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Int. J. Mol. Sci. 2013, 14(9), 18599-18614; doi:10.3390/ijms140918599
Abstract: Alpha thalassaemia is highly prevalent in the plural society of Malaysia and is a public health problem. Haematological and molecular data from 5016 unrelated patients referred from various hospitals to the Institute for Medical Research for α thalassaemia screening from 2007 to 2010 were retrieved. The aims of this retrospective analysis were to describe the distribution of various alpha thalassaemia alleles in different ethnic groups, along with their genotypic interactions, and to illustrate the haematological changes associated with each phenotype. Amongst the patients, 51.2% (n = 2567) were diagnosed with α thalassaemia. Of the 13 α thalassaemia determinants screened, eight different deletions and mutations were demonstrated: three double gene deletions, – – SEA, – – THAI, ––FIL; two single-gene deletions, α–3.7 and – α4.2; and three non-deletion mutations, Cd59G > A (haemoglobin [Hb] Adana), Cd125T > C (Hb Quong Sze) and Cd142 (Hb Constant Spring). A high incidence of α–3.7 deletion was observed in Malays, Indians, Sabahans, Sarawakians and Orang Asli people. However, the – – SEA deletion was the most common cause of alpha thalassaemia in Chinese, followed by the α–3.7 deletion. As many as 27 genotypic interactions showed 1023 α thalassaemia silent carriers, 196 homozygous α+ thalassaemia traits, 973 heterozygous α0 thalassaemia carriers and 375 patients with Hb H disease. Statistical analysis showed a significant difference in the distribution of α thalassaemia determinants amongst the various ethnic groups. Hence, the heterogeneous distribution of common determinants indicated that the introduction of an ethnicity-targeted hierarchical α thalassaemia screening approach in this multi-ethnic Malaysian population would be effective.
Alpha thalassaemia is an inherited autosomal recessive disorder caused by a complete absence or decrease in the production of alpha globin peptides due to a deletion or mutation of one or more of the four alpha globin genes—two on each copy of chromosome 16. The normal haplotype is indicated as αα and its genotype as αα/αα. Deletion of one or both α globin genes, expressed as (–α/) and (– – ) respectively, represents the most common forms of α thalassaemia. Rarer nondeletional –α thalassaemia resulting from point mutations in either the α2 (αTα) or α1 (ααT) gene is commoner in Southeast Asia than any other part of the world. Clinically, these deletional and nondeletional forms of alpha thalassaemia can be broadly classified into four syndromes depending on the number of functional α globin gene inherited. When all four genes are deleted or dysfunctional, the resulting syndrome is known as haemoglobin (Hb) Bart’s hydrops foetalis or α thalassaemia major (– – /– – ) and is incompatible with extra-uterine life . Inheritance of just one functional α globin gene out of the four (– – /– α) results in Hb H disease, which is also known as α thalassaemia intermedia. This is usually the result of the compound heterozygous state for α0 thalassaemia and α+ thalassaemia. Patients with this disorder show chronic haemolytic anaemia of variable severity. Hb H due to nondeletional types is relatively more severe in clinical presentation than with deletional forms . The α thalassaemia trait (also known as α-thalassaemia minor), characterised by cis or trans positional loss of two α genes, results in heterozygosity for α0 thalassaemia (– – /αα) and homozygosity for α+ thalassaemia (– α/– α). The affected individuals are essentially asymptomatic with minimal hypochromic microcytic anaemia. Alpha thalassaemia silent carriers are inherited with three functional genes (–α/αα) and exhibit no clinical abnormalities; they may show normal to mild changes in the haematological indices.
Malaysia and its neighbouring Southeast Asian countries have a high prevalence of alpha thalassaemia. The gene frequencies in northern and southern Thailand were reported to be 30% and 16%, respectively ; 5% on the islands of Philippines ; 2.6%–3.2% and 2.7%–11% for α0 and α+ carriers, respectively, in Indonesia ; and 4.3% was expected in Brunei, where 65% of the population was Malay and 20% Chinese . As in many Asian countries, α thalassaemia is a public health concern in Malaysia, with a gene frequency of 4.1% .
Malaysia has a population of 28.3 million people, with Malays and other Bumiputera groups making up 67.4% of the population. Chinese, Indians and other ethnic groups form 24.6%, 7.3% and 0.7% of the population, respectively . East Malaysia, comprising Sabah and Sarawak, is populated with multiple clades of sub-ethnic groups. Aboriginal people known as Orang Asli are present in the east and peninsular Malaysia.
Population studies have indicated that the types and frequencies of the different α thalassaemia defects vary among different ethnic communities and tend to be geographically specific . Few studies describing the frequencies of deletional and nondeletional α thalassaemia in Malaysia have been conducted , and they lack the scale and magnitude presented here; in this study, a large cohort of multi-ethnic patients was included, thereby maximising the demographic characteristics.
The present study aims to provide data on the incidence of the various forms of α globin gene deletions, mutations and their genotypes reflected in the diverse ethnic population of Malaysia in the context of their laboratory presentations, and to examine the data to elucidate the possibility of an ethnicity-based alpha thalassaemia screening programme.
