TRINIDAD AND TOBAGO
Trinidad and Tobago (T&T) is an Archipelagic nation with 2 main islands—5128 and 300 km2—in addition to 21 smaller located in the southern Caribbean Sea (Figure 1). The country gained Independence from British colonial rule in 1962 and adopted a Republican constitution in 1976. The population of 1.3639 million is multi-ethnic and multi-religious.1 Life expectancy at birth is 73.4 years.2 The main official language is English with Spanish as the second idiom. The Gross Domestic Product at Purchasing Power Parity is $45.6 billion Intl. $ - ranking 18th in the 33 countries of the Latin America and Caribbean Region and first among the English-speaking Caribbean island states. Gross Domestic Product at Purchasing Power Parity per capita is $33 026 Intl $, which ranks second for the entire Latin America and Caribbean Region.3 The public healthcare system is administered via 8 public hospitals.
The first living donor kidney transplant was done at the public hospital San Fernando General Hospital in 1988 by a pioneering surgical team which performed 3 further transplants that week. Until 1991, additional renal transplants were performed at both, Port of Spain and San Fernando General Hospitals. There were then no legal guidelines or framework, and the public program was discontinued; a few transplants continued to be done in the private sector.
The first public hospital corneal transplant was done in 1961 in San Fernando, then in Port of Spain using corneas retrieved from executed prisoners and postmortem patients. Later, corneas came via donations from the United Kingdom, Canadian, and United States eye banks, and finally, in 1985 from deceased patients after consent from relatives. In the 1990s, the Ministry of Health began discouraging the use of corneas from executed prisoners and postmortem cadavers. Several international collaborations allowed the expansion of implantation services to Tobago and Sangre Grande using foreign corneal donations or purchases.
Since 2006, there is a single transplant center, the National Organ Transplant Unit (NOTU) located at the Eric Williams Medical Sciences Complex performing both kidney retrieval and transplantation. The center has a laboratory with human leucocyte antigen (HLA) testing facilities and performs living and deceased donor kidney transplantations. There are 4 additional public hospitals with Intensive Care Units (ICU) that also serve as organ retrieval hospitals since 2012: Port of Spain, San Fernando, Sangre Grande, and Tobago. NOTU performs administration, organ donation and transplantation (ODT) education, organ allocation, maintaining a registry of living and deceased donors, transplant waiting list, transplant recipient follow-up, multidisciplinary screening of donors and lifelong follow-up of all living donors.
Transplant evaluations, surgery, and posttransplant medication and immunosuppression are covered by NOTU. Deceased donor corneal retrievals started legally in 2017. However, the discontinuation of contracts with the Cuban Ophthalmic team in 2019 and the current lack of local expertise in corneal retrieval have restricted the service to implanting grafts purchased from the United States. At this time, there is no corneal waitlist, corneal registry, or eye bank in T&T.
GOVERNMENTAL AND REGULATORY INVOLVEMENT AND OVERSIGHT
The Human Tissue Transplant Act 13 of 20006 conceptualized an OPT-IN system, defined brain death, established NOTU, made provisions for the removal of human tissue and organs for transplantation, in addition to blood for transfusion. The act also defined relatives in a strict priority order—spouse, adult child, parent or guardian, adult sibling, permitted transplantation between relatives and non-relatives, and prohibited organ trading. The system, however, did not include regular quality audits by NOTU, retrieval/transplant teams, or retrieval hospitals. Notably, Trinidad and Tobago was also a signatory to the Declaration of Istanbul in 2008.7
Since 2010, the Donation and Transplantation Institute (DTI) of Spain,8 Refinería Española de Petróleo Sociedad Limitada (REPSOL). Foundation and the Pan American Health Organization partnered with the Government of T&T by:
- Training Transplant Coordinators (TPMs) in the 5 public hospitals with ICUs emphasizing on the early detection of all potential donors using a Deceased Donor Alert System.
- Training local surgeons for renal transplants via internships in Spain and knowledge and skill transfer through visiting Transplant Teams from Spain. Hand-assisted laparoscopic donor nephrectomies became standard practice in 2011.
- Ongoing regular videoconferencing between DTI and the 3 main retrieval hospital TPMs.
- Reporting of donation/transplantation activity annually to DTI/International Registry of Organ Donation and Transplantation.
- Ongoing educational efforts on donation, transplantation, and kidney health to all categories of Hospital Staff, media, and the public.
One hundred and eighty-five ABO compatible (blood group system to denote presence of one, both or neither of A and B antigens on erythrocytes) kidney transplants were performed between 2006 and 2019; 143 (77%) of those transplants were from living donors (LD) of which the clear majority (70%) were genetically related to the recipient.
Twenty-six deceased donors moved forward to organ procurements but only 23 (89%) had their kidneys transplanted due to HLA incompatibility of 3 donors. All deceased donors were brain dead, < 60 years, with 42 kidneys utilized for transplant (23% of all transplants). Six corneal transplants were procured from 3 donation after brain death (DBD) donors.
The Donor Registry lists 1898 individuals. There are currently 1317 patients on Hemodialysis (HD) and 200 on peritoneal dialysis. The annual cost of HD is $72 million TTD (ratio of $TTD to $USD is 7:1) representing 1.2% of the total $6084 million TTD healthcare budget of the country in 2019/2020.9 In sharp contrast, the annual budget to NOTU for all transplantation activity is $0.75 million TTD representing 1% of the HD budget or 0.01% of the health allocation.
