1 No.Z. 28020/50/2003-CH Government of India Ministry of Health & Family Welfare Department of Family Welfare CH Section Nirman Bhavan New Delhi Dated The 8th April.2004 To Director of Family Welfare of all States/UTs Subject:- Recommendations of National Workshop on Micronutrients Sir. Indian Council of Medical Research. New Delhi has organized a National Workshop on Micronutrients in New Delhi from 24-25 November 2003. Recommendations of workshop are enclosed for information. Yours faithfully Sd/ Dr. Sangeeta G. Saxena Assistant Commissioner(CH) Copy to:- UNICEF (Dr. Werner Schultink) 73, Lodhi Estate New Delhi-110003. 2 RECOMMENDATIONS NATIONAL WORKSHOP ON MICRONUTRIENTS (24-25TH NOVEMBER, 2003, NEW DELHI) ORGANIZED BY INDIAN COUNCIL OF MEDICAL RESEARCH NEW DELHI ON BEHALF OF MINISTRY OF HEALTH AND FAMILY WELFARE NEW DELHI 3 CONTENTS Page 1. General recommendations 1 2. Recommendations on anaemia 5 3. Recommendations on vitamin A 9 4. Recommendations on Iodine Deficiency Disorders 12 4 RECOMMENDATIONS OF NATIONAL WORKSHOP ON MICRONUTRIENTS HELD ON 24-25TH NOVEMBER, 2003 AT DELHI AND ORGANIZED BY INDIAN COUNCIL OF MEDICAL RESEARCH ON BEHALF OF MINISTRY OF HEALTH AND FAMILY WELFARE 1. GENERAL RECOMMENDATIONS. Integrated National Programme activity for Prevention, Control and Elimination of all the three Micronutrient Deficiencies of Iron, Vitamin A and Iodine has been recommended. This activity should form part of Reproductive & Child Health (RCH-2), Department of Women and Child Development (DWCD) and Ministry of Health efforts. 1.1 The following strategies should be adopted: 1.1.1 The distribution of Iron & Folic Acid (IFA) and Vitamin A supplements and promotion of iodized salt should be pursued actively throughout the year as a part of routine Primary Health Care activities. Attempts should be made to cover the beneficiaries of National Anaemia Control Programme (NACP) and Vitamin A Prophylaxis Programme through the routine Primary Health Care/ICDS activities throughout the year. 1.1.2 Two months in a year, six months apart, (say May and November) should be declared as, “Health and Nutrition promotion month”. During these months intensive activities for promotion of consumption of iodized salt, IFA and Vitamin A supplement should be undertaken. The choice of the months may be at the discretion of the State government. 1.1.3 The following activities should be undertaken during the Health and Nutrition Promotion month. 22.214.171.124 A family-wise list of all the adult and child beneficiaries of NACP and Vitamin A Prophylaxis Programme will be prepared. 126.96.36.199 The sub-centre level health workers will allot one week for each village for the delivery of package of following services with the help of the Anganwadi workers (AWWs) of ICDS Scheme. i. IFA supplementation to preschool children 6 months and older, school going children, adolescents, pregnant and lactating mothers. ii. Vitamin A supplementation to children in the age group of 9 months to 36 months. It would be ensured that all children who have not been immunized for measles vaccine would be given measles immunization along with the first mega dose of vitamin A. This would provide life-time protection to children against measles and its complications. iii. Antenatal contact points should be utilized to promote “early initiation of breast feeding” to enable feeding of “colostrums” to the new born, and exclusive breast feeding for the first six months, complementary feeding from six months of age and utilization of services under 5 National programmes for all the three micronutrients. Lactating mothers should be advised on advantages of breast feeding, adequate complementary feeding of infants with home based foods from 6 months of age while continuing breast feeding up to age of 12 years and ensuring complete immunization. iv. The salt consumed in the families would be tested for its iodine content using salt testing kit and mothers would be educated about benefits of daily consumption of iodized salt. 1.2 Procurement and Supplies 1.2.1 Under the RCH Program, Kit A supplies to the sub centers should be regular. 1.2.2 In view of additional beneficiaries as per the recommendations and also effective implementation of the ongoing programme goals the additional requirements per sub-centre would be as follows: Micronutrients Numeber IFA Adult tabs = 26,300 Paed. tabs = 67,000 IFA syrup bottles = 368 (50 ml) (1 ml = 20 mg of Fe) Vitamin A Bottles of 100 ml = 4 Iodine Salt testing kits = 7 Provision should also be made for the population growth in the sub centre area. Urban areas, especially the slums, need to be also provided with Kit A supplies. These should be estimated taking wastage into account. 