Joint external evaluation of Latvia Executive summary May 2017
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Acknowledgements The WHO JEE Secretariat would like to acknowledge the following, whose support and commitment to the principles of the International Health Regulations (2005) have ensured a successful outcome to this JEE mission: The Government and national experts of Latvia for their support of, and work in, preparing for the JEE mission. The governments of Belgium, Finland, Germany, Sweden and the United States of America for providing technical experts for the peer review process. The European Centers for Disease Control(ECDC), Food and Animal Organization (FAO), Robert Koch Institute, US Centers for Disease Control and Prevention (CDC), World Health Organization AFRO, EURO and HQ offices for their contribution of experts and expertise. The following WHO entities: WHO Country Office of Latvia, WHO Regional Office for Europe, WHO HQ Country Health Emergencies Preparedness and IHR Department. Global Health Security Agenda Initiative for their collaboration and support.
Full Report will be published on the WHO website http://www.who.int/ihr/procedures/mission-reports/en/
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Latvia: High Level Summary and Recommendations 1. Latvia has a high level of capacity that is guided by skilled and dedicated health professionals. There are areas for improvement including strengthening the collaboration between the human and animal health sector, improving antimicrobial stewardship, ensuring a multi-sectoral approach to biosafety and biosecurity and disseminating standard operating procedures across a number of sectors. The main risk to Latvia’s health security is due to the lack of adequate financial resources to address the challenges of maintaining and retaining a skilled and appropriately sized workforce. Addressing this will be a challenge given the size of the population and the current overall budget available to the Government of Latvia but the issue should be highlighted. 2. Latvia has achieved high scores, with either developed, demonstrated or sustainable capacity in most of the technical areas. But in the absence of major, real incidents, there is risk of complacency and, as a result, cuts or redistribution of resources. Therefore it is imperative to continuously invest in IHR capacity for the health security of the people of Latvia. 3. Latvia has demonstrated a willingness to fully implement IHR requirements and be quite transparent of their health capacity’s weaknesses and strengths. Latvia should be applauded for being one of the first countries in the European region to volunteer for a Joint External Evaluation and it is hoped that other countries will follow their lead.
Latvia Scores and Priority Actions Consensual Priority Actions Score Strengthen human resources to implement the existing legislation and policies 4 o In view of the aging public health workforce and the reluctance of public health workers to work in rural areas, strengthen human resources to support IHR and global health security implementation that is aligned with the overall public health workforce development plan. Streamline roles and responsibilities to implement the legislation and policies 5 o Conduct a desk review to identify areas of overlap for the numerous legislations/policies and subsequently streamline the roles and responsibilities of key stakeholders in areas of overlap Streamline policies for risk communication through protocols 3
Technical areas
Indicators
P.1.1
National legislation, policy and financing P.1.2
for the responsible focal points to ensure consistent messaging during emergencies and capacitate the focal points with modern communication facilities and technologies Conduct regular practical trainings, simulations and exercises to test the functionality of the existing legislation and policies, as well as, conduct after action reviews (AARs) to learn lessons as to how existing legislation and policies support or enable response to real events Establish a robust supervision and monitoring system to enforce the implementation of existing legislations, policies and regulations Strengthen knowledge and understanding of the IHR as a global health framework with a multi-sectorial dimension to all the relevant sectors. Conduct simulations/exercises or after actions reviews so as to draw lessons on the functionality of the multisectoral IHR coordination mechanisms for all relevant sectors Strengthen the capacity of the IHR NFP to perform its expanded legal roles and responsibilities. Develop a coherent system for the detection and response to chemical events (surveillance, monitoring of chemicals used and how they are transported Develop a National AMR Action Plan involving all relevant sectors, building on the recommendations of the Global AMR Action Plan. This plan will support consolidation of the national response to AMR, improve national coordination and address all areas that need strengthening. Develop and implement activities for antimicrobial stewardship in humans and animals, including local antibiotic treatment guidelines. Strengthen infection prevention and control capacity (related to implementation of Cabinet Regulation No. 104) up to the peripheral health facility level in humans and animals Establish Inter-ministerial “One-Health” platform and formalize the approach to zoonoses, food safety and antimicrobial resistance among human and animal health sectors involving all stakeholders o e.g. Ministry of Environment, academia and university Conduct an in depth gap analysis of mechanisms for early warning and early detection and early response for all stakeholders involved
IHR coordination, communication and advocacy
P.2.1 4
P.3.1 P.3.2 Antimicrobial resistance
5 4
P.3.3
3
P.3.4 1 P.4.1 4
P.4.2 Zoonotic diseases P.4.3
4 4
4
Food safety P.5.1 5
P.6.1 3
