Skip to main content
Download PDF

Sickle cell disease in Sri Lanka: clinical and molecular basis and the unanswered questions about disease severity

Orphanet Journal of Rare Diseases volume 15, Article number: 177 (2020) Cite this article

Abstract

Background

Though case reports and limited case series of Sickle cell disease in Sri Lanka have been reported previously, no attempt has been made hitherto to undertake a comprehensive genotypic-phenotypic analysis of this “rare” group of patients.

Results

All accessible Sickle cell disease patients, totaling 60, including, 51 Sickle β-thalassaemia and 9 homozygous sickle patients were enrolled from seven thalassaemia treatment centres between December 2016–March 2019. The majority of patients were of Sinhalese ethnicity (n = 52, 86.67%). Geographically, two prominent clusters were identified and the distribution of Sickle haemoglobin in the island contrasted markedly with the other haemoglobinopathies. 3/ 9 homozygous sickle patients and 3/ 51 Sickle β-thalassaemia patients were receiving regular transfusion. Joint pain was the commonest clinical symptom among all sickle cell disease patients (n = 39, 65.0%). Dactylitis was significantly more common in homozygous sickle patients compared with the Sickle β-thalassaemia groups (p 0.027). Two genetic backgrounds sickle mutation were identified namely, Arab Indian and Benin. Among the regulators of Foetal hemoglobin in Sickle patients of the present study rs1427407 G > T seemed to be the most prominent modifier, with a significant association with Foetal haemoglobin levels (p 0.04).

Conclusions

Overall, the clinical course of the Asian version of Sickle cell disease in Sri Lanka appears to be milder than that described in India.

Background

Sickle Cell Disease (SCD) is the collective term for a group of inherited disorders characterized by mutations in the gene encoding the β-haemoglobin subunit (HBB). The prevalence of the disease is high in sub-Saharan Africa, Middle East, India, Jamaica and Brazil [1]. Sri Lanka is a multi-ethnic country with a population of 20.4 million, comprised of Sinhalese (74.9%), Tamils (15.2%), Moors (9.3%) and several other minor groups [2].

Sickle haemoglobin (Hb S) was first reported in the country among Sinhalese in 1962 in the Eastern province of the country [3]. Even though Sri Lanka is geographically adjacent to India, where the prevalence of Hb S is high, particularly among tribal populations, the prevalence of Hb S in Sri Lanka is lower and is confined mainly to coastal areas [4]. No detailed descriptions of SCD in Sri Lanka are available in the literature, although there are several reports for some sporadic cases of SCD, including homozygous sickle cell anaemia (Hb SS), sickle-β thalassaemia (SBT) and Hb SD disease [5,6,7,8,9,10]. Currently, SCD patients in Sri Lanka are typically treated in either thalassaemia centres or general paediatric or medical wards. A recent island-wide hospital based epidemiological survey of haemoglobinopathies identified 1774 patients with a haemoglobinopathy. 51 of whom were sickle patients (un specified SCD), confirming that SCD is uncommon in Sri Lanka (2.8%) (51/1774). The same survey identified significant inconsistencies in care of SCD patients between centres [11]. Genetic information including haplotype analysis for SCD in Sri Lanka is scarce, and has been reported for a single patient with SBT [12] only. Hence, in the present study we intend to describe the clinical picture of SCD patients in Sri Lanka, analyze its molecular basis, including the effects of genetic modifiers on the phenotype.

Methods

Study design and population

We conducted a cross-sectional study between December 2016 and March 2019 recruiting patients previously diagnosed with SCD from seven thalassaemia centres in Sri Lanka. The thalassaemia centres were located in the districts of Mahara, Kurunegala, Anuradhapura, Hambantota, Monaragala, Ampara and Batticaloa. All SCD patients were eligible for the study and there were no exclusion criteria. All patients were examined by the study physician and clinical details were obtained using a pre-tested interviewer-administered questionnaire. Ethical approval for the study was obtained from Faculty of Medicine, University of Kelaniya, Sri Lanka (P/01/01/2016). Informed written consents form adult SCD patients and assents from the parents of the participating SCD children were obtained before enrollment for the present study.

