Regional stakeholders’ meeting to map out the needs for implementing IHR core capacities during the extension period (2012–2014)

(1)

Regional stakeholders’

meeting to map out the needs for implementing IHR core capacities

during the extension period (2012–2014)

Rabat, Morocco

12–15 November 2012

(2)

Report on the

Regional stakeholders’ meeting to map out the needs for implementing IHR core

capacities during the extension period (2012–

2014)

Rabat, Morocco 12–15 November 2012

(3)

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

Publications of the World Health Organization can be obtained from Health Publications, Production and Dissemination World Health Organization, Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 2670 2535, fax: +202 2670 2492; email: [email protected]).

Requests for permission to reproduce, in part or in whole, or to translate publications of WHO Regional Office for the Eastern Mediterranean – whether for sale or for noncommercial distribution – should be addressed to WHO Regional Office for the Eastern Mediterranean, at the above address: email:

[email protected].

Document WHO-EM/IHR/005/E/05.13/196

(4)

CONTENTS

1. INTRODUCTION ... 1

2. TECHNICAL PRESENTATIONS ... 2

2.1 Update on global IHR implementation and extensions ... 2

2.2 Regional progress on IHR and preparedness in the Eastern Mediterranean Region3 3. LEGISLATION, NATIONAL FOCAL POINT FUNCTIONS AND COORDINATION . 3 3.1 Qatar: legislation for IHR implementation ... 3

3.2 Egypt: multisectoral coordination and functions of the national focal point ... 4

4. SURVEILLANCE AND RESPONSE ... 4

4.1 Afghanistan: early warning function... 4

4.2 Pakistan: national response mechanism to public health emergencies ... 5

5. PREPAREDNESS ... 6

5.1 Islamic Republic of Iran: multi-hazard national public health preparedness ... 6

6. HUMAN RESOURCES AND RISK COMMUNICATION ... 6

6.1 Morocco: human resources strategy development ... 6

6.2 Tunisia: mechanism for communication during emergencies... 7

7. LABORATORY ... 7

7.1 Oman: national laboratory services and laboratory quality management system .... 7

8. POINTS OF ENTRY ... 8

8.1 Yemen: surveillance and response at points of entry ... 8

8.2 Saudi Arabia: surveillance and response at points of entry during mass gatherings9 9 IHR HAZARDS – ZOONOTIC AND FOOD SAFETY ... 9

9.1 Sudan: response to zoonotic outbreaks ... 9

9.2 Jordan: detection and response to foodborne diseases and food management system ... 10

10. IHR HAZARDS – CHEMICAL AND RADIONUCLEAR ... 11

10.1 Morocco: national mechanisms for detection and response to chemical and radionuclear emergencies ... 11

10.2 Morocco: national chemical hazard management activities ... 12

11. EXERCISES ... 12

12. WORKING GROUPS ... 12

12.1 Description of working group activities ... 12

13.2 Outcomes of working groups ... 12

(5)

13.2 Donor statements ... 18

13.3 Interventions by countries ... 20

14. CONCLUSIONS ... 22

15. RECOMMENDATIONS ... 22

Annexes... 24

1. AGENDA ... 24

2. LIST OF PARTICIPANTS ... 26

3. SUMMARY OF GAPS, CHALLENGES, AND RECOMMENDATIONS BY CORE CAPACITY ... 38

(6)

A regional stakeholders’ meeting to map out the needs for implementing International Health Regulations (IHR 2005) core capacities during the extension period 2012–2014 was organized by WHO headquarters and the WHO Regional Office for the Eastern Mediterranean in Rabat, Morocco, from 12 to 15 November 2012. The objectives of the meeting were to:

 provide a forum for stakeholders to review the current regional situation

 identify the main achievements and existing gaps

 provide an opportunity for stakeholders to identify strategies to bridge the identified gaps

 commit support to match identified needs, gaps and priorities.

The expected outcomes of the meeting were the identification of national and regional achievements and gaps in strengthening IHR core capacities; mapping of technical and financial resources for IHR implementation; development of a roadmap to address subregional and regional vulnerabilities; strengthened collaboration and coordination within and between regions, countries and partners; pledging of stakeholder commitments to provide essential country support and foster intersectoral collaboration in and between countries and increased advocacy and resources to strengthen IHR capacities.

Dr Ala Alwan, WHO Regional Director for the Eastern Mediterranean, in his opening address, noted the commitment of Member States in the Region to meeting the new deadline of June 2014 for implementation of IHR core capacities, and made reference to the support provided by the WHO Regional Office to develop these core capacities. He said that the IHR encompassed a broad range of public health hazards (biological, chemical, radionuclear and those of unknown etiology). Therefore, different sectors (e.g. health, agriculture, customs and travel, trade, education, defense) must work in partnership for implementation of the Regulations. Effective communication, coordination and collaboration among different sectors were vital for efficient application of the Regulations. Enhancing human resources in order to achieve the best results was paramount. This represented a unique opportunity to mobilize resources and develop sustainable public health capacities, serving both domestic and global public health and global health security in the long term.

He said that global and regional partnerships were essential for successful implementation of the IHR. For that reason, WHO at different levels had been engaged with various national institutes, international initiatives, intergovernmental organizations, donor agencies and technical agencies to provide effective technical support to Member States for implementation of the IHR. Greater collaboration and coordination among these partners could ensure greater coherence and efficiency by focusing on respective comparative advantages and areas of expertise and strengths of partners. Ultimately, this would ensure greater impact in IHR implementation. Dr Alwan encouraged meeting participants to develop a well-defined roadmap with important milestones to guide the timely and effective implementation of the IHR, and establish a mechanism to monitor and follow up the translation of the roadmap in the Region.

(7)

Dr Mustapha Ismaili Lalaoui, the Inspector General, Ministry of Health, Morocco, delivered a message on behalf of the Minister of Health of Morocco His Excellency, Dr El Hossein El Ouardi. Dr Lalaoui expressed the need for efficient cooperation for countries to implement IHR core capacities and encouraged countries to take the necessary steps to strengthen capacities and skills and overcome gaps and challenges. Morocco would be implementing its action plan for IHR extension, in cooperation with all sectors and stakeholders.

