Poole Africa Link Report – Lira, Uganda. October 2022

Dr Pasco Hearn, Microbiology Consultant, UHD Microbiology Department

This was my first trip with the Poole Africa Link (PAL), but I hope not my last as it was hugely enjoyable and felt like a real success.

I’m a Microbiology Consultant, trained in Infectious Diseases and Microbiology and I was hoping to achieve a few objectives during the trip. I wanted to contribute to the organised teaching at Lira University Hospital (LUH), whilst also building relationships at the nearby Lira Regional Referral Hospital (LRRH) where I hoped to teach the medical teams and the microbiology staff, whilst setting up what I hope to be lasting links with my own department at University Hospitals Dorset. This should enable us to have continued interaction and allow us to provide support to ward teams as well as lab staff and to enhance their activities around antimicrobial stewardship, tackling the ever-growing challenges of antimicrobial resistance.

During my training I worked for a year in Uganda as a Medical Senior at Mbarara Regional Referral Hospital and a Visiting Lecturer at Mbarara University of Science and Technology in the Southwest the country. Since that time, I have made several return trips to teach as faculty on the East African Diploma of Tropical Medicine and Hygiene, run by the London School of Hygiene and Tropical Medicine and based in Tanzania and Uganda. I have also worked for two years as an Infectious Diseases/Microbiology Doctor in a paediatric hospital in Siem Reap, Cambodia.

Having worked in resource poor settings, I understand the importance of a robust microbiology service providing timely and reliable results. In the absence of this, it is very difficult to inform sensible antibiotic decisions beyond empirical choices. In time, such a service may allow a shift in first line antimicrobial choices based on accumulated local resistance data. A robust service also leads to an improvement in the general management of infection cases, satisfies medical teams who see their patients respond better to targeted treatment and encourages closer working between medical professionals and the microbiology laboratory. The benefits in the long run ought to be felt by both the teams and their patients.

My aims therefore were: to introduce myself to the medical teams, starting with the lead medical consultant; to get to know the way in which they work on the wards by joining ward rounds; to provide opportunistic teaching along the way on the wards, as well as finding time to deliver more focussed teaching sessions in organised, protected time. I also wanted to contact the Microbiology lead, visit the lab, understand what they are able to do, what their limitations are and what their direction of travel and likely trajectory is. In addition to this I wanted to explore pharmacy, know a little about the way in which they procure antibiotics, understand supply issues and their effect on antibiotic delivery to patients. I then wanted to understand the interplay between nursing staff and the patients’ families to unpick what role they might play in antibiotic stewardship, since administration of medication is their responsibility. Finally, I wanted to find out more about the role of Infection Prevention and Control, especially in the wake of the COVID pandemic and in the context of an ongoing Ebola outbreak that was gaining pace during our visit, about 6 hours to the West.

Activities:

Monday

• LRRH – Meeting Deputy Director and general tour/orientation
• LUH – Meeting Midwifery and HDU Leads and general tour/orientation

Tuesday

• Meeting Senior Medical Doctor – agree agenda, plans and potential timetable
• Meeting Medical Ward Sisters
• Meeting Micro Lead – agree agenda, plans, lab orientation and SOP review

Wednesday

• Teaching at LUH – HIV management and opportunistic infections + Maternal sepsis
• Contact with LUH Intern doctors – failure to engage meaningfully

Thursday

• Teaching at LUH – HIV management and opportunistic infections

Friday

• Postgraduate and Intern ward round – teaching around infection cases
• Work up of samples in Micro lab – review of SOPs, discussion of sensitivity testing

Monday

• Meeting with Meningitis Research Team – insights into ward practices/politics
• Senior Medical Doctor ward round – teaching around infection cases
• Micro Lab Teaching – mechanisms of action and resistance in antibiotics

Tuesday

• Intern Teaching – antibiotic mechanisms/resistance/choice/stewardship etc.
• Meeting with Pharmacy Leads – antimicrobial use/stewardship/procurement
• Meeting with Senior Principal Nursing Officer – antibiotic delivery by night shift

Wednesday

• Intern ward round – teaching around infection cases
• Senior Medical Doctor ward round – teaching around infection cases
• Micro Lab Teaching – standardising AB panels, aligning with available Abx

Thursday

• Ebola CME/Grand Round – by Dr Francis Kiweewa
• Intern ward round – teaching around infection cases
• Micro Lab Teaching – development of antibiogram templates for common isolates
• Meeting with Infection Prevention and Control Volunteer – role and future plans

Friday

• Delivery of donated material/PPE to SPNO for wider distribution
• Intern ward round – teaching around infection cases
• Meeting with Sean Puleh – discussion of potential PHD project and collaboration
• Micro Lab Teaching – finalisation of ABx panels, discussion of ongoing support, list of potential donations, plans for ongoing input and next steps

The trip was a success from my point of view. I was able to contribute to some of the teaching of midwives on the LUH site, focussing on perinatal infection, HIV management and maternal sepsis.

However, my main contribution was at the LRRH, where patient numbers and clinical challenges are plenty. I was able to start building relationships there that have subsequently allowed me to apply for funding to support a body of work around Microbiology processing, Infection Prevention and Control and Antimicrobial Stewardship.

The result of this funding application has not yet come through, but the activities planned can now progress regardless of outcome, because the right people have been brought together to form a team, with a clear action plan drawn out. This will allow for a collaborative approach and push forwards plans for teaching courses around the management of infection, to be delivered with a ‘train the trainer’ approach to allow sustainability and repeated local delivery; improved microbiology processes leading to local antibiograms that can inform front-line antimicrobial use and procurement; antimicrobial stewardship ambassadors and IPC champions to be identified and supported on that wards. This will allow Lira to address growing concerns around antimicrobial resistance, will build on activities already being supported by the Fleming Fund and will formalise a number of roles that should really help improve the knowledge and use of antimicrobial treatment.

I aim to return with PAL, possibly annually and if the funding application is successful, I aim to recruit people to join future trips, with a view to progressing the projects outlined above, as well as contributing where appropriate to other activities planned by the visiting PAL team.

I would urge anyone who is interested in joining a future PAL trip to Uganda to come along and find out more. We had a really good, mixed team of healthcare professionals who each had something different to bring to the table and we formed lasting friendships during our time there. The students we met were smart, well read, interactive and keen to learn. The medical professionals were friendly, welcoming and also keen to interact whenever their time allowed. It can be a challenging environment to work in and can take some adjusting to for visitors like us. It requires a flexible approach, as things don’t always go as planned. Experiences on the wards can at times be shocking and emotionally challenging and will be a real eye-opener for many. It may act as a healthy reminder that the world is not a fair place and that the NHS is a valuable and extraordinary service that we are lucky to have – but we knew that anyway. Your trip will most likely be hugely rewarding and enjoyable too and you will likely learn as much as you teach whilst there. It’s also a beautiful country with a fascinating and at times troubling history with wealth of wildlife experiences to be had, should time allow.