Frontline Field Epidemiology Training Programs as a Strategy to Improve Disease Surveillance and Response

Investigating the barriers and enablers to outbreak reporting in the Asia-Pacific region: A mixed-methods study protocol

INTRODUCTION

The COVID-19 pandemic has raised concerns about the global capacity for timely outbreak reporting. However, gaps remain in our understanding of barriers and enablers to outbreak reporting, particularly at the local level. Field epidemiology training program (FETP) fellows often participate in the outbreak reporting process as part of both their training and the public health roles they assume after graduating; they therefore represent a potentially valuable source of information for better understanding these barriers and enablers. This study will investigate the barriers and enablers to outbreak reporting through a mixed methods approach that will encompass a review of the existing literature as well as surveying and interviewing FETP trainees and graduates from the Asia-Pacific region.

METHODS

This study will begin with a scoping review of the literature to identify existing evidence of barriers and enablers to outbreak reporting. Based on our findings from the scoping review, we will administer a survey to FETP trainees and graduates from the World Health Organization Western Pacific and South-East Asian Regions and conduct interviews with a subset of survey respondents to investigate the survey findings in more detail. We will summarise and compare the survey results according to various country-level economic and political indicators, and we will employ thematic analysis to evaluate the interview responses. Based on the findings from the scoping review, survey, and interviews, we will construct a model to comprehensively describe the various barriers and enablers to outbreak reporting.

CONCLUSION

This study will contribute to our understanding of the determinants of outbreak reporting across several geographic, political, and economic contexts by eliciting the viewpoints and experiences of persons involved with outbreak reporting, particularly at the local level. This information will help improve the outbreak reporting process, allowing for more timely reporting and helping prevent future outbreaks from becoming pandemics.

Investigating the workforce capacity and needs for animal disease surveillance and outbreak investigation: a mixed-methods study of veterinary services in Vietnam

The need for strengthening national capacities for disease prevention, preparedness, and response is increasingly becoming urgent. Central to this is strengthening existing systems and workforce capacity for disease surveillance and disease outbreak response. This study aimed to evaluate the national capacity and needs of veterinary services in Vietnam in animal disease surveillance and outbreak investigation skills. A cross-sectional, convergent, mixed-methods study was conducted between November 2020 and April 2021. An online questionnaire was administered to government field veterinarians, followed by descriptive and multivariable analyses to understand field capacity, specifically levels of experience in outbreak investigation and animal health surveillance. Semi-structured interviews were conducted with various stakeholders in veterinary services and interview transcripts were coded and thematically analyzed. Qualitative results were used to contextualize quantitative findings from the survey. Overall, 178 field veterinary staff completed the online survey, and 25 stakeholders were interviewed. Eighty percent of respondents reported a high priority for further training in both animal disease surveillance and outbreak investigation. Training and competence were more limited at the district and commune levels, highlighting a gap in capacity at the subnational level. Reasons included a lack of in-depth training opportunities, limited access to resources and high staff turnover. Respondents who completed postgraduate qualifications in epidemiology or Field Epidemiology Training Programs were more likely to have higher levels of experience in animal health surveillance and outbreak investigation. This study identified gaps in knowledge and adoption of practices most often related to local-level or less experienced veterinary staff with limited training opportunities in epidemiology. Findings inform the prioritization of training and planning activities to further enhance the national capacity of veterinary services in Vietnam. Underlying explanations for existing gaps in capacity include inequities in skill development and training opportunities across levels of veterinary staff, gaps in the chain of command and unequal funding across provinces.

Evaluation of the blended public health empowerment program-basic field epidemiology in the Eastern Mediterranean Region

Introduction

The COVID-19 pandemic encouraged the shift toward technology-based learning globally, impacting education systems profoundly. In response to this emerging need, the Eastern Mediterranean Public Health Network (EMPHNET) adapted its Public Health Empowerment Program-Basic Field Epidemiology (PHEP-BFE) to a Blended Learning Model. This study evaluates the Blended PHEP-BFE program in Iraq, Egypt, and Lebanon, focusing on participant reactions and learning outcomes.

Methods

A descriptive evaluation was conducted, aligned with the first two levels of Kirkpatrick's model. Online questionnaires were administered to participants and facilitators through EMPHNET's Learning Management System (LMS). Qualitative and quantitative data were analyzed to assess program effectiveness, satisfaction, and challenges.

Results

A total of 138 PHEP-BFE participants (119 (86.2%) males and 19 (13.8%) females) from Iraq (n = 61), Egypt (n = 66), and Lebanon (n = 11) responded to the questionnaire. The majority of the participants (96.4%) reported that they were satisfied with PHEP-BFE. Notably, 77.5% of participants rated the blended learning program as very good or excellent, 18.1% rated it good, and 3.6% found it average, with a minimal 0.7% expressing dissatisfaction. The majority of participants agreed that the blended PHEP-BFE enhanced their capacity to conduct, review and monitor surveillance data (95.7%), perform descriptive data analysis (94.2%), effectively communicate information with agency staff and the local community (95.7%), write summaries of surveillance findings or outbreak investigations (95.7%), use MS Excel to enter, analyze, and display public health surveillance data (91.3%), prepare and administer an oral presentation for fieldwork (94.9%), and increase their knowledge of fundamental field epidemiology (94.9%). The participants responded positively to the program's content, training duration, learning platform, facilitators and mentors, and fieldwork.

Conclusion

The study showcases the success of the blended PHEP-BFE in diverse contexts, emphasizing positive participant reactions and improved competencies. The evaluation underscores the program's success in advancing public health training in the EMR. Blended learning models prove promising for future FETP initiatives, contributing valuable insights to public health workforce development. Positive outcomes and identified challenges, provide a roadmap for continuous improvement.

Using EpiCore to Enable Rapid Verification of Potential Health Threats: Illustrated Use Cases and Summary Statistics

BACKGROUND

The proliferation of digital disease-detection systems has led to an increase in earlier warning signals, which subsequently have resulted in swifter responses to emerging threats. Such highly sensitive systems can also produce weak signals needing additional information for action. The delays in the response to a genuine health threat are often due to the time it takes to verify a health event. It was the delay in outbreak verification that was the main impetus for creating EpiCore.

OBJECTIVE

This paper describes the potential of crowdsourcing information through EpiCore, a network of voluntary human, animal, and environmental health professionals supporting the verification of early warning signals of potential outbreaks and informing risk assessments by monitoring ongoing threats.

METHODS

This paper uses summary statistics to assess whether EpiCore is meeting its goal to accelerate the time to verification of identified potential health events for epidemic and pandemic intelligence purposes from around the world. Data from the EpiCore platform from January 2018 to December 2022 were analyzed to capture request for information response rates and verification rates. Illustrated use cases are provided to describe how EpiCore members provide information to facilitate the verification of early warning signals of potential outbreaks and for the monitoring and risk assessment of ongoing threats through EpiCore and its utilities.

RESULTS

Since its launch in 2016, EpiCore network membership grew to over 3300 individuals during the first 2 years, consisting of professionals in human, animal, and environmental health, spanning 161 countries. The overall EpiCore response rate to requests for information increased by year between 2018 and 2022 from 65.4% to 68.8% with an initial response typically received within 24 hours (in 2022, 94% of responded requests received a first contribution within 24 h). Five illustrated use cases highlight the various uses of EpiCore.

CONCLUSIONS

As the global demand for data to facilitate disease prevention and control continues to grow, it will be crucial for traditional and nontraditional methods of disease surveillance to work together to ensure health threats are captured earlier. EpiCore is an innovative approach that can support health authorities in decision-making when used complementarily with official early detection and verification systems. EpiCore can shorten the time to verification by confirming early detection signals, informing risk-assessment activities, and monitoring ongoing events.

