SETTING: A rural Zimbabwean hospital and the surrounding community.OBJECTIVES: To determine whether a particular haptoglobin phenotype is associated with increased susceptibility to clinical pulmonary tuberculosis, and to determine the outcome of treatment for pulmonary tuberculosis according to haptoglobin phenotype.DESIGN: A case-control study, and a prospective cohort study.RESULTS: We studied 98 consecutive patients with sputum-positive pulmonary tuberculosis and 98 sex- and age-matched controls. The haptoglobin (Hp) phenotype distributions did not differ significantly between the tuberculosis patients and controls (P = 0.5). During the 18-month follow-up period after the start of tuberculosis treatment, 6/18 (33%) cases with Hp 2-2 phenotype died compared to 9/47 (19%) with Hp 2-1 and 3/31 (10%) with Hp 1-1. In a logistic regression model, the odds of dying were 6.1-fold greater with Hp 2-2 than with Hp 1-1 (95% CI 1.04-35.1, P = 0.04).CONCLUSION: Our results suggest that there is equal susceptibility to clinical pulmonary tuberculosis disease amongst different haptoglobin phenotypes. Nonetheless, tuberculosis patients with Hp 2-2 phenotype had a higher risk of mortality.

BACKGROUND Transferrin is the major iron binding protein in human plasma. In black persons, the transferrin CD phenotype has been associated with alterations in certain markers of iron status. OBJECTIVE We studied vitamin C status in a Zimbabwean population according to transferrin phenotype because vitamin C metabolism is influenced by iron-driven oxidative stress. DESIGN The study population consisted of 150 black African adults, 90 of whom were at risk of iron overload on the basis of high dietary iron content in the form of traditional beer. Transferrin phenotypes, indirect measures of iron status, and leukocyte ascorbic acid concentrations were determined. The in vitro rate of L-ascorbic acid depletion in sera from different transferrin phenotypes was investigated. RESULTS The transferrin phenotype frequencies of transferrin CC and CD were 0.893 and 0.107, respectively. The iron status of transferrin CC and CD subjects was similar. After adjustment for traditional beer consumption, baseline leukocyte vitamin C concentrations were significantly higher in 16 transferrin CD subjects ( +/- SE: 2.10 +/- 0.34 and 2.61 +/- 0.28 fmol/leukocyte in men and women, respectively) than in 134 transferrin CC subjects ( +/- SE: 1.65 +/- 0.11 and 1.99 +/- 0.11 fmol/leukocyte in men and women, respectively; P = 0.024). Oral administration of ascorbic acid (2.0 g every 24 h for 48 h) led to slower rises in leukocyte vitamin C concentrations in subjects with the transferrin CD phenotype than in subjects with the transferrin CC phenotype (P = 0.028). After in vitro supplementation of serum with 570 micromol vitamin C/L, the rate of L-ascorbic acid depletion was significantly lower in subjects of a transferrin CD phenotype than in subjects with the transferrin CC phenotype. CONCLUSION Transferrin polymorphism may affect vitamin C status in blacks.

To determine whether increased dietary iron could be a risk factor for active tuberculosis, dietary iron history and human immunodeficiency virus (HIV) status were studied in 98 patients with pulmonary tuberculosis and in 98 control subjects from rural Zimbabwe. Exposure to high levels of dietary iron in the form of traditional beer is associated with increased iron stores in rural Africans. HIV seropositivity was associated with a 17.3-fold increase in the estimated odds of developing active tuberculosis (95% confidence interval [95% CI], 7.4-40.6; P<.001), and increased dietary iron was associated with a 3.5-fold increase (95% CI, 1.4-8.9; P=.009). Among patients treated for tuberculosis, HIV seropositivity was associated with a 3.8-fold increase in the estimated hazard ratio of death (95% CI, 1.0-13.8; P=.046), and increased dietary iron was associated with a 1.3-fold increase (95% CI, 0.4-6.4; P=.2). These findings are consistent with the hypothesis that elevated dietary iron may increase the risk of active pulmonary tuberculosis.

