Will the Eastern Mediterranean Region be the first to prevent all of folic acid-preventable spina bifida and anencephaly?

Address correspondence and reprint request to: Dr. Godfrey P. Oakley Jr., Center for Spina Bifida Research, Prevention and Policy, Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America. E-mail: [email protected] The global total prevention of folic acid preventablespina bifida and anencephaly (FAP SBA) is long overdue. It has been 24 years since the publication of findings from the randomized clinical trial by the Medical Research Council proving unequivocally that folic acid taken shortly before and during early pregnancy will prevent a large proportion of spina bifida and anencephaly.1 Within this same time period, vaccine programs have assured that almost every child in the world is receiving newly developed conjugate vaccines, leading to remarkable global improvements in associated child mortality and child health. Unlike the expansive global support achieved for preventing vaccine-preventable diseases, no country or donor organizations has provided sufficient resources to build the global program for the total prevention of FAP SBA. Due to lack of support, the current level of global prevention for FAP SBA has stalled at approximately 25%.2 The bottom line is that we are collectively failing children globally by letting FAP SBA to occur, which is associated with high risk of death and disability, including orthopedic, motor, neurologic, and learning and developmental deficits. Global total prevention of FAP SBA requires implementing effective prevention programs in each country. Experience with infectious disease prevention programs suggests that total prevention is achieved through country-by-country and World Health Organization (WHO) region-by-region efforts. For example, we know that rubella infection during early pregnancy causes a cluster of severe birth defects termed as congenital rubella syndrome. There is a strategic plan for the global total prevention of rubella. Recently, the Pan American Health Organization (PAHO) announced that there had been no cases of rubella and congenital rubella syndrome for the last 5 years in their region. The PAHO became the first of WHO regions to achieve total prevention of this vaccine preventablebirth defect. Given that FAP SBA is just as preventable as the congenital rubella syndrome, we ask, which will be the first WHO region to achieve and to demonstrate total prevention of FAP SBA? Perhaps it will be PAHO, as national mandatory folic acid fortification programs are widespread in the region. In the United States, where folic acid fortification has been implemented countrywide as a mandatory policy since January 1, 1998, FAP SBA has reached a near-total prevention.3 The Pan American Health Organization may not be the first to achieve total prevention of FAP SBA. It could be the Eastern Mediterranean Region (EMR). We hope that this editorial will spark the Kingdom of Saudi Arabia (KSA) to provide the leadership and resources to prevent all FAP SBA in the EMR. In 1996, during a workshop for developing a common standard for micronutrient fortification for the EMR, Oman, which at the time had a single flour mill, elected to begin folic acid fortification, and became the first country in the world to successfully implement a country-wide folic acid fortification program. In 2003, KSA required flour to be fortified with folic acid at 1.5 part per million (ppm), similar to the 1.4 ppm adopted by United States, and exactly the concentration used