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Global prevalence of prenatal alcohol consumption and FASD - Professor Svetlana Popova

Dr James Lush, MC, says:

We have the pleasure of having Professor Svetlana Popova over.

Well, she's got so many accolades, but I'm gonna go through a few of them. She's MD, PhDs, MPH, a Senior Scientist at CAMH's Institute for Mental Health Policy Research. She's also an Associate Professor of the Dalla Lana School of Public Health. She has an appointment as a graduate, Faculty Associate Member with the Institute of Medical Science, University of Toronto.

She has a national and global presence as a researcher in the field of mental health and addiction, particularly Fetal Alcohol Spectrum Disorders, which are recognised as the leading known preventable cause of developmental delay and intellectual disability among Canadians.

Her research focuses on the epidemiology, economic costs, prevention and intervention strategies related to FASD.

And she's here to talk about global prevalence of prenatal alcohol consumption and Fetal Alcohol Spectrum Disorder.

Please make her welcome.

[audience applauds]

Professor Svetlana Popova says:

Okay, thank you so much, Dr. Lush for your very kind introduction.

Good afternoon, everyone. I am very pleased to be here today and very honoured to be chosen as a plenary speaking at this very important event.

I also would like to thank the organisers of this conference for the opportunity to be here for me today in such a beautiful country, and present the results of our recently conducted studies at the Centre for Addiction and Mental Health in Toronto, Canada.

So, my story is my data or data of our team, I will tell you my story through our research.

So today I will be talking about prevalence of alcohol consumption among women of childbearing age in the world.

I will also present the prevalence of alcohol consumption and binge drinking, as well as prevalence of FAS and FASD in different populations in different countries, including countries of Australia and New Zealand, as well as by World Health Organisation regions and globally.

Then I will present some data on co-morbidity and economic costs.

And finally, I will briefly outline the World Health Organisation global prevalence study on FASD.

Alcohol can cause more than 200 disease conditions, and very serious disease conditions such as cancers, cardiovascular diseases, injuries, intentional and unintentional. And according to the recent World Health Organisation, global status report on alcohol and health, alcohol contributes to 5.3% of all deaths worldwide. And this is greater than those caused by HIV/AIDS, violence, and tuberculosis together.

We all know that alcohol is associated with many serious social issues such as violence, child neglect and abuse, absenteeism, law enforcement problems.

And it's estimated that costs associated with alcohol abuse, including costs of mortality, morbidity, law enforcement problems, is approximately 15 billion per year in Canada.

But we know that alcohol can cause harm not only to the drinker, but harm to others. For example, a drunk driver kills pedestrians and a drunk father abuses his children.

But FASD is the most dramatic harm to others. And of course, this harm is unintentional, because no mother in the world would want to harm her unborn child.

We specifically created these maps for this conference based on the most recent World Health Organisation data for 2016. And this data is not published anywhere yet.

So let's review how women of childbearing age consume alcohol in the world. This is the percentage of current drinkers, which means women who consumed alcoholic beverages in the previous 12 months among childbearing age, from 15 to 49.

The darker the colour, the higher the prevalence, so you probably can easily spot two places.

The first one is European region. And the second one, Western Pacific region, Australia and New Zealand. So the percentage of current drinkers is over 65.6%. The second highest is in the Americas, in North and South America, as well as in Central and Eastern Europe. The prevalence is between 56.4 to 65.6%.

The lowest prevalence is in the Eastern Mediterranean region and in some countries in the African region. And the majority of the population is in these regions of Muslim faith, the religion associated with very high abstention rates.

The next slide shows alcohol per capita consumption among childbearing age women, in litres of pure alcohol per person. And again, you can see that the highest prevalence is in European region, over 5.2 litres of pure alcohol per woman. The second highest in the Americas, the Western Pacific region, some African countries, and the prevalence is between 4.1 to 5.2 litres.

And again, the lowest prevalence in the Eastern Pacific region and some Muslim countries of Africa and in South East region, and the prevalence is lower than 0.2 litres.

So in overall alcohol consumption and binge drinking among childbearing age women, and especially among young women, is increasing in many countries, including the most populous countries of the world, such as China and India.

That's why in the near future, we expect more alcohol related problems, health problems as well as increased rate of FAS and FASD if we do nothing.

Now let's see, what is the prevalence of alcohol use during pregnancy and FAS and FASD in the world? Our team recently conducted several studies, which were published in high impact journals, such as "The Lancet Global Health", "JAMA Paediatrics." We conducted a comprehensive literature review, which was not limited geographically or by language.

