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Dr.Sunil Shroff, www.mohanfoundation.org Cadaver Organ Donation & Transplantation in Asia – The Way Ahead Dr. Sunil Shroff Head of Department - Urology.

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Presentation on theme: "Dr.Sunil Shroff, www.mohanfoundation.org Cadaver Organ Donation & Transplantation in Asia – The Way Ahead Dr. Sunil Shroff Head of Department - Urology."— Presentation transcript:

1 Dr.Sunil Shroff, 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 Managing Trustee, MOHAN Foundation,

2 Dr.Sunil Shroff, Organ Shortage Each day, about 60 people around the world receive an organ transplant, while another 13 die due to non-availability of organs. 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. 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 Dr.Sunil Shroff, Cadaver Transplant in Asia – The Road Ahead Overview of Cadaver Transplants in Asia Overview of Cadaver Transplants in Asia Common Problems & Platforms Common Problems & Platforms The Road Ahead The Road Ahead

4 Dr.Sunil Shroff, Overview of Asia AsiaWorld Population3.6 Billion 6.4 Billion Population3.6 Billion 6.4 Billion No Of Countries51235 No Of Countries51235 Land Mass44,390,000 Sq.Km6,233,821,945 Sq.Km Land Mass44,390,000 Sq.Km6,233,821,945 Sq.Km Life Expectancy M 63 yr F 66yrs Life Expectancy M 63 yr F 66yrs

5 Dr.Sunil Shroff, Cadaver Transplants in Asia Kidney Kidney Liver Liver Heart Heart Heart Lung Heart Lung Pancreas Pancreas Source: Asian Transplant Registry

6 Dr.Sunil Shroff, PER CAPITA INCOME FOR ASIAN COUNTRIES ( In US Dollars) High Per Capita Income 2500 Japan 34,180 Hong Kong 25,860 Singapore 21,230 Kuwait 17,960 Israel 16,240 S Korea 12,030 Taiwan 13,530 Saudi Arabia 9,240 Lebanon 4,040 Malaysia 3,880 Turkey 2,800 Maldives 2,510 Average Per Capita Income 1000 Thailand 2,190 Iran 2,010 Kazakhstan 1,780 Jordan 1,850 Syria 1,190 Turkmenistan 1,120 China 1,100 Philippines 1,080 No Data - Afghanistan -Bhutan, Palestine, Bahrain, Cyprus, Iraq, Qatar, UAE, Myanmar, Timor, Oman, Brunei, N.Korea Low Per Capita Income Sri Lanka 930 Armenia 950 Indonesia 810 Azerbaijan 820 Georgia 770 India 540 Yemen 520 Pakistan 520 Mongolia 480 Vietnam 480 Bangladesh 400 Uzbekistan 420 Laos 340 Kyrgyzstan 340 Cambodia 300 Nepal 240 Tajikistan 210

7 Dr.Sunil Shroff, High per capita income & Successful Living Transplant Programmes Japan Hong Kong SingaporeKuwaitIsrael S Korea Taiwan Saudi Arabia LebanonMalaysiaTurkey

8 Dr.Sunil Shroff, High per capita income & Cadaver Tansplant Programme Hong Kong SingaporeTaiwan Saudi Arabia MalaysiaTurkeyIranLebanonKuwaitIsrael S Korea Japan Most of Asia is struggling with Cadaver Programme including regions with high per capita

9 Dr.Sunil Shroff, Kidney Tx Waiting List in Asia (2002) Japan – 12,974 Japan – 12,974 Taiwan – 7000 Taiwan – 7000 Saudi Arabia – 4248 Saudi Arabia – 4248 Korea – 4000 Korea – 4000 Pakistan Pakistan Hong Kong Hong Kong Singapore – 666 Singapore – 666 Bangladesh Bangladesh 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. No figures available for China, India, Philipines, Indonesia

10 Dr.Sunil Shroff, Transplant Expertise - Asia Japan has transplant centres Japan has transplant centres Thailand - 27 kidney, 6 liver, & 6 Cardiac transplantation centers Thailand - 27 kidney, 6 liver, & 6 Cardiac transplantation centers Iran has 22 centres – mainly kidneys 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 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 However only 6 centres do cadaver Tx. regularly

