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Al Ghamdi A, Pachul JW, Al Shaqaq A, Fraser M, Watts-Dickens A, Yang N, Vong L, Kim VHD, Siu VM, Pham-Huy A, Brager R, Reid B, Roifman CM. A Unique Comprehensive Model to Screen Newborns for Severe Combined Immunodeficiency-An Ontario Single-Centre Experience Spanning 2013-2023. Genes (Basel) 2024; 15:920. [PMID: 39062699 PMCID: PMC11276121 DOI: 10.3390/genes15070920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Revised: 07/11/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Severe combined immunodeficiency (SCID) is a life-threatening genetic disorder caused by critical defects of the immune system. Almost all cases are lethal if not treated within the first two years of life. Early diagnosis and intervention are thus essential for improving patient outcomes. In 2013, Ontario became the first Canadian province to perform newborn screening (NBS) for SCID by T cell receptor excision circles (TRECs) analysis, a surrogate marker of thymic function and lymphocyte maturation. METHODS This retrospective study reports on nearly 10 years of NBS for SCID at a quaternary referral centre. RESULTS From August 2013 to April 2023, our centre's densely populated catchment area flagged 162 newborns with low TRECs levels, including 10 cases with SCID. Follow-up revealed other causes of low TRECs, including non-SCID T cell lymphopenia (secondary/reversible or idiopathic causes, and syndromic conditions) and prematurity. A small number of cases with normal repeat TRECs levels and/or T cell subsets were also flagged. Province-wide data from around this period revealed at least 24 diagnosed cases of SCID or Leaky SCID. CONCLUSIONS This is the first report of NBS outcomes in a Canadian province describing the causative genetic defects, and the non-SCID causes of a positive NBS for SCID.
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Affiliation(s)
- Abdulrahman Al Ghamdi
- Division of Immunology & Allergy, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON M5S 1A1, Canada
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center Ar Rawdah, Jeddah 23433, Saudi Arabia
| | - Jessica Willett Pachul
- Division of Immunology & Allergy, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Azhar Al Shaqaq
- Division of Immunology & Allergy, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Meghan Fraser
- Newborn Screening Program, Department of Clinical and Metabolic Genetics, Hospital for Sick Children, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Abby Watts-Dickens
- Newborn Screening Program, Department of Clinical and Metabolic Genetics, Hospital for Sick Children, University of Toronto, Toronto, ON M5S 1A1, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Nicole Yang
- Newborn Screening Program, Department of Clinical and Metabolic Genetics, Hospital for Sick Children, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Linda Vong
- Division of Immunology & Allergy, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON M5S 1A1, Canada
- Canadian Centre for Primary Immunodeficiency, Hospital for Sick Children, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Vy H. D. Kim
- Division of Immunology & Allergy, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Victoria Mok Siu
- Division of Medical Genetics, Department of Pediatrics, London Health Sciences Centre, Western University, London, ON N6A 5A5, Canada
| | - Anne Pham-Huy
- Division of Infectious Diseases, Immunology and Allergy, Children’s Hospital of Eastern Ontario, Faculty of Medicine, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Rae Brager
- Division of Rheumatology, Immunology, and Allergy, Department of Paediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Brenda Reid
- Division of Immunology & Allergy, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON M5S 1A1, Canada
- Canadian Centre for Primary Immunodeficiency, Hospital for Sick Children, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Chaim M. Roifman
- Division of Immunology & Allergy, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON M5S 1A1, Canada
- Canadian Centre for Primary Immunodeficiency, Hospital for Sick Children, University of Toronto, Toronto, ON M5S 1A1, Canada
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Blom M, Bredius RGM, van der Burg M. Efficient screening strategies for severe combined immunodeficiencies in newborns. Expert Rev Mol Diagn 2023; 23:815-825. [PMID: 37599592 DOI: 10.1080/14737159.2023.2244879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/02/2023] [Indexed: 08/22/2023]
Abstract
INTRODUCTION Severe combined immunodeficiency (SCID) is one of the most severe forms of inborn errors of immunity (IEI), affecting both cellular and humoral immunity. Without curative treatment such as hematopoietic stem cell transplantation or gene therapy, affected infants die within the first year of life. Due to the severity of the disease, asymptomatic status early in life, and improved survival in the absence of pretransplant infections, SCID was considered a suitable candidate for newborn screening (NBS). AREAS COVERED Many countries have introduced SCID screening based on T-cell receptor excision circle (TREC) detection in their NBS programs. Screening an entire population is a radical departure from previous paradigms in the field of immunology. Efficient screening strategies are cost-efficient and balance high sensitivity while preventing high numbers of referrals. NBS for SCID is accompanied by (actionable) secondary findings, but many NBS programs have optimized their screening strategy by adjusting algorithms or including second-tier tests. Harmonization of screening terminology is of great importance for international shared learning. EXPERT OPINION The expansion of NBS is driven by the development of new test modalities and treatment options. In the near future, other techniques such as next-generation sequencing will pave the way for NBS of other IEI. Exciting times await for population-based screening programs.
