J Med Genet: first published as 10.1136/jmg.24.6.357 on 1 June 1987. Downloaded from

Journal of Medical Genetics 1987, 24, 357-361

High frequency of thalassaemia in a small island population in Melanesia

D K BOWDEN*, A V S HILLt, D J WEATHERALLt, AND J B CLEGGt From *the Department of Anatomy, Monash University, Clayton, Victoria 3168, Australia; and tMRC Molecular Haematology Unit, Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford.

SUMMARY A study of the causes of anaemia in the south west Pacific archipelago of Vanuatu has identified one island, Maewo, where the carrier rate for 13 thalassaemia exceeds 20%, one of the highest recorded incidences in the world. Homozygous ,B thalassaemia is a major cause of infant mortality and a serious drain on health resources on this island. Interactions of ,B thalassaemia with various forms of a' thalassaemia were common in this population. Coexistent a+ thalassaemia leads to better haemoglobinised and larger red cells than are seen in simple ,B thalassaemia heterozygotes and screening for the latter can only be reliably carried out by Hb A2 estimation.

In a recent study of the causes of hypochromic malarious islands of the south west Pacific. The

anaemia in the south west Pacific archipelago of extremely high frequency of 13 thalassaemia in the copyright. Vanuatu we identified a variety of haemoglobino- isolated community of Maewo thus affords a rare pathies on many of the islands. ' Most common were opportunity to study the natural history of 13 deletion forms of a' thalassaemia, which occur thalassaemia in its 'natural' environment. The clini- throughout the country, but reach their highest gene cal and haematological characterisation of the frequency of 40% on the northern island of Espiritu variant are presented in this paper. Santo. Apart from being misdiagnosed as iron deficiency they have had few direct clinical conse- Materials and methods http://jmg.bmj.com/ quences. In contrast, 1 thalassaemia was found to an appreciable extent only on two islands, Malekula, A total of 2289 subjects from the 17 larger islands of and, in particular, Maewo, where it has reached a Vanuatu, formerly the New Hebrides (fig 1), was carrier rate of over 20%, one of the highest recorded investigated for the presence of 13 thalassaemia. incidences in the world. This probably results from a Blood was collected by venepuncture from volun- combination of malarial selection and genetic drift teers of all ages and both sexes as previously in a small isolated community, and homozygous 13 described. ' Detailed clinical histories were collected thalassaemia is now a serious health problem and a and physical examinations carried out whenever on September 30, 2021 by guest. Protected major cause of infant mortality on this island. possible. Populations were studied without any Although there is a considerable amount of deliberate selection procedures and on the largest circumstantial evidence that high frequencies of 13 islands collections from different geographical areas thalassaemia result from malarial selection,2 conclus- were made to prevent unrepresentative sampling. ive microepidemiological and in vitro studies such as When the high incidence of 13 thalassaemia in the those that established the interaction between the central coastal region of Maewo became known, sickle cell gene and malaria3 4 are lacking. Further- further blood collections were carried out in the more, in many countries vector control programmes, northern and southern regions of the island to prophylactic treatment, and the availability of determine its overall distribution and frequency. sophisticated medical services have ended by now Blood samples were routinely collected into heparin, any possible interaction between 13 thalassaemia and EDTA, and plain tubes and blood films were made the malarial parasite. These considerations unfortu- at the time of the initial collection. Samples were nately do not yet apply in many of the remote immediately placed on melting ice for transportation Received for publication 22 September 1986. to the laboratory, where buffy coat samples were Revised version accepted for publication 12 November 1986. prepared from heparinised blood and deep frozen 357 J Med Genet: first published as 10.1136/jmg.24.6.357 on 1 June 1987. Downloaded from

358 D K Bowden, A V S Hill, D J Weatherall, and J B Clegg copyright.

FIG I Map of Vanuatu, south west Pacific. Left: south west Pacific. V= Vanuatu, A =Australia, PNG=Papua New Guinea, SI=Solomon Islands, NC=New Caledonia, F=Fiji. Right: Vanuatu. ES=Espiritu Santo, M=Maewo,

