MUCU ADOLESCENT HEALTH NEWSLETTER

Welcome to Our Inaugural Issue!

Issue 1, May 1 st 2013 Welcome 1 Editorial Board& 2 Newsletter Submissions

Transformation of Care 3 Member News 4 SAHU

Makerere University and Columbia University Information: 5 (MUCU) are pleased to introduce you to the SAHU Membership FIRST of our biannual adolescent newsletters! Interesting Programs 6 We are delighted that you have expressed an Adolescent Clinic interest in the care of the adolescent patient. Each At newsletter will explore a different issue facing adolescents in Uganda and the surrounding Adolescent Pregnancy: countries in East Africa. Case History 7 OUR MISSION is to provide a forum to share Case Discussion 8 member news, interesting program updates, clinical cases, and discuss the latest in “hot” Facts/Reflection 9 adolescent topics. The Latest in… 10 OUR FIRST ISSUE is dedicated to adolescent Useful Websites 11 pregnancy in Uganda.

FUTURE TOPICS will include: Contraception; Sexual Activity/Coercion/Violence; Taking a Psychosocial History; Managing the Confidential Visit: Parents and Teens.

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Meet the Newsletter Editorial Board

Co-Editors in Chief: Sabrina Kitaka M.D., Senior Lecturer & Paediatric & Adolescent Health Specialist, Department of Paediatrics and Child Health, College of Health and Sciences , Uganda. Dr. Kitaka is passionate about promoting adolescent health and medicine in East Africa. For the past 11 years, she has taught Adolescent Medicine at Makerere University College of Health Sciences. Since 2006 she has collaborated with Dr. Betsy Pfeffer and her colleagues at Columbia University and since 2010 they have conducted three annual in-service adolescent health workshops for East African health providers. She is the director of the Adolescent Program at the Paediatrics Infectious Diseases Clinic at the Mulago National Referral Hospital.

Betsy Pfeffer , M.D., Assistant Professor of Pediatrics at Columbia University Medical Center and New York Presbyterian Hospital, New York, U.S.A. Dr. Pfeffer is an adolescent medicine clinician who sees teens in an outpatient and inpatient setting, teaches medical students and residents and lectures internationally on multiple topics related to adolescent health care. She has been working together with Dr. Kitaka for over six years and is committed to their efforts to help improve health care delivery to teens in Uganda.

Editorial Team Kampala, Uganda

Nicolette Nabukeera -Barungi , M.D ., Department of Paediatrics and Child Health, School of Medicine, Makerere College of Health Sciences

Juliet Nassali , ASRH Volunteer Trainer, Uganda Red Cross

Lena Mpalampa M.D., Paediatrician, LifeLink Medical Center

Gorretti Nakabugo , Senior Trainer the AIDS Support Organization (TASO) Training Centre

Kilonzo Richard Mutua , Children and Youth program supervisor, Reach Out Mbuya Parish HIV/AIDS Initiative

Emmanuel Mugalanzi , Counselor, The AIDS Support Organization (TASO)

Christine Seremba Nursing Sister, Mulago Hospital

NEWSLETTER SUBMISSIONS: The next newsletter will focus on sexual activity in adolescents and will be published in Nov, 2013. SAHU members are encouraged to submit member news, program updates and interesting cases related to this newsletter topic with all patient identifiers removed. The editorial board will conduct a peer review process for all submissions. Submissions will be accepted from May 15 th –June 30 th , 2013. Please e- mail all submissions to: [email protected]

