Proportion of countries and population covered by the GODT database in the WHO regions. Year 2015 [17].
\r\n\tSolar radiation is the radiant energy that originated from the sun in the form of electromagnetic radiation at various wavelengths. Solar radiation is the source of renewable energy and can be captured and converted into various forms of energy (e.g. electricity and heat) using different technologies.
\r\n\tA very vast amount of solar energy reaches the atmosphere and surface of the earth and solar energy has been used for heating purposes for a very long-time and after solar cells’ invention in 1954, solar cells have also been used widely for electricity generation. Solar cells convert the sunlight into electricity by the creation of voltage and electric current through the so-called photovoltaic effect.
\r\n\tPhotovoltaic (PV) solar energy has attracted significant attention in the recent decade as a reliable source for power generation due to various merits such as the free source of energy, abundant materials resources, environmentally friendly and noise-free, longtime service life, requiring low maintenance, technological advancements, market potential, and very importantly, low cost. The growth of using photovoltaic (PV) solar energy as a promising renewable energy technology, is being increased more and more worldwide. Therefore, much further research is needed for possible future developments in the field of solar photovoltaic energy.
\r\n\tThe aim of this book is to provide detailed information about solar radiation as the source of photovoltaic (PV) solar energy for a broad range of readership including undergraduate and postgraduate students, young or experienced researchers and engineers.
\r\n\tThis should be accomplished by addressing the various technical and practical aspects of solar radiation fundamentals, modeling and the measurement for photovoltaic (PV) solar energy applications.
\r\n\tThe majority of this book should describe the basic, modern, and contemporary knowledge and technology of extraterrestrial and terrestrial solar irradiance for photovoltaic (PV) solar energy.
\r\n\tThe book covers the most recent developments, innovation and applications concerning the following topics:
\r\n\t• Fundamental of solar radiation and photovoltaic solar energy
\r\n\t• Solar radiation and photovoltaic solar energy potential
\r\n\t• Solar irradiance measurement: techniques, instrumentation and uncertainty analysis
\r\n\t• Solar radiation modeling for photovoltaic solar energy applications
\r\n\t• Solar monitoring and data quality assessment
\r\n\t• Solar resource assessment and photovoltaic system performance
\r\n\t• Solar energy and photovoltaic power forecasting
\r\n\tThese are accompanied with other useful research topics and material.
",isbn:"978-1-83968-859-1",printIsbn:"978-1-83968-858-4",pdfIsbn:"978-1-83968-860-7",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"4c3d1319d7286e81bfb15c1f4b20460a",bookSignature:"Dr. Mohammadreza Aghaei",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/9862.jpg",keywords:"Solar Radiation Modeling, Solar Data Assessment, Solar Monitoring, Solar Radiation Forecasting, Solar Irradiance Measurements, Solar Instruments, Solar Spectral Distributions, Uncertainty Analysis, Solar Cell Technologies, Photovoltaics (PV), Solar Resource Assessment, Photovoltaics Power Forecasting",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"September 17th 2020",dateEndSecondStepPublish:"October 15th 2020",dateEndThirdStepPublish:"December 14th 2020",dateEndFourthStepPublish:"March 4th 2021",dateEndFifthStepPublish:"May 3rd 2021",remainingDaysToSecondStep:"5 months",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!1,biosketch:"A senior researcher in the field of photovoltaic solar energy, a postdoctoral scientist at Eindhoven University of Technology (TU/e), Chair of the WG2: reliability and durability of PV in EU COST PEARL PV.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"317230",title:"Dr.",name:"Mohammadreza",middleName:null,surname:"Aghaei",slug:"mohammadreza-aghaei",fullName:"Mohammadreza Aghaei",profilePictureURL:"https://mts.intechopen.com/storage/users/317230/images/system/317230.jpg",biography:"Mohammadreza Aghaei is a senior researcher in the field of photovoltaic solar energy, Eindhoven University of Technology (TU/e), The Netherlands. He is chair of the Working Group 2: reliability and durability of PV in European Cooperation in Science and Technology, COST Action PEARL PV.\nHe received the M.S. degree in electrical engineering from the Universiti Tenaga Nasional (UNITEN), Selangor, Malaysia, in 2013, and the Ph.D. degree in electrical engineering from the Politecnico di Milano, Milan, Italy, in 2016.\nHe was a Postdoctoral Scientist with Fraunhofer ISE and Helmholtz-Zentrum Berlin (HZB)-PVcomB, Germany, in 2017 and 2018, respectively. He is a Guest Scientist with the Department of Microsystems Engineering (IMTEK), Solar Energy Engineering, University of Freiburg since 2017. He is currently a Postdoctoral Scientist with the Design of Sustainable Energy Systems Group, Eindhoven University of Technology (TU/e), The Netherlands. He has authored numerous publications in international refereed journals, book chapters, and conference proceedings. The main his research interests include Solar Energy, Photovoltaic systems, PV monitoring, LSC PV, solar cells, machine learning, and UAVs.\nDr. Aghaei is a member of the International Energy Agency, PVPS program-Task 13 and International Solar Energy Society, and also an MC member in EU COST Action PEARL PV.",institutionString:"Eindhoven University of Technology",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Eindhoven University of Technology",institutionURL:null,country:{name:"Netherlands"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"10",title:"Earth and Planetary Sciences",slug:"earth-and-planetary-sciences"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"247865",firstName:"Jasna",lastName:"Bozic",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/247865/images/7225_n.jpg",email:"jasna.b@intechopen.com",biography:"As an Author Service Manager, my responsibilities include monitoring and facilitating all publishing activities for authors and editors. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"4816",title:"Face Recognition",subtitle:null,isOpenForSubmission:!1,hash:"146063b5359146b7718ea86bad47c8eb",slug:"face_recognition",bookSignature:"Kresimir Delac and Mislav Grgic",coverURL:"https://cdn.intechopen.com/books/images_new/4816.jpg",editedByType:"Edited by",editors:[{id:"528",title:"Dr.",name:"Kresimir",surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"45477",title:"Variation in Forearc Basin Configuration and Basin-filling Depositional Systems as a Function of Trench Slope Break Development and Strike-Slip Movement: Examples from the Cenozoic Ishikari–Sanriku-Oki and Tokai-Oki–Kumano-Nada Forearc Basins, Japan",doi:"10.5772/56751",slug:"variation-in-forearc-basin-configuration-and-basin-filling-depositional-systems-as-a-function-of-tre",body:'This chapter aims to elucidate variation of forearc basins in terms of basin configurations and basin-filling depositional systems with some examinations of their controlling factors, using actual examples from the Cenozoic forearc basins along the Northeast and Southwest Japan Arcs. Forearc basin is a sedimentary basin formed in the arc-trench gap between a volcanic arc and plate subduction zone (Figure 1) [1]. Although there are some notable past forearc basin studies (e.g., [1, 2]), the detailed characteristics of forearc basins have not been fully understood, since they show wide-range variation in styles, possibly reflecting various plate tectonic conditions at the plate subduction zone. As well-documented textbooks, Dickinson and Seely [2] and Dickinson [1] compiled and summarized the general outline of the forearc basin architecture and basin-filling sediments with explanations about some actual ancient and modern example forearc basins. The major contributions of these comprehensive textbooks include not only the presentation of various forearc basin styles, but also the explanation of related elements characterizing the forearc basin styles, such as dimension, subsidence, basin filling patterns, accretionary sill conditions and trench slope break development. Among these forearc basin elements, Dickinson [1] especially picked up two major elements: basin filling conditions and sectional basin configuration controlled by the relative height of trench slope break, to determine the morphological classification of forearc basins.
This chapter attempts to examine these two major factors: basin filling condition and basin configuration, by diagnosing two contrasting actual forearc basin packages around Japan: the Eocene Ishikari–Sanriku-oki forearc basins along the NE Japan Arc and the Pleistocene Tokai-oki–Kumano-nada forearc basins along the SW Japan Arc (Figure 2). To delineate the basin filling condition, we examine sedimentological characteristics including depositional systems, sequence stratigraphic contexts and related controlling factors. Regional seismic survey sections are used to manifest the basin configuration and to discuss controlling factors on forearc sedimentation for the two example forearc basins. In addition to these major factors, we discuss the role of strike-slip tectonics on the forearc basins, as it is reported in a former literature that strike-slip movement related to oblique plate subduction may affect the forearc basin tectonics and sedimentation.
Schematic cross section of a forearc zone including a forearc basin, showing the basic terms used in this chapter. Modified after [1].
A) Index map showing the locations of two example forearc basins: Early to Middle Eocene Ishikari–Sanriku-oki forearc basins (ISFB) and Pleistocene Tokai-oki–kumano-nada forearc basins (TKFB). B) Close-up map showing the distribution of the Early to Middle Eocene Ishikari–Sanriku-oki forearc basins (orange lines) and the Cretaceous Yezo forearc basins (sky blue lines). The Eocene Ishikari–Sanriku-oki forearc basins are segmented into several subbasins (blue dashed lines). Compiled after [6, 8, 10, 11]. C) Close-up map of the Pleistocene Tokai-oki–Kumano-nada forearc basins, showing the mapping area and 2D seismic survey line positions used for seismic facies analysis. Modified after [23, 24].
The Eocene Ishikari–Sanriku-oki forearc basins were developed in the forearc zone along the NE Japan Arc (Figure 2A), which corresponds to the N-S trending narrow zone extending from the “Sorachi–Yezo Belt [3]” in central Hokkaido to the Pacific side offshore of northeast Honshu Island (Figure 2B). Although paleogeography around the NE Japan Arc was quite different from the present because the backarc basins of the NE Japan and Kuril Arcs had not opened [e.g., 4, 5], the tectonic history along the forearc zone during the Cretaceous to Paleogene can be summarized using the geologic evidences as follows. During the Cretaceous time, the eastern plates, which were regarded as the Izanagi and Kula Plates [4, 6], subducted underneath the western volcanic arc, and the forearc basin fully developed along this zone (Yezo Forearc Basin; Figure 2B [6, 7, 8]). During the Early Paleocene time, it is believed that a ridge between the Kula and Pacific Plates passed by along this forearc zone [5], causing total extinction of the forearc basins once. This tectonic event was widely recorded as “KT gap unconformity [6, 8] (Figure 3)” seen in sedimentary successions along the Sorachi-Yezo Belt and the Ishikari–Sanriku-oki forearc zone with a minor time transgressive trend of the unconformity development possibly related to the ridge passage [8, 9]. After this tectonic event, fragmented small basins sporadically developed along the Ishikari–Sanriku-oki forearc zone. The Eocene was a relatively widespread phase of forearc basins, extending from Sanriku-oki to central Hokkaido (Figures 2B, 3). These Eocene forearc basins were segmented into several subbasins: Sanriku-oki, Yufutsu-oki, Yubari, Sorachi and Uryu subbasins [10, 11] (Figure 2B). This section picks up the Sorachi, Yubari and Sanriku-oki subbasins for examining the basin filling condition and basin configuration.
