α-thalassaemia

1Why should α thalassaemia be considered in a forum dedicated to rare diseases? It is certainly not a rare genetic trait. On the contrary, it is one of the most common human genetic abnormalities known. Carriers of α thalassaemia are found at polymorphic frequencies (>1%) in all tropical and subtropical populations that have been studied and, in some areas, the carrier state has almost gone to fixation. This is because carriers of α thalassaemia are thought to be at a selective advantage in areas where falciparum malaria is or has been endemic. In areas where the carrier state is common, two clinically important diseases (HbH disease and Hb Bart's hydrops foetalis) occur in compound heterozygotes and homozygotes. The reason for discussing this here is therefore not because these diseases are rare, rather that they may be rarely considered by physicians outside of the regions where thalassaemia commonly occurs. For example, a retrospective study of obstetric records in the U.K. by Petrou et al. revealed an underdiagnosis of both α0-thalassaemia trait and α-thalassaemia hydrops foetalis. With the massive migrations that have occurred over the past few decades it is important to bring these rarely considered diseases to the general attention of clinicians in Northern Europe and North America.

2The generic term α thalassaemia encompasses all of those conditions in which there is a deficit in the production of the α globin chains of haemoglobin (Hb) which is a tetrameric molecule including two α-like and two β-like globin chains (α2β2). Underproduction of α globin chains gives rise to excess β-like globin chains which form γ4 tetramers, called Hb Bart's (in foetal life) and β4 tetramers, called HbH (in adult life). Individuals who carry mutations affecting the α globin genes on one chromosome, associated with minimal anaemia, are said to have α thalassaemia trait. Compound heterozygotes and some homozygotes for α thalassaemia have a moderately severe anaemia characterised by the presence of HbH in the peripheral blood. This condition is referred to as HbH disease. Finally some individuals who make very little or no α globin chains have a very severe form of anaemia which, if untreated, causes death in the neonatal period. This condition is called the Hb Bart's hydrops foetalis syndrome.

3Rarely patients have been seen with very large deletions which remove the α globin genes but also remove many other genes that surround them. This condition is associated with developmental abnormalities (including intellectual disability) and is referred to as the α thalassaemia/mental retardation syndrome on chromosome 16 (ATR16 syndrome: OMIM:141750, reviewed in Higgs et al., 2009 and Wilkie et al., 1990). Also patients with a rare form of syndromal X-linked mental retardation associated with α thalassaemia have been described, in which the intellectual disability is more severe and the dysmorphic features show striking similarities among patients. This rare condition is called ATR-X syndrome and has been found to involve mutations in a chromatin associated protein called ATRX on the X-chromosome (ATR-X syndrome: OMIM:301040, reviewed elsewhere). Finally, an acquired form of alpha-thalassaemia referred to as the ATMDS syndrome has been described. This predominantly occurs in elderly males with a pre-malignant, clonal haematopoietic disease called myelodysplasia (MDS). This rare syndrome involves acquired mutations in the ATRX gene causing α thalassaemia (OMIM:300448, reviewed in Gibbons et al., 2003;Higgs et al., 2009). Since these rare conditions have all been reviewed elsewhere they will not be discussed further in this synopsis.

4Alpha thalassaemia is most frequently suspected initially on the basis of a routine full blood count. All affected individuals have a variable degree of anaemia (Hb), reduced mean corpuscular haemoglobin (MCH/pg), reduced mean corpuscular volume (MCV/fl) and a normal or slightly reduced level of the minor HbA2. These parameters are discussed in greater detail below. When the level of α globin synthesis falls below ~70% of normal, in the foetal period, excess γ globin chains form Hb Bart's which can be detected on routine Hb analysis. In adult life, excess β globin chains form β4 tetramers of HbH in the cell and these can be identified by staining the peripheral blood with 1% brilliant cresyl blue (BCB), or when present in sufficient quantity by routine Hb analysis. Previously α thalassaemia was confirmed by globin chain biosynthesis, when the α/β globin chain biosynthesis ratio was reduced to less than ~0.8. All of these parameters are reduced in α thalassaemia but none of them alone or in combination can accurately or consistently predict the genotype for which directed molecular analysis of the α globin cluster is required and this is discussed below.