Thank you beforehand for your participation. 2

Commitment Can Transform Care

In the developing world, more than 55% are less benefit from having a doctor and in Uganda than 18 years. The of their own. Dr. Gallagher specifically, there is population of adolescents went on to create the first limited training for health continues to grow. adolescent clinic in 1951 at care providers about how Uganda has a very high Boston Children’s Hospital, to care for the adolescent birth cohort of 1 million in the U.S. Sixty years later, patient. There are also per annum and a fertility multiple adolescent services limited health care rate of 6.2 per child- and training programs exist services designed bearing woman. Despite throughout the country, specifically for this age the presence of tertiary highlighting how group. For example, in and regional hospitals in commitment can transform Uganda there are few the country, and the care. presence of well-regarded designated adolescent We are confident that your medical schools in friendly outpatient health commitment to improving Uganda, there has been an care facilities. Inpatient the care of the adolescent overwhelming neglect of pediatric wards care for patient is what will drive adolescents in the health children up to age 12 improved services in your care system. years so adolescents are location. Thank you for typically admitted to In the United States, the your ongoing participation adult wards. Despite these birth of Adolescent and we look forward to limitations, there is a Medicine began with the hearing about member nationwide recognition vision of one man, J.R. news, your programs, and that adolescents have Gallagher, a physician interesting cases so we can special health care needs trained in internal share them in future and that there is a medicine and cardiology, newsletters. dedicated group of who had no formal Ugandan health care training in adolescent providers committed to medicine. During the improving the state of great economic depression adolescent health care in of the 1930’s, he found Uganda. Young people work as a school 10-24 years of age now physician. He recognized number more than 1.8 that adolescents had their billion globally, making unique strengths and up 27% of the world’s vulnerabilities and would population. Uganda has a total population of 33 million people, of whom

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Member News: SAHU The Society of Adolescent Health in Uganda (SAHU ), was launched in November 2012, following a regional training in Kampala, Uganda, that was led by experts from Columbia, and Makerere Universities and the Naguru Teenage Center. The purpose of SAHU is to improve adolescent medicine in Uganda by promoting research, training, clinical care and advocating for best practices. The goal is for SAHU to hold its first Annual Scientific Meeting at the end of 2013, in Kampala. STAY TUNED, an e-mail will be sent to SAHU members in Aug., 2013 with instructions about how to submit an abstract.

SAHU Executive Committee

Chairperson: Webmasters: Regional Representatives: Sabrina Kitaka M.D. Peter Katumba SOROTI: Department of Paediatrics and Child Health, Paediatrics post graduate Odoi Moses Waka Makerere University College of Health and Makerere University School of Medicine Kampala, Clinical Officer,

Sciences Kampala, Uganda Uganda The AIDS Support Organization, (TASO), Soroti Centre Clinician in charge, Adolescent Vice Chairperson: Reproductive Health Denis Bukenya Training Manager, Naguru Teenage Centre, Kampala, Uganda Joel Serubanja M.D. Medical Officer, Baylor College of Medicine, Children's Foundation Kampala, Uganda GULU: Achan Judith Obita Social Worker General Secretary: The AIDS Support Organization (TASO) Godfrey Zari Rukundo M.D. Senior Lecturer, Mbarara University of Committee Members: MBARARA: Science and Technology Terry Kigozi M.D. Child & Adolescent Psychiatrist, Mbarara Francis Oriokot M.D. International Medical Center, Kampala, Uganda Regional Referral Hospital Consultant Paediatrician

Mbarara - Uganda Mbarara Regional Referral Hospital Rose Nasejje The AIDS Support Organization (TASO), Kampala, Uganda

Margaret Kaggwa Communications Focal Person: Community Representative, Uganda National Lena Mpalampa M.D . Association of Community and Occupational International Paediatrician, LifeLink Medical Center Health (UNACOH), Kampala, Uganda Representatives : ETHIOPIA: Student Representative: Yayeh Negash M.D., M.P.H. , Faith Nawagi SP-Pediatrics and Child Health, Medical student, Makerere University School HIV/AIDS Manager and Expert of Medicine Kampala, Uganda Community Representatives : Edith Nassuuna Community Representative, Uganda, National USA : Association of Community and Occupational Betsy Pfeffer M.D. Health (UNACOH), Kampala, Uganda Assistant Professor of Pediatrics at Columbia University Medical Center and Derrick Nsubuga New York Presbyterian Hospital, Masters student, Makerere University School of NewYork Social Sciences, Kampala, Uganda 4

INFORMATION: SAHU MEMBERSHIP

GOOD NEWS: SAHU membership will initially be FREE !