11 Dr.Sunil Shroff, Transplants - Japan Kidney Transplant since Kidney Transplant since Liver transplants since Liver transplants since Heart Transplants since Heart Transplants since Lung transplants since Lung transplants since The organs have largely been obtained from living and to some extent from non-heart beating donors Ref: Shirakura -WHO/HTP/EHT/T Ethics, access and safety in tissue and organ transplantation:Issues of global concern. Madrid, Spain, 6-9 October 2003

12 Dr.Sunil Shroff, Cadaver Kidney Transplants in Asia India, Taiwan, Korea, Thailand, Iran, Saudi Arabia and Singapore – Regularly are undertaking Kidney Cadaver Transplants 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 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 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 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 Very Little information from China is Available on their modus operandi

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

14 Dr.Sunil Shroff, Cadaver Liver Transplants in Asia Korea do the maximum living liver transplants and has high level of expertise in the field 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. 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 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. 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 Dr.Sunil Shroff, Cadaver Kidney Transplants Scene in India In past ten years approx Cadaver organ transplants over 900 kidneys and 100 Livers and heart have been performed In past ten years approx 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 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 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 Dr.Sunil Shroff, Historical Aspects – Cadaver Transplantation - India First successful cadaver Kidney Transplant in India at KEM Hospital, Bombay First successful heart transplant done at AIIMS, N.Delhi 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 Dr.Sunil Shroff, Asian Countries Undertaking Transplants – Kidneys alone (n-10) Pakistan - K Pakistan - K Philippines – K Philippines – K Indonesia – K Indonesia – K Malaysia – K, Malaysia – K, Iran – K, Iran – K, Israel – K Israel – K Turkey – K Turkey – K Syria – K Syria – K Malaysia – K Malaysia – K Bangladesh – K Bangladesh – K Some of these countries have done (eg Pakistan) occasional liver or heart (eg Malaysia) transplant.

18 Dr.Sunil Shroff, Asian Countries Undertaking Multi–organ Transplants (n-9) Hong Kong – K, H, Li, H-L Hong Kong – K, H, Li, H-L India – K, H, Li, H-L, P India – K, H, Li, H-L, P Japan – K, H, L, L, K-P Japan – K, H, L, L, K-P Korea - K, H, Li, L, K-P Korea - K, H, Li, L, K-P People Rep China – K, H, Li People Rep China – K, H, Li Saudi Arabia –K, H, L, Li Saudi Arabia –K, H, L, Li Singapore – K, H, L, Li Singapore – K, H, L, Li Taiwan – K, H, H-L, Li Taiwan – K, H, H-L, Li Thailand – K, H, H-L, Li Thailand – K, H, H-L, Li Legend: K-Kidneys, K-P - Kidneys & Pancreas, H-Heart, L-Lung, H-L-Heart & Lung, Li- Liver

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

20 Dr.Sunil Shroff, Common Problems & Platforms Incidence of organ failure in Asia Incidence of organ failure in Asia Public and Professionals Attitude to Brain Death & Organ Donation Public and Professionals Attitude to Brain Death & Organ Donation Religion & Organ Donation Religion & Organ Donation Legal Aspects Legal Aspects Media and Scandals Media and Scandals Reporting of Brain Death Reporting of Brain Death Hospital Infrastructure Hospital Infrastructure Trained Transplant Co-ordinators /Counsellors Trained Transplant Co-ordinators /Counsellors

21 Dr.Sunil Shroff, 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 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 This rises to eight times more likely for older Asians Diabetes five times the rate of the white population Diabetes five times the rate of the white population Hypertension was at least twice the rate of the white population. Hypertension was at least twice the rate of the white population.

