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Atta CAM, Fiest KM, Frolkis AD, Jette N, Pringsheim T, St Germaine-Smith C, Rajapakse T, Kaplan GG, Metcalfe A. Global Birth Prevalence of Spina Bifida by Folic Acid Fortification Status: A Systematic Review and Meta-Analysis. Am J Public Health 2016; 106:e24-34. [PMID: 26562127 PMCID: PMC4695937 DOI: 10.2105/ajph.2015.302902] [Citation(s) in RCA: 198] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND Birth defects remain a significant source of worldwide morbidity and mortality. Strong scientific evidence shows that folic acid fortification of a region's food supply leads to a decrease in spina bifida (a birth defect of the spine). Still, many countries around the world have yet to approve mandatory fortification through government legislation. OBJECTIVES We sought to perform a systematic review and meta-analysis of period prevalence of spina bifida by folic acid fortification status, geographic region, and study population. SEARCH METHODS An expert research librarian used terms related to neural tube defects and epidemiology from primary research from 1985 to 2010 to search in EMBASE and MEDLINE. We searched the reference lists of included articles and key review articles identified by experts. SELECTION CRITERIA Inclusion criteria included studies in English or French reporting on prevalence published between January 1985 and December 2010 that (1) were primary research, (2) were population-based, and (3) reported a point or period prevalence estimate of spina bifida (i.e., prevalence estimate with confidence intervals or case numerator and population denominator). Two independent reviewers screened titles and abstracts for eligible articles, then 2 authors screened full texts in duplicate for final inclusion. Disagreements were resolved through consensus or a third party. DATA COLLECTION AND ANALYSIS We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses, or PRISMA, abstracting data related to case ascertainment, study population, folic acid fortification status, geographic region, and prevalence estimate independently and in duplicate. We extracted overall data and any subgroups reported by age, gender, time period, or type of spina bifida. We classified each period prevalence estimate as "mandatory" or "voluntary" folic acid fortification according to each country's folic acid fortification status at the time data were collected (as determined by a well-recognized fortification monitoring body, Food Fortification Initiative). We determined study quality on the basis of sample representativeness, standardization of data collection and birth defect assessment, and statistical analyses. We analyzed study-level period prevalence estimates by using a random effects model (α level of < 0.05) for all meta-analyses. We stratified pooled period prevalence estimates by birth population, fortification status, and continent. RESULTS Of 4078 studies identified, we included 179 studies in the systematic review and 123 in a meta-analysis. In studies of live births (LBs) alone, period prevalences of spina bifida were (1) lower in geographical regions with mandatory (33.86 per 100,000 LBs) versus voluntary (48.35 per 100,000 LBs) folic acid fortification, and (2) lower in studies of LBs, stillbirths, and terminations of pregnancy in regions with mandatory (35.22 per 100,000 LBs) versus voluntary (52.29 per 100,000 LBs) fortification. In LBs, stillbirths, and terminations of pregnancy studies, the lowest pooled prevalence estimate was in North America (38.70 per 100,000). Case ascertainment, surveillance methods, and reporting varied across these population-based studies. CONCLUSIONS Mandatory legislation enforcing folic acid fortification of the food supply lags behind the evidence, particularly in Asian and European countries. This extensive literature review shows that spina bifida is significantly more common in world regions without government legislation regulating full-coverage folic acid fortification of the food supply (i.e., Asia, Europe) and that mandatory folic acid fortification resulted in a lower prevalence of spina bifida regardless of the type of birth cohort. African data were scarce, but needed, as many African nations are beginning to adopt folic acid legislation.
