Continued . . .

 

4.   Assessment of IDD in District Kangra, Himachal Pradesh

 

4.1  Objectives    

 

        The present study was conducted with the following objectives:-

 

i)     To assess the prevalence of IDD in district Kangra, HP.

 

ii)    To estimate the iodine content of salt consumed by population in district Kangra.

 

4.2  Methodology

 

        The study was conducted in the district Kangra of Himachal Pradesh. The “30 cluster” sampling methodology as recommended by the joint WHO/UNICEF/ICCIDD Consultation on IDD indicators was followed for selecting the survey sites (9).

 

 

        Children in the age group of 6-11 years were considered for the present study.  School children in this age group  are recommended  for the assessment of IDD  because of their  combined high vulnerability to disease, representativeness of their age group in community and easy accessibility (9) (Appendix II).  In district Kangra, the school enrollment of primary classes was more than 90% and hence the school approach was adopted.  

 

        The sample size of children to be surveyed was calculated with a presumption  that the prevalence of goiter at the time of the survey  as 5%. The confidence level of 95%, relative precision of 10% and design effect of three was considered for calculation of sample size. Utilising these parameters, a sample size of 21,897 was obtained (Appendix III).      

 

        District Kangra had a total of 1691 primary schools. All the primary schools in rural and urban units in the district with their respective school children population were enlisted for population proportionate to size  cluster sampling methodology (9). Thus, from the total, 30 clusters of school units were selected using  population proportionate to size cluster sampling procedure (Appendix IV).    

 

        In  each identified school unit (cluster) the detailed survey was conducted (Appendix V). In each school, about 730 children  were surveyed. If the sample could not be covered in one school, the adjoining school/schools were included to complete the sample of minimum 750 children of a cluster. The cluster wise list of schools visited in district Kangra is given in appendix VI. In each class, the children were briefed about the study objectives. Subsequently, the children between  6-11 years of age were identified with the help of school records for inclusion in the study. An attempt was made to  study an equal number of children (730-750) in the age group of 6-11 years. The clinical examination for goitre was done by medical doctors specially recruited and trained for the survey. Grading of goitre was done according to the criteria recommended by the joint WHO/UNICEF/ICCIDD (grade 0 = no goitre; grade 1 = thyroid palpable but not visible; and grade 2 = thyroid visible with neck in normal position)(Appendix VII). When in doubt, investigators were asked to record the immediate lower grade. Intra and inter-observer variation was controlled by repeated training and random examinations of goitre grades by the experts. The results were recorded in a pre-designed questionnaire. The sum of grades 1 and 2 provided the total goitre rate (TGR) in the study population.

 

        On the spot urine samples were collected from every tenth child included in the study. In each cluster, about 70 casual urine samples were collected in wide mouthed screw capped plastic bottles (one drop of toluene was added to each sample to inhibit bacterial growth and to minimize bad odour). Iodine was determined by the wet digestion method (10). The results were expressed  as mcg iodine/dl urine.  The severity of IDD based on the median UIE levels was done according to the criteria of WHO/UNICEF/ICCIDD (Appendix VIII).

 

        In each cluster, more than 35 salt samples were randomly collected  from  the school children who were included in the study. The subjects were asked to bring about 20g of salt which was routinely being consumed in their respective homes in auto seal polythene pouches.  The iodine content of the salt was estimated by the idometric titration method.

 

4.3  Results

 

        A total of 23,348 school children in the age group of 6-11 years were included for the study (Table I). Nearly an equal number of children in each age group between 6 to 11 years  of age were studied (Table II).  Table III  gives the distribution of children according to sex and age.  The male:female ratio of the study samples was 1:1.

 

        The total goitre prevalence rate was found to be 12.1% (Table IV).

 

        The  prevalence of goitre in male and female children has been shown in tables V and VI, respectively. No significant  difference was found in goitre prevalence amongst the male and female children.      

 

        The age wise goitre prevalence has been depicted in table VII. The highest prevalence of goitre  was observed in children of 8 years of age.    

 

        Table VIII depicts the prevalence of goitre in different clusters studied. 

 

        The table IX depicts the urinary iodine excretion level in children. It was found that 3.5, 3.8 and 14.2 percent of the children had  urinary excretion levels of < 2, 2 - 4.9 , and 5 - 9.9 mcg/dl, respectively. The median urinary iodine excretion of the children studied was found to be 15.00 mcg/dl.

 

 

        The iodine content of salt samples collected and analysed is depicted in table X. Salt with a nil iodine content was consumed  by only 0.8% of the beneficiaries. About 11.9% of families consumed salt with an iodine content of less than 15 ppm. 