5Like all common globin gene disorders (sickle cell trait and β thalassaemia) α thalassaemia occurs at high frequencies throughout all tropical and subtropical regions of the world (Figure 1). In some areas, the carrier frequency of α thalassaemia may be as high as 80-90% of the population, almost at fixation. It is thought that all of these globin gene disorders (including α thalassaemia) have been selected because in some way they protect carriers from the ravages of falciparum malaria. The micro epidemiological evidence supporting this is very strong. The mechanisms underlying this protection have been extensively studied but remain unknown. Of all globin disorders, α thalassaemia is the most widely distributed and therefore many individuals in these areas have interacting combinations of these variants (e.g. both α and β thalassaemia). Due to differences in the interactions between the various molecular defects underlying α thalassaemia (see below) HbH disease is predominantly seen in South East Asia, the Middle East and the Mediterranean. Similarly the Hb Bart's Hydrops foetalis syndrome is predominantly seen in South East Asia. In passing it should be mentioned that ATR16, ATR-X and ATMDS syndromes show no geographical bias in their distributions.

6Although the previously established distribution of α thalassaemia is represented in Figure 1, over the past few decades there have been massive population movements so that now the globin gene disorders, thought to be rarities in North European and North American clinical practice, have become major diagnostic and therapeutic challenges for our current health care systems.

7The clinical phenotypes of most individuals with α thalassaemia are very mild and may not be noticed during life other than when a routine full blood count is examined. Patients with HbH disease have a variable phenotype and those with Hb Bart's hydrops foetalis have a lethal form of anaemia.

8Apart from mild to moderate microcytic hypochromic anaemia (detected on a routine blood count), carriers (heterozygotes) of α thalassaemia, whatever the molecular basis (see below), are clinically asymptomatic and the diagnosis (when made) is often established during a regular health check or during antenatal screening. Complaints related to more severe anaemias, such as fatigue, listlessness and shortness of breath are uncommon and almost certainly related to other concomitant disorders.

9HbH disease is most frequently seen in patients who are compound heterozygotes for two different mutations or less frequently homozygotes for a moderately severe molecular defect. They usually produce less than 30% of the normal amount of α globin. The predominant features in HbH disease are anaemia (2.6-13.3 g/dl) with variable amounts of HbH (0.8-40%), occasionally accompanied by Hb Bart's in the peripheral blood. The patients usually have splenomegaly (which may be severe) and occasionally this is complicated by hypersplenism. Jaundice may be present in variable degrees and children may show growth retardation. Other complications include infections, leg ulcers, gall stones, folic acid deficiency and acute haemolytic episodes in response to drugs and infections. Older patients often have some degree of iron overload. The severity of the clinical features is clearly related to the molecular basis of the disease. Patients with non-deletional types of HbH disease are more severely affected than those with the common deletional types of HbH disease.

10Infants with the Hb Bart's hydrops foetalis syndrome have the most severe deficiencies in α globin expression. While it most frequently results from the inheritance of no α globin genes from either parent, in some cases it results from the inheritance of a severe nondeletion mutation from one parent and no α genes from the other. Patients on the borderline between severe HbH disease and Hb Bart's hydrops foetalis syndrome are said to have HbH hydrops syndrome. Physiologically non-functional homotetramers γ4 and β4 make up most of the haemoglobin in the erythrocytes in infants with the Bart's hydrops foetalis syndrome. They also have variable amounts of an embryonic Hb Portland (ζ2γ2), which is the only functional Hb in these infants and must be the only oxygen carrier keeping these infants alive. The clinical features are those of a pale oedematous infant with signs of cardiac failure and prolonged intra-uterine anaemia (Figure 2). Pronounced hepatosplenomegaly, retardation in brain growth, skeletal and cardiovascular deformities and gross enlargement of the placenta are characteristic features. Infants with the Hb Bart's hydrops foetalis syndrome almost always either die in utero (23-38 weeks) or shortly after birth, although few cases have been described in which the neonate is given intensive life-support therapy and treated with blood transfusion.

