Spatio-temporal pattern of congenital hypothyroidism screening success in Iran (Case study, Fars counties during 2005-2013)

Abstract

Objective: 1) Spatio-temporal analysis of CH screening success in Fars counties during 2005-2013; 2) To analyze Neonatal CH clusters in Fars counties during 2005-2013; and 4) Help to provide better planning budget and facilities for Disease Control of CH in the study area and other regions.

Results: The results of this study showed that the incidence of disease duration was variable from 2 to 10 in every 1,000 newborn boys more than girls in the rate. Also, the spatial distribution pattern of CH in newborns in the period studied based on the statistical significance level (p-value) and the index of spatial autocorrelation (Moran 's I) had a random pattern. This result can identify factors involved in disease in order to better planning in the field budget and facilities needed for Disease Control and CH in the Fars province are very helpful. In different geographical areas of the province, the analysis of the spatial distribution of CH in newborns every year to show differences and show a uniformity pattern decrease and tend to focus on specific areas of space that may be the pattern (focus spatial) happen in the next few years. 

Introduction:

The CH, a condition of thyroid hormone deficiency can be cured if indiscrimination in time and treated properly, can cause severe retardation and impaired development of the child (1-3). Newborn screening for metabolic diseases starting from the 60s, opened new horizons for improving the health of infants and young children (4,5). GIS is the tool of investigate geographic distribution. (6). CH incidence of 1 in every 3,500 to 4,500 live births is estimated (7). On the basis of previous academic research on the spread of disease varied from 1 in 370 to 1000 (8-10), which is much higher than the global average. If that does not prevent disorder and its complications every year the number of newborns will suffer from some degree of reduced IQ and developmental disorders. Due to the unpleasant complications effects along with heavy financial burden on the economy, social services and child care imposes an urgent need to investigate and adopt the preventive measures for this condition is congenital. Therefore, using GIS and mapping of disease risk, could be a clearer picture of trend of variation and spatial extension of disease the dimensions of the urban health system to provide health policymakers. By identifying the location of the disease, people are aware than their surroundings and better will understand prevent problems. By identifying the disease centers, health costs and expenses will be adjusted, because the people prone disease areas, risk factors, understand and prevention seeks to overcome. Knowing the distribution of occurrence of disease in the city and the provinces one of the CH in neonatal screening program needs to be allocated on the basis of budget and facilities needed. Geographical distribution of information on health effective factors, also can be a reliable supplier by researchers the direction of compiling evidence-based causal hypotheses and test them used. The aim of this study was to determine the Pattern of spatial distribution of CH by using GIS in the Fars province. The obtained results can help to provide better planning budget and facilities for Disease Control of CH in the study area.

Materials And Methods:

Data description. The current research is based on performed cross-sectional a descriptive study. The population size was all newborn infants alive during the years 2005 to 2013, in the Fars counties in south of Iran. Neonatal screening program in the Fars province started since 2004 and so far continued. In this program, all newborns in province in terms of CH by TSH, as the primary screening test, to identify patients are examined. If the TSH level in newborns is less than 5 mu/l is born removed from the program and if equal to or more than 5mu/l is order to confirm the diagnosis of venous blood samples will be recall. If the sample is positive for treatment, introducing baby to the physician. In this study, data from screening program of CH in newborns were obtained from the Department of Health, Shiraz University of Medical Sciences (SUMS), the data were entered MS-excel and after spatial data mining, spatial analysis in GeoDaSpace and ArcGIS Pro software were done. 

Software and packages. Data mining and data cube were performed using MS-excel software (version 2013). The Spatio-Temporal was performed using the Space-Time function in the ArcGIS Pro package. The Spatial autocorrelation were generated using the “Moran’s Index” and “LISA” functions in the GeoDa package. Maps were produced using ArcGIS Pro software.

Ethics approval and consent to participate. This study used National Neonatal screening program data from the SUMS, all the methods were performed in accordance with relevant guidelines and regulations, and all participants provided written informed consent.

