Vincenzo De Sanctis1, Christos Kattamis2, Duran Canatan3, Ashraf T. Soliman4 , Heba Elsedfy5, Mehran Karimi6, Shahina Daar7, Yasser Wali8, Mohamed Yassin9, Nada Soliman10, Praveen Sobti11, Soad Al Jaouni12, Mohamed El Kholy5, Bernadette Fiscina13 and Michael Angastiniotis14
1 Pediatric and Adolescent Outpatient Clinic, Quisisana Hospital, Ferrara, Italy.
2 First Department of Paediatrics, University of Athens, Athens, Greece.
3 Director of Thalassemia Diagnosis Center of Mediterranean Blood Diseases Foundation, Antalya, Turkey.
4 Department of Pediatrics, Division of Endocrinology, Alexandria University Children's Hospital, Alexandria, Egypt.
5 Department of Pediatrics, Ain Shams University, Cairo, Egypt.
6 Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
7 Department of Haematology, College of Medicine and Health Sciences, Sultan Qaboos University, Sultanate of Oman
8 Pediatric Hematology Unit, Child Health Department, Sultan Qaboos University Hospital, Muscat, Oman and Department of Pediatrics, Alexandria University Children's Hospital, Egypt.
9 National Center for Cancer Care and Research, Medical Oncology Hematology Section HMC, Doha, Qatar.
10 Primary Health Care, Ministry of Health, Alexandria, Egypt.
11 Professor, Pediatric Hemato-Oncology, Christian Medical College and Hospital, Ludhiana, Punjab, India.
12 Head, Division of Pediatric Hematology Oncology, Deputy Chair of Hematology and Head, Section of Hematology Research Lab, King Fahd Medical Research Center, Department of Hematology Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
13 Department of Pediatrics, NYU School of Medicine, New York, USA.
14 Medical Advisor, Thalassemia International Federation (TIF), Nicosia, Cyprus.
Received: November 20, 2016
Accepted: February 5, 2017
Mediterr J Hematol Infect Dis 2017, 9(1): e2017018 DOI 10.4084/MJHID.2017.018
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Haemoglobinopathies constitute the commonest recessive monogenic
disorders worldwide, and the treatment of affected individuals presents
a substantial global disease burden. β -thalassaemia is characterised
by the reduced synthesis (β+) or absence (βo) of the β-globin chains in
the HbA molecule, resulting in accumulation of excess unbound
α-globin chains that precipitate in erythroid precursors in the bone
marrow and in the mature erythrocytes, leading to ineffective
erythropoiesis and peripheral haemolysis. Approximately 1.5% of the
global population are heterozygotes (carriers) of the β-thalassemias;
there is a high incidence in populations from the Mediterranean basin,
throughout the Middle East, the Indian subcontinent, Southeast Asia,
and Melanesia to the Pacific Islands.
Variants of thalassaemias and main abnormal haemoglobins interact to produce a wide range of clinical disorders of varying severity.[1-3] Homozygotes for β-thalassemia may develop either thalassemia major or thalassemia intermedia. Individuals with thalassemia major are usually diagnosed within the first 2 years of life and require regular blood transfusions to survive. Patients with thalassemia intermedia are diagnosed later and as a rule, have milder anemia and do not depend on transfusion for survival.
The clinical manifestations of β-thalassemias are highly variable. They range from asymptomatic cases with mild (silent) mutations, to those with mild hypochromic anemia, to others with moderate and severe lifelong transfusion-dependent anemia and multi organ involvement.
β-thalassemia is mainly caused by mutations resulting in a single nucleotide substitution, small deletions or insertions within the β-globin gene or its immediate flanking sequence and, rarely, by gross deletions.[2,3] To date, more than 350 β-thalassaemia mutations have been reported in the IthaGenes database.
Nearly all β-thalassemia variants are inherited in a Mendelian recessive manner, but there is a small subgroup of β-thalassemia alleles that behave in a dominant fashion.
The principal aim of this paper is to review, from a historical standpoint, our knowledge of an ancient disease, the β-thalassemias, and to discuss when, how and in what way β-thalassemia has spread in the old world to reach such high incidences in certain populations. To this end, knowledge of the molecular defects that prevail in each country provides valuable information that can be used for population screening in prevention programmes and facilitates effective prenatal diagnosis.[2,3]
Epidemiology and Global Burden of the Thalassemia Disorders
The carrier frequencies for β-thalassemia in these areas range from 1 to 20%, and rarely may be higher. The frequencies for the milder forms of β-thalassemia are much greater, varying from 10 to 20% in parts of sub- Saharan Africa, to 40% or more in some Middle Eastern and Indian populations, to as high as 80% in northern Papua New Guinea and some isolated groups in the northeast of India.
Globally, it is estimated that there are 270 million carriers with abnormal haemoglobins and thalassemias, of which 80 million are carriers of β-thalassemia. Recent surveys suggest that between 300,000 and 400,000 babies are born with a serious hemoglobin disorder each year (23,000 with β-thalassemia major) and that up to 90% of these births occur in low- or middle-income countries.[1-6]
Origin, Spread and Evolutionary History of Beta-Globin Gene Mutations
β-thalassaemia is characterised by the partial reduction of synthesis (mild=β++, severe=β+) or total reduction (βo), of the β-globin chains in the HbA molecule. This results in accumulation of excess, unbound α-globin chains that precipitate in erythroid precursors in the bone marrow and in the mature erythrocytes, leading to ineffective erythropoiesis and peripheral haemolysis.[1-3]
While α- and β- thalassemias are caused by more than 450 mutations, almost 1200 mutations have been reported that change the structure of the α- and β-globin genes to create abnormal hemoglobin tetramers of HbA.[1-3] Among this broad spectrum of mutations, some are very frequent and population specific.
DNA haplotypes in the β-globin gene can help to determine the date of origin, track gene flow of a particular β-globin gene mutation and detect major migrations.
The β0-39 nonsense (C→T) and the β+ IVS-1-110 (G>A) mutations are largely prevalent in the Mediterranean basin.1-3 β+ IVS-1-110 is found in the eastern part of the Mediterranean area, including Turkey, Lebanon, and Egypt. The β+ IVS-1-110 seems to be older than the β0-39 mutation because of its nearly exclusive association with ancestral haplotype I. In addition, β+ IVS-1-110, which is believed to have arisen in the Middle Orient and reaches its highest frequencies in the Eastern Mediterranean populations, may have been introduced to the other countries by a variety of settlers from the East. Its diffusion to the occident probably happened at the time of the expansion of Greek civilization, starting from the eighth century B.C.
Most Common β-Thalassemia Variants in the Mediterranean Belt and Arabic Countries
On the other hand, the β0-39 (C>T) mutation is found almost exclusively in Sardinia. This dominating mutation seems to have undergone a significant founder effect influence on the island. It is also highly prevalent in continental Italy and Spain and is frequently encountered in Portugal and Tunisia.
The exclusive presence of β0-thalassemia type in southern Sardinia, which most likely arose from a single mutational event, is not surprising since Sardinia has been free from external colonisation for a long period of time. In fact, Greek colonisation was localised to the north-east of the island while Romans and Carthaginians settled only along the southern coast. Moreover, other populations, such as Vandals, Goths, Saracens, Pisans, and Spanish did not stay on the island long enough or in a sufficient number to modify the genetic structure of the autochthonous population significantly. The relatively high prevalence of β+- thalassemia in the northern part of the island was probably due to the Greek colonisation.[16,17]
More heterogeneity is detected in Sicily, where there are a variety of mutations and where the frequency of the β0-39 mutation is only 37%.
2. Cyprus: In Cyprus, the estimated β-thalassaemia carrier rate is around 12–15% of the population. The most common β-globin gene mutation is IVS-1-110 (G> A), with a percentage of 74-80%, followed by three other alleles, specifically IVS-2-745 (C> G), IVS-1-6 (T> C), IVS-1-1 (G> A), with frequencies of 5–8%. The presence of various haemoglobin variants in low prevalence, such as Hb S, Hb D, and Hb Lepore, is likely to be directly linked to the history of Cyprus, as archeological monuments have been found throughout the island signifying the presence for many years of the Greeks, Syrians, Persians, Arabs, Byzantines, Franks, Venetians, and Turks.
