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                            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.

1.1.3.1    A family-wise list of all the adult and child beneficiaries of NACP and
           Vitamin A Prophylaxis Programme will be prepared.

1.1.3.2    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
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       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.
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         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.

				
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