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A novel locus of resistance to severe malaria in a region of ancient balancing selection


The high prevalence of sickle haemoglobin in Africa shows that malaria has been a major force for human evolutionary selection, but surprisingly few other polymorphisms have been proven to confer resistance to malaria in large epidemiological studies1,2,3. To address this problem, we conducted a multi-centre genome-wide association study (GWAS) of life-threatening Plasmodium falciparum infection (severe malaria) in over 11,000 African children, with replication data in a further 14,000 individuals. Here we report a novel malaria resistance locus close to a cluster of genes encoding glycophorins that are receptors for erythrocyte invasion by P. falciparum. We identify a haplotype at this locus that provides 33% protection against severe malaria (odds ratio = 0.67, 95% confidence interval = 0.60–0.76, P value = 9.5 × 10−11) and is linked to polymorphisms that have previously been shown to have features of ancient balancing selection, on the basis of haplotype sharing between humans and chimpanzees4. Taken together with previous observations on the malaria-protective role of blood group O1,2,3,5, these data reveal that two of the strongest GWAS signals for severe malaria lie in or close to genes encoding the glycosylated surface coat of the erythrocyte cell membrane, both within regions of the genome where it appears that evolution has maintained diversity for millions of years. These findings provide new insights into the host–parasite interactions that are critical in determining the outcome of malaria infection.

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Figure 1: Signal of association with severe malaria across the FREM3/GYPE region.
Figure 2: Evidence for association at SNPs in the FREM3/GYPE region, assuming an additive model of association.
Figure 3: Haplotype analysis across the FREM3/GYPE region.

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Data deposits

Genotype and phenotype data underlying this manuscript have been deposited in the European Genome-phenome Archive under accession number EGAS00001001311. Access to individual-level genotype data is available by application to an Independent Data Access Committee: see For further details of data underlying this manuscript, see


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The Malaria Genomic Epidemiology Network Project is supported by the Wellcome Trust (WT077383/Z/05/Z) and the Bill & Melinda Gates Foundation through the Foundations of the National Institutes of Health (NIH; 566) as part of the Grand Challenges in Global Health Initiative. The Resource Centre for Genomic Epidemiology of Malaria is supported by the Wellcome Trust (090770/Z/09/Z). This research was supported by the Medical Research Council (MRC; G0600718; G0600230), the Wellcome Trust Biomedical ethics Enhancement Award (087285) and Strategic Award (096527). D.P.K. receives support from the MRC (G19/9). C.C.A.S. was supported by a Wellcome Trust Career Development Fellowship (097364/Z/11/Z). The Wellcome Trust also provides core awards to The Wellcome Trust Centre for Human Genetics (075491/Z/04; 090532/Z/09/Z) and the Wellcome Trust Sanger Institute (077012/Z/05/Z and 098051). The Mali MRTC–BMP group is supported by a contract (N01AI85346) and a cooperative agreement (U19AI065683) from the National Institute of Allergy and Infectious Diseases (NIAID) and by a grant (D43TW001589) from the Fogarty International Centre, NIH to University of Maryland and University of Bamako and the Mali-NIAID/NIH International Center for Excellence in Research at the University of Sciences, Techniques, and Technology of Bamako. E.A. received partial funding from the European Community’s Seventh Framework Programme (FP7/2007-2013) under grant agreement no. 242095–EVIMalaR and the Central African Network for Tuberculosis, HIV/AIDS and Malaria (CANTAM) funded by the European and Developing Countries Clinical Trials Partnership (EDCTP). T.N.W. is funded by Senior Fellowships from the Wellcome Trust (076934/Z/05/Z and 091758/Z/10/Z) and through the European Community’s Seventh Framework Programme (FP7/2007-2013) under grant agreement no. 242095–EVIMalaR. The KEMRI-Wellcome Trust Programme is funded through core support from the Wellcome Trust. C.M.N. is supported through a strategic award to the KEMRI-Wellcome Trust Programme by the Wellcome Trust (084538). Tanzania/Kilimanjaro Christian Medical College Joint Malaria Programme, Moshi, Tanzania received funding from MRC grant number G9901439. We acknowledge the work of B. Poudiougou and A. Niangaly for their help in collecting clinical data and biological samples for the Bamako study. We thank L. Jostins and M. Pirinen for advice on statistical analyses.