The Sorachi and Yubari subbasins are located in central Hokkaido (Figures 4), and situated near the northern end of the Eocene Ishikari–Sanriku-oki forearc basins (Figure 2B). The Sorachi and Yubari subbasins developed and started sedimentation at the early Middle Eocene time, and continued until the Early Oligocene time with some short breaks by unconformities [12] (Figure 3). This section focuses on the Middle Eocene Ishikari Group (Figure 3), which constitutes the major part of the Sorachi and Yubari subbasin fill.
Generalized stratigraphic framework of the Paleocene, Eocene and Lower Oligocene in the Sorachi, Yubari and Sanriku-oki subbasins of the Ishikari–Sanriku-oki forearc zone. Colored columns beside the stratigraphic unit names denote the major depositional systems. This chapter mainly targets the Early to Middle Eocene basin fills. Compiled after [10–13, 15].
The Ishikari Group is divided into nine lithostratigraphic units: the Noborikawa, Horokabetsu, Yubari, Wakkanabe, Bibai, Akabira, Ikushunbetsu, Hiragishi and Ashibetsu Formations. From the standpoint of sequence stratigraphy, the Ishikari Group can be divided into four 3rd-order depositional sequences: Sequence Isk-1 to -4 in ascending order, and each depositional sequence is further divided into TST (transgressive systems tract) and HST (highstand systems tract), based on transgressive/regressive trends and marine incursion beds (Figures 3, 5) [11, 13]. In the Sorachi subbasin, the nine lithostratigraphic units are all developed, whereas in the Yubari basin, the Bibai, Akabira, Hiragishi and Ashibetsu Formations are absent, suggesting that the basin filling sedimentation was not continuous but episodic in the Yubari subbasin.
A) Geologic map showing the distributions of the Eocene forearc basin sediments in central Hokkaido, near the northern end of the Ishikari–Sanriku-oki forearc basins. B) Close-up geologic map showing the surface distributions of the Middle Eocene Ishikari Group in central Hokkaido. The Middle Eocene forearc basin in this area was segmented into the Sorachi subbasin on the north and the Yubari subbasin on the south. Numbers shown along rivers denote transect numbers of geologic survey, which correspond to numbers on the geologic cross section in Figures 5 and 7B. Modified after [11].
Sedimentary facies analysis reveals that the Ishikari Group in the Sorachi and Yubari subbasins is composed of 24 sedimentary facies. These sedimentary facies are further assembled into five facies associations: braided fluvial facies association (BF), meandering fluvial facies association (MF), lacustrine facies association (LA), bay margin–estuarine facies association (ES) and bay center facies association (BA), as groups of sedimentary facies based on genetically related sedimentary environments and succession patterns [11, 13] (Figure 5). These five facies associations indicate that the Ishikari Group consists of five depositional systems: braided fluvial system, meandering fluvial system, lacustrine system, bay margin–estuarine system and bay system. Figure 5 depicts the schematic cross section showing the temporal and spatial distributions of depositional systems within the sequence stratigraphic framework in the Sorachi subbasin. As Figure 5 shows, the Ishikari Group mainly consists of a meandering fluvial system with some developments of a braided fluvial system. Lacustrine, bay margin / estuarine and bay center systems cyclically occur as marine incursion beds at around the maximum flooding surface of each 3rd-order depositional sequence.
Schematic cross section of the Middle Eocene Ishikari Group in the Sorachi subbasin, showing sequence stratigraphic division and temporal and spatial distributions of depositional systems. Numbers above the cross section denote transect numbers of geologic survey shown in Figure 4B. Modified after [11, 13].
Figure 6 depicts facies maps showing spatial distributions of depositional systems for each systems tract of Sequences Isk-1 to -3. It is estimated that in response to relative sea level changes, the sedimentary environments in the Sorachi subbasin changed by cyclic transgression and regression. At the early phase of transgression and the late phase of regression, braided and meandering fluvial environments were dominant, whereas at the maximum flooding phase, bay center and bay margin environments were dominant. These facies maps indicate that marine influence became strong northeastward, whereas terrestrial environments such as braided / meandering river environments were dominant in the southern or southwestern area of the Sorachi subbasin.
One of the notable characteristics of the depositional systems in the Ishikari Group in the Sorachi subbasin can be predominance of tidal deposits in a bay margin–estuarine system. Even though shallow marine condition periodically occurred during deposition, there are no wave-influenced sandy shallow marine facies such as foreshore and shoreface sandstone facies in the Ishikari Group. These facts indicate that the basin setting of the Sorachi subbasin was protected by wave action, and was not directly facing an open sea.
Spatial distribution maps of depositional systems in the Sorachi subbasin, showing paleogeographical changes for systems tracts (TST: transgressive interval; mfs: maximum transgression; HST: regressive interval) of 3rd-order Sequences Isk-1 to -3. Maps were created on the basis of facies association plots at the survey transect position. MF: meandering fluvial, BF: braided fluvial, LA: lacustrine, ES: bay margin–estuarine, BA: bay center. Blue contours denote isopach (iso-thickness) lines. Modified after [11].
Figure 6 also depicts isopach contours for each systems tract of depositional sequences in the Sorachi subbasin. These isopach maps suggest that the thickness trend, indicating the depocenter, changed intermittently during deposition of the Ishikari Group. Since the depositional environments (altitude of deposition) in the Sorachi subbasin were more or less equivalent to a relative sea level or base level, it is regarded that the thickness trend indicates a spatial trend of total basin subsidence. Figure 7A demonstrates total subsidence curves of three different positions of the Sorachi subbasin, which were created on the basis of the thickness information. These isopach maps and total subsidence curves indicate that the western part of the subbasin rapidly subsided first. Subsequently during deposition of Sequence Isk-3 and -4, the northeastern part selectively subsided at a drastically rapid rate, and finally accumulated 3000 m-thick tidal-dominant deposits. Thus the Sorachi subbasin is characterized by a differential subsidence especially in the later half of the Ishikari Group deposition [11].
In addition to a differential subsidence within a subbasin, the subsidence patterns between subbasins show a notable difference. Figure 7B depicts the schematic cross section across the Sorachi and Yubari subbasins, showing a large thickness difference [14], possibly related to the difference in subsidence pattern as shown in Figure 7A. Accordingly, it is suggested that the segmented forearc basins in the Ishikari–Sanriku-oki forearc zone show highly variable subsidence patterns within and between subbasins.
A) Diagram showing total subsidence histories along the selected transects during deposition of the Ishikari Group in the Sorachi and Yubari subbasins. Modified after [11]. B) Schematic sectional diagram showing thickness change of the Ishikari Group between the Sorachi and Yubari subbasins. Numbers above the Ishikari Group on the section denote transect numbers of surveys shown in Figure 4B. SB: sequence boundary, mfs: maximum flooding surface. Modified after [14].
The Sanriku-oki subbasin is located in northeastern offshore of the Honshu Island, and situated near the southern end of the Eocene Ishikari–Sanriku-oki forearc basins (Figure 2B). After the K/T gap unconformity, the Sanriku-oki subbasin started basin-filling sedimentation in Late Paleocene time, and continued until the large-scale Oligocene unconformity (Ounc [10]) was formed (Figure 3). This section focuses on the Lower to Middle Eocene forearc basin-filling sediments, which are divided into the B2, C1, C2, C3 and C4 units [15] (Figure 3), for examining the depositional condition and basin configuration.
According to the MITI Sanriku-oki well report [15], the Lower to Middle Eocene successions in the Sanriku-oki subbasin are mainly composed of mudstone, sandstone and coal-bearing alternating beds of sandstone and mudstone, which were deposited in terrestrial, brackish and neritic marine environments. Figure 8 demonstrates interpreted seismic facies maps of the lower and upper intervals of the Lower Eocene B2 unit in the 3D seismic surveyed area, including the MITI Sanriku-oki well location, in the central part of the Sanriku-oki subbasin (Figure 2B). These seismic facies maps, which were displayed by different colors assigned for each “seismic trace shape” class, show intricate meandering, braided or partly networked fluvial channel zones and floodplain–back mash zones.
Based on the sedimentary environment information from the MITI Sanriku-oki well and the seismic facies maps, it is interpreted that the B2 and C3 units consist mainly of a coal-bearing meandering fluvial system with minor bay center to bay margin systems as marine incursion beds, and the C1, C2 and C4 units consist mainly of bay to muddy shelf systems (Figure 3). Since all these component depositional systems resemble those of the Sorachi/Yubari subbasins, it is regarded that the Eocene Sanriku-oki subbasin was in a confined forearc setting, which was not directly facing an open sea and was protected by wave action. This basin setting during the Eocene time is supported by the basin configuration shown on a long 2D seismic section transecting the Sanriku-oki subbasin (Figure 9), in which the trench slope break prominently uplifted and eroded by Ounc (Oligocene Unconformity [10]), and the Cretaceous to Eocene basin-filling succession seems to be confined within the arcward side of the uplifted trench slope break. This confined forearc setting was terminated by the Ounc event, accompanied with seaward migration and large subsidence of the trench slope break, which finally caused transformation of the forearc basin setting from a fluvial to deep-marine slope condition as shown in the cross section in Figure 9. Consequently, it is regarded that the Sanriku-oki forearc basin setting was strongly controlled by the trench slope development.
Seismic facies maps showing the distributions of a fluvial channel zone and a floodplain–back marsh zone in a meandering fluvial system in the central part of the Sanriku-oki subbasin. Map colors were assigned for each different seismic trace shape, which can indicate difference in sedimentary environment. A) Case of a lower horizon of the B2 unit. Bluish colors are interpreted as a channel zone on the basis of the seismic trace shape and distribution pattern. B) Case of an upper horizon of the B2 unit. Reddish colors are interpreted as a channel zone. The map location is shown in Figure 2B.
An E-W long 2D seismic section transecting the Sanriku-oki subbasin, showing trench slope break uplift and subbasin confinement. Although the present status of the Cretaceous to Eocene forearc basin fill and trench slope break seems to be inclined seaward, it is estimated that the trench slope break was more or less uplifted and emerged as a barrier because of the leaping-up morphology and fluvial-dominated environments in the Cretaceous to Eocene forearc basin-fill successions. The 2D seismic data were acquired in a MITI survey [16]. The seismic survey line location is shown in Figure 2B.
