Urgent call for compulsory premarital screening: a crucial step towards thalassemia prevention in Bangladesh

Thalassemia poses a major public health concern in Bangladesh with a high prevalence of carriers. However, there is a substantial knowledge gap regarding its epidemiology, clinical aspects, and treatment outcomes. Despite its high prevalence, there is a notable lack of awareness regarding thalassemia in the Bangladeshi population. The absence of precisely validated data impedes a comprehensive understanding of this disease.Premarital thalassemia screening is reportedly a successful strategy for countries such as Saudi Arabia and Iran and has also been proposed for Bangladesh. Mandatory screening coupled with genetic counseling is promising for reducing the prevalence of thalassemia by identifying carriers and providing relevant health education. However, sociocultural barriers, challenges, financial constraints, and health risks associated with prenatal diagnosis and abortion could hinder the success of such programs.Positive outcomes from other countries underscore the effectiveness of such programs in reducing thalassemia incidence. The early identification of carriers and genetic counseling can significantly reduce the burden of thalassemia. Additionally, the strain on the healthcare system would be eased, and the quality of life of thalassemia patients would be improved.In conclusion, based on evidence mandatory premarital screening with genetic counseling could be an effective measure to reduce the prevalence of thalassemia in Bangladesh. Leveraging positive attitudes, adopting successful international models, and addressing existing challenges are crucial for the successful implementation of programs that contribute to the overall health and well-being of the country's population.

Health beliefs of unmarried adult Saudi individuals toward safe marriage and the role of premarital screening in avoiding consanguinity: a nationwide cross-sectional study

Introduction

Premarital screening (PMS) is an essential global measure that seeks to reduce the occurrence of specific genetic disorders and sexually transmitted diseases common in consanguineous marriages. Due to the lack of a nationwide study, this research was designed to comprehend how unmarried individuals perceive the risks and benefits of PMS.

Method

A cross-sectional study was conducted using an online questionnaire distributed through different social media platforms, responses from the native adult population (18-49 years) Saudi Arabia was only included in the study. The questionnaire was based on the Health Belief Model (HBM) to assessing seven different constructs including susceptibility, seriousness, benefits-, barriers-, & cues- to action, self-efficacy, and social acceptance. Data frequency was represented by mean and standard deviation; chi-square and t-tests were conducted for the comparison of independent and dependent variables. A multinomial logistic regression was used to predict factors influencing decisions related to PMS.

Results

1,522 participants completed the survey, mostly 18-25 years old and most of them were women. The majority were single with 85 men and 1,370 women. Most participants (59.6%) believed their parents were related, while 40.5% did not. 122 respondents reported they had to marry within their tribe. Findings revealed significant correlations among all HBM themes, with varying strengths. Notably, a moderate positive relationship was found between the perception of benefits and cues to action, suggesting that enhancing the perceived benefits of PMS could facilitate safe marriage practices. Multinomial regression analysis revealed that demographic factors and health beliefs significantly influence individuals' intentions and behaviors toward PMS and safe marriage.

Conclusion

The study concludes that by identifying and addressing barriers, and promoting positive social acceptance, PMS can significantly contribute to preventing genetic diseases and promoting safe marriage practices, although the cross-sectional design limits the establishment of causal relationships and further research is needed.

Current Status of Newborn Bloodspot Screening Worldwide 2024: A Comprehensive Review of Recent Activities (2020-2023)

Newborn bloodspot screening (NBS) began in the early 1960s based on the work of Dr. Robert "Bob" Guthrie in Buffalo, NY, USA. His development of a screening test for phenylketonuria on blood absorbed onto a special filter paper and transported to a remote testing laboratory began it all. Expansion of NBS to large numbers of asymptomatic congenital conditions flourishes in many settings while it has not yet been realized in others. The need for NBS as an efficient and effective public health prevention strategy that contributes to lowered morbidity and mortality wherever it is sustained is well known in the medical field but not necessarily by political policy makers. Acknowledging the value of national NBS reports published in 2007, the authors collaborated to create a worldwide NBS update in 2015. In a continuing attempt to review the progress of NBS globally, and to move towards a more harmonized and equitable screening system, we have updated our 2015 report with information available at the beginning of 2024. Reports on sub-Saharan Africa and the Caribbean, missing in 2015, have been included. Tables popular in the previous report have been updated with an eye towards harmonized comparisons. To emphasize areas needing attention globally, we have used regional tables containing similar listings of conditions screened, numbers of screening laboratories, and time at which specimen collection is recommended. Discussions are limited to bloodspot screening.

Islamic perspectives on preconception, prenatal, and perinatal counseling

With advances in prenatal imaging, genetic testing, and medical treatment of premature neonates, new bioethical challenges have arisen. Many Muslims turn to their faith and religious leaders to help navigate these novel challenges. This article briefly discusses the factors that are involved in religious leaders issuing a fatwa, or religious opinion. Using clinical scenarios, this article reviews the current discourse amongst Islamic scholars and laws in Muslim-majority countries regarding challenging bioethical topics surrounding preconception counseling, antenatal testing and termination of pregnancy, as well as Islamic scholars' attempts to determine a minimum gestational age of viability using primary religious texts, the Quran and hadith. Challenges and shortcomings in the Islamic perspective on these issues are also addressed to highlight areas in which further research should be pursued. A deeper understanding of Islamic religious perspectives on these topics can help clinicians in providing care that is informed by patients' cultural and religious values.

Perceptions and preferences for genetic testing for sickle cell disease or trait: a qualitative study in Cameroon, Ghana and Tanzania

Sickle cell disease (SCD) is a single gene blood disorder characterised by frequent episodes of pain, chronic anaemic, acute chest syndrome, severe disease complications and lifelong debilitating multi-system organ damage. Genetic testing and screening programs for SCD and the sickle cell trait (SCT) are valuable for early diagnosis and management of children living with SCD, and in the identification of carriers of SCT. People with SCT are for the most part asymptomatic and mainly identified as through genetic testing or when they have a child with SCD. This qualitative study explored perceptions towards genetic testing for SCD and SCT in Cameroon, Ghana, and Tanzania. The results show a general preference for newborn screening for SCD over prenatal and premarital/preconception testing, primarily due to its simpler decision-making process and lower risk for stigmatization. Premarital testing for SCT was perceived to be of low public health value, as couples are unlikely to alter their marriage plans despite being aware of their risk of having a child with SCD. Adolescents were identified as a more suitable population for SCT testing. In the case of prenatal testing, major concerns were centred on cultural, religious, and personal values on pregnancy termination. The study revealed a gender dimension to SCD/SCT testing. Participants mentionned that women bear a heightened burden of decision making in SCD/SCT testing, face a higher risk of rejection by potential in-laws/partners if the carriers of SCT, as well as the possibility of  divorce if they have a child with SCD. The study highlights the complex cultural, ethical, religious and social dynamics surrounding genetic testing for SCD and emphasises the need for public education on SCD and the necessity of incorporating genetic and psychosocial counselling into SCD/SCT testing programs.

Screening for haemoglobin disorders: One size may not fit all

Accurate laboratory screening for sickle cell disease and other haemoglobin disorders is expanding worldwide. Two new reports describe different methods and strategies for screening in Mali and Denmark, respectively, and their encouraging results suggest that countries should tailor their screening programmes according to local needs, resources and opportunities. Commentary on: Guindo et al. Potential for a large-scale newborn screening strategy for sickle cell disease in Mali: a comparative diagnostic performance study of two rapid diagnostic tests (SickleScan® and HemotypeSC®) on cord blood. Br J Haematol 2024;204:337-345 and Gravholt et al. The Danish national haemoglobinopathy screening programme: report from 16 years of screening in a low-prevalence, non-endemic region. Br J Haematol 2024;204:329-336.

