saving lives through newborn screeningcase study #3 improving the sensitivity of the screen for...
TRANSCRIPT
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Saving Lives Through Newborn Screening:
Making the Most of a Simple Blood Test
February 26, 2018
John D. Thompson, PhD , MPH, MPA
Director - NBS Program
Washington State Public Health Laboratories
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What is Newborn Screening?
An integrated system that includes:
• Universal screening - all infants
• Follow-up to assure appropriate clinical response
• Referral for diagnosis of affected infants
• Appropriate treatment and clinical care
• Evaluation of system effectiveness (long-term follow-up)
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Why is Newborn Screening Important?
It prevents death and disability to affected infants by providing early treatment
It benefits the public through savings in health care and disability support costs
Two 6 year old girls with congenital hypothyroidism
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Annual Newborn Screening Numbers
Screen ~90,000 newborns
Receive ~180,000 specimens
Track ~5,000 infants with abnormal results
Prevent ~200 babies from death or disability
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Annual Newborn Screening Numbers
Screen ~90,000 newborns
Prevent ~200 babies from death or disability
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NBS Sequence of Events
recommended window for NBS specimen collection
hospital – blood collection
transit time
NBS lab testing
follow-up
Birth 1Time (days)
2 3 4 5 6 7
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Washington Criteria for NBS
Early identification benefits the newborn
Treatment is available
Nature of the condition justifies population-based screening
A good screening test exists
The benefits justify the costs of screening
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PKUCHCAHHB
2003 2006
PKUCHCAHHBBIOGALTMCADDMSUDHCYSCF
2008
PKUCHCAHHBBIOGALTMCADDMSUDHCYSCF
2010 PKUCHCAHHbBioGALTMCADDMSUDHCYSCFASACITTYR-IGA-IIVAMMAPROPHMGBKTMCDVLCADDLCHADDTFPCUD
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Case Study #3
Improving the Sensitivity of the Screen for Cystic Fibrosis
PKUCHCAHHbBioGALTMCADDMSUDHCYSCFASACITTYR-IGA-IIVAMMAPROPHMGBKTMCDVLCADDLCHADDTFPCUDSCID 2014
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Level of Urgency
HIGH!!• CAH• Galactosemia• MSUD• CIT/ASA• VLCAD/LCHAD/TFP• MCAD• IVA• MMA/PROP• CCHD
Diagnosis and treatment should be initiated ASAP!
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Level of Urgency
MODERATE• Biotinidase deficiency
• Congenital Hypothyroidism
• Homocystinuria
• PKU
• GA-I
• BKT
Treatment recommended by 1 to 3 weeks of age
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Level of Urgency
Low – can wait over a weekend to contact baby’s provider
• Cystic Fibrosis
• Hemoglobin disorders
• TYR-I
• HMG/MCD
• CUD
• Hearing Loss
• SCID
Treatment recommended by 3 to 4 weeks of age
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Laboratory Testing
Normal Cases
Normal Cases
Distribution of lab values
Ideal
Common
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Laboratory Testing
Normal Cases
Distribution of lab values
False (+) False (-)
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Laboratory Testing
Ways to mitigate false (+) results:
• Stratify results• birthweight• age at collection• secondary analytes or ratios
• Routine 2nd screens
End result – reduce the impact on families
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How is screening done?Specimen Testing
– A variety of testing platforms are used to screen for the 28 disorders– Any abnormal result is repeated in duplicate for confirmation
Washington State Department of Health
Hemoglobin Gel Electrophoresis3 disorders1 punch
Flouroimmunoassay Instrument3 disorders3 punches
PCR Instrument1 disorder
1 punch
Tandem Mass Spectrometer19 disorders1 punch
Spectrophotometer2 disorders2 punches
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Case Study #1Sickle Cell Disease
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Sickle Cell Disease:Historical Overview
• 1910 “sickle shaped” red blood cells described
• 1949 Linus Pauling: Abnormal hemoglobin protein described as cause of disease
• 1956 Molecular basis described
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Sickle Cell Disease:Historical Overview
• 1975 New York begins screening all newborns using the dried blood spot
• 1986 Efficacy of penicillin prophylaxis shown
• 1987 NIH Consensus Development Conference recommends screening all newborns
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Sickle Cell Disease:Simple Ideas
• Screen all infants
• Enroll those affected into comprehensive care that includes penicillin prophylaxis
• Save lives, improve outcomes
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Sickle Cell Disease:Complex Realities
• Multiple genotypes and phenotypes: homozygous SS vs compound heterozygotes(S thalassemia, SC, SD, SE)
• Clinical heterogeneity
• Screening test casts a wide net:– Other structural abnormalities (Hb C, D, E) – Thalassemias– Hemoglobin traits– > 700 other hemoglobin variants
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Sickle Cell Disease:Complex Realities
• Very large numbers of patients - clinical care capacity for affected individuals
• Genetic counseling resources for those identified with hemoglobin traits
• Treatments (transfusions, hydroxyurea, bone marrow transplants) – who pays?