SAHU MEMBERSHIP: You can join SAHU by sending an e-mail to: [email protected] . Please include the following information in your e-mail:

K Name, surname, title K Job title Pediatrician Internal Medicine Obstetrician Psychiatrist Postgraduate Trainee Medical Officer Nurse Social Worker Community Health Worker Other K City, Country of work K Your institution /affiliations K Your e-mail address

A Special Thank You to : Lawrence Stanberry M.D., Ph.D ., Chair, Department of Pediatrics, Columbia University Medical Center, New York, U.S.A., Sarah Kiguli M.D., Chair, Department of Paediatrics & Child Health, College of Health Sciences, Makerere University, Kampala, Uganda, Susan Rosenthal Ph.D ., Professor of Behavioral Medicine, Columbia University Medical Center, New York, U.S.A., and Philip LaRussa M.D., Professor of Pediatrics, Columbia University Medical Center, New York, U.S.A., for their support of the Makerere-Columbia collaboration. Additionally, we would like to thank Clare Matschullat for her work on the construction of this newsletter.

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First Adolescent Clinic Opens at Mulago Hospital

The Makerere/Mulago The MMCA’s aims are to The MMCA is accepting Columbia Adolescent improve healthcare for both walk- in adolescent clients and referrals. adolescents in the Kampala Clinic (MMCA) opened Standard referral for patient care in May area and to serve as a model for procedures should be 2013. future adolescent clinics in followed. Uganda and East Africa. Clinic hours: The MMCA will a ddress gaps Fridays 8:30AM-12:30PM in services by providing Its mission is to serve as a holistic adolescent health care “medical home” for Location: Ward 15, Upper for teens aged 10-19 years adolescents; a place where they Mulago next to Jeliffe Ward within the environs of a can be confidentially evaluated, tertiary and university treated and guided through Contact Information: teaching hospital. It will also their transition into adulthood. Dept. of Pediatrics serve as a teaching resource +256414531875 and practical skills training Sabrina Kitaka M.D., site for undergraduate and Paediatrician/Adolescent post-graduate students at the Health Specialist Makerere University College 0772401790 of Health and Sciences, and Nicolette Nabukeera M.D., Paediatrician/Infectious visiting students. Young people are our future- Diseases Specialist the future workers, parents Services are comprehensive 0772435166 and leaders of our nations. and include: Akiiki Kajeru R.N ., Yet over the last 50 years, • Psychosocial counseling Ward 15 Manager global, social, economic and • School health assessment 0793440655 political changes have • STI screening & adversely affected young treatment people’s health, to the extent • Sexual & reproductive that adolescence and young healt h services including adulthood are no longer the contraception healthiest time of life. • Treatment of chronic diseases • Immunization updates.

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Adolescent Pregnancy in Uganda: Case History L.M. Submitted by Dr. Sabrina Kitaka

Patient L.M.’s history: hospital she was found to be Follow-Up: HIV positive. Her care was When L.M. was 16, her L.M. was 7 years old when transferred to the Paediatrics adherence to treatment she was admitted to school. Infectious Disease Clinic became erratic. She was lost She was a good student where she was started on to follow-up and missed her who attended school daily, anti-retroviral therapy ART, and reproductive studied hard and showed (ART). On a follow up visit, health appointments. She promise. At the age of 12, when she was 14, she remained involved with the she expressed the desire to disclosed that her period was same boyfriend, became stay in school and late and she was found to be pregnant again and ultimately go to a pregnant. She and her reconnected to care. ART University, aspirations boyfriend had been sexually was re-started. Her which her mother active for over one year and pregnancy was difficult, supported. However, never used condoms or other complicated by repeated because of multiple forms of birth control. She attacks of malaria, problems at home, L.M. did not bring her 17-year old pneumonia and persistent dropped out of school when boyfriend to the clinic for diarrhea. Before the birth of she was 13 years old. When counseling but she stated her child, her boyfriend died L.M. was 14, she became that her boyfriend was from AIDS. Her son was very ill with a persistent excited about the news. born at 36 weeks, and sadly headache. She was thought When her mother found out was found to be HIV- to have meningitis and was that she was pregnant she positive at 6 weeks of life. referred to Mulago, an banished her from their L.M. is an HIV- positive 18 urban teaching hospital in home. L.M. moved in with year old female who is a Kampala. L.M. was found her boyfriend who was single mother of two small to have Cryptococcal working as a mechanic. She children, the youngest of meningitis. She was treated gave birth to an HIV- whom is also HIV- positive. with IV antifungal negative daughter. medication and ultimately recovered. While in the If L.M. had access to adolescent specific services how might have things turned out differently?

