Recently in Partner Site: Uganda Category

First Patient Enrolled - Nate Herr (PL2)

Posted on behalf of Nate Herr (PL2)

With nearly perfect triumphal timing, it's my final week here and we just enrolled the first patient.  The process went smoothly, and in observing it all, it felt good see the family acting quite content and pleased to be receiving quality care and attention to detail both now and over the next year. 

They weren't the only ones pleased.  Many members of the NDI study team stopped by to say hello; from the lab technicians to the home visit coordinators.  The first enrollment is always a big day!

enrollment.JPG
GHU NDI Project Director, Ruth Namazzi, and Medical Officer, Denis, go over the enrollment forms in the consultation room.  (patient and family not photographed)

Also, I must note that Ruth is an excellent Ugandan pediatrician and is the Project Director here for the NDI study.  If you're in Minnesota this month you'll have the chance to meet her on April 29th when she presents her results on "Change in Hemoglobin concentration of Children with Severe Anemia at Mulago Hospital: A Prospective study."  It's her first time visiting Minnesota and the presentation will be at Dr Cindy's house at 6:30pm.


Nate Herr (PL2) on Getting an R01 Study Launched

Posted on behalf of Nate Herr (PL2)

After the safari, I returned to my routine of rounding in the PICU and stabilization room 2-days a week.  The remaining days of the week were dedicated to the various and many research study tasks surrounding getting a new R01 study launched.  This study will follow a spectrum of children admitted with severe malaria-- taking detail to discover more about the causes and outcomes of the different types; Coma, Seizures, Anemia, Acidosis, and Prostration.

Chandy John, Director of the Division of Global Pediatrics at UMN, had arrived in Uganda while I was out on safari.  In the next 3 weeks that he was here he facilitated meeting after meeting on his multiple clinical studies here-- including the NDI study I've been working on and described briefly above.

To answer a question, you need data.  And to get data you need forms.  The forms for our study collect somewhere around 7,000 variables per patient.  With our goal to take in all comers with severe malaria, we are expecting a lot of variables and a short and fast enrollment period-- both of which called for efficiency in the data collection and verification process.

CRF4.jpg

Karen Hamre, MPH, a PhD candidate at the UMN and current Fogarty Fellow, arrived 2 weeks ago and brought her skilled eye for detail and perspective of data analysis to the group.  It took almost a weeks worth of revisions and multiple rounds of feedback from everyone.  We spoke with everyone from the bedside nurses to the principle investigators to create a set of forms that we believe will efficiently and accurately collect the information we'll need. While it brought on headaches, it was great to have the many perspectives involved early on before the actual roll our of the study.

At the end of Chandy's time here, we weren't yet ready to enroll any patients, but we had made much progress in ensuring that the process would be smoother when it happens.  That last weekend he was here, the Global Health Uganda staff from across the country met for their annual retreat, and ventured out to an island in Lake Victoria.

boat.JPG

For most it was their first time at the island, and for many it was their first time on a boat.  With the entire GHU staff at the island you soon saw how they were a big family, enjoying the company and friendships build over time as the NGO approaches 15 years.  It's been a great privilege to work with them as it's apparent to all that they strive for excellence in whatever their task or role.

cuttingcake.JPG

The retreat did it's job in bringing rest and relaxation, something we needed with the multiple studies set to launch this spring.

Nate Herr's (PL2) Safari Story in Pictures

Posted on behalf of Nate Herr (PL2)

Hello again from Uganda!  I realize now that it's been a month since last checking in with our blog-- sorry about that!  I've been quite busy with a few things.  Chandy John has been on site and we've had productive meetings, and have been working on editing of forms to make our data collection more efficient.  Look for an upcoming post with more details.  

Since arriving back in mid-February for my 2 month rotation there was time to fit in a visually breathtaking safari.  

safari.JPG

I took some of my PTO in early March when Abby came to visit for a week. While we did spend a couple days around Kampala and at the Mulago Hospital, we first went up north on a 3-day safari.  Our main stops along the way were the Ziwa Rhino Sanctuary, where they're reintroducing them back into their natural habitat after being poached to elimination years ago, the big Murchison Falls Game Park, and the Budongo Forest for chimp tracking.  

Pictures say it all, so here they are! 

sunrise.JPG
Sunrise

rhino1.JPG
Rhinos resting in Ziwa Rhino Sanctuary

rhino2.JPG

murchison.JPG
A view of the Murchison Falls Game Park

antelope.JPG
Antelope at the Murchison Falls Game Park
elephant.JPG
An elephant at the Murchison Falls Game Park

giraffes.JPG
Giraffes at the Murchison Falls Game Park

hippo.JPG
A hippo at the Murchison Falls Game Park

warthogs.JPG
Warthogs at the Murchison Falls Game Park

cranes.JPG
Cranes at the Murchison Falls Game Park

croc.JPG
A crocodile at the Murchison Falls Game Park

mahoganytree.JPG
A mahogany tree

chimp1.JPG
A chimpanzee at the Budongo Forest

chimp2.JPG

nateabby.JPG

Hope you enjoyed the photos!
-Nate

Posted on behalf of Nate Herr (PL2)

Beth Thielen invited me to try rafting with her this past weekend. (Beth is in the UMN Med-Peds program and is here working on the adult side of Mulago hospital on the ASTRO-CM trial with Dr. Boulware).  

