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Vyšlo v časopise: Čes-slov Pediat 2009; 64 (4): 200-210.

68. Evaluation study for neonatal screening of cystic fibrosis: comparison between two different Delfia Neonatal IRT kits

Tamanini A.1, Stanzial V.1, Bertaso G.1, Facchin A.1, Kerokoski P.2, Kinos R.2, Seppälä J.2, Rizzotti P.1, Cabrini G.1

1Hospital of Verona, Italy, Laboratory of Molecular Pathology, Laboratory of Clinical Chemistry and Haematology, Verona, Italy

2PerkinElmer Life and Analytical Sciences, Wallac Oy, Neonatal Reagents Product Development, Turku, Finland

Cystic fibrosis (CF) is the most common autosomal recessive disorder that affects children in Caucasian populations. CF is characterised by abnormalities in secretions of exocrine glands. This disease leads to chronic pulmonary infections and digestive disorders. All screening algorithms, in current use in the world, rely on testing for Immuno Reactive Trypsinogen (IRT) on the dried blood spot (DBS) as the primary screen for CF. In this study a new DELFIA Neonatal IRT kit A005-210 has been compared to the current A005-110 IRT kit to ensure that the new kit complies with user needs and the intended use. The reagents for the current A005-110 kit and the new A005-210 kit, instruments and software were provided by PerkinElmer Life and Analytical Sciences, Turku, Finland. Approximately 2,000 newborn DBS specimens, confirmed CF and IRT positive samples, were analysed during routine newborn screening (NBS) in Northeastern Italy with both IRT kits. The assay is a fluoroimmunometric sandwich technique. Descriptive analysis, population distribution data and a linear regression with the two kits have been done. A number of 2,212 routine screening samples was used for both kits. The IRT value ranges (ng/ml) of A005-110 and A005-210 kits were, respectively, 2.8 (min) and 157 (max) with a median of 16.9 and 1.2 (min) and 204 (max) with a median of 15.5. Percentiles between the 95th and 99.5th were calculated. The 99.5th percentile was 65.7 ng/ml for the current kit and 66.7 ng/ml for new kit . CF-cases (n=15) had IRT values above cut-off (65 ng/ml) with both kits. The results of this study demonstrate that the two kits do not show significant differences. Based on this data, the characteristics of the new DELFIA Neonatal IRT kit A005-210 could be established for the future use of this product for NBS for CF.

69. Pancreatitis-associated protein in CF screening

Vernooij-van Langen A.1, Dankert- -Roelse J.2, Reijntjens S.3, Elvers B.4, Triepels R.5, Loeber G.4

1Atrium Medical Centre – RIVM, Reasearch and Innovation – LIS, Heerlen – Bilthoven, The Netherlands

2Atrium Medical Centre, Pediatrics, Heerlen, The Netherlands

3Atrium Medical Centre, Research and Innovation, Heerlen, The Netherlands

4National Institute for Public Health and the Environment (RIVM), Laboratory for Infectious Diseases and Perinatal Screening, Bilthoven, The Netherlands

5St. Elisabeth Hospital, Clinical Chemical Laboratory, Tilburg, The Netherlands

Pancreatitis-associated Protein (PAP) is a secretory protein synthesized in high amounts after pancreatic stress. The combination of high IRT and PAP may be useful in CF screening. Advantage would be limited carrier detection, less detection of mild disease. We report the first results of PAP concentrations in screened newborns in the Netherlands. To determine if PAP values are influenced by gestational age, birth weight and day of heelprick. Heelprick, cards of all newborns provided by two screening laboratories were screened for IRT and PAP. Information on day of heel prick, gestational age, birth weight, and sex was recorded for all newborns. IRT (PerkinElmer) was performed according to the manufacturer’s manual. For measurement of PAP the MucoPAP ELISA (Dynabio S.A.; France) was converted into a time-resolved fluoroimmunoassay DELFIA-method, following instructions of PerkinElmer. Cut-off values used were a combination of IRT above 50 µg/l and PAP ≥1.8 µg/l or IRT ≥100 µg/l and PAP ≥1.0 µg/l. A PAP test was done in 72,890 newborns. In the group with negative CF-screening the mean PAP concentration was 0.44 µg/l, median 0.30 µg/l. In the false positive group (n=115) mean PAP was 3.33. Mean PAP concentration in CF patients detected by newborn screening (n=9) was 4.0 µg/l (1.1–9.9). One CF patient born with a meconium ileus was missed because of a low PAP (0.2 µg/l). Of the screened neonates 4% had a PAP between 1.0 and 1.8 µg/l, 1% ≥1.8 µg/l. PAP values were not influenced by gestational age, birth weight or day of heelprick. Sensitivity of the IRT-PAP strategy was 90%, specificity 99.8% and a PPV of 7.2%. PAP seems to be increased in most neonates with CF, except for one patient with meconium ileus. PAP concentrations were not influenced by gestational age, birth weight and day of heelprick.

70. European newborn screening survey

Loeber J. G.

National Institute for Public Health (RIVM), Bilthoven, The Netherlands

See table in preamble article.

