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Field Epidemiology Training Programs to accelerate public health workforce development and global health security

2021; Elsevier BV; Volume: 110; Linguagem: Inglês

10.1016/j.ijid.2021.08.021

1878-3511

Rebecca Martin, Ibrahima Socé Fall,

Public Health Policies and Education

•FETPs build a global workforce that significantly enhances global health security.•FETPs have trained tens of thousands of disease detectives around the world.•More work is needed to strengthen field epidemiology workforce capacity through FETP.•A new global partnership has launched to ensure progress for the FETP Enterprise.•FETP should remain a model for global public health workforce capacity building. In 1980, the U.S. Centers for Disease Control and Prevention (CDC) partnered with the World Health Organization (WHO) and the Thailand Ministry of Public Health to launch the first Field Epidemiology Training Program (FETP) outside North America in Thailand (Training Programs in Epidemiology and Public Health Interventions Network (TEPHINET) 2020Training Programs in Epidemiology and Public Health Interventions Network (TEPHINET),. Four Decades of the Field Epidemiology Training Program (FETP): TEPHINET's Role in the Context of FETP History. https://www.tephinet.org/four-decades-of-the-field-epidemiology-training-program-fetp-tephinet%E2%80%99s-role-in-the-context-of-fetp, 2020 (accessed 21 May, 2021).Google Scholar; CDC, 2020). Many countries have since developed national FETPs with support from WHO, CDC, and other partners; regional initiatives and networks have adapted the original approach and focused on epidemiological health workforce capacity building within their regions. This initiative began over 40 years ago when CDC recognized that its successful training model for developing epidemiologic competence among the national public health workforce, the Epidemiologic Intelligence Service (EIS) (Koo, 2010Koo D Thacker SB In Snow's Footsteps: Commentary on Shoe-Leather and Applied Epidemiology.American Journal of Epidemiology. 2010; 172: 737-739Crossref PubMed Scopus (27) Google Scholar), could be shared globally to benefit all countries. In the EIS model, physicians and other health professionals received an intensive 3-week course in epidemiology and biostatistics, and then were assigned for two years to public health units at CDC or placed in state health departments. During each assignment, an experienced field epidemiologist mentored the trainee in attending to incoming surveillance data, disease outbreaks, other immediate threats to public health, and issues arising in ongoing public health programs. This model had at least two notable outcomes. The public health workforce became competent in applying epidemiology to its ongoing work. The investigations done by the trainees had immediate consequences in improving surveillance and data use, curtailing disease transmission from outbreaks and epidemics, and modifying public health programs to respond to changes in the epidemiologic situation. The global application of the EIS model became FETP, which was first adopted independently by Canada in 1975. This model, now referred to as Advanced FETP, devotes at least 75% of the two-year program to mentoring field activities. In more recent years, FETPs have evolved to include an additional two tiers: a three-month (Frontline); and a 9-12-month (Intermediate) program to meet disease surveillance and response needs at all levels of countries' public health systems (André and Lopez, 2017André MA Lopez A et al.Frontline Field Epidemiology Training Programs as a Strategy to Improve Disease Surveillance and Response.Emerg Infectious Diseases. 2017; 23: S166-S172PubMed Google Scholar). Field epidemiology competencies vary by tier, based on criteria, thus FETP-Frontline graduates do not replace graduates from FETP-Intermediate or FETP-Advanced, without further training. However, Frontline addresses a critical need for surveillance, data quality, and case investigation skills at the community and the lower levels of the public health system. Since 1980, FETPs have graduated tens of thousands of disease detectives from all three training tiers in more than 80 countries. Support to FETP by host country governments, U.S. Government agencies such as CDC, and multilateral organizations have significantly enhanced global health security by building a global workforce with skills in surveillance, data use, and outbreak detection and response. For example, the Government of Guinea launched its FETP in 2016, after the 2014-2016 Ebola virus disease (EVD) outbreak. Since then, it has graduated 179 