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Volume
2:
No. 2, April 2005
ESSAY
Developing
Academic–Practice Partnerships to Enhance the Integration of Genomics Into
Public Health
Sarah F. Raup, MPH, Kristin Peterson Oehlke, MS, Karen L.
Edwards, PhD
Suggested citation for this article: Raup SF, Oehlke
KP, Edwards KL. Developing academic–practice partnerships to
enhance the integration of genomics into public health. Prev Chronic Dis [serial online]
2005 Apr [date cited]. Available from: URL:
http://www.cdc.gov/pcd/issues/2005/
apr/04_0064.htm.
Abstract
The sequencing of the human genome has provided tools to gain
a better understanding of the role of genes and their interaction
with environmental factors in the development of disease.
However, much work remains in translating discoveries into new
opportunities for disease prevention and health promotion. Both
public health academia and practice have important roles to play
in bridging the gap between the growth in knowledge stemming from
the Human Genome Project and its application in public health.
Recognizing this, the Centers for Disease Control and Prevention,
through the Association of Schools of Public Health, established
Centers for Genomics and Public Health at three schools of public
health in 2001: the University of Michigan, the University of North
Carolina, and the University of Washington. This paper describes the
experience of the University of Washington Center for Genomics
and Public Health in forging partnerships with public health
practitioners to translate genomic advances into public health
practice.
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Introduction
The sequencing of the human genome has provided tools to gain
a better understanding of the role of genes and their interaction
with environmental factors in disease development (1). This
understanding is predicted to improve methods for targeting
interventions aimed at preventing disease and improving health.
In the future, for instance, some believe that individuals will
be screened for genetic susceptibility to common disorders such
as cancer, heart disease, and diabetes, thus yielding
recommendations for personalized prevention strategies. Primary
prevention strategies (such as dietary changes) and secondary
prevention strategies (such as more frequent or earlier
initiation of medical screening) might be used to minimize disease risk (2). Disease management is expected to improve through pharmacogenomics, which promises safer and more efficacious drugs
through the customization of drug therapies based upon an
individual’s genetic makeup (3).
Much work remains, however, in translating discoveries into new opportunities for disease prevention and health promotion. While new reports of gene–disease associations are published almost daily, most are not replicable (4). Most chronic diseases are caused not by a single gene but by the complex interplay among several genes and numerous environmental factors. Therefore, population-based studies that assess the prevalence of genotypes, the disease risk associated with gene variants, and gene–gene and gene–environment interactions are needed (5). Furthermore, as new genetic tests are developed, information on their analytical validity (accuracy with which a genetic characteristic can be detected in a given laboratory test), clinical validity (accuracy with which a test predicts a clinical outcome), clinical utility (likelihood that the test will lead to an improved health outcome), and ethical, legal, and social consequences will be needed to make decisions about their use in clinical and public health practice (6).
The impact of genomic information on risk perception and health behavior change
needs to be better studied, and the added value of targeted interventions based
upon genetic susceptibility compared with population-based prevention recommendations needs to be determined (7). Health care providers and public health professionals will need to be educated about genomics (7) and the public will need to be “genetically literate” if genomics is to be used as a tool for disease prevention (8). Concerns about the use of genomic information (e.g., fear of employment or insurance discrimination) will need to be well understood through community input and adequately addressed as programs or policies incorporating genomics are developed (9).
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The Centers for Genomics and Public Health: Linking Academia and Practice
Both public health academia and practice have important roles to play in bridging the gap between the growth in knowledge stemming from the Human Genome Project and its application in improving health and preventing disease. Recognizing this, the Centers for Disease Control and Prevention’s Office of Genomics and Disease Prevention (CDC OGDP), through the Association of Schools of Public Health, established Centers for Genomics and Public Health at three schools of public health in 2001: the University of Michigan,
the University of North Carolina, and the University of Washington. CDC OGDP, which
since 1997 has taken the lead in promoting the use of genomics to improve health and prevent disease across the lifespan by integrating genomics into public health research, policy, and programs (10), established the
centers with the mission of further integrating genomics into public health practice by increasing the genomics and public health knowledge base; providing technical assistance to local, state, and regional public health systems; and training the public health workforce (11). In 2002, the Institute of Medicine released the report Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century.
The report acknowledged genomics as an important component of public health and
called upon schools of public health to provide students and practicing public
health professionals with a framework for understanding the importance of
genomics to public health (12). Although the centers were established prior to development of this report, they are clearly playing a role in answering this call.