22 Dr.Sunil Shroff, 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 Dr.Sunil Shroff, Cadaver Donor Rates The Cadaver donors per million population per year USA USA Europe Europe Asia Asia South America South America - 2.6

24 Dr.Sunil Shroff, Physicians Attitude to Organ Donation Korean health professionals' attitudes and knowledge toward organ donation and transplantation. Kim JR, Elliott D, Hyde C Mar;41(3): There was a lack of knowledge by Korean health professionals surrounding brain death and the organ procurement process. 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 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 Dr.Sunil Shroff, 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 Jun;37(5): 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%), Lack of information regarding the donation process (28.7%), Concerns about the sale of organs (22.1%), Concerns about the sale of organs (22.1%), Islamic religious beliefs (21.6%) Islamic religious beliefs (21.6%)

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

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

28 Dr.Sunil Shroff, Public Attitude - China Investigation of understanding and willingness of organ transplantation in young people in Beijing, Shanghai, Wuhan. Zhonghua Yi Xue Za Zhi 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 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. Conventional attitudes and feudal habits are the major obstacle to the development of organ transplantation in China.

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

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

31 Dr.Sunil Shroff, Brain Death – Law & Guidelines Countires CountiresLawGuidelines Apnea Test Physicians Obv Time Conf, Test ArmeniaAAAAAOptional BangladeshPPDVO3AOptional ChinaAAAAAOptional GeorgiaPPDVO324Mandatory Hong Kong PP PCO 2 1AOptional IndiaIranPPPPpDVO-4-A-Mandatory- IndonesiaAP 324Optional

32 Dr.Sunil Shroff, Brain Death – Law & Guidelines CountriesLawGuidelines Apnea Test Physicians Obv Time Conf, Test JapanPP PCO 2 1AMandatory Korea (S) PP PCO 2 16Optional MalaysiaPP 212Mandatory PakistanAAAAANot known PhilippinesAPDVO124Optional SingaporePP PCO 2 2AOptional TaiwanAP 16Optional ThailandPPDVO36Optional VietnamAADVOAAOptional

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

34 Dr.Sunil Shroff, Thailand - Legal Aspects There is no law to directly govern transplant procedures in Thailand. 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. 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 Medical Council in Thailand determines whether any punitive action should be taken against the doctors

35 Dr.Sunil Shroff, 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 Dr.Sunil Shroff, RELIGIOUS & CULTURAL ASPECTS Religion plays major role in promoting Organ Donation. Religion plays major role in promoting Organ Donation. Major religions in Asia Pacific include - Major religions in Asia Pacific include - Islam Islam Buddhism Buddhism Christianity Christianity Hinduism Hinduism Sikhism Sikhism Judaism Judaism

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

38 Dr.Sunil Shroff, Religious Attitude to Donation Chinese–Americans are influenced by Confucian values, and to a lesser extent, Buddhist, Daoist spiritual beliefs 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 – 1 st to close relatives, then in descending order – The subjects were most willing to donate their organs after their deaths – 1 st 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 October 2000 doi: /j x

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

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

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

42 Dr.Sunil Shroff, Muslims & Organ Donation Muslims the most controversial group - Koran does not forbid tissue donation 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. 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 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. Muslims must bury the body as soon as possible after death – the sooner the better usually less than 8 hours.

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

44 Dr.Sunil Shroff, Muslims & Organ Donation Each country has its own MUFTI -religious official appointed by Govt to deal with Islamic matters 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. 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 Fatwa Committee chaired by MUFTI includes prominent religious leaders, lawyers, doctors and other members of public Fatwas are not legal binding. Fatwas are not legal binding.

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

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

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

48 Dr.Sunil Shroff, 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 Dr.Sunil Shroff, Hinduism and Organ Donation Predominantly India India LESS DOMINANT Sri Lanka (<10%) Sri Lanka (<10%) Singapore (5%) Singapore (5%) Malaysia Malaysia Indonesia Indonesia Thailand Thailand Veitnam Veitnam

50 Dr.Sunil Shroff, Religions against organ donation Greek Orthodox, Shinto and Gypsies are three religions that do not encourage body donation Greek Orthodox, Shinto and Gypsies are three religions that do not encourage body donation Jehovahs witness is another Christian sect that is against such acts Jehovahs witness is another Christian sect that is against such acts

51 Dr.Sunil Shroff, Media and Scandals - T hailand Doctors May Face Murder Charge The New Straits Times, September 1, 2000 Three doctors from a Bangkok private hospital allegedly killed patients in 1997, harvested the kidneys and sold their kidneys to rich transplant patients will face murder charges. faking paperwork to cover their crime. Three doctors from a Bangkok private hospital allegedly killed patients in 1997, harvested the kidneys and sold their kidneys to rich transplant patients will face murder charges. faking paperwork to cover their crime. A police inquiry into the scandal said - the organs were removed from patients who were pronounced brain dead, a condition not accepted as legally dead in Thailand. A police inquiry into the scandal said - the organs were removed from patients who were pronounced brain dead, a condition not accepted as legally dead in Thailand.

