Progress Towards Optimum Iodine Nutrition in Turkmenistan

October, 2004

Dr. Chandrakant.S. Pandav, Professor and Head, Centre

for Community Medicine, AIIMS, New Delhi

Progress Towards Optimum Iodine Nutrition in Turkmenistan

• Ministry of Health and Medical Industry• State Concern “Turkmendokunkhimiya”• Ministry of Trade • Standard Agency “ Turkmenstandartlary”• State Custom• Food Industry Association• In collaboration with• UNICEF Turkmenistan and ICCIDD• (Mission supported by USAID)

Objectives

To provide an independent assessment of :

• The history and present situation of National Iodine Deficiency Disorders Elimination Program in Turkmenistan

• The ongoing national efforts toward optimum iodine nutrition, with special emphasis on universal salt iodization

• The progress made in elimination of Iodine Deficiency Disorders in Turkmenistan with special attention to sustainability

Team members - 1• National Counterparts:

• Mr. Annamurad Orazov – Deputy Head of the State Sanitary and Epidemiological Service

of MoH

• Mr. Annamyrat Nazarov - Head of Sanitary Department, State Sanitary and

Epidemiological Service

• Mr. Chary Nazarov – Director of MCH Centre named after Gurbansoltan-Eje

• Mr. Agamurad Akiev - Deputy Head of the Production Departnment of the State Concern

“Turkmendocunkhimiya”

• Mr. Annakurban Mollayev – Director of Guvlyduz Salt Plant

• Ms. Raisa Sukhova – Chief of Production and Laboratory Department of the Salt plant

Team members - 2• National Counterparts:

• Mr. Kurban Khashimov - Head of the Sanitary and Epidemiological Service of Balkan

Velayat

• Mr. Charyyev Anakurban- Head of Sanitary & Epidemiological service of

Turkmanbashy city

• Ms. Shirin Turaeva - Head of Reproductive Department, Mother and Child Health

Centre

• Hasanova, Dilara - Laboratory Specialist, Mother and Child Health Centre

• Mr. Rejep Geldiev – Head of Information Health centre

• Mr. S. Mukhammetkulyev - Head of the State Surveillance Department of the State

Service “Turkmenstandartlary”

• Mr. R. Godina - Deputy Head of the Reformation and Certification Department of

Food Industry Association of Turkmenistan

• Mr. G. Berdiev - Head of the State Custom of Ashgabat city and Akhal valayat

Team members - 3• UNICEF Turkmenistan:

• Ms. Enegul Djumaeva - Assistant Project Officer

• Ms. Dilara Ayazova – Project Assistant Health and Nutrition

• UNICEF Consultants:

• Dr Chandrakant Pandav – Team Leader, ICCIDD

• Mr. Lorenzo Locatelli – Rossi – Salt Production and monitoring, ICCIDD

Special Acknowledgements • Mr. G. Berdimukhammedov -

Deputy Prime Minister, Minister of Health and Medical Industry

• Mr. S. Khanov – Head of the State Concern

Turkmendokuhkhimiya

• Mr. B. Sopiev

Deputy Minister of Health and Medical Industry

• Ms. L. Shamuradova

Deputy Minister of Health and Medical Industry, Head of the

State Sanitary Epidemiological Service

• Mr. Mahboob Shareef – Head of UNICEF in Turkmenistan

• Ms. Regina Molera – Program Coordinator, UNICEF in

Turkmenistan

• Mr. Bradford Camp - Country Representative USAID in

Turkmenistan

Methodology & Agenda of Review

• Considered

- Programme Policy & Management- Salt Iodization- Health Information & Communication- Monitoring & Quality Assurance

• International collaboration and experience exchange

• Interviews with existing stakeholders

• Field visits to Guvluduz Salt Plant, SES

• Visit to shops & markets

• Review of existing reports and documents

Basic Country Facts

Location: Central Asia, bordering the Caspian Sea, between Iran and Kazakhstan

Coastline: Turkmenistan borders the Caspian Sea (1,768 km)

Climate: subtropical desert

Terrain: flat-to-rolling sandy desert with dunes rising to mountains in the south; low mountains along border with Iran; borders Caspian Sea in west

Natural resources: petroleum, natural gas, coal, sulfur, salt

Important Ethnic Groups include: Turkmen 85%, Uzbek 5%, Russian 4%, other 6% (2003)

Government: Republic.