How do field epidemiologists learn? A protocol for a qualitative inquiry into learning in field epidemiology training programmes

INTRODUCTION

COVID-19 underscored the importance of field epidemiology training programmes (FETPs) as countries struggled with overwhelming demands. Experts are calling for more field epidemiologists with better training. Since 1951, FETPs have been building public health capacities across the globe, yet explorations of learning in these programmes are lacking. This qualitative study will (1) describe approaches to training field epidemiologists in FETP; (2) describe strategies for learning field epidemiology among FETP trainees and (3) explain the principles and practices aligning training approaches with learning strategies in FETP.

METHODS AND ANALYSIS

The research design, implementation and interpretation are collaborative efforts with FETP trainers. Data collection will include interviews with FETP trainers and trainees and participant observations of FETP training and learning events in four FETP in the Western Pacific Region. Data analysis will occur in three phases: (1) we will use the constant comparison method of Charmaz's grounded theory during open coding to identify and prioritise categories and properties in the data; (2) during focused coding, we will use constant comparison and Polkinghorne's analysis of narratives, comparing stories of prioritised categories, to fill out properties of those categories and (3) we will use Polkinghorne's narrative analysis to construct narratives that reflect domains of interest, identifying correspondence among Carr and Kemmis's practices, understandings and situations to explain principles and processes of learning in FETP.

ETHICS AND DISSEMINATION

We have obtained the required ethics approvals to conduct this research at The Australian National University (2021/771) and Taiwan's Ministry of Health and Welfare (112206). Data will not be available publicly, but anonymised findings will be shared with FETP for collaborative interpretation. Ultimately, findings and interpretations will appear in peer-reviewed journals and conferences.

The Field Epidemiology Training Program's Contribution to Essential Public Health Functions in Seven National Public Health Institutes

Objective: This study explores how Field Epidemiology Training Programs (FETP) whose National Public Health Institutes (NPHI) are supported by U.S. Centers for Disease Control and Prevention (CDC) have contributed to strengthening essential public health functions. Methods: We conducted 96 semi-structured interviews with public health experts including NPHI staff, non-NPHI government staff, and staff from non-governmental and international organizations in Cambodia, Colombia, Liberia, Mozambique, Nigeria, Rwanda, and Zambia. We managed data using MAXQDA and employed direct content analysis to derive themes. Results: Three overarching themes emerged in relation to FETPs' role within the NPHIs' public health functions. These themes included contribution to improving country surveillance systems, role in providing leadership in outbreak responses, and strengthening countries' and the NPHIs' surveillance workforce capacity. Participants also shared challenges around FETPs' implementation and suggestions for improvement. Conclusion: The results demonstrate the value of FETPs in strengthening public health systems through building workforce capacity and improving surveillance systems. By identifying the successes of FETPs in contributing to essential public health functions, our findings might inform current and future FETP implementation and its integration into NPHIs.

Strengthening surveillance, disease detection, and outbreak response through Guinea-Bissau's Frontline Field Epidemiology Training Program: a cross-sectional descriptive study

Introduction

the goal of the Field Epidemiology Training Program (FETP) - Frontline is to strengthen the country's surveillance capacity at the district level to prepare and respond to health emergencies, including outbreaks, by training a skilled frontline public health workforce. We describe the FETP - Frontline program, including implementation, structure, achievements, impact, and its role in improving the epidemiological workforce capacity of Guinea-Bissau.

Methods

this cross-sectional descriptive study uses 2015-2019 program data collected through record reviews and historical narratives from FETP students and graduates. We generated descriptive summary statistics using the Guinea-Bissau's FETP-Frontline program database, student assignments, and investigation reports, after reviewing the FETP standardized curriculum and program guidelines.

Results

since its inception in 2016, FETP Frontline has implemented 14 cohorts and trained 198 frontline surveillance officers. Program participants improved surveillance data quality, investigated 51 outbreaks at national and regional levels, and contributed to disease research and surveillance in 227 separate field investigations. Participants frequently responded to priority health emergencies, including clusters or outbreaks of Zika, microencephalies, dengue, yellow fever, anthrax, malaria, and tuberculosis.

Conclusion

Guinea-Bissau's FETP - Frontline program provides a practical example of an effective strategy to strengthen health systems through a well-prepared workforce trained to quickly detect and respond to health threats.

Evaluation of the public health empowerment program in the Eastern Mediterranean region

Background

The Public Health Empowerment Program (PHEP) is a 3-month training program for frontline public health staff to improve surveillance quality and strengthen the early warning system capacities. Studies evaluating the program and its impact on the health systems in the Eastern Mediterranean Region (EMR) are lacking. Therefore, this study aimed to assess the level of PHEP graduates' engagement in field epidemiology activities, assess their perceived skills and capacity to perform these activities and assess the extent to which PHEP helped the graduates to perform field epidemiology activities.

Methods

A descriptive evaluation study was conducted based on levels 3 and 4 of Kirkpatrick's model for evaluating training programs to assess the change in graduates' behavior and the direct results of the program. Data were collected using two online surveys targeting PHEP graduates and programs' directors/ technical advisers.

Results

A total of 162 PHEP graduates and 8 directors/ technical advisers participated in the study. The majority of PHEP graduates reported that they are often involved in activities such as responding to disease outbreaks effectively (87.7%) and monitoring surveillance data collection (75.3%). High proportions of PHEP graduates rated their skills as good in performing most of field epidemiology activities. The majority of graduates reported that the PHEP helped them much in conducting, reviewing, and monitoring surveillance data collection (92%), responding effectively to public health events and disease outbreaks (91.4%), and communicating information effectively with agency staff and with the local community (85.2%).

Conclusion

PHEP appears to be an effective program for improving the public health workforce's skills and practices in epidemiological competencies in the EMR. PHEP strengthened the engagement of the graduates in most field epidemiology activities, especially during COVID-19.

Evaluation of Ethiopia's field epidemiology training program - frontline: perspectives of implementing partners

BACKGROUND

Field Epidemiology Training Program (FETP) has been adopted as an epidemiology and response capacity building strategy worldwide. FETP-Frontline was introduced in Ethiopia in 2017 as a three-month in-service training. In this study, we evaluated implementing partners' perspectives with the aim of understanding program effectiveness and identifying challenges and recommendations for improvement.

METHODS

A qualitative cross-sectional design was utilized to evaluate Ethiopia's FETP-Frontline. Using a descriptive phenomenological approach, qualitative data were collected from FETP-Frontline implementing partners, including regional, zonal, and district health offices across Ethiopia. We collected data through in-person key informant interviews, using semi-structured questionnaires. Thematic analysis was conducted, assisted with MAXQDA, while ensuring interrater reliability by using the consistent application of theme categorization. The major themes that emerged were program effectiveness, knowledge and skills differences between trained and untrained officers, program challenges, and recommended actions for improvement. Ethical approval was obtained from the Ethiopian Public Health Institute. Informed written consent was obtained from all participants, and confidentiality of the data was maintained throughout.

RESULTS

A total of 41 interviews were conducted with key informants from FETP-Frontline implementing partners. The regional and zonal level experts and mentors had a Master of Public Health (MPH), whereas district health managers were Bachelor of Science (BSc) holders. Majority of the respondents reflected a positive perception towards FETP-Frontline. Regional and zonal officers as well as mentors mentioned that there were observable performance differences between trained and untrained district surveillance officers. They also identified various challenges including lack of resources for transportation, budget constraints for field projects, inadequate mentorship, high staff turnover, limited number of staff at the district level, lack of continued support from stakeholders, and the need for refresher training for FETP-Frontline graduates.

