Distilling the Fundamentals of Evidence-Based Public Health Policy.

Public health policy interventions are associated with many important public health achievements. To provide public health practitioners and decision makers with practical approaches for examining and employing evidence-based public health (EBPH) policy interventions, we describe the characteristics and benefits that distinguish EBPH policy interventions from programmatic interventions. These characteristics include focusing on health at a population level, focusing on upstream drivers of health, and involving less individual action than programmatic interventions. The benefits of EBPH policy interventions include more sustained effects on health than many programs and an enhanced ability to address health inequities. Early childhood education and universal preschool provide a case example that illustrates the distinction between EBPH policy and programmatic interventions. This review serves as the foundation for 3 concepts that support the effective use of public health policy interventions: applying core component thinking to understand the population health effects of EBPH policy interventions; understanding the influence of existing policies, policy supports, and the context in which a particular policy is implemented on the effectiveness of that policy; and employing a systems thinking approach to identify leverage points where policy implementation can have a meaningful effect.

Advancing Evidence-Based Public Health Policy: How Core Component Thinking Can Illuminate the Multilevel Nature of Public Health Policy.

A growing body of literature uses the concept of core components to better understand small-scale programmatic interventions. Instead of interventions being viewed as unitary "black boxes," interventions are viewed as configurations of core components, which are the parts of interventions that carry their causal potential and therefore need to be reproduced with fidelity to produce the intended effect. To date, the concept of core components has not been as widely applied to public health policy interventions as it has to programmatic interventions. The purpose of this topical review is to familiarize public health practitioners and policy makers with the concept of core components as applied to public health policy interventions. Raising the profile of core component thinking can foster mindful adaptation and implementation of public health policy interventions while encouraging further research to enhance the supporting evidence base. We present 3 types of multilevel interactions in which the core components of a public health policy intervention produce effects at the population level by (1) seeking to directly affect individual behavior, (2) facilitating adoption of programmatic interventions by intermediaries, and (3) encouraging intermediaries to take action that can shape changes in upstream drivers of population health. Changing the unit of analysis from whole policies to core components can provide a basis for understanding how policies work and for facilitating novel evidence-generating strategies and rapid evidence reviews that can inform future adaptation efforts.

Trends in the Impact of Medicaid Expansion on the Use of Clinical Preventive Services.

INTRODUCTION: This study aims to evaluate the trends in the impact of Medicaid expansion on the use of selected recommended clinical preventive services and examine the differences in use by income level over time. METHODS: The data were obtained from the 2011-2019 Behavioral Risk Factor Surveillance System and were analyzed in 2021. This study conducted a difference-in-differences analysis of the association between Medicaid expansion and the use of 5 clinical preventive services, including colon/breast/cervical cancer screenings, HIV testing, and influenza vaccination. Annual percentage change was applied to assess the trends in the impact of Medicaid expansion on the use of clinical preventive services. RESULTS: The use of all the 5 clinical preventive services varied over time. In almost every year, the use of 4 clinical preventive services (all but HIV testing) among Medicaid expansion states was higher than that among the nonexpansion states. People with lower income used 4 clinical preventive services (all but HIV testing) less frequently than those with higher income, regardless of their residence in expansion or nonexpansion groups. Among the lower-income group, the use of 5 clinical preventive services increased after Medicaid expansion almost every year, with the use of colon cancer screening and HIV testing reaching statistical significance and the impact of Medicaid expansion in the use of each clinical preventive service kept stable from 2014 to 2019. CONCLUSIONS: These findings provide evidence that Medicaid expansion may be associated with sustainably increased use of the selected recommended clinical preventive services among the lower-income population and that Medicaid expansion to reduce financial barriers may be an effective strategy to improve population health.

Preventing Leading Causes of Death: Systematic Review of Cost-Utility Literature.