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Affiliation(s)
- Maartje Blom
- Laboratory for Pediatric Immunology, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Robbert G M Bredius
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Miriam van der Burg
- Laboratory for Pediatric Immunology, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
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Neonatal Screening for SCID: The French Experience. Int J Neonatal Screen 2021; 7:ijns7030042. [PMID: 34287257 PMCID: PMC8293192 DOI: 10.3390/ijns7030042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/29/2021] [Accepted: 07/08/2021] [Indexed: 11/30/2022] Open
Abstract
After it was demonstrated in 2005 that T cell receptor excision circle (TREC) quantification for dried blood spot (DBS) samples on Guthrie cards is an effective means of SCID screening and following several pilot studies, the practice was formally recommended in the US in 2010. More and more countries have adopted it since then. In France, before the health authorities could recommend adding SCID to the list of five diseases that were routinely screened for, feasibility and cost-effectiveness studies had to be conducted with a sufficiently large cohort of neonates. We carried out three such studies: The first sought to verify the effectiveness of the assay. The second, DEPISTREC, evaluated the feasibility of universal SCID screening in France and assessed the clinical benefit and economic advantage it would provide. Through the third study, NeoSKID, still under way and to continue until recommendations are issued, we have been offering SCID screening in the Pays de la Loire region of France. This review briefly describes routine newborn screening (NBS) and management of primary immunodeficiency diseases (PIDs) in France, and then considers the lessons from our studies and the status of SCID screening implementation within the country.
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Elsink K, van Montfrans JM, van Gijn ME, Blom M, van Hagen PM, Kuijpers TW, Frederix GWJ. Cost and impact of early diagnosis in primary immunodeficiency disease: A literature review. Clin Immunol 2020; 213:108359. [PMID: 32035178 DOI: 10.1016/j.clim.2020.108359] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 01/07/2020] [Accepted: 02/04/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND New, innovative, costly diagnostic methods for patients with primary immunodeficiencies (PID) demand upfront insight into their potential cost savings and added value for individual patients. As such, high quality, comparable economic evaluations are of utmost importance to enable informed decisions. The objective of this review was therefore to create an extensive overview of current costing studies and potential cost savings of early diagnosis in primary immunodeficiency disease. METHODS A literature search in PubMed was conducted and studies involving any form of costing study in the field of PIDs were included. Of the included studies, study characteristics, cost parameters and benefits of early diagnosis were extracted and outlined in separate tables. RESULTS Twenty two studies met the inclusion criteria and were included in the review. The papers were categorized according to their subject: neonatal screening for severe combined immunodeficiency (SCID), Ig replacement therapies and studies reporting on costs of general or specific PIDs. Within and between these groups variability in reported costing characteristics was observed. In studies that reported cost savings pre- and post-diagnosis, cost savings ranged from 6500 to 108,463 USD of total costs per patient. CONCLUSION This literature review shows that, regardless of what aspect of PIDs has been studied, in nearly all cases early diagnosis reduces health care consumption and leads to better health outcomes for patients with PIDs. We found considerable variability in costing characteristics of economic evaluations of PID patients, which hampers the comparability of outcomes. More effort is needed to create uniformity and define cost parameters in economic evaluations in the field of PIDs, facilitating further prospective research to extensively assess the benefits of early diagnosis.
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Affiliation(s)
- Kim Elsink
- Department of Pediatric Immunology and Infectious Diseases, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Joris M van Montfrans
- Department of Pediatric Immunology and Infectious Diseases, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Mariëlle E van Gijn
- Department of Genetics, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Maartje Blom
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - P Martin van Hagen
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - T W Kuijpers
- Department of Internal Medicine/Immunology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Geert W J Frederix
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands.
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Abstract
Primary immunodeficiency diseases are a heterogeneous group of rare inherited disorders of innate or adaptive immune system function. Patients with primary immunodeficiencies typically present with recurrent and severe infections in infancy or young adulthood. More recently, the co-occurrence of autoimmune, benign lymphoproliferative, atopic, and malignant complications has been described. The diagnosis of a primary immunodeficiency disorder requires a thorough assessment of a patient's underlying immune system function. Historically, this has been accomplished at the time of symptomatic presentation by measuring immunoglobulins, complement components, protective antibody titers, or immune cell counts in the peripheral blood. Although these data can be used to critically assess the degree of immune dysregulation in the patient, this approach fall short in at least 2 regards. First, this assessment often occurs after the patient has suffered life-threatening infectious or autoinflammatory complications. Second, these data fail to uncover an underlying molecular cause of the patient's primary immune dysfunction, prohibiting the use of molecularly targeted therapeutic interventions. Within the last decade, the field of primary immunodeficiency diagnostics has been revolutionized by 2 major molecular advancements: (1) the onset of newborn screening in 2008, and (2) the onset of next-generation sequencing in 2010. In this article, the techniques of newborn screening and next-generation sequencing are reviewed and their respective impacts on the field of primary immunodeficiency disorders are discussed with a specific emphasis on severe combined immune deficiency and common variable immune deficiency.
