04.14.2018

Guide to Laboratory Services: Newborn Screening

Arizona Department of Health Services Bureau of State Laboratory Services

250 North 17th Avenue Phoenix, Arizona 85007

(602) 542-1188

04.14.2018

Daniel M. Lavine, M.D. Laboratory Director

Victor Waddell Ph.D.

Bureau Chief

Ward B. Jacox Assistant Bureau Chief

04.14.2018

Table of Contents Table of Contents .............................................................................................................................................. 2

General Information.......................................................................................................................................... 1

Arizona State Public Health Laboratory Contact Information ................................................................... 2

Core Functions and Capabilities of State Public Health Laboratories ....................................................... 3

Newborn Screening Services ............................................................................................................................ 4

Specimen Collection .......................................................................................................................................... 6

Shipment of Specimens ..................................................................................................................................... 8

Specimen Rejection Policy ................................................................................................................................ 9

Reporting and Interpretation of Results ....................................................................................................... 10

Sample Submission Guidelines ...................................................................................................................... 12

Requesting Collection Kits and Mailing Containers ................................................................................... 13

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General Information

Bureau Chief, Laboratory Services Victor Waddell, Ph.D. Director, Laboratory Services Daniel M. Lavine, M.D. Assistant Bureau Chief Ward B. Jacox Hours of Operation: 8:00 am to 5:00 pm Monday through Friday. Sample receipt services

available on Saturdays (9:00 am to 4:30 pm). Annual Holiday Schedule: Laboratory Services observes all state recognized holidays. Location: 250 North 17th Avenue, Phoenix, Arizona 85007 Telephone Number: (602) 542-1188 WATTS Line: (800) 525-8915 Fax Number: (602) 542-0760 Emergency Phone (Weekends/After Hours): (480) 303-1676

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Arizona State Public Health Laboratory Contact Information

Section Supervisor/Coordinator Telephone Number

Receiving /Shipping

Jennifer Elston jennifer.elston@azdhs.gov

(602) 542-1190

Newborn Screening Laboratory

Sonal Bhakta sonal.bhakta@azdhs.gov

(602) 364-0722

Newborn Screening Demographics

Yvonne Carroll yvonne.carroll@azdhs.gov

(602) 364-1468

Newborn Screening Follow-Up

Fran Altmaier fran.altmaier@azdhs.gov

(602) 364-1814

Newborn Screening Education/Quality Improvement

Sondi Aponte NBSeducation@azdhs.gov

(602) 364-1642

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Core Functions and Capabilities of State Public Health Laboratories State public health laboratories face the broad challenge of working towards prevention and control of disease and improvement of health. To function in this capacity, the public health laboratories provide population surveillance or screening for conditions of interest to the public health community. This includes screening for inherited genetic disorders. The public health laboratories also perform testing to meet the specific program needs of the public health agencies. The goals of the Arizona Office of Newborn Screening are:

1. To identify newborns with certain disorders and assist families of affected infants so that they receive appropriate and timely treatment to prevent or delay serious medical problems.

2. To identify possible hearing loss before one month of age and link families with appropriate assessment and intervention.

3. To ensure that all newborns referred for a follow-up hearing screen prior to discharge return for an outpatient screen and receive appropriate assessment by three months of age and intervention by six months of age.

For most types of genetic or metabolic disease, early diagnosis and treatment are critical. Although babies born with these disorders may appear to be normal at birth, with time the disorder may have a devastating or lethal effect on the infant's health and development. Early screening, detection, and treatment of these disorders can, in many cases, result in normal growth and development. For most of these disorders, the incidence in the population is rare, but the potential for devastating consequences and the high costs of treating undiagnosed infants who do have the disorders is thought to justify mass screening. The purpose of this manual is to provide a ready reference to our clients and to assist them in obtaining laboratory services as efficiently as possible. Charts are provided for quick reference and more detailed information is available by test name in each section of the manual. This manual can be downloaded or viewed at http://www.aznewborn.com or http://www.azdhs.gov/lab/shipping-receiving.htm

