Challenges in Laboratory Haematology: Perspective from Pakistan Dr Saleem Ahmed Khan MBBS, MCPS, FCPS, FRCP, PhD Consultant Haematologist & Principal Army Medical College Rawalpindi
INDIA
Indus Valley Civilization 3
4
Northern Areas Climbers Paradise 5
Women Contribution
Indicator Pakistan Demographic Statistics Details Total Population (Census 2017 est) Gender Ratio (2016 est) Per Capita income (US$ - 2016 est) 207 million approximate 1.06 male(s)/female $ 1629 / yr Literacy Rate (total population 2016 est) 57. 9% Crude Birth Rate (2017 est) 21.9 / 1000 Crude Death Rate (2017 est) 6.3 / 1000 Life expectancy total population (2017 est) 68.1 yrs
Total Expenditure on Health as % of GDP 2016 2017 0.46% Global Health Expenditure Database (2016) http://www.who.int/health-accounts/en/
Contributors in Health Expenditure 1% Private House Hold, Out of Pocket Expenditure 4% 1% Local NGOs & Insurance 3% Official Donor Agencies 24% Federal (Civ) & Provincial Govt 1% 6% 60% Military Health Exp District/ Tehsil Govt Social Security Funds Autonomous Bodies / Corporations GoP (2016). Pakistan national Health Accounts 2013-14. S. Bureau. Islamabad.
Health Care System Pakistan Federal Govt Policy making National Programmes Provincial Govt Implementation of Healthcare system
Health Care Delivery System Pakistan
Health Care System Organization Tertiary Care Facilities (Teaching Hospitals) Secondary Care Facilities (THQ, DHQ Hospitals) Primary Care facilities (Basic Health Units, Rural health Centres)
Health Facilities in Pakistan FACILITIES Total Number Number /population Hospitals (secondary and tertiary care) 1,205 1 per 167,110 Total Hospital Beds 122,769 1 per 1,592 Dispensaries 5,802 1 per 35,677 Basic Health Units 5,518 1 per 36,371 Maternal Child Health centres 731 1 per 137,351 females Source: Pakistan Bureau of statistics 2016
Manpower in Public Health Sector Healthcare manpower Numbers Registered Doctors Registered Dentists Registered Nurses 195,896 (1 per 997) 18,333 (1 per 10,658) 99,228 (1 per 2100) Source: Pakistan Bureau of statistics 2016
BURDEN OF HAEMATOLOGICAL DISORDERS
Abnormal Haemoglobins in Pakistan T. Major (89%) Hb-S/Thal (3.5%) Hb-S/S (2.0%) Hb-E/Thal (3.5%) Hb-E/E (2.0%) (S. Ahmed 1998)
Thalassemia in Pakistan Thalassemia carriers Total Carriers 5% population 8 million Thalassemia births/year 5,000 6,000 Thalassemia Major prevalence 60,000 Only 4% national health budget goes to thalassemia care Thalassemia is the main donated blood consumer Lawrence Faulkner. 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias Limassol, 24 26 October 2012
Thalassemia Survival in Pakistan 120 100 80 60 40 1996 2006 20 0 2 4 6 8 10 12 14 16 18 20 22 24 25 1996: data from HBB Karachi, 2006: data from BTIHS, Karachi
Index Families 183/591 (31%) Control Families 0/397 (0%) General Population (5%) (S. Ahmed et al, 2002)
(S. Ahmed et al, 2002) Carrier Screening
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Prenatal Diagnosis 1600 1400 1200 1000 800 600 400 200 0 (S. Ahmed, 2018)
Impediments to PND Religious belifs 9% Did not know 23% Advised against 12% Expensive 23% Delay in seeking 16% No access 17% (S. Naseem, 2008)
Can prevention succeed in Pakistan? Re-organize the resources Adopt a uniform policy Prenatal Diagnosis and carrier screening Legislation for premarital screening Aggressive campaign Mark the starting point Role of NGOs
Aplastic Anaemia (AA) Wide variation in prevalence of AA worldwide Three times more common in Pakistan than the western world Affected patients of AA are much younger Increased incidence in rural areas and low socioeconomical group Genetic factors, chemicals (Arsenic & Benzene), environmental factors (Pesticides) Mostly present as severe or very severe AA
Aplastic anemia in Pakistan CATCHMENT AREA (n=1324) AFBMTC DATA
