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2024 Update on Cord Blood Utilization in China and Comparison to Other Countries

October 2024
Frances Verter, PhD

 

2024 Update on Cord Blood Utilization in China

Last year we published an article, Cord Blood Utilization is Booming in China, which relied on translations of blogs from Chinese banks to compile the number of cord blood units used for therapies in China1. There was a cord blood conference in May 2023 where a leading Chinese researcher stated that “the number of cord blood applications in China has exceeded 30,000” (this is the cumulative number up to 2023)2. This year we found an on-line report from the May 2024 cord blood conference, where a leading Chinese researcher stated that “there are nearly 40,000 cases of clinical application in China”3. Clearly, if the cumulative number of applications was 30,000 in 2023, and 40,000 a year later in 2024, it leads to the conclusion that there have been 10,000 cord blood applications in China over the past year. By comparison, the member banks in the World Marrow Donor Association have only reported about 2,300 cord blood transplants worldwide in 20234.

China is performing more cord blood therapies per year than the rest of the world combined.

 

Treating Thalassemia Major in China

This leads to the question of what types of therapies are utilizing so much cord blood in China? It was not possible to find enough information in bank blogs to perform a complete breakdown by diagnosis, but one fact that did emerge is that Chinese doctors often use cord blood to treat children with Thalassemia. Thalassemia is an inherited blood disease which is very common in southeast Asia5,6. There are multiple variants of Thalassemia, but in general patients that have transfusion-dependent Thalassemia, or “Thalassemia Major” (TM) have shortened life expectancies. Caring for TM patients is a big public health burden, which could be alleviated if more low- and middle-income countries developed hospital programs to provide stem cell transplants for children with this diagnosis7.

Professor Liu Sixi, chief physician of the Hematology and Oncology Department of Shenzhen Children's Hospital, has said, "In 11 years, we performed 909 cases of Thalassemia transplantation, and the overall survival rate was 99%. This data is ahead of countries and regions such as Europe and the United States" (he is reporting cord blood transplants)2. During the years 2020 and 2021, the Chinese Blood and Marrow Transplantation Registry Group reported over 1300 stem cell transplants for Thalassemia (this number combines all types of transplants)8.

Some hospitals in China are using donated cord blood as part of Haplo-Cord transplants. The name “Haplo-Cord” describes a transplant where two donors are combined, one is a half-matched or haploidentical adult donor, and the other is a donated cord blood unit. Haplo-Cord transplants are becoming popular in China, for treating both Thalassemia as well as Leukemias9-14. There is more than one approach to Haplo-Cord transplants, ranging from a protocol that gives the cord blood 8 hours before the haplo transplant, to another than gives the cord blood 6 days after the haplo transplant9-14. Regardless of the protocol details, in general Haplo-Cord transplants solve the unique challenge of finding matched stem cell donors in China, a country which has had a one-child per family policy for 35 years. The vast majority of Chinese patients that need a stem cell transplant do not have a matched sibling donor, and many do not even have a half-matched family donor. Hence the motivation for the “double-insurance” Haplo-Cord transplant with two imperfect donors9.

 

Comparison to Other Countries

Population Parameter

China

India

USA

Population1

1.425 Billion

1.450 Billion

342 Million

Birth Rate1

9 Million

24 Million

3.6 Million

# Cord Blood Banks2 Private/Public

10/8

11/1

17/20

% Banking Penetration2

3%

0.4%

3%

Banked CBU3

270K / year

96K / year

100K / year

# Thalassemia Major patients

790K4

65K4,5

1.5K6

Cord Blood Therapies

10,0007 / year

Handful8 / year

4508,9 / year

Table Notes

  1. Population & Birth Rates for 2024 from Statista
  2. Cord Blood Bank numbers & % penetration from Parent's Guide to Cord Blood Foundation
  3. Banked CBU = (Birth Rate) x (% Penetration)
  4. Beta Thalassemia prevalence by country: Tuo Y, Li Y, Li Y, Ma J, Yang X, Wu S, Jin J, He Z. Global, regional, and national burden of thalassemia, 1990–2021: a systematic analysis for the global burden of disease study 2021. The Lancet 2024; 72:102619
  5. Thalassemia Major prevalence in India: National Health Mission Guidelines on Hemoglobinopathies in India. Govt. of India. Published 2016
  6. Thalassemia Major prevalence in USA: BluebirdBio. Press Release. Published 2022-08-17
  7. Cord Blood therapies in China: Blog 2023 & Blog 2024
  8. Cord Blood therapies in India & USA: WMDA Global Trends Report. Published 2024-05-30
  9. Additional cord blood therapies in USA from CBR, Viacord, Cryo-Cell

 

The table above compares some population and healthcare statistics for China, India, and the United States. We chose the USA as an example of a western country for which we have easy access to healthcare data. We chose India as the main comparator in Asia, partly because India is now the world’s most populous country, and also because it is straightforward to find healthcare data for India in English.

