Journal of Clinical Apheresis 00:00–00 (2014)
Apheresis in Developing Countries Around the World Quentin Eichbaum,1* W. Martin Smid,2 Robert Crookes,3 Norris Naim,4 Alfredo Mendrone Jr.,5 Francisco Comenalli Marques Jr.,6 and Marisa B. Marques7 Jose 1
Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee 2 Department of Transfusion Medicine, Sanquin Blood Bank, Amsterdam, The Netherlands 3 Independent Transfusion Medicine Consultant, South Africa 4 Consultant Pathology (Haematology) and Quality Manager, National Blood Centre, Ministry of Health Malaysia, Kuala Lampur, Malaysia 5 ~o Pro -Sangue Hemocentro de Sa ~o Paulo, University of Sa ~o Paulo, Sa ~o Paulo, Brazil Fundac¸a 6 Blood Center of the State University of Campinas, Campinas, SP, Brazil 7 Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama At the combined American Society for Apheresis (ASFA) Annual Meeting/World Apheresis Association (WAA) Congress in San Francisco, California, in April of 2014, the opening session highlighted the status of apheresis outside of the United States. The organizers invited physicians active in apheresis in countries not usually represented at such international gatherings to give them a forum to share their experiences, challenges, and expectations in their respective countries with regard to both donor and therapeutic apheresis. Apheresis technology is expensive as well as technically and medically demanding, and low and median income countries have different experiences to share with the rest of the world. Apheresis procedures also require resources taken for granted in the developed world, such as reliable electrical power, that can be unpredictable in parts of the developing world. On the other hand, it was obvious that there are significant disparities in access to apheresis within the same country (such as in Brazil), as well as between neighboring nations in Africa and South America. A common trend in the presentations from Brazil, Indonesia, Malaysia, Nigeria, and South Africa, was the need for more and better physicians and practitioners’ training in the indications of the various apheresis modalities and patient oversight during the procedures. As ASFA and WAA continue to work together, and globalization allows for increased knowledge-sharing, improved access to apheresis procedures performed by qualified personnel with safety and high-quality standards will be increasingly available. J. Clin. Apheresis 00:000–000, C 2014 Wiley Periodicals, Inc. 2014. V Key words: Africa; South Africa; Malaysia; Brazil; donor apheresis; therapeutic apheresis
INTRODUCTION
“Apheresis Around the World” was the title of the opening plenary session of the 15th World Association for Apheresis (WAA) Congress at the American Society for Apheresis (ASFA) 2014 Annual Meeting. The session was intended to provide insight into the status of therapeutic and donor apheresis in low and middle income countries (LMICs). Apheresis conferences in the US and Europe have to date focused mostly on applications of this sophisticated technology in developed countries where the instrumentation has been implemented for some decades and the protocols generally well-defined. This conference session aimed at gaining an understanding of the status of apheresis technologies, methodologies, and quality assurance in developing countries. As technology and healthcare systems advance in the developing countries, the implementation of sustainable apheresis programs has become more feasible. Disease profiles in certain regions, such as malaria and sickle cell disease in Africa, as well as the alarming C 2014 Wiley Periodicals, Inc. V
increase in non-communicable diseases (NCDs) in these countries has also rendered apheresis an essential component of standard of care. Treatment of hematological malignancies through peripheral blood stem cell transplants is being increasingly within reach of health care practice in even some low income countries. Appropriate standardization, and quality control and assurance are, however, essential for effective and sustainable therapy. In LMICs, the affordability and cost-effectiveness of therapeutic and donor apheresis remains an important and pressing question requiring thoughtful analysis. The *Correspondence to: Quentin Eichbaum, Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Vanderbilt University Medical Center, TVC 4511C, Nashville, TN 37232-0242, USA. E-mail: [email protected] Received 27 September 2014; Accepted 30 September 2014 Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jca.21368
2
Eichbaum et al.
