Rounding at Kiruddu

By Sara Brown

This past week Dr. Nicol and I have been rounding on the meningitis wards at Kiruddu hospital. This is what that looks like: we meet at the Infectious Disease Institute (IDI) and hop in a van with other doctors, nurses and lab technicians. Thirty minutes later we arrive at Kiruddu and get to work. Dr. Nicol and I walk with the doctors when they are examining the patient and the paper chart at the bedside. We answer any drug-related questions, sometimes with the assistance of medication resource apps on our phones, like Micromedex or UpToDate. The most common questions are about maximum doses or drug-drug interactions. A few hours later, we get back into the van and travel back to IDI. Traffic has been worse on the way home, so it takes over an hour to get back. We’ve had about 5-6 meningitis patients each day— “a slow week.”

Before going home today, we stopped at a roadside stand and got a rolex. It’s a chapati (greasy, thin flatbread) rolled up with a thin omelet. Delicious!

I am enjoying being part of an interprofessional team. I feel valued and useful, even though I am still a student. I have learned so much this past week about tuberculosis, Cryptococcal meningitis and HIV. It’s incredible how much you can learn by observing and asking questions. I even got to see a lumbar puncture! Rounding on the meningitis wards is such a unique experience and I am blessed to be a part of it. I cannot wait to see and learn more!

"Mushroom Meningitis of Uganda"

By Melanie Nicol

Hard to believe that my time in Uganda for this trip is halfway over. I honestly feel like I just got here and am still getting settled in.

This week Sara and I have been rounding with the meningitis research team. Working with this team is a unique experience for the students as they get to see firsthand the intersection of clinical research and clinical care. The cryptococcal meningitis team from University of Minnesota has been working in Uganda for over 10 years; their work has led to landmark findings that have changed clinical guidelines for the management of cryptococcal disease. While also doing groundbreaking research, the team (comprised of health professionals from Uganda, U.S., and the UK) is also providing quality clinical care for these very sick patients. Today Sara got to see a lumbar puncture being performed on a patient newly diagnosed with cryptococcal meningitis. Lumbar punctures are done to 1) collect cerebrospinal fluid to test for the presence of cryptococcal antigen and confirm diagnosis and 2) relieve intracranial pressure which becomes quite high during this disease leading to severe headaches, and sometimes seizures and neurological damage.

Postings on the infectious disease wards at Kiruddu Hospital

Cryptococcus is a fungus that typically only affects those with significant immunosuppression, such as those with advanced HIV. We learned today that there is no good word in Luganda ( the common language spoken in Central Uganda) for fungus so one of the doctors describes the disease to the patients as "Mushroom Meningitis of Uganda"

My involvement with the meningitis team began in 2015 when one of my mentors, Paul Bohjanen, introduced me to David Boulware, one of the principal investigators of the team. This all stemmed from when I was approached by my college Dean and asked to find connections between my work and what was going on in Uganda. I met with David, trying to think of a way my work in HIV prevention and drug exposure in the female genital tract (more on this research in a later post) could tie in to his work in advanced HIV and co-infections of the brain. I asked about access to tissues to measure drug exposure- he talked about ongoing initiatives to do more autopsy related work.

There is a great deal we don't know about HIV and related co-infections because many events are happening in tissues, while most of the sampling for clinical monitoring comes from the blood (and sometimes urine, CSF, or other fluids). Autopsies provide a unique opportunity to study some of these infections and understand how the drug is interacting with the bugs in tissues that we cannot sample in living patients. I decided to apply for and was ultimately awarded a Global Health Seed Grant to test the feasibility of combining autopsy and pharmacology research. We presented results of this proof of concept study at CROI 2018. Part of my time in Uganda this trip has been working on the logistics of keeping the next phase of this study going. I hope to have a later post describing some of the unique challenges and rewards to performing international clinical research.

Another productive day!

By Kunkun Wang

Another productive day!

