EPA-60Q/1-77 015
Marcr- 1977
Environmental Health Effects Rssearc-
FACTORS ASSOCIATED WITH THE INCIDENCE
OF CONGENITAL ANOMALIES:
A Localized Investigation
Health Effects Research Laboratory
Office of Research and Development
U.S. Environmental Protection Agency
Research Triangle Park, North Carolina 27711
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RESEARCH REPORTING SERIES
Research reports of the Office of Research and Development, U.S. Environ-
mental Protection Agency, have been grouped into five series. These five broad
categories were established to facilitate further development and application
of environmental technology. Elimination of traditional grouping was con-
sciously planned to foster technology transfer and a maximum interface in
related fields. The five series are:
1. Environmental Health Effects Research
2. Environmental Protection Technology
3. Ecological Research
4. Environmental Monitoring
5. Socioeconomic Environmental Studies
This report has been assigned to the ENVIRONMENTAL HEALTH EFFECTS
RESEARCH series. This series describes projects and studies relating to the
tolerances of man for unhealthful substances or conditions. This work is gener-
ally assessed from a medical viewpoint, including physiological or psycho-
logical studies. In addition to toxicology and other medical specialities, study
areas include biomedical instrumentation and health research techniques uti-
lizing animals—but always with intended application to human health measures.
This document is available to the public through the National Technical Informa-
tion Service, Springfield, Virginia 22161.
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EPA-600/1-77-016
March 1977
FACTORS ASSOCIATED WITH THE INCIDENCE OF CONGENITAL
ANOMALIES:
A Localized Investigation
John A. Burdeshaw and Sheldon Schaffer
Southern Research Institute
2000 Ninth Avenue, South
Birmingham, Alabama 35205
Contract No. 68-02-0791
Project Officer
Edythalena Tompkins
Population Studies Division
Health Effects Research Laboratory
Research Triangle Park, N.C. 27711
U.S. ENVIRONMENTAL PROTECTION AGENCY
OFFICE OF RESEARCH AND DEVELOPMENT
HEALTH EFFECTS RESEARCH LABORATORY
RESEARCH TRIANGLE PARK, N.C. 27711
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DISCLAIMER
This report has been reviewed by the Health Effects Research
Laboratory, U.S. Environmental Protection Agency, and approved for
publication. Approval does not signify that the contents necessarily
reflect the views and policies of the U.S. Environmental Protection
Agency, nor does mention of trade names or commercial products
constitute endorsement or recommendation for use.
n
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FOREWORD
The many benefits of our modern, developing, industrial society are
accompanied by certain hazards. Careful assessment of the relative risk
of existing and new man-made environmental hazards is necessary for the
establishment of sound regulatory policy. These regulations serve to
enhance the quality of our environment in order to promote the public
health and welfare and the productive capacity of our Nation's population.
The Health Effects Research Laboratory, Research Triangle Park,
conducts a coordinated environmental health research program in toxicology,
epidemiology, and clinical studies using human volunteer subjects. These
studies address problems in air pollution, non-ionizing radiation,
environmental carcinogenesis and the toxicology of pesticides as well as
other chemical pollutants. The Laboratory develops and revises air quality
criteria documents on pollutants for which national ambient air quality
standards exist or are proposed, provides the data for registration of new
pesticides or proposed suspension of those already in use, conducts research
on hazardous and toxic materials, and is preparing the health basis for
non-ionizing radiation standards. Direct support to the regulatory function
of the Agency is provided in the form of expert testimony and preparation of
affidavits as well as expert advice to the Administrator to assure the
adequacy of health care and surveillance of persons having suffered imminent
and substantial endangerment of their health.
This report details the work and results of a program concerned with
studying the relationship of congenital anomalies and parental exposure
to radar at a Fort Rucker, Alabama military base. On the basis of
retrospective data available for the study, this report concludes that
there are no strong indications that the incidence of congenital anomalies
in the Fort Rucker area is higher than normal.
John H. Knelson, M.D.
Director,
Health Effects Research Laboratory
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TABLE OF CONTENTS
Page No,
Abstract vi
I. Purpose, Study Plan, and Summary 1
A. Purpose 1
B. Study Plan 2
C. Summary 4
II. Anomaly Incidence Rates in Coffee and Dale Counties
and in Other Alabama Counties 6
A. County Anomaly Rates 6
B. Division of the Study Period into Early and
Late Subsamples 6
III. Anomaly Incidence Rates at Lyster Army Hospital and
Forty-Six Other Alabama Hospitals 8
A. Hospital Anomaly Rates 8
B. Low Anomaly Rate at University Hospital 9
C. Prediction Limits, Based on a Regression
Analysis, for a Hospital with Certain Character-
istics of Lyster Army Hospital 12
D. Analysis of Certain ICDA Congenital Anomaly
Categories for Alabama Counties, Selected on
Basis of their Rates at Lyster Army Hospital... 13
E. Analysis of Certain ICDA Congenital Anomaly
Categories for Lyster Army Hospital 15
IV. Comparison of Anomaly Incidence Rates at Lyster
with Those Obtained from Other Studies 16
A. Overall Rates 16
B. Rates by ICDA Category 17
V. Early Attempts to Test Association of Lyster
Hospital Anomaly Incidence Rates with Residential
Area of Mother at Time of Birth 19
A. Classification According to Radar Exposure 20
B. Need for Data on Normal Births 20
C. Location of Residences and Radar Sites on
County Maps 20
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TABLE OF CONTENTS (Cont'd)
Page No.
VI. Conclusions and Recommendations 21
Acknowledgment 23
List of References 43
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ABSTRACT
This report concludes that, in net terms, and on the basis
of available retrospective data, primarily from birth records,
there are no strong indications that the incidence of congenital
anomalies in the Ft. Rucker, Alabama area is higher than normal.
The original hypothesis that the situation might be serious has
been traced, for the most part, to earlier reliance on faulty
diagnosing and reporting, and especially to reliance on the
birth certificate, which, there is reason to believe on the basis
of the findings of this study, is a relatively insensitive
instrument for measuring the incidence of congenital anomalies.
The attempt to relate this incidence to specific factors
associated with military life, or in particular to factors
associated with exposure to military radar, was largely un-
successful because the military in effect denied access to
pertinent records on the grounds that no prima facie case had
been made that a problem really exists. Unfortunately, no
fairly positive statement can be made denying the existence of
a problem without access in the first place to pertinent mili-
tary records, or access to present or past military personnel
and families. The most conclusive type of information would,
of course, involve a prospective research approach, and that
was deemed not justifiable without at least the benefit of the
findings of a defensible retrospective study.
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FACTORS ASSOCIATED WITH THE INCIDENCE OF CONGENITAL
ANOMALIES: A LOCALIZED INVESTIGATION
I. PURPOSE, STUDY PLAN, AND SUMMARY
A. Purpose
In 1971, Peacock1 reported what appeared to be unusually
high incidence rates of clubfoot and anomalies of the heart among
infants born in Dale and Coffee Counties, Alabama. These findings
were based on an analysis of birth record data for the period
July 1969-November 1970. Dale and Coffee are adjacent counties
in the southeastern part of the state and are the site of Fort
Rucker, the Army Aviation Center.
These findings gave rise to concern about whether or .
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B. Study Plan
During the study period July 1968-December 1972, the Birth
Defects Center, Department of Pediatrics, School of Medicine,
University of Alabama in Birmingham (UAB), maintained a file of
all birth defects reported each month to the Bureau of Vital
Statistics, Alabama Department of Public Health. Included on
each record are the child's name, race, sex, and date and place
of birth, the parent's name and address, name of attending
physician, and the type of malformation, which was later assigned
a four-digit ICDA code. The reported congenital anomaly incidence
rates were determined, overall and by ICDA category for each
Alabama county, by dividing the number of reported anomalous
births by the number of live births reported to the Bureau of
Vital Statistics during the study period.1 In the absence of
acceptable national rates, the incidence rates for Coffee and Dale
Counties were then compared to the rates for the other 65 counties
in Alabama.
Lyster Army Hospital at Fort Rucker was particularly sus-
pect as having significantly higher-than-usual anomaly rates.
This question was investigated by comparing Lyster's rates to
those computed for a sample of 46 other Alabama hospitals. The
sample included the 22 largest hospitals in the state and approxi-
mately 20 percent of the remaining hospitals. A questionnaire
that requested information on factors that could possibly
influence or explain the quality of anomaly reporting was sub-
mitted to each hospital in the sample. An equation that predicted
a hospital's anomaly rate as a function of its "explanatory"
variables was computed from data reported by the 46 hospitals.
These "hospital variables", which were selected because they might
be associated with reported anomaly rates, are:
1. Number of births at the hospital.
2. Number of incubators in service at each hospital.
3. Whether or not the "APGAR" newborn rating system
is required by the hospital.
4. Number of hours after birth that the birth
certificate is completed.
It is important to realize that these rates are computed from
birth certificate data and may not be a realistic measure of
the true anomaly rate. The reported rates are multiplied by
1,000, thus resulting in number of anomalous births per 1,000
live births.
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5. Average per capita income for the county in which
the hospital is located.
6. Type hospital: government nonmilitary, nongovernment
nonprofit, military, or nongovernment profit.
7. Who completes the birth certificates: medical records
department, nurse, ward secretary, or other.
8. Whether or not the maternity or related staff
attend in-service training programs.
9. Ratio of the number of pediatricians to the number
of births during a specific week.
10. Ratio of the number of registered nurses to the
number of births during a specific week.
11. Ratio of the number of licensed practical nurses
to the number of births during a specific week.
12. Ratio of the number of ward clerks to the number
of births during a specific week.
13. Average age of mothers giving birth at each
hospital.
14. Percentage of nonwhite births for each hospital.
Values of Lyster Army Hospital's explanatory variables were then
substituted into the prediction equation to see if the overall
observed anomaly rate for Lyster fell within "normal" limits.
Finally, anomaly rates observed at Lyster for the study
period were compared with some other congenital anomaly studies,
whose purpose was to establish baseline rates against which rates
determined at other hospitals or clinics could be compared.
Particular attention was given to a recently reported study,1
conducted at a hospital affiliated with Mayo Clinic. In the Mayo
study, infants were observed for anomalies on the day of birth
and, also, the fourth day after birth.
1. Lloyd E. Harris, Lois A. Stayura, Perla F. Ramirez-Talavera,
and John F. Annegers, "Congenital and Acquired Abnormalities
Observed in Live-Born and Stillborn Neonates", Mayo Clinic
Proceedings, Vol. 50, February 1975.
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C. Summary
The findings in this Alabama study were of two types—
evidence for and against the conclusion that there is an unusually
high anomaly incidence rate in the Fort Rucker area. The evidence
against such a conclusion is as follows:
1. During the study period July 1968-December 1972,
the overall rates for Coffee and Dale Counties,
in which Rucker is situated, rank only sixth and
eighth among the 67 counties in Alabama.
2. Although the two highest rates in a sample of 47
hospitals are 17.7 at Lyster Army Hospital, Fort
Rucker, and 18.0 at the Air Force Regional Hospital,
Maxwell Air Force Base in Montgomery County,
there are five other hospitals in the Alabama
sample that have rates between 12.2 and 14.5.
There is no statistically significant difference
between these rates and Lyster's.
3. Prediction intervals show that Lyster's overall
rate is well within what would be expected from
a hospital with Lyster's characteristics.
4. When the addresses of the mothers of anomalous
infants were plotted on county road maps, no
significant clustering, especially in the
vicinity of presumed radar sites, was apparent.
5. The rates, by ICDA category, from Lyster seem to
be consistent with rates obtained from carefully
controlled studies, such as one reported recently
from Mayo Clinic.1 Because there is no reason to
believe that Mayo's rates are unusually high, they
should serve as a reasonable "normal control" for
the Rucker study.
6. When the occurrences of anomalies within categories
with the highest rates at Lyster are plotted on a
time axis, significant clustering is apparent.
There is evidence that, in most cases, the reporting
of anomalies within a cluster may be attributable
mainly to one or two physicians, rather than to
the several physicians on the staff at any one
time.
1. Ibid./ Lloyd E. Harris, et al.
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Two observations, however, prevent the question of an
anomaly problem from being dismissed. They are:
1. The two highest rates from the hospital survey,
at Fort Rucker and Maxwell AFB, are both from
military installations and aviation centers.
These rates cannot be explained easily by the
fact that military hospitals are more alert to
the presence of an anomaly, because the rates
at Redstone Arsenal and Fort McClellan in
Alabama are 7.1 and 0.7, respectively.
2. Thirteen of 17 counties with overall rates in
the upper quartile lie within a contiguous band
that has one terminus in Houston, the south-
eastern-most county in Alabama, and that extends
west-northwesterly to Marengo, one county
removed from the Mississippi state line. The
20 counties in the southeast quadrant of Alabama
have ten counties in the upper quartile, and
this is more than can be explained by chance.
