XI CAR MATERNAL and CHILD HEALTH FORUM , Ashgabat - 2008

1. XI CAR MATERNAL and CHILD HEALTH FORUM, Ashgabat -2008 Monitoring of Food Fortification in Turkmenistan Annamurad Nazarov Head of the State Sanitary Surveillance Department State Sanitary and Epidemiological Service of Turkmenistan Ministry of Health and Medical Industry of Turkmenistan

2. Monitoring of Foodstuff Fortification in Turkmenistan • Disease prevention is the main healthcare objective of the Presidential State Health Programme adopted in 1995 in Turkmenistan. • In May 1996, for the purpose of prevention diseases caused by micronutrient deficiency the President of Turkmenistan signed Decree No. 2626 “On Salt Iodization and Flour Fortification with Iron”. Pursuant to that, all salt produced in Turkmenistan should be iodized and salt iodization should be compulsory for all salt producers irrespective of ownership type in the whole territory of Turkmenistan

3. Monitoring of Foodstuff Fortification in Turkmenistan • The Inter-Sectoral Commission on provision the population with iodized salt and iron-fortified wheat was established in 1996. It comprises state institutions responsible for food production, quality control, sale, as well as implementation of the relevant policy and taxation reform. • Being the only salt producer in Turkmenistan the production complex “GUVLYDUZ” completely satisfies the country’s demand in iodized salt and is exempted from all types of taxes. • Internal and external quality control of iodized salt is conducted both by the producer’s laboratory and the State Sanitary and Epidemiological Service.

4. Monitoring of Foodstuff Fortification in Turkmenistan The main consumers of the final product are retail trading network, food industry and other industrial sectors. Import volume of salt is insignificant and if any only iodized salt is allowed to be imported. To improve iodized salt quality and ensure much more preservation of iodine in salt at the level of consumers the Ministry of Health and Medical Industry of Turkmenistan approved and introduced a new international salt iodization standard 40±15 ppm in 2002.

5. Monitoring of Foodstuff Fortification in Turkmenistan • In order to strengthen the system of control for iodized salt production, distribution and transportation the Ministry of Health and Medical Industry of Turkmenistan issued Decree No. 61 “On Permanent Iodized Salt Quality Laboratory Control and Monitoring” on 6 May 2002. Pursuant to this Decree: • -permanent monitoring of iodized salt quality based on the laboratory methodology is imposed on the State Sanitary and Epidemiological Service under the Ministry of Health and Medical Industry of Turkmenistan.

6. Monitoring of Foodstuff Fortification in Turkmenistan • A monthly reporting form and a monitoring procedure including laboratory tests on iodine availability in iodized salt composition were approved. • A list of objects including households subject to continuus monitoring through laboratory methodology was approved. • During monitoring of quality and circulation of iodized salt specific attention is paid to the principle “first in – first out” and to conducting laboratory control.

7. Monitoring of Foodstuff Fortification in Turkmenistan • As a result of continuous monitoring through laboratory tests at the monitoring objects and households universal consumption of iodized salt was achieved. • In 2003 a National Representative survey was conducted jointly with international experts. In 2004 UNICEF, WHO and ICCIDD awarded Turkmenistan, the first country in CIS and the fourth in he world, with the International Certificate on achievement of optimal iodine content in nutrition of population through universal salt iodization and stable iodine deficiency disorders elimination.

8. Findings of Universal Salt Iodization Monitoring In Turkmenistan, 2002-2007 102 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 99,7 99,7 99,4 100 98,7 97,7 98 96 94 92,6 92 90 88 Ashgabat Akhal velayat Balkan velayat Dashoguz velayat Lebap velayat. Mary velayat Turkmenistan 99,4 98,7 100 99,7 92,6 97,7 99,7 2002 100 100 100 100 100 100 100 2003 100 100 100 100 100 100 100 2004 100 100 100 100 100 100 100 2005 100 100 100 100 100 100 100 2006 100 100 100 100 100 100 100 2007