Develop a plan to increase diagnostic tests on stool samples (for sporadic and outbreak cases) and food samples in Food Borne Disease Outbreaks (FBDO). Develop a protocol for molecular subtyping of samples in foodborne outbreaks o This should include when to apply (which) methods and formalises information exchange between NRL and BIOR (and CDPC). Sustain training activities on investigations of FBDO. Ensure that biosafety and biosecurity regulations and guidelines are inclusive and integrate a cross-government collaboration and create an oversight mechanism for biosafety and biosecurity that include all sites. Establish external audit at the national level to monitor surveillance procedures. Strengthen and systematize practical (not theoretical) training for ALL professionals working or that could be working with dangerous pathogens. Enhance education and communication efforts to raise awareness and compliance with biosafety and biosecurity practices among all relevant professionals Streamline policies for risk communication through protocols for the responsible focal points to ensure consistent messaging during emergencies and capacitate the focal points with modern communication facilities and technologies Introduce a vaccination register within the E-Health framework Address vaccine hesitancy by educating health care workers and analysing factors influencing vaccination behaviours (e.g. through tools from the WHO tailoring immunization programmes) Introduce a casualty assessment for adverse events following immunization, according to WHO recommendation Supplement the National Disaster Medical Plan by drafting an attachment regarding the import and distribution of medical countermeasures and equipment (including vaccines) Define national priority core tests by matching relevant test capacities to national priority diseases Improve specimen transport system from district levels to Microbiology NRL and TB reference laboratory. (currently 1-2 transports/week) 5
Biosafety and biosecurity P.6.2 2
P.7.1
5
Immunization P.7.2 5
D.1.1 National laboratory system D.1.2 D.1.3 D.1.4
4 3 4 5
Improve registry of laboratories for having precise and actual list of all laboratories with fields of testing Finalize organization of system for development and approval of national diagnostic algorithms Develop and link the eHealth system and VISUMS further to allow clinicians and laboratories to report directly into the system o If the eHealth system and VISUMS systems were linked and made available for clinicians and the national reference laboratories to report into directly, time and resources would be saved Improve integration of human and animal health surveillance, investigate the feasibility of a common surveillance system o A one health perspective would be strengthened if a common electronic system for cross-species disease surveillance and reporting came into place. This should be investigated. Include SARI in syndromic surveillance o Right now Severe Acute Respiratory Illness (SARI) is not included in the list of syndromes monitored. SARI could easily be added since 11 hospitals are part of the sentinel system. This would enhance the capability of early detection of some severe diseases. o Since the VISUM is integrated with the patient system VIS, algorithms that triggers for certain events would be possible (no of cases with specific ICD10-codes etc. ). Develop standard templates/reporting protocols that are approved by all stakeholders/institutions Training for all level/sectors to strengthen the knowledge for IHR and OIE reporting criteria, specifically train skills to fully complete the reporting protocols and forms Improve, and keep the existing, capability for notifications and activation of response activities 24/7 o Suggestion: SOP to help the duty specialist on call Produce multi-sectoral workforce development strategy o Tiered approach that addresses needs at different levels for laboratorians, human and animal health specialists Develop workforce retention policy with appropriate incentives including in-service trainings and adjusted salaries 6
D.2.1 4
D.2.2
3
D.2.3
5
Real-time surveillance
D.2.4
4
D.3.1 Reporting D.3.2 4 4
D.4.1 Workforce development D.4.2
2
2
D.4.3
2
Expand applied epidemiology training program Ensure that State Disaster Medical Plan explicitly address all IHR-relevant issues, including Points of Entry and medical counter-measures Further formalize and intensify activities of the Cross-sectoral Readiness Planning Commission on Serious Health Risk Management Move towards real-time mapping of surge capacities Address resource gaps in Disaster Medicine system Strengthen collaboration with private sector Designate and develop a dedicated public health EOC facility, drawing upon guidance such as the WHO Framework for a Public Health Emergency Operations Centre Develop guidance and SOPs for operationality of the PHEOC and for each essential role/function within the incident management structure Ensure staff training and awareness of emergency/incident management structure and SOPs Regularly test the Emergency Operations Program through functional exercises, some involving key partners from other sectors (e.g. Food and Agriculture, Security) Improved exchange of knowledge and practices between health, animal health and security sectors, particularly at regional and local levels. Provide experts with technical equipment and PPE at national level; training of specialists at regional level; improve first risk assessment if it is a threat to public health or not. Implementation of a new concept on the SMR management by establishing a national plan that identifies procedures and decision-making related to sending and receiving health personnel Improve Financial resources to complete SMR formulary Establish a procedure for sending and receiving health personnel during public health emergency Establish a procedure for distribution/dissemination of medical countermeasures during a health emergency (received as an international support) Establish a database for trained personnel and volunteers and provide training courses
R.1.1 Preparedness
5
R.1.2
4
R.2.1
3
Emergency response operations
R.2.2
3
R.2.3 3 R.2.4 4
Linking public health and security authorities
R.3.1
4
R.4.1
4
Medical countermeasures and personnel deployment
R.4.2 2
7
R.5.1 R.5.2 R.5.3 R.5.4 Risk communication R.5.5
3 3 3 3
3