Dr Keiji Fukuda, WHO Assistant Director-General, Health Security and Environment Cluster, said that all countries of the Region were facing numerous challenges in fully implementing the IHR, and despite success stories in core capacity development, gaps still existed in countries’ ability to meet health challenges. The goal for all Member States was to work with the entire community of stakeholders to close the gaps as the 2014 IHR implementation deadline approached.

In her address Ambassador Jenkins, Coordinator for Threat Reduction Programs, Department of State, United States, said that partnerships were a key focus of the Global Partnership Against the Spread of Weapons and Material of Mass Destruction. Partners and international organizations had come together to promote multisectoral collaborations that spanned across health, security, agriculture, travel, trade, and education. Implementation of IHR core capacities was no longer just a concern of WHO and ministries of health, but numerous stakeholders.

The Chair was shared on a rotating basis. The programme and list of participants are included as Annex 1 and 2, respectively. Annex 3 presents a summary of gaps, challenges and recommendations by core capacity.

2. TECHNICAL PRESENTATIONS

2.1 Update on global IHR implementation and extensions

Dr Stella Chungong, Coordinator, IHR Monitoring, Procedures and Information, WHO/HQ

Globally, 106 Member States have requested an extension in implementation of IHR core capacities from WHO. Fifteen Member States in the Eastern Mediterranean Region have formally requested an extension until June 2014 to achieve full compliance in implementation of IHR core capacities. For the 2012 reporting cycle, 94 questionnaires have been returned.

Using the reporting questionnaires and the extension action plans received from countries, WHO has developed a summary of the most significant gaps in IHR implementation in each country. This summary, is provided in Annex 3. WHO strongly encourages all Member States in the Region to submit the 2012 implementation questionnaires as soon as possible.

(8)

2.2 Regional progress on IHR and preparedness in the Region

Dr Jaouad Mahjour, Director, Department of Communicable Disease Prevention and Control, WHO/EMRO

The Region has made significant progress in implementation of the IHR, with important achievements in each of the core capacities. Highlights of the achievements include development of necessary legislation in 14 Member States, establishment of surveillance units in all Member States, and rapid response teams established in 17 Member States.

Four overarching challenges to implementation of the IHR in the Region have been identified: 1) lack of supportive legal instrument; 2) insufficient coordination at the national level and between countries; 3) high turnover of qualified personnel; and 4) insufficient financial resources.

The specific core capacities which remain weak in the Region are preparedness, risk communication, human resources, points of entry, and capacities to handle food safety and chemical, and radionuclear hazards. To meet the June 2014 deadline and fully develop all core capacities, Member States must review national policy and legislation, and establish a multisectoral coordination body. Additionally, Member States should clearly outline the responsibilities and obligations of IHR national focal points.

It is critical to assess existing gaps in human resources, strengthen cross-border coordination, mobilize resources as necessary, and consistently report on progress of IHR (2005) implementation. WHO is committed to supporting Member States through harmony and consistency in WHO actions, provision of assessments in Member States, assistance with monitoring implementation, and formation of a regional committee to monitor progress in implementation.

3. LEGISLATION, NATIONAL FOCAL POINT FUNCTIONS AND COORDINATION

3.1 Qatar: legislation for IHR implementation

Dr Mohamed Al Thani, Director, Department of Public Health, Supreme Council of Health, Qatar

Qatar has formed a multisectoral IHR national focal point committee, which comprises five working groups, it provides a mechanism for continuous communication and coordination. The working groups meet regularly and have demonstrated a successful multisectoral response to potential public health emergencies of international concern (PHEIC). The responsibilities of national focal points have been translated into a legal document developed and reviewed by the Committee. This document will be endorsed by the Minister of Health in the form of a ministerial decree.

In addition to defining the role of the national focal point, the legislation includes the formation of the multisectoral committee responsible for development of action plans for IHR implementation. Challenges to full implementation of this core capacity include ensuring

(9)

enforcement of the ministerial decree and developing amendments to laws in other sectors to ensure full IHR implementation.

3.2 Egypt: multisectoral coordination and functions of the national focal point Dr Mohamed Genedy, Director General of Communicable Diseases Control Department, Ministry of Health and Population, Egypt

Egypt has made numerous key achievements in multisectoral coordination, including:

establishment of an IHR taskforce in the Ministry of Health and Population; establishment of an event-based surveillance system; development of a tracing and recall mechanism for contaminated food products; establishment of a new epidemiology unit in the General Organization of Veterinary Services, and establishment of a four-way liking framework between the Ministry of Health and Population and the Ministry of Agriculture and Land Reclamation.

Despite these successes, Egypt must still enhance activities for coordination and partnerships with ministries responsible for animal health, water and food safety, chemical threat, and radiological threat. Additionally, improved coordination with neighbouring countries to share information on communicable diseases and toxin exposure is critical to IHR implementation.

Egypt has enacted several pieces of legislation related to IHR implementation, including a preparedness plan for pandemic influenza and a crisis management plan.

Broadly, the major limitations to IHR implementation in Egypt include limitation of legislation; improper funding mechanisms; lack of multisectoral awareness of the IHR;

training of staff to handle radiological events; and mechanisms to respond to cross-border public health events.

To address these challenges, the list of priority events will be reviewed and updated to include additional hazards; develop and implement an action plan; work collaboratively with the environmental sector to map potentially hazardous areas; implement IHR awareness activities; and work with WHO to promote cross-border coordination mechanisms.

4. SURVEILLANCE AND RESPONSE 4.1 Afghanistan: early warning function

Dr Mohammad Nadir Hassas, Head of Emergency Preparedness and Response, Afghanistan

The organizational structure of the disease reporting infrastructure in Afghanistan includes reporting from provincial and regional offices to the national surveillance/DEWS office. DEWS then distribute surveillance information to the Ministry of Public Health, WHO and other stakeholders.

Highlights of DEWS achievements in Afghanistan include: weekly reports on 15 priority diseases from more than 300 sentinel sites; an average of eight alerts and outbreak

(10)

investigations per week have taken place in the country (with almost 99% of them investigated within 48 hours of the first notification); 100% timely distribution of a weekly report to all stakeholders; and more than 3500 specimens tested in the Central Public Health Laboratory in 2012.

