Queen Sri Savarindira & Prince Mahidol Adulayadej Commemoration Conference

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GEOGRAPHIC DISTRIBUTION PATTERN OF CONGENITAL

HYPOTHYROIDISM AND ENVIRONMENTAL RELATED FACTORS IN
NAKHON PATHOM PROVINCE THAILAND
Ratsida Saithong*, Kitiphong Harncharoen1, Mathuros Tipayamongkholgul1
and Sangsom Sinawat2
*Master of Science (Public Health) Programme in Infectious Diseases and Epidemiology
1
Department of Epidemiology
Faculty of Public Health, Mahidol University, Bangkok, Thailand
2
Department of Health, Ministry of Public Health, Nonthaburi, Thailand
*E-mail: ratsida@gmail.com

ABSTRACT
This study was performed to analyze the distribution pattern of congenital hypothyroidism
(CH) and risk factors as display of spatial data in all subdistricts of Nakhon Pathom province.
Geographic information systems (GIS) of provincial data had been used for studying a situation
of CH. CH-screening program on the newborn baby was necessary for diagnosis and treatment
of a defected case. It was usually done and obtained from community hospitals. Agriculture
areas and factory distribution data were obtained from District Agriculture Offices and
Department of Industry Works during years 2007 2011.
Over all prevalence of CH in Nakhon Pathom was 0.68 per 1,000 newborns. It varied from
0.13 per 1,000 to 0.78 per 1,000 during these 5 years peroid. Results revealed that prevalence of
CH was significantly associated with a prevalence of factories (p-value <0.01) equal more than
17 factories in the same subdistrict (compared with less than 17 factories), industrial type of
chemical and plastics production plants were associated at the prevalence equal or more than 3
plants (p-value <0.01). CH was also associated with a number of agricultural areas (p-value
<0.01) equal or more than 6,105 rai in the same area, compared with less than 6,105 rai.
Prevalence of CH was not associated with coverage of an antenatal care (along a criterion of at
least four times with iodine supplementing per pregnant woman). Prediction of these three
factors for five years was about 91.5% of all CH cases in Nakhon Pathom. During five years,
provincial data indicated that the number of factorial plants and the rate of chemical consuming
in agricultural sectors are rising up in each year.
These data show for further studies have to be done with CH not only in the way of chemical
used in industry and agriculture but also in the socioeconomic mobilization of employees
especially in high risk areas.
Keywords: Congenital hypothyroidism, GIS
INTRODUCTION
Congenital hypothyroidism (CH) is defined as thyroid hormone deficiency present at birth.
Thyroid hormone deficiency present at birth is most commonly caused by developmental
abnormalities of the thyroid gland or or by thyroid hormone itself that related with mutation of
genes involved in hormonogenesis (Beardsall & Amanda L, 2004; Rastogi & LaFranchi, 2010).
CH is a major health problem of many countries including Thailand.
The prevalence rate of CH as worldwide affects about 1:2,000 4,000 newborns (Rastogi &
LaFranchi, 2010). The prevalence rate in Thailand affects about 1:4,000 newborns that is health
problem of country. It is expected that patient found 250 - 400 person per year (Department of
Medical Sciences Thailand Ministry of Public Health 2511). Around 4.8 million baht were
spent in treating people who have mental retardation and total loses revenue from their work
was around 3.6 million baht per person. Therefore, state loses economic income from these
causes around 8.4 millon baht per person. If state have new patient in one year 400 people, state
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will loses costs around 3,360 millon baht ( 2511). So,

