Transplant tourism: A ‘pervasive’ and dangerous ‘shadow world of medicine’

Transplant tourism, in which a patient travels to another country to acquire an organ, is thought to make up 10% of all solid organ transplants worldwide.

“It is not just an infectious disease problem but a global problem that spans not just ID medicine and surgery but health care in general, politics, policymakers, lawyers and a vulnerable population,” Infectious Disease News Editorial Board member Peter Chin-Hong, MD, professor of medicine and director of the transplant infectious disease program at University of California, San Francisco, said in an interview. “It is really very pervasive in society.”

Chin-Hong said there are about 100,000 solid organ transplants performed worldwide each year, and about 30,000 of them are performed in the United States. More than 113,000 people are waiting for an organ in the U.S. alone, according to the United Network for Organ Sharing.

“The availability of organs is not what the demand is,” Chin-Hong said.

As for the prevalence of organs obtained through transplant tourism, the 10% figure is an “appropriate estimate,” Camille Nelson Kotton, MD, clinical director of transplant and immunocompromised host infectious diseases at Massachusetts General Hospital, told Infectious Disease News. “Unfortunately, because many of these transplantations are below the radar, they are not reported and rates of infections and complications are not really known.”

According to reports from Canada and the U.S., many of the people who undergo transplant surgery in this manner are educated, male, and returning to the country where they were born to get the organs.

Kotton noted research presented in a 2011 study in Kidney International that identified 93 residents of British Columbia, Canada, who had undergone a kidney graft in this manner. The study found that 90% of the patients were ethnic minorities who traveled to their country of origin for transplant surgery.

She said that in the study, some patients had not been evaluated at the local Canadian transplant centers but decided to go for commercial transplant surgery, “which was sad in that the authors wrote that they would have been potential candidates in the Canadian system.”

Chin-Hong said a system in the U.S. was formed to allocate organs in a fair way, based on how ill the transplant patient is, what conditions the patient has and how available the organs are. Patients are ranked, which can be adjusted depending on how sick they are.

“What this means with the availability of organs is that some people have to wait as long as 7 years,” Chin-Hong said.

Infectious Disease News Editorial Board member Herbert L. DuPont, MD, a professor of epidemiology and infectious diseases at the University of Texas Health Science Center at Houston, said in an interview that patients on waiting lists for organs are frustrated.

“Many of them are dying, waiting for organs. So, I can understand why they want to push to find what’s available outside the country,” he said.

Peter Chin-Hong

Because of this, a situation similar to medical tourism — in which people go abroad for joint replacements or other medical reasons — has developed. However, with transplant tourism, patients go outside the country not only because it might be cheaper, but because they might be able to get an organ without having to wait a long time. Chin-Hong said these patients are primarily from high-income countries going to poorer countries to get organs.

“And that leads to the insidious problem,” Chin-Hong said. “The vast majority of the organs are acquired in illicit and other unethical ways.”

He said most people donating the organs are impoverished.

“Poverty is really what drives organ trafficking, not only demand, but it is really poverty,” Chin-Hong said.

He said a stark example of this was the recent Syrian refugee crisis. In Turkey, advertisements targeted refugees to consider being donors.

“The issue is much broader than ID, it is much broader than medicine,” he said. “It has to do with social justice and poverty, and has to do with equity, justice and respect for human dignity.”

Chin-Hong said many organs used in transplants in China might have been acquired from prisoners. A 2019 study in BMJ Open by Wendy Rogers, PhD, a professor of clinical ethics at Macquarie University in Australia, and colleagues found that out of 445 published studies reporting on 85,477 transplants in China, 92.5% failed to report whether or not the organs were sourced from executed prisoners. They noted that 19 studies involving 2,688 transplants took place before 2010, when there was no volunteer donor program in the country. Rogers called for the retraction of these studies pending investigation of individual papers.

A 2008 American Journal of Transplantation study found that China, the Philippines, India and Pakistan were countries where U.S. patients were most likely to receive transplanted organs.

Numerous ID risks

Chin-Hong noted that patients who engage in transplant tourism face numerous infectious disease risks, including a risk for wound infections. Performing surgeries in a nonsterile environment can result in surgical site infections, including those caused by multidrug-resistant organisms.

Camille Nelson Kotton

This could be an issue “particularly in places like India, where there are a lot of multidrug-resistant organisms that are really hard to treat in general,” Chin-Hong said.

