Prevention of type 1 diabetes from laboratory to public health

Despite recent progress in immunology and genetics, the causes of type 1 diabetes remain unknown. Prevention of autoimmune diseases through immunomodulation or gene therapy has not yet been successful in humans. In contrast, some autoimmune diseases such as celiac disease, rheumatic fever, and congenital rubella induced diabetes can be avoided through modification of environmental factors. Candidate environmental causes of type 1 diabetes are now being characterized in cohort studies and clinical trials. An alternative approach to prevention of type 1 diabetes may include a "vaccination" in early childhood to induce tolerance to critical autoantigen(s). This paper reviews the status of current diabetes prevention trials in humans and selected new interventions that are being tested in animal models. We estimate the cost of public health implementation of selected screening and intervention scenarios. The ethical, logistic, and funding issues underlying these scenarios are discussed.