A 2024 article in The Lancet reports that there are only 1.3 million people living with transfusion-dependent Thalassemia Major worldwide, because without a curative stem cell transplant the patients have short life expectancies6. The countries that have the highest rates of TM, as a percentage of the population, are Cambodia, Laos, and Thailand6. Combining the rate of Thalassemia with the country population, the sheer numbers of TM patients is highest in China, with 790 thousand TM patients. The number of TM patients in India is more than ten times lower, at 65 thousand. However, despite government efforts to prevent Thalassemia with widespread testing, each year another 10 to 15 thousand babies are born in India with TM15. 

The dramatic difference between India and China is that very few cord blood transplants take place in India. This is surprising given that most children in India have siblings that could be donors, and India has roughly the same number of cord blood banks as China. However, the landscape of healthcare delivery is very different between China and India. China currently has about 175 hospitals that are able to perform stem cell transplants8. India has been rapidly building its capacity for stem cell transplants, with 28 qualified hospitals listed in 2016, 65 in 2018, and over 100 today15-17. In China, most of the cost of a stem cell transplant is covered by the patient’s public health insurance, whereas in India patients often pay for their healthcare expenses out of pocket8,16,18. Chinese regulations on cord blood banking license only one bank per province, and that bank must be a hybrid combination of public and private banking19. Hence in the table above the pubic banks and private banks in China overlap, and China has hundreds of thousands of donated cord blood units available for unrelated patients1. India does not have an active public cord blood bank and donor registry20. Instead, the largest family bank in India has invented a business model called Community Banking, and most of the other family banks claim to offer this service as well21. In a Community Bank, families that pay to bank privately are joining a mutual insurance pool. If one of the community members needs cord blood for a qualified therapy, they can receive any of the suitable units listed on the pool registry, and they will also receive a cash payout to cover the cost of therapy21. So far, there has been limited overlap in India between the families enrolled in community cord blood banks and the families that need transplants to treat TM22.

In the United States, the FDA has approved a gene therapy for Thalassemia which can cure the disease at a cost that is over USD 2 million per patient23. This price is considered to be “cost effective” in a high-income country which only has a total of 1500 TM patients. In fact, even though Thalassemia is one of the world’s most common inherited diseases, in the US it qualifies as a “rare” disease.

In summary, our comparison of cord blood transplants to treat TM patients in China versus India and the US shows that healthcare business models play a vital role in determining access to care. China has the highest number of TM patients in the world but they also have a healthcare system that delivers care efficiently8. The United States has the luxury of offering cutting edge therapies to insured TM patients because they have very few TM patients. India is between these extremes. India is one of the top countries for numbers of TM patients and is also one of the top countries for numbers of cord blood banks6,24. Yet, very few TM patients are receiving cord blood transplants in India, due to the lack of public donor registries and the high out of pocket costs of transplantation16,21. If the healthcare system in India could be modified to make transplantation more accessible to TM Patients, they would be one of the world leaders in numbers of stem cell transplants, including cord blood transplants.

 

Thalassemia Major in China versus India

 

