Field epidemiology training programs contribute to COVID-19 preparedness and response globally.

BACKGROUND: Field epidemiology training programs (FETPs) have trained field epidemiologists who strengthen global capacities for surveillance and response to public health threats. We describe how FETP residents and graduates have contributed to COVID-19 preparedness and response globally. METHODS: We conducted a cross-sectional survey of FETPs between March 13 and April 15, 2020 to understand how FETP residents or graduates were contributing to COVID-19 response activities. The survey tool was structured around the eight Pillars of the World Health Organization's (WHO) Strategic Preparedness and Response Plan for COVID-19. We used descriptive statistics to summarize quantitative results and content analysis for qualitative data. RESULTS: Among 88 invited programs, 65 (74%) responded and indicated that FETP residents and graduates have engaged in the COVID-19 response across all six WHO regions. Response efforts focused on country-level coordination (98%), surveillance, rapid response teams, case investigations (97%), activities at points of entry (92%), and risk communication and community engagement (82%). Descriptions of FETP contributions to COVID-19 preparedness and response are categorized into seven main themes: conducting epidemiological activities, managing logistics and coordination, leading risk communication efforts, providing guidance, supporting surveillance activities, training and developing the workforce, and holding leadership positions. CONCLUSIONS: Our findings demonstrate the value of FETPs in responding to public health threats like COVID-19. This program provides critical assistance to countries' COVID-19 response efforts but also enhances epidemiologic workforce capacity, public health emergency infrastructure and helps ensure global health security as prescribed in the WHO's International Health Regulations.

Analysis of Joint External Evaluations in the WHO Eastern Mediterranean Region.

BACKGROUND: Joint External Evaluation (JEE) was developed as a new model of peer-to-peer expert external evaluations of IHR capacities using standardized approaches. AIMS: This study aimed to consolidate findings of these assessments in the Eastern Mediterranean Region and assess their significance. METHODS: Analysis of the data were conducted for 14 countries completing JEE in the Region. Mean JEE score for each of the 19 technical areas and for the overall technical areas were calculated. Bivariate and multivariate analyses were done to assess correlations with key health, socio-economic and health system indicators. RESULTS: Mean JEE scores varied substantially across technical areas. The cumulative mean JEE (mean of indicator scores related to that technical area) was 3 (range: 1-4). Antimicrobial resistance, Biosecurity and Biosafety indicators obtained the lowest scores. Medical countermeasures, personnel deployment and linking public health with security capacities had the highest cumulative mean score of 4 (range: 2-5). JEE scores correlated with most of the key indicators examined. Countries with better health financing system, health service coverage and health status generally had higher JEE scores. Adolescent fertility rate, neonatal mortality ratio and net primary school enrollment ratio were primary factors within a country's overall JEE score. CONCLUSIONS: An integrated multisectoral approach, including well-planned cross-cutting health financing system and coverage, are critical to address the key gaps identified by JEEs in order to ensure regional and global health security.

US Centers for Disease Control and Prevention and Its Partners' Contributions to Global Health Security.

To achieve compliance with the revised World Health Organization International Health Regulations (IHR 2005), countries must be able to rapidly prevent, detect, and respond to public health threats. Most nations, however, remain unprepared to manage and control complex health emergencies, whether due to natural disasters, emerging infectious disease outbreaks, or the inadvertent or intentional release of highly pathogenic organisms. The US Centers for Disease Control and Prevention (CDC) works with countries and partners to build and strengthen global health security preparedness so they can quickly respond to public health crises. This report highlights selected CDC global health protection platform accomplishments that help mitigate global health threats and build core, cross-cutting capacity to identify and contain disease outbreaks at their source. CDC contributions support country efforts to achieve IHR 2005 compliance, contribute to the international framework for countering infectious disease crises, and enhance health security for Americans and populations around the world.

Joint External Evaluation-Development and Scale-Up of Global Multisectoral Health Capacity Evaluation Process.

The Joint External Evaluation (JEE), a consolidation of the World Health Organization (WHO) International Health Regulations 2005 (IHR 2005) Monitoring and Evaluation Framework and the Global Health Security Agenda country assessment tool, is an objective, voluntary, independent peer-to-peer multisectoral assessment of a country's health security preparedness and response capacity across 19 IHR technical areas. WHO approved the standardized JEE tool in February 2016. The JEE process is wholly transparent; countries request a JEE and are encouraged to make its findings public. Donors (e.g., member states, public and private partners, and other public health institutions) can support countries in addressing identified JEE gaps, and implementing country-led national action plans for health security. Through July 2017, 52 JEEs were completed, and 25 more countries were scheduled across WHO's 6 regions. JEEs facilitate progress toward IHR 2005 implementation, thereby building trust and mutual accountability among countries to detect and respond to public health threats.

First confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection in the United States, updated information on the epidemiology of MERS-CoV infection, and guidance for the public, clinicians, and public health authorities - May 2014.

Since mid-March 2014, the frequency with which cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection have been reported has increased, with the majority of recent cases reported from Saudi Arabia and United Arab Emirates (UAE). In addition, the frequency with which travel-associated MERS cases have been reported and the number of countries that have reported them to the World Health Organization (WHO) have also increased. The first case of MERS in the United States, identified in a traveler recently returned from Saudi Arabia, was reported to CDC by the Indiana State Department of Health on May 1, 2014, and confirmed by CDC on May 2. A second imported case of MERS in the United States, identified in a traveler from Saudi Arabia having no connection with the first case, was reported to CDC by the Florida Department of Health on May 11, 2014. The purpose of this report is to alert clinicians, health officials, and others to increase awareness of the need to consider MERS-CoV infection in persons who have recently traveled from countries in or near the Arabian Peninsula. This report summarizes recent epidemiologic information, provides preliminary descriptions of the cases reported from Indiana and Florida, and updates CDC guidance about patient evaluation, home care and isolation, specimen collection, and travel as of May 13, 2014.

Advancing Health Security and Disease Eradication Through Peace and Health: A Mali Case Study.

Conflict and violence constitute threats to public health. As levels of conflict increase within and between countries, it is important to explore how conflict resolution initiatives can be adapted to meet the health needs of communities, and how addressing the health needs of communities can assist in conflict resolution and contribute to health security. In conflict-affected central Mali, a Peace through Health Initiative, piloted between 2018 and 2022, used conflict resolution trainings, facilitated community meetings, and human and animal health interventions to negotiate "periods of tranquility" to achieve public health goals. Project activities resulted in improved health, improved livelihoods, reduced violence, improved trust among stakeholders, and greater inclusion of community members in peace and health decisionmaking. The Peace-Health Initiative generated several lessons learned related to 3 phases of peace-health programming: preintervention, program development, and implementation. These lessons can be applied to support expanded Peace through Health Initiatives within Mali, may be adaptable to other conflict-afflicted contexts, and should be considered in relation to the implementation of global health security.

Addressing the challenges of implementing evidence-based prioritisation in global health.

Global health requires evidence-based approaches to improve health and decrease inequalities. In a roundtable discussion between health practitioners, funders, academics and policy-makers, we recognised key areas for improvement to deliver better-informed, sustainable and equitable global health practices. These focus on considering information-sharing mechanisms and developing evidence-based frameworks that take an adaptive function-based approach, grounded in the ability to perform and respond to prioritised needs. Increasing social engagement as well as sector and participant diversity in whole-of-society decision-making, and collaborating with and optimising on hyperlocal and global regional entities, will improve prioritisation of global health capabilities. Since the skills required to navigate drivers of pandemics, and the challenges in prioritising, capacity building and response do not sit squarely in the health sector, it is essential to integrate expertise from a broad range of fields to maximise on available knowledge during decision-making and system development. Here, we review the current assessment tools and provide seven discussion points for how improvements to implementation of evidence-based prioritisation can improve global health.

International Health Regulations--what gets measured gets done.

The global spread of severe acute respiratory syndrome highlighted the need to detect and control disease outbreaks at their source, as envisioned by the 2005 revised International Health Regulations (IHR). June 2012 marked the initial deadline by which all 194 World Health Organization (WHO) member states agreed to have IHR core capacities fully implemented for limiting the spread of public health emergencies of international concern. Many countries fell short of these implementation goals and requested a 2-year extension. The degree to which achieving IHR compliance will result in global health security is not clear, but what is clear is that progress against the threat of epidemic disease requires a focused approach that can be monitored and measured efficiently. We developed concrete goals and metrics for 4 of the 8 core capacities with other US government partners in consultation with WHO and national collaborators worldwide. The intent is to offer an example of an approach to implementing and monitoring IHR for consideration or adaptation by countries that complements other frameworks and goals of IHR. Without concrete metrics, IHR may waste its considerable promise as an instrument for global health security against public health emergencies.

Integrating genome-based informatics to modernize global disease monitoring, information sharing, and response.