1.3 Behaviour Change Communication: Mother Child contacts should be used to pass on five standard messages on feeding and caring practices. Action should be taken to identify appropriate local foods to be recommended in different regions for 6 months to 3 years children through operational research projects. A communication strategy for all the three micronutrients considering life cycle approach to nutrition and health should be developed. 1.4 Food fortification Ready to eat foods provided under various nutrition programmes/foods consumed regularly should be fortified. It is recommended that a relevant group be constituted to develop a concrete strategy and action plan for micronutrient fortification of food supplements given in the national programmes and foods commonly used. 6 1.5 Intersectoral-Co-ordination: A Co-ordination committee should be formed involving all the stakeholders at all levels to have an integrated approach to child health, nutrition and development. The co-ordination between the Ministries of Health & Family Welfare and Women and Child Development should be strengthened through regular meetings and contacts. There is a need for integration of control programmes of all the three micronutrients. This has been successfully done under RCH programme in Maharashtra, Gujarat, Jharkhand and Orissa. Successful State experiences/strategies should be shared between states for incorporation in their activities with appropriate modifications. There is a need for involved of Panchayati Raj Institutions for effective implementation of all three micronutrient programmes at the district, block and village level. 1.6 Need for Regular Reviews: There is a need for regular review meetings at the national, regional and state level so as to track the progress of the integrated national programme activity for all the three micronutrients. 1.7 Monitoring and Maintenance of Registers: Immunization card, with provision for five doses of vitamin A, IFA should be provided to each child to monitor its Immunization. The present reporting “Form 9 of the RCH Program” and “Immunization card” should also incorporate provision for recording IDD activities such as assessing iodine content of salt. Registers should be maintained at the sub centre and Anganwadi Centre (AWC) to record and track left/drop outs. Clear guidelines should be given to the health functionaries for its maintenance and regular reporting. Targets and coverage achieved should be regularly monitored as a part of the RCH monthly review at the sub district, district level and subsequently at the state level at regular intervals. 1.8 Supervision & Training Intensive training of health and ICDS personnel is required to enable them to undertake various activities envisaged in the proposed Integrated Programme of all three micronutrients. Upgrading the current manual for training for the functionaries covering all three micronutrients and specially in regard to dose, dose interval, side effects and their management and contraindications (uncontrolled vomiting, severe diarrhea and very sick child requiring hospitalization) has been emphasized. Trained AWW under the overall supervision of the ANM should administer Vitamin A. Local adaptation may be done in difficult circumstances (tribal/hard to reach areas and staff unavailability). Precaution should be taken 7 that no untrained personnel‟s services are used in the supplementation efforts. Supervisors need also to be oriented for Vitamin A supplementation. Members of the local self government such as Panchyats, other Government department such as ICDS and Education and NGO‟s need to be involved in mobilizing support for the program. A manual on Integrated Operationalisation of all the three micronutrients should be developed for training at district, block, PHC level for health and ICDS functionaries. 1.9 Capacity Building Strengthening of four existing regional institutional laboratories for assessment of micronutrient situation in the region should be undertaken on a priority basis. 2. RECOMMENDATIONS ON ANAEMIA: 2.1 Tenth Five Year Plan (2002-2007) Goals: i. Screening of children for anaemia wherever required and appropriate treatment of those found anaemic. ii. Universal screening of pregnant women for anaemia and appropriate treatment. iii. Reducing the prevalence of anaemia by 25% and moderate and severe anaemia by 50% in children, pregnant and lactating women and adolescents. 2.2 National Anaemia Control Programme (NACP): 2.2.1 Objective: The programme is aimed at decreasing the incidence of anaemia among the vulnerable sections of the population namely pregnant and lactating women, intrauterine device (IUD) users as well as children in the 1-5 year age group. 