Luc Noel

Addressing the Millennium Development Goals From a Surgical Perspective Essential Surgery and Anesthesia in 8 Low- and Middle-Income Countries

HYPOTHESIS Surgical and anesthetic care is increasingly recognized as a neglected but cost-effective component of primary health care in low- and middle-income countries (LMICs). Strengthening delivery can help achieve Millennium Development Goals 4, 5, and 6. Large gaps in access to essential surgical care in LMICs result in considerable morbidity and mortality. The goal of this study was to provide a baseline overview of essential surgical and anesthetic capacity at district-level health facilities in multiple LMICs. DESIGN Survey. SETTING District-level health facilities in multiple LMICs MAIN OUTCOME MEASURES A standardized World Health Organization tool was used at selected district-level hospitals to assess infrastructure, supplies, and procedures relating to essential surgical and anesthetic capacity. The analysis included facilities from countries that assessed more than 5 health facilities. All data were aggregated and blinded to avoid intercountry comparisons. RESULTS Data from 132 facilities were analyzed from 8 countries: Democratic Socialist Republic of Sri Lanka (n = 32), Mongolia (n = 31), United Republic of Tanzania (n = 25), Islamic State of Afghanistan (n = 13), Republic of Sierra Leone (n = 11), Republic of Liberia (n = 9), Republic of The Gambia (n = 6), and Democratic Republic of São Tomé and Príncipe (n = 5). Universally, facilities demonstrated shortfalls in basic infrastructure (water, electricity, oxygen) and functioning anesthesia machines. Although 73% of facilities reported performing incision and drainage of abscesses, only 48% were capable of undertaking an appendectomy. In line with Millennium Development Goals 4, 5, and 6, only 32% of facilities performed congenital hernia repairs, 44% of facilities performed cesarean sections, and few facilities always had goggles and aprons to protect surgical health care workers from human immunodeficiency virus. CONCLUSION Enormous shortfalls in infrastructure, supplies, and procedures undertaken are common at district-level health facilities in LMICs.

One million haemopoietic stem-cell transplants: a retrospective observational study

BACKGROUND The transplantation of cells, tissues, and organs has been recognised by WHO as an important medical task for its member states; however, information about how to best organise transplantation is scarce. We aimed to document the activity worldwide from the beginning of transplantation and search for region adapted indications and associations between transplant rates and macroeconomics. METHODS Between Jan 1, 2006, and Dec 31, 2014, the Worldwide Network for Blood and Marrow Transplantation collected data for the evolution of haemopoietic stem-cell transplantation (HSCT) activity and volunteer donors in the 194 WHO member states. FINDINGS 953,651 HSCTs (553,350 [58%] autologous and 400,301 [42%] allogeneic) were reported by 1516 transplant centres from 75 countries. No transplants were done in countries with fewer than 300,000 inhabitants, a surface area less than 700 km(2), and a gross national income per person of US

A call for government accountability to achieve national self-sufficiency in organ donation and transplantation

1260 or lower. Use of HSCT increased from the first transplant in 1957 to almost 10,000 by 1985. We recorded a cumulative total of about 100,000 transplants by 1995, and an estimated 1 million by December, 2012. Unrelated donor registries contributed 22·3 million typed volunteer donors and 645,646 cord blood products by 2012. Numbers of allogeneic HSCTs increased in the past 35 years with no signs of saturation (R(2)=0·989). Transplant rates were higher in countries with more resources, more transplant teams, and an unrelated donor infrastructure. INTERPRETATION Our findings show achievements and high unmet needs and give guidance for decisions; to grant access for patients, to provide a donor infrastructure, and to limit overuse by defining risk and region adapted indications for HSCT as an efficient and cost-effective approach for life-threatening, potentially curable diseases. FUNDING Funding for this study was indirectly provided by support of the WBMT.

International guideline development for the determination of death.

Roughly 100,000 patients worldwide undergo organ transplantation annually, but many other patients remain on waiting lists. Transplantation rates vary substantially across countries. Affluent patients in nations with long waiting lists do not always wait for donations from within their own countries. Commercially driven transplantation, however, does not always ensure proper medical care of recipients or donors, and might lengthen waiting times for resident patients or increase the illegal and unethical purchase of organs from living donors. Governments should systematically address the needs of their countries according to a legal framework. Medical strategies to prevent end-stage organ failure must also be implemented. In view of the Madrid Resolution, the Declaration of Istanbul, and the 63rd World Health Assembly Resolution, a new paradigm of national self-sufficiency is needed. Each country or region should strive to provide a sufficient number of organs from within its own population, guided by WHO ethics principles.

The critical pathway for deceased donation: reportable uniformity in the approach to deceased donation

Introduction and MethodsThis report summarizes the results of the first phase in the development of international guidelines for death determination, focusing on the biology of death and the dying process, developed by an invitational forum of international content experts and representatives of a number of professional societies.Results and ConclusionsPrecise terminology was developed in order to improve clarity in death discussion and debate. Critical events in the physiological sequences leading to cessation of neurological and/or circulatory function were constructed. It was agreed that death determination is primarily clinical and recommendations for preconditions, confounding factors, minimum clinical standards and additional testing were made. A single operational definition of human death was developed: ‘the permanent loss of capacity for consciousness and all brainstem functions, as a consequence of permanent cessation of circulation or catastrophic brain injury’. In order to complete the project, in the next phase, a broader group of international stakeholders will develop clinical practice guidelines, based on comprehensive reviews and grading of the existing evidence.