To accomplish their mission of further integrating genomics into public
health practice, particularly in the area of chronic disease prevention, the
centers have developed strong ties with public health practitioners within state
public health agencies and to a lesser extent with practitioners at the local
level. Both academics and practitioners have benefited from partnerships
through new concepts and applications. For instance, though some researchers within schools of public health have long
been engaged in a variety of research activities related to
genomics in the areas of biostatistics, epidemiology,
environmental and occupational health, health policy, health
services, and the behavioral sciences, these researchers rarely engage in public health activities
at the state or local level, and many do not have a solid
understanding of public health in the real world. State health
departments have also been engaged in genomics activities for a
number of years, ranging from newborn screening programs to the
provision of genetic services. However, a 2000 survey of state
health departments conducted by the Council of State and
Territorial Epidemiologists indicated that few state health
departments had begun to consider opportunities for using
genomics outside of the context of maternal and child health,
despite an increasing awareness of the potential application of
genomics in broader public health efforts. Survey respondents
identified lack of resources, proven disease prevention measures,
and outcomes data as potential barriers (13). Through the
centers, academic researchers and public health practitioners
have begun to collaborate more closely, and opportunities for
using genomics to improve public health, particularly in the area
of chronic disease prevention, have been identified as a result.
This paper describes the experience of the University of
Washington Center for Genomics and Public Health (UWCGPH) in
forging partnerships with public health practitioners to
translate genomic advances into public health practice.
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The University of Washington Center for Genomics
and Public Health
At UWCGPH, we have learned a tremendous amount about how to
develop genomics-centered collaborations with state public health
agencies, and these collaborations enhance the work of both
researchers and practitioners. Relationship building is a first
step toward identifying opportunities for collaboration. Despite
the distance that may lie between universities and state health
agencies, face-to-face contact and regular communication is
important to developing relationships. We traveled from Seattle
to the Washington State Health Department (WA DOH) in Olympia,
Wash, numerous times to meet with chronic disease program staff.
We also traveled to the Oregon Health Division (OHD) in Portland to meet with
genetics program staff; Oregon is one of four states currently leading
efforts to integrate genomics into chronic disease with recent funding from the
CDC’s National Center for Chronic Disease Prevention and Health Promotion (14).
We attended several public health conferences and participated in evaluating
state public health programs to learn more about public health activities in
Washington. All these efforts
provided us with the opportunity to better understand the role of
state public health programs and the knowledge and skills held by
public health practitioners, as well as to share information
about our expertise and to work together to identify ways in
which genomics might be integrated into state public health
efforts.
We have found that both formal and informal educational
efforts are effective for stimulating interest in genomics and
encouraging ongoing learning about genomics terms and concepts.
For example, we collaborated with the CDC and other Centers to
develop an animated Web-based module, Genomics for Public
Health Practitioners: The Practical Application of Genomics in
Public Health Practice. Pilot testing of this module
indicates that it addresses many questions raised by public
health practitioners about the use of genomics in public health.
We also identified genomics training courses within the Pacific
Northwest for interested public health practitioners to attend.
While such formal educational efforts are effective in some
instances, we also believe that adding genomics terms and
concepts to the public health lexicon can be accomplished through
ongoing joint efforts between the centers and state health
departments. Over time, a common understanding of terms and
concepts begin to emerge as academics and practitioners work
together to tackle issues.
To address the common notion that genomics is a separate field, rather than
an area that is becoming increasingly relevant to almost every disease and
public health program area, we have learned the value of framing genomics as an
additional tool for informing and addressing public health issues. For example,
we conducted a project to examine the impact of genomics on public health
efforts to reduce asthma morbidity and mortality by using a consultative process that engaged public health
professionals, researchers, health care providers, and community
representatives in dialogue about this issue. The final
conclusions and recommendations drawn from this process are
summarized in a final report, Asthma Genomics: Implications
for Public Health (15). We hope that by engaging a variety of
experts in the examination and dialogue process and by broadly
disseminating the final report, those involved in asthma public
health efforts at the local, state, and national levels will be
more prepared to manage issues that may arise with the use of
genomics to prevent, diagnose, and treat asthma and will think
more about how genomics might play a role in reducing the effects
of this common disease.
Family history, which reflects the consequences of genetic susceptibilities,
shared environment, and common behaviors, is a risk factor for almost all
chronic diseases (7) and can be incorporated into efforts to address many
diseases of public health importance. Although family history has been long collected
within the medical setting, there have been few public health
efforts promoting the use of family history as a tool for disease
prevention (16). In 2003, the CDC funded three sites to answer
many important questions regarding the use of family history in
public heath and preventive medicine (17). In the meantime,
however, state health agencies appear interested in playing a
role in answering important questions, including the following:
Can a simple family history tool accurately and reliably collect information from family
members? Can disease information about an
individual’s relatives be used to inform their risk for
disease? If so, would individuals found to be at increased risk
be more likely to adopt lifestyle changes and participate in
early detection and prevention strategies (16)?
