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3 4

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7

8

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Addis Ababa

>10,000

5,000 to 10,000

< 5,000

Cross-Sectional Community Based Assay of Thyroid Volume, Serum TSH Levels, and Urinary Iodine

Concentrations with Association to Goiter Prevalence and Iodized Salt Availability in Addis Ababa, Ethiopia

Joshua A. Schell Department of Biological Sciences, York College of Pennsylvania

An example of a goiter in a subject

IntroductionIodine is an essential element for neural growth and development that must be obtained through diet since the human body is incapable of producing it.

Iodine deficiency causes the thyroid gland to progressively enlarge as it attempts to keep up with the demand for thyroid hormone production, resulting in goiter.

Goiter is associated with numerous debilitating medical conditions, including tachycardia, cardiac palpitations, nervousness, hyper- and hypo- tension, metabolic changes in protein metabolism, exophthalmos, and much more9.

Worldwide, over 90.54% of all goiter cases are caused by iodine deficiency8.

Globally, >2 billion people are estimated to be at risk for iodine deficiency disorder (IDD) and ~ 740 million people are affected with goiter8.

In Ethiopia, ~42 million people (78% of the total population) are exposed to IDD, and >14 million (26% of the population) have goiter1.

In the high land areas of Ethiopia, where soil iodine concentration have been significantly depleted by erosion, the prevalence of goiter among the population ranges from 50 to 95%2.

Iodine deficiency is a global public health problem. In order to combat IDD and goiter, emphasis should be placed on diagnosis and correction at the community level rather than the individual level.

Iodine nutrition at the community level is best assessed by measurements of urinary iodine concentration (UIC), thyroid volume (TV), and thyroid stimulating hormone (TSH)7.

After years of assessing UIC, IDD, TSH, and TV it is unknown as to why goiter is still endemic in all regions of Ethiopia and why USI programs are not successful 1,2,4,7,8.

Study findings indicate considerable differences in goiter prevalence among geographical regions of Ethiopia1,2,4.

However, there are no know studies that explore geographical location and population density of regions, with association to goiter prevalence for Ethiopia as a whole.

Review of Literature

In Ethiopia, IDD has been recognized as a major public health problem for the last 60 years9.

Despite the introduction of Universal Salt Iodization (USI) programs in 1990, Ethiopia is still the top iodine deficient country in the world based on a national UIC <100 ug/L8.

Girma et al (2014) determined that in Northwest Ethiopia the total goiter prevalence was 39.5%, with UIC ranging from 20.54 - 62.3 ug/L. Further more, only 15 – 20% of households in this region had and used iodized salt4.

Review of Literature

Living Word Community Church of Red Lion, PA sponsored a medical mission trip in Ethiopia from 7/7/2014 to 7/11/2014.

Sendafa, Aleltu, Beke, and Sheno were the sites where physical examination and treatment occurred.

For patients who presented with goiter; age, gender, place of residence, and goiter grade were recorded.

Results indicate that goiter prevalence might be negatively correlated to population density.

Pilot Study

aMean

• Goiter prevalence is expected to increase as population density decreases.

• TSH and UIC are expected to have a negative correlation to thyroid volume and goiter grade. As thyroid volume and goiter grade increase, TSH and UIC levels should decrease.

• Females are expected to have a greater total goiter rate (TGR) than males, with no difference in classification of nodules.

I would like to sincerely thank Dr. Bridgette Hagerty, and Dr. Richard Daly for making this project possible through their invaluable guidance and expertise. In addition, I would like to thank Living Word Community Church and the civilians of Ethiopia for making my pilot study and the foundational work associated with this project possible.

Acknowledgements

Literature Cited

1. Analyse urinary iodine concentration, thyroid volume, and thyroid stimulating hormone levels to determine prevalence of goiter among Ethiopians.

2. To determine if there are regions in Addis Ababa where iodization efforts and education should be focused in attempt to mitigate IDD and goiter.

HA – As population density increases the prevalence of goiter will decrease.

