Evidence-based clinical guidelines for immigrants and refugees

To The Editor:

We appreciated the thorough review by Pottie et al of evidence-based clinical guidelines for immigrants and refugees (Sept. 6 issue). The guidelines recommend screening immigrant and refugee women of reproductive age for iron-deficiency anemia with hemoglobin, and investigating and recommending iron supplementation if appropriate. We would like to point out an opportunity to draw more attention to evidence-based guidelines on carrier screening for hemoglobinopathies and thalassemias in Canada(1).

While the authors acknowledge hemoglobinopathies and thalassemias as possible alternative or co-existing causes of anemia, they do not mention screening by hemoglobin electrophoresis to rule out these non-nutritional causes in the absence of iron deficiency in this section of their comprehensive guidelines(2). Though referred to in the appendicies, mention here of the joint SOGC-CCMG clinical practice guidelines published in 2008 could help identify an opportunity for carrier screening (ideally pre-conceptionally) for thalassemia and hemoglobinopathies in women who are or who have a partner from an ethnic group at increased risk to carry these conditions. If both partners are found to be carriers of thalassemia, a hemoglobin variant, or a combination of these, they should be referred for genetic counselling and any appropriate additional molecular studies to clarify carrier status and risk of affected offspring.

Certainly, as the authors suggest, the immigrant and refugee population in Canada will continue to grow. Per the 2006 Canadian Census, we can estimate that closer to 25% of Canadians identify as belonging to at least one ethnicity known to be at increased risk of thalassemia or hemoglobinopathy(3). We therefore submit that screening by hemoglobin electrophoresis for hemoglobinopathies and thalassemias should be included in the iron-deficiency recommendations. This should be considered particularly in immigrant/refugee women of reproductive age from high-risk populations, with referral for genetic counselling, testing, and family studies if screen positive.

References: (1) Langlois S et al. Carrier Screening for Thalassemia and Hemoglobinopathies in Canada. J Obstet Gynaecol Can. 2008 Oct;30(10):950- 71. (2) Appendix 15 to Pottie K et al. Evidence-based clinical guidelines for immigrants and refugees. CMAJ. 2011 September 6; 183(12): E824-E925. (3) Statistics Canada. 2007. Ethnic origins 2006 counts for Canada provinces and territories - 20% sample data (table). http://www12.statcan.ca.proxy1.lib.umanitoba.ca/census-recensement/2006/rt -td/eth-eng.cfm.

Conflict of Interest:

None declared