【作者】 樊利春；

【导师】 杜玉开；

【作者基本信息】 华中科技大学 ， 儿少卫生与妇幼保健学， 2013， 博士

【摘要】 目的：分析海南地区出生缺陷的基本情况、影响因素及变化趋势，研究孕期空气污染物暴露与出生缺陷、早产以及低出生体重等妊娠不良结局的关系，探讨降低出生缺陷、早产和低出生体重等妊娠不良结局的预防策略，为公共卫生决策提供科学依据。方法：1.利用海南省2000～2010年以医院为基础的出生缺陷监测资料，对海南地区出生缺陷总发生率、发生顺位、城乡的发生率、围产儿性别的发生率等特征进行描述；采用Poisson回归法对出生缺陷发生率的城乡差异、性别差异和在孕母年龄上的差异进行分析，了解海南地区出生缺陷的一般影响因素；利用海口、三亚两市2009～2011年的空气污染资料和出生登记资料，采用成组设计的病例-对照研究法，采用t检验和logistic回归法，分析孕期不同阶段空气污染物暴露与出生缺陷的关系；2.利用海口市2009～2011年的空气污染资料、气象资料及出生登记系统的活产儿早产、低出生体重等出生情况资料，采用Poisson广义相加模型进行时间序列分析，研究空气污染物暴露与早产和低出生体重的关系。结果：1.2001～2010年海南省出生缺陷总发生率99.13/万，低于全国平均水平；出生缺陷发生率城市低于农村（IRR=0.765，95%CI：0.715-0.819，P<0.001）；男性围产儿高于女性围产儿（IRR=1.092，95%CI：1.021-1.169，P=0.010）；出生缺陷发生率与孕母年龄相关，<20岁年龄组和≥35岁年龄组发病率较高，且组间没有差异（P>0.05），其次为20～25岁年龄组（IRR=0.816，95%CI：0.701-0.949，P=0.008）、25～30岁（IRR=0.761，95%CI：0.655-0.883，P<0.001）及30～35岁年龄组（IRR=0.731，95%CI：0.623-0.858，P<0.001）。2.孕早期空气污染物PM₁₀的暴露对出生缺陷有不良影响。海口市多污染物logistic回归调整模型结果显示，在控制了一般因素和另外两种污染物的影响后，妊娠第2月（OR=1.039，95%CI：1.016-1.063，P=0.001）与第3月（OR=1.066，95%CI：1.043-1.090，P<0.001）空气中PM₁₀的暴露对出生缺陷的总发生率有不良影响。三亚市多污染物logistic回归调整模型结果显示，妊娠第3月（OR=1.025，95%CI：1.006-1.044，P=0.009）空气中PM₁₀的暴露对出生缺陷总发生率有不良影响。海口市空气污染物暴露与先天性心脏病和唇腭裂的关系研究显示，海口市孕早期空气中PM₁₀的暴露为先天性心脏病的影响因素（OR=1.103，95%CI：1.023-1.190，P=0.011）。而所研究的三种污染物孕早期对婴儿唇腭裂发生的影响无统计学意义。3.海口市大气主要污染物PM₁₀和SO₂浓度水平对早产发生率有不利影响，全污染物模型拟合分析结果显示，PM₁₀污染物滞后当天对新生儿日早产数影响的相对危险度为1.016（95%CI：1.003-1.030，P<0.05）；SO₂污染物累积6天对新生儿日早产数影响的相对危险度为1.141（95%CI：1.039-1.242，P<0.05）；大气主要污染物PM₁₀对低出生体重发生率有不利影响，PM₁₀污染物滞后1天对新生儿日低出生体重数影响的相对危险度为1.024（95%CI：1.011-1.038，P<0.05）；累积6天对新生儿日低出生体重数影响的相对危险度为1.064（95%CI：1.042-1.087，P<0.05）。结论：孕早期空气污染物PM₁₀的暴露是出生缺陷和先天性心脏病的危险因素；大气主要污染物SO₂和PM₁₀的浓度水平与早产率发生有关，PM₁₀浓度水平与新生儿低出生体重率发生有关；一级预防是控制和减少妊娠不良结局最具成本效益的预防措施，要考虑探讨医疗保健部门与环境监控与保护部门联动的预防机制，努力发挥一级预防的效力。更多还原