2.2.2 Beneficiaries and Dosage of Supplementation: For prevention in “high risk groups” Pregnant women One big (adult) tablet per day 100 mg elemental iron and 500 µg of folate for 100 days after first trimester of pregnancy. Lactating women One big (adult) tablet per day 100 mg elemental iron and 500 µg of folate for 100 days Pre-school children One small (paediatric) tablet per day 1<5 year old 20 mg elemental iron and 100 µg of folate for 100 days every year For treatment of severe anaemia cases (Haemoglobin <7 g/dl) Pregnant women/15-45 year old women Two big (adult) tablets per day 200 mg elemental iron 1000 µg of folate for at least 100 days Also, referral to Primary Health Centre 8 2.3 Implementation: The NACP is implemented through existing primary health care infrastructure and with the assistance of ICDS network. 2.4 Current Status: Big and small IFA tablets are made available at subcentre in the blister packing under RCH Programme. The NACP has varied level of compliance. There are states like Kerala, Tamil Nadu, Goa where compliance for pregnant women (IFA tablets) are over 90%, the state of Bihar, U.P. have compliance of less than 30%. Further, there are districts spread over the whole country with good compliance of over 90% as also with poor compliance of less than 30%. 2.5 Recommendations of the Workshop: 2.5.1 In view of the high prevalence of anaemia among population and also keeping in view the consequences of anaemia, the NACP should be accorded high priority. 2.5.2 The recommendations made in the workshop which related to relate to additions to the program are as under:- Table A. Additional beneficiaries and doses of IFA tabs and syrup Beneficiary Existing Basis for new Implication program recommendation Infants 6-12 months: Infants are not Irreversible effects Provision for Iron 10 mg/day IFA in beneficiaries of anemia on syrup, training of syrup form. under NACP. cognitive growth. service providers, and community awareness. Children 1-3 yrs: 20 One IFA tablet Children 1-3 year Provision for Iron mg/day IFA in syrup (small: 20 mg) have difficulty in syrup, training of form for minimum 100 per day is consuming tablets service providers, and days in a year recommended resulting in poor community awareness. currently for 1-5 compliance. (for >3-5 years years children for children IFA tablet 100 days in a year as in existing programme). Children >5-10 yrs: Children >5-10 High prevalence of Additional provision Two small IFA tablets yrs not included anaemia. for small IFA tablets, (40 mg) per day for in NACP. training of service minimum 100 days in providers, and a year. community awareness. Adolescent girls>10- Adolescent girls High prevalence of Additional provision 18 years: One big IFA are not included anaemia. for big IFA tablets, tablet daily for in NACP. Adolescent girls training of service minimum of 100 days need to be prepared provider, and in a year or one big for pregnancy, community awareness. IFA tablet weekly therefore stored iron throughout the year. needs to be good. Pregnant and One big IFA High prevalence of Additional provision lactating mothers: tablet per day for anaemia in pregnant for big IFA tablets, One big IFA tablet 100 days after and lactating training of service 9 daily after 3 months of first trimester of mothers. providers, and pregnancy till 6 pregnancy and community awareness. months of lactating also minimum post partum. 100 IFA tablets during lactating. Table B: Requirements of small and big IFA tablets as well as syrup for a sub center (5000 population) for a period of 6 months in RCH kit-A Beneficiary (Age group) Likely number of Requirements of IFA Beneficiaries 6-12 months (Infants) 75 IFA syrup (1 ml containing 20 mg) 68 bottles [50 ml] 1-3 years 300 IFA syrup (1 ml containing 20 mg) 300 bottles [50 ml] >3-5 years 300 IFA tabs (paediatric) 15,000 >5-10 years 650 IFA tabs (paediatric) 65,000 >10-18 years 1000 IFA tabs (adult) 26,000 Pregnant women 100 IFA tabs (adult) 9,000 Lactating women 70 IFA tabs (adult) 6,300 * This is the ideal situation requirement as per the recommendations 2.5.3 Screening of children, adolescent girls, pregnant and lactating women should be done for identification of severely anaemic cases based on clinical signs and symptoms. 2.5.4 All severely anaemic should also be referred to health institutions for treatment at First Referral Unit (FRU) PHCs. These institutions need to be strengthened for management of severe anaemia cases. 2.5.5 Pregnant and lactating women diagnosed as severely anaemic require daily additional dose of IFA. The children and adolescents suffering from severe anaemia should be given daily the IFA in the same doses as mentioned in Table A. 2.6 The Group also reiterated the following:- 2.6.1 Exclusive breast feeding for the first six months should be promoted universally. 