COVID-19 Response Roles among CDC International Public Health Emergency Management Fellowship Graduates

Since 2013, the US Centers for Disease Control and Prevention has offered the Public Health Emergency Management Fellowship to health professionals from around the world. The goal of this program is to build an international workforce to establish public health emergency management programs and operations centers in participating countries. In March 2021, all 141 graduates of the fellowship program were invited to complete a web survey designed to examine their job roles and functions, assess their contributions to their country’s COVID-19 response, and identify needs for technical assistance to strengthen national preparedness and response systems. Of 141 fellows, 89 successfully completed the survey. Findings showed that fellowship graduates served key roles in COVID-19 response in many countries, used skills they gained from the fellowship, and desired continuing engagement between the Centers for Disease Control and Prevention and fellowship alumni to strengthen the community of practice for international public health emergency management.

Since 2013, the US Centers for Disease Control and Prevention has offered the Public Health Emergency Management Fellowship to health professionals from around the world. The goal of this program is to build an international workforce to establish public health emergency management programs and operations centers in participating countries. In March 2021, all 141 graduates of the fellowship program were invited to complete a web survey designed to examine their job roles and functions, assess their contributions to their country's COVID-19 response, and identify needs for technical assistance to strengthen national preparedness and response systems. Of 141 fellows, 89 successfully completed the survey. Findings showed that fellowship graduates served key roles in COVID-19 response in many countries, used skills they gained from the fellowship, and desired continuing engagement between the Centers for Disease Control and Prevention and fellowship alumni to strengthen the community of practice for international public health emergency management.
objectives of the survey were to assess the number and proportion of total graduates engaged in COVID-19 response in the public health emergency management system in the respondent's country; identify the organizations served and positions filled by graduates within the country's public health emergency management system before and during the COVID-19 response; identify public health emergency response skills acquired through the PHEM Fellowship program that the respondent considered useful after graduation; identify additional technical skills related to public health emergency management needed to sustain the COVID-19 response; and identify modes of technical assistance support (remote or onsite) preferred by graduates.

Methods
We developed a 21-question web-based survey that could be answered in 10-15 minutes designed to address the 5 survey objectives (Appendix, https:// wwwnc.cdc.gov/EID/article/28/13/22-0713-App1. pdf). We analyzed responses grouped by semiannual cohort (n = 12) and region. On March 20, 2021, we sent an email with a secure link to the survey to all persons who had graduated from the PHEM Fellowship program by that date (n = 141). The survey remained open for 5 weeks; reminder emails were sent 2 and 4 weeks after the initial mailing. CDC reviewed the activity and determined that it did not involve human subject research and therefore did not require Institutional Review Board approval.
The survey collected deidentified information on respondents' countries, roles, graduation month and year (cohort), and organization type of current and any previous employment. Survey questions required multiple-choice, multiple-answer, free text, or 5-point Likert scale responses (12). We created the survey in the Epi-Info Secure Web Survey tool (https://www. cdc.gov/epiinfo/index.html) and included relevant skip patterns to simplify entry for respondents. We used the number of graduates of the PHEM Fellowship program from each country and cohort to determine the expected number of responses, then compared those to survey responses to identify and remove duplicates.
Once the survey closed, we combined French and English responses based on common data elements, then cleaned and analyzed the data using Epi Info and Microsoft Power BI (https://powerbi.microsoft. com). We calculated response rates using standard definitions (13). We calculated 95% CIs around percentages with the finite population correction factor for known population size (n = 141 graduates). To examine differences by region, we organized respondents by their corresponding World Health Organization (WHO) regional offices (Table 1).

