Januari 11, 2017
good afternoon or morning orevening, depending on where and when you're listening to thissession. i'm dr. john iskander.welcome to public health's grand rounds.continuing education credits are available for physicians,nurses, pharmacists and health professionals.please see more at the grand rounds web site.grand rounds is also available on all of your favorite web andsocial media sites. we have a featured video segmentcalled beyond the data on
youtube.we're also live-tweeting today use hash tag cdc grand roundsfor all of your tweeting needs. we're happy to help share in theobservance of january, which is national birth effectsprevention month. the theme for the year is makinghealthy choices to prevent birth defects by making a pact forprevention. new and ongoing research can belocated in current and upcoming mmwr articles as well as accessto state level data at the web sites listed here.so it's now awards season in the
entertainment industry.i'm happy to recognize today's stars as well as the numeroustalented individuals listed who have credited to this session.i'd like to give a special acknowledgement to peggy honoreand regina simeone. we've partnered to featurescientific articles relevant to this session.the full listing is available at cdc.gov/scienceclips.for those of you who turned in last no to our session onclimate change and health we wanted to share these key latebreaking points with you.
2014 was, again, the hottestyear on record. here is a preview of upcominggrand round sessions. please join us live on theweb at your convenience. it's now my pleasure tointroduce dr. ileana arias principal director of cdc.thank you, dr. arias for joining us.>> good afternoon. welcome to today's veryimportant and important for us grand rounds.about 1 in 33 babies is born with a birth defect in theunited states.
that means that every year about120,000 babies are born with birth defect.and, as was pointed out in the video, that means every 4 1/2 minutes we have a baby born inthis country with a birth defect.that's unacceptable. birth defects can occur in anyfamily regardless of race, health history, economic statusand level of education. we know that most birth defectsdevelop during the first weeks of pregnancy, which iscritically important to
recognize because that meansthat planning for a pregnancy and taking steps beforepregnancy is incredibly important for primaryprevention. unfortunately, we also know thatnot all birth defects can be are prevented, but we do knowthere's some actions that can be taken before pregnancy toincrease a woman's chance of having a healthy baby.for example, two of the most important ones are quittingsmoking and taking a folate supplement.it's something we've known,
something we communicate widelyand something we have heard. although it seems obvious to us,we still know 1 out of 10 women smoke sometime during pregnancy.we know some medications cause birth defects.we're working on alternatives to use during pregnancy.it's not only about personal choices that individual womencan make in order to prevent birth defects.we have begun to identify critical and commonenvironmental exposures that increase women's risk of havinga child born with a birth
defect.and further, we are seeking to better understand other lesscommon but equally impactful exposures.with our partners we're working together to identify the causesof birth defects and importantly to find opportunities forpreventing them and improving the health of individuals of allages living with health defects. we're committed to broadlycommunicating science to health care providers and the public sothey can act to protect patients and themselves using events suchas the public health grand
rounds today.today we're going to hear how public health experts arefurthering our understanding of the causes of major birthdefects, their impact on our communities, and, especiallyimportant, what it is we can do to ensure safe and healthypregnancies for all women. i would like to thank all of ourpresenters today and welcome them to atlanta, our visitors,and look forward to the wonderful presentations we'reabout to hear. [ applause ]>> our first speaker today is
dr. marcia feldkamp.>> thank you. good afternoon.the children you see here and throughout the session arefeatured in a powerful video involving utah parents and theirchildren with birth defects along with the national birthdefect prevention network. i will talk briefly about theimpact of birth defects and our current understanding of theircauses. the term birth defect also knownas congenital malformation or abnormality.is an abnormality present at
birth.a birth defect may be clinically obvious at birth or may bediagnosed in infancy, childhood or later in life.there are two main categories of birth defects.first are functional defects, developmental -- metabolicconditions such as pku or sickle cell.or there's major and minor malformations.major include any structural abnormal with surgical, cosmeticor medical importance or minor birth defects are thosestructural abnormalities without
any surgical, cosmetic ormedical situations. so today we're going to talkabout major malformations. major birth defects, as wasmentioned, are common occurring in 1 of every 33 babies or 3% ofbirths, resulting in an estimated 120,000 affectedbabies per year in the united states.by 5 years of age, 1 in 20 children will be diagnosed witha birth defect. shown here, congenital heartdefects is the largest group, approximately one-quarter of allbirth defects.
