1. DEPARTMENT NAME Imelda Celine Hanson, M.D. Immunology, Allergy and Rheumatology NEWBORN SCREEN FOR SEVERE COMBINED IMMUNE DEFICIENCY AND THE TEXAS CHILDREN’S HOSPITAL BONE MARROW TRANSPLANT EXPERIENCE

2. DEPARTMENT NAME Bullet point field – Font: Calibri, 24pt, Black Second level – Font: 20pt Third level – Font: 16pt Fourth level – Font: 14pt Fifth level – Font: 14pt HEADLINE (UPPERCASE) FONT: CALIBRI BOLD, 32PT, RED

3. DEPARTMENT NAME PRESENTATION OBJECTIVES  History of the Texas Newborn Screen and Severe Combined Immune Deficiency (SCID).  Process of implementing screening for SCID.  Implications of SCID in nursing care of infants.

4. DEPARTMENT NAME PRIMARY IMMUNE DEFICIENCY Immunodeficiency is the result of a diverse group of abnormalities of the immune system resulting primarily in an increased incidence of infection Primary Immunodeficiency Congenital and hereditary Autosomal recessive, X-linked, etc Secondary Immunodeficiency Acquired on a transient or permanent basis Involves either the innate or adaptive immune system or both

5. DEPARTMENT NAME WARNING SIGNS OF IMMUNODEFICIENCY WWW.INFO4PI.ORG 4 or more new episodes of otitis in 1 year 2 or more serious sinus infections in 1 year 2 or more months on antibiotics without resolution 2 or more radiographically proven pneumonia in 1 year Failure to grow (weight and/or height)

6. DEPARTMENT NAME WARNING SIGNS OF IMMUNODEFICIENCY WWW.INFO4PI.ORG Recurrent deep skin or organ abscesses Persistent thrush of mouth, nails, skin IV antibiotics required for infection clearance 2 or more deep-seated infections including bacteremia Family history of PIDD

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8. SEVERE COMBINED IMMUNE DEFICIENCY SCID describes a primary immune deficiency disorder that is associated with profound T cell dysfunction and humoral (antibody) deficiency Over 15 genetic mutations or enzymatic deficiencies have been described in association with SCID Children with SCID appear normal at birth

9. DEPARTMENT NAME SEVERE COMBINED IMMUNE DEFICIENCY Illness typically begins as passively acquired maternal antibody (IgG) wanes between 3 and 6 months of age Early identification is critical to allow for optimal correction of this disorder Diagnosis is a true immune emergency

10. DEPARTMENT NAME OTHER POTENTIAL CLINICAL CLUES *Absent Thymic Shadow on lateral CXR Pneumocystis pneumonia *

11. DEPARTMENT NAME EARLY SCID DIAGNOSIS AFFECTS OUTCOMES Comparison of infant mortality between those groups of neonates who were not tested (n = 138, left) and tested (n = 20, right) for SCID. Testing was performed only if an affected relative's SCID diagnosis had made parents and medical providers aware of the risk. Proportion of deceased infants is shaded in each pie chart.

12. DEPARTMENT NAME EFFECT OF AGE AT TIME OF TRANSPLANTATION ON SURVIVAL 3 3 Buckley, Rebecca H. "The Long Quest for Neonatal Screening for Severe Combined Immunodeficiency." Journal of Allergy and Clinical Immunology 129.3 (2012): 597-604. Web.

13. DEPARTMENT NAME DOES SCID FULFILL NEWBORN SCREENING CRITERIA? Prevalence of the disease (1:100,000 or greater) SCID: 1:66,000 (conservative estimate) Can the disorder be detected by routine physical exam? SCID: No, SCID babies appears normal at birth. Does the disorder have a short asymptomatic period after birth? SCID: Yes, SCID babies can be protected by passive maternal immunity. Does the disease cause serious medical complications? SCID: Yes, universally fatal within the first year of life

14. DEPARTMENT NAME DOES SCID FULFILL NEWBORN SCREENING CRITERIA? Is there potential for successful treatment? SCID: Yes, hematopoietic stem cell transplantation Is there a confirmatory test? SCID: Yes, lymphocyte subpopulation analysis (flow cytometry) Does early intervention lead to better outcome? SCID: Yes! Is there a screening test? SCID: Yes, measurement of TRECs using real-time qPCR

