Fetal Alcohol Spectrum Disorder: Prevalence, Comorbidity ......Fetal Alcohol Spectrum Disorder:...
Transcript of Fetal Alcohol Spectrum Disorder: Prevalence, Comorbidity ......Fetal Alcohol Spectrum Disorder:...
Fetal Alcohol Spectrum Disorder: Prevalence, Comorbidity, and Economic Cost
Presented by Svetlana (Lana) Popova, MD, PhD, MPH
Centre for Addiction and Mental Health,
University of Toronto, PAHO/WHO Collaborating Centre
Toronto, Canada
Training on FASD Santiago, Chile
April 26-28, 2017
OVERVIEW • Prevalence of alcohol consump7on and binge drinking during pregnancy, FAS/FASD in different popula7ons of different countries (including countries of La7n America and the Caribbean), World Health Organiza7on (WHO) regions and globally.
• Es7mated global incidence of children born with FAS and FASD annually
• Co-‐morbidity • Economic cost
Fetal Alcohol Spectrum Disorder (FASD)
What is FASD? • An umbrella term describing the range of effects that can
occur in a person whose mother drank alcohol during pregnancy
What are the effects of FASD? • Physical and mental disabilities • Problems associated with behaviour and learning • Problems with memory, speech, attention, problem solving • Trouble with the law, school,
drug abuse etc. • Irreversible and lifelong FASD is preventable!
Fetal Alcohol Spectrum Disorder (FASD) is an umbrella term that covers several alcohol-‐
related diagnoses
FASD
Fetal Alcohol
Syndrome (FAS)
Alcohol- Related Neuro-
developmental Disorder (ARND)
Alcohol- Related
Birth Defects (ARBD)
Fetal Alcohol Effects (FAE)
Partial Fetal Alcohol
Syndrome (pFAS)
• Par$al FAS (some defects) • Alcohol-‐related neurodevelopmental disorder
• Alcohol-‐related birth defects • In the normal range, but never reach their poten$al (largest number of cases)
Fetal alcohol syndrome (most severe)
What are Fetal Alcohol Spectrum Disorder (FASD)?
Prevalence of Alcohol Use During Pregnancy and FAS/FASD
1) Popova S, Lange S, Probst C, Gmel G, & Rehm J (2017). Lancet Global Health 2) Lange S, Probst C, Gmel G, Rehm J, Popova S (accepted). JAMA, Pediatrics
Objec7ve: To es$mate the prevalence of alcohol use and binge drinking during pregnancy and FAS/FASD by country, WHO region, and globally
Methodology: Comprehensive Literature search: not limited geographically/language Meta-‐analyses: Pooled prevalence for countries with 2+ studies, assuming a random-‐effects model Data predic@on: For countries with one or no studies:
a) For AC: using frac$onal response regression modelling and; b) For FAS/FASD: based on the propor$on of women who gave birth to a
child with FAS/FASD among women who consumed alcohol during pregnancy
• Es$mated WHO regional and global averages of FAS/FASD prevalence weighted by the number of live births in each country
Prevalence of Alcohol Use During Pregnancy in
General Popula7on for select Countries (any amount of alcohol consumed and at any point during pregnancy)
60.4%
46.6% 45.8%
41.3% 36.5%
36.3% 35.6% 34.0%
33.1% 32.7%
30.5% 29.7% 28.3% 27.0%
26.7% 25.8%
18.5% 18.0% 15.2% 15.0% 14.8% 13.2% 13.0% 12.7%
10.6% 10.0% 10.0% 9.4% 8.1%
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Five Countries with the Highest Prevalence of Binge Drinking During Pregnancy in General Popula7on Es7mated propor7on of women who binge drank during pregnancy out of all
