1. Trends & Forecasts in Florida Jane Correia, HSEE Coordinator, Florida Birth Defects Registry Bureau of Community Environmental Health Florida Department of Health Kimberlea Hauser, MBA Project Director, Birth Defects Surveillance Program Department of Pediatrics University of South Florida

2. Trends Do we know what percentage of Florida women of childbearing age are consuming alcohol? Do we know what percentage of Florida women of childbearing age are consuming alcohol? Do we know who is using alcohol during pregnancy? Do we know who is using alcohol during pregnancy? Do we know the rate of FAS in Florida? Do we know the rate of FAS in Florida?

3. Data Sources Behavioral Risk Factor Survey System (BRFSS) Behavioral Risk Factor Survey System (BRFSS) Pregnancy Risk Assessment Monitoring System (PRAMS) Pregnancy Risk Assessment Monitoring System (PRAMS) Florida Birth Defects Registry (FBDR) Florida Birth Defects Registry (FBDR)

4. Florida BRFSS A Population-based random sampling telephone survey, following CDC survey protocol A Population-based random sampling telephone survey, following CDC survey protocol Monitors behavioral risk factors and chronic diseases Monitors behavioral risk factors and chronic diseases Surveys residents 18 years and older Surveys residents 18 years and older Conducted annually since 1986 Conducted annually since 1986 Over 7,100 completed interviews in 2004 Over 7,100 completed interviews in 2004

5. Strengths and Limitations Strengths: Strengths: –Population-based survey –Conducted every year –Flexible and relatively inexpensive –Data are comparable to other states Limitations: Limitations: –Selection bias: telephone coverage and participation –Sample size and sampling errors –Self-report

6. Current Alcohol Use (Past 30 days) among Women in Florida, Ages 18-44, 2004

7. Current Binge Drinking (Past 30 Days) among Women in Florida, Ages 18-44, 2004

8. Heavy or Binge Drinking among Women in Florida by County, 2002 Counties with the highest percentages: Counties with the highest percentages: –Monroe: 17.8% –Brevard: 14.6% –Alachua: 14.5% –Desoto: 13.2% –Jefferson: 12.4% –Dade, St. Johns, & Seminole: 11.0% Counties with the lowest percentages: Counties with the lowest percentages: –Bradford: 2.4% –Hardee: 3.0% –Sumter: 3.1% –Osceola & Suwannee: 3.2% –Gadsden & Hamilton: 3.3% –Holmes & Madison: 3.5%

9. Use of Birth Control Methods among Women in Florida, Ages 18-44, 2004

10. Youth Risk Behavior Survey (YRBS) School-based self-reported survey of health risk behaviors among high school students School-based self-reported survey of health risk behaviors among high school students First conducted in Florida in 1991, administered every Spring in odd-numbered years First conducted in Florida in 1991, administered every Spring in odd-numbered years Since 2001, in collaboration with the Department of Education Since 2001, in collaboration with the Department of Education Administered as part of the Florida Youth Survey Administered as part of the Florida Youth Survey In 2003, approx. 4100 students completed the YRBS In 2003, approx. 4100 students completed the YRBS

11. Health Risk Behaviors Monitored One of a number of surveillance systems utilized by the CDC to monitor health risk behaviors that contribute to disease morbidity and mortality, including: One of a number of surveillance systems utilized by the CDC to monitor health risk behaviors that contribute to disease morbidity and mortality, including: –Tobacco use –Unhealthy dietary behaviors –Inadequate physical activity –Alcohol and other drug use –Sexual behaviors that contribute to unintended pregnancy and sexually transmitted diseases, including HIV infection –Behaviors that contribute to unintentional injuries and violence

12. Current Alcohol Use (Past 30 Days) among Florida High School Students, 2003

13. Binge Drinking among Florida High School Students, 2003

14. Current Sexual Activity (Past 3 Months) among Florida High School Students, 2003

15. Among Florida High School Students Who Were Currently Sexually Active, the Percentage Who Drank Alcohol or Used Drugs Before the Last Time They Had Sexual Intercourse, 2003