CONCLUSIONS

Implementing partners reflected a positive perception towards FETP-Frontline in Ethiopia. In addition to scaling-up the program to reach all districts to achieve the International Health Regulation 2005 goals, the program also needs to consider addressing immediate challenges, primarily lack of resources and poor mentorship. Continued monitoring of the program, refresher training, and career path development could improve retention of the trained workforce.

Development of core competencies for field veterinary epidemiology training programs

A workforce with the adequate field epidemiology knowledge, skills and abilities is the foundation of a strong and effective animal health system. Field epidemiology training is conducted in several countries to meet the increased global demand for such a workforce. However, core competencies for field veterinary epidemiology have not been identified and agreed upon globally, leading to the development of different training curricula. Having a set of agreed core competencies can harmonize field veterinary epidemiology training. The Food and Agriculture Organization of the United Nations (FAO) initiated a collective, iterative, and participative process to achieve this and organized two expert consultative workshops in 2018 to develop core competencies for field veterinary epidemiology at the frontline and intermediate levels. Based on these expert discussions, 13 competencies were identified for the frontline and intermediate levels. These competencies were organized into three domains: epidemiological surveillance and studies; field investigation, preparedness and response; and One Health, communication, ethics and professionalism. These competencies can be used to facilitate the development of field epidemiology training curricula for veterinarians, adapted to country training needs, or customized for training other close disciplines. The competencies can also be useful for mentors and employers to monitor and evaluate the progress of their mentees, or to guide the selection process during the recruitment of new staff.

Field epidemiology capacity of the national veterinary services of Lao PDR: An online survey

Introduction

Capacity in veterinary epidemiology is critical to detect, respond and control infectious diseases. Laos veterinary service is limited by having only a small number of veterinarians who graduated from overseas. Animal science graduates support the majority of the Laos veterinary services. The veterinary program was established in 2009 at the National University of Laos. We aimed to understand the national veterinary epidemiology capacity and identify gaps and training needs.

Method

A cross-sectional online study was conducted in 2021 targeting central (DLF), provincial (PAFO) and district (DAFO) government animal health officers and veterinary/animal science academics (n = 332). The questionnaire addressed skills, experiences and perceived training needs in outbreak investigation, disease surveillance, data management and analysis, epidemiological surveys, One Health, leadership and communication and biosecurity. A descriptive analysis was performed and associations between demographic factors and epidemiological skills were examined.

Results and discussion

In total, 205 respondents completed the questionnaire (61.8% response rate). Respondents reported low or no skills and experience in data management and analysis, epidemiological surveys and One Health. In contrast, higher but limited skills and experiences were reported in outbreak investigation, disease surveillance and biosecurity. Previous epidemiology training was primarily associated with stronger experiences in veterinary epidemiology competencies, followed by respondents that had completed a veterinary degree, highlighting the value of the currently available epidemiology training and veterinary-trained personnel in Lao PDR. This study could help inform the Laos government in its policy planning for field veterinary epidemiology capacity and future training.

Health System Resilience in the Eastern Mediterranean Region: Perspective on the Recent Lessons Learned

BACKGROUND

Public health has a pivotal role in strengthening resilience at individual, community, and system levels as well as building healthy communities. During crises, resilient health systems can effectively adapt in response to evolving situations and reduce vulnerability across and beyond the systems. To engage national, regional, and international public health entities and experts in a discussion of challenges hindering achievement of health system resilience (HSR) in the Eastern Mediterranean Region, the Eastern Mediterranean Public Health Network (EMPHNET) held its seventh regional conference in Amman, Jordan, between November 15 and 18, 2021, under the theme "Towards Resilient Health Systems in the Eastern Mediterranean: Breaking Barriers." This viewpoint paper portrays the roundtable discussion of experts on the core themes of that conference.

OBJECTIVE

Our aim was to provide insights on lessons learned from the past and explore new opportunities to attain more resilient health systems to break current barriers.

METHODS

The roundtable brought together a panel of public health experts representing Field Epidemiology Training Programs (FETPs), Centers for Disease Control and Prevention in Atlanta, World Health Organization, EMPHNET, universities or academia, and research institutions at regional and global levels. To set the ground, the session began with four 10-12-minute presentations introducing the concept of HSR and its link to workforce development with an overall reflection on the matter and lessons learned through collective experiences. The presentations were followed by an open question and answer session to allow for an interactive debate among panel members and the roundtable audience.

RESULTS

The panel discussed challenges faced by health systems and lessons learned in times of the new public health threats to move toward more resilient health systems, overcome current barriers, and explore new opportunities to enhance the HSR. They presented field experiences in building resilient health systems and the role of FETPs with an example from Yemen FETP. Furthermore, they debated the lessons learned from COVID-19 response and how it can reshape our thinking and strategies for approaching HSR. Finally, the panel discussed how health systems can effectively adapt and prosper in the face of challenges and barriers to recover from extreme disruptions while maintaining the core functions of the health systems.

CONCLUSIONS

Considering the current situation in the region, there is a need to strengthen both pandemic preparedness and health systems, through investing in essential public health functions including those required for all-hazards emergency risk management. Institutionalized mechanisms for whole-of-society engagement, strengthening primary health care approaches for health security and universal health coverage, as well as promoting enabling environments for research, innovation, and learning should be ensured. Investing in building epidemiological capacity through continuous support to FETPs to work toward strengthening surveillance systems and participating in regional and global efforts in early response to outbreaks is crucial.

Improving the effectiveness of Field Epidemiology Training Programs: characteristics that facilitated effective response to the COVID-19 pandemic in Uganda

BACKGROUND

The global need for well-trained field epidemiologists has been underscored in the last decade in multiple pandemics, the most recent being COVID-19. Field Epidemiology Training Programs (FETPs) are in-service training programs that improve country capacities to respond to public health emergencies across different levels of the health system. Best practices for FETP implementation have been described previously. The Uganda Public Health Fellowship Program (PHFP), or Advanced-FETP in Uganda, is a two-year fellowship in field epidemiology funded by the U.S. Centers for Disease Control and situated in the Uganda National Institute of Public Health (UNIPH). We describe how specific attributes of the Uganda PHFP that are aligned with best practices enabled substantial contributions to the COVID-19 response in Uganda.

METHODS

We describe the PHFP in Uganda and review examples of how specific program characteristics facilitate integration with Ministry of Health needs and foster a strong response, using COVID-19 pandemic response activities as examples. We describe PHFP activities and outputs before and during the COVID-19 response and offer expert opinions about the impact of the program set-up on these outputs.

RESULTS

Unlike nearly all other Advanced FETPs in Africa, PHFP is delinked from an academic degree-granting program and enrolls only post-Master's-degree fellows. This enables full-time, uninterrupted commitment of academically-trained fellows to public health response. Uganda's PHFP has strong partner support in country, sufficient technical support from program staff, Ministry of Health (MoH), CDC, and partners, and full-time dedicated directorship from a well-respected MoH staff member. The PHFP is physically co-located inside the UNIPH with the emergency operations center (EOC), which provides a direct path for health alerts to be investigated by fellows. It has recognized value within the MoH, which integrates graduates into key MoH and partner positions. During February 2020-September 2021, PHFP fellows and graduates completed 67 major COVID-related projects. PHFP activities during the COVID-19 response were specifically requested by the MoH or by partners, or generated de novo by the program, and were supervised by all partners.

