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Filmed as Xerox University Microfilms 300 North Zseb Road Ann Arbor, Michigan 40100 75-7207 MACK, Astrld Karona, 1935AN ANALYSIS OF THE SIGNIFICANCE OF SICKLE CELL TRAIT IN THREE MICHIGAN POPULATIONS. Michigan State University, Ph.D., 1974 Zoology Xerc~ University M icrofilm s, AnnArbor, Michigan48ios © 1974 ASTRXD KARONA M AC K ALL RIGHTS RESERVED AN ANALYSIS OF THE SIGNIFICANCE OF SICKLE CELL TRAIT IN THREE MICHIGAN POPULATIONS By Astrid Karona Mack A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Zoology 1974 ABSTRACT AN ANALYSIS OF THE SIGNIFICANCE OF SICKLE CELL TRAIT IN THREE MICHIGAN POPULATIONS By Astrid K. Mack A survey was undertaken to obtain a reliable estimate of the prevalence of sickle cell trait and to gather evidence for its effects on blacks in three Michigan populations. Laboratory diagnoses of hemoglobinopathies were deter­ mined from blood specimens secured from more than 3,500 black Americans in the three sample groupings. Prior to the diagnosis, questionnaires were administered by trained inter­ viewers to ascertain information pertaining to health problems and symptomatology frequently observed among individuals with sickle cell anemia. Comparisons were made between those individuals found to have sickle cell trait and those with normal hemoglobin. The prevalence of sickle cell trait in the randomly selected sample of Lansing, Michigan was 8.2 per cent, similar to previously reported, but less systematically Astrid K. Mack sampled populations in the United States. However, comparisons of observed and expected trait children in sibships of trait families were significantly different. Fewer trait children were observed in both the Lansing and Grand Rapids populations. Prevalences of health problems and symptoms revealed that weakness in legs, pain in bones, sense of exhaustion and epistaxis were significantly associated with sickle cell trait in the Lansing sample, while swollen joints, numbness in legs and epistaxis were more prevalent among trait persons in the Grand Rapids survey. There was no significant difference in the number of symptoms which were more prevalent in either group in the two populations. Further analysis by a single test of association of health problems and sickle cell trait revealed no significant difference between trait and control subjects. An age trend analysis among trait subjects in the random sample does not show a decrease in the proportion of carriers in the older age groups, providing no evidence that the carrier state is associated with an increased mortality. Neither of the populations revealed a differential in primary or secondary infertility among females with sickle cell trait. Nor was there any statistical difference between trait and control females of reproductive age for miscarriages or stillbirths or number of children living. Astrid K. Mack The proportions of trait and normal females using oral contraceptives were similar and no statistical difference in problems resulting from the use of contraceptives was ascertained. A comparison of means and standard deviations of seven hematological indices between trait and normal sub­ jects sampled in the Michigan State University study revealed no significant differences. To Norma and Kyle and my mother and sister ii ACKNOWLEDGEMENTS I wish to express my gratitude to Dr. James V. Higgins, my major professor, for his guidance and counsel throughout my graduate program and especially in the writing of the thesis. A special thanks is extended to Dr. Herman Slatis for his valuable suggestions and critique in the planning and implementation of the study and in the thesis writing. Thanks also are extended D r s . Hiram Kitchen, Emanuel Hackel and Terrell Phenice, members of my graduate committee, for their help, encouragement and confidence. I am especially grateful to Frankie Brown for her collaboration in conceiving, planning, and, most of all, implementation and follow-up with the study. This vast project demanded our total cooperation and understanding. Special thanks is extended to Dr. Ajovi Scott-Emuakpor for his h e l p , guidance and encouragement during the initial stages of the project and for his genuine friendship through­ out our common residence at the University. I must express my sincere appreciation to the entire faculty and staff of the Department of Epidemiology and Public Health at the University of Miami Medical School. These persons include Dr. John Davies, Chairman; Dr. Charles Hennekens, Dr. Richard Donelson and Janet Cassady. A very special thanks is extended to Dr. William Page who graciously iii accepted my plea for help In the analysis of the data and worked with me for many months in advising and implementing the methods of computer analysis and implications of the results. Special appreciation is extended to Sandra Kasper for typing, re-typing, editing the thesis and listening and encouraging me during moments of depression. Also, thanks to Judy Botana for typing the initial tables. Further appreciation is extended to the staff that I supervise for continuing with their functions while I neglected them during the writing phase of this project. This document could not have been completed without the cooperation of black residents of Lansing and Grand Rapids and the black students at Michigan State University who willingly participated in the study. Most of all, wife, Norma, I shall be forever grateful to my for her encouragement, understanding and confidence through my entire graduate program. The Grand Rapids study was supported in part by a grant from the Michigan Regional Medical Program, through the efforts of Dr. Robert Nalbandian. secured Also, the subjects in this study were made available by Dr. Nalbandian. The Lansing and University studies were supported by a grant from the Center of Urban Affairs, Michigan State University and the Lansing Demonstration Agency (Model Cities). iv TABLE OF CONTENTS Page LIST OF TABLES........................................... vii LIST OF F I G U R E S ........................................ xi INTRODUCTION............................................ 1 REVIEW OF THE LITERATURE............................... 3 METHODS AND M A T E R I A L S .................................. 26 A. Sampling P r o c e d u r e s ........................... 26 1. Lansing, Michigan.......................... 2. Grand Rapids, M i c h i g a n .................... 3. Michigan State University, East Lansing, M i c h i g a n ................................... 26 29 30 B. Health Survey and Questionnaire .............. 31 C. Laboratory Procedures 32 1. 2. 3. 4. ......................... Solubility T e s t ............................. Hemoglobin Electrophoresis.. .............. D e n s i t o m e t r y .............................. . Alkali Denaturation........................ R E S U L T S ................................................. A. B. C. D. E. F. Prevalence of Hemoglobin Types in Lansing Survey.......................................... Prevalence of Hemoglobin Types in Grand Rapids Survey ................................. Awareness of Sickle Cell A n e m i a ............. General Health................................. Drug, Tobacco and Alcohol Usage ............. Symptoms of Health P r o b l e m s .................. 1. 2. 3. 4. 5. 6. Ophthalmologic and Hearing Problems. . . . I n f e c t i o n s ................................. Symptoms of A n e m i a ........................ Musculoskeletal Symptoms .................. Genitourinary Problems . ............... Cardiovascular and Gastrointestinal P r o b l e m s ................................... 7. Epistaxis................................... 8. Neurologic Symptoms........................ v 32 34 37 37 40 41 41 41 45 49 54 54 54 57 60 60 67 70 70 TABLE OF CONTENTS (continued) Page G. A Single Test of Association ofHealth and Sickle Cell Tra i t .......................... 77 H. Relative Odds R a t i o s .......................... 82 I. Age T r e n d s ..................................... 82 J. Pregnancy His tory............................... 88 K. Use of Oral C o n t r a c e p t i v e s ................... 98 L. Hematological Indices.......................... 100 D I S C U S S I O N .............................................. 102 A. Prevalence of Hemoglobin Types inLansing S u r v e y .......................................... 102 Prevalence of Hemoglobin Types inGrand Rapids Survey................................... 105 C. Awareness of Sickle Cell A n e m i a ............... 106 D. General H e a l t h ................................. 107 E. Drug, Tobacco and Alcohol U s age............... 107 F. Symptoms of Health Problems................... 108 G. Age T r e n d s ..................................... Ill H. Pregnancy History.............................. 112 B. SUMMARY................................................... 114 BIBLIOGRAPHY ............................................ 117 APPENDICES A. Letter of I n t r o d u c t i o n ........................ 124 B. Health Survey and Questionnaire............... 125 C. Questionnaires used in Michigan State University Survey............................... 151 vi LIST OF TABLES Table Page 1 Fatal Cases of Sickle Cell T r a i t ................... 8 2 Sample for Sickle Cell Study - Lansing, Michigan. 28 3 Prevalence of Hemoglobin Types by Age Groups in L a n s i n g ............................................... 42 4 Prevalence of Hemoglobin Types by Age Groups in Grand Rapids...........................................43 5 Percentage of Individuals Aware of Sickle Cell Anemia Among Black Adults Surveyed in Lansing and Grand Rapids...................................... 44 6 Comparison of General Health as Obtained by Questionnaire from Subjects with and without Sickle Cell Trait in Lansing Survey .............. 47 General Health by Genotype (Grand Rapids) . . . . 47 6a 7 7a Comparison of General Health as Obtained by Questionnaire from Subjects with and without Sickle Cell Trait in Grand Rapids Survey............ 48 General Health by Genotype (Grand Rapids) . . . . 48 8 Prevalence of Drug, Tobacco and Alcohol Usage Among Adults in Lansing According to Type of Hemoglobin............................................. 52 9 Prevalence of Drug, Tobacco and Alcohol Usage Among Adults in Grand Rapids According to Type of H e m o g l o b i n ........................................ 53 10 Prevalence of Ophthalmologic and Hearing Problems Among Subjects with and without Sickle Cell Trait in the Lansing S u r v e y ............................... 55 11 Prevalence of Ophthalmologic and Hearing Problems Among Subjects with and without Sickle Cell Trait in the Grand Rapids Survey........................... 56 12 Prevalence of Infections in the Lansing Population According to Type of H e m o g l o b i n .................... 58 13 Prevalence of Infections in the Grand Rapids Population According to Type of Hemoglobin. . . . vii 59 LIST OF TABLES (continued) Page Prevalence of Symptoms of Anemia Among Blacks in Lansing According toType of Hemoglobin. . . Prevalence of Symptoms of Anemia Among Blacks in Grand Rapids According to Type of Hemoglobin 16 17 18 19 61 62 Prevalence of Musculoskeletal Symptoms Among Blacks in Lansing According to Type of Hemoglobin.................................. 63 Prevalence of Musculoskeletal Symptoms Among Blacks in Grand Rapids According to Type of Hemoglobin.................................. 64 Prevalence of Genitourinary Problems Among Blacks in Lansing According to Type of Hemoglobin.................................. 65 Prevalence of Genitourinary Problems Among Blacks in Grand Rapids According to Type of Hemoglobin 66 20 Prevalence of Cardiovascular Problems Among Blacks in Lansing According to Type of Hemoglobin. . . 68 21 Prevalence of Cardiovascular Problems Among Blacks in Grand Rapids According to Type of 69 Hemoglobin.................................... 22 Prevalence of Gastrointestinal Problems in Lansing According to Type of Hemoglobin . . . . 23 24 Prevalence of Gastrointestinal Problems in Grand Rapids According to Type of Hemoglobin. 71 . 72 Prevalence of Epistaxis in Lansing According to Type of Hemoglobin. .................... 73 25 Prevalence of Epistaxis in Grand Rapids According to Type of H e m o g l o b i n ....................... 73 26 Prevalence of Neurologic Symptoms in Lansing According to Type of Hemoglobin............. 74 27 Prevalence of Neurologic Symptoms in Grand Rapids According to Type of H e m o g l o b i n ............ 75 27a Tabulation of Symptoms for the 36 Health Problems Indicating the Group (AS v s . AA) with Lower F r e q u e n c y ..................................... 78 viii LIST OF TABLES (continued) Tables 28 29 30 31 32 33 34 35 36 37 38 39 40 Page A Comparison between Sick and Well Individuals with and without Sickle Cell Trait for Lansing and Grand Rapids Samples........................ 81 Age Specific Relative Odds Ratios for Sickness in Lansing........................................ 83 Age Specific Relative Odds Ratios for Good or ........................ Bad Health in Lansing 83 The Relation between Age and Sickle Cell Trait in the Lansing S a m p l e ........................... 84 The Relation between Age and Sickle Cell Trait in Males, Females and Combined Sample, Lansing (Divided into Four Groups)...................... 86 The Relation between Age and Sickle Cell Trait in the Grand Rapids Study....................... 87 Pregnancy History Obtained by Questionnaire from 630 Females with and without Sickle Cell Trait in the Lansing S u r v e y ........................... 89 Number of Pregnancies Among Females with and without Sickle Cell Trait in Lansing Survey . . 90 Miscarriage and Stillbirth History Among Females with and without Sickle Cell Trait in the Lansing Survey................................... 91 Number of Miscarriages or Stillbirths Obtained by Questionnaires from Females in the Lansing Survey............................ 91 Early Childhood Deaths Reported by Mothers with and without Sickle Cell Trait in Lansing. . . . 93 Pregnancy History Obtained by Questionnaire from 73 Females with and without Sickle Cell Trait in the Grand Rapids S u r v e y ........ ' .............. 94 Number of Pregnancies Among Females with and w i t h ­ out Sickle Cell Trait in Grand R a p i d s ......... 95 ix LIST OF TABLES (continued) Table 41 42 43 44 45 46 47 Page Miscarriage and Stillbirth History Among Females with and without Sickle Cell Trait in Grand Rapids........................................... 96 Numbers of Miscarriages or Stillbirths Obtained by Questionnaire from Females in Grand Rapids . 96 Early Childhood Deaths Reported by Mothers with and without Sickle Cell Trait in Grand Rapids . 97 Prevalence of Use of Oral Contraceptives Among Females with and without Sickle Cell Trait in L a n s i n g .......................................... 98 Prevalence of Use of Oral Contraceptives Among Females with and without Sickle Cell Trait (Grand Rapids)................................... 99 Comparisons of Means and Standard Deviations of Seven Hematological Indices of Female College Students with Normal Hemoglobin and with Sickle Cell T r ait....................................... 101 Comparisons of Means and Standard Deviations of Seven Hematological Indices of Male College Students with Normal Hemoglobin and with Sickle Cell Trait ........................................ 101 x LIST OF FIGURES Figure Page 1 Sampling Scheme for Lansing Survey................ 27 2 Hemoglobin Electrophoresis on Cellulose Acetate: Migratory Pattern at pH 8 . 6 ........... 36 Densitometrie Graph Used for Semi-Quantitation of Hemoglobin T y p e s ................................ 38 Awareness of Sickle Cell Anemia by Educational Level Among Adults in Lansing and Grand Rapids. 46 3 4 . INTRODUCTION Sickle cell trait, the heterozygous state for the abnormal hemoglobin S, is believed to be a benign condition and asymptomatic unless circumstances are exceptional. The scientific literature abounds with case reports of sudden death of individuals, previously healthy, due to sickle cell trait and there are numerous reports of a variety of nonfatal pathologic concomitants. The few population studies concern­ ed with mortality and morbidity of sickle cell trait under nonmalarious conditions have largely been of hospital admissions. Because of truncated studies, neither the evidence for mortality nor morbidity is clear. Findings could indicate either a differential death rate or better health for individuals with sickle cell trait. With respect to morbidity, when the carrier state is as common as sickle cell trait, coincidental associations are to be expected. In many of the early reports of associations, techniques did not allow the clear delineation of sickle cell trait or the exclusion of the sickle cell gene in combination with other abnormal hemoglobins or abnormal quantities of other hemoglobins. With increased public awareness of sickle cell anemia in recent years and the large number of screening programs established, it is important, at least to the black commun­ ity, that the true state of affairs be known. This becomes especially true when one considers genetic counseling of individuals with the trait. This study was designed to 1 gather evidence on the effect of sickle cell trait under nonmalarious conditions. REVIEW OF THE LITERATURE In 1910 Herrick described "Peculiar elongated and sickle-shaped red blood corpuscles in a case of severe anemia" in a Black West Indian student. Many investigators attempted to find the reason for this phenomenon. Emmel (1917) ob ­ served that exclusion of air by the vaseline-sealed cover slip technique resulted in a great increase in the number of sickled cells observed after a short period of time. Huck (1923) "presented evidence that this was a property of the red blood cell itself, inherited by the individual according to the Mendelian Law." Hahn and Gillespie (1927) explained this by showing that sickling would take place only if the hemoglobin within the erythrocytes was in the reduced state. Also, they hypothesized that the only specific cause for active sickle cell anemia was the unique hereditary anomaly of the red corpuscles which predisposed to it. In 1933 Diggs and associates noted that many of the patients who exhibited the sickling phenomenon were asymptomatic while others had a chronic disease beginning in infancy and characterized by chronic anemia, jaundice, leg ulcers, periods of severe abdominal pain, cardiac hypertrophy, hepatomegaly, bone lesions, and decreased longevity. Sherman (1940) attempted to relate the severity of the disease to the sickling tendency. His work supported the theory that sick­ ling is brought about by the lowering of the oxygen tension due to metabolic activity. In 1949 Neel showed that the asymptomatic group was heterozygous for the condition while the symptomatic group was composed of homozygotes. In the 4 same year, Pauling and co-workers published a paper des­ cribing a technique of hemoglobin electrophoresis which identified the abnormal hemoglobin involved and permitted the identification of some other abnormal hemoglobins. This abnormal hemoglobin is called hemoglobin S. It has been established that the sickling phenomenon occurs when hemoglobin S is present in the red blood cells, regardless of the type of hemoglobin present with it. It occurs when hemoglobin S is combined with normal adult hemoglobin (hemoglobin A ) , when combined with other abnormal hemoglobins such as hemoglobin C, or when only hemoglobin S is present. Before the work of Pauling and co-workers, patients were reported who manifested atypical forms of the disease. Usually they were not as ill as those patients who were classified as having sickle cell anemia, nor were they as symptom-free as those patients who were classified as having sickle cell trait. It was not until later that their disease patterns were discovered to be due to combinations of hemo­ globin S with other abnormal hemoglobins. Retrospective studies performed to determine the effects of sickle cell trait on other conditions yielded results which were often contradictory. It is generally agreed that the diagnoses were based on the presence of the sickling phenomenon in vitro in the absence of the classical symptom complex of sickle cell anemia. Obviously, included in this group were individuals with AS hemoglobin as well as those w i t h hemoglobin S in combination with other ab­ normal hemoglobins. Consequently, what was previously considered to be a homogeneous group was, in reality, a heterogenous one. Accurate diagnoses can be made with the use of electro­ phoretic techniques coupled with solubility tests, as well as hemoglobin quantitation and alkali denaturation determinatior for fetal hemoglobin. "Sickle cell trait" denotes the combination of a gene for hemoglobin S with a gene for normal hemoglobin A. "Sickle cell anemia" denotes the homozygous condition of the gene for hemoglobin S. The only difference between hemoglobin A and hemoglobin S is the substitution of the amino acid valine for glutamic acid at the sixth position of the beta chain in the tetrameric hemoglobin molecule (Ingram, 1957). Apparently