Data collection, processing, validation, and verification

Protocol for establishing an Adaptive Diseases control Expert Programme in Tanzania (ADEPT) for integrating care of communicable and non-communicable diseases using tuberculosis and diabetes as a case study

INTRODUCTION

Most sub-Saharan African countries endure a high burden of communicable infections but also face a rise of non-communicable diseases (NCDs). Interventions targeting particular epidemics are often executed within vertical programmes. We establish an Adaptive Diseases control Expert Programme in Tanzania (ADEPT) model with three domains; stepwise training approach, integration of communicable and NCDs and a learning system. The model aims to shift traditional vertical programmes to an adaptive diseases management approach through integrating communicable and NCDs using the tuberculosis (TB) and diabetes mellitus (DM) dual epidemic as a case study. We aim to describe the ADEPT protocol with underpinned implementation and operational research on TB/DM.

METHODS AND ANALYSIS

The model implement a collaborative TB and DM services protocol as endorsed by WHO in Tanzania. Evaluation of the process and outcomes will follow the logic framework. A mixed research design with both qualitative and quantitative approaches will be used in applied research action. Anticipated implementation research outcomes include at the health facilities level for organising TB/DM services, pathways of patients with TB/DM seeking care in different health facilities, factors in service delivery that need deimplementation and the ADEPT model implementation feasibility, acceptability and fidelity. Expected operational research outcomes include additional identified patients with dual TB/DM, the prevalence of comorbidities like hypertension in patients with TB/DM and final treatment outcomes of TB/DM including treatment-related complications. Findings will inform the future policies and practices for integrating communicable and NCDs services.

ETHICS AND DISSEMINATION

Ethical approval was granted by The National Research Health Ethical Committee (Ref-No. NIMR/HQ/R.8a/Vol.IX/2988) and the implementation endorsed by the government authorities. Findings will be proactively disseminated through multiple mechanisms including peer-reviewed journals, and engagement with various stakeholders' example in conferences and social media.

Development of site profiles for dose reconstruction used in worker compensation claims

For the purpose of dose reconstruction, personal dosimeter data and measured intakes through bioassay analysis (i.e., in-vivo and in-vitro measurements) should be used whenever possible and given precedence over area monitoring data, survey data, or source term data. However, this is not always possible. A worker's exposure record may be incomplete or missing, or, based on directives and guidelines at the time, a worker may not have been monitored during his or her time of employment. In an effort to recognize, analyze, and incorporate all possible considerations of potential exposures, the National Institute for Occupational Safety and Health Radiation Dose Reconstruction Program developed "site profiles" for all of the major U.S. Department of Energy sites and Atomic Weapons Employer sites. Site profiles are technical documents that (1) provide a brief, general overview of the site; (2) identify the facilities on site with a brief description of the processes and radionuclides used in these processes; (3) contain detailed information on the historical detection limits for film, thermoluminescent dosimeter, and bioassay measurements that are used by the dose reconstructor to interpret a worker's available monitoring records; and (4) provide important supporting information for the dose reconstructor to use if the monitoring data are inadequate or unavailable. When a complete set of monitoring data for an individual is unavailable, it is the parameters in the site profile that are of the most use to the dose reconstructor. These parameters include facility monitoring data (by radionuclide, mechanism of intake, year of exposure, location within a facility); occupational medical x rays and techniques used; environmental measurements (by area on site, radiation type, energy range); minimum detectable activities of the types and kinds of instruments used to detect the different radionuclides; specific source terms (quantities of material and their molecular form) within each facility or process; and specifics of the overall dosimetry programs as they evolved over time. An additional benefit of having a site profile for a site is that it promotes consistency among the numerous health physicists that are working on the project. Resources used in the development of site profiles include technical basis documents for external and internal dosimetry programs, facility descriptions, environmental reports, safety analysis reports, input from past and present site workers, and other reports that have been written to describe the workplace environments within the facilities.

