After four years of meticulous preparation, Lagos University Teaching Hospital (LUTH) has successfully performed its first bone marrow transplant (BMT). This milestone marks Nigeria?s return to the global list of countries offering this life-saving procedure, joining a select group of six African nations.

The pioneering work of Donnall Thomas in 1956 paved the way for BMTs worldwide. Since then, over a million procedures have been performed in 75 countries. LUTH?s new transplant programme aims to address the critical need for such services within Nigeria, reducing the need for medical tourism.

?So, we need to do that. The food they are going to eat is special, and that?s why we have our dietitian there. When we treat them, they must not be infected with anything, including catarrh.?

The hospital?s multidisciplinary team, comprising haematologists, doctors, nurses, dieticians, and medical social workers, has been instrumental in achieving this success. Their dedication and expertise have allowed LUTH to successfully treat two patients with severe sickle cell disorder.

In an exclusive interview, Wasiu Adeyemo, LUTH?s chief medical director, and the eggheads of the Bone Marrow Transplant Team tell Temitayo Oladehinde, BusinessDay?s senior health journalist, about the programme?s goals, the importance of private-public partnerships, and their vision for expanding access to BMT in Nigeria.

?We also built a bone marrow transplant centre, including the processing lab. We built a team, and this is how we are able to achieve that. We also had a lot of support from the Lagos State Government when we started.?

How did you build LUTH?s bone marrow transplant programme?

This team was set up some years ago. We understood that it?s a big thing, it must be multidisciplinary, and we also need to extend our hands of fellowship to those who can help us. We have an NGO called Sickle Cell Foundation. They understand that Nigeria has the largest body of sickle cell, not only in Africa but in the world, and they are doing a lot to help in terms of treatment, research, and training. We have been collaborating with them for years. Because we have little experience in bone marrow transplants, we also got people from abroad who are particularly Nigerians. We have Professor Kazeem, who is at Vanderbilt University, USA, who has been a big mentor on this programme. He has been here several times and has also taken some of our people to the US for training. Those are things that we needed to do. We also built a bone marrow transplant centre, including the processing lab. We built a team, and this is how we are able to achieve that. We also had a lot of support from the Lagos State Government when we started.

What are your expectations for this programme?

There?s only one expectation: continuity. Sustainability. That?s my expectation. I hope we get a lot of support. This is a capital-intensive programme. We need a lot of support from the government, non-government organisations, and anybody that can help us.

Do you have an estimate of the financial aid required for this procedure?

In the US, to do a bone marrow transplant is between $500,000 and $800,000. You can see how many people can afford that. That is the reason why we need a lot of support. We have developed the expertise, and now it can be done here. We do not want to scare anybody about costs. We have done this, and the next set is going to be done in January or thereabouts.

Can universal health coverage pave the way for affordable BMT?

Don?t let us deceive ourselves. It?s not going to be. It?s very unlikely until maybe the next 50 years or so. But the question is that Nigerians do go abroad to go and do it. If you have things that can be done here, it?s going to save us foreign exchange. We have seen over 12,000 cancer patients in the last five years, and so many people that would have travelled abroad are here because it is available here and done by us.

For many Nigerians with sickle cell disease, every day feels like living on borrowed time. How does bone marrow transplantation offer a glimmer of hope, and what were the key challenges and triumphs in developing this life-saving treatment at LUTH?

First and foremost, let me correct a misnomer that sickle cell disease is a time bomb and that anyone who has it is just waiting to give up. It is not so. Many people with sickle cell disorder live to adulthood and live productive lives. We have to understand that. It?s estimated that about 70 out of 100 will live a fairly good life. But about 30 of them, 30 percent, will have complications. With modern treatment, that is changing. For example, in developed countries, from inside the mother, they know that the child will have sickle cell disorder. They start planning treatment. As soon as the child is born, the child is on treatment. They live fairly well to the extent that in the US now, the life expectancy is averagely 50 years. We are doing fairly well in Nigeria too. For those who have severe disease, then we need to intervene with more than what we are doing now. And the only cure for sickle cell disorder today in the world is bone marrow or stem cell transplant. And it?s been going on for a long time in the world. In the last 30 years, a lot of centres have been doing sickle cell transplants to cure sickle cell disorder. So, it?s not new in the world, but in Africa, where we have the largest disease burden, it is still new.

How did the journey begin?

