“Take off,” my son says as he shakes his vegetable-laden fork.
I try a persuasive argument geared toward toddler interests. “You like broccoli trees. Dinosaurs like to eat trees – grrr – yummy!”
The game isn’t working today.
Because I want him to be healthy, I try hard to get my son to at least taste his vegetables. As parents, we face many challenges as we work to raise healthy, happy children – a job that starts well before the picky toddler stage. Shortly after his birth, my son was screened for 28 life-threatening disorders with a simple heel stick (he’s in the photo at the top of our July 2011 issue).
We recently celebrated the addition of SCID to our newborn screening panel, bringing the total to 29 screened disorders. Read about this important addition in the article “DSHS Laboratory Celebrates New Life-Saving Test for Newborns.”
Outbreaks sometimes happen in surprising ways. Read the article on “DSHS Laboratory Aids in Fungal Meningitis Outbreak” to see how fungi infected healthy individuals from an unexpected source and learn how the outbreak was quickly investigated and contained.
I am a big proponent of vaccinations. I have a lot to say on the subject, but I’ll try to keep it brief here and point out that this is another way to protect everyone – from your children to the public. Disease prevention via vaccinations is preferred over having to treat disease symptoms, which can have a significant impact on your health and that of those around you. Recently, the DSHS celebrated our successful vaccination program; this is touched on in "Celebrating Immunizations." (Watch for a more in-depth article in an upcoming issue.) If you haven’t already done so, resolve to make 2013 a healthier and happier year by updating your vaccinations now.
by Jimi Ripley-Black
On November 30, 2012, the DSHS Laboratory celebrated the addition of severe combined immunodeficiency (SCID) to the list of diseases that all newborns in Texas are screened for at birth. This brings the total to 29 disorders screened by the Newborn Screening (NBS) Laboratory using a simple heel stick.
The ribbon-cutting ceremony, marking the opening of the new SCID screening laboratory, was hosted by Laboratory Director, Grace Kubin, Ph.D., Laboratory Operations Unit Director, Susan Tanksley, Ph.D., Biochemistry and Genetics Branch Manager, Rachel Lee, Ph.D., Newborn Screening Unit Manager, David Martinez, and Medical Director for NBS and Genetics, Dr. Debra Freedenberg. The ceremony also commemorated the work of SCID screening advocate and mother Jennifer Garcia who cut the ribbon to the new laboratory.
Garcia joined NBS Laboratory and Clinical Care Coordination managers and staff in celebration as the first NBS dried blood spot to be tested for SCID was punched. She delivered remarks in memory of her son Cameron Garcia who died of SCID in March 2011. “I was recently asked what does the addition of SCID screening mean to me,” she said. “I would say that it personally gives me peace. Peace in my heart that Cameron’s life, as well as the life of all other SCID angels, truly had a purpose to get us to this amazing day.” Garcia then shared Jeremiah 29:11 from which she garners “…hope for the families whose lives will forever be changed when their baby is identified with SCID. I am hopeful that now these babies will be given an opportunity for their best chance at a future.”
Garcia’s advocacy was a key factor in raising awareness of the rare disease. She brought a photo of her son Cameron that remains in the SCID testing laboratory. Eight full-time Laboratory employees joined the Newborn DNA Analysis Group as part of the SCID Screening Team.
SCID is a group of genetic disorders that causes profound defects of the immune system, the body’s line of defense against all types of infections. SCID is one of the most critical immune system problems and occurs in an estimated one in 40,000 to one in 100,000 newborns. If it is not treated, most affected infants die within the first year of life. The SCID screening test uses real-time polymerase chain reaction (RT-PCR) to detect the presence of T-cell receptor excision circles (TRECs) in the DNA eluates of dried blood spots.
The DSHS NBS Laboratory tests about 750,000 specimens per year, making it the largest newborn screening program in the nation. The blood to be tested is drawn by a simple heel stick within 48 hours of birth and again at one to two weeks of age. The screening provides an opportunity to detect medical conditions that, if not addressed early, would cause serious problems like developmental delays, major illness or death.
Screening for SCID began on December 1, 2012. For more information on the addition of SCID to the NBS panel, please read the July 2012 issue of The Laboratorian.
by Jimi Ripley-Black
On September 18, 2012, an epidemiologist at the Tennessee Department of Health received an e-mail that started an investigation into a case of fungal meningitis and stroke. The man’s immune system was normal. His only risk factor for the infection was the spinal injection of a steroid.
