Joint External Evaluation. of THE REPUBLIC OF LIBERIA. Mission report: September 2016

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1 Joit Exteral Evaluatio of IHR Core Capacities of THE REPUBLIC OF LIBERIA Missio report: September 2016

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3 Joit Exteral Evaluatio of IHR Core Capacities of the republic of liberia Missio report: September 2016

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5 ACKNOWLEDGEMENTS The WHO Joit Exteral Evaluatio Secretariat would like to ackowledge the followig, whose support ad commitmet to the priciples of the Iteratioal Health Regulatios (2005) have esured a successful outcome to this JEE missio: The Govermet ad atioal experts of Liberia for their support of, ad work i, preparig for the JEE missio. The govermets of Eritrea, Sierra Leoe, South Africa ad the Uited States, for providig techical experts for the peer review process. The Food ad Agriculture Orgaizatio of the Uited Natios (FAO), the World Orgaizatio for Aimal Health (OIE), Iteratioal Orgaizatio for Migratio (IOM), UNICEF ad the World Bak for their cotributio of experts ad expertise. The govermets of Germay ad Filad for their fiacial support to this missio. The followig WHO etities: WHO Coutry Office, Regioal Office ad Headquarters. Global Health Security Ageda for their collaboratio ad support.

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7 Cotets Abbreviatios vi Executive Summary Liberia Scores PREVENT 5 Natioal legislatio, policy ad fiacig IHR coordiatio, commuicatio ad advocacy Atimicrobial resistace Zoootic diseases Food safety Biosafety ad biosecurity Immuizatio DETECT 22 Natioal laboratory system Real-time surveillace Reportig Workforce developmet RESPOND 34 Preparedess Emergecy respose operatios Likig public health ad security authorities Medical coutermeasures ad persoel deploymet Risk commuicatio OTHER IHR-RELATED HAZARDS AND POINTS OF ENTRY 45 Poits of etry Chemical evets Appedix 1: Joit Exteral Evaluatio Backgroud Appedix 2. Participats i the Joit Exteral Evaluatio Appedix 3. Supportig documetatio provided by host coutry

8 Joit Exteral Evaluatio Abbreviatios AFENET Africa Field Epidemiology Network AMR Atimicrobial resistace BIN Bureau of Immigratio ad Naturalizatio CBRN Chemical, biological, radiological ad uclear CDC Uited States Ceters for Disease Cotrol ad Prevetio CEBS Commuity evet-based surveillace EET Exteral Evaluatio Team EPI Expaded Programme o Immuizatio EPR Epidemic preparedess ad respose EVD Ebola virus disease FAO Uited Natios Food ad Agriculture Orgaizatio FELTP Field Epidemiology ad Laboratory Traiig Programmes FETP Field EpidemiologyTtraiig Programme GHSA Global Health Security Ageda HCAI Fealth-care associated ifectio IDSR Itegrated Disease Surveillace ad Respose system IHR (2005) Iteratioal Health Regulatios (2005) IOM Iteratioal Orgaizatio for Migratio IPC Ifectio cotrol ad prevetio IRC Iteratioal Rescue Committee JEE Joit Evaluatio Exercise LIBR Liberia Istitute for Biomedical Research LMHRA Liberia Medicies ad Health Products Regulatory Authority MCM Medical coutermeasure MoU Memoradum of Uderstadig NPHRL Natioal Public Health Referece Laboratory OIE World Orgaisatio for Aimal Health PACS Parterships for Advacig Commuity-Based Services PHEIC Public health emergecy of iteratioal cocer POE Poit(s) of Etry PVS Performace of Veteriary Services SOP Stadard operatig procedure SQS Safety quality systems TOR Terms of referece UNICEF Uited Natios Childre s Fud USAID Uited States Agecy for Iteratioal Developmet WAHIS OIE World Aimal Health Iformatio System vi