71. Newborn screening for phenylketonuria in Bulgaria – past, present and future

Sinigerska I., Ivanova M., Vazharova R., Savov A., Kalaydjieva L. Kremensky I.

University Hospital of Obstetrics and Gynecology, National Genetic Laboratory, Sofia, Bulgaria

Neonatal screening for phenylketonuria (PKU) and galactosemia (later on suspended as mass screening) in Bulgaria is established in 1978 and is carried out in the National Genetic Laboratory. Until now more than 2,030,000 infants (average 76% from newborns, more than 95% for the last three years) were tested using Guthrie bacterial inhibition assay (BIA). Positive results from BIA were confirmed by fluorometric analysis. The call-rate of the screening is less than 0.03%. From 2008 a part of the samples is tested using an automated fluorimetric assay. A total of 63 PKU and 70 other forms of hyperphenylalaninemia were detected. Due to errors in collections of specimens 19 patients with PKU were missed in the early years of the screening. Since 1982 the laboratory participates in Japanese Interlaboratory Quality Control Survey. A total of 4,380 samples were tested and 1,447 abnormal detected – 97.5% from all received abnormal samples, for the last ten years – 100%. Mutation analyses and genotype determination were performed in 50 families.The most frequent mutations are arg408 -> trp (R408W) in the main Bulgarian ethnic group and IVS10nt546 in the families from Turkish origin. In 16 cases prenatal diagnosis were attempted. More than 400,000 newborn screening cards are stored as a DNA source for further assays. PKU is a rare disease for Bulgaria with a total prevalence 1:25,000 (1:36,250 for the Bulgarian ethnic group). The established model for screening, diagnosis, treatment, follow-up and prevention of PKU is optimal for our country (7,300,000 inhabitants). The benefit of newborn screening will extend and the costs will decrease with expanding the neonatal screening program with other inborn metabolic disorders. The introducing of tandem mass technology next year is discussed. The existing network and services will facilitate the new program.

72. Neonatal screening program for congenital hypothyroidism in Armenia

Tovmasyan I.1, Babloyan A.1, Leumann E.2, Torresani T.3, Steinmann B.4

1Arabkir Joint Medical Centre, Neonatal Screening, Yerevan, Armenia

2University Children´s Hospital, Nephrology, Zurich, Switzerland

3University Children´s Hospital, Proteinhormone Laboratory, Zurich, Switzerland

4University Children´s Hospital, Division of Metabolism, Zurich, Switzerland

Introduction: The concept of neonatal screening is new for Armenia. As one of the post-Soviet republics it faced major economic problems after the independence in 1991. The National Screening Program for Congenital Hypothyroidism (CH) started in July 2005, under an agreement between the Ministry of Health (MoH) of Armenia and the Hospital Partnership Program with Children’s Hospital of Zurich (Switzerland).

Methods: Dried blood samples were initially collected from infants born in Yerevan (capital of Armenia) and gradually from other regions. The samples are brought to the only Armenian screening laboratory at Arabkir JMC (Yerevan). Thyreotropic hormone is measured by DELFIA. The costs have increasingly been covered by yearly budget increments of 20% by the MoH. Thus, in 2010, the program will run on an independent governmental basis.

Results: The number of newborns screened yearly increased markedly, from 2,300 in 2005 to 26,000 in 2008. Between July 2005 and December 2008 we screened 63,000 newborns and identified 16 cases with CH. All were immediately recalled and the diagnoses were confirmed. All except one were put on thyroxin substitution. In one case the parents refused medication. The psychomotor development of the 15 treated children, now aged 2 to 34 months, is normal. The program had several starting difficulties such as poor co-operation with some maternity hospitals and parents. At present, the coverage rate of neonatal screening for CH in Armenia is 65%.

Conclusion: The incidence of CH in Armenia is approximately 1 in 4,000 newborns, thus comparable with other countries. A better understanding of the urgent need for neonatal screening of CH is still needed. This highly successful neonatal screening program will be further improved to cover the whole country and will be expanded to screen for further disorders (e.g. phenylketonuria) that require close co-operation between different health care providers.

73. PKU and congenital hypothyroidism screening in east region of Ukraine

Grechanina O.1, Novikova I.2, Pokaziy N.2, Anruschenko O.2

1Ukrainian Institute of Clinical Genetics of KNMU, Specialised Medical Genetic Centre, Kharkiv, Ukraine

2Kharkiv Specialised Medical Genetic Centre, Biochemical laboratory, Kharkiv, Ukraine

