Cadaver Organ Donation & Transplantation in Asia – The Way Ahead

1. Cadaver Organ Donation & Transplantation in Asia – The Way Ahead Sunil Shroff Head of Department - Urology & Renal Transplantation, Sri Ramachandra Medical College & Research Institution, Managing Trustee, MOHAN Foundation, Chennai

2. The Organ Shortage • Each day, about 60 people around the world receive an organ transplant, while another 13 die due to non-availability of organs. • Organ shortage — the main limitation to saving lives of critically ill patients — is due to individuals and their families not considering organ donation out of fear, ignorance or misunderstanding.

3. Cadaver Transplant in Asia – The Road Ahead • Overview of Cadaver Transplants in Asia • Common Problems & Platforms • The Road Ahead

4. Overview of Asia Asia World • Population 3.6 Billion (1.7% inc) 6.4 Billion • No Of Countries 51 235 • Land Mass 44,390,000 Sq.Km 6,233,821,945 Sq.Km • Life Expectancy M 63 yr F 66yrs

5. Cadaver Transplants in Asia • Kidney • Liver • Heart • Heart Lung • Pancreas Source: Asian Transplant Registry

6. PER CAPITA INCOME FOR ASIAN COUNTRIES ( In US Dollars)

7. High per capita income & Successful Transplant Programmes

8. High per capita income & Cadaver Tansplant Programme Most of Asia is struggling with Cadaver Programme including regions with high per capita

9. Japan – 12,974 Taiwan – 7000 Saudi Arabia – 4248 Korea – 4000 Pakistan - 1650 Hong Kong - 1018 Singapore – 666 Bangladesh - 125 Waiting Time Taiwan – 1.9 yrs Korea – 2.2 yrs Hong Kong – 4.3 yrs Singapore – 5.8 yrs Kidney Tx Waiting List in Asia (2002) No figures available for China, India, Philipines, Indonesia

10. Transplant Expertise - Asia • Japan has - 352 transplant centres • Thailand - 27 kidney, 6 liver, and 6 Cardiac transplantation centers, • India has 5 centres- Liver, 6 - Cardiac and over 100 for Kidneys. • 35 centres have undertaken cadaver transplants • However only 6 do it regular frequency.

11. Historical Aspects – Cadaver Transplantation - India 1967 - First succeesful cadaver Kidney Transplant in India at KEM Hospital, Bombay 1994 - First successful heart transplant done at AIIMS, N.Delhi 1995 - First successful multi-organ transplant done at Apollo Hospital, Chennai 1998 – First Successful Lung transplant, Madras Medical Mission Hospital, Chennai 1999 – First Pancreas Transplant, Ahembdabad

12. Transplants - Japan • Kidney Transplant since 1964 -15 113 • Liver transplants since 1989 - 2411 • Heart Transplants since 1998 - 17 • Lung transplants since 1998 - 39 The organs have largely been obtained from living and to some extent from non-heart beating donors Ref: Shirakura -WHO/HTP/EHT/T-2003.1Ethics, access and safety in tissue and organ transplantation:Issues of global concern. Madrid, Spain, 6-9 October 2003

13. Cadaver Kidney Transplants in Asia • India, Taiwan, Korea, Thailand, Iran, Saudi Arabia and Singapore – Regularly are undertaking Kidney Cadaver Transplants • Taiwan, Thailand, Singapore follow the western model and run the programme almost on the same line • Japan is still struggling with the programme though their numbers are slowly rising • India is emerging as one of the Key players despite still struggling with the programme logistics • Very Little information from China is Available on their modus operandi

14. Cadaver Heart Transplants in Asia • Hong Kong, India, Japan, Malaysia, Saudi Arabia, Singapore and Thailand are doing Heart transplants • Taiwan and Korea do the max heart transplants in Asia

15. Cadaver Liver Transplants in Asia • Korea do the maximum living liver transplants and has high level of expertise in the field • 2,345 LTs (1,860 from the living donor and 485 from the deceased donor) were performed in 24 institutes from March 1988 to December 2004, although 5 institutes had performed more than 10 LTs per year. • Japan, Hong Kong, Taiwan similarly have expertise in living liver transplants • Four centres in India – located atHyderabad, Vellore and Delhi have fair expertise with liver transplants and emerging as the key players in the country.