Spatial Autocorrelation. The pattern of disease, CH in infants and focus on the disease using spatial statistical functions and the overall and local indicators of spatial autocorrelation (Moran’s I) was calculated and determined. Moran’s I tested by calculating the standard deviation of the normal range (1, -1). The method is as follows (Equation 1) can be obtained by:  

Equation 1:

Then zoning of neonatal TSH deficiency, extracted by IDW for mapping and spatial patterns were generated and analyzed. IDW method is based on the assumption that the impact of the phenomenon decreases with increasing distance (11, 12).

According to collected data by the Department of Health of SUMS, total live births during 2005 to 2013,was 609491 children (29435 baby girls and 315146 baby boy), in the Fars province. 572390 cases during these years have been screened for CH that 1217 of whom are suffering from CH have been diagnosed and treated. Spatial pattern of results indicates that the rate of population covered by screening program of CH in newborns, during the years 2005 to 2013 has increased in all the counties of Fars province, during the first period (2005-2008) the rate of 50% to 97% in the second (2009-2013) has been changed from 97% to 100% (Figure 1).

Figure 1: Population covered by screening program CH in the Fars province during 2005-2013 years

The frequency of CH in newborns, of Fars province from 2 to 10 in every 1000 infants screened during the study period varied (fig 2). 

Figure 2: The incidence of CH in newborns in Fars province during 2005-2013 years

This amount includes both types of illness (temporary and permanent). Also, the highest incidence of female infants in the years 2006, 2007, 2012 and 2013 in the Khonj, Pasagard, Abadeh and Mohr were between 6.41 to 8 Case and infants male in 2012 in the Khonj and Mohr between 7.21 to 9 cases per 1000 newborns were screened. Spatial pattern of CH in newborns by Moran’s I showed random distribution of the disease (Table 1). 

Table 1: Indicators of spatial autocorrelation in the Fars counties during 2005-2013

 Also, trend of CH in infants based on the level of TSH in the Fars province in three period has been shown (fig 3). According Figure 3 in the first period zones that is marked with white color and is included in Shiraz has the highest cluster of disease and zones that are between 3 to 9 and includes the Firoozabad, Qyrvkarzyn, Zarindasht , Lar and Kazeroon will be have fluctuated. In the second period, zones that is marked with brown color and contains Arsanjan the most mass compared to other parts of Fars province, and in the third period, zones that is marked with purple color and includes the Abadeh and Mohr were the cluster of disease to other areas of Fars province.

Figure 3: The time zone value incidence of CH based on neonatal TSH in the Fars during the 2005-2013 years province

