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Choudhary S, Muise ED, Hammouda S, Goetz D, Giusti R. New York cystic fibrosis consortium newborn screening quality improvement: Development and implementation of a statewide consensus recommendations for management of infants with CFTR-related metabolic syndrome. Pediatr Pulmonol 2024. [PMID: 38990093 DOI: 10.1002/ppul.27160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 05/24/2024] [Accepted: 06/20/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND New York (NY) State implemented a new cystic fibrosis (CF) newborn screen (NBS) algorithm in December 2017 with improvement in positive predictive value and unanticipated increased identification of infants with cystic fibrosis transmembrane conductance regulator (CFTR)-related metabolic syndrome (CRMS). Repeat sweat testing is recommended in infants with CRMS. During the COVID-19 pandemic infants with CRMS were lost to follow up. With this quality improvement (QI) initiative, we aimed to perform repeat sweat testing in 25% of infants lost to follow up. We also describe consensus recommendations for CRMS from the NY CF NBS Consortium. METHODS Our QI team identified the primary drivers contributing to absent follow up, outreached to families, and created a questionnaire to evaluate parental understanding of CRMS using QI-based strategies. RESULTS Of 350 infants diagnosed with CRMS during the study period, 179 (51.1%) infants were lost to follow up. A total of 31 (17.3%) were scheduled for repeat sweat tests and followed up at CF Centers. Families reported high satisfaction with the CRMS knowledge questionnaire. CONCLUSIONS With this QI-based approach, we effectively recaptured infants with CRMS previously lost to follow up during the COVID-19 pandemic. Ongoing concerns about infection risk and lack of understanding on the part of families and pediatricians likely contributed to patients with CRMS lost to follow up. Consensus recommendations for CRMS include annual visits with repeat sweat testing until 2-6 years of age and education for adolescents about clinical and reproductive implications of CRMS.
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Affiliation(s)
- Saroj Choudhary
- Division of Pulmonary Medicine, Department of Pediatrics, New York University Langone Hospital-Long Island, Long Island, New York, USA
| | - Eleanor D Muise
- Division of Pulmonary Medicine, Department of Pediatrics, New York University, New York City, New York, USA
| | - Soumia Hammouda
- Division of Pulmonary Medicine, Department of Pediatrics, New York University, New York City, New York, USA
| | - Danielle Goetz
- Division of Pulmonary Medicine, Department of Pediatrics, University of Buffalo, Buffalo, New York, USA
| | - Robert Giusti
- Division of Pulmonary Medicine, Department of Pediatrics, New York University, New York City, New York, USA
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2
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Kay DM, Sadeghi H, Kier C, Berdella M, DeCelie-Germana JK, Soultan ZN, Goetz DM, Caggana M, Fortner CN, Giusti R, Kaslovsky R, Stevens C, Voter K, Welter JJ, Langfelder-Schwind E. Genetic counseling access and service delivery in New York State is variable for parents of infants with complex CFTR genotypes conferring uncertain phenotypes. Pediatr Pulmonol 2024; 59:1952-1961. [PMID: 38695616 DOI: 10.1002/ppul.27023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 02/26/2024] [Accepted: 04/10/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND New York State (NYS) utilizes a three-tiered cystic fibrosis newborn screening (CFNBS) algorithm that includes cystic fibrosis transmembrane conductance regulator (CFTR) gene sequencing. Infants with >1 CFTR variant of potential clinical relevance, including variants of uncertain significance or varying clinical consequence are referred for diagnostic evaluation at NYS cystic fibrosis (CF) Specialty Care Centers (SCCs). AIMS As part of ongoing quality improvement efforts, demographic, screening, diagnostic, and clinical data were evaluated for 289 CFNBS-positive infants identified in NYS between December 2017 and November 2020 who did not meet diagnostic criteria for CF and were classified as either: CFTR-related metabolic syndrome/CF screen positive, inconclusive diagnosis (CRMS/CFSPID) or CF carriers. RESULTS Overall, 194/289 (67.1%) had CFTR phasing to confirm whether the infant's CFTR variants were in cis or in trans. Eighteen complex alleles were identified in cis; known haplotypes (p.R117H+5T, p.F508del+p.L467F, and p.R74W+p.D1270N) were the most common identified. Thirty-two infants (16.5%) with all variants in cis were reclassified as CF carriers rather than CRMS/CFSPID. Among 263 infants evaluated at an NYS SCC, 70.3% were reported as having received genetic counseling about their results by any provider, with 96/263 (36.5%) counseled by a certified genetic counselor. CONCLUSION Given the particularly complex genetic interpretation of results generated by CFNBS algorithms including sequencing analysis, additional efforts are needed to ensure families of infants with a positive CFNBS result have CFTR phasing when needed to distinguish carriers from infants with CRMS/CFSPID, and access to genetic counseling to address implications of CFNBS results.
