Developing new research partnerships within the THRiVE Consortium

LSHTM staff have been involved in developing research projects within Kilimanjaro Christian Medical University College (KCMUC).

Dr Sia Msuya, a THRiVE supported senior lecturer, and Jim Todd (LSHTM) started the ‘Making It Happen’ project on 1st May 2013, funded through Liverpool School of Tropical Medicine. The project aims to evaluate grassroots training of health workers in Essential Obstetrics and Gynaelogical practices in primary health facilities.

Drs Hugh Reyburn and Jenny Renju (both from LSHTM) along with colleagues in KCMUC, and National Institute for Medical Research (NIMR) in Mwanza have initiated two small research projects to improve screening and treatment for hypertension in Tanzania.  One, with Gloria Temu (KCMUC), is looking at the role of fetal programming in determining risk of hypertension, while the second, with Dr Sia Msuya (KCMUC) and Dr Denna Michael (NIMR Mwanza) is looking at the role of private pharmacies in screening for hypertension in the community. This has led to a proposal to GSK (a pharmaceutical company), in collaboration with Dr Chaote (KCMUC), to initiate devolved management of hypertension to primary health facilities.

SEARCH is a new project, led by Jim Todd, which aims to develop the analysis of routinely collected HIV data in Malawi, Tanzania and Zambia, thereby leading to strengthening of health services and transparency on the equity and benefits of HIV services. An essential component of the project is the training of three data analysts from the ministries of health in each country, enabling long-term sustainability of the project.

The foundations of the project have already been laid in Tanzania, with previous work on the national care and treatment clinic (CTC) database. In 2010 and 2013, LSHTM supported the Tanzanian ministry of health in analysing and writing the national HIV Care and Treatment report, and in doing so developed some of the analyses that could be used in the SEARCH project. One such analysis assesses rates and predictors of immunological failure, and subsequent use of second line therapy. The results will help identify gaps in services and groups of people who are particularly at risk, and will shortly be submitted for peer-reviewed publication.

The SEARCH project will develop new analyses of CTC data, prevention of mother to child transmission (PMTCT) data, and HIV testing and counselling (HTC) data, and these promise to uncover some of the impact that routine HIV services are having on the lives of Tanzanians. In Tanzania the training of the data analysts will be done in collaboration with Kilimanjaro Christian Medical University (KCMU) college, where the three analysts will be enrolled into a PhD program, thereby giving recognition of their work. The research questions, analysis and interpretation will be developed in conjunction with MoHSW personnel, academics from KCMU college and LSHTM staff.

SEARCH is a two and half year project funded by the Bill and Melinda Gates Foundation. Further background and output from SEARCH are available on our website.

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Mentoring and supporting new and existing researchers across the Consortium

KCMU MSc in Epidemiology and Applied Biostatistics

The THRiVE consortium has provided the technical support for the development of the MSc in Epidemiology and Applied Biostatistics in KCMU College. The MSc program was conceived by Seif Shekalaghe (KCMU College) and Jim Todd (LSHTM) as a way to improve research capacity in Tanzania, by building practical skills in research methods, epidemiology and biostatistics.  Materials from LSHTM MSc biostatistics courses were adapted to develop modules in the college, and lecturers were invited from NIMR, UVRI and LSHTM to help deliver the initial courses.  To support the course, KCMU College formed the Department of Epidemiology and Biostatistics.

Teaching practical skills in Epidemiology and Biostatistics is essential to all Masters level students.  After the first year, Jenny Renju developed a 6 week Foundation course which was taken by all Masters level students (around 70 students per year), and which taught basic concepts, and skills using Epi-Info. The benefits of this are that all students are now expected to analyse and interpret their own project data (which had not always been the case beforehand). With the backing of the Director of Postgraduate Studies, and in collaboration with the Danida funded Building Stronger Universities program, the Masters courses in KCMU College were revised to incorporate shared modules across the different MSc programs.  PhD candidates, and external students, were then able to take selected modules, which brought in short course fees to the College.

There were 4 students on the first year of the course, who not only learned the statistical skills for themselves, but also had the opportunity to provide assistance to other students and staff during, and after, their studies.  On completion three of the four students have now enrolled in the PhD program in KCMU College. Student numbers are building slowly, with around 16 new students accepted for the 2014/15 academic year.  With limited staff numbers the most difficult aspect, is the student attachment for research experience, and the supervision of the projects in the second year of the course.  However five members of staff from KCMU will have completed the course by 2015, and they will be mentored to provide supervision to future students, and to lecture in various MSc and undergraduate programs. With the difficulty in finding good epidemiologists and biostatisticians in Tanzania, becoming self-reliant and, growing your own is definitely a viable alternative.

LSHTM has a long history of collaboration in vector control research and capacity building in Tanzania and Uganda.

Under the lead of Professor Mark Rowland a number of research proposals to evaluate the impact of existing and novel vector control tools have been developed with both institutions, and a wide variety of grants received (Gates, WHO, USAID etc.). A project looking at control of malaria in the community, funded by USAID, has just been completed; findings will be used by the National Malaria Control Program to design their new malaria vector control plan for the next 5 years. A new laboratory has been set up under the supervision of Alex Wright (LSHTM) and Dr Kavishe (Kilimanjaro Clinical Research Institute, KCRI), and several KCMUC staff have been trained in molecular techniques for entomology. Two KCMUC PhD students (Jovin Kitau & Jonhson Matowo) have been trained and are attached to these projects. A student from the MSc in Epidemiology and Applied Biostatistics is currently starting his MSc research on the USAID-funded project evaluating the impact of LLIN and IRS on malaria prevalence and transmission. LSHTM staff members Natacha Protopopoff and Matt Kirby  are managing these research projects at KCMUC, and supporting MSc and DTM&H teaching in medical entomology and malaria control.