16. Cadaver Kidney Transplants Scene in India • In past seven years approx. 592 Cadaver organ transplants (518 kidneys, 35 Livers and 37 Hearts) have been performed • 35 Centres have undertaken Cadaver transplants • Majority of these 35 centres are Private or trust hospitals • Of these only half a dozen undertake cadaver transplants regularly • Almost 50% of the cadaver transplants in India done in Tamil Nadu • Tamil Nadu Organ Sharing Network could become the role model for rest of the country Approx.200 centres in India have expertise to undertake kidney transplants

17. Brain Death Legislation Most countries have some law for tissue procurement but not all have Brain Death Legislation in Place Over 20 countries in Asia do transplants

18. Bangladesh – K Pakistan - K Philippines – K Indonesia – K Malaysia – K, Iran – K, Israel – K Turkey – K Syria – K Malaysia – K Asian Countries Undertaking Transplants – Kidneys alone Some of these countries have done (eg Pakistan) occasional liver or heart (eg Malaysia) transplant.

19. Hong Kong – K, H, Li, H-L India – K, H, Li, H-L, P Japan – K, H, L, L, K-P Korea - K, H, Li, L, K-P People Rep China – K, H, Li Saudi Arabia –K, H, L, Li Singapore – K, H, L, Li Taiwan – K, H, H-L, Li Thailand – K, H, H-L, Li Asian Countries Undertaking Multi–organ Transplants Legend: K-Kidneys, K-P - Kidneys & Pancreas, H-Heart, L-Lung, H-L-Heart & Lung, Li- Liver

20. Overview of Cadaver Transplants in Asia Common Problems & Platforms The Way Ahead Cadaver Transplant in Asia – The Road Ahead

21. Common Problems & Platforms • Magnitude of the Problem • Public and Professionals Attitude to Brain Death & Organ Donation • Religion & Organ Donation • Legal Aspects • Media and Scandals • Reporting of Brain Death • Hospital Infrastructure • Trained Transplant Co-ordinators /Counsellors

22. Incidence of ESRD In Asians & Blacks • Black and Asian people are three to four times more likely to develop end stage renal failure than white people • This rises to eight times more likely for older Asians • Diabetes five times the rate of the white population • Hypertension was at least twice the rate of the white population.

23. World Status of Transplants Annual Number of kidney transplantations per million population (pmp) - USA - 52 Predominantly Cadaver Donors Europe - 27 Predominantly Cadaver Donors Asia - 3 Predominantly Living Donors In last 10 to 15 years the rate of both kidney an liver transplants have increased but heart has remained static. In 2000 approx. 15,000 kidneys were transplanted in each region.

24. Cadaver Donor Rates The Cadaver donors per million population per year • USA - 20.7 • Europe - 15.9 • Asia - 1.1 • South America - 2.6

25. Waiting List for Organs keep Growing • Only about 2.5% of the Japanese carry donor cards, but more than 13,000 Japanese are waiting for transplants. • In February 2000, a 44-year-old woman who was declared brain dead following a brain hemorrhage and stroke donated all four of the organs used in recent transplants. The woman's heart went to a man in his 40s

26. Physicians Attitude to Organ Donation Korean health professionals' attitudes and knowledge toward organ donation and transplantation. Kim JR, Elliott D, Hyde C. 2004 Mar;41(3):299-307. • There was a lack of knowledge by Korean health professionals surrounding brain death and the organ procurement process. • Participants' attitudes were mixed and somewhat negative, as they did not regard brain death as true death Korea – Organ donation rate below 2 per million population per year.

