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Original Investigation
January 28, 2020

Yield of a Public Health Screening of Children for Islet Autoantibodies in Bavaria, Germany

Author Affiliations
  • 1Institute of Diabetes Research, Helmholtz Zentrum München, German Research Center for Environmental Health, Munich-Neuherberg, Germany
  • 2Forschergruppe Diabetes, Technical University Munich, at Klinikum rechts der Isar, Munich, Germany
  • 3German Center for Diabetes Research (DZD), Munich, Germany
  • 4DFG Center for Regenerative Therapies Dresden, Technische Universität Dresden, Dresden, Germany
  • 5Paul Langerhans Institute Dresden, Helmholtz Center Munich, Faculty of Medicine, University Hospital Carl Gustav Carus, TU Dresden, Germany
  • 6Institute for Diabetes and Obesity, Helmholtz Diabetes Center at Helmholtz Zentrum München, Munich-Neuherberg, Germany
  • 7Klinikum Augsburg, Klinik für Kinder und Jugendliche, Augsburg, Germany
  • 8Berufsverband der Kinder- und Jugendärzte e.V., Landesverband Bayern, Augsburg, Germany
  • 9PaedNetz Bayern e.V., Rosenheim, Germany
  • 10Department of Pediatrics, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
  • 11Department of Medical Psychology, Hannover Medical School, Hannover, Germany
JAMA. 2020;323(4):339-351. doi:10.1001/jama.2019.21565
Key Points

Question  What is the yield of primary care–based screening of children for islet autoantibodies?

Findings  In a program that screened 90 632 children aged 2 to 5 years in Bavaria, Germany, during primary care visits, 280 children (0.31%) had 2 or more islet autoantibodies, among whom 62 developed clinical type 1 diabetes and 2 had mild or moderate diabetic ketoacidosis. Mothers of children with presymptomatic type 1 diabetes reported more symptoms of depression at diagnosis than mothers of children without islet autoantibodies (median psychological stress score of 3 vs 2).

Meaning  These findings may inform considerations of population-based screening of children for islet autoantibodies.

Abstract

Importance  Public health screening for type 1 diabetes in its presymptomatic stages may reduce disease severity and burden on a population level.

Objective  To determine the prevalence of presymptomatic type 1 diabetes in children participating in a public health screening program for islet autoantibodies and the risk for progression to clinical diabetes.

Design, Setting, and Participants  Screening for islet autoantibodies was offered to children aged 1.75 to 5.99 years in Bavaria, Germany, between 2015 and 2019 by primary care pediatricians during well-baby visits. Families of children with multiple islet autoantibodies (presymptomatic type 1 diabetes) were invited to participate in a program of diabetes education, metabolic staging, assessment of psychological stress associated with diagnosis, and prospective follow-up for progression to clinical diabetes until July 31, 2019.

Exposures  Measurement of islet autoantibodies.

Main Outcomes and Measures  The primary outcome was presymptomatic type 1 diabetes, defined by 2 or more islet autoantibodies, with categorization into stages 1 (normoglycemia), 2 (dysglycemia), or 3 (clinical) type 1 diabetes. Secondary outcomes were the frequency of diabetic ketoacidosis and parental psychological stress, assessed by the Patient Health Questionnaire-9 (range, 0-27; higher scores indicate worse depression; ≤4 indicates no to minimal depression; >20 indicates severe depression).

Results  Of 90 632 children screened (median [interquartile range {IQR}] age, 3.1 [2.1-4.2] years; 48.5% girls), 280 (0.31%; 95% CI, 0.27-0.35) had presymptomatic type 1 diabetes, including 196 (0.22%) with stage 1, 17 (0.02%) with stage 2, 26 (0.03%) with stage 3, and 41 who were not staged. After a median (IQR) follow-up of 2.4 (1.0-3.2) years, another 36 children developed stage 3 type 1 diabetes. The 3-year cumulative risk for stage 3 type 1 diabetes in the 280 children with presymptomatic type 1 diabetes was 24.9% ([95% CI, 18.5%-30.7%]; 54 cases; annualized rate, 9.0%). Two children had diabetic ketoacidosis. Median (IQR) psychological stress scores were significantly increased at the time of metabolic staging in mothers of children with presymptomatic type 1 diabetes (3 [1-7]) compared with mothers of children without islet autoantibodies (2 [1-4]) (P = .002), but declined after 12 months of follow-up (2 [0-4]) (P < .001).

Conclusions and Relevance  Among children aged 2 to 5 years in Bavaria, Germany, a program of primary care–based screening showed an islet autoantibody prevalence of 0.31%. These findings may inform considerations of population-based screening of children for islet autoantibodies.

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