any red blood cell containing hemoglobin S can undergo bizzare distortion under certain conditions which decrease the solubility of the hemoglobin and thus favor tactoid (crystal) formation. M u r a y a m a 's hypothesis for the mechanism of sickling in Hb S-containing cells is a synthesis of experimental data and theoretical concepts. According to Murayama, in the interior of an intact Hb S red blood cell upon deoxygenation a series of events occur. are displaced laterally. First, the beta S globin chains In the presence of adequate concentrations of a sickling cofactor, hydrophobic bonds are formed between alternate Interacting molecules of Hb S and pairs of cofactor molecules which lead to helical aggregations or m o n o f i l a m e n t s , The monofilaments then aggregate laterally to form six-membered microcables. Eventually, the entire molecular population within the sickled red cell may participate in these reactions ex­ cluding hemoglobin F and stray molecules of methemo­ globin (Murayama, 1971). This process results in the "sickling" phenomenon and in turn favors intravascular clumping. These sickled red blood cells have greater mechanical fragility, liability to hemolysis, and a shortened life span. The major factors which determine if sickling will occur are the proportion of hemoglobin S present in the red blood cell and the oxygen tension of the blood. Leukocyte concentration, bacterial contamination, temperature elevation, decreased pH, potassium ions, increased pCC^, hypothermia and hypotonicity have also been implicated as sickling potentiators Greenberg and Kass, stein, (Sherman, 1954: 1956; Griggs and Harris, 1956; Ruben- 1961; Perillie, 1962). Recognition of the varied clinical manifestations of sickle cell hemoglobin and disorders associated with it has been repeatedly emphasized in the medical literature. Although many clinicians maintain that sickle cell trait is a completely benign condition, there are several reports of cases of mortality which have appeared in the literature due to the complications of sickle cell trait. Moreover, reports of non-fatal complications of sickling in sickle cell trait include bone, joint and abdominal pain, splenic enlarge­ ment, hematuria, neurologic disorders, priapism, splenic, 7 pulmonary and hepatic infarction, retinopathy and other ocular abnormalities, and increased incidence of toxemia and complications during pregnancy, bladder atony and femoral necrosis. A. Fatal Cases of Sickle Cell Trait Among the cases of complications published prior to the use of hemoglobin electrophoresis (approximately 1954), many were described as "sicklemia" or as "sickle cell disease without anemia." Also, several case reports since the estab­ lishment of electrophoresis as the unequivocal diagnosis of sickle cell trait, do not specifically indicate that this technique was used. For this reason, some cases summarized in Table 1 may have been sickle cell-thalassemia, hemoglobin S/C disease, or any one of several other hemoglobinopathies characterized in part by the presence of hemoglobin S. This review reveals forty reports of cases in which it is reported that sickle cell trait was a major factor in death. Even though hemoglobin electrophoresis was not per­ formed in 16 of these cases, genetic and clinical histories as well as autopsy findings were typical of sickle cell trait. It is quite possible that among these 16 cases, other genotypes such as hemoglobin S/C disease or sickle cell thalassemia could have been present. In most cases, evidence that sickle cell trait was responsible for the deaths lies with the exclusion of other obvious causes of death, demonstration of massive generalized sickling and demonstration that appropriate circumstances were present to cause sickling. Table 1 FATAL CASES OF SICKLE CELL TRAIT Finding Relative to Hemoglobin Sickle cell trait Electrophoresis Investigator(s) Age, Race,Sex Other Disease 1. Bauer & Fisher (1943) 24, B M Lobar pneumonia Massive generalized None sickling, splenic infarcts and osteo­ sclerosis 2. Bauer & Fisher (1943) 26, B F Severe back and flank pain and generalized ab­ dominal tenderness Massive generalized sickling and kidney infarcts None 3. Thompson, Wagner & MacLeod (1948) 20, B M Dizziness, right arm pain and convulsions Massive generalized sickling None 4. Diggs & Jones (1952) 48, B F Drug-induced coma Generalized sickling None and hypoxia and focal hemorrhage and focal ischemia necrosis 5. Thoma (1953) 34, B M None Intense vascular congestion with packed sickle cells None Table 1 (Cont'd.) Investigators Age, Race, Sex Other Disease Finding Relative to Hemoglobin Sickle cell trait Electrophoresis 6. Thoma (1953) 55, B M Bronchopneumonia 7. Thoma (1953) 65, B M Lobar pneumonia, Massive generalized None scleral jaundice sickling in all and acute fibri­ organs nous pericarditis 8. Thoma (1953) 8, B F Meningococcemia No specific indication None 9. Thoma (1953) 50, B M Tuberculosis "Full blown histologic sickle cell crisis 11 None A few scattered sickle cells None Perifollicular None hemorrhage and con­ gestion of the spleen and other organs with masses of packed sickle cells * * 10. Thoma (1953) 65, B M Spinal cord in­ jury and pneu­ monia 11. Thoma (1953) 33, B F Acute alcoholism Few congested vessels with some sickle cells and a perifollicular ring of hemorrhage on the spleen None Table 1 (Cont'd.) Investigator(s) Finding Relative to Sickle cell trait Hemoglobin Electrophoresis Age,Race,Sex Other Disease 12. Thoma (1953) 34, B F Pulmonary embolus Scattered sickle cells 13. Adams (1957) 25, B F Coma Massive generalized None sickling and enlarg­ ed spleen, focal hemorrhage and necrosis of liver 14. Ende, Pizzalato & Zaskino (1955) 46, B M Death after a period of con­ fusion and dis­ orientation Extensive sickling None pulmonary and renal infarcts and neuronal satellitosis 15. Tellem, Rubenstone & Frumin (1957) 35, B M Fever, vomiting, diarrhea and uremia Massive generalized None sickling, azotemia, focal erosion of bony trabeculae of vertebrae 16. Tseng (1959) 56, B F Marked dis­ orientation and shock Slightly anemic, .None sickling blood smear enlarged spleen with focal coagulation. Necrosis, focal liver hemorrhages and sickle cells in glomerular capillary tufts None Table 1 (Cont'd.) Investigator(s) Finding Relative to Sickle cell trait Hemoglobin Electrophoresis Age,Race,Sex Other Disease 17. Tseng (1959) 86, B M Projectile vomiting, fever pneumonia and shock Enlarged spleen with Hone infarct, generalized sickling 18. Ober et al. (1960) 15, B M Severe abdominal pain, nausea and vomiting Positive S.C. prep. AS (post mortem) occlusion of right colic artery and intense intravascular sickling 19. McCormick (1961) 2 1/2 mo, B M Pulmonary edema Massive generalized AS sickling 20. McCormick (1961) 8 mo., B M Mild interstitial Massive generalized AS pneumonitis sickling 21. McCormick (1961) 4 mo., B M Mild interstitial Massive generalized AS pneumonitis sickling 22. McCormick (1961) 2, B F Mild diarrhea Massive generalized AS sickling 23. McCormick 32, B F Pulmonary edema, mild Massive generalized AS sickling 24. McCormick 2 mo., B F Whooping cough Massive sickling AS 25. McCormick 82, B F 50% 2°body burns Massive sickling AS Table 1 (Cont'd.) Investigator(s) Age,Race,Sex Finding Relative to Hemoglobin Other Disease_____Sickle cell trait electrophoresis 26. McCormick (1961) 70, B M Post-spinal anesthesia Massive generalized sickling and multiple infarcts AS 27. McCormick (1961) 40, B M Staph, foodpoisoning with shock Massive sickling AS 28. McCormick (1961) 40, B F Anemia and congestive heart failure Massive sickling AS 29. McCormick (1961) 51, B M Bronchial asthma Massive sickling AS with perifollicular hemorrhages in spleen 30. McCormick (1961) 51, B M Alcoholism (0.26^ Generalized massive sickling 31. McCormick (1961) 54, B F Acute and chronic Massive sickling and AS tracheobronchitis,visceral infarcts moderate 32. McCormick (1961) 8 mo., B F Pillow found over Massive sickling head AS 33. McCormick (1961) 2 mo., B F Otitis media and Massive sickling minimal broncho­ pneumonia AS AS Table 1 (Cont'd.) Investigator(s) Finding Relative to Sickle cell trait Hemoglobin electrophoresis Age,Race,Sex Other Disease 34. Mull (1964) 35, B F Rash, sore throat, Vessels filled with AS stiff neck and conglutinations of fever sickled erythrocytes and marked congestion of all viscera 35. Schenck (1964) 12, B M Tonsillectomy, convulsion, confusion and vomiting Thrombi of superior AS longitudinal sinus and many veins emptying into it 36. Jones et al. (1970) 21, B M Shortness of breath, faintness, epistaxis and absence of deep tendon re­ flexes, hypo­ tension Fluid-filled lungs, AS massive sickling 37. Jones et al. (1970) 19, B M Complete unresponsiveness and lower gastrointestinal tract hemorrhage, hypotension Diffuse vascular con-AS gestion in all organs, Small foci of perivascular hemorrhage in brain, 6.1. tract, lungs and spleen 38. Jones et al. (1970) 21, B M Faintness and loss Generalized congestion AS of consciousness and marked coronary atherosclerosis, massive sickling Table 1 (Cont'd.) Investigator(s) Age,Race,Sex Other Disease Finding Relative to Sickle cell trait Hemoglobin electrophoresis 39. Jones et al. (1970) 21, B M Faintness and Generalized congesnumbness of legs; tion of all organs. loss of con­ Massive sickling sciousness (apneic) AS 40. E.B. Smith (1970) 34, B F Epigastric and Gastro-intestinal abdominal pain; infarction nausea; post­ operative compli­ cations of lobar pneumonia and hypertension AS (1) 4> 15 The reviewed cases clearly illustrate that the reported symptoms and organ involvement are as variable in sickle cell trait as in sickle cell anemia. Splenic weights vary markedly from case to case and evidence of prior sickling may be present or absent. The ages ranged from two months to 86 years and sex ratios were not significantly different from 1:1. B. Nonfatal Complications Due to Sickle Cell Trait Usually individuals with sickle cell trait do not demonstrate the sickling phenomenon in their peripheral blood. This requires a reduction in the oxygen tension to the range of 10-15 m m Hg which is inconsistent with life. In contrast, sickling will occur in vovo in individuals with sickle cell anemia w hen the oxygen tension is reduced to only 45-60 m m Hg. At a given partial pressure of oxygen, the amount of hemoglobin S present in a red blood cell influences the degree of sickling. sickled cells present, in turn influences the viscosity of the blood (Greenberg and Kass, 1. The concentration of 1955). Splenic Infarction Between 1950 and 1968 more than 20 cases have appeared in the literature which have reported the asso­ ciation of splenic infarction, plane flight (Sullivan, 1954; Harvey, 1956; Nichols, 1954; sickle cell trait and air­ 1950; Cooley et al., Smith and Conley, 1978). 1954; Conn, 1955; Rotter et a l ., Several of the earlier reports were 16 based on positive sickle cell tests and clinical symptoms and histories. Rotter and co-workers in their discussion of this problem noted that an altitude of 10,000 - 15,000 feet is required to reduce the oxygen tension sufficiently for subjects with sickle cell trait to manifest sickling; moreover, this must be maintained for 10-15 minutes. The modern airplane cabin is pressurized to reflect altitudes of 4,000 - 6,000 feet. Assuming normal splenic circulation, no problem should arise. If, however, aberration in splenic circulation, there is any it is possible that even this slight reduction in oxygen tension might be sufficient to produce splenic infarction (Blank and Freedman, 2. 1969). Hematuria and Hyposthenuria Since Abel and Brown (1948) reported the first case of massive hematuria in sickle cell trait in a 23 year old, previously healthy black soldier, nearly 100 additional cases have appeared in the literature Harrison and Mostofi, et a l . , 1959). reports, (Goodwin et al., 1957; Bruegge and Diggs, 1950; 1957; Myerson In the largest series among the above diagnosis was made on the finding of sickled cells in the kidney sections and review of clinical data. Twenty-one papers on this subject covering 97 patients were reviewed by Lucas and Bullock (1960). They found 80 per cent of the patients were male and that the bleeding came from the left kidney four times as often as from the right. In established cases of sickle cell trait 17 the age of presentation varied from 13 to 46 (mean 28.7). In 37 patients electrophoresis had been performed and 25 were shown to have sickle cell trait. There were three cases of true sickle cell anemia, eight cases of sickle cell hemoglobin-C disease and one case of sickle cell thalassemia. Classification of all 97 patients on clinical grounds showed that 15 had sickle cell anemia and 82 had sickle cell trait. One additional case of massive unilateral hematuria was reported by Bennett and co-workers (1957). These authors include a review of most reported cases of hematuria associated with sickle cell trait. In view of the pathological changes occurring in the renal papillae, Harrow, Sloane, and Liebman (1963) paid close attention to these areas in a radiological study of this condition. In five patients they found definite evidence of renal papillary necrosis in pyelography. The tendency of the massive hematuria of sickle cell trait to originate in the left kidney is striking. et al. Harrow (1963) suggest that the many tributaries of the left renal vein may lead to an elevated venous pressure on that side with resultant stagnation and sickling. There are distinct differences in the pattern of venous drainage between the left and right kidneys, as emphasized by Erlik, Barzilai and Shramek (1965), but the influence of these anatomical differences on the left renal venous pressure is undetermined. 18 Many authors have attributed the massive hematuria in sickle cell trait to a reduction in oxygen tension in the venous limb of the vasa recta with subsequent local­ ized infarction- However, Harrow et al. (1963) put forward the theory that the graded increase in osmolality from the base of the medulla to the tips of the pyramids resulting from the countercurrent mechnaism of urinary concentration accounts for the distribution of the pathological changes at the papillae. Perillie and Epstein (1963) showed that the renal medulla is the only body structure in which osmolality is normally increased to four times the plasma level in both the interstitial and intravascular structures. More­ over, it has been shown that cells from the inner medulla of the kidney are able to gain their energy from anaerobic as well as aerobic processes. These cells are therefore adapted to survival if oxygen tension should become critical (Ullrich, Kramer and Boylan, 1962). Thus, in­ creased osmolality and low oxygen tension, both of which are factors favorable to sickle cell formation, obtain in the renal medulla. This peculiarity in the renal architecture also permits explanation of the finding of hyposthenuria in patients with sickle cell disease, clinically detected by finding a persistently low urine specific gravity even after water deprivation (Schlitt and Keitel, 1960). sickling in the medulla leads to an increase in blood viscosity and a relative decrease in renal medullary The 19 blood flow. There is no significant change in renal cortical blood flow or glomerular filtration rate. The oxygenation of the loop of Henle is decreased and as a result, the metabolic function of its cells is affected. There is a decrease in the ability to reabsorb sodium actively. Hypertonicity of the medullary interstitium results and this, in turn, produces a lowering of the con­ centration of solutes in the final urine (Blank and Freedman, 1969). Miller et al. (1969) described the unusual occur­ rence of massive renal infarction with perirenal hematoma formation secondary to sickle cell trait. Of the 144 cases of sickle cell trait reviewed by McCormick (1961) and Tellem (1957), only four instances of renal infarction were encountered. Bansbach et al. (1960) found four of 16 patients with sickle cell trait to have sensory paralysis of the urinary bladder without evidence of intravesical obstruction. Hypotonia was thought to result from the overdistension secondary to the sensory loss. 3. Other Nonfatal Trait-associated Dysfunctions There are numerous reports in the literature of infarction and abnormal function occurring in other o rga n s . Ende and co-workers (1955) reported two cases of electro- phoretically proven sickle cell trait associated with priapism and one additional case with pain in the occipital region. Rahimtoola (1960) described three cases of pulmonary 20 infarction in West Indian Blacks with hemoglobinopathies. Two of these individuals had sickle cell trait and the third had S-C disease. His findings do not prove that the illnesses from which the patients suffered were a consequence of intravascular sickling, but no other cause for pulmonary infarction in these previously healthy men could be found, and there was collateral evidence of activity of the sickling process. Greer and Schotland (1962) reported the occurrence of neurologic manifestations in 18 per cent of 400 patients with abnormal hemoglobins. 8%; meningeal signs, These included convulsions, 5.75%; cerebral vascular syndromes, 3.75%; impaired visual acuity, acute mental disorders, 3%; radiculopathy, 1%; and vertigo, 0.75%. 1.25%; Among the patients in w hom hemoglobin electrophoresis was performed, the incidence of neurologic abnormalities was hemoglobin SS, 34.8%; hemoglobin SC, 24.2%; and hemoglobin AS, 6.47». There were no fatalities or cerebral vascular syndromes in patients with hemoglobin AS. These authors indicate that in these disorders, only cerebral infarction can be clearly attributed to the ab­ normal hemoglobin and even here the pathogenesis is not always clear. However, there is circumstantial evidence that the other neurologic symptoms were also due to vascular lesions related to the abnormal hemoglobin in most cases. i 21 The case histories of two black men with avascular necorsis of the femoral head were described by Ratcliff and Wolf (1962). bones as well. One patient had avascular necrosis of other The lesions these patients demonstrated were found in areas usually involved in sickle cell anemia, the ends of long b o n e s . Both patients were proven to have sickle cell trait by hemoglobin electrophoresis. Other causes for avascular necrosis could not be incriminated. Konotey-Ahulu (1965) listed 16 well-documented predisposing causes of sickle cell crises. this list is general anesthesia. Included in Konotey-Ahulu (1969) indicates..."Given the appropriate (or rather inappro­ priate) change in the internal environment, persons with the sickle cell trait may, rarely, have splenic or pulmonary infarcts, priapism, hematuria, polyuria, vitreous haemorrhages, and musculoskeletal/arthritic pains and, not so very rarely, may die from general anaesthesia." The ocular findings described in sickle cell trait have included retinitis proliferans, a chrioretinal scar resembling a black sunburst, optic atrophy, papilledema (Welch and Goldberg, 1966), chorioretinitis (Isbey, et. al., 1958), acute open angel glaucoma (Shipiro and Baum, 1964), venous tortuosity (Kennedy and Cope, 1957; Lieb et al., 1959), micoraneurysms, edma, and exudates (Lieb et al., 1959). In addition, there have been three reported cases of central retinal artery occlusion (Welch and Goldberg, 1966; Conrad and Penner, 1967; Kabakow et a l . , 1955). 22 Isbey et al. (1958) reported four cases of vitreous hemorrhage associated with sickle cell trait. Stein and Gay (1970) reported a six-month old patient who sus­ tained a bilateral retinal artery occlusion and extensive vaso-occlusive disease of the choriod with chorioretinal scarring. Adams et al. (1953), Whalley et atl (1963), Jenkins and Clark (I960), Anderson et al. (1960), Petrakis et al. (1970) and others, have reported incidence rates of preg­ nancy patients with sickle cell trait to be approximately the same as found in their general clinic populations. The investigations by Adams and Whalley indicate, in addition, that there is no secondary infertility involved. Most studies indicate that the spontaneous abortion rate in women with sickle cell trait is no higher than that in a control group with similar socioeconomic background and the number of children previously born (Adams et al. 1953; Whalley et a l . , 1963; Abrams, 1959; Beacham and Beacham, 1960 and Petrakis et a l ., 1970). Clark (1962), however, Jenkins and found a much higher incidence among patients with the trait in their series. Similarly, there has been no evidence to indicate an increase in prematurity or stillbirth rates in patients with the trait. With the many reported cases of fatal and nonfatal complications associated with sickle cell trait, evidence 23 strongly supports the belief that it is not a totally benign condition. According to Konetey-Ahulu (1969), "while the difference in hemoglobinopathy, between normal homozygotes and persons with sickle cell trait is qualitative, that between persons with sickle cell trait and those with sickle cell anemia is quantitative; so that the same conditions which would cause crises in patients with sickle cell anemia could, if pushed to a further unphysiological degree, also cause in-vivo sickling in persons with sickle cell trait." That this is true is illustrated by the protean symptoms and problems and organ involvement in these cases with the trait as is seen in those individuals with sickle cell anemia. These reviewed cases strongly suggest that acute intravascular sickling in persons with sickle cell trait may constitute a serious threat to life, since the sickling crisis may be precipitated by mild illness or physiologic stress in an otherwise healthy person. Hyposthenuria, an increased tendency to hematuria, and renal infarction appear to be firmly established asso­ ciations with sickle cell trait. The same is true of an in­ creased frequency of splenic and pulmonary infarction, especially under conditions of low oxygen tension. The increased incidence of pylelonephritis and urinary tract infection reported to occur in women with sickle cell trait (Whalley et a l . , 1964) may be explained on the basis of susceptibility of a' damaged kidney to infection (Neel, 1973). 