The IHR are comprehensive and broad in scope, and maintenance of the core capacities is a challenge in Afghanistan. In the face of technical and financial obstacles, it is difficult to meet all requirements in the short term. However, the availability of DEWS in the Ministry of Public Health is a positive advantage in IHR implementation. Successful use of DEWS requires integrated, multisectoral efforts, and without the commitment of governments, technical support, and the support of donors, IHR implementation will remain a challenge.

4.2 Pakistan: national response mechanism to public health emergencies

Dr Najam Ullah Baig, Scientific Officer, Public Health Laboratories Division, National Institute of Health, Pakistan

Pakistan is developing a legal framework for disease surveillance, in collaboration with multiple Ministries, WHO, and technical partners; this framework is currently under review by provincial health departments. There are numerous challenges in establishing disease surveillance capacity in Pakistan. Disease-specific programmes have their own independent surveillance systems, which are self-contained, vertical, and cover only one or a few diseases.

Additionally, these vertical systems lack coordination and communication and a uniform system of reporting.

To meet existing challenges in disease surveillance, existing surveillance mechanisms must be augmented to follow international best practices in field and applied epidemiology, disease early warning, laboratory diagnostic capacity, and bio-risk management.

In the area of surveillance, Pakistan will work to implement the integrated disease surveillance programme, monitor infectious disease trends at the animal–human interface, establish response units for disease outbreaks, and develop a regional network for a wider, collaborative response. In the area of regulations, Pakistan will finalize and implement a legal framework for disease surveillance.

Pakistan seeks to incorporate applied, operational and translational research and training into public health prevention activities. Pakistan is working with technical partners, including the US Centers for Disease Control and Prevention, on disease surveillance, response systems and networking of public health laboratories.

(11)

5. PREPAREDNESS

5.1 Islamic Republic of Iran: multi-hazard national public health preparedness Dr Payman Hemmati, Centers for Disease Control, Ministry of Health and Medical Education, Islamic Republic of Iran

Fourteen syndromes have been approved for inclusion in national public health preparedness and response plans, and materials to assist medical professionals in identification of these syndromes have been distributed. Syndromic surveillance works effectively in the Islamic Republic of Iran, with information flowing from a variety of sources to a single surveillance system, aiding in outbreak detection. The value of developing a strong surveillance system is the ability to identify numerous potential public health emergencies of international concern (PHEICs) through reporting of a single or small number of syndromes detected. Additionally, through the reporting of multiple data sources, as opposed to the conventional surveillance model sources, which include non-clinical data, non-routine clinical data and clinical syndromes – the time to detection of an outbreak can be reduced.

6. HUMAN RESOURCES AND RISK COMMUNICATION 6.1 Morocco: human resources strategy development

Dr Abel Aziz Barkia, Head of Epidemic Disease Service, Directorate of Epidemiology and Disease Control, Ministry of Health, Morocco)

Morocco is currently experiencing a severe shortage of medical professionals. This shortage of qualified human resources is due to a reduction of training available during the structural adjustment programme; a reduced number of staff available during the economic recovery period; the systematic removing of positions that are vacated due to retirement; a restriction in job creation; and the recruitment of high numbers of physicians to the detriment of filling other medical and technical positions.

In 2008, a plan was implemented to move from a ratio of 1.86 care providers per 1000 inhabitants to a ratio of 2.5 in 2012, and 3.0 in 2020. This plan aimed to meet this goal through the increase in class sizes at medical school, creation of new faculties of medicine, development of training for paramedical professionals in the public and private sectors, rationalization of human resources management, and implementation of a training plan and incentive programmes.

To improve human resources capacity as related to IHR implementation, Morocco identified three specific activities in a plan of action: 1) strengthening of intervention epidemiology training; 2) integration of an IHR module into medical and paramedical curricula; and 3) insertion of IHR into the national training and human resources plan.

Morocco has working closely with WHO and other donor and technical partners to improve human resources capacity through assessments, consultations, and training. There is a need to develop and implement a national human resources strategy, which should include a thorough analysis of the human resources capacity in the country and a strategy which outlines the

(12)

functions and skill required, provides a training plan, provides incentives for career progression and supports operational research.

6.2 Tunisia: mechanism for communication during emergencies

Dr Mondher Bejaoui, IHR National Focal Point, Director of Communicable Diseases, Ministry of Public Health, Tunisia

Tunisia has established a national IHR Committee, designated a IHR national focal point, and worked to sensitize and provide information to multisectoral partners on surveillance, prevention and crisis management. There is no official designation of an institution, committee, or person to be responsible for communication activities during emergencies. However, during a crisis with public health impact, the Ministry of Health will organize a national committee (with expertise in handling the event), designate a specific person or persons to manage communication, centralize management of communication by involving the cabinet-level press unit, and charge a subcommittee of communications specialists to develop and implement a communications strategy.

To fill remaining gaps in communications during emergencies, it has been recommended that a permanent subcommittee for communications within the national IHR committee be established, develop and distribute standard operating procedures for communication and conduct greater advocacy efforts for multisectoral partners to adhere to adopted communications strategies during emergencies. To reinforce the power of the IHR national focal point in communications, the leaders and points of contact responsible for emergency communication in all sectors should be identified, and to involve both communications specialists and representatives of all levels of the health system in the development of communications strategies.

The support of WHO, technical partners and donors in enhancing communication capacity is critical; requested support has included training in communications methods and strategies; technical and financial support; local workshops and meetings on communications;

and facilitating an exchange of experiences between countries in the Region.

7. LABORATORY

7.1 Oman: national laboratory services and laboratory quality management system Dr Idris Al Abaidani, Acting Director, Department of Communicable Diseases Surveillance and Control, Ministry of Health, Oman

In Oman, all laboratories have at least biological safety level (BSL)-2 standards, while the Veterinary Research Center has a BSL-3 certified facility and there are plans for two new BSL-3 suites in the Central Public Health Laboratory in 2013. Personal protective equipment (PPE) is available in all laboratories, standard operating procedures (SOPs) are in place, most laboratories can execute internal quality control, and a few laboratories participate in external quality assessment programmes. Manuals for sample collection, sample storage, sample transportation, and biological safety are available, and biological safety legislation is under development.

