Screening Jews and genes: a consideration of the ethics of genetic screening within the Jewish community: challenges and responses

Development and biological characterization of a clinical gene transfer vector for the treatment of MAK-associated retinitis pigmentosa

By combining next generation whole exome sequencing and induced pluripotent stem cell (iPSC) technology we found that an Alu repeat inserted in exon 9 of the MAK gene results in a loss of normal MAK transcript and development of human autosomal recessive retinitis pigmentosa (RP). Although a relatively rare cause of disease in the general population, the MAK variant is enriched in individuals of Jewish ancestry. In this population, 1 in 55 individuals are carriers and one third of all cases of recessive RP is caused by this gene. The purpose of this study was to determine if a viral gene augmentation strategy could be used to safely restore functional MAK protein as a step toward a treatment for early stage MAK-associated RP. Patient iPSC-derived photoreceptor precursor cells were generated and transduced with viral vectors containing the MAK transcript. One week after transduction, transcript and protein could be detected via rt-PCR and western blotting respectively. Using patient-derived fibroblast cells and mak knockdown zebra fish we demonstrate that over-expression of the retinal MAK transgene restored the cells ability to regulate primary cilia length. In addition, the visual defect in mak knockdown zebrafish was mitigated via treatment with the retinal MAK transgene. There was no evidence of local or systemic toxicity at 1-month or 3-months following subretinal delivery of clinical grade vector into wild type rats. The findings reported here will help pave the way for initiation of a phase 1 clinical trial for the treatment of patients with MAK-associated RP.

'We are all in the image of God': reproductive imaginaries and prenatal genetic testing in American Jewish communities

How are we to understand the complexities of prenatal genetic testing across social and cultural worlds? Availability and uptake of this biotechnology is variable, deeply influenced not only by national frameworks but also by local regimes of value. We argue that these intersections of genetic testing and local cultural worlds must be understood as part of broader 'reproductive imaginaries', including everything from kinship, pregnancy and gender norms to children's links to specific community norms of national and cultural futures. In the USA, preconceptual/prenatal genetic testing is widely available, driven by a neoliberal market-based model of consumer choice. In contrast, such tests are far more restricted by bioethical laws and medical regulations in France. This article will examine how particular cultural and religious communities - primarily American orthodox Jewish communities - shape prenatal genetic testing in their own distinct ways.

NIDA-Drug Addiction Treatment Outcome Study (DATOS) Relapse as a Function of Spirituality/Religiosity

BACKGROUND

The connection between religion/spirituality and deviance, like substance abuse, was first made by Durkheim who defined socially expected behaviors as norms. He explained that deviance is due in large part to their absence (called anomie), and concluded that spirituality lowers deviance by preserving norms and social bonds. Impairments in brain reward circuitry, as observed in Reward Deficiency Syndrome (RDS), may also result in deviance and as such we wondered if stronger belief in spirituality practice and religious belief could lower relapse from drugs of abuse.

METHODS

The NIDA Drug Addiction Treatment Outcome Study data set was used to examine post hoc relapse rates among 2,947 clients who were interviewed at 12 months after intake broken down by five spirituality measures.

RESULTS

Our main findings strongly indicate, that those with low spirituality have higher relapse rates and those with high spirituality have higher remission rates with crack use being the sole exception. We found significant differences in terms of cocaine, heroin, alcohol, and marijuana relapse as a function of strength of religious beliefs (x2 = 15.18, p = 0.028; logistic regression = 10.65, p = 0.006); frequency of attending religious services (x2 = 40.78, p < 0.0005; logistic regression = 30.45, p < 0.0005); frequency of reading religious books (x2 = 27.190, p < 0.0005; logistic regression = 17.31, p < 0.0005); frequency of watching religious programs (x2 = 19.02, p = 0.002; logistic regression = ns); and frequency of meditation/prayer (x2 = 11.33, p = 0.045; logistic regression = 9.650, p = 0.002). Across the five measures of spirituality, the spiritual participants reported between 7% and 21% less alcohol, cocaine, heroin, and marijuana use than the non-spiritual subjects. However, the crack users who reported that religion was not important reported significantly less crack use than the spiritual participants. The strongest association between remission and spirituality involves attending religious services weekly, the one marker of the five that involves the highest social interaction/social bonding consistent with Durkheim's social bond theory.

CONCLUSIONS

Stronger spiritual/religious beliefs and practices are directly associated with remission from abused drugs except crack. Much like the value of having a sponsor, for clients who abuse drugs, regular spiritual practice, particularly weekly attendance at the religious services of their choice is associated with significantly higher remission. These results demonstrate the clinically significant role of spirituality and the social bonds it creates in drug treatment programs.

Perceptions of genetic testing for cancer predisposition among Ashkenazi Jewish women

BACKGROUND

Clinical genetic testing can help identify individuals who are predisposed to a variety of diseases and conditions; thus, it is important to understand attitudes and perceptions of individuals who may consider or who may be offered such testing.

