Pattara Sanchaisuriya

A reliable screening protocol for thalassemia and hemoglobinopathies in pregnancy: an alternative approach to electronic blood cell counting.

Primary screening for thalassemia and hemoglobinopathies usually involves an accurate blood count using an expensive electronic blood cell counter A cheaper alternative method was tested by using a modified osmotic fragility (OF) test and a modified dichlorophenolindophenol (DCIP) test. Altogether 423 pregnant Thai women participated in this project. Hemoglobin patterns and globin genotypes were determined using an automated high-performance liquid chromatography analyzer and polymerase chain reaction analysis of alpha- and beta-globin genes. Among the 423 subjects, 264 (62.4%) carried thalassemia genes. The combined OF and DCIP tests detected all pregnant carriers of the 3 clinically important thalassemias, ie, alpha0-thalassemia, beta-thalassemia, and hemoglobin E with a sensitivity of 100.0%, specificity of 87.1%, positive predictive value of 84.5%, and negative predictive value of 100.0%, which show more effectiveness than these values for the standard method based on RBC counts. A combination of modified OF and DCIP tests should prove useful and applicable to prenatal screening programs for thalassemia and hemoglobinopathies in communities with limited facilities and economic resources.

Association of Hb Q‐Thailand with homozygous Hb E and heterozygous Hb Constant Spring in pregnancy

Abstract:  Hemoglobin (Hb) Q‐Thailand [α74(EF3): Asp→His] is an abnormal Hb found mainly in China and South‐east Asian countries. Association of the αQ‐Thailand allele with α‐thalassemia has important implications in diagnosis. We report the hitherto undescribed conditions of this variant in two unrelated pregnant Thai women. Routine Hb analyses using high‐performance liquid chromatography identified abnormal Hb migrating after Hb A2 in addition to a homozygous Hb E in the proband 1 and to a heterozygous Hb Constant Spring (Hb CS) in the proband 2. Further α‐globin gene analysis identified that the variant was caused by the GAC to CAC mutation at codon 74 of the α1‐globin gene corresponding to the Hb Q‐Thailand, detected in cis to the 4.2 kb deletional α‐thalassemia 2 in both cases. Interaction of the αQ‐Thailand with the βE globin chains in the proband 1 leads to a Hb variant, namely the Hb QE. Family study of the proband 1 showed that her non‐pregnant sister had the same genotype but her father was a double heterozygote for Hb E and Hb Q‐Thailand in whom both Hb Q‐Thailand and Hb QE were detected. Genotype–phenotype relationships observed in these families with complex hemoglobinopathies are presented and compared with those of simple homozygote for Hb E, heterozygote for Hb CS and heterozygote for Hb Q‐Thailand found in other unrelated subjects. A simple DNA assay based on allele‐specific polymerase chain reaction for simultaneous detection of the Hb Q‐Thailand mutation and the 4.2 kb deletional α‐thalassemia 2 determinant was developed and validated.

Adherence to Antiretroviral Therapy (ART) among People Living With HIV (PLHIV): a cross-sectional survey to measure in Lao PDR