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Affiliation(s)
- Denise M Kay
- Newborn Screening Program, Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, New York, USA
| | - Hossein Sadeghi
- Columbia University Irving Medical Center, New York City, New York, USA
| | - Catherine Kier
- Department of Pediatrics, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
| | - Maria Berdella
- Lenox Hill Hospital, Northwell Health System, New York City, New York, USA
| | | | - Zafer N Soultan
- Division of Pediatric Pulmonary Medicine, Department of Pediatrics, Upstate Medical University, Syracuse, New York, USA
| | | | - Michele Caggana
- Newborn Screening Program, Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, New York, USA
| | - Christopher N Fortner
- Division of Pediatric Pulmonary Medicine, Department of Pediatrics, Upstate Medical University, Syracuse, New York, USA
| | | | - Robert Kaslovsky
- Department of Pediatrics, Albany Medical College, Albany, New York, USA
| | - Colleen Stevens
- Newborn Screening Program, Division of Genetics, Wadsworth Center, New York State Department of Health, Albany, New York, USA
| | - Karen Voter
- Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - John J Welter
- Division of Pediatric Pulmonology, New York Medical College, Valhalla, New York, USA
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3
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McGarry ME, Sciortino S, Graham S, Bishop T, Gibb ER. Improved detection of cystic fibrosis by the California Newborn Screening Program for all races and ethnicities. Pediatr Pulmonol 2024. [PMID: 38940324 DOI: 10.1002/ppul.27155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 06/17/2024] [Accepted: 06/20/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Newborn screening (NBS) for cystic fibrosis (CF) is universal in the United States. Protocols vary but include an immunoreactive trypsinogen (IRT) level and CFTR variant panel. California CF NBS has a 3-step screening: IRT level, variant panel, and CFTR sequencing if only one variant identified on panel. METHODS This was a cohort study of infants with CF born in California (2007-2021) to examine racial and ethnic differences in having a false-negative NBS result for CF and at which step the false-negative occurred. We examined how different CFTR variant panels would improve detection of variants by race and ethnicity: original 39-variant panel, current 75-variant panel, and all 402 disease-causing CFTR variants in the CFTR2 database. RESULTS Of the 912 infants born in California with CF, 84 had a false-negative result: 38 due to low IRT level and 46 with a high IRT value (but incomplete variant detection). Asian (OR 6.3) and Black infants (OR 2.5) were more likely to have a false-negative screening result than non-Hispanic white infants. The majority of false-negative screening (but CF diagnosis) cases among American Indian/Native Alaskan and non-Hispanic White infants were due to low IRT levels. The majority of Asian and Hispanic infants with false-negative screening had no variants detected. Detection of two CFTR variants was improved with the 75-variant panel in Black, Hispanic, and non-Hispanic White infants and with the 402-variant panel in Black, Hispanic, non-Hispanic White, and other race infants. CONCLUSIONS Larger CFTR panels in NBS improved the detection of CF in all races and ethnicities.
