Report of Out of Programme Experience at the Health Protection Agency Centre for Infections, London, from May-November 2008.

Dr Anjay Pillai, SpR Paediatrics, East of England Deanery

Contents:
Jump to a section by clicking on the title, return to Contents by clicking: Top: ▲
 
  1. Background
  2. Recruitment
  3. Training approval
  4. Health Protection Agency(HPA) and the Centre for Infections (CFI)
  5. Educational supervision
  6. Job description and experience at the HPA-CFI
  7. Research project sponsered by ECDC
  8. Clinical exposure
  9. Other work done in a personal capacity
  10. What I gained from this placement
  11. Publications and Presentations
  12. Acknowledgements
 
1. Background Top: ▲
 
I started my core training in the Eastern Deanery SpR rotation in March 2007. I have a special interest in paediatric immunology/allergy/infectious diseases. Since there is no paediatric infectious disease department in the deanery, and this is a highly competitive speciality, I was looking for a period of Out of Programme Experience to gain some exposure to this as well as enhancing my CV.
 
It was at this time that the advertisement for a Research Fellow in Infectious Diseases, supported by the RCPCH and the Health Protection Agency (HPA) appeared in the BMJ. This was a short term post with a maximum tenure of 9 months based at the Health Protection Agency Centre for Infections (CFI), Colindale, London and aimed to provide a paediatric trainee with some experience in the public health/epidemiologic aspects of infectious disease, as well as the chance to work as Research Fellow on a specific project. After obtaining clearance from the Deanery and the Regional advisor, I applied for this job in February 2009.
 
2. Recruitment: Top: ▲
 
Recruitment was following a national selection open to trainees in paediatrics or public health.6 candidates were shortlisted. The interview included a 10 minute presentation on "How evidence-based medicine influences government policy with regard to infectious diseases". Following my success in the interview, I had to wait for 3 months (being the mandatory notice period) before joining the job, although the position was available immediately. Ultimately I started at the CFI in May 2009.
 
3. Training approval: Top: ▲
 
The post was directly administered by the RCPCH and was approved for training. The Deanery was very supportive of my application. Dr Wilf Kelsall, regional advisor was kind enough to formally support my application for Out of Programme Experience. The application was forwarded to the PMETB, who approved it in principle to begin with and after a few months, sent a document confirming formal approval towards training. My CCST date remains unchanged.
 
4. Health Protection Agency(HPA) and the Centre for Infections (CFI) Top: ▲
 
The Health Protection Agency (HPA) has as its main goals, protecting the population from infection by the prevention and control of communicable disease, epidemiologic investigation and research.
 
The HPA Centre for Infections (CFI) at Colindale is one of the three specialist centres of the HPA and was established by the merger of the Communicable Disease Surveillance Centre and the Specialist and Reference Microbiology Division. The remit of the centre includes infectious disease surveillance, providing specialist and reference microbiology and microbial epidemiology, co-ordinating the investigation and cause of national and uncommon outbreaks, helping advice governments on the risk posed by various infections and responding to international health alerts. Thus the CFI represents a unique collaboration between clinicians, epidemiologists and microbiologists under one roof. The immunisation department at the CFI also has significant input into national vaccine policy and publications like the "Green Book"
 
5. Educational supervision Top: ▲
 
The principal investigator for the project was Jeremy Hawker, head of Public Health Development at the HPA. My day to day supervisor was Dr Anna Sharma, Consultant Paediatrician who was working as a Locum Consultant Epidemiologist at the HPA and who had been deputed to this project. Paediatric supervision was provided by Dr Mike Sharland, Consultant in Paediatric Infectious Diseases at St Georges Hospital, London. A personal learning plan was made soon after joining and I had regular appraisals, supervision and support throughout my tenure at the HPA.
 

6. Job description and experience at the HPA:

Top: ▲
 
The post was officially called RCPCH-HPA Fellow in Infections and the terms and conditions were that of a Specialist Registrar in Public Health. This was originally started in view of the overlap between paediatrics and public health especially with regards to communicable diseases and immunisation. The post had lapsed due to lack of funding but was reactivated following funding from the European Centre for Disease Control (ECDC)
 
My experience at the CFI can be summarised under the following headings:
 
Introduction to public health/epidemiology of infectious diseases: This was achieved through a 1 week exhaustive induction course titled "Introduction to the Epidemiology and Surveillance of Infectious Diseases", as well as meetings with various section heads and experts where doubts could be clarified. Shared training with Public Health SpRs : The CFI is an apex centre for Public Health SpR training in infectious diseases and has a very active educational programme in which I participated. This included a daily morning update meeting, a weekly Teusday national teleconference followed by SpR teaching, a Monday lunchtime review of on-call queries, a monthly journal club and periodic teaching sessions by relevant experts . I also did a few presentations in the immunisation department meetings.
 
On-call duty on the Public Health SpR rota at CFI: The CFI receives queries from all over the country involving complex vaccination issues, advice regarding communicable disease surveillance and control, issue of immunoglobulins, etc. The first point of call for this is the on-call SpR who then refers to the available databases and liaises with the appropriate expert if necessary. I participated in the on-call rota for a few days and it was a good educational experience.
 
Training in immunisation/vaccine preventable diseases: The project office was situated in the Immunisation Department and this gave a valuable opportunity to interact with experts in immunisation and vaccine preventable diseases, informally and formally via in-house teaching sessions.
 
Training in critical appraisal of research, evidence based medicine and formulating guidelines: Public Health SpRS are given extensive training in these areas and in my limited time there, I was able to get a flavour of this training.
 
