As the world turns

By Melanie Nicol

The first week of Uganda APPE 2019 is already over! Granted, it was a quick week since the first two days were spent travelling and much of our time here was spent settling in and getting oriented to our housing and the different parts of Makerere and Mulago where the students will be spending their time. Despite the short week, the students have already been exposed to so much. Issues such as drug availability and antibiotic resistance have been topics of recurring discussion among our group. The students have been enjoying the weekend with some excursions in Kampala- yesterday they visited the Uganda National Mosque and this afternoon we plan to visit one of the craft markets!

Melanie M, An, and Joe inside the Uganda National Mosque

I keep needing to remind myself that it's been 12 months since I was last in Kampala. I've been here enough times now that everything seems familiar yet it is very obvious that when I am a half a world away, things here are constantly changing. The first significant change- the expressway from Entebbe to Kampala has been completed!  Everytime I have asked about this road for the last 3 years the response was always "it will be done in 3 months". Guess the inability to predict how long road construction projects will take is a universal one. To put in perspective the impact of this, this expressway took what used to be between a 2-4 hour drive to the airport down to about 45-60 minutes, something we were very grateful for when landing at 11pm after 24 hours of traveling.

A second difference I've already observed is the effect of the rollout of dolutegravir in Uganda. When I was last here in May 2018, the country was just beginning the rollout and it was only available in a limited capacity at a few locations. Since that time, the country has had to deal with the Botswana study report which had the unexpected finding of increased neural tube defects when women were on dolutegravir at the time of conception. The low prevalence of these birth defects (0.09% of pregnancies in the HIV-negative population) makes it very difficult to determine whether the increased prevalence observed in this study (just 4 births out of 496 pregnancies) was truly a drug effect, due to some other unidentified factor, or just random.  This has been carefully followed in the months since the report but updates at CROI earlier this year seem promising as there have been no new cases reported. This is all particularly relevant in Uganda as women of child-bearing age make a significant portion of the population living with HIV and dolutegravir is really a game-changer in HIV treatment in regards to efficacy and tolerability. Despite the struggles in rollout with how to manage this uncertain risk, dolutegravir has continued to roll out and uptake is significantly higher now than when I was here last. This opens the door for many research questions. What is the frequency of adverse effects from dolutegravir in this population? Given dolutegravir's potency, will this affect the incidence of IRIS (a question the meningitis team is particularly interested in)? Will we see changes in prevalence of antiretroviral resistance since dolutegravir has a particularly high barrier to resistance?

Many changes have been going on with my research projects as well. One of my projects in Uganda has been a collaborative project with MUJHU research that I have previously posted about (Preventing HIV infection in women). This study had just wrapped on when I was last year and we've spent the last year running lots of assays and analyzing our results. We presented our findings at CROI earlier this year and I'm excited to say these results will soon by published in Clinical Infectious Disease (link to abstract/paper here) . We found some interesting and unexpected interactions between the use of DMPA injection and the vaginal microbiome and the effects on drug concentrations in cervical tissues. Overall, our findings were encouraging in that they provide reassurance that DMPA does not negatively effect drug concentrations and women should be able to use DMPA and oral PrEP safely. Here is a link to a video interview I did with Contagion Live that summarize our findings: Contagion Live Interview.

Me with  collaborator Flavia Matovu Kiweewa presenting our results at CROI in March 2019

Watch for updates in future blogs regarding some other Kampala-based projects!

The other Melanie

A post by Melanie Mahoney, PD4

Hi everyone! My name is Melanie Mahoney and I’m a fourth year pharmacy and public health student and the University of Minnesota. I was born in France but have lived most of my life now in Minnesota. My husband and I both love travelling and have been to lots of interesting places around the United States and Europe together. We also have 2 cats that we love despite how spazzy they are!

My professional interests include infectious diseases, antimicrobial stewardship, and global health. I am currently in the Department of Experimental and Clinical Pharmacology Research Emphasis and have been working in Dr. Elizabeth Hirsch’s lab, studying Escherichia coli ST131 for about a year and a half. I have also had the opportunity to expand my understanding of global health through several international trips in pharmacy school. My first and second year I traveled to Haiti and set up a temporary clinic with other students. This past fall I attended an international pharmacy conference in Glasgow, Scotland and just last month I presented a research poster at an infectious disease conference in Amsterdam, Netherlands. While I have been fortunate enough to have traveled a lot, this experience is my first in Africa!

