Sustainable universal salt iodization in low-income countries - time to re-think strategies?

OBJECTIVE: Sustained iodine deficiency control requires sustainable mechanisms for iodine supplementation. We aim to describe the status of salt iodation machines, salt producers' experiences and quality of salt produced in Tanzania. METHODS: Qualitative and quantitative data was collected from the factory sites, observations were made on the status of UNICEF-supplied assisted-iodation machines and convenience samples of salt from 85 salt production facilities were analysed for iodine content. RESULTS: A total of 140 salt works visited had received 72 salt iodation machines in 1990s, but had largely abandoned them due to high running and maintenance costs. Locally devised simple technology was instead being used to iodate salt. High variability of salt iodine content was found and only 7% of samples fell within the required iodation range. CONCLUSION: Although iodine content at factory level is highly variable, overall iodine supply to the population has been deemed largely sufficient. The need for perpetual iodine fortification requires reassessment of salt iodation techniques and production-monitoring systems to ensure sustainability. The emerging local technologies need evaluation as alternative approaches for sustaining universal salt iodation in low-income countries with many small-scale salt producers.

Iodine deficiency persists in the Zanzibar Islands of Tanzania.

BACKGROUND: Iodine is an essential micronutrient for normal human growth and development. It is estimated that more than 1.6 billion people live in iodine-deficient environments, yet there are still some countries and areas where the prevalence of iodine-deficiency disorders is unknown. OBJECTIVE: To establish the prevalence of iodine-deficiency disorders in the Zanzibar Islands, a community assumed to have ready access to iodine-rich seafoods. METHODS: In a cross-sectional study, 11,967 schoolchildren were palpated for goiter prevalence, a subsample was evaluated for urinary iodine concentration, and the availability of iodated salt was assessed at the household and retail levels. RESULTS: The mean total goiter prevalence was 21.3% for Unguja and 32.0% for Pemba. The overall median urinary iodine concentration was 127.5 microg/L. For Unguja the median was 185.7 microg/L, a higher value than the median of 53.4 microg/L for Pemba (p < .01). The household availability of iodated salt was 63.5% in Unguja and 1.0% in Pemba. The community was not aware of the iodine-deficiency problem and had never heard of iodated salt. CONCLUSIONS: The inadequate intake of iodine documented in the Zanzibar Islands belies the common assumption that an island population with access to seafood is not at risk for iodine-deficiency disorders. We urge health planners to implement mandatory salt iodation and education efforts to alleviate the situation.

Coverage and cost of iodized oil capsule distribution in Tanzania.

Distribution of oral iodized oil capsules (IOC) is an important intervention in areas with iodine deficiency disorders (IDD) and low coverage of iodized salt. The mean reported coverage of 57 IOC distribution campaigns from 1986-1994 of people aged 1-45 years in 27 districts of Tanzania was 64% (range 20-96%). This declined over subsequent distribution rounds. However, due to delayed repeat distribution, only 43% of person-time was covered, based on the programme objective of giving two IOC (total 400 mg iodine) at 2-year intervals. Three different capsule distribution strategies used in 20 distribution rounds in 1992-1993 were analyzed in depth. Withdrawal of financial support for district distribution expenses under the 'district team' strategy, and the subsequent change to integrated 'primary health care' distribution, increased delays and capsule wastage. The third, more vertical strategy, 'national and district teams', accomplished rapid distribution of IOC about to expire and subsequently a return to the initial 'district team' allowance strategy was made. Annual cost of 'district team' distribution was 26 cents per person (400 mg iodine/2 years). Cost analysis revealed that the IOC itself accounts for more than 90% of total costs at the levels of coverage achieved. IOC will be important in the elimination of IDD in target areas of severe iodine deficiency and insufficient use of iodized salt, provided that high coverage can be achieved. Campaign distribution of medication with high item cost and long distribution intervals may be more cost-effectively performed if separated from regular PHC services at their present resource level. However, motivating health workers and community leaders to do adequate social mobilization remains crucial even if logistics are vertically organized. Insufficient support of distribution expenses and health education may lead to overall wastage of resources.

PIP: This paper analyzes the experience of using iodized oil capsules (IOCs) in Tanzania as a stopgap measure to control iodine deficiency disorder (IDD) in a target population of 7 million during a 9-year period (1986-94). The article also evaluates the costs and coverages of three different mass distribution strategies used in 1992-93. The assessment revealed that the distribution of oral IOCs was an important intervention in areas with IDD and low coverage of iodized salt. The mean reported coverage of 57 IOC distribution campaigns during 1986-94 of people aged 1-45 years in 27 districts of Tanzania was 64% (range, 20-96%). This declined over subsequent distribution rounds. However, due to delayed repeat distribution, only 43% of person-time was covered, based on the program objective of giving 2 IOCs (total of 400 mg iodine) at 2-year intervals. Further analysis of the 1992-93 data on the three different capsule distribution strategies used in 20 distribution rounds indicates the withdrawal of financial support for district distribution expenses under the "district team" strategy, and the subsequent change to integrated "primary health care" distribution, increased delays and capsule wastage. The third, more vertical strategy "national and district teams", accomplished a rapid distribution of IOCs and subsequently made a return to the initial "district team" allowance strategy. Annual cost of "district team" distribution was 26 cents per person (400 mg iodine per 2 years). Cost analysis revealed that the IOCs themselves account for more than 90% of total costs at the levels of coverage achieved.

Case management and preventive services among infants from low-income families.

To determine the impact of an experimental approach to case management on use of child health clinic and immunization services, a nonequivalent control group with covariate measures design was employed in a sample of 98 infants from low-income families. The innovative pattern of care featured continuity of care; a single public health nurse (PHN) provided child health care to an infant by integrating case management and preventive services. In contrast, the customary pattern of child health care was characterized by fragmentation of services. Case management was segregated from preventive services, and multiple PHNs delivered care to an infant. As predicted, experimental-group infants (44%) were more likely to achieve adequate child health clinic services than control-group infants (8%) (p < 0.001). Moreover, the cost-effectiveness (C/E) ratio (dollar cost per effective intervention) for adequate child health clinic visits in continuous care ($523) was one-fifth of that in fragmented care ($2,900). The C/E ratio related to adequate immunization was 8% less in continuous care ($359) than in the fragmented approach ($386), although the difference in rates of adequate immunization was nonsignificant (experimental group, 64%; control group, 60%). These findings suggest that continuous PHN care with integrated case management is a more effective, cost-efficient approach to critical child preventive services than the customary, segregated case-management approach.