HIV Immunopaedia.html
REVIEW
Immunology for Clinicians:
A ‘Trojan Horse’ Approach*
Clive M Gray, Shayne Loubser, Carina Kriel, Monica Mercer
National Institute for Communicable Diseases, National Health Laboratory Services, Johannesburg, South Africa
Heather Brookes
University of Johannesburg, Johannesburg
A South African website imparts basic immunology information to clinicians and other health care workers.
To determine how a program for learning immunology could be most
useful for clinicians in South Africa, we consulted with the
country’s 20 leading HIV specialist pediatricians. They told us
that immunology and its underlying concepts were perceived to be
complex and arcane and that there was a need for immunology to be
better integrated into “real-life” clinical practice. Most
saw immunology as predominantly a laboratory science with little
application to clinical practice; this highlighted a gap between
clinical management of patients and theoretical understanding of the
etiology and immunopathogenesis of disease. We speculated that one of
the possible reasons for this perception and knowledge gap is that
immunology is not an independent discipline within the South African
medical curriculum. Instead, it is diffusely integrated into
disciplines such as pathology or internal medicine and is not
specifically provided for during post-degree training.
We initially developed the project Immunopaedia
(www.immunopaedia.org) to help bridge the knowledge gap between
laboratory research and pediatric HIV clinical science. The rationale
for Immunopaedia was based on the paradox between the void in knowledge
of immunology among HIV infectious disease clinicians and the need to
understand and treat the HIV epidemic in South Africa. South Africa has
one of the fastest-growing HIV epidemics with over 5.5 million people
living with HIV, many of whom are young children and women (1). The
2008 national population-based surveys estimated HIV prevalence at
16.9% (2). Provision of treatment and care for such a large population
makes it hard for HIV clinicians to stay informed about the latest
developments in infectious disease. Immunopaedia was thus created to
provide an easy-to-understand summary of the effects of HIV infection
on the immune system, which could facilitate improvement in clinical
practice. Immunopaedia has since progressed to include more general
immunology knowledge that is relevant to other disease conditions. We
use a clinical case–based perspective to target interns in
multiple clinical specialities. Immunopaedia is an alternative to more
advanced online immunology studies that target the basic-science
student (3). Information and educational materials are available
through open access, and the site can be used as an adjunct to more
formal courses or as a stand-alone learning tool.
Our main method is what we have termed the “Trojan Horse” approach. Derived from the Greek Iliad,
“Trojan Horse” has come to mean any ploy or scheme used to
insinuate a rival into a securely protected stronghold. We use clinical
case studies as our Trojan Horse to tempt clinicians, most of whom
consider immunology to have little application to clinical needs, to
engage with immunological concepts relevant to diagnosis and treatment
(see the figure, above). We explain the key immunological points
related to the cases by means of a series of graphics.
The Web site consists of three key components: Clinical Cases,
Immunology Learning, and Treatment and Diagnostics. At present, 34
clinical cases are available on the site. In addition to HIV, clinical
cases span topics such as hypersensitivity, tuberculosis (TB)
immunopathology, primary and secondary immunodeficiencies, drug
responses, gastrointestinal disorders, autoimmunity, and malignancies.
Each of our cases is used to examine an immunological concept that
leads to greater understanding of the human immune system. For example,
a case of a 14-year-old boy presenting with severe hip pain allowed us
to discuss ankylosing spondylitis and to explore the concept of mimicry
and the “arthritogenic peptide” hypothesis. The case of
repeated apnea and infections in a premature infant allowed us to
highlight “physiological immunodeficiency” caused by
impaired humoral and cellular responses in premature infants, a
situation that leaves such infants vulnerable to both viral and
bacterial pathogens. Another presenting case was an 8-month-old boy
with recurrent infections. We explored the most likely hypothesis, that
the mother had a primary HIV-1 infection during pregnancy in the third
trimester and that the child was infected perinatally before maternal
seroconversion. These are real-life cases, and in the last-mentioned
case, as often in real life, the underlying immunological problem may
not be clear.
Each case discussion provides, in consecutive windows, patient
presentation, history, differential diagnosis, examination,
investigations, discussion, treatment, and a final outcome. Related
case studies are cross-referenced. Users then evaluate their knowledge
and understanding of the concepts in the case study by means of
questions accompanied by explanations. To earn the full quota of
continuing medical education (CME) points, the user can complete five
multiple choice questions for each case study that are freely available
but require log-in information. Integral to our approach with each case
study is the use of clear graphics to explain the immunological basis
and mechanisms underlying the condition. The graphics can be downloaded
freely as a PDF and used for offline reference or for further teaching
tools.
The second key component, Immunology Learning, is divided into three
main areas: “Immunology” (dealing with the basics),
“Childhood Diseases and Vaccinations” (dealing with
hypersensitivity reactions and immune reconstitution, for example), and
“Infections” (dealing with a range of infections from
rickettsia to Guillain-Barré syndrome).
The third key component, Treatment and Diagnostics, covers
information related to TB and antiretroviral (ARV) drugs, modes of drug
action, the HIV life cycle, and specific guidelines for treatment. The
“Diagnostic Tools” section provides laboratory assay
information, such as enzyme-linked immunosorbent assays (ELISAs),
polymerase chain reactions (PCRs), and flow cytometry.
Immunopaedia provides links to other Web sites that focus on medical
and general aspects of HIV, pediatrics, and treatment guidelines. The
design of the Web site is such that the user can easily find a source
of information in the form of a case study, a graphic, or a scientific
article on specific immunological conditions. In addition, breaking
scientific news on clinical immunology is posted on the home page and
is updated daily. Registered users are sent a monthly newsletter that
coincides with a monthly clinical case study posting.
