CDC staff visited each country and met with representatives of each MOH to describe the program and explore the value and feasibility of implementing FETP-Frontline. Upon agreement to launch the program, CDC staff, along with MOH colleagues, assessed the country’s training needs and priorities, gathering information from site visits and interviews with surveillance workers at multiple levels within the health system. Shortly thereafter, a 1- to 2-day implementation workshop was held with key stakeholders from relevant ministries within the country and key nongovernmental partners. During the meeting, leaders and stakeholders discussed strategic elements of program implementation, such as defining the subnational unit targeted for training and the personnel or job classes to be prioritized for training. In this article, we refer to the targeted administrative unit as the health district, even though the nomenclature varies across countries, because this is where data are first aggregated within the surveillance system. We also determined at the workshop possible sources of mentors to supervise participants in the field. Each country then developed a plan to cover all subnational units with >1 FETP-Frontline–trained person.

In each country, a FETP team was established to work closely with the MOH, implementing partners, and the CDC country office to implement FETP-Frontline. Each team was led by a resident advisor, a senior-level epidemiologist who was either a CDC staff member or a contractor, usually from another country and a graduate of a 2-year FETP-Advanced. Other staff included a field coordinator, usually from the host country, who was most often a physician with experience in surveillance and epidemiology; and an administrator to assist with the logistics of program implementation. The resident advisor provided overall technical leadership for the program and worked closely with an identified MOH person to manage the program. The teams were often embedded within the MOH offices to facilitate planning and operation of the program.

Curriculum

The standardized curriculum and program schedule, incorporating both classroom workshops and on-the-job fieldwork, were originally developed in English and then translated into French and Portuguese to accommodate Francophone and Lusophone countries. Training materials also incorporated the Integrated Disease Surveillance and Response (IDSR) framework, which is used in 43 of 46 countries in the WHO Regional Office for Africa for disease surveillance and response reporting (11). In each country, the curriculum was then adapted to the country context, incorporating national reporting guidelines and practices. The classroom training is reinforced by the completion of field projects designed to help participants develop competencies related to specific job functions (Table 1).

Figure 1

Figure 1. General program schedule showing the 3 classroom workshops (green boxes) and 2 field stages (gray boxes) in a standard Frontline Field Epidemiology Training Program curriculum.

The program schedule (Figure 1) for FETP-Frontline consists of an initial 5-day workshop introducing basic epidemiology principles and importance of disease surveillance. The participants then return to their regular job sites for 5 weeks. There, they receive onsite and remote mentoring from program staff to review local surveillance data and conduct a data quality audit around a priority disease in their coverage area. All Frontline FETP participants create a weekly surveillance report using real-world data derived from their home districts. The FETP resident advisors and mentors then guide the participants to aggregate and analyze the data at the district level. The participants return for a second 5-day workshop to present their work and receive feedback from the staff and their peers on their projects. During the second workshop, participants learn how and when to conduct field investigations and how to effectively communicate results. Participants then return to the field for the second 5-week field stage to put in practice what they have learned under the guidance of the mentors and to complete 2 of 4 possible field activities: conducting a field investigation to confirm or rule out a reportable disease, participating in an outbreak investigation, developing an expanded surveillance summary report, or completing an analysis of surveillance quality with appropriate recommendations. In the third workshop, participants present their final projects and receive a certificate of course completion cosigned by MOH and CDC representatives. At the end of each module and in between cohorts, the technical staff conducted internal evaluations. Participant feedback is gathered through questionnaires. Program staff are encouraged to review the feedback and work with the MOH to tailor the curriculum materials and training schedule as needed.

Figure 2

Figure 2. Geographic coverage of Frontline Field Epidemiology Training Programs established (black), July–December 2016.

Figure 3

Figure 3. Frontline Field Epidemiology Training Programs launched and cumulative number of participants trained by quarter (Q) of program launch through Q4 2016. Quarter of launch is defined by the date of the...

