- GALT & Biotinidase
- SCID Meeting
- Influenza Training
- 1st Responder Training
- Photo Puzzle
This issue marks five years of publication for The Laboratorian.
In that time, we have sometimes touched on similar themes, but there
is always additional detail to be explored in the marvelously complex
world of laboratory testing. In July 2009, we covered “DNA Analysis for Galactosemia.” The DNA screen is actually second-tier testing for the Newborn Screening Galactosemia and Biotinidase Screening program – our featured Lab Tour area.
Our most recent Newborn Screening test,
implemented in December 2012, checks for Severe Combined Immune
Deficiency (SCID). Read about the “First Annual Texas NBS SCID Pediatric Immunology Consultants Meeting” to learn how we are already soliciting feedback from medical professionals to improve the screening’s effectiveness.
Training is an important part of testing
here at the DSHS Laboratory. In support of testing flu specimens, the
Viral Isolation Team hosted training on influenza testing and
subtyping. This kind of training promotes quick identification of flu
outbreaks – increasing the chance of stopping the identified strains
before they spread. Read “Influenza Detection and Subtyping Workshop” for more details.
Training also promotes effective
response. On June 6, first Responders had an important training
opportunity presented by the DSHS Laboratory Emergency Preparedness
Branch. Eight people participated in the workshop covering biological
and chemical threats, as detailed in “First Responder BioThreat and ChemThreat Training.”
by Jimi Ripley-Black
Did you know?
The Texas Governor's Committee on People with Disabilities created online learning modules to help make Microsoft Office 2010 documents accessible to people with disabilities. You can view these tutorials on the Governor's accessible documents pages.
The Galactosemia (GALT) and Biotinidase
Deficiency Screening Laboratory is tucked into a small area at the end
of the third floor. The team of nine staff tests approximately 2,500
Newborn Screening (NBS) patient samples per test per day, six days a
week, largely by hand. Test results are entered into the Laboratory
Information Management System (LIMS) and checked for accuracy using
computers in an adjoining cubicle area. However, the small work area
does not mean that they are unimportant. Testing can literally mean
life or death for babies with galactosemia. Babies with biotinidase
deficiency may take longer to exhibit symptoms, but diagnosis can
prevent life-long effects, including severe neurologic impairment.
Laboratorians in the area don’t often
see the end result of their work. Instead they take pride in the
accuracy of their results. Galactosemia and Biotinidase Deficiency
Screening Team Manager, Chris Goben, assisted in a recent effort to
track down demographic information for four patient samples. Due to a
printing error, mismatched serial (kit) numbers had been printed in
five different numbered areas on the Newborn Screening forms. All five
areas should have the same number. “It was like solving a puzzle,” he
said. “We were able to put the pieces back together within two hours.
Preventing and solving problems like this is where I get my job
the first signs and symptoms of galactosemia include vomiting,
diarrhea, lethargy, failure to thrive and jaundice, caused by hepatic
failure. Without treatment,
disease progression is rapid and death (typically due to E. coli septicemia) can be the tragic final outcome within 7-14
days of birth. The screening team races to beat the clock. Testing for
galactosemia is completed within three business days, including the
time from specimen accessioning in the laboratory to final release of
Treatment for galactosemia involves a
change from feeding milk-based products to soy-based products and
avoiding all foods containing lactose and galactose. This can have a
larger impact on the family, particularly the mother and baby, as it
negates the option of breast-feeding. This dietary change must be
continued for life.
If untreated, symptoms of biotinidase
deficiency include seizures, hypotonia, neurologic impairment such as
lack of coordination (ataxia), hearing loss, severe skin rashes, hair
loss (alopecia) and, in some rare instances, metabolic coma resulting
in death. Some of these effects can be reversed with treatment.
The lack of available biotin caused by
biotinidase deficiency is addressed by administering high doses of
biotin as a supplement. Additional dietary restrictions may include
avoiding consumption of certain foods such as raw eggs, which contain
high levels of avidin, a compound that irreversibly binds to biotin and
counteracts treatment. Like with galactosemia, treatment and dietary
modifications are life-long.
