From the Directorate of Health Services, Government of Himachal Pradesh, Himachal Pradesh and Department of Human Nutrition, * All India Institute of Medical Sciences,
Ansari Nagar, New Delhi 110 029, India.
Reprint requests: Dr. Umesh Kapil, Additional Professor, Department of Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India.
Manuscript received: March 19, 1998; Initial review completed: May 5, 1998;
Revision accepted: May 8, 1998.
Iodine deficiency not only causes endemic goiter and cretinism but also a wide spectrum of disabilities which includes deaf mutism, mental and physical retardation and various degrees of neuromotor
Surveys conducted in 239 districts of 25 states and 4 union territories have identified 197 districts as endemic for
IDD. The states having a high prevalence of goitre
include Jammu and Kashmir, Himachal Pradesh, Punjab, Haryana, Bihar, Uttar Pradesh, West Bengal, Sikkim, Assam, Mizoram, Meghalaya, Tripura, Manipur, Nagala.n9 and Arunachal Pradesh. Others
include the National Capital Territory of Delhi, Maharashtra, Madhya Pradesh and Gujarat(2,3).
The district Hamirpur, Himachal Pradesh is a known iodine deficiency endemic area. A survey conducted in 1956 reported a goiter prevalence of 41.2% in the district(4). To ensure adequate availability and use of iodised salt, the government of HP issued a ban on the sale of non-iodised
salt for human consumption in 1976(5). Under this ban notification iodised salt with a mmimum of 30 ppm iodine at the manufacturer's level and 15 ppm iodine at the consumer level should be available in the state.
in the ages of 8,
The present study was conducted with the objective to assess the current prevalence of 100 in district Hamirpur and to estimate the iodine content of salt consumed by population in the district.
Subjects and Methods
The study was conducted in the district Hamirpur of Himachal Pradesh. The multi- stage cluster sampling methodology was followed for selecting the survey sites. The district Hamirpur has a total population of 3,86,295. All the rural and urban units in the district with their respective populations were enlisted. The 30 clusters to be
surveyed were selected by using population proportionate to size sampling methodology. In each population
unit one or more schools were covered till the sample size of 220 children in the population unit was not covered.
Children in the age group of 8-10 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(6). In Himachal
Pradesh, the school enrollment of primary classes was more than 90% and hence the school approach was adopted.
Calculation of Sample Size
The sample size of children to be surveyed was calculated with a presumption that the prevalence of goitre
at the time of the survey was 15%. The Confidence level of 95%,
relative precision of 10% and de- sign effect of three was
considered for calculation of sample size. Utilizing these parameters
a sample size of 6570 was obtained (i.e., 219 children per cluster).
Selection of Subjects
In each identified population unit (cluster), all the primary schools were enlisted and one school was selected for the de- tailed survey. In each school, about 220 children were surveyed. If the sample could not be covered in the school, an ad- joining school was included to complete the sample of a cluster. The school teachers and children were briefed about the activities
to be undertaken during the survey. Subsequently, the children
yrs 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
Assessment of Goiter
The clinical examination for goiter was done by the first. three
authors who are public health specialist with 20 years of experience.
Grading of goiter was done according to the criteria recommended by the joint WHO/UNICEF/ICCIDD. The goiter was classified into three categories:
'When neck is in normal position, goitre neither palpabe nor visible; (ii)
When neck is in normal position, goiter not visible but palpable; and (iii)
When neck is in normal position, and goitre visible. In doubt, investigators were asked to record the immediate lower grade. Inter- observer variation was controlled by initial training in goiter grades by the experts. The sum of grades 1 and 2 provided the total goiter rate (TGR) in the study population.
Urinary Iodine Excretion
spot urine samples were collected from 20% of the subjects (every fifth child included in the study). The 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(7). The results were expressed as mcg iodine/ dl urine.
In each cluster, about 100 salt samples were randomly collected from the school children who were included (every second child) in the study. The subjects were asked to bring about 20g of salt which was routinely being consumed in their respective homes in autoseal polythene pouches. The iodine content of the salt was estimated by the spot testing kit (STK). The STK has a sensitivity of 85% and specificity of 71 % (developed by MBI Chemicals, Madras)(8).
A total of 6897 school children in the age group of 8-10 years were included for the study. Three thousand four hundred and eleven males and 3486 females were studied. The total goitre prevalence rate
was found to be 8.8%. The prevalence of goiter in male and female children is shown in Table I. No significant difference was found in goiter prevalence amongst the male and female children.
It was found that 7.0 (n
= 99), 8.8%
(n = 125) and 17.0% (n = 240) of the children had urinary iodine excretion (DIE) levels of < 2, 2-4.9, and 5-9.9 mcg/ dl, respectively. Nine hundred and forty nine children had UIE of 10 mcg/ dl and above. The median urinary iodine excretion of the children studied was found to be 14.0 mcg/ dl.
It was observed that salt with a nil iodine content was consumed only by 2.5% of the beneficiaries. About 10.8% of families consumed salt with an iodine content of less than 15 ppm.
It has been recommended that if more than 5% school age children (8-12 yrs) are suffering from goitre, the area should be classified as endemic to iodine deficiency(7). In the present study, a total goitre prevalence rate of 8.8% was found, signifying that in district Hamirpur, HP
mild iodine deficiency existed. An earlier study in 1956, a goitre prevalence of 41.2% was reported in the district. The decrease in the prevalence of TGR
could be possibly attributed to the availability of iodised salt to the beneficiaries.
Prevalence of Goiter in Children
WHO /UNICEF /ICCIDD have recommended that no iodine deficiency is indicated in a population when median urinary iodine excretion is 10 mcg/ dl, i.e., 50% of the samples should be above 10 mcg/ dl, and not more than 20% of sample should be below 5 mcg/ dl(6). In the present study the median urinary iodine excretion of the children studied was 14.0 mcg/dl indicating that there was no biochemical deficiency of iodine in the subjects studied.
In the present study, 13.3% of the beneficiaries consumed salt with an iodine content of less than 15 ppm, i.e., below the
In conclusion, Hamirpur district appears to be in a transition phase from iodine deficient to iodine sufficient. This is reflected in the reported prevalence of the TGR of 8.8% in children between 8-10 years and median UIE of 14.0 mcgl
dl. This finding indicates that to achieve elimination of IDD from the district
there is a need of further strengthening the existing monitoring system for the quality of iodised salt in the district.
The present research study was con- ducted as a part of implementation of GO 1- UNICEF project to have baseline data on iodine deficiency in district Hamirpur.
Authors would like to thank Director, Health Services, Himachal Pradesh and Dr. Sheila Vir, Project Officer, UNICEF, India Country
Officer for the technical help extended during different stages of the survey.
We would also like. to thank school principals, teachers and students for their
kind co-operation in the data collection.
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