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Affiliation(s)
- Jocelyn R Farmer
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, MA, USA; Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA; Center for Advanced Molecular Diagnostics, Brigham and Women's Hospital, Boston, MA, USA.
| | - Vinay S Mahajan
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA; Center for Advanced Molecular Diagnostics, Brigham and Women's Hospital, Boston, MA, USA
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Bessey A, Chilcott J, Leaviss J, de la Cruz C, Wong R. A Cost-Effectiveness Analysis of Newborn Screening for Severe Combined Immunodeficiency in the UK. Int J Neonatal Screen 2019; 5:28. [PMID: 33072987 PMCID: PMC7510246 DOI: 10.3390/ijns5030028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/27/2019] [Indexed: 01/05/2023] Open
Abstract
Severe combined immunodeficiency (SCID) can be detected through newborn bloodspot screening. In the UK, the National Screening Committee (NSC) requires screening programmes to be cost-effective at standard UK thresholds. To assess the cost-effectiveness of SCID screening for the NSC, a decision-tree model with lifetable estimates of outcomes was built. Model structure and parameterisation were informed by systematic review and expert clinical judgment. A public service perspective was used and lifetime costs and quality-adjusted life years (QALYs) were discounted at 3.5%. Probabilistic, one-way sensitivity analyses and an exploratory disbenefit analysis for the identification of non-SCID patients were conducted. Screening for SCID was estimated to result in an incremental cost-effectiveness ratio (ICER) of £18,222 with a reduction in SCID mortality from 8.1 (5-12) to 1.7 (0.6-4.0) cases per year of screening. Results were sensitive to a number of parameters, including the cost of the screening test, the incidence of SCID and the disbenefit to the healthy at birth and false-positive cases. Screening for SCID is likely to be cost-effective at £20,000 per QALY, key uncertainties relate to the impact on false positives and the impact on the identification of children with non-SCID T Cell lymphopenia.
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Van der Ploeg CPB, Blom M, Bredius RGM, van der Burg M, Schielen PCJI, Verkerk PH, Van den Akker-van Marle ME. Cost-effectiveness of newborn screening for severe combined immunodeficiency. Eur J Pediatr 2019; 178:721-729. [PMID: 30805731 DOI: 10.1007/s00431-019-03346-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 01/28/2019] [Accepted: 02/12/2019] [Indexed: 02/04/2023]
Abstract
Severe combined immunodeficiency (SCID) is a condition that often results in severe infections and death at young age. Early detection shortly after birth, followed by treatment before infections occur, largely increases the chances of survival. As the incidence of SCID is low, assessing cost-effectiveness of adding screening for SCID to the newborn screening program is relevant for decision making. Lifetime costs and effects of newborn screening for SCID were compared to a situation without screening in the Netherlands in a decision analysis model. Model parameters were based on literature and expert opinions. Sensitivity analyses were performed. Due to earlier detection, the number of deaths due to SCID per 100,000 children was assessed to decrease from 0.57 to 0.23 and a number of 11.7 quality adjusted life-years (QALYs) gained was expected. Total yearly healthcare costs, including costs of screening, diagnostics, and treatment, were €390,800 higher in a situation with screening compared to a situation without screening, resulting in a cost-utility ratio of €33,400 per QALY gained.Conclusion: Newborn screening for SCID might be cost-effective. However, there is still a lot of uncertainty around the cost-effectiveness estimate. Pilot screening projects are warranted to obtain more accurate estimates for the European situation. What is Known: • Severe combined immunodeficiency (SCID) is a condition that often results in severe infections and death at a young age. • As the incidence of SCID is low, assessing cost-effectiveness of adding screening for SCID to the newborn screening program is needed. What is New: • Newborn screening for SCID is expected to reduce mortality from 0.57 to 0.23 per 100,000 children at additional healthcare costs of €390,800. The cost-utility ratio is €33,400 per QALY gained. • Due to large uncertainty around cost-effectiveness estimates, pilot screening projects are warranted for Europe.
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Affiliation(s)
| | - Maartje Blom
- Department of Pediatrics, Leiden University Medical Center, PO box 9600, 2300 RC, Leiden, The Netherlands
| | - Robbert G M Bredius
- Department of Pediatrics, Leiden University Medical Center, PO box 9600, 2300 RC, Leiden, The Netherlands
| | - Mirjam van der Burg
- Department of Pediatrics, Leiden University Medical Center, PO box 9600, 2300 RC, Leiden, The Netherlands
| | - Peter C J I Schielen
- RIVM, Department Biologicals, Screening and Innovation, PO box 1, 3720 BA, Bilthoven, The Netherlands
| | - Paul H Verkerk
- TNO - Child Health, PO box 3005, 2301 DA, Leiden, The Netherlands
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8
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Hays LH. Societal value of newborn screening for severe combined immune deficiency in Arkansas: An economic analysis. Public Health Nurs 2019; 36:541-544. [PMID: 30945355 DOI: 10.1111/phn.12614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 03/19/2019] [Accepted: 03/21/2019] [Indexed: 11/30/2022]
Abstract
Newborn screening (NBS) is a public health program that detects genetic conditions in neonates enabling treatment before clinical symptoms manifest. Severe combined immune deficiency (SCID) is a primary immune deficiency found in the absence of functioning T and B lymphocytes. Hematopoietic cell transplantation is a potentially curative treatment if received within the first 42 months of life; without treatment, this condition is fatal in the first 2 years of life due to severe opportunistic infections. SCID was added to the recommended uniform panel of conditions for inclusion in state NBS programs in 2010. This manuscript examines the societal costs and benefits of NBS for SCID in Arkansas and implications to health services and social welfare. Total cost per year of all NBS for SCID and resulting early treatment for one patient with SCID in Arkansas is estimated at $1,078,714. Cost of late treatment of one patient with SCID is estimated at $1.43 million. Based on an expected diagnosis of one patient per year in Arkansas, this results in an estimated net cost savings for NBS for SCID in Arkansas of $351,286 per year. Based on cost-effectiveness analysis, NBS for SCID in Arkansas is cost-effective, with higher societal benefit than cost.
