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.

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.
maintaining essential health services and systems; and pillar 10, vaccination (against COVID-19). Pillars 9 and 10 were added to the original 8 (13). We asked each program director for the total number of graduates and current trainees in their program. We asked if persons in any stage of their FETP training (trainees) or those who successfully completed their graduation requirements (graduates) or both were engaged in response activities and asked for brief descriptions of those activities.
We distributed invitations to respond to the online SurveyMonkey (Momentive Inc., https://www. surveymonkey.com) survey to 92 FETP program directors via email in February 2021 in coordination with the Training Programs in Field Epidemiology and Public Health Interventions Network (TEPHI-NET), a global network of FETPs. If a program director had responded to our first survey in 2020, they were asked to report on the activities conducted since that submission. If a program director had not responded to the first survey, we asked them to report on all the activities in which FETP trainees or graduates had engaged for COVID-19 preparedness or response. We followed up on incomplete or duplicate responses by email or telephone calls with respondents during April-July 2021 to complete or reconcile responses.

Quantitative Analysis
We mapped the responding programs to describe the geographic distribution. We analyzed selected characteristics of responding programs: years between the establishment of the program and July 2021, and days between the report of the first case of COVID-19 in the country and the date of survey response. We calculated medians and reported minimum and maximum values aggregated by WHO region. We tabulated responses and calculated by WHO region and WHO pillar percentages of programs reporting FETP trainee or graduate engagement in COVID-19 preparedness or response activities by using Microsoft Excel (Microsoft, https://www.microsoft.com).

Qualitative Analysis
Four team members conducted content analysis on qualitative responses using MaxQDA (VERBI Software, https://www.maxqda.com). Each analyst reviewed the original codebook used for the qualitative analysis of the responses to our first survey (11). After reviewing all responses, we updated the codebook to reflect novel responses, new codes, new themes, and the activities corresponding to the 2 new response pillars. The 4 staff met weekly to reach consensus on new codes, consolidate codes, and identify themes across the 10 WHO pillars with appropriately illustrative quotes. Some survey respondents answered in their primary language; bilingual CDC staff translated responses in French, Portuguese, and Spanish, and we used Google Translate (https://translate.google.com) for responses in Ukrainian and Chinese.

Quantitative Findings
Of 92 program directors invited to the survey, 32 (35%) responded, reporting on COVID-19 preparedness and response activities in 69 countries across all WHO regions (Figure 1, panel A). Thirty of the respondents represented national programs and 2 represented regional programs, 1 serving 24 countries in the Caribbean (Americas region, Pan American Health Organization [PAHO]), and the other 19 countries covered by the WHO Regional Office for the Eastern Mediterranean (EMRO). Four programs in Belize, Haiti, Egypt, and Ukraine implemented training nationally but were also served by a regional program. Of the 32 responding programs, 17 (53%) were implementing frontline training as well as advanced, intermediate, or both tiers; 6 programs were implementing all 3 tiers of field epidemiology training. Among responding programs, 4 (13%) were implementing frontline only.
Half of the programs that responded to this survey were >10 years old, and nearly all were in countries S130 Emerging Points of entry, international travel and transport, and mass gatherings 5 Laboratories and diagnostics 6 Infection prevention and control, and protection of the health workforce 7 Case management, clinical operations, and therapeutics 8 Operational support and logistics, and supply chains 9 Maintaining essential health services and systems 10 Vaccination *As of February 2021. Source: World Health Organization (11).
in which the earliest known COVID-19 case was >1 year prior (Table 2). Only the 4 reporting programs in the PAHO region had yet to surpass the 1-year mark between the earliest reported case of COVID-19 and responding to this survey. Programs <5 years old from 3 WHO regional offices responded; those countries were Burkina Faso (Regional Office for Africa [AFRO]), Ukraine (Regional Office for Europe [EURO]), and Afghanistan and Somalia (EMRO). Of note, the Somalia FETP established frontline training in 2021, during the COVID-19 pandemic. The 32 programs reported a combined total of 2,300 trainees and 7,372 graduates. All 32 responding programs reported engagement of FETP trainees and graduates in all pillars of WHO response activities. The most frequently reported pillars of engagement for trainees or graduates, in order of decreasing frequency, were WHO pillar 3, surveillance, rapid response teams, and case investigation; pillar 1, coordination, planning, financing, and monitoring; pillar 2, risk communication and community engagement; and pillar 4, points of entry ( Figure 2). Engagement of FETP trainees or graduates variable in activities corresponding to pillar 5, national laboratories; pillar 7, case management; pillar 6, infection prevention and control; and pillar 8, operational support ( Figure 3). More programs reported engagement of graduates than reported engagement of trainees in response activities. Most evident of this trend were reports of engagement in activities of pillar 8, operational support and logistics; pillar 7, case management; and pillar 9, maintaining essential health services and systems. Notable exceptions to the more frequent engagement of graduates than trainees were in the EMRO region, where programs reported more trainees than graduates engaged in pillar 3, surveillance, response teams and case investiga-Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 28, No. 13, Supplement to December 2022 S131 tions; in the AFRO region in pillar 6, infection prevention and control activities; and in the EURO region in pillar 7, case management. Although pillar 9, maintaining essential health services and systems, and pillar 10, vaccination, were introduced in the updated WHO response plan of February 2021, >25% of programs reported that trainees and graduates were involved in activities of these new pillars ( Figure 4).