this figure shows threedifferent hearts. on the left is an image of anormal heart. in the center, this figureillustrates hypoplastic left heart syndrome.on the right, transposition of the great arteries.heart defects vary in their level of severity.those of these heart defects would require surgery in thefirst year of an infant's life. spina bifida affect the brainand spinal chord that occur early in pregnancy.serious birth defects of the
abdominal wall include two maintops. on the left is gastroschisis iswhere some of the organs are outside of the abdominal cavityusually on the right side of the membrane. on right, the organs are outsideof the and abdomen but covered by membrane.birth defects are costly. the average daily hospitalcharges per newborn based on the average stay and average chargesfor uncomplicated birth represented for an infantwithout a birth defect at the
top of the figure compared toten different types of birth defects.however, it is important to keep in mind these charges do notreflect the medical cost to the family after the newborn period.based on 2004 data, an estimated 2.6 billion u.s. dollars arespent annually to care for infants, children and adultswith a birth defect. medical care and technologyimproved the long-term survival of children born with birthdefects. other costs are the financialimpact when only one parent is
able to work or a parent'smissed days at work to care for a child or the impact on otherchildren within the family. we don't understand the cost ofthe child affected and their family's emotional well-being.these associated costs are important and require moreresearch. birth defects with critical,representing the leading cause of infant mortality.for every 1,000 babies born in the u.s. in 2011, seven diedduring their first year of life. of these, 20% or about 1 inevery 5 infant deaths will be
due to a birth defect.again, congenital heart defects represent the largest birthdefect group among infant deaths.infant mortality was higher than -- sudden infant death oraccidents. the causes of birth defects areconsidered complex with both genetic and environmentalfactors playing a role. we know that birth defects occurearly in pregnancy. often before a woman knows she'spregnant. for most birth defects there isa critical time period in organ
development when these occur.the process for many of these organs are likely patternedduring the first 14 days after conception, as early as 14 daysafter conception the brain, spinal cord, circulatory, heartsystems begin to develop. most organ development iscompleted by eight weeks but some are complete a couple ofweeks later and others such as the brain continue to developthroughout the pregnancy. because organ development beginsafter conception, the critical time period for all women toreduce their risk is before they
become pregnant.for example, in order to reduce risk of -- completed by 28 days.folic acid has been a very effective strategy because itincreases foe late levels in women.however, because women may not consume enough fortified grainseach day, it's important for women in their child bearingyears to take a multivitamin with folic acid.monitoring the prevalence of birth defects is important tounderstand if they're increasing over time.based on prevalent data in 11
years, the overall gastroschisishas improved, mothers younger than 20 show the biggestincrease. it suggests that one or morefactors are increasing in the environment.continuing to investigate environmental factors is veryimportant. though great advances have beenmade to improve medical care among children born with birthdefects we still don't understand the cause of themajority of birth defects. in utah, we recently completed astudy based on data from the
population date statewidesystem. from 2005 to 2009, 6500 caseswere re-reviewed representing an overall percentage of majorbirth defects in utah at 2.1%. this figure is lower thanexpected because not only major birth defects were monitoredduring the time period. among these, 77% of babies bornwith at least one major birth defect did not have anidentifiable cause. less than 1% of the cases weredue to a known teratogen. most of the them diabetes.because the most recent data
suggests that the majority ofbirth defects do not have an identifiable cause, our workmust focus on the 77% of babies born with a birth defect.to do this, we must systematically monitor all birthdefects in the united states to understand their frequency andwhether or not they're increasing in the population.we must also investigate both the modifiable and nonmodifiableenvironmental factors to which women are exposed.birth defects are common, costly and critical.we need to improve our
understanding of birth defectsso we may help reduce the risk for all and improve lives.thank you. our next speaker isdr. jennita reefhuis. good afternoon.today i will talk to you about cdc funded case control studiesof birth defects. you can study rare outcomes suchas birth defects using cohort studies which provideperspective exposure information but you need a very large and avery expensive study to ascertain sufficient cases.doing data linkage studies is
cost efficient however creatingthe linkage can be challenging and diagnostic information is itnot always sufficient. pregnancy registries are usefulfor effects of medications but are not population based.case control studies are efficient and often contain highquality diagnostic data giving us power to look at the specificbirth defects instead of those overall.the challenge is the overall number of specific cases issmall requiring many years of data, there is the potential forrecall bias.
