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 ALBANIAARMENIAAZERBAIJANBELARUSPOPULATION3,300,0003,300,0007,100,00010,300,000LAND AREA (000 Sq Km)27,429,886,6208,01995 GDP per capita (US$)6365455211,748EXTENT 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/AMild to moderate, endemic goitre in 23 of 48 provinces (national survey). Recent data on goiter prevalence, urinary iodine N/AMild 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 USSRLocal 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 EuropeSALT 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 iodizedPartial the amount of iodized salt production N/A. KI at 25 ppm is most likely usedNo 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 labelledLEGISLATION NoNoNoNoOTHER PREVENTIVE MEASURES N/AN/AN/AIodine tablets (1 mg) and KI solution for childrenMONITORING Quality assurance system NoNoNoNo Laboratory for urinary iodine available.NATIONAL IDD CONTROL PROGRAMNoNoNoNoHUMAN RESOURCES AVAILABLE IDD training Limited, personnel needs training in IDDLimited, personnel needs training in IDD; previous experience in salt iodizationLimited,personnel needs training in IDDHuman resources available but need training in IDDOTHER COMMENTSNoNoBefore 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.POPULATION4,600,0008,800,0004,700,00010,400,000LAND AREA (000 Sq Km)51,2110,656,478,61995 GDP per capita (US$)N/A1,1362,9364,328EXTENT 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/LSALT 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/A60% produced local- ly, 40% imported (amounts N/A) Expected demand for iodized salt - 30,000 tons/year1 large and 2 small plants (amounts N/A)1 producer, the amounts of locally produced and imported salt N/ASALT IODIZATION % of iodized salt compound iodine (ppm) source of iodine Cost of I salt Labelling Yes, details N/AMandatory 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 KIO3LEGISLATION YesYesYesYesOTHER PREVENTIVE MEASURES N/AIodine tablets (1 mg per week) for risk groups at riskN/AN/AMONITORING Quality assurance system N/AN/AN/AN/ANATIONAL IDD CONTROL PROGRAM N/AYes (since 1991)N/AN/AHUMAN RESOURCES AVAILABLE IDD training Limited, personnel needs training in IDDReasonable level of training and experienceReasonable level of training and experience High level of training and experienceOTHER COMMENTSIDD prophylaxis disrupted by warNoNoNo 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 KAZAKHSTANPOPULATION1,600,0005,400,00010,300,00017,200,000LAND AREA (000 Sq Km)45,269,793,22,717,31995 GDP per capita (US$)1,6256673,981390EXTENT 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/Amild 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 soonMarginal, 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 sector1 producer and import (amount N/A)Salt locally produced (650,000 tones in 1993) by 2 plants, import of salt is smallSALT IODIZATION % of iodized salt compound iodine (ppm) source of iodine Cost of I salt Labelling NoNo Some Armenian salt has traces of iodineYes, 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 improvementLEGISLATION PendingYes, but not enforcedYesPendingOTHER PREVENTIVE MEASURES N/AN/AN/AIodized bread in 4 endemic region, 1 small supply of iodized oil (1993)MONITORING Quality assurance system N/AN/AN/AIodized salt controlled at the level of production, monitoring system N/ANATIONAL IDD CONTROL PROGRAM N/AYes, coordination Council Against IDD foundedN/AN/AHUMAN RESOURCES AVAILABLE IDD training Limited, personnel needs training in IDDLimited, personnel needs training in IDDQualification is reasonably highPersonnel is reason- ably qualified (asse- ssment, iodization), additional training neededOTHER 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 MACEDONIAPOPULATION4,400,0002,700,0003,700,0002,700,000LAND AREA (000 Sq Km)198,563,765,224,81995 GDP per capita (US$)5901,5561,3511,519EXTENT 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/AMild Median urinary iodine is 75 þcg/L (national survey, 1995), data on goiter