Improving Disease Recognition and Management
A proposal from the International Clinical Epidemiology Network
The International Clinical Epidemiology Network (INCLEN, Inc.), on behalf of its member faculty in Brazil, Chile, China, Colombia, India, Indonesia, Philippines and Thailand, cordially submits the following proposal on Improving Disease Recognition and Management to the Ad Hoc Group of the States Parties to the Convention on the Prohibition of the Development, Production and Stockpiling of Bacteriological (Biological) and Toxin Weapons and their Destruction. The proposal addresses the following goals of Article VII of the Biological Weapons Convention Protocol:
- [Promote] [Support] the establishment and assist peaceful activities of research institutes through the dissemination of knowledge about examination and identification techniques, laboratory safety, vaccine production and other research projects in the biosciences;
- Promote public health, as well as the monitoring, diagnosis, prevention and control of outbreaks of diseases, including international cooperation on the development and production of vaccines;
- Assist in improving and participating in the functioning of international systems for the global [and set up] programmes for the development of human resources in the biological sciences, including advancing the education of personnel.
The proposal is presented in two parts: the first calls for short course training of health workers in the initial identification, treatment and referral protocols for serious and emerging infectious diseases; the second addresses the creation of long term health research capacity through the focused training of clinicians and health workers in the use and application of epidemiologic tools to the study of infectious and emerging infectious diseases. This two-pronged approach is intended to deal with critical health problems emergently, while simultaneously building long-term capacity in the study, treatment and control of these diseases.
INCLEN is an international federation of health practitioners in 54 institutions in 24 countries, trained to use the best available evidence for conducting research, in all areas of health, that will significantly affect health policy, the practice of medicine and patients' lives. Over a period of 18 years, INCLEN has trained some 500 faculty members at the Master's degree level and built multidisciplinary groups in developing-world medical schools in Africa, Asia and Latin America, with the intent of making a sustained impact on the health of people in the developing world. Its faculty sees it doing so through complementary programs of capacity building and research that take advantage of INCLEN's strengths: regional and global networks; indigenous scientists; and multidisciplinary skills to address problems of efficacy, equity and cost-effectiveness.
We believe that there is no other network of health researchers in the developing world that is able to focus on such a broad spectrum of health problems involving almost all clinical specialties. Although most of INCLEN's epidemiologists are clinicians, many are deeply involved in community-based work, given the importance of interventions at that level to prevent or ameliorate important health problems. As conveyed in our mission statement, the objective of our work is to improve the health of people by promoting clinical practice based on the best evidence of effectiveness and the efficient use of resources.
While INCLEN's primary objective has been to improve the health of populations in the developing world, there has also been the commitment to build capacity in the countries themselves so that they may continue training new generations of health researchers. The original INCLEN training program which began in 1980 brought faculty from the developing world to institutions in the United States, Canada and Australia. Today, however, ten training centers in Brazil, Chile, China, Colombia, India, Indonesia, the Philippines and Thailand are training clinical epidemiologists from their own countries and regions. These centers are enormously important in building national and regional capacity for dealing with critical health questions. Regional training will make it possible to develop skills without the draining of expertise that, so often, results from taking individuals abroad for extended periods. The development of indigenous expertise makes it more likely that the research undertaken will ask the right questions for the local situation and propose socially appropriate and culturally acceptable interventions. Yet, the existence of a global network allows INCLEN researchers, wherever they live and work, to access technical expertise and to partner with other institutions around the world.
I. Training clinicians for recognition and management of emerging infections
A critical element in the control of emerging infections is the recognition, evaluation and reporting of such cases. For some emerging infections (e.g. plasmid-mediated antibiotic resistance), the laboratory is the major resource. For others, however, like those clinical syndromes caused by previously unrecognized infectious agents, the primary resource for both recognition and clinical management of patients is the clinical physician. As clinicians trained in epidemiology, INCLEN faculty are particularly well prepared not only to monitor infectious disease outbreaks but also to design a system for doing so and to teach others how to conduct it. Training physicians and other health care workers in primary care settings to recognize and refer suspect cases would add greatly to the effectiveness of such a system.
INCLEN training centers offer to design and conduct short training courses and follow-up reinforcements of lessons learned to prepare clinicians at the primary care level as well as at referral hospitals to recognize, evaluate, manage and report cases of emerging infections.
The training curriculum for primary care clinical physicians would cover both epidemiological principles (so that clinicians are socialized to the importance of monitoring outbreaks) and clinical features of disease, differential diagnosis, basic laboratory evaluation, specimens required for definitive testing, treatment and criteria for referral.
If, for example, hemorrhagic fever and meningoencephalitis are two of the syndromes to be monitored, the epidemiologic part of the curriculum would review incidence data for the various known agents of those syndromes, age- and sex-specific variations in their incidence and other known risk factors. This syndrome-specific epidemiologic information would be in addition to more widely applicable epidemiologic principles, which would include the determination of incidence, prevalence, endemicity, sensitivity, specificity and predictive value. For each syndrome, the clinical aspects of the training would include criteria for a suspected case; a clinical checklist for signs, symptoms and simple laboratory tests of value in differential diagnosis; directions for collection, storage and shipment of clinical samples (e.g., blood, serum, cerebrospinal fluid) for definitive testing; treatment procedures; and criteria for further referral.
For each group of clinicians, initial training would likely require one to two days for review of epidemiologic principles and one-half day for each of the clinical syndromes or diseases to be monitored. Training might best be done at major regional hospitals, and include general practitioners, pediatricians, internists and obstetricians from that hospital and surrounding local hospitals. Annual one-day reinforcement sessions would be devoted to new information about occurrence, diagnosis and management of the clinical syndromes, as well as feedback about the results of the prior year's outbreaks.