Other potential infectious complications include UTIs with multidrug-resistant organisms as a result of kidney transplants — the most common transplants sought abroad. The risk for tuberculosis is thought to be as high as 15% in patients coming back with transplanted organs from other countries, Chin-Hong said. And in a 2015 study in Current Infectious Disease Reports, Chin-Hong wrote that the transplants can lead to “high rates of bloodborne viral infections and invasive, often fatal, fungal infections.”

Although the U.S. does “a really good job screening organs” for viral infections including HIV, hepatitis B virus and hepatitis C virus, screening of donor organs is not widespread in some foreign countries, especially when organs are acquired illicitly, Chin-Hong said. Because of this, in commercial transplantation, HIV, HBV and cytomegalovirus (CMV) are estimated to be transferred at higher rates than in traditional transplantation, with 7.1% of patients returning with HBV, 4.1% with HIV and around 30% with CMV, according to some studies.

The risk for fungal infections also can be attributed to nonsterile operating environments, Chin-Hong said. He noted that malaria can be acquired from blood transfusions and organs, and malignancies are also possible. Data on the risks are sparse because most organ recipients do not report their transplant tourism. But DuPont, a former president of the Infectious Diseases Society of America and the National Foundation for Infectious Diseases, emphasized that seeking out organs through transplant tourism is risky.

“The standards expected in this country do not exist in other countries,” he said. “I wouldn’t do it and I wouldn’t allow a family member to do it. But it is all about making a choice, and if desperately ill people make such a decision, assuming great risks, they should collect as much information as possible about the program to give themselves the best chance for success.”

‘A shadow world of medicine’

The Declaration of Istanbul on Organ Trafficking and Transplant Tourism, originally published in 2008 following a summit convened by The Transplantation Society and the International Society on Nephrology in response to concerns of international trafficking of human organs, established definitions of practices to help guide ethical practice in organ donation and transplant surgery around the world.

“We need a better idea of what global bioethics is over individual ethics,” Chin-Hong said. “How do we think of ethics in terms of not just individuals, but in terms of a problem or an issue on a population level over that one-to-one direction of a patient?”

Herbert L. DuPont

He said there needs to be ways to increase the number of organs that are available globally.

Kotton, a past president of The Transplantation Society’s transplant infectious disease section, said she tries to identify people she suspects are going to another country for a transplant.

“I think that there is a real opportunity to decrease the risk of people undergoing transplant tourism,” she said. “I screen people in-clinic if they are from an endemic area, from an area where people are doing these types of transplants, and if they seem to have the financial means.”

She noted that the transplants can cost between $20,000 and $100,000, including travel.

“I would say many people think about it,” she said. “I think talking about it in-clinic when I see somebody who seems to be at risk and trying to decrease the risk that they would actually undergo transplant tourism is really key.”

She said people are sometimes encouraged by family “back home” to return to their birth country to receive a transplant as a way to get the organ faster.

“I talk to them about the risk of poor outcomes, major infectious disease issues, major surgical site infections. All kinds of complications,” she said, adding that patients in the U.S. are reluctant to bring the issue up with their physicians because they know it is either frowned upon or potentially illegal.

“I feel it is not necessary for me to interpret the law in that place but to make sure that my individual patient ends up healthy with a functioning organ,” she said.

Chin-Hong said that despite efforts by individuals and organizations, transplant tourism is still common. The Transplantation Society emphasized this recently, noting in an article that “there continue to be reports of unethical cases of organ donation and transplantation from all over the world, and it is time for the international transplant community to take a firm stance against such activities.”

“The Transplantation Society has worked diligently to curtail ‘transplant tourism’ and ‘organ trafficking’ globally,” the authors wrote. “Among our primary concerns have been meeting the growing demand for organs through ethical living and deceased organ donation by encouraging the establishment and enhancement of such programs throughout the world, promoting scientific understanding and equality in standards of clinical practice and patient care, transparency in transplantation activities, and of course educational programs to address the needs of transplant programs everywhere in the world.”

The authors said countries have a responsibility to assess the transplant needs of their patients and should “strive to achieve national or regional self-sufficiency in meeting the need for organ transplants” while eradicating practices like transplant tourism.

The society asked that conference organizers ensure that data and findings presented at meetings are not a result of unethical or illegal transplant activities, and that journals assess submissions for such cases and reject any papers that include unethical practices.

“It is like a shadow world of medicine,” Chin-Hong said of transplant tourism. “It is like this huge, crazy topic with shady criminals and people running in the dark of night and prisoners.” – by Bruce Thiel

Disclosures: Chin-Hong, DuPont and Kotton report no relevant financial disclosures.

Disclaimer: DuPont noted that he was giving his opinion and not that of the IDSA or the NFID.