Qualitative Findings
Six themes emerged during content analysis that illustrate the contributions of FETPs to COVID-19 preparedness and response a year into the pandemic (Table 3). We identified these themes from the activity descriptions across multiple WHO pillars.  FETP trainees and graduates were heavily involved in efforts to train and build COVID-19-related response capacity across sectors and levels of society. The data showed that from the community level (such as in Uganda, where graduates conducted "training of village health teams of community-based health surveillance") all the way to the national and state levels (as in India, where trainees and graduates conducted "cascade training of national and state level officials on IPC [Infection Prevention and Control]"), their expertise was widely required. Programs reported their participation in training for the following responserelated activities: point-of-entry screening, infection prevention and control at healthcare facilities and in the community, case management, specimen collection, and the incident management system. FETP trainees and graduates served as trainers for vaccine-related rollout activities. They contributed to training on cold-chain standards (Rwanda), training healthcare workers on how to administer the vaccine (Jordan); and "training on abnormal response monitoring," also known as adverse events monitoring (China).

Theme VI: Developing Guidelines and Protocols
FETP trainees and graduates were engaged in developing guidelines and protocols. They developed standard operating procedures and participated in national-level strategic planning, particularly for the preservation of essential health services and vaccine rollout. Their wide participation in vaccine-related planning was illustrative, as in this example from China: "FETP participants were integrated into the National Immunization Centre Vaccine Task Force to participate in the Vaccination Information Group." Drafting case-management guidelines were also reported by many programs, such as in Jordan where both graduates and trainees " [ cases coming to Jordan and confirmed as well" and "were responsible for updating the management guidelines as soon as it needed and follow up [on] admitted cases."

