Hematopoeitic Stem Cell Transplantation in the Developing World: A Case Study of Dhaka Medical College, Bangladesh
Authors: Yeh Albert C. , Dey Bimalangshu R. , Spitzer Thomas R. , Akter Mafruha , Biswas Akhil , Khan Mohiuddin Ahmed , Ara Tasneem , Ferdous Jannatul , Aforse Salma , Islam Manirul 
Published: October 2019

Abstract
INTRODUCTION
While hematopoietic stem cell transplantation has become the standard of care for many patients in developed countries, the significant economic investment, infrastructure, and healthcare provider training that are required has prohibited it from being widely adapted. We describe our experience in developing a transplant program at Dhaka Medical College and Hospital (DMCH) in Bangladesh via a partnership with health care providers at the Massachusetts General Hospital (MGH). In 2011, the Minister of Health in Bangladesh became interested in establishing a transplant program at Dhaka Medical College and Hospital (DMCH). DMCH was established in 1946 and has 2300 beds located in two buildings (DMCH-1 with 1800 beds and DMCH-2 with 500 beds). The Bangladesh government and AK Khan Healthcare trust, an interested non-governmental organization (NGO), provided funding for the endeavor. Despite available funding, we faced significant challenges due to limitations in experienced healthcare personnel.
METHODS
The DMCH transplantation unit was built on the top floor of DMCH-2 and includes 5 patient rooms, an apheresis area, the hematopathology and general hematology labs, and also includes rooms for leukemia patients who are not currently undergoing transplantation. Three hematologists, two apheresis technicians, one lab technician, and 1 pharmacist from DMCH participated in an exchange program during which they each spent 2-3 months at MGH observing transplantation practices. Additionally, several physicians from MGH traveled to Bangladesh and spent several weeks training DMCH physicians in diagnostics, peripheral blood stem cell collection, transfusion medicine, and management of potential complications.
The training of Bangladeshi nurses was an extensive undertaking. In brief, 25 nurses from DMCH were selected to take part in a novel enhanced specialized nurses training program (ESPNTP) run by nurses from MGH, which is described in detail in a separate report. This intensive 12-month program included 3 months of training in English language, 3 months of fundamental nursing training, and 6 months of specialized training in HSCT. Nurses continue to train on an ongoing basis via an advanced curriculum taught by MGH nursing staff.
RESULTS
The first transplant was performed on March 10, 2014. Since that time, DMCH has performed 14 autologous stem cell transplants (9 multiple myeloma, 2 diffuse large B-cell lymphoma, acute myelogenous leukemia, Hodgkin's lymphoma, and peripheral T-cell lymphoma). Baseline characteristics, transplant protocol, and summary of results are shown in (Table 1). All patients engrafted successfully (range 9-16 days). Remission was achieved in all cases, and so far there has only been one case of relapsed disease in a patient with multiple myeloma. Significant complications include mucositis (grade II-IV: 12), febrile neutropenia (8), bacteremia (S. epi: 2; P. aeurginosa: 2, MRSA/K. pneumonia: 1), one case of acinetobacter pneumonia, and one case of cytomegalovirus reactivation.
DISCUSSION
We attribute a large part of the program's ability to successfully perform its first transplants within 3 years of conception due not only to available financial support but also logistical and personnel support from collaboration with an established transplant center. A major goal of the current program is to ultimately establish a transplant center capable of performing allogeneic stem cell transplantation, as this would enable treatment of patients with thalassemia, the most common genetic disorder in the country that carries a high burden on the economy. We hope that our experience will encourage more partnership and collaboration between transplant programs in developed countries and those countries who currently lack expertise but could benefit from having this therapeutic modality available.
Figure 1. Transplant Characteristics Figure 1. Transplant Characteristics

Disclosures
No relevant conflicts of interest to declare.