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Affiliation(s)
- Meghan E McGarry
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, University of Washington, Seattle, Washington, USA
- Center for Respiratory Biology and Therapeutics, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Stanley Sciortino
- Center for Respiratory Biology and Therapeutics, Seattle Children's Research Institute, Seattle, Washington, USA
- California Department of Public Health, Genetic Disease Screening Program, Richmond, California, USA
| | - Steve Graham
- California Department of Public Health, Genetic Disease Screening Program, Richmond, California, USA
| | - Tracey Bishop
- California Department of Public Health, Genetic Disease Screening Program, Richmond, California, USA
| | - Elizabeth R Gibb
- Department of Pediatrics, Division of Pulmonary Medicine, University of California San Francisco, San Francisco, California, USA
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4
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Wu M, Davis JD, Zhao C, Daley T, Oliver KE. Racial inequities and rare CFTR variants: Impact on cystic fibrosis diagnosis and treatment. J Clin Transl Endocrinol 2024; 36:100344. [PMID: 38765466 PMCID: PMC11099334 DOI: 10.1016/j.jcte.2024.100344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/21/2024] [Accepted: 04/14/2024] [Indexed: 05/22/2024] Open
Abstract
Cystic fibrosis (CF) has been traditionally viewed as a disease that affects White individuals. However, CF occurs among all races, ethnicities, and geographic ancestries. The disorder results from mutations in the CF transmembrane conductance regulator (CFTR). Varying incidence of CF is reported among Black, Indigenous, and People of Color (BIPOC), who typically exhibit worse clinical outcomes. These populations are more likely to carry rare CFTR variants omitted from newborn screening panels, leading to disparities in care such as delayed diagnosis and treatment. In this study, we present a case-in-point describing an individual of Gambian descent identified with CF. Patient genotype includes a premature termination codon (PTC) (c.2353C>T) and previously undescribed single nucleotide deletion (c.1970delG), arguing against effectiveness of currently available CFTR modulator-based interventions. Strategies for overcoming these two variants will likely include combinations of PTC suppressors, nonsense mediated decay inhibitors, and/or alternative approaches (e.g. gene therapy). Investigations such as the present study establish a foundation from which therapeutic treatments may be developed. Importantly, c.2353C>T and c.1970delG were not detected in the patient by traditional CFTR screening panels, which include an implicit racial and ethnic diagnostic bias as these tests are comprised of mutations largely observed in people of European ancestry. We suggest that next-generation sequencing of CFTR should be utilized to confirm or exclude a CF diagnosis, in order to equitably serve BIPOC individuals. Additional epidemiologic data, basic science investigations, and translational work are imperative for improving understanding of disease prevalence and progression, CFTR variant frequency, genotype-phenotype correlation, pharmacologic responsiveness, and personalized medicine approaches for patients with African ancestry and other historically understudied geographic lineages.
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Affiliation(s)
- Malinda Wu
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Pediatric Institute, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Jacob D. Davis
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Conan Zhao
- Interdisciplinary Graduate Program in Quantitative Biosciences, Georgia Institute of Technology, Atlanta, GA, USA
| | - Tanicia Daley
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Pediatric Institute, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Kathryn E. Oliver
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Pediatric Institute, Children’s Healthcare of Atlanta, Atlanta, GA, USA
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5
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Therrell BL, Padilla CD, Borrajo GJC, Khneisser I, Schielen PCJI, Knight-Madden J, Malherbe HL, Kase M. Current Status of Newborn Bloodspot Screening Worldwide 2024: A Comprehensive Review of Recent Activities (2020-2023). Int J Neonatal Screen 2024; 10:38. [PMID: 38920845 PMCID: PMC11203842 DOI: 10.3390/ijns10020038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/28/2024] [Accepted: 03/28/2024] [Indexed: 06/27/2024] Open
Abstract
Newborn bloodspot screening (NBS) began in the early 1960s based on the work of Dr. Robert "Bob" Guthrie in Buffalo, NY, USA. His development of a screening test for phenylketonuria on blood absorbed onto a special filter paper and transported to a remote testing laboratory began it all. Expansion of NBS to large numbers of asymptomatic congenital conditions flourishes in many settings while it has not yet been realized in others. The need for NBS as an efficient and effective public health prevention strategy that contributes to lowered morbidity and mortality wherever it is sustained is well known in the medical field but not necessarily by political policy makers. Acknowledging the value of national NBS reports published in 2007, the authors collaborated to create a worldwide NBS update in 2015. In a continuing attempt to review the progress of NBS globally, and to move towards a more harmonized and equitable screening system, we have updated our 2015 report with information available at the beginning of 2024. Reports on sub-Saharan Africa and the Caribbean, missing in 2015, have been included. Tables popular in the previous report have been updated with an eye towards harmonized comparisons. To emphasize areas needing attention globally, we have used regional tables containing similar listings of conditions screened, numbers of screening laboratories, and time at which specimen collection is recommended. Discussions are limited to bloodspot screening.
