A Framework for Developing Effective Advocacy and Communication to Support Universal Salt Iodization.

Objectives: Tremendous progress has been made toward achieving universal salt iodization (USI). Nonetheless, in some countries USI's momentum has stalled. UNICEF and GAIN have created a Partnership, under Gates Foundation funding, to revitalize and innovate for reaching the "last mile" of coverage in such countries and to ensure sustainability of past achievements. Under this initiative, USI advocacy and communications (A&C) activities were assessed in 13 countries to create a framework for guiding national programs in the creation of effective A&C strategies. Methods: Countries were selected based on low USI coverage or questionable sustainability of current coverage. Assessments examined legislation and enforcement, current coverage, salt manufacturing, and the consumer market, analyzed the salt distribution chain in detail, and identified priority needs and recommended approaches for expanding coverage. Results: As expected, constraints to stalled progress were unique to each country, requiring recommendations tailored to the local situation. Nonetheless, the exercise generated a framework, modifiable for use in any country, detailing a process for assessing legislation and enforcement; pinpointing links of the salt distribution chain; identifying key actors, actions, and communications needs at each link; and obtaining information about these actors and actions. The framework's summary matrix allows prioritization of A&C initiatives for greatest impact using available resources. Conclusions: This "salt chain" approach creates new opportunities for expanding A&C beyond the usual focus of simply targeting producers and consumers, and the new framework provides a useful tool for country programs to use when assessing A&C needs, formulating strategy and prioritizing A&C activities.

Monitoring salt Iodization in Indonesia: the Need to Account for Iodine from Household and Food Industry Salt.

Objectives: Universal iodization of all edible salt (USI), including household and food industry salt, is the most cost-effective intervention to improve dietary iodine intake. The main metric to track USI programs is the proportion of households consuming adequately iodized salt. However, this does not capture salt consumed from processed foods, such as instant noodles, which are widely consumed in Indonesia. Analyze the association between iodine in household salt, consumption of instant noodles and iodine status, while accounting for the level of iodine in local water, as a possible confounder. Methods: We are currently undertaking analysis of data from the 2013 Indonesia National Health Survey (Riskedas) which included estimates of iodine in household salt, frequency of instant noodle consumption, iodine in local water sources and iodine status. Results: We will have results ready for presentation at the MN Forum. It is expected that estimates of iodine in household salt and the consumption of instant noodles will predict iodine status better than from household salt alone, and suggest that iodized salt is used in most instant noodle production. Conclusions: It was feasible to collect data on the consumption of instant noodles as part of a large nationally representative survey in Indonesia, which enables the analysis of presumed iodine intake from multiple sources. Information from this survey can be used to optimize the salt iodization level in Indonesia and provide important lessons on tools, methods and interpretation that can lead to improved salt iodization program guidance.

Role of National Legislation in the Interpretation and Practice of Salt Iodization Standards.

Objectives: The ICCIDD/GN Iodine Task Force was established in response to changing environment and program maturity of salt iodization programs worldwide. It aims to improve the evidence and thus the quality and effectiveness of iodine nutrition programs to help update program guidelines. To assess the role of national legislation in the interpretation and practice of salt iodization standards to achieve optimal iodine intake. Methods: A review of scientific literature, reports and data, including the development of a database to review current legislation and policies regarding universal salt iodization (USI) in national programs for eliminating iodine deficiency disorders, was conducted and analyzed to provide information on the interpretation of iodization standards. Results: Review of legislation governing iodization indicates variation in the interpretation of normative guidance (20-40 ppm) on standards. True USI (iodize all salt for human and animal consumption) is not always mandated or implemented. There are examples of changes in legislation in response to dynamic national contexts such as consumption of processed foods. Varied standards and legislation between countries complicate regional approaches to standards setting and can create trade barriers. When iodization is voluntary, information gaps often exist regarding application of the standard and the extent to which iodized salt is used in processed foods. Conclusions: Adherence to normative guidance for iodization standards is not a prerequisite for achieving optimal iodine intake. Legislation governing iodization should preferably be mandatory and support the use of iodized salt for ALL human consumption, to facilitate an evidence based approach to setting standard in a dynamic context.

Complementary Interventions for Preventing and Controlling Iodine Deficiencies in Pregnant Women, Infants, and Young Children.

Objectives: Inadequate dietary iodine is the main cause of preventable brain damage, posing a serious threat to intellectual development and productivity throughout the world. Salt iodization is the primary strategy for preventing and eliminating iodine deficiencies, and 76% of households worldwide have access to adequately iodized salt. In several settings, new interventions provide iodine containing products for vulnerable groups - pregnant and lactating women, infants (0-5 months), and young children (6-23 months). However, the extent to which these ‘complementary interventions' meet the iodine requirements of these groups has not been investigated. We therefore examined these interventions to understand whether they meet vulnerable groups' needs. We also estimated the number of recipients reached. Methods: We reviewed literature, household surveys, and guidelines to assess whether salt iodization can meet vulnerable groups' iodine requirements. Then, complementary interventions used in public health contexts were mapped, their iodine contribution estimated, and the number of recipients reached calculated. Results: Our analysis suggests that salt iodization may meet the requirements of pregnant and lactating women, but possibly not all infants and young children. There is great variability in objectives, delivery methods, and iodine contribution of complementary interventions. The coverage of various complementary interventions ranges from 0 to 13% of the vulnerable population groups. Conclusions: There is a need for careful coordination to ensure appropriate amounts of iodine are delivered to recipients. Failing to do so can result in the delivery of too little or too much iodine, which can have negative health consequences.

