Indian Pediatr 2011;48:
Iodine Deficiency Disorders in 6-12 Years -
Old Rural Primary School Children in Kutch District, Gujarat
Rajesh Chudasama, Umed V Patel, Ravikant R and Pramod H Verma
From the Department of Community Medicine, PDU Medical
College, Rajkot, India.
Correspondence to: Dr Rajesh K Chudasama, "Shreeji Krupa",
Meera Nagar, Street No 5,
Raiya Road, Rajkot, Gujarat, India.
Received: December 04, 2009;
Initial review: March 10, 2010;
Accepted: May 20, 2010.
Published Online: 2010 November
Objective: To compare prevalence of goitre in primary school children;
to determine median urinary iodine concentration in children; and, to
assess level of salt iodization at retail trader level.
Design: 30 cluster survey study.
Settings: Primary schools of Kutch district,
Methods: Total 70 students including five boys and
five girls from 1st to 7th standard, present in class on the day of visit
were selected randomly for Goitre examination (n=2100). Urine
sample was collected from one boy and one girl from each standard in each
cluster. From the community, 28 children, including two boys and two girls
from each standard in the same age group were examined, and salt samples
were tested from their households. From each village, one retail shop was
visited and various salts available were purchased and tested for iodine
on the spot with spot kit.
Results: Goitre prevalence of 11.2% was found among
primary school children (grade 1- 8.6% and grade 2-2.6%). As the age
increased, the Goitre prevalence also increased except in age group of 8
years. Median urinary iodine excretion level was 110 µg/L. Iodine level
more than 15 ppm was found in 92.3% salts samples tested at the household
Conclusion: Present study showed mild goitre
prevalence in primary school children in Kutch district of Gujarat
Key words: Goitre survey, India, Iodine deficiency disorder,
Prevalence, School children.
Iodine Deficiency Disorders (IDD) refers
complex clinical and subclinical disorder
caused for the lack of adequate dietary intake of
iodine . Out of 587 districts in India, 282 have been surveyed for IDD
and 241 were found goiter endemic . Several studies conducted all over
India have shown high prevalence of goitre [3-5]. After implementation of
National Iodine Deficiency Disorders Control Programme (NIDDCP) in the
year 1992, India has made considerable progress towards IDD elimination.
Recently, less than 5 % total goitre rate was found in 9 out of 15
districts studied in 11 states by the Indian Council of Medical Research (ICMR)
In February 2009, Government of Gujarat started IDD
re-survey in all the districts of Gujarat state. In Kutch district, first
baseline IDD survey was done in 1990-91, and then re-survey was done in
1999-2000. The present goitre survey was done in Kutch district in 2009 to
document the prevalence of goitre in primary school children aged 6-12
years; to determine median urinary iodine concentration in sample of
children; to assess the level of iodine in salt samples at retail trader
level; and to study the profile of salt sold at retail shops.
The present study was done in Kutch district of Gujarat
state. The main source of water is rain. Almost all type of routine
vegetables are available and consumed by the people. The district has a
total populations of 15,83,225, as per 2001 census . The national
program was implemented in the district in 1992 after the result of
baseline survey conducted in 1990, which indicated low goiter prevalence.
A cross sectional study of children aged 6-12 years age
group studying in 1st to 7th standard in primary schools of rural areas
(excluding urban areas) was conducted. The study included two types (a)
school survey and (b) community survey. As per State Nutrition Cell
guidelines, school enrollment of children in primary school was considered
70% as per the data available at state level for different districts. Five
boys and five girls from each standard, present in class on the day of
visit were selected randomly for examination. So total 70 students were
examined from each school in selected villages. As per guidelines
provided, almost 30% school children were considered absent at any given
time and so, 28 students were examined from the community from each
selected village. Out of 28 students examined out of schools in community,
two boys and two girls from each standard in age group 6-12 years were
examined. Thus, a total of 2100 students were examined in schools and 840
students were examined out of schools in the selected villages.
Training and survey technique: A state level
training workshop was conducted by State Nutrition Cell, including various
medical colleges participants for cases identification and grading of
goiter. The current survey included the WHO grading system as per the
revised guidelines under NIDDCP . The child was examined by examiner in
sitting position with neck in normal position. The following
classification was used for goiter: (a) grade 0 – not visible, not
palpable, (b) grade 1- palpable, but not visible, and (c)
grade 2- palpable & visible, as per the WHO/UNICEF/ICCIDD guidelines .
Sampling method: Cluster sampling method was used
for selection of villages. A list of villages of all talukas of Kutch
district was obtained from Zila Panchayat, Office of District
Health Office (DHO). Then cumulative population was counted by using MS
Excel. By calculating cluster interval, 30 villages were selected from the
list. Only rural areas were included and urban population was excluded in
calculating cumulative population. The study was confined only to rural
areas of Kutch district. The primary schools of these 30 selected villages
were visited for school survey. When desired sample size of five boys and
girls each from each standard was not achieved, primary school of nearest
village was approached and desired sample size was achieved and similarly,
community survey was also done.