With a few recommendations we decided to go with Nile River Explorers, an established rafting company here in Uganda.  Our raft guides, safety kayakers, etc, were all Ugandan, who have grown up into and thrived in the development of adventure tourism and sports.  Several of them, including our raft guide Juma, have competed at the international level in whitewater kayaking-- representing Uganda and Africa all through the energy of waterfalls and rapids in the backyard of their home village.

rafting02.JPG
The fun and adventure of rafting with excellent guides

By the end of the day we were exhausted, sun burnt, and winded from the three times our raft flipped in the rapids. But, all-in-all we were glad to be able to experience the thrill of the Nile river rapids.  These rapids have been sequentially disappearing with each installment of hydro-electric dams on the Nile, built to fill the need of reliable electricity in a developing country. A third dam is currently being proposed and depending on the height, additional habitat, communities, rapids, and tourism economies will be displaced or eliminated.  A petition is circulating both in hard copy in communities and online internationally to encourage the building of a smaller hydro-dam that would preserve the remaining falls and rapids on the river.

rafting04.JPG
Flat stretches of water were time for discussion and brainstorming

On the flat stretches between the rapids, we talked these issues of the Nile and more.  I also found out that it's hard to escape healthcare all together, even on your weekend off.  The two guys in the front of the boat were logisticians with MSF, in Uganda for a 2-week training session.  On the water and in the rafting truck we were discussing the challenges behind ensuring a cold-chain to deliver vaccines and the future promises of mHealth, the later which got me thinking-- a lot. mHealth is a broad term to describe mobile phone technology interfaced with healthcare and I see great potential for it here and elsewhere around the world.  If anyone has any experience or ideas on mHealth, please email me. It's hard to imagine future implementation research without it.

rafting21.JPG
Getting a bit wet after one of those flat stretches

Posted on behalf of Nate Herr (PL2)

I've alluded to some of the pediatric clinical research and collaboration happening here in Kampala, it's really quite extensive and thorough.  I'll do my best to summarize.

Malaria has long been a common disease in the equatorial tropics.  It has a spectrum of severity, depending on the type of malaria one is infected with and the age and health of the person infected.  The most severe form of malaria is cerebral malaria which involves a patient in coma and is fatal if the malaria is not treated.  This is thought to be from the parasitized red blood cells sequestering in the blood flow to the brain or due to inflammation, the answer is not yet clear.

Earlier, the same collaboration group with UMN and Mulago Hospital, studied and compared two types of severe malaria.  One that I mentioned, Cerebral Malaria, and Severe Malaria with Anemia.  They followed the children through their illness and after they went home.  They did continued EEGs tracking seizures, neuropsych and cognition testing and found that children with anemia and no initial brain involvement with their malaria still had deficits and disability down the road.  These disabilities are a big problem in Uganda and sub-saharan Africa and already the research group here is studying to see if rehab programs can help children regain their abilities.

malariadisability.jpg

What is about to start is a broader look at children with milder forms of malaria to see if they also have disability from it.  In this study, blood tests will also be done to look for clues as to what is actually causing it.  Home visits and clinic visits will again follow the children after their initial illness.

Neuro Exam Photo.JPG
Ahmed, Denis (our two medical officers with the study) and Dr. Postels

Our Ugandan Medical Officers are a critical part of this.  We held a training session today with Dr Doug Postels, our Michigan State collaborator.  He lectured on the neuro exam then afterwards the medical officers practiced, asked questions, and gave much needed feedback on the forms and documentation that we've been editing and creating these last weeks.

Every day I'm learning another piece of what it takes to get good information to answer good questions for the betterment child health care.  Nothing is ever simple and straightforward and the best insight comes from looking at the problem from all angles-- with medicine being only one of the angles.

Nate Herr (PL2) tells us about The Container

Posted on behalf of Nate Herr (PL2)

This is the building we affectionately call 'The Container" because, well, it's a shipping container.  Granted, it has a few upgrades since its shipping days including a roof, windows, WiFi, a water cooler, and thankfully an oscillating fan. 

The Container.JPG

This is one of the hubs of research collaboration with Makerere University in Uganda, the University of Minnesota, and Michigan State University.  In it you'll find medical students from the UMN-- Nick Sausen is here putting together donated EEG machines to help better define EEG changes in cerebral malaria and correlate it with the neuropsych testing that's being done.  Remember Tundun Williams?  She graduated from our Peds Residency last year and has been here since on a Fogarty Fellowship working on a clinical trial regarding sickle cell disease treatment in Africa.

