The global distribution of the Duffy blood group

Abstract

Blood group variants are characteristic of population groups, and can show conspicuous geographic patterns. Interest in the global prevalence of the Duffy blood group variants is multidisciplinary, but of particular importance to malariologists due to the resistance generally conferred by the Duffy-negative phenotype against Plasmodium vivax infection. Here we collate an extensive geo-database of surveys, forming the evidence-base for a multi-locus Bayesian geostatistical model to generate global frequency maps of the common Duffy alleles to refine the global cartography of the common Duffy variants. We show that the most prevalent allele globally was FY*A, while across sub-Saharan Africa the predominant allele was the silent FY*B^ES variant, commonly reaching fixation across stretches of the continent. The maps presented not only represent the first spatially and genetically comprehensive description of variation at this locus, but also constitute an advance towards understanding the transmission patterns of the neglected P. vivax malaria parasite.

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Received 9 Aug 2010 | Accepted 3 Mar 2011 | Published 5 Apr 2011 DOI: 10.1038/ncomms1265

Rosalind E. Howes1, Anand P. Patil1, Frdric B. Piel1, Oscar A. Nyangiri2, Caroline W. Kabaria3, Peter W. Gething1, Peter A. Zimmerman4, Cline Barnadas5, Cynthia M. Beall6, Amha Gebremedhin7, Didier Mnard8,

Thomas N. Williams2, David J. Weatherall9 & Simon I. Hay1

Blood group variants are characteristic of population groups, and can show conspicuous geographic patterns. Interest in the global prevalence of the Duffy blood group variants is multidisciplinary, but of particular importance to malariologists due to the resistance generally conferred by the Duffy-negative phenotype against Plasmodium vivax infection. Here we collate an extensive geo-database of surveys, forming the evidence-base for a multi-locus Bayesian geostatistical model to generate global frequency maps of the common Duffy alleles to rene the global cartography of the common Duffy variants. We show that the most prevalent allele globally was FY*A, while across sub-Saharan Africa the predominant allele was the silent FY*BES

variant, commonly reaching xation across stretches of the continent. The maps presented not only represent the rst spatially and genetically comprehensive description of variation at this locus, but also constitute an advance towards understanding the transmission patterns of the neglected P. vivax malaria parasite.

The global distribution of the Duffy blood group

1 Spatial Ecology and Epidemiology Group, Tinbergen Building, Department of Zoology, University of Oxford, South Parks Road, Oxford OX1 3PS, UK. 2 Kenya Medical Research Institute (KEMRI)/Wellcome Trust Programme, Centre for Geographic Medicine Research, Coast, PO Box 230, Kili District Hospital, Kili 80108, Kenya. 3 Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine, KEMRIUniversity of OxfordWellcome

Trust Collaborative Programme, Kenyatta National Hospital Grounds (behind NASCOP), PO Box 43640-00100, Nairobi, Kenya. 4 Center for Global

Health and Diseases, Case Western Reserve University, Wolstein Research Building, 2103 Cornell Road, Cleveland, Ohio 44106-7286, USA.

5 Vector Borne Diseases Unit, Papua New Guinea Institute for Medical Research, PO BOX 60, Goroka, EHP 441, Papua New Guinea. 6 Anthropology Department, Case Western Reserve University, 238 Mather Memorial Building, 11220 Bellower Road, Cleveland, Ohio 44106-7125, USA. 7 Department of Internal Medicine, PO Box 14227, Faculty of Medicine, Addis Ababa University, Addis Ababa, Ethiopia. 8 Molecular Epidemiology Unit, Pasteur Institute of Cambodia, 5 Boulevard Monivong, PO Box 983, Phnom Penh, Cambodia. 9 Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, Oxford OX3 9DS, UK. Correspondence and requests for materials should be addressed to S.I.H. (email: [email protected]).

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First described 60 years ago in a multiply transfused haemolytic patient who lent his name to the system1, the Duy blood group has since been of interest in diverse elds from

anthropology2 to genetics3 and malariology4,5. Being of only occasional clinical signicance6, much of the research into this weakly immunogenic blood group has been concerned with establishing characteristic expression patterns among populations. Easily diagnosable, the Duy blood group quickly became part of the package of commonly investigated blood groups used to characterize the worlds populations7 and assess relatedness between communities. Interest in the Duy blood group rose substantially, however, following experimental demonstration of the malaria parasite Plasmodium vivaxs dependency on the Duy antigen for establishing erythrocytic infection810, and therefore that erythrocytes lacking the antigen were refractory to this parasitic infection. This Duy negativity phenotype, long known to be common among sub-Saharan African populations11, provided an explanation for the apparent absence of P. vivax among these populations and their diaspora12. To date, no other erythrocyte receptor has been described for P. vivax, although some cases of infection have been reported in Duy-negative individuals1315. Furthermore, the universal expression of the Duy antigen binding protein (PvDBP) has made this merozoite invasion ligand protein a prime P. vivax vaccine target16.

The role of the Duy receptor in P. vivax infection, therefore, allows the Duy-negative phenotype to be a proxy of host resistance to blood stage infection17.

Recognizing its physiological function as a chemokine receptor involved in inammation, the Duy antigen is also known as the Duy antigen receptor for chemokines (DARC). Although specic

mechanisms underlying its functions remain uncertain, there is interest in DARC as an explanatory variable for population-specic dierences in disease susceptibility18, as demonstrated by ongoing research into its role in inammation-associated pathology and malignancy18,19, and the recent, though highly controversial20, surge in interest around the antigens role in HIV infection21.

The monogenic Duy system was the rst human blood group assigned to a specic autosome: position q21q25 on chromosome 1 (ref. 22). The gene product has two main variant forms: Fya and Fyb antigens, which dier by a single amino acid (Gly42Asp), encoded by alleles FY*A and FY*B, which are dierentiated by a single base substitution (G125A)23,24. Duy expression is disrupted by a T to C substitution in the genes promoter region at nucleotide 33, preventing transcription and resulting in the null erythrocyte silent (ES) phenotype. This promoter-region variant is commonly haplotypically associated with the FY*B coding region (corresponding to the FY*BES allele)24, although occasional reports of association with the FY*A sequence have been published (FY*AES allele)25,26. These four alleles combine to ten possible genotypes (Fig. 1), with FY*A and FY*B alleles expressed codominantly over the null variants FY*BES and FY*AES. Genotypes therefore correspond to four phenotypes: Fy(a+b+), Fy(a+b), Fy(ab+) and Fy(ab). Further details about the genetics and molecular aspects of the Duy system, including other rare variants such as the weakly expressed FY*X allele27 (expressed as the Fy(b + weak) phenotype), are fully discussed by Langhi and Bordin23 and Zimmerman24.