Discussion
We documented the diverse contributions of FETP trainees and graduates to COVID-19 preparedness and response activities 1 year into the pandemic, across all WHO regions and response pillars, including the new pillar 9: maintaining essential health services and systems, and pillar 10: vaccination. Programs more commonly reported graduate than trainee engagement. Through content analysis, common themes emerged describing active engagement and vital roles in all types of activities of COVID-19 preparedness and response. The more frequent reporting of trainees and graduates working in specific pillars and the emerging themes reflect the core competencies of the advanced and intermediate tiers of FETPs (Table 4). The FETPs' core competencies of epidemiologic methods, communication, and management and leadership were closely aligned with the pillars of most frequently reported trainee and graduate engagement: pillar 3, surveillance, rapid response teams, and case investigation; pillar 1, coordination, planning, financing, and monitoring; pillar 2, risk communication and community engagement; and pillar 4, points of entry. FETP trainees and graduates were also reported as involved in activities of the 2 new pillars in the revised WHO response plan (strengthening essential health services, and vaccination activities). FETPs' contributions to these 2 pillars demonstrated that trainees and graduates can leverage their skills and knowledge to take on related response activities, likely with additional orientation as needed. We found differences between this survey and our March-April 2020 survey (11) documenting FETPs' contributions to COVID-19 preparedness and response. The response rate for this survey was lower than for the first (35% vs. 74%) ( Table 2). Three (9%) programs responded to the second survey that had not responded to the initial survey: Mongolia FETP, Turkey FETP, and Somalia FETP. Among the 29 (91%) programs that responded to both surveys, more programs reported engagement of trainees and graduates than in the first survey. All programs responding to this second survey were well into COVID-19 response activities, having passed or approaching 1 year since COVID-19 introduction into their respective countries. This increase was noted across all WHO regions and pillars, underscoring the contributions of FETPs, its integration into national responses, and its adaptability through the engagement of FETPs in the new pillars. The themes that emerged in this survey were comparable to those identified in the first survey. The ongoing S134 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 28, No. 13, Supplement to December 2022  (7). Recent publications describe the discrepancy between JEE scores and outbreak response performance (14,15). One of Yemen's highest JEE technical area score of 4 was in the workforce development indicator, stating that the country has "two levels of FETP or comparable applied epidemiology training programs in place in the country or in another country through an existing agreement." However, the JEE assessment of IHR (2005) framework functions showed capacity to detect outbreaks but limited or no capacity to prevent or respond to them, reflecting that an FETP alone cannot yield an effective outbreak response. Our survey findings support that implementing FETPs could positively influence JEE results beyond the workforce development technical area, including the areas of emergency preparedness, emergency response operations, medical countermeasures, personnel deployment, risk communication, and points of entry. Engagement of FETP trainees and graduates in response operations and logistics, which are not FETP core competencies (Table  4), highlights the importance of regular assessments of the skills needed by the modern field epidemiologists or potential public health staffing gaps which FETPs may be filling (1).
We identified 4 limitations in the contribution of FETPs to COVID-19 preparedness and responses worldwide. First, the response rate to the second survey was about half that of the first (35% vs. 74%); responses from programs >20 years old were absent in most regions (EURO, PAHO, Southeast Asia Regional Office, and Western Pacific Regional Office). In the midst of the global pandemic, in the first quarters of 2021 when we conducted this follow-up survey, there were several factors that may account for the reduced response rate: program staff may have had limited time to respond to detailed surveys or to track graduates, and the expanded information requested made the second survey more time-intensive to complete. Second, FETP trainees and graduates bring diverse skillsets to the training, which limits our ability to attribute their contributions solely to their participation, particularly with regard to response pillar activities that do not align with FETP core competencies. Trainee and graduate engagement in pillars that did not require field epidemiologic competencies may be a function of either skills trainees had before enrolling in an FETP, skills they acquired elsewhere, seniority associated with career progression since  FETP graduation, or a combination of those factors. Third, reporting bias is inherent to this documentation approach because of respondents' motivation to inflate engagement of programs and their graduates. Quantifying the level of support needed by the trainees and graduates to participate effectively in response activities was beyond the scope of this effort. Finally, English was not the dominant language of some respondents. Misinterpretation of questions, inaccurate translations, and loss of nuance were possible. Nonetheless, the consistency of findings about engagement across the 2 surveys, in all WHO regions and response pillars, supports the importance of FETPs in countries preparing for and responding to public health threats. This second documentation of FETPs' contributions to responses to the COVID-19 pandemic highlights 3 needs in field epidemiology training. Systematic chronicling of how trainees, graduates, and program staff work to detect, respond, and prevent public health threats would help to build the body of evidence that field epidemiology training is valuable, and merits continued investment. Periodic tierby-tier assessments could ensure that the skills developed through this training are the skills required by most field epidemiologists. Finally, regular updating of each tier of the FETP curriculum would assure that new skills required for field epidemiologists can be developed through FETPs.
Future assessments of FETPs could include eliciting feedback from public health institutions on the quality of the contributions to the COVID-19 response of trainees, graduates, and staff. FETP evaluators can also engage with human-resource offices to ensure alignment of competencies with job requirements, pay scale, and a career path for epidemiologists. In addition, assessments can elicit self-reported information from FETP graduates about progression in their career attributable to training in field epidemiology. Evaluate and prioritize the importance of diseases or conditions of national public health concern *Source: Traicoff et al. (1)