Iodized Salt Coverage Study 2010: Household Consumption and Consumer Behavior about Iodized Salt in Rural Areas of Select States of India.

Objectives: This study assessed the household coverage with iodized salt and consumer behavior with regards to edible salt in rural areas of eight selected states of India. Methods: The study was conducted by ICCIDD in association with MI and the Salt Commissioner’s Office in 2010. Iodine content of household edible salt was measured and consumer behavior in terms of knowledge and perceptions regarding iodized salt and edible salt buying behavior was assessed in 9600 rural household in selected states. Results: 47.2% of the households were consuming adequately iodized salt; 47%, 35%, 45%, 59%, 50%, 42%, 35%, and 64% respectively in states of Andhra Pradesh, Karnataka, Madhya Pradesh, Orissa, Rajasthan, Tamil Nadu, Uttar Pradesh and Uttarakhand. 58% of the respondents were aware about the iodized salt but only 13% of the respondents perceived ‘iodized salt’ to be an attribute of good quality salt. 54% of the households were using packaged crushed salt. Households with higher wealth index, awareness about iodized salt, using packaged crushed salt, and purchasing edible salt from general stores or Public Distribution System (PDS) were more likely to use adequately iodized salt. Conclusions: Despite an improvement of twenty percentage points from a previous survey in 2005-06, the coverage with adequately iodized salt in these states remains below the national average for rural areas. Increasing awareness and demand generation at the household level and introduction of good quality iodized salt in the Public Distribution System at affordable cost will help in improving the household coverage with adequately iodized salt in these states.

Academic Institutions Role in Ensuring Sustainability of IDD Control Program: A Case Study from India.

Objectives: This paper discusses the role of academic institutions in ensuring sustainability of Iodine Deficiency Disorders (IDD) control Programme. Methods: A case study of six decade long (1956-2013) contribution of All India Institute of Medical Sciences (AIIMS), New Delhi in IDD Control Programme in India is presented. Results: AIIMS, New Delhi, in association with other partners, launched seminal Kangra Valley Study in 1956 to assess the impact of iodized salt on IDD. Success of the study led to initiation of National Goitre Control Programme in 1962. Researchers from AIIMS provided evidence for extra- Himalayan existence of IDD, and impact of iodine on cognition leading to introduction of universal salt iodization in 1986 and subsequent renaming of programme as National Iodine Deficiency Disorders Control Programme (NIDDCP). In the year 2000,when ban on sale of non-iodized salt was lifted research and policy advocacy was carried out to to achieve re-imposition of ban on non-iodized salt. AIIMS took lead in bringing all agencies working on IDD on the same platform through formation of National Coalition in 2006, the Secretariat of which is located at AIIMS. AIIMS continues to influence policy through representation in expert committees and other government forum. Currently tenth generation of IDD researchers is active in research and policy advocacy on IDD in the country. Conclusions: The reason for success of academic institution in ensuring sustainability is continuity in efforts, presence of champion, a multi-disciplinary team, , mentorship, credibility, evidence based policy and programme research and a facilitating role in coalition building to achieve coordination.

Iodine deficiency disorders (IDD) control in India.

Iodine deficiency disorders (IDD) constitute the single largest cause of preventable brain damage worldwide. Majority of consequences of IDD are invisible and irreversible but at the same time these are preventable. In India, the entire population is prone to IDD due to deficiency of iodine in the soil of the subcontinent and consequently the food derived from it. To combat the risk of IDD, salt is fortified with iodine. However, an estimated 350 million people do not consume adequately iodized salt and, therefore, are at risk for IDD. Of the 325 districts surveyed in India so far, 263 are IDD-endemic. The current household level iodized salt coverage in India is 91 per cent with 71 per cent households consuming adequately iodized salt. The IDD control goal in India was to reduce the prevalence of IDD below 10 per cent in the entire country by 2012. What is required is a “mission approach” with greater coordination amongst all stakeholders of IDD control efforts in India. Mainstreaming of IDD control in policy making, devising State specific action plans to control IDD, strict implementation of Food Safety and Standards (FSS) Act, 2006, addressing inequities in iodized salt coverage (rural-urban, socio-economic), providing iodized salt in Public Distribution System, strengthening monitoring and evaluation of IDD programme and ensuring sustainability of IDD control activities are essential to achieve sustainable elimination of IDD in India.

