ENSURING AN INFECTIOUS DISEASE WORKFORCE

Education and Training Needs for the 21st Century

Workshop Summary

Stacey L. Knobler, Thomas Burroughs, Adel Mahmoud, Stanley M. Lemon Editors

Forum on Microbial Threats

Board on Global Health

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu



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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century ENSURING AN INFECTIOUS DISEASE WORKFORCE Education and Training Needs for the 21st Century Workshop Summary Stacey L. Knobler, Thomas Burroughs, Adel Mahmoud, Stanley M. Lemon Editors Forum on Microbial Threats Board on Global Health INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century THE NATIONAL ACADEMIES PRESS 500 FIFTH STREET, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This project was supported by the U.S. Department of Health and Human Services’ National Institutes of Health, Centers for Disease Control and Prevention, and Food and Drug Administration; U.S. Agency for International Development; U.S. Department of Defense; U.S. Department of State; U.S. Department of Veterans Affairs; U.S. Department of Agriculture; American Society for Microbiology; Aventis Pasteur, Burroughs Wellcome Fund; Pfizer; GlaxoSmithKline; and The Merck Company Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. This report is based on the proceedings of a workshop that was sponsored by the Forum on Microbial Threats. It is prepared in the form of a workshop summary by and in the name of the editors, with the assistance of staff and consultants, as an individually authored document. Sections of the workshop summary not specifically attributed to an individual reflect the views of the editors and not those of the Forum on Microbial Threats. The content of those sections is based on the presentations and the discussions that took place during the workshop. Library of Congress Cataloging-in-Publication Data Ensuring an infectious disease workforce : education and training needs for the 21st century : workshop summary / Stacey L. Knobler … [et al.], editors ; Forum on Microbial Threats, Board on Global Health. p. ; cm. Includes bibliographical references. ISBN 0-309-10010-0 (pbk). 1. Communicable diseases—Prevention—Congresses. 2. Public health personnel—Education—Congresses. 3. Public health personnel—Training of—Congresses. [DNLM: 1. Communicable Disease Control—trends—Congresses. 2. Public Health—education—Congresses. 3. Public Health—manpower—Congresses. WA 110 E59 2006] I. Knobler, Stacey. II. Institute of Medicine (U.S.). Forum on Microbial Threats. RA643.E57 2006 614.5—dc22 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2006 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. COVER: A detailed section of a stained glass window 21 × 56″ depicting the natural history of influenza viruses and zoonotic exchange in the emergence of new strains was used to design the front cover. Based on the work done at St. Jude Children’s Research Hospital supported by American Lebanese Syrian Associated Charities (ALSAC) and the National Institute of Allergy and Infectious Diseases (NIAID). Artist: Jenny Hammond, Highgreenleycleugh, Northumberland, England.

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century FORUM ON MICROBIAL THREATS STANLEY M. LEMON (Chair), Dean, School of Medicine, The University of Texas Medical Branch, Galveston P. FREDRICK SPARLING (Vice Chair), J. Herbert Bate Professor Emeritus of Medicine, Microbiology, and Immunology, University of North Carolina, Chapel Hill MARGARET HAMBURG (Vice Chair), Senior Scientist, Nuclear Threat Initiative/Global Health & Security Initiative, Washington, D.C. DAVID ACHESON, Chief Medical Officer, Center for Food Safety and Applied Nutrition, Food and Drug Administration, Rockville, Maryland RUTH L. BERKELMAN, Rollins Professor and Director, Emory University, Center for Public Health Preparedness and Research, Rollins School of Public Health, Atlanta, Georgia ROGER G. BREEZE, Chief Executive Officer, Centaur Science Group, Washington, D.C. STEVEN J. BRICKNER, Research Advisor, Pfizer Global Research and Development, Pfizer Inc., Groton, Connecticut JOSEPH BRYAN, Interim Laboratory Director, Office of Medical Services, Department of State, Washington, D.C. NANCY CARTER-FOSTER, Director, Program for Emerging Infections and HIV/AIDS, U.S. Department of State, Washington, D.C. GAIL H. CASSELL, Vice President, Scientific Affairs, Eli Lilly & Company, Indianapolis, Indiana MARK FEINBERG, Vice President for Policy, Public Health & Medical Affairs, Merck Vaccine Division, Merck & Co., West Point, Pennsylvania J. PATRICK FITCH, Chemical & Biological National Security Program Leader, Lawrence Livermore National Laboratory, Livermore, California S. ELIZABETH GEORGE, Deputy Director, Biological and Chemical Countermeasures Program, Department of Homeland Security, Washington, D.C. JESSE L. GOODMAN, Director, Center for Biologics Evaluation and Research, Food and Drug Administration, Rockville, Maryland EDUARDO GOTUZZO, Director, Instituto de Medicina Tropical–Alexander von Humbolt, Universidad Peruana Cayetano Heredia, Lima, Peru JO HANDELSMAN, Professor of Plant Pathology, College of Agricultural and Life Sciences, University of Wisconsin, Madison, Wisconsin