11In normal individuals α globin synthesis is regulated by four α globin genes two on each copy of chromosome 16 (in band 16p13.3 Figure 3) and this genotype is written as αα/αα. Expression of these genes is dependent on remote regulatory elements (named Multispecies Conserved Sequences or MCS-R1 to R4) located far upstream of the α globin genes in the introns of a flanking, widely expressed gene (Figure 3). Alpha thalassaemia most frequently results from deletion of one (-α) or both α genes from the chromosome. Occasionally point mutations in critical regions of the α2 (αTα) or α1 (ααT) genes may cause, so-called, nondeletional α thalassaemia. Very rarely, α thalassaemia results from deletion of the MCS-R regulatory elements (written as (αα)T), in all of these deletions MCS-R2 is always removed and thus appears to be the major regulatory element. When a mutation(s) completely abolishes expression from a chromosome this is called α0-thalassaemia and when the mutation(s) only partially downregulate expression from the chromosome this is called α+-thalassaemia.

12The α-globin genes are embedded within two highly homologous 4 kb duplication units. One very common α-thalassaemia deletion is the rightward deletion, a 3.7 kb deletion caused by reciprocal recombination between Z segments producing a chromosome with only one functional α-gene (α-3.7 or rightward deletion) causing α-thalassaemia and an α-triplication allele without a thalassaemic effect (Figure 4). Likewise a reciprocal recombination between mispaired X-boxes results in a 4.2 kb deletion, called leftward deletion (-α4.2). An increasing number of deletions resulting in the loss of a single α-gene are reported due to non-homologous recombination events, most of which are rare, or highly region specific. The most common α+-thalassaemia deletions are shown in Figure 5. More extensive overviews of all deletions are reported elsewhere (in: Disorders of Hemoglobin Cambridge University Press 2009).

13Alpha-thalassaemia is more frequently caused by deletion than single point mutations or nucleotide insertions and deletions involving the canonical sequences controlling gene expression. In general the non-deletion α+-thalassaemia determinants may give rise to a more severe reduction in α-chain synthesis than the -α deletion type of chromosomes. Many mutations have been described affecting mRNA processing, mRNA translation, and α-globin stability. Table 1 shows all the currently known non-deletion mutants causing α+-thalassaemia. Of these the most common non-deletional variants are the αIVSI(-5 nt)α (in Mediterraneans), polyadenylation site mutations α2AATAAG, α2AATGAA and α2AATA-- (in the Mediterranean and Middle East), termination codon mutations leading to elongated Hb variants, such as Hb Constant Spring (HbCS), Hb Icaria, Hb Koya Dora, Hb Seal Rock and Hb Paksé (middle East, Mediterranean and South East Asia) and structural mutations causing highly unstable α-globin variants; for example, Hb Quong Sze, Hb Suan Dok, Hb Petah Tikvah, Hb Adana, Hb Aghia Sophia. These common mutations are summarised in Tables 1 and 2. A regularly updated overview is provided by the HbVar web-site.

14The complete or partial deletion of both α-genes in cis results in no α-chain synthesis directed by these chromosomes in vivo (Figures 6 and 7a). Homozygotes for such deletions have the Hb Bart's Hydrops Foetalis Syndrome. Many deletions were described which remove the ζ- and α-genes and although heterozygotes appear to develop normally, it is unlikely that homozygotes could survive even the early stages of gestation since neither embryonic (ζ2γ2) nor foetal (α2γ2) haemoglobins could be made. Rare deletions causing α0-thalassaemia remove the regulatory region, which lies 40-50 kb upstream of the α-globin gene cluster leaving the α-genes intact. This region composed of four multispecies conserved sequences (MCS), called MCS-R1 to R4, correspond to the previously identified erythroid-specific DNAse1 hypersensitive sites referred to as HS-48, HS-40, HS-33 and HS-10. Of these elements, only MCS-R2 (HS-40), 40 kb upstream from the ζ globin mRNA cap-site has been shown to be essential for α globin expression. An overview showing all currently known (αα)T deletions is given in Figure 7b, a regularly updated summary is given elsewhere (deletions are reviewed in detail in Higgs et al Disorders of Hemoglobin Cambridge University Press 2009.

15A different spectrum of both α+- and α0-thalassaemia mutations is often found in different populations as indicated in Table 2 {Bain, 2006 126/id}. Ethnic origin may therefore guide molecular diagnosis. Knowledge of the mutations found in a specific population may allow strategic choice in laboratory diagnostics, especially in selection of the molecular techniques to be applied.

