Impact of prenatal diagnosis on revised livebirth prevalence estimates of Down syndrome in the Lothian region of Scotland, 1978-1992

Prenatal Screening, Ethics and Down’s Syndrome: a literature review

This article reviews the literature on prenatal screening for Down’s syndrome. To be evidence based, medicine and nursing have to take account of research evidence and also of how this evidence is processed through the influence of prevailing social and moral attitudes. This review of the extensive literature examines how appropriate widely-held understandings of Down’s syndrome are, and asks whether or not practitioners and prospective parents have access to the full range of moral arguments and social evidence on the matter. Highly valued ideals of justice, personal autonomy, parental choice, women’s control over their reproduction and of avoiding harm can all tend towards negative rather than neutral approaches to Down’s syndrome. This article considers how ethics and prenatal screening policies and practice that take greater account of social evidence of disability could use moral arguments that inform rather than determine the choices of people who use prenatal services.

The human sex odds at birth after the atmospheric atomic bomb tests, after Chernobyl, and in the vicinity of nuclear facilities

BACKGROUND, AIM, AND SCOPE

Ever since the discovery of the mutagenic properties of ionizing radiation, the possibility of birth sex odds shifts in exposed human populations was considered in the scientific community. Positive evidence, however weak, was obtained after the atomic bombing of Japan. We previously investigated trends in the sex odds before and after the Chernobyl Nuclear Power Plant accident. In a pilot study, combined data from the Czech Republic, Denmark, Finland, Germany, Hungary, Norway, Poland, and Sweden between 1982 and 1992 showed a downward trend in the sex odds and a significant jump in 1987, the year immediately after Chernobyl. Moreover, a significant positive association of the sex odds between 1986 and 1991 with Chernobyl fallout at the district level in Germany was observed. Both of these findings, temporality (effect after exposure) and dose response association, yield evidence of causality. The primary aim of this study was to investigate longer time periods (1950-2007) in all of Europe and in the USA with emphasis on the global atmospheric atomic bomb test fallout and on the Chernobyl accident. To obtain further evidence, we also analyze sex odds data near nuclear facilities in Germany and Switzerland. DATA AND STATISTICAL METHODS: National gender-specific annual live births data for 39 European countries from 1975 to 2007 were compiled using the pertinent internet data bases provided by the World Health Organization, United Nations, Council of Europe, and EUROSTAT. For a synoptic re-analysis of the period 1950 to 1990, published data from the USA and from a predominantly western and less Chernobyl-exposed part of Europe were studied additionally. To assess spatial, temporal, as well as spatial-temporal trends in the sex odds and to investigate possible changes in those trends after the atomic bomb tests, after Chernobyl, and in the vicinity of nuclear facilities, we applied ordinary linear logistic regression. Region-specific and eventually changing spatial-temporal trends were analyzed using dummy variables coding for continents, countries, districts, municipalities, time periods, and appropriate spatial-temporal interactions.

RESULTS

The predominantly western European sex odds trend together with the US sex odds trend (1950-1990 each) show a similar behavior. Both trends are consistent with a uniform reduction from 1950 to 1964, an increase from 1964 to 1975 that may be associated with delayed global atomic bomb test fallout released prior to the Partial Test Ban Treaty in 1963 and again a more or less constant decrease from 1975 to 1990. In practically all of Europe, including eastern European countries, from 1975 to 1986, and in the USA from 1975 to 2002, there were highly significant uniform downward trends in the sex odds with a reduction of 0.22% to 0.25% per 10 years. In contrast to the USA, in Europe there was a highly significant jump of the sex odds of 0.20% in the year 1987 following Chernobyl. From 1987 to 2000, the European sex odds trend reversed its sign and went upward, highly significantly so, with 0.42% per 10 years relative to the downward trend before Chernobyl. The global secular trend analyses are corroborated by the analysis of spatial-temporal sex odds trends near nuclear facilities (NF) in Germany and Switzerland. Within 35 km distance from those NF, the sex odds increase significantly in the range of 0.30% to 0.40% during NF operating time.

CONCLUSIONS

The atmospheric atomic bomb test fallout affected the human sex odds at birth overall, and the Chernobyl fallout had a similar impact in Europe and parts of Asia. The birth sex odds near nuclear facilities are also distorted. The persistently disturbed secular human sex odds trends allow the estimation of the global deficit of births in the range of several millions.

Changes in yearly birth prevalence rates of children with Down syndrome in the period 1986-2007 in The Netherlands

BACKGROUND

The Netherlands are lacking reliable national empirical data in relation to the development of birth prevalence of Down syndrome. Our study aims at assessing valid national live birth prevalence rates for the period 1986-2007.

