1. Allison Derrick Masters of Public Health Candidate UW School of Medicine and Public Health Regional Distribution of Orofacial Cleft Defects in Wisconsin

2. Acknowledgements Delora Mount, MD; UW Plastic and Reconstructive Surgery Glen Leverson, PhD; Biostatistics Henry Anderson, MD, MPH; DHFS Kristen Malecki, PhD; DHFS Liz Oftedahl, MPH; DHFS Laura Ninneman, DHFS

3. Outline Background Objectives Methods Results Discussion Conclusion

4. Background

5. Orofacial clefts are the most common craniofacial birth defects Incidence ranging from approximately 0.5 to 2 per 1,000 births* Multifactorial etiology –Both genetic and environmental factors implicated Public health Problem –significant lifelong morbidity –complex etiology –requires extensive treatment surgical, psychological, speech and dental interventions Lifetime cost of >$101,000 Marazita, M. L. and M. P. Mooney. Clin Plast Surg 2004; 31 (2): 125-40 Waitzman NJ, Romano PS, Scheffler RM. Inquiry 1994;31:188-205.

6. Objectives Perform the first analysis of the distribution of orofacial cleft births in Wisconsin Evaluate the incidence of orofacial cleft births in the Fox River Valley with respect to the rest of Wisconsin Examine the geographical distribution for potential associations between environmental factors and orofacial cleft defects

7. Methods Performed a comprehensive literature review on the etiology and CL/P, environmental risk factors, research methodology IRB approval Data Collection: –Vital Records: 1997-2006* –WBDR: 2005-2006 –WISH database: 1997-2006 Calculated incidences by county* Logistical regression to adjust for confounders* Determined OR for OFCs w/in FRV vs. WI-FRV*

8. Results

10. Incidence Rates WI…………..1.046/1,000 FRV………..… 1.463/1,000 WI - FRV…….. 0.997/1,000 Adjusted OR …1.52 (95% CI 1.23, 1.89; p=0.0001) Results

11. Demographic Trends Maternal age - NS Maternal race - NS Maternal educational achievement - NS Maternal smoking status OR 1.032 (95% CI 1.017,1.048) P-value = 0.0009 Results

12. Interpretation of results –Incidence of 1.46/1,000 births in FRV is significantly higher than the rest of WI, but still WNL Cluster by chance? Potential Environmental associations –PCBs? –TTHMs? –Pesticides? Discussion

13. US EPA: www.epa.gov/region5/foxriver/lower_fox_river_map WI DNR: http://www.dnr.state.wi.us/org/gmu PCBs

14. Results* *Texas Sharpshooter

15. WI DNR: http://dnr.wi.gov/org/water/dwg/swap/delineation.htm Bove et al. Am J Epidemiol. 1995; 141 (9): 850-62. Distribution of Drinking Water from Surface Water Sources TTHMs* *Texas Sharpshooter

16. U.S. Geological Survey Fact Sheet: Pesticides in ground water in the Western Lake Michigan Drainages. 1996 *Texas Sharpshooter Pesticides in Groundwater*

17. Discussion Limitations of study –Sensitivity of Birth Certificate Data –Differences in reporting among counties –Maternal migration during pregnancy Misclassification bias –No differentiation between CL/P and CP alone, or those cases associated with syndromes –Potential Confounders prenatal care/nutritional status alcohol intake during pregnancy –Descriptive geographic study Cannot define causality Watkins ML et al. Am J Public Health 1996;86:731-4.

18. Conclusions Established a geographic distribution of OFC births in WI Found a statistically significant elevated risk of OFCs in the FRV Useful for formulating hypotheses for future testing, but no causal relationship can be established Need to encourage reliable birth defect reporting and regular environmental exposure measurements –WI EPHT system Sept 2008…