16. Percentage of Florida High School Students Who Had Been Pregnant or Gotten Someone Pregnant One or More Times, 2003

17. Florida PRAMS A population-based surveillance system of maternal behaviors and experiences before and during a women’s pregnancy and during early infancy of her baby A population-based surveillance system of maternal behaviors and experiences before and during a women’s pregnancy and during early infancy of her baby Overall goal is to reduce infant morbidity and mortality by changing maternal behaviors both before and during pregnancy and early infancy Overall goal is to reduce infant morbidity and mortality by changing maternal behaviors both before and during pregnancy and early infancy

18. PRAMS Methodology Random selection of Florida residents who gave birth to a live- born infant Random selection of Florida residents who gave birth to a live- born infant Six sampling strata Six sampling strata –Low birth weight among Whites, Blacks, and minors –Normal birth weight among Whites, Blacks, and minors

19. Strengths/Limitations Strengths Strengths –Flexible and relative inexpensive for collecting public health data (use of a mail/phone surveillance system) –Population-based survey –Conducted in 32 states over multiple years Weaknesses Weaknesses –Self-reported information –Limited number of complete interviews (75% in 2003) –Complex sampling method subject to sampling errors

20. Percent of Alcohol Use Before Pregnancy Among Women in Florida, 2003 Yes No NH White NH Black Hispanic <= 19 20 - 24 25 - 34 35 + < 12 yrs 12 yrs > 12 yrs <=$15600 $15,601 - $39,600 > $39,600 Overall : 42.5%

21. Percent of Binge Drinking Before Pregnancy Among Women in Florida, 2003 Yes No NH White NH Black Hispanic <= 19 20 - 24 25 - 34 35 + < 12 yrs 12 yrs > 12 yrs <=$15600 $15,601 - $39,600 > $39,600 Overall : 21.8%

22. Percent of Alcohol Use During Pregnancy Among Women in Florida, 2003 Yes No NH White NH Black Hispanic <= 19 20 - 24 25 - 34 35 + < 12 yrs 12 yrs > 12 yrs <=$15600 $15,601 - $39,600 > $39,600 Overall : 7.1%

23. Percent of Binge Drinking During Pregnancy Among Women in Florida, 2003 Yes No NH White NH Black Hispanic <= 19 20 - 24 25 - 34 35 + < 12 yrs 12 yrs > 12 yrs <=$15600 $15,601 - $39,600 > $39,600 Overall : 1.4%

24. Surveillance of FASD in Florida Florida Birth Defects Registry Florida Birth Defects Registry Reliance on a single ICD-9 CM code: 760.71 Reliance on a single ICD-9 CM code: 760.71 –Noxious influences (alcohol) affecting fetus via placenta or breast milk Used to describe full-blown FAS as well as alcohol exposure Used to describe full-blown FAS as well as alcohol exposure

25. Surveillance Methods Passive Passive –Uses 760.71 ICD-9 CM code from secondary data sources to identify cases –No confirmation Active Active –Uses same code for identification –Medical record reviewed for confirmation of diagnosis

26. Rates And Counts For Cases With 760.71 ICD-9 CM Code, 1998-2002 Source: FBDR/Florida Department of Health

27. Race/Ethnicity Of Cases With 760.71 ICD-9 CM Code, 1998-2001 Source: Birth Defects Research (Part A), October 2005, page 777

28. Maternal Age Of Cases With 760.71 ICD-9 CM Code, 1998-2002 Source: FBDR/Florida Department of Health

29. Active Surveillance of FASD Cases, 2003-2004 Catchment area: 50 hospitals in Escambia, Bay, Leon, Duval, Alachua, Pinellas, Hillsborough, Broward, and Miami-Dade Catchment area: 50 hospitals in Escambia, Bay, Leon, Duval, Alachua, Pinellas, Hillsborough, Broward, and Miami-Dade Hospital submits list of cases based on ICD-9 CM discharge codes for surveillance conditions Hospital submits list of cases based on ICD-9 CM discharge codes for surveillance conditions –CNS conditions, oral clefts, gastroschisis/omphalocele, trisomies (13,21,18), and FAS Abstractor reviews medical record to determine alcohol exposure for all cases meeting surveillance criteria Abstractor reviews medical record to determine alcohol exposure for all cases meeting surveillance criteria

