Thalassemia in the United Arab Emirates: Why it can be prevented but not eradicated

Perception of consanguineous marriage among the qatari population

Background

Hereditary blood diseases are widespread among the Arab population due to the high rates of consanguineous marriages; research regarding the perception of consanguineous marriage in some countries, such as Qatar, is extremely scarce. Therefore, this study aimed to investigate the prevalence of consanguineous marriage and assess the perception of consanguineous marriage among the Qatari population.

Methods

A cross-sectional study used a self-administered questionnaire among 395 Qatari adults aged 18-35 who attended primary healthcare institutions in Qatar. A convenience sampling technique was used to select the study participants. An independent t-test was used to compare the significance of the mean between the two groups with positive and negative perceptions of consanguineous marriage. Categorical data were analyzed for association using the chi-square or Fisher's exact test. Finally, a multiple logistic regression analysis was conducted to determine the significant predictors of the positive perception of consanguineous marriage. A significant level was set at p < 0.05.

Results

Approximately 45% of the participants had a positive perception toward consanguineous marriage, and the most common reason stated by those participants was "habit and traditions." The prevalence of consanguineous marriage among married couples was 62.6%, and among those with consanguineous marriage, most were married to first cousins (81.7%). Moreover, compared to the participants with negative perceptions of consanguineous marriage, those with positive ones were significantly older, married, with lower educational levels and higher monthly income levels, did not hear about glucose-6-phosphate dehydrogenase (G6PD) deficiency, did not know what kinds of diseases are being screened in the premarital test, and were married to a relative.

Conclusion

The prevalence of consanguineous marriage is high among the Qatari population, and this requires an immediate need for community-based campaigns to raise public awareness about the problem and its potential impact.

Nursing Interventions to Improve Quality of Life Among Children and Adolescents with Thalassemia: A Scoping Review

Thalassemia is an inherited blood disorder affecting hemoglobin synthesis which leads to chronic hemolysis that can reduce the quality of life of children with it due to the disease and the treatment given. However, the intervention still focuses on handling physical problems due to thalassemia. So that an intervention that focuses on improving the quality of life of children with thalassemia is needed. The purpose of this study is to explore interventions that could improve the quality of life of children with thalassemia. A scoping review study design was used in this study. The databases used are CINAHL, PubMed, and Scopus. Articles published from last five years (2018-2022), open access full-text, in English, and with the type of randomized controlled trial (RCT). The keywords used in English are "thalassemia or beta-thalassemia" AND "quality of life OR Life Quality OR Health-Related Quality of Life" AND "nursing intervention OR nursing care". From ten articles analyzed, we found five types of nursing intervention: Health Care Instructions, Psychological Program, Educational Program, Counseling Program, and Self-care Model, which were carried out for 1-7 months. The articles in this study are from Egypt and Iran. The sample in this study is the range of 20-173 respondents. The thalassemia patients in this study were in the age range of 7-35 years, but the average age of the patients was in their 20s. Nursing intervention can potentially improve the quality of life in children and adolescents with thalassemia. Nurses need to pay attention to the patient's age, family and patient knowledge about the disease, length of stay, and the patient's physical and psychological condition in providing nursing care to patients with thalassemia. Implementation of nursing is given by paying attention to the stages of child development and involving the family. Nursing interventions can be carried out by nurses or nurses teach families to intervene at home. This nursing intervention has the potential to improve the quality of life of patients with thalassemia while still taking into account the conditions of the patient and family in a comprehensive manner.

Healthcare resource utilization and direct costs of transfusion-dependent thalassemia patients in Dubai, United Arab Emirates: a retrospective cost-of-illness study

Background

Patients with transfusion-dependent thalassemia (TDT) require lifelong blood transfusions and iron chelation therapy. Thus, patients afflicted with TDT often have to undergo blood transfusion and iron chelation therapy, which causes a major economic burden on them. However, this topic has not been reported in Dubai, United Arab Emirates (UAE). Hence, this study aimed to evaluate healthcare resource utilization and associated direct costs related to patients with TDT in Dubai, UAE.

Methods

For this study, a retrospective prevalence-based cost-of-illness analysis based on the UAE healthcare system and patient perspectives was conducted among patients with TDT treated at the Dubai Thalassemia Center in 2019. Information regarding healthcare resource utilization and direct medical costs was collected from the billing system connected to the electronic medical record system. Patients and their families were interviewed for direct non-medical cost estimations.