Like yesterday, Prosperity and I went to Nakasero hospital for rounds in the morning. Professor Otim was very engaging going over his patients with us. I had the same meal as yesterday - goat stew in the hospital cafeteria and yes I am planning to eat it 5 days in a row while I am at Nakasero. When Dr.Nicol and I met the pharmacist Esther here the first day, she was worried if I was picky about food. When she asked that I was also thinking if the hospital food would be as bad as the US hospital food but it was actually very good with reasonable price. We also had some down time in the afternoon so we went to help in the main pharmacy for some outpatient/discharge prescriptions. Looking for drugs on the shelf was challenging because the medications were all boxed with brand name on it. We also observed the process of taking in prescriptions, preparing, dispensing and counseling.

The picture below is when the pharmacy run out of certain strength we (Prosperity did the work:) had to cut it half for patient. They don’t have prescription bottles. They use paper bags and usually do 30 days supply to make sure the drug won’t go bad.

"I can't believe we learnt all that in one day"

By Prosperity Eneh

As we sat down to have dinner today (Monday 5/28/18) at one of our favorite restaurants so far (Cafe Javas) Sara exclaimed, "wow. I can't believe we learnt all that in one day". She made this statement as we were recalling our experiences from the day. As our colleagues in the U.S took the day off to celebrate Memorial day, it was a busy day for us in Kampala. We opted to take the day off June 15th when it will be a public holiday here in Uganda to celebrate Eid (end of Ramadan).

Front entrance of IDI -Mulago

We split up today for clinical experiences. Sara and Dr. Nicol were in the Infectious Disease Institute (IDI) and were part of the virtual rounds with the Cryptococcal meningitis team. It was a virtual round because the team travels a bit far away everyday for physical rounds at Kiruddu General Hospital since the New Mulago hospital (close to IDI) where the patients would normally be located is still under renovations. They did not make the trip because Sara had to shadow a medical officer at IDI later in the day and the Kiruddu team will not be back in time for her. On Wednesday they will get to participate in the physical rounds.

Kunkun and Winnie at Nakasero Hospital main entrance

Kukun and myself went to Nakasero Hospital. We met with Esther (the pharmacist) and Winnie (another pharmacist). We went on rounds at the general ward with Winnie and the rest of the  inter professional team (physician, nurse, physiotherapist, and patient advocate) and visited with many interesting patients and cases. We were privileged to work with an enthusiastic endocrinologist that loved to teach his colleagues and asked many questions. Now we have so much to look up and prepare for tomorrow.




After the rounds, the students immediately met with Eva, the pharmacist at the Prevention, Care and Treatment Clinic within IDI in Mulago. We had previously met with Eva and talked about some goals and objectives for working with her. Today she introduced us to two medical officers that Sara and Kunkun would each shadow for a few hours today and tomorrow. They both got to sit in on medical visits as a way to get some context for working with Eva on the clinics' ongoing antimicrobial stewardship program pilot. This clinic is often used as a place for pilot projects prior to rolling out to other clinics and hospitals and the students are brainstorming ideas with Eva and the other pharmacists on strategies to incorporate patient and physician education on the rational use of antibiotics.  Sara and Kunkun expressed that they were amazed by how many patients the medical officers were able to see and the time shadowing them was  a great learning experience.

Here are some other details we have learnt so far;

Uganda is divided into three main categories when it comes to provision of healthcare.
1) Government hospitals and clinics (with a bottom up referral approach moving from health centers > district hospitals>regional hospitals>referral hospitals)
2) Non-government or private (for-profit) hospitals and clinics
3) Faith based or donor sponsored (not for profit) hospitals and clinics

Mulago hospital and Kiruddu General hospital are examples of government hospitals.
Nakasero hospital is a private for profit hospital.
The infectious Disease Institute PCT clinic is an example of a donor sponsored (not for profit) clinic.

The patients that visit government hospitals mostly receive basic care without paying but there is often shortage of some supplies and drugs. Sometimes patient families are responsible for purchasing medications and labs if not available in the hospital. The private non-government hospital are for paying patients and can often times be better stocked with supplies, medical/lab equipment and essential medications. The donor sponsored facilities can also provide free care with occasional options for patients to pay for added convenience.

It is interesting to be plugged into these various settings as learners and we have had such warm welcome from everyone we have met so far. We look forward to more days filled with wow moments!

Weekend Adventures

A post by Sara Brown

This was our first weekend in Uganda. Friday night we went to the Kurb to eat Ugandan street food. The building housed five different restaurants, each with a unique menu. Fried plantains were by far my favorite item!