At age 15, L.M. presents to YOU for care:

What are some things you would want to ask her?

How might you help her?

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Case Discussion Dr. Betsy Pfeffer

How is her mood? CASE DISCUSSION: obstacles, capturing what How is she managing with her works, and attempting to baby? Does she show any We often see adolescent build on it might help patients similar to L.M. increase her compliance. A signs of depression: feelings of who deserve adolescent scheduled follow up visit to hopelessness; loss of appetite; specific care, the goal of review the outcome could be absence of energy; which is to optimize the beneficial. Since you are a trouble falling asleep; inability chance of favorable referral service and this to feel pleasure from activities outcomes. For our first patient in particular is usually found enjoyable visit with L.M., it would receiving HIV care (anhedonia); poor self –esteem; be useful to determine our somewhere, you might want decreased concentration; immediate and future to dis cuss coordination of care thoughts of self- injury? If goals, and to allow time with other involved health needed, are there resources during the visit to answer care providers. and support systems available L.M.’s questions and to her? address her concerns. Is she safe? Where is she living? What is Future goals: Immediate visit goals: she doing for money? Is she in Does she plan to go back to Is she using contraception? an unsafe environment? school? What are her If L.M. is presently sexually aspirations? active and interested in L.M. was a good student with birth control, educating her World Health hopes of achieving higher about contraceptive education. If she still wants to Organization choices, helping her decide go back to school, is that on a method and informing “The whole health care realistic? Some advice or her about how to access it system needs to be made details on obstacles, how to would be useful. It might overcoming them and helping more responsive to the be worthwhile discussing with a plan might be helpful. special needs of whether she has other adolescents…Special sexual partners and the risk If adolescent specific care had of her transmitting to them, approaches or models are been available to L.M., her depending on her choice of needed to ensure that the chances for a better outcome type of protection/ social and cultural might have been improved. contraception. circumstances around adolescent pregnancy and Is she taking her the special biological and antiretroviral medication? physiological If she is unable to take her vulnerabilities of medication as prescribed, adolescents are addressed what makes it possible for and access to services her to take them sometimes improved.” and not others? Outlining