women who used any amount of alcohol during pregnancy (% shown on the top of bars)
17.4%
25.9% 35.8%
42.0% 77.7%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
Ireland CzechRepublic Moldova Lithuania Paraguay
bingedrinking anyamount
Prevalence of Alcohol Use During Pregnancy in General Population by WHO Region, 2012
AFR 10.0% (95% CI:8.5%–11.8%)
AMR 11.2% (95% CI: 9.4%–12.6%)
EUR 25.2% (95% CI: 21.6%–29.6%)
EMR 0.2% (0.1%–0.9%)
SEAR 1.8% (95% CI: 0.9%–5.1%)
WPR 8.6% (95% CI: 4.5%–11.6%)
AFR=African Region, AMR=Region of the Americas, EMR=Eastern-Mediterranean Region, EUR=European Region, SEAR=South-East Asia Region, WPR=Western Pacific Region
Prev
alen
ce
Prevalence of Alcohol Use and Binge Drinking During Pregnancy in General Popula7on by WHO Region
and Globally, 2012
AFR=African Region, AMR=Region of the Americas, EMR=Eastern-Mediterranean Region, EUR=European Region, SEAR=South-East Asia Region, WPR=Western Pacific Region
2.7% 2.8% 3.1% 1.8% 2.0%
25.2%
11.2% 10.0% 8.6%
1.8% 0.2%
9.8%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
EUR AMR AFR WPR SEAR EMR Worldwide
bingedrinking anyamount
10.0%
14.6% 17.0%
2.0%
7.5%
17.5% 14.4%
10.5%
0.5%
10.5%
2.0%
30.1%
10.8% 11.2%
22.3%
0.6%
16.8%
9.9%
34.5%
48.8% 46.0%
50.8%
26.3% 24.3% 25.3%
60.5%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
Prevalence of Alcohol Use During Pregnancy in Canada
(any amount, and at any point during pregnancy)
(Range: 0.5% to 30.1%) (Range: 24.3% to 60.5%) General Population Northern Communities
Prevalence of Any Amount of Alcohol Use During Pregnancy in General Popula7on of La7n America
and the Caribbean in 2012 • Lange, Probst, Heer, Roerecke, Rehm, Monteiro, Shield, de
Oliveira & Popova. In press. Rev Panam Salud Publica [Pan American Journal of Public Health]
• Data from published studies on the prevalence of alcohol consump7on during pregnancy were available from 5 of the 33 countries in La7n America and the Caribbean:
• Brazil [n=17], Chile [n=2], Guatemala [n=1], Mexico [n=3], and Uruguay [n=1]; no studies from the Caribbean.
• Meta-‐analysis for Brazil and Mexico, based on the criterion of three available studies per country.
• The prevalence of alcohol consump7on during pregnancy was predicted for 31 countries.
23% 22%
18% 18%
15% 15% 15% 15% 15% 13% 13% 12% 12% 12%
11% 11% 11% 10% 10% 10% 10% 10% 9% 9% 9% 9% 9% 8% 8% 7%
6% 5%
1%
10%
0%
5%
10%
15%
20%
25%
Grena
da
St. Lucia
Guyan
a Pa
raguay
Brazil†
Hai7
St. V
incent and
Grena
dine
s Ba
rbad
os
Dominica
Argen7
na
Peru
Dominican
Rep
ublic
Baha
mas
Pana
ma
Chile
Hond
uras
Bolivia
Surin
ame
Vene
zuela
An7g
ua and
Barbu
da
Belize
St. K
ijs a
nd Nevis
Jamaica
Colombia
Ecua
dor
Nicaragua
Uruguay
Costa Rica
El Salvado
r Gua
temala
Trinidad
and
Tob
ago
Cuba
Mexico†
Globa
l
Lange, Probst, Heer, … & Popova. In press. Rev Panam Salud Publica
Prevalence of Any Amount of Alcohol Use During Pregnancy in General Popula7on of La7n
America and the Caribbean in 2012
†Es7mate of alcohol use (any amount) during pregnancy based on a meta-‐analysis of the current literature
