CDC's COVID-19 International Vaccine Implementation and Evaluation Program and Lessons from Earlier Vaccine Introductions.

The US Centers for Disease Control and Prevention (CDC) supports international partners in introducing vaccines, including those against SARS-CoV-2 virus. CDC contributes to the development of global technical tools, guidance, and policy for COVID-19 vaccination and has established its COVID-19 International Vaccine Implementation and Evaluation (CIVIE) program. CIVIE supports ministries of health and their partner organizations in developing or strengthening their national capacities for the planning, implementation, and evaluation of COVID-19 vaccination programs. CIVIE's 7 priority areas for country-specific technical assistance are vaccine policy development, program planning, vaccine confidence and demand, data management and use, workforce development, vaccine safety, and evaluation. We discuss CDC's work on global COVID-19 vaccine implementation, including priorities, challenges, opportunities, and applicable lessons learned from prior experiences with Ebola, influenza, and meningococcal serogroup A conjugate vaccine introductions.

WHO competency framework for health authorities and institutions to manage infodemics: its development and features.

BACKGROUND: In April 2020, the World Health Organization (WHO) Information Network for Epidemics produced an agenda for managing the COVID-19 infodemic. "Infodemic" refers to the overabundance of information-including mis- and disinformation. In this agenda it was pointed out the need to create a competency framework for infodemic management (IM). This framework was released by WHO on 20th September 2021. This paper presents the WHO framework for IM by highlighting the different investigative steps behind its development. METHODS: The framework was built through three steps. Step 1 included the preparatory work following the guidelines in the Guide to writing Competency Framework for WHO Academy courses. Step 2 was based on a qualitative study with participants (N = 25), identified worldwide on the basis of their academic background in relevant fields of IM or of their professional experience in IM activities at the institutional level. The interviews were conducted online between December 2020 and January 2021, they were video-recorded and analyzed using thematic analysis. In Step 3, two stakeholder panels were conducted to revise the framework. RESULTS: The competency framework contains four primary domains, each of which comprised main activities, related tasks, and knowledge and skills. It identifies competencies to manage and monitor infodemics, to design, conduct and evaluate appropriate interventions, as well as to strengthen health systems. Its main purpose is to assist institutions in reinforcing their IM capacities and implementing effective IM processes and actions according to their individual contexts and resources. CONCLUSION: The competency framework is not intended to be a regulatory document nor a training curriculum. As a WHO initiative, it serves as a reference tool to be applied according to local priorities and needs within the different countries. This framework can assist institutions in strengthening IM capacity by hiring, staff development, and human resources planning.

Surveillance Training for Ebola Preparedness in Côte d'Ivoire, Guinea-Bissau, Senegal, and Mali.

The 2014-2015 epidemic of Ebola virus disease in West Africa primarily affected Guinea, Liberia, and Sierra Leone. Several countries, including Mali, Nigeria, and Senegal, experienced Ebola importations. Realizing the importance of a trained field epidemiology workforce in neighboring countries to respond to Ebola importations, the Centers for Disease Control and Prevention Field Epidemiology Training Program unit implemented the Surveillance Training for Ebola Preparedness (STEP) initiative. STEP was a mentored, competency-based initiative to rapidly build up surveillance capacity along the borders of the at-risk neighboring countries Côte d'Ivoire, Mali, Senegal, and Guinea-Bissau. The target audience was district surveillance officers. STEP was delivered to 185 participants from 72 health units (districts or regions). Timeliness of reporting and the quality of surveillance analyses improved 3 months after training. STEP demonstrated that mentored, competency-based training, where learners attain competencies while delivering essential public health services, can be successfully implemented in an emergency response setting.

A systematic review of pre-service training on vaccination and immunization.