3. Greece: Greece is a country of approximately 11 million people with a mean frequency of β-thalassaemia carriers of 7.4%.
Extensive studies have disclosed that the distribution of β-thalassemia carriers is extremely uneven. The low fertile areas of Thessaly, Western Peloponnesus, and Western Epirus, as well as the islands of Rhodes, Lesbos, Corfu and other areas, displayed frequencies of up to 15%. In contrast, in the high altitude areas (that were free of malaria) and Macedonia, the prevalence of heterozygotes was significantly lower.
The molecular basis of β-thalassaemia is very heterogeneous in Greece, and up to 30 β-thalassaemia mutations have been observed. The molecular characterization of β- thalassaemia was evaluated in three studies on 857 thalassemia patients (106 with thalassaemia intermedia (TI) covering more than 25% of the 3,241 patients with TM and TI registered in 2010.
In the three studies, 27 β-thalassemia mutations were observed. Of interest are:
i) the rates of the prevalent β-thalassaemia mutations. In order of frequency they were: IVS-1-110(G>A) with an incidence of 43.8%; Codon 39(C>T), 18%; IVS-1-1(G>A), 12.7%; IVS-1-6(T>C), 6.9%; IVS-2-745(G>A), 4.7% and IVS- 2-1(G>A), 3%. The five mutations cover 89.1 % and the six 91.4% of the β-thal genes.
(ii) the three very mild mutations (+1480 ( C>T), -101 (C>T) and + 33 C>G ) that were found only in TI patients covering 22% of TI β-thalassaemia mutations.[21-23]
4. Turkey: The overall incidence of β-thalassemia trait in Turkey is 2.1% (range: 0.6-13%). At present, the Turkish population is about 80 million, with 1.6 million people with thalassemia trait and about 5500 patients with homozygous thalassemia and other hemoglobinopathies.
By April 1999, the total number of β-thalassemia alleles described in the Turkish population was ~40, and this number can be considered as a testimony of past settlements in Asia Minor. The most frequent thalassemia allele in the Turkish population is IVS-I-110 (G>A) mutation (40%), being the most common thalassemia mutation in the majority of the high risk regions of the Mediterranean area. The other common mutations in Turkey are: IVS-1-6(T>C), FSC-8(-AA), IVS-1-1(G>A), IVS-2-745(G>A), Cd39 (C>T), -30 (T>A) and FSC-5 (-CT). Malarial selection for the oldest β-thalassemia allele in Anatolia (i.e., IVS-1-110 G>A) may have occurred between 6,500 and 2,000 BC. Since then, Arab, Byzantine, Sumerian, Hittite and Turkish societies have played an important role in the history of the country, leading to a complex ethnic structure.
Currently, the minority of the population living in Adana and Mersin, in southern Turkey, is of Arab and African origin, and are known as “Eti-Turks”, whose ancestors immigrated from Syria and Egypt centuries ago. From that date on, most of the common β-thalassemia mutations in Turkey were established, and by the 13th century A.D., most of them were present at frequencies close to those 7% observed today.[25,26] Turkey's large molecular heterogeneity can be explained by its unique geographical position and rich history, an important crossroad between cultures, civilizations, and continents for several centuries.
The three most prevalent mutations include: IVS-1-110 (G>A): 39.5%, IVS -1-6 (T>C):10.1% and FSC -8 (-AA): 5.5%.
5. Arab populations. The standard definition of the Arab world includes the 22 states and territories from the Atlantic Ocean in the west to the Arabian Sea in the east, and from the Mediterranean Sea in the north to the Horn of Africa and the Indian Ocean in the southeast. It has a combined population of around 350 million people, one third of who are under 15 years of age. β-thalassemia is encountered in polymorphic frequencies in almost all Arab countries with carrier rates ranging from 1 to 11%.
Various papers reporting the spectrum of β-thalassemia mutations in different Arab countries have been published.[28-46] However, data for some countries is still lacking or only preliminary.
The spectrum of β-thalassemia mutations in the Arab populations has been extensively reported by Zahed in 2001, Tadmouri in 2003 Haj Khelil in 2010 and Hamamy in 2013.
The number of mutations detected in each population varies depending on its origin and interaction with other populations as well as the methods used for characterisation.[27-43]
Among Arabs, the heterogeneity of these mutations varies from 44 different mutations in UAE to 10 in Eastern Saudi Arabia. The most widespread and common mutation among Arabs is IVS-1-110 (G>A). The latter mutation has its highest prevalence in Cyprus and Greece suggesting that it may be of Greek origin. In the Eastern Arabian Peninsula, the Asian Indian mutations (IVS-1-5 (G>C), codons 8/9 (+G) and IVS-1 (−25 bp del) are more common.
Although β-thalassemia mutations reported are mainly of Mediterranean and Asian origin, some countries have unique mutations, e.g. Hb Dhofar in Oman. Codon 39 (C>T) has been found in all Arab countries without exception. IVSI-110 (G>A), the most common mutation, has rates of 12%–38% in Arab countries of the eastern Mediterranean but reaches lower frequencies in countries around the Gulf (0%–2%). IVS-2-1 (G>A) has been detected in all countries except Tunisia and Algeria. The highest frequency has been reported in North Jordan (20%) (IVS-2-1) and in Kuwait.
The most widespread and common mutations are presumably the oldest. Codon 39 (C>T) is believed to be of Roman origin, and IVS-1-110 is believed to have arisen in Turkey. It reaches its highest frequency in the Eastern Mediterranean Arab countries and may have been introduced to other countries by a variety of settlers from the East, including Turks, Greeks, or Phoenicians.
a. Egypt: Egypt is divided into three main geographical regions: the Nile Valley, the Eastern desert and the Western desert. The Nile Valley represents 4% of the area of Egypt and is divided into Upper Egypt, Lower Egypt, Suez Canal, and Northern coast lakes regions.
Cairo’s population has risen to more than 18 million (the highest population density in Egypt).
Egyptians are mainly descended from ancient Egyptians (94%). Ethnic minorities in Egypt include Nubians, Berbers, Bedouin Arabs, Beja and Dome (4%) and others (2%). The position of Egypt in the center of the Middle East, contiguous with the Mediterranean countries, has facilitated genetic admixture of Egyptians with several populations of diverse geographic and ethnic origins.
El-Hashemite et al. reported that of 1.5 million annual live births, approximately 1000 babies are born with β-thalassemia major. The most common mutations in Egyptian children with β-thalassemia are IVS-1-110(G>A) 48%, IVS-1-6 (T>C) 40%, IVS-1-1(G>A) 24%, IVS-1-5(G>C) 10%, IVS-2-848 (C>A) 9%, IVS-2-745(C>G) 8%, IVS-2-1(G>A) 7%.
b. Oman: The nature of the β-thalassaemia mutations that have been determined in the Omani population suggests that the majority have been introduced by gene flow. There was active commerce between Oman and the area around the Indus Valley for centuries. Burial sites and pottery dating to around 3,000 B.C. have also been unearthed in the surrounding Gulf countries. Using archaeological data from all these various sites it has been possible to establish that there was trade between Mesopotamia (present day Iraq), the lands bordering the Arabian Gulf and the Indus Valley peoples. Historically, Oman was a major maritime nation with links to the Far East and India on the one hand and East Africa and Egypt on the other, as well as trade in the Arabian Gulf. IVS-1-5 (G>C), a severe β+ allele, is the most prevalent of the mutations thus far described in Oman. A detailed analysis of the distribution of β-thalassaemia mutations in Pakistan shows that the IVS I-5 (G>C) mutation is widespread in that country, reaching a peak incidence in the Baluchis (76.2%) and having a high prevalence among the Sindhis (43.9%). It is also found at a high frequency in India.[27,29]
Other common β-thalassemia alleles common in Oman are the codon 44 (-C) (frequent in Iraq),37 IVS-1-3’ –25bp (epicentre Bahrain), IVS-2-1 (G>A) (Indian subcontinent) mutations, and the 619bp deletion at the 3’ end of the beta globin gene (Indian subcontinent), all of which almost certainly were introduced to Oman through gene flow. The only mutation unique to Oman is Hb Dhofar, which has originated in the southern region of the Sultanate and thus far has only been described in Omanis.
c. Qatar: Qatar is a peninsula bordering the Arabian Gulf and Saudi Arabia. The country’s population has been roughly split with 20% native Qatari, largely tribal, and 25% other Arabs from Egypt, Syria, Iraq, Lebanon, Yemen, Palestine, and Jordan. The rest of the population (55%) consists of expatriate workers from the East and the West.