2. Results and Discussion
The Malaysian meta-population at large is not homogeneous . It is composed of many subpopulations partly isolated by their mate choices, which are principally based on mutually shared phenotypic characteristics. Major demes include ethnic Malays, Chinese and Indians. Malaysian Chinese are descendants of ancestral immigrants from South China, while the majority of Malaysian Indians are originally immigrants descending from Southern India. In the east, isolated from Peninsular Malaysia, lies Sabah and Sarawak, with the two major subpopulations of Sabahans and Sarawakians, respectively.
Haematological and molecular data from the patients who were referred to the Institute for Medical Research (IMR) for α thalassaemia screening over four years ending in 2010 were retrospectively reviewed to determine the ethnic distribution of various α thalassaemia determinants. The study subjects included 3139 Malays; 706 Malaysian Chinese; 258 Malaysian Indians; 391 and 41 indigenous citizenries of Sabah and Sarawak, respectively; 26 Orang Asli (aboriginal people); and 428 patients with undefined ethnic background. The ethnic communities in Sabah from which we received blood samples were KadazanDusun, Bajau, Murut, Rugus, Sungai, Suluk, Dusun, Bisaya and other citizenries. In Sarawak, the ethnic communities of Melanau, Bidayuh, Kedayan and Iban were the major contributors to the 41 blood samples received.
The most common reason for referral was hypochromic microcytic anaemia amongst patients attending general or specialist practices. Others included family members with α thalassaemia, members of ethnic groups at risk, children of couples at risk, partners of α0 thalassaemia carriers, negative for β thalassaemia screening and voluntary requests.
This analysis had a few significant limitations. Most importantly, as this was an audit of molecular diagnosis made on nationwide hospital-based blood samples submitted for alpha thalassaemia screening, the incidences reported here would not accurately correspond to the population prevalence of the α thalassaemia variant. Especially, the incidence of α thalassaemia due to single deletion may be under represented as their red cell indices are generally unremarkable on a routine blood counts and hence are not likely to be sent for screening. Second, the referred samples were not genotyped for β thalassaemia or other haemoglobinopathies. These observations would have determined the co-inheritance or explained the α thalassaemia free hypochromic microcytic anaemia. Third, as the samples were submitted only for α thalassaemia screening, other causes of microcytic anaemia such as iron deficiency were not determined. Finally, patients negative for the 13 α thalassaemia determinant screening panel were assumed to be probable αα/αα genotype without further investigation for other possible genotypes.
2.1. Ethnic Distribution of α Thalassaemia Determinants
Table 1 shows the molecular characterisation of alpha-globin genes in 10,032 chromosomes screened for α thalassaemia. Out of the 13 α thalassaemia determinants screened, eight variants were positive on 3138 chromosomes. These were three double gene deletions, – – SEA, – – THAI, – – FIL; two single-gene deletions, α–3.7 and –α4.2; and three nondeletion mutations, specifically Cd59G > A (Hb Adana), Cd125T > C (Hb Quong Sze) and Cd142 (Hb Constant Spring). All of the chromosomes were negative for – – MED, –(α)20.5, init ATG→A-G (Hb Vietnam), Cd30 (-3bp) and Cd35T > C (Hb Evora). In this analysis, 85% of the alpha thalassaemia chromosomes had deletional type and the remaining 15% had nondeletional mutations.
A total of 2449 (48.8%) subjects were negative for the 13 α thalassaemia determinants tested at the institute and were assumed to be αα/αα genotype (Table 2). More than half (n = 2567, 51.2%) of the patients studied were diagnosed with α thalassaemia, specifically 1568 Malays, 486 Chinese, 68 Indians, 226 Sabahans, 19 Sarawakians, 14 Orang Asli patients and 186 patients of unspecified ethnicity.
2.1.1. α–3.7 Rightward Deletion
The highest incidence of α–3.7 was observed in Sabahans, while it was the most predominant in all ethnic groups except for Malaysian Chinese. This distinction in allele frequency observed amongst ethnic Chinese consolidates our previous finding  and is in accordance with the findings of other similar studies on the local population . In general, the α–3.7 single gene deletion has a global distribution among all ethnic groups, and is especially prevalent in most tropical and subtropical populations studied .
2.1.2. – – SEA Deletion
Contrary to all the other ethnic groups, the most common alpha thalassaemia determinant amongst the Malaysian Chinese was the – – SEA deletion. More than a third (75.8%) of all the alpha thalassaemia chromosomes examined amongst the Chinese ethnic group had the – – SEA deletion—which represented 29.9% of all the chromosomes studied within the entire ethnic group. Interestingly, almost all (360/364, 98.9%) α0 thalassaemia carriers in them were the result of the αα/– – SEA genotype. This finding is in accordance with a previous study, where a preponderance of – – SEA deletions was reported in Malaysian Chinese in a cohort of 650 pregnant women represented by the three major subpopulations of Malaysia—Malays, Chinese and Indians . This increased predominance of the ––SEA deletion in Malaysian Chinese elevated their predisposition of conceiving foetuses with Hb Bart’s hydrops foetalis with the – – SEA/– – SEA genotype to a relatively greater extent than any other subpopulation from Malaysia. It was shown in our previous survey that at least 63 pregnancies annually were at risk of hydrops foetalis in the Malaysian population .
