64 This work is licensed under a Creative Commons Attribution 4.0 International License IHJPAS. 37 (2) 2024 Ibn Al-Haitham Journal for Pure and Applied Sciences Journal homepage: jih.uobaghdad.edu.iq PISSN: 1609-4042, EISSN: 2521-3407 A Review of Consanguinity in the Iraqi Population: A Call to Action to Prevent a Future Health Catastrophe Zaid Ali Hawi 1 , Kealan Pugsley 2 , Atefeh Namipashaki 3 , Walied Samarrai 4 and Ziarih Hawi 5* 1 Faculty of Science, Deakin University, Melbourne, Australia 2,3,5 Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia 4 New York City College of Technology, City University of New York, New York, USA *Corresponding Author . Received: 8 May 2023 Accepted: 19 June 2023 Published: 20 April 2024 doi.org/10.30526/37.2.3472 Abstract Although not uncommon worldwide, consanguinity has been a part of Arab culture and tradition as a means to strengthen tribal blood relations. However, this type of union has been linked to inherited diseases, particularly those of a recessive nature (e.g., hemoglobinopathies). Furthermore, several recent studies have documented highly significant associations between consanguineous parentage and common multifactorial diseases, including but not limited to hypertension, mental disorders, and several cardiovascular diseases. In Iraq, the prevalence of consanguinity is very high and still on the rise. This has resulted in an increased prevalence of inherited diseases and has significant negative impacts on Iraq’s limited economy. To address this issue, epidemiological studies are urgently required to generate a comprehensive database comprising the distribution of genetically inherited diseases that will be fundamental to establishing an effective future healthcare system. An educational public awareness campaign should accompany these efforts to inform the population about the profound consequences of consanguinity on offspring health. Finally, legislation needs to be put in place to ensure highly vetted genetic testing is conducted prior to any blood-related marriage in order to prevent further genetic complications for future generations of Iraq. Keywords: Consanguinity, inherited diseases, genetic testing, legislative measures. 1. Introduction Consanguineous marriage describes the unification of blood relatives with an inbreeding coefficient (F; the probability that two genes at any given genomic locus are identical by descent) of ≥ 0.0156 in the resulting progeny [1]. Such unions represent 10.4% of marriages worldwide [2], but are particularly prevalent within Arab populations [3]. This can be attributed, in part, to the traditional role of intrafamilial relations in reinforcing tribal alliances and preserving family wealth. The incidence of cognate relationships among the Arab community ranges between 10.9 and 80.4% [4]. However, it has been reported at markedly higher rates among certain ethnic groups, particularly in Egypt and Syria. Further, first cousin marriages are the most preferred type of blood-related union, accounting for as much as 85% of such marriages https://jih.uobaghdad.edu.iq/index.php/j/index#1609-4042 https://jih.uobaghdad.edu.iq/index.php/j/index#2521-3407 https://orcid.org/ mailto: https://orcid.org/0000-0001-7507-9532 mailto:kealan.pugsley@monash.edu https://orcid.org/0000-0001-9350-6155 mailto:atefeh.namipashaki@monash.edu https://orcid.org/ mailto:wsamarrai@citytech.cuny.edu https://orcid.org/0000-0002-0814-9112 mailto:ziarih.hawi@monash.edu https://orcid.org/ mailto: https://orcid.org/0000-0001-7507-9532 mailto:kealan.pugsley@monash.edu https://orcid.org/0000-0001-9350-6155 mailto:atefeh.namipashaki@monash.edu https://orcid.org/ mailto:wsamarrai@citytech.cuny.edu https://orcid.org/0000-0002-0814-9112 mailto:ziarih.hawi@monash.edu https://orcid.org/ mailto: https://orcid.org/0000-0001-7507-9532 mailto:kealan.pugsley@monash.edu https://orcid.org/0000-0001-9350-6155 mailto:atefeh.namipashaki@monash.edu