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News from the Secretary |
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News from the Secretary |
Message from the Secretary
April, 1st 1998
This is a report from our colleague E. A. Pretell, RC.
ICCIDD American Region - 1997 Annual ReportProgresses towards the goal of IDD control by the year 2000 in the American Region have continued without pause. The mid decade goal, USI, has been reached in almost all the countries, except Paraguay. We must admit, however, that figures on iodized salt production and consumption in some countries, particularly from Central America, need to be ascertain. Legislation to secure an adequate level of salt iodization has been updated in those countries where formerly the levels were low, such as Brazil and Mexico. So far, 4 out of the 16 countries with recognized IDD in the past have gone through the process of an external evaluation of their IDD control programs. ICCIDD has participated in the four evaluations. It is expected that during 1998 four or five additional countries will also be evaluated.
In general, PAHO's and UNICEF's support to the countries' programs, it is my impression, had slowed down. In any case, UNICEF's contribution has been and continuous to be more important.
Inter agencies collaborative work and support of other institutions
PAHO-UNICEF-ICCIDD Partnership. The support for a PAHO-UNICEF-ICCIDD partnership in the evaluation of programs has recently been reinforced. In response to a suggestion of the RC, Dr. Wilma Freire (PAHO) and Dr. Aaron Lechtig (UNICEF) accepted to meet in Bogotá, Colombia, early February. Important outcomes of our conversation are: 1) a preliminary working plan for 1998, that includes to approach a number of countries as candidates for partnership evaluation; 2) to proceed with the evaluation when feasible; 3) to edit guidelines for monitoring and declaration of elimination of IDD, based on documents produced by ICCIDD in collaboration with others, as well as on the experience gained with the evaluation of four countries within the Region.
LATS IDD Task Force. LATS, as an institution and through its membership, is giving support to IDD activities in the Region. Information on ICCIDD and on countries' situation is disseminated through its web site. At the last Executive Council Meeting (Viña del Mar, Chile, May 1997) it was approved the creation of an IDD Task Force, chaired by E A Pretell (Peru) and integrated by S Muzzo (Chile), G Sartório (Argentina), and O González (Mexico).
Panamerican Federation of Endocrine Societies. Under the request of the Executive Council, the RC wrote the first draft of the document entitled "Consensus on IDD in Latin America. Criteria for evaluation and monitoring towards its sustained eradication". The document was then sent to qualified leaders in the Region (including some members of ICCIDD) for their opinion and suggestions. Afterwards the document was discussed and approved at the Panamerican Congress of Endocrinology, held in Cancún, Mexico, Nov. 2-7, 1997.
The Consensus includes conclusions and recommendations. Among the conclusions it is stressed the presence of a high risk of IDD in extensive parts of the continent, the commitment assumed by all the countries to reach the goal of IDD eradication, and the approval by the Federation of the adoption of the criteria given by OMS, UNICEF, and ICCIDD. Among the recommendations, the following are of particular importance: 1) to negotiate in each country the incorporation and active participation of a member of the Federation in the local IDD control program; 2) to support negotiations towards a uniform legislation on the levels of salt iodization; 3) to look at the content of iodine in the different types of milk for children; 4) to favor the use of urinary iodine as the main indicator and to progressively implement the use of ultrasonography for the evaluation of goiter. The 12 pages Spanish document was circulated among some members of ICCIDD and will be published by the PFES.
Evaluation of countries' programs and consultancies
A total of 5 countries have been visited by the RC, in one accompanied by J Dunn. The evaluation of Colombia was jointly accomplished with PAHO and UNICEF.
Colombia
Convened by the Minister of Health, a team of three experts, W Freire, as representative PAHO/WHO, A Lechtig, as representative of UNICEF, and E A Pretell, as representative of ICCIDD, met in Bogotá to evaluate the Colombian IDD Control Program, from 3 to 6 last February.