(13)

The national external quality assessment scheme (NEQAS) was established in 1997, while the regional external quality assessment scheme (REQAS) was established in 2005. The objectives of the NEQAS and REQAS are to identify laboratory capabilities and weaknesses to determine where training is needed; identify mechanisms to increase laboratory capacity in a sustainable manner; improve the quality of results and improve interpretation and reporting;

and serve as a platform for advocating laboratory accreditation. Twenty-six laboratories currently participate in the government-run NEQAS, while thirty-four laboratories participate in a private sector NEQAS. Twenty-three laboratories currently participate in the REQAS, which covers bacteriology, tuberculosis, mycology and parasitology.

Challenges in fully implementing laboratory capacity include: fragmentation and duplication of services; limited quantity of qualified human resources; limited biological risk management; and the need for improved data management and networking.

Recommendations for continuing to improve laboratory capacity have been provided, including review and mapping of existing laboratory services; human resources capacity- building and training in molecular diagnosis and biological risk management; and improving and expanding the infrastructure of and services offered by the Central Public Health Laboratory. Additionally, it was recommended to improve the quality assurance of diagnostic and analytical methods and improve diagnostic capabilities for infectious diseases and other hazards.

8. POINTS OF ENTRY

8.1 Yemen: surveillance and response at points of entry

Yemen has organized many training courses for health workers and personnel from other sectors which work at points of entry, conducted a needs assessment at points of entry, and improved the readiness of buildings at airports and other points of entry. Numerous challenges have impaired the full implementation of IHR in Yemen, including conflicts and instability which have had a significant impact on the functionality of the health system.

Challenges include, but are not limited to, inadequate legal instrument, insufficient national SOPs, lack of commitment to IHR from non-health sectors, gaps in human resources and surveillance capacity, a lack of IHR advocacy and awareness, and a restriction on transportation of specimens outside of the country. To improve implementation of IHR in Yemen, it has been recommended to update national policy documents and guidance, improve national SOPs, finalize the national all-hazards preparedness plan, and enhance intra- and intersectoral collaboration. Additionally, it is important to enhance veterinary and food safety sectors, improve human resources through training, enhance the capabilities of subnational laboratories, and build surveillance and response capacity at points of entry.

(14)

8.2 Saudi Arabia: surveillance and response at points of entry during mass gatherings Dr Ziad Memish, Deputy Minister for Public Health, Ministry of Health, Professor, College of Medicine

Mass gatherings present unique public health challenges, and all aspects of the mass gathering (such as the type of event, participant demographics, and cultural factors) must be considered when preparing for the event. Mass gatherings present unique opportunities to study and research public health issues in mobile populations. The hajj is the second largest in the world, with more than four million people from 183 countries travelling to Saudi Arabia.

In preparing for the mass gathering, there are three main areas of focus: 1) risk assessment; 2) surveillance; and 3) response. Three times in the year leading up to the events, public health entry requirements for the hajj are published. Prevention and control measures must be implemented at three airports, two seaports, and eleven land ports; these points of entry are manned by 1400 public health officers that report directly to public health departments. There are meetings every three months to inform the public health officers of the syndromes and diseases of concern and rehearse implementation of the requirements.

Saudi Arabia has implemented a health electronic disease reporting network for reporting of surveillance data, has an integrated public health information system, and has implemented a digital pen system which automatically enters data into electronic forms.

Additionally, response activities are enhanced through an automated vehicle location system, which is able to monitor ambulance locations and monitor traffic for redirection if necessary.

Mass gatherings are inherently multidisciplinary activities, and the lessons learned from the hajj can be applied throughout the region to enhance preparedness, surveillance, and response capabilities.

9. IHR HAZARDS – ZOONOTIC AND FOOD SAFETY 9.1 Sudan: response to zoonotic outbreaks

Dr Mohamed A Rahman, National Focal Point for IHR Secretariat and Implementation Coordinator, Federal Ministry of Health, Sudan

In October 2007, a 31-year-old herdsman died immediately after severe bleeding;

several deaths occurred with similar syndromes and the events were reported from the community level directly to national level authorities. The state level epidemiology team was dispatched to evaluate the situation, followed by late arrival of the national level epidemiology team; initial assessments indicated yellow fever, Rift Valley fever (RVF) or dengue fever.

The epidemiological investigation led to the following information: heavy rainfall had occurred, but there was not presence of Aedes aegypti within the residences of the affected persons; most cases had come into contact with animals or animal products; there was not an increased level of cattle abortion reported; and local veterinarians confirmed that a recent survey indicated animals were free of serious disease. Initial laboratory findings indicated yellow fever, and the event was officially reported to WHO.

(15)

Enhanced surveillance activities included activation of daily zero-case reporting, expansion of surveillance coverage, and training on yellow fever case definitions. Enhanced response activities included case management (using a general protocol for treatment of haemorrhagic fevers) and health education; however, no education materials regarding contact with animals were included, and case numbers continued to increase. Two weeks later, a positive laboratory result for RVF was obtained, and a multidisciplinary team was immediately dispatched to all affected areas. International assistance was provided for epidemiology, laboratory, logistics, and environmental health. Risk communication was a significant challenge during the outbreak, including release of contradicting messages and denial of access to mass media. Because of the outbreak, several veterinary control measures were taken, including banning movement of animals from affected areas, vaccination in disease-free areas, continuous sharing, and increased information sharing. This zoonotic disease outbreak case study revealed many lessons learned and recommendations, including, but not limited to, legislation; coordination; surveillance; laboratory; and response.

 Legislation: defining national and subnational responsibilities and identifying sufficient resources to support a response

 Coordination: resulted in a decree on coordination during health emergencies

 Surveillance: revised case definitions, expanded surveillance coverage, improved community input into surveillance, and highlighted the need for integrated surveillance programmes

 Laboratory: improved diagnostic capability, the need for SOPs and bio-risk

management procedures, and the need for sample collection and transport equipment

 Response: the need for multi-disciplinary response teams and improvement in surge capacity and mobilization of resources.

9.2 Jordan: detection and response to foodborne diseases and food management system

Mr Kamel Ibrahim Abusal, National Focal Point for International Health Regulations, Ministry of Health, Jordan

The surveillance system, established more than three decades ago, includes computerized surveillance and reporting for 42 communicable diseases, both immediate and weekly notification, continuous training, and central data evaluation and monitoring.

However, although all public sector ministries are involved in the health system, there is no integration with the public sector; additionally, there is a lack of human resources and experienced personnel to handle emergency response.

