The importance of epidemiology – an interview with Rebecca Prevots

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After hearing Rebecca Prevots speak at the second state-of-the-art symposium on nontuberculosis mycobacteria (NTM) infections in April, we at Infectious Diseases Hub took the opportunity to ask more about her work on NTMs and her broader research interests in epidemiology.

Rebecca joined the National Institute of Allergy and Infectious Diseases (NIAID; MD USA) in 2003, focusing on studies related to the epidemiology of tuberculosis and nontuberculous mycobacteria, before becoming chief of the newly created Epidemiology Unit in the Division of Intramural Research in 2007. Currently the Unit is involved in a range of infectious disease research, including studies of nontuberculous mycobacteria, antibiotic resistance, malaria and Zika.

In this interview, Rebecca discusses her research projects, the importance of epidemiology in studying infectious diseases and also the challenges this field currently faces. Find out more below.

First, could you introduce yourself and tell us a bit about your career to date?

I am lucky to have had the opportunity to work as an epidemiologist in a variety of different settings, starting with the public health realm, at the local, federal and international level, including in the NYC Health Department (NY, USA), at the Centers for Disease Control and Prevention (CDC; GA, USA) and at international health organizations such as WHO and PAHO. During college I had an internship at the NYC Health Department, and after I graduated I did a summer project related to HIV and tuberculosis. When I finished I was hired to work full time in the AIDS Surveillance and Epidemiology unit. That experience made me want to continue in public health, and so I went to graduate school to get my Master’s degree in public health and my PhD in epidemiology.

“That experience made me want to continue in public health”

When I finished my PhD I joined the Epidemic Intelligence Service at the CDC, which focuses on investigating outbreaks and using surveillance data and research projects to understand the epidemic dynamics, risk factors and impact of public health interventions.   During my time at CDC I worked in the areas of vaccine preventable diseases as well as on AIDS epidemiology. As part of global cooperation in vaccine preventable disease, I was posted to Brazil from 2000–2002 to serve as a technical advisor for the Pan American Health Organization in the Brasilia office, working with the Brazilian Ministry of Health on measles elimination. I came to the National Institutes of Health (NIH; MD, USA) in 2003 which is a more academic-like research setting, where I use my training in a different way but still rely on the same tools and training.

Could you describe your current research projects at the NIH?

“We have a range of research projects, with a focus in several areas:  nontuberculous mycobacterial disease, antibiotic resistance and vector-borne diseases, including malaria and Zika”

We have a range of research projects, with a focus in several areas:  nontuberculous mycobacterial disease, antibiotic resistance and vector-borne diseases, including malaria and Zika. The type of research projects range from descriptive epidemiology, such as describing the epidemiology of these relatively rare infections including nontuberculous mycobacterial disease, to analyzing clinical and genetic data of people and the mycobacteria or other organisms infecting them to improve our understanding of why some people become sicker than others or  respond better to treatment.. We use a variety of data sources, including administrative claims data, laboratory/microbiology datasets from healthcare systems, as well as data from research protocols at NIAID. We are also involved in developing protocols related to malaria vaccine development, as part of NIAID’s international population-based research collaborations.

How does your research fit in to the wider projects and aims of NIAID?

We seek to add value to the ongoing biomedical research at NIAID by describing the population burden of selected diseases, and also by integrating the molecular, clinical and population information (demographic, geographic, or other population data) to better understand the relative contribution of host and environmental risk factors to disease.

“We seek to add value to the ongoing biomedical research at NIAID by describing the population burden of selected diseases”

The mission of NIAID is to “conduct and support basic and applied research to better understand, treat, and ultimately prevent infectious, immunologic, and allergic diseases.” By conducting epidemiologic research we can both generate and test hypotheses related to risk factors for these diseases. That means that first, we aim to describe the burden and distribution of diseases in populations – how much disease is there, who gets it, is it increasing or decreasing. And second, within the realm of ‘clinical epidemiology’ we aim to describe clinical or other risk factors for disease, including microbial risk factors such as virulence factors of antibiotic resistance, and on the other hand, host genetic variants that influence disease susceptibility. We collaborate with clinical researchers at NIAID to design and analyze data from observational research studies here.

