Hemoglobinopathy Carrier Prevalence in The United Arab Emirates: First Analysis of The Dubai Health Authority Premarital Screening Program Results

Beta Thalassemia Carrier Rate: Problem Burden among High School Children

Background & Aim of the Work: β-Thalassemia (βT) is highly prevalent in some countries like Egypt. Accurate data about actual disease prevalence and heavily prevalent geographic locations are essential to help in early detection and in setting up effective preventive programs. We aim for screening βT carriers among Egyptian high school students in the Delta region.

SUBJECTS AND METHODS

A cross-sectional multicenter study was carried out on 4320 randomly selected students from four governorates of the Nile Delta region, Egypt. All patients were to be tested for their complete blood count. Those with microcytic hypochromic anemia not caused by iron deficiency were tested for βT carrier status using high-performance liquid chromatography.

RESULTS

The total prevalence of βT carrier rate was 6.13%. The highest prevalence was detected in Al-Sharkia Governorate, reaching 7.89%, followed by 6.90% in Al-Gharbia Governorate. Al- Dakahilia and Al-Menoufia showed lower rates of 4.86% and 3.73%, respectively.

CONCLUSION

Despite the premarital national screening program for βT in Egypt, the carrier rate is still high. More effort should be done into the proper implementation of national prevention programs.

Going Back to Fundamentals: Three Marriageable Actions for Thalassemia and Carrier Population Management

We investigated the impact of three marriageable actions: normal-to-carrier, carrier-to-normal, and carrier-to-carrier marriages on thalassemia and carrier populations. The well-known strategy is limiting the carrier-to-carrier marriage to reduce the thalassemia population. Thus, the other two marriageable actions were often ignored. Other than a simple explanation of their genetic consequences, their important aspect in the thalassemia inheritance mechanism has never been studied at the population level. Moreover, there is no mathematical model investigating problem of interest for blood disorders at the population level. Hence, we developed a mathematical model to examine the possibility of eradication/reduction of thalassemia and carrier populations through each of the three marriageable actions in the long-term. We conducted computer simulations with the demographic data of the United Arab Emirates in which high thalassemia carrier prevalence is identified. We found that promoting more carrier-to-normal marriage will eventually have the same effects on marriage reconsideration for carrier-carrier couples, contributing to the reduction of the carrier population in the long-term. Interestingly, the normal-to-carrier marriage does not necessarily have a similar effect on thalassemia and carrier populations as that of the carrier-to-normal marriage. Thus, the two marriageable actions should be distinguished and also seriously considered in education and public awareness campaigns for thalassemia.

Current Updates on Expanded Carrier Screening: New Insights in the Omics Era

Genetic carrier screening has been successfully used over the last decades to identify individuals at risk of transmitting specific DNA variants to their newborns, thus having an affected child. Traditional testing has been offered based on familial and/or ethnic backgrounds. The development of high-throughput technologies, such as next-generations sequencing, able to allow the study of large genomic regions in a time and cost-affordable way, has moved carrier screening toward a more comprehensive and extensive approach, i.e., expanded carrier screening (ECS). ECS simultaneously analyses several disease-related genes and better estimates individuals’ carrier status. Indeed, it is not influenced by ethnicity and is not limited to a subset of mutations that may arise from poor information in some populations. Moreover, if couples carry out ECS before conceiving a baby, it allows them to obtain a complete estimation of their genetic risk and the possibility to make an informed decision regarding their reproductive life. Despite these advantages, some weakness still exists regarding, for example, the number of genes and the kind of diseases to be analyzed and the interpretation and communication of the obtained results. Once these points are fixed, it is expectable that ECS will become an ever more frequent practice in clinical settings.

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.

Systematic review of outcomes in studies of reproductive genetic carrier screening: Towards development of a core outcome set

PURPOSE

Current practice recommendations support the widespread implementation of reproductive genetic carrier screening (RGCS). These consensus-based recommendations highlight a research gap, with findings from current studies being insufficient to meet the standard required for more rigorous evidence-based recommendations. This systematic review assessed methodological aspects of studies on RGCS to inform the need for a core outcome set.

METHODS

We conducted a systematic search to identify peer-reviewed published studies offering population-based RGCS. Study designs, outcomes, and measurement methods were extracted. A narrative synthesis was conducting using an existing outcome taxonomy and criteria used in the evaluation of genetic screening programs as frameworks.

RESULTS

Sixty-five publications were included. We extracted 120 outcomes representing 24 outcome domains. Heterogeneity in outcome selection, measurement methods and time points of assessment was extensive. Quality appraisal raised concerns for bias. We found that reported outcomes had limited applicability to criteria used to evaluate genetic screening programs.