This phenomenon, however, may involve more than
a "military base" explanation.
Certainly, on the basis of the available data recorded on
birth certificates, it cannot be concluded that an unusually
large number of infants with congenital anomalies are born to
military personnel at Fort Rucker or to other residents in the
immediate area. Negative findings, however, such as those
developed during the course of this study, leave some questions
unanswered. It is possible, of course, for a birth certificate
study to result in a positive finding. Because of the insensi-
tivity of the measuring device, however, the true anomaly rate
would probably have to be several times higher than "normal" in
order to detect an abnormally high rate. In such a situation, it
is possible that high rates would have been detected and reported
to appropriate state or federal agencies by local medical associ-
ations, newspapers, or concerned citizens, before being detected
by analysis of rates computed from birth certificates.
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II. ANOMALY INCIDENCE RATES IN COFFEE AND DALE COUNTIES
AND IN OTHER ALABAMA COUNTIES
A. County Anomaly Rates
Anomaly rates, overall and categorically (ICDA), and fetal
death rates have been computed by race for each of 67 counties in
Alabama. Because the rates for the nonwhite population are less
than the state average, each county analysis for this report will
be restricted to a consideration of the white population only
(Table 1). The overall anomaly rates for the white population
have been ranked (from highest to lowest) and plotted on a county
map of Alabama. (See Figure 1, in which the county rank is stated
within the parentheses under the rate; the shading on the map
indicates the quartile grouping of the overall county rates.) Of
the 17 counties in the third quartile (highest rates), 13 are in
the southern half of the state. The counties with the eight
highest overall anomaly rates for whites lie contiguously along a
line with one terminus in Houston, the southeastern-most county,
extending west-northwesterly to Marengo in the Black Belt, only
one county removed from the Mississippi boundary. Within this
band of counties, Coffee and Dale rank sixth and eighth, respec-
tively, but Henry, Crenshaw, and Houston Counties, which adjoin
either Coffee or Dale, are ranked second, third, and fifth,
respectively. If these overall rates are higher than would other-
wise be expected under "normal" circumstances, then the underlying
problem is certainly not restricted to Coffee and Dale Counties,
in which Fort Rucker is situated.
Anomaly rates for four categories selected because their
rates at Lyster Army Hospital ranked among the top ten in the
sample of 47 hospitals are also plotted on county maps of Alabama
(Figures 2-5). These will be discussed in a later section.
B. Division of the Study Period into Early and Late Subsamples
The time period, July 1968-December 1972, under study in
this project has been divided into an early period, which was
originally observed by Peacock,1 and a late period, which provides
data for an independent test of the hypothesis2 suggested by results
1. Peter Peacock, et al., loc. cit.
2. The null hypothesis was that there is no difference in the con-
genital anomaly rates between Coffee and/or Dale Counties and
the remainder of Alabama.
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of Peacock's study of the early period. For purposes of this
particular analysis, the early period was considered to be July
1969-December 1970 and the late period was considered to be
January 1971-December 1972. Separate and combined incidence rates
were computed for white residents of Coffee and Dale Counties
(see Tables 2, 3, and 4). The number of live births among white
residents in the two counties for the selected periods are pre-
sented in Table 5.
To determine the statistical significance of the rates for
each anomaly and the all-anomalies category, the probability of
obtaining the observed number of cases, or more, was computed
under the assumption that the anomaly rate for the county or
counties is the same as the rate for Alabama, excluding Coffee and
Dale Counties. The probability thus obtained is reported as the
"Binomial probability", or P-value for a one-tailed test of the
null hypothesis. The assumption is also made that each infant in
Coffee and Dale Counties has an equal probability of being con-
genitally malformed, and that the probability is the same as the
rate for the remainder of the state for the comparable period.
There is little difference in the overall anomaly rates
for the two counties during the combined period. The rate for
Coffee is 12.0 and for Dale is 11.3, both being almost double the
state rate of 6.2. When period differences are examined, a
decrease from 13.9 to 9.0 is evident for Dale. However, a change
of this magnitude provides insufficient evidence to reject
equality of overall rates for the two periods. There is a slight,
but insignificant, increase from 11.4 to 12.5 for Coffee.
Compared to the state rates, the only individual anomaly
categories for Coffee County that appear to be significant for the
combined period are Genital Organs (ICDA No. 752), and Other Limbs
(755) . All four of the Genital Organ Anomalies were reported
during the late period, and the six anomalies in the Other Limbs
category were divided equally between the two periods. No cate-
gory showed a dramatic change from one period to the next, with
the possible exceptions of the increase from zero to four in Other
Limbs and a decrease from four to one in Clubfoot (754) .
The individual anomaly categories for Dale County, in de-
creasing order of significance, are Genital Organs (ICDA No. 752),
Circulatory (747) , Other Limbs (755), and Musculoskeletal (756) .
It should be noted, though, that the occurrence of one or two cases
of an anomaly with a low incidence in the state may produce a
highly significant result for the county. This is evidenced in
the Circulatory category, where the state rate is less than 0.05
per 1,000 births, and the reporting of two cases in Dale County
results in a low P-value of 0.002. For three of the four most
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significant categories for the combined period, the rates actually
increased from the early period to the late period. Perhaps the
greatest change among the individual categories was a decrease from
six to two cases in Clubfoot.
Some additional insight may be gained by pooling the results
from the two counties. The five most significant categories for
the combined period are the same as the four most significant for
Dale County alone, with the addition of Clubfoot. The most signifi-
cant category was Genital Organs (14 cases), which had a consistent
rate for the two periods. The second most significant was Circula-
tory, but, because only two cases were reported in the two-county
area for the combined period, not much significance can be attached
to this result. The third was Other Limbs (15 cases), with
consistent rates for the two periods. Fourth was Musculoskeletal
with only four cases. Fifth was Clubfoot which showed the most
dramatic change of all categories between the two periods. In the
early period, the reporting of ten cases made Clubfoot the most
significant finding, but the reporting of three cases during the
late period resulted in a rate slightly lower than that of the
state. The reason for this large difference may be attributable
to the fact that Clubfoot is easily overdiagnosed, which may have
been the case during the early period studied by Peacock.
In summary, it appears that virtually all differences in
anomaly rates between the early and late time periods for Coffee
and Dale Counties, separately and combined, are consistent, within
the limits of statistical variation, with the hypothesis of equal
rates for the two time periods. Therefore, for the purpose of com-
paring rates with the remainder of Alabama, it seems justifiable to
pool rates over time periods and the two counties.
III. ANOMALY INCIDENCE RATES AT LYSTER ARMY HOSPITAL
AND FORTY-SIX OTHER ALABAMA HOSPITALS
A. Hospital Anomaly Rates
Anomaly rates based on numbers of births and anomalies for
the four and one-half year period extending from mid-1968 through
1972 have been computed (Table 6) for Lyster Army Hospital at Fort
Rucker and for each of the 46 hospitals in the sample, which was
selected as a basis on which to "adjust" the rates at Lyster. The
hospital anomaly rates, it should be noted, are based on the number
of live births plus the number of stillbirths, whereas the county
rates are the number of anomalies or fetal deaths per 1,000 live
births. Also, it was estimated that the number of births during
the last half of 1968 was one-half the total number of births
during 1968.
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The Air Force Regional Hospital at Maxwell Air Force Base
was highest, with an overall rate of 18.0. Lyster was next highest
with 17.7, followed by L. V. Stabler (Butler County), 14.6; Henry
County, 14.3; North Jackson (Jackson County), 13.4; Hale County,
12.5; and Burdick-West Memorial (Winston County), 12.2. Only one
of the hospitals among those with the highest seven anomaly rates
had a number of births plus stillbirths greater than the sample
median of 3,673. On the lower end of the rate scale, three of the
six very large hospitals (greater than 10,000 births during the
period) were among those with the six lowest rates. University
Hospital (University of Alabama in Birmingham) reported six
anomalies among more than 15,000 births, with none during the years
1970-1972.
When the 46 rates for the hospitals (other than Lyster) in
the study were correlated (unweighted observations) with the
hospital variables listed in Section I(B), only two, number of
births and whether or not APGAR was used, were significantly
related to anomaly incidence. Both of these correlations were
contrary to normal expectations. The larger hospitals had lower
overall anomaly rates than the smaller hospitals (Figure 6) and
those hospitals that used the APGAR scoring system had lower rates
than those that did not. It should also be noted (Figure 6) that
the smaller hospitals were much more variable in their overall
anomaly rates than the larger hospitals. Surprisingly, the average
age of the mother and percentage of nonwhite mothers were not
associated with the anomaly rates. Another moderately surprising
result is that the fetal death rate has no association with the
anomaly rate.
B. Low Anomaly Rate at University Hospital
The anomaly rates at University Hospital in the Medical
Center at the University of Alabama in Birmingham are of special
interest in this study for at least two reasons. First, because it
is a teaching and research hospital, one would expect thoroughness
and expertise in the examination of births for anomalies.
University Hospital would, therefore, be a likely candidate to use
as a "control" hospital against which the rates at Lyster Hospital,
or any hospital suspected of having high rates, could be compared.
Secondly, University Hospital is in the sample of hospitals used
to "adjust", by a regression analysis, the anomaly rates at Lyster
for non-radar factors that reflect hospital characteristics.
Because the regression analysis is weighted and University is
the largest maternity hospital in the study, University has a
great influence on conclusions derived from the analysis.
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During the study period, July 1968-December 1972, a total
of six anomalies were reported on certificates of 14,142 live
births at University Hospital. All six of the anomalies occurred
during the first 18 months of the study period, with not a single
anomaly being reported for approximately 9,000 births during the
last three years of the study. The overall anomaly rate of 0.4
per 1,000 live births computed for University Hospital ranks it
45th from the highest rate among the sample of 47 hospitals for
which data are available, and is only about 1/15 the sample median
rate of 6.4.
The Director of the Laboratory of Medical Genetics, a
faculty member of the School of Nursing, with an emphasis on ob-
stetrics, and the Director of the Newborn Division, Department of
Pediatrics, who has published on certain types of anomalies, all
from UAB, were interviewed in an attempt to find an explanation
for the unusually low incidence rate at University Hospital.
The faculty member of the School of Nursing, who worked in
the Department of Obstetrics and Gynecology at UAB during the
study period, believes the reason that so few anomalies are
recorded for births at University Hospital is a communication
problem. The birth is registered in the delivery room, the mothers
furnish information for the birth certificate, and a physician,
perhaps a resident in obstetrics who did not make the delivery,
may sign certificates for several births at one sitting. Many
anomalies are noted in the nursery, which is under a different
medical service, and may never be reported to the Department of
Obstetrics, the unit responsible for reporting births. Also,
unlike many hospitals where the records of infant and mother are
kept together, University Hospital issues separate hospital
numbers to the two patients, and their care is administered
separately by two different services. The obstetrical nurse esti-
mated that one or two out of every hundred or so births, apparently
births with congenital malformations, are discussed at the peri-
natal conferences. She also said that she remembers that during
the time she was employed by the Department of Obstetrics, which
was a period of 3 or 4 years, there were 30 to 40 births with
anomalies.
The geneticist who was interviewed said that "good"
studies indicate that about 25 out of every 1,000 live births
have an anomaly serious enough to require medical attention.
These "good" studies, to which he referred, more than likely in-
volve some follow-up after delivery, or at least some intensive
examination before the infant leaves the hospital. This geneti-
cist has a particular interest in mongolism, which occurs on
average once in 600 births. One of his medical colleagues,
wanting to study mongoloids, thus expected 40 to be born within
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a six-month period, but only 9 were reported. Substantial under-
reporting is suspected as the reason for the paucity of cases of
mongolism.
The geneticist also commented on the difficulties in diag-
nosing and measuring the incidence of congenital anomalies. Some
anomalies, such as Clubfoot, may be overly diagnosed. For instance,
the feet of some infants naturally turn outward and are not neces-
sarily Clubfoot, but are diagnosed as such. On the other hand,
some anomalies, such as Cleft Lip and Palate, Hydrocephalus,
Anencephalus, and Spina Bifida, are not difficult to diagnose. He
also remarked that the Center for Disease Control (CDC) in Atlanta
often observes clusters of cases in certain areas which apparently
turn out to be artifacts of statistical variation. While not
claiming to be a statistician, he recognizes the need for good
statistical (prospective) studies and believes that conclusions
drawn from birth certificate data are only impressions.
The communication problem referred to by the nurse was
confirmed during an interview with the Director of the Newborn
Division, Department of Pediatrics, University Hospital. He said
that, although the Department of Obstetrics is responsible for
reporting births, a member of the Department of Pediatrics sees a
newborn infant four to six hours after birth. The pediatrician
may note an anomaly once the infant is in the newborn nursery, but
he has no obligation and, usually, no compulsion to mention it to
the obstetrician who made the delivery. Therefore, except in un-
usual circumstances, the finding of an anomaly by a pediatrician
is not reported on the birth certificate. He also said that the
obstetrician does not, as a practice, look for anomalies and will
not usually notice one unless it is overt. When informed of the
anomaly incidence rate computed for University Hospital for a
period during 1968-1972, he was not shocked at its being unu.sually
low; however, in contrast to the medical geneticist who was inter-
viewed, he did not seem to have a well-founded idea about what
anomaly rates were accepted as "normal".
