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IDD prevention program in Bulgaria-Progress of Universal Salt Iodization

IDD prevention program in Bulgaria-Progress of Universal Salt Iodization. Ludmila Ivanova, MD, PhD Sofia, Bulgaria. The main purpose of the presentation. To share Bulgarian experience in USI as most effective strategy for sustainable Elimination of IDD.

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IDD prevention program in Bulgaria-Progress of Universal Salt Iodization

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  1. IDD prevention program in Bulgaria-Progress of Universal Salt Iodization Ludmila Ivanova, MD, PhD Sofia, Bulgaria

  2. The main purpose of the presentation • To share Bulgarian experience in USI as most effective strategy for sustainable Elimination of IDD

  3. Iodine deficiency – an age old problem Bulgarian icons with goiter

  4. Bulgaria is a country with 1/3 of the territory being endemic For the first time a Regulation on IDD prevention was introduced in 1958 • The strategies were focused on endemic regions only. • Salt iodization and iodine supplementation with tablets of target groups (children, pregnant women) was implemented • The outcome was reduction of goiter from 55.9% to 12.1% in the following 15 years.

  5. In 1994 the new Legislation was introduced based on: • Lessons learned by the previous National Regulation – lack of sustainability • Focused on endemic regions only • Irregular production and distribution of iodine tablets • High costs and low coverage rate of iodine tablets • Lack of intersectorial co-operation • IDD situation in Bulgaria – increased incidence of goiter • International Recommendations – Universal salt iodization (ICCIDD/UNICEF/WHO)

  6. National Legislation on IDD Control • Government Decree 96/17.05.1994 of the Council of Ministers (State Gazette 43/27.05.1994) • Order N RD-09-244/14.06.1994. of the Chief State Sanitary Inspector of the Republic of Bulgaria (State Gazette 52/26.06.1994) • Amendment N 7/01.07.1996 to Bulgarian State Standard 628-77 “Table salt” • Ordinance for Requirements to the composition and characteristics of food grade salt (State Gazette 11/06.02.12001)

  7. Government Decree 96/17.05.1994 was developed to set the foundational of the IDD Elimination Program Main Principles/Activities • Universal salt iodization covering all salt for human consumption, food industry and cattle breeding • Short term additional prophylaxis of risk groups-(schoolchildren and pregnant women) in the “endemic regions” with iodine tablets for the first 2 years of the program ( high goiter grade over 30% ) • Trade policy stimulating the import of iodized table salt • Establishment of National Monitoring System-capacity building, training ect.

  8. National Program for Control of IDD - Multisectoral Efforts • Institutional support / Intersectoral Co-ordination • National Coordinating Committee for IDD Control (MOH,- Industry, -Trade, Salt Producers, Finances, Agriculture, Committee of Standardization, Thyroidologists, Nutritionists, NGO,s) • Expert Council on IDDat Ministry of Health

  9. Order N RD-09-244/14.06.1994. of the Chief State Sanitary Inspector of the Republic of Bulgaria • Prohibition of placing non-iodized table salt at the market • Definition of a system and methods for control of the quality of iodized salt • Creation of a database for recording results of iodized salt at the market through the Ministry of Health

  10. Amendment N 7/01.07.1996 to Bulgarian State Standard 628-77 “Table salt” • Salt iodization with potassium iodate at level 28-55 ppm KJO3 (16.6-32 ppm I).

  11. Ordinance for Requirements to the composition and characteristics of food grade salt (State Gazette 11/06.02.2001) Definition “For food purposes only salt iodized with KJO3 at level 28-55 ppm must be used; • Expiry time, not longer than 12 months after iodization • Specification of storage condition (clean, closed and dry rooms) • Specification of Package material • Labeling (Ordinance for food labeling, Decree 136/2000(SG, 62/2000)

  12. Ordinance for Requirements to the composition and characteristics of food grade salt (State Gazette 11/06.02.2001) • Requirements to Laboratory control • Sampling procedure (Ordinance 2/1997, SG 10/97) • Methods-Bulgarian State Standard methods-8840-71, BSS 2/92),

  13. As a result of effective implementation of enacted legislation First National Survey on IDD Situation in Bulgaria two years after implementation universal salt iodization 1996 Optimistic results

  14. Based on the Results of the National survey the strategies were revised • The supplementation with tablets was discontinued because • High cost taken by the budget of MOH – 3 USD/capita/per year • Relatively low coverage rate (50%) - distribution problems • Low actual usage • Perception by population as a drug • Concern of side effect by health specialists

  15. Based on the Results of the National survey the strategies were revised • Universal salt iodization was recognized as the only strategy for control of IDD in Bulgaria • Low cost covered by Producers/consumers 1.25 USD/capita/year for iodized salt • Universal coverage rate • No risk of toxicity/overdosing • Perception by peopleas “ food” • Health specialists are aware of long-term consequences of Iodine Deficiency (TSH congenital screening)and need of prevention, not treatment

  16. Second National Survey on IDD Situation in Bulgaria after implementation universal salt iodization spring 2003

  17. National Survey on IDD Situation in Bulgaria - Spring 2003-Results based on USI

  18. Box plot of results from salt analyses from household survey conducted in 2003 in ten regions of Bulgaria

  19. Results of salt monitoring at market levelin the period 1996-2003

  20. National Survey on iodine nutrition of schoolchildren, aged 6-11 years, Spring 2003 Urinary iodine (ioduria) • Median (mg/L) 198.0 • Proportion below 100 mg/L 6.9 % • Proportion below 50 mg/L 0.8 %

  21. National Survey on IDD Situation in Bulgaria -Spring 2003 Goiter grade (ultrasonography) • Proportion above P97 (WHO, 1997) 4.3%

  22. Comparison of individual values of ioduria from two National surveys of shshoolchildren 1996 – 2003

  23. Distribution of individual values of ioduria from two National surveys of schoolchildren 1996 – 2003 according the ICCIDD/UNICEF/WHO criteria

  24. Ioduria of pregnant women, National survey 2003 Total group 355 Age ( years) 26 (21-31) Median ioduria (mcg/L) 165 Minimum (mcg/L) 40 Maximum (mcg/L) 600

  25. Percentile distribution (P25, P50,P75) of ioduria from schoolchildren for the period 1994-2003

  26. Аassessment/Monitoring/Evaluation • Monitoring plan of IDD status Indicators • Proportion of adequately iodized salt at the market • Annual plan prepared by the MOH • Sampling – monthly-Hygiene Inspectorates, • Analyses – HEI Laboratories • Reporting-every three months to MOH

  27. Assessment/Monitoring/Evaluation Biological monitoring • Ioduria/biomarker of intake • Nat. surveys – school aged children/every 5 years Total Goiter Rate: palpation; ultrasound • Neonatal TSH program screening (separate)

  28. Conclusions • The iodine nutrition of the Bulgarian population was substantially improved after the implementation of universal salt iodination in 1994 • The legislation and the establishment of effective monitoring system builds up an fundamental of the National IDD Elimination Program • Bulgaria is already achieving the final goal – elimination of IDD trough the most cost effective and adequate strategy Universal Salt Iodization

  29. Thank you

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