Management of transfusion-dependent β-thalassemia (TDT): Expert insights and practical overview from the Middle East

β-Thalassemia is one of the most common monogenetic diseases worldwide, with a particularly high prevalence in the Middle East region. As such, we have developed long-standing experience with disease management and devising solutions to address challenges attributed to resource limitations. The region has also participated in the majority of clinical trials and development programs of iron chelators and more novel ineffective erythropoiesis-targeted therapy. In this review, we provide a practical overview of management for patients with transfusion-dependent β-thalassemia, primarily driven by such experiences, with the aim of transferring knowledge to colleagues in other regions facing similar challenges.

Barriers and Facilitators of Premarital Genetic Counseling for Sickle Cell Disease in Northern Nigeria

In high-income countries, premarital genetic counseling for Sickle Cell Disease (SCD) is a standard practice. However, in Nigeria, there is no formal premarital genetic counseling program available for SCD. We conducted a series of focus group discussions with health care professionals, patients with SCD, and parents of the patients with or without SCD to gain an understanding of their attitudes and beliefs towards SCD/Sickle Cell Trait and premarital genetic counseling for SCD. Data were analyzed using Charmaz's constructivist grounded theory approach. Two themes were highlighted in the analysis as follows: (1) the difference between the perception of premarital sickle cell screening among individuals with SCD versus the general population, and (2) the personal beliefs and physical challenges that could lead to the avoidance of premarital screening within the general community. Lack of disease-related knowledge, testing facilities, transportation, and stigma associated with the disease were the most commonly perceived barriers to premarital testing. Also, a willingness to receive premarital testing for SCD exists within our community to reduce the spread of the disease and advocate for improved health-related quality of life of patients with SCD. The content and structure of a premarital genetic counseling program in Kano, Northern Nigeria, needs to be developed.

Consanguinity and willingness to perform premarital genetic screening in Sudan

Consanguineous marriage is prevalent in certain world regions due to cultural, economic, and social reasons. However, it can lead to negative consequences including an increased risk of genetic disorders in offspring. Premarital genetic screening (PMGS) is an important tool to identify and manage these risks before marriage. This study aimed to assess the magnitude of consanguineous marriage, knowledge of genetic diseases and PMGS, and attitudes and willingness to perform PMGS in Sudan. A national household survey was conducted using a multistage sampling technique, with a sample size of 2272 participants. Data were collected from December 2022 to March 2023 using an interviewer-administered questionnaire. A significant proportion of respondents (364/850, 42.8%) were married to consanguineal partners, with various types of relatedness. Moreover, 32.1% (242/755) of single respondents were planning to marry a close relative, signifying the likely persistence of consanguineous marriages in Sudan. The level of knowledge regarding genetic diseases and PMGS was relatively low in many states of Sudan, indicating the need for increased awareness interventions. A significant number of participants (85.2%) agreed that premarital screening is effective in reducing genetic diseases, whereas 71.2% supported the introduction of a mandatory PMGS program. Excluding married participants, 82.3% (1265/1537) of respondents were willing to perform PMGS, if implemented. These findings reflect the public positive attitude towards introducing the PMGS program and policies in Sudan and underscore the importance of addressing the knowledge gap of PMGS before such a potential implementation.

Challenges Facing Viral Hepatitis C Elimination in Lebanon

Hepatitis C is a hepatotropic virus that causes progressive liver inflammation, eventually leading to cirrhosis and hepatocellular carcinoma if left untreated. All infected patients can achieve a cure if treated early. Unfortunately, many patients remain asymptomatic and tend to present late with hepatic complications. Given the economic and health burdens of chronic hepatitis C infection, the World Health Organization (WHO) has proposed a strategy to eliminate hepatitis C by 2030. This article describes the epidemiology of hepatitis C in Lebanon and highlights the challenges hindering its elimination. An extensive search was conducted using PubMed, Medline, Cochrane, and the Lebanese Ministry of Public Health–Epidemiologic Surveillance Unit website. Obtained data were analyzed and discussed in light of the current WHO recommendations. It was found that Lebanon has a low prevalence of hepatitis C. Incidence is higher among males and Mount Lebanon residents. A wide variety of hepatitis C genotypes exists among various risk groups, with genotype 1 being the most predominant. In Lebanon, many barriers prevent successful hepatitis C elimination, including the absence of a comprehensive screening policy, stigma, neglect among high-risk groups, economic collapse, and a lack of proper care and surveillance among the refugees. Appropriate screening schemes and early linkage to care among the general and high-risk populations are essential for successful hepatitis C elimination in Lebanon.

Prevalence of Consanguineous Marriage among Saudi Citizens of Albaha, a Cross-Sectional Study

Consanguineous marriage (CM) is a prevalent kind of relationship in Muslim and Arab countries, and this type of relationship is linked to several health risks. This study was conducted to determine the prevalence of (CM), its associated hereditary diseases, and health-related issues among Saudi citizens in Albaha. This cross-sectional study was conducted between March 2021 to April 2021. Saudi citizens in Albaha who were aged ≥ 18 years and willing to participate were eligible for the study. A total of 1010 participants were included in this study. In total, 757 participants were married, widowed, or divorced. CM partnerships comprised 40% (N = 302) of the marriages among participants, of which first- and second-cousin marriages comprised 72% and 28%, respectively. The prevalence of CM among the participants' parents was lower than that among the participants (31% versus 40%, respectively). Children of participants in a CM were more likely to have cardiovascular diseases (p < 0.001), blood diseases (anaemia, thalassemia) (p < 0.001), cancer (p = 0.046), hearing loss and speech disorder (p = 0.003), and ophthalmic diseases (p = 0.037). Albaha showed a high percentage of consanguinity. An educational program must be established to enhance the population's knowledge of the consequences of CM. The current national premarital screening program should be extended to involve more screening tests for common hereditary diseases that result from CM.

Interventions addressing genetic disease burdens within selected countries in the MENA region: a scoping review

BACKGROUND

The MENA region is disproportionately affected by genetic disease. The aim of this research is to scope the region for evidence of genetic services and public health interventions to identify geographic gaps, and to provide a descriptive overview of interventions to identify knowledge gaps.

METHODS

This study is conducted as a scoping review and follows the Arksey & O'Malley scoping review framework.

RESULTS

Seventy-six articles spanning 16 MENA nations met inclusion criteria. Studies included interventions in the form of genetic service provision (n=28), as well as comprehensive programs including pilot programs (n=7), community-based genetics programs (n=6) national-level prevention programs (n=18), and national-level mandatory programs (n=17).

CONCLUSIONS

There is an imbalanced response to genetic disease burdens across the MENA region. More research is warranted where interventions are scarce, particularly to inform development of pilot community-based programs. There is also a need for better monitoring and evaluation of existing nation-wide programs.