27. Physicians Attitude to Organ Donation Outmoded attitudes toward organ donation among Turkish health care professionals. Topbas M, Can G, Can MA, Ozgun S.Transplant Proc. 2005 Jun;37(5):1998-2000. A large proportion of Physicians are indifferent to organ donation process. Reason cited for this were - • Lack of information regarding the donation process (28.7%), • Concerns about the sale of organs (22.1%), • Islamic religious beliefs (21.6%)

28. Public Attitude • Turkey (n=774) - 59.2% would consider donating organs • Pakistan(n 367) – 59.9% Willing to donate their organs • Hong Kong - 60.3% of the respondents were are willing to donate organs • Viet Nam- 66% urban Vietnamese surveyed were willing to donate organs or tissues after death Ref - Turkey- Ozdag N. EDTNA ERCA J. 2004 Oct-Dec;30(4):188-95 Pakistan - Artif Organs. 2005 Nov;29(11):899-905. Ashraf O, Ali S, Li SA, et al Hong Kong - Yeung I, Kong SH, Lee J. Soc Sci Med. 2000 Jun;50(11):1643-54 Viet Nam - Hai TB, Eastlund T, Chien LA, Duc PT, Giang TH, Hoa NT, Viet PH, Trung DQ.

29. Public Attitude - Singapore Social and cultural aspects of organ donation in Asia. Woo KT. Ann Acad Med Singapore. 1992 May;21(3) Important misconceptions and fears were – • Fear of death, • Belief that removal of organ violates sanctity of decreased • Concern about being cut up after death, • Desire to be buried whole, • Dislike of idea of kidneys inside another person, • Wrong concept of brain death, • Idea of donation being against religious conviction

30. Public Attitude - China Investigation of understanding and willingness of organ transplantation in young people in Beijing, Shanghai, Wuhan. Zhonghua Yi Xue Za Zhi. 1997 Jan;77(1):22-7. Liu Y, Lei H, Qiu F. China Foundation of Organ Transplantation Development, Wuhan Cities of China – • Young people have a better understanding of organ transplantation • Conventional attitudes and feudal habits are the major obstacle to the development of organ transplantation in China.

31. Public Attitude and Organ donation in India SURVEY ON “PUBLIC ATTITUDE TOWARDS ORGAN DONATION & TRANSPLANATATION” Shroff S, Shankar R et al, Indian Medical Tribune, 1996 Results of the Survey • Less than 50% overall positive response in favour of donating solid organs • 72% were willing for “Eye” donation and carry a “Donor Card” • All major religions were willing to consider organ donation

32. CONCLUSION - “PUBLIC ATTITUDE SURVEY” HOW TO ASK FOR ORGANS IN THE EVENT OF “BRAIN DEATH” PATIENT “Request for EYES” FIRST” - SEE HOW FAMILY REACTS Family Willing Family Reluctant Ask For Solid Organs Abandon Efforts (Heart, Liver, Kidneys ..) Inform Transplant Co-coordinator Above protocol called “THE RAMACHANDRA PROTOCOL” to ask for organs

33. Singapore - Legal Aspects THE HUMAN ORGAN TRANSPLANT ACT (HOTA) OF 1987 – Singapore “….. Kidneys can be procured from patients of road traffic accidentswho have been declared “brain-dead” unless they have OPTED OUT ( Presumed Consent) (Muslims exempted)

34. Legal Aspects Malaysia - The “LAWS OF MALAYSIA, ACT 130 1974 - which provides for the use of parts of the human bodies of deceased persons for therapeutic purposes and for purposes of medical education and research. S.Korea -The Transplant Act was first passed in 1999 and then reviewed in 2002. • The Act covers organs and tissues (only bone marrow (BM) and corneas).