INTRODUCTION: The World Health Organization's Global Strategy on Human Resources for Health: Workforce 2030 sets policy recommendations and targets for in-service and pre-service training programs to improve workforce competency. To date, comprehensive reviews on immunization training have mainly focused on in-service trainings. This systematic review aimed to synthesize current literature on pre-service immunization training, including primary immunization competencies covered, methods used, outcomes on improving competencies and behavior change for immunization service delivery, and student readiness for immunization practice, in both low-resource and high-income settings. METHODS: A systematic search of seven scholarly databases identified published literature on pre-service training on immunization published between January 2001 and November 2021. It included all geographic regions and languages, study designs, and individuals preparing to enter the immunization workforce. Additional search methods included reviewing references of retrieved articles, scanning journals, and engaging pre-service training experts for unpublished reports. RESULTS: Search results yielded 5,611 articles; 39 articles met the inclusion criteria. Five articles were identified through other search methods. Studies took place mostly in high-income countries (35/44), targeted professional (medical, nursing, and pharmacy) students and tutors at health training institutions. Eight of the ten recommended immunization competencies were included in the curricula and methods used to deliver pre-service training varied. Teaching techniques and applied learning strategies using realistic situations increased students' knowledge, attitudes, and awareness of vaccine benefits; built confidence to administer vaccines and communicate with hesitant patients; and increased the likelihood of recommending vaccines. CONCLUSION: This review was the first step to understanding pre-service training on immunization. Further research is needed to inform pre-service training programs in low- and middle-income countries, particularly for nurses, vaccinators with low-level educational backgrounds, and other healthcare professional students. Prioritizing essential audiences, designing and delivering practical training, and evaluating results will help prepare students for the immunization challenges of tomorrow.

Applying Adult Learning Best Practices to Design Immunization Training for Health Care Workers in Ghana.

INTRODUCTION: A 2016 assessment of frontline health care workers (HCWs) in Ghana identified knowledge, skill, and attitude gaps related to immunization during the second year of life (2YL). The U.S. Centers for Disease Control and Prevention subsequently supported the Ghana Health Service Immunization Program to apply best practices of adult learning and training of trainers (TOT) for a cascade training program for 2YL. METHODS: Five districts from each of the 3 regions (Greater Accra, Northern, and Volta) were selected for the TOT based on key measles and rubella vaccination coverage indicators. The design incorporated best practices of adult learning and TOT. The curriculum integrated 3 major topical themes: technical (immunization topics), operational, and training adults. The technical and operational content was based on HCW tasks most directly affecting 2YL objectives. A cross-functional team developed all classroom, field activity, and training evaluation materials. RESULTS: Seventy-four participants attended TOT workshops in 2017. Based on a rubric defined by the course designers, 99% of the participants reported an acceptable level of confidence to apply and teach the course content. After the TOTs, participants conducted 65 workshops, 43 field visits, and 4 review meetings, reaching 1,378 HCWs within 7 months. Fifty-four percent of HCWs who received training from TOT participants reported an acceptable level of confidence in using the skills, and 92% reported they would prioritize applying the skills acquired during the training. DISCUSSION: The success factors for effective adult learning and TOT can be applied to design and implement high-quality TOT even in resource-limited settings. The factors include using a variety of approaches, spending enough class time to prepare TOT participants for their training role, setting specific expectations for cascading the training, and following up through mentorship and reporting. Strong collaboration across the administrative levels of the Ghana Health Service enabled cascade training.

Evaluation of the Impact of Immunization Second Year of Life Training Interventions on Health Care Workers in Ghana.

INTRODUCTION: As part of a suite of training interventions to improve the knowledge and practice of immunization in the second year of life (2YL), training of trainers workshops were conducted with regional and district health management teams (DHMTs) in 15 districts in 3 regions of Ghana. Using adult learning principles, DHMTs implemented several capacity-building activities at the subdistrict and health facility levels, including health facility visits, on-the-job training, and review meetings. The current evaluation investigated whether frontline health care workers (HCWs) reported or demonstrated improvements in knowledge, attitudes, and practices after training interventions. METHODS: Quantitative and qualitative methods with a utilization-focused approach guided the framework for this evaluation. A systematic random sample of 115 HCWs in 3 regions of Ghana was selected to complete a competency survey before and after training, which focused on 3 core competency areas-Expanded Programme on Immunization (EPI) policy; communication with caregivers; and immunization data management, recording, and use. Interviews and direct observations by data collectors were done to assess HCWs' knowledge, self-reported attitude, and behavior changes in practices. RESULTS: Of 115 HCWs, 102 were surveyed before and 4 months after receiving capacity-building interventions. Modest but not statistically significant improvements were found in knowledge on EPI policy, immunization data management, and communication skills with caregivers. HCWs reported that they had improved several attitudes and practices after the 2YL training. The most improved practice reported by HCWs and observed in all 3 regions was the creation of a defaulter list. DISCUSSION: Findings of this evaluation provide encouraging evidence in taking the first step toward improving HCW knowledge, attitudes, and practices for 3 core immunization competency areas. The use of learner-focused teaching methods combined with adult learning principles is helpful in solving specific performance problems (such as lack of knowledge of EPI policy).