How to improve issuing, transfusion and follow-up of blood components in Southern and Eastern Mediterranean countries? A benchmark assessment

To determine the existence of guidelines regarding the appropriate clinical use of blood and blood components, transfusion requests, and blood issuing/reception documents and procedures. The different bedside transfusion organizations/processes and hemovigilance are also analyzed. The ultimate objective is to identify safe potential options in order to improve blood safety at the lowest cost. Data emanating from eight Arabic eastern/southern Mediterranean countries who responded to five surveys were collected and tabulated. National recommendations for the clinical use of blood components especially for hemoglobinopathies are lacking in some countries. In matter of good practices in the prescription, issuing and reception of BCs, efforts were made either on national or local basis. Procedures regarding patient information and ethical issues are still lacking. Almost all Mediterranean countries apply two blood testing procedures on each patient sample. Only Morocco, Tunisia and Algeria perform bed side blood group testing; Egypt and Lebanon perform antibody screen and antiglobulin cross matching universally. Automation for blood testing is insufficiently implemented in almost all countries and electronic release is almost absent. National hemovigilance policy is implemented in Tunisia, Morocco, and Lebanon but the reporting system remains inoperative. Insufficient resources severely hinders the implementation of expensive procedures and programs; however, the present work identifies safe procedures that might save resources to improve other parts in the transfusion process (e.g. electronic release to improve safety in issuing). Moreover, setting up regulations regarding ethics in transfusing recipients along with local transfusion committees are crucially needed to implement hemovigilance in transfusion practice.

Knowledge and Perception of and Attitude toward a Premarital Screening Program in Qatar: A Cross-Sectional Study

Premarital screening (PMS) is a primary preventive measure to decrease the incidence of certain genetic disorders and sexually transmitted diseases. This study aimed to explore the knowledge and perception of and the attitude toward PMS and predictors of knowledge and attitude. A cross-sectional study was conducted among Qatar University students using an online survey. Multivariable regression analyses were used to identify factors associated with PMS knowledge and attitude. A total of 476 students participated in the study; 424 (89.1%) were females; two-thirds were 18–21 years old. Only 100 participants had heard about PMS. Knowledge of PMS was significantly associated with females, students enrolled in a health-related college, and non-consanguineous marriage of a participant’s parents. The majority of the participants agreed that genetic diseases are psychological and economic burdens. For attitude, only 178 participants were willing to cancel marriages, given incompatible PMS results. The following factors were positively associated with attitude: PMS knowledge, enrollment in a health-related college, and the belief that PMS does not interfere with destiny. Our study findings revealed that despite the mandatory PMS in Qatar, the study participants, future couples, had low knowledge about the program. Therefore, strategies to increase awareness of PMS should be considered toward improving its outcomes.

Factors Affecting the Willingness to Undertake Premarital Screening Test Among Prospective Marital Individuals

Introduction

Awareness toward premarital screening test and its influence on preventing high risk marriages has become a concern to the health care system in Oman. This is due to the increased rates of inherited diseases and genetic disorders among the Omani population secondary to consanguineous marriages.

Objectives

This cross-sectional study aims to describe the utilization of premarital screening tests of selected university study participants as future prospective couples.

Methods

The study included 400 Omani study participants from different majors at a national governmental university that receives students from all over the country. Data was collected using a self-administered questionnaire.

Results

Out of the 400 study participants 193 [48.3%] were females and 195 [48.8%] were males, and 380 [95%] were unmarried and 19 [4.8%] were married. Personal and family history of hereditary diseases and consanguinity between parents were reported by 40 participants [10%], 158 [39.5%] and 175 [43.8%] respectively. Three hundred and sixty-one [90.3%] of the total participants were aware of the availability of premarital screening tests in Oman. A total of 357 [89.3%] thought it is necessary to do a premarital screening test and 367 [91.8%] agreed to carry out it in the future. The novel contribution of this manuscript is that our logistic regression showed that people with personal or family history of hereditary disease, and have consanguinity between parents, being a female did not show willingness to undertake the screening while those who are married, have higher GPA, and older supported it.

Conclusion

Usability of the freely available premarital screening is low despite the study participants awareness and willingness. Future studies should target those who have a history of genetic disease and females as we found them not willing to undertake the test in this study. We also recommend putting in place mandatory rules and regulations for premarital screening tests with better counselling strategies.

Knowledge and attitude of Engaged and Recently Married Couples Toward Premarital Screening: A Cross-Sectional Study

Background and Objective: Despite that inherited (thalassemia and SCA) and infectious (hepatitis B, hepatitis C and AIDs) diseases and their risk factor consanguineous marriage are widespread among Yemen population, community-based awareness studies towards premarital screening (PMS) is extremely limited, so our study is designed to elicit knowledge and attitude of engaged and recently married couples in Taiz (Yemen) toward PMS. Methods: A cross-sectional study was conducted from April to September 2021 at Taiz. A well-structured questionnaire was designed and then delivered to participants to collect data. Results: The results revealed that majority of respondents (83.60%-94.18%) had knowledge about inherited and infectious diseases, respectively, and educational institution was the main knowledge source. Females had significantly higher knowledge than males (P ≤ .01), except about AIDs since no difference (P = .539). The results also revealed that majority of respondents had positive attitudes toward PMS, except toward AIDs testing since 70% of males and 68.91% of females had negative attitudes. The majority of respondents agreed that screening reduces the diseases incidence. Approximately half of respondents (50.79%-56.61%) tend to go ahead for marriage in case of positive results for inherited and infectious diseases respectively. Making PMS as an obligatory step prior engagement was agreed by 47.62% of respondents (45.71% of males, 48.74% of females). Conclusion: A high level of knowledge and positive attitudes toward inherited and infectious diseases and PMS were reported. This knowledge reflected on the agreement of majority of respondents regarding PMS importance in term of reduction of diseases incidence.

Identification of optimal thalassemia screening strategies for migrant populations in Thailand using a qualitative approach

Background

Thalassemia is a common inherited hemoglobin disorder in Southeast Asia. Severe thalassemia can lead to significant morbidity for patients and economic strain for under-resourced health systems. Thailand’s thalassemia prevention and control program has successfully utilized prenatal screening and diagnosis to reduce the incidence of severe thalassemia in Thai populations, but migrant populations are excluded despite having high thalassemia prevalence. We sought to identify key barriers to and facilitators of thalassemia screening and to develop tailored recommendations for providing migrants with access to thalassemia prevention and control.

Methods

We conducted 28 in-depth interviews and 4 focus group discussions (FGDs) in Chonburi, Thailand with Myanmar and Cambodian migrants, Thai healthcare providers, Thai parents of children affected by thalassemia, and migrant agents.

Results

Participant narratives revealed that migrants’ lack of knowledge about the prevalence, manifestations, severity, and inherited nature of thalassemia led to misconceptions, fear, or indifference toward thalassemia and screening. Negative perceptions of pregnancy termination were based in religious beliefs but compounded by other sociocultural factors, presenting a key obstacle to migrant uptake of prenatal screening. Additionally, structural barriers included legal status, competing work demands, lack of health insurance, and language barriers. Participants recommended delivering public thalassemia education in migrants’ native languages, implementing carrier screening, and offering thalassemia screening in convenient settings.

Conclusions

An effective thalassemia prevention and control program should offer migrants targeted thalassemia education and outreach, universal coverage for thalassemia screening and prenatal care, and options for carrier screening, providing a comprehensive strategy for reducing the incidence of severe thalassemia in Thailand and establishing an inclusive model for regional thalassemia prevention and control.

