Clinical diagnosis and laboratory methods

A study survey of Prevalence of Thalassemia Trait among Secondary School Students in Jenin District


Thalassemia is a common and important genetic blood disorder in Palestine which has three types; Thalassemia major, Thalassemia intermedia, andThalassemia minor(trait)(carriers). Relatively large number of population have thalassemia trait. Thalassemia is getting recognition as an important health problem in Palestine Recent studies have shown that Jenin area has the highest frequency of thalassemics. In this study we targeted the secondary school students in Jenin District. About five hundred students (231 males and 269 females) were surveyed in their classes between September 2001 and February 2002.

The study sample was selected randomly from five areas of Jenin District ( east, west, north, south and middle).

All participants filled out a questionnaire, then blood samples were collected. All blood samples were tested for CBC and only selected samples were tested for Hemoglobin electrophoresis and Serum iron.

The main results of this study survey are the following:

  1. About 1.6 % of secondary school students in Jenin District suffer from thalassemia trait.62.5 % were males and 37.5 % were females.
  2. There are some variations in this percentage according to the area of the study. It was found to be 5.3 % in the east area, 0.4 % in the capital (middle), 1.3 % in the south area, 1.7 % in the west area, and 0 % in the north area of study.
  3. In this study survey the most effective equation used in thalassemia screening was:

( MCV : RBC ratios less than 13 correspond to patients with thalassemia trait). This equation identified all the cases and didn't dismiss any case.


Thalassemia is an inherited disease of blood. It is characterized by a hypochromic microcytic anemia, splenomegaly, changes in the bones and skin which occurs especially in children of Mediterranean origin. [Dr. Rino, Dr.Bernadette Modell]and Dr. Evgenia Georganda, 1995]. It may be classified into a-thalassemia and b -thalassemia [TIF, 1999,2000][Whaley &Wongs, 1996] .

There are three types of thalassemia according to its severity:

1)Thalassemia major:a severe anemia that starts between 6 months and 1 year of age [TIF,1999],2)Thalassemia intermedia: a mild anemia that needs fewer blood transfusions and less medical treatment than beta thalassemia major,and 3)Thalassemia minor: which is usually asymptomatic, but changes in the blood do occur. [Whaley &Wongs, 1996] Carrying beta thalassemia (i.e: having one gene of the disease) dose not affects the health or life span of an affected individual. Carriers may be mildly anemic (have lower hemoglobin than usual), but some carrier women may become anemic during pregnancy. [APOGI, 1998].It is not unusual to carry beta thalassemia. About one in 50 of the world population is a carrier. Carrying beta thalassemia is much more common in some population groups ,for example it is 1 in 7 in Cyprus,1 in 12 in Greece,and 1 in 30 in Egypt, Lebanon, Gulf States and other Middle East countries [APOGI, 1998].

Thalassemia is getting recognition as an important health problem in Palestine. Relatively large number of population (3-4%) is thalassemia trait[Al-Yonus study - 1996], which causes socioeconomic problem. A comprehensive survey has been conducted in 1999 in the West-Bank showed that the total number of thalassemics by April 1999 was 600 patients, 172 of them in Gaza strip and 428 in the West Bank. 64% of which was in the northern region of the West Bank. At the district level, Jenin has the highest frequency of thalassemics (87 patients/ 24%). In other study [Al-Yonus study - 1996], there were 70 families with more than one thalassemic per family, of which, 19 families with 3-4 thalassemics and one family with 5 patients. As to age distribution of thalassemics, 64% of them were below the age of 10 years and 4% beyond the second decade of life. The early death is most probably due to the low level of health care provided to them. Annually, there are 20-25 new cases. Most of our thalassemics (76%) are the result of related marriages. [Al-Yonus study - 1996]

The Thalassemia Society was established in 1996 in Palestine acting mainly as a pressure group to improve the level of health care provided to thalassemics. However, thalassemia has to be recognized at the national level as a socioeconomic problem.

According to a scientific study that included 10,000 Palestinian university students, three to four percent were found to be carrier to - thalassemia thus, it is estimated 100,000 of Palestinian people are carrier to this disease. .

The objective of this study is to identify the percent of thalassemia trait among secondary school students in Jenin District.

  1. Study sample:
  2. Jenin District was chosen to carry out this important study aiming to find the percent of thalassemia trait among school students. The total number of students in secondary schools in this district was about 6000.

    The sample study consists of first and second year of secondary school students with their ages ranging between 16 - 18 years.