In summary, it was found that according to the requirements settled by WHO, UNICEF, and ICCIDD, the country could be considered free of IDD as a public health problem. The production and quality control of iodized salt, as well as the urinary excretion of iodine, were within the limits accepted in the guidelines for evaluation of ICCIDD. The overall goiter prevalence in the country was 7.2%, although in some departments it was higher..
However, the evaluating team agreed to make the following observations, which do not warranty the sustainability of the control :
1. The activities of the control program are carried out by different units within the Ministry of Health, without an adequate integration among them.
2. The evaluation of urinary iodine and goiter prevalence was made through a cross-sectional study in 74 urban communities carried out in two stages with two years interval; 55 communities had been evaluated in 1994 and the remaining 19 in 1996.
3. It was observed a marked drop in the iodine content of the salt from the production site, where it was 50-100 ppm to the household site where 15% of samples in rural areas and 6% in urban areas the iodine content was less than 20 ppm. A fall of this magnitude could not be explained by the expected loss of 20%, but rather raises the question of adulteration by mixing non iodized salt during the process of repacking.
4. Awareness on the risk of IDD and the measures for its prevention is very poor. An ECI program has not been implemented and so, the population at risk and other actors involved in the prevention of IDD are not aware of the need for iodized salt consumption.
The experience in Colombia has been an opportunity to realize that the guidelines of ICCIDD for evaluation and declaration of elimination of IDD are in some cases imprecise.
Mexico
Mexico was visited by E A Pretell (RC) and J T Dunn (Secretary), November 8-14. The purpose of the visit was to make a rapid review of Mexico's IDD status and to observe SQM/AMICA water iodization unit in Guanajuato.
IDD Program
This visit was an initiative of ICCIDD, since little information on progresses after the consultancy of E A Pretell in 1993 was available. The UNICEF Office helped us to accomplish our visits with the health authorities.
With the help of Dr. Moreno and Dr. Gonzáles of UNICEF we visited the different units in charge of the program's activities, the General Direction of Sanitary Control of Services, the General Direction of Epidemiology and the National Institute of Diagnosis and Epidemiological References, to review current information on IDD status and salt iodization. Mexico had an effective program with iodization of salt in the 1950's and 1960's but later the problem was considered solved and received little subsequent concern and no monitoring. A recent survey showed several States with significant goiter prevalence and low urinary iodines in a number of areas. Review of salt samples show up to 20% have been below and up to 35% have been above the recommended levels (20-40 ppm). The consultants recommended a national coordinating group, a more complete picture of the salt trade, monitoring of iodine content at the plant level, further establishment of State and Regional laboratories, conducting impact assessment prin
cipally by urinary iodines, and an external evaluation in approximately a year. A preliminary report of our observations and suggestions was shared and discussed with the UNICEF representatives and also with Dr. J Gonzáles-Molina of PAHO.
A letter accompanied by our report was sent to Dr. Juan Ramón de la Fuente, Minister of Health.
Water iodization
We visited a pilot site at Guanajuato for water iodization using the SQM Iodopur system. With the local health authorities it was reviewed the plans for a larger scale program by the State of Guanajuato as part of a water purification plan. The opportunity exists for a prospective study of the effects of water iodization for the twin problems of water purification and correction of iodine deficiency. Follow-up with SQM and others is planned.
Chile
The RC visited Chile in May 19-20, to make a rapid review of the IDD Control Program and to observe the SQM Iodo water iodization experiment in a town near Santiago.
IDD Program
The main objective of the visit was to update the situation of the iodized salt, and to insist in our concern for the high levels of salt iodization and the risk of IIH. It was found that at least the legislation has been changed to accept as legal iodization levels between 40 to 100 ppm, instead of only 100 ppm as it was before. Although there are not statistic evidences that IIH has continued to happen in the last years, it was recommended to watch at such a risk. It was also recommended to implement a monitoring system and a IEC program. The need of an external evaluation of the Program was recognized and a request for it was going to be channeled at a proper time.
