Strengthening Health System in Cabo Verde: Implementation of Frontline Field Epidemiology Training Program From 2021 to 2024

Strengthening Health System in Cabo Verde: Implementation of Frontline Field Epidemiology Training Program From 2021 to 2024 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Strengthening Health System in Cabo Verde: Implementation of Frontline Field Epidemiology Training Program From 2021 to 2024 Maria da Luz Lima Mendonça, Ngibo Mubeta Fernandes, Sarah Mendes D’Angelo, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7475170/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background: Field Epidemiology Training Programs (FETPs) are global strategies for strengthening public health surveillance by training professionals to respond to health emergencies. In Cabo Verde, following the 2019 Joint External Evaluation (JEE), gaps in the national epidemiological workforce were identified. In response to this challenge, the Frontline Field Epidemiology Training Program of Cabo Verde (EpiCV) was implemented. This study aims to describe the process of implementation and the main results of the EpiCV, wich was carried out between 2021 and 2024 on the country’s public health surveillance system. Methods: Descriptive study based on an analysis of documentary sources and program databases. Descriptive statistics were used to characterize the profile of the professionals trained and the products generated during the training. Results: EpiCV has implemented six cohorts and trained 93 frontline surveillance officers, with representation across all 22 municipalities in the country. The majority were female (61; 65.59%) and the median age was 37 years (median range 25-59). Nurses (n=30; 32.26%), and physicians (n=22; 23.66%) are professions most common among graduates. In addition, 32 (53.33%) of the professionals had more than 10 years' service and work in municipality (n=54; 58.08%), and the majority were in the country's capital, Praia (n=29; 31.18%). During training, more than 370 technical reports were produced, including surveillance data quality reports; case studies; investigations and responses to various public health events, such as the COVID-19 pandemic; cases of imported malaria, gastroenteritis and shigellosis outbreaks, and the first documented urinary schistosomiasis outbreak in the country. Conclusions: The implementation of EpiCV represented a breakthrough in the country's health surveillance, promoting the formation of a multidisciplinary workforce aligned with the “One Health” approach. It is recommended that the program continues, as well as its institutionalization in the National Health System, as a way of guaranteeing the consolidation of the gains already achieved and facing future threats to public health with greater preparedness and resilience. Field Epidemiology Public Health Surveillance Health Workforce One Health Figures Figure 1 BACKGROUND Field Epidemiology Training Programs (FETPs) are recognized worldwide as effective means to strengthen countries’ capacity to qualify health workforce in terms of epidemiology, surveillance, and outbreak response 1 – 4 . FETPs are competency-based training programs that play a critical role in strengthening global health security and enhancing the epidemiological capabilities of public health professionals 5 – 7 . They are currently present in more than 150 countries on all continents and our member programs are developing global capacity for timely detection, investigation, and response to public health emergencies 8 . This program is known as the Epidemiology Intelligence Service (EIS), created in 1951 by Alexander Langmuir. This initiative was part of a strategy to strengthen the epidemiology capabilities of the then newly created Centers for Disease Control and Prevention (CDC) 2 , 9 . Since 1980s onwards, CDC has supported the establishment of FETPs around the world 2 , which aligns with the International Health Regulation (IHR) of 2005, which mandate that World Health Organization (WHO) member states build capacities to “detect, assess, notify, and respond” to potential public health emergencies 10 , 11 . Owing to the increase in programs and the need for integration between them, the worldwide network of field epidemiology and intervention programs was created, called Training Programs in Epidemiology and Public Health Interventions Network (Tephinet) with the function of supporting and assisting in the exchange of information and successful experiences 12 , 13 . Currently the FETP is structured on the three-tiered concept, according to the pyramid model of education, in three levels of training and complexity, basic (frontline), intermediate and advanced, which has varied somewhat in its implementation in each country, and is now evolving into a standardized and integrated approach, with a vision that all countries share a common set of core competences at each tier 13 , 14 . Notably, the last model implemented was the basic level, in 2015, on the basis of the need to prepare frontline teams to detect a public health threat in a timely manner, strengthening local capacity 15 . Furthermore, the IHR, which reinforces the need for countries to develop basic capacities to adress possible public health emergencies, to aims to protect against the international spread of diseases 10 , 16 . The training at all three tiers is conducted in both the classroom and, most importantly, in the field, where trainees develop their skills and competences while performing the day-to-day duties of a field epidemiologist 13 . The Joint External Evaluation (JEE) carried out in the country in 2019 highlighted important gaps in the surveillance system, including the lack of epidemiologists in the country 17 . In 2020, a team led by the National Institute of Public Health and with the participation of the National Directorate of Health, began working on the basis for the implementation of the FETP-Frontline, initially with the Brazilian Association of Field Epidemiology Professionals (ProEpi), a Brazilian on governmental organization, and the CDC in Atlanta as partners. Thus, this study aims to describe the implementation process and the main results and impact of the Frontline Field Epidemiology Training Program in Cabo Verde (EpiCV) from 2021–2024, with the goal of contributing to the strengthening of the country's health surveillance system, as well as to the sustainability of the Program. METHODS A descriptive study was conducted of the implementation of the Frontline Cabo Verde Field Epidemiology Training Program (EpiCV) between 2021 and 2024. Study area The Republic of Cabo Verde is an island country located in an archipelago in the central Atlantic Ocean, consisting of ten volcanic islands, with a combined land area of approximately 4,033 km², nine are inhabited, and a population of approximately 491,233 inhabitants. The country has 22 municipalities and Praia is its capital 18 . The economy of the country is primarily service oriented, with an increasing focus on tourism, and foreign investment accounts for approximately 40% of all economic activity 19 . Data and information sources We describe the implementation and results of EpiCV, and the following sources were used: meeting reports; the EpiCV database; data from standardized training material; documents of the graduates’ weekly reports and scientific technical production developed. Additionally, information was provided by the management and technical team of the INSP professionals and EpiCV staff and, by the country's laws. Regarding the profile of the professionals trained and the respective fieldwork, we used the EpiCV registration database prepared in Microsoft Excel @ , as well as the database of the FETP Monitoring, Assessment and Evaluation Unit/Center for Global Health/U.S. Centers for Disease Control and Prevention. The data were analyzed via descriptive statistics through absolute and relative frequency measures and measures of central tendency and dispersion. Descriptive statistics were summarized for each question via Epiinfo 7 software and maps were generated via QGIS 3.28 software. RESULTS Description of Cabo Verde's National Health System Cabo Verde's National Health System aims to ensure universal access to health services, with an emphasis on care for the most vulnerable populations. It is structured into public and private sectors, which perform complementary roles in the provision of healthcare 20 . It is organized on the basis of the principle of complementarity among the public, private, and social sectors, operating in a coordinated and integrated manner to ensure continuity of care and coherence in health promotion, protection, and disease prevention actions, in line with the principles of comprehensive, people-centered care and integrated health service delivery networks 21 . The Ministry of Health of Cabo Verde serves as the central authority responsible for the governance, regulation, and oversight of the national health system. This system is organized into hierarchical levels of care, with a particular emphasis on primary and secondary healthcare. Primary care services are predominantly provided through a network of health centers strategically located across all inhabited islands, with a focus on health promotion, disease prevention, and the delivery of essential health services. Secondary care is delivered by regional-level hospitals situated on selected islands, offering a broader range of specialized diagnostic, curative, and referral services to support the primary care level 22 . The public component of the National Health System encompasses the Ministry of Health, central administrative bodies, decentralized territorial services, autonomous entities, and specialized institutes 20 . Among these, the National Institute of Public Health (INSP). The INSP, created in 2014 as part of the State's Indirect Administration and with administrative, financial, patrimonial, scientific and technical autonomy, has various functions 23 . Cabo Verde Frontline Field Epidemiology Program (EpiCV) The Cabo Verde Field Epidemiology Training Program (EpiCV) began to be considered in 2019 with some funding possibilities from the West African Health Organization. However, it was not until 2020 that it was possible to start a project involving other actors. Thus, it was conceived with a local focus on strengthening health information management, involving human, animal and environmental health professionals. In addition, the aim was also to have a frontline epidemiologist on the ground in each of the country's 22 municipalities within a maximum of three years. The structure of the training is based on that proposed for programs at this level, lasting 12 weeks, with a combination of face-to-face and distance learning. Classroom training is reinforced by the completion of field projects designed to help participants develop competencies related to specific job functions. The classroom sessions were conducted by epidemiologists and public health professionals from Brazil Advanced and Intermediate-FETP, as well as professionals from Cabo Verde World Health Organization and the Ministry of Health and West