INTRODUCTION: Heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke are the 5 leading causes of death in the U.S. The objective of this review is to examine the economic value of prevention interventions addressing these 5 conditions. METHODS: Tufts Medical Center Cost-Effectiveness Analysis Registry data were queried from 2010 to 2018 for interventions that addressed any of the 5 conditions in the U.S. Results were stratified by condition, prevention stage, type of intervention, study sponsorship, and study perspective. The analyses were conducted in 2020, and all costs were reported in 2019 dollars. RESULTS: In total, 549 cost-effectiveness analysis studies examined interventions addressing these 5 conditions in the U.S. Tertiary prevention interventions were assessed in 61.4%, whereas primary prevention was assessed in 8.6% of the studies. Primary prevention studies were predominantly funded by government, whereas industry sources funded more tertiary prevention studies, especially those dealing with pharmaceutical interventions. The median incremental cost-effectiveness ratio for the 5 conditions combined was $68,500 per quality-adjusted life year. Median incremental cost-effectiveness ratios were lowest for primary prevention and highest for tertiary prevention. DISCUSSION: Primary prevention may be more cost effective than secondary and tertiary prevention interventions; however, research investments in primary prevention interventions, especially by industry, lag in comparison. These findings help to highlight the gaps in the cost-effectiveness analysis literature related to the 5 leading causes of death and identify understudied interventions and prevention stages for each condition.

Trends in the Utilization of Recommended Clinical Preventive Services, 2011-2019.

INTRODUCTION: The Patient Protection and Affordable Care Act requires many health insurance plans to cover certain clinical preventive services in network with no cost sharing. This study describes the utilization trends of 8 clinical preventive services by insurance status and analyzes utilization disparities. METHODS: Data were collected from 2011 to 2019 through the Behavioral Risk Factor Surveillance System and were analyzed in 2021. Logistic regression and generalized linear modeling were fitted to calculate the absolute and relative differences by insurance status, respectively. Annual percentage point change was applied to assess the trends in utilization and the relative difference. RESULTS: Trends in utilization ranged from an annual percentage point change high with zoster vaccination of 8.03 (p<0.01) and a low with cervical cancer screening of -1.01 (p<0.01). Trends (except for HIV testing) were consistently substantially lower among the uninsured. Utilization among all participants increased for 4 clinical preventive services, although larger increases were observed among the uninsured for breast and colon cancer screenings. The utilization of cervical cancer screening decreased, and the utilization of the other 3 services did not change significantly. The relative difference between the insured and the uninsured decreased modestly with the greatest reductions observed for breast cancer screening and zoster vaccination, whereas increases were observed for HIV testing. CONCLUSIONS: Despite the reduction of cost barriers for the insured, there were larger increases in utilization among the uninsured, and a narrowed gap was observed over time for some services. Ongoing efforts to monitor the trends in clinical preventive services utilization may help identify and evaluate the strategies designed to increase their use.

Use of Selected Recommended Clinical Preventive Services - Behavioral Risk Factor Surveillance System, United States, 2018.

Clinical preventive services play an important role in preventing deaths, and Healthy People 2020 has set national goals for using clinical preventive services to improve population health (1). The Patient Protection and Affordable Care Act (ACA) requires many health plans to cover certain recommended clinical preventive services without cost-sharing when provided in-network (covered clinical preventive services).* To ascertain prevalence of the use of selected recommended clinical preventive services among persons aged ≥18 years, CDC analyzed data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS), a state-based annual nationwide survey conducted via landline and mobile phones in the United States, for 10 clinical preventive services covered in-network with no cost-sharing pursuant to the ACA. The weighted prevalence of colon, cervical, and breast cancer screening, pneumococcal and tetanus vaccination, and diabetes screening ranged from 66.0% to 79.2%; the prevalence of the other four clinical preventive services were <50%: 16.5% for human papillomavirus (HPV) vaccination, 26.6% for zoster (shingles) vaccination, 33.2% for influenza vaccination, and 45.8% for HIV testing. Prevalence of HIV testing had the widest variation (3.1-fold differences) across states among the 10 services included in this report. The prevalence of use of clinical preventive services varied by insurance status, income level, and rurality, findings that are consistent with previous studies (2-6). The use of nine of the 10 services examined was lower among the uninsured, those with lower income, and those living in rural communities. Among those factors examined, insurance status was the dominant factor strongly associated with use of clinical preventive services, followed by income-level and rurality. Understanding factors influencing use of recommended clinical preventive services can potentially help decision makers better identify policies to increase their use including strategies to increase insurance coverage.

