Gastroschisis prevalence patterns in 27 surveillance programs from 24 countries, International Clearinghouse for Birth Defects Surveillance and Research, 1980-2017

BACKGROUND

Gastroschisis is a serious birth defect with midgut prolapse into the amniotic cavity. The objectives of this study were to evaluate the prevalence and time trends of gastroschisis among programs in the International Clearinghouse for Birth Defects Surveillance and Research (ICBDSR), focusing on regional variations and maternal age changes in the population.

METHODS

We analyzed data on births from 1980 to 2017 from 27 ICBDSR member programs, representing 24 countries and three regions (Europe+ (includes Iran) , Latin America, North America). Cases were identified using diagnostic codes (i.e., 756.7, 756.71, or Q79.3). We excluded cases of amniotic band syndrome, limb-body wall defect, and ruptured omphalocele. Programs provided annual counts for gastroschisis cases (live births, stillbirths, and legally permitted pregnancy terminations for fetal anomalies) and source population (live births, stillbirths), by maternal age.

RESULTS

Overall, gastroschisis occurred in 1 of every 3268 births (3.06 per 10,000 births; 95% confidence intervals [CI]: 3.01, 3.11), with marked regional variation. European+ prevalence was 1.49 (95%CI: 1.44, 1.55), Latin American 3.80 (95%CI: 3.69, 3.92) and North American 4.32 (95%CI: 4.22, 4.42). A statistically significant increasing time trend was observed among six European+ , four Latin American, and four North American programs. Women <20 years of age had the highest prevalence in all programs except the Slovak Republic.

CONCLUSIONS

Gastroschisis prevalence increased over time in 61% of participating programs, and the highest increase in prevalence was observed among the youngest women. Additional inquiry will help to assess the impact of the changing maternal age proportions in the birth population on gastroschisis prevalence.

Population-based prevalence and trend of birth defects in Costa Rica from 2000 to 2019

BACKGROUND

We aimed to analyze the prevalence and trend of birth defects (BDs) in Costa Rica, where BDs are the second leading cause of infant and under-five mortality.

METHODS

A descriptive analysis of selected BDs prevalence and trends from 2000 to 2019 was performed, based on data from the Costa Rican Birth Defects Register Center, the national BDs surveillance system with coverage of 98% of live births in the country. We used Joinpoint regression to identify any calendar year where a significant change in trend occurred; the annual percent change (APC) and the average annual percent change (AAPC) were determined. Marginal means and prevalence ratios by subperiod (2000-2009 as referent and 2010-2019) were estimated using Poisson regression, and compared using Wald's chi-square tests (alpha ≤0.05).

RESULTS

From 2000 to 2019, BDs occurred in 2.3% of live births (95% CI: 2.3-2.4); 73% of which were major BDs. Males presented a significantly higher prevalence (sex ratio 1.13 males/females). The trend showed an AAPC of +3.7 (p < .05) with two joinpoints, 2005 and 2013. A significant APC (+11.3) was observed during 2005-2013, within the context of improvements in the surveillance system, such as the increase in the reporting age, and the incorporation of other data sources in addition to maternity hospitals. Most of the BDs groups presented a significant upward trend. The highest AAPC was observed for the respiratory system (+11.7), congenital heart defects (+9.5), and nervous system (+8.5).

CONCLUSIONS

The BDs present a clear upward trend in the last two decades due, among other things, to a significant improvement in the surveillance system.

Integrated surveillance strategy to support the prevention of neural tube defects through food fortification with folic acid: the experience of Costa Rica

PURPOSE

(1) To describe how Costa Rica implemented an integrated surveillance strategy of folate deficiency, neural tube defects (NTDs) prevalence, NTDs-associated infant mortality rate (NTDs-IMR), and folic acid food fortification (FAFF), to support with evidence NTDs prevention policies; (2) to disseminate updated data from monitoring programs.

METHODS

We performed a cross-sectional analysis, using the databases of national surveillance systems for NTDs outcomes to compare NTDs-prevalence and NTDs-IMR observed in the pre-fortification (1987-1998) and post-fortification (2010-2020) periods. In addition, using data from FAFF monitoring program (2010-2020), means of folic acid concentration (mg/kg) and folic acid daily intake (μg/day) were calculated for each fortified food (corn and wheat flour, rice and milk), as well as its contribution to folic acid estimated average requirement (EAR).