Results

A total of 255 patients with TDT were included in the study. The mean annual direct medical cost was estimated at AED 131,156 (USD 35,713) (95% CI: 124,735 – 137,578). The main driver of the medical cost for the participants as iron chelation therapy AED 78,372 (95% CI: 72,671 – 84,074) (59.8%), followed by blood transfusions, which accounted for AED 34,223 (95% CI: 32,854 – 35,593) 26.1% of the total direct medical costs. The mean annual direct non-medical costs was AED 2,223 (USD 605) (95% CI: 1,946 – 2,500). Age (p < 0.001), severe serum ferritin levels (p = 0.016), the presence of complications (p < 0.001), and the type of iron chelation therapy (p < 0.001) were significant predictors of higher direct medical costs incurred by the participants.

Conclusion

Transfusion-dependent thalassemia poses a substantial economic burden on the healthcare system, patients, and their families. Our results show that the highest medical cost proportion was due to iron chelation therapy. In this regard, efforts must be made to improve the patients’ acceptance and satisfaction with their iron chelation therapy to increase their compliance and improve the effectiveness of treatment, which could play an essential role in controlling the economic burden of this disease. Moreover, greater support is essential for families that suffer catastrophic out-of-pocket expenses.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07663-6.

Productivity Loss and Associated Costs Among Patients with Transfusion-Dependent Thalassemia in Dubai, United Arab Emirates

Objective

The aim of this study was to assess the indirect burden of patients with transfusion-dependent thalassemia (TDT) in Dubai, the United Arab Emirates (UAE).

Methods

Adult patients with TDT were enrolled during blood transfusion sessions. Productivity loss for patients in the preceding four weeks was reported using the validated iMTA Productivity Cost Questionnaire (iPCQ).

Results

A total of 161 adult patients with TDT were included in the study. The annual total productivity loss cost at paid work among 79 employed patients was AED 17,230 (USD 4691) (95% CI: 12,302-22,159), out of which absenteeism contributed AED 10,328 (USD 2812) and presenteeism contributed AED 6902 (USD 1879), whereas the annual total productivity loss cost at unpaid work was AED 4053 (USD 1104) (95% CI: 3471-4661). The annual mean total indirect cost for paid and unpaid work was AED 21,283 (USD 5795). Monthly income, nationality, and having two and more disease complications were the significant predictors of higher productivity loss costs. Having previously had a splenectomy was a negative and significant predictor of productivity loss costs.

Conclusion

TDT was associated with substantial productivity loss and indirect costs in the UAE. Health policies that aim to control transfusion-dependent thalassemia effectively are necessary and could result in cost savings for patients and employers.

Epidemiology of Thalassemia in Gulf Cooperation Council Countries: A Systematic Review

Background

Thalassemia has a burden on the healthcare systems of many countries. About 56000 conceptions result in thalassemia, globally.

Objective

To assess the epidemiological profile of thalassemia in the Gulf Cooperation Council (GCC) countries.

Methods

A systematic search was conducted in MEDLINE/PubMed (National Library of Medicine), CINAHL, and Embase. Relevant observational studies reporting the epidemiology of thalassemia among the GCC population were selected. Data on the prevalence, frequency, and complications of thalassemia were extracted. The quality of the retrieved studies was assessed according to the Newcastle-Ottawa Quality Assessment Scale.

Results

Eighteen studies (14 cross-sectional studies, two retrospective observational studies, and two retrospective analysis) with a total of 3343042 participants were included in this systematic review. Of the 18 studies, 11 studies were conducted in Saudi Arabia, two in the Kingdom of Bahrain, one in Kuwait, three in the United Arab Emirates (UAE), and one in Qatar. The prevalence of thalassemia among children below five years of age ranged from 0.25% to 33%, while it was 0.9% in children above five years and from 0.035% to 43.3% among adult thalassemia patients. The most-reported risk factors were consanguineous marriage and high-risk marriage. There was a lack of data regarding mortality rates in thalassemia.

Conclusions

Despite the premarital screening and genetic counseling (PMSGC) program for thalassemia, the incidence of high-risk couple marriages in GCC countries cannot be effectively diminished. This study suggested that the PMSGC program should adopt more attention for the high-risk areas, to enhance the level of consciousness about the hemoglobinopathy diseases and the consequences of consanguinity among the at-risk couple.