the national birth defectsprevention study or nbdps is a population study of birthdefects that included births from 1997 through december 2011.cases were identified from state based birth defects surveillancesystem in ten states. the total birth populationduring this period was approximately 6 million births,more than 48,000 case pregnancies were identified.case pregnancies had at least one of the more included 30defects and life-born controls were ascertained from birthhospitals or vital records.
mothers participated in aninterview on a range of topics and more than 44,000 womentaken. it's so far resulted in 200 peerreviewed manuscripts. data from the nbdps determinedthe -- also for non-heart defects we observed other ratios.we also started asking about stressful life events in 2006.the data indicates there could be an association of neural tubeeffects and stressful events during pregnancy.over one-third of the papers so far have assessed medicationsduring early medication.
one is opioid medication wheredata confirmed an association with heart defects such as hypoplastic left heart syndrome and spina bifida and some otherdefects. often maternal disease inpregnancy needs to be treated. treating fevers is important asstudies show fever to be associated with some birthdefects. but it is important to do arisk/benefit assessment of medications to make sure thebenefits outweigh the risks one of our goals is to definebenefit risks for certain
medications for diseases tooffer women and health care providers guidance.we have looked at different ssris and antibacterial usedby women reporting a urinary tract infections.both offer treatments. to use antibacterials,colleagues wanted to estimate the association of differentclasses of antibacterials and selected birth defects.here i'm presenting some of the results looking at specificgroups of birth defects and different classes of anantibacterials.
you can see the associationbetween an antibiotic class and birth defect differs with eachbirth defect and medication class.one approach that the birth effect branch has taken is thetreating for two initiative, better research, reliableguidance and informed decisions. we aim to expand research tofill knowledge gaps, to evaluate evidence, to develop reliableguidance and support decision making among prescribers,pharmacists, and patients and consumers.we really wanted to continue to
explore modifiable risk factorssuch as medications. there is a continued need forresearch into medications because pregnant women are notincluded in premarketing medication trials for newmedications, which are constantly introduced.in addition, existing medication could be used for newindications. an example is the antiepilepticdrug associated with cleft lip, which is now used for weightloss. we know obesity is also involvedin birth defects.
antiepileptics are now beingused to treat migraines. knowing the dosage has gottenmore important since different indications require differentdoses. the changes were extensiveenough to warrant a new name. the birth defect study.we reduces the number of included defects to 17 byfocusing on severe defects that are more common and defectsconsistently ascertained across study stops.this is a collaboration between seven centers.we started it with births
starting january 1, 2014, and wewill focus or questions on the first trimester of pregnancy.another area we are focusing on is maternal chronic disease.we wanted to explore how many mothers of babies with birthdefects are cancer survivors or have under gone organ or tissuetransplants. the numbers will be small, butwe want to explore how many women report it.we also want to focus on increaseincreasing prevalence such as asthma and autism.asthma has increased among
women.we saw evidence between asthma medication and birth defects.we're also looking at diabetes and mental health disorders suchas depression. for all our findings it'simportant they get replicated. confirmation in an independentstudy sample is needed. for instance, we do now knowthat smoking causes -- therefore, we need to continuesmoking cessation products. other risks is a treatment foracme and thalidomide one to treat multiple myeloma.we are able to assess the impact
we can have by eliminating anunnecessary exposure such as smoking or substituting onemedication with another. as you think through theseassociations and how they might affect your patients or yourfamily, it is very important to remember that 1 in 33pregnancies are affected by birth defects.cdc's birth defect branch and collaborators will continue tocollaborate and really focus on clarifying the risk/benefit ofmedications and whether safer treatment options might beavailable.