Haematological and haemoglobin analyses

A Five ml venous blood sample was collected into EDTA (Ethylenediaminetetraacetic acid) from each participant. Routine haematological measurements were conducted using a Coulter counter Ac•T 5diff OV (Beckman Coulter, Inc., Brea, California, United States). Haemoglobin phenotype was determined by capillary electrophoresis (CE) using Capillarys 2 flex piercing analyzer (Sebia, France). DNA for genetic analyses was extracted by QIAamp DNA Blood Mini Kit (Qiagen, Hilden, Germany) and stored at − 20 °C until further use.

Basic genetic analyses

Classical β- globin haplotyping was performed. Six regions around and within the β globin gene cluster were amplified by the polymerase chain reaction (PCR), using primers from Integrated DNA Technologies, Inc., Iowa, United States. Primer sequences were those referenced by [13]. PCR products of each patient were treated with appropriate restriction enzymes (from Thermofisher scientific) according to manufactures instructions and the resulting fragments were separated on 2% agarose gel. Bands were visualized and photographed by UVP BioDoc-It® Imaging System. Six polymorphic restriction sites were studied; 5′ to ε gene by Hind II, 5' to Gγ gene by Xmn I, within IVS 2 of the Gγ and Aγ genes by Hind III, 3′ to ψβ by Hind II, and IVS 2 of the β gene by Ava II. When the Restriction Fragment Length Polymorphism (RFLP) pattern was heterozygous, the sickle haplotype was determined based on the assumption that common sickle haplotypes were present [14]. Common α+ globin gene deletions (3.7 and 4.2 kb) were studied by multiplex GAP polymerase chain reaction [15]. Beta- thalassaemia mutations of the SBT patients were determined by Amplification Refractory Mutation System (ARMS) [16].

Sequencing analyses of Hb SS patients

New generation sequencing (NGS) was done using a customized panel which sequenced 5 regions of the genome of all the Hb SS patients reported in study including; Chromosome 2 (hg 19 Grch build 37) - chr2:60,575,685 - 60,753,050, Chromosome 6 (hg 19 Grch build 37) - chr6:135,281,347 - 135,540,835, Chromosome 11 (hg 19 Grch build 37) - chr11:3,779,641 - 7,224,114, Chromosome 16 (hg 19 Grch build 37) - chr16: 575,307- 2,619,179 and Chromosome X (hg 19 GrCh build 37) - chrX:11,253,922-11,377,717 using Illumina platform (Illumina Miseq). Variations found were annotated with Integrative Genomic Viewer version 2.6 (Broad Institute) using GRCh37 - hg19 - Genome – Assembly by NCBI (National Centre for bio-informatics) as the reference sequence.

Genotyping of Foetal Haemoglobin (Hb F) modifiers among SCD patients

Four known Hb F modifiers (rs1427407 and rs6545816 in BCL11A, rs66650371 in HMIP-2A and rs9402686 in HMIP-2B) were genotyped by Taqman assay real time PCR using Viia 7 Applied Biosystems. One Hb F modifier (rs7482144 in Xmn1-HBG2) was genotyped by RFLP. These Hb F markers were selected based on their positive association with Hb F levels in SCD patients suggested by several studies [17,18,19].

Results

Basic demographic data

Between December 2016 and March 2019, 60 SCD patients were recruited for the study. Fifty-one patients (51/60; 85%) were SBT patients and 9 (9/60; 15%) were homozygous Hb SS patients. Homozygosity was confirmed in all 9 patients by typing the sickle mutation rs334 (T > A) at chr11:5227002 (GRCh38.p12) by NGS. There were 30 male and 30 female participants. Thirty-seven (72.55%) SBT patients had IVS 1–5 (G → C) mutation, 11(21.57%) had IVS 1–1 (G → A) mutation, 2 had CD-16 mutation and one SBT patient had CD 41/42 mutation. Even though IVS 1–5 (G → C) clinically behaves as an β0 mutation for all practical purposes SBT patients with IVS 1–5 (G → C) was classified separately as severe Hb S/β+ as it is known to produce some Hb A (n = 37) [20,21,22,23]. SBT patients identified with other β mutations were all unquestionably severe mutations and were classified as Hb S/β0 type (n = 14). SCD patients in the present study were living in 10 out of the 25 districts of Sri Lanka. Geographically, two prominent patient clusters were noted and the Southern cluster comprising Hambantota and Monaragala districts accounting for 27 (45.0%) SCD patients was the dominant cluster (Fig. 1). The SCD patients comprised of three ethnic groups; 52 (86.67%) were Sinhalese, 5 (8.33%) were Moors and 3 (5.0%) were Tamils. Non-parametric statistical methods were used since data were not normally distributed.