METHODS

We examined knowledge and attitudes about cancer genetic testing among 59 women of Ashkenazi Jewish descent (age 25-80 years) through six focus group discussions. Participants were asked about their knowledge and experience with hereditary conditions and genetic testing, and attitudes regarding risk management options, genetic privacy, and potential discrimination issues.

RESULTS

Although 54% reported having a personal and/or some family history of breast, ovarian, or colorectal cancer, none had undergone cancer genetic counseling or testing and few expressed an interest or intention in doing so. While most endorsed benefits of genetic testing for those with a significant cancer family history, women also expressed concerns over the possible distress of learning that one carried a cancer-predisposing mutation and suggested that increasing cancer screening practices may be preferable to having genetic testing. Participants doubted the ability of state genetic privacy legislation to protect against insurance or employment discrimination.

CONCLUSION

Findings underscore the need for public education on the broad range of benefits and limitations associated with genetic testing, in order to help consumers to appropriately interpret complex information and make decisions about these services.

Knowledge and attitudes toward a free education and Ashkenazi Jewish carrier testing program

Carrier testing is offered on the basis of Ashkenazi Jewish background in both the prenatal and preconception settings, with the goal of decreasing the prevalence of affected individuals and allowing informed decision-making during childbearing. The purpose of this study was to (1) document the demographic characteristics of individuals who attended a free education and screening program, (2) learn how the education program changed attendees' knowledge and attitudes by learning more about these disorders, and (3) determine how participants perceived their carrier status risk. One hundred seventy-four individuals completed questionnaires at the beginning and end of an educational program about the Ashkenazi Jewish genetic disorders. There was a statistically significant difference in the participant's level of knowledge from the pre- to post education (p < .001). Females reported a significantly higher level of concern about the disorders (p = .004) and their carrier status (p = .006) before the education, as well as about their carrier status post education (p = .05). Finally, having one or more parent affiliated with Orthodox Judaism was related to higher knowledge before the education program (p = .05). In conclusion, this study demonstrated that an educational carrier screening program increased knowledge about the disorders and also produced mild anxiety regarding personal and reproductive risks.

What influences participation in genetic carrier testing? Results from a discrete choice experiment

This study explores factors that influence participation in genetic testing programs and the acceptance of multiple tests. Tay Sachs and cystic fibrosis are both genetically determined recessive disorders with differing severity, treatment availability, and prevalence in different population groups. We used a discrete choice experiment with a general community and an Ashkenazi Jewish sample; data were analysed using multinomial logit with random coefficients. Although Jewish respondents were more likely to be tested, both groups seem to be making very similar tradeoffs across attributes when they make genetic testing choices.

Carrier screening panels for Ashkenazi Jews: is more better?

PURPOSE

To describe the characteristics of Ashkenazi Jewish carrier testing panels offered by US Laboratories, including what diseases are included, the labels used to describe the panels, and the prices of individual tests compared to the prices of panels for each laboratory.

METHODS

GeneTests (http://www.genetests.org) was searched for laboratories that offered Tay-Sachs disease testing. Information was obtained from laboratory web sites, printed brochures, and telephone calls about tests/panels.

RESULTS

Twenty-seven laboratories offered up to 10 tests. The tests included two diseases associated with death in childhood (Niemann-Pick type A and Tay-Sachs disease), five with moderate disability and a variably shortened life span (Bloom syndrome, Canavan disease, cystic fibrosis, familial dysautonomia, Fanconi anemia, and mucolipidosis type IV), and two diseases that are not necessarily disabling or routinely shorten the lifespan (Gaucher disease type I and DFNB1 sensorineural hearing loss). Twenty laboratories offered a total of 27 panels of tests for three to nine diseases, ranging in price from $200 to $2082. Of these, 15 panels cost less than tests ordered individually. The panels were described by 24 different labels; eight included the phrase Ashkenazi Jewish Disease or disorder and six included the phrase Ashkenazi Jewish Carrier.

CONCLUSION

There is considerable variability in the diseases, prices, and labels of panels. Policy guidance for establishing appropriate criteria for inclusion in panels may be useful to the Ashkenazi Jewish community, clinicians, and payers. Pricing strategies that offer financial incentives for the use of "more tests" should be reexamined.

Community involvement in developing policies for genetic testing: assessing the interests and experiences of individuals affected by genetic conditions

Because the introduction of genetic testing into clinical medicine and public health creates concerns for the welfare of individuals affected with genetic conditions, those individuals should have a role in policy decisions about testing. Mechanisms for promoting participation range from membership on advisory committees to community dialogues to surveys that provide evidence for supporting practice guidelines. Surveys can assess the attitudes and the experiences of members of an affected group and thus inform discussions about that community's concerns regarding the appropriate use of a genetic test. Results of a survey of individuals affected with inherited dwarfism show how data can be used in policy and clinical-practice contexts. Future research of affected communities' interests should be pursued so that underrepresented voices can be heard.

