Current Iodine Nutrition Situation

Population

Population:  146.736 millions

Population < 18 years:  65,342 thousands; <5 yrs: 19,408 thousands

Population annual growth rate:   2.3%

Crude birth rate:   29 per 1000
Life expectancy at birth:  62 years

Prevalence of Goitre/ UIE

A national survey conducted in 1999 showed that prevalence of goiter was 17.8%. This considered as an improvement since 1993, in which the national survey revealed a high prevalence of total goiter (47.1%), visible goiter (8.8%), cretinism (0.5%) and biological iodine deficiency as indicated by a low urinary iodine concentration (68.9%). The survey indicated that the prevalence of total goiter in adolescent girls and women aged 15-44 years (55.6%) was much higher than in adolescent boys and men of the same age (33.6%), as observed elsewhere in the world.

Median urinary iodine concentration: 123 µg/L (1999).

Iodized salt Coverage

Household used adequately iodized salt 1 : 70% (2003).

Salt Situation Analysis

Production

Salt is produced in the coastal areas of southeastern Bangladesh by approximately 38,000 crude salt producers, and edible salt is not imported except following poor salt harvests. However, there is illegal smuggling of relatively cheap non-iodized salt from India and Myanmar. The quality of crude salt produced in the country is often poor because it contains a substantial proportion (10-20%) of mud and other insolvable compounds. This has affected the salt industry performance in salt iodization because the impurities raise the cost of refining the crude salt and hamper the iodization process. To resolve this problem, the UNICEF introduced a simple new technology to improve the quality of crude salt and thereby facilitate better iodization of salt. This new method involves the use of polyethylene sheets in the salt fields to separate the crude salt from mud and other impurities during production.

All domestic salt factories must be registered and licensed with Bangladesh Small and Cottage Industry Corporation (BSIC). The BSCIC keeps a record of all operating salt factories and wholesalers in the country using a computerized Management Information System installed at the BSCIC Head office, Dhaka, and in nine regional offices.

Consumption

• Iodized salt use is now estimated at 70%, and about 73% of the population knows that iodized salt is beneficial. 2

Iodine Procurement and Utilization

A cost-sharing scheme for potassium iodate was established between the Salt Mill Owner's Association and BSCIC to ensure the sustainability of salt iodization in Bangladesh, wherein the private sector gradually increase its contribution to the financial cost of potassium iodate from 25% in 2001 to 100% in 2003. This means that all costs of potassium iodate are now covered through a revolving system, without any addition external resources input.

Universal Salt Iodization Program

Information, Education, C ommunication (IE C ) Activities

Various information, education and communication (IEC) activities were undertaken to create awareness of IDD and iodized salt, and activities to improve the quality of crude salt at salt growers' level in Cox's Bazaar area were initiated to help improve the iodization of salt.

IEC materials were printed and developed, including TV spots; guidelines for establishing a quality control laboratory in salt mills to monitor the quality of iodized salt; leaflets on the salt law for salt mill owners and District Salt Committees; and posters explaining the harmful effects of iodine deficiency and IDD and the benefits of consuming iodized salt.

Legislation

In 1989, the Government of Bangladesh passed a law making it mandatory that all edible salt be iodized. The law prohibits the production, distribution, marketing and selling of non iodized salt in the country, and stipulates that all salt for human consumption must contain 45-50 parts per pillion (ppm) of iodine at the time of production and not less than 20 ppm iodine at the time of retail. Defaulters of the salt law face a monitory fine (BDT 5000, approximately US$ 85) and/or jail sentence (3 years).

The Salt Bi-Law of 1994 describes how iodized salt should be packaged, the registration of salt factories, inspection, and role of the Salt Committee, which is appointed by the government to oversee the law. The National Salt Committee headed by Secretary, Ministry of Health and Family Welfare, comprises members from the Ministry of Industries, Health and Family Welfare, Commerce, Law and Home affairs. There are also Salt Committees at the district level for local level monitoring and supervision of salt retailers and wholesaler. District Salt Committee can request District Commissioners to arrange mobile courts for on-the-spot fining.

