Journal of the Academy of Hospital Administration

p>Abstract: National Iodine Deficiency Disorders Control Programme (NIDDCP) was initiated in 1962 after the results of Kangra Valley Experiment proved that iodised salt can reduce the prevalence of iodine deficiency disorders under the programmatic conditions. The implementation of NIDDCP continued till 1983 but with limited success. During this period, attempts were made to provide iodised salt only to districts identified as endemic to iodine deficiency. In 1984, Government of India decided to adopt the programme of Universalt Salt Iodisation under which all salt for human consumption was to be fortified with iodine. The manufacturing of iodised salt was opened to the private manufacturers. Under GOI-UNICEF Plan, increased emphasis was laid down on improving the production of iodised salt in the salt producing states. Also, a number of advocacy measures were initiated to promote the consumption of iodised salt by the beneficiaries. Efforts were also made for banning the sale of non-iodised salt in different states. A multipromg strategy helped in improving the production and availability of iodised salt to the beneficiaries. Today, NIDDCP is one of the success story of a National Public Health Programme which has helped in prevention of Iodine Deficiency Disorders in the country. As of now, more than 70% of the population in the country is consuming iodised salt. The recent step of Governemnt of India for allowing the sale of Non iodised salt for human consumption would lead to serious setback to the universal salt iodisation programme and efforts towards elimination of IDD from the country.

Introduction

India is the second most populous country in the world, with a population of more than 1000 million Iodine Deficiency Disorders IDD constitute a major public health problem for the country. Iodine deficiency is the most common preventable cause of mental deficiency in the world today. In India, the surveys carried out by Central and State Health Directorates, Indian Council of Medical Research and various Medical Colleges have documented that not even a Single State or Union Territory is free from the problem of IDD. Out of 587 districts in the country, 282 districts have been surveyed for IDD and 241 districts have been found to be endemic (Table 1). These districts cover all the States and Union Territories in India.

Health consequeces of Iodine Deficiency:

Iodine is an essential nutrient. The normal human requirement is 150 micrograms per day. About 90 per cent of this normally come from food, and the rest from water. Foodcrops and water derive iodine from the soil. Consumption of crops and plants from iodine deficient soils leads to iodine deficiency in population solely dependent on these vegetations for their iodine requirements. If a pregnant woman is starved of iodine, the foetus cannot produce enough thyroxine, and hence foetal growth is retarded. Hypothyroid foetuses often perish in the womb, and many infants die within a week of birth. Hypothyroid children are intellectually subnormal with impaired school performance and lowered IQs and may also suffer physical impairment. They lack the aptitudes of normal children of similar age, and are often incapable of completing school.

Studies have documented that in areas with an incidence of mild to moderate IDD, IQ of school children are, on average, 10 points below those of children living in areas where there is no iodine deficiency.

National Iodine Deficiency Disorders Control Programme ( NIDDCP)

Following the successful trial of iodized salt in the Kangra valley, Himachal Pradesh, a National Goitre Control Programme (NGCP) was launched by the Government of India in 1962. The objectives of the programme were i) to survey the problem of iodine deficiency in the country, ii) produce and supply iodized salt and iii) to resurvey the area after five years to assess the impact of the iodized salt programme.

There has been a steady progress in the production of iodized salt over the past few years in India. In 1983, the country's production of iodised salt was only 3 Lakh tonnes. However, after adoption of Universal Salt Iodisation Policy in 1984, under which the production of iodised salt was opened to the private manufacturers, the quantity of iodised salt produced increased significantly. In the year 1999, 45 lakh tonnes of iodised salt was produced, against the total requirements of 52 lakh tonnes for the country. There are over 500 iodization plants installed for the commercial production of iodized salt with an annual installed capacity of nearly 6 million tonnes. The Salt Department, Ministry of Industry, is responsible for monitoring the production, distribution and quality control of iodized salt.

Initiative under NIDDCP after 1990

Under the GOI-UNICEF Project (1993-98), a total of 106 districts in 13 states were covered for the increasing the accessibility of iodized salt. This initiative made a significant positive impact on improving the acessibility of iodised salt in the country.

The status of Total Goiter Rate (TGR) in baseline surveys conducted under NIDDCP to assess the magnitude of IDD has been depicted in Table-II. The re-surveys have also been conducted under NIDDCP. The prevalence of goiter after supply of iodized salt in selected districts of the states to assess the impact of iodized salt in reducing the incidence of goitre. The resurvey results are presented in Table-II.

