Logistic Issues Important to EM Region
Reports from the European Blood and Marrow Transplantation (EBMT) and the Centre for International Blood and Marrow Transplant Registry (CIBMTR) have illustrated earlier that number of transplants differ significantly between different countries.44 This is true for all regions, but no detailed information is available about the EM region.
By tradition, some EBMT reports include data from few non-European countries that fall in the EM region (Iran, Saudi Arabia, and Tunisia) and report their HSCT activity to EBMT registry. Their data are in part included in some of the analyses. Hence, data published by the EBMT group may also be informative for patient counseling and decisions making by health care professionals and planners/administrators in the EM region. However, more detailed information specific to this region is desirable.45
The EBMT has analyzed factors associated with differences in HSCT activity between the participating teams from more than 240 countries over a time span of 15 years. Results have revealed that gross national income (GNI) per capita, numbers of transplant teams per 10 million inhabitants or per 10,000 kilometers, team size and team experience all had impact on transplant activity.46
Moreover, it was realized that some other factors might have been involved in the decisions to perform or not to perform HSCT.
The recent EBMT report based on the activity survey 200647
shows that transplant rates predictably increased over time with nearly linear trends, in clear association with GNI per capita and distinctly by World Bank income category within a narrow window of variation for both autologous HSCT and allogeneic HSCT when breast cancer (autologous) and CML (allogeneic) were excluded.47
Team density and team distribution were also associated with transplant rates.47
summarizes the various factors that affect HSCT activity in European countries as reported by the EBMT group.47, 48
These included economic factors such as GNI per capita or health care expenditures per capita, team density, and team distribution. There were also clear differences in transplant rates for certain disease indications which might relate to a different prevalence of the disease, e.g. hemoglobinopathies. 47, 48
Our preliminary findings reported here are based on cumulative experience of 17 teams in 9 countries of the EM region over the last two decades. Of the 17 teams, 16 (94 %) did both allogeneic and autologous HSCT and one (6%) restricted its activity to autologous HSCT only.
Table 3 Factors associated with differences in transplant rates between European countries40, 41
Team density in the EM region is very low (1.5583) as compared to 13.4333 in Europe)48
and HSCT team distribution in the countries where significant HSCT exists is also very low (0.2729) in comparison to European countries where it ranges from <1 to 6 teams per 10,000 sq km area. 47, 49
reflects total HSCT performed to date in the reported countries of the EM region is quite variable. HSCT teams in Saudi Arabia, Iran and Egypt have crossed the figure of 1000 transplants. exhibits GNI per capita based WHO income categories in the EM region. Most of the reported countries are in the upper middle income category, except Saudi Arabia and Oman being in the high income group and Pakistan being in the lower middle income category. reflects low HSCT team densities in most of the EM region, except one relatively small country (Lebanon) with a density of 4.932182. These numbers are very low compared with European data. shows HSCT activity and the related economic/logistic indices in the EM region. It is evident that more than the GNI per capita (which is not easily changeable factor), team densities and team distribution need special attention of the health care planners. Patients must have access to a transplant team in order to receive a transplant. EBMT survey figures illustrate that probably one team per 1 – 2 million inhabitants and one team per 10,000 km2
are reasonable targets. 47
Currently a good but uncertain number of patients from the EM region, especially from countries with WHO high income category, are referred to United States or Western Europe for HSCT. However authors have no estimates of such referrals. Such cases are mostly sponsored by the state, charity support or family resources.
