Iodine Deficiency Disorder

Bangladesh

Vitamin A

BHUTAN

Iodine

Iron




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	EPIDEMIOLOGICAL DATA


Goiter
Most Recent Goiter Survey
	Date:	May 1996
	Groups Surveyed:	School age population
	Sample Size:	1200 (40 primary school children per cluster)
	Sampling Method:	30-Cluster Probability Proportionate to Size. Thirty administrative blocks were selected and one primary school was randomly selected from each of these blocks. Sample size of 1200 (40 primary school children per cluster) calculated with a estimated goiter prevalence of 0% to give confidence interval of 5%.
	Estimated Goiter Prevalence:

Group	Sample size	Prevalence in sample (%)			Population with Goiter
Group	Sample size	Grade 1	Grade 2	Total goiter rate	Population with Goiter
Age 6-7 years	278	13.3 %	1.1%	14.4 %
Age 8-9 years	491	13.4 %	0.4 %	13.8 %
Age 10-11 years	431	11.8 %	2.3 %	14.1 %
National Total	1200	12.8 %	1.2 %	14.0 %

Urinary Iodine
Most Recent Urinary Iodine Survey
	May 1996 (no information reported on age group or sampling)

Estimated Prevalence of IDD: Indicator < 100 microgram/L

Region/Group

Sample size

Prevalence in Sample

Population with Low Urinary Iodine

Median Urinary Iodine Level

National Total *

*(Regional/subgroup estimates not reported)

333

24%

(calculate this)

230 mcg/L

Top	POLICY AND LEGISLATION

Legislation on IDD
	There is IDD legislation in Bhutan but it only covers the import of salt. No other legislation is being developed or is about to be enacted into law. Iodization of salt is mandatory at the level of 60 ppm. The government of Bhutan has not published documents that state the national policy regarding IDD.

Government Agency to Address IDD
	The government agency that deals with IDD is the Nutrition Unit, Public Health Division, Ministry of Health and Education, Royal Government of Bhutan. The Nutrition Unit functions as both a coordination agency and a monitoring agency, but it does not provide funding.

	Contact information: Program Officer, Nutrition Unit, Public Health Division, Ministry of Health and Education, Royal Government of Bhutan, Thimphu Bhutan.


	PROGRAM DATA

Supplementation
	Oral supplementation with iodized oil capsules is not currently used and has not been used in the past. There are no supplementation activities currently in place.

Fortification
Production and Importation of Salt
	There is no salt production, but un-iodized sea salt is imported and iodized.
	The total annual national production of iodized salt was 4983 metric tons in 2001.
	The intended level of salt iodization at the point of production is >60PPM.
	Large-scale salt iodization started in 1985.
	There is currently one salt producer and it is also an iodization plant.
	Potassium iodate is used to iodize salt.
	High density, polyethylene bags for bigger packs and plastic packing for 1kg packs are used for packaging.
	The salt imported by Bhutan salt enterprise is un-iodized salt but gets iodized in the border town of Phuentsholing before distribution inside the country. A few other agencies import salt, but the salt not imported by the Bhutan Salt Enterprise has to be iodized salt.
	The salt is imported from India at the intended level of iodization of 30 PPM.
	Salt iodine content at production level is assessed by 1) Manufacturers quality control check and 2) Monitoring of samples of each batch of salt iodized in the plant by the local Government Hospital laboratory.
	As a routine procedure, samples from each batch of salt iodized are tested for iodine content by the nearest Government hospital laboratory and only salt having 60 PPM iodine is approved for distribution. If it is less than that, the salt is not allowed to be distributed but has to go through the iodization process again, therefore all salt produced by the plant has adequate iodine.
	There are no other measures of fortification with iodine in widespread use.


Retail
	The average retail cost of salt is as follows:
		Bhutan Salt Enterprise iodized salt:
			- Ngultrum 3/Kg for single Kg pack (1 USD = 48.5 Ngultrum
			- Ngultrum 2.30/Kg for 37.5 packs
		Imported iodized salt:
			- Ngultrum 7 per Kg
		Un-iodized salt
			- Salt not permitted within Bhutan, but people living near the border can get it from Indian towns at a lower cost.


Household Consumption
	The estimated daily per capita consumption of salt is not known.
	The estimated percent of adequately iodized salt consumed, as a national avg. (for 1992-1998) is 82%.

(Source for above information on IDD: “Tracking Progress Towards Sustainable Elimination of Iodine Deficiency Disorder in Bhutan,” a joint publication of Royal Government of Bhutan, UNICEF, WHO, Micronutrient initiative and ICCIDD, published in 1996)

Iodized Salt Survey (1996)

Survey level	Date	Geographic area/ other grouping	Sample size	Sampling method	% of samples with ppm=					Average or Range of Iodine Content
Survey level	Date	Geographic area/ other grouping	Sample size	Sampling method	0	1-14.9	> 15	15- 24.9	>25	Average or Range of Iodine Content
Retail	*	NR	*	*	0	16.1		10.2	73.7	NR
Household	May 1996	NR	333	30 cluster	0	18	82			NR

*For sample sizes and method for retail surveys, please see MONITORING section below.

NR = Not Reported

Other Programs
Education Campaigns
	The AV and print media have limited reach in Bhutan. As a result, the campaigns/health education efforts focus more on interpersonal contacts through the health care providers and village health workers. IDD posters, video cassettes and religious banners with IDD messages endorsed by the chief abbot are produced and provided to health centers for use during important local festivals. IDD information booklets have been very successful in getting IDD messages to the literate population.

Top	MONITORING

Salt Iodine
Current monitoring activities for iodine levels in salt
	All health centers collect and analyze a minimum of 10 samples collected from households and retail outlets each month using field testing kits.
	District hospitals test 10 samples each using titration method and report to public health laboratory (PHL). Sources of samples with inadequate iodine content are traced and also sent to National Public Heath laboratory (PHL) for cross checking.
	Quality control is done by National Public heath laboratory for analysis.
	- Cyclic monitoring of five districts each four years for iodized salt consumption, urinary iodine in school children and goiter rate in children.
	- Community-level monitoring of iodine content in salt is done by BHU's. Each BHU tests 10 samples each month and reports to PHL.

IDD Indicators
	There is no ongoing monitoring of goiter rate.



	PROGRAM RESOURCES


Donor and Implementing Agencies Involved in IDD Programs
	National/State Government contributes policy support and staff costs of monitoring and promotional activities.
	UNICEF, with support from UNICEF NATCOMs and Kiwanis international, works in advocacy, capacity development, monitoring and evaluation (including supplies), and salt iodization, including installation and subsidization of iodization activities.

IDD Program Funding History and Projections

Year	IDD Activity			Total $(000)
	Fortification* $(000)	Other
	Fortification* $(000)	Activity	$(000)
1998	23,000.00**	NONE	NONE	23,000.00
1999	34,559.76			34,559.76
2000	20,225.00			20,225.00
2001	30,659.23			30,659.23
2002	62,000.00			62,000.00***
2003	35,000.00			35,000.00
2004	35,000.00			35,000.00
2005	35,000.00			35,000.00

*Including salt iodization M&E, behavior change communication and capacity development for ensuring USI.

**Staff cost contributed by the Government and the private sector contribution is not included.

***Major evaluation planned in 2002.

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EPIDEMIOLOGICAL DATA

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IDD Activity