Effective Technical Assistance Towards the Elimination of Iodine Deficiency the role of the Iodine Global Network Jonathan Gorstein Clinical Associate Professor, Department of Global Health/ Nutrition Science Program Executive Director, Iodine Global Network UW Nutrition Think Tank Technical Symposium Friday, 13 November 2015 / BMGF
Outline 1. Importance of Iodine 2. Historical developments moving from evidence to elimination 3. Global progress 4. Key Factors for Successful Scaling up
Outline 1. Importance of Iodine 2. Historical developments moving from evidence to elimination 3. Global progress 4. Key Factors for Successful Scaling up
Why is iodine important Iodine deficiency disorders Caused by a lack of thyroid hormone due to inadequate iodine for synthesis World s most preventable cause of brain damage Public health problem since ancient times On verge of global elimination
Outline 1. Importance of Iodine 2. Historical developments moving from evidence to elimination 3. Global progress 4. Key Factors for Successful Scaling up
From Evidence to Elimination First records of goiter and cretinism date back to Chinese, Hindu cultures Switzerland implemented salt iodization, saw drop in goiter and cretinism Ancient 1915 1924 1960 David Marine studied impact of iodized oil on goiter in Akron, Ohio Iodized salt first introduced in USA WHO published first global review on goiter, highlighting magnitude and severity of the problem
From Evidence to Elimination Intervention trial demonstrated impact of iodized oil in pregnancy in preventing mental disability Observational studies confirmed presence of cretinism in China, Nepal, India and Pakistan ICCIDD founded to bridge gap between evidence and programs 1964 1966 1970 s 1983 1985 Basil Hetzel observed cretinism and goiter in Papua New Guinea Term IDD coined to capture the full range of effects of deficiency, focusing on brain development
From Evidence to Elimination World Summit for Children adopts plan of action calling for elimination of IDD by 2000 National program started in China with endorsement of Vice Premier (700 million people deficient), by 2000 USI had eliminated IDD WHO Resolution 58.24 requiring reporting on iodine nutrition status every three years 1990 1993 2002 2005 43 rd WHA recognizes IDD elimination as a public health priority, recommends USI. Global coverage of iodized salt about 20% UN General Assembly Special Session on Children adopts A World Fit for Children. Declaration that set the goal of sustainable elimination of IDD
From Evidence to Elimination BMGF funded GAIN and UNICEF to implement USI Partnership Project ICCIDD changes its name to IGN as the landscape to achieve optimal iodine nutrition matures 2008 2012 2015 Copenhagen Consensus recognizes USI as one of the most cost-effective intervention to improve development IGN links USI and iodine to the broader nutrition agenda (SUN) and salt reduction efforts
Iodine Global Network
Iodine Global Network (IGN) Multi-layered governance model: global Multi-sector representation on the Board Implementing Agencies Normative Agency Foundation Aid Agency Private Sector Academia UNICEF GAIN MI U.S. CDC WHO Kiwanis USAID Salt Univ. Washington Industry ETH Zurich China India Brazil Univ. Sydney AIIMS Delhi Tianjin Univ. 11
Iodine Global Network (IGN) Multi-layered governance model: national Multi-sector representation on the national level Government bodies Implementing Agencies Foundations Private Sector Aid Agencies National Coalition Academia 12
Simple Operating Framework Clear health impact: iodine deficiency causes loss of IQ points, impairs social and economic development Effective intervention: direct impact of iodine repletion
in utero iodine deficiency damages the developing brain 14 Iodine repletion significantly reduces goiter and cretinism DQ/IQ 10-15 points higher in children born to supplemented mothers Reduced risk of: goiter RR = 0.18-0.59 [depending on study design] cretinism OR = 0.13 low intelligence (IQ<70) RR = 0.24-0.28 [depending on study design] Aburto NJ, et al. Geneva: WHO, 2014 Pharoah et al, 1971; Thilly et al,1994; Cao et al, 1994
Simple Operating Framework Inexpensive and sustainable intervention: USI, to effectively increase iodine intakes World Bank and the Copenhagen Consensus list USI as one of the best development investments Lancet Series emphasizes importance of multi-sector partnerships and collaboration Growing political consensus that development funds should address health and nutrition
Remarkably high cost-effectiveness of iodized salt Iodized salt 2x more cost-effective than Fe fortification or Zn supplements Intervention Iron Cost per child covered (US$) Supplements 3.17-5.30 Cost per DALY averted Fortification 0.09-1.00 66-70 Iodine Salt Fortification 0.02-0.05 34-36 Zinc Health (DALYs) Supplementation 0.47 73 Productivity gains Example: West Africa Region Assumptions Annual per capita GNP US$430 Wage share of GNP 40% Goiter rate 15% Births to women with goiter average productivity loss 11% If cost of iodized salt is $0.10 pp/y, benefit-cost ratio is 26.5:1 If costs are $0.01 pp/y (as in Central America) benefit-cost ratio is 265:1 WHO Food Fortification Guidelines, 2006 Disease Control Priorities in Developing Countries 2nd Ed. 2006 The World Bank 16
1 Best investment Copenhagen Consensus 2008: Micronutrients for children IMPROVED CHILD GROWTH AND HEALTH, BETTER SCHOOL LEARNING $ 35 1 Best investment Copenhagen Consensus 2012: Micronutrient interventions LEADS TO EQUALS PAY-OFF HEALTHIER PREGNANCIES INCREASED WORK PRODUCTIVITY $1
Outline 1. Importance of Iodine 2. Historical developments moving from evidence to elimination 3. Global progress 4. Key factors
Household Coverage with Iodized Salt <50 % 50-89 % 90 % 2014 No data UNICEF, State of the World s Children, 2014 19
Progress Towards the Elimination of IDD Severe Moderate Mild Adequate No data Iodine Global Network, 2015 1993: 113 countries iodine deficient
Progress Towards the Elimination of IDD Severe Moderate Mild Adequate No data Iodine Global Network, 2015 2003: 54 countries iodine deficient
Progress Towards the Elimination of IDD Severe Moderate Mild Adequate No data Iodine Global Network, 2015 2007: 47 countries iodine deficient
Progress Towards the Elimination of IDD Severe Moderate Mild Adequate Excess No data Iodine Global Network, 2015 2012: 30 countries iodine deficient
Progress Towards the Elimination of IDD Severe Moderate Mild Adequate Excess No data 2015: 25 countries iodine deficient
Outline 1. Importance of Iodine 2. Historical developments moving from evidence to elimination 3. Global progress 4. Key Factors for Successful Scaling up
Scaling Up Critical Factors Implementation through public-private partnership model of collaboration between Governments, private sector (salt industry), international agencies, scientific community and donors (Kiwanis, USAID, BMGF) Persistent advocacy - Use of data on program process (coverage) and impact (iodine status) have enabled advocacy, to celebrate and sustain success, we well as to raise urgency
Program Maturation and Changing Landscape Sustainability iodine deficiency cannot be eradicated and requires continuous commitment and vigilance Harmonization link USI with other fortification activities to the broader nutrition and development agenda Salt consumption patterns changing salt consumption patterns (processed foods, condiments) requires a shift in strategy to true USI Synergy with salt reduction USI and salt reduction strategies should be aligned through integrated monitoring and program implementation
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