This double deletion was noted as the second most common in the Malay, Indian, Sabahan and Orang Asli groups, with an incidence of 30.2%, 9.3%, 21.5% and 26.3% respectively. The – – SEA deletion, which removes nearly 20 kb DNA that extends from the 3′ end of the HBZps gene through the HbA1 gene, has been observed at high frequencies in several Southeast Asian populations and in Asians worldwide . More specifically, a high prevalence of α0 thalassaemia (82.87% of all α thalassaemias) due to – – SEA/αα was reported in South China . Hence, the high incidence of – – SEA deletions observed in Malaysian Chinese could safely be attributed to the high gene frequency in South China. Historically, most of the Malaysian Chinese are ancestral descendants from South China .
2.1.3. αCSα Mutation
Allele αCSα, similar to many other studies, was the most common nondeletional α thalassaemia mutation observed in this analysis, and was the third most frequent α thalassaemia determinant in Malays and Sabahans. Interestingly, the highest incidence was recorded in Orang Aslis aboriginal people (11.5%). The lowest (0.7%) was observed in Malaysian Chinese, while the mutation was not detected in Malaysian Indians or Sarawakians.
2.1.4. –α4.2 Leftward Deletion
The leftward deletion –α4.2, with a uniformly low incidence of 1.1% on average, was observed in Malays, Chinese and Indians. Its incidences showed no significant difference amongst these ethnic groups (Pearson Chi-square, p = 0.792). The same result was reported in our previous paper in terms of 16 years old Malaysian school children, who showed a very low frequency of –α4.2 . Appreciable amounts of this deletion were observed in Hong Kong and in the western fringes of Remote Oceania on haplotype backgrounds different from Southeast Asian type 1a .
2.1.5. – – THAI Double Gene Deletion
The – – THAI double gene deletion, observed only in the three major ethnic groups of Malaysian Malays, Chinese and Indians at a uniformly low incidence (of 0.3% in average), showed no significant difference in their distribution (Pearson Chi-square, p = 0.574). This alelle, common in Thai population , may likely be lost from the Malaysian population through the action of genetic drift if the selection was not acting. The – – THAI allele observed on a single Indian chromosome was presumably due to intermarriage between the different ethnic groups.
2.1.6. – – FIL Double Gene Deletion
In the Sabah subpopulation, 2.7% (6/226) of those diagnosed with alpha thalassaemia inherited the Filipino deletion. Out of these six patients, four were from the Bajau tribe and presented with genotypes αα/– – FIL and α–3.7/– – FIL, two cases each; and two were from the Suluk tribal community, with genotypes αα/– – FIL and αCSα/– – FIL. Kadazandusun, the major ethnic group in Sabah, represented in this analysis by 82 patients, did not show a single alpha Filipino deletion. This is in accordance with a previous study done in the Kadazandusun community, where 12.8% of the Kadazandusuns were found to have inherited the Filipino β thalassaemia deletion but not the alpha Filipino deletion .
Interestingly, all 10 patients with the Filipino deletion observed in Sarawakians were of Iban ancestry; seven had heterozygous α0 thalassaemia (αα/– – FIL) and the other three had Hb H disease (α–3.7/– – FIL).
The high incidence of the – – FIL gene in the two eastern states of Malaysia, Sabah and Sarawak could be the result of gene flow from high gene frequency neighbours. At least 2% of individuals in Philippines are carriers for the – – FIL deletion , and globally, the deletion is most frequent in Philippinians . Therefore, resettling Philippinians could be the biggest contributor of the gene, as Philippines—with its geographical proximity to East Malaysia—shares a maritime border and was the preferred destination for a fair number of asylum seekers .
The single – – FIL allele observed on a lone Indian chromosome presumably represents an isolated importation of allele through intermarriages.
2.1.7. Haemoglobin Adana
The nondeletional allele Cd59, (Hb Adana), observed at an incidence of 0.14% in Chinese, 1.7% in Malays, 1.9% in Orang Asli aboriginal people and 3.7% in Sarawakians, was reportedly encountered at a higher frequency of 16% in Indonesia . This cline suggests that Hb Adana in Malaysian ethnic groups may be the result of gene flow from Indonesia, as there has been regular travel since antiquity between the coastal port cities of Sumatra and the Malay Peninsula. This hypothesis is further supported by the interconnected past history and the common Malayo-Polynesian language. As countries in Southeast Asia had regular contact with the Mediterranean through the silk route, this allele found in Indonesia, Malaysia and countries bordering the Mediterranean Sea might have a single origin. Hb Adana was first described in 1993 in Turkey on α1 and later on α2 in an Albanian family in 1999 [19,20].