The rapid advancement of genome technologies holds great promise for improving the quality and speed of clinical and public health laboratory investigations and for decreasing their cost. The latest generation of genome DNA sequencers can provide highly detailed and robust information on disease-causing microbes, and in the near future these technologies will be suitable for routine use in national, regional, and global public health laboratories. With additional improvements in instrumentation, these next- or third-generation sequencers are likely to replace conventional culture-based and molecular typing methods to provide point-of-care clinical diagnosis and other essential information for quicker and better treatment of patients. Provided there is free-sharing of information by all clinical and public health laboratories, these genomic tools could spawn a global system of linked databases of pathogen genomes that would ensure more efficient detection, prevention, and control of endemic, emerging, and other infectious disease outbreaks worldwide.

Dracunculiasis Eradication: End-Stage Challenges.

This report summarizes the status of the global Dracunculiasis Eradication Program as of the end of 2021. Dracunculiasis (Guinea worm disease) has been eliminated from 17 of 21 countries where it was endemic in 1986, when an estimated 3.5 million cases occurred worldwide. Only Chad, Ethiopia, Mali, and South Sudan reported cases in humans in 2021. Chad, Ethiopia, and Mali also reported indigenous infections of animals, mostly domestic dogs, with Dracunculus medinensis. Insecurity and infections in animals are the main obstacles remaining to interrupting dracunculiasis transmission completely.

Tuberculosis outbreak investigations in the United States, 2002-2008.

To understand circumstances of tuberculosis transmission that strain public health resources, we systematically reviewed Centers for Disease Control and Prevention (CDC) staff reports of US outbreaks in which CDC participated during 2002-2008 that involved ≥3 culture-confirmed tuberculosis cases linked by genotype and epidemiology. Twenty-seven outbreaks, representing 398 patients, were reviewed. Twenty-four of the 27 outbreaks involved primarily US-born patients; substance abuse was another predominant feature of outbreaks. Prolonged infectiousness because of provider- and patient-related factors was common. In 17 outbreaks, a drug house was a notable contributing factor. The most frequently documented intervention to control the outbreak was prioritizing contacts according to risk for infection and disease progression to ensure that the highest risk contacts were completely evaluated. US-born persons with reported substance abuse most strongly characterized the tuberculosis outbreaks in this review. Substance abuse remains one of the greatest challenges to controlling tuberculosis transmission in the United States.

Tuberculosis transmission and use of methamphetamines in Snohomish County, WA, 1991-2006.

OBJECTIVES: We investigated a cluster of tuberculosis (TB) cases among persons using methamphetamines in Snohomish County, Washington, to determine the extent of the outbreak, examine whether methamphetamine use contributed to TB transmission, and implement strategies to prevent further infections. METHODS: We screened contacts to find and treat persons with TB disease or infection. We then formed a multidisciplinary team to engage substance abuse services partners and implement outreach strategies including novel methods for finding contacts and a system of incentives and enablers to promote finding, screening, and treating patients with TB and their infected contacts. RESULTS: We diagnosed and completed treatment with 10 persons with TB disease. Eight of 9 adult patients and 67% of their adult contacts reported using methamphetamines. Of the 372 contacts, 319 (85.8%) were screened, 80 (25.1%) were infected, 71 (88.8%) started treatment for latent infection, and 57 (80.3%) completed treatment for latent infection. CONCLUSIONS: Collaborative approaches integrating TB control, outreach, incentives, and enablers resulted in high rates of treatment adherence and completion among patients and infected contacts. TB control programs should collaborate with substance abuse programs to address addiction, overcome substance abuse-related barriers to treatment, treat TB, and prevent ongoing transmission.

One Field Epidemiologist per 200,000 Population: Lessons Learned from Implementing a Global Public Health Workforce Target.

The World Health Organization monitoring and evaluation framework for the International Health Regulations (IHR, 2005) describes the targets for the Joint External Evaluation (JEE) indicators. For workforce development, the JEE defines the optimal target for attaining and complying with the IHR (2005) as 1 trained field epidemiologist (or equivalent) per 200,000 population. We explain the derivation and use of the current field epidemiology workforce development target and identify the limitations and lessons learned in applying it to various countries' public health systems. This article also proposes a way forward for improvements and implementation of this workforce development target.

Limited utility of name-based tuberculosis contact investigations among persons using illicit drugs: results of an outbreak investigation.

