Healthier Babies Worldwide Partnership for Neural Tube Defect Prevention

Alina L. Flores, MPH, CHES

Aliki Pappas Weakland, MPH, MSW

National Center on Birth Defects and Developmental Disabilities Centers for Disease Control and Prevention

World Health Organization Geneva, Switzerland

22 October 2012

National Center on Birth Defects and Developmental Disabilities

Division of Birth Defects and Developmental Disabilities

Disclaimer: The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy.

Serious birth defects of the brain and spine that form in the first month of pregnancy

Most common are anencephaly and spina bifida

Majority of neural tube defects are preventable with folic acid before and during early pregnancy

Neural Tube Defects

(The “other” NTD)

Global Burden of Neural Tube Defects

Neural tube defects affect more than 300,000 babies each year worldwide1

Occur widely In different geographical areas

In countries of varying levels of economic development

Among diverse populations

Remain a significant, preventable cause of mortality and morbidity

1 Christianson A, Howson CP, Model B. March of Dimes Global Report on Birth Defects: the hidden toll of dying and disabled children. 2006. March of Dimes Birth Defects Foundation, New York.

Folic Acid and Neural Tube Defect Prevention

Role of folic acid in preventing neural tube defects is well known

The majority can be prevented with 400 micrograms (mcg) of folic acid daily before and during early pregnancy

Globally many women of reproductive age do not consume enough folic acid to prevent neural tube defects

Folic acid fortification is a cost effective public health intervention to ensure more babies are born without these birth defects

CDC. www.cdc.gov/mmwr/mmwrrhtml/mmm5931a2.htm. CDC Grand Rounds: Additional Opportunities to Prevent NTD with Folic Acid Fortification

Factors that might increase risk for NTDS

Folic acid deficiency

Previous pregnancy affected by an NTD

Certain medications

Certain medical conditions such as pre-existing diabetes, obesity, and vitamin B12 deficiency

Race/ethnic origin

Exposure to high temperatures early in pregnancy

Genetics - MTHFR

Fortification: Cost Effectiveness South Africa and Chile

Folic acid fortification has been proven to be effective

South Africa In 2003 South Africa fortified wheat flour and maize meal

Reduction in neural tube defects (through June 2005): 31%

Return on investment of 46 to 1

Chile In 1998 Chile fortified wheat flour

Reduction in neural tube defects (through 2001): 41%

Return on investment of 11 to 1

South Africa – Sayed AR, Bourne D, Pattinson R, Nixon J, Henderson B. Decline in the prevalence of neural tube defects following folic acid fortification and its cost-benefit in South Africa. Birth Defects Research Part a-Clinical and Molecular Teratology2008 Apr;82(4):211-6. Chile – Llanos A, Hertrampf E, Cortes F, Pardo A, Grosse SD, Uauy R. Cost-effectiveness of a folic acid fortification program in Chile. Health Policy2007;83(2-3):295-303.

Fortification: Cost Effectiveness United States

Since mandatory folic acid fortification of cereal grain products labeled as enriched in the US:

36% reduction in NTDs (1998-2006)

10,000 more babies born without NTDs in the past decade

More than 4 billion dollars in direct costs saved over the past decade

MMWR Ten Great Public Health Achievements—United States 2001-2010, May 20, 2011 60(19); 619-623

Healthier Babies Worldwide Partnership for Neural Tube Defect Prevention

CDC is working with partners to advance neural tube defect prevention globally

Goal: Increase the intake of folic acid among women of reproductive age

Healthier Babies Worldwide Partnership for Neural Tube Defect Prevention

Preventing NTDs through increased intake of folic acid would

Reduce infant and child mortality and childhood morbidity

Contribute to the achievement of the Millennium Development Goal 4 (reduce under-5 mortality)

Support the 63rd World Health Assembly resolution on birth defects

Healthier Babies Worldwide Partnership for Neural Tube Defect Prevention

Key components of the Initiative:

Build the science base (surveillance, epidemiology, laboratory and prevention capacity) to support neural tube defect prevention

Educate and inform on the benefits of fortification policies for neural tube defect prevention

Establish programs and strategic partnerships to advance prevention

Platforms for Capacity Building and Integration of Birth Defect Surveillance

Strengthen national capacity for surveillance Conduct workshops and trainings for:

• Healthcare workforce

• Field Epidemiology Training Programs

• Epidemiologists

Strengthen the existing vital registration systems and other health information systems and develop surveillance mechanisms for birth defects Conduct pilot surveillance projects

Integrate into existing HIV, Immunization and Maternal and Child Health efforts

Healthier Babies Worldwide Partnership for Neural Tube Defect Prevention

Collaboration with WHO (HQ and SEARO)

Supporting fortification guidelines for food staples

Determining a target range of blood folate concentrations to maximize prevention of neural tube defects

Developing regional and country level approaches for birth defect prevention

Healthier Babies Worldwide Partnership for Neural Tube Defect Prevention

Working with partners

Monitoring effectiveness of fortification efforts

Improving surveillance to evaluate impact of prevention efforts

Strengthening laboratory capacity to measure blood folates and support quality control

Identifying new strategies to increase folic acid intake to reach women of reproductive age not reached by fortification

Key Points

Neural tube defects are life-threatening and cause life-long disabilities

Majority of neural tube defects are preventable with folic acid

Globally many women of reproductive age do not consume enough folic acid to prevent neural tube defects

Fortification of foods with folic acid is a feasible, economical, safe and effective public health policy to prevent neural tube defects

Acknowledgements

• World Health Organization/Headquarters

– Dr Juan Pablo Pena- Rosas

– Dr Luz Maria de Regil

– Ms Paule Pillard

• World Health Organization/Regional Office for South-East Asia

– Dr Neena Raina

– Dr Rajesh Mehta

For more information please contact Centers for Disease Control and Prevention

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Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348

E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

National Center on Birth Defects and Developmental Disabilities

Division of Birth Defects and Developmental Disabilities

Thank you!

www.cdc.gov/folicacid