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Prevalence and assessment of the impact of iron-deficiency anemia in beta-thalassemia trait subjects: A study from a tertiary care center of western India

1 Department of Immunohematology and Blood Transfusion, Armed Forces Medical College, Pune, Maharshtra; Department of Zoology, School of Applied Science, Om Sterling Global University, Hisar, Haryana, India
2 Department of Immunohematology and Blood Transfusion, Armed Forces Medical College, Pune, Maharshtra, India
3 Department of Zoology, School of Applied Science, Om Sterling Global University, Hisar, Haryana, India

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Date of Submission29-Aug-2022
Date of Decision02-Oct-2022
Date of Acceptance23-Oct-2022
Date of Web Publication12-Dec-2022


INTRODUCTION: Beta-thalassemia trait (BTT) and iron-deficiency anemia (IDA) are the most common causes of microcytic hypochromic anemia (MHA). Concomitant presence of both BTT and IDA can cause a more severe form of anemia that may increase morbidity and mortality. Therefore, the present study was conducted to check the prevalence and assess the impact of IDA on various hematological parameters in BTT subjects.
SUBJECTS AND METHODS: The present study was conducted at the department of immunohematology and blood transfusion after taking ethical clearance and written informed consent from all the participants. One hundred and sixty-eight known cases of BTT were included in this study. Out of these, 88 were females and the remaining 80 were males with ages ranging from 9 to 65 years. Blood samples collected in ethylenediaminetetraacetic acid and sterile vacutainers were assessed for complete blood count, serum iron, total iron-binding capacity (TIBC), and ferritin. All the data were analyzed using IBM SPSS Statistics software version (15).
RESULTS: The majority of the patients had MHA on peripheral blood smears. Thirty-nine (23.21%) out of 168 BTT subjects were found to have IDA. Hemoglobin, mean corpuscular volume, mean cell hemoglobin, and mean cell hemoglobin concentration levels were significantly reduced in patients of Group I (BTT with IDA) when compared to Group II (BTT without IDA). The mean (± standard deviation) value of serum iron, total TIBC, and ferritin showed significant differences between the two groups.
DISCUSSIONS & CONCLUSION: High prevalence of IDA in patients of BTT in the current study suggests that there is a need for careful evaluation in the differentiation and diagnosis of BTT and IDA, especially in females, as IDA is more common in females. Moreover, IDA has a significant impact on various hematological parameters in BTT subjects.

Keywords: Anemia, beta-thalassemia, ferritin, iron deficiency, total iron-binding capacity

How to cite this URL:
Singh V, Baranwal AK, Biswas AK, Mishra RC, Singh I. Prevalence and assessment of the impact of iron-deficiency anemia in beta-thalassemia trait subjects: A study from a tertiary care center of western India. Asian J Transfus Sci [Epub ahead of print] [cited 2023 Jan 28]. Available from:

   Introduction Top

Anemia is a major public health problem worldwide with a prevalence of 43% in developing countries and 9% in developed countries.[1] Iron-deficiency anemia (IDA) and beta-thalassemia trait (BTT) are the most common cause of microcytic hypochromic anemia (MHA) spread throughout the world including India.[2] A traditional approach is followed by most of the general or nonhematologist physicians as they prescribe iron supplements whenever MHA is encountered. However, in the case of BTT, it can lead to iron overload, mask the diagnosis of BTT, and increase the chances of homozygosity in the next generation.[3] Thus, it is important to diagnose these two common etiologies of MHA.

BTT is the most common autosomal recessive inherited single gene disorder that arises due to mutations in the β-globin genes cluster resulting in decreased production of the β-globin chain.[4] About 70,000 children are born with β-thalassemia worldwide each year.[5] India being located in the thalassemia belt of the world also has a high frequency of thalassemia trait and transfusion-dependent thalassemia.[5],[6] Beta-thalassemia is more common in India than that of α-thalassemia and comprises about 80%–90% of the total thalassemias reported.[7],[8] It constitutes 10% of β-thalassemia in the world with about 10,000 children being born with β-thalassemia major each year. The average prevalence of BTT is 3%–4% with around 35–45 million carriers present in India.[9],[10],[11] There is no cure for β-thalassemia and screening of BTT is the only way to prevent the occurrence of homozygotes in future generations.[12],[13]

IDA is considered to be the most common nutritional disorder with about 1/3rd of the world's population being affected by it. The prevalence of IDA in India is around 70%–80% in children, 70% in pregnant women, and 24% in adult men.[13],[14] The severe deficiency of iron in the body can impair the function of several organs. It also increases the risk of morbidity and mortality in preterm babies.[6]

For a long period of time, it was believed that iron deficiency did not exist in thalassemia minor as well as major. However, some studies have shown the occurrence of iron deficiency in patients of BTT and reported that IDA was common in BTT.[6],[14] However, many of the physicians overlooked the iron deficiency in patients of BTT and the patients remain untreated which results in severe anemia. Iron levels can also interfere with the diagnosis of BTT as reported by few published literature showing low hemoglobin A2 levels in IDA.[15],[16] Therefore, the present study was conducted to estimate the prevalence of IDA along with its impact in patients of BTT.