And for our countries, these two or more studies, we conducted a meta-analysis in order to produce pooled estimate based on available data. But for countries with no data or only with one study, we predicted these estimates.

So basically, we provided all countries with these indicators, exactly 186 countries with actual or predicted estimates.

On this slide, you can see the prevalence of alcohol use during pregnancy in general population for select countries.

And the highest prevalence was observed in Ireland 60%, Belarus 47%, Denmark 46%, UK 42% and Russia about 37%. And you can see that all these countries belong to WHO European region.

However, if you look at the prevalence in the countries from other parts of the world, you will see that quite a large proportion of pregnant women consume alcohol. For example, in Australia, it's 37%. In New Zealand, it's about 27%. In Zambia, 19%, in Brazil and United States about 15%. And in Canada, it's about 10%.

This slide shows prevalence of alcohol use during pregnancy in general population by World Health Organisation regions and there are six World Health Organisation regions.

The highest prevalence of alcohol use was in the Eastern European region 25%, followed by the Americas 11%. African region 10%. Western Pacific Region 8.6%. South East Asia region 1.8%. And the lowest prevalence again was estimated for Eastern Mediterranean region. Eastern Mediterranean region 0.2%.

Again the reason, because majority of the population are of Muslim faith with very high rates of abstention from alcohol.

This slide presents the same data on the prevalence of alcohol use and binge drinking defined as four plus drinks per occasion during pregnancy in general population.

And again, you can see that the highest prevalence is in Europe 25% and the lowest in eastern Mediterranean region 0.2%. But in terms of binge drinking, the highest prevalence was observed in African regions 3.1%, followed by Americas 2.8%, European region 2.7%, Pacific Region 1.8% and the lowest was observed in Eastern Mediterranean region.

Worldwide, we estimated that the prevalence of alcohol consumption among general population is about 10%, which means that one out of 10 pregnant women consume alcohol in the world. And 20% of them consume alcohol in binges during pregnancy, which is very alarming because this is the direct cause of FAS and FASD.

Next slide presents five countries with the highest prevalence of binge drinking during pregnancy in general population. About 10% of pregnant women reported binge drinking in Ireland, Czech Republic, Moldova, Lithuania and little bit higher in Uruguay, 14%.

But proportionally, the highest proportion of women who binged drunk during pregnancy, out of all women who used any amount of alcohol during pregnancy was the highest in Paraguay 78%. Followed by Lithuania 42%, Moldova 36%, Czech Republic 26% and Ireland 17%.

Next slide present prevalence of any amount of alcohol use during pregnancy in general population of Australia.

Dr. Elliott has outlined epistemological data in her presentation today. And if I may, I will just reiterate these findings.

From the world literature we identified 21 studies from Australia, which reported prevalence of alcohol use during pregnancy. And you can see that the prevalence ranges from 7.5%, to 76.6%.

And based on this data, we estimated pooled prevalence with meta-analysis and the pool prevalence is 35.6%. And it's approximately 3.6 times higher as the global average 10%. And because we did search up to 2015, on the bottom of the slide you can see a couple of studies which appear after the year of 2015 in Australia.

So next slide shows prevalence data of any amount of alcohol use during pregnancy in general population of New Zealand. And we identified only six studies and the prevalence was ranging from 13% to 42%. And our meta-analysed estimate is about 27%, which is approximately 2.7 times higher than global average of 10%.

This slide presents the prevalence of any amount of alcohol use and binge drinking during pregnancy in WHO Western Pacific region. There are 21 studies. And you can see that Australia and New Zealand have highest prevalence among all these countries.

However, what was very interesting is the proportion of binge drinking was the lowest in these countries. You can see that in Australia it's 6.7% and in New Zealand, it's even lower 3%.

And the highest proportion of binge drinking during pregnancy was observed in, if I can show you, was observed in Brunei Darussalam 50%, and the second highest was in Mongolia 41%. Only five countries in the Western Pacific region have the prevalence lower than the global average of 10%.

Now, I'm moving on to prevalence of FASD and FAS in general population.

And this is our flow chart for systematic literature search. We identified only 19 studies, sorry, 62 studies from only 19 countries, which met our very strict inclusion and exclusion criteria. Majority of the studies were from the United States 24 studies and second was South Africa, nine studies. In Australia we identified seven studies and in New Zealand, one study.

And this is again a map of the prevalence of FAS in general population by World Health Organisation regions. And in line with the prevalence of alcohol use during pregnancy, the prevalence of affairs again was the highest in European region 37.4 per 10,000 people, followed by the Americas 16.6 per 10,000. African region 14.8, Western Pacific Region 12.7, South East Asia region 2.7.