https://orcid.org/ mailto:wsamarrai@citytech.cuny.edu https://orcid.org/0000-0002-0814-9112 mailto:ziarih.hawi@monash.edu https://orcid.org/ mailto: https://orcid.org/0000-0001-7507-9532 mailto:kealan.pugsley@monash.edu https://orcid.org/0000-0001-9350-6155 mailto:atefeh.namipashaki@monash.edu https://orcid.org/ mailto:wsamarrai@citytech.cuny.edu https://orcid.org/0000-0002-0814-9112 mailto:ziarih.hawi@monash.edu https://orcid.org/ mailto: https://orcid.org/0000-0001-7507-9532 mailto:kealan.pugsley@monash.edu https://orcid.org/0000-0001-9350-6155 mailto:atefeh.namipashaki@monash.edu https://orcid.org/ mailto:wsamarrai@citytech.cuny.edu https://orcid.org/0000-0002-0814-9112 mailto:ziarih.hawi@monash.edu https://orcid.org/ mailto: https://orcid.org/0000-0001-7507-9532 mailto:kealan.pugsley@monash.edu https://orcid.org/0000-0001-9350-6155 mailto:atefeh.namipashaki@monash.edu https://orcid.org/ mailto:wsamarrai@citytech.cuny.edu https://orcid.org/0000-0002-0814-9112 mailto:ziarih.hawi@monash.edu https://orcid.org/ mailto: https://orcid.org/0000-0001-7507-9532 mailto:kealan.pugsley@monash.edu https://orcid.org/0000-0001-9350-6155 mailto:atefeh.namipashaki@monash.edu https://orcid.org/ mailto:wsamarrai@citytech.cuny.edu https://orcid.org/0000-0002-0814-9112 mailto:ziarih.hawi@monash.edu https://orcid.org/ mailto: https://orcid.org/0000-0001-7507-9532 mailto:kealan.pugsley@monash.edu https://orcid.org/0000-0001-9350-6155 mailto:atefeh.namipashaki@monash.edu https://orcid.org/ mailto:wsamarrai@citytech.cuny.edu https://orcid.org/0000-0002-0814-9112 mailto:ziarih.hawi@monash.edu https://orcid.org/ mailto: https://orcid.org/0000-0001-7507-9532 mailto:kealan.pugsley@monash.edu https://orcid.org/0000-0001-9350-6155 mailto:atefeh.namipashaki@monash.edu https://orcid.org/ mailto:wsamarrai@citytech.cuny.edu https://orcid.org/0000-0002-0814-9112 mailto:ziarih.hawi@monash.edu https://orcid.org/ mailto: https://orcid.org/0000-0001-7507-9532 mailto:kealan.pugsley@monash.edu https://orcid.org/0000-0001-9350-6155 mailto:atefeh.namipashaki@monash.edu https://orcid.org/ mailto:wsamarrai@citytech.cuny.edu https://orcid.org/0000-0002-0814-9112 mailto:ziarih.hawi@monash.edu https://orcid.org/ mailto: https://orcid.org/0000-0001-7507-9532 mailto:kealan.pugsley@monash.edu https://orcid.org/0000-0001-9350-6155 mailto:atefeh.namipashaki@monash.edu https://orcid.org/ mailto:wsamarrai@citytech.cuny.edu https://orcid.org/0000-0002-0814-9112 mailto:ziarih.hawi@monash.edu https://orcid.org/ mailto: https://orcid.org/0000-0001-7507-9532 mailto:kealan.pugsley@monash.edu https://orcid.org/0000-0001-9350-6155 mailto:atefeh.namipashaki@monash.edu https://orcid.org/ mailto:wsamarrai@citytech.cuny.edu https://orcid.org/0000-0002-0814-9112 mailto:ziarih.hawi@monash.edu https://orcid.org/ mailto: https://orcid.org/0000-0001-7507-9532 mailto:kealan.pugsley@monash.edu https://orcid.org/0000-0001-9350-6155 mailto:atefeh.namipashaki@monash.edu https://orcid.org/ mailto:wsamarrai@citytech.cuny.edu https://orcid.org/0000-0002-0814-9112 mailto:ziarih.hawi@monash.edu https://orcid.org/ mailto: https://orcid.org/0000-0001-7507-9532 mailto:kealan.pugsley@monash.edu https://orcid.org/0000-0001-9350-6155 mailto:atefeh.namipashaki@monash.edu https://orcid.org/ mailto:wsamarrai@citytech.cuny.edu https://orcid.org/0000-0002-0814-9112 mailto:ziarih.hawi@monash.edu IHJPAS. 