RationaleSince 2001, antiretroviral therapy (ART) for people living with HIV (PLHIV) has been available in the Lao People’s Democratic Republic (PDR). A key factor in the effectiveness of ART is good adherence to the prescribed regimen for both individual well-being and public health. Poor adherence can contribute to the emergence of drug resistant strains of the virus and transmission during risky behaviors. Increased access to ART in low-income country settings has contributed to an interest in treatment adherence in resource–poor contexts. This study aims to investigate the proportion of adherence to ART and identify possible factors related to non-adherence to ART among people living with HIV (PLHIV) in Lao PDR.MethodsA cross-sectional study was conducted with adults living with HIV receiving free ART at Setthathirath hospital in the capital Vientiane and Savannakhet provincial hospitals from June to November 2011. Three hundred and forty six PLHIV were interviewed using an anonymous questionnaire. The estimation of the adherence rate was based on the information provided by the PLHIV about the intake of medicine during the previous three days. The statistical software Epidata 3.1 and Stata 10.1 were used for data analysis. Frequencies and distribution of each variable were calculated by conventional statistical methods. The chi square test, Mann–Whitney test and logistic regression were used for bivariate analyses. Multiple logistic regression analysis was conducted to determine the predictors of non-adherence to ART. A p-value < 0.05 was considered to indicate statistical significance.ResultsOf a total of 346 patients, 60% reported more than 95% adherence to ART. Reasons for not taking medicine as required were being busy (97.0%), and being forgetful (62.2%). In the multivariate analysis, educational level at secondary school (OR=3.7, 95% CI:1.3-10.1, p=0.012); illicit drug use (OR=16.1, 95% CI:1.9-128.3, p=0.011); dislike exercise (OR=0.6, 95% CI:0.4-0.9, p=0.028), and forgetting to take ARV medicine during the last month (OR=2.3, 95% CI:1.4-3.7, p=0.001) were independently associated with non-adherence.ConclusionsNon-adherence to ART was associated with individual factors and exposure to ART. Priority measures to increase adherence to ART should aim to intensify counseling and comprehensive interventions, such as guidance for PLHIV on medication self-management skills, tailoring the regimen to the PLHIV life style, and improving adherence monitoring and health care services.

Micromapping of Thalassemia and Hemoglobinopathies in Diferent Regions of Northeast Thailand and Vientaine, Laos People's Democratic Republic

In order to determine the prevalence of thalassemia and hemoglobinopathies in different regions of northeast (NE) Thailand and Vientiane, Laos Peoples Democratic Republic (PDR), a total of 1,809 blood samples were collected consecutively from individuals attending antenatal care services at 11 community hospitals in different regions of NE Thailand and three hospitals in Vientiane, Laos PDR, from May 2009 to April 2010. All individuals were investigated for thalassemia and hemoglobinopathies using standard methods. For individuals from NE Thailand, the carrier frequencies were 41.7% for Hb E [β26(B8)Glu→Lys, GAG>AAG], 5.8% for α0-thalassemia (α0-thal), and 0.9% for β-thal. The THAI deletion type of α0-thal was found in one individual from an ethnic minority. From a group of pregnant Laotian women, 30.1% were Hb E carriers. The prevalence of α0-thal of 8.6% for the Laotian women was similar to that found in the upper northeastern part of Thailand. The frequency of β-thal was 2.3 %. The proportion of carriers of α+-thal and Hb Constant Spring (Hb CS, α142, Term→Gln (TAA>CAA in α2)] ) from Thailand and Laos was significantly different. The frequency of Hb Paksé [α142, Term→Tyr (TAA>TAT in α2)] was relatively low for Thailand as well as for Laos. The results indicate that thalassemia and hemoglobinopathies are a significant health burden in the region and that a prevention and control program for severe thalassemia diseases should be established in Laos.

A Self-Administered Device for Cervical Cancer Screening in Northeast Thailand

OBJECTIVE To test a self-scraping device as a mass screening device against a routine scraping method and to evaluate the acceptance of the self-scraping device by a group of rural females from Northeast Thailand. STUDY DESIGN From a rural area of Northeast Thailand, 552 women were trained and motivated, through primary health care structures, to participate in a cervical cancer screening exercise using a self-scraping device. After one week, the same females were reexamined by gynecologists using the routine scraping method. In both cases the specimens were stained according to Papanicolaou. Through questionnaires the acceptance of the self-scraping device was evaluated. RESULTS Through the self-scraping method, 13 cases suspicious for malignancy were detected. Specimens obtained through examination by physicians confirmed 11 cases to be suspicious for malignancy. No false negative cases were found. In the detection of inflammation, the self-scraping method was not as accurate as examination by a physician. The device was accepted by the females who participated in the study. CONCLUSION In the rural areas of developing countries, where physicians and other trained medical personnel are not often available to carry out regular screening tests on a population basis, the self-scraping method can be applied as an integral part of primary health care for mass screening for uterine cervical cancer.