2.1.8. Cd125T > C (Hb Quong Sze)
The αQZα was a private allele observed only in the Malay and Chinese ethnic groups at low incidence. This unstable α+ mutation (HBA2 c.377T > C), more frequent in Southern China, was seven times more prevalent in Malaysian Chinese than that observed for Malays. This relative increase in the Malaysian Chinese represents an ancestral gene flow and probably has not had sufficient evolutionary time to disperse to any greater degree.
2.2. Inter Ethnic Diversity and Screening Strategy
Although all eight determinants showed heterogeneous distribution, without clear restriction to any distinct ethnic group, inter-ethnic comparisons of their incidences showed a significant difference (Pearson Chi-square, p < 0.001) for all except –α4.2 and – – THAI. These were probably because the three most commonly encountered α thalassaemia determinants demonstrated clear ethnic preponderances: α–3.7, – – SEA and αCSα were three times more common in Sabahans, Chinese and Orang Aslis respectively. Furthermore, the less frequent – – THAI allele observed in Chinese, and excess-of-rare allele such as ––FIL observed amongst Sabahans may have complemented to this inter-ethnic differences.
Noticeably, Malaysian Malays—who exhibited all eight determinants—were the most diverse of the patient groups, while Sarawakians and Orang Aslis were the least, with only four alleles. Despite the plethora of corresponding genotypes observed in Malays, they had a close resemblance in the genotype frequencies with that observed in the Sabah, Sarawak and Orang Asli groups, as no significant differences were calculated (Mann-Whitney U test, p > 0.05; Table 3). However, the Chinese sample showed a significant difference (p < 0.001) in genotype frequencies with Malays, Indians and sub-clades of Sabah (Table 3). This difference could be attributable to the relative abundance of the α thalassaemia gene (39.5%) observed amongst Malaysian Chinese which has led to the highest incidence of alpha thalassaemia (68.8%) within the ethnic group (Table 1), and to the relative abundance of – – SEA gene.
Given the heterogeneity of the eight alleles (Table 1), clear ethnic preponderance of most frequent alleles and the statistical significant difference in the inter-ethnic distribution of most α thalassaemia determinants, it could be suggested that an assertion of ethnicity-based hierarchical screening approach for Malaysian multi-ethnic population would be effective in maximising the resources.
3. Experimental Section
IMR serves as the national reference centre for diagnostic molecular genetic diseases. Clinical and laboratory data from 5016 unrelated patients referred to IMR for α thalassaemia testing from various geographically distinct hospitals between 2007 and 2010 were retrieved. Laboratory data accessed included complete blood counts (CBC), Hb chromatogram findings and α globin genotyping results done at IMR. To preserve the anonymity of these patients, demographic data accessed were limited to ethnicity only.
In most cases, initial blood work was performed at the referring hospital laboratory and included CBC counts from automated haematology analysers and Hb chromatography analysis from Bio-Rad Variant or Variant II high performance liquid chromatography (Bio-Rad Laboratories, Hercules, CA, USA). Blood specimens were transported in K3EDTA tubes at 4 °C to IMR from the referring hospitals along with the requisition form and initial blood investigation results. However, those blood samples referred without CBC and Hb chromatogram information were tested at IMR on an automated blood analyser (CellDyn 3200, Abbott Laboratories, IL, USA) and a VARIANT Haemoglobin Testing System (Bio-Rad Laboratories, Hercules, CA, USA), respectively.
For molecular studies, genomic DNA was extracted from whole blood using the standard protocol of Qiagen Inc. (Valencia, CA, USA). Alpha thalassaemia screening panel consisted of 13 deletions and mutations representing common α thalassaemia determinants encountered in South-East Asia, India and Middle East. The single-tube seven-plex PCR method was applied to detect the two most common single gene deletions α–3.7 and –α4.2, and double gene deletions including – – SEA, – – FIL, – – THAI and ––MED and –(α)20.5, as previously described . For the detection of α2 globin gene mutations, the single-tube multiplex amplification refractory mutation system (ARMS) method was used as previously described . The nondeletional mutations detected by this method were αCSα, the codon 125 CTG→CCG mutation or Hb Quong Sze, the codon 59 (GGC→GAC) mutation, the initiation codon mutation (ATG→A–G), the codon 30 mutation (ΔGAC) and the codon 35 mutation (TCC→CCC). All the amplification reactions were done on an Eppendorf Mastercycler® (Eppendorf Scientific, Hamburg, Germany). We also used the α-thalassaemia StripAssay® hybridisation test commercially available from ViennaLab Diagnostics GmbH, Vienna, Austria for cases where the nondeletional mutations were suspected to exhibit the homozygous state. All subsequent diagnoses of α thalassaemia status were reported to the respective referring centres.