Total HSCT Performed in 9 Countries of the EM Region with significant HSCT programs
GNI Per Capita based WHO Income Categories of the 9 Countries of the EM Region with significant HSCT programs
HSCT Team Densities in 9 Countries of the EM Region with significant HSCT programs
HSCT Activity and the Related Economic/Logistic Indices in the EM Region
For comparison, the EBMT data based on a 15-year observation period within the EBMT activity survey demonstrate that transplant rates in Europe are highly predictable, show a clear association with GNI per capita and are distinct in their evolution by World Bank income category.47
These data indicate that although transplant teams do their best to meet the needs, they still fail to do so. They are limited by resources, as illustrated by the clear association of transplant rates with GNI per capita and World Bank income category.47
EBMT data and our initial findings indicate that HSCT activity is also limited by the infrastructure, as documented by the association between transplant activity, team density and team distribution.48
The countries in EM region lacking significant HSCT activity suffer from limited economic resources and or lack of expertise and logistic support. In addition, more curable and more prevalent health problems may be competing for the limited resources in lower income category countries. A significant number of patients are referred from the EM region, especially from countries with WHO high income category, to United States or Western Europe for HSCT. However as noted above, the authors have no estimates of such referrals. Obviously, the programs offering HSCT facilities in the region are unable to meet the needs of the patients from their respective countries. Hence the desirable referral between countries of the EM region is not yet fully developed, although such a referral system may help those EM countries who particularly have no internal access to HSCT. Practically, it will be more prudent to help such countries in establishing their own HSCT centres through collaboration, training and outreach programs such as those offered by EBMT to develop medical and nursing work force.
This report is based on initial data from EM region which is obviously limited. Recent EBMT analysis on predictability of HSCT rates 47
also had some limitations. Firstly, there is no uniform database on the incidence or prevalence of the individual disease categories in the participating countries. Secondly, data were limited to Europe and it is difficult to extrapolate the conclusions in other continents. Nevertheless, it is likely that similar factors, such as GNI per capita and team density also affect transplant rates in the EM region. It is also likely that considerations on cost-effectiveness will affect decisions between HSCT and lifelong expensive therapies in countries of the EM region (CML being typical example).50, 51
Most of the EM region countries have health care systems, economically supported by the state as is the case in the Europe. If HSCT is performed in a private centre, the procedure cost is paid by the patient in full or in part and the remaining is paid by the charity resources. Most countries lack health care insurance systems covering the cost of HSCT procedure, making HSCT a financial ordeal for the patient and family.
It is clear that the need for HSCT will continue to increase in the near future. Improvement in supportive care and antimicrobial therapy, increasing donor pools worldwide, increasing availability of cord blood products and novel conditioning regimens should provide access to HSCT for patients previously not considered as candidates for these procedure.1
Health care providers in the EM region will face this complex problem and they should initiate rigorous actions to put the infrastructure in place.
It is important to find the correct balance between a restricted number of HSCT teams (so that they have sufficient expertise and quality service) and an adequate number in order to guarantee access for all patients, independently of travel distances. Above all, there is no indication of an abundance of transplant beds. There is a need to provide infrastructure for more HSCT centers. The anxiety of health care agencies fearing abundance of HSCT centers (due to the example of CML) now seems unnecessary and they can be reassured that trends, with the advent of novel therapies which affect the demand for HSCT, are timely recognized. With up-to-date instruments, such as the EBMT activity survey, changes in therapy can easily be recognized at an early stage and appropriate measures can be taken to curtail the feared unnecessary growth of HSCT centers.
These data clearly illustrate the need for more research to understand the mechanism of HSCT activity and into the mechanisms of technology dissemination in the EM region. If possible, such studies should be performed on a wider collaborative basis. This appears essential in order to enable health care agencies to provide adequate infrastructure for this high cost procedure especially in the EM region and other developing countries.
To improve the HSCT activity related performance standards acquisition of FACT and JACIE accreditation by the centres in EM region will obviously be helpful. However, potential logistic hurdles in accreditation related to transplant volumes, access to collection & processing facilities, and geographical factors might present challenges. Moreover, such requirements for accreditation may result in rationalization of health resources into centres capable of achieving accreditation where resources are limited. On the other hand, mandatory application of accreditation requirements, at least in the beginning, may challenge the efforts to establish new centres with already limited enthusiasm & resources.
Severe shortage of trained personnel in the field of HSCT at all levels mandates the need for an eastern Mediterranean HSCT League to promote recent technologies and improve experience related to HSCT in the region. Formation and identification of a regional HSCT training center for nurses, physicians, coordinators, researchers, data base instructors, etc will be highly instrumental in accomplishing this goal. This will be a source of exchanging experiences, providing training for new centers, and also serves as a reference for standardization of procedures. Other strategies may include initiating eastern Mediterranean ‘Nursing Board’ to manage the problems related to paramedical manpower, updating HSCT procedures and increasing awareness about HSCT among the staff and patients.