Results
We successfully reached 136/141 (96.5%) PHEM Fellowship program graduates. Overall, respondents submitted 111 completed surveys; 21 were duplicates, and 1 did not include country name and cohort ( Figure). Duplicates were most likely to occur right after the respondent's first submission or shortly after reminder emails were distributed. After excluding duplicates and the 1 incomplete response, we analyzed data from the remaining 89 surveys, a response rate of 74.2% (13). Respondents from WPRO (Western Pacific Regional Office) countries had a 42.9% response rate, lower than those for other WHO regions: AFRO (Africa), 77.5%; SEARO (South-East Asia), 91.7%; EMRO (Eastern Mediterranean), 100%; and EURO (Europe), 100%. There were no PHEM Fellowship program graduates from the Americas at the time the survey was conducted. Overall, the first 2 cohorts had lower response rates (0% for cohort 1 and 14.3% for cohort 2) and cohort 10 had a higher response rate (93.8%) than those for the other groups combined. The distribution of survey participants by WHO region was similar to the overall distribution of total fellowship participants by region (Table 1). We analyzed the survey data to assess the 5 predetermined survey objectives.

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Emerging The 89 respondents reported diverse professional backgrounds, and many had served in several different positions before participating in the PHEM Fellowship program. More respondents (n = 60, 67.4%) worked for the country's ministry of health than any other organization type. During the COVID-19 pandemic, more respondents reported engaging in emergency response functions after graduating from the fellowship program than before. More than half (n = 47, 52.8%) served in managerial or nonmanagerial roles in emergency operations centers to support COVID-19 and other public health responses (

Discussion
This survey provided information on how participation in the PHEM Fellowship program contributed to improving international workforce capacity to manage public health emergencies. The PHEM Fellowship program provides standard training and mentorship and networking components that enable countries to build systems unique to their needs and context. Nearly 90% of respondents indicated that they held a role in their country's COVID-19 response, demonstrating the relevance of a trained public health emergency management workforce during emergencies. Program graduates credited the fellowship with developing skills essential for public health emergency management, including conducting risk assessments, developing response plans, aiding with training and exercises, and managing resources, and most expressed interest in sharing their experiences.  PHEM fellowship program graduates are likely more culturally aware of local politics, resources, languages, and challenges than are US-based experts. Anecdotal examples from the survey of initiatives by graduates in the field included conducting reciprocal site visits between Uganda and Sierra Leone to observe how other nations operate their PHEOCs and providing technical assistance (e.g., Cameroon supporting the Democratic Republic of the Congo by sharing risk assessment and response plans). Other opportunities for in-depth, longitudinal relationship management with PHEM graduates are likely and could be modeled after the alumni engagement networks of other CDC training programs.
All data were self-reported and therefore possibly subject to biases that tend toward overestimates. Respondents might have been more likely to rate their skills and confidence more positively (social desirability bias) and attribute skills gained from a CDC program more highly on a survey conducted by CDC (acquiescence bias) (14). Several factors might have suppressed the overall response rate, including differences in language understanding and perception, length of time since participation in the fellowship, lack of time because of engagement in the COVID-19 response, or incorrect contact information. Regions such as WPRO were underrepresented in survey responses compared with AFRO, which could affect generalizability of the results and subsequent programmatic recommendations.
Overall, our findings indicated that fellowship graduates served key roles in country COVID-19 responses, used skills gained from participating in the fellowship, and desired ongoing engagement between CDC and fellowship alumni to continue strengthening the community of practice for international public health emergency management. Investments in this program could address the growing demand for public health emergency responders with the expertise to combat future epidemics and pandemics (15,16). Response needs prompted by the COVID-19 pandemic have increased interest from more countries and regions to provide applicants to future fellowship cohorts (CDC PHEM Fellowship Program, unpub. data).
Strong investments in building international workforce capacity should combine time-limited intensive in-person learning with ongoing mentorship and cultivated alumni networks. CDC is working to expand the fellowship's curriculum, develop advanced training opportunities, and translate materials into additional languages. The goal of these Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 28, No. 13, Supplement to December 2022 S149 Table 3. Confidence to perform emergency management skills acquired in the CDC PHEM Fellowship program as reported by respondents to a survey of program graduates, April 2021* training improvements and advancement of peer-topeer mentoring is to continue strengthening international public health emergency management workforce capacity. Using a combination of virtual and in-person trainings, peer-to-peer learning, and sharing best practices can strengthen the nascent global network of fellowship graduates and other public health emergency management experts. As the field of public health emergency management continues to advance, systematic evaluations are needed to understand how best to support PHEM fellowship program graduates and identify strengths and gaps of the program at large. CDC is developing an evaluation framework and evaluation plan to address this need.