Neural Tube Defects in Costa Rica, 1987–2012: Origins and Development of Birth Defect Surveillance and Folic Acid Fortification

Abstract

Our aim was to provide a descriptive overview of how the birth defects surveillance and folic acid fortification programs were implemented in Costa Rica—through the establishment of the Registry Center for Congenital Anomalies (Centro de Registro de Enfermedades Congénitas—CREC), and fortification legislation mandates. We estimated the overall prevalence of neural tube defects (i.e., spina bifida, anencephaly and encephalocele) before and after fortification captured by CREC. Prevalence was calculated by dividing the total number of infants born with neural tube defects by the total number of live births in the country (1987–2012).A total of 1,170 newborns with neural tube defects were identified from 1987 to 2012 (1992–1995 data excluded); 628 were identified during the baseline pre-fortification period (1987–1991; 1996–1998); 191 during the fortification period (1999–2002); and 351 during the post-fortification time period (2003–2012). The overall prevalence of neural tube defects decreased from 9.8 per 10,000 live-births (95 % CI 9.1–10.5) for the pre-fortification period to 4.8 per 10,000 live births (95 % CI 4.3–5.3) for the post–fortification period. Results indicate a statistically significant (P < 0.05) decrease of 51 % in the prevalence of neural tube defects from the pre-fortification period to the post-fortification period. Folic acid fortification via several basic food sources has shown to be a successful public health intervention for Costa Rica. Costa Rica’s experience can serve as an example for other countries seeking to develop and strengthen both their birth defects surveillance and fortification programs.

Prevalence of neural tube defects and estimation of cases averted in the post-fortification period in Argentina

“…The reduced prevalence observed in our study is lower than that observed in Chile 5 and Costa Rica, 14 but higher than that seen in Brazil. 5 Such variation may be due to the effectiveness of different fortification strategies: variations in dose, in selected basic foods, and in the FAF period that was assessed.…”

Prevalencia de defectos del tubo neural y estimación de casos evitados posfortificación en Argentina

“…La disminución de la prevalencia observada en nuestro trabajo es menor a la observada en Chile 5 y Costa Rica, 14 pero mayor a la observada en Brasil. 5 Esta variación puede deberse a la efectividad de diferentes estrategias de fortificación: variación en las dosis, en los alimentos básicos seleccionados y en el tiempo de FAF evaluado.…”

Folate status and health: challenges and opportunities

“…Protective levels of serum and RBC-folate are estimated to be > 18 nmol/L and > 1000 nmol/L respectively [9,20,21]. After introducing a population-wide fortification of staple foods with FA, the prevalence of NTDs in the US, Costa Rica [22], and many other countries declined to < 5-6 cases per 10,000 births and thus, it is now only about half as high as the average rate of 9.3 cases per 10,000 births in Europe in 2012 (source EUROCAT, University of Ulster). The pathogenesis of NTDs and the protective mechanisms of FA are still not well understood [23], but it appears that FA cannot prevent all NTD cases.…”

“…The fortification has shown to be effective in terms of lowering tHcy, increasing serum, and RBC-folate [80,81], eliminating anemia [82], and reducing NTD [22]. Fortification of staple foods requires supportive legislations or regulations, and its implementation and effects should be monitored.…”