9. Monitoring of Foodstuff Fortification in Turkmenistan • The Research Council of the Ministry of Health and Medical Industry of Turkmenistan passed and approved the methodological guide “Prevention of Diseases Caused by Iodine Deficiency through Universal Salt Iodization in Turkmenistan”. It was developed on the bases of experience received during assessment of preventive activities on iodine deficiency diseases and monitoring conducted by the Sanitary Epidemiological Service and the Research Clinic Center of Mother and Child Health Protection after Gurbansoltan eje of the Ministry of Health and Medical Industry of Turkmenistan. • The methodological guide provides in detail all stages and methodology for conducting biological monitoring and epidemiological studies.

10. Monitoring of Foodstuff Fortification in Turkmenistan • In 2006 with participation of the UNICEF international expert a Sentinel Survey was conducted in Akhal, Balkan, Mary velayats and Ashgabat city through examination of schoolchildren aged 8-10 years, as well as pregnant women on the first trimester of pregnancy. The survey was conducted in accordance with the recommendations “Methodology for studying iodine deficiency diseases and monitoring their elimination” developed by UNICEF, WHO and ICCIDD (2003). • Findings received during the Sentinel Survey (indicators) prove good status of the Iodine Deficiency Elimination Programme in nutrition of the population.

11. Monitoring of Foodstuff Fortification in Turkmenistan • Evidence to that is adequate iodine concentration in urine of the examined representative group of schoolchildren and pregnant women (median 188 mkg/l at norm100-300 mkg/l) and small amount of samples containing iodine in the amount less than 100 mkg/l (12,0%, acceptable level < 50 %) and less than 50 mkg/l (4,0%, acceptable level <20 %), which is considerably less than the recommended threshold values. • The highest median indicator was observed in Balkan velayat (264 mkg/l). It is caused by the vicinity of the Caspian Sea to Balkan velayat and prevalence of seafood in nutrition of this velayat’s population. The only factory producing iodized salt is located in this velayat.

12. Monitoring of Foodstuff Fortification in Turkmenistan • In Akhal velayat the median was 125 mkg/l, in Mary velayat - 205 mkg/l, in Ashgabat city that indicator was 190 mkg/l. During that Survey 245 salt samples were collected. Iodine content in the samples were analyzed by qualitative and quantitative methods. Qualitative analysis was made by express-test kits directly at schools and health centers. The results in all samples were positive. • Adequate consumption of iodine was reached due to universal salt iodization and the number of households consuming qualitative iodized salt is 100%.

13. Monitoring of Foodstuff Fortification in Turkmenistan • Turkmenistan also takes important steps in prevention iron-deficiency anemia in women of fertile age and young children, therefore promoting MDGs achievement. • Pursuant to Presidential Decree No.2626 “On Salt Iodization and Flour Fortification with Iron”(28 May 1996) four fortification with iron was initiated. In order to improve effectiveness of the activities the Presidential Enactment “On Production of Flour Fortified with Folic Acid and Iron” was signed in 2006. Pursuant to it, all wheat flour produced in Turkmenistan has been fortified both with iron and folic acid.

14. Monitoring of Foodstuff Fortification in Turkmenistan • Feeders for premix containing iron and folic acid were installed at all mills of the country to fortify flour of extra and first grades. • In order to provide sustainability and long-term duration of the Programme on prevention of iron-deficiency anemia the President signed the Resolution authorizing the “Turkmengallaonumleri” Association to sign a long-term Memorandum of Understanding and Cooperation with UNICEF to provide fortification with micronutrients of extra and first grade flour produced in Turkmenistan by enterprises of all property forms. In accordance with the document Turkmenistan undertook obligation to procure in future all necessary premixes and feeders for its own account.

15. Monitoring of Foodstuff Fortification in Turkmenistan • The State Sanitary and Epidemiological Service of the Ministry of Health and Medical Industry of Turkmenistan and the “Turkmengallaonumleri” Association developed and approved a guide on conducting internal and external monitoring of fortified flour using methods of laboratory analysis.