Volume 13 Number 1 February 1997



IN THIS ISSUE

Thai Royal Family Leads Fight for IDD Elimination

Eastern Europe and Central Asia:  Overview of IDD Status

Regional Meeting on IDD Control in Eastern Europe and Central Asia

Endemic Goiter in Turkey.  Is Iodine Really Deficient?

Iodine Deficiency Disorders in Albania

Timothy J. Stone

Recommended Iodine Levels in Salt and Guidelines for Monitoring Their Adequacy
and Effectiveness

The Role of Women's Organizations and Village Cooperation Units in the Social
Marketing of Iodized salt

Bread Iodization for Iodine Deficient Regions of Russia and Other Newly Independent
States

Simple Test Kit to Determine Cyanide in Cassava

In Brief

Recent Publications

Pretell Receives Spain's Queen Sofia Prize





THAI ROYAL FAMILY LEADS FIGHT AGAINST IDD ELIMINATION
         Thailand has made major strides towards eliminating its iodine deficiency during
the past decade.  Previous issues of the IDD Newsletter (e.g., 5(3):1, August 1989;
8(3):25, August 1992) have chronicled this progress and highlighted the contributions
of Professor Romsai Suwanik, a pioneer in the correction of iodine deficiency, Dr.
Sangsom Sinawat, Chief of the Division of Nutrition in the Ministry of Health, and
others.  A key ingredient in the success so far has been the direct and personal
involvement of the Royal Family.  The Crown Princess Maha Chakri Sirindhorn has
taken an especially keen interest in the IDD elimination program, presiding over
national seminars in 1992 and 1994 and serving as Chairperson of the National
Committee for IDD Control.
         Another event in the Royal involvement took place in January 1996, when
Thailand celebrated the initiation of a national campaign to eliminate iodine deficiency
disorders through salt iodization.  The campaign launch, organized jointly by the
Ministries of Public Health and Interior and by the Thai Red Cross Society,
commemorated the 50th anniversary of His Majesty the King's accession to the throne
and was honored by the presence of Her Royal Highness, Crown Princess Maha
Chakri Sirindhorn.
         The day-long event was designed to mobilize the entire country to consume
iodized salt in a bid to eliminate the iodine deficiency that has continued to plague
Thailand despite a long history of IDD control interventions.  Over 2,000 tons of
specially packaged iodized salt were distributed to the Thai people during that day, to
enable everyone to begin using iodized salt.  The salt had been donated by private
salt producers to His Majesty the King and was known as the "King's Salt."
         Early in the day, thousands gathered at King Rama V Square where movie
stars, singers, and acting groups performed songs and skits informing the public about
iodine deficiency and advocated iodized salt as the cure for the problem.  Thai officials
and government guests joined the event.  Her Royal Highness arrived and presided
over the official proceedings.  She recognized the contribution of hundreds of people
with medals of appreciation and thanked them for their help.  UNICEF were among
those recognized.  She also gave out "iodine victory flags" to villages that have
successfully switched from non-iodized to iodized salt.
         The Prime Minister then spoke, noting the link between iodized salt and its
effects on the intellectual capacity of the Thai people.  He declared that only iodized
salt should be available in Thailand.  An iodine display was also organized.  Exhibits
included presentations on the prevalence of IDD, a stand depicting a typical store
where iodized salt could be purchased, samples of how iodized salt can be used in
Thai cooking and demonstrations of equipment used to add iodine to salt.
         The day culminated in a Royal send-off ceremony for a caravan of trucks
carrying iodized salt to all the provinces in the kingdom.  Her Royal Highness,
Princess Maha Chakri Sirindhorn presided over the inspection and departure of the
trucks, which were provided by the Office of the Supreme Command of the Royal Thai
Army, Navy, and Air Force.  Military aircraft transported salt to the most remote
provinces.  The following day, health officers, village health volunteers and Red Cross
volunteers delivered packages of the King's Salt to every household in the country. 
Upon accepting the salt, households were asked to pledge to continue to buy iodized
salt thereafter.
         As night fell, the Prime Minister ended the campaign launch with a public
ceremony.  Candles were distributed to the thousands still gathered and the national
anthem, King's song and an official IDD song were sung.  The entire event was
broadcast live on national television and provinces held simultaneous ceremonies
throughout the country.
         The event greatly raised public awareness of the IDD problem and of iodized
salt as its solution.  His Majesty, the King's support of the campaign highlighted the
importance the country places on solving the IDD problem with iodized salt.  Salt
producers have reported rising sales since the campaign and a forthcoming evaluation
is expected to find nearly 100% of households using iodized salt.
         Another advocacy event was the Food Fair held early in 1997.  Some groups of
people in Thailand believe that food cannot be preserved by iodized salt because the
taste and color will change, and consequently, the food will become dark and bitter. 
Preserved foods are widely eaten in the nation, so the Nutrition Division of the Ministry
of Health set out to prove that iodized salt can be used successfully in such food.  A
Preserved Food Contest took place in each province of the country during November
of 1996 for foods preserved from either meat or vegetables.  The Food Fair was set
up in one of the big shopping malls in Bangkok by the combined efforts of the Thai
Red Cross, the Community Development Department, the Department of Health, and
the Fashion Island Department Store.  Its theme was "Cooking Thai Food With Iodized
Salt."  Activities included booths selling and showing foods cooked with iodized salt
from all parts of the country, demonstrations of cooking and preserving foods with
iodized salt, and a contest awarding prizes to the three best preparations for each
type of food.  Princess Somsawalee presided over the event, and herself
demonstrated preserving eggs with iodized salt.
         Currently, the Thai government is committed to the reduction of IDD to below
5%.  The Department of Health has adopted comprehensive approaches with
emphasis on population participation and appropriate technology suitable for individual
localities.  This strategy includes use of iodized drinking water in primary schools and
households in the endemic areas, and distribution of iodine tablets to pregnant and
lactating mothers to avoid mental reduction in newborns.  For prevention, the program
includes increased production and distribution of iodized salt to cover the country's
target population, encouraging the regular consumption of iodized salt, accelerating
and sustaining education and communication on IDD through various media,
developing an IDD monitoring system, and supporting applied research to promote
sustainable elimination of iodine deficiency.
         The IDD prevalence rate nationwide has decreased steadily over the last seven
years, from 19.3% in 1989 to 5.65% in 1995 and 4.29% in 1996.  However, in six
districts of four provinces the prevalence remains over 30% (three districts in Mae
Hong Son, one each in Chiangrai, Kanchanaburi and Udonthani).  In addition, some
districts in nine provinces have prevalence rates over 20%.  The Division of Nutrition
notes that in these intense IDD areas, major steps must be taken to eliminate IDD.
         The Program affirms that iodization of salt is the major and sustainable strategy
to control IDD because salt is normally consumed by all sections of society.  To
encourage sufficient and regular salt consumption among the people, several
measures have been implemented, including:  (1) issue of Ministry of Public Health
Notification 153, regulating the iodization of all edible salt, in force since September
14, 1994; (2) declaration by the Department of Health on September 30, 1994 of its
support for salt iodization; (3) organization of a meeting of marine and rock salt
producers to follow-up Notification 153 and to encourage iodized salt production; (4)
support for salt iodization machines and for resources to obtain bigger machines for
large salt producers; (5) support for providing free KIO3 to salt producers; (6) a
campaign to promote iodized salt consumption through social marketing; (7) stimulus
to set up village iodized salt funds nationwide; (8) encouragement to include iodized
salt in school lunch programs; and (9) monitoring of iodized salt quality.
         In addition, iodization of drinking water is used in some endemic areas, and
iodizing solutions have been provided for their primary schools and households.  Also,
the Nutrition Division provides a concentrated iodine solution for inclusion in fish sauce
under the guidance of local health authorities, to encourage iodine supplementation in
the many households that consume it.  Finally, iodine tablets are distributed in remote
areas with severe IDD where iodized salt and iodized drinking water are not yet
accessible.  
         A surveillance system currently operates at several levels.  Surveys for visible
goiter have been conducted annually in primary school children.  Cord TSH levels
have been randomly obtained at birth for assessment and monitoring of the control
program.  Urine samples have also been collected randomly for monitoring.  Iodized
salt quality has been monitored from samples provided by producers or collected
directly from the salt shops, by laboratory determination or by test kits provided by the
Nutrition Division.  Simple test kits are used for monitoring of iodized salt and drinking
water in the villages.  
         The Control Program has addressed human resource development by
organizing meetings, seminars, and training courses for administrative officers and
field workers of relevant agencies at the central and rural levels, including teachers
from the border police.  Additional efforts include press releases on various occasions,
coordination with the Ministry of Education to incorporate IDD material in school
curricula, promotion of annual campaigns in the provinces, production and distribution
of IDD educational materials and TV spot to provincial authorities, and mobile units to
communicate and educate villagers.  
         The Division has also been active in supportive projects.  The 50th Anniversary
of His Majesty the King's Accession to the Throne was used as an occasion for
cooperation among relevant agencies on IDD control to instill awareness of IDD and
its effect on the quality of Thai life.  Another project is developing systematic
monitoring to assure satisfactorily iodized salt.  This monitoring is now being carried
out regularly as part of the consumer protection program.  A working group with
representatives from concerned agencies has been set up to prepare a National IDD
Plan for 1995-2001.  Campaigns to encourage iodized salt consumption in Thailand
have been organized.  The program is providing salt iodizing machines, KIO3 powder,
iodine solutions, iodine tablets, iodine test kits, educational materials, and mass media
material (film, video, slides, tapes, spots, etc.) and distributing them to provincial
agencies.  Supervision and evaluation are carried out at the provincial, regional, and
central levels.  Evaluation of progress in IDD control comes from annual provincial
records.  A project is being set up to assess the National IDD Control Program.  Also,
various research studies on IDD have been carried out to enhance the efficiency of
the program.  
         Although the IDD prevalence nationally is 4.29% and the mid decade goal of
universal salt iodization has been attained, moderately severe IDD persists in districts
of some provinces.  The Department of Health plans vigorous action to complete IDD
elimination in these areas.  Teams of central supervisors will be dispatched to
determine and resolve local working difficulties, to be followed by forming provincial
and regional teams that will prepare plans for strengthening local field operations. 
Meetings of administrators of relevant provincial agencies in areas of intense IDD will
be organized, to discuss and plan measures and cooperation to reduce the IDD
prevalence rate.  Participatory agencies include the Community Development