Urine samples: One boy and one girl from 1st to 7th
standard were selected randomly for taking urine
sample. So, in each cluster 14 urine samples were collected, 7 samples
from boys and 7 from girls. In 30 clusters, total 420 urine samples were
collected and tested for urinary iodine excretion. Plastic bottles with
screw caps were used to collect the urine samples, which were stored in a
cool dry place and sent for testing to state IDD laboratory at Surat. Few
drops of toluene were added to each urine sample to inhibit bacterial
growth and to minimize bad odor. Ammonium per sulfate titration method was
used to detect the urinary iodine excretion level.
Salt samples: As per the guidelines provided, 28
salt samples were tested of all the children of 6- 12 years examined for
goitre during community survey at their homes in each village. A total 840
salt samples were assessed and iodine concentration was recorded as 0,
less than 15, and 15 ppm and more . From each village, one retail shop
was visited and various salt varieties available were purchased and tested
for iodine on the spot with spot kit.
Data were entered in MS Excel 2007 and analyzed by
using Epi Info software, version 3.5.1.
Goitre prevalence of 11.06% was found among 2940
primary school children in the present survey (8.61% grade 1 goiter, 1.2%
grade 2 goiter). This goiter status indicates that it is a mild (5-19.9%)
public health problem. Seven blocks had mild prevalence and two blocks had
zero prevalence of goiter in the present study. Goiter prevalence
increased with age, 7.8% at 6 years age and reaching upto 14.2% by 12
Urinary Iodine Excretion Level in Rural Areas of Kutch District
||< 50 µg/L (%)
||>50 µg/L (%)
Of the total 420 urine samples collected (Table
I), 81.4% samples were found with urinary iodine excretion (UIE) level
100 µg/L or more, while 11% samples shown UIE between 50-99.9 µg/L, 7.1%
between 20-49.9 µg/L and 2.4% below 20 µg/L. Out of 840 salt samples
tested, 92.3% salt samples shown adequate iodine i.e. 15 ppm and more at
retail trader levels (Table II). The salt packs sold at
retail shops were found to be well packed, branded, powdered and having
symbol of iodized salt on the pack.
Taluka Specific Assessment of Iodine in Salt Samples by Spot Kit at Retail Trader
Levels in Rural Area of Kutch District
No. of salt
of salt in ppm
> 15 ppm
% of salt samples
To evaluate the severity of IDD in a region, the most
widely accepted marker is the prevalence of endemic goitre in school
children. WHO/UNICEF/ICCIDD  on the basis of IDD prevalence,
recommended the criteria to understand the severity of IDD as a public
health problem in a region. According to these criteria, a prevalence rate
of 5.0-19.9% is considered as mild; 20- 29.9% as moderate and a prevalence
rate of above 30% considered as a severe public health problem.
In the present study, the total goitre prevalence rate
was 11.2%, indicating that IDD is a mild public health problem. Since
January, 2001 in Gujarat, the ban on sale of non-iodized salt was
withdrawn. With this withdrawal of ban, the availability of non-iodized
salt in the market increased. In November, 2005, the Central government
issued notification banning the sale of non-iodized salt for direct human
consumption in the entire country . A study from another district of
Gujarat reported goitre prevalence of 20.5%  which was very high
compared to the present study.
In the present study, the urinary iodine excretion
level 100 µg/L and above was found in 81.4% samples. Present study
indicates continued and adequate efforts of ensuring a supply of iodized
salt to the population. Different median urinary iodine levels were
reported by different authors indicating deficiency or no deficiency of
iodine in respective populations in their areas [15-18].
WHO/UNICEF/ICCIDD recommends that 90% of retail trader
levels salts should get iodized at the recommended level of 15 ppm ,
and the study shows that about 92% of retail trader levels salts have
adequate level (15 ppm and more). Chandra, et al.  reported more
than 95% of population consuming salts at adequate level, while others
[20, 21] reported only 50% of community consuming salts at adequate level.
These results suggest that there is still need to strengthen the system of
monitoring quality of salt to ensure availability of 15 ppm of iodine at
retail trader levels.
In the present study, 100% branded packed salt samples
claiming iodization shown 30 ppm or more iodine level sold at retail shops
(consumer level). Mishra S, et al.  reported 39% such salt
samples having less than 30 ppm iodine level at retail shops, which
indicates higher availability of iodine in iodized salts in the present
What is Already Known?
· Goitre is mainly prevalent in hilly and also
in plain areas of India.
What This Study Adds?
· More than 92% samples salt had iodine content of 15 ppm or
more at beneficiary levels in Kutch, District of Gujarat.
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