FICCI and Frost & Sullivan released two whitepapers on the impact of untreated maternal hypothyroidism in pregnant women and the fetus and highlight the need for universal screening influenza vaccination for pregnant women. The whitepapers include compelling statistics indicating that by making universal thyroid screening mandatory and ensuring flu vaccinations for all pregnant women, India can further bring down maternal and child deaths.
Commenting on these findings, Ms Vandana Gurnani, Joint Secretary, Ministry of Health & Family Welfare, said, “India has made tremendous progress in bringing down maternal and child mortality over the years and this has been possible by introducing multiple interventions at various stages before, during and post pregnancy. These whitepapers show that now there is need to improve diagnosis and treatment of thyroid disorders and a possible need for vaccination for pregnant women.”
Ms Ankita Kothari, Industry Analyst, Frost & Sullivan added, “A significant number of clinicians interviewed endorsed the need to screen for thyroid disorders and most agreed to give flu vaccinations to pregnant women. Currently this is a gap and many hospitals do not do this routinely. We would like to urge the government to include regular thyroid screening and influenza vaccinations in both government and private hospitals.”
The white papers reveal the need to reduce the impact of untreated thyroid disorder on the maternal & fetal health outcomes, set in relevant health systems in place to ensure universal screening of the pregnant women during antenatal checkups and neonates for congenital thyroid to reduce feto-maternal mortality & morbidity as well. With high fertility and high birth rates and multi-level challenges of access to quality healthcare, especially in the rural areas, it is critical that India invests in preventive health. One of the critical inference is also that investment in thyroid care has huge health and economic benefits.
Some highlights from the white papers are:
- Congenital hypothyroidism situation in India is alarming: Congenital hypothyroidism requires early diagnosis (within the first seven days of birth), which is usually followed by appropriate therapy that can prevent the further brain damage. The situation is more alarming in India: an abnormally high rate of 1 in 800 neonates as against a global average of 1 in 3,800 neonates suffering from hypothyroidism. Hence universal screening of pregnant women and of neonates is critical.
- Many pregnant women suffer from thyroid disorders:11% – 25% of pregnant women have hypothyroidism and majority of these women have subclinical hypothyroidism. Abnormal levels of thyroid hormones during pregnancy are associated with maternal complications such as miscarriages, increased risk of abortion and postpartum bleeding. The impact of thyroid disorders is not visible early enough; however, optimum levels of thyroid hormones during the first three months of pregnancy are critical for brain development in the foetus. Our research shows that reversibility of the damage to the foetus and the woman, from thyroid disorders, is up to 90%, if detected in first trimester and goes down as low as 25% – 30% if detected in the third trimester.
- Lack of thyroid testing and treatment:India has made significant progress in reducing maternal and under-five mortality through the implementation of multiple initiatives under the National Health Mission. One of the biggest pushes has been for early registration of pregnancy and complete antenatal care for all pregnant women, which includes a battery of tests. But thyroid testing and treatment and vaccination against influenza is abysmally low.
- Less than a quarter of the pregnant women are screened for thyroid disorders currently.
- Less than 5% women are counselled on thyroid disorders, prevention and treatment during antenatal care.
- There is no much difference between public health service providers and private health care settings when it comes to screening for thyroid and no difference between a Tier 1 or Tier 2 hospital. The prevalence of thyroid screening ranges between 5% – 10% in government hospitals and 20% – 25% in private hospitals.
- Less than 1% women in both public and private hospitals get the Complete Thyroid Panel tests routinely done.
- Misplaced public health focus:India is the thyroid capital of the world: The Sustainable Development Goals recognise non communicable diseases as a growing public health concern. The focus is on prevention, diagnosis and management of cardio-vascular disease, diabetes, cancer, mental disorders and chronic respiratory diseases, but little focus is given to thyroid disease. Though the prevalence rate of diabetes (5.4%) is lower than that of thyroid disease (10.95% in non-pregnant context & 14.3% in case of pregnant women), less is being done for thyroid screening and management in the health care sector.
- Investment in thyroid care makes economic sense: The white paper has projected the cost of management of complications from hypothyroidism in pregnancy (keeping the annual number of births in India – 28 lakh – as the parameter) and the associated cost of early detection and treatment. For example, the cost of thyroid screening ranges from INR 100-700 and a three month therapy costs between INR 100-125. On the other hand the economic impact of miscarriages/abortions as a result of hypothyroidism during pregnancy is INR 91.76 crores. The cost of pre-term delivery is INR 618 crores and that of pre-eclampsia is INR 101.92 crores.
- Influenza is another ignored disease:WHO & International Centre for Disease Control & Prevention (ICDC) recommends universal influenza vaccination to all pregnant mothers. The Indian Academy of Paediatrics also recommends seasonal annual vaccination for pregnant women, which will also protect the foetus in the womb and 6 months after delivery for the following reasons:
- Pregnant women are at an 18-fold higher risk of hospitalization as compared to healthy non-pregnant women during both pandemic and inter-pandemic influenza periods.
- Pregnant women, in later stages of pregnancy and with co-existing medical conditions such as asthma or diabetes, are at 3 to 4 times greater risk of morbidity as compared to non-pregnant women.
- There is poor uptake of influenza vaccination during pregnancy in northern India. Among 1,000 women aged 18 – 41 years (13.6% first trimester, 26.8% second trimester), none was offered or received influenza vaccination.
- There are higher odds of preterm delivery, caesarean delivery and foetal distress in pregnant women hospitalized for respiratory illness during the influenza season and their infants are more likely to be small for gestational age and with a lower mean birth weight as compared to pregnant women and their infants not hospitalized for respiratory illness.
Clear cut guidelines for mandatory screening and assessment of thyroid and influenza in pregnancy will be a significant step towards achieving the goal of reducing the maternal and child mortality rates in India.