Fig. 1
figure 1

Locations from which SCD patients were reported in present study (each dot represents one patient)

Full size image

Haematological data

Basic haematological parameters of those who had not received a blood transfusion in the three months prior to blood sampling are summarized in Table 1.

Table 1 Haematological parameters of Hb SS, Hb S/β+ severe and Hb S/β0 type patients
Full size table

Clinical findings

Age at presentation of all SCD patients was highly variable, ranging from 4 months to 55 years (Mean 9.8 years; SD- 11.3 years). Most of the patients (51.7%; n = 31) had presented with fever, whilst the next common presenting symptoms were joint pain and abdominal pain (26.7%; n = 16). Icterus led to identification of the disease in a further 9 (15%) cases. Six more patients were incidentally diagnosed whilst investigating anaemia. A further three patients were diagnosed during pregnancy (including two Hb S/β0 patients and one severe Hb S/β+ patient). Three out of 9 (33.33%) Hb SS, 1/37 (2.7%) severe Hb S/β+ and 2/14 (14.3%) Hb S/β0 (p 0.012) patients were on regular blood transfusion (defined as > 8 transfusions/year). Based on clinical records it appeared that blood transfusions had mostly been given when haemoglobin concentration of the patient fell to 6 g/dl or less, although this could not be ascertained with certainty. Incidentally, 12 (23.53%) of SBT patients (7 severe Hb S/β+ and 5 Hb S/β0 patients) never had any transfusion in their lifetime.

Clinical features of Hb SS, severe Hb S/β+ and Hb S/β0 and patients are summarized in Table 2. Joint pains were the most common clinical symptom observed among all SCD patients. Ischemic cerebrovascular event had occurred in one severe Hb S/β+ and one Hb SS patient. Similarly, avascular necrosis of the hip was present in one Hb SS patient and one severe Hb S/β+ patient. Fisher’s exact test showed that the incidence of dactylitis was the only clinical feature which was significantly different between Hb SS, severe Hb S/β+ and Hb S/β0 patients (p 0.027). Nevertheless, none of the clinical features were significantly different between severe Hb S/β+ and Hb S/β0 patients. Genotype-phenotype associations were also assessed separately between Hb SS, severe Hb S/β+ and Hb S/β0 patients those who were on regular transfusions and those who were not. Nevertheless, Fisher’s exact test was unable to find any difference between the patients in the two transfusion categories. Splenectomy had been carried out in 1 / 9 Hb SS and 4/51 severe Hb S/β+ patients. The exact reason for splenectomy and its justification could not be deduced from the clinical records. Four of the splenectomized patients had undergone the surgery before the age of 20 years. Forty-one SCD patients (6 Hb SS, 23 severe Hb S/β+ and 12 Hb S/β0 patients) (68.3%) in our series had a history of at least one pain event (Joint/Abdominal/Chest) in their lifetime, while 19 SCD patients including three Hb SS individuals had not experienced any pain events. Cold weather (33.33%, n = 20) was the most frequently identified precipitating factor for pain events among SCD individuals, followed by infections (26.32%, n = 15). Thirteen (21.66%) SCD patients who had pain crisis reported no obvious precipitant factor for pain events. At the time of data collection 26 (43.33%) SCD patients were taking Hydroxyurea. Nineteen (31.67%) SCD patients were on Folic acid only. Twenty-eight (48.7%) SCD patients were on penicillin prophylaxis. Six SCD patients (10%) were not on any medication.

Table 2 Summary of clinical features observed between severe Hb S/β+, Hb S/β0 and Hb SS groups
Full size table

Genetic findings

Gap PCR for common α+ gene deletions found only 4 (6.67%) SBT patients with 3.7 kb deletions. None of the SCD patients had the 4.2 kb α gene deletion.