Qatar’s history is very rich indicating the various phases that led to the ultimate development of the present State. The first trace of human settlements was found in the Qatar peninsula around 4,000 B.C. At the beginning of the 16th century, Qatar fell under the control of the Portuguese who were successful in establishing their control in many parts of the Arabian Peninsula. Later, the Ottomans ruled Qatar for four centuries.
The frequency of β- thalassemia heterozygotes is estimated to be 2-3%. Al-Obaidli et al. analyzed the molecular basis of β-thalassemia in Qatar. They found the most common mutant alleles were IVS-1-5 (G>C) and codon 8/9 (+G), representing 35.4% and 26.1% of the total, respectively. Most of these two mutations are homozygous, probably because of the high rate of consanguinity. The frequencies of three other common mutant alleles, IVS-2-1 (G>A), 25bp deletion and IVS-1-110 (G>A) are higher in surrounding locations, such as Southern Iran, Kuwait, eastern Saudi Arabia and Bahrain.
Recently, a novel β-thalassemia deletional variant allele in an ethnic Qatari patient was reported. The deletion spans exon 1, the entire intron 1 and the first two bases of exon 2 causing a frameshift and the premature appearance of a stop codon. The presence of this novel deletional allele in a compound heterozygous state with a non-deletional allele is alarming in a diagnostic setting, especially in the absence of family studies.
6. Iran: Iran, centrally located in the Asian continent, has served for centuries as a gateway for movement of human populations across diverse spheres of Asia and Europe. The Iranian population consists of diverse ethnic and linguistic groups namely Arabs, Armenians, Assyrians, Azeris, Baluchis, Gilaks, Mazandarani, Kurds, Lurs, Persian, Turkmen, and Zoroastrians.
In the eastern Mediterranean region, Iran is one of the major centers for the prevalence of β-thalassemia. Due to the high consanguinity in the population, it is estimated that there are more than three million β-thalassemia carriers (4-8%) and 20,000 patients.
The gene frequency of β-thalassemia is high and varies considerably between areas, with double the country average rate in Mazandaran, Sistan and Baluchistan, Fars, Hormozgan, and Kerman provinces and half the average country rate in provinces of Tehran, East Azerbaijan, Khorasan, Hamedan, Yazd and West Azerbaijan. There are more than 47 different β-globin gene mutations. Among them, the most common is IVS-2-1 (G > A; beta0) mutation, followed in decreasing order of frequency by IVS-1-5 (G > C, beta+), codons 8/9 (+G, beta0), IVS-1-110 (G > A, beta+), IVS-1-1(G > A, beta0), 25 bp deletion (beta0), IVS-I-6 (T > C, beta+), codon 5 (-CT, beta0), and codon 39 (C >T, beta0) mutations. It seems that codons 8/9 (+G) might reflect two historical events: one connected to the secular trade along the great Silk Road which extends from Xian in China through the Indian subcontinent to Iran and the Eastern Mediterranean and the other to the invasion of the Mongols (1,220 A.D.) and the Tatars (1,380–87 A.D.). The prevalence of codon 8/9 (+G) in the Northeast of Iran, and toward the center and northwest, may be related to the Oghuz Turks who migrated there from central Asia.
From extensive studies on the geographical distribution of the molecular basis of β-thalassemia, it has been shown that, despite the wide spectrum of mutations, the number of prevalent molecular defects for each population is limited.
The information provided in Table 1 is derived from published reports. The reported data often do not represent the entire population. Therefore, each single publication should be judged and used according to its merits, including sample size, the population group studied, geographical location within a country, and methodology used. A complete updated list of β-thalassemia variants is available through the Globin Gene Server Web Site (http://www.globin.cse.psu.edu).
|Table 1. The distribution of β-thalassemia variants in other countries.|
The Phylogeography and Phytogeographic Brief History of People in Ancient Times
The most controversial issue at present is exactly when and how these anatomically and genetically modern populations first spread from Africa to other parts of Asia and Europe. There are two main possibilities. The first is that the initial expansion occurred via North Africa and the Nile valley, with subsequent dispersals to the west into Europe and to the east into Asia.[50-54] The second is that the initial dispersal was from Ethiopia, across the mouth of the Red Sea, and then either northward through Arabia or eastward along the south Asian coastline to Australasia.[55,56] The strongest evidence at present for the second pothesis is provided by the mtDNA lineage- analysis patterns.[50,51] This model would mean that modern populations in southwest Asia and Europe must have reached these areas substantially later, via western or central Asia.
Why did modern human populations disperse from Africa ca. 60,000 years ago?
Childe suggested that, after the glaciations, North Africa and South-west Asia became drier and humans began to aggregate in areas where water was available.
The hypothesis of Childe on the role of the Younger Dryas (a geological period from c. 12,900 to c. 11,700 calendar years ago, characterized by a cool and dry climate) which was contemporary with the beginning of cultivation (c. 10,000 B.C.) in the region, is supported by recent studies from ancient sites of the Middle Euphrates region.[58-61]
These suggest that the world’s first civilization emerged in the late fourth millennium B.C. in southern Iraq, developing urban centers situated along the banks of the Tigris and Euphrates Rivers (Mesopotamia). This area, a small region of south-east Turkey and north-east Syria around the Middle Euphrates, might be the cradle of wheat agricultural innovation.[62-66]
After domestication, free-threshing wheat spread west through the Mediterranean basin, reaching its western edge by 5,000 B.C.[67,68]. Between 2,000 B.C. and 1,100 A.D., Anatolia served as the ground for several civilizations (Hittite, Persian, Greek, Roman, Byzantine, and Seljuk), resulting in an intensive flow of mutations into and out of present-day Turkey. Before reaching the Western Europe, agriculture spread in Greece during 4th millennium B.C.; it is possible that during that period Greece was one of the most malarious regions of the Mediterranean.[69,70]
During the 8th century B.C. the Greeks arrived in Italy. They came from Euboea, Argolis, Locris, Crete and the Aegean islands, settling on the southern coasts (from Campania to Apulia) and eastern and southern Sicily. They founded many prosperous colonies whose economy was generally based on agriculture and commerce.
It is possible that thalassemia existed among Sicily's native populations (Lymians, Sicanians, and Sicels) before that time, as it is postulated that some of these earlier inhabitants migrated to Sicily from the eastern Mediterranean, albeit probably before 4,000 B.C. A further historical influx of the thalassemia genes may be associated with mass immigration of the Saracens (Arabs) in the ninth and tenth centuries, as this population had a strong Middle-eastern Semitic component.
Silvestroni and Bianco recorded a very high percentage of β-thalassemia trait in people originating from the area of the Po River’s delta (Upper Adriatic): 10% in Ferrara, 16% in Codigoro and 12% in Pomposa. These towns in the past were in direct connection to the important Greek emporium of Spina through an ancient branch of the Po River. Spina was a commercial port founded at the beginning of the 6th century B.C. by Etruscans. Because of its location, along the Po River delta, the port became an ideal community to facilitate trade with the Greeks. The port was abandoned towards the end of the 3rd century B.C.
The expansion of the Ottoman Empire (15th and 16th centuries) towards Eastern Europe, Northern Africa, and Central Asia permitted further spread of β-thalassemia mutations in and out of Anatolia making it a melting-pot of a large number of alleles. The migration of many Muslim groups living in former Turkish territories in Southeastern Europe during the decline of the Ottoman Empire (starting from 1914 AD) contributed more to the racial mixture (i.e., the introduction of IVS-2-745, -87, IVS-2-654) .[24-26].
