Community-wide medical entomology training for medical practitioners. (Review Article).

MEDICAL STUDENT TRAINING (the 4-year standard course) has changed dramatically since World War II. The amount of basic biological information that each medical student is required to master in the preclinical curriculum has vastly increased; coverage of many traditional, classical disciplines has, therefore, been dropped to make way for voluminous information in rapidly expanding areas such as molecular biology, genetic testing/counseling, neuroscience, and pharmacology. (1'2) Examples of classic disciplines dropped to make way for new ones include parasitology and medical entomology. The Association of American Medical Colleges maintains a detailed comparison of curricula of participating American and Canadian medical schools as an online searchable database named CurrMIT. (3) A recent search of CurrMIT using the keyword "arthropods" revealed that only 11 of 120 participating institutions include arthropods in course content. For most of these institutions, information on arthropods comprises only a small pa rt of a course in microbiology or pathology.

Designers of medical school curricula may be assuming that information pertaining to the pathogenesis and identification of arthropods is a component of the training of medical laboratory technologists/clinical laboratory scientists. Two organizations that administer national examinations to certify clinical laboratory scientists, however, do not include medical entomology as part of the examination content. The American Society of Clinical Pathologists has recommended that material related to arthropods should be "deleted or should not be included in the curriculum" for medical technology. (4) The National Gredentialing Agency for Laboratory Personnel provides a detailed content-outline of the certification examination for clinical laboratory sciences. (5) A thorough search of this content-outline revealed that medical entomology is not even considered important in the knowledge base of an entry-level clinical laboratory scientist. The question then becomes, which, if any, health care professional is being t rained in medical entomology?

Unless another major war is fought in the tropics, it is unlikely that courses in medical entomology and parasitology will return to medical training. The best that can be hoped for is inclusion of a block of material on medical parasitology within medical microbiology courses, and inclusion of a few medical entomology lectures (perhaps including laboratory experience) within that medical parasitology block. There is, however, a definite need for broader coverage of these subjects. The importance of entomology and parasitology in health-care-worker training is highlighted by recent examples of vector-borne tropical diseases being introduced into the urban environment by rapid modem air travel. The latest example of this is the introduction of West Nile encephalitis to the eastern United States. (6) In fact, a large portion of tropical diseases are caused by or transmitted by arthropods and parasites. (7) Immigration, both legal and illegal, combined with rapid international air travel, increasingly bring these diseases into industrialized countries. (8) Compounding the situation, the number of international departures from airports in the United States doubled in a 12-year span, climbing from 20 million in 1983 to nearly 40 million in 1995; more than 50% of those departures each year were bound for tropical countries. (9) A report by the Institute of Medicine has identified "increases in travel and commerce" as a major contributor to infectious disease emergence and reemergence. (10) Even a cursory scan of the medical literature will yield numerous citations of imported cases of myiasis, malaria, yellow fever, dengue, intestinal parasites, and West Nile encephalitis, all of which are related to various insects or parasites. Who is going to be able to recognize arthropod or worm pests in the clinical set ting? Identification of these organisms and subsequent advice on treatment, prevention, and control are complex issues for which medical technologists should not be the solely responsible. One of us (J.G.) often gets entomologic specimens for identification from laboratory personnel (specimens originally sent from physicians) who do not know to which major group the organism belongs. In one such recent case, a soft tick (family Argasidae) was removed from a patient's. ear by a physician who called it a "baby crab". Additional physician training is clearly needed. Just as is the case with microbial agents, treatment or control recommendations for arthropod problems hinge on correct identification, a skill that is best acquired with hands-on training.

DESCRIPTION OF TRAINING EVENTS IN MISSISSIPPI

To address the need for entomology training in Mississippi, we developed and conducted a 1-day continuing medical education (CME) course entitled, "Entomology for the Medical Practitioner." It was held twice (January 18, 1995, and October 29, 1999) at the University of Mississippi Medical Center. Announcements and registration forms for the event were sent statewide to physicians in 3 specialties (family practice, dermatology, and emergency medicine), as well as to nurse-practitioners, medical technologists, and toxicologists (poison control center personnel). The first event in 1995 consisted of 3 lectures on medical entomology, a case-studies session, and a laboratory session. The 1999 event was modified to include an additional entomology lecture and a treatment lecture taught by a physician from a local emergency department. The topics of the medical entomology lectures covered (1) direct effects, such as bites and stings; (2) indirect effects, such as disease transmission and insect allergies; (3) lesion s caused by arthropods; and (4) ticks and tick-borne diseases. The case-studies session was essentially a group activity, involving scenarios of real or imagined arthropod-problems. The group was challenged to determine possible causes and remedies. Laboratory sessions included demonstration of microscopic and gross specimens of all of the major arthropod parasites of humans. "Unknown" specimens were provided for the students to identify, and self-tests were administered. In both cases, the textbook used was Physician's Guide to Arthropods of Medical Importance. (11) Other medical entomology texts, such as Medical Entomology for Students, (12) could easily be substituted, however.

