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.

Salt iodization programmes in Africa.

PIP: This article discusses the success of program efforts in treating iodine deficiency disorder (IDD) in Africa. IDD programs are a good example of how Africa can rapidly progress in dealing with a health and nutrition issue. Progress was made due to affordable cost-effective technology and the alliance between government, the private sector, and international agencies. Almost all of the 50 countries of Africa that were identified as having IDD problems had implemented IDD control programs by 1995. The programs emphasized the long-term use of iodized salt. By February 1996, over 50% of the salt consumed in Africa was estimated to be iodized. It also appears that the proportion of households using iodized salt is increasing. Preliminary evidence suggests that the prevalence of goiter in three districts of Kenya declined rapidly after the introduction of legislation authorizing use of iodized salt. Success is not just limited to declines in IDD. Programs have proven the ability to build capacity and sustainability; to obtain international and national commitment to an objective; to achieve interagency, public, and private sector collaboration; to intensify capacity building; and to build strong networks. It is a realistic goal to expect IDD to be eradicated in the next century.^ieng

Milling reduces the goitrogenic potential of cassava.

Cyanide exposure from consumption of insufficiently processed cassava has been implicated in aggravating iodine deficiency disorders (IDD). The cyanide metabolite, thiocyanate (SCN) may interfere with iodine (I) uptake of the thyroid gland. A study on 217 women in an IDD endemic area in western Tanzania showed that 98% consumed cassava daily. Total and visible goitre rates were 72.8% and 13.3%, respectively. Median urinary iodine was 3.6 micrograms/dl indicating moderate iodine deficiency. Processing methods which remove cyanogens from cassava roots have changed with time. Urinary thiocyanate (mean; 128 mumol/l) was moderately increased, but women who frequently milled cassava had significantly lower urinary thiocyanate levels. This indicates that mechanical milling could reduce the goitrogenic potential of cassava and we conclude that IDD in the studied area is mainly due to iodine deficiency and sustainable iodine supplementation should be given highest priority.

Adherence to iron supplementation during pregnancy in Tanzania: determinants and hematologic consequences.

Limited adherence to iron supplementation is thought to be a major reason for the low effectiveness of anemia-prevention programs. In rural Tanzania, women at 21-26 wk of gestation were randomly given either 120 mg of a conventional (Con) iron supplement or 50 mg of a gastric-delivery-system (GDS) iron supplement for 12 wk. Adherence was assessed by using a pill bottle equipped with an electronic counting device. Adherence in the GDS group was 61% compared with 42% for the Con group. In both groups, women experiencing side effects had about one-third lower adherence. Fewer side effects were observed in the GDS group. In a subgroup of women with a low initial hemoglobin concentration (< or = 120 g/L), the response to the iron supplements suggested that both of the applied doses were unnecessarily high for adequate hematologic response in a population with a marginal hemoglobin concentration. The GDS group appeared to require a dose one-fourth as high as that of the Con group for an equal effect on improving hemoglobin to normal concentrations.

Investing in nutrition at the national level: an African perspective.

PIP: Investing in nutrition requires conducive political, economic, technological, and social environments, all which are determined by economic, moral, and ethical considerations. Investing in nutrition not only yields economic returns, but should be considered as a human right. The author presents an African perspective at the national level, using Tanzania as an example of ways in which the impact and quality of various interventions can be maximized through increasing investments in nutrition. Africa's fluid development, emerging hopes, Tanzania's experience in investing in nutrition, a framework for investing in nutrition, financial investments in nutrition, human resource investments in nutrition, organizational investments in nutrition, and the programmatic context and costs of maximizing quality and impact are discussed. It may be learned from the Tanzanian experience in investing in nutrition that investing in community-based interventions is a most cost-beneficial approach, and that investing in a social-action package including advocacy and communication, community-based information systems, targeted and gender-sensitive education, and training and service delivery can cost-effectively achieve quality, impact, and sustainability. Other insight is discussed.^ieng

Development of vitamin A control programs : an exemple from Tanzania

This article describes the rationale for starting vitamin A deficiency control programs and the experience from Tanzania on starting such programs. The objective is to draw lessons which could be applied elsewhere as countries move towards the elimination of vitamin A deficiency by the year 200. The successful development and implementation of sustainable national vitamin A programs is possible even in poor countries like Tanzania; provided that there is a political will

A prospective area-based study of the outcome of pregnancy in rural Tanzania.

A prospective area-based study on the outcome of pregnancy was carried out in the rural village of Ilula in Tanzania. A coverage of 99% (n = 719) regarding the ultimate outcome for mother and child was achieved, including deliveries that took place in hospital (9%), at the dispensary (67%) and at home (23%). There were four maternal deaths (6/1,000). The mean birth weight for singletons was 3,070 g and the low birth weight (less than 2,500 g) rate 13%. From a gestational age of 37 weeks onwards there was a definite slowing of fetal growth. Perinatal mortality rate was 82 per 1,000 born, half of the deaths occurring in low birth weight babies. Twinning occurred in 3.5% and the mean length of gestation at delivery for these pregnancies was 35.5 weeks. Twins constituted 6.8% of newborns but accounted for 23.0% of perinatal losses, making twin pregnancy a major contributor to perinatal mortality. Post-term pregnancies carried no significant increase in mortality. It is concluded that reliable area-based data on the outcome of pregnancy in Tanzania can be obtained at village level, with good coverage of the study population, by properly instructed and motivated local staff with moderate supervisory support.

Prevalence of xerophthalmia in relation to nutrition and general health in preschool-age children in three regions of Tanzania.

Integrated nutrition/health surveys were carried out in Mbeya, Iringa and Kagera Regions in Tanzania in which a total of 12,880 children were examined for the presence of xerophthalmia. Xerophthalmia was found to be a problem of public health significance in two of the three regions surveyed where the prevalence of active corneal xerophthalmic lesions was above the criteria set by WHO. Because of clustering of the children with Bitot's spots, corneal xerosis/ulceration and corneal scarring, only certain villages or groups of villages could be regarded as areas where xerophthalmia is a problem. The results of the ophthalmological examinations are discussed in relation to the nutritional status of the children as measured by anthropometric indices, serum levels of retinol-binding protein and prealbumin, haematological parameters, and vaccination status.

A simple surveillance system for xerophthalmia and childhood corneal ulceration.

A simple cost-effective surveillance system is described for reporting cases of xerophthalmia and childhood corneal ulceration. The system is suitable for use by ophthalmic auxiliaries in developing countries.Presented are the results of a 2-year surveillance involving 15 hospitals in 11 areas of the United Republic of Tanzania. Cases of xerophthalmia in its early stages (characterized by night blindness or Bitot's spots) were found in all areas surveyed. Of almost 300 cases of unilateral and bilateral corneal ulceration, 46% and 79%, respectively, followed a recent infection with measles. The single most important cause of bilateral corneal ulceration was vitamin A deficiency. The surveillance system has proved to be particularly useful as a first step in defining the type and distribution of serious corneal disease in children.