Bleeding Disorders in Pakistan Pakistan Haemophilia Patients Welfare Society Rwp/Isbd Chapter Total Patients summary (20/02/2018) Total Patients 983 Males 822 Females 161 Males = 822 Females = 161 Sr.# Factor/Disease No. of Patients Factor/Disease No. of Patients 1 FVIII 554 VWD 85 2 FIX 107 G.T 34 3 VWD 73 FVII 5 4 G.T 24 FX 7 5 FVII 16 FV 9 6 FX 5 FXIII 4 7 FV 9 B.S 1 8 FXIII 9 SPD 1 9 B.S 1 F1 1 10 SPD 1 Un Diagnosed 13 11 Un Diagnosed 23 FIX 1 12 Total 822 Total 161 Source: AFIP, PHPWS
Malaria 8.6 / 100,000 population at risk Plasmodium vivax Plasmodium falciparum Reported confirmed cases Health facilities (2016 est) = 318,449 (Pv= 79%, Pf = 21%) http://www.who.int/malaria/publications/country-profiles/profile_pak_en.pdf?ua=1
Top 10 malignancies in Pakistan at SKMCH&RC (1994-2016) All ages, both genders S.No ICD Category Count Percentage 1. Breast 16790 21.37 2. Leukemia 4802 6.11 3. Lip and oral cavity 4435 5.65 4. Non-Hodgkin lymphoma 4348 5.54 5. Colon, rectum, anal canal and anus 3993 5.08 6. Hodgkin lymphoma 3434 4.37 7. Liver and intrahepatic bile duct 3261 4.15 8. Prostate 2715 3.46 9. Trachea, bronchus & lung 2381 3.03 10. Brain 2357 3.00
Organization of Laboratory Service Lab is an integral part of each public and private sector hospital There are many stand alone laboratories of variable capability Few large private labs with their collection centers through out the country Smaller labs are supervised by clinical pathologist Larger or referral labs have all subspecialties of pathology including haematology
Anemia / Thalassemia Blood Transfusion Leukaemias / Lymphomas Hematology Flowcytometry Bleeding Disorders Molecular Analysis Cytogenetics
Existing Haematology Facilities PUBLIC Non existent at primary & secondary care hospitals Haematology diagnostic facilities at some tertiary care hospitals A few stand alone haematology specialty centers Armed Forces diagnostic centers PRIVATE Not more than a dozen for a population of 207 M Concentrated in main cities only Cost
Major Referral Haematology Centers
Haematology Training Undergraduate Part of the curriculum of Pathology in 4 th year Part of the curriculum of Medicine in Final year Rotation to laboratory and blood transfusion facility
Haematology Training (Contd) Postgraduate College of physicians and surgeons Pakistan (CP&SP) Fellowship in Haematology 30 centers recognized for training Fellowship in Clinical Haematology
Haematology Training (Contd) Fellowship in Haematology A four year programme Rotational training in diagnostic haematology, cytogenetics, molecular haematology, flow cytometery and blood transfusion Accepted in Gulf countries if their respective licensing exams are qualified Accredited by Saudi Council of Health Sciences in April 2012
Haematology Training (Contd) M.Phil in Haematology It is a 2 years programme (1 year course work and 1 year research work) PhD in Haematology It is a 4 years programme (2 years course work and 2 years research work)
Haematologist Data Qualified FCPS 325 M.Phil 150 FRC-Path 12 Ph.D 09 American Board 06 Under Training FCPS 375 M.Phil 45 Ph.D 17
Medical Technologist Data BSc MLT (Haematology and Immunohaematology) 50 Master in Laboratory Science (MLS Haematotechnology) 10 PhD 02 Medical Technologist Trainee Data BSc MLT 15 MLS 07 PhD 01
Haematology Training LEVEL Post graduate M. Phil FCPS PhD Lab Technologist BSc MLS PhD ISSUES Curriculum issue Training Institutes Training slots Training facilities Employment
Challenges in Lab Haematology Haematology facilities and centers are far less considering the population (207 M) Limited health budget and resources Shortage of equipment and trained staff Capacity building and training Quality assurance and lab accreditation Carrier progression and foreign courses for young haematologist and technologist