CONCLUSION

Specific attributes of the PHFP enable effective service to the Ministry of Health in Uganda. Among the most important is the enrollment of post-graduate fellows, which leads to a high level of utilization of the program fellows by the Ministry of Health to fulfill real-time needs. Strong leadership and sufficient technical support permitted meaningful program outputs during COVID-19 pandemic response. Ensuring the inclusion of similar characteristics when implementing FETPs elsewhere may allow them to achieve a high level of impact.

Continuing Contributions of Field Epidemiology Training Programs to Global COVID-19 Response

We documented the contributions of Field Epidemiology Training Program (FETP) trainees and graduates to global COVID-19 preparedness and response efforts. During February-July 2021, we conducted surveys designed in accordance with the World Health Organization's COVID-19 Strategic Preparedness and Response Plan. We quantified trainee and graduate engagement in responses and identified themes through qualitative analysis of activity descriptions. Thirty-two programs with 2,300 trainees and 7,372 graduates reported near-universal engagement across response activities, particularly those aligned with the FETP curriculum. Graduates were more frequently engaged than were trainees in pandemic response activities. Common themes in the activity descriptions were epidemiology and surveillance, leading risk communication, monitoring and assessment, managing logistics and operations, training and capacity building, and developing guidelines and protocols. We describe continued FETP contributions to the response. Findings indicate the wide-ranging utility of FETPs to strengthen countries' emergency response capacity, furthering global health security.

India Field Epidemiology Training Program Response to COVID-19 Pandemic, 2020-2021

The India Field Epidemiology Training Program (FETP) has played a critical role in India's response to the ongoing COVID-19 pandemic. During March 2020-June 2021, a total of 123 FETP officers from across 3 training hubs were deployed in support of India's efforts to combat COVID-19. FETP officers have successfully mitigated the effect of COVID-19 on persons in India by conducting cluster outbreak investigations, performing surveillance system evaluations, and developing infection prevention and control tools and guidelines. This report discusses the successes of select COVID-19 pandemic response activities undertaken by current India FETP officers and proposes a pathway to augmenting India's pandemic preparedness and response efforts through expansion of this network and a strengthened frontline public health workforce.

Texas professionals are employing a one health approach to protect the United States against biosecurity threats

Texas is a geographically large state with large human and livestock populations, many farms, a long coastal region, and extreme fluctuations in weather. During the last 15 years, the state of Texas has frequently suffered disasters or catastrophes causing extensive morbidity and economic loss. These disasters often have complicated consequences requiring multi-faceted responses. Recently, an interdisciplinary network of professionals from multiple academic institutions has emerged to collaborate in protecting Texas and the USA using a One Health approach. These experts are training the next generation of scientists in biopreparedness; increasing understanding of pathogens that cause repetitive harm; developing new therapeutics and vaccines against them; and developing novel surveillance approaches so that emerging pathogens will be detected early and thwarted before they can cause disastrous human and economic losses. These academic One Health partnerships strengthen our ability to protect human and animal health against future catastrophes that may impact the diverse ecoregions of Texas and the world.

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Texas has suffered from numerous disasters or catastrophes, often more than other US states.

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These disasters have caused tremendous morbidity, mortality, and economic loss.

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Texas professionals are partnering in One Health ways to mitigate such catastrophes.

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These numerous collaborations are important to Texas, the USA, and abroad.

Evaluation of the first two Frontline cohorts of the field epidemiology training program in Guinea, West Africa

BACKGROUND

The 2014-2016 Ebola virus disease outbreak in West Africa revealed weaknesses in the health systems of the three most heavily affected countries, including a shortage of public health professionals at the local level trained in surveillance and outbreak investigation. In response, the Frontline Field Epidemiology Training Program (FETP) was created by CDC in 2015 as a 3-month, accelerated training program in field epidemiology that specifically targets the district level. In Guinea, the first two FETP-Frontline cohorts were held from January to May, and from June to September 2017. Here, we report the results of a cross-sectional evaluation of these first two cohorts of FETP-Frontline in Guinea.

METHODS

The evaluation was conducted in April 2018 and consisted of interviews with graduates, their supervisors, and directors of nearby health facilities, as well as direct observation of data reports and surveillance tools at health facilities. Interviews and site visits were conducted using standardized questionnaires and checklists. Qualitative data were coded under common themes and analyzed using descriptive statistics.

RESULTS

The evaluation revealed a significant perception of improvement in all assessed skills by the graduates, as well as high levels of self-reported involvement in key activities related to data collection, analysis, and reporting. Supervisors highlighted improvements to systematic and quality case and summary reporting as key benefits of the FETP-Frontline program. At the health facility level, staff reported the training had resulted in improvements to information sharing and case notifications. Reported barriers included lack of transportation, available support personnel, and other resources. Graduates and supervisors both emphasized the importance of continued and additional training to solidify and retain skills.

CONCLUSIONS

The evaluation demonstrated a strongly positive perceived benefit of the FETP-Frontline training on the professional activities of graduates as well as the overall surveillance system. However, efforts are needed to ensure greater gender equity and to recruit more junior trainee candidates for future cohorts. Moreover, although improvements to the surveillance system were observed concurrent with the completion of the two cohorts, the evaluation was not designed to directly measure impact on surveillance or response functions. Combined with the rapid implementation of FETP-Frontline around the world, this suggests an opportunity to develop standardized evaluation toolkits, which could incorporate metrics that would directly assess the impact of equitable field epidemiology workforce development on countries' abilities to prevent, detect, and respond to public health threats.

Leadership, politics, and communication: challenges of the epidemiology workforce during emergency response

BACKGROUND

Improving the epidemiological response to emergencies requires an understanding of who the responders are, their role and skills, and the challenges they face during responses. In this paper, we explore the role of the epidemiologist and identify challenges they face during emergency response.

METHODS

We conducted a cross-sectional survey to learn more about epidemiologists who respond to public health emergencies. The online survey included open and closed-ended questions on challenges faced while responding, the roles of epidemiology responders, self-rating of skills, and support needed and received. We used purposive sampling to identify participants and a snowballing approach thereafter. We compared data by a number of characteristics, including national or international responder on their last response prior to the survey. We analysed the data using descriptive, content, and exploratory factor analysis.

RESULTS

We received 166 responses from individuals with experience in emergency response. The most frequently reported challenge was navigating the political dynamics of a response, which was more common for international responders than national. National responders experienced fewer challenges related to culture, language, and communication. Epidemiology responders reported a lack of response role clarity, limited knowledge sharing, and communication issues during emergency response. Sixty-seven percent of participants reported they needed support to do their job well; males who requested support were statistically more likely to receive it than females who asked.

CONCLUSIONS

Our study identified that national responders have additional strengths, such as better understanding of the local political environment, language, and culture, which may in turn support identification of local needs and priorities. Although this research was conducted prior to the COVID-19 pandemic, the results are even more relevant now. This research builds on emerging evidence on how to strengthen public health emergency response and provides a platform to begin a global conversation to address operational issues and the role of the international epidemiology responder.

Strengthening the global one health workforce: Veterinarians in CDC-supported field epidemiology training programs

Background

Effective prevention, detection, and response to disease threats at the human-animal-environment interface rely on a multisectoral, One Health workforce. Since 2009, the U.S. Centers for Disease Control and Prevention (CDC) has supported Field Epidemiology Training Programs (FETPs) to train veterinarians and veterinary paraprofessionals (VPPs) alongside their human health counterparts in the principles of epidemiology, disease surveillance, and outbreak investigations. We aim to describe and evaluate characteristics of CDC-supported FETPs enrolling veterinarians/VPPs to understand these programs contribution to the strengthening of the global One Health workforce.

Methods

We surveyed staff from CDC-supported FETPs that enroll veterinarians and VPPs regarding cohort demographics, graduate retention, and veterinary and One Health relevant curriculum inclusion. Descriptive data was analyzed using R Version 3.5.1.