   Subjects and Methods Top

The current study was conducted in the department of immunohematology and blood transfusion, of a tertiary care center of western Maharashtra in India from October 2021 to June 2022 after taking approval from our Institutional Ethical Committee. A total of 168 known subjects of BTT were randomly selected in the present study from patients who attending the various departments of a tertiary care center. The majority of patients were from lower socioeconomic strata. Written informed consent was taken from all study participants.

The BTT subjects with transfusion history during the past 3 months, subjects with borderline HbA2, patients taking on iron supplements, and patients with other diseases such as chronic kidney disease, leukemia, HIV, and other acute infections were excluded in the present study.

Venous blood samples were drawn into a K2-ethylenediaminetetraacetic acid tube for peripheral blood smear (PBS), complete blood count (CBC), and high-performance liquid chromatography (HPLC) and in sterile plain vacutainer (Becton Dickinson) for estimation of serum iron, total iron-binding capacity (TIBC), and ferritin. The sample for CBC was processed within 4 h of blood collection. The CBC test was performed using a fully automated 5-part analyzer Beckman Coulter LH 750 (Beckman Coulter, Inc. USA) along with calibration and controls run as per the manufacturer's recommendations. PBS was also prepared from fresh blood and stained with Leishman stain. All the PBS reports were examined by viewing under microscope at 40X for the evidence of MHA. HPLC test was performed using a Bio-Rad D-10 analyzer (Bio-Rad Laboratories, Hercules, CA, USA) for patients who did not have a prior HPLC or electrophoresis report. Iron studies which include serum iron, TIBC, and ferritin were performed using a fully automated Siemens Dimension EXL-200 (Siemens Healthcare Diagnostics Inc. Newark, USA) analyzer. The inaccuracy of methods of serum iron, TIBC, and ferritin is shown in [Table 1]. The flow chart of subjects and methods with inclusion and exclusion criteria is shown in [Figure 1].
Table 1: Inaccuracy of test used for different iron parameters

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Figure 1: Flow chart of subjects and methods with inclusion and exclusion criteria

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Sample calculation

The expected prevalence of BTT in the western Maharashtra region was 12%.[9],[10],[17] Therefore, the required sample size was 163 for the margin of error or absolute precision of ±5% in estimating the prevalence with 95% confidence. With this sample size, the anticipated 95% confidence interval is/was (7%, 17%). This sample size is calculated using the Scalex SP calculator.[18]

Statistical analysis

The data were represented as mean ± standard error. All the data were evaluated using SPSS software version (15) (IBM, Armonk, New York, United States) (IBM SPSS Statistics 2015). The independent sample t-test was used to compare the data. P < 0.05 was considered to be statistically significant.

   Results Top

The study population was divided into two groups (Group I and Group II) based on their serum ferritin, serum iron, and TIBC levels. Out of total of 168 BTT subjects, 39 (23.22%) had IDA and were placed in Group I and the remaining 129 (76.78%) patients without IDA were placed in Group II. The mean age (±standard deviation [SD]) of Group I patients was 34.41 ± 8.74 while that of Group II was 37.05 ± 10.72. Group I consisted of 9 males and 30 females as compared to 71 males and 58 females in Group II.

Mean (± SD) values of hemoglobin (Hb), red blood cell (RBC) count, mean corpuscular volume (MCV), mean cell hemoglobin (MCH), and mean cell hemoglobin concentration (MCHC) levels of Group I were 9.74 ± 1.98 g/dl, 5.51 ± 0.78 × 106, 58.52 ± 7.66 fl, 17.78 ± 2.90 pg, and 30.27 ± 1.66, respectively, while it was 11.50 ± 1.42 g/dl, 5.86 ± 0.71 × 106, 63.07 ± 7.98 fl, 19.77 ± 1.74 pg, and 31.27 ± 0.95, respectively, in Group II.

Statistically significant differences were found in Hb, MCV, MCH, and MCHC levels between the two groups. The Mentzer score was calculated by dividing the MCV level from the RBC count and was 10.61 and 10.88 in Group I and II, respectively, and was not found statistically significant.

