上海市基于监测的神经管缺陷发生率变化趋势与干预效果评价

Prevalence and intervention effect of neural tube defects in Shanghai

目的分析国家重大公共卫生服务项目"增补叶酸预防神经管缺陷"(简称为叶酸项目)在上海市的实施情况和干预效果。方法基于上海市叶酸项目统计表和上海市《出生缺陷儿、残疾儿童报告卡》数据,分析2008-2018年神经缺陷(neonatal neural tube defects, NTD)发生率的分布趋势,并与上海市妇女孕期前后叶酸服用行为进行线性分析。结果 2010-2018年,累计87 133名育龄期妇女增补了叶酸,依从比>90%。上海市全孕周NTD病例共910例,发生率为4.06■。其中,2010年发生率(5.42■)最高,2017年(2.56■)最低。上海市NTD发生率呈总体显著下降趋势(Z=3.272,P=0.001)。2008-2018年,910例NTD病例中,叶酸项目区病例数为459例(50.44%),非叶酸项目区病例数为450例(49.45%),1例为弃婴。叶酸项目区和非叶酸项目区NTD发生率均呈显著下降趋势(Z=-3.272,P=0.022;Z=-2.451,P=0.014);上海市户籍人口NTD发生率的变化趋势无统计学意义(Z=-1.420,P=0.156),非上海市户籍人口NTD发生率亦呈显著下降趋势(Z=-3.067,P=0.002)。2008-2018年,上海市NTD以无脑畸形为主,占54.62%,其次是脊柱裂(26.37%)和脑膨出(19.01%),三者发生率均在波动中下降。2011-2018年,上海市NTD产前确诊的平均比例为86.52%,2018年达94.74%,总体呈显著上升趋势(Z=2.085,P=0.037);2008-2018年,有109例NTD(11.99%)活产,733例(80.64%)治疗性引产,59例(6.49%)死胎死产,8例(0.88%)出生后死亡。活产儿NTD的发生率为0.23■~0.89■,平均值为0.49■,总体变化趋势无统计学意义(Z=-1.630,P=0.103)。叶酸项目实施前后,叶酸项目区、非叶酸项目区与上海市NTD的发生率均下降,差异具有统计学意义(P=0.003、P<0.001和P<0.001),其中上海市降幅达27.1%。叶酸服用人数和服用依从人数与叶酸项目区NTD发生率呈良好的线性关系(调整R2均为0.709),而叶酸服用人数和服用依从人数与上海市NTD发生率无显著的线性关系。结论非上海市户籍人口是NTD干预健康教育的重点人群,建议探索育龄期妇女增补叶酸个性化方案,形成孕产妇人群叶酸增补长效机制。

Objective To investigate the implementation and intervention effect of "taking folic acid to prevent neonatal neural tube defects(NTD)" in Shanghai. Methods Behavior data of taking folic acid and NTD data(2008-2018) were respectively retrieved from the report of "Folic Acid Project"(a national major public health service project) and Shanghai Birth Defects Surveillance Network. The linear relation between NTD rate and oral folic acid in women in childbearing period was analyzed. Results During 2010-2018, 87 133 women in childbearing period took folic acid, and the compliance rate was more than 90%. A total of 910 full-term NTD infants were reported and the incidence of NTD was 4.06■. The highest incidence was 5.42■ in 2010 and the lowest was 2.56■ in 2017, showing an overall downward trend(Z=3.272, P=0.001). Among these NTD infants, 459(50.44%) were born in the "Folic Acid Project" districts and 450(49.45%) were in non-project districts while one case was an abandoned bady. The incidence of NTD showed a downward trend in both project districts and non-project districts(Z=-3.272, P=0.022;Z=-2.451, P=0.014). The NTD incidence showed no significant difference in household population(Z=-1.420, P=0.156), while a downward trend was found in non-household population(Z=-3.067, P=0.002). From 2008 to 2018, anencephaly accounted for 54.62% of NTD in Shanghai, followed by spina bifida(26.37%) and encephalocele(19.01%). The occurrence trend of the three diseases is declining in fluctuations. During 2011-2018, the average prenatal diagnostic rate of NTD in Shanghai was 86.52%, and it was 94.74% in 2018, showing a significant upward trend(Z=2.085, P=0.037). There were 109(11.99%) live births, 733(80.64%) therapeutic induced labors, 59(6.49%) stillbirths and 8(0.88%) postnatal deaths. The average rate of NTD was 0.49■ in live births(range, 0.23■-0.89■), and there was no statistical difference in the NTD rate(Z=-1.630, P=0.103). After the implementation of "Folic Acid Project", the fetal proportion of NTD in project districts, non-project districts and the whole city of Shanghai decreased(the decline rate was 27.1% in Shanghai), and the difference was statistically significant(P=0.003, <0.001 and <0.001). There was a good linear relationship between the proportion of NTD and the number of folate users, the number of compliance users in the project districts(both adjusted R2=0.709). But the proportion of NTD was not related to the number of folate users or the number of compliance users in Shanghai. Conclusion The non-household population is a key group of the folic acid project. It is suggested to explore individual strategy of folic acid supplement among women of childbearing age and form a long-term mechanism.