I am very excited to spend the next 5 weeks in Uganda! I am most looking forward to learning about a culture and healthcare system that is new to me. While I was nervous at first about my clinical knowledge and being able to apply it when asked questions, those nerves have worn off already in a couple days here. In my first few days here I have already had the chance to see infections and treatment plans that are not commonly seen in the United States.

I can’t wait to see what the rest of this experience brings!

Meet An Le

A post by An Le, PD4

Melanie M, An, and Joe in front of the Minnesota House

Hello all,

My name is An Le. I’m a fourth year pharmacy student at the University of Minnesota, Twin Cities campus. I’m originally from Ho Chi Minh City, Vietnam. I have a younger sister, who’s four years younger than me. We ALSO have the same name (how crazy!). In my free time, I enjoy trying new baking recipes, going to new restaurants/coffee shops, and doing yoga.

My dream career goal is to work in an area where I’m able to combine both clinical and research aspects. I decided to participate in the Uganda Advanced Pharmacy Practice Experience (APPE) rotation because the projects/activities of this rotation will give me a better understanding of how pharmacists can utilize both aspects in their jobs, which will prepare me well for my future career. After hearing more about this rotation from Dr. Nicol and other previously fourth year students, I knew this would be a great learning opportunities for me to utilize the knowledge acquired from classes and observe the pharmacists’ roles in Uganda.

My first international travel was during my junior year of high school when I decided to come to the United States to complete my high school degree and undergraduate degree. Although this is not the first time I’m traveling to another country for study abroad, I’ve had mixed feelings when I think about this trip to Kampala, Uganda. I’m most looking forward to working alongside with Ugandan students and other healthcare providers to expand my clinical knowledge and learn more about different sectors that may help narrow down the health disparities in developed countries. I’m also very excited to visit different places to absorb more Ugandan cultures during these next 5 weeks. On there other hand, I’m more nervous about being to recall and apply appropriately the knowledge in these real-life situations. However, these 5 weeks will definitely help me grow and become more prepared for the next few rotations in the United States.

Overall, I believe that these next 5 weeks in Kampala will be busy and I’m very happy that I have a chance to step out of my comfort zone to see other parts of the world. And I can’t wait to tell you all more about what I get to see and learn.

Meet Joe Corbino

Post by Joe Corbino, PD4

Hello everyone! My name is Joe Corbino and I am currently a PD4 on the Twin Cities campus. I grew up in the western suburbs of Chicago, but many of my friends like to joke that I am from Iowa due to my family now residing there. I had a fairly unconventional path to pharmacy, graduating with a bachelor’s in music from the University of Iowa. A career as a pharmacist was attractive due to being able to combine my interest in biology and infectious diseases along with the opportunity to have an impact on individuals’ lives. A few of my hobbies include traveling, listening/playing music (big surprise!!), and learning about languages and different cultures.

I’ve had several opportunities throughout my time in pharmacy school to travel abroad, which has helped to expand my understanding of the profession to a more global perspective. In fall 2017, I traveled to Seoul, South Korea with a fellow classmate to attend an international pharmacy conference. In August 2018, I traveled around central and northern Italy with my mom before hooking up with one of my close pharmacy friends to visit an international pharmacy student in Croatia that we had hosted in Minnesota the previous summer. Before heading to Kampala for my first APPE I was able to spend several days in Amsterdam exploring the city with a family friend.

Since the beginning of 2017 I have had the opportunity to be a part of Dr. Melanie Nicol’s research lab. Since hearing about this elective experience in Uganda as a first year I have wanted to be a part of it. The greater medical community in the Minneapolis/St. Paul has provided me with incredible opportunities to become more informed and involved in the area of HIV/AIDS. It was through this educational exposure that I began to become interested in care around the world, especially resource limited settings. I soon began to realize during my second and third year of pharmacy school that this experience I had merely been interested in due to the international travel aspect would also be extremely beneficial in my professional growth as a future pharmacist. I believe that it is invaluable to gain firsthand experience to how individuals are compassionately and comprehensively cared for around the world, especially in resource limited settings.

My excitement and nerves for this rotation are closely linked with one another. It will be a life changing experience to be in Uganda and experience healthcare and another culture firsthand. I want to ensure that this experience is approached as seriously as possible to ensure that the impact that the impact on patients during this 5-week experience is as beneficial for them as it is for me. After all, I am the stranger that has come to their home in order to further my abilities as a practitioner.