Fig. 1. Schematic of the Sanquin conceptualization of improvement and training in apheresis, demonstrating an iterative process of consecutive appropriate steps between the present situation and the desired future. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
sustainability of this complex technology in resourcelimited settings should also be carefully examined so that programs are not implemented without a long-term plan for supporting them financially and technologically. The introduction of new apheresis instruments and the “sun-setting” of older instruments also presents both financial and technical conundrums in such settings. The regions represented at the 2014 ASFA/WAA conference were: Africa (South Africa and Nigeria), South America (Brazil), and Southeast Asia (Indonesia and Malaysia). Learning from the countries in these regions provides useful insights into the status of apheresis in the developing world. In this article, we summarized the talks given by panelists on donor and/or therapeutic apheresis from South Africa, Malaysia, and Brazil. Drs. Triyono and Vrielink submitted the apheresis experience in Indonesia as a separate manuscript [1]. Funding and Training for Apheresis
The development of the need for apheresis in Southeast Asia, South America, and Africa follows the economic growth in these countries. Health care strengthening becomes a possibility as a result of economic improvement and with funding increasingly available, apheresis instruments and equipment have become affordable. However, funding is essential but not sufficient. Without appropriate knowledge, no procedure can be safely performed, which implies that appropriate training and education are paramount. In Southeast Asia and South America, such training needs and requests for training have been defined, while in Sub-Saharan Africa (outside of South Africa) such requests have recently increased. Sanquin Blood Bank, in The Netherlands, through its Consulting Services department is active in knowledge transfer in the field of the blood transfusion chain. In Sanquin’s experience, it is important to consider differences in circumstances for the application and transfer of available knowledge to other countries. Journal of Clinical Apheresis DOI 10.1002/jca
In general, the “picture of the desired future” is evident to the stakeholders and not substantially different between countries. The best way to arrive at such a desired future is through the accurate assessment of the present situation. With the end in mind, the appropriate next step for improvement can often be identified through optimal cooperation between trainee and trainer. In essence, solutions chosen in one country may not fit circumstances in another. This may be especially true when LMICs are compared with high-income countries. The educational program will help define the appropriate and required solutions that fit local challenges. This approach can be repeated during the process of ongoing and iterative improvement (Fig. 1). In Sanquin’s experience, an important factor for successful training was that the request originated from the country where the training was needed. A modular training program was designed with support of the European Society for Haemapheresis and Haemotherapy (ESFH) and Sanquin [2]. This basic program was adapted to the local situation and included a train-the-trainer program in order to gain sustainable knowledge transfer. According to Blumberg’s revised taxonomy of knowledge, there are six levels of cognitive processing in knowledge acquisition: remember, understand, apply, analyze, evaluate, and create [3]. For executing apheresis procedures, “apply” and “analyze” are considered the minimum level. In education and training efforts, this level requires interactive teaching. An approach to apheresis instruction in developing countries would do well to be cognizant of emerging findings in education and training to ensure that efforts on both sides of the interaction are optimized. This approach should lead to implementation of best practices that are also cost-effective and sustainable in resource-challenged settings. DONOR APHERESIS IN AFRICA
Apheresis technology currently plays a vital role in the provision of blood components and plasma derivatives in a limited number of African countries. There is vast potential for the use of this technology across the Continent, however, in each region, its application needs to be critically assessed in the context of the clinical need for blood products and available resources. Many countries in Africa do not have basic blood transfusion services and, as emphasized by the World Health Organization (WHO), establishing sustainable such services and implementing voluntary, nonremunerated whole blood donor programs remains a priority in Africa [4]. The primary rationale for using apheresis technology varies in different geographical regions. Table I broadly illustrates the extent of current donor apheresis practice in a few African countries.