• Language and Cultural Barriers – need interpreters and case managers
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Case Study #2New Screening Method for Congenital Hypothyroidism
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• Condition of thyroid hormone deficiency that is present at birth
• Left untreated, severe forms lead to permanent growth failure and intellectual disability
• Treatment in the newborn period leads to virtually normal growth and development
Congenital Hypothyroidism (CH)
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Timing of the Screen• First newborn screen is required by
48 hours of age (>97% compliance)
• Second screen recommended for all infants between 7 & 14 days (>90% comlpiance)
• Third screen recommended for NICU infants at ~30 days of age
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Background• Prior to July 2004: primary thyroxine (T4) screen lowest 10% pulled for secondary thyroid stimulating hormone (TSH) screen (normal cutoff: TSH < 20 mIU/mL)
• ~15% of babies with hypothyroidism were only identified on the second screen because of normal T4 levels on first screen
• Data from retrospective TSH analyses for babies missed on the first screen suggested that we could reduce the false negative rate by 50%
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Day 1 – normal cutoff: TSH < 20.00 Day 2
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Hourly TSH (Normal Infants)
0.00
5.00
10.00
15.00
20.00
25.00
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46
Age (hrs)
TSH
( mIU
/mL)
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TSH mIU/mL serum 1 to 12 hrs 13 to 24 hrs 25 to 36 hrs 37 to 48 hrs 49 to 504 hrs > 504 hours
0 – 14.99 Normal Normal Normal Normal Normal Normal
15.00 – 19.99 Normal Normal Normal Normal Normal Borderlinec
20.00 – 24.99 Normal Normal Normal Normal Borderlinea Borderlinec
25.00 – 29.99 Normal Normal Normal Borderlineb Borderlinea Borderlinec
30.00 – 44.99 Normal Normal Borderlineb Borderlinea Borderlinea Borderlinec
45.00 – 54.99 Normal Borderlineb Borderlinea Borderlinea Borderlinea Borderlinec
55.00 – 59.99 Borderlineb Borderlinea Borderlinea Borderlinea Borderlinea Borderlinec
60.00 – 99.99 Borderlineb Borderlinec Presumptivec Presumptivec Presumptivec Presumptivec
> 100.00 Presumptived Presumptived Presumptived Presumptived Presumptived Presumptived
Note: Superscript letters ( a,b,c,d ) denote general guidelines for the different follow-up responses that will be initiated by Follow-up staff. a - if first test, wait for routine second specimen; if second test, call health care provider immediately to request a follow-up specimenb - wait for routine second specimenc - call health care provider immediately to request follow-up specimend - call health care provider immediately to recommend immediate diagnostic work-up
TSH Cutoff Stratification
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Case Study #2 – lessons learned• Why isn’t this working (better)?
– utility of additional investigation/analyses
• What is the impact of these changes? – unintended consequences of changing
protocols
• How can we make this better? – utility of stratification to reduce the false
positive rate
• How did things turn out? – importance of evaluation
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TSH Level(≥)
True (+) False (+) PPV
411 111 0 100%
300 150 4* 97%
200 188 9 95%
150 208 29 88%
125 229 60 79%
100 258 172 60%
75 296 587 34%
55 348 1985 15%
25 535 3736 13%
15 666 4308 13%
ALL 780 8007 9%
TSH Thresholds – What is Urgently Presumptive?
