Accelerating Progress to Universal Salt Iodization in India Achievements, Challenges, and Future Actions.

Objectives: India was one of the first countries to introduce salt iodization. This presentation reviews the national efforts towards universal salt iodization (USI) in India, documents achievements and progress, and highlights key challenges in programme implementation. Methods: The Salt Department of the Government of India and its development partners have made concerted efforts to improve availability, access and use of adequately iodized salt. Results: National and state level advocacy meetings were carried out to ensure high political commitment and prioritization of the USI programme. The National Coalition for Sustained Iodine Intake was launched to improve the overall programme management and coordination. The technical capacity of salt producers was enhanced and salt wholesalers and retailers were mapped, sensitized and equipped with tools and skills to procure only adequately iodized salt. A state-of-the-art management information system was launched to improve the efficiency in monitoring the flow of iodized salt. In addition, awareness and communication activities were scaled up to generate demand for iodized salt. As a result, the national household coverage of adequately iodized salt increased from 51% in 2005 to 71% in 2009. However, data indicate a clear urban-rural and rich-poor differential, leaving some of the most disadvantaged populations vulnerable to iodine deficiency. Conclusions: An evidence-based, well-defined strategy will be necessary to reach the last 30% of households, which are are likely to be least accessible and most socio-economically vulnerable. Both national and state level policies should mainstream the use of adequately iodized salt in feeding programmes for the benefit of all.

Feasibility of Using Electronic Rapid Testing Kits for Improved Monitoring of Salt Processors.

Objectives: Quality control is a process to detect and correct production default from specified standards during actual processing. In salt iodization units, iodized salt samples are collected and tested through iodometric titration, in a laboratory attached to the production unit. Small and medium-scale producers do not have these adjacent laboratories. The time-lag between sample collection, testing, and incorporation of corrective guidance increases the risk of producing non-standard iodized salt. The objective of this study was to assess real-world accuracy of a recently developed electronic Rapid Testing kit (eRTK, Innovative design) as a more rapid method of controlling iodine levels in salt, particularly in small-scale production sites. Methods: 3198 iodized field salt samples were tested using 15 eRTKs, in accordance to the standard operating protocol of the instrument and compared with results from standard iodometric titration. Sample types included free flow salt, washed and crushed salt, crushed salt and crystal salt from eight different geographical areas, representing each type of salt produced in India. Results: The instrument is accurate to ±3 ppm in salt iodization between 15 – 55 ppm. Results from the study report a sensitivity of 76.3%, specificity of 81.9%, positive predictive value of 79.5% and negative predictive value 79%. The cost of testing iodized salt samples using eRTK is 25% of that of iodometric titration. Conclusions: eRTK was found to be a rapid, accurate and portable alternative to titration testing that is suitable for salt traders, retailers and enforcement agencies to ensure the iodization levels of salt.

External Monitoring of Small and Medium Salt Processors Results in Improved Salt Iodization Levels in India.

Objectives: Small & medium scale salt processors are the main defaulters in the production of adequately and uniformly iodized salt. Monitoring of these processors by enforcement agencies is inadequate given the scale and geographic spread of the salt industry. The Government Salt Department requested Micronutrient Initiative’s (MI) support to strengthen the monitoring system of salt processors to improve enforcement and improve quality of salt produced. Methods: The salt samples are collected from 400 small and medium scale salt processors on daily basis and results of iodometric titration is communicated to the salt producers for corrective action. The results are analysed using web based software and shared with enforcement agencies and other stakeholders at routine intervals, for initiating necessary action to improve salt iodization. Results: In the past six years, this system has monitored an average of two million tonnes of salt produced per year by small and medium scale processors. Through this process, MI was able to engage directly with salt producers on technical issues, including encouragement to adopt improved iodization processes. Sharing monitoring data with the government and salt associations enhanced the effectiveness of government enforcement mechanisms and provided a platform to discuss problems and resolve issues. These activities contributed to improvement in adequately iodized salt, from 9% in 2007 to 35% in 2013. Conclusions: External monitoring of small salt processors resulted in more effective enforcement and adoption of better production processes. The increased compliance of small and medium scale processors has contributed to India’s progress towards Universal Salt Iodization.