Regarding management of foodborne diseases and the food management system, the Food and Drug Administration Programme (FDA) was a part of the Ministry of Health in Jordan until 2003. Jordan has well-developed national guidelines for food poisoning and food inspection; the national focal person for Information for Food Safety Authorities Network (INFOSAN) is located within the FDA. The FDA houses the national rapid alert system for food safety, and the accredited FDA laboratory has established a strong quality management system. The FDA programme has the capacity to detect radioactive material in food products,

(16)

sets food standards and regulations, and has developed a continuous training plan. The control of imported food is carried out at border inspection posts under the direct control of FDA, while inland food inspection is carried out according to FDA standards and procedures by Ministry of Health directorates.

Successes of the water foodborne disease control programmes include establishment of an efficient surveillance system for water and foodborne diseases; improved cooperation among health sectors to control water and foodborne diseases; increased medical staff and public awareness on prevention, control, and management of diseases; and establishment of surveillance programmes for visitors, migrants and refugees. Challenges in IHR implementation include coordination across all sectors, strengthening of disease notification, financial and logistics resources, and development of legislations for IHR implementation.

Future plans for enhancing IHR implementation include training of medical staff for emergencies, improvement in all core capacities, and seeking assistance in testing the national public health response plan.

10. IHR HAZARDS – CHEMICAL AND RADIONUCLEAR

10.1 Morocco: national mechanisms for detection and response to chemical and radionuclear emergencies

Mr El Hali Lakbir El Hadi, National Center for Radiation Protection, Morocco

The National Center for Radiation Protection is the national authority for the protection of the public and the environment against the hazards of ionizing radiation. It is responsible for licensing, control and inspection of all radiation practices and sources; safety of radioactive waste; transport of radioactive materials; management of radiological and nuclear emergencies; and radiologic control at borders. Morocco has developed a strategy for the prevention of radiological and nuclear emergencies; the objectives of the strategy are to avoid radiological and nuclear emergencies at all costs; reduce the probability of the occurrence of a crisis situation; and limit the consequences of a radiological or nuclear emergency.

The strategy includes radiation monitoring during normal operating conditions;

monitoring and control of the inadvertent movement and illicit trafficking of radioactive materials; a monitoring and control system for radiological materials at borders; monitoring and control of radioactivity in the scrap metal industry; preparation for radiological or nuclear crisis situation; and mechanisms for intersectoral coordination and cooperation.

To continue improving the existing system, Morocco seeks to continue information sharing and awareness measures for processes outlined in the strategy; generalization of the system for monitoring and control and radioactivity; establishment of procedures for detection and notification; and legalization of all procedures.

(17)

10.2 Morocco: national chemical hazard management activities

Dr Mouncef Idrissi Belkasmi, Head, Laboratory of Toxicology and Pharmacology, Poison Control Center of Morocco

The ultimate goal of activities in Morocco to prevent and mitigate the risks due to chemical hazards is protection of human health, while also protecting the environment, consumer products and the occupational environment. Risk assessment, risk communication, and risk management are integrated to analyse and incorporate all aspects of risk due to a chemical hazard. Morocco has successfully demonstrated the integration of multiple sectors in these activities, including the Ministry of Health, Ministry of Defense, Ministry of the Interior, and the Environmental Department.

The National Poison Control Center in Morocco was established in 1989. Laboratory services to handle chemical hazards have been available since 1994; laboratory staff provide drug monitoring services for hospitals; acute toxicology exposure analysis; and is available to all hospitals, as well as external users, via its toxicological information department. Within its IHR Extension Action Plan, Morocco included several measures for improvement of core capacities to handle chemical hazards; these include: establishment of a national platform for the prevention of chemical risks; development of sectoral action, including surveillance, alert and response to face chemical hazards; and simulation exercises for chemical hazards management.

11. EXERCISE

Participants were led through a simple exercise to explore existing and potential arrangements for the shipment and testing of samples during an outbreak of unknown origin;

to validate notification and alert procedures in the context of the IHR; and to identify opportunities for improvement in existing preparedness and response plans, procedures and coordination mechanisms. The objectives of the exercise were to validate capacity for the collection and shipment of samples from local level to national and/or international laboratories; explore existing and potential collaboration for investigation, diagnostics and response, and confirm processes and notification procedures under the IHR (2005).

12. WORKING GROUPS

12.1 Description of working group activities

The working group activity was designed to facilitate interaction and discussion among all stakeholders and meeting participants to identify the priority gaps and challenges in implementing the IHR (2005) in the Region and identify what contributions Member States, WHO, technical partners, and donors could make to address the challenges. Meeting participants were divided into four groups. Tables 1–11 provide the results of the working group sessions.

(18)

Table 1. Group 1: Legislation, coordination and national focal points functions, and human resources

Priority, gaps and challenges

Fragmented legal framework

Challenges in translation of legislation into laws and into a multisectoral implementation plan

Lack of horizontal binding agreements and IHR legal status Resources and

recommendations

Multisectoral funding Capacity-building

Technical support from WHO, including guidelines and legal subject matter experts Areas of requested

support

Legislative workshops and exercises Guidance on developing laws Legislative assessments

Table 2. Coordination and national focal point functions

Priority gaps and challenges

High-level support and coordination is required Lack of national focal point empowerment

Lack of a multisectoral plan which outlines roles and responsibilities Lack of involvement by the private sector

Resources and recommendations

Establish high-level committee, led by the ministry of health and supported by working groups of subject matter experts

The national focal point should be an official positions

Establish a network of focal points within all sectors, led by the IHR national focal point

Private sector advocacy and active participation

Coordination with focal points from other United Nations (UN) agencies in the country

Areas of requested support

Advocacy tools for decision makers and technical experts Training tools and workshops for national focal points

(19)

Table 3. Human resources

High turnover rates

Need for training and capacity-building in all sectors Resources and

recommendations

Improve training in IHR (include IHR in undergraduate and postgraduate training;

training of trainers; online training; training for IHR beyond the health sector) Ensure continuous training for current staff and develop incentive structure for career development

Parliament involvement in training courses

Member States share experiences and training materials and conducts joint training activities

Establish regional mechanisms to share training resources between Member States and other partners

Training and technical support Human resources assessments

Develop human resource strategy for surveillance and field epidemiology Develop IHR online courses