Birth defect survival for Hispanic subgroups.

BACKGROUND: Previous studies demonstrate that infant and childhood mortality differ among children with birth defects by maternal race/ethnicity, but limited mortality information is published for Hispanic ethnic subgroups. METHODS: We performed a retrospective cohort study using data for children with birth defects born to Hispanic mothers during 1999-2007 from 12 population-based state birth defects surveillance programs. Deaths were ascertained through multiple sources. Survival probabilities were estimated by the Kaplan-Meier method. Cox proportional hazards regression was used to examine the effect of clinical and demographic factors on mortality risk. RESULTS: Among 28,497 Hispanic infants and children with major birth defects, 1-year survival was highest for infants born to Cuban mothers at 94.6% (95% confidence intervals [CI] 92.7-96.0) and the lowest for Mexicans at 90.2% (95% CI 89.7-90.6; p < .0001). For children aged up to 8 years, survival remained highest for Cuban Americans at 94.1% (95% CI 91.8-95.7) and lowest for Mexican Americans at 89.2% (95% CI 88.7-89.7; p = .0002). In the multivariable analysis using non-Hispanic White as the reference group, only infants and children born to Mexican mothers were noted to have a higher risk of mortality for cardiovascular defects. CONCLUSIONS: This analysis provides a better understanding of survival and mortality for Hispanic infants and children with selected birth defects. The differences found in survival, particularly the highest survival rates for Cuban American children and lowest for Mexican American children with birth defects, underscores the importance of assessing Hispanic ethnic subgroups, as differences among subgroups appear to exist.

Congenital Heart Defects in the United States: Estimating the Magnitude of the Affected Population in 2010.

BACKGROUND: Because of advancements in care, there has been a decline in mortality from congenital heart defects (CHDs) over the past several decades. However, there are no current empirical data documenting the number of people living with CHDs in the United States. Our aim was to estimate the CHD prevalence across all age groups in the United States in the year 2010. METHODS: The age-, sex-, and severity-specific observed prevalence of CHDs in Québec, Canada, in the year 2010 was assumed to equal the CHD prevalence in the non-Hispanic white population in the United States in 2010. A race-ethnicity adjustment factor, reflecting differential survival between racial-ethnic groups through 5 years of age for individuals with a CHD and that in the general US population, was applied to the estimated non-Hispanic white rates to derive CHD prevalence estimates among US non-Hispanic blacks and Hispanics. Confidence intervals for the estimated CHD prevalence rates and case counts were derived from a combination of Taylor series approximations and Monte Carlo simulation. RESULTS: We estimated that ≈2.4 million people (1.4 million adults, 1 million children) were living with CHDs in the United States in 2010. Nearly 300 000 of these individuals had severe CHDs. CONCLUSIONS: Our estimates highlight the need for 2 important efforts: planning for health services delivery to meet the needs of the growing population of adults with CHD and the development of surveillance data across the life span to provide empirical estimates of the prevalence of CHD across all age groups in the United States.

Retrospective Assessment of Cost Savings From Prevention: Folic Acid Fortification and Spina Bifida in the U.S.