Interviews with a medical geneticist, a pediatrician, and
a former obstetrics nurse indicate that a rather small fraction
of the anomalous births at University Hospital are reported on
birth certificates. Therefore, the overall rate determined for
University is unacceptable as a control for Lyster Army Hospital,
and its influence on any conclusions drawn from a regression
analysis that adjusts incidence rates for hospital characteristics
should be interpreted with caution.
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C. Prediction Limits, Based on a Regression Analysis, for a
Hospital with Certain Characteristics of Lyster Army Hospital
The purpose of the regression analysis is to see if the
overall anomaly incidence rate for Lyster Army Hospital is within
the limits of variation of a sample of 45* other Alabama hospitals
when adjusted for the non-radar hospital factors, such as average
age of mothers, percent of mothers who are nonwhite, and size and
type of hospital. To this end, it seems appropriate to compute a
prediction interval,2 95%, say, as opposed to a confidence
interval,3 for a hospital whose selected non-radar characteristics
are the same as those of Lyster. A prediction interval is
analogous to using the standard deviation, s, of a single obser-
vation to establish "normal" limits, whereas a confidence interval
is analogous to using the standard error of the mean, s/^n", to
measure the precision with which the mean is estimated.
Results of four regression analyses are summarized in
Table 7. The unweighted analysis with no transformation of rates
(Model 1) gives equal weight to each of the hospitals used in
estimating the model parameters, but admits negative predicted
values. Nevertheless, the results are not unreasonable when com-
pared to those obtained by a proper transformation and weighting
of the variables. A logarithmic transformation (Models 2, 3, and
4) of the anomaly rates precludes negative predicted values, but
the observations used in the analysis should be weighted (Models 3
and 4) to make the variances for the observations approximately
equal. These have been weighted by the number of anomalies
reported at each hospital. A prediction interval was computed
using all 18 independent variables (Model 3), but some of these
had so little association with the anomaly rates that they actually
"explained" less of the overall variance than was measured by the
residual variance. Therefore, seven variables were excluded by
the "backward elimination" variable selection procedure, and the
prediction interval was re-computed (Model 4) and had narrower
limits than those yielded by the full model analysis.
1. Macon County Hospital, by far the smallest maternity hospital
in the study, was excluded from the regression analysis.
2. Franklin A. Graybill, An Introduction to Linear Statistical
Models, Volume I, McGraw-Hill Book Co., Inc., New York, 1961,
pp 122-124.
3. Ibid., pp 121-122.
-12-
-------
The anomaly rate, 17.7, observed at Lyster for the period
July 1968-December 1972, is remarkably close to the rates of 18.8
and 17.2 predicted by the weighted models using transformed rates
and, for each model, is well within those limits predicted for
Lyster Army Hospital.
Similar type analyses were planned for certain categories
selected on the basis of higher frequency of occurrence of these
anomalies at Lyster. However, the number of hospitals with zero
occurrences during the study period ranged from seven for Other
Limbs to 31 for Musculoskeletal. Because the regression equation
developed for the overall rate involved logarithmic transforma-
tions of the rates, those hospitals with zero rates would
necessarily be dropped from the analysis, thus leaving, in most
cases, an inadequate number of hospitals on which to base reason-
able conclusions.
It is possible, though, to pool the data for Clubfoot, Other
Limbs, and Musculoskeletal into a general heading of Musculo-
skeletal. These are categories in which Lyster ranked among the
highest in the sample of 47 hospitals. Only five of the 47
hospitals failed to have at least one anomaly in the pooled clas-
sification. These five hospitals, with the exception of
University Hospital, Birmingham, are all much smaller than Lyster,
and can, with some justification, be dropped from a regression
analysis. Because of time limitations,• this analysis was not
performed.
D. Analysis of Certain ICDA Congenital Anomaly Categories for
Alabama Counties, Selected on Basis of their Rates at Lyster
Army Hospital
Of the twenty ICDA categories for congenital anomalies,
there are eleven in which Lyster either had no entries for the
period July 1968-December 1972 or did not rank in the top ten in
the sample of 47 Alabama hospitals. These categories are as
follows:
ICDA Anomaly
740 Anencephalus
741 Spina Bifida
742 Hydrocephalus
744 Eye
745 Ear, Face, Neck
748 Respiratory
749 Cleft Palate or Lip
751 Digestive System
753 Urinary System
758 Unspecified
759 Multiple
-13-
-------
In addition to the above, there are four categories in which
Lyster ranked in the top ten, but the number of anomalies for the
four and one-half year period was either one or two and, therefore,
should not cause any special concern. These are:
ICDA Anomaly
743 Nervous System
747 Circulatory
750 Upper Alimentary
757 Skin, Hair, Nails
Because the aforementioned congenital anomaly categories either
had two or fewer entries or had a comparatively low incidence
rate, only the remaining categories, in which Lyster had at least
five entries and ranked in the top ten within the sample of 47
hospitals, will be examined more closely:
Lyster Army Hospital
ICDA Anomaly Number Rate, IQOCT1 Rank
746 Heart 12 2.5 3
752 Genital Organs 19 4.0 1
754 Clubfoot 19 4.0 2
755 Other Limbs 15 3.2 8
756 Musculoskeletal 5 1.1 2
Interestingly, the last three categories, Clubfoot, Other
Limbs, and Musculoskeletal, are all musculoskeletal in nature and
could well be combined for purposes of analysis.
Selected on the basis of Lyster's high rates relative to
other Alabama hospitals, the categories of Heart, Genital Organs,
Clubfoot, and Other Limbs have been depicted graphically on county
maps of Alabama (Figures 2, 3, 4, 5). On each map, the category
incidence rate, per 1,000 live births, and its rank within the
state are given for each of the 67 counties for which anomalies
were reported. Each quartile of rates has a different shading.
Those counties which reported no anomalies for a particular cate-
gory for the study period have entries of 0 and are unranked.
Because the four individual categories were chosen for
having high rates at Lyster Army Hospital, it is not surprising
that the rates for Dale and Coffee Counties, in which Fort Rucker
is located, rank among the top ten in the state. However, there
is only one category, Genital Organs, in which either or both
counties rank within the top five; Dale ranks first and Coffee,
fourth. For each of the other three selected categories, there
are two counties bordering Coffee or Dale that have higher rates
than both Coffee and Dale. In fact, Houston is one of the two
counties with rates higher than Coffee and Dale in each of the
-14-
-------
three categories. Using other Alabama counties as controls, we
cannot conclude that a serious congenital anomaly problem is mani-
festing itself in these selected categories. Any problem, if one
exists, extends beyond Coffee and Dale Counties.
E. Analysis of Certain ICDA Congenital Anomaly Categories for
Lyster Army Hospital
The race, sex, attending physician, and residence of mother
for each of the 84 anomalous infants born at Lyster Army Hospital
during the study period are listed by month and year of birth for
each of the anomaly categories which included more than two
infants (Table 8).
There were a total of 17 attending physicians during the
four and one-half year period, none of whom reported an anomaly
either before or after a particular two-year interval. This ob-
servation suggests that these physicians were stationed at Lyster
Army Hospital for a period not exceeding two years. At any par-
ticular time during the study period there were at least four to
six attending physicians on the staff.
Examination of time trends within the individual categories
and, also, across categories reveal several interesting patterns:
1. Four of the five diagnoses for Cleft Palate or
Lip were made within a seven-month period during
the early part of the study. Interestingly, all
four were reported by Physician B, who had only
four other diagnoses of anomalies. Given that
Physician B had eight anomalies to report, four
appears to be a disproportionate number to report
for a particular category.
2. Within the Heart category, there appears to be a
moderate amount of clustering in late 1968 and
early 1969. Most of these were reported by
Physicians C and B.
3. Three equally spaced clusters are apparent within
Genital Organs, and the reporting within any one
cluster cannot be credited to one or two physicians.
4. A heavy concentration of reported Clubfoot is evi-
dent in 1969, twelve of the nineteen cases for the
entire study period occurring within this one year.
However, six of the twelve may be attributed to
Physician D, and, perhaps significantly, he reported
no other type of congenital anomaly.
-15-
-------
5. Within the Other Limbs category, there is a moderate
amount of clustering during late 1970 and 1971, but
half of that may be ascribed to Physician F, who
made almost twice as many diagnoses, fifteen, for
all categories than any other physician at Lyster.
With the exception of Genital Organs, the apparent clusters
are attributable primarily to one or two physicians of the minimum
of four to six who are responsible for reporting births in a given
month. These phenomena may be explained by one or more of the
following reasons:
1. A physician is particularly alert to the occurrence
of a certain type anomaly and reports it when it
exists (true positive).
2. A physician is overly zealous concerning a certain
type and reports it when it does not really exist
(false positive).
3. Particular clusters, which are attributable to one
or two physicians, are chance phenomena.
With the paucity of information available and with no follow-up of
these cases, it is impossible to determine with certainty which of
the above reasons is pertinent. However, a very few instances
of "overreporting", as in reason (2), above, would result in
Lyster"s relatively high ranking in some categories.
IV. COMPARISON OF ANOMALY INCIDENCE RATES AT LYSTER
WITH THOSE OBTAINED FROM OTHER STUDIES
A. Overall Rates
Many problems that arise in measuring the incidence of
congenital malformations are discussed by Warkany in Congenital
Malformations.! Incidence rates are reported from at least 11
studies conducted at hospitals or clinics in several countries
over a 30-year period. Differing interests of the authors and
ethnic, racial, or geographic factors can influence incidence
figures greatly. Also, the inclusion or exclusion of stillbirths
1. Joseph Warkany, Congenital Malformations, Yearbook Medical
Publishers, Chicago, 1971
-16-
-------
and minor abnormalities, the length of time after birth that the
newborn was observed for detection of an anomaly, as well as other
factors, affect the rates. Nevertheless, examination of some of
these figures may give an idea of what overall rates might be con-
sidered as "normal". These estimates of anomaly rates at hospitals
and clinics ranged from 8.9 to 74 per 1,000 live births, with half
the rates being between 13 and 30. The median value was about 20
computed for major anomalies in newborn babies.1
The estimates from clinics and hospitals are understandably
higher than rates obtained from birth registration records.
According to Warkany,2 incidences from birth records varied from
7.4 to 11.6 in the United States. With special efforts, higher
figures, between 13.7 and 19.8, were obtained in directed studies.
The Lyster Army Hospital anomaly rate, also determined from birth
records for the four and one-half year study period, was 17.7,
with approximate 95 percent confidence limits of 13.9 and 21.4.
Certainly the Lyster rate is consistent with those obtainable
from directed birth certificate studies.
B. Rates by ICDA Category
A recent paper by Harris, et al,3 reports on abnormalities
observed during the first four days of life in 21,142 live-born
infants born at a Mayo Clinic affiliated hospital in Rochester,
Minnesota, during the period January 1, 1951 through December 31,
1963. The purpose of the Mayo study was to provide base-line data
on the incidence of abnormalities present at birth for use in com-
parative studies among different populations. The newborn infants
were examined for congenital anomalies within the first 24 hours
after birth and later in the newborn nursery. The large majority
of the mothers were from the Rochester area, and the population
represented is almost entirely of Northern European extraction.
1. P. M. Marden, D. W. Smith, and M. J. McDonald, "Congenital
Anomalies in the Newborn Infant, including Minor Variations.
A study of 4,412 Babies by Surface Examination for Anomalies
and Buccal Smear for Sex Chromatin", Journal of Pediatrics,
Vol. 64, p 357, 1964.
2. J. Warkany and H. Kalter, "Congenital Malformations", New
England Journal of Medicine, Vol. 265, p 993 and p 1046, 1961
3. Ibid, Lloyd E. Harris, et_ al.
-17-
-------
Each of the 89 anomalies reported for the 84 anomalous
infants born at Lyster during the study period has been assigned
a four-digit ICDA code. The rate (per 1,000 live births) for each
category was then computed and compared to the corresponding rates
reported in the Mayo study (Table 9). One cannot reasonably
expect a perfect assignment for each of the anomalies to its
appropriate sub-classification, but in most cases, the category
to which an anomaly belonged seemed clear from its description on
the birth certificate. Only the categories in which Lyster had
an entry are given, there being as many more categories in which
Mayo reported an anomaly and Lyster reported none.