Factors Influencing the Global Distribution of Thalassemias
1.The resistance to malaria: World-wide, the distribution of malaria and the common haemoglobinopathies have largely confirmed the close relationship between malaria and high prevalence of hemoglobinopathy traits (HbS and β-thalassemia) and G-6PD deficiency in populations living in highly malarious areas. Micro-population epidemiological surveys have established this association. [72,73]
In 1948, Haldane suggested that the heterozygote state in β-thalassaemia provided a selective advantage against attack by the malarial parasite. This theory was based on the fact that homozygous beta thalassaemia results in a lethal condition, whereas the heterozygote only has a mild microcytic anaemia. If the carrier had no selective advantage over the normal or was less fit, then a very high mutation rate for beta thalassaemia would be required to secure equilibrium. Haldane felt that the heterozygote was fitter than normal, and he suggested that this might be due to the resistance of the microcytic erythrocytes to attack by the malaria parasite.[74,75]
It is not possible at this point to say exactly when malarial parasites evolved. Although there is no direct evidence as to the antiquity of malaria, there are many historical references to intermittent fevers and splenomegaly. Most authors believe that malaria was established in pre-historic times; it may have originated in tropical areas of the Old World, but the Pleistocene glaciations (130,000- 10,000 years ago) delayed its spread in the Northern Hemisphere.[76,77]
Until about 3,000 - 4,000 years ago population groups were small and isolated and infection could not spread easily. In addition, the vector for malaria, Anopheles gambiae, breeds in stagnant water that does not generally occur in the unbroken tropical rain forest. It is only when forest is cut down to make way for agriculture that these stagnant pools are found. The spread of malaria probably evolved with the development of tools during the Neolithic period (~6,000 B.C.–1,000 B.C.), which has traditionally been associated with the origins of farming and more settled human groups. It is possible that the infection then spread to most of the tropical and much of the temperate regions of the world.
Genetic variants that affect the structure and production of the β- or α-chains of haemoglobin are variously associated with protection from a range of clinical manifestations of P. falciparum infection. The degree of protection varies between haemoglobinopathies, but in general is greatest against severe malaria, moderate against uncomplicated malaria, and absent against asymptomatic P. falciparum parasitaemia.[78-83] HbS and to a lesser extent HbC protect from malaria but not from parasitaemia, suggesting that these haemoglobin variants prevent the transition from asymptomatic parasitaemia to malaria. This protective effect may derive from the abnormal display of parasite virulence factors on the surface of parasitized HbC and HbS erythrocytes,[78,79] possibly owing to the disruption of the parasite’s remodeling of erythrocyte’s intracellular trafficking network by HbS and HbC. Additionally, the age-dependent nature of malaria protection due to HbAS[81,82] and α-thalassaemia among children in recent reports support a protective mechanism based upon an enhanced acquisition of malaria immunity.
Additional possible mechanisms for protection due to haemoglobinopathies include an enhanced clearance of parasitized erythrocytes, impaired parasite growth, or the induction of protective immunomodulatory mechanisms by parasitized erythrocytes.
2. Consanguinity: The roots of Western attitudes toward consanguinity extend back over 1,500 years. Consanguineous marriage is especially common throughout the Eastern Mediterranean, Anatolia, North Africa and the Indian sub-continent, where 25-70% of unions involve related family members. Religious, cultural and economic factors are commonly perceived reasons for such marriage. As a consequence, at least 8.4% of the world’s children have related parents. The practice is also accepted in South America and parts of sub-Saharan Africa. The highest overall prevalence of consanguineous unions is in poor rural communities, which are typified by low levels of maternal education, early age at marriage and first birth, short birth intervals, and longer reproductive spans.[87-89]
3. Nutrition and infections: Another important factor is the diseases’ epidemiological transition. Because social and public health standards have gradually improved in developing countries, nutritional and infectious diseases are less frequent causes of mortality compared to the past.[1,90,91]
Furthermore, despite premarital screening and prenatal diagnosis, sociocultural challenges (traditional customs, religious beliefs or superstition) especially in countries with high thalassemia trait populations, still impact on β-thalassaemia major birth rates and global distribution of thalassemia.
4. Migration: The consistent multi-ethnic migrations of the last decades have considerably changed the epidemiology of hemoglobinopathies (Figure 1). Healthy carriers of these conditions are living today in many nonendemic countries, and severely affected children are now born in areas where these diseases were previously rare or unknown. In view of population migration, the distribution of the thalassemia gene appears to be worldwide affecting all ethnic groups except those originating from western, central and north Europe. The number of patients with haemoglobinopathies has been estimated to be almost 44,000 in the 10 EU countries, varying from 150 cases in Sweden to 10,500 in France.
Since β-thalassemia major has increased markedly in some European countries due to immigration from Africa and Asia, therefore national programmes of care and prevention are needed. Furthermore, major health organizations and funding agencies must support these initiatives.
5. Prevention: In the late 1970s, pilot programs directed to prevent β-thalassemia major started in several at-risk populations in the Mediterranean area. At present, several countries have set up comprehensive national prevention programs, which include public awareness and education, carrier screening, and counseling, as well as information on prenatal diagnosis and preimplantation diagnosis. The efficacy of the prevention programmes in Italy, Cyprus, and Greece is reflected by the fact that the number of babies with thalassemia major has decreased substantially in the last two decades. In Sardinia, for instance, the number of thalassemia major children born per year predicted on the basis of the carrier rate, assuming random mating, shows a reduction from 1:250 live births to 1:1660 in 2009 with an effective prevention of 85% of the cases. In Greece, the expected number of 160 annual births of affected newborns per 100,000 live birth decreased to 8 during 2005 to 2009.
Archeological Remains Suggestive of Hereditary Anemias
Angel analysed 2334 skeletal specimens coming from several archaeological sites in the Eastern Mediterranean (in particular from Turkey, Greece, Cyprus, and Morocco), belonging to the Upper Paleolithic period to Middle Ages. He used bone modifications, in particular, the porotic hyperostosis of the skull, as a marker of thalassemia trait and on this basis, started researching the appearance and diffusion of malaria and thalassemia. Porotic hyperostosis was classified as a thickening of the cranial vault caused by expansion of the diploë due to anaemia usually accompanied by porosity on the external cranial vault (cribra cranii) and often on the orbital roof (cribra orbitalia). Changes can be observed in both adults and older children and may occur in an active or healed condition. Healed and activecribra orbitalia differ by size of the affected bone tissue, size of the perforating lesions and thickness of the porous bone.
An infant skull (2-4 months old) with porotic hyperostosis was found in a cemetery in the old city of Nicosia between two churches of the late Byzantine and early Frankish period (around 1,200 A.D.) (Angastiniotis et al., unpublished data). The researchers tried to isolate DNA and to identify mutations but even though fragmented DNA was isolated no mutations were found.
Several other documented skeletal remains with bone pathology suggestive of β-thalassemia were discovered in various prehistoric sites of the world in areas such as Greece, Albania, Australia, the Middle East and Southeast Asia.
It is now it is known that porotic hyperostosis is not a characteristic mark of β-thalassemia, as Angel thought, but is an unspecific indicator of several diseases such as megaloblastic anae¬mia, deficiency of vitamin C and B12 and chronic iron-deficiency anemia. These difficulties are characteristic of all morphological skeletal diagnosis of ancient diseases.[97-99]
Rabino Massa et al. examined samples from the Marro Collection, belonging to the Anthropological and Ethnographic Museum of Turin, to determine the presence of malaria antigens. They assessed the specimens belonging to predynastic mummies (3,200 B.C.) from Gebelen excluding only the poorly conserved mummies. They analyzed about fifty of the 85 individuals of this collection. In these Egyptian mummies, the authors detected the presence of malaria.
The existence of a hemolytic disorder was observed in histological preparations of one individual, indicating pathological variations of hemoglobin. Radiographic examination confirmed the existence of hemoglobinopathy: in some mummified heads, there was the classical presence of "brush skulls".