President Saparmurat Niyazov

Number of regions/provinces: 5 provinces (welayatlar,singular - welayat):

Ahal Welayaty (Ashgabat),

Balkan Welayaty (Balkanabat),

Dashoguz Welayaty,

Lebap Welayaty (Turkmenabat),

Mary Welayaty (Mary)

Population : 6,4 million

Economy : GDP - composition by sector:

• agriculture: 27% (cotton, grain, livestock)

• industry: 50% (gas 57%, oil 26%, cotton fiber 3%, textiles 2% (2001)

• services: 23% (2001 est.)

Basic Country Facts

Parameters of the Tracking Progress

Indicators of measuring progress towards sustainable elimination of

IDD• Salt Iodization

- Proportions of households using adequately iodized salt > 90%

• Urinary iodine below 100 µg/L < 50 %- Proportion below 50 µg/L < 20 %

• Programmatic indicators- Attainment of the specified indicators :

at least 8 out of 10

Salt Iodization

• Local production and/or importation of iodized salt (IS) in a quantity sufficient to satisfy potential human demand (4-5 kg/person/year)

• 95% of salt for human consumption must be iodized

• Household IS of adequate quality must be at least 90%

• Iodine estimation at the point of production or importation must be determined by titration; at household level may be determined by certified kits

Population iodine status

• Median UIE should be at least 100 µg/L

with less than 20% below 50 µg/L

• The most recent monitoring data should have been

collected in the last 2 years

Programmatic indicators - 1

• An effective functional national body (council or committee) responsible to government for the national program. It should be multidisciplinary with a Chairman appointed by the Minister of Health

• Evidence of political commitment to USI and elimination of IDD

• Appointment of a responsible executive officer for IDD elimination program

• Legislation or regulations for USI, ideally covering both human and agricultural salt

Programmatic indicators - 2

• Commitment to assessment and reassessment of progress towards elimination with access to laboratories able to provide accurate data on salt and urinary iodine

• A program of public education & social mobilization on importance of IDD & consumption of iodized salt

• Regular data on salt iodine at the factory, retail and household levels

• Regular laboratory data on UIE in school age children with appropriate sampling for higher risk areas

Programmatic indicators - 3

• Cooperation from the salt industry in maintenance of quality control

• A database for recording of results of regular monitoring procedures particularly for salt iodine, Urinary Iodine Excretion, and if available Neonatal TSH monitoring with mandatory public reporting

Current Situation in Turkmenistan

95.4 94.3

59.9

92.1

70.6

88.2

83.4

99.7 98.7 100 99.7

92.6

97.7 98.8100 100 100 100 100 100 100

0

20

40

60

80

100

120

2001 95.4 94.3 59.9 92.1 70.6 88.2 83.4

2002 99.7 98.7 100 99.7 92.6 97.7 98.8

2003 100 100 100 100 100 100 100

Ashgabat city Ahal province Balkan province Dashoguz province Lebap province Mary province Turkmenistan

Comparative Data on Coverage of Iodized Salt for

2001-2002-2003

Household Coverage with Adequately Iodized Salt

(2003-2004) Results of quality testing of iodized salt in Turkmenistan

Velajats Amount of salt samples tested by rapid tests

Tested positively for iodine

Amount of salt samples tested by titration

Conforming requirements of GOST 630-2003

Balkan 90 90 30 30

Akhal and Ashgabat city

210 210 70 70

Mary 210 210 105 105

Lebap 210 210 105 105

Dashgovuz 180 180 90 90

TOTAL for Turkmenistan

900 900 400 400

Frequency distribution of UI levels (mg/L) in samples from Turkmenistan survey

(2003-2004)

01020304050607080

Balkan

vela

yat

Ahkal ve

layat

and A

shgab

at City

Mar

y ve

layat

Lebap

vel

ayat

Dashoguz v

elay

t

Turkm

enis

tan

< 20

20-49,9

50-99,9

100-299

> 300

Frequency distribution of UI levels in samples from Turkmenistan survey

(2003-2004)