Blood Transfusion Service BT Sector in Pakistan was quite fragmented and disorganized It was not guided by national standards or overseen by regulatory authorities or a national program The system s backbone were multifunctional hospital blood banks, complemented by an ever increasing number of private blood banks Estimated number of blood centers in Pakistan is more than 1800 Annual blood collection is estimated to be approximately 3.5 million units Overwhelming reliance is on replacement donors
Safe Blood Transfusion Program In 2008, Govt initiated blood safety systems reforms with the support of the German government to replace the fragmented BTS with centrally coordinated blood transfusion services National Health Policy National Blood Policy National Strategic Framework National Steering Committee Safe Blood Transfusion Law Blood Transfusion Authorities Blood Transfusion Programs Blood safety included as a priority area Proposed establishing a Nat. Blood Transfusion Service Highlighted fundamental principles & reforms areas Strategic body to review reform implementation Legislation reviewed and revised Established at the federal & provincial levels Project established at national & provincial levels
Safe Blood Transfusion Program Phase 1 2010 2016 It is based on the centralized model consisting of Regional Blood Centers (RBCs) - Collecting, processing, testing, storing and distributing blood Hospital Blood Banks (HBB) - Storing and issuing blood In Phase I, 10 RBCs and 60 affiliated HBBs completed constructed/refurbished (cover 15% of the blood demand) along with associated technical work.
Voluntary Blood Donations National Blood Donor Policy developed in 2012 National Strategy is: Strengthening of University based BDOs Conversion of Replacement Donors to VNRBD General awareness abut blood safety Resource constraints hampering optimum promotion of VNRBD.
World Blood Donor Day National Celebrations
Safe Blood Transfusion Program - Phase II 2016-2019 In Phase II, the scope and coverage will be expanded, additional infrastructure will be created to further expand the RBCs-HBBs network in the country In addition to building more RBCs, large existing public sector HBBs will be upgraded to RBCs and support provided to large NGOs. Reputable private sector BBs will also be co-opted as Collaborating RBCs and technical assistance provided to adapt them to assume their new role. By 2019, about 50 % BT coverage will be through the new system
Blood Transfusion Services Pakistan - Challenges Key issue remains lack of governance and will Quality assurance and validation of blood banks Deficiency of trained specialists and technologists in BTS Capacity building and training VNRBD promotion needs to be geared up as the project infrastructure has now become operational The system has improved in last decade but still largely unregulated and unsafe with serious consequences for the public
The Way Forward Needs gap analysis in all aspects of hematology services Development of National Haematology Task Force Provision of adequate budget Disease prevention program Recommend optimum equipment Manning level of lab facilities and training Public private partnership Policy for lab/blood bank licensing, regulation, inspection and accreditation
Pakistan Society of Haematology (PSH) Established in 1991 Aims and Objectives To promote the advancement of Haematology, including transfusion medicine, through encouragement of research, improvement of technical methods and affiliation with other national and international organizations To provide a forum for persons practicing Haematology and transfusion medicine to discuss problems and to formulate and present agreed viewpoint at national and international forum To offer guidance and training to technologists and residents in order to improve their skills To coordinate and standardize the practice of Haematology through expert committees