Developing standardized competencies to strengthen immunization systems and workforce.

Despite global support for immunization as a core component of the human right to health and the maturity of immunization programs in low- and middle-income countries throughout the world, there is no comprehensive description of the standardized competencies needed for immunization programs at the national, multiple sub-national, and community levels. The lack of defined and standardized competencies means countries have few guidelines to help them address immunization workforce planning, program management, and performance monitoring. Potential consequences resulting from the lack of defined competencies include inadequate or inefficient distribution of resources to support the required functions and difficulties in adequately managing the health workforce. In 2015, an international multi-agency working group convened to define standardized competencies that national immunization programs could adapt for their own workforce planning needs. The working group used a stepwise approach to ensure that the competencies would align with immunization programs' objectives. The first step defined the attributes of a successful immunization program. The group then defined the work functions needed to achieve those attributes. Based on the work functions, the working group defined specific competencies. This process resulted in three products: (1) Attributes of an immunization program described within eight technical domains at four levels within a health system: National, Provincial, District/Local, and Community; (2) 229 distinct functions within those eight domains at each of the four levels; and (3) 242 competencies, representing eight technical domains and two foundational domains (Management and Leadership and Vaccine Preventable Diseases and Program). Currently available as a working draft and being tested with immunization projects in several countries, the final document will be published by WHO as normative guidelines. Vertical immunization programs as well as integrated systems can customize the framework to suit their needs. Standardized competencies can support immunization program improvements and help strengthen effective health systems.

Laboratory epidemiologist: skilled partner in field epidemiology and disease surveillance in Kenya.

Although for over 20 years the Field Epidemiology Training Programs (FETPs) have provided a model for building epidemiology capacity in Ministries of Health worldwide, the model does not address laboratory training and its integration with epidemiology. To overcome this, Kenya added a laboratory management component in 2004, creating the first field epidemiology and laboratory training program (FELTP) to train both medical and laboratory epidemiologists. Laboratory management and epidemiology candidates were recruited from among degree-holding scientists at the Ministry of Health and trained in both applied epidemiology and laboratory management using a combination of short courses and extensive field placements. The course generated a cohort of laboratory epidemiologists with demonstrated capacity in disease surveillance and management of outbreaks. Early indicators suggest programmatic success: the start of laboratory-based disease reporting and better laboratory involvement in outbreak responses.

Replicating success: developing a standard FETP curriculum.

Field epidemiology training programs have been successful models to address a country's needs for a skilled public health workforce, partly due to their responsiveness to the countries' unique needs. The Centers for Disease Control and Prevention has partnered with ministries of health to strengthen their workforce through customized competency-based training programs. While desirable, emphasis on program flexibility can result in redundancy and inconsistency. To address this challenge, the ADDIE model (analysis, design, development, implementation, and evaluation) of instructional design was used by a cross-functional team to guide completion of a standard curriculum based on 15 competencies. The standard curriculum has supported the development and expansion of programs while still allowing for adaptation. This article describes the process that was used to develop the curriculum, which, together with needs assessment and evaluation, is crucial for successful training programs.

Using Predictive Evaluation to Design, Evaluate, and Improve Training for Polio Volunteers.