Department, National Office of Primary Education, the Border Patrol Police, the Office
of Project Development through the Royal Initiatives by H.R.H. Princess Maha Chakri
Sirindhorn, and others.  More details can be obtained from the Nutrition Division,
Ministry of Health and two recent publications - the report of the 2nd National IDD
Seminar (1994) and a study of population compliance towards iodine supplementation
measures.
(Material for this article was provided by Dr. Sangsom Sinawat, Director, Division of
Nutrition, Ministry of Health; Fida Shah, Program Officer, UNICEF area office,
Thailand; and Dr. John Stanbury, ICCIDD Board Member and Chairman Emeritus.)
EASTERN EUROPE AND CENTRAL ASIA:  OVERVIEW OF IDD STATUS
G.Gerasimov1, MD and F. Delange2, MD
1ICCIDD Subregional Coordinator for Eastern Europe and Central Asia,
Moscow, Russia
2ICCIDD Executive Director and Regional Coordinator for Europe, Brussels, Belgium
         Iodine deficiency has been greatly underestimated in Europe in recent decades
and has not generally been considered a significant problem.  Surveys carried out in
the 1980's clearly demonstrated the persistence of moderately or even severely
affected areas, especially in the Eastern and Southern parts of the continent (1).  An
important step in the evaluation of IDD in Europe was a workshop in Brussels, April
1992, which summarized the current information on iodine nutrition as a step towards
proposing practical measures to correct its deficiency.  A monograph entitled Iodine
Deficiency in Europe: A Continuing Concern, contains the proceedings (2)
(summarized in (IDD Newsletter 9(1):1, 1993) (3).  Since that time the IDD situation in
Europe has changed.  Recent surveys show that iodine nutrition has improved, at
least in some countries (4). 
         Despite the progress made in Western Europe, IDD remain a significant
socioeconomic problem in most of Central and Eastern Europe (CEE), in the part of
the former USSR now included in the Commonwealth of Independent States (CIS),
and in the Baltic States (BS).  In the USSR, where severe IDD had been eliminated by
effective control measures between the 1930's and 1960's, government programs
were discontinued in 1970.  After dissolution of the Soviet Union in 1991, IDD became
a common problem of nearly all the Newly Independent States (NIS), and appear to
be worsening.  Now each of the 15 NIS must assess its IDD status and develop its
separate IDD control program.
         This article offers newer information on the IDD status, control programs and
salt supplementation in the CEE, CIS, and BS.  We have critically analyzed published
and unpublished information available as of January 1997 to the ICCIDD Office in
Brussels, including reports from countries and from UNICEF, other articles and
reports, data from agencies, and personal communications.  The amount and quality
of information vary considerably among countries.  Our results are presented as
tables, in a format compatible with the documents produced by other international
agencies and in ICCIDD's CIDDS database (5), which incorporates this new
information. 
Data Sources
         We present information on 27 countries, including 15 countries of the former
USSR (3 Slavic, 3 Baltic, 3 Transcaucasian, 5 Central Asia, and Moldova) and 12
countries of CEE (Poland, Romania, Hungary, Czech Republic, Slovakia, Bulgaria,
Albania, Turkey, Yugoslavia, Croatia, Macedonia and Bosnia).  These countries have
a global population of more than 460 million inhabitants and occupy a huge part of the
land mass of Europe and Asia.  They differ greatly in economic development, health
system priorities and severity of the IDD problem.  Some have made marked progress
and virtually eliminated IDD, while iodine deficiency remains critical in others.
         We classify countries into 3 categories as follows, according to available
information:
                  1.  No information:  Yugoslavia.
                  2.  Partial information:  Albania, Armenia, Azerbaijan, Bosnia, Estonia,
Georgia, Latvia, Lithuania, Turkey, Ukraine.
                  3.  Reasonably complete information:  Belarus, Bulgaria, Croatia, Czech
Republic, Hungary, Kazakhstan, Kyrgyzstan, Macedonia, Moldova, Poland, Romania,
Russia, Slovakia, Tajikistan, Turkmenistan, Uzbekistan.
         The presence and extent of IDD in the first group of countries is unknown. 
They do not have IDD control programs.  In countries of the second group, despite
incomplete information, the level of iodine deficiency can be determined, at least
roughly.  In the Baltic States (Estonia, Latvia, Lithuania), iodine deficiency is mild and
does not represent a major health problem, from the unpublished reports of UNICEF
consultant Dr. R. Gutekunst, who, with national teams, conducted surveys of iodine
concentration in spot urine samples from schoolchildren in all areas of these countries
(6).  Information on the degree of IDD severity and on control programs in other
countries is incomplete (7-9).  More detailed assessment is needed to evaluate their
IDD status and to develop plans of action.  [Ed note:  A recent note from Albania
appears elsewhere in this issue of the Newsletter.]
         Countries of the third group have more complete information.  In most, the
assessment, development and implementation of control programs have been
performed by country experts (2,10-14), while in the countries of Central Asia this
activity was carried out by international agencies working closely with governments
and local experts.  The technical documents of an IDD Workshop held in Ashkhabad,
1994 (15-18) provide detailed information on IDD status and salt iodization in Central
Asian countries.  Another important source of recent information is the Thyromobil
Study (4), which covered several Eastern European countries.  Comprehensive
information up to 1992 is also available in the proceedings of the Brussels workshop
on IDD (2,3).
Present IDD Status
         We can classify the countries as follows:
                  1.  IDD virtually eliminated:  Slovakia.
                  2.  Marginal and mild IDD:  Czech Republic, Estonia, Hungary, Latvia,
Lithuania, Macedonia. Moldova.
                  3.  Generally moderate IDD (with some areas of severe and/or mild IDD): 
Armenia, Azerbaijan, Belarus, Bulgaria, Croatia, Georgia, Kazakstan, Kyrgyzstan,
Poland, Romania, Russia, Turkey, Turkmenistan, Ukraine, Uzbekistan.
                  4.  Severe or critical IDD:  Albania, Tajikistan.
                  5.  Not enough information:  Bosnia, Yugoslavia (Serbia).
         The latest available data show that IDD is virtually eliminated in only one
country of the subregion, Slovakia (4).  In the second group of countries listed above,
IDD is either close to elimination or can be eliminated reasonably soon by salt
iodization.  Programs of IDD control through salt iodization are a high priority in
countries of the third group, while urgent measures (including iodized oil
administration) are needed in Albania and especially in Tajikistan and parts of
Uzbekistan, where IDD is critical.
Control Programs and Salt Iodization
         Effective and sustained elimination of IDD depends largely on the existence of
IDD control programs, proper legislation and successful salt iodization.  Based on
these parameters, we classify countries of the Subregion into the following groups:
                  1.  Currently effective control program through salt iodization:  Czech
Republic, Hungary, Slovakia.  In Poland, universal salt iodization became effective in
January, 1997. 
                  2.  Legislation on salt iodization exists (or is pending), but not enforced: 
Bosnia, Bulgaria, Croatia, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Macedonia,
Moldova, Romania, Turkey, Turkmenistan, Yugoslavia (?).
                  3.  Lack of legislation and control programs, with partial or no salt
iodization:  Albania, Armenia, Azerbaijan, Belarus, Latvia, Lithuania, Russia, 
Tajikistan, Ukraine, Uzbekistan. 
Monitoring, Human Resources and Training
         Most of the countries of the Subregion require development of an effective IDD
monitoring system.  History teaches that even effective control programs decay
without proper monitoring, feedback control and management.  All components of
effective control programs (assessment, salt iodization, and especially monitoring)
need qualified personnel.  Some of the Subregional countries have all the required
specialists, or need training only in particular fields (e.g., monitoring, communication,
management).  The other countries need extensive personnel training in most
components of IDD control, as follows:
                  1.  Training needed in selected areas (priorities to be determined for
each country):  Belarus, Bulgaria, Croatia, Czech Republic, Hungary, Macedonia,
Poland, Romania, Russia, Slovakia, Ukraine. 
                  2.  More extensive training needed:  all other countries. 
Conclusion
         Substantial progress has been made in the Subregion in the evaluation of
iodine nutritional status and in the implementation of preventive programs against
iodine deficiency.  The following actions are now needed:
                  1.  Review the current status of iodine deficiency disorders in many
countries.
                  2.  Identify the main constraints to the implementation of effective salt
iodization and IDD elimination programs in the Region.
                  3.  Consider practical approaches to overcoming such constraints,
primarily through the examination of successful experiences in countries with effective
programs.
                  4.  Devise a plan of action at the regional and national levels, to reach
the goal of IDD elimination by the year 2000.
         Providing adequate responses to these needs is the objective of the
forthcoming Regional Conference on Elimination of Iodine Deficiency Disorders in
CEE/CIS/BS, to be held in Munich, Germany, September 3-6, 1997 (see
accompanying announcement).
REFERENCES
         1.  Subcommittee of the European Thyroid Association for the study of endemic
goiter and iodine deficiency.  Goiter and iodine deficiency in Europe.  Lancet I:1289-
1293, 1985.
         2.  Iodine Deficiency in Europe:  A Continuing Concern, ed. F. Delange et al.,
Plenum Press, NY, 1993
         3.  Iodine deficiency persists in Europe, IDD Newsletter, 9(1):1, 1993. 
         4.  F. Delange et al.  Thyroid volume and urinary iodine in European
Schoolchildren.  Standardization of values for assessment of iodine deficiency.
European Journal of Endocrinology 136: 180-187, 1996.
         5.  CIDDS Database, available on ICCIDD home page,
http://avery.med.virginia.edu/~jtd/iccidd.
         6.  R. Gutekunst.  Reports on IDD in Estonia, Latvia, Lithuania.  1995
(unpublished). 
         7.  Tahirovic H. et al.  How war disrupts iodine prophylaxis:  an example from
Bosnia.  IDD Newsletter 11(1):13, 1995.
         8.  J. Cruse.  TSH levels in neonates born in Tbilisi, Republic of Georgia in
April, 1995.  Report (unpublished).
         9.  R. Gutekunst.  Report on iodine deficiency disorders.  Tirana, Albania, July,
1993 (unpublished).
         10.  G. Gerasimov.  Update on IDD in the former USSR.  IDD Newsletter
9(4):43-48, 1993.
         11.  Szybinski et al.  Investigation on iodine deficiency in Poland and model of
iodine prophylaxis, 2nd Scientific Conference, Krakow, 10-11 May, 1993.  Polish J. of
Endocrinology 44(3).
         12.  Iodine deficiency in Poland.  IDD Newsletter 11(3):38-40, 1995.
         13.  M. Simescu.  Data on IDD in Romania.  Report (unpublished).
         14.  Dunn JT.  Iodine deficiency in Macedonia.  IDD Newsletter 12(4):59, 1996.
         15.  Report of the Joint Workshop on the Elimination of Iodine Deficiency
Disorders, Ashkhabad, Turkmenistan, 15-16 June 1994, ECO-UNICEF-WHO.
         16.  Technical Proceedings of the Joint Workshop on the Elimination of Iodine
Deficiency Disorders, Ashkhabad, Turkmenistan, 15-16 June 1994, ECO-UNICEF-
WHO, volume 2.
         17.  G. Gerasimov, D.P. Haxton.  IDD in Central Asia.  In:  S.O.S. for a Billion.
The Conquest of Iodine Deficiency Disorders.  B.S. Hetzel and C.S. Pandav (eds). 
2nd ed., Oxford University Press, Bombay 1996, pp. 257-271.
         18.  Central Asia assesses its IDD.  IDD Newsletter 10(4):44-48, 1994.
An overview of IDD status, control programs and salt supplementation in the
countries of Central and Eastern Europe (CEE), Commonwealth of Independent
States (CIS) 
and Baltic States (BS).