Based on the characteristics of depositional systems and basin configurations of the Sorachi, Yubari and Sanriku-oki subbasins, a forearc setting model of the Eocene Ishikari–Sanriku-oki forearc basins can be proposed as shown in Figure 10. The trench slope break ridge is estimated to have emerged above the sea along the eastern margin (subduction zone side) of the forearc basins, and formed a barrier to the open sea condition in the trench side of the trench slope break. This uplifted trench slope break condition is supported by previous petrography studies [17–19], which reveal that sandstones of the forearc basin fill (Ishikari Group) contain chromspinels derived from an emerged ridge of the Kamuikotan Belt. The N-S trending Kamuikotan Belt is distributed along the eastern margin of the forearc zone in Hokkaido (Sorachi–Yezo Belt), and mainly consists of serpentinite and various kinds of high pressure-type metamorphic rocks with tectonic mélanges, formed in an accretional prism [3, 20].
Schematic and conceptual forearc setting model for the Eocene Ishikari–Sanriku-oki forearc basins, including the Sorachi, Yubari and Sanriku-oki subbasins. Small rectangles inside the basin denote approximate positions of the mapped areas for the Sorachi subbasin (Figure 6) and the Sanriku-oki subbasin (Figure 8).
Inside the forearc basin, major depositional systems were bay to fluvial systems without any wave-influenced facies. In response to relative sea level changes, transgression and regression repeated, and the major depositional system alternated between a fluvial system-dominated condition and a bay system-dominated condition. Because of the existence of marine sediments, it is estimated that there were an inlet interconnecting between the open sea and the inside of the forearc basin, through which the seawater came into the inside of the forearc basin.
Our forearc setting model also demonstrates forearc basin segmentation, reflecting the fact that the Eocene Ishikari–Sanriku-oki forearc basins were segmented into 50 to 150 km long subbasins aligned along the forearc extension (Figure 2B). As described above, the segmented subbasins show a different subsidence pattern and different sediment thickness for each subbasin.
The Pleistocene Tokai-oki–Kumano-nada forearc basins were developed in the forearc zone between the SW Japan Arc and the Nankai Trough subduction zone (Figures 2A, 2C). On the contrary to the sporadic developments of forearc basins during the late Paleogene and early Neogene time, thick sedimentary packages of the Late Pliocene to Pleistocene Tokai-oki–Kumano-nada forearc basins widely developed in this forearc zone. This section picks up the major basin-filling sediments equivalent to the Late Pliocene to Early Pleistocene Kakegawa Group (Atsumi-oki Group [21]) and Middle Pleistocene Ogasa Group (Hamamatsu-oki Group [21]; Figure 11) to examine the basin filling conditions and basin configurations. The Kakegawa Group unconformably overlies the underlying units with a certain time gap, indicating the different phase of forearc basin tectonics, and the Ogasa Group unconformably overlies the Kakegawa Group, indicating a tectonic event between depositions of the two groups. The study area is set between the Present continental slope toe and the trench slope break zone, which covers the Tokai-oki, Atsumi-oki and Kumano-nada areas (Figure 2C). From the standpoints of sequence stratigraphy and sedimentology, the targeted forearc sediments are divided into seventeen depositional sequences: Sequence Kg-a to -h and Og-a to –i, based on reflection termination patterns on the seismic sections and facies succession patterns on the well successions [22, 23](Figure 11). The major depositional system of the whole interval is a submarine fan turbidite system [22, 23].
Litho- and sequence stratigraphic framework of the latest Pliocene to Pleistocene successions in the Tokai-oki–Kumano-nada forearc basins. Modified after [22, 23].
Takano et al. [22] demonstrated a series of facies maps in the Tokai-oki–Kumano-nada forearc basins for each depositional sequence unit for the interval equivalent to the Kakegawa and Ogasa Groups (Figure 12). These facies maps were created on the basis of seismic facies information plotted on the seismic survey line maps as well as some exploration well data (Figure 2C) [22–25]. These facies maps clearly show the depositional patterns of submarine fans, indicating that quite a few numbers of submarine canyons from the main land of Japanese Islands functioned as fixed feeder systems, along which submarine fans were formed in the forearc basins (Figure 12). These facies maps also suggest that submarine-fan architecture was intermittently transformed through time (Figure 12)[22, 26]; from a braided channel-dominated condition (Stage 1 represented by the map of Sequence Kg-a), through a small fan-dominated condition with shrinking separated small basins (Stage 2 represented by the map of Sequence Kg-e), and a trough-fill turbidite-dominated condition (Stage 3 represented by the map of Sequence Og-e), to a channel-levee system-dominated condition (Stage 4 represented by the map of Sequence Og-h). Although the submarine-fan architecture was transformed temporary, some spatial differences in depositional patterns between the Tokai-oki, Atsumi-oki and Kumano-nada areas can also be recognized (Figure 12), possibly resulting from forearc basin segmentation and sediment supply variation.
Facies maps of Sequence Kg-a, -e, Og-e and -h in the Tokai-oki–Kumano-nada forearc basins, showing the transformation of submarine-fan morphology and distributions. Modified after [22]. The mapping area is shown in Figure 2C.
To examine the relationships between the changes in the submarine-fan depositional styles and basin configuration, which may be indicating the background tectonics, we investigated seismic sections transecting the Tokai-oki–Kumano-nada forearc basins. Figure 13 depicts the interpreted cross sections with depositional stage division characterized by the different submarine-fan depositional styles as mentioned above. The interrelationships between the geologic structures and sediment thickness change shown on these cross sections reveal that the depositional stage division can be connected with tectonic phases that created specific geologic structures related to basin configuration (Figures 13, 14). Since the Stage 1 sediments show a mostly uniform thickness and a braided channel-dominated condition, the forearc basin during Stage 1 (Late Pliocene to earliest Pleistocene) is interpreted to have been a gently inclined, sloped basin without major topographic undulation, which is characteristic of an incipient phase of forearc basin development [27]. Stage 2 (Early Pleistocene) is interpreted as a compressional stress stage with trench slope break uplift, since only limited synclinal areas contain thick sediments, and the depositional areas shrunk continuously. Stage 3 (Middle Pleistocene) can be a relaxing phase, which induced subsidence of folded forearc basins, since the sedimentation is characterized by trough-fill (syncline-fill) turbidite systems and the depositional territory became wider gradually. Stage 4 (Middle to Late Pleistocene) can be a compressional stress stage again, as trench slope break prominently uplifted as shown on the section B–B’ in Figure 13.
Consequently, it is suggested that during the Pleistocene time, two compressional phases occurred in response to trench slope break uplift and arcward suppression, and the forearc depositional styles were strongly controlled by these tectonic events.
Cross sections based on the interpreted seismic sections transecting the Tokai-oki–Kumano-nada forearc basins, showing the basin deformation and background tectonics during Stages 2, 3 and 4. Traced lines on the cross sections denote sequence boundary (SB) horizons corresponding to those of Figure 14 in line colors. The section locations (seismic survey lines) are shown on the maps in Figure 12. Seismic sections were acquired in a MITI (Ministry of International Trade and Industry of Japan) survey [24]. Large red arrows denote compression and uplift during Stage 2, subsidence during Stage 3 and uplift during Stage 4.
Generalized summary chart showing the transformation of the tectono-sedimentary conditions and submarine-fan types of the Pleistocene Tokai-oki–Kumano-nada forearc basin fill. Compiled and modified after [23, 26].
Dickinson’s simple classification scheme for forearc basin morphology [1] is based on the basin filling conditions and sectional basin configurations basically controlled by trench slope break height (Figure 15). Since the basin filling condition comprises two classes: underfilled and overfilled, and the sectional basin configuration comprises four classes: sloped, ridged/terraced, ridged/shelved and ridged/benched, depending on the trench slope break height, forearc basins can be classified into eight different types in the Dickinson’s classification scheme [1] (Figure 15). According to our analysis results, the Eocene Ishikari–Sanriku-oki forearc basins can be categorized into the “emergent ridged”, “overfilled shelved” to “benched” types (Figure 15), as it is interpreted that the trench slope break was uplifted and emerged, and the major sedimentary environments were mostly near the sea level except partly developed braided rivers in an elevated setting. On the contrary, the Pleistocene Tokai-oki–Kumano-nada forearc basins can be categorized into the “overfilled sloped”, “underfilled submerged ridged” to “overfilled deep marine terraced” types (Figure 15), as the estimated trench slope break was submerged and low, and the major sedimentary environments were submarine fans and muddy slope to basin floor.
Dickinson’s forearc basin classification chart on the basis of basin filling conditions and sectional basin configuration. Modified after [1]. TSB: trench slope break.
This section attempts to discuss major controlling factors on the variation in forearc basin configurations and depositional systems on the basis of the results of the examinations above (Figures 16, 17).
Trench slope break is a topographic high bounding the forearc basin to a trench slope steeply dipping to the subduction zone (Figure 1). As the Dickinson’s forearc basin classification places great importance [1] (Figure 15), the results of our examination also indicate that the development condition of a trench slope break is the most principal factor to control the forearc basin configurations and basin filling depositional systems. In case the trench slope break development is minor or moderate as seen in the Tokai-oki–Kumano-nada forearc basins, the trench slope break ridge is submerged, and the basin filling sediments tend to be deeper marine shales or turbidites. On the other hand, in case the trench slope break prominently develops as seen in the Ishikari–Sanriku-oki forearc basins, the trench slope break ridge is emerged, and the basin filling depositional systems tend to be fluvial to bay systems if sediment supply is enough. Dickinson [1] suggests that the trench slope break development is strongly related to differences in plate subduction conditions such as accretional prism formation and tectonic erosion.
In addition to the height of a trench slope break, related arcward suppression accompanied with the trench slope break uplift is also regarded as an important factor to control basin deformation as seen in the Tokai-oki–Kumano-nada forearc basin (Figure 13).
Even in a fully uplifted trench slope break setting, a condition under minor sediment supply or relatively rapid subsidence causes a deeper marine forearc basin. The Ishikari–Sanriku-oki forearc basins maintained a balanced condition between the amount of sediment supply and the basin accommodation space, causing a thick accumulation of fluvial to bay sediments. Accordingly, it is suggested that the balance between sediment supply and forearc basin accommodation created by a trench slope break barrier and basin subsidence [28] (total subsidence) can be a crucial controlling factor not only on the forearc basin filling conditions such as underfilled and overfilled conditions but also on the variation of depositional systems. Dickinson [1] suggests that the underfilled types mostly occur along an island arc with a small amount of sediment supply, whereas the overfilled types mostly occur along a continental arc with a large amount of sediment supply.
Our examination results suggest that a forearc zone is commonly segmented into subbasins. The Ishikari–Sanriku-oki forearc basins were segmented into 50 to 150 km long subbasins aligned along the forearc extension (Figure 2B). The Tokai-oki–Kumano-nada forearc basins are also possible to have been segmented as suggested by Sasaki et al. [29] and as seen in the facies maps (Figure 12), in which the sedimentary packages tend to be segmented into the Tokai-oki, Atsumi-oki and Kumano-nada possible subbasins. As described above, the segmented subbasins show a different subsidence pattern and sediment thickness for each subbasin (Figures 7, 13), and differential subsidence within a subbasin is characteristically observed (Figures 6, 7).
