenditure and the rest isfunded by external agencies mainly in relation to specific health programmes. For thecapital cost, Royal Government of Bhutan (RGB) is expected to cover 10 per cent. Therest is funded by external agencies.
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1.3) Nutrition Section
The Nutrition Section was created in 1985 under the Directorate of Health Services.The ," Nutrition Cell" was created for inter sectoral coordination of nutrition relatedactivities under the Planning Commission. This cell was transferred in 1986 to theMinistry of Social Services and subsequently handed over to the Nutrition Section in1990. At present all nutrition related activities, including Iodine Deficiency DisordersControl Programme (IDDDCP), are looked after by this section. Most of the activitiesof this section are funded by UNICEF under the "Health and Nutrition Programme"budget.
1.4) IDD Control Programme activities
Considering the diverse nature of the activities related to IDD control, a number ofgovernment sectors and private individuals are involved in the functioning of the IodineDeficiency Disorders Control Programme (IDDCP). These include Agriculture, Health,Trade & Industries, Education, the National Women's Association, the salt iodisationplant proprietor, shopkeepers and traders. Within government sectors, the activitiesare carried on as an integral part of routine public health activities, rather than ascomponents of a vertical programme.
1.4.1) Historical aspects of IDDCP
The oldest reports which are available suggest that Iodine Deficiency Disorders (IDD),have long been present in Bhutan. A history of glacial activity, the mountainous terrainand the heavy monsoon rains have resulted in the removal of iodine from Bhutan'ssoil, so that none of the foods produced in Bhutan have significant iodine levels.
Considering the seriousness of the situation, Bhutan have initiated an IDD controlprogramme in ths 1960's based upon the importation of iodized salt from India. Thissupply was discontinued in 1970 because of non acceptance of salt by the populationdue to bad appearance and flavour. However, a small proportion of the populationcontinued to receive iodine in food items provided by the World Food Programme.
1.4.2) IDD studies performed in Bhutan prior to 1996
In the 1960's and early 1970's health personnel observed large numbers of peoplesuffered from goitre. They felt it was necessary to obtain quantitative data on theextent and severity of the problem.
Since 1964, there have been six studies on IDD in Bhutan. The first known publishedreport on the prevalence of IDD in Bhutan, is by two English doctors in 1964. Duringtheir five weeks observational study in Bhutan, they reported that goitre was almostuniversally prevalent.
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A study conducted in 1975 by Dr Mahendra in nine districts across Bhutan indicateda goitre prevalence of 47 per cent to 68 per cent in school children, and 50 per centto 53 per cent among the adult population.
Bhutan's first national IDD survey was undertaken in 1983 for the Royal Governmentof Bhutan (RGB) with UNICEF and WHO support, by a team from the All India Instituteof Medical Sciences (AIIMS), New Delhi. The survey was carried out in 11 of Bhutan'sthen 18 districts and included adult males and females, primary school students andpre-school children. The districts visited were widely scattered throughout the country.The team reported a total goitre rate (TGR) of 64.5 per cent. Cretinism was reportedin all districts, reaching 10 per cent or higher in those districts most severely affected.Urinary iodine estimations were also carried out, and 62 per cent of school childrenand 77 per cent of the general population were found to have urinary iodineconcentrations lower than 50 fjg iodine / g creatinine (approximately equivalent to50/yg/l).
Two smaller national studies, in 1985 and 1989, reported lower prevalence than theabove study, but concluded that goitre was an important national problem, especiallyamongst women.
A nationwide study was conducted in late 1991 and early 1992, to assess the IDDsituation, the impact of the IDDCP on this, and the knowledge and attitudes of thepopulation concerning the nature and causes of IDD. A further aim was to investigate 1iodine content of salt throughout the country. The study was conducted by the |Directorate of Health Services, Ministry of Social Services, RGB.
The "30 cluster sample survey method", was employed, with children aged 6-11 yearsand women aged 1 5-45 years as the study groups. Two surveys were conducted, onein the northern districts and one in the southern border districts. In each, 30 clusterswere selected. All subjects were examined for goitre and cretinism. Urine and bloodsamples were collected for estimation of urinary iodine and thyroid stimulatinghormone, respectively.
The study revealed that total goitre prevalence was 18.4 per cent in the northernchildren and 32.5 per cent in the southern children. Goitre prevalence in northern andsouthern women was 28.5 per cent and 45.9 per cent, respectively. The prevalenceof cretinism in both northern and southern children was 0.4 per cent. Cretinismprevalence in northern and southern women was 0.9 per cent and 0.8 per cent,respectively.
A total of 87.4 per cent of the northern children and 83.8 per cent of the southernchildren had acceptable urinary iodine excretion (UIE), i.e. urinary iodine J>. 100 pg/I. While, 85.2 per cent of northern women and 81.9 per cent of southern women hadacceptable UIE. The mean and median UIE for the four groups were all above 200/;g/l.
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The median urinary iodine values for northern and southern children were 283/vg/l and244 /;g/l respectively.
A total of 79.6 per cent of the northern children and 77.6 per cent of the southernchildren had acceptable Thyroid Stimulating Hormone (TSH) values, i.e. TSH _>_ 5 mu/l.The corresponding figures for the women were 89.2 per cent and 92.6 per cent,respectively.
Certain aspects of salt purchasing, storage and cooking practices observed requiredmodifications so as have the optimum benefits of salt iodisation programme. It wasobserved that 96.6 per cent of the 146 household salt samples collected from thenorth, and 95.0 per cent of the 140 household salt samples from the south werefound to have acceptable iodine content, i.e. iodine _>_ 15 parts per million (PPM) .
1.4.3) Components of Iodine Deficiency Disorders Control Programme (IDDCP)
The IDD Control Programme in Bhutan is a well coordinated multi sectoral programmehaving the following major components:
Salt iodisation and distributionIodized oil injections
iii) Monitoring of iodine in saltiv) Evaluation of the Programmev) Community level education
i) Salt iodisation and distribution
In 1985, the salt iodisation plant was commissioned at Phuntsholing (located onBhutan's southern border), to iodise all salt entering Bhutan. All salt importation anddistribution is controlled by the government. Legislation is in force to prevent theimport or sale of salt which has not passed through the salt iodisation plant (SIP). Tillrecently, the Food Corporation of Bhutan (FCB), was responsible for procurement,storage and distribution of iodised salt through FCB depots and commission agentsthroughout the country. Bhutan Salt Enterprises (BSE) was responsible for iodisation,packaging it in laminated bags supplied by FCB and its supply as directed by FCB.
