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A decade of field epidemiology training in India

Manoj Murhekar and FETP-India Team

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INSIGHT

A decade of field epidemiology training in India

Manoj Murhekar and FETP-India Team

Strengthening the scientific and epidemiological basis for programme and policy decisions to prevent and control priority diseases is the key to public health impact. Right from its inception, the National Institute of Epidemiology (NIE) has been promoting, strengthening and emphasizing epidemiology as a core discipline of public health and its application in generating evidence for action. In fact, in 2010, the “Delhi Declaration on Epidemiology – March 2010” reflected on the non-availability of skills of public health (including those of epidemiology) to all communities in the South East Asia Region. In this context, we review and offer an insight into decadal journey of NIE’s flagship programme to strengthen India’s public health systems through its Masters level training in applied epidemiology (MAE).

The beginning of MAE

The NIE was established on July 2, 1999 with a major mandate of developing the human resources in epidemiology and bio-statistics in the country. Within two years of its establishment, NIE started the Master’s level course in field epidemiology which was named as Masters in Applied Epidemiology (MAE). The Board of Studies of Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST) which is an Institute of National Importance under Govt. of India granted affiliation for this course. Several institutions, organizations and individuals helped NIE in putting this course in place; notable among them were researchers and academicians from Centers for Disease Control (CDC), Atlanta, USA, World Health Organization’s South-East Asia Regional Office (WHO-SEARO), Australian National University (ANU) and the global network of such field-based epidemiology training programmes (called Training in Epidemiology and Public Health Interventions Network- TEPHINET). This initiative of NIE received a top priority from ICMR leadership and the required support from the Ministry of Health, Govt of India.

As culmination of these efforts and initiatives, NIE initiated the two-year field epidemiology training programme (FETP) on 1 January 2001. The goal of the FETP was to facilitate the development of a cadre of public health professionals who are practitioners of epidemiology at the field level and are competent in addressing public health needs and priorities efficiently and effectively. Thus, MAE-FETP was aimed at strengthening health services through training of ‘in-service’ middle level health managers. The two-year programme led to the award of MAE degree from SCTIMST.

Programme philosophy and course organization

MAE-FETP was modelled on the Epidemic Intelligence Services (EIS) programme of the CDC1 and the MAE programme of the ANU.2 MAE-FETP was designed to provide two-year ‘learning-by-doing’ experience for medical officers working at the district or sub-district level who were primarily interested in developing careers in epidemiology and public health. As part of ICMR’s commitment to strengthen the Indian public health system, this programme was offered free of cost to the government-sponsored candidates.

The MAE consisted of two parts: the first part of six-months (25% of course duration) involved ‘on campus’ training during which the trainees (referred to as ‘scholars’) received theoretical inputs through residential contact sessions at the NIE. These contact sessions included an initial foundation course on applied epidemiology, bio-statistics and public health surveillance. In the subsequent sessions, the scholars received inputs on programme management, scientific writing, health economics and qualitative studies.

The other part of the course extended for 18-months (75% of course duration) of field-based experience spread over three “field postings” of six-month duration each. During these postings, the scholars planned and executed epidemiological projects of immediate relevance to public health practice at their field placement sites. In consultation with the sponsoring state health authorities, the scholars and NIE identified the field placement site (usually at a district level). During the field work, the scholars received technical support from the line-managers and NIE-based mentors. During this process, the scholars were expected to provide valuable information to the district programme.

Curriculum and competencies

MAE-FETP joined the TEPHIENT3 and used an international curriculum template for the programme. MAE-FETP also had additional modules to suit the needs of the Indian public health system. The MAE-FETP curriculum was a right mix of in-class training and practical, ‘hands on’ experience through mentored field-work. The field-work provided practical learning opportunities for the scholars to implement concepts learnt during the contact sessions and acquire the competencies expected of them. Over the years, the curriculum adopted and developed more than 25 case-studies based on Indian investigations in the areas of outbreak investigations, laboratory support for outbreaks, surveillance data analysis, evaluation of surveillance system, programme evaluation, framing the research questions and ethics4.