24 The other reports of complications in sickle cell trait, though plausible, do not yet have the status of the fore­ going . Despite the many case reports, the question of whether sickle cell trait shortens the average life span has not been satisfactorily answered. In some of the reports in which death was attributed to the trait, other causes have not been excluded. In the present state of knowledge, the clinical significance of this genetic abnormality remains confused. If .001 of all cases had some rare effect (e.g. priapism) not otherwise seen in people, case reports would be a good source of information and a survey would be entirely useless. All of the foregoing reports provide one kind of evidence for a plausible deleterious effect of sickle cell trait. Another kind of evidence consists of data that raise the possiblilty that sickle cell trait is less frequent in older individuals, presumably on the basis of individual mortality. With respect to mortality, Neel (1973) has summarized all of the pertinent data to date. The summarization confines its attention to data from temperate climates to avoid the effects of positive selection for the trait by malaria. Three early series from the United States, summarized in 1951 (Neel), all showed a lower frequency of sickling in older Individuals. Of five series reported since then (Rucknagel and N e e l , 1961; Pollitzer, 1958; 25 McCormick and Kashgarian, 1965; Heller, 1968; Petrakis et al., 1970) three show less sickling in older persons (McCormick and Kashgarian, Heller and Petrakis et al.). The age trend is not clearly significant in any of these series. Neel (1973) points out that the series are sufficiently heterogeneous that it seems unwise to attempt to combine them. Most of the series have been assembled from hospital populations and could therefore indicate either a differential death rate or better health for persons with sickle cell trait. A random sampling of a large population of "at risk" individuals would give a more reliable indication of age trends. METHODS AND MATERIALS The purpose of this study was to detect the presence of the sickle cell gene in the black population of several metropolitan areas in Michigan and to gather information to ascertain possible deleterious effects of this gene in single dose on health and welfare (morbidity and m ortality). Three surveys were conducted. A. Sampling Procedures 1. Lansing Michigan A random sampling technique was used in this p op­ ulation. Demographic data were obtained from Tri-County Regional Planning Commission in Lan s i n g , Mic h i g a n . These data were part of the 1970 census collection including the greater Lansing community. The sample was a cluster sample with unequal cluster sizes within two strata. The strata were defined by the amount of clustering of the black population. Stratum one contained all the black population which clustered in groups of one hundred or more persons per block group. Stratum two contained all the black population which clustered in groups of two to ninety-nine persons per block group. Eighty per cent of the sample was drawn from the first stratum and twenty per cent from the second stratum (see Figure 1). The total sample as selected included approximately 3,000 persons (see Table 2). 26 27 Total Black Population Lansing 12,234 9,858 (80.5%) who live in clusters of 100 or more per Block Group 2,376 (19.5%) who live in clusters of 2 - 9 9 per Block Group Cluster sample 13 Blocks spf persons 2,326 persons; TOTAL SAMPLE Figure 1. /Cluster I sample 32 Blocks \^f persons 1,147 persons 3,473 Black Persons 45 Blocks Sampling Scheme for Lansing Survey Table 2 SAMPLE FOR SICKLE CELL STUDY - Lansing, Michigan Census Tract Block Sampled Number Black 1. 1 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 3 4 5 6 8 11 11 12 12 12 13 15 15 15 15 15 15 15 15 15 16 16 116 404 306 302 303 404 101 404 304 404 408 314 203 204 206 304 307 401 402 404 405 103 104 10 10 23 116 23 69 155 4 16 5 13 8 162 143 93 77 177 246 123 164 176 18 37 Cumulative No. Black 10 20 43 159 182 251 406 410 426 431 444 452 614 757 850 927 1,104 1,350 1,473 1,637 1,813 1,831 1,868 Census Tract 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 16 16 16 18 18 18 18 18 18 18 18 19 20 21 21 27 30 36.02 36.02 37 15 15 Block Sampled Number Black Cumulative No. Black 111 115 216 303 308 402 403 404 407 413 414 112 316 109 306 403 114 209 213 204 403 407 36 14 57 173 98 78 85 80 81 41 13 2 47 59 9 7 17 12 291 5 233 167 1,904 1,918 1,975 2,148 2,246 2,324 2,409 2,489 2,570 2,611 2,624 2,626 2,673 2,732 2,741 2,746 2,765 2,777 3,068 3,073 3,306 3,473 29 After each block was identified, a physical survey was made and a letter of introduction was sent to each household. (Copy in Appendix A ) . Shortly thereafter, an interviewer was sent to each household to inform the family about sickle cell anemia and sickle cell trait and to complete a demographic and medical questionnaire with the family or individual. When the questionnaire was completed an appointment was made with the family for the collection of blood specimens for hemoglobinopathy detection. 2. Grand Rapids, Michigan Dithionite tests for sickling had previously been made on 5,192 students enrolled in several public and paro­ chial schools in the Grand Rapids community by Dr. Robert Nalbandian and his staff at Blodgett Memorial Hospital. these students, 309 Of (5.95 per cent) were found to have sickle cell trait and one had sickle cell anemia. Demographic information on those students with positive dithionite tests was given to this investigator for the primary purpose of performing more definitive tests and for genetic counseling. The parents of the 309 propositi were informed and the entire family was invited to come to the Franklin Hall Complex, one of several neighborhood health clinics, for testing and genetic counseling. The adminis­ trator of Franklin Hall Complex assisted in contacting the families and making appointments for the interview and collection of blood specimens. When families reported, the 30 health information questionnaire was administered and each family member, including the propositus, received a blood test. 3. Michigan State University, East Lansing, Michigan The names and addresses of all known black students enrolled at Michigan State University during the Spring term, 1971, were obtained and letters were sent to each, inviting them to Olin Health Center to be tested for sickle cell anemia, trait and other hemoglobinopathies. All of the predominantly black sororities and fraternities were contacted, informed and invited to be tested, and announcements were made in the State News, the student daily newspaper. In addition, teams of authorized and certificated personnel were organ­ ized to visit dormitory complexes where black students were housed and additional invitations and information were made available to black students. Black students were further identified through black aids in each dormitory. The testing was begun on April 11, 1971 and continued until June 12, 1971. In the Michigan State University sample, 40 students tested at Olin Health Center whose blood specimens showed positive turbidity tests, plus 40 selected controls, were tested for additional hematological i n d i c e s , including hemo­ globin levels, hematocrits, mean corpuscular volume, m ean corpuscular hemoglobin, mean corpuscular hemoglobin con­ centration, red blood cell count and total protein. The purpose of these tests was to collect additional data for 31 comparisons between those individuals with sickle cell trait and normal controls. B. Health Survey and Questionnaire A common health questionnaire was administered by trained interviewers to respondents in the Lansing and Grand Rapids surveys. General objectives, instructions and interviewer responsibilities and behavior in the collection of information, as well as the questionnaire are included in Appendix B. In each instance the interview was completed before the blood test for diagnosis of hemoglobin type was made. With the exception of basic demographic information, most of the questions pertaining to health were related to those problems of symptoms frequently observed or reported in individuals with hemoglobinopathies. Many of htese questions had to be phrased to assure understanding by the respondents. For example, hyposthenuria is a commonly reported abnormality in sickle cell disease. In questioning, the respondent was asked if he had observed an increased urine flow. In most instances during the interview, one adult respondent answered questions pertaining to minors in the household and for other adults not present at that time. In the Lansing survey, if the respondent was not know­ ledgeable enough of the information pertaining to others in the household, the interviewer made arrangements to return at a time when the absent person would be at home. 32 In Grand Rapids, those questions which could not be answered for an absent member of the family were ascertained when the respondent or the absent family member returned to the clinic for their results and for counseling. The brief questionnaire used in the Michigan State University survey was self-administered. completed immediately prior to testing, C. Laboratory Procedures 1. Solubility Test This form was (see Appendix C ) . All blood specimens were tested for solubility of their hemoglobins by a method commonly used in screening procedures. The basic principle of this procedure included the placement of whole blood in a buffer, lysing of the red blood cells, and the deoxygenation of the hemoglobins with a reducing agent, merize, causing any sickling hemoglobin to poly­ thus becoming insoluble in the buffer. specimens containing sickling hemoglobins Those (S, C Harlem, Barts, and I) would appear cloudy when compared to the non-sickling varieties and could thus be qualitatively identified. a. Sickletest reagent: sodium phosphate buffer, This reagent contains 2.5 M 0.15 M sodium dithionite (reducing agent), and 3 per cent saponin (erythrolytic compound). prepare the reagent, To 165.6 grams of monobasic sodium phosphate and 156.2 grams of dibasic sodium phosphate were weighed. These two compounds were dissolved in 500 ml of water in a liter flask. Twenty-six and two-tenths grams of sodium dithionite 33 and 30 grams of saponin were added and the solution brought to the one liter mark with distilled water. Two ml of sickletest reagent was pipetted into a 12 x 75 m m test tube. To this was added 20 microliters of well mixed whole blood collected in ethylenediaminetetraacetic acid (EDTA). This was mixed by inverting the tube and allowed to sit at room temperature for 3 minutes. After three minutes the tube was held approximately three centimeters from a typewritten page. A positive test was represented by a turbid solution (print behind the tube was not visible). represented by a clear, b. A negative test was transparent solution. Sickletest-Urea reagent: This reagent contains 2.0 M urea in the sickletest reagent. To prepare the reagent, 120.1 grams of urea was placed in a liter flask and sickle­ test reagent added to equal one liter. Two ml of the sickle- test-urea solution was pipetted into a 12 x 75 m m test tube and 20 microliters of whole blood from a positive specimen was added, mixed and allowed to stand at room temperature for three minutes. If the sickletest-urea solution was transparent (print visible), but the same specimen gave a positive sickletest reaction, the hemoglobin present was presumed to be either hemoglobin S or hemoglobin C (Harlem). If the sickletest-urea solution remained turbid and the sickletest reaction was positive, the presence of a non-S sickling hemoglobin was indicated - e .g., hemoglobin C (Georgetown), Bart's, or perhaps Alexandra. For structural reasons, hemoglobin I (also a non-S sickling hemoglobin) 34 would be expected to be negative. The theoretical explanation for those specimens that were turbid in the sickletest reagent, but transparent in the sickletest-urea reagent, was interference of urea with the hydrophobic bonds formed within the interlocking tetramers of the sickled hemoglobin S. Once the bonds are broken the microfilaments break down and the solution mimics those of the normal hemoglobins in the first reagent. 2. Hemoglobin Electrophoresis All blood specimens were subjected to hemoglobin electrophoresis, regardless of solubility test results. Five to 10 ml of blood were collected in EDTA and refrigerated at 4° C until used, usually within 24 hours. The blood was then centrifuged at 2,OOOX g for 15 minutes and the plasma removed. The packed red blood cells were then washed three times with 0.85 per cent saline solution to remove serum proteins. After the final wash 0.2 ml of the packed red blood cells was pipetted into a small test tube and lysed by adding six parts hemolysate reagent, a commercial preparation, (V:V). The hemolysate was then applied to a cellulose acetate plate that had been soaked in buffer for 15 m i n u t e s , along with a control, another hemolysate containing a variety of known hemoglobin types. It was then electrophoresed in Supre Heme buffer, pH 8.6, at 1.5 milliamperes per strip. Each strip was then stained for 10 minutes in Ponseau S, a protein stain, washed (de-stained) twice in five per cent 35 glacial acetic acid for two minutes each, methanol for two minutes each, acid: methanol dehydrated in cleared in glacial acetic (1:3) for two minutes and air dried. Movement through cellulose acetate depends on the nature of the charged particle, the character of the buffer, and the intensity of the electric field. amphoteric, As protein is it may be charged either positively or negatively, depending upon the p H of the buffer used. Since positively charged proteins usually exhibit greater absorption, negative charges (with less absorption) are usually induced w i t h an alkaline buffer. With respect to hemoglobin S, the charge difference results from the shift from the negative glutamic acid to the neutral valine. When hemoglobin S is placed in the alkaline buffer w ith hemoglobin A, the two migrate from the cathode to the anode with hemoglobin A moving faster. As molecular weight and shape have negligible effects, hemoglobins align in an order of (A£, C, E, 0): the (D, S ) ; (G, F ) ; and A^ from cathode to anode, relative to each other's charge difference Voltage, of the proteins. (Figure 2). or potential difference is the driving force Yet, as voltage is increased or prolonged, amperage and heat also increase. leading to greater mobility, the proteins, Higher temperature, although leads also to denaturation of evaporation of the buffer, and subsequent shifting of the ionic strength as the salts become concentrated. FIGURE 2 Hemoglobin Electrophoresis on Cellulose Acetate Migratory Pattern at pH 8.6 37 Lower ionic strength is usually desired in increasing the velocity of the movement of protein. Evaporation is kept to a minimum to maintain a constant ionic strength and to minimize free diffusion. 3. Densitometry After the strips were dried and a diagnosis made, densitometrie readings were made to determine the relative percentages of the various hemoglobins present in each blood specimen. used. A Densicord Photovolt, Model 542 was This machine operates on the principle of a photo­ electric cell which measures relative intensities of light. The strip was passed over a light source at a uniform rate and its translucence was plotted on a graph (Figure 3). In calculating percentages, lines were dropped from the low points of the graph (the points at which one hemoglobin stops and another starts) and the area under each curve was calculated from the integrated markings below. The low point between carbonic anhydrase and hemoglobin A£ was considered ground zero. Thus the integrated areas were counted (the area below ground zero and the full light setting being subtracted from the integration), added, and the percentage of each hemoglobin calculated. 4. Alkali Denaturation Aliquots of the hemolysates of those specimens that revealed fetal hemoglobin on the electrophoregrams were subjected to alkali denaturation to determine the percentage 38 FIGURE 3. An Example of a Densitometric Graph Used for Semi-Quantitation of Hemoglobin Types of fetal hemoglobin. Singer was used. The one minute denaturation test of In this method potassium hydroxide is added to a solution containing a known amount of hemoglobin and exactly one minute later denaturation is stopped by adding half-saturated ammonium sulfate. The ammonium sulfate lowers the pH and precipitates the denatured hemo­ globin. After filtration, the amount of unaltered hemoglobin is measured and expressed as the per cent of alkali-resistant (fetal) hemoglobin. RESULTS In Lansing, the sample contained 3,473 individuals, based on the 1970 census data. Of this number, 2,026 individuals representing 538 families were actually inter­ viewed. There were several instances of household refusals, but primarily as a result of an urban renewal project and extensive demolition of houses and relocation of families subsequent to the 1970 census taking, large numbers of houses were no longer in existence or were unoccupied. This was especially evident in those blocks where blacks were numbered 100 or more. Of the 533 families interviewed, 48 were infants too young for definitive laboratory diagnosis (due to the large percentage of fetal hemoglobin); 56 non-infants refused to allow blood to be drawn for testing and 62 could not be contacted even after numerous visits to the home and several written invitations to visit a nearby clinic for the purpose of having blood drawn for testing. Complete data, consisting of an interview and blood test, were obtained on 1,860 individuals in the Lansing sample frame. In the Grand Rapids survey, health data were obtained on 769 individuals; blood specimens and complete health data were secured from 643 persons, representing 145 families. The only data included here concerning the 1,012 students tested in the Michigan State University survey are those comparing hematological indices between 31 students with sickle cell trait and 36 selected controls with normal hemoglobin. 40 41 A. Prevalence of Hemoglobin Types in Lansing Survey Table 3 shows the prevalence of hemoglobin genotypes in the Lansing population. Of the 1,860 individuals tested, 1,642 (88.3 per cent) had only normal adult hemoglobin (AA); 152 (8.2 per cent) had sickle cell trait (AS), 45 (2.4 per cent) had hemoglobin C trait (AC); 9 (.43 per cent) were thalassemia heterozygotes (thalassemia m i n o r ) ; one child was homozygous for hemoglobin C disease (CC), and three (.16 per cent) had sickle cell anemia B. (SS). Prevalence of Hemoglobin Types in Grand Rapids Survey The proportions of genotypes in the Grand Rapids study are different from those in the Lansing group. to the difference in method of ascertainment. Rapids study 330 individuals hemoglobin; This is due In the -Grand (51.3 per cent) had normal adult 306 (47.6 per cent) had sickle cell trait; (.47 per cent) were carriers of hemoglobin C disease; three two (.31 per cent) were found to have sickle cell hemoglobin C disease and two (.31 per cent) had sickle cell anemia (see Table 4). C. Awareness of Sickle Cell Anemia Of the 1,097 adults (18 years of age or older) who were interviewed in the two cities, 437 (39.8 per cent) had never before heard of sickle cell anemia; 329 (38.3 per cent) in the Lansing sample and 130 (45.4 per cent) in Grand Rapids. As expected, the more elderly individuals were least aware of sickle cell anemia (see Table 5). The difference in 42 Table 3 PREVALENCE OF HEMOGLOBIN TYPES BY AGE GROUPS IN LANSING Age Group Number AA AS AC CC SS A/F Thai, minor 0 - 4 234 200 15 7 1 1 1 0 5 - 8 249 225 13 9 0 1 1 0 9-12 221 198 16 6 0 0 1 0 13 - 17 258 221 30 4 0 0 2 1 18 - 25 292 258 27 4 0 0 1 2 26 - 35 214 184 17 10 0 1 2 0 36 - 45 169 148 17 2 0 0 0 2 46 - 55 98 89 6 0 0 0 1 2 56 - 65 76 67 6 3 0 0 0 0 66 + 49 43 5 0 0 0 0 1 1,860 1,642 152 45 1 3 9 8 Total (All ages) 43 Table 4 PREVALENCE OF HEMOGLOBIN TYPES BY AGE GROUPS IN GRAND RAPIDS Number AA AS AC SC SS 0 - 4 67 48 19 0 0 0 5 - 8 111 40 71 0 0 0 9-12 141 63 75 2 1 0 13 - 17 112 61 50 0 1 0 18 - 25 48 29 18 0 0 1 26 - 35 74 34 39 0 0 1 36 - 45 61 37 24 0 0 0 46 - 55 24 15 9 0 0 0 56 - 65 0 0 0 0 0 0 66 + 5 3 1 1 0 0 642 330 306 3 2 2 Age Group Total (All ages) 44 Table 5 PERCENTAGE OF INDIVIDUALS AWARE OF SICKLE CELL ANEMIA AMONG BLACK ADULTS SURVEYED IN LANSING AND GRAND RAPIDS Lansing Age Group (Years) 18 26 36 46 55 66 + 25 35 45 55 65 Total (All Ages) N Grand Rapids Combined No. Per Cent No. Per Cent No. Per Cent 153 150 115 64 35 13 60.9 68. 