RESULTS

After FAFF Costa Rica showed a decrease of 84% in folic acid deficiency in women of childbearing age, as well as a 53% decrease in the prevalence of NTDs, falling from 11.82/10,000 to 5.52/10,000 livebirths. In addition, there was a 76% reduction in the NTDs-IMR from 77.01/100,000 to 18.66/100,000 livebirths. Between 2010 and 2020, all fortified foods provided an average contribution of 119% of the EAR of folic acid in the population.

CONCLUSION

To reduce NTD risk, an integrated surveillance strategy is essential not only to base prevention strategies on evidence, but also to demonstrate their impact and improve interventions over time. The experience in Costa Rica provides evidence that this type of surveillance is feasible to be implemented in developing countries.

Global strategies for the prevention of neural tube defects through the improvement of folate status in women of reproductive age

INTRODUCTION

Neural tube defects represent a global public health problem, mainly in countries where effective prevention strategies are not yet in place. The global prevalence of neural tube defects is estimated at 18.6/10,000 (uncertainty interval: 15.3-23.0) live births, where ~ 75% of cases result in under-five mortality. Most of the mortality burden is in low- and middle-income countries. The main risk factor for this condition is insufficient folate levels in women of reproductive age.

METHODS

This paper reviews the extent of the problem, including the most recent global information on folate status in women of reproductive age and the most recent estimates of the prevalence of neural tube defects. Additionally, we provide an overview of the available interventions worldwide to reduce the risk of neural tube defects by improving folate status in the population, including dietary diversification, supplementation, education, and fortification.

RESULTS

Large-scale food fortification with folic acid is the most successful and effective intervention to reduce the prevalence of neural tube defects and associated infant mortality. This strategy requires the coordination of several sectors, including governments, the food industry, health services providers, the education sector, and entities that monitor the quality of the service processes. It also requires technical knowledge and political will. An international collaboration between governmental and non-governmental organizations is essential to succeed in saving thousands of children from a disabling but preventable condition.

DISCUSSION

We propose a logical model for building a national-level strategic plan for mandatory LSFF with folic acid and explain the actions needed for promoting sustainable system-level change.

Reduction of infant mortality from congenital heart defects in a middle-income country: Costa Rican experience

BACKGROUND

We aimed to analyze recent infant and neonatal mortality from congenital heart defects (CHD) in Costa Rica, a middle-income country where CHD mortality was above expectations.

METHODS

A descriptive analysis of infant and neonatal mortality rates from CHD (IMR-CHD and NMR-CHD) during 2000-2019 was performed, according to province, sex, specific CHD, and sub-period, using data from the National Institute of Statistics and Censuses. We used joinpoint regression to identify any calendar-year where a significant change in trend occurred; the average annual percent change (AAPC) was determined. Using Poisson regression, marginal means and mortality ratios (MR) for IMR-CHD and NMR-CHD by sub-period (2000-2006-referent-, 2007-2013, 2014-2019) were estimated and compared using Wald's chi-square tests (α ≤ .05).

RESULTS

During 2000-2019, CHD accounted for 12% of overall infant mortality. IMR-CHD and NMR-CHD decreased linearly over the study period (AAPC = -3.4; p < .01). IMR-CHD decreased by 41%, from 13.6 per 10,000 in 2000-2006 (13.4% of infant mortality) to 8.1 per 10,000 in 2014-2019 (10% of infant mortality) (MR = 0.59; 95% confidence intervals [CI] = 0.52-0.68). NMR-CHD decreased by 38%, from 7.9 per 10,000 in 2000-2006 (11.1% of neonatal mortality) to 4.9 per 10,000 in 2014-2019 (7.9% of infant mortality) (MR = 0.59; 95% CI = 0.52-0.68). Male presented significantly higher NMR-CHD. The main causes of mortality (2014-2019) were total anomalous pulmonary venous connections, hypoplastic left heart syndrome, and double inlet ventricle.

CONCLUSIONS

IMR-CHD, NMR-CHD, and their proportional contribution to mortality by all causes and by birth defects decreased significantly, demonstrating that all improvements implemented in the last decades have yielded favorable results.

