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

Abstract

What is the yield of primary care–based screening of children for islet autoantibodies? 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). These findings may inform considerations of population-based screening of children for islet autoantibodies. Public health screening for type 1 diabetes in its presymptomatic stages may reduce disease severity and burden on a population level. 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. 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. Measurement of islet autoantibodies. 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). 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). 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. This study categorizes the prevalence of 2 or more islet autoantibodies identified in preschool children in a population screening program, and the progression from presymptomatic to clinical symptomatic type 1 diabetes.