Saturday afternoon we went to the Kampala National Mosque, also known as the Gaddafi National Mosque. It is a beautiful building with intricate detail shaped by three different cultures: African, Arabic and European. Go up 224 steps to the top of the tower for an amazing view of the city. The price per person is 15,000 ugx and the people in the tourism tent will wrap your legs and head if needed. We spent a few hours here since our tour guide was very knowledgeable and talkative.

After this, we went to the Uganda Museum for another 15,000 ugx. The displays were interesting but were brought to life when our tour guide started narrating the history of the Ugandan people. As pharmacists, we enjoyed the traditional medicine display the most. 

For supper, we went to the Asian Bistro on the top floor of the Acacia mall. Kunkun ordered pineapple rice and it was served in an actual pineapple! 

Sunday was more relaxing. We went to a craft market to buy African souvenirs and then to Mediterreaneo for supper. Overall, it was a fun weekend in Kampala

We made it!

By Melanie Nicol

We made it safely! Our flights and layover were thankfully uneventful. Customs at Entebbe airport was an unusually long process but we eventually (around 1:30 am) made it to We'lo Inn, our new home for the next several weeks (2 weeks for me, 4 weeks for the students). 

View of Kampala from balcony at We'lo Inn

Wednesday morning we got settled in. We made our way down to the Acacia Mall area (within walking distance). We grabbed a late breakfast at Cafe Java's where we met Winnie Nambatya, a pharmacist at Makerere University who is working with us on many projects and helping facilitate experiences for the students. From there we went to the mall where we took care of banking as well as getting groceries for the week!

Prosperity, Kunkun, and Sara outside the Minnesota-Uganda Hub

In the afternoon, the students got a tour of some of the main locations they will be working from. First we went to IDI-Mulago where I dropped off some study supplies and introduced everyone to the cryptococcal meningitis study team. Next stop was the International Student office at Makerere University where we got our badges so we're official! And lastly we went to the Minnesota Uganda Hub where the students were introduced to Martha Kandole, the hub manager.

We were quickly immersed in Ugandan culture on our first night by joining a group from the International Student Office on a trip to the Ndere Troupe Cultural Show. This group tells the history/culture of the many tribes from different regions of Uganda through song and dance. It was my second time attending this event and it's a definite favorite.

Thursday morning we settled into the hub. Later in the morning, Winnie, Kunkun, and myself went to Nakasero Hospital, a private 71-bed hospital in Kampala. Their pharmacist Esther is very eager to work with our students. Each student will spend a week rotating at Nakasero- I am excited about this  as it will provide opportunity for the students to see the differences between private and government-run hospitals.

Kunkun, Dr. Nicol, and pharmacist Esther in the Nakasero Hospital Pharmacy

Friday we met with IDI pharmacists to discuss possible projects for the students. The first meeting was Peter from the IDI Global Health Security Partner Engagement Project. He shared with us many of the policies IDI is working to develop, write, and implement. Later we met with pharmacist Eva who works in the Prevention, Treatment, and Care clinic at IDI. She gave a nice overview for the students on the mission of IDI and how HIV treatment and care has evolved over the years in Uganda. The students are going to be working with Eva in the coming weeks on developing some educational interventions (for both prescribers and patients) to improve appropriate antibiotic use at IDI.

First week is already over! With only three full work days, it feels like a lot of our time was spent making introductions, orienting students with facilities tours, and planning projects. The students have a full 4 weeks ahead of them and I am excited to hear about their initial impressions of Uganda in upcoming blogposts. 

Kunkun Wang intro

Hello,

My name is Kunkun Wang. I am a fourth year pharmacy student from University of Minnesota, twin cities campus. I am originally from Shijiazhuang, China. I am the only child in my family. My father is a veterinary doctor and my mother is an engineer. Under the influence of my father, I became interested in healthcare.

I came to the US around 7 years ago for my undergrad following pharmacy school. Seeing the large difference in health care between China and US made me interested in global health. During pharmacy school, I volunteered at different underserved communities in the twin cities area including African America, Hmong, Vietnamese, Cambodian and Chinese communities. The volunteer experience and direct patient interactions with the medically underserved population make me realize how important it is for healthcare practitioner to understand patients’ culture and background while treating their disease. I am hoping to learn the clinical knowledge as well as to know more about African culture.