And the lowest was observed in Eastern Mediterranean region 0.2 per 10,000, almost zero cases.

This slide presents the prevalence of FAS in general population.

Is that right? Yes, globally, we estimated that prevalence of FASD is 14.6 per 10,000, which is equivalent of 0.15%.

And next slide presents prevalence of FASD.

And again, the highest prevalence was in European region around 2%, the lowest in Eastern Mediterranean region 1.3 per 10,000. And globally, we estimated that the prevalence of FASD is about 0.77%.

This slide shows five countries with the highest prevalence of FASD in the general population. And the highest was observed in South Africa, approximately 11%, Croatia 5.3%, Ireland 4.8%, Italy 4.5% and Belarus 3.7%. And this is the prevalence studies of FAS and FASD per 10,000 population in Australia. We found seven published studies of the prevalence of FAS in general population. And based on these studies, we estimated that the prevalence of FAS is 2.4 per 10,000 which is much lower as compared to global average of 14.6. We also estimated prevalence of FASD based on only two available studies. And the prevalence is six per 10,000, which is also much lower than the global average of 77.3 per 10,000.

In order to understand the true prevalence of FASD, we have to look at special populations because this prevalence is very different to what we see in the general population. So we compared, based on some select studies, prevalence of special populations with the global average 7.73. As compared to the global average, the prevalence of FASD among children in care was from five to 68 times higher as compared to the global average. Prevalence among Aboriginal populations, based on Australian and Canadian Studies was from 16 to 25 times higher. Prevalence among psychiatric care population was approximately 19 times higher. Prevalence among low socioeconomic status population was approximately 24 times higher. And prevalence in correctional population was about 30 times higher. And this is data on existing studies on FASD prevalence in special populations of Australia, which Professor Elliot has already presented.

So there is one recent study by Dr. Bower and colleagues, which estimated 36.4% of use of this FASD in detention centre.

And four studies reported prevalence of FASD in Aboriginal populations. The most recent study by Dr. Fitzpatrick estimated about 19% of people with FASD, but other studies reported much lower rates of FASD, 0.4%, 0.5% and 1.5%.

Now, I would like to show you some data on comorbidities of FASD. We all know that FASD associated with many comorbidities, physical and mental disorders due to permanent damage of prenatal exposure on the fetus.

However, what we did not know is how many diseases? What type of diseases? And with what frequencies they occur in individuals with FASD? So again, we conducted a comprehensive literature review and analysis, we looked at all medical and epidemiological literature and we identified a list of comorbid conditions. We also estimated pool prevalence of these comorbid conditions which were found to occur among people with FAS.

And this is our systematic literature review, you can see flow chart, you can see that we identified more than 5,000 records. But after all steps, only 127 studies were included in our qualitative synthesis and 33 studies were included in our meta-analysis.

And based on this available data, we found that 428 comorbid conditions spanning across 18 out of 22 chapters of International Classification of Diseases seen in people with FASD. And the most prevalent disease conditions are congenital malformations, deformities and chromosomal abnormalities.

And the second highest prevalent group of disorders were mental and behavioural disorders, which accounted for 19%. Among other groups of disease conditions you can see on the slide are diseases of the eye, ear, neoplasms, diseases of the nervous system, circulatory, respiratory, digestive, musculoskeletal, genital urinary systems, diseases of the skin and many others.

So this is a solid evidence that prenatal alcohol exposure can affect any organs in any systems of the fetus. Based on 33 studies, which reported data on frequency of at least one disease conditions were eligible for inclusion in our meta-analysis. And these studies contain over 1,700 subjects with diagnosed FAS. Based on this data, we identified the comorbid conditions, which was a pool prevalence over 50% among people with FAS. The highest pool prevalence of comorbid conditions was observed in group of mental and behavioural disorders, red bars. Conduct behavioural problems, was estimated to be about 90% among people with FAS, followed by receptive and expressive language deficit about 80%. Developmental cognitive disorder and speech language delay almost close to 70%. Alcohol and drug dependence as a secondary disability about 55% and attention deficit hyperactivity disorder about 50%. The second largest group of diseases is diseases of the eye, which consisted of refractive errors slightly about 70% and visual impairment about 60%.

The third largest group is diseases of the ear, yellow bars. Chronic and acute otitis media. Chronic is about 80% and acute form is about 50%. Central hearing disorder and conductive hearing loss are both about 55%.

Among conditions originating in the perinatal period, green bars, are intrauterine growth retardation, about 70% and premature births 65%.