From 1994, Bhutan Salt Enterprises (BSE), is directly responsible for procurement ofcommon salt from India, its iodisation and packaging at Phuntsholing, and subsequentdistribution in Bhutan.
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ii) Iodised oil injections
As^a short term measure in border districts of Bhutan, during the years 1988 to 1991,iod'ised oil injections were administered to women of child bearing age. In all, 54,220injections were administered. The injection campaign was completed in 1991.
Hi) Monitoring of iodine in salt
This is an important aspect of the IDDCP. The recommended levels of iodine atdifferent levels are as follows, iodisation plant level - 60 ppm of iodine, at the retaillevel - 25 ppm of iodine, and at the household level - 15 ppm of iodine.
Earlier iodine levels in salt at the factory level were determined regularly by the staffemployed by BSE and checked daily by FCB personnel. Presently, BSE is solelyresponsible for it. Iodine levels in the salt at the shop/FCB agent and household levelare determined by BHU and hospital staff.
All Basic Health Units (BHUs), are required to test a minimum of 60 samples quarterlyby field test kit. These are collected from households, retail shops and FCB agents.The results are then sent to the district headquarter.
£Testing is done using field kits as well as the laboratory titration method. The other |components of monitoring i.e. clinical and biochemical investigations, are not included |in the present monitoring system. |
Mn
iiv) Evaluation of the Programme
^Evaluation of the Programmes is to be carried out by a nationwide survey either by anational team or an external agency. So far, internal evaluation has been carried outthrough a nationwide survey by a national team.
v) Community level education
The universal use of iodised salt, proper purchasing, storage and cooking practices areimportant areas that the Royal Government of Bhutan is attempting to focus upon inits community level education activities.
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2) Goals and Objectives of the Present Study
2.1) Background and rationale
"Iodine Deficiency Disorders-The Bhutan Stcry" published by the Directorate of HealthServices, Ministry of Social Services, Royal Government of Bhutan in 1992, showedthat it is possible for a small nation such as Bhutan to make significant progresstowards controlling iodine deficiency disorders (IDD). This report was based onfindings of internal evaluation. It has shown that during the preceding 10 years,prevalence of IDD has been dramatically reduced. Bhutan now has a programme whichis providing iodine in adequate quantities throughout the country, and a populationwhose understanding of IDD is slowly but steadily growing.
"To establish a programme such as this (IDD Control Programme in Bhutan), is ofcourse a major task. To maintain the programme and constantly improve it, is an evengreater one. This has been well recognised by the Government and stated in the 1992Report referred to above. They also recognise that those working in public healthprogrammes, in scores of countries, are well aware that there are many factors whichcan reduce the effectiveness of these programmes. Indeed, many programmes whichbegan well have ceased to function at all.
However, if all concerned sectors co-operate in paying sustained attention to allaspects of the control programme, it is fully possible for the progress made so far tobe extended and maintained. In this way, IDD can be controlled not only by the year2000, but indefinitely. It was precisely with this idea in mind that a Joint ICCIDD-UNICEF-WHO-CIDA-MI meeting was held in Dhaka in April 1 995. The main theme ofthe meeting was, "Partnership to End Hidden Hunger : Collaboration of Stakeholdersin Sustaining Elimination of Iodine Deficiency Disorders".
It was concluded at the meeting that the strategy for the management of sustainedIDD elimination focuses on three essential issues :
i) Product: ensuring that a high quality product (i.e iodised salt with appropriate iodinelevels) is available for ALL times to come
ii) Process: ensuring that a management process is in place that covers all componentsof the IDD Elimination Programme with active participation of key stakeholders.
iii) Progress: monitoring and tracking biological progress with respect to IDD status ofthe population.
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Four years after the completion of internal evaluation, the Royal Government of Bhutanexpressed interest in, "Tracking Progress Towards Sustainable Elimination of IDD inBhutan" by an external team so as to receive an independent feedback on the currentstatus of the programme and recommendations thereof. The present study wasdesigned to answer this question.
2.2) Goal
To track progress towards sustainable elimination of Iodine Deficiency Disorders inBhutan.
2.3) Objectives
i) To review IDD Control Programme activities related to assessment, intervention (saltiodisation & iodised oil injections), monitoring, Information, Education &Communication (1EC), training, experience-exchange, documentation and programmemanagement
ii) To review the process of effective salt iodisation at Salt Iodisation Plant (SIP) inPhuntsholing covering procurement, transportation and storage of common salt,quality assurance at salt iodisation plant inclusive of equipment inventory &maintenance, iodisation level, packaging, labelling, storage & price of iodised salt and |its distribution !
Itiii) To review the monitoring of iodised salt at community level
iv) To study the current status of IDD as measured by goitre prevalence and urinaryiodide excretion (DIE) pattern in primary school children aged 6 to 11 years
v) To determine the proportion of households using adequately iodised salt (iodine >_15 PPM), by analysing the salt samples brought by school children from theirrespective households
vi) To determine the proportion of retail shops selling adequately iodised salt (iodine>. 25 PPM)
vii) To study the Knowledge, Attitude, Practice and Behaviour (KAPB) on IodineDeficiency Disorders (IDD) of key stakeholders namely health, salt (producer,distributors and retailers), education, agriculture & livestock, trade, administrators,consumers etc in sustainable elimination of IDD.
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3) Review of IDD Control Programme activities in Bhutan
The Royal Government of Bhutan, since 1983 has carried out a series of IDD controlprogramme activities covering the following components:
1. Political Support, Programme, Policy
2. International Advocacy
3. Administrative Infrastructure
4. Assessment of Surveys on IDD Prevalence / KAPB / Salt
5. Legislation and Enforcement
6. Salt Industry
7. Information, Education and Communication
8. Training
9. Monitoring Programme : Tracking Progress towards USI
10. External Evaluation
1 "7
4) Monitoring of Salt lodisation in Bhutan
Monitoring of salt iodisation in Bhutan is described in two parts.