METHOD

On the basis of the annual child/adult ratio of Down syndrome diagnoses in five out of the eight Dutch cytogenetic centres, the national annual figures of the National Cytogenetic Network on total numbers of postnatal Down syndrome diagnoses were transformed into national figures on total numbers of postnatal Down syndrome diagnoses in newborn children only. In combination with the national annual data of the Working Group for Prenatal Diagnostics and Therapeutics on numbers of Down syndrome pregnancies not aborted after diagnosis, national figures on birth prevalence were constructed.

RESULTS

For the period 1986-2007, results based on the data of the cytogenetic centres are almost similar to the theory-based model data of de Graaf et al., with a small discrepancy of approximately 4%. Down syndrome birth prevalence in the Netherlands shows an upward trend from around 11 per 10,000 births in the early 1990s to around 14 per 10,000 births nowadays.

CONCLUSION

In spite of expansion of antenatal screening in the Netherlands, Down syndrome live birth prevalence has risen in the last two decades as a result of rising maternal age. This increase in Down syndrome birth prevalence is in contrast to studies from other European countries.

Birth defects in the vicinity of nuclear power plants in Germany

Living in the vicinity of nuclear power plants (NPP) is discussed here in terms of adverse health effects. A prospective population-based cohort study was conducted to evaluate whether the prevalence of birth defects in the vicinity of NPPs is elevated and scrutinize a possible distance correlation. A birth cohort born to mothers living within 10 km of two selected NPPs (study region) was compared to a region without NPP (comparison region), and an active surveillance of all live births, stillbirths, and induced abortions in the defined regions was performed. Between 01/2007 and 02/2008, all newborns were examined by specially trained study paediatricians according to the protocols of the Birth Registry Mainz Model. The cohort consisted of 5,273 infants (90% completeness). The outcome measure was an infant with birth defect(s). The prevalence of infants with birth defects was 4.5% in the study region and 4.7% in the comparison region, which corresponds to a relative risk (RR) of 0.94 (lower 95% confidence level (CL): 0.76). Thus, the prevalence of birth defects in the regions surrounding NPPs was not increased compared to those of the comparison region. Adjustment for potential confounders did not substantially change the result (RR 0.90, lower 95% CL 0.73). The adjusted and unadjusted distance approach (1/distance in km) did not show any correlation to vicinity to a NPP (p = 0.38). Specifically, within the study region, the prevalence of birth defects showed no upward trend with decreasing distance. Birth defect prevalence and most descriptive parameters in the comparison region were identical to those in the Birth Registry Mainz Model.

Increasing total prevalence rate of cases with Down syndrome in Hungary

Recently the population-based large data set of the Hungarian Congenital Abnormality Registry showed an increase in the recorded total (birth + fetal) prevalence rate of informative offspring with Down syndrome. This finding was checked and confirmed in the completed data set due to the field study including all cytogenetic labs and prenatal diagnostic centres. The previous birth prevalence of 1.17 per 100 in the 1970s increased to 1.50 per 1000 between 1989 and 1999 with a maximum 1.77 in 1992. The completeness of the Registry was only 65.9% between 1970 and 1999, i.e. 30 years. One-third of cases had not been karyotyped, however, this figure is now about 10%. The major explanation of this increase is the significantly higher proportion of prenatally diagnosed fetuses with Down syndrome and an increasing number of women over 35. In addition better ascertainment may also contribute to this increase, but new etiological factors cannot also be excluded.

Epidemiology of Down syndrome (Trisomy 21), Hawaii, 1986-97

BACKGROUND

The live birth prevalence of Down syndrome is approximately 10 per 10,000 live births in the United States. Down syndrome prevalence has been reported to change over time and to vary by selected demographic factors.

METHODS

Data from a population-based birth defects registry in Hawaii involving 363 Down syndrome cases delivered during 1986-97 were used to calculate overall prevalence and to investigate secular trends and differences by selected demographic factors.

RESULTS

The total (live birth, fetal death, and elective termination) prevalence was 14.74 per 10,000 live births and fetal deaths. The unadjusted live birth prevalence was 8.67 per 10,000 live births. The adjusted live birth (live births and proportion of elective terminations expected to have resulted in live births) prevalence was 12.59 per 10,000 live births. No significant secular trends were observed for either total prevalence (P = 0.688) or adjusted live birth prevalence (P = 0.604). The total Down syndrome prevalence per 10,000 live births was highest for Far East Asians (22.01), followed by whites (17.06), Filipinos (15.94), and Pacific Islanders (9.21). Prevalence per 10,000 births was higher in metropolitan Honolulu (18.57) than in the rest of Hawaii (14.15). After adjusting for maternal age, however, the differences within the demographic groups were not statistically significant.