The common Duy alleles present striking patterns of geographic dierentiation, which have only once been mapped spatially, as part of Cavalli-Sforza et al.s28 eorts to unravel the genetic

Global database of Duffy blood group frequencies

(19502010)

Survey exclusion rules

N by data type (single data type per site)

Genotype

N examined

Location

Phenotype-a Fy(a+) Fy(a)

Phenotype-b Fy(b+) Fy(b)

Promoter Fy(+) Fy()

Phenotype Fy(a+b+) Fy(a+b) Fy(ab+) Fy(ab)

FY*A/*A FY*A/*B FY*B/*B FY*A/*AES FY*A/*BES FY*B/*AES FY*B/*BES FY*AES/*AES FY*AES/*BES FY*BES/*BES

Africa covariate

Bayesian geostatistical model with HardyWeinberg principles

Predicted global distribution of FY*BES allele frequency

Global Duffy negativity phenotype frequency map: Fy(ab) (FY*BES allele frequency)2

Predicted global distribution of FY*B allele frequency

Predicted global distribution of FY*A allele frequency

Model validation

Figure 1 | Schematic overview of the procedures and methods. Blue diamonds describe input data. White boxes within the N by data type diamond represent different possible data types, with each spatially unique survey being represented by only one white box. Orange boxes denote models and experimental procedures. Green rods indicate model outputs.

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history of human populations. Alleles were mapped in isolation of each other (FY*A, FY*B and FY*BES) using limited subsets of data which directly informed the frequency of each particular variant. Previous methodology, which used a sequential inverse distance weighting algorithm, was unable to estimate uncertainty in the mapped predictions. Since this publication in 1994, new data have been generated, much of which have benetted from full genotyping. In addition, signicant advances have been made to geostatistical mapping techniques allowing more rigorous predictions of spatially continuous variables using data obtained at a limited number of spatial locations29, and varied data inputs to inform all output predictions simultaneously.

Here we rst assembled an updated data set based on a thorough review of published and unpublished data, then used this to generate global maps of the Duy alleles and the Duy negativity phenotype using a bespoke Bayesian geostatistical model. This generated for every location on a gridded surface a posterior distribution of all predicted values from the models thousands of iterations, representing a complete model of uncertainty from which median values were derived to generate point-estimate maps. In addition to providing fundamental biomedical descriptions of human populations with potential applications for explaining population-level variation to a range of clinical conditions19, these maps are intended to support contemporary analyses of P. vivax transmission risk17.

ResultsThe survey database. Literature searches identied 821 spatially unique data points of Duy blood type prevalence matching the database inclusion criteria for representativeness (Supplementary Data). These represented a total of 131,187 individuals sampled, 17.8% of whom were surveyed on the African continent (Table 1). Of this total, 536 surveys were geopositioned as points (25 km2), and 285 mapped as polygon centroids. Polygons were digitized and centroid coordinates calculated in GIS soware (ArcView GIS 3.2 and ArcMap 9.3, ESRI). Surveys reported only to province or country level were considered to lack sufficient geographical specicity and were thus excluded. A total of 89 additional data points were excluded, as they could not be located with sufficient precision. The selected data points were relatively evenly distributed between regions, with 32% in the Americas, 25% in Africa, 26% in Asia and 17% in Europe (Fig. 2). Survey sample sizes were highly variable: ranging from 1 to 2,470. The mean size was 160 and the median 99.

Serological techniques were the only methods used for blood typing until the 1990s, (Supplementary Fig. S1). Half of the surveys (49%) used anti-Fya antiserum only, thus were recorded as Pheno-type-a data types (402 of 821 surveys). Complete Phenotype data were provided in 247 surveys (30%). Molecularly diagnosed Geno-type and Promoter data (9 and 12%, respectively) were only commonly reported in post-2000 surveys, and mainly across Africa (71% of the 168 DNA-based records were from Africa). The ve categories of data types are summarized in Table 2, and the spatial distribution of each is represented by the colour-coded data point map in Figure 2. Relative proportions of each variant-type reported by data type and continent are displayed in Table 1; further summaries of the data are presented graphically by decade in Supplementary Figures S1S2.

The maps. To generate continuous global maps from the assembled database, a Duy-specic geostatistical model was developed (Supplementary Methods). Its key features are as follows: rst, to incorporate all genotypic variants and data types simultaneously; second, to predict any genotype or phenotype frequency desired; third, to allow for local heterogeneity; and fourth, to take into account sampling error through sample size, while also generating uncertainty estimates with the prediction at each spatial unit (pixel).

Allele frequencies. Continuous global frequency maps of each of the three common Duy alleles (FY*A, FY*B and FY*BES) were

generated simultaneously, along with summaries of uncertainty in the predictions quantied by the 50% interquartile range (IQR; Fig. 3). Full statistical summaries of the model parameters at each locus are provided in Supplementary Table S1. The silent FY*AES allele could not be modelled spatially due to its rarity (see Methods).

The allele frequency maps reveal strong geographic patterns, the most conspicuously focal being the distribution of the silent FY*BES

allele across sub-Saharan Africa. Allelic frequencies across 30 countries in this region are characterized by > 90% FY*BES and frequencies of 05% for FY*A and FY*B (Fig. 3ac). Frequencies indicate xation (that is, frequencies of 100% (ref. 30)) in parts of west, central and east Africa, suggesting total refractoriness of the local population to P. vivax infection3,30. The FY*BES allele, however, is not conned to the mainland African sub-continent, with frequencies predicted above 80% across Madagascar and above 50% through the Arabian Peninsula (Fig. 3c). Low allelic frequencies have also spread into the Americas, notably along the Atlantic coast and in the Caribbean. Median frequencies of 520% are predicted across India and up to 11% in South-East Asia.