37 (2) 2024 65 in Yemen [4]. Although less frequent in non-Arab Muslim countries, consanguinity remains high, particularly in Pakistan, where up to 50.3–78.5% of marriages are between cousins [5-7]. Intrafamily coupling is associated with a substantial increase in the rate of monogenic and autosomal recessive inherited diseases among offspring. Children born of consanguineous unions possess elevated genome homozygosity, the consequence of which is known to increase the expression of potentially deleterious recessive phenotypes. Up to 6% of the genome of offspring resulting from first-cousin marriages is predicted to be homozygous. However, this has been reported in excess of 11% among such children with a recessive health condition [8]. It is therefore unsurprising that communities that socially favor inbreeding experience an increased burden of diseases. For example, the recessively inherited blood disorder β-Thalassemia is highly prevalent in tribal populations that favor consanguinity [9]. Additionally, cognate marriages have also been reported to increase the risk of common multifactorial diseases, likely due to a reduction in the overall genetic fitness of the population. In Qatar, for example, inbreeding has been associated with higher odds of common diseases including cancer, hypertension, hearing deficits, mental disorders, heart diseases, gastrointestinal disorders, and diabetes mellitus [10– 12]. The aim of the current article is to review the distribution of consanguinity prevalence in Iraq and highlight the gaps of knowledge that urgently need to be filled. Further, the article will also provide an expert opinion to minimize the negative impact of blood-related diseases on the future health of the population. 2. Methods Evidence for the current article was compiled using a selective PubMed database search inclusive of publications available up to January 2023. The search terms employed included (“consanguinity” OR “blood-related marriage” OR “cousin marriage”), in combination with (Iraq), (“blood diseases” OR “hemoglobinopathies” OR “disease” OR “health” OR “inherited disease”). Only publications describing the prevalence of relevant health conditions (i.e., of public concern) with well-described data collection and statistical analyses were used for the current article. 3. Consanguineous Marriages in Iraq The literature concerning the prevalence of intrafamilial marriage and its implications on population health in Iraq is sparse and largely outdated see Table 1. Overall, available studies have reported a nation-wide consanguinity rate ranging between 24 and 71%, with notable province-to-province variation. In the semi-autonomous Kurdish region of Northern Iraq, estimates of the prevalence of intrafamilial unions have been consistently calculated between 24.3 and 36.9% [13–15], with a single study reporting that above 70% of marriages in the region involve individuals with a degree of relatedness [13]. However, this upper estimate was calculated by surveying a small number of families (n = 21), bringing its accuracy and broader generalisability into question. An elevated rate of cognate unions is observed in the predominantly Arab Central and Southern regions of the country, between 44.0 and 53.4% [16– 18], and in the Anbar province in the West of Iraq, estimated at 64.6% [19]. The most extensive study examining the prevalence of consanguinity in the country was published in 2000 [20]. With the support of the United Nations International Children's Emergency Fund (UNICEF), the authors concluded that up to 61.0% of marriages within South and Central Iraq were among IHJPAS. 37 (2) 2024 66 blood relatives. It is important to note, however, that the degree of relatedness was not specified for all unions; hence, it may include relationships between extended family members with a clinically non-significant inbreeding coefficient in the resulting progeny. Table 1. Prevalence of Consanguineous Marriage in Iraq Provence/ region Sample size Information Source Consanguinity (%) First Cousin (%) Reference Kirkuk 21 families Population survey 71.4 57.1 Barth (1954) South Kurdistan 46 families Population survey 36.9 17.4 Barth (1954) Dohuk 591 couples Healthcare centres 27.2 ND Al-Allawi & Al- Dousky (2010) Sulaimani 736 couples Healthcare centres 24.3 ND Jalal et al. (2008) Baghdad 4491 families Hospital: in- and outpatients 46.4 29.2 Hamamy et al. (1986) Baghdad 382 families Hospital and research centre staff 53.4 35.9 Hamamy & Al- Hakkak (1989) Baghdad 302 families Population based sample 44.0 56.4 Lafta (2010) Anbar 150 families Outpatient clinic of hospital 64.6 36.6 Yahyaa et al. (2019) South/central Iraq 13897 women* Household survey 61.0 ND Ali & Shah (2000) *Household survey of women conducted with financial and technical support from UNICEF. The 61% includes marriages of cousins and other relatives. Consanguineous and other relatives’ marriages in the semi- autonomous Kurdish region were found in less than 50% of the 11099 interviewed women. ND= not defined. 