Refinements to Assessment of Iodine Nutrition.

Objectives: The main target groups of iodine programs are pregnant women (PW) and nonpregnant women of reproductive age (NPW), yet surveys frequently focus on school age children (SAC). It is unclear whether median urinary iodine concentration (mUIC) in SAC can be used as a surrogate for PW and NPW. It is also unclear what range of iodine intake is adequate in SAC. The objectives of this research were to: 1) Compare mUIC values in SAC with those in PW and NPW; and 2) determine if the current mUIC range for SAC is appropriate by assessing thyroglobulin (Tg), a functional biomarker of iodine status. Methods: 1) The Iodine Task Force (ITF) reviewed surveys where mUIC in SAC, PW, and NPW were available and compared iodine status across groups; and 2) for determining the adequate range of mUIC in SAC, the ITF analyzed and interpreted a multicenter study. Results: 1) When SAC had adequate or above adequate iodine status, PW were inadequate in 47% of the surveys. 2) In SAC, the two current WHO/UNICEF/ICCIDD mUIC categories for classification of iodine nutrition as "adequate" and "above adequate" could be combined into a single "adequate" range based on Tg results showing no negative effect on the thyroid at the current "above adequate" range. Conclusions: A number of refinements to the current global recommendations in assessing iodine status were identified, including the importance of including PW and/or NPW in population-based assessments, and reconsideration of current mUIC criteria for the classification of optimal iodine nutrition in SAC.

Monitoring of Flour Fortification Programs: Case Studies in Three Countries.

Objectives: Although monitoring should be an integral part of any fortification program, little is publicly known about the design, implementation, and results of flour fortification monitoring systems. The objectives are to assess the monitoring systems in three countries including the strengths and weaknesses of each system, how weaknesses are addressed, and lessons learned. Methods: South Africa, Indonesia, and Chile were selected using predetermined criteria (e.g., mandatory fortification legislation, represent different world regions, importation of flour, and existence of a functioning flour fortification monitoring system). Eight categories of regulatory and household/individual monitoring were assessed. Results: The monitoring systems for each country had different strengths and weaknesses. Overall, strengths included having a structured plan for at least some aspects of monitoring, an adequate number of trained inspectors, and the ability to modify regulations and protocols. Monitoring weaknesses included an insufficient multiple agency approach with poor communications within and between organizations, absent commercial monitoring, and lack of laboratory resources and funds. None of the countries had a cohesive monitoring program with regular collection of regulatory and household/individual monitoring information. Conclusions: A functioning flour fortification program depends on having an effective monitoring system in place. Critical to a successful monitoring system was the planning, budget, human resources, and political will necessary to implement monitoring and review monitoring data on a regular basis.

The Micronutrient Survey Manual: A Manual for Assessing Vitamin and Mineral Nutritional Status and Interventions Using Cross-sectional Surveys.

Objectives: An important component of public health nutrition programs is the periodic assessment of vitamin and mineral nutritional status and coverage of micronutrient interventions. Performing high quality cross-sectional surveys can be enhanced by the availability of guidance on steps in survey methods, sample size, sampling methods, data collection, analysis and interpretation, dissemination of results, and appropriate feedback to improve intervention programs. A manual to assist implementers is described. Methods: A previously published manual, "Indicators and Methods for Cross-Sectional Surveys of Vitamin and Mineral Status of Populations", by the Centers for Disease Control and Prevention (CDC) and the Micronutrient Initiative (MI) served as the basis for this newer manual. New technical partners, WHO and UNICEF, have collaborated in the development of this up-to-date "Micronutrient Survey Manual". Results: In addition to updated resources for the assessment of anemia and iodine, iron, and vitamin A deficiencies, the manual has added information on folate and zinc deficiencies. Program indicators for assessing fortification of staple foods, point-of-use fortification with micronutrient powders, micronutrient supplementation, and dietary counselling are included. The manual contains detailed information on biologic sample collection and processing, sample size calculations, and analysis of survey data. Quality assurance throughout the survey process is emphasized. The issues of ethics, confidentiality, and informed consent are addressed. Conclusions: The "Micronutrient Survey Manual" can assist survey managers to improve the validity, efficiency, and standardization of cross-sectional surveys to better serve public health practice.

The Home Fortification Community of Practice: An Approach to Improve Inter-country Communication and Collaboration to Support the Implementation and Scaling-up of Home Fortification Programs.

Objectives: Home fortification is an innovative way to improve the diet with essential nutrients for targeted vulnerable groups who have higher requirements or do not benefit from other micronutrient interventions. As a relatively new program, there is a tremendous need for technical support. The idea of a community of practice was developed to facilitate inter-country and inter-agency dialogue and learning, with the following objectives: 1. To provide an opportunity and space to exchange information and experiences between program. Implementers. 2. To enhance learning, generate new knowledge and document lessons learned and best practices; and 3. To facilitate coordination, harmonization and support for the scale up of home fortification. Methods: Online survey and informal interviews were conducted to incorporate target users’ opinions on the online community’s organizational, technical and operational features, and the desired benefits and potential barriers to participation. Lessons from existing successful online communities were used to inform stakeholders’ engagement and increase their awareness and involvement. Results: The Home Fortification Network (network.hftag.org) was branded and created as an online discussion forum with organized topics and with document-sharing capabilities. A moderator helps to connect users and facilitate discussion. Different stakeholders around the world are engaged and promote its global awareness and participation. Conclusions: The Home Fortification Network at network.hftag.org is an online community of practice created to facilitate and improve inter-country and inter-agency communication and collaboration to support the implementation and scaling-up of home fortification programs around the world.