Although skeletal changes are important additional findings for some clinical assessments, they cannot be used alone for diagnosis. Many other criteria have to be used for accurate diagnosis. Most recently, a variety of chemical methods has been used to study human bones at the molecular level including DNA analysis.
In 1995, Filon et al. presented the first direct proof of the occurrence of an inherited anemia in the archeological remains of a child, eight years old, with severe bone pathology consistent with β-thalassemia major. The remains came from an Israeli archaeological site, Akhziv, thought to date to the Ottoman period, sometime between the 16th and the 19th centuries. DNA analysis has shown that the child was homozygous for the frameshift mutation at codon 8 (-AA) as well as the variant (C-T) in the second codon of the β-globin gene.
Unfortunately, quantitation of aDNA templates was not carried out in this analysis. Quantitation of aDNA should be carried out in aDNA studies to estimate the authenticity of aDNA sequences and the risk of contamination with modern DNA.[103,104] If amounts of the aDNA templates are insufficient, then it is possible that PCR amplifications may have preferentially amplified one specific allele (mutant codon 8) over another (normal codon 8), resulting in homozygous sequences.
Before the advent of agriculture, roughly 5,000 years ago, it is unlikely that humans were exposed to large malaria outbreaks and that this stage was only reached whenever Neolithic (early) farmers settled in mosquito-infested soft and marshy soil near standing water. In these surroundings young carriers of the thalassemias (α and β) had better chances than normal to survive malaria during infancy, and were able to reproduce and pass the trait to the next generation, thus increasing the gene frequency. The higher and varying distribution of certain hemoglobin disorders in different populations may also reflect the high frequency of consanguineous marriages, mass migration, improvement of nutritional status, prevention and treatment of infectious diseases, settlements and the strong constitutions of inhabitants.[96-98]
Considering the current distribution of β-thalassemia and the diversity of mutation patterns, it is unlikely that β-thalassemia originated from a single place and time and then spread throughout the rest of the malaria belt. In fact, the contiguous distribution of β-thalassemia, as well as other β-globin gene mutations in localized areas of the world, had led to the conclusion that these mutations had emerged even before malaria became an important selective factor.
Because hemoglobinopathies are endemic or have expanded following mobility flows, they are present in all European countries creating an important impact on health services that has not yet been effectively addressed by Member States Health authorities. Recent surveys suggest that between 300,000 and 400,000 babies are born with a serious hemoglobin disorder each year (23,000 babies with β-thalassemia major) and that up to 90% of these births occur in low- or middle-income countries.[1-6]
The global distribution of the various globin gene mutations poses a number of interesting and important conundrums. Nowadays, a suitable strategy for identifying the β-globin mutations calls for the knowledge of the frequency of mutations, common or rare, in the ethnic group of the individuals.
The chronicity of the disease and the high cost of life-long treatment make prevention strategies crucial in the management of this disease. This requires intervention in high risk/targeted populations. Thanks to the implementation of massive prevention programs, mainly for thalassemia, in several countries the incidence of the disease has been reduced substantially, and in some areas, the annual rate of affected births has decreased by more than 90%.[105-107]
- Weatherall DJ, Clegg JB. 2001. The thalassaemia syndromes. 4th Edition. Oxford: Blackwell Science Ltd 2001 https://doi.org/10.1002/9780470696705
- Thein SL. The molecular basis of ß-thalassemia. Cold Spring Harb Perspect Med. 2013 May 1;3(5):a011700. doi: 10.1101/cshperspect.a011700. https://doi.org/10.1101/cshperspect.a011700
- Cao A, Kan YW. The prevention of thalassemia. Cold Spring Harb Perspect Med. 2013 Feb 1;3(2):a011775. doi: 10.1101/cshperspect.a011775 https://doi.org/10.1101/cshperspect.a011775
- Kountouris P, Lederer CW, Fanis P, Feleki X, Old J, Kleanthous M. IthaGenes: an interactive database for haemoglobin variations and epidemiology. PLoS One. 2014 Jul 24;9(7):e103020. doi: 10.1371/journal.pone.0103020. eCollection 2014 https://doi.org/10.1371/journal.pone.0103020
Ladis V.Kaagiorga–Langana M, Tsiarta I Chouliaras. Thirty-year experience in preventing hemoglobinopathies in Greece:
achievements and potentials for optimisations. Eur J Haematol .2013; 90:
313-322 https://doi.org/10.1111/ejh.12076 PMid:23331260
- Williams TN, Weatherall DJ. World distribution, population genetics, and health burden of the hemoglobinopathies. Cold Spring Harb Perspect Med. 2012 Sep 1;2(9):a011692 https://doi.org/10.1101/cshperspect.a011692 PMid:22951448 PMCid:PMC3426822
- Basak AN. The molecular pathology of beta-thalassemia in Turkey: the Bogaziçi University experience. Hemoglobin. 2007;31:233-241 https://doi.org/10.1080/03630260701296735 PMid:17486506
- Chehab FF, Der Kaloustian V, Khouri FP, Deeb SS, Kan YW. The molecular basis of beta-thalassemia in Lebanon: application to prenatal diagnosis. Blood 1987;69:1141–1145 PMid:3828533
- El-Hazmi MA, al-Swailem AR, Warsy AS. Molecular defects in beta-thalassaemias in the population of Saudi Arabia. Hum Hered.1995;45:278–285 https://doi.org/10.1159/000154314 PMid:7590760
- Zhong Chen L, Easteal S, Board PG. Evolution of the ß-globin haplotypes in human populations. Mol Biol Evol. 1990;7: 423–437
- Del Senno L, Pirastu M, Barbieri R, Bernardi F, Buzzoni D, Marchetti G, Perrotta C, Vullo C, Kan YW, Conconi F. beta (+)-Thalassaemia in the Po River Delta region (northern Italy): genotype and beta globin synthesis. J Med Genet. 1985;22:54-58 https://doi.org/10.1136/jmg.22.1.54 PMid:2580095 PMCid:PMC1049378
- Pirastu M, Saglio G, Camaschella C, Loi A, Serra A, Bertero T, Gabutti W, Cao A. Delineation of specific beta-thalassemia mutations in high-risk areas of Italy: a prerequisite for prenatal diagnosis. Blood 1987;71:983–988
- Amselem S, Nunes V, Vidaud M, Estivill X, Wong C, d'Auriol L, Vidaud D, Galibert F, Baiget M, Goossens M. Determination of the spectrum of beta-thalassemia genes in Spain by use of dot-blot analysis of amplified beta-globin DNA. Am J Hum Genet. 1988; 43:95–100 PMid:2897787 PMCid:PMC1715291