For the clinical case component, medical practitioners submit case
studies from their clinics. Our team of clinical and immunology experts
reviews and modifies these case studies for presentation on the Web
site (see the first figure). The rationale behind this approach is that
case studies from, or closely related to, real situations are effective
learning tools (4). The case-study approach is a form of experiential
learning; it integrates practice, knowledge, and skills that further
equip clinicians in their professional work (5). As the user reads
through the case study on the site, dividing the case study into stages
in separate windows, the user is challenged to think about and predict
a possible diagnosis based on the clinical evidence he or she has just
read. This process is similar to the way a clinician might operate on
the job, and the approach fosters lateral and critical thinking, as
well as self-guided learning (6).
Immunopaedia also includes a workshop component as a follow-up to
the online material (see the second figure). We use the workshops to
evaluate our new case-study material before posting it on the Web site,
and our teaching team travels to medical schools within South Africa to
hold 3-hour sessions for medical interns who are specializing in
pediatrics, pathology, or internal medicine. The aim of the workshops
is to create greater awareness and increased use of Immunopaedia as a
learning site for clinical immunology.
The monthly average number of unique users was 320 in 2007;
1518 in 2008; 2326 in 2009; and 1723 in 2010 (through June). Since the
site first went live, we have received a total of 87,550 visitors, of
which 11,520 have spent more than 5 minutes on the site. Each user who
completes a case study earns three CME points, and in total, we have
awarded 699 CME points over 3 years. We currently have 892 registered
users.
Future directions for Immunopaedia involve the expansion of
our user base to include point-of-care clinicians for the ARV drug
roll-out in South Africa. We will use clinical case studies to
highlight common diagnostic decision points as a mechanism to educate
clinicians on laboratory tools and interpretation of results.
Immunopaedia is an immediate source of information for professionals
and represents an effective means for learning and dissemination of
immunology information. Our aim is to integrate immunology into
clinical options for patient management.
References and Notes
1. S. S. Abdool Karim, Q. Abdool Karim, HIV/AIDS in South Africa (Cambridge Univ. Press, Cambridge, ed. 2, 2010).
1. S. S. Abdool Karim, Q. Abdool Karim, HIV/AIDS in South Africa (Cambridge Univ. Press, Cambridge, ed. 2, 2010).
2. UNAIDS, 2009: AIDS Epidemic Update; www.unaids.org.
2. UNAIDS, 2009: AIDS Epidemic Update; www.unaids.org.
3. N. Debard et al., Nat. Rev. Immunol. 5, 736 (2005).
3. N. Debard et al., Nat. Rev. Immunol. 5, 736 (2005).
4. C. Davis, E. Wilcock, Teaching Materials Using Case Studies, The UK
Centre for Materials Education;
www.materials.ac.uk/guides/casestudies.asp.
4. C. Davis, E. Wilcock, Teaching Materials Using Case Studies, The UK
Centre for Materials Education;
www.materials.ac.uk/guides/casestudies.asp.
5. L. Maguire, K. Lay, J. Peters, J. Scholarship Learn. Teach. 9, 93 (2009).
5. L. Maguire, K. Lay, J. Peters, J. Scholarship Learn. Teach. 9, 93 (2009).
6. C. Kreber, Teach. High. Educ. 6, 217 (2001).
6. C. Kreber, Teach. High. Educ. 6, 217 (2001).
7. Immunopaedia (www.immunopaedia.org/) initially received funding
through the Elizabeth Glaser Pediatric AIDS Foundation International
Leadership Award to C.M.G. in 2004. We have also received funding
through South African educational grants, as well as grants for
implementing new learning technology, through the National Institute of
Allergy and Infectious Diseases, NIH. Immunopaedia is a result of
collaborative ventures with many clinicians and scientists.
7. Immunopaedia (www.immunopaedia.org/) initially received funding
through the Elizabeth Glaser Pediatric AIDS Foundation International
Leadership Award to C.M.G. in 2004. We have also received funding
through South African educational grants, as well as grants for
implementing new learning technology, through the National Institute of
Allergy and Infectious Diseases, NIH. Immunopaedia is a result of
collaborative ventures with many clinicians and scientists.
*SPORE Science Prize for Online Resources in Education) Series
Winner (www.sciencemag.org/special/spore/). Corresponding author: C
Gray (cgray@nicd.ac.za).
From Science Vol. 329, 24
September 2010, pp. 1613-1614. Reprinted with permission from the
American Association for the Advancement of Science.
Trojan Horse
approach. Immunopaedia uses a case study to lure clinicians into
learning immunology. Shown are the steps followed for each case before
posting on the Web site. The case is used to underpin an immunology
concept.
About the authors
Clive Gray, founder of Immunopaedia, has a PhD in immunology
and conducts research on HIV/AIDS in South Africa. He received the
Elizabeth Glaser Pediatric AIDS Foundation International Leadership
Award, which has allowed the development of Immunopaedia. Shayne
Loubser writes the immunology materials and produces the
computer-generated graphics for each case study. Carina Kriel is the
curator and coordinator of the Web site and oversees all administrative
aspects. Monica Mercer (not pictured) holds an MD and is a clinical
materials writer and leads the development of educational materials.
Heather Brookes (not pictured) has a PhD in language, literacy, and
culture and is a consultant for Internet learning. From left to right:
Shayne Loubser, Clive Gray, and Carina Kriel.
Workshop participants
evaluate case study material. Participants of workshops come from
tertiary teaching hospitals within South Africa and include interns
specialising in paediatrics, pathology, and internal medicine.