Abnormal diastolic function and Global longitudinal strain in patients with Thalassemia Major on long term chelation therapy

Cardiac complications are the major cause of mortality in patients with Thalassemia major (TM). Cardiac T2* MRI is currently the gold standard for assessing myocardial iron concentration. The aim of our study was to assess whether any echocardiographic parameter would correlate with these findings in patients well established on chelation therapy. This was a prospective study on patients with TM who are regularly followed in our clinic. Patients had a cardiac MRI and echocardiogram within 2 months of each other. Echo parameters included global longitudinal strain and diastolic function. We also compared these findings with those from a cohort of thalassemia intermedia (TI) and normal controls. A total of 84 patients (mean age 26.3 ± 6.1 years, 42.8% male) with TM were enrolled. All had normal left ventricular ejection fraction and only 8 patients had MRI T2* < 10. As compared to 17 patients with TI and 53 controls, these patients had significantly higher E/E' and lower pulmonary vein s/dd ratio suggesting early diastolic dysfunction. 28 patients fulfilled criteria for diastolic dysfunction even in the presence of normal MRI T2*. Global longitudinal strain (GLS) was significantly lower in the TM group as compared to the TI and controls. We found no correlation between any of the echo findings and the MRI T2*in TM patients. In patients with thalassemia and MRI T2* > 20 ms features of diastolic dysfunction persist even in the presence of normal LV function and normal GLS. This suggests that diastolic function remains abnormal even when myocardial iron concentrations are normal and follow up therefore is essential.

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.

Maternal and birth cohort studies in the Gulf Cooperation Council countries: a systematic review and meta-analysis

BACKGROUND

We systematically reviewed and chronicled exposures and outcomes measured in the maternal and birth cohort studies in the Gulf Cooperation Council (GCC) countries and quantitatively summarized the weighted effect estimates between maternal obesity and (1) cesarean section (CS) and (2) fetal macrosomia.

METHODS

We searched MEDLINE-PubMed, Embase, Cochrane Library, Scopus, and Web of Science electronic databases up to 30 June 2019. We considered all maternal and birth cohort studies conducted in the six GCC countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates (UAE)). We categorized cohort studies on the basis of the exposure(s) (anthropometric, environmental, medical, maternal/reproductive, perinatal, or socioeconomic) and outcome(s) (maternal or birth) being measured. Adjusted weighted effect estimates, in the form of relative risks, between maternal obesity and CS and fetal macrosomia were generated using a random-effects model.

RESULTS

Of 3502 citations, 81 published cohort studies were included. One cohort study was in Bahrain, eight in Kuwait, seven in Qatar, six in Oman, 52 in Saudi Arabia, and seven in the UAE. Majority of the exposures studied were maternal/reproductive (65.2%) or medical (39.5%). Birth and maternal outcomes were reported in 82.7% and in 74.1% of the cohort studies, respectively. In Saudi Arabia, babies born to obese women were at a higher risk of macrosomia (adjusted relative risk (aRR), 1.15; 95% confidence interval (CI), 1.10-1.20; I2 = 50%) or cesarean section (aRR, 1.21; 95% CI, 1.15-1.26; I2 = 62.0%). Several cohort studies were only descriptive without reporting the magnitude of the effect estimate between the assessed exposures and outcomes.

CONCLUSIONS

Cohort studies in the GCC have predominantly focused on reproductive and medical exposures. Obese pregnant women are at an increased risk of undergoing CS delivery or macrosomic births. Longer-term studies that explore a wider range of environmental and biological exposures and outcomes relevant to the GCC region are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017068910.

Consequences of β-Thalassemia or Sickle Cell Disease for Ovarian Follicle Number and Morphology in Girls Who Had Ovarian Tissue Cryopreserved

Women with β-thalassemia (BT) and sickle cell disease (SCD) have a high risk of infertility and premature ovarian insufficiency. Different fertility preserving strategies, including ovarian tissue cryopreservation (OTC) and oocyte cryopreservation has been considered, and healthy babies have been born after successful OTC and transplantation. We evaluated follicle number and follicle health in ovarian tissue from a cohort of BT and SCD patients who underwent OTC before the age of 18 years. Patients undergoing OTC from 2002 to 2019 were included. A total of 14 girls and adolescents with BT and four with SCD, aged 2.8-17.4 years at OTC were included together with a reference group of 43 girls and adolescents with non-anemia diseases considered to have normal ovaries aged 0.6-17.9 years at OTC. Ovarian follicle density was measured in cortex biopsies and compared to the reference group. Expression of proteins associated with follicular health was evaluated using immunohistochemistry. Follicles were detected in the ovarian cortex biopsies from all patients with BT and SCD. The follicle densities were within the 95% prediction interval of the reference group in all cases. A similar expression of six proteins essential for follicular health was detected using immunohistochemistry in BT, SCD, and references. OTC should be considered an option for young girls and adolescents with BT and SCD.