Haplotyping by traditional RFLP showed that the sickle mutation occurred on two main beta globin haplotypes in Sri Lanka. Namely Arab-Indian (AI) and Benin. Out of 18 β globin haplotypes among the 9 Hb SS patients, 14 were AI haplotype and 4 were Benin haplotype. Presence of AI haplotype and Benin haplotype in Sri Lanka was confirmed with NGS by typing 4 different SNPs (rs3834466, rs28440105, rs10128556 and rs968857) in 9 Hb SS patients as described previously [27]. When looking at the genetic variants that moderate Hb F levels, rs6545816 in BCL11A was found at the highest allele frequency (88%) followed by rs7482144 in Xmn I-HBG2 (47%) (Table 3). Allelic discrimination plot of rs6545816 is shown in Fig. 2.

Table 3 Presence and frequency of Hb F determining variants in Sri Lankan SCD patients
Full size table
Fig. 2
figure 2

Allelic discrimination of the marker Hb F marker rs6545816 of SCD patients

Full size image

Discussion

Our study is the first description of the genotypic and phenotypic associations of SCD in Sri Lanka. Haplotype data in our present study sheds new light on the genetic background of Hb S in Sri Lanka. Both AI and Benin haplotypes of Hb S are common in Saudi Arabia [28, 29]. The presence of AI and Benin haplotypes of Hb S in Sri Lanka suggests that occurrence of Hb S in Sri Lanka is more likely to have originated from Arab migrations than African settlings: Historical records also indicate the existence of Arab settlements near coastal towns of Beruwala, Colombo, Chilaw, Galle, Mannar, Puttalam and Trincomalee by ninth century A.D. [30]. In the present study most of the SCD patients recruited were living fairly close to some of above-mentioned coastal areas.

There have been several island wide’s surveys of anaemia conducted in Sri Lanka and in a nationwide study involving 7526 adolescent age school children conducted in 2009–2010 anaemia prevalence was 172 (5.6%) in males and 298 (11.1%) in female children. In the same survey 28 (1.0%) male and 130 (4.6%) female students were found to have Iron deficiency anaemia. Further analysis of the same study identified that β thalassaemia trait and deletional α thalassaemia contributed to anaemia in a further 3%. Eleven children with Sickle cell trait had been identified in this study but there is no mention about their haemoglobin level [4, 31,32,33]. Though anaemia is identified to be an important finding in the present study, it is unlikely that SCD has a significant bearing on the national anaemia figures due to its relative low prevalence.

Joint pain was the most common clinical feature observed among Hb SS (77.78%), severe Hb S/β+ (54.05%) and Hb S/β0 (85.70%) patients. Joint pains are not uncommon among sickle patients in the Indian subcontinent. A recent study from Madhya Pradesh, Central India reported that the incidence of joint pain is over 80% in both Hb SS and SBT groups [34]. Bone pain reported at high frequencies in Indian SCD patients [24, 25, 35], was not present in any participants in our study. Requirement for regular blood transfusions was higher among Hb SS (33.33%) than severe Hb S/β+ (2.70%) and Hb S/β0 (14.30%) patients in the present study. These findings differ from a study reported from Madhya Pradesh (India) in which 16.1% of Hb SS and 17.4% of SBT patients were on regular blood transfusion [34]. Furthermore, seven severe Hb S/β+ (18.90%) and 5 Hb S/β0 (35.70%) patients had never received a transfusion in their lifetime. As the indication for blood transfusions were very often physician initiated and there was no defined rationale, these observations need to be interpreted with caution, and suggests the need for clear guidelines on the management of SCD in Sri Lanka, including the use of transfusion.

Only two cases of avascular necrosis of the hip were reported in the present study, which is in contrast to eastern Indian SCD patients, in whom incidences over 10% have been reported across several age groups [26]. Priapism and leg ulcers were not found in our study. There were no deaths in any of the SCD patients reported during the period of observation.