4. The Gap of Knowledge in Iraq The profound impact of inbreeding on population health outcomes necessitates the development of a better understanding of consanguinity in Iraq. To address the consequences of consanguinity for the Iraqi populace, researchers need to establish three key areas of knowledge: 1. Despite their widespread prevalence and continued increase [21], there has been no recent comprehensive study to estimate the prevalence of cousin marriages in Iraq. Further, existing estimates have not included unregistered marriages, which are widely practiced in the country’s rural areas. 2. There is a notable lack of epidemiological data comparing the prevalence of health diseases in people borne of blood-related marriages versus background population risk. This is necessary on two counts: (1) it is essential to establish which common multifactorial diseases are increased by consanguinity, allowing for early screening and intervention implementation in at-risk groups; and (2) although inbreeding is highly associated with the inheritance of rare recessive genetic disorders, grossly insufficient population data are available on these conditions. As such, the generation of epidemiological records will support efforts to determine the impact of inbreeding on family health and the broader health of society. 3. The economic burden of treatment and symptom management of health disorders associated with consanguinity within the fast-growing Iraqi population is enormous. For example, the Federal Board of Supreme Audit in Iraq estimates the monthly cost of β-thalassemia per patient at USD$17,136 to $54,420 [22, 23]. This culminates in an annual sum of $191,323 to $507,114 million for 11,165 registered patients in 16 of 19 thalassemia centers. However, researchers have IHJPAS. 37 (2) 2024 67 not conducted systematic studies to estimate the economic cost of inherited diseases on a fast- growing population that heavily relies on revenue from selling oil. 5. Recommendation 5.1.Public Awareness Campaign At present, there are few public awareness initiatives focussed at educating the population of the devastating consequences of consanguineous marriage on the transmission of recessive and common diseases. Continual prompts from the research community for increased premarital genetic screening and enforceable legislative measures to decrease the incidence of these in the community [23] have not led to consistent action to challenge traditional tribal rules favouring blood-related marriages. For example, in the first five years of the premarital mandatory screening programme for haemoglobin diseases in the Kurdish region of Iraq (commenced in 2008), 93.1% of the couples identified at risk for having children with hemoglobinopathies proceeded with their marriage [24]. In this context, a public health awareness campaign focused on the health risks associated with intrafamilial marriages are urgently needed in Iraq, particularly in the rural, less educated population [19] where the prevalence of consanguineous marriages is high and still on the rise [21]. Historically, Cyprus had one of the highest frequencies of the β-Thalassemia globally, estimated at ~18% [25-26]. In an effort to eradicate the condition, a well-organized awareness campaign was instituted by Cyprus government. Commencing in high school, students were introduced to the fundamentals of