The Newborn Screening Quality Assurance Program

W. Harry Hannon, Ph.D. Chief, Newborn Screening Branch Centers for Disease Control and Prevention

 Quality (QC) control materials  Proficiency testing (PT) panels and evaluations  Training, consultations, network resources  Technical help  Follow-up by a CDC lab scientist for false-negative reports  Additional dried blood spot specimens can be provided for repeats for repeats Filter paper evaluations for pre-distribution certification  Filter paper evaluations for pre-distribution certification  Reference materials  Start-up materials: blood spot reference materials, archived QC materials, and previously distributed PT specimens Quality Assurance Services provided by NSQAP:

On April 13, 2001, a report was published in the MMWR Vol. 50 No. RR-3 with recommendations for using Tandem Mass Spectrometry for Metabolic Disease Screening using dried blood spots. This document contains valuable information about laboratory practice, follow-up, diagnosis, and treatment proposals. MMWR Morbidity and Mortality Weekly Report April 13, 2001/Vol. 50/No. RR-3

DISORDER OF AMINO ACID METABOLISM PhenylketonuriaPhe Maple syrup urine diseaseLeu/Ile, Val HomocystinuriaMet HypermethioninemiaMet CitrullinemiaCit Argininosuccinic aciduriaCit TyrosinemiaTyr

DISORDERS OF FATTY ACID METABOLISM Medium-chain acyl-CoA dehydrogenase deficiencyC8, C6, C10, C10:1, Very-long-chain acyl-CoA dehydrogenase deficiencyC14:1, C14, C16 Short-chain acyl-CoA dehydrogenase deficiencyC4 Multiple acyl-CoA dehydrogenase deficiencyC4, C5, C8:1, C8, C12, C14, C16, C5DC Carnitine palmitoyl transferase deficiencyC16, C18:1, C18 Carnitine/acylcarnitine translocase defectC16, C18:1, C18 Long-chain hydroxy acyl-CoA dehydrogenase deficiencyC16OH, C18:1OH, C18OH Trifunctional protein deficiency C16OH, C18:1OH, C18OH

DISORDERS OF ORGANIC ACID METABOLISM Glutaric acidemia Type 1C5DC Propionic acidemiaC3 Methylmalonic acidemiaC3 Isovaleric acidemiaC5 3-hydroxy-3-methylglutaryl CoA lyase deficiencyC5OH 3-methylcrotonyl-CoA carboxylase deficiencyC5OH

Amino Acid Reference Materials for Phe, Leu, Met, Tyr, and Val described in Clinical Chemistry 1999;45:

Amino Acid Reference Materials (AARMS) for Start-Up n=12

BLOOD MATRIX: each set made from a single multi-donor batch of pooled red cells and clarified serum; hematocrit adjusted to 55%+1%; frozen before use to hemolyze red blood cells. SET DESCRIPTION: each set contains a non-enriched pool for measurement of endogenous levels and three pools enriched with low, medium, and high levels of amino acids or acylcarnitines. AMINO ACID ENRICHMENTS: each set enriched with Phe, Leu, Met, Tyr, Val, and Cit. ACYLCARNITNE ENRICHMENTS: each set enriched with C2, C3, C4, C5, C5DC, C6, C8, C10, C14, and C16. DRIED BLOOD SPOT QUALITY CONTROL MATERIALS

ENRICHMENTS OF ACYLCARNITINES QUALITY CONTROL MATERIALS (  mol/L whole blood) Analyte Lot 365 Lot 366 Lot 367 Lot 368 C C C C C5DC 0 -- C C C C C

Annual programs must provide minimum of 5 specimens per testing event – NSQAP provides five specimens. Must be at least 3 testing events at equal intervals during the year - NSQAP has 4 events per year, one per quarter. Specimens must simulate the unknown test sample - NSQAP specimen matrix: whole blood adjusted to a newborn hematocrit. Specimens must cover the clinically relevant range of values or clinical significance - NSQAP enriches specimens with analyte concentrations that are typical of real disease states. Specimens may be distributed by Federal Express or mail - NSQAP sends all packages by FedEx with tracking. Assess the accuracy of the laboratory’s response (grading) in accordance with specified criteria – NSQAP provides instructions with codes for the assessment grading. 42 Code of Federal Regulations (CFR), 430.0, October 2000 A Model CLIA Certified Proficiency Testing Program

PROFICIENCY TESTING (PT) Participation usually a regulatory requirement for labs that report patient specimen results Provides an external measure of the total system Uses blind-coded samples: normal and disorder/range Evaluates performance of the moment only/snapshot Meets requirements for certification

Means and Ranges of Acylcarnitine Cutoff Values Reported by Domestic MS/MS Laboratories Mean Cutoff  mol/L blood Source: Quarter 3, 2003 NSQAP Data C3 C4 C5 C6 C8 C10 C14 C16 C5DC N Represents a wide spread of reported cutoff values N = Number of laboratories reporting their cutoff values Min/Max

Distribution of Propionylcarnitine (C3) Cutoff Values among Participating Laboratories Source: Quarter 3, 2003 NSQAP MS/MS Data

Amino Acid Mean Cutoff Values Reported by MS/MS Laboratories Min/Max mg/dL Mean Cutoff Value mg/dL blood Phenylalanine Leucine Methionine Tyrosine Valine Citrulline N = Number of laboratories reporting their cutoff value Wide min/max cutoff range N Source: Quarter 3, 2003 NSQAP MS/MS Data

Distribution of Tyrosine Cutoff Values among Participating Laboratories Source: Quarter 3, 2003 NSQAP MS/MS Data

How Can Labs Use NSQAP for MS/MS Start-up? Enroll in NSQAP PT program as soon as MS/MS instrument start-up begins. Request previous quarter’s PT specimens and report. Request supplies of archived QC materials for instrument comparison and performance monitoring. Request Reference Materials for method calibration and assessments of method linearity. View the 2003 MS/MS annual report online at Contact Connie Singleton at or at for enrollment and to request materials.