Hb F plays a significant role in ameliorating complications is SCD [36]. In the present study, in patients who were not on transfusion, mean Hb F concentrations were 24.4%, 23.7% and 21.2% in Hb SS, severe Hb S/β+ and Hb S/β0 patients, respectively. These values are in accordance with the observations from the Maharashtra (India) but are higher than the values observed in Madhya Pradesh (India) [25, 34]. The Hb F levels are much higher than those found in SCD patients of Sub-Saharan African origin, and levels greater than 20% would typically be associated with less severe clinical picture. Hb F boosting allele “C” of rs6545816 was detected at a much higher frequency in Sri Lankan patients than in patients from the United Kingdom (34%), Tanzania (36%) and Nigeria (35%) [18, 19]. Furthermore, among those who were not on transfusion and hydroxyurea (n = 22), “T” allele of rs1427407 was significantly associated with high Hb F levels (p 0.046). The presence of common α+ gene deletions was surprisingly low in this study. This is in contrast with observations in Western Indian SCD patients in whom the prevalence of α gene deletions was 29/51;56.8% [19]. Similarly, in a study of 60 SCD patients in New Delhi, the prevalence of α globin gene deletions was 18/60;30.% [37].

One of the most notable observational findings of our study was the gross inconsistency in the clinical management of SCD patients across the different centres across Sri Lanka. Usage of hydroxyurea was not consistent among sickle patients in these centres. Equally, the practice of blood transfusions was also very variable, reflecting perhaps the lack of familiarity in the management of the disease by the attending medical teams and the need for national guidelines on the management of patients with SCD. The prevalence of SCD in Sri Lanka however is rare permitting us to gather data from only 60 SCD patients which is a limitation in the present study.

Conclusions

Overall, though the numbers may be limited the clinical course of the Asian version of SCD in Sri Lanka appears to be milder than that described from India. High Hb F levels are common and deletional α thalassaemia rarer. The natural selection, early migratory patterns of Arabs and settlements may explain why SCD is found mostly in coastal regions and low lands of Sri Lanka. We plan to undertake further work to elucidate the causative elements responsible for the milder appearance of SCD in Sri Lanka.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

SCD:

Sickle Cell Disease

HBB:

β-haemoglobin subunit

Hb S:

Sickle Haemoglobin

Hb SS:

Homozygous Sickle Cell Anaemia

SBT:

Sickle β-thalassaemia

EDTA:

Ethylenediaminetetraacetic acid

CE:

Capillary Electrophoresis

PCR:

Polymerase Chain Reaction

RFLP:

Restriction Fragment Length Polymorphism

ARMS:

Amplification Refractory Mutation System

NGS:

New Generation Sequencing

Hb F:

Foetal Haemoglobin

References

  1. Kato GJ, Piel FB, Reid CD, Gaston MH, Ohene-Frempong K, Krishnamurti L, et al. Sickle cell disease. Nature Reviews Disease Primers. 2018;4:18010.

    Article  PubMed  Google Scholar 

  2. Lanka DS-S. Census of population and housing (table A3). Sri Lanka; 2012.

    Google Scholar 

  3. De Silva CC, Bulugahapitiya TD, De Silva J, Wickremasinghe RL, Jonxis HP. Sinhalese family with haemoglobin S. Br Med J. 1962;1(5291):1519–21.

    Article  PubMed Central  Google Scholar 

  4. Premawardhena A, Allen A, Piel F, Fisher C, Perera L, Rodrigo R, et al. The evolutionary and clinical implications of the uneven distribution of the frequency of the inherited haemoglobin variants over short geographical distances. Br J Haematol. 2017;176(3):475–84.

    Article  CAS  PubMed  Google Scholar 

  5. Lucas GN, Jayawardena DR. A case of homozygous sickle cell disease in Sri Lanka. Ceylon Med J. 1991;36(4):172–4.

    CAS  PubMed  Google Scholar 

  6. Thalagahage KH, Jayaweera J, Kumbukgolla W, Perera N, Thalagahage E, Kariyawasam J, et al. HbS/D-Punjab disease: report of 3 cases from Sri Lanka. Indian J Hematol blood Transfusion. 2018;34(2):350–2.

    Article  Google Scholar 

  7. Tudawe MN, Senadheera NB, Gooneratne LV. Variations in the presentation of sickle cell beta thalassaemia--a report of two cases. Ceylon Med J. 2005;50(3):134–5.