Transplant tourism, in which a patient travels to another country to acquire an organ, is thought to make up 10% of all solid organ transplants worldwide.

“It is not just an infectious disease problem but a global problem that spans not just ID medicine and surgery but health care in general, politics, policymakers, lawyers and a vulnerable population,” Infectious Disease News Editorial Board member Peter Chin-Hong, MD, professor of medicine and director of the transplant infectious disease program at University of California, San Francisco, said in an interview. “It is really very pervasive in society.”

Chin-Hong said there are about 100,000 solid organ transplants performed worldwide each year, and about 30,000 of them are performed in the United States. More than 113,000 people are waiting for an organ in the U.S. alone, according to the United Network for Organ Sharing.

“The availability of organs is not what the demand is,” Chin-Hong said.

As for the prevalence of organs obtained through transplant tourism, the 10% figure is an “appropriate estimate,” Camille Nelson Kotton, MD, clinical director of transplant and immunocompromised host infectious diseases at Massachusetts General Hospital, told Infectious Disease News. “Unfortunately, because many of these transplantations are below the radar, they are not reported and rates of infections and complications are not really known.”

According to reports from Canada and the U.S., many of the people who undergo transplant surgery in this manner are educated, male, and returning to the country where they were born to get the organs.

Kotton noted research presented in a 2011 study in Kidney International that identified 93 residents of British Columbia, Canada, who had undergone a kidney graft in this manner. The study found that 90% of the patients were ethnic minorities who traveled to their country of origin for transplant surgery.

She said that in the study, some patients had not been evaluated at the local Canadian transplant centers but decided to go for commercial transplant surgery, “which was sad in that the authors wrote that they would have been potential candidates in the Canadian system.”

Chin-Hong said a system in the U.S. was formed to allocate organs in a fair way, based on how ill the transplant patient is, what conditions the patient has and how available the organs are. Patients are ranked, which can be adjusted depending on how sick they are.

“What this means with the availability of organs is that some people have to wait as long as 7 years,” Chin-Hong said.

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Infectious Disease News Editorial Board member Herbert L. DuPont, MD, a professor of epidemiology and infectious diseases at the University of Texas Health Science Center at Houston, said in an interview that patients on waiting lists for organs are frustrated.

“Many of them are dying, waiting for organs. So, I can understand why they want to push to find what’s available outside the country,” he said.

Peter Chin-Hong

Because of this, a situation similar to medical tourism — in which people go abroad for joint replacements or other medical reasons — has developed. However, with transplant tourism, patients go outside the country not only because it might be cheaper, but because they might be able to get an organ without having to wait a long time. Chin-Hong said these patients are primarily from high-income countries going to poorer countries to get organs.

“And that leads to the insidious problem,” Chin-Hong said. “The vast majority of the organs are acquired in illicit and other unethical ways.”

He said most people donating the organs are impoverished.

“Poverty is really what drives organ trafficking, not only demand, but it is really poverty,” Chin-Hong said.

He said a stark example of this was the recent Syrian refugee crisis. In Turkey, advertisements targeted refugees to consider being donors.

“The issue is much broader than ID, it is much broader than medicine,” he said. “It has to do with social justice and poverty, and has to do with equity, justice and respect for human dignity.”

Chin-Hong said many organs used in transplants in China might have been acquired from prisoners. A 2019 study in BMJ Open by Wendy Rogers, PhD, a professor of clinical ethics at Macquarie University in Australia, and colleagues found that out of 445 published studies reporting on 85,477 transplants in China, 92.5% failed to report whether or not the organs were sourced from executed prisoners. They noted that 19 studies involving 2,688 transplants took place before 2010, when there was no volunteer donor program in the country. Rogers called for the retraction of these studies pending investigation of individual papers.

A 2008 American Journal of Transplantation study found that China, the Philippines, India and Pakistan were countries where U.S. patients were most likely to receive transplanted organs.

Numerous ID risks

Chin-Hong noted that patients who engage in transplant tourism face numerous infectious disease risks, including a risk for wound infections. Performing surgeries in a nonsterile environment can result in surgical site infections, including those caused by multidrug-resistant organisms.

PAGE BREAK
Camille Nelson Kotton

This could be an issue “particularly in places like India, where there are a lot of multidrug-resistant organisms that are really hard to treat in general,” Chin-Hong said.

Other potential infectious complications include UTIs with multidrug-resistant organisms as a result of kidney transplants — the most common transplants sought abroad. The risk for tuberculosis is thought to be as high as 15% in patients coming back with transplanted organs from other countries, Chin-Hong said. And in a 2015 study in Current Infectious Disease Reports, Chin-Hong wrote that the transplants can lead to “high rates of bloodborne viral infections and invasive, often fatal, fungal infections.”