 CH is the most common preventable cause of mental retardation. The incidence of the disease in different populations between 1 in 2000 to 1 in 4000 people have been reported (13). Screening in various countries, show that the incidence of disease is different depending on the geographic region (14). Results indicate that the coverage ratio screening program during the study period was not fixed at all levels of the province has increased that this ratio of 49.99 percent to 100 percent. Also incidence of the disease in the province during the years 2005-2013 was varied from 2 to 10 per 1000 newborns. Study in 2014 by Stephen as "Coverage of Newborn Screening for CH a Public Health Challenge” was performed indicated despite the fact that the screening program order to identify newborns with CH has been more than 40 year, Currently only 30% of all live births in the world covered by the screening program order to identify this disorder. The population covered by neonatal screening programs vary in different geographical area. For example in Europe 84.2 percent, in America 82.3, in Africa 37.8 percent and in Asia 24.4 percent and due to the incidence of disease has been estimated that an average of 1 in 3000 newborns This means that about 30000 infants with CH are not recognized worldwide and in early life, was not treated and are at risk of mental retardation (15-27). In another study performed by Hinton and et.al.(2010) incidence of CH in infants in the United States of America, was studied. Before screening, program with Clinical symptoms were detected. Approximately 1 in 7000 to 1 in 10000 cases have been reported. While at the beginning of the screening program, approximately 1 in 3000 to 1 in 4000 cases were reported. This is not due to the increased amount of clear, but it's one of the reasons for the change in strategy order to diagnostic tests are known. Newborn Screening Program in France to investigate a 20-year period, the incidence of CH was 1 in 10000 newborns. In Greece with a 11-year study on the population of Cyprus reported incidence of this disease is 1 in 800 newborns. Today, Incidence rate the spread of disease screening programs in different parts of the world due to its geographical location is different (28). Compared with studies on screening programs cover Fars province has been successful, but the incidence of disease is very high compared with the incidence in different countries more research is needed in this area. In the case of sex, Rezaeian study in 2014 indicated during the years 2005- 2011 in the province incidence rate of CH in girls than boys was 1.2 to 1 and based on logistic regression indicated that gender (female) and birth season (summer) 3.09 percent increases the risk of diseases in infants (29). Other studies have also shown that getting girls to boys ratio 1.6 to 1 in Iraq, Saudi Arabia1.8 to 1 and India 2 to 1 and inside the country in Arak this ratio between boys and girls were equal, ratio girls to boys in Yazd1 to 1.25 and in Isfahan 1.45 to 1 was reported and in Kermanshah Incidence rate was observed among boys (30-32). According to information obtained Incidence rate of CH in the Fars province among boys than girls are more which is not consistent with previous studies. Giuseppe and partners (2012) examined the distribution of neonatal TSH using GIS in Italy. According to the results, in northern Italy, 35% of the population of neonatal with 99 percentile threshold disease their TSH is lower than the southern part of the region. According to the authors, in the southern part concentration of iodine near the coast is high due to gas in the sea. And considering that people living near the beach, so for the southern part should consider a higher percentage than the 99 percentile (33,34). According to the spatial pattern obtained from of developments place - time incidence of CH in newborns Fars province, its spatial variation was not statistically significant. Also focus of the spatial pattern of the disease using spatial autocorrelation index indicated that this pattern of a quasi-uniform pattern, towards pattern rather focused is changing, but this change is not severe enough that it can be noted that location we have focused pattern. In fact spatial distribution pattern of CH in newborns based on the statistical significance level (p-value) of the total study period is a random pattern this suggests that the decrease in uniformity and tend to focus on specific zones of space that may be this pattern (focus of location) happen in the next few years(Table 1). 

The time zone value the incidence of CH based on neonatal TSH levels during 2005-2013indicated city of Shiraz in the first period (2005), Arsanjan city in the second period (2009) and the city of Abadeh and seal in the third period (2013) The most focus of disease CH in newborns based on TSH levels compared to other regions of Fars province and and the cities like Firoozabad, Qyrvkarzyn, Zarindasht, Lar and Kazeroon been fluctuating during this period.

Conclusion:

Based on our findings, it can be stated that the spatial distribution pattern of CH in newborns in Fars province during the period, showing the differences in each year. Since, the most basic principles of non-communicable fighting against diseases such as CH in newborns, Creation a change in people's lifestyles it seems to be through education and empowerment of people, policy making and creating laws and regulations required in order to create an environment that promotes appropriate behavior and healthy lifestyles, This is achieved and with correct intervention in the society impact of many of risk factors eliminated or reduced.  This results can also identifying factors affecting the incidence of disease in order to better planning and budget and facilities needed for disease control of CH in the Fars province are very helpful.

Abbreviations:

Congenital Hypothyroidism (CH) 

Geographic Information System (GIS)

Intelligence quotient (IQ)

Inverse Distance weighting (IDW)

Shiraz University of Medical Sciences (SUMS)

Declarations:

Data availability:

All data gathered and generated during this study are included in this published article as supplementary information files.

Acknowledgments: 

Authors wish to thank all staff of Shiraz University of Medical Sciences for their kindly help in data access.

Author’s contributions: 

All authors contributed equally to the study. AG and NM conceptualized the study design, AG revised the manuscript, submitted to the journal and responded to the reviewers’ comments. Ra.S and Ro.S Acquisition of data, geocoded the point data, conducted data analysis and interpretation. All authors approved the final version of the article, including the authorship list. All authors read and approved final manuscript.

Competing interests: 

The contributing authors have no potential conflict of interest.

Additional information: 

Correspondence and requests for materials should be addressed to A.G.

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Table:

Table 1: Indicators of spatial autocorrelation in the cities during 2005-2013