Goitre in district Swat, NWFP-Pakistan: Current situation

INTRODUCTION

According to WHO (1992)1, iodine deficiency disorders (IDD) are problems of concern in developing countries including Pakistan. Recent estimates2 shows that about one billion people all over the world are at risk of IDD, 200 million people have goitre and 20 million are suffering from preventable brain damage. In Asia alone 400 million people are at risk, 30 million are suffering from goitre, 0.9 million are cretin and 36 million have some degree of mental impairment due to iodine deficiency3.

According to UNICEF (1998)⁴,70% of the total population in Pakistan is at risk of IDD.

Northern areas of Pakistan (Dir, Swat, Chitrral and Gilgit) are highly endemic for IDD^5-6. Iodine deficiency is also reported from other parts of the country like Azad Jammu and Kashmir, Peshawar, Swabi, Islamabad, Karachi and Quetta^7-12.

IDD can only be eliminated by addition of iodine through any mean in the food items. Pakistan among the nations of the world raised the slogan to eliminate IDD by the year 2000. In 1983, Government of Pakistan in collaboration of UNICEF started a crash programme of oil iodization and its administration in the population of northern areas of the country, but due to high cost the program could be sustained for 10 years. Universal Salt Iodization (USI) an easy, cheap, most effective and sustainable strategy successfully practiced through out the world to eliminate IDD was adopted in 1989-90 through legislation in Pakistan. District Swat being one of the highly endemic area for IDD in NWFP, ha been developed as a model district for USI since 1993. Sustained and dedicated efforts could raise the iodized salt consumption to 20% in the families by 1997¹³. This survey was undertaken with an aim to document the existing situation, and the impact of salt iodization on the deficiency status in children 8-10 years in District Swat.

SUBJECTS AND METHODS

The survey was carried out in the year 2000, in various schools of district Swat as per table-1. Both boys and girls age 8-10 years were included. Two schools (one each for boys and girls) in each of the tehsil were selected for the survey. A total of 960 students from these schools in the age group of 8-10 years were randomly selected with 1:1 ratio of boys to girls by using Epi info 6 software computer package. All the students were examined by palpation method. Goitre was graded according to WHO recommended¹⁴ criteria. Total Goitre Rate for the area is taken as sum of Goitre I and Goitre II.

Table-1: Details of schools included in the survey.

Tehsil	Govt. Primary Schools for Boys (N=8)	Govt. Primary Schools for Girls (N=8)
Babozai	Malookabad, Mingora	Shagai
Barikot	Najigram	Abooha
Kabal	Sersanai	Kalakalay
Shamozai	Dadahara	Parrai
Khwaza Khela	Mashkoomi	Chalyar
Madayan	Shahgram	Madayan
Mata	Shakardara	Bara Durush Khela
Kalam	Mankial	Mata

RESULTS

Overall goitre rate in the boys and girls has been found to be 52% and 45% respectively. No significant difference has been found in the male and female students (P>0.05).

Age wise distribution of TGR in male and female students is shown in figure-1. A high frequency of TGR has been observed in both boys and girls, age 9 years as 56 and 47.5% respectively.

Figure-1: Prevalence of Goiter in Boys and Girls Students in District Swat, Pakistan.

It can be seen from figure-2 that the prevalence of goitre grade-I is higher (40%) in children of 9 years age group, while goitre grade-II is found higher 13.5% in 10 years old students.

Total goitre rate in different primary schools for boys is shown in table-2. The results show that prevalence of goitre in age 8-10 years students is high (85%) in the village of Najigram followed by Sersanai, Shakardara and Manlial as 51.7%, 51.7% and 50% respectively. The students of Dadahara, tehsil Shamozai are least (33.3%) affected with goitre. A high (45%) prevalence of goitre grade-I has been found in the students of village Sersenai and Shahgram, while the area of Najigram is more prevalent for Goitre grade-II.

Figure-2: Age-wise distribution of goitre grade-I and II in district Swat, Pakistan

Table-2: Frequency of Goitre grade- I and II in Boys (8-10 years) in different villages of district Swat.