VARIABLES
ALBANIAARMENIAAZERBAIJANBELARUSPOPULATION3,300,0003,300,0007,100,00010,300,000LAND AREA
(000 Sq Km)27,429,886,6208,01995 GDP per capita
(US$)6365455211,748EXTENT OF IDD
Recent surveys
Goitre prevalence
(palpation/US)
Urinary iodine
TSH screening
Cretinism
Severe,
Goitre rate (national 
survey 1992) - 41%, 
sporadic cases of
cretinism, urinary
iodine 2-49 æcg/L
(1993) Mild to moderate,
Data on recent
surveys N/AMild to moderate,
endemic goitre in 23 
of 48 provinces
(national survey).
Recent data on goiter
prevalence, urinary
iodine N/AMild to moderate,
goiter prevalence (by
US) - 10-30%, uri-
nary iodine - 70-90 
þcg/L (regional).
Data on TSH N/A. 
National IDD survey
in action.SALT 
PRODUCTION
Number of salt
producers
Amount of edible
salt production
Amount of imported 
salt
Packaging
1 manufacturer
covers actual salt
consumption of
15,000 tones, low
quality of salt,
problems with
packaging.1 manufacturer,
which before 1991
supplied iodized salt 
(33,000 tones),
including to other
regions of former
USSRLocal production
small (3,000 tones),
95% of salt (not
iodized) imported
from Ukraine.2 modern salt plants
amount of salt pro-
duction N/A, high
quality salt, good
packaging. Salt is
exported to Russia
and Eastern EuropeSALT
IODIZATION
% of iodized salt
compound
iodine (ppm)
source of iodine
Cost of I salt
Labelling
No 
(5,600 tones reported
in 1992),
KI: 1/40,000
Cost of iodized salt 3
times higher than
non iodizedPartial
the amount of
iodized salt
production N/A.
KI at 25 ppm is most
likely usedNo
Huge local produc-
tion of KI suitable
for iodization.
Salt not labelled.Partial
the amount of
iodized salt
production N/A, KI
at 25 ppm is most
likely used, salt
labelledLEGISLATION
NoNoNoNoOTHER
PREVENTIVE
MEASURES
N/AN/AN/AIodine tablets (1 mg)
and KI solution for
childrenMONITORING
Quality assurance
system
NoNoNoNo
Laboratory for
urinary iodine
available.NATIONAL IDD
CONTROL
PROGRAMNoNoNoNoHUMAN
RESOURCES
AVAILABLE
IDD training
Limited, personnel
needs training in
IDDLimited, personnel
needs training in
IDD; previous
experience in salt
iodizationLimited,personnel
needs training in
IDDHuman resources
available but need
training in IDDOTHER
COMMENTSNoNoBefore 1991 iodine
production (high
quality) covered 45%
of the total needs of 
USSR. 12,000 tones 
of stocked iodine
(1994)High public aware-
ness in thyroid prob-
lems due to
Chernobyl. Negative 
attitude of some
local experts to USI.An overview of IDD status, control programs and salt supplementation in the countries of
Central and Eastern Europe (CEE), Commonwealth of Independent States (CIS) 
and Baltic States (BS).


VARIABLES

BOSNIA/HERZE-
GOVINA
BULGARIA
CROATIA
CZECH REP.POPULATION4,600,0008,800,0004,700,00010,400,000LAND AREA
(000 Sq Km)51,2110,656,478,61995 GDP per capita
(US$)N/A1,1362,9364,328EXTENT OF IDD
Recent surveys
Goitre prevalence
(palpation/US)
Urinary iodine
TSH screening
Cretinism
Mild to severe (in
mountains and near
rivers), urinary
iodine in
Srebrenica - 49
þcg/L, in Tuzla -
113 þcg/L (local
survey)Mild to severe
endemic regions -
1/3 of territory,
goiter rate 29%,
urinary iodine - 20-
60 þcg/L (national
survey)Mild to moderate
Goiter prevalence in 
children 13-35%,
urinary iodine - 74
þcg/L (national
survey)Marginal,
Recent local survey 
showed low goiter
prevalence, urinary
iodine 85 þcg/LSALT 
PRODUCTION
Number of salt
producers
Amount of edible
salt production
Amount of imported 
salt
Packaging
Salt locally produced
(Tuzla salt factory)
amount of production
and import N/A60% produced local-
ly, 40% imported
(amounts N/A)
Expected demand for
iodized salt - 30,000 
tons/year1 large and 2 small
plants (amounts N/A)1 producer,
the amounts of
locally produced and
imported salt N/ASALT
IODIZATION
% of iodized salt
compound
iodine (ppm)
source of iodine
Cost of I salt
Labelling
Yes,
details N/AMandatory
KI 20 ppm (1992)
Cost of iodized salt
as not iodized (1992)
Labelled
Mandatory iodized
law passed in 1996
30% currently
iodized at 25 ppm KI
(for humans and
animals)Mandatory,
KI 12 ppm, 
KI is being replaced 
by KIO3LEGISLATION
YesYesYesYesOTHER
PREVENTIVE
MEASURES
N/AIodine tablets (1 mg 
per week) for risk
groups at riskN/AN/AMONITORING
Quality assurance
system
N/AN/AN/AN/ANATIONAL IDD
CONTROL
PROGRAM
N/AYes (since 1991)N/AN/AHUMAN
RESOURCES
AVAILABLE
IDD training
Limited, personnel
needs training in
IDDReasonable level of
training and
experienceReasonable level of
training and
experience High level of
training and
experienceOTHER
COMMENTSIDD prophylaxis
disrupted by warNoNoNo

An overview of IDD status, control programs and salt supplementation in the countries of
Central and Eastern Europe (CEE), Commonwealth of Independent States (CIS) 
and Baltic States (BS).


VARIABLES

ESTONIA
GEORGIA
HUNGARY
KAZAKHSTANPOPULATION1,600,0005,400,00010,300,00017,200,000LAND AREA
(000 Sq Km)45,269,793,22,717,31995 GDP per capita
(US$)1,6256673,981390EXTENT OF IDD
Recent surveys
Goitre prevalence
(palpation/US)
Urinary iodine
TSH screening
Cretinism
mild to moderate,
recent national
survey (1995)
showed median
urinary iodine - 65
þcg/L, data on goiter
and TSH N/Amild to severe 
Recent local surveys 
(1996) - 63%
neonates had TSH > 
5 mU/L, goitre
prevalence 36-93 %
(by palpation and
US), urinary iodine
to be completed soonMarginal, 
urinary iodine in
recent local survey:
52-115 þcg/L, goiter
rate in children 1.5-
7% Moderate to severe, 
2/3 of population at 
risk, extensive evide-
nce of IDD (urinary 
iodine 32-70 þcg/L),
goiter 63-92%,
sporadic cases of
cretinism)SALT 
PRODUCTION
Number of salt
producers
Amount of edible
salt production
Amount of imported 
salt
Packaging
Salt is imported
(amount N/A)All salt imported
(mostly from
Armenia, some from 
Ukraine and Russia),
amount N/A. Salt
trade is completely
with the private
sector1 producer and
import (amount N/A)Salt locally produced
(650,000 tones in
1993) by 2 plants,
import of salt is
smallSALT
IODIZATION
% of iodized salt
compound
iodine (ppm)
source of iodine
Cost of I salt
Labelling
NoNo
Some Armenian salt 
has traces of iodineYes, but not
universal, KI 20
ppm, price for
iodized salt reduced
(1992)Not at present, 22% 
of salt was iodized
in 1 plant (1993)
with KI at 25 ppm,
supply of KI from
Azerbaijan requires 
payments in hard
currency. Packaging 
and quality need
improvementLEGISLATION
PendingYes, but not
enforcedYesPendingOTHER
PREVENTIVE
MEASURES
N/AN/AN/AIodized bread in 4
endemic region, 1
small supply of
iodized oil (1993)MONITORING
Quality assurance
system
N/AN/AN/AIodized salt
controlled at the
level of production, 
monitoring system
N/ANATIONAL IDD
CONTROL
PROGRAM
N/AYes, coordination
Council Against IDD
foundedN/AN/AHUMAN
RESOURCES
AVAILABLE
IDD training
Limited, personnel
needs training in
IDDLimited, personnel
needs training in
IDDQualification is
reasonably highPersonnel is reason-
ably qualified (asse-
ssment, iodization),
additional training
neededOTHER
COMMENTS
An overview of IDD status, control programs and salt supplementation in the countries of
Central and Eastern Europe (CEE), Commonwealth of Independent States (CIS) 
and Baltic States (BS).


VARIABLES

KYRGYZSTAN
LATVIA
LITHUANIA
MACEDONIAPOPULATION4,400,0002,700,0003,700,0002,700,000LAND AREA
(000 Sq Km)198,563,765,224,81995 GDP per capita
(US$)5901,5561,3511,519EXTENT OF IDD
Recent surveys
Goitre prevalence
(palpation/US)
Urinary iodine
TSH screening
Cretinism
moderate to severe,
60% of neonates had 
blood TSH >5mU/L
, goiter rate 38-49%, 
urinary iodine 30
þcg/L, (local survey,
1994)Mild
Median urinary
iodine is 98 þcg/L
(national survey,
1995), data on goiter
prevalence N/AMild
Median urinary
iodine is 75 þcg/L
(national survey,
1995), data on goiter
prevalence N/AGoiter 18.7% 
UI 117 æg/L; 
  8/30 areas < 10SALT 
PRODUCTION
Number of salt
producers
Amount of edible
salt production
Amount of imported 
salt
Packaging
Domestic production 
developing, salt for
humans imported
from Kazakhstan,
Turkmenistan and
Ukraine. Poor
packaging, no
labellingAll salt imported
(amount N/A)All salt imported
(amount N/A)All imported, from
Bulgaria, BelarusSALT
IODIZATION
% of iodized salt
compound
iodine (ppm)
source of iodine
Cost of I salt
Labelling
No, 
salt requirement for 
humans is 30,000
tons/yearNoNo5 ppm as KILEGISLATION
NoNoNoYes; new law being
formulatedOTHER
PREVENTIVE
MEASURES
KI (1 mg) tablets to 
risk groupsN/AN/AN/AMONITORING
Quality assurance
system
NoN/AN/ASalt on importNATIONAL IDD
CONTROL
PROGRAM
NoN/AN/AN/AHUMAN
RESOURCES
AVAILABLE
IDD training
Limited, personnel
needs training in
IDDLimited, personnel
needs training in
IDDLimited, personnel
needs training in
IDDLimited, personnel
needs training in
IDD.  Good
epidemiology.OTHER
COMMENTSNoNoNoNoAn overview of IDD status, control programs and salt supplementation in the countries of
Central and Eastern Europe (CEE), Commonwealth of Independent States (CIS)
and Baltic States (BS).