staff from the Frontline, i.e., district-level, program and 16 from the Intermediate program, in addition to ten Advanced FETP graduates who participated in the regional West Africa program in Burkina Faso. These disease detectives have played leading roles in the response to the 2021 EVD outbreak in the southeastern part of the country, including alert validation, case investigations, active case finding, contact tracing, and data management. Their contributions led to successful follow-up of >95% of EVD contacts, an essential component of successful EVD response. On June 19, 2021, Guinea's Ministry of Health officially declared the outbreak over after 23 cases and 12 deaths in a To date, cases have been limited in number and confined to a single prefecture (World Health Organization (WHO) 2021World Health Organization (WHO)Coronavirus disease 2019 (COVID-19) situation reports.2021https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reportsGoogle Scholara), contrasting greatly with the 2014-16 outbreak, which spread over 3 countries, sickened over 28,000 and killed 11,000 in West Africa (Heymann et al., 2015Heymann DL Chen L Takemi K Fidler DP Tappero JW Thomas MJ et al.Global health security: the wider lessons from the west African Ebola virus disease epidemic.Lancet. 2015; 385: 1884-1901Abstract Full Text Full Text PDF PubMed Scopus (266) Google Scholar). Neighboring countries have also mobilized FETP graduates to conduct intensified surveillance and investigation of suspect cases along their borders. In addition, Guinea's FETP trainees and graduates have supported concurrent outbreaks of vaccine-derived poliovirus, measles, Yellow Fever, and COVID-19, which might otherwise threaten to overwhelm the country's health system. Guinea's robust response to the recent EVD outbreak cannot be attributed to FETP alone, but a competent field epidemiology workforce is required to complement quality surveillance, emergency management systems, laboratories, and other critical health security functions. FETP trainees and graduates have been mobilized to support COVID-19 preparedness and response activities in their countries (Hu et al., in press). In a March – April 2020 survey of 65 FETPs around the world, 85% of programs reported FETP trainee engagement in COVID-19 response activities, and 98% of programs reported graduate engagement (unpublished data; publication in process). For both trainees and graduates, the most common pillar of engagement was surveillance – a core competency of field epidemiology training. This pandemic and the varied national-level responses have reinforced the need for countries to invest in a trained public health workforce. We have learned that epidemiological skills are valuable assets and that other skills and disciplines such as data science need to be part of modern field epidemiology training. This pandemic and the varied national-level responses have reinforced the need for countries to invest in a trained public health workforce. We have learned that epidemiological skills are valuable assets and that other skills and disciplines such as data science need to be part of modern field epidemiology training. We have also seen evidence of measurable impact of FETP. Previous work has demonstrated the correlation between FETP and key indicators of surveillance quality (Macharia et al., 2021Macharia D Jinnai Y Hirai M et al.Impact of Kenya's Frontline epidemiology training program on outbreak detection and surveillance reporting: A geographical assessment, 2014-2017.Health Secur. 2021; 19 (May-Jun): 243-253Crossref PubMed Scopus (1) Google Scholar) as well as improved timeliness and frequency of outbreak reporting (Crawley et al., 2021Crawley AW Divi N Smolinski MS Using timeliness metrics to track progress and identify gaps in disease surveillance.Health Secur. 19. 2021: 309-317Google Scholar). The manuscripts in this supplement highlight and demonstrate the importance of FETP trainees and graduates in the public health architecture and the manifold ways in which FETPs prepare for and respond to all public health threats and emergencies. While the impact of FETP has been substantial, periodic large and complex infectious disease outbreaks, including COVID-19 (World Health Organization Executive Board 2021World Health Organization Executive Board., January 2021: EB148/18 148th session 16, item 14.2 WHO's work in health emergencies Strengthening WHO's global emergency preparedness and response Report by the Director-General. https://apps.who.int/gb/ebwha/pdf_files/EB148/B148_18-en.pdf, 2021 (accessed 31 March, 2021).Google Scholarb) and Ebola (Heymann et al., 2015Heymann DL Chen L Takemi K Fidler DP Tappero JW Thomas MJ et al.Global health security: the wider lessons from the west African Ebola virus disease epidemic.Lancet. 