Establishing haemopoietic stem cell transplant services with limited resources, Tiruchirappalli, India

Subbaiah Ramanathan¹, Vinod Gunasekaran2, Prabhakaran Shankar³, Sunil Jai Karnesh⁴, Anand Vikas⁴, Aparna Devi C⁴, Amritha Saravanan⁴, Thilagavathy⁵, Anitha Jasmine⁶, Senthilvel Murugan⁷, Senthilkumar Kaliannan⁸

¹Consultant Haemato – Oncologist, Kauvery Hospital, Cantonment, Trichy

²Senior Consultant Paediatrician, Kauvery Hospital, Cantonment, Trichy

³Consultant Transfusion Medicine, Kauvery Hospital, Cantonment, Trichy

⁴PG –Residents, Kauvery Hospital, Kauvery Hospital, Cantonment, Trichy

⁵Consultant Microbiologist, Kauvery Hospital, Cantonment, Trichy

⁶Microbiologist, Kauvery Hospital, Maa Kauvery, Trichy

⁷HOD and Senior Consultant Radiologist, Kauvery Hospital, Tennur, Trichy

⁸HOD and Chief Cardiothoracic Vascular Surgeon, Kauvery Hospital, Heart City, Trichy

Introduction

Most of the haemopoietic stem cell transplant (HSCT) centres are established in tier-1 cities (population of 1 million and above). Establishing a HSCT centre in a tier-2 city (0.5 to less than 1 million population) remains a challenge but there is a necessity to increase access and to reduce cost. Here we share our experience in establishing the first HSCT in Tiruchirapalli (a tier-2 city in Tamil Nadu, South India) in a resource limited health care environment.

Methods

A single physician managed clinical haematology unit when it was started in Sep 2019 at Kauvery hospitals, Tiruchirappalli, India which is a 250 bedded tertiary care centre. The hospital caters adult & paediatric patients, for both malignant & benign haematological disorders. Preparing for HSCT services, training nurses in oncology care, improving transfusion medicine services, expanding the scope of laboratory services particularly microbiology were also done gradually. The first autologous BMT was performed in Aug 2020 & the first allogeneic BMT was done in March 2021. A paediatric haematologist joined the transplant team in Nov 2021. Later we could do haploidentical and MUD BMTs. Tests like HLA typing, donor specific antibodies, CD34 enumeration, chimerism analysis are outsourced and doing fine. Access to conditioning regimen and other drugs for post-transplant infections or GVHD are present and in rare instances if not immediately available they might be shipped from Chennai within next 6-12 hours. Allied department consultations for transplant patients are available in the hospital. We started doing BMTs in a non-HEPA filtered clean single room (2020) and then established a 2 bedded HEPA filtered unit (2021) which is now upgraded to a 5 bedded unit (Sep 2024).

Results

Till date we have done 102 BMTs (autologous 49 and allogeneic 53) including 16 haploidentical and 4 MUD BMTs. Adult and paediatric patients were 78 and 24 respectively. Indications for autologous BMT are myeloma (39), non-Hodgkin lymphoma (4), Hodgkin lymphoma (4), acute promyelocytic leukaemia (1) and neuroblastoma (1). Indications for allogeneic BMT are leukaemia (total 32- AML (18), ALL (12), MPAL (1), CML (1)), myelofibrosis (3), Myelodysplastic syndrome (2), Aplastic anaemia (6), Fanconi anaemia (3), Thalassemia (4), osteoporosis (1), severe combined immunodeficiency (1) and bare lymphocyte syndrome (1). Overall survival is 73% (85.8% in autologous and 60.4% in allogeneic BMTs). GVHD accounted to 35.8% in allogeneic BMTs (19/53). Amongst mortality in autologous transplant, progressive disease was in 7/8 patients and infection was in 1/8 patient. Amongst mortality in allogeneic transplant, steroid refractory GVHD was in 8/22 and relapse in 6/22 patients. 4/53 patients in allogeneic transplant died prior to engraftment due to infection/HLH. The cost for an autologous BMT is about 5K USD and that for allogeneic BMT about 10K USD.

Conclusion

This experience shows that a single physician haematology including HSCT services can be initiated in suitable non-teaching hospitals. People in smaller cities and surrounding rural areas benefit as they cannot travel to HSCT centres in larger and often distant cities, neither afford lodging or boarding there for sophisticated BMT services. Our services provide a model for setting up HSCT services in service hospitals in smaller cities.

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Establishing haemopoietic stem cell transplant services with limited resources, Tiruchirappalli, India