2.6.2 Appropriate and adequate complementary feeding of infants with home based foods from 6 months of age along with continued breast feeding up to the age of 2 years should be promoted and supported. 2.6.3 Behavioural Change Communication (BCC) on health consequences of anaemia and importance of food for infants and young children should be strengthened. 2.6.4 All contact points with beneficiaries should be utilized for counseling the mothers on health consequences of anaemia and benefits of prevention and control of anaemia and importance of a diversified diet, improved hygiene and sanitation and use of footwear while in field. 2.6.5 Periodic de-worming specially in hookworm endemic areas should be undertaken. However, de-worming of pregnant women is not recommended in the first trimester of pregnancy. 10 2.6.6 Foods provided under various supplementary programmes should be fortified with iron. 2.7 Researchable Issues 2.7.1 Operational Research: i. To assess the impact of compliance on prevalence of anaemia under NACP ii. To evaluate supply and logistics of sub center kits vis-à-vis compliance/coverage of IFA tablets by beneficiaries. iii. To study the relationship between worm infestation on prevalence of anaemia and periodic de-worming. 2.7.2 Basis Research: i. To study the feasibility of fortification of various types of foods with iron. 3. RECOMMENDATIONS ON VITAMIN A: 3.1 Tenth Five Year Plan (2002-2007) Goals: i. Achieve Universal coverage for each of the five doses of Vitamin A. ii. Reduce prevalence of Night blindness to below 1 percent and that of Bitot‟s spot to below 0.5 per cent in children between six months to six year of age. iii. Eliminate Vitamin A deficiency as a public health problem. 3.2 The National Prophylaxis Program for Prevention of Blindness due to Vitamin A deficiency: 3.2.1 Objective: National Prophylaxis Program for Prevention of Blindness due to Vitamin A deficiency was launched in 1970 by the Ministry of Health and Family Welfare with an aim to protect children 1-5 years against Blindness due to Vitamin A deficiency. In 1992 the age group was modified to 9-36 months, in view of higher risk of blindness and deaths due to infection in this age group and also to focus on better coverage for at least 5 doses. 3.2.2 Beneficiaries: The program beneficiaries are children in the age group of 9- 36 months. The first dose of 100,000 IU is given to children at 9 months along with Measles immunization. The second and subsequent doses (200,000 IU) are given every six months till children complete 3 years of age. 3.3 Implementation The program is implementation through the Primary Health Care infrastructure. The services of the Anganwadi workers under ICDS are utilized for the distribution of Vitamin A and educating mothers on measures to prevent Vitamin A deficiency. It is also include under the „Strengthening of Routine Immunization Strategy‟ of the Ministry of Health and Family Welfare Government of India. There is a 11 provision of Vitamin A administration in the Routine Immunization card. The program implementation also takes into consideration the state specific needs. Under the RCH program for every 5000 population, six 100 ml bottles of vitamin A concentrate are provided in the drug kit six monthly. 3.4 Current Status: The coverage as per the NFHS 2 survey of 1998 is inadequate;29.7% children in the age group of 12-35 months are reported to have received at least one dose to vitamin A during the previous year. The district level rapid household RCH survey 1998-99 indicated that 35% of Children had received at least one dose of Vitamin A during the previous year. Recent second district level RCH survey (2002-2003) showed that 23% of children had received one dose while 13% had received 2-5 doses of Vitamin A. 3.5 Recommendations of the Workshop: 3.5.1 In view of the public health significance of VAD in young children, Vitamin A supplementation should be continued to children between 9-36 months of age at six monthly intervals. 3.5.2 Distribution schedule: Age group Dose Dosage 9<12 months First dose (1 dose) 100,000 IU 12<36 months Second to fifth dose (4 dose) 200,000 IU Children in the age range of 9-12 months should receive 100,000 IU of vitamin A, which should be provided along with measles vaccination. Intensive efforts should be made to increase the coverage of both measles vaccination and the first dose vitamin A supplementation through the routine system. Provision of 200,000 IU every 6 months to children in the age range of 13-36 months should be ensured through the implementation of a bi-annual one month long special effort. These special efforts should be designated as, “Health and Nutrition Promotion” months, and should be organized 6 months apart, in addition to the ongoing routine activities of the RCH programme. 