Research Design and Methods

1Abuye, C., and Berhane, Y. 2007. The goitre rate, its association with reproductive failure, and the knowledge of iodine deficiency disorder (IDD) among women in Ethiopia: cross-sectional community based study. BioMed Central Public Health [Online] 7:316-328.2Berhanu, N., Michael, K., and Bezabih, M. 2004. Endemic goitre in school children in southwestern Ethiopia. Ethiopian Journal of Health and Development 18(3):175-178.3Bolgale, A., Abebe, Y., Stoecker, B., Abuye, C., Ketema, K., and Hambidge, M. 2009. Iodine status and cognitive function of women and their five year-old children in rural Sidma, Southern Ethiopia. East Africa Journal of Public Health 6:299-302. 4Kibatu, G., Nibret, E., and Gedefaw, M. 2014. The status of iodine nutrition and iodine deficiency disorders among school children in Metekel zone, northwest Ethiopia. Ethiopian Journal of Health Science 23:109-116.5Lui, Y., Huang, H., Zeng, J., and Sun, C. 2013. Thyroid volume, goiter prevalence, and serum levels in iodine-sufficient area: a cross-sectional study. BioMed Central Public Health [Online] 13:1153-1165. 6Stockigt, J. 2000. Serum thyrotropin and thyroid hormone measurements and assessment of thyroid hormone transport. Pages 377-396 in Braverman LE, Utiger RD (eds.) Werner and Ingbar’s The Thyroid. Lippincott Raven. Philadelphia, PA. 7World Health Organization. 1996. Recommended iodine levels in salt and guidelines for monitoring their adequacy and effectiveness. 1st ed. WHO micronutrient series. Geneva. 8World Health Organization & United Nations Children’s Fund & International Council for the Control of Iodine Deficiency Disorders. 2007. Assessment of iodine deficiency disorders and monitoring their elimination. 3rd ed. Geneva. World Health Organization.9World Health Organization & United Nations Children’s Fund & International Council for the Control of Iodine Deficiency Disorders. 1994. Indicators for assessing iodine deficiency disorders and their control through salt iodization. 1st ed. Geneva. World Health Organization. 10Zimmermann, M., DeBenoist, B., Corigliano, S., Jooste, P., Molinari, L., Moosa, K., Pretell, E., Al-Dallal, Z., Wei, Y., Zu-pei, C., and Torresani, T. 2006. Assessment of iodine status using dried blood spot thyroglobulin: development of reference material and establishment of an international reference range of iodine-sufficient children. Journal of Clinical Endocrinology and Metabolism 91(12):488-497.

Map #

District Area

(Km2)

Population

Density

1 Addis Ketema

7.41 271,644 36,659

2 Arada 9.91 225,999 23,000

3 Lideta 9.18 214,769 23,000

4 Kirkos 14.62 235,441 16,104

5 Gullele 30.18 284,865 9,439

6 Yeka 98.25 745,719 7,590

7 Kolfe Keranio 61.25 546,219 7,449

8 Nifas Silk-Lafto

68.30 335,740 4,916

9 Bole 122.08 328,900 2,694

10 Akaky Kaliti 118.08 195,273 1,654

Addis Ababa, Ethiopia’s capital city, located at 9°1′48″N 38°44′24″E at the base Mount Entoto, altitude 2,300 meters.

Divided into ten districts, total area 527 km2, pop. 3,384,569.

Districts were categorized as urban, suburban or rural based on their mean population density.

Study Area

Population Density

Thyroid Volume5

Urinary Iodine Concentration

Assay7

Goiter Presentation

No Goiter Presentation

Quality Assurance

(1/5 of Goitrous)

Urban(n = 400)

Inclusion Criteria(n = 1200)

Rural(n = 400)

Exclusion Criteria9

(pregnancy & contraindicated

medications)

Suburban

(n = 400)

Physical Examination9

(vitals & thyroid status)

Serum Collection6

(TSH)

Data Processing & Analysis

Sample Size Determination

(Sloven’s Formula )

Goiter Assessment9

(Grading & Classification)

Expected Results

Variable Urban Suburban RuralPop. density1 >

10,0005,000 to 9,999 < 5,000

UIC2 (ug/dL) 15.2 10.91 5.42

TSH3 (uU/L) 0.350 0.292 0.245

TV4 (mL) 16.2 18.4 21.8

Grade5 0 (%) 86.50 71.75 45.25

Grade 1 (%) 9.75 20.50 35.5

Grade 2 (%) 3.50 6.75 16.25

Grade 3 (%) 0.25 1.00 3.00

TGR6 Males (%) 4.42 9.08 26.92

TGR Females (%)

8.83 18.17 53.83

TGR (%) 13.25 27.25 80.751Individuals/Km2, 2Urinary Iodine Concentration, 3Thyroid Stimulating Hormone, 4Thyroid Volume, 5number of subjects in grade/total number of subjects in that density category, 6Total Goiter Rate (sum of Grades 1 and 2).25 100 250 1000 >1000

0

0.05

0.1

0.15

0.2

0.25

Population Density Range (Individuals/Km2)

Goi

ter F

requ

ency

http://en.wikipedia.org/wiki/Goitre

http://en.wikipedia.org/wiki/Ethiopia

Dr. Richard Daly, 7/10/2014

http://www.atozmapsdata.com/

In Southeastern Ethiopia, goiter prevalence was determined to be 27.4 - 42.0%1.

In Southwestern Ethiopia, it was 63.3% in villages, and 93.4% in schools1,2.

If goiter prevalence is association to population density, then population density maps could be utilized to focus USI and education programs in those regions most in need.

Objectives/Hypothesis

Community Based Self-Assessment Health Survey & Medical History