genetics with a focus on the transmission of β-Thalassemia and its impacts on individuals’ health [27]. This was delivered in conjunction with increased practitioner education, as well as a wide-spread media campaign targeting the broader population, and played a critical role in encouraging voluntary pre-natal screenings [27]. Weaving education of β- Thalassemia in public life has resulted in a statistically significant decrease of 1.89% in the disease frequency of the Greek Cypriot population in 24 years [28] demonstrating the efficacy of this approach in improving public health literacy and outcomes. 5.2. Availability of Database While surveying the published literature, we observed a notable lack of relevant statistical data regarding the health of Iraq’s population. The absence of quantitative data makes it difficult to assess the impact of blood-related marriages on community wellbeing as well as the financial implications for the country’s economy. We have entered the modern era of information, where primary data must be available to experts to adequately plan for the future. Urgent action must be taken to fill the void of Iraq’s medical database shortcomings. For example, the Dunedin Multidisciplinary Study of Health and Development in New Zealand tracked the health and well- being of 1037 individuals from birth. Detailed qualitative and quantitative data was recorded regarding the participants’ physical, mental, social, and emotional status [29], garnering a detailed understanding of New Zealand’s public health. This permitted researchers to conduct relevant studies into the medical pitfalls and needs of the population. If replicated in Iraq, this level of understanding would undoubtedly produce data to interpret the medical needs of the country, including those concerning the social and economic burdens conferred by consanguineous unions. Such a database would benefit from the collection of accompanying biological samples (e.g., IHJPAS. 37 (2) 2024 68 salivary DNA) and physical/mental measures, as in the UK prospective Biobank study [30–31], an ongoing research effort aiming to assess the genetic, environmental, and lifestyle determinants of a wide range of diseases in over 500,000 individuals aged 40–69 years. The combined analysis of survey data with genetic and other physiological factors allows researchers to investigate the role of genes and the environment on health outcomes. The benefits of such studies are innumerous for a country with elevated rates of recessive and monogenic diseases and to determine what is needed to manage the health sector of a fast-growing population. 5.3. Legislative Measures As an overwhelmingly Muslim country, the influence of religious views greatly impacts Iraqi and other Arab societies. As such, the involvement of Islamic Religious Institutions (including but not limited to Al-Azhar of Egypt and Jaafari Jurisprudence in Najaf, Iraq) could prove instrumental in challenging the societal structures and deeply religious traditions that favor intrafamilial marriages. It is critical that religious and law-making authorities jointly legislate the prohibition of marriage without prior genetic testing authenticated by a reputable laboratory testing center, with sustainable measures to prevent the distribution of disingenuous premarital certificates based on inaccurate laboratory results. Such measures have proven successful in Cyprus, with the Cyprus Thalassemia Center being the only organization able to distribute authentic certificates recognized by the Holy Church of Cyprus. To this end, a public health genetic testing laboratory should be commissioned within Iraq and linked to the highest religious authorities, liaising with the legal establishment responsible for issuing marriage certificates. The authorities responsible for issuing marriage certificates should not recognize genetic testing results from private laboratories to authorize