VARIABLES

MOLDOVA
POLAND
ROMANIA
RUSSIAPOPULATION4,500,00038,500,00023,200,000148,600,000LAND AREA
(000 Sq Km)33,7304,5230,317,075,21995 GDP per capita
(US$)3782,4681,2502,639EXTENT OF IDD
Recent surveys
Goitre prevalence
(palpation/US)
Urinary iodine
TSH screening
Cretinism
mild to moderate
National survey
(1996) goiter preva-
lence by palpation
27-42 %, median
urinary iodine - 78
mcg/Lmild to severe
National survey
(1995) urinary iodine
49-93 þcg/L, goiter
rate 10-43%,
increased TSH levels
in neonatesmild to moderate
urinary iodine in
recent national
survey (1995) 34-140
þcg/L, goiter rate -
13-36%.Mild to severe
Local surveys:
urinary iodine - 23-
80 þcg/L, goiter rate
- 20-60% (US), IDD
more severe in rural 
sites, Siberia,
mountain areas.SALT 
PRODUCTION
Number of salt
producers
Amount of edible
salt production
Amount of imported 
salt
Packaging
Most of salt
imported from
Ukraine and
Romania. Level of
iodization uncertain.6 producers
(amount N/A)6 mines
(amount of
production N/A)7 producers
2,800,000 tn (1993),
2 mines produce salt
for humans, 40% of 
edible salt imported 
from Ukraine, Be-
larus, Kazakstan.
Quality high, packa-
ging needs improve-
ment.SALT
IODIZATION
% of iodized salt
compound
iodine (ppm)
source of iodine
Cost of I salt
Labelling
NoMandatory from
01.97, 
30 ñ 10 ppm KI
No,
Iodized salt was
produced in 1992
(KIO3, 15 ppm),
distribution limitedYes, but limited
KI 25 ppm
KIO3 50 ppm (from 
1997)
Production needs
more requests from
trade. Iodized salt
exported (Mongolia)LEGISLATION
NoYesYes, but not
enforcedNoOTHER
PREVENTIVE
MEASURES
N/AN/AN/AIodized bread (local-
ly), iodized oil (Che-
rnobyl areas), iodine 
tablets MONITORING
Quality assurance
system
NoN/AN/ANo,
4 laboratories to
control urinary
iodineNATIONAL IDD
CONTROL
PROGRAM
NoYesYesNo,
Moderate awareness 
of Government in
IDD problemsHUMAN
RESOURCES
AVAILABLE
IDD training
Limited, personnel
needs training in
IDDYes, qualification of 
personnel is highYes, personnel needs
additional training in
IDDYes, personnel needs
additional training in
IDDOTHER
COMMENTSNoNoNoLocal production and
export of high
quality KI and KIO3
An overview of IDD status, control programs and salt supplementation in the countries of Central and Eastern
Europe (CEE), Commonwealth of Independent States (CIS) 
and Baltic States (BS).


VARIABLES

SLOVAKIA
TAJIKISTAN
TURKEY
TURKMENISTANPOPULATION5,400,0005,400,0004,200,000LAND AREA
(000 Sq Km)48,8143,1488,11995 GDP per capita
(US$)2,222148643EXTENT OF IDD
Recent surveys
Goitre prevalence
(palpation/US)
Urinary iodine
TSH screening
Cretinism
marginal or no IDD
Recent local survey
(1995) urinary iodi-
ne: 130-143 þcg/LCritical
Local surveys in
1994-96: goiter rate 
up to 90%, median
urinary iodine < 10 
þcg/L. New cases of
cretinism reported.mild to severe
Local survey in 1988
- 30% goiter rate. 
Data on urinary
iodine, TSH and
cretinism N/Amild to moderate
Local survey (1994) 
goiter rate 20-64%
(US), urinary
iodine -37-72 þcg/LSALT 
PRODUCTION
Number of salt
producers
Amount of edible
salt production
Amount of imported 
salt
Packaging
1 producer
(amount N/A)Total production of
edible salt by 2
plants is 58,000 tons.
No salt imported.
Poor packaging of
salt. 27 salt producers
806,000 tons/year
Small amount
imported from Iran.
Packaging in
polyethylene bags.
1 salt producer
covers all needs for 
alimentary salt
(63,300 tons in
1993) plus export
Packaging needs
improvement SALT
IODIZATION
% of iodized salt
compound
iodine (ppm)
source of iodine
Cost of I salt
Labelling
YesBefore 1991 all iodi-
zed salt was
delivered from
Armenia. Attempts
to produce iodized
salt were made in
1994. Shortage of KI
(imported from
Turkmenistan).5 producers iodize
31,3% of salt at 50-
70 ppm of KI
(imported?)
Iodized salt labelled No,
in spite that
equipment is present
and iodine locally
produced.LEGISLATION
YesNoYes, but not
enforcedYes, but not
enforcedOTHER
PREVENTIVE
MEASURES
N/AOral iodized oil was 
given in Gorno-Bad-
akshan (GBAO) area
to childrenN/AN/AMONITORING
Quality assurance
system
N/ANoNoNoNATIONAL IDD
CONTROL
PROGRAM
YesNoNoNoHUMAN
RESOURCES
AVAILABLE
IDD training
Yes, qualification is 
highLimited, personnel
needs training in
IDDLimited, personnel
needs training in
IDDLimited, personnel
needs training in
IDDOTHER
COMMENTSNoAga-Khan Founda-
tion is developing
local IDD control
program for GBAO.NoLocal production of 
KI and KIO3 of
reasonable quality,
capable to export
themAn overview of IDD status, control programs and salt supplementation in the countries of
Central and Eastern Europe (CEE), Commonwealth of Independent States (CIS)
and Baltic States (BS).


