Epidemiology Surveillance and Capacity Improvement: A Characterization of Texas, 2017.

OBJECTIVES: In response to increasing caseloads of foodborne illnesses and high consequence infectious disease investigations, the Texas Department of State Health Services (DSHS) requested funding from the Texas Legislature in 2013 and 2015 for a new state-funded epidemiologist (SFE) program. METHODS: Primary cross-sectional survey data were collected from 32 of 40 local health departments (LHDs) via an online instrument and analyzed to quantify roles, responsibilities, and training of epidemiologists in Texas in 2017 and compared to similar state health department assessments. RESULTS: Sixty-six percent of SFEs had epidemiology-specific training (eg, master's in public health) compared to 45% in state health department estimates. For LHDs included in this study, the mean number of epidemiologists per 100 000 was 0.73 in medium LHDs and 0.46 in large LHDs. SFE positions make up approximately 40% of the LHD epidemiology workforce of all sizes and 56% of medium-sized LHD epidemiology staff in Texas specifically. CONCLUSIONS: Through this program, DSHS increased epidemiology capacity almost twofold from 0.28 to 0.47 epidemiologists per 100 000 people. These findings suggest that capacity funding programs like this improve epidemiology capacity in local jurisdictions and should be considered in other regions to improve general public health preparedness and epidemiology capacity.

Changes to Timeliness and Completeness of Infectious Disease Reporting in Texas After Implementation of an Epidemiologic Capacity Program.

OBJECTIVES: The objective of this study was to characterize the changes in timeliness and completeness of disease case reporting in Texas in response to an increasing number of foodborne illnesses and high-consequence infectious disease investigations and the Texas Department of State Health Services' new state-funded epidemiologist (SFE) program. METHODS: We extracted electronic disease case reporting data on 42 conditions from 2012 through 2016 in all local health department (LHD) jurisdictions. We analyzed data on median time for processing reports and percentage of complete reports across time and between SFE and non-SFE jurisdictions using Mann-Whitney t tests and z scores. RESULTS: The median time of processing improved from 13 days to 10 days from 2012 to 2016, and the percentage of disease case reports that were complete improved from 19.6% to 27.7%. Most reports were for foodborne illnesses; both timeliness (11 to 7 days) and completeness (20.9% to 23.5%) improved for these reports. CONCLUSIONS: Disease reporting improvements in timeliness and completeness were associated with the SFE program and its enhancement of epidemiologic capacity. SFEs were shown to improve surveillance metrics in LHDs, even in jurisdictions with a high volume of case reports. Adding epidemiologist positions in LHDs produces a tangible outcome of improved disease surveillance.

How Do Infectious Disease Epidemiologist Positions Increase Public Health Capacity? Results from a Qualitative Study of Local Health Departments.

The purpose of this study was to characterize changes in and impacts on epidemiologic capacity in local health departments after the implementation of a state-funded epidemiologist program using qualitative data. The study used key informant interviews in Texas health departments, which were conducted and inductively analyzed to identify themes. Five predominant themes emerged from interviews on the impact of state-funded epidemiologists on the epidemiology capacity of local health departments. State-funded epidemiologists were seen as increasing overall epidemiology capacity in local health departments. Specifically, they improved timeliness of infectious disease reporting and quality and thoroughness of disease investigations. They also improved community stakeholder relationships with local health departments and communications across local, regional, and state public health agencies. Key informants at all levels described positive effects of the state-funded epidemiologists on disease surveillance. Local epidemiology capacity has increased, and, in turn, Texas public health surveillance capacity has improved at the local, regional, and state levels. Funding programs like this should be considered when public health capacity is low and in need of an increase.

Dietary intake of choline and neural tube defects in Mexican Americans.

BACKGROUND: Low maternal intake of dietary choline and betaine (a choline derivative) has recently been investigated as a possible risk factor for neural tube defects (NTDs). METHODS: This case-control study examined the NTD risk associated with choline and betaine in 409 Mexican-American women who gave birth during 1995 to 2000 in the 14-county border region of Texas. RESULTS: Using data from the food frequency questionnaire and the lowest quartiles of intake as the reference categories, a protective association was suggested between higher intakes of choline and betaine and NTD risk although the 95% confidence intervals for all risk estimates included 1.0. For choline intake in the second, third, and fourth quartiles, adjusted odds ratios were 1.2, 0.80, and 0.89, respectively. Betaine appeared more protective with odds ratios of 0.62, 0.73, and 0.61, respectively, for the second, third, and fourth quartiles of intake. CONCLUSION: Study findings suggest that dietary betaine may help to prevent NTDs.