NBS specimens are collected from all
Texas babies 24-48 hours after birth and again at 7-14 days of age in
the form of dried blood spots. All NBS areas use 96 well microtiter
plates for specimen analysis. Each well holds either a small dot
punched from a NBS bloodspot card or a dried spot control specific to
The Galactosemia and Biotinidase
Deficiency Screening Team runs two separate enzyme assays for these two
metabolic disorders. The galactosemia assay detects the presence of
the enzyme galactose-1-phosphate uridyl transferase (GALT) through use
of a fluorometric, semi-quantitative method. A lack of fluorometric
signal indicates an abnormal result and the possibility of classical
galactosemia. This process involves a two-step reagent addition process
interspersed with two incubation periods and is largely handled
manually by technical staff: add first reagent and incubate for three
hours at 37°C, add second reagent and incubate for 30 minutes at room
temperature, then analyze on a fluorometer.
Test results are expressed as a quantitative value but reported qualitatively (abnormal, borderline, or normal) based on fixed analyte result ranges. Specimens that test abnormal for GALT enzyme activity are referred for second-tier DNA testing in the DNA Analysis Laboratory.
The biotinidase assay detects the
presence or absence of the biotinidase enzyme through use of a
qualitative, colorimetric method – meaning that a series of reagents
are added to test samples in order to produce a visible color change.
Technicians visually examine each test well individually for the
presence or absence of a color change and record results manually onto a
standardized worksheet. This test requires a more elaborate five-step
reagent addition process with a single six-hour incubation: add first
reagent and incubate for six hours at 37°C with agitation at 900rpm, add
remaining four reagents in specific, timed succession, then visually
analyze. To ensure precision and minimize technical or transcription
errors, test results are read and recorded by two technicians. These
results are then entered and checked by two technicians into the
laboratory information management system (LIMS).
are time-sensitive and can have a significant impact on the success of
treatment,” said Goben. “With regard to testing, we have enough
emergency power outlets to continue testing in the event of a power
outage.” The final assessment and reporting step requires an active
connection to an internal computer network, but testing can continue on
a limited basis until it is restored.
Test results for these two disorders are
not impacted by patient feedings, age, birth weight or the typical
course of treatment for the disorder. However, test results may be
negatively affected if a specimen is exposed to excessive heat and/or
humidity, which is a real concern during Texas summers. Certain
chemicals, such as alcohols and polyurethane, can also skew results.
More rarely, results can be skewed through administration of
sulfonamides (not common for newborns), either orally or topically to
the puncture site; drawing blood samples from peripherally inserted central catheter (PICC) lines; drawing patient samples post-transfusion; and administration of enzyme replacement therapy (ERT).
Galactosemia and biotinidase are both
genetic disorders – the inheritance pattern is autosomal, recessive. An
autosomal recessive disorder means two copies of an abnormal gene must
be present in order for the disease or trait to develop; in other
words, both parents have to carry the trait to pass it on to their
children. Both genes in a pair must be defective to cause the disorder.
People with only one defective gene are carriers who do not suffer from
the disorder. Classical galactosemia impacts approximately one in
60,000 births. Biotinidase manifests as partial deficiency in
approximately one out of 60,000 births and profound deficiency in
approximately one out of 110,000 births. Given the Texas annual birth
rate (approximately 350,000), roughly 5-7 critically effected patients
may be detected per disorder annually. Actual detections can vary
widely as these disorders are rare and dependent on the genetic makeup
of the population.
NBS for Galactosemia in Texas began in 1978. The original
galactosemia screening assay was performed using a bacterial inhibition
assay to detect the biochemical marker galactose in blood spots. In
2005, Texas switched to the current fluorometric method that measures
the GALT enzyme. NBS for Biotinidase deficiency started in 2007.
Through the NBS process, the dedicated staff on the DSHS Galactosemia
and Biotinidase Deficiency Screening Team and the NBS support teams
work to increase the chance of a healthy life for each Texas baby
identified with one of these disorders.
by Jimi Ripley-Black
The first annual Texas Newborn Screening
(NBS) Severe Combined Immune Deficiency (SCID) Pediatric Immunology
Consultants Meeting was held at the DSHS Laboratory on May 16, 2014.
