Newborn screening for cystic fibrosis

Newborn screening (NBS) for cystic fibrosis (CF) has evolved considerably from its beginnings. We review the early history of NBS in the USA and the evolution of CF NBS from its conception in observational studies, to the development of mass-screening methodology in the 1970s, and to its early applications in the USA and other countries. We review the development of current CF NBS algorithms, particularly the development of those used in the Wisconsin randomized controlled trial, and discuss the comparative utility of different algorithms. We also discuss the identified nutritional and respiratory benefits of CF NBS, discuss treatment strategies for newborns identified with CF, and also discuss opportunities for slowing the progression of this disease.

Abuses of women's rights in sexual and reproductive health-care settings

For many years, the intersection between HIV/AIDS and sexual and reproductive rights focused on the prevention of the epidemic. The violations to reproductive rights that HIV positive women face were not visible. However, this has begun to change. In this article, which is based on her presentation in the Human Rights Networking Zone at the conference, Ximena Andión Ibañez describes six areas where women's reproductive rights have been violated. The author advocates the use of litigation as a tool for advancing these rights.

Long-term follow-up study of patients with phenylketonuria detected by the newborn screening programme in Japan

The objective of this report is to determine the need for and value of the long-term follow-up study of phenylketonuria (PKU) patients detected by newborn screening (NBS) in Japan. NBS was started in 1977 and the nationwide follow-up study of the identified patients was introduced into the NBS system. Outcome data from the continuous follow-up study showed in 1993 that IQ of PKU patients was inversely correlated with blood phenylalanine levels. Accordingly, in 1995, new treatment guidelines were issued that involved more stringent restriction of phenylalanine levels. Follow-up data confirmed that mean blood phenylalanine levels decreased after the introduction of the new guidelines, which included the recommendation to start dietary treatment within 20 days postpartum. Follow-up data also confirmed that dietary treatment did in fact commence earlier after the guidelines were issued. The need for lifelong dietary treatment is a difficult issue and the number of patients who stop dietary treatment was found to increase gradually with age. At present 60% of PKU patients born between 1977 and 1981 have stopped their dietary restriction of phenylalanine. The data gained from NBS and the long-term follow-up study were found to be valuable for the improvement of blood phenylalanine levels for patients with PKU, indicating the need for parties responsible for NBS and the follow-up study of the identified patients to work cooperatively. Further, the evaluations of the effectiveness of the two initiatives as well as the treatment guidelines issued should be based on outcome data, which depend on the continuation of the follow-up study of patients with PKU.

Newborn screening: a national public health programme in Brazil

The newborn screening programme started in Brazil (1976) through isolated initiatives, without governmental directions and/or policies. According to Health Ministry (2000) data the coverage was 55% and unevenly distributed. Only 17 out of 27 Brazilian states had more than 30% coverage. Public budgets covered only diagnostic examinations. There were no official data about assistance, patient follow-up or detected disorders. The creation of the National Programme (2001) has provided new perspective for newborn screening (NBS) in the public health system. It has provided important official data and established management and care units for each state: Reference Services in Newborn Screening. The programme screened about 13 million newborns from October 2001 to December 2005. The coverage increased to 80.2% (2005) and 74% of the states presented coverage of over 70%. Within 34 accredited Reference Services in 27 Brazilian states, all provide screening for PKU and CH. Ten of them provide screening for haemoglobinopathies as well, and three of them provide also for CF. The Reference Services altogether count on at least 170 health professionals, such as paediatricians, endocrinologists, nutritionists, psychologists and social workers. They are qualified to assist positive cases, within the policies established by the National Programme. There has been significant increase in NBS coverage and follow-up assuredness, including detected cases before the National Programme (10,935 positive cases) mostly in those regions where the programme did not exist. There has been significant evolution in the Newborn Screening as a Public Health Program in Brazil due to the government's commitment (federal and each component state).

The Current Revolution in Newborn Screening

Newborn screening has provided a model of a successful public health screening program for the past 40 years. However, the history of newborn screening is not without controversy. Many of these controversies have been rekindled with the introduction of tandem mass spectrometry, a technology that has greatly increased our ability to detect potential disease in asymptomatic newborns. This review highlights the challenges raised by this and future technological advances as we strive to maintain the success of newborn screening in the 21st century.