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Affiliation(s)
- Bradford L. Therrell
- Department of Pediatrics, University of Texas Health Science Center San Antonio, San Antonio, TX 78229, USA
- National Newborn Screening and Global Resource Center, Austin, TX 78759, USA
| | - Carmencita D. Padilla
- Department of Pediatrics, College of Medicine, University of the Philippines Manila, Manila 1000, Philippines;
| | - Gustavo J. C. Borrajo
- Detección de Errores Congénitos—Fundación Bioquímica Argentina, La Plata 1908, Argentina;
| | - Issam Khneisser
- Jacques LOISELET Genetic and Genomic Medical Center, Faculty of Medicine, Saint Joseph University, Beirut 1104 2020, Lebanon;
| | - Peter C. J. I. Schielen
- Office of the International Society for Neonatal Screening, Reigerskamp 273, 3607 HP Maarssen, The Netherlands;
| | - Jennifer Knight-Madden
- Caribbean Institute for Health Research—Sickle Cell Unit, The University of the West Indies, Mona, Kingston 7, Jamaica;
| | - Helen L. Malherbe
- Centre for Human Metabolomics, North-West University, Potchefstroom 2531, South Africa;
- Rare Diseases South Africa NPC, The Station Office, Bryanston, Sandton 2021, South Africa
| | - Marika Kase
- Strategic Initiatives Reproductive Health, Revvity, PL10, 10101 Turku, Finland;
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Martiniano SL, Wu R, Farrell PM, Ren CL, Sontag MK, Elbert A, McColley SA. Late Diagnosis in the Era of Universal Newborn Screening Negatively Affects Short- and Long-Term Growth and Health Outcomes in Infants with Cystic Fibrosis. J Pediatr 2023; 262:113595. [PMID: 37406853 DOI: 10.1016/j.jpeds.2023.113595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/19/2023] [Accepted: 06/26/2023] [Indexed: 07/07/2023]
Abstract
Newborn screening for cystic fibrosis was fully implemented in the US by 2010, but delays in timeliness of evaluation for infants with positive newborn screening tests persist. Through evaluation of national patient registry data, we determined that late initiation of cystic fibrosis care is associated with poorer long-term nutritional outcomes.
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Affiliation(s)
- Stacey L Martiniano
- University of Colorado School of Medicine, Aurora, CO; Breathing Institute, Children's Hospital Colorado, Aurora, CO.
| | - Runyu Wu
- Cystic Fibrosis Foundation, Bethesda, MD
| | - Philip M Farrell
- University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | - Clement L Ren
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Children's Hospital of Philadelphia, Division of Pulmonary and Sleep Medicine, Philadelphia, PA
| | - Marci K Sontag
- Center for Public Health Innovation, CI International, Littleton, CO
| | | | - Susanna A McColley
- Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Northwestern University Feinberg School of Medicine, Chicago, IL
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7
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Farrell PM. Why cystic fibrosis newborn screening programs have failed to meet original expectations… thus far. Mol Genet Metab 2023; 140:107679. [PMID: 37573205 DOI: 10.1016/j.ymgme.2023.107679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/14/2023]
Abstract
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.
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Affiliation(s)
- Philip M Farrell
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Clinical Sciences Center (K4/948), Madison, WI 53792, USA.