Mortalidad infantil por defectos congénitos en Costa Rica: actualización 2010-2018

Objetivo. El objetivo de este estudio fue identificar la tendencia de los diferentes tipos de defectos congénitos en la tasa de mortalidad infantil y neonatal en Costa Rica durante el período 2010-2018 con respecto al primer período 2000-2009.Métodos. Se realizó un análisis de estadísticas vitales. La fuente de información fue el Instituto Nacional de Estadísticas y Censos de Costa Rica, mediante su sistema de acceso público y consulta en línea, se consultó la base de defunciones por causa y la base de nacimientos para el período 2000-2018. Las causas de defunción por defectos congénitos se agruparon por sistemas, además se seleccionaron los defectos de mayor mortalidad en el periodo de estudio para su análisis específico. Para describir el comportamiento de la mortalidad infantil por defectos congénitos de 2010-2018 con respecto al decenio anterior, se calcularon tasas de mortalidad infantil y neonatal para los períodos 2000-2009 y 2010-2018 con su respectivo intervalo de confianza (IC95%). Se construyó un modelo de regresión Poisson Log lineal para cada grupo de defectos congénitos y para los defectos específicos seleccionados, tomando como factor de ajuste los subperíodos comparados. Se estimaron razones de prevalencias y se compararon mediante chi cuadrado de Wald usando como base el período 2000-2009. Resultados. En las últimas dos décadas, los defectos congénitos causaron 29% a 38% de la mortalidad infantil general. La tasa de mortalidad infantil por defectos congénitos durante 2000-2009 fue 3,19 (IC95%: 3,1-3,3) y descendió significativamente a 2,97 (IC95%: 2,8-3,1) en el período 2010-2018. Esta disminución se dio a expensas de la afectación de los sistemas circulatorio y digestivo. Al analizar la mortalidad infantil por defectos congénitos específicos, se demostró una disminución significativa únicamente en espina bífida y algunos defectos cardiacos: transposición de grandes arterias, defecto septal ventricular, coartación aorta y otras anomalías cardiacas no especificadas. La tasa de mortalidad neonatal por defectos congénitos no varió significativamente entre los períodos comparados, en 2000-2009 fue 2,13 (IC95%: 2,0-2,2) y 2,17 (IC95%: 2,1-2,3) en 2010-2018. El único grupo de defectos congénitos que presentó una disminución significativa en la tasa de mortalidad neonatal en la última década fue el sistema circulatorio. Conclusiones. En la última década se presentó una disminución significativa de la tasa de mortalidad infantil por defectos congénitos. Este descenso obedeció principalmente a una disminución significativa en las tasas de mortalidad infantil y neonatal por defectos cardiacos.

Zika Virus-Associated Birth Defects, Costa Rica, 2016-2018

Enhanced birth defect surveillance increased identification of virus-associated abnormalities, including microcephaly.

After Zika virus (ZIKV) infection in Costa Rica was confirmed in January 2016, the national surveillance system was enhanced to monitor associated birth defects. To characterize the ZIKV outbreak among live-born infants during March 2016–March 2018, we conducted a descriptive analysis. Prevalence of ZIKV-associated birth defects was 15.3 cases/100,000 live births. Among 22 infants with ZIKV-associated birth defects, 11 were designated as confirmed (positive for ZIKV) and 11 were designated as probable cases (negative for ZIKV or not tested, but mother was expsed to ZIKV during pregnancy). A total of 91% had microcephaly (head circumference >2 SDs below mean for age and sex), 64% severe microcephaly (head circumference > 3 SDs below mean for age and sex), 95% neurodevelopmental abnormalities, 82% brain anomalies, 41% eye abnormalities, and 9% hearing loss. Monitoring children for > 1 year can increase identification of ZIKV-associated abnormalities in addition to microcephaly.

Prevalence of microcephaly: the Latin American Network of Congenital Malformations 2010-2017

OBJECTIVE

The Latin American Network of Congenital Malformations: ReLAMC was established in 2017 to provide accurate congenital anomaly surveillance. This study used data from ReLAMC registries to quantify the prevalence of microcephaly from 2010 to 2017 (before, during and after the Zika virus epidemic).

DESIGN

Nine ReLAMC congenital anomaly registries provided case-level data or aggregate data for any live births, still births or terminations of pregnancy with microcephaly. Births to pregnant women infected with Zika virus first occurred in Brazil in 2015, and in the remaining registry areas in 2016 with the exception of Chile that did not experience Zika virus. Therefore the prevalence of microcephaly for 2010-2014 and individual years 2015, 2016 and 2017 was estimated using multilevel random effect Poisson models. Clinical classification and characteristics of the cases were compared pre and post Zika for all centres providing individual case-level data.