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Affiliation(s)
- Laura H Hays
- College of Nursing, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Thomas C, Durand-Zaleski I, Frenkiel J, Mirallié S, Léger A, Cheillan D, Picard C, Mahlaoui N, Riche VP, Roussey M, Sébille V, Rabetrano H, Dert C, Fischer A, Audrain M. Clinical and economic aspects of newborn screening for severe combined immunodeficiency: DEPISTREC study results. Clin Immunol 2019; 202:33-39. [PMID: 30946917 DOI: 10.1016/j.clim.2019.03.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 03/18/2019] [Accepted: 03/31/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Severe combined immunodeficiency (SCID) refers to a group of genetic disorders characterized by greatly compromised cellular and humoral immunity. Children with SCID are asymptomatic at birth, but they die from infections within the first months of life if not treated. Quantification of T-cell receptor excision circles is an extremely sensitive screening method for detecting newborns who may have SCID.The goal of the DEPISTREC study was to evaluate the feasibility of nationwide newborn screening for severe T-cell lymphopenia in France as well as its economic and clinical utility. METHODS The test universally used for neonatal screening for SCID was the quantification of TRECs on Guthrie cards. We compared a group of 190,517 babies from 48 maternities across the country who underwent newborn SCID screening with a control group of 1.4 million babies out of whom 28 were diagnosed with SCID without such screening during the course of the study. RESULTS Within the screening group, 62 babies were found to be lymphopenic, including three with SCID. The cost of screening ranged from 4.7€ to €8.15 per newborn. The average 18-month cost was €257,574 vs €204,697 in the control group. CONCLUSIONS In this large-scale study, we demonstrate that routine SCID screening is feasible and effective. This screening offers the additional benefit of aiding in the diagnosis of non-SCID lymphopenia. Economic evaluation allowed us to calculate the cost per test. Newborn screening may also prevent death by SCID before any curative treatment can be administered. The difference in cost between screened and control children could not be ascertained because of the very low numbers and death of one of the children tested.
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Affiliation(s)
- Caroline Thomas
- Service d'oncologie-hématologie et immunologie pédiatrique, CHU Nantes, Nantes, France.
| | | | | | - Sophie Mirallié
- Laboratoire de dépistage néonatal, CHU Nantes, Nantes, France
| | - Alexandra Léger
- Service d'oncologie-hématologie et immunologie pédiatrique, CHU Nantes, Nantes, France
| | - David Cheillan
- Service de Biochimie et Biologie Moléculaire Grand Est, Centre de Biologie et de Pathologie Est, Hospices Civils de Lyon, Lyon, France
| | - Capucine Picard
- CEDI, Hôpital Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France; Institut Imagine, INSERM, U1162 Paris, France; Centre de référence Déficits Immunitaires Héréditaires (CEREDIH), Hôpital universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Nizar Mahlaoui
- Centre de référence Déficits Immunitaires Héréditaires (CEREDIH), Hôpital universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | | | | | - Véronique Sébille
- Plateforme de Méthodologie et Biostatistique, Direction de la Recherche, CHU Nantes, Nantes, France
| | | | - Cécile Dert
- Direction de la Recherche, Cellule Innovation, CHU Nantes, Nantes, France
| | - Alain Fischer
- Institut Imagine, INSERM, U1162 Paris, France; Centre de référence Déficits Immunitaires Héréditaires (CEREDIH), Hôpital universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; Unité d'Immunologie-Hématologie et Rhumatologie pédiatrique, Hôpital universitaire Necker- Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; Collège de France, Paris, France
| | - Marie Audrain
- Laboratoire d'Immunologie, CHU Nantes, Nantes, France
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Blom M, Bredius RG, Weijman G, Dekkers EH, Kemper EA, van den Akker-van Marle ME, van der Ploeg CP, van der Burg M, Schielen PC. Introducing Newborn Screening for Severe Combined Immunodeficiency (SCID) in the Dutch Neonatal Screening Program. Int J Neonatal Screen 2018; 4:40. [PMID: 33072960 PMCID: PMC7548907 DOI: 10.3390/ijns4040040] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 12/04/2018] [Indexed: 01/19/2023] Open
Abstract
The implementation of newborn screening for severe combined immunodeficiency (SCID) in the Netherlands is a multifaceted process in which several parties are involved. The Dutch Ministry of Health adopted the advice of the Dutch Health Council to include SCID in the Dutch newborn screening program in 2015. As newborn screening for SCID is executed with a new, relatively expensive assay for the Dutch screening laboratory, an implementation pilot study is deemed instrumental for successful implementation. A feasibility study was performed in which the practicalities and preconditions of expanding the newborn screening program were defined. Cost-effectiveness analysis (CEA) indicated that SCID screening in the Netherlands might be cost-effective, recognizing that there are still many uncertainties in the variables underlying the CEA. Data and experience of the pilot study should provide better estimates of these parameters, thus enabling the actualization of CEA results. Prior to the implementation pilot study, a comparison study of two commercially available SCID screening assays was performed. A prospective implementation pilot study or so-called SONNET study (SCID screening research in the Netherlands with TRECs) started in April 2018 and allows the screening for SCID of all newborns in three provinces of the Netherlands for one year. Based on the results of the SONNET study, the Dutch Ministry of Health will make a final decision about national implementation of newborn screening for SCID in the Netherlands.