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8
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DeCelie-Germana JK, Bonitz L, Langfelder-Schwind E, Kier C, Diener BL, Berdella M. Diagnostic and Communication Challenges in Cystic Fibrosis Newborn Screening. Life (Basel) 2023; 13:1646. [PMID: 37629501 PMCID: PMC10455801 DOI: 10.3390/life13081646] [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: 07/07/2023] [Revised: 07/14/2023] [Accepted: 07/25/2023] [Indexed: 08/27/2023] Open
Abstract
As of December 2009, cystic fibrosis (CF) newborn screening (NBS) is performed in all 50 US states and the District of Columbia. Widespread implementation of CF newborn screening (CFNBS) in the US and internationally has brought about new and varied challenges. Immunoreactive trypsinogen (IRT) remains the first, albeit imperfect, biomarker used universally in the screening process. Advances in genetic testing have provided an opportunity for newborn screening programs to add CFTR sequencing tiers to their algorithms. This in turn will enable earlier identification of babies with CF and improve longer-term outcomes through prompt treatment and intervention. CFTR sequencing has led to the ability to identify infants with CF from diverse ethnic and racial backgrounds more equitably while also identifying an increasing proportion of infants with inconclusive diagnoses. Using the evolution of the New York State CF newborn screening program as a guide, this review outlines the basic steps in a universal CF newborn screening program, considers how to reduce bias, highlights challenges, offers guidance to address these challenges and provides recommendations for future consideration.
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Affiliation(s)
- Joan Kathleen DeCelie-Germana
- Cohen Children’s Medical Center, Division of Pediatric Pulmonary and Cystic Fibrosis, Zucker School of Medicine at Hofstra/Northwell, New York, NY 11040, USA;
| | - Lynn Bonitz
- Cohen Children’s Medical Center, Division of Pediatric Pulmonary and Cystic Fibrosis, Zucker School of Medicine at Hofstra/Northwell, New York, NY 11040, USA;
| | - Elinor Langfelder-Schwind
- The Cystic Fibrosis Center, Department of Pulmonary Medicine, Lenox Hill Hospital, Northwell Health, New York, NY 10075, USA; (E.L.-S.); (M.B.)
| | - Catherine Kier
- Department of Pediatrics, Renaissance School of Medicine at Stony Brook, Stony Brook, New York, NY 11794, USA; (C.K.); (B.L.D.)
| | - Barry Lawrence Diener
- Department of Pediatrics, Renaissance School of Medicine at Stony Brook, Stony Brook, New York, NY 11794, USA; (C.K.); (B.L.D.)
| | - Maria Berdella
- The Cystic Fibrosis Center, Department of Pulmonary Medicine, Lenox Hill Hospital, Northwell Health, New York, NY 10075, USA; (E.L.-S.); (M.B.)
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9
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Rehani MR, Marcus MS, Harris AB, Farrell PM, Ren CL. Variation in cystic fibrosis newborn screening algorithms in the United States. Pediatr Pulmonol 2023; 58:927-933. [PMID: 36507555 DOI: 10.1002/ppul.26279] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/06/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
RATIONALE Cystic fibrosis (CF) newborn screening (NBS) algorithms in the United States vary by state. Differences in CF NBS algorithms could potentially affect the detection rate of CF newborns and lead to disparities in CF diagnosis amongst different racial and ethnic groups. OBJECTIVES Generate a database of CF NBS algorithms in the United States and identify processes that may potentially lead to missed diagnoses or lead to healthcare disparities. METHODS We sent an online survey to state and regional CF and NBS leaders about the type and threshold of immunoreactive trypsinogen (IRT) cutoff used and methods used for CFTR gene variant analysis. Follow-up by email and phone was done to ensure a response from every state, clarify responses, and resolve discordances. RESULTS There is wide variation in the NBS algorithms employed by different states. Approximately half the states use a floating IRT cutoff, and half use a fixed IRT cutoff. CFTR variant analysis also varies widely, with two states analyzing only for the F508del variant and four states incorporating CFTR gene sequencing. The other states use CFTR variant panels ranging from 23 to 365 CFTR variants. CONCLUSIONS CF NBS algorithms vary widely amongst the different states in the United States, which affects the ability of CF NBS to diagnose newborn infants with CF consistently and uniformly across the country and potentially may miss more infants with CF from minority populations. Our results identify an important area for quality improvement in CF NBS.