16Although there are now ~128 different molecular defects known to cause α thalassaemia and an ever increasing number of potential interactions, the clinical phenotypes (broadly classified as α thalassaemia trait, HbH disease and Hb Bart's hydrops foetalis) resulting from the interactions between these various molecular defects can be simply summarised as in Table 3. The severity of the clinical phenotype correlates very well with the degree of α globin chain deficiency. An important additional point is that, in general, interactions involving non-deletional forms of α+-thalassaemia result in a more severe phenotype than in those with deletional forms of α+-thalassaemia.

17Initial laboratory testing should include a complete blood count with red cell indices, HPLC or Hb electrophoresis and eventually α/β-globin chain synthesis ratio measurement. The latter procedure, however, is sometimes bypassed by DNA analysis as a less complicated method to diagnose α-thalassaemia.

18The red blood cell indices in patients with various genotypes associated with α-thalassaemia are depicted in figure 8 and 9. In general, the degree of microcytic (low MCV), hypochromic (low MCH) anaemia (low Hb) depends roughly on the number of α genes mutated and correlates well with the reduction in α-chain synthesis predicted for each mutant. The combined use of HPLC and Capillary Electrophoresis to separate abnormal haemoglobin fractions is of particular importance to demonstrate HbH in individuals with HbH disease (figure 10) and Hb Bart's in newborns carrying α-thalassaemia determinants or any Hb variant associated with an α-thalassaemia phenotype (figure 11). Hb Bart's is found in a large proportion of neonates with α-thalassaemia but does not detect all cases with mild α-3.7/αα interactions and does not clearly distinguish the various α thalassaemia genotypes. A reduction in HbA2 level is sometimes indicative of α-thalassaemia trait. Although this nicely distinguishes α and β thalassaemia trait it can hardly be relied upon as a guide to the degree or type of α thalassaemia. A reduction in the level of HbA2 is only distinctive in patients with HbH disease (see figure 12). Staining the peripheral blood cells with 1% Brilliant Cresyl Blue is a sensitive method to visualise inclusion bodies in the red cells. The typical inclusion-body cells have a golf-ball like appearance with stippling regularly distributed over a blue stained background (Figure 13). They appear occasionally (one to two cells in approximately 10 fields 1000× magnification) in carriers of the --/αα genotype and in carriers of many nondeletional defects. Numerous red cells containing inclusions can be seen in the BCB-stained peripheral blood smears of patients with HbH disease.

19Measuring the ratio of α- and β-globin chain synthesis is the most direct approach (at the protein level) to diagnose α-thalassaemia. The procedure was first described by Weatherall and Clegg in 1965 and consists of several steps, including removal of white blood cells, reticulocyte enrichment, in vitro globin chain synthesis in the presence of radio-actively labelled Leucine, separation of the newly synthesized, radio-actively labelled α- and β-globin chains and measurement of the radio-active signal. If the α/β ratio appears lower than ~0.8 this is indicative of α-thalassaemia, a ratio around 0.75 being consistent with the loss of expression of a single α gene (-α/αα), 0.5 for two α genes (--/αα) and 0.25 for three α-genes (--/-α).

20Over the past 30 years it has become increasingly possible to diagnose α thalassaemia accurately and define the precise defects underlying these disorders using a variety of molecular genetic approaches. Ultimately, most α globin rearrangements have been characterised by Southern blotting and DNA sequence analysis. However, for today's diagnostic demands these techniques are far too laborious to apply in each case, and from the original work defining these mutations, rapid screening assays have been developed.

21Gap-PCR has been developed for the 7 most common α-thalassaemia deletions. This method is applied to detect the 2 most common α+ thalassaemia deletions -α3.7 and α-4.2 and the 5 α0-thalassaemia deletions -(α)20.5, - - SEA, - - Med I, - - Thai and - - Fil.

22When a point mutation (non-deletional mutation) is suspected re-sequencing the α genes has become a routine procedure. The α genes are relatively small (~1.2 kb) which allows them to be sequenced rather easily compared to many other genes involved in human genetic disease, like for instance Duchenne Muscular Dystrophy (DMD gene; ~2.3 Mb), Cystic Fibrosis (CF-gene; ~250 kb) and Breast Cancer (BRCA1 and BRCA2 genes, ~16 and ~10 kb respectively). However, the GC-richness and the high homology between the duplicated α-genes require the use of high fidelity, heat stable polymerases, specific reaction conditions (using DMSO and betaine) and limits the choice of specific primers for PCR. The α-genes can be conveniently sequenced in two overlapping fragments for each of the duplicated α1 and α2 genes.