52 Dr.Sunil Shroff, Media & Scandals - Japan The Washington Post: April 25, 1997 A Japanese surgeon who performed the operation was investigated in connection with the alleged murder of the donor. He was not indicted, but the lengthy criminal proceedings blocked all further operations

53 Dr.Sunil Shroff, Media & Organ Donation The power of the press can also be demonstrated in the so-called "Nicholas Green effect. Nicholas was a 7-year-old American child, shot dead by bandits in Italy in 1994 Nicholas was a 7-year-old American child, shot dead by bandits in Italy in 1994 His parents agreed to donate his organs His parents agreed to donate his organs Italian press reported it extensively Italian press reported it extensively The positives impact kick started the Italian cadaver programme The positives impact kick started the Italian cadaver programme

54 Dr.Sunil Shroff, Under-reporting of Brain death The efficiency of utilization of potential donors for organ transplantation in Saudi Arabia: a pilot study. Al Sebayel MI, Khalaf HA. Transplant Proc Sep;36(7):1881 Data – 2001 to out of 542 deaths were due to Brain Death & 54% - occurred in one hospital. 38 cases were reported to the Saudi Center for Organ Transplantation & in 23 Documentation was completed 38 cases were reported to the Saudi Center for Organ Transplantation & in 23 Documentation was completed 4 Cases became actual donors 4 Cases became actual donors Conclusion – There is underreporting of brain death cases.

55 Dr.Sunil Shroff, Problems with Cadaver Organ Donation Programme in Asia Govt. Problem No Funding for programme Hospital problem No efforts to identify & maintain Brain Dead donors Community Problem No Awareness of Brain- Death Concept Spain has the highest number of brain death patients going on to organ donation – 32 per million population

56 Dr.Sunil Shroff, Transport of organs – between cities Adequate No. of Qualified Intensivists in ICUs Well qualified Surgeons to undertake Retrieval & TX HLA Tissue typing and Cross-match Qualified Trained transplant Co-coordinators Qualified Trained transplant Co-coordinators Support Organisation to Network Hospital Infra-Structural & Support Logistics

57 Dr.Sunil Shroff, Cadaver Transplants Scene in Asia – The Way Forward Overview of Cadaver Transplants in Asia Overview of Cadaver Transplants in Asia Common Problems & Platforms Common Problems & Platforms The Way Ahead The Way Ahead

58 Dr.Sunil Shroff, The Way Forward Strengthen the Asian Transplant Network Strengthen the Asian Transplant Network Establish a common programme similar to Euro- transplant Network Establish a common programme similar to Euro- transplant Network Start sharing organs that are not used locally Start sharing organs that are not used locally Use technology effectively Use technology effectively Evolve a Spanish style co-ordinators course for Asian countries Evolve a Spanish style co-ordinators course for Asian countries Do our own Asian Transplant Games to build patient fellowship Do our own Asian Transplant Games to build patient fellowship Have more frequent Asian Transplant Society meeting Have more frequent Asian Transplant Society meeting

59 Dr.Sunil Shroff, Organisational changes Model National Transplant Service Model National Transplant Service – Like a network to share organs that is linked to a Asian Network for Organ Sharing (ANOS) Employing and training more transplant co-ordinators and having a separate body in Asia for Tx. Co- ordinators Employing and training more transplant co-ordinators and having a separate body in Asia for Tx. Co- ordinators Regular Courses to impart expertise to the co- ordinators Regular Courses to impart expertise to the co- ordinators Training and sensitising ICU staff on brain-death Training and sensitising ICU staff on brain-death