CH is still a major health problem in Thailand.
Thailand has newborn screening programs by Department of Medical Sciences. CHscreening is performed by heel prick collected on special filter paper cards and measuring a
total TSH and T4 that obtained shortly after birth (U.S. Department of Health and Human
Services & Centers for Disease Control and Prevention, 2008). The prevalence of neonatal TSH
levels above 5 mU/L were 20.00 39.9 % during years 2005-2006 in Nakhon Pathom province
(Charoensiriwatana, Srijantr, Janejai, & Hasan, 2008).
Nakhon Pathom province has a geographic variation. The people in Nakhon Pathom
province have many occupations such as farming, agriculture, fishery and factory. Nakhon
Pathoms people have various of culture and behavious because they migrate to this province
for living and working. Especially, behavior of prevation is very important for healthly. For
example, in case agriculture if people use pesticide for occupation. They was disrupted
endocrine and thyroid disease. The result about morbidity rate of pesticide poisoning in Nakhon
Pathom Province during 2009 - 2011 were 1.82, 2.51 and 3.19, respectively (Center of
Epidemiological Information, Bureau of Epidemiology, & Mininstry of Public Health, 2552).
Trends in the incidence of these disease in Nakhon Pathom Province increase every year.
According to the previously study, pesticide was risk factor for thyroid disease such as
insecticides, herbicides and fungicides have been endocrine disruptors and related thyroid
disruptors through diverse mechanisms such as inhibition of thyroid iodine uptake, interference
with iodothyronine deiodinases , interference with thyroid hormone receptor, binding to
transport proteins and increased clearance of thyroid hormone (Whitney, et al., 2010). Nakhon
Pathom province have many factory, especially chemicals and plastics industries. The
compounds of chemicals and plastics industries may affect thyroid function such as BisphenolA, polychlorinated biphenyls (PCBs), Styrenes. It was direct actions on the thyroid hormone
receptor and associated with low serum T4 levels (Pearce & Braverman, 2009).
GIS and epidemiological methods can use identify that locate environmental risk factor
associated disease. GIS was used in locate high prevalence areas and populations at risk through
monitor intervention and control programs in areas that affected disease (Clarke, Mclafferty, &
Tempalski, 1996). So, this study use GIS tool for study about CH. Especially, study distribution
pattern of CH and risk factors as display of spatial data.
OBJECTIVE/RESEARCH QUESTION
1. To explore distribution pattern of prevalence rate of congenital hypothyroidism in every
subdistrict of Nakhon Pathom province.
2. To determine association factors of distribution pattern of prevalence rate congenital
hypothyroidism every subdistrict in Nakhon Pathom province.
RESEARCH METHODS
Study design
The present research is design as an ecological study that explore distribution pattern of
prevalence rate of congenital hypothyroidism and factors association in every subdistrict of
Nakhon Pathom province.
Population study
The unit of study is subdistrict of Nakhon Pathom provinces.The subdistrict of Nakhon
Pathom provinces are 106 subdistricts.
Data collection
- Congenital hypothyroidism screening program on the newborns was necessary for
diagnosis of a defected case begins with serum TSH level as or above 25 mU/L, leading to
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serum thyroid function tests (typically TSH and free T4) to confirm the diagnosis that were
obtained from community hospital in Nakhon Pathom province that data during the years 2007
2011.
- Environmental factors such as factories and industrial type of chemical and plastics
production were obtained from Department of Industry Works. Agriculture areas were obtained
from department of District Agricultural Office.
- Health service factors such as antenatal care ( at last four times with iodine
supplementing) were obtained from community hospitals in Nakhon Pathom province.
Data analysis
Data were obtained from:
1. Descriptive statistic : General characteristic such as factory, industrial type of chemical
and plastics production, agriculture land and anternal care, show in the form of percentage.
2. Inferential statistic : Studied results were presented association between environmental
factors, health servince and congenital hypothyroidism by poisson regression.
3. Map data analysis by STATA version 8.0.
Ethical
This project have been reviewed and approved according to the Standard Operating
Procedures of Ethical Review Committee for Human Research, Faculty of Public Health,
Mahidol University during May 18, 2012.
RESULTS
This research aimed for study distribution pattern of prevalence rate of congenital
hypothyroidism and determine association factors of distribution pattern of prevalence rate this
disease in every subdistrict of Nakhon Pathom province. The studied results were presented as
follows:
General characteristics
Units of analysis are 106 subdistricts in Nakhon Pathom province and variable factors are
factory, industrial type of chemical and plastics production, agriculture area, antenatal care. The
percentage of factories that located in each subdistrict are varies from place to place then
quartiles of factories distribution were used in categorized this factor in four levels (<10, 10-16,
17-31, >31 factories). The percentage of industrial type of chemical and plastics production in
four levels (<1, 1-2, 3-4, >4 factories), agriculture area in four levels (<2,443, 2,443-6,104,
6,105-12,035, >12,035 rai) , and antenatal care in four levels(<7, 7-14, 15-24, >24 person) were
categorized by the same manner (Table 1).
Prevalence rate of congenital hypothyroidism
Prevalence rate of congenital hypothyroidism in Nakhon Pathom province during years 2007
2011 are, also, varies from 0.13 to 1.05:1,000 newborns. For subdistrict scale, probability to
find CH baby was 0.05 (95%CI, 0.032-0.068).
The number of CH cases that presented in subdistrict level are minimum 1 and maximum 4
cases, it located in
for study showed prevalence rate of subdistrict with congenital
hypothyroidism (1 persons) during years 2007 2011 were 0.94%, 4.72%, 7.55%, 5.66% and
5.66%, respectively. The area reported to have congenital hypothyroidism repeatedly was
1.89% during five years (Table2).
The association among environmental factors, health service factors and congenital
hypothyroidism
The results from univariate analysis of poisson regression was used to examine congenital
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hypothyroidism and factories (>17-31, >31 factories, compared with less than 10 factories)
were significant in year 2010 (p-value<0.01, 95%CI: 26.48-30.40, 26.60-30.52). Chemical and
plastics industries (3-4,>4 factories, compared with less than 1 factories) were significant with
disease during years 2009 (p-value < 0.01, 95%CI: 26.29-29.57, 26.26-29.12) and during years
2010 (p-value < 0.01, 95%CI: 25.25-29.78, 25.61-29.19). Agricultural area and antenatal care
was not significant with disease (Table3).
The result from adjusted by multivariate technique of poisson regression was used to
examine congenital hypothyroidism and chemical and plastics industry
(3-4, >4 factories,
compared with less than 1 factories) was significant with disease during years 2009 (pvalue<0.01, 95%CI: 25.25-31.58, 21.35-32.53) and during years 2010 (p-value < 0.01, 95%CI:
23.40-29.77, 21.83-29.46). Agriculture area (6,105-12,035, >12,035 rai, compared with less
than 2,443 rai) was adjust associated with congenital hypothyroidism during year 2009 (p-value
< 0.001, 95%CI: 24.50-29.91, 24.43-30.20) Table4).
Geographical distribution of congenital hypothyroidism and environmental factors , health
service factors
The number of subdistrict with prevalence rate of congenital hypothyroidism (1 persons)
during year 2007 2011 were 1, 5, 8, 6, 6, respectively (Figure 1).
The number of subdistrict with factory (<10, 10-16, 17-31, >31 factorys) during year 2007
were 29, 28, 25, 24 during year 2008 were 30, 29, 25, 22 during year 2009 were29, 31, 23, 23
during year 2010 were 29, 28, 26, 23 and during year 2011 were 25, 31, 24, 26 (Figure 2).
The number of subdistrict with prevalence of chemical and plastics industry (<5, 5-10,1119,>19 factorys) during year 2007 were 35, 21, 30, 20 during year 2008 were 35, 28, 25, 18
during year 2009 were 34, 23, 24, 25 during year 2010 were 24, 30, 29, 23 and during year
2011 were 26, 28, 26, 26 (Figure 3).
The number of subdistrict with agriculture area (<2,443, 2,443-6,104, 6,105-12,035, >12,035
rai) during year 2007 were 26, 31, 23, 26 during year 2008-2010 were 24, 29, 27, 26 during
year 2011 were 26, 27, 27, 26 (Figure 4).
The number of subdistrict with prevalence of antenatal care (<17, 17-26, 27-35, >35 persons)
during year 2007 were 29,7,11,19 during year 2008 were 37,22,7,15 during year 2009 were 26,
28, 7, 20 during year 2010 were 36, 21, 6, 18 and during year 2011 were 21, 23, 17, 20 (Figure
5).

