Field Notes from FETPs Fighting COVID-19: September 2020
India Field Epidemiology Training Program, Chennai
COVID-19 has claimed more than one million lives globally, and India is currently recording the largest number of new cases per day out of any country in the world (source). The India Field Epidemiology Training Program (FETP) in Chennai is innovating in responding to and controlling the pandemic in the country that has become the second-largest hotspot in the world after the United States, with more than 4.2 million cases (source). As of August 16, 118,928 COVID-19 cases were reported in India. 221,503 contacts were traced from 14,858 cases in a two-week period, with a median number of 16 contacts traced per case.
Greater Chennai Corporation (GCC) is the city’s public health authority. The FETP engaged its host institution, the National Institute of Epidemiology (Indian Council of Medical Research), or NIE, to support GCC by increasing the workforce to 167 virtual contact tracers and 215 in the field as well as providing technical support through training the designated contact tracing team. In order to attain the required workforce, NIE involved volunteers from multiple organizations, including information technology (IT) companies, schoolteachers, and college students. To mitigate variability in the contact tracing process, NIE established a protocol by implementing a standardized checklist and clearly defining eligible contacts based on criteria from the standardized training.
The FETP deployed an integrated web portal of GCC, where contact listing happens automatically, to serve as a solution to the tedious large-scale documentation process. The FETP has taken the approach of contact tracing, listing, and following up with contact tracers through conducting field investigations and analyzing data to improve health outcomes in India.
Uganda Public Health Fellowship Program at Makerere School of Public Health
The experience of the Uganda Public Health Fellowship Program (PHFP) demonstrates the role that contact tracing plays in early detection and interruption of transmission. Between July 21 and August 12, Uganda reported 11 deaths from COVID-19 with an average daily case count of 10 to 15. By August 12, Uganda had 3,363 confirmed cases as well as 1,067 active contacts. Contacts are tested on days 0, 7 and 13 during the 14-day follow-up period and are then isolated.
Without the availability of a vaccine, contact tracing has been one of the most important interventions to prevent transmission. In Uganda, contact tracing is done through a central data management team, a central mechanism where teams are deployed to all 12 regions of the country. The PHFP collaborates with lab and surveillance teams, regional contact tracing teams, and case management teams. Their central team manages the data, compiles it and reports it daily to the Incident Management Team. The Go.Data tool, a software application used to collect data on phones, aids contact tracers by automatically analyzing data and monitoring the performance of regional teams. 16,527 (98 percent of) contacts were tested during the follow-up period, and 94 percent of contacts had completed the 14-day follow-up period.
Belize Field Epidemiology Training Program
As of October 2, Belize has reported 2,026 COVID-19 cases and 27 deaths (source). Right from the outset, the government of Belize took a “whole of government” approach and involved other government stakeholders, including the tourism sector, in planning the response to COVID-19. The government instituted risk communication and community engagement efforts prior to seeing COVID-19 transmission in the country.
Belize’s ability to employ FETP alumni at the community level has contributed to their cohesive response. Belize has four health regions with local teams comprised mostly of Frontline-level FETP alumni as well as four alumni from the advanced-level FETP. All teams were led by FETP alumni trained in outbreak investigation. The fact that team members had multiple skill sets and were flexible as a result of their FETP training was an advantage. The FETP conducted case management wherever cases were detected. A health worker was assigned to each case and would follow up to monitor the case for 14 days. In addition to sending health professionals to remote areas, the FETP conducted training of field officers and utilized a variety of digital tools to collect data.
The Belize FETP played a critical role in the early detection and early response that controlled the initial outbreak. They are now able to apply lessons learned from the first wave to their recent reemergence of new cases.
Ethiopia Field Epidemiology and Laboratory Training Program
Ethiopia FELTP graduates, residents, program coordinators, resident advisors and other health workers have been fully engaged in COVID-19 surveillance activities. As of September, Ethiopia had more than 65,486 confirmed cases and 228,271 contacts identified. This equates to nearly four contacts identified per confirmed case, and 144,920 (63 percent) completed the 14-day follow-up. 15,645 (7 percent) of the contacts tested positive, and the suggestive positivity rate among contacts was 10 percent.
The number of contacts increased with the case surge in Ethiopia. Based on the population dynamics, Ethiopia has one contact tracing team per 32,000 population or one team per 12 cases on average. The COVID-19 task force and emergency operation centers are working to increase capacities throughout the country and increase the number of contact tracers. A scenario-based contact tracing approach is used in all 12 regions, with daily performance monitoring.
Electronic data systems (ODK, DHIS2) have been deployed as mobile applications for data collection and reporting and for contacting individuals who have been in contact with patients. A digital contact tracing system called DEBO is also on the verge of launching.
Decentralizing contact tracing to the district or woreda level has been a strength of the response in Ethiopia, as well as the fact that all contacts are being tested. Challenges include a shortage of human and material resources, difficulty in home quarantining of contacts, a long turnaround time (more than three days), and a lack of electronic reporting of contact tracing in certain regions.