thank you.our next speaker is dr. allen mitchell.[ applause ] good afternoon.today i am speaking on behalf of the vaccines and medications inpregnancy surveillance system or vampss.over the past four decades, exposure to medications inpregnancy has been increasing both in the mean number ofpregnant women taking any medication and the proportion ofwomen taking four or more medications at any time or inthe first trimester of
pregnancy.medications whose use in pregnancy has increased inrecent years include selective serotonin reuptake inhibitorsand those for adhd. these are markers that warrantparticular attention, our focus is on preparedness on how tomonitor safety during widespread uptake of vaccines ormedications in response to a public health emergency.for the purposes of birth defects prevention, we need tofocus on medications and vaccines for which trendsdocument increasing use in
pregnant women and wherepregnancy exposure is common but data on pregnancy risk andsafety are insufficient. the safety of medication andvaccines in pregnancy is largely unknown because pregnant womenare exclusively left out of trials.medications and vaccines to adverse pregnancy effects suchas birth defects is unknown. however, use of medications andvaccine that's may be harmful during pregnancy is usuallyavoidable. since 2004, the cdc advisorycommittee has recommended that
pregnant women receive influenzavaccine regardless of vie trimester.safe thank you must be monitored.data from the vamps program show the prevalence of exposure toany type of influenza vaccine by year of last menstrual period.prevalence of exposure to the flu shot has increased steadilysince 2005, with 18% of pregnant women exposed in that year and54% of women exposed in 2013. the exception was a largeincrease in uptake in response to the 2009/2010 h1n1 pandemic.again from the vampss data, use
of antivirals also increasedduring the pandemic in 2009/2010.given antigen adrift that has been observed in ahn 32 andconcerns that this may reduce the effectiveness of thevaccine, we may well see increased use of influenzaantivirals for the 2014-15 season.vaccination in pregnancy is recommended to prevent otherillnesses such as pertussis in the offspring.along with increase of pertussis outbreaks since 2011, there hasbeen a corresponding increase in
acellular pertussis use amongpregnant women. in order to learn about therisks and relative safety of pregnancy of new exposures suchas vaccines, drugs and biologics, we need to have asystem in place that's agile in its ability to identify andstudy new products. vamps is a unique systemdesigned specifically to assess the risks and safety of vaccinesand medications that are used in pregnancy.there is a particular focus on those vaccines and medicationsthat are newly introduced into
the pregnant population.funding comes from both federal sources including cdc andpharmaceutical manufacturers. funders are not directlyinvolved in the conduct of vamps studies.vamps is able to identify the wide range of relatively commonadverse pregnancy outcomes, importantly, it also has thepower to evaluate specific birth defects.vamps targets new and old drugs and vaccines that arerecommended for use in pregnancy or that may come into use duringpregnancy.
these include products beingused for purposes or in populations other than those forwhich they were approved, including use in pregnant women.among vaccines currently recommended for use in pregnancyare annual influenza vaccines and dtap.should an ebola vaccine be marketed, it would easily beincluded under vamps surveillance.of critical importance, vampss can direct focus on newexposures within only several months' time.vamps is a collaboration among
the american academy of asthma,allergy and immunology and two research arms.a pregnancy cohort operated by the organization of teratologyresearch center at the university of california sandiego and a case control study operated by our sloanepidemiology center at boston university.it also includes an independent advisory committee compromisedof members from the cdc, national institute of childhealth and human development, the national institute ofallergy and infectious diseases,
the american congress ofobstetricians and gynecologists and a consumer representativeand biostatistician. they review the data andprovides suggestions and guidance for analysis andinterpretation. additionally, the advisorycommittee helps to ensure rigor and independence of data moontouring. of the two research arms, otisprovides the prospective cohort, a north american widenetwork of university or hospital based services inexistence since 1979.
specialists provide riskcounseling to 80 to 100,000 pregnant women and health careproviders each year. the network can screen callersfor a geographically diverse area to those exposed to avaccine of interest as opposed to an uncomparisison group.to a coordinating center, three cohorts are concurrentlyrecruited, an exposed cohort, a diseased match cohort andhealthy unexposed cohort. each is followed for birthdefects over all, preterm birth, growth and spontaneousabortion.