4.1) Monitoring of iodised salt at production level
4.2) Monitoring of iodised salt at community level
4.1) Monitoring of iodised salt at production level
This section is covered as follows :
4.1.1) Objectives
4.1.2) Methodology
4.1.3) Background of salt iodisation in Bhutan
4.1.4) Current status of salt procurement, iodisation and distribution
4.1.5) Conclusions and Recommendations
I4.1.1) Objectives §£ri
To review the process of effective salt iodisation at Salt lodisation Plant (SIP), g§Phuntsholing, covering procurement, transportation and storage of common salt,quality assurance at salt iodisation plant inclusive of equipment inventory &maintenance, iodisation level, packaging, labelling, storage & price of iodised salt andits distribution.
4.1.2) Methodology
Information was collected by :
i) conducting interviews with key officials of Bhutan Salt Enterprises (Mr. GomchenWangchuk, Proprietor and Mr. Kesang - Manager cum Officer-in-charge of IodineMonitoring Laboratory at SIP at Phuntsholing; officials of Food Corporation of Bhutanat Phuntsholing;
ii) site visit at SIP, Phuntsholing for observing the present status of all activities relatedto salt iodisation, and
iii) review of existing documents and records both published and unpublished.
18
4.1.3) Background of salt iodisation in Bhutan
i) Requirement of salt in Bhutan
The total estimated annual requirement of common salt in Bhutan is 5,000 metrictons. The RGB has a total annual import quota of 7,000 tons from India. All thecommon salt is imported from India and enters Bhutan at Phuntsholing.
ii) Role of Food Corporation of Bhutan (FCB)
Since 1985, the beginning of the salt iodisation programme in Bhutan, FoodCorporation of Bhutan (FCB) was responsible for :
1) Procurement of common salt from India2) Supplying the procured common salt to Bhutan Salt Enterprises (BSE), Phuntsholingfor iodisation as per the recommended levels of iodine3) Monitoring iodine content of salt at the factory level on a daily basis - externalquality control4) Providing good quality laminated jute bags (37.5 kg) for packaging of iodised salt5) Procuring iodised salt from BSE for distribution in Bhutan. Iodised salt was thendistributed through the network of nine FCB depots, 64 FCB Commission agents andthrough 198 centres of World Food Programme.6) ensuring that BSE maintained 300 MT of buffer iodised salt stock.7) maintaining iodised salt stocks at FCB Regional Offices in Thimphu, Gaylegphug,Samdrup Jongkhar, Samchi, Tashigang, Tongsa and Sarbang.
Thus, Bhutan Salt Enterprises was responsible for iodisation of salt, packaging it inlaminated jute bags supplied by FCB and supplying it to FCB. The FCB made therequired payments for iodisation to the BSE.
From 1994, it was decided by the Royal Government of Bhutan (RGB), as a part of itsliberalisation policy to hand over iodisation of salt and its distribution to the privatecompany. Since then, Bhutan Salt Enterprise is now directly responsible forprocurement of common salt from India, its iodisation and packaging at Phuntsholingand subsequent distribution in Bhutan. Presently, FCB has NO ROLE in iodisation ofsalt and its distribution.
4.1.4) Current status of salt procurement, iodisation and distribution
i) Procurement and transportation
Presently, common salt is procured from a private trader in Bhavnagar, Gujarat. Everyyear, M/s Bhutan Salt Enterprises (Mr. Gomchen W.angchuk) signs annual contractwith the selected private trader for supply of common salt as per the schedule.
Common salt is transported by railway from Bhavnagar (Gujarat), to Falakata,(Alipurdwar district), in West Bengal. The average time taken for the wagons to reachFalakata is 15 to 20 days. After reaching Falakata, it is transported by trucks toPhuntsholing. The distance between Falakata and Phuntsholing is 60 km.
1 Q
In general, the salt is transported by railways in box (open) wagons and not closedwagons. One broad gauge rake carries approximately 1,800 tons of salt. One broadgauge rake is equivalent to two meter gauge rakes.
For the year 1996, the contract was signed with M/s Shree Shyam Enterprises,Bhavnagar for supply of common salt. The schedule for the movement of salt is givenin Table 4.1
Table 4.1 : Schedule for movement of salt for the year 1996
From
Bhavnagar
Bhavnagar
Bhavnagar
Bhavnagar
To
Falakata
Falakata
Falakata
Falakata"
No. of rakes
1 Broad GaugeOR
2 Meter Gauge
1 Broad GaugeOR
2 Meter Gauge
1 Broad GaugeOR
2 Meter Gauge
1 Broad GaugeOR
2 Meter Gauge
Month, 1996
Upto 15 Feb.,
30 th April
July / August
30 th November
Ever since BSE has taken the responsibility of procuring common salt, there have beenconsistent delays in its procurement from India. For the year 1996, till June 1996,even though 3,600 tons of common salt should have arrived in Phuntsholing, NOTeven a single rake of common salt procured by BSE has been allotted by the railways.This has resulted in BSE making efforts to get common salt by road. Thus, there havebeen delays in iodisation of salt by BSE leading to the non-availability of locallyproduced iodised salt in Bhutan. In addition, BSE had to pay significantly higher pricefor road transportation as compared to the salt procured by railway, causing avoidablefinancial burden on BSE.
ii) Type of salt procured
The only type of salt that is procured from India is crushed "kurkutch" variety of salt.Refined powdered salt as well as big crystals, i.e. "baragara" and "phoda", are notprocured.
Hi) Packaging and labelling of common salt
Common salt imported from India comes in High Density Polyethylene (HOPE) bags of75 kgs. These bags DO NOT have a label stating that it is ," common salt forimportation to Bhutan."