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century CAROLE A. HEILMAN, Director, Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland DAVID L. HEYMANN, Executive Director, Polio Eradication, World Health Organization, Geneva, Switzerland PHIL HOSBACH, Vice President of New Products and Immunization Policy, Sanofi Pasteur, Swiftwater, Pennsylvania JAMES M. HUGHES, Director, Global Infectious Diseases Program, Emory University, Atlanta, Georgia STEPHEN JOHNSTON, Professor, Director, University of Texas Southwestern Medical Center, Dallas, Texas GERALD T. KEUSCH, Assistant Provost for Global Health, Boston University School of Medicine, and Associate Dean for Global Health, Boston University School of Public Health, Boston, Massachusetts LONNIE KING, Dean, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan GEORGE KORCH, Chief, Medical Science and Technology Program for Chemical and Biological Defense, Defense Threat Reduction Agency, Ft. Belvoir, Virginia JOSHUA LEDERBERG, Raymond and Beverly Sackler Foundation Scholar, The Rockefeller University, New York, New York JOSEPH MALONE, Director, Department of Defense Global Emerging Infections System, Walter Reed Army Institute of Research, Silver Spring, Maryland LYNN MARKS, Senior Vice President of Infectious Diseases, Medicine Development Center, GlaxoSmithKline, Collegeville, Pennsylvania STEPHEN S. MORSE, Director, Center for Public Health Preparedness, Columbia University, New York, New York MICHAEL T. OSTERHOLM, Director, Center for Infectious Disease Research and Policy, and Professor, School of Public Health, University of Minnesota, Minneapolis, Minnesota GEORGE POSTE, Director, Arizona BioDesign Institute, Arizona State University, Tempe, Arizona DAVID A. RELMAN, Associate Professor of Medicine and Associate Professor of Microbiology and Immunology, Stanford University, Stanford, California GARY A. ROSELLE, Program Director for Infectious Diseases, Central Office, Veterans Health Administration, Department of Veterans Affairs, Washington, D.C. ANNE SCHUCHAT, Acting Director, National Center for Infectious Disease, Centers for Disease Control and Prevention, Atlanta, Georgia

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century JANET SHOEMAKER, Director, Office of Public Affairs, American Society for Microbiology, Washington, D.C. BRIAN STASKAWICZ, Professor, Department of Plant and Microbial Biology, University of California, Berkeley, California TERENCE TAYLOR, President and Executive Director, International Institute for Strategic Studies, Washington, D.C. Liaisons ENRIQUETA BOND, President, Burroughs Wellcome Fund, Research Triangle Park, North Carolina NANCY CARTER-FOSTER, Director, Program for Emerging Infections and HIV/AIDS, U.S. Department of State, Washington, D.C. EDWARD McSWEEGAN, Program Officer, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland Staff EILEEN CHOFFNES, Director, Forum on Microbial Threats STACEY KNOBLER, Former Director, Forum on Microbial Threats THOMAS BURROUGHS, Science Writer ELIZABETH KITCHENS, Research Associate KIM LUNDBERG, Research Associate KATHERINE OBERHOLTZER, Research Associate KATE SKOCZDOPOLE, Senior Program Assistant