A review of tracking progress towards elimination of Iodine deficiency disorders in Tamil Nadu, India.

Background : Iodine deficiency disorders (IDD) are significant health problem in India. But there is dearth of regional/state level information for the same. Objective: This study was designed to study the current status of IDD in Tamil Nadu. Materials and Methods: A cross-sectional community-based survey was conducted in the state of Tamil Nadu. The study population was children in the age group of 6-12 years and the probability proportional to size 30 cluster methodology was used for sample selection. The parameters studied were prevalence of goiter, urinary iodine excretion, and iodine content in salt at the household level. Results: A total of 1230 children aged between 6 and 12 years were studied. The total goiter rate was 13.5% (95% CI: 11.1-14.9). The median urinary iodine excretion was found to be 89.5 μg/L (range, 10.2-378 μg/L). The 56% of the urinary iodine excretion values were <100 μg/L. The proportion of households consuming adequately iodized salt (iodine content ≥ 15 parts per million) was 18.2% (95% CI: 16.1-20.5). Conclusion: The total goiter rate of 13.5% and median urinary iodine excretion of 89.5 μg/L is indicative of iodine deficiency in Tamil Nadu.

Tracking progress towards sustainable elimination of iodine deficiency disorders in Bihar.

OBJECTIVES: To assess the status of the iodine deficiency in the population of Bihar and track progress of the elimination efforts. METHODS: A community based field survey was conducted. Using quantitative and qualitative research methods, data was collected by following internationally recommended protocol and methodology. Thirty clusters were selected using population proportionate to size technique. School age children (6 to 12 years) were the target group studied. Urinary iodine in target children and iodine content of salt at households were the indicators used. RESULTS: Total of 1169 children were studied. The median urinary iodine concentration was found to be 85.6 microg/L. Urinary iodine concentration was less than 50 microg/L in 31.5% of the subjects. Only 40.1% of the household salt samples were found to be adequately iodised as determined by titration method (> or =15 ppm iodine). CONCLUSIONS: Study results show existence of iodine deficiency in the state. There is need to accelerate our efforts to achieve iodine sufficiency and this should be done on a war-footing.

Estimation of iodine in salt fortified with iodine & iron.

BACKGROUND & OBJECTIVE: The National Institute of Nutrition (NIN), Hyderabad has developed double fortified salt (DFS) containing both iodine and iron to control the twin problems of iodine deficiency disorders (IDD) and iron deficiency anaemia (IDA). When the iodine content of DFS was estimated by the conventional iodometric titration using sulphuric acid (H(2)SO(4)), problems such as wide variation between duplicate analysis and under/overestimations of iodine content were encountered, which led to inconsistent results. This study was undertaken to develop a modified method for the estimation of iodine in DFS so as to get reliable iodine content of DFS. METHODS: A modified method was developed using orthophosphoric acid (H(3)PO(4)) and the sensitivity of the method was confirmed by estimating the iodine content of potassium iodate (KIO(3)) standard at different concentrations of iodine (0 to 100 ppm). The iodine content of DFS and iodized salt (IS) from local market and factory was estimated by the modified method as well as the conventional iodometric titration and the results were compared. RESULTS: The pH of DFS was acidic. The time gap between the additions of acid and potassium iodide (KI) played a crucial role in getting the actual iodine content of DFS. The H(2)SO(4) and ferrous sulphate (FeSO(4)) interfered with the estimation of iodine in DFS resulting in underestimation or overestimation of iodine. Modified method (H(3)PO(4)) produced consistent and reliable iodine content of DFS. Both H(2)SO(4) and H(3)PO(4) gave same results when tested with KIO(3) standard, Reference salt and IS (both experimental and purchased from local market). Actually 0.50 ml of 1 per cent KI was sufficient to estimate the iodine content of DFS or IS. INTERPRETATION & CONCLUSION: The results of the present study showed that the conventional method using H(2)SO(4) was not suitable for the estimation of iodine in DFS. The modified method using H(2)PO(4) was ideally suited for the estimation of iodine in DFS. Also, iron from DFS did not interfere during estimation of iodine by this method. As both the conventional and the modified methods gave the same results for the iodine content of IS, it is practically prudent to use the modified method (H(2)PO(4)) for both DFS and IS instead of following one method (H(3)PO(4)) for DFS and another (H(2)SO(4)) for IS. The quantity of KI is also reduced and the order of additions of reagents is changed in the modified procedure.