African Health Organization (WAHO). During the program, each trainee was assigned a mentor who was in regular contact with them and who provided feedback and guidance, once a week, for the successful completion of the field project. The maximum ratio of mentors to mentees was 1: 3. The material was adapted for local reality via a schedule proposed by Andre et al., (2017) 9 (Table 1). Table 1. Schedule and curriculum of the Frontline Field Epidemiology Training Program in Cabo Verde, 2021-2024. Activite Duration Training Content Workshop 1 1 week (face to face) ● Health surveillance and public health emergencies ● Data collection, analysis, and interpretation ● Basic statistics ● Data quality assessment ● Use of management tools (SWOT) for data quality evaluation ● Case investigation ● Data-driven decision-making On the job projects 5 weeks ● Fieldwork ● Data quality audit (including visits to reporting structures) ● Surveillance data analysis ● Summary surveillance report Workshop 1 1 week ● Presentation of results from the first field work ● Lab collection and transport ● Outbreak investigation and response with laboratory integration ● “One Health” strategy ● Problem analysis (cause and effect diagram) ● Scientific communication through report and technical presentation development On the job projects 4 weeks Fieldwork ● Case report ● Outbreak investigation ● Problem analysis of surveillance and proposal of improvement recommendations ● Description of priority public health surveillance data Workshop 3 3 days ● Training and preparation for scientific presentations ● Presentation of final field work results to managers ● Closing ceremony Source: Adapted from Andre et al., 2017 9 . The first EpiCV cohort began in June 2021 and was coordinated by the President of the INSP within the scope of his duties related to the ‘One Health’ approach, with the director of the National Health Observatory as its focal point. The strategy was implemented by an external team of professional experts from Brazil linked to ProEpi with a resident advisor and mentors, as well as field epidemiologists from Guinea-Bissau. Members of the Multisectoral Committee of Cabo Verde's ‘One Health’ National Coordination Body (CMINC), those responsible for surveillance at the central level and health authorities, and those responsible for surveillance on the two islands with designated points of entry and the two islands with international airports in the country were prioritized for training. At the end of first year, two cohorts were executed. These two cohorts were supported by the CDC and the Skoll Foundation. Multiple efforts have been to continue EpiCV. In 2022, the program will continue with the third and fourth cohorts. The training of graduates to act as facilitators also continued to support professionals in training, with a view to the sustainability of human resources. This training for graduates was described and planned in the program’s sustainability plan drawn up in 2021. Funding for these cohorts was supported by the CDC in addition to support from Vital Strategies, which made it possible to hold the 1st Scientific Meeting of Field Epidemiologists in the country and the initial preparation of a Public Health Bulletin. The 1st EpiCV Scientific Meeting brought together the professionals who were finalizing the fourth cohort and the graduates of the previous classes, totaling approximately 60 graduates. It was also attended by managers from the Ministry of Health of Cabo Verde and Brazil; the Ministry of Agriculture and Environment of Cabo Verde; the Independent Health Regulatory Authority of Cabo Verde (ERIS), and representatives and partners from the World Health Organization of Cabo Verde; Vital Strategies; the CDC; WAHO and ProEpi. In June 2023, the first edition of Cabo Verde's National Public Health Bulletin was launched, an INSP project resulting from a partnership with the CDC Atlanta-USA; Bloomberg Philanthropies Data for Health Initiative and ProEpi. This edition featured the technical products developed by the graduates of EpiCV. This strategy has become one of the mechanisms for encouraging the scientific production of content by trained epidemiologists, with the aim of disseminating scientific information of national and international importance within the One Health approach. That same year, with the experience gained, six field epidemiologists who graduated from EpiCV were selected to be part of the first Master's program in Field Epidemiology at the University of Cape Verde (UNICV). This strategy was funded by the European & Developing Countries Clinical Trials Partnership (EDCTP), the result of a consortium involving the National Public Health Institutes of the Portuguese-speaking African Countries (PALOP), Mozambique's Eduardo Mondlane University and the Institute of Hygiene and Tropical Medicine and the University of Southern Denmark. The fifth cohort was also implemented in 2023 and the sixth cohort was implemented the following yaer in 2024. Both were implemented through a financial effort provided by the INSP through the general budget of the Government of Cabo Verde and by WAHO. Description of the profile of the graduates of the Cabo Verde Frontline Field Epidemiology Training Program (EpiCV) From the program’s launch in June 2021 through the end of 2024, 93 professionals completed the EpiCV in six cohorts (mean=16 graduates/cohort; SD±2). There are ten trained and active local facilitators, a focal point professional and a national program coordinator. Table 2 summarizes the demographic and professional characteristics of the EpiCV graduates in each cohort. Among those graduates, the majority were female (61; 65.59%) and the median age was 37 years (median range 25-59). Nurses (n=30; 32.26%), and physicians (n=22; 23.66%) are the professions most common among graduates. In addition, 32 (53.33%) of the professionals had more than 10 years of service and work in municipalities (n=54; 58.08%) and the majority were in the country's capital Praia (n=29; 31.18%). All the municipalities have at least one graduate (Figure 1). Table 2. Distribution of the number of professionals trained by the Cabo Verde Frontline Field Epidemiology Training Program, by cohort from 2021 - 2024 (N=93). Characteristics Implementation period jun-sept, 2021 sept-dec, 2021 fev-may, 2022 jun-sept,2022 jun-sept,2023 sept-dec, 2024 Total Cohort 1 N=12 Cohort 2 N=17 Cohort3 N=17 Cohort 4 N=15 Cohort 5 N=15 Cohort 6 N=17 n (%) n (%) n (%) n (%) n (%) n (%) n (%) Sex Female 8 (66.67) 13 (76.47) 12 (70.59) 8 (53.33) 8 (53.33) 12 (70.59) 61 (65.59) Male 2 (33.33) 4 (23.53) 5 (29.41) 7 (46.67) 7 (46.67) 5 (29.41) 32 (34.41) Age in years Median 47 (NA) 37 (NA) 37 (NA) 34.5 (NA) 37 (NA) 37 (NA) 37 (NA) Median range 30 - 59 (NA) 28 - 49 (NA) 27 - 57 (NA) 27 - 57 (NA) 29 - 56 (NA) 25 - 54 (NA) 25 - 59 (NA) Professional Background Animal Health - technician 0 2 (11.76) 0 0 0 1 (5.88) 3 (3.23) Veterinarian 1 (8.33) 0 2 (11.76) 2 (13.33) 1 (6.67) 2 (11.76) 8 (8.60) Environmental Health 1 (8.33) 1 (5.88) 0 0 0 0 2 (2.15) Human Health - Technican of Laboratory 0 1 (5.88) 2 (11.76) 0 3 (20.0) 3 (17.65) 9 (9.68) Human Health - Other 2 (16.67) 1 (5.88) 7 (41.18) 4 (26.67) 5 (33.33) 0 19 (20.43) Nurse 3 (25.0) 3 (17.65) 3 (17.65) 7 (46.67) 6 (40.0) 8 (47.06) 30 (32.26) Physician 5 (41.67) 9 (52.94) 3 (17.65) 2 (13.33) 0 3 (17.65) 22 (23.66) Years in the profession (N=60) 20 4 4 0 0 2 4 14 (23.33) Activity sector Nacional 5 (41.67) 5 (29.41) 8 (47.06) 1 (6.67) 4 (26.67) 2 (11.76) 25 (26.88) Regional 0 1 (5.88) 3 (17.65) 1 (6.67) 0 2 (11.76) 7 (7.53) Municipality 6 (50.00) 10 (58.82) 6 (35.29) 13 (86.67) 11 (73.33) 8 (47.06) 54 (58.08) Health facility 1 (8.33) 1 (5.88) 0 0 0 5 (29.41) 7 (7.53) Municipality Boa Vista 1 (8.33) 0 0 1 (6.67) 0 0 2 (2.15) Brava 0 0 1 (5.88) 0 0 0 1 (1.08) Maio 0 0 1 (5.88) 0 2 (13.33) 0 3 (3.23) Mosteiros 0 0 0 1 (6.67) 0 0 1 (1.08) Paul 0 0 0 1 (6.67) 0 1 (5.88) 2 (2.15) Porto Novo 0 0 1 (5.88) 2 (13.33) 1 (6.67) 1 (5.88) 5 (5.38) Praia 7 (58.33) 4 (23.53) 8 (47.06) 2 (13.33) 5 (33.33) 3 (17.65) 29 (31.18) Ribeira Brava 0 1 (5.88) 0 0) 1 (6.67) 0 2 (2.15) Ribeira Grande de Santiago 0 1 (5.88) 0 0 0 1 (5.88) 2 (2.15) Ribeira Grande de Santo Antão 0 0 1 (5.88) 0 1 (6.67) 2 (11.76) 5 (5.38) Sal 1 (8.33) 0 0 2 (13.33) 1 (6.67) 1 (5.88) 5 (5.38) Santa Catarina 0 3 (17.65) 2 (11.76) 1 (6.67) 0 0 6 (6.45) Santa Catarina de Fogo 0 0 0 1 (6.67) 0 0 1 (1.08) Santa Cruz 0 1 (5.88) 0 0 0 1 (5.88) 2 (2.15) São Domingos 0 1 (5.88) 0 1 (6.67) 1 (6.67) 0 3 (3.23) São Filipe do Fogo 0 1 (5.88) 1 (5.88) 0 0 0 2 (2.15) São Lourenço dos Órgãos 0 1 (5.88) 0 0 2 (13.33) 0 3 (3.23) São Miguel 0 2 (11.76) 0 0 0 1 (5.88) 3 (3.23) São Salvador do Mundo 0 0 0 1 (6.67) 0 1 (5.88) 2 (2.15) São Vicente 3 (25.0) 1 (5.88) 2 (11.76) 0 1 (6.67) 5 (29.41) 12 (12.90) Tarrafal de Santiago 0 1 (5.88) 0 0 0 0 1 (1.08) Tarrafal de São Nicolau 0 0 0 1 (6.67) 0 0 1 (1.08) Source: Programme's database. N = total graduates; n=number of graduates; %= proportion; Human Health - Other= Biologists, statisticians and data management technicians; NA = Not Applicable, in cases where it was not appropriate to calculate a percentage value for the data. Field products completed by the six cohorts of the Cabo Verde Frontline Field Epidemiology Training Program (EpiCV) During the training sessions and the field work between them, the professionals were able to intervene in various health situations that required efforts to resolve. The following activities stand out: Support for the response to COVID-19 and the introduction of new variants and subvariants of COVID-19 (2020-2022); Investigations into fish deaths (2021) and imported cases of malaria (2022) in the capital of the country; Investigations of Gastroenteritis (2022) and Shigellosis (2022-2023) outbreaks in Sal; Investigation of the first findings of urinary schistosomiasis in in one district in the country in 2022 and the establishment of the disease in the years 2023 and 2024, and Support for the response to the Dengue outbreak that occurred in 2024. Additionally, during training, more than 370 reports were produced on the various topics of case and outbreak investigation topics, SWOT analyses and cause-and-effect diagrams. Impact of implementing the Cabo Verde Frontline Field Epidemiology Training Program We can already see several achievements that have had an impact on the country's public health. The implementation of health situation rooms in various health services by trained professionals. This activity helps the timely detection of events of public health relevance in the territory. To improve the field epidemiology skills of the trained professionals, six field epidemiologists were included in the master's program at the UNICV, which was supported by the EDCTP through a project involving several National Public Health Institutions from five Portuguese-speaking African countries; the Institute of Hygiene and Tropical Medicine in Portugal and Eduardo Mondlane University in Mozambique. With respect to scientific communication and the dissemination of knowledge and evidence, we highlight the 1st Scientific Meeting of Field Epidemiologists, the Public