Antenatal screening for haemoglobinopathies: current status, barriers and ethics
Corresponding Author
Subarna Chakravorty
Paediatric Haematology, King's College Hospital, London, UK
Correspondence: Dr S Chakravorty, Paediatric Haematology, King's College Hospital, London SE5 9RS, UK
E-mail: [email protected]
Search for more papers by this authorMoira C Dick
Paediatric Haematology, King's College Hospital, London, UK
Search for more papers by this authorCorresponding Author
Subarna Chakravorty
Paediatric Haematology, King's College Hospital, London, UK
Correspondence: Dr S Chakravorty, Paediatric Haematology, King's College Hospital, London SE5 9RS, UK
E-mail: [email protected]
Search for more papers by this authorMoira C Dick
Paediatric Haematology, King's College Hospital, London, UK
Search for more papers by this authorSummary
Sickle cell disease (SCD) and thalassaemia are genetic disorders that are caused by errors in the genes for haemoglobin and are some of the most common significant genetic disorders in the world, resulting in significant morbidity and mortality. Great disparities exist in the outcome of these conditions between resource- rich and resource-poor nations. Antenatal screening for these disorders aims to provide couples with information about their reproductive risk and enable them to make informed reproductive choices; ultimately reducing the likelihood of children being born with these conditions. This review provides an overview of the current status of antenatal, pre-marital and population screening of SCD and thalassaemia in countries with both high-and low prevalence of these conditions, methods of screening in use, and discusses some of the pitfalls, ethical issues and controversies surrounding antenatal screening. It also discusses outcomes of some screening programmes and recognises the need for the establishment of antenatal screening in areas where their prevalence is highest; namely sub-Saharan Africa and India.
References
- Abi Saad, M., Haddad, A.G., Alam, E.S., Aoun, S., Maatouk, P., Ajami, N., Khairallah, T., Koussa, S., Musallam, K.M., & Taher, A.T. (2014). Preventing thalassemia in Lebanon: successes and challenges in a developing country. Hemoglobin, 38, 308–311.
- Aderotoye-Oni, S., Diaku-Akinwumi, I.N., Adeniran, A. & Falase, B. (2018) Unprepared and misinformed parents of children with sickle cell disease: time to rethink awareness campaigns. Cureus, 10, e3806.
- Aguila, J.D., Zamora, M.C., Fernandez, O.A., Jimenez, L.P., Vicente, O.M. & Alvarez, I.V. (2008) Comprehensive care for patients with sickle cell disease in Cuba. Haematologica, 93, e20.
- Ahmed, S., Saleem, M., Sultana, N., Raashid, Y., Waqar, A., Anwar, M., Modell, B., Karamat, K.A. & Petrou, M. (2000) Prenatal diagnosis of beta-thalassaemia in Pakistan: experience in a Muslim country. Prenatal Diagnosis, 20, 378–383.
10.1002/(SICI)1097-0223(200005)20:5<378::AID-PD815>3.0.CO;2-7 CAS PubMed Web of Science® Google Scholar
- Ahmed, S., Green, J. & Hewison, J. (2005) Antenatal thalassaemia carrier testing: women's perceptions of "information" and "consent". Journal of Medical Screening, 12, 69–77.
- Ahmed, S., Green, J.M. & Hewison, J. (2006) Attitudes towards prenatal diagnosis and termination of pregnancy for thalassaemia in pregnant Pakistani women in the North of England. Prenatal Diagnosis, 26, 248–257.
- Al-Allawi, N.A., Al-Doski, A.A., Markous, R.S., Mohamad Amin, K.A., Eissa, A.A., Badi, A.I., Asmaro, R.R. & Hamamy, H. (2015) Premarital screening for hemoglobinopathies: experience of a single center in Kurdistan, Iraq. Public Health Genomics, 18, 97–103.
- Alhamdan, N.A., Almazrou, Y.Y., Alswaidi, F.M. & Choudhry, A.J. (2007) Premarital screening for thalassemia and sickle cell disease in Saudi Arabia. Genetics in Medicine, 9, 372–377.
- Amato, A., Cappabianca, M.P., Lerone, M., Colosimo, A., Grisanti, P., Ponzini, D., di Biagio, P., Perri, M., Gianni, D., Rinaldi, S. & Piscitelli, R. (2014) Carrier screening for inherited haemoglobin disorders among secondary school students and young adults in Latium, Italy. Journal of Community Genetics, 5, 265–268.
