|Year : 2017 | Volume
| Issue : 2 | Page : 54-57
National health programs related to thyroid
Kanica Kaushal1, Sanjay Kalra2
1 Department of Community Medicine, School of Public Health, PGIMER, Chandigarh, India
2 Department of Endocrinology, Bharti Hospital and BRIDE, Karnal, Haryana, India
|Date of Web Publication||26-May-2017|
Department of Community Medicine, School of Public Health, PGIMER, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Identification of health objectives is one of the more visible strategies to direct the activities of the health sector. The government of India and its nodal ministry – Ministry of Health and Family Welfare undoubtedly has the central and primary role in the implementation of the health program. In this article, the authors have tried to review the available national programs for prevention and treatment of thyroid diseases; National Newborn Screening Programme including congenital hypothyroidism, Rashtriya Bal Swasthya Karyakram, National Guidelines for Screening of Hypothyroidism during Pregnancy, National Iodine Deficiency Disorders Control Programme and National Family Health Survey 3 and 4.
Keywords: Congenital hypothyroidism, iodine, national programmes, review, screening, thyroid
|How to cite this article:|
Kaushal K, Kalra S. National health programs related to thyroid. Thyroid Res Pract 2017;14:54-7
| Introduction|| |
Thyroid diseases are common worldwide. In India too, there is a significant burden of thyroid diseases; congenital hypothyroidism (CH), goiter and iodine deficiency disorders (IDDs), and thyroid cancer. A cross-sectional, multi-centered epidemiology study conducted at eight sites in India namely Bangalore, Chennai, Delhi, Goa, Ahmedabad, Hyderabad, Kolkata, and Mumbai revealed the overall prevalence of hypothyroidism as 10.95% (95% confidence interval, 10.11–11.78); of which, only 7.48% of patients self-reported the condition, whereas 3.47% were previously undetected. Hence, this is an important public health concern and a challenge to the policy makers of India. This calls for action at the end of doctors, policy makers as well as the patient themselves. The latter needs to be educated, empowered, and enabled so that they can be active partners in the care and decision-making process and better care can be imparted to them; reducing the burden of care and improve treatment outcomes in a sustainable way. Much is said and written about how things need to be done at individual, community, and government level if we wish to see a change. Working individually, however, in clinics and academic departments will not bear as much results as would the transdisciplinary approach. Thyroid diseases are the most fruitful to focus on as the diseases are easy to diagnose, the treatment modalities are already available and accessible, and that thyroid is easily visible or palpated at initial stages. Thyroid disease is not a major cause of mortality. However, it does cause significant sequelae which lead to disability. Hence, thyroid diseases are a perfect ground for primary, secondary, and tertiary prevention. The government of India and its nodal ministry - Ministry of Health and Family Welfare undoubtedly has the central and primary role in the implementation of the health program related to thyroid specifically. In this article, the authors have tried to review the available national programs for prevention and treatment of thyroid diseases.
| Methodology|| |
To identify relevant studies for this review, an initial search was conducted in U.S. National Library of Medicine's PubMed in English using the keywords; national programs, thyroid disorders, iodine, pregnancy, CH, India. The titles and abstracts of the articles identified were reviewed, and full copies of the most relevant articles were obtained. All the documents related to the same, for instance, policy documents, guidelines, newspaper reports, task force reports, etc., were also reviewed. Additional articles were cross-referred from the citations of relevant publications. Nonindexed articles and documents were also reviewed along with the internet search and Google Scholar using the above mentioned keywords.
National Newborn Screening Programme including congenital hypothyroidism
Popularly known as newborn screening (NBS), NBS is a medical procedure where a newborn baby is screened within 72 h of birth for any disorders of diseases that might affect the baby's normal functions. NBS including for CH is a quite common public health related preventive approach in the developed countries due to the various advances in technology and knowledge in genetics. In many countries, hospitals have made the screening for CH mandatory, but it is a sad thing that in India there is no Government funded Neonatal screening center.