The Prevalence of β-Thalassemia and Other Hemoglobinopathies in Kuwaiti Premarital Screening Program: An 11-Year Experience

This study aims to estimate the prevalence rates of β-thalassemia and Sickle cell disorders in the adult population screened (n = 275,819) as part of the Kuwaiti National Premarital Screening Program. All the individuals who applied for a marriage license during the years 2009 and 2020 were covered by the program. A network of four reception centers in the Ministry of Health facilities and one Premarital Diagnostic Laboratory (PDL) in Maternity Hospital were involved in performing all investigations for hemoglobinopathies. The total number of individuals identified with β-thal trait was 5861 (2.12%), while 22 individuals (0.008%) were diagnosed with β-thal disease. A total of 5003 subjects (1.81%) were carrying the Sickle cell trait, while 172 subjects (0.062%) had Sickle cell disease including Sickle cell anemia (SCA). Results showed that the program succeeded indeed in preventing the marriage of 50.4% of risky couples by issuing unsafe marriage certificates. Yet more efforts are needed to improve the program’s main objective of decreasing high-risk marriages. In particular, health care systems should be ameliorated in a way to intensify the counselling mechanism for the high-risk couples, strengthen the awareness of the general population and induce earlier age screening policies.

Causes of Birth of More Than One Thalassemia Major Patient in Families in South-east of Iran: Lessons for Prevention Programs

Background: Beta-thalassemia major (TM) is one of the most common genetic diseases in Iran. Despite some efforts to reduce the incidence of TM, its incidence is still relatively high in some areas of the country. Methods: This cross-sectional study was performed on 635 families who had children with TM. The families that had more than one child with TM were enrolled. A demographic data questionnaire and a checklist containing queries about the reasons for the birth of the second or subsequent TM children were completed by each family. Finally, the data were analyzed using SPSS version 16. Results: Among the families that had more than one child with TM, 90, 23, and three families had two, three, and four children with the disease, respectively. Of the 261 patients studied, 125 (47.9%) and 136 (52.1%) had been born prior and after the implementation of the pre-marital screening program for beta-thalassemia in Iran, respectively. Also, in 29.4% of these families, parents were unaware of having thalassemia minor. In other cases, factors such as lack of knowledge about screening tests (14.0%), lack of financial compliance (13.2%), late referral for genetic tests (11.8%), and not undergoing screening tests despite recommendations (9.6%) were among the reasons declared by the families. In addition to these, religious and cultural reasons should also be mentioned as effective factors. Conclusions: This study showed that in only about 30% of the studied families, the parents were unaware of having thalassemia minor, and in other families, miscellaneous reasons were involved in the birth of the second or subsequent child with TM. In some cases, despite sufficient parental knowledge about the possibility of giving birth to a child with TM, no action was taken to prevent this event.

Undiagnosed haemoglobinopathies among pregnant women attending antenatal care clinics in Pune, India

Pregnant women with iron deficiency and those who are carriers of haemoglobinopathies present with anaemia of varying severity. There is no antenatal screening for haemoglobinopathies in India. The objective of this study was to determine the prevalence of undiagnosed haemoglobinopathy carriers in a random sample of pregnant women attending antenatal care clinics in Pune city, India. Biobanked DNA of 360 randomly selected pregnant women was genotyped for six common mutations and two common haemoglobin variants, HbS and HbE. Odds ratios (OR) with 95% confidence intervals were computed to determine association of carrier status with socio-demographic, haematological and clinical characteristics. The prevalence of undiagnosed haemoglobinopathy carriers was 6.3% (95% CI 4.2-9.4%) of which 3.3% (95% CI 1.9-5.7%) were beta thalassaemia carriers. There was an increased odds that beta thalassaemia carriers had moderate anaemia (OR 10.59, 95% CI 1.15-96.90). This study reveals the high prevalence of undiagnosed haemoglobinopathy carriers among pregnant women, indicating the need to immediately implement carrier screening and genetic counselling services across the country.

Assessment of Factors Associated with the Effectiveness of Premarital Screening for Hemoglobinopathies in the South of Saudi Arabia

Purpose

Southern region of Saudi Arabia has one of the highest prevalence of sickle cell disease and thalassemia in the kingdom. This study aims to assess the factors associated with the rejection of premarital clinical counselling in the Jazan region.

Methods

This is a cross-sectional investigation conducted in the Jazan region of Saudi Arabia. The investigation targeted subjects who performed premarital screening and, with their screened partners, were identified as high-risk couples and proceeded with their marriage. Data were collected via a web-based self-administered questionnaire. A section of the questionnaire targeted those who attended the premarital counselling clinic in the Jazan region and assessed the factors that led to the rejection of premarital counselling advice.

Results

A total of 413 participants were recruited. The mean age of the respondents was 33 years, and the majority of the respondents were female (62.5%). The majority of the respondents were related to their partners (66.8%) and were carriers of sickle cell disease (67.8%). Among the respondents, only 192 had attended premarital counselling clinics in the Jazan region. More than half of the attendees rejected the premarital counseling advice because they believed that their marriage was their unavoidable destiny. About 30% of the attendees reported that disease complications were not well explained during the counselling. Thirty-five attendees (18.2%) proceeded with the marriage because they thought the risk of transmitting the disease to their children was small and 10 attendees (5.2%) proceeded with their marriage because they believed their children’s lives would not be affected by the disease.

Conclusion

The findings explain the limited influence of the premarital counselling advice in raising the awareness of the attendees about inherited blood disorders. The findings indicate a strong cultural influence leading to the reduced effectiveness of premarital counselling in the Jazan region.

Premarital screening for genetic blood disorders — an integrated review on the knowledge and attitudes of Middle Eastern university students

Background

Genetic blood disorders are prevalent in the Middle Eastern countries causing physical, mental, and economic handicap. Premarital screening (PMS) is actively implemented to reduce the burgeoning load of these disorders. Literature shows a low response rate for PMS in this region. This integrated review aims to identify the knowledge and attitude of university students on PMS, as they are at the verge of entering into marriage relationships.

Main body of the abstract

We systematically reviewed the electronic databases like MEDLINE, PubMed, CINAHL, and Scopus. Studies reporting about the knowledge and attitudes of Middle Eastern university students between 2010 and 2020 are included in the review. Twelve cross-sectional descriptive studies conducted in six countries met the inclusion criteria. Majority of the studies reported good level of knowledge on PMS among the university students, whereas not all of them agreed to undergo PMS due to various religious and cultural beliefs.

Short conclusion

We recommend massive health education programs at the higher secondary and university levels to create better awareness on PMS. To improve the attitude towards PMS, life cycle approach and support of the religious leaders could be sought.

Distribution of β-Thalassemia and Other Hemoglobinopathies in Bangladeshi University Students and Ready-Made Garment Workers

Background

The inheritable thalassemia and other structural hemoglobinopathies are prevalent globally. In Bangladesh, there is a scarcity of studies concerning thalassemia and other structural hemoglobinopathies. Hence, the present study investigated the prevalence and distribution of β-thalassemia and other hemoglobinopathies among the university students and ready-made garment (RMG) workers.

Methods

A cross-sectional study was conducted, whereas a total of 989 subjects were selected randomly from 10 garments industries (n=495) and five universities (n=494) for diagnosis and counseling from April 2018 to August 2018. Basic information related to the study and venous blood was collected and subjected to capillary Hb-electrophoresis for each participant.