VARIABLES

UKRAINE
UZBEKISTAN
YUGOSLAVIA
POPULATION51,800,00022,100,00010,700,000LAND AREA
(000 Sq Km)603,7447,488,41995 GDP per capita
(US$)676919972EXTENT OF IDD
Recent surveys
Goitre prevalence
(palpation/US)
Urinary iodine
TSH screening
Cretinism
mild and moderate
IDD is more severe
in Carpathian
mountainous
districts. TSH data
N/Amild to severe
National survey of
65,000 children
(1990): goiter rate 8-
30%, mean urinary
iodine - 35 þcg/
24 h. Data on TSH
and cretins N/A.mild (?)
Results of recent
surveys N/ASALT 
PRODUCTION
Number of salt
producers
Amount of edible
salt production
Amount of imported 
salt
Packaging
Salt is locally produ-
ced by 8 salt plants.
In 1990 3 plants
produced 330,000
tons of iodized salt.Before 1991 salt was
not produced locally,
in 1994 local pro-
duction achieved
210,000 tons on 4
plants. Packaging
material is in short
supply. Distribution
controlled by the
Government.Locally produced.
(Amounts N/A)SALT
IODIZATION
% of iodized salt
compound
iodine (ppm)
source of iodine
Cost of I salt
Labelling
No
Before 1990 KI at a 
level of 25 ppm was 
used. Iodine was de-
livered mainly from
Azerbaijan. Equip-
ment and experience 
in salt iodization are 
present.No
It is generally
believed that local
salt contains iodine.NoLEGISLATION
PendingNoPendingOTHER
PREVENTIVE
MEASURES
N/A
Iodine tablets conta-
ining 1 mg of KI lo-
cally produced. N/AN/AMONITORING
Quality assurance
system
No
Laboratory for uri-
nary iodine determi-
nation is available.NoN/ANATIONAL IDD
CONTROL
PROGRAM
NoNoN/AHUMAN
RESOURCES
AVAILABLE
IDD training
Yes, personnel needs
additional training in
IDDLimited, personnel
needs training in
IDDLimited, personnel
needs training in
IDDOTHER
COMMENTSOpposition to USI
existsNoNoRegional Meeting on IDD Control in Eastern Europe and Central Asia - This
conference, entitled "Regional Conference on Elimination of IDD in Cental and Eastern
Europe, the Commonwealth of Independent States, and the Baltic States," is
scheduled for Munich, Germany, September 3-6, 1997.  It is jointly sponsored by
ICCIDD, WHO, and UNICEF, the next in a series of meetings held in different regions
of the world to advance the goal of virtual elimination of IDD by the year 2000.  The
regional meetings are mostly focussed on identifying constraints in the implementation
of national IDD programs and on devising ways and means of overcoming these
constraints.  This meeting immediately follows the 24th annual meeting of the
European Thyroid Association, August 30-September 3, also in Munich.  The tentative
program includes overviews of both global and regional status of IDD control, case
studies of specific countries, technical and legal issues, the importance of iodine
deficiency in approaching nuclear hazards, monitoring and social mobilization
programs, group discussions with and among countries on problems and ways to
overcome them, and finally, recommendations.  Further details are available from the
office of the Executive Director in Brussels and will be placed on the ICCIDD home
page.
ENDEMIC GOITER IN TURKEY.  IS IODINE REALLY DEFICIENT?  Murat Faik
Erdogan and Gurbuz Erdogan, Department of Endocrinology and Metabolism, Ankara
University, Ankara, Turkey.
         Endemic goiter is still an important and underestimated health concern in
Turkey.  Epidemiological studies on the subject started with Atay (1) in 1935 and Onat
(2) in 1948.  They reported that goiter was endemic in some cites of western Anatolia. 
Eser (3) in 1956 found that goiter was also common in autopsy material from the
Black Sea coast.  In 1960 WHO reported that endemic goiter is not an important
problem in Turkey, probably misled by the lack of information from the country (4). 
Kologlu (5,6) reported extensive studies on the etiology and epidemiology of endemic
goiter in the 1960's and found that the iodine content of food and water from the Black
Sea region was much lower than that reported by Vought for iodine-sufficient areas. 
He also conducted studies on the goitrogen vegetable, Brassica olaracea acephala,
highly consumed by people and animals in the Black Sea region, and concluded that it
was not the reason for the region's goiter endemia (6).  Hatemi and Urgancioglu (7)
made the largest epidemiological studies in the field, beginning in 1981.  Initially they
also measured iodine in drinking water from different parts of Turkey and found that
iodine was deficient in 19% of the samples.  Following these results, 73,750 people of
various ages from all geographical parts of the country were examined by neck
palpation in 1987, and a total goiter prevalence of 30.5% was found (8).  The Black
Sea coast, followed by eastern Anatolia and the Aegean coast, had the highest
prevalences.  Local studies on neonates, school-age children and adults were carried
out during the following years, reporting prevalences between 9.2 and 72.4% (9-13). 
The latest epidemiological data came from a large study in 1995 conducted by neck
palpation of 7,144 school-age children (6-12 year olds) from 15 different cities of the
country, in which the overall prevalence was 30.3% (14).  Trabzon (68.5%), Malatya
(46.5%), Bayburt (44.3%) and Kastamonu (35.3%) had the highest prevalences.  The
only study that measured urinary iodine concentrations, by Erdogan and Kamel (15),
showed that urinary iodine is relatively deficient in goitrous people compared to normal
controls but the actual values were higher than those typical of iodine deficiency as
defined by WHO/UNICEF/ICCIDD, probably due to the ionometric method used.
         The above data confirm that goiter is endemic in Turkey but direct evidence for
iodine deficiency as the etiologic factor is still missing.  Under these circumstances,
the IDD control program that was initiated in 1992 needs a stronger scientific basis. 
Another problem is the current low usage of iodized salt, including only 24.2% of the
people questioned in a large 1995 study (14).  Also, the storage of iodized salt is not
optimal.
         A surveillance study of urinary iodine concentrations in endemic regions of
Turkey may show the importance of iodine deficiency as the primary etiologic factor
for endemic goiter.  Such data can help build new strategies to cope with iodine
deficiency in Turkey.
References
         1.  Atay K III 1935 Ulusal Cerrahi Kurultayina Rapor Kader Basimevi Istanbul
(3rd National Congress of Surgery, Istanbul).
         2.  Onat AR 1948 X Milli Turk Tip Kongresi Ankara, Kader Basimevi Istanbul
(10th National Congress of Medicine, Ankara).
         3.  Eser S 1956 Yurdumuzda Guvatr Istanbul Tip Fak. Mec. 19:129.
         4.  Kelly FC, Snedden WW 1960 Prevalence and geographical distribution of
endemic goiter.  In:  Endemic Goiter, pp 27-333 (WHO Geneva).
         5.  Kologlu S, Kologlu LB 1977 Turkiye' de endemik guvatr'in etyopatogenezi
Istanbul Tip Kurultayi Tutanaklari Istanbul, 63.
         6.  Kologlu S, Kologlu LB 1968 Dogu Karadeniz bolgesi guatr endemisinde tabii
guatrogenlerin rolu uzerinde inceleme.  Ankara Universitesi Tip Fakultesi Mecmuasi
21:421.
         7.  Urgancioglu I, Hatemi H, Uslu I, et al 1987 Endemik Guatr Taramalarinin 2.
degerlendirilmesi Klinik Gelisim 36-38.
         8.  Urgancioglu I, Hatemi H 1989 Turkiye' de endemik guatr.  Cerrahpasa Tip
Fak., Nukleer Tip Bilim Dali yayin no 14, Istanbul.
         9.  Aygun R 1980 Ankara ili Cubuk ilcesi Kislacik Saglik Ocagi koylerinde guatr
prevelansi ve okul cocuklarinin temel zihni yeteneklerinin gelismesine etkisi.  H. U.
Halk Sagligi ABD Uzmanlik Tezi, Ankara.
         10.  Pekcan H, Pekcan G, Aykut M, Unal A 1979 Kayseri ve yoresinde endemik
guatr sikligi.  Kayseri Universitesi Gevher Nesibe Tip Fak. Mecmuasi 1:239.
         11.  Keles E, Yucel A 1987 Ankara ili Cubuk Ilcesi, Kislacik saglik ocagi
bolgesindeki koylerde guatr prevelansi ve iyodlu tuz kullanma orani arastirmasi.  Intern
Calismasi, Ankara.
         12.  Bircan I 1989 Antalya'da 5-11 yas gurubu cocuuklarda guatr sikligi. 
Akdeniz Universitesi Tip Fak.  Dergisi 54:79-83.
         13.  Tumerdem Y, Ayhan B ve ark 1990 Tiroid bezi hiperplazisini etkileyen
faktorler.  Doga Turk Saglik Bilimleri Dergisi 14:136.
         14.  Arslan P, Pekcan G, Dervisoglu AA, et al. 1996 15 il'de beslenme egitimi
ve arastirma projesi, 1995, Ankara.
         15.  Erdogan MF, Kamel N 1997 Turkiye'nin degisik cografi bolgelerinden gelen
hastalada otiroid guatr etiyolojisinde iyod eksikliginin yeri T. Klinikleri tip bilimleri dergisi
16:5.


IODINE DEFICIENCY DISORDERS IN ALBANIA
Adriana Bardhoshi, Valdete Bizhga, Mimoza Gjoka, Institute of Public Health, Tirana;
Rainer Gutekunst, UNICEF; Lindita Grimci, Institute of Pediatrics, Tirana; Abdulla
Subashi, Maternity Clinic, Tirana, Albania
         Iodine is only sparingly available in the natural environment of Albania.  Its
deficiency occurs in most parts of the country and is severe in some of the
mountainous regions.  Signs of iodine deficiency are common in Tirana clinics.  At the
1992 Brussels workshop on IDD in Europe, Kalo et al. reported a survey of 196,669
people, aged 6-20 years from throughout the country.  Goiter was found in 80,280 or
40.8%, and 192 cases of cretinism and 46 of deaf-mutism were noted.  
         Because the previous data were old, unsystematically collected, and sometimes
vague, we carried out a national survey in 1993 to assess the prevalence of IDD.  Our
goals were to establish a basis for intervention programs, to exclude or identify other
causes of endemic goiter such as goitrogens or iodine excess, to establish systematic
baseline data for monitoring of future intervention programs, and to present sound
ammunition for political advocacy.  
         We collected casual urine samples from 2,395 children, aged 8-10 years old at
32 cluster sites, for analysis in Germany.  We performed ultrasonographic assessment
of thyroid size in 241 children from four villages in the country's northeast.  Whole
blood samples were collected for TSH assay from 227 newborns from the Maternity
Clinic in Tirana.
         Of the urinary iodine measurements, 63% of samples showed severe iodine
deficiency, 29% moderate, 5% mild and only 3% were iodine-sufficient.  The median
urinary iodine levels ranged from 20-49 æg/L.  From these data we constructed the
accompanying map.  It shows that no part of the country has sufficient iodine intake. 
Iodine deficiency is moderate in 10 of the 32 regions and severe in 22.  
         Of the 227 newborns investigated, the TSH concentration in whole blood was
4.9 ñ 5.3 (mean ñ SD), median 3.0, minimum < 1, maximum 35 mU/L; of these 67%
were less than 5 mU/L and 33% were greater.
         The ultrasound of the 241 northeast Albanian children showed that 29% had
goiter.  
         We conclude that moderate to severe iodine deficiency is present in all parts of
Albania.
TIMOTHY J. STONE
         Tim Stone died on November 23, 1996 in the hijacked Ethiopian airplane that
crashed over the Comoros Islands.  The Executive Director of PATH Canada, he was
on a mission to develop projects and review programs against vitamin A deficiency. 
Tim graduated in science from Carleton University in Canada and recieved a master's
degree in human nutrition from the London School of Hygiene and Tropical Medicine
in England.  He worked with UNICEF in Cambodia in 1985 and then in Mali, and later
with Save the Children in Afghanistan.  With PATH, he spearheaded efforts against
malnutrition, malaria, AIDS, tobacco advertising, and antipersonnel land mines.  Under
his direction, PATH rapidly developed as an innovative force in dealing with pressing
health and development problems.  Tim had an ongoing interest in IDD, during both
his experience as a field officer in developing countries and his later efforts with
PATH.  Many in ICCIDD worked with him directly at both levels.  All found him to be a
clear-headed, reliable, vigorous colleague with a strong drive for improving the lot of
his fellow humans.  He did this with a quiet, understated determination and sense of
balance that made him an exceptionally effective development officer.
         The Micronutrient Initiative has established the Tim Stone Memorial Award,
from a grant from the Canadian International Development Agency.  It will support the
design and implementation of innovative and lasting vitamin A interventions and is
designated to 15 NGO's in 12 countries to increase coverage or improve quality,
sustainability, and monitoring of existing programs towards vitamin A elimination.  
         ICCIDD joins Tim's many other colleagues and friends in mourning his untimely
death, and sends its condolences to his widow, Jean Lash, and their two children.

RECOMMENDED IODINE LEVELS IN SALT AND GUIDELINES FOR MONITORING
THEIR ADEQUACY AND EFFECTIVENESS.  Based on a Joint
WHO/UNICEF/ICCIDD Consultation, World Health Organization, Geneva, July 8-9,
1996.

