Project Details

International Trans-Disciplinary Collaboration on Population and Public Health

Background

Canada is strengthening its science and technology relationships with India under an Emerging Markets Strategy, part of the new International Science and Technology Partnerships Program launched with a $20-million, five-year investment announced in the 2005 federal budget. Areas for research and development increasingly common and of priority to both India and Canada include population and public health and the environment. Capacity for leadership and management in the public and private sectors of these domains is also a critical issue.  

A major component of the Indo-Canadian developing partnership strategy is the linkage between universities regarding science and technology research and education. Within the last few years, the private sector universities in India have been playing an increasingly important role in the growth of science and technology and in the establishment of innovative high-quality research initiatives. Within the private university sector, the Sri Ramasamy Memorial (SRM) University  is a major contributor and has established a bilateral research and education linkage with Queen’s University.

The Partnership – Collaboration

Very early on in the process, the SRM and Queen’s research teams discovered that the strengths of their institutions were highly complimentary. Being a private institution, SRM has the ability to forge its own programs in very short order, given the nature of its management structure and philosophy. In particular, SRM has made incredible advances in infrastructure, networks and development. SRM is very quickly growing its capacity in the delivery of high-quality education. Being a mature institution, Queen’s has different strengths. In particular, Queen’s has a reputation for excellence in research, as well as innovation in the delivery of high-quality education (i.e. e-learning). A core dimension of Queen’s contributions to science is that it has developed highly specialized knowledge in areas such as infectious disease control, community epidemiology, and knowledge transfer and management.

In February 2006, a Queen’s delegation visited the Sri Ramasamy Memorial (SRM) University in Tamil Nadu, India, which led to the development and signing of a Memorandum of Understanding in June 2006 in Kingston, Ontario, Canada outlining how the institutions will encourage research collaboration in population and public health with a focus on communicable diseases.

A Unique Situation Creates Unique Opportunities

SRM has access to a very unique research cluster, thanks to its health care service-delivery model. Within 130 villages, a population of 250,000 people has access to SRM’s health care delivery system consisting of a tertiary care hospital and research centre, a hospital of dentistry, two primary care community health centres, and rotating public health outreach “camps.” Patients are not charged for the health services SRM provides to ensure inclusiveness and access of the whole population base, regardless of socio-economic status. This “Cradle to Grave” health care system creates conditions for data collection that are idyllic, if executed properly.

Because SRM’s health care service delivery system is so new and unencumbered, we are presented with the unique opportunity of developing a health and demographic data collection system that will be robust and flexible at the outset. We can engineer a system so as to avoid duplication of effort, and to collect the right information at the right level of the epidemiological hierarchy, based on the principles of community health.

Project Summary

“Building Global Capacity for Disease Surveillance through Evidence-Based Research”

There are many population health issues in Tamil Nadu: antibiotic-resistant organisms (like MRSA), neonatal sepsis, TB, HIV/AIDS, Hepatitis B, rotavirus, diarrhea in children, anemia in women and its effect on birth weight, and others. Compounding the problem is mounting evidence of anti-microbial resistance, though the reasons for this are unclear.

Vision for an Integrated Regional Health Registry

To design effective interventions that address communicable diseases in the mostly rural district of Kancheepuram, we need to build capacity to monitor community health over time, space and “place”, and link trends to individual and household demography, health behaviors and environmental risks. We plan to pilot and build a Queen’s – SRM Regional Population Health Registry (QS-RPHR), a central linked data base that will include patients visiting SRM hospitals, community health centres, both urban and rural, as well as SRM’s outreach “camps.” Over time, we hope to have all citizens within the region surveyed and registered with a “Unique Individual Identifier.” This will enable us to track the health status of individuals from pre-birth to old age.

Accurate, appropriate and valid data is key. We can avoid duplication of effort in collection by the development and utilization of a common core demographic module. This will enable the collection of the right information at the right level of the epidemiological hierarchy: Region – Village – Household – Individual. We will create and maintain an integrated, digitized database, including additional features such as Geographic Information Systems (GIS) mapping (XY geo-referencing of households, environmental confounders such as water supplies and sanitation, and gathering places like schools, temples, etc.), and research project-specific modules. The utilization of a collaborative research design will maximize capacity and inclusiveness. The QS-RPHR database will be expandable to include specific components and/or modules as research questions arise and research agenda evolves.