7. Research project sponsered by ECDC Top: ▲
 
This occupied the bulk of my time at the CFI. European Centre for Disease Prevention and Control (ECDC) co-ordinates communicable disease surveillance and control across the European Union. The ECDC funded a new project with the following three arms:
 
a. Develop evidence based fact sheets on common infections to be used by clinicians across Europe:
 
This involved an exhaustive structured literature search, selection of around 50-100 relevant references for each disease, critically appraising them and then writing a review paper. The paper was then peer- reviewed by UK and European experts before being approved by ECDC. The final list will soon be published on the ECDC website. This gave me a golden chance to develop my skills in literature search, critical appraisal and medical writing. I was the first author for the following fact sheets : Hepatitis B, Cholera, Poliomyelitis, Cryptosporidiosis, Toxoplasmosis
 
b. Develop evidence based guidelines for inclusion and exclusion of children with communicable diseases from schools and day care centres.
 
An abstract of the project is reproduced below:
 
Background and aims: International recommendations on exclusion from schools for communicable diseases vary widely and are often not evidence based. This new collaborative project, funded by the European Centre for Disease Prevention and Control (ECDC) aimed to update previously published evidence-based guidelines (Richardson et al ,2001), and to make recommendations which would be applicable to the whole of Europe.
 
Methods: The following primary parameters were studied for 39 communicable diseases: mode of transmission, incubation period, risk of transmission, period of infectivity, duration of shedding and serial interval. For each of these variables, the best available evidence was obtained by systematic searches of the medical literature . The evidence was critically reviewed and categorised into high, moderate or low quality and was then peer reviewed by experts. A UK steering group and a European expert panel considered the evidence as well as other relevant factors including public health importance of the disease and effectiveness of exclusion. Consensus recommendations were made for each disease which were categorised into 'strong' or 'weak'.
 
Results: High quality evidence was not available for many of the diseases.The final guidance for 39 diseases was presented to the ECDC scientific advisory forum. European consensus was achieved on all diseases except typhoid fever and will be presented.
 
Conclusion: The best available evidence for the relevant epidemiologic parameters of 39 communicable diseases was collected and European guidance for school exclusion policies were produced based on the same.
 
This was a team project involving several workers at different sites. I made supervised contributions to several of the diseases and summarising the final evidence tables. It was a great experience interacting with international experts from various European countries and learning how national and international guidelines are formulated
 
c. Developing fact sheets on infections for use by the lay public across Europe:
 
I was not directly involved in this but took part in the steering committee meetings.
 
Facilities available: A separate office and 3 computers were allocated to the project. A research nurse was also allocated to the project. The library at CFI provided access to an exhaustive list of journals and medical databases. Additional software like Ref Man was provided.
 
8. Other work done in a personal capacity Top: ▲
 
I was able to take part in a few study days organised at CFI. Further I was allowed study leave funding to attend a course on critical appraisal of medical and scientific papers, held at Southampton
 
In my free time I also enrolled in and completed the following distance learning courses:
 
PENTA/ESPID European certificate course in Paediatric HIV Fundamentals of epidemiology course from London School of Hygiene and Tropical Medicine.
 
I also utilised study leave to attend training days organised by the British Paediatric Allergy, Immunology and Infection (BPAIIG) group.
 
9. Clinical exposure Top: ▲
 
This post did not officially include a clinical placement. However I was able to negotiate some clinical activity in view of my interest in paediatric infectious diseases. This took the form of a honorary attachment in Paediatric Infectious Diseases (PID) at St Georges Hospital, London, supervised by Dr.Mike Sharland, Consultant in PID. As part of this, I was given time off every Wednesday to attend the morning ward rounds in the PID unit. This was followed by a Grand Round discussion of all paediatric infection cases, as well as a formal presentation. I also came back to do some locum work at James Paget hospital on weekends, thus maintaining general paediatric clinical exposure.
 
10. What I gained from this placement Top: ▲
 
  •  Unique chance to work in a stimulating environment with world class experts in an apex centre. I was able to interact with leading figures in infectious diseases.
  • Able to witness a lot of the behind the scenes action which goes behind the scenes with regard to prevention and control of communicable diseases.
  • Gain a deeper understanding of how epidemiology affects clinical practice and national health policy.
  • Able to hone my skills in literature search, critical appraisal and evidence based medicine.
  • Present papers and participate in European level meetings.
  • Formal competencies in Higher Specialist Training in General Paediatrics as recognised by RCPCH : Infection Control and Immunisations
  • Formal competencies in Higher Specialist Training in Paediatric Infectious Diseases and Community Child Health as recognised by RCPCH: including epidemiology of infectious diseases, infection control, immunisations, management skills and research skills
  • Formal competencies in Public Health as recognised by the Faculty of Public Health: including Health and Social Service Quality, Public Health Intelligence, Surveillance of communicable diseases, policy and strategy development, organising data and knowledge, conducting systematic reviews, communicating with the public with regard to health issues.
 
11.Presentations and publications: Top: ▲
 
  • Anna Sharma, Anjay MA, Jeremy Hawker, Mike Sharland, Martin Richardson, Tina Endericks, Helen Bedford, Laura Craig, David Elliman, Daniel Lévy-Bruhl, Paolo Bonanni, Zsofia Mészner, Maria Tsolia, Vytautas Usonis. European guidance on inclusion and exclusion of children with communicable diseases from schools and day care centres: An evidence-based approach : poster session at RCPCH spring meeting in York, March/April 2009 and poster walk session at the European Society for Paediatric Infectious Disease(ESPID) annual meet in Brussels, Belgium, June 2009
 
This will also be submitted for publication in a major peer reviewed journal.
 
Five review articles which I generated for the project will soon be uploaded on the website of the European Centre for Disease Control (ECDC) soon
 
12. Acknowledgements: Top: ▲
 
Dr Wilf Kelsall and the East of England Deanery for their support.
Dr Anna Sharma and Dr Mike Sharland for their supervision and help.
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