A population-based study of Ashkenazi Jewish women's attitudes toward genetic discrimination and BRCA1/2 testing

PURPOSE

The Human Genome Project continues to produce an increasing number of genetic susceptibility tests. Some of these genetic tests target social or ethnic groups who are at increased risk of developing a disease. The Ashkenazi Jewish community is one ethnic group that is an ongoing subject of genetic investigation. We assessed the attitudes of a population-based sample of Ashkenazi Jewish women toward breast-ovarian cancer susceptibility testing (BRCA 1/2). In particular, we assessed concerns about group discrimination, perceptions of the advantages and disadvantages of testing, and the relationship between concerns about discrimination and the potential benefits of genetic testing.

METHODS

A telephone survey of a population-based sample of 200 Jewish women.

RESULTS

A minority of women (17%) in this study expressed concern or discomfort with Jews being offered testing. Most women believed there were scientific reasons for testing Jews (71%), and only 5% of women felt that research that focused on Jews was bad for Jews as a group. Increased concern about genetic discrimination was associated with women who were highly educated (odds ratio 2.68). Forty percent of women surveyed were interested in testing, 40% were not interested, and 20% were uncertain about whether they would obtain testing. Increased interest in genetic testing was associated with a desire to obtain information about children's risk of disease and valuing information for its own sake.

CONCLUSIONS

The majority of a population-based sample of Jewish women did not express concerns about group discrimination resulting from genetic testing. Women who are highly educated are more concerned about genetic discrimination. There is significant variation among Jewish women's interest in breast cancer susceptibility testing.

The frequency of Tay-Sachs disease causing mutations in the Brazilian Jewish population justifies a carrier screening program

CONTEXT

Tay-Sachs disease is an autosomal recessive disease characterized by progressive neurologic degeneration, fatal in early childhood. In the Ashkenazi Jewish population the disease incidence is about 1 in every 3,500 newborns and the carrier frequency is 1 in every 29 individuals. Carrier screening programs for Tay-Sachs disease have reduced disease incidence by 90% in high-risk populations in several countries. The Brazilian Jewish population is estimated at 90,000 individuals. Currently, there is no screening program for Tay-Sachs disease in this population.

OBJECTIVE

To evaluate the importance of a Tay-Sachs disease carrier screening program in the Brazilian Jewish population by determining the frequency of heterozygotes and the acceptance of the program by the community.

SETTING

Laboratory of Molecular Genetics--Institute of Biosciences--Universidade de São Paulo.

PARTICIPANTS

581 senior students from selected Jewish high schools.

PROCEDURE

Molecular analysis of Tay-Sachs disease causing mutations by PCR amplification of genomic DNA, followed by restriction enzyme digestion.

RESULTS

Among 581 students that attended educational classes, 404 (70%) elected to be tested for Tay-Sachs disease mutations. Of these, approximately 65% were of Ashkenazi Jewish origin. Eight carriers were detected corresponding to a carrier frequency of 1 in every 33 individuals in the Ashkenazi Jewish fraction of the sample.

CONCLUSION

The frequency of Tay-Sachs disease carriers among the Ashkenazi Jewish population of Brazil is similar to that of other countries where carrier screening programs have led to a significant decrease in disease incidence. Therefore, it is justifiable to implement a Tay-Sachs disease carrier screening program for the Brazilian Jewish population.

Tay-Sachs disease carrier screening: a 21-year experience

This paper presents the findings of a community-based carrier screening program for Tay-Sachs disease, initiated on the University of Wisconsin-Madison campus in 1978. The Madison Community Tay-Sachs Screening Program (MCTSSP) is a collaborative, interdisciplinary program that organizes and conducts periodic screening for Tay-Sachs disease (TSD) for the purpose of identifying Tay-Sachs carriers. We present and analyze data on carrier detection with regard to various demographics, including family history of TSD, ancestry, gender, medication exposure, and illness. Individuals participating in the MCTSSP between 1978 and 1999 were primarily of the target population, and the carrier rate was within the expected range (1/25). Despite aggressive publicity efforts and a well-established program, attendance at the screens has declined. A recent survey of Jewish undergraduate students at the University of Wisconsin-Madison showed poor recall of family screen history and carrier status and reinforced the perception that utilization of the Madison screening program has been low. Ways to increase awareness of and interest in carrier screening for TSD are explored.

Ethical issues in DNA testing

Molecular tests for single gene disorders have become the "gold standard," surpassing in sensitivity and specificity other ancillary tests such as imaging or neurophysiologic tests. Although direct technical problems are rare for DNA tests, few outcomes studies have been reported that examine sensitivity, specificity, and usage of tests outside the setting of academic medical centers. Ethical problems of DNA testing are mainly discussed in a theoretical framework and few published studies or case reports deal with real-life situations. Among neurologists, ethical dilemmas and attempts at their resolution are communicated mainly on a verbal basis, and even then relatively little follow-up is available. The potential use of information obtained through DNA testing by other family members, employers, insurance companies, and governmental agencies deserves scientific investigation and societal discussion. A major educational effort is needed to inform patients, providers, and third parties that the presence of a particular allele in an individual is only one piece in a complex puzzle of environmental and genetic interactions that may ultimately result in disease.