Balkan232 mcg/l Akhal and

Ashgabat city – 194 mcg/l Lebap –

168 mcg/l

Mary – 160 mcg/l

Dashoguz – 156 mcg/l

Main Findings

Programme Policy & Management

• Long history of iodine deficiency &

prevention in Turkmenistan

• Presidential patronage & support to the

National Iodine Deficiency Disorders

Elimination Programme : Three Presidential

Decrees in last 10 years

• IDD elimination has been a major priority of

the Ministry of Health & Medical Industry and

Concern “Turkmendocunkhimiya”

• National Commission on,’ Salt Iodization and Flour Fortification with Iron’ formed in 1996

• Deputy Prime Minister is the Chairman• As a result, highest priority given to IDD &

many programme elements receive priority attention

• Regular and effective on-going inter-sectoral collaboration

• Monitoring data linked to decision making process e.g. Increased iodine content in salt at production level from 23 +/- 11.5 ppm to 40 +/- 15 ppm in the year 2002 based on DHS Survey results of the year 2000

Key events: 11991-1993 - After dissolution of Soviet Union in 1991 production of iodised salt in Turkmenistan seized due to breakdown of economic ties within the former state and lack of some necessary equipment, reagents and supplies.

1994:•Decree of Turkmenistan President № 1656 “On Supply of Salt to the Population of Turkmenistan free of charge” (February) •UNICEF opens its office in Turkmenistan •First survey of IDD with support of UNICEF and ICCIDD (March)•Turkmenistan Govt hosts ministerial level ECO/UNICEF/WHO meeting on IDD (June).

1996:•President of Turkmenistan S.Nyazov adopted a Decree № 2626 “On salt iodization and flour fortification with iron" (April)•Ministry of Health and other government agencies approved the use of potassium iodate (KIO3) for salt iodization at the level of 23 +/- 11 mg/kg. • Local production of potassium iodate on Khazar Chemical Plant restarted•UNICEF provided “Guvlyduz” salt plant with necessary iodization equipment to produce iodized salt.

Key Events – 2

1999: Training workshop in IDD monitoring was conducted in MCH Center with UNICEF support.

2000: •Government of Turkmenistan invested in construction of a new factory for iodization and packaging of edible salt. •Demographic Health Survey (DHS) was performed in Turkmenistan with support of UNICEF and US Agency for International Development (USAID).

2002:•State Customs forbid import of non-iodized salt. •By resolution of the Ministry of Health and in agreement with State Standard Service “Turkmenstandardlary” and State Consortium “Turkmendokunkhimia” the level of salt iodization was increased from 23 +/- 11.5 mg/kg to internationally recommended level of 40 +/- 15 mg/kg. •Resolution of Ministry of Health and Medical Industry of Turkmenistan № 61 (6.05.2002) «On constant laboratory control and monitoring of iodized salt quality» •With UNICEF support all provincial (velajat) SEI were equipped with laboratories for qualitative iodine measurement in salt by titration & personnel trained in this method.

Key Events – 3

2003 •Resolution of Khalk Maskhatly № 35 extended action of Turkmenistan President Decree «On free supply of Turkmenistan population with electricity, natural gas, water and edible salt” up to 2020 (August). •Turkmenistan President adopted a Decree № 6351 “On Exemption of salt plant “Guvlyduz” from taxes”. (August) •On high level International Meeting for the Sustained Elimination of Iodine Deficiency Disorders in Beijing (15-17 October 2003) with attendance by 27 countries and 10 international agencies and organizations Turkmenistan announced that the country reached USI and is close to elimination of IDD among its population.

2003-2004•The National IDD Laboratory established•National IDD Survey conducted

2004•Turkmenistan government prepared Official Report on the Achievement of Elimination of Iodine Deficiency in Turkmenistan through Universal Salt Iodisation. •Team for tracking the progress for country certification

National Iodine Deficiency Disorders Elimination Programme - 1

Byashim SopievDeputy Minister of the Ministry of Health and Medical Industry

Gurbangully BerdimukhammedovDeputy Prime Minister, Minister of the Ministry of Health and Medical Industry

Guljemal EzizovaDepartment of treatment and Prevention of the

Ministry of Health

Bike GayirovaChief Pediatrician

Department of treatment and Prevention of the Ministry of Health

Gary NazarovDirector of the Scientific and Clinical Centre of Mother and Child

Health

Shirin Torayeva Head of the Laboratory Department

MCH Centre

Leyla Shamuradova

Deputy Minister, Head of the State Sanitary and Epidemiological Service of the Ministry of Health and Medical Industry