all three groups receivemultiple maternal structured telephone interviews at standardtime points. women's medical records are alsoreviewed. in some studies, specializedphysical examination, developmental follow-up areconducted. maternal interviews and medicalrecords review provide detailed information on dose, timing,duration of medication and vaccine exposure as coded by thesloan drug dictionary. maternal disease or indicationfor medication, pregnancy
history, health history anddemographic factors and importantly a wide range ofpotential confounders including other medications,body mass index, tobacco alcohol and vitamin and mineral use.the other research arm is case control surveillance provided bythe birth defects study initiated in 1976 at the sloanepidemiology center. its objectives are to identifyrisks and safety of the wide range of medications andvaccines with respect to the wide range of specific birthdefects to establish ranges of
safety for various specificmedications and to identify rates of exposure to specificagents. case infants are infants bornwith specific major malformations, control infantsare those born without malformations.we have a multicenter including selective hospitals in greatermetropolitan boston, philadelphia, san diego, andnashville. it also includes state birthdefect registries in massachusetts and new yorkstate.
mothers are interviewed withinsix months of delivery by trained study nurses, interviewsconducted by phone using a computer assisted telephoneinterview. data collected in the interviewinclude demographic and reproductive factors such asage, occupation, et cetera. use of any and all medications,vaccines, vitamins and minerals supplements.all of these are coded again by sloan drug dictionary making acommon coding platform. indication for use of each drugis also captured.
in addition to these factors,the interview elicits information on a wide range ofpotential confounders such as smoking, alcohol and diet.vampss has conducted studies examining vaccine risks duringthe pandemic h1n1 influenza response.anticipating a pandemic caused by the h1n1 influenza andwidespread exposure to the vaccine 2009-10 by pregnantwomen, barda, a part of dhhs, requested that vamps monitor therisks and relative safety of the pandemic h1n1 vaccine andanti-influenza drug.
vampss was easily able to meet the objective.of note, any major signal would likely have been detected priorto the first presentation of data to the vamps advisorycommittee, which occurred only a few months after the commissionof the season. the cohort arm considered manyadverse outcomes. for birth defects in theaggregate, it found no increase in risk.the case control arm was powered to consider risks related tospecific birth defects found no
evidence of risks for virtuallyall defects studied. and for some, the effort matswere sufficiently stable to suggest relative safety.we don't know which infectious threat will emerge next.pregnant women may be at high risk for disease complicationswhich endanger their pregnant pregnancies.drugs, vaccines or other products may be used in pregnantwomen with little or no prior study.vamps is proven to work in monitoring safety of emergencycounter measures in pregnant
women and on short notice.vamps represents a key tool to maintain confidence amongproviders and the public alike that preventive measures areindeed being monitored. thank you, and our final speakeris suzanne gilboa. [ applause ]>> good afternoon. i will be sharing with you oneclear success story about the prevention of birth defects aswell as some of our current work to estimate the impacts that wemight be able to have in the future.the story of folic acid
fortification is considered ahuge public health achievement. randomized controlled trials andobservational studies demonstrated folic acid intakecould protect against neural tube defects.based on this knowledge, in 1992, the united states publichealth service issued a recommendation that all women ofchild bearing potential consume 400 micrograms of folic aciddaily. in 1998, enriched cereal grainproducts were required to be fortified and ready to eatcereals were allowed to be
fortified.immediately following mandatory fortification, the birth defects declined.we estimated that folic acid fortification in the unitedstates prevents 1,300 birth defects a year for a combinedtotal of 15,000 prevented since 1999.this has resulted in direct savings of over $4.7 billion.folic acid fortification in the prevention of neural tubedefects was a public health home run and showed we could have animpact on birth defects.
we have used mathematicalmodeling for other birth defects to see where we might have afurther impact. in the next several slides i'lldescribe a basic method as well as the data inputs and resultsfocused on pre-pregnancy obesity, gestational diabetesand smoking. our basic approach is threesteps. first, we assemble our data inputs, the prevalence of the ris risk factor among pregnant women from national surveys. the prevalence of birth defectand the magnitude of the
association between the riskfactor and birth defects generally from published metaanalyses. sometimes in the pregestationaldiabetes example we needed to conduct our own analyses.then we estimate the population attributable fraction orproportion of birth defects in the population that areattributable to that given risk factor.finally, we estimate the number of preventable cases of thebirth defect if that risk factor were eliminated or had a reducedimpact.