Health Bulletin (BSP) and the network of field epidemiologists in Cabo Verde. The fourth edition of the BSP was published between 2023 and 2024. The implementation of BSPs is a project that has been implemented in African countries, such as Cabo Verde and Guinea-Bissau, with the aim of strengthening the production and dissemination of quality epidemiological information and keeping the network of epidemiologists active. The main focus of the project was to improve the quality of epidemiological data and analysis to support effective public policies and increase the timely response to outbreaks and epidemics. The main activities conducted include the following: Situational analysis through interviews with technicians, managers and FETP graduates to identify gaps in technical areas (Epi Info, Statistics, Geoprocessing and Scientific Writing). Online mentoring sessions, with experts addressing the topics identified. Face-to-face workshop in Cabo Verde, with practical activities and the production of scientific articles for the bulletins. Production of courses and teaching materials, available free of charge on the ProEpi platform. The participation of EpiCV graduates was central to the project's success: Eight of the country's 10 participants in the face-to-face workshop had been trained by the FETP program, demonstrating the strong involvement of these professionals in health surveillance. These graduates work in strategic positions at the National Institute of Public Health (INSP), health delegations and the Ministry of Health, contributing to the practical implementation and sustainability of the BSP strategy. The graduates were instrumental in producing the 11 scientific articles that were a direct result of the workshop. The accumulated experience, with a median of 4.5 years working in health surveillance, allowed the professionals to apply the knowledge acquired and strengthen the country's technical capacity. Cabo Verde's network of field epidemiologists holds monthly meetings and shares health situations, with the aim of strengthening the One Health approach. It also consolidates the participation of graduates in drawing up the National Action Plan for Health Security, updating risk mapping and supporting the drafting of the country's Integrated Surveillance and Disease Response Plan. Many partnerships remain in place and others are being agreed upon. One of the EpiCV graduates is currently attending advanced field epidemiology training in Brazil, as part of the collaboration established in the Strategic Health Cooperation Plan of the Community of Portuguese-Speaking African Countries. DISCUSSION The implementation of EpiCV, between 2021 and 2024, represents a strategic effort to strengthen local capacities in health surveillance, emergency response and the use of data for decision-making. As observed in experiences of implementing FETP in other low and middle-income countries 24 , EpiCV has contributed to the qualification of the public health workforce, especially at the levels closest to the community and where resources and technical training are often more limited similar to other findings 9 , 15 , 16 , 25 . FETPs are essential for ensuring timely responses to health emergencies, especially in countries with structural vulnerabilities in their health systems 6 , 26 , 27 . Our findings demonstrate tangible impacts: there have been advances in detecting and responding to outbreaks, in producing and analyzing epidemiological data and in preparing technical reports. These gains are consistent with the results found in other African contexts that have implemented the Frontline FETP 15 , 24 , 25 , 28 . Like the Ghana-FETP Program 29 , EpiCV also adopted the “One Health” approach, promoting integration between the human, animal and environmental health sectors. This perspective has broadened technical skills and strengthened a systemic view of public health, which is essential in the face of complex threats such as zoonoses and climate change. Our program initially trained the members of the Multisectoral Commission of the National Coordination Body for a One Health approach from the two islands with designated points of entry and the two with international airports in the country, to ensure that a manager was prepared to face the challenges of global health. This approach is also in line with the guidelines of the International Health Regulations (IHR) 2 , which establish the need for basic capacities in surveillance and response in all countries. In addition, having an FETP or other applied epidemiology program in place is one of the JEE's human resource indicators 17 . One of the greatest challenges is the training of human resources, which is fundamental to guaranteeing several of the basic surveillance and response capacities of a health system 30 , 31 . In many countries, FETPs have proven to be successful models for building public health workforce capacity 2 ; however, critical gaps remain in terms of epidemiologic capacity 32 . Considering the country's population and territorial dimensions, as well as its challenges related to insularity and the limitation of specialized human resources, this number is significant. The diversity of trained professionals also reflects the commitment to the "One Health" approach, which involves integrating multiple areas of knowledge and creating a more qualified and multidisciplinary workforce, which is essential for dealing with complex public health problems. EpiCV has increased the country's capacity to detect, investigate and respond to public health emergencies, especially at the local level. This has improved the rapid response to possible outbreaks and health events, preventing the spread of diseases and reducing the impact on public health, as demonstrated by the work of professionals investigating outbreaks, such as the investigation of urinary schistosomiasis, a disease that had not previously been recorded in the country 33 and the production of evidence published in the National Epidemiological Bulletins 34 – 37 . The implementation of the program was a multisectoral effort, involving various institutions and partners. This has strengthened the resilience of the health system, guaranteeing the sustainability of the EpiCV, which has completed six cohorts in four years. However, despite the progress made, some challenges remain, especially with respect to retaining these professionals in their original health services and keeping epidemiologists up to date. This effort needs to continue, giving increasing presence in quantity and quality to the different sectors involved and facilitating the operationalization of multisectoral cooperation to promote alerts, early detection and response to public health threats. However, the sustainability of the program is still a challenge. Although there was initial support from international agencies and the national public budget, the continuity of the training, the expansion to the intermediate and advanced levels of the FETP, and the institutionalization of the program require ongoing strategic planning. Zambia-FETP shows that the full institutionalization of the FETP depends on legal frameworks, permanent budget lines and career progression mechanisms for graduates 15 . Similarly, the evaluation of the FETP in Central America trevealed that although the programs were initially supported by external funds - especially from USAID and the CDC, full institutionalization was possible only as the countries gradually began to assume the operational costs. The authors emphasize the importance of co-financing strategies and the inclusion of programs in ministerial budgets as mechanisms to strengthen long-term sustainability 14 . CONCLUSIONS The structuring of EpiCV represented a milestone in strengthening the country's public health surveillance capacity. The training of 93 professionals in six cohorts demonstrated that, even in the context of limited resources, it is possible to advance the technical qualifications of the health workforce through a sustained, multisectoral strategy. The multisectoral initiative results in greater resilience for the program, which can now rely on various stakeholders to support the continuity of training. This implementation model has proven effective, allowing qualified professionals to contribute directly to improving responses to health emergencies and to developing local public health capacities. The "One Health" approach used to recruit professionals from different fields has created a more qualified and multidisciplinary workforce, which is essential for dealing with complex public health problems. Importantly, to consider that the program's impacts could be even broader if systematic long-term evaluations, including performance indicators, the quality of routine surveillance and the impact on the population's health outcomes, are performed. These aspects should guide future research and decision-making for the continued strengthening of public health surveillance in Cabo Verde. They should also ensure its institutionalization in the National Health System, as a way of consolidating the gains already made and facing future threats to public health with greater preparedness and resilience. Declarations COMPETING INTERESTS The authors declare that they have no competing interests. SOURCE OF FUNDING This manuscript did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Contribution - Design of the study: Mendonça M.L.L and Costa, V.M- Data collection, analysis and writing original draft: Mendonça, M.L.L.; Costa, V.M.; D’Angelo S.M. ; Fernandes, N.M.; Costa, F.B.P.; and Paiva, P.- Final review and supervision: Mendonça, M.L.L.; Costa, V.M.; Brant, J.L.; Lopez, A. and Brito, C.P.F. J- All authors reviewed the manuscript and agreed to the final manuscript. Acknowledgement We thank all the institutions and people who contributed to the sustainability of the Program and the partners who made this possible. In particular, the Multisectoral Committee of the National Coordination Body “One Health” of Cabo Verde; the Brazilian Association of Field Epidemiology-ProEpi, Center Disease Control-CDC/ Atlanta; Tephinet, in particular Dr. Carl Reddy; the West African Health Organization-WAHO; the WHO Office in Cabo Verde; Skoll Foundation - Support for the TiLS COVID-19 Task Force; Vital Strategies; the CDC Foundation and the World Bank's Emergency Resilience Program. References Traicoff, D. A. et al. Strong and Flexible: Developing a Three-Tiered Curriculum for the Regional Central America Field Epidemiology Training Program. Pedagogy in Health Promotion 1 , 74–82 (2015). Schneider, D., Evering-Watley, M., Walke, H. & Bloland, P. B. 