ALCOHOLISM: CLINICAL AND EXPERIMENTAL RESEARCH

Vol. 39, No. 6 June 2015

Prevalence of Fetal Alcohol Syndrome in a South African City with a Predominantly Black African Population Michael F. Urban, Leana Olivier, Denis Viljoen, Chanelle Lombard, Jacobus G. Louw, Lian-Marie Drotsky, Marleen Temmerman, and Matthew F. Chersich

Background: Fetal alcohol spectrum disorder (FASD) and fetal alcohol syndrome (FAS) are common in some South African populations, notably those of mixed ancestry descent in rural areas and small towns. Little is known about FAS/FASD prevalence in the majority of South Africans: city dwellers of Black African ethnicity. This study describes the prevalence of FAS in a South African city, comparing 2 suburbs with predominantly mixed ancestry (Roodepan) and Black African (Galeshewe) populations that house over 60% of the city population. Methods: We conducted a tiered, active case ascertainment study for the prevalence of FAS and also detected some less clinically specific FASD cases. All first-grade learners in the 2 suburbs were eligible for anthropometric screening, and screen-positive learners were assessed for dysmorphic features of FAS. Those with suggestive clinical features received neurocognitive assessment, and maternal or collateral interview. Final diagnosis was made following a case conference. Results: Complete ascertainment of FAS status was made in 1,503 (94.7%) of 1,587 eligible learners (435 in Roodepan and 1,152 in Galeshewe). Overall, FAS was diagnosed in 83 (5.5%, 95% confidence interval [CI] = 4.4 to 6.8) learners and FASD in 96 (6.4%, 95% CI = 5.2 to 7.7). Levels of FAS were high in both areas: 26 (6.3%, 95% CI = 4.2 to 9.2) learners from Roodepan, compared to 57 (5.2%, 95% CI = 4.0 to 6.7) from Galeshewe (p = 0.39). No cases were previously diagnosed. The mortality rate for mothers of FASD children from Galeshewe was 19 of 65 (29%), compared to 3 of 31 (9.7%; p = 0.03) for Roodepan. Interviewed mothers in Galeshewe were older and had higher body mass index. Conclusions: Prevalence of FAS is high in both Galeshewe and Roodepan, and the lack of prior diagnoses indicates that awareness remains low. The maternal mortality rate was especially high in Galeshewe. The unexpectedly high burden of FAS in an urban area with predominantly Black African population mandates extension of surveillance and intervention measures in southern Africa. Key Words: Fetal Alcohol Syndrome, South Africa, Prevalence, Ethnicity, Alcohol.

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ETAL ALCOHOL SYNDROME (FAS) and fetal alcohol spectrum disorder (FASD) more broadly result from the adverse effects of alcohol on the developing fetus and constitute an important cause of developmental disability worldwide (Jonsson et al., 2014). The primary risk factor for FASD is alcohol consumption by pregnant women, especially in a regular and heavy episodic drinking pattern,

From the Division of Molecular Biology and Human Genetics (MFU, LO, DV, CL), Faculty of Health Sciences, University of Stellenbosch, Cape Town, South Africa; Foundation for Alcohol Related Research (FARR) (LO, DV, CL, JGL, L-MD), Cape Town, South Africa; International Centre for Reproductive Health (MT, MFC), Department of Obstetrics and Gynaecology, University of Ghent, Ghent, Belgium; and Wits Reproductive Health and HIV Research Institute (MFC), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. Received for publication November 23, 2014; accepted March 9, 2015. Reprint requests: Michael F. Urban, FCPaed(SA), Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, University of Stellenbosch, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa. Tel.: +27-21-938-9124; Fax: +27-21-9389863; E-mail: [email protected] Copyright © 2015 by the Research Society on Alcoholism.