For the 29 categories compared in Table 9 there are 18 in
which the Lyster rate exceeds the Mayo rate, although most of the
18 positive differences are obviously trivial. A more objective
test would be to compute the probability of obtaining the observed
number of Lyster anomalies, or more, in 4,750 live births, given
that the total number of anomalies for a particular category in
the combined study groups is that number observed. This test is
performed by means of an F statistic, and is described in
Brownlee.1 The P-value thus obtained is a measure of the departure
of the observed rates from the hypothesis of equal rates; the
smaller the P-value, the more significant the difference in rates.
If significance is claimed for P-values less than 0.10, then the
only significant differences are for 755.7, Other Anomaly of Lower
Limbs (P <.05), and 754, Clubfoot (P <.001).
In the category Other Anomaly of Lower Limbs, there are no
entries from Mayo and two from Lyster; from Lyster, one is a
positional bowing of a leg and the other is an anomaly of the foot
(clubfoot?). An improper classification of an anomaly in either
study would cause a seemingly significant finding.
The difference in rates in the Clubfoot category are highly
significant. However, it is well-known that this anomaly is
easily over-diagnosed. It was noted in a previous section that
12 of the 19 reported cases of Clubfoot occurred in the same year
(1969) of the four and one-half year study period, and six of the
twelve were reported by the same physician. Moreover, Mclntosh,
et al,2 reports a Clubfoot (Talipes and/or Metatarsus Varus) rate
of" TJ.4 per 1,000 live births compared to Lyster's 4.0.
1. K. A. Brownlee, Statistical Theory and Methodology in Science
and Engineering, 2nd Ed., John Wiley and Sons, Inc., New York,
1965, pp 183-185.
2. R. Mclntosh, K. K. Merritt, M. R. Richards, M. H. Samuels, and
M. T. Bellows, "The Incidence of Congenital Malformations: A
Study of 5,964 Pregnancies", Pediatrics, Vol. 14, p 505, 1954.
-18-
-------
Comparison of Lyster's rates with those measured in the
Mayo study does not suggest that the Lyster rates are unusually
high.
V. EARLY ATTEMPTS TO TEST ASSOCIATION OF LYSTER HOSPITAL
ANOMALY INCIDENCE RATES WITH RESIDENTIAL AREA
OF MOTHER AT TIME OF BIRTH
One of the principal reasons that this study was initiated
was a concern that non-ionizing radiation from radar might possibly
cause a higher incidence of anomalies among the newborn. Of
course, if it cannot be established that the anomaly incidence
rates are significantly higher than those in suitable controls,
then an investigation to determine causal or associated factors
cannot readily be justified.
In the early phases of this study, it appeared that the
rates in the Fort Rucker area were considerably higher than else-
where in the state, and plans were formulated to obtain data that
might aid in explaining the high rates. These data were mainly
medical and occupational items measured on military personnel and
their spouses, who were stationed at Fort Rucker during the time
interval being studied. However, when permission to obtain certain
items of information was requested of the Office of the Surgeon
General (OSG), Department of the Army, it was denied, although
never formally.
An independent evaluation of the anomaly data, presented
in previous sections of this report, shows that the Lyster rates
are consistent with those found in several other studies and in
other Alabama hospitals. Therefore, the acquisition of sensitive
data from OSG for that reason does not appear to be necessary.
It is possible, however, for there to be an association
between radar exposure and incidence of congenital anomalies, even
though the average county and hospital incidence rates are within
normal limits. Of interest, but impossible to measure with the
data made available, is the within.-county or within-geographical
area variation of anomaly incidence. If radar is an environmental
hazard, then sub-county areas with high radar intensity might also
have a higher incidence of anomalies than other areas. This, of
course, might cloud an association between occupational exposure
and anomaly incidence.
Along these lines, consideration was given to measuring the
relative risk of giving birth to an anomalous infant for a mother
whose residence is within a radar-affected area. This requires
that each birth in a sample of births be classified by two factors:
-19-
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1. Radar exposure at a critical period before or
during pregnancy.
2. Whether or not the infant is anomalous.
A. Classification According to Radar Exposure
Late in the study, a map was furnished to the Institute of
a nine-county area of southeast Alabama and neighboring parts of
Georgia and Florida on which navigational radar sites were indi-
cated. Also included with the map was a classification of types
of installations according to certain operational characteristics,
such as power, frequency, and beam direction. Approximately 15
or 20 installations were active during the four and one-half year
period under study. Had this information been received earlier,
it may have been possible to determine the approximate areas that
are subjected to hazardous amounts of non-ionizing radiation from
these radar sites, and to determine thereby whether these areas
have higher than normal incidences of congenital anomalies.
B. Need for Data on Normal Births
The data collected for the study pertained only to anomalous
infants. Inquiries into the availability of similar information
for a sample of normal births were made to the Alabama Bureau of
Vital Statistics. It was learned that, with a moderate amount of
effort, birth data for normal births matched by race and sex with
the 84 anomalous infants born at Lyster could be provided. At
first, a condition for obtaining this type data from Vital
Statistics was approval of officials at Lyster Hospital, who had
earlier said that authorization would be required from a higher
source. Late in the program, the Institute was advised that, if
permission could not be obtained through the hospital, the
Institute could petition the State Board of Health for the birth
records. Because of time and monetary constraints, this route
was also not pursued further.
C. Location of Residences and Radar Sites on County Maps
In anticipation of acquiring data for normal births, the
locations of radar sites and residences of most of the mothers of
anomalous infants at time of birth were indicated on large county
maps. No significant clustering was apparent near any of the
radar sites. However, this crude analysis was unsatisfactory for
at least two reasons:
-20-
-------
1. No residences of mothers of normal infants could
be used for comparison.
2. Residence of mother at time of delivery may not
have been her residence before or soon after
conception.
Because the areas affected by radar and the residences of the
mothers can be accurately located on large county maps, it should
be possible, with more data, to compute the relative risk of
having an anomalous infant for mothers living within a radar-
affected area. However, efforts in this-regard have been
inconclusive.
VI. CONCLUSIONS AND RECOMMENDATIONS
As was perhaps realized before this study began, the birth
certificate is a highly insensitive device with which to measure
anomaly incidence rates. Several reasons for this are obvious.
Some defects are not recorded, even when recognized, because of
possible future embarrassment to the parents or the child. This
is especially true if it is a type anomaly that is correctable by
simple surgery, or one that is self-correcting during the child's
early life. Often the person responsible for furnishing the vital
statistics for the birth has not been trained to recognize birth
defects. In this case, only the most overt anomalies will be
noticed, and then there is no guarantee that it will be recorded.
In some hospitals, the birth record is completed without specific
inquiry as to whether or not an anomaly was found. In these situ-
ations, it is only by accident that a malformation is recorded on
the birth certificate. On the other hand, some anomalies, such
as Clubfoot, are easily overdiagnosed, and a physician, or
physicians, who think they detect certain types of anomalies when
they do not exist can cause the overall anomaly rate in an area
to be inflated.
Military hospitals, such as Lyster Army Hospital at Fort
Rucker, Alabama, are atypical in certain respects. There is a
complete turnover in the staff of obstetricians and pediatricians
every two years. As concerns the appearance of certain anomalies
during a certain period of time, there is sometimes no way of
knowing whether this is characteristic of the medical staff
stationed there, or whether it is an outbreak caused by some
hazard. In addition to the turnover of physicians, the patient
population is likely to be transitory. Thus, if radar, or any
other factor, somehow caused a mother to give birth to an anomalous
infant, and she was not at Lyster at time of delivery, the Lyster
-21-
-------
rates would not reflect this. Moreover, it may be that most of
the infants at Lyster are born of parents who lived elsewhere at
a hypothetical critical time during pregnancy when radar could
cause birth defects. These questions were not answerable during
this particular study.
Three types of analyses lead to the conclusion that birth
certificate data contains insufficient evidence with which to
infer the existence of significantly higher rates in Dale and
Coffee Counties, Alabama, and at Lyster Army Hospital, in partic-
ular. These are:
1. The county analysis, in which Coffee and Dale
ranked only sixth and eighth in overall rates
among the 67 counties in Alabama.
2. The hospital analysis, in which the observed
rate for Lyster was well within limits deter-
mined from other hospitals.
3. Comparison with other studies, particularly
one reported recently from Mayo Clinic, in
which the rates were, for the most part,
consistent with those reported for Lyster.
It may be that, before a problem is serious enough to be
detected by analyses based on birth certificates, it would have
been obvious to, or at least highly suspected by, local residents
and local medical practitioners, especially those whose practice
includes obstetrics and pediatrics. Sensitive methods of detec-
tion should therefore be based on well designed studies in which
tighter control can be exerted on the techniques used to diagnose
and report congenital anomalies. These are usually of a pros-
pective nature and may involve thousands of patients, especially
when attempting to detect events that are relatively rare.
If a number of responsible persons are convinced that a
serious health problem is prevalent in their community, then it
should not be too difficult to enlist the support of local
residents in verifying the problem and investigating its cause.
An investigation of a problem involving birth defects would
necessarily require the cooperation of almost all health pro-
fessionals in the area, particularly physicians whose practice
includes obstetrics or pediatrics, hospital administrators, and
the public health department.
Investigations of causal factors, or factors associated
with birth phenomena, would require obtaining information about
factors such as nutrition, occupation, other disease, medical
-22-
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regimens, and residence of the parents during the year or so before
delivery. This information gathering process could perhaps be
initiated with the first prenatal visit of the prospective mother.
A standard protocol that includes items designed to reveal
anomalies that are not immediately obvious, or that could possibly
be caused by radiation exposure, could be developed by a committee
of experts on congenital anomalies and on factors suspected to be
associated with anomalies. The protocol could then be followed
uniformly immediately after birth and then again before the
newborn infant leaves the hospital. Because all congenital defects
are not apparent at birth, the infant might be re-examined
according to a standard protocol a few months after birth. The
entire data collection process—prenatal, perinatal, and postnatal—
might be coordinated by the county and state public health depart-
ments.
As noted elsewhere in this report, a problem, if it exists,
apparently extends beyond Coffee and Dale Counties. Some
neighboring counties have higher rates, both overall and in most
ICDA categories. As a minimal consequence of this report, com-
parable data for the years since 1972 should be acquired to see
if the same anomaly pattern exists. If so, the cause of such
higher rates should be investigated. It may be simply that for
reasons not entirely apparent at present there is over-reporting
in some areas and under-reporting in others.
ACKNOWLEDGMENT
This report was prepared with the assistance of the follow-
ing Institute staff:
Stephen-R. Williams
Senior Statistician
(served as principal investigator for a limited period)
Elizabeth Nash
Associate Statistician
Pearl Tropper
Associate Economist
Wayne Satterwhite
Associate Statistician
Thomas E. Dutton
Social Science Technician
James H. Hardin
Statistical Technician
-23-
-------
Penelope Newfield
Mathematical Research Technician
The following persons also assisted on a consultant basis:
Peter B. Peacock, MB, DPH, DIH, MD
Adjunct Research Advisor in Public Health and Epidemiology
(served as principal investigator for a limited period)
Edwin L. Bradley, Jr., Ph.D.
Assistant Professor, Biostatistics Department
University of Alabama in Birmingham
Malcolm E. Turner, Jr., Ph.D
Chairman, Department of Biomathematics
University of Alabama in Birmingham
Herman F. Lehman, Jr., DOS, MPH
Assistant Professor in Public Health and Epidemiology
University of Alabama in Birmingham
Submitted by:
A. Burdeshaw
nior Statistician
"Sheldon Schaffd
Head, Health Systems
Planning Section
Approved by:
Saoert Oglesby, Jr ..X,
Vice President '
Birmingham, Alabama
March 31, 1976
SORI-EAS-76-212
3118-XXIII
(1:4:12) Ih
-24-
-------
Anomaly Incidence Rates per 1,000 Births in
Table 1
Children Born to White Residents, by County,
Alabama, 1969-1972
Anomaly rates
ICDA categories
County
Autauga
Baldwin
Barbour
Bibb
Blount
Bullock
Butler
. Calhoun
to
ji Chambers
1
Cherokee
Chi 1 ton
Choc taw
Clarke
Clay
Cleburne
Coffee
Colbert
Conecuh
Coosa
Covington
Crenshaw
Cull ma n
Dale
Live
births
1260
3322
726
709
1753
199
TOO
5986
1465
858
1385
689
1028
661
625
25
0.9
0.2
746
0.0
0.9
0.0
1.0
0.0
5.0
o.o
0.0
0.0
o.o
0.0
1.5
o.o
3.0
o.o
1.2
O.It
0.0
0.0
o.o
o.n
n.9
1.1
747
0.0
0.0
0.0
0.0
0.0
0.0
o.o
o.o
0.0
0.0
0.0
o.o
0,0
o.o
0.0
0.0
0.0
o.o
0.0
0.0
0.0
0.0
O.u
748
0.0
0.3
o.o
n.n
O.h
0.0
o.o
0.0
0.0
0.0
0.0
o.o
1."