- Angastiniotis, M.A. & Hadjiminas, M.G. (1981) Prevention of thalassaemia in Cyprus. Lancet, 1, 369–371.
- Angastiniotis, M. & Modell, B. (1998) Global epidemiology of hemoglobin disorders. Annals of the New York Academy of Sciences, 850, 251–269.
- Barrett, A.N., Saminathan, R. & Choolani, M. (2017) Thalassaemia screening and confirmation of carriers in parents. Best Practice & Research: Clinical Obstetrics & Gynaecology, 39, 27–40.
- Bhukhanvala, D.S., Sorathiya, S.M., Sawant, P., Colah, R., Ghosh, K. & Gupte, S.C. (2013) Antenatal screening for identification of couples for prenatal diagnosis of severe hemoglobinopathies in surat, South gujarat. The Journal of Obstetrics and Gynecology of India, 63, 123–127.
10.1007/s13224-012-0271-4 Google Scholar
- Bianco, I., Graziani, B., Lerone, M., Congedo, P., Aliquo, M.C., Ponzini, D., Braconi, F., Foglietta, E. & Modiano, G. (1985) Prevention of thalassaemia major in Latium (Italy). Lancet, 2, 888–889.
- Bombard, Y., Miller, F.A., Hayeems, R.Z., Avard, D. & Knoppers, B.M. (2010) Reconsidering reproductive benefit through newborn screening: a systematic review of guidelines on preconception, prenatal and newborn screening. European Journal of Human Genetics, 18, 751–760.
- Bozkurt, G. (2007) Results from the north cyprus thalassemia prevention program. Hemoglobin, 31, 257–264.
- Camunas-Soler, J., Lee, H., Hudgins, L., Hintz, S.R., Blumenfeld, Y.J., El-Sayed, Y.Y. & Quake, S.R. (2018) Noninvasive prenatal diagnosis of single-gene disorders by use of droplet digital PCR. Clinical Chemistry, 64, 336–345.
- Canatan, D. & Delibas, S. (2016) Report on ten years' experience of premarital hemoglobinopathy screening at a center in Antalya, southern Turkey. Hemoglobin, 40, 273–276.
- Canatan, D., Kose, M.R., Ustundag, M., Haznedaroglu, D. & Ozbas, S. (2006) Hemoglobinopathy control program in Turkey. Community Genet, 9, 124–126.
- Cao, A. & Kan, Y.W. (2013) The prevention of thalassemia. Cold Spring Harbor Perspectives in Medicine, 3, a011775.
- Chandrasekharan, S., Minear, M.A., Hung, A. & Allyse, M. (2014) Noninvasive prenatal testing goes global. Science Translational Medicine, 6, 231fs15.
- Colah, R., Surve, R., Wadia, M., Solanki, P., Mayekar, P., Thomas, M., Gorakshakar, A., Dastur, A. & Mohanty, D. (2008) Carrier screening for beta-thalassemia during pregnancy in India: a 7-year evaluation. Genet Test, 12, 181–185.
- Cousens, N.E., Gaff, C.L., Metcalfe, S.A. & Delatycki, M.B. (2010) Carrier screening for beta-thalassaemia: a review of international practice. European Journal of Human Genetics, 18, 1077–1083.
- Davis, L.R., Huehns, E.R. & White, J.M. (1981) Survey of sickle-cell disease in England and Wales. British Medical Journal (Clinical Research Ed), 283, 1519–1521.
- Department of Health (2000) The NHS Plan. A plan for investment. A plan for reform. Cm 4818-I. HM Stationery Office, Norwich UK. © Crown Copyright 2000.
- Department, of Health (2019) Sickle cell and thalassaemia screening: education and training [Public Health England. WWW document. Available at. [Accessed] https://www.gov.uk/guidance/sickle-cell-and-thalassaemia-screening-education-and-training.
- England, J.M. & Fraser, P. (1979) Discrimination between iron-deficiency and heterozygous-thalassaemia syndromes in differential diagnosis of microcytosis. Lancet, 1, 145–148.
- ETHNOS (2006) Evaluation of the "Family Origin Questionnaire". NHS Sickle and Thalassaemia Screening Programme, London.
- Firdous, N., Gibbons, S. & Modell, B. (2011) Falling prevalence of beta-thalassaemia and eradication of malaria in the Maldives. Journal of Community Genetics, 2, 173–189.
