Improving Donation Rates in Taiwan

Abstract

In traditional Asian societies, sociocultural beliefs are frequently not supportive of procuring organs from deceased donors. Therefore, donor rates are frequently lower than those in Western countries.1-4 Although many Asian regions are comprised of developing countries, economically more prosperous countries including Taiwan, Japan, or South Korea have established a more solid network for organ donation. Taiwan may be considered as a model among Asian countries with high deceased donor rates, a supportive legislation and active educational plrograms.5 Since 1987, policies and education in Taiwan have yielded steadily growing organ donor rates. We submit that the successful deceased donation program in Taiwan may also help to support organ donation in other areas of Asia. REGULATING DECEASED ORGAN DONATIONS In June 1987, the Human Organ Transplantation Act came into effect in Taiwan as the first Asian law regulating organ transplants. At the same time, Guidelines for the determination of Brain Death were instituted.5,6 These laws comprehensively address ethical, legal, and organizational aspects of organ donation while providing guidelines for the determination of brain death. The World Health Organization Guiding Principles explicitly state that equity and transparency are crucial for an effective organ donation and transplantation system.7 In 2002, the Taiwan Organ Registry and Sharing Center (TORSC) has been established, charged to coordinate organ donation and allocation while organizing educational and outreach activities. The legal framework governing Transplantation and Allocation of Human Organs has been implemented in 2014, stipulating that waitlisted candidates will be prioritized if a close (first to third degree) family member had previously donated an organ. Numbers of Transplant Programs To provide maximal efficiency in organ allocation, the Ministry of Health and Welfare assigned all 36 transplant hospitals in Taiwan to 4 organ procurement and transplantation networks. Currently, kidney, liver, and heart transplantations are performed in 36, 25, and 17 hospitals, respectively; lung, pancreas, and small bowel transplants are approved in 8, 5, and 2 hospitals, respectively. Kidney transplant volumes range in average from 0.2 to 31.9 per transplant/year/hospital. Data Systems and Overall Transplant Volume To improve efficiency, the TORSC implemented a computer-based organ donation and matching system in 2005. This system allocates organs based on criteria that include medical urgency, waiting time, compatibility and other aspects. Each organ type has its individual allocation protocol. Allocation of kidneys, for example, is based on a medical estimated point system considering HLA compatibility, waiting time, and recipient age; liver allocation is based upon a model for end-stage liver disease-based system and medical urgency with a preference provided for pediatric recipients. Cardiothoracic organs are allocated on medical urgency, severity of illness, and progression of the underlying condition. Clearly, measures set in place have improved both, living and deceased donation rates (Figures 1, 2). Moreover, Taiwanese seeking transplants outside of the country have steadily declined.FIGURE 1: Transplant activities in Taiwan 2005 to 2015: A, Overall transplant volume. B, Living and deceased donor renal transplants. C, Living and deceased donor liver transplants. D, Renal transplants performed abroad.FIGURE 2: Annual donation rates 2005 to 2015: A, Annual deceased organ donor rates/million pp and absolute numbers of deceased organs donors. B, Annual living donor rates/million pp and absolute numbers of living donors.The number of living organ donors has steadily increased (from 157 in 2005 to 589 in 2015, Figure 2) with physicians emphasizing on the advantages of living donor kidney and liver transplants.8 Of particular relevance, the number of deceased donor organs increased markedly from 154 in 2005 to 256 in 2015. At the same time, deceased donors/per million population (pmp) have increased steadily from 6.7 in 2005 to 10.9 in 2015. Barriers to Living/Deceased Donation Taiwanese donor families often worry about the donor's well-being in the afterlife with disfigurations of the donor's body when procuring organs; religious beliefs influence the decision of the next of kin greatly.3 Fortunately, a major Taiwanese Buddhist organization, Tzu Chi, and most religious leaders encourage deceased organ donations as a life-giving approach. Nevertheless, a reluctance in the overall societal acceptance of organ donation remains. As a response, the TORSC and transplantation hospitals have supported early educational activities in schools and communicate the advantages of organ donations through social media, such as Facebook and Youtube, with a particular focus on addressing the younger generation. Significant Achievements and Challenges Taiwan has succeeded in steadily increasing rates of organ donation through effective legal frameworks, education, and public relations. Although there is room for further improvement, our deceased donation rate of 10.9 pmp has been the highest in Asia in 2015. At the same time, the overall public reception remains very sensitive: although an accidental transmission of human immunodeficiency virus (HIV)-infected organs in 2011 reduced the support of donation, the deceased donation of a well recognized attending physician and a medical student who were victims of an accident set a positive public example. Based on principles of equity, infectious diseases are not a contraindication to receive organs in Taiwan. In the early days of the HIV epidemic in Taiwan, HIV-infected patients had not been considered for transplantation. However, in early 2016, the Taiwan government changed this approach and included HIV-infected patients as recipients of deceased donor organs.9 Moreover, a paired kidney exchange is expected to be enacted in 2016.10 Summary Continuing improvements to Taiwanese health policies and public education have resulted in steadily rising organ donor rates. Following the example of Israel,4 Taiwan's organ allocation legislation stipulates that candidates will be prioritized if a family member had donated an organ. Moreover, Taiwan has revised the Human Organ Transplantation Act to define purchasing human organs as criminal, independently if a purchased organ is transplanted in or outside of the country. Moving forward, the Taiwan government will continue to focus on establishing a culture of deceased donor donation with the hope that this initiative will spread throughout Asia.