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Affiliation(s)
- Maartje Blom
- Department of Pediatrics, Laboratory for Immunology, Leiden University Medical Center (LUMC), P.O. Box 9600, 2300 RC Leiden, The Netherlands
- Department of Biologicals, Screening and Innovation, Centre for Health Protection, National Institute of Public Health and the Environment (RIVM), P.O. Box 1, 3720 BA Bilthoven, The Netherlands
| | - Robbert G.M. Bredius
- Department of Pediatrics, Leiden University Medical Center (LUMC), P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Gert Weijman
- Department of Vaccine Supply and Prevention Programmes, National Institute for Public Health and the Environment (RIVM), P.O. Box 1, 3720 BA Bilthoven, The Netherlands
| | - Eugènie H.B.M. Dekkers
- Centre for Population Screening, National Institute of Public Health and the Environment (RIVM), P.O. Box 1, 3720 BA Bilthoven, The Netherlands
| | - Evelien A. Kemper
- Department of Clinical Chemistry, IJsselland Hospital, P.O. Box 690, 2900 AR Capelle aan den IJssel, The Netherlands
| | - M. Elske van den Akker-van Marle
- Department of Biomedical Data Sciences, section Medical Decision Making, Leiden University Medical Center (LUMC), P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | | | - Mirjam van der Burg
- Department of Pediatrics, Laboratory for Immunology, Leiden University Medical Center (LUMC), P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Peter C.J.I. Schielen
- Department of Biologicals, Screening and Innovation, Centre for Health Protection, National Institute of Public Health and the Environment (RIVM), P.O. Box 1, 3720 BA Bilthoven, The Netherlands
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11
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Guffroy A, Martin T, Korganow AS. Adolescents and young adults (AYAs) affected by chronic immunological disease: A tool-box for success during the transition to adult care. Clin Immunol 2018; 197:198-204. [PMID: 30347239 DOI: 10.1016/j.clim.2018.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/17/2018] [Accepted: 10/18/2018] [Indexed: 12/12/2022]
Abstract
Adolescence is a time of physical, psychological and social changes between childhood and adulthood. All adolescents and young adults (AYAs) are in transition and experience key underlying processes that will influence their later life. It is a critical period, particularly for AYAs with a chronic medical condition. Diseases can start at any point during adolescence. The transition of care will concern health care providers, as well as more unexpected actors such as social workers, teachers, business managers and the family. In this review, we focus on transition in primary immunodeficiencies (PIDs) and autoimmune diseases (AIDs). We describe the challenges and needs of transition in the field. Questions that AYAs with PID and/or AID must face during transition in their familial, professional and personal life are discussed. We expose a practical, AYA centered approach to help physicians in their daily practice, and we propose a position for the future.
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Affiliation(s)
- Aurélien Guffroy
- Department of Clinical Immunology and Internal Medicine, National Reference Center for Autoimmune Diseases (RESO), Referral Centre for Primary Immunodeficiencies, Strasbourg University Hospital, 67091 Strasbourg, France; CNRS UPR 3572, Immunopathology and Therapeutic Chemistry, Strasbourg University, 67000 Strasbourg, France; UFR Médecine, Université de Strasbourg, 67000 Strasbourg, France.
| | - Thierry Martin
- Department of Clinical Immunology and Internal Medicine, National Reference Center for Autoimmune Diseases (RESO), Referral Centre for Primary Immunodeficiencies, Strasbourg University Hospital, 67091 Strasbourg, France.
| | - Anne-Sophie Korganow
- Department of Clinical Immunology and Internal Medicine, National Reference Center for Autoimmune Diseases (RESO), Referral Centre for Primary Immunodeficiencies, Strasbourg University Hospital, 67091 Strasbourg, France; CNRS UPR 3572, Immunopathology and Therapeutic Chemistry, Strasbourg University, 67000 Strasbourg, France; UFR Médecine, Université de Strasbourg, 67000 Strasbourg, France.