Status of IDD and Iodine Nutriture in Post-Iodisation Phase:

Pilot surveys have been conducted during 1996-99 by Human Nutrition Unit, AIIMS, New Delhi, to assess the IDD status in the population, in 28 districts of 7 States and 1 Union Territory of the country, namely i) Andaman and Nicobar, ii) Bihar, iii) Delhi, iv) Himachal Pradesh, v) Kerela, vi) Rajasthan, and vii) Uttar Pradesh, and viii) Tripura. The children in the 6-12 years age group were studied as they are representative of community's iodine nutriture.

In the each selected district, one rural block, at least 30 Km away from the district headquarters, was identified. In the block, all the primary schools were enlisted. Three to four primary schools were selected randomly and more than 600 children were clinically examined. Similarly, from more than 150 children "on the spot" casual urine samples were collected in all the districts (except Hamirpur, Solan, Kangra, Meerut and Delhi from where a larger sample children were included by utilising the 30 cluster methodology). The urine samples were analysed using the standard laboratory procedures.

a) Assessment of Goitre:

Children were clinically examined for goitre by the palpation method. Goitre size was graded according to the criteria recommended by the WHO.

b) Iodine Content of Salt Samples:

In each district more than two hundred salt samples were collected through school approach. The iodine content was analysed using the standard iodometric titration method.

c) Urinary Iodine Excretion:

Urine samples were randomly collected from more than 10 per cent of the subjects examined for goiter. Plastic bottles with screw caps were used to collect the urine samples. The samples were stored in the refrigerator until analysis. The urinary iodine excretion levels were analysed using the standard laboratory method.

Results of Pilot Surveys Conducted

1. Status of IDD

Table III depicts the status of iodine deficiency in the selected states. The goitre prevalence was found to be as high as 20.5 per cent in district Bikaner, Rajasthan to as low as 0.8 per cent in Pauri, Uttar Pradesh. Less than 10 mcg/dl of median urinary iodine excretion (UIE) was used as a criterion for assessing iodine deficiency in a population. No state included in the study was found to be deficient in iodine. It was found that 68 to 100 percent population in the study area was consuming iodised salt.

The study results revealed that the prevalence of goitre was more than 5% in all the districts except three districts of Uttar Pradesh (Pauri, Pithoragarh and Uttarkashi) and Pondicherry indicating the presence of iodine deficiency. However, the median urinary excretion levels were 15.5 mcg/dl (Rajasthan), 17 mcg/dl (Delhi), 10 mcg/dl (Bihar), 13.5-19.5 mcg/dl (Himachal Pradesh), 20 mcg/dl (Andaman and Nicobar) and 14.5 mcg/dl (Pondicherry), indicating an iodine sufficient nutriture in the areas. The low prevalence of goitre had an inverse association with consumption of iodised salt. Also, a positive association was found between consumption of iodised salt and high level of median urinary iodine excretion levels.

The findings of the these pilot studies revealed the success of salt iodisation programme. It also indicated that the population was in transition phase from iodine deficient to iodine sufficient as indicated by goitre prevalence of more than 5% and UIE levels, respectively. One of the possible reasons of TGR of more than 5% inspite of the availability of iodised salt could be over diagnosis of grade I goiter by the investigators. This is known to occur commonly during the palpation method.

2. Status of Iodine Content of Salt at Beneficiary Level

Table IV presents the iodine content of salt at the beneficiary level. A total of 17,654 samples were collected from the 7 States and Union Territores (Annexure-I). It was observed that more than 90 per cent of the salt samples were iodised with the exception of Goa and Rajasthan. The salt samples which had a nil iodine content in the states/UTs studied ranged from 0 to 6 per cent with the exception of Rajasthan (31.9 per cent) and Goa (48.9 per cent). In the states of Bihar, Punjab, Himachal Pradesh, and UT of Andaman and Nicobar, more than 80 per cent of the salt samples had an iodine content of 15 ppm and more.

3. Status of Iodine Content of Salt at Traders Level

The profile of iodine content of salt at traders level in 7 States and Union Territories (Table V). A total of 525 salt samples were collected at the traders level. It was found that 99 per cent of the salt samples were iodised. It was observed that in all the states more than 70% of the salt samples had an iodine content of 15 ppm and more, with the exception of UT of Pondicherry.

4. Status of Urinary Iodine Excretion

The urinary iodine excretion (UIE) levels provides the true picture of current iodine nutriture in a population. A total of 9,286 urine samples were collected from 28 districts. The UIE levels in different districts is depicted in Table-VI. It was found that the median UIE level was more than 10 or more mcg/dl in all the districts except for District Lakhimpur, Uttar Pradesh. These findings revealed that the UIE level in were in the acceptable range (between 10 to 20mcg/dl). Also, the current salt iodisation level recommended in the country is appropriate to maintain the iodine nutriture of the population (15 ppm of iodine at the household level).