BACKGROUND
1.  Introduction
         1.1      Universal salt iodization is the recommended intervention for
                  preventing and correcting iodine deficiency.
         1.2      In the past, recommendations for iodine levels in salt were made on
                  the assumption that, from producer to consumer, iodine losses from
                  iodized salt were commonly between 25% and 50%, and that
                  average salt intakes were commonly between 5 and 10 g/person/day.
         1.3      Substantial experience has been gained in the last decade in
                  implementing universal salt iodization and assessing its impact on
                  iodine deficiency disorders (IDD).
         1.4      A major achievement is the spectacular reduction of IDD in countries
                  that have implemented universal salt iodization.
         1.5      However, it appears that some people in some countries now have
                  iodine intakes that are unnecessarily high and that may occasionally
                  be associated with iodine-induced hyperthyroidism.
         1.6      For this reason,WHO, UNICEF and the International Council for
                  Control of Iodine Deficiency Disorders carried out a study in seven
                  African countries to examine the relationship between salt iodization
                  and population iodine status.
         1.7      Previous recommendations for iodine levels in salt have been
                  reconsidered as a result of this study, and in the light of other
                  technical and scientific developments.
2.  Iodine requirements
         2.1      To meet iodine requirements, the current recommended daily iodine
                  intakes are:
                            50 æg for infants (first 12 months of age).
                            90 æg for children (2-6 years of age).
                            120 æg for schoolchildren (7-12 years of age).
                            150 æg for adults (beyond 12 years of age).
                            200 æg for pregnant and lactating women.
3.  Risk of iodine-induced hyperthyroidism
         3.1      Iodine-induced hyperthyroidism is an iodine deficiency disorder which
                  may occur - primarily in older people - when severely iodine-deficient
                  populations increase their iodine intake, even when the total amount
                  is within the usually accepted range of 100-200 æg/day.
         3.2      On a population basis, iodine-induced hyperthyroidism represents a
                  transient increase in the incidence of hyperthyroidism, which will
                  disappear in due course with the correction of iodine deficiency.
         3.3      Iodine-induced hyperthyroidism occurs in some subjects who have
                  pre-existing autonomous nodular goiter.  It appears likely that some
                  patients with latent Graves' disease are also at risk.
         3.4      The number of people at risk of iodine-induced hyperthyroidism is
                  directly proportional to the number of subjects with nodular goiter.
         3.5      The occurrence of iodine-induced hyperthyroidism is probably related
                  to the relative increase, and rapidity of increase, of iodine intake,
                  which occurs when iodized salt is introduced in populations that are
                  severely iodine deficient.
         3.6      An increase in the incidence of hyperthyroidism may follow relatively
                  small increments in iodine intake, but the risk is most likely to be
                  greatest following ingestion of larger increments.
         3.7      There is no level of iodine in salt that offers complete protection
                  against some increase in the incidence of hyperthyroidism in a
                  previously iodine-deficient population.
         3.8      On a population basis, the benefits of correcting iodine deficiency
                  through universal salt iodization vastly outweigh the risk of iodine-
                  induced hyperthyroidism.
RECOMMENDATIONS
4.  Required iodine levels in salt
         4.1      Taking into account the following revised assumptions, which are
                  based on new information:
                            iodine lost from salt is 20% from production site to household,
                            another 20% is lost during cooking before consumption,
                            average salt intake per capita is 10 g/day,
                  in order to provide 150 æg/day of iodine via iodized salt, iodine
                  concentration in salt at the point of production should be within the
                  range of 20-40 mg of iodine (or 34-66 mg potassium iodate) per kg of
                  salt.  When all salt used in processed food is iodized, the lower limit
                  (20 mg) is recommended.  Under these circumstances, median
                  urinary iodine levels will vary from 100-200 æg/l.
         4.2      In many situations in developing countries, however, despite
                  improvements in salt production and marketing technology, the quality
                  of available salt is poor, or salt is incorrectly iodized, or salt that has
                  been correctly iodized deteriorates due to excessive or long-term
                  exposure to moisture, light, heat and contaminants.  Under these
                  circumstances, iodine losses can be 50% or more from the moment
                  salt is produced until it is actually consumed, and median urinary
                  iodine levels could thus fall below the recommended range (100-200
                  æg/l).  In addition, salt consumption is sometimes considerably less
                  than 10 g/person/day.  All these factors should be taken carefully into
                  account, particularly when establishing the initial level of iodine in
                  salt.
         4.3      If median urinary iodine levels from a representative sample of the
                  population at risk are not within the recommended range, salt
                  iodization levels and factors affecting its utilization should be
                  reassessed focusing on:
                            Salt quality and iodization procedures.
                            Factors affecting iodine losses in salt, e.g., packaging,
                              transport, storage, cooking.
                            Food habits in relation to salt intake and cooking practices.
5.  Risk of iodine-induced hyperthyroidism associated with iodine levels in salt
         5.1      Where severe iodine deficiency has been a long-term problem, in the
                  light of the risk factors for iodine-induced hyperthyroidism noted in
                  part 3, especially points 3.5 to 3.7, iodine levels in salt should be set
                  at the lowest level that will prevent all manifestation of iodine
                  deficiency disorders while minimizing the risks of iodine-induced
                  hyperthyroidism.
         5.2      Periodic surveys of urinary iodine are necessary to monitor actual
                  iodine intake.  Iodine levels in salt should be adjusted accordingly to
                  progressively ensure a median of 100-200 æg/l.
6.  Requirements for monitoring iodine status and adequacy of iodine levels in salt
         6.1      A national monitoring program should include:
                  6.1.1    Establishing an IDD committee of qualified individuals
                           who are responsible for program monitoring and
                           evaluation.
                  6.1.2    Ensuring regular quality control of iodine concentration
                           in salt at the point of production by using titration
                           methods or, in the case of imported salt, at the point of
                           entry by using reliable test kits.  Consignments with
                           suspect iodine levels should be rechecked by titration.
                  6.1.3    Setting up independent laboratories capable of carrying
                           out salt iodine titration and urine iodine analysis to
                           ensure external quality control.
                  6.1.4    Designating sentinel sites to carry out the following
                           activities:
                                    Monitoring periodically salt iodine levels in retail
                                      shops and households using reliable test kits.
                                    Conducting occasional goiter prevalence surveys.
                                    Measuring regularly urinary iodine.
                  6.1.5    Adjusting salt iodine levels based on monitoring results,
                           especially of iodine in urine.
                  6.1.6    Alerting health workers to possible occurrence of
                           hyperthyroidism, and ensuring access to appropriate
                           treatment when necessary.
                  6.1.7    Establishing a health notification system for cases of
                           hyperthyroidism at selected hospitals in areas of former
                           severe/moderate iodine deficiency.
         6.2      The following equipment and procedures may also be required:
                  6.2.1    A laboratory capable of investigating thyroid function,
                           particularly TSH and thyroid hormones.
                  6.2.2    Ultrasound equipment to complement palpation.
                  6.2.3    Semi-quantitative tests kits for measuring urinary iodine,
                           as soon as such kits are available.
THE ROLE OF WOMEN'S ORGANIZATIONS AND VILLAGE COOPERATION UNITS IN THE
SOCIAL MARKETING OF IODIZED SALT.  Widanto Hardjowasito and Djoko W. Soeatmadji,
Faculty of Medicine, Brawijaya University, Malang, Indonesia.
         To convince the community about the importance of consuming iodized salt to prevent
IDD, we have introduced a unique cooperation between women's organizations and the iodized
salt production system in Malang, Indonesia.  The cooperating groups are the university
(faculties of medicine, economics, and technology), the state pharmaceutical industry (Kimia
Farma), the government's regional health and related offices, and local Rotary Clubs.  The main
activities are:  (1) supporting production levels of small scale salt farmers; (2) supporting small
scale village cooperatives to produce iodized salt that meets the government's standard of
quality; and (3) distribution of iodized salt to the community by small scale women salt
merchants who receive salt loans or revolving loans.  Through this activity two local brand
labels of salt are now spreading through their communities, one in the Malang area (East Java
Province) and another in Maumere (Flores Island, in the province of Nusa Tenggara Timur).  
         From 20 brands of iodized salt collected by governmental authority in Malang recently,
the brand produced by the village cooperative (KUD Subur) ranked number two in quality. 
Currently the cooperative can sell from one to two tons per month.  It is hoped that the quantity
can be doubled soon.  In Maumere the cooperative can sell one ton each month.
         For financing, the small scale salt traders, especially women, receive a salt loan that can
be revolving.  The loan from Kimia Farma went through the Family Planning Board as a means
of economic support for low income families.  Funds from the Rotary Club are principally a
revolving loan for low income groups through the women's cooperative organization Anisa, or
under the religious women's organization Muslimat.  Other Rotary Clubs are beginning to
conduct similar activities in their area.  These activities can help the farmers in Maumere, to
increase salt production as well as to develop a cooperative for iodization.  Similar benefits can
be expected through the distribution system "PKK" and "Puskesmas."  
         The approach described here provides a means for university personnel and the Rotary
Club to coordinate efforts and serve as a bridge between governmental institutions and the low
income community, especially women's groups.  IDD in Indonesia is particularly a problem of
low income groups so this approach has special promise.  Various types of difficulties occurred
in the beginning and slowed the effort, but with experience in communication and
understanding, considerable progress is now being made.  As expected, the improved
economic condition of the community helps it take more responsibility for its health problems.  
BREAD IODIZATION FOR IODINE-DEFICIENT REGIONS OF RUSSIA AND OTHER NEWLY
INDEPENDENT STATES
G. Gerasimov, A. Shishkina, N. Mayorova, N. Sviridenko, A. Nazarov, G. Alexandrova, G.
Kotova, S. Butrova, M. Arbuzova, B. Mishchenko and I. Dedov, Endocrinology Research
Center, Russian Academy of Medical Sciences, Moscow, Russia.
         Bread is a major dietary item in Russia ("Father Bread" in folklore).  By tradition,
practically all meals are eaten with bread.  The average bread consumption nationwide is 121
kg/per capita/year, about 350 grams per person each day.  It is still one of the cheapest dietary
items, 1 kg of brown or white bread costing US $0.30-0.50.  Consumption has increased during
the past 2-3 years due to economic changes in the country and to large increases in prices for
meat, milk, fish, and poultry.  Thus, bread has become a key dietary item for many families with
low incomes, about 60% of the entire population.
         The former USSR developed a unique system of centralized bread production.  Most
bread (80-90%) in certain areas is produced in relatively big, centrally-located mechanical
bakeries (bread factories) and then delivered to consumers over a wide area.  The factories
either belong to local administrations or are private.  Other conditions also suggest that bread
would be a good vehicle for iodine supplementation.  It is consumed within one to two days
after purchase, so no iodine is lost during baking or storage.  Potassium iodide is produced in
Russia, can easily be obtained from existing stocks, and does not change the taste or odor of
bread.  Further, no changes in baking technology or capital investments are required for bread
iodization.  Costs are very low, about US $0.05 per capita/year, and can be met by the
consumers.
         Our objectives in the present project were to investigate the feasibility of bread iodization,
to evaluate the amount of iodine required for effective fortification, and to study the effects of
iodized bread in target groups.
Methodology
         The study took place in Pavlov-Posad district of the Capital province, 60 km east of
Moscow, an area of mild to moderate iodine deficiency.  Its 110,900 inhabitants include 22,470
children below age 14 years.  Most families are self-sufficient with vegetables, fruits, milk,
poultry, and meat from their own production.  Iodized salt was not available in this area.  The
local bread factory can produce 20 tons daily and covers the entire population of the district,
including the villages.  No other large and regular sources of bread were available.  
         Bread - No major changes were made in baking technology.  Potassium iodide solution
was added to a salt solution in a proportion of 60 mg KI/100 kg of flour, to reach a final level of
500-600 æg KI/kg of bread.  This dose was chosen to provide consumers with a physiologic
amount of iodine for a mean daily consumption of 350-500 g bread.  The ingestion of more than
1 mg iodine/day by this route is highly unlikely.  We carried out regular control of the iodine
concentration in the bread in the biochemical laboratory of the Endocrinology Research Centre. 
To examine possible losses during baking, we measured iodine levels at 6, 24, and 48 hours
after bread production.  The mean concentration remained at 500-650 æg/kg without change.
         Subjects - We followed two groups of children for nine months, as follows.  Group 1
contained 162 students, age 7-14 years, who spent six days a week in their boarding school in
the town and received only iodized bread.  The average daily bread consumption in this group
amounted to 300 g, which contains about 150 æg of KI, near the recommended daily allowance. 
Group 2 had 178 students, age 9-11 years, from the secondary school in a neighboring village
3 km away; they received iodized bread for five days a week, but only with the school
breakfast; their average daily bread consumption was about 100 grams, or about 55 æg iodine
from this source.  
         Children were studied according to WHO/UNICEF/ICCIDD recommendations (1) at 0, 3,
and 9 months after beginning iodized bread consumption.  Thyroid size was measured by
thyroid ultrasonography with a portable Philips SDR 1200 scanner (5.0 MHz transducer).  The
results were compared with normative data from populations with sufficient iodine (2).  The
volume of each lobe was calculated by multiplying thickness with length in cm and a correction
factor (0.479) (3), and was considered enlarged when the volume exceeded the upper limit of
normal for the given age.  We measured iodine concentration in casual urine samples by the
method of Wawschinek et al. (4).
Results and Discussion
         The goiter prevalence in Group 1 was 11% (Table 1) and the urinary iodine concentration
was 48 æg/l.  Group 2 had more initial iodine deficiency, with a median urinary iodine level of 30
æg/l and a 24% goiter prevalence.  These results agree with our earlier data showing a
difference in iodine nutrition in rural and urban populations in Russia (5).  The more severe
degrees of IDD in the rural population may be attributed to greater dependency on local food
supply (meat, milk, poultry, vegetables and fruits).  
         After three months of iodized bread consumption, the median urinary iodine level
increased in both groups, reaching 126 æg/L in Group 1 and 60 æg/L in Group 2.  The thyroid
volumes did not change at that time.  On final assessment at nine months, the median urinary
iodine levels remained about the same as at three months (138 æg/L in Group 1 and 62 in
Group 2).  Before introduction of iodized bread, 13% of the urine samples had less than 20
æg/L iodine and only 7% were greater than 100 æg/L.  Nine months later, 66% of samples were
greater than 100 æg/L and none contained less than 20 æg/L.  In Group 2, the fraction of
samples with iodine concentrations below 20 æg/L decreased from 42% to 10% and those
greater than 100 æg/dL increased from 4% to 18%. 
         The goiter prevalence decreased in both groups after nine months of iodized bread
consumption, going from 11% to 5% in Group 1 and from 24% to 14% in Group 2.  The thyroid
volume in Group 1 decreased in most age groups.  Median volumes by age before and after
nine months were, respectively:  10 years, 5.7 ml, 6.0; 11 years, 6.8, 5.9; 12 years, 6.7, 6.6; 13
years, 7.9, 7.8; and 14 years, 9.9, 9.2.  (It should be remembered that some increase is
expected from normal growth over nine months).
         Our study shows that iodized bread was highly effective for this region of Russia with
mild and moderate iodine deficiency.  As already pointed out, Russia's centralized system of
baking provides a simple, convenient, effective, and inexpensive means for providing daily
supplements of iodine.  We found that an iodized bread intake of 300 g/day quickly (within three
months) normalizes iodine intake.  This effect appears sustainable and after nine months, the
goiter prevalence had decreased to 5%.  Considerable improvement was noted even in the
children receiving only 100 g iodized bread per day.  
         Nearly all of the Newly Independent States have iodine deficiency (6).  Most do not have
national IDD control programs or iodized salt.  Iodized bread could be an immediate means for
correcting their iodine deficiency while awaiting universal salt iodization.  The method is
recommended for implementation in regions with an established infrastructure of centralized
bread production and mild or moderate iodine deficiency.