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century BOARD ON GLOBAL HEALTH MARGARET HAMBURG (Chair), Consultant, Nuclear Threat Initiative, Washington, D.C. YVES BERGEVIN, Senior Program Advisor, Africa Division, United Nations Population Fund, New York, New York JO IVEY BOUFFORD, Professor, Robert F. Wagner School of Public Service, New York University, New York, New York DONALD BERWICK, Clinical Professor of Pediatrics and Health Care Policy, Harvard Medical School, and President and CEO, Institute of Healthcare Improvement, Boston, Massachusetts DAVID R. CHALLONER (IOM Foreign Secretary), Vice President for Health Affairs, Emeritus, University of Florida, Gainesville, Florida SUE GOLDIE, Associate Professor of Health Decision Science, Department of Health Policy and Management, Center for Risk Analysis, Harvard University School of Public Health, Boston, Massachusetts RICHARD GUERRANT, Thomas H. Hunter Professor of International Medicine, and Director, Center for Global Health, University of Virginia School of Medicine, Charlottesville, Virginia GERALD KEUSCH, Assistant Provost for Global Health, Boston University School of Medicine, and Associate Dean for Global Health, Boston University School of Public Health, Boston, Massachusetts JEFFREY KOPLAN, Vice President for Academic Health Affairs, Emory University, Atlanta, Georgia SHEILA LEATHERMAN, Research Professor, University of North Carolina School of Public Health, Chapel Hill, North Carolina MICHAEL MERSON, Anna M.R. Lauder Professor of Public Health, Yale University School of Public Health, New Haven, Connecticut MARK L. ROSENBERG, Executive Director, The Task Force for Child Survival and Development, Emory University, Decatur, Georgia PHILIP RUSSELL, Professor Emeritus, Bloomberg School of Public Health, Johns Hopkins University, Potomac, Maryland Staff PATRICK KELLEY, Director DIANNE STARE, Research Assistant ALLISON BRANTLEY, Program Assistant

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century Reviewers All presenters at the workshop have reviewed and approved their respective sections of this report for accuracy. In addition, this workshop summary has been reviewed in draft form by independent reviewers chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the Institute of Medicine (IOM) in making the published workshop summary as sound as possible and to ensure that the workshop summary meets institutional standards. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. The Forum and the Institute of Medicine thank the following individuals for their participation in the review process: Sambe Duale, Support for Analysis and Research in Africa (SARA) Project, Washington, D.C. M.R.C. Greenwood, University of California Office of the President, Oakland, California Daniel Lucey, Georgetown University, Washington, D.C. Carol Woltring, Center for Health Leadership and Practice, Public Health Institute, Oakland, California The review of this report was overseen by Melvin Worth, M.D., Scholar-in-Residence, The National Academies. Appointed by the National

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century Research Council, he was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the editors and the institution.

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century Preface The Forum on Microbial Threats (previously named the Forum on Emerging Infections) was created in 1996 in response to a request from the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH). The goal of the Forum is to provide structured opportunities for representatives from academia, industry, professional and interest groups, and government to examine and discuss scientific and policy issues that are of shared interest and that are specifically related to research and prevention, detection, and management of emerging infectious diseases. In accomplishing this task, the Forum provides the opportunity to foster the exchange of information and ideas, identify areas in need of greater attention, clarify policy issues by enhancing knowledge and identifying points of agreement, and inform decision makers about science and policy issues. The Forum seeks to illuminate issues rather than resolve them directly; hence, it does not provide advice or recommendations on any specific policy initiative pending before any agency or organization. Its strengths are the diversity of its membership and the contributions of individual members expressed throughout the activities of the Forum. ABOUT THE WORKSHOP Recent increased attention to both United States and international public health systems as well as the medical research and treatment infrastructure has revealed significant deficiencies in their capacity to respond to infectious diseases. Medical and public health professionals may be poorly

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century equipped to detect, diagnose, and treat common infectious diseases as well as those diseases that pose an unexpected threat. The need for the development of domestic and international training programs in the expanding field of emerging and reemerging infectious diseases is well recognized. Well-trained infectious disease professionals form the basis of a strong national healthcare system. Increasing costs of care have prompted training in medicine and public health to focus on improving efficiency, cutting costs while maintaining gains in life expectancy and reducing morbidity. In the past decade, public health and medical schools have introduced new educational and communications technologies (Internet and health informatics), problem-based learning approaches, and partnerships and networking to encourage new areas of core competencies. However, there is an increasing need for programs that can improve the breadth and quality of training infectious disease professionals receive. Recent investments made to address the threat of biological weapons seem to be beneficial in strengthening the public health infrastructure but may or may not address the nation’s most critical needs. The workshop will review trends in research training programs and discuss the requirements for establishing successful educational initiatives and training programs to ensure a competent and prepared workforce for current and future challenges in infectious diseases. Some key disciplines to be explored as case-study examinations include infectious disease epidemiology, vaccinology, vector biology, and public health laboratorians. The goals of the workshop were to: Identify infectious disease training initiatives sponsored by government, foundations, academia, or industry that are or have been successful, and factors required for continued success. Identify topics of public, private, or Congressional interest, such as food safety, vector-borne diseases, restrictions on foreign scientists, and public health preparedness where there may be a dearth of training initiatives or other barriers. Discuss the role of the U.S. Agency for International Development, World Health Organization, and other international organizations in the training of foreign nationals and identify additional training needs (e.g., surveillance, epidemiology, and laboratory training) that would be beneficial in capacity-building and infrastructure development initiatives. Discuss possible alterations in academic programs at the professional student, clinical training, and research training levels to increase awareness of and capacity to recognize and treat or prevent emerging infections. Consider whether current government training programs at the CDC, NIH, and Department of Defense are adequately supported and