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Affiliation(s)
- Maryann R Rehani
- Milken Institute of Public Health, George Washington University, Washington, District of Columbia, USA.,Madison Waisman Center, University of Wisconsin, Madison, Wisconsin, USA
| | - Mary S Marcus
- Madison Waisman Center, University of Wisconsin, Madison, Wisconsin, USA
| | - Anne B Harris
- Madison Waisman Center, University of Wisconsin, Madison, Wisconsin, USA
| | - Philip M Farrell
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Clement L Ren
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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10
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Rock MJ, Baker M, Antos N, Farrell PM. Refinement of newborn screening for cystic fibrosis with next generation sequencing. Pediatr Pulmonol 2023; 58:778-787. [PMID: 36416003 DOI: 10.1002/ppul.26253] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 11/12/2022] [Accepted: 11/15/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Newborn screening for cystic fibrosis (CF) has been underway universally in the United States for more than a decade, as well in most European countries, and algorithms have been evolving throughout this period with quality improvement projects as immunoreactive trypsinogen (IRT) determinations alone have been transformed to a 2-tier strategy with DNA analyses. OBJECTIVE To apply next generation sequencing (NGS) as a screening method to expand the DNA tier and identify substantially more variants in the CF transmembrane conductance regulator (CFTR) gene to enhance sensitivity and equity while minimizing incidental findings. DESIGN Sequential evaluation and improvement plan in three phases using algorithm modifications coupled to statewide follow up and analysis of screening outcomes. RESULTS After demonstrating feasibility in the first phase, we studied an IRT/NGS algorithm that included CFTR Variants with Varying Clinical Consequences (VVCCs). This revealed a high identification of CF patients with 2-variants detected through screening, but for every CF case there were 1.4 with CF metabolic syndrome/CF screen positive, inconclusive diagnosis (CRMS/CFSPID). This led us to a third phase of improvement in which the VVCCs were eliminated except for R117H, resulting in 94% 2-variant detection of patients and 0.44:1 ratio of CRMS/CFSPID to CF. CONCLUSION NGS can be used with IRT as an effective method of identifying infants at risk for CF without an appreciable increase in detection of carriers. Its potential added value includes facilitating equity, enhancing sensitivity and detecting more CF patients with 2-variants during the screening process.
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Affiliation(s)
- Michael J Rock
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Mei Baker
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,Newborn Screening Laboratory, Wisconsin State Laboratory of Hygiene, University of Wisconsin school of Medicine and Public Health, Madison, Wisconsin, USA
| | - Nicholas Antos
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Philip M Farrell
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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11
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McGarry ME, Ren CL, Wu R, Farrell PM, McColley SA. Detection of disease-causing CFTR variants in state newborn screening programs. Pediatr Pulmonol 2023; 58:465-474. [PMID: 36237137 PMCID: PMC9870974 DOI: 10.1002/ppul.26209] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/29/2022] [Accepted: 10/12/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Newborn screening (NBS) algorithms for cystic fibrosis (CF) vary in the United State of America and include different cystic fibrosis transmembrane conductance regulator (CFTR) variants. CFTR variant distribution varies among racial and ethnic groups. OBJECTIVE Our objectives were to identify differences in detection rate by race and ethnicity for CFTR variant panels, identify each US state detection rate for CFTR variant panels, and describe the rate of false-negative NBS and delayed diagnoses by race and ethnicity. METHODS This is a cross-sectional analysis of the detection rate of at least 1 CFTR variant for seven panels by race and ethnicity in genotyped people with CF (PwCF) or CFTR-related metabolic syndrome (CRMS)/CFTR-related disorders in CF Foundation Patient Registry (CFFPR) in 2020. We estimated the case detection rate of CFTR variant panels by applying the detection rate to Census data. Using data from CFFPR, we compared the rate of delayed diagnosis or false-negative NBS by race and ethnicity. RESULTS For all panels, detection of at least 1 CFTR variant was highest in non-Hispanic White PwCF (87.5%-97.0%), and lowest in Black, Asian, and Hispanic PwCF (41.9%-93.1%). Detection of at least 1 CFTR variant was lowest in Black and Asian people with CRMS/CFTR-related disorders (48.4%-64.8%). States with increased racial and ethnic diversity have lower detection rates for all panels. Overall, 3.8% PwCF had a false-negative NBS and 11.8% had a delayed diagnosis; Black, Hispanic, and mixed-race PwCF were overrepresented. CONCLUSION CFTR variant panels have lower detection rates in minoritized racial and ethnic groups leading to false-negative NBS, delayed diagnosis, and likely health disparities.