The DSHS Newborn Screening Clinical Care Coordination and Newborn
Screening DNA Analysis Group SCID Screening Team hosted five Pediatric
Immunology consultants. These consulting doctors came from cities across
Texas, including Austin, San Antonio, Houston, Dallas and Corpus
On the agenda were NBS Laboratory
updates, NBS Clinical Care Coordination updates, and a review of the
first 17 months of screening data, from December 2012 through April
2014. (SCID screening was implemented at the DSHS Laboratory on December
1, 2012.) Three physicians also presented cases.
The consultants were impressed by the low
false positive rate (0.08%) of the SCID screen and suggested that the
DSHS provide the screening false positive rate to hospital
neonatologists. This would help remove the current misconception that
the false positive rate for SCID testing is high. During the first two
months of SCID testing, before screening algorithms were adjusted, a
higher number of presumptive positive specimens were initially
reported. Knowing the false positive rate is actually low would
encourage neonatologists, and other physicians, to pursue diagnostic
testing with the assistance of an immunologist.
The SCID screening test identifies a
reduction or absence of T cell receptor excision circles (TRECs), which
are a byproduct of normal T cell development. From December 2012
through April 2014, a total of 14 SCID cases were diagnosed in Texas
after an out-of-range newborn screen. In addition, another 247 cases of
T-cell lymphopenias were identified through screening for SCID.
One of the 14 cases diagnosed with SCID
was a child from India who received a polio vaccine before coming to
the United States. The infant was immunocompromised and developed polio
from the vaccine (SCID diagnosis was made due to a mutation in the
Rag-1 gene). Because this case was discovered and referred to a Texas
immunologist, it was diagnosed as a “Texas case” and will be reported in
publication in the CDC’s Morbidity and Mortality Weekly Report.
The consultants felt that SCID screening
and testing for TRECs brought about a “new day” in how doctors review
patients and proceed with diagnosis. Because of NBS, patients are being
referred to immunology specialists before symptoms appear, and that
increases survival rates and makes the screen very useful.
by Lucindra "Cindy" Corrigan
On May 20 and 21, 2014, the DSHS Viral
Isolation Team hosted a workshop at the DSHS Laboratory called
“Influenza Detection and Subtyping: CDC Flu rRT-PCR Dx Panel.” The
training, presented in partnership with the Association of Public
Health Laboratories (APHL), Centers for Disease Control and Prevention
(CDC) Division of Influenza, and National Center for Immunization and
Respiratory Disease (NCIRD), was intended for public health
laboratorians who work at the bench and perform influenza detection and
subtyping using the CDC Flu rRT-PCR Dx Panel. The public health
laboratories that participate in influenza surveillance in Texas use
this flu testing kit, provided by the CDC.
Seven people attended. They came from
local health departments around the state, including San Antonio, South
Texas, Corpus Christi, Dallas, Houston, Tyler, and Laredo. The
workshop consisted of both lectures and a hands-on laboratory component
to cover all aspects of the assay performed. Information was also
presented regarding influenza viruses, surveillance programs, how the
assays fit into the influenza testing and reporting algorithm, and
Day one focused on the lecture portion
of the training. Steve Lindstrom, from the CDC, provided an overview of
the influenza virus, use of molecular typing and subtyping of
influenza, and updates on the H5, H7 and H3v virus components. LaShondra
Berman, also from the CDC, presented the various shipping requirements
for submitting specimens for influenza surveillance and diagnostic
testing. Virology Group Manager Martha Thompson presented on various
aspects of influenza surveillance in Texas and the diagnostic testing
performed in the DSHS Laboratory. The day concluded with an overview of
the CDC Flu kit panel used for testing, including how to order
reagents and where to go for technical assistance.
Day two was a mixture of lecture and
hands-on time spent running the assay. The morning portion was spent in
the laboratory learning the nucleic acid extraction process as well as
the preparation reaction. After a break for lunch, the group
reconvened to retrieve the results and attend a few more lectures. They
discussed electronic reporting and surveillance, PCR performance
evaluation and validation, and data analysis and reporting the results
of the morning PCR run.