Radiation Dose Reconstruction Program of the National Institute for Occupational Safety and Health: overview

Over the past 65 years, hundreds of thousands of workers have been engaged in nuclear weapons-related activities for the U.S. Department of Energy or its predecessor agencies. To date, almost 27,000 such employees (or their survivors) have filed claims under Part B of the Energy Employees Occupational Illness Compensation Program Act of 2000, which provides monetary compensation and medical benefits to energy employees who have developed certain types of cancer that have been determined, under the guidelines of the program, to have resulted from occupational radiation exposure covered under the Act. Although it is difficult to predict the number of cancer claims that will be evaluated under this program, the number could double or triple. In each case, the processing of a claim requires that the National Institute for Occupational Safety and Health reconstruct the radiation dose received by the employee followed by a determination by the U.S. Department of Labor as to whether the employee was "at least as likely as not" to have sustained the cancer as a result of his or her occupational exposure to ionizing radiation. Although some of the dose assessments are straightforward, many are extremely complex due to (1) missing, non-interpretable, or undocumented records; (2) a wide variety of external and internal exposure conditions; and/or (3) highly variable work assignments and work loads. The program objectives are to process claims in an effective, efficient, and timely manner. One of the initial challenges was to develop the necessary infrastructure to meet these objectives. Subsequent challenges included documenting that assessments are fair and scientifically consistent. Ensuring that each claimant receives the "benefit of the doubt" in any cases where the required background information and data are ambiguous or not available is also an important objective. Fortunately, there are some aspects of the processing requirements that have tended to reduce the complexity, two examples being that compensation is based on exposures that occurred during covered employment after a cancer has developed and that the required dose estimates are for individual body organs, not effective doses. Throughout the process, every effort has been made to ensure that the dose assessments have the support of the best available science.

The NIOSH Radiation Dose Reconstruction Project: managing technical challenges

Approximately two years after promulgation of the Energy Employees Occupational Illness Compensation Program Act, the National Institute for Occupational Safety and Health Office of Compensation and Analysis Support selected a contractor team to perform many aspects of the radiation dose reconstruction process. The project scope and schedule necessitated the development of an organization involving a comparatively large number of health physicists. From the initial stages, there were many technical and managerial challenges that required continuous planning, integration, and conflict resolution. This paper identifies those challenges and describes the resolutions and lessons learned. These insights are hopefully useful to managers of similar scientific projects, especially those requiring significant data, technical methods, and calculations. The most complex challenge has been to complete defensible, individualized dose reconstructions that support timely compensation decisions at an acceptable production level. Adherence to applying claimant-favorable and transparent science consistent with the requirements of the Act has been the key to establishing credibility, which is essential to this large and complex project involving tens of thousands of individual stakeholders. The initial challenges included garnering sufficient and capable scientific staff, developing an effective infrastructure, establishing necessary methods and procedures, and integrating activities to ensure consistent, quality products. The continuing challenges include maintaining the project focus on recommending a compensation determination (rather than generating an accurate dose reconstruction), managing the associated very large data and information management challenges, and ensuring quality control and assurance in the presence of an evolving infrastructure. The lessons learned concern project credibility, claimant favorability, project priorities, quality and consistency, and critical path project activities.

Scientific issues in radiation dose reconstruction

Stakeholders have raised numerous issues regarding the scientific basis of radiation dose reconstruction for compensation. These issues can be grouped into three broad categories: data issues, dosimetry issues, and compensation issues. Data issues include demographic data of the worker, changes in site operations over time (both production and exposure control), characterization of episodic vs. chronic exposures, and the use of coworker data. Dosimetry issues include methods for assessment of ambient exposures, missed dose, unmonitored dose, and medical x-ray dose incurred as a condition of employment. Specific issues related to external dose include the sensitivity, angular and energy dependence of personal monitors, exposure geometries, and the accompanying uncertainties. Those related to internal dose include sensitivity of bioassay methods, uncertainties in biokinetic models, appropriate dose coefficients, and modeling uncertainties. Compensation issues include uncertainties in the risk models and use of the 99th percentile of the distribution of probability of causation for awarding compensation. A review of the scientific literature and analysis of each of these issues distinguishes factors that play a major role in the compensation decision from those that do not.