Several months ago, a five-person team from Nebraska Medicine’s Biocontainment Unit traveled to Western Uganda, where they trained refugee health workers on appropriate infection prevention and control practices. Dr. James Lawler, one of our Infectious Diseases Faculty, was the team leader on this trip. Dr. Lawler is the Director of International Programs and Innovation for the Global Center for Health Security, and Director of Clinical and Biodefense Research for the National Strategic Research Institute. Dr. Lawler shared his thoughts about the trip with us:
[In Uganda], we were preparing for the seemingly inevitable day when an active case of Ebola virus disease makes its way across the porous border between Uganda and Eastern Democratic Republic of the Congo (DRC) – where the second largest outbreak of Ebola in history continues to smolder along.
Most healthcare workers in top-notch, tertiary-care American hospitals are sufficiently aware and probably don’t need a trip to a developing country to understand how spoiled we are compared to a majority of the world – but most of us don’t realize how constrained we are by working in that environment. As American healthcare becomes more complex and more technologically advanced, its practitioners become more dependent upon advanced systems of care. As our reliance on these systems and technologies increases, our ability to effectively practice becomes more fragile.
Source: CDC
When thrust into situations where we must teach and perform public health and medicine in resource-constrained settings – where ample supplies of personal protective equipment (PPE), routine laboratory tests, and even running water are often unavailable luxuries – we are forced to return to the basics. The key to effective practice becomes comprehending underlying principles, doing the fundamentals well, and improvising. These skills are important for clinicians and practitioners in all aspects of medicine and public health, and they are invaluable in situations where our sophisticated systems are stretched or fail – such as in rural areas with limited access or in public health emergencies and disasters, where degraded or overwhelmed resources can replicate the austere environment.
The international community should do much more to assist DRC and its neighbors to avert an even greater public health and humanitarian crisis. I am proud of our team and the work that we did. The need for such training is great and the impact potentially important in preventing the continued spread of the ongoing epidemic. Despite this pride, I always walk away from this type of mission with a greater sense of humility and an understanding that we probably learned more than we imparted to our “students.”
Working in the austere environment of rural Africa is well outside our comfort zone as American healthcare workers – and that is the best environment in which to learn. Experience outside of our comfort zone makes us better – better in our daily practice and better in our ability to adapt to the unpredictable. I hope we left Uganda a little more able to manage a potential case of Ebola virus disease, but I know we returned with a better biocontainment unit team. I look forward to future opportunities to expand Nebraska Medicine and UNMC’s international engagement and improve our ability to deliver care back home.
Check out this video to learn more about Dr. Lawler and his team’s trip to Uganda. We are proud to have such talented faculty dedicated to global health and international training!
http://https://www.youtube.com/watch?v=BKk4Afxt9tY&feature=youtu.be
Bianca’s project is a retrospective cohort study identifying the demographic features and virologic outcomes associated with health insurance enrollment among AIDS Drug Assistance (ADAP) participants in Nebraska. The study found that ADAP users who received insurance in addition to ART supply were more likely to achieve virological suppression than those who only received ART supply. She presented her capstone project at the the American Conference for the Treatment of HIV in Chicago in April 2018, and will be submitting her work for publication. You can read more information about Bianca 
Travis’ project looked at characterizing HIV practitioners’ recommendations regarding treatment as prevention, pre-exposure prophylaxis and condom use. The study found that most practitioners commonly or always recommend condoms despite the fact that most acknowledge the validity of data that successful treatment of HIV or use PrEP prevents transmission. Travis was the first author on the resulting paper entitled: “U.S. HIV practitioners’ recommendations regarding condom-free sex in the era of HIV pre-exposure prophylaxis and treatment as prevention“, published in 
Congratulations again to Bianca and Travis, we are proud of you! And congratulations to all M4s out there who found out where they matched today!
Our department is proud to participate in UNMC College of Medicine’s Enhanced Medical Education Track (EMET) program! EMETs are enrichment opportunities to explore interdisciplinary fields of medicine with in small groups and with close faculty mentorship. Two students from each medical school class are selected to participate in our Comprehensive HIV Medicine EMET, a program that spans their four years in medical school and includes journal clubs, seminars, and clinical experiences culminating in a capstone project focused on an aspect of HIV care. Today we’re excited to feature Bianca Christensen, an M4 completing her EMET experience!
Yadav et al. conducted a quasi-experimental quality improvement study to determine the impact of implementing an “Expected Practice” (EP) method to alter antibiotic prescribing practices towards favoring shorter duration of therapy (DOT). This method leverages the prescriber’s desire to meet their own institutional expectations, which may be viewed as more authoritative than external medical society guidelines. The authors chose DOT as the endpoint because clinicians were concerned about potential poor outcomes with shorter DOT.
In the 12 months after implementing EP, the average antibiotic DOT decreased by 10%, 11%, 11%, and 27% for UTI, SSTI, CAP and VAP respectively, with concomitant decreases in total antibiotic exposure measured in total milligrams administered. This impact was statistically sustained by the end of that year for UTI and CAP, but seemed to wane toward the end of the year for SSTIs and VAP.
One of the studies I will lead next year will be in assessing proper utilization of chlorhexidine. Chlorhexidine gluconate is a broadly active, biguanide antimicrobial disinfectant that appears to decrease hospital-acquired infections when it is used to bathe patients in intensive care units. However, it remains unclear what the best method is for applying CHG. We seek to evaluate two methods of CHG bathing 2% CHG impregnated cloths and 4% solution with regard to residual CHG skin concentration and quantitative skin microbial burden.
In order to provide me this opportunity the Internal Medicine department graciously awarded me the Scientist Development Award. I am honored that they selected me, in order to provide me the opportunity to continue to developing my skills as a clinical researcher. Beyond leading several studies in the upcoming year, I am looking forward to beginning work towards a Masters in Public Health with a focus in biostatistics, which I believe will further augment my training.
“Richard has been a real asset for our fellowship and it is very gratifying to see him succeed. He has worked hard to grow as an Infectious Disease clinician and scientist and this award is validation of those efforts. I am looking forward to working with Richard on his projects next year.” – Dr. Trevor Van Schooneveld (ID Fellowship Program Director, Infection Control Associate Medical Director, and one of Dr. Hankins’ mentors)
“I have been a research and career mentor for Dr. Hankins starting in his final year of residency and through fellowship thus far, and supported his completion of several projects, presentations and manuscripts. Dr. Hankins has been motivated to create an academic, research career; with ongoing guidance, he will absolutely succeed in that role and I am pleased to play a part in his career development.” – Dr. Kelly Cawcutt (Infection Control Associate Medical Director, and one of Dr. Hankins’ mentors)
“This is a terrific honor for Rich and will enable him to join the ID division faculty as an instructor and devote significant time to career development. Rich’s research project will greatly expand our knowledge regarding this important infection prevention intervention, and take advantage of UMMC faculty development opportunities to hone his teaching and research skills.” – Dr. Mark Rupp (Infectious Diseases Division Chief, Infection Control Medical Director, and Dr. Hankins’ primary mentor)
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