Dr Ezio Bonifacio Discusses Barriers to Widespread T1D Screening

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Ezio Bonifacio, PhD, addresses barriers inhibiting widespread screening for type 1 diabetes (T1D), and offers insights on whether all individuals should be screened, or only those known to be at genetic risk for the disease.


When we have the benefit of preventing a portion of those screened for type 1 diabetes from developing clinical disease, then economically, widespread screening will be much more accepted, said Ezio Bonifacio, PhD, a professor of diabetes and preclinical stem cell work at the Technical University of Dresden, in Germany.


What barriers inhibit widespread screening for type 1 diabetes (T1D) in children? What steps can be taken to overcome these barriers?

I'm part of 2 studies to do widespread screening, so genetically we can do it, at least in Europe. We have a program that genetically screens, we've screened nearly 300,000 newborns in this program, the GPPAD [The Global Platform for the Prevention of Autoimmune Diabetes] one, that I spoke about. That's genetic screening. In Germany, we have an antibody screening for children. That's done well over 100,000. It's possible to be done.

As always, the barriers are: for now, these remain research studies. You've got to convince authorities that there's a benefit, that is financial, and health. The health one is, there are some health benefits. We identify them, these children, we can look after them, prevent diabetic ketoacidosis when they develop diabetes, etc. But the key benefit is the prevention. We need to have some way to prevent a portion of them developing clinical disease.

Second, as I said, economical. When we have the clinical benefit of eliminating some clinical cases, then economically it will be much more accepted. And those who have to pay for that screening, governments or whoever it is in the country will be more likely to do that.

But just one thing to add on that, in terms of finding those interventions, we're really good at screening children. But most of the interventions are not quite there yet to test in children. It would be great to have interventions that we can give to 3-year-old children, at least also in trial. And not all the ones that are out there to test are yet available for that age.

Would you recommend doing genetic screening first and then testing those at risk for antibodies, or would you screen everybody for antibodies?

There is controversy on whether it's more practical to select people for antibodies testing based on their genetic risk, or to test everybody for antibodies. Our data suggests that it's going to be much more effective to test everybody for antibodies. There are really cheap ways to do that now. You can have cheap screening antibody tests, which then select out those few who need further antibody tests.

With a genetic test up front, you're going to exclude a lot of people who are going to get diabetes, more than 50% and probably 60%-70%. Therefore, you've already eliminated a possibility of treating with something that works in the majority of people. By testing antibodies, the trick is to find the right ages to screen, because some children develop it early, and then get diabetes. So if you screen too late, you've missed them. And some people will develop it a little bit later.

But what we found is that many of the children who develop their autoantibodies or diabetes, let's say, by the time they're adolescents, they already have their antibodies somewhere in that first 5, 6 years of life. If you screen around 3 years of age, you have a reasonably good balance. You're probably get to pick up 50% of those that develop T1D by a single antibody screening. I think it's cost effective to do the antibody testing. And in the long run, it's going to be the one that's going to detect most cases. That's from our data in Europe. And of course, it may be a little bit different in other countries and particularly other ethnic groups where, as I said, we're missing a lot of data.