Allelic heterogeneity is greatest in the Americas, with all three alleles predicted as being present and with only localized patches of predominance of single alleles. The FY*A allele (Fig. 3a) is close to xation across pockets of eastern Asia, and remains high with

Table 1 | Summary of input data.

Total individualssampled Africa Americas Asia Europe World

23,349 37,410 32,971 37,457 131,187

17.8% 28.5% 25.1% 28.6% Genotype 1,720 1,107 5,993 336 9,156

FY*A/*A 40 183 5,805 42 6,070 FY*A/*B 88 341 24 174 627 FY*B/*B 49 217 6 117 389 FY*A/*AES 0 0 157 0 157

FY*A/*BES 226 122 0 0 348 FY*B/*AES 0 0 0 0 0

FY*B/*BES 190 122 1 1 314 FY*AES/*AES 0 0 0 0 0 FY*AES/*BES 4 0 0 0 4 FY*BES/*BES 1,123 122 0 2 1,247

Phenotype 11,370 10,939 11,143 17,126 50,578 Fy(a+b+) 1,448 3,841 2,471 7,355 15,115 Fy(a+b) 1,338 3,904 6,821 4,872 16,935 Fy(ab+) 2,493 2,595 1,493 4,873 11,454 Fy(ab) 6,091 599 358 26 7,074

Promoter 7,290 803 187 104 8,384 Fy(+) 7,266 406 0 0 7,672 Fy() 24 397 187 104 712

Phenotype-a 2,821 24,420 15,648 17,891 60,780

Fy(a+) 589 19,950 12,436 11,616 44,591 Fy(a) 2,232 4,470 3,212 6,275 16,189

Phenotype-b 148 141 0 2,000 2,289 Fy(b+) 1 55 0 1,651 1,707 Fy(b) 147 86 0 349 582

Total sites 203 265 217 136 821 surveyed 24.7% 32.3% 26.4% 16.6%

The table shows the total number of individuals sampled by continent, broken down by variant within each data type category. Totals are shown in bold. The number of spatially unique sites in each continent is given in the bottom row.

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Data pointGenotype (n=73) Phenotype-a (n=402)

Phenotype-b (n=4)

Sub-Saharan Africa boundary

Phenotype (n=247)

Promoter (n=95)

Figure 2 | Spatial distribution of the input data points categorized by data type. Symbol colours represent the type of information in the survey: orange when full genotypes were detected (Genotype); red for full phenotype diagnosis (Phenotype); yellow for expression/non-expression of Duffy antigen (Promoter); green and blue for partial phenotypic data, about expression of Fya (Phenotype-a) and Fyb (Phenotype-b) respectively. Total data points are n = 821; totals by data type are listed in the legend. The sub-Saharan Africa covariate boundary is shown in black.

Table 2 | Diagnostic methods and corresponding classication data type categories.

Diagnostic method

Diagnostic type

Data type Description Information given Homo/heterozygote status

Serological Phenotype Phenotype Study tested for Fya and Fyb

Four phenotypes No

Phenotype-a Study only tested for Fya Two data types (Fya+/): cannot distinguish Fy(ab+) from Fy(ab)

No

Phenotype- b Study only tested for Fyb Two data types (Fyb+/): cannot distinguish Fy(a+b) from Fy(ab)

No

DNA-based Genotype Promoter Study only looked at promoter region SNP

Distinguishes expression from non-expression: cannot distinguish FY*A from FY*B coding region

Yes (promoter SNP only)

Genotype Study looked at promoter and a/b SNP

Fully distinguishes all individual alleles Yes

SNP, single-nucleotide polymorphism.

During the abstraction process, data points were classied into data types according to the diagnostic methodology used.

median frequencies above 80% predicted across large extents of south Asia, Australia and in populations from Mongolia and eastern parts of China and Russia. The allele is also at high frequencies ( > 90%) in Alaska and northwest Canada. Outside these regions of highest predominance, FY*A remains relatively common outside the African continent, with median frequencies > 50% predicted across 67.7% of the global surface. The FY*B allele (Fig. 3b) is the allele least prevalent globally, with a maximum predicted median frequency of 83% (thus xation is never reached). Reecting its reduced prevalence, the distribution of FY*B matches areas of highest allelic heterogeneity, where its presence increases to frequencies similar to, or greater than, FY*A and FY*BES. Frequencies above 50% are restricted to Europe and pockets of the Americas, notably along the east coast of the United States of America. FY*B frequencies decrease from their European epicentre eastwards, as the FY*A allele becomes predominant in Asia. FY*B is also prevalent in the buer zones around the region of FY*BES predominance, in northern, north-eastern and southern Africa.

Duy negativity phenotype. The phenotype map of Duy negativity (Fig. 4) reveals very low frequencies of the homozygous null genotype (FY*BES/*BES) from much of the predicted non-African FY*BES distribution (Fig. 3c). Despite being present, the low allelic frequencies mean that homozygotic inheritance is too low to feature in the phenotype map. Therefore, even more pronounced than the alleles distribution, the Duy negativity phenotype is highly constrained to sub-Saharan African populations, and localized patches in the Americas. Across the African continent, the phenotypes median frequency is greatest (98100%) in western, central and south-eastern regions from The Gambia to Mozambique, buered by a high median frequency region of 90% frequency covering 22 countries (Fig. 4a). Around this high frequency region, steep clines into the Sahel in the north, and Namibia and South Africa in the south lead to median phenotypic frequencies of < 10% in parts of these extremities.