As a possible formation mechanism of forearc segmentation, Dickinson [1] suggests strike slip tectonics along a forearc zone, induced by oblique plate subduction underneath a forearc zone. As many of plate subduction direction at the convergent margin tend to be not complete normal direction to the subduction trench, oblique plate subduction is quite common. The oblique subduction may induce a strike-slip motion of forearc sliver and basin segmentation as seen in the Sumatra forearc and Aleutian forearc [1].
To examine the effect of strike-slip motion on the forearc basin segmentation, Kusumoto et al. [30] conducted dislocation modeling for basin segmentation, using the Sorachi and Yubari subbasins as examples. Dislocation modeling is to simulate basin dislocation by fault movement with the assumption of a homogeneous elastic body. Kusumoto et al. [30] picked up fault arrays around the subbasins, which indicate a strike-slip fault system consisting of main faults and splay faults, and set them in the model. When right-lateral motion occurred along the main faults, then the subbasins corresponding to the Sorachi and Yubari subbasins were properly simulated in the modeling [30]. This result suggests that the forearc basin segmentation was caused by strike-slip tectonics along the forearc zone.
Consequently, strike-slip tectonics is also one of the crucial factors to determine basin configuration and depositional system distributions in a forearc zone (Figures 16, 17). Figure 17 demonstrates schematic diagram showing type variations of forearc basins as functions of trench slope break development, arcward compression and strike-slip movement. In addition to the Dickinson’s forearc basin classification scheme (Figure 15), this study delineates that both arcward compression and strike-slip movement are crucial factors in forearc basin classification. In case arcward compression is intense due to trench slope break evolution, a confined shrinking or trough-fill type forearc basin can be formed, as seen in Stages 2 and 3 in the Tokai-oki–Kumano-nada forearc basins (Figures 12, 13, 14). In case strike-slip movement is dominant, a segmented marine or non-marine forearc basins can be formed, as seen in the Sorachi and Yubari subbasins (Figures 5, 10). When strike-slip movement is intense, the forearc basin can be transformed into a fragmented strike-slip basin.
Controlling factors on variation in forearc basin configuration and depositional systems.
Schematic diagram showing type variations of forearc basins as functions of trench slope break development, arcward compression and strike-slip movement. Arrow direction denotes intensity of each factor.
To elucidate forearc basin variation and its controlling factors, the basin configurations and basin-filling depositional systems were examined for actual examples from the Eocene Ishikari–Sanriku-oki forearc basins and the Pleistocene Tokai-oki–Kumano-nada forearc basins. As the results, the following points were revealed.
The Ishikari–Sanriku-oki forearc basins are filled with aggradational sediments consisting of bay to fluvial systems. Since the trench slope break is estimated to have uplifted and emerged to form a barrier to an open sea condition, the Ishikari–Sanriku-oki forearc basins can be categorized into the “emergent ridged”, “overfilled shelved” to “benched” types of Dickinson’s forearc basin classification [1]. Basin segmentation is commonly observed, and the subsidence pattern is different between subbasins.
The Tokai-oki–Kumano-nada forearc basins are filled with continuously changing submarine-fan systems. Since the trench slope break is estimated to have submerged, the Tokai-oki–Kumano-nada forearc basins can be categorized into the “overfilled sloped”, “underfilled submerged ridged” to “overfilled deep marine terraced” types [1].
Our examination results suggest that the major controlling factors on the forearc basin configurations and depositional systems include a) the trench slope break condition such as development height and arcward suppression, b) the balance between basin accommodation and sediment supply, c) and the strike-slip movement of forearc sliver, inducing forearc basin segmentation. Although the Dickinson’s forearc basin classification [1] is effective, two factors of arcward compression and lateral-slip movement should be added for useful classification (Figure 17).
The authors are grateful to Drs. Ray Ingersoll, Cathy Busby and Paul Heller for useful suggestions on the tectonics and sedimentation of forearc basins. JAPEX, JX, JOGMEC, METI and MH21 Research Consortium kindly provided permission for data publication. This study was partly conducted under the MH21 Research Consortium.
Many diseases especially non-communicable diseases (NCDs) culminate in end-stage organ failures; the preferred treatment for most end-stage organ diseases is transplantation. Transplantation programme is a complex healthcare service which entails huge costs and requires highly skilled health professionals, complex infrastructure and equipment, and well-articulated legal frameworks to enable its operationalization [1]. The need for appropriate interventions for organ failures in sub-Saharan Africa (SSA) is underscored by the high prevalence of end-organ diseases such as chronic kidney disease (CKD), chronic liver disease (CLD), chronic lung and heart diseases (interstitial lung disease, cystic fibrosis, cardiomyopathies and chronic rheumatic heart diseases) which cause increased morbidity and mortality. For example, Kaze et al [2] in a systematic review of prevalence studies on CKD in SSA documented the highest prevalence in West Africa 19.8%, Central Africa 16%, East Africa 14.4%, and Southern Africa 10.4%.
Globally, beside organs, tissues and cells (bone marrow cornea, etc.) are also transplanted. However, in SSA, apart from South Africa which also does liver and heart transplantation, the common organ transplanted is the kidney [3]. Though outcomes for transplantation have improved over the years due to better surgical techniques including minimal access surgeries, newer and better immunosuppressive medications, innovations in organ donation; improvement in transplant services is not apparent in SSA. Organ transplantation remains largely inaccessible and unaffordable to this population.
Sub-Saharan Africa has a disproportionate burden of communicable diseases (CDs) and NCDs compared to other world regions [4]. Currently, NCDs are responsible for a large and increasing burden of death and disability in the region. World Health Organization (WHO) in 2018, documented that NCDs killed 41 million people per year accounting for 71% of the global deaths [5]. The ages most affected were 30 to 69 years age-group, belonging to the productive workforce of any population. People from low income countries (LICs) and lower-middle income countries (LMICs) accounted for most of these deaths approximating over 85%. Four of the five commonly quoted diseases i.e. the “Big Five” (cardiovascular diseases, cancers, respiratory diseases, diabetes mellitus (DM) and mental illness) that account for most NCD deaths are drivers of CKD. Several risk factors with multiplier effect on NCDs are tobacco use, physical inactivity, harmful use of alcohol and unhealthy diets. Communicable diseases, though less common in high income countries (HICs) and upper-middle income countries (UMICs) are still prevalent in LICs and LMICs prompting WHO to highlight the double burden of diseases in these regions [6]. Both CDs and NCDs culminate in end-organ disease underscoring the high prevalence of end-organ failures, disabilities and deaths in SSA (see Figure 1). Unfortunately, most countries in this region lack resources to cope.
Causes of deaths in sub Saharan Afirca 1990 and 2017 [from Institute for Health Metrics and Evaluation (IHME) data].
In 2014, Stanifer et al [7], in a systematic review and meta-analysis of 21 studies in SSA documented an overall CKD prevalence of 13·9%. According to the Institute for Health Metrics and Evaluation (IHME) data, CKD and DM were the 14th cause of death in SSA in 1990 but worsened to 11th by 2017 (see Figure 1). Hypertension and DM constitute the main NCDs that cause CKD globally [8]. In many low resource countries (LRCs), chronic glomerulonephritis and interstitial nephritis assume significance because of the pervading and persisting high prevalence of CDs (mainly bacterial, parasitic, and viral infections) [9]. Human Immunodeficiency virus (HIV) infection which continues to plague SSA, albeit better controlled, is a key driver of kidney disease. Of the 38 million people living with HIV globally, more than 25 million live in this region [10, 11]. The recent pandemic of COVID-19 infection which has adverse acute effects on the kidney has probable unknown long-term sequelae [12]. Both CDs and NCDs fuel the high and increasing prevalence of CKD in LRCs. Without renal registries in many LRCs, there is poor documentation of data on kidney diseases.
Viral hepatitis is prevalent in Africa with high endemicity of Hepatitis B Virus (HBV) in SSA and Hepatitis C virus (HCV) in North Africa. Africa has approximately 60–100 million of the world’s 257 million viral hepatitis infections [13]. The WHO noted that between 1980 and 2010, cirrhosis-related deaths doubled in the region. The increasing burden of obesity and DM leading to non-alcoholic fatty liver disease contributes to high prevalence of CLD and end-stage liver disease (ESLD). Up to 40% of patients with chronic hepatitis may progress to liver cirrhosis and/or liver cancer [14] and without liver transplantation mortality is estimated at about 15% in one year [15]. All patients with ESLD will invariably require liver transplantation; however, liver transplants are uncommon in SSA.
There is scant information on prevalence of other end organ failures such as heart, lung, and small bowel requiring organ transplantation in SSA.
The WHO in collaboration with the Organización Nacional de Trasplantes of Spain set up the Global Observatory on Donation and Transplantation (GODT) with the mandate to document the distribution of organ transplantation programmes in the countries that report their data to the Observatory and to evaluate the access of transplantation activities worldwide [16]. Upon subsequent request of the World Health Assembly (Resolutions WHA57.18 and 63.22) that global data on the practices, safety, quality, efficacy, epidemiology and ethical issues of allogeneic transplantation be collected and documented, the GODT was inaugurated in 2007 [16]. This database has ensured provision of transparent and equitable monitoring of national transplant systems.
Currently, according to the GODT database, [17], 139,024 solid organ transplants were reported globally in 2017: 90,306 kidney (36% from living donors), 32,348 liver (19.0% from living donors), 7881 heart, 6084 lung, 2243 pancreas and 162 small bowel transplants. Africa contributes the least number of transplant activity per continent and SSA the least number per WHO World region (Tables 1 and 2; Figure 2). Tables 1 and 2 show data from 2016 GODT Report.
Region | Countries N | Countries with data N (%) | Population millions | Population with data millions (%) |
---|---|---|---|---|
AFR | 46 | 10 (21.7) | 1139.1 | 506.6 (44.5) |
AMR | 35 | 21 (60.0) | 986.5 | 968.5 (98.2) |
EMR | 22 | 15 (68.2) | 656.1 | 535 (81.5) |
EUR | 53 | 49 (92.5) | 909.7 | 904.2 (99.4) |
SEAR | 11 | 5 (45.5) | 1928.4 | 1408.8 (73.1) |
WPR | 27 | 11 (40.7) | 1847.7 | 1815.3 (98.3) |
Total | 194 | 111 (57.2) | 7467.5 | 6138.4 (82.2) |
Proportion of countries and population covered by the GODT database in the WHO regions. Year 2015 [17].