While there's no room for me in the container, I'm often working nearby with others in the Global Health Uganda team on their both ongoing and upstarting malaria research projects.  More on that later. for now, please take a moment and send some cold Minnesota vibes to those working in the container.
Posted on behalf of Nate Herr (PL2)

Leaving Minneapolis, I left behind a consistently cold winter. averaging temperatures in the single digits.  A day's worth of flying later, and a much more ambient temperature, greeted me in Kampala.  As it's in the 70s and 80s here. Gone are the snow banks and drifting snow, replaced by red dirt and dust that coats most everything and keeps a layer of haze across the skyline.

Red Roads in Kampala.JPG

Warm temperatures and dusty red roads weren't the only thing to greet me.  What I found in Kampala was group of collaborators from Uganda and the University of Minnesota who are working here to answer the unanswered questions of some of the most aggressive and common infectious diseases here; from cryptococcal meningitis to severe malaria. Some have been here for months, others a few years or their entire life.  As the newcomer to the team, here only for a week now, I look forward to taking it all in and helping where I can.

Shapiro In Bugobero

The following was written by Miriam Shapiro, 3rd year pediatric resident at University of Minnesota.

The rains have started here in eastern Uganda. The storms can be brief and, despite the significant amount of rain that comes down, the red dirt soaks it up in little time, leaving just a hint that it was here at all - the scent of dampness, a few puddles, a bit less dirt kicked up on the roads as we drive.

I am working at a rural health center in a village called Bugobero. It is about a 45-minute drive along these red dirt roads from Mbale, the largest city in the area. My primary task here is a clinical investigation of a syndrome of malaria, severe anemia and hematuria.

Though both severe anemia and hematuria are known complications of malaria, they were being seen at an increased frequency and with increased mortality in January and February of this year.

The health center in Bugobero is unique because it was adopted by an American health care NGO, which has partnered with the government to improve care delivery. Because of the extra funds provided through the NGO, the clinic is able to hire more staff and have a more reliable and wider supply of medications. The community has responded to the increase in services with a huge increase in patient visits.

BugoberoWaitingAreaWEB.jpg
The health center includes adult and pediatric inpatient wards, a maternity ward, an operating theater and a steady stream of outpatients seen daily on a first-come, first-served basis. It is now drawing patients from all around the vicinity.

The health center has one doctor, who spends most of his time working on surgical cases, and is otherwise staffed by clinical officers, midwives, nurses and nursing assistants.

There is a laboratory here, which can do rapid HIV tests, thick blood smears for malaria, urine microscopy and urine dip stick. Usually they can do hemoglobin estimates, but of late have run out of the slides required to run the test. This limitation has required that I rely more heavily on history and physical exam findings than ever before. It also means there are several children here whose diseases fall outside the ability of the health center to diagnose or treat, even if they were diagnosed properly.

Our primary role here has been the malaria investigation, though we also see patients on the pediatric ward and outpatients, as time allows. Though the numbers of patients are not huge, the investigation is taking much of our time because, in addition to taking histories from the patients' parents and doing physical exams, we also draw the blood samples and prepare the thin smear slides. We also must leave from Bugobero early enough each day to deliver the samples to the research laboratory and have them run prior to its closing time. Because we are relying on an outside laboratory, we rarely get results back in time for them to be relevant to clinical care.

It is a stark contrast to the help we get in the hospitals in the U.S. - write an order and (usually) our work is done. Here, we rely heavily on the nurses and nursing assistants for aid in translation. Few of the villagers speak enough English to get through the detailed interview, and medical records as we know them do not exist. Each patient has a small notebook that is usually purchased upon arrival to the clinic, though occasionally is brought from home with information from previous clinic/hospital visits. When we are lucky, we can read about half of what is written in the notebook; generally the amount of clinical documentation is minimal.

Occasionally we are asked to see a child who is particularly sick. Last week, it was a 6 year-old boy with pneumonia who presented in severe respiratory distress. By the time we were called, they had already put him on supplemental oxygen via the one concentrator available. Despite the oxygen, he remained tachypneic and in significant distress, with an O2 saturation in the mid-80s. He was given a dose of ceftriaxone, which is sometimes present in small supply, and given fluids. The oxygen concentrator was then required in the operating theater, so he was taken off oxygen.

Given his persistent distress, the decision was made to transfer the child to the district hospital in Mbale, where hopefully more resources would be available. We made the 45-minute drive with him in the backseat, off oxygen; by the time we reached Mbale, his saturation was down to 59%. He was admitted in Mbale, placed on oxygen (delivered by an intranasal catheter, which was not very effective; at least at first, his O2 sat had only increased a small amount).

When we checked on him again later, it turned out that the hospital was out of the drugs that they had prescribed for him, so he wasn't actually getting them. We went to the pharmacy, purchased more ceftriaxone and paracetamol and brought it back. While we were there, the power went out, which meant that the oxygen also went off. In the end, this child was not getting much more at the district hospital than he was at the health center. Despite it all, he steadily improved, and a couple days later was asking for chapattis.

Sometimes these stories end well.

ShapiroWithBugoberoChildrenWEB.jpg
Miriam Shapiro poses with some children at the health center in Bugobero.