Annamurad OrazovDeputy Head of the State Sanitary and Epidemiological Service

Nazarov AnnamyratHead of the Sanitary Department of the State Sanitary and

Epidemiological Service

Heads of Velayat’sSanitary Epidemiological Services

Heads of Etrap’sSanitary Epidemiological Services

National Iodine Deficiency Disorders Elimination Programme - 2

Agamurad AkievConcern “Dokunchemistry”

Mr. Elly GurbanmuradovDeputy Prime Minister

Annakurban MollaevDirector of the “Guvlyduz” Salt Plant

Ms. Raisa SukhovaChief of the Laboratory Department

“Guvlyduz” Salt Plant

Yazmuradov Atamurad

Concern “Dokunchemistry

Yagshiyev Sary HaylievichDirector of Khazar Chemical Plant

Ms. Ogulbibi Ashirova Head of Production Section

Suleyman Khanov Head of the Concern “Dokunchemistry”

National Iodine Deficiency Disorders Elimination Programme- 3

State Service

“Turkmenstandartlary”

Ministry of Trade State Custom Food Industry

Association

Main Findings

Salt Iodization

Only one producer “Guvlyduz” Salt Plant

• Production capacity of salt : 500,000 tons

Actual production of salt: 230,000 tons

• Production capacity of iodised salt :70,000 – 80,000 tons per year

• Actual production of iodised salt ( as per requirement):

25,000 - 32,000 tons per year

Turkmenistan is self sufficient in salt production and Potassium iodate

Turkmenistan is self sufficient in salt production and Potassium iodate

Requirement :

•Total for edible : 32,000 tons

•Industrial use : 190,000 – 200,000 tons

•Personal : 400g per month/person (free of charge)

• Production of fortificant Khazar Chemical Plant :

potassium iodate - 40 tons/ year potassium iodide - 330 tons/year

• Requirement of Potassium iodate:

2.16 tons/year

Turkmenistan is self sufficient in salt production and Potassium iodate

•Salt is produced from self-segmenting of the Guvly Lake of a sea origin

•Located along Caspian sea coast

• 40 kilometers to the north of Turkmebashy city, Balkan Province

Guvly Lake: Salt production site

Regulations specifying iodine levels for salt

State Industry Standard GOST 630-2003 “Edible Salt. Technical Conditions”

Starting from January 2003 the level of salt iodization was increased from 23 +/- 11.5 mg/kg to internationally recommended level of 40 +/- 15 mg/kg State Customs forbid import of non-iodized salt Salt imported by private foreign Companies is negligible

Annual imports: 0,002%Types imported: iodizedCountries imported from: Iran, Turkey

Salt Production

• Salt iodination is done by adding a potassium iodate, using the using sprayer method for salt iodization (three lines producing iodized salt)

• Since 1 June 2003 the iodine content in salt is corresponding to new adopted standards 40+/-15ppm

• Potassium iodate is obtained locally from “Hazar” Chemical Plant

Internal (factory level) monitoring of salt iodization

Responsible Parties: Salt Plant and SES

Potassium iodate solution for spraying salt prepared under supervision of Senior official of Laboratory

Samples taken regularly from each batch to determine amount of iodine

Titration method used for testing of iodine in saltInternal/external quality control

Iodized salt samples systematically taken during production runs and tested for iodine.Results of control checks and measurements of iodine content in salt samples entered in a special laboratory logbook

Regulations for QA State Standard GOST-TS 630-2003

External monitoring of salt iodization

Responsible PartiesSanitary Epidemiology Service (SES)Standard Agency

Reporting

MoH Resolution № 61 (6.05.2002) «Constant laboratory control and monitoring of iodized salt quality» strengthened monitoring system for production, distribution and transportation of iodized salt

Monthly reporting forms and system for monitoring and laboratory assessment of iodine in salt

Monitoring and laboratory control for iodized salt quality at different levels and executed by specialists of sanitary service of cities and regions

Monitoring forms are reported to provincial (velayat) level and State Sanitary Epidemiological Service

Results of monitoring periodically reported to Cabinet of Ministers of Turkmenistan