Africa Region (AFR) | America Region (AMR) | Eastern Mediterranean Region (EMR) | Europe (EUR) | South East Asia Region (SEAR) | Western Pacific Region (WPR) | |
---|---|---|---|---|---|---|
Kidney | 488 (1.0) | 31,859 (32.9) | 6127 (11.5) | 26,131 (28.9) | 7202 (5.1) | 12,540 (6.9) |
Liver | 67 (0.1) | 10,426 (10.8) | 1539 (2.9) | 9582 (10.6) | 1292 (0.9) | 4853 (2.7) |
Heart | 14 (0.03) | 3604 (3.7) | 135 (0.3) | 2646 (2.9) | 40 (0.03) | 584 (0.3) |
Lung | 12 (0.02) | 2507 (2.6) | 56 (0.1) | 2007 (2.2) | 1 (0.0) | 463 (0.3) |
Pancreas | 5 (0.01) | 1236 (1.3) | 24 (0.04) | 890 (1.0) | 1 (0.0) | 143 (0.1) |
Small Bowel | 0 (0.0) | 147 (0.2) | 4 (0.01) | 43 (0.05) | 0 (0.0) | 1 (0.0) |
Total Organs | 586 (1.2) | 49,779 (51.4) | 7885 (14.7) | 41,299 (45.7) | 8536 (6.1) | 18,585 (10.2) |
Absolute numbers and rates of the organ transplant activities per WHO region. 2015 [17].
World map of transplantation in 2019 showing total sum of transplants [from global Observatory of Donation and Transplantation].
Kidney transplants are available in 102 countries; living kidney transplants in 98 countries and deceased donors in 76 countries [16]. Sixteen countries representing 6.6% of the global population perform only living donor kidney transplants. In SSA, a handful of countries carry out transplantation: South Africa, Sudan, Seychelles, Ivory Coast, Namibia, Nigeria, Kenya, Ghana, Tanzania, Mauritius, Ethiopia but only five countries (Ethiopia (0.34 pmp), Kenya (1.51 pmp), Nigeria (0.47 pmp), South Africa (6.81 pmp) and Sudan (6.58 pmp)) report their data to GODT (Figure 2).
Sub-Saharan Africa is heterogeneous and has a population estimated at 1.1billion [18]. It is projected that countries in this region would account for more than half of the world’s growth by 2050 [19]. This geographical region fully or partially located south of the Sahara Desert occupies an area of about 24 million Km2 (Figure 3). It is made up of 47 countries divided into 4 WHO sub-regions. Most countries in this region belong to the LICs and LMICs according to World Bank Classification of economies and are also described as LRCs. Africa is the second largest and second most populous continent; SSA occupies about 80% of the continent [20]. Although the economic growth in Africa has been remarkable in recent years, the gap between the rich and poor is wide and many people still do not have access to basic amenities such as potable water, good sanitation and basic health services [20].
Map of Africa showing UN sub-regions.
The WHO defines health systems as “all organizations, people and actions whose primary intent is to promote, restore, or maintain health” [21]. In LRCs, these systems have long been weak and deficient in most aspects of healthcare delivery and therefore, there is persistent need to evaluate health system challenges at all levels [22]. Health security is a crucial public health issue. It is ensured when there is protection against any health threats and also involves ability to handle emerging new health conditions by adapting and developing new approaches [23]. The epidemics in recent years (SARS, MERS and Ebola) including the COVID-19 pandemic bring to the fore the inability of the health systems in SSA to cope with health crisis and other prevalent health conditions [24].
Some healthcare professionals have poor work ethics deriving from unsavory work environment and remunerations. Transplantation is a highly specialized service that entails full commitment of the workforce and long work hours. For a good transplant programme, the national health system and the hospitals have to commit to improving the skill set of the work force through adequate staff training and other development opportunities, incentivization of the programme and offering a very supportive work environment [25].
Traditions and cultures influence the mindset of a people; decision to access healthcare service is informed by many factors (accessibility, affordability, spirituality and religiosity, and knowledge of the disease condition) [26]. When ill, many people in LRCs seek alternative healthcare service including traditional health providers and religious institutions resulting in late presentation to hospitals [27].
In 2018 and 2019, Africa’s economic growth was at 3.4% and was expected to rise to 3.9% and 4.1% in 2020 and 2021 respectively [28]. Amid the COVID-19 pandemic of 2020, the dynamics changed resulting in contraction of economies globally with expected 1.7% to 3.4% contraction of Africa’s economy [29].
The 2001 Abuja Declaration recommended allocation of 15% of the annual national budget to the health sector; achieving this has been challenging [30]. In 2012, 6 countries met the target; and this reduced to 4 in 2014. Currently, the preferred indicator for health financing is the percentage gross domestic product (% GDP). To achieve universal health coverage (UHC), the World Health 2010 Report suggested that a national government has to spend at least 4–5% of GDP on health [31]. Whilst per capita expenditure on health in America and Europe were over $1800 in 2014, the per capita expenditure on health in Africa averaged only $51.6 [32]. Further analysis shows that over the same period, in Africa, general government health expenditure was less than 50% of the total health expenditure while other sources such as out of pocket (OOP) payments and external sources (from funders) accounted for over 50% [32]. In general, transplantation service largely depends on robust and adequate finances hence the programme thrives in HICs and UMICs.
South Africa: the first organ transplantation in Africa was kidney transplant performed by Thomas Starlz and colleagues in 1966 at Wills Donald Gordon Medical Centre, Johannesburg, South Africa [33]. This was followed in 1967 by the first successful heart transplant performed in the world at Groote Shuur Hospital, Cape Town, South Africa by Christian Barnard [34, 35]. Barnard and his team championed the orthotopic and heterotopic (‘piggy-back’) heart transplant. From 1968 to 1983, they engaged in research on cardiac transplantation thereby laying the foundation for heart transplantation as therapy for end-stage cardiac disease. The team advanced the concept of brain death, organ and tissue donation, and ethical issues in transplantation. They also researched on methods to improve preservation and protection of the donor heart: their studies ranged from developing appropriate hypothermic perfusion for heart storage, haemodynamics and metabolic changes in brain death to xenotransplantation [34].
Though, South Africa has the most advanced transplant programme in the continent, globally, their transplant activities remain lower than those of other countries with comparable economic capacity [35, 36]. South African liver programme has existed for about 2 decades and presently offers living-related liver transplantation. Other solid organ programmes available are combined kidney-pancreas and lung transplantation. Her donor programmes have advanced to extended criteria donors (ECD) and donors after circulatory death [37]. South Africa has high prevalence of HIV resulting in a huge HIV-positive population prompting Muller and colleagues to pioneer HIV-positive-to-positive transplant program in 2008 [38]. By 2018, this programme had successfully transplanted 43 kidneys from 25 deceased donors [39].
Namibia had first kidney transplantation in March 2016 [40] and is also reported to have done a heart transplant [41].
Ghana started a kidney transplant programme in 2008 at Korle Bu Teaching Hospital, Accra in collaboration with a hospital and a charity organization in UK. Between 2008 and 2014, the programme performed 17 transplants and in 2015, they established a national registry [42].
Ivory Coast implemented the law authorizing organ donation in 2012 [43] and between 2013 and 2015, ten living-related kidney transplantations had been done [44].
Nigeria commenced organ transplantation activity in 2000 in a privately-owned hospital [45]. Currently, there are 15 centres (public 9, private 6) and over 770 transplants had been performed between 2000 and 2019 [Personal Communication].
Ethiopia commenced its transplant programme in collaboration with an American hospital in September 2015 and by February 2018, had done 70 living donor kidney transplants at their only transplant centre [46].
Kenya started kidney transplantation in 2009 and by 2019 had performed 200 transplants. Their government augmented the existing infrastructures to support 10 transplants per month [47].
Mauritius began kidney transplantation in 1980 and discontinued in 1982 following poor outcomes but resumed in 1993 [48]. Although the “Human Tissue (Removal, Preservation and Transplant) Act” was promulgated in 2006 and amended in 2013, a new legislation was enacted in 2018 [49].
Sudan, according to the African Union belongs to East African sub-region even though the United Nations categorized her as North Africa. Sudan had her first kidney transplant in 1974 and for the subsequent 25 years performed very few transplants. However, in 2000, the program was reactivated; and 222 transplants were performed in 2016 [50].
Tanzania started kidney transplantation services locally in collaboration with hospitals in India and Japan in November 2017 [51]. Earlier, her program consisted of government-sponsored transplantation overseas. Recipients and donors received pre-transplantation work-up locally and donor verification by DNA profiling was done to curtail commercialization.
Ugandan cabinet in June 2020 approved a bill to establish a legal framework for human organs, cells and tissue transplant, and to regulate donations and trade in human organs, cells and tissue [52].
No country in this sub-region has a transplant programme but Angola in March 2019 passed a law on human tissue, cell and organ transplant to enable transplantation [53].
In SSA, the national programs for donation and transplantation of organs and tissues are slow and poorly developed and they are fraught with inadequacies in infrastructures, institutional support, and technical expertise [3]. These are attributed to the huge costs and complexity of transplantation, low GDP, lack of subsidy and dearth of facilities.
Loua et al in 2018, documented that 62 transplant centres across seven countries in Africa had transplant activities involving kidney, heart, cornea, liver and bone marrow [3].
Programmes are classified into different stages of development of transplant services with those from HICs better developed than those from LMICs and LICs [54] (See Table 3).
Stage | Characteristic | Country |
---|---|---|
I | No existing transplant programme with little or no posttransplant and post-donation care. Transplant tourism is rife. | The poorest countries of the world |
II | Faltering or poorly developed transplant programme offering only living-related donation, no nationally structured transplant program, and often no legislation. There is nonexistent deceased-donor program and proliferation of transplant tourism with little or no posttransplant and post-donation care. | Countries in sub-Saharan Africa and many other low- and middle-income countries |
III | Fairly developed transplant programme offering mostly living-related donation with rudimentary deceased-donor program. Poorly developed kidney paired exchange and organ sharing programs, often with poor posttransplant and post-donation care. Some level of transplant tourism and moderate to long wait time. | Many countries in Asia, Central and South America, the Middle East, and North Africa |
IV | Well-developed structured transplant programme and accompanying legislation offering deceased donation, kidney paired exchange, and organ sharing programs with good posttransplant and post-donation care. Little transplant tourism and short to moderate wait times for transplant. | Many of the developed economies belong to this stage |
V | Highly developed and structured transplant programme and accompanying legislation offering mostly deceased donation, advanced donation/kidney paired exchange, and organ sharing programs with excellent posttransplant and post-donation care. There is no transplant tourism and short or no wait times for transplant. | Utopian |
Proposed staging for transplant stratification model (transplant transition) [54].
Careful evaluation of potential organ transplant recipients is necessary to detect co-existing illnesses that can adversely affect the prognosis of the transplantation. The subsisting clinical practice guidelines including the 2020 KDIGO guideline and the 2011 UK Renal Association Clinical Practice guideline (5th Edition) [55, 56] recommend the standard process of evaluation of prospective transplant recipients. Regardless of the recommendations of the practice guidelines, most transplant centres have their in-house protocols for transplant recipient evaluation. However, in SSA, the evaluation may be tailored to the available resources but should be efficient and cost-effective. The discussion below is typical for kidney transplant units in Nigeria but may apply to other organ transplantations and transplantations in other countries in the sub-region.
