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STUDENT ARTICLE – DOCTORAL
Open Access

High Background Congenital Microcephaly in Rural Guatemala: Implications for Neonatal Congenital Zika Virus Infection Screening

Anne-Marie Rick, Gretchen Domek, Maureen Cunningham, Daniel Olson, Molly M Lamb, Andrea Jimenez-Zambrano, Gretchen Heinrichs, Stephen Berman and Edwin J Asturias
Global Health: Science and Practice December 2017, 5(4):686-696; https://doi.org/10.9745/GHSP-D-17-00116
Anne-Marie Rick
aDepartment of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
bCenter for Global Health, Colorado School of Public Health, Aurora, CO, USA.
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  • For correspondence: anne-marie.rick@ucdenver.edu
Gretchen Domek
aDepartment of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
bCenter for Global Health, Colorado School of Public Health, Aurora, CO, USA.
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Maureen Cunningham
aDepartment of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
bCenter for Global Health, Colorado School of Public Health, Aurora, CO, USA.
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Daniel Olson
bCenter for Global Health, Colorado School of Public Health, Aurora, CO, USA.
cDepartment of Epidemiology, Colorado School of Public Health, Aurora, CO, USA.
dPediatric Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA.
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Molly M Lamb
bCenter for Global Health, Colorado School of Public Health, Aurora, CO, USA.
cDepartment of Epidemiology, Colorado School of Public Health, Aurora, CO, USA.
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Andrea Jimenez-Zambrano
bCenter for Global Health, Colorado School of Public Health, Aurora, CO, USA.
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Gretchen Heinrichs
eDepartment of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO, USA.
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Stephen Berman
aDepartment of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
bCenter for Global Health, Colorado School of Public Health, Aurora, CO, USA.
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Edwin J Asturias
bCenter for Global Health, Colorado School of Public Health, Aurora, CO, USA.
cDepartment of Epidemiology, Colorado School of Public Health, Aurora, CO, USA.
dPediatric Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA.
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Figures & Tables

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  • FIGURE 1
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    FIGURE 1

    Box Plot With Whiskers of Estimated Gestational Agea

    Note: Median gestational age is 38.7 weeks, and the interquartile range is 37.4 to 39.9 weeks.

    a Gestational age was estimated by centering an infant's height at a z-score of zero on gender-adjusted Fenton growth curves.

  • FIGURE 2
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    FIGURE 2

    Measured Head Circumference and Z-Score for All Infants by Month of Birth

Tables

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    TABLE 1.

    Established and Proposed Microcephaly Case Definitions

    Origin of Case DefinitionMicrocephaly Case Definition
    Brazil MOH 1Term: OFC ≤33.0 cm for all infants
    Preterm: OFC ≤3rd percentile Fenton GC adjusted for GA and gender
    Brazil MOH 2Term: OFC ≤32.0 cm for all infants
    Preterm: OFC ≤3rd percentile Fenton GC adjusted for GA and gender
    PAHO 1Term: OFC <−2 SD WHO GC for males (<31.9 cm) and females (<31.5 cm)
    Preterm: OFC <−2 SD Fenton GC adjusted for GA and gender
    PAHO 2Term: OFC <3rd percentile WHO GC for males (<32.0 cm) and females (31.6 cm)
    Preterm: OFC <3rd percentile Fenton GC adjusted for GA and gender
    WHO 1Unknown GA, suspected term: OFC <−2 SD WHO GC
    0–6 days: males: <31.9 cm; females: <31.5 cm
    7–13 days: males: <32.7 cm; females: <32.2 cm
    WHO 2Unknown GA, suspected term: OFC <3rd percentile WHO GC
    0–6 days: males: <32.0 cm; females: <31.6 cm
    7–13 days: males: <32.8 cm; females: <32.4 cm
    WHO 3Unknown GA, suspected term: OFC <−3 SD WHO GCa
    0–6 days: males: <30.7 cm; females: <30.3 cm
    7–13 days: males: <31.5 cm; females: <31.1 cm
    Fenton 1All infants: <−2 SD Fenton GC adjusted for gender and estimated GA
    Fenton 2All infants: <3rd percentile Fenton GC adjusted for gender and estimated GA
    Fenton 3All infants: <−3 SD Fenton GC adjusted for gender and estimated GAa
    • Abbreviations: GA, gestational age; GC, growth curve; MOH, Ministry of Health; OFC, occipital frontal head circumference; PAHO, Pan American Health Organization; SD, standard deviation; WHO, World Health Organization.