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Affiliation(s)
- Callie A M Atta
- Callie A. M. Atta, Kirsten M. Fiest, Nathalie Jette, Tamara Pringsheim, and Christine St Germaine-Smith are with the Department of Clinical Neurosciences, University of Calgary, Alberta. Kirsten M. Fiest and Nathalie Jette are also with Hotchkiss Brain Institute, University of Calgary. Tamara Pringsheim and Thilinie Rajapakse are with the Department of Paediatrics, University of Calgary. Kirsten M. Fiest, Alexandra D. Frolkis, Nathalie Jette, Tamara Pringsheim, and Gilaad G. Kaplan are with Department of Community Health Sciences, University of Calgary. Amy Metcalfe is with the Department of Obstetrics and Gynecology, University of Calgary
| | - Kirsten M Fiest
- Callie A. M. Atta, Kirsten M. Fiest, Nathalie Jette, Tamara Pringsheim, and Christine St Germaine-Smith are with the Department of Clinical Neurosciences, University of Calgary, Alberta. Kirsten M. Fiest and Nathalie Jette are also with Hotchkiss Brain Institute, University of Calgary. Tamara Pringsheim and Thilinie Rajapakse are with the Department of Paediatrics, University of Calgary. Kirsten M. Fiest, Alexandra D. Frolkis, Nathalie Jette, Tamara Pringsheim, and Gilaad G. Kaplan are with Department of Community Health Sciences, University of Calgary. Amy Metcalfe is with the Department of Obstetrics and Gynecology, University of Calgary
| | - Alexandra D Frolkis
- Callie A. M. Atta, Kirsten M. Fiest, Nathalie Jette, Tamara Pringsheim, and Christine St Germaine-Smith are with the Department of Clinical Neurosciences, University of Calgary, Alberta. Kirsten M. Fiest and Nathalie Jette are also with Hotchkiss Brain Institute, University of Calgary. Tamara Pringsheim and Thilinie Rajapakse are with the Department of Paediatrics, University of Calgary. Kirsten M. Fiest, Alexandra D. Frolkis, Nathalie Jette, Tamara Pringsheim, and Gilaad G. Kaplan are with Department of Community Health Sciences, University of Calgary. Amy Metcalfe is with the Department of Obstetrics and Gynecology, University of Calgary
| | - Nathalie Jette
- Callie A. M. Atta, Kirsten M. Fiest, Nathalie Jette, Tamara Pringsheim, and Christine St Germaine-Smith are with the Department of Clinical Neurosciences, University of Calgary, Alberta. Kirsten M. Fiest and Nathalie Jette are also with Hotchkiss Brain Institute, University of Calgary. Tamara Pringsheim and Thilinie Rajapakse are with the Department of Paediatrics, University of Calgary. Kirsten M. Fiest, Alexandra D. Frolkis, Nathalie Jette, Tamara Pringsheim, and Gilaad G. Kaplan are with Department of Community Health Sciences, University of Calgary. Amy Metcalfe is with the Department of Obstetrics and Gynecology, University of Calgary
| | - Tamara Pringsheim
- Callie A. M. Atta, Kirsten M. Fiest, Nathalie Jette, Tamara Pringsheim, and Christine St Germaine-Smith are with the Department of Clinical Neurosciences, University of Calgary, Alberta. Kirsten M. Fiest and Nathalie Jette are also with Hotchkiss Brain Institute, University of Calgary. Tamara Pringsheim and Thilinie Rajapakse are with the Department of Paediatrics, University of Calgary. Kirsten M. Fiest, Alexandra D. Frolkis, Nathalie Jette, Tamara Pringsheim, and Gilaad G. Kaplan are with Department of Community Health Sciences, University of Calgary. Amy Metcalfe is with the Department of Obstetrics and Gynecology, University of Calgary
| | - Christine St Germaine-Smith
- Callie A. M. Atta, Kirsten M. Fiest, Nathalie Jette, Tamara Pringsheim, and Christine St Germaine-Smith are with the Department of Clinical Neurosciences, University of Calgary, Alberta. Kirsten M. Fiest and Nathalie Jette are also with Hotchkiss Brain Institute, University of Calgary. Tamara Pringsheim and Thilinie Rajapakse are with the Department of Paediatrics, University of Calgary. Kirsten M. Fiest, Alexandra D. Frolkis, Nathalie Jette, Tamara Pringsheim, and Gilaad G. Kaplan are with Department of Community Health Sciences, University of Calgary. Amy Metcalfe is with the Department of Obstetrics and Gynecology, University of Calgary
| | - Thilinie Rajapakse
- Callie A. M. Atta, Kirsten M. Fiest, Nathalie Jette, Tamara Pringsheim, and Christine St Germaine-Smith are with the Department of Clinical Neurosciences, University of Calgary, Alberta. Kirsten M. Fiest and Nathalie Jette are also with Hotchkiss Brain Institute, University of Calgary. Tamara Pringsheim and Thilinie Rajapakse are with the Department of Paediatrics, University of Calgary. Kirsten M. Fiest, Alexandra D. Frolkis, Nathalie Jette, Tamara Pringsheim, and Gilaad G. Kaplan are with Department of Community Health Sciences, University of Calgary. Amy Metcalfe is with the Department of Obstetrics and Gynecology, University of Calgary
| | - Gilaad G Kaplan
- Callie A. M. Atta, Kirsten M. Fiest, Nathalie Jette, Tamara Pringsheim, and Christine St Germaine-Smith are with the Department of Clinical Neurosciences, University of Calgary, Alberta. Kirsten M. Fiest and Nathalie Jette are also with Hotchkiss Brain Institute, University of Calgary. Tamara Pringsheim and Thilinie Rajapakse are with the Department of Paediatrics, University of Calgary. Kirsten M. Fiest, Alexandra D. Frolkis, Nathalie Jette, Tamara Pringsheim, and Gilaad G. Kaplan are with Department of Community Health Sciences, University of Calgary. Amy Metcalfe is with the Department of Obstetrics and Gynecology, University of Calgary