Enterococcal infections with special reference to phenotypic characterization & drug resistance.

BACKGROUND & OBJECTIVES: Enterococci, classified as group D streptococci, are the second leading cause of nosocomial infections. The incidence of enterococcal infections and species prevalent in India is not thoroughly investigated. The present study was undertaken to isolate and characterize enterococci from clinical specimens and determine the antimicrobial susceptibility pattern of these isolates. METHODS: Clinical specimens (blood, urine and swabs) were cultured on bile esculin azide agar (BEAA) for isolation of enterococci. The phenotype based scheme included Gram staining of growth on BEAA and subculturing of cocci on sheep blood agar plates for vancomycin disk diffusion and hydrolysis of L-pyrrolidonyl-beta-napthylamide (PYR) testing. The phenotypic method was used to surveillance cultures that yielded growth on BEAA. Enterococcal strains were further identified to the species level by conventional biochemical tests. PYR positive isolates were further characterized into vancomycin resistant enterococci (VRE) and nonVRE depending upon vancomycin inhibition zone size. The isolates were characterized into vanA, vanB and vanC depending upon minimum inhibitory concentration (MIC) values. Conventional method was used to study the antibiogram of isolates. RESULTS: A total of 52 isolates of enterococci (10 Enterococcus faecalis, 42 E. faecium) were isolated from 534 clinical specimens. Of the 52 isolates, 12 isolates were resistant to vancomycin with an MIC > 4 microg/ml but sensitive to teicoplanin (vanB isolates). INTERPRETATION & CONCLUSION: Our study reveals the problem of multiple drug resistant enterococci and emergence of VRE. Better susceptibility tests need to be used to measure the vancomycin resistance accurately.

Evaluation & revaluation of upper limits of normal values of anti-streptolysin O & anti-deoxyribonuclease B in Mumbai.

BACKGROUND & OBJECTIVES: For the serodiagnosis of group A streptococcal (GAS) infections and their late sequelae, a battery of tests have been suggested. However, anti-streptolysin O (ASO) and antideoxyribonuclease B (ADNase B) are the most widely accepted tests for the same. It is essential to evaluate the upper limits of ASO and ADNase B levels in age and sex matched normal population before using them for the detection of patients. For this study, these values were determined in the past and were revaluated again in 2001-2002, in normal subjects. METHODS: A total of 200 healthy individuals were included in the study in 1991-1992 and same number of age and sex matched healthy individuals were included in 2001-2002. The methodology used for determination of ASO and ADNase B levels were as per the techniques recommended by the WHO. RESULTS: The findings show that the upper limits of normal ASO titers are 195 IU and 305 IU for adults and children respectively while the said levels for ADNase B for both adults and children were found to be 200 IU. INTERPRETATION & CONCLUSION: The findings of the present study will be helpful in the follow-up, better diagnosis and prognosis of group A streptococcal infections.

Radioiodine kinetics and thyroid function following the universal salt iodization policy.

BACKGROUND: Universal salt iodization was introduced in Delhi in 1989. The present study quantifies the change in iodine kinetics as a result of this. The previous values were reported 10-30 years earlier, when Delhi was iodine deficient. METHODS: Thirty subjects (18 men and 12 women, 17-48 years of age) who were residents of Delhi and had no thyroid disorder, were recruited from our outpatient clinic in 1999. The 24-hour urinary excretion of iodine and the iodine content of salt consumed at home by these subjects were estimated. Kinetic studies of iodine using radiotracer 131I were done to determine thyroid iodine clearance, renal iodine clearance, percentage uptake and absolute iodine uptake by the thyroid gland, and plasma inorganic iodine. RESULTS: The median 24-hour urinary iodine excretion was 341.3 micrograms. The mean (SD) thyroid uptake of radioactive iodine was 4.9 (2.3)% at 2 hours and 19.1 (8.0)% at 24 hours. The median calculated plasma inorganic iodine was 1.36 micrograms/dl, absolute iodine intake 6.5 micrograms/hour and thyroid iodine clearance was 4.8 ml/minute (geometric means 1.68 micrograms/dl, 8.5 micrograms/hour and 8.1 ml/minute, respectively). The serum thyroid hormones and thyroid stimulating hormone were within normal limits. CONCLUSION: Compared to the values reported 10-30 years ago when the population was iodine deficient, the present urinary iodine excretion, plasma inorganic iodine and absolute iodine intake have increased, while the percentage thyroid uptake of iodine ingested and thyroid clearance have decreased. The lack of change in the serum thyroid hormone levels after 10 years of universal salt iodization indicates that iodine consumption has had no adverse effect on thyroid function in these normal individuals. These changes are consistent with the increase in iodine consumption. Since the iodine ingestion in a community may change with time, assessment of iodine kinetics should be done periodically in different regions of the country.