Main Findings

Health Information & Communication

Advocacy, Education, Communication for Salt

• Salt Iodization promotion activities

Produced video-spots on national TV, articles in newspapers calendars, posters

KAP Study, 2004 Development of National

Communication Strategy

• Product labeling examples - developed

• Logo for Iodized salt developed, tested and adopted by MoH and Concern Turkmendokunchemistry

• Public knowledge on the importance of IDD prevention is gradually being increased

• Information Health Centre and State Sanitary Epidemiological Service of the MOH&MI, responsible for IEC, with participation by MOE

• Variety of channels of communication at community level n are being utilized, including mass media, group activities & interpersonal communication

• Key messages have focused primarily on benefits of iodized salt with emphasis on prevention of IDD (IQ, need for regular consumption of iodized salt during pregnancy, etc.)

• IDD is being taught to school children & health workers

Main Findings

Monitoring & Quality Assurance

Establishing the monitoring system

•IDD/USI Monitoring System throughout the country and for biological monitoring of IDD established, 2001

MCH Center and Sanitary Epidemiological Inspections (SEI), Ministry of Health responsible for assessment and reassessment of national IDD program

MCH Center acquired laboratory that provides data on urinary iodine

Network of regional (velayat) inspections received laboratories for iodine testing in salt by titration

Staff trained in laboratory procedures

SES established system for regular collection and analysis of data on salt iodine content on the production, retail and household levels.

Overview of Monitoring & Assessment of National IDD Elimination Program

Monitoring tools have been developed & there are data & numbers providing some information on different aspects of the IDD program, including:

Activity Frequency Representation indicators

Quality control at the Salt Plant

Daily by shift production site Adequacy of iodized salt by titration

Routine salt quality monitoring (SES)

Monthly All provinces Adequacy of iodized salt by titration and STK

School-based salt quality monitoring (SES)

Monthly Provincial Adequacy of iodized salt by STK

Biological monitoring of urinary iodine in School children

Annual National representation based on 60 etraps

UIE, IS

The organizational chart of the State Sanitary and Epidemiology Service, which carries out monitoring of the

iodized salt quality

State Sanitary and Epidemiology Service of the

Ministry of Health and Medical Industry of Turkmenistan

Provincial Sanitary and Epidemiology Services

Experimental-Industrial Centre

Sanitary and Epidemiology Service of the Ashgabat

city

Urban Sanitary and Epidemiology Services

District Sanitary and Epidemiology Services

   

The list of facilities

to be continuously monitored for the iodized salt quality during transportation, storage and realization, using rapid-test kits

 1. Storage and trade facilities under the supervision of the Ministry of Trade and Foreign Economic Relations;  2. Storage and trade facilities under the supervision of the “Turkmenbirlishik” Consumers’ Association; 3.  Canteens and storage facilities in schools, preschools, and Infant Homes; 4.  Canteens and storage facilities in health centres and hospitals; 5.   Canteens and storage facilities in seasonal child health-improving institutions;  6. Privately-owned enterprises and trade facilities;

7. Households .

The Quality Assurance for Salt

• samples taken regularly from each batch to determine amount of iodine

• titration method used for testing of iodine in salt

• internal/external quality control

• iodized salt samples systematically taken during production runs

and tested for iodine.

• results of control checks and measurements of iodine content in salt samples entered in a special laboratory logbook

• The method used - titration

National Laboratory for biological monitoring of IDD prevention was equipped and re-established at the MCH Institute, Ashgabat

National Laboratory for biological monitoring

The laboratory team of four persons was formed and trained in performance iodine in urine analyses

Implemented:

• ammonium persulfate method for determination of ioduria

• Total Quality Control/Quality assurance being practiced

Laboratory activities- 1

Laboratory Activities - 2

MCH center established laboratory for urinary iodine for regular monitoring of iodine nutrition, specifically in high risk areas