Apheresis Around the World TABLE I. Extent of Donor Apheresis Practice across Africa
Country Algeria Botswana Egypt Eritrea Ghana
Present; approximate number of apheresis platelet collections per year 9,000 150 21,500 0 0
Kenya
0
Lesotho
0
Libya Morocco Mauritius Namibia Nigeria South Africa Sudan Swaziland
Uganda
Zambia Zimbabwe
3,000
Apheresis in Developing Countries Around the World Quentin Eichbaum,1* W. Martin Smid,2 Robert Crookes,3 Norris Naim,4 Alfredo Mendrone Jr.,5 Francisco Comenalli Marques Jr.,6 and Marisa B. Marques7 Jose 1
Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee 2 Department of Transfusion Medicine, Sanquin Blood Bank, Amsterdam, The Netherlands 3 Independent Transfusion Medicine Consultant, South Africa 4 Consultant Pathology (Haematology) and Quality Manager, National Blood Centre, Ministry of Health Malaysia, Kuala Lampur, Malaysia 5 ~o Pro -Sangue Hemocentro de Sa ~o Paulo, University of Sa ~o Paulo, Sa ~o Paulo, Brazil Fundac¸a 6 Blood Center of the State University of Campinas, Campinas, SP, Brazil 7 Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama At the combined American Society for Apheresis (ASFA) Annual Meeting/World Apheresis Association (WAA) Congress in San Francisco, California, in April of 2014, the opening session highlighted the status of apheresis outside of the United States. The organizers invited physicians active in apheresis in countries not usually represented at such international gatherings to give them a forum to share their experiences, challenges, and expectations in their respective countries with regard to both donor and therapeutic apheresis. Apheresis technology is expensive as well as technically and medically demanding, and low and median income countries have different experiences to share with the rest of the world. Apheresis procedures also require resources taken for granted in the developed world, such as reliable electrical power, that can be unpredictable in parts of the developing world. On the other hand, it was obvious that there are significant disparities in access to apheresis within the same country (such as in Brazil), as well as between neighboring nations in Africa and South America. A common trend in the presentations from Brazil, Indonesia, Malaysia, Nigeria, and South Africa, was the need for more and better physicians and practitioners’ training in the indications of the various apheresis modalities and patient oversight during the procedures. As ASFA and WAA continue to work together, and globalization allows for increased knowledge-sharing, improved access to apheresis procedures performed by qualified personnel with safety and high-quality standards will be increasingly available. J. Clin. Apheresis 00:000–000, C 2014 Wiley Periodicals, Inc. 2014. V Key words: Africa; South Africa; Malaysia; Brazil; donor apheresis; therapeutic apheresis
INTRODUCTION
“Apheresis Around the World” was the title of the opening plenary session of the 15th World Association for Apheresis (WAA) Congress at the American Society for Apheresis (ASFA) 2014 Annual Meeting. The session was intended to provide insight into the status of therapeutic and donor apheresis in low and middle income countries (LMICs). Apheresis conferences in the US and Europe have to date focused mostly on applications of this sophisticated technology in developed countries where the instrumentation has been implemented for some decades and the protocols generally well-defined. This conference session aimed at gaining an understanding of the status of apheresis technologies, methodologies, and quality assurance in developing countries. As technology and healthcare systems advance in the developing countries, the implementation of sustainable apheresis programs has become more feasible. Disease profiles in certain regions, such as malaria and sickle cell disease in Africa, as well as the alarming C 2014 Wiley Periodicals, Inc. V
increase in non-communicable diseases (NCDs) in these countries has also rendered apheresis an essential component of standard of care. Treatment of hematological malignancies through peripheral blood stem cell transplants is being increasingly within reach of health care practice in even some low income countries. Appropriate standardization, and quality control and assurance are, however, essential for effective and sustainable therapy. In LMICs, the affordability and cost-effectiveness of therapeutic and donor apheresis remains an important and pressing question requiring thoughtful analysis. The *Correspondence to: Quentin Eichbaum, Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Vanderbilt University Medical Center, TVC 4511C, Nashville, TN 37232-0242, USA. E-mail: [email protected] Received 27 September 2014; Accepted 30 September 2014 Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jca.21368
2
Eichbaum et al.
