By : A. Bhebhe, C. Leonard, M. Ng’uni, S Hachizovu

National Health Research Authority

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Citation Style For This Article: Bhebhe A, Leonard C, Ng’uni M, Hachizovu S . The Sweet Solution: Mandatory Folic Acid Fortification of Sugar to Prevent Neural Tube Defects in Zambia. Health Press Zambia Bull. 2020; 4(01); pp 9-12

Key Messages

A Neural tube defect (NTD) is a birth defect of the brain and spinal cord, which results from the failure of the neural tube closing in the first month of pregnancy1

• NTDs result in stillbirths, infant and under-five mortality, and disability for life1

• NTDs are preventable2,3

• We estimate that 1,418 infants are born with an NTD each year in Zambia

• Over half of all NTD cases can be prevented through folic acid fortification of sugar in Zambia

Problem Statement

Neural tube defects include various birth defects resulting from the failure of the brain and spinal cord to close during the first month of pregnancy. These birth defects range from anencephaly to acceptlocales to spina bifida, which all result in a variety of disabilities1. Globally, it is estimated that approximately 300,000 babies are born each year with a neural tube defect4, resulting in approximately 88,000 deaths and 8.6 million disability-adjusted life-years (DALYs)5. In low income countries, NTDs may account for 29% of neonatal deaths due to observable birth defects1. Sub-Saharan Africa has an overall NTD birth prevalence of 1.5/1,000 live births6. It is estimated that Zambia has an overall NTD birth prevalence of 2/1,000 live births. This means that in 2018, approximately 1,418 infants were born with an NTD in Zambia, or about 4 infants per day. However, there is large underreporting as only 200 new patients were treated for an NTD at the University Teaching Hospital, the largest referring hospital in Zambia, last year7.

There are five countries in the SADC region with mandatory maize and / or wheat flour fortification programs (Malawi, Mozambique, South Africa, TanTanzania, and Zimbabwe). Currently, Zambia has a Folic Acid Supplementation Program, which provides folic acid pills to pregnant women who attend antenatal care visits in Zambia. However, this program misses a key population: women who are yet to become pregnant and most pregnant women who are in their first month of pregnancy. Folic acid is needed before pregnancy and during the first month of pregnancy to prevent NTDs10. Therefore, this program is not sufficient to stop all NTDs. A more comprehensive prevention initiative spearheaded by the Ministry of Health could prevent the death and disability caused by NTDs in Zambia. Folic acid has been proven to prevent NTDs2,3. A 1991 study published in The Lancet found that folic acid had a 72% protective effect against NTDs and recommended that public health measures are taken to ensure that all women of child-bearing age (WCBA) have an adequate amount of folic acid2. Currently, there is no legislation mandating the fortification of any food with folic acid in Zambia.

Policy Options

In order to prevent deaths and lifelong disability from NTDs, we need to prevent NTDs from occurring among infants in the first place. We identified three policy options: maintain the status quo, fortifying sugar with folic acid, and a public health campaign to increase awareness of the importance of folic acid in preventing NTDs.

1.Maintain status quo Continue the current practice of treating patients with NTDs. There is no NTD prevention strategy or programme, and thus, it is estimated that over 1,400 infants are born with an NTD each year in Zambia. This causes approximately 315 stillbirths and 1,064 under-five deaths each year. However, there is no register to capture the number of infants born with an NTD across the country. Hence, the severity of the problem is likely underestimated. Those who survive are left with disabilities for life. Most are paralyzed from the waist down and have cognitive disabilityties9. There are only two neurosurgeons in Zambia and 12 neurosurgery registrars (all in Lusaka) that perform the necessary life-saving surgeries. Therefore, most of the patients are referred to Lusaka for treatment and consequently, many patients living in rural areas are unable to receive proper care on time. There is also an added cost to the Ministry of Health (MoH) because patients outside of Lusaka are taken via MoH ambulances to get treatment in Lusaka. In addition, all patients operated at UTH have to come back to attend neurosurgery clinics at UTH.