Frequencies of Duy negativity increase by ~10% south of the sub-Saharan desert boundary, as dened in the model by the

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FY*A IQR

FY*B IQR

FY*A frequency

FY*B frequency

FY*BES frequency

05% 5070%

510% 1020% 2030% 3050%

7080% 8090% 9095% 95100%

7085%

05% 510% 1020% 2030%

5060%

05% 510% 1020%

2030% 3050% 5070%

3050%

05%

5070%

510%

1020%

2030%

3050%

3050%

FY*BES IQR

510%

05% 510% 1020% 2030% 3050% 5070% 7090%

1020%

05% 5070% 7080%

8090%

9095% 95100%

2030%

Figure 3 | Global Duffy blood group allele frequencies and uncertainty maps. (ac) Correspond to FY*A, FY*B and FY*BES allele frequency maps, respectively (median values of the prediction posterior distributions); (df) show the respective interquartile ranges (IQR) of each allele frequency map (2575% interval). Predictions are made on a 55 km grid in Africa and 1010 km grid elsewhere. Supplementary Figure S5 is a greyscale image of this gure.

GlobCover bare ground data set31 (Fig. 5). This trend of increased frequencies is reected by the positive values associated with the sub-Saharan Africa covariate, fully described in Supplementary Table S2. The increase is sharpest where there are few underlying data points, contrasting with the prediction in data-rich regions, such as West Africa, which is smoother across the desert boundary due to the abundance of input data overriding its inuence.

Prediction uncertainty. The output generated by the Bayesian framework is a predictive posterior distribution for each modelled variable for each 1010 km pixel on the global grid (and 55 km across Africa). The posterior quanties the probabilities associated with every candidate value of each modelled variable and therefore represents a complete description of uncertainty in the model output32.

The outputs, summarized in Figures 3ac and 4a, are the median values of these distributions. The uncertainties around these predictions, represented by the intervals between the 25 and 75% quartiles of the posterior distributions (or IQRs), are shown for the allele maps in Figures 3df and for Duy negativity in Figure 4b. Remarkable certainty in the prediction for high Duy negativity in sub-Saharan Africa is reected by IQRs of 05% for all outputs. The absence of data points from the Democratic Republic of the Congo leads to a slightly elevated level of uncertainty relative to the surrounding region (Figs 4b and 5). Certainty in the prediction of the highest frequencies of Duy negativity is illustrated by the hatched areas of 95% Duy negativity prevalence, determined with 75 and 95% condence (Fig. 5). As would be expected from the heterogeneity in allelic make-up (Fig. 3a,b), the greatest uncertainty in the global predictions of FY*A and FY*B prevalence is associated with the predictions across Europe, western Asia and the Americas (Fig. 3d,e).

Validation statistics. Bespoke validation procedures were developed to quantify the models ability to predict frequencies of each allele, as well as the validity in the underlying assumption of Hardy Weinberg equilibrium: rst, by validating the Duy-negative pheno-type surface; second, by assessing rates of heterozygosity between FY*A and FY*B. The models predictive ability was quantied by assessing the disparity between model predictions and held-out subsets of data excluded for validation analyses33. The validations were summarized using simple statistical measures: mean error (assesses overall model bias) and mean absolute error (quanties overall prediction accuracy as the average magnitude of the errors, Supplementary Methods).

First, the mean error in the prediction of the Duy negativity phenotype revealed a slight positive bias in the posterior predictive distribution of Duy negativity (mean error: 1.3%), while the mean absolute error revealed relatively high typical precision in the predictions (mean absolute error: 5.8%). Second, the heterozygosity validation process identied an overall positive bias in the posterior predictive distribution of rates of heterozygosity (frequencies of the FY*A/*B genotype) with mean error of 5.5% and mean absolute error of 7.8%. Overall, therefore, the models predictive ability for the clinically signicant Duy-negative phenotype was relatively high, although the assumption of HardyWeinberg equilibrium was not strongly supported, indicating that better predictions might be achieved in future iterations by modelling the xation index as a third geostatistical random eld. However, the resulting model would be substantially more complicated than the current one, which is already a major advance beyond the state of the art, and commensurately more difficult to t. Given the relatively small size of the heterozygote deciency in the holdout data set, we decided

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Fy(ab) frequency

010% 6070% 7080% 8090% 9095% 9598% 98100%

Fy(ab) IQR

05%

510%

1020%

2030%

3050%

5070%

7090%

1020%

2030%

3040%

4050%

5060%

Figure 4 | Global distribution of the Duffy negativity phenotype. (a) Global prevalence of Fy(a b ); (b) associated uncertainty map. Uncertainty is represented by the interval between the 25 and 75% quartiles of the posterior distribution (IQR). Supplementary Figure S6 is a greyscale image of this gure.

against elaborating the model in the current study. More validation results are given in Supplementary Figure S3.

Discussion

The spatial distribution of the Duy blood group variants has been of interest since its discovery 60 years ago because of its link to the pathology of both infectious and non-communicable diseases, including most notably with P. vivax infection. We have assembled an up-to-date database of Duy phenotypic and genotypic data, from which we identied 821 geographically unique community surveys, and developed a geostatistical model to generate global frequency maps for the main Duy alleles, as well as the rst map of the Duy-negative phenotype. These rened maps and associated uncertainty measures allow both an assessment of the quality and distribution of existing data as well as a discussion of how the maps may help direct further research into the interactions between Duy negativity and P. vivax malaria. A detailed comparison with the existing maps from Cavalli-Sforza et al.28 is presented in the Supplementary Discussion and Supplementary Figures S8S10.

The summary median maps presented reveal relatively smooth global-scale patterns of geographic dierentiation among populations. Despite being considered the ancestral allele34, our maps show

a remarkable restriction in the distribution and frequency of the FY*B allele, with highest prevalence found in Europe and parts of the Americas, with further patches of increased prevalence in areas buering the region of FY*BES predominance in sub-Saharan Africa. Frequencies of FY*A prevalence increase with distance from Africa and Europe, becoming dominant across south-east Asia, including those areas where P. vivax endemicity is highest17. Although the FY*BES allele map predicts presence outside the African continent and the Arabian Peninsula, its frequencies remain too low for the Duy-negative phenotype frequencies to exceed 10%. Although these static contemporary representations of allelic frequencies cannot alone be interpreted to advance current speculation regarding the causative mechanisms of selection of the high frequencies of the FY*BES allele4,5,35,36, the Duy negativity map does reect visually the historical areas of malaria transmission, as dened by Lysenkos pre-control era malaria map37 (Supplementary Fig. S4, recently republished by Piel et al.38)