I currently don’t have specific goals after my graduation. I am still figuring out my interests. This trip will definitely broaden my prospective and give me some hints about which career path I should pursue in the future.

Prosperity Eneh - Hello!

Hello all,

I am Prosperity Eneh.




To start off, I have to say that it is pretty awesome to feel a special connection to a group of people. I have always had this sort of unexplained love for East Africa and that is why I feel so privileged to have to opportunity to visit Uganda. My first travel to the eastern part of Africa was in January 2017 to visit Tanzania as a 4th year pharmacy student. This experience revitalized my passion to be in the global health sector even as a pharmacist. I am originally from Nigeria and hence, I am familiar with the differences that exist in healthcare in developing versus developed countries. However, I realized while in Tanzania that I do see it in a unique lens when I am able to visit as a healthcare practitioner compared to while I was growing up in Nigeria. This is what pushes me to continue to explore opportunities that expose me to various global health challenges and to continue to understand ways that pharmacy practitioners can uniquely be a part of the solution.

I am participating in this current global health excursion to Uganda as a Global Pharmacy Engagement, Education and Research fellow. I graduated with my PharmD in 2017 and continued on with the College of Pharmacy to pioneer this fellowship. The goal of this fellowship spans across three arms; (1) Strengthening global engagement opportunities available to pharmacy students (2) Understanding the educational needs for global health in the pharmacy curriculum and (3) Engaging in global infectious disease research.

This visit to Uganda aligns well with the goals of the fellowship. I have been involved with organizing the details of this excursion and refining this APPE course offering. I have also been engaged in the clinical research work ongoing with the infectious disease team in the Uganda Hub and so I will be spending a large amount of time while in Uganda focusing on some of these research projects. I will spend sometime in a later blog-post talking about the research projects I will be participating in the most while in Uganda.

I am most looking forward to the growth that will come with this trip especially as a global health practitioner. I am also excited for the huge learning curve and working hard to internalize all the knowledge that I will gain from the team of practitioners.

I am nervous about missing loved ones while I am gone but I also know I will meet so many amazing people in Uganda and this makes me less nervous about my time away.


My hobbies include watching various TV shows, running and traveling to new places for hikes or doing other touristy things. I hope to find time while in Uganda to train for my first 10 mile run! Outside of the college I work as a casual pharmacist with Walmart Health and Wellness and I enjoy being plugged into community pharmacy practice in this capacity.


Overall, I am excited for the next few weeks here in Kampala, and I also hope to have some time to visit friends in Rwanda.

Sara Brown intro

Hello, my name is Sara Brown and I am a PD4 on the Duluth campus. Mason, Wisconsin is where I call home. It is a small village out in the country; we even live on Brown Road. I have two older brothers and one adorable, 16-month-old nephew. I’m the first in my family to obtain degrees of higher education and work in healthcare. Stream fishing, road biking, and running are my favorite pastimes. October 7, 2018 will be my fourth full marathon.

I believe life consists of moments, experiences, and opportunities. I push myself to do things because I know I may never get the chance again. Due to that mindset, I studied abroad in India for 3 weeks during my undergrad to learn about infectious diseases and population health. I was able to compare public health services to private and see firsthand the wide gaps in healthcare. After that, I got the travel bug. This January I went to Cusco, Peru for a medical service trip and provided free, basic healthcare to Spanish-speaking locals. Shortly after, a vacation to Paris, France and Naples, Italy was in order. Now, I get to go to Uganda, Africa! Four countries on three different continents, all within in five months—life is about going outside your comfort zone and accepting unique opportunities.

After graduation, I am considering a residency out West and potentially specializing in infectious disease. I am also thinking about occasionally volunteering internationally in an underserved region. This trip will help solidify or rule-out these considerations. I am most excited to see what healthcare is like in Kampala and how it differs from the US. I also love learning about different cultures and seeing different ways of life. I am most nervous about finding the time and space to continue my marathon training for this month, but I’m sure it will be fine. For preparation, I brushed up on infectious disease notes and Googled information about Kampala, Uganda.