The first time we started was in 2007. We first had an agreement with a centre in Italy to start bone marrow transplants in Nigeria. We took the patients to Italy, transplanted them, and returned here to manage them. After you give the transplant, you have to take care of them for their body to eventually accept the new bone marrow. So, we started managing them after the transplant. We thought we were going to proceed, but that programme collapsed after about 40 people were transplanted. Again, it?s a collaboration between LUTH and the Sickle Cell Foundation. Then we met with a top Nigerian stem cell transplant expert, Professor Adetola Kazeem, in the USA, and we started planning how we were going to do this. In 2019, this team was officially set up, and I was made the chairman. We started pulling a few people we call haematologists, blood experts, first. We then started inviting every other person that was needed to form this team. Step-by-step training started from doctors, nurses, pharmacists, and social workers that are involved in stem cell transplants. In September 2023, we did something we called a dry run. We did this transplant, but we did not give it to anybody. We had somebody whom we collected the bone marrow from. We processed it, and that gave us room to experiment with things. Eventually we were able to admit our first patient on September 6, 2024. Two days later, we started the process that resulted in us giving them their transplants on the 17th and 19th of September. We have been able to discharge one home now, and the other one is on her way home.

What?s your assessment of the outcome?

For now, it has been fantastic. We use medication to knock out the bone marrow of that person in a process called conditioning. We get somebody, which we have prepared before, whose system matches that person. We are built in a way that our body tries to prevent other systems from coming to us. Somebody whose tissue matched the recipient was used. We collected the bone marrow and processed it in a high-end laboratory with a lot of top-notch equipment that processes the stem cell in a way that it is only what we need that goes into the receiver. We transplanted that into the recipient and then allowed the bone marrow to settle in that person. It takes about 10 to 14 days before it starts settling. It takes almost a year before the whole thing will settle properly. Sometimes, up to 18 months, we still have to be treating the person. But the worst has ended to the extent that one of the patients can go home and stay in her natural environment, and we continue to follow up from there.

Who can benefit from this sickle cell treatment?

Currently, we are prioritising sickle cell patients with severe symptoms that cannot be adequately managed with medication alone. This includes those experiencing severe pain, complications such as kidney disease, stroke, bone destruction, or eye defects that may lead to blindness. We are accepting patients aged 5 to 55 years for transplant at this time.

What challenges can patients expect to face during the BMT process?

The patient must have a matched donor. If you don?t have a match donor, we are not going to do it. We use siblings now because your sibling is the closest to you, not your father or mother. The closest person to you is a sibling. As we progress, we are going to use other people who are not fully matched. They will have more problems, but we are starting with this to farm up our hands. When you get a matched sibling donor, we are going to run some tests. Have you had some infections before? Do you have to deal with those infections? Have you had some motor complications before? When we are satisfied that everything is okay, then you will be brought in for the transplant. The other challenge is blood transfusion. This has improved the blood transfusion services in LUTH because your blood transfusion service must be top-notch. For example, we just don?t go and collect blood from somebody and just transfuse it. We have to treat it. Again, because we have a well-equipped radiotherapy unit, it is easy for us to radiate the blood and the blood product we want to give to these people. So, we need to do that. The food they are going to eat is special, and that?s why we have our dietitian there. When we treat them, they must not be infected with anything, including catarrh. Catarrh does not kill. But when we knock out the system of these people, including their immunity, catarrh may kill. So, we have to prepare their food specially. We have to visit their home to ensure the whole environment is good enough to prevent infection. Our social workers are involved from the beginning through the transplant and discharge, and they visit the home. They ensure everything is okay before patients go home. And while at home, they are going to visit.

Of course, they are going to be on various medications. Many of the medications we need to use are not even available in the country. We have to source it from all over the place. Sometimes we run into problems with the NAFDAC. Some of the property we are bringing in was delayed at the airport by customs. And they have to go and clear them. So, availability of the things we need is a problem. When we give the medication, the medication has to be in the blood, in a particular range. The machines to measure them, we had difficulty with them. We had to start looking for where to do it, including going to some private hospitals to measure this thing for us. Because those medications have to be exactly this amount in the blood.

Tell us about the infrastructure assembled to make this possible . . .