Guinea Field Epidemiology Training Program
The Guinea FETP contact tracing strategy involves using community health workers and both in-person and telephone approaches. Contact tracers use the DHIS 2 platform to register people at testing sites using a case notification form and to establish the relationship between the contact and the case to determine the chain of transmission. Then, the patient and the field staff receive laboratory results through this platform. When the team of FETP graduates in the field learns of a positive case, they go on a home visit to conduct contact tracing (unless the case is in the hospital). The Guinea FETP creates lists to distinguish between close contacts and distant contacts so that the field team can give the list of contacts to the district-level contact tracers. They administer two tests to contacts while monitoring them for 14 days. Most of the contacts have tested negative on days 7 and 14.
To overcome the challenge of a lack of standardization in the approach to contact tracing training, they standardized the training approach for all trainees. While Guinea was able to increase community engagement to deal with the issue of contacts’ unwillingness to be listed during investigations, there was still far less community engagement than that of the contact tracing process for the response to Ebola in West Africa in 2014. There was also the challenge of testing contacts outside of the deadline (day 7 and day 14), and FETP’s solution was to practice community engagement to sensitize the contacts on why they should be tested at these times. Another challenge was that some districts were not using DHIS 2 for contact tracing, so the FETP trained the district data managers and distributed tablets to trace contacts directly in DHIS 2.
COVID-19 tests administered through September 14 indicated that 10,061 people were COVID-19-positive, or 9.3 percent of Guinea’s population. 93 percent of cases have recovered, and 0.6 percent have died. As of September 14, Guinea registered 25,002 contacts. With the goal of contact tracing being to interrupt transmission, this process is central and fundamental to managing the pandemic and minimizing loss of life through early detection and early response.
Mexico Field Epidemiology Training Program
As of September 16, Mexico had 676,487 confirmed cases of COVID-19 and 71,678 deaths. Over the seven preceding weeks, the rate of positive cases decreased from 53 to 38 percent.
Within the National Health System, officials established epidemiological and laboratory surveillance of viral respiratory diseases to generate quality epidemiological information to guide decision-making for the implementation of effective prevention measures. Epidemiological surveillance of COVID-19 is carried out using a sentinel model in 475 active units called Monitoring Units for Viral Respiratory Disease.
On a daily basis, FETP residents conduct event-based surveillance and check official national and international sites and media. FETP trainees have also participated in special surveillance activities in cities such as Cancun, which had 25 million travelers last year. Contact tracers are following up on the close contacts of suspected cases during the 14 days after the onset of symptoms. The local and state levels report the health status of the contacts and perform daily activities to update their status in the SISVER platform for epidemiological surveillance of viral diseases. At points of entry throughout Mexico, contacts are defined based on a risk analysis that includes proximity, activity of the case within the ship (or airplane), and possible interactions before and during their trip. All airplane passengers sitting within two seats (in all directions) around a confirmed case are considered contacts, as are crew members who have provided their services in the section of the aircraft where the confirmed case was sitting, as well as those who had close contact with a confirmed case during a maritime trip.
Contact follow-up has been a major challenge, for which a solution has been increasing epidemic intelligence through event-based and indicator-based surveillance. Health officials currently working with the Pan American Health Organization (PAHO) on the implementation of Go.Data as a complement for their surveillance system. Another challenge has been that there are different epidemic transmission phases in Mexico, to which officials responded by implementing special indicators for every state. In addition, Mexico experienced a shortage of field epidemiology personnel, so through the FETP, they are working to train more.
Costa Rica Field Epidemiology Training Program
From March 6 to September 13, Costa Rica had 56,422 cases of COVID-19 and 583 deaths. When a suspected case is detected, as established in the national protocol, the person is assessed at the place of detection. If the person meets the case definition, the FETP coordinates with the Costa Rican Ministry of Health to issue a health order for home quarantine after taking a sample. Field epidemiology staff conduct telephone surveys of the case and his or her contacts for the clinic. A team of residents follows up with cases and contacts to identify the severity of the disease and, if needed, transfer them to hospitals.
Concerning specialized strategies at Costa Rica’s borders, the FETP coordinated COVID-19 screening of truckers who were entering the country, with the goal of identifying possible cases. If they tested positive, they could not enter the country. Similarly, at the airports, the FETP coordinated with different airlines to screen visitors and tourists. If residents of Costa Rica tested positive, the FETP coordinated a health order for home quarantine. For tourists who tested positive, they facilitated accommodations in community quarantine centers with daily home monitoring by healthcare and epidemiology staff. Using the same strategy, the FETP coordinated with travel agencies to screen cruise ship passengers.
Costa Rica focused on everything related to the chain of transmission in order to contain the outbreak through community surveillance. At the national level, priority was given to screening call centers, construction sites, and nursing homes, among other sites where cases were appearing. Monitoring continues to this day. The FETP is working to reduce the propagation of the virus in vulnerable areas. Many families with a lower socioeconomic status have been relocated to hotels to quarantine for 14 days until testing negative.
Field epidemiologists with the FETP designed surveys to establish the magnitude and dispersion of cases. The FETP integrated technology into their approach. Using the EDUS app, people could enter their personal data, symptoms, and contacts, allowing the FETP to identify possible transmission chains and thus facilitate the location of clusters for field epidemiologists to respond quickly at the local level.