The first FETP-Frontline cohort began in Tanzania in July 2015. All the FETPs -Frontline that started in 2015 and 2016 were in Africa and southern Asia, with a heavy concentration in West Africa (Figure 2). The FETP-Frontline underwent a rapid expansion across these countries, with most programs launching their first cohort during the first 6 months of 2016 (Figure 3).

From the program’s launch in July 2015 through the end of 2016, a total of 1,354 persons completed FETP-Frontline training (Figure 3). Participants were almost all MOH employees and represented a variety of backgrounds: data managers, nurses, physicians, environmental health officers, veterinarians, laboratorians, and public health officials. The proportion of districts in each country with >1 FETP-Frontline–trained surveillance officer has expanded steadily. Four countries (Sierra Leone, Guinea-Bissau, Liberia, and Senegal) achieved complete or near-complete district-level coverage by the end of 2016 (Table 2).

Weekly surveillance data were collected from 3 countries for the duration of FETP-Frontline. The timeliness of surveillance reporting, defined as the proportion of weekly surveillance reports delivered to the district level by a predetermined deadline, from these 3 programs increased from an average timeliness rate of 33% in week 1 to 96% in week 12. An example can be seen in the reported timeliness data from the first cohort in the Benin program, in which the average reported timeliness went from 37% on-time to 85% on-time (Table 3).

FETP-Frontline participants have used their training to identify gaps and promote change in the public health systems in which they work. Guinea-Bissau FETP-Frontline participants made policy recommendations to improve the way in which dog bites are tracked, in terms of follow-up with rabies testing, and to improve data confidentiality and protection for patients. In The Gambia, under the resident advisor’s guidance, members of the first cohort created recommendations for improving the surveillance system; among these were appointing district surveillance officers where there were none previously, training new staff in basic epidemiology, implementing and revising protocols to match IDSR recommendations, and including private health clinics in the national surveillance strategy. Liberia realized a need to appoint surveillance personnel between the community and regional levels.

In Côte d’Ivoire, only 4 of the 36 participants in the first 2 cohorts had ever conducted a field investigation before the training; upon program completion, 20 had conducted a field investigation with the assistance of a field mentor. Investigations included suspected cases of yellow fever, measles, and rabies (Table 4). In Liberia, participants conducted outbreak investigations on conditions such as food poisoning, suspected acute flaccid paralysis, and measles. In the Democratic Republic of the Congo, participants investigated typhoid fever, yellow fever, and cholera outbreaks. In Benin and Burkina Faso, program participants have mobilized from their home districts to respond to outbreaks in other parts of the country, serving as a trained, in-country pool of epidemiologists from which to draw during emergencies. In Côte d’Ivoire, Senegal, and Togo, where training has included participants from both the human and animal health sectors, trainees have worked together to conduct coordinated joint investigations to combat rabies.

As countries address gaps in surveillance and begin to develop the core capacities for surveillance and response as set by the IHR 2005, they will need to ensure that there is capacity at the local level “to detect unusual public health events, to report key epidemiological information to relevant intermediate and national authorities, and to immediately implement primary control measures” (12). The FETP-Frontline was initiated as a response to identified gaps in surveillance and response capacity at the local level. In many developing countries, district-level surveillance officers have historically only passed information on to the national level, without taking the opportunity to analyze the data locally or respond immediately. These missed opportunities can contribute to delays in disease recognition and timely interventions. By tailoring a training program and field products to the routine responsibilities and expected job duties of a district surveillance officer, participants develop relevant and practical competencies in field epidemiology.

