Regional Perspective
2015; Wolters Kluwer; Volume: 99; Issue: 9 Linguagem: Inglês
10.1097/tp.0000000000000895
ISSN1534-6080
AutoresR. Matesanz, Carlos Soratti, Ma Dolores Pérez-Rosales,
ResumoBased on historical, cultural, and linguistic similarities, international cooperation between Iberoamerican countries (Portuguese and Spanish speaking nations of the Americas and Europe) have expanded over the years. The proposal for creating an Iberoamerican Network/Council on Donation and Transplantation (Red/Consejo Iberoamericano de Donación y Trasplante [RCIDT]) was approved during the 7th Iberoamerican Conference of Health Ministers which took place in Granada (Spain) in September 2005, and subsequently endorsed at the 15th Summit of Heads of States and Governments held in Salamanca (Spain).1 The RCIDT aims at promoting collaborations in legislative and organizational aspects, professional training, in addition to ethical and social features of organ, tissue, and cell donation and transplantation. The network is composed of 21 Spanish- and Portuguese-speaking countries with representatives officially designated by the corresponding Ministries of Health, with the support of the Pan American Health Organization (PAHO). The project is funded by the Spanish Agency of Cooperation and Development; the Spanish National Transplant Organization (Organización Nacional de Trasplantes) holds the permanent secretariat. Since its inaugural meeting in Mar de Plata (Argentina, 2005), RCIDT has held 14 meetings on an annual or biannual basis. During its founding years, the RCIDT tackled many different challenges. Health care systems were usually fragmented, with an important presence of the private sector covering predominantly live donor transplantation activities. Deceased donation on the other hand had mainly been developed in the public sector with limited resources for transplant activities. Political instability and lack of leadership by Health Authorities were crude realities, and transplantation had not been included in the political agenda within the region. Transplant legislations did not exist in many countries. The majority of participating countries did not have a national transplant agency and, should it exist, it was frequently separate from the Ministry of Health. Overall, systems were unstructured, with an urgent need for training of donor coordinators, transplant professionals, and tissue bankers. REGULATORY GUIDANCE AND DEVELOPMENT Over the years, a series of recommendations have been produced and adopted by the RCIDT (Table 1).2 Although not legally binding, these documents compose a regulatory body of references that inspired: (i) national legislations in transplantation that were newly enacted in several countries, (ii) common ethical approaches to regional problems, (iii) the organization of donation and transplantation networks, and (iv) professional guidelines and standards.TABLE 1: Resolutions, Recommendations, and Other Standards Developed by the RCIDT Since Its CreationInspired by internationally recognized legal standards developed by the World Health Organization, the Council of Europe and the Declaration of Istanbul on Organ Trafficking and Transplant Tourism, the RCIDT has also implemented a framework of ethical principles guiding the practices of donation and transplantation in Iberoamerica.3-6 These core principles cover aspects, such as altruistic donation, justice, respect for the dignity and autonomy of the human being, in addition to equity in organ donation and allocation.7 Subsequently, a declaration against transplant tourism in all regions has been developed.8 ORGANIZING STRUCTURES FOR DONATION, TRANSPLANTATION SYSTEMS, AND PROFESSIONAL TRAINING National Transplant Organizations that are linked to the Ministries of Health representing governmental responsibility have been implemented in a series of countries that lacked this structure (e.g., Brazil, Chile, Costa Rica, or Panama); in other countries, similar organizations have been restructured or reactivated.9 Implemented donation and procurement systems have predominantly followed the organizational features of the Spanish model with key roles for in-house donor coordinators that have intensive care medicine as their professional background.10 At the same time, other models have been built, structured on a network of Organ Procurement Organizations; in other countries, mixed models have been established to meet regional needs. Professional training has been effectively addressed through different initiatives. Through the Alianza Master Program, 344 professionals from Iberoamerican countries have been trained as donor transplant coordinators since 2005 based on the Spanish model exemplifying a productive collaborative approach (Figure 1). Moreover, additional training courses covering aspects of transplant coordination, deceased donation and transplantation, and the communication of emotionally sensitive news have been offered in participating countries; sessions also included modules of training for future trainers. Finally, courses focusing on quality and safety in the management of tissue banks have been offered.FIGURE 1: Number of professionals/country trained as donor transplant coordinators in the Alianza Master during the years 2005 to 2014.ADDRESSING ORGAN TRAFFICKING AND OTHER