References
         1.  Indicators for assessing iodine deficiency disorders and their control through salt
iodization.  WHO/NUT/94.6
         2.  Delange F, Beaker G, Caron P, et al 1997 Thyroid volume and urinary iodine in
European schoolchildren:  standardization of values for assessment of iodine deficiency.  Eur J
Endocrinol (in press).
         3.  Brunn J, Block U, Ruf G, Bos I, Kunze W, Scriba P 1981 Volumetrie der
Schilrddrussenlappen mittels Real-time Sonograpie.  Dtsch med Wschr 106:1338.
         4.  Wawschinek O, Eber O, Petek W, et al. 1985 Ber der OGKC, Bd 8, S 13-15.
         5.  Nazarov A, Mayorova N, Sviridenko N, Kenzhibaeva M, Arbuzova M, Mischenko B,
Gerasimov G 1994 Goiter endemism im Moscow and the Moscow region.  Problemi
Endockrinologii 40(4):11-13 (in Russian).
         6.  Gerasimov G 1993 Update on IDD in the former USSR.  IDD Newsletter, November
1993, 43-48.
Table.  Effects of nine months use of iodized bread on goiter and urinary iodine concentrations.

                  Iodized bread             Goiter Prevalence                      Urinary Iodine
Group                  per day              before            after             before            after
                           g                   %              æg/L

  1                         300                 11                5                   48              138

  2                         100                 24               14                   30               62

SIMPLE TEST KIT TO DETERMINE CYANIDE IN CASSAVA.  J. Howard Bradbury,
Division of Botany and Zoology, Australian National University, Canberra, ACT 0200,
Australia.
         Cassava (tapioca) is a staple food for 500 million people and is the third most
important crop in the tropics, after rice and maize.  The cassava tuber is eaten by
people in Indonesia, Brazil, the South Pacific and tropical Africa.  There are over 100
different methods of processing cassava in Africa.  In East Africa cut cassava tubers
are dried in the sun before being pounded to produce cassava flour.
         Cassava is relevant to iodine deficiency because it contains cyanide, which in
the body is detoxified by conversion to thiocyanate.  Thiocyanate competes with iodine
for uptake by the thyroid, hence iodine deficiency disorders (IDD) are made worse by
consumption of cassava that contains cyanide components (cyanogens) (1).  Cyanide
intoxication can occur from eating cassava.  Symptoms include stomach pains,
diarrhea and dizziness.  Children in Mozambique and elsewhere have even died of
cyanide poisoning from eating cassava.  In the past 10 years about 10,000 people in
Mozambique, Tanzania, and Zaire have developed "konzo," a disease caused by
cyanide intoxication and characterized by an irreversible paralysis of the legs (2).
         We have developed a simple and inexpensive test to determine the amount of
cyanide compounds present in cassava and cassava products (3,4).  A small weighed
sample of cassava tuber or cassava flour is mixed with water and placed with a
buffered paper containing an enzyme, linamarase, that reacts with cyanogens.  An
indicator paper containing picric acid changes from yellow, when there is no cyanogen
present, to brown, which indicates high levels of linamarin, the main cyanogen present
in cassava.  By using a color chart with ten levels, even a high school student could
determine how much cyanogen is present in the sample.  In the laboratory, a more
accurate result is obtained by dissolving the color from the indicator paper in water
and observing the intensity of the color in a spectrophotometer.
         On a recent trip to Mozambique, I and Dr. Julie Cliff, an Australian physician
based in Mozambique, with Ms. Paula Cardoso and Mr. Mario Ernesto, tested 80
samples of cassava flour.  The average level of cyanogens in the samples was 4.5
times that recommended as safe by the World Health Organization, i.e., 19 mg
hydrogen cyanide per kg flour (10 ppm).  In two cases, we obtained values of 200
ppm (5).  Possible interventions to reduce the extent of this health hazard in
Mozambique include improved methods of processing to reduce the cyanogen content
of cassava flour, introduction of additional vegetables, pulses and fruits to alleviate the
monotonous diet of the people and introduction of low cyanide cultivars of cassava.
         In the past, cassava samples have been sent from Africa to overseas
laboratories for expensive and difficult tests to determine the cyanide content.  We
hope that this work, funded by the Australian Center for International Agricultural
Research, will change that need.  The kit is being adapted to enable users to
distinguish individually, when necessary, each of the three forms of cyanogens that
occur in cassava.  We aim to have a kit ready for semi-commercial distribution in the
near future.

