The strengthening of health systems is becoming increasingly recognized as necessary for the achievement of many objectives promoted or supported by global public health initiatives. Key within the effort to strengthen health systems is the development of a well-prepared, skilled, and knowledgeable public health workforce. Over 60 years ago, the United States Centers for Disease Control and Prevention (CDC) began the first training program in applied epidemiology, the Epidemic Intelligence Service (EIS), a two-year, in-service training program in epidemiology and public health practice. Since 1951, the EIS has produced welltrained and highly qualified applied or field epidemiologists, many of whom later became leaders within the US public health system. In 1980, the CDC began assisting other countries to develop their own field epidemiology training programs (FETPs), modeling them after the highly successful EIS program. FETPs differ from other training programs in epidemiology in that: (1) they are positioned within Ministries of Health and the activities of the residents are designed to address the priority health issues of the Ministry; (2) they stress the principle of training through service; and (3) they provide close supervision and mentoring by trained field epidemiologists. While FETPs are designed to be adaptable to the needs of any given country, there exist many fundamental similarities in the skills and knowledge required by public health workers. Recognizing this, CDC developed a standard core FETP curriculum that can be adapted to any country's needs. Countries can further customize FETP trainings to meet their specific needs by adding specialized "tracks" or by targeting different audiences and levels of the health system. Although FETPs require substantial investments in time and resources as well as 190Public Health Reviews, Vol. 33,No 1,[190][191][192][193][194][195][196][197][198][199][200][201][202][203] Applied Epidemiology Training Programs: CDC's Experience 191 significant commitment from ministries, CDC's vision is that every country will have access to an FETP to help build its public health workforce and strengthen its public health systems.

Recent multinational disease outbreaks demonstrate the risk of disease spreading globally before public health systems can respond to an event. To ensure global health security, countries need robust multisectoral systems to rapidly detect and respond to domestic or imported communicable diseases. The US Centers for Disease Control and Prevention International Border Team works with the governments of Nigeria, Togo, and Benin, along with Pro-Health International and the Abidjan-Lagos Corridor Organization, to build sustainable International Health Regulations capacities at points of entry (POEs) and along border regions. Together, we strengthen comprehensive national and regional border health systems by developing public health emergency response plans for POEs, conducting qualitative assessments of public health preparedness and response capacities at ground crossings, integrating internationally mobile populations into national health surveillance systems, and formalizing cross-border public health coordination. Achieving comprehensive national and regional border health capacity, which advances overall global health security, necessitates multisectoral dedication to the aforementioned components.

Background. Tuberculosis (TB) is a leading cause of morbidity and mortality worldwide. In Armenia, case reports of active TB increased from 590 to 1538 between 1990 and 2003. However, the TB case detection rate in Armenia in 2007 was only 51%, indicating that many cases go undetected or that suspected cases are not referred for confirmatory diagnosis. Understanding why Armenians do not seek or delay TB medical care is important to increase detection rates, improve treatment outcomes, and reduce ongoing transmission. Methods. Two hundred-forty patients hospitalized between August 2006 and September 2007 at two Armenian TB reference hospitals were interviewed about symptoms, when they sought medical attention after symptom onset, outcomes of their first medical visit, and when they began treatment after diagnosis. We used logistic regression modeling to identify reasons for delay in diagnosis. Results. Fatigue and weight loss were significantly associated with delay in seeking medical attention [aOR = 2.47 (95%CI = 1.15, 5.29); aOR = 2.99 (95%CI = 1.46, 6.14), resp.], while having night sweats protected against delay [aOR = 0.48 (95%CI = 0.24, 0.96)]. Believing the illness to be something other than TB was also significantly associated with delay [aOR = 2.63 (95%CI = 1.13, 6.12)]. Almost 20% of the 240 TB patients were neither diagnosed at their first medical visit nor referred for further evaluation. Conclusions. This study showed that raising awareness of the signs and symptoms of TB among both the public and clinical communities is urgently needed.