Hard work went into creating this
training. Thompson worked with representatives at the APHL and the CDC
to coordinate speakers and the logistics. DSHS Viral Isolation Team
members Jennifer Gonzales and Peter So “…were very involved in setting
up the lab and helping to facilitate the wet lab portion,” said
In a normal flu season, the DSHS
Laboratory Viral Isolation Team tests about 1,000 influenza specimens.
These specimens come from across the state of Texas. Providers that
participate in influenza surveillance include physicians, clinics,
hospitals and local health department laboratories.
The DSHS Laboratory performs real time
RT-PCR to detect and identify influenza A and B along with influenza
subtypes H1, H3 and 2009 pandemic H1. This assay also allows detection
of novel strains of influenza. Some of the specimens received in the
laboratory are then sent to the Centers for Disease Control and
Prevention (CDC) for further characterization of the virus. This
information may contribute to the vaccine strain for the upcoming year.
by Vanessa Telles
In addition to testing, the Emergency
Preparedness Branch Biological Threat and Chemical Threat teams provide
specialized workshops and training opportunities. Most recently, they
hosted their first pilot training on “Biological and Chemical
Terrorism: A Laboratory Overview for First Responders and Law
Enforcement.” This training was designed for first responders and law
enforcement officials who may respond to suspicious mail or substances
and then collect and submit these specimens for biological and/or
chemical testing at the State Laboratory Response Network (LRN)
Laboratory. While the actual training took place on one day, the
planning and coordination that led up to the day was conducted over the
course of eight months. The 6th Civil Support Team (CST) acted as a
consultant to refine the finished product and documentation. Other
laboratories that previously conducted the training were used as
Eight participants from the Austin Fire
Department, Killeen Fire Department, and Williamson County and Cities
Health District were in attendance. The training consisted of
presentations from the BioThreat and ChemThreat Teams detailing LRN
capabilities. This was followed by a tour of each laboratory area that
participates in sample receipt and processing. Topics of discussion
included the Laboratory Response Network (LRN), specimen submission and
processing, and laboratory testing capabilities and turnaround time for
the presentations, participants were taken to the BioThreat
Laboratory. There they observed a demonstration on how threat letters
are processed and the different strains of bacteria such as Bacillus anthracis
(anthrax) growing on agar plates. They then visited the Chemical Threat
Laboratory where they gained an understanding of the instrumentation
used for clinical samples for chemical warfare agents and
The complexities of sample matrices and the interpretation of Fourier
Transform Infrared Spectroscopy (FTIR) and Gas Chromatography/Mass
Spectrometry (GC/MS) in making an identification of a substance or
mixture were also discussed.
This type of training is important. It
fosters better relationships and communication between the BioThreat
and ChemThreat teams and their counterparts. The opportunity
communicates what goes on behind the scenes and why certain
requirements are in place.
The BioThreat team has received rather
interesting specimens for testing. For example, a suspicious white
powder was found in the packaging of a steam vacuum. Instead of sending
the suspected white powder, the entire steam vacuum was shipped to the
DSHS Laboratory. This poses an interesting dilemma. How do you fit the
vacuum under a biosafety cabinet? Training like this helps minimize
the arrival of inappropriate specimens – such as steam vacuums, large
mail boxes, or loaded guns.
At the completion of the training,
participants were given a paint can containing job aids related to
specimen submission and collection. Each can contained biological and
chemical testing contact numbers and provided a visual aid on the
appearance of a appropriately sized specimen. Most importantly,
participants gained knowledge, including the ability to describe
chemical warfare agents and industrial chemicals of concern, the field
screening requirements prior to specimen submission, an understanding of
the incubation and sample processing times and how they affect
turnaround times for results, and the types of equipment utilized in
the different laboratories and their uses.
by Vanessa Telles
Count the safety violations.
This photo was staged for entertainment purposes.
Click here to view the answer key.
- No open-toed shoes in the laboratory
- Talking on a cellphone in the laboratory
- Talking on a cellphone with gloves on
- Not wearing a lab coat
- Not wearing eye protection
- Not wearing gloves
- No food and drink in the laboratory
- Unlabeled chemical containers
Note: External links to other
sites are intended to be informational and do not have the endorsement
of the Texas Department of State Health Services. These sites may not be
accessible to people with disabilities.