30. Active Surveillance Cases 35 cases reviewed with 760.71 ICD-9 CM code from hospital discharge information 35 cases reviewed with 760.71 ICD-9 CM code from hospital discharge information Cases by year Cases by year –200322 –200413 Counties with highest numbers (based on maternal or child residence) Counties with highest numbers (based on maternal or child residence) –Hillsborough:9 –Miami-Dade:6 –Sarasota:3

31. Alcohol Exposure 3 infants with FAS facial features and exposure noted 3 infants with FAS facial features and exposure noted 15 infants with maternal alcohol exposure noted ranging from 1 drink in first trimester to known alcoholic but no defects noted 15 infants with maternal alcohol exposure noted ranging from 1 drink in first trimester to known alcoholic but no defects noted 17 infants with no alcohol exposure noted in chart and no birth defects noted 17 infants with no alcohol exposure noted in chart and no birth defects noted

32. Maternal Conditions of 760.71 ICD-9 CM Code Cases Tobacco smoking21 Tobacco smoking21 Illicit drug use17 Illicit drug use17 Infections16 Infections16 OTC/Prescription Drugs12 OTC/Prescription Drugs12 Vitamins 6 Vitamins 6

33. Do we know what percentage of Florida women of childbearing age are consuming alcohol? In the past 30 days In the past 30 days –Approximately 1/3 of Florida women of child bearing age have consumed alcohol –14.4% of 18-24 year olds have had 2 drinking binges –44% of Florida high school girls have consumed alcohol –21% of Florida high school girls have had a drinking binge

34. Do we know who is using alcohol during pregnancy? Before Pregnancy Before Pregnancy –Non-Hispanic White, 25 to 34 year old, upper SES, married women During Pregnancy During Pregnancy –Non-Hispanic and Hispanic, 25 to 34 year old, upper SES, married women

35. Do we know the rate of FAS in Florida? Identification of FAS at birth is difficult Identification of FAS at birth is difficult Only 8% of cases using the ICD-9 CM code had FAS facial features noted in chart Only 8% of cases using the ICD-9 CM code had FAS facial features noted in chart The ICD-9 CM code may only be useful as a proxy for in-utero alcohol exposure not FAS The ICD-9 CM code may only be useful as a proxy for in-utero alcohol exposure not FAS

36. Impact of Alcohol Use 2004 Florida live births – 218,048 2004 Florida live births – 218,048 Overall alcohol use by women during pregnancy – 7.1% (5.2-8.9) Overall alcohol use by women during pregnancy – 7.1% (5.2-8.9) Overall binge drinking by women during pregnancy – 1.4% (0.3-2.5) Overall binge drinking by women during pregnancy – 1.4% (0.3-2.5) Potential impact Potential impact –Alcohol exposed infants: 11,000 to 19,000 –Binge drinking exposed infants: 600 to 5,400

37. What lies ahead? Younger women are common alcohol users Younger women are common alcohol users Older women may not know risks and waiting until later in life to become pregnant Older women may not know risks and waiting until later in life to become pregnant Current methods of surveillance do not identify cases Current methods of surveillance do not identify cases FASD 100% preventable by stopping alcohol consumption during pregnancy FASD 100% preventable by stopping alcohol consumption during pregnancy

38. For more information BRFSS BRFSS –Melissa Murray Melissa_Murray@doh.state.fl.us Melissa_Murray@doh.state.fl.us Melissa_Murray@doh.state.fl.us PRAMS PRAMS –Curtis Miller Curtis_Miller@doh.state.fl.us Curtis_Miller@doh.state.fl.us Curtis_Miller@doh.state.fl.us FBDR FBDR –Jane Correia Jane_Correia@doh.state.fl.us Jane_Correia@doh.state.fl.us Jane_Correia@doh.state.fl.us