| | - Amy Metcalfe
- Callie A. M. Atta, Kirsten M. Fiest, Nathalie Jette, Tamara Pringsheim, and Christine St Germaine-Smith are with the Department of Clinical Neurosciences, University of Calgary, Alberta. Kirsten M. Fiest and Nathalie Jette are also with Hotchkiss Brain Institute, University of Calgary. Tamara Pringsheim and Thilinie Rajapakse are with the Department of Paediatrics, University of Calgary. Kirsten M. Fiest, Alexandra D. Frolkis, Nathalie Jette, Tamara Pringsheim, and Gilaad G. Kaplan are with Department of Community Health Sciences, University of Calgary. Amy Metcalfe is with the Department of Obstetrics and Gynecology, University of Calgary
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Shin M, Kucik JE, Siffel C, Lu C, Shaw GM, Canfield MA, Correa A. Improved survival among children with spina bifida in the United States. J Pediatr 2012; 161:1132-7. [PMID: 22727874 PMCID: PMC4547557 DOI: 10.1016/j.jpeds.2012.05.040] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Revised: 02/24/2012] [Accepted: 05/17/2012] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To evaluate trends in survival among children with spina bifida by race/ethnicity and possible prognostic factors in 10 regions of the United States. STUDY DESIGN A retrospective cohort study was conducted of 5165 infants with spina bifida born during 1979-2003, identified by 10 birth defects registries in the United States. Survival probabilities and adjusted hazard ratios were estimated for race/ethnicity and other characteristics using the Cox proportional hazard model. RESULTS During the study period, the 1-year survival probability among infants with spina bifida showed improvements for whites (from 88% to 96%), blacks (from 79% to 88%), and Hispanics (from 88% to 93%). The impact of race/ethnicity on survival varied by birth weight, which was the strongest predictor of survival through age 8. There was little racial/ethnic variation in survival among children born of very low birth weight. Among children born of low birth weight, the increased risk of mortality to Hispanics was approximately 4-6 times that of whites. The black-white disparity was greatest among children born of normal birth weight. Congenital heart defects did not affect the risk of mortality among very low birth weight children but increased the risk of mortality 4-fold among children born of normal birth weight. CONCLUSIONS The survival of infants born with spina bifida has improved; however, improvements in survival varied by race/ethnicity, and blacks and Hispanics continued to have poorer survival than whites in the most recent birth cohort from 1998-2002. Further studies are warranted to elucidate possible reasons for the observed differences in survival.
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Affiliation(s)
- Mikyong Shin
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and, Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
- RTI International, Atlanta, GA
| | - James E. Kucik
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and, Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Csaba Siffel
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and, Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Chengxing Lu
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and, Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
- Oak Ridge Institute for Science and Education, Oak Ridge, TN
| | - Gary M. Shaw
- Stanford University School of Medicine, Stanford, CA
| | | | - Adolfo Correa
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and, Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS
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Shin M, Besser LM, Siffel C, Kucik JE, Shaw GM, Lu C, Correa A. Prevalence of spina bifida among children and adolescents in 10 regions in the United States. Pediatrics 2010; 126:274-9. [PMID: 20624803 DOI: 10.1542/peds.2009-2084] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The goal was to estimate the number of children and adolescents, 0 to 19 years of age, living with spina bifida (SB) in the United States. METHODS A retrospective study was conducted by using population-based, birth defect surveillance data from 10 US regions, with vital status ascertainment. Birth defect surveillance data were obtained from Arkansas, Georgia (5 central counties of metropolitan Atlanta), California (11 counties), Colorado, Iowa, New York (New York City excluded), North Carolina, Oklahoma, Texas, and Utah. We estimated the numbers of children 0 to 19 years of age who were living with SB in the 10 US regions in 2002, according to age group, race/ethnicity, and gender, and examined a long-term trend in the prevalence of SB among children 0 to 11 years of age in 1991-2002. RESULTS The overall prevalence of SB among children and adolescents 0 to 19 years of age in the study regions was 3.1 cases per 10,000 in 2002. The prevalence of SB among children was lower among male and non-Hispanic black children. CONCLUSIONS The prevalence estimates of SB among children and adolescents varied according to region, race/ethnicity, and gender, which suggests possible variations in prevalence at birth and/or inequities in survival rates. Additional studies are warranted to elucidate the reasons for these variations and to derive prevalence estimates of SB among adults.