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Facts and Reflection

FACTS: Safety: REFLECTION: Repeat pregnancy: Assessing for safety is Teenage pregnancy remains a Many adolescents become important to include during recalcitrant problem in pregnant again within a year all adolescent visits. If a Uganda. For change to occur, after giving birth (1). patient is found to be in an the first thing that needs to Educating L.M. about the unsafe situation putting plans happen is that the problem inherent health risks of into place to assure safety is needs to be uncovered and adolescent pregnancy could necessary. If available, a acknowledged. Once this be helpful. Since her first sexual/physical abuse referr al occurs, providers can begin to pregnancy was successful, she to the child protection unit confidentially dialogue with might assume future would be advised. their adolescent patients so as pregnancies are without risk. to determine the risk profile She may not be aware that an Mood state: of each patient seen. As adolescent who gives birth Adolescent mothers may be at providers, we may be the first before age 16 poses a much risk of greater rates of higher health risk to herself depression compared to older to learn about confidential and her baby compared to a mothers. One thought as to adolescent issues and it is women who gives birth in her why adolescent mothers have imperative that we are well 20’s (2). Some of the medical a greater risk of depression is versed on how to best counsel risks include an increase in: that the teens tend to be less and support our patients. maternal death; neonatal psychologically prepared for Additionally, it is important death; delivery of a stillborn, pregnancy and this may to know available services so, low birth weight or small for trigger depression (2). This if necessary, appropriate gestational age infant; not only affects the individual referrals can then be made. preterm delivery (defined as but potentially may comprise Providers can also group giving birth before 37 the care of the infant. together and begin to create completed weeks of new programs and advocacy pregnancy); congenital Education: groups that address the Many societies do not allow malformations (2, 3) . unmet needs of their adolescent girls who become adolescent population. Medication adherence: pregnant to stay in school. Psychological distress and Because of advocacy for the self- efficacy, defined as an rights of female adolescents in individual’s confidence in Uganda, adolescent mothers their ability to take their recently have been allowed to return to school after delivery medication, have been shown to be associated with (6). As noted by the World medication adherence in HIV Health Organization (WHO), positive youth (4). Other supporting education for teen possible explanations for mothers is desirable and failure of medication overall it is beneficial to both compliance in adolescents the mother and the baby by include poorer pharmacy providing social, economic, refill adherence compared to and health benefits to both. adults and lack of social support (5). 9

Latest In….

Teen Pregnancy in Uganda: The Facts analysis of survey data from 51 developing countries from the mid-1990s to the early 2000s shows that almost 10% of girls were mothers by age 16, with the highest rates in sub-Saharan Africa and South-Central and South-Eastern Asia (14). Adolescents in rural Uganda become parents sooner than their urban counterparts (24% versus 21% respectively) as do adolescents with no education compared to girls with secondary school education (45%versus 16% respectively) (3). Adolescent pregnancy entails increased health risks of early childbearing to both mother and child. Adolescents 16 years or Though fertility rates in developing regions younger face four times the risk of maternal worldwide have continuously declined, Sub- death compared to women older than 20 years, Saharan Africa continues to have the fastest and the rate of neonatal death is about 50% population growth and one of the highest higher (14). Additionally, pregnancy can fertility rates worldwide (number of births per interrupt education. Of females aged 12-19 woman)(7,8). In Uganda, the incidence of years who dropped out of school, 10% teenage pregnancy was 24% in 2011 and identified pregnancy as the cause (15). Almost although there has been a decline from the 31% all unsafe abortions occur in the developing observed in the 2000-2001 Uganda still has one world and adolescents aged 15-19 years account of the highest rates of teenage pregnancy for 25% of all unsafe abortions in Africa (16). among sub-Saharan countries (9, 10). This is Currently, abortion is illegal in Uganda except partly linked to early marriage and cohabitation under exceptional circumstances that include as well as early onset of sexual activity (11). saving the life of the woman, or preserving her According to the 2011 Uganda Demographic physical and mental health (17). Unwanted and Health Survey (UDHS), of those aged 15-19 unplanned pregnancies in adolescents coupled years, 8.6% of females and 0.6% of males are with the high teenage pregnancy rates married and 11.4% of females and 1.2% of contribute to the high incidence of abortion. males are living together (3). Married females Although abortion is illegal, between 15-23% of have more unprotected intercourse and have Ugandan females aged 15-24 years who have sex more frequently than their unmarried age been pregnant have had an abortion and mates (12). Between the years 2000-2009, 35% of Ugandan adolescents represent 25-33% of women aged 20-24 gave birth before age 18 females hospitalized for abortion complications years (13). Many of the pregnancies in female (18, 19). In Mulago hospital in Kampala, adolescents aged 15-19 years are neith er desired Uganda, almost 50% of the women who died nor planned. The 2011 UDHS reports that 40% from abortion complications were adolescents of adolescents under the age of 20 years who (20). Additionally, adolescents tend to seek had a child five years prior to the survey did abortion later than their older peers and are not want to have a child at that time. The WHO more likely to use unskilled providers.