Neural tube defects on the Texas-Mexico border: what we've learned in the 20 years since the Brownsville cluster.

We reviewed the published findings from the Texas Neural Tube Defect Project, a 6-year case-control study (1995-2000) of neural tube defects (NTDs) on the Texas-Mexico border. In this review, we highlight what was learned about environmental, genetic, and nutritional factors (i.e., those related to the folate and other metabolic pathways) and the novel putative risk factors that emerged from this study of Mexican American women living on the Texas-Mexico border. Our investigations of the micronutrients and metabolic pathways involved confirmed the findings of other researchers that increased folate intake has a protective effect and that low serum B(12) , high serum homocysteine levels, and obesity independently contribute to risk. Studies of this population also have implicated hyperinsulinemia and low ferritin, metabolic risk factors, which require additional study to elucidate their physiologic mechanism. Environmental contaminants such as heavy metals, pesticides, and polychlorinated biphenyls (PCBs), which were of community concern, did little to explain NTD risk. Studies in this folic acid deficit-population also revealed several novel risk factors, namely, diarrhea, stress, fumonisins, and the combination of nitrosatable drug exposure with high nitrate/nitrite intake. In conclusion, the 23 studies among the Mexican American women living along the Texas-Mexico border have demonstrated the multifactorial nature of NTDs and that a population deficient in folic acid will be vulnerable to a variety of insults whether brought on by individual behaviors (e.g., obesity) or through the surrounding environment (e.g., fumonisins). Birth Defects Research (Part A), 2012. © 2012 Wiley Periodicals, Inc.

Dieting to lose weight and occurrence of neural tube defects in offspring of Mexican-American women.

Lowered maternal weight gain and reduction in early pregnancy have been associated with risk of neural tube defects (NTDs) in offspring. We examined the association of self-reported maternal dieting behaviors on the occurrence of NTDs. We conducted a population based case-control study among Mexican-American women who were residents of the 14 Texas counties bordering Mexico. Case women had an NTD-affected pregnancy identified at birth or prenatally and had deliveries during the years 1995-2000. Control women were those who delivered live born infants without an apparent congenital malformation, randomly selected and frequency-matched to cases by year and facility. One hundred eighty-four case women and 225 control women were asked in person about the use of nutritional supplements, dieting to lose weight, and type of weight reduction supplements used during the 3 months before conception. Women who reported being on a diet to lose weight during the 3 months before conception had an NTD odds ratio (OR) of 1.9 (95% confidence interval (CI) = 1.1, 3.3) compared with those not reporting being on a diet. Neither consuming vitamin drinks (OR = 1.2) nor using diet pills (OR = 1.6) during the 3 months before conception had ORs that were different from the null, when compared to women not reporting those behaviors. The risk effect for dieting did not differ markedly among normal or underweight (OR = 2.0, 95% CI = 0.7, 5.6), overweight (OR = 1.9, 95% CI = 0.7, 5.0), or obese women (OR = 1.5, 95% CI = 0.6, 4.0). No effect was seen among dieting women who were consuming at least 1.0 mg/day of folate (OR = 1.1, CI = 0.3, 4.5). Maternal dieting prior to conception may increase the risk of NTDs in offspring.

Maternal smoking, passive tobacco smoke, and neural tube defects.

BACKGROUND: Although cigarette smoke is a well-established toxin and harmful to the developing embryo, the evidence for an independent effect on the occurrence of neural tube defects (NTDs) is mixed. In this study, we examined the relation between NTDs and maternal exposures to cigarette smoke, including passive smoke exposure. METHODS: We used cases and controls from the large, multistate, population-based National Birth Defects Prevention Study. A total of 1041 NTD cases and 5862 live birth controls, delivered during 1997 to 2004, were available for analyses. Mothers were interviewed by telephone between 6 weeks and 24 months after delivery. Participation rates were 71% for NTD case mothers and 69% for control mothers. RESULTS: Compared with nonsmokers (and also not exposed to passive cigarette smoke), mothers exposed only to passive smoke had an increased NTD odds ratio (OR, 1.7; 95% confidence interval [CI], 1.4-2.0), adjusted for race-ethnicity, and study center. There was no increased OR for mothers who actively smoked 24 or fewer cigarettes per day. Mothers who smoked 25 or more cigarettes per day had an elevated OR (OR, 1.6; 95% CI, 0.9-3.0), but the OR adjusted for race-ethnicity, and center was compatible with the null. CONCLUSION: Results suggest that maternal exposure to passive smoke is associated with NTDs. Women who plan on becoming pregnant should minimize their exposure to passive smoke and refrain from smoking.