20
iv) Storage of common salt
BSE has sufficient space for storing 3,600 tons of common salt. Half the quantity canbe accommodated in the main building and verandah and the remaining in the adjacentbuilding.
v) Crushing of common salt
Before iodisation, it is necessary to have salt in uniform powdered form. Since"kurkutch" salt procured gets caked during transportation, it is necessary to crush it.During the factory visit, it was observed that the crusher was not in working order.Therefore, crushing was done manually and hence desired uniform powdered salt wasnot obtained, thereby interfering with proper iodisation and iodine content of salt.
vi) Availability of Potassium iodate
The BSE has in stock 17 drums of potassium iodate of 50 kg each, equivalent to 850kg.
vii) Salt iodisation plant (SIP)
The present salt iodisation plant was set up in 1984 and was commissioned inApril,1935. It has a capacity of 6 tons/ hour and is of standard continuous spraymixing type of UNICEF design. - '
1Generally, the life span of SIP is five years. It was recommended in 1989 that the |plant was in need of extensive replacements. However, the SIP was not replaced but |repaired in 1991. Even though it is functioning normally, there is a likelihood of its -ibreaking down any time.
viii) Iodisation of salt at SIP
The recommended iodisation level at the Salt Iodisation Plant (SIP) in Phuntsholing is60 parts per million (PPM) of iodine.
The iodisation of salt is being done properly. However, some quantity of salt procuredfrom India was already iodised. Hence it is necessary to analyse the salt beforeiodisation so that iodisation level at SIP can be maintained at the recommended level.
ix) Iodine content of salt at SIP
To analyse and record iodine content of salt at SIP, the resources required are :laboratory facility, laboratory technician and records.
71
a) Laboratory facility
The laboratory space at SIP is adequate. The necessary equipment like balance,burette etc. were either out of order or broken. Chemicals were available. Reagentswere prepared but were not labelled and stored properly. The titrimetric analysis wasNOT being carried out in the laboratory at SIP. It was reported by BSE that theanalysis was being carried out at a place away from SIP.
b) Laboratory Technician
The laboratory technician has been trained at Jaipur (India) in 1989. The technicianis also the Manager of the SIP and is involved in several other activities. This hasobvious implications on maintaining quality control at SIP.
c) Quality control
At present, neither internal nor external quality control programmes are beingpracticed.
d) Records and Registers
The records and registers were not available at the laboratory. Computer print outs ofsome of the results were provided later on.
x) Packaging and labelling of iodised salt
Presently, most of the iodised salt is packaged into 37.5 kg. HOPE bags. Somequantity is packed in 1 kg. packets. However, the quality of HOPE bags hasdeteriorated as compared to the laminated jute bags used earlier.
The labelling of iodised salt is being done properly.
xi) Storage of iodised salt
There is adequate indoor space for storing iodised salt on wooden pellets. This is beingeffectively used.
xii) Distribution of iodised salt
The distribution of iodised salt produced by the BSE is being done properly and recordsare maintained. For the year 1995, a total of 51,915 bags of 37.5 kg. equivalent to1946.8 tons were sold. This quantity is approximately 40 per cent of the totalestimated annual requirement of 5,000 tons in Bhutan.
xiii) Pricing of iodised salt
With respect to the price of iodised salt, BSE is following the prices agreed by theMinistry of Trade. The price variation for 37.5 kg bag during the year 1995 has beenbetween Nu 46 to Nu 126 with average price ranging from Nu 64 to Nu 69.
22
xiv) Availability of iodised salt
Since 1994, BSE is encountering consistent difficulties in procurement of common saltfrom India. Therefore, BSE is not in a position to meet the entire demand for iodisedsalt in Bhutan. To meet demand, wholesalers and retailers have been procuring iodisedsalt from across the border.
4.1.5) Conclusions and Recommendations
i) As a result of liberalisation, a private trader engaged in a national public healthprogramme is facing consistent difficulty in procuring common salt. It appears that themarket forces have effectively phased his requirements by not making availablecommon salt as per the agreed upon despatch schedule.
In order to facilitate timely procurement of common salt from India, BSE should begiven all the possible assistance by the Royal Government of Bhutan. This matterneeds attention at the highest level between the Governments of Bhutan and India.This would raise the level of commitment for ensuring timely and adequateprocurement of common salt from India.
ii) As the salt iodisation plant has surpassed it's life span, it should be replacedimmediately to avoid possible breakdown. In addition, the crusher needs to be repairedon a urgent basis.
iii) BSE should enter into a service contract with the manufacturer so as to maintainthe equipments in functioning condition.
iv) It is very vital to carry out iodine estimation of salt by titration at the SIP during theprocess of iodisation. This is the most critical step in the whole process of ensuringa good quality product with adequate iodine. Therefore,
a) laboratory should be well equipped and functional at SIP.
b) BSE should employ a laboratory technician EXCLUSIVELY for carrying out iodineestimation at SIP and also be responsible for maintaining internal quality control.
c) In order to provide supportive supervision, the laboratory technician fromPhuntsholing Hospital should visit SIP daily and collect samples for carrying outexternal quality control at the Hospital laboratory.
4) All records should be maintained at SIP and be available when required.
v) Quality of HOPE bags should be improved. The previously used laminated jute bagsshould now be re-introduced and made available for packaging.
Since there is a change in consumer purchasing behaviour, iodised salt should bepacked in 1 kg packets of polyethylene with proper labelling.
4. 2) Monitoring of iodised salt at Community Level
This section is covered as follows :
4.2.1) Objective
4.2.2) Methodology
4.2.3) Current status of monitoring of iodised salt
4.2.4) Conclusions
4.4.5) Recommendations
4.2.1) Objective
i) To review the process of monitoring of iodised salt at community level.
4.2.2) Methodology
i) Interviews with staff of Public Health Laboratory (PHL), Thimpu, and DMO/DHSOat district level.
ii) site visit to District Hospital.laboratory of selected districts. t6
iii) Review of existing documents and records both published and unpublished.
4.2.3) Current status of monitoring of iodised salt
The information on current status of monitoring of iodised salt was collected by dataavailable from the annual reports on salt iodisation in the country (1989-1996); reviewof Ministry of Health documents namely: Yearly health bulletin of Ministry of Health,Iodine monitoring reports for the year 1990-96 sent by Public Health Laboratory (PHL)to Nutrition Section, District salt monitoring forms submitted to PHL, Quarterly reportssent by the district laboratories and basic health units (BHU's), and yearly reportscompiled by PHL.
i) Existing infrastructural facilities available for monitoring
Public Health Laboratory (PHL), Thimpu is the apex institution and reference centre formonitoring and evaluation of public health programs. There are two regional referencelaboratories to support PHL. These are situated in Gaylephug (Central Bhutan), andMongar (Eastern Bhutan). Both regional laboratories carry out most of the activitiesavailable at PHL. However quality control, supportive supervision and reference facilityis provided by PHL. District laboratories attached to district hospitals provide testingfacilities for clinical specimens and also for salt and water testing. District laboratories
24
have been established in 1 6 districts. Staff in Basic Health Units (BHU's) also providesupport in the monitoring of the public health programs specially the IDD controlprogram through salt testing kits.