Family history was a topic for which we identified
opportunities for collaboration with the Washington State
Diabetes Prevention and Control Program (DPCP). For example, we
took part in an assessment of the Washington State Diabetes
Public Health System Performance, which was aimed at identifying
the strengths and weaknesses of the statewide diabetes public
health program. Opportunities for improvement resulting from the
assessment included capturing the nonidentified diabetics in the
state, developing a robust research agenda relevant to diabetes
public health practice, and developing strategies to work more
closely with academic partners. To help the WA DOH address these
identified gaps, we proposed to develop a research project
involving the use of family history as a public health tool. The
Washington State Collaborative (WSC) Adult Preventive Services, a systematic
approach to health care quality improvement in which organizations and providers
test procedural innovations and then share their experiences to
accelerate learning and promote widespread implementation of best
practices, was an ideal setting in which to perform this project.
We plan to collaborate with DPCP to collect more structured
family histories as part of the WSC’s quality improvement
efforts, as well as to provide training to physicians regarding
the utility of family history information.
After solid relationships with public health practitioners have
been developed, in which practitioners begin to understand how
genomics can be used as a tool for addressing issues of public
health importance and academics begin to understand how
genomics fits within the context of current public health
programs and priorities, collaborative projects aimed at
integrating genomics into public health are more easily
identified. Funding for collaborative projects is an important
issue, as state health departments often do not have the
resources to carry out special projects.
In some instances,
genomics-related projects can be proposed within the context of
larger public health program proposals. For example, as a result
of our efforts to demonstrate the relevance of family history to
diabetes public health efforts, we were invited by the WA DOH to
present information on the use of family history as a potential
public health tool to those communities submitting proposals to
the U.S. Department of Health and Human Services initiative,
Steps to a HealthierUS. We suggested several potential community projects,
including a community campaign to increase knowledge of family history. By
incorporating family history into a comprehensive disease prevention and health
promotion strategy, the communities would address many objectives of Steps to
a HealthierUS. The
Washington communities received funding, and we plan to assist
them in identifying ways in which family history can be used to
meet their goals.
Proposals also can be developed around other
projects. For example, to evaluate the potential use of family
history information, we are in the process of identifying funding
to pilot a family history tool in a sample of clinics
participating in the WSC. In addition, some projects can be best
implemented in conjunction with the four states that have
obtained funding to address genomics and chronic disease (14).
For example, we are working with the health departments of the
four states in reviewing existing family history questions
included on various state surveys (e.g., Behavioral Risk Factor
Surveillance System) and in developing new questions about family
history for such surveys. Lastly, we have had discussions
with OHD about collaborating on the development of a genomics
awareness campaign for the health agency.
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Benefits of Using Academic–Practice
Collaborations
Because they have only been in existence for two and a half years, it is
difficult to fully assess the benefits of the collaborations the centers have
developed with their state public health agency partners. Several benefits of
these academic–practice partnerships, however, have been casually observed.
Academics have
gained an awareness of what public health practice means,
including an appreciation for the valuable expertise held by
program staff and the day-to-day work they carry out. As a result, many have
become involved in practice-based research, teaching, and service activities
that they would have been less likely to consider prior to the exposure to
public health practice afforded to them through these centers.
State public health departments are also taking better advantage of the
expertise held by public health genomics researchers. For example, requests to
the centers for guest speakers at conferences and representatives for statewide
committees and taskforces have increased. Both academics and practitioners
have come together to identify collaborative projects and opportunities to
participate in research aimed at questions of public health importance.
Lastly, public health students have gained invaluable experience with
real-world public health genomics issues through their involvement in projects
carried out through the centers, creating a new generation of public health
professionals with exposure to genomics in practice. In some cases, public
health departments have benefited because these students have tackled valuable
projects that they otherwise would not have had resources to address.
The academic–practice partnerships created through the centers for Genomics
and Public Health are slowly transforming the landscape of public health
genomics research and practice. The well-traveled bridge between the centers and
state health departments has created partnerships in which both sides benefit
and flourish. The work of academics is informed and enriched by real-world
issues that affect real populations while the work of public health
practitioners is sharpened with the developing knowledge and new approaches the
academy has to offer. This burgeoning synergy, strengthened by time, shared
experiences, and successes, is ultimately greater than the sum of its parts and
will be an important element for the genomics revolution to
maximally benefit public health.
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Acknowledgments
This project is supported by a cooperative agreement with the
Centers for Disease Control and Prevention through the
Association of Schools of Public Health, Grant Number
U36/CCU300430-23.
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Author Information
Corresponding Author: Karen L. Edwards, PhD, Department of
Epidemiology, Box 357236, School of Public Health and Community
Medicine, University of Washington, Seattle WA 98195. Telephone:
206-616-1258. E-mail: keddy@u.washington.edu. The
author is also affiliated with the Institute for Public Health
Genetics, School of Public Health and Community Medicine,
University of Washington, Seattle, Wash.
Author Affiliations: Sarah F. Raup, MPH, Department of
Epidemiology, School of Public Health and Community Medicine,
University of Washington, Seattle, Wash; Kristin Peterson Oehlke,
MS, Minnesota Department of Health, Minneapolis, Minn.
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