Two faces of patient advocacy: the current controversy in newborn screening

Why cystic fibrosis newborn screening programs have failed to meet original expectations… thus far

This Commentary summarizes what the author has learned in 46 years of research on newborn screening (NBS) for cystic fibrosis (CF) combined with healthcare and public health practice. The original expectation was that screening for this relatively common, life-threatening genetic disorder would lead to consistently timely diagnoses in the neonatal period and be equitable. Unfortunately, this ambitious goal has not been achieved in the USA despite the availability of an excellent, although imperfect, 2-tiered screening test employing immunoreactive trypsinogen (IRT) and DNA analysis for pathogenic variants in the gene that encodes the cystic fibrosis transmembrane conductance regulator (CFTR). In fact, variations in the quality of NBS programs, inconsistencies in their operations, and disparities in outcomes have been prominent features. The causes include leadership challenges and deficiencies among both CF centers and NBS labs; failures to form effective partnerships among CF centers and with NBS programs; relatively rapid implementation after 2005 with variable quality planning; misunderstandings and erroneous dogma about CF; data limitations regarding IRT, especially cutoff values, and CFTR genetics; tolerance of suboptimal protocols and false negative results; problems in dried blood spot collections plus a lack of transparency and national oversight; partial lack of readiness, qualifications, funding and/or willingness to innovate with floating IRT cutoffs and DNA/CFTR analyses; follow up challenges/deficiencies impairing timeliness, including sweat testing limitations; and published guidelines that are more descriptive than sufficiently critical and directive. But the lessons learned through uniquely intensive CF NBS research have been enlightening and guided the U.S. Cystic Fibrosis Foundation to nationwide quality improvement initiatives.

Is Our Newborn Screening Working Well? A Literature Review of Quality Requirements for Newborn Blood Spot Screening (NBS) Infrastructure and Procedures

Newborn screening using dried blood spots (NBS) is widely acknowledged as a highly successful procedure in secondary prevention. For a number of congenital disorders, severe disability or death are impressively prevented by early detection and early treatment through NBS. However, as with any other screening, NBS can also cause harm, and the principle that "the overall benefits of screening should outweigh the harms" must be considered when introducing and implementing NBS programmes. This publication compiles the results of a systematic literature research on requirements for NBS infrastructure and procedures which was conducted as part of a research project on the quality and shortcomings of the NBS pathway in Germany. The compilation contains the requirements and recommendations for realising the principle of "maximise benefits and minimise harms" in relevant NBS pathway components such as parental education and information, coverage, timeliness, laboratory quality assurance, follow-up of abnormal results, confirmatory diagnostics, documentation, and evaluation. The results reflect the complexity of NBS infrastructure, and thus, they illustrate the importance of considering and implementing NBS as a well-coordinated public health programme with continuous quality management. Special attention should be paid to the perspectives of parents and families. Some NBS issues can substantially benefit from digital instruments or international cooperation. The literature review presented here has contributed to a concept of proposals for the advancement of NBS in Germany, and despite different settings, it may as well be of interest for other countries to achieve the best possible course and outcome of NBS for each child.

Identifying and overcoming barriers to harmonize newborn screening programs through consensus strategies

The benefits of newborn screening (NBS) programs have been widely demonstrated after more than 50 years since first established. NBS enables the detection of the disease before the child shows clinical symptoms, allowing clinicians to act early and facilitating appropriate interventions to prevent or improve adverse outcomes. Delay or lack of medical intervention in these infants may lead to developmental delay, severe disability, or premature death. NBS programs have grown exponentially both in the number of diseases screened and in complexity, creating controversy. New technological advances, as well as the emergence of new therapies that require early disease detection, have allowed for the inclusion of new diseases in NBS screening programs. However, different countries and even different regions have in turn adopted very diverse strategies and diagnostic algorithms when it comes to NBS. There are many factors responsible for these differences, such as the health care system, available funds, local politics, professional groups, and others that depend on the position taken by policymakers. These differences in NBS have led to discrepancies in detection opportunities between countries or regions, which has led to many varied attempts to harmonize NBS programs but not all have been equally satisfactory. Some countries have achieved good results, but always within their borders. Therefore, there are still many differences between NBS programs at the international level that must be overcome. These advances have also brought considerable uncertainty regarding ethical aspects and balance between benefits and harms. For this reason, and so that the situation of disparity in the global NBS programs can be minimized, health authorities must work to develop uniform criteria for decision-making and to take a further step toward harmonization. To do so, it is necessary to identify the crucial factors that lead to the adoption of different NBS programs worldwide, in order to analyze their influence and find ways to overcome them.

Screening of Newborns for Disorders with High Benefit-Risk Ratios Should Be Mandatory

Newborn screening has evolved to include an increasingly complex spectrum of diseases, raising concerns that screening should be optional and require parental consent. Early detection of disorders like PKU and MCAD is essential to prevent serious disability and death in affected children. These are examples of high benefit-risk ratio disorders because of the irrefutable health benefits of early detection, coupled with the low risks of treatment. The dire consequences of not diagnosing an infant with a treatable disorder because of parental refusal to screen are wholly unacceptable. Thus, we believe that newborn screening for disorders with high benefit-risk ratios should continue to be mandatory.

Governance Through Privacy, Fairness, and Respect for Individuals

INTRODUCTION

Individuals have a moral claim to be involved in the governance of their personal data. Individuals' rights include privacy, autonomy, and the ability to choose for themselves how they want to manage risk, consistent with their own personal values and life situations. The Fair Information Practices principles (FIPPs) offer a framework for governance. Privacy-enhancing technology that complies with applicable law and FIPPs offers a dynamic governance tool for enabling the fair and open use of individual's personal data.

PERCEPTIONS OF RISK

Any governance model must protect against the risks posed by data misuse. Individual perceptions of risks are a subjective function involving individuals' values toward self, family, and society, their perceptions of trust, and their cognitive decision-making skills.

THE HIPAA PRIVACY RULE PUTS SOME GOVERNANCE IN THE HANDS OF INDIVIDUALS

Individual privacy protections and individuals' right to choose are codified in the HIPAA Privacy Rule, which attempts to strike a balance between the dual goals of information flow and privacy protection. The choices most commonly given individuals regarding the use of their health information are binary ("yes" or "no") and immutable. Recent federal recommendations and law recognize the need for granular, dynamic choices.

BUILDING A GOVERNANCE FRAMEWORK BASED IN TRUST AVOIDING SURPRISES

Individuals expect that they will govern the use of their own health and genomic data. Failure to build and maintain individuals' trust increases the likelihood that they will refuse to grant permission to access or use their data. The "no surprises principle" asserts that an individual's personal information should never be collected, used, transmitted, or disclosed in a way that would surprise the individual were she to learn about it.

FAIR INFORMATION PRACTICES PRINCIPLES

The FIPPs provide a powerful framework for enabling data sharing and use, while maintaining trust. We introduce the eight FIPPs adopted by the Department of Health and Human Services, and provide examples of their interpretation and implementation.

REDUCING RISK THROUGH CONSUMER ENGAGEMENT

Privacy risk and health risk can be reduced by giving consumers control, autonomy, and transparency, and by engaging them in managing their own health. Explicit "consent" may not always be necessary - the FIPPs offer multiple ways to engender trust and avoid surprises.