Attitudes toward and beliefs about prenatal HIV testing policies and mandatory HIV testing of newborns among drug users

BACKGROUND

Controversy remains about perinatal HIV testing in many clinical settings. We sought to examine the attitudes and health beliefs among drug users about mandatory HIV testing of newborns and about voluntary versus mandatory testing of pregnant women. We also examined to what extent negative experiences and stigmatization affected attitudes toward HIV testing.

METHODS

To establish a baseline, we examined 610 structured interviews conducted from 1997 to 2001, of active drug users who were recruited using respondent-driven sampling. We then conducted five focus groups of five subjects per group to further analyze responses in September 2003. The responses of the members of the focus groups were transcribed, coded, and analyzed using Microsoft Word 2000.

RESULTS

Quantitative Longitudinal Cohort Studies. Of the 610 drug users interviewed in the two longitudinal cohort studies conducted from 1997 to 2001, nearly all (89 percent) had been previously tested for HIV Nearly all subjects (91 percent) believed that pregnant women should be tested for HIV. More subjects who had prior HIV testing believed all pregnant women should be tested for HIV (92.9 percent versus 82.6 percent, p = 0.008). Although 86 percent of the subjects agreed that all newborns should be tested, only 57 percent of all of the subjects believed that it should be mandatory. Among the female subjects, however, more injectors than non-injectors would avoid prenatal care if HIV testing was required during pregnancy (16.2 percent versus 6.1 percent, p < 0.01). Of the 499 subjects who reported that they had a usual site for care, 31.8 percent believed that "certain types of people" received better treatment than others. Not using drugs, being of a certain race/ethnicity, and having private insurance were associated with receiving better care. The majority of subjects believed that being a drug user resulted in receiving suboptimal care from the healthcare establishment. Qualitative Focus Group Study. In the focus groups, arguments against mandatory testing of pregnant women included the loss of choice, the right not to know one's HIV status, and the belief that mandatory testing was both a means of provoking rebellion and promoting discrimination. Concern for a baby's health was the primary reason for supporting mandatory testing. Perceived discrimination by the healthcare system was cited as a barrier to acceptance of testing strategies, as it was in the structured interviews.

CONCLUSIONS

The current practice of mandatory newborn and voluntary prenatal screening for HIV in the State of Connecticut appears to have been acceptable to a population of highly stigmatized drug users who have been or were at risk for HIV. Despite this acceptance, perceived discrimination by the healthcare system persists and may result in adverse outcomes for a minority of high-risk women, particularly where drug misuse is more highly stigmatized.

Implementation of extended neonatal screening and a metabolic unit in the State of Qatar: developing and optimizing strategies in cooperation with the Neonatal Screening Center in Heidelberg

Qatar is a country in the Gulf area and member of the Gulf Cooperation Council states. The country is populated by original Qatari tribes that amount to about 200,000 people and about 600,000 expatriates mainly from Arabic and Asian countries. Inbreeding over centuries and high rates of consanguinity in the Qatari population and in some groups of expatriates, in addition to large family sizes and rapid population growth, have contributed to a high frequency of autosomal recessive disorders. In December 2003 Hamad Medical Corporation in Doha and the University Children's Hospital of Heidelberg, Germany, started an extended state-wide neonatal screening programme for metabolic and endocrine disorders, with the laboratory situated in Heidelberg, Germany. All aspects of the screening process had to be adapted to the unique situation of the laboratory being 6000 km from the birthplace of the neonates. Within 32 months, samples of 25,214 neonates were screened. In 28 cases an endocrine or metabolic diagnosis was identified (incidence 1:901, in Germany 1:1728). In particular, a variety of monogenic metabolic diseases were prevalent, with 19 patients detected giving an incidence of metabolic diseases of 1:1327 (Germany 1:2517). Each euro spent on the screening programme saved more than 25 euros in health and social costs. The programme revealed a high incidence of treatable inborn metabolic diseases in the population of Qatar. A reliable screening for classical homocystinuria showing a unique incidence of >1:3000 and for sickle cell disease has now been added.