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Zambia field epidemiology training program: strengthening health security through workforce development. Pan Afr Med J 36 , (2020). MacDonald, P. D. M. et al. Evaluation of the first two Frontline cohorts of the Field Epidemiology Training Program in Guinea, West Africa. Preprint at https://doi.org/10.21203/rs.3.rs-1284182/v1 (2022). WHO. Avaliação Externa Conjunta das Principais Capacidades do RSI Da República de Cabo Verde: Relatório de Missão, 4-8 Novembro 2019 . (World Health Organization, Geneva, 2020). INE. Instituto de Estatística de Cabo Verde. Recenseamento geral da população e habitação. (2022). INE. Instituto de Estatística de Cabo Verde. Estatística do Turismo. (2024). Cabo Verde. Lei n. o 41/VI/2004 . vol. 10 (2004). Cabo Verde. Lei n. o 76/IX/2020. Boletim Eletrônico Oficial. Assembleia Nacional . vol. 24 (2020). Cabo Verde. Decreto-Lei N o 56/2021 . vol. 91 2336 (2021). Cabo Verde. Decreto-Regulamentar. Boletim Oficial Da República de Cabo Verde . vol. 91 (2024). Camará, M., Johnson, K., Rullan-Oliver, P. & Lopez, A. Strengthening surveillance, disease detection, and outbreak response through Guinea-Bissau’s Frontline Field Epidemiology Training Program: a cross- sectional descriptive study. PAMJ 45 , 1–11 (2023). Roka, Z. G. et al. Strengthening health systems in Africa: a case study of the Kenya field epidemiology training program for local frontline health workers. Public Health Rev 38 , 23 (2017). Hu, A. E. et al. Field epidemiology training programs contribute to COVID-19 preparedness and response globally. BMC Public Health 22 , 63 (2022). Kandun, I. N. et al. Strengthening Indonesia’s Field Epidemiology Training Programme to address International Health Regulations requirements. Bull World Health Org 88 , 211–215 (2010). Collins, D. et al. Evaluation of the first two Frontline cohorts of the field epidemiology training program in Guinea, West Africa. Hum Resour Health 20 , 40 (2022). Wurapa, F. et al. One Health concept for strengthening public health surveillance and response through Field Epidemiology and Laboratory Training in Ghana. Carvalho Malta, D. et al. Formação de recursos humanos em saúde: desafios e oportunidades. Anais do Instituto de Higiene e Medicina Tropical v. 18 , 17-24 Páginas (2019). Edward L Baker et al. The public health infrastructure and our nation’s health. Annu Rev Public Health 26 , 303–18 (2005). Heymann, D. L. et al. Global health security: the wider lessons from the west African Ebola virus disease epidemic. The Lancet 385 , 1884–1901 (2015). Da Costa, V. M. et al. Urinary schistosomiasis outbreak in Cabo Verde: the first description in the country, May-June, 2022. PAMJ-OH 13 , (2024). INSP. Instituto Nacional de Saúde de Cabo Verde. Boletim Epidemiológico de Cabo Verde. Terceira Edição. (2). INSP. Instituto Nacional de Saúde de Cabo Verde. Boletim Epidemiológico de Cabo Verde. Primeira Edição. (2023). INSP. Instituto Nacional de Saúde de Cabo Verde. Boletim Epidemiológico de Cabo Verde. Segunda Edição. (2023). INSP. Instituto Nacional de Saúde de Cabo Verde. Boletim Epidemiológico de Cabo Verde. Quarta Edição. (2024). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 26 Oct, 2025 Reviews received at journal 17 Oct, 2025 Reviews received at journal 17 Oct, 2025 Reviewers agreed at journal 15 Oct, 2025 Reviewers agreed at journal 15 Oct, 2025 Reviewers agreed at journal 13 Oct, 2025 Reviewers agreed at journal 08 Oct, 2025 Reviewers invited by journal 06 Oct, 2025 Editor invited by journal 08 Sep, 2025 Editor assigned by journal 05 Sep, 2025 Submission checks completed at journal 05 Sep, 2025 First submitted to journal 27 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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National Institute of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Ngibo","middleName":"Mubeta","lastName":"Fernandes","suffix":""},{"id":530607467,"identity":"5656fbea-d4a9-4c40-8dcb-e65f6a67d896","order_by":2,"name":"Sarah Mendes D’Angelo","email":"","orcid":"","institution":"Brazilian Association of Field Epidemiology Professionals","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"Mendes","lastName":"D’Angelo","suffix":""},{"id":530607468,"identity":"d1a02d22-87af-4cec-9f8d-b292b3d40dc8","order_by":3,"name":"Jonas Brant","email":"","orcid":"","institution":"University of Brasília – Brasília-Distrito Federal","correspondingAuthor":false,"prefix":"","firstName":"Jonas","middleName":"","lastName":"Brant","suffix":""},{"id":530607469,"identity":"acd92443-3621-489a-aef6-079e0655b357","order_by":4,"name":"Augusto Lopez","email":"","orcid":"","institution":"Centre for Disease Control and Prevention 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15:47:49","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":107300,"visible":true,"origin":"","legend":"","description":"","filename":"9d2b10972c3d413ba421091bbc5ffd521structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7475170/v1/94f392928a4901aad857ea17.xml"},{"id":93795280,"identity":"3722406f-6916-43c3-b4ce-797931ae87fb","added_by":"auto","created_at":"2025-10-17 15:47:49","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":118421,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7475170/v1/d718f5b98a7ac16bd9c648ad.html"},{"id":93795275,"identity":"2c25852e-7e8d-4dfa-a95e-a7f1bb6842e0","added_by":"auto","created_at":"2025-10-17 15:47:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":58591,"visible":true,"origin":"","legend":"\u003cp\u003eMap of municipalities Staffed by the Cabo Verde Frontline Field Epidemiology Training Program, 2021 - 2024 (N=93).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7475170/v1/e6561138ece88d2e69ee678d.png"},{"id":93797785,"identity":"8b08dec2-3310-4885-afb3-1844e271f2e1","added_by":"auto","created_at":"2025-10-17 16:03:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1155644,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7475170/v1/2fe22f8b-d760-41c9-a590-40df21aad218.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eStrengthening Health System in Cabo Verde: Implementation of Frontline Field Epidemiology Training Program From 2021 to 2024\u003c/p\u003e","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eField Epidemiology Training Programs (FETPs) are recognized worldwide as effective means to strengthen countries\u0026rsquo; capacity to qualify health workforce in terms of epidemiology, surveillance, and outbreak response\u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. FETPs are competency-based training programs that play a critical role in strengthening global health security and enhancing the epidemiological capabilities of public health professionals\u003csup\u003e\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. They are currently present in more than 150 countries on all continents and our member programs are developing global capacity for timely detection, investigation, and response to public health emergencies\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. This program is known as the Epidemiology Intelligence Service (EIS), created in 1951 by Alexander Langmuir. This initiative was part of a strategy to strengthen the epidemiology capabilities of the then newly created Centers for Disease Control and Prevention (CDC)\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eSince 1980s onwards, CDC has supported the establishment of FETPs around the world\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, which aligns with the International Health Regulation (IHR) of 2005, which mandate that World Health Organization (WHO) member states build capacities to \u0026ldquo;detect, assess, notify, and respond\u0026rdquo; to potential public health emergencies\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Owing to the increase in programs and the need for integration between them, the worldwide network of field epidemiology and intervention programs was created, called Training Programs in Epidemiology and Public Health Interventions Network (Tephinet) with the function of supporting and assisting in the exchange of information and successful experiences\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eCurrently the FETP is structured on the three-tiered concept, according to the pyramid model of education, in three levels of training and complexity, basic (frontline), intermediate and advanced, which has varied somewhat in its implementation in each country, and is now evolving into a standardized and integrated approach, with a vision that all countries share a common set of core competences at each tier\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Notably, the last model implemented was the basic level, in 2015, on the basis of the need to prepare frontline teams to detect a public health threat in a timely manner, strengthening local capacity\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Furthermore, the IHR, which reinforces the need for countries to develop basic capacities to adress possible public health emergencies, to aims to protect against the international spread of diseases\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. The training at all three tiers is conducted in both the classroom and, most importantly, in the field, where trainees develop their skills and competences while performing the day-to-day duties of a field epidemiologist\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe Joint External Evaluation (JEE) carried out in the country in 2019 highlighted important gaps in the surveillance system, including the lack of epidemiologists in the country\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. In 2020, a team led by the National Institute of Public Health and with the participation of the National Directorate of Health, began working on the basis for the implementation of the FETP-Frontline, initially with the Brazilian Association of Field Epidemiology Professionals (ProEpi), a Brazilian on governmental organization, and the CDC in Atlanta as partners. Thus, this study aims to describe the implementation process and the main results and impact of the Frontline Field Epidemiology Training Program in Cabo Verde (EpiCV) from 2021\u0026ndash;2024, with the goal of contributing to the strengthening of the country's health surveillance system, as well as to the sustainability of the Program.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eA descriptive study was conducted of the implementation of the Frontline Cabo Verde Field Epidemiology Training Program (EpiCV) between 2021 and 2024.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy area\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Republic of Cabo Verde is an island country located in an archipelago in the central Atlantic Ocean, consisting of ten volcanic islands, with a combined land area of approximately 4,033 km\u0026sup2;, nine are inhabited, and a population of approximately 491,233 inhabitants. The country has 22 municipalities and Praia is its capital\u003csup\u003e18\u003c/sup\u003e.\u003csup\u003e\u0026nbsp;\u003c/sup\u003eThe economy of the country is primarily service oriented, with an increasing focus on tourism, and foreign investment accounts for approximately 40% of all economic activity\u003csup\u003e19\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData and information sources\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe describe the implementation and results of EpiCV, and the following sources were used: meeting reports; the EpiCV database; data from standardized training material; documents of the graduates\u0026rsquo; weekly reports and scientific technical production developed. Additionally, information was provided by the management and technical team of the INSP professionals and EpiCV staff and, by the country\u0026apos;s laws.