2 68.9 61.5 46.0 61.7 26 36 43 21 2 2 56.5 43.4 63.2 67. 7 50.0 33.3 179 186 158 85 37 15 60.3 61.4 67. 2 63.0 46.2 31.9 530 61. 7 130 54.6 660 60.2 859 238 1,097 45 awareness in the two populations was not statistically significant (Chi square = .3895, d.f. = 1). Those adults who indicated that they had heard of sickle cell anemia before were asked, by this group, "Before being contacted did you know that sickle cell anemia is an inherited kind of anemia and is passed from parent to offspring?" Eighty-one per cent (430 of 530) in the Lansing group and 99 of 130 (76 per cent) in the Grand Rapids group answered in the affirmative. An analysis of awareness of sickle cell anemia by educational level (Figure 4) revealed in the combined survey (Lansing and Grand Rapids) that those adults who had previously heard of sickle cell anemia were 61 of 164 (37.2 per cent) who had completed eight years or less of school, 168 of 352 (47.7 per cent) who had completed 9 to 11 years of school, 226 of 369 (61.2 per cent) who had completed 12 years of school and 127 of 174 (73 per cent) of those who had at least one year of college. D. General Health Respondents to the health survey were asked to describe their general health as excellent, good, fair or poor. In the Lansing survey (see Table 6) 1,331 of 1,603 individuals (83 per cent) with normal hemoglobin described their health as excellent or good and 272 (17 per cent) considered their general health as fair or poor. diagnosed as sickle cell trait, Among those individuals 116 of 152 (76.3 per cent) were in excellent or good health and the remainder, 23.6 per cent, thought their health was fair or poor. 46 80 70 Per Cent "Yes" Response 60 50 40 30 20 10 0-8 yrs. 9-11 yrs. 12 yrs. College Educational Level FIGURE 4. Awareness of Sickle Cell Anemia by Educational Level Among Adults with and without Sickle Cell Trait in Lansing and Grand Rapids Table 6 COMPARISON OF GENERAL HEALTH AS OBTAINED BY QUESTIONNAIRE FROM SUBJECTS WITH AND WITHOUT SICKLE CELL TRAIT IN LANSING SURVEY Sickle Cell Trait (AS) Excellent or Good Fair or Poor Age Group (Years) Normal Hemoglobin (AA) Total AS Excellent or Good Fair or Poor Per No. Cent Total AA No. Per Cent 0-12 39 8 47 30.9 562 59 621 38.7 13 - 25 46 9 55 36.2 421 53 474 29.6 26 - 45 24 10 34 22.4 242 82 324 20.2 46 - 65 6 6 12 7.9 88 63 151 9.4 66 + 1 3 4 2.6 18 15 33 2.1 116 36 152 100.0 1,331 272 Total Table 6a General Health by Genotype (Lansing) Ex. - Good Fair - Poor AS 116 36 AA 1,331 272 Chi square = 4.33, d.f. = 1 1,603 100.0 Table 7 COMPARISON OF GENERAL HEALTH AS OBTAINED- BY QUESTIONNAIRE FROM SUBJECTS WITH AND WITHOUT SICKLE CELL TRAIT IN GRAND RAPIDS SURVEY Sickle Cell Trait (AS) Excellent or Good Fair or Poor Age Group (Years) Normal Hemoglobin (AA) Total AS Excellent or • Good Fair or Poor Per No. Cent Total AA No. Per Cent 0 - 12 147 18 165 54.1 135 15 150 45.7 13 - 25 58 9 67 22.0 79 10 89 27.1 26 - 45 48 15 63 20.6 55 16 71 21.7 46 - 65 6 3 9 3.0 2 15 4.6 66 + 1 0 1 0.3 13 2 1 3 0.9 260 45 305 100.0 284 44 328 100.0 Total (All Ages) Table 7a General Health by Genotype (Grand Rapids) AS AA Ex. - Good 2b0 284 Fair - Poor 55 44 Chi Square = 0.234, d.f. = 1 49 Chi square analysis (see Table 6a) reveals that the difference in general health among all individuals with trait, as compared with all normals, five per cent level. is significant at the This indicates that those respondents with sickle cell trait do not consider themselves in as good a state of health as those with normal hemoglobin (AA) . In the -Grand Rapids survey the responses to general state of health were proportionately the same among those persons with and without the trait in all five age groups (see Table 7). sickle cell Eighty-five per cent of all respondents with trait had excellent or good health, 87 per cent of all normals. compared to Chi square analysis with one degree of freedom (see Table 7a) indicates no significant difference between the two groups. The proportions of normals in excellent or good health and in fair or poor health are similar in all age groups. E. Drug, Tobacco and Alcohol Usage The prevalences of the use of patent medicines, pre­ scription drugs, tranquilizers, alcohol and cigarettes on most days or everyday among adults (18 years of age or older) are shown in Table 8 for Lansing and Table 9 for Grand Rapids. Patent medicines are used on a daily basis by 43 of 463 (9 per cent) adult females with normal hemoglobin and four of 45 (9 per cent) with trait in Lansing. Comparable rates among males were 9 per cent of those without the trait and 6 per cent of those with the trait. When the data for both sexes are pooled and tested for association between all t 50 normal adults and all adults with the trait, the difference is not significant at the five per cent level. Drugs prescribed by the doctor were used daily by 20 per cent of those adults with normal hemoglobin and by 13 per cent of those with sickle cell trait. Chi square analysis reveals no significant difference at the five per cent l e v e l . Nearly 11 per cent of the normal control adults in Lansing consume alcoholic beverages on a daily basis, com­ pared with 20 per cent of those with trait. by Chi square analysis, The difference, is significant at the five per cent level (Chi square = 4.7, d.f. « 1, p. = .03). This difference is reflected in both sexes. The prevalence of the use of tranquilizers regularly is small in both sexes both among trait and normal adults. Only one of 33 males and two of 45 females w i t h trait use tranquilizers regularly. controls are similar. The percentages among the normal F i s h e r ’s exact test of association gives a probability value of 85 per cent. Cigarette smoking in the Lanising sample is not significantly different between trait and normal adults. Forty-three per cent of normals and 53 per cent of trait adults smoke regularly, but the difference is not statistically significant at the five per cent level. The prevalence of patent medicines usage in the Grand Rapids survey was very small among male and female adults and among those with and without sickle cell trait; 51 two (1.7 per cent) normals and four (4.4 per cent) of those with the trait. Fisher's exact test gives a probability value greater than 45 per cent. Fourteen per cent of the controls in the Grand Rapids survey use prescription drugs daily, compared with 18 per cent of the heterozygotes. groups The difference between the two is not significant at the five per cent level. None of the adult females in Grand Rapids admitted to regular consumption of alcoholic beverages. A l s o , only two of 41 male controls and two of 26 males with the trait indicated daily consumption. It is difficult to explain these results, especially when compared to the findings in Lansing. The differences are probably not due to the interviewing technique, as the two most reliable interviewers, who conducted nearly 100 per cent of the Grand Rapids interviews, also administered a relatively large proportion of the Interviews in Lansing. The prevalence of the Rapids was also small. use of tranquilizers in Grand Only two per cent of adult controls and four per cent of trait persons use tranquilizers regularly. The prevalence of cigarette smoking on a regular basis was not significantly different when comparisons were made between adult controls and heterozygotes. Forty-eight per cent of the controls and 43 per cent of heterozygotes smoke cigarettes regularly. No attempt was made to determine the number consumed per day. Table 8 PREVALENCE OF DRUG, TOBACCO AND ALCOHOL USAGE AMONG ADULTS IN LANSING ACCORDING TO TYPE OF HEMOGLOBIN ___________ Patent Medicines___________________ Prescription Drugs_____ Tested Females Males Total AA "Yes11 Response Per No. Cent AS "Yes11 Response Per No. Cent Tested Tested AA rlYei11 Response Per No. Cent Tested AS "Yes11 Response Per No. Cent 45 33 4 2 8.9 6.1 463 323 Ill 42 24.0 45 7 15.6 29 9.3 9.0 13.0 33 3 9.1 72 9.2 78 6 7,7 786 153 19.5 78 10 12.8 463 323 43 786 Tranquilizers Alcoholic Beverages Females 463 32 6.9 43 7 16.3 463 28 6.0 45 2 4.4 Males 323 52 16.1 33 8 24.2 323 13 4.0 33 1 3.0 786 84 10.7 76 15 19.7 786 41 5.2 78 3 3.8 Total __________Cigarette Smoking_________ Females 463 173 37.4 45 Males 323 168 52.0 33 786 341 Total 43.4 78 - 22 48.9 19 57.6 41 52.6 Table 9 PREVALENCE OF DRUG, TOBACCO AND ALCOHOL USAGE AMONG ADULTS IN GRAND RAPIDS ACCORDING TO TYPE OF HEMOGLOBIN Patent Medicines AA Prescription Drugs AS "Yes” Response Per Test­ ed No. Cent "Yes" Response Test­ Per ed No. Cent AA AS "Yes" Response Per Test­ No. Cent ed Tested "Yes" Response Per No. Cent Females 76 2 2.6 65 3 4.6 76 14 18.4 65 15 23.1 Males 41 0 0 26 1 3.8 41 2 4.8 26 1 3.8 117 2 1.7 91 4 4.4 117 16 13.7 91 16 17.6 Total Alcoholic Beverages_____________________ Tranquilizers Females 76 0 0 65 0 0 76 2 2.6 65 4 6.2 Males 41 2 4.8 26 2 7.7 41 0 0 26 0 0 117 2 1.7 91 2 2.2 117 2 1.7 91 4 4.4 Total Cigarette Smoking Females 76 32 42.1 65 25 38.5 Males 41 24 58.5 26 14 53.8 117 56 47.9 91 39 42.9 Total 54 F. Symptoms of Health Problems 1. Ophthalmologic and Hearing Problems Among the respondents in the Lansing survey, 20 per cent of trait persons and 22 per cent of normals use glasses or contact lenses regularly (see Table 10). difference is not statistically significant. There were no children under 9 years of age that use glasses. bution among other ages were roughly the same, The The distri­ except that no trait males between the ages of 26 and 55 use glasses or contact lenses. Only 11 of 1,636 "normals" in the Lansing survey re­ ported that they used a hearing aid and none of the 152 trait persons used hearing aid devices. In Grand Rapids, as shown in Table 11, 16 per cent of "normals" and 15 per cent of trait persons wear glasses or contact lenses regularly. Also, The difference is not significant. in Grand Rapids, no "normals" use hearing aids and only three persons w i t h trait use them. Two of these were females between the ages of 46 and 55 years and the third person was another female between 13 and 17 years of age. 2. Infections The prevalence of influenza, sore throat, colds, ulcers and earaches are shown in Tables 12 and 13. Lansing sample, In the 284 (17.4 per cent) of 1,636 persons w ith normal hemoglobin had at least one attack of influenza as compared wi t h 17 (11.2 per cent) of 152 persons with sickle cell trait. In Grand Rapids, 44 of 329 controls (13.4 per cent) and 50 of 306 individuals w i t h trait (16.3 per cent) had en ­ countered at least one episode of influenza in the past year. Table 10 PREVALENCE OF OPHTHALMOLOGIC AND HEARING PROBLEMS AMONG SUBJECTS WITH AND WITHOUT SICKLE CELL TRAIT IN THE LANSING SURVEY Use of Glasses or Contact Lenses AA AS AA AS "Yes" Response "Yes" Response "Yes" Response "Yes" Response Test­ ed No. Per Cent Test­ ed Female 894 227 25.4 Male 742 130 1,636 357 Total Use of Hearing Aid Per Cent No. Per Cent Test­ ed No. Per TestNo. Cent ed 77 22 28.6 894 6 0.7 77 0 0 17.5 75 8 10.6 742 5 0.7 75 0 0 21.8 152 30 0.7 152 0 0 19.7 1,636 11 Table 11 PREVALENCE OF OPHTHALMOLOGIC AND HEARING PROBLEMS AMONG SUBJECTS WITH AND WITHOUT SICKLE CELL TRAIT IN THE GRAND RAPIDS SURVEY Use of Glasses or Contact Lenses___________Use of Hearing Aid_____ ________AA__________________AS_________________ AA____________ AS "Yes" Response Tested Female Male Total "Yes" Response No. Per Cent Tested 196 42 21.4 133 11 329 53 "Yes" Response "Yes" Response No. Per Cent Tested 174 35 20.1 196 0 0 174 3 1.7 8.3 132 11 8.3 133 0 0 132 0 0 16.1 306 46 15.0 329 0 0 306 3 1.98 No. Per TestPer Cent ed No. Cent 57 These differences were not statistically significant at the five per cent level. It is interesting to note that the large majorit] of reported cases of influenza had been diagnosed by physicians as opposed to self-diagnosis. This was ascertained by asking if a doctor had been seen if an affirmative answer was given to the question pertaining to presence or absence of the symptoms. In the Lansing population, a significantly larger proportion of controls had a throat infection in the past year than among those with the trait (28.7 per cent controls to 19.1 per cent traits). However, in the Grand Rapids pop­ ulation roughly the same proportion of normal and trait persons had throat infections (27.7 per cent normals to 25.8 per cent traits). In both populations the prevalence of ulcers and earaches was small and not statistically different. Sixty-five per cent of the controls (1,068 of 1,636 respondents) in Lansing had at least one cold in the past year as compared with 58.5 per cent (89 of 152) of the traits. The difference was not significant at the five per cent level. In Grand Rapids the difference between those with and without the trait with at least one cold was not statistically significant at the five per cent level. Sixty-three per cent of normals and 64 per cent of traits had at least one cold in the past year. 3. Symptoms of Anemia Prevalences of affirmative responses to symptoms of anemia, such as easy fatigue, sense of exhaustion, and dizziness are shown in Tables 14 and 15. faintness There were no Table 12 PREVALENCE OF INFECTIONS IN THE LANSING POPULATION ACCORDING TO TYPE OF HEMOGLOBIN Influenza Sore Throat AA AS AA Test­ ed ''Yes'' Response Per No. Cent "Yes" Response Test­ Per Test­ ed No. Cent ed "Yes" Response Per No. Cent Female 894 176 19.7 77 10 13.0 894 292 32.7 77 19 24.7 Male 742 108 14.5 75 7 9.3 742 178 24.0 75 10 12.3 Total 1,636 284 17.4 152 17 470 28.7 152 29 19.1 11.2 1,636 AS Test­ ed "Yes" Response Per No. Cent Earaches Ulcers Female 894 27 3.0 77 1 1.3 894 77 3.6 77 5 6.5 Male 742 23 3.1 75 0 0 742 56 7.5 5 6.7 Total 1,636 50 3.0 152 1 133 8.1 75 152 10 6.6 0,7 1,636 Colds Female 894 570 63.7 77 49 63.6 Male 742 Total 1,636 498 1,068 67.1 65.3 75 152 40 89 53.3 58.5 Table 13 PREVALENCE OF INFECTIONS IN THE GRAND RAPIDS POPULATION ACCORDING TO TYPE OF HEMOGLOBIN Influenza Sore Throat AA AS "Yes" Response Test­ Per ed No. Cent AA "Yes" Response Test­ Per Test­ ed No. Cent ed AS "Yes" Response Per No. Cent Test­ ed "Yes" Response Per No. Cent Female 196 28 14.3 174 34 19.6 196 65 33.2 174 52 29.9 Male 133 16 12.1 132 16 12.1 133 26 19.5 132 27 20.4 329 44 13.4 306 50 16.3 329 91 27.7 306 79 25.8 Total Earaches Ulcers Female 196 5 2.5 174 3 1.7 196 22 11.2 174 9 5.2 Male 133 1 0.7 132 0 0 133 5 3.8 132 8 6.1 329 6 1.8 306 3 1.0 329 27 8.2 306 17 5.5 Total Colds Female 196 122 62.2 174 118 67.8 Male 133 84 63.1 132 78 59.1 329 206 62.6 306 196 64.0 Total 60 statistically significant differences in prevalences of any of these symptoms in either population, haustion in the Lansing population. except sense of ex­ Nineteen of 152 individuals with trait (12.5 per cent) indicated that they frequently experienced a sense of exhaustion as compared with 7.4 per cent among the controls (122 of 1,636). This difference was statistically significant at the five per cent level. 4. Musculoskeletal Symptoms The musculoskeletal symptoms inquired about in the survey were muscle pain, weakness in legs, pain in bones, swollen and painful joints. The prevalences of these symptoms are included in Table 16 (Lansing and Table 17 (Grand Rapids). Even though relatively few individuals indicated that they had experienced any of these symptoms, the prevalences of weakness in legs and pain in bones were greater among individuals with the trait in the Lansing survey and the differences in both categories were statistically significant at the five per cent level. In the Grand Rapids survey, the prevalence of swollen joints was the only category among musculoskeletal symptoms where there was a significant difference. The ratio of problems with swollen joints was greater than two to one, when traits are compared to controls. 5. Genitourinary Problems In the category of genitourinary p r oblems, Tables 18 (Lansing) and 19 (Grand Rapids), it was anticipated that there would be a greater prevalence of problems among individuals with sickle cell trait. This anticipation was based on previous Table 14 PREVALENCE OF SYMPTOMS OF ANEMIA AMONG BLACKS IN LANSING ACCORDING TO TYPE OF HEMOGLOBIN Easy Fatigue_______________ AA AS Sense of Exhaustion AA "Yes” "Yes" Response Response Per Test­ Per Test­ ed No. Cent ed No. Cent Test­ ed AS "Yes" Response Per TestNo. Cent ed "Yes" Response Per No. Cent Female 894 160 17.9 77 16 20.8 894 91 10.2 77 13 16.9 Male 742 46 6.2 75 7 9.3 742 31 4.2 75 6 8.0 1,636 206 12.6 152 23 15.1 1,636 122 7.4 152 19 12.5 Total Dizziness Faintness Female 894 49 5.5 77 7 9.1 894 117 13.1 77 12 15.6 Male 742 16 2.2 75 1 1.3 742 23 3.1 75 2 2.6 1,636 65 4.0 152 8 5.3 1,636 140 8.5 152 14 9.2 Total Table 15 PREVALENCE OF SYMPTOMS OF ANEMIA AMONG BLACKS IN GRAND RAPIDS ACCORDING TO TYPE OF HEMOGLOBIN Sense of Exhaustion Easy Fatigue____________ AA AA AS "Yes" Response Test­ Per Test­ ed No. Cent ed AS "Yes" Response Per Test­ No. Cent ed "Yes" Response Per Test­ No. Cent ed "Yes" Response Per No. Cent Female 196 25 12.7 174 18 10.3 196 11 5.6 174 10 5.7 Male 133 7 5.3 132 4 3.0 133 3 2.2 132 3 2.3 329 32 9.7 306 22 7.2 329 14 4.2 306 13 4.2 Total Faintness Dizziness Female 196 7 3.6 174 6 3.4 196 12 6.1 174 14 8.0 Male 133 1 0.7 132 4 3.0 133 6 4.5 132 4 3.0 329 8 2.4 306 10 3.3 329 18 5.5 306 18 5.8 Total Table 16 PREVALENCE OF MUSCULOSKELETAL SYMPTOMS AMONG BLACKS IN LANSING ACCORDING TO TYPE OF HEMOGLOBIN Muscle Pain Weakness in Legs AA AS "Yes" Response Test­ Per ed No. Cent Test­ ed AS AA "Yes" Response Per No Cent "Yes" "Yes 11 Response Response Test­ Per Test Per ed No. Cent ed No. Cent - Female 894 75 8.4 77 9 11.7 894 61 6.8 77 11 14.3 Male 742 40 5.4 75 7 9.3 742 24 3.2 75 4 5.3 1,636 115 7.0 152 16 10.5 1,636 85 5.2- 152 15 9.8 Total Swollen Joints Pain in Bones Female 894 32 3.6 77 6 7.8 894 78 8.7 77 2 2.6 Male 742 19 2.6 75 4 5.3 742 30 4.0 75 4 5.3 1,636 51 3.1 152 10 6.6 1,636 108 6.6 152 6 3.9 Total Painful Joints Female 894 73 8.2 77 5 6.5 Male 742 46 6.2 75 5 6.6 1,636 119 7.3 152 10 6.6 Total Table 17 PREVALENCE OF MUSCULOSKELETAL SYMPTOMS AMONG BUCKS IN GRAND RAPIDS ACCORDING TO TYPE OF HEMOGLOBIN Weakness in Legs Muscle Pain AA AA AS "Yes” Response Per Test­ ed No. Cent Test­ ed "Yes" Response Per No. Cent AS "Yes” "Yes" Response Response Per TestPer Test­ ed No Cent ed No. Cent Female 196 7 3.6 174 10 5.7 196 6 3.1 174 8 4.6 Male 133 6 4.5 132 4 3.0 133 4 3.0 132 4 3.0 329 13 3.9 306 14 4.6 329 10 3.0 306 12 3.9 Total Pain in Bones Female 196 4 2.0 Male 133 3 329 7 Total Swollen Joints 196 5 2.5 174 11 6.3 3 0.6 2.2 133 2 1.5 132 6 4.5 4 1.3 329 7 2.1 306 17 5.5 1 2.2 174 132 2.1 306 Painful Joints Female 196 8 4.1 174 7 4.0 Male 133 3 2.2 132 6 4.5 329 11 3.3 306 13 4.2 Total Table 18 PREVALENCE OF GENITOURINARY PROBLEMS AMONG BLACKS IN LANSING ACCORDING TO TYPE OF HEMOGLOBIN Hematuria Kidney or Bladder Trouble AA AS AA "Yes" Response Per Test­ No. Cent ed Test­ ed AS "Yes" Response Per Test­ No. Cent ed "Yes" Response Per No. Cent Test­ ed "Yes" Response Per No, Cent Female 894 12 1.3 77 1 1.3 894 93 10.4 77 9 11.7 Male 742 14 1.9 75 0 0 742 27 3.6 75 4 5.3 1,636 26 1.6 152 1 0.7 1,636 120 7.3 152 13 8.5 Total Hyposthenuria____________________________Vaginal Discharge Female 894 48 5.4 77 5 6.5 Male 742 15 2.0 75 3 4.0 1,636 63 3.8 152 8 5.3 2 2.7 Total Priapism Male 742 5 0.7 75 894 67 7.5 77 4 5.2 Table 19 PREVALENCE OF GENITOURINARY PROBLEMS AMONG BLACKS IN GRAND RAPIDS ACCORDING TO TYPE OF HEMOGLOBIN Kidney .or: Bladder Trouble Hematuria AA AS AA "Yes" Response Test­ Per ed No. Cent AS Test­ ed "Yes" "Yes" Response Response Per TestPer No. Cent No. Cent ed Test­ ed "Yes" Response Per No. Cent Female 196 3 1.5 174 0 0 196 18 9.2 174 20 11.5 Male 133 1 0.7 132 0 0 133 0 0 132 1 0.8 329 4 1.2 306 0 0 329 18 5.5 306 21 6.9 Total Hyposthenuria______________________________ Vaginal Discharge Female 196 5 2.5 174 10 5.7 Male 133 3 2.2 132 4 3.0 329 8 2.4 306 14 4.6 132 0 0 Total Priapism Male 133 1 0.7 196 8 4.1 174 4 2.3 67 studies and case reports. The specific symptoms queried were hematuria, kidney or bladder trouble, hyposthenuria, vaginal discharge among females and priapism among m a l e s . In neither of the two populations was there a significant difference in the prevalences of any of these symptoms. In the category of vaginal discharge among females in the Lansing survey, 466 of the "normals’1 were between the ages of 14 and 45 years. Fifty-six of these (12 per cent) reported problems with this condition. Fifty-one of the 77 females with trait who responded were in the same age group (14-45 years) and four (8 per cent) had problems with vaginal discharge. 