Both CME-events were well-attended and received excellent evaluations regarding their form, structure, and relevance. The sessions in 1995 and 1999 drew 16 participants and 12 participants, respectively. Results of the course evaluations revealed that all participants rated the events as "excellent" meetings that were "about right" in length (Table). The majority of respondents said that the activity enhanced their current knowledge.

CONCLUSION

While many of the most serious insect-related health problems and vector-borne diseases do not ordinarily occur in the United States (although many of them do), international travel has created a global village in which tropical maladies are easily imported. Most recently, increases in "adventure vacations" and ecotourism have contributed to the spread of tropical infections. Accordingly, there will certainly be an ongoing need for physician training in medical entomology. Perhaps the CME events described herein will serve as a model for other states.

TABLE. Excerpts From Course Evaluations From "Entomology for the Medical
Practitioner", October 29, 1999

Question                                         Percent Marking
Asked                                Response     That Response

What overall rating would you give   Excellent        100%
 the entire meeting?

Was the length of the meetings:     About right       100%

To what degree did this activity     Very much         58%
 enhance your current knowledge?     Moderate          42%

To what degree will you use the      Very much         42%
 information from this activity in   Moderate          50%
 your clinical practice?

Were your personal objectives for    Very much         92%
 attending this course satisfied?    Moderate           8%

References

(1.) Downie RS, Charlton B, Calman KG, et al: The Making of a Doctor. New York, Oxford University Press, 1992

(2.) Pope AN, Rall DP, eds: Environmental Medicine: Integrating a Missing Element into Medical Education. Washington, DC, National Academy Press, 1995

(3.) Association of American Medical Schools: Curriculum management and evaluation web site. Available at: http://www.aamc.org/meded/curric/start.htm. Accessed August 28, 2001. [Database password-restricted to AAMC members only]

(4.) American Society of Clinical Pathologists: Technical curricula for MT and MLT programs. Available at: http://www.ascp.org/bor/directors/tech_mt. Accessed September 6, 2001

(5.) National Credentialing Agency for Laboratory Personnel: NCA examinations. 2001. Available at: http://www.ncainfo.org/outlines.html. Accessed September 6, 2001

(6.) Peterson LR, Roehrig JT: West Nile virus: a reemerging global pathogen. Emerg Infect Dis 2001; 7:611-614

(7.) Goddard J: Arthropods and medicine. J Agromed 1998; 5:55-83

(8.) Cunningham NM: Lymphatic filariasis in immigrants from developing countries. Am Fam Physician 1997; 55:119-120

(9.) Gubler DJ: Arboviruses as imported disease agents: the need for increased awareness. Arch Virol 1996; 11:21-32

(10.) Scheld WM, Armstrong D, Hughes JM (ed): Emerging Infections. Washington, DC, ASM Press, Vol 1, 1998

(11.) Goddard J: Physician's Guide to Arthropods of Medical Importance. Boca Raton, Fla, CRC Press, 3rd Ed, 2000

(12.) Service MW: Medical Entomology for Students. London, Chapman and Hall, 1996

RELATED ARTICLE: KEY POINTS

* Classic biological disciplines such as medical entomology and parasitology have mostly been dropped from formal medical education curricula nationwide.

* Increased international travel and establishment of a global village contribute to importation of exotic, arthropod-borne tropical diseases.

* This paper describes a community-wide continuing medical education event to provide local physicians with medical entomology training, including topics covered, format, and course evaluations.

From the Mississippi State Department of Health and the University of Mississippi Medical Center, Jackson.

Reprint requests to Jerome Goddard, PhD, Mississippi State Department of Health, 570 East Woodrow Wilson Ave, PO Box 1700, Jackson, MS 39215-1700.