INTRODUCTION: Although fortification of food with folic acid has been calculated to be cost saving in the U.S., updated estimates are needed. This analysis calculates new estimates from the societal perspective of net cost savings per year associated with mandatory folic acid fortification of enriched cereal grain products in the U.S. that was implemented during 1997-1998. METHODS: Estimates of annual numbers of live-born spina bifida cases in 1995-1996 relative to 1999-2011 based on birth defects surveillance data were combined during 2015 with published estimates of the present value of lifetime direct costs updated in 2014 U.S. dollars for a live-born infant with spina bifida to estimate avoided direct costs and net cost savings. RESULTS: The fortification mandate is estimated to have reduced the annual number of U.S. live-born spina bifida cases by 767, with a lower-bound estimate of 614. The present value of mean direct lifetime cost per infant with spina bifida is estimated to be $791,900, or $577,000 excluding caregiving costs. Using a best estimate of numbers of avoided live-born spina bifida cases, fortification is estimated to reduce the present value of total direct costs for each year's birth cohort by $603 million more than the cost of fortification. A lower-bound estimate of cost savings using conservative assumptions, including the upper-bound estimate of fortification cost, is $299 million. CONCLUSIONS: The estimates of cost savings are larger than previously reported, even using conservative assumptions. The analysis can also inform assessments of folic acid fortification in other countries.

State Legislation, Regulations, and Hospital Guidelines for Newborn Screening for Critical Congenital Heart Defects - United States, 2011-2014.

Critical congenital heart defects (CCHD) occur in approximately two of every 1,000 live births. Newborn screening provides an opportunity for reducing infant morbidity and mortality. In September 2011, the U.S. Department of Health and Human Services (HHS) Secretary endorsed the recommendation that critical congenital heart defects be added to the Recommended Uniform Screening Panel (RUSP) for all newborns. In 2014, CDC collaborated with the American Academy of Pediatrics (AAP) Division of State Government Affairs and the Newborn Screening Technical Assistance and Evaluation Program (NewSTEPs) to assess states' actions for adopting newborn screening for CCHD. Forty-three states have taken action toward newborn screening for CCHD through legislation, regulations, or hospital guidelines. Among those 43, 32 (74%) are collecting or planning to collect CCHD screening data; however, the type of data collected by CCHD newborn screening programs varies by state. State mandates for newborn screening for CCHD will likely increase the number of newborns screened, allowing for the possibility of early identification and prevention of morbidity and mortality. Data collection at the state level is important for surveillance, monitoring of outcomes, and evaluation of state CCHD newborn screening programs.

Racial/ethnic differences in survival of United States children with birth defects: a population-based study.

OBJECTIVES: To examine racial/ethnic-specific survival of children with major birth defects in the US. STUDY DESIGN: We pooled data on live births delivered during 1999-2007 with any of 21 birth defects from 12 population-based birth defects surveillance programs. We used the Kaplan-Meier method to calculate cumulative survival probabilities and Cox proportional hazards models to estimate mortality risk. RESULTS: For most birth defects, there were small-to-moderate differences in neonatal (<28 days) survival among racial/ethnic groups. However, compared with children born to non-Hispanic white mothers, postneonatal infant (28 days to <1 year) mortality risk was significantly greater among children born to non-Hispanic black mothers for 13 of 21 defects (hazard ratios [HRs] 1.3-2.8) and among children born to Hispanic mothers for 10 of 21 defects (HRs 1.3-1.7). Compared with children born to non-Hispanic white mothers, a significantly increased childhood (≤ 8 years) mortality risk was found among children born to Asian/Pacific Islander mothers for encephalocele (HR 2.6), tetralogy of Fallot, and atrioventricular septal defect (HRs 1.6-1.8) and among children born to American Indian/Alaska Native mothers for encephalocele (HR 2.8), whereas a significantly decreased childhood mortality risk was found among children born to Asian/Pacific Islander mothers for cleft lip with or without cleft palate (HR 0.6). CONCLUSION: Children with birth defects born to non-Hispanic black and Hispanic mothers carry a greater risk of mortality well into childhood, especially children with congenital heart defect. Understanding survival differences among racial/ethnic groups provides important information for policy development and service planning.

