Intervention and prevention of hereditary hemolytic disorders in India: a case study of two ethnic communities of Sundargarh district in Orissa.

OBJECTIVES: This study was aimed at to sensitize, motivate, and screen two major vulnerable tribal communities--Bhuyan and Kharia, for hemoglobinopathies and allied hemolytic disorders, along with prospective and retrospective genetic/marriage counseling to the affected persons. For sustainability, imparting of relevant training to local paramedical staff, and to undertake periodic follow up for evaluation, intervention and clinical management through local PHCs/hospitals. METHODOLOGY: Tribal people in Orissa live in clusters practicing inter-village marriages following tribal endogamy and clan exogamy. The random sampling procedure for the selection of whole village was followed. Population of each tribe was representative because incoming and outgoing married women represent other surrounding villages belonging to their community. The pre- and post-intervention knowledge, attitude and practice (KAP) studies were conducted. Sensitization, motivation and education for carrier detection were carried out through IEC materials, holding interactive meetings and discussions at district, block and village levels. Standard biochemical and hematological techniques were followed for analysis of blood samples. Relevant training to local health personnel was imparted. Both prospective and retrospective intervention and genetic/marriage counseling was done through local PHC doctor. RESULTS: Study revealed high occurrence of hemoglobinopathies in Bhuyan (9.8%) and Kharia (13.3%) tribes, including uncommon hemoglobin variants like hemoglobin D, E, beta-thalassemia, and hereditary persistence of fetal hemoglobin (HPFH). G-6-PD enzyme deficiency was high in Dhelki Kharia (30.7%) and in Dudh Kharia (19.2%), whereas, it was recorded to be 21.1%, 16.3% and 13.7% in Paraja, Paik and Paudi Bhuyan subtribes, respectively. Use of antimalarials was cautioned in these tribal communities. Due to low frequency of Rhesus (D) negative (0.2-1.2%), the Rhesus (D) incompatibility problem seemed to be absent. Impact of methodical and prudent intervention and preventive strategies was found positive and encouraging. CONCLUSIONS: Adoption of a biomedical anthropological approach for implementing and evolving health seeking cooperative strategy that was tribal-oriented, tribal-friendly and tribal-participatory for intervention and prevention of common hemolytic disorders was found effective. Success of this strategy was apparent with overwhelming response of tribal people towards changing the traditional mindset, improving the health and quality of life. Health must meet the needs and perception of the people.

Hematological profile of twenty-nine tribal compound cases of hemoglobinopathies and G-6-PD deficiency in rural Orissa.

Background: Hematogenetic disorders are commonly encountered in Orissa state in Central-Eastern India. Hemoglobinopathies and G-6-PD deficiency are the most frequently occurring hereditary hemolytic disorders causing high morbidity and mortality in vulnerable people. Aims: There is no study available reporting combined condition of hemoglobinopathies and G-6-PD deficiency in a single individual from India. This study aims to assess the coincidence of G-6-PD enzyme deficiency with different hemoglobinopathies and beta-thalassemia and to evaluate the influence of combined conditions on the hematological expression. Settings and Design: The study was carried out in rural Orissa with a random sampling procedure. Materials and Methods: Following the standard methodology and techniques, this study highlights 29 tribal cases of compound occurrence of hemoglobinopathy with G-6-PD deficiency in a randomly conducted study in Sundargarh district of Orissa. Statistical Analysis: Results were subjected to statistical analysis. Results: Both female heterozygotes and homozygotes of G-6-PD deficiency in association with different hemoglobinopathies showed reduced values of hematological indices: hemoglobin level, MCV, MCH, MCHC and RBC in comparison to normals. Red cell indices were found further reduced in male G-6-PD deficiency concurrence with hemoglobinopathies in homozygous condition, i.e. sickle cell disease (HbSS) or hemoglobin E disease (HbEE). Hematological indices were significantly lower except WBC counts and fetal hemoglobin in male G-6-PD deficiency with co-existing homozygous sickle cell disease in comparison with counterpart sickle cell trait and normal controls. Conclusions: Hemoglobin polymorphism with G-6-PD deficiency is advantageous to the community against lethal effects of malaria especially against Plasmodium falciparum at population level, but their combination is harmful at the individual level because of low levels of red cell indices to cope with the routine human physiology.

Identification of a rare blood group, “Bombay (Oh) phenotype,” in Bhuyan tribe of Northwestern Orissa, India.

