Have you ever wondered how a country or State collates data about a disease outbreak? Or how a nation calculates the number of persons who are infected or affected by a disease ? Or how an outbreak is prevented?
A silent, diligent army of men and women works daily to collect information about diseases in the community. The army, embedded in the public health division of the health department, is a group of epidemiologists who gather data that helps to develop programmes and drive policy decisions.
Earlier this month Sowmya Swaminathan, former chief scientist at World Health Organisation, expressed her happiness at meeting with graduating scholars at the Indian Council of Medical Research-National Institute of Epidemiology (ICMR). She termed them the human resource for public health, the cadre that is “well trained in epidemiology, surveillance, outbreak investigation, data analysis”.
The country now has over 300 trained epidemiologists, but it needs around 1,000 every year, says Manoj Murhekar, director, NIE.
The State health departments are required to depute their cadre for training. The cadre spends around 75% of their time in the field and learn first-hand to assess the input they receive and understand what the data means.
Seven core competencies are built into the training module for these field epidemiologists. They include understanding the cause of a disease (epidemiology); surveillance; outbreaks; research; protecting people; communication and management of the disease. Each student (scholar) receives one-to-one mentoring from the alumni and faculty.
“It is more about skill building. We teach them to detect the pattern of disease and teach them analytical skills. We train them to investigate an outbreak. We also teach them to evaluate a health programme and methods to implement it better. We train them to conduct epidemiological study,” said a Chennai-based mentor, who did not want to be named.
The scholars learn to take samples, interview and analyse the research data.
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The country-wide training programme is supported by the National Centre for Disease Control, ICMR-NIE, the World Health Organisation and the U.S. Centres for Disease Control.
Despite the rich value these healthcare workers add to the health systems of a State, only a few States have been sending their cadre for training. Kerala, Maharashtra, Odisha, West Bengal and Tamil Nadu are the few States that depute health workers for training regularly. In fact, in Tamil Nadu every district deputy director of health service is a trained epidemiologist. “They are also trained postgraduates in public health. It is considered a must for public health cadre (posting),” he pointed out.
Degrees and training modules
P. Manickam, mentor and core faculty in ICMR-NIE, has been part of the programme since 1999. A graduate of MSc Epidemiology from Christian Medical College, Vellore, he started his career in the NIE. In January 2001, the NIE launched its Field Epidemiologists Training programme (FETP). In 2001, a two-year full-time Masters in Applied Epidemiology programme was introduced.
In 2008, the NIE launched a Masters in Public Health. In 2011, the courses were merged and a Masters in Public Health and Applied Epidemiology was launched.
Since getting sufficient cadre to participate remained a bottleneck, smaller packages such as a frontline FETP (3-month) and intermediate (12-15 month) and an advanced (2-year) programme are offered.
In Tamil Nadu, while each district has an epidemiologist the Corporation of Chennai alone has two trained epidemiologists, according to P. Kolandaisamy, former director of Public Health. He enrolled in the masters programme in 2010. “It teaches you to understand the situation and quickly come up with an appropriate solution,” he said.
In 2015, during the Chennai floods (the suburbs were affected for longer periods), residents feared that an epidemic could erupt. But the health department had mapped the city and was prepared. Not only were the healthcare workers in the field but they also were quick to assess the issues and prevented them from flaring up.
The department conducted a measles vaccination drive after a scare in a southern suburb. Similarly, in the heart of the city in Saidapet a person was diagnosed with cholera and the health department prevented an epidemic from erupting, recalled Dr. Kolandaisamy, who was then the State’s Director of Public Health.
“The FETP is for the entire country. Field epidemiologists are foot soldiers. If they know the terrain and the system that handles the population, they will be able to handle an outbreak, even prevent it.. The two eyes are survelliance and outbreak investigation,” said Mr. Manickam.
The health personnel who are trained include doctors and non-medical professionals; the latter are those recruited under the National Health Mission. Each candidate (scholar) is assigned a mentor. Alumni also train the candidates.
According to Mr. Manickam given India’s vast diverse geography and population, the situation would determine how the training happens.
COVID-19 awakens States
The COVID-19 pandemic has brought in awareness about the need to have a responsive healthcare cadre. State governments have felt the need to have trained epidemiologists, said Dr. Murhekar.
It is only recently that Odisha and Chattisgarh have started deputing cadre for training. “The mentors and faculty from Tamil Nadu have visited these States and train the health officers to conduct mentoring in the field. On-field training has an advantage as the officers will continue to do their routine work, while the mentors will be their guides,” explained a Chennai-based mentor.
In-service training programmes have been received well said Dr. Murhekar as the scholars attend webinars “and there is more focused mentoring of scholars across India.”
The FETP has gained popularity in northern and northeastern States as well. A component of the training programme is that health workers must make presentations at conferences and in internal meetings. This taught communication skills, Dr. Kolandaisami added. The training requires that the scholars publish their findings in peer-reviewed journals.
Candidates who complete the FETP are termed graduates. “A lot of our graduates have made a difference. The impact of the programme is also evaluated. We have investigated more than 500 outbreaks in the country in the past 15 years. The first COVID cluster of a family in Uttar Pradesh was identified and investigated by our graduate,” said the Chennai-based mentor.
According to him all the first publications on COVID-19 related to hospital outbreaks and unique clusters were investigated by FETP graduates.
“We have produced nearly 100 publications during COVID-19; we published nearly 20 publications in peer-reviewed journals,” he remarked.