CONCLUSION

Despite a large body of literature, diverse approaches to research have limited the conclusions that can be cumulatively drawn from this body of evidence. Consensus regarding meaningful outcomes for evaluation of RGCS would be a valuable first step in working towards evidence-based practice recommendations, supporting the development of a core outcome set.

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.

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.

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.

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.

Social and cultural influences on genetic screening programme acceptability: A mixed-methods study of the views of adults, carriers, and family members living with thalassemia in the UK

As population‐level carrier screening panels for reprogenetic information emerge globally, conditions to be included, and the timing of implementation is widely debated. Thalassemia is the only condition for which population‐based prenatal carrier screening is offered in the UK. However, little is known about the views and experiences of the UK thalassemia‐affected community toward this screening or other forms of genetic screening for thalassemia (newborn, preconception), despite the range of direct consequences of screening programmes for this group.

Using a mixed‐methods integrative analysis (qualitative interviews n = 20 and quantitative survey n = 80), this study outlines the experiences and attitudes of adults with thalassemia, their family members, and screen‐identified thalassemia carriers toward preconception, prenatal, and newborn screening for thalassemia. The majority of participants described thalassemia as a burdensome condition with a range of negative impacts, which contributed to their strong support for screening in all its potential formats. However, the data also highlight the challenges of each screening mode for this group, reflected in the high level of value conflict in participants' accounts and decisions. Cultural, social, and (to a lesser extent) religious factors were found to mitigate against the advantages of early screens, particularly within faith communities. Social stigma emerged as key to this process, informing the way that thalassemia severity was not only perceived, but also experienced by affected adults, which ultimately influenced screening uptake and outcomes.

These findings suggest that cultural and social sensitivity is as important as the mode of screening delivery itself, if the iatrogenic and unintended harms of screening—particularly the social/psychological burden of value conflict—are to be adequately addressed and minimized.

Hemoglobin disorders: lentiviral gene therapy in the starting blocks to enter clinical practice

The β-hemoglobinopathies, transfusion-dependent β-thalassemia and sickle cell disease, are the most prevalent inherited disorders worldwide and affect millions of people. Many of these patients have a shortened life expectancy and suffer from severe morbidity despite supportive therapies, which impose an enormous financial burden to societies. The only available curative therapy is allogeneic hematopoietic stem cell transplantation, although most patients do not have an HLA-matched sibling donor, and those who do still risk life-threatening complications. Therefore, gene therapy by one-time ex vivo modification of hematopoietic stem cells followed by autologous engraftment is an attractive new therapeutic modality. The first proof-of-principle of conversion to transfusion independence by means of a lentiviral vector expressing a marked and anti-sickling β^T87Q-globin gene variant was reported a decade ago in a patient with transfusion-dependent β-thalassemia. In follow-up multicenter Phase II trials with an essentially identical vector (termed LentiGlobin BB305) and protocol, 12 of the 13 patients with a non-β⁰/β⁰ genotype, representing more than half of all transfusion-dependent β-thalassemia cases worldwide, stopped red blood cell transfusions with total hemoglobin levels in blood approaching normal values. Correction of biological markers of dyserythropoiesis was achieved in evaluated patients. In nine patients with β⁰/β⁰ transfusion-dependent β-thalassemia or equivalent severity (β^IVS1-110), median annualized transfusion volume decreased by 73% and red blood cell transfusions were stopped in three patients. Proof-of-principle of therapeutic efficacy in the first patient with sickle cell disease was also reported with LentiGlobin BB305. Encouraging results were presented in children with transfusion-dependent β-thalassemia in another trial with the GLOBE lentiviral vector and several other gene therapy trials are currently open for both transfusion-dependent β-thalassemia and sickle cell disease. Phase III trials are now under way and should help to determine benefit/risk/cost ratios to move gene therapy toward clinical practice.

Evolution of family medicine residency training program in Dubai Health Authority: A 24-year review, challenges, and outcomes

Introduction:

It is well known that family medicine (FM) is a cornerstone for developing a community-based health-care system, and training family physicians is critical for the society. In Middle East, only 5%–10% of physicians, nurses, and health technicians are citizens. This demands more efforts toward having national FM practitioners in the country. The development of FM residency training program through the past two decades in Dubai has played a crucial rule in this aspect.

Methods:

The primary purpose of this study is to review the status of FM specialty training in the Emirates of Dubai throughout the past two decades.

Results:

The FM residency training program started since 1993 and had intake of 230 residents till 2017; out of which, 200 (87%) were female and 211 (92%) were the United Arab Emirates national. From 176 residents who are supposed to be graduated by 2017, 162 (92%) completed 4-year training, 132 (75%) has got the Arab Board certificate, and 116 (66%) qualified by the Membership of the Royal College of General Practitioners (MRCGP) international.