INCLEN faculty members could also prepare training materials that could be used by others to train primary health care clinicians (physicians and others) to identify, stabilize and refer to regional hospital centers any suspected cases of the syndromes and diseases to be monitored.
II. Masters-Degree-Level Training in Clinical Epidemiology/Emerging Infectious Disease
INCLEN proposes to build on the existing foundation of experienced faculty with strong training skills in clinical epidemiology to create a new vehicle for the development of human resources in the area of emerging infectious diseases. The objective of this new course of training is to equip the trainee to generate and evaluate new information and technology relevant to the field of infectious disease through the application of the principles of epidemiology, biostatistics, clinical economics, health social science, health technology assessment and health policy making. Specifically, the graduate will be able to:
The curriculum for the Master's level training in clinical epidemiology with a focus on emerging infectious diseases would be similar at all the potential training centers, with some variation on course work, length of course and teaching methodology. Dependent on the center, the course would run from 12-24 months, with the expectation of a final research thesis for completion of requirements. As the training centers will vary slightly, INCLEN would provide more detailed information on specific centers on submission of the complete proposal.
The curriculum is outlined in Annex A.
In summary, the offering of both short- and long-term training will have the advantage of preparing cadres of health practitioners to address immediate issues of emerging infectious disease in the shortest period of time, while laying the groundwork for long-term regional expertise with the Masters-level training course. Training clinicians in the recognition and management of serious infections would benefit clinicians and patients alike, have a positive impact on disease control. Linking that training to the improvement of the system for monitoring emerging infections will likely markedly improve the speed with which emerging infections are recognized and contained, since informed and interested physicians will greatly enhance the sensitivity and specificity of disease reporting. Developing a cadre of clinical epidemiologists with particular expertise in infectious disease will create the opportunity for scientifically sound, judiciously chosen investigations by indigenous clinician-scientists to address a range of crucial questions concerning rapid diagnosis, specific and supportive treatment, primary prevention, and transmission.
The INCLEN training centers would seek guidance and assistance from regional centers and national Ministries of Health in tailoring the training programs to focus on identified regional health priorities, in selecting the particular diseases and clinical syndromes to be focused on and in identifying appropriate groups for training at all levels.
Curriculum for Masters-Degree-Level Training in the Clinical Epidemiology of Infectious Diseases
Core Curriculum in Clinical Epidemiology:
1. Clinical Epidemiology
This course presents the basic principles of Clinical Epidemiology. One of the objectives is that fellows will be able to determine causation and distribution of illness, and assess its treatment, from a clinical perspective. The emphasis will be on the application of epidemiologic methods to clinical practice, including such important concepts as: frequency, diagnosis, risk and prevention, prioritizing important topics related with the investigation and forms of evaluating health services using epidemiological methods, including the ethics of investigation.
Topics: Concepts of normality and abnormality; diagnostic tests; bias; risk; causality; natural history; investigation strategies and priorities; quality of care.
2. Biostatistics I and II (basic level)
The biostatistics courses give the student the theoretical and practical knowledge of statistics to understand the biomedical literature, as well as to be able to carry out informed independent analysis of their investigation projects. Computer laboratory work emphasizes the application of theoretical concepts using different statistical programs.
Topics: Sampling elements and determination of sample size; exploratory analysis of data; descriptive analysis and graphics; probability; introduction to the statistical inference: confidence intervals, hypothesis testing, contingency charts; introduction to statistical models.
3. Critical Analysis of the Biomedical Literature
This module focuses on the principles of the critical reading of biomedical literature and gives the student the opportunity to apply these principles and strategies in their daily readings.
Topics: Critical analysis of diagnostic tests; screening; causation; prevention; therapy; quality of care.
4. Social Sciences in Health
The module of Social Sciences arises from a necessity to establish the link between the biological problems of individuals and the social milieu in which they function. This module focuses on the strengthening of clinical epidemiologic investigations by taking into consideration both the biological and the social, psychological and cultural situation of the population.
Topics: Health and culture; theoretical models; methods of qualitative investigation and epidemiology; technical of qualitative investigation; analysis of qualitative data; introduction to the construction of instruments; introduction to administration; politics of health and epidemiology.
5. Design of Clinical Investigation (theoretical)
This course contains the basic and advanced principles about the various designs used in clinical or applied research. The focus will be on the process of design selection, their advantages and disadvantages and some basic aspects of the analysis of data and interpretation of the information.
Topics: Designs of epidemiologic investigation: descriptive studies; cohort studies; case-control studies; clinical trials.
6. Economics in Health
This course presents the basic principles of economics, and its relationship with investigation and health in particular. The focus will be on understanding basic concepts of economics; the relationship between health and economics; recognizing various forms of economic evaluation, their advantages and their limitations; developing ability to read economic evaluations critically; learning the process of clinical decision making and basic management of decision making trees; and designing an economic evaluation of specific health care interventions.
Topics: Concepts of general of economics; introduction to the design of economic studies; analysis of cost effectiveness, cost benefit, and cost utility.
Tailoring the Training Program to Emerging Infectious Diseases:
The training centers propose tailoring the program to emerging infectious diseases by incorporating focused courses as follows:
Introduction to the Epidemiology of Infectious Diseases:
Practical Applications of Research in Infectious Diseases:
In addition, the training centers will capitalize on their links to other departments of the medical schools such as infectious disease and tropical medicine, to draw specialized expertise to the training.
Taking advantage of links with Public Health Departments, a few of the centers plan on expanding the core course in Field Epidemiology to include issues specifically related to field studies in infectious diseases. In some instances, it may be possible to have fellows spend 2-3 months in a research internship focusing on tropical diseases.