Program Monitoring and Evaluation

National USI and IDD surveys are conducted every 5-6 years. In 1999, based on the recommendations arising from an intensive review of USI quality control system by BSCIC and UNICEF, a more comprehensive monitoring and quality control system was proposed and implemented. The external and internal monitoring systems were clearly defined, and the outcome of external monitoring has been effectively linked with the private sector's own quality control mechanism. BSCIC inspectors analyse salt samples from each salt factory twice a month. The ICCIDD provides independent monitoring of salt quality by conducting a salt factory survey twice a year. In addition a specialized 'Intensive Monitoring Team' from BSCIC visits each factory every day for one month, 2-3 times a year, for daily monitoring of salt quality. The findings from the biannual salt factory survey and Intensive Monitoring Team are disseminated to factory owners. Sixteen salt factors have invested in salt-testing laboratories, which they use to test the iodine concentration of each batch of iodized salt produced. The Salt Committees at the district levels are also responsible for making spot checks on salt factories, wholesalers and retailers to collect salt samples for analysis. ICCIDD also conducts sentinel urinary iodine surveillance among pregnant women and adolescent girls in Dhaka.

National Coalition

USI in Bangladesh has been implemented with the strong commitment and support of the national committee that includes government, private sectors, donors and other stakeholders .

Other Interventions

To overcome the problems of IDD in Bangladesh, an iodated oil injection program was implemented in 38 IDD-prone districts from 1981-1985. Sixteen IDD-prone districts were covered by the same project from 1991-1997. Later, there was a plan to replace the injection program with iodated oil capsules for oral intake. However, this plan was shelved when USI was proposed as a cost-effective and sustainable CIDD intervention in Bangladesh. USI has one of the lowest unit costs per beneficiary of all public health interventions, and one of the highest benefits per cost of social sector intervention projects.

Lesson Learned

USI for control iodine deficiency has been one of the most extensive fortification efforts in Bangladesh indicates that a large-scale food fortification is possible. This program has provided knowledge and experience that can be utilized in upcoming fortification efforts such as Vitamin A and iron. Particularly valuable lessons have been learned in areas of quality control, pricing and legislative support.

Challenges and Constraints

•  The adoption of the new technology for crude salt production is hindered by the lack of microcredit/loans for farmers to purchase polyethylene at the beginning of the production season. In addition, the commercial sector is facing difficulties in obtaining permission to produce polyethylene sheeting due to government restrictions on the production of plastic bags.

•  Although quality control has been strengthened through regular supervision and monitoring, some salt factories, particularly smaller factories, have not complied with the salt iodization at all, or at an optimal concentration level.

•  Non-iodized salt, originating from neighboring countries or from industrial salt that is illegally repackaged, continues to infiltrate the market.

•  Law enforcement has been handicapped due to low availability of mobile courts in each district and to the low penalty for non-compliance with the law.

•  Consumer demand and proper understanding of the importance of salt iodization has increased, but there are still a significant percentage of households who do not perceive its importance and who are not sufficiently motivated or empowered to demand iodized salt.

Future Plans for Sustained IDD Elimination

•  IDD control activities has created a good professional network of various research institutes, government implementing agencies, donor agencies, and private sectors to achieve its goals. This network will be used to strengthen a coordination mechanism for programs for micronutrient deficiency control.

•  To improve crude salt quality, a new collaboration mechanism with BSCIC, Salt Grower's Association and UNICEF should be maintained.

•  USI for CIDD as one of the most extensive fortification efforts in Bangladesh indicates that a large-scale food fortification is possible. This program has provided knowledge and experience that can be utilized in upcoming fortification efforts such as Vitamin A and iron. Particularly valuable lessons have been learned in areas of quality control, pricing and legislative support.

Sources:

•  UNICEF. The State of the World's Children. 2005

•  IDD NL 17(4):64, 2001

•  Moorthy D. and Pandav C.S. Reports from the Regions and the Countries by ICCIDD Regional Coordinators. In Towards the Global Elimination of Brain Damage Due to Iodine Deficiency. Oxford University Press, 2004.

•  UNICEF. Control of Iodine Deficiency Disorders in Bangladesh. UNICEF Bangladesh. 2004.