Statistical analyses were performed using ANOVA to compare parametric means of haematological variables measured within the α thalassaemia phenotypic groups, and post-hoc range tests of LSD were used to determine which parametric means differed by pair-wise comparison of different phenotypes. Difference in the incidence of each allele among ethnic groups was checked using the Pearson Chi-square test. The associations amongst ethnic group and α genotype frequencies were evaluated using the non-parametric Kruskal-Wallis test. The two-sample non-parametric Mann-Witney U test (at p < 0.05) was employed to check the null hypothesis that any two ethnic groups had the same distribution of α thalassaemia phenotypes. All data were analysed using IBM SPSS software version 20 (IBM Corp., Armonk, NY, USA).
Ethical approval for this project was obtained from the ethics committee of the Ministry of Health Malaysia.
We described the molecular epidemiological characteristics of α thalassaemia in Malaysia. Significant differences in its prevalence, molecular defects and phenotypic expression exist amongst different geographic locations and ethnic groups. We observed a genetic heterogeneity of the common alpha thalassaemia alleles in all major ethnic groups. Hence, the data suggest that an ethnicity-based hierarchical screening protocol should be implemented to screen α thalassaemia determinants in relation to the frequency of alleles in each subpopulation.
The prevalence data on the plethora of α thalassaemia determinants observed in this study may help in estimating the disease heterogeneity amongst the various ethnic groups of Malaysia. Since our study sample comprised a wide representation of multiple ethnic groups of the peninsula and west Malaysia, the findings could safely be generalised to the target subpopulations and should prove useful in carrier screening programmes, genetic counselling and patient management.
The authors gratefully acknowledge the support of the Director-General of Health, Malaysia for his permission in publishing this paper. We would also like to thank the Director of the Institute for Medical Research and the National Prevention and Control Program for Thalassaemia Fund for supporting our efforts.
Conflicts of Interest
The authors declare no conflict of interest.
- Harteveld, C.L.; Higgs, D.R. Alpha thalassaemia. Orphanet. J. Rare Dis 2010, 5, 1–21. [Google Scholar]
- Origa, R.; Sollaino, M.C.; Giagu, N.; Barella, S.; Campus, S.; Mandas, C.; Bina, P.; Perseu, L.; Galanello, R. Clinical and molecular analysis of haemoglobin H disease in Sardinia: Haematological, obstetric and cardiac aspects in patients with different genotypes. Br. J. Haematol 2007, 136, 326–332. [Google Scholar]
- Winichagoon, P.; Fucharoen, S. Thalassaemia and haemoglobinopathies. Mahidol. Univ. Ann. Res. Abstr 2000, 28, 343. [Google Scholar]
- Ko, T.M.; Hwa, H.L.; Liu, C.W.; Li, S.F.; Chu, J.Y.; Cheung, Y.P. Prevalence study and molecular characterization of alpha-thalassaemia in Filipinos. Ann. Hematol 1999, 78, 355–357. [Google Scholar]
- Setianingsih, I.; Harahap, A.; Nainggolan, I.M. Alpha thalassaemia in Indonesia: Phenotypes and molecular defects. Adv. Exp. Med. Biol 2003, 531, 47–56. [Google Scholar]
- Ismail, J.B. Thalassaemia and haemoglobinopathies in Brunei Darussalam. Med. J. Malaysia 1992, 47, 98–102. [Google Scholar]
- Rahimah, A.; Sabrina, N.; Bahrin, S.; Hassan, R.; Yelumalai, P.; Hidayat, N.; Hassan, S.; Zakaria, Z. Distribution of alpha thalasaemia in 16 year old Malaysian students in Penang, Melaka and Sabah. Med. J. Malaysia 2012, 67, 562–567. [Google Scholar]
- Department of Statistics Malaysia. Population distribution and basic demographic characteristics, 2011. Available online: http://www.statistics.gov.my/portal/index.php?option=com_content&id=1215 (accessed on 11 October 2012).
- Higgs, D.R.; Vickers, M.A.; Wilkie, A.O.; Pretorius, I.M.; Jarman, A.P.; Weatherall, D.J. A review of the molecular genetics of the human alpha globin gene cluster. Blood 1989, 73, 1081–1104. [Google Scholar]
- Wee, Y.C.; Tan, K.L.; Chow, T.W.; Yap, S.F.; Tan, J.A. Heterogeneity in alpha thalassaemia interactions in Malays, Chinese and Indians in Malaysia. J. Obstet. Gynaecol. Res 2005, 31, 540–546. [Google Scholar]
- Rosnah, B.; Rosline, H.; Zaidah, A.W.; Noor, H.M.N.; Marini, R.; Shafini, M.Y.; Nurul, A.F.A. Detection of common deletional alpha-thalassaemia spectrum by molecular technique in Kelantan, Northeastern Malaysia. ISRN Hematol. 2012, 2012. [Google Scholar] [CrossRef]
- Bowden, D.K.; Hill, A.V.; Higgs, D.R.; Oppenheimer, S.J.; Weatherall, D.J.; Clegg, J.B. Different hematologic phenotypes are associated with the leftward (-alpha 4.2) and rightward (-alpha 3.7) α+ thalassaemia deletions. J. Clin. Invest 1987, 79, 39–43. [Google Scholar]
- Duan, S.; Li, H.Y.; Chen, Z.; Chen, S.Q.; Bi, X.J.; Chen, L.M.; Du, C.S. Study on gene mutations of alpha thalassemia in the South of China. J. Exp. Hematol 2003, 11, 54–60. [Google Scholar]
- Barbara, A.W. Encyclopedia of the Peoples of Asia and Oceania; Infobase Publishing: New York, NY, USA, 2009; Volume 1. [Google Scholar]
- O'Shaughnessy, D.F.; Hill, A.V.; Bowden, D.K.; Weatherall, D.J.; Clegg, J.B. Globin genes in Micronesia: Origins and affinities of Pacific Island peoples. Am. J. Hum. Genet 1990, 46, 144–155. [Google Scholar]
- Tan, J.A.; Lee, P.C.; Wee, Y.C.; Tan, K.L.; Mahali, N.F.; George, E.; Chua, K.H. High prevalence of alpha and beta thalassemia in the Kadazadusuns in East Malaysia: Challenges in providing effective health care for an indegenous group. J. Biomed. Biotechnol 2010, 11, 1–5. [Google Scholar]
- United Nation Committee for Refugees and Immigrants. World refuge World Refugee Survey 2009—Malaysia, Available online: http://www.unhcr.org/refworld/country (accessed on 1 October 2012).