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Correspondence to Chris C. A. Spencer, Dominic P. Kwiatkowski, Dominic P. Kwiatkowski, Chris C. A. Spencer, Chris C. A. Spencer or Dominic P. Kwiatkowski.

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Extended data figures and tables

Extended Data Figure 1 Sample collections included in the study.

a, Study sites and ethics approving institutions. b, Phenotypic makeup of discovery and replication samples from each site. ‘Uncomplicated’ refers to case individuals who were not identified as cerebral malaria (CM) or severe malarial anaemia (SMA) cases. ‘Both’ refers to individuals who have both CM and SMA phenotypes. c, Overall sample counts and number of samples excluded by each quality control (QC) criterion. Asterisk denotes the number of samples removed after explicitly including samples with low heterozygosity in Gambia. Dagger: the Kenyan cohort included parents of a subset of case samples; these were not used in subsequent analyses d–f, Plots of average genome-wide heterozygosity and missingness with outliers coloured, as outputted by the ABERRANT algorithm.

Extended Data Figure 2 Genotyped SNP quality control for the three discovery cohorts.

a, b, Total numbers of pre- and post-quality control SNPs on the autosomes (a) and the X chromosome (b), and numbers of SNPs excluded by each quality control (QC) criterion. Diff, the test of difference in frequency between males and females; HWE, Hardy–Weinberg equilibrium; Plate, plate test of association. Details of quality control are given in Methods. c, Plot showing the –log10(P values) for the genotypic association test in the discovery data including the first five principal components as covariates. Grey dots show SNPs that are removed due to the quality control as defined in Methods. The total fraction of SNPs removed from each cohort is given at the top of the plot.

Extended Data Figure 3 Imputation performance.

a, b, Empirical distribution of concordance and accuracy (r2) between typed and re-imputed SNPs in the three discovery cohorts. Solid lines represent SNPs with frequency below 5% and dashed lines represent SNPs with frequency of at least 5%. c, Per-sample concordance and accuracy (type 0 r2) across the whole genome, as estimated by re-imputing genotyped SNPs. Values are averaged over imputation chunks. d, Average accuracy between genotype and re-imputed SNPs in each cohort, plotted against frequency, in 1% frequency bins.

Extended Data Figure 4 Detail of population structure.

ac, Top ten principal components (PCs) in Gambia (a), Malawi (b) and Kenya (c). Where ethnicity was reported, points are coloured by ethnicity for ethnicities with at least 50 samples. d, Logistic regression P values and direction of effect for the top ten PCs on severe malaria status in each cohort. e, qq plots for additive model association test P values in Gambia, Malawi, Kenya, and for fixed-effect meta-analysis. Dashed lines represent the 99% CI computed marginally at each variant. Circles and points represent points lying respectively outside and inside the 99% CI. f, Comparison of association test P values for logistic regression (SNPTEST, x-axis) and linear mixed model (MMM, y-axis) for Gambia, Malawi, Kenya, and for fixed-effect meta-analysis. Variants in tier 1 are coloured blue, with the lead marker at the FREM3/GYPE region coloured red.