BACKGROUND:Genetic variants of human transferrin (TF) have been described, but little is known about their functional differences. We studied iron status according to TF phenotype in a healthy Zimbabwean population and in subjects at risk of African iron overload.METHODS:The study population consisted of 483 nondrinkers, 31 drinking spouse pairs, and 5 family pedigrees (n = 88) with index cases of iron overload. TF phenotypes were determined using starch gel electrophoresis. To evaluate iron status, serum iron, total iron-binding capacity (TIBC), ferritin, and soluble TF receptors were measured, and the percentage of saturation and the serum iron:TF ratio were calculated. The binding of the TF variants was studied by equilibrium dialysis.RESULTS:The reference population was characterized by a high TF D allele frequency (0.050) and a complete absence of homozygous TF DD individuals. Similar allele frequencies were observed in subjects at risk of African iron overload. In the reference population, male TF CD heterozygotes had significantly lower (P <0.01) values for serum iron, TIBC, TF saturation, and serum iron:TF ratio than the TF CC homozygotes; in females, only TIBC was significantly different. Overall red blood cell indices did not differ according to TF phenotype. In the population at risk of African iron overload, only serum iron:TF ratio was consistently significantly lower in TF CD phenotypes (P <0.05). After equilibrium dialysis, the amount of iron bound by TF was significantly lower (P <0.01) in TF CD individuals.CONCLUSIONS:The present data demonstrate a functional difference between TF phenotypes in blacks.

Reference values for serum haptoglobin (Hp), were established in a Black Zimbabwean population. The upper limit (2.15 g/l) is comparable to the one in Caucasians, but the lower limit (0.12 g/l) is much lower than the proposed interim international reference limit (0.3 g/l). Subjects that typed as Hp 0-0 by starch gel electrophoresis technique were retyped using high performance gel permeation chromatography. This resulted in a 32% decrease in the frequency of Hp 0-0, but an increase in Hp 2-2 and Hp 2-1M phenotype frequencies. In the Zimbabwean Blacks, the Hp 0-0 frequency was estimated to be 2.9%. Haptoglobin reference values were found to be Hp phenotype-dependent; highest values were found in Hp 1-1 (median 0.88 g/l; range 0.31-1.69 g/l) and in Hp 2-1 (median 0.90 g/l; range 0.31-2.22 g/l) and lower values (median 0.66 g/l; range 0.13-1.79 g/l) in Hp 2-2 subjects. The Hp 2-1M phenotype was characterized by low reference values (0.18-1.25 g/l) (P<0.05). In three cases of the rare variant Hp Johnson, high Hp concentrations were found (median 1. 57 g/l; range 0.98-1.57 g/l).

BACKGROUND In a previously described model, heterozygotes for an African iron loading locus develop iron overload only when dietary iron is high, but homozygotes may do so with normal dietary iron. If an iron loading gene is common, then homozygotes with iron overload will be found even in an urban population where traditional beer, the source of iron, is uncommon. AIMS To determine whether iron overload and the C282Y mutation characteristic of hereditary haemochromatosis are readily identifiable in an urban African population. METHODS Histological assessment, hepatocellular iron grading, and dry weight non-haem iron concentration were determined in post mortem tissue from liver, spleen, heart, lungs, and skin. DNA of subjects with elevated hepatic iron indexes was analysed for the C282Y mutation. Iron concentrations in other tissues were compared. RESULTS A moderate increase (>30 μmol/g) in hepatic iron concentrations was found in 31 subjects (23%; 95% confidence interval 15.9 to 30.1%), and they were considerably elevated (>180 μmol/g) in seven subjects (5.2%; 95% confidence interval 1.5 to 8.9%). Appreciably elevated hepatic iron concentrations were associated with heavy iron deposition in both hepatocytes and macrophages, and either portal fibrosis or cirrhosis. All were negative for the C282Y mutation. Very high concentrations were uncommon in subjects dying in hospital. Concentrations of iron in spleen, heart, lung, and skin were significantly higher in subjects with elevated hepatic iron. CONCLUSIONS Iron overload is readily identified among urban Africans and is associated with hepatic damage and iron loading of several tissues. The condition is unrelated to the genetic mutation found in hereditary haemochromatosis.

OBJECTIVES:To determine the concentrations of iron and alcohol in traditional beer, as well as how these may be related to the brewing process.DESIGN:Cross sectional study.SETTING/SUBJECTS:Rural communities living in four of Zimbabwe's nine provinces.MAIN OUTCOME MEASURES:Ionic iron concentration and alcohol concentration in 94 different types of alcoholic beverages prepared in rural areas, and 18 commercially produced beers.RESULTS:The commonest types of traditional beer were a seven day beverage called 'doro rematanda', a by-product of this seven day beer called 'muchaiwa,' and a one-day beverage called 'chikokiyana'. Methods of preparation were similar in the four provinces. Median (Q1, Q3) ionic iron concentrations were 52 (31 to 75) mg/L for the seven-day beer (n = 51), 24 (18 to 36) mg/L for muchaiwa (n = 30) and 21 (17 to 63) mg/L for chikokiyana (n = 13). In contrast, ionic iron concentrations in 12 samples of commercially prepared clear beers were 0.1 mg/L and in commercial opaque beer were 3.6 mg/L. Mean (SD) alcohol concentration in traditional beer was 4.1 g/100 ml (+/- 0.873) compared to 2.8 g/100 ml +/- 1.394) in the muchaiwa and 3.6 g/100 ml (+/- 1.445) in the one day brew, chikokiyana. Mean alcohol concentrations in the three commercial beers are reportedly 3.5 g/100 ml in the opaque beer (Scud), and 4.7 to 5.0 g/ml in clear beer (Zambezi and Castle lagers).CONCLUSIONS:Several preparation methods lead to traditional fermented beverages with very high iron concentrations. Measures to prevent dietary iron overload should include all of these beverages in their scope.

