Researchers Recommend Enriching Iodized Salt with Folic Acid in Ethiopia to Fight Spina Bifida and Anencephaly Epidemic

December 3, 2019

A recent study conducted by researchers at the Rollins School of Public Health and published in Birth Defects Research provided recommendations for preventing folic acid-preventable spina bifida and anencephaly cases and related mortality in Ethiopia. Vijaya Kancherla, PhD, research assistant professor in the Department of Epidemiology, was corresponding author of the article, with Meredith Dixon, MPH candidate, and Godfrey P. Oakley, MD, research professor and Director for the Center for Spina Bifida Prevention at Emory, contributing.

Ethiopia has recently witnessed epidemic levels of spina bifida and anencephaly, both of which lead to high levels of stillbirths and deaths in children under the age of 5. While the global average of these birth defects is 1.9 per 1,000 live births, Ethiopia’s rates, according to a recent hospital-based surveillance study, were 13 per 1,000, which is one of the highest levels recorded. Though it has been scientifically proven that folic acid can prevent both birth defects, the epidemic remains high, particularly in countries without effective interventions like mandatory fortification of staple foods with folic acid.

Using estimates on the prevalence of spina bifida and anencephaly in both live and stillbirths from a recent surveillance study in Ethiopia, the researchers found that folic acid interventions could have prevented about 41,610 cases of folic acid-preventable spina bifida and anencephaly affected pregnancies in 2016. Drs. Tony Magana and Afeworki Mulugeta, who were authors on the surveillance study from Ethiopia, collaborated with Emory researchers on the current study.

Given that Year 2030 Every Newborn Action Plan’s goal is to reach a stillbirth rate of 12 per 1,000 births and the Sustainable Development Goal of reducing under-5 mortality to 25 per 1,000 births by 2030 in every country, the researchers investigated how many stillbirths and child deaths could have been prevented in a given year through folic acid interventions in Ethiopia. The researchers stressed that if staple foods were to be enriched with folic acid in Ethiopia, approximately 31,800 stillbirths and 7,350 child deaths could be prevented each year, helping the country reach its health goals.

“These preventable birth defects kill more people each year than three times the number of all Africans who died in the 2014-2016 Ebola outbreak,” says Oakley. “This is a public health emergency.”

While many Western countries, like the United States, enrich cereal grain products with folic acid, the researchers recommended an alternative approach for Ethiopia and suggested enriching iodized salt with folic acid instead. Though enriching iodized salt with folic acid is a novel approach, it’s one that could be achieved and have a large impact, considering iodized salt is ubiquitous among Ethiopian homes (85.6 percent of Ethiopian households consume iodized salt according to the UNICEF).

Oakley and members of the Center for Spina Bifida Prevention (CSBP) at Emory have worked to raise awareness surrounding the epidemic and develop a plan, in coordination with several partners, and assisting the Ethiopian Ministry of Health and Ethiopian Public Health Institute, to control the epidemic. The combined efforts contributed to the release of a policy brief in May titled, “Preventing Neural Tube Defects in Ethiopia,” that recommended fortifying iodized salt with folic acid.

The CSBP has also been actively contributing to subsequent steps in Ethiopia, collaborating with partners, ReachAnother Foundation, Mekelle University, Nutrition International, International Federation for Spina Bifida and Hydrocephalus, and the Ethiopian Public Health Institute in ongoing efforts to address the prevention of neural tube defects. The group’s efforts were also recently outlined in an article published in Science.