An examination of the successful health system response to thalassaemia in Cyprus

1. Cyprus Case Study
What can other countries learn from this experience?
Carsten W. Lederer
The Cyprus Institute of Neurology and Genetics
The Cyprus School of Molecular Medicine
Lederer@cing.ac.cy
The Cyprus
Institute of
Neurology
and Genetics
UNESCO Headquarters
Paris, France
30 – 31st May 2016
Human Variome Project
Consortium
6th Biennial Meeting
GG2020 Fringe Meeting
http://mycyprusinsider.com/wp-content/uploads/2015/06/Tzelefos-Bridge.jpg

2. The Cyprus
Institute of
Neurology
and Genetics
Outline
 Thalassaemia
 Provision, Needs, Prevention
 Result
 Societal Parameters in Cyprus
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3. The Cyprus
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and Genetics
Thalassaemia
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Haemoglobin
 Two loci for H.s. globin genes
 Haemoglobin, a tetrameric
metalloprotein
 2 α-like globin chains
 2 β-like globin chains
 4 haeme molecules with central Fe2+/3+
 Human adult haemoglobins
α
ε
γ
Chr. 16 Chr. 11
ζ δ
β
β
α
α
β HbA
>95 % δ
α
α
δ HbA2
<3.5 %
γα
αγ
HbF
<1.0 %
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5. The Cyprus
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Neurology
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Key Features of β-thalassaemia
β
α
α
β
α
α
α
α
γα
αγ
γ
γ
Toxicity of α-globin
 (Myeloid) ineffective
erythropoiesis
 (Splenic) haemolysis
Iron overload ( iron chelation)
 Secondary endocrinopathology
 Organ failure (liver, pancreas, heart)
δα
αδ
Anaemia ( blood transfusions)
 Tissue hypoxia & myeloid expansion
 Osteoporosis
 Skeletal deformities
Diagnostic: HbF & HbA2 increase
Modifier: high HbF
 Genetic (HPFH)
 Pharmacological induction
 Gene-therapeutic induction
Modifier:
low/high α
ε δ βAγGγ
β-globin locus
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6. The Cyprus
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Critical Factors
 Blood transfusions
 Supply
 Biosafety
 Increased iron absorption
 Iron chelation
 Risk of noncompliance
 Cost
 Genotype-phenotype correlation & HPFH
 Known and unknown modifiers, mutations and variants
 Personalised therapies
http://thetab.comhttp://bernsteincrisismanagement.comcreativebits.orggenius.com
€£

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Provision, Needs, Prevention
(Provision Needs Prevention.)
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8. The Cyprus
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Provision of Care
 1969 Governmental policy for thalassaemia
 Iron chelation (defer(ri)oxamine) and transfusion to [Hb]=11 g/dL
 1 paediatrician/government hospital responsible for thalassaemia
 1977 Introduction of a voluntary blood donation scheme
 Committee for blood donation with political, medical and patient representatives
 Provision of deferoxamine by the government
 Increased societal awareness of blood requirements
 Voluntary blood donations rise from 6% to 50%
 1981 Thalassaemia outpatient clinics with dedicated premises
 Addition of experts for complications in puberty and adulthood
 1983 Deferoxamine 44% of governmental drug cost
 1999 Introduction of oral chelator deferiprone
 Increase in compliance and rate of successful chelation
 2007 Introduction of 2nd oral chelator deferasirox
Angastiniotis et al. 1986; Kolnagou et al. 2015
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9. The Cyprus
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Need to Act
 Status quo 1969
 1/7 of Cypriots carriers for β-thalassaemia
 1/49 couples are at risk (i.e. both partners carriers)
 1/158 birth expected to be affected
 1/1000 disease prevalence
 Projected rise for thalassaemics by 2010
 Unmanageable drug cost
 Impossible transfusion requirements
 To maintain level of care and quality of life for existing patients:
Need for a national prevention programme
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10. The Cyprus
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Prevention
 1973 Testing of patients’ relatives
 High detection rate
 No prenatal diagnosis
 The “stigma”  implicit discouragement for carrier couples
of pregnancies
of marriages
 1977 Foetal diagnosis abroad
 Gradual removal of the “stigma”
 1981 Foetal diagnosis in Cyprus
 1983 Introduction of a premarital certificate
 1984 National cost/benefit analysis
 On-going education of patients, public and clinicians
 Undiminished need for screening and blood donations
 Disease-management, reproductive, and diagnostic options
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Prevention
 Ministry of Health
 4 Branches of the Thalassaemia Centre
 Disease Management
 Patient counselling
 1 central haematological laboratory
 Sample referral
 CING (a not-for-profit, semi-GO) – Department of
Genetics Thalassaemia
 >800 test cases/year
 β-thalassaemia
 α-thalassaemia
 Hb Variants
 δβ-thalassaemias
 δ-thalassaemias
 HPFH

