Cutoff and Validation-MPS I and Pompe. NewSTEPs National New Disorders Implementation Meeting 6/19/18 Mike Sarzynski Michigan NBS
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1 Cutoff and Validation-MPS I and Pompe NewSTEPs National New Disorders Implementation Meeting 6/19/18 Mike Sarzynski Michigan NBS
2 Michigan LSD Screening Start MI went live with full population MPS I and Pompe screening on 8/7/17 before our validation population study was complete (~6 weeks earlier than planned) This decision was based on the need to begin screening ASAP; NBS card fee for LSD ~2yrs, litigious environment (Flint) Baebies SEEKER 2-Plex Digital Microfluidic Platform After ~10,000 screens, MI set our own cutoffs
3 Population Study Cutoffs 8/7/17-10/4/17 Conservatively used Missouri instrument flag cutoffs (MO using SEEKER 4-plex platform) Sent to Missouri for 2 nd tier risk assessment (MO is a New Disorders learning resource partner state)
4 Population Study Cutoffs 8/7/17-10/4/17 Positive samples reported out based on Missouri 2 nd tier risk assessment Age at Birthweight IDUA GAA MO Risk Assessment Gestation Race/ Collection (weeks) Ethnicity (hours) (grams) MI White Normal MI White Pompe Borderline MI Black Normal MI Black Inconclusive (multiple low enzyme levels) MI Black Normal MI Black MPS I Referral
5 MI Initial Cutoff Analysis MI cutoffs based on 9,437 non-nicu samples tested through 9/6/17 as part of population study as well as confirmed true positive samples (MI clinically identified and partner state samples) Cutoffs were set with a safety factor that encompasses the reproducibility of the assay and # of replicates to reduce the risk of a false negative based on variability
6 MI Initial Cutoff Analysis Cutoffs based on highest affected (as per confirmatory testing) validation patient enzyme level for IDUA or GAA and standard error (SE) and standard deviation (SD) SE: SD / square root (# of replicates) Highest affected IDUA = <LOQ 2.77 μmol/l/hr Highest affected GAA = 6.42 μmol/l/hr
7 MI Initial Cutoff Analysis Instrument Cutoff (repeat)-set 3 SD above highest affected patient enzyme activity Borderline positive-set 3 SE above highest affected patient enzyme activity Strong positive-set 1 SE above highest affected patient enzyme activity
8 MI Initial Cutoff Analysis MI cutoffs set with 3 age bins each for IDUA and GAA Each age bin beyond the first had cutoffs adjusted for the change in median enzyme activity for samples falling within that age bin
9 MI Initial Cutoffs 10/4/17-12/19/17 IDUA μmol/l/hr GAA μmol/l/hr Michigan NBS Baebies SEEKER cutoffs 0-47 hrs hrs 216+ hrs 0-47 hrs hrs 384+ hrs Instrument flag Borderline positive Referral
10 Cutoff Refinement-Mayo MPS I 2 nd Tier Testing Before go-live, no 2 nd tier testing recommended by advisory committee; LSD clinicians did not want 2 nd Tier test making clinical decisions for them Quickly overwhelmed with number of referrals (conservative cutoffs) Subsequent advisory committee guidance to add 2 nd tier testing to decrease referrals Mayo MPS I 2 nd tier Mucopolysaccharidosis Blood Spot (MPSBS) was piloted Nov.-early Dec. 2017
11 Cutoffs 12/19/17-present IDUA μmol/l/hr GAA μmol/l/hr Michigan NBS Baebies SEEKER cutoffs 0-47 hrs hrs 216+ hrs 0-47 hrs hrs 384+ hrs Instrument flag send to Mayo 2 nd tier MPS I or B+ Pompe Referral Positive Mayo MPS I 2 nd tier result
12 Cutoffs Future Iterations Progress in cutoff evaluation and Pompe 2 nd tier testing addition has been slowed by many factors-no LIMS, vacant management positions (unit, section, division) Add Mayo Pompe 2 nd tier testing-pilot study May-June 2018 Include more demographic info (NICU, gestational age, etc.) Goal to drive down the false positive rate (started conservative)
13 MPS I and Pompe Screening Algorithms Initial screen flagged for repeat x2 based on instrument cutoffs Repeat screen x2 result risk assessed based on cutoffs for 3 age bins
14 MPS I Algorithm-Initial Screen
15 MPS I Algorithm-Confirmation ( 47 hrs)
16 Pompe Algorithm-Initial Screen
17 Pompe Algorithm-Confirmation ( 47 hrs)
18 MPS I Reporting 8/7/17-6/7/18 83 Borderline positive MPS I-repeat NBS screen 81 Strong positive MPS I-confirmation testing
19 MPS I Confirmation Testing Results 9 Pseudodeficiency 4 Pseudodeficiency/Variant of unknown significance 2 Carriers/Variant of unknown significance 8 Variants of uncertain significance 1 Carrier 50 Normal confirmatory results 1 Normal result on repeat NBS-case closed 6 Closed on Normal Mayo MPSBS 2 nd tier results
20 MPS I False Positive Rate 164 total B+ and S+ reported MPS I screens 0 Confirmed affected 164 False positive MPS I screens 91,228 Total babies screened 8/7/17-6/7/18 MPS I False positive rate-164/91,228 = 0.18%
21 MPS I False Positive Rate 0% MPS I false positive rate since Mayo MPS I 2 nd tier testing (MPSBS) implemented mid-december 2017 Single MPS I cutoff-all positive screens sent for 2 nd tier testing, only report positive MPS I 2 nd tier results All 2 nd tier results negative, no positive babies referred to follow-up
22 Pompe Reporting 8/7/17-6/7/ Borderline positive Pompe-repeat NBS screen 106 Strong positive Pompe-confirmation testing
23 Pompe Confirmation Testing Results 3 Affected - Late Onset 1 Affected - Unknown Onset-Asymptomatic-parents carriers 1 Pseudodeficiency / Variant of unknown significance 4 Pseudodeficiency 2 Variant of uncertain significance 4 Carrier 74 Normal confirmatory results 1 Deceased 16 Pending confirmation results
24 Pompe False Positive Rate 244 Total B+ and S+ reported Pompe screens 4 Confirmed affected 240 False positive Pompe screens 91,228 Total babies screened 8/7/17-6/7/18 Pompe False positive rate-240/91,228 = 0.26%
25 Pompe False Positive Rate Mayo turn around time for Pompe 2 nd tier testing (PD2T) during pilot study averaging 2 days Advisory committee to decide on Pompe reporting algorithm: Single cutoff-all positive screens sent for 2 nd tier testing B+ 2 nd tier testing; S+ direct referral with concurrent 2 nd tier testing 2 nd tier testing will decrease Pompe false positive rate
26 LSD Overall False Positive Rate 164 false positive MPS I screens 240 false positive Pompe screens 91,228 total babies screened 8/7/17-6/7/18 LSD False positive rate-404/91,228 = 0.44%
27 Inconclusive Reporting 8/7/17-6/7/18 51 Inconclusive (both IDUA and GAA B+ cutoff) 44 Normal results on repeat specimen 6 Pending 1 parent non-compliant with obtaining repeat specimen
28 Questions? Thanks to: MI NBS LSD team Missouri-Patrick Hopkins and Tracy Klug Partner states Georgia, Illinois, Kentucky, Missouri, New York, North Carolina, and Ohio for validation samples Baebies
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