    Article  CAS  PubMed  Google Scholar 

  8. Nagaratnam N. Hemoglobinopathies in Sri Lanka and their anthropological implications. Hemoglobin. 1989;13(2):201–11.

    Article  CAS  PubMed  Google Scholar 

  9. Karunatilake H, Vithiya K, Malavan R, Natalia H, Ratnayake H. Exchange transfusion for intrahepatic cholestasis due to sickle beta thalassaemia. Ceylon Med J. 2009;54(3):95–6.

    Article  PubMed  Google Scholar 

  10. Premathilaka LHRA, Lakmini MS, Darshana LGT, Nawaratne SB, Mettananda S, De Silva S, et al. Stroke in sickle beta thalassemia - a case report highlighting pitfalls in management in a low prevalence country. Sri Lanka J Med. 2018;26:55.

    Article  Google Scholar 

  11. Premawardhana AP, Mudiyanse R, De Silva ST, Jiffry N, Nelumdeniya U, de Silva U, et al. A nationwide survey of hospital-based thalassemia patients and standards of care and a preliminary assessment of the national prevention program in Sri Lanka. PLoS One. 2019;14(8):e0220852.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Fisher CA, Premawardhena A, de Silva S, Perera G, Rajapaksa S, Olivieri NA, et al. The molecular basis for the thalassaemias in Sri Lanka. Br J Haematol. 2003;121(4):662–71.

    Article  CAS  PubMed  Google Scholar 

  13. Rahimi Z, Karimi M, Haghshenass M, Merat A. Beta-globin gene cluster haplotypes in sickle cell patients from Southwest Iran. Am J Hematol. 2003;74(3):156–60.

    Article  CAS  PubMed  Google Scholar 

  14. Steinberg MH, Hsu H, Nagel RL, Milner PF, Adams JG, Benjamin L, et al. Gender and haplotype effects upon hematological manifestations of adult sickle cell anemia. Am J Hematol. 1995;48(3):175–81.

    Article  CAS  PubMed  Google Scholar 

  15. Chong SS, Boehm CD, Higgs DR, Cutting GR. Single-tube multiplex-PCR screen for common deletional determinants of alpha-thalassemia. Blood. 2000;95(1):360–2.

    Article  CAS  PubMed  Google Scholar 

  16. Old JM, Khan SN, Verma I, Fucharoen S, Kleanthous M, Ioannou P, et al. A multi-center study in order to further define the molecular basis of beta-thalassemia in Thailand, Pakistan, Sri Lanka, Mauritius, Syria, and India, and to develop a simple molecular diagnostic strategy by amplification refractory mutation system-polymerase chain reaction. Hemoglobin. 2001;25(4):397–407.

    Article  CAS  PubMed  Google Scholar 

  17. Bhanushali AA, Patra PK, Nair D, Verma H, Das BR. Genetic variant in the BCL11A (rs1427407), but not HBS1-MYB (rs6934903) loci associate with fetal hemoglobin levels in Indian sickle cell disease patients. Blood Cells Mol Dis. 2015;54(1):4–8.

    Article  CAS  PubMed  Google Scholar 

  18. Gardner K, Fulford T, Silver N, Rooks H, Angelis N, Allman M, et al. G (HbF): a genetic model of fetal hemoglobin in sickle cell disease. Blood Adv. 2018;2(3):235–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Adeyemo TA, Ojewunmi OO, Oyetunji IA, Rooks H, Rees DC, Akinsulie AO, et al. A survey of genetic fetal-haemoglobin modifiers in Nigerian patients with sickle cell anaemia. PLoS One. 2018;13(6):e0197927 e.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Thein SL. The molecular basis of β-thalassemia. Cold Spring Harb Perspect Med. 2013;3(5):a011700 a.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Weatherall DJ, Clegg JB. The thalassaemia syndromes, vol. xiv. 4th ed. Oxford: Blackwell Science; 2001. p. 846.

    Book  Google Scholar 

  22. Bohara V, Raut L, Badarkhe G, Roy SS, Chaudhuri U. Homozygosity for the severe beta(+)-thalassemia mutation [IVS-I-5 (G>C)] causes the phenotype of thalassemia trait: an extremely rare presentation. Hemoglobin. 2013;37(1):101–5.