RESULTS

The prevalence of microcephaly for all registries excluding Brazil was 2.3 per 10 000 (95% CI 2.0 to 2.6) for 2010-2014 rising to 5.4 (95% CI 4.8 to 6.0) in 2016 and 5.9 (95% CI 5.3 to 6.6) in 2017. Brazil had a prevalence of 0.6 per 10 000 (95% CI 0.5 to 0.6) in 2010-2014, rising to 5.8 (95% CI 5.6 to 6.1) in 2015, 8.0 (95% CI 7.6 to 8.3) in 2016 and then falling in 2017. Only 29 out of 687 cases of microcephaly were reported as congenital Zika syndrome in countries excluding Brazil.

CONCLUSIONS

The prevalence of microcephaly was influenced both by Zika causing congenital Zika syndrome and by increased reporting awareness.

The Latin American network for congenital malformation surveillance: ReLAMC

The early detection of congenital anomaly epidemics occurs when comparing current with previous frequencies in the same population. The success of epidemiologic surveillance depends on numerous factors, including the accuracy of the rates available in the base period, wide population coverage, and short periodicity of analysis. This study aims to describe the Latin American network of congenital malformation surveillance: ReLAMC, created to increase epidemiologic surveillance in Latin America. We describe the main steps, tasks, strategies used, and preliminary results. From 2017 to 2019, five national registries (Argentina [RENAC], Brazil [SINASC/SIM-BRS], Chile [RENACH], Costa Rica [CREC], Paraguay [RENADECOPY-PNPDC]), six regional registries (Bogotá [PVSDC-Bogota], Cali [PVSDC-Cali], Maule [RRMC SSM], Nicaragua [SVDC], Nuevo-León [ReDeCon HU], São Paulo [SINASC/SIM-MSP]) and the ECLAMC hospital network sent data to ReLAMC on a total population of 9,152,674 births, with a total of 101,749 malformed newborns (1.1%; 95% CI 1.10-1.12). Of the 9,000,651 births in countries covering both live and stillbirths, 88,881 were stillborn (0.99%; 95% CI 0.98-0.99), and among stillborns, 6,755 were malformed (7.61%; 95% CI 7.44-7.79). The microcephaly rate was 2.45 per 10,000 births (95% CI 2.35-2.55), hydrocephaly 3.03 (2.92-3.14), spina bifida 2.89 (2.78-3.00), congenital heart defects 15.53 (15.27-15.79), cleft lip 2.02 (1.93-2.11), cleft palate and lip 2.77 (2.66-2.88), talipes 2.56 (2.46-2.67), conjoined twins 0.16 (0.14-0.19), and Down syndrome 5.33 (5.18-5.48). Each congenital anomaly showed heterogeneity in prevalence rates among registries. The harmonization of data in relation to operational differences between registries is the next step in developing the common ReLAMC database.

Prevalence and mortality in children with congenital diaphragmatic hernia: a multicountry study

PURPOSE

This study determined the prevalence, mortality, and time trends of children with congenital diaphragmatic hernia (CDH).

METHODS

Twenty-five hospital- and population-based surveillance programs in 19 International Clearinghouse for Birth Defects Surveillance and Research member countries provided birth defects mortality data between 1974 and 2015. CDH cases included live births, stillbirths, or elective termination of pregnancy for fetal anomalies. Prevalence, cumulative mortality rates, and 95% confidence intervals (CIs) were calculated using Poisson regression and a Kaplan-Meier product-limit method. Joinpoint regression analyses were conducted to assess time trends.

RESULTS

The prevalence of CDH was 2.6 per 10,000 total births (95% CI: 2.5-2.7), slightly increasing between 2001 and 2012 (average annual percent change = 0.5%; 95% CI:-0.6 to 1.6). The total percent mortality of CDH was 37.7%, with hospital-based registries having more deaths among live births than population-based registries (45.1% vs. 33.8%). Mortality rates decreased over time (average annual percent change = -2.4%; 95% CI: -3.8 to 1.1). Most deaths due to CDH occurred among 2- to 6-day-old infants for both registry types (36.3%, hospital-based; 12.1%, population-based).

CONCLUSIONS

The mortality of CDH has decreased over time. Mortality remains high during the first week and varied by registry type.

[Characterisation of the paediatric population of Costa Rica with tuberous sclerosis and a description of the behaviour of the associated epilepsy]

INTRODUCTION

Tuberous sclerosis (TS) is a pathology with an autosomal dominant pattern of inheritance that is due to a disorder affecting cell differentiation and proliferation that produces hamartomas in different organs. Its variable forms affect the central nervous system, the kidneys, the skin and other organs. No studies have been conducted on its prevalence and behaviour in the paediatric population of Costa Rica.