Dietary methionine intake and neural tube defects in Mexican-American women.

BACKGROUND: Nutrients other than maternal folic acid are also thought to play a role in preventing neural tube defects (NTDs). Evidence suggests that methionine interacts with folic acid and vitamin B(12) in the methylation of contractile proteins involved in closing the neural folds. The role of dietary intake of methionine in NTD risk has not been specifically studied among Mexican Americans, a population with one of the highest prevalences of NTDs in the United States. METHODS: We conducted a case-control study of 184 Mexican American women with NTD-affected pregnancies (case women) and 225 women with normal offspring (control women) who resided along the Texas-Mexico border. The average daily intakes of methionine were calculated from periconceptional food frequency questionnaire data. Women were categorized according to quartiles of daily methionine intake, based on the control mothers' distribution, and the risk for an NTD-affected pregnancy was calculated using the lowest quartile of intake as the referent. RESULTS: With adjustment for income, body mass index, hyperinsulinemia, and diarrhea, the odds ratios for increasing quartile of methionine intake were: 0.95 (95% confidence interval [CI], 0.48,1.90), 0.92 (95% CI, 0.46,1.84), and 0.66 (95% CI, 0.30,1.45). Some evidence of interaction between dietary methionine and serum vitamin B(12) was noted particularly at higher levels of both components. CONCLUSIONS: This study was limited by a small sample size but examined this association in an exclusively Hispanic population. Results were suggestive of a potential protective effect for NTDs with increasing maternal dietary methionine intake.

Maternal pesticide exposure and neural tube defects in Mexican Americans.

PURPOSE: The relation between maternal pesticide exposures and neural tube defects (NTDs) in offspring was evaluated in 184 Mexican American case-women and 225 comparison women. METHODS: In-person interviews solicited information about environmental and occupational exposures to pesticides during the periconceptional period. RESULTS: With adjustment for maternal education, smoking, and folate intake, women who reported using pesticides in their homes or yards were two times more likely (95% confidence interval [CI], 1.2-3.1) to have NTD-affected pregnancies than women without these reported exposures. Case-women were also more likely to report living within 0.25 mile of cultivated fields than control-women (odds ratio [OR] 3.6; 95% CI, 1.7-7.6). As sources of pesticide exposure opportunities increased, risk of NTDs also increased. The adjusted ORs and 95% CIs for one, two, and three or more exposure sources were 1.2 (0.69-1.9), 2.3 (1.3-4.1) and 2.8 (1.2-6.3) respectively, and this positive trend was stronger for risk of anencephaly than for spina bifida. CONCLUSIONS: Self-reported pesticide exposures were associated with NTD risk in this study population, especially use of pesticides within the home and a periconceptional residence within 0.25 mile of cultivated fields.

Detection of Staphylococcus aureus including MRSA on environmental surfaces in a jail setting.

We examined jail environmental surfaces to explore whether they might serve as reservoirs of viable methicillin-resistant Staphylococcus aureus (MRSA). We swabbed 132 surfaces, inoculated primary and secondary mannitol salts and oxacillin-resistant screening agar, and used API tests to identify S. aureus and E-tests to determine methicillin/oxacillin resistance. We recovered S. aureus from 10 (7.6%) surfaces; eight (6.1%) isolates were MRSA. We ran pulsed-field gel electrophoresis on six resistant isolates and observed three patterns, one of which was identical to that identified in a previous study of inmates' nasal specimens. Finding MRSA-contaminated surfaces on a variety of environmental surfaces in the absence of an overt outbreak emphasizes that correctional facilities should have protocols for environmental cleaning as a component of MRSA prevention.

Maternal serum homocysteine and risk for neural tube defects in a Texas-Mexico border population.

