Prevalence of Alcohol Consumption during Pregnancy and Fetal Alcohol Spectrum Disorder

Prevalence of Alcohol Consumption during Pregnancy and Fetal Alcohol Spectrum Disorder 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 in general popula7on of different countries (including countries of La7n America and the Caribbean), World Health Organiza7on (WHO) regions and globally. Prevalence of FAS/FASD in different popula7ons in different countries (including countries of La7n America and the Caribbean), WHO regions and globally. Es7mated global incidence of children born with FAS and FASD annually

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) 0.7 0.6 60.4% 0.5 46.6% 45.8% 0.4 0.3 41.3% 36.5% 36.3% 35.6% 34.0% 33.1% 32.7% 30.5% 29.7% 28.3% 26.7% 27.0% 25.8% 0.2 0.1 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

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) 70.0% 60.0% 17.4% 50.0% 40.0% 30.0% 20.0% 25.9% 35.8% 42.0% 77.7% 10.0% 0.0% Ireland Czech Republic Moldova Lithuania Paraguay binge drinking any amount

Prevalence of Alcohol Use During Pregnancy in General Population by WHO Region, 2012 EUR 25.2% (95% CI: 21.6% 29.6%) AMR 11.2% (95% CI: 9.4% 12.6%) EMR 0.2% (0.1% 0.9%) SEAR 1.8% (95% CI: 0.9% 5.1%) AFR 10.0% (95% CI:8.5% 11.8%) 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 30.0% 25.0% 25.2% 20.0% Prevalence 15.0% 10.0% 11.2% 10.0% 8.6% 9.8% 5.0% 0.0% 2.7% 2.8% 3.1% 1.8% 0.2% 1.8% 2.0% EUR AMR AFR WPR SEAR EMR Worldwide binge drinking any amount 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 During Pregnancy in 70.0% Canada (any amount, and at any point during pregnancy) 60.0% 60.5% 50.0% 50.8% 48.8% 46.0% 40.0% 34.5% 30.0% 30.1% 26.3% 24.3% 25.3% 22.3% 20.0% 10.0% 10.0% 14.6% 17.0% 7.5% 17.5% 14.4% 10.5% 10.5% 11.2% 10.8% 16.8% 9.9% 0.0% 2.0% 0.5% 2.0% 0.6% General Population Northern Communities (Range: 0.5% to 30.1%) (Range: 24.3% to 60.5%)

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.

Prevalence of Any Amount of Alcohol Use During Pregnancy in General Popula7on of La7n America and the Caribbean in 2012 25% 20% 23% 22% 18% 18% Lange, Probst, Heer, & Popova. In press. Rev Panam Salud Publica 15% 10% 5% 0% 15% 15% 15% 15% 15% 13% 13% 12% 12% 12% 11% 11% 11% 10% 10% 10% 10% 10% 9% 9% 9% 9% 9% Grenada St. Lucia Guyana Paraguay Brazil Hai7 St. Vincent and Grenadines Barbados Dominica Argen7na Peru Dominican Republic Bahamas Panama Chile Honduras Bolivia Suriname Venezuela An7gua and Barbuda Belize St. Kiis and Nevis Jamaica Colombia Ecuador Nicaragua Uruguay Costa Rica El Salvador Guatemala Trinidad and Tobago Cuba Mexico Global 8% 8% 7% 6% 5% 1% 10% 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

*Es7mate of binge drinking during pregnancy based on a meta- analysis of the current literature 16% 14% Prevalence of Binge Drinking During Pregnancy in General Popula7on of La7n America and the Caribbean in 2012 13.9% 12% 10% 8% 6.7% 6% 4% 2% 3.6% 3.6% 3.0% 3.3% 2.7% 3.0% 2.4% 2.3% 2.7% 2.7% 2.2% 2.4% 2.3% 2.0% 2.3% 1.9% 1.9% 1.5% 2.8% 2.3% 2.2% 2.0% 1.9% 1.9% 1.8% 1.6% 1.6% 1.5% 1.4% 1.2% 1.4% 1.2% 0%

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 5,965 records screened 430 full- text ar&cles assessed for eligibility 5,145 duplicates removed 5,535 records excluded 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)]