- Faustino P, Pacheco P, Loureiro P, Nogueira PJ, Lavinha J. The geographic pattern of beta-thalassaemia mutations in the Portuguese population. Br J Haematol. 1999;107:903–904 https://doi.org/10.1046/j.1365-2141.1999.01821.x PMid:10671033
- Fattoum S, Guemira F, Oner C, Li HW, Kutlar F, Huisman TH. Beta-thalassemia, HB S-beta-thalassemia and sickle cell anemia among Tunisians. Hemoglobin. 1991;15:11–21 https://doi.org/10.3109/03630269109072481 PMid:1917531
- Falchi A, Giovannoni L, Vacca L, Latini V, Vona G, Varesi L.ß-globin gene cluster haplotypes associated with beta-thalassemia on Corsica island. Am J Hematol. 2005;78:27-32 https://doi.org/10.1002/ajh.20199 PMid:15609277
- Maggio A, Giambona A, Cai SP, Wall J, Kan YW, Chehab FF. Rapid and simultaneous typing of hemoglobin S, hemoglobin C, and seven Mediterranean beta-thalassemia mutations by covalent reverse dot-blot analysis: application to prenatal diagnosis in Sicily. Blood.1993;81:239–242 PMid:8417793
- Kountouris P, Kousiappa I, Papasavva T, Christopoulos G, Pavlou E, Petrou M, Feleki X, Karitzie E, Phylactides M, Fanis P, Lederer CW, Kyrri AR, Kalogerou E, Makariou C, Ioannou C, Kythreotis L, Hadjilambi G, Andreou N, Pangalou E, Savvidou I, Angastiniotis M, Hadjigavriel M, Sitarou M, Kolnagou A, Kleanthous M, Christou S. The molecular spectrum and distribution of haemoglobinopathies in Cyprus: a 20-year retrospective study. Sci Rep. 2016 May 20;6:26371. doi: 10.1038/srep26371 https://doi.org/10.1038/srep26371
- Baysal E, Indrak K, Bozkurt G, Berkalp A, Aritkan E, Old J, Ioannou P, Angastiniotis M, Droushiotou A, Yüregir GT. The beta thalassaemia mutations in the population of Cyprus. Br J Haematol. 1992; 81: 607-609 https://doi.org/10.1111/j.1365-2141.1992.tb03000.x PMid:1390250
- Kyrri AR, Felekis X, Kalogerou E, Wild BJ, Kythreotis L, Phylactides M, Kleanthous M. Hemoglobin variants in Cyprus. Hemoglobin 2009;33:81-94 https://doi.org/10.1080/03630260902813502 PMid:19373583
- Malamos B, Fessas Ph, Stamatoyiannopoulos G. Types of thalassemia trait carriers, as revealed by a study of their incidence in Greece. Br J Haemat. 1962;8:5-14 https://doi.org/10.1111/j.1365-2141.1962.tb06489.x
- Loukopoulos D. Current status of thalassemia and sickle cell syndromes in Greece. Sem Hematol.1996;33:76-86 PMid:8714587
- Kattamis C, Hu H, Cheng G, Reese J, Gonzalez-Redondo M Kutlar A, Kutlar F, Huisman THJ. Molecular characterization of ß–thalassemia in 174 Greek patients with thalassemia major. Br.J Haem.1990;74:342-346 https://doi.org/10.1111/j.1365-2141.1990.tb02593.x
- Canatan D. Thalassemias and hemoglobinopathies in Turkey. Hemoglobin 2014;38:305-307 https://doi.org/10.3109/03630269.2014.938163 PMid:25030194
- Tadmouri GO, Garguier N, Demont J, Perrin P, Basak AN. History and origin of beta-thalassemia in Turkey: sequence haplotype diversity of beta-globin genes. Hum Biol. 2001;73:661-674 https://doi.org/10.1353/hub.2001.0075 PMid:11758688
- Aksoy M, Ikin EW, Mourant AE Lehmann H. Blood groups, haemoglobins, and thalassaemia in Turks in southern Turkey and Eti-Turks. Br Med J. 1958;2:937-939 https://doi.org/10.1136/bmj.2.5102.937 PMid:13584804 PMCid:PMC2026570
- Hamamy HA, Al-Allawi NA. Epidemiological profile of common haemoglobinopathies in Arab countries. J Community Genet. 2013;4:147-167 https://doi.org/10.1007/s12687-012-0127-8 PMid:23224852 PMCid:PMC3666833
- Agouti I, Badens C, Abouyoub A, Levy N, Bennani M. Molecular basis of beta-thalassemia in Morocco: possible origins of the molecular heterogeneity. Genet Test. 2008;12:563-568 https://doi.org/10.1089/gte.2008.0058 PMid:18976160
- Daar S, Gravell D, Hussein HM, Pathare AV, Wali Y, Krishnamoorthy R. Haematological and clinical features of beta-thalassaemia associated with Hb Dhofar. Eur J Haematol. 2008;80:67-70 https://doi.org/10.1111/j.1600-0609.2007.00989.x PMid:18173741
- De Leo R, Deidda G, Novelletto A, El-Kalla S, Mathews AR, Felicetti L. Analysis of ß-thalassemia mutations in the United Arab Emirates provides evidence for recurrent origin of the IVSI nt 5 (G-C) mutation. Hum Mutat. 1995;5:327–328 https://doi.org/10.1002/humu.1380050409 PMid:7627187
- Kyriacou K, Al-Quobaili F, Pavlou E, Christopoulos G, Ioannou P, Kleanthous M. Molecular characterization of ß-thalassemia in Syria. Hemoglobin 2000;24:1–13 https://doi.org/10.3109/03630260009002268 PMid:10722110
- Zahed L, Qatanani M, Nabulsi M, Taher A. ß- thalassemia mutations and haplotype analysis in Lebanon. Hemoglobin 2000;24:269–276 https://doi.org/10.3109/03630260008993133 PMid:11186256
- Filon D, Oron V, Shawa R, Shawa R, Elborno E, Najjar K, Tulchinsky T, Rachmilewitz E, Rund D, Oppenheim A. Spectrum of ß- thalassemia mutations in the Gaza area. Hum Mutat. 1995;5:351–353 https://doi.org/10.1002/humu.1380050416 PMid:7627194
- Jassim N, Merghoub T, Pascaud O, al Mukharraq H, Ducrocq R, Labie D, Elion J, Krishnamoorthy R, Arrayed SA. Molecular basis of ß-thalassemia in Bahrain. Ann NY Acad Sci. 1998;850:407–409 https://doi.org/10.1111/j.1749-6632.1998.tb10505.x PMid:9668568
- El-Hashemite N, Petrou M, Khalifa AS, Heshmat NM, Rady MS, Delhanty JD. Identification of novel Asian Indian and Japanese mutations causing ß-thalassemia in Egyptian population. Hum Genet 1997;99:271-274 https://doi.org/10.1007/s004390050352 PMid:9048934
- El-Shanshory M, Hagag A, Shebl S, Badria I, Abd Elhameed A, Abd El-Bar E, Al-Tonbary Y, Mansour A, Hassab H, Hamdy M, Alfy M, Sherief L, Sharaf E. Spectrum of beta globin gene mutations in Egyptian children with ß-Thalassemia. Mediterr J Hematol Infect Dis. 2014 Nov 1;6(1):e2014071 https://doi.org/10.4084/mjhid.2014.071 PMid:25408857 PMCid:PMC4235483
- Al-Allawi NA, Al-Mousawi BM, Badi AI, Jalal SD.The spectrum of ß-thalassemia mutations in Baghdad, Central Iraq. Hemoglobin 2013;37:444-453 https://doi.org/10.3109/03630269.2013.810641 PMid:23826747
- Al-Obaidli A, Hamodat M, Fawzi Z, Abu-Laban M, Gerard N, Krishnamoorthy R. Molecular basis of thalassemia in Qatar. Hemoglobin 2007;31:121-127 https://doi.org/10.1080/03630260701288815 PMid:17486492
- Al-Obaidli A, Gerard N, Al Zadjali S, Fawzi Z, Pravin S, Pathare A, Krishnamoorthy R. A novel deletional betathalassemic variant in an ethnic Qatari patient. Hemoglobin. 2009; 33:214-219 https://doi.org/10.1080/03630260903081398 PMid:19657835
- Haj Khelil A, Denden S, Leban N, Daimi H, Lakhdhar R, Lefranc G, Ben Chibani J, Perrin P. Hemoglobinopathies in North Africa: a review. Hemoglobin 2010;34:1-23 https://doi.org/10.3109/03630260903571286 PMid:20113284
- Zahed L. The spectrum of beta-thalassemia mutations in the Arab populations. J Biomed Biotechnol. 2001;1:129-132 https://doi.org/10.1155/S1110724301000298 PMid:12488606 PMCid:PMC129059
- Tadmouri GO, Gulen RI. Deniz: the electronic database for beta-thalassemia mutations in the Arab world. Saudi Med J. 2003;24:1192-1198 PMid:14647552