6. Cardiovascular and Gastrointestinal Problems High and low blood pressure, pain In chest and short­ ness of breath were the symptoms included in the category of cardiovascular problems. With respect to high and low blood pressures, the respondents would have to have been informed by a clinician, as it is highly possible that a person could have these conditions and not know i t . No statistically significant differences were dis­ cerned in either of the separate populations in any of these symptoms (see Table 20 and 21). When the data pertaining to high and low blood pressures were analyzed by age groups and sex, no differences were seen. The gastrointestinal problems inquired about in the surveys included jaundice, blood in stool, blood in sputum, liver trouble (cirrhosis, hepatomegaly, etc.), diarrhea and abdominal pain. The relative proportions of the prevalences of these conditions in Lansing, (Table 22) and Table 20 PREVALENCE OF CARDIOVASCULAR PROBLEMS AMONG BLACKS IN LANSING ACCORDING TO TYPE OF HEMOGLOBIN Low Blood Pressure High Blood Pressure AA AA AS "Yes" Response Per Test­ Test­ ed No. Cent ed "Yes" Response Per No. Cent Test­ ed AS "Yes" Response Per No. Cent "Yes" Response Per Test­ ed No. Cent Female 894 105 11.7 77 8 10.4 894 81 9.1 77 8 10.4 Male 742 33 4.4 75 3 4.0 742 17 2.3 75 0 0 1,636 138 8.4 152 11 7.2 1,636 98 6.0 152 8 5.3 Total Shortness of Breath Pain in Chest Female Male Total 894 742 108 12.1 77 5 6.5 894 104 11.6 77 8 10.4 43 5.8 75 4 5.3 742 34 4.6 75 3 4.0 1,636 151 9.2 152 9 5.9 1,636 138 8.4 152 11 7.2 Table 21 PREVALENCE OF CARDIOVASCULAR PROBLEMS AMONG BLACKS IN GRAND RAPIDS ACCORDING TO TYPE OF HEMOGLOBIN High Blood Pressure AA Low Blood Pressure AS "Yes" Response Per Test­ Test­ No. Cent ed ed AA "Yes" Response Per Test­ No. Cent ed AS "Yes" Response Per TestNo. Cent ed "Yes" Response Per No. Cent Female 196 11 5.6 174 9 5.2 196 11 5.6 174 12 6.9 Male 133 1 0.8 132 0 0 133 3 2.3 132 5 3.8 329 12 3.6 306 9 2.9 329 14 4.3 306 17 5.5 Total Pain in Chest Shortness of Breath Female 196 18 9.2 174 10 5.7 196 14 7.1 174 9 5.2 Male 133 7 5.3 132 3 2.3 133 5 3.8 132 5 3.8 329 25 7.6 306 13 4.2 329 19 5.8 306 14 4.6 Total 70 Grand Rapids, (Table 23) are similar w h e n controls are compared with sickle cell trait subjects. The difference in each case is not statistically significant. 7. Epistaxis The prevalence of spontaneous nosebleeds was greater among individuals w ith sickle cell trait in both populations (see Tables 24 and 25). normals In the Lansing survey, 191 of 1,636 (11.7 per cent) reported nosebleeds in the past year as compared with 26 of 152 the trait. cent level. (17.1 per cent) individuals with The difference is significant at the five per In the Grand Rapids survey 31 of 329 controls (9.4 per cent) and 48 of 306 (15.7 per cent) trait individuals reported nosebleeds in the past year. 8. Neurologic Symptoms Confusion and disorientation, convulsions and n u m b ­ ness in legs w ere the symptoms included in the neurologic category. In Lansing, there was no significant difference between traits and controls in any of these symptoms Table 26). In Grand Rapids with the trait (Table 27), (see 15 of 306 persons (4.9 per cent) reported problems of n u m b ­ ness in legs, while only six of 329 controls (1.8 per cent) had similar problems. A second set of analyses was done on the data collected from the Grand Rapids survey. All probands and data concerning them were removed and prevalences of the 34 health problem symptoms were re-calculated. The purpose for doing this was to remove some of the bias Inherent in Table 22 PREVALENCE OF GASTROINTESTINAL PROBLEMS IN LANSING ACCORDING TO TYPE OF HEMOGLOBINS Jaundice Blood in Stool AA Female Male Total AA AS "Yes" Response Per Test­ Test­ ed No. Cent ed 1.2 77 894 11 "Yes11 Response Per Test­ No. Cent ed "Yes" Response Per No. Cent Test­ ed "Yes" Response Per No. Cent 1 1.3 894 16 1.8 77 3 3.9 742 8 1.1 75 1 1.3 742 20 2.7 75 0 0 1,636 19 1.2 152 2 1.3 1,636 36 2.2 152 3 3.0 Blood in Sputum Liver Trouble 77 2 2.6 894 8 0.9 77 1 1.3 21 3.0 2.8 75 0 0 742 6 0.8 75 0 0 43 2.9 152 2 1.3 1,636 14 0.8 152 1 0.6 Female 894 27 Male 742 1,636 Total AS Abdominal Pain Diarrhea Female 894 64 7.2 77 3 3.9 894 97 10.8 77 10 13.0 Male 742 39 5.2 5 6.7 742 40 5.4 75 2 2.7 1,636 103 6.3 75 152 8 5.3 1,636 137 8.4 152 12 7.9 Total Table 23 PREVALENCE OF GASTROINTESTINAL PROBLEMS IN GRAND RAPIDS ACCORDING TO TYPES OF HEMOGLOBIN Blood in Stool Jaundice AA Test­ ed AA AS "Yes” "Yes" Response Response Per Test­ Per Test­ No. Cent ed No. Cent ed AS "Yes" Response Per No. Cent "Yes" Response Test­ Per ed No. Cent 174 3 132 3 1.7 2.3 306 6 2.0 Female 196 2 1.0 174 0 0 196 3 Male 133 0 0 132 1 0.8 133 3 1.5 2.2 329 2 0.6 306 1 0.3 329 6 1.8 Total Liver Trouble Blood in Sputum Female 196 4 2.0 174 3 1.7 196 2 1.0 174 2 1.1 Male 133 2 1.5 132 2 1.5 133 0 0 132 1 0.7 329 6 1.8 306 5 1.6 329 2 0.6 306 3 1.0 Total Diarrhea Abdominal Pain Female 196 22 11.2 174 13 7.5 196 16 8.2 174 11 6.3 Male 133 12 9.0 132 10 7.6 133 9 6.8 132 6.8 329 32 10.3 306 23 7.5 329 24 7.6 306 9 20 Total 6.5 73 Table 24 PREVALENCE OF EPISTAXIS IN LANSING ACCORDING TO TYPE OF HEMOGLOBIN AA Female Male Total AS Response TestPer ed No. Cent 894 87 9.7 742 104 14.0 1,636 191 11. 7 Tested 77 74 Response Per No. Cent 18.2 14 12 16.0 152 26 17.1 Table 25 PREVALENCE OF EPISTAXIS IN GRAND RAPIDS ACCORDING TO TYPE OF HEMOGLOBIN Female Male Total AA "Yes" Response Per Test­ ed No. Cent 16 8.2 196 133 15 11.3 329 31 9.4 Test­ ed 174 132 306 AS "Yes" Response Per No. Cent 20 11.5 28 21.2 48 15.7 Table 26 PREVALENCE OF NEUROLOGIC SYMPTOMS IN LANSING ACCORDING TO TYPE OF HEMOGLOBIN Confusioni and Disorientation AA Test­ ed Convulsions AS AA "Yes” Response Per TestNo. Cent ed "Yes” Response Per No. Cent Test­ ed AS "Yes" "Yes" Response Response Per TestPer No. Cent ed No. Cent Female 894 43 4.8 77 3 3.9 894 16 1.8 77 0 0 Male 742 14 1.9 75 1 1.3 742 8 1.1 75 0 0 1,636 57 3.5 152 4 2.6 1,636 24 1.5 152 0 0 Total Numbness in Legs Female 894 47 5.3 77 6 7.8 Male 742 16 2.2 75 1 1.3 1,636 63 3.8 152 7 4.6 Total Table 27 PREVALENCE OF NEUROLOGIC SYMPTOMS IN GRAND RAPIDS ACCORDING TO TYPE OF HEMOGLOBIN Convulsions Confusion and Disorientation AA Test­ ed AS AA AS "Yes" Response Per Test No. Cent ed "Yes" Response Per Test­ No. Cent ed "Yes" "Yes" Response Response Per TestPer No. Cent ed No. Cent Female 196 5 2.5 174 6 3.4 196 1 0.5 174 6 3.4 Male 133 2 1.5 132 2 1.5 133 4 3.0 132 5 3.8 329 7 2.1 306 8 2.6 329 5 1.5 306 11 3.6 Total Numbnes s in Legs Female 196 5 2.5 174 10 5.7 Male 133 1 0.7 132 5 3.8 329 6 1.8 306 15 4.9 Total 76 the previous analyses. Specifically, parents may have been prone to remember better any of the problems the probands may have had. This assumption was made, based on the fact that parents knew which of their children had participated in the initial screening program at the schools. As a result of the test findings parents, along with the rest of the family were invited in for definitive testing, education and counseling. Of the 33 symptoms the only one that was significantly different at the five per cent level between trait and normal homozygous individuals was prevalence of swollen joints in the category of musculoskeletal symptoms. Specifically, seven of 329 (2 per cent) of the controls reported problems with this symptom compared to 13 of 160 (8 per cent) persons with sickle cell trait. In the previous calculations pertaining to the Grand Rapids data s e t , including probands, three of the symptoms were significantly more pre­ valent among trait persons. These were swollen joints, epistaxis and numbness in legs. In the Lansing sample, sense of exhaustion, pain in bones, weakness in legs and epistaxis were the only variables significantly associated with sickle cell trait. Table 27a shows a listing of all of the health problems asked about and indicates the group (trait vs normal) that is less affected. sample, Of the 35 conditions summarized, in the Lansing 21 were less frequently reported among persons with sickle cell trait and 15 were less frequently reported among individuals with normal hemoglobin. In the Grand Rapids survey, 77 16 of the symptoms were less frequently reported by trait persons, 19 less frequently by the AA group and with one symptom (sense of exhaustion) each group was equally affected. These differences in frequencies are not significantly different in either population. With respect to the itemized symptoms or conditions, the apparent general health of average trait individuals is about the same as that of average persons with only normal hemoglobin. This is generally true in both populations studied. G. A Single Test of Association of Health and Sickle Cell Trait Thirty-four separate symptoms of health problems were ascertained in the two separate populations. In the Lansing sample, five of these were statistically significantly different, all except one, more prevalent among those persons with sickle cell trait. In the Grand Rapids survey, three of the 34 symptoms were significantly different at the five per cent level, all more prevalent among those persons with sickle cell trait. Only one symptom, epistaxis, was significnatly different in both populations. When probands in the Grand Rapids survey were excluded only one symptom was found to be significantly different. In the utilization of the Chi square test of significance for several separate comparisons, difference is amplified. five per cent level, five per cent. the probability of a false If one test is performed at the the probability of a type one error is The probability of finding at least one false difference by performing 34 independent tests is 82 per cent. Table 27a TABULATION OF SYMPTOMS FOR THE 36 HEALTH PROBLEMS INDICATING THE GROUP (AS vs. AA) WITH LOWER FREQUENCY Condition or Symptom AA Lansing______________ AS Group less AA Fair or Poor Health Use of Glasses or Contact Lenses Hearing Aid Influenza Sore Throat Ulcers Earaches Colds Easy Fatigue Sense of Exhaust. Faintness Dizziness Muscle Pain Weakness in Legs Pain in Bones Swollen Joints Painful Joints Hematuria Kidney/Bladder Trouble % Affected 13 306 14 AA 329 16 306 15 AS 329 329 329 329 329 329 329 329 329 329 329 329 329 329 329 329 329 0 306 13 306 27.7 306 2 306 8 306 306 63 10 306 306 4 2 306 5.5 306 3.9 306 3.0 306 2.1 306 2.1 306 3.3 306 1.2 306 5.5 306 2 16 25.8 1 6 64 7 4 3 5.8 4.6 3.9 1.3 5.5 4.2 0 6.9 AA AA AS AS AS AA AS N 1603 17 152 24 AA* 328 1636 22 152 20 AS 1636 1636 1636 1636 1636 1636 1636 1636 1636 1636 1636 1636 1636 1636 1636 1636 1636 1 17 28.7 3 8 65 13 7.4 4 8.5 7.0 5.2 3.1 6.6 7.3 1.6 7.3 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 152 0 11 19.1 1 7 59 15 12.5 5 92 10.5 9.8 6.6 3.9 6.6 0.7 8.5 AS AS AS* AS AS AS AA AA* AA AA AA AA* AA* AS AS AS AA % Affected Group less N % N Grand Rapids As N % AA AA AA AA AS AA* AA AS AA Table 27a (Cont'd.) Condition or Symptom Lansing___________________ AA AS Group less AA Affected N N N I % Hyposthenuria 1636 3.8 152 Vaginal Discharge 894 7.5 77 742 0.7 Priapism 75 High Blood Pres. 1636 8.4 152 1636 6.0 152 Low Blood Pres. Pain in Chest 1636 9.2 152 Shortness of Breathl636 8.4 152 1636 1.2 152 Jaundice 1636 2.2 152 Blood in Stool 1636 2.9 152 Blood in Sputum Liver Trouble 1636 0.8 152 Diarrhea 1636 6.3 152 Abdom. Pain 1636 8.4 152 Epistaxis 1636 11.7 152 Confus. and 1636 3.5 152 Disorientation Convulsions 1636 1.5 152 Numbness in Legs 1636 3.8 152 Grand Rapids AS N % % 5.3 5.2 2.7 7.2 5.3 5.9 7.2 1.3 3.0 1.3 0.6 5.3 7.9 17.1 2.6 AA AS AA AS AS AS AS AA AA AS AS AS AS AA* AS 329 2.4 196 4.1 133 0.7 329 3.6 329 4.3 329 7.6 329 5.8 329 0.6 329 1.8 329 1.8 329 0.6 329 10.3 329 7.6 329 9.4 329 2.1 0 4.6 AS AA 329 329 Total Number for Each Group: AS » 21; AA * 15 * Denotes Statistically Significant Difference 1.5 1.8 Group less Affected 306 4.6 174 2.3 132 0 306 2.9 306 5.5 306 4.2 306 4.6 306 0.3 306 2.0 306 1.6 306 1.0 306 7.5 306 6.5 306 15.7 306 2.6 AA AS AS AS AA AS AS AS AA AS AA AS AS AA* AA 3.6 4.9 AA AA* 306 306 Total Number for Each Group: AS -16; AA = 19 No Diff = 1 80 In an effort to avoid the above difficulty, an attempt was made to devise a single test of association of health and the trait. An analysis was made by categorizing in both traits and normals, those individuals with any symptoms who had seen a doctor as "sick". That is, if a person indicated that he had problems with at least one of the 34 symptoms and reported that he had seen a doctor for it, that person was categorized as "sick". On the other hand, those persons who had no problems with any of the 34 symptoms, along with those who reported that they had one or more of the symptoms, but had not seen a doctor about it, were categorized as "well". overall Chi square test with one degree computed. An of freedom was then As shown in Table 28, the percentage of individuals in the Lansing sample with normal hemoglobin defined as "sick" was 43.7, compared with 44.7 per cent (68 of 152) of those with sickle cell trait. In the Grand Rapids sample, 33.6 per cent of the controls were defined as sick, compared with 36.9 per cent of those with sickle cell trait. A Chi square test of significance shows no difference in either of the two separate samples. 81 Table 28 A COMPARISON BETWEEN SICK AND WELL INDIVIDUALS WITH AND WITHOUT SICKLE CELL TRAIT FOR THE LANSING AND GRAND RAPIDS SAMPLES AA Relative Odds Ratio AS N o .______Per Cent____ N o .____ Per Cent Lansing Well Sick Total Grand Rapids Well Sick Total 925 717 1,642 56.3 43.7 91.5 84 _68 152 55.3 44.7 8.5 219 111 330 66.4 33.6 51.9 193 113 306 63.1 36.9 48.1 1. 04 1.16 82 H. Relative Odds Ratios The kind of crosstabulation shown in Table 28 lends itself to another computation, the relative odds ratio, which gives some indication of the risk of being well or sick among trait individuals compared with controls. Such a computation of the data included in Table 28 reveals that the odds that individuals with the trait are sick is 1.04 times the odds of individuals with normal hemoglobin in Lansing and 1.16 in Grand Rap i d s . Table 29 shows age specific relative odds ratios for sickness in the Lansing sample. There is an increasing risk of sickness with increasing age among trait and normal in­ dividuals . In contrast to the implications of data contained in Table 29 of symptomatic health problems, interviewees were asked to characterize their general health as excellent, good, fair or poor (Table 6). Dividing the respondents into two categories: Good Health (those who perceived their general health as excellent or good) and Bad Health (those who in­ dicated that their general health was fair or p o o r ) , 30 was obtained. Table It is clear that among trait persons, there is a decrease in bad health with increasing age. I. Age Trends The relation between age and sickle cell trait in the Lansing sample is shown in Table 31. The mean frequency for trait in this group is 8.5 per cent. No statistically significant relation to age was seen in the frequency of sickle cell trait when ages were grouped. 83 Table 29 AGE SPECIFIC RELATIVE ODDS RATIOS FOR SICKNESS IN LANSING Normal (AA) Age Group (Years) 0-17 18 - 35 36 - 55 56 + Trait (AS) Relative Odds Ratio Well Sick 598 255 49 25 1.196 Well Sick 195 247 24 20 0. 658 Well Sick 90 147 6 17 1. 735 Well Sick 32 61 4 6 0.787 Table 30 AGE SPECIFIC RELATIVE ODDS RATIOS FOR GOOD OR BAD HEALTH IN LANSING Age Group (Years) 0-17 18 - 35 36 - 55 56 + Good Health Bad Health Normal Trait 562 39 59 8 Normal Trait Normal Trait 421 46 292 53 26 9 117 14 Normal Trait 56 5 43 5 Relative Odds Ratio 1.95 1.50 1. 34 1.30 84 Table 31 THE RELATION BETWEEN AGE AND SICICLE CELL TRAIT IN THE LANSING SAMPLE Age Group (Years) 0-4 5-8 9-12 13-17 18-25 26-35 36-45 46-55 56-65 66 + Total Number 224 238 214 251 285 201 165 95 73 48 1,794 Hemoglobin Types AA AS 209 225 198 221 258 184 148 89 67 43 1,642 6.7 5.5 7.5 11.9 9.5 15 13 16 30 27 17 17 6 6 5 152 X 2 = 9.8, d.f. = 9, p> Per Gent With Trait 8.5 10.3 6.3 8.2 10.4 8.5 .35 85 In order to facilitate comparison with several pre­ vious reports, the subjects were re-grouped into four age periods, zero to four, five to 20, 21 to 49 and 50 years and over, respectively (see Table 32). No statistically significant relation to age was seen in the frequency of sickle cell trait in either sex. The age trend of sickle cell trait in the Grand Rapids survey (Table 33) shows a decrease in the older age groups. This type of pattern was expected from the outset, due to the method of ascertainment. In this population the study began with propositi with some sickling involvement but no definitive diagnoses as to specific hemoglobin types. Subsequently, the propositi were re-tested for definitive diagnoses along with other family members, including parents, siblings and, in several instances, more distant relatives living in the household. Since the propositi were school- aged and all with sickle positive solubility tests, it would be expected that at least one parent and one-half of the sibs would have sickle cell positive tests. Moreover, a high percentage of the parents would be expected to fall in an age group preceding 55 years. part as implied in Table 33. This is true for the most Those persons in the older age group were usually grandparents or other older relatives who were guardians of the propositi. 86 Table 32 THE RELATION BETWEEN AGE AND SICKLE CELL TRAIT IN MALES, FEMALES AND COMBINED SAMPLE, LANSING (DIVIDED INTO FOUR AGE GROUPS) . Age Group (Years) Number M a l e s :* 0-4 5-20 21-49 50 + All Ages 809 F e m a l e s :** 0-4 5-20 21-49 50 + All Ages 112 415 353 82 962 Combined:*** 0-4 5-20 21-49 50 + Total All Ages 111 398 226 74 223 813 579 156 1,771 Hemoglobin Types AA AS Per Cent With Trait 101 359 208 67 735 10 39 18 7 74 9.1 9.8 8.0 9.5 9.1 107 379 322 77 885 5 36 31 5 77 4. 5 8.7 8.8 6.1 8.0 208 738 530 144 1,620 15 75 49 12 151 6.7 9.2 8.5 7.7 8.5 * X 2 = .59, d.f. = 3, p > .5 * * X 2 - 2.8, d.f. = 3, p > .4 * * * X 2 = 1 . 6 , d.f. = 3 , p > .5 87 Table 33 THE RELATION BETWEEN AGE AND SICKLE CELL TRAIT IN THE GRAND RAPIDS STUDY Age Group (Years) 0-4 5-8 9-12 13-17 18-25 25-35 36-45 46-55 56-65 66 + Total Number 67 111 138 111 47 73 61 24 0 4 636 Hemoglobin Types AA AS 48 40 63 61 29 34 37 15 0 3 330 19 71 75 50 18 39 24 9 0 1 306 Per Cent With Trait 28.4 64.0 54. 3 45.0 38. 3 53.4 39.3 37.5 - 25. 0 48.1 88 J. Pregnancy History Table 34 contains pregnancy data obtained from 630 females, 14 years of age or older, in the Lansing survey. Of the 573 females with normal hemoglobin, 407 (71 per cent) had at least one pregnancy as compared with 33 of 57 (58 per cent) females with sickle cell trait. When a Chi square test of independence was employed, no significant difference was revealed at the .05 level. Among those females in the 14-17 age group, 92 per cent of the trait females have never been pregnant, compared with 88 per cent of normal females.The greatest difference is seen among females in the 18-25 age group. per cent of with 30 Fifty-three trait females have never been pregnant, compared per cent of the normals. Twenty-one of the 24 never pregnant trait females are between the ages of 14 and 25 years. When comparisons are made with respect to the number of pregnancies among those females with at least one preg­ nancy (see Table 35), no significant difference between trait and normal females is detected. Among those females who had at least one pregnancy, 124 normals (30.5 per cent) had at least one miscarriage or stillbirth while 13 (43.3 per cent) trait females had at least one miscarriage or stillbirth. The difference is not statistically significant at the .05 level (see Table 36). Further analysis of the numbers and distribution of miscarriages or stillbirths among those females who had a history of at least one pregnancy reveals no significant Table 34 PREGNANCY HISTORY OBTAINED BY QUESTIONNAIRE FROM 630 FEMALES WITH AND WITHOUT SICKLE CELL TRAIT IN THE LANSING SURVEY Trait Age Group (Years) None At Least One % No. Normal Total % No. None No. No. At Least One 7o Total No. % No. 14-17 12 92.3 1 7.7 13 98 87.5 14 12.5 112 18-25 9 52.9 8 47.1 17 46 30.3 106 69.7 152 26-35 1 9.1 11 6 5.4 106 94.6 112 36-45 0 0 9 100 9 4 4.6 83 95.4 87 46-55 1 33.3 2 3 3 5.7 50 94.3 53 56-65 0 0 3 100 3 4 11.1 32 88.9 36 66 + 1 100 0 1 5 23.8 16 76.2 21 57.9 57 166 29.0 407 71.0 573 Total 24 42.1 10 0 33 90.9 66.7 X2 - 3.65, d.f. = 1, p = .056 90 Table 35 NUMBER OF PREGNANCIES AMONG FEMALES WITH AND WITHOUT SICKLE CELL TRAIT IN LANSING SURVEY No. of F r e g s . Normal Trait Totals 1 81 19.9% 2 76 18.7% 3 73 17.9% 10 30.3% 5 15. 2% 3 9.1% 3 7 9.1% 21. 2% 91 20. 7% 81 18.4% 76 17.3% 48 56 10.9% 12. 7% X 2 = 5.73, d.f. = 5 , 4 45 5 49 11.1% 12% p = .33 6+ Total 83 20.4% 407 5 15.2% 33 88 20% 440 91 Table 36 MISCARRIAGE AND STILLBIRTH HISTORY AMONG FEMALES WITH AND WITHOUT SICKLE CELL TRAIT IN THE LANSING SURVEY Trait Normal Total None N o . Per Cent At Least One Per Cent No. 17 283 300 13 124 56. 7 69.5 68. 5 Total No. 30 407 437 43.3 30.5 31.4 137 X2 = 1,6,d.f. “ 1, p = .2069 Table 37 NUMBER OF MISCARRIAGES OR STILLBIRTHS OBTAINED BY QUESTION­ NAIRES FROM FEMALES IN THE LANSING SURVEY 3 4 7 5.6% 0 5+ 1 124 90.5 20 Normal 89 71.8% 16.1% 7 5.5% Trait 8 61.5% 4 30.8% 1 7. 7% 0 0 0 97 70.8% 24 17.5% 8 5. 