Cadaver Organ Donation & Transplantation in Asia – The Way Ahead

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

2. 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 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 Living 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 No Waiting list in Iran for Kidney Tx. 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, & 6 Cardiac transplantation centers • Iran has 22 centres – mainly kidneys • India has 110 centres for Kidney Tx 5 centres Liver, 6 – Cardiac. over 35 centres have undertaken cadaver transplants • However only 6 centres do cadaver Tx. regularly

11. 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

12. 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

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

14. 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 at Hyderabad, Vellore and Delhi have fair expertise with liver transplants and emerging as the key players in the country.

15. Cadaver Kidney Transplants Scene in India • In past ten years approx. 1000 Cadaver organ transplants over 900 kidneys and 100 Livers and heart have been performed • Almost 40% 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.110 centres in India do kidney Tx.however only 25 to 30 centres do over 25 per year.

16. Historical Aspects – Cadaver Transplantation - India 1967 - First successful 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, Ahemdabad

17. Pakistan - K Philippines – K Indonesia – K Malaysia – K, Iran – K, Israel – K Turkey – K Syria – K Malaysia – K Bangladesh – K Asian Countries Undertaking Transplants – Kidneys alone (n-10) Some of these countries have done (eg Pakistan) occasional liver or heart (eg Malaysia) transplant.

18. 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 (n-9) Legend: K-Kidneys, K-P - Kidneys & Pancreas, H-Heart, L-Lung, H-L-Heart & Lung, Li- Liver

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

20. Common Problems & Platforms • Incidence of organ failure in Asia • 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

21. 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.

22. World Status of Transplants Annual Number of kidney transplantations per million population (pmp) per year - 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.

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

24. 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.

25. 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%)

26. 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.

27. 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

28. 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.

29. 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

30. 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

31. Brain Death – Law & Guidelines

32. Brain Death – Law & Guidelines

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

34. 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

35. 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

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

37. Religion and Organ Donation Common thread that binds all religions of the world – • Saving of life overrides all objections • There is no religion 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

38. 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

39. 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. Gujarat in India has high number of eye donations (Jains) gets 4000 corneas - highest in India.

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

41. 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.

42. 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.

43. Predominantly – Saudi Arabia Iran Iraq Kuwait Turkey Pakistan Bangladesh Malaysia Brunei Indonesia (Secular-PANCASILA) Less Dominant – China (200 million) India Singapore (20%) Muslims & Organ Donation

44. Muslims & Organ Donation • Each country has its own ‘MUFTI’ -religious official appointed by Govt to deal with Islamic matters • ‘FATWAS’ are religious rulings made by ‘Fatwa Committee’ as official stand by Govt. on various issues. • ‘Fatwa Committee’ chaired by MUFTI includes prominent religious leaders, lawyers, doctors and other members of public • Fatwas are not legal binding.

45. Muslims & Organ Donation • Fatwas declared in several countries • Saudi Arabia : 1985 - permit both living related and cadaveric donation of organs • Pakistan, • Bangladesh, • Malaysia - 1995 • Indonesia

46. CULTURAL PRACTICES OF MUSLIMS • Despite Fatwas Muslims reluctant to donate organs • God created them whole. They prefer to return to him whole. • Many Muslims bury amputated limbs, foreskin from circumcision, amnion from delivery. • Not religious requirement but cultural practice. Not all Muslims do this

47. Predominantly - Philippines Less Dominant – Singapore (30%) Korea (30%) Malaysia India Christianity - Organ Donation No bar to organ donation - Shortage of Donors in Philippines, Singapore and Korea due to cultural factors.

48. Christianity - Organ Donation STATEMENT BY POPE JOHN PAUL II – Full support of organ and tissue donation concluded with words of Jesus narrated by evangelist and physician LUKE: “give…, and it will be given to you; good measure, pressed down, shaken together, running over, will be put into your lap (Luke 6 : 38).” We shall receive our supreme reward from God according to the genuine and effective love we have shown to our neighbour.

49. Predominantly India LESS DOMINANT Sri Lanka (<10%) Singapore (5%) Malaysia Indonesia Thailand Veitnam Hinduism and Organ Donation

50. Religions against organ donation • Greek Orthodox, Shinto and Gypsies are three religions that do not encourage body donation • Jehovah’s witness is another Christian sect that is against such acts