Prevalence of Any Amount of Alcohol Use During Pregnancy in General Popula7on of La7n America and the Caribbean in 2012
Lange, Probst, Heer … & Popova. In press. Rev Panam Salud Publica
13.9%
6.7%
3.6% 3.6%
3.3% 3.0%
3.0%
2.7% 2.7%
2.7% 2.4%
2.4% 2.3%
2.3%
2.3% 2.3%
2.2% 2.2%
2.0%
2.0% 1.9%
1.9% 1.9%
1.9% 1.8%
1.6% 1.6%
1.5%
1.5% 1.4%
1.4% 1.2%
1.2%
2.8%
0%
2%
4%
6%
8%
10%
12%
14%
16%
*Es7mate of binge drinking during pregnancy based on a meta-‐analysis of the current literature
Prevalence of Binge Drinking During Pregnancy in General Popula7on of La7n America and the
Caribbean in 2012
Prevalence of Alcohol Use During
Pregnancy (cont’)
• Alcohol consump7on during pregnancy is a significant public health concern worldwide and an established cause of FASD
• FASD is theore7cally, largely preventable • However, globally, FASD may increase in the near future due
to two reasons: 1) the rates of alcohol use, binge drinking and drinking during pregnancy appear to be increasing among young women in a number of countries; and 2) a vast majority of pregnancies are unplanned
Prevalence of FAS/FASD in General Popula7on Flow chart for systema7c literature search on prevalence of FAS/FASD
11,089 records iden$fied through database searching
21 addi$onal records iden$fied through other sources
11,110 records found 5,145 duplicates removed
5,965 records screened
430 full-‐text ar$cles assessed for eligibility
368 full-‐text ar$cles excluded; lack of relevant data or did not meet
the inclusion criteria
62 ar$cles iden$fied as including relevant data from 19 countries [African Region (South Africa, 9 studies), European
Region (Croa$a, 2 studies; Denmark, 1 study; France, 7 studies; Germany, 1 study; Ireland, 1 study; Italy, 3 studies; Netherlands, 1 study; Portugal, 1 study; Spain, 1 study; Sweden, 2 studies; Switzerland, 1 study; and United
Kingdom, 3 studies), Region of the Americas (Canada, 2 studies; United States, 24 studies; and Uruguay, 1 study), and Western Pacific Region (Australia, 7 studies; New Zealand, 1
study; and Republic of Korea, 1 study)]
5,535 records excluded
Prevalence of FAS in General Popula7on by WHO Region, 2012
SEAR 2.7 per 10,000 (95% CI: 1.3–8.1 per 10,000)
EUR 37.4 per 10,000 (95% CI: 24.7–54.2 per 10,000)
AFR 14.8 per 10,000 (95% CI:8.9–21.5 per 10,000)
EMR 0.2 per 10,000 (0.2–0.9 per 10,000)
WPR 12.7 per 10,000 (95% CI: 7.7–19.4 per 10,000)
AMR 16.6 per 10,000 (95% CI: 11.0–24.0 per 10,000)
AFR=African Region, AMR=Region of the Americas, EMR=Eastern-Mediterranean Region, EUR=European Region, SEAR=South-East Asia Region, WPR=Western Pacific Region
Prevalence of FAS in General Popula7on by WHO Region and Globally, 2012
Prev
alen
ce (p
er 1
0,00
0)
37.4
16.6 14.8
12.7
2.7 0.2
14.6
0
5
10
15
20
25
30
35
40
EUR AMR AFR WPR SEAR EMR Worldwide
AFR=African R, AMR=R of the Americas, EMR=Eastern-Mediterranean R, EUR=European R, SEAR=South-East Asia R, WPR=Western Pacific R
0.15%
Prevalence of FASD in General Popula7on by WHO Region, 2012
AMR 87.9 per 10,000 (95% CI: 57.5–113.4 per 10,000)
SEAR 14.1 per 10,000 (95% CI: 4.0–33.6 per 10,000)
EUR 198.2 per 10,000 (95% CI: 119.1–252.6 per 10,000)
AFR 78.3 per 10,000 (95% CI:44.8–107.0 per 10,000)
EMR 1.3 per 10,000 (0.9–5.7 per 10,000)
WPR 67.4 per 10,000 (95% CI: 31.6–95.1 per 10,000)