15. DEPARTMENT NAME TESTS CONSIDERED FOR SCID SCREENING PUCK JM. JACI. 2012 MAR; 129(3): 607–616. Lymphocytes CBC and differential white blood count to determine lymphocyes/uL Hospital clinical lab test on liquid cord blood or postnatal blood (heelstick or venous) Costly, decentralized; false negatives for SCID with oligoclonal T cells, elevated B cells or maternal cells Sample could be obtained from Guthrie Card

16. DEPARTMENT NAME TESTS CONSIDERED FOR SCID SCREENING PUCK JM. JACI. 2012 MAR; 129(3): 607–616. Interleukin-7 IL-7 immuno-assay performed by ELISA or other method Stability, purification and assay problems T cell proteins CD3, CD45 Immuno-assay for low CD3 (multiplex) Limited availability; false negatives for maternal or oligoclonal T cells Sample could be obtained from Guthrie Card

17. DEPARTMENT NAME TESTS CONSIDERED FOR SCID SCREENING PUCK JM. JACI. 2012 MAR; 129(3): 607–616. Mutation in SCID gene Performed by DNA sequence determination or custom resequencing array False negatives T cell receptor excision circle Copy number of circular DNA joints; Quantitative PCR on DNA Biomarker for newly produced T cells Sample could be obtained from Guthrie Card

18. DEPARTMENT NAME AUTHORITY FOR CONSIDERATION OF SCID WITH NEWBORN SCREENING? Recommendation for SCID to be added to routine newborn screening panel approved by the Secretary’s Advisory Committee on Heritable Disorders of Newborns and Children in 2010 Subsequently approved by the Secretary of Health and Human Services 10 US States or Territories or Nations currently screen for SCID Texas began newborn screening for SCID December 2012

19. DEPARTMENT NAME US STATES PERFORMING NBS SCID 34 US states currently participate in SCID NBS in the US 10 States and Territories to add SCID NBS in 2015

20. DEPARTMENT NAME SCID NEWBORN SCREENING IN TEXAS BEGUN 12/1/2012 Uses current dried blood spot specimen collection methodology Blood punch performed By use of PCR, DNA amplification occurs to identify a biomarker of naïve T cells (TRECs)

21. DEPARTMENT NAME TIMELINE FOR PERFORMANCE AND REPORTING OF SCID NBS ●Specimen arrives. ●Specimen accessioned. ●Galactosemia & Cystic Fibrosis DNA results are sent to Clinical Care Coordination. ●Result report is printed, sent to mailroom, and available online. ●Specimen punched. ●Data entry begins. ●Testing begins for all disorders except Biotinidase Deficiency (BIOT). ● DNA extraction completed. ●RT-PCR retests completed ● Results for remaining disorders are released, including SCID ● Clinical care coordination contacts provider if have out-of- range results for remaining disorders. ●DNA testing (M-F) for Galactosemia and Cystic Fibrosis, if specimen is out-of-range. Day 1Day 2 Day 4 Day 5Day 3 ●Data entry is completed ●Testing begins for BIOT ●Testing completed for the most time sensitive disorders. ●Clinical Care Coordination contacts provider if have out-of-range results. ●RT-PCR completed. Retests punched and extracted Hemoglobinopathy and MCAD DNA testing performed in weekly batches. Provided by Rachel Lee, Biochemistry & Genetics Branch, DSHS

22. DEPARTMENT NAME Provided by Rachel Lee, Biochemistry & Genetics Branch, DSHS

23. DEPARTMENT NAME REFERRAL TO PEDIATRIC SPECIALISTS FOR ABNORMAL SCID TEST Just as with other NBS programs, DSHS has identified pediatric immunologists in every Region of Texas to counsel physicians who might provide care for children with an abnormal SCID screen. In Region 5/6 (Houston and surrounding areas), immunologists at Texas Children’s Hospital are available to primary care physicians to discuss testing and care plans for patients with abnormal SCID tests.