- Fucharoen, S. & Winichagoon, P. (2011) Haemoglobinopathies in southeast Asia. Indian Journal of Medical Research, 134, 498–506.
- Fucharoen, G., Sanchaisuriya, K., Sae-Ung, N., Dangwibul, S. & Fucharoen, S. (2004) A simplified screening strategy for thalassaemia and haemoglobin E in rural communities in south-east Asia. Bulletin of the World Health Organization, 82, 364–372.
- Goonasekera, H.W., Paththinige, C.S. & Dissanayake, V.H.W. (2018) Population screening for hemoglobinopathies. Annual Review of Genomics and Human Genetics, 19, 355–380.
- Grosse, S.D., Odame, I., Atrash, H.K., Amendah, D.D., Piel, F.B. & Williams, T.N. (2011) Sickle cell disease in Africa: a neglected cause of early childhood mortality. American Journal of Preventive Medicine, 41, S398–405.
- Herraiz, I., Villalba, A., Ajuria, E., Barasoain, A., Mendoza, A., Pizarro, N., Escribano, D. & Galindo, A. (2019) Impact of cell-free fetal DNA on invasive prenatal diagnostic tests in a real-world public setting. Journal of Perinatal Medicine, 47, 547–552.
- Hsu, L., Nnodu, O.E., Brown, B.J., Tluway, F., King, S., Dogara, L.G., Patil, C., Shevkoplyas, S.S., Lettre, G., Cooper, R.S., Gordeuk, V.R. & Tayo, B.O. (2018) White paper: pathways to progress in newborn screening for sickle cell disease in Sub-Saharan Africa. Journal of Tropical Diseases & Public Health, 6, 260.
- Hui, L. & Bianchi, D.W. (2017) Noninvasive prenatal DNA testing: The vanguard of genomic medicine. Annual Review of Medicine, 68, 459–472.
- Jiang, F., Chen, G.L., Li, J., Xie, X.M., Zhou, J.Y., Liao, C. & Li, D.Z. (2017) Pre-gestational thalassemia screening in Mainland China: the first two years of a preventive program. Hemoglobin, 41, 248–253.
- Kazal, R.K., Chowdhury, S.A., Mirza, T.T., Pervin, H.H., Noor, F., Chakma, B. & Aalpona, F.Z. (2018) Feasibility and safety of chorionic villus sampling (CVS) for prenatal diagnosis of thalassemia in Bangladesh. Mymensingh Medical Journal, 27, 578–584.
- Koren, A., Zalman, L., Palmor, H., Zamir, R.B., Levin, C., Openheim, A., Daniel-Spiegel, E., Shalev, S. & Filon, D. (2009) Sickle cell anemia in northern Israel: screening and prevention. Israel Medical Association Journal, 11, 229–234.
- Lee, S.Y., Yap, E.S., Lee, E.Y., Goh, J.H., Liu, T.C. & Yip, C. (2019) Evaluation of Thalassaemia Screening Tests in the Antenatal and Non-Antenatal Populations in Singapore. Annals of the Academy of Medicine, Singapore, 48, 5–15.
- Lena-Russo, D., Badens, C., Aubinaud, M., Merono, F., Paolasso, C., Martini, N. & Mattei, J.F. (2002) Outcome of a school screening programme for carriers of haemoglobin disease. Journal of Medical Screening, 9, 67–69.
- Leslie, H.H., Sun, Z. & Kruk, M.E. (2017) Association between infrastructure and observed quality of care in 4 healthcare services: a cross-sectional study of 4,300 facilities in 8 countries. PLoS Medicine, 14, e1002464.
- Li, D.Z. & Yang, Y.D. (2017) Invasive prenatal diagnosis of fetal thalassemia. Best Practice & Research Clinical Obstetrics & Gynaecology, 39, 41–52.
- Liao, C., Mo, Q.H., Li, J., Li, L.Y., Huang, Y.N., Hua, L., Li, Q.M., Zhang, J.Z., Feng, Q., Zeng, R., Zhong, H.Z., Jia, S.Q., Cui, Y.Y. & Xu, X.M. (2005) Carrier screening for alpha- and beta-thalassemia in pregnancy: the results of an 11-year prospective program in Guangzhou Maternal and Neonatal hospital. Prenatal Diagnosis, 25, 163–171.