2015; 385: 1884-1901Abstract Full Text Full Text PDF PubMed Scopus (266) Google Scholar; Christie et al., 2020Christie A Neatherlin JC Nichol ST Beach M Redfield RR Ebola Response Priorities in the Time of Covid-19.N Engl J Med. 2020; 383: 1202-1204Crossref PubMed Scopus (7) Google Scholar), remind us that more work is needed to strengthen the field epidemiology workforce capacity through FETP. More work is also needed to institutionalize FETPs within national governments so that programs are sustained and more consistently play leading roles in responses to public health threats. A global group of public health experts and leaders recently coined the term FETP Enterprise to describe the "totality of the leaders, funders, implementing partners, government agencies, and other stakeholders engaged in this global effort, along with associated workforce competency targets, standards, agreements, technologies, etc. that undergird this work." This group also developed the Global Field Epidemiology Roadmap to chart a path to build and strengthen high-quality field epidemiology training in all countries, while addressing longstanding challenges and expanding partnerships. Most importantly, the Roadmap calls for high-level leadership through a Strategic Leadership Group (SLG) to ensure accountability and progress for these priorities. We (RM and ISF) have agreed to co-lead the SLG. This senior leadership from the U.S. CDC and WHO signals a high-level commitment from our respective agencies and formalizes our partnership for a program that we see as one of the most important for all countries' ability to achieve International Health Regulations (IHR) core capacities and to ensure global health security. We have confirmed 14 global health leaders to serve as SLG members (Roadmap Recommendation #1) (O'Carroll et al., 2021), which held its inaugural meeting in April 2021. In that meeting, the SLG identified leaders for eight workgroups to develop implementation strategies for each of the Roadmap recommendations. Additionally, U.S. CDC and WHO have forged new collaborations to improve documentation and benchmarking of the field epidemiology workforce through national health workforce accounts (World Health Organization WHO, 2018World Health Organization (WHO), National health workforce accounts. https://www.who.int/publications/i/item/national-health-workforce-accounts-implementation-guide, 2018a (accessed 19 March 2021).Google Scholara). This work will facilitate countries' standardized measurement and reporting of the workforce (Roadmap #3) and reinforce the central role of the FETP for strengthening capacities of the health workforce in emergency management for greater resilience and health-care response capacity, as outlined in the Global Strategy on Human Resources for Health: Workforce 2030 (Roadmap #8) (Prevention (CDC) 21 May 2021Centers for Disease Control and Prevention (CDC), Thailand FETP Celebrates 40 Years of Training, Mentorship, and Public Health Successes. https://www.cdc.gov/globalhealth/healthprotection/fetp-40th-anniversary/stories/thailand-fetp-40.html, 2020 (accessed 21 May 2021).Google Scholar). Initiatives are underway to modernize the FETP curriculum through expanded online and lifelong learning initiatives (Roadmap #2) and strengthened competencies in emergency management and response (Roadmap #4). As part of the need to promote quality (Roadmap #6), Training Programs in Epidemiology and Public Health Interventions Network (TEPHINET) and partners are developing a process and standards for accreditation of FETP – Intermediate programs, to complement the current process for Advanced programs (TEPHINET, 2019Training in Epidemiology and Public Health Interventions Network (TEPHINET), Accreditation of field epidemiology training programs. https://www.tephinet.org/accreditation, n.d. (accessed 19 March 2021).Google Scholar). Finally, U.S. CDC, in partnership with the International Association of National Public Health Institutes, WHO, Africa Centres for Disease Control and Prevention, and others, have increased activities toward the development and strengthening of national public health institutes (Nkengasong, 2019Nkengasong J. How Africa can quell the next disease outbreaks.Nature. 2019; 567: 147Crossref PubMed Scopus (7) Google Scholar; Frieden and Koplan, 2010Frieden TR Koplan JP Stronger national public health institutes for global health.Lancet. 