Dear members,
The mission of the March of Dimes Birth Defects Foundation is to improve the health of babies by preventing birth defects and infant mortality. March of Dimes Global Programs builds on the foundation's strengths through establishing partnerships to implement innovative perinatal health programs worldwide.
This electronic newsletter provides you with announcements about resources and activities of the March of Dimes and its partners, promising new research results, upcoming conferences and other useful topics. Earlier issues of the newsletter, as well as additional information about the March of Dimes and its Global Programs, may be found on our Web site.
Integrating Perinatal Health and Birth Defects Prevention into Primary Care in Eastern Europe
Eastern European countries face major public health challenges, including the need to strengthen perinatal health education for primary care practitioners. Over the past 10 years, U.S. organizations have partnered with their colleagues in Eastern Europe to improve health services and health professional education. These partnerships have shared resources and expertise, and built collaboration between health care professionals in the United States and their colleagues in Eastern European countries. Partnership activities have yielded major improvements in the quality of care, yet the need persists for strengthening the training of primary care professionals in the best practices in perinatal health, and for broad dissemination of these best practices.
In response to these challenges, the March of Dimes and the American International Health Alliance (AIHA) co-hosted a conference, "Integrating Perinatal Health and Birth Defects Prevention into Primary Care," in November 2003 in Kiiv, Ukraine. Approximately 75 primary care physicians from AIHA's Women's Wellness Centers and primary care centers in the Ukraine, Moldova and Belarus, as well as regional and national level health policy-makers, attended the conference.
The conference focused on four important areas of perinatal health for the region: prevention of mother-to-child transmission of HIV/AIDS; prevention of fetal alcohol syndrome; development of primary care genetics services; and the World Heath Organization’s (WHO) rubella vaccination campaign. Presentations by experts from the United States, South Africa and the Ukraine highlighted interventions for programs that had been successful in industrialized nations as well as those with demonstrated efficacy in developing countries.
A principal goal of the conference was to inform about best practices effective in other countries and make the information directly applicable to the participants' clinical practice and to local health policy. In order to facilitate a discussion and to build consensus, the conference participants gathered in workshops to develop recommendations for applying the interventions within their clinical settings. To see the conference proceedings and to read more about the conference and the partnership, please visit http://www.aiha.com/.
Promoting Folic Acid Fortification in the Countries of the Americas
A Regional Conference of the Pan American Health Organization, March of Dimes and Centers for Disease Control and Prevention
Neural tube defects (NTDs) are common congenital malformations originating when the neural tube fails to close by the 29th day after conception. Research has shown that neural tube defects can be reduced by 50 to 70 percent if all women get 400 micrograms of synthetic folic acid every day before pregnancy (1). Approximately 200,000 children worldwide die from folic acid-preventable NTDs every year. NTDs, thus, constitute one of the most common forms of congenital malformations, with varying prevalence depending on genetic and environmental conditions.
There is overwhelming evidence that consuming folic acid reduces NTD risk. The findings lend support to the 1992 recommendation by the U.S. Public Health Service that all women of childbearing age should consume 0.4 mg (400 µg) of synthetic folic acid (the more bioavailable form of folate) daily, in addition to folate from a varied diet, in order to reduce their risk of an NTD-affected pregnancy. Women who are capable of becoming pregnant should consume daily folic acid so that body levels of folate are adequate before and after conception, as many pregnancies are unplanned.
Providing folic acid supplementation to all women of childbearing age, however, poses major logistical challenges. In light of this challenge, increasing folate levels through folic acid fortification of foods is an important public health strategy. In January 1998, the United States and Canada, began folic acid fortification of grains. In the following years, other countries in the Americas began to implement mandatory fortification of grains with folic acid. Currently, 17 of these countries are fortifying wheat flour with folic acid at levels that vary between 1.5 and 3.4 mg/kg flour. Unfortunately, countries have adopted different levels of fortification without any standardized criteria for determining these fortification levels.
Responding to this lack of standardized criteria, the Nutrition Unit of the Pan American Health Organization (PAHO), Institute of Human Nutrition and Food Technology of the University of Chile, March of Dimes and Centers for Disease Control and Prevention (CDC) cosponsored a regional conference on 7-9 October 2003 in Santiago, Chile, to promote standards for fortification with folic aid and other micronutrients in the countries of the Americas. The goal of the conference, which was attended by representatives from 20 countries of the region, was to strengthen national fortification programs. The conference highlighted the experience of the successful national folic acid fortification campaign instituted by Chile in January 2000 and drew on recommendations of a Technical Consultation of the partners that was held in Washington, DC, in January 2003.