    • ↵a <-3 SD defines severe microcephaly.

    • View popup
    TABLE 2.

    Characteristics of Neonates Born Between August 1, 2014, and March 31, 2016, in Rural Guatemala (N=296)

    CharacteristicNo. (%)
    Gender
        Male143 (48.3)
        Female153 (51.7)
    Birth year
        201420 (6.8)
        2015214 (72.3)
        201662 (20.9)
    Age, days
        0–6257 (86.8)
        7–1339 (13.2)
    Weight, kg
        1.5 to <2.02 (0.7)
        2.0 to <2.58 (2.7)
        2.5 to <3.078 (26.4)
        ≥3.0208 (70.3)
    Length, cm
        40 to <454 (1.4)
        45 to <50139 (47.0)
        ≥50153 (51.7)
    OFC, cm
        ≤307 (2.4)
        >30 to ≤3117 (5.7)
        >31 to ≤3248 (16.2)
        >32 to ≤3391 (30.7)
        >33133 (44.9)
    • Abbreviation: OFC, occipital-frontal head circumference.

    • View popup
    TABLE 3.

    Estimated Microcephaly Cases and Microcephaly Background Prevalence Using Established and Proposed Microcephaly Case Definitions in Neonates Born Between August 1, 2014, to March 31, 2016, in Rural Guatemala

    Origin of Case DefinitionMicrocephaly No. (%)Microcephaly Background Prevalence per 10,000 Live Births
    Brazil MOH 1125 (42.2)a4,223
    Brazil MOH 248 (16.2)a1,622
    WHO 243 (14.5)b1,453
    WHO 136 (12.2)b1,216
    PAHO 220 (6.8)a676
    Fenton 220 (6.8)a676
    PAHO 115 (5.1)a507
    Fenton 113 (4.4)a439
    WHO 39 (3.0)b304
    Fenton 31 (0.3)a34
    • Abbreviations: MOH, Ministry of Health; PAHO, Pan American Health Organization; WHO, World Health Organization.

    • ↵a Based on infant's estimated GA using z-score of zero for length on Fenton growth curve adjusted for gender. Term if estimated GA ≥37 weeks; preterm if estimated GA <37 weeks.

    • ↵b Assumes term (≥37 weeks) GA for all infants.

    • View popup
    TABLE 4.

    Percent Agreement Between Established Microcephaly Case Definitions and Proposed Fenton Growth Curve Definitions

    Fenton GC <−2 SD (n=13)Fenton GC <3rd Percentile (n=20)Fenton GC <−3 SD (n=1)
    No. (%)No. (%)No. (%)
    Brazil MOH 113 (100.0)20 (100.0)1 (100.0)
    Brazil MOH 211 (84.6)18 (90.0)1 (100.0)
    PAHO 15 (38.5)11 (55.0)1 (100.0)
    PAHO 26 (46.2)12 (60.0)1 (100.0)
    WHO 16 (46.2)12 (60.0)1 (100.0)
    WHO 27 (53.8)13 (65.0)1 (100.0)
    WHO 32 (15.4)2 (10.0)1 (100.0)
    Identified on all case definitions5 (38.5)11 (55.0)1 (100.0)
    • Abbreviations: GC, growth curve; MOH, Ministry of Health; PAHO, Pan American Health Organization; SD, standard deviation; WHO, World Health Organization.

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Global Health: Science and Practice: 5 (4)
Global Health: Science and Practice
Vol. 5, No. 4
December 28, 2017
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High Background Congenital Microcephaly in Rural Guatemala: Implications for Neonatal Congenital Zika Virus Infection Screening
Anne-Marie Rick, Gretchen Domek, Maureen Cunningham, Daniel Olson, Molly M Lamb, Andrea Jimenez-Zambrano, Gretchen Heinrichs, Stephen Berman, Edwin J Asturias
Global Health: Science and Practice Dec 2017, 5 (4) 686-696; DOI: 10.9745/GHSP-D-17-00116

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High Background Congenital Microcephaly in Rural Guatemala: Implications for Neonatal Congenital Zika Virus Infection Screening
Anne-Marie Rick, Gretchen Domek, Maureen Cunningham, Daniel Olson, Molly M Lamb, Andrea Jimenez-Zambrano, Gretchen Heinrichs, Stephen Berman, Edwin J Asturias
Global Health: Science and Practice Dec 2017, 5 (4) 686-696; DOI: 10.9745/GHSP-D-17-00116
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