Hematopoietic Stem Cell Transplantation in the Resource-Limited Setting: Establishing the First Bone Marrow Transplant Unit in Bangladesh and Initial Outcomes
Authors: Yeh Albert C. , Khan Mohiuddin Ahmed , Khan Sabrina , Harlow Jason , Biswas Akhil , Akter Mafruha , Ferdous Jannatul , Ara Tasneem , Islam Manirul , Barron Anne-Marie , Moran Jenna , Brezina Mark , Saha Anup , Afrose Salma , Stowell Christopher P. , Preffer Frederic , Bangsberg David , Goodman Annekathryn , Attar Eyal C. , McAfee Steven L. , Spitzer Thomas R. , Dey Bimalangshu R. 
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 have impeded widespread implementation in resource-constrained settings. 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 determined that there was a need for a transplant program in Bangaladesh. The Bangladesh government and AK Khan Healthcare trust, an interested non-governmental organization, provided funding for the endeavor. We discuss four key aspects of the program, including: (1) formalizing of a collaborative partnership; (2) infrastructure development; (3) human resource capacity building and implementation of the concept of clinical teamwork; and (4) financial considerations. We also present the results of our first 21 autologous transplants.
METHODS
To codify the scope and scale of the collaboration, a Memorandum of Understanding was signed between the Ministry of Health and Family Welfare and MGH. The DMCH transplantation unit was built on the top floor of a new building and includes 5 patient rooms, an apheresis area, hematopathology and general hematology labs, as well as rooms for patients with hematologic malignancies who are not currently undergoing transplantation. Three hematologists, two apheresis technicians, one lab technician, and one pharmacist from DMCH participated in an exchange program during which they each spent 2-3 months at MGH observing transplantation practices. Additionally, several physicians, nurses and technologists from MGH traveled to Bangladesh and spent several weeks training DMCH staff. Physicians training was provided in diagnostics, peripheral blood stem cell collection, transfusion medicine, and management of complications. In order to elevate the clinical competencies and professional status of the nurses in the DMCH HSCT unit, a comprehensive curriculum for the care of HSCT patients was developed by nurses and nurse practitioners at MGH and the Simmons College School of Nursing and Health Sciences.
RESULTS
The first autologous stem cell transplant was performed on March 10, 2014. As of May 2016, twenty-one patients (age range 18-58) have undergone autologous transplants at DMCH. We have treated eleven patients with myeloma, four with diffuse large B-cell lymphoma, four with Hodgkin's lymphoma, one with acute myelogenous leukemia, and one with peripheral T cell lymphoma. Conditioning regimens used included melphalan (11), BEAM (9), and Bu/Cy (1). Engraftment occurred in all patients (range 9-16 days). There were ten documented infections, including seven cases of bacteremia, two C. difficileinfections, and one case of pneumonia. There have been no transplant-related deaths to date. Five patients have relapsed (ranging from day 213 to 598), and the patient with the longest disease-free survival is now 639 days out from transplantation.
DISCUSSION
We attribute the program's ability to perform its first transplants successfully within 3 years of conception not only to the available financial support but also to the logistical and personnel support that collaboration with an established transplant center provided. A major goal of the current program is ultimately to establish a transplant center capable of performing allogeneic stem cell transplantation, which would enable treatment of patients with thalassemia, the most common genetic disorder in the country, and one which imposes a substantial burden on the national economy. We hope that our experience will encourage more partnerships and collaborations between transplant programs in developed countries and those countries that currently lack expertise but could benefit from having this therapeutic modality available.

Disclosures
Attar: Agios: Employment, Equity Ownership.