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Newborn Screening Services The Arizona State Public Health Laboratory (ASPHL) serves as the laboratory to provide testing services for the Arizona Newborn Screening Program. The ASPHL receives all newborn screening specimens for the state of Arizona, including some tribes, and conducts initial testing for twenty-nine disorders. These include conditions related to the endocrine system, amino acid metabolism, fatty acid oxidation, organic acid metabolism, and other disorders of metabolism, hemoglobin production, and cystic fibrosis. The twenty-nine disorders screened for by ASPHL include the following:

Endocrine:

Congenital hypothyroidism (CH) Congenital adrenal hyperplasia (CAH)

Amino Acid Metabolism Disorders:

Phenylketonuria (PKU)

Maple syrup urine disease (MSUD) Homocystinuria (HCY)

Citrullinemia type 1 (CIT I) Tyrosinemia type I (TYR I)

Argininosuccinic acidemia (ASA)

Fatty Acid Oxidation Disorders:

Medium chain acyl-CoA dehydrogenase deficiency (MCAD) Very long-chain acyl-CoA dehydrogenase deficiency (VLCAD)

Long-chain L-3-OH acyl-CoA dehydrogenase deficiency (LCHAD) Trifunctional protein deficiency (TFP)

Carnitine uptake defect (CUD)

Organic Acid Disorders:

Isovaleric acidemia (IVA) Glutaric acidemia type I (GA1)

3-Hydroxy-3-Methylglutaric Aciduria (HMG) Multiple carboxylase deficiency (MCD)

Methylmalonic acidemia (Cobalamin defects) (Cbl A,B) Methylmalonic acidemia (mutase deficiency) (MUT)

3-Methylcrotonyl-CoA carboxylase deficiency (3-MCC) Propionic acidemia (PROP)

Beta-ketothiolase deficiency (BKT)

Hemoglobin Disorders:

Hb S/Beta-thalassemia (S, βTh) Hb S/C disease (Hb S/C)

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Sickle cell anemia (Hb SS)

Other Disorders:

Biotinidase deficiency (BIOT) Galactosemia (GALT) Cystic Fibrosis (CF)

Severe Combined Immunodeficiency (SCID) Screening for hearing loss and Critical Congenital Heart Defects is also part of the newborn screen, but this is not performed by the ASPHL.

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Specimen Collection Additional information can be found at http://azdhs.gov/preparedness/state-laboratory/newborn-screening/index.php#testing-collection The ASPHL has developed two-specimen collection kits listed below:

Linked Kit Use of the Linked Kit allows for linkage of the first and second Newborn Screen Specimens. Names of newborn infants frequently change during the first weeks of life. The linked kits allow better identification of infants. These paired kits have a common collection kit number, which is used to link first and second specimens collected from a single infant. The first bloodspot card of the kit is used to collect a heel-stick specimen at the hospital or birthing institution prior to the baby’s discharge. The second bloodspot card of the linked kit is sent home with the mother for use by the baby’s Primary Care Physician at the first well-care visit. Supplemental Kit The Supplemental Kit is used in situations when the linked kit is lost or otherwise unavailable, to collect a sample for a repeat testing of a previous positive result, or for the repeat testing of an unsatisfactory specimen. They are routinely used at commercial laboratories, at physicians’ offices and by midwives.

Regardless of the specimen collection kit used, all infants born in Arizona are required by law to have a Newborn Screen ordered. It is the responsibility of the birthing institution to ensure that a first screen specimen is collected ideally between 24-36 hours but no later than 72 hours, or prior to discharge. The state of Arizona also mandates the collection of second screen specimens for all infants born in Arizona. The second screen specimen should be collected between 5 and 10 days after the birth of the infant. To order specimen collection kits from the ASPHL, please visit the Shipping and Receiving Department website at http://www.azdhs.gov/preparedness/state-laboratory/#shipping-receiving and submit electronically to labreceiving@azdhs.gov or print and fax to (602) 364-0758. The following outlines the procedure for Heel Stick specimen collection: Check the expiration date on the bloodspot card before collecting the sample.

1. Warm the infant’s foot for approximately 3 minutes with a warm, moist towel or foot warmer (heated to a temperature no higher than 42 °C) to increase the blood flow. Hold the foot in a position which increases venous pressure (lower than the heart so that blood will pool in the heel).

