The COVID-19 pandemic has brought unprecedented global physical and economic suffering, disability and death. In spite of these tragedies, the pandemic has also provided an opportunity to harness time and technology to renew and organize a neurosurgical attack on a longstanding global neurosurgical problem: spinal dysraphism. The most common form of spinal dysraphism is the myelomeningocele (open spina bifida) which has high morbidity and mortality.1 Multidisciplinary care and surgical intervention are needed across the lifespan to ameliorate but not cure fundamental morbidities. As such, opportunities to prevent MMC are essential.
It is well-established that folic acid fortification of staple foods (e.g., wheat and maize flour) is associated with a significant reduction in the prevalence of neural tube disorders (NTDs).2 With mandatory fortification, baseline rates of 6-10 cases of MMC/10,000 live births are observed(3). Currently, there are global hot spots where fortification is lacking and the prevalence rates are orders of magnitude higher than these rates. For example, recent prevalence rates in Ethiopia exceed 150 cases of MMC/10,000 live births.3 Birthrates are accelerating in many of these regions creating focal epidemics of dysraphism that are largely preventable. Despite this, there has been no progress in prevention in the last 30 years, since the randomized clinical trial by the UK Medical Research Council study in 1991 demonstrating the benefit of folic acid.
During the pandemic, we utilized our unexpectedly available time and the ubiquitous availability of Zoom meetings to organize and launch an international neurosurgical Folic Acid Fortification Advocacy Team. Neurosurgeons contribute to the care of those living with spina bifida and have been advocates for improved quality of life of those affected with spina bifida; however, there has been no formal united global role of neurosurgeons in advocating strategies upstream for primary prevention of NTDs until now. Our goal is to prevent folic acid-preventable spina bifida and other NTDs worldwide through science-based advocacy and raising political will for prevention in countries without folic acid fortification of staple foods.
In this effort to bring a new and strong voice to the ongoing advocacy of global prevention of NTDs, we first solicited and continue to seek interested participants to create a team with broad possible membership and invite interested readers to contact the author(s). We also hope to foster new members of the working group who provide neurosurgical care in affected countries who will serve as strong advocates trained in the science of folic acid-based prevention of NTDs. We believe these neurosurgeons harbor a unique opportunity to be instrumental in generating needed political will in their respective countries.
We found Zoom was widely available as a video platform at nearly all hospitals for our meetings. We also flattened the hierarchy of our working group, so that the most junior members organized meetings and documents, senior members provided ready access to other experts and their publications, and all meetings included a consensual summary of next steps for each team member.
Next, we identified the ongoing country-specific mandatory folic acid fortification efforts in countries aimed at preventing spina bifida and anencephaly. Local cultures determine preferred dietary sources of carbohydrates. Whether such sources are primarily artisanal (i.e. home-grown) or commercial has major impact on regulatory strategies. We examined the countries with mandatory folic acid fortification regulations in place as of 2019 including 56 countries which have mandatory folic acid fortification of wheat and/or maize flour reaching recommended fortification levels.4 We have also noted the prevention potential through novel fortification vehicles, including salt.5
While the scientific work takes place, the advocacy work continues in parallel. Our Zoom meetings include collaboration with stakeholders in other surgical and medical fields. We regularly update diplomats through our contacts at the World Health Organization, the G4 Alliance and foreign missions in Geneva and Washington, D.C.
We have found that the disruption of our busy clinical lives as a result of the COVID-19 pandemic has allowed us to re-focus our efforts in NTDs and commit to optimizing available prevention of a crucial neurosurgical disease.
References
[expand title=”View All”]
1. Wallingford JB, Niswander LA, Shaw GM, Finnell RH. The Continuing Challenge of Understanding, Preventing, and Treating Neural Tube Defects. Science. 2013 Mar 1;339(6123):1222002–1222002.
2. Crider KS, Bailey LB, Berry RJ. Folic Acid Food Fortification—Its History, Effect, Concerns, and Future Directions. Nutrients. 2011 Mar 15;3(3):370–84.
3. Murphy ME, Westmark CJ. Folic Acid Fortification and Neural Tube Defect Risk: Analysis of the Food Fortification Initiative Dataset. Nutrients. 2020 Jan 18;12(1):247.
4. Blencowe H, Kancherla V, Moorthie S, Darlison MW, Modell B. Estimates of global and regional prevalence of neural tube defects for 2015: a systematic analysis: Worldwide neural tube defects: estimates for 2015. Ann NY Acad Sci. 2018 Feb;1414(1):31–46.
5. Kancherla V, Tsang B, Wagh K, Dixon M, Oakley GP. Modeling shows high potential of folic acid?fortified salt to accelerate global prevention of major neural tube defects. Birth Defects Research. 2020 Aug;bdr2.1769.
[/expand]