Community socioeconomic disadvantage and the survival of infants with congenital heart defects.

OBJECTIVES: We examined the association between survival of infants with severe congenital heart defects (CHDs) and community-level indicators of socioeconomic status. METHODS: We identified infants born to residents of Arizona, New Jersey, New York, and Texas between 1999 and 2007 with selected CHDs from 4 population-based, statewide birth defect surveillance programs. We linked data to the 2000 US Census to obtain 11 census tract-level socioeconomic indicators. We estimated survival probabilities and hazard ratios adjusted for individual characteristics. RESULTS: We observed differences in infant survival for 8 community socioeconomic indicators (P < .05). The greatest mortality risk was associated with residing in communities in the most disadvantaged deciles for poverty (adjusted hazard ratio [AHR] = 1.49; 95% confidence interval [CI] = 1.11, 1.99), education (AHR = 1.51; 95% CI = 1.16, 1.96), and operator or laborer occupations (AHR = 1.54; 95% CI = 1.16, 1.96). Survival decreased with increasing numbers of indicators that were in the most disadvantaged decile. Community-level mortality risk persisted when we adjusted for individual-level characteristics. CONCLUSIONS: The increased mortality risk among infants with CHDs living in socioeconomically deprived communities might indicate barriers to quality and timely care at which public health interventions might be targeted.

Role of health insurance on the survival of infants with congenital heart defects.

OBJECTIVES: We examined the association between health insurance and survival of infants with congenital heart defects (CHDs), and whether medical insurance type contributed to racial/ethnic disparities in survival. METHODS: We conducted a population-based, retrospective study on a cohort of Florida resident infants born with CHDs between 1998 and 2007. We estimated neonatal, post-neonatal, and infant survival probabilities and adjusted hazard ratios (AHRs) for individual characteristics. RESULTS: Uninsured infants with critical CHDs had 3 times the mortality risk (AHR = 3.0; 95% confidence interval = 1.3, 6.9) than that in privately insured infants. Publicly insured infants had a 30% reduced mortality risk than that of privately insured infants during the neonatal period, but had a 30% increased risk in the post-neonatal period. Adjusting for insurance type reduced the Black-White disparity in mortality risk by 50%. CONCLUSIONS: Racial/ethnic disparities in survival were attenuated significantly, but not eliminated, by adjusting for payer status.

Prevalence and correlates of gastroschisis in 15 states, 1995 to 2005.

OBJECTIVE: To identify trends in the prevalence and epidemiologic correlates of gastroschisis using a large population-based sample with cases identified by the National Birth Defects Prevention Network over the course of an 11-year period. METHODS: This study examined 4,713 cases of gastroschisis occurring in 15 states during 1995-2005, using public use natality data sets for denominators. Multivariable Poisson regression was used to identify statistically significant risk factors, and Joinpoint regression analyses were conducted to assess temporal trends in gastroschisis prevalence by maternal age and race and ethnicity. RESULTS: Results show an increasing temporal trend for gastroschisis (from 2.32 per 10,000 to 4.42 per 10,000 live births). Increasing prevalence of gastroschisis has occurred primarily among younger mothers (11.45 per 10,000 live births among mothers younger than age 20 years compared with 5.35 per 10,000 among women aged 20 to 24 years). In the multivariable analysis, using non-Hispanic whites as the referent group, non-Hispanic black women had the lowest risk of having a gastroschisis-affected pregnancy (prevalence ratio 0.42, 95% confidence interval [CI] 0.37-0.48), followed by Hispanics (prevalence ratio 0.86, 95% CI 0.81-0.92). Gastroschisis prevalence did not differ by newborn sex. CONCLUSIONS: Our findings demonstrate that the prevalence of gastroschisis has been increasing since 1995 among 15 states in the United States, and that higher rates of gastroschisis are associated with non-Hispanic white maternal race and ethnicity, and maternal age younger than 25 years (particularly younger than 20 years of age). LEVEL OF EVIDENCE: III.

