Establishment of Pediatric Bone Marrow Transplant Unit in Public Sector Hospital, a Dream Accomplished.

Background Bone Marrow Transplant (BMT) is a highly sophisticated curative treatment of many Hematological, immunological, metabolic and Oncological conditions. Pakistan is a Lower middle income country. The treatment facilities are very limited as compared to the need of the region. Our Pediatric Hematology/Oncology unit is in one of the busy center of the country. We decided to start the First ever Public sector Pediatric Bone Marrow Transplant. Objective This study was done to know & enlighten the hurdles in establishment of BMT unit in Public Sector Hospitals in LMIC. The task to start BMT was taken as a challenge in collaboration with NIBD & BMT, Karachi, Pakistan in 2016. The Physicians and other supportive Team were sent for short term training.On return the Team started renovation of old building. In next step arrangement of instrumentation was done step by step, includes Cell separators, Platelet Aphresis Machines, HEPA Filters, CBC Analyzer, Handy Electrolyte Machine, Fridge (-80C0) for Cryopreservations & Plasma Storage, PRBC storage fridge and Blood grouping/Cross matching reagents and Gel Cards arranged. Then two patients with Beta Thalassemia Major were selected who had full matched sibling donors. The standard Conditioning Protocol of BU/Cy/ATG with GVHD prophylaxis Steroids/MTx and Cyclosporine started after saving the Autologus Bone Marrow Harvest. The Bone Marrow Harvest was done on both donors on same day and Infusion was done. The MNC and CD34 count were appropriate. The senior team members of Pediatric Hem/Onco department were involved and senior most staff nurses had taken care of the patients along with mothers of the patients. But unfortunately one patient died of Severe Pneumonia along with Pharyngeal abscess on day +11 and the second on +25 due to Primary engraftment Failure and severe Pulmonary Hemorrhage. The initial two patient's mortality depressed the Hospital administration as well as the Treating Team. We decided to review the supportive care techniques, restricted the entry and limited the Treating staff. After getting these improvements we again decided to start the BMT unit again in March 2018 and selected Aplastic Anemia patient of 8 years who had 6/6 matched sibling donor.The five days conditioning was done with Fludarabine, Cyclophsphamide and GVHD prophylaxis with Cyclosporin, MTX and steroids. PBSC was done on cell separator and stem cell infusion done. Patient engrafted Neutrophil on +10, Platelets on +18 and RBC on +45. Th immnunosupression was tapered off 6 months post BMT and now free of medication. Since then we have done so far total 23 patients including Aplastic Anemia, Thalassemia, Fanconi Anemia.Our success rate is 60%. I know it is far behind the international data but we are thriving to improve it day by day. Conclusion The persistent struggle is needed for establishment of BMT units in LMICs. Recommendation When there is a will, there is a way.