Interpretation of indicators of iodine deficiency disorders: recent experiences.

Considerable progress has been made in the implementation of the universal salt iodization programmes in countries affected by iodine deficiency disorders (IDD). WHO/UNICEF/ICCIDD have jointly recommended outcome and process indicators to track the progress of IDD elimination programmes. Of the several indicators recommended in developing countries, goitre grading and urinary iodine are the most feasible to use as outcome indicators while iodine content of salt is the best as a process indicator. The WHO/UNICEF/ICCIDD recommendations provide separate cut-off points for these indicators to assess the severity of IDD. Recently, a nation-wide survey in Bhutan and another in New Delhi provided evidence that suggests that it is essential to view the results of all these indicators in totality rather than in isolation to make a proper assessment of the progress of the IDD elimination programmes. In view of these findings, we recommend (i) changing the goitre grading to only two grades from the current three, (ii) presenting urinary iodine values as median, cut-off points as well as the frequency distribution, and (iii) viewing the results of process and outcome indicators in totality to assess the severity of IDD.

Using government schools to monitor iodine content of salt at household level in Delhi.

The Government had banned the sale of un-iodized salt in Delhi in 1989 as a step towards elimination of iodine deficiency disorders. The present study was done to detect the presence of iodine in salt samples every month from households of the students of government middle schools in Delhi using spot testing kits. One section each, from the classes six to eight of the thirty selected middle schools was chosen randomly. The children were asked to bring salt from their homes on a prefixed day. The salt samples were examined for the presence of iodine by a spot testing kit. This was repeated every month during the study (August '94 to February '95) among the same students in each school. A total of 16,596 salt samples were collected. Of this 12,736 (76.7%) tested positive for iodine and the rest (23.3%) of the salt samples did not contain iodine. The proportion of children who brought the salt samples varied between 53% to 72% in different months. As the study progressed, the trend showed more samples being tested positive for iodine. The differences in districts were not significant. Un-iodized salt thus still continues to be available in the households of the government school children of the National Capital Territory of Delhi. The use of rapid testing kits in schools is a practical and feasible way to enhance the monitoring activities of the government.

Knowledge beliefs and practices regarding iodine deficiency disorders among the tribals in Car Nicobar.

It is estimated that 1,570 million people are at risk of iodine deficiency. Because of the wide spectrum of disorders that IDD includes, and lack of any obvious association between iodine deficiency and its health effects, IDD is not perceived as a major public health problem. For any disease to be effectively controlled, awareness at all levels from community to policy makers is necessary. This study was conducted to assess knowledge, beliefs and practices regarding iodine deficiency Disorders in Car Nicobar districts of Andaman and Nicobar Islands. The population is predominantly tribals involved in coconut plantations. All the village heads of the sixteen villages and parents of 10% of the school children examined for goiter were interviewed. Initial focus group discussions were conducted as no prior knowledge about local names for goitre or other related IDD information was available. The interview schedule was designed in English which was then translated into Hindi and Nicobarese and back translated into Hindi and English. A total of 114 persons were interviewed 60 males, 54 females. The local name for goiter was "Rulo" and 44% felt that it only affected females. No one had correct knowledge of the cause of goiter. About half of the respondents believed that these swellings caused problems. Sixty three (55.3%) of respondents believed that there was treatment, of which 33 said there was medical treatment, 18 respondents said traditional treatment by "LAM-EEN" and 12 felt that both therapies are required. Majority (85%) brought salt samples from the Government canteen. They did not now whether this salt was iodised. Salt was not washed before use and storage practice was satisfactory. The awareness about IDD needs reinforcement. At present the community is a passive participant in the I.D.D. Control Programme.