Consultations with partners and village leaders indicate that creating the QS-RPHR is feasible. Tested in three villages, the survey will be piloted with 5% of the regional population.

Purpose and Goals

The purpose of our pilot project is to provide proof of concept for expanding the QS-RPHR and SRM healthcare services to all 130 villages in the catchment area. We need to ensure that individual demographic and health data is digitally captured via a unique individual identifier that is linked to a household geo-reference, which is further linked to environmental factors in the village using GIS. Extension of our work presupposes the existence of organized communities (villages) and a leading public health agency (SRM). Our goal is to determine the best methodology to expand the deployment of the QS-RPHR to understand a variety of communicable diseases at the regional level. Our methodology could be replicated for use in other regions providing the survey is calibrated to the unique features at the village level.

Once we have an understanding of the incidence of disease in the region, we can then begin to design appropriate interventions based on specialized local knowledge of disease trends, health behaviors and environmental risks.

The QS-RPHR will provide us with a powerful research tool to enable the study of the distribution, determinants and deterrents of morbidity and mortality within the defined population, explain and prevent public health problems and, on a greater scale, develop existing knowledge and provide new knowledge in the prioritization and evaluation of public health programs in India (Oleckno, 2002). Our ultimate goal is to demonstrate the capacity to reduce morbidity and mortality in vulnerable populations.

In general, we can build mutual capacity by employing a trans-disciplinary, multicultural approach to problem solving in the area of Population and Public Health, and developing knowledge and technology transfer that is sustainable, accessible, and transferable to other regions, in India, Canada and the world.

Proof of Concept

The project will result in the implementation of proactive solutions to prevent further spread of illness and unnecessary use of resources. The QS-RPHR will act as a tool to understand determinants and confounders of communicable disease, leading to early reporting of outbreaks and the development of informed interventions that recognize the socio-economic factors influencing the health of villagers, particularly the vulnerable populations. Quality of and access to health care will improve for ~ 13,000 people as SRM community health workers provide on-going health education on infection control, hygiene, nutrition, family planning and antepartum/antenatal care.

In order to illustrate the power of the QS-RPHR, our initial research will focus on Community-Acquired Multi-drug resistant Staphylococcus Aureus (CA-MRSA), a disease that is spreading at an alarming rate in North American communities, whose high incidence rate in India provides us with a robust sample size. Results of this research are expected to inform health care decision-making, not only in India, but also in Canada.

Using the QS-RPHR to address CA-MRSA in the pilot will benefit the community by applying effective strategies to reduce morbidity and mortality rates, and lead to a greater understanding of the pathogen. There is little evidence on the transmission dynamics, epidemiology and changing biology of CA-MRSA, so findings will be highly relevant in addressing the pathogen in other settings world-wide.

Measurability

The pilot project will include and serve a subset of ~ 13,000 persons in 5 villages. We will assess the impact of building the registry and extension of health services as follows:

• Qualitative monthly feedback from village leaders and local health workers to ensure that the most efficient and appropriate procedures are used;
• Quantify the role of local health care workers in the villages via the QS-RPHR to determine
• how many additional patients entered the SRM system during the pilot study period versus the same preceding period
• changes in proportion of patients served by the SRM system (versus traveling outside the village to other healthcare providers like private practitioners or government hospitals/clinics)
• how the range of health issues examined/treated change over time (bi-annually);
• Quantify the prevalence of CA-MRSA carriage and incidence of disease in the community, identify risk factors associated with these, design and implement an intervention strategy and assess the impact on CA-MRSA subsequently.

Trans-disciplinary Collaboration Leading to Advances in Community Health

We have developed a vision of how we need to proceed in order to be successful in both the short and long terms. The “Cradle to Grave” defined population provides us with incredible cross-disciplinary research capacity, and a unique opportunity to develop a trans-disciplinary research strategy to address the many and complex community health issues of Tamil Nadu. In building the health registry, we envision the participation of researchers from a variety of disciplines: Infectious Diseases, Community Epidemiology, Medical Microbiology, GIS/Geography, Information Technology and Management of Information Systems, Knowledge Management, etceteras. Additional disciplines will be invited to participate as subsequent research streams are developed.