 

4.4  Discussion

 

        It has been recommended that if more than 5% school age children (6 - 11 years) are suffering from goitre, the area should be classified as endemic to  iodine deficiency (appendix IX) (9). In the present study, a total goitre prevalence rate of 12.1% was found, signifying  that in district Kangra,  mild iodine deficiency existed. An earlier  pilot study conducted in district Kangra in  1997 revealed goitre prevalence of 5.6%. The difference in the prevalence of TGR of present study could be due to the fact that the present study was conducted on a larger sample and subjects were selected from the entire district.

 

        The median urinary iodine excretion of the children studied was found to be 15.00 mcg/dl indicating that there was no biochemical deficiency of iodine in the subjects studied (when the cut off of 10 mcg/dl or more of median urinary iodine excretion  was used as a criteria for predicting status of iodine deficiency) .

 

        In the present study only 12.7% of the beneficiaries consumed salt with an iodine content of less than 15ppm which was below the stipulated level. This finding revealed that although the salt was being iodised but possibly either an inadequate quantity of iodine was added to it at the production level or there were losses of iodine at the different points of distribution. Similar findings have been reported in earlier studies from Himachal Pradesh (12,13,14). Results of the present study indicated that the population of district Kangra is in a transition phase from iodine deficient to iodine sufficient nutriture. The possible reason of this transition might be due to the increased consumption of salt with sufficient iodine content.

 

4.5  Conclusion 

 

        In the present study a total of 23,348 school children in the age group of 6-11 years were selected using probability proportionate to size cluster sampling methodology.  

 

        A  total goitre prevalence rate of 12.1% was found, signifying  that a mild iodine deficiency existed in district Kangra, HP.

 

        It was found that 3.5, 3.8 and 14.2 percent of the children had  urinary excretion levels of < 2, 2 - 4.9, and 5-9.9 mcg/dl, respectively. The median urinary iodine excretion of the children studied was found to be 15.00 mcg/dl indicating that there was no biochemical iodine deficiency in the group of subjects studied.    

 

        In the present study 12.7% of the beneficiaries consumed salt with an iodine content of less than 15ppm which was below the stipulated level.

 

 

 

 

Table - I

 

Cluster Number  and Child Population Studied                                                  

(n=23348)

 

Cluster   No.

Number

       1

832

       2

793

       3

759

       4

788

       5

821

       6

803

       7

833

       8

754

       9

763

      10

752

      11

757

      12

760

      13

787

      14

755

      15

825

      16

770

      17

759

      18

750

      19

757

      20

778

      21

802

      22

782

      23

817

      24

755

      25

761

      26

750

      27

757

      28

752

      29

756

      30

820

 

                        

Table - II

Agewise distribution of children                                                    

(n=23348)

                  

   Age

  (Years)

Number

Percentage 

    6

4235

18.1

    7

4227

18.1

    8

4496

19.3

    9

4456

19.1

   10

4405

18.9

   11

1529

6.5

 

 

Table - III

Distribution of children according to age and sex  

(n=23348)

 

Age

 

 

Sex   (Years)

Males

 

Females

 

6

7

8

9

10

11

 

2192 (18.3)

2096 (17.5)

2354 (19.7)

2292 (19.1)

2290 (19.1)

745 ( 6.2)

 

2043 (18.0)

2131 (18.7)

2142 (18.8)

2164 (19.0)

2115 (18.6)

784 (6.9)

 

Total

11969 (51.3)

11379 (48.78)

 

 

                         

Table - IV

Distribution of children according to various grades of goitre

(n=23348)

      

Goiter size

Number

Percentage

     0

20527

87.9

     I

2669

11.4

    II

92

0.7

 

 

 

Table -  V

Prevalence of goitre in male children

(n=11969)

 

Goiter

size

Number

Percentage 

   0

10556

88.2 

   I

1368

11.4

  II

45

0.4    

 

 

 

 

Table - VI

Prevalence of goitre in female children

(n=11379)

 

Goiter

size

Number

Percentage   

     0

10036

88.2

     I

1302

11.4

    II

47

0.4

 

 

 

Table - VII

Agewise prevalence of goitre

(n=23348)

 

Goiter size

Age of children

 

6 yr

7 yr

8 yr

9 yr

10 yr

11 yr

 

 

 

 

 

 

 

0

2057

(93.8)

1903

(90.8)

1991

(84.6)

2004

(87.4)

1949

(85.1)

652

(87.5)

I

134

(6.1)

190

(9.1)

353

(15.0)

276

(12.0)

328

(14.3)

87

(11.7)

II

1

(0.1)

3

(0.1)

10

(0.4)

12

(0.6)

13

(0.6)

6

(0.8)

Total

2192

2096

2354

2292

2290

745

 

 

Figures in parentheses denotes percentages


 

 

Table - VIII

Prevalence of goitre in different clusters

 (n=23348)

 

 

Goiter size

Cluster No.