Therefore, it always comes as an extra financial cost on the parents wishing to perform the test. Another huge pull down is that there is a very less awareness of these tests in India. CH is one of the most common preventable causes of mental retardation in children. The first multi-centric study screening above 1 lakhs neonates born throughout India was launched by Indian Council of Medical Research (ICMR) National Task Force Team on NBS at AIIMS New Delhi (2007–2012) and the preliminary results reveal a much higher incidence of CH all over India at 1 in 1172, particularly in South Indian population (1 in 727).
Timely treatment is very important to effect adequate neurocognitive development during the critical first 3 years of life. The earlier the treatment is started, the higher the intelligence quot levels are achieved later in life. A vicious cycle exists, that prevents the early identification and subsequent management of CH in India. Despite its simplicity, accuracy, and cost effectiveness, CH screening as mandatory primary health-care activity in India is yet awaited. The screening program in India is currently not funded by the central/state government. Private hospitals are the only active organizations in the scenario and that too in few of the metropolitan states of the country offering the NBS services to the clients who can afford price ranging from Rs. 2500 to Rs. 6000 to cover the screening costs for disorders such as CH and others.
In the absence of a national program, organizations like Indian Academy of Pediatrics should bring out guidelines for CH screening and institutions should develop local guidelines for screening all newborns for CH. Neonatal hypothyroidism screening if properly timed and performed has the potential for preventing catastrophic health outcomes, including death.
Rashtriya Bal Swasthya Karyakram
Rashtriya Bal Swasthya Karyakrams (RBSK's) child health screening and Early Intervention Services under RBSK envisages to cover thirty selected health conditions for screening, early detection and free management. Goiter finds mention in RBSK's charter (listed under deficiencies). “hypothyroidism” is listed in the “others” category and can be taken up by various states, based on epidemiologic data and availability of testing/specialized support facilities. Various conditions or symptoms, which may be due to hypothyroidism, are also listed by RBSK. These include anemia; developmental delay, including hearing deficit, neuromotor impairment, cognitive, and language delay; and also learning disorders.
The RBSK is an important milestone achieved for thyroid health. Intersectoral coordination amongst public health professionals, endocrinologists, and pediatricians can help streamline the screening and identification of thyroid disorders through RBSK. Optimal thyroid health, achieved through such secondary preventive measures, will ensure healthy physical and mental growth for India's next generation.
National Guidelines for Screening of Hypothyroidism during Pregnancy
Screening procedures in newborns have to take into account the complex interaction between feto-maternal and placental unit. Although fetal endocrine system functions largely independently of that of the mother, maternal endocrine disorders can influence the fetus adversely. Hence, Maternal Health Division, Ministry of Health and Family Welfare, Government of India have released National Guidelines for Screening of Hypothyroidism during Pregnancy in the year of 2014.
Thyroid-stimulating hormone (TSH) levels during pregnancy are lower than TSH levels in a nonpregnant state. Pregnancy-specific and trimester-specific reference levels for TSH are as follows:First trimester - 0.1–2.5 mIU/L; second trimester - 0.2–3 mIU/L; third trimester - 0.3–3 mIU/L. Hence, in pregnancy, subclinical hypothyroidism is defined as a serum TSH between 2.5 and 10 mIU/L with normal free thyroxine (FT4) concentration and over hypothyroidism (OH) is defined as serum TSH >2.5–3 mIU/L with low FT4 levels. TSH >10 mIU/L irrespective of FT4 is OH. National guidelines have set a standard protocol for that is being followed in the country for screening and treating hypothyroidism in pregnancy.
The strategy for implementation for this was that all high-risk pregnant women attending antenatal care outpatient department shall be screened for hypothyroidism at the first antenatal visit for early diagnosis and treatment. Patients coming from the periphery may be followed-up by the obstetrician/physician/medical officer at their concerned primary or secondary health facility and cases with associated medical/obstetric complications would be referred to physicians/obstetricians at medical college/district hospital.
The effects of hypothyroidism on maternal and fetal well-being are well documented. Untreated hypothyroidism during pregnancy is associated with adverse effects for the mother and the baby. Early diagnosis and treatment of hypothyroidism are known to reduce maternal and fetal morbidity and improve neonatal well-being. Therefore, these guidelines for screening and treatment of hypothyroidism in pregnancy are a timely measure to address this gap.