The evaluation of such candidates involves risk/benefit assessment and they should have at least five-year life expectancy derived from age, gender and race of the individual [57]. Many clinicians, however, consider other factors including severity of life-threatening diseases, functional status, clinical experience and knowledge of the patient to determine suitability for organ transplantation.
The workup evaluation includes: hematological, clinical chemistry, infection profile, diagnostic procedures, imaging and immunological tests. The list of relevant investigations is shown in Table 4.
Blood |
|
Radiology |
|
Urine |
|
Immunology |
|
Gynecological |
|
Other tests |
|
Workup for prospective organ transplant recipients.
Blood grouping establishes the candidate’s blood type and determines if further evaluation should proceed. Recipient and donor must be compatible. Complete blood count and clotting profile should be optimal.
All candidates are assessed for presence of cardiac disease by history, physical examination and electrocardiogram. Recipients with cardiac disease, comorbidities that predispose to coronary artery disease (CAD), history of previous CAD or poor cardiac function are further assessed by cardiologists. Generally, contraindications for transplantation include severe heart disease (New York Heart Association [NYHA] Functional Class III/IV), severe CAD, left ventricular dysfunction [ejection fraction <30%] and severe valvular disease.
Chest radiograph is required for all candidates while chest computerized tomography (CT) is reserved for current or former heavy smokers (≥ 30 pack-years). Candidates with lung disease are further evaluated by a pulmonologist. Severe irreversible obstructive or restrictive pulmonary diseases are contraindications for transplantation.
Sub-Saharan Africa has high prevalence of tuberculosis (TB). It is therefore necessary to screen for TB in prospective organ recipients with a chest radiograph and purified protein derivative (PPD) skin test. Candidates with positive TB screening tests are treated before organ transplantation.
Candidates with history of peptic ulcer disease (PUD) are screened with oesophagogastroscopy and Helicobacter pylori test. Active diseases including PUD, diverticulitis, pancreatitis, cholelithiasis and inflammatory bowel disease should be controlled before transplantation.
Serological tests for potentially transmissible diseases, like HIV, HBV, HCV, cytomegalovirus (CMV), Epstein–Barr virus and varicella-zoster virus are usually performed, and appropriate management instituted when indicated.
Routine cancer screening is done for all recipients. Chest radiograph is mandatory while chest CT is reserved for current or former heavy smokers. Ultrasonography is used for screening candidates at risk of renal cell carcinoma (dialysis >3 years, family history of renal cancer, acquired cystic disease, analgesic nephropathy). Those at risk of urinary bladder cancer (high-level exposure to cyclophosphamide, heavy smoking) require cystoscopy. Patients at risk of hepatocellular carcinoma are screened with ultrasonography and serum alpha fetoprotein. Colonoscopy is done to screen for bowel cancer and inflammatory bowel disease. Females undergo PAP smear and mammography to exclude cervical and breast cancer respectively.
Obesity increases the risk of post-operative complications. Many transplant centres prefer a body mass index (BMI) of <30.
These are very important aspects of the workup for prospective organ transplant recipients and will be discussed later.
Donor protection should always be taken into account during living donor selection and assessment. Organ donation should be altruistic, voluntary and never coerced. Donor evaluation is a multidisciplinary exercise, and is done before, during and after donation. Due to lack of requisite legislation, supporting infrastructure, religious and cultural beliefs, mostly living organ donations are done in SSA countries.
There are risks associated with organ donation and consequently, potential donors should receive medical, surgical and psychological screening. Pre, intra, and post-operative care as well as structured post-donation follow up are important.
Potential donors should be healthy and neither too young nor too old. Medical history and physical examination could elicit risk factors for kidney disease such as: DM, hypertension, family history of kidney disease, herbal drug, non-steriodal anti-inflammatory drugs (NSAIDs), and other nephrotoxin use. History and/or presence of CLD could be suggested by jaundice and alcohol abuse. Also, history of psychiatric illness, malignancies, smoking and substance abuse, etc. should be sought and positive candidates excluded. Donors should not be morbidly obese and blood pressures should be <140/90 mmHg.
For various investigations see Table 5.
Parameters | Relevant indices |
---|---|
Age | >18, <60 years |
History | Diabetes mellitus, hypertension, nephrotoxins, alcohol and other substance abuse, cigarette smoking, psychiatric illness, malignancy |
Physical features | Jaundice, pallor, BP >140/90 mmHg, BMI >35 |
Laboratory features | |
Hematological | FBC, PT/INR |
Chemistry | SEUCr, LFT, lipid profile, FBG, HBA1C, PSA, TFT |
Microbiology | Urinalysis, urine culture |
Serological/ immunological | HIV, Anti HCV, HBsAg, CMV, EBV, ABO blood group, HLA A, B and DR matching, HLA antibody cross- matching |
Imaging | Ultrasound, CT angiography, |
Others | ECG, Echocardiography |
Workup for potential organ transplant donors.
Absence of urinary markers of disease such as proteinuria, haematuria, pyuria and casts, may rule out kidney diseases in potential donors. Glomerular filtration rate (GFR) should ideally be measured but is often estimated using serum creatinine in most LRCs. Prospective donors are screened for chronic viral diseases. Notably, CMV positivity in a donor has implication for a CMV-negative recipient, who due to subsequent immunosuppressive drug use will likely succumb to its infection. Screening for TB (CXR, Mantoux test, sputum GeneXpert) is important in SSA because 1/3 of the population is infected with M. tuberculosis [58]. The ABO blood group compatibility with recipient is mandatory; however, Rhesus factor mismatch is not a major consideration for solid organ matching. There are many HLA antigens (Class I: HLA-A, B, and C; Class II: HLA-DR, DQ and DP), but the HLA A, B and DR are usually cross-matched between donors and recipients (i.e. tissue typing).HLA antibody cross-matching is important to prevent early graft rejection. It detects the presence of HLA antibodies in recipients that can react with donor’s lymphocytes, i.e. donor specific antibodies (DSA).
HLA antibody cross-matching was originally based on complement dependent cytotoxicity (CDC) assays. It is done with recipient’s serum on donor lymphocytes or pooled lymphocytes of previous donors within the transplant centre’s population to determine the Panel Reactive Antibodies (PRA). Reactive Antibodies (PRA). The PRA estimates the recipient’s chances of tolerating allografts from that population and is useful for deceased donation.
Solid phase assays, ELISA or flow cytometry (Luminex)-based are now available and preferred. Most transplant centres in SSA, outsource tissue typing and HLA antibody cross-matching. Protocols require at least two HLA antibody cross-matches, with the last, just before the transplant procedure.
Imaging evaluation using ultrasonography and doppler in prospective donors should demonstrate normal kidneys (sizes and echotexture) and renal blood flow.
The CT-angiography helps to rule out solitary kidney or detect the presence of multiple or abnormal renal arteries, which have surgical implications for nephrectomy in donors and anastomoses in recipients.
Counseling donors on short and long-term risks associated with organ donation is necessary. Possible complications such as pain, post-operative infections, blood loss, deep venous thrombosis and pulmonary embolism can occur. Studies have shown that peri-operative mortality and morbidity during organ donation, are about 0.03% and 10% respectively [59]. Some studies show that with careful selection, kidney donors live long, although hypertension, proteinuria and reduced GFR can occur over time [60]. The risk of ESKD following kidney donation is about 0.3% [61]. Emotional consequences after organ donation should be anticipated therefore psychosocial assessment should be independently organized by the transplant team before and after donation.
Many transplantation programmes in SSA adopt protocols from established and experienced centres.
According to US Organ Procurement and Transplantation Network (OPTN) guidelines, living donor follow-up is done at discharge (or at 6 weeks), 1 year and 2 years [62]. Parameters monitored include weight, blood pressure, lipid profile, kidney and liver functions. Healthy eating, regular exercise and the dangers of substance abuse are emphasized. After uneventful 2 years, donor follow-up is continued by the primary care physicians but for those with adverse outcomes appropriate referral is made. Post-donation follow-up is important for donor safety and wellbeing to enable diagnosis and treatment of co-morbidities.
In transplantation, recipients, donors and their families are faced with various challenges including psychological and behavioral issues. Evaluation is essential in the following aspects: candidate and donor selection, counseling, pre- and post-transplant assessment, patient, caregiver and family adjustments to transplant and issues related to psyche of transplant staff.
Various factors exert neuropsychiatric effects in transplantation. Studies link significant neuropsychiatric adverse effects to cyclosporine, tacrolimus, steroids and other components of treatment. Therefore, psychosocial issues should be considered and addressed in order to achieve a successful transplant.
Psychosocial evaluation of patients for transplant include [63]:
Patient profile: relationships, education, work and legal history
Expectations from the surgery
Organ failure: cause, complications, course, adherence to treatment
Ways of coping with the illness
Support network: caregivers, family, friends, faith organizations and employers
Psychiatric history: extant, past and family.
Substance abuse history
Mental status exam: neuropsychiatric tests
Ability to give informed consent
There are known stressors before and after transplantation including depression and hopelessness, anxiety, uncertainty and aggression. These may be followed by hope, and confidence in an unpredictable pattern as recipients gradually process adaptation to the new situation.
After Transplantation, recipients pass through three phases of adaptation [64]:
“Foreign body” phase: the organ feels strange to the recipient. Persecution anxiety or idealization could arise. The organ could be seen as fragile and precious, thereby generating excessive protective feelings towards it.
“Partial incorporation” phase: recipient begins to integrate the organ.
“Total incorporation” phase: recipient is no longer aware of the organ.
In the long-term postoperative period, medication side effects and associated comorbidities become central stressors affecting the recipients’ quality of life (QOL). The most bothersome stressors are work related, like farming, schooling, etc. [65]. Recipients might feel stressed by the strict adherence to the medical regimen. This, in turn, can compromise their adherence after transplantation. Financial problems and legal disputes constitute other possible sources of psychological strain with health or pension insurance agencies, where available.
Enabling transplant recipients commence productive employment constitutes the main goal of transplantation and is considered an indicator of societal participation [66]. Globally, data show that 18% - 86% of recipients return to work or find new employment. [67, 68] but no data is available for SSA.
Multiple factors motivating donors include intrinsic factors (e.g., desire to relieve another’s suffering or to act in accordance with religious convictions) and extrinsic factors (social pressures or perceived norms) that may operate simultaneously. The combination of motivational forces differs depending on whether and how the donor is related to the recipient.
Most living donors use two decision-making strategies: [69]: “moral” which involves awareness that one’s actions can affect another [70] and “rational” which is focused on gathering relevant information, evaluating alternatives, selecting an alternative, and implementing the decision.
