Socio-Economic Determinants of Hematopoietic Stem Cell Transplantation (HSCT) in Nepal

Nepal is a low income country in Asia with 38M inhabitants. In August 2016 a Blood & Marrow Transplant (BMT) Center was opened at Civil Service Hospital in Kathmandu initially performing autologous HSCT and since August 2017 also allogeneic HSCT. University of Illinois at Chicago (UIC) has been collaborating with Civil Hospital since 2012 to provide training for staff, advice on infrastructure and stem cell lab operations, clinical protocols, and implementation of a quality program. Until September 2019, a total of 46 HSCT were performed for patients (29 males and 17 females) with hematologic malignancies or aplastic anemia. Of 46 transplants, 26 were autologous (median age: 48 years, range: 15-63) and 20 allogeneic HSCT (median age: 20 years, range: 9-38), including 15 from a matched related (MRD) and 5 from a haploidentical donor. The median time of follow-up for autologous and allogeneic HSCT was 24 mo (4-37) and 6.5 mo (3.5-18), respectively. In all transplants the stem cell source was mobilized peripheral blood stem cells (PBSC). In allogeneic HSCT, all the patients received GVHD prophylaxis including post-transplant cyclophosphamide (PTCY) regardless of type of donor. Overall D100 mortality was 7%. At the last follow-up, 24 of 26 (92%) patients who received an autologous HSCT and 13 of 19 (68%) who received an allogeneic HSCT were alive, while 1 patient was lost at follow-up at d140. CMV reactivation was detected in 45% of patients. Acute GVHD grade 2 was observed in 5% of patients and no grade 3 or 4 was detected. Chronic GVHD (mouth) was observed in 3% of patients. Access to transplant was only possible to patients who could: travel to the hospital, afford the cost of transplant and lodging, and have a caregiver. The average distance from home to hospital was 296 km (184 miles) and family members and patients after discharge stayed mostly at a hotel close to the hospital. In all 46 cases, the caregiver assisting the patient either had to stop working or, in 3 cases of minors In conclusion, the collaboration between UIC and Civil Service Hospital in Kathmandu has been successful in building capacity for the establishment of the first BMT program in Nepal. Socio-economic determinants affecting access to HSCT such as financial costs, availability of a caregiver and transportation from long distance locations remain often a challenge for BMT in a low income country.