I look forward to writing more posts during my stay here and updating everyone on everything that I have been able to experience both in clinic and during leisure time!

The Return of the Blog

Uganda APPE 2019 has officially begun! All of us (and thankfully all our luggage) made it to Entebbe late last evening and got into our house in the early morning hours.The "Minnesota House" has moved a few plots down the street from where I have stayed previously so we all got a quick tour and tried to catch some sleep before our first full day. Unfortunately, some Ugandan dogs had other ideas- apparently they had a lot to talk about with each other between 4-7am.

For the first time in my 8 (?) visits to Uganda, I had to complete this health form, which is clearly an "Ebola Screening" form, before entering the country. Speaks to the ongoing epidemic that is not too far away in the Democratic Republic of Congo and I'm sure the Ugandan government and health officials are very aware and mindful of.

It has been 11 months since I was last in Uganda, the longest time away since my fist trip in October 2015. It means there is a LOT on my plate while I'm here. A long list of people to touch base with and projects to move forward

Over the next few days, each of the APPE students will introduce themselves. I am particularly excited about this year's cohorts as all three are students in my Department's Experimental and Clinical Pharmacology Research Emphasis program

Recap! - Exploring the intriguing details of International Clinical Research in Uganda

By Prosperity Eneh

I have continued to learn and grow since Dr. Nicol and the 4th year students (Sara and Kunkun) went back to Minnesota. I have had the opportunity to focus more on clinical practice and research with the meningitis team here at IDI and Mulago/Kirrudu general hospital. I have also had the ability to dive deeper into organizing and finalizing logistics for the post-mortem drug distribution research study in HIV patients (learn more).

Preparing items for the post-mortem research study with Paul and Carol

I head back to Minnesota today and for this final reflection, I will break it down into the various aspects of international research work that were most intriguing to me for the past 10 weeks;

International clinical research - collaboration between institutions is vital for sustainability 

It has been very interesting to be plugged into a team that conducts clinical trials on a large scale. In the past when I have read published papers on big studies that have the potential to affect and change national guidelines, it is often hard to imagine the work that goes into ensuring that these clinical studies goes successfully. I have come to understand the intricacies of this sort of work and the level of organization, team work and perseverance that leads to success. The clinical research team in Uganda is often a mix of international and local partners with various roles to play. The team I worked with consisted of medical doctors, nurses, lab assistants, pharmacy personnel, clinical officers, administrative assistants, research assistants, and a few others. The partners in this team include personnel from Uganda, USA and London. Currently the team is preparing for about 3/4 major studies to start and there has been many training sessions. It is rewarding to contribute to these discussions from a pharmacy perspective but I would say more than the contributions, I have learned so much. 

Clinical rounds and its immediate patient benefits

The research team also conducts clinical rounds at the Mulago/Kirrudu General Hospital where patients with suspected or confirmed cryptococcal or tuberculosis meningitis are referred to. They see these patients in the infectious disease ward. During ongoing trials/studies, the patients can be consented and enrolled in trials if eligible, and when there is no ongoing trial, the patients are still seen and treated. It is however an interesting point to be made about availability of necessary supplies during studies versus when there isn't any studies ongoing. I refer to this as immediate benefits for the patients. In a previous post, I mentioned the lack of medications, labs and various other medical supplies needed for patients in the government hospitals. Often, patients are also unable to fund themselves to receive these vital medical supplies. However, when there are ongoing studies, the team often has funds available to provide these essential labs, medications and other medical supplies to the patients free of charge. Both those enrolled in the study and those that are not enrolled get to benefit from this supply. The impact can be life-saving. Prior to each day of clinical rounds, the team with the latest information on the patients, hands off to the clinical team for the day via phone discussions of the patients. The team is  also available in the infectious disease ward for questions regarding other non-meningitis patients.

Sub-projects, data analysis and publications

While there is often some bigger longer term studies ongoing with the clinical team, there are also opportunities for sub projects and other smaller data analysis projects. These offer opportunities for trainees to use data from large cohorts to answer other clinical questions. As one goes on clinical rounds and sees other potential research questions, it is common to see sub projects come out of these observations. The MN Uganda team has been a great training facility for many students, residents and fellows from various healthcare professions. There is often something for everyone that is dedicated to finding answers to questions. This has also led to very many publications that has come out of this group. During the weekly team phone call, sub-projects are also discussed and trainees are able to get mentorship and direction from the team on the direction of the various ongoing projects. During my stay in Uganda, we worked on a case report now submitted for publication involving a patient with concomitant HIV-Malaria and TB meningitis as this presented a unique case of drug-drug interaction in the management strategy. This is one example of how various activities can stem out of the bigger studies. It provides so many opportunities for the team to continue to add to the literature in this area. 

