INTRODUCTION
In the case of outbreaks of infectious diseases, it is imperative to find sources of infection through timely epidemiological investigations and to establish an appropriate prevention method based on the results of the investigations. However, inadequate initial epidemiological investigations sometimes lead to an inability to elucidate the causes of the spreading of infectious diseases and to establish clear disease prevention strategies as well as strategies to prevent recurrence. For timely prevention, it is necessary to find the sources and routes of infection through prompt epidemiological investigations in the initial stages of outbreak. To do this, the availability of epidemiology experts in infectious diseases and staff dedicated to infectious diseases is the most crucial factor [
1]. Nevertheless, South Korea (hereafter Korea) currently lacks experienced field epidemiologists who have an adequate understanding of epidemiology of infectious diseases [
2].
The expertise of field epidemiologists requires sufficient field data and an ability to make epidemiological judgments for making decisions relating to public health [
3]. In the last Middle East Respiratory Syndrome (MERS) outbreak in May 2015 criticism on the lack of field epidemiologists available to conduct epidemiological investigations in emergency situations and the lack of continuity and expertise in epidemiological investigations gained support [
4]. The Act on the Prevention and Management of Infectious Diseases, which aims to improve adequacy in the existing infectious disease management system revealed through the MERS outbreak, has been revised in part on July 6, 2015; the revisions include increases in the number and authority of field epidemiologists [
5].
Therefore, the present paper aims to review the current Korean field epidemiologist system and training programs that seek to improve the competency of field epidemiologists.
DISSCUSSION
We reviewed and summarized the current states and problems of the Korean field epidemiologist system and future improvements, discussed through focus group interviews (FGI) conducted with experts in preventive medicine and internal medicine in infectious diseases based on review of literature published within and outside of Korea; surveys conducted on experts, field epidemiologists, staff at KCDC, and municipal and provincial civil servants responsible for epidemiological investigation based on the FGI results; and workshops conducted with FETP and Epidemic Intelligence Service experts from CDC and Korean experts and researchers. In particular, the chapter focuses on ways to improve systems to train field epidemiologists; to improve programs for training, education, and evaluation of field epidemiologists; to establish and manage an institution for training; and to plan training of experts in epidemiological investigations from KCDC staff and municipal and provincial civil servants responsible for epidemiological investigation.
Ways to improve systems to train field epidemiologists
The lack of continuity between expertise and experiences is recognized as the biggest problem in the current system. To recruit more field epidemiologists, it is important to promote occupational security (promotion and compensation), compensation at equal levels as private institutions, cooperation with various overseas institutions performing similar tasks, and field epidemiologists’ pride. In addition to compensation, promotion, and welfare, the following should also be implemented to recruit more field epidemiologists: a stable supply through establishment of public medical schools, connection to degree programs, provision of compensation at equal levels as private institutions while also providing high quality training and education, recruitment of experienced professors from private institutes to manage training and education to promote transfer of experienced experts through open positions, and improvement of expertise of field epidemiologists. The following opinions were also noted: exceptions from military service, transition from term system to continued service at related positions in the Ministry of Health and Welfare or KCDC, provision of incentives to field epidemiologists (current and retired), and management of long-term and short-term overseas training programs.
There is a need to improve the sense of duty and suggest future plans for field epidemiologists. First, the scope of work currently limited to infectious diseases should be expanded to chronic and environmental diseases, systematic support for preparation and response to national disasters should be provided, and the sense of duty should be promoted. Second, based on the excellent manpower, techniques, and experiences in Korea, communication with developed and third-world countries should be promoted to expand the scope of work and competency of field epidemiologists to outside of Korea. Third, beyond the term system, which is limited to KCDC, opportunities to work at the Ministry of Health and Welfare and other central government positions should be provided; at the same time, opportunities to work in related public service positions through promotion and transfer should be provided when field epidemiologists meet certain criteria.
It is also necessary to increase the financial compensation for field epidemiologists to a level equal to those at private institutions. Due to the intensifying delays in promotion, it is very difficult to unite civil servants through promotion. When promotion is limited, it is necessary to seek other methods to unite members through other methods of compensation. In such cases, provision of financial incentives is considered most effective; therefore, providing compensation at equal levels to private institutions should be considered. As another alternative, the experienced expert staff system, which was once available for Korean civil servants, can also be used when promotion is delayed due to an oversupply of medical civil servants with equal levels of experiences.
Opportunities for self-improvement should also be provided to field epidemiologists. Overseas training and participation in Korean and overseas conferences should be promoted to encourage continued self-development during employment. As in recruiting long-term employees in the army, medical school students should be recruited through scholarships, military service, degree programs, and preventive medical specialist programs.
