viernes, 4 de mayo de 2012

CDC - Blogs - CDC Works For You 24/7 – Godfrey Oakley: Persistence Is Key in the Folic Acid Success Story

CDC - Blogs - CDC Works For You 24/7 – Godfrey Oakley: Persistence Is Key in the Folic Acid Success Story

Godfrey Oakley: Persistence Is Key in the Folic Acid Success Story

Categories: General
Editor’s Note: In 2012 we will mark the 20th anniversary of the US Public Health Service recommendation that women of childbearing age should consume 400 micrograms (mcg) of folic acid every day to help prevent certain neural tube defects (NTDs) – spina bifida and anencephaly. Several CDC scientists were involved in the research that led up to the recommendation, or contributed to the subsequent work on folic acid that continues today, including Joseph Mulinare, Robert J. Berry, J. David Erickson, and Godfrey Oakley. The four blogs in this series tell their stories.
Photo of Cordero and Oakley and Erickson (seated)
Jose Cordero (l) founding director of the National Center for Birth Defects and Developmental Disabilities; Oakley (r); and Erickson (seated). Photo courtesy of Godfrey Oakley
Godfrey P. Oakley, Jr., MD, came to CDC in 1968 as an EIS officer. He was the initial head of CDC’s first section of birth defects, which developed into a division by the early 1980s and later became a center in the 1990s.
Oakley jokingly often asks people: “Do you know where you were on June 24, 1991 at 5 pm?” It’s a date and time that Oakley vividly remembers. He was at a hotel attending a birth defects meeting, and it was on that day, he says, that the intervention part of folic acid started. “I got a call from Sir Nicholas Wald (he wasn’t a ‘Sir’ then, but is now), and he told me that the randomized controlled trial that he conducted had proved that folic acid would prevent most of spina bifida and anencephaly. I knew we had to get every woman in the world to get 400 micrograms of folic acid. His study was a game changer.”
Later that evening Oakley met with Dave Erickson and Jose Cordero, MD, MPH (later to be director of the National Center on Birth Defects and Developmental Disabilities), “and I told them the most important information I ever had as a professional,” says Oakley.
The big push was on to get a recommendation for women who already had a pregnancy affected by an NTD because the study that Wald conducted was with women who already had an affected pregnancy. The first recommendation was published in the summer of 1991. “That was about the easiest policy thing I ever did,” says Oakley. “It was before a whole lot of emails and stuff, so we did it by faxes; nobody fussed about it. We put it out in MMWR and said that all women who had previously had an affected child should take 4,000 micrograms of folic acid when planning a pregnancy.”
But as important as the recommendation was for women who had had a pregnancy affected by an NTD, it did not target women who had never had an affected pregnancy. “Most women who have a child with spina bifida had not had an affected baby before,” Oakley points out. “High risk women only have 5 percent of the births and low risk women have 95 percent, so if you want a program that’s going to prevent this in the population, you have to have a population approach. That took us a year to get through CDC. Dave (Erickson), Jose (Cordero), Joe (Mulinare) and I and others worked on this. And Steve Thacker and Claire Broome were also helpful.”
During the summer of 1992, Oakley and others often went to Washington to meet with FDA officials and public health representatives, many of whom were resistant to the broader recommendation for folic acid. “So we have this powwow and they picked on certain scientific things that were really trivial,” says Oakley. “Finally, I think what changed the day was a question I asked: ‘Is there anybody in this room who can’t agree with the following statement—that folic acid prevents some of spina bifida but not all of it?’” Ultimately, CDC received the green light to write the recommendation.
“Dave Erickson wrote it up, we sent it back, and it was put in a MMWR article,” continues Oakley, who says the recommendation was released September 11, 1992, just in time for an international meeting on birth defects. “I think it’s one of the most important MMWR articles that’s ever been written—the recommendation that all women who could get pregnant should get 400 micrograms of folic acid,” says Oakley. “That is an enormously important policy document. The FDA signed it, NIH signed it, HRSA signed it—everybody signed it. It’s a public health service recommendation, not just CDC’s.”

“Persistence was key,” states Oakley, referring to William Foege’s book, House on Fire, in which (former CDC Director) Foege tells the story of how smallpox was eradicated. Oakley thinks that lessons learned from the smallpox eradication effort can be helpful in the fight to prevent birth defects. “We’re in the midst of making spina bifida go away globally, so we can’t tell the end of the story yet. But one thing Foege says—‘Persistence is required’—and that’s what we had to do. We had to have the science right, and it was impeccable; and then, we had to be persistent. For every roadblock, we had to find a solution around it.”
Oakley left CDC in 1998, but is still working on folic acid and birth defects as a research professor at the Rollins School of Public Health of Emory University. He stays in touch with his former colleagues at CDC whom he describes as “remarkable and fantastic—they understood what we were working on and why it was important.” Adds Godfrey, “We know that folic acid fortification prevents NTDs in every country where it has occurred. We also know that it raises blood folate concentrations such that folate deficiency anemia is almost completely prevented. This is a very nice side benefit to folic acid fortification and it improves the public health not only of children, but also men and women of all ages.”
In this year of the 20th anniversary of the US Public Health Service recommendation on folic acid, Oakley, who has a penchant for dates, points out that the 1992 recommendation came out on September 11. “It was a good 9/11,” he emphasizes. A very good one, indeed.
For more information about CDC’s folic acid success story, go Folic Acid: Helping to Prevent Birth Defects. For more detailed information on folic acid, visit the CDC Folic Acid Web Page on the CDC Works For You 24/7 website. Thanks to Faye McDonald Smith of CDC who wrote the original article on which this blog was based.

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