Because of the rarity of fungal meningitis, the epidemiologist immediately began what became a national investigation. The investigation has now identified 656 cases, including 39 deaths, from a fungus so unusual that it is not in medical textbooks. The fungus was transmitted through injections of a contaminated steroid drug prepared by the New England Compounding Center (NECC) in Framingham, Massachusetts.
There have been two cases in Texas linked to the outbreak – both with meningitis – though there are no associated deaths in Texas. The DSHS Laboratory participated by advising health care personnel on what types of specimens to collect and facilitated shipping the specimens to the CDC for further analysis. However, there were no positive results from the specimens that were sent to the CDC from the DSHS Laboratory.
Two healthcare facilities in the Dallas-Ft. Worth area received many of the contaminated products. More than 100 North Texans were treated with the steroid, and all have been notified by telephone and certified letter that they received an injection from the medication involved in the nationwide meningitis outbreak.
The Centers for Disease Control and Prevention (CDC) in Atlanta continues to work closely with state public health departments in response to the multi-state outbreak of fungal meningitis and other infections among patients exposed to contaminated steroids – specifically methylprednisolone acetate (MPA) – from one of three lots distributed by NECC. Nineteen states are involved in the outbreak as of December 28, 2012.
Since early October 2012, CDC has advised clinicians to closely monitor and evaluate patients who received injections of contaminated MPA from NECC. A substantial portion of patients have developed a localized spinal infection, including epidural abscess, phlegmon, arachnoiditis, discitis, or vertebral osteomyelitis following exposure to contaminated injections from NECC. Investigation is also being done into fungal meningitis and other infections in a peripheral joint, such as a knee, shoulder or ankle. Since December 3, 2012, states have reported to CDC a total of 116 new cases, most of which are spinal/paraspinal infections. The predominant fungus identified in patients continues to be Exserohilum rostratum. One patient – the index case – had a laboratory-confirmed Aspergillus fumigatus infection. One patient had a laboratory-confirmed fungal knee infection.
On September 26, 2012, the Tennessee cases led the NECC to stop producing and shipping the steroid. On October 6, 2012, NECC voluntarily recalled all products compounded at and distributed from its facility in Framingham, Massachusetts. On October 31, 2012, The U.S. Food and Drug Administration (FDA) announced that Ameridose, LLC, based in Westborough, Mass., voluntarily recalled all of its unexpired products in circulation. FDA continues to provide updates for NECC customers, healthcare professionals and patients on its Fungal Meningitis Outbreak website.
Though hospitals and clinics often detect the initial cases in outbreak situations, only health departments and other government agencies have the ability and authority to track down additional cases to document disease outbreaks and warn those at risk. The national surveillance system for outbreaks of infectious and other communicable diseases relies on reports that physicians are required to send to local and state health departments, which are then relayed to the CDC. At the federal agency in Atlanta, epidemiologists identify outbreaks by studying trends.
CDC's Fungus Reference Laboratory has the capacity and technology to examine fungal isolates under the microscope and to confirm their identification using DNA sequencing methods. CDC and some of the states involved are testing tissue and fluid samples from patients with probable or confirmed fungal infection. As of December 7, 2012, the predominant fungus identified in patients and confirmed in the CDC laboratory continues to be Exserohilum rostratum.
Tests at CDC and FDA laboratories on the preservative-free MPA vials have confirmed the presence of the same fungus, Exserohilum rostratum, in unopened vials from two of the three recalled lots. Testing on the third lot of preservative-free MPA is ongoing. These laboratory test results strengthen the link between preservative-free MPA vials and the outbreak. The fungi found in both patients and in recalled vials are common in the environment but were not recognized as a cause of meningitis before this outbreak.
by Elizabeth Delamater, Ph.D.
The Texas Department of State Health Services (DSHS) recognizes the importance of keeping employees healthy so that they can respond to public health needs. Part of this initiative is the annual Laboratory flu shot clinic for employees. In October 2012, a record-breaking 220 shots were administered to laboratorians.
This accomplishment continues the work recognized at a DSHS immunization celebration hosted by DSHS Commissioner Dr. David L. Lakey. Special focus is on childhood immunizations, where Texas currently ranks as the eleventh most immunized state in the nation, with a rate of 90 percent according to survey results by the U.S. Centers for Disease Control and Prevention (CDC). The celebration marks continued efforts by the Texas Immunization Program, as illustrated by a 2009 award from the CDC for the most improved state and city/county. This overall improvement trend has continued since 2002 when the Texas immunizations rate was 65 percent.
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