1.5
o.o
0.0
0.0
0.0
o.n
o.o
0.0
0.3
o.?
749
o.n
0.6
0.0
0.0
2.3
0.0
5.«
0.8
2.0
0.0
0.7
1.5
1.0
o.o
1.6
2.0
0.7
o.o
o.o
1 .1
0.0
0.3
1.1
750
0.0
0.0
o.o
n.O
0.0
0.0
2.7
0.2
0.0
0.0
0.0
o.o
0,0
0.0
o.o
c.o
0.0
o.o
0.0
n.O
n.n
o.o
".2
751
o.a
o.o
n.o
o.o
o.o
5.0
1.3
0.5
0.0
0.0
n.O
1.5
1.0
1.5
0.0
0.0
o.a
o.o
o.o
0.6
S.«
".3
o.«
752
1.6
0.6
l.«
0.0
0.0
0.0
0.0
0.2
0.0
n.o
i.«
n.n
o.o
0.0
o.o
1.6
o.a
o.n
o.o
0.6
o.o
1.5
2.3
753
0.0
0.3
o.n
1 .«
0.0
0.0
o.n
o.o
o.o
n.n
o.o
0.0
n.o
o.n
o.n
o.o
o.o
o.o
o.o
o.h
o.o
o.o
o.o
754
2.«
0.9
0.0
0.0
2.3
0.0
1.3
l.o
2.7
1.?
0.7
o.n
1 .0
o.o
0.0
?.7
o.o
0.0
2.R
1 . 1
s.«
1.2
2.6
755
1 .6
d . 0
1 .«
o.o
1.1
5.0
1.3
2.2
«.l
0.0
0.7
n.n
1.9
1.5
0.0
2.-J
0.7
0.0
0.0
1.7
3.6
1 .5
2.3
756
0.0
0.3
0. f
o.n
n.n
o.n
o.o
o.n
0,0
n.o
1.0
o.o
l.n
o.o
o.n
O.u
o.o
o.o
O.n
0. 1
o.n
0.3
0.9
757
U.P
O.n
n.o
O.n
o.o
0.0
0.0
n.n
0,0
0.0
n.o
o.o
0,0
n.n
0.0
0,o
o.o
o.o
o.o
(•.<>
0.0
0.0
0.2
758
0.0
••'. i
O.o
o.n
O.n
n.o
O.o
n.o
0,0
o.o
o.n
o.o
n.n
n . n
n.n
o.o
o.o
0.0
o.o
n.n
n.n
(..n
o.2
759
0.8
n , o
i'."
n.n
1.1
c.o
u.o
". 7
0.7
o.n
''.7
d.O
" . n
0 . r.
r> .r
1 .?
0 .0
o.n
o.c
n . n
o.n
0.9
n .0
Fetal
deaths
11.9
11.7
17.9
R .^
5.7
<>n. 1
12.1
13. «
13.7
21 .0
->2.u
10.2
H.7
-------
Anomaly Incidence Rates per 1,000 Births in
Table 1 (Cont'd)
Children Born to White Residents, by County, Alabama, 1969-1972
Anomaly rates
ICDA categories
County
Dallas
DeKalb
Elmore
Escambia
Etowah
Fayette
Franklin
Geneva
1
to Greene
7
7
6
3
4
9
5
0
a
8
t
u
3
a
0
a
3
2
0
1
U
s
740
0.«
0.7
n.O
n.o
0.2
o.o
0,0
0.0
o.o
0.0
0.2
o.o
o.o
0.1
0.0
o.o
0.6
o.o
o.o
n.o
o.o
0.0
o.o
741
O.P
1.1
0.0
0.6
1,3
1.2
0.6
o.o
0.0
3.7
0.2
2.7
l.o
l.J
I.?
o.o
0.6
o.o
O.U
0.0
0.0
0.5
l.o
742
0.0
o.o
1.3
n.o
0.2
0.0
0.6
0,0
0.0
0.0
0.0
o.o
0.3
0.3
0.0
o.o
0,0
n.o
0.8
o.o
o.o
n.5
o.o
743
O.P
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
n.O
0.3
0,0
0.0
0.0
0.0
0.0
0,0
0.0
0.0
0.0
7J4
0.
0.
0.
0.
0.
0.
0.
0,
0.
0.
o.
0.
o.
o.
o.
o.
o.
o.
0.
o.
n.
o.
o,
n
0
0
0
0
0
0
0
0
0
0
3
0
1
0
0
0
0
'o
0
0
0
0
745
0
0
n
0
0
0
0
0
0
3
0
0
0
0
1
n
0
0
0
0
0
n
n
."
.0
.0
.0
.0
.0
.0
.0
.0
.7
.1
.3
.3
.2
.2
.0
.6
.0
.0
.0
.l>
.0
.0
746
O.U
0.0
1.3
0.0
o.o
o.o
0,6
0.8
0,0
o.n
2.1
1.5
1,0
O.U
0.0
0.0
n.o
0.0
O.U
o.n
0,0
0.5
1."
747
D.O
0.0
0.0
o.n
0.2
o.o
0.0
0.0
0.0
0.0
0.0
0.0
o.o
0.0
o.o
0.0
o.o
0.0
0.0
n.o
o.o
1.1
o.o
748
0.0
o.n
n.o
0.0
0.2
o.o
0.6
0.0
0.0
0.0
o.o
0.0
o.o
0.0
o.o
o.n
o.o
o.o
O.U
o.o
0.0
0,1
0.0
749
0
1
0
1
1
0
0
n
0
0
0
1
0
1
1
0
0
0
0
0
u
0
2
.«
.0
.6
.1
.3
.0
.6
.0
.0
.0
.0
.2
.7
.7
.2
.0
.0
.7
.u
.0
.1
.7
.8
750
n.o
n.n
0.0
0.6
p.?
o.o
0.0
0.0
o.o
o.o
0.0
o.o
o.o
n.2
1.2
0.0
o.o
0.3
O.n
0.0
0.0
n.2
o.n
751
1.2
o.u
0.6
0.6
0.2
0.0
0.6
0.0
0.0
0,0
0.0
0.0
0.7
0.3
0.0
0.0
«.6
o.o
O.P
n.o
0.0
0.2
o.o
752
1.2
O.U
0.6
1.1
1 . 1
o.o
0.3
0.8
n.o
o.o
n.o
1.5
0.7
n.9
0.0
0.0
0.0
0.7
o.n
0.0
n.o
0.5
1 ."
753
o.n
o.u
o.o
o.o
o.o
c.o
o.o
o.o
n.o
o.o
o.o
o.o
0.0
n.i
0.0
o.o
0.0
n.o
n.n
o.o
0.0
P. 2
o.n
754
O.H
2.9
1.3
n.o
1.3
o.n
1.2
0.0
0.0
n.o
n.o
3.6
3.1
1.3
o.n
0.0
1.9
0.7
n.u
0.0
n.o
G.fl
o.n
755
2.5
1
1
1
0
1
1
0
0
0
2
3
1
1
2
n
0
n
n
0
(1
r
u
.1
.9
.1
. Q
.2
.2
.8
.0
.0
.1
."
.n
.5
.u
. n
.6
.7
.0
,p
.1
.5
.?
756 757
n.
0.
n .
0.
0.
o.
o.
0.
0.
o.
o.
o.
f! .
o.
I .
o.
o.
0.
n .
n.
o.
n.
I.
u
n
h
b
0
0
6
0
0
n
0
h
7
1
2
n
n
7
.1
0
0
n
u
" 1 "
n.n
0.0
1.1
•1.0
0.0
0.0
0.0
0.0
0.0
0.0
o.n
0.3
0.1
0.0
o.n
o.o
o.o
O.n
n. n
0.0
O.n
n.n
75J3
0
n
n
n
0
0
n
0
0
n
n
n
n
n
0
0
0
n
n
n
n
c
0
.n
. u
.h
.0
.1
.0
.0
,n
.0
.0
.n
.0
. 0
.1
.1
,0
."
. n
.u
.0
.0
.0
.n
759
,1.H
n . i'
n.o
n.o
O.u
n.n
0.6
o.n
o.o
n.o
u.2
n .«)
l.«
O.u
0.0
" . n
r'.6
n.o
n.o
0.0
O.o
o . u
o.n
Fetal
deaths
12. P
1 u.S
9.7
ic.s
15.1
12.2
16.0
7.U
10.2
18. S
12.6
10.2
in. 3
11.2
U.R
10.3
12.0
II. 1
12. i
5.9
12.3
12.7
II. 1
-------
Table 1 (Cont'd)
Anomaly Incidence Rates per 1,000 Births in Children Born to White Residents, by County, Alabama, 1969-1972
Anomaly rates
ICDA categories
County
Marion
Marshall
Mobile
Monroe
Montgomery
Morgan
( Perry
SJ . ,
^j Pickens
1
Pike
Randolph
Russell
St. Clair
Shelby
Sumter
Talladega
Tal .lapoosa
Tuscaloosa
Walker
Washington
Wi Icox
Winston
State
Live Over-
births all
15H5
3712
15755
757
6590
5226
319
621
1110
9J(|
1986
1751
229?
323
3331
1603
5«01
3B61
«07
3U7
13B6
173315
«.
8.
«.
10.
9.
3.
3.
3.
'.
3.
".
8.
«>.
3.
«.
2.
1 .
«.
3.
1".
10.
6.
U
(1
1
h
9
3
1
2
0
3
0
0
5
1
5
5
1
1
5
U
1
S
740
0
0
0
?
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
n
0
.0
.0
.1
.6
.2
.2
.0
.0
."
.0
.0
."
.0
.0
.0
.0
.0
.0
."
,0
.0
. 1
741
I.'
0.8
0.6
n.o
l.»
o.u
0.0
o.o
0.9
0.0
1.0
0.6
o.«
0.0
1.2
0.6
0.2
0.0
1.2
?."
•>.2
0.9
742
0.
0.
0.
0.
0.
o.
o.
0.
o.
o.
0.
0,
o.
0.
o.
o.
o.
o.
o.
o.
o.
o.
0
0
3
n
5
0
0
0
0
0
0
0
0
0
3
0
2
0
0
0
0
2
7_43
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
.0
.3
.0
.0
.2
.0
.0
.0
.0
.0
.0
.0
.0
.0
.0
.0
.0
.0
.0
.0
.0
. 1
744
o.o
0.5
0.1
0.0
0,0
o.o
0,0
0.0
0.0
0,0
0.0
o.o
o.o
0.0
o.o
0.0
0.2
0.3
0.0
0.0
0.0
0.1
745
0.1
0.3
O.I
0.1
0.5
0.1
0.0
o.o
0.9
o.o
0.0
0.6
0.0
0.0
0.0
o.o
0.0
0.3
o.o
0.0
0.7
C.2
746
0,
0.
0,
1.
o.
o.
o.
o.
0.
o.
o.
o.
0.
o.
o.
o.
n.
n.
o,
i.
0.
0.
0
»
7
3
6
6
0
0
9
0
0
6
U
0
0
0
6
3
0
0
7
5
747
0.0
n.n
o.o
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
o.o
o.o
o.o
o.o
o.o
o.o
0.0
r..O
0.0
0.0
748
0.0
0.3
0.0
0.0
o.o
0.0
0.0
0.0
0.0
o.o
0.0
0.0
o.o
o.n
n.o
o.o
o.n
o.o
o.o
o.o
o.o
1.1
749
0.6
O.B
o.«
0.0
2.0
0.0
o.o
3.2
0.9
2.2
0.5
1.7
0.9
0.0
0.3
0.6
0.0
1.0
n.O
n.n
2.2
1.0
750
0.
1,
0.
?.
0.
o.
1.
0,
0.
o.
1,
o.
0.
0.
0.
0.
0.
o.
0.
o.
o.