CONCLUSIONS

The live birth prevalence of Down syndrome in Hawaii during 1986-97 was lower than reported in the literature. Prevalence did not change significantly over time. Any differences in prevalence by maternal race/ethnicity and place of residence appeared to result from differences in maternal age distribution.

Investigation of a cluster of children with Down's syndrome born to mothers who had attended a school in Dundalk, Ireland

OBJECTIVES

To investigate a reported cluster of Down's syndrome in offspring of former pupils of a girls' school in Ireland, to establish the prevalence of Down's syndrome among live births in the area around the school, and to review the literature on the possible causes of reported clusters of Down's syndrome.

METHODS

Questionnaire survey of obstetric and personal histories of women who had attended the girls' school at Dundalk, County Louth, Republic of Ireland, at some time during 1956-7, and also of women who had attended another, nearby, girls' school during the same period. Comparison of observed numbers of cases of Down's syndrome identified by these surveys with maternal age adjusted expected numbers for the reported live births. Laboratory tests were conducted to verify and characterise the cases of Down's syndrome constituting the cluster. Retrospective collection and collation of data on Down's syndrome occurring among live births, and the compilation of maternal age specific incidences, in County Louth and in Newry and Mourne District in neighbouring Northern Ireland, during 1961-80. These rates were compared with reference rates and rates for other areas of Ireland.

RESULTS

Six children with Down's syndrome were confirmed among 387 reported live births to women who had been pupils at the girls' school in Dundalk during 1956-7, compared with 0.69 expected (nominal p<10(-4)). Five of the affected births were to mothers under 30 years of age, against 0.15 expected (nominal p<10(-6)), although only four of these mothers were attending the school at any one time. The origin of the non-disjunction was found to be maternal first meiotic in four children, mitotic after fertilisation in another (with the youngest mother), and in the remaining one could not be determined. The marked excess of Down's syndrome in births to young mothers did not extend to offspring of former pupils of the other Dundalk girls' school surveyed, or to live births in County Louth generally or in adjacent Newry and Mourne District.

CONCLUSION

A striking, highly localised, excess of Down's syndrome in births to young mothers who had attended a girls' school in Dundalk during 1956-57 has been confirmed. However, not all of the mothers of the affected children attended the school concurrently and the origin of non-disjunction in one child was an error occurring after conception. Some exposure essentially confined to girls attending the school at this time is a possible, although unlikely, explanation, but a review of potential risk factors does not suggest what this could be. Previous suggestions that an influenza epidemic or contamination from the Windscale nuclear reactor fire might be implicated, both of which occurred in October 1957, can be effectively dismissed because three of the women with affected offspring had left the school by then and had moved away from Dundalk, and Down's syndrome in the child of another mother originated in an error after fertilisation. Owing to the retrospective nature of the investigation and the characteristics of the cases, chance is the most likely explanation for the cluster.

Trends in prenatal diagnosis of Down syndrome and other autosomal trisomies in Scotland 1990 to 1994, with associated cytogenetic and epidemiological findings

The present report summarizes findings on 670 cases of autosomal trisomy diagnosed in Scotland, with actual or expected dates of delivery in 1990 to 1994 inclusive. Cases were notified by cytogenetic service laboratories. There were 277 prenatal and 369 postnatal diagnoses and 24 spontaneous losses. Excluding the latter, numbers diagnosed with trisomy 21, trisomy 18, trisomy 13, and other trisomies were, respectively, 470 (72.8%), 108 (16.7%), 36 (5.6%), and 32 (5.0%). Estimated maternal age-specific birth rates for trisomy 21 were close to published values from other jurisdictions. However, comparisons with a clinically based national register of congenital anomalies suggested that 3-4% of Down syndrome births were never karyotyped, most being early neonatal deaths. There was a striking increase over the period in the proportion of cases detected prenatally, associated with increased maternal serum screening in mothers <35 years old. Over the 3 final years (1992-1994), prenatal screening followed by elective termination was estimated to reduce the birth rate in trisomy 21 by 24% in mothers aged <35 years, by 57% in older mothers, and by 35% in all mothers. The crude incidence per 1,000 births fell from 1.08 in 1990-1991 to 0.77 in 1992-1994, in spite of an upward shift in the overall maternal age distribution. For trisomies 18 and 13, the estimated overall reductions in the birth rate over the whole 5-year period were respectively, 26 and 17%. In free trisomy 18, there was a significant reduction in the sex ratio (male/female) to 0.65, in line with earlier studies.