we used statistical methods toadequately incorporate the uncertainty in our input parameters.the first example i'm going to talk about is obesity.the map on the left displays the percentage of each state'spopulation that was classified as obese in 1990 based on heightand weight and behavioral risk factors.notice no state had more than 14% of their populationconsidered obese. 20 years later, this is thepicture on the right with no
state having less than 20% oftheir population obese. estimates of the prevalance ofpre-pregnancy obesity varies widely.based on the pregnancy risk assessment monitoring system,the prevalence is 18.7%. based on measured data on heightand weight from the national health and nutrition examinationsurvey, 33% of women were classified as obese.whereas based on self-reported height and weight, 20% of women20 years of able or older were classified as such.this is confusing.
for our model, we started withthe effort mat of 18.7% and created a bias factor to adjustfor the underreporting of obesity.and these are the additional data used to model the impact ofpre-pregnancy obesity. in the first column are the birth defects.in the second column are the odds ratios representing themagnitudes of the associations between prepregnancy obesity andeach birth defect. in the third column are theeffort mates of the prevalence
of birth defects per 10,000births. and the third column are theestimated annual number of child calculated -- approximately 4million. the percent of cases in thepopulation estimated to be caused by pre-pregnancy obesityare here in column two with the highest attributablecontraction. the annual preventable number ofcases for each defect for two different scenarios one with theelimination of pre-pregnancy obesity and the other with a 10%reduction in the risk associated
with pre-pregnancy obesity.because congenital heart defects are more common, elimination ofpre-pregnancy obesity would have the biggest decrease there.with a more modest 10% reduction, we could expect that285 congenital heart defects could be prevented every year.for other defects the potential impact is smaller withapproximately 400 cases of spina bifida averted. the second example i will talkabout is pregestational diabetes.the prevalence of type 1 and
type 2 diabetes has increased inthe u.s. among all ages. for the modeling of the impactof diabetes on birth defects we used the race ethnicity pr-- theare the rest of the inputs we used to model the impact ofdiabetes control on the prevalence of congenital heartdefects. for presentation purposes i'mfocusing on just a few of the heart defects included.in the second column are the summary odds ratios of the --these were derived from a meta analysis we conducted followinga systemic review of the
literature.the third column are the estimated prevalences ofcongenital heart defects and the last column the annual number ofchildren born with each heart defect.in column two, we have the population attributablefractions which range from 7.9% for -- to 14.8%.the next two columns show the annual preventable number ofheart defect. first under the scenario of theelimination of the risk associated with pregestational
diabetes.we estimated that approximately 2,670 cases of congenital heartdefects could be averted each year if women withpregestational diabetes were under perfect blood sugarcontrol. it ranged from 75 per year to230 per year. under the scenario of 50%reduction in risk associated with pregestational diabetes weestimated 1,335 children would be born without a congenitalheart defect. with respect to pregestationaldiabetes, we have estimated the
impact on costs.in a different modeling analysis, we estimated the costaverted if universal preconception care for womenwith either diagnosed or undiagnosed pregestationaldiabetes were in case. we again used -- on theprevalence of diagnosed and undiagnosed diabetes of women inchild bearing years. we used meta analyses also.finally, we used estimates of the lifetime cost in 2012dollars of birth defects including medical care and otherservices and lost productivity.
the modeling study estimatedthere would be approximately 4,730 birth defects averted eachyear and $1.9 billion in lifetime costs.the last example i will talk about is smoking.the release in january 2014 of the 50th anniversary surgeongeneral's report on the health consequences of smoking waslandmark for its recognition of smoking during early pregnancyas a cause of oral facial cleft. smoking during pregnancy is oneof the known risk factors for the potential for prevention.even with widespread knowledge
of hazards of smoking, accordingto data, nearly one-fourth of women smoked just beforepregnancy. we modeled the cessation ofsmoking on oral facial cleft. this is the input data used forthe smoking and oral cleft study.we used the summary odds ratios of 1.28.the results of the smoking modeling estimated a populationattributable fraction of just over 6%.and approximately 430 oral facial clefts preventable eachyear with cessation of smoking
just before pregnancy.as dr. feldkamp discussed, birth defects are common, costly andcritical. despite our work, the majoritystill don't have a known cause. the causes are multifactorial.however, considering the modeling we have done usingrecognized modifiable risk factors for birth defects weknow we can have an impact on prevention.thank you for your time, and we'll be happy to take yourquestions. you're asked to keep yourquestions brief.