Since the conference, countries have been engaged in reviewing their national food fortification programs in light of the new recommendations. Several countries have activated national micronutrient committees to analyze the feasibility of the recommended changes. Some countries, for example Colombia, are organizing workshops to discuss the technical components of their ongoing food fortification activities. Two countries, the Dominican Republic and Bolivia, have been recommended by the independent Proposal Review Panel of the Global Alliance for Improved Nutrition (GAIN) to receive grants to reinforce their food fortification programs. PAHO is also responding to the recommendations of the regional meeting through specific technical cooperation to the countries.
Readers interested in knowing more about the health benefits of folic acid fortification or about current national fortification efforts in the Americas should visit the March of Dimes web site at http://www.marchofdimes.com/, or the PAHO web site at http://www.paho.org/.
Congenital Rubella Syndrome (CRS) Eradication Efforts Worldwide
Congenital rubella syndrome (CRS) is a significant cause of deafness, blindness and mental retardation that can result when a woman contracts rubella during the first trimester of pregnancy. An estimated 110,000 infants are born with CRS every year in the developing nations.
National estimates of rubella infection and CRS are hampered by a lack of data. Developing country surveys, however, suggest that a substantial proportion of individuals who had presumed measles infection actually had rubella. For example, 30 percent of serologic specimens from diseases with rash, considered measles cases, in Kenya and Benin and 50 percent of such cases in Ghana indicated rubella, not measles. It is reasonable to expect that a certain number of these occur in pregnant women and result in infants born with CRS.
Targeting Rubella and Measles Jointly
An effective rubella vaccine is available. What is needed is to combine it with current global measles eradication efforts through use of combined measles/rubella or measles/ mumps/rubella vaccines. This strategy has been highly successful in reducing rubella infection and CRS in Latin America and eliminating it in English-speaking Caribbean and in many countries of the industrialized world. Because the cost of the bivalent vaccine averages 48 cents U.S. versus 15 cents U.S. for the univalent measles vaccine, a reasonable first step for countries that have not yet implemented rubella immunization is to assess the incidence of rubella infection in target populations through serologic studies and the incidence of CRS through examination of newborns.
International Partnerships Grow
The March of Dimes has been active in promoting CRS control efforts worldwide. In 1998, the foundation provided support to the Pan American Health Organization (PAHO) to help implement rubella/CRS surveillance strategies across the region of the Americas.The grant accelerated CRS eradication efforts to the degree that CRS has now disappeared in the English-speaking Caribbean and Uruguay. It is expected that CRS will be controlled in all countries of the Americas by the year 2010. In addition, March of Dimes, with UNICEF and the European Regional Office of the World Health Organization (WHO), helped initiate control of CRS in Kyrgyzstan in 2001 and Moldova in 2003. Other countries in the regions will follow soon.
Another key ally in global efforts to eradicate CRS is the U.S. Centers for Disease Control and Prevention (CDC). Those interested in learning more about CRS and its prevention through rubella immunization should visit the March of Dimes and CDC web sites.
Experience Points the Way to Rubella Control
Current experience with vaccination strategies in the Americas teaches us how to control rubella transmission and thus prevent congenital rubella syndrome (CRS) anywhere, including developing countries and those with economies in transition.
A rubella control program must begin with creation of infrastructure, including serologic testing capability, a surveillance system, and arrangements for vaccine distribution and administration to target populations. This can be best accomplished by linking this effort to the current measles vaccination programs.
Surveillance shows that epidemiological patterns of rubella transmission and CRS in developing and transitional countries generally reflect those that were seen in industrialized countries before successful vaccination campaigns. Epidemics occur in four- to seven-year cycles. Attack rates are similar, as is incidence of CRS. Where mass vaccination programs focus only on infants and young children among whom rubella mostly circulates, this leaves many adults (who were not immunized earlier) susceptible to this infection. Therefore, the disease shifts to this older age group, including women in the childbearing years.
Bringing CRS under control promptly, therefore, requires a strategy that includes routine vaccination of all infants, but simultaneously also targets postpubertal women, who are not immune. This needs to be done only once, if routine immunization of infants has been implemented, because it will maintain universal immunity against this infection. This dual strategy will rapidly eliminate rubella and consequent CRS, as it already has in parts of the Americas.
All analyses to date have shown rubella vaccination programs to be cost-effective. If the initiation of the rubella immunization campaign is coupled to that against measles, the extra cost is small and no additional effort in terms of personnel and equipment is required.