BACKGROUND: Blood group serology plays a vital role in transfusion medicine. The Bombay (Oh) phenotype is characterized by the absence of A, B, and H antigens on red cells and occurs rarely, especially in tribal populations of India. AIMS AND OBJECTIVES: This is a field-based random population study in the Bhuyan tribal community. The study reports three cases of the rare Bombay (Oh) phenotype for the first time in the Bhuyan tribe of Sundargarh district in North-Western Orissa. MATERIALS AND METHODS: Taking informed consent, red blood cells of 836 Bhuyan subjects were tested with three antisera, i.e., anti-A, anti-B, and anti-H (lectin) for forward reaction. Agglutinations of plasma with A, B, and O (H) red cells (reverse reaction) were also tested for the presence or absence of antibodies in the serum. Specialized tests like absorption-elution, titration of naturally occurring antibodies at different temperatures, inhibition of anti-H by O saliva secretor, and determination of secretor status were performed. RESULTS: Three cases of a rare blood group, Bombay (Oh) phenotype, (2 out of 244 Khandayat Bhuyan and 1 out of 379 Paudi Bhuyan from Hemgiri and Lahunipara blocks, respectively) in the Bhuyan tribe of Sundargarh district in North-Western Orissa were detected, giving an incidence of 1 in 122 in Khandayat Bhuyan and 1 in 379 in Paudi Bhuyan, with an average of 1 in 278 among the Bhuyan tribal population. This incidence is high in comparison to earlier studies reported from India. CONCLUSIONS: The practice of tribal and territorial endogamy in a smaller effective populations (for example, there are only 3,521 individuals in Paudi Bhuyan) results in smaller marital distance and inbreeding, leading to increased homozygous expression of rare recessive genetic characters like the Bombay (Oh) phenotype. This study further testifies that the incidence is higher in those states of India where the consanguinity is a common practice.

A monozygotic twin pair with β-thalassemia carrier status in a Dudh Kharia tribal family of Orissa.

BACKGROUND: The β-thalassemia syndrome is a genetically inherited commonly encountered hematological disorder in the state of Orissa. It causes high degree of morbidity, mortality and fetal wastage in the poor vulnerable people. AIMS AND OBJECTIVES: There is an equal probability (50% chance) in every singleton pregnancy that a carrier parent of β-thalassemia major would either bear normal or carrier offspring, but not two offspring with carrier of β-thalassemia major genotype together. For the first time, a carrier parent of β-thalassemia major gene has born progeny (three daughters and a twin male offspring) with a carrier status of β-thalassemia major in Dudh Kharia tribal family studied from Sundargarh district of Orissa. MATERIALS AND METHODS: We screened randomly selected population of Dudh Kharia tribe from Sundargarh district of Orissa for hemoglobinopathies to assess the extent of the problem, design possible interventions and provide genetic counseling to them. A family with twin children was identified during screening in Lata Gaon in Bargaon block of Sundargarh district of Orissa for the above-mentioned study. Background information for this family such as name, age, sex, tribe, native place, reproductive history, family pedigree and clinical signs and symptoms were also recorded. Standardized genetic and hematological procedures and techniques were followed for analysis. RESULTS: Laboratory investigations for alkaline electrophoresis of blood lysate on cellulose acetate membrane showed raised hemoglobin A2 level in mother (Hb A2 = 5.3%), in three daughters (Hb A2 =6.5, 5.9, 5.5% in chronological and birth order), in two twin sons (Hb A2 =5.9% and 6.0%) and normal (Hb A2 = 3.3%) for father. Hence, all the children i.e., three daughters and two twin sons, including the mother were β-thalassemia carriers. Since all the hematological parameters i.e., red cell indices, G-6-PD enzyme activity, ABO and Rhesus blood groups and identical β-thalassemia (trait) genotypes with identical clinical manifestations and hematological profile of the twin sons under similar environmental conditions, hence they were labeled as identical monozygotic twins. CONCLUSIONS: It is a rare occasion when a single pregnancy carries either one or two abnormal genotypes at a time in a womb in human beings. Monozygotic twins are genetically alike and provide appraisal of the expression of identical genotype under the different environmental conditions.

Genetic heterogeneity of population structure in 15 major scheduled tribes in central-eastern India: A study of immuno-hematological disorders.