- Sadiq MFG, Huisman THJ. Molecular characterization of ß-thalassemia in North Jordan. Hemoglobin1994;18:325–332 https://doi.org/10.3109/03630269408996198 PMid:7852087
- Adekile AD, Gu LH, Baysal E, Haider MZ, al-Fuzae L, Aboobacker KC, al-Rashied A, Huisman TH. Molecular characterization of alpha thalassemia determinants, beta thalassemia alleles and beta S haplotypes among Kuwaiti Arabs. Acta Haematol. 1994;92:176–181 https://doi.org/10.1159/000204216 PMid:7701914
- Fattoum S, Guemira F, Oner C, Li HW, Kutlar F, Huisman TH.. Beta-thalassemia, HbS-beta-thalassemia and sickle cell anemia among Tunisians. Hemoglobin. 1991;15:11–21 https://doi.org/10.3109/03630269109072481 PMid:1917531
- Maryami F, Azarkeivan A, Fallah MS, Zeinali S. A large cohort study of genotype and phenotype correlations of beta-thalassemia in Iranian population. Int J Hematol Oncol Stem Cell Res. 2015;9:198-202 PMid:26865931 PMCid:PMC4748687
- Varawalla NY, Fitches AC, Old JM. Analysis of beta-globin gene haplotypes in Asian Indians: origin and spread of beta-thalassaemia on the Indian subcontinent. Hum Genet. 1992;90:443-449 https://doi.org/10.1007/BF00220475 PMid:1362388
- Rezaee AR, Banoei MM, Khalili E, Houshmand M. Beta-Thalassemia in Iran: new insight into the role of genetic admixture and migration. Sc World J. 2012; 2012:635183. doi: 10.1100/2012/635183. Epub 2012 Dec 18 https://doi.org/10.1100/2012/635183
- Harcourt AH. Human phylogeography and diversity. Proc Natl Acad Sci USA. 2016;113:8072- 8078 https://doi.org/10.1073/pnas.1601068113 PMid:27432967 PMCid:PMC4961125
- Lahr MM, Foley RA. Towards a theory of modern human origins: geography, demography, and diversity in recent human evolution. Am J Phys Anthropol. 1998;Suppl 27:137-176 https://doi.org/10.1002/(SICI)1096-8644(1998)107:27+<137::AID-AJPA6>3.0.CO;2-Q
- Liu H, Prugnolle F, Manica A, Balloux F. A geographically explicit genetic model of worldwide human-settlement history. Am J Hum Genet. 2006;79:230-237 https://doi.org/10.1086/505436 PMid:16826514 PMCid:PMC1559480
- Mellars P. Why did modern human populations disperse from Africa ca. 60,000 years ago? A new model. Proc. Natl. Acad. Sci. USA. 2006; 103:9381– 9386 https://doi.org/10.1073/pnas.0510792103 PMid:16772383 PMCid:PMC1480416
- O'Connell J. Allen J. Dating the colonization of the Sahul (Pleistocene Australia-New Guinea): A review of recent research. J Archaeol Sc. USA. 2004; 31:835– 853
- Armitage SJ, Jasim SA, Marks AE, Parker AG, Usik VI, Uerpmann HP. The southern route "out of Africa": evidence for an early expansion of modern humans into Arabia. Science 2011;331:453-456 https://doi.org/10.1126/science.1199113 PMid:21273486
- Forster P, Matsumura S. Evolution. Did early humans go north or south? Science 2005; 308: 965-966 https://doi.org/10.1126/science.1113261 PMid:15890867
- Stringer C. Palaeoanthropology. Coasting out of Africa. Nature 2000;405:24-25 https://doi.org/10.1038/35011166 PMid:10811201
- Childe VG. New light on the most ancient east. London: Routledge and Paul, 4th ed.1952 PMid:14946582
- Bar-Yosef O. On the nature of transitions: the middle to upper Palaeolithic and the Neolithic revolution. Cambridge Archaeol J. 1998;8:141–163 https://doi.org/10.1017/S0959774300001815
- Bar-Yosef O, Kislev M. Early farming communities in the Jordan Valley. In: Harris DR, Hillman GC, eds. Foraging and farming. The evolution of plant exploitation. London: Unwin Hyman, 1989; pp. 633–642
- Zohary D, Hopf M, Weiss R. Domestication of plants in the old world, 4th ed. New York: Oxford University Press. 2012; pp.1-264 https://doi.org/10.1093/acprof:osobl/9780199549061.003.0001
- Araus JL, Ferrio JP, Buxó R, Voltas J. The historical perspective of dryland agriculture: lessons learned from 10,000 years of wheat cultivation. J Exp Bot. 2007;58:131-145 https://doi.org/10.1093/jxb/erl133 PMid:17050642
- Salamini F, Ozkan H, Brandolini A, Schäfer-Pregl R, Martin W. Genetics and geography of wild cereal domestication in the near east. Nat Rev Genet. 2002;3:429-441 PMid:12042770
- Kenoyer JM, Price TD, Burton JH.A new approach to tracking connections between the Indus Valley and Mesopotamia: initial results of strontium isotope analyses from Harappa and Ur. J Archaeol Sci.2013;40: 2286–2297 https://doi.org/10.1016/j.jas.2012.12.040
- Crawford HEW. Sumer and the Sumerians: Cambridge University Press, 2004; pp.1-11
- Wiercinski A. Anthropology of ancient Mesopotamia. In: Mesopotamia, Ed. Braun, PWN - National Scientific Publishing. 1997; pp 42–45 PMid:9562802
- Araus JL, Buxo´ R. Changes in carbon isotope discrimination in grain cereals from the north-western Mediterranean Basin during the past seven millenia. Aust J Plant Physiol.1993;20:117–128 https://doi.org/10.1071/PP9930117
- Buxo´ R. Arqueologi’a de las plantas: la explotacion economica de las semillas y los frutos en el marco mediterraneo de la Peninsula Iberica. Barcelona: Critica, Grijalbo eds, 1998; pp- 1-367
- Feldman M. Origin of cultivated wheat. In: Bonjean AP, Angus WJ, eds. The world wheat book. a history of wheat breeding. Paris: Lavoisier Publishing, 2001; pp.3–57
- Iandola F. La thalassemia dall'alba della civiltà occidentale ad oggi. Tesi di Laurea, In: Fondazione De Marchi, www.demarchi.org/thalassemia.htm
- Grmek MD. Malaria in the Eastern Mediterranean in prehistory and antiquity. Parassitologia, 1994;36:1–6 PMid:7898948
- Silvestroni E, Bianco I, Alfieri N. Sulle origini della microcitemia in Italia e nelle altre regioni della terra. Medicina 1952;2:187–216
- Choremis C, Fessas Ph, Kattamis C, Stamatoyiannopoulos G, Zannos-Mariolea L, Karaklis A, Belios G. Three inherited red-cell abnormalities in a district of Greece. Thalassemia, sickling and glucose-6-phosphate-dehydrogenase deficiency. Lancet 1963;1;907-909 https://doi.org/10.1016/S0140-6736(63)91688-X
- Flint J, Harding RM, Boyce AJ, Clegg JB. The population genetics of the haemoglobinopathies. Baillieres Clin Haematol. 1998;11:1-51 https://doi.org/10.1016/S0950-3536(98)80069-3
- Haldane JBS: Disease and evolution. La Ricerca Scientifica 1949, 19:68–76
- Canali S. Researches on thalassemia and malaria in Italy and the origins of the "Haldane hypothesis". Med Secoli. 2008;20:827-846 PMid:19848219
- Ratcliffe AW. The historical background of malaria; a reconsideration. J Indiana State Med Assoc. 1946;39:339-347 PMid:20988762
- Bruce-Chwatt LJ. Aleogenesis and paleo-epidemiology of primate malaria. Bull World Health Organ.1965;32:363-387 PMid:14315710 PMCid:PMC2555232
- Fairhurst RM, Baruch DI, Brittain NJ, Ostera GR, Wallach JS, Hoang HL, Hayton K, Guindo A, Makobongo MO, Schwartz OM, Tounkara A, Doumbo OK, Diallo DA, Fujioka H, Ho M, Wellems TE. Abnormal display of PfEMP-1 on erythrocytes carrying haemoglobin C may protect against malaria. Nature 2005;435:1117–1121 https://doi.org/10.1038/nature03631 PMid:15973412