The Kharkov Specialised Medical Genetic Centre (KhSMGC) has been performing neonatal screening of newborns of East region of Ukraine on PKU and Congenital Hypothyroidism (CH). Kharkov, Poltava, Sumy and Chernigov areas are districts of the East Ukraine’s on territory of 115.9 thousand sq. km with population of 7.1 million people. The numbers of newborns are screened annually more than 60 thousand. PKU screening has been providing from 1986. There were screened 1,132,945 newborns. From 1986 to 1991 we used Guathrie test and microplate fluorometric assay till today. The screening allow us diagnose 170 cases of PKU. Frequency of PKU is 1:6,664. The pilot screening on CH of newborns of the Kharkov area was spent from 2001 to 2005 and in 1991. We detect TSH level from dried blood sports with time resolved immunoassay (Wallac, Arcus 1230). Screening had been covered 61,3% of the Kharkov area’s newborns. The Government Newborns Screening Program is existing in Ukraine from 2005 till today. We use immunoassay (Ani Labsystems) with equipment Sunrise (Tecan) and Victor1420 ( Perkin Elmer) from 2008. The mean TSH level is 3,8±5,6 mIU/l (m±SD, n=1578). During Government Program is covered about 99% of newborns. There were screened 217,661 newborns on CH. The confirmatory assays we provide with NovaTec Immunodiagnostica GmbH, ELISA (TSH >5.0 mIU/l and free T4 <0.7 ng/dl in serum) and the follow up of the patient were in the same establishment by geneticist together with endocrinologist. The diagnosis has been verified in 39 children. Thus, prevalence of CH has made 1:5,581 newborns. According the frequency of neonatal TSH >5 mIU/l, 7.4% of newborns had a mild iodine deficiency in 2008. We use screening’s result for prospective genetic consultations.

74. National newborn screening in Slovakia

Knapkova M.

Children Hospital, Newborn Screening Centre Slovak Republic, Banská Bystrica, Slovak Republic

Screening Centre of Newborns of Slovak Republic (SCNSR) is a central unit for congenital hypothyreosis (CH), phenylketonuria (PKU), congenital adrenal hyperplasia (CAH) and cystic fibrosis (CF). The first CH screening started in 1985, followed of PKU in 1995 and CAH (2004). All participans – maternity hospitals, SCNSR, regional centres of medical specialist and primary health care – cooperate according the mandatory Standards and policy documented as Methodical guideline of Ministry of Health of SR. We present the information about newborn screening in SR – incidence, recall, sensitivity of screening tests. The present information are from annual register of SCNSR from 1985 to 2007. SCNSR tested 1,483,410 newborns for CH, 313 cases were detected, the incidence of CH 1:4,739 liveborns, recall 0.47%. PKU tested 706,729 newborns, 111 cases were detected, incidence 1:6,448 liveborns, recall 0.053%. In CAH screening was screnned of 221,145 newborns, 37 cases detected, incidence 1:5,977 liveborns, recall 0.23%. No escaped case has been registered. From 2009 we started screening for CF methods IRT + IRT + Cl strategy. 27,974 newborns were tested since May 2007 to December 2008 in a pilot study, five CF cases were detected, incidence 1:5,594 liveborns. Model of Slovakia newborn screening in one centre – SCNSR – is recognised as highly effective from medical, organizational and economical point of view. The close cooperation of SCNSR and regional centres for follow-up and treatment gives the effective feed back for continuous evaluation of screening effectivity.

75. Newborn screening in Szeged, Hungary

Karg E., Rozsa M., Wittmann G., Barath A., Monostori P., Gorog M., Papp F., Soltysiak J., Laszlo A., Turi S.

University of Szeged, Department of Paediatrics, Szeged, Hungary

Newborn screening in Hungary started in the mid 1970s. The first tests introduced were for phenylketonuria followed by galactosemia, congenital hypothyreodism and biotinidase deficiency. The method for expanded screening by tandem mass spectrometry (MS/MS) has been available since 2004, and it became a part of the newborn panel at the end of 2007. The number of disorders screened for by MS/MS is 23. Determination of succinylacetone is a part of the screening process. Parallel to the MS/MS method, we have introduced a new computerized data management system that proved highly efficient relative to the card-based data collection system. Hungary has two screening centers (Szeged, Budapest), each testing approximately 50,000 newborns a year.

76. Expanded newborn screening in Norway; advisory report from a national working group

Klingenberg C.1, Pettersen R. D.2, Markestad T.3, Martinussen M.4, Rogne S.5, Frydenberg K.6, Grønvik O.7, Hofmann B.8, Sørensen I. L.9, Heiberg A.10

1University Hospital of North Norway, Dept. of Paediatrics, Tromsø, Norway

2Rikshospitalet-Oslo University Hospital , Dept. of Pediatric Research, Oslo, Norway

3Haukeland University Hospital, Dept. of Paediatrics, Bergen, Norway

4St. Olavs Hospital, Dept. of Obstetrics and Gynecology, Trondheim, Norway

5The Norwegian Biotechnology Advisory Board, Director, Oslo, Norway

6Skreia Health Care Centre, Primary Care Physician, Skreia, Norway

7Parental Support Group for MPS, User Representative, Gol, Norway

8University of Oslo, Section for Medical Ethics, Oslo, Gjøvik, Norway

9Norwegian Directorate of Health , Dept. for Hospital Services, Oslo, Norway

10Rikshospitalet-Oslo University Hospital, Dept. of Medical Genetics, Oslo, Norway