Background: The aboriginal tribes of India constitute an important segment of the society in the world. Though a large number of genetic studies have been carried out in India, the genetic data of the populations in the state of Orissa are very limited, especially pertaining to the indigenous tribal people. Most of the earlier studies were restricted to either a single tribe or a few genetic markers. Data on population structure of tribal communities of Orissa pertaining to common hemolytic disorders and genetic variations are still scanty. AIMS AND OBJECTIVES: In view of the limited data available on the tribes and the huge tribal population, a cross-section of ashram schools was investigated for immuno-hematological disorders in relation to geographical, linguistic and genetic variations. MATERIALS AND METHODS: A cross-section of 15 major scheduled tribes in ashram schools from eight districts of Orissa was randomly studied for five hereditary immuno-hematological markers, namely, the ABO and Rhesus (D) blood groups, sickle cell hemoglobinopathy, β -thalassemia syndrome and G-6-PD deficiency, following the standard hematological procedures and techniques. RESULTS: A preponderance of blood group B over A and low incidence of Rhesus-negative (D-) among Bathudi, Bhuyan, Kissan, Kolha, Kondh, Munda oraon, Paraja, Santal and Saora tribes was observed. The deficiency of G-6-PD enzyme was found to be quite high, varying from 5.1 to 15.9% among these scheduled tribes of Orissa. Both deficient female heterozygotes and homozygotes were encountered. Marked variation was seen in the prevalence of β -thalassemia trait, varying from 0 to 8.5%, in the aboriginal tribes. The frequency of sickle cell disorders was found to vary from 0 to 22.4% among the major tribes, but it was comparatively higher in Paraja (21.5%), Dhelki Kharia (13.7%), Gond (11.9%) and Bhatra (10.5%) tribes. CONCLUSIONS: The study showed genetic heterogeneity and diversity with respect to above immuno-hematological genetic markers and indicated not only the inter-tribal admixture but also diffusion with other racial groups of India. Further, the heterogeneous tribal populations from Orissa were found to harbor almost all major hemoglobinopathies. This is the first comprehensive study of immuno-hematological disorders among the scheduled tribes from the state of Orissa.

Spectrum of hemoglobinopathies in the state of Orissa, India: a ten years cohort study.

OBJECTIVES: i) To determine the pattern of spectrum of hemoglobinopathies in the state of Orissa, ii) To find the ethnic groups at high risk of hemoglobinopathies, iii) Geographical distribution of hemoglobinopathies, and iv). To know epidemiological aspects of hemoglobinopathy cases in Orissa. MATERIAL AND METHODS: One thousand fifteen cases of anemia were analysed referred from different peripheral hospitals and Medical Colleges and Hospitals of Orissa state for diagnosis and counseling during 1994 to 2003. About 2-3 ml. intravenous blood samples were collected after obtaining informed consent from each individual. Hematological indices were measured using MS4 Cell Counter. Background data of each individual were recorded like age, sex, caste, place of origin, consanguinity, etc. Hemoglobin electrophoresis was carried out on CAM in Tris-EDTA-Borate buffer at pH 8.9 and quantification of A2 fraction of hemoglobin by elution method. The value more than 3.5% of A2 fraction of hemoglobin was taken as cut off point for beta-thalassemia trait and more than 10% as Hb E. Hb electrophoresis in acidic medium (pH 6.2) was also carried out to confirm Hb D or E band. Estimation of fetal hemoglobin was done. Family studies were carried out to confirm the diagnosis. RESULTS: Most common hemoglobinopathies observed out of 1015 cases were: sickle cell trait (29.8%), sickle cell disease (7.5%), sickle cell-beta-thalassemia (1.7%), beta-thalassemia trait (18.2%), thalassemia major (5.3%), thalassemia intermedia (0.9%), Hb E trait (0.9%), Hb E disease (0.3%), E-beta-thalassemia (0.7%), Hb D trait (0.2%) and SD disease (0.2%). Sickle cell disorders with high level of fetal hemoglobin were common in general castes (0.3-20.7%), scheduled castes (0-8.9%) and scheduled tribals (0-5.5%).Transfusion dependent beta-thalassemia syndrome was prevalent in Brahmin, Karan, Khandyat, Teli, etc. Most of the cases belong to Anugul district, followed by Khurda, Nayagarh, Phulbani, Cuttack, Jajpur, Dhenkanal, Ganjam, Keonjhar, Mayurbhanj, etc. CONCLUSIONS: The heterogeneous population is harbouring almost all major hemoglobinopathies in general castes, scheduled castes and tribes, belonging to Coastal and South-Western regions of Orissa. This study provides for the first time a comprehensive database on the pattern of spectrum of hemoglobinopathies in Orissa.