- Cholera R, Brittain NJ, Gillrie MR, Lopera-Mesa TM, Diakité SA, Arie T, Krause MA, Guindo A, Tubman A, Fujioka H, Diallo DA, Doumbo OK, Ho M, Wellems TE, Fairhurst RM. Impaired cytoadherence of Plasmodium falciparum-infected erythrocytes containing sickle hemoglobin. Proc Natl Acad Sci U S A. 2008;105:991–996 https://doi.org/10.1073/pnas.0711401105 PMid:18192399 PMCid:PMC2242681
- Cyrklaff M, Sanchez CP, Kilian N, Bisseye C, Simpore J, Frischknecht F, Lanzer M. Hemoglobins S and C Interfere with Actin Remodeling in Plasmodium falciparum Infected Erythrocytes. Science 2011;334:1283-1286 https://doi.org/10.1126/science.1213775 PMid:22075726
- Williams TN, Mwangi TW, Roberts DJ, Alexander ND, Weatherall DJ, Wambua S, Kortok M, Snow RW, Marsh K. An immune basis for malaria protection by the sickle cell trait. PLoS Med. 2005 May;2(5):e128 https://doi.org/10.1371/journal.pmed.0020128 PMid:15916466 PMCid:PMC1140945
- Gong L, Maiteki-Sebuguzi C, Rosenthal PJ, Hubbard AE, Drakeley CJ, Dorsey G, Greenhouse B. Evidence for both innate and acquired mechanisms of protection from Plasmodium falciparum in children with sickle cell trait. Blood 2012 Apr 19;119(16):3808-14. doi: 10.1182/blood-2011-08-371062 https://doi.org/10.1182/blood-2011-08-371062
- Veenemans J, Jansen EJ, Baidjoe AY, Mbugi EV, Demir AY, Kraaijenhagen RJ, Savelkoul HF, Verhoef H. Effect of alpha (+) -thalassaemia on episodes of fever due to malaria and other causes: a community-based cohort study in Tanzania. Malar J. 2011 Sep 22;10:280. doi: 10.1186/1475-2875-10-280 https://doi.org/10.1186/1475-2875-10-280
- Tan X, Traore B, Kayentao K, Ongoiba A, Doumbo S, Waisberg M, Doumbo OK, Felgner PL, Fairhurst RM, Crompton PD. Hemoglobin S and C heterozygosity enhances neither the magnitude nor breadth of antibody responses to a diverse array of Plasmodium falciparum antigens. J Infect Dis. 2011;204:1750–1761 https://doi.org/10.1093/infdis/jir638 PMid:21998476 PMCid:PMC3203232
- Cabrera G, Cot M, Migot-Nabias F, Kremsner PG, Deloron P, Luty AJ. The sickle cell trait is associated with enhanced immunoglobulin G antibody responses to Plasmodium falciparum variant surface antigens. J Infect Dis. 2005;191:1631–1638 https://doi.org/10.1086/429832 PMid:15838789
- Ayi K, Turrini F, Piga A, Arese P. Enhanced phagocytosis of ring-parasitized mutant erythrocytes: a common mechanism that may explain protection against falciparum malaria in sickle trait and beta-thalassemia trait. Blood. 2004;104:3364–3371 https://doi.org/10.1182/blood-2003-11-3820 PMid:15280204
- Christianson A, Howson CP, Modell B. March of Dimes global report on birth defects. March of Dimes Birth Defects Foundation, New York, 2009; pp.21-23
- Rudra S, Chakrabarty P, Hossain MA, Ripon MJ, Rudra M, Mirza TT. Awareness among parents of ß-Thalassemia major patients regarding prenatal diagnosis and premarital screening in day care centre of Transfusion Medicine Department. Mymensingh Med J. 2016;25:12-17 PMid:26931242
- Canatan D, Karadogan C, Oguz N, Balta N, Cosan R: The frequency of consanguineous marriages in patients with hereditary blood disorders in South of Turkey. Community Genet. 2003.6:58
- Moghadam M. Karimi M, Dehghani SJ, Dehbozorgian J, Montazeri S, Javanmardi E, Asadzade R, Amiri A, Saghatoleslam Z, Sotodegan F, Morshedi N, Imanifard J, Afrasiabi A. Effectiveness of ß-thalassemia prenatal diagnosis in Southern Iran: a cohort study. Prenat Diagn. 2015; 35:1238-1242 https://doi.org/10.1002/pd.4684 PMid:26296249
- Weatherall DJ. Thalassemia as a global health problem: Recent progress towards its control in the developing countries. Ann NY Acad Sci. 2010;1202:17–23 https://doi.org/10.1111/j.1749-6632.2010.05546.x PMid:20712767
- Weatherall, D.J. The inherited diseases of hemoglobin are an emerging global health burden. Blood 2010;115:4331–4336 https://doi.org/10.1182/blood-2010-01-251348 PMid:20233970 PMCid:PMC2881491
- Angel JL. Porotic hyperostosis, anemias, malarias, and marshes in the prehistoric eastern Mediterranean. Science 1966;153:760-763 https://doi.org/10.1126/science.153.3737.760 PMid:5328679
- Webb S. Cranial thickening in an Australian hominid as a possible palaeoepidemiological indicator. Am J Phys Anthropol.1990;82:403-411 https://doi.org/10.1002/ajpa.1330820402 PMid:2205102
- Hershkovitz I, Ring B, Speirs M, Galili E, Kislev M, Edelson G, Hershkovitz A. Possible congenital hemolytic anemia in prehistoric coastal inhabitants of Israel. Am J Phys Anthropol. 1991;85:7-13 https://doi.org/10.1002/ajpa.1330850103 PMid:1853944
- Tayles N. Anemia, genetic diseases, and malaria in prehistoric mainland Southeast Asia. Am J Phys Anthropol. 1996;101:11-27 https://doi.org/10.1002/(SICI)1096-8644(199609)101:1<11::AID-AJPA2>3.0.CO;2-G
- Aufderheide AC. Progress in paleopathology. Biomedical studies of human mummies. Minn Med.1998;81:28-31 PMid:9842233
- Stuart-Macadam P. Porotic hyperostosis: new evidence to support the anemia theory. Am J Phys Anthropol. 1987;74:521-526 https://doi.org/10.1002/ajpa.1330740410 PMid:3327384
- Schultz M. Paleohistopathology of bone: a new approach to the study of ancient diseases. Am J Phys Anthropol. 2001;Suppl 33:106-147 https://doi.org/10.1002/ajpa.10024 PMid:11786993
- Rabino Massa E. Conservazione dei Globuli in Tessuti di Mummie Egiziane. Archivio per L'Antropologia e L'Etnologia. La Nuova Italia1967;3:181-182
- Rabino Massa E. Presence of Thalassemia in Egyptian Mummies. J. Hum. Evol. 1977;6:223-225
- Filon D, Faerman M, Smith P, Oppenheim A. Sequence analysis reveals a beta-thalassaemia mutation in the DNA of skeletal remains from the archaeological site of Akhziv, Israel. Nat Genet. 1995;9:365-368 https://doi.org/10.1038/ng0495-365 PMid:7795641
- Handt O, Krings M, Ward RH, Pääbo S. The retrieval of ancient human DNA sequences. Am J Hum Genet. 1996;59:368-376 PMid:8755923 PMCid:PMC1914746
- Paabo S. 1989. Ancient DNA: extraction, characterization, molecular cloning, and enzymatic amplification. Proc Natl Acad Sci USA.1989;86:1939-1943 https://doi.org/10.1073/pnas.86.6.1939 PMid:2928314 PMCid:PMC286820
- Christianson A, Howson CP, Modell B. March of Dimes global report on birth defects. March of Dimes Birth Defects Foundation, New York, 2006; pp.18-23
- Aguilar Martinez P, Angastiniotis M, Eleftheriou A, Gulbis B, Ma-ú Pereira Mdel M, Petrova-Benedict R, Corrons JL. Haemoglobinopathies in Europe: health & migration policy perspectives. Orphanet J Rare Dis. 2014 Jul 1;9:97. doi: 10.1186/1750-1172-9-97 https://doi.org/10.1186/1750-1172-9-97
- Giordano PC,
Harteveld CL, Bakker E. Genetic epidemiology and preventive healthcare in
multiethnic societies: the hemoglobinopathies. Int J Environ Res Public Health.
2014;11:6136-6146 https://doi.org/10.3390/ijerph110606136 PMid:24921462 PMCid:PMC4078570
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