3.5.3 Syrup or Capsule: It was recommended to continue to use vitamin A supplement in syrup form. The spoon to be used should be two-ended with 1 and 2 ml capacities at respective ends. Capsule (vegetable based), if found economical should be considered as it has longer shelf life, dosing is accurate, loss is minimal and is hygienic. 3.5.4 Dietary diversification & food fortification The ready to eat supplementary foods supplied through various nutrition programmes of Government should be fortified. Dietary diversification and 12 fortification of foods are recognized as important strategies and these should be encouraged. 3.5.5 Therapeutic Needs: Children suffering from Night Blindness/Bitot‟s spot, severe Pem and Measles should be given an additional dose of Vitamin A, irrespective of age. Pregnant and lactating mothers suffering from Night Blindness should be appropriately managed at the health center with Vitamin A dose not exceeding 10,000 IU per day for a period of 6 weeks or until night blindness disappears. As a part of comprehensive antenatal care, pregnant and lactating women should be screened for night blindness in antenatal and postnatal clinics regularly. 3.5.6 Procurement and Supplies: Under the RCH programme, kit A supplies to the sub centers should be regular. Requirement of Vitamin A per sub center [5000 population] per round are summarized below: Beneficiaries Likely number Vitamin A Bottles of Vitamin [Age in months] of beneficiaries required in ml A required [100ml] 9-12 30 30 12-24 125 250 24-36 125 250 10 bottles of 100 ml XN + XB 10 20 Severe PEM 100 200 Measles 125 250 Total 515 1000 For pregnant and lactating women with XN additional provision of 250 capsules (10,000 IU) of vitamin A should be made at the primary health center. Extra provision should also be made for the population growth in the sub center area. Urban areas especially the slums need to be provided with Kit A supplies. This should be estimated taking wastage into account. 3.6 Research Issues: 3.6.1 Operational Research: i. To assess impact of coverage/compliance on prevalence of VAD under Vitamin A supplementation. ii. To evaluate supply and logistics of sub center kits vis-à-vis compliance and coverage of Vitamin A doses by beneficiaries. 13 3.6.2 Basic Research: i. To study the feasibility of fortification of various types of foods with Vitamin A. 4. RECOMMENDATIONS ON IODINE DEFICIENCY DISORDERS: 4.1 Tenth Five Year Plan (2002-2003) Goals: i. Achieve universal access to iodised salt. ii. Generate district-wise data on iodised salt consumption. iii. Reduction in the iodine deficiency disorders (IDD) prevalence in the country to < 10% by 2010. 4.2 National Iodine Deficiency Disorders Control Programme (NIDDCP): This programme was initially named as National Goitre Control Programme (NGCP) in 1962. However, in 1992 it was renamed ad NIDDCP to give due importance to the spectrum of physical and mental disorders caused due to iodine deficiency affecting all stages of human growth and development. 4.2.1 Objectives: The main objectives of the program are: i. Baseline surveys to assess the magnitude of iodine deficiency disorders in the districts. ii. To supply iodised salt in place of non-iodised salt. iii. To resurvey the districts after every five years to assess the prevalence of iodine deficiency disorders and impact of universal consumption of iodised salt. iv. Monitoring of iodine content of salt and urinary iodine excretion levels in the population. v. Nutrition and health education to improve the universal consumption of iodized salt. The goal of NIDDCP is universal iodization of salt for human consumption so as to reduce the prevalence of IDD below 10% in endemic districts of the country. 4.2.2 Beneficiaries and Services: The beneficiaries of the programme are the entire population of the country. 4.3 Implementation: 14 The Directorate General of Health Services (DGHS) of the Ministry of Health and Family Welfare, Government of India is the nodal agency for policy decisions on the NIDDCP. The Salt Commissioner‟s Office under the Ministry of Industry is responsible for monitoring the production and distribution of iodised salt to all the states and Union Territories. The Salt Commissioner, in consultation with the Ministry of Railways, arranges for movement of iodised salt from the production sites to the states and union territories on a priority basis. The important activities being undertaken by the NIDDCP are: 4.3.1 DGHS: i. Technical guidance on NIDDCP to states and Union Territories. ii. Undertaking independent IDD surveys in the states and UTs. iii. Imparting training in IDD to the state health personnel. iv. Collection, compilation and analysis of relevant data on IDD from the states. v. Monitoring the distribution of iodised salt at consumer level through the State Health Directorate/State Prevention of Food Adulteration (PFA) Authority. 