0.
o
0
0
6
2
2
0
0
0
n
0
0
0
0
0
0
0
n
0
n
7
1
751
0.0
0.5
0.1
l.i
0.3
o.«
0.0
0.0
0.0
0.0
i.o
0.0
0.0
n.n
0.0
0.0
0.0
o.o
o.n
o.n
o.o
0. 3
752
0.0
1.1
0. 1
l.i
O.fl
0.8
1.0
0.0
0.9
0.0
1.5
1.7
1.3
o.o
0.3
0.6
0.1
0.3
n.n
o.o
o.o
0.7
753
0.6
0.0
o.l
0.0
o.?
o.n
o.o
0.0
0.0
0.0
o.n
o.o
o.n
o.o
o.o
o.o
o.o
O.n
o.l
0.0
o.o
o.l
754
1.9
1.3
O.B
o.n
2.3
0.0
3.1
0.1
0.9
1.0
1.1
1.1
1.7
0.0
2.1
0.6
0.0
i.o
o.n
o.o
0.7
1.2
755
0
1
n
0
1
n
n
n
i
n
n
i
i
3
1
0
0
1
1
5
3
1
.0
.6
.6
.0
.«
.«
.0
.0
.8
.0
.S
. 7
.3
.1
.2
.0
.1
,3
.2
.H
.6
.2
756
0.0
1 . 1
o.l
O.n
0.3
0.0
n.n
0,0
o.n
o.n
o.n
O.fc
o.o
o.o
o.n
o.o
n . n
o.s
i .?
r,.n
O.n
1,2
757 7J,£
n
0
n
0
0
n
n
n
0
0
n
n
0
0
0
0
0
0
n
0
0
0
.0
.3
, n
.0
.n
.0
.1
.0
.9
.1
.0
.1
,«
.0
.3
.0
.0
.0
,f
. n
.0
.1
O.l
n.n
n.n
n.n
o.n
o.n
o.o
n.n
o.o
n.n
n.n
o.n
o.o
n.n
n.n
o.n
0.0
n.n
n .n
n . n
O.n
". 1
Fetal
759 deaths
0.0
1 . 1
0.3
l.i
n.Q
u. 0
o.o
o.n
0.9
1,1
r.o
o.n
o . n
o . n
o.n
0 .0
"."
i.*
r % n
S.H
o.n
O.u
12.6
15.1
10.5
i n.6
15. S
13.0
1«.8
1?.9
9.0
1 J.I
IS. 6
1«.B
15.3
3. 1
13. S
16.2
11.3
15.5
15.3
P.6
1 7. 3
12.7
-------
Table 2
Incidence of Congenital Anomalies by ICDA Category and Fetal Deaths Among white Residents,
Coffee County, Alabama, Selected Time Periods, July, 1969-December, 1972
Early period (7/69-12/70)
"Late period (1/71-12/72)
Combined period (7/69-12/72)
1
rO
CO
1
Anomaly
All5
Anencepha lus
Spina bifida
Hydrocephalus
Nervous system
Eye
Ear, face, neck
Heart
Circulatory
Respiratory
Cleft palate, lip
Upper alimentary
Digestive system
Genital organs
Urinary system
Clubfoot
Otner limbs
Musculoskeletal
Skin, hair, nails
Unspecified
Multiple
Fetal deaths'
ICDA Observed
code cases'
740
741
742
743
744
745
746
747
748
749
750
751
752
753
754
755
756
757
758
759
11
0
0
0
0
0
0
1
0
0
1
0
0
0
0
4
3
0
0
0
2
6
Observed
rate2
11
0
0
0
0
0
0
1
0
0
1
0
0
0
0
4
3
0
0
0
2
6
.4
.0
.0
.0
.0
.0
.0
.0
.0
.0
.0
.0
.0
.0
.0
.1
.1
.0
.0
.0
.1
.2
Binomial
probability'
0
1
1
1
1
1
1
0
1
1
0
1
1
1
1
0
0
1
I
1
0
0
.062
.000
.000
.000
.000
.000
.000
.363
.000
.000
.629
.000
.000
.000
.000
.032
.120
.000
.000
.000
.071
.983
Expected
rate'
6,
0,
0
0
0.
0
0
0
0,
0,
1.
0
0,
0,
0
1
1.
0
0
0
0.
12.
,7
.1
.9
.1
.1
.1
.2
.5
.0
.1
.0
.2
.2
.7
.1
.2
.2
.2
.1
.1
.5
.7
Observed
cases'
16
0
2
0
1
0
0
1
0
0
2
0
0
4
0
1
3
1
0
0
1
12
Observed
rate2
12
0
.1
0
0
0
0
0
0
-o
1
0
0
3
0
0
2
0
0
0
0
9
.5
.0
.6
.0
.8
.0
.0
.8
.0
.0
.6
.0
.0
.1
.0
.8
.3
.8
.0
.0
.8
.3
Binomial
probability'
0
1
0
1
0
1
1
0
1
1
0
1
1
0
1
0
0
0
1
1
0
0
.005
.000
.288
.000
.105
.000
.000
.462
.000
.000
.294
.000
.000
.003
.000
.761
.129
.212
.000
.000
.444
.894
Expected
rate11
5.
0.
0.
0,
0.
0.
0.
0,
0.
0,
0.
0,
0,
0
0
1
1,
0,
0.
0.
0.
12.
9
.1
,8
.2
.1
,0
.2
.5
,0
.1
.8
.1
.3
.5
.1
.1
.0
.2
,0
,0
.5
,8
Observed
cases'
27
0
2
0
1
0
0
2
0
0
3
0
0
4
0
5
6
1
0
0
3
18
Observed
rate'
12.
0.
0.
0
0.
0.
0.
0.
0.
0.
1.
0
0
1
0
2
2
0
0
0
1.
8.
0
.0
.9
.0
.4
.0
.0
.9
.0
.0
.3
.0
.0
.8
.0
.2
.7
.4
.0
.0
.3
.0
Binomial
probabi lity J
0.
1.
0.
1.
0.
1.
1.
0.
1.
1.
0.
1,
1.
0
1
0
0
0.
1.
1.
0.
0.
.001
.000
.581
.000
.170
.000
.000
,290
000
.000
.344
.000
.000
.037
.000
.125
.039
.342
.000
.000
.085
.987
Expected
rate11
6
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
0
0
0
0
12
.2
.1
.9
.2
.1
.1
.2
.5
.0
.1
.9
.1
.3
.6
.1
.2
.1
T
.1
. 1
.5
.8
1. Number of nnomalies recorded on birth certificates and fetal deaths reported for Coffee County by the Bureau of Vital
Statistics, Alabama Department of Public Health.
2. Number of anomalies or fetal deaths per 1,000 live births.
3. The probability of obtaining the observed number, or more, of anomalies or fetal deaths, if the risk for each individual
in Coffee County were the rate experienced by the State of Alabama, excluding Coffee and Dale Counties, for the same period.
4. The rate expected for Coffee County, if its rate were the same as that experienced by the State of Alabama, excluding Dale
and Co£ fee Counties, for the same period.
5. The overall anomaly category counts an infant with more than one anomaly just once and does not include fetal deaths.
6. Not considered an anomaly.
-------
Table 3
Table 3
Incidence of Congenital Anomalies by ICDA category and Petal Deaths Among White Residents,
Dale County, Alabama, Selected Time Periods, July, 1969-December, 1972
Early period (7/69-12/70)
Late period (1/71-12/721
Combined period (7/69-12/72)
. Anomaly
All1
Anencephalus
Spina bifida
Hydrocephalus
Nervous system
Eye
Ear, face, neck
Heart
Circulatory
Respiratory
Cleft palate, lip
Upper alimentary
Digestive system
Genital organs
Urinary system
Clubfoot
Other limbs
Musculoskeletal
Skin, hair, nails
Unspecified
Multiple
Petal deaths'
ICDA Observed
code cases'
740
741
742
743
744
745
746
747
748
749
750
751
752
753
754
755
756
757
758
759
27
0
3
0
1
0
0
2
0
0
3
1
2
6
0
6
3
1
0
0
0
16
Observed
rate*
13.9
0.0
1.5
0.0
0.5
0.0
0.0
1.0
0.0
0.0
1.5
0.5
1.0
3.1
0.0
3.1
1.5
0.5
0.0
0.0
0.0
8.2
Binomial
probability'
0.
1.
0.
1.
0.
1.
1.
0.
1.
1.
0.
0.
0.
0.
1.
0.
0.
0.
1.
1.
1.
0.
000
000
266
000
141
000
000
231
000
000
323
283
077
002
000
035
436
305
000
000
000
976
Expected
rate*
6
0
0
0
0
0
0
0
0
0
1
0
0
0
0
1
1
0
0
0
0
12
.7
.1
.9
.1
.1
.1
.2
.5
.0
.1
.0
.2
.2
.7
.1
.2
.2
.2
.1
.1
.5
.7
Observed
cases '
20
0
1
0
0
0
1
1
2
1
2
0
0
4
0
2
6
2
0
1
0
29
Observed
rate1
9
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
2
0
0
0
0
13
.0
.0
.4
.0
.0
.0
.4
.4
.9
.4
.9
.0
.0
.8
.0
.9
.7
.9
.0
.4
.0
.0
Binomial •
probability'
0
1
0
1
1
1
0
0
0
0
0
1
1
0
1
0
0
0
1
0
1
0
.045
.000
.842
.000
.000
.000
.301
.658
.000
.129
.558
.000
.000
.022
.000
.708
.022
.065
.000
.104
.000
.483
Expected
rate*
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
0
0
0
0
12
.9
.1
.8
.2
.1
.0
.2
.5
.0
.1
.8
.1
.3
.5
.1
.1
.0
.2
.0
.0
.5
.8
Observed
cases '
47
0
4
0
1
0
1
3
2
1
5
1
2
10
0
8
9
3
0
1
0
45
Observed
rate7
11.3
0.0
1.0
0.0
0.2
0.0
0.2
0.7
0.5
0.2
1.2
0.2
0.5
2.4
0.0
1.9
2.2
0.7
0.0
0.2
0.0
10.8
Binomial
probability'
0.000
1
0
1
0
1
0
0
0.
0.
0.
0.
0
0
1
0.
0.
0.
1.
0.
1.
0.
.000
.490
.000
.292
.000
.566
.319
.002
.250
.342
.421
.340
.000
.000
.119
.042
044
000
206
000
888
Expected
rate"
6.2
0.1
0.9
0.2
0.1
0.1
0.2
0.5
0.0
0.1
0.9
0.1
0.3
0.6
0.1
1.2
1.1
0.2
0. 1
0.1
0.5
12.8
1. Number of anomalies recorded on birth certificates and fetal deaths reported for Dale County by the Bureau of Vital Statistics,
Alabama Department of Publir Hoa1th.
2. Number of anomalies or fetal deaths per 1,000 live births.
3. The probability of obtaining the observed number, or more, of anomalies or fetal deaths, if the risk for each individual in
Dale County were the rate experienced by the State of Alabama, excluding Coffee and Dale Counties, for the same period.
4. The rate expected for Dale County, if its rate were the same as that experienced by the State of Alabama, excluding Dale and
Coffee Counties, for the same period.
5. The overall anomaly category counts an infant with more than one anomaly just once and does not include fetal deaths.
6. Not considered an anomaly.
-------
Table 4
Incidence of Congenital Anomalies by ICDA Category and Petal Deaths Among White Residents,
Dale and Coffee Counties, Alabama, Selected Time Periods, July, 1969-December, 1972
Earlv oeriod (7/69-12/70)
1
Co
o
I
Anoma Ly
All5
Anencephalus
Spina bifida
Hydrocephalus
Nervous system
Eye
Ear, face, neck
Heart
Circulatory
Respiratory
Cleft palate, lip
Upper alimentary
Digestive system
Genital organs
Urinary system
Clubfoot
Other limbs
Musculoskeletal
Skin, hair, nails
Unspecified
Multiple
Petal deaths'
ICDA Observed
code cases'
740
741
742
743
744
745
746
747
748
749
750
751
752
753
754
755
756
757
758
759
38
0
3
0
1
0
0
3
0
0
4
1
2
6
0
10
6
1
0
0
2
22
Observed
rate1
13.0
0.0
1.0
0.0
0.3
0.0
0.0
1.0
0.0
0.0
1.4
0.3
0.7
2.1
0.0
3.4
2.1
0.3
0.0
0.0
0.7
7.6
Binomial
probability*
0.000
1.000
0.500
1.000
0.203
1.000
1.000
0.157
1.000
1.000
0.350
0.392
0.149
0.013
1 .000
0.004
0.159
0.419
1.000
1.000
0.378
0.997
Expected
rate*
6.7
0.1
0.9
0.1
0.1
0.1
0.2
0.5
0.0
0.1
1.0
0.2
0.2
0.7
0.1
1.2
1.2
0.2
0.1
0.1
0.5
12.7
Observed
cases '
36
0
3
0
1
0
1
2
2
1
4
0
0
8
0
3
9
3
0
1
1
41
Late period (1/71-12/72)
Observed
rate'
10.3
0.0
0.9
0.0
0.3
0.0
0.3
0.6
0.6
0.3
1.1
0.0
0.0
2.3
0.0
0.9
2.6
0.9
0.0
0.3
0.3
11.7
Binomial
probability1
0.001
1.000
0.556
1.000
0.262
1.000
0.431
0.505
0.001
0.195
0.342
1.000
1.000
0.000
1.000
0.748
0.008
0.029
1.000
0.159
0.799
0.738
Expected
rate'
5.9
0.1
0.8
0.2
0.1
0.0
0.2
0.5
0.0
0.1
0.8
0.1
0.3
0.5
0.1
1.1
1.0
0.2
0.0
0.0
0.5
12.8
Combined period (7/69-12/72)
Observed
cases'
74
0
6
0
2
0
1
5
2
1
8
1
2
14
0
13
15
4
0
1
3
63
Observed
rate'
11.5
0.0
0.9
0.0
0.3
0.0
0.2
0.8
0.3
0.2
1.2
0.2
0.3
2.2
0.0
2.0
2.3
0.6
0.0
0.2
0.5
9.8
Binomial
probability 3
0.000
1.000
0.484
1.000
0.100
1.000
0.723
0.194
0.004
0.358
0.246
0.569
0.554
0.000
1.000
0.042
0.006
0.033
1.000
0.298
0.559
0.987
Expected
rate*
6.2
0.1
0.9
0.2
0.1
0.1
0.2
0.5
0.0
0.1
0.9
0.1
0.3
0.6
0.1
1.2
1.1
0.2
0.1
0.1
0.5
12.8
1. Number of anomalies recorded on birth certificates and fetal deaths reported for Dale and Coffee Counties by the Bureau of
Vital Statistics, Alabama Department of Public Health.