A major challenge in this study was synthesizing the results of surveys, which used a range of diagnostic methods with potentially dierent reliabilities, particularly between genotyping and pheno-typing methods. The possible inuence of such variability on the model input is reviewed in detail in the Supplementary Methods,

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P. vivax-positive surveys

P. vivax-negative surveys

Duffy surveys

Sub-Saharan Africa boundary

75% Confidence of 95% Fy(ab)

95% Confidence of 95% Fy(ab)

Fy(ab) frequency

010% 6070%

7080%

8090%

9095%

9598%

98100%

1020%

2030%

4050%

5060%

3040%

Figure 5 | Characteristics of the Duffy negativity phenotype in Africa. This gure shows the covariate line (in green), which separates sub-Saharan African populations from the rest of the continent; hatched areas indicate areas of condence in the distribution of 95% Duffy negativity frequency: with 75%and 95% condence. Black data points correspond to the input Duffy data points (n = 821). Yellow stars indicate locations of P. vivax-positive community surveys (n = 354), and blue stars P. vivax-negative surveys (n = 1405) (data assembled by the Malaria Atlas Project17,46). Supplementary Figure S7 is a greyscale image of this gure.

but is not considered to have major inuence on the nal output. By categorizing results into ve data types (Table 2) and developing a versatile geostatistical model, we were able to draw information from the diering data types in our full data set to generate each allele frequency map simultaneously. The Genotype data, generated from molecular diagnostic methods only widely available aer the previous maps28 were published, were most informative for the model. Despite a generally good global spread of survey data points (Fig. 2), the uncertainty maps allow identication of areas where additional data would have proportionally greatest impact on our understanding of the distributions. Both the quality (data type) and quantity (data distribution) of the data aect the uncertainty measures. Uncertainty is increased by both scarcity of input data (exemplied across the Arabian Peninsula where only Phenotype-a data were available) and heterogeneity (characteristic of the Americas where populations of diverse origins coexist; Figs 3df and 5). In contrast, areas of lowest uncertainty match data-rich regions and areas of near-xation, illustrated by the hatched areas of 95% condence in the prediction shown in Figure 5. Scarcity of input data also leaves us uncertain about possible ne-scale variation of allelic heterogeneity. This is demonstrated by the relatively high uncertainty in the predictions of the patchily distributed FY*BES allele across the Americas, where spatial heterogeneity is expected to be high and perhaps not fully represented by the data set. As well as improv-

ing reliability in the current predictions, additional molecularly diagnosed data would allow renements of the model to include additional polymorphic variants, such as the low-frequency weak FY*X variant39. This is discussed in detail in the Supplementary Discussion.

Reecting the growing appreciation of P. vivaxs public health signicance and the realization that it is not benign16,40,41, the parasites relationship with the Duy receptor is the primary focus of contemporary studies of the Duy antigen. However, two lines of evidence, both from a community and an individual standpoint, support the need for further research into the Duyparasite association. First, contrary to expectation, there is evidence of P. vivax transmission in areas mapped with highest Duy negativity frequencies. Although widespread surveys have failed to identify the parasite in this region (including a continental-wide survey by Culleton et al.42, and the data set of community parasite rate surveys displayed in Fig. 5), reports of infected mosquitoes13, travellers17 and exposed individuals43 suggest low level transmission. Across this predominantly Duy-negative region, very low numbers of Duy-positive individuals were identied (0.6% of individuals in 123 surveys across the 98100% Fy(ab) region; Supplementary Table S3). To see whether these two observations can be reconciled to explain transmission, mathematical modelling is needed to estimate the basic reproductive number (R0) of P. vivax (as done for Plasmodium falciparum44) to

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Phenotype-a

Fya/b coding locus

Geostatistical model framed by HardyWeinberg principles

Promoter locus

T-33C variant

Phenotype-b Promoter Phenotype Genotype

Predicted FY*A allele frequency

Predicted FY*B allele frequency

Predicted FY*BES

allele frequency

Predicted FY*AES

allele frequency

G125A variant

Figure 6 | Relationship between data types and the information conveyed to the model. Left to right along the large arrow, the deepening colour intensity represents each data types relative inuence on the model output. Dashed vertical arrows denote information about only one locus. Thickness of vertical lines emphasizes the completeness of the data type. Orange boxes represent the Bayesian model. Green rods indicate output data. The grey horizontal arrow and greyed FY*AES prediction rod indicates that this allele was accounted for in the model structure, but not one of the nal outputs.

help assess whether the very low predicted frequencies of susceptible Duy-positive hosts could sustain transmission in populations mapped as predominantly Duy negative.

Second, from areas mapped with high Duy phenotypic heterogeneity, P. vivax infections have been identied in Duy-negative hosts (in Madagascar15 and Brazil14). If this phenomenon of infected Fy(ab) individuals is associated with local Duy heterogeneity, as hypothesized by Mnard et al.15, the Duy maps presented here could be used to target further studies in other heterogeneous P. vivax endemic areas17, including southern Africa, Ethiopia, southern Sudan and pockets of the Brazilian and Colombian coasts. Investigation of P. vivax transmission in these areas particularly, but also across regions with a spectrum of characteristic Duy phenotypes, could provide vital public health insights into P. vivax populations at risk, particularly when coupled with host-level data on Duy types.

In this era of increasing concern about the P. vivax parasite, we believe that a contemporary spatial description of the prevalence of the Duy antigen receptor is essential for optimizing our understanding of the parasites clinical burden. The geopositioned database and maps represent a new eort to document the spatial characteristics of a fundamental biomedical trait implicated in haematological and other clinical contexts. The versatile geostatistical model developed was adapted to a multiple-locus trait, informed by a range of input data types to generate a suite of output products. Such methods are uncommonly used by the genetics community, but we believe could have an important role in the current era of large-scale spatial genomic analyses. Although we present a cartographic suite which we believe constitutes a signicant improvement from previously published attempts28 (see Supplementary Discussion and Supplementary Figs S8S10), this study highlights limitations to our current knowledge of the Duy blood group: both in terms of the scarcity of data from many areas, and in relation to the P. vivax invasion pathway. All collated data and model code will be made openly accessible.