P=Pentecost, Pa=Paama, Mk=Malekula, Em=Emae, MM=Makura-Mataso, E=Efate, T= Tanna, F=Futuna, http://jmg.bmj.com/ A =Aneityum. for later DNA extraction.5 A Coulter counter model thalassaemia heterozygotes in Vanuatu are given in S or S plus was used to determine the haemoglobin table 1. While sporadic cases are seen on many level and red cell indices. Haemoglobin electro- islands, the disease reaches very high frequencies phoresis and quantification of haemoglobin A2 was only on Malekula and Maewo. A detailed survey of carried out by standard methods.6 Hb F levels were Maewo revealed that it was largely confined to the determined by the modified Betke method7 and coastal populations, with a uniform incidence in all on September 30, 2021 by guest. Protected serum ferritin levels were measured by a standard areas sampled (table 1). radioimmunoassay method.7 Two untransfused Haematological data on 249 Ni-Vanuatu, includ- infants with homozygous 13 thalassaemia were studied ing 63 13 thalassaemia heterozygotes and compund by standard methods (biosynthesis studies8 and heterozygotes with a thalassaemia, are given in isoelectric focusing9) to determine whether or not 1 tables 2, 3, and 4. These values fall within the range globin chain synthesis and the formation of Hb A seen for a thalassaemia in other populations.6 1' The was occurring. Alpha thalassaemia is commonly effects of interacting a thalassaemia genes in mini- found in this population so Southern blot hybridis- mising the reduction in MCH and MCV values in ation studies for the presence of deletion forms of heterozygous ,3 thalassaemia have been noted pre- the disorder were routinely carried out on all viously and are in agreement with the data pre- samples as previously described.' sented here."' Both the -a37 and -a42 deletion forms of a' thalassaemia are found in this Results population.' It is evident from table 2 that they result in very similar haematological phenotypes The island by island distribution and frequency of upon interaction with heterozygous 13 thalassaemia. J Med Genet: first published as 10.1136/jmg.24.6.357 on 1 June 1987. Downloaded from

High frequency of 13 thalassaemia in a small island population in Melanesia 359

There were no significant differences in serum before the age of one year with severe anaemia ferritin levels between 1 thalassaemic and normal requiring regular blood transfusion. However, four subjects (table 5). of the six children were eventually withdrawn from Six subjects, five from Maewo and one from the transfusion programme by their parents and Malekula, who were homozygous for 1 thalassaemia later died before the age of six. The fifth child died were identified during this study. All presented suddenly at the age of six years, five months after undergoing splenectomy, despite continuous anti- TABLE 1 O thalassaemia heterozygote frequencies in malarial and antibiotic prophylaxis postoperatively, Vanuatu. and one child remains alive but requires regular blood transfusion. Island Population ,B thalassaemiad In addition to these there is evidence (1979 censuis) _ _ patients of °/0% No studied considerable childhood mortality in families in which children known to have thalassaemia have Espiritu Santo 16 242 () 160) been born. Thus, in family A (fig 2), in which two Maewo (North) 2)11 154 children were proven thalassaemia homozygotes, (Central) 1771 20(7 179 (South) 21 9 73 two other infants died of unknown causes, although Ambac 782(0 O) 3(03 they were known to be anaemic. Similarly, in family Pentecost 9544 () 57 Malekula 15 935 6-2 113 B, in which two homozygotes died in infancy, a Ambrym 6324 4-5 22 further eight infants (all with a clinical history of Paama 2354 () 66 was Epi 2672 (0-7 288 anaemia) had died before this study under- Tongariki 362 - - taken. In contrast, we have no evidence of any Emae/Tongoa 754/2892 significant childhood mortality in families in this Makura/Mataso 162/102 - - Efate 21) 11() 3.3 61 population in which only one or neither parent Tanna 15 715 () 9 3(06 carries a thalassaemia gene. Futuna 357 2(0 11)2 Ancityum 465 () 2611 Haemoglobin analysis and biosynthesis was car- Average (total) 5-7 1301/2289 ried out on peripheral blood samples from two copyright. cases was un- *Defincd bv Hb A, levcls >3 5%. untransfused infants. In both there

TABLE 2 Haematological data in 249 Ni-Vanuatu according to a and /3 thalassaemia genotypes.

Adult No Genotvs'pe fIb(gltll) MCV (rt) MCH(p/glelll

M 45 No o or (3 thalasacmiai detected 14 7± 2 89-4±4-7 29-1±1-5 http://jmg.bmj.com/ F 47 13-5±09) M 6 (5 thalasaemia heterozygotc only 12-4+1-2 F 13 II-3± I-0 65-8±5-3 20-7± 1-7 M 7 -( 7/uu plus hctcrozygous thala.ssaicmia 12-7±01-9 69-11±4 (1-7+1-4 F I( 11-8± I-I 62 M 3 .(_X(L plus hctcrozygous r) thalassacmia 13.3±12 08-8+±2-2 21-8+ 1-3 F 2 1-9±l-1 2 M 4 -(t/-(t plus hctcrozygous /3 thalassacmia 7413±:3523-'1 - F 3 13-0±0-777 10-15 vear.s on September 30, 2021 by guest. Protected M 40 No o or /3 thalassacmia dctectced 12-7± Il0 7186-3±5-4 1 -3 F 39 12-8±0-9 6 4 M 3X ictcrozygous r) thalassacmian 12-01±01-4 63-3±3-01 19-1 ±10-6 MF 3} -(o /700m plus hctcrozygous j3 thala.ssaemic 116±)68±6±3(10)I-1 21- F 686±J. J-210 5-9 vear.s M lIlt No (t or r3 thalassecmia detected I2-8± I-I1 80-1±45 26 1+X F 7f 12-5±0-914 M(2)+F(2)Ifctcrozygous r3 thailalssacmia 63-0)±2-0( 19-3±01-8

TABLE 3 Hb F levels in 361 Ni-Vanuatu of all ages (above five years) according to a+f3 thalassaemia genotypes.