In Norway, newborn screening for phenylketonuria (PKU) and congenital hypothyroidism (CH) has been offered on a national basis since 1979, and the program is uniformly accepted. The service is centralized to a national newborn screening unit in Oslo. Each year 4–5 patients with PKU and 15–20 with CH are detected. In May 2008, The Norwegian Directorate of Health appointed a multidisciplinary working group to give recommendations for an update of the Norwegian newborn screening (NBS) program. The working group reviewed international literature and recent recommendations from the USA, the Netherlands and Denmark. To be included in an expanded NBS program, a disorder had to be clearly described, an efficient method for detection should be accessible, and early presymptomatic treatment should be available. The working group recommends an expansion of the Norwegian NBS program to include the following 25 disorders; four aminoacidopathies (PKU, MSUD, TYR I, HCY), eight organic acidurias (PROP, MUT, Cbl A,B, Cbl C,D, IVA, MCD, βKT, GA1), nine beta-oxidation and carnitine cycle defects (MCAD, LCHAD, VLCAD, TFP, CUD, CPT IA, CPT II, CACT, GA2), two endocrinopathies (CH, CAH), one vitamin disorder (BIOT) and cystic fibrosis (CF). Glutaric aciduria type 2 (GA2) was included as a secondary target. DNA testing is not recommended as primary screening for any disorders. However, for CF screening we propose a second tier by DNA testing. For homocystinuria, primary screening with methionine and a second tier with homocystein is recommended. Succinylacetone is used as the primary biomarker for tyrosinemia type I. It is estimated that the expanded NBS program will be cost effective. On basis of current knowledge, the working group recommends a substantial expansion of the NBS program in Norway. The proposed program is similar to what is established or under consideration in several other countries.

77. Four Years of Expanded Newborn Screening in Portugal

Vilarinho L., Rocha H., Marcao A., Sousa C., Fonseca H., Osorio R. V.

National Institute of Health, Medical Genetics Center, Genetics Department, Newborn Screening Unit, Porto, Portugal

The Portuguese Neonatal Screening Program started in 1979 testing for PKU deficiency (2,590,700 newborns screened; relative prevalence 1:11,031) and, shortly after, for congenital hypothyroidism screening (2,558,455 newborns screened; 1:3,198). Our laboratory implemented the expanded neonatal screening by adopting tandem mass spectrometry (MS/MS) testing for selected amino acids and acylcarnitines in 2004. MS/MS now allows newborn screening for more than 20 biochemical metabolic disorders. This has been accomplished with a better organization for samples collection and handling. The program has a 99.8% coverage of the Country and during the last four years it has screened 316,243 babies using MS/MS and identified 132 patients with 24 different inherited metabolic diseases. The overall frequency of these disorders (classic forms and variants) is 1:2,396 newborns, with a positive predictive value of 24% and a negative positive rate of 100%. The false positive rate was 0.12% with a sensitivity of 100% and a specificity of 99.9%.

78. Expanded neonatal screening program in the Netherlands: results and some pitfalls

Elvers B.1, Bouva M.1, Caren L.2, Loeber J. G.1

1Natl. Inst. for Public Health and the Environment, Lab. for Infectious Diseases and Perinatal Screening, Bilthoven, The Netherlands

2TNO Quality of Life, Dept. of Prevention and Health, Leiden, The Netherlands

On January 1 2007 the neonatal screening program in the Netherlands has been expanded from 3 to 17 diseases. The screening of ~180,000 newborns per year is performed in 5 regional screening laboratories. Results and pitfalls of the first year of screening are described. The existing program (PKU, CH and CAH) was expanded with 13 metabolic diseases (BIOT, GAL, GA-I, HMG, HCS, HCY, IVA, LCHAD, MSUD, MCAD, 3-MCC, TYR-I and VLCAD) and sickle cell disease (SCD) and thalassemia. All metabolic diseases, except for BIOT and GAL (enzymatic/colorimetric method), are screened with an underivatized-MS/MS method. For SCD a HPLC-method is used. In general the expansion of the program proceeded without major analytical problems except for galactosemia (GAL), tyrosinemia type I (TYR-I) and homocystinuria (HCY). The screening on GAL, initially with total-galactose (TGAL) as marker, produced a lot of false positives (FP) and was successfully changed into a two-step strategy: measuring the enzyme GALT followed by TGAL. The screening on TYR-I with tyrosine as marker, was stopped after two months, due to much FP and a relatively high risk of false negatives. In October 2008 the screening on TYR-I was resumed with succinylaceton as marker. For homocystinuria (HCY), with methionine as marker, a lot of FP were observed. The majority (92%) of these false positives were very premature infants who were all admitted to the neonatal intensive care unit of the same academic medical centre. It appeared that these newborns received parenterally an amino acid mixture with large amounts of methionine.

Conclusion: In 2007 182,300 newborns were screened. 813 (0.445%) were referred to the paediatrician and for 194 newborns the diagnosis was confirmed: CAH: 7, CH: 57, metabolic disease 70; and SCD/thalassemia 60. Furthermore, 815 newborns were reported to the general practitioner as a possible carrier for SCD.

79. Challenges for NBS in emerging countries: is it possible for a NBS program to be better than the health system that carries it out?

Botler J., Camacho L. A. B., Cruz M. M., Duarte D. E. T., Costa K. K. F.