marriage. This level of vetting will assist in the prevention of the birth of children to cognate parents, minimizing the transmission of inherited diseases such as hemoglobinopathies. Acknowledgment Many thanks to the editor-in-chief and members of the editorial committee in Ibn Al-Haitham Journal for Pure and Applied Sciences. Conflict of Interest The authors declare that they have no conflicts of interest. Funding No funding. References 1. Bittles, A. Consanguinity and its relevance to clinical genetics. Clinical Genetics 2001, 60, 89–98. DOI: 10.1034/j.1399-0004.2001.600201.x. 2. Bittles, A.; Black, M. Consanguinity, human evolution, and complex disease. PNAS 2010, 107, 1779–1786. DOI: 10.1073/pnas.090607910. 3. Hamamy, H. Consanguineous marriages: Preconception consultation in primary health care settings. Journal of Community Genetics 2012, 3, 185–192. DOI: 10.1007/s12687-011-0072-y. 4. Khalil, A.M. Arabization and Islamization of consanguineous marriages: is it right? Medical Journal of Islamic World Academy of Sciences 2022, 29(1), 4-14. DOI: 10.5505/ias.2022.09735. https://doi.org/10.1034/j.1399-0004.2001.600201.x https://doi.org/10.1073/pnas.0906079106 https://doi.org/10.1007/s12687-011-0072-y IHJPAS. 37 (2) 2024 69 5. Bittles, AH. Consanguinity in Context. Cambridge University Press: Cambridge, UK 2012. 6. Khalid, N.; Noreen, K.; Qureshi, FM.; Mahesar, M. Knowledge of Thalassemia and Consanguinity: A Multicentre Hospital Based Retrospective Cohort Study from Metropolitan City of Karachi, Pakistan. The Professional Medical Journal. 2019, 26, 1580 1586. DOI: 10.29309/TPMJ/2019.26.09.168 7. Nawaz, A.; Zaman, M.; Malik, S. Consanguinity, inbreeding coefficient, fertility and birth-outcome in population of Okara district, Pakistan. Pakistan journal of Medical Sciences 2021, 37(3), 770-775. DOI: 10.12669/pjms.37.3.2263. 8. Woods, C.G.; Cox, J.; Springell, K.; Hampshire, D.J.; Mohamed, M.D.; McKibbin, M.; Stern, R.; Raymond, FL.; Sandford, R., Malik, Sharif, S.; Karbani, G.; Ahmed, M.; Bond, J.; Clayton, D.; Inglehearn, C.F. Quantification of homozygosity in consanguineous individuals with autosomal recessive disease. American Journal of Human Genetics 2006, 78, 5, 889–896. DOI: 10.1086/503875. 9. Denic, S.; Aden, B; Nagelkerke N.; Al Essa, A. β-Thalassemia in Abu Dhabi: Consanguinity and Tribal Stratification are Major Factors Explaining the High Prevalence of the Disease. Haemoglobin 2013, 37(4), 351–358. DOI: 10.3109/03630269.2013.790827. 10. Bener, A.; Hussain, R.; Teebi, A. Consanguineous Marrages and their effects on common Adult diseases: Studies from an Endogamous Population. Medical Principles And Practice: International Journal of The Kuwait University, Health Science Centre 2007, 16, 262–267. DOI: 10.1159/000102147. 11. Lotfi, Y.; Mehrkian, S. Hearing impairments in consanguineous marriage. Iranian Rehabilitation Journal 2004, 2(2), 9-14. DOI: http://irj.uswr.ac.ir/article-1-643-en.html. 12. Alzahrani, S.H.; Alzahrani, N.M.; Al Jabir, F.; Alsharef, M.K.; Zaheer, S.; Hussein, S.H.; Alguwaihes, A.M.; Jammah, A.A. Consanguinity and Diabetes in Saudi Population: A Case-Control Study. Cureus 2021,13(12), e20836. DOI: 10.7759/cureus.20836. 13. Barth. F. Father's Brother's Daughter Marriage in Kurdistan. Southwestern Journal of Anthropology 1954, 10(2), 64–171. DOI: 10.1086/soutjanth.10.2.3628823. 14. Jalal, S.D.; Al-Allawi, N.; Faraj, Z.H.; Ahmed, N.H. Prevalence of Haemoglobinopathies In Sulaimani – Iraq. Dohuk Medical Journal 2008, 2(1), 71–77. 15. Al-Allawi, N.; Al-Dousky, A. Frequency of haemoglobinopathies at premarital health screening in Dohuk, Iraq. Implications for a regional prevention programme. Eastern Mediterranean health journal = La revue de sante de la Mediterranee orientale = al-Majallah al-sihhiyah li-sharq al- mutawassit 2010, 16(4), 381–385. 16. Lafta, F. Consanguineous Marriage and some Reproductive Health Parameters for Sample from Families in Baghdad, Iraq. AL-Mustansiriya Journal of Science 2010, 21(5), 344 –354. 