No Getotspe Hh F ('1%) 277 No I/) thalalssaemia dectctced 0-48±0)-18 (includels all -(ol gctiotvpcs) 84 Hctcrozvgous r3 thalassacmia ()-79±()-38 (includes all -(ol genotypes) 42 Hctcrozvgous I3 thala.lss.icmiai and no a thala.lssatcmiat dctcctcd 01-81±)-44 8 Hctcrozygous r3 thalassacmia plus -ot-( of a1ll types (-39±()- I() J Med Genet: first published as 10.1136/jmg.24.6.357 on 1 June 1987. Downloaded from

360 DK Bowden, A V S Hill, D J Weatherall, and J B Clegg equivocal evidence for small amounts of 13 chain preparation), a mutation previously described1" synthesis, or the presence of Hb A, indicating that only in Asians and known to result in inefficient these subjects have a form of homozygous f3 splicing of 13 mRNA transcripts with consequent thalassaemia. Subsequent characterisation of the reduced output of 1 globin.'2 However, the variant defective ,B gene has shown that it carries a G-*C present in the Maewo population has a different 13 change at position 5 in IVS-1 (Hill et al, in gene complex haplotype than that previously described'1 13 and is presumably a new mutation. TABLE 4 Hb A2 levels in 510 Ni-Vanuatu ofall ages (above Discussion five years) from the islands of Maewo and Aneityum. Sporadic cases of 13 thalassaemia in Vanuatu had No Genotype Hb A2 (%) Island originally come to our attention during investiga- 129 No fI thalassaemia detected 2.4±0.4 Aneityum tions of hospital patients with anaemia of preg- 298 No ,3 thalassaemia detected 2-4±0-3 Maewo nancy. However, it was not until a widespread 83 Heterozygous thalassaemia 4-8±0-7 Maewo survey of the entire archipelago had been completed'

TABLE 5 Serum ferritin levels in 217 Ni-Vanuatu from the island of Maewo.

Age Sex No Genotype Serum ferritin (pgll)

Adult M 42) No thalassaemia detected [72-1±37-0 F 67 ,3 75617±3970 M 14j j63.0±41 8 F 25 Heterozygous thalassaemia 05745±36.8 10-15 years F 134 No thalassaemia detected 41 2±14-6 M 8 Heterozygous 15 thalassaemia 42-4±13 9

F2 copyright. 5-9 years M 151 No 15 thalassaemia detected 39 0±22() F t~~3j 143-3±27-7 M 4 Heterozygous 16 thalassaemia 39-8±23-0

A Normal http://jmg.bmj.com/ 3 thalassaemia status not known a thalassaemia heterozygotes t t t 3thalassaemia homozygotes t on September 30, 2021 by guest. Protected

t t FIG 2 Pedigrees oftwo unrelatedfamilies in which children with proven homozygous f6 thalassaemia have been born. J Med Genet: first published as 10.1136/jmg.24.6.357 on 1 June 1987. Downloaded from

High frequency of 13 thalassaemia in a small island population in Melanesia 361 that the grossly uneven distribution of the disease Hodgson, and Nicola Leech for assistance; Bryan became apparent. On Maewo, over 20% of the Rush and John Allen, St Vincent's Hospital, Mel- population are carriers whereas, apart from bourne for use of a Coulter counter; Vivienne Malekula, most other islands are largely free of the Phillips and Elizabeth Gunson for preparing the disease. manuscript; and the Rockefeller Foundation for The clinical and laboratory findings are in keeping financial support. with I+ thalassaemia as seen in other populations,' in which heterozygotes have a mild hypochromic References microcytic anaemia and are usually asymptomatic, Bowden DK, Hill AVS, Higgs DR, Weatherall DJ, Clegg JB. except for females in pregnancy when there is an Relative roles of genetic factors, dietary deficiency, and exaggerated fall in haemoglobin level in the mid- infection in anaemia in Vanuatu, Southwest Pacific. Lancet trimester. are affected severe 1985;ii: 1025-8. Homozygotes by 2 Siniscalco M, Bernini L, Filippi G, Latte B, Merra Khan P, anaemia within the first six months requiring four- Piomelli S. Population genetics of haemoglobin variants, thalas- to six-weekly blood transfusions to maintain saemia and glucose-6-phosphate dehydrogenase deficiency, with adequate haemoglobin levels. particular reference to the malaria hypothesis. Bull WHO 1966;34:379-93. Because there is a high incidence of deletion 3 Allison AC. The distribution of the sickle cell trait in East Africa forms of a' thalassaemia in Vanuatu, their inter- and elsewhere and its apparent relationship to the incidence of actions with 1 thalassaemia are frequently encoun- subtertian malaria. Trans R Soc Trop Med Hyg 1954;48:312-8. tered on Maewo. As seen in table 2, MCV and 4 Pasvol G. The interaction between sickle haemoglobin and the malarial parasite Plasmodium falciparum. Trans R Soc Trop MCH indices in these cases are usually higher than Med Hyg 1980;74:701-5. for the simple heterozygous 13 thalassaemia, espe- Old JM, Higgs DR. Gene analysis in the thalassaemias. In: cially when the interacting a' thalassaemia is Weatherall DJ, ed. The thalassemias. Edinburgh: Churchill present in the homozygous state (1 thal -a/-a). Livingstone, 1983:74-102. for 13 thalassaemia can not out 6 Weatherall DJ, Clegg JB. The thalassaemia syndromes. 3rd ed. Screening be carried Oxford: Blackwell Scientific Publications, 1981:744-69. satisfactorily by electronic cell counting in these 7 Dacie JV, Lewis SM. Practical haematology. 5th ed. London: circumstances; raised Hb A2 levels are, however, a Churchill Livingstone, 1975. copyright. reliable indication of 13 thalassaemia in the simple or Clegg JB. Haemoglobin synthesis. In: Weatherall DJ, ed. The state. 14 thalassemias. Edinburgh: Churchill Livingstone, 1983:54-73. compound heterozygous Cossu G, Maria M, Gavina Pirastu M, et al. Neonatal screening Malaria is endemic and widespread in Vanuatu. of ,1 thalassemia by thin layer isoelectric focussing. Am J Hence, it might have been expected that, as in Hematol 1982;13:149-57. malarial areas elsewhere, haemoglobinopathies " Kanavakis E, Wainscoat JS, Wood WG, et al. The interaction of would not be uncommon. The restricted distribution a thalassaemia with heterozygous f3 thalassaemia. BrJ Haematol 1982;52:465-73. http://jmg.bmj.com/ of 13 thalassaemia probably points to a recent Orkin SH, Antonarakis SE, Sexton JP, Boehm CD, Goff SC, introduction on Maewo which, because of relatively Waber PG. Molecular characterisation of seven ,I thalassaemia limited inter-island population movement, has not mutations in Asian Indians. EMBO J 1984:3:593-6. had time to the 2 Treisman R, Orkin SH, Maniatis T. Specific transcription and yet spread throughout archipelago. RNA splicing defects in five cloned ,1 thalassaemia genes. Thus, homozygous 13 thalassaemia, while of minor Nature 1983;302:591-6. importance nationally in Vanuatu, is a serious public '3 Cheng T, Orkin SH, Antonarakis SE, et al. ,1 thalassemia in health problem for the 2000 inhabitants of Maewo; Chinese: use of in vivo RNA analysis and oligonucleotide hybridisation in systematic characterisation of molecular de- it accounts for a high infant mortality in affected on September 30, 2021 by guest. Protected fects. Proc Natl Acad Sci USA 1984;81:2821-5. families while seriously stretching the limited re- 4 Weatherall DJ. Prenatal diagnosis of inherited blood diseases. sources of local health services. Although trans- Clin Haematol 1985;14:747-74. fusion has proved practicable and well tolerated, '5 Thein SL, Wallace RB. The use of synthetic oligonucleotides as specific hybridisation probes in the diagnosis of genetic dis- chelation therapy is not yet considered feasible for orders. In: Davies KE, ed. Human genetic diseases. Oxford: both social and practical reasons. On the other IRL Press, 1986: 33-50. hand, if in the future the island population re- 16 Old JM. Fetal DNA analysis. In: Davies KE, ed. Human genetic quested genetic counselling and prenatal diagnosis diseases. Oxford: IRL Press, 1986: 1-17. for homozygous 13 thalassaemia, it should now be possible to use chorion biopsy and DNA analysis Correspondence and requests for reprints to Dr J B with oligonucleotide probes for this purpose.'5 I6 Clegg, MRC Molecular Haematology Unit, Depart- ment of Medicine, John Radcliffe Hospital, Head- We thank Muriel Tari, Graham Tabi, Yvonne ington, Oxford OX3 9DU.