Hemoglobin Profiles and Hematologic Features of Thalassemic Newborns: Application to Screening of α-Thalassemia 1 and Hemoglobin E

CONTEXT Thalassemia and hemoglobinopathies are major public health problems worldwide. To establish a cost-effective screening tool for newborns in regions where the incidence of these disorders is significant, study of the hemoglobin and hematologic features of normal and thalassemic newborns is necessary. OBJECTIVE To study hemoglobin and hematologic characteristics of normal and various thalassemic newborns and to assess the effectiveness of simple screening methods for alpha-thalassemia 1 and hemoglobin E. DESIGN Study was made of 402 cord blood specimens collected from unrelated Thai individuals. Hematologic parameters and hemoglobin profiles were determined. Thalassemia mutations were identified using polymerase chain reaction-related techniques. RESULTS As many as 178 subjects (44.3%) were found to carry thalassemia genes with 18 different genotypes. All forms of alpha-thalassemia including double heterozygote for hemoglobin E and alpha-thalassemia showed significant reduction in hemoglobin, mean corpuscular volume, and mean corpuscular hemoglobin with increasing trend of red blood cell as compared with a non-alpha-thalassemic group. Although heterozygous hemoglobin E and beta-thalassemia showed no hematologic difference from nonthalassemic group, heterozygous alpha-thalassemia 1 including those with hemoglobin E showed significant increase in hemoglobin Bart level. CONCLUSIONS Based on these findings, effective primary screening with 100% accuracy for alpha-thalassemia 1 and hemoglobin E in newborns in the region could be carried out using mean corpuscular volume less than 95 fL, mean corpuscular hemoglobin less than 30 pg, or hemoglobin Bart greater than 8.0% and hemoglobin E greater than 0.5%, respectively.

Use of glucometer and fasting blood glucose as screening tools for diabetes mellitus type 2 and glycated haemoglobin as clinical reference in rural community primary care settings of a middle income country.

BackgroundThailand is considered to be a middle income country, and to control and prevent type 2 diabetes mellitus (T2DM) is one of the main concerns of the Thai Ministry of Public Health (MoPH). Screening for T2DM and care for T2DM patients has been integrated into the primary health care system, especially in rural areas. The intention of this investigation is to link public health research at the academic level with the local health authorities of a district of a north-eastern province of the country.MethodsEpidemiological methods were applied to validate the screening tools fasting capillary blood glucose (CBG), measured by glucometer and venous blood for the determination of plasma glucose (VPG), used for screening for T2DM among asymptomatic villagers. For assessing the validity of these two methods glycated haemoglobin (HbA1c) values were determined and used as the ‘clinical reference’.ResultsAll together 669 villagers were investigated. Determinations of CBG and VPG resulted in suspected T2DM cases, with 7.3% when assessed by CBG and 6.4% by VPG using a cutoff point of 7 mmol/L (126 mg/dl). Taking HbA1c determinations with a cutoff point of 7% into account, the proportion of T2DM suspected participants increased to 10.4%. By estimating sensitivity, specificity and the positive predictive value of CBG and VPG against the ‘clinical reference’ of HbA1c, sensitivity below 50% for both screening methods has been observed. The positive predictive value was determined to be 58.5% for CBG and 56.8% for VPG. The specificity of the two screening tests was over 96%.ConclusionsThe low sensitivity indicates that using fasting CBG or VPG as a screening tool in the field results in a high proportion of diseased individuals remaining undetected. The equally low positive predictive values (below 60%) indicate a high working load for the curative sector in investigating suspected T2DM cases to determine whether they are truly diseased or false positive cases according to the screening method. Further implications of the results and the controversial discussion related to the use of HbA1c as clinical evidence for suffering from T2DM are also discussed.