BACKGROUND: To better understand the neural tube defect (NTD) causal pathway, the authors measured homocysteine, an indicator of tissue micronutrient deficiencies. The authors examined independent and joint associations of serum homocysteine, B12, and folate and red blood cell (RBC) folate with NTD-affected pregnancies. METHODS: Case women in this population-based study had NTD-affected pregnancies and resided and delivered in one of the 14 Texas-Mexico border counties from 1995 through 2000. Control women were study area residents delivering normal live births during the same period. The authors measured homocysteine levels using tandem mass spectroscopy; competitive binding was used for other biomarkers. RESULTS: Homocysteine testing was done on 103 cases and 139 controls. Odds ratios (ORs) were increased in all upper homocysteine quintiles compared to the lowest quintile (1.7, 1.3, 2.8, 2.4). Women with high homocysteine values had increased ORs regardless of high versus low levels for B12 (OR = 3.5, 4.8, respectively) or RBC folate (OR = 2.9, 3.5, respectively). CONCLUSIONS: High serum homocysteine levels are associated with NTD-affected pregnancies. Moreover, high homocysteine levels have a detrimental effect on NTD-risk even when serum B12 or RBC folate levels are high. Excess homocysteine might play an independent role in the development of NTDs.

Maternal exposures to cigarette smoke, alcohol, and street drugs and neural tube defect occurrence in offspring.

OBJECTIVES: Cigarettes, alcoholic beverages, and street drugs contain substances potentially toxic to the developing embryo. We investigated whether maternal cigarette smoking, secondhand smoke exposure, and alcohol or street drug use contributed to neural tube defect (NTD) occurrence in offspring. METHODS: We conducted a population-based case-control study among Mexican American women who were residents of the 14 Texas counties bordering Mexico. Case women had an NTD-affected pregnancy and delivered during 1995-2000. Control women were those who delivered live born infants in the same study area, without an apparent congenital malformation, randomly selected by year and facility. We interviewed women in person, 1-3 months postpartum, to solicit relevant information. RESULTS: Nonsmoking mothers exposed to secondhand smoke during the first trimester had an NTD odds ratio (OR) of 2.6 (95% confidence interval (CI)=1.6, 4.0) compared to those who neither smoked nor were exposed to secondhand smoke. Compared to the referent, the OR among women who smoked less than half a pack a day during the first trimester was 2.2 (95% CI=1.0, 4.8) and 3.4 (95% CI=1.2, 10.0) among those who smoked a half pack or more. Adjustment for maternal age, education, body mass index, and folate intake had a negligible effect on results. Alcohol and street drug use had no relation to NTD risk when adjusted for cigarette smoking. CONCLUSIONS: This study suggests that cigarette smoke including secondhand exposure is not only hazardous to the mother but may also interfere with neural tube closure in the developing embryo.

Neural tube defects, micronutrient deficiencies, and Helicobacter pylori: a new hypothesis.

BACKGROUND: Previous findings for the Texas Neural Tube Defects Project suggested that while maternal access to nutrients is adequate, bioavailability of nutrients to the fetus is compromised in NTD-affected pregnancies. Helicobacter pylori could cause nutrient loss to the fetus. Folate, B12, and ferritin are depleted in H. pylori infection; these same deficiencies are related to NTD risk. METHODS: Using H. pylori IgG ELISA Test System, we tested for H. pylori serum antibodies in participants in the population-based case-control study component of the Texas Neural Tube Defect Project conducted along the Texas-Mexico border. Case-women had pregnancies affected by NTD (anencephalus, spina bifida, encephalocele) and resided and delivered in one of the 14 Texas-Mexico border counties from 1995 through 2000. Control-women were study area residents delivering normal live births during the same period. RESULTS: Of 225 case- and 378 control-women, 103 cases and 156 controls provided questionnaire and H. pylori antibody data. H. pylori seropositivity was modestly associated with NTD-affected pregnancies (OR 1.4; 95% CI: 0.8-2.4). ORs of 2.0 or greater were seen in women younger than age 25 and with less than 7 years education. CONCLUSIONS: Our findings intimate that H. pylori could play a role in NTD causation in certain populations. While results did not provide compelling support for this proposal, subgroup findings prompt us to advocate an evaluation of this hypothesis in developing nations among populations with higher prevalence of H. pylori, marginal nutrient intake, and young childbearing age.