prevalence N/AGoiter 18.7% UI 117 æg/L; 8/30 areas < 10SALT 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 labellingAll salt imported (amount N/A)All salt imported (amount N/A)All imported, from Bulgaria, BelarusSALT IODIZATION % of iodized salt compound iodine (ppm) source of iodine Cost of I salt Labelling No, salt requirement for humans is 30,000 tons/yearNoNo5 ppm as KILEGISLATION NoNoNoYes; new law being formulatedOTHER PREVENTIVE MEASURES KI (1 mg) tablets to risk groupsN/AN/AN/AMONITORING Quality assurance system NoN/AN/ASalt on importNATIONAL IDD CONTROL PROGRAM NoN/AN/AN/AHUMAN RESOURCES AVAILABLE IDD training Limited, personnel needs training in IDDLimited, personnel needs training in IDDLimited, personnel needs training in IDDLimited, personnel needs training in IDD. Good epidemiology.OTHER COMMENTSNoNoNoNoAn 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 RUSSIAPOPULATION4,500,00038,500,00023,200,000148,600,000LAND AREA (000 Sq Km)33,7304,5230,317,075,21995 GDP per capita (US$)3782,4681,2502,639EXTENT 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/Lmild to severe National survey (1995) urinary iodine 49-93 þcg/L, goiter rate 10-43%, increased TSH levels in neonatesmild 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 NoMandatory from 01.97, 30 ñ 10 ppm KI No, Iodized salt was produced in 1992 (KIO3, 15 ppm), distribution limitedYes, but limited KI 25 ppm KIO3 50 ppm (from 1997) Production needs more requests from trade. Iodized salt exported (Mongolia)LEGISLATION NoYesYes, but not enforcedNoOTHER PREVENTIVE MEASURES N/AN/AN/AIodized bread (local- ly), iodized oil (Che- rnobyl areas), iodine tablets MONITORING Quality assurance system NoN/AN/ANo, 4 laboratories to control urinary iodineNATIONAL IDD CONTROL PROGRAM NoYesYesNo, Moderate awareness of Government in IDD problemsHUMAN RESOURCES AVAILABLE IDD training Limited, personnel needs training in IDDYes, qualification of personnel is highYes, personnel needs additional training in IDDYes, personnel needs additional training in IDDOTHER COMMENTSNoNoNoLocal 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 TURKMENISTANPOPULATION5,400,0005,400,0004,200,000LAND AREA (000 Sq Km)48,8143,1488,11995 GDP per capita (US$)2,222148643EXTENT 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/LCritical 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/Amild to moderate Local survey (1994) goiter rate 20-64% (US), urinary iodine -37-72 þcg/LSALT 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 YesBefore 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 YesNoYes, but not enforcedYes, but not enforcedOTHER PREVENTIVE MEASURES N/AOral iodized oil was given in Gorno-Bad- akshan (GBAO) area to childrenN/AN/AMONITORING Quality assurance system N/ANoNoNoNATIONAL IDD CONTROL PROGRAM YesNoNoNoHUMAN RESOURCES AVAILABLE IDD training Yes, qualification is highLimited, personnel needs training in IDDLimited, personnel needs training in IDDLimited, personnel needs training in IDDOTHER COMMENTSNoAga-Khan Founda- tion is developing local IDD control program for GBAO.NoLocal production of KI and KIO3 of reasonable quality, capable to export themAn 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 POPULATION51,800,00022,100,00010,700,000LAND AREA (000 Sq Km)603,7447,488,41995 GDP per capita (US$)676919972EXTENT 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/Amild 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/ASALT 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.NoLEGISLATION PendingNoPendingOTHER PREVENTIVE MEASURES N/A Iodine tablets conta- ining 1 mg of KI lo- cally produced. N/AN/AMONITORING Quality assurance system No Laboratory for uri- nary iodine determi- nation is available.NoN/ANATIONAL IDD CONTROL PROGRAM NoNoN/AHUMAN RESOURCES AVAILABLE IDD training Yes, personnel needs additional training in IDDLimited, personnel needs training in IDDLimited, personnel needs training in IDDOTHER COMMENTSOpposition to USI existsNoNoRegional 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.