2. Number of anomalies or fetal deaths per 1,000 live births.
3. The probability of obtaining the observed number, or more, of anomalies or fetal deaths, if the risk for each individual in
Dale and Coffee Counties were the rate experienced by the State of Alabama, excluding Dale and Coffee Counties, for the same
period.
4. The rate expected for Dale and Coffee Counties, if its rate were the same as that experienced by the State of Alabama,
excluding Dale and Coffee Counties for the same period.
5. The overall anomaly category counts an infant with more than one anomaly just once and does not include fetal deaths.
6. Not considered an anomaly.
-------
Table 5
Live Births, White Residents Only, Coffee and Dale Counties,
and Alabama excluding Coffee and Dale Counties,
Selected Time Periods, July, 1969-December, 1972
Early period Late period Combined period
Area (7/69-12/70! (1/71-12/72) (7/69-12/72)
Coffee County
Dale County
965
1,948
1,284
2,225
2,249
4,173
Coffee and Dale
Counties 2,913 3,509 6,422
State of Alabama,
excluding Coffee
and Dale Counties 64,313 80,834 145,147
-31-
-------
Table 6
Anomaly and Fetal Death Rates for 47 Selected Hospitals, Alabama, 196B-1972
I
OJ
Rank by
Lot a 1
rttmmitly
I
2
3
4
5
6
7
e
9
10
11
12
13
14
15
16
17
IB
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
Air rorci- RfMjion.il (Mnxwell)
l.ysLer Array (Ft. Ruckor>n
L. V. stabler Memorial
Henry County
North Jackson
Hale County
Burdick-West Memorial
Carraway Methodist
Southeast Alabama General
New Vaughn Memorial
St. Margaret's
Birmingham Baptist Medical
Centers
Grove Hill Municipal
John A. Andrew Memorial
Flowers
Guntersville
Anniston Memorial
Lamar County General
East End Memorial
Holy Naae of Jesus
Redstone Arsenal
Dale County
Montgomery Baptist
Lloyd Noland
Suburban
Baugh-Wiley-Smith
St. Vincents
Mizell Memorial
Baptist Memorial
Guin
Thomas
Mobile Infirmary
Peoples
Providence
Huntsville
Medical Center
Arab
Lee County
Sylacauga
Colbert County
D. H. McMillan Memorial
Druid City
Mobile General
Noble Army (Ft. Mcclellan)
University of Alabama
Eliza Coffee Memorial
Macon County
Type
County hospital0
Montgomery
Dale
Butler
Henry
Jackson
Hale
Winston
Jefferson
Houston
Dal las
Montgomery
Jefferson
Clarke
MACOn
Houston
Marshall
Calhoun
La mar
Jefferson
Etowah
Madison
Dale
Montgomery
Jefferson
Mobile
Morgan
Jefferson
Covington
Etowah
Marion
Baldwin
Mobile
Walker
Mobile
Madison
Madison
Marshall
Lee
Ta 1 Ladoga
Colbert
Escambia
Tuscalooaa
Mobile
Calhoun
Jefferson
Lauderdale
Macon
CM
CM
PNP
CNM
GNM
GNM
GNM
PNP
GNM
PNP
PNP
PNP
GNM
PNP
PP
GNM
GNM
GNM
PNP
PNP
GM
GMN
PNP
PNP
PP
PP
PNP
PNP
PNP
GNM
GNM
PNP
GNM
PNP
GNM
PNP
GNM
GNM
GNM
GNM
GNM
GNM
GNM
CM
GNM
GNM
GNM
Reported
number
of births.
1968-1972"
2,602
(q)
906
321
1,225
935
1.232
4,897
4,766
3,971
3,314
15,780
596
8,213
2,615
2,039
8,099
406
5,470
4,001
1,767
1,735
5,500
2,636
393
1,015
6,162
1,970
4,923
484
960
15,061
4,476
6,581
11,988
3,673
1,544
4.558
3.813
4,832
1,747
11,529
10,934
1,668
15.690
6,977
68
Adjusted
number
of births.
196B-1972C
2.339
4,750
824
279
1,122
878
1,232
4,362
4,396
3,819
3,000
14,570
556
7,467
2,380
1,859
7,335
363
4,950
3,574
1,545
1,572
5,124
2,347
329
874
5,564
1,814
4,508
430
879
13,766
4,060
5,954
10,465
3,673
1,379
4,148
3,464
4,378
1,602
10,474
9,808
1,483
14,142
6,316
54
Number of
births,
1968-197111
2.074
(q)
734
(9)
990
735
881e
4.086
3.646
2,792
2,627
12,548
431
6,269
2,069
1,637
6,473
331
4,486
3,452
1,599
1.419
4,178
2,241
366
942
3,548e
1,531
3.775
414
804
12,136
3,644
5,326
10,202
2,563r
1.265
3,629
3,106
3.951
1,331
9,222
8,639
1.431
12,870
5.608
(9)
Average
hours after
birth when
birth
APGAR certificate
scoring completed
Yes 42
Yes 8
N
N
N
N
Ye
Ye
Ye
Ye
N
Ye
N
Ye
Ye
N
Ye
N
Ye
Ye
Ye
Ye
Ye
Ye
Ye
Ye
Ye
Ye
36
12
1
24
8
48
8
48
36
24
8
24
24
24
9
48
24
22
8
8
24
24
1
24
24
2
Yes 10
Yes 8
Yes 120
Yes 24
No 13
Yes 12
Yes 30
Yes 24
Yes 12
Yes 12
Yes 18
Yes 12
Yes 1
Yes 24
Yes 18
Yes 48
Yes 36
No 24
Yes 24
Average
nge of
mothers
24.0
23.0
22.8
22.0
23.0
22.1
17.3
24.0
23.7
22.7
24.0
24.7
?«.o
22.2
18.8
23.0
24.0
21.2
22.1
23.0
25.0
23.7
24.0
26.1
24.0
22.2
24.0
20.8
23.7
25.6
23.0
21.2
19.8
24.0
22.3
22.2
24.8
24.2
22.8
25.8
23.0
24.2
21.7
24.0
25.0
25.8
22.6
Nonwhite
mothers
in
percent
24.7
7.8
22.6
64.6
10.9
76.4
0.2
10.2
19.4
33.7
19.5
12.8
50.3
97.3
16.0
4.1
21.2
27.8
2.3
12.4
15.0
21.2
11.0
54.8
21.6
22.5
6.8
24.1
21.8
10.5
25.3
7.4
8.8
30.2
31.4
5.5
0.1
21.5
36.0
22.9
36.8
33.2
76.4
20.5
77.6
12.7
60.0
Births with
anoma lies
Number
42
77
12
4
15
11
. 15
52
52
45
34
135
5
67
21
16
62
3
37
26
11
11
35
15
2
5
30
9
22
2
4
61
16
22
38
12
4
12
8
9
2
12
8
1
6
2
0
Rate
1B.O
16.2
14.5
14.3
13.4
12.5
12.2
11.9
11.8
11.8
11.3
9.3
9.0
9.0
8.8
8.6
8.4
8.3
7.5
7.3
7.1
7.0
6.8
6.4
6.1
5.7
5.4
5.0
.9
.6
.6
.4
.9
3.7
3.6
3.3
2.9
2.9
2.3
2.0
1.2
1.1
0.8
0.7
0.4
0.3
0.0
Fcta I deaths
Number
14
S5
13
(q)
7
20
12C
51
47
49
43
148
10
130
24
22
166
4
48
32
16
15
62
46
2
13
33*
31
65
7
9
141
64
60
U7f
27f
18
60
58
59
18
137
146
11
311
68
(9)
RatO
6.1
11.6
17.7
(9)
7.1
27.2
13.6
12.5
12.9
17.6
16.4
11.8
23.2
20.7
11.6
13.4
25.6
12.1
10.7
9.3
10.0
10.6
14.8
20.5
5.5
13.8
9.3
20.2
17.2
16.9
11.2
11.6
17.6
11.3
11.5
10.5
14.2
16.5
18.7
14.9
13.5
14.8
16.9
7.7
24.2
12.1
(9)
a. HospitaIs by type are coded: GM - Government, military
GNM - Government, nonmilitary
PP - Private, profit
PNP - Private, nonprof i t
b. As reported to Southern Research Institute by the hospitals participating in this survey.
c. Estimated number of births during study period, mid-196B through 1972, which is used as the denominator in calculating anomaly
incidence rates. The number of births during the last half of 1**68 is assumed to be one-half the total number of birtha during
1968.
d. Number of births, which is used as the denominator in calculating fetal death rates. The number of fetal deaths for each hos-
pilrtl in 1972 was unavailable for this study.
e. Data not available for 1968.
f. Data not avnilable for 1968 and 1969.
g. Not available.
h. Data exr r.-ictotl f i cm Phase ! f itiri 1 report.
-------
Table 7
Estimate of and 95% Prediction Interval for the Overall Anomaly
Incidence Rate for a Hospital with 18 Non-Radar Characteristics
of Lyster Army Hospital Using Four Regression Models
Model
1. Unweighted,
no transformation
2. Unweighted,
log transformation
3. Weighted,13
log transformation,
full modelc
4. Weighted f
log transformation,
reduced model^
Lower
95%
prediction
limit
0.7
0.6
4.7
6.1
Estimate
of Lyster
ratea
11.4
5.4
18.8
17.2
Upper
95%
prediction
limit
22.1
48.7
75.0
48.2
a. The observed rate for Lyster for the period July 1968-December
1972 was 17.7.
b. Logarithmic transformation of rate, which precludes negative
predicted rates, weighted by number of anomalies.
c. All 18 predictor (independent) variables included in the
model.
d. Eleven predictor variables included in the model. Seven
variables removed by the method of "backward elimination"
"explained" less of the variation than was in the residual
error.
-33-
-------
Table 8
Race, Sex, Attending Physician, and Residence of Mother for Anomalous Infanta Born
by Major
Year Month
1972
1971
1970
1969
1968
Total
12
11
10
9
8
7
6
5
4
3
2
1
12
11
10
9
e
7
,
5
4
3
2
1
12
11
10
9
8
7
6
5
4
3
2
1
12
11
10
9
a
7
6
•,
4
3
2
1
12
11
10
9
8
7
anomalies
749 Cleft
palate 746 Heart
9,WF,O,FTR
9,WF,J,DTN
9,WF,N,ELB
9,WM,N,DTN
2,WM,I,OZK
9,WP,F,OZK
9,WM,F,BEL
9,WM,E,DLV
9.WF.B.FTR
9 , WM , B , ENT
1,WM,B,ENT
1 . WM , D , ENT
9,WF,C,DLV
9,WM,C,OZK
1,WM,B,ENT 9.WF.C.NEW
0,WM,B,OZK
5 12
ICDA
Category and Honth
752 Cenital
organs 754 Clubfoot
i!;
2,
1,
2,
1,
2,
2,
4,
2,
1,
2,
G:
4.
I,
1,
4,
BH.N,
WM.M,
HM,0.
WM,O,
WM,O,
WH.J.
WM,F.
WM.J,
WM,G,
WM,I,
WM.E.
WM.I,
WM.F,
WH.E,
WM.G,
WM,H,
HM.F,
WM.E,
WM,C,
19
MID
££|! 9,WM,M,FTRb
2.WM.O.DLV
DLV
ENT
ENT 9 , WM , J , ENT
ENT
DTD
DLV
OZK
{S'wM'G'iv
JAC
8 . WM , F , DTN
DLV
DLV
S™ 8,WM.G,ENT
DTN 8. WF, G, OZK
ft , HM , D , ENT
CUP <8.W.F.EHT
}8,WM,P.ENT
(2)£8,WM,D.FTR
FTR
DLV P -WH.C , DLV°
I.
fo.WF.D.OZK
8 , WF , D , DLV
19
July 1968 through December 1972
and Year of Birth'1
755 Other 756 Musculo-
limbs skeletal All other
(T'WM'P'FTR 7431. OF, o. FTR
7419,WM.M.r.NT
6,WF,P,FTR 7475, WM. P. OZK
7450.WM.P.KTR
8,WM,P,FNT
7419, WF. P. FTR
7,WM,J,DLV
8,WF,0,OZK
6,WF,M,ENT g;™;!;;™; ™;.WI.F.OLV
O.WF.F.ENT
1, WM.E. ENT
2,WM,F,ENT /7419.HM.I.DLV
O.BF.F.DLV
0, WM.F. DLV
7419, WF, I ,FTR
7430.BM, I ,ENT
0 , WM , F , DLV
7502,WM,E.OLV
6,WF,E,FTR 7571. WF , B . OZK
j.WM.C.DLV3 8,WM,E,ENT
6.WF.B.ENT
O.BM.A.ENT
16 5 1]
Total
infants
1
4
1
1
3
2
2
0
0
2
1
0
1
0
1
2
0
1
0
6
0
1
1
2
1
]
fe
2
0
2
1
\
I
1
0
2
0
0
3
3
6
3
0
3
i
I
3
2
1
0
3
1
!