    Article  CAS  PubMed  Google Scholar 

  23. HbVar: A database of Human Hemoglobin Variants and Thalassemias [Internet]. HbVar. 2001. Available from: http://globin.bx.psu.edu/cgi-bin/hbvar/query_vars3?mode=output&display_format=page&i=824. Accessed 8 May 2020.

  24. Kulozik AE, Bail S, Kar BC, Serjeant BE, Serjeant GE. Sickle cell-beta+ thalassaemia in Orissa state, India. Br J Haematol. 1991;77(2):215–20.

    Article  CAS  PubMed  Google Scholar 

  25. Jain D, Warthe V, Dayama P, Sarate D, Colah R, Mehta P, et al. Sickle cell disease in Central India: a potentially severe syndrome. Indian J Pediatr. 2016;83(10):1071–6.

    Article  PubMed  Google Scholar 

  26. Mashon RS, Dash PM, Khalkho J, Dash L, Mohanty PK, Patel S, et al. Higher fetal hemoglobin concentration in patients with sickle cell disease in eastern India reduces frequency of painful crisis. Eur J Haematol. 2009;83(4):383–4.

    Article  CAS  PubMed  Google Scholar 

  27. Shaikho EM, Farrell JJ, Alsultan A, Qutub H, Al-Ali AK, Figueiredo MS, et al. A phased SNP-based classification of sickle cell anemia HBB haplotypes. BMC Genomics. 2017;18(1):608.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Jastaniah W. Epidemiology of sickle cell disease in Saudi Arabia. Ann Saudi Med. 2011;31(3):289–93.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Alsultan A, Alabdulaali MK, Griffin PJ, Alsuliman AM, Ghabbour HA, Sebastiani P, et al. Sickle cell disease in Saudi Arabia: the phenotype in adults with the Arab-Indian haplotype is not benign. Br J Haematol. 2014;164(4):597–604.

    Article  CAS  PubMed  Google Scholar 

  30. Dasanayaka R. Muslim Trade Relations with Sri Lanka: Historical Respective- In Sinhala: Ada Sanda Saha Tharadiya; 2019.

    Google Scholar 

  31. Allen A, Allen S, Rodrigo R, Perera L, Shao W, Li C, et al. Iron status and anaemia in Sri Lankan secondary school children: A cross-sectional survey. PLoS One. 2017;12(11):e0188110 e.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Premawardhena A, Perera PS. Anaemia in Sri Lanka: the missing pieces. Ceylon Med J. 2018;63(3):105–7.

    Article  CAS  PubMed  Google Scholar 

  33. Rodrigo R, Allen A, Manampreri A, Perera L, Fisher CA, Allen S, et al. Haemoglobin variants, iron status and anaemia in Sri Lankan adolescents with low red cell indices: a cross sectional survey. Blood Cells Mol Dis. 2018;71:11–5.

    Article  CAS  PubMed  Google Scholar 

  34. Yadav R, Lazarus M, Ghanghoria P, Singh M, Gupta RB, Kumar S, et al. Sickle cell disease in Madhya Pradesh, Central India: A comparison of clinical profile of sickle cell homozygote vs. sickle-beta thalassaemia individuals. Hematology (Amsterdam, Netherlands). 2016;21(9):558–63.

    CAS  Google Scholar 

  35. Patel J, Patel B, Serjeant GR. The bone pain crisis of sickle cell disease and malaria: observations from Gujarat, India. Indian J Community Med. 2017;42(3):167–9.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Piel FB, Steinberg MH, Rees DC. Sickle cell disease. N Engl J Med. 2017;376(16):1561–73.

    Article  CAS  PubMed  Google Scholar 

  37. Pandey S, Pandey S, Mishra RM, Sharma M, Saxena R. Genotypic influence of α-deletions on the phenotype of Indian sickle cell anemia patients. Korean J Hematol. 2011;46(3):192–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

This research was funded by National Research Council Sri Lanka, grant number NRC 16–001 and The APC was not funded by any funding agency.