National Iodine Deficiency Disorders Control Programme
Iodine Deficiency is the most common cause of preventable mental retardation and brain damage in the world. IDDs surveys conducted by the Central and State Health Directorates, ICMR and medical institutes since the 1950s have clearly demonstrated that IDD is a public health problem in all States and Union territories in India. Thus, no state/UT are free from IDD. National Iodine Deficiency Disorders Control Programme (NIDDCP) is in operation since 1987. India was one of the first countries to globally start the IDD control program in India and it has evolved over the years from the scientific research to programme (National Goitre Control Programme in 1962 to NIDDCP), from lifting the ban on sale of noniodized salt World Economic Forum year 2000 till 2005 to reinstatement of ban on sale of noniodized salt and consolidation of sustainable elimination of IDD (since 2005). The current important objectives and components of NIDDCP are:
- Surveys to assess the magnitude of the IDDs
- Supply of iodated salt in place of common salt
- Resurvey after every 5 years to assess the extent of IDDs and the Impact of iodated salt
- Laboratory monitoring of Iodated salt and urinary iodine excretion
- Health education and publicity.
This program has come a long way from the 2nd 5-year plan and is still finds place in the 12th 5 years plan. Strategies of 12th 5 years plan  with respect to the NIDDCP are:
- IDD surveys
- Establishment of IDD control cells
- Establishment of IDD monitoring labs
- Training programs
- Production and distribution of iodated distribution salt-universal use of iodine and iron fortified salt. Ensure that only double fortified salt (iron-iodine) is used in Integrated Child Development Services scheme, Mid-Day Meal and sold through public distribution system
- Health education and publicity
- Community level iodated salt testing
- Incentive to accredited social health activist for community level awareness of iodated salt
- Strengthening of central IDD control cell
- Health education and publicity by the state/UT health directorate.
National Family Health Survey 3 and 4
According to the National Family Health Survey 3 (NFHS 3) conducted in 2005–2006, only half of children who are 6–59-month-old live in households that use cooking salt containing an adequate level of iodine (at least 15 parts per million), especially the poorest, most vulnerable and those who live in rural areas and have very little access to iodized salt. During NFHS 3, eight states evidenced consumption of iodized salt at much below the national average.
However, Coverage Evaluation Survey 2009 shows that the household consumption for iodized salt has increased to 71%.
The recently conducted NFHS 4 reports on the usage of iodized salt in 15 states. The percentage of all households which use iodized salt varies from 81.6% in Andhra Pradesh (AP) to 99.6% in Sikkim. While most states report >90% usage of iodized salt, the outliers include AP (81.6%), Tamil Nadu (82.8%), and Karnataka (86.8%). Other Southern states such as Telangana (95.8%) and Puducherry (92.7%), however, report much higher rates of iodized salt usage. Smaller states and union territories, too, including Sikkim (99.6%), Andaman and Nicobar Islands (99.5%), Meghalaya (99.1%), and Tripura (99.1%), enjoy near universal iodized salt consumption.
| Thyroid Cancer|| |
Even after extensive search on PubMed and other search engines, we could not outline any guidelines or policy on the screening of thyroid cancer or any mention of thyroid cancer with the National Programme for Prevention and Control of Cancer, Diabetes, CVD and Stroke (NPCDCS). The NPCDCS program has two components viz., (I) Cancer and (II) Diabetes, CVDs and Stroke. The district will be linked to tertiary cancer care health facilities for providing comprehensive care. Tertiary cancer center (TCC) will provide the comprehensive cancer care including prevention, early diagnosis and treatment, palliative care, and rehabilitation. One of the objectives of the TCC scheme is provide training and research facilities in all types of cancer with a focus on oral, cervix, and breast cancer in particular. Thyroid cancer finds no special mention in the program which it could have.
| Conclusion|| |
The Constitution of the World Health Organization rightly puts that “Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures.” Policies, strategies, plans and programs are not an end in themselves. They are part of the larger process that aims to align India's health priorities with the health needs of the population, make better use of all available resources for health – so that all people in all places have access to quality health care and live healthier lives.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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