Fig. 1. Schematic of the Sanquin conceptualization of improvement and training in apheresis, demonstrating an iterative process of consecutive appropriate steps between the present situation and the desired future. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
sustainability of this complex technology in resourcelimited settings should also be carefully examined so that programs are not implemented without a long-term plan for supporting them financially and technologically. The introduction of new apheresis instruments and the “sun-setting” of older instruments also presents both financial and technical conundrums in such settings. The regions represented at the 2014 ASFA/WAA conference were: Africa (South Africa and Nigeria), South America (Brazil), and Southeast Asia (Indonesia and Malaysia). Learning from the countries in these regions provides useful insights into the status of apheresis in the developing world. In this article, we summarized the talks given by panelists on donor and/or therapeutic apheresis from South Africa, Malaysia, and Brazil. Drs. Triyono and Vrielink submitted the apheresis experience in Indonesia as a separate manuscript [1]. Funding and Training for Apheresis
The development of the need for apheresis in Southeast Asia, South America, and Africa follows the economic growth in these countries. Health care strengthening becomes a possibility as a result of economic improvement and with funding increasingly available, apheresis instruments and equipment have become affordable. However, funding is essential but not sufficient. Without appropriate knowledge, no procedure can be safely performed, which implies that appropriate training and education are paramount. In Southeast Asia and South America, such training needs and requests for training have been defined, while in Sub-Saharan Africa (outside of South Africa) such requests have recently increased. Sanquin Blood Bank, in The Netherlands, through its Consulting Services department is active in knowledge transfer in the field of the blood transfusion chain. In Sanquin’s experience, it is important to consider differences in circumstances for the application and transfer of available knowledge to other countries. Journal of Clinical Apheresis DOI 10.1002/jca
In general, the “picture of the desired future” is evident to the stakeholders and not substantially different between countries. The best way to arrive at such a desired future is through the accurate assessment of the present situation. With the end in mind, the appropriate next step for improvement can often be identified through optimal cooperation between trainee and trainer. In essence, solutions chosen in one country may not fit circumstances in another. This may be especially true when LMICs are compared with high-income countries. The educational program will help define the appropriate and required solutions that fit local challenges. This approach can be repeated during the process of ongoing and iterative improvement (Fig. 1). In Sanquin’s experience, an important factor for successful training was that the request originated from the country where the training was needed. A modular training program was designed with support of the European Society for Haemapheresis and Haemotherapy (ESFH) and Sanquin [2]. This basic program was adapted to the local situation and included a train-the-trainer program in order to gain sustainable knowledge transfer. According to Blumberg’s revised taxonomy of knowledge, there are six levels of cognitive processing in knowledge acquisition: remember, understand, apply, analyze, evaluate, and create [3]. For executing apheresis procedures, “apply” and “analyze” are considered the minimum level. In education and training efforts, this level requires interactive teaching. An approach to apheresis instruction in developing countries would do well to be cognizant of emerging findings in education and training to ensure that efforts on both sides of the interaction are optimized. This approach should lead to implementation of best practices that are also cost-effective and sustainable in resource-challenged settings. DONOR APHERESIS IN AFRICA
Apheresis technology currently plays a vital role in the provision of blood components and plasma derivatives in a limited number of African countries. There is vast potential for the use of this technology across the Continent, however, in each region, its application needs to be critically assessed in the context of the clinical need for blood products and available resources. Many countries in Africa do not have basic blood transfusion services and, as emphasized by the World Health Organization (WHO), establishing sustainable such services and implementing voluntary, nonremunerated whole blood donor programs remains a priority in Africa [4]. The primary rationale for using apheresis technology varies in different geographical regions. Table I broadly illustrates the extent of current donor apheresis practice in a few African countries.
Apheresis Around the World TABLE I. Extent of Donor Apheresis Practice across Africa
Country Algeria Botswana Egypt Eritrea Ghana
Present; approximate number of apheresis platelet collections per year 9,000 150 21,500 0 0
Kenya
0
Lesotho
0
Libya Morocco Mauritius Namibia Nigeria South Africa Sudan Swaziland
Uganda
Zambia Zimbabwe
3,000