Although the U.S. does “a really good job screening organs” for viral infections including HIV, hepatitis B virus and hepatitis C virus, screening of donor organs is not widespread in some foreign countries, especially when organs are acquired illicitly, Chin-Hong said. Because of this, in commercial transplantation, HIV, HBV and cytomegalovirus (CMV) are estimated to be transferred at higher rates than in traditional transplantation, with 7.1% of patients returning with HBV, 4.1% with HIV and around 30% with CMV, according to some studies.

The risk for fungal infections also can be attributed to nonsterile operating environments, Chin-Hong said. He noted that malaria can be acquired from blood transfusions and organs, and malignancies are also possible. Data on the risks are sparse because most organ recipients do not report their transplant tourism. But DuPont, a former president of the Infectious Diseases Society of America and the National Foundation for Infectious Diseases, emphasized that seeking out organs through transplant tourism is risky.

“The standards expected in this country do not exist in other countries,” he said. “I wouldn’t do it and I wouldn’t allow a family member to do it. But it is all about making a choice, and if desperately ill people make such a decision, assuming great risks, they should collect as much information as possible about the program to give themselves the best chance for success.”

‘A shadow world of medicine’

The Declaration of Istanbul on Organ Trafficking and Transplant Tourism, originally published in 2008 following a summit convened by The Transplantation Society and the International Society on Nephrology in response to concerns of international trafficking of human organs, established definitions of practices to help guide ethical practice in organ donation and transplant surgery around the world.

“We need a better idea of what global bioethics is over individual ethics,” Chin-Hong said. “How do we think of ethics in terms of not just individuals, but in terms of a problem or an issue on a population level over that one-to-one direction of a patient?”

PAGE BREAK
Herbert L. DuPont

He said there needs to be ways to increase the number of organs that are available globally.

Kotton, a past president of The Transplantation Society’s transplant infectious disease section, said she tries to identify people she suspects are going to another country for a transplant.

“I think that there is a real opportunity to decrease the risk of people undergoing transplant tourism,” she said. “I screen people in-clinic if they are from an endemic area, from an area where people are doing these types of transplants, and if they seem to have the financial means.”

She noted that the transplants can cost between $20,000 and $100,000, including travel.

“I would say many people think about it,” she said. “I think talking about it in-clinic when I see somebody who seems to be at risk and trying to decrease the risk that they would actually undergo transplant tourism is really key.”

She said people are sometimes encouraged by family “back home” to return to their birth country to receive a transplant as a way to get the organ faster.

“I talk to them about the risk of poor outcomes, major infectious disease issues, major surgical site infections. All kinds of complications,” she said, adding that patients in the U.S. are reluctant to bring the issue up with their physicians because they know it is either frowned upon or potentially illegal.

“I feel it is not necessary for me to interpret the law in that place but to make sure that my individual patient ends up healthy with a functioning organ,” she said.

Chin-Hong said that despite efforts by individuals and organizations, transplant tourism is still common. The Transplantation Society emphasized this recently, noting in an article that “there continue to be reports of unethical cases of organ donation and transplantation from all over the world, and it is time for the international transplant community to take a firm stance against such activities.”

“The Transplantation Society has worked diligently to curtail ‘transplant tourism’ and ‘organ trafficking’ globally,” the authors wrote. “Among our primary concerns have been meeting the growing demand for organs through ethical living and deceased organ donation by encouraging the establishment and enhancement of such programs throughout the world, promoting scientific understanding and equality in standards of clinical practice and patient care, transparency in transplantation activities, and of course educational programs to address the needs of transplant programs everywhere in the world.”

The authors said countries have a responsibility to assess the transplant needs of their patients and should “strive to achieve national or regional self-sufficiency in meeting the need for organ transplants” while eradicating practices like transplant tourism.

The society asked that conference organizers ensure that data and findings presented at meetings are not a result of unethical or illegal transplant activities, and that journals assess submissions for such cases and reject any papers that include unethical practices.

“It is like a shadow world of medicine,” Chin-Hong said of transplant tourism. “It is like this huge, crazy topic with shady criminals and people running in the dark of night and prisoners.” – by Bruce Thiel

PAGE BREAK

Disclosures: Chin-Hong, DuPont and Kotton report no relevant financial disclosures.

Disclaimer: DuPont noted that he was giving his opinion and not that of the IDSA or the NFID.