Prevalence of FAS in General Popula7on by WHO Region, 2012 EUR 37.4 per 10,000 (95% CI: 24.7 54.2 per 10,000) AMR 16.6 per 10,000 (95% CI: 11.0 24.0 per 10,000) EMR 0.2 per 10,000 (0.2 0.9 per 10,000) SEAR 2.7 per 10,000 AFR (95% 14.8 per CI: 1.3 8.1 10,000 per 10,000) (95% CI:8.9 21.5 per 10,000) WPR 12.7 per 10,000 (95% CI: 7.7 19.4 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 40 37.4 35 Prevalence (per 10,000) 30 25 20 15 10 5 0 0.15% 16.6 14.8 12.7 14.6 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 EUR 198.2 per 10,000 (95% CI: 119.1 252.6 per 10,000) EMR 1.3 per 10,000 (0.9 5.7 per 10,000) SEAR 14.1 per 10,000 CI: 10,000 4.0 33.6 per 10,000) AFR (95% 78.3 per (95% CI:44.8 107.0 per 10,000) AMR 87.9 per 10,000 (95% CI: 57.5 113.4 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 Prevalence (per 10,000) 250.0 200.0 150.0 100.0 50.0 0.0 2% 198.2 0.77% 87.9 78.3 67.4 77.3 14.1 1.3 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

Five Countries with the Highest Prevalence of FASD 120 in the General Popula7on 111.1 100 Prevalence (per 1,000) 80 60 40 53.3 47.5 45 36.6 20 0 South Africa* Croa7a* Ireland Italy* Belarus *Based on actual data

Prevalence of FAS and FASD in La7n America and the Caribbean in 2012 Prevalence (per 1,000) 20 18 16 14 12 10 8 6 4 2 0 18.4 Grenada 17.2 St Lucia 14.3 14.1 12.0 11.7 11.7 11.5 11.5 9.8 9.5 10.2 9.5 9.2 FASD 8.4 8.3 8.0 7.6 8.3 7.8 7.5 7.5 7.4 FAS 7.1 7.0 7.0 6.9 6.5 6.5 5.1 4.4 3.8 2.7 Guyana Paraguay Brazil Hai7 St Vincent and Grenadines Barbados Dominica Argen7na Peru Bahamas Dominican Republic Panama Honduras Bolivia Chile Suriname Venezuela An7gua and Barbuda Belize St Kiis and Nevis Jamaica Colombia Ecuador Nicaragua Uruguay Costa Rica El Salvador Guatemala Trinidad and Tobago Cuba Puerto Rico 1.0 Mexico 7.7 Global 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

Comparison FASD prevalence among special popula7ons, based on select studies, to the global prevalence among the general popula7on 600.0 500.0 400.0 300.0 200.0 100.0 0.0 Prevalence (per 1,000) 521.13 8Adoptees from Eastern Europe, Sweden (Landgren et al. 64) 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 285.19 233.45 189.66 182.4 170.21 142.39 120.37 _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) 40 @Pre-adoption & foster care children, Israel (Tenenbaum et al. 72) 7.73 General population, Globally

Prevalence of FAS in Canada General Popula7on vs. Northern Communi7es 140 120 120.7 100 Prevalence (per 1,000) 80 60 40 61.8 20 2.4 0.6 1.0 7.2 0 Asante & Nelms- Matzke, 1985 Habbick et al., 1996 Roberts & Nanson, 2000 Robinson et al., 1987 Kowlessar, 1997 Williams et al., 1999 General Population Northern Communities (Range: 0.6 to 2.4 per 1,000) (Range: 7.2 to 120.7 per 1,000)

Prevalence of FASD in Canada General Popula7on vs. Northern Communi7es 200 189.7 180 160 140 Prevalence (per 1,000) 120 100 80 60 40 32.8 95.0 101.1 20 5.3 9.0 11.7 7.0 0 Asante & PHAC, 2003 Thanh et al., Nelms- 2014 Matzke, 1985 General Population (Range: 5.3 to 11.7 per 1,000) Asante & Nelms- Matzke, 1985 Robinson et al., 1987 Square, 1997 Kowlessar, 1997 Northern Communities (Range: 7.0 to 189.7 per 1,000) Werk et al., 2013

The Prevalence of Children with FASD in Various Child Care Systems

The Prevalence of Children with FASD in Various Child Care Systems (cont ) Literature Review In total, 33 studies were iden7fied and included in the analysis (Lange et al., 2013, Pediatrics; 132: e980- e995) Data on the prevalence of FAS/D in child care systems are available from only 11 countries/regions, including: Brazil, Chile, Canada, Eastern Europe (Romania, Ukraine, Moldova), Israel, Russia, Spain, Sweden, and USA The prevalence was reported for six major seqngs: boarding schools, child welfare agencies, foster care, homes for children with mental deficiencies, orphanages, and mixed- care seqngs

