Cost-effectiveness of a folic acid fortification program in Chile
Introduction
Periconceptional intake of folic acid (FA) has been demonstrated to reduce the risk of having a fetus affected with anencephaly or spina bifida by 50–70% [1], [2]. Anencephaly and spina bifida are among the most common birth defects contributing to infant mortality and disability. In Chile, they together represent the second most frequent isolated type of birth defect after congenital heart disease [3].
In response to the evidence of a beneficial effect of periconceptional intake of FA, statements from USA, Europe [4], [5] and FAO/WHO recommended that all women of fertile age should consume 400 μg of FA daily to reduce the risk of NTDs. Several evaluations identified grain fortification as the most cost-effective way to increase consumption of folic acid [6], [7]. Studies show that fortification of cereals with FA significantly increases blood folate levels and is associated with reductions in NTDs [8], [9], [10], [11], [12].
In Chile, a wheat flour folic acid fortification program showed an increase in blood folate levels [13] and a decrease in the risk of NTDs [14], [15]. An ex-post economic evaluation of the program should provide useful information for policy makers in other countries where congenital malformations are an important cause of infant mortality.
Section snippets
Methods
We compared the strategy of fortification with the baseline alternative of no fortification. Other alternatives directed to increase FA intake such as promoting consumption of supplements were excluded from consideration because they were not in place during the period of evaluation. Consequently, improvements in folate intake and blood folate status and subsequent reductions in the risk of NTDs can best be explained by the implementation of the fortification program.
Birth defects surveillance
Results
Estimates of the numbers of cases, fetal and infant deaths prevented, and cost-effectiveness ratios for the different health outcomes are presented in Table 3, along with upper and lower bounds for the estimates. These numbers apply the incidence rates from the study sample of hospitals to all births in Chile during 2001. Fortification is calculated to have resulted in 175 averted NTD births per year, including 107 births with spina bifida and 68 with anencephaly. The estimated reduction in the
Discussion
A CEA evaluation provides information that allows the health sector to allocate resources to those programs in which the ratio of health benefits of the intervention to costs exceeds alternatives. In this analysis, we utilized data derived from prospectively designed evaluations on NTDs risks, morbidity, and mortality from our NTD registry in combination with cost data from program implementation to estimate cost-effectiveness ratios for health outcomes.
We have conducted a CEA of a wheat flour
References (40)
- et al.
Trends in serum folate after food fortification
Lancet
(1999) - et al.
Association of neural tube defects and folic acid food fortification in Canada
Lancet
(2002) - et al.
Consumption of folic acid-fortified bread improves folate status in women of reproductive age in Chile
Journal of Nutrition
(2003) - et al.
Iron fortification and iron supplementation are cost-effective interventions to reduce iron deficiency in four subregions of the world
Journal of Nutrition
(2004) - et al.
Effects of supplementation with folic acid and antioxidant vitamins on homocysteine levels and LDL oxidation in coronary patients
Nutrition
(2000) - et al.
Low vitamin B12 concentrations in patients without anemia: the effect of folic acid fortification of grain
American Journal of Clinical Nutrition
(2003) - Prevention of neural tube defects: results of the Medical Research Council Vitamin Study. MRC Vitamin Study Research...
- et al.
Prevention of the first occurrence of neural-tube defects by periconceptional vitamin supplementation
New England Journal of Medicine
(1992) - et al.
ECLAMC: 30-year study of epidemiological surveillance of neural tube defects in Chile and Latin America
Revista Medica de Chile
(2001) Folate
Dietary references intakes for thiamin, riboflavin, nicin, vitamin B6, folate, vitamin B12, panthotenic acid, biotin and choline
(1998)
Folic acid fortification of grain: an economic analysis
American Journal of Public Health
Cost-effectiveness of strategies to prevent neural tube defects
Impact of folic acid fortification of the US food supply on the occurrence of neural tube defects
Journal of the American Medical Association
Increased red cell folate concentrations in women of reproductive age after Canadian folic acid food fortification
Epidemiology
Prevalence of spina bifida and anencephaly during the transition to mandatory folic acid fortification in the United States
Teratology
Folic acid fortification of wheat flour: Chile
Nutriton Reviews
Reduction of birth prevalence rates of neural tube defects after folic acid fortification in Chile
American Journal of Medical Genetics A
Development of WHO guidelines on generalized cost-effectiveness analysis
Health Economics
Cited by (63)
Economics of Food Fortification
2018, Food Fortification in a Globalized WorldNational Mandated Food Fortification Programs
2018, Food Fortification in a Globalized WorldRetrospective Assessment of Cost Savings from Prevention: Folic Acid Fortification and Spina Bifida in the U.S.
2016, American Journal of Preventive MedicineCitation Excerpt :Incomplete data on costs of care for spina bifida can result in conservative estimates of avoided costs. For example, a CEA of fortification in Chile concluded that fortification was cost saving, although only the subset of surgical repair and rehabilitation costs through age 22 years were included (present value per birth of approximately $20,000 in 2007 dollars).45 A South African CEA calculated cost savings based on estimated treatment costs during infancy.46
Maternal predictors of RBC folate levels in an urban Canadian population
2015, Reproductive ToxicologyCitation Excerpt :Low periconceptional folic acid (folate) levels are associated with complications of pregnancy and neural tube defects (NTDs) [1–7]. Fortification of flour with folic acid in Canada and the US since 1998 has been associated with a 46% reduction in the occurrence of neural tube defects [8,9]. Daly et al. [10] reported a strong correlation between levels of red blood cell folate and risk of giving birth to an infant with neural tube defects, from a prevalence at birth of >3 per 1000 in women with levels below 452 nmol/L to <1 per 1000 with levels above 906 nmol/L. RBC folate reflects total folic acid storage, and an RBC folate level of ≥906 nmol/L is now accepted as the optimal folate concentration to minimize the occurrence of NTD [11].
Economic burden of neural tube defects in Germany
2014, Public HealthCitation Excerpt :The burden of spina bifida in Germany is substantial and continuous throughout the person's life, both in terms of the level of healthcare expenditures and relative to overall population. As the link between elevated periconceptional maternal folate levels, folic acid fortification programs and the reduction in development of NTDs is well recognized, primary prevention of NTDs can be considered a valuable, easy and cost-saving opportunity.4,6,24,27–30 Even if the direct costs of primary prevention were to exceed the direct costs to persons with spina bifida, it is likely that such costs will be lower than the overall burden of NTDs, which includes indirect costs and cost of parents and caregivers.