Results

Forty-seven FETPs reported veterinarian/VPP trainees, 68% responded to our questionnaire, and 64% reported veterinary/VPP graduates in 2017. The veterinary/VPP graduates in 2017 made up 12% of cohorts. Programs reported 74% of graduated veterinarians/VPPs retained employment within national ministries of agriculture. Common veterinary and One Health curriculum topics were specimen collection and submission (93%), zoonotic disease (90%) and biosafety practices (83%); least covered included animal/livestock production and health promotion (23%) and transboundary animal diseases (27%). Less than half (41%) of programs reported the curriculum being sufficient for veterinarians/VPPs to perform animal health specific job functions, despite most programs being linked to the ministry of agriculture (75%) and providing veterinary-specific mentorship (63%).

Conclusions

Our results indicate that FETPs provide valuable training opportunities for animal health sector professionals, strengthening the epidemiology capacity within the ministries retaining them. While veterinary/VPP trainees could benefit from the inclusion of animal-specific curricula needed to fulfill their job functions, at present, FETPs continue to serve as multisectoral, competency-based, in-service training important in strengthening the global One Health workforce by jointly training the animal and human health sectors.

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Global health security requires multisectoral epidemiology workforce capacity.

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FETPs with veterinarians/VPPs were linked to ministries of agriculture and health.

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Veterinary/VPP FETP trainees jointly train alongside public health epidemiologists.

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One Health and Zoonotic Diseases curriculum was offered by most FETPs.

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FETPs train in epidemiology and surveillance at human-animal-environment interface.

Field Epidemiology Training Program Response to COVID-19 During a Conflict: Experience From Yemen

COVID-19 pandemic has underscored the need for a well-trained public health workforce to save lives through timely outbreaks detection and response. In Yemen, a country that is entering its seventh year of a protracted war, the ongoing conflict severely limited the country's capacity to implement effective preparedness and response measures to outbreaks including COVID-19. There are growing concerns that the virus may be circulating within communities undetected and unmitigated especially as underreporting continues in some areas of the country due to a lack of testing facilities, delays in seeking treatment, stigma, difficulty accessing treatment centers, the perceived risks of seeking care or for political issues. The Yemen Field Epidemiology Training Program (FETP) was launched in 2011 to address the shortage of a skilled public health workforce, with the objective of strengthening capacity in field epidemiology. Thus, events of public health importance can be detected and investigated in a timely and effective manner. During the COVID-19 pandemic, the Yemen FETP's response has been instrumental through participating in country-level coordination, planning, monitoring, and developing guidelines/standard operating procedures and strengthening surveillance capacities, outbreak investigations, contact tracing, case management, infection prevention, and control, risk communication, and research. As the third wave is circulating with a steeper upward curve than the previous ones with possible new variants, the country will not be able to deal with a surge of cases as secondary care is extremely crippled. Since COVID-19 prevention and control are the only option available to reduce its grave impact on morbidity and mortality, health partners should support the Yemen FETP to strengthen the health system's response to future epidemics. One important lesson learned from the COVID-19 pandemic, especially in the Yemen context and applicable to developing and war-torn countries, is that access to outside experts becomes limited, therefore, it is crucial to invest in building national expertise to provide timely, cost-effective, and sustainable services that are culturally appropriate. It is also essential to build such expertise at the governorate and district levels, as they are normally the first respondents, and to provide them with the necessary tools for immediate response in order to overcome the disastrous delays.

Public health workers' knowledge, attitude and practice regarding COVID-19: the impact of Field Epidemiology Training Program in the Eastern Mediterranean Region

BACKGROUND

This study aimed to compare knowledge, attitude and practice (KAP) regarding COVID-19 between public health workers (PHWs) attended field epidemiology training program (FETP-trained) and those who did not attend FETP (non-FETP trained).

METHODS

Multi-country cross-sectional survey was conducted among PHWs who participated in COVID-19 pandemic in 10 countries at EMR. Online questionnaire that included demographic information, KAP regarding COVID-19 pandemic was distributed among HCWs. Scoring system was used to quantify the answers, bivariate and Multivariate analysis performed to compare FETP-trained with non-FETP trained PHWs.

RESULTS

Overall, 1337 PHWs participated, with 835 (62.4%) < 40 years of age, and 851 (63.6%) males. Of them, 423 (31.6%) had FETP, including that 189 (44.7%) had advanced level, 155 (36.6%) intermediate and 79 (18.7%) basic level training. Compared with non-FETP trained, FETP trained were older, having higher KAP scores. FETP participation was low in infection control, and PH laboratories. KAP mean scores for intermediate level attendees are comparable to advanced level.

CONCLUSIONS

FETP-trained are having better KAP than non-FETP PHWs. Expanding the intermediate level, maintain the Rapid Response training and introduce the laboratory component are recommended to maximize the benefit from FETP. Infection control, antimicrobial resistance and coordination are areas where training should include.

Innovations to maximise impact of a data for decision-making training programme in the Federated States of Micronesia

Accurate and timely health information is an essential foundation for strengthening health systems. Data for decision making (DDM) is a training curriculum designed to enhance capacity of health department staff to capture and use high-quality data to address priority health issues. In 2013, the Pacific Public Health Surveillance Network adapted and piloted the DDM curriculum as an 'at work, from work, for work' field epidemiology training programme component for low-income and middle-income Pacific Island jurisdictions. Based on lessons learned from the pilot, we made several innovations, including delivery on-site at each district (rather than bringing trainees to a central location), conducting pre-DDM consultations and ongoing contact with health leaders across the programme, taking more care in selecting trainees and enrolling a larger cohort of students from within each health department. The decentralised programme was delivered in-country at four sites (both at national and state levels) in the Federated States of Micronesia. Following delivery, we performed an external evaluation of the programme to assess student outcomes, benefits to the health department and general programme effectiveness. Of the 48 trainees who completed all four classroom modules, 40 trainees participated in the evaluation. Thirty-two of these trainees completed the programme's capstone field project. Eighteen of these projects directly contributed to changes in legislation, revised programme budgets, changes in programme strategy to augment outreach and to target disease and risk factor 'hot spots'.

Evaluation of Advanced Field Epidemiology Training Programs in the Eastern Mediterranean Region: A Multi-Country Study

Field Epidemiology Training Programs (FETPs) are competency-based training programs aiming to strengthen the epidemiologic capacity of the public health workforce. This study aimed to evaluate the impact of the advanced FETPs in the Eastern Mediterranean region (EMR) and ascertain whether the expected objectives of the programs are met. A descriptive study was conducted based on Kirkpatrick's model for evaluating training programs. Data were collected from FETP graduates and FETP technical advisers on the practices of FETP graduates, their engagement in key areas of field epidemiology, and their perceived skills and capacity to perform such activities. A total of 166 FETP graduates responded to the online survey. Almost two-thirds of FETP graduates reported that they are often engaged in managing public health surveillance systems (n = 119, 71.7%), analyzing the surveillance data (n = 116, 69.9%), training public health professionals (n = 113, 68.1%), investigations on and response to outbreaks (n = 109, 65.7%), and managing staff and resources (n = 106, 63.9%). However, only 28.3% reported that they are often engaged in writing scientific research articles. More than two-thirds of graduates reported that the FETP helped them to perform most of the field epidemiology activities and rate their skills as good. In conclusion, the FETP graduates in the EMR were well engaged in many field epidemiology activities including managing public health surveillance systems, surveillance data analysis, training public health professionals, and investigations on and response to outbreaks. Therefore, the FETPs should continue supporting the graduates to work toward strengthening surveillance systems and investigating outbreaks and to participate in regional and global efforts as part of the Global Health Security.