The Prevalence of Children with FASD in Various Child Care Systems (cont ) Fuch et al. (2005): 11.3% of children and youths in care have FASD in Manitoba Burge (2007): 3.3% children who are permanent wards in Ontario have FASD => Prevalence of FASD in child welfare system is 3 to 11 7mes higher as compared to FASD prevalence in general popula7on of Canada (1%)

The Prevalence of Children with FASD in Various Child Care Systems (cont ) Canada Source: Tri-Provincial FASD Project, a collaborative initiative between ON, MA, AB (Fuchs & Burnside, 2014) Note: Includes both diagnosed and suspected cases of FASD

The Prevalence of Children with FASD in Various Child Care Systems (cont ) Canada (by age groups) Total 10.5% Total 10.3% Total 12.3% Source: Fuchs & Burnside, 2014 Note. In Alberta and Ontario, children in care include children 0-17 years of age; In Manitoba, children in care include children 0-21 years of age

The Prevalence of Children with FASD in Various Child Care Systems (cont ) - Wide Ranges - The prevalence of FAS ranges from 5 per 1,000 (child welfare system, USA; Ringeisen et al., 2008) to 680 per 1,000 (orphanage for children with special needs, Russia; Palchik & Legonkova, 2011) The prevalence of FASD ranges from 37 per 1,000 (foster care, USA; Astley et al., 2002) to 521 per 1,000 (adoptees from Eastern Europe, adopted in Sweden; Landgren et al., 2010)

The Prevalence of Children with FASD in Various Child Care Systems (cont ) 16.00% Prevalence of FAS: Child Welfare, Foster Care, Orphanages 15.1% 14.00% 12.00% 10.00% 8.00% 6.00% 6.2% 4.00% 2.00% 3.2% 2.0% 1.5% 0.00% Brazil Chile Isreal Russia USA

The Prevalence of Children with FASD in Various Child Care Systems (cont ) 35.00% Prevalence of FAS: Interna7onal Adoptees 30.00% 29.6% 25.00% 20.00% 15.00% 10.00% 11.0% 5.00% 3.5% 2.4% 0.00% Canada Spain Sweden USA

The Prevalence of Children with FASD in Various Child Care Systems (cont ) The pooled prevalence of FAS in child care seqngs is approximately 70 7mes higher than the prevalence of FAS in the general popula7on of Canada Screening for FASD in this high- risk popula7on is necessary, in order to facilitate early diagnosis!

Popova et al. (2011) Canadian Journal of Public Health, 102(5), 336-340. Prevalence of FASD in Canadian Correc7onal System (Range youths: 10.9% to 23.4%, adults: 9.9% to 17.5%) 25.0% 23.4% 20.0% 17.5% 15.0% 10.0% 11.7% 10.9% 9.9% 5.0% 0.0% Fast et al., 1999 (British Columbia & Yukon) Murphy & Chittenden, 2005 (British Columbia) Rojas & Gretton, 2007 (British Columbia) MacPherson et al., 2011 (Manitoba) McLachlan et al., 2016 (Yukon Territories) YOUTHS Youths with FASD are nineteen times more likely to be incarcerated than youths without FASD in any given year (Popova et al., 2011) ADULTS

Discussion FASD is a rela7vely prevalent alcohol- related developmental disability globally This study used the best available data and provides a working es7mate of the prevalence of alcohol use during pregnancy and FAS/FASD in countries that do not currently have actual data Should inspire countries to do their own research to obtain their own prevalence data

Discussion (con ) Establish a universal public health message about the poten7al harm of prenatal alcohol exposure Establish rou7ne screening protocols Provide brief interven7ons, where appropriate, to all pregnant women Special aien7on has to be paid to high- risk popula7ons where the impact of FASD is especially severe

Contact Informa7on Svetlana (Lana) Popova Senior Scientist, Associate Professor Institute for Mental Health Policy Research Centre for Addiction & Mental Health, University of Toronto, WHO Collaborating Centre 33 Russell Street, room T507 Toronto, ON, Canada M5S 2S1 Tel. (416) 535-8501 ext. 34558 e-mail: lana.popova@camh.ca Remember: When you drink, so does your child