24. DEPARTMENT NAME SCID SCREENING MARKER: T CELL RECEPTOR EXCISION CIRCLES (TREC) TRECs are pieces of DNA extruded during intrathymic T cell receptor gene rearrangement PCR can identify TRECs by real time PCR of DNA in dried blood spots Absent TRECs suggests profound T cell depletion Identifies most mutations associated with SCID and other T cell deficiencies

25. DEPARTMENT NAME TREC AS A BIOMARKER FOR THYMUS-DERIVED T CELLS Presence of TREC is associated with presence of circulating newly produced naïve T cells from thymus Newborns and infants have the highest number of circulating TRECs 1 TREC/10 T cells Older children and adults have 10 to 100 fewer circulating TRECs 0 TREC is SCID unless proven otherwise

26. DEPARTMENT NAME DIAGNOSIS AND COURSE OF 52 INFANTS WITH PRIMARY TARGET CONDITIONS: SCID AND LEAKY SCID SCID incidence of 1: 58,000 live births Survival 87% of cohort and 92% who received transplant No genetic testing 8% Gene variants Other Rag1 8% Jak3 6% IL-7Rα Chain: 11% IL2 γ Chain: 45% Kwan et al. "Newborn Screening for Severe Combined Immunodeficiency in 11 Screening Programs in the United States." JAMA 312.7 (2014): 729. Web.

27. DEPARTMENT NAME DIAGNOSES OF 411 INFANTS WITH NON-SCID T CELL LYMPHOPENIA IDENTIFIED BY NBS KWAN ET AL. JAMA 2014 Syndromes with T cell impairment (n=136) DiGeorge variants78 Trisomy 2121 Ataxia telangiectasia4 Trisomy 184 CHARGE3 Jacobsen2 CLOVES, ECC, Fryns, Nijmegen breakage, Noonan, Rac2 defect, Renpenning, TAR (each with n=1)8 Not specified10 Cytogenetic abnormalities6 Secondary T cell impairments (n=117) and unspecified lymphopenia (n=117) Cardiac anomalies30 Multiple congenital anomalies23 Loss into third space15 Gastrointestinal anomalies15 Neonatal leukemia4 Not specified30 Preterm birth alone29 Variant SCID12

28. DEPARTMENT NAME MORBIDITY/MORTALITY IN SCID/ T CELL DISORDERS SCID Fatality by 2 years of age without corrective intervention, e.g., HSCT, gene therapy, ERT DiGeorge Syndrome Fatality by 2 years of age without corrective intervention, e.g., thymic transplant, MRD HSCT WAS 13% with cancer risk; poor treatment outcome Ataxia-telangiectasia Cancer risk in affected and heterozygous females

29. DEPARTMENT NAME HOW QUICKLY SHOULD CHILDREN WITH AN ABNORMAL NBS SCID BE REFERRED FOR SPECIALTY ASSESSMENT? Once you are notified of an abnormal NBS SCID screen, immediate referral is recommended, no less than 2 days. The preferred referral physician should be a pediatric immunologist. DSHS can provide primary physicians with a listing of pediatric immunologists across each Region of the State who have expertise and are willing to assess children with abnormal testing. Referrals should conform with local patterns of care access and consider both payer limitations and parental choice.

30. DEPARTMENT NAME SPECIAL CARE PLANS FOR CHILDREN WITH ABNORMAL TRECS WHILE AWAITING SPECIALTY ASSESSMENT Emphasize adequate nutrition Many physicians may consider avoidance of breast feeding to avoid CMV exposure Immediate hospitalization is not typically required for well appearing infants Avoidance of known ill individuals and crowds is important Avoid daycare placement Live viral vaccines should be AVOIDED NO Rotavirus, MMR, Varicella vaccines If blood transfusions are immediately needed Use CMV negative, irradiated blood products

31. DEPARTMENT NAME WHAT TESTS ARE LIKELY TO BE PERFORMED BY SPECIALISTS ON CHILDREN WITH ABNORMAL TREC TESTING AT BIRTH AND 2 WEEKS OF AGE? CBC with differential and platelet count Serum immunoglobulin/antibody levels IgG, IgA, IgM, IgE Lymphocyte subset analysis Special attention to mature T lymphocyte, B lymphocyte and Natural Killer cell markers Lymphocyte proliferation analyses In vitro responses to plant proteins and dependent upon age antigens that the child has been exposed to (diphtheria, tetanus, etc) Imaging is likely to be performed Chest radiograph and others Genetic testing