Potential donors’ psychological stability has been one of the greatest concerns for living transplant programmes, particularly in the context of unrelated donation. The willingness or desire to donate to a stranger has been historically viewed with suspicion [71, 72]. Studies suggest that most potential donors do not suffer from mental illness. [73, 74]. Many donors have reported positive feelings about donation however, a few have observed psychological distress, anxiety and depression. Thus, it becomes critical to identify, and mitigate key risk factors for these poorer outcomes: non-first degree relatives [75, 76], ambivalent donors [76, 77] and “black sheep” donors (persons who donate in order to compensate for past wrong doings or to restore their position in the family) are at higher risk for poorer post-donation psychosocial outcomes [76, 77].
The donor kidney angiogram is decisive in selecting the kidney to be harvested. The larger kidney with better blood flow is left for the donor. Minimal access donor nephrectomy and robot-assisted renal engraftment reduce postoperative complications. These, however, are not easily available in most LRCs.
The harvested kidney is covered in ice slush, wrapped in gauze piece and preserved in ice container as organ perfusion machine is not readily available in the sub-region.
Kidneys with multiple arteries are avoided but if inevitable, arteries are anastomosed side to side, end to side, or separately onto the external iliac artery (Figure 4). The right external iliac vessels are more superficial than the left and this side is frequently preferred for the first renal engraftment.
Donor angiogram with multiple left renal arteries.
Anti-reflux uretero-cystostomy is performed over a size 4Fg double J-ureteric stent (Figure 5).
End-to-side donor-recipient arterial anastomosis with kidney wrapped in gauze piece packed with saline ice slush.
Sclerosed External Iliac Vein (EIV): this results from repeated cannulation of EIV for hemodialysis. Recipient pre-operative EIV doppler ultrasound scan for patency is important. Major complications of recipient engraftment include bleeding, delayed graft function, hyperacute rejection and allograft renal vein thrombosis.
Immunosuppressive regimen is divided into induction and maintenance phases.
This is required to prevent acute rejection. Due to sensitization from blood transfusions, previous pregnancies (females) and increased susceptibility to graft rejection (in blacks) recipients undergo induction [81]. A combination of anti-thymocyte globulin (ATG) and methylprednisolone is often used. Prior to this, patients receive pretreatment with acetaminophen and antihistamines to prevent cytokine release syndrome associated with ATG.
Biologic agents (Alemtuzumab, Basiliximab, Daclizumab) may be used when available in less sensitized patients.
To prevent allograft rejection, maintenance immunosuppression is achieved with a combination of low dose corticosteroid (prednisolone is widely in available SSA), an antiproliferative agent (mycophenolate mofetil (MMF) or azathioprine) and a calcineurin inhibitor (CNI) (tacrolimus (TAC) or cyclosporine (CYP)). Tacrolimus has shown superiority over cyclosporine in improving graft survival and preventing acute rejection. Thus, TAC remains an integral part of the common post- transplant immunosuppressive combination [82]. The initiating dose is titrated to achieve a trough level of 8-10 ng/ml in the first three months post-transplant.
Prophylaxis against bacteria, fungi and viruses are commenced within this time.
First day post-surgery, emphasis is on haemodynamic and respiratory stability as well as urine output. By the first week, good graft function should have been established and urethral catheter is removed.
Within this period opportunistic infections are anticipated and appropriate measures taken. The ureteric stent is removed within 4 – 6 weeks.
Absence of transplant registries in SSA precludes transplant data availability. However, between 2010 and 2015, a hospital in South Africa documented recipient survival at 1 and 5 years as 90.4% and 83.1% and that of graft 89.4% and 80% respectively [83].
Organ donation and transplantation in SSA is fraught with numerous challenges including costs of treatment, inadequate infrastructure and equipment, dearth of highly skilled health professionals, and lack of well-articulated ethico-legal framework and policies [3].
Cost of kidney transplant varies from country to country. For example, the cost is estimated at about $32,000 in Nigeria [84], $18,775 in Ghana [85], and $10,000 in Tanzania [20].
Source of funding for organ and tissue donation and transplant depends on the country: public sources in Ethiopia, Ghana, Mali, Seychelles and Comoros but private in Nigeria, Burkina Faso, Madagascar and 10 other countries SeeTable 6. Most recipients pay OOP either personally or by relatives, employers and to a lesser extent philanthropists [45]. While the National insurance pays two-thirds of the transplant cost in Kenya [47], it is free in Tanzania [51].
Indicator | Countries |
---|---|
Countries with functional transplantation programmes | |
Functional transplantation programmes from living donors | Algeria, Côte d’Ivoire, Ethiopia, Ghana, Kenya, Namibia, Nigeria, United Republic of Tanzania, Uganda, South Africa |
No. of transplant centres in the region | |
Kidney centres | Algeria, Côte d’Ivoire, Ethiopia, Ghana, Kenya, Namibia, Nigeria, United Republic of Tanzania, Uganda |
Corneal centres | Kenya, Nigeria, South Africa |
Bone marrow centres | Nigeria, South Africa |
Liver centres | South Africa |
Heart centres | South Africa, others perform open heart surgeries |
Countries having legal requirements | |
Legal requirements in place covering organ donations and/or transplantations | Burkina Faso, Comoros, Côte d’Ivoire, Ethiopia, Kenya, Mauritius, Namibia, Nigeria, Rwanda, Senegal, Sudan, United Republic of Tanzania, Uganda, Zimbabwe |
Governments intended to adopt new legal requirements | Cameroon, Chad, Eswatini, Ghana, Guinea, Madagascar, Mali, Mozambique |
No legislations in place | Angola, Benin, Burundi, Cabo Verde, Congo, Eritrea, Gabon, Guinea Bissau, Seychelles, Sierra Leone |
Legal requirements in place to inform living donors on the risks of the operation | Comoros, Ethiopia, Kenya, Mali, Nigeria, Rwanda, Senegal, Seychelles, United Republic of Tanzania, Uganda |
Legal restrictions on the coverage of donation costs for living donors | Comoros, Mali, Rwanda, Senegal |
Legal requirement to follow-up on the outcomes of living donors | Ethiopia, Mali, Senegal, Seychelles |
Legal requirement to provide care to living donors in case of adverse or medical consequences | Ethiopia, Senegal, Seychelles |
Prohibition of organ trafficking/transplant commercialization | Burkina Faso, Comoros, Côte d’Ivoire, Mali, Namibia, Nigeria, Rwanda, Senegal |
Legal permit and regulation of financial incentives for living donors | None |
Import or export of organs authorized | Ghana, Namibia, Rwanda |
Import or export of organs explicitly prohibited | Burkina Faso, Seychelles |
Legal requirements for organ and tissue donations from living donorsa | Burkina Faso, Comoros, Côte d’Ivoire, Kenya, Mali, Nigeria, Rwanda, Senegal, Seychelles, United Republic of Tanzania, Uganda |
No. of countries having an organization and management system | |
Authorization for transplant services | Burkina Faso, Comoros, Côte d’Ivoire, Ethiopia, Ghana, Guinea, Kenya, Madagascar, Mali, Nigeria, Senegal, Uganda, Zimbabwe |
Ethics Committees at the national or local level | Burkina Faso, Comoros, Côte d’Ivoire, Ethiopia, Gabon, Kenya, Mali, Nigeria, Rwanda, Senegal |
Government recognized authority at the national level | Algeria, Côte d’Ivoire, Ethiopia, Ghana, Kenya, Mali, Nigeria, Senegal, Uganda |
Setting up protocols, guidelines, recommendations | Comoros, Côte d’Ivoire, Ethiopia, Mali, Senegal |
Transplant follow-up registries for post-transplant living donor and for recipients | Côte d’Ivoire, Ethiopia, Namibia, Uganda |
Affiliation with an international organ allocation organization | None |
Cooperation framework to allow transplantation abroad | Côte d’Ivoire, Ethiopia, Kenya, Namibia, United Republic of Tanzania, Uganda |
Training programme for staff in place | Côte d’Ivoire, Ethiopia |
Source of funding | |
Public | Comoros, Ethiopia, Ghana, Mali, Seychelles, United Republic of Tanzania |
Private | Côte d’Ivoire, Ghana, Nigeria |
Public and Private | Kenya, Namibia, South Africa, Uganda |
Not Specified | Eswatini, Gabon, Zimbabwe |
Aspects of transplantation programmes in SSA modified from Loua et al [3].
Post-transplant maintenance of immunosuppression is a major challenge. This is exigent since therapy must be individualized. Two perspectives associated with immunosuppression in SSA include:
Availability, affordability and patient’s adherence to prescription.
Therapeutic drug monitoring (TDM).
Adequate immunosuppression is key to allograft survival. In patients who pay OOP, prohibitive costs of medications may have negative impact on their finances. Furthermore, side effects of medications affect their health-related QOL. In many LRCs, these medicines are imported at high cost and not readily available. These contribute to poor adherence with subsequent allograft rejection and graft loss.
Despite their impactful role in improving transplant outcome and graft survival, immunosuppressive medicines exhibit narrow therapeutic range between levels that inhibit rejection and toxic levels hence TDM is often required. Establishing a patient’s dose requirements in the immediate post – surgery period and avoiding over immunosuppression remains a challenge. Calcineurin inhibitors have variable pharmacokinetics [86, 87, 88, 89]. While ethnic differences have not been demonstrated in pharmacokinetics of MMF and AZA, African Americans have been shown to have 20–50% lower oral bioavailability for TAC, CYP, sirolimus and everolimus and as such require higher drug doses than Caucasians [90, 91]. This has been attributed to genetic polymorphism of key enzymes in the metabolism of these medications [90]. Genetic profiling is not readily done in SSA hence, TDM is essential. This attracts huge costs for the health system and for patients who pay OOP. It is imperative to tailor medications to patient’s need. Some countries do not have the capacity to analyze drug levels, so patient’s blood samples are sent overseas for analysis. Within the first-year post-transplant, TDM is done at least twice during timed follow-up visit for patients coming from rural and urban areas. However, more frequent monitoring is done when indicated. During emergency presentation for allograft dysfunction, patients are admitted, samples for TDM sent out and other possible causes of allograft dysfunction are excluded or managed if present. Decision to increase drug dosage is often delayed till TDM result is available but dose reduction or withdrawal can be done in the presence of overt signs and symptoms suggestive of toxicity. For subsequent years, TDM is done as indicated.
Tissue typing, cross-matching and some viral studies, which are major aspects of patient preparation, are done overseas. This tends to delay the procedure and leads to an increase in the cost of transplantation. Adequate histological evaluation of biopsy specimens are largely unavailable, making prompt management of rejections and infections problematic.