2.Folic Acid Fortification of Sugar What: The Zambian government would mandate that all Zambian-produced and imported sugar is fortified with folic acid. This option will also include a public awareness campaign during which MoH will inform the public about the new fortification initiative and the benefits of folic acid for all, especially WCBA. Why: NTDs develop within the first 28 days of pregnancy1 when many women do not even know that they are pregnant yet. Folic acid taken around the time of conception can prevent 60- 70% of NTDs5. Therefore, it is necessary that women have adequate folic acid levels at all times and before they become pregnant. This option will ensure that all women have adequate levels of folic acid before they become pregnant and during pregnancy. In addition, over 95% of all NTDs are a first occurrence12, meaning we cannot solely target women who have had a child with an NTD before for folic acid supplementation. Not only is folic acid benefits for women, but it is also beneficial for men and children/adolescents. Folic acid can help treat anemia11. Also, folic acid supplementation is effective to preventing stroke in those with cardiovascular disease13.

Over 80 countries have implemented a folic acid fortification program with great success14. In 2003, South Africa embarked on folic acid fortification of staple foods. They experienced a significant decline in the prevalence of NTDs by 33%15. We predict this policy option will more than half all cases of NTDs, reduce NTD-related stillbirths and neonatal and under-five morbidity and mortality. This option will also reduce government spending.

Feasibility: Medium. Mandatory fortification of folic acid has proven to be feasible and economical in the countries that have implemented it, including the United States, Canada, Costa Rica, South Africa, Guatemala, Vietnam, and others16. Although the upfront cost of implementing this policy option will be expensive, the cost-savings over the long-term will be high.

3.Public Health Campaign What: The Zambian government would implement a campaign to encourage women of child-bearing age to take folic acid supplements and increase their intake of folic acid-rich foods. The campaign would consist of an advocacy media campaign and supporting the Ministry of Health’s Folic Acid Supplementation program by distributing folic acid pills to health facilities that offer family planning services. The media campaign would include: televised commercials, radio adverts, and printed adverts to encourage WCBA to take folic acid pills and encourage everyone to eat local foods with high levels of folate (legumes, eggs, leafy greens (rape, chibwabwa), citrus fruits, beef liver17. This option would also include community sensitization meetings to explain the benefits of folic acid taken before conception for all WCBA and to encourage planned pregnancy. Furthermore, MoH would hold workshops with healthcare providers, including doctors, nurses, and pharmacists to encourage them to talk to their patients about taking folic acid pills if they are thinking about becoming pregnant or currently pregnant. Why: As previously mentioned, folic acid is beneficial because when taken around the time of conception, it can prevent 60- 70% of NTDs5. Folic acid supplements are generally safe and side effects are rare. Less than 1 in 1,000 patients may experience nausea, loss of appetite, or an allergic reaction18. A limitation of this option is compliance with folic acid supplementation as seen in various studies around the world, only 20- 30% of women take folic acid supplements before pregnancy even after awareness campaigns19,20. Feasibility: Medium.

This strategy will require community sensitization and engagement with health workers. It will require funds, the majority of which will be for procuring more folic acid supplements to accommodate the increased demand from the public health campaign. Additional costs will include advertising, transport, and human resources. This option is highly costly and will result in net spending of 154,360,535 kwacha by the government over a five-year period. As well, this option is continuous and will be rolled out over a five-year period.

Recommendations and next steps There is a need to urgently prevent NTDs. The fortification of sugar with folic acid is the only viable choice if we want to substantially prevent NTDs in Zambia. This policy option has the highest public health impact and is politically feasible. Actions have already been taken engaging external stakeholders who have experience supporting folic acid supplementation initiatives in other countries, including the Global Alliance for Improved Nutrition (GAIN), Food Fortification Initiative (FFI), Nutrition International, Smarter Futures, and the International Federation Spina Bifida and Hydrocephalus (IFSBH). In addition, the 5-year cost savings is around 6.6 Million USD, while on the other hand, the public health campaign has an added cost of 11.8 Million USD.

A statutory instrument should be adopteded to make folic acid fortification of sugar mandatory in Zambia. In addition, all sugar manufacture and/or imported into Zambia should be fortified with folic acid. The Zambian government must mandate the Zambian Bureau of Standards (ZABS) to adopt fortified sugar as a standard and monitor the process of fortification. In addition to the legal framework, this policy option will require:

•Baseline/ endline and ongoing evaluations of folic acid levels and uptake of sugar to inform needed improvements and effects of the initiative

•The sugar manufacturing companies to implement fortification of sugar additionally with folic acid and rebrand their products to display that the sugar is fortified with folic acid

•Laboratory capacity to enable the testing of sugar to monitor the fortification program locally or outsourced •ZABS to monitor the fortification of all sugar (locally produced and imported) with folic acid

•ZRA to waiver tax on the importation of premix fortificant and fortification equipment Ministry of Health to engage the public to make them aware of the new fortification initiative


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