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chorionic
villus sampling
ultrasound
sensor
placenta
Diagnostic Methods
 Diagnostic methods for routine CVS & PB samples
 For α-thalassaemia
 Sequencing
 MLPA
 GAP-ARMs
 For β-thalassaemia
 Sequencing
 MLPA
 NIPD (cf-mDNA-based)
 RHD status
 Thalassaemia
(SNP-based, experimental)
 PGD (in conjunction with IVF)
 qPCR- and HRM-based
Online list of services
Immunosuppression!
2004 – 2011
Total cases: 52
Pregnancies: 14
Births: 12
PMID23362932 Papasavva et al. 2013

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Decision Trees (Simplified!)
Population-wide
Screening
Normal Haematology
Go Forth and
Multiply
Abnormal
Haematology (MCV,
MCH)
Elevated HbA2
Test for β-
thalassaemia
Normal HbA2
Test for α-
thalassaemia
Test for δ/δβ-
thalassaemia
Abnormal CE-HPLC
Peaks
Sequence for α/β/δ
Variants
Results for Both
Partners
Single Carrier or
Alternate-locus
Carriers
Go Forth and
Multiply
Both Partners Same-
locus Carriers
Counselling
Advise: in Case of
Pregnancy PD
No Conception /
Repeatedly Affected
IVF/PGD

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Result
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Electronic Patient Database
 Knowing your patient population
 Geographical fine-mapping of epidemiologies
 Mutations in patients and patient genotypes
 Mutation-specific carrier frequencies
 Longitudinal nationwide studies
 Basis for genotype/phenotype studies
 Feeding into international summary databases, such as IthaGenes
 Enabling collaborative studies
PMID: 24006929 Kyrri et al. 2013
PMID: 25058394 Kountouris et al. 2014
PMID: 27199182 Kountouris et al. 2016

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Result!
Annual Number of Thalassaemic Births in Cyprus
Actual (x) vs. Expected (x)
0
10
20
30
40
50
60
70
1974
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
Annual Number of Thalassaemic Births
% of Expected
 Carrier Database
 α-thalassaemia: 8,412
 β-thalassaemia: 2,335
 δ-thalassaemia: 428
 Cypriot population: 659115
 Patient Database
 H-disease (--/α-): 595 [608]
 β-thalassaemia: 592 [630]

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Beyond the Primary Mutation
β-globin locus
δ βAγGγε
HbF
HbA
HbA2
HPFH
HbF
HbA
HbA2
Normal
PMID 25737641 Finotti et al. 2015
 Patient
stratification
 Mild and severe
thalassaemia
 High and low
HbF levels
 Response in
cell culture to
chemical and
gene-
therapeutic HbF
induction
 Identification of
population-wide
key modifiers,
such as BCL11A
and KLF1
variants