2. Disinfect the skin with an alcohol pad (70% isopropanol) and dry with sterile gauze, sterile cotton ball, or air dry. Avoid using disinfectants containing anesthetics (e.g. Benzocaine) as they can affect results.

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3. Puncture the skin on the heel using a sterile lancet or automated lancet device with a tip no longer than 2.4 mm. A longer point could pierce the heel bone. Use the most medial or lateral portion of the plantar surface of the heel. Do not use previous puncture sites or the curvature of the heel. Do not perform skin punctures on the central area of the infant’s foot. This may result in injury to the nerves, tendons or cartilage. Wipe away and discard the first drop of blood (using sterile gauze), since it may be contaminated with disinfectant or tissue fluids. Note: In small premature infants the heel bone may be no more than 2.0 mm beneath the plantar heel skin surface. Puncturing deeper than 2.0 mm may be excessive and a lancet length of 1.75 mm or less is recommended to prevent bone damage.

4. Allow the second drop of blood to form by spontaneous free flow of blood. CAUTION: Milking or squeezing the heel at the site of the puncture may cause hemolysis of the specimen or a mixture of tissue fluids with the specimen. This would be cause for rejection of the Newborn Screening specimen.

5. Touch the drop of blood to the center of the first filter paper circle. The paper must not be pressed against the puncture site on the heel. Fill the circle with the single application of the filter paper to the heel. Apply blood to one side of the filter paper only. After filling the first circle, proceed with filling the remaining circles. It is important to ensure that the circles are completely filled. Both sides of the filter paper should be examined to ensure the blood has uniformly penetrated and saturated the paper.

6. Air-dry the filter paper at room temperature (15 °C to 22 °C) in a horizontal position away from direct sunlight for at least 3 hours.

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Shipment of Specimens Ensure that all patient demographic information has been filled out completely on the bloodspot card top sheet before specimen collection. Specimens must be completely dry before insertion into a mailing envelope. For all College of American Pathologists (CAP) regulated collection laboratories, a packing list of all samples being submitted must be sent with each shipment of samples that is submitted to ASPHL.

This packing list must include each of the following items:

1. Submitter name

2. Name and phone number of contact

3. Date the list is generated (date sent)

4. Baby first and last name, and Medical Record Number

5. Baby Date of Birth

6. Courier tracking number; if applicable

The additional requirements for the shipment of the bloodspot cards are as follows:

1. Bloodspot cards must be organized in the same order that they are listed on the packing list (alphabetical or otherwise).

2. Bloodspot cards must be rubber-banded together (no tape or staples).

3. Do not package the dried blood spot specimens inside a sealed plastic bag. The lack of air exchange inside the sealed plastic bag may cause heat buildup, moisture accumulation, and/or chemical leaks from the plastic, which can damage specimen integrity.

ASPHL will ensure that all samples that are included on the packing lists received are accounted for. If there are any discrepancies between the packing list and the samples included in a shipment, ASPHL will contact the submitter to investigate. Within 24 hours of collection, the specimens should either be sent by courier (Specialized Delivery Services (SDS), FedEx, or other) or mailed to the ASPHL in Phoenix. The ASPHL should receive specimens within 3 days of collection to allow for rapid detection of these serious disorders. Specimens not received within 14 days of collection will be rejected as “Unsatisfactory: Specimen too old upon receipt.” See the Sample Submission Guidelines section for submission address and other information.

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Specimen Rejection Policy Specimens are rejected as unsatisfactory to test for the following reasons:

• Insufficient Specimen (UIS) – The specimen is considered (UIS) if there is insufficient specimen to punch the blood spots for the laboratory tests.

• Specimen Contaminated (USC) – Gross contamination with alcohol, water, or other foreign substance.

• Serum or Tissue Fluid Separation (UST) – Caused from squeezing or milking the puncture site during specimen collection.

• Multiple Specimen Applications (UMA) – Application of successive drops of blood to the same printed circle.

• Circles Torn or Scratched (UTS) – A result of improper application of the sample through use of capillary tubes.

• Specimen Too Old Upon Receipt (UTO) – Specimens must be received within 14 days of collection.

• No Sample Collected (UNO) – No collection was made.