Our visit was arranged with the help of Dr. S Muzzo, prominent member of the Program, who managed to organize a reunion with the participation of representatives from the Ministry of Health, the salt industry, and academic institutions.
Iodization of Water
Together with Dr. S Muzzo, Dr. P Michaud in charge of the water iodization research, and Mr. R. Gonzáles, representative of SQM, we visited the area of Pirque, a rural community about 2 hours from Santiago, to observe the installation and operation of the Iodopur unit, an equipment designed by SQM Iodo to iodize water for human consumption.
The Iodopur is an easy to install and operate unit, which provides a uniform iodization of the water (200 ugI/L). In Pirque and in other 9 rural communities of Chile it is operated by trained local personnel.
Paraguay
The Paraguayan IDD Control Program was visited in May 23-24 for a rapid review of progresses. A renewed and reinforced staff working for the Program was found, as part of the Department for Control of Micronutrients in the National Institute of Food and Nutrition. Dr. María Nicolicchia, Director of the Institute, was very supportive to the activities of the Program. The laboratory for urinary iodine analysis was now properly equipped, although it was not operating by the time of our visit. The volume of iodized salt for human consumption available in the country was still below the required one. However, it is expected that the inauguration in a short time of a modern large capacity plant for salt iodization will contribute to overcome this problem. We had the opportunity to visit the plant already installed. Review of salt samples collected at retail place level show up to 15% of samples have been below 10 ppm and up to 67% have been above 20 ppm. During our visit we were accompanied by the UNICEF
representatives.
Peru
Our technical assistance to the Peruvian IDD Control Program (PRONEDDI) has been very intensive. Under the request of the Program, I have travelled throughout the country to participate in five training seminars for the health personnel of the national IDD network. The seminars were addressed to update knowledge and reinforced skills on monitoring, the risk of IIH, and goiter evaluation. I have also participated in the planning for the recent national evaluation of the program and am contributing with the data analysis.
The last progresses and achievements of the Program, including the fulfillment of recommendations made in 1995 at its external evaluation, were reassessed by the end of 1997. Preliminary results clearly demonstrate the success in a sustained elimination of IDD. For three consecutive years the volume of iodized salt produced in the country exceeds the human potential demand, and the median UEI has progressively increased from 71 ugI/L in the baseline study in 1986, to 130 ug/L in 1995, to 250 ug/L in 1966 and about the same in 1997. As a matter of fact, PRONEDDI has been recognized as a model of success among the health programs in the Ministry of Health and receives the required political and financial support from the government.
Special situations
Brazil
A recent political decision of the government on the issue of the IDD Control Program has raised the concern of Brazilian scientists, the ICCIDD Executive and RC, and LATS Executive.
A brief account of the situation could be summarized as follows :
a)The potassium iodate for the iodization of salt has been subsidized by the government since 1982. Brazil is the only country in the Region doing this.
b)This program was apparently working all right until 1992. From thereon in some occasions the government failed to secure the potassium iodate to the almost 200 salt mills that exist in the country. During my visit to the country in 1994, I was informed that some of the large plants were already purchasing the potassium iodate by their own and it seems that this situation is still going on.
c)The level of iodization of the salt was low until 1994, 10-30 ppm. Following our recommendations during a consultancy in March 1994, the legislation was changed, and the iodization level was raised to 40-60 ppm.
d)The quality control of iodized salt was carried out mainly at the plants level. In the large plants it was done in their own laboratories and by the health authorities in the small plants, which provided the salt samples to the collecting inspectors. Periodical reports on the results were sent to the health authorities.
e)While until 1993 only about 1.5% of the salt samples failed to meet the official minimal requirement of iodization (10 ppm), in 1994 this figure raised to 13.2%. Beyond the approval of the new legislation (minimal level 40 ppm), the failure became higher, 29.9% in 1995 and 31.6% in 1996.
f)In some States, particularly those from the North and Middle West, there had been some complaints about the effectiveness of the distribution of iodized salt to remote areas. As a matter of fact, a survey carried out in 1990 disclosed that the goiter prevalence was still significantly high in some sentinel sites : Minas Gerais 42%, Goyas 36%, Tocantins 36%, Para 24%, Maranhao 18%.