[ applause ] how many states participateand how are they funded or supported?>> yes. approximately over 40 states inthe united states have birth defect surveillance systems.they're funded through a variety of modalities.cdc currently funds 14 of those states.states also receive funds through mch title 5 funding aswell as their state general funds.but each state has its own
system.>> hi, i'm godfrey oakley from emory.thank you for lovely presentations.i would just like to -- sometimes people think birthdefects are just developed country diseases.now people want to lower the perinatal -- if we don't prevent the birth defects in everycountry in the world we will never reach that perinatalobjective. you've done a nice thing ofdoing thing that's can be
prevented.they can be prevented here and all over the world. good afternoon.thank you for a wonderful presentation.marsha, you showed a concerning slide about gastroschisis inyoung women. i'm wondering what's been doneto address that concern. there is a lot of interestaround the world trying to figure out why young women areat the greatest risk. we still don't know.it's definitely unique to
gastroschisis.some of us are looking at infection and inflammation as apossible cause. but we don't know.they're certainly known to have more risky behaviors.>> again, from our online audiences, what is the state ofthe science about tri quo ed ethylene and heart defects.are there places to learn more about tce and birth defects?>> using the -- in the mbdps, we ask mothers where they work.that is one avenue we're exploring to identify exposuresduring early pregnancy and the
solvents are definitely a classthat we include in that. in addition, for the mpdps,we're also duo coding. one of the projects we'd like todo perhaps is look at locations of different exposures.back when i worked at -- we talked about women who livedclose to dry cleaning places to see if that might be somethingto pursue. again from our onlineaudience, is anyone studying the relationship between communityenvironmental exposures to hazardous substances and birthdefects?
again, tce is mentioned inliving and work spaces, pesticides drifting intoresidential areas, et cetera. yes.in the mbdps, there have been papers published using our data.so far they have been from one of our sites and it hasn't beencollaborative across because as you might imagine, the exposuresin the differerent sites are different whether you're dealingwith a rural area such as the san fernando valley incalifornia or metropolitan atlanta where we are right now.we are looking into trying to
link our location information ofwhere moms lived during early pregnancy to possibleenvironmental exposures. could you clarify for meabout neural tube defects. in '98 and '99, as was pointedout, we got fda to agree to fortify.i'm wondering if there is information on what's been goingon in terms of women's consumption of folic acid,particularly of more interest, too, since there is an obesityepidemic that has come up. and as you pointed out, there'san impact of obesity on spina
bifida.so could you just talk a little bit about some of those --elaborate on those issues for me?>> our data on consumption of folic acid supplements showsthat most women take a folic acid supplement later duringpregnancy but only approximately 20% to 30% are taking it duringearly pregnancy. so those messages about taking asupplement have not been as effective as getting women totake it during the time we'd love them to take it.you're right, there's competing
risk and protecting factors atthe same time, and there's data to suggest that obese women mayneed more folic acid if they're unable to absorb folic acid interms of an non-obese woman. i also want to -- this pastthursday's mmwr also has some interesting studies about theconsumption of folic acid and neural tube defects.>> could you clarify if that 20% to 30% is early pregnancy or -- i think that's firsttrimester. thank you very much for allof these presentations.