- Nainggolan, I.M.; Harahap, A.; Setianingsih, I. Hydrops fetalis associated with homozygosity for Hb Adana [alpha59(E8) Gly→Asp (alpha2)]. Hemoglobin 2010, 34, 394–401. [Google Scholar]
- Curuk, M.A.; Dimovski, A.J.; Baysal, E.; Gu, L.H.; Kutlar, F.; Molchanova, T.P.; Webber, B.B.; Altay, C.; Gürgey, A.; Huisman, T.H. Hb Adana or α259(E8)Gly→Aspβ2, a severely unstable α1-globin variant, observed in combination with the -(α)20.5 α-thal-1 deletion in two Turkish patients. Am. J. Hematol 1993, 44, 270–275. [Google Scholar]
- Traeger-Synodino, J.; Metaxotou-Mavrommati, A.; Karagiorga, M.; Vrettou, C.; Papassotiriou, I.; Stamoulakatou, A.; Kanavakis, E. Interaction of an α+-thalassemia deletion with either a highly unstable α globin variant (α2, codon 59, GGC→GAC) or a non-deletional α thalassemia mutation (AATAAA→ AATAAG): comparison of phenotypes illustrating ‘dominant’ α thalassemia. Hemoglobin 1999, 23, 325–337. [Google Scholar]
- BCSH. Laboratory diagnosis of haemoglobinopathies. Br. J. Haematol. 2001, 101, 783–792.
- Sin, S.Y.; Ghosh, A.; Tang, L.C.; Chan, V. Ten years’ experience of antenatal mean corpuscular volume screening and prenatal diagnosis for thalassaemias in Hong Kong. J. Obstet. Gynaecol. Res 2000, 26, 203–208. [Google Scholar]
- Chan, L.C.; Ma, S.K.; Chan, A.Y.; Ha, S.Y.; Waye, J.S.; Lau, Y.L.; Chui, D.H. Should we screen for globin mutations in blood samples with mean corpuscular volume (MCV) greater than 80 fL in areas with a high prevalence of thalassaemia? J. Clin. Pathol 2001, 54, 317–320. [Google Scholar]
- Coa, A.; Galanello, R.; Rosatelli, M.C. Prenatal Diagnosis and Screening of the Haemoglobinopathies. In Bailliere's Clinical Haematology; Rodgers, G.P., Ed.; Elsevier Ltd: Philidelphia, PA, USA, 1998; pp. 215–238. [Google Scholar]
- Ma, E.S.; Chan, A.Y.; Ha, S.Y.; Lau, Y.L.; Chan, L.C. Thalassemia screening based on red cell indices in the Chinese. Haematologica 2001, 86, 1310–1311. [Google Scholar]
- Li, D.; Liao, C.; Li, J.; Xie, X.; Huang, Y.; Zhong, H. Detection of α -thalassaemia in β-thalassaemia carriers and prevention of Hb Bart's hydrops fetalis through prenatal screening. Haematologica 2006, 91, 649–651. [Google Scholar]
- Kosaryan, M.; Mahdavi, M.R.; Shahmoradi, M.; Arabzadeh, M.; Maleki, I. Is it necessary to give folic acid to thalassaemia minor or major? Proceedings of International Congress on Pediatrics, Tehran, Iran, 17–23 October 2003.