    The study sample was selected randomly by dividing Jenin District into five areas (east, west, north, south, and middle). Also randomly selecting a village from each area, in addition to the middle (Jenin City). The assigned villages were (Al-Yammon, Ybad, Tubas and Jalqamus). Five hundred students were chosen randomly including males and females, taking into consideration the scientific statistical measures . So that the study sample is representative of the secondary school students of Jenin District.

  3. Tools of study:
  4. A self administered questionnaire was filled by all participants including personal data, andquestions about health profile pertinent to thalassemia, and anemia. Blood tests including Complete blood count CBC ( All samples),Hemoglobin electrophoresis ( Selected samples).

    were performed on collected blood from all participants.

  5. Procedure:
  6. A permission from Ministry of education was obtained to carry out the survey study. [Appendix 2] Also parents consent to fill questionnaire and collect blood from each student was obtained

    All students participating in the study filled out the questionnaire then blood samples were collected

    Hemoglobin electrophoresis was done on all samples with MCV less than 80 femtoliter. [Charles E.Seiverd, 1983; John D. Bauer, 1982], All samples with HbA2 more than or equal to 3.7% (according to the range prescribed in the test substances) were considered as thalassemia trait. [John D. Bauer, 1982; John Bernard Henry, 1996; Rodgert L. Bick, MD 1993]. CBC was done by using Swelab AC900 (Auto analyzer).Hemoglobin electrophoresis was done by Pecman using biosystem kit.

  7. Data analysis:
  8. Data of questionnaire and blood tests were entered, computed, and analyzed using SPSS soft ware.

    Descriptive studies, Chi square, T test and one way Anova were used to obtain the study survey results.

  9. Equations for thalassemia screening:

In Rodger L. Bick, MD, 1993 four equations have been used for thalassemia screening:

  1. MCV:RBC ratios less than 13 correspond to patients with thalassemia trait.
  2. MCV-RBC- (5 x Hb) -3.4 if the result is positive value (over 0) indicates iron deficiency anemia, and a negative value (below 0) indicates thalassemia trait.
  3. (O.23 x MCV) - (0.22 x RBC)-(0.93 x H6) - 3 < 0 indicates thalassemia trait.
  4. MCV2x MCH = < 15.30 indicates thalassemia trait.

This study survey showed that 1.6% of secondary school students in Jenin District were thalassemia trait, 62.5% thalassemia trait students were males and 37.5% of them were females. [Table 2] and [figure 1]

The east area of the study survey has the largest percent of thalassemia trait. [Table 2] and [figure 1]

This is compatible with the results of previous surveys in this area.

This area has some traditional values such as close marriage and having many children, which may increase the probability of thalassemia trait. [TIF,2001]

Percent of thalassemia trait in the middle area of the study was 0.4%. [Table 2] and [figure 1] this percent is low when compared with other areas of this study survey because the main risk factor (close - marriage) in the middle area (which increases percent of thalassemia) is not that common as it is in other areas of study. In addition being, a city area people living in the middle area tend to enjoy higher social living standards in comparison to other areas. In the south area of this study survey, percent of thalassemia trait was 1.3% [Table 2] and [figure 1] while it was nearly around that in the west area of the study survey (1.7 %). [Table 2] and [figure 1].

These two areas have large number of families which might decrease chances of having thalassemia trait.

In the north area of the study survey percent of thalassemia trait is 0%. [Table 2] and [figure 1] this does not mean that this area is thalassemia trait free, but the percentage in our study sample was 0 % (the sample size in the north area is already small).

The overall percentage of thalassemia trait among secondary school students in Jenin District in our study was 1.6 %,. Comparing our results with previous studies in Palestine and neighbor countries, it was 3-4%in Palestine [Al-Yonus study - 1996], 1in 30 in Egypt, Lebanon, and the Gulf states, 1in 7 in Cyprus [Table 1.1] therefore our results are acceptable /

The effectiveness of the four equations that are usually used in thalassemia trait screening have been examined in this study survey.

  1. Equation number one was the most effective equation because it identified all the secondary school students that have thalassemia trait, and may not dismiss any one. [Table 3. ]
  2. Equation number two did not pick all cases of thalassemia trait. It dismisses 12.5 % of the cases [Table 3. ]
  3. Equation number three dismissed 75 % of the cases. [Table 3.1.10]
  4. Equation number four dismissed 100 % 0f the cases.[Table 3. ]

Adopted from [Rodger L. Bick, MD, 1993].


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