2000 DHS survey provided basis for increasing level of salt iodization from 23 to 40±15 ppm in 2002

2004 National representative survey of iodine nutrition, MCH Centre

National Epidemiological Representative 30 cluster Survey, January-March 2004

Sampling of 879 schoolchildren aged 8-10 covering all administrative districts of the country

collection of salt samples : SES

collections of urinary samples: MCH Centre

NATIONAL REPRESENTATIVE SURVEY OF PROGRESS IN ELIMINATIONOF IODINE DEFICIENCY IN TURKMENISTAN THROUGH UNIVERSAL

SALT IODIZATION

Details of laboratory tests

Velayats Number of clusters

Number of samples tested for urinary iodine

Number of salt samples tested with rapid test kits

Number of salt samples tested by titration

Balkan 3 91 90 30

Akhal andAshgabat city

7 208 210 70

Mary 7 206 210 105

Lebap 7 205 210 105

Dashoguz 6 169 180 90

Turkmenistan 30 879 900 400

External Quality Assurance

Urinary samples (n=177) from Dashoguz velayat were analyzed at the Reference Laboratory in Sofia, Bulgaria

The results :

• median 150.0 g/L

• samples with iodine < 100 g /L – 28.8 % <50 g/L - 5.1 %

Median urinary iodine (UI) levels for Turkmenistan population

Velayats Number of clusters

Amount of urinary iodine

tests

Median UI levels

Minimal UI value

Maximal UI value

Balkan 3 91 232 32 490

Akhal and Ashgabat city

7 208 194 37 430

Mary 7 206 168 18 560

Lebap 7 205 160 20 380

Dashoguz 6 169 156,5 10 460

Total for Turkmenistan

30 879 170 10 560

Reporting

MoH Resolution № 61 (6.05.2002) «Constant laboratory control and monitoring of iodized salt quality» strengthened monitoring system for production, distribution and transportation of iodized salt

Monthly reporting forms and system for monitoring and laboratory assessment of iodine in salt

Monitoring and laboratory control for iodized salt quality at different levels and executed by specialists of sanitary service of cities and regions

Monitoring forms are reported to provincial (velayat) level and State Sanitary Epidemiological Service

Results of monitoring periodically reported to Cabinet of Ministers of Turkmenistan

Achievements related to sustained salt iodization

• Regulatory : Resolution of Khalk Maskhatly № 35 extended action of Turkmenistan President Decree «On free supply of Turkmenistan population with electricity, natural gas, water and edible salt” up to 2020 (August 2003)

• Producers: Turkmenistan President adopted a Decree № 6351 “On Exemption of salt plant “Guvlyduz” from taxes” (August 2003)

• Consumers: All segments of the population have access to the

iodized salt. The average per capita rate for free distribution of salt is 400 gram/month

• There is a clear set of rules & regulations that guide & support producer of iodized salt. Specifically:

- Salt standards are used- Legislation is adequate- Internal / external quality control &

assurance is adequate- There is a national logo

Main Findings onGoals and indicators of elimination of

iodine deficiency in Turkmenistanand status of Programmatic Indicators

Data of the National Representative Survey of iodine nutrition in Turkmenistan shows that country has achieved the goal of elimination of iodine deficiency among population

Indicators Goal Turkmenistan results

Urinary iodine levels:

Median (mcg/L)

Proportion of samples below 100 mcg/L

Proportion of samples below 50 mcg/Ll

100-300

< 50%

< 20%

170

13,3%

4,6%

Salt iodization: Proportion of households consuming quality

iodized salt

> 90% 100%

Programmatic indicators - 1

• An effective functional national body (council or committee) responsible to government for the national program. It should be multidisciplinary with a chairman appointed by the Minister of Health

• National Commission Chairman – Deputy Prime Minister Minister of Health & Medical Industry

It is multidisciplinary• Evidence of political commitment to USI & elimination of IDD• Highest Level : Three Presidential Decrees in last 10 years• Appointment of a responsible executive officer for IDD elimination

program• Executive Officer located in MH & MI• Legislation or regulations for USI, ideally covering both human &

agricultural salt• In place since 1996

Programmatic indicators - 2

• Commitment to assessment & reassessment of progress towards elimination with access to laboratories able to provide accurate data on salt & urinary iodine

• Yes, in place. Carried out,” base-line survey” in 1994, later DHS survey in 2000 and more recently country-wide IDD survey in 2003 - 2004

• A program of public education & social mobilization on importance of IDD & consumption of iodized salt

• Yes. Already developed. National logo for iodized salt present• Regular data on salt iodine at the factory retail & household levels• Yes. Meticulously maintained records and registers (Computerziation

recommended)• Regular laboratory data on UIE in school age children with appropriate

sampling for higher risk areas• Yes. Meticulously maintained records & registers(Computerzation

recommended)

Programmatic indicators - 3

• Cooperation from the salt industry in maintenance of quality controlYes. Active and regular collaboration between salt producer and Sanitary Epidemiology Service responsible for quality control

• A database for recording of results of regular monitoring procedures particularly for salt iodine and UIE

• Yes. Presently it is in the form of records and registers. (Computerization recommended)• (And if available neonatal TSH monitoring with mandatory

of public reporting)• Presently neonatal TSH not being carried out.