Health research capacity building of health workers in fragile and conflict-affected settings: a scoping review of challenges, strengths, and recommendations

BACKGROUND

Fragile and conflict-affected settings (FCAS) have a strong need to improve the capacity of local health workers to conduct health research in order to improve health policy and health outcomes. Health research capacity building (HRCB) programmes are ideal to equip health workers with the needed skills and knowledge to design and lead health-related research initiatives. The study aimed to review the characteristics of HRCB studies in FCASs in order to identify their strengths and weaknesses, and to recommend future directions for the field.

METHODS

We conducted a scoping review and searched four databases for peer-reviewed articles that reported an HRCB initiative targeting health workers in a FCAS and published after 2010. Commentaries and editorials, cross-sectional studies, presentations, and interventions that did not have a capacity building component were excluded. Data on bibliographies of the studies and HRCB interventions and their outcomes were extracted. A descriptive approach was used to report the data, and a thematic approach was used to analyse the qualitative data.

RESULTS

Out of 8822 articles, a total of 20 were included based on the eligibility criteria. Most of the initiatives centred around topics of health research methodology (70%), targeted an individual-level capacity building angle (95%), and were delivered in university or hospital settings (75%). Ten themes were identified and grouped into three categories. Significant challenges revolved around the lack of local research culture, shortages in logistic capability, interpersonal difficulties, and limited assessment and evaluation of HRCB programmes. Strengths of HRCB interventions included being locally driven, incorporating interactive pedagogies, and promoting multidisciplinary and holistic training. Common recommendations covered by the studies included opportunities to improve the content, logistics, and overarching structural components of HRCB initiatives.

CONCLUSION

Our findings have important implications on health research policy and related capacity building efforts. Importantly, FCASs should prioritize (1) funding HRCB efforts, (2) strengthening equitable international, regional, and national partnerships, (3) delivering locally led HRCB programmes, (4) ensuring long-term evaluations and implementing programmes at multiple levels of the healthcare system, and (5) adopting engaging and interactive approaches.

Evaluation through outbreak simulation exercise points to the need for considerable improvement in the capacity of peripheral health workers for outbreak detection and response, South India, 2018

Background:

Outbreaks are emergencies, requiring skilled peripheral health workers in the health system. Given the lack of evaluation of the knowledge and practices of peripheral health workers regarding outbreak investigation and response, we surveyed to estimate the performance level of health workers in outbreak detection and response.

Methods:

We developed a simulation exercise based on hepatitis and fever outbreak to ascertain knowledge and skills in outbreak detection and response. Following a pilot test and with inputs from public health experts, we finalized the instrument in the local language. The simulation exercise was self-administered among all health inspectors (HI) (n = 39) from a district in South India responsible for outbreak investigation. We collected sociodemographic factors, training, education level, awareness about the surveillance program, outbreak triggers, and prior experience with an outbreak. We assigned a score of 0.25 for each correct response (range 0 to 10.75). We categorized a score of <75% as poor performance. The academic ethics committee of ICMR-National Institute of Epidemiology approved the protocol.

Results:

All the HIs were male except one. Median age is 51 years (Range: 37.5–54). The median years of service is 12 (range 5.3 to 23). Twenty-two received training, and fifteen had prior exposure to an outbreak in the previous year. The overall performance of HIs was poor, with the highest mark being below 40%. The median score in the section of history taking was 0.25 [interquartile range (IQR) 0–0.5], 31% (n = 12) scored zero. The median score in the section of data entry, analysis, and outbreak detection was 0.25 (0–0.25), 28% (n = 11) scored zero. The median score in the section of outbreak response was 0.75 (IQR 0.75–1.13), 5% (n = 2) scored zero.

Conclusion:

The HIs performed poorly in outbreak preparedness and response. We recommend improving their performance through field-epidemiology training and regular field or facility-based evaluations.

The role of Namibia Field Epidemiology and Laboratory Training Programme in strengthening the public health workforce in Namibia, 2012-2019

Namibia faces a critical shortage of skilled public health workers to perform emergency response operations, preparedness activities and real-time surveillance. The Namibia Field Epidemiology and Laboratory Training Programme (NamFELTP) increases the number of skilled public health professionals and strengthens the public health system in Namibia. We describe the NamFELTP during its first 7 years, assess its impact on the public health workforce and provide recommendations to further strengthen the workforce. We reviewed disease outbreak investigations and response reports, field projects and epidemiological investigations conducted during 2012-2019. The data were analysed using descriptive methods such as frequencies and rates. Maps representing the geographical distribution of NamFELTP workforce were produced using QGIS software V.3.2. There were no formally trained field epidemiologists working in Namibia before the NamFELTP. In its 7 years of operation, the programme graduated 189 field epidemiologists, of which 28 have completed the Advanced FELTP. The graduates increased epidemiological capacity for surveillance and response in Namibia at the national and provincial levels, and enhanced epidemiologist-led outbreak responses on 35 occasions, including responses to outbreaks of human and zoonotic diseases. Trainees analysed data from 51 surveillance systems and completed 31 epidemiological studies. The NamFELTP improved outcomes in the Namibia's public health systems; including functional and robust public health surveillance systems that timely and effectively respond to public health emergencies. However, the current epidemiological capacity is insufficient and there is a need to continue training and mentorship to fill key leadership and strategic roles in the public health system.

Using chaos indicators to determine vaccine influence on epidemic stabilization

Virus outbreaks have the potential to be a source of severe sanitarian and economic crisis. We propose a new methodology to study the influence of several parameter combinations on the dynamical behavior of simple epidemiological compartmental models. Using this methodology, we analyze the behavior of a simple vaccination model. We find that for susceptible-infected-recovered (SIR) models with seasonality and natural death rate, a new vaccination can reduce the chaoticity of epidemic trajectories, even with nonvaccinated adults. This strategy has little effect on the first infection wave, but it can stop subsequent waves.

What do we mean by individual capacity strengthening for primary health care in low- and middle-income countries? A systematic scoping review to improve conceptual clarity

BACKGROUND

Capacity strengthening of primary health care workers is widely used as a means to strengthen health service delivery, particularly in low- and middle-income countries. Despite the widespread recognition of the importance of capacity strengthening to improve access to quality health care, how the term 'capacity strengthening' is both used and measured varies substantially across the literature. This scoping review sought to identify the most common domains of individual capacity strengthening, as well as their most common forms of measurement, to generate a better understanding of what is meant by the term 'capacity strengthening' for primary health care workers.

METHODS

Six electronic databases were searched for studies published between January 2000 and October 2020. A total of 4474 articles were screened at title and abstract phase and 323 full-text articles were reviewed. 55 articles were ultimately identified for inclusion, covering various geographic settings and health topics.

RESULTS

Capacity strengthening is predominantly conceptualised in relation to knowledge and skills, as either sole domains of capacity, or used in combination with other domains including self-efficacy, practices, ability, and competencies. Capacity strengthening is primarily measured using pre- and post-tests, practical evaluations, and observation. These occur along study-specific indicators, though some pre-existing, validated tools are also used.

CONCLUSION

The concept of capacity strengthening for primary health care workers reflected across a number of relevant frameworks and theories differs from what is commonly seen in practice. A framework of individual capacity strengthening across intra-personal, inter-personal, and technical domains is proposed, as an initial step towards building a common consensus of individual capacity strengthening for future work.