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12
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Meehan C, Bonfim C, Dasso JF, Costa-Carvalho BT, Condino-Neto A, Walter J. IN TIME: THE VALUE AND GLOBAL IMPLICATIONSOF NEWBORN SCREENING FORSEVERE COMBINED IMMUNODEFICIENCY. REVISTA PAULISTA DE PEDIATRIA : ORGAO OFICIAL DA SOCIEDADE DE PEDIATRIA DE SAO PAULO 2018; 36:388-397. [PMID: 30540106 PMCID: PMC6322803 DOI: 10.1590/1984-0462/;2018;36;4;00020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Indexed: 01/06/2023]
Affiliation(s)
- Cristina Meehan
- Division of Allergy and Immunology, Children’s Research Institute,
University of South Florida, St. Petersburg, FL, United States
| | - Carmem Bonfim
- Clinics Hospital, Universidade Federal do Paraná, Curitiba, PR,
Brazil
| | - Joseph F. Dasso
- Division of Allergy and Immunology, Children’s Research Institute,
University of South Florida, St. Petersburg, FL, United States
- Department of Biology, University of Tampa, Tampa, FL, United
States
| | - Beatriz Tavares Costa-Carvalho
- Division of Allergy, Clinical Immunology and Rheumatology,
Department of Pediatrics, Universidade Federal de São Paulo, São Paulo, SP,
Brazil
| | - Antonio Condino-Neto
- Department of Immunology, Institute of Biomedical Sciences,
Universidade de São Paulo, São Paulo, SP, Brazil
| | - Jolan Walter
- Division of Allergy and Immunology, Children’s Research Institute,
University of South Florida, St. Petersburg, FL, United States
- Division of Allergy and Immunology, Johns Hopkins All Children’s
Hospital, St. Petersburg, FL, United States
- Division of Pediatric Allergy and Immunology, Massachusetts General
Hospital, Boston, MA, United States
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13
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Gramer G, Hauck F, Lobitz S, Sommerburg O, Speckmann C, Hoffmann GF. Neugeborenenscreening 2020. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-016-0233-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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14
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Gardulf A, Winiarski J, Thorin M, Heibert Arnlind M, von Döbeln U, Hammarström L. Costs associated with treatment of severe combined immunodeficiency-rationale for newborn screening in Sweden. J Allergy Clin Immunol 2016; 139:1713-1716.e6. [PMID: 28012934 DOI: 10.1016/j.jaci.2016.10.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 10/17/2016] [Accepted: 10/25/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Ann Gardulf
- Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine, Karolinska Institutet, Huddinge, Stockholm, Sweden; Jeffrey Modell Diagnostic and Research Centre for Primary Immunodeficiencies, Department of Laboratory Medicine, Karolinska Institutet, Huddinge, Stockholm, Sweden.
| | - Jacek Winiarski
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Huddinge, Stockholm, Sweden; Division of Paediatrics, Department of Clinical Science Intervention and Technology, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Moa Thorin
- Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine, Karolinska Institutet, Huddinge, Stockholm, Sweden; Jeffrey Modell Diagnostic and Research Centre for Primary Immunodeficiencies, Department of Laboratory Medicine, Karolinska Institutet, Huddinge, Stockholm, Sweden
| | - Marianne Heibert Arnlind
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Ulrika von Döbeln
- Division of Molecular Metabolism, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Lennart Hammarström
- Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine, Karolinska Institutet, Huddinge, Stockholm, Sweden; Jeffrey Modell Diagnostic and Research Centre for Primary Immunodeficiencies, Department of Laboratory Medicine, Karolinska Institutet, Huddinge, Stockholm, Sweden
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15
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Chinen J, Notarangelo LD, Shearer WT. Advances in clinical immunology in 2015. J Allergy Clin Immunol 2016; 138:1531-1540. [PMID: 27931534 PMCID: PMC5157931 DOI: 10.1016/j.jaci.2016.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 10/02/2016] [Accepted: 10/07/2016] [Indexed: 12/17/2022]
Abstract
Advances in clinical immunology in the past year included the report of practice parameters for the diagnosis and management of primary immunodeficiencies to guide the clinician in the approach to these relatively uncommon disorders. We have learned of new gene defects causing immunodeficiency and of new phenotypes expanding the spectrum of conditions caused by genetic mutations such as a specific regulator of telomere elongation (RTEL1) mutation causing isolated natural killer cell deficiency and mutations in ras-associated RAB (RAB27) resulting in immunodeficiency without albinism. Advances in diagnosis included the increasing use of whole-exome sequencing to identify gene defects and the measurement of serum free light chains to identify secondary hypogammaglobulinemias. For several primary immunodeficiencies, improved outcomes have been reported after definitive therapy with hematopoietic stem cell transplantation and gene therapy.