they were incredibly great.my favorite part always is the section on what would happen if.so given that, i was wondering if you could comment on theimplications for action either on our part or in collaborationwith our partners as a result of the modeling you've beenconducting. i think probably our mostfruitful path is going to be preconception care with respectto diabetes control. that is a huge risk factor forbirth defects especially congenital heart defects.i think we can probably have our
greatest impact there.it's a matter of collaborating probably better with ourcolleagues in division of diabetes control and other areasof chronic to try to push that area of work towardsimplementing interventions. so i wonder what you havefound out about the risk of birth defects with theincreasing proportion of births to older women.>> so we've done some analyses looking at maternal age andbirth defects, and it's actually a little bit of a u-shape and itdepends on which birth defect
you're looking at.the risk for gastroschisis is mainly among younger motherswhere risk for the other defects is more among mothers who areover 35. so i think it depends.it's definitely something that we keep an eye on and that wetend to adjust for a lot in our analyses because, as you know,the risk or the odds of a woman being obese is much higher asshe's older as well. those factors all come intoplay. i was thinking specificallyabout down syndrome.
what's happened to down syndromein the last 20 years? in the utah perspective, ithink it's been pretty stable. certainly the risk goes up withmaternal age, but we haven't seen any change that i'm awareof. our twitter audience isgetting very lively here. what can men do to prevent birthdefects? i think couples should plantheir pregnancies and make sure that, if there are chronicdiseases, that they get handled before conception occurs.there.
and i think also from anoccupational point of view, it is important that -- there issome occupational exposures that men could take home so beingaware of that is important as well.>> we have more. as a community health worker, isee lots of pre-pregnancy obesity.should this be included as part of a reproductive life plan?>> that's actually one of the things that mbd steps werelooking at. we know that obessity is a riskfactor.
i haven't seen research yet andif people want to correct me where it shows that if youreally lose the weight again before you get pregnant whetherthat really helps. i think it's a very solidrecommendation to make, just because not being obese ishealthier overall. but the true impact is somethingthat i think we're still looking at.we're actually having a specific question in mbd steps asking awoman who her maximum weight was and when this was to see ifshe's actually lost weight to
see if that's in any way, shapeor form associated with a birth defect.>> how are you addressing the prevalence virus, the number one that causes birth defects?>> i think in terms of cmv, if a baby is born and diagnosed withcmv and they have a structural malformation, they will beincluded in a registry. but often that's not the case.what we may see is just a small head or microcephaly.some states have that and some do not.unfortunately, it's not always
part of the state surveillancesystem. i'll let you talk, too.we really have tried also to have study site that's kind ofreflects the overall u.s. population.and we do try to reach them by phone so we're currentlyexploring, for instance, online questionnaires, knowing thatthat might limit some access. so that's actually somethingthat we want to look into to see whether that does indeed favorsome groups of people over others to estimate if that'ssomething that we can do in the
future.but for now i think we really try to reach all women and givewomen an opportunity. we're doing a pilot, forinstance, in one of our sites in the next year where, if womendon't have enough money to actually pick up the phone to dothe phone interview, we're going to send out a cell phone to seeif that would aid in including. because we really want to beinclusive and provide everybody with an opportunity toparticipate so that our data will also be as representativeas possible.
last one.and part of this was answered in dr. mitchell's talk.have there been safety studies done on vaccination inpregnancy? could you repeat thequestion? i'm sorry.have there been -- have there been safetystudies done in vaccination in pregnancies?>> if the question refers to influenza vaccine, there havebeen a number of safety studies, but one of the limitations inthis session is focused on birth
defects is that most of thestudies have considered birth defects as a single outcome andgrouped them all together. and what we know from drugs thatcause birth defects is that they cause very specific birthdefects, and those may get lost, if you will, when you look atbirth defects as a group. so what's missing from many ofthe studies of safety of vaccines, influenza vaccines, isa focus on specific birth defects.the other factor, which is just a reality, is that every yearpretty much the vaccine changes
and even within a given year themanufacturing processes vary by company and so forth.so we really need to conduct studies every year of eachyear's vaccine and over the accumulated period of years wedevelop a safety record, one hopes, we which we so far haveseen, which would be reassuring and help reduce one of the majorbarriers to pregnant women receiving vaccination, whetherit's pertussis or influenza vaccine.and that's concern about what harm it might do to their fetus.so we really need to assure the
public that those studies arebeing conducted. i'd like to ask for anotherround of applause, real or virtual, for our speakers.[ applause ] thanks also to thoseparticipants who asked questions in person orvirtually. please join us next month wherewe will have an update on the global polio eradicationinitiative. thank you very much.
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