AFR=African Region, AMR=Region of the Americas, EMR=Eastern-Mediterranean Region, EUR=European Region, SEAR=South-East Asia Region, WPR=Western Pacific Region
Prevalence of FASD in General Popula7on by WHO Region and Globally, 2012
Prev
alen
ce (p
er 1
0,00
0) 198.2
87.9 78.3 67.4
14.1 1.3
77.3
0.0
50.0
100.0
150.0
200.0
250.0
EUR AMR AFR WPR SEAR EMR Global
AFR=African Region, AMR=Region of the Americas, EMR=Eastern-Mediterranean Region, EUR=European Region, SEAR=South-East Asia Region, WPR=Western Pacific Region
0.77%
2%
111.1
53.3 47.5 45
36.6
0
20
40
60
80
100
120
South Africa* Croa7a* Ireland Italy* Belarus
Prevalen
ce (p
er 1,000
)
Five Countries with the Highest Prevalence of FASD in the General Popula7on
*Based on actual data
Prevalence of FAS and FASD in La7n America and the Caribbean in 2012
0
2
4
6
8
10
12
14
16
18
20
Grenada
StLucia
UnitedStatesofAmerica*†
Guyana
Paraguay
Brazil
Haiti
StVincentandGrenadines
Barbados
Dominica
Argentina
Peru
Bahamas
DominicanRepublic
Panama
Honduras
Bolivia
Chile
Suriname
Canada*
Venezuela
AntiguaandBarbuda
Belize
StKittsandNevis
Jamaica
Colombia
Ecuador
Nicaragua
Uruguay
CostaRica
ElSalvador
Guatemala
TrinidadandTobago
Cuba
PuertoRico
Mexico
FAS FASD
0
2
4
6
8
10
12
14
16
18
20
Grenada
StLucia
UnitedStatesofAmerica*†
Guyana
Paraguay
Brazil
Haiti
StVincentandGrenadines
Barbados
Dominica
Argentina
Peru
Bahamas
DominicanRepublic
Panama
Honduras
Bolivia
Chile
Suriname
Canada*
Venezuela
AntiguaandBarbuda
Belize
StKittsandNevis
Jamaica
Colombia
Ecuador
Nicaragua
Uruguay
CostaRica
ElSalvador
Guatemala
TrinidadandTobago
Cuba
PuertoRico
Mexico
FAS FASD
18.4
17.2
14.3 14.1
12.0 11.7
11.7 11.5
11.5 10.2
9.8 9.5
9.5 9.2
8.4 8.3
8.3 8.0
7.8 7.6
7.5 7.5 7.4 7.1 7.0 7.0 6.9 6.5 6.5 5.1
4.4 3.8
2.7
1.0
7.7
0
2
4
6
8
10
12
14
16
18
20
Grena
da
St Lucia
Guyan
a Pa
raguay
Brazil
Hai7
St Vincent and
Grena
dine
s Ba
rbad
os
Dominica
Argen7
na
Peru
Baha
mas
Dominican
Rep
ublic
Pana
ma
Hond
uras
Bolivia
Chile
Surin
ame
Vene
zuela
An7g
ua and
Barbu
da
Belize
St Kijs a
nd Nevis
Jamaica
Colombia
Ecua
dor
Nicaragua
Uruguay
Costa Rica
El Salvado
r Gua
temala
Trinidad
and
Tob
ago
Cuba
Pu
erto Rico
Mexico
Globa
l
FAS FASD
Prev
alen
ce (p
er 1
,000
)
Global Incidence of FAS and FASD
Fetal Alcohol Syndrome • Globally, one out of 67 women who consume alcohol during pregnancy in the general popula7on delivered a child with FAS, which translates to about 119,000 children born with FAS in the world each year
Fetal Alcohol Spectrum Disorder • One out of 13 pregnant women who consumed alcohol while pregnant delivered a child with FASD
• Over 1,700 cases of FASD are born every day • 630,000 cases of FASD are born every year globally
521.13
285.19 233.45
189.66 182.4 170.21 142.39 120.37
40 7.73
0.0
100.0
200.0
300.0
400.0
500.0
600.0
8Adoptees from Eastern Europe,
Sweden (Landgren et al.
64)
_Foster and adopted youth referred to a
children’s mental health centre,
USA (Chasnoff et al.65)
/Correctional population,
Canada (Fast et al.66)
1Aboriginal population,
Canada (Robinson et al.
67)
RRural population with a
low socioeconomic status, South
Africa (de Vries et al.68)
>Children residing in an
orphanage, Brazil (Strömland et al.