References
         1.  Ermans AM, Bourdoux P, Kinthaert J, Lagasse R, Luvivila K, Mafuata M,
Thilly CM, Delange F 1983 Role of cassava in the etiology of endemic goiter and
cretinism.  In:  Delange F, Ahluwalia R (eds) Cassava Toxicity and Thyroid:  Research
and Public Health Issues, Ottawa, International Development Research Center, pp 9-
16.
         2.  Howlett WP, Brubaker GR, Mlingi N, Rosling H 1990 Konzo, an epidemic
upper motor neuron disease studied in Tanzania.  Brain 113:223-235.
         3.  Egan SV, Yeoh HH, Bradbury JH 1997 Simple picrate paper kit for
determination of the cyanogenic potential of cassava flour.  J Sci Food Agric
(submitted for publication).
         4.  Yeoh HH, Bradbury JH, Egan SV 1997 A simple and rapid method for
isolating cassava leaf linamarase suitable for cassava cyanide determination.  J. Sci
Food Agric (in press).
         5.  Cardoso AP, Ernesto M, Cliff J, Egan SV, Bradbury JH 1997 Cyanogenic
potential of cassava flour:  field trial in Mozambique of a simple kit.  Intern J Food Sci
Nutr (submitted for publication).
In Brief.........
         CONFERENCE ON IDD IN SOUTHEAST ASIA - This WHO/SEARO Regional
Consultation on "Elimination of Iodine Deficiency Disorders in Southeast Asia" was
organized by the WHO Regional Office for Southeast Asia in New Delhi from February
24-26, 1997.  Over 32 participants from 9 countries of the Region attended, as well as
agency representatives from UNICEF, ICCIDD, and the MI, including Prakash, Haxton,
Karmarkar, Kodyat, Sangsom, Salamatullah, and Pandav from ICCIDD.  Dr. Pandav
was the temporary advisor for the meeting.  The objectives of the meeting were to: 
(1) review trends in IDD prevalence and in iodized salt coverage in the countries of
the Region; (2) discuss mechanisms for quality assurance of iodized salt, from
production to the consumer level; (3) analyze IDD elimination activities in countries of
the Region and identify obstacles and difficulties in their speedy implementation; and
(4) stimulate countries in the Region to accelerate implementation of Universal Salt
Iodization and to sustain it thereafter, and to promote technical collaboration for IDD
elimination among countries.  A full report is in preparation and will be available from
WHO-SEARO office, New Delhi.  Details are available from Dr. Sultana Khanum,
Regional Advisor (Nutrition), WHO-SEARO and Dr. Pandav.  
         SUPPORT FOR ELIMINATION OF IDD IN THE RUSSIAN FEDERATION -
This meeting in Washington, D.C., February 3-4, 1997, was convened to advance
cooperation between the Russian Ministry of Health, the US Government, and
international NGO's, for elimination of micronutrient malnutrition, in preparation for the
Gore-Chemomyrdin Health Commission.  Dr. Delange attended officially for ICCIDD;
other Board members present were Mr. Mannar for the MI, Dr. Gerasimov for Russia,
and Dr. Maberly for PAMM.  Areas identified for future collaboration include training
courses, technical support, surveillance systems, monitoring, technology transfer, and
social marketing.  A workshop will follow in Moscow in 1997 to develop an overall
collaborative strategy for the elimination of micronutrient malnutrition and to develop
integrated plans of action for each specific micronutrient.  The statement gave special
emphasis to the importance of micronutrients for women and children.  The document
was signed by the US Secretary of Health and Human Services and by the Russian
Minister of Health.  A highlight of the meeting was the presentation by Delange and
Gerasimov providing an overview of the IDD status and salt iodization in Eastern
Europe, appearing elsewhere in this issue of the Newsletter. 
         More ICCIDD on the Internet - The ICCIDD Communication Focal Point is now
on the Internet.  Address is:  (http://www.tulane.edu/~icec/iddcomm.htm).  Its
colorful home page offers information about IDD, ICCIDD, iodized salt, communication
guides, and links to other relevant websites, including to the ICCIDD home page
(http://avery.med.virginia.edu/~jtd/iccidd/).  The latter is being expanded and will
provide links to other relevant organizations and databases.  It contains the text files
of the IDD Newsletter since 1992, and the CIDDS database, which is being updated. 
Further coordination among these ICCIDD databases and the Micronutrient Initiative is
planned.  
         Kiwanis International Worldwide Service Project - Kiwanis International has
as its goal raising $75 million towards the elimination of IDD.  The organization's
500,000 members are now active all over the USA and the globe in raising funds,
which are channeled through UNICEF for IDD elimination.  ICCIDD has been working
with Kiwanis towards this common goal, and a representative of the Kiwanis
Worldwide Service Project has been a member of the ICCIDD Board.  Dr. Connie
Pittman, also of the ICCIDD Board, is both an international thyroidologist and a
Kiwanian.  Future issues of the IDD Newsletter will give more details on the Kiwanis
campaign.  A bulletin on progress is issued bimonthly by Kiwanis.  More information
on this effort is available from Kiwanis International, 3636 Woodview Trace,
Indianapolis, IN  46268, USA; fax (317) 879-0204, and on the Internet: 
http://www.kiwanis.org/wsp/.
         Annual Report for 1995, Nutrition Center of the Philippines - This booklet
describes the many activities of the Center, including several involving IDD.  For the
three CAR provinces in the north of Luzon, where iodine deficiency has been
particularly severe, 90,900 (84%) preschoolers and 92,451 (94%) of schoolchildren
received Oriodol, delivered through local government personnel.  Beneficial effects on
breathing, swallowing, and goiter reduction were noted.  Despite this high coverage,
there was some difficulty in reaching preschool children in the most remote areas.
         The quality of iodized salt produced in Benguet and the mountain provinces
was reviewed.  By 1995, 24 iodizing machines had been installed in various parts of
the country with support from UNICEF for the machines and for KIO3.  Six plants were
in the Cordillera Administrative Region (CAR).  Workshops on quality control were
conducted.  Both the field kit and the rapid test semiquantitative method failed to show
decreasing levels of iodine over time, for unexplained reasons.  Details of the start-up
of salt plants are given.
         The report also gives follow-up information on Oriodol (oral iodized oil) given as
a single dose of 0.5 ml (308 mg iodine) in schoolchildren 8-14 years old.  Of 160
iodine-deficient subjects (UI < 100 æg/L) at baseline, 58 became iodine sufficient in
three months and 91 by 12 months.  The study concluded that 308 mg iodine reduced
iodine deficiency and improved iodine status in about 80% of the schoolchildren.  The
dose was well tolerated and could be delivered by classroom teachers.  
         Further details available from the Nutrition Center of the Philippines, and Dr.
Florentino Solon.
         IVACG Meeting - The next annual meeting for IVACG is scheduled for Cairo,
Egypt, September 22-26, entitled "Sustainable Control of Vitamin A Deficiency: 
Defining Progress Through Assessment, Surveillance, Evaluation."  Sponsors include
the Nutrition Institute of the Egyptian Ministry of Health, and IVACG.  Deadline for
registration is June 30, 1997.  Further details are available from the IVACG
Secretariat, ILSI Human Nutrition Institute, 1126 16th Street, N.W., Washington, D.C.
20036, USA; fax (202) 659-3617.  
         Thrasher Fund Request for Proposals - The Thrasher Research Fund
requests proposals for food-based approaches to prevent micronutrient malnutrition. 
This step follows the Salt Lake City Declaration on Micronutrients, from a November
1995 conference that concluded "food-based systems offer sustainable solutions to
malnutrition including the health problems caused by micronutrient deficiencies, thus
making material improvements to the health, well being and productivity of millions of
people."  The guidelines note "food-based approaches include all activities affecting
human nutrition and health, which are associated with production, acquisition,
preservation, and utilization of food."  Proposals will be accepted until December 31,
1998 or until designated funds have been committed.  Further information is available
from the Thrasher Research Fund, 50 East North Temple Street, Salt Lake City, Utah
85150, USA; fax (801) 240-1964.  
         Leeds Course in Clinical Nutrition - Scheduled for September 2-5, 1997, this
course in Leeds, England, covers nutrition in surgery, gastroenterology, minority
groups, pediatrics, and nutritional treatment.  Further details can be obtained from The
Course Secretary - Clinical Nutrition, School of Continuing Education - CVE,
Continuing Education Building, Springfield Mount, Leeds LS2 9NG, UK; fax 0113 233
3240.
RECENT PUBLICATIONS
         1.  Iodine Deficiency Disorders in Livestock:  Ecology and Economics - C.
S. Pandav and A. R. Rao, Oxford University Press, Delhi, 1997.  This ICCIDD book,
edited by its Regional Coordinator for Southeast Asia, Dr. Pandav, reports the
proceedings of a technical review meeting, held in January 1995.  Papers from a
multidisciplinary group of economists, soil scientists, nutritionists, physicians, policy
makers, biochemists and veterinarians describe the iodine status of feed and fodders,
IDD in animals, control measures for IDD in livestock, and recommendations for future
action.  The book is available from the ICCIDD Regional Office in New Delhi, US
$15.00 per copy.  
         2.  YES - Worthwhile Investment in Health; Economic Evaluation of IDD
Control Program in Sikkim - This book, also by Dr. Pandav, compares an iodized
salt program and an iodized oil injection program in Sikkim, a severely iodine-deficient
region in India.  He analyzes costs and outcome measures and concludes that for this
population the iodized oil program is currently more efficient than one with iodized salt. 
He notes that a reassessment should be conducted after the iodine deficiency has
been partially corrected.  The book is available through Dr. Pandav's office in Delhi.
         3.  Iodine Deficiency:  What it is and How to Prevent it - This booklet, in
either English or Arabic, is available from the Regional Adviser for Nutrition, Food,
Security and Safety, WHO Regional Office for the Eastern Mediterranean, P. O. Box
1517, Alexandria 21511, Egypt.
         4.  The State of the World's Children, 1997 - This annual report focusses on
child labor.  It also includes useful tables that give demographic information, including
goiter rate and percent of households consuming iodized salt, from data available to
UNICEF.  The report can be obtained from the United States Committee for UNICEF,
333 E. 38th Street, New York, NY  10016, USA.
         5.  Health Care of Women and Children in Developing Countries, Second
Edition, edited by Helen M. Wallace, Kanti Giri, and Carlos V. Serrano, Third Party
Publishing Company, P. O. Box 13306, Montclair Station E, Oakland, CA 94661-0306,
USA, fax (510) 339-6729 - This book of approximately 750 pages has extensive
information on all aspects of health care in developing countries.  Its six sections are
an overview (global views, fertility, risks, strategies, evaluation, women's health, infant
and child mortality), child health (including survival), normal growth, specific conditions
including iodine deficiency, adolescent health, delivery of maternal and child health
and family planning services.  Contributors include experts in international medicine
and health policy and the book has forwards by the Director General of WHO, the
Executive Director of UNICEF, and the Executive Director of the United Nations
Population Fund.
PRETELL RECEIVES SPAIN'S QUEEN SOFIA PRIZE
         In a ceremony in Madrid, Queen Sofia of Spain awarded the prize bearing her
name to Dr. Eduardo Pretell, ICCIDD Regional Coordinator for the Americas.  A jury
under the Queen's patronage selects from a list of international nominees a recipient
who has made the greatest contribution to the prevention of deficiencies.  Dr. Pretell
was cited for his many years of work investigating causes and effects of iodine
deficiency and implementing effective preventive measures in both Peru and the rest
of the Americas.  His award address was entitled "Iodine Deficiency and Diminished
Quality of Life:  Three Decades of Fighting for its Eradication."  
         Dr. Pretell has been active in many phases of the battle against IDD.  He was
one of the first to use injections of iodized oil in areas of severe iodine deficiency.  In
addition to correcting the iodine deficiency, he conducted valuable investigations on
the effects of injected iodized oil on thyroid function and its optimal dose, as well as its
cost effectiveness.  He subsequently carried out similar studies with oral iodized oil. 
The maternal-fetal relationship in iodine deficiency has been a particular investigative
interest.  He carried out detailed metabolic and anthropometric studies to show the
beneficial effects of iodized oil on intelligence, hearing, and language, and
demonstrated the importance of maternal milk in iodine nutrition of the infant.  All his
investigations have been aimed at improving public health, but in addition, he has
been closely associated with the Peruvian Ministry of Health in its efforts towards IDD
elimination and served as Director of the Peruvian Program Against Iodine Deficiency
during its most active years.  The rapid progress in correction of iodine deficiency in
Peru during the last 10 years owes much of its success to his direction and guidance. 
Finally, in addition to his national work, Dr. Pretell has been the Regional Coordinator
for the Americas for ICCIDD since its inception in 1985.  In that role, he continues to
be one of the key players in the dramatic progress made in the Region.