SUMMARY Before 1987, iodine deficiency was not considered an issue of major importance in the countries of the Eastern Mediterranean Region (EMR). Progress began with a systematic national study of goitre and other iodine deficiency disorders (IDD) in the Islamic Republic of Iran in 1983. Following a major review of the prevalence of IDD in member states, Guidelines for national programmes for the control of iodine deficiency disorders in the EMR were published by the World Health Organization (WHO) in 1988. This paper discusses progress towards elimination of iodine deficiency by reviewing the status of IDD in the countries of EMR and programmes for prevention and control of IDD with particular reference to the Islamic Republic of Iran, the first country to be declared IDD-free by WHO.

Although a high prevalence of goitre and severe iodine deficiency in the Chitral and Gilgit regions of Pakistan was first reported as far back as 1908 [1], prior to 1987 iodine deficiency was not considered an issue of major importance in the countries of the Eastern Mediterranean Region (EMR). Despite the high rates in many areas of many countries of the Region (for example, Mosul province in Iraq, Shahryar in the Islamic Republic of Iran, and in most regions of Lebanon), goitre was regarded as being strictly restricted to certain geographical areas and thus not considered as an important public health problem [2,3]. Therefore, surveys in EMR countries had been limited to one or two endemic areas. This changed in 1983, when the Islamic Republic of Iran began to systematically study the prevalence of goitre and other iodine deficiency disorders and in 1989 conducted a national survey of iodine deficiency disorders (IDD), which revealed hyper-endemic and endemic goitre in all provinces of that country [4].

In order to respond to the growing interest of the member states, the EMR Office (EMRO) of the World Health Organiza- tion (WHO) convened an inter-country consultation of experts in December 1987 to collect more information, exchange experiences and develop guidelines that would assist countries to define the problem and mount national control programmes. These guidelines were published (in Arabic and English) in 1988 as EMRO Technical Publication No. 12, entitled Guidelines for a national programme for the control of iodine deficiency disorders in the EMR.

In 1990, an inter-country workshop on IDD was held in Tehran to exchange experiences and to develop approaches. Subsequently, a technical paper was presented to the 37th session of the WHO Regional Committee for the Eastern Mediterranean, alerting the ministers of health of all countries in the Region to the devastating effect of IDD on brain development and cognitive function. Since then, WHO, often jointly with UNICEF and the International Council for the Control of Iodine Deficiency Disorders (ICCIDD), has made great efforts to support countries in their efforts to deal with this very important deficiency.

A number of important workshops and training courses have been held. A WHO tri-Regional travelling seminar was organized with EMRO and the South-East Asia and Western Pacific Region Offices in India and Nepal in 1991 to observe salt and oil iodization in practice. The first meeting on universal salt iodization for salt producers in the EMR Region was held in Jordan in 1995 and a number of technical consultancies were conducted. Among these, UNICEF held a Regional IDD workshop in 1994 in Tehran and WHO held a symposium workshop on assessment and monitoring of IDD in countries of EMR in 1999, also in Tehran [5].

In 1988, the Islamic Republic of Iran carried out the first national IDD survey in the Region, which revealed a high prevalence of IDD [4]. By 1999, Egypt, Jordan, Lebanon, Morocco, Oman and the Syrian Arab Republic had also carried out surveys. The Islamic Republic of Iran and the Syrian Arab Republic were the first countries in the Region to start iodizing salt. The first Regional meeting of salt producers in the EMR, held in 1995, led to the establishment of a Regional association of iodized salt producers.

The Islamic Republic of Iran was the first country in the Region to become iodine sufficient by showing that more than 95% of households consumed adequately iodized salt and the median urinary iodine level was above 100 µg/L in each of the 26 provinces [6]. More recently, Tunisia also achieved satisfactory iodine status and both countries were accorded IDD-free status by WHO-EMRO in the year 2000 [6]. In 2001, the Endocrine Research Centre and the Ministry of Health of the Islamic Republic of Iran were appointed by WHO-EMRO to hold an annual training course on monitoring and evaluation of IDD elimination programmes. The first 2 courses were offered in 2001 and 2002 with the participation of 12 and 21 countries of the Region and countries of Central Asia and Eastern Europe respectively.

By 2004, the status of IDD in the EMR countries was as follows:

The Islamic Republic of Iran conducts an optimal programme for control of IDD. A sustainable and well-managed iodization programme is functioning in the country with the programmatic indicators set by WHO/UNICEF/ICCIDD [7,8].

The programme began in 1988, when reports of hyper-endemic and endemic areas of goitre in different parts of the Islamic Republic of Iran [9,10] prompted the Ministry of Health and Medical Education to form the Iranian National Committee for Control of IDD (INCCI). A nationwide survey, performed under the supervision of INCCI, showed that goitre was endemic in all cities and hyper-endemic in the capital cities of 5 provinces [4]. Median urinary iodine excretion was < 100 µg/L in all localities and < 20 µg/L in many localities examined [4,9,10].

The INCCI prepared a national plan, which detailed objectives and strategies for IDD control. Iodization of household salt supplies began in 1990. Although the production, distribution and consumption of iodized salt increased gradually, a nationwide survey in 1993 showed that less than 50% of the households were using iodized salt [11]. INCCI announced universal salt iodization and all salt factories were obliged by law to produce only iodized salt for household use. National surveys in 1994, 1996 and 1998 showed that more than 95% of Iranian households were consuming iodized salt [11].

The most sensitive method for the monitoring and evaluation of an IDD control programme is the determination of urinary iodine excretion. The 1996 Iranian national survey showed that the median urinary iodine excretion in schoolchildren (20.5 µg/dL) was at the top of the optimal range (10 to 20 µg/dL) recommended by WHO/UNICEF/ICCIDD [7,8] and 85.1% of children had urinary iodine ³ 10 µg/dL. By 2001, median urinary iodine was 16.7 µg/dL and only 5.8% of the study population had urinary iodine < 5 µg/dL which, based on international standards, is favourable.

According to these criteria, the Islamic Republic of Iran appears to have reached a sustainable IDD control programme since 1996, an achievement that was recognized by WHO-EMRO in the year 2000 [6]. Monitoring of the IDD control programme is planned every 5 years to evaluate the sustainability of the programme.

The lessons from the Iranian experience are that implementation of an adequate and sustainable programme of IDD control requires many effective programmatic steps, in particular integration of IDD control into the health network and mandatory iodization of household salt.

20. Zein AZ et al. The epidemiology of iodine deficiency disorders (IDD) in Yemen. Public health nutrition, 2000, 3:245–52.