69)
3Psychiatric care population, USA
(Bell & Chimata70)
7Aboriginal population, Australia
(Fitzpatrick et al.71)
@Pre-adoption & foster care
children, Israel (Tenenbaum et al.
72)
General population,
Globally
Prev
alen
ce (p
er 1
,000
)
As compared to the global FASD prevalence among the general popula7on: 5 to 68 7mes higher among children in care 16 to 25 7mes higher among Aboriginal popula7ons 19 7mes higher among a psychiatric care popula7on 24 7mes higher in a low socioeconomic status popula7on 30 7mes higher in a correc7onal popula7on
Comparison FASD prevalence among special popula7ons, based on select studies, to the global prevalence among the general popula7on
INTRODUCTION Comorbidity of FASD
• FASD is related to numerous comorbidities due to the permanent effects of prenatal alcohol exposure on the fetus
• However, the existing comorbid conditions and their prevalence among individuals with FASD remained to be established Popova, S., Lange, S., Shield, K., Mihic, A., Chudley, A. E., Mukherjee, R. A. S., Bekmuradov, D., & Rehm, J. (2016). Comorbidity of fetal alcohol spectrum disorder: a systematic review and meta-analysis. The Lancet, 387, 978-8. DOI: http://dx.doi.org/10.1016/S0140-6736(15)01345-8.
OBJECTIVES
• The objectives of the current study were to: 1) Identify the comorbid conditions that occur among individuals with FASD, and 2) Estimate the pooled prevalence of comorbid conditions found to occur among individuals with FAS
• The latter objective was limited to FAS because FAS is the only expression of FASD in the International Classification of Diseases (ICD):
• ICD, version 9 – Alcohol affecting foetus or newborn via placenta or breast milk - 760.71
• ICD, version 10 – Fetal alcohol syndrome (dysmorphic) - Q86.0
METHODS
• A systematic literature search was performed in multiple electronic bibliographic databases in order to locate original published studies that reported on the comorbidity among individuals with diagnosed FASD • The search was not limited geographically • All comorbid conditions were coded according to the ICD-10 • Meta-analyses were performed, assuming a random-effects model
Systematic Literature Review
RESULTS
Systematic Literature Review Additional records identified
through other sources (n = 52)
Records excluded (n = 2,625)
Full-text articles excluded; lack of relevant
data/did not meet the inclusion criteria
(n = 172)
Studies included in quantitative synthesis (meta-analyses; n = 33)
Canada (6); Germany (4); Ireland (1); Italy (1); Norway (1); Portugal (1); Scotland (1); South Africa
(3); Sweden (3); USA (12)
Full-text articles assessed for eligibility
(n = 299)
Duplicates removed (n = 2,144)
Articles included in qualitative synthesis
(n = 127)
Records screened (n = 2,924)
Records identified through database searching
(n = 5,016)
RESULTS (Con’t)
• 428 comorbid conditions, spanning across 18 (out of 22) chapters of the ICD-10
• The most prevalent disease conditions were:
- Congenital malformations, deformities and chromosomal abnormalities (Q00-Q99; Chapter XVII), and
- Mental and behavioural disorders (F00-F99; Chapter V)
Systematic Literature Review
RESULTS (Con’t) Percentage of conditions found to occur among individuals with FASD by ICD-10 chapter
RESULTS (Con’t)
Meta-analyses • 33 studies reported data on frequency of at least one disease condition and were eligible to be included in the meta-analyses • Contained 1,728 subjects with diagnosed FAS • Reported frequencies for 183 comorbid conditions coded in ICD-10 • In order to estimate pooled prevalence, 183 meta-analyses were performed; one for each comorbid condition found to occur among individuals with FAS