The values (mean ± SD) of serum iron, TIBC, and ferritin levels (μg/dl) were 43.18 ± 19.99, 426.46 ± 58.01, and 8.85 ± 2.89, respectively, in Group I, while it was 91.91 ± 33.91, 336.55 ± 33.91, and 107.01 ± 158.84, respectively, in Group II. The difference in the values of all three parameters in Group I and II was statistically significant. The comparison of various hematological and iron parameters along with mean age and sex between Group I and II is shown in [Table 2].
Table 2: Comparison of various hematological and iron parameters along with age and gender between Groups I and II

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   Discussion Top

Worldwide, the most common etiologies of MHA are IDA and BTT. India has a high prevalence of IDA as well as BTT. The causes of IDA are multifactorial, of which low dietary intake, menstrual loss in woman of reproductive age, and chronic blood loss in the gastrointestinal tract are among the most common ones.[19] BTT alone is an asymptomatic condition, however, the concomitant presence of BTT along with IDA causes a more severe form of anemia with significantly decreased levels in various hematological parameters.[15],[16]

The iron level and complications associated to its deficiency or overload are the major focus in the management of thalassemia.[20] In general, BTT patients absorb more iron from the gut and may have the problem of iron overload and it was believed for a long time that IDA did not exist in thalassemia patients.

The BTT is diagnosed by HbA2 level with a cutoff value of 3.9-8%. However, serum iron level can interfere with HbA2 level, as the iron bound to the heme group of Hb and deficiency of iron in the body can reduce the overall concentration of Hb. It may reduce the amount of HbA2 and can mask the diagnosis of BTT, especially in borderline cases.[21] Several studies suggested that the HbA2 level reduced in IDA is due to the reduction in transcription and translation of the delta gene along with the fact that the beta chain is more competitive than delta chains for heme binding, which leads to reduced production of HbA2.[15],[22],[23]

Ferritin level is a good marker of iron stores and should be used to diagnose iron deficiency in otherwise apparently healthy individuals. We use ferritin levels along with serum iron and TIBC levels for diagnosis of IDA. This was because ferritin is an acute-phase reactant and can be elevated in several conditions such as in pregnant women, renal diseases, leukemias, and infection while serum iron levels can fluctuate with daily dietary intake of iron.[24],[25] Therefore, a single test may not be able to detect the true status of iron.

In the present study, we detected a 23.21% prevalence of IDA in BTT subjects which corroborated with that of Yousafzai et al.[26] and Dolai et al.[6] Another study demonstrated that the prevalence of IDA in patients of BTT was 31% which was higher than the prevalence detected in the current study.[27] Sundh et al.[28] and Tiwari et al.[29] reported 2.4% and 8% of cases, respectively, with concomitant IDA and BTT which was lower than the prevalence detected in the present study. The higher prevalence of IDA in our study may be due to the fact that most of the study participants were from lower to middle socioeconomic backgrounds.

According to earlier research, females were more likely than males to have the IDA.[6],[27] In the current study, we also discovered that BTT females had a higher prevalence of IDA (34.09%) than BTT males (11.25%). IDA was said to affect women of childbearing age more frequently.[26] This may be due to menstrual loss which is the major cause of blood loss in females.[30] Therefore, the concomitant BTT and IDA, especially in females during pregnancy, can increase the risk of morbidity and mortality in them and can also affect their preterm babies as it causes more severe anemia compared to IDA or BTT alone.

In the present study, Hb, MCV, MCH, and MCHC levels were significantly reduced in Group I when compared to Group II. Similar findings were also reported by some previous studies.[6],[14] There was no significant differences were found in RBC count between the two groups. This was in conflict from a result reported by Lin et al.[27] and similar to the result reported by Dolai et al.[6] and Mohanty et al.[14]

   Conclusions Top

The current investigation demonstrated a high prevalence of iron deficiency in BTT participants, indicating the necessity for carefully evaluation to differentiate between BTT and IDA. Iron studies and if needed thalassemia screening should be done in all the anemic cases during pregnancy as well as in borderline cases of HbA2, as it can reduce the mortality and morbidity in antenatal women, fetuses, and also prevent a more severe form of hemoglobinopathies in future generations. The study revealed that IDA has a significant impact on various hematological parameters in patients with concomitant BTT and IDA.


We sincerely pay gratitude and are thankful to all the participants who participated in the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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Correspondence Address:
Virender Singh,
Department of Immunohematology and Blood Transfusion, Armed Forces Medical College, Pune - 411 040, Maharshtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajts.ajts_111_22


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