The findings of the pilot studies on IDD documented success of NIDDCP programme in the country during the last 15 years. Similar findings have been reported from other countries which have successfully implemented the Universal Salt Iodisation Programme.

Possible Impact of Lifting Ban on Sale of Non-Iodized Salt

The recent notification of the Government of India proposing wihdrawal of restriction on the sale of uniodised common salt has deeply disappointed and shocked all scientists interested in the health and well being of our people. This notification would finally harm the poor and undo the good results which India has so far achieved in the control of iodine deficiency which impairs mental development of several thousands of children in our country.

In November 1997, the government ordered that "common salt meant for direct human consumption should be iodised" and thus restricted the sale of uniodised salt. Before issuing the order, the government had invited "objections and suggestions from all persons that are likely to be affected", and had allowed 10 months for receipt of such suggestions. The order was finally discussed after due consideration of all the suggestions received. Epidemiological studies have already shown that the programme has been a success. Neonatal iodine deficiency, which was once widespread in some parts of the country and which was responsible for impaired mental development in many of our children, has now been controlled. With the modern agricultural technologies, soils are getting depleted of iodine and foods grown on these soils are low in their iodine content. As a result, the IDD problem, which was earlier confined to the foothills of Himalayas, has now extended to the plains. Moreover, we have growing evidence that goitrogens present in certain foods and the environment are aggravating the problem of iodine deficiency and increasing the iodine requirements.

Even those areas which are now relatively free of this problem can become endemic because of intensive agricultural technologies and soil depletion. Considering that we have to intensify our agricultural operations in order to increase the yield of food per unit of land to meet the growing needs of our population, the problem will be further aggravated if adequate steps are not taken. We are now entering the age of 'Knowledge Societies' and it is important that we enable our children to give full expression to their innate genetic potential for mental development.

Salt iodation is a perfectly harmless procedure that has been used, and is being used, with remarkable success around the world. In fact, countries such as Switzerland have wiped out the goitre problem with this approach. By lifting the restriction, manufacturers of poor quality salt who were till recently obliged to iodise the salt and sell it at Rs. 2.00/kg will now not iodised the salt and will sell it at the same price. On the other hand, in the well-to-do sections of the population, people will continue to consume iodised salt. Thus, the removal of the restriction will harm the poor rather than the rich. Since mental impairment does not cause dramatic symptoms, the poor may not be aware of the disability that they are suffering from, as a result of our failure to take simple and preventive action. The poor, unlike the rich, just do not know that lack of adequate iodine in their diet could permanently damage the mental development of their children. The recent National Family Health Survey II also found that the higher percentage of poor people consumed salt with nil iodine as compared to rich people( table VII)

Table I: Prevalence of Iodine Deficiency Disorders and Status of National Iodine Deficiency Disorders Programme in Different States/UTs of India

State	Total No of , Districts	No of District Surveyed	No of Distt. Endemic	Ban Notification issued	IDD Cell
Andhra Pradesh	23	10	910	Partial	Yes
Arunachal Pradesh	10	10	18	Complete	Yes
Assam	23	18	21	Complete	Yes
Bihar	55	22	2	Complete	Yes
Goa	2	2	8	Complete	Yes
Gujarat	25	16	8	Complete	Yes
Haryana	19	9	10	Complete	No
Himachal Pradesh	12	10	11	Complete	No
Jammu and Kashmir	15	14	6	Complete	Yes
Karnataka	27	17	11	No Ban	Yes
Kerala	20	14	16	Complete	Yes
Madhya Pradesh	61	16	21	Partial	Yes
Maharashtra	35	29	4	Complete	Yes
Mizoram	8	4	8	Complete	Yes
Manipur	9	8	2	Complete	Yes
Meghalaya	7	2	7	Complete	Yes
Nagaland	8	7	4	Complete	Yes
Orissa	30	4	3	Complete	Yes
Punjab	17	3	3	Complete	Yes
Rajasthan	31	3	4	Complete	Yes
Sikkim	4	4	12	Complete	Yes
Tamil Nadu	29	12	4	Complete	Yes
Tripura	4	3	12	Complete	Yes
Uttar Pradesh	83	34	29	Complete	Yes
West Bengal	18	5	5	Complete	Yes
Andaman and Nicobar Islands	2	2	2	Complete	Yes
Chandigarh	1	1	1	Complete	Yes
Dadar and Nagar Haveli	1	1	1	Complete	Yes
Delhi	1	-	1	Complete	Yes
Daman and Diu	1	1	1	Complete	Yes
Lakshwadeep	1	-	-	Complete	No
Pondicherry	4	-	-	Complete	No
Total No of Districts	587	262	241	Complete