Health-workforce is the backbone of any health care system. Transplantation involves collaboration of many health professionals (nephrologists, transplant surgeons, urologists, renal nurses, pathologists, etc.). Worldwide transplant workforce and training capacity remain unknown. Of the 47 countries in SSA, only 15 (32.6%) had data on the number of nephrologists in their countries. Nigeria and South Africa have the greatest number of nephrologists with rates <10 per 10,000 population while others have < two per 10,000 population [3]. The situation is worse for other specialists involved in transplantation. Opportunities for training and employment have caused brain drain to developed countries from LRCs [3].
Despite the burden of ESKD in SSA, only few countries have sustained transplant programmes [20]. There are only 62 centres across 7 countries in SSA [3]. Nigeria with a population of 206 million has 15 renal transplant centres (RTCs) with majority recording low activities ranging 1–5 transplants per year (Personal Communication). South Africa with a population of 59.37 million (2020) has 14 RTCs and did 250 to 450 kidney transplants annually between 1991 and 2015 [35].
Scarcity of organs for transplantation is a multi-factorial global problem. Living donors remain the major source of organs for transplantation in SSA with largely non-existent deceased donor programmes. This has resulted in the persistent dearth of organs in the face of continuous rise in demand [92]. Unavailable storage facilities, poor knowledge about transplantation, socio-cultural and religious beliefs (which discourage living organ donation, view deceased organ donation as a taboo or an act of mutilating the dead with violation of the person’s dignity [84]) contribute to shortage of organs [93].
There is pervading poverty in SSA with US bureau of statistics reporting rates of 87.8%, 56.9%, 40.1%, 40% and 36.1% in Uganda, Ghana, Nigeria, Cameroun and Kenya respectively [94]. In Nigeria, 85% of ESKD patients earn between $800–7333 annually making kidney transplantation unaffordable [27, 95]. Although unemployment rate in SSA averages 6.2%, many are underemployed and earn low income [96].
Most transplant centres are located in urban cities or state capitals reducing accessibility to rural dwellers [3, 41].
Christianity, Islam and African traditional religion are the major faiths in SSA. Interplay of faith, religion and cultural attitudes and their relationship with views on organ donation is complex. Response to illness as God’s will negates organ donation or reception. Belief in resurrection and reincarnation precludes organ donation since the ‘new body’ may have some missing parts. Desecration of the body of the deceased is reported as a factor prohibiting family members from donating body parts of their deceased relatives.
Functional organizational mechanism for transplant programmes including authorization for transplant services; ethics committees, guidelines and protocols, etc. are few in the region [41, 93]. Additionally, transplant is not sufficiently integrated into national health services and collaboration between SSA countries is limited.
Absence of functional and reliable registries militate against planning and implementation of policies due to lack of data. Most countries do not include performance indicators for organ donation and transplantation in their national health information systems. In addition, there is insufficient multisectoral (schools, transport departments, NGOs, Civil Society Organizations, etc.) involvement in transplantation programmes in SSA.
Some countries have legislation for organ donation and transplantation while others are in various stages of developing theirs (Table 6). The weak regulatory frameworks observed in these countries are often insufficient to ensure the effective oversight needed for the implementation of quality standards for organ transplantation.
The Declaration of Istanbul defines organ transplant tourism as travel for transplantation involving trafficking in persons, for the purpose of organ removal. Organ trafficking is defined as “the recruitment, transport, transfer, harboring, or receipt of living or deceased persons or their organs by means of any form of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability, or of the giving to, or the receiving by, a third party of payments, or benefits to achieve the transfer of control over the potential donor for the purpose of exploitation by the removal of organs for transplantation [97].” Transplant commercialism is the buying and selling of organs i.e. treating of organs as commodities. Travel for transplantation is the transport of organs, donors, recipients, or the professionals across borders for transplantation and it becomes TT if it entails organ trafficking and/or transplant commercialism [97]. Transplant tourism has become an increasing component of medical tourism (MT) especially in SSA. The disparity between the demand for and supply of organs encourages illegal organ procurement as transplantation may the only life-saving treatment in many end-organ failure. Unavailability and high cost of healthcare, lack of faith in local health systems, widening economic gap, ease of global travel and uneven global application of laws, have led to increase in TT.
Transplantation holds lots of opportunities which if well harnessed can improve healthcare in SSA.
For sustainable transplantation programme, individuals, community and governmental commitment and collaboration are required. Availability of organs can be increased through heightened public enlightenment campaigns emphasizing preventive medicine and change in the community’s organ donation perception. This can be achieved by partnering with religious bodies, individual, family and community education, inclusion of transplantation and donation in school syllabus, alliance with the department of motor vehicles (DMV) and novel donation programmes (kidney paired donation, extended criteria organ donation and altruistic non-directed donation).
Transplantation has significant medico-legal implications requiring robust legal framework. This should cover organ donation legitimacy, regulatory bodies, criteria and processes of accreditation, certification and standardization of transplant centres [98]. Transplantation programmes afford SSA opportunities to learn and adapt legislation from other regions. In 2008, Israeli parliament accepted two laws from their Ministry of Health - the Brain-Respiratory Death for determination of brain death and the Organ transplantation laws [99]. These laws defined the ethical, legal and organizational aspects of organ donation, allocation and transplantation with prioritization of registered donors, donor reimbursement and life insurance [99]. These and stoppage of illegal TT reimbursement significantly increased living and deceased organ donation by 2011 [99, 100].
The Multidisciplinary nature of transplant programmes demands highly skilled manpower often not obtainable in many parts of SSA, hence the need for collaboration with advanced transplant centres. Such patnership enables capacity development and training of specialized workforce which will serve the local and sister institutions.
Successful transplantation requires protocols for recipient and donor care. Transplant centres in LRCs can develop or adapt protocols from advanced centres, international organizations like United Network for Organ Sharing, Donation and Transplant Institute etc. National registries of organ transplant and outcomes are essential for documentation of transplant activities, reporting of short and long-term outcomes, and for planning and budgeting.
Each country should establish a sustainable transplant programme. Development of such services will curb organ trafficking and TT [101]. It entails infrastructural, legislative and manpower development with national government’s political will [35, 102]. A well-defined mode of funding which includes transplantation in national health insurance coverage ensures sustainability.
Transplantation programme can be established in a staged fashion [101]: enacting transplantation related laws and regulations, capacity building, extensive public enlightenment campaigns and transplant beginning with live-donor and subsequently, deceased-donor.
Models that can be adapted include:
In the Pakistani model [103, 104], following intense public enlightenment, the community assumed ownership of the programme through donations as individuals, communities and NGOs. Government provided 30–40% of required cost, infrastructure, staff training and emolument enabling patients to receive free nephrology and transplantation care plus post-transplant rehabilitation. Accountability, transparency and equity ensured the success of this model.
Following development of indigenous transplant programme in 1985, there was an unwieldy transplant waiting list necessitating government-sponsored live-unrelated transplant with donor compensation [105]. This programme successfully eliminated waiting list by 1999 increasing kidney transplantation to 28 pmp per year. The Dialysis and Transplant Patients Association facilitated donor-recipient matching excluding third party. Donors also received government-funded life health insurance and gifts. Government additionally supported importation and free distribution of immunosuppressive medications to recipients. Deceased donor transplantation has steadily increased since 2000.
These models emphasize the indispensable roles of community, government and NGOs in ensuring the existence of a sustainable transplantation programme.
The World Health Assembly (WHA) adopted resolutions WHA57.18 and WHA63.22 [106, 107], and the WHO guiding principles on human cell, tissue and organ transplantation to guide transplantation programmes and activities [108]. The United Nations General assembly adopted these resolutions to strengthen and promote effective measures and international cooperation to prevent and combat organ trafficking [109]. The Istanbul declaration on organ trafficking and TT recommends a legal and professional framework to govern organ donation and transplantation activities, transparent regulatory oversight system to ensure donor and recipient safety, enforce standards and prohibit unethical practices in all countries. [97]. A Task Force to check unwholesome practices in transplantation was set up and inaugurated by WHO in 2017 [110].
During the 2013 Global Alliance of Transplantation (GAT) meeting organized by Southern African Transplant Society in Durban [3], the transplantation society (TTS) sponsored a meeting for countries in SSA to assess the need for and ability to optimize or develop local transplant programmes. In 2015, the South African Renal Society–African Association of Nephrology in collaboration with European Renal Association-European Dialysis and Transplant Association held a pre-congress workshop to encourage SSA countries to develop renal registries [111]. Attempts at establishing renal registries in SSA have met with challenges. The International Society of Nephrology (ISN) is supporting establishment of renal registries worldwide through her SHARing Expertise (
To improve kidney disease patients’ care and capacity building worldwide, ISN pioneers these programs: fellowship, ISN continuing medical education, sister renal centre (SRC), sister transplant centre (STC) and educational ambassadors programme. Through ISN- TTS-STC program, ISN encourages establishment and development of transplant centres (
Improvement in the transplant landscape of SSA can be achieved by adapting models that have proven successful in LRCs such as those of Pakistan and Iran. Implementing the 2007 World Health Organization Regional Consultation recommendations: establishment of national legal framework and self-sufficient organ donation and transplantation in each country, transparent transplantation practices, and prevention of commercialized transplantation and TT will improve transplantation programmes in SSA. Also, adopting the WHO Regional Committee for Africa’s proposed actions on organ transplantation for member states and establishment of national registries for organ transplantation in each country are needed.
Sub-Saharan Africa, comprising of 47 countries and occupying an area of about 24 million Km2 is heterogeneous with estimated population of 1.1 billion people. Most of the countries belong to the LICs and LMICs according to World Bank Classification of economies. This region has a high prevalence of end-organ diseases including CKD, CLD, chronic lung diseases and chronic heart diseases resulting from CDs and NCDs.
Although South Africa performed Africa’s first kidney transplant in 1966 and pioneered heart transplantation in 1967, SSA lags behind the developed world in transplant activity. According to WHO, SSA contributes the least number of transplant activity per WHO World region. Cost of treatment, low GDP, inadequate infrastructural and institutional support, dearth of facilities and technical expertise and absence of subsidy have all adversely affected organ donation and transplantation.
The health-care systems in SSA are weak and deficient. Peoples’ decision to access healthcare services is influenced by knowledge of the disease condition, accessibility to health-care facility, affordability, religious and trado-cultural practices. Many people in LRCs patronize alternative healthcare service including traditional health providers and religious institutions as first choice resulting in late presentation to hospitals.
These challenges can be surmounted by adopting the 2007 World Health Organization Regional Consultation recommendations of establishment of national legal framework, self-sufficient organ donation and transplantation in each country, transparent transplantation practice, and prevention of commercialized transplantation and TT. In addition, establishment of national registries of organ transplantation is essential.
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\\n"}]'},components:[{type:"htmlEditorComponent",content:'Work - a book Chapter (as well as Conference Papers), including any and all content, graphics, images and/or other materials forming part of, or accompanying, the Chapter/Conference Paper.
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