Excerpts from Hubert Fellow Experiences
- Data Collection to Improve Hospital Outcomes - Malawi, Africa
- Testing for Bat Lyssavirus in the Philippines
- Surveillance of Bloodstream Infections in Hospitalized Adults - Mozambique, Africa
David Doostan - 1998 Hubert Fellow
Data Collection to Improve Hospital Outcomes - Malawi, Africa
“My recent work on a CDC infectious disease project in Malawi took me far beyond study parameters or anything else I could have foreseen. It was as powerful and eye-opening of an experience as I have ever had - certainly the most interesting of my medical training thus far. My experience moved me in many ways. As I expected it would, the project introduced me to the nuances of clinical research in a foreign setting. But above and beyond this exposure, I became immersed in a health care setting only remotely resembling that of the United States. During my previous training, in hospitals in the Los Angeles area, I had never watched patients die from lack of such simple things as oxygen of pRBC’s, but in the context of sub-Saharan Africa, such events were commonplace. I learned the true meaning of ‘limited resources’ there, and most of all, I was quite moved by the kindness and hardship-born strength of Malawi’s people.
“Our study represented a data-collection phase within a long-term effort to improve medical outcomes in this hospital. It was not the first time that the CDC had been collecting and studying data from this hospital, and would not be the last. This continuity and dedication to the hospital were among the first things that impressed me about the project; we were not there to just get our data so we could have something interesting to write up back home. Our efforts would indeed be of benefit to the care providers and patients in the hospital, and therefore to the entire country of Malawi. We were responding to a need. A previous pilot study, in the ‘wet season,’ had shown that empiric medical therapy given to febrile children was often based on inaccurate diagnosis and thus ineffective, likely owing to scarcity of resources which prohibited the kind of sophisticated diagnostics we use in the U.S. Children were being over treated for malaria, for instance, and under treated for mycobacterial bloodstream infection. In addition, HIV and AIDS, alarmingly prevalent in both adult and pediatric populations in Malawi, were rewriting the traditional rules which continued to guide clinical decision-making in the hospital. So our role was, in theory, simple. We were to follow up this pilot pediatric study by carefully collecting a large number of pediatric blood samples in ‘dry season,’ and performing analytical and diagnostic tests, which would allow us to make statically significant conclusions about the ‘real’ patterns of bloodstream infection in the hospital. By providing a more accurate picture of the infection patterns in the hospital, we hope to help refine the empiric therapy guidelines for antibiotic use. Ultimately, our efforts should result in more accurate treatment, less waste, and better individual patient outcomes.
“I thought about all of these issues as I spent the days in the hospital, and evenings in the lab. My job on the project was fascinating; my terrific partner (Wendy Gill from Stanford Medical School) and I were charged with interacting with Malawian families in order to recruit their children into the study, and help take a small sample of blood. By learning some ‘Chichewa’ and enlisting the help of clinical officers and nurses as translators, I had the chance to interact with hundreds of families. This was the part of the study which I enjoyed most; shaped by adversity, the Malawian attitude toward life and death was completely different and new to me. Despite the potentially somber air in the hospital, mothers were dressed in the most beautiful cloths they could afford, always washing and cooking and caring for their children in the hospital wards. There was a tremendous amount of love and hope in the hospital. And when deaths occurred, there was always wailing that followed. It was an eye-opening experience for me in an amazing place.”
Carol McLaughlin - 1998 Hubert Fellow
Testing for Bat Lyssavirus in the Philippines
“Before leaving for the field, I flew down to CDC in Atlanta to meet Dr. Rupprecht and to get oriented with the project. This included gathering reading materials and receiving training in bat necropsy technique. Once in the field, a typical day consisted of processing samples in the lab in morning, traveling to a field site in the afternoon, and finally netting for bats in the evening. Specimens were speciated, weighed, and necropied preserving tissue in frozen section and formalin. Serum and brain samples were tested the following day by staff at the Philippines’ Research Institute for Tropical Medicine (RITM). During our month at RITM, approximately 250 bats were collected and processed with none positive for rabies. In addition to field sites identified by Dr. Miranda at RITM, we sought the help of biologists and locals to find a diversity of collection areas where a diversity of species of bats could be obtained. These included caves, underground pipes, attics, and around particular types of ripe fruit trees. During the sampling, we were able to discuss with locals their feelings concerning bats, including use of giant fruit bats as a food source.