60 Dr.Sunil Shroff, Organisation helping with organ donation & Transplants programmes in India MOHAN Foundation (INOS) - Tamil Nadu, Andhra Pradesh, Maharastra 236 Organs shared 236 Organs shared. ( 212-Kidneys, 9-Hearts, 15-Liver ) MOHAN Foundation (INOS) - Tamil Nadu, Andhra Pradesh, Maharastra 236 Organs shared 236 Organs shared. ( 212-Kidneys, 9-Hearts, 15-Liver ) FORTE, BANGALORE – 32 Organs Shared ( 32 - Kidneys, 1- Heart, 1- Liver ) FORTE, BANGALORE – 32 Organs Shared ( 32 - Kidneys, 1- Heart, 1- Liver ) ZTCC, Mumbai – 55 Organs Shared - all kidneys ORBO, N.Delhi – Few organs shared SORT, Cochin – 4 organs shared

61 Dr.Sunil Shroff, Cadaveric Donation For cadaveric donation - For cadaveric donation - society remains a crucial aspect in a transplant programme society remains a crucial aspect in a transplant programme Strategies to decrease refusal rates by families include efforts at education - Strategies to decrease refusal rates by families include efforts at education - the general population, the general population, Religious heads & opinion leaders Religious heads & opinion leaders health care workers individually health care workers individually through the mass media through the mass media

62 Dr.Sunil Shroff, Encouraging People to Discuss Organ Donation When the wishes of the deceased are not known, only 50% of people will agree to organ retrieval from their relatives When the wishes of the deceased are not known, only 50% of people will agree to organ retrieval from their relatives Encouraging people to speak about organ donation and transplantation and to make their wishes known to their relatives could change the picture resulting in 93-94% of people allowing donation Encouraging people to speak about organ donation and transplantation and to make their wishes known to their relatives could change the picture resulting in 93-94% of people allowing donation

63 Dr.Sunil Shroff, Presence of Family Member During Brain Death Testing Most families faced with brain stem death of a relative find the concept difficult to understand and have trouble in accepting that their relative is actually dead Most families faced with brain stem death of a relative find the concept difficult to understand and have trouble in accepting that their relative is actually dead Family members were given choice to be or not to be present during brain stem death testing Family members were given choice to be or not to be present during brain stem death testing It is suggested that presence of family members during brain stem death testing not only helps families to accept this concept of death but also promotes the grieving process It is suggested that presence of family members during brain stem death testing not only helps families to accept this concept of death but also promotes the grieving process The presence of family during brain stem death testing. Doran M. Intensive Crit Care Nurs Feb;20(1):32-7

64 Dr.Sunil Shroff, Project Positive Aspects Many donor relatives have stated that donating their loved one's organs does not make the pain of their death disappear Many donor relatives have stated that donating their loved one's organs does not make the pain of their death disappear Bereaved families can experience comfort that their loved one's gift gave another person a second chance at life Bereaved families can experience comfort that their loved one's gift gave another person a second chance at life

65 Dr.Sunil Shroff, Consent for Donation Pre-mortem – via Donor Cards, Driving License Pre-mortem – via Donor Cards, Driving License Consent of his family following death Consent of his family following death Some form of a combination of the two are necessary Some form of a combination of the two are necessary Supererogatory permission - Underlying premise of such a consent would be that organs of dead people are public goods, and donation must be considered similar to other compulsory civil obligations within society Supererogatory permission - Underlying premise of such a consent would be that organs of dead people are public goods, and donation must be considered similar to other compulsory civil obligations within society The permission is a moral rather than a legal requirement The permission is a moral rather than a legal requirement

66 Dr.Sunil Shroff, Essence of INOS – Not to Waste Any Organ. Organs should be treated like National Resource Essence of INOS – Not to Waste Any Organ. Organs should be treated like National Resource Hospital in group includes – Apollo, CMC Vellore, Sri Ramachandra Hospital and Sundaram Medical Foundation Hospital in group includes – Apollo, CMC Vellore, Sri Ramachandra Hospital and Sundaram Medical Foundation Hospitals in Andhra Pradesh- Nizams Institute of Medical Sciences, Global Hospitals, Kamanneini Hosp, Apollo Hospital, Care Hospital Hospitals in Andhra Pradesh- Nizams Institute of Medical Sciences, Global Hospitals, Kamanneini Hosp, Apollo Hospital, Care Hospital Many Affiliate hospitals from other parts of country Many Affiliate hospitals from other parts of country Mohan Foundation Intiatives – INOS ( Indian Network for Organ Sharing)