Extended Data Figure 5 Detail of Bayesian analysis of discovery cohorts.

a, Visualization of slices through the combined prior on effect sizes in three cohorts for mode-of-inheritance-specific models. Top row: slices through the prior effect size on Kenya (x-axis) and Malawi (y-axis) for constant effect size in The Gambia (panels). Bottom row: slices through the prior effect size on Kenya (x-axis) and The Gambia (y-axis) for constant effect size in Malawi (panels). Red lines represent a factor of 10 in the prior density. b, Comparison of BFavg (x-axis) with the minimum fixed-effect meta-analysis P value minimized across additive, dominant, recessive or heterozygote modes of inheritance (y-axis). Values are plotted on log10 and −log10 scales. Colour indicates the heterogeneity model of the model with the highest posterior weight. c, Sensitivity of BFavg to changes in prior. Plots show BFavg ratio (y-axis) plotted against one-dimensional parameterisations of the prior (x-axis), for the 32 autosomal SNPs in tier 1. Solid lines represent variants with MAF < 5% averaged across populations, and dashed lines represent variants with MAF ≥ 5%. Black dots indicate the lead marker at the FREM3/GYPE locus. Colour indicates the effect size, mode of inheritance, or heterogeneity model for the model with highest posterior weight under the GWAS prior. Dashed grey vertical lines indicate the x-axis value corresponding to the prior used in the GWAS, and one-half and twice that value. Plots are parameterized by (1) the prior standard deviation of the small-effect model keeping the prior standard deviation of the large and small-effect models in the ratio 0.75:0.2; (2–5) the prior weight on additive, dominant, recessive or heterozygote modes of inheritance; (6–10) the prior weight on fixed, correlated, independent, fixed-structured and correlated-structured models. For each parameterization prior, weights on other models are kept in the same relative proportion. For further details see Supplementary Note 4.

Extended Data Figure 6 Strongest regions of association in the Bayesian analysis of the three discovery cohorts.

Plot on left shows the log10 model-averaged Bayes Factor (BFavg). Table shows the SNP with the highest BFavg in each region (lead SNP), gene(s) of interest in the region, the model with the highest posterior weight at the lead SNP and its BF. Models are described in Methods; sml, big: small- and large-effects models; fix, cor, ind, fix-str, cor-str: fixed, correlated, independent, fixed-structured and correlated-structured effect models; add, dom, rec, het: additive, dominant, recessive, heterozygote models; fs: fixed-between-sex model. Coloured points indicate the OR and the protective allele frequency in Gambia (red), Malawi (green) and Kenya (blue). The right-hand columns indicate regions containing shared chimpanzee–human haplotypes or coding SNPs4 (ABPs), blood group genes, or immunoglobulin superfamily genes.

Extended Data Figure 7 Evidence for association in the FREM3/GYPE, INPP4B and ARL14 regions.

a, Evidence for association at directly typed SNPs. b, Posterior probability that variants in the FREM3/GYPE region are causal, assuming a single variant in the region is causal50, based on the BFavg for typed and imputed variants. Dashed lines indicate the 95% and 99% credible sets. See Fig. 1 legend for further details. c, Details of SNPs encoding the common MNS blood groups. Coordinates and alleles are with respect to the NCBI b37 human reference sequence. d, Evidence for possible independence of effects at the FREM3 and INPP4B loci in Kenya by conditional analysis. y-Axis represents −log10(association P value) conditional on the imputed dosage at rs184895969. Points are coloured by linkage disequilibrium with the top SNP rs13103597. e, Forest plot showing sample size, estimated OR and 95% CI for the lead imputed SNP (rs149373719) in INPP4B under an additive model of association. f, Bar plot showing the posterior weight on different models of heterogeneity at rs149373719 under the prior used in the GWAS, assuming an additive model of association. g, Forest plot showing evidence in both discovery and replication samples in the Sequenom data at rs77389579 in INPP4B. See Fig. 2 legend for further details.