\u003c/p\u003e\n\u003cp\u003eRegarding the profile of the professionals trained and the respective fieldwork, we used the EpiCV registration database prepared in Microsoft Excel\u003csup\u003e@\u003c/sup\u003e, as well as the database of the FETP Monitoring, Assessment and Evaluation Unit/Center for Global Health/U.S. Centers for Disease Control and Prevention. The data were analyzed via descriptive statistics through absolute and relative frequency measures and measures of central tendency and dispersion. Descriptive statistics were summarized for each question via Epiinfo 7 software and maps were generated via QGIS 3.28 software.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDescription of Cabo Verde\u0026apos;s National Health System\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCabo Verde\u0026apos;s National Health System aims to ensure universal access to health services, with an emphasis on care for the most vulnerable populations. It is structured into public and private sectors, which perform complementary roles in the provision of healthcare\u003csup\u003e20\u003c/sup\u003e. It is organized on the basis of the principle of complementarity among the public, private, and social sectors, operating in a coordinated and integrated manner to ensure continuity of care and coherence in health promotion, protection, and disease prevention actions, in line with the principles of comprehensive, people-centered care and integrated health service delivery networks\u003csup\u003e21\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe Ministry of Health of Cabo Verde serves as the central authority responsible for the governance, regulation, and oversight of the national health system. This system is organized into hierarchical levels of care, with a particular emphasis on primary and secondary healthcare. Primary care services are predominantly provided through a network of health centers strategically located across all inhabited islands, with a focus on health promotion, disease prevention, and the delivery of essential health services. Secondary care is delivered by regional-level hospitals situated on selected islands, offering a broader range of specialized diagnostic, curative, and referral services to support the primary care level\u003csup\u003e22\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe public component of the National Health System encompasses the Ministry of Health, central administrative bodies, decentralized territorial services, autonomous entities, and specialized institutes\u003csup\u003e20\u003c/sup\u003e. Among these, the National Institute of Public Health (INSP). The INSP, created in 2014 as part of the State\u0026apos;s Indirect Administration and with administrative, financial, patrimonial, scientific and technical autonomy, has various functions\u003csup\u003e23\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCabo Verde Frontline Field Epidemiology Program (EpiCV)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Cabo Verde Field Epidemiology Training Program (EpiCV) began to be considered in 2019 with some funding possibilities from the West African Health Organization. However, it was not until 2020 that it was possible to start a project involving other actors. Thus, it was conceived with a local focus on strengthening health information management, involving human, animal and environmental health professionals. In addition, the aim was also to have a frontline epidemiologist on the ground in each of the country\u0026apos;s 22 municipalities within a maximum of three years.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe structure of the training is based on that proposed for programs at this level, lasting 12 weeks, with a combination of face-to-face and distance learning. Classroom training is reinforced by the completion of field projects designed to help participants develop competencies related to specific job functions. The classroom sessions were conducted by epidemiologists and public health professionals from Brazil Advanced and Intermediate-FETP, as well as professionals from Cabo Verde World Health Organization and the Ministry of Health and West African Health Organization (WAHO). During the program, each trainee was assigned a mentor who was in regular contact with them and who provided feedback and guidance, once a week, for the successful completion of the field project. The maximum ratio of mentors to mentees was 1: 3. The material was adapted for local reality via a schedule proposed by Andre \u003cem\u003eet al.,\u003c/em\u003e (2017)\u003csup\u003e9\u003c/sup\u003e (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1. Schedule and curriculum of the Frontline Field Epidemiology Training Program in Cabo Verde, 2021-2024.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"620\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eActivite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eDuration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 424px;\"\u003e\n \u003cp\u003eTraining Content\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eWorkshop 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 week (face to face)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 424px;\"\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Health surveillance and public health emergencies\u0026nbsp;\u003cbr\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Data collection, analysis, and interpretation\u003cbr\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Basic statistics\u0026nbsp;\u003cbr\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Data quality assessment\u0026nbsp;\u003cbr\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Use of management tools (SWOT) for data quality evaluation\u0026nbsp;\u003cbr\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Case investigation\u003cbr\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Data-driven decision-making\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eOn the job projects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 424px;\"\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Fieldwork\u003cbr\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Data quality audit (including visits to reporting structures)\u0026nbsp;\u003cbr\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Surveillance data analysis\u0026nbsp;\u003cbr\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Summary surveillance report\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eWorkshop 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 424px;\"\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Presentation of results from the first field work\u0026nbsp;\u003cbr\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Lab collection and transport\u003cbr\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Outbreak investigation and response with laboratory integration\u0026nbsp;\u003cbr\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026ldquo;One Health\u0026rdquo; strategy\u0026nbsp;\u003cbr\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Problem analysis (cause and effect diagram)\u0026nbsp;\u003cbr\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Scientific communication through report and technical presentation development\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eOn the job projects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 424px;\"\u003e\n \u003cp\u003eFieldwork\u003c/p\u003e● Case report\u003cbr\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Outbreak investigation\u003cbr\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Problem analysis of surveillance and proposal of improvement recommendations\u003cbr\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Description of priority public health surveillance data\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 92px;\"\u003e\n \u003cp\u003eWorkshop 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 424px;\"\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Training and preparation for scientific presentations\u003cbr\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Presentation of final field work results to managers\u0026nbsp;\u003cbr\u003e● \u0026nbsp; \u0026nbsp; \u0026nbsp; Closing ceremony \u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSource: Adapted from Andre \u003cem\u003eet al.,\u003c/em\u003e 2017\u003csup\u003e9\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe first EpiCV cohort began in June 2021 and was coordinated by the President of the INSP within the scope of his duties related to the \u0026lsquo;One Health\u0026rsquo; approach, with the director of the National Health Observatory as its focal point. The strategy was implemented by an external team of professional experts from Brazil linked to ProEpi with a resident advisor and mentors, as well as field epidemiologists from Guinea-Bissau. Members of the Multisectoral Committee of Cabo Verde\u0026apos;s \u0026lsquo;One Health\u0026rsquo; National Coordination Body (CMINC), those responsible for surveillance at the central level and health authorities, and those responsible for surveillance on the two islands with designated points of entry and the two islands with international airports in the country were prioritized for training. At the end of first year, two cohorts were executed. These two cohorts were supported by the CDC and the Skoll Foundation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMultiple efforts have been to continue EpiCV. In 2022, the program will continue with the third and fourth cohorts. The training of graduates to act as facilitators also continued to support professionals in training, with a view to the sustainability of human resources. This training for graduates was described and planned in the program\u0026rsquo;s sustainability plan drawn up in 2021. Funding for these cohorts was supported by the CDC in addition to support from Vital Strategies, which made it possible to hold the 1st Scientific Meeting of Field Epidemiologists in the country and the initial preparation of a Public Health Bulletin.\u003c/p\u003e\n\u003cp\u003eThe 1st EpiCV Scientific Meeting brought together the professionals who were finalizing the fourth cohort and the graduates of the previous classes, totaling approximately 60 graduates. It was also attended by managers from the Ministry of Health of Cabo Verde and Brazil; the Ministry of Agriculture and Environment of Cabo Verde; the Independent Health Regulatory Authority of Cabo Verde (ERIS), and representatives and partners from the World Health Organization of Cabo Verde; Vital Strategies; the CDC; WAHO and ProEpi.