H63D Mutation of the Hemochromatosis Gene and Serum Ferritin Levels in Thai Thalassemia Carriers

We determined the prevalence of the H63D and the IVS5#1G-A HFE mutations in 370 (169 males and 201 females) Thai thalassemia carriers and 201 normal subjects. While no IVS5#1G-A mutation was found, the H63D heterozygosity was identified in 5.5% (11/201) of normal subjects and 7.3% (27/370) of thalassemia carriers. Within the thalassemic group, the medians (ranges) of serum ferritin were 217.5 ng/ml (20.1–424.3) and 169.8 ng/ml (3.9–3,536.0) in male subjects and 30.4 ng/ml (11.9–130.7) and 49.3 ng/ml (0.6–931.0) in female subjects with (HD) and without (HH) H63D mutation, respectively. The proportions of subjects with elevated ferritin were found to be 37.5% (6/16) for HD and 14.0% (18/129) for HH in male and 0% (0/11) for HD and 3.0% (5/164) for HH in female subjects, respectively. Statistical analysis of all the data revealed no significant difference. Among 14 Hb E/β-thalassemia patients, no difference in hematological data as well as serum ferritin levels was observed between those with (HD) and without (HH) H63D mutation. Therefore, the H63D heterozygosity has no significant effect on the serum ferritin level and screening for this HFE mutation in thalassemic patients is not recommended.

Hemoglobin Constant Spring is markedly high in women of an ethnic minority group in Vietnam: a community-based survey and hematologic features.

A community-based survey was conducted to determine the prevalence and gene frequency of Hemoglobin Constant Spring (Hb CS) and other forms of thalassemia among an ethnic minority in Vietnam. A total of 298 ethnic minority women, the Có-Tu, participated. Hematological parameters and hemoglobin profiles were analyzed using standard automated analyzers. Alpha- and beta-thalassemia mutations were identified using polymerase chain reaction (PCR) based technology. Of the 298 women, 141 (47.3%) carried thalassemia genes. Hemoglobin Constant Spring (Hb CS) is the most common with a markedly high frequency of 0.143 (overall prevalence=26.2%). The heterozygous state of Hb CS was found in one-fifth (20.5%) of women participating. Seven women (2.4%) were Hb CS homozygote. The overall prevalence for Hb E was 13.8%, and 10.7% for α(+)-thalassemia. Other forms of thalassemia included 0.67% β-thalassemia, and 0.34% Hb Paksé. None of the participants had the α(0)-thalassemia gene. The study provides basic epidemiological information about Hb CS as well as other forms of thalassemia for a specific group of an ethnic minority in Vietnam. The data will be useful for further study on the distribution of thalassemia in Southeast Asia.

Thalassemia and Hemoglobinopathies in Thua Thien Hue Province, Central Vietnam

A community-based assessment of thalassemias and hemoglobinopathies was conducted at the Thua Thien Hue Province, Central Vietnam. By cluster sampling, a total of 410 pregnant women attending the antenatal care service at 30 commune health centers were recruited consecutively from September 2011 to June 2012. Hemoglobin (Hb) analysis was performed using an automated Hb analyzer. α-Thalassemia (α-thal) genes were identified by polymerase chain reaction (PCR)-based techniques. Out of the 410 pregnant women, 2.7% carried α0-thal and 1.2% were β-thal carriers. One woman with the – –THAI deletion was also found. Among the females under survey, structural Hb variants with 3.2% Hb E [β26(B8)Glu→Lys, GAG>AAG; HBB: c.78G>C] and 3.7% Hb Constant Spring [Hb CS; α142, Term→Gln, TAA>CAA (α2); HBA2: c.427T>C] were found. Assessing the frequency of thalassemias and hemoglobinopathies by ethnicity, Kinh (Vietnamese) and ethnic minority groups, Hb CS with a high frequency of 24.0% was observed in the ethnic minority groups. These results provide basic population-based information, are useful not only for implementing measures for prevention and control of thalassemias in the region but also for studying the importance of thalassemias and hemoglobinopathies in ethnic minorities within Southeast Asia.