FETP-Frontline has targeted the district level for training because, quite simply, this is where the action is. In most countries, the district level is the point at which surveillance data first enter the formal public health system and also the point at which data are aggregated and can be analyzed to detect abnormalities and represents the first opportunity to mount a public health intervention. Preliminary data from FETP-Frontline have shown improvements in local detection and response capacity within weeks of initiating the training. This capacity can be seen in the local functioning of the public health surveillance system. There have been improvements in the timeliness of surveillance reporting and an increase in field activity that result in quicker identification of diseases in the community. The purpose of FETP-Frontline is not only to improve the timeliness of the surveillance data that are collected but also to improve the quality of the data and to promote critical thinking by district-level surveillance officers who are responsible for the data. In conducting data quality analysis, trainees identify gaps and propose recommendations to improve surveillance in their locales. During the third workshop, higher-level members of the surveillance system are invited to attend the presentations and react to some of the findings, ensuring that the problems identified during the field work are brought to the attention of MOH leadership. Some of the recommendations formulated by FETP-Frontline participants have already led to local changes in surveillance systems such as the adoption and utilization of rumor logs, increased distribution of standardized case definitions for diseases under surveillance, and increased emphasis on surveillance data during monthly district management meetings.

The successful implementation of FETPs-Frontline occurred simultaneously across several countries and demonstrated that a large-scale, multicountry capacity-building program could be implemented quickly with external support and country engagement. This effort did not take staff away from their jobs in-country and provided benefits in a short timeframe by addressing actual problems at individual work sites. However, for the program to be sustainable, countries will ultimately have to take on the technical and logistical leadership of the program. The implementation of FETPs-Frontline is not without challenges. This initiative was greatly supported by the CDC and several partners including WHO, the African Field Epidemiology Network (AFENET), Training Programs in Epidemiology and Public Health Interventions Network (TEPHINET), and the Defense Threat Reduction Agency (DTRA). Because the FETP-Frontline model is continuing education for existing public health personnel, it requires the involvement and commitment of the host country’s MOH. During the training, each participant received >1 day of onsite mentoring and supervision during each of the 2 field stages. Mentorship in the field requires both financial and technical resources. The costs for implementing FETP-Frontline varied from US $5,000 to $8,000 per student (data not shown) based on many factors, including the existence of locally trained personnel.

Several countries had difficulty identifying professionals with the appropriate skills and experience in field epidemiology who could devote the time required to mentor participants. Several strategies were used to address this gap, including providing an orientation on effective mentoring techniques for staff, fully training a small group of central-level candidates in the first cohort to familiarize them with the field-based training approach and then having them serve as mentors for later cohorts, and engaging mentors from outside the country for the first few cohorts.

There is a concern that, once trained, graduates may leave their posts for better opportunities outside the public health system. A few countries have addressed this issue through the following mechanisms: making participation in the program contingent upon staying in that position for a set period, setting an upper age limit for participants so that newly trained staff will not retire shortly after the course, and designating new and more appropriate positions for those who are trained in FETP-Frontline. FETP-Frontline will need to continue until there is a critical mass of trained personnel representing each district or other identified subnational unit in every country. MOHs are responsible for continuing to support the training to address staff turnover and to make available the resources for the field activities of effective public health surveillance.

Although comparing the outcomes of FETP-Frontline implementation between countries is complicated due to the wide variability in public health systems, there are important lessons and implications for other countries from each implementation. Currently, standard indicators across programs are in development. The national IDSR indicators and the results of efforts such as the independent Joint External Evaluation process will enable countries to track progress in detecting and responding to emergencies (13). It is likely that other countries can learn from the lessons in FETP-Frontline implementation we have described and embark upon efforts to launch the program for themselves.

In-service FETP-Frontline training can be an effective strategy to improve the functioning of a public health surveillance system in a short time with immediate benefits. Trainees are working in their home districts, analyzing their own data, addressing their local health priorities, and identifying ways to better detect and respond to public health emergencies given their unique local constraints. By empowering actors to analyze and intervene at the district level, the program helps decentralize some of the initial analysis and decision making, which leads to more accurate communication within the system and a timelier public health response. In some countries, the veterinary and laboratory sectors were included in training cohorts to foster local cross-sector collaboration and a One Health approach to surveillance and response activities. This initiative should be viewed not as a training program but as part of a larger workforce development strategy to improve a country’s local surveillance and response capacity that complements FETP training activities at the intermediate and advanced levels. Participants who have completed the training are contributing to enhanced global health security by being able to detect outbreaks sooner, respond faster, and, through quick response, limit the spread of infectious disease outbreaks at the source.