“Beyond the study itself, RITM proved to be a wonderful location for a student to get a broad view of public health in a developing country. In the Rabies department itself, we were able to appreciate the extent of the dog rabies problem from the many patients who came into the ER daily after suspicious bites. During the month of July, three patients died of rabies on the wards and many others received post-exposure vaccines and treatment for positive bites. From Dr. Miranda we learned the many political, economic and social issues preventing implementation of a successful dog/cat rabies control program in the Philippines and some of the creative solutions they were developing to attack the problem. She also shared with us other public health priorities such as her experience doing field work in collaboration with the CDC on the monkey Ebola outbreaks in the early 1990s.
“In addition to the Rabies department, Amanda Cooper [another Hubert Fellow] and I tried to use all the opportunities at the RITM to learn about public health and tropical diseases that we knew would be rare in the U.S. We attended teaching conferences on such topics as Hanson’s disease / leprosy, emerging resistance in malaria, and proper AIDS therapy (when the drugs are not available). We participated in patient hospital rounds with the infectious disease team where we saw patients with fatal rabies, dengue fever, neonatal tetanus, cerebral malaria, tuberculoid abscess and typhoid fever. From each patient’s story, we learned much about the social, economic, political and environmental factors contributing to the persistence of these mostly preventable diseases in the Philippines. Moreover, the relative lack of resources at RITM contrasted with the severity of cases (e.g. multidrug-resistant TB) emphasized the great need for international collaboration on these serious global public health issues.”
Rishi Manchanda - 2001 Hubert Fellow
Surveillance of New Emerging Pathogens Causing Bloodstream Infections in Hospitalized Adults in a Tertiary Medical Center - Mozambique, Africa
“The study’s primary objective was to determine the prevalence, etiology and clinical outcome of blood stream infections caused by mycobacteria, bacteria and fungi, in febrile hospitalized adult patients in Mozambique. Only four similar studies in sub-Saharan Africa had been published prior to the start of this study. Beyond directly contributing to patient care and developing local laboratory capacity, the study also aimed to contribute algorithms for empiric management of bloodstream infections in patients hospitalized in the adult medical wards in Mozambique. In its design, the study consisted of five integrated parts.
- Clinical: Patient care, enrollment and routine specimen collection.
- Blood Culture: Blood drawn from the study patients was cultured for bacteria, fungi and mycobacteria, including Mycobacterium tuberculosis.
- HIV-1 Status: Following pre-test counseling and patient consent, HIV-1 tests for study patients and controls were conducted.
- Malaria: In addition to a full blood count and differential, thick blood smears checked for malaria-carrying parasites in patients and controls.
- Immune Profile: Blood samples were checked for the expression of various immune system markers, including cytokines, and correlated with patients’ clinical profiles.
“Not surprisingly in the resource-poor setting, each of the study’s five components came with its own set of challenges. Materials were slow to arrive, logistics of enrollment consent, and blood draws had to be reworked, and laboratory capacity was often strained. Some of those obstacles were to be expected, though that made them no easier to grapple with. In the last week of the study, we rallied around a colleague who suffered a needle stick injury, breathing a collective and cautious prayer of gratitude when the patient whose blood was in the needle tested HIV negative. Mostly, we bore witness to the suffering of Mozambique’s citizens with just claims but little access to needed resources and medicines. Their experience was palpable testimony to the deep structural problems in the nation’s recovering public health system.
“In Mozambique, I learned about a beautiful country that was emerging from a devastating civil war, only to find itself in the midst of the more insidious onslaught of HIV. As daunting as these challenges appeared though, there seemed to be many dedicated public health workers and doctors (from Mozambique, the U.S. and elsewhere) to meet them. Working alongside some of them, as we contributed to research aimed at improving the health of that country was a wonderful experience.”