- Lindenau, J.D., Wagner, S.C., Castro, S.M. & Hutz, M.H. (2016) The effects of old and recent migration waves in the distribution of HBB*S globin gene haplotypes. Genetics and Molecular Biology, 39, 515–523.
- Lo, T.K. (2017) The pitfall of antenatal thalassaemia screening. Journal of Obstetrics and Gynaecology, 37, 109–110.
- Lobitz, S., Telfer, P., Cela, E., Allaf, B., Angastiniotis, M., Backman Johansson, C., Badens, C., Bento, C., Bouva, M.J., Canatan, D., Charlton, M., Coppinger, C., Daniel, Y., de Montalembert, M., Ducoroy, P., Dulin, E., Fingerhut, R., Frommel, C., Garcia-Morin, M., Gulbis, B., Holtkamp, U., Inusa, B., James, J., Kleanthous, M., Klein, J., Kunz, J.B., Langabeer, L., Lapoumeroulie, C., Marcao, A., Marin Soria, J.L., Mcmahon, C., Ohene-Frempong, K., Perini, J.M., Piel, F.B., Russo, G., Sainati, L., Schmugge, M., Streetly, A., Tshilolo, L., Turner, C., Venturelli, D., Vilarinho, L., Yahyaoui, R., Elion, J. & Colombatti, R. (2018) Newborn screening for sickle cell disease in Europe: recommendations from a Pan-European Consensus Conference. British Journal of Haematology, 183, 648–660.
- Locock, L. & Kai, J. (2008) Parents' experiences of universal screening for haemoglobin disorders: implications for practice in a new genetics era. British Journal of General Practice, 58, 161–168.
- Makani, J., Cox, S.E., Soka, D., Komba, A.N., Oruo, J., Mwamtemi, H., Magesa, P., Rwezaula, S., Meda, E., Mgaya, J., Lowe, B., Muturi, D., Roberts, D.J., Williams, T.N., Pallangyo, K., Kitundu, J., Fegan, G., Kirkham, F.J., Marsh, K. & Newton, C.R. (2011) Mortality in sickle cell anemia in Africa: a prospective cohort study in Tanzania. PLoS ONE, 6, e14699.
- Martins, M.C., Olim, G., Melo, J., Magalhaes, H.A. & Rodrigues, M.O. (1993) Hereditary anaemias in Portugal: epidemiology, public health significance, and control. Journal of Medical Genetics, 30, 235–239.
- Modell, B. & Darlison, M. (2008) Global epidemiology of haemoglobin disorders and derived service indicators. Bulletin of the World Health Organization, 86, 480–487.
- Modell, B., Harris, R., Lane, B., Khan, M., Darlison, M., Petrou, M., Old, J., Layton, M. & Varnavides, L. (2000) Informed choice in genetic screening for thalassaemia during pregnancy: audit from a national confidential inquiry. BMJ, 320, 337–341.
- Mohapatra, R., Warang, P., Ghosh, K. & Colah, R. (2016) Hemoglobinopathy screening by osmotic fragility test based on flow cytometer or naked eye. Cytometry Part B: Clinical Cytometry, 90, 279–284.
- Moudi, Z., Phanodi, Z., Ansari, H. & Zohour, M.M. (2018) Decisional conflict and regret: shared decision-making about pregnancy affected by beta-thalassemia major in Southeast of Iran. Journal of Human Genetics, 63, 309–317.
- National Services Scotland (2019). Pregnancy and Newborn Screening- Haemoglobinopathies WWW document. National Services Scotland. Available: https://www.pnsd.scot.nhs.uk/pregnancy/antenatal-haemoglobinopathies/ [Accessed].
- NHS Sickle Cell and Thalassaemia Screening Programme (2017). Handbook for Laboratories, 4th Edition. Public Health England.
- Penman, B.S., Gupta, S. & Weatherall, D.J. (2015) Epistasis and the sensitivity of phenotypic screens for beta thalassaemia. British Journal of Haematology, 169, 117–128.
- Piel, F.B., Patil, A.P., Howes, R.E., Nyangiri, O.A., Gething, P.W., Dewi, M., Temperley, W.H., Williams, T.N., Weatherall, D.J. & Hay, S.I. (2013) Global epidemiology of sickle haemoglobin in neonates: a contemporary geostatistical model-based map and population estimates. Lancet, 381, 142–151.