17. Hamamy, H.; Bayati, N.; Kubaisy, W. Consanguineous marriagesin the Iraq urban population and the effect on pregnancy outcome and infant mortality. Iraq Medical Journal 1986, 34, 75–79. 18. Hamamy, H.; Hakkak, Z.; Consanguinity and Reproductive Health in Iraq. Human Heredity 1989, 39, 271–275. DOI: 10.1159/000153871. 19. Yahyaa, B.; Ali, M.; Saad, A.J. Prevalence and Perception of Women about Consanguineous Marriage in Al-Ramadi city. Indian Journal of Public Health Research & Development 2019, 10(4), 567. DOI: 10.5958/0976-5506.2019.00758.7. 20. Ali, M.M.; Shah, I.H. Sanctions and Childhood Mortality in Iraq. Lancet 2000, 335, 1851–1857. DOI: 10.1016/S0140-6736(00)02289-3. 21. Al-Ghanim K.A. Consanguineous marriage in the Arab societies. Journal of Psychology and Clinical Psychiatry 2020, 11(6), 166‒168. DOI: 10.15406/jpcpy.2020.11.00692. 22. Iraqi Federal Board of Supreme Audit–Performance Evaluation Reports. [cited Aug, 2016]. Available from: http://www.d-raqaba-m.iq/pages_ar/repo_performance_ar.aspx. https://doi.org/10.29309/TPMJ/2019.26.09.168 https://doi.org/10.12669%2Fpjms.37.3.2263 https://doi.org/10.1086%2F503875 https://doi.org/10.3109/03630269.2013.790827 https://doi.org/10.1159/000102147 http://irj.uswr.ac.ir/article-1-643-en.html https://doi.org/10.7759%2Fcureus.20836 https://doi.org/10.1086/soutjanth.10.2.3628823 https://doi.org/10.1159/000153871 https://doi.org/10.1016/s0140-6736(00)02289-3 https://doi.org/10.15406/jpcpy.2020.11.00692 http://www.d-raqaba-m.iq/pages_ar/repo_performance_ar.aspx IHJPAS. 37 (2) 2024 70 23. Kadhim, A.; Baldawi; K.; Lami, F. Prevalence, Incidence, Trend, and Complications of Thalassemia in Iraq. Hemoglobin 2017, 41(3), 164–168. DOI: 10.1080/03630269.2017.1354877. 24. Al-Allawi, N.; Al Allawi, S.; Jalal, S.D. Genetic epidemiology of hemoglobinopathies among Iraqi Kurds. Journal of Community Genetics 2021, 12, 5–14. DOI: 10.1007/s12687-020-00495-z. 25. Fawdry, A. Report on present state of knowledge of erythroblastic anaemia in Cyprus. Cyprus Med Sanitary Report. 1946 Appendix D.12. 26. Banton, A.H. A genetic study of Mediterranean anaemia in Cyprus. American Journal of Human Genetics 1951, 3(1), 47– 64. 27. Ioannou, P. Thalassemia prevention in Cyprus past, present and future, published in a book titled: The Ethics of Genetic screening edited by Ruth Chadwick, Darren Shickle, Henk ten Have and Urban Wiesing, Springer-science & Business Media, B.V 1999, 55 – 67. 28. Kyrri, A.R.; Kalogerou, E.; Loizidou, D.; Ioannou, C.; Makariou, C.; Kythreotis, L.; Phylactides, M.; Kountouris, P.; Angastiniotis, M.; Modell, B.; Kleanthous, M. The changing Epidiomology of beta- Thalassemia in the Greek-Cypriot population. Hemaglobin 2013, 37(5), 435–443. DOI: 10.3109/03630269.2013.801851. 29. Silva, P. The Dunedin Multidisciplinary Health development Study: a 15 years longitudinal Study. Paediatric and Perinatal Epidemiology. 1990, 4, 76–107. DOI: 10.1111/j.1365- 3016.1990.tb00621.x. 30. Allen, N.; Sudlow, C.; Downey, P.; Peakman, T.; Danesh, J.; Elliott, P.; Gallacher, J.; Green, J.; Matthews, P.; Pell, J.; Sprosen, T.; Collins, R. UK Biobank Current status and what it means for epidemiology. Health Policy &Techno 2012, 1, 123–126. DOI: 10.1016/j.hlpt.2012.07.003. 31. Fry, A.; Littlejohns, T.J.; Sudlow. C.; Doherty,N.; Adamska,L.; Sprosen,T.; Collins,R.; Allen, N.E. Comparison of Sociodemographic and Health-Related Characteristics of UK Biobank Participants with Those of the General Population. American Journal of Epidemiology 2017, 186(9), 1026 –1034. DOI: 10.1093/aje/kwx246. https://doi.org/10.1080/03630269.2017.1354877 https://doi.org/10.1007/s12687-020-00495-z https://doi.org/10.3109/03630269.2013.801851 https://doi.org/10.1111/j.1365-3016.1990.tb00621.x https://doi.org/10.1111/j.1365-3016.1990.tb00621.x https://doi.org/10.1016/j.hlpt.2012.07.003 https://doi.org/10.1093/aje/kwx246