Challenges and Enabling Environments of Universal Salt Iodization in Eastern and Southern Africa Countries.

Objectives: There has been reasonable progress in the universal salt iodization (USI) programmes in the Eastern and Southern Africa Region with 6 countries achieved USI and 11 have coverage between 50-89%. However regional coverage remains at 50% with 5.6 million infants born every year unprotected against iodine deficiency. The bottleneck and determinants of USI programmes remain unclear. This review aims to investigate challenges and enabling environments of USI programmes at different stages of country progress. Methods: A systematic review using data from Demographic Health Surveys and UNICEF's Household Iodized Salt database, and technical reports/studies from 21 countries in the region. Analyses were done through stratifying countries based on their progress within the last decades. Results: (i) Countries achieved USI generally have strong government and salt industry commitments, improved political and regulatory environment, effective monitoring, strategic advocacy and communications and strong public-private partnership, (ii) Countries on tract have reasonable government commitment, established systems for production/importation and monitoring but remain vulnerable to programmes sustainability, (iii). Countries with stagnated or declined coverage have initiated programmes but unable to increase coverage because of issues related to capacity of small producers, quality assurance/control and enforcement, (iv). Countries with low coverage are either in conflict/emergency or have poorly developed salt industries. Conclusions: Political and regulatory environment, monitoring systems, partnership, advocacy and communication are key enabling environments to attain USI. Issues related to quality assurance/control, capacity of small producers and enforcement remain as bottlenecks in some countries. These evidence-based findings are keys to enabling a sustainable approach to eliminating iodine deficiency.

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.