References

  1. Verter F, Woon J, Lai L. Cord Blood Utilization is Booming in China. Parent's Guide to Cord Blood Foundation Newsletter Published 2023-11
  2. Guangdong Cord Blood Hematopoietic Stem Cell Bank. Guangzhou Daily: More than 85,000 cord blood applications worldwide, 4,061 cord blood applications in Guangdong. News. Published: 2023-05-26
  3. Guangdong Cord Blood Hematopoietic Stem Cell Bank. The application of autologous umbilical cord blood in China is on the rise, and the application prospects of autologous umbilical cord blood are broad. News. Published: 2024-05-26
  4. WMDA Global Trends Report. Published 2024-05-30
  5. Goh LPW, Chong ETJ, Lee PC. Prevalence of Alpha(α)-Thalassemia in Southeast Asia (2010–2020): A Meta-Analysis Involving 83,674 Subjects. Int J Environ Res Public Health. 2020; 17(20):7354.
  6. Tuo Y, Li Y, Li Y, Ma J, Yang X, Wu S, Jin J, He Z. Global, regional, and national burden of thalassemia, 1990–2021: a systematic analysis for the global burden of disease study 2021. The Lancet 2024; 72:102619
  7. Verter F. Role of Cord Blood Transplants to Treat Sickle Cell Anemia & Thalassemia in the Age of Gene Therapy.  Parent's Guide to Cord Blood Foundation. Newsletter Published 2023-08
  8. Xu LP, Lu DP, Wu DP, Jiang EL, Liu DH, Huang H, .... on behalf of the Chinese Blood and Marrow Transplantation Registry Group. Hematopoietic Stem Cell Transplantation Activity in China 2020–2021 During the SARS-CoV-2 Pandemic: A Report From the Chinese Blood and Marrow Transplantation Registry Group. Transpl. Cellular Therapy 2023; 29(2):136.e1-136.e7.
  9. Li C, Liu S, He Y, Wang X,  Liao J, Li S, ... Wing L. Complementary Transplantation Improved Results of Both Peripheral Blood Stem Cells and Unrelated Cord Blood Transplants in Thalassemia: A Multi-Center Study from China. Blood 2019; 134(S1):4617.
  10. Xiao Y, Feng X, He Y, Li. Outcome of Sibling's and Unrelated Umbilical Cord Blood Stem Cell Transplantation Combined PBSC in Thalassemia Major and Related Factors Analysis:76 Cases Reported in Single Center. Blood 2020; 136(S1):19.
  11. Wang X, Zhang X, Yu U, Wang C, Yang C, Li Y, ... Liu S. Co-Transplantation of Haploidentical Stem Cells and a Dose of Unrelated Cord Blood in Pediatric Patients with Thalassemia Major. Cell Transplantation 2021; 30:1-9.
  12. Zhou B, Xu M, Lu S, Liu Y, Qi L, Liu T, ... Xu Y. Clinical Outcomes of B Cell Acute Lymphoblastic Leukemia Patients Treated with Haploidentical Stem Cells Combined with Umbilical Cord Blood Transplantation. Transpl. and Cellular Therapy 2022; 28:173.e1-173.e6.
  13. Lei M, Zhang Y, Jiao W, Li X, Zhou H, Wang Q, ... Wu D. Comparison of Haploidentical Hematopoietic Stem Cell Transplant With or Without Unrelated Cord Blood Infusion in Severe Aplastic Anemia: Outcomes of a Multicenter Study. Frontiers Immunology. 2022; 13:912917
  14. Zhou B, Chen J, Liu T, Zhang Y, Ye Y, Ding Y, ... Wu D. Poster 1041. Haploidentical Hematopoietic Cell Transplantation Combined with an Unrelated Cord Blood Unit for Adult Acute Myeloid Leukemia Results in Improved Survival Compared to Haploidentical Hematopoietic Cell Transplantation: Results of a Multicenter, Randomized, Phase III Trial. Blood. 2023; 142(S1):1041.
  15. National Health Mission. Prevention and Control of Hemoglobinopathies in India. Govt. of India. Published 2016
  16. Kulkarni U, George B. Access to hematopoietic stem-cell transplantation in India. J Postgrad Med. 2019; 65(1):1–4.
  17. Indian Society for Blood and Marrow Transplantation (ISBMT). Members. Accessed 2024-10-07
  18. Kumar A. The Transformation of The Indian Healthcare System. Cureus. 2023; 15(5):e39079.
  19. Li Y, Verter F, Wang B, Gu N. Regulations on cell therapy products in China: a brief history and current status. Regenerative Medicine 14(8):791-803.
  20. Jeevan. Parent's Guide to Cord Blood Foundation. Bank page. Last updated 2018
  21. Verter F, Mandot VA. The Business Model of Community Banking in India. Parent's Guide to Cord Blood Foundation Newsletter Published 2019-07
  22. Verter F. ‘Thank You LifeCell & Community Cord Blood Banking!’ said Little Gauri’s Parents. Parent's Guide to Cord Blood Foundation Newsletter Published 2022-11
  23. Institute for Clinical and Economic Review (ICER). Betibeglogene Autotemcel for Beta Thalassemia: Effectiveness and Value. Report. Published 2022-07-19
  24. Verter F. Consolidation of Family Cord Blood Banks. Parent's Guide to Cord Blood Foundation Newsletter Published 2023-09