Results

The present study identified thalassemia carriers and other hemoglobinopathies among 13.6% of the participants (14.1% university students and 13.2% RMG workers). The most common form of hemoglobin formation disorder was the Hb-E trait (10.5%), considering both participants’ groups. Other forms of hemoglobin formation disorders observed were a β-thalassemia trait, Hb-D trait, Hb-E disease, and β-thalassemia major. The hemoglobinopathies were significantly associated with the individuals who had a family history of thalassemia and were not vaccinated against hepatitis B in the total sample. Although not statistically suggestive, the most considerable portion (87.3%) of the carriers was unmarried in the present findings.

Conclusion

The present study findings are anticipated to help the public health authorities by providing novel data (of a neglected cohort, ie, RGM workers), facilitating the upcoming comprehensive national thalassemia prevention programs.

Genetic counseling in the context of Bangladesh: current scenario, challenges, and a framework for genetic service implementation

With the advancements in genetics and genomics in the twenty-first century, genetic services have become an integral part of medical practices in high-income and upper-middle-income countries. However, people living in low and lower-middle-income countries (LICs and LIMCs), including Bangladesh, are rather underprivileged in receiving genetic services. Consequently, genetic disorders are emerging as a significant public health concern in these countries. Lack of expertise, high expense, the dearth of epidemiological data, insufficiently updated medical education system, poor infrastructure, and the absence of comprehensive health policies are the main factors causing people living in these countries not having access to genetic services. In this article, the authors took benefit from their professional experience of practicing medical genetics in the area and reviewed existing literature to provide their opinions. Particularly, it reviews the current knowledge of genetic disorders' burden and their causative factors in Bangladesh. It focuses on why providing genetic services is challenging in the context of the country's cultural and religious sentiment. Finally, it proposes a physician-academician collaborative framework within the existing facility that aims to tackle the challenges. Such a framework could also be useful for other LICs and LMICs to address the challenges associated with providing genetic services.

The Changing Trends in Prenatal Diagnosis of Hemoglobinopathies in India: The Quest of a Single Center to Reduce the Burden of Disease over Three Decades

The β-thalassemias and sickle cell disorders pose a considerable health burden in India. Of the more than 10,000 annual births of children with a severe hemoglobinopathy, only around 10.0% are managed optimally. Thus, genetic counseling and prenatal diagnosis (PND) is a valid option for a large and diverse country. Our center was one of the first to initiate PND and we present our experience over 30 years to evaluate the impact of awareness in changing the trends of PND of hemoglobinopathies. Both second and first-trimester diagnoses were undertaken by fetoscopy/cordocentesis and globin biosynthesis/high-performance liquid chromatography (HPLC) analysis of fetal blood and chorionic villus sampling (CVS) and DNA analysis. Over 30 years, 3478 couples (first trimester: 2475; second trimester: 1003) from all over India were offered PND. The number of couples coming in the first trimester increased significantly over each decade and couples coming prospectively increased from 2.5 to 18.4%. A cost-effective stepwise approach was used for molecular analysis. Eight hundred and one fetuses (23.0%) were affected and all except three couples opted for termination of these pregnancies. Genetic counseling and PND is the only way to reduce the burden of disease. With awareness, there was a shift from second trimester to first trimester PND over each decade, with an increasing number of couples coming during the first pregnancy. There are only 15 to 20 centers in India offering PND. We have compared our study with other reports on PND from different regions in India.

A large-scale study exploring understanding of the national premarital screening program among Jordanians: Is an at-risk marriage a valid option for Jordanians?

Detecting carrier couples through premarital screening implementation is an effective way of controlling thalassaemia. The aim of this study was to investigate the knowledge of university students towards premarital screening and their possible involvement in an at-risk marriage. Students (n = 976) were chosen randomly from Jordanian universities. The questionnaire consisted of three sections: socio-demographical data, the students' knowledge about the screening programme, and finally their beliefs and future decisions related to it. Most (90%) participants were aware of the premarital screening availability. Females had significantly better understanding of premarital screening compared to males. Despite the majority of the participants not wanting to go ahead with at-risk marriages, 23% would not be deterred from marrying their anticipated partner and believed engaging in at-risk marriage was a valid idea. We suggest providing more effective educational programmes, genetic counselling and free prenatal diagnosis for at-risk couples.

Attitudes and impact among people with abnormal premarital screening test results in Muscat governorate's primary healthcare centers in 2018

Hereditary hemoglobin disorders are among the most common inherited diseases globally. In Oman, the burden of hereditary hemoglobin disorders has long been recognized as a major public health problem. In Oman, the prevalence of SCD ranges between 0.2 and 0.3% and of homozygous B-thalassemia was 0.07-0.08% while the prevalence of sickle cell trait and B-thalassemia trait reached up to 4.8-6% and 2-2.6% respectively. Glucose-6-phosphate dehydrogenase (G6PD) had a high prevalence in Oman, being 25% in males and 10% in females. The premarital screening and counseling (PMSC) program is an important preventative service for the most common hereditary hemoglobin disorders in Oman. The aim of this research is to study the attitude of those with abnormal premarital screening results and the impact of these results. This cross-sectional study was carried out in all primary healthcare centers in the Muscat governorate in 2018 to analyze abnormal premarital screening (PMS) tests results which mainly include sickle cell disease, thalassemia, and G6PD deficiency. Data were collected through telephone questionnaires with those with abnormal PMS test results. The questionnaire consisted of 3 parts investigating sociodemographic characteristics, attitudes toward PMS, and impact of the screening on participants. Of the 159 participants, 72.3% were between 20 and 29 years of age. Over two-thirds (71.5%) took PMS test while engaged. Consanguineous marriage was reported in 38.4% of married participants. The majority (94.3%) of participants believed PMSC to be important and (90%) agreed PMS should be obligatory before marriage. Half took the test as a personal decision while 17% complied with their spouse. Healthcare worker advice accounted for 21.4% of participants' decisions. Participant response to positive PMS results showed that 23% canceled their engagement, while 13.8% continued with marriage. Overall, 57.9% believed that PMS affected their lives positively. There is a relatively high favorable attitude toward PMSC. More effort is needed to raise public awareness regarding early PMS. Additionally, further genetic counseling before and after PMS testing is essential for the program's success.

Changing patterns in the epidemiology of β-thalassemia

β‐thalassemia major is an inherited hemoglobinopathy that requires lifelong red blood cell transfusions and iron chelation therapy to prevent complications due to iron overload. Traditionally, β‐thalassemia has been more common in certain regions of the world such as the Mediterranean, Middle East, and Southeast Asia. However, the prevalence of β‐thalassemia is increasing in other regions, including Northern Europe and North America, primarily due to migration. This review summarizes the available data on the changing incidence and prevalence of β‐thalassemia as well as factors influencing disease frequency. The data suggest that the epidemiology of β‐thalassemia is changing: Migration has increased the prevalence of the disease in regions traditionally believed to have a low prevalence, while, at the same time, prevention and screening programs in endemic regions have reduced the number of affected individuals. Various approaches to prevention and screening have been used. Region‐specific prevention and treatment programs, customized to align with local healthcare resources and cultural values, have been effective in identifying patients and carriers and providing information and care. Significant challenges remain in universally implementing these programs.