And we're off!

And we're off! We're just minutes away from boarding our flight! A layover in Amsterdam and we'll arrive in Entebbe airport Tuesday around 10:30 pm local time.

I asked each of the students to prepare a short intro. I asked them to describe a bit of their personal background as well as what their previous international experiences have been. I also asked them what they were hoping to get out of this trip, what they were most excited about and what most nervous about.

Look for these intros over the next few days. We'll be spending the next 24 hours in airports and airplanes!

You can also follow along on twitter @MelanieRNicol for more real-time updates.

LtoR: Melanie Nicol, Asst Prof; Sara Brown, PD4; Prosperity Eneh, Global Health Fellow; Kunkun Wang, PD4

From "country" to Country

By Melanie Nicol
 
Tomorrow I will be departing for my sixth trip to Uganda. Traveling with me are three students from the UMN College of Pharmacy. Over the next few days I will have them introduce themselves and over the next few weeks we will be taking turns sharing more details about our experiences in Kampala.


But first a little bit more about myself. I am an Assistant Professor at the University of Minnesota in the College of Pharmacy. To start, international travel was not something I ever imagined would be a major component of my work..it certainly wasn't something I was looking for in a job or career. In fact, I've always considered myself a bit of a homebody. I grew up in the "country"on a family dairy farm in Central Ohio. By the time I finished pharmacy school at Ohio Northern University, I could count on one hand the number of times I'd been outside of Ohio. I was a second year graduate student at University of North Carolina when I left U.S. borders for the first time on a trip to Niagara Falls. So if you'd told that graduate student that in her next job she'd be taking 2-3 trips a year to Africa, she would have likely responded with a combination of disbelief and panic.

My brother and I on our family farm in Chuckery, OH; circa 1989 

My first trip to Uganda was in November 2015. I was just beginning my second year of faculty at Minnesota. The University of Minnesota was celebrating 10 years of collaboration with the Infectious Disease Institute in Kampala, Uganda with a 3-Day symposium. It was also the launch of UMN-Uganda Hub , established by the UMN Academic Health Center to serve as a resource to foster collaborations between Makerere University and University of Minnesota. At the time, the College of Pharmacy did not have a significant presence in Uganda. In an attempt to enhance interdisciplinary opportunities, the College leadership approached me and asked if I would be interested in attending the symposium and using the new Hub to explore collaborations. They believed my work in HIV/AIDS research would align with those of researchers at Makerere and the Infectious Disease Institute. " Just go and meet people," I was told. "Explore opportunities. No pressure."


So I went. I met people. I met Dr. Flavia Matovu at MUJHU research (an NGO research organization in Kampala). Flavia and I quickly recognized a shared research interest in HIV prevention for women. Further conversation led to some ideas for research projects and we launched our first study together in November 2017 which completed enrollment in April 2018 (more on this later). I'm excited to talk with Flavia during this upcoming trip about next directions and future projects. At the symposium, I also got connected with a team of researchers studying cryptococcal meningitis (CM), a fungal infection that is devastating to individuals living with HIV, killing over 200,000 people a year. This team is a blended group of individuals from Minnesota and Uganda performing high-impact clinical research. You'll hear more about my involvement with the CM team in upcoming posts as well.


In addition to research collaborations, I've also spent the past few years looking for opportunities for students to get involved in international research. Last year, I piloted an elective APPE (Advanced Practice Pharmacy Experience- clinical experiences for 4th year pharmacy students). Amy Tran, PD4 (now PharmD) was brave enough to be the first person to sign up; she presented a poster on her experiences at the American College of Clinical Pharmacy Annual Meeting last October (Abstract #323). Collaborations with KarenBeth Bohan (read her blog here!) from Binghamton University, and Winnie Nambatya from Makerere University,have led to a variety of experiences  developed for pharmacy students to experience pharmacy practice (and research) in Uganda. Tomorrow two more 4th year students will begin my second offering of this APPE. You'll hear much more from us in the coming weeks about these experiences.

Me, Winnie Nambatya, and Amy Tran reviewing charts in the Neurosurgery Ward at Mulago Hospital; April 2017

Amy Tran and I with her poster at ACCP in Phoenix, AZ; Oct 2017