High school athletic departments as sentinel surveillance sites for community-associated methicillin-resistant staphylococcal infections.

Methicillin-resistant Staphylococcus aureus (MRSA) is an emerging infection in athletes. Our study assessed MRSA burden in Texas 4A and 5A high school athletic departments by contacting 447 licensed athletic trainers (LATs) regarding skin infections in athletes; 186 (41.6%) responded. Sixty LATs reported MRSA in their athletic departments. The largest MRSA outbreak (23 infected persons) occurred in football players. The trainers also reported MRSA in wrestlers, volleyball players, cross-country runners, nonathlete students, and adults. Students and adults involved in high school athletics require MRSA intervention because of their large numbers and extensive contacts. Physicians should be aware of the potential for MRSA and should culture rather than treat empirically, communicate with school health staff to maximize surveillance for affected students when MRSA occurs in their student community, and contact their health department when the number of students with MRSA meets the unusual group expression, outbreak, or unusual severity criteria.

Exposure to fumonisins and the occurrence of neural tube defects along the Texas-Mexico border.

Along the Texas-Mexico border, the prevalence of neural tube defects (NTDs) among Mexican-American women doubled during 1990-1991. The human outbreak began during the same crop year as epizootics attributed to exposure to fumonisin, a mycotoxin that often contaminates corn. Because Mexican Americans in Texas consume large quantities of corn, primarily in the form of tortillas, they may be exposed to high levels of fumonisins. We examined whether or not maternal exposure to fumonisins increases the risk of NTDs in offspring using a population-based case-control study. We estimated fumonisin exposure from a postpartum sphinganine:sphingosine (sa:so) ratio, a biomarker for fumonisin exposure measured in maternal serum, and from maternal recall of periconceptional corn tortilla intake. After adjusting for confounders, moderate (301-400) compared with low (< or = 100) consumption of tortillas during the first trimester was associated with increased odds ratios (ORs) of having an NTD-affected pregnancy (OR = 2.4; 95% confidence interval, 1.1-5.3). No increased risks were observed at intakes higher than 400 tortillas (OR = 0.8 for 401-800, OR = 1.0 for > 800). Based on the postpartum sa:so ratio, increasing levels of fumonisin exposure were associated with increasing ORs for NTD occurrences, except for the highest exposure category (sa:so > 0.35). Our findings suggest that fumonisin exposure increases the risk of NTD, proportionate to dose, up to a threshold level, at which point fetal death may be more likely to occur. These results also call for population studies that can more directly measure individual fumonisin intakes and assess effects on the developing embryo.

Maternal exposure to arsenic, cadmium, lead, and mercury and neural tube defects in offspring.

Arsenic, cadmium, lead, and mercury are neurotoxins, and some studies suggest that these elements might also be teratogens. Using a case-control study design, we investigated the relation between exposure to these heavy metals and neural tube defects (NTDs) in offspring of Mexican-American women living in 1 of the 14 Texas counties bordering Mexico. A total of 184 case-women with NTD-affected pregnancies and 225 control-women with normal live births were interviewed about their environmental and occupational exposures during the periconceptional period. Biologic samples for blood lead and urinary arsenic, cadmium, and mercury were also obtained for a subset of these women. Overall, the median levels of these biomarkers for heavy metal exposure did not differ significantly (P > 0.05) between case- and control-women. However, among women in the highest income group, case-women were nine times more likely (95% confidence interval (CI) 1.4-57) than control-women to have a urinary mercury 5.62 microg/L. Case-women were 4.2 times more likely (95% CI 1.1-16) to report burning treated wood during the periconceptional period than control-women. Elevated odds ratios (ORs) were observed for maternal and paternal occupational exposures to arsenic and mercury, but the 95% CIs were consistent with unity. The 95% CIs of the ORs were also consistent with unity for higher levels of arsenic, cadmium, lead, and mercury in drinking water and among women who lived within 2 miles at the time of conception to industrial facilities with reported emissions of any of these heavy metals. Our findings suggest that maternal exposures to arsenic, cadmium, or lead are probably not significant risk factors for NTDs in offspring. However, the elevated urinary mercury levels found in this population and exposures to the combustion of treated wood may warrant further investigation.

Iron status indicators in women with prior neural tube defect-affected pregnancies.