National School of Public Health - Oswaldo Cruz Foundation, Epidemiology and Quantitative Methods, Rio de Janeiro, Brazil

Since 2001, Brazilian Government has implemented a National Program for NBS targeting 3 million newborns per year for Phenylketonuria (PKU), Congenital Hypothyroidism (CH), Sickle Cell Disease (SCD) and Cystic Fibrosis (CF). In the state of Rio de Janeiro (RJ) (216,777 births in 2007), NBS program regularly screens for the first three conditions, completely sponsored by Government.

Objective: To assess performance of NBS program in RJ regarding coverage, timeliness of specimen collection, testing and treatment.

Methods: Analysis of infants’ data obtained from Health Department database and State NBS program’s data collected from reports sent to the National Health Department. Period of study was between January 2005 and December 2007. Analysis focused on coverage and timeliness of all the steps until treatment.

Results: Preliminary results show a decrease in coverage from 83.7% (2005) to 80.3% (2007). In 2005, 29.6% of specimens were collected before 7 days with an increase to 39.5%, in 2007. Mean age of treatment was over 25 days of life. Annual incidence rates (2007) were: 1:43,795 for PKU; 1:963 for HC; 1:1,317 for SCD; and 1:21 for SC trait.

Conclusion: RJ’s NBS program indicators show a poor performance which worsened within the last 3 years. Low incidence for PKU may result from programmatic issues and/or population features. High incidence of CH deserves more discussion about technical issues and contextual aspects. Afro-descendent contribution to population ethnicity can explain such high incidence of SCD and SCT. Insufficient coverage, late specimen collection and beginning of treatment reveal NBS programmatic deficiencies, leading to the necessity of a deep evaluation of its structure and process. An evaluation model is being developed to search for opportunities of improvement of the NBS programs in middle-income countries.

80. Evaluation of 3-year application of the enzymatic colorimetric phenylalanine assay in the setting of neonatal screening for phenylketonuria in Serbia

Grkovic S.1, Djordjevic M.1, Kecman B.1, Sarajlija A.1, Nikolic R.2, Cvorkov Drazic M.1

1Mother and child health care institute of Serbia, pediatric, Belgrade, Serbia

2Mother and child health care institute of Serbia, gynecology, Belgrade, Serbia

The Serbia state newborn screening program for phenylketonuria (PKU) screens ~ 54,000 births annually. Screening newborns for PKU was initiated in 1982 used the Guthrie bacterial inhibition assay (BIA) to measure increased concentrations of phenylalanine (Phe) in dried blood specimens. The aim of this study was to evaluate an enzymatic Phe determination in the whole context spanning from the initial investigation over the recall period, up to the confirmation or exclusion of the disease. Phe of dried blood spot specimens was analysed colorimetrically in a microtitre-plate assay based on the L-phenylalanine dehydrogenase reaction coupled with an intermediate electron acceptor system. This assay was evaluated for analytical variables and for neonatal PKU screening in a total number of 158,664 neonates during a 3-year period. Method validation with respect to linearity, precision (within run CVs 4.2–5.1%, between run CVs 7.14–9.69%) and accurancy fulfilled all requirements for a screening method. Mean Phe (±SD) of 50,000 healthy neonates was 92 (±24) µmol/L with a cut-off point of 182 µmol/L. From 158,664 neonates, PKU was confirmed in 13 cases. The recall rate was 0.01% and no false negatives were noted. Detailed studies over a period of 3 years clearly show that the enzymatic assay is a reliable and sensitive method for neonatal screening of PKU. Application of tandem mass spectrometry in neonatal screening will not derogate the usefulness of the enzymatic assay in PKU screening in foreseeable future.

81. Neonatal screening and prevention of the congenital malformation in Saratov region

Gumenuyk O., Nechaev V., Chernenkov Y., Kosinova T.

Saratov Medical University, Policlinic, social pediatrics and neonatology, Saratov, Russia

Neonatal screening and prevention of the congenital malformation (CM) in Saratov region is an important task of perinatology.

Purpose: To investigate efficiency of the special complex program of screening and prevention of CM.

Methods and objects: 1,736 newborns with CM for the last 10 years in Saratov Regional Perinatal Center. We analyze the history and case report in order to evaluate efficiency of the special complex program of screening and prevention of CM.

Results: We revealed 1,736 newborns with congenital malformation (CM) for the last 10 years in Saratov Regional Perinatal Center, with 47 of them (2.7%) having died in the maternity hospital. Maximum mortality of newborns with CM was registered in 1994, 1996, 1999 (lethality 3.4‰), minimum mortality in 2005 (lethality 0.5‰), 2006, 2007 and 2008 (lethality to 0.4‰). We have been implementing the special program since 2005. This program includes: 1) detecting and observing women of the risk group of CM in fetus; 2) analyzing the causes of CM, monitoring (ultrasonic investigation screening – UIS, placentobiopsy, chorionbiopsy); 3) therapeutic abortion at early pregnancy in case of CM incompatible with life, delivery of the pregnant with CM in fetus to Perinatal Center; 4) genetic consultation, detoxication, diet, metabolic therapy; 5) treatment of children (surgical, observation, physiologic and pedagogic correction, social rehabilitation and support of family). The three-years realization of the program showed the recession in the rate of newborns with various CM by 2.8%, decrease of the newborns with incurable CM, lowering of lethality (to 0.4‰) and invalidity among the newborns with CM, increase in the percentage of the CM in fetus detected by UIS from 47.4% to 66.7%.