8% 7 5.1% 1 0.7% Totals X 2 *= 2.54, d.f. = 4 , p > .5 Total o 00 2 1 13 9.5 137 100 92 difference (see Table 37). Sixty-seven of 437 females had at least one child die during childhood (before 15 years of a g e ) ; 66 mothers with normal (16,2 per cent) hemoglobin and one with sickle cell trait (3.3 per cent). Fisher's Exact Test gives a probability value of .0771. The number of early childhood deaths of children of trait women is too small for comparison (see Table 38). In Grand Rapids a tabulation was made of females ever pregnant (14 years of age or older) the mothers of propositi. The results, after excluding as shown in Table 39, reveal that 79 per cent of the trait females have no history of pregnancy, compared to 73 per cent of the females with normal hemoglobin. The difference is not significant at the five per cent level. There is no statistical difference in the number of pregnancies among trait and normal females (including mothers of propositi) with a history of at least one pregnancy (see Table 40). Further analysis of data obtained from those females (Table 41) with at least one pregnancy reveals that 30.2 per cent of trait females had at least one miscarriage or stillbirth, while 36.6 per cent of normal females had at least one. significant. The difference again, Moreover, is not statistically a Chi square test of independence indicates no significant difference in the number of miscarriages or stillbirths among those females with and without trait who had at least one miscarriage or still­ birth (see Table 42). 93 Table 38 EARLY CHILDHOOD DEATHS REPORTED BY MOTHERS WITH AND WITHOUT SICKLE CELL TRAIT IN LANSING No. Normal Trait Total None Per Cent At Least One Per Cent No Total No. 341 83.8 66 16.2 407 29 96. 7 1 3.3 30 370 84.7 67 15.3 437 p< .10 Table 39 PREGNANCY HISTORY OBTAINED BY QUESTIONNAIRE FROM 73 FEMALES WITH AND WITHOUT SICKLE CELL TRAIT IN THE GRAND RAPIDS SURVEY Age Group _________Trait______________ Normal At Least None No. % One__ No. % At Least Total AS None __ One ___ No. % No. % Total AA 30 14 - 17 19 95.0 1 5.0 20 30 100.0 0 0 18 - 25 2 33.3 4 66.7 6 2 28.6 5 71.4 26 - 35 1 100.0 0 0 1 0 0 2 100.0 7 2 36 - 45 0 0 0 0 0 1 50.0 1 50.0 2 46 - 55 0 0 0 0 0 0 2 100.0 2 66 + 0 0 1 0 0 1 0 0 _2 100.0 2 22 78.6 6 21.4 28 33 73.3 12 26.7 45 Total X2 = .0509, d.f. = 1, p = .82 95 Table 40 NUMBER OF PREGNANCIES AMONG FEMALES WITH AND WITHOUT SICKLE CELL TRAIT IN GRAND RAPIDS Normal Trait Totals 1 5 7. 07c 2 9 1 2 . 67o 3 8 11.27c 4 10 14.17c 5 5 7.07c 6+ 34 4 7 . 97c 4 6. 37c 10 15.97, 10 15.97 , 11 7 17 .57, 1 1 . 17c 21 33.37c 63 9 6 . 77c 19 14. 27, 18 13.47c 21 15.77c 55 41 .07, 134 X 2 = 3.37, d . f . » 5, p « > 12 8. 97c .5 Total 71 96 Table 41 MISCARRIAGE AND STILLBIRTH HISTORY AMONG FEMALES WITH AND WITHOUT SICKLE CELL TRAIT IN GRAND RAPIDS Normal Trait Total None No. Per Cent At Least One No. Per Cent 45 44 89 26 63.4 69. 8 66.4 36. 6 30. 2 33.6 19 45 X 2 = .37, d.f. = 1, Total No. p> 71 63 134 .5 Table 42 NUMBERS OF MISCARRIAGES OR STILLBIRTHS OBTAINED BY QUESTION­ NAIRE FROM FEMALES IN GRAND RAPIDS 2 3 4 5+ 15 57. 7 4 15.4 4 15.4 2 7. 7 1 3.8 26 15 78. 9 2 10.5 2 10.5 0 0 0 0 19 30 66. 7 6 13.3 6 13.3 2 4. 4 1 2.2 45 1 Normal m Trait T O Total <%) X 2 = 3.3, d.f. = 4, p > .5 Total 97 Table 43 EARLY CHILDHOOD DEATHS REPORTED BY MOTHERS WITH AND WITHOUT SICKLE CELL TRAIT IN GRAND RAPIDS Normal Trait Total No. 63 54 117 None Per Cent 88.7 85. 7 87.3 X 2 = .07, d.f. = 1 , At Least One Total No. Per Cent No. 8 11.2 71 63 9 14.3 17 12. 7 134 p > .7 98 Eight of the 71 females (11.2 per cent) with normal hemoglobin and nine of 63 (14.3 per cent) with sickle cell trait had a history of at least one childhood death among their children. A g a i n , there is no significant difference between the two groups of mothers (see able 43). Table 44 PREVALENCE OF USE OF ORAL CONTRACEPTIVES AMONG FEMALES WITH AND WITHOUT SICKLE CELL TRAIT IN LANSING Normal Trait No. Yes Per Cent 78 8 16. 7 18.2 No N o . Per Cent 390 36 83.3 81.8 Total No. 468 44 X 2 = .002, d.f. = 1, p > .5 K. Use of Oral Contraceptives Table 44 shows the prevalence of the use of oral contra­ ceptives among females with and without sickle cell trait in the Lansing population. Among those with the trait, 18.2 per cent use the pill as compared with 16.7 per cent among the controls. Twenty-four of the 78 females with normal hemoglobin who take the pill have had problems since taking them while only one of the eight females with trait has had problems. The one trait female who indicated that she had p roblems, 99 had not seen a doctor about it. No effort was made to ascertain what the problems were unless the person had seen her doctor about the problem. Of those females who reported problems with the pill, doctors. 18 had seen their Their problems included weight gain, menses, blood clots, (controls) skin rashes, nausea, irregular tenderness in brests, vaginal discharge and kidney problems. In Grand Rapids 15.8 per cent of normal females use the oral contraceptive as compared w ith 19.4 of those with sickle cell trait. The difference is not statistically significant (see Table 45). Table 45 PREVALENCE OF USE OF ORAL CONTRACEPTIVES AMONG FEMALES WITH AND WITHOUT SICKLE CELL TRAIT (GRAND RAPIDS) No. Normal Trait 13 14 Yes Per Cent 15. 8 19.4 X 2 - .14, d.f. = 1, p No No. Per Cent 69 58 84.2 80.6 Total No. 82 72 .5 Only one of the 13 control females who takes the pill reported a problem, while 5 of the 14 trait females had problems resulting from the use of the pill. Only 3 of the 5 trait women who reported problems had subsequently seen their doctors. 100 These women indicated that their doctors said their troubles were weight gain, L. tenderness in breasts and irregular menses. Hematological Indices Hematological indices were done on several specimens from the Michigan State University Study. The profiles of all of the individuals included in Tables 46 and 47, were made on college students, all between the ages of 18 and 23 years of age. Means ana standard deviations of all determined values show no consistent differences between those with normal hemoglobin and those with trait. It is interesting to note that in almost all of the categories, those individuals with sickle cell trait have higher values (toward the upper limits of "normality") in both sexes. than those with normal hemoglobin When statistical tests were done none were statistically significant, thus confirming previous work demonstrating that the trait does not generally contribute to a tendency to be a n e m i c . 101 Table 46 COMPARISONS OF MEANS AND STANDARD DEVIATIONS OF SEVEN HEMATOLOGICAL INDICES OF FEMALE COLLEGE STUDENTS WITH NORMAL HEMOGLOBIN AND WITH SICKLE CELL TRAIT A 17 7.4 ■ MCH (AAgm ) MCHC (g/100 ml) RBC (mil/mm ) Total Protein (g/100 ml) S .D . 0.9 3.4 3.2 1.5 1.0 0.4 0.3 AS N o . Mean S.D. 16 13.0 16 37. 9 2.3 16 84. 7 6.1 16 29.0 2.0 16 34.1 1.3 16 4.46 18.0 16 0.2 7.6 00 o Hemoglobin (g/100 ml) Hematocrit MCV (A3) No. 17 18 18 18 18 18 AA Mean 12.7 35.8 84.0 29.4 34.6 4.22 None statistically significant at .01 level. Table 47 COMPARISONS OF MEANS AND STANDARD DEVIATIONS OF SEVEN HEMATOLOGICAL INDICES OF MALE COLLEGE STUDENTS WITH NORMAL HEMOGLOBIN AND WITH SICKLE CELL TRAIT Hemoglobin (g/100 ml) Hematocrit MCV (*3) MCH <#Agm) MCHC (g%) RBC (mil/nun3) Total Protein (g/100 ml) No. 18 18 18 18 18 18 15 AA Mean 13. 8 39.3 82.3 28.8 34.6 4. 76 7. 72 S.D. 2.5 6.7 4.2 2.2 0.9 0.9 0.4 AS N o . Mean 15.0 15 15 43.6 82. 8 15 14 28. 7 14 34.3 15 5.29 7.58 8 None statistically significant at .01 level. S.D. 1.2 3.6 6.0 1.9 1.5 0.4 0.3 DISCUSSION The two populations emphasized in this report are quite different and each offered an opportunity for making reliable observations. The Lansing sample provided an opportunity for ascertaining a reliable estimate of the frequency of the hemoglobin S gene in an urban sub-population of blac k s . The Grand Rapids survey provided for an opportunity to make comparisons between approximately equal proportions of individuals with sickle cell trait and normal contols. Nearly every family in this survey had at least one person with sickle cell trait and one or more persons with normal hemoglobin only. The Lansing population, though excellent for gene frequency studies, required making comparisons between large numbers of families and individuals without the hemoglobin S gene and small numbers of persons with the trait. Although the two populations could have been made comparable by the exclusion of all non-S hemoglobin families in Lansing and all probands in Grand Rapids, real trends, if any existed, could be obscured. greatly reduced. Moreover, sample sizes would have been Because of the above factors, and others, careful thought had to be given to the extent of bias and the composition of the populations when various comparisons were made. A. Prevalence of Heomglobin Types in Lansing Survey Few studies of frequency of the various abnormal hemoglobins, particularly hemoglobin S, are based on representative samples of defined populations. 102 The reported 103 prevalence of sickle cell trait among American blacks varies from 6.5 to 14.6 per cent (Diggs, 1933; Myerson et a l . , 1959; Boyle and Thompson, 1968; Smoot et a l . , 1961; Switzer, 1950; Petrakis et al., 1970). figure is stated as 8.5 per cent (Wintrobe, The average 1967). In the recent literature, Stultz and his collaborators (1968) reported an attempted complete ascertainment of homozygotes in Erie County, New York. Estimates of heterozygotes, based on mathematical calculations suggest a rate from sickle cell disease of about eight per cent, well within the range of other studies reported in the United States. Myerson et al. (1959) reported the hemoglobin determinations on a series of 1,000 hospitalized black veterans which included comparisons with four other large groups similarly studied in different hospitals. The percentage of individuals shown to have sickle cell trait from these five studies was 8.5 per cent. The prevalence of sickle cell trait in the Lansing population is 8.2 per cent, very similar to other reported prevalences. The reported incidence of hemoglobin C trait among American blacks ranges from 2 - 3 per cent. In the Lansing sample the incidence of hemoglobin C trait was 2.4 per cent. Homozygous C disease is estimated to occur in about 1 in 10,000 American blacks. Lansing survey. One was discovered In the Reports on the incidence of sickle cell anemia In the U.S. range from 0.3 - 1.3 per cent. Most of the literature indicates that the homozygous disease occurs in 1 in every 500 births among American blacks (0.2 per cent). 104 Three (0.16 per cent) persons with sickle cell anemia were found in the Lansing sample. Fetal hemoglobin comprises approximately 75 per cent of the pigment of cord blood at birth. first year of life, it has fallen to its adult level of less than two per cent. blacks By the end of the Approximately one in 1,000 American (Bradley et a l . , 1961) retains 20 per cent to 30 per cent of hemoglobin F, even into adulthood, and it appears that this trait is determined by a single Mendelian gene (Rucknagel, 1973). Nine persons (0.48 per cent) in the Lansing sample were diagnosed as heterozygotes for high persistence of fetal hemoglobin (HPFH). Four of these were in one family (a mother and three of five children). Approximately one per cent of American blacks have beta-thalassemia trait (Goldstein et a l . , 1964). The most outstanding feature is that the proportion of hemoglobin A 2 is double the normal proportion of two to three per cent. Other forms of thalassemia are presently an enigma concerning both their genetics and their biochemistry. A form characterized by modest elevation of fetal hemoglobin (8-10 per cent), and normal or low levels of hemoglobin A 2 in the heterozygous state has been designated as beta delta-thalassemia (Weatherall, 1967 and Fessas, 1966). The prevalence of this latter form among American blacks has not been estimated. Eight individuals (.43 per cent) in the sample were diagnosed as thalassemia minor (betathalassemia heterozygotes or beta delta-thalassemia heterozygotes). 105 The prevalence figures of the various hemoglobin types diagnosed in the Lansing sample, agreement with other, B. are in excellent less randomized samples. Prevalence of Hemoglobin Types in Grand Rapids Because of the method of ascertainment in the Grand Rapids survey, the prevalence figures for the various hemo­ globin types are not as would be expected in a random sample. The family studies began wi t h 309 probands previously identified in a school-wide screening program in the city. The screening procedure was comprised of an automated solubility test, incapable of identifying non-sickling hemoglobins other than hemoglobin A. It was expected that greater than 50 per cent of the persons diagnosed would have at least one gene for the production of sickling hemoglobin (including the p r o b a n d s ) . It was found that 51.8 per cent had no sickling hemoglobin and 48.2 per cent had at least one sickling hemoglobin. the probands were excluded, When 164 of 497 (33 per cent) were found to have at least one gene for the production of h e m o ­ globin S. Approximately 50 per cent were expected. When an analysis was made by including only those sibships where both parents had b een diagnosed and excluding one proband per family, only 39 per cent of the sibs were found to have sickle cell trait. This represents a significant difference in the proportion of trait persons expected (Chi square « 7, d.f. = 1, p < . 0 1 ) . A similar analysis in the Lansing sample revealed that 34 per cent of the sibs were carriers while 66 per cent had normal hemoglobin (Chi square = 10.24). 106 In every family included, the parents indicated that they were the biological parents and laboratory diagnosis for hemoglobin types among the parents and offspring failed to disprove t his. It is unlikely that illegitimacy would be responsible for these differences. An estimate was made of illegitimacy in the Lansing population where there were many matings of normal by normal parents. There was one case of Illegitimacy detected in this population where the gene frequency for hemoglobin S was .043. The estimate of illegitimacy was determined to be .0605, providing evidence that it is unlikely that this would explain the small proportion of trait persons in these two populations. These findings, along with those implied by the relatively fewer number of trait children in the age trend analysis, are provocative enough to suggest more definitive studies with respect to determining if there is a higher mortality rate in the younger age groups among persons with sickle cell trait. C. Awareness of Sickle Cell Anemia A surprisingly large percentage of adults In both cities indicated that they had heard of sickle cell anemia before. This may have been the result of public awareness through the various news media in both cities prior to the testing programs. In a similar survey conducted by Lane and Scott in Richmond, Virginia In 1968, only three out of ten adult blacks had ever heard of sickle cell anemia. 107 Another striking finding in the Richmond study was that the level of awareness of the disease was strongly related to the educational level achieved by the individuals. This was clearly confirmed in the Lansing and Grand Rapids surveys. D. General Health In the Lansing sample, a significantly greater pro­ portion of persons with sickle cell trait had their general health described as fair or poor. The age group that was the most disproportionate was the 0-12 age g o u p . There were 621 children with normal hemoglobin in the age group of 0-12 years. Fifty-nine (9.5 per cent) had their health described as fair or poor . There were 47 trait children in this age group and eight (17 per cent) of them were described as having fair or poor general health. In most previous epidemiological studies comparing sickle cell trait with normal controls, children were not included. Also, previously reported cases did not inquire of each person's general health. Therefore, it is not possible to compare these findings with other studies. In the Grand Rapids survey there was no significant difference in general health between trait and normal individuals. E. Drug, Tobacco and Alcohol Usage There was no significant difference in the prevalences of the use of drugs or tobacco in either of the two pop­ ulations. However, in the Lansing sample, a significantly greater proportion of trait adults consumed alcoholic beverages regularly. As mentioned earlier, only four adults 108 with or without sickle cell trait in the Grand Rapids pop­ ulation admitted to regular consumption of alcoholic beverages. This difference in the two populations is difficult to explain. However, it is doubtful that interviewing techniques were responsible for these d i f f e m e c e s . These questions were asked to find out if trait persons would be more likely to show symptoms of sickling due to frequent consumption of agents that might induce in vivo sickling and/or consume drugs more frequently that would relieve pain that might be associated with in vivo sickling. F. Symptoms of Health Problems 1. Ophthalmologic and Hearing Problems When comparisons were made in the separate samples, there was no significant difference between the normal controls and trait persons in the use of glasses and hearing aids. 2. Infections In the separately tabulated populations there were no differences between subjects with and without trait for infections, except in Lansing, the prevalence of sore throat, which occurred more frequently among the controls. It was expected that if differences were observed in the category of infections, they would be more prevalent among subjects with sickle cell trait. 3. Symptoms of Anemia Among the symptoms of anemia, sense of exhaustion was the only variable significantly associated with sickle cell trait in Lansing. The magnitude of association was very 109 low, as with other variables associated with the trait. 4. Musculoskeletal Symptoms Weakness in legs and pain in bones were the two variables significantly associated with the trait in the Lansing sample and swollen joints in the Grand Rapids survey. The magnitude of association in each of these is also low. 5. Genitourinary Problems In the separate samples of thetwo cities, the prevalences of genitourinary problems were so small that statistical analysis would be meaningless. The most fre­ quently reported and established problems among persons with sickle cell trait are hematuria, hyposthenuria and renal infarction. Also, among women with sickle cell trait, there is an increased incidence of pyeleonephritis and urinary tract infection and among men with the trait there are many reported cases of priapism. None of these hold true in the two populations in this study. 6. Cardiovascular and Gastrointestinal Problems There were no differences in either population for any of the cardiovascular or gastrointestinal problems asked about. It was not expected that there would be any differences in the cardiovascular symptoms, except by chance. In the gastrointestinal symptomatology, if differences had been observed, the greater prevalences would have been expected to occur among trait persons. 110 7. Epistaxis This condition was significantly more prevalent among trait persons in the Lansing survey and in the Grand Rapids tabulation which included the probands. However, when the probands were removed from the tabulation, the proportion of trait and normal persons was almost identical. 