23For suspected but currently unknown rearrangements, Southern blotting or MLPA analysis may be used. Southern blot is the classical method to detect deletions causing α-thalassaemia. More recently Multiplex Ligation-dependent Probe Amplification (MLPA) is used, based on ligation of multiple probe-pairs hybridised across a (usually large) region of interest (Figure 14), followed by semi-quantitative amplification using universal-tag PCR primers and subsequently fragment analysis. This is a valuable alternative for Southern blot analysis and a supplementary method to gap-PCR when investigating known and unknown deletions causing α-thalassaemia.

24Sometimes carriers of α+-thalassaemia present with normal haematology, especially carriers of -α3.7 and nondeletional mutations affecting the α1-gene. Such individuals may be normocytic or borderline hypochromic without anaemia. These can only be found by chance during routine molecular analysis for haemoglobinopathies.

25Occasionally, especially in countries where thalassaemia is uncommon, α-thalassaemia trait may be confused with iron deficiency anaemia, especially when the iron status is not carefully assessed. Haematological parameters for thalassaemia and iron deficiency are quite similar therefore ferritin levels should be measured. If the microcytic hypochromic parameters persist in a patient with normal levels of ferritin or Zinc Protoporphyrin (ZPP, a measure for long-lasting iron depletion), elevated RBC and normal (or low) HbA2, (especially in patients originating from areas where haemoglobinopathies are common) there is a good chance that the individual is a carrier of α-thalassaemia. Molecular analysis is usually required, especially in silent α-thalassaemia and α-thalassaemia trait to confirm the haematological observations.

26There is a difference in clinical severity between deletional (most common) and non-deletional HbH disease. The clinical diagnosis of deletional HbH disease (the mildest form) is often made only after the detection of complications, such as exacerbations of the anaemia induced by infections, growth failure (in children) or findings of splenomegaly. The laboratory findings show a pronounced microcytic hypochromic anaemia and the presence of inclusion bodies. HbH and Hb Bart's are fast moving haemoglobins appearing on electrophoresis or HPLC, however, they are unstable and may go undetected. The more severe forms of HbH disease are predominantly those involving non-deletion mutations, of which Hb CS is the most common in South-East Asia. This form is characterized by a significantly more ineffective erythropoiesis and erythroid apoptosis than the deletion types of HbH disease. The haemoglobin is lower (on average 2 g/dL), but the MCV higher due to overhydration of cells containing HbCS.

27Hydrops Foetalis without α-thalassaemia is a common non-specific finding in a wide variety of foetal and maternal disorders. The distinguishing features of the Hb Bart's hydrops foetalis syndrome is the presence of Hb Bart's and the total absence of HbF, which is easily differentiated by HPLC or Hb-electrophoresis. Although there have been a few reports of Hydrops Foetalis infants with very low levels of α-chain synthesis and HbH hydrops.

28When both parents carry an αo thalassaemia mutation (--/αα) the risk of their offspring having Hb Bart's hydrops foetalis is 1:4 (25%). When one parent carries αo thalassaemia (--/αα) and the other carries an α+ thalassaemia (-α/αα) the risk of their offspring having HbH disease is 1:4 (25%). If the carrier of α+ thalassaemia is a homozygote clearly the risk of HbH disease is 1:2 (50%). Since there are many different alleles of αo and α+ thalassaemia, genetic counselling may be more complex than outlined in this simple model.

29In families with α thalassaemia the main reason for offering prenatal diagnosis is to avoid pregnancies with the Hb Bart's hydrops foetalis syndrome which causes neonatal death. Continued pregnancy may also present a considerable risk to the mother. Prenatal diagnosis for Hb Bart's is offered when both parents are found to be carriers of α0-thalassaemia trait. This is of most importance in individuals of South East Asian origins. Although some reports have demonstrated the feasibility of treating this syndrome, the lack of knowledge of the long-term prognosis and the capacity for treating such individuals probably do not justify changing the conventional management of offering prenatal diagnosis and selective abortion for Hb Bart's Hydrops Foetalis syndrome.