Conclusions: Our study show the high efficiency of the implemented special complex program and allow us to recommend this program for screening and early prevention of CM in Perinatal Center.

82. The efficiency of neonatal screening in Saratov Region

Gumenuyk O., Chernenkov Y.

Saratov Medical University, Policlinic, social pediatrics and neonatology, Saratov, Russia

The neonatal screening (NS) is carried out in Saratov Region for five diseases: congenital hypothyroidism (CH), congenital adrenal hyperplasia (CAH), phenylketonuria (PKU), cystic fibrosis (CF) and congenital deafness (CD).

Objective: To evaluate the efficiency of the NS in Saratov Region.

Methods: Analysis of the materials of the genetic laboratory, history and case reports of the children. Blood tests were taken from the heel on the 4th day of the life in fill-term neonates and on the 7–14th days in premature neonates. The enzyme-linked immunosorbent assay (for NS of the CH, CAH, PKU, CF) and audiometry (for NS of the CD) were used for diagnostics.

Results: 27,117 (99.7%) neonates were examined for NS. Retesting was necessary in 48 babies (0.2%) with TSH level >20 mU/l and 131 babies with 17-OHP levels >30 nmol/l. CH and PKU were diagnosed in 4 babies, CAH in 3, CF in 1 baby. In low-weight and premature infants 17-OHP levels were significantly higher than those in full-term and normal-weight neonates (median 33.7 +- 11.2 nmol/l respectively, p=0.0005). Correlation has been found between 17-OHP levels and birth-weight, gestational age (r=-0.27, p=0.01 r=-0.4, p=0.007). We have registered relatively high percentage of false-positive results for CH (iodine deficiency in Saratov region) and for CAH (low sensitivity of the IRT method and lack of the distinct commonly accepted reference range for 17-OHP). Implementation of NS is economically effective, since the cost of one test is about 2 euro, while the medical treatment of one child with congenital disease costs more than 10,000 euro.

Conclusions: This study has showed the NS to be economically effective, with the following activities being necessary: introducing genetic analysis in the NS, determining the distinct com-monly accepted reference range for 17-OHP, continuing with the compensation of iodine deficiency.

83. Selective metabolic screening base for introduction of expanded newborn screening for Inherited Metabolic Diseases

Ivanova M., Sinigerska I., Vazharova R., Bradinova I., Kremenski I.

University Hospital of Obstetrics and Gynecology, National Genetic Laboratory, Sofia, Bulgaria

National Genetic Laboratory offers modern genetic services for diagnosis and prevention of inherited metabolic diseases (IMD) for a clinical genetics department, 5 medico-genetic centres, more than 70 paediatric and 119 neonatal units in Bulgaria. The laboratory performs: Mass newborn screening for PKU (over 2,030,000 neonates); Selective screening for over 70 inborn disorders of metabolism; Prenatal metabolic and enzymatic diagnostics. The comprehensive selective screening plays important role for detection of IMD in patients with clinical sings for metabolic disorders among newborns and children. Our analytical approach includes the following priorities: urine analysis (obligatory stage of qualitative methods, followed by a number of chromatographic techniques – TLC, HPLC, GC/MS) and in some cases enzyme and DNA analysis. All the methods are under internal and external laboratory control. For a 30 year period 9,118 high risk patients have been included in the selective screening program. A total of 805 patients (8.8%) were diagnosed as follows: 149 aminoacid disorders (1.6%); 139 organic acidurias (1.5%); 21 urea cycle defects (0.2%); 14 fatty acid oxidition disorders (0.2%); 13 peroxisomal disorders (0.1%); 131 carbohydrate disorders (1.4%); 7 glycoprotein degradation (0.08%); 112 mucopolysaccharidoses (1.2%); 217 ganglioside disorders (2.4%). Our results are comparable to the data of the leading European laboratories. The prevalence of IMD in Bulgaria is probably higher as a great part of patients remain undiagnosed due many clinicians will not have come across the rare IMD during their practice. Extended Newborn Screening (for more than 20 diseases) by MS/MS technology is the best tool with high detection rate for IMD. Our experience from the selective metabolic screening program and the Mass PKU newborn screening, existing network for diagnosis, treatment and follow-up of IMD is a strong base for the introduction of Expanded Newborn Screening Program in Bulgaria.