• No Specimen Information (UNI) – Specimen was not properly identified to ensure the integrity of the specimen.

• Clotted or Caked Blood (UCC) – Blood clots are dried on collection card.

• Age of Infant Too Old to Test (UIO) – Age of infant must be less than 1 year of age for testing to be performed.

• Incomplete Saturation (UNS) – Circles on collection card are filled in but the blood did not saturate through to the back of the card.

• Parent Refused Test (UPR) – Parent wishes to decline testing.

• Results Inconsistent (URS) – After testing specimen several times, results vary and are not reliable.

• Specimen Detached From Form (USD) – The filter paper portion of collection card was detached from the patient information and either taped or stapled together by the submitting agency.

• Specimen Collection Cards Expired (UCE) – The collection card used to collect specimen is expired; date of expiration on top side of filter paper card.

• Laboratory Error (ULA) – An error was detected by the collecting laboratory. This code is used only if an error was communicated by the collecting laboratory to ASPHL Newborn Screening Department.

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Reporting and Interpretation of Results Normal laboratory results are reported as “Normal”. Abnormal and high/critical results are reported as “Abnormal”, with quantitation of test values provided when applicable. Other non-normal results may be flagged and reported as Quantity Not Sufficient (QNS), Unsatisfactory (UNSAT), Borderline, TPN (Total Parenteral Nutrition), or Equivocal. All non-normal results are sent to the Newborn Screening Follow-up Section. The Follow-Up section is responsible for tracking and case management of presumptive positive, incomplete, or inconclusive results. Results that are determined to require emergency notification are phoned by laboratory staff directly to the Arizona Newborn Screening Follow-up Section immediately for follow up. Laboratory test result mailers are generated within 24 hours of completion of laboratory testing and are mailed to the submitting agency and the physician of record. An EXAMPLE of a Disorders and Reference Range summary chart is shown on the next page. Always refer to the website below for the most current Disorders and Reference Range summary chart. http://azdhs.gov/preparedness/state-laboratory/newborn-screening/index.php#testing-abnormal-results

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Arizona Department of Health Services Endocrine Disorders Analytes Reference Ranges Other Disorders Analytes Reference Ranges

Hypothyroidism (CH) TSH 1st Screen 2nd Screen

< 30 µU/mL < 20 µU/mL

Hemoglobinopathies (Hb) Hb FA Normal

Congenital Adrenal Hyperplasia (CAH)

17-OHP Birth weight Biotinidase Deficiency (BIOT) Biotinidase Enzyme Present

≤ 1250 g < 135.0 ng/mL Galactosemia (GALT) GALT Abnormal ≤ 2.4 U/g Hb 1251 – 1749 g < 90.0 ng/mL SCID TREC copies ≥ 19 copies/µL

1750 – 2499 g < 65.0 ng/mL Cystic Fibrosis (CF) IRT < 65 ng/mL > 2500 g < 50.0 ng/mL (Panel of 23 mutations to the CFTR gene) DNA No mutations detected

Amino Acid Disorders Analytes (Markers) Reference Range

Phenylketonuria (PKU) Phe Phe/Tyr

< 170 µmol/L < 1.8

Maple syrup urine disease (MSUD)

Xle < 96 hrs ≥ 96 hrs

< 400 µmol/L < 480 µmol/L

Xle/Phe

< 96 hrs ≥ 96 hrs

< 4 < 5

Homocystinuria (HCY) Met Met/Phe

< 85 µmol/L < 1

Citrullinemia type I (CIT-I) & Argininosuccinic acidemia (ASA)

Cit < 121 hrs ≥ 121 hrs

< 50 µmol/L < 65 µmol/L

Cit/Arg < 121 hrs ≥ 121 hrs

< 2.5 < 3.5

Tyrosinemia type I (TYR I) SUAC < 1.4 µmol/L

Organic Acidemia Disorders

Isovaleric acidemia (IVA) C5 < 0.71 µmol/L C5/C3 < 0.34

Glutaric acidemia type I (GA-I) C5DC_C6OH < 0.50 µmol/L C5DC_C6OH/C16 < 0.25

Methylmalonic acidemia (Cbl A,B/MUT) & Propionic acidemia (PROP)