The updated waiting list has 8 potential recipients, with 40 currently undergoing evaluation.
Rates for living donor kidney transplants ranged from 2.9 to 12.4 pmp, while corresponding deceased donor transplants were 1.4 to 7.3 pmp (Figure 2). Rates for corneal retrieval with implantation were 1.4 and 2.9 pmp in 2017 and 2018.
LIVING AND DECEASED DONATION RATES
Living donation rates ranged from 2.9 to 12.4 pmp (Figure 2).
Deceased donation rates were sporadic for the first 6 years, but with DTI support of nationwide TPM training, became consistent though fluctuating between 0.73 to 3.65 pmp. Both living and deceased donation took a recent nosedive due to a protracted shortfall in HLA typing reagents for the first half of 2019.
We celebrate that the tiny country of Trinidad and Tobago has an established and functioning Donation and Transplantation system that facilitated to exchange dialysis for transplantation in 185 nationals. A few examples of patients that have done extremely well: The historic first LD kidney recipient from 1988 celebrated the 32nd anniversary of his successful transplant in February 2020 with a public Thanksgiving ceremony in which he encouraged nationals to become organ donors.10 NOTU’s first deceased donor kidney recipient is doing well after 12 years; 4 of our first 8 LD recipients are doing well after 13 years; one female LD recipient successfully conceived naturally 2 years after her 2015 transplant and is the proud first time mother of a robust 1 year and 6 month old son; at the end of December 2019, 127 grafts were functional (Table 1). An enthusiastic network of TPMs assiduously identifies potential deceased donors and participates in their ICU management as ICU doctors/nurses. ODT educational outreaches to Health Care Workers and visitors to the hospitals take place regularly; March has been recognized as National Kidney Month and the Kidney Recipients Support Group of Trinidad and Tobago actively promotes it with its annual health fair and walkathon.10
BARRIERS AND CHALLENGES
The major national challenge is the limited budget for transplantation with a current funding for HD that is 100 times larger compared with support for transplantation. Consequently, there are no full-time TPMs at retrieval hospitals. TPM activity is thus based on unpaid voluntary acts of goodwill by trained Doctors and Nurses with demanding full-time responsibilities.
The deceased donor registry nets < 1% of the population. A lack of public knowledge on ODT is a major contributor to our low conversion of potential donors with refusal rates by relatives ranging between 50 and 70%. Clearly, publicly funded ODT education targeting young and healthy adults, aiming for 10% of our population to sign up as deceased donors would present a game changer and decrease wait time for transplantation and improve consent.
The current waiting list is too small, which NOTU is addressing. In 2019 an AB Rhesus positive deceased donor could not be utilized as there had not been a matching recipient listed.
The Ministry of Health has committed to ensuring reliable availability of HLA reagents. With the discontinuation of the Cuban cornea team, we will need to train local physicians in retrieving corneas.
Albeit its small size, Trinidad and Tobago has maintained a resilient Donation-Transplantation Service through the dedication, enthusiasm, and training of its local professionals, and the support of its international partners, including DTI. Each challenge also represents an opportunity for growth and paradigm shift, including, but not limited to:
- Tissue Banking of eyes, amniotic membranes, bone, skin-feasible, and desperately needed by burns, trauma, and corneal patients.
- Potential for T&T as Caribbean ODT leader especially as Barbados and Jamaica are rolling out their LD renal transplantation programs.
- Partnership with our larger colleagues of the Society of Transplantation of Latin America and the Caribbean (STALYC) for technical cooperation.
- Extending our waitlist to qualifying older recipients.
- Extending our acceptance of suitable older donors (60–75 y).
- Legislative change to an OPT-OUT system.
1. Government of the Republic of Trinidad and Tobago - Central Statistical Office. Available at https://www.cso.gov.tt
. Accessed December 16, 2019
2. United States of America - Central Intelligence Agency fact book. Available at https://www.cia.gov/library/publications/the-world-factbook
. Accessed December 18, 2019
3. International Monetary Fund (IMF) World Economic Outlook Database. 2019 ed. Available at https://www.imf.org/external/pubs
. Accessed December 15, 2019
4. Public domain map of the Caribbean. Available at https://ian.macky.net/pat/map/cari/cariblu2.gif
. Accessed January 31, 2020
5. Trinidad and Tobago free map- boundaries, divisions, names, color. Available at https://d-maps.com/carte.php?num_car=28050&lang=en
. Accessed January 31, 2020
6. Laws of Trinidad and Tobago - Human Tissue Transplant Act 13 of 2000. Available at https://rgd.legalaffairs.gov.tt/laws2/Alphabetical_List/lawspdfs/28.07.pdf
. Accessed Jan 25, 2020
8. Balleste C, Arrendondo E, Gomez MP, et al. Successful example of how to implement and develop a deceased organ donation system in the Caribbean Region: a five year experience of the SEUSA program in Trinidad & Tobago Transplant Proc. 2015; 47:2328–2331
9. Government of Trinidad and Tobago Budget Statement 2020, pages 95, 108. Available at https://www.finance.gov.tt
. Accessed December 10, 2019