All stakeholders will participate in research design through collaboration and integration. Concurrent investigations by researchers looking at the issues through different lenses produce insights not possible through conventional research, as well as deep contextual understanding of the subject matter.

The research alliance will create opportunities to develop a genuine understanding of vital issues relating to infectious disease prevention and control through interdependent, complementary research projects. “Hence, in knowledge creation, one tries to see the entire picture of reality by interacting with those who see the reality from other angles, that is, sharing their contexts.” (Nonaka & Toyama, 2003) Rich in context, our research will enable appropriate interventions and enhanced educational opportunities.

Excellence in Research and Education on the Worldwide Stage

The partnership enables both institutions to build capacity in Community Epidemiology, Public Health Nursing, Medical Microbiology and Infectious Diseases. As well, there are several training opportunities, such as expanded and enhanced educational opportunities for undergraduate and graduate students in Community Epidemiology, the creation of a joint International Standard for Masters training, E-learning, a Faculty Exchange Program as well as the development of departments for Clinical Infectious Diseases and Medical Microbiology at SRM.

Through the partnership, both institutions have the opportunity to develop best practices, and to test and track interventions longitudinally, demonstrating proof positive that their methods work. This new knowledge can be transferred through innovative educational programs. Research findings are likely to be top-of-class and relevant within the areas of academia and practice the world over.

Methodology

Community Health

In recognition of:

1. the importance of a demonstration of the feasibility and usefulness of the proposed registry;
2. the need for an achievable, fundable initial project;
3. the fact that SRM’s provision of healthcare services (i.e. penetration into catchment area) is variable, but growing;

… we unanimously agreed that an initial pilot project (~13,000 individuals) conducted in a more limited number of villages (5 ), selected on the basis of key criteria focusing on ensuring maximal SRM presence/coverage, is both desirable and necessary.

Critical to the validity of the ‘numerator’ data (i.e. numbers of cases of disease as reported to or captured through provision of Health Care by SRM) is ensuring homogeneity of access and comprehensive use of the SRM healthcare system in the population of interest. That is to say, the presence and use of alternative health care providers (i.e. government hospitals/clinics/health nurses and other private practitioners) within the proposed SRM catchment/service area raises the potential of bias.

A variety of measures are proposed to assist in maximizing the coverage within the villages chosen to participate in the initial pilot project including:

1. Active Collection

      Combined with survey and/or for a subset of surveyed population

• Data (e.g. medical history, diagnoses, etc.)
• Samples (e.g. MRSA swabbing)

2. Passive Collection

a)      Increase coverage / “Market Share”

      Focus pilot project in villages based on:

• Lack of other healthcare providers
• Proximity to SRM Hospital / Rural or Urban Centres
• Existing high level of use (query SRM Hospital database)

b)      Promote SRM Activities

• Establish presence in villages through outreach centre and survey team
• “Market” SRM through extension activities
• Increase access to existing data where possible, ie. Village Health Nurses, Government Hospitals

c)      Increase frequency or intensity of follow-up by surveyors:

Longitudinal (versus initial cross-sectional only)

Given SRM’s commitment to building research capacity and service delivery, we proposed that as part of the pilot project a number of “SRM Outreach Centres” be opened in the study villages. We envision that these centres become the conduit both for the provision of service and extension activities as well as the collection of appropriate data. Centres could be staffed with SRM Public Health Workers or nurses (or similarly trained/experienced individuals) as well as surveyors, etc. Such centres would provide a number of advantages/opportunities both project-specific and in a broader SRM context. For example:

• Develop and launch a Public Relations and Awareness Program
• Integrate awareness with village surveying and SRM Health Care Camps
• Opportunity for field work for students
• Provide public health education as well as treatment
• Update regional health registry longitudinally
• Flag structural and infrastructural changes to GIS department
• Provide antepartum care (90% of villagers have 2 visits with the private or public system)
• Provide antenatal care
• Cooperate with state health nurses  (sensitivity to existing relationships in the village)

Geographic Information System (GIS) & Digital Mapping Component

Tasks:

