Standardization of clinical assessment and sample collection across all PERCH study sites

Background. Variable adherence to standardized case definitions, clinical procedures, specimen collection techniques, and laboratory methods has complicated the interpretation of previous multicenter pneumonia etiology studies. To circumvent these problems, a program of clinical standardization was embedded in the Pneumonia Etiology Research for Child Health (PERCH) study. Methods. Between March 201and August 2013, standardized training on the PERCH case definition, clinical procedures, and collection of laboratory specimens was delivered to 33clinical staff at study sites in countries (The Gambia, Kenya, Mali, South Africa, Zambia, Thailand, and Bangladesh), through 3on-site courses and a training website. Staff competency was assessed throughout 2months of enrollment with multiple-choice question (MCQ) examinations, a video quiz, and checklist evaluations of practical skills. Results. MCQ evaluation was confined to 15clinical staff members who enrolled PERCH cases and controls, with scores obtained for >86% of eligible staff at each time-point. Median scores after baseline training were =80%, and improved by 1percentage points with refresher training, with no significant intersite differences. Percentage agreement with the clinical trainer on the presence or absence of clinical signs on video clips was high (=89%), with interobserver concordance being substantial to high (ACstatistic, 0.62-0.82) for of signs assessed. Staff attained median scores of >90% in checklist evaluations of practical skills. Conclusions. Satisfactory clinical standardization was achieved within and across all PERCH sites, providing reassurance that any etiological or clinical differences observed across the study sites are true differences, and not attributable to differences in application of the clinical case definition, interpretation of clinical signs, or in techniques used for clinical measurements or specimen collection.