g)In 1994, therefore, it was approved to carry out a national survey to evaluate goiter prevalence, urinary iodine, salt consumption and awareness. The RC attended as a consultant to the planning and training for such a survey.
h)The results of the survey, recently available, show an overall 23% of urine samples with an iodine concentration below 100 ug/L. This figure is much higher in the Northern States (45.8%), and in the Middle West (21.8%). In the South East the figure is 18.5% and in the North East 13.5%. Goiter prevalence is also > than 10% in 4 States of the two first regions.
i)In 1997 the government decided to dissolve the National Institute of Food and Nutrition (INAM), within which the DDI Control Program was part of it. The responsibilities and different activities of the Program have been distributed among different units of the Ministry of Health, with the participation of the Health Secretariat in each State.
j)The high concern on this last decision of the government has been reflected in many letters sent to the Brazilian authorities. As a RC of ICCIDD, I have sent letters to Dr. Carlos Cesar Silva de Alburquerque, Minister of Health; Dr. Lauro Becerra Gonzalves, President of INAM; Mr. Elenio Rodriguez, Statistician of University of Sao Paulo in charge of the data analysis of the last survey; Ms. Carolina Siu, UNICEF-Brazil; Ms. Zuleica Albuquerque, PAHO-Brazil. Dr. G Medeiros, Dr. R Maciel, and Dr. A C. Bianco have been maintained informed on these. The issue has also been discussed with Dr. W Freire, PAHO-Washington and with A Lechtig, UNICEF-Regional Office. J Dunn has also written to PAHO and UNICEF representatives, at different levels. No answers have been received from the Brazilian authorities.
k)I do not believe that this problem will be solved with more letters. Rather, I am convinced on the necessity of an international external evaluation of the issue.
l)I have suggested Dr. Medeiros and others in Brazil to work out an official request of their government for such an evaluation. During our talks with W Freire and A Lechtig in Bogotá, there was also a consensus on this matter.
Advocacy and participation in scientific events
February
Lecture Iodine Deficiency and Quality of Life. Rotary Club, Lima, Peru.
Lecture at the ceremony of Queen Sophia Prize to award the work on iodine deficiency and its prevention. This was an opportunity to advocate the commitment around the world to eliminate IDD in the present decade.
Symposium on Iodine Deficiency, organized by the Real Patronato de Prevención y de Atención a Personas con Minusvalía, Madrid, Spain. It was discussed the experience on IDD control in Latin America and the present situation in Spain. Participants of the Symposium were Gabriela Morreale and Francisco Escobar, and representatives from all the Autonomous Communities of Spain.
March
Lecture The Importance of Eradication of IDD. Kiwanis Club, Lodi, California.
May
Lecture Iodine Deficiency and Diminished Quality of Life. Three Decades of Fighting for its Eradication. National Academy of Medicine, Homage to the recipient of Queen Sophia Prize. Lima, Peru.
Meet the Professor on IDD (E Pretell and S Muzzo from ICCIDD). VII LATS Congress, Viña del Mar, Chile.
September
Lecture Effects of Iodine Deficiency on the Human Development. Actual Situation in Peru. Faculty of Medical Sciences, National University of Trujillo, Academic Ceremony of Recognition as a Distinguished Visitor.
Lecture The Goal of Eradication of IDD Around the World and in Peru.
IV Congress of the National Academy of Medicine. Piura, Peru.
Round Table on Hyperthyroidism and Controversies in Treatment.
E A Pretell : Iodine Induced Hyperthyroidism.
IV Paraguayan Congress of Internal Medicine and VI Symposium with the American College of Physicians, Asunción, Paraguay.
October
Lecture Goiter in Peru. XII National Congress of the Peruvian Society of Surgery of Head, Neck and Maxillofacial, Cajamarca, Peru.