Support field epidemiology training

Table 4. Group 2: Surveillance, response, preparedness, and risk communication

Integrated surveillance

Risk assessment and monitoring Human resources

Electronic surveillance platforms Resources and

recommendations

Improve coordination and communication Enhance disease reporting systems

Conduct both syndromic and event-based surveillance Improve existing data management processes

Implement monitoring and evaluation schemes Areas of requested

support

Technical and financial support and resources Human resources development

Advocacy

Assistance with coordination

(20)

Table 5. Response

Trained, multi-disciplinary rapid response teams Response plans and standard operating procedures Stockpiling and logistics

Conduct simulation drills and exercises Implement monitoring and evaluation schemes Improve preparation of health facilities

Enhance coordination and information management Improved isolation capacity and provision of PPE Areas of requested

support

Advocacy

Table 6. Preparedness

All hazard response plan for national, subnational, and local levels based on real- time vulnerability assessments and risk mapping

Readiness of health facilities Trained human resources Integrated risk management Resources and

Recommendations

Conduct multidisciplinary training Conduct needs assessments

Enhance coordination and communication Improve information management

Implement monitoring and evaluation schemes Areas of requested

support

Advocacy

(21)

Table 7. Risk communication

Strategic framework for public health risk communication Skills and competencies

Institutional capacity Resources and

recommendations

Integration of risk communication professional into strategic planning Involve policy-makers in risk communication

Ensure international assistance is available

Improve communication between the ministry of health and the media Areas of requested

support

Advocacy

Table 8. Group 3: Laboratory, zoonosis, and food safety

National laboratory policies, mapping of laboratory capacity, and multisectoral coordination

Integration of the private sector as part of national policies and reporting structures Laboratory services (including lack of a laboratory quality management system;

biorisk management programmes; systems for specimen collection and transport;

standard operating procedures; regional and national reference laboratories, and capacity to handle chemical events)

Laboratory-based surveillance Human resources

Lack of coordination among ministries of health and agriculture during zoonotic disease outbreaks

Lack of awareness of IHR (2005) in other sectors

Analysis of priority hazards, including chemical and radionuclear hazards Resources and

recommendations

Implementation of the biorisk management advanced training programme Conduct assessments and mapping of current capacities

Adaptation of legislation to support laboratory and zoonotic and food safety hazards Areas of requested

support

Training on laboratory quality management systems

Support to regional and national microbiology external quality assessment schemes Translation of guidelines

Support for training programmes and twinning activities

Facilitation of acquisition, maintenance of, and training on equipment Financial support for equipment, training, logistics, and assessments

(22)

Table 9. Group 4: Points of entry, chemical hazards, and radionuclear hazards

Legal and administrative framework (regulations, SOPs, definition of roles and functions for different agencies, and necessary facilities and equipment)

Coordination and information sharing (coordinating different stakeholders, lack of awareness of IHR (2005), event communication and integration with surveillance, and international border collaboration)

Human resources development (training health workers and other stakeholders) Resources and

recommendations

Sharing national guidance and SOPs Workshops for sharing experiences Site-visits to other countries

Bilateral agreements to facilitate cooperation Multisectoral exercises

Updated and harmonized guidance and tools Capacity-building and workshops

Table 10. Chemical hazards

Chemical databases

Recognition and management of chemical exposure Multisectoral management of chemical accidents Surveillance for chemical exposure

Outbreak investigation

Risk assessment and risk management of chemical hazards Chemical emergency management and response planning Mapping chemical risk

Multisectoral coordination and communication

Strengthening poison centres and other related facilities

Mapping chemical expertise and laboratory resources, both nationally and regionally Resources and

recommendations

Human resources development and guidance

Training for poison centre development and strengthening Make poison management and chemical databases available Advocacy with other ministries and agencies on IHR (2005) Areas of requested

support

Assistance with preparing and updating national chemical profiles Multisectoral training for chemical response

(23)

Table 11. Radionuclear hazards

Coordination and information sharing Legislation, national policies, and standards Mapping of hazards and risk assessments

Equipment and procedures for monitoring (including PPE)

Guidance and training on management and response to radionuclear events Regional reference centres

Training and human resource capacity-building

In- country site visits for assessment and building capacities Sharing of protocols, guidelines and manuals

Establishment of regional reference centres Areas of requested

support

Management of radionuclear events

Development of national plans for preparedness and response to radionuclear events Risk assessment

13. IHR 20122014 AND BEYOND 13.1 Costing of the IHR

Dr Stella Chungong (Coordinator, IHR Monitoring, Procedures and Information, WHO) Member States have requested support from WHO in making realistic estimates of activities, plans and budgets for their national implementation of IHR; additionally, donors and other partners have requested information on the costs of IHR implementation. To provide the best resources to meet these requests, the WHO Office of Global Capacities, Alert, and Response (GCR) recognizes the need for standardized methodology of IHR costing.

WHO/GCR is currently developing a standardized framework for estimating the costs of achieving and maintaining the minimum core capacity requirements. Through a thorough review of existing efforts, analysis of IHR Extension Plans and associated key cost elements, and stratification of countries according to similar characteristics and needs, WHO/GCR is finalizing development of a standard, generic costing tool which includes functions required by IHR for all core capacities, the necessary system components, and required costs (fixed, operating, and marginal). Over the next several months, WHO/GCR will work with partners to finalize development of the tool, share the draft tool with a technical advisory consultation team, pilot the tool in a set of representative Member States, and develop and electronic version of the tool to facilitate utilization by countries in all WHO regions.

13.2 Donor statements 13.2.1United States of America

There are many challenges associated with full implementation of the IHR and the US is committed to working together with, and to assisting, WHO headquarters, its regional offices, and Member States to help fill the gaps and needs. The US has supported substantial

(24)

programmes to improve biosurveillance, public awareness, and response in the Region and to support countries in their implementation of the core capacities of the IHR. To strengthen the cooperation between the US Government and the WHO on matters that affect many sectors and are in line with the principals set forth in the IHR, the US and WHO signed a memorandum of understanding (MoU) in September 2011 to advance common global health security objectives. The US is also working though multilateral mechanisms, such as the Global Partnership, to emphasize that IHR implementation is of key importance to member economies, as well as to developing countries. The US encouraged Member States to work with WHO to facilitate further dialogue so that the US and other partners can work collaboratively with Member States to identify key priorities and address critical gaps.