LSHTM staff have provided support to masters level students at KCMU College to write up their research dissertations for publication. Five students have submitted their papers so far, and more will be helped in a writing workshop after submitting their dissertation in July 2013. Mentoring students to write papers provides an opportunity to assess their skills, and their ability to become independent researchers. LSHTM staff are also mentoring 3 members of staff in NIMR/MITU, and 4 members of staff in NIMR Tanga in the analysis of data and the writing of papers.

LSHTM and Uganda Virus Research Institute (UVRI)

One member of UVRI staff, Ivan Kasamba, completed the MSc in Medical Statistics at LSHTM in 2012. He has a one year fellowship following the masters course to work in another organisation, and has chosen to spend the year at NIMR Mwanza. He is being mentored, by LSHTM staff Kathy Baisley and Jim Todd, to apply his statistical knowledge to analysis of data from NIMR, Tanzania and UVRI, Uganda, to write papers and to submit a new proposal for his future career work.

Another UVRI staff member, Ismail Sebina, has been supervised by LSHTM staff member Steve Cose for his Wellcome Trust Masters Training Fellowship, from which he has published one paper, with two others to come. He has recently been offered a PhD scholarship in Australia.

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East African Diploma in Tropical Medicine and Hygiene course

Hopefully readers are familiar with the Diploma in Tropical Medicine and Hygiene (DTM&H) and its aim of encouraging talented young doctors to take their first steps towards a career in clinical research. This is the fourth year that LSHTM has offered the course in East Africa and the faculty has grown to include over 140 lecturers, drawn from host’s KCMUC, Makerere University and institutions as far away as New Zealand, Vietnam, South Africa and the USA.

A highlight of the course is the Ugandan field placement, where students spend a week in small groups visiting rural clinics and learning at first hand about healthcare in marginalized communities.

This year students visited Bugoigo village on the banks of Lake Albert. Bugoigo is a site for the Ministry of Health’s research programme on Schistosomiasis. Led by Dr Amaya Bustinduy, the group’s task was to examine the complete lifecycle of the parasite and understand the various targets for control. The accompanying pictures show Dr Nuriat Nambooze from Uganda collecting freshwater snails, the intermediate hosts of Schistosoma mansoni (top/right), and Dr Luis Malheiro from Portugal using a portable ultrasound to examine a patient for hepatosplenomegaly (left).

In a cross-sectional survey the DTM&H students found that over a third of school children in Bugoigo are heavily infected with Schistosome eggs and many have already developed liver disease. Their presentation highlighted the failure of current control programmes using mass administration with Praziquantel and instead recommended an integrated approach targeting the economic causes of poverty with a combination of molluscicides, improved sanitation and health education (Ross et al Lancet 2014).

A second group visited Bwindi Community Hospital in the south west of Uganda. Many of you will know Bwindi Impenetrable Forest as the home to half of the World’s remaining 880 Mountain gorillas. Less well known is the impact that creating the UNESCO World Heritage Site had on the lives of the Batwa people, for whom the forest had been a home for over a thousand years. In the 20 years since their forced migration the health and welfare of the Batwa has suffered considerably. Loss of traditional food sharing systems has had a major impact on maternal and child mortality and the disruption of social structures and cultural identity has led to high rates of HIV, alcoholism and communicable diseases (Ohenjo et al Lancet 2006).

At Bwindi Community Hospital students learned that it is possible to make a difference by taking a human rights-based approach to care. Since opening in 2003 the hospital has introduced a sustainable health insurance programme for the entire community, developed a health education to improve nutrition, opened an ante-natal hostel for high risk mothers, and introduced mobile HIV clinics to reach remote communities inaccessible by road.

Dr Ivan Mambule, a DTM&H student from the Infectious Diseases Institute, was so moved by his visit that he wrote the following poem:

Plight of the Batwa

They lived on wild yams and fruits, honey and bush meat

Hunter gatherers was their trade

They buried under bushes and walked away

They worshipped Gods hidden in rocks

They lived in trees and natural shelters

They made fires by rubbing sticks and habituated with the animals

They told stories and tales to entertain and educate their children

– no radio, no TV, no phones

Dancing and drinking was their form of wild entertainment

 

1992, a year painfully etched in their hearts

The Bwindi impenetrable forest, their home, gazetted a national park

A world heritage site for the conservation

Of the now money minting mountain gorilla

No land, no compensation, left without a home

No compensation to replace a way of life thousands of years old

Conservation refugees they became to save an endangered species

And yet an endangered species they almost became…

 

Assuaging our guilt as a race, efforts have been made

Lives dedicated to sooth a people so sorely hurt

Bwindi Community Hospital the efforts of a committed few

Saving the Batwa, a tribe so fondly referred to as “the tiny people of the forest” Bwindi!

The next East African DTM&H runs from September to December 2015 and the deadline for applications is 31^st March. 24 scholarships have been reserved for African doctors with an excellent academic record and minimum of two years postgraduate clinical experience. For further details please contact Miss Angela Steiger at LSHTM Registry: angela.steiger@lshtm.ac.uk

Phil Gothard, Course Director, East African DTM&H