SOPs are needed to ensure coordination of communication activities among various institutions’ focal points. o Regular meetings among various Ministries’ communication focal points should be reinstated to ensure exchange of information and coordination of activities. Staff capacity building o Includes in-service trainings, multi-sectoral communication focused exercises Systematic active/dynamic listening and response to rumours and misinformation should be institutionalized/formalized, identifying roles and mechanism within each organization. Strengthen legislation and provide guidelines regarding some specifics PH measures (quarantine, ship hygiene control, waste management) Strengthen capacity of resources at all PoE (PPE, disinfection, waste management capacity) Conduct risk assessment on vectors at points of entry. As needed, develop core capacities for the detection and management of vectors and reservoirs in and around PoE. Develop a national strategy to reinforce the workforce, via training of new staff and their deployment in designated PoE Improve the collaboration between public and private actors Training with cross-sectoral involvement (maintain level of preparedness and update skills) Appropriate risk assessment in different sectors (allocate financial resources and identify priorities) Disaster loss database and sharing (map the situation and ensure proper data for risk assessment) Address areas of limited capacities (strengthen/establish lab capacity, modernize equipment and strengthen skilled personnel with HR) Continue providing training for medical and first responders to a radiological incident that includes handling of contaminated victims and the symptoms of acute radiation syndrome Conduct regular training and exercises to test and improve the written protocols and multi-sector working relationships and understanding at the operational, tactical and national level
PoE.1 3 Points of entry PoE.2 4
CE.1
2
Chemical events CE.2 4
Radiation emergencies RE.1 3
RE.2
3
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List of indicators Technical areas National legislation, policy and financing IHR coordination, communication and advocacy Antimicrobial resistance Indicators P.1.1 Legislation, laws, regulations, administrative requirements, policies or other government instruments in place are sufficient for implementation of IHR (2005) P.1.2 The State can demonstrate that it has adjusted and aligned its domestic legislation, policies and administrative arrangements to enable compliance with IHR (2005) P.2.1 A functional mechanism is established for the coordination and integration of relevant sectors in the implementation of IHR P.3.1 Antimicrobial resistance detection P.3.2 Surveillance of infections caused by antimicrobial-resistant pathogens P.3.3 Health care-associated infection (HCAI) prevention and control programmes P.3.4 Antimicrobial stewardship activities P.4.1 Surveillance systems in place for priority zoonotic diseases/pathogens P.4.2 Veterinary or animal health workforce P.4.3 Mechanisms for responding to infectious and potential zoonotic diseases are established and functional P.5.1 Mechanisms for multisectoral collaboration are established to ensure rapid response to food safety emergencies and outbreaks of foodborne diseases P.6.1 Whole-of-government biosafety and biosecurity system is in place for human, animal and agriculture facilities P.6.2 Biosafety and biosecurity training and practices P.7.1 Vaccine coverage (measles) as part of national programme P.7.2 National vaccine access and delivery D.1.1 Laboratory testing for detection of priority diseases D.1.2 Specimen referral and transport system D.1.3 Effective modern point-of-care and laboratory-based diagnostics D.1.4 Laboratory quality system D.2.1 Indicator- and event-based surveillance systems D.2.2 Interoperable, interconnected, electronic real-time reporting system D.2.3 Integration and analysis of surveillance data D.2.4 Syndromic surveillance systems D.3.1 System for efficient reporting to FAO, OIE and WHO D.3.2 Reporting network and protocols in country D.4.1 Human resources available to implement IHR core capacity requirements D.4.2 FETP1 or other applied epidemiology training programme in place D.4.3 Workforce strategy R.1.1 National multi-hazard public health emergency preparedness and response plan is developed and implemented R.1.2 Priority public health risks and resources are mapped and utilized R.2.1 Capacity to activate emergency operations
Zoonotic diseases
Food safety Biosafety and biosecurity Immunization National laboratory system
Real-time surveillance
Reporting Workforce development
Preparedness Emergency 1
FETP:
9
response operations Linking public health and security authorities Medical countermeasures and personnel deployment
R.2.2 EOC operating procedures and plans R.2.3 Emergency operations programme R.2.4 Case management procedures implemented for IHR relevant hazards. R.3.1 Public health and security authorities (e.g. law enforcement, border control, customs) are linked during a suspect or confirmed biological event R.4.1 System in place for sending and receiving medical countermeasures during a public health emergency R.4.2 System in place for sending and receiving health personnel during a public health emergency R.5.1 Risk communication systems (plans, mechanisms, etc.) R.5.2 Internal and partner communication and coordination R.5.3 Public communication R.5.4 Communication engagement with affected communities R.5.5 Dynamic listening and rumour management PoE.1 Routine capacities established at points of entry PoE.2 Effective public health response at points of entry CE.1 Mechanisms established and functioning for detecting and responding to chemical events or emergencies CE.2 Enabling environment in place for management of chemical events RE.1 Mechanisms established and functioning for detecting and responding to radiological and nuclear emergencies RE.2 Enabling environment in place for management of radiation emergencies
Risk communication
Points of entry Chemical events Radiation emergencies
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