Mapping Spatiotemporal Diffusion of COVID-19 in Lombardy (Italy) on the Base of Emergency Medical Services Activities

The epidemic of coronavirus-disease-2019 (COVID-19) started in Italy with the first official diagnosis on 21 February 2020; hence, it is now known how many cases were already present in earlier days and weeks, thus limiting the possibilities of conducting any retrospective analysis. We hypothesized that an unbiased representation of COVID-19 diffusion in these early phases could be inferred by the georeferenced calls to the emergency number relevant to respiratory problems and by the following emergency medical services (EMS) interventions. Accordingly, the aim of this study was to identify the beginning of anomalous trends (change in the data morphology) in emergency calls and EMS ambulances dispatches and reconstruct COVID-19 spatiotemporal evolution on the territory of Lombardy region. Accordingly, a signal processing method, previously used to find morphological features on the electrocardiographic signal, was applied on a time series representative of territorial clusters of about 100,000 citizens. Both emergency calls and age- and gender-weighted ambulance dispatches resulted strongly correlated to COVID-19 casualties on a provincial level, and the identified local starting days anticipated the official diagnoses and casualties, thus demonstrating how these parameters could be effectively used as early indicators for the spatiotemporal evolution of the epidemic on a certain territory.

Africa Centres for Disease Control and Prevention Is Closing Gaps in Disease Detection

In 2017, the African Union established a new continent-wide public health agency, the Africa Centres for Disease Control and Prevention (Africa CDC). Many outbreaks are never detected in Africa, and among outbreaks that are detected, countries often respond slowly and ineffectively. To address these problems, Africa CDC is working to increase early detection and reporting, improve access to diagnostic tests, promote novel laboratory approaches, help establish national public health institutes, improve information exchange between health agencies, and enhance recording and reporting of acute public health events and vital statistics. The health security of Africa will be strengthened by this new public health agency's ability to build comprehensive, timely disease surveillance that rapidly detects and contains health threats.

Zambia field epidemiology training program: strengthening health security through workforce development

The Zambia Field Epidemiology Training Program (ZFETP) was established by the Ministry of Health (MoH) during 2014, in order to increase the number of trained field epidemiologists who can investigate outbreaks, strengthen disease surveillance, and support data-driven decision making. We describe the ZFETP´s approach to public health workforce development and health security strengthening, key milestones five years after program launch, and recommendations to ensure program sustainability. Program description: ZFETP was established as a tripartite arrangement between the Zambia MoH, the University of Zambia School of Public Health, and the U.S. Centers for Disease Control and Prevention. The program runs two tiers: Advanced and Frontline. To date, ZFETP has enrolled three FETP-Advanced cohorts (training 24 residents) and four Frontline cohorts (training 71 trainees). In 2016, ZFETP moved organizationally to the newly established Zambia National Public Health Institute (ZNPHI). This re-positioning raised the program´s profile by providing residents with increased opportunities to lead high-profile outbreak investigations and analyze national surveillance data-achievements that were recognized on a national stage. These successes attracted investment from the Government of Republic of Zambia (GRZ) and donors, thus accelerating field epidemiology workforce capacity development in Zambia. In its first five years, ZFETP achieved early success due in part to commitment from GRZ, and organizational positioning within the newly formed ZNPHI, which have catalyzed ZFETP´s institutionalization. During the next five years, ZFETP seeks to sustain this momentum by expanding training of both tiers, in order to accelerate the professional development of field epidemiologists at all levels of the public health system.

The United Kingdom Field Epidemiology Training Programme: meeting programme objectives

Introduction

Most evaluations of field epidemiology training programmes (FETP) are limited to process measures, but stakeholders may need evidence of impact.

Objective

To ascertain if the United Kingdom (UK) FETP met its objectives to: (i) strengthen capacity and provision of national epidemiology services, (ii) develop a network of highly skilled field epidemiologists with a shared sense of purpose working to common standards and (iii) raise the profile of field epidemiology through embedding it into everyday health protection practice.

Methods

The evaluation consisted of: (i) focus groups with training site staff, (ii) individual interviews with stakeholders and (iii) an online survey of FETP fellows and graduates. Findings were synthesised and triangulated across the three evaluation components to identify cross-cutting themes and subthemes.

Findings

Eight focus groups were undertaken with 38 staff, ten stakeholders were interviewed and 28 (76%) graduates and fellows responded to the survey. Three themes emerged: confidence, application and rigour. FETP was perceived to have contributed to the development, directly and indirectly, of a skilled workforce in field epidemiology, increasing stakeholders’ confidence in the service. Graduates applied their learning in practice, collaborating with a wide range of disciplines. Fellows and graduates demonstrated rigour by introducing innovations, supporting service improvements and helping supervisors maintain their skills and share good practice.

Conclusion

The UK FETP appears to have met its three key objectives, and also had wider organisational impact. FETPs should systematically and prospectively collect information on how they have influenced changes to field epidemiology practice.

Study protocol: building an evidence base for epidemiology emergency response, a mixed-methods study

INTRODUCTION

Determinants and drivers for emergencies, such as political instability, weak health systems, climate change and forcibly displaced populations, are increasing the severity, complexity and frequency of public health emergencies. As emergencies become more complex, it is increasingly important that the required skillset of the emergency response workforce is clearly defined. To enable essential epidemiological activities to be implemented and managed during an emergency, a workforce is required with the right mix of skills, knowledge, experience and local context awareness. This study aims to provide local and international responders with an opportunity to actively contribute to the development of new thinking around emergency response roles and required competencies. In this study, we will develop recommendations using a broad range of evidence to address identified lessons and challenges so that future major emergency responses are culturally and contextually appropriate, and less reliant on long-term international deployments.

METHOD AND ANALYSIS

We will conduct a mixed-methods study using an exploratory sequential study design. The integration of four data sources, including key informant interviews, a scoping literature review, survey and semistructured interviews will allow the research questions to be examined in a flexible, semistructured way, from a range of perspectives. The study is unequally weighted, with a qualitative emphasis. We will analyse all activities as individual components, and then together in an integrated analysis. Thematic analysis will be conducted in NVivo V.11 and quantitative analysis will be conducted in Stata V.15.

ETHICS AND DISSEMINATION

All activities have been approved by the Science and Medical Delegated Ethics Review Committee at the Australian National University (protocol numbers 2018-521, 2018-641, 2019-068). Findings will be disseminated through international and local deployment partners, peer-reviewed publication, presentation at international conferences and through social media such as Twitter and Facebook.

Addressing the workforce capacity for public health surveillance through field epidemiology and laboratory training program: the need for balanced enhanced skill mix and distribution, a case study from Tanzania

Introduction

Skill mix refers to the range of professional development and competencies, skills and experiences of staff within a particular working environment that link with specific outcome while responding to client needs. A balanced skill-mix and distribution of core human resources is important to strengthen decision-making process and rapid responses. We analysed graduates´ information of the Tanzania Field Epidemiology and Laboratory Training Program (TFELTP) between 2008-2016, distribution of skill-mix and the surveillance workforce-gaps within regions.

Methods

Trainees´ data of nine cohorts enrolled between 2008 and 2016 were extracted from the program database. Distribution by sex, region and cadres/profession was carried out. An indicator to determine enhanced-skill mix was established based on the presence of a clinician, nurse, laboratory scientist and environmental health officer. A complete enhanced skill-mix was considered when all four were available and have received FELTP training.

Results

The TFELTP has trained 113 trainees (male=71.7%), originated from 17 regions of Tanzania Mainland (65.4% of all) and Zanzibar. Clinicians (34.5%) and laboratory scientists (38.1%) accounted for the most recruits, however, the former were widely spread in regions (83% vs. 56%). Environmental health officers (17.7%) were available in 39% of regions. The nursing profession, predominantly lacking (6.2%) was available in 22% of regions. Only two regions (11.7%) among 17 covered by TFELTP presented complete skill-mix, representing 7.7% of Tanzanian regions. Seven regions (41%) had an average of one trainee.