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Table 1 The number and percent of general characteristics.

*The total of newborns using newborns during year 2011 and have missing data as follow; year
2007 (37.7%), 2008-2011 (23.6%)
Table 2 The prevalence rate of congenital hypothyroidism

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Table 3 Factors associated with congenital hypothyroidism

a. Hessian matrix singularity is caused by this parameter. The parameter estimate at the last
iteration is displayed.
b. Set to zero because this parameter is redundant. * statistical significance at <0.05
**The total of newborns using newborns during year 2011 and have missing data as follow;
year 2007 (37.7%), 2008-2011 (23.6%)
*** The congenital hypothyroidism were in missing data of antenatal care.
Table 4 Factors associated with congenital hypothyroidism by standardized coefficient

a. Hessian matrix singularity is caused by this parameter. The parameter estimate at the last
iteration is displayed.
b. Set to zero because this parameter is redundant.
* statistical significance at <0.05 ,adjust by standardized coefficients
**The total of newborns using newborns during year 2011 and have missing data as follow;
year 2007 (37.7%), 2008-2011 (23.6%)
*** The congenital hypothyroidism were in missing data of antenatal care.

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Figure 1 spatial distribution of prevalence rate of subdistrict with congenital hypothyroidism in Nakhon
Pathom province during years 2007 2011

Figure 2 spatial distribution of subdistrict with factory in Nakhon Pathom province during years 2007
2011.

Figure 3 spatial distribution of prevalence rate of subdistrict with chemical and plastics industry in
Nakhon Pathom province during years 2007 2011.

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Figure 4 spatial distribution of agriculture area in every subdistrict of Nakhon Pathom province during
years 2007 2011.