Unconditional hospitality: HIV, ethics and the refugee 'problem'

Refugees, as forced migrants, have suffered displacement under conditions not of their own choosing. In 2000 there were thought to be 22 million refugees of whom 6 million were HIV positive. While the New Zealand government has accepted a number of HIV positive refugees from sub-Saharan Africa, this hospitality is under threat due to negative public and political opinion. Epidemic conditions raise the social stakes attached to sexual exchanges, contagion becomes a major figure in social relationships and social production, and the fears of the contagious nature of those 'just off the plane' connect refugees to an equally deep-seated fear of racial miscegenation. Jacques Derrida's notion of unconditional hospitality is a dream of a democracy which would have a cosmopolitan form. This means that one cannot decide in advance which refugees one might choose to resettle. This paper will use Derrida's notion of unconditional hospitality to emphasise the fragility of HIV positive refugees' position, caught between becoming newly made New Zealand subjects while at the same time having that subjecthood threatened. For Derrida, both ethics and politics demand both an action and a need for a thoughtful response (a questioning without limit).

New developments in mandatory blood testing legislation

In November 2005, the Liberal government in Ontario introduced a bill that would allow policy officers, other community safety workers and victims of crime to find out more quickly whether they have been exposed to infection from certain viruses. Meanwhile, the Saskatchewan Medical Association (SMA) is opposing similar legislation enacted in that province.

Newborn screening: complexities in universal genetic testing

Newborn screening (NBS)--in which each newborn infant is screened for up to 50 specific metabolic disorders for early detection and intervention--is the first program of populationwide genetic testing. As a public health intervention, NBS has greatly improved the lives of thousands of affected children. New technologies and new economic and social forces pose significant ethical and clinical challenges to NBS. Two primary challenges concern (1) accommodating clinical and ethical standards to rapid technological developments in NBS and (2) preparing public health systems to respond to the medical advances and social forces driving expansion of NBS programs. We describe and analyze these challenges through consideration of 3 disorders: phenylketonuria, medium-chain acyl-CoA dehydrogenase deficiency, and cystic fibrosis.

HIV care in the U.S. Navy: a multidisciplinary approach

We provide a review of the medical care provided to human immunodeficiency virus (HIV)-positive service members in the U.S. Navy and Marine Corps. An overview of the history of HIV and its impact on the U.S. Navy is presented. We also explain the policies of mandatory HIV testing within the U.S. Navy and the evaluation process for those found to have HIV infection. We specifically describe the multidisciplinary HIV medical care provided at Naval Medical Center San Diego, which is one of three HIV specialty clinics within the U.S. Navy.

HIV/AIDS and other infectious diseases among correctional inmates: transmission, burden, and an appropriate response

Correctional inmates engage in drug-related and sexual risk behaviors, and the transmission of HIV, hepatitis, and sexually transmitted diseases occurs in correctional facilities. However, there is uncertainty about the extent of transmission, and hyperbolic descriptions of its extent may further stigmatize inmates and elicit punitive responses. Whether infection was acquired within or outside correctional facilities, the prevalence of HIV and other infectious diseases is much higher among inmates than among those in the general community, and the burden of disease among inmates and releasees is disproportionately heavy. A comprehensive response is needed, including voluntary counseling and testing on request that is linked to high-quality treatment, disease prevention education, substance abuse treatment, and discharge planning and transitional programs for releasees.

Food for thought in women's health. The gynecologist: the new European gatekeeper inChlamydia trachomatisinfection

Genital Chlamydia trachomatis infection is the principal cause of bacterial sexually transmitted disease in industrialized countries. A wide spectrum of pathologic conditions has been associated with the disease ranging from urethritis, cervicitis, to pelvic inflammatory disease, ectopic pregnancy, tubal infertility and cervical neoplasia. Screening for genital Chlamydia infection may prevent its serious complications. The need of a comprehensive European screening policy has been recently underlined by PACMeR's scientific committee. Anyhow invitational screening programs are only at the beginning. Chlamydia trachomatis control ''orphan'' and women's health at risk. Until organized programs are developed, implementation of opportunistic screening is mandatory. Since the infection is more commonly observed among juvenile females proper testing of the young women is recommended. As asymptomatic young women in reproductive age are more eager to visit gynaecologists for periodical gynaecological examination and councelling (cervical cytology, breast examination, contraception and family planning), gynaecologist represents the only specialist able to provide early diagnosis of Chlamydia trachomatis. Gynaecologists are called to play a new role in public healthcare, being ''gatekeepers'' for the early detection of the disease, emphasizing their crucial part in young women's health.