84. Newborn screening by tandem mass spectrometry in Lebanon: 2 years experience

Khneisser I.1, Abid S. M.1, Rizkallah M.1, Megarbane A.1, Lukacs Z.2

1Saint Joseph, University, Newborn Screening Laboratory, Beirut, Lebanon

2University Medical Center, Metabolic Laboratories, Hamburg, Germany

In 1996, a Lebanese community-based university established a newborn screening laboratory (NSL) offering a voluntary, hospital-based, out-of-pocket program, not otherwise covered by any insurance or social security schemes. The screening initially covered four diseases: CH, PKU, G6PD deficiency and galactosemia (GAL). Among 155,000 newborn screened, 95 cases (6 per 10,000) of CH; 801 cases (1% among males) of G6PD deficiency; 16 cases (1 per 10,000) of PKU variants and 6 cases of GAL variants (0.4 per 10,000) have been diagnosed. In late 2006, the laboratory expanded its panel of diseases screened by using MS/MS. Among 27,000 newborn samples tested by MS/MS, except PKU, 40 (15 per 10,000) were recalled for result confirmation. Of those, 19 were confirmed with different metabolic diseases, giving a positive predictive value (PPV) of 45%. An estimated 60% of all live births in Lebanon are not currently screened. Efforts should continue to obtain that they benefit from a nationally mandated and publicly paid scheme so major human tragedies can be averted. During the MS/MS analysis, two major troubles were solved: 1- The light carnitines FIA-TIC was not coincident to the heavy carnitines FIA-TIC with a drop of the signal of FIA-TIC, the problem was due the deterioration of the quality of the reconstitution solution of acetonitrile:water (80:20). 2- Increasing number of samples with unusual chromatogram starting to appear from the second quartile of the daily batch inducing a high number of samples to be reanalyzed. This problem was solved by changing the flow method from 0.05 min at 0.2 ml and 1.8 min at 0.02 ml to the current one 0.03 at 0.1 ml, 0.90 min at 0.015 ml and 0.91 ml at 0.1 ml. Running MS/MS is very sensitive, QA material should be always used. Sharing problems is encouraged to help other and save time.

85. Audit of the neonatal screening programme in Estonia

Muru K.1, Kahre T.1, Temberg T.1, Jaanits M.1, Palo K.1, Teder-Laving M.2, Õunap K.1

1Tartu University Hospital, Department of Genetics, Tartu, Estonia

2Tartu University Hospital, Estonian Biocentre, Tartu, Estonia

Neonatal screening for PKU was started in Estonia in 1993. CH was added in 1996. After fifteen years, it is time to review the operation efficiency of the program.

Aims and objectives: Were to revise national standards for neonatal screening, to compare practice against agreed standards and to identify reasons for the failures. Information on screening is provided to parents verbally and with leaflets by nurses, midwifes and pediatricians. Filter paper samples, collected by heel prick, are sent to laboratory by mail or hospital transportation. All test are analyzed in one laboratory at Tartu University Hospital. PKU is analyzed once and CH twice a week. In Estonia the aim is to start treatment by 21 days of life.

Results: We analyzed laboratory data during selected months from 3 years period. Sampling was done at 3–5 days of life in 86.8% and before 7 days in 97.2% of cases. Laboratory received 69.5% of specimens by 7 days after sampling. 96% of results were available within 7 calendar days after receipt for both tests. Results of first specimens were available by the 20 day after birth in 96.5%. The mean age at beginning of treatment for PKU was 22.4 days (excluded one patient, whose test card was lost for 5 months) and for CH 24.1 days. For different reasons 0.16% of families refused testing during 2006–2007.

Conclusions: Newborn screening is well established in Estonia. Coverage rate was over 99% during last 5 years. In Estonia the proposed standard is to start treatment by 21 days. For PKU the standard was achieved in the last 10, for CH in the last 5 years. To improve screening program standards we need to receive tests quicker and perform analysis twice a week.

86. Outcome of Newborn Screening Program in the Kingdom of Saudi Arabia

Rahbeeni Z.1, Niazi K.2, Rashed M.3

1King Faisal Specialist Hospital & Research Centre, Medical Genetics, Riyadh, Saudi Arabia

2Ministry of Health, Medical Genetics, Riyadh, Saudi Arabia

3King Faisal Specialist Hospital & Research Centre, Research Centre, Riyadh, Saudi Arabia

Introduction: Healthcare providers especially Ministries of Health in the world should provide the healthcare from diagnosis till treatment and prevention of diseases for every resident. However, limitations of resources make the preventive strategies are the best to target in many parts of the world. Neonatal screening program proved without doubt that it is one of the best means for healthy children and community. In addition, it decreases the handicapped by early treatment. However, the neonatal screening program should not be a test but a complete program.

Method: Blood samples were extracted from neonates during the first 3 days of life to be sent to King Faisal Specialist Hospital and Research Centre with biographic data including age, sex, weight, etc. The research involved more than 24 hospitals in the Kingdom. Inclusive dates: The period of research is from 20 August 2005 to 30 April 2007.

Result: We screened 84,226 samples and there was one neonate affected among 732 neonates with one of the 15 disorders that we screened (115 positive neonates).

Discussion: This study showed doubt the high incidence of genetic disorders including inherited metabolic disease (IMDs) in the Kingdom (and Arab worlds) if compared with Western Countries.

Conclusion: This high incidence of IMDs make Neonatal Screening Program in the Kingdom (and Arab Countries) necessary if the program is taking completely from diagnosis till treatment and follow up including Genetic Counseling in order to prevent these disorders in the future.

87. Newborn screening (NBS) in the United States: decision making about the NBS panels

Howell R. R.

