Date: Sun, 16 Aug 1998 11:40:23 +0100

From: "Dr. Hanaa Ismail" <ismailattecmina.com>

Subject: Ngonut: Egypt -iodination of salt.

Dear All,

We are working on the iodination of salt in Egypt where IDD was found to be

as high as 82% in some areas .Universal salt iodination is the case however

some cries are emerging from the media triggered by some nutritionists that

this may lead to thyrotoxicosis and that people should have the choice.

References have been made of the Zimbabwe experience.

I am compiling a report on the (Iodization of salt ,The Egyptian

Experience) .I would appreciate feed back on how to effectively counter

this criticism

Hanaa

DR H. Ismail

Head Nutrition Department

HIPH

Alexandria University.

Date: Thu, 20 Aug 1998 14:27:11 +0100

From: Ted Greiner <Ted.Greineratich.uu.se>

Subject: Ngonut: Egypt -iodination of salt.

Dear Dr. Ismail,

Perhaps you should explain that it is virtually only people with nodular goiters who can be affected in this way. These people may be too few to justify uniodized salt being available generally on the market. However, if funds are not available to provide these people with alternative methods of treatment, perhaps you should make uniodized salt available for such people through the health services for several years (until nodular disappears).

Sincerely,

Ted Greiner, PhD, Nutritionist

Section for International Child Health

Department of Women's and Children's Health Entrance 11

Uppsala University

75185 Uppsala

Sweden

ph +46 18 511598

fax 515380

email Ted.Greineratich.uu.se

Ted Greiner's Breastfeeding Website:

http://www.geocities.com/HotSprings/Spa/3156/

Date: Thu, 20 Aug 1998 10:58:21 -0400

From: Laurie Aomari <LAomariatilsi.org>

Subject: Re: Ngonut: Egypt -iodination of salt.

Dear Dr. Ismail:

Your email dated 16 August just reached me.

I am forwarding a copy of your message to Dr. Anna Verster at the WHO

office in Alexandria just on the outside chance that you're not

already working closely with her.

I will also forward your message to Dr. John Dunn who is an

endocrinologist and an expert in iodine nutrition. Through his work

with the International Council for the Control of Iodine Deficiency

Disorders (ICCIDD) I expect he's encountered resistance similar to

what you are describing for Egypt.

Good luck and best personal regards,

Laurie Aomari, RD

IVACG Secretariat

Date: Thu, 20 Aug 1998 11:24:51 -0400

From: jcseteatunicef.org (Joanne Csete)

Subject: Re:Ngonut: Egypt -iodination of salt.

Two publications that lay out the arguments well are:

1. Joint WHO/UNICEF/ICCIDD Consultation: Review of findings from 7-country study

in Africa on levels of salt iodization in relation to iodine deficiency

disorders, inclduing iodine-induced hyperthroidism (WHO/NUT/97.5, Geneva), which

the WHO office in Egypt may have.

2. Iodine-induced hyperthyroidism: Report of a workshop organized by ICCIDD,

March 1996, found in the journal Thyroid, volume 8, number 1, 1998.

An excerpt from the summary of the first document is as follows:

"The findings of the African multicentre study show that universal salt

iodization was introduced within the past five years, although iodized salt has

been on the market for 15 years in Kenya and 25 in Zambia. The marked decrease

in the prevalence of goitre in most surveyed areas is a striking confirmation of

the effectiveness of universal salt iodization in Africa. The increase in

urinary iodine concentrations gives an objective confirmation of this, although

in five countries the median concentrations of urinary iodine were as high as 30

microgrammes/dl. Nevertheless, iodine-induced hyperthyroidism was documented in

only two countries and was clearly linked to iodine overload at the household

level. This was due to excess during production and lower losses than expected

between production and consumption.

"The Zimbabwe case study is an example of a longitudinal study that should be

replicated in other countries. The data indicate that the high iodine content

of salt is the most likely factor behind iodine-induced hyperthyroidism. These

high levels of iodine in salt are in part due to ineffeicient monitoring of salt

iodization during production....

"To minimize iodine-induced hyperthyroidism, the iodine level should be set at

the lowest level which prevents all manifestations of iodine deficiency

diseases. A basic monitoring programme includes a qualified IDD committee,

supported by a network of field-testing with reliable kits; independent

laboratories able to carry out iodine titration in salt and urinary iodine

analysis; data from sentinel sites which will permit readjustment of the salt

iodiszation programme; surveillance of the incidence of hyperthyroidism by a

thyroid hormone laboratory."

Let us know if you need help getting copies of these documents.

Joanne Csete

UNICEF Nutrition Section

Date: Thu, 20 Aug 1998 14:43:25 +0100

From: "John T. Dunn" <jtdatavery.med.virginia.edu>

Subject: Re: Ngonut: Egypt -iodination of salt.

REPLY: The data we have in ICCIDD, from the 1996 Harare

Conference, describes 9 of 22 governorates with goiter

prevalence greater than 5%, and three considered problems, with

prevalences from 27% to 82%. The same report mentions urinary

iodine concentrations that are normal or borderline, being 89

mcg/L, 108, and 151 for the three. The thyroid may remain

large even after correction of iodine deficiency, particularly

if longstanding or in older subjects. Thus we generally put

more weight on the UI than on thyroid size, unless the latter

is done by ultrasound. From this, I conclude the ID is mild in

Egypt now. This point is important because the IIH

(iodine-induced hyperthyroidism) is usually correlated with the

severity of the preexisting ID and the rapidity of its

correction, eg. Zimbabwe. Still, you can expect some increase

in IIH, usually in older subjects with nodules. We have

published a lengthy report of a symposium on this (THYROID

8(1): 81-112), detailing country examples, pathogenesis, and

recommendations. The conclusions are that yes, some IIH will

occur, but it can be treated and its consequences are much less

than the benefits of correcting iodine deficiency. The best

tactic is to make people aware of the possibility, the general

benefits to the public health from iodine, and the measures for

prompt diagnosis and treatment. Patient discussion of these

points to the dissenting groups can usually be successful.