 

Table II: Resurvey Results of Total Goiter Rate (TGR) after Supply of Iodized Salt

States Districts	Baseline Survey (Year)	Prevalence Rate (%)	Commencement of Iodized Salt (Year)	Re-Survey Year	Time Interval Between	Prevalence Rate (%) (5 and 6 year)
Bihar
E. Champaran	1960	40.3	1964	1979	19	64.5
W. Champaran	1960	40.3	1964	1979	19	51.2
HP
Kangra	1956	41.2	1957	1962	5	32.1
Mandi	1959	39.9	1963	1981	18	34.5
Sirmaur	1959	35.8	1963	1980	17	28.1
Gurdaspur	1961	40.3	1964	1969	5	23.6
Hoshiarpur	1961	40.3	1964	1969	5	23.6
UP
Garhwal	1930	40.0	1966	1974	8	25.4
Pithoragarh	1930	40.0	1966	1974	8	25.4
Tehri Garhwal	1954	35.0	1966	1974	8	25.4
Uttar Kashi	1930	40.0	1966	1974	8	25.4
West Bengal
Darjeeling	1963	34.5	1967	1976		35.6

 

Table III: Status of Iodine Deficiency In Selected States, India

State	Name of the district	Prevalence of goiter selected	Age group (years) %	Year of Survey (mcg/dl)	Median UIE	Percentage of population Consuming iodized salt
Andaman and Nicobar	Andman n=622	9.5	6-12	1997	20.0	99.5
Bihar	East Champaran and West Champaran n=1328	11.6	6-12	1997	10.0	100.0
Delhi	Entire state n=7475	8.6	8-10	1996	17.0	98.6
Kerala	Ernakulam n=1254	1.0	6-12	1998	20.0	97.4
Himachal Pradesh	Kangra n=1358	5.7	8-10	1996	16.5	97.9
	Hamirpur n=1413	8.8	8-10	1996	13.5	97.5
	Kinnaur n=1094	6.1	6-10	1996	19.5	99.5
	Solan n=6724	11.4	8-10	1997	15.0	98.1
Pondicherry	Entire UT n=2065	2.6	6-11	1997	14.5	100.0
Rajasthan	Bikaner n=623	20.5	6-12	1996	15.5	68.1
Uttar Pradesh	Uttarkashi n=216	2.8	6-12	1998	20.0	98.4
	Pauri n=604	0.8	6-12	1998	17.5	97.3
	Pithoragarh n=740	1.5	6-12	1998	20.0	98.9

 

UIE : Uninary Iodine Excretion

Table IV: Status of Iodine Content of Salt at Beneficiary Level

State	No. of districts selected	Sample size	Year of Data Collection	Iodine Nil	Content <15	(ppm) 15 and more
Bihar	5	1052	1996	0	300(28.5)	752(71.5)
MP	9	1992	1996	25(1.3)	676(33.9)	1291(63.8)
Haryana	13	3000	1996	176(5.8)	1224(40.8)	1600(53.4)
Punjab	17	3869	1997	100(2.6)	1009(26.1)	2760(71.8)
HP	5	4816	1996	105(2.1)	831(17.3)	3880(80.6)
Delhi Entire	UT	1854	1996	26(1.4)	759(40.9)	1069(57.7)
Andaman and Nicobar	1	211	1997	1(0.5)	26(12.3)	184(87.2)
Pondicherry Entire	UT	201	1997	0	138(69.0)	63(31.0)
Rajasthan	1	526	1995	168(31.9)	42(8.0)	316(60.1)
Goa 1	1	133	1996	65(48.9)	39(29.1)	29(22.0)
Total >	54	17654		666	5044	11944

Figures in parentheses indicate percentages

Table V: Status of Iodine Content of Salt at Traders Level

State	No. of districts selected	Sample size	Iodine Nil	Content <15	(ppm) 15 and more
Bihar	5	71	0	14(19.7)	57(80.3)
MP	9	108	0	19(17.6)	89(82.4)
Haryana	13	117	1(0.8)	23(19.7)	93(79.6)
Punjab	17	177	1(0.6)	50(28.2)	126(71.2)
HP	1	10	0	0	10(100)
Andaman and Nicobar	1	13	0	1(7.7)	12(92.3)
Pondicherry	Entire UT	29	0	21(72.4)	8(27.6)
Total	47	525	2	128	395
Figures in parentheses indicate percentages

 

