Preventing Local Outbreaks from Becoming Global Pandemics: FETP Enhances Capabilities to Track Diseases and Stop Them at the Source
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Christine Kihembo, FETP graduate from Uganda led a study in her country on Podoconiosis, a neglected tropical diseases that affects about 4 million people around the world. Above, the typical asymmetrical lymphedema (lower limb swelling) seen in podoconiosis. The skin on the affected limbs is thickened with warty and mossy nodules and toes are disfigured. Photo credit: Christine Kihembo.
Every day, somewhere in the world, field epidemiologists or “disease detectives” save lives by detecting and controlling disease outbreaks. Most likely these public health professionals are residents or graduates of Field Epidemiology Training Programs (FETPs) supported by CDC. The first FETPs were established more than 30 years ago and modelled after CDC’s Epidemic Intelligence Service program. The programs are owned by individual countries and each is tailored to reflect that country’s culture, priorities, partners, capacities, and public health systems.
In many countries, FETP trainees and graduates constitute the core of public health workforce, working at all levels of country’s public health care system. They are the ones building sustainable national capabilities to detect disease outbreaks locally and preventing those outbreaks from spreading across borders.
A worldwide movement
In 1979, Canada established the first FETP outside of the United States. A year later, the Thai Ministry of Health formed a partnership with CDC and set up the first FETP outside of North America. Since 1980, CDC has supported over 70 countries as they established FETPs. The resulting global cadre now consists of over 9,500 well-trained disease detectives skilled in collecting, analyzing, and interpreting public health data and turning it into action. Since 1979, FETP graduates have participated in over 3,100 outbreak investigations of the most serious public health threats in the world, including outbreaks of HIV infections, Ebola viral disease, anthrax, severe acute respiratory syndrome, botulism, malaria, drug-resistant tuberculosis, and influenza.
Approximately 80% of FETP graduates continue to work in their home countries in public health positions, responding to the world’s most urgent public health events. FETPs help countries strengthen their surveillance capabilities and move towards meeting the goals of the International Health Regulations (IHR, 2005) and the Global Health Security Agenda, which includes having at least one trained field epidemiologist per 200,000 people in country.
All three levels of FETP training —frontline, intermediate, and advanced— focus on “learning by doing.” Residents spend over 75% of their time in the field investigating outbreaks, conducting surveys, setting-up surveillance systems, and training other healthcare workers in their area.
Putting training into action
Disease detectives are critical in preventing local outbreaks from becoming global pandemics. In many countries, FETP residents and trainees are the “boots on the ground” in the ongoing battles against infectious diseases, natural disasters, and environmental hazards.
Controlling disease outbreaks at their source requires that disease detectives think outside the box, as they often deal with unexpected, urgent problems that demand immediate and innovative solutions. The curious mind of an FETP graduate conducting a malaria study helped identify the first four cases of Zika in Guinea-Bissau. Vitor Inhane, a nurse responsible for surveillance in Bijagos Region, was studying 21 severe cases of malaria when he tested for other diseases that have similar signs and symptoms to malaria. Due to his diligence and creativity, patients were tested for Zika, Dengue, and Chikungunya. He helped put Zika on Guinea-Bissau’s radar.
Between 2015-16 FETP fellows in Uganda successfully investigated more than 60 distinct disease outbreaks and conducted dozens of other applied epidemiologic investigations on emerging public health threats across the country. FETP graduate Christine Kihembo led a study on podoconiosis, a neglected tropical diseases that affects about 4 million people around the world, particularly in East and Central Africa, Central and South America, and Southeast Asia. Kihembo’s study highlighted a lesser known cause of podoconiosis, which can result in debilitating elephantiasis, repeatedly trauma to the feet resulting from walking barefoot in volcanic soils that have tiny, sharp mineral crystals that can penetrate the soles of the feet. The easiest way to prevent podoconiosis is to wear shoes and regularly wash their feet. Inspired by this study, a public health education campaign focused on the importance of better foot hygiene is underway. This will decrease the burden of this terrible affliction.
Outbreaks can signal gaps in childhood immunization. When this happens, disease detectives are on the scene making a difference. Between January and March 2017, Pakistan’s FELTP graduates responded to distinct outbreaks of measles, pertussis, and diphtheria, all vaccine-preventable diseases, across five provinces caused by low childhood vaccination coverage. Disease detectives investigated the reasons for low vaccination coverage and initiated a campaign that provided vaccinations to 16,798 children and conducted health awareness sessions. During the same period, FELTP Pakistan polio initiative, NSTOP, identified and vaccinated 1,631 children who had not been vaccinated for polio.
In 2010 CDC helped establish the Central Africa Republic-Field Epidemiology Laboratory Training Program (CAR-FELTP) to build local capacity in disease surveillance and response. Thousands of children in CAR die each year from vaccine-preventable diseases. Improved surveillance through the CAR-FELTP has provided information critical to developing effective vaccination campaigns and building local capacity to detect and respond to the spread of cholera, yellow fever, and other infectious diseases endemic in the region.
FETPs enhance global health security
The Democratic Republic of Congo faced Ebola outbreaks in 1976 and the mid-1990s. Knowing how challenging it can be to control an outbreak of Ebola without disease detectives, the country started an FETP. This investment paid off when Ebola briefly returned in the summer of 2014; this time the country was better prepared to control the outbreak at its source. A trained team of field epidemiologists swiftly helped control the outbreak, limiting it to 66 cases. When the West African Ebola outbreak was reported also in 2014, the DRC FETP, with its five-year history of training disease detectives through FETP, was called upon to support the Ebola response in West Africa. More than 30 FETP disease detectives from the DRC took their expertise to Guinea to help control the Ebola epidemic.
In Senegal, where the FETP program is just one year old, 64 frontline surveillance staff were trained in 2016. After their training, they were deployed in the country’s 14 regions. Since then, these frontline staff have investigated suspected food poisoning outbreaks in four districts, measles cases in three districts, outbreaks of animal illnesses in two districts, maternal deaths in one district, and malaria cases in one district. This new cadre of surveillance officers is helping make Senegal stronger in the fight against disease outbreaks, making the world safer and more secure.
The outbreaks of Ebola and Zika have reminded us that infectious diseases can be unpredictable and require ongoing vigilance and action. Having a well-trained public health workforce on the ground, prepared to quickly detect and respond to health threats and stop them at their source is essential. Establishing FETPs and having trained disease detectives on the ground, is our best frontline defense against public health emergencies and threats. CDC stands with them, ever-ready to face known and unknown disease threats.