Persons named by a patient with tuberculosis (TB) are the focus of traditional TB contact investigations. However, patients who use illicit drugs are often reluctant to name contacts. Between January 2004 and May 2005, 18 isoniazid-resistant TB cases with matching Mycobacterium tuberculosis genotypes (spoligotypes) were reported in Miami; most patients frequented crack houses and did not name potentially infected contacts. We reviewed medical records and re-interviewed patients about contacts and locations frequented to describe transmission patterns and make recommendations to control TB in this population. Observed contacts were not named but were encountered at the same crack houses as the patients. Contacts were evaluated for latent TB infection with a tuberculosis skin test (TST). All 18 patients had pulmonary TB. Twelve (67%) reported crack use and 14 (78%) any illicit drug use. Of the 187 contacts evaluated, 91 (49%) were named, 16 (8%) attended a church reported by a patient, 61 (33%) used a dialysis center reported by a patient, and 19 (10%) were observed contacts at local crack houses. Compared to named contacts, observed contacts were eight times as likely to have positive TST results (relative risk = 7.8; 95% confidence interval = 3.8-16.1). Dialysis center and church contacts had no elevated risk of a positive TST result. Testing observed contacts may provide a higher yield than traditional name-based contact investigations for tuberculosis patients who use illicit drugs or frequent venues characterized by illicit drug use.

Multidrug-resistant tuberculosis outbreak among US-bound Hmong refugees, Thailand, 2005.

In January 2005, tuberculosis (TB), including multidrug-resistant TB (MDR TB), was reported among Hmong refugees who were living in or had recently immigrated to the United States from a camp in Thailand. We investigated TB and drug resistance, enhanced TB screenings, and expanded treatment capacity in the camp. In February 2005, 272 patients with TB (24 MDR TB) remained in the camp. Among 17 MDR TB patients interviewed, 13 were found to be linked socially. Of 23 MDR TB isolates genotyped, 20 were similar according to 3 molecular typing methods. Before enhanced screening was implemented, 46 TB cases (6 MDR TB) were diagnosed in the United States among 9,455 resettled refugees. After enhanced screening had begun, only 4 TB cases (1 MDR TB), were found among 5,705 resettled refugees. An MDR TB outbreak among US-bound refugees led to importation of disease; enhanced pre-immigration TB screening and treatment decreased subsequent importation.

Investigation of Mycobacterium tuberculosis transmission aboard the U.S.S. Ronald Reagan, 2006.

Pulmonary tuberculosis (TB) was diagnosed in a sailor aboard the U.S.S. Ronald Reagan; an investigation was conducted to determine a screening strategy for 1,172 civilian passengers who were aboard during a temporary guest rider program. Sailors were screened for latent TB infection (LTBI) and TB disease. A case-control study was conducted among sailors to determine factors associated with new LTBI. No secondary TB disease was identified; 13% of close contacts had new LTBI. Factors associated with new LTBI among sailors were having been born outside the United States (adjusted odds ratio = 2.80; 95% confidence interval, 1.55--5.07) and being a carrier air wing member (adjusted odds ratio = 2.89; 95% confidence interval, 1.83--4.58). Among 38 civilian passengers berthed near the patient, 1 (3%) had LTBI. The investigation results indicated that Mycobacterium tuberculosis transmission was minimal and eliminated unnecessary TB screening for 1,134 civilians which saved public health resources.

World Health Organization Joint External Evaluations in the Eastern Mediterranean Region, 2016-17.

By 2014, only 33% of countries had self-reported compliance with the International Health Regulations (2005), including 8 countries from the Eastern Mediterranean Region (EMR). During the Ebola epidemic, the discovery of a gap between objective assessment and self-reports for certain IHR capacities prompted the World Health Organization (WHO) to review and update the IHR monitoring and evaluation framework to include a voluntary objective review process, called Joint External Evaluation (JEE), that did not exist before. The regional committee for the EMR approved the JEE and encouraged its 21 member states to volunteer for reviews. Standardized processes and procedures were developed for conducting JEEs. Of the 52 JEEs completed to date globally, 14 (27%) are from the EMR. Three (21%) of 14 member states completing the JEE in the EMR have also worked on a post-JEE national action plan for health security (NAPHS). A survey conducted about the JEE experience from focal points in EMR member states underlined the strengths of the JEE process: its multisectoral and open discussion approach; standardization of the JEE process; WHO's critical role in supporting JEE preparation and conduct; and the need for guidance development for a costed NAPHS. The success of JEEs depends not only on proper preparations and completion of the JEE but also on the development of a country-led, owned, and costed NAPHS and its implementation, including financial commitments along with donor and partners' engagement and coordination.