TRANSPLANT RELATED CRIMES Transplant tourism, misleading advertisement, and transplant commercialism in several Iberoamerican countries were first addressed at the meeting in La Habana (Cuba, 2008). Discussions at the meeting led to the development of a specific Declaration against Transplant Tourism, calling national authorities into action with legislative and enforcement measures to curtail transplant tourism while offering support to authorities, public and private institutions to identify those promoting and participating in these activities.11 Self-sufficiency in transplantation was established as the paradigm by which citizens should have access to the desired therapy. At the same time, regional and cooperative agreements between countries were established based on equity and solidarity. The Declaration is being effectively implemented by the RCIDT, as made evident by the case of Colombia where the government has taken action to prosecute and prevent transplant tourism. Supported by the RCIDT, the Colombian government embarked on an amendment to the legislation in place, by which transplantation to non-residents was limited to exceptional circumstances under the approval of the National Institute of Health.11 A recent Supreme Court Verdict demonstrates the effective enforcement of the amended legislation.12 Of note, while 16.5% of all transplants in 2005 went to non-residents, declining to 0.3% in 2013.13,14 Moreover, representatives at the RCIDT from Costa Rica and Peru played key roles in the investigation of local practices consistent with organ trafficking.15,16 OTHER ACTIVITIES A centralized acquisition of immunosuppressants for countries in Iberoamerica has been implemented through the PAHO by the Strategic Fund. This initiative resulted into significant savings. A combined initiative by RCIDT, the Latin-American Association of Tissue Banks (Asociación Latinoamericana de Banco de Tejidos) and PAHO helped implementing the Latin-American Network of Skin Banks providing support in case of major disasters. International organizations including the Council of Europe, PAHO, professional societies, such as Latinamerican Association of Tissue Banks (Asociación Latinoamericana de Banco de Tejidos), Iberoamerican Society of Transplant Coordinators (Sociedad Iberoamericana de Coordinadores de Trasplante), The Transplantation Society, Transplant Society of Latin America, and the Caribbean (Sociedad de Trasplante de América Latina y El Caribe), and the Declaration of Istanbul Custodian Group are participating as observers in activities of the RCIDT. Other bilateral and subregional agreements and conventions such as the Intergovernmental Commission on Donation and Transplantation of the MERCOSUR (2006) have been established. CONCLUSIONS With the help and support of RCIDT, National Transplant Organizations have been structured and organized as entities under regional Health Authorities in Iberoamerica. Training activities for donor coordinators have been consolidated. In close cooperation with professional societies, initiatives are being developed to harmonize criteria that are aligned with international standards on a wide number of aspects including the diagnosis of brain death and the evaluation of organ donors. As a result, RCIDT has become a reference for the development of transplant programs in the region. Moreover, RCIDT has become an inspirational model of international cooperation that the World Health Organization is aiming to implement in other regions of the world. In parallel to those initiatives, deceased donation and transplantation activities are progressively increasing in Iberoamerica (Figure 2) and the number of deceased organ donors has increased by an average 52% since the network was founded in 2005.FIGURE 2: Evolution of deceased donation, kidney and liver transplantation activities in countries represented at the RCIDT from 2005 to 2013. Countries included: Argentina, Brazil, Bolivia, Chile, Colombia, Costa Rica, Ecuador, Guatemala, Mexico, Panama, Paraguay, Peru, Dominican Republic, Uruguay, and Venezuela.ACKNOWLEDGMENTS The Red/Consejo Iberoamericano de Donación y Trasplante includes Silvia Marisol Paz Zambrana (Bolivia), Heder Murari Borba (Brazil), José Luis Rojas (Chile), María Angélica Salinas Nova (Colombia), Cesar Augusto Gamboa Peñaranda (Costa Rica), Antonio Enamorado (Cuba), Fernando Raúl Morales Billini (Dominican Republic), Diana Almeida Ubidia (Ecuador), Eduardo Manrique Rodríguez Loza (El Salvador), Rudolf García-Gallont (Guatemala), Claudia Aguilar Ponca (Honduras), Salvador Aburto Morales (Mexico), Tulio René Mendieta Alonso (Nicaragua), Cesar Jeremías Cuero Zambrano (Panama), Hugo A. Espinoza (Paraguay), Cesar Augusto Flower Peroné (Peru), Ana Franca (Portugal), Eduardo Martín Escobar and Beatriz Domínguez-Gil (Spain), and Inés Alvarez Saldias (Uruguay), Nelson Hernández (Venezuela). Raúl Mizraji (Sociedad Iberoamericana de Coordinadores de Trasplante [SICT]), Alejandro Niño Murcia (Sociedad de Trasplante de América Latina y El Caribe [STALYC]), José Navas (Asociación Latinoamericana de Banco de Tejidos - ALABAT), Francis L. Delmonico (The Transplantation Society [TTS] & Custodian Group of the Declaration of Istanbul on Organ Trafficking and Transplant tourism).
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