- Lie-Injo, L.E.; Solai, A.; Herrera, A.R.; Nicolaisen, L.; Kan, Y.W.; Wan, W.P.; Hasan, K. Hb Bart’s level in cord blood and deletions of alph-globin genes. Blood 1982, 59, 370–376. [Google Scholar]
- Laig, M.; Pape, M.; Hundrieser, J.; Flatz, G.; Sanguansermsri, T.; Das, B.M.; Deka, R.; Yongvanit, P.; Mularlee, N. The distribution of the Hb Constant Spring gene in Southeast Asian populations. Hum. Genet 1990, 84, 188–190. [Google Scholar]
- Chong, S.S.; Boehm, C.D.; Higgs, D.R.; Cutting, G.R. Single-tube multiplex-PCR screen for common deletional determinants of alpha-thalassaemia. Blood 2000, 95, 360–362. [Google Scholar]
- Eng, B.; Patterson, M.; Walker, L.; Chui, D.H.; Waye, J.S. Detection of seven non-deletional alphathalassaemia mutations using a single tube multiplex ARMS assay. Genet. Test 2001, 5, 327–329. [Google Scholar]
|Ethnic group||Alpha gene alleles|
|αα||α–3.7||––SEA||αCSα||Cd59 G > A||–α4.2||––FIL||––THAI||αQZα|
|Malay, n (%)||4353 (69.3%)||840 (13.4%)||581 (9.2%)||273 (4.3%)||113 (1.8%)||83 (1.3%)||9 (0.14%)||18 (0.28%)||8 (0.13%)|
|Chinese, n (%)||854 (60.5%)||88 (6.2%)||423 (29.9%)||10 (0.70%)||2 (0.14%)||16 (1.1%)||0||6 (0.42%)||13 (0.92%)|
|Indian, n (%)||495 (86.8%)||60 (10.5%)||7 (1.2%)||0||0||6 (1.0%)||1 (0.2%)||1 (0.2%)||0|
|Sabah, n (%)||470 (60.1%)||227 (29.0%)||67 (8.6%)||10 (1.3%)||2 (0.25%)||0||6 (0.76%)||0||0|
|Sarawak, n (%)||56 (68.3%)||11 (13.4%)||2 (2.4%)||0||3 (3.7%)||0||10 (12.2%)||0||0|
|Orang Asli, n (%)||33 (63.5%)||7 (13.5%)||5 (9.6%)||6 (11.5%)||1 (1.9%)||0||0||0||0|
|Ethnicity unknown, n (%)||633 (73.9%)||105 (12.3%)||80 (9.3%)||17 (2.0%)||9 (1.0%)||6 (0.7%)||1 (0.1%)||1 (0.1%)||4 (0.5%)|
|Total number of chromosomes||6894 (68.7%)||1338 (13.3%)||1165 (11.6%)||316 (3.2%)||130 (1.30%)||111 (1.1%)||27 (0.27%)||26 (0.26%)||25 (0.25%)|
|αα/αα||1571 (50.0%)||220 (31.2%)||217 (76.1%)||165 (42.2%)||22 (53.7%)||12 (46.2%)||242 (56.5%)||2449 (48.8%)|
|αα/––SEA||423 (13.5%)||360 (51.0%)||6 (2.1%)||33 (8.4%)||1 (2.4%)||2 (7.7%)||57 (13.3%)||882 (17.6%)|
|αα/α–3.7||486 (15.5%)||31 (4.4%)||48 (16.8%)||100 (25.6%)||4 (9.8%)||5 (19.2%)||73 (17.1%)||747 (14.9%)|
|α–37/– –SEA||120 (3.8%)||45 (6.4%)||1 (0.4%)||32 (8.2%)||1 (2.4%)||1 (3.8%)||14 (3.3%)||214 (4.27%)|
|αα/αCSα||175 (5.6%)||5 (0.7%)||0||4 (1.0%)||0||2 (7.7%)||8 (1.9%)||194 (3.87%)|
|α–3.7/α–3.7||68 (2.2%)||4 (0.6%)||5 (1.8%)||44 (11.3%)||0||0||5 (1.2%)||126 (2.51%)|
|αα/–α4.2||53 (1.7%)||5 (0.7%)||5 (1.8%)||0||0||0||3 (0.7%)||66 (1.32%)|
|α–3.7/αCd59α||45 (1.4%)||1 (0.1%)||0||2 (0.5%)||3 (7.3%)||0||5 (1.2%)||56 (1.12%)|
|αα/αCd59α||44 (1.4%)||1 (0.1%)||0||0||0||0||4 (0.9%)||49 (0.98%)|
|α–3.7/αCSα||41 (1.3%)||1 (0.1%)||0||3 (0.8%)||0||1 (3.8%)||2 (0.5%)||48 (0.96%)|
|––SEA/αCSα||24 (0.8%)||4 (0.6%)||0||2 (0.5%)||0||2 (7.7%)||6 (1.4%)||38 (0.76%)|
|–α4.2/––SEA||14 (0.4%)||10 (1.4%)||0||0||0||0||2 (0.5%)||26 (0.52%)|