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Affiliation(s)
- Mikyong Shin
- Division of Birth Defects and Developmental Disabilities, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
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Aschengrau A, Weinberg JM, Janulewicz PA, Gallagher LG, Winter MR, Vieira VM, Webster TF, Ozonoff DM. Prenatal exposure to tetrachloroethylene-contaminated drinking water and the risk of congenital anomalies: a retrospective cohort study. Environ Health 2009; 8:44. [PMID: 19778411 PMCID: PMC2761868 DOI: 10.1186/1476-069x-8-44] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Accepted: 09/24/2009] [Indexed: 05/18/2023]
Abstract
BACKGROUND Prior animal and human studies of prenatal exposure to solvents including tetrachloroethylene (PCE) have shown increases in the risk of certain congenital anomalies among exposed offspring. OBJECTIVES This retrospective cohort study examined whether PCE contamination of public drinking water supplies in Massachusetts influenced the occurrence of congenital anomalies among children whose mothers were exposed around the time of conception. METHODS The study included 1,658 children whose mothers were exposed to PCE-contaminated drinking water and a comparable group of 2,999 children of unexposed mothers. Mothers completed a self-administered questionnaire to gather information on all of their prior births, including the presence of anomalies, residential histories and confounding variables. PCE exposure was estimated using EPANET water distribution system modeling software that incorporated a fate and transport model. RESULTS Children whose mothers had high exposure levels around the time of conception had an increased risk of congenital anomalies. The adjusted odds ratio of all anomalies combined among children with prenatal exposure in the uppermost quartile was 1.5 (95% CI: 0.9, 2.5). No meaningful increases in the risk were seen for lower exposure levels. Increases were also observed in the risk of neural tube defects (OR: 3.5, 95% CI: 0.8, 14.0) and oral clefts (OR 3.2, 95% CI: 0.7, 15.0) among offspring with any prenatal exposure. CONCLUSION The results of this study suggest that the risk of certain congenital anomalies is increased among the offspring of women who were exposed to PCE-contaminated drinking water around the time of conception. Because these results are limited by the small number of children with congenital anomalies that were based on maternal reports, a follow-up investigation should be conducted with a larger number of affected children who are identified by independent records.
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Affiliation(s)
- Ann Aschengrau
- Department of Epidemiology, Boston University School of Public Health, Talbot 3E, 715 Albany Street, Boston, MA 02118, USA
| | - Janice M Weinberg
- Department of Biostatistics, Boston University School of Public Health, Crosstown, 715 Albany Street, Boston, MA 02118, USA
| | - Patricia A Janulewicz
- Department of Epidemiology, Boston University School of Public Health, Talbot 3E, 715 Albany Street, Boston, MA 02118, USA
| | - Lisa G Gallagher
- Department of Environmental Health, Boston University School of Public Health, Talbot 4W, 715 Albany Street, Boston, MA 02118, USA
| | - Michael R Winter
- Data Coordinating Center, Boston University School of Public Health, Crosstown, 715 Albany Street, Boston MA 02118, USA
| | - Veronica M Vieira
- Department of Environmental Health, Boston University School of Public Health, Talbot 4W, 715 Albany Street, Boston, MA 02118, USA
| | - Thomas F Webster
- Department of Environmental Health, Boston University School of Public Health, Talbot 4W, 715 Albany Street, Boston, MA 02118, USA
| | - David M Ozonoff
- Department of Environmental Health, Boston University School of Public Health, Talbot 4W, 715 Albany Street, Boston, MA 02118, USA
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