Challenges in Laboratory Haematology:

Dr Saleem Ahmed Khan

MBBS, MCPS, FCPS, FRCP, PhD

Consultant Haematologist &

Principal Army Medical College Rawalpindi

Perspective from Pakistan

INDIA

3

Indus Valley Civilization

4

5

Northern Areas

Climbers Paradise

Women Contribution

Pakistan Demographic

StatisticsIndicator Details

Total Population (Census 2017 est) 207 million approximate

Gender Ratio (2016 est) 1.06 male(s)/female

Per Capita income (US$ - 2016 est) $ 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/

60%

6%1%

24%

3%

4%1%

1% Private House Hold, Out of PocketExpenditure

Local NGOs & Insurance

Official Donor Agencies

Federal (Civ) & Provincial Govt

Military Health Exp

District/ Tehsil Govt

Social Security Funds

Autonomous Bodies / Corporations

GoP (2016). Pakistan national Health Accounts 2013-14. S. Bureau. Islamabad.

Contributors in Health Expenditure

Health Care System – Pakistan

•Policy making

•National ProgrammesFederal

Govt

•Implementation of Healthcare system

Provincial Govt

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 Doctors195,896

(1 per 997)

Registered Dentists18,333

(1 per 10,658)

Registered Nurses99,228

(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)

Lawrence Faulkner. 3rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias

Limassol, 24 – 26 October 2012

Thalassemia in Pakistan

• Thalassemia carriers 5% population

• Total Carriers 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

0

20

40

60

80

100

120

2 4 6 8 10 12 14 16 18 20 22 24 25

1996

2006

1996: data from HBB Karachi, 2006: data from BTIHS, Karachi

Thalassemia Survival in Pakistan

Index Families

183/591 (31%)

General Population

(5%)

Control Families

0/397 (0%)

(S. Ahmed et al, 2002)

Carrier Screening

(S. Ahmed et al, 2002)

Prenatal Diagnosis

0

200

400

600

800

1000

1200

1400

1600

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

(S. Ahmed , 2018)

Impediments to PNDDid not know

23%

Expensive23%

No access17%

Delay in seeking16%

Advised against12%

Religious belifs9%

(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

CATCHMENT AREA (n=1324)

AFBMTC DATA

Aplastic anemia in Pakistan

PakistanHaemophiliaPatientsWelfareSocietyRwp/IsbdChapterTotalPatientssummary(20/02/2018)

TotalPatients 983

Males 822

Females 161

Males=822 Females=161

Sr.# Factor/Disease No.ofPatientsFactor/Disease No.ofPatients1 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 UnDiagnosed 13

11 UnDiagnosed 23 FIX 1

12 Total 822 Total 161 Source: AFIP, PHPWS

Bleeding Disorders in Pakistan

Malaria8.6 / 100,000 population at risk

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

Plasmodium vivax Plasmodium falciparum

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

Hematology

Anemia /

Thalassemia

Leukaemias /

Lymphomas

Bleeding

Disorders

Cytogenetics Molecular

Analysis

Flowcytometry

Blood

Transfusion

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

• Not more than a dozen for

a population of 207 M

• Concentrated in main cities

only

• Cost

PRIVATE

Existing Haematology Facilities

Major Referral Haematology Centers

Haematology Training

Undergraduate

• Part of the curriculum of Pathology in 4th 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)

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

Haematologist Data

• BSc MLT (Haematology and Immunohaematology) 50

• Master in Laboratory Science (MLS Haematotechnology) 10

• PhD 02

Medical Technologist Data

Medical Technologist Trainee Data

• BSc MLT 15

• MLS 07

• PhD 01

LEVEL

• Post graduate

– M. Phil

– FCPS

– PhD

• Lab Technologist

– BSc

– MLS

– PhD

• Curriculum issue

• Training Institutes

• Training slots

• Training facilities

• Employment

ISSUES

Haematology Training

• 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

Challenges in Lab Haematology

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

National Health Policy Blood safety included as a priority area

National Blood Policy Proposed establishing a Nat. Blood Transfusion Service

National Strategic Framework Highlighted fundamental principles & reforms areas

National Steering Committee Strategic body to review reform implementation

Safe Blood Transfusion Law Legislation reviewed and revised

Blood Transfusion Authorities Established at the federal & provincial levels

Blood Transfusion Programs Project established at national & provincial levels

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

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

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 un-regulated and unsafe with serious consequences for the public

Blood Transfusion Services Pakistan - Challenges

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