4.3.2 DGHS/Salt Commissioner/DWCD: i. Intersectoral Coordination and maintenance of close liaison with the Ministry of Industries, Railways, Department of Women and Child Development, Information Broadcasting and various stake holders of NIDDCP in the states and Union Territories. ii. Monitoring the quality of iodised salt as the production level in collaboration with the office of the Salt Commissioner. iii. IEC activities to generate awareness about IDD in the country. 4.4 Current Status: Available data suggest that there has been substantial increase in the availability and consumption of iodised salt during the 1990s. The National Family Health Survey (NFHS-2) during 1998-99 showed that 49 per cent of households use iodised cooking salt at the recommended level of 15 ppm or more, whereas 22 per cent use salt containing less than 15 ppm of iodine. Twenty eight per cent of the households use salt that is not iodised. The survey also reports that the low income group has the lowest percentage of population consuming adequately iodised salt. The recent Reproductive and Child Health (RCH) surveys (2002-2003) have reported a significant decline in the consumption of adequately iodised salt. The data from NFHS-2 shows that in coastal states like Tamil Nadu, Andhra Pradesh, Kerala and Gujarat, the percentage of households consuming adequate iodised salt is much lower than in many of the northern states. One of the reasons could be that the salt transported by road is not subject to any knid of quality control regarding iodisation. This loophole in the law makes it 15 possible for transport of non-iodised salt by road to areas even beyond 250 km. Therefore, these states have ready access to non-iodised salt. 4.5 Recommendations of the Workshop: In view of the country wide endemicity of Iodine deficiency disorders (IDD) among population and also keeping in view the serious consequences of IDD, the NIDDCP should be accorded high priority. 4.6 Implementation of State Ban on the sale of non-iodised salt and Policy Support There is a need of encouraging states like Kerala, Gujarat, Maharashtra, which either do not have the ban or have a partial ban, to implement the ban on sale of non-iodised salt in the entire state. Other states, which have the statewide ban, should be encouraged to implement PFA more strictly. In that context, the Ministry of Health and Family Welfare, Human Resource Development, and Industry, Government of India should communicate the urgency in IDD elimination to the state governments, urging them to intensify efforts to implement the IDD control program effectively. 4.7 Demand Creation: Information, Education and Communication (IEC) messages regarding universal salt iodisation (USI)/IDD should shift from goiter to loss of IQ and poor scholastic performance, effects of iodine deficiency on pregnancy outcome (stillbirths, abortions, low birth weight and mental handicap). New education and communication approaches also involving school children must be considered and successful experiences should be shared between states. 4.8 Increasing Supply of Iodized Salt Support and encourage salt producers and salt traders to increase the supply of adequately iodised salt, Effective partnership with the private sector should be forged and continuously maintained. 4.9 FA Act Implementation Modification of Prevention of Food Adulteration (PFA) Act should be undertaken as under: Current PFA Act Recommended Amendments to the PFA Act * Non-bailable warrants if the salt * Non-bailable warrants and iodine content is less than 30 ppm at imprisonment should be omitted the production level and 15 ppm at the consumption level * This rule should amended to include a fine amount not less than * Imprisonment for not less than 6 Rs 10,000/- months 16 * Fine of up to Rs 1000/- * The legal provisions to prevent Detection of misbranding of iodised misbranding (Brand name, content, salt should be given high priority. A MRP, batch number, address) exist. fine amount of not less than Rs Presently there is no monetary fine. 10,000 should be imposed on the concerned producer, wholesaler and retailer. The modified PFA Act should be effectively enforced. 4.10 Monitoring of Iodine Content of Salt Establishment of effective quality control and monitoring system of iodine content of salt at all levels, as per the national guidelines should be carried out. 4.11 Provision of salt testing kits Salt Testing Kits should be made available to multi-purpose health workers (Male and Female), and Anganwadi Workers for testing iodine levels at the household level. Under the RCH Program Kit A provided at the sub-centre level should also include 7 salt testing kits. Of these, one kit each is to be provided to the Male and Female Multi-purpose health workers and one esch to five Anganwadi workers. The results of analysis should be included in the monthly reporting forms, i.e. Form 9 of RCH for multi-purpose health workers (male and female) and in appropriate forms for anganwadi workers. 