Next one is congenital malformations, also very prevalent, about 50%. For example, cervical spine fusion and hypertelorism.

So these results clearly demonstrate that a large spectrum of diseases is extremely prevalent among people with FAS.

We also were able to compare the pooled prevalence of some selected diseases among people with FAS and among the general population of the United States. We chose the population of the United States because the majority of the subjects in our studies were from the United States population.

And you can see here that conduct disorder and receptive language deficit disorder among individuals with FAS was estimated to be about 10 times higher than among the general population of the United States.

Chronic otitis media is 77 times higher. Expressive language disorder 11 times higher. Disorder of psychological development 98 times higher. Preterm infants 5.6 times higher, visual impairment including blindness 31 times higher. Hearing loss about 126 times higher. Alcohol and drug dependence 4.4 times higher. Disturbance of activity and attention 7.6 times higher.

So this data clearly demonstrates that the prevalence of some disease conditions are enormously higher among people with FAS as compared to the general populations.

I also wanted to show you our data on economic cost of FASD. Based on the burden associated with FASD, it's not surprising that the annual cost due to FASD is enormously high for any society. And now it's estimated that annual costs for Canada ranges from 1.3 to 2.3 billion Canadian dollars per year. And we still believe that this cost is severely underestimated because of the data and availability.

And secondly, these estimates were produced based on the assumption that FASD prevalence in Canada is 1%. But now we know that it's much higher. So the cost probably will be double, maybe even triple.

And you can see here that the highest contributor to the overall FASD attributable cost is the indirect cost of productivity losses due to disability and premature mortality of people this FASD which accounted for 42% of the total cost. And the second highest cost is direct costs of corrections, which accounted for 30%. And third highest cost contributor is the cost of health care.

However, when I present this cost, I'm very careful because these cost estimates, they are certainly very helpful to present to policymakers and decision makers, because it's really clear for them how much burden exists in the country.

However, these cost figures should not further stigmatise mothers with children with FASD and families with FASD. Instead, this course figures should be used as solid scientific evidence in order to fight for support of these families and these mothers and kids.

So based on observed epidemiological data, it's clear that data on the prevalence of maternal alcohol consumption, and FASD are completely absent for the majority of the countries in the world.

However, in order to understand severity and impact of FASD in the world, we have to know how many people exist in each country. Therefore, it was a call from the World Health Organisation to initiate a study on the global prevalence of FASD. And this study is currently in place, guided by World Health Organisation with support from National Institute on Alcohol Abuse and Alcoholism.

The objective of the study is to estimate the prevalence of FASD among children from seven to nine years of age using an active case ascertainment approach, which means that researchers are actively seeking out and finding cases in the general population.

As of now, there are several countries which are participating in this large study are countries from Central and Eastern Europe, African countries and Canada.

In Canada, we recently completed the study and published the report. And other collaborating centre of World Health Organisation where I am working.

Our team is responsible for support from all involved countries in this project, and I'm the principal investigator.

This is a very brief schema of our data collection process. There are two phases of data collection. In the first phase, which is pre-screening stage. We physically go to schools or other institutions, and assess consented children on physical status, we're measuring height, weight, head circumference and we also take behavioural and learning difficulties history from teachers and/or caregivers. And then those children who met criteria, there's a gross deficit with small head circumference with behavioural or learning problems, they are moving to the next stage.Active case ascertainment itself for this morphological assessment and neurodevelopmental assessment, and mothers of children with suspected FASD are invited for interview. And of course, our major goal is to get a history on prenatal alcohol exposure, and other exposures. But we also assess mothers on many other risk factors. That's how we estimate prevalence in this study.

And very briefly, if I may, as I said, we completed prevalence study in Canada based on this methodology. And they found that the prevalence in general population among elementary school children ranges between 2% and 3%. And this estimate is double or even possibly triple previous crude estimates of 1%.

And what is important here is that FASD prevalence which we estimated, exceeds that of other common birth defects, such as Down Syndrome, spina bifida, trisomy 18, as well as autism spectrum disorder in Canada, which is about a 1%.

So to conclude, FASD is a prevalent and alcohol-related neurodevelopmental disability, globally.

However, FASD is preventable. That's why it's so important to establish a universal public health message about the detrimental consequences of alcohol around the globe. Establish routine screening protocols not only for pregnant, but for women of childbearing age. Provide brief interventions where appropriate to all pregnant women and women of childbearing age. And we should pay special attention to high risk populations, special populations, where the impact of FASD is especially severe.

Thank you so much for your attention.

[audience applauds]