Conclusion

The TFELTP is yet to reach the required skill-mix in many regions within the country. The slow fill-rate for competent and key workforce cadres might impede effective response. Strategies to increase program awareness at subnational levels is needed to improve performance of surveillance and response system in Tanzania.

One Field Epidemiologist per 200,000 Population: Lessons Learned from Implementing a Global Public Health Workforce Target

The World Health Organization monitoring and evaluation framework for the International Health Regulations (IHR, 2005) describes the targets for the Joint External Evaluation (JEE) indicators. For workforce development, the JEE defines the optimal target for attaining and complying with the IHR (2005) as 1 trained field epidemiologist (or equivalent) per 200,000 population. We explain the derivation and use of the current field epidemiology workforce development target and identify the limitations and lessons learned in applying it to various countries' public health systems. This article also proposes a way forward for improvements and implementation of this workforce development target.

Leveraging Partnerships to Maximize Global Health Security Improvements in Guinea, 2015-2019

In response to the 2014-2016 West Africa Ebola virus disease (EVD) outbreak, a US congressional appropriation provided funds to the US Centers for Disease Control and Prevention (CDC) to support global health security capacity building in 17 partner countries, including Guinea. The 2014 funding enabled CDC to provide more than 300 deployments of personnel to Guinea during the Ebola response, establish a country office, and fund 11 implementing partners through cooperative agreements to support global health security engagement efforts in 4 core technical areas: workforce development, surveillance systems, laboratory systems, and emergency management. This article reflects on almost 4 years of collaboration between CDC and its implementing partners in Guinea during the Ebola outbreak response and the recovery period. We highlight examples of collaborative synergies between cooperative agreement partners and local Guinean partners and discuss the impact of these collaborations in strengthening the above 4 core capacities. Finally, we identify the key elements of the successful collaborations, including communication and information sharing as a core cooperative agreement activity, a flexible funding mechanism, and willingness to adapt to local needs. We hope these observations can serve as guidance for future endeavors seeking to establish strong and effective partnerships between government and nongovernment organizations providing technical and operational assistance.

Lessons from the first 6 years of an intervention-based field epidemiology training programme in Papua New Guinea, 2013-2018

Papua New Guinea (PNG) faces a critical shortage of human resources to address pressing public health challenges arising from an increasing burden of communicable and non-communicable diseases. PNG is an independent State in the Pacific and home to 8.2 million people. Resource and infrastructure constraints due to the country’s challenging geography have made it difficult and expensive to deliver health services and implement health programmes. The National Department of Health and its partners developed a field epidemiology training programme of Papua New Guinea (FETPNG) to strengthen the country’s public health workforce. The training programme covers field epidemiology competencies and includes the design, implementation and evaluation of evidence-based interventions by Fellows. From 2013 to 2018, FETPNG graduated 81 field epidemiologists. Most FETPNG graduates (84%) were from provincial or district health departments or organisations. Many of their intervention projects resulted in successful public health outcomes with tangible local impacts. Health challenges addressed included reducing the burden of multi-drug resistant-tuberculosis (TB), increasing immunisation coverage, screening and treating HIV/TB patients, and improving reproductive health outcomes. FETPNG Fellows and graduates have also evaluated disease surveillance systems and investigated disease outbreaks. Early and unwavering national ownership of FETPNG created a sustainable programme fitting the needs of this low-resource country. A focus on designing and implementing effective public health interventions not only provides useful skills to Fellows but also contributes to real-time, tangible and meaningful improvements in the health of the population. The graduates of FETPNG now provide a critical mass of public health practitioners across the country. Their skills in responding to outbreaks and public health emergencies, in collecting, analysing and interpreting data, and in designing, implementing and evaluating public health interventions continues to advance public health in PNG.

Uganda public health fellowship program's contribution to building a resilient and sustainable public health system in Uganda

Background: Low-income countries with relatively weak-health systems are highly vulnerable to public health threats. Effective public health system with a workforce to investigate outbreaks can reduce disease impact on livelihoods and economic development. Building effective public health partnerships is critical for sustainability of such a system. Uganda has made significant progress in responding to emergencies during the past quarter century, but its public health workforce is still inadequate in number and competency.

Objectives: To reinforce implementation of priority public health programs in Uganda and cultivate core capacities for compliance with International Health Regulations.

Methods: To develop a competent workforce to manage epidemics and improve disease surveillance, Uganda Ministry of Health (MoH) established an advanced-level Field Epidemiology Training Program, called Public Health Fellowship Program (PHFP); closely modelled after the US CDC’s Epidemic Intelligence Service. PHFP is a 2-year, full-time, non-degree granting program targeting mid-career public health professionals. Fellows spend 85% of their field time in MoH placements learning through service delivery and gaining competencies in major domains.

Results: During 2015–2018, PHFP enrolled 41 fellows, and graduated 30. Fellows were placed in 19 priority areas at MoH and completed 235 projects (91 outbreaks, 12 refugee assessments, 50 surveillance, and 60 epidemiologic studies, 3 cost analysis and 18 quality improvement); made 194 conference presentations; prepared 63 manuscripts for peer-reviewed publications (27 published as of December 2018); produced MoH bulletins, and developed three case studies. Projects have resulted in public health interventions with improvements in surveillance systems and disease control.

Conclusion: During the 4 years of existence, PHFP has contributed greatly to improving real-time disease surveillance and outbreak response core capacities. Enhanced focus on evidence-based targeted approaches has increased effectiveness in outbreak response and control, and integration of PHFP within MoH has contributed to building a resilient and sustainable health system in Uganda.

Building Global Epidemiology and Response Capacity with Field Epidemiology Training Programs

More than ever, competent field epidemiologists are needed worldwide. As known, new, and resurgent communicable diseases increase their global impact, the International Health Regulations and the Global Health Security Agenda call for sufficient field epidemiologic capacity in every country to rapidly detect, respond to, and contain public health emergencies, thereby ensuring global health security. To build this capacity, for >35 years the US Centers for Disease Control and Prevention has worked with countries around the globe to develop Field Epidemiology Training Programs (FETPs). FETP trainees conduct surveillance activities and outbreak investigations in service to ministry of health programs to prevent and control infectious diseases of global health importance such as polio, cholera, tuberculosis, HIV/AIDS, malaria, and emerging zoonotic infectious diseases. FETP graduates often rise to positions of leadership to direct such programs. By training competent epidemiologists to manage public health events locally and support public health systems nationally, health security is enhanced globally.

Contributions of the US Centers for Disease Control and Prevention in Implementing the Global Health Security Agenda in 17 Partner Countries

The Global Health Security Agenda (GHSA), a partnership of nations, international organizations, and civil society, was launched in 2014 with a mission to build countries’ capacities to respond to infectious disease threats and to foster global compliance with the International Health Regulations (IHR 2005). The US Centers for Disease Control and Prevention (CDC) assists partner nations to improve IHR 2005 capacities and achieve GHSA targets. To assess progress through these CDC-supported efforts, we analyzed country activity reports dating from April 2015 through March 2017. Our analysis shows that CDC helped 17 Phase I countries achieve 675 major GHSA accomplishments, particularly in the cross-cutting areas of public health surveillance, laboratory systems, workforce development, and emergency response management. CDC’s engagement has been critical to these accomplishments, but sustained support is needed until countries attain IHR 2005 capacities, thereby fostering national and regional health protection and ensuring a world safer and more secure from global health threats.