- Piel, F.B., Tatem, A.J., Huang, Z., Gupta, S., Williams, T.N. & Weatherall, D.J. (2014) Global migration and the changing distribution of sickle haemoglobin: a quantitative study of temporal trends between 1960 and 2000. Lancet Glob Health, 2, e80–e89.
- Piel, F.B., Steinberg, M.H. & Rees, D.C. (2017) Sickle Cell Disease. New England Journal of Medicine, 376, 1561–1573.
- Public Health England (2017) Sickle Cell and Thalassaemia Antenatal Screening Pathway. Department of Health, United Kingdom.
- Public Health England. (2018a. Antenatal and newborn screening KPIs for 2018 to 2019: definitions. ID1: antenatal infectious disease screening – HIV coverage WWW document. Public Health England, London. Available: https://www.gov.uk/government/publications/nhs-population-screening-reporting-data-definitions/antenatal-and-newborn-screening-kpis-for-2018-to-2019-definitions#contents [Accessed 19 April 2019].
- Public Health England (2018b) Sickle and Thalassaemia Screening Programme. Data report 2016 to 2017: trends and performance analysis. Public Health England, London. © Crown copyright.
- Public Health England2019. Screening KPI data summary factsheets: August 2019 - Issue 8. Public Health England, London. © Crown copyright 2019. Available https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/824600/Screening_KPI_Summary_Factsheets_August-2019_Issue_8.pdf.
- Public Health Wales (2019). Antenatal Screening Wales Policy, Standards and Protocols 2019 [Online]. Wales: Public Health Wales. Available: http://www.newbornbloodspotscreening.wales.nhs.uk/sitesplus/documents/1008/2.Policies%20and%20standards%20stand%20alone1.pdf [Accessed 2019].
- Rao, S., Saxena, R., Deka, D. & Kabra, M. (2009) Use of HbA estimation by CE-HPLC for prenatal diagnosis of beta-thalassemia; experience from a tertiary care centre in north India: a brief report. Hematology, 14, 122–124.
- Ratanasiri, T., Charoenthong, C., Komwilaisak, R., Changtrakul, Y., Fucharoen, S., Wongkham, J., Kleebkaow, P. & Seejorn, K. (2006) Prenatal prevention for severe thalassemia disease at Srinagarind Hospital. Journal of the Medical Association of Thailand, 89, S87–93.
- Roth, I.L., Lachover, B., Koren, G., Levin, C., Zalman, L. & Koren, A. (2018) Detection of beta-Thalassemia Carriers by Red Cell Parameters Obtained from Automatic Counters using Mathematical Formulas. The Mediterranean Journal of Hematology and Infectious Diseases, 10, e2018008.
- Ryan, K., Bain, B.J., Worthington, D., James, J., Plews, D., Mason, A., Roper, D., Rees, D.C., de la Salle, B., Streetly, A.& on behalf of the British Committee for Standards in Haematology (2010) Significant haemoglobinopathies: guidelines for screening and diagnosis. British Journal of Haematology, 149, 35–49.
- Saffi, M. & Howard, N. (2015) Exploring the effectiveness of mandatory premarital screening and genetic counselling programmes for β-thalassaemia in the middle east: a scoping review. Public Health Genomics, 18, 193–203.
- Samavat, A. & Modell, B. (2004) Iranian national thalassaemia screening programme. BMJ, 329, 1134–1137.
- Shine, I. & Lal, S. (1977) A strategy to detect beta-thalassaemia minor. Lancet, 1, 692–694.
- Shukla, S., Singh, D., Dewan, K., Sharma, S. & Trivedi, S.S. (2018) Antenatal carrier screening for thalassemia and related hemoglobinopathies: A hospital-based study. Journal of Medical Society, 32, 118–122.
10.4103/jms.jms_5_17 Google Scholar
- Srivorakun, H., Fucharoen, G., Sae-Ung, N., Sanchaisuriya, K., Ratanasiri, T. & Fucharoen, S. (2009) Analysis of fetal blood using capillary electrophoresis system: a simple method for prenatal diagnosis of severe thalassemia diseases. European Journal of Haematology, 83, 57–65.
- Sulaiman, A.L., Suliman, A., Al Mishari, M., Al Sawadi, A., & Owaidah, T.M. (2008) Knowledge and attitude toward the hemoglobinopathies premarital screening program in Saudi Arabia: population-based survey. Hemoglobin, 32, 531–8.