The effect of mother's β-thalassemia minor on placental histology and neonatal outcomes

Objective: β-thalassemia is a prevalent disease in Iran. The adverse effects of anemia on placental and neonatal outcomes have previously been shown. Women require additional iron during pregnancy and the anemia of women with β-thalassemia may adversely affect the neonatal outcome and increase placental abnormalities. In this study, we compared the placental histology and neonatal outcomes among pregnant women with and without β-thalassemia.Material and methods: In this population-based cross-sectional study, 144 pregnant women with β-thalassemia minor (case group) were compared to 142 women without β-thalassemia (control group). Women with singleton pregnancies over 20 weeks of gestation without pregnancy complications, anemia, collagen vascular diseases, or other hemoglobinopathies, all referred to hospitals affiliated to Shiraz University of Medical Sciences from March 2014 to February 2016, were included and maternal and neonatal data were extracted from medical records. After child birth, the placenta was evaluated for macroscopic and microscopic changes.Results: The frequency of LBW was significantly higher in the case group than that in the control group (19.7 vs. 9.7%, respectively) (p = .019). Six in the case group had gross abnormalities of placenta, while none in the control group (p = .03) and the case group had a higher frequency of chorangiosis, calcification, syncytial knot, and umbilical cord position (p < .05).Conclusion: As β-thalassemia increases the chance of placental abnormalities, it is recommended to pay more attention to patients with β-thalassemia, especially during pregnancy, to prevent placental and neonatal adverse outcomes.

Enabling routine β-thalassemia Prevention and Patient Management by scalable, combined Thalassemia and Hemochromatosis Mutation Analysis

BACKGROUND

Beta (β)-thalassemia is one of the most common inherited disorders worldwide, with high prevalence in the Mediterranean, the Middle East and South Asia. Over the past 40 years, awareness and prevention campaigns in many countries have greatly reduced the incidence of affected child births. In contrast, much remains to be done in South-Asia. Thus, for Pakistan, an estimated ~ 7000 children annually are born with thalassemia, with no sign of improvement. Although there is good agreement that intermarriage of carriers significantly contributes to the high prevalence of the disorder, effective tools for molecular screening and diagnosis on which to base prevention programs are not readily available.

METHODS

Here, we present results for a novel LeanSequencing™ process to identify a combination of 18 β-thalassemia mutations (including the sickle cell anemia mutation, HbS, and structural variants HbC and HbE) and 2 hemochromatosis mutations in a multi-ethnic population of 274 pediatric and adolescent patients treated at Afzaal Memorial Thalassemia Foundation in Karachi, Pakistan.

RESULTS

We found substantial differences in the predominance of disease-causing mutations among the principal ethnic groups in our cohort. We also found the hemochromatosis mutation H63D C > G in 61 (or 22.1%) of our patients including 6 (or 2.2%) homozygotes.

CONCLUSIONS

To our knowledge, this is the first screen combining a large set of β-thalassemia and hemochromatosis mutations, so as to facilitate the early identification of patients who may be at increased potential risk for complications from iron overload and thereby to improve the prospective management of thalassemia patients.

Lack of knowledge and misperceptions about thalassaemia among college students in Bangladesh: a cross-sectional baseline study

BACKGROUND

Thalassaemia is a potentially life-threatening yet preventable inherited hemoglobin disorder. Understanding local socio-cultural context and level of public awareness about thalassaemia is pivotal for selecting effective prevention strategies. This study attempted to assess knowledge and perceptions about thalassaemia among college students in Bangladesh.

METHODS

A supervised cross-sectional survey was conducted on 1578 college students using a self-administered structured questionnaire. The survey took place from 15 February 2018 to 17 March 2018 in the Jamalpur district in Bangladesh. Besides the attitude-related questions, the study asked a total of 12 knowledge-related questions, which were scored on a scale of 0-12 points.

RESULTS

Over two-thirds (67%) of the college students had never heard of thalassaemia. The urban-rural dichotomy was observed among those familiar with the term; (46.4% from urban vs. 25.8% from rural colleges). A similar pattern was observed for knowledge score; 5.07 ± 1.87 for students from the urban colleges compared to 3.69 ± 2.23 for rural colleges. Students from the science background had the highest knowledge score (5.03 ± 1.85), while those from arts and humanities background scored lowest (3.66 ± 2.3). Nearly 40% of the students were not sure or did not want to be a friend of a thalassaemia patient. Whereas 39% either declined or remained hesitant about helping thalassaemia patients by donating blood. However, most of the respondents (88%) showed a positive attitude towards 'premarital' screening to prevent thalassaemia.

CONCLUSIONS

This study has identified critical knowledge gaps and societal misperceptions about thalassaemia. A better understanding of these aspects will be pivotal for disseminating thalassaemia related information. As the first study of this kind in Bangladesh, findings from this study has generated baseline data that would contribute to developing effective intervention strategies in Bangladesh and other countries with a comparable socio-cultural setting.

Familial/inherited cancer syndrome: a focus on the highly consanguineous Arab population

The study of hereditary cancer, which accounts for ~10% of cancer cases worldwide is an important subfield of oncology. Our understanding of hereditary cancers has greatly advanced with recent advances in sequencing technology, but as with any genetic trait, gene frequencies of cancer-associated mutations vary across populations, and most studies that have located hereditary cancer genes have been conducted on European or Asian populations. There is an urgent need to trace hereditary cancer genes across the Arab world. Hereditary disease is particularly prevalent among members of consanguineous populations, and consanguineous marriages are particularly common in the Arab world. There are also cultural and educational idiosyncrasies that differentiate Arab populations from other more thoroughly studied groups with respect to cancer awareness and treatment. Therefore, a review of the literature on hereditary cancers in this understudied population was undertaken. We report that BRCA mutations are not as prevalent among Arab breast cancer patients as they are among other ethnic groups, and therefore, other genes may play a more important role. A wide variety of germline inherited mutations that are associated with cancer are discussed, with particular attention to breast, ovarian, colorectal, prostate, and brain cancers. Finally, we describe the state of the profession of familial cancer genetic counselling in the Arab world, and the clinics and societies dedicated to its advances. We describe the complexities of genetic counselling that are specific to the Arab world. Understanding hereditary cancer is heavily dependent on understanding population-specific variations in cancer-associated gene frequencies.

How to manage transfusion systems in developing countries: The Experience of Eastern and Southern Mediterranean countries

OBJECTIVES

To outline and analyse the national organisation, infrastructure and management of transfusion systems in countries sharing common historical, cultural and economic features and to decipher management trends, in order to potentially benchmark.

BACKGROUND

Little is known regarding transfusion systems in Eastern/southern Mediterranean at a time international organisations are calling for the establishment of a safe and sustainable blood system.

MATERIALS AND METHODS

Data emanating from eight Arabic-speaking Eastern/Southern Mediterranean countries who responded to five surveys were collected and tabulated.

RESULTS

While similarities in terms of supervision by national authorities, authorization of blood centres, quality control and management information system are evident, some significant divergence between these countries do exists. Only Lebanon does not possess a national blood establishment or organisation for blood supply. Blood components are fully government-subsidised in Algeria and Mauritania. Algeria, Morocco and Tunisia have a blood supply that relies mainly on Voluntary non-remunerated donors. Plateletpheresis is performed in all countries except Mauritania while plasmapheresis exists only in Algeria and Egypt. Morocco is the sole country outsourcing its plasma for Plasma derived products.

CONCLUSION

Despite the various challenges facing these countries, lot of progresses have been made so far in the field of transfusion medicine. Yet, nationally coordinated blood programs overviewed by national regulatory authorities and actively supported by local governments are still needed to ensure the optimum level of blood safety.

Awareness and Attitude Towards the Premarital Screening Programme Among High School Students in Muscat, Oman

Objectives

This study aimed to explore high school students' awareness and attitude towards premarital screening (PMS).