【Abstract】 Objective: To explore the relationship between the air pollutants exposure withadverse pregnancy outcomes such as birth defects, premature birth and low birth weight; toprovide scientific basis for proper intervention strategies to adverse pregnancy outcomes.Methods:1. The prevalence and the rank of birth defects, the urban-rural differencesand sex differences in the prevalence of birth defects were analyzed on the base of birthdefects monitoring data of Hainan province during2000～2010. The methods ofPoisson-regression and Linear Chi-Square tests were used respectively to compare thedifferences in the prevalence of birth defects between male and female infants, urban andrural areas and the tendency of birth defects prevalence in Hainan province during the past11years according to the data from the monitoring program of birth defects in Hainanprovince. T-test and logistic regression was used to analyze the association between airpollutant exposure and birth defects.2. Generalized Additive Model extended Poisson regression model were used toanalyze the relationship between air pollutant exposure and premature and low birth weightduring2009to2011.Results:1. The prevalence of birth defects in Hainan area from2000²011was99.13/10000, which was lower than the prevalence of our country. The prevalence of birthdefects in urban area was lower than that of rural area （IRR=0.765,95%CI:0.715-0.819,P<0.001）; the prevalence of birth defect of male infants was lower than that of femaleinfants （IRR=1.092,95%CI:1.021-1.169, P=0.010）; our study showed the birth defectswere associated with maternal age: women less than20years old and the age group greaterthan35had more higher prevalence, there were no difference between the twogroup（P>0.05）, following by age group of20～25（IRR=0.816,95%CI:0.701-0.949, P=0.008）, age group of25～30（IRR=0.761,95%CI:0.655-0.883, P<0.001） and age groupof30～35（IRR=0.731,95%CI:0.623-0.858, P<0.001）；2. Peri-gestational exposure to air pollutants of PM₁₀was associated with birth defects.The multiple logistic regression analysis showed that the effect of PM₁₀on the secondmonth （OR=1.039,95%CI:1.016-1.063, P=0.001） and third month （OR=1.066,95%CI:1.043-1.090, P<0.001） of pregnancy was statistically significant associated with birthdefects according to the data from Haikou city. The multiple logistic regression analysisshowed that the effect of PM₁₀on the third month （OR=1.025,95%CI:1.006-1.044,P=0.009） of pregnancy was statistically significant associated with birth defects accordingto the data from Sanya city. The multiple logistic regression analysis showed that the effectof PM₁₀on first trimester was statistically significant with congenital heart diseases（OR=1.103,95%CI:1.023-1.190, P=0.011） according to the data from Haikou city and theeffect of studied air pollutants on the cleft lips had no statistical significance.3. Exposure to PM₁₀and SO₂was a risk factor of preterm delivery in Haikou city. Theresults of model fitting with all pollutants showed that on the same day, exposure to PM₁₀was significantly associated with increased risk of preterm delivery （RR=1.016,95%CI:1.003-1.030, P<0.05） and on the cumulative6days, exposure to SO₂was significantlyassociated with increased risk of preterm delivery （RR=1.141,95%CI:1.039-1.242,P<0.05）. Exposure to PM₁₀was a risk factor of low birth weight. The results of modelfitting with all pollutants showed that on the first day, exposure to PM₁₀was significantlyassociated with increased risk of low birth weight （RR=1.024,95%CI:1.011-1.038,P<0.05） and on the cumulative6days, was significantly associated with increased risk oflow birth weight （RR=1.064,95%CI:1.042-1.087, P<0.05）.Conclusions: Exposure to PM₁₀during the early stages of pregnancy was a risk factorof birth defects and congenital heart disease. Exposure to SO₂and PM₁₀was associated withpreterm delivery. And exposure to PM₁₀during the pregnancy was a risk factor of low birthweight. Primary prevention should be strengthened in order to control and reduce theprevalence of birth defects and adverse pregnancy outcomes, and it is necessary to explorea linkage mechanism between departments of medical health care and environmentalprotection so as to bring out the full effectiveness of primary prevention.更多还原