OBJECTIVE:To determine if a traditional item in the diet might be useful in preventing iron deficiency in African women of child-bearing age.DESIGN:In a prospective study, the iron status of women who did and did not drink traditional beer high in iron and folic acid, was compared. Iron status was determined by a combination of haemoglobin, serum ferritin and transferrin saturation.SETTING:The study was conducted amongst rural villagers in the Murehwa and Zaka districts of Zimbabwe and in Mpumalanga Province, South Africa.SUBJECTS:112 women aged between 12 and 50 y from a population of 425 rural people participating in on-going family genetic studies.RESULTS:Women who consumed traditional beer had significantly higher serum ferritin concentrations and transferrin saturations compared to non-drinkers (P = 0.0001 and 0.03 respectively). Iron deficiency anaemia was not present in drinkers but the prevalence in non-drinkers was 13%. Forty seven percent of the non-drinkers and only 14% of the drinkers had evidence of iron deficiency (P = 0.002). Six (21%) of the drinkers and none of the non-drinkers had evidence of iron overload (transferrin saturation > 55% and serum ferritin > 400 ug/l).CONCLUSION:We conclude that the consumption of traditional beer, rich in iron, protects women against iron deficiency. While the use of an alcoholic beverage is not ideal, our findings suggest that indigenous cultural practices might be successfully employed or adapted for promoting iron nutrition.

Since Szent-Gyorgyi first purified ascorbic acid (vitamin C) in 1928 (1), a number of associations between ascorbic acid and iron metabolism have been described. At the molecular level, ascorbic acid mobilizes iron from the crystal core of ferritin in vitro by reducing Fe3 to Fe2 (2). Intracellularly, ascorbic acid enhances iron-induced translation of ferritin (3) by favoring the conversion of the iron regulatory protein (IRP) from the RNA binding form to aconitase (3). Ascorbic acid also retards degradation of ferritin by blocking lysosomal autophagy of ferritin and transformation to hemosiderin (4)(5). In humans, the oral administration of ascorbic acid enhances the absorption of non-heme iron from the diet (6) and leads to increases in serum iron in subjects with iron overload and ascorbic acid deficiency (7). Moreover, iron overload states are associated with reduced ascorbic acid concentrations, possibly because of increased catabolism of ascorbic acid (7)(8). The amount of labile iron in the cytosol influences the stability of transferrin receptor mRNA and the translation of ferritin mRNA (9)(10)(11). Posttranscriptional regulation occurs by means of an interaction between IRPs, proteins that sense changes in the chelatable intracellular iron pool, and iron-responsive elements located on untranslated regions of transferrin receptor mRNA and ferritin mRNA (12)(13)(14). In states of iron abundance, an IRP has aconitase activity and does not bind to iron-responsive elements, producing increased transferrin receptor mRNA degradation and increased ferritin mRNA translation. Conversely, when iron is deficient, an IRP loses aconitase activity and binds to iron-responsive elements, causing increased transferrin receptor mRNA stability and a repression of ferritin mRNA translation (15)(16). Thus, intracellularly, the presence of iron leads to inhibition of transferrin receptor expression and promotion of higher ferritin expression, whereas the deprivation of …

Although HLA-linked hemochromatosis greatly increases the risk for hepatocellular carcinoma in people of European ancestry, iron overload in Africa is not thought to be etiologically related to this malignancy, To determine if African iron overload may be associated with hepatocellular carcinoma, we reviewed 320 consecutive diagnostic liver biopsies processed at the University of Zimbabwe from 1992 to 1994 and we selected for analysis 215 biopsies from adults that were suitable for the histological assessment of hepatocellular iron. Subjects were stratified according to hepatocellular iron grades of 0-2+ (normal levels to mild siderosis; n=183) and grades of 3+ and 4+ (distinctly elevated levels consistent with iron overload; n=32). Thirty-six subjects had hepatocellular carcinoma. Logistic regression modeling revealed a significant association between iron overload and hepatocellular carcinoma after adjustment for age, sex and and the presence of portal fibrosis or cirrhosis (p=0.041). The odds of hepatocellular carcinoma in subjects with iron overload was 3.1 (95% confidence interval of 1.05-9.4) times that of subjects without iron overload, While we could not test for exposure to viral hepatitis or to aflatoxins in this study, our findings suggest that iron overload may be a risk factor for hepatocellular carcinoma in Africa.