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century whether establishment of public/private partnerships to expand current initiatives would be of value. The issues pertaining to the stated goals were addressed through invited presentations and subsequent discussions, which highlighted ongoing programs and actions taken, and also identified priority needs in these areas. ACKNOWLEDGMENTS The Forum on Microbial Threats and the Institute of Medicine (IOM) wish to express their warmest appreciation to the individuals and organizations who gave valuable time to provide information and advice to the Forum through their participation in the workshop. A full list of presenters can be found in Appendix B. The Forum is indebted to the IOM staff who contributed during the course of the workshop and the production of this workshop summary. On behalf of the Forum, we gratefully acknowledge the efforts led by Stacey Knobler, director of the Forum; Marjan Najafi, research associate; Elizabeth Kitchens, research associate; and Katherine Oberholtzer, research associate, who dedicated much effort and time to developing this workshop’s agenda, and thank them for their thoughtful and insightful approach and skill in translating the workshop proceedings and discussion into this workshop summary. We would also like to thank the following IOM staff and consultants for their valuable contributions to this activity: Patrick Kelley, Dianne Stare, Bronwyn Schrecker, Eileen Choffnes, and Kate Skoczdopole. Finally, the Forum also thanks sponsors that supported this activity. Financial support for this project was provided by the U.S. Department of Health and Human Services’ National Institutes of Health, Centers for Disease Control and Prevention, and Food and Drug Administration; U.S. Department of Defense; U.S. Department of State; U.S. Department of Veterans Affairs; U.S. Department of Agriculture; American Society for Microbiology; Aventis Pasteur; Burroughs Wellcome Fund; Pfizer; GlaxoSmithKline; and the Merck Company Foundation. The views presented in this workshop summary are those of the editors and workshop participants and are not necessarily those of the funding organizations. Adel Mahmoud, Chair Stanley M. Lemon, Vice-Chair

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century Contents     SUMMARY AND ASSESSMENT   1      Exploring the Characteristics of the Workforce,   2      The Role of Physician–Scientists,   4      Fields of Special Emphasis,   11      Assessing Domestic and International Training Programs and Educational Needs,   26      Addressing the Workforce Crisis in the Developing World,   33      Implications of Visas and Select Agent Research Restrictions,   39      Identifying Priorities for the Future,   43     APPENDIXES     A   Authored Papers          Implications of Restrictions on Foreign Students and Scientists for Infectious Disease Research, Ronald M. Atlas   51      Training and Sustaining the Public Health Laboratory Workforce—Our First Line of Defense against Infectious Disease, Scott J. Becker   56      Who Will Live in the “House of Genomics”?, Tara Acharya, Halla Thorsteinsdóttir, Peter A. Singer, and Abdallah S. Daar   67

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century      Public Health for All: Workforce Development through an Integrated Approach to Health Care Curricula, Walid El Ansari   76      Stakeholders’ Perceptions of Outcomes in Public Health Educational Partnerships, Walid El Ansari   89      Health Protection: Communicable Disease, Public Health and Infection Control Educational Programmes—A Case Study from the UK, W. El-Ansari and S. Privett   105      Addressing the Health Workforce Crisis in the Developing World, A. Edward Elmendorf   127      Ensuring an Adequate Infectious Diseases Physician Response to Emerging Infections, Gary L. Gorby   129      Addressing the Microbial Threat to Health: Training Ph.D. Scientists to Help Lead the Way, Martha L. Gray   143      What Kinds of Scientists Do We Need to Train, and How?, Victoria McGovern   156      Vaccines in the 21st Century, Stanley Plotkin   166      Schools of Public Health: Meeting the Workforce Challenge of Emerging Infections, Margaret A. Potter   176      U.S. Capacity to Confront Emerging Vector-Borne Pathogens, Andrew Spielman   183 B   Workshop Agenda,   195 C   Forum Member Biographies,   201

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Ensuring an Infectious Disease Workforce: Education and Training Needs for the 21st Century ENSURING AN INFECTIOUS DISEASE WORKFORCE

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