30The syndrome of HbH disease is usually mild (thalassaemia intermedia) but there is considerable variability in the clinical and haematological severity. Although, precise characterisation of the mutations involved allows some prediction of the severity of the disease this is by no means certain, which makes prenatal diagnosis offered to parents at risk of having a child with HbH disease a complicated ethical issue. Most cases resulting from simple deletion of the α globin genes are mildly affected. Nearly all severe cases have at least one nondeletional allele. However the clinical course can be influenced by other genetic factors, environmental factors and infections. In rare cases the interaction of α0-thalassaemia with a non-deletional α+-thalassaemia allele has led to individuals with hydrops foetalis syndrome. When there is a risk of such severely affected individuals there may be a case for considering prenatal diagnosis.

31Carriers of α+- or α0-thalassaemia alleles generally do not need treatment, because their anaemia is either very mild or absent due to a compensating high red blood cell count. On the other hand, once a diagnosis of α thalassaemia trait is made, there is a tendency to discard iron-deficiency as a subsequent cause of anaemia. Carriers of α thalassaemia can be anaemic as a consequence of co-existing nutritional deficiencies, such as iron deficiency, folate or vitamin B12 deficiencies and should be managed correctly from this point of view. Of course prophylactic iron should never be given to carriers of α thalassaemia who are at risk of developing iron overload if treated inappropriately.

32HbH disease may be a mild disorder, but recent studies suggest its clinical course is often more severe than previously recognized. As discussed above, the type of mutation influences the clinical severity of HbH disease. The most common form is the deletion type, which causes a milder form of HbH disease. These patients may require intermittent transfusion therapy especially during intercurrent illness. Chronic transfusion therapy is very uncommonly required in this group. However, patients with non-deletional types of HbH disease may have moderately severe splenomegaly and require more regular transfusion and ultimately splenectomy. In some studies almost half of such patients have required repeated transfusions, particularly in early infancy and later adulthood. However, there is a marked clinical variation in both categories. Iron overload is uncommon in HbH disease patients (compared with β thalassaemia) but has been recorded in older patients (>45 years) and those treated with regular blood transfusion.

33Most pregnancies in which the foetus is known to have the Bart's hydrops foetalis syndrome are terminated. In a very small number of cases intra-uterine transfusions following early detection of homozygous α0-thalassaemia have resulted in the birth of non-hydropic infants, some without significant neurological or congenital abnormalities, however, most survivors experience a stormy perinatal course and a high prevalence of congenital urogenital and limb defects. Affected infants who survive are good candidates for haematopoietic stem cell transplantation. Obstetric complications and the necessity for long-term transfusion therapy are however serious arguments for counselling and selective abortion. Increased risk of both maternal and foetal morbidity should be taken into account when counselling couples at risk for having a child affected with this syndrome.

34There is no reason to think that carriers for α thalassaemia have any altered prognosis for life compared to the normal population. The prognosis for patients with HbH disease who are newly emerging in previously non-endemic countries, like Northern Europe and Northern America, is less clear. Anecdotally many patients with HbH disease appear to lead a normal life in all respects. Some even remain undiagnosed throughout their lives. However, detailed actuarial studies are not available. When complications arise, of course the outcome depends on the awareness and availability of health care systems. Certainly some complications suffered by patients with HbH disease are life threatening in the absence of adequate medical care. A long term problem for all patients with HbH disease is the unwanted accumulation of iron which may be more of a problem for those with severe HbH disease with non-deletional α- thalassaemia.

35Clearly, previously undiagnosed and untreated infants with the Hb Bart's hydrops foetalis syndrome die in the perinatal period. The recent attempts to rescue infants with this syndrome either by intra-uterine transfusion or by transfusion in the perinatal period have met with variable success. As discussed above many infants develop other irreversible abnormalities during foetal life and even with rescue the infant will be required, either to receive lifelong blood transfusion and iron chelation therapy, or bone marrow transplantation with its attendant risks.

361. How is the expression of genes in the α- (and β-) globin gene cluster regulated and how can it be influenced? A detailed understanding of globin gene regulation might hold the key to developing new treatments for both α and β thalassaemia.

372. What other factors (genetic and environmental) influence the clinical severity of HbH disease and might explain the large variability even between individuals with the same α globin genotypes?

383. What role does α-thalassaemia play in modifying the natural history of sickle cell disease and β-thalassaemia major? These interactions are not always well understood.

394. In what way are carriers of α-thalassaemia protected from some of the effects of malaria?

40The authors declare that they have no competing interests.

41The authors CLH and DRH have contributed equally to the draft of the manuscript. Both authors have read and approved the final manuscript.