*Mom was on thyroid medication in all 4 cases
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Case Study #3Congenital Adrenal
Hyperplasia Kits
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Case study - CAHCongenital Adrenal Hyperplasia
– Disorder of hormone synthesis in the adrenal glands
– Can be life threatening in the first weeks of life
– Kits: 3-4 months
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Case study - CAH
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Case study - CAH
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Case study - CAH
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Case Study #4DNA Testing for Galactosemia
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Enzyme Activity Assays
substrate
substrate
Enzyme Product
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Galactosemia – Lab Test
• GALT enzyme activity– Profound deficiency < 2 units/gHb– Partial deficiency – 2 to 2.5 units/gHb– Normal >2.5 units/gHb
• Specimen handling is very important for accurate results – potential for false positives if specimen is exposed to heat or direct sunlight
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Classic GalactosemiaSymptoms within first two weeks• Jaundice• Vomiting and diarrhea after ingesting milk
Can be life-threatening if untreated• Sepsis• Liver failure• Kidney failure• Brain damage
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Mild Galactosemia
• Some infants with mild galactosemia will show signs of poor feeding and digestion and may benefit from treatment
• Some infants will not require treatment
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Genotype/Phenotype CorrelationGenotype GALT activityNN 100%ND 75%NG 50%DD 50%DG 5-20%GG <5%
N = normalG = severe galactosemia allele (Q188R, S135L or K285N)D = Duarte allele (N314D: present in 5% of the U.S. population)
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NBS resourcesInitial GALT results
Time of tests• GALT assay = 4.5 hours
• DNA assay = 2.5 hours
Alleles available• Q188R, S135L and K285N (severe)
• N314D (Duarte)
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Considerations
• Are we sure this is real?– check other enzyme activity results– repeat in duplicate to confirm original results
• How can we minimize the amount of “crying wolf”?– DNA testing for alleles that cause severe
disease– DNA testing for Duarte allele (mild disease
and prevalent in population)
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GALT DNA Case
• LBW African-American baby boy • 1st NBS drawn at 24 hours GALT= 2.79
(cut-off of 3.76) • In NICU w/ hyperbilirubinemia but sepsis
had already been ruled out • Baby had multiple congenital deformities• DOH recommended shifting to soy formula
until we ran in-house DNA
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GALT DNA Case
• DNA results = Q188R/N314D • DOH recommended stopping soy formula
• Pending diagnostic labs showed profound enzyme deficiency
• DNA sequencing revealed 3 mutations: Q188R/N314D/R25P.
• False reassurance from limited DNA panel
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Tyler Mize 5/1/98 to 5/10/98
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Newborn Screening System
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• Test every baby • Assure hospital compliance
– Quality specimens– Complete and accurate information– Quick transit time
• Perform accurate testing– Balance sensitivity with specificity
• Assure that babies with abnormal test results get appropriate and timely additional testing
• Assure that diagnosed babies get needed treatments without delay
• Provide clear and understandable information to the public
• Quality improvement
NBS Program Goals
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Final Thoughts• Be courteous• Ask questions!
– what do/don’t we know?– what would be important to find out?– how are we doing and what could we do better?
• Data are our friends – get acquainted, try to understand them and question them if they seem wrong
• Don’t fly on autopilot!• Where can we get the biggest bang for our
buck?
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Washington State
Newborn Screening
www.doh.wa.gov/nbs
(206) 418-5410or
1-866-660-9050
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What Not to Do• Initial hemoglobin results were indicative of
transfusion (AA)• Results from second NBS were inconsistent with
first results (FA)• Analyzed all four blood spots – obviously blood
from two individuals: one baby and one adult
• Baby did not bleed well and phlebotomistsupplemented with someone else’s blood to fillcircles
• Letter from our Program Director to HospitalManagement about this dangerous practice
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What Not to Do• Initial hemoglobin results were indicative of
transfusion (AA)• Results from second NBS were inconsistent with
first results (FA)• Analyzed all four blood spots – obviously blood
from two individuals: one baby and one adult
• Baby did not bleed well and phlebotomist supplemented with someone else’s blood to fill circles
• Letter from our Program Director to Hospital Management about this dangerous practice