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Affiliation(s)
- Javier Chinen
- Immunology, Allergy and Rheumatology Section, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex.
| | - Luigi D Notarangelo
- Division of Immunology, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - William T Shearer
- Immunology, Allergy and Rheumatology Section, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex
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16
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Primary Immunodeficiency Diseases in Oman: 10-Year Experience in a Tertiary Care Hospital. J Clin Immunol 2016; 36:785-792. [PMID: 27699572 DOI: 10.1007/s10875-016-0337-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/16/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Primary immunodeficiency (PID) diseases are rare, complex medical disorders that often are overlooked in clinical settings. There are emerging reports of PID from Middle Eastern populations. This study describes the features of PID patients in a tertiary care setting in Oman and compares them with regional and worldwide reports. METHOD Sultan Qaboos University Hospital (SQUH) is an academic tertiary care-level hospital for specialized healthcare, including PID patients. At the time of diagnosis, patients' sociodemographics, clinical features, laboratory investigations, and management were entered in electronic form. This study included patients seen between August 2005 and July 2015. RESULTS One hundred forty patients were registered with a minimum estimated population prevalence of 7.0/100,000. The male/female ratio was 1.6:1, the median age of onset of symptoms was 8 months, and diagnosis was 21 months with a delay of 13 months. Family history was positive in 44 %, consanguinity was present in 76 %, death of a previous sibling was present in 36 %, and there was an overall mortality in 18 %, with an 85 % probability of survival 10 years following diagnosis. The most common type of immunodeficiency was phagocytic disorders (35.0 %), followed by predominantly antibody disorders (20.7 %), combined immunodeficiency (17.8 %), other well-defined PID syndromes (15.0 %), immune dysregulation syndromes (3.5 %), complement deficiencies (3.5 %), and unclassified immunodeficiency (4.2 %). The commonest presenting infection was pneumonia (47.1 %). CONCLUSION PID is not a rare condition in Oman. The prevalence is in concordance with reports from the region but higher than in Western populations. The findings of the current study would help to improve the awareness and management of, and policy making for PID.
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Ding Y, Thompson JD, Kobrynski L, Ojodu J, Zarbalian G, Grosse SD. Cost-Effectiveness/Cost-Benefit Analysis of Newborn Screening for Severe Combined Immune Deficiency in Washington State. J Pediatr 2016; 172:127-35. [PMID: 26876279 PMCID: PMC4846488 DOI: 10.1016/j.jpeds.2016.01.029] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 12/16/2015] [Accepted: 01/07/2016] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To evaluate the expected cost-effectiveness and net benefit of the recent implementation of newborn screening (NBS) for severe combined immunodeficiency (SCID) in Washington State. STUDY DESIGN We constructed a decision analysis model to estimate the costs and benefits of NBS in an annual birth cohort of 86 600 infants based on projections of avoided infant deaths. Point estimates and ranges for input variables, including the birth prevalence of SCID, proportion detected asymptomatically without screening through family history, screening test characteristics, survival rates, and costs of screening, diagnosis, and treatment were derived from published estimates, expert opinion, and the Washington NBS program. We estimated treatment costs stratified by age of identification and SCID type (with or without adenosine deaminase deficiency). Economic benefit was estimated using values of $4.2 and $9.0 million per death averted. We performed sensitivity analyses to evaluate the influence of key variables on the incremental cost-effectiveness ratio (ICER) of net direct cost per life-year saved. RESULTS Our model predicts an additional 1.19 newborn infants with SCID detected preclinically through screening, in addition to those who would have been detected early through family history, and 0.40 deaths averted annually. Our base-case model suggests an ICER of $35 311 per life-year saved, and a benefit-cost ratio of either 5.31 or 2.71. Sensitivity analyses found ICER values <$100 000 and positive net benefit for plausible assumptions on all variables. CONCLUSIONS Our model suggests that NBS for SCID in Washington is likely to be cost-effective and to show positive net economic benefit.
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Affiliation(s)
- Yao Ding
- Association of Public Health Laboratories, Newborn Screening and Genetics, Silver Spring, MD
| | - John D. Thompson
- Washington State Department of Health, Office of Newborn Screening, Shoreline, WA
| | - Lisa Kobrynski
- Allergy Division, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Jelili Ojodu
- Association of Public Health Laboratories, Newborn Screening and Genetics, Silver Spring, MD
| | - Guisou Zarbalian
- Association of Public Health Laboratories, Newborn Screening and Genetics, Silver Spring, MD
| | - Scott D. Grosse
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, GA
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18
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Espinosa-Rosales FJ, Condino-Neto A, Franco JL, Sorensen RU. Into Action: Improving Access to Optimum Care for all Primary Immunodeficiency Patients. J Clin Immunol 2016; 36:415-7. [DOI: 10.1007/s10875-016-0277-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 03/23/2016] [Indexed: 01/17/2023]
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19
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Booth C, Silva J, Veys P. Stem cell transplantation for the treatment of immunodeficiency in children: current status and hopes for the future. Expert Rev Clin Immunol 2016; 12:713-23. [PMID: 26882211 DOI: 10.1586/1744666x.2016.1150177] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Primary immunodeficiencies (PID) are rare inherited disorders affecting immune function and can be life-threatening if not treated. Haematopoietic stem cell transplantation (HSCT) offers a curative approach for many of these disorders and gene therapy is increasingly used as an alternative therapeutic strategy for patients lacking a suitable donor. Early diagnosis, improved supportive care and advances in gene and cell therapies have resulted in increased survival rates and improved quality of life. This review describes current strategies employed to improve outcomes in PID, focusing on new developments in HSCT, gene and cell therapy. We also address the challenges associated with newborn screening (NBS) programmes and novel mutations identified through improved diagnostic technology.