- Tan, A. (2005) Prenatal Genetic Screening and Testing. Genetic Testing and Genetic Research. Bioethics Advisory Committee, Singapore.
- Tarazi, I., Al Najjar, E., Lulu, N. & Sirdah, M. (2007) Obligatory premarital tests for beta-thalassaemia in the Gaza Strip: evaluation and recommendations. The International Journal of Laboratory Hematology, 29, 111–118.
- Theodoridou, S., Prapas, N., Balassopoulou, A., Boutou, E., Vyzantiadis, T.A., Adamidou, D., Delaki, E.E., Yfanti, E., Economou, M., Teli, A., Karakasidou, O., Skatharoudi, E., Theodoridis, T. & Voskaridou, E. (2018) Efficacy of the National Thalassaemia and Sickle Cell Disease Prevention Programme in Northern Greece: 15-Year Experience, Practice and Policy Gaps for Natives and Migrants. Hemoglobin, 42, 257–263.
- Therrell, B.L., Jr & Padilla, C.D. (2018) Newborn screening in the developing countries. Current Opinion in Pediatrics, 30, 734–739.
- Therrell, B.L., Padilla, C.D., Loeber, J.G., Kneisser, I., Saadallah, A., Borrajo, G.J. & Adams, J. (2015) Current status of newborn screening worldwide: 2015. Seminars in Perinatology, 39, 171–187.
- Tongprasert, F., Srisupundit, K., Luewan, S., Traisrisilp, K., Jatavan, P. & Tongsong, T. (2019) The best cutoff value of middle cerebral artery peak systolic velocity for the diagnosis of fetal homozygous alpha thalassemia-1 disease. Prenatal Diagnosis, 39, 232–237.
- Verma, I.C., Saxena, R. & Kohli, S. (2011) Past, present & future scenario of thalassaemic care & control in India. Indian Journal of Medical Research, 134, 507–521.
- Wastnedge, E., Waters, D., Patel, S., Morrison, K., Goh, M.Y., Adeloye, D. & Rudan, I. (2018) The global burden of sickle cell disease in children under five years of age: a systematic review and meta-analysis. Journal of Global Health, 8, 021103.
- Weatherall, D.J. (2010) Thalassemia as a global health problem: recent progress toward its control in the developing countries. Annals of the New York Academy of Sciences, 1202, 17–23.
- WHO (1998) Proposed international guidelines on ethical issues in medical genetics and genetic services (part I). World Health Orgnisation. Rev Derecho Genoma Hum, 219–233.
- WHO (2007) Resolution EB118/R1: Thalassemia and other Haemoglobinopathies -WHO Executive Board 118th Session. Resolutions and Decisions. World Health Organisation, Geneva.
- Wu, H., Wang, H., Lan, L., Zeng, M., Guo, W., Zheng, Z., Zhu, H., Wu, J. & Zhao, P. (2018) Invasive molecular prenatal diagnosis of alpha and beta thalassemia among Hakka pregnant women. Medicine (Baltimore), 97, e13557.
- Xiong, L., Barrett, A.N., Hua, R., Ho, S., Jun, L., Chan, K., Mei, Z. & Choolani, M. (2018) Non-invasive prenatal testing for fetal inheritance of maternal beta-thalassaemia mutations using targeted sequencing and relative mutation dosage: a feasibility study. BJOG, 125, 461–468.
- Yeo, G.S., Tan, K.H. & Liu, T.C. (1995) The role of discriminant functions in screening for beta-thalassaemia traits during pregnancy. Singapore Medical Journal, 36, 615–618.
- Zhao, S., Xiang, J., Fan, C., Asan, Shang, X., Zhang, X., Chen, Y., Zhu, B., Cai, W., Chen, S., Cai, R., Guo, X., Zhang, C., Zhou, Y., Huang, S., Liu, Y., Chen, B., Yan, S., Chen, Y., Ding, H., Guo, F., Wang, Y., Zhong, W., Zhu, Y., Wang, Y., Chen, C., Li, Y., Huang, H., Mao, M., Yin, Y., Wang, J., Yang, H., Xu, X., Sun, J. & Peng, Z.(2019) Pilot study of expanded carrier screening for 11 recessive diseases in China: results from 10,476 ethnically diverse couples. European Journal of Human Genetics, 27, 254–262.