Extended Data Figure 8 Sequence homology, alignability and structural variation in the glycophorin region.

a, Co-occurrence of short segments of DNA (k-mers; top triangle: k = 100, bottom triangle: k = 25) in the human reference sequence Each point represents a k-mer that maps to the locations indicated by the x- and y-axis positions, either on the same strand (black points) or opposite strands (red points). Green vertical lines in this and subsequent panels delineate the region of high homology surrounding the three glycophorins. b, The location of the lead GWAS marker, ABPs, and protein-coding genes in the region. c, Alignability of the 100-mer at each position of the reference, up to two mismatches. Values are taken from the UCSC genome browser mappability track and averaged over 5 kb bins. d, IMPUTE info measure in Kenya for variants with frequency at least 5%, averaged over 5 kb bins. eg, Coverage for samples from YRI and LWK in 1000 Genomes Project Phase I carrying esv2662558, carrying esv2668125, or not carrying either deletion, respectively. Coverage for each individual is normalized by the mean coverage for that individual across chromosome 1, and only computed at positions with alignability = 1 for all 100-mers overlapping the position, and for reads with mapping quality at least 20. Values are averaged over 5 kb (grey) and 10 kb (blue) bins. Three samples with apparently erroneous calls in the 1000 Genomes Phase I genotype release are coloured (NA18519, red; NA19185, yellow; NA19222, green) and assigned to the status indicated by their coverage profile. Panel g represents a random sample of 30 individuals not carrying the deletion in addition to the two with erroneous genotype calls. Coverage computation was performed using the BAM files available from the 1000 Genomes Project in October 2014, downloaded from Four African samples in the Phase I release were not assessed because they are not included in this directory.

Extended Data Figure 9 Correlation between the genotypes at SNPs of interest within the GYPE/A/B locus and reported gene transcription levels in samples from the YRI and LWK HapMap cohorts17.

P values are for a trend test of association where more than one genotype class is present. Only assays targeting the glycophorins, and those with a P value below 0.05 are shown.

Extended Data Figure 10 Detail of enrichment analysis.

a, Red histogram: the empirical distribution of the log10 distance of observed tier 1 loci to the nearest ABP haplotype. Grey histogram, distribution of distances for 10,000 simulated tier 1 sets. b, The log10 distance of tier 1 (filled red circles) and tier 2 (empty circles) loci to the nearest ABP, plotted against their rank in BFavg order (stronger signals have lower rank). Loci are annotated with the nearest gene where a gene exists within the association region. Asterisks denote nearest genes that are also the nearest gene to an ABP shared haplotype. c, Empirical null distribution of the odds ratio for the enrichment of tier 1 loci in the set of genes closest to an ABP shared haplotype, based on 10,000 simulated SNP sets. The red asterisk and text indicate the odds ratio for the observed tier 1 loci. d, Distribution of the proportion of the genome which identifies a given gene as nearest, for genes in or not in the set annotated as nearest an ABP haplotype. Left, distribution of the length of the genome for which the given gene is unambiguously the closest gene. Middle, distribution of the number of SNPs in our study for which the given gene is the closest gene. Right, distribution of the number of SNPs in our study for which the given gene is the nearest gene within a recombination interval of 2.5 cM ± 25 kb around the SNP, as used to determine nearest genes to GWAS lead SNPs. e, Empirical P values for enrichment of ABP haplotypes and coding SNPs in tier 1 and tier 2 GWAS regions. Second column, P values for enrichment by gene overlap. Third to tenth column, P values for enrichment by proximity at different length scales. †Results for simulations using SNPs frequency-matched to GWAS tier 1 loci in 1% frequency bins. ††Results for simulations excluding the regions of ABO, HBB, ATP2B4, FREM3, INPP4B, and HHIP-AS1.

Supplementary information

Supplementary information

This file contains Supplementary Notes 1-4 and additional references. (PDF 183 kb)

Supplementary Table

This file contains a summary of statistics for 32 autosomal tier 1 loci for logistic regression and linear mixed model tests. (XLSX 51 kb)

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Malaria Genomic Epidemiology Network. A novel locus of resistance to severe malaria in a region of ancient balancing selection. Nature 526, 253–257 (2015).

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