To test the hypothesis that the quantities of circulating transferrin receptors are reduced in iron overload, we studied serum transferrin receptors and indirect measures of iron status in 150 subjects from rural Zimbabwe. We found significant inverse correlations between serum concentrations of transferrin receptors and ferritin, the ratio of ferritin to aspartate aminotransferase, and transferrin saturation (r > or = 0.44; P < 0.001). The mean +/- SD concentration of serum transferrin receptors in 23 subjects classified as having iron overload (ferritin > 300 microg/L and transferrin saturation > 60%) was 1.55 +/- 0.61 mg/L, significantly lower than the 2.50 +/- 0.62 mg/L in 75 subjects with normal iron stores (ferritin 20-300 microg/L and transferrin saturation 15-55%; P < 0.0005) and the 2.83 +/- 1.14 mg/L in 8 subjects with iron deficiency (ferritin < 20 microg/L; P = 0.001). In keeping with the regulation of transferrin receptor expression at the cellular level, our findings suggest that serum transferrin receptors are decreased in the presence of iron overload.

Iron overload in Africa was previously regarded as purely due to excessive iron in traditional beer, but we recently found evidence that transferrin saturation and unsaturated iron binding capacity may be influenced by an interaction between dietary iron content and a gene distinct from any HLA-linked locus. To determine if serum ferritin follows a genetic pattern and to confirm our previous observations, we studied an additional 351 Zimbabweans and South Africans from 45 families ranging in size from two to 54 members. Iron status was characterized with repeated morning measurements of serum ferritin, transferrin saturation, and unsaturated iron binding capacity after supplementation with vitamin C. For each measure of iron status, segregation analysis was consistent with an interaction between a postulated iron-loading gene and dietary iron content (P < .01). In the most likely model, transferrin saturation is 75% and serum ferritin is 985 micrograms/L in a 40-year-old male heterozygote with an estimated beer consumption of 10,000 L, whereas the saturation is 36% and serum ferritin is 233 micrograms/L in an unaffected individual with identical age, sex, and beer consumption. This segregation analysis provides further evidence for a genetic influence on iron overload in Africans.

BACKGROUND:Hepatitis B is a common cause of chronic liver disease in Zimbabwe but other viral infections are also important. The prevalence of viral hepatitis C has not been previously described in healthy rural Zimbabwean adults.OBJECTIVES:To determine the prevalence of seropositivity to hepatitis C in rural healthy adults in Zimbabwe, and to determine if there is evidence of active liver disease in subjects who are seropositive.STUDY DESIGN:Cross sectional descriptive study.SETTING:Rural communities around different parts of Zimbabwe, as part of a larger study into the prevalence and genetic pattern of iron overload.SUBJECTS:An initial 150 rural Zimbabweans over the age of 12 years.MAIN OUTCOME MEASURES:Presence of the following serological markers: hepatitis B surface antigen; antibodies to hepatitis C, B surface and B core antigens; hepatic enzymes and iron status determined on the basis of serum ferritin and transferrin saturation.RESULTS:11 (7.7%) of the subjects were positive for antibodies to hepatitis C and they had significant elevations in hepatic enzymes and serum iron levels suggesting substantial hepatocellular damage. Twenty (14.1%) of the subjects were positive for hepatitis B surface antigen, but they did not have significant elevations in hepatic enzymes or indirect measures of iron status.CONCLUSION:Seropositivity for hepatitis C is common and is approximately half the prevalence of hepatitis B chronic carrier status. Chronic hepatitis C may be more damaging to the liver than chronic hepatitis B and, therefore, may be an important cause of liver disease in rural Zimbabwe.

To examine the relationship between dietary iron exposure through the consumption of traditional beer and the presence of iron overload in black Africans not related by birth, we studied 28 husband and wife pairs from a rural Zimbabwean community. Lifetime traditional beer consumption was estimated by questioning subjects and iron status was assessed by repeated measurements of serum ferritin and transferrin saturation in subjects who were fasting and had received vitamin C supplementation. Each of the 56 study subjects had an estimated lifetime traditional beer consumption >1,000 L. The mean +/- standard deviation (SD) concentration of iron in the supernatants of nine samples of traditional beer from the community was 46 +/- 10 mg/L. Four of 28 men (14.3%) and no women had the combination of an elevated serum ferritin and a transferrin saturation >70%, suggestive of substantial iron overload. Significant correlations were not found between the iron status of the husbands and their wives or between dietary iron exposure and iron stores. Our findings suggest that dietary iron exposure may not fully explain the development of iron overload in Africans and are consistent with the hypothesis that an iron-loading gene may also be implicated in pathogenesis.