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Societal Parameters in Cyprus
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 Small size (9,251 km2) and population (0.7 / 1.1 Mio)
 Regular meetings of all key clinicians, molecular researchers and patients
 Homogeneity and community spirit at the country level
 Universal awareness of screening requirement and the need for blood donations
 Strength of the Greek Orthodox Church
 Church influence on society and politics
 Greek Orthodox weddings before (or early during) most pregnancies
 Dedicated diagnostic infrastructure of the Thalassaemia Centre
 Four haematology and care centres in each major city (Nicosia, Larnaca, Limassol and Paphos)
 Central haematology laboratory
 Central molecular testing and database at the CING
 Integration of diagnostic work and molecular research
 Availability of sample material for research
(novel diagnostics, e.g. NIPD)
 Research programs involving all
stakeholders
Family, Church and State 19

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Annual Number of Thalassaemic Births in Cyprus
Challenges
 For Cyprus: changing attitudes
 Changing societal structure
 Secularisation of society
 Pregnancies out of wedlock
 Success its own worst enemy
 Sinking awareness amongst the young
 Increasing choice to have thalassaemic children
 For others: horses for courses
 Religious or ethical homogeneity is an exception
 Coordination problems for larger or geographically dispersed countries
 Legality and social acceptance of abortion as key factor
 Compulsory screening (and church interference) untenable elsewhere
 EU law: Cyprus as a special case
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www.oecd.org/social/family/database
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Challenges! 21
MY
Malay, Peninsular
Han Chinese, Hokkien
Tamil
Han Chinese, Hakka
Han Chinese, Cantonese
Banjar Malay
Han Chinese, Teochew
Han Chinese, Mandarin
Minangkabau
F
NG
Yoruba
Hausa
Igbo
Fulani
Urhobo-Isoko
Efik-Ibibio
Kanuri
Edo
Tiv
Ijaw
CY
Greek Cypriot
Foreign Residents
Illegal immigrants

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This project has received funding from
the European Union’s Seventh
Framework Programme for research,
technological development and
demonstration under grant agreement
no. 306201 and from the Research
Promotion Foundation of Cyprus under
grant agreement ΥΓΕΙΑ/ΒΙΟΣ/0311(ΒΕ).
Acknowledgements
 CING & ITHANET
 Marina Kleanthous
 Petros Kountouris
 Pavlos Fanis
 Coralea Stephanou
 Xenia Felekki
 The whole diagnostics team
 Ministry of Health/Thalassaemia Centre
 Soteroulla Christou
 Maria Sitarou
 Annita Kolnagou
 Michael Hadjigavriel
 Haematology Laboratory
 All our collaborators and patients!
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23. The Cyprus
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and Genetics
Thank you!
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24. The Cyprus
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and Genetics
Acknowledgements
Thalassaemia Centre & General
Hospital
 Σωτηρούλα Χρίστου
 Ελένη Καλογήρου
 Μαρία Σίταρου
 Μιχάλης Ηατζηγαβριήλ
 Ανίτα Κολνάγου
 Μάριος Αντωνιάδης
 Μιχάλης Αγκαστινιώτης
Cyprus Antianaemia Association
 Ναταλία Μιχαηλίδου
 Λοΐζος Περικλέους
 All patients and sample volunteers!
«Genome Editing»
University of Freiburg
 Toni Cathomen
 Claudio Mussolino
«Advancing Lentiviral Vector»
King’s College London, ΗΒ
 Mike Antoniou
University of Ferrara, Italy
 Roberto Gambari
Lederer@cing.ac.cy
«ThalaMoSS»
University of Ferrara, Italy
 Roberto Gambari
Erasmus MC, The Netherlands
 Sjaak Philipsen
Ίδρυµα Ιατροβιολογικών Ερευνών της
Ακαδημίας Αθηνών, Ελλάδα
 Eleni Katsantoni
Weill Cornell Medical College, ΗΠΑ
 Stefano Rivella
University of Masaryk, Czech Republic
 Petr Holub
University of Cagliari, Italy
 Paolo Moi
King’s College London, ΗΒ
 Swee Lay Thein
Λαϊκό Γενικό Νοσοκομείο, Ελλάδα
 Ersi Voskaridou
Weill Cornell Medical College, ΗΠΑ
 Stefano Rivella
NovaMechanics, Cyprus
BioCep Ltd., Israel
Harbour Antibodies BV, The Netherlands
IRBM Science Park, Italy
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