For monitoring iodine content of salt,two methods are being used. They are :i) Salttitration method, and (ii) Salt testing kit. The necessary equipment and reagentsfor titration method are available in most of the district laboratories. Salt testing kitsare available with district laboratories and BHU's.
During their training period at the Royal Institute of Health Sciences, Thimpu,technicians have learnt methods for iodine estimation by titration method. They areexpected to receive re-orientation in titration method by PHL Staff periodically whenthey travel to district hospital for quality control visits.
ii) Quality control activities at PHL
There are established protocols for conducting quality control, exercises regularly forall the tests carried out at PHL.
Titration method to estimate salt iodine content are regularly checked usingappropriate controls. However the urinary iodine estimation has not been done for along period.
iii) The monitoring system of IDDCP
Salt Collection
There is a "Proforma for iodine analysis of salt", for recording salt related information(Annexure - 1). The technicians working in the district laboratory or the healthassistant at BHUs collects the salt samples from households, retail shops and FCBagents. Instructions noted on the salt collection form state "Please attempt to analyzeat least 60 samples every quarter taken from a mixture of houses, shops and schools.Please fill out these proforma after testing salt samples and send them to your DHSOfor onward forwarding to PHL, Thimpu."
Format for collection of salt samples for iodine estimation
Source of salt, name of the owner, address including block and village are recorded.In addition it has the following questions:
Date of purchase/date of iodisation as mentioned on packing, batch number, place ofstorage, duration of storage at the point of collection, name of collector, date & placeof analysis of salt for iodine content and name of technicians.
In some forms, the method of iodine testing (kit or titration method), is also enquiredinto. [Most of the forms screened didn't mention the method of iodine estimation].
Preparation of quarterly salt testing report in the district
Technicians of the district laboratory or the health assistant of the BHU collect thesamples and estimate their iodine content either by titration or kit method (asavailable). The original forms containing the salt information are then forwarded to PHLThimpu, through the respective DMO's or DHSO's. No salt samples are sent to PHLfor cross checking. Records indicated that salt monitoring is done through selectedDistrict laboratories and BHU's. It was not clear from discussions, of the names andnumber of designated district laboratories and the BHU's that collected and sent thequarterly reports.
Compilation of national salt iodine testing report
PHL Staff compiles the quarterly reports received from the districts and makes acomprehensive national report for onward transmission to the Nutrition Section,Directorate of Health Services, Thimpu. The four quarterly reports are made into asingle yearly report. The format of the report sent to the Nutrition Section is enclosedin Annexure - 2. In brief, the report states the name of district, number of salt samplescollected from various sources and proportion of salt samples with adequate andinadequate iodine content. Adequate iodine content is defined as the salt containing1 5 ppm iodine available at household level and 25 ppm iodine in salt samples collectedfrom retail shop or FCB agents store.
Feedback to districts - Iv*
IThe comprehensive national salt monitoring report are not usually communicated todistrict authorities to take up follow up action if required. Similarly it was not clear inthe discussions with PHL Staff, the actions taken against the DMO/DHSO's of districtwho did not send their quarterly reports regularly.
Feedback to retailers
The shopkeepers/FCB agents are not informed about the quality of salt samplescollected from their premises.
iv) Critical analysis of quarterly iodine monitoring reports (1989-1996)
As is clear from the Table 4.2, out of 20 districts, 9 (45%) to 16 (80%), districts hadsent iodine monitoring report at least once in a calendar year during the period1989 to 1996.
26
Table 4.2 : Year-wise salt iodine monitoring reports from districts
Period
1989
1990
1991
1992
1993
1994
1995
1996 (1st Qtr)
No. of districts submitting salt iodine monitoring reports
Source
House
12
14
13
13
15
9
8
8
Shops
9
15
12
13
14
6
8
5
Total*
14
16
13
14
16
9
11
10
* at some places, samples were analysed from both, house and shops
Closer scrutiny of annual reports compiled by PHL indicated the following:
i) Quarterly reports were sent from the district at erratically. Several times, only asingle quarterly report was available from a district in the whole calendar year.
ii) Reports from several districts particularly from central Bhutan were few.
iii) Samples were not a uniform mix of shops and houses. On some occasions, eitherhouses or shops were sampled.
Thus, iodine monitoring reports represent time periods that were irregularly monitoredwithin the districts and across districts. There was also a lack of consistent anduniform representation of household and retail shopkeepers.
V) Critical analysis of Iodine monitoring forms filled in the district laboratory/ BasicHealth Units
Inadequacy of filling existing monitoring forms:
Questions pertaining to batch number of the salt, date of iodisation; were notanswered. In addition answers to queries regarding; usual duration of storage of saltin the house/shop and date of purchase of salt were interestingly uniform in thebatches of forms sent as part of a quarterly report:
In a majority of forms screened, the method of iodine testing was not mentioned.However the place of testing was mentioned as "home" in these forms. This indicatedthe use of salt testing kits.
The reports compiled by PHL to prepare quarterly and annual iodine monitoring reportscombined the findings from salt testing kit and titration method. This is likely tointroduce a major bias in the interpretation of results since kit test representsqualitative iodine content of salt and titration, a quantitative determination.
vi) Constraints in monitoring
Discussion with PHL staff and district health authorities revealed some of theconstraints in iodine monitoring program.
a) Manpower : there is only a single technician in the district laboratory. He has tofulfill his clinical responsibility and thereafter collect salt and water samples. This putshim under significant time constraint to complete public health activities
b) Equipment status : If the equipment in out of order or broken, it takes a long timefor its repair or replacement.
c) Feedback : No feed back is given to field for any follow up action.