Bethesda, MD, United States

Newborn screening in the United States is a public health program, and the decisions about the conditions to be included in the newborn screening panels are made by the 50 individual states. In the past, this has led to great variation between the states, creating serious issues for our very mobile families. In 2001, the Health Resources and Services Administration (HRSA) a part of our federal Health and Human Services Administration awarded a contract to the American College of Medical Genetics (ACMG), with several major goals. The principal goal was to recommend a uniform panel of conditions to include in state newborn screening programs. This very large expert panel included clinical and laboratory genetic-metabolic experts, legal scholars, ethicists, public health persons, psychologists, primary care physicians, and affected families. This group worked for several years, and published in 2006 an identified “core panel” or primary targets which included 29 conditions for which screening should be mandated. All of these conditions were felt to be clinically significant and have an identified treatment. The conditions recommended in the core panel are shown in the following chart:

jp_4845_f_1
jp_4845_f_1
Courtesy M.Watson

An additional 25 conditions were identified because they are a part of the differential diagnosis of a condition in the core panel, they are clinically significant and revealed with screening technology but lack an efficacious treatment, or they represent incidental findings for which there is potential significance (Newborn Screening: Toward a Uniform Screening Panel and System Genet Med 2006:8(Supplement)1S-252S). These secondary targets are shown in the next chart:

jp_4845_f_2
jp_4845_f_2
Courtesy M.Watson

The criteria used in this study, which included information about the condition, the test, and the treatment will be presented and discussed.

In the meantime, The United States Congress established a committee to provide recommendations on NBS to our federal government (Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children). This is a diverse group with wide expertise. This committee adopted the ACMG recommendations, and has refined a process for evaluating and selecting conditions suitable for newborn screening. The mechanisms and forms developed by the Committee for the nomination of a condition and of the subsequent independent expert evidence review which will be presented (www.hrsa.gov/heritabledisorderscommittee). Nominations to date to this Advisory Committee for additions to newborn screening panels have been Pompe Disease, Fabry Disease, Niemann-Pick Disease, Krabbe Disease, Spinal Muscular Atrophy (SMA) and Severe Combined Immune Deficiency (SCID). No new additions have yet been recommended by this Committee for routine screening although reviews have been completed on Pompe, Fabry, Niemann-Pick and SMA. Since the ACMG report was published, these recommendations were studied by the professional advisory committees of each state, and by early 2009, well over 90% of the 4.1 million babies born annually in the United States were receiving an “expanded” newborn panel very similar (or identical) to the ACMG panel. Our National Institutes of Health has recently funded a Translational Research Network coordinating center whose major purpose will be to gather detailed information about these rare-screened disorders to provide evidence-based information derived from long-term follow-up and treatment.

88. Psychological effects of false positive results in CF newborn screening: a 2 years follow-up

Roussey M.1,2, Beucher J.1, Leray E.1, Roblin M.1, Veillard D.1, Deneuville E.1

1CF Centre University Hospital of Rennes, France

2AFDPHE (Association Française pour le Dépistage et la Prévention des Handicaps de l’Enfant), Paris, France

Cystic fibrosis newborn screening (CF NBS) was implemented throughout France in 2002. It combines Day 3 immunoreactive trypsinogen (IRT) assay/DNA analysis. Depending on the results, a sweat test (ST) is performed to eliminate false positive (FP) cases, due to heterozygosity (HZ) or hypertrypsinemia (HIRT): parents are called to perform the ST within 24 h. Families of 11 CF centres (CFC) were followed at 3, 12 and 24 months (m) after a false alarm in the NBS to evaluate the psychological consequences. An interview was done at home by a psychologist to assess the perceived stress scale (PSS) and the vulnerable child scale (VCS), and compare them to the self-report measure of parental perception of child vulnerability (PPCV). The VCS score goes from 15 to 60; a lower score is correlated with higher PPCV. At 3 m, 86 families were explored: 62 HZ, 24 HIRT. 96.5% of parents said they had been anxious at the time of the ST, and 91% while waiting for the results. But 86% felt entirely reassured 3 m after. The mean score for the PSS did not differ from the French female mean (20.3 +/- 1.5 vs. 20.9 +/- 6.7). Mean VCS scores were 51.3 and 50.9 respectively for the HZ and for the HIRT. This is a high VCS score correlated with a low PPCV. At 1 and 2 years, there is no difference neither for the VCS nor the PPS, in both groups. There is also no difference according to CFC or maternal education level. 87.7% of families never think about CF when their child is sick. 93.4% of parents HZ informed their family of their HZ status and the possibilities of research of CFTR mutations. All families considered the knowledge of the HZ status as an advantage and wanted to tell their child. NBS can lead to FP cases resulting in parental anxiety, quickly decreasing after the ST performed in brief delay and care by a specialized team. At medium and long term, the impact is reassuring: parents are satisfied with the NBS and 100% would do it again for another child.

Acknowledgements: Supported by “PHRC” of Ministry of Health and the association “Vaincre la Mucoviscidose”. Acknowledgements to CF centers of Angers, Grenoble, Lille, Nancy, Nantes, Roscoff, Toulouse, Tours, Vannes, Versailles.


Štítky
Neonatologie Pediatrie Praktické lékařství pro děti a dorost

Článek vyšel v časopise

Česko-slovenská pediatrie

Číslo 4

2009 Číslo 4

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