0

I

II

Total

     1

706 (84.9)

114 (13.7)

12 (1.4)

832

     2

711 (89.7)

81 (10.2)

1 (0.1)

793

     3

674 (88.8)

79 (10.4)

6 (0.8)

759

     4

700 (88.8)

87 (11.0)

1 (0.2)

788

     5

707 (86.1)

105 (12.8)

9 (1.1)

821

     6

734 (91.4)

66 ( 8.2)

3 (0.4)

803

     7

747 (89.7)

83 ( 9.9)

3 (0.4)

833

     8

677 (89.8)

74 ( 9.8)

3 (0.4)

754

     9

711 (93.2)

51 ( 6.7)

1 (0.1)

763

    10

646 (85.9)

103 (13.7)

3 (0.4)

752

    11

634 (83.7)

123 (16.2)

0 (0.0)

757        

    12

670 (88.2)

87 (11.4)

3 (0.4)

760        

    13

685 (87.0)

99 (12.6)

3 (0.4)

787        

    14

648 (85.8)

107 (14.2)

0 (0.0)

755        

    15

736 (89.2)

89 (10.8)

0 (0.0)

825        

    16

670 (87.0)

98 (12.7)

2 (0.3)

770       

    17

658 (86.7)

101 (13.3)

0 (0.0)

759        

    18

668 (89.1)

82 (10.9)

0 (0.0)

750        

    19

705 (93.1)

50 ( 6.6)

2 (0.3)

757         

    20

706 (90.7)

71 ( 9.1)

1 (0.2)

778        

    21

710 (88.5)

90 (11.2)

2 (0.3)

802        

    22

678 (86.7)

99 (12.7)

5 (0.6)

782        

    23

663 (81.2)

148 (18.1)

6 (0.7)

817        

    24

663 (87.8)

91 (12.1)

1 (0.1)

755        

    25

686 (90.1)

75 ( 9.8)

0 (0.0)

761        

    26

653 (87.1)

95 (12.7)

2 (0.2)

750        

    27

684 (90.4)

69 ( 9.1)

4 (0.5)

757        

    28

666 (88.6)

75 ( 9.9)

11 (1.5)

752        

    29

667 (88.2)

84 (11.1)

5 (0.7)

756        

    30

724 (88.3)

93 (11.3)

3 (0.4)

820        

  Total

2052(87.9)

2669 (11.4)

92 (0.7) 

23348

 

 

Figures in parentheses denotes percentages

 

 

 

 

Table IX

 

Urinary iodine excretion levels in the study population

(n=1952)

 

 

Urinary Iodine

excretion levels

(mcg/dl)

 

 

Number

 

 

 

 

Percentage

 

 

 

 

 < 2.0

 

 

69

 

 

3.5

 

 2.0-4.9

 

74

 

3.8

 

 5.0-9.9

 

278

 

14.2

 

 10.0 and above

 

1531

 

78.5

 

    

 

Median UIE level = 15.00  mcg/dl

                       

 

Table X

Iodine content of salt samples

(n=1175)

        

 

Iodine content

(ppm)

 

 

Number

 

 

 

Percentage

 

 

Nil

9

0.8

< 15

 

140

 

 

11.9

 

15 and more

 

 

1026

 

 

87.3

 

 

 

 

References

 

1.     Vir S. Universal Iodisation of salt : a mid decade  goal. In: Nutrition in Children - Developing country concerns. Eds. Sachdev HPS and Choudhary P. Cambridge Press, New Delhi 1994, pp 525-535.

 

2.     Venkatesh Mannar MG.  Control of Iodine Deficiency Disorders in India through Iodisation of Salt, UNICEF, New Delhi, 1991.

 

3.     Kapil Umesh.  Iodine Deficiency in India. National Medical Journal of India 1989; 3:98-99.

 

4.     Kapil Umesh.  Status of Nutrition Programmes in India.  Report of National Seminar on “Towards a National Nutritional Policy”.  National Institute of Public Co- operation and Child Development, New Delhi 1989, pp 75-101.

 

5.     Sooch SS, Deo MG, Karmarkar MG, Kochupillai N, Ramachandran K, Ramalingaswami V. Prevention of endemic goitre with iodised salt. Bull WHO 1993; 49: 307-312.