We have a bone marrow transplant centre. The rooms where the patients are going to stay are specially equipped. They are sealed in such a way that we don?t even want raindrops to enter that room, because that is a breach. The air cleaning system is special. In that place, when we admit, nobody sees the person except the carer, who we also screen to make sure he doesn?t carry any germ that can affect the person. So, we expect the patient to stay in the ward for about 30 days to six weeks and then to move to a special place before we move home. It?s a place that is almost sterile. We did a stem cell processing lab. That stem cell processing lab is the only one we are aware of in West Africa today that is so equipped to handle blood processing the way we need to do it. It has so much equipment that we run there to ensure that the processing of the stem cell is perfect. The blood transfusion service is not just grouping and cross-matching. We have to spend a lot of money improving the blood transfusion services I groups to meet international standards that can support bone marrow transplants. Feeding, we have to create a special place where the food is prepared, treated, and taken to the patient. When we are going to collect the blood, it?s not the ordinary blood transfer bag that you are going to use. They are specially built bags that are very expensive.

For Nigerians who have the wherewithal to undertake this procedure, what do they need in terms of cost?

We don?t even know yet how much this costs. What we thought it was going to cost us when we first started changed by the time the economy moved. We now found that what we have now moved to is not sustainable. We know that in developed countries it costs about $450,000 to $600,000 to do a transplant. We are not aiming for that because we know most Nigerians will not be able to afford that. We are hoping that we will be able to offer a more affordable cost. We will set up a committee to put things together. Then we will know exactly how much ? the possible amount ? it will cost to do this programme. We are doing it not for profit, not for loss. That?s our target. Our target is to be a training centre in West Africa for transplants. That?s our target.

What steps are being taken to achieve accreditation for BMT at LUTH?

You must meet specific criteria to be accredited. We must do a particular number of transplants before the international accreditation bodies will come and assess everything we have done from the beginning. Our target is that we become a training centre for bone marrow transplants in Africa. By this time next year, we should have done at least 10.

Titi Adeyemo, professor of haematology and blood transfusion, LUTH

Can you explain the stem cell donation process and why healthy individuals should consider donating?

Blood transfusion support is very key to a bone marrow or stem cell transplant. You have to wipe out the bone marrow of the recipient to get rid of the disease and introduce the stem cell that does not have the disease. The new stem cells will engraft and start to produce new body cells. You have to support the recipient during this critical period with blood and blood products. Also, transition support is very key to the transplant programme. We look for blood donors that match the recipients. We make sure that the donor is fit enough and has extra blood that they can give out. For some people, we collect their red cells; for some, we collect their whole blood; and for others, we collect their platelet, which is also another part of blood. Special parts of the blood are required to maintain the hemostasis. That means to keep the blood flowing and not to clot too much or bleed. So, anybody can donate as long as they match the recipients. All we need to do is screen them and make sure they are disease-free and their blood type also matches the recipient.

How many pints of blood does a donor need to help somebody survive?

It depends on the individual patient. There is no specific, because it?s also depending on how quick the recipient engrafts. Some recipients may engraft within 14 days. Remember I said that we need to support them during the period of conditioning before they engraft? That is the period where you have wiped out their own bone marrow and they cannot produce blood by themselves. Before they engraft, the donor stem cells are starting to produce new blood cells from the donor stem cells. So, there?s a critical period of about two to three weeks where their own body cannot produce blood. So we need to support them.

Do the diseased cells really go out completely?

Yes, they go out completely. We wipe out the bone marrow completely with medications. Then we keep checking every day through blood tests, and we get to a point where we know we have done it.

How does the patient survive without that blood?

During that critical period, we have to support them with blood transfusions and blood products. We infuse them at intervals until their own body starts to make new blood cells from the stem cells you have transplanted into them.

Is any part of this procedure invasive?

The only invasion that you will see is when we put a needle into the donor to donate the blood. That?s all. And it usually takes 30 minutes if you are donating blood or one and a half hours if you are donating a little concentrate. For the recipient, it is still not invasive. To collect the stem cell from the recipient, we make the recipient sleep. While the recipient is sleeping, using some special needles, we aspirate the blood from the bone marrow and keep it in special bags. That is where you have the stem cells. So, the invasion is to just use several specialised needles to collect blood from the bone marrow of the donor. So, it is not as if you cut open the bone and start taking the stem cells. No, it?s just using special needles to puncture into the bone and aspirate as much blood as we can or as necessary for the donor.

Vivian Chuka-Ebene, deputy director, Pharmacy, LUTH:

Give us an overview of the importance of your role to the success of a bone marrow transplant . . .

