Characterisation of the opposing effects of G6PD deficiency on cerebral malaria and severe malarial anaemia
Clarke GM., Rockett K., Kivinen K., Hubbart C., Jeffreys AE., Rowlands K., Jallow M., Conway DJ., Bojang KA., Pinder M., Usen S., Sisay-Joof F., Sirugo G., Toure O., Thera MA., Konate S., Sissoko S., Niangaly A., Poudiougou B., Mangano VD., Bougouma EC., Sirima SB., Modiano D., Amenga-Etego LN., Ghansah A., Koram KA., Wilson MD., Enimil A., Evans J., Amodu OK., Olaniyan S., Apinjoh T., Mugri R., Ndi A., Ndila CM., Uyoga S., Macharia A., Peshu N., Williams TN., Manjurano A., Sepúlveda N., Clark TG., Riley E., Drakeley C., Reyburn H., Nyirongo V., Kachala D., Molyneux M., Dunstan SJ., Phu NH., Quyen NN., Thai CQ., Hien TT., Manning L., Laman M., Siba P., Karunajeewa H., Allen S., Allen A., Davis TME., Michon P., Mueller I., Molloy SF., Campino S., Kerasidou A., Cornelius VJ., Hart L., Shah SS., Band G., Spencer CCA., Agbenyega T., Achidi E., Doumbo OK., Farrar J., Marsh K., Taylor T., Kwiatkowski DP.
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is believed to confer protection against Plasmodium falciparum malaria, but the precise nature of the protective effect has proved difficult to define as G6PD deficiency has multiple allelic variants with different effects in males and females, and it has heterogeneous effects on the clinical outcome of P. falciparum infection. Here we report an analysis of multiple allelic forms of G6PD deficiency in a large multi-centre case-control study of severe malaria, using the WHO classification of G6PD mutations to estimate each individual’s level of enzyme activity from their genotype. Aggregated across all genotypes, we find that increasing levels of G6PD deficiency are associated with decreasing risk of cerebral malaria, but with increased risk of severe malarial anaemia. Models of balancing selection based on these findings indicate that an evolutionary trade-off between different clinical outcomes of P. falciparum infection could have been a major cause of the high levels of G6PD polymorphism seen in human populations.