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Useful Adolescent Websites American Social Health Association: http://ashastd.org/ Advocates for Youth: http: //advocatesforyouth.org/ YMC: Young Men’s Clinic: http: //www.youngmensclinic.org/ Center for Young Women’s Health, Children’s Hospital Boston: http://youngwomenshealth.org/ Go Ask Alice: http://goaskalice.columbia.edu/ Guttmacher Institute: http://guttmacher.org/ Sexually Transmitted Disease Guidelines, 2010 CDC: http://cdc.gov/std/treatment/2010/ WHO: Sexual and Reproductive Health : http://who.int/reproductivehealth/en/ WHO: Sexually Transmitted : http://who.int/topics/sexually_transmitted_infections/en/

References 1. Education for contraceptive use by women after childbirth. Lopez LM, Hiller JE, Grimes DA.Cochrane Database Syst Rev. 2010 Jan 20 2. World Health Organization position paper on mainstreaming adolescent pregnancy in efforts to make pregnancy safer. Department of Making Pregnancy Safer. Prepared by James E. Rosen . World Health Organization, 2010. http://www.gfmer.ch/SRH-Course-2010/adolescent-sexual-reproductive-health/pdf/WHO-mainstreaming-adolescent- pregnancy-efforts-MPS-2010.pdf 3. Adolescent Pregnancy and Policy Responses in Uganda . Ashley Wallace . AfricaPortal. November 9, 2011 4. Psychosocial factors and medication adherence in HIV-positive youth. Naar-King S, Templin T, Wright K, Frey M, Parsons JT, Lam P. AIDS Patient Care STDS. 2006 Jan; 20(1):44-7 5. Survival of HIV-Infected Adolescents on Antiretroviral Therapy in Uganda: Findings from a Nationally Representative Cohort in Uganda , Celestin Bakanda, Josephine Birungi, Robert Mwesigwa, Jean B. Nachega, Keith Chan, Alexis 6.Adolescent Sexual and ReproductiveHealth in Uganda: A Synthesis of Research Evidence Stella Neema, Nakanyike Musisi and Richard Kibombo Occasional Report No. 14, December 2004 Palmer, Nathan Ford, Edward J. Mills , PLoS ONE, April 2011, Volume 6, Issue 4 7. 2009 World Population Data Sheet, 2009, Population Reference Bureau. 8. Fatusi,A. and R.W. B.um, Adolescent health in an International Context; the challenge of sexual and reproductive health in Sub-Saharan Africa. Adolesc Med State Art Review, 2009 20(3): P. 874-86 9. Uganda Demographic and Health Survey, 2011 10. Wallace, A., Adolescent Pregnancy and Policy Responses in Uganda, 2011, African Portal 11. The State of Uganda Population Report, 2011. 12. Wellings K, C.M., Slaymaker E, Singh S, Hodges Z, Patel D, Bajos N, Sexual behaviour in context: a global perspective. The Lancet, 2006. 368(9548): p. 1706-28. 13. Uganda Statistics, 2000-2009, UNICEF. 14. Making Pregnancy Safer Notes, 2008. 15. Neema, S., Ahmad., F.,Kibombo, R., Bankole, A., Adolescent Sexual and Reproductive Health in Uganda: Results from the 2004 National Survey of Adolescents, 2006, Guttmacher. 16. Grimes, D.A., et al., Unsafe abortion: the preventable pandemic. Lancet, 2006. 368(9550): p. 1908-19. 17. Nalwadda Gorrette, S.N., & Hamisu M. Salihu, The abortion paradox in Uganda: Fertility regulator or cause of maternal mortality. Journal of Obstetrics and Gynaecology,, 2005. 25(8): p. 776-780. 18. Ssengooba, F., Neema, S., Mbonye, A., Sentubwe, O., Onama, V., Maternal Health Review Uganda, 2004, Makerere University Institute of Public Health, Health Systems Development Programme. 19. Boonstra, H., Young People Need Help in Preventing Pregnancy and HIV; How Will the World Respond?, 2007, Guttmacher 20. Research on Sexual and Reproductive Care in Uganda, 1999, Uganda, Delivery of Improved Services for Health

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