|αCd59α/αCSα||21 (0.7%)||0||0||0||0||1 (3.8%)||0||22 (0.44%)|
|αα/––THAI||16 (0.5%)||4 (0.6%)||1 (0.4%)||0||0||0||1 (0.2%)||22 (0.44%)|
|αα/––FIL||9 (0.3%)||0 (0.42%)||1 (0.4%)||3 (0.8%)||7 (17.1%)||0||0||20 (0.40%)|
|αα/αQZα||5 (0.2%)||8 (1.1%)||0||0||0||0||3 (0.7%)||16 (0.32%)|
|α–3.7/–α4.2||9 (0.3%)||1 (0.1%)||1 (0.4%)||0||0||0||0||11 (0.22%)|
|α–3.7/– –FIL||0||0||0||2 (0.5%)||3 (7.3%)||0||1 (0.2%)||6 (0.12%)|
|––SEA/αQZα||0||4 (0.6%)||0||0||0||0||1 (0.2%)||5 (0.10%)|
|–α4.2/αCSα||3 (0.1%)||0||0||0||0||0||1 (0.2%)||4 (0.08%)|
|αCSα/αCSα||4 (0.1%)||0||0||0||0||0||0||4 (0.08%)|
|α–3.7/– –SEA||2 (0.1%)||1 (0.1%)||0||0||0||0||0||3 (0.06%)|
|–α4.2/αCd59α||3 (0.1%)||0||0||0||0||0||0||3 (0.06%)|
|––FIL/αCSα||0||0||0||1 (0.3%)||0||0||0||1 (0.02%)|
|––THAI/αQZα||0||1 (0.1%)||0||0||0||0||0||1 (0.02%)|
|α–3.7/αQZα||1 (0.03%)||0||0||0||0||0||0||1 (0.02%)|
|–α4.2/αQZα||1 (0.03%)||0||0||0||0||0||0||1 (0.02%)|
|αQZα/αCSα||1 (0.03%)||0||0||0||0||0||0||1 (0.02%)|
|Ethnicity||Alpha thalassaemia syndromes|
|(αα/αα)||Silent carrier||α+ thal trait||α0 thal trait||Hb H disease|
|Malay||1571 (50.0%)||719 (22.9%)||128 (4.1%)||492 (15.7%)||229 (7.3%)|
|Chinese||220 (31.2%)||49 (6.9%)||6 (0.84%)||365 (51.7%)||66 (9.3%)|
|Indian||217 (76.1%)||53 (18.6%)||6 (2.1%)||8 (2.8%)||1 (0.4%)|
|Sabah||165 (42.2%)||104 (26.6%)||47 (12.0%)||36 (9.2%)||39 (9.9%)|
|Sarawak||22 (53.6%)||4 (9.7%)||0||8 (19.5%)||7 (17.1%)|
|Orang Asli||12 (53.8%)||7 (11.5%)||1 (7.7%)||2 (23.1%)||4 (3.8%)|
|Unknown||242 (59.3%)||87 (12.6%)||8 (4.4%)||62 (21.7%)||29 (1.9%)|
|Mann-Whitney U test statistic p-values|
|Measured parameters||(αα/αα)||Silent carrier||α+ thal trait||α0 thal trait||Hb H disease||p value|
|Age (years), mean ± SD||20.6 ± 15.5||21.0 ± 15.7||21.3 ± 16.5||20.7 ± 15.2||21.7 ± 15.3||0.860|
|Hb (g/dL), mean ± SD||11.1 ± 2.2||11.5 ± 2.0||10.8 ± 1.7||11.3 ± 1.7||8.8 ± 1.4||<0.001|
|RBC (mil/μL), mean ± SD||4.6 ± 0.76||4.78 ± 0.72||4.97 ± 0.81||5.32 ± 0.81||4.72 ± 0.99||0.000|
|RDW (%), mean ± SD||19.7 ± 8.2||17.9 ± 6.1||17.8 ± 5.4||18.0 ± 4.9||26.2 ± 6.7||<0.001|
|MCV (fL), mean ± SD||75.1 ± 10.0||75.8 ± 8.5||69.8 ± 8.1||67.8 ± 7.2||64.9 ± 12.6||<0.001|
|MCH (pg), mean ± SD||23.9 ± 3.8||24.2 ± 3.6||21.8 ± 2.4||21.2 ± 2.1||19.1 ± 3.2||<0.001|
|MCHC (g/dL), mean ± SD||31.8 ± 5.1||31.8 ± 2.2||31.4 ± 2.2||31.5 ± 3.1||30.4 ± 3.0||<0.001|
|Hb A (%), mean ± SD||84.1 ± 12.6||83.5 ± 15.6||85.2 ± 11.3||86.1 ± 6.1||86.0 ± 12.5||0.048|
|Hb A2 (%), mean ± SD||4.1 ± 7.3||3.7 ± 6.4||3.4 ± 3.5||3.1 ± 4.3||2.4 ± 2.4||0.002|
|Hb F (%), mean ± SD||2.7 ± 10.6||1.8 ± 7.8||2.9 ± 13.1||0.9 ± 2.6||2.0 ± 4.9||0.003|
|Retic (%), mean ± SD||1.7 ± 3.0||1.9 ± 4.5||1.9 ± 1.5||1.3 ± 1.6||4.3 ± 5.2||0.000|
© 2013 by the authors; licensee MDPI, Basel, Switzerland This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution license (http://creativecommons.org/licenses/by/3.0/).