AIMS

To characterise the paediatric population with TS in Costa Rica and to describe the behaviour of its epilepsy.

PATIENTS AND METHODS

The study analyses prevalence based on a review of the clinical records of all the patients under 18 years of age diagnosed with TS treated at the National Children's Hospital over the period 2000-2010. RESULTS; During the period under study a total of 37 patients were included for a prevalence of 3.09 per 100,000 live births (95% confidence interval = 1.88-4.31). No significant differences were observed according to sex. The mean age at diagnosis was 14 months. The most frequent major criteria were hypomelanotic macules (97.3%), facial angiofibromas (56%) and cortical tuberomas (54.1%). Thirty-five patients presented convulsions (95%). The treatments that achieved a reduction in the number of seizures of at least 50% were vigabatrine (16.2%) and epilepsy surgery (16.2%). CONCLUSIONS; All patients with epilepsy should be submitted to a thorough examination of the skin, since skin lesions are a very frequent finding in TS. Epilepsy in TS is pharmacoresistant in a large number of patients, and vigabatrine must be considered as first-line pharmacological treatment.

[Infant mortality from birth defects in Costa Rica, 1981-2010]

OBJECTIVE

Identify trends for different types of birth defects and their impact on infant (IMR) and neonatal (NMR) mortality rates in Costa Rica from 1981 to 2010.

METHODS

Infant, neonatal, and postneonatal mortality trends were analyzed, using data from the Central American Population Center, which uses the International Classification of Diseases, versions 9 and 10, to classify causes of death. For each group of birth defects, a Poisson log-linear regression model was constructed. IMR and NMR, relative risk, and 95% confidence intervals (95%CI) were calculated for the three decades (1981-1990, 1991-2000, and 2001-2010). Estimates were compared using Wald chi square.

RESULTS

Comparison of the 1980s and the 2000s found a significant decrease in NMR and IMR from birth defects in these decades, from 2.37 (95%CI: 2.26-2.48) to 2.13 (2.03-2.23) and from 4.13 (3.99-4.27) to 3.18 (3.05-3.31), respectively. Reduction in IMR was significant for birth defect groups for nervous, digestive, and circulatory systems. There was also a significant drop in NMR for nervous and digestive system groups. All other groups experienced a significant increase or no change.

CONCLUSIONS

IMR and NMR from birth defects have decreased, although these rates have increased proportionately due to a greater decline in other causes. This reduction is much smaller for neonatal mortality. Primary prevention and neonatal care of birth defects should be strengthened.

[Epidemiology and registry of congenital heart disease in Costa Rica]

OBJECTIVE

Characterize the population of children born with congenital heart disease (CHD) in Costa Rica and evaluate the country's registry processes.

METHODS

Exploratory observational study that included all children with CHD diagnosed at the National Children's Hospital between 1 May 2006 and 1 May 2007. Considering children under 1 year of age and their respective birth cohort, prevalence was estimated by sex, type of heart disease, age at diagnosis, maternal age, habitual residence, and associated extracardiac malformations, with 95% confidence intervals (95% CI). The data was compared with those of the Congenital Disease Registry Center (CREC).

RESULTS

During the period studied, 534 cases with CHD were diagnosed. There were 473 cases in children under 1 year of age in a birth cohort of 77 140 children. Prevalence was 0.6% (95% CI: 0.5-0.7). Based on CREC data, it was demonstrated that 71% of the cases were not detected at birth. The average age of diagnosis in infants under 1 year of age was 46.6 days. There were no differences by sex. Prevalence of CHD in children of mothers aged 35 years or over was significantly higher. However, when chromosomal abnormalities were excluded, the risk was no longer statistically significant. The provinces in the country with maritime ports were the areas with the highest risk in children of adolescent mothers. The most common CHDs were ventricular and atrial septal defects, patent ductus arteriosus, pulmonary valve stenosis, atrioventricular septal defects, coarctation of the aorta, and tetralogy of Fallot. Thirty-four percent of the cases of CHD were multiple, 11.2% were associated with chromosomal abnormalities, and 19% had associated congenital malformations.

CONCLUSIONS

CHD prevalence in Costa Rica is within the range reported globally. Significant underreporting of CHD was found in the CREC, primarily due to the age criteria applied. The results suggest that maternal age (under 20 and over 34) is a factor associated with CHD.