Methods

Analysis outline. The methodological steps of this work were threefold: rst, to assemble a library of full-text references describing Duy blood group surveys, complemented with unpublished data; second, to abstract the Duy frequency data from each source and to georeference survey locations; and third, to develop a spatial model which uses the full heterogeneous data set assembled to predict continuous global frequency maps of the Duy variants. A schematic overview of the methodological process is given in Figure 1, and each component is now discussed in more detail.

Library assembly. Systematic searches, adapted from those developed by the

Malaria Atlas Project (MAP, http://www.map.ox.ac.uk)45,46, were conducted in an

attempt to assemble a comprehensive database of Duy blood group surveys dating from 1950, the publication year of Cutbushs description of the blood group1.

Keyword searches for Duy and DARC were conducted in online bibliographic archives PubMed (http://www.pubmed.gov), ISI Web of Knowledge (http://isiwebofknowledge.com) and Scopus (http://www.scopus.com). Searches were last performed on 08 December 2009. Manual duplicate removal and abstract reviews of the amalgamated search results identied 303 references likely to contain data, in addition to the 296 and 60 references from existing databases published by Mourant et al.47 and Cavalli-Sforza et al.28, respectively. Full-text searches were then conducted for each of these 659 unique references. Following direct contact with researchers, 15 additional unpublished data sets were also included. All sources from which data met the criteria for inclusion are cited in the Supplementary References.

Data abstraction and inclusion criteria. The library of assembled references was reviewed to identify location-specic records of Duy variant frequencies representative of local populations. Data were abstracted into a customized database, including population descriptions and ethnicities as reported by authors, methodological details and Duy variant frequencies. Potentially biased samples of hospital patients with malaria symptoms or recently transfused individuals were excluded, as were family-based investigations and studies focussing on selected subgroupsof larger mixed communities (for example, African-American communities in American cities). No constraints were placed on sample size, as the geostatistical framework downweighted the information content of very small surveys in accordance with a binomial sampling model33.

Geopositioning. The geographic location of each survey was determined as precisely as possible using the georeferencing protocol previously described by Guerra et al.45. Author descriptions of survey sites were used to verify locations identied in digital databases including Microso Encarta (Microso Corporation), and online databases such as Geonames (National Geospatial-Intelligence Agency, http://geonames.nga.mil/ggmagaz/, accessed JuneDecember 2009) and Global Gazetteer Version 2.2 (Falling Rain Genomics, http://www.fallingrain.com/world/ index.html, accessed JuneDecember 2009). Surveys were categorized according to the area they represented: points (25 km2), and small (25 and 100 km2) or large polygons (>100 km2).

Duffy blood group data. In addition to prevalence data of specic variants, details of diagnostic methodology were recorded to classify the type of information provided from the survey (Table 2). According to the range of possible serological and molecular diagnostic methods, data points were classied into ve data types: Genotype, where full genotypes were reported; Phenotype, if full serological diagnoses were performed (with both anti-Fya and anti-Fyb antisera); Promoter,if results reported only antigen expression/non-expression without distinguishing Fya from Fyb (data were mainly from molecular studies examining only the promoter-region locus, but also occasionally from serological tests not distinguishing between antigenic variants); Phenotype-a, if only the Fya antigen was testedfor (meaning that presence of Fyb antigen could not be distinguished from the negativity phenotype); and Phenotype-b, if the study was only concerned with Fyb

expression (Fig. 6).

Modelling. To accommodate the ve input data types described and to model the multiallelic system, the two primary loci dierentiating the Duy variants were considered simultaneously. These were position 33 in the promoter region, which determines expression/non-expression, and base position 125 of exon 2, dieren-

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tiating Fya from Fyb coding regions23. Including the full data set while modelling each variant optimizes the model predictions, as each data type informs, either directly or indirectly, the frequency of variants at both loci, by ruling out certain genotypes. This feature was not possible with previously used mapping models28.

Genetic loci modelled. The genetic loci were considered as two spatially independent random elds, but modelled in association: rst, the random eld representing the coding region variant modelled the frequency of Fya or Fyb expression; and second, a random eld represented the probability of the promoter ES variant being associated with the Fyb coding variant, thus determining prevalence of FY*B versus FY*BES alleles. Reports in the data set of the ES variant in association with the Fya variant (that is, the FY*AES allele) were too infrequent and, when identied, were too rare to be modelled as a spatial random eld. Therefore, this variant was modelled by a small constant. Further details about the model are given in the Supplementary Methods.

Sub-Saharan Africa covariate. Preliminary examination of the Genotype data set conrmed the assumption that the haplotypic association between the Fyb coding variant and the ES promoter variant, together corresponding to the FY*BES allele, was very high within sub-Saharan African populations, but rare outside the region. To allow the model to reect this high probability of association across sub-Saharan Africa, we used a generalized version of the GlobCover Land Cover V2.2 bare ground surface (channel 200)31 to dierentiate the sub-Saharan populations (presence), including those living in Madagascar and on other nearby islands (decision informed by the Genotype data), from the other populations (absence; Fig. 2). This binary descriptor was the only covariate used in the model.

Model implementation. The analyses were implemented in a Bayesian model-based geostatistical framework29, the principal aspects of which have been previously described33,48. In brief, the geostatistical model uses Gaussian random elds to represent the spatial heterogeneity observed in the data and to predict values at unsampled locations. Repeated sampling of the random elds ensures that a representative sample of all the possibilities consistent with the input dataset is used in predicting pixel values at sites where there is no data (Supplementary Methods). Estimates for pixels distant from any input data points or in areas of high spatial heterogeneity are inherently more difficult to predict precisely, and so are associated with greater prediction uncertainty. The posterior median values and associated uncertainty (IQR (25th to 75th percent quartile ranges) of the posterior distribution) are used to summarize the models predictions for each pixel33,49.

Generating the map surfaces. The models predictions for allele frequencieswere mapped at all pixels on the global grid (at 55 km in Africa and 1010 km elsewhere). Median values of the posterior distribution were chosen for the maps as these were considered more appropriate than mean values, due to the long-tailed distributions of the predictions that could strongly skew mean estimates. From these allele frequency surfaces, genotype frequencies could be obtained using the standard HardyWeinberg formula50,51. Thus, the Duy negativity phenotype was expressed by the squared frequency of the silent FY*BES allele (the FY*AES allele being too rare to occur in homozygous form).