8. Neurologic Problems There were no significant differences between trait and normal persons in any of the neurologic symptoms in the Lansing sample and none in this category in the Grand Rapids survey that excluded probands. However, the total surveyed Grand Rapids population showed a significantly greater pro­ portion of trait persons with numbness in legs. Analysis of the responses related to health symptom­ atology reveals in the Lansing random sample that only four of the 34 variables were significantly associated with sickle cell trait and one significantly associated with the normal controls. In the Grand Rapids survey, excluding probands, only swollen joints was significantly associated with the trait. In addition to swollen joint problems, epistaxis and numbness in legs were significantly associated with the trait before the exclusion of the 146 probands. school-aged children, Since probands were all this finding would suggest that these symptoms might in some fashion be age related. When a single test of association of overall health was made by categorizing respondents into "sick’1 and "well” , Ill there was no statistical difference between trait and normal respondents in either of the too populations. Further analysis of age specific relative odds ratios for sickness and general health were made for the Lansing sample because it was observed that there were relatively fewer children with sickle cell trait in this population and a greater proportion of them (trait subjects) had their health described as fair or poor. The age specific relative odds ratios for sickness among trait persons do not show a specific age related pattern, but does show an increasing proportion of "sick" subjects among both traits and normal controls (with one exception among trait subjects). The trend in age specific relative odds ratios for good or bad health is quite clear. The younger the trait individuals, the more likely (e.g., 0-17 nearly twice as likely) they are to view themselves ( or parents view them) in bad health. This trend holds even with the increasing bad health risk, that is, the risk of bad health for traits and normals increases with age, but relative risk decreases. Hence, somewhat contrary to the age trend of poorer health, the younger trait individuals are at greater relative risk. G, Age Trends The observed data relating to age trends among subjects with sickle cell trait in the Lansing sample do not show a decrease in the proportion of carriers in the older age groups. If the carrier state were associated with an 112 increased mortality as several reports have indicated (Neel, 1951; Rucknagel and Neel, 1961; Pollitzer, 1958), one would expect a significant decrease in the proportion of carriers in the older age gro u p s . These observed data are in agreement with the data of Petrakis et al. (1970), McCormick and Kasgarian (1965) and Heller (1968). H, Pregnancy History No significant differences in primary or secondary fertility were observed in either of the two populations of females of reproductive age. The mean number of preg­ nancies among females in the Grand Rapids survey (trait and normal controls) was 5.5. The frequency with which sickle cell trait is encountered in pregnant black women in this country is not clear. Jenkins and Clark (1962) identified it in less than five per cent of their subjects, while Switzer and Fouche (1948) reported a frequency of more than 14 per cent. Possible criticisms of these studies, as well as the present one, are the small numbers of patients evaluated. That the sickle cell trait group was similar to the normals with respect to miscarriages, stillbirths, secondary fertility and number of children living, is in agreement with several hospital and clinic studies reported in the literature (Adams et a l . , 1953; Whalley et a l . , 1963; Hendrickse and Watson-Williams, 1966; Abrams, 1959; Beacham and Beacham, 1960). 113 No differences were seen in responses of females (14 years of age or older) to questions concerning the use of oral contraceptives and problems as a result of using them. The health-problem symptoms asked about in the interview were those that frequently occur in individuals regardless of whether they have sickle cell anemia or sickle cell trait or normal hemoglobin. with sickle cell anemia, these symptoms may or may not present themselves from time to time. protean symptoms, Even in individuals Because of these sickle cell anemia has frequently been referred to as the great "mimicker". If this type of variability of symptomatology exists among those individuals with sickle cell anemia, then the variability would be even more subtle among those individuals with sickle cell trait. SUMMARY A survey was undertaken to obtain a reliable estimate of the prevalence of sickle cell trait and to gather evidence for its effect on blacks in three Michigan populations. The results of the observations are listed below: 1. The prevalence of sickle cell trait in the randomly selected sample of Lansing, Michigan was 8.2 per cent. This frequency is very similar to previously reported, but less systematically sampled populations in the United States. 2. Sixty per cent of 1,097 black adults surveyed in Lansing and Grand Rapids had heard of sickle cell anemia at the time of the interview. Eighty per cent of those who had heard of the disease indicated that they knew it was inherited. 3. A comparison of general health as obtained by questionnaire from 1,755 subjects with and without sickle cell trait in the Lansing sample revealed a significantly greater proportion of trait persons who described their health as fair or poor. A similar comparison among 633 subjects in the Grand Rapids survey revealed no significant difference in response between heterozygotes and homozygous normals. 4. Responses to 34 items pertaining to health problems and symptoms revealed only four which were significantly associated with sickle cell trait in the Lansing sample (sense of exhaustion, weakness in legs, pain in bones and epistaxis) 114 115 and only three in the Grand Rapids survey (swollen joints, numbness in legs and epistaxis). No significant difference was found between trait and normal individuals in terms of the number of these symptoms more or less frequent in either group. 5. Further analysis by a single test of association of health problems and sickle cell trait revealed no significant difference between trait and control subjects. 6. In the Lansing sample there were significantly fewer trait persons in the younger age groups and a significantly greater proportion of these children had their general health described as fair or poor. These observations indicate that the younger trait individuals may be at a greater risk. 7. An age trend analysis among trait subjects in the random sample does not show a decrease in the proportion of carriers in the older age groups, providing no evidence that the carrier state is associated with an increased mortality. However, an analysis of sibships containing children with sickle cell trait revealed that significantly fewer than expected trait children were found. 8. Neither of the populations revealed a differential in primary or secondary infertility among females with sickle cell trait. Nor was there any statistical difference between trait and control females of reproductive age for miscarriages or stillbirths or number of children living. 116 9. The proportions of trait and normal f using oral contraceptives were similar and no statistical difference in problems resulting from the use of contra­ ceptives was ascertained. 10. A comparison of means and standard deviations of seven hematological indices between trait and normal subjects revealed no significant differences. These findings confirm previous reports demonstrating that the trait does not generally contribute to a tendency to be anemic. 4 BIBLIOGRAPHY BIBLIOGRAPHY Abel, M.S., Brown, C,R, 1948, Sickle cell disease with severe hematuria simulating renal neoplasm, J. Amer. Ass. 136:624-625, Abrams, J. 1959. Sickle cell trait in prenancy, and Gynec. 14:123-126. Obstet. Adams, J. 1957. Sudden death in pregnancy due to sickle cell trait. Southern Med. J. 50:898-901. Adams, J.Q., Whitacre, F.E. and Diggs, L,W. 1953, Prenancy and sickle cell disease. Obstet. and Gynec. 2:335-352. Anderson, M. , Went, L.N. and Maclver, J.E. 1960. cell disease in pregnancy. Lancet 2:516-521. Sickle Bansbach, W . A . , May, R. and Rogast, M. 1960. Hypotoxic bladder associated with sickle cell trait. J, Urol. 84: 470-471. Bauer, J . , Fisher, L,J, 1943. Sickle cell disease, with special regard to its non-anemic variety. Arch. Surg. (Chicago) 47:553-563. Beacham, W.D., Beacham, D.W. 1960. Sickle cell disease and pregnancy. Amer. J. Obstet. Gynec. 60:1217-1226. Bennett, M.A., Heslop, R.W. and Meynell, M,J, hematuria associated with sickle cell trait. J. 1:667-679. Blank, A.M., Freedman, W.L, 1969. pregnancy. Clin. Obstet. Gynec. 1967. Massive British Med. Sickle cell trait and 12:123-133. Boyle, E . , Jr., Thompson, C. and Tyroler, H.A. 1968. Pre­ valence of the sickle cell trait in adults of Charleston County, S.C. Arch. Environ. Health 17:891-898. Bradley, T.B., Jr., Brawner, J.N., III and Conley, C.L. 1961. Further observations on an inherited anomaly characterized by persistence of fetal hemoglobin. Bull. John Hopkins Hosp. 108:242-257. Conrad, W.C., Penner, R. 1967. Sickle cell trait and central retinal artery occlusion. Amer. J. Opthal. 63:465-468. Cooley, J.C., Peterson, W . L . , Engel, C.E. and Jernigan, J.P. 1954. Clinical triad of massive splenic infarction, sicklemia trait and high altitude flying. JAMA 154:111-113. 117 118 Conn, H.O. 1954, Sickle cell trait and splenic infarction associated w i t h high^altitude flying. N. Engl, J. Med. 251:417-420, Diggs, L.W., Ahmann, C.F. and Bibb, T. 1933. Incidence and significance of sickle cell trait. Ann. Intern, Med, 7: 769-778. Diggs, L . W . , Jones, R.S. 1952. Amer. J. Med. Sci, 22:194. Clinicopathologic Conference Emmel, V.E. 1917. A study of the erythrocytes in a case of severe anemia with elongated and sickle-shaped red blood corpuscles. Arch. Intern, Med. 20:586-598. E n d e , N . , Pizzalato, P. and Ziskind, Ann. Intern. Med. 42:1065-1075, J, 1955. Sicklemia, Erlik, D . , Barzilai, A., and Shramek, A. 1965. Renal function after left renal vein ligation. J. Urol. 93: 540-544. Fessas, P. 1968. The heterogeneity of Thalassemia. Plenary session papers, Twelth Congress of the International Society of Haematology, pp. 52-63. Goldstein, M . A . , Patapongpanij, N. and Minnich, V. 1964, The incidence of elevated hemoglobin A? levels in the American Negro. Ann. Intern. Med. 60: 95-99. Goodwin, W.E., Alston, E.F. and Semans, J.H. 1950. and sickle cell disease. J. Urol. 63:79-96. Hematuria Greenberg, M.S., Kass, E.H. 1955, Correlation of in-vitro studies of blood with clinical observations in patients with the sickling phenomenon. Clin. Res. Proc. 3:96-97. Greenberg, M.S., Kass, E.H. 1956. Alkali in the treatment of painful crises in patients with sickle cell anemia. Proc. Amer. Soc. Clin. Invest. 48:25. Greer, M . , Schotland, D. 1962. Abnormal hemoglobin as a cause of neurologic disease. Neurology 12:114-123. Griggs, R.C., Harris, J.W. 1956. The critical role of potassium in the sickling phenomenon. Clin. Research Proc. 4:80. Hahn, E.V., Gillespie, E.B. 1927. Arch. Intern. Med. 39:233-254. Sickle cell anemia. Harrow, B . R . , Sloane, J.A. and Liebman, N.C. 1963. Roentgenologic demonstration of renal papillary necrosis in sickle cell trait. New Engl. J. Med. 268:969-976. 119 Harvey, G.M. , Jr. 1954. Sickle cell crises without anemia, occurring during air flight. Mil. Surgeon, 115:271-275, Heller, P. 1968. The clinical impact of abnormal hemoglobins. Proc. Inst. Med. Chic. 27:143-145, Hendricks, J.P., W a tson-Williams, E.J. 1966. The influence of hemoglobinopathies on reproduction. Amer, J. Obstet. Gynec. 94:739-48. Herrick, J.B. 1910. Peculiar elongated and sickle-shaped red blood corpuseles in a case of severe anemia. Arch. Inter. Med. 6:517-521. Huck, J.S. 1923. Sickle cell anemia. Bull. 34:335-344. John Hopkins H o s p . Ingram, V.M. 1957. Gene mutations in human hemoglobin) the chemical difference between normal and sickle cell hemo­ globin. Nature 180:326-328. Isbey, E.K. Jr., Clifford, G.O. and Tanaka, K.R. 1958. Vitreous hemorrhage. Amer. J. Ophthal. 45:870-879. Jenkins, M.E., Clark, J.F.J. 1962. Studies into maternal influences on the well being of the fetus and newborn. I. Distribution of abnormal hemoglobins among pregnant Negro women. Amer. J. Obstet. Gynec. 84:57-61. Jones, S.R., Binder, R.A. and D o n o w h o , E., Jr. 1970. Sudden death in sickle cell trait. N e w Engl. J. Med. 282:323-325. Kabakow, B . , Van Weimokly, S.S. and Lyons, H.A. 1955. Bi­ lateral central retinal artery occlusion. Arch. Ophthal. 54:670-676. Kennedy, J.J., Cope, C.B. 1957. Intraocular lesions associated with sickle cell disease. Arch. Ophthal. 58:163-168. Konotey-Ahulu, F.I.D. Lancet 1:1003-1004. 1965. Sicklaemic human hygrometers. Konotey-Ahulu, F.I.D. 1969. Anaesthetic deaths and the sickle cell trait. Lancet 1:267-268. Lane, J.C., Scott, R.B. 1969. Awareness of sickle cell anemia among Negroes of Richmond, Virginia. Public Health Rep. 84:949-953. L i e b , W . A . , G e e r a e t s , W.J. and Guerry, D. 1959. retinopathy. Acta Ophthal., suppl. 58, 3-45. Sickle cell 120 Lucas, W.M. , Bullock, W.H. 1960. disease. J. Urol. 8 3 i733-741. Hematuria in sickle cell McCormick, W.F. 1961. Abnormal hemoglobins, II, The p a tho­ logy of sickle cell trait. Amer. J. Med. Sci. 241:329-335. McCormick, W.F. 1964. Abnormal hemoglobins. IV. A n ana­ lysis of more 9,000 patients. J. Tenn. Acad. Sci. 39:145147. McCormick, W.F., Kashgarian, M. 1965. Abnormal hemoglobins. V. Age at death of patients with sickle cell trait. Amer. J. Human Genetics 17:101-103. Miller, W . A . , Peck, D, and Lowman, R.M. 1969. Perirenal hematoma in association with renal infarction in sickle cell trait. Radiology 93:351-352. Mull, J.D. 1964. Clinical significance of the sickle cell trait: a case associated with bizzare cerebral manifesta­ tions. Univ. Mich. Med. Cent. J. 30:289-291. Murayama, M. (with Hb.S) Sickle Cell Nalbandian, 1971. Molecular m e c hanism of human red cell sickling. Chapter 1 in Molecular Aspects of Hemoglobin: Clinical applications. Ed., R.M. C.C. Thomas, Springfield, 111. Myerson, M . , Harrison, E. and Lohmuller, W. 1959. Incidence and significance of abnormal hemoglobins (Report of a series of 1,000 hospitalized Negro veterans). Am. Jour, of Med. 26:543-546. Neel, J.V. 1949. Science 110:64-66. The inheritance of sickle cell anemia. Neel, J.V. 1951. The population genetics of two inherited blood dyscrasias in man. Symp. Quant. Biol. 15:141-156. Neel, J.V. 1973. Sickle cell disease: Abramson, Bertles, Withers, editors: diagnos i s , education, and research. Louis. a w o rld wide problem. Sickle cell diseaseC.V. Mosby Co., St. Nichols, S.D. 1968. Splenic and pulmonary infarction in a Negro athlete. Rocky Mountain Med. J. 65:49-50. Ober, William B . , Bruno, M.S., Weinberg, S.B., Jones, F.M. and Weiner, Leo. 1960. Fatal intravascular sickling in a patient with sickle-cell trait. New Engl. J. Med. 263: 947-949. Pauling, L , , Itano, II,A,, Singer, S,J, and Wells, I,C, 1949, Sickle cell anemia, a molecular disease, Science 1 1 0 i543548. 121 Perillie, P.E. 1962. Sickling phenomenon produced by hypertonic solutions: a possible explanation for the hyposthenuria of sicklemia. J. Clin, Invest. 41:1391. Perillie, P.E., Epstein, F.H. 1963. Sickling phenomenon produced by hypertonic solutions; a possible explanation for the hyposthenuria of sicklemia. J. Clin. Invest. 42: 570-579. Petrakis, N.L. , Wiesenfeld, S.L., Sams, B . J . , Collen, M . F . , Cutler, J.L. and Siegelarub, M.S. 1970. Prevalence of sickle cell trait and G6PD. N e w Engl. J. Med. 282:767-770. Pollitzer, W.S. 1958. The Negroes of Charleston (S.C.): a study of hemoglobin types, serology and morphology. Am. J. P h y s . A n t h r o p o l . 16:241-263. Rahimimto o l a , S., Good, C.J., and Davies, P.D.B. 1960. Pulmonary infarction in disorders associated with sickle cell trait. Thorax 15:320-324. Ratcliff, R.G., Wolf, M.D. 1962. Avascular necrosis of the femoral head associated w ith sickle cell trait. Ann. Intern. Med. 57:299-304. Rotter, R . , Luttgens, W.F., Peterson, W . L . , Stock, A.E. and Motulsky, A.G. 1956. Splenic infarction in sicklemia during airplane flight: Pathogenesis, hemoglobin analysis and clinical features of six cases. Ann. Intern. Med. 44: 257-270. Rubenstein, E. 1961. Studies on the relationship of temperature to sickle cell anemia. Amer. J. Clin. Invest. 41:1391. Rucknagel, D.L. 1973. Genetic basis of sickle cell disease. Abramson, B e r t l e s , Wethers, editors: Sickle cell disease diagnosis, management, education and research. C.V. Mosby C o ., S t . L o u i s . Rucknagel, D . L . , Neel, J,V, 1961, The hemoglobinopathies, Steingberg, A. editor: Progress in medical genetics, Vol. 1. Grune and Stratton, Inc., N e w York. Schenk, E.A. 1964. Sickle cell trait and superior longi­ tudinal sinus thrombosis. Ann. Intern. Med. 60:465-470. Schlitt, L.E., Kertel, H.G. 1960. Renal manifestations of sickle cell disease-a review. Amer. J. Sci. 239:773-777. Shapiro, A.L., Baum, J.L. 1964. Amer. J. Ophthal. 58:292-294. Acute open angle glaucoma. 122 Sherman, I.J. 1940, Sickling phenomenon w i t h special reference to the differentiation of sickle cell anemia from sickle cell trait. Bull. Johns Hopkins Hosp. 67: 309-324. Smith, E.B. 1970, Complications in sickle cell trait. National Med. Ass. 62:334-336. J. Smith, E.W. ,Conley, C.L. 1954. Clinical features of the genetic variants of sickle cell disease. Bull. Johns Hopkins Hosp. 94:289-316. Smith, E.W. ,Conley, C.L. 1955. Sicklemia and infarction of the spleen during aerial flight; electrophoresis of the hgb. in 15 cases. Bull. Johns Hopkins Hosp. 96:35-41. Smoot, R.T., Trader, J.D., D o w e , C.R. and Allain, C.C. 1961. The sickle cell disease: current status and preliminary research observation. J. Nat. Med. Ass. 53:137. Stein, M . R . , Gay, A.J. in sickle cell trait. 1970. Acute chorioentinal infarction Arch, of Ophthal. 84:485-490. Sullivan, B.H., Jr. 1950. Dange of airplane flight to p e r ­ sons w i t h sicklemia. Ann, Intern. Med. 32:338-342. Sultz, H . A . , Schlesinger, E.R. and Mosher, W.E. 1968. The Erie County survey of long-term childhood illness. II. Incidence and prevalence. Am. J. Public Health 58:491-498. Switzer, P.K. 1950. The incidence of sickle cell trait in Negroes from Sea Island area of South Carolina. Southern Medical J. 43:48-49. Switzer, P . K . , Fouche, H.H. 1948. Sickle cell trait: In­ cidence and influence in pregnant colored women. Amer. J. Med. Sci. 216:330-332. Tellem, M . , Rubenstone, A.I. and Frumin, A.M. 1957. Renal failure and other unusual manifestations in sickle cell trait. Arch. Path. 63:508-512. Thoma, G.W. 1953. The incidence and significance of sickle cell diseasw in death subject to medicolegal investigation. Am. J. Med. Sci. 226:412-418. Thompson, R . K . , Wagner, J.A., and MacLeod, C.M. 1948. Sickle cell disease: report of a case w i t h cerebral m a n i ­ festations in the absence of anemia. Ann. Intern. Med. 29:921-928. Tseng, H.L. 1959. Path. 67:339-346. Fatal cases of acute sicklemia. Arch. 123 Ullrich, K.J., Kramer, J. and Boylan, J.W. 1962. jn Renal Disease, edited by D ,A ,K . Black, Blackwell, Oxford, Weatherall, D.J. G e n e t . 5:8. 1967. The Thalassemias. Progr. Med. Welch, R.B., Goldberg, M.F. 1966. Sickle cell hemoglobin and its relation to fundus abnormality. Arch. Ophthal. 75:353-362. Whalley, P.J., Pritchard, J. and Richards, J . R . , Jr. 1963. Sickle cell trait and pregnancy. JAMA 186:1132-1135. Whalley, P.J., Martin, F.G. and Pritchard, J.R. 1964. Sickle cell trait and urinary tract infection during pregnancy. JAMA. 189:903-906. Wintrobe, M.M. Clinical Hematology, Lea and Febiger, 1967. ed. 6. Philadelphia, APPENDIX A LETTER OF INTRODUCTION .APPENDIX B HEALTH SURVEY AND QUESTIONNAIRE 124 M I C H I G A N STATE UNIVERSITY e a s t la n s in o * M i c h i g a n 488 2 3 CENTER F O R URBAN AFFAIRS • O W E N G R A D U A TE CENTER July 28, 1971 Dear Lansing Residenti Do you know that If you aro black, the chancos are about 1 in 10 that you carry a gene for sickle cell anemia (->CA)? Do you knoxj that if you carry a gene for this inherited dlsordor that tho chances are 1 in 2 that you may pass this geno on to your children? 30 ‘/HAT?I ? Carriers of tho gone for sicklo coll anemia often have no idea that they havo this gono which can havA harmful effects on tho individual* Frequently the effects of this geno are so similar to other sicknesses that they are often overlooked by doctors* Because of the high prevalence of this geno among blacks, wo, the black members of the genetics group of tho department of zoology, feel that all blacks should know if they have this gone. Therefore, we, in collaboration with the "odel Cities health program and the Ingham County Health Department, will bo coming into your neighborhood to offer a quick, easy tost* You ott o i t to yourself a n d to your children to obtain this free, important information* Beginning August 2, 1971, our team will bo in your neighbor­ hood days and evenings for tho test* At this time we would like to ask you a few questions about your family's health and give the tost to as many family mambers as possible, especially all parents and adults in your household* Approximately one weok following tho testing you will bo notified of tho results (positive or negative), If your test is positive, us viill provide you with free additional informa­ tion, gonetic counseling and Inform your doctor if you desire* Also, wo can refer you to a doctor for help in modical manage­ ment in case of complications* Respectfully, *. jf .■ .