67 Dr.Sunil Shroff, Presumed Consent & Organ Donation Belgium, Austria, Finland, France, Norway, Spain, and Singapore implemented "presumed consent" Belgium, Austria, Finland, France, Norway, Spain, and Singapore implemented "presumed consent" France's presumed consent (PC) law has produced increases in organ donation approaching 5,000%. France's presumed consent (PC) law has produced increases in organ donation approaching 5,000%. Belgium passed its version of PC in 1986, and organ donation climbed by 183%, with multi-organ retrieval significantly increased to 119% for kidneys. T he donor rate increased from 10 to 22 donors per million population between 1986 and Belgium passed its version of PC in 1986, and organ donation climbed by 183%, with multi-organ retrieval significantly increased to 119% for kidneys. T he donor rate increased from 10 to 22 donors per million population between 1986 and Austria passed its PC law in By the end of 1990, the number of patients receiving kidneys was nearly the same as the number on the waiting list Austria passed its PC law in By the end of 1990, the number of patients receiving kidneys was nearly the same as the number on the waiting list

68 Dr.Sunil Shroff, Required Request Law Requires that formal request for organ donation be made of the families of all potential donors in the ICU. Requires that formal request for organ donation be made of the families of all potential donors in the ICU. The rationale is that a statutory approach would overcome hesitancy by healthcare professionals at a time of such emotional distress. The rationale is that a statutory approach would overcome hesitancy by healthcare professionals at a time of such emotional distress. Required Request Law has been introduced into many states in the USA by legislation and helped improve organ donation rate Required Request Law has been introduced into many states in the USA by legislation and helped improve organ donation rate

69 Dr.Sunil Shroff, Mandated Choice Mandated choice: This requires people to state their willingness to donate or not when filing some state of institutional return such as a driving licence or income tax form. Mandated choice: This requires people to state their willingness to donate or not when filing some state of institutional return such as a driving licence or income tax form. The information would be kept on a central register, accessible at time of death The information would be kept on a central register, accessible at time of death

70 Dr.Sunil Shroff, Mandated Choice & Driving License Sweden instituted a mandated choice law. There was an immediate increase of 600,000 potential donors Sweden instituted a mandated choice law. There was an immediate increase of 600,000 potential donors. A similar 1990 law in Denmark increased their donor registry by 150,000. A similar 1990 law in Denmark increased their donor registry by 150,000.

71 Dr.Sunil Shroff, Action Required – Muslim Countries More public education needed to change cultural beliefs and practices although Islam does not forbid Organ or tissue donation More public education needed to change cultural beliefs and practices although Islam does not forbid Organ or tissue donation Fatwas alone will not work. Fatwas alone will not work. Constantly addressing masses through media by religious head may help to improve sentiments Constantly addressing masses through media by religious head may help to improve sentiments

72 Dr.Sunil Shroff, Religion & Organ Donation Plan major conferences of religious heads on organ donation and transplantation in all regions of Asia. Plan major conferences of religious heads on organ donation and transplantation in all regions of Asia. Most people are ill- informed about their religions attitude towards organ donation. Most people are ill- informed about their religions attitude towards organ donation. Major initiative required to correct this Major initiative required to correct this An Exploratory Study Examining the Influence of Religion on Attitudes Towards Organ Donation Among the Asian Population in Luton,UK Nephrology Dialysis and Transplantation (1998) Volume 13:

73 Dr.Sunil Shroff, NGO or Groups involved in Organ donation in any part of the Asia have to tackle various issues in the field of cadaver organ donation and transplantation simultaneously More Support groups with common objectives are needed More resources necessary to Kick start such an Initiative What is Required

74 Dr.Sunil Shroff, Patient Support Group Purpose of the group - to provide emotional support to organ failure & transplant patients Meeting held every two months between doctors, dietician and counselors and patients to discuss their problems Provide subsidized investigation and a few selected drugs We have about 250 members from Mumbai and Chennai Patients should be the advocate of cadaver organ movement, this will generate better publicity for the cause