BACKGROUND: Predictive Evaluation (PE) uses a four-step process to predict results then designs and evaluates a training intervention accordingly. In 2012, the Sustainable Management Development Program (SMDP) at the Centers for Disease Control and Prevention used PE to train Stop Transmission of Polio (STOP) program volunteers. METHODS: Stakeholders defined specific beliefs and practices that volunteers should demonstrate. These predictions and adult learning practices were used to design a curriculum to train four cohorts. At the end of each workshop, volunteers completed a beliefs survey and wrote goals for intended actions. The goals were analyzed for acceptability based on four PE criteria. The percentage of acceptable goals and the beliefs survey results were used to define the quality of the workshop. A postassignment adoption evaluation was conducted for two cohorts, using an online survey and telephone or in-person structured interviews. The results were compared with the end of workshop findings. RESULTS: The percentage of acceptable goals across the four cohorts ranged from 49% to 85%. In the adoption evaluation of two cohorts, 88% and 94% of respondents reported achieving or making significant progress toward their goal. A comparison of beliefs survey responses across the four cohorts indicated consistencies in beliefs that aligned with stakeholders' predictions. CONCLUSIONS: Goal statements that participants write at the end of a workshop provide data to evaluate training quality. Beliefs surveys surface attitudes that could help or hinder workplace performance. The PE approach provides an innovative framework for health worker training and evaluation that emphasizes performance.

Strong and Flexible: Developing a Three-Tiered Curriculum for the Regional Central America Field Epidemiology Training Program.

Field Epidemiology Training Programs (FETPs) are recognized worldwide as an effective means to strengthen countries' capacity in epidemiology, surveillance, and outbreak response. FETPs are field-based, with minimum classroom time and maximum time in the field, providing public health services while participants achieve competency. The Central America FETP (CAFETP) uses a three-level pyramid model: basic, intermediate, and advanced. In 2006, a multidisciplinary team used a methodical process based on adult learning practices to construct a competency-based curriculum for the CAFETP. The curriculum was designed based on the tasks related to disease surveillance and field epidemiology that public health officers would conduct at multiple levels in the system. The team used a design process that engaged subject matter experts and considered the unique perspective of each country. The designers worked backwards from the competencies to define field activities, evaluation methods, and classroom components. The 2006 pyramid curriculum has been accredited for a master's of science in field epidemiology by the Universidad del Valle de Guatemala and has been adapted by programs around the world. The team found the time and effort spent to familiarize subject matter experts with key adult learning principles was worthwhile because it provided a common framework to approach curriculum design. Early results of the redesigned curriculum indicate that the CAFETP supports consistent quality while allowing for specific country needs.

Developing standardized competencies to strengthen immunization systems and workforce

Despite global support for immunization as a core component of the human right to health and the maturity of immunization programs in low- and middle-income countries throughout the world, there is no comprehensive description of the standardized competencies needed for immunization programs at the national, multiple sub-national, and community levels. The lack of defined and standardized competencies means countries have few guidelines to help them address immunization workforce planning, program management, and performance monitoring. Potential consequences resulting from the lack of defined competencies include inadequate or inefficient distribution of resources to support the required functions and difficulties in adequately managing the health workforce. In 2015, an international multi-agency working group convened to define standardized competencies that national immunization programs could adapt for their own workforce planning needs. The working group used a stepwise approach to ensure that the competencies would align with immunization programs' objectives. The first step defined the attributes of a successful immunization program. The group then defined the work functions needed to achieve those attributes. Based on the work functions, the working group defined specific competencies. This process resulted in three products: (1) Attributes of an immunization program described within eight technical domains at four levels within a health system: National, Provincial, District/Local, and Community; (2) 229 distinct functions within those eight domains at each of the four levels; and (3) 242 competencies, representing eight technical domains and two foundational domains (Management and Leadership and Vaccine Preventable Diseases and Program). Currently available as a working draft and being tested with immunization projects in several countries, the final document will be published by WHO as normative guidelines. Vertical immunization programs as well as integrated systems can customize the framework to suit their needs. Standardized competencies can support immunization program improvements and help strengthen effective health systems.