4.2.4) Conclusions
i) An infrastructure to carry out monitoring salt iodisation at the community level existsin Bhutan. There is a potential for improving the functioning of the monitoring system.
ii) The district level monitoring unit in district laboratory is overburdened with severalother public health and routine clinical activities. At several places, monitoring ofiodine in salt using titration method is not being done.
iii) The inflow of quarterly salt testing reports was irregular and information on severaldistricts was not available. The reports of titration and test kit were combined.
iv) Based on the salt monitoring reports received from the districts, there is aconsiderable delay in follow-up action taken either at district administration or districthealth department level.
4.2.5) Recommendations
i) On-going development of a trained manpower by regular refresher courses forlaboratory technicians at district, regional and national level.
ii) Recruitment of additional laboratory personnel at district level to exclusively lookafter public health monitoring activities including IDD.
28
iii) Timely repair and/or replacement of laboratory equipment at district level
iv) Timely submission of reports; proper compilation of reports i.e. maintainingseparate records of titration and kit results
v) Regular feedback to the field for any follow up action
vi) Annual ranking of districts based on total number of salt samples analysed and saltsamples with adequate iodine levels
vii) At the community level, the following monitoring system is recommended.
In this monitoring system, the main emphasis is on intersectoral co-ordination betweenthe Department of Education and the Directorate of Health Services, both of which areunder the Ministry of Social Services.
The system requires active participation of Primary and Junior Schools and on-goingsupport and collaboration between the District Health Laboratory and the Public HealthLaboratory.
a) Primary School
To begin with, once in three months (later on once a year on a designated day),primary school teachers will ask.the children of one specific class to bring salt fromtheir home. One of the designated teachers', trained in testing the salt by kit willconduct the test and record the results. The results will be then sqbmitted to the localBasic Health Unit for further transmission to District Health Laboratory.
The designated teacher of the primary school will also send 5 samples of the saltbrought by the children (at least 20 gm) in a plastic packet to the Junior High Schoolfor testing the salt by titration method.
b) Junior High School
The Science teacher of the Junior High School will be trained to test the salt bytitration method and will be provided with the required chemicals and reagents. He willtest all the salt samples and record the results. The results will be transmitted to theDistrict Health Laboratory for compilation and further transmission to Public HealthLaboratory. Along with the results, he will also send 10 per cent of salt sample to theDistrict Health Laboratory for quality control.
c) District Health Laboratory
The laboratory technician will analyze all the salt samples sent by Junior High Schooland compile the reports for onward transmission to Public Health Laboratory atThimpu.
29
Along with the report of the Junior High School and BHU, the District laboratory willalso send 10 per cent of the samples to Public Health Laboratory for quality control.It will also provide feed back to the Junior High School.
Public Health Laboratory
PHL will monitor the quality control of laboratory testing. It will compile, analyze andfind out the deficiency in iodised salt supply in different parts of the country and sendfeed back to the respective District Administration, DM0 and DHSO for necessaryaction.
«*
PHL, Thimphu-/N
v
Feed back
District HQ. District LabA\ A\ A 10%-
rfa
VillagePrimarySchool
(5 Samples)
Junior High SchoolScience Teacher
/K
<-
Feed back
VillagePrimarySchool
(5 Samples)
VillagePrimarySchool
(5 Samples)
Feed back
Fig.2. Proposed Community Level Monitoring System
30
5) Current Status of Iodine Deficiency Disorders in Bhutan
This section is covered as follows :
5.1) Objectives
5.2) Methodology
5.3) Results and Discussions
5.4) Conclusions
5.5) Recommendations
5.1) Objectives
i) To study the current status of IDD as measured by goitre prevalence and urinaryiodide excretion (UIE) pattern in primary school children aged 6 to 11 years
ii) To determine the proportion of households using adequately iodised salt (iodine _>_15 PPM) by analysing salt samples brought by the school children from theirrespective households
iii) To determine the proportion of retail shops selling adequately iodised salt (iodine>. 25 PPM)
iv) To study the Knowledge, Attitude, Practice and Behaviour (KAPB) on IodineDeficiency Disorders (IDD) of key stakeholders namely health, salt (producer,distributors and retailers), education, agriculture & livestock, trade, administrators,consumers etc in sustainable elimination of IDD
5.2) Methodology
5.2.1) Study design
This was a cross sectional survey wherein sampling procedure using,"Probabilityproportionate to size (PPS)" was followed. All the blocks with their respectivepopulation in the country were listed. Using the standard "30 cluster PPS"methodology, a total of 30 cluster (blocks) were selected. A primary school wasrandomly selected and visited from the selected cluster (block). An additional samplingframe of 10 clusters were prepared so that it could be used for substituting the blocksthat could not be visited during the proposed time frame of field survey.
The final selection of the blocks was decided taking into consideration the time tocomplete the present study (2 weeks), accessibility, time period available for follow-upon the recommendations of the study during the Nutrition Action Year.
31
Limitations of the study : In stating this methodology, the authors are aware of thewell recognised trade-off between representativeness and generalizability; andbetween feasibility and timely feedback to the Programme Managers. The 1991-1992study, which covered "30 clusters" each in Northern and Southern Bhutan in arepresentative manner demonstrated that over 95 per cent of salt samples collectedfrom households had iodine levels more than the recommended 15 parts per million(ppm.) The above survey included many villages that were away from the road headsand in fact represented a "worst scenario" situation. In terms of iodine content of salt,there was no difference between accessible and inaccessible villages.
*
Therefore, taking into consideration the factors mentioned above, the iodine nutriturestatus of the primary schools that are accessible from the selected blocks may serveas a "proxy", to the those that are not accessible from the road heads. This strategyfacilitated completing the field component of the present study, that requiredextensive country-wide travel, in a record period of two weeks.
5.2.2) Sample size determination
Estimated goitre prevalence(conservative estimate) : 50% (or 0.50)
Confidence interval : +/- 5% (or +/- 0.05%)
Width (admissible error) : +/- 10%
Design effect .. : 3
Total samples size(no. of children examined) : 1152 = 1200
Samples size per cluster(no. of children per cluster) : 40
5.2.3) Selection of school children
One primary school in the study cluster was selected randomly. The list of selectedschools and their location is given in Annexure - 3. A list of all the children in agegroup of 6 to 11 years was compiled. Using random numbers, a total of 40 children(both boys and girls) present on the day of the survey were selected and examined forgoitre grading and collection of urine samples. Information was recorded on a pre-designed proforma which is enclosed as Annexure - 4.
