IODINE DEFICIENCY (IDD) QUESTIONNAIRE Responding to the Questionnaire: Thank you for taking the time to complete the following questionnaires. Please provide as complete of answers as possible and email this form back to us at email@example.com by MARCH 6, 2002. To answer numbered questions, place the cursor just after or one line below the question and start typing, making sure the “insert” key is active. To avoid reformatting the questionnaire place the cursor where you would like to begin typing and DO NOT press “Enter” (which may activate the automatic numbering). This will provide you with as much space as necessary for your answers. Additional lines can be added to tables by going to the last cell of the last column and pressing the “tab” key. For “Yes/No” questions, please type the appropriate answer. In order for us to differentiate our questions from your answers, responses should be in either bold, italics or capital letters. Sending Survey Reports: We would appreciate it if you could send us copies of important survey reports, as well as providing the information in the questionnaire. Survey reports may be sent via hard copy (e.g. on paper), or if you have them available as computer files, these would be equally useful. If emailed, attachments usually transmit suitably up to 500k. If the files are larger than 500k, or if there is a potential problem, please send the files on a floppy disk, zip disk, or CD-ROM (we can reimburse costs). I am sending survey reports (Yes/No): If yes, please list title of reports: Otherwise, packages that weight less than one pound or 500 grams can be sent via FedEx or DHL. Please contact us via email at firstname.lastname@example.org for payment information. Larger packages should be sent via UNICEF Pouch. Method (check one): Email Fed Ex DHL UNICEF Pouch I. CORE INFORMATION Current Date: Country: Completed by: Name: Position: Email Address: II. EPIDEMIOLOGICAL DATA Surveys of iodine deficiency disorder (IDD): We would like to collect information on goiter and urinary iodine surveys. Please complete the questions and tables below. Please also send a copy of the survey report if available, using one of the four methods listed above. A. Goiter Data 1. What was the most recent goiter survey? Please give a brief description including date and duration of the survey, location or area, and groups surveyed (e.g. adults, school-age, overall population). 2. How was the sampling done and what was the overall sample size? Please give a brief description. 3. Please summarize survey results in the table below including overall findings and distribution by important group (e.g. geographical area, age, gender). School age children (age 6-11) is the standard age group assessed for goiter, please indicate the group surveyed. Visible and/or palpable goiter (grades 1+2 as defined by WHO) is the standard indicator used to measure goiter. Please indicate which indicator was assessed. If cretinism was also assessed, please include these results. The table below may be expanded by placing the cursor in the last box and pressing “tab”. Survey Results of Estimated Goiter Prevalence Date of Survey_________ Specify Indicator (e.g. grades 0+1 goiter) _________ Region/Group* Sample size Population in Prevalence in region/group sample % (if available) #1 #2 #3 #4 #5 More groups Hit tab National Total: *e.g. by geographic region (e.g. province) and school age children; or by geographic region and all ages; etc B. Urinary Iodine 1. What was the most recent urinary iodine survey? Please give a brief description including date and duration of survey, location or area, and groups surveyed (e.g. adults, school-age, overall population). (If more than one survey is relevant, please give additional information.) 2. How was the sampling done and what was the overall sample size? Please give a brief description. 3. Please summarize survey results in the table below including the indicator assessed, overall findings, and distribution by important group (e.g. geographical area, age, gender). The standard indicator used to measure urinary iodine is the prevalence of < 100mcg/L. Please indicate the group surveyed. (e.g. school aged children, general population). The table below may be expanded by placing the cursor in the last box and pressing “tab”. If sending a survey report, please see instructions at the beginning of the IDD questionnaire. Survey Results of Estimated Prevalence of Low Urinary Iodine, and/or Median Urinary Iodine Date of Survey_________ Region/Group* Sample Population in Indicator(s) Prevalence in size region/group specify cutoff sample % (if available) and/or median urinary iodine #1 #2 #3 #4 #5 More groups Hit tab National Total: *e.g. by geographic region (e.g. province) and school age children; or by geographic region all ages; etc C. TSH 1. Has TSH (thyroid stimulating hormone) been measured? If so, please briefly describe overall results. III. POLICY AND LEGISLATIVE DATA A. Status of Legislation on IDD Is there IDD legislation in your country? YES ٱ NO ٱ If “No”, is legislation developed or about to be enacted into law? YES ٱ NO ٱ If “Yes”, what year was it passed? Year: Has that legislation been significantly revised? YES ٱ NO ٱ Is iodization of salt mandatory? YES ٱ NO ٱ What is the mandated level of salt iodization? Has the government published (e.g. a white paper or other documents such as regulations) regarding IDD? YES ٱ NO ٱ If “yes”, please briefly describe: B. Government agency to address IDD Is there a government agency that deals with IDD? YES ٱ NO ٱ If “Yes”, what is its name? Contact Information: If “Yes”, is that agency’s function: Coordination: Monitoring: YES ٱ NO ٱ YES ٱ NO ٱ Funding: Other: (specify below) YES ٱ NO ٱ IV. PROGRAM DATA A. Supplementation 1. Is oral supplementation with iodized oil capsules now used? (If “no”, skip to section B.) 2. Was this type of supplementation used in the past? If so, please give dates. 