Modeling the potential public health impact of prepregnancy obesity on adverse fetal and infant outcomes.

OBJECTIVE: Approximately one-third of US reproductive-aged women are obese, and prepregnancy obesity is a strong risk factor for adverse fetal and infant outcomes. The annual number of preventable adverse fetal and infant outcomes associated with prepregnancy obesity in the U.S. was estimated. DESIGN AND METHODS: Adverse fetal and infant outcomes for which statistically significant associations with prepregnancy obesity had been reported by peer-reviewed meta-analyses, which included fetal deaths and nine different major birth defects, were assessed. The true prevalence of prepregnancy obesity was estimated by multiplying self-reported prepregnancy obesity by a bias factor based on the difference between measured and self-reported obesity in U.S. adult women. A Monte Carlo simulation approach was used to model the attributable fraction and preventable number, accounting for uncertainty in the estimates for: strength of the association with obesity, obesity prevalence, and outcome prevalence. RESULTS: Eliminating the impact of prepregnancy obesity would potentially prevent the highest numbers of four outcomes: fetal deaths (6,990; uncertainty interval [UI] 4,110-10,080), congenital heart defects (2,850; UI 1,035-5,065), hydrocephalus (490; UI 150-850), and spina bifida (405; UI 305-505). If 10% of women with prepregnancy obesity achieved a healthy weight before pregnancy or otherwise mitigated the impact of obesity, nearly 300 congenital heart defects and 700 fetal deaths per year could potentially be prevented. CONCLUSION: This simulation suggests that effective prevention strategies to reduce prepregnancy obesity or the risk associated with obesity could have a measurable impact on infant health in the US.

Trends in survival among children with Down syndrome in 10 regions of the United States.

OBJECTIVE: This study examined changes in survival among children with Down syndrome (DS) by race/ethnicity in 10 regions of the United States. A retrospective cohort study was conducted on 16,506 infants with DS delivered during 1983-2003 and identified by 10 US birth defects monitoring programs. Kaplan-Meier survival probabilities were estimated by select demographic and clinical characteristics. Adjusted hazard ratios (aHR) were estimated for maternal and infant characteristics by using Cox proportional hazard models. RESULTS: The overall 1-month and 1-, 5-, and 20-year survival probabilities were 98%, 93%, 91%, and 88%, respectively. Over the study period, neonatal survival did not improve appreciably, but survival at all other ages improved modestly. Infants of very low birth weight had 24 times the risk of dying in the neonatal period compared with infants of normal birth weight (aHR 23.8; 95% confidence interval [CI] 18.4-30.7). Presence of a heart defect increased the risk of death in the postneonatal period nearly fivefold (aHR 4.6; 95% CI 3.9-5.4) and continued to be one of the most significant predictors of mortality through to age 20. The postneonatal aHR among non-Hispanic blacks was 1.4 (95% CI 1.2-1.8) compared with non-Hispanic whites and remained elevated by age 10 (2.0; 95% CI 1.0-4.0). CONCLUSIONS: The survival of children born with DS has improved and racial disparities in infant survival have narrowed. However, compared with non-Hispanic white children, non-Hispanic black children have lower survival beyond infancy. Congenital heart defects are a significant risk factor for mortality through age twenty.

Improved survival among children with spina bifida in the United States.