OBJECTIVES: Iron deficiency is the most common nutrient deficiency in pregnant women and has been linked to negative impacts on the fetus. We describe the association of various iron-deficiency indices with risk of neural tube defect (NTD) among a high-risk Mexican-American population. METHODS: The study included 158 case-women (NTD-affected pregnancies) and 189 control-women (normal births) who were residents of the 14 Texas-Mexico border counties and delivered or terminated pregnancies during 1995-2000. In-person interviews and laboratory assays provided data. RESULTS: Case-women had higher odds of having minimal or no iron stores (serum ferritin <30 microg/L) compared to control-women (OR = 1.8, 95% CI = 1.0-3.3). The risk effect was not explained by low folate or B12 or other risk factors. CONCLUSION: Low serum ferritin may reflect the additive effect of multiple long-term factors, many of them related to poverty such as poor quality diet, lack of supplementation, and frequent pregnancies. Interpartum care is indicated in this population.

Exposure to polychlorinated biphenyls and risk of neural-tube defects in a Mexican American population.

The authors examined the association between maternal polychlorinated biphenyl (PCB) levels and risk of neural tube defects (NTDs) in Mexican American women with NTD-affected pregnancies who resided in the 14 Texas-Mexico border counties during 1995-2000 (cases). Controls were randomly selected from study area women delivering normal live births. For PCB congeners with sufficient numbers of detectable values (PCB 99, 101, 110, 118, 138, 153, 180), there was little association between the proportions with detectable PCB levels in cases and controls. Odds ratios were <1 or compatible with the null, but power was low for some congeners. An index of seven PCB congeners (105, 118, 138, 153, 170, 180, 194) was also not associated with NTD risk. The maternal serum PCB levels in this study population (median PCB 153 level: 18 ng/g) were comparable to those with background exposure and do not appear to have contributed to the high prevalence of NTDs in this population.

The wound care team: a new source of group a streptococcal nosocomial transmission.

BACKGROUND: In August 2001, the Centers for Disease Control and Prevention (CDC) notified the Texas Department of Health (TDH) of an unusually high number of wounds infected with group A streptococci (GAS) in an acute care facility. The TDH initiated an investigation, ultimately identifying 28 cases of non-pharyngeal, non-community-acquired GAS that had occurred between December 2000 and August 2001 and resulted in 3 deaths and 4 nonfatal cases of invasive disease. Ten specimens were sent to the CDC for emm typing; all isolates were emm type 114. However, the source of the outbreak could not be confirmed through laboratory testing at that time. METHODS: A case-control study was conducted comparing the 10 case-patients with 52 control-patients with wounds that were not infected with GAS. Age, gender, type of wound, underlying medical conditions, and treatment by the wound care team were examined for association with GAS infection. RESULTS: The odds of having wound care team treatment versus not having it were 424.2 (95% confidence interval, 19.0 to 9,495.2) among case-patients when compared with control-patients. No other risk factor showed this magnitude of association. CONCLUSIONS: This study provided overwhelming epidemiologic evidence that the wound care team was the means of transmission. One year later, when two patients receiving wound care were concurrently diagnosed as having GAS, a member of the wound care team was found to be GAS positive for the matching emm type. This is the first report of a GAS hospital outbreak linked to a wound care team.

Implementation and outcomes of recommended folic acid supplementation in Mexican-American women with prior neural tube defect-affected pregnancies.

BACKGROUND: Upon discovering an NTD incidence rate of 27/10,000 in a Texas border county, the Texas Department of Health initiated folic acid intervention for prevention of recurrent NTDs in this predominantly Mexican-American population. This paper describes compliance of this population with USPHS folic acid recommendations and the impact of supplementation on pregnancy outcomes. METHODS: Based upon information from active surveillance, field teams personally contacted women having NTD-affected pregnancies to enroll them in FA intervention. Enrollees were provided FA at home visits at 3-month intervals throughout the project. RESULTS: Of 405 women identified with NTD-affected pregnancies, 299 (73.8%) enrolled in the intervention. One hundred ninety-three pregnancies occurred among 138 women. FA supplementation of 0.4 mg/day or more occurred during the last month preconception in 161 (83.4%) of the 193 pregnancies. No NTDs were detected in the 130 livebirths to women who received supplementation nor were NTDs detected in the 23 supplemented women who experienced pregnancy loss. CONCLUSIONS: Supplementation was successful in preventing recurrent NTDs in Mexican-American women.