November
Presentation and discussion of the Consensus on IDD in Latin America. Criteria for Evaluation and Monitoring Towards its Sustained Eradication.
Symposium on Human Biology in the Andes.
E A Pretell : Thyroid Function in High Altitude Natives.
XIV Panamerican Congress of Endocrinology, Cancún, Mexico.
Congenital Hypothyroidism. VII International Course on Progresses in Pediatrics. National Institute of the Child, Lima, Peru.
Inventory of laboratories for urinary iodine analysis
One country is running a laboratory for urinary iodine analysis since 1996, and other eleven have implemented their own laboratories during the last years. The RC has visited and checked seven of them. The features of these laboratories are listed below.
Laboratory Method* QC Activity
Argentina F ? ?
División de Endocrinología, Hospital Ramos Mejía
Bolivia A yes +
PRONALCOBO
Brazil S.Pino ? +
Escola Paulista de Medicina, Sao Paulo
Colombia A yes +
Instituto Nacional de Salud
Chile D yes +
Instituto de Nutricion y Tecnologia de los Alimentos
Ecuador C/D yes +
Programa Lucha Operacional Contra el Bocio Endémico
Guatemala F ? ?
INCAP
Mexico A ? +
Instituto Nacional de Diagnóstico y Referencias Epidemiológicas
Paraguay A no ?
Instituto Nacional de Alimentación y Nutrición
Peru C yes +++
Laboratorio de Endocrinología, Universidad Peruana Cayetano Heredia
Uruguay A no ?
Facultad de Química, Universidad Nacional de Uruguay
Venezuela A ? +
Universidad de los Andes modified
* Methods for Measuring Iodine in Urine, by J T Dunn, H E Crutchfield, R Gutekunst, and D Dunn. ICCIDD, UNICEF, WHO, 1993.
Working plan for 1998
1)The approach a number of countries as candidates for partnership evaluation has been agreed with W Freire (PAHO) and A Lechtig (UNICEF). Tentative countries to be evaluated include Brazil, Venezuela, Chile and Uruguay. Additionally, the follow up of the three countries already evaluated, Bolivia, Ecuador, and Peru, has also been considered.
2)Edition of regional guidelines for monitoring and declaration of elimination of IDD.
3)A workshop with the participation of statisticians from the countries already evaluated is planned for the second semester. The objective will be to discuss the statistical model of data collection for diagnosis and monitoring, taking into consideration the guidelines provided by WHO-UNICEF-ICCIDD, and the experiences gained in the Region. This workshop will be sponsored by the Regional Office of UNICEF.
4)Research
a.ThyroMobil Project in Latin America
An international project to be conducted under the auspices of ICCIDD has been negotiated to be sponsored by MERCK KGaA, Darmstadt, Germany. The project has been submitted to the ICCIDD Board for approval (anex).
The main objectives of the project are to update the present situation of IDD, to evaluate progresses on USI and IDD Control Programs, to increase the awareness on IDD, and to stimulate the commitments of local governments to reach the goal of IDD eradication by the year 2000.
The study will cover 9 countries, Argentina, Bolivia, Brazil, Colombia, Chile, Ecuador, Peru, Venezuela, and Mexico. An average of 10 towns in each country will be evaluated. The towns will be selected among those previously known as severely affected by iodine deficiency or new ones.
Data collection will include thyroid volume determined by ultrasonography (a minimum of 100 children in each town) and urinary iodine (a minimum of 50 urine samples in each town).
The project will be effectively started in Argentina by August 1998, and will end in Mexico by June 1999.
b.Pilot study on water iodization
This project, to be carried out in Peru, was already described in our 1996 report of regional activities. The starting of it has been postponed because of the effects of the Children Phenomenon on the places where the project was planned.
5)Contribution to international events
A symposium on micronutrients deficiency and its effect on quality of life has been included in the scientifical program of the International Congress of Internal Medicine, to be held in Lima, Peru, next November. The deficiency of the iodine will be discussed by a senior member of ICCIDD.