 

6.     Pandav CS, Karmarkar MG, Nath LM. The National Goitre Control  Programme. National Health Programme Series 5, National Institute of Health and Family Welfare, New Delhi 1988, pp 39.

 

7.     Prakash R, Sundaresan S, Mohan R, Mukherjee S, Vir S,  Kapil U. Universalizaztion of access to iodised salt - a mid- decade goal. The Salt Department, Ministry of Industry,  Government  of India.  Thompson Press (India) Ltd 1994, pp 2-6.

 

8.     Global prevalence of IDD.  Micronutrient Deficiency Information system, WHO/UNICEF/ICCIDD 1993, pp 68.

 

9.     Report of a joint WHO/UNICEF/ICCIDD consultation on indicators for assessing IDD and their control programmes. World Health Organisation, Geneva, 1992.

 

10.   Dunn JT, Crutchfield HE, Gutekunst R, Dunn D. Methods for measuring iodine in urine. A joint publication of  WHO/UNICEF/ICCIDD 1993, 18-23.

 

11.   Kapil Umesh, Bhanti T, Saxena N, Nayar D, Dwivedi SN.      Comparison of spot testing kit with iodometric titration      method in the estimation of iodine content of salt. Indian  J Physiology Pharmcol 1996; 40:279-280.

 

12.   Kapil U, Nayar D. Supply of Iodised salt and its iodine content in Himachal Pradesh, India.  Health and Population Perspectives & Issues 1994; 17:137-144. 

 

13.   Kapil Umesh, Sohal KS,Nayar D. Process of implementation of National Iodine Deficiency Disorders control Programme activities in Himachal Pradesh, India, Indian Journal of Public  Health 1995; 39:172-175.

 

14.   Kapil Umesh. Distribution and management of Iodised salt in Himachal Pradesh, IDD Newsletter 1995; 11:47-51. Industry,  Government  of India.  Thompson Press (India) Ltd 1994, pp 2-6.

 

8.     Global prevalence of IDD.  Micronutrient Deficiency Information system, WHO/UNICEF/ICCIDD 1993, pp 68.

 

9.     Report of a joint WHO/UNICEF/ICCIDD consultation on indicators for assessing IDD and their control programmes. World Health Organisation, Geneva, 1992.

 

10.   Dunn JT, Crutchfield HE, Gutekunst R, Dunn D. Methods for measuring iodine in urine. A joint publication of  WHO/UNICEF/ICCIDD 1993, 18-23.

 

11.   Kapil Umesh, Bhanti T, Saxena N, Nayar D, Dwivedi SN.      Comparison of spot testing kit with iodometric titration      method in the estimation of iodine content of salt. Indian  J Physiology Pharmcol 1996; 40:279-280.

 

12.   Kapil U, Nayar D. Supply of Iodised salt and its iodine content in Himachal Pradesh, India.  Health and Population Perspectives & Issues 1994; 17:137-144. 

 

13.   Kapil Umesh, Sohal KS,Nayar D. Process of implementation of National Iodine Deficiency Disorders control Programme activities in Himachal Pradesh, India, Indian Journal of Public  Health 1995; 39:172-175.

 

14.   Kapil Umesh. Distribution and management of Iodised salt in Himachal Pradesh, IDD Newsletter 1995; 11:47-51.

 

 

Appendix I

Prevalence of IDD & Status of NIDDCP in different

States/Uts of India

 

 

 State

 

                               

Total

No of

District

 

No of

Dists

Surveyed

 

No of

Dists

Endemic

 

Ban

Notification

issued

    

 

IDD

Cell

estb.

 

 

