Neural Tube Defect Investigation in Benton, Franklin and Yakima Counties, 2010-2016 September 2017 DOH Pub 210-092 September 2017 Neural Tube Defect Investigation in Benton, Franklin and Yakima Counties, 2010-2016 September 2017 For more information or additional copies of this report contact the Washington State Department of Health: Cathy Wasserman Office of the State Health Officer, Non-Infectious Conditions Epidemiology (360) 236-4250 [email protected] John Wiesman, DrPH, MPH Kathy Lofy, MD Secretary of Health State Health Officer DOH Pub 210-092 September 2017 Neural Tube Defect Investigation in Benton, Franklin and Yakima Counties, 2010-2016 Washington State Department of Health Table of Contents List of Tables .....................................................................................................................................iii List of Figures .................................................................................................................................... iv Executive Summary ............................................................................................................................1 Background .......................................................................................................................................4 Methods ............................................................................................................................................6 Case Definition and Area of Concern ...............................................................................................6 Surveillance for Neural Tube Defects in the Three-County Area .......................................................6 Surveillance for Neural Tube Defects Statewide ..............................................................................8 Spatial Analysis...........................................................................................................................8 Medical Records-Based Case-Control Study .....................................................................................9 Community Concerns ................................................................................................................... 10 Radiation..................................................................................................................................10 Nitrates in Drinking Water ........................................................................................................ 10 Pesticides ................................................................................................................................. 11 Genetics ...................................................................................................................................12 Fumonisins ...............................................................................................................................12 Fortification of Corn Masa Flour ................................................................................................ 12 Interviews of Women with Neural Tube Defect-Affected Pregnancies ............................................ 13 Outreach and Prevention ............................................................................................................. 13 Results and Discussion ..................................................................................................................... 15 Surveillance for Neural Tube Defects in the Three-County Area ..................................................... 15 County-Specific Rates ............................................................................................................... 18 Rates by Race and Hispanic Ethnicity ......................................................................................... 18 Rates by Maternal Age .............................................................................................................. 19 Case Ascertainment Concerns ................................................................................................... 20 Surveillance for Neural Tube Defects Statewide ............................................................................ 23 Rates of Anencephaly by Accountable Communities of Health Regions ...................................... 23 Spatial Analysis......................................................................................................................... 25 Medical Records-Based Case-Control Study ................................................................................... 26 Community Concerns ................................................................................................................... 28 Radiation from Fukushima Daiichi Disaster ................................................................................ 28 i Radiation from Hanford Site ..................................................................................................... 29 Nitrates in Drinking Water ........................................................................................................ 29 Pesticides ................................................................................................................................. 32 Genetics ...................................................................................................................................36 Fumonisins ...............................................................................................................................36 Fortification of Corn Masa Flour ................................................................................................ 37 Interviews of Women with Neural Tube Defect-Affected Pregnancies ............................................ 37 Interview Response .................................................................................................................. 37 Characteristics of Interviewees ................................................................................................. 38 Vitamin Use and Dietary Factors ............................................................................................... 41 Medication Use ........................................................................................................................ 44 Drinking Water ......................................................................................................................... 45 Occupational Exposures and Household Pesticide Use ............................................................... 46 Any Risk Factor for Neural Tube Defects .................................................................................... 48 Outreach and Prevention ............................................................................................................. 49 Families and Women of Reproductive Age in Three-County Area and Statewide ........................ 49 Activities to Address Community Concerns in Three-County Area .............................................. 50 Hospitals and Healthcare Providers ........................................................................................... 50 Qualitative Interviews .............................................................................................................. 51 Conclusions .....................................................................................................................................56 Future Efforts...................................................................................................................................56 Glossary...........................................................................................................................................58 References .......................................................................................................................................59 Appendix A: Project Team ................................................................................................................ 65 Appendix B: Advisory Committee ..................................................................................................... 66 Appendix C: Timeline ....................................................................................................................... 67 Appendix D: Case Abstraction Form .................................................................................................. 72 Appendix E: Letter in Support of Fortification of Corn Masa Flour .......................................................... 74 ii List of Tables Table 1: Hospital Facilities............................................................................................................................. 6 Table 2: Diagnostic Codes Used to Detect Neural Tube Defects in Medical Records .................................. 7 Table 3: Clinics Participating in Case-Control Study ..................................................................................... 9 Table 4: Neural Tube Defects in the Three-County Area by Year of Delivery, 2010-2017 ......................... 16 Table 5: Neural Tube Defects by County of Residence ............................................................................... 18 Table 6: Neural Tube Defects (NTD) by Maternal Race and Ethnicity, Three-County Area ........................ 19 Table 7: Neural Tube Defects (NTD) by Maternal Age at Delivery ............................................................. 20 Table