Main Findings

International Collaboration And Experience Exchange

International Collaboration & Experience Exchange

• Key role played by UNICEF, USAID (for financial resources) and ICCIDD since the beginning of the National IDD Elimination Programme

• ICCIDD provided technical inputs at all stages of program development

• UNICEF provided continued technical expertise and resources both capital and recurring

• Well defined guidelines of,’ ICCIDD / UNICEF/WHO Assessment of Iodine Deficiency Disorders and Monitoring their Elimination – A guide for Program Managers’ played a pivotal role

Recommendations

Programme Policy & Management

• Impressive political commitment as evidenced by three Presidential Decrees in last 10 years

• Build on to this success to other micronutrients – vitamin A , iron deficiency anemia, folic acid and to promotion of young child feeding practices

• Excellent leadership by MOH & MI for effective inter-ministerial collaboration

• Administrative infrastructure is effective and in place for on-going implementation and monitoring of sustainability of IDD Elimination

• Consider inviting representative of Livestock Department as a Member of Co-ordination Committee

Recommendations

Salt Iodization

Recommendations

Health Information & Communication

• Initiate celebration of ,”IDD Day” for e.g. Presidents Birthday

• Organize Annual National Conference with participation from all stakeholders

• Document and print the success of National IDD Elimination Program and circulate widely both nationally and internationally

• Introduce National IDD Newsletter – later on include other micronutrients

• Display message at all eating places with National Iodized Salt Logo“We use only iodized salt”

• Integrate IDD messages into other on-going programs, especially those that target reproductive age women/adolescent girls

• Create forums for sharing innovative ideas, success stories & lessons learnt

Recommendations

Monitoring & Quality Assurance

• Introduce Annual Cyclical Monitoring Protocol

There are five provinces in Turkmenistan Select one province every year by rotation The whole country will be covered in five years time. For the sixth year, do a country-wide survey Sampling should be representative for each selected

province using 30 cluster methodology Target group is school children Main indicators are same as school-based survey, e.g.

urinary iodine excretion, iodine in salt from households brought by children as measured by titration

Also include 10 pregnant women per cluster

• Quality Assurance : Internal & external – Very good

• Introduce computerized Data System for Monitoring

• Initiate local production of salt testing kits

• Introduce new methods on urine iodine estimation (Hitachi) – 300 samples per day

Recommendations

International Collaboration And Experience Exchange

• Plan already in place for modernization of iodization facility

• Since Turkmenistan is self – sufficient in production of common salt and potassium iodate and iodide,

• Consider actively exporting – iodized

salt, potassium iodate & potassium iodide

• In view of the success story of IDD Elimination, International collaboration and experience exchange to be actively promoted

• Organize training and demonstration workshops for regional and international fellows in Turkmenistan

• Actively promote participation of stakeholders in regional and international forums, meetings, conferences and seminars

Indicators of measuring progress towards sustainable elimination of IDD in

Turkmenistan• Salt Iodization

- Proportions of households using adequately iodized salt > 90% : 100 %

• Urinary iodine below 100 µg/L < 50% : 13,3%- Proportion below 50 µg/L < 20% : 4,6%

• Programmatic indicators- Attainment of the specified indicators : 10 / 10

8 out of 10

UNICEF/WHO/ICCIDDCertificate

Government of Turkmenistan on Achieving Optimal Iodine Nutrition, Through Universal Salt Iodization and Sustaining Elimination of IDD

In the field of nutrition and health, the task is to do what is possible, without forgetting to do what is necessary.

Universal Salt Iodization and Sustaining Elimination of IDD in Turkmenistan is a story where ,”So much has been achieved for so many, for all time to come, for so little, in such a short time”