5.2.4) Household Salt Samples
On the day of survey, all the children were asked to bring salt samples from theirhouse. The salt samples brought by the children who were examined for goitregrading were then tested for iodine content using field test kits. From these, a totalof 10 samples were selected randomly and collected for analysis by titrimetric methodat PHL, Thimpu.
32
5.2.5) Retail Shop Salt Samples
Salt samples were collected from all the retail outlets encountered during field visits.These were tested by field test kits and also collected for analysis by titrimetricmethod at PHL, Thimpu.
5.2.6) Study procedures
i) School Children
Clinical: All the children were clinically examined for thyroid enlargement by thetrained and experienced physicians of the external team. Goitre was graded as per thecriteria recommended by the Joint WHO-UNICEF-ICCIDD Technical ConsultationGroup. The classification of goitre is given in Annexure - 5
Biochemical: From the 40 children examined, a total of 10 children were selectedrandomly. On the spot urine samples were collected from them in the plastic screw-capped bottles.
ii) Retail shops
Interview & Observation : The information on procurement, storage, re-packing andpricing of salt was collected -from the retail shops using an interview schedule. Inaddition, storage and packaging was also observed. Information was recorded in a pre-designed proforma which is enclosed as Annexure - 6.
Collection of salt samples: One or more - depending on the type of salt samplesavailable in the shop, were collected for both analysis by field test kit and titrimetricanalysis.
iii) KAPB of stakeholders
Using an interview schedule, Knowledge, Attitude, Practice and Behaviour (KAPB) onIodine Deficiency Disorders (IDD) of the key stakeholders namely health, salt(distributor and retailer), education, agriculture and livestock, trade, administrators,consumers - involved in sustainable elimination of IDD were collected. An attempt wasmade to interview at least one representative stakeholder in each cluster. Informationwas recorded in a pre-designed proforma enclosed as Annexure - 7.
5.2.8) Study Teams
The survey was carried out by four teams consisting of international and nationalmembers. The list of team members is given in Annexure - 8.Each team had threemembers, of which one was an international member.
33
5.2.9) Laboratory Analysis
i) Salt samples
Salt samples were analysed by using titrimetric method at the Public HealthLaboratory, Thimphu. The internal quality assessment protocol using Levy Jenning plotwas followed and is shown in Fig.3.
ii) Urine Samples
Urine samples were analysed at the Public Health Laboratory, Thimphu using themethod of Gutekunst et al at Public Health Laboratory, Thimphu. The internal qualityassessment protocol using Levy Jenning plot was followed and is shown in Fig.4.
Both salt and urine sample analysis was carried out by well trained technical personnelworking at PHL, Thimpu, under the guidance and supervision of Prof. M. G.Karmarkar, Senior Advisor, ICC1DD, New Delhi.
5.2.10) Study period
Field work : 10 th to 30 th May, 1 996
Data entry and analysis : 1. st to 30 th June, 1996
Laboratory analysis : 1 st to 10 th July, 1996
Report Preparation and \Submission : 1 5 July to 31 st August, 1 996
34
•=)J3i
W7-30
- >ciV "-JJ
I.X
-«H& J\ S>
Q ,.11
oMi
IXJv.'Z
dSb
——-0- V
vN.
fV.O ft-
^
<\1 1
'U A^ i<^•v ^>. ^ N-I
•V.<i
~^
4,in
»3-A,bai"
Fig.3. Internal Quality Control Levy Jcnning plot Tor iodine estimation in salt by iodomctric titration
2^+2 Sb
'V1^
UfllAI K
Fi>f/tf "l **
Ufff9-2s-l>
BftTCH -»
j>ATC
I
31?
13)7
1 l I >
3
«f?
4
"/T Jh4
«/T
'I
B/7
S
•>/»
Fig.4. Internal Quality Control Levy Jcnning plot for urinary iodine estimation
' -Arlf ".• lil'.it- fciik.f jj^VflTffiPT? '
5.3) Results and Discussion
Part-1 : Age and sex distribution of school children
In 30 randomly selected clusters of Bhutan, a total of 1200 school children wereexamined. The survey was carried among school children aged 6-11 years; of which23.2 per cent were in the age group of 6-7 years, 40.9 per cent were between 8-9years and 35.9 per cent were between 10-11 years of age. The male childrenconstituted 56.3 per cent and the remaining were females. Fig.5. shows the age & sexdistribution of school children examined. The details are given in Table 5.1
Table 5.1 : Age & sex distribution of school children
Age
6-7
8-9
10-11
Total
Sex
Male
161(57.9%)
272- (55.4%)
243(56.4%)
676(56.3%)
Female
117(42.1%)
219(44.6%)
188(43.6%)
524(43.7%)
Total
278(23.2%)
491(40.9%)
- 431(35.9%)
1200(100%)
37
1200 r
1000
800
600
400
200 •
-I—-
£3 MaleII FemaleD Total
6 to 7 8 to 9 10 to 11 Total
Fig .5. Age & sex distribution orthe sampled school children examined in Bhutan
:«K" * WfWtWftStTJIViW 'SSHT
Part -2 : Goitre prevalence and urinary iodine excretion
The age-wise prevalence of goitre in school children is given in Table 5.2. Of thechildren examined, 1031 children out of 1200 i.e. 86 per cent had no goitre. A totalof 154 children (12.8%) had goitre of grade 1 (palpable enlarged thyroid); and only15 children (1.2%) were found to have visible goitre (grade 2). The total goitre rate -TGR (goitre grade 1 + 2) was 14.0%. As per the WHO/UNICEF/ICCIDD criteria, this
TGR indicates," mild iodine deficiency in the community." Rg.6. shows thedistribution of goitre grade in children aged 6 to 11 years.