Tehsil	Village	0-Goitre		Grade-1 Goitre		Grade-II Goitre		TGR
		N	%	N	%	N	%	N	%
Barikot	Najigram	08	13.3	20	33.3	32	53.3	51	85.0
Babozai	Malookabad	31	51.7	24	40.0	05	08.3	29	48.3
Kabal	Sersanai	29	48.3	27	45.0	04	06.7	31	51.7
Shamozai	Dadahara	40	66.7	18	30.0	02	03.3	20	33.3
Khwazakhela	Mashkomai	32	53.3	23	38.3	05	08.3	28	46.7
Madyan	Shahgram	31	51.7	27	45.0	02	03.3	29	48.3
Kalam	Mankial	30	50.0	24	40.0	06	10.0	30	50.0
Mata	Shakardara	29	48.3	19	31.7	12	20.0	31	51.

In girl students maximum TGR 71.7% has been observed in the village of Bara- Durushkhela Tehsil Matta (Table-3). Aboha and Shagai are the villages ranking 2^nd and 3^rd with total goitre rate of 60 and 58.3% respectively. The children in village Kala kaley Tehsil Kabal exhibited the lowest TGR of 25%. It is also revealed from the results that the frequency of grade-I goitre is high (45%) in the villages of Aboha, Shagai, while that of grade-II goitre is found to be highest (26.7%) in the village of Bara Durushkhela.

Table-3: Frequency of Goitre grade I and II in girls in different villages of district Swat.

Tehsil	Village	0-Goitre		Grade-1 Goitre		Grade-II Goitre		TGR
Tehsil	Village	N	%	N	%	N	%	N	%
Barikot	Aboha	24	40.0	27	45.0	9	15	36	60
Baboozai	Shagai	25	41.7	27	45.0	8	13.3	35	58.3
Kabal	Kala Kaley	45	75.0	13	21.7	2	3.3	15	25
Shamozai	Par Rai	43	71.7	15	25.0	2	3.3	17	28.3
Khwazakhela	Charyar	43	71.7	14	23.3	3	5	17	28.3
Madyan	Madayan	34	56.7	21	35.0	5	8.3	26	43.3
Mata	Mata	34	56.7	21	35.0	5	8.3	26	43.3
Mata	Bara Durushkhela	17	28.3	27	45.0	16	26.7	43	71.7

DISCUSSION

The first well-documented study¹⁵ in the district Swat published in 1981 reported goitre prevalence to an extent of 83%. In 1998 a study conducted in different parts of the area has reported¹⁶ a prevalence of goitre upto 70% in boys and 63% in girls. A subsequent study in 1999 indicated⁵ TGR in boys and girls as 62.3% and 57.3% respectively. The results of our study revealed 52% TGR in boys and 45% in girls. If the results of the study conducted in 1981 are taken as base line and comparison is made with the results of the studies conducted in the era of USI introduction in the area, a total decline (34.5%) in the prevalence of goitre is obtained. The decrease in the frequency of goitre can definitely be attributed to the utilization of iodized salt as reported from other parts of the world^17-18. Our study indicates that although the prevalence of goitre is decreased, but overall TGR is still high enough and make the area to a red alert as per WHO reccommendation¹⁴.

Since the introduction of USI in district Swat, 12 iodized salt producers are currently providing 750 metric tons of iodized salt to combat the needs of nearly 1.2 million population¹³ and as a consequence a sharp decline in the prevalence of TGR was expected. The high level of TGR found in this study indicates that either the people of the area are not using iodized salt or the iodine content of the edible salt is not adequate to meet the body requirements as reported by the others^5,12. It is also possible that due to improper packing, high level of humidity and certain temperature changes the iodine contents are lost during transportation and storing before reaching the consumers. So this study concludes that the area is still highly endemic to IDD and further integrated sustained efforts are still required. The model is sufficiently effective and it should be extended to other districts in the northern areas of Pakistan having the problem.

The authors are grateful to UNICEF Peshawar for the financial assistance for the study. Thanks are due to the schools administration, who provided their full support during the survey. Prof. Zahir Shah, Chief Executive Khyber Teaching Hospital and the then Principal Saidu Medical College are acknowledged for providing boarding and lodging facilities to the field team.

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