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Affiliation(s)
- Meghan E McGarry
- Department of Pediatrics, University of California, San Francisco, California, USA
| | - Clement L Ren
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Runyu Wu
- Cystic Fibrosis Foundation, Bethesda, Maryland, USA
| | - Philip M Farrell
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Susanna A McColley
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Farrell MH, Mooney KE, Laxova A, Farrell PM. Parental Preferences about Policy Options Regarding Disclosure of Incidental Genetic Findings in Newborn Screening: Using Videos and the Internet to Educate and Obtain Input. Int J Neonatal Screen 2022; 8:ijns8040054. [PMID: 36278624 PMCID: PMC9590039 DOI: 10.3390/ijns8040054] [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: 08/22/2022] [Revised: 09/16/2022] [Accepted: 09/17/2022] [Indexed: 11/16/2022] Open
Abstract
Our objective was to develop and test a new approach to obtaining parental policy guidance about disclosure of incidental findings of newborn screening for cystic fibrosis (CF), including heterozygote carrier status and the conditions known as CFTR-related metabolic syndrome (CRMS) and/or cystic fibrosis screen positive inconclusive diagnosis, CFSPID. The participants were parents of infants up to 6 months old recruited from maternity hospitals/clinics, parent education classes and stores selling baby products. Data were collected using an anonymous, one-time Internet-based survey. The survey introduced two scenarios using novel, animated videos. Parents were asked to rank three potential disclosure policies-Fully Informed, Parents Decide, and Withholding Information. Regarding disclosure of information about Mild X (analogous to CRMS/CFSPID), 57% of respondents ranked Parents Decide as their top choice, while another 41% ranked the Fully Informed policy first. Similarly, when considering disclosure of information about Disease X (CF) carrier status, 50% and 43% gave top rankings to the Fully Informed and Parents Decide policies, respectively. Less than 8% ranked the Withholding Information policy first in either scenario. Data from value comparisons suggested that parents believed knowing everything was very important even if they became distressed. Likewise, parents preferred autonomy even if they became distressed. However, when there might not be enough time to learn everything, parents showed a slight preference for deferring decision-making. Because most parents strongly preferred the policies of full disclosure or making the decision, rather than the withholding option for NBS results, these results can inform disclosure policies in NBS programs, especially as next-generation sequencing increases incidental findings.
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Affiliation(s)
- Michael H. Farrell
- Departments of Internal Medicine and Pediatrics, University of Minnesota Medical School, Minneapolis, MN 55455, USA
| | - Katherine E. Mooney
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA
| | - Anita Laxova
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA
| | - Philip M. Farrell
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, CSC Room K4/948, 600 Highland Avenue, Madison, WI 53792, USA
- Correspondence: ; Tel.: +1-608-345-2308; Fax: +1-608-263-2820
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Savant AP. Cystic fibrosis year in review 2021. Pediatr Pulmonol 2022; 57:1590-1599. [PMID: 35501666 DOI: 10.1002/ppul.25948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/13/2022] [Accepted: 04/28/2022] [Indexed: 11/06/2022]
Abstract
People with cystic fibrosis (CF) have an amazing outlook with the treatment availability of highly effective modulators. Unfortunately, not all people with CF are eligible for modulators leading to continued pulmonary exacerbations and advanced lung disease. Additionally, optimizing diagnosis and evaluation for CF in the newborn period continues to be an area of focus for research. This review article will work to cover articles published in 2021 with high clinical relevance related to the above topics; however, due to the extensive body of research published, this review will not be comprehensive.