Table 5.2 : Age-wise prevalence of goitre in school children
Age
6-7
8-9
10-11
Total
Totalexamined(n)
278(100%)
491(100%)
431(100%)
1200(100%)
Goitre Grade
0
238(85.6%)
423(86.2%)
370(85.8%)
1031(86.0%
1
37(13.3%)
66(13.4%)
51(11.8%)
154(12.8%)
2
3(1.1%)
2(0.4%)
10(2.3%)
15(1.2%)
TGR = 1+2
40(14.4%)
68(13.8%)
61(14.1%)
169(14.0%)
39
1200 1031(86.0%)
1000
800
600
400
200
154(12.8%)
15(1.2%)
[a] Goitre Grade
(n=1200)
Fig .6. Distribution of Goitre Grade in Children Aged 6 to II Years
The urinary iodine excretion pattern is given in Table 5.3 and Fig.7. The medianurinary iodine excretion level in these school children was 230 pg/\. As per theWHO/UNICEF/ICCIDD criteria, this is indicative of NO iodine deficiency in thecommunity. However, it is important to note here that frequency distribution arenecessary for full interpretation of urinary data. The frequency distribution showed thefollowing pattern : 10 (3%) showed excretion less than or equal to 20/;g/l; 33 (9.9%)showed values between 21 and 50/;g/l, and 37 (11.1%) had between 51 and 100fjg/\ and 253 (76%) showed excretion higher than 100/;g/l. Thus, almost one fourthof the urine samples examined (80/333; 24%) had values less than or equal to 100fjg/\, the level which is indicative of adequate iodine intake.
Table 5.3 : Urinary iodine levels (/yg/l) in school children
Urinary Iodine(//g/l)
0- 20
21 - 50
51 - 100
101 & above
Frequency(n = 333)
10(3.0%)
33(9.9%)
37(11.1%)
253(76.0%)
41
c(0o(5Q.
80
70
60
50
40
30
20
10
0
76.0%
9.9% 11.1%
(n = 333)
0-20 21-50 51-100 > = 101
Fig.7. Urinary iodine excretion pattern (ng/1) in children :igcd 6 to 11 Yrs
SK'.aMassafSKaa-:
Now in Bhutan, there are a total of three nation-wide surveys including the presentstudy. The findings of these three studies are summarised in the table below. In thefirst nationwide IDD survey in 1983, the TGR was reported to be 64.5 per cent and62 per cent of school children had urinary iodine levels less than 50 /vg/gm ofcreatinine (equivalent to 50 fjg of iodine/I of urine). The second nationwide IDD surveywas conducted in 1991-92. TGR in Northern Bhutanese children and SouthernBhutanese children was 18.4 per cent and 32.5 per cent respectively. The summaryof the results of the 1983 survey, 1991-92 internal evaluation and the present studyis given in Table 5.4.
Table 5.4 : Results of the National IDD Survey 1983; internal evaluation (1991-92) andthe present study (1996)
Indicator
Total Goitreprevalence(%)
Visible GoitrePrevalence(%)
Cretinismprevalence(%)
(%) With UIEi>_100/vg/l)
Median UIE(/vg/l)
%With TSH> 5 mU/l
NationalIDD survey(1983)
60.0%(12,045)
";
>. 10
3.1**(822)
-
-
(* Figures in brackets are num(** UIE > 100 pg/g of creatin
NorthernChildren(age 6-11years)
18.4(1443)
0.3(1443)
0.4(1443)
87.4(864)
283(864)
20.38(1423)
SouthernChildren(age 6-1 1years)
32.5(992)
1.0(922)
0.4(922)
83.8(871)
244(871)
22.34(985)
PresentStudy(age 6-11years)
14.0(1200)
1.2(1200)
Not done
76(333)
230(333)
Not done
bers of people examined or samples collected)ine)
The present study (1996), indicates that TGR has reduced significantly as compared to 1983and further declined as compared to 1991-92 levels. Comparison of goitre prevalence urinaryiodine excretion between 1983, 1991-92 and 1996 studies is shown in Fig.8. & Fig.9respectively.
43
60%DU
50
40 -
cQ)0 30 -i~0)Q.
20 -
10 -
0 -
11miii
n1 1 1
32.5%
lllll
1 1 Districts SouthernDistrict
(n= 12,045) (n=1443)
1983 Study
Total GoitrcPrcvalcncc(adult males & females, primary school& preschool children in 11 districts at Bhutan)
18.4%
NorthernDistrict
(n = 992)
1991-92 Study
14.0%
Bhutan
(n = 1200)
1996 Study
Total goitre rate in children aged 6 - 1 1 years
Fig.8. Comparison of goitre prevalence between 1983,1991-92 and 1996 studies
•*"•• wwswpsasssr-
83.8%
C0)ol_0)Q.
87.4%
10
0 -0 26 51 76 > = 101to to to to25 50 75 100
11 Districts
(n = 822)
1983 Study
<20 20 50 > = 100to to
49.99 99.99
SouthernDistrict
(n = 871)
8%4.2%
ar'% 1111
<20 20 50 > = 100to to
49.99 99.99
NorthernDistrict
(n = 864)
76.0%
1991-92 Study
0 21 51 > = 101to to to20 50 100
Bhutan
(n = 333)
1996 Study
Urinary iodine excretion fig/g ofcrcatininc(adult males & females,primary school& preschool children in 11 districts of Bhutan)
Urinary iodine levels (UR/|) in children aged 6 to 1 1 years
Fig.9. Comparison of/urinary iodine excretion between 1983, 1991-92 and 1996 studies
•TCimHMtaMBJOSR.'%-::
Similarly the proportion of children excreting inadequate iodine in urine came downsignificantly between 1 983 and 1996. Even though the median urinary iodine excretion hasremained the same as compared to the 1991-92 study, the proportion of children excretingiodine less than 100 /vg/l has increased to 24 per cent as compared to 12 per cent to 1 6 percent in the 1991-92 study. This may be attributed to the fact that in the 1991-92 study, 95per cent to 96.5 per cent of salt samples were adequately iodised (iodine _>_ 15 PPM), athousehold level compared to 82 per cent of the salt samples in the present study. This iscorroborated with the finding that since 1994,there is a breakdown in the monitoring ofiodine content of salt at the production level (SIP) in Phuntsholing.
46