Andhra Pradesh

23

7

6

Partial*

Yes

Arunachal Pradesh

10

10

10

Complete

Yes

Assam

18

18

18

Complete

Yes

Bihar

38

21

20

Complete

Yes

Goa

2

2

2

Complete

Yes

Gujarat

19

17

9

Complete

Yes

Haryana

16

8

8

Complete

Yes

Himachal Pradesh

12

10

10

Complete

No

Jammu Kashmir

15

14

14

Complete

No

Karnataka

20

17

5

Complete

Yes

Kerala

14

14

11

No Ban

Yes

Madhya Pradesh

45

16

16

Complete

Yes

Maharashtra

31

29

19

Partial

Yes

Mizoram

4

4

4

Complete

Yes

Manipur

8

8

8

Complete

Yes

Meghalaya

5

2

2

Complete

Yes

Orissa

30

2

2

Complete

Yes

Punjab

12

3

3

Complete

Yes

Rajasthan

27

3

3

Complete

Yes

Sikkim

4

4

4

Complete

Yes

Tamil Nadu

21

13

13

Complete

Yes

Tripura

3

3

3

Complete

Yes

Uttar Pradesh

67

34

29

Complete

Yes

West Bengal

18

5

5

Complete

Yes
Andaman Nicobar -Islands
2
Survey not done

 
Complete
Yes
Chandigarh
1
1
1
Complete
Yes
Dadar & Nagar Haveli
1
1
1
Complete
Yes
Delhi
1
1
1
Complete
Yes
Daman & Diu
1
1
1
Complete
Yes
Lakshasweep
1
Survey not done
 
Complete
No
Pondicherry
4
Survey not done
 
Complete
No
Total No. of districts
480
275
235
 
 
 

* Complete ban notification w.e.f 27th May, 1998 as per notification issued under Prevention of Food Adulteration Act

*Reference: Policy guidelines on National Iodine Deficiency Disorders Control  Programme, Nutrition and IDD Cell, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India, New Delhi, 1997.

 

 

 

Appendix II                                                                                                                                                       

Criteria for Selection of Study Population for IDD Survey

 

        The WHO/UNICEF/ICCISS group has critically reviewed the advantages and disadvantages of undertaking an IDD survey in potential target groups.

 

        Keeping in view the operational feasibility and vulnerability to the clinical manifestations of iodine deficiency, the group recommended that children in the age group of 6 yr to <12 yrs should be included.

 

Framework for Considering Target Groups for  IDD Surveillance

 

                 

 

 

 

 

Usefulness for

Other**

 

 

 

 

Vulnerability Representativesness* Accessibility Surveillance**

 

 

 

Newborns

 

High

 

Intermediate

 

Intermediate

 

Intermediate

 

 

 

 

Preschool

children in

MCH clinics

 

 

High

 

 

Intermediate

 

 

High

 

 

High

 

 

 

 

 

 

Preschool

children in

households

 

 

 

 

High

 

 

 

 

High

 

 

 

 

Intermediate

 

 

 

 

High

 

 

 

 

Children in

schools

 

 

High

 

 

Intermediate

 

 

High

 

 

High

 

 

 

 

Pregnant

women in

MCH clinics

 

 

High

 

 

Intermediate

 

 

High

 

 

High

 

 

 

 

 

 

Adult women

in households

      Intermediate

      Intermediate

 

 

 

 

 

 

 

 

Intermediate

 

 

Intermediate

 

 

 

 

 

 

 

Adult men

      Intermediate

 

 

 

 

Low

 

 

 

 

Low

 

 

 

Low

 

 

                        * Level of representativenes depends on access or coverage

                        ** Usefulness of group for surveillance of other nutrition and health problems

 

 

Appendix III

 

Criteria Used for Calculation of Sample Size

 

i)     Prevalence of goitre       5%

ii)    Confidence level 95%

iii)   Relative precision          10%

 

        Sample to be covered     =          7299

 

        For goitre assessment PPS cluster sampling methodology a design effect 3 has been recommended

 

        7299 X  3                         =          21,897

 

        Therefore number of subjects per cluster will be

 

        =  21,897 / 3                    =          729

 

 

Appendix IV

PPS Sampling Methodology Adopted

 

        The sample population studied was selected using probability proportional to size cluster method which was  as  follows:

 

i)                    All the primary schools in district Kangra were enlisted. This information was obtained from the District Education Officer (Primary), district Kangra at Dharamsala.

 

ii)                  Against the name of each primary school the corresponding 6-11 year age group school children were enlisted and the cumulative population was   calculated.

 

iii)                The sampling interval was calculated using the following formula.

 

                                    Total cumulative population of 6-11 yrs school children                 

        Sampling interval =     

                                                            Number of clusters to be studied (i.e.30)

 

            In district Kangra, the total primary school children population was 1,56,017.

 

       

                                                                        1,56,017

        The sampling interval was         =         

                                                                           30

 

        Sampling interval                        =          5,200

 

        A random number of 2262 was selected between 00001 and 5,200 (4 digits).

 

        The first primary school in which the cumulative population of school children was nearly equal to the random number was identified as the first cluster.

 

Cluster 1

The corresponding cumulative population with 2262 was selected.

 

 

Cluster 2

2262 + sampling interval =2262+5200 = 7462. The cluster with corresponding cumulative population of 7462 was

selected.

 

Cluster 3

Subsequent cluster were selected using the above mentioned procedure.

 

 

 

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