35. Thailand - Legal Aspects • There is no law to directly govern transplant procedures in Thailand. • The Medical Council is responsible in regulating human organ transplantation. They decide the criteria from time to time. • Medical Council in Thailand determines whether any punitive action should be taken against the doctors

36. S.Korea – Legal Aspects

37. PHILIPPINES - LEGAL ASPECTS REPUBLIC ACT 7170, 1991 - which authorizes the legacy or donation of all or part of the human body after death for specified purposes

38. VIETNAM - LEGAL ASPECTS THE CIVIL CODE, ARTICLE 32, CHAPTER 2 - requiring consent from donor or next-of-kin. “THE PEOPLE’S HEALTH PROTECTION CODE, CHAPTER 4” providing for tissue transplantation.

39. INDONESIA - LEGAL ASPECTS : THE INDONESIA 1992 HEALTH REGULATION - provides for procurement of tissues from living donors only. FATWA FOR BONE, SKIN & AMNION - introduced in JUNE 1997 by religious council permitting tissue procurement from cadaveric donors.

40. BANGLADESH - LEGAL ASPECTS TISSUE DONATION & TRANSPLANTATION 1999 ACT - passed recently permitting donation from both living and cadaveric donors.

41. SRI LANKA - Legal Aspects LEGAL ASPECTS : “THE HUMAN TISSUE TRANSPLANTATION ACT NO 48 OF 1987 which requires consent from donor or next-of-kin.

42. India – Legal Aspects Transplantation of Human Organs Act, 1994 Aims • Regulate removal, storage and transplantation of human organs for therapeutic purposes • To prevent commercial dealings in organs • Recognise Brain Death

43. RELIGIOUS & CULTURAL ASPECTS Religion plays major role in promoting Organ Donation. Major religions in Asia Pacific include - • Islam • Buddhism • Christianity • Hinduism • Sikhism • Judaism

44. Religion and Organ Donation Common thread that binds all religions of the world – • Saving of life overrides all objections • There is no religions that is against organ donation • What holds back is cultural reservations, • Ignorance of the process of organ donation, • Fear of mutilation, • Lack of emotional support at time of tragedy, • Fear that organs will be sold or used only by the rich • Mistrust of hospitals and health professionals • Myths.

45. Religious Attitude to Donation • Chinese–Americans are influenced by Confucian values, and to a lesser extent, Buddhist, Daoist spiritual beliefs - associate an intact body with respect for ancestors or nature. • The subjects were most willing to donate their organs after their deaths – 1st to close relatives , then in descending order – distant relatives, people from their home country and strangers Influence of religious and spiritual values on the willingness of Chinese–Americans to donate organs for transplantation.Wilbur Aaron Lama & Laurence B McCulloughb .Clinical TransplantationVolume 14 Issue 5 Page 449  - October 2000 doi:10.1034/j.1399-0012.2000.140502.x

46. Buddhism & Organ Donation “The attitude of Buddhism is in perfect agreement with organ and tissue donation; and in Buddhist Scriptures there are stories where donation of tissues have been referred to as an act of charity earning merits” - The Late Dr Hudson Silva World renowned success of the Eye Donation Society of Sri Lanka led by late Dr. Hudson Silva: target of 40,000 eyes procurement reached in May 1999. Guajrat in India with high no. of Jains gets 4000 corneas - highest in India.

47. Predominantly Buddhist Countries Sri Lanka Thailand Vietnam Myanmar Less Dominant Korea (30%) Singapore (30%) Buddhism & Organ Donation

48. Buddhism & Organ Donation In countries where Buddhism is predominant there is no shortage of Tissue / ? Organ donors - • Sri Lanka • Thailand • Vietnam • Myanmar

49. Buddhism & Organ Donation Even in countries where Buddhism is less dominant • Singapore and Korea - Buddhists are main source of tissue donors. • Success of NUH Tissue Bank in Singapore, entirely due to strong support by Buddhist Community. All donors Buddhists.

50. Muslims & Organ Donation Muslims the most controversial group - • Koran does not forbid tissue donation • Koran states that if by not transplanting an organ or tissue, the person will die, then it is permissible to donate. It is allowed for an emergency to save life. • Different interpretations by different religious leaders, ‘ustazs’ and ‘ulamas’ • Muslims must bury the body as soon as possible after death – the sooner the better usually less than 8 hours.