The prevalence of neural tube defects (NTDs) in Ethiopia is approximately 63-83 per 10,000 births, which is 4-5 times greater than the estimated global prevalence. The main risk factor for NTDs in maternal folate insufficiency in early pregnancy. The most recent Ethiopian national food and nutrition survey found that 59% of adult females have folate deficiency or insufficiency.
Folic acid fortification of cereal grains is the main intervention for the control of folate insufficiency globally. However, most cereal grains in Ethiopia are not centrally processed making them unsuitable for large-scale fortification. In contrast, the national salt iodization program reaches nearly all Ethiopian households. Consequently, our group, in collaboration with the Ethiopian Public Health Institute and Nutrition International, conducted a community-based RCT that demonstrated doubly-fortified salt (DFS-IoFA; salt fortified with iodine and folic acid) improved women’s folate status. Following the presentation and dissemination of these trial results to senior leadership, the Ethiopian government decided to mandate the double-fortification of salt with both iodine and folic acid. Implementing universal double fortified salt with iodine and folic acid across Ethiopia is projected to prevent most NTDs-affected pregnancies and avert child deaths.
Christine McDonald (UCSF and UCD IGN) and Charles Arnold (UCD IGN) are continuing this collaboration to assess the impact of scaling up DFS-IoFA. The project, which is funded by a grant from the Gates Foundation to Nutrition International, is developing a surveillance system to evaluate changes in women’s folate status and NTD cases over time. Baseline and follow-up household surveys will assess dietary intake of folic acid (via DFS-IoFA, fortified wheat flour, and supplements), biomarkers of women’s folate status, and NTD prevalence in the community. These surveys will be complemented by ongoing surveillance of NTDs at five sentinel hospitals. Together, the findings will inform the implementation and sustained scale-up of DFS-IoFA for the prevention of NTDs in Ethiopia.