Comorbid conditions with a pooled prevalence over 50% among individuals with FAS
Mental and behavioural disorders (F00-F99)
Congenital malformations,
(Q00-Q99) Diseases of the eye
and adnexa (H00-H59)
Diseases of the ear and mastoid process
(H60-H95)
Certain conditions originating in the perinatal period
(P00-P99)
90.7%
81.8% 76.2%
69.2% 67.2%
54.5% 51.2%
71.4%
61.9%
77.3% 57.9%
56.8% 51.2%
72.2%
65.3%
54.1% 52.6%
50.0%
90.9%
50.0%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Con
duct
/beh
avio
ural
pro
blem
s/di
srup
tive
beha
viou
r/im
puls
ivity
(F91
)
Rec
eptiv
e la
ngua
ge d
efic
it (F
80.2
)
Expr
essi
ve la
ngua
ge d
efic
it (F
80.1
)
Dev
elop
men
tal/c
ogni
tive
diso
rder
; de
velo
pmen
tal d
elay
(s) (
F89)
Spee
ch/la
ngua
ge d
elay
/dis
orde
r/ret
arde
d sp
eech
dev
elop
men
t/spe
ech
defe
cts/
acqu
isiti
on (F
80.9
) A
lcoh
ol d
epen
denc
e/dr
ug d
epen
denc
e (F
10.2
/F19
.2)
Atte
ntio
n de
ficit
hype
ract
ivity
dis
orde
r/at
tent
ion
defic
it di
sord
er (F
90.0
)
Ref
ract
ive
erro
r(s)
(H52
.6)
Subn
orm
al/d
ecre
ased
vis
ual a
cuity
/pr
oble
ms/
visu
al im
pairm
ent (
H54
)
Chr
onic
/recu
rren
t (se
rous
) otit
is m
edia
(H
65.2
)
Cen
tral
hea
rdin
g di
sord
er (H
90.5
)
Con
duct
ive
hear
ing
loss
(H90
.2)
(Acu
te/s
erou
s/se
rous
muc
ous)
otit
is m
edia
(H
65.0
)
Intr
aute
rine
grow
th re
tard
atio
n (P
05.9
)
Pre-
mat
ure
birt
h/bo
rn p
rem
atur
ally
/pr
eter
m b
irth
(P07
.3)
Coc
cyge
al fo
vea
(Q14
.1)
Con
geni
tal f
usio
n of
cer
vica
l ver
tebr
ae/
cerv
ical
spi
n fu
sion
(Q76
.4)
Hyp
erte
loris
m (Q
75.2
)
Abn
orm
al re
tinal
func
tion
- ER
G re
cord
s (R
94.1
)
Failu
re to
thriv
e (R
62.8
)
Symptoms, signs and abnormal clinical and lab findings (R00-R99)
RESULTS (Con’t) Pooled prevalence of comorbid conditions in individuals with
FAS vs the general population of the USA
FAS General population
9.5 times 10.3
times 11.1
times 77.0
times 97.5 times
5.6 times
31 times
128.7 times
126.2 times
4.4 times
7.6 times
Productivity Losses Due to Morbidity and Mortality
42.2%
Health Care10.2%
Corrections30.0%
Children in Care4.7%
Supportive Housing1.8%
Long-term Care6.2%
Special Education4.3%
Prevention and Research0.6%
$378.3 M $532 M - $1.2 B
$128.5 M-$226.3 M
Popova et al. (2015). Available at: http://www.camh.ca/en/research/Pages/research.aspx
Percentage of main cost components attributable to FASD in Canada in 2013
Total annual cost: $1.3 B - $2.3 B
Cost of FASD in Canada
Popova et al (2012) Journal of Population Therapeutics and Clinical Pharmacology, Incorporating Fetal Alcohol Research, 19(1), e51-e65. Available from http://www.jptcp.com
If Not Now, When?
• The presented data will raise awareness of harmful effects of PAE and draw attention to the need for screening and early diagnosing
• Improving screening and diagnosis would promote access to interventions and resources that may subsequently reduce burden and cost
• The harmful effects of alcohol on a fetus, representing many cases of preventable disability, should be recognized globally as a large public health problem. The presented results clearly demonstrate the need for such recognition
This work was supported by the Public Health Agency of Canada
Many people worked on these
projects!
ACKNOWLEDGEMENTS
CONTACT INFORMATION
Svetlana (Lana) Popova Senior Scientist, Associate Professor Social & Epidemiological Research Department Centre for Addiction & Mental Health, University of Toronto, WHO Collaborating Centre 33 Russell Street, room T507 Toronto, Ontario, Canada M5S 2S1 Tel. (416) 535-8501 ext. 34558 e-mail: [email protected]