4.12 Strengthening of Salt Department There is a need carry out rigorous monitoring of quality of iodised salt at the production level. The activities should include upgrading of laboratory facilities, periodic and regular training of staff, development of standard protocol for monitoring, internal and external quality assurance, development of a system for reporting and dissemination of results, and development of Geographical Information System (GIS)/Information Technology (IT) road map of the Salt Department. These steps would be effective and efficient only when the salt department develops linkages with the health department so that appropriate action is taken against the salt producers and traders who do not meet the set standards under the PFA. 4.13 Laboratory Facilities There is a need for establishing regional IDD laboratories for monitoring the iodine content of salt. At present there are three laboratories (AIIMS and NICD at Delhi, AIIPH at Kolkata) carrying out estimation of urinary iodine excretion levels. There is a need to strengthen these laboratories and establish a standard protocol, including quality assurance, amongst these laboratories. 4.14 Annual Cyclic, Monitoring and Information Management There is a need of collecting data on iodised salt consumption and urinary iodine excreation level in the different districts of the country. About 120 17 representative districts should be covered each year for assessment of iodine centent of the salt and urinary iodine excretion level. This would ensure that, over 5 years, all the districts of the country would be covered. Standardized methodology and uniform indicators should be utilized to collect, compile and analyze the collected data. This data should be incorporated into a database of IDD indicators (including salt iodine, urinary iodine, goiter rates), which should be available to all. This database needs to be updated annually. 4.15 Packing of Iodised Salt Iodized salt should also be packed in ½ kg consumer polypacks at the production site itself to prevent iodine losses during transportation and storage. 4.16 Support to Small scale salt producers Small scale salt producers should be encouraged to form cooperatives and, in that case, Government of India should provide iodization plants to these cooperatives. 4.17 Transportation of Iodized Salt Rail transport is the most important means for transport of iodised salt in India. The Ministry of Railways should be requested to provide covered wagons for transport of iodised salt, and ensure its regular and periodic supply. 4.18 Ensuring Iodized Salt to Poor/Low Socio-economic Communities In view of lower consumption of iodised salt by the low income group, iodised salt should become part of Public Distribution System (PDS) catering to population Below Poverty Line (BPL). Many states are selling the salt through the public distribution system (PDS) and there is a need of universalizing the same. 4.19 Intersectoral Co-ordination There is a need of integration of IDD control programme activities with prevention and control of iron land vitamin A deficiencies. This has been successfully done under RCH programme in Maharashtra and Gujarat. There is a need of involvement of Panchayati Raj institutions for effective implementation of NIDDCP at the district, block and village level. 4.20 Need for Regular Reviews: The Workshop reiterated the need for regular review meetings of the four committees for IDD elimination that have been established for monitoring the implementation of NIDDCP. These Committees are, National Steering Committee chaired by Secretary Health, Program Implementation Committee under Director General of Health Services, National and State Level Lab Monitoring Committee, National Level IEC Committee. 18 Similar state level committees should be re-activated/constituted to include all stakeholders – Departments of Health and Family Welfare, Education, Food and Civil Supplies, Women and Child Development, State Planning Commission, Managers from other programs like RCH, ICDS, National agencies like Salt Department, ICMR, NIN, NIE, AIIMS; Salt producers and traders, NGOs, International agencies like UNICEF, MI, ICCIDD, WHO 4.21 Researchable Issues: i. Operational Research To determine feasible strategies for monitoring iodine content of salt at different levels. ii. Basic Research To study the relevance of different indicators of iodine status in pregnancy and suggest suitable indicators for screening for iodine deficiency during pregnancy.