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Birth Defects COUNT Partner Newsletter

Birth Defects COUNT Partners Newsletter Logo


Coleen A. Boyle, PhD, MS hyg

A Message from the NCBDDD Director

Dear Colleagues:

Welcome to the sixth issue of Partners COUNT, a newsletter to update partners on the activities of Birth Defects COUNT- CDC’s global initiative to reduce morbidity and mortality due to neural tube defects.

In this issue, we highlight our most recent efforts to expand research and partnerships across the globe. We continue to work with partners in Tanzania to strengthen the implementation of maize flour fortification in small- and medium-scale mills. These efforts would help to increase the reach of fortified products to a broader population. In addition, we continue to collaborate with our partners in India with the Haryana Fortification Demonstration Project, to assess the feasibility, sustainability, and health impact of fortifying wheat flour with folic acid, vitamin B12, and iron using India’s existing open market and government systems. Further, in July 2017, CDC staff members, along with representatives from WHO’s South East Asia Regional Office, attended a three-day South East Asia Regional meeting to review progress in birth defects surveillance and prevention in the region. These efforts continue to have a positive outcome on the lives of children and families across the globe and we would not have been able to accomplish these achievements without your partnership.

We wish you all a very productive end to this 2017 year, and look forward to further collaborations with you in 2018!


Coleen A. Boyle, PhD, MS hyg
Director, National Center on Birth Defects and Developmental Disabilities
Centers for Disease Control and Prevention

Program Highlight

Partner Group Evaluates Maize Flour Fortification Project in Tanzania

Studies have shown that the addition of folic acid (vitamin B9) to foods (known as food fortification) is an effective way to prevent neural tube defects (severe birth defects of the brain and spine). However, fortified foods are often not produced widely in many low-and middle-income countries, limiting their availability to consumers. Tanzania is a prime example of this type of limited availability.

Fortification of all industrially milled wheat and maize flours in Tanzania is mandatory. However, much of the country’s maize is milled in small- or medium-sized mills that are not subject to mandatory fortification. Fortification of flour in small- and medium-sized mills is not common and often only done by millers who have the necessary resources. Because maize flour is consumed by 93% of the Tanzanian population (FACT survey, 20151), there needs to be a more comprehensive fortification strategy that includes mills of all sizes.

To address the availability of fortified maize flour in Tanzania, the United States Agency for International Development funded the Tuboreshe Chakula project in 2011-2015. This project was one of the first in Tanzania aimed at expanding the capacity of small- and medium-scale mills for fortification. Through this project, 44 businesses in Tanzania acquired machines called dosifiers to fortify maize flour.

In 2016, the Centers for Disease Control and Prevention (CDC), in partnership with Helen Keller International (HKI), Deutsche Gesellschaft fuer Internationale Zusammenarbeit GmbH, and Project Healthy Children/SANKU, focused on increasing market supply and demand for fortified maize flour produced by small- and medium-scale mills. The partners worked together to build capacity of millers in the Morogoro Region of Tanzania through marketing and communication activities and outreach to officials in government, education and healthcare facilities. In addition, SANKU continues to support millers who started fortification under the Tuboreshe Chakula project by providing fortification equipment, access to the powdery blend of vitamins and minerals used in fortification (premix) and technical assistance.

In May 2017, CDC and HKI conducted an evaluation to understand the factors influencing acceptance, adoption, and sustainability of maize flour fortification in medium-scale mills in Tanzania. The evaluation compared a district that received intensive support to enable maize fortification (Morogoro) to one that received very little assistance (Dodoma). Both regions had been targeted under the Tuboreshe Chakula project, but no additional fortification promotion campaigns had been implemented in Dodoma Region since the project’s completion in 2015. The evaluation included in-depth interviews with medium-scale maize flour millers and local government officials to examine the barriers to implementation of maize flour fortification. The evaluation also included a survey of retailers who sell maize flour to assess their awareness and perceptions of maize flour fortification and the availability of fortified products in the market. An analysis of the information collected during this evaluation is underway. These findings will aid in the development of strategies to improve and sustain maize flour fortification efforts in Tanzania.

[1] Fortification Assessment Coverage Tool (FACT) Survey in Tanzania, 2015. [cited 2017 Sep 8]. Available from:

Partner Spotlight

Developing a Sustainable Surveillance and Prevention System for Birth Defects: Spina Bifida and Hydrocephalus Care Foundation of Nigeria

The Spina Bifida and Hydrocephalus Care Foundation of Nigeria (SBH Nigeria) was founded in 2009 and is a national non-governmental organization that supports individuals living with a neural tube defect or hydrocephalus (a build-up of fluid in the brain). The goal of SBH Nigeria is to provide information on ways to prevent neural tube defects and hydrocephalus and to create awareness of longer-term health issues related to these conditions.