Regulatory bodies (IRB, NDA, UNSCT, SRC) - Ethical conduct of research is a big deal

There are many acronyms as you see above for the various regulatory bodies. In Uganda, I have noticed that ethical conduct of research is extremely important. While the process can often be tedious and discouraging, it is vital and ensures that patients are not taken advantage of in the research that is conducted. There are some policies that are strict and there are others that can take a long time to process. However, it is still all done as a way to weed out research that only benefits the researcher and not the local population. Changes to the protocol and other sub projects also have to go through the approval bodies as needed. I spent some time ensuring that our regulatory binder for the post-mortem drug study is up to date and while this was challenging, it was also very rewarding.  

Pharmacist role as part of the team - Drug-Drug interactions, medication management and unique perspectives

As pharmacists, we are trained to be the drug experts. I think the biggest contribution to the clinical research team comes from being knowledgeable about the medications. I found it hard at first, as the medications often have different names and I needed time to look up the generic name. However, as I got comfortable with the names of the drugs and their use in this patient setting, it became easier to make medication related recommendations to the medical officers. Furthermore, in my fellowship and Master’s program thus far, I have also been exposed to more extensive research principles which helped me tremendously in being a part of the research team. We spent many hours reviewing data collection instruments for upcoming studies. Providing the pharmacist perspective in relation to research instruments that will be used for the collection of medication information was unique. Also, as mentioned above, sub projects often stem from larger studies. One of the projects that I will be working on moving forward will involve looking at the large data collected from hospitalized patients enrolled in two previous studies and highlighting likelihood for drug-drug interactions and strategies to mitigate them in the future. I am excited to be able to collaborate with the Ugandan pharmacist and medical officer on this project. 

In conclusion

Goodbye lunch!

I will definitely miss Uganda! It has been such an amazing experience in all aspects. I hope to start making plans to visit again soon. I had a chance to meet up with the pharmacists I worked with while I was in Uganda for a goodbye lunch. They were great to work with and I am glad for their continued friendship moving forward. I am heading back to Minnesota for a while and then off to Glasgow, Scotland in September for the International Pharmaceutical Federation (FIP) Annual Conference!

Sara's Post-APPE Reflections

By Sara Brown

Today, we gave a presentation on pharmaceutical care in the US. We discussed how pharmacists have moved from being in a purely dispensing role to one that is more clinical-based. I realized I never had to work for this since I am entering pharmacy at a time when clinical pharmacists already have an established position, unlike in Uganda. Here, I have met pharmacists that have paved their way into their current role. They are working hard at being a mentor for young pharmacists to inspire them to step beyond a traditional dispensing role and into one of a clinician. It is a culture change that will take time to be accepted, adopted and implemented.

Looking back over the past month, it is hard to pick out a favorite day or memory (embedded are some great pictures, though). I experienced a lot of what Uganda had to offer: safaris, street food, plantains, fresh pineapple, Nile River rafting and more. However, I was also exposed to poverty, lack of healthcare resources and endemic infectious diseases.

My perception on Ugandan healthcare has dramatically changed. Beforehand, I was expecting primitive care. Now, I understand that doctors practice evidence-based medicine just like in the United States, but the lack of resources is the driving factor behind the difference in care. Having daily labs for a patient is something I never thought twice about, before coming to Uganda. From my experience in these different hospitals, daily labs are not possible. Oftentimes, the patient’s family cannot afford to get labs done. Or, there is no family member present to bring the sample to the lab. Or, the hospital is lacking the resources to get the sample processed. It is a problem I have never been exposed to before and I realized I have taken so much for granted.

I have also grown in character in the past month, partly due to being abroad, but also due to having experience as an almost-pharmacist. By participating in rounds, answering questions and making drug therapy recommendations, I am gaining valuable knowledge and experiences that increase my confidence.

I will miss aspects of Uganda: the warm hospitality of people, the beautiful weather, the slower pace and the relaxed atmosphere. The fresh fruit is incredible, too. However, I am thankful to leave the steep hills and traffic behind! I am very glad I participated in this APPE, I would highly recommend it!