13.2.2The United Kingdom (UK)

IHR implementation is a complex process and the UK also faces significant challenges in implementing the IHR in its overseas territories. WHO, the Food and Agriculture Organization of the United Nations (FAO), and other international organizations have recognized that meeting public health objectives strengthens global biological security. The following activities have been conducted.

 The UK signed a MoU with WHO in 2010 to support IHR implementation (through funding only);

 The UK funded three country-wide core capacity assessments in the first year, and committed this year to follow up on capacity-building in those countries, including sponsoring subregional training, and to support three additional country core capacity assessments; and

 The UK is also supporting the assessment and development or revision of legal instruments to support IHR implementation, and has already funded ongoing efforts in several countries.

There is a specific link between the Biological and Toxin Weapons Convention (BTWC) and the IHR; IHR-related capacity-building meets the requirements of Article X of the BTWC (calling for technical assistance between States Parties in building national capacities) by helping to strengthen global disease surveillance. IHR capacities need to be strengthened to prevent deliberate misuse of biological agents, and capabilities developed to detect and respond if necessary to deliberate outbreaks. Safe specimen transport is a priority.

13.2.3Canada

Canada’s goals are to reduce the risks of biological security threats, promote safe and responsible conduct of biological sciences, and strengthen abilities to respond to deliberate misuse. There is ongoing work to upgrade vulnerable biological laboratories in West Africa as an example of Canada’s support for Global Partnership objectives.

13.2.4 Germany

The German Government is only starting to think about how to support other countries in implementing the IHR. The delegation from Germany will take discussions back to Berlin

(25)

to discuss with the Ministry of Health and with technical experts in the Robert Koch Institute.

Germany will, with the technical support of WHO, respond to potential partners in the near future.

13.2.5Denmark

Global health security priorities are overlapping objectives of public health and security sectors. Denmark is working together with partners though multilateral mechanisms, such as the security-focused US-led Global Partnership to emphasize that IHR implementation is of key importance to member economies, as well as developing countries. Denmark was an observer at this meeting, but looks forward to working with WHO to face biological health threats, regardless of source.

13.2.6 European Commission (EC)

The European Union/EC remains supportive and would like to participate in a process of implementing IHR in the Region where the needs and health risks are most important for the EC’s Centre of Excellence initiative, which is based on a bottom-up approach. Proposals should be prepared by two or three countries, with WHO facilitating proposal preparation and matching with other donors. The Commission will define mechanisms and processes for application in conjunction with the Global Partnership. The programme will emphasize training of trainers, biorisk management, preparedness, prevention (POE), and includes the possibility of reviewing the needs of the Region on chemical and radiological events. WHO headquarters will define proposal mechanism with WHO Regional Office and will engage with Global Partnership donors and will match requests with donors. The EC will develop a template for proposal submission and try to get it to the Member States by March 2013.

13.3 Interventions by countries 13.3.1Egypt

Egypt has offered the following support to Member States in the Region: training and capacity development in field epidemiology; infection control to improve response capacity;

training for rapid response teams; development of capacities for surveillance and laboratory personnel; sharing of studies and research; and assistance in the area of radionuclear hazards (including emergency planning, preparedness, response, exposure treatment, awareness of radionuclear hazards, and radionuclear detection in contaminated goods).

13.3.2 Islamic Republic of Iran

Disease surveillance is a shared priority among all donor programmes represented during the meeting. The Islamic Republic of Iran offered its support for disease surveillance capacity-building for the Region and expressed its desire to work with WHO and other partners. They have advanced disease surveillance information technology and a large data hub which could serve as a resource for the entire Region.

(26)

13.3.3 Morocco

Morocco can make available its technical and reference laboratories; can make available its poison center or training activities; and can assist in capacity-building for radiological protection. Morocco expressed its gratitude to WHO and to the donor organizations for their support of the meeting.

13.3.4 Saudi Arabia

Support to developing IHR core capacities in the Region is critical. The newly established WHO collaborating centre for mass gatherings is a mechanism to support regional capacity development. Saudi Arabia can support Member States in the Region through training, research and technical assistance on all aspects of mass gatherings, as well as other core capacities, including preparedness, surveillance and risk communication.

13.3.5 Libya

Libya stressed the importance of training and human resources capacity-building for all sectors related to implementation of the IHR.

13.3.6 Iraq

Iraq shared that there have been many lessons learned as the Region assessed its implementation of IHR and it is important to continue to share experiences between Member States in the Region. Iraq offered to shared experiences and lessons learned regarding development of the core capacities for handling chemical and radionuclear hazards.

13.3.7 Kuwait

Kuwait expressed its gratitude and appreciation to the US and the UK for their support in reducing the biological and chemical threat in Kuwait. They expressed their appreciation for the shared technical support, guidance and collaboration. Kuwait hopes that this collaboration will continue and other donor states and organizations will share experiences and expertise and support similar activities for all Member States in the Region.

13.3.8 Oman

Oman offered the following support to Member States in the Region: training in outbreak management; a national course in public health emergencies; technical support with development of materials; the use of the National Poison Control Centre in Oman as a regional centre; sharing experiences in vulnerability risk assessment mapping; sharing of materials and lessons learned from an all-hazards project, including materials on laboratory bio-risk management and emergency preparedness and response plans; sharing of information and experiences with electronic and event-based disease surveillance; sharing of emergency preparedness plans at points of entry; and hosting a subregional workshop on surveillance and response, in collaboration with WHO and other donor and technical partners.

(27)

14. CONCLUSIONS

Stakeholders should undertake regular mapping, assessment, monitoring and evaluation of existing capacities in each country and within the Region. The creation of regional forums to share best practices and lessons learned could also support Member States in identifying successful methods for strengthening core capacities. Coordination and collaboration among all stakeholders is critical. Coordination could be improved by ensuring the empowerment of national focal points and ensuring high-level support for multisectoral cooperation to implement the Regulations.

WHO Regional Office will seek to hold regional stakeholder meetings every six months. A list of regional IHR experts will be created to support IHR (2005) capacity- building and online resources developed. Regional and international networks, including WHO collaborating centres, should be established and enhanced to support the development of core capacities. Sustainable human resource capacity needs to be built, including developing national human resource strategies and enhancing training opportunities.