In 2014, SBH Nigeria, with support from the World Health Organization, held its first meeting on birth defects tracking (public health surveillance) and prevention. This meeting highlighted the need for more training of healthcare professionals on how to track and prevent birth defects. This led to a pilot training on birth defects tracking and prevention for healthcare professionals in South East Nigeria. This project was done in collaboration with the Ebonyi State Ministry of Health and was supported by the Center for Clinical Care and Clinical Research of Nigeria.

The training participants will work together to help develop a birth defects tracking system and provide high quality health care for children with birth defects in Ebonyi State and Nigeria.

News & Events

Haryana Fortification Demonstration Project in India

CDC, World Health Organization South-East Asia (WHO-SEARO) Regional Office, and other partners (including CDC’s Division of Nutrition, Physical Activity, and Obesity) are working together on the Haryana Fortification Demonstration Project in Haryana State, Ambala District in India. The purpose of the demonstration project is to assess

  • How feasible it is to fortify wheat flour with folic acid (vitamin B9), vitamin B12
    and iron using India’s existing open market and government systems;
  • How such a program can be sustained over the long term; and
  • How people’s health in Haryana is improved through the program.

The project consists of three phases:

Phase 1

  • Survey households to find out where and how they obtain their wheat flour
  • Collect blood samples from non-pregnant women of reproductive age in a rural area of Ambala District to find out the amounts of each of these in their blood: folate (the natural form of folic acid), vitamin B12, hemoglobin (the blood protein that carries oxygen throughout the body), and iron
  • Create a birth defects tracking system in the project areas
  • Determine how people in Haryana cook wheat flour products and which products they eat
  • Determine how much wheat flour is made in mills and how people get it
  • Conduct a workshop (at the end of Phase 1) to develop a strategy for wheat flour fortification

Phase 2

  • Begin the wheat flour fortification program
  • Track and assess the progress of the wheat flour fortification program
  • Continue the birth defects tracking system for the project areas

Phase 3

  • Collect blood samples from non-pregnant women of reproductive age in the same area to measure the changes in the amounts of folate, vitamin B12, hemoglobin, and iron in their blood
  • Evaluate how well the wheat flour fortification program was carried out
  • Evaluate how well the population-based birth defects tracking system was conducted

For additional information about this project, please contact CDC’s Birth Defects COUNT program at

South- East Asia Regional Meeting to Review Progress in Birth Defects Surveillance and Prevention

In July 2017, representatives from 10 member states of the World Health Organization South-East Asia Region (WHO-SEARO) attended the “Regional Meeting to Review Progress in Perinatal Surveillance and Prevention of Birth Defects” held in Denpasar, Bali, Indonesia. WHO-SEARO, with support from CDC, conducted the three-day progress review meeting and workshop.

The meeting included the following:

  • An overview of CDC’s Birth Defects COUNT Initiative;
  • Other birth defects tracking and prevention topics, including congenital rubella syndrome and congenital Zika syndrome (infection during pregnancy with rubella virus or Zika virus that results in birth defects);
  • Integration of the Newborn and Birth Defects (NBBD) tracking and reporting system into existing country systems;
  • Food fortification programs; and
  • Selected country birth defects management programs.

The 10 member states were represented by delegations that included an appointee from the Ministry of Health, a representative from the WHO country office, and country officers for birth defects surveillance. Together, these country teams provided updates on the status of birth defects tracking and prevention in their countries, while highlighting challenges, potential solutions, and successes. The workshop concluded with representatives from each member state developing and presenting their birth defects program action plans for the coming year. Moving forward, WHO-SEARO and CDC will focus on conducting tracking evaluations and quality improvement and evaluation workshops so that the overall performance of the regional system and the quality of NBBD data are continually improved.

Key Resources

CDC and Partners Publish New Study: Folate Deficiency is Common in Women of Childbearing Age

The Journal of Nutrition published a 2017 study that looks at the amounts of folate (vitamin B9) and vitamin B12 in the blood of non-pregnant women of reproductive age in Belize1. In 2011, researchers collected data from a group of non-pregnant women in Belize, aged 15-49 years, who have similar characteristics to the entire population of non-pregnant women in the country. The researchers measured folate and vitamin B12 in the blood of these women and also checked them for anemia. The study showed that many non-pregnant women in Belize had low amounts of folate and/or vitamin B12 in their blood despite laws in Belize that allow, but do not require, fortification of wheat flour with folic acid. In addition, women with low amounts of vitamin B12 in their blood typically also had low amounts of folate, which would put them at increased risk to have a pregnancy affected by a neural tube defect. These results revealed that additional interventions are needed to promote adequate intake of both vitamins in order for women of reproductive age to have optimal amounts of each of these vitamins in their blood.

1Rosenthal J, Largaespada N, Baily LB, Cannon M, Alverson CJ, Ortiz D, Kauwell GPA, Sniezek J, Figueroa R, Daly R,
and Allen P. Folate Deficiency Is Prevalent in Women of Childbearing Age in Belize and Is Negatively Affected by
Coexisting Vitamin B-12 Deficiency: Belize National Micronutrient Survey 2011. Journal of Nutrition.