32. DEPARTMENT NAME DIAGNOSED TX SCID CASES BY NBS DECEMBER 2012 TO JUNE 2015 25 infants with SCID over 2.5 years All expected cases appear to have been identified (6-10/year would predict 15-25) 5/25 expired 560gram infant twin, no option transplant 1 died during work up, no option transplant 1 tested at 7 mos moved to US, died of polio 2 with demise post transplant Infection prior to engraftment GVHD 20/25 transplanted, alive and doing well Since June 2015 to December 2015, 3 additional SCID identified and referred to TCH system All transplanted and engrafted.

33. DEPARTMENT NAME HOW MANY SCID CHILDREN ARE EXPECTED TO BE IDENTIFIED IN TEXAS? With a birth rate of about 350,000/year in Texas, 6-10 children with SCID diagnosis may be detected each year The majority of genetic forms of SCID (>90%) are associated with early lymphopenia and will be detected by the TREC assay X-linked SCID (Bubble Boy SCID) representing >50% of all SCID Autosomal Recessive SCID Enzymatic Deficiencies associated with SCID

34. DEPARTMENT NAME REFERENCES Douek DC et al. Changes in thymic function with age and during the treatment of HIV infection. Nature 1998;396(6712):690-5. Jeffrey Modell Foundation 10 warning signs of immune deficiency. www.info4pi.orgwww.info4pi.org Kwan A, et al. Newborn screening for severe combined immunodeficiency in 11 screening programs in the United States. JAMA 2014;312(4):729-738. Notarangelo LD. Primary immunodeficiencies. JACI 2010;125 (2) Supplement 2:S182-94. Schonland SO, et al. Homeostatic control of T cell generation in neonates. Blood 2003;102(4):1428- 34. Shearer WT, et al. Establishing diganositc criteria for severe combined immunodeficiency disease (SCID), leaky SCID, and Omenn syndrome: the Primary Immune Deficiency Treatment Consortium experience. JACI 2104; 133(4):10-92-8.

35. DEPARTMENT NAME ADDING & OPTIMIZING IMAGES PowerPoint allows you to optimize images to three different PPI (pixels per inch) resolutions depending on how you will be using your presentation. Use the “Compress Pictures” feature (under tools in 2007 and older versions; under picture format in 2011) to select the ideal ppi resolution

36. DEPARTMENT NAME Print (handouts) – 220 ppi – excellent quality on most printers and screens Screen (presentation/most common use) - 150 ppi –Good for web pages and projectors Email – 96 ppi – minimize documents for sharing Images can be optimized throughout the presentation or individually by selecting the “Apply to selected pictures only” feature in the Compress Pictures dialogue box. **Note that the compress pictures format feature will only work on images that have been manually inserted through the insert tab or picture toolbar icon. Compression is not available for images that are dragged and dropped into the presentation.

37. DEPARTMENT NAME ADDING & OPTIMIZING VIDEO **Note: You can preview a clip before you add it to your presentation. In the Clip Art task pane, in the Results box that displays the available clips, move your mouse pointer over the clip's thumbnail, click the arrow that appears, and then click Preview/Properties. In Normal view, click the slide to which you want to add a movie or animated GIF file. On the Insert tab, in the Media Clips group, click the arrow under Movie. Do one of the following: Click Movie from File, locate the folder that contains the file, and then double-click the file that you want to add. Click Movie from Clip Organizer, scroll to find the clip that you want in the Clip Art task pane, and then click it to add it to the slide.

38. DEPARTMENT NAME OPTIMAL VIDEO RESOLUTION 16:9 ASPECT RATIO: 1920×1080 PIXELS

39. DEPARTMENT NAME ADDING CHARTS & GRAPHS To create a new chart, go to INSERT on the main top menu and select CHART. Select the arrow located at the bottom of the menu. When you select CHART, the Datasheet View appears for entry of your table data. Add values by selecting a cell and typing in the value. You can also paste information from another source into a cell. Close the Datasheet window by selecting ESC from your keyboard.

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