75 Dr.Sunil Shroff, Patient Support Group We have held Eight meetings in Chennai, four in Mumbai and one in Hyderabad We have held Eight meetings in Chennai, four in Mumbai and one in Hyderabad Some of them keen to help out with cadaver organ donation programme Some of them keen to help out with cadaver organ donation programme The group held All India Transplant Games in Dec 2003 The group held All India Transplant Games in Dec 2003

76 Dr.Sunil Shroff, Promote Organ Donation Among Blood Donors Study shows that blood donors have better knowledge of organ donation and are more willing to donate their organs and sign an Donor card than general public. Study shows that blood donors have better knowledge of organ donation and are more willing to donate their organs and sign an Donor card than general public. A substantial proportion of blood donors have not signed a Donor Card. A substantial proportion of blood donors have not signed a Donor Card. It would be useful to design promotion programs to facilitate blood donors' participation in organ donation. It would be useful to design promotion programs to facilitate blood donors' participation in organ donation. Attitudes about organ and tissue donation among the general public and blood donors in Hong Kong. Li PK, Lin CK, Lam PK, Szeto CC, Lau JT, Cheung L, Wong M, Chan AY, Ko WM. Prog Transplant Jun;11(2): Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong

77 Dr.Sunil Shroff, Make Local Sharing Protocols 6 Kidneys have been wasted in the last four years of the 112 Kidneys shared in the INOS network due to these problems Poor Retrieval Technique – 2 Poor Retrieval Technique – 2 No Blood for Cross Match – 2 No Blood for Cross Match – 2 Poor Packing of Organ - 2 Poor Packing of Organ - 2 INOS- Initiative for Organ Sharing facilitated by MOHAN Foundation in Tamil Nadu

78 Dr.Sunil Shroff, Retrieval Surgery & Packing of Organs MOHAN in its INOS Group of hospitals have made: Attempts to standardize retrieval techniques Attempts to standardize retrieval techniques CD made on kidney Retrieval to be circulated to all the hospitals in the group CD made on kidney Retrieval to be circulated to all the hospitals in the group Packing of organs being standardised for transportation Packing of organs being standardised for transportation

79 Dr.Sunil Shroff, Potential Countries That can Succeed with Programme Countries that can have success with Cadaver Transplant programmes in Asia and make a difference - India – No Religious bar to donation India – No Religious bar to donation Iran – Has a logistic approach Iran – Has a logistic approach Saudi Arabia – Has the laws Saudi Arabia – Has the laws Turkey – Liberal Muslim Country Turkey – Liberal Muslim Country Taiwan – Well organized Skills Taiwan – Well organized Skills China – Capable of organizing the programme China – Capable of organizing the programme Sri Lanka – High Buddhist community. Eye programme success Sri Lanka – High Buddhist community. Eye programme success Mynamar - High Buddhist community Mynamar - High Buddhist community

80 Dr.Sunil Shroff, ORGAN DONATION RATE If in India - 1 per million donation rate we would have 1100 organ donors – 2200 kidneys,1000 hearts, 1100 Livers, 2200 Eyes At 10 per million donation rate- 11,000 organ donors 22,000 kidneys, 11,000 hearts, 11,000 Livers, 22,000 Eyes 20 per million donation rate - 22,000 organ donors 44,000 kidneys, 22,000 hearts, 22,000 Livers, 22,400 Eyes Current organ donation rate - India is 0.05 per million population per year At 3 per million Donation rate we would have 3300 organ donors – 6600 kidneys,3300 hearts, Livers, 6600 Eyes Source: Indian Transplant Newsletter Issue no.19 Feb 2006

81 Dr.Sunil Shroff, Organ Shortage is a Crisis, however the Crisis has a Cure In Asia we need to Network and start thinking of sharing resources, expertise and organs Set up Collaborative projects Use Television Media for Promotion Get Religious heads to Participate regularly Have Transparency in programme Set up regional Transplant co-ordinators Forums Cadaver Transplant - Conclusion

82 Dr.Sunil Shroff, In Asia we have failed to explore all the options and simple steps and changes can make all the difference for our patients Cadaver Transplant - Conclusion

83 Dr.Sunil Shroff, THANK YOU MOHAN Foundation –INOS Mission Statement ORGANS WASTED ARE LIVES LOST In my end is my beginning - T.S.Eliot, Four Quartets


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