With regards to your research on NTMs, why do you feel this is a research area of unmet need?

“Before we began doing epidemiologic studies on NTM in the US, no data were available to describe the current burden of NTM in this country.”

Before we began doing epidemiologic studies on NTM in the US, no data were available to describe the current burden of NTM in this country. Our initial studies have focused on describing burden and trends. Because NTM pulmonary disease (unlike tuberculosis) is not reportable, it was very difficult to determine whether those patients seen at the NIH clinical center were representative of all patients in the community, or whether they represented a biased subset. In addition, without population based or standardized, systematically collected data, we can’t accurately generate hypotheses or monitor trends.

Finally, this lack of data was a particular challenge for drug developers because it was hard for those working in that arena to justify developing drugs for this condition without knowing how many people are affected and what the ‘market share’ might be.    By using population-based data we now have a better picture of this disease in the US. We are currently conducting research to more fully understand patterns of antibiotic resistance in the US, as well as environmental and behavioral factors that may influence disease risk.

More broadly, how important do you feel the role of epidemiology is in infectious disease research?

Critical. In the old days, if a physician found the bug that made people get sick, some might have thought that the problem was solved. Now we know that just finding the organism is not just enough – epidemiology is an integrative discipline and we need to understand how the host and the environment interact to cause disease. Through using advanced study design and analytic techniques, epidemiologists can use information both about the humans, or hosts, including genetic risk factors, and the organisms.

“Now we know that just finding the organism is not just enough – epidemiology is an integrative discipline and we need to understand how the host and the environment interact to cause disease”

Do you think the field of epidemiology has changed with technological developments in recent years?

Absolutely. The past 10–20 years have seen the advent of ‘Big Data’ with large amounts of data being generated through a variety of sources, including electronic health records and the internet (e.g., Google). In particular, the availability of inexpensive and rapid tools for genetic sequencing has led to an explosion in the amount of information available, and the challenge is now how to handle it.

Finally, what do you consider to be the greatest challenges currently hindering the field of infectious disease epidemiology?

The future of epidemiology faces several challenges. First, as I mentioned previously, we live in an increasingly digital world, with reams of electronic data available for almost everything imaginable, and in multiple layers. These kinds of data range from Google search data, for example, the number searches for ‘flu’, to electronic health data. The challenge is on the one hand, how to find the signal in the noise of ‘Big data’, and secondly, how to develop the expertise to meaningfully analyze ‘Big data’, and also integrate the genomic, molecular and clinical data to understand risk factors for disease susceptibility and progression. The ‘precision medicine’ initiative will greatly increase the scope and amount of genetic data available. We will need increased training of epidemiologists versed in these tools, and improved development and validation of methods for approaching these analytic challenges.

Acknowledgments/Disclosures

Dr. Prevots is supported by the Division of Intramural Research, NIAID, NIH

Further Reading

https://blogs.cdc.gov/genomics/2015/08/11/the-future-of-epidemiology/

http://www.thoracic.org/statements/resources/tb-opi/nontuberculous-mycobacterial-diseases.pdf

Biography

Dr. Prevots began her epidemiology and public health  career at the New York City Department of Health in 1985, working as a public health advisor in the AIDS Surveillance and Epidemiology Unit. From there she went to the University of Michigan, where she earned her M.P.H. in 1988 and her Ph.D. in epidemiology in 1991. Upon completing her Ph.D., she joined the Epidemic Intelligence Service at the Centers for Disease Control and Prevention (CDC). During her time at CDC, she worked primarily on the epidemiology of vaccine preventable diseases, as well as on HIV/AIDS. After joining the National Institute of Allergy and Infectious Diseases (NIAID) at the National Institutes of Health in 2003, she began focusing on studies related to the epidemiology of tuberculosis and nontuberculous mycobacteria. In 2007, she became chief of the newly created Epidemiology Unit in the Division of Intramural Research.  Currently the Unit is involved in a range of infectious disease research, including studies of nontuberculous mycobacteria, antibiotic resistance, malaria, and Zika. [/userpro_private]

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