From mandatory to voluntary testing: balancing human rights, religious and cultural values, and HIV/AIDS prevention in Ghana

This paper examines efforts by some churches in Ghana to reduce the spread of HIV/AIDS. The analysis is based on focus group discussions with two groups of men and two groups of women, along with in-depth interviews with 13 pastors and marriage counsellors in the churches studied. In response to government and public criticisms about human rights violations, churches that previously imposed mandatory HIV testing on members planning to marry now have voluntary testing programmes. However, the results suggest that what the churches refer to as voluntary testing may not be truly voluntary. Cultural values and traditional practices, including traditional courtship and marriage rites (which are performed before church weddings), not only clash with considerations about pre-marital HIV testing but also complicate the contentious issue of confidentiality of information on HIV testing. Associated with these complexities and issues of confidentiality is a reluctance among participants, particularly those from northern Ghana, to test for HIV. The results reveal how broader social impacts of HIV testing for those planning to marry may extend beyond individuals or couples in different cultural contexts. The findings also support the general view that there are no perfect or easy solutions to combating the HIV/AIDS pandemic. Practical solutions and programs for Ghana cannot be neutral to cultural values and need to be tailored for particular (ethnic) populations.

A missed opportunity: hepatitis C screening of prisoners

In 2003, the Centers for Disease Control and Prevention issued recommendations to screen all inmates with a history of injection drug use or other risk factors for hepatitis C. We compared self-reported risk factors for hepatitis C with serostatus from inmates in the Rhode Island Department of Corrections. Of the male inmates who were hepatitis C positive, 66% did not report injection drug use. Risk-based testing underestimates the hepatitis C virus (HCV) prevalence in correctional settings and limits the opportunity to diagnose and prevent hepatitis C infection.

Two-tiered immunoreactive trypsinogen-based newborn screening for cystic fibrosis in Colorado: screening efficacy and diagnostic outcomes

OBJECTIVE

To examine immunoreactive trypsinogen (IRT)-based screening for cystic fibrosis (CF) for recall rate, genotype distribution, and "borderline" sweat test results.

STUDY DESIGN

CF newborn screening in Colorado began in 1982, and >1,153,000 infants were screened through 2002 with an IRT-based screen (IRT/IRT).

RESULTS

We have identified 313 infants with CF, giving an overall incidence of 1 in 3684 and a Hispanic incidence of 1 in 6495. Fifty-five infants with meconium ileus (17.6%) were excluded from analysis. Fourteen infants with false-negative results were identified (5.4%). The average recall rate was 0.6%, with a positive predictive value of 4.7%. Ninety-three percent of the infants had at least 1 DeltaF508 mutation, and 98% of the infants had at least 1 mutation from the American College of Medical Genetics recommended panel. Six infants had hypertrypsinogenemia and borderline results on sweat tests (30-60 mmol/L). Increased variability in sweat chloride levels were seen in these infants compared with infants with homozygous DeltaF508. Three children with initial borderline results on sweat tests had CF diagnosed.

CONCLUSIONS

The recall and false-negative rates of our IRT/IRT CF screening program are reported. Additionally, genotypes of the patients identified mirror the CF population genotypes, reflecting similar disease severity in the screened population. Finally, infants with persistent hypertrypsinogenemia and borderline sweat test results need long-term follow-up.

Balancing benefits and risks for cystic fibrosis newborn screening: implications for policy decisions

Policy decisions for newborn screening (NBS) are particularly challenging when the balance of benefits and risks is not tipped dramatically in 1 direction. When this is the case, as with cystic fibrosis (CF), the traditional approach of mandatory testing of all newborns in all states may not be appropriate. Alternative approaches may produce a substantial reduction in psychosocial risks, at the cost of a small reduction in medical benefits, and thus improve the benefit/risk balance. At the provider level, this could include greater engagement and discussion with parents before testing. At the program implementation level, specific decisions about tradeoffs between sensitivity and specificity that could result in not identifying all infants with CF may be appropriate. At the policy decision level, deciding whether to implement CF NBS in a particular state could involve consideration of the availability of the financial resources, clinical services, and systems for assessing outcomes. Although CF NBS can be justified in settings in which the specific approach has a favorable benefit/risk balance, an inadequately designed screening program has the potential for being less favorable than the current approach of diagnosis on the basis of clinical criteria or family history.