OBJECTIVE: To evaluate trends in survival among children with spina bifida by race/ethnicity and possible prognostic factors in 10 regions of the United States. STUDY DESIGN: A retrospective cohort study was conducted of 5165 infants with spina bifida born during 1979-2003, identified by 10 birth defects registries in the United States. Survival probabilities and adjusted hazard ratios were estimated for race/ethnicity and other characteristics using the Cox proportional hazard model. RESULTS: During the study period, the 1-year survival probability among infants with spina bifida showed improvements for whites (from 88% to 96%), blacks (from 79% to 88%), and Hispanics (from 88% to 93%). The impact of race/ethnicity on survival varied by birth weight, which was the strongest predictor of survival through age 8. There was little racial/ethnic variation in survival among children born of very low birth weight. Among children born of low birth weight, the increased risk of mortality to Hispanics was approximately 4-6 times that of whites. The black-white disparity was greatest among children born of normal birth weight. Congenital heart defects did not affect the risk of mortality among very low birth weight children but increased the risk of mortality 4-fold among children born of normal birth weight. CONCLUSIONS: The survival of infants born with spina bifida has improved; however, improvements in survival varied by race/ethnicity, and blacks and Hispanics continued to have poorer survival than whites in the most recent birth cohort from 1998-2002. Further studies are warranted to elucidate possible reasons for the observed differences in survival.

Racial/ethnic variations in the prevalence of selected major birth defects, metropolitan Atlanta, 1994-2005.

OBJECTIVES: Birth defects are the leading cause of infant mortality and are responsible for substantial child and adult morbidity. Documenting the variation in prevalence of birth defects among racial/ethnic subpopulations is critical for assessing possible variations in diagnosis, case ascertainment, or risk factors among such groups. METHODS: We used data from the Metropolitan Atlanta Congenital Defects Program, a population-based birth defects registry with active case ascertainment. We estimated the racial/ethnic variation in prevalence of 46 selected major birth defects among live births, stillbirths, and pregnancy terminations at >20 weeks gestation among mothers residing in the five central counties of metropolitan Atlanta between 1994 and 2005, adjusting for infant sex, maternal age, gravidity, and socioeconomic status (SES). We also explored SES as a potential effect measure modifier. RESULTS: Compared with births to non-Hispanic white women, births to non-Hispanic black women had a significantly higher prevalence of five birth defects and a significantly lower prevalence of 10 birth defects, while births to Hispanic women had a significantly higher prevalence of four birth defects and a significantly lower prevalence of six birth defects. The racial/ethnic disparities in the prevalence of some defects varied by SES, but no clear pattern emerged. CONCLUSIONS: Racial/ethnic disparities were suggested in 57% of included birth defects. Disparities in the prevalence of birth defects may result from different underlying genetic susceptibilities; exposure to risk factors; or variability in case diagnosis, ascertainment, or reporting among the subpopulations examined. Policies that improve early diagnosis of birth defects could reduce associated morbidity and mortality.

Prevalence of spina bifida among children and adolescents in 10 regions in the United States.

OBJECTIVE: The goal was to estimate the number of children and adolescents, 0 to 19 years of age, living with spina bifida (SB) in the United States. METHODS: A retrospective study was conducted by using population-based, birth defect surveillance data from 10 US regions, with vital status ascertainment. Birth defect surveillance data were obtained from Arkansas, Georgia (5 central counties of metropolitan Atlanta), California (11 counties), Colorado, Iowa, New York (New York City excluded), North Carolina, Oklahoma, Texas, and Utah. We estimated the numbers of children 0 to 19 years of age who were living with SB in the 10 US regions in 2002, according to age group, race/ethnicity, and gender, and examined a long-term trend in the prevalence of SB among children 0 to 11 years of age in 1991-2002. RESULTS: The overall prevalence of SB among children and adolescents 0 to 19 years of age in the study regions was 3.1 cases per 10,000 in 2002. The prevalence of SB among children was lower among male and non-Hispanic black children. CONCLUSIONS: The prevalence estimates of SB among children and adolescents varied according to region, race/ethnicity, and gender, which suggests possible variations in prevalence at birth and/or inequities in survival rates. Additional studies are warranted to elucidate the reasons for these variations and to derive prevalence estimates of SB among adults.