We use drugs to clear the diseased blood. Our work starts with the protocol that has the drugs we use. You have to get the dose for individual patients, according to the weight, for instance. We also check the drug interaction and ensure that there won?t be challenges with the liver or kidney function. We also deal with sourcing the drugs, and most of our drugs are sourced from outside the country. We check for vendors here to find the ones that are available here or outside the country. There are so many processes involved in importing, including regulatory issues.

What challenges do you face?

The key challenge now is the sourcing and the procurement. Most of the drugs are not manufactured in the country. We don?t get them in large quantities. We import for the patient only, and that makes it costly.

Olufunto Kalejaiye, consultant physician, haematologist, LUTH:

What is your contribution to the work of this team?

I run a robust adult sickle cell clinic. We also run clinics for haematological malignancies like cancer. Basically, we run what we call the pre-transplant evaluation clinic, involving searching for eligibility and suitability of a recipient as well as a donor. This team is multidisciplinary. You have all the specialists involved in the pre-transplant evaluation. It?s our duty to find out about the severity of disease because we do need some criteria for it to qualify for a transplant. Now, during the course of this history, we also take into consideration the medications the patients will get. We delve into the family history to find out if there are potential donors for this recipient. Apart from that, we look to see which donor can match the recipient best. When this has been done, the recipient will undergo a series of laboratory tests. It involves not just our immediate team but also a lot of external consultants, including cardiologists, neurologists, endocrinologists, and respiratory physicians.

Titilayo Bamigboye, assistant director, Nursing, LUTH:

When we talk about transplants, the nursing team is so vital. We are about six in the unit, and I coordinate the nursing team. We have the pre-transplant phase. There, we take them through the blood work. Also, we play a major role in ensuring that patients are well informed about the pros and cons of the procedure before they eventually sign the consent. We are there to take their samples, to send them to the lab, collect the results, ensure that we read the results together, and ensure that they are really fit for transplant. And then the second phase is what we call the peri-transplant phase, or we call it the intra-transplant phase. And this is when they come for 10 days of chemotherapy. For 10 days, they will be on chemotherapy. The essence of the chemotherapy is to dry out the recipient?s blood cells because we are preparing to infuse new bone marrow into them. So, for those 10 days, nurses give the chemotherapy, both orally and intravenously, and monitor them for reactions and any side effects.

What kind of reactions manifest in this phase?

Some of them face serious nausea and vomiting. They may be weak or have a high fever. Some may have anaphylactic signs and symptoms, which we monitor. As soon as anyone arrives, we tackle it immediately. At the end of the 10 days when the cells are collected from the donor, our nurse takes them to the stem cell laboratory to be analysed, and they give us the right dose we want. The nurses will infuse the cells and monitor for reaction. We ensure that everything they need at that moment is supplied

Titi Tade, medical social worker:

What?s your contribution to the BMT team?

What we do within the BMT program is one: we are involved in pre-assessment, pre-transplant, intra-transplant, and post-transplant processes. During the pre-transplant, we handle the social and psychological part of the patient assessment. People have mood disorders like anxiety and depression. All those are things we assess at the beginning. If we identify people that have that, we would refer to the clinical psychologist or the psychiatrist. One of the other things we do is also assess the carers and also the donors. We want to be sure that the donors are not being compelled to donate and they are not giving up their free will. If we identify a donor that is being compelled, we would ask that the transplant not go forward. We monitor the carer also because this is a year-long process, and at some point, that recipient?s immune system would be be nonexistent. So, they would need people who would be their carers, who would need to run around and do things for them. It takes a while for the immunity levels to reach the pre-transplant level. It will take maybe between six months and a year. During that period, the person can?t go out freely and can?t mix with people. So, you have to have somebody help care for the recipient. So, we also need to ensure that the carer is psychologically and socially fit to provide that one-year care.

We also do home visits to assess it and ensure that when the patient has been discharged from the hospital, their house is in a state of cleanliness.

You have worked with two families. How did they receive you?

They were very happy. They were also quite happy about the fact that we were doing a home visit. Everybody wants the thing to work. They don?t want to be the person who will botch it. So, they are willing to cooperate with us. Whatever we recommend for them, they do. Then, they ask us sometimes, ?What else can they do? Is this fine??, and we have discussions with the family because they are also part of the decision-makers. (BusinessDay)

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