Model validation. To validate the three allele frequency surfaces and cross-examine the models assumption of HardyWeinberg equilibrium, both the frequency of Duy negativity and frequency of FY*A/*B heterozygosity were validated. For each validation procedure, the model was run with a random subset of the data set le out and predictions at these locations were compared with the observed frequencies. Estimates of the models overall bias and precision were quantied as mean error and mean absolute error values, respectively (Supplementary Methods).

Availability of data. The survey database and maps are publicly accessible through the MAP website (http://www.map.ox.ac.uk) in line with the MAPs open-access policy and the terms of the Wellcome Trust Biomedical Resources Grant (#085406) funding this work.

References

1. Cutbush, M. & Mollison, P. L. The Duy blood group system. Heredity 4, 383389 (1950).

2. Mourant, A. E. Blood Relations: Blood Groups and Anthropology (Oxford University, 1983).

3. Hamblin, M. T., Thompson, E. E. & Di Rienzo, A. Complex signatures of natural selection at the Duy blood group locus. Am. J. Hum. Genet. 70, 369383 (2002).

4. Carter, R. Speculations on the origins of Plasmodium vivax malaria. Trends Parasitol. 19, 214219 (2003).

5. Rosenberg, R. Plasmodium vivax in Africa: hidden in plain sight? Trends Parasitol. 23, 193196 (2007).

6. Klein, H. G. & Anstee, D. J. (eds.) Mollisons Blood Transfusion in Clinical Medicine (Blackwell Publishing, 2005).

7. Mourant, A. E. & Domaniewska-Sobczak, K. The use in anthropology of blood groups and other genetical characters. J. Afr. Hist. 3, 291296 (1962).

8. Miller, L. H., Mason, S. J., Clyde, D. F. & McGinniss, M. H. The resistance factor to Plasmodium vivax in blacks. The Duy-blood-group genotype, FyFy. N. Engl. J. Med. 295, 302304 (1976).

9. Barnwell, J. W., Nichols, M. E. & Rubinstein, P. In vitro evaluation of the role of the Duy blood group in erythrocyte invasion by Plasmodium vivax. J. Exp. Med. 169, 17951802 (1989).10. Wertheimer, S. P. & Barnwell, J. W. Plasmodium vivax interaction with the human Duy blood group glycoprotein: identication of a parasite receptor-like protein. Exp. Parasitol. 69, 340350 (1989).

11. Miller, L. H., Mason, S. J., Dvorak, J. A., McGinniss, M. H. & Rothman, I. K. Erythrocyte receptors for (Plasmodium knowlesi) malaria: Duy blood group determinants. Science 189, 561563 (1975).

12. Barber, M. A. & Komp, W. H. W. The seasonal and regional incidence of types of malaria parasites. Public Health Rep. (18961970) 44, 20482057 (1929).

13. Ryan, J. R. et al. Evidence for transmission of Plasmodium vivax among a Duy antigen negative population in Western Kenya. Am. J. Hum. Genet. 75, 575581 (2006).

14. Cavasini, C. E. et al. Plasmodium vivax infection among Duy antigen-negative individuals from the Brazilian Amazon region: an exception? Trans. R. Soc. Trop. Med. Hyg. 101, 10421044 (2007).

15. Mnard, D. et al. Plasmodium vivax clinical malaria is commonly observed in Duy-negative Malagasy people. Proc. Natl Acad. Sci. USA 107, 59675971 (2010).

16. Galinski, M. R. & Barnwell, J. W. Plasmodium vivax: who cares? Malar. J. 7, S9 (2008).

17. Guerra, C. A. et al. The international limits and population at risk of Plasmodium vivax transmission in 2009. PLoS Negl. Trop. Dis. 4, e774 (2010).

18. Anstee, D. J. The relationship between blood groups and disease. Blood 115, 46354643 (2010).

19. Horne, K. & Woolley, I. J. Shedding light on DARC: the role of the Duy antigen/receptor for chemokines in inammation, infection and malignancy. Inamm. Res. 58, 431435 (2009).

20. Walley, N. M. et al. The Duy antigen receptor for chemokines null promoter variant does not inuence HIV-1 acquisition or disease progression. Cell Host Microbe 5, 408410; author reply 418409 (2009).

21. He, W. et al. Duy antigen receptor for chemokines mediates trans-infection of HIV-1 from red blood cells to target cells and aects HIV-AIDS susceptibility. Cell Host Microbe 4, 5262 (2008).

22. Donahue, R. P., Bias, W. B., Renwick, J. H. & McKusick, V. A. Probable assignment of the Duy blood group locus to chromosome 1 in man. Proc. Natl Acad. Sci. USA 61, 949955 (1968).

23. Langhi, D. M. Jr. & Bordin, J. O. Duy blood group and malaria. Hematology 11, 389398 (2006).

24. Zimmerman, P. A. in Infectious Disease and Host-Pathogen Evolution (ed. Dronamraju, K. R.) 141172 (Cambridge University, 2004).

25. Zimmerman, P. A. et al. Emergence of FY*Anull in a Plasmodium vivax-endemic region of Papua New Guinea. Proc. Natl Acad. Sci. USA 96, 1397313977 (1999).

26. Sellami, M. H. et al. Duy blood group system genotyping in an urban Tunisian population. Ann. Hum. Biol. 35, 406415 (2008).

27. Olsson, M. L. et al. The Fy(x) phenotype is associated with a missense mutation in the Fy(b) allele predicting Arg89Cys in the Duy glycoprotein. Br. J. Haematol. 103, 11841191 (1998).

28. Cavalli-Sforza, L. L., Menozzi, P. & Piazza, A. The History and Geography of Human Genes (Princeton University, 1994).

29. Diggle, P. J. & Ribeiro, P. J. Jr. Model-based Geostatistics (Springer, 2007).30. Hamblin, M. T. & Di Rienzo, A. Detection of the signature of natural selection in humans: evidence from the Duy blood group locus. Am. J. Hum. Genet. 66, 16691679 (2000).