Hereditary persistence of foetal haemoglobin in a tribal family of Orissa, India.

BACKGROUND: The hereditary persistence of foetal haemoglobin (HPFH) is an autosomal co-dominant, rare, inherited condition. It occurs due to failure of switching off of the production of gamma-chains during the neonatal period leading to a high level of foetal haemoglobin in adult life but without any anaemia. During screening a randomly selected Paraja Bhuyan tribal population for haemoglobinopathies in the Sundargarh district of western Orissa, HPFH was detected in a family. METHODS: Horizontal haemoglobin electrophoresis was carried out to identify abnormal haemoglobins and quantitation of the haemoglobin A2 fraction was done by the elution method at pH 8.9. Haemoglobin F was estimated. Haematological parameters were studied using an automated blood cell counter. The acid elution-staining test was used to demonstrate the intracellular distribution of haemoglobin F-containing erythrocytes. RESULTS: Four members of the tribal family had a high level (6.5%-13.7%) of foetal haemoglobin--the mother and 3 children. None of them had any apparent clinical or haematological abnormality except for mild pallor in the two younger children. The add elution-staining test revealed pancellular distribution of foetal haemoglobin in the erythrocytes of all the affected family members. CONCLUSION: Genetic traits such as hereditary persistence of foetal haemoglobin, although rare, are prevalent in India.

Hereditary hemolytic disorders among the Ashram school children in Mayurbhanj district of Orissa.

Hemoglobinopathy and allied hemolytic disorders are important genetic and public health problems in Orissa. These cause high degree of hemolytic anemia, morbidity and mortality in the vulnerable populations. A total of 465 Ashram School children aged 6-15 years belonging to Bathudi, Bhumiz, Kolha and Santal tribes in six localities of Mayurbhanj district of Orissa were screened for hemoglobinopathy, glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, ABO and Rhesus blood groups serology and any other hereditary condition. The sickle cell trait (Hb AS) was detected in Santal (1.0%), Bathudi (1.0%) and Bhumiz (0.9%) tribals. No case of homozygous sickle cell disease was detected among the tribes of Mayurbhanj district. The beta-thalassemia trait was detected in Santal (8.0%), Kolha (2.0%), Bhumiz (1.7%) and other tribal (3.8%) students. Sickle cell hemoglobinopathy and beta-thalassemia are prevalent in this district among the tribes, but the frequency is very low. The prevalence of G-6-PD deficiency is considerably high (7.7-9.8%) among the tribes of Mayurbhanj district in Orissa. Out of total 43 G-6-PD deficient subjects, there were 32 males, 9 heterozygote females and 2 homozygous females. This shows that the antimalarial drugs should be administered with caution as these cause hemolytic anemia, sometimes fatal also. The distribution of ABO and Rhesus blood groups shows the preponderance of B blood group (33.8%) over O (29.6%) and 2.1% cases of Rhesus negativity were detected among the Bathudi tribe. This pattern is consistent with the characteristic features of tribal populations in India.

Control and prevention of the genetic load of haemoglobinopathies in India.

Haemoglobinopathies and thalassaemia are inherited disorders which affect a large number of individuals in India. With a population of 950 million and a birth rate of 28 per thousand, it has been estimated that there would be about 42 million carriers and about 12,000 infants born each year will be inheriting a major haemoglobin disorder in India. In view of this heavy genetic load, frequent blood transfusions, high cost of treatment and management, physical trauma, and psychological and mental harassment to the patients and their families, it has been realized that the preventive genetic approach is the most suitable for the Indian setting. After carrier detection, prenatal diagnosis and genetic counselling are important options for couples at high risk for haemoglobinopathies. A prerequisite for a successful prevention and control programme is health education, public awareness and sensitization, and screening of the population for identification of heterozygotes or carriers in the community.

Fetal outcome and childhood mortality in offspring of mothers with sickle cell trait and disease.