Conclusion:

The present study revealed that despite all challenges, the well-structured FM program enabled the graduates to reach high clinical, administrative, leadership, and academic positions such as consultant (40), chief executive officer (1), chief advisor for primary care (1), director (9), head of sections (9), head/deputy head of primary health center (55), head of academic affair center (1), chair of MRCGP international (1), program director of FM (4), MRCGP convener (6), MRCGP coordinator (6), and MRCGP examiner (42). However, the program is still lacking certification by an international accreditation body. This will help in reaching a better balance between education and clinical duties for all trainers and faculty; and will positively advocate support for an environment conducive to learning for residents as well as faculty members.

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.

Analysis of blood donor pre-donation deferral in Dubai: characteristics and reasons

Background

To ensure an adequate and safe blood supply, it is crucial to select suitable donors according to stringent eligibility criteria. Understanding the reasons for donor deferral can help in planning more efficient recruitment strategies and evaluating donor selection criteria. This study aims to define donor pre-donation deferral rates, causes of deferral, and characteristics of deferred donors in Dubai.

Materials and methods

This retrospective study was conducted on all donors who presented for allogeneic blood donation between January 1, 2010, until June 30, 2013, in Dubai Blood Donation Centre, accredited by the American Association of Blood Banks. The donation and deferral data were analyzed to determine the demographic characteristics of accepted and deferred donors, and frequency analyses were also conducted.

Results

Among 142,431 individuals presenting during the study period, 114,827 (80.6%) were accepted for donation, and 27,604 (19.4%) were deferred. The overall proportion of deferrals was higher among individuals less than 21 years old (35%, P<0.000), females (44% were deferred compared to 15% of males, P<0.0001), and first-time donors (22% were deferred vs 14% of repeat donors, P<0.0001). The main causes for a temporary deferral were low hemoglobin and high blood pressure.

Discussion

The deferral rate among blood donors in Dubai is relatively high compared to the internationally reported rates. This rate was higher among first-time donors and females, with low hemoglobin as the major factor leading to a temporary deferral of donors. Strategies to mitigate deferral and improve blood donor retention are urged in Dubai to avoid additional stress on the blood supply.

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

Thalassemia is a genetic blood disorder that causes abnormal hemoglobin. Hemoglobin is a protein in red blood cells that carries oxygen and is made of two proteins from four α-globin genes and two β-globin genes. A defect in one or more of these genes causes thalassemia. The treatment of thalassemia mostly depends on life-long blood transfusions and removal of excessive iron from the blood stream. Such tremendous blood consumption puts pressure on the national blood stock in many countries. In particular, in the United Arab Emirates (UAE), various forms of thalassemia prevention have been used and hence, the substantial reduction of the thalassemia major population has been achieved. However, the thalassemia carrier population still remains high, which leads to the potential increase in the thalassemia major population through carrier-carrier marriages. In this work, we investigate the long-term impact and efficacy of thalassemia prevention measures via mathematical modeling at a population level. To our best knowledge, this type of assessment has not been done before and there is no mathematical model that has investigated such a problem for thalassemia or any blood disorders at a population level. By using UAE data, we perform numerical simulations of our model and conduct sensitivity analysis of parameter values to see which parameter values affect most the dynamics of our model. We discover that the prevention measures can contribute to reduce the prevalence of the disease only in the short term but not eradicate the disease in the long term.

Genetic testing and genomic analysis: a debate on ethical, social and legal issues in the Arab world with a focus on Qatar

In 2013 both Saudi Arabia and Qatar launched genome projects with the aim of providing information for better diagnosis, treatment and prevention of diseases and, ultimately to realize personalized medicine by sequencing hundred thousands samples. These population based genome activities raise a series of relevant ethical, legal and social issues general, related to the specific population structure as well as to the Islamic perspective on genomic analysis and genetic testing. To contribute to the debate, the Authors after reviewing the existing literature and taking advantage of their professional experience in the field and in the geographic area, discuss and provide their opinions. In particular, the Authors focus on the impact of consanguinity on population structure and disease frequency in the Arab world, on genetic testing and genomic analysis (i.e. technical aspects, impact, etc.) and on their regulations. A comparison between the Islamic perspective and the ethical, social and legal issues raised in other population contexts is also carried. In conclusion, this opinion article with an up-to-date contribution to the discussion on the relevance and impact of genomic analysis and genetic testing in the Arab world, might help in producing specific national guidelines on genetic testing and genomic analysis and help accelerate the implementation and roll out of genome projects in Muslim countries and more specifically in Qatar, and other countries of the Gulf.