Table VI: Status of Iodine Nutriture amongst children in 6-12 yrs in selected districts of India

Sl. No.	Name of the	Year of Survey	Age group	UIE levels (mcg/dl)				Median
	district	Survey	(years)	<2	2-<5	5-<10	10 and more	(mcg/dl)
1.	Andaman (n=154)	1997	6-12	0(0.0)	5(3.3)	9(5.8)	140(90.9)	20.0
2.	East Champaran (n=138)	1997	6-12	12(8.7)	36(26.1)	70 (50.7)	20(14.5)	10.0
3.	West Champaran (n=123)	1997	6-12	20(16.3)	15(12.2)	25(20.3)	63(51.2)	10.0
4.	Ernakulum (n=220)	1998	6-12	2(0.9)	3(1.4)	18(8.2)	197(89.5)	20.0
5.	Kottayam (n=251)	1999	6-12	16(6.4)	15(6.0)	52(20.7)	168(66.9)	17.5
6.	Kangra (n=245)	1996	8-10	6(2.4	10(4.1)	42(17.1)	187(76.3)	16.5
7. )	Hamirpur (n=787	1996	8-10	69(8.8)	65(8.3)	137(17.4)	516(65.6)	13.5
8.	Kinnaur (n=226)	1996	6-10	3(1.3)	13(5.8)	24(10.6)	186(82.3)	19.5
9.	Solan (n=720)	1997	8-10	21(21.9)	42(5.8)	142(19.7)	515(71.5)	15.0
10.	Bikaner (n=400)	1996	6-12	12(3.0)	36(9.0)	73(18.0)	279(70.0)	15.5
11.	Uttarkashi (n=61)	1998	6-12	6(9.8)	2(3.2)	7(11.4)	135(87.6)	20.0
12.	Pauri (n=100)	1998	6-12	2(2.0)	2(2.0)	13(13.0)	83(83.0)	17.5
13.	Pithorgarh (n=154)	1998	6-12	(0.0)	2(1.2)	17(11.4)	135(87.6)	20.0
14.	Meerut (n=170)	1998	6-10	38(5.4)	21(2.9)	142(20.2)	509(71.7)	15.0
15.	Agra (n=92)	1998	6-11	0(0.0)	0(0.0)	10(10.8)	82(89.1)	17.5
16.	Bareily (n=82)	1998	6-11	11(13.4)	18(21.9)	10(12.3)	43(52.4)	10.2
17.	Gorakhpur (n=147)	1998	6-11	7(4.8)	3(2.0)	17(11.6)	120(81.6)	15.0
18.	Kanpur (n=72)	1998	6-11	1(1.4)	2(2.8)	25(34.7)	44(61.1)	10.5
19.	Lakhimpur (n=128)	1998	6-11	18(14.1)	18(14.1)	39(30.4)	53(41.4)	5.0
20.	Lalitpur (n=109)	1998	6-11	0(0.0)	10(9.3)	28(25.7)	61(55.9)	13.5
21.	Padrona (n=80)	1998	6-11	0(0.0)	0(0.0)	6(6.2)	75(93.8)	20.0
22.	Saharanpur (n=192)	1998	6-11	1(0.4)	5(2.6)	12(6.2)	174(90.6)	20.0
23.	Sidharth Nagar (n=148)	1998	6-11	15(10.1)	13(8.8)	37(25.0)	83(56.1)	10.0
24.	Sultanpur (n=103)	1998	6-11	1(1.0)	13(12.6)	37(25.0)	83(56.1)	10.0
25.	Varanasi (n=107)	1998	6-11	18(16.8)	0(0.0)	30(28.0)	59(55.1)	10.0
26.	Delhi (n=1652)	1996	8 - 10	35(2.1)	138(8.4)	291(17.6)	1188(71.9)	17.0
27.	Agartala (n=133)	1999	8-10	0(0.0)	19(14.3)	27(20.3)	87(65.4)	17.5
28.	Kangra (n=1952)	1999	6-11	69(3.5)	74(3.8)	238(14.2)	1531(78.5)	15.0
* UIE : Urinary Iodine Excretion, **Figures in parentheses indicate percentages

Table VII: Iodine Content of Salt as per the Socio-Economic Groups (NFHS -2 Survey Results 1999)

Background characteristic	Not iodized	7 ppm	15 ppm	30 ppm	Missing	Total %	Number of households
Standard of living index
Low	36.0	28.1	18.6	16.5	0.8	100.0	33,064
Medium	28.6	21.5	17.5	31.7	0.6	100.0	40,434
High	12.8	9.2	11.6	66.0	0.4	100.0	16,640

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