31. Bicheron,, P. et al. GLOBCOVER: Products Description and Validation Report (MEDIAS, 2008).

32. Hogg, R. V. & Craig, A. Introduction to Mathematical Statistics (Pearson Education, 2005).

33. Hay, S. I. et al. A world malaria map: Plasmodium falciparum endemicity in 2007. PLoS Med. 6, e1000048 (2009).

34. Tournamille, C. et al. Sequence, evolution and ligand binding properties of mammalian Duy antigen/receptor for chemokines. Immunogenetics 55, 682694 (2004).

35. Carter, R. & Mendis, K. N. Evolutionary and historical aspects of the burden of malaria. Clin. Microbiol. Rev. 15, 564594 (2002).

36. Livingstone, F. B. The Duy blood groups, vivax malaria, and malaria selection in human populations: a review. Hum. Biol. 56, 413425 (1984).

37. Lysenko, A. J. & Semashko, I. N. in Itogi Nauki: Medicinskaja Geograja (ed. Lebedew, A. W.) 25146 (Academy of Sciences, 1968).

38. Piel, F. B. et al. Global distribution of the sickle cell gene and geographical conrmation of the malaria hypothesis. Nat. Commun. 1, 104 (2010).

39. Chown, B., Lewis, M. & Kaita, H. Duy blood group system in Caucasians - evidence for a new allele. Am. J. Hum. Genet. 17, 384389 (1965).

40. Price, R. N. et al. Vivax malaria: neglected and not benign. Am. J. Hum. Genet. 77, 7987 (2007).

NATURE COMMUNICATIONS | 2:266 | DOI: 10.1038/ncomms1265 | www.nature.com/naturecommunications

2011 Macmillan Publishers Limited. All rights reserved.

ARTICLE

NATURE COMMUNICATIONS | DOI: 10.1038/ncomms1265

41. Baird, J. K. Severe and fatal vivax malaria challenges benign tertian malaria dogma. Ann. Trop. Paediatr. 29, 251252 (2009).

42. Culleton, R. L. et al. Failure to detect Plasmodium vivax in West and Central Africa by PCR species typing. Malaria J. 7, 174 (2008).

43. Culleton, R. et al. Evidence for the transmission of Plasmodium vivax in the Republic of the Congo, West Central Africa. J. Infect. Dis. 200, 14651469 (2009).

44. Smith, D. L., McKenzie, F. E., Snow, R. W. & Hay, S. I. Revisiting the basic reproductive number for malaria and its implications for malaria control. PLoS Biol. 5, e42 (2007).

45. Guerra, C. et al. Assembling a global database of malaria parasite prevalence for the Malaria Atlas Project. Malaria J. 6, 17 (2007).

46. Hay, S. I. & Snow, R. W. The Malaria Atlas Project: developing global maps of malaria risk. PLoS Med. 3, e473 (2006).

47. Mourant, A. E., Kope, A. C. & Domaniewska-Sobczak, K. The Distribution of the Human Blood Groups and other Polymorphisms (Oxford University, 1976).

48. Diggle, P. J., Tawn, J. A. & Moyeed, R. A. Model-based geostatistics. J. R. Stat. Soc. Ser. C Appl. Stat. 47, 299326 (1998).

49. Gething, P. W., Patil, A. P. & Hay, S. I. Quantifying aggregated uncertainty in Plasmodium falciparum malaria prevalence and populations at risk via efficient space-time geostatistical joint simulation. PLoS Comput. Biol. 6, e1000724 (2010).

50. Hardy, G. H. Mendelian proportions in a mixed population. Science 28, 4950 (1908).

51. Weinberg, W. ber den nachweis der vererbung beim menschen. Jahresh. Wuertt. Verh. Vaterl. Naturkd. 64, 369382 (1908).

Acknowledgments

Data from the MalariaGEN Consortium (http://www.malariagen.net) have been shared for inclusion in our database. We thank all its contributing collaborators and members for collecting, preparing and genotyping the samples. We also thank the following people for sharing unpublished data: Anabel Arends and Gilberto Gmez for Venezuela data; Marcelo Urbano Ferreira for Brazil data; Rick Fairhurst, Carole Long and Mahamadou Diakite for Mali data; Rick Fairhurst and Duong Socheat for Cambodia data. We

acknowledge Kevin Baird, Carlos Guerra, Kevin Marsh, Robert Snow and William Wint for comments on the manuscript, and Anja Bibby for editing the manuscript. This work was supported by a Wellcome Trust Biomedical Resources Grant (#085406), which funds R.E.H., F.B.P. and O.A.N., a Senior Research Fellowship to S.I.H. from the Wellcome Trust (#079091), which also supports P.W.G., and a Wellcome Trust Principal Research Fellowship (#079080) to Professor Robert Snow, which funds A.P.P. T.N.W. is funded by a Senior Clinical Fellowship (#076934) from the Wellcome Trust. D.J.W. is funded by the Wellcome Trust. This paper is published with the permission of the director of KEMRI. This work forms part of the output of the MAP (http://www.map.ox.ac.uk), principally funded by the Wellcome Trust, UK.

Author contributions

R.E.H. assembled the data and wrote the rst dra of the manuscript with S.I.H. and F.B.P., who conceived the study and advised on all aspects of the project; O.A.N. and C.W.K. helped assemble and geoposition the data; A.P.P. and P.W.G. conceived and helped to implement the modelling and all computational tasks. T.N.W. and D.J.W. had advisory roles throughout the project. P.A.Z. contributed data for the West Africa region and Papua New Guinea, C. Beall and A.G. contributed unpublished data from Ethiopia, and C. Barnadas and D.M. contributed data from Madagascar. All authors contributed to the revision of the nal manuscript.

Additional information

Supplementary Information accompanies this paper at http://www.nature.com/ naturecommunications

Competing nancial interests: The authors declare no competing nancial interests.

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How to cite this article: Howes, R.E. et al. The global distribution of the Duy blood group. Nat. Commun. 2:266 doi: 10.1038/ncomms1265 (2011).

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