Methods

This cross-sectional study was conducted in 10 public high schools in Muscat, Oman from May to July 2016. A three-part self-administered questionnaire was used to collect data from grade 12 students. The first part focused on respondents' sociodemographic characteristics, while the second part dealt with awareness of the national PMS programme and the third part explored attitudes towards the national PMS programme.

Results

A total of 1,541 participants (response rate: 91.1%) completed the questionnaire. Most participants (78.1%) were aware of the availability of the PMS programme and their main source of information was family and friends (34.3%). The majority of students (87.4%) believed that PMS is important and most students (87.2%) indicated that they would undergo PMS. Over half of the students (55.3%) agreed that PMS should be mandatory before marriage and approximately one-third (38.3%) were in favour of having laws and regulations to prevent consanguineous marriages. Females were significantly more in favour of making PMS mandatory (P = 0.002) and enforcing PMS laws (P = 0.010) compared to males.

Conclusion

Most respondents had good levels of knowledge about the PMS programme and half thought it is important to be tested. However, some students were not in favour of PMS. Increasing awareness about Oman's PMS programme is important and motivating students could contribute significantly to increasing the utilisation of the PMS programme and to limiting genetic blood disorders.

Undiagnosed Hemoglobinopathies: A potential threat to the premarital screening program

Objectives

To evaluate the prevalence of undiagnosed hemoglobinopathies among individuals visiting the premarital screening Centre.

Methods

This study was conducted at Premarital Screening Centre, King Fahad Central Hospital and Research Centre, Jazan, between January 2018 and October 2018. A total of 3,970 (male n =1,859 and female n = 2,111) individuals were included in the study. Data of complete blood count, hemoglobin electrophoresis and sickling tests of all individuals recruited in the study were obtained and statistically analyzed.

Results

One thousand three hundred and twelve individuals had abnormal complete blood counts or hemoglobin electrophoresis results, that include sickle cell trait (13.5%), sickle cell disease (0.7%), β thalassemia with sickle cell trait (2.46%), β thalassemia trait (1.51%), β thalassemia major (0.075%), suspected α thalassemia or other hemoglobinopathies (4.43%), hemoglobin H (0.3%), hemoglobin E (0.075%), undiagnosed cases (0.91%) and iron deficient (7.23%).

Conclusion

A high percentage of individuals are suspected for α thalassemia or other hemoglobinopathies that needs to be diagnosed. Further investigations shall be included in the premarital screening program to diagnose these inconclusive cases. Coexistence iron deficiency with thalassemia shall also be ruled out during premarital screening program.

Antenatal screening for haemoglobinopathies: current status, barriers and ethics

Sickle cell disease (SCD) and thalassaemia are genetic disorders that are caused by errors in the genes for haemoglobin and are some of the most common significant genetic disorders in the world, resulting in significant morbidity and mortality. Great disparities exist in the outcome of these conditions between resource- rich and resource-poor nations. Antenatal screening for these disorders aims to provide couples with information about their reproductive risk and enable them to make informed reproductive choices; ultimately reducing the likelihood of children being born with these conditions. This review provides an overview of the current status of antenatal, pre-marital and population screening of SCD and thalassaemia in countries with both high-and low prevalence of these conditions, methods of screening in use, and discusses some of the pitfalls, ethical issues and controversies surrounding antenatal screening. It also discusses outcomes of some screening programmes and recognises the need for the establishment of antenatal screening in areas where their prevalence is highest; namely sub-Saharan Africa and India.

Quantifying the Levels of Knowledge, Attitude, and Practice Associated with Sickle Cell Disease and Premarital Genetic Counseling in 350 Saudi Adults

Our study aims to observe the levels of knowledge, attitude, and practice (KAP) associated with sickle cell disease (SCD) and premarital genetic counseling (PMGC) in 351 Saudi adults. The relationships between KAP levels and sociodemographic characteristics (age, gender, marital status, and educational level) were observed. The study was conducted in King Khalid University Hospital between February 21, 2017, and March 7, 2018. A total of 351 Saudi participants attending the primary care clinic were selected using convenience sampling and were given a self-administered questionnaire. Overall, the 351 participants had the best attitude (41% scoring "good"), followed by knowledge (28.8%), and, lastly, practice (19.1%). Out of the sociodemographic characteristics, age group was the most statistically significant in all the three categories (knowledge, attitude, and practice). The > 50-year age group performed the worst in all the three categories. Despite the advancements in public healthcare measures in Saudi Arabia, our study revealed that there are still many gaps to be filled regarding the knowledge, attitude, and practice associated with SCD and PMGC.

Population Screening for Hemoglobinopathies

Hemoglobinopathies are the most common single-gene disorders in the world. Their prevalence is predicted to increase in the future, and low-income hemoglobinopathy-endemic regions need to manage most of the world's affected persons. International organizations, governments, and other stakeholders have initiated national or regional prevention programs in both endemic and nonendemic countries by performing population screening for α- and β-thalassemia, HbE disease, and sickle cell disease in neonates, adolescents, reproductive-age adults (preconceptionally or in the early antenatal period), and family members of diagnosed cases. The main aim of screening is to reduce the number of affected births and, in the case of sickle cell disease, reduce childhood morbidity and mortality. Screening strategies vary depending on the population group, but a few common screening test methods are universally used. We discuss the salient features of population-screening programs around the globe as well as current and proposed screening test methodologies.

Hemoglobin A2 (HbA2) has a measure of unreliability in diagnosing β-thalassemia trait (β-TT)

INTRODUCTION

Detection of β-thalassemia trait or carriers (β-TT) depends significantly on an increase in Hemoglobin A₂ (HbA₂) levels, which is found at low levels (<3%) in normal healthy individuals and elevated levels (≥3.5%) in β-TT individuals. The study was designed to evaluate the reliability of the diagnostic parameter HbA₂ in the differentiation of β-TT and non-β-TT in Saudis.

METHODS

The widely used high performance liquid chromatography (Variant II Bio-Rad) was used to measure HbA₂ levels in blood. Sanger sequencing was used to screen the variation in globin genes (HBB, HBD, HBA1, and HBA2). All the study subjects were divided into βTT and non-βTT (wild) categories based on the presence or absence of HBB variations and further sub-divided into false positive, true positive, false negative, and true negative, based on HbA₂ values.

RESULTS

Out of 288 samples, 96 had HBB gene mutations. Of the 96 β-TT samples, sickle cell trait (SCT) samples (n = 58) were excluded, while the remaining (38 β-TT) were included in the detailed analysis: seven subjects with the HBB mutation had normal HbA₂ (<3%), and three were borderline (3.1-3.9%). The remainder (n = 28) had an elevated HbA₂ level (>4%). Based on HbA₂ analysis alone, both these groups would be incorrectly diagnosed as normal. Similarly, of the 189 non-β-TT samples, 179 had normal HbA₂, eight had borderline HbA₂, and two had a HbA₂ level above 4%. Based on HbA₂ analysis alone, borderline and >4% HbA₂ individuals, negative for β-TT, can be incorrectly diagnosed as carriers.

CONCLUSION

Given the percentage of samples falling in the HbA₂ "borderline" and "normal" categories, it can be concluded that HbA₂ has a measure of unreliability in the diagnosis of β-thalassemia carriers.

Should Premarital Screening for Blood Disorders be an Obligatory Measure in Oman?