The development of guidance to enhance core capacities to handle all hazards, including food safety, chemical safety, and radionuclear events, is a critical step in meeting gaps and challenges. Laboratory capacity-building is also critical, including enhancing quality assurance and quality control programmes, training in biological risk management, enhancing diagnostic capability, and providing technical training for laboratory services.

Sustainable risk communication capacity must be built through the development of risk communication strategic frameworks that describe core risk communication functions linked to public health functions that support other core capacities.

15. RECOMMENDATIONS To Member States

1. Develop the necessary legislation for implementation of IHR (2005) and enhance multisectoral cooperation and coordination across all core capacities.

2. Empower IHR national focal points in order to be able to successfully fulfil all duties.

3. Strengthen core capacities at points of entry and core capacities to handle chemical and radionuclear hazards.

4. Develop integrated surveillance systems of networks for both communicable diseases and other hazards.

5. Develop and implement national risk communication policies, methodologies, guidelines and tools.

6. Strengthen laboratory capacity, including availability of reagents, biological risk management and technical services and human resources for all core capacities.

(28)

Annex 1 AGENDA 12 November 2012

08:30–09:00 Registration 09:00–10:00 Opening session

Keynote address Keynote address

Objectives and expected outcomes of the meeting Introduction of the participants

Adoption of the programme

Nomination of Chairperson and Rapporteur Administrative announcements

Dr Jaouad Mahjour Dr Ala Alwan

Dr El Hossein El-Ouardi Dr. Jaouad Mahjour

10:00–10:45 Update on global IHR implementation and extensions

Dr Stella Chungong 10:15–10:30 Regional progress on IHR and preparedness in the

Eastern Mediterranean Region

Dr Jaouad Mahjour 10:30–11 :00 Plenary discussion

11:15–11:30 Legislation for IHR implementation (Qatar) 11:30–11:45 Multisectoral coordination and national focal

point functions (Egypt) 11:45–13:00 Plenary discussion

14:00–14:15 Early warning function (Afghanistan)

14:15–14:30 National response mechanism to public health emergencies (Pakistan)

14:30–15:15 Plenary discussion

15:15–15:30 Multi-hazard national public health preparedness (Islamic Republic of Iran)

15:30–16:00 Plenary discussion 16:15–17:00 Poster session 18:00–20:00 R e c e p t i o n 13 November 2012

09:00–09:15 Human resources strategy development (Morocco) 09:15–09:30 Mechanism for communications during

emergencies (Tunisia) 09:30–10:00 Plenary discussion

10:00–10:15 National laboratory services and laboratory quality management system (Oman)

11:15–11:30 Surveillance and response at points of entry (Yemen) 11:30–11:45 Surveillance and response at points of entry

(29)

During mass gatherings (Saudi Arabia) 11:45–12:10 Plenary discussion

12:10–12:25 Response to zoonotic outbreaks (Sudan)

12:25–12:40 Detection and response to foodborne diseases and food management system (Jordan)

14:00–14:20 National mechanisms for detection and response to chemical and radionuclear emergencies (Morocco) 14:20–15:00 Plenary discussion

15:00–15:30 Introduction to exercises Ms Tamara Curtin Niemi 15:45–17:45 Table-top scenario

14 November 2012

09:00–09:05 Introduction and film: Global health security – an investment for a safer future

9:05–10:00 Welcoming note

Keynote address

Dr Keiji Fukuda Ambassador Bonnie Jenkins

10:15–10:30 Introduction to working groups Mr Ludy Suryantoro 10:30–13:00 Working groups: discussion, mapping, and

matching resources

14:00–15:45 Panel discussion, presentations of group work, and summary of working group outcomes

Dr Isabelle Nuttall 16:00–17:00 Road map for completion of IHR core capacities,

collaborative approach for IHR implementation, strategy for support, and donor coordination and partnership

Dr Isabelle Nuttall

15 November 2012

09:00–09:15 Costing of the IHR Dr Stella Chungong

09:15–09:30 09:30–10:45

Plenary discussion

Multisectoral collaboration, donor statements, and interventions by countries

Dr Isabelle Nuttall 11:00–12:30 Next steps in the Eastern Mediterranean Region

Meeting summary: conclusions and recommendation

Dr Jaouad Mahjour

12:30–13:00 Closing session Dr Jaouad Mahjour

14:00–16:00 Meeting between WHO staff, donors, and technical partners

Mr Ludy Suryantoro

(30)

Annex 2

LIST OF PARTICIPANTS AFGHANISTAN

Dr Bashir Noormal General Director

Afghanistan National Public Health Institute Ministry of Public Health

Kabul

Dr Mohammad Nadir Hassas Director

Emergency Preparedness and Response Ministry of Public Health

Kabul

BAHRAIN

Dr Muna S. Jawad Al Musawi National IHR Focal Point Public Health Directorate Ministry of Health Manama

Dr Kubra S. Nasser Salman Public Health Consultant

Head of Communicable Disease group Ministry of Health

Manama

DJIBOUTI

Mr Maoulid Mohamed Barkad

Chief of Toxicology and Environment National Institute of Public Health Djibouti City

Mrs Fatouma Hamadou Hamid

Chief of Service Alert and Risk Analysis National Institute of Public Health Djibouti City

(31)

EGYPT

Dr Mohamed Abdelhamied Genedy Director General

Communicable Disease Department Ministry of Health and Population Cairo

Dr Mayada Said Saadoun Epidemiologist

Responsible for International Health Regulations Ministry of Health and Population

Cairo

ISLAMIC REPUBLIC OF IRAN Dr Payman Hemmati

Senior Technical Officer of Surveillance Department, Center for Disease Control, Ministry of Health and Medical Education

Teheran

IRAQ

Dr Haidar Majeed Al Mowaly Specialist Physician

Communicable Disease Control Ministry of Health

Baghdad

Dr Hashim Sadeq Hammoudi

Health Audit, General Health Directorate Ministry of Health

Baghdad

Dr Karim Abdulkadim Muftin Al Zadawi IHR National Focal Point

Communicable Disease Control Public Health Directorate Ministry of Health Baghdad

Dr Samer Abdulsattar Ameen Al Obaidi Manager of Health Audit

Public Health Directorate Baghdad