\u003c/p\u003e\n\u003cp\u003eIn June 2023, the first edition of Cabo Verde\u0026apos;s National Public Health Bulletin was launched, an INSP project resulting from a partnership with the CDC Atlanta-USA; Bloomberg Philanthropies Data for Health Initiative and ProEpi. This edition featured the technical products developed by the graduates of EpiCV. This strategy has become one of the mechanisms for encouraging the scientific production of content by trained epidemiologists, with the aim of disseminating scientific information of national and international importance within the One Health approach. That same year, with the experience gained, six field epidemiologists who graduated from EpiCV were selected to be part of the first Master\u0026apos;s program in Field Epidemiology at the University of Cape Verde (UNICV). This strategy was funded by the European \u0026amp; Developing Countries Clinical Trials Partnership (EDCTP), the result of a consortium involving the National Public Health Institutes of the Portuguese-speaking African Countries (PALOP), Mozambique\u0026apos;s Eduardo Mondlane University and the Institute of Hygiene and Tropical Medicine and the University of Southern Denmark.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe fifth cohort was also implemented in 2023 and the sixth cohort was implemented the following yaer in 2024. Both were implemented through a financial effort provided by the INSP through the general budget of the Government of Cabo Verde and by WAHO.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDescription of the profile of the graduates of the Cabo Verde Frontline Field Epidemiology Training Program (EpiCV)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom the program\u0026rsquo;s launch in June 2021 through the end of 2024, 93 professionals completed the EpiCV in six cohorts (mean=16 graduates/cohort; SD\u0026plusmn;2). There are ten trained and active local facilitators, a focal point professional and a national program coordinator.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2 summarizes the demographic and professional characteristics of the EpiCV graduates in each cohort. Among those graduates, the majority were female (61; 65.59%) and the median age was 37 years (median range 25-59). Nurses (n=30; 32.26%), and physicians (n=22; 23.66%) are the professions most common among graduates. In addition, 32 (53.33%) of the professionals had more than 10 years of service and work in municipalities (n=54; 58.08%) and the majority were in the country\u0026apos;s capital Praia (n=29; 31.18%). All the municipalities have at least one graduate (Figure 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2. Distribution of the number of professionals trained by the Cabo Verde Frontline Field Epidemiology Training Program, by cohort from 2021 - 2024 (N=93).\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"973\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"7\" style=\"width: 709px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImplementation period\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ejun-sept, 2021\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003esept-dec, 2021\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003efev-may, 2022\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ejun-sept,2022\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ejun-sept,2023\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003esept-dec, 2024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Cohort 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;N=12\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Cohort 2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN=17\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Cohort3\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN=17\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Cohort 4\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN=15\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Cohort 5\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN=15\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Cohort 6\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN=17\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Sex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e8 (66.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e13 (76.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e12 (70.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e8 (53.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e8 (53.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e12 (70.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e61 (65.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4 (23.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5 (29.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7 (46.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7 (46.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5 (29.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e32 (34.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge in years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Median\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e47 (NA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e37 (NA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e37 (NA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e34.5 (NA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e37 (NA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e37 (NA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e37 (NA)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Median range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e30 - 59 (NA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e28 - 49 (NA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e27 - 57 (NA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e27 - 57 (NA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e29 - 56 (NA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e25 - 54 (NA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e25 - 59 (NA)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProfessional Background\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Animal Health - technician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (11.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3 (3.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Veterinarian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (8.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (11.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (13.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (11.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e8 (8.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Environmental Health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (8.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2 (2.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Human Health - Technican of Laboratory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (11.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3 (17.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e9 (9.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Human Health - Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (16.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7 (41.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4 (26.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5 (33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e19 (20.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Nurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3 (17.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3 (17.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7 (46.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e6 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e8 (47.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e30 (32.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Physician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5 (41.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e9 (52.94)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3 (17.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (13.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3 (17.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e22 (23.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears in the profession (N=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3 (5.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;3 to 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e15 (25.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;6 to 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e10 (16.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;10 to 19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e18 (30.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026gt; 20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e14 (23.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eActivity sector\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Nacional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5 (41.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5 (29.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e8 (47.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4 (26.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (11.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e25 (26.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Regional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3 (17.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (11.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e7 (7.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Municipality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e6 (50.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e10 (58.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e6 (35.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e13 (86.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e11 (73.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e8 (47.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e54 (58.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Health facility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (8.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5 (29.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e7 (7.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMunicipality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Boa Vista\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (8.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2 (2.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Brava\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1 (1.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Maio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (13.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3 (3.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Mosteiros\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1 (1.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Paul\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2 (2.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Porto Novo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (13.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5 (5.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Praia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7 (58.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4 (23.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e8 (47.