Let us know if ICCIDD can provide more information.

John Dunn

ICCIDD, University of Virginia jtdatvirginia.edu

Date: Thu, 20 Aug 1998 14:01:54 +0100

From: Mehari Gebre-Medhin <Mehari.Gebre-Medhinatich.uu.se>

Subject: Re: Ngonut: Egypt -iodination of salt.

Dear Dr Ismail!

We share your concern that the risk and possible harm of iodine-induced thyrotoxicosis in areas where IDD is endemic is being exaggerated and viewed from the perspective of countries that have virtually eliminated iodine deficiency and the risk of neonatal brain damage is practically nil.

This makes life difficult for those of us whose primary and legitimate objective is "saving brains" from irreversible damage. Indeed, we wonder whether these two issues,the RISK of iodine-induced thyrotoxicosis and DEMONSTRABLE neonatal brain damage should be mentioned in the same breath.

Let me refer you to a recent letter to the Lancet that we have written, it might be of help.The Lancet vol 352, July 4, 1998. Salt iodation and risk of neonatal brain damage. Sundqvist et al.

With best wishes.

Mehari Gebre-Medhin, MD Professor

Unit for International Child Health, University Hospital, Entrance 11

S-751 85 Uppsala

Phone: +46 18 665990, Fax: +46 18 508013

E-mail: Mehari.Gebre-Medhinatich.uu.se

From: "Verster, Dr Anna NFS" <Versteraatwho.sci.eg>

Subject: FW: Ngonut: Egypt -iodination of salt.

Date: Tue, 25 Aug 1998 12:44:11 +0300

Dear all, I noticed that my reply didn't reach the ngonut-network, so I re-send it. I will meet with Dr Ismail tomorrow, in my office, and I have also discussed the whole issue with the Dean of the High Institute of Public Health in Alexandria, whom I met today. Many people have put a lot of energy into salt-iodization in Egypt, notably the Ministry of Health, UNICEF and WHO. We will all try to make very sure that salt remains properly iodized in Egypt!

Anna Verster

Date: Tue, 25 Aug 1998 15:21:54 +0200

From: fdelangeatulb.ac.be (Delange)

Subject: Ngonut: Iodine-Induced Hyperthyroidism

Dear Doctor Ismail,

Doctor Ted GREINER from Upsala kindly copied to me his correspondance from and to you dated August 20 and discussing the risk of hyperthyroidism induced by iodine following the implementation of a program of salt iodization.

Following the recent report of such cases from Zimbabwe, a very ambitious multicentre study was conducted in seven African countries by ICCIDD, WHO and UNICEF. The purpose was to indentify the causes of the phenomenon and, if necessary, to review the ongoing recommendations on salt iodization. The report was published by WHO, as well as updated recommendations by WHO-UNICEF-ICCIDD on salt iodization and its monitoring.

I would be more than pleased to provide you with the report as well as a set of publications on the topic if you kinldy provide me with your complete mailing address. In brief, the cases in Zimbabwe were due to the introduction of excessively iodized salt produced in Botswana and to inadequate monitoring of the iodine content of salt and the status of iodine nutrition of the population. Such events underline the absolute necessity to implement adequate monitoring during salt iodization, especially during its early phase. Precise recommendations for this are provided by the publication indicated above. The firm conclusion of the three organizations, WHO, UNICEF and ICCIDD is that the occurrence of these avoidable side effects should not question the validity at necessity of implementing salt iodization in case of iodine deficiency. Again, please let me know if you are interested to receive these documents, the address to which they should be mailed and optimally the structure of the IDD program in your country.

More generally, ICCIDD is ready to get much more involved in your region because we feel that our links are unsufficient with many countries in the region in spite of the degree and severity of iodine deficiency prevailing in some of them. We are looking for national partners in order to develop these contacts. You might be interested to know that we had a Regional WHO-UNICEF-ICCIDD meeting on IDD control in the region in Alexandria in 1993. Please let me know as to whether we can be of any further help and support.

Looking forward to hearing from you, I am,

Yours sincerely,

F. DELANGE, MD

Executive Director, ICCIDD

153, av. de la Fauconnerie

1170 - Brussels, Belgium.

Tel. : +32-2-675 85 43

Fax : +32-2-675 18 98

E-mail : fdelangeatulb.ac.be

Date: Thu, 20 Aug 1998 14:52:40 +0100

From: "Dr. Hanaa Ismail" <ismailattecmina.com>

Subject: Ngonut: thanks

Thanks to all for the wonderful response to the salt iodization question i

asked a few weeks back.I hope the report will help prevent the cancellation

of the universal salt iodization programme in Egypt.

As per the aflatoxin problem in Somalia. We were faced with a similar

problems around 15 years ago in faba beans one of the stable diet in this

country.It was unofficially dealt with through use of ammonia and dry sun

plus hand sorting.