2010; 20: 1721-1722Abstract Full Text Full Text PDF Scopus (28) Google Scholar), which facilitate institutionalization and sustainability of FETPs within national governments (Roadmap #5). The importance of FETP to countries' achieving WHO's IHR and global health security has been codified in the IHR Monitoring and Evaluation Framework (WHO, Joint external evaluation tool: International Health Regulations, 2018bbWorld Health Organization (WHO)Joint external evaluation tool: International Health Regulations.2018: Institutional Repository for Information Sharing. 2nd ed. W.H. Organization, 2018Google Scholarb). The Joint External Evaluation (JEE) calls for countries to have at least two tiers of FETP to demonstrate capacity in the human resources technical area. The JEE also defines an optimal target of one trained field epidemiologist per 200,000 population, which can be achieved through FETP (Williams et al., 2020Williams SG Fontaine RE Turcios Ruiz RM Walke H Ijaz K Baggett HC One Field Epidemiologist per 200,000 Population: Lessons Learned from Implementing a Global Public Health Workforce Target.Health Secur. 2020; 18: S113-S118Crossref PubMed Scopus (10) Google Scholar). To complement its role in IHR core capacity development, WHO recently launched an initiative to enhance field epidemiology workforce capacity in Africa. WHO Headquarters, together with regional offices for the Eastern Mediterranean and Africa, and in collaboration with the African Field Epidemiology Network and the Eastern Mediterranean Public Health Network, provides opportunities to FETP fellows from African countries to support ongoing WHO activities in surveillance, epidemiological analysis, and risk assessment within the scope of their deliverables. Further, WHO, together with Food and Agriculture Organization of the United Nations (FAO), the World Organization for Animal Health (OIE) and other stakeholders, is developing technical guidance and standards for One Health curricula following an FETP model, and for building workforce capacity to address zoonotic diseases. Major public health emergencies during the first two decades of this century have catalyzed decisions for WHO to establish a global health emergency workforce. At the 148th session of the WHO Executive Board (WHO Executive Board, World Health Organization Executive Board 2021World Health Organization Executive Board., January 2021: EB148/18 148th session 16, item 14.2 WHO's work in health emergencies Strengthening WHO's global emergency preparedness and response Report by the Director-General. https://apps.who.int/gb/ebwha/pdf_files/EB148/B148_18-en.pdf, 2021 (accessed 31 March, 2021).Google Scholar), the Director-General announced that WHO would mobilize "a global health emergency workforce that is rapidly deployable nationally, regionally and globally to detect and respond to health emergencies – expanding on the Global Outbreak Alert and Response Network and Emergency Medical Teams initiatives." It was noted that all countries need rapidly deployable, multidisciplinary teams of trained and equipped health emergency responders. FETP provides a strong and practical model for building sustained capacity for health emergency response work. Its approach using a tiered, sustained, and blended program that marries didactic training with experience (applied field work) and exchange (mentorship and peer learning) meets modern standards of andragogy and life-long learning approaches. The first World Field Epidemiology Day (Training in Epidemiology and Public Health Interventions Network (TEPHINET) 2021Training in Epidemiology and Public Health Interventions Network (TEPHINET), World Field Epidemiology Day. https://www.tephinet.org/events/world-field-epidemiology-day, 2021 (accessed 19 March 2021).Google Scholar) is being celebrated on September 7, 2021 and marks a new era to increase awareness of the essential contributions of field epidemiologists worldwide. World Field Epidemiology Day also aims to increase visibility of FETP and advocacy for further development of the FETP Enterprise (O'Carroll et al., 2021). It will draw attention to the vital role FETPs play in global health security and strengthening global health leadership at all levels. It will encourage governments to support training field epidemiologists and deploy them within ministries of health at national and sub-national levels, national public health institutes, and other public health agencies. For its importance to IHR core capacities, evidence-based public health actions that save lives, and health security, FETP has been and should remain a standard bearer for public health workforce capacity building around the world. Approval was not required. No funding from sources outside the authors' agencies supported this work.