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (13.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5 (33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3 (17.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e29 (31.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Ribeira Brava\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2 (2.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Ribeira Grande de Santiago\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2 (2.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Ribeira Grande de Santo Ant\u0026atilde;o\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (11.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5 (5.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Sal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (8.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (13.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e5 (5.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Santa Catarina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3 (17.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (11.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e6 (6.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Santa Catarina de Fogo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1 (1.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Santa Cruz\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2 (2.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;S\u0026atilde;o Domingos\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3 (3.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;S\u0026atilde;o Filipe do Fogo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2 (2.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; S\u0026atilde;o Louren\u0026ccedil;o dos \u0026Oacute;rg\u0026atilde;os\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (13.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3 (3.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;S\u0026atilde;o Miguel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (11.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e3 (3.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;S\u0026atilde;o Salvador do Mundo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e2 (2.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;S\u0026atilde;o Vicente\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (11.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5 (29.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e12 (12.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Tarrafal de Santiago\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1 (1.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 265px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Tarrafal de S\u0026atilde;o Nicolau\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (6.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e1 (1.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSource: Programme\u0026apos;s database. \u003cem\u003eN = total graduates; n=number of graduates; %= proportion;\u0026nbsp;\u003c/em\u003eHuman Health - Other=\u003cem\u003eBiologists, statisticians and data management technicians; NA = Not Applicable, in cases where it was not appropriate to calculate a percentage value for the data.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eField products completed by the six cohorts of the Cabo Verde Frontline Field Epidemiology Training Program (EpiCV)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the training sessions and the field work between them, the professionals were able to intervene in various health situations that required efforts to resolve. The following activities stand out:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eSupport for the response to COVID-19 and the introduction of new variants and subvariants of\u0026nbsp;COVID-19 (2020-2022);\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;Investigations into fish deaths (2021) and imported cases of malaria (2022) in the capital of the country;\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;Investigations of Gastroenteritis (2022) and Shigellosis (2022-2023) outbreaks in Sal;\u003c/li\u003e\n \u003cli\u003eInvestigation of the first findings of urinary schistosomiasis in in one district in the country in 2022 and the establishment of the disease in the years 2023 and 2024, and\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;Support for the response to the Dengue outbreak that occurred in 2024.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAdditionally, during training, more than 370 reports were produced on the various topics of case and outbreak investigation topics, SWOT analyses and cause-and-effect diagrams.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eImpact of implementing the\u003c/em\u003e\u003c/strong\u003e \u003cstrong\u003e\u003cem\u003eCabo Verde Frontline Field Epidemiology Training Program\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe can already see several achievements that have had an impact on the country\u0026apos;s public health. The implementation of health situation rooms in various health services by trained professionals. This activity helps the timely detection of events of public health relevance in the territory.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo improve the field epidemiology skills of the trained professionals, six field epidemiologists were included in the master\u0026apos;s program at the UNICV, which was supported by the EDCTP through a project involving several National Public Health Institutions from five Portuguese-speaking African countries; the Institute of Hygiene and Tropical Medicine in Portugal and Eduardo Mondlane University in Mozambique.\u003c/p\u003e\n\u003cp\u003eWith respect to scientific communication and the dissemination of knowledge and evidence, we highlight the 1st Scientific Meeting of Field Epidemiologists, the Public Health Bulletin (BSP) and the network of field epidemiologists in Cabo Verde. The fourth edition of the BSP was published between 2023 and 2024. The implementation of BSPs is a project that has been implemented in African countries, such as Cabo Verde and Guinea-Bissau, with the aim of strengthening the production and dissemination of quality epidemiological information and keeping the network of epidemiologists active.\u003c/p\u003e\n\u003cp\u003eThe main focus of the project was to improve the quality of epidemiological data and analysis to support effective public policies and increase the timely response to outbreaks and epidemics. The main activities conducted include the following:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eSituational analysis through interviews with technicians, managers and FETP graduates to identify gaps in technical areas (Epi Info, Statistics, Geoprocessing and Scientific Writing).\u003c/li\u003e\n \u003cli\u003eOnline mentoring sessions, with experts addressing the topics identified.\u003c/li\u003e\n \u003cli\u003eFace-to-face workshop in Cabo Verde, with practical activities and the production of scientific articles for the bulletins.\u003c/li\u003e\n \u003cli\u003eProduction of courses and teaching materials, available free of charge on the ProEpi platform.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe participation of EpiCV graduates was central to the project\u0026apos;s success:\u003c/p\u003e\n\u003cul class=\"decimal_type\"\u003e\n \u003cli\u003eEight of the country\u0026apos;s 10 participants in the face-to-face workshop had been trained by the FETP program, demonstrating the strong involvement of these professionals in health surveillance.\u003c/li\u003e\n \u003cli\u003eThese graduates work in strategic positions at the National Institute of Public Health (INSP), health delegations and the Ministry of Health, contributing to the practical implementation and sustainability of the BSP strategy.\u003c/li\u003e\n \u003cli\u003eThe graduates were instrumental in producing the 11 scientific articles that were a direct result of the workshop.\u003c/li\u003e\n \u003cli\u003eThe accumulated experience, with a median of 4.5 years working in health surveillance, allowed the professionals to apply the knowledge acquired and strengthen the country\u0026apos;s technical capacity.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eCabo Verde\u0026apos;s network of field epidemiologists holds monthly meetings and shares health situations, with the aim of strengthening the One Health approach. It also consolidates the participation of graduates in drawing up the National Action Plan for Health Security, updating risk mapping and supporting the drafting of the country\u0026apos;s Integrated Surveillance and Disease Response Plan.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMany partnerships remain in place and others are being agreed upon. One of the EpiCV graduates is currently attending advanced field epidemiology training in Brazil, as part of the collaboration established in the Strategic Health Cooperation Plan of the Community of Portuguese-Speaking African Countries.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe implementation of EpiCV, between 2021 and 2024, represents a strategic effort to strengthen local capacities in health surveillance, emergency response and the use of data for decision-making. As observed in experiences of implementing FETP in other low and middle-income countries\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e, EpiCV has contributed to the qualification of the public health workforce, especially at the levels closest to the community and where resources and technical training are often more limited similar to other findings\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eFETPs are essential for ensuring timely responses to health emergencies, especially in countries with structural vulnerabilities in their health systems\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Our findings demonstrate tangible impacts: there have been advances in detecting and responding to outbreaks, in producing and analyzing epidemiological data and in preparing technical reports. These gains are consistent with the results found in other African contexts that have implemented the Frontline FETP\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eLike the Ghana-FETP Program\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e, EpiCV also adopted the \u0026ldquo;One Health\u0026rdquo; approach, promoting integration between the human, animal and environmental health sectors. This perspective has broadened technical skills and strengthened a systemic view of public health, which is essential in the face of complex threats such as zoonoses and climate change. Our program initially trained the members of the Multisectoral Commission of the National Coordination Body for a One Health approach from the two islands with designated points of entry and the two with international airports in the country, to ensure that a manager was prepared to face the challenges of global health. This approach is also in line with the guidelines of the International Health Regulations (IHR)\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, which establish the need for basic capacities in surveillance and response in all countries. In addition, having an FETP or other applied epidemiology program in place is one of the JEE's human resource indicators\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eOne of the greatest challenges is the training of human resources, which is fundamental to guaranteeing several of the basic surveillance and response capacities of a health system\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. In many countries, FETPs have proven to be successful models for building public health workforce capacity\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e; however, critical gaps remain in terms of epidemiologic capacity\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. Considering the country's population and territorial dimensions, as well as its challenges related to insularity and the limitation of specialized human resources, this number is significant. The diversity of trained professionals also reflects the commitment to the \"One Health\" approach, which involves integrating multiple areas of knowledge and creating a more qualified and multidisciplinary workforce, which is essential for dealing with complex public health problems.