Readers interested in learning more about this issue should visit the following websites:
Cutts FT, et al. Modelling the incidence of congenital rubella syndrome in developing countries. International Journal of Epidemiology 1999;28:1176-1184
http://ije.oupjournals.org/cgi/reprint/28/6/1176
Cutts FT, et al. Guidelines for surveillance of congenital rubella syndrome and rubella. World Health Organization 1999
http://www.who.int/vaccines-documents/DocsPDF99/www9934.pdf
Cutts FT, et al. Control of rubella and congenital rubella syndrome (CRS) in developing countries, part 1: burden of disease from CRS. Bulletin of the World Health Organization 1997;75(1):55-68
http://whqlibdoc.who.int/bulletin/1997/Vol75-No1/bulletin_1997_75(1)_55-68.pdf
Robertson SE, et al. Control of rubella and congenital rubella syndrome (CRS) in developing countries, part 2: vaccination against rubella. Bulletin of the World Health Organization 1997;75(1):69-80
http://whqlibdoc.who.int/bulletin/1997/Vol75-No1/bulletin_1997_75(1)_69-80.pdf
Hinman AR, et al. Economic analyses of rubella and rubella vaccines: a global review. Bulletin of the World Health Organization 2002;80(4):264-270
http://www.who.int/bulletin/archives/en/80(4)264.pdf
World Health Organization 2000. Report of a meeting on preventing congenital rubella syndrome: immunization strategies, surveillance needs
http://www.who.int/vaccines-documents/DocsPDF00/www508.pdf
Castillo-Solorzano C, et al. New horizons in the control of rubella and prevention of congenital rubella syndrome in the Americas. Journal of Infectious Diseases 2003;187(Supplement 1):S146-152
Prenatal Health Information for Spanish-speaking Women: An Internet Resource
In Latin America, 10 times as many women die from pregnancy-related causes as do women in North America. In addition, over four times as many babies die before their first birthday in Latin America as in North America (1). A woman can improve her chances of having a healthy baby if she has accurate and up-to-date information about pregnancy and preconception health. Although a woman's family and health care provider have traditionally been the sources of information, increasingly the Internet is considered a resource for answers to questions about health.
The March of Dimes Spanish-language consumer Web site - http://www.nacersano.org/ - is targeted to women who are pregnant or are contemplating pregnancy, to their families and to health care providers looking for information on specific pregnancy related topics. Although the Web site was designed for the United States Hispanic population, people from outside the U.S. increasingly use it. Monthly totals for first-time visitors now exceed 126,000. Recent visitors from Latin America include more than 18,600 from Mexico, 9,500 from Peru, 8,500 from Chile, 6,200 from Argentina and 6,000 from Colombia.
The most popular pages are preconception health, pregnancy and information on folic acid, a B vitamin that helps prevent birth defects. Although nacersano is a consumer-oriented site, fact sheets on pregnancy-related conditions are of particular interest to health care professionals. These fact sheets are accessible in the health library section of the Web site.
GENETICS & YOUR PRACTICE Goes Online
Recent advances in DNA technology have led to identification of the genetic basis of many diseases, including a number of single gene disorders and common chronic diseases. Primary care professionals need to be provided with information on how to use these advances in their day-to-day practice. While a number of genetics curricula exist, few provide practical information that can help primary care professionals to integrate genetics into their practices.
Genetics & Your Practice (G&YP) CD-ROM was developed to provide practical information on genetics to primary care professionals. Its curriculum offers guidelines on how to conduct a family health and social history, interact with patients and their families who have genetic concerns, refer to genetic services where appropriate and necessary, and obtain additional tools and resources as needed.
Genetics & Your Practice Online, (www.marchofdimes.com/gyponline), launched in August 2003, is a new genetic education program and information resource for primary care professionals – including physicians, nurses, physician assistants, and nurse practitioners, as well as social service professionals. Designed to enhance and improve the quality of the exchange between professionals and patients, this new Web site builds on the success of the March of Dimes interactive Genetics & Your Practice CD-ROM released in 1998; updated in 2003. Access to this Web site is free and provides practical “how-to” information and downloadable tools to help health care professionals integrate genetics into their current practice. This online resource illustrates step-by-step processes for taking a family history, genetic testing and screening, and referring to genetic services. A unique feature of this site is that it is customized, allowing users to receive content relevant to the type of patients they see, i.e., preconception/prenatal, infants/children, and adolescents/adults. Free continuing education credits can be obtained through interactive case studies.
Readers interested in knowing more about Genetics & Your Practice Online can access the free curriculum at www.marchofdimes.com/gyponline
Until next time,
The March of Dimes
The Global Programs Newsletter is written by Dr. Christopher P. Howson, Dr. Mary-Elizabeth Reeve and Richard P. Leavitt. We gratefully acknowledge the editorial contributions of Dr. Michael Katz.