1. To determine the feasibility of adding a geo-reference for each household in the survey area that can be linked to the unique identifier for each patient in the RPHR.
2. To capture the location of all water related distribution and storage points i.e. water taps, bore wells, water storage tanks, etc.
3. To recommend appropriate procedures, personnel, software and equipment to accomplish # 1 and #2 in an easy, cost effective manner that can be transferred to other areas.
4. To document ancillary resources such as sources of mapping (contours, geology, roads, parcel fabric), remote sensing and other studies that will assist in subsequent epidemiologic studies of temporal and spatial patterns of disease.
5. To devise data capture procedures that will ensure long-term maintenance of the spatial aspects of the population health registry and ensure its transferability to other areas.

The benefits of capturing point geoferenced data for each household and linking this with health, behaviour and demographic information are enormous.  Point data can be aggregated to any resolution for linking and comparison with other relevant data.  Point patterns of disease, health and behaviour have value in their own right for epidemiological hypothesis testing and generation. We will also capture the household locations as if the location of their front doors were projected onto the street.   This permits the assignment of homes to the street network for studies of accessibility and routing. 

MRSA Microbiology Research Project

Proposal components were identified as well as the scope and its relationship to the Regional Population Health Registry. Specifically, we will conduct at least two (or more if funding permits) point prevalence studies of MRSA in the pilot selected village communities. We will use routine cost effective culture methods with new MRSA Select Chromogenic Agar. All MRSA isolates will be comprehensively tested for their antimicrobial susceptibility. Data will be recorded using the WHO-Net database program already in place. DNA will be extracted from isolates and subjected to Pulse Field Gel Electrophoresis as well as PCR for MEC genotyping and testing for the PVL gene, which is a marker for community acquired MRSA. The results will be entered into the RPHR and analyzed on the basis of geospatial and health risk factors. Repeating the point prevalence survey will permit analysis of changes in geospatial features as well as emergence of MRSA in the villages where risk factors are common. Genotyping data will be included in the analysis to understand the pattern of spread. Cases of clinical MRSA infection will be detected by the village health workers who will offer primary care in the village, as well as by admission history to SRM Hospital. Planning is based upon testing ~ 10,000 villagers.

Our findings will allow for the development of interventions to reduce, or even eliminate MRSA through increased hygiene, access to clean water, etc. We hope to uncover other risk factors for community-acquired MRSA not yet understood.

QS-RPHR Census Summary of Data Sets

Village Level Census:

• Village name and GIS code
• Rate of change of village population
• Type of “Municipal” leadership
• Number of Self-Help Groups
• Police Services
• Geo-referenced inventory of: Community centers, PDS/Ration shops, Police stations, Banks, Post Offices, Libraries, Places of Worship, Burial and Cremation grounds, Food Establishments, Sources of drinking water, Number of irrigation ponds, Community toilets/public latrines, Public Transit Terminals/Stops, Industries that are noxious air and water polluters, Industries with 50+ employees, schools/educational institutions
• Type(s) of water treatment for drinking water
• Disposal system(s) for liquid waste
• Availability of government-supported employment schemes
• Availability of other government or NGO sponsored development programs/projects
• Access to Public Transit
• Types of industries in the village and immediate vicinity
• Proximity/Access to SRM Health Services
• Proximity/Access to Other Health Care providers
• School/educational institution database: list, Ratio number of teachers to students to classrooms, Services available to children and mothers, Type of structure, Floor type, Kitchen, stove, ventilation, Source(s) of drinking water, Types of water treatment for drinking water, Type(s) of sanitation used

Household Level Census:

• Religion
• Primary Language used and use of English
• Community/Caste
• Places of worship frequented by household members
• Community centres frequented by household members
• Access to communication channels
• Land ownership and farming
• Details on dwelling tenure
• Details on dwelling structure
• Primary and secondary sources of water for drinking/cooking, washing/hygiene
• Individual and Household sanitation
• Care of animals - how many, location and sanitation
• Health services utilization
• Details on household income sources
• Expenditures and durable goods
• Nutrition and Vulnerability
• Relative prosperity over time in the village

“General” Individual Level Census (males and females 10 years of age and older):