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Affiliation(s)
- Adrienne P Savant
- Department of Pediatrics, Children's Hospital of New Orleans, New Orleans, Louisiana, USA.,Department of Pediatrics, Tulane University, New Orleans, Louisiana, USA
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Veldman A, Kiewiet MBG, Heiner-Fokkema MR, Nelen MR, Sinke RJ, Sikkema-Raddatz B, Voorhoeve E, Westra D, Dollé MET, Schielen PCJI, van Spronsen FJ. Towards Next-Generation Sequencing (NGS)-Based Newborn Screening: A Technical Study to Prepare for the Challenges Ahead. Int J Neonatal Screen 2022; 8:ijns8010017. [PMID: 35323196 PMCID: PMC8949100 DOI: 10.3390/ijns8010017] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 01/28/2022] [Accepted: 02/08/2022] [Indexed: 01/27/2023] Open
Abstract
Newborn screening (NBS) aims to identify neonates with severe conditions for whom immediate treatment is required. Currently, a biochemistry-first approach is used to identify these disorders, which are predominantly inherited meta1bolic disorders (IMD). Next-generation sequencing (NGS) is expected to have some advantages over the current approach, for example the ability to detect IMDs that meet all screening criteria but lack an identifiable biochemical footprint. We have now designed a technical study to explore the use of NGS techniques as a first-tier approach in NBS. Here, we describe the aim and set-up of the NGS-first for the NBS (NGSf4NBS) project, which will proceed in three steps. In Step 1, we will identify IMDs eligible for NGS-first testing, based on treatability. In Step 2, we will investigate the feasibility, limitations and comparability of different technical NGS approaches and analysis workflows for NBS, eventually aiming to develop a rapid NGS-based workflow. Finally, in Step 3, we will prepare for the incorporation of this workflow into the existing Dutch NBS program and propose a protocol for referral of a child after a positive NGS test result. The results of this study will be the basis for an additional analytical route within NBS that will be further studied for its applicability within the NBS program, e.g., regarding the ethical, legal, financial and social implications.
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Affiliation(s)
- Abigail Veldman
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands;
- Correspondence: (A.V.); (M.B.G.K.)
| | - Mensiena B. G. Kiewiet
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands;
- Department of Genetics, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (R.J.S.); (B.S.-R.)
- Correspondence: (A.V.); (M.B.G.K.)
| | - Margaretha Rebecca Heiner-Fokkema
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands;
| | - Marcel R. Nelen
- Department of Human Genetics, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands; (M.R.N.); (D.W.)
| | - Richard J. Sinke
- Department of Genetics, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (R.J.S.); (B.S.-R.)
| | - Birgit Sikkema-Raddatz
- Department of Genetics, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (R.J.S.); (B.S.-R.)
| | - Els Voorhoeve
- Centre for Health Protection, National Institute for Public Health and the Environment, 3720 BA Bilthoven, The Netherlands; (E.V.); (M.E.T.D.)
| | - Dineke Westra
- Department of Human Genetics, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands; (M.R.N.); (D.W.)
| | - Martijn E. T. Dollé
- Centre for Health Protection, National Institute for Public Health and the Environment, 3720 BA Bilthoven, The Netherlands; (E.V.); (M.E.T.D.)
| | - Peter C. J. I. Schielen
- Centre for Population Screening, National Institute for Public Health and the Environment, 3720 BA Bilthoven, The Netherlands;
| | - Francjan J. van Spronsen
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands;
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