Author information

Authors and Affiliations

  1. Department of Medical Laboratory Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka

    Thamal Darshana

  2. National Thalassaemia Centre, Teaching Hospital, Kurunegala, Sri Lanka

    Dayananda Bandara

  3. Department of Pediatrics, Teaching Hospital, Kurunegala, Sri Lanka

    Upul Nawarathne

  4. Thalassaemia Unit, Teaching Hospital, Anuradhapura, Sri Lanka

    Udaya de Silva

  5. Department of Haematology, Teaching Hospital, Ragama, Sri Lanka

    Yasinta Costa

  6. Department of Pediatrics, District General Hospital, Matara, Sri Lanka

    Kalavitigoda Pushpakumara

  7. Department of Pediatrics, District General Hospital, Hambantota, Sri Lanka

    Sumithra Pathirage

  8. Department of Haematology, District General Hospital, Monaragala, Sri Lanka

    Seuwandi Basnayake

  9. Department of Haematology, Teaching Hospital, Batticaloa, Sri Lanka

    Chamila Epa

  10. Department of Haematology, District General Hospital, Ampara, Sri Lanka

    Pradeepa Dilrukshi

  11. Department of Pediatrics, District General Hospital, Ampara, Sri Lanka

    Maheshaka Wijayawardena

  12. Department of Clinical Sciences, Eastern University, Batticaloa, Sri Lanka

    Angela A. Anthony

  13. Thalassaemia Adult and Adolescent Care Centre, Teaching Hospital, Ragama, Sri Lanka

    Rexan Rodrigo

  14. Molecular Medicine Unit, University of Kelaniya, Ragama, Sri Lanka

    Aresha Manamperi

  15. Molecular Pathology Department, Viapath at King’s College Hospital, London, UK

    Frances Smith

  16. Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK

    Angela Allen

  17. School of Cancer and Pharmaceutical Sciences, The Rayne Institute, King’s College London, London, UK

    Stephan Menzel

  18. Department of Haematological Medicine, King’s College Hospital, London, UK

    David Rees

  19. Department of Medicine, University of Kelaniya, Ragama, Sri Lanka

    Anuja Premawardhena

Authors
  1. Thamal Darshana
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Dayananda Bandara
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Upul Nawarathne
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Udaya de Silva
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yasinta Costa
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Kalavitigoda Pushpakumara
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Sumithra Pathirage
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Seuwandi Basnayake
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Chamila Epa
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Pradeepa Dilrukshi
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Maheshaka Wijayawardena
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Angela A. Anthony
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Rexan Rodrigo
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Aresha Manamperi
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Frances Smith
    View author publications

    You can also search for this author in PubMed Google Scholar

  16. Angela Allen
    View author publications

    You can also search for this author in PubMed Google Scholar

  17. Stephan Menzel
    View author publications

    You can also search for this author in PubMed Google Scholar

  18. David Rees
    View author publications

    You can also search for this author in PubMed Google Scholar

  19. Anuja Premawardhena
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

TD has contributed to haplotype sickle haemoglobin with RFLP, total data curation, analyze the data and write the original manuscript. AP has contributed to design the research, clinical data collection, supervise the overall work and to revise and edit the manuscript. DR, AA and AM have contributed to revise and edit the manuscript. FS has contributed to NGS of Hb SS patients, SM has contributed to genotyping of Hb F markers, RR has contributed to Gap PCR of common α plus gene deletions and ARMS PCR for β-thalassaemia mutations, DB, UN, US, YC, KP, SP, SB, CE, PD, MW and AAA have contributed to clinical data collection and edit the manuscript. The author(s) read and approved the final manuscript.

Corresponding author

Correspondence to Thamal Darshana.

Ethics declarations

Ethics approval and consent to participate

Ethical approval for the study was obtained from Faculty of Medicine, University of Kelaniya, Sri Lanka (P/01/01/2016). Informed written consents form adult SCD patients and assents from the parents of the participating SCD children were obtained before enrollment for the present study.

Consent for publication

Not applicable.

Competing interests

All authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Darshana, T., Bandara, D., Nawarathne, U. et al. Sickle cell disease in Sri Lanka: clinical and molecular basis and the unanswered questions about disease severity. Orphanet J Rare Dis 15, 177 (2020). https://doi.org/10.1186/s13023-020-01458-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13023-020-01458-w

Keywords

Orphanet Journal of Rare Diseases

ISSN: 1750-1172