C3 < 6.00 µmol/L C3/C2 < 0.23

3-Methylcrotonyl-CoA carboxylase deficiency (3MCC), 3-Hydroxy-3-methylglutaric acidemia (HMG) & Multiple carboxylase deficiency (MCD)

C5-OH_C4DC < 0.8 µmol/L

Beta-ketothiolase deficiency (BKT) C5:1 < 0.1 µmol/L

Fatty Acid Oxidation Disorders

Carnitine uptake defect (CUD) C0 (Low) C3+C16 C2 (Low)

> 5 µmol/L > 1.5 µmol/L > 6 µmol/L

Medium-chain acyl-CoA dehydrogenase deficiency (MCAD) C8 < 0.45 µmol/L Very long-chain acyl-CoA dehydrogenase deficiency (VLCAD) C14:1 < 0.68 µmol/L Long-chain L-3-hydroxy acyl-CoA dehydrogenase deficiency (LCHAD) & Trifunctional protein deficiency (TFP)

C16-OH

< 0.09 µmol/L

CCHD ≥ 95% in RH or Foot and ≤ 3% difference between RH or Foot

Pediatric Specialists for Newborn Screening Consultation

Endocrinology Phoenix Children’s Hospital, Dr. Reeti Chawla Division of Pediatric Endocrinology Banner University Medical Center Tucson, Dr. Mark Wheeler Division of Pediatric Endocrinology

(602) 933-0935 (520) 626-6077

Cystic Fibrosis Centers Banner University Medical Center Tucson, Dr. Wayne Morgan Department of Pediatrics, Pulmonary Division Phoenix Children’s Hospital, Dana Valetta, MS, RN, CPNP AC/PC Division of Pediatric Pulmonology

(520) 626-7780 (602) 933-0985

Metabolic Genetics Phoenix Children’s Hospital, Dr. Kirk Aleck, Dr. Phil James

(602) 933-4363

Immunology Phoenix Children’s Hospital, Dr. Holly Miller Immunohematology Clinic Banner University medical Center Tucson, Dr. Michael Daines Division of Pediatric Allergy, Immunology and Rheumatology Revised 8/09/2017

(602) 933-5014 (520) 270-6401

Hematology Phoenix Children’s Hospital, Dr. Sanjay Shah, Dr. Christine Knoll Center for Cancer and Blood Disorders Banner University Medical Center Tucson, Dr. Neha Bhasin Division of Pediatric Hematology/Oncology

(602) 933-0920 (520) 694-3325

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Sample Submission Guidelines Submit all samples to the following location:

Arizona Department of Health Services State Public Health Laboratory

250 N. 17th Ave Phoenix, AZ 85007

(602) 542-1188 Ordering: labreceiving@azdhs.gov Secure: labreceiving@siren.az.gov

All samples and their containers must be identified with the appropriate labels, client, and patient information. Any samples which are leaking and/or not properly identified will be rejected. Newborn Screening Blood Cards Primary and secondary Newborn Screening bloodspot cards being sent for metabolic

disorder testing are considered non-infectious and are exempt from the hazardous material regulations. See the Requesting Collection Kits and Mailing Containers section for requesting screening cards from the ADHS Shipping and Receiving section

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Requesting Collection Kits and Mailing Containers Supplies ordered from the Arizona State Public Health Laboratory are to be used ONLY to submit specimens to the State Laboratory. There are two “Request for Materials” forms currently in use: a Newborn Screening Supplies Request Form and a Request Form for all other supplies available from the ASPHL. Supplies can be requested by mailing, faxing, calling, or emailing the Receiving Section at:

Arizona Department of Health Services Bureau of State Laboratory Services ATTN: Receiving Section 250 North 17th Avenue Phoenix, AZ 85007 Fax: (602) 364-0758 Phone: (602) 542-1190 Email: labreceiving@azdhs.gov

Please request materials before they are required as the expected turn-around time per order is FIVE business days. Most materials do have a limited shelf life; therefore, only order what will be used before the expiration date. Please do not use expired kits or any kits in which the medium has changed characteristics. Dispose of the media properly and order replacement supplies.