\u003c/p\u003e\u003cp\u003eEpiCV has increased the country's capacity to detect, investigate and respond to public health emergencies, especially at the local level. This has improved the rapid response to possible outbreaks and health events, preventing the spread of diseases and reducing the impact on public health, as demonstrated by the work of professionals investigating outbreaks, such as the investigation of urinary schistosomiasis, a disease that had not previously been recorded in the country\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e and the production of evidence published in the National Epidemiological Bulletins\u003csup\u003e\u003cspan additionalcitationids=\"CR35 CR36\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe implementation of the program was a multisectoral effort, involving various institutions and partners. This has strengthened the resilience of the health system, guaranteeing the sustainability of the EpiCV, which has completed six cohorts in four years. However, despite the progress made, some challenges remain, especially with respect to retaining these professionals in their original health services and keeping epidemiologists up to date. This effort needs to continue, giving increasing presence in quantity and quality to the different sectors involved and facilitating the operationalization of multisectoral cooperation to promote alerts, early detection and response to public health threats.\u003c/p\u003e\u003cp\u003eHowever, the sustainability of the program is still a challenge. Although there was initial support from international agencies and the national public budget, the continuity of the training, the expansion to the intermediate and advanced levels of the FETP, and the institutionalization of the program require ongoing strategic planning. Zambia-FETP shows that the full institutionalization of the FETP depends on legal frameworks, permanent budget lines and career progression mechanisms for graduates\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Similarly, the evaluation of the FETP in Central America trevealed that although the programs were initially supported by external funds - especially from USAID and the CDC, full institutionalization was possible only as the countries gradually began to assume the operational costs. The authors emphasize the importance of co-financing strategies and the inclusion of programs in ministerial budgets as mechanisms to strengthen long-term sustainability\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThe structuring of EpiCV represented a milestone in strengthening the country's public health surveillance capacity. The training of 93 professionals in six cohorts demonstrated that, even in the context of limited resources, it is possible to advance the technical qualifications of the health workforce through a sustained, multisectoral strategy.\u003c/p\u003e\u003cp\u003eThe multisectoral initiative results in greater resilience for the program, which can now rely on various stakeholders to support the continuity of training. This implementation model has proven effective, allowing qualified professionals to contribute directly to improving responses to health emergencies and to developing local public health capacities. The \"One Health\" approach used to recruit professionals from different fields has created a more qualified and multidisciplinary workforce, which is essential for dealing with complex public health problems.\u003c/p\u003e\u003cp\u003eImportantly, to consider that the program's impacts could be even broader if systematic long-term evaluations, including performance indicators, the quality of routine surveillance and the impact on the population's health outcomes, are performed. These aspects should guide future research and decision-making for the continued strengthening of public health surveillance in Cabo Verde. They should also ensure its institutionalization in the National Health System, as a way of consolidating the gains already made and facing future threats to public health with greater preparedness and resilience.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eCOMPETING INTERESTS\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eSOURCE OF FUNDING\u003c/h2\u003e\u003cp\u003eThis manuscript did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003e- Design of the study: Mendon\u0026ccedil;a M.L.L and Costa, V.M- Data collection, analysis and writing original draft: Mendon\u0026ccedil;a, M.L.L.; Costa, V.M.; D\u0026rsquo;Angelo S.M. ; Fernandes, N.M.; Costa, F.B.P.; and Paiva, P.- Final review and supervision: Mendon\u0026ccedil;a, M.L.L.; Costa, V.M.; Brant, J.L.; Lopez, A. and Brito, C.P.F. J- All authors reviewed the manuscript and agreed to the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe thank all the institutions and people who contributed to the sustainability of the Program and the partners who made this possible. In particular, the Multisectoral Committee of the National Coordination Body \u0026ldquo;One Health\u0026rdquo; of Cabo Verde; the Brazilian Association of Field Epidemiology-ProEpi, Center Disease Control-CDC/ Atlanta; Tephinet, in particular Dr. Carl Reddy; the West African Health Organization-WAHO; the WHO Office in Cabo Verde; Skoll Foundation - Support for the TiLS COVID-19 Task Force; Vital Strategies; the CDC Foundation and the World Bank's Emergency Resilience Program.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTraicoff, D. 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(2024).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Field Epidemiology, Public Health Surveillance, Health Workforce, One Health","lastPublishedDoi":"10.21203/rs.3.rs-7475170/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7475170/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003eField Epidemiology Training Programs (FETPs) are global strategies for strengthening public health surveillance by training professionals to respond to health emergencies. In Cabo Verde, following the 2019 Joint External Evaluation (JEE), gaps in the national epidemiological workforce were identified. In response to this challenge, the Frontline Field Epidemiology Training Program of Cabo Verde (EpiCV) was implemented. This study aims to describe the process of implementation and the main results of the EpiCV, wich was carried out between 2021 and 2024 on the country’s public health surveillance system.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eDescriptive study based on an analysis of documentary sources and program databases. Descriptive statistics were used to characterize the profile of the professionals trained and the products generated during the training.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eEpiCV has implemented six cohorts and trained 93 frontline surveillance officers,\u003cstrong\u003e \u003c/strong\u003ewith representation across all 22 municipalities in the country. The majority were female (61; 65.59%) and the median age was 37 years (median range 25-59). Nurses (n=30; 32.26%), and physicians (n=22; 23.66%) are professions most common among graduates. In addition, 32 (53.33%) of the professionals had more than 10 years' service and work in municipality (n=54; 58.08%), and the majority were in the country's capital, Praia (n=29; 31.18%). During training, more than 370 technical reports were produced, including surveillance data quality reports; case studies; investigations and responses to various public health events, such as the COVID-19 pandemic; cases of imported malaria, gastroenteritis and shigellosis outbreaks, and the first documented urinary schistosomiasis outbreak in the country.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThe implementation of EpiCV represented a breakthrough in the country's health surveillance, promoting the formation of a multidisciplinary workforce aligned with the “One Health” approach. It is recommended that the program continues, as well as its institutionalization in the National Health System, as a way of guaranteeing the consolidation of the gains already achieved and facing future threats to public health with greater preparedness and resilience.\u003c/p\u003e","manuscriptTitle":"Strengthening Health System in Cabo Verde: Implementation of Frontline Field Epidemiology Training Program From 2021 to 2024","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 15:47:45","doi":"10.21203/rs.3.rs-7475170/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-10-26T13:57:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-17T20:31:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-17T12:49:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"185838807379543157369036840433412026809","date":"2025-10-15T14:54:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"247951290653453937748242390957406814479","date":"2025-10-15T13:09:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"52069679243855976958736637003737660405","date":"2025-10-13T11:51:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"21036859972349341614348229736258383279","date":"2025-10-08T15:34:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-06T11:18:54+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-08T10:54:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-05T11:52:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-05T11:52:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-08-28T00:49:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dd7f6193-c8a2-45da-8d75-bba146ee492e","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-17T15:47:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-17 15:47:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7475170","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7475170","identity":"rs-7475170","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}