Figure 5 spatial distribution of prevalence rate of subdistrict with antenatal care in Nakhon Pathom
province during years 2007 2011.

DISCUSSION AND CONCLUSION

The prevalence rate of CH in Nakhon Pathom province during five years study was
approximately 0.13 : 1,000 newborns and end up 0.78 : 1,000 newborns by year 2011. The
prevalence rate in Thailand affects about 1:4,000 newborns. Therefore, the prevalence rate of
CH in Nakhon Pathom province more than prevalence rate in Thailand that year 2008-2011
(Department of medical Sciences Thailand Ministry of Public Health). The prevalence rate of
subdistrict with CH during years 2007 2011 were 0.94%, 4.72%, 7.55%, 5.66% and 5.66%,
respectively. The problem was incerased in severity from year to year.
In this study, the majority of subdistricts consisted of factory were <10 factorys during year
2007, 2008, 2010 (27.4%, 28.3%, 27.4%) and ranging from 10 to 16 during year 2009 and 2011
(29.2%), chemical and plastics industry ranged between 1-2 factories during year 2007-2011
(37.7%, 39.6%, 40.6%, 42.5%, 41.5%) , agriculture area ranged between 2,443-6,104 rai during
year 2009 and 2010 (29.2%, 27.4%, 27.4%, 27.4%) and year 2011 ranged between 2,443-6,104
and 6,105-12,035 rai (25.5%), antenatal care were <7 persons during year 2007-2011 (29.2%,
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33.0%, 25.5%, 31.1%, 23.6%). The result has found agriculture area and factory in all
subdistrict.
The present study shows that association factory, chemical and plastics industry, agriculture
area and antenatal care with CH. This study showed industrial type of chemical and plastics
production (1-2, 3-4 factories) was adjust associated with CH during year 2010 (p-value< 0.01,
95%CI:21.53-29.16, 22.96-30.20) and during years 2011 (1-2 factories, p-value< 0.01, 95%CI:
18.09-23.63). The previous study found the substances or compounds in this industry that may
affect thyroid function such as polychlorinated biphenyls (PCBs), bisphenol-A and styrenes.
The effects of PCBs and Bisphenol-A were direct actions on the thyroid hormone receptor. The
effects of styrenes was inhibit T4 and T3 (Pearce & Braverman, 2009). Therefore, the
prevalence of subdistrict with CH was may correlation with compounds in industrial type of
chemical and plastics production.
Agriculture area (2,443-6,104, 6,105-12,035 rai) was adjust associated with CH during year
2009 (p-value< 0.01, 95%CI: 25.29-31.05, 23.84-30.57). The previous study about pesticide use
and thyroid disease among women in the agricultural health study in 1993-1997 North Carolina,
and was increased odds of hypothyroidism with ever use of organochlorine insecticides
(ORadj=1.2 (95%CI: 1.9-5.1)) and fungicides (ORadj=1.4 (95%CI: 1.1-1.8) (Whitney, et al.,
2010). And previous study that study association between organochlorine and thyroid hormone
levels in cord serum: A study from north Thailand that found levels of
dichlorodiphenyldichloroethylene
(DDE),
dichlorodiphenyl
trichloroethane
(DDT),
dichlorodiphenyl dichloroethane (DDD) and dierin in maternal serum were positively
associated with levels in cord serum(r=0.86, 0.77, 0.66 and 0.60, respectively; p-value <0.001)
(Asawasinsopon R, et al., 2006).
The distribution map of CH in every subdistrict of Nakhon Pathom province had prevalence
rate of CH during year 2007-2011 were 1, 5, 8, 6, 6 subdistricts and CH repeatedly was 1.89%
all five years. The most of distribution pattern of prevalence rate of CH lived in prevalence rate
of chemical and plastics industry (11-19, >19 factories) and agriculture area (6,105-12,035,
>12,035 rai).
The result of present study Nakhon Pathom province have CH all five years and have
factorys in all subdistrict, especially chemical and plastics industry may cause some effects on
CH.
SUGGESTIONS
The study showed CH in risk area. Therefore, surveillance the risk areas of CH in Nakhon
Pathom province. Further research is needed to correlate this disease with chemical and plastics
industry and agriculture area.
ACKNOWLEDGEMENTS
The authors would like to thank the community hospital, department of district office of
agricultural and department of industry works for data collection, Grant to Support Graduate
Students in Academic Presentations in Thailand Academic Year 2012. The authours also wish
to expess thanks to Dr. Kitiphong Harncharoen (Department of Epidemiology, Mahidol
University) for editing this research.
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