*■ j <■ Frankie J , Brown, Graduate - tudont Astrid K* ->ack, Graduate student Department of Zoology Ajovi bcott-iilmiakpor, PHD. Ass't* Prof* GENERAL OBJECTIVES To obtain a reliable estimate of the frequency of the sickle cell gene in the Black population. Previous United States studies exploring this question have largely enployed nonsystematic sampling procedures, institutionalized populations, and the like. To Investigate the overall effect of the gene for sickle cell anemia on the health of the Black population. It has been claimed that there is a higher incidence of certain clinical symptoms and more diffuse patterns of social adjustment among persons with one gene for sickle cell anemia than in persons without this gene. To make the public aware of Sickle Cell Anemia, its mode of inheritance, and its manifestations as a major health problem of the Black cornnunity so as to encourage more funding, research and better management of the disease. To identify carriers and those with the disease so that persons with health problems related to this disease may be able to take advantage of existing treatments for the disease. To establish referral services so that individuals with the disease may be sent to centers for effective treatment to be enployed. To provide genetic counseling, based on information from this study. PURPOSE AND INSTRUCTIONS FOR TEE HEALTH SURVEY General Introduction Sanple every dwelling unit - addresses and apartment nurbers will be pro\riLded. If addressee designated is not at home, note this and make arrangements to return later, leave cards with number to call. Sample household in DU - i.e., the entire group of persons who live in one dwelling unit. It may be several persons living together or one person living alone. It may include more than one family. For our purposes, we are interested in obtaining health data and blood samples from as marry individuals as possible, tfe are especially interested in getting blood samples from all biological parents of the children in each dwelling unit and all other adults. One health questionnaire should be completed for all menbers of one nuclear family - i.e. father, mother, and children. In cases where several families occupy one dwelling unit (house­ hold) or where there is an extended family situation a separate questionnaire should be completed for each nuclear family (see instructions for question #1). 'Do not request health information on absentee menbers who are more or less continually away, e.g. persons away in the service, in an institution, etc. but these should be noted in renarks. Health information should be obtained about all family menbers from whom we may potentially obtain blood sanples even though some of the family may refuse to give blood at the time of the interview. INTERVIEWER RESPONSIBILITIES AND BEHAVIOR. IN THE COLLECTION OF THE INFORMATION Introduction Every question in the questionnaire is here because of a need to obtain information to help us determine the effects of the gene for SCA on the health of its possessors. There should be no act or mannerism or any statement or other indication of judgement by you as to "good or bad" in terms of social acceptance of any topic in the course of the interview. Even if you feel that a given question might be personnally offensive, not all respondents would agree. Experience has shown that most people are willing to give the information sought if an adequate explanation is given about the purpose and the needs. Analysis and use of these data are designed to obtain accurate frequency estimates and effects of the SCA. gene on the health of the Black community, to help us reconmend better management procedures for this disease. The information sought is respect­ fully requested of the household as a gift of time and information. This gift should be given and received in dignity. It must not be demanded nor obtained by coercion. A refusal is the perogative of the respondent; it is no personal affront, but the expression of a fundamental human right. 1'28 B. Your Responsibility in Contact With the Public In collecting information, the first responsibility is to main­ tain a high standard of accuracy in the data which you record on the questionnaires, lb honor this responsibility and as a representative of the Sickle Cell Anemia Testing Program, you are expected to conduct each interview in a straight-forward business-like way and to conduct each interview in such a manner as to reflect credit to the profession of which you are a part. Some of your respondents may seek advice from you regarding health matters; for exanple, you might be asked for your views on fats in the diet, the relation of smoking to lung cancer, or the like. You should avoid giving advice on any subject whatsoever. Refer them to the clinic or a doctor. You should also avoid conversation which is not directed at the details you desire. You should refrain from any discussion of politics, religion, sex, income or other topics which may cause unrelated conversation or create an unprofessional atmosphere. Having found the specified sample dwelling unit, you should identify yourself, and briefly state the purpose of the visit. If not invited in immediately, you should add, "May I come in?" If the respondent appears to be reluctant, you should further explain the purpose and add, "May I come in and talk with you about it?" If there is still no response, request an appointment at a later time. Lengthy discussion should be avoided. The interview should NOT be conducted at the door; for the sake of consistency, the results should be obtained in a setting xdiich will allow careful consideration and recording. The introduction should serve to: 1. Let the respondent lcncw who you are and why you are there. 2. Set the scene and arrange for you to conduct the health appraisal interview. 3. Point out all information about individuals and families will be held strictly confidential and will be seen only by scientists and health and medical professionals. The information about individuals will not be revealed to any other agency, local, state or federal, although summary information for groups of blocks or larger areas will be usable by all. You should be prepared to discuss and explain the purpose and philosophy of the project. You will find that most respondents will accept a brief explanation in the introduction. However, there will be a few who will want more information, or who may actually refuse to be interviewed for a variety of reasons. Their attitudes and intentions are their own and are to be honored at all times. Our experience has been that very few respondents actually refuse to cooperate. However, if you have difficulty in obtaining an interview, explain the purpose and importance of the project and stress the 129 confidential treatment accorded all information furnished by the respondent. Ihis should be done also at any point during the inter­ view if the respondent should hesitate to answer certain questions. If the respondent states that she has no time right new for an interview, find out when you can come back. However, always assume (without asking) that the respondent has the time right now unless she tells you otherwise. C. Selection of Respondent The wife or mother is the preferred respondent. If she is not at home at the initial visit, arrange to return when you can talk to her. Another adult may be interviewed if the spouse so desires. People present may respond for themselves, but usually a parent's interpretation of an illness should be accepted if conflicting statements are given by child and mother. When there is no obvious "mother" and if the opportunity presents itself choose as a respondent the adult in the family who seems most likely to know the family's health. D. Confidentiality Collection of valid information on any topic, and particularly on matters related to health or ill health, requires the establishment and constant maintenance of confidnece on the part of the respondent. A prime requisite for establishing proper rapport Is a clear understand­ ing of how the information will be used and, more importantly, that it will not be misused. In most instances, the legitimacy of your mission will not be questioned. When it is, considerable effort on your part may be required. The information will be used only as a part of a scientific and statisti­ cal picture, and will not be used in any way which would be harmful to anyone. You can reinforce this by describing the care that is taken: Ihis project uses the same kinds of protection controls as the U.S. Census; while in your possession, any completed questionnaires are kept in special folders and your car is locked when not in use; no un­ authorized person is ever permitted to see the forms and, at all points of handling, strict security is maintained. Names and addresses will not be used except for the necessary purpose of making sure that the recorded information is for the person to whom it refers and for sending test results. The responses obtained are suoraarized and shown only in the form of statistical stannaries, in groupings such as age, sex, or neighborhood, so that published details cannot be traced back to families nor to individuals. 130 E. Interviewing Techniques Your greatest asset in conducting an interview efficiently is to combine a friendly attitude with a business-like manner. If a respondents conversation wanders away from the interview, try to cut it off tactfully - preferably by asking the next question on the questionnaire. Over-friendliness and concern on your part about the respondent's personal troubles may actually lead to your obtaining less information. Start each section by asking the questions as worded on the record, listen to the respondent until she finishes her statement. (Failure to do so can result in your putting down incorrect or incomplete entries). The two most common types of errors made in this regard are: 1. Failure to listen to the last half of the sentence because are busy recording the first half. 2. Interrupting the respondent before she has finished, especially if the respondent hesitates. A respondent often hesitates when trying to recollect some fact, and you should allow sufficient time for this to be done. Also, people will sometimes answer "I don't know" at first, when actually they are merely considering a question. When you think that this may be the situation, wait for the respondent to finish the statement before repeating the question or asking an additional question. Sometimes a person will give you an answer which does not furnish the kind of information you need or one which is not complete. You should always ask additional questions in such cases, being careful to encourage the respondent to explain without your suggesting what the response "should be". In all sections of the questionnaire, you should ask as many questions as necessary to satisfy yourself that you have obtained complete and accurate information insofar as the respondent is able to give it to you. NEVER frame a question in the negative (eg. "You don't have any heart trouble, do you?"). Every effort should be made to encourage the respondent to give specific and complete answers to the questions. Sometimes the respondent doesn't have the information needed to answer a question. In such cases, you should enter "DKV for "don't know” or enter a check in the space for the answer. Ask additional questions as required in order to get a recordable answer, but you should not probe beyond the intent of the question. Record any pertinent remarks which the respondent may volunteer. Do this at any point in the questionnaire, even though the information may have to do with some question other than the one you are dealing with. Later, you can make the needed cross-referencing. There may be some items of information which the respondent doesn't knew, for exanple, height of child. In such cases, you should enter "DK" for "don't know". Do not leave any items blank where entries 131 are required. If the respondent refuses to give the required information for a particular item and still is unwilling to give it after you have explained how the information is protected for confidentiality, you should enter "Ref." for refused in the "DK" column. F. tfaking Contact with the Household 1. Having selected the dwelling unit for health appraisal work and blood sampling, inquiry as to persons, relationships and location of the people will verify the place as the true dwelling unit and will raise questions which will help determine whether more than one set of health records is indicated. 2. Absent households - Since a household respondent is required, you need to find out who she is and when she is likely to be at home. Housekeepers, babysitters, neighbors and even small children will be helpful. Seme night visits will be required and Saturday is usually a good day to catch working people at heme. 3. The respondent is at heme but says she is too busy - If she says so, she is. But she may be just putting you off: If you think that is the case, ask if you could take a few minutes to tell her about it. This should result in completing the interview at the time. If not, set a definite appoint­ ment for a return visit. 4. Procedure for handling call backs - Always try to complete the interview at your first visit to the dwelling unit. However, there will be cases where no one is at home during the day and an evening or Saturday call will be required. These are often working people and they must be equally represented in the results. Your work schedule should be arranged so that the necessary evening calls can be made. AN ENTHUSIASTIC AND EARNEST ATTITUDE IS PERHAPS THE MOST IMPORTANT - AND YET UNSPOKEN - ASPECT OF YOUR ABILITY TO OBTAIN RELIABU2 AND COMPLETE INFORMATION. Sample Group Address and Description of Location (Include apt. nuriber) --------------------------------- Family Sample Nos. Telephone No._______ Scheduled Appointment Best Time to Visit Signature___________________ __ Not Completed (Check Ctie) Record of Calls to Complete Interview: Household refusal Date: Extended Absence Date: Other (Specify) I f / I Time Interview Began Time Interview Completed__________________ Mo. Day Yr. Interviewer No. Bloods to be Drawn Date of Drawing Time of Drawing Sample Block # 132 133 1. What is the name of the head of this family? (Continue with other household members. At the end ask:) "Is there anyone else, anyone temporarily away, any baby not mentioned?" 1. 2. (Circle respondent lumber) 2. How i s related to the head of this family? (Are all children of this marriage? - if appropriate). (Specify) 3. Sex 4. Before being contacted by this group, had you ever heard of sickle cell anania? (Ask adults only). (Circle) Yes No DK Yes No DK Before being contacted by this group, did you know that sickle cell anemia is an inherited kind of anemia and is passed from parent to offspring? (Circle) Yes No DK Yes No UK 5. (Circle) 6. Would you say that (-- 's) general health is excellent, good, fair, or poor? (Circle) 7. When w a s 8. In what state w a s 9. What is the highest grade (or years) of school last attended (or is new attending)? (Number) REMARKS: bom? (Date) bom? (Specify) (State or Country) M F 1, Excellent 2. Good 3. Fair 4. Poor 5. DK M F 1. Excellent 2. Good 3. Fair 4. Poor 5. DK 134 DK Yes No DK Yes No DK No •DK Yes No Yes No DK Yes No DK Yes No DK Yes No Yes No IK Yes No DK Yes Excellent Good Fair Poor DK 1. 2. 3. 4. 5. Excellent Good Fair Poor DK 1. 2. 3. 4. 5. Excellent Good Fair Poor DK 2 F M M 1. 2. 3. 4. 5. F M F F 1. 2. 3. 4. 5. F M M DK Excellent Good Fair Poor DK 1. 2. 3. 4. 5. Excellent Good Fair Poor DK 135 10. What i s -- 's height? (specify) Ft. 11. What i s -- 's weight? (specify) Ibs. 12. What i s -- ’s current work status? (Probe as needed to enter code for each person aged 14 or older). In. DK. Ft. DK Ibs. In. DK DK Wbrking at a iob or business Puii ...... :oi Part t i m e ..............02 Incidental..............03 Not working............. 04 DK as to work status.... 09 (Enter appropriate code #) code code IF CODED 02, 03, OR 04 UNDER WORK STATUS a. I s -- not working full time because of illness or some disability? (circle) IF YES b. What is the illness or disability? (specify) c. How long h a s -- been limited in his ability to wrok because of this? (specify) REMARKS: 3 Yes No ESC Yes No DK 136 Ft. U ps. Code In. DK DK Ft. Ilis. Code In. DK Ft. DK Lbs. In DK Ft. DK Lbs. Code Code 4 In. DK Ft. DK Lbs. Code In. 137 13. Does anyone, on most days or every day: a. Wear glasses or contact lenses? b. Use a hearing aid? c. Smoke cigarettes? d. Use patent medicines or ’'pain killers"? (specify what and reason) e. Use any drug prescribed by doctor? (specify what and reason) 14. Yes £. Drink any alcoholic beverages? g. Take "relaxing" pills? How many times in the past year has had a cold? (specify) (If at least once, ask: D i d --- see a doctor for it (them)? How many times? (specify) REMARKS: 5 No DK. Yes No IK 138 DK Yes No DS DNS DK Yes No DK Yes No DS DNS DK DS DNS DK 6 DK Yes No DS DNS DK DK Yes No DK DS DNS DK 139 15. In the past year has — had trouble with Yes any of the following conditions or diseases? DS ENS (If yes) D i d -- see a doctor about it? (check) (If yes) Was — rushed to see a doctor or to the hospital for this? (Double check) (If yes) W a s -- required to be in a hospital overnight or longer? (X) (How many days?) (If yes) Did the illness cause-- to be away from his usual activities? (XX) (How many days?) a. Flu? b. Jaundice? c. High blood pressure? d. Low blood pressure? e. Blood in stool? f. Blood in urine? g. Blood in sputum? h. Nosebleeds? i. Faintness? REMARKS: 7 No DK Yes to DK DS DNS 140 es v DS DNS No DK Yes DS DNS No No DK DK Yes DS DNS Yes DK Yes No No DK DS DNS DS DNS ---- 8 4 141 15. cont'd. Yes DS j. Shortness of breath? k. Trouble breathing? 1. Tire easily (easy fatigue)? m. Sense of exhaustion? n. Pain in chest? o. Dizziness? p. Confusion and disorientation? q. Convulsions? r. Sore throat? s. Swelling joints? t. Painful joints? u. Muscle pain? v. Weakness in legs? w. Nurrbness in legs? REMARKS: 9 DNS No DK Yes DS DNS No DK 142 Yes DS DNS No DK Yes DS DNS No EK Yes DS ms — 10 No Yes DK DS DNS No DK Yes DS DNS No DK 143 15. cant'd, Yes DS DNS x. Pain in bones: y. Kidney or bladder trouble? z. liver trouble aa. Increased urine flow? bb. Pain in stcmach or abdomen? cc. Excessive formation of tissue? (unusual growth - tumor) dd. Ulcers (sores)? — Leg, foot or arm ee. Earaches? ff. Diarrhea or loose bowels? gg. Vaginal discharge? (females only) hh. Persistent erection penis without sexual excitement (priapism)? (males only) REMARKS: 11 No DK 1fcs No DS DNS DK 144 No DK Yes No Yes DS DNS DS DN! ■ DK Yes DS DNS 12 No DC Yes DS m No DK s No DK Yes DS DNS 145 16. In the past year h a s -- been seen by a doctor because of any other illness? (If yes) What was it? (If yes) Was it an emergency? (double check) (If yes) W a s -- required to be hospital overnight or (X) How many days? (If yes) Did the illness cause be away from is usual (XX) (How many days?) in a longer? — to activities? Yes No DK a. What? b. What? c. What? d. What? 17. How many pregnancies has each female had? (Number or DK) a. Has there been any trouble connected with any pregnancy? (Circle) (Specify) yeg Have there been any miscarriages or stillbirths? (Number or DK) Misc. Still. b. REMARKS: 13 ^ DK Yes No DK Yes No DK Misc. Still. 146 Yes No DK Yes No DK Misc. Still. Yes No EK Yes No DK Mi.sc. Still. Yes No DK Yes No DK Yes No DK Yes No DK Yes No DK Yes Misc. Misc. Misc. Still. 14 Still. No DK Still. 147 17. cond'd. c. Any early childhood deaths or other deceased family members? (Circle) Yes No DK Yes No DK (If yes) Age at death: Cause of death: d. How many children are now living? (Number or DK) e. Is anyone taking birth control pills? (females only) (Circle) Yes No DK Yes No DK Have there been any problems noticed since-- has been taking the contraceptives? (Circle) Yes No DK Yes No DK Yes No DK Yes No DK f. (If yes) Was a doctor seen? (Circle) (If yes) What did the doctor say the troiible was? REMARKS: 15 4 148 Yes No DK Yes No DK Yes No DK Yes No Yes No DK Yes No DK Yes No DK Yes No DK Yes Yes No DK Yes No DK Yes No 'DK Yes No DK Yes No DK DK Yes No DK Yes No DK Yes No DK Yes No DK Yes No DK Yes No DK Yes No DK Yes No DK Yes Yes No 16 DK Yes No DK No DK No DK 149 18. FAMILY INCCME. Now I'd like to show you a table which shows the broad levels of income and ask you to tell me the nunber next to the amount which comes closest to the combined total income which all members of your household received during the past 12 months. We would like it to be as close as you can estimate, but we don't want it any closer than the broad levels shown. (Include the combined incomes, before tax or other deductions, of all members of the family. Where the income is from other than salaries or wages, gross profit before deductions determines the level). LEVEL OF FAMILY INCCME DURING PAST 12 MONTHS D. $7,500 - above A. $2,499 or below E. DK B. $2,500 - $4,499 C. $5,000 - $7,499 (Circle appropriate code letter) 19. Do you know of anyone in your family who has sickle - cell anemia? (Circle) Yes (If yes) specify REMARKS: 17 No DK 150 * 18 APPENDIX C QUESTIONNAIRES USED IN MICHIGAN STATE UNIVERSITY SURVEY 151 Please fill out the following questionnaire completely. Infornntion is confidential and for use in this project only. Name last First Middle Address_____________________________________________ Student No. Date of Birth Birthplace______________________________ Age_ PART II 1. Before being contacted by this group, had you ever heard of Sickle Cell Anemia (SCA)? yes no (circle one) 2. Did you know that SCA is an inherited abnormality and is transmitted from parent to offspring? yes no 3. Do you know of anyone in your family who has SCA? yes no 4. How many sisters and brothers do you have? LIVING No. DEAD ** No. ■**Cause of death_ **Age at death 5. Is your general health: PART III: Yes Good____ , Fair____ , Poor_ Check at the left all of the following which apply now or in the past: Check at left Yes Check at left Easy fatigue Sense of exhaustion Pneumonia Pain in chest Shortness of breath Poor appetite Jaundice ____ ____ ____ ____ ____ ____ ____ High blood pressure Low blood pressure Swelling or painful joints Dizziness Kidney disease Sugar or albtinin in urine Stomach, liver, or intes­ tinal trouble