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Affiliation(s)
- Claire Booth
- a Department of Paediatric Immunology , Great Ormond Street Hospital , London , UK
| | - Juliana Silva
- b Department of Bone Marrow Transplantation , Great Ormond Street Hospital , London , UK
| | - Paul Veys
- b Department of Bone Marrow Transplantation , Great Ormond Street Hospital , London , UK
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20
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de Felipe B, Olbrich P, Lucenas JM, Delgado-Pecellin C, Pavon-Delgado A, Marquez J, Salamanca C, Soler-Palacin P, Gonzalez-Granado LI, Antolin LF, Borte S, Neth O. Prospective neonatal screening for severe T- and B-lymphocyte deficiencies in Seville. Pediatr Allergy Immunol 2016; 27:70-7. [PMID: 26498110 DOI: 10.1111/pai.12501] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Early diagnosis of primary immunodeficiency such as severe combined immunodeficiency (SCID) and X-linked agammaglobulinemia (XLA) improves outcome of affected children. T-cell-receptor-excision circles (TRECs) and kappa-deleting-recombination-excision circles (KRECs) determination from dried blood spots (DBS) identify neonates with severe T- and/or B-lymphopenia. No prospective data exist of the impact of gestational age (GA) and birth weight (BW) on TRECs and KRECs values. METHODS TRECs and KRECs determination using triplex RT-PCR (TRECS-KRECS-β-actin-Assay) from prospectively collected DBS between 02/2014 and 02/2015 in three hospitals in Seville, Spain. Cut-off levels were TRECs < 6/punch, KRECs < 4/punch and -β-actin>700/punch. Internal (SCID, XLA, ataxia telangiectasia) and external controls (NBS quality assurance program, CDC) were included. RESULTS A total of 5160 DBS were tested. Re-punch was needed in 77 samples (1.5%) due to insufficient β-actin (<700 copies/punch). Pre-term neonates (GA<37 weeks) and neonates with a BW<2500 g showed significantly lower TRECs and KRECs levels (p < 0.001). Due to repeat positive results five neonates were re-called (<0.1%): Fatal chromosomopathy (n = 1; TRECs 1/KRECs 4); extreme pre-maturity (n = 2; TRECs 0/KRECs 0 and TRECs 1/KRECs 20 copies/punch); neonates born to mothers receiving azathioprine during pregnancy (n = 2; TRECs 92/KRECs 1 and TRECs 154/KRECs 3 copies/punch). All internal and external controls were correctly identified. CONCLUSIONS TRECS-KRECS-β-actin-Assay correctly identifies T- and B-cell lymphopenias. Pre-maturity and low BW is associated with lower TREC and KREC levels. Extreme pre-maturity and maternal immune suppressive therapy may be a cause for false positive results of TRECs and KRECs values, respectively. To reduce the rate of insufficient samples, DBS extraction and storage need to be improved.
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Affiliation(s)
- Beatriz de Felipe
- Seccion de Infectología e Inmunodeficiencias, Unidad de Pediatria, Hospital Virgen del Rocío, Sevilla/Instituto de Biomedicina de Sevilla (IBiS), Sevilla, Spain
| | - Peter Olbrich
- Seccion de Infectología e Inmunodeficiencias, Unidad de Pediatria, Hospital Virgen del Rocío, Sevilla/Instituto de Biomedicina de Sevilla (IBiS), Sevilla, Spain
| | - José Manuel Lucenas
- Unidad de Inmunología, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | | | | | - Carmen Salamanca
- Unidad de Neonatología, Hospital Universitario Virgen de Macarena, Sevilla, Spain
| | - Pere Soler-Palacin
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | | | - Laura Ferreras Antolin
- Unidad de Enfermedades Infecciosas e Inmunodeficiencias, UGP de Pediatría. Hospital Materno-Infantil, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Stephan Borte
- Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden.,Translational Centre for Regenerative Medicine (TRM), University of Leipzig, Leipzig, Germany.,ImmunoDeficiencyCenter Leipzig at Hospital St Georg gGmbH Leipzig, Jeffrey Modell Diagnostic and Research Center for Primary Immunodeficiencies, Leipzig, Germany
| | - Olaf Neth
- Seccion de Infectología e Inmunodeficiencias, Unidad de Pediatria, Hospital Virgen del Rocío, Sevilla/Instituto de Biomedicina de Sevilla (IBiS), Sevilla, Spain
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21
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Newborn screening for severe combined immune deficiency (technical and political aspects). Curr Opin Allergy Clin Immunol 2015; 15:539-46. [DOI: 10.1097/aci.0000000000000221] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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