Moreover, the current field epidemiologist system employing public health practitioners should also stay in place. Although field epidemiologists do not have to be doctors, epidemiological investigations of cases of infectious diseases require understanding of public health and clinical knowledge as they also involve patients. Thus, major activities and decision making mainly involve doctors. This is why it is difficult to recruit only public health experts in shortages of doctors applying to become field epidemiologists. It is also important to recruit adequate numbers of medical doctor field epidemiologists through allocation of a certain percentage of positions to doctors.
Improvement of education, training, and evaluation programs for field epidemiologists.
It is necessary to set core competencies required for Korean field epidemiologists. According to the results of surveys on core competencies, it is necessary to set education and learning goals based on core competencies with consideration of the capabilities and scopes of capabilities required for field epidemiologists and the distribution of diseases in Korea.
Moreover, expert groups or committees to systematically support the field epidemiologist program should be recruited. Such groups or committees should be responsible for the maintenance of the overall quality of the program, development or revision of lectures or case studies in training curricula, and actual training and education of field epidemiologists. Further, an independent pool of dedicated staff or departments should be created to support programs within the KCDC.
Regarding training curricula, introductory and on-the-job training lasts for a total of 5 weeks, which is relatively shorter than FETP conducted overseas. It is necessary to expand the on-the-job training (2-3 days) rather than the introductory training. In particular, the on-the-job training should be expanded to conduct lectures, case studies, and practical training as in introductory training for each required competency. Moreover, since separate training on required core competencies was not provided for epidemiologists with different years of experience, education on core competency should be provided separately for epidemiologists with different experiences. Lectures should be prepared according to core competencies, and lecture time should be distributed accordingly for different core competencies. The time spent for case studies should be increased, and case studies should also be included in on-the-job training. Moreover, review and revision of questionnaires used in coursework training are also required.
In particular, seminars, which were not available previously, should be conducted every week. Since field epidemiologists are deployed at the KCDC and in each municipality and province, online video conferences (weekly) or in-person seminars (weekly or monthly) can be conducted to encourage the epidemiologists to report on their projects and receive guidance and feedback from experts.
For this, it is necessary to invite experts in various areas to conferences. Since some presentations do not involve discussions due to lack of time, this should be improved to enable presenters to receive in-depth guidance and feedback after presentation.
For field training, field managers should be present. The previous advising professor system cannot provide adequate guidance and feedback to trainees. Since experienced epidemiologists who can function as field managers at institutions at which epidemiologists are deployed are lacking, experienced epidemiologists should be encouraged to act as advisors even if they are not deployed at institutions. This would also improve mentorship. Technical advisors and supervisors are also required within institutions; in order for these people to acquire various in-field experiences, administrative support and dedicated staff are required.
For evaluation, criteria and requirement for completion should be made stricter. Moreover, shared parts on multisite FETP reports, completion on epidemiological investigations of epidemics, activities related to surveillance systems, and protocols for planned studies should be evaluated. For periodic evaluation of competency and project progress of field epidemiologists, on-the-job training can be expanded and conducted every 6 months. Evaluations should aim to enable epidemiologists to acquire competencies and complete projects. In other words, systems that can help epidemiologists to complete projects within 2 years should be prepared. Moreover, guidance and feedback are necessary for epidemiologists to complete projects with the help of stronger mentorship. Through the Epi-Aid (epidemiologic assistance) program, completion of projects (e.g., reports on epidemiological investigations of epidemics) should be encouraged.
Plans for establishment of a dedicated training institution for selection and training of field epidemiologists
The current management of training for field epidemiologists have the following problems: limitations in continuity in education and training, lack of systematic investigation of demands for human resources, inadequate international networking systems, short-term systems for field epidemiologists, and limitations in ensuring a steady supply of human resources owing to field epidemiologists working in clinical areas rather than in public health areas after completion of service terms.
When the causes of the 2015 MERS epidemic were investigated, limitations in experts in field epidemiology, limitations in the current infectious disease management system, lack of field epidemiologists in infectious disease training and response training, and the need for organization and management of other public health human resources were emphasized.
To solve these problems, Korean and overseas experts, field epidemiologists, and researchers agreed that it would be most reasonable to operate a separate “training institute for field epidemiologists” with verified expertise, systematic management, continuous employment of human power (field epidemiologists), and excellence as a training institute.
To implement this in the long run, partial contracted training, which is currently being conducted by the KCDC and Konyang University College of Medicine, should be conducted in the near future. Dedicated staff within the KCDC capable of analyzing and managing such training institutes should then be recruited to form a committee for establishment of the training institute for field epidemiologists, also with the participation of various experts from within and outside of Korea, to train field epidemiologists in a practical manner.
The current Korean field epidemiologist system requires improvements in the system and training program evaluation. Moreover, the KCDC should also conduct its own evaluations to improve the systems to train experts in epidemiological investigations. Further, systematic methods for training experts in the management of infectious diseases, developing a basis for systematic and phased operation of FETP, and sustainable systems for development of strategies should be established. It is also necessary to revise the guidelines on training and improvement of the competency of experts in public health, and to establish dedicated training facilities.