Implementing Liberia's poverty reduction strategy: An assessment of emergency and essential surgical care.

The critical pathway of deceased donation provides a systematic approach to the organ donation process, considering both donation after cardiac death than donation after brain death. The pathway provides a tool for assessing the potential of deceased donation and for the prospective identification and referral of possible deceased donors.

The global diffusion of organ transplantation: trends, drivers and policy implications

OBJECTIVE To document infrastructure, personnel, procedures performed, and supplies and equipment available at all county hospitals in Liberia using the World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care. DESIGN Survey of county hospitals using the World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care. SETTING Sixteen county hospitals in Liberia. MAIN OUTCOME MEASURES Infrastructure, personnel, procedures performed, and supplies and equipment available. RESULTS Uniformly, gross deficiencies in infrastructure, personnel, and supplies and equipment were identified. CONCLUSIONS The World Health Organization Tool for Situational Analysis of Emergency and Essential Surgical Care was useful in identifying baseline emergency and surgical conditions for evidenced-based planning. To achieve the Poverty Reduction Strategy and delivery of the Basic Package of Health and Social Welfare Services, additional resources and manpower are needed to improve surgical and anesthetic care.

Anesthesia Capacity in 22 Low and Middle Income Countries

Abstract Rising incomes, the spread of personal insurance, lifestyle factors adding to the burden of illness, ageing populations, globalization and skills transfer within the medical community have increased worldwide demand for organ transplantation. The Global Observatory on Donation and Transplantation, which was built in response to World Health Assembly resolution WHA57.18, has conducted ongoing documentation of global transplantation activities since 2007. In this paper, we use the Global Observatory’s data to describe the current distribution of – and trends in – transplantation activities and to evaluate the role of health systems factors and macroeconomics in the diffusion of transplantation technology. We then consider the implications of our results for health policies relating to organ donation and transplantation. Of the World Health Organization’s Member States, most now engage in organ transplantation and more than a third performed deceased donor transplantation in 2011. In general, the Member States that engage in organ transplantation have greater access to physician services and greater total health spending per capita than the Member States where organ transplantation is not performed. The provision of deceased donor transplantation was closely associated with high levels of gross national income per capita. There are several ways in which governments can support the ethical development of organ donation and transplantation programmes. Specifically, they can ensure that appropriate legislation, regulation and oversight are in place, and monitor donation and transplantation activities, practices and outcomes. Moreover, they can allocate resources towards the training of specialist physicians, surgeons and transplant coordinators, and implement a professional donor-procurement network.

International human xenotransplantation inventory

Objective: A high mortality rate is associated with anesthesia in low and middle income countries. The provision of basic and emergency surgical services in developing countries includes safe anesthetic care. We sought to determine the resources available to deliver anesthesia care in low and middle income countries. Methods: A standard World Health Organization tool was used to collect data from 34 Low and Middle-Income Countries (LMICs) regarding infrastructure and capacity of facilities. We then performed a database query to extract information on anesthesia-related capacity. Findings: Twelve countries were excluded for providing data on less than four facilities, leaving 22 countries in our results, with a total of 590 facilities surveyed. Thirty five percent of hospitals had no access to oxygen and 40% had no anaesthesia machines; despite this, 58.5% of hospitals offered general inhalational anesthesia. All facilities reported presence of an anaesthesia provider: a nurse or clinical assistant was present in all 590 facilities. Hospitals with > 200 beds reported a range of 2-10 providers; the average number of anesthesia physicians increased from one to four as the hospital size increased from less than to greater than 300 beds. The majority of facilities were district/rural/community hospitals (34.7%), followed by health centres (23.2%), private/NGO/missions hospitals (16.6%), provincial hospitals (11.7%), and general hospitals (13.1%). Conclusion: The delivery of anesthesia is limited by deficiencies in human resources, equipment availability and system capacity in many low and middle income countries.

2009 global data in organ donation and transplantation: activities, laws, and organization.

Background. Xenotransplantation carries inherent risks of infectious disease transmission to the recipient and even to society at large, and it should only be carried out with strict regulation and oversight. In collaboration with the International Xenotransplantation Association, the University Hospital Geneva, and the World Health Organization, an international inventory has been established (www.humanxenotransplant.org) aiming to collect basic data on all types of currently ongoing or recently performed xenotransplantation procedures in humans. Methods. We collected information from publications in scientific journals, presentations at international congresses, the internet, and declarations of International Xenotransplantation Association members on xenotransplantation procedures in humans performed during the past 15 years. Results. We identified a total of 29 human applications of xenotransplantation, including 7 that were currently ongoing. Procedures involved transplantation of xenogeneic cells, i.e., islets of Langerhans, kidney cells, chromaffin cells, embryonic stem cells, fetal and adult cells from various organs or extracorporeal perfusion using hepatocytes, liver, spleen, or kidney. The treatments were performed in 12 different countries, 9 of them having no national regulation on xenotransplantation. Conclusion. Several clinical applications of cell xenotransplantation are ongoing around the world, often without any clear governmental regulation. This information should be used to inform national health authorities, healthcare staff, and the public, with the objective of encouraging good practices, with internationally harmonized guidelines and regulation of xenotransplantation.