but multiple environmental cofactors are important and it is more common in women of low socioeconomic status (Abel and Hannigan, 1995; May and Gossage, 2011; May et al., 2013b). Genetic factors may also predispose to FASD (Khaole et al., 2004; Warren and Li, 2005). Rates of FASD vary between ethnic groups—for example, in the United States, there is an increased risk among Native Americans and Blacks, compared to Whites and Hispanics (Chartier et al., 2013). Ethnicity, however, is a complex concept that encompasses ancestry, national group, birthplace, and language—each of which could have distinct relationships to alcohol-related harm (Cheung, 1993). This makes it difficult to determine whether ethnic variation in FAS prevalence relates to drinking behavior and associated cultural or historical factors, or to environmental and even genetic cofactors. Nonetheless, ethnicity is a commonly used demographic indicator, and it is therefore important to explore the extent to which it serves as a risk factor for FAS in a particular environment. FAS and FASD occur with very high prevalence in some South African populations (May et al., 2000, 2007, 2013a; Olivier et al., 2013; Urban et al., 2008; Viljoen et al., 2003, 2005), but nationwide data are not available. To date, FAS

DOI: 10.1111/acer.12726 1016

Alcohol Clin Exp Res, Vol 39, No 6, 2015: pp 1016–1026

FAS IN AN URBAN BLACK SOUTH AFRICAN POPULATION

prevalence studies in South Africa have almost exclusively targeted populations with 2 demographic characteristics believed to confer increased risk: (i) residents of rural areas or small towns, and (ii) areas with populations comprising predominantly the mixed ancestry minority group, designated officially as “Coloured.” However, the South African population is 79% Black African and only 9% Coloured, and currently over 60% of the population is urbanized due to rapid urbanization in the last 3 decades (Statistics South Africa, 2011). See the Appendix for a fuller description of the “Coloured” and “Black African” population groups in South Africa. Alcohol abuse is common among adults in South and southern Africa (World Health Organization, 2014), and risky drinking is among the commonest modifiable risk factors for ill health in the region (Lim et al., 2012). Two national surveys found that 15 to 19% of Black African women reported ever drinking alcohol, a rate approximately half that of Coloured women (Department of Health and Medical Research Council, 2007; Parry et al., 2005). Among Black African women, alcohol consumption was higher if they were urbanized, and risky weekend drinking was a common drinking pattern. Morojele and colleagues (2010) also found significant rates of risky drinking among urban Black African women. The evidence regarding FAS prevalence in city-dwelling and Black African populations of South Africa is limited to a single study in metropolitan Gauteng (Viljoen et al., 2003). This study found 1.9% prevalence of FAS among 830 firstgrade learners, with 1.7% prevalence in the subset of 414 learners from 2 predominantly Black African suburbs. The small sample size did not allow for extrapolation to the whole metropole, with over 8 million Black African inhabitants. The current study, conducted at the request of the Northern Cape provincial government, aimed to describe the prevalence of FAS in an urban center where risky drinking is believed to be common. Two suburbs were selected for the study, with predominantly Coloured and Black African populations, respectively. MATERIALS AND METHODS Study Population The study was conducted at primary schools in the Galeshewe and Roodepan suburbs of Kimberley, the capital city of the sparsely populated Northern Cape Province of South Africa. Kimberley has 236,000 inhabitants and is among the oldest towns in the interior of the country. It developed during the diamond rush of the 1870s and diamond mining has since been the backbone of its economy, which has stagnated in recent decades due to downscaling of mining operations. Galeshewe developed during the diamond rush and is among the oldest “townships” in South Africa, dating to the 1880s (the term township refers to a high-density suburb set aside for Black South Africans, often in the apartheid era). It has a population of 118,000 people (Sol Plaatjie Municipality, unpublished data) with an ethnic composition of 92% Black African, 7% Coloured,

1017

and 1.0 1.0 to 1.9 ≤ 2.0 Performance > 1.0 1.0 to 1.9 ≤ 2.0 Practical reasoning > 1.0 1.0 to 1.9 ≤ 2.0

Roodepan

Galeshewe

p

n = 1,510 715 (47.4%) 6.34 years (0.61)

n = 411 195 (47.4%) 6.19 (0.57)

n = 1,099 520 (47.3%) 6.39 (0.62)

0.96*

Prevalence of fetal alcohol syndrome in a South African city with a predominantly Black African population.

Fetal alcohol spectrum disorder (FASD) and fetal alcohol syndrome (FAS) are common in some South African populations, notably those of mixed ancestry ...
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