Due to the high rate of consanguineous marriages in Oman, there is a correspondingly high prevalence of hereditary blood disorders, particularly sickle cell disease and β-thalassaemia. This article proposes the possibility of implementing mandatory premarital carrier screening for blood disorders in Oman, while giving due consideration to potential social and cultural obstacles. Although the implementation of such legislation would require collaboration between different sectors and may negatively affect the autonomy of certain individuals, mandatory premarital screening would help to alleviate the burden of hereditary blood disorders on the national healthcare system, as well as reduce avoidable suffering among carriers and their families.

How Can Eastern/Southern Mediterranean Countries Resolve Quality and Safety Issues in Transfusion Medicine?

Unlike their Western counterparts, some of the Eastern/Southern Mediterranean countries lack centralized coordinated blood transfusion services leading to an unequal blood safety level. This was recently highlighted by a recent World Health Organization (WHO) regional committee report in which WHO urges these countries to establish and implement a national blood system with well-coordinated blood transfusion activities and to make attempts to reach 100% voluntary non-remunerated blood donation. The objective is thus to meet the same levels or standards as Western countries in term of self-sufficiency and blood safety. This raises the question whether these countries can either comply with Western countries’ guidelines and experiences or develop their own safety scheme based on proper sociopolitical and economic features. Another option is to identify efficient and cost-effective strategies setup successfully in neighbor countries sharing cultural and economic features. To address this issue—and make an attempt to achieve this goal—we designed a number of surveys specifically addressed to Mediterranean countries, which were sent out to the national authorities; so far, five surveys aim at covering all aspects in blood collection, processing, testing, inventory and distribution, as well as patient immune-hematological testing and follow-up (including surveillance and vigilances). It is anticipated that such practice can help identifying and then sharing the more successful and cost-effective experiences, and be really focused on Mediterranean areas while not necessarily copying and pasting experiences designed for Western/Northern areas with significantly distinct situations.

Distribution of hemoglobinopathy disorders in Saudi Arabia based on data from the premarital screening and genetic counseling program, 2011-2015

The prevalence rates of β-thalassemia (β-thal) and Sickle Cell Disease (SCD) in Saudi Arabia are considered one of the highest compared to surrounding countries in the Middle East (0.05% and 4.50%, respectively). In this study, Secondary data analysis was obtained from the premarital screening and genetic counseling program (PMSGC), and included 12,30,582 individuals from February 2011 to December 2015. Prevalence rates (per 1000 population) for β-thal and SCD were calculated for carrier status, disease status and their combination. During the 5-year study period, the overall prevalence rate per 1000 population for β-thal was 13.6 (12.9 for the trait and 0.7 for the disease). The prevalence rate for SCD was 49.6 (45.8 for the trait and 3.8 for the disease). Rates for β-thal were found to decrease from 24.2 in 2011, to 12 in 2015. However, SCD rates remained rather constant and ranged from 42.3 in 2011 to 49.8 in 2015. The highest rate for both β-thal and SCD was observed in the Eastern and Southern regions. This result reflects major accomplishment of the PMSGC. This study recommends further improvement in preventive measures in high-risk regions, and enhanced community awareness to provide the highest rate reduction for these disorders.

Changes in Attitudes towards Marriage and Reproduction among People with a Genetic Illness

In this article, the change in attitude towards marriage and reproduction among Iranian people with a genetic illness called thalassemia has been investigated, along with an analysis of the impact brought by the national thalassemia prevention programmes, which were introduced to discourage marriage between carriers (thalassemia minor) and the birth of severe homozygous cases (thalassemia major). Marriage and reproductive choices of people with both thalassemia minor and thalassemia major were focused upon in order to prevent the birth of affected babies. Thalassemia carrier couples prefer to choose abortion of affected foetuses, rather than giving up their marriage, and some people with thalassemia major choose a person with thalassemia major as a marriage partner, though they must give up having their own child.

Prenatal Diagnosis of HbE-β-Thalassemia: Experience of a Center in Western India

The clinical presentation of HbE-β-thalassemia is extremely variable, however, many cases are severe and transfusion dependent. We offered prenatal diagnosis to 108 couples, 20 of whom came prospectively. CVS was done in 93 cases (9.5-13 weeks of gestation) while amniocentesis/cordocentesis was done for 15 cases in the second trimester. Diagnosis was done by reverse dot blot hybridization, ARMS, DNA sequencing and in a few cases by HPLC analysis of fetal blood. The genetic combinations in the couples at-risk were the following: HbE trait/β-thal trait-95, HbE-thal/HbE trait-5, HbE homozygous/β-thal trait-3, HbE-thal/β-thal trait-3, HbE Lepore/β-thal trait-1, HbE trait/HbD^Punjab trait-1. IVS1-5(G>C) was the commonest β-thalassemia mutation followed by codon15(G>A), codon30(G>C), codons41/42(-CTTT), the 619 bp deletion and codon8/9(+G) in the β-thalassemic parent. However, several rare mutations seen in India like -90(C>T), -88(C>T),codon15(-T), IVS1-129(A>C), IVS1-130(G>C), IVSII-1(G>A), IVSII-837(C>T) and IVSII 848(C>A) were also encountered. Twenty-one fetuses were affected (HbE-β-thal-20, β-thal major-1) and all the couples opted for termination of the pregnancies. Couples with affected children wish to undergo prenatal testing for HbE-β-thal in subsequent pregnancies. More regional centers are needed for these services, particularly in West Bengal and the North-East where HbE is very common.

Differentiation of beta thalassemia trait from iron deficiency anemia by hematological indices

Objective:

We aimed at finding out reliable parameter in the differentiation of iron deficiency anemia (IDA) and beta-thalassemia trait (β-TT) in the adult population subjected to Saudi Arabian Premarital Screening Program.

Methods:

A total of 620 adults (age range 21-36 years) reported during February 2012 to November 2012. Tests for serum iron and ferritin were carried out in individuals showing low hemoglobin (Hb). All the selected subjects’ samples were subjected to blood morphology, comparison of MCV, RBC count. Red Cell Distribution Width (RDW) was noted from the Coulter Report whereas Red Cell Distribution Width Index (RDWI) value was calculated for all the samples.

Results:

A total of one hundred &thirty-five individuals with hypochromic microcytic anemia having normal hemoglobin F and hemoglobin A2 < 3.2% were inducted in the study. Ninety-three were diagnosed having IDA, whereas thirty-two were having βTT. Ten individuals revealed other causes of anemia. The RBC count was higher, and MCV was much lower in βTT as compared to IDA. Both groups were subjected to RDW and RDWI, however, RDWI which showed better sensitivity and specificity for βTT.

Conclusion:

RDWI is a reliable and useful index for differentiation among IDA and βTT, as compared to RDW.

Thalassemias in South Asia: clinical lessons learnt from Bangladesh

Thalassemias are emerging as a global public health concern. Due to remarkable success in the reduction of childhood mortality by controlling infectious diseases in developing countries, thalassemias are likely to be a major public health concern in the coming decades in South Asia. Despite the fact that Bangladesh lies in the world’s thalassemia belt, the information on different aspects (epidemiology, clinical course, mortality, complications and treatment outcomes) of thalassemias is lacking. In this comprehensive review, the aim is to to depict the epidemiological aspects of thalassemias, mutation profile and current treatment and management practices in the country by sharing the experience of dealing with 1178 cases over 2009–2014 time periods in a specialized thalassemia treatment centre. We have also discussed the preventative strategies of thalassemias from the context of Bangladesh which could be effective for other developing countries.