3. What is the target population? 4. Total number supplemented 5. Please describe other supplementation activities, if any. B. Fortification Please provide the following information on iodized salt at the production, retail and household consumption levels. Production and Importation of Salt 1. Is iodized salt produced? (If “no”, please skip to question number 9) 2. What is the total annual national production of iodized salt? Please provide information for most recent year available.(state year) 3. What is the intended level of salt iodization at the point of production? 4. When did large-scale salt iodization start? 5. Approximately how many salt producers are there now? 6. Do all of these iodize salt? If not, how many producers iodize salt? 7. What compound is used to iodize salt? (e.g. potassium iodate or iodide) 8. What packaging methods are used? 9. Is imported salt iodized? (If “no”, please skip to question 12) 10. Where is this salt imported from? 11. What is the intended level of iodization in imported salt? 12. How is salt iodine content at production level assessed? (e.g. manufacturers quality control checks) Note: If assessed by sample survey, details are asked in section D below. 13. If there is a recent estimate of the percent of salt production that achieves the target iodine level, please provide this percent and date it applies to. 14. How was this assessment done? Please see the survey section D. 15. Are other measures of fortification with iodine in widespread use? (e.g. in water, in fortified processed foods etc.) Retail 16. What is the average retail cost of salt per kilo or other unit? (Please specify.) Iodized Uniodized 17. Are there important regional differences? (e.g. urban/rural, remote areas etc.) Please briefly describe. 18. We would also be interested in survey results of retailers, if these have been done. Please see the survey section D. Household Consumption 19. What is the estimated daily per capita consumption of salt? (if known) 20. What is the estimated percent of adequately iodized salt consumed, as a national average? 21. What is the source of this data? (If the data is from a survey, please see section D below.) C. Other Programs Related to Control of IDD 1. Please briefly describe any mass media campaigns to promote good iodine status. 2. Please briefly describe any community-based programs to promote good iodine status. (Please include program coverage, if known.) D. Surveys of Iodized Salt Surveys of salt iodization may be done at the producer, retail, and household/consumer level. All of these would be of interest. Please complete the questions and tables below. Also, please send a survey report if available. (If sending a survey report, please see instructions at the beginning of the IDD questionnaire.) 1. What was the most recent salt iodization survey? 2. In the table below, please specify level of the survey (producer, retail, household)) date, sampling method, sample size, and overall findings. Also, include distribution by geographical area or other grouping as appropriate. Please reproduce this table for each recent survey. If no survey has been done, skip to next section. The table below may be expanded by placing the cursor in the last box and pressing “tab”.* *If cutoffs other than 15ppm and 30ppm were used, please change the column headings accordingly. SURVEY RESULTS (Please enter the overall survey results in the first row of the table. In subsequent rows, please specify the results for producer/retail/household.) % of % of Average Survey Level Date of Geographic Sample Sampling samples samples and/or (producer/ Survey area/ other size Method with > 15 with > 30 Range of retail/ grouping ppm ppm Iodine household) Content Hit Tab V. MONITORING A. Salt Iodine 1. Please summarize current monitoring activities for iodine levels in salt. 2. Are the surveys described above being repeated? 3. Is there facility or community based monitoring of salt iodine? (e.g. use of UNICEF salt testing kits) (If “yes”, please describe any activities not mentioned in question number 1.) B. IDD Indicators 1. Is there any monitoring of goiter rate (or other IDD indicators) from clinic/hospital records, or sources other than the surveys as referred to above? If “yes”, please describe these activities. 2. Are there lab facilities available for biochemical measurements (e.g. urinary iodine)? If so, please briefly describe. VI. RESOURCES FOR PROGRAMS 1. What donors and implementing agencies are involved in IDD programs? Expenditure in Implementing Description of Activities current year Agency Supplementation Salt Other (if applicable) Iodization (specify) National/State Governments External Agencies* Hit Tab *Please list major agencies individually if feasible, plus totals. 2. Is there a project plan developed which provides information on funding needs for IDD control? If yes, what amount of money is designated in the plan? If sufficient detail exists, please fill in the following table. Total IDD Program Funding History and Forecast for Country IDD Activity Year Supplementation $(000) Fortification $(000) Other (specify) Total $(000) (if applicable) Activity $(000) 1998 1999 2000 2001 2002 2003 2004 2005 Thank you for your time and effort in completing the IDD questionnaire. Your information will be of great assistance.