Fetal Alcohol Spectrum Disorder: Prevalence, Comorbidity ......Fetal Alcohol Spectrum Disorder: Prevalence, Comorbidity, and Economic Cost Presented by Svetlana (Lana) Popova, MD,

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

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)

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%

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)

25.9% 35.8%

42.0% 77.7%

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

Prevalence of Alcohol Use and Binge Drinking During Pregnancy in General Popula7on by WHO Region

and Globally, 2012

2.7% 2.8% 3.1% 1.8% 2.0%

11.2% 10.0% 8.6%

1.8% 0.2%

EUR AMR AFR WPR SEAR EMR Worldwide

bingedrinking anyamount

14.6% 17.0%

17.5% 14.4%

10.8% 11.2%

48.8% 46.0%

26.3% 24.3% 25.3%

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%

St. Lucia

raguay

Brazil†

incent and

Dominica

Argen7

Dominican

Bolivia

ua and

Belize

nd Nevis

Jamaica

Colombia

Nicaragua

Uruguay

Costa Rica

El Salvado

temala

Trinidad

Mexico†

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

3.6% 3.6%

3.3% 3.0%

2.7% 2.7%

2.7% 2.4%

2.4% 2.3%

2.3% 2.3%

2.2% 2.2%

2.0% 1.9%

1.9% 1.9%

1.9% 1.8%

1.6% 1.6%

1.5% 1.4%

1.4% 1.2%

*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)

Prevalence of FAS in General Popula7on by WHO Region and Globally, 2012

16.6 14.8

2.7 0.2

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

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)

Prevalence of FASD in General Popula7on by WHO Region and Globally, 2012

0) 198.2

87.9 78.3 67.4

14.1 1.3

EUR AMR AFR WPR SEAR EMR Global

53.3 47.5 45

South Africa* Croa7a* Ireland Italy* Belarus

Prevalen

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

Grenada

StLucia

UnitedStatesofAmerica*†

Guyana

Paraguay

Brazil

StVincentandGrenadines

Barbados

Dominica

Argentina

Bahamas

DominicanRepublic

Panama

Honduras

Bolivia

Suriname

Canada*

Venezuela

AntiguaandBarbuda

Belize

StKittsandNevis

Jamaica

Colombia

Ecuador

Nicaragua

Uruguay

CostaRica

ElSalvador

Guatemala

TrinidadandTobago

PuertoRico

Mexico

FAS FASD

Grenada

StLucia

UnitedStatesofAmerica*†

Guyana

Paraguay

Brazil

StVincentandGrenadines

Barbados

Dominica

Argentina

Bahamas

DominicanRepublic

Panama

Honduras

Bolivia

Suriname

Canada*

Venezuela

AntiguaandBarbuda

Belize

StKittsandNevis

Jamaica

Colombia

Ecuador

Nicaragua

Uruguay

CostaRica

ElSalvador

Guatemala

TrinidadandTobago

PuertoRico

Mexico

FAS FASD

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

St Lucia

raguay

Brazil

St Vincent and

Dominica

Argen7

Dominican

Bolivia

ua and

Belize

St Kijs a

nd Nevis

Jamaica

Colombia

Nicaragua

Uruguay

Costa Rica

El Salvado

temala

Trinidad

erto Rico

Mexico

FAS FASD

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

8Adoptees from Eastern Europe,

Sweden (Landgren et al.

_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.

RRural population with a

low socioeconomic status, South

Africa (de Vries et al.68)

>Children residing in an

orphanage, Brazil (Strömland et al.

3Psychiatric care population, USA

(Bell & Chimata70)

7Aboriginal population, Australia

(Fitzpatrick et al.71)

@Pre-adoption & foster care

children, Israel (Tenenbaum et al.

General population,

Globally

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)

81.8% 76.2%

69.2% 67.2%

54.5% 51.2%

77.3% 57.9%

56.8% 51.2%

54.1% 52.6%

100.0%

) otit

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

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: lana.popova@camh.ca

Fetal Alcohol Spectrum Disorder: Prevalence, Comorbidity ......Fetal Alcohol Spectrum Disorder: Prevalence, Comorbidity, and Economic Cost Presented by Svetlana (Lana) Popova, MD,

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