9 Executive summary fidigs from the Joit Exteral Evaluatio Sice Jue 2007, coutries are stregtheig the core capacities required for the implemetatio of the Iteratioal Health Regulatios (IHR (2005)). Uder article 54 of the IHR (2005), coutries were selfreportig aually their implemetatio status to World Health Assembly. IHR review committees ad various expert paels recommeded the review of evets, ad volutary idepedet exteral evaluatio. As a result of IHR review committees ad recommedatios, the World Health Orgaizatio (WHO) ad parters developed the Joit Exteral Evaluatio (JEE) based o available tools such as the IHR moitorig questioaire, the Global Health Security Ageda (GHSA) assessmet ad others. This assessmet was a WHO-led IHR (2005) core capacity assessmet usig the IHR JEE tool. A iteratioal, multisectoral team of experts (omiated by the JEE Secretariat) ad observers from Eritrea ad South Africa participated i the week-log assessmet which took place from 5 to 9 September 2016, i Morovia Liberia. I the WHO Africa Regio, Liberia is the fourth coutry to voluteer for the JEE, after the Uited Republic of Tazaia, Ethiopia ad Mozambique. Importatly, Liberia is the first coutry i West Africa to udergo the JEE ad also the first coutry where the WHO Regioal Office for Africa was the sole orgaizer of the JEE ad also the team lead. All the 19 techical areas of the JEE tool were assessed. Liberia first completed a self-assessmet usig the JEE tool. The results of this assessmet, icludig self-assessed scores for the 19 techical areas, were the preseted to the Exteral Evaluatio Team (EET). The EET ad host coutry experts participated i a facilitated discussio to joitly assess Liberia s curret stregths, areas which eed stregtheig ad priority actios; scores were developed through a process of cosesus. Techical area scores, supportig iformatio ad specific recommedatios for priority actios are provided uder the techical area sectios of this report. The results of the assessmet ad observatios of the host coutry s health security preparedess were preseted to Miister of Health (Ho. Dr Berice T. Dah), the Seator o the health committee i the Seate ad former Miister of Health (Ho. Dr Peter Colema), seior Govermet officials from the Miistry of Health ad several other miistries ad Govermet departmets, represetatives from door ad techical parter agecies, couty health officials, ad the media. of IHR Core Capacities of the Republic of Liberia Overarchig issues ad priority actios Key best practices There is strog political will to develop IHR capacities by takig forward a multisectoral health systems approach. There are strog parterships ad stakeholder ivolvemet at subatioal, atioal, regioal ad global levels. The coutry has made sigificat progress post-ebola i all domais of huma ad public health. There is a robust surveillace system with coutrywide coverage i the huma health sector. The foudatio for the Field Epidemiology Traiig Programme (FETP) has bee set i collaboratio with Emory Uiversity (Atlata, GA, Uited States of America) ad the Africa Field Epidemiology Network (AFENET). Robust emergecy operatios cetres (EOCs) ad icidet maagemet systems (IMS) have bee established at atioal ad itermediate levels. 1

10 2Joit Exteral Evaluatio The coutry has a good vaccie delivery system i the huma health sector to deliver mass vacciatios if ecessary. Experieces of likig public health ad security authorities i Liberia are commedable. There is robust experiece of deploymet of medical coutermeasures ad persoel ad a strog foudatio for ifectio prevetio ad cotrol (IPC) practices i health facilities through the safety quality systems (SQS) traiig programme. Key areas for improvemet Liberia is urged to revise laws ad legislatio i the cotext of IHR ad Oe Health, for example the 1976 Public Health Act. Key policies ad strategies still i draft form should be quickly fialized i collaboratio with relevat atioal stakeholders. I the cotext of Oe Health, the aimal health sector eeds additioal efforts ad itervetios. Liberia s IHR focal poit ad the World Orgaisatio for Aimal Health (OIE) focal poit (who is still a idividual rather tha a orgaizatioal set-up or cetre) should be orgaized as a cetre ad provided with ecessary resources (iformatio ad commuicatio techology, huma, logistical ad fiacial resources) to facilitate their fuctio of reportig to WHO ad/or OIE ad to be accessible 24 hours a day, seve days a week. Liberia should develop a multihazard atioal public health emergecy preparedess ad respose pla, which should be itegrated with the poits of etry (POE) emergecy plas. IHR-compliat air ad sea plas should also come uder this pla. I additio, cross-border collaboratio/iitiatives should be addressed durig the developmet of the multihazard atioal public health emergecy preparedess ad respose pla. It will be importat to stregthe laboratory capacity ad etworks, icludig supply chai systems, ad to establish iteral quality cotrol ad exteral quality assurace systems. Atimicrobial resistace detectio, mitigatio ad stewardship strategies ad plas are urgetly eeded ad should be addressed usig a Oe Health approach, with close collaboratio of