0
XJ«
»\
Hote: Footnotes And legend ore on the following page.
-34-
-------
Footnotes and Legend for Table 8
b.
c,
d,
These anomalous births were reported to the Birth Defects
Center, University of Alabama in Birmingham, through the
Division of Vital Statistics, Alabama Department of Public
Health. The major categories are those in which Lyster's
rate ranked among the top ten in a stratified sample of 47
Alabama hospitals.
Infant with multiple birth defect reported in November, 1972,
Duplicate entry.
Infant with multiple birth defect reported in April, 1969.
Legend
1,
3
4
The fourth digit of the indicated ICDA category, or the
entire four-digit code, if the anomaly is in the All Other
category.
Race and sex: W = White, B = Black, H = Hawaiian, M = Male,
F = Female
Code for attending physician.
Residence of mother: BEL = Bellwood
CHP = Chipley, Fla
DLV = Daleville
DTN = Dothan
ELB = Elba
ENT = Enterprise
FTR = Fort Rucker
JAC = Jack
OZK = Ozark
MID = Midway
NEW = Newton
-35-
-------
CTi
I
Table 9
Comparison of Congenital Anomaly Incidence Rates between Lyster Army Hospital,
July 1968 through December 1972, and Mayo Clinic, 1951-19631
Mayo Clinic
ICDA
741
743.0
743.1
745.0
746
747.3
747.5
749.0
749. 1
749.2
750.2
752.1
752.2
752.4
754
755.0
755. 1
755.4
755.6
755.7
755.8
756.0
756.4
756.8
756.8
756.8
Abnormality
Spina Bifida
Encephalocele
Microcephalus
Atresia of Ear Canal
Congenital Heart Disease
Heart Murmur
Truncus Arteriosus
Pulmonary Atresia
Absence of Umbilical Artery
Cleft Palate
Cleft Lip
Cleft Lip and Palate
Tracheoesophageal Fistula
Undescended Testicle
Hypospadias
Hydrocele
Clubfoot (all types)
Polydactyly
Syndactyly
Reduction Deformities7
Congenital Dislocation of Hip
Other Anomaly of Lower Limb
Ar throgryposis
Skull and Face Bones
Ribs
Diaphramatic Hernia
Absence of Pectoralis Major
Other Muscle, Tendon, Fascia
Number of
anomalies
14
3
4
1
32
0
0
0
8
9
15
2
93s
695
173s
25.
19
7
10
12
0
3
5
0
1
5
5
2
Rate,
per 1,000
live
0
0
0
0
1
8
0
0
0
0
8
6
15
1
0
0
0
0
0
0
0
0
0
births
.65
.14
.19
.05
.51
.61
-
-
-
.38
.43
.71
.09
.52
.32
.84
.18
.90
.33
.47
.57
-
.14
.24
-
.05
.24
.24
Lyster Army Hospital3
Number of
anomalies
-
1
1
1
9
1
1
1
1
3
1
1
86
86
3'
19
4
2
3
4
2
1
1
1
1
1
1
Rate,
per 1,000
live births
1
0
0
0
1
0
0
0
0
0
0
0
0
3
3
1
4
0
0
0
0
0
0
0
0
0
0
0
.05
.21
.21
.21
.89
.63
.21
.21
.21
.21
.63
.21
.21
.26
.26
.22
.00
.84
.42
.63
.84
.42
.21
.21
.21
.21
.21
.21
Degrees of
freedom
F for F-test
1
1
0
2
1
<1
4
4
4
<1
1
<1
1
<1
<1
<1
3
<1
1
1
1
8
1
<1
4
2
<1
<1
.48
.11
.89
.23
.21
.00
.45
.45
.45
.00
.34
.00
.48
.00
.00
.00
.25
.00
.11
.21-
.37
.90
.11
.00
.45
.23
.00
.00
30,10
8,2
10,2
4,2
66,18
-
2,2
2,2
2,2
-
20,6
-
6,2
-
-
-
52,38
-
16,4
22,6
26,8
2,4
8,2
-
2,2
4 ,2
-
-
P-value
n.s."
n.s.
n.s.
n.s.
n.s .
n.s.
n.s.
n.s.
n.s.
n.s .
n.s.
n.s .
n.s.
n.s .
n.s.
n.s.
P<0.001
n.s.
n.s.
n.s.
n.s .
P<0.05
n.s.
n.s.
n.s .
n.s.
n.s.
n.s.
757.1 Pigmented Nevus
84
3.97
0.21
<1.00
1. Harris, et al., loc. cit.
2. Live births at Mayo were 21,142.
3. Live births at Lyster were 4,750.
4. Nonsignificant.
5. Totol male live births at Mayo were 10,919.
6. Total male live births at Lyster were approximately 2,453, based on assumption that proportion of male births
.it Lyster was same as that in Mayo study.
7. Combination of two cases of Reduction Deformities of Upper Limb (755.2) and one case of Lower Limb (755.3) at.
l.ystcr .
-------
Figure 1
Number of OVERALL Congenital Anomalies per 1,000 Births of Children
Born to White Residents, by County, Alabama, 1969-1972
Note: The OVERALL anomaly rate and, in parentheses, the relative
rank of that rate within the state are given for each
county. Counties with no anomalies are unranked.
Overall
anomaly rate
II 0-3.1
3.2 - 5.8
5.9 - 9.0
9.1 - 18.8
-37-
-------
Figure 2
Number of HEART DISEASE Congenital Anomalies per 1,000 Births of Children
Born to White Residents, by County, Alabama, 1969-1972
Note: The HEART DISEASE anomaly rate and, in parentheses, the
relative rank of that rate within the state are given for
each county. Counties with no anomalies are unranked.
Heart disease
anomaly rate
-38-
-------
Figure 3
number of GENITAL Congenital Anomalies per 1,000 Births of Children
Born to White Residents, by County, Alabama, 1969-1972
Note: The GENITAL anomaly rate and, in parentheses, the relative
rank of that rate within the state are given for each
county. Counties with no anomalies are unranked.
Genital
anomaly rate
-39-
-------
Figure 4
Mumber of CLUBFOOT Congenital Anomalies per 1,000 Birthis of Children
Born to White Residents, by County, Alabama, 1969-1972
Note: The CLUBFOOT anomaly rate and, in parentheses, the relative
rank of that rate within the state are given for each
county. Counties with no anomalies are unranked.
Clubfoot
anomaly rate
-40-
-------
Figure 5
Number of OTHER LIMBS Congenital Anomalies per 1,000 Births of Children
Born to White Residents, by County, Alabama, 1969-1972
Note: The OTHER LIMBS anomaly rate and, in parentheses, the
relative rank of that rate within the state are given for
each county. Counties with no anomalies are unranked.
Other limbs
anomaly rate
-41-
-------
20. CCCCCMP J *
to 16.00000000
S
o
o
o
i £
tsj
I °
' 41
a
12.C1000000
| 8.COCOCOOO
0)
O
'*.CCCoCOOC «
C.CICCOOf.'i «
Figure 6
Anomaly Rates for 47 Hospitals, Alabama, 1968-1972
(Plot of overall anomaly rate versus number of study-period births)
A H
AA
A
A A
A A
r = -0.288
P < .05
U A
H;J .L'i ), J i lOC.CCOC'J
,\ - i .its , 8 = I HHS , CFC.
5SCO.CUOOO S700.0UUJO
Number of births
I 1500.00000
14300.00000
-------
LIST OF REFERENCES
K. A. Brownlee, Statistical Theory and Methodology in Science
and Engineering, 2nd Ed., John Wiley and Sons, Inc., New York,
1965, pp 183-185.
Franklin A. Graybill, An Introduction to Linear Statistical
Models, Volume I, McGraw-Hill Book Co., Inc., New York, 1961,
pp 122-124.
Lloyd E. Harris, Lois A. Stayura, Perla F. Ramirez-Talavera,
and John F. Annegers, "Congenital and Acquired Abnormalities
Observed in Live-Born and Stillborn Neonates", Mayo Clinic
Proceedings, Vol. 50, February 1975.
P. M. Marden, D. W. Smith, and M. J. McDonald, "Congenital
Anomalies in the Newborn Infant, including Minor Variations.
A Study of 4,412 Babies by Surface Examination for Anomalies
and Buccal Smear for Sex Chromatin", Journal of Pediatrics,
Vol. 64, p 357, 1964.
R. Mclntosh, K. K. Merritt, M. R. Richards, M. H. Samuels,
and M. T. Bellows, "The Incidence of Congenital Malformations:
A Study of 5,964 Pregnancies, Pediatrics, Vol 14, p 505, 1954.
Peter Peacock, e_t al., "Congenital Anomalies in Alabama",
Journal of the MedTcal Association of the State of Alabama,
July, 1971, pp 42-50.
Public Health Services, U. S. Department of Health, Education
and Welfare, Eighth Revision International Classification of
Diseases, Adapted for Use in the United States, P.H.S.
Publication #1693, Vol. 2, 1968.
Joseph Warkany, Congenital Malformations, Yearbook Medical
Publishers, Chicago, 1971.
J. Warkany and H. Kalter, "Congenital Malformations", New
England Journal of Medicine, Vol. 265, p 993 and p 104^7^1961.
-43-
-------
TECHNICAL REPORT DATA
(Please read Instructions on the reverse before completing)
REPORT NO.
EPA-600/1-77-016
2.
3. RECIPIENT'S ACCESSION-NO.
4. TITLE AND SUBTITLE
FACTORS ASSOCIATED WITH THE INCIDENCE OF CONGENITAL
ANOMALIES: A LOCALIZED INVESTIGATION
5. REPORT DATE
March 1977
6. PERFORMING ORGANIZATION CODE
7. AUTHOR(S)
John A. Burdeshaw and Sheldon Schaffer
8. PERFORMING ORGANIZATION REPORT NO.
SORI-EAS-76-212
9. PERFORMING ORGANIZATION NAME AND ADDRESS
Southern Research Institute
2000 Ninth Avenue, South
Birmingham, Alabama
10. PROGRAM ELEMENT NO.
1FA628
11. CONTRACT/GRANT NO.
68-02-0791
12. SPONSORING AGENCY NAME AND ADDRESS
Health Effects Research Laboratory
Office of Research and Development
U.S. Environmental Protection Agency
Research Triangle Park, N.C. 27711
13. TYPE OF REPORT AND PERIOD COVERED
14. SPONSORING AGENCY CODE
EPA-ORD
15. SUPPLEMENTARY NOTES
16. ABSTRACT
This report concludes that, in net terms, and on the basis of available retrospective
data, primarily from birth records, there are no strong indications that the incidence
of congenital anomalies in the Ft. Rucker, Alabama area is higher than normal. The
original hypothesis that the situation might be serious has been traced, for the
most part, to earlier reliance on faulty diagnosing and reporting, and especially
to reliance on the birth certificate, which, there is reason to believe on the
basis of the findings of this study, is a relatively insensitive instrument for
measuring the incidence of congenital anomalies.
The attempt to relate this incidence to specific factors associated with military
life, or in particular to factors associated with exposure to military radar, was
largely unsuccessful because the miliary in effect denied access to pertinent
records on the grounds that no prima facie case had been made that a problem really
exists. Unfortunately, no fairly positive statement can be made denying the
existence of a problem without access in the first place to pertinent military records
or access to present or past military personnel and families. The most conclusive
type of information would, of course, involve a prospective research approach and
that was deemed not justifiable without at least the benefit of the findings of
a defensible retrospective study. a
17.
KEY WORDS AND DOCUMENT ANALYSIS
DESCRIPTORS
b.lDENTIFIERS/OPEN ENDED TERMS
c. COSATl Field/Group
Radar
Radiation
Congenital abnormalities
06 R
13. DISTRIBUTION STATEMENT
RELEASE TO PUBLIC
19. SECURITY CLASS (This Report)
UNCLASSIFIED
21. NO. OF PAGES
50
20. SECURITY CLASS (This page I
UNCLASSIFIED
22. PRICE
EPA Form 2220-1 (9-73)
44
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