Optimization and application of a dried blood spot-based genetic screening method for thalassemia in Shenzhen newborns

BACKGROUND

To optimize and apply an approach suitable for large-scale neonatal thalassemia genetic screening in China, thalassemia genotypes were determined by polymerase chain reaction-reverse dot blot using DNA extracted from dried blood spots (DBS) obtained from newborn screening programs.

METHODS

Firstly, the most suitable commercial DNA extraction kit for DBS was screened. Then, the appropriate amount of DBS required for the automated high-throughput DNA extraction system was evaluated. Finally, the thalassemia prevalence and genotype spectrum in Shenzhen were investigated in 2028 newborns using the optimized screening procedure.

RESULTS

The Magentec extraction kit was best suited for the automated DBS DNA extraction system using eight 3-mm DBS discs. The neonatal thalassemia prevalence in Shenzhen was 9.12%; 6.31% α-thalassemia, 2.37% β-thalassemia, and 0.44% α-/β-thalassemia.

CONCLUSIONS

Genetic screening based on DBS can precisely identify the thalassemia genotypes. Both α- and β-thalassemia are widely distributed in Shenzhen newborns. Newborn genetic screening is important for establishing a comprehensive thalassemia prevention program and for public education.

Hemoglobinopathies in the North of Morocco: Consanguinity Pilot Study

Consanguinity is a social behavior characterized by the arrangement of marriages between relatives. It coincides generally with the geographic distribution of recessive genetic diseases as it increases the likelihood of homozygosis and, consequently, the incidence of their pathologies in the population. In this pilot study, we assess the effect of inbreeding on the burden of hemoglobinopathies in Northern Morocco. From January 2016 to December 2018, 197 children born in the studied region to three ancestral generations and diagnosed with hemoglobinopathies were subject to investigation. The rate of consanguinity in the parents' generation of children with hemoglobinopathies was 50.25%, with first cousin marriages accounting for 68.69% of consanguineous unions (FI = 0.02). The corresponding rates in the general population, based on a sample of N = 900, were 29.67% and 82.02%, respectively. The marriages between first cousins are the most common among the other types of consanguineous unions. Our study propounds that consanguinity substantially contributes to the hemoglobinopathy burden in the studied region and has changed little over time. Refraining from consanguineous marriages and detecting couples at risk could contribute to the reduction of the incidence of genetic diseases in our country.

Oral manifestations and dentofacial anomalies in β-thalassemia major children in Dubai (UAE)

AIMS

The purpose of this study was to identify special oral and dentofacial manifestations of β-thalassemia major (ΒTM) in Emarati children in Dubai (UAE).

MATERIALS AND METHODS

A total of 38 (ΒTM) and 76 healthy Emirati children were recruited. An oral examination was conducted to determine dmft/DMFT indices, Simplified Oral Hygiene Index, occlusal anomalies, dentofacial, and soft-tissue abnormalities.

RESULTS

ΒTM children had significantly higher DMFT compared to the healthy controls (p-value, 0.017). The Met Need Index (MNI) and the Restorative Index (RI) were lower in the ΒTM group but without statistical significance. Calculus Index (CI) was found to be significantly higher in ΒTM children (p-value, 0.002). The proportion of gingivitis was significantly lower in the ΒTM group (p-value, 0.009). ΒTM children had significantly higher proportion of retained primary teeth (p-value, 0.001) and gingival pigmentation compared with healthy controls (p-value, 0.001). BTM children did not have any statistically significant difference in the Angle molar classiication compared to the control. Interestigly, a significantly higher proportion of transverse cross bite was found in the control subjects compared to the BTM group (p-value, 0.004).

CONCLUSIONS

Significantly higher DMFT, retained primary teeth, gingival pigmentation, and CI was found in the BTM group compared to the controls while significantly lower gingivitis index and transverse cross bite was seen in the BTM group.