The MAE imparted seven core competencies during the training period. They were (1) mastering epidemiological science (2) investigating the outbreaks (3) managing public health surveillance (4) conducting epidemiological studies (5) protecting human subjects in research (6) oral and written communication and (7) programme management and evaluation. Towards achieving these competencies, the scholars conducted the following field-based projects during the 18 months of field posting: (A) Public health situation analysis: This was the first field assignment the scholars had to do at the beginning of the first field posting. Scholars had to review the field placement site (usually district) and its population to place it into a public health perspective. This exercise at the beginning of the field posting helped the scholars identify key public health priorities in the district and thereby identify potential topics for various field projects as well as their dissertations. (B) Outbreak investigations: The MAE-FETP model proposed quality investigations of disease outbreaks, with full technical support from the faculty. The faculty ensured that the scholars followed the standard procedures while investigating disease clusters. Peer-review at all stages of the investigation and reporting were the keystones of the quality assurance process. During the last 10 years, NIE scholars have investigated more than 100 outbreaks caused by bacteria (e.g., Cholera, anthrax, leptospirosis, pertussis), viruses [e.g., measles, hepatitis A, hepatitis E, Chikungunya, A (H1N1)], parasites (e.g., malaria) and toxic agents. (C) Surveillance projects: The MAE-FETP scholars had to complete two projects: First, analyze the surveillance data set and secondly, evaluate the surveillance system. These two mandatory projects built the key attitudes that a public health person needed in the area of surveillance: Knowing everything one can say about the data and everything one cannot say about the data! (D) Programme evaluation: The scholars had to evaluate any public health programme with a focus on logical framework and development of input, process, output and outcome indicators to identify existing gaps. (F) Operational research projects: As a part of the dissertation, the scholars had to conduct an epidemiological study on locally relevant health problems. The process began with identification of the right research questions. The line managers played an important role in guiding the scholars to identify a locally relevant health problem for epidemiological investigation. Scholars were encouraged to select a topic that could generate a body of data that would fill a gap in the information needs, and filling that gap would trigger some kind of public health action.

Quality assurance

NIE took several steps to assure and improve the quality of the MAE training programme. These included (a) On-going evaluation of the teaching using qualitative and quantitative methods by the scholars (b) use of peer-review to develop improved learning tools (c) documentation of the training conducted in a compact disc (d) monitoring of the acquisition of the core competencies through the standardized supportive supervision tool (e) evaluation of the final reports with standardized checklists and (f) participation in the TEPHINET led continuous quality improvement initiative.

Key achievements

The success of a capacity building initiative could be measured in a variety of ways. In terms of the numbers, NIE has trained 108 field epidemiologists (Figure 1) from 20 Indian states. Almost all the NIE graduates are working for public health in India and several of them are holding key positions in disease surveillance and other public health programmes in different states (Figure 2).

Figure 1. Distribution of MAE graduates

Figure 2. Placement of graduates*

*updated as of 2008

In terms of the work conducted by the scholars during their training, >200 abstracts based on scholars’ work were presented in national and international conferences and nearly 60 papers have been published in peer-reviewed journals. All the MAE-FETP investigations were debriefed at the district and/or the state level to ensure that those who needed the information the most could take immediate action. Although we completed an internal evaluation of the programme in 2008 , we propose to evaluate the programme in terms of its contribution in public health services of different States.

Where are we today?

In 2011, NIE integrated the MAE and the then on-going Master of Public Health (Health Services Development and Research) [ongoing since 2008] course into a new MPH course with a focus on applied epidemiology and health systems. The two primary reasons for this change were (1) making the MPH (Health Systems Development Research) course less didactic and more skill-oriented and (2) aligning the MAE course content with the health system goals and reforms as per the National Rural Health Mission. The Board of Studies of SCTIMST approved this change and the new MPH (Epidemiology & Health Systems) programme was launched on 1 July 2012. The last cohort of MAE (2010) has completed all its academic formalities a few months back and would soon be awarded with their degrees.

The MAE-FETP has contributed significantly towards strengthening the public health workforce in the country. We are confident that the course in its new form will continue our commitment to contribute towards strengthening the public health human resources in India.

References

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1Thacker SB, Dannenberg AL, Hamilton DH. Epidemic intelligence service of the Centers for Disease Control and Prevention: 50 years of training and service in applied epidemiology. Am J Epidemiol 2001; 154:985-92.

2Patel MS, Philips CB. Strengthening field-based training in low and middle-income countries to build public health capacity: lessons from Australia’s Master of Applied Epidemiology program. Aust New Zealand Health Policy 2009;6:5.

3Training programmes in epidemiology and public health interventions network. TEPHINET. http://www.tephinet.org [accessed on 26 April 2010]

4WHO-SEARO Virtual Resource Centre of the public health initiative http://203.90.70.117/phi/VirtualResourceCenter.asp [accessed on 26 April 2010]

5Bhatnagar T, Gupte MD, Hutin YJ, Kaur P, Kumaraswami V, Manickam P, Murhekar M, Vidya R, Ramakrishnan R. Seven years of the field epidemiology training programme (FETP) at Chennai, Tamil Nadu, India: an internal evaluation. Hum Resour Health. 2012;10(1):36.

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