The sickle cell hemoglobinopathy is a major public health problem which causes high morbidity and mortality in India. Although the hematological and clinical profile of the patients is extensively studies. The reproductive outcome of mothers afflicted with sickle cell trait and disease is still unknown in India. In a retrospective study, we have examined the reproductive profile of 190 mothers afflicted with sickle cell, attending Medical Out-Patient Department at V.S.S. Medical College Hospital, Burla in Western Orissa, India during the year 1991-1992. Seventy-three mothers who were found normal after medical examination and were free from hemoglobinopathic disorders, anemia, jaundice, iron deficiency, etc. constituted the control group and 66 mothers with sickle cell trait and 51 with sickle cell disease formed the study group. The reproductive history was recorded for number of conceptions, fate of offspring, live birth, surviving children and childhood mortality. Hematological investigations and hemoglobin electrophoresis were done as per the standard procedure. There was no difference in mean number of livebirths per mother between controls and sickle cell trait mothers. But between the controls and sickle cell homozygotes (p < 0.01), and sickle cell trait and disease (p < 0.01) mothers, this mean number was significant. For abortions/miscarriages, the difference between controls and sickle cell homozygotes (p < 0.001), and sickle cell trait and disease (p < 0.01) mothers was highly significant. The number of stillbirths per mother in homozygous sickle cell mothers was higher (p < 0.01) as compared to controls. There were significantly higher childhood deaths in sickle cell trait (p < 0.05) and disease (p < 0.05) mothers than in the controls. It seems that the sickle cell heterozygote and hemoglobin E heterozygote mothers are genetically better fit than the sickle cell homozygotes. Further, the sickle cell disease is clinically severer than the hemoglobin E disease in India probably due to molecular diversity.

Genetic epidemiology of the three predominant abnormal hemoglobins in India.

Hemoglobinopathies in India are Important public health problems. Of the several abnormal of hemoglobin molecules, there are three variants, viz. Sickle cell, hemoglobin E and hemoglobin D which are predominantly prevalent in India. The cumulative gene frequencies of these hemoglobins have been found to be 5.35% in India. The average gene frequency of sickle cell and hemoglobin D in India has been observed to be 4.3% and 0.86%, respectively. In the North Eastern region of India, the gene frequency of hemoglobin E is 10.9%. Gene frequencies and spatial distribution of the predominant abnormal hemoglobins in India have been discussed in variance with the previous generalisations.

Age at menarche and first conception in sickle cell hemoglobinopathy.

Sickle cell hemoglobinopathy has emerged as a major public health problem in the tropical countries of the world including India. This paper deals with the age at menarche and first conception of women in relation to sickle cell genotypes. The mean age at menarche was slightly higher in sickle cell affected girls compared to controls. The delay in onset of menarche affects the age at first conception of the sickle cell afflicted individuals.

Menarcheal age in relation to ABO blood group phenotypes and haemoglobin-E genotypes.

The age at menarche in relation to ABO blood group phenotypes and haemoglobin-E genotypes has been studied among 290 girls belonging to Mongoloid ethnic stock in the North Eastern region of India. The study shows that the age at menarche is influenced by the abnormal haemoglobin E genotype as well as ABO blood group phenotype. Thus, the genetic markers play a pivotal role in the growth and development of an individual.

Dermatoglyphics in cleft lip and cleft palate anomalies.

Dermatoglyphic characteristics of sixty nine cases of cleft lip with or without cleft palate and twenty eight isolated cleft palate cases were evaluated for digital patterns, interdigital patterns, palmar simian crease and sydney line, and model types of C- and D-line terminations. Increased frequency of ulnar and radial loops than the arches and whorls was observed in cleft lip with or without cleft palate patients compared to controls. Interdigital patterns were less frequent in cleft lip and cleft palate patients. Simian crease and Sydney line were more common in patients than in controls. Model types of C- and D-line terminations showed variations in patients and controls. Wider 'atd' angle (more than 30 degrees) and dermatoglyphic asymmetry were noted in the patient groups. The findings suggest the dichotomy or heterogeneity of cleft lip and cleft palate anomalies. The role and utility of dermatoglyphics in genetical etiology of congenital defects were emphasized.

Reproductive profile of mothers in relation to hemoglobin E genotypes.

The reproductive profile of 190 Ahom-Kachari mothers belonging to Mongoloid ethnic stock of Assam has been studied in relation to hemoglobin (Hb) E genotypes. No significant variations have been observed in the reproductive performance between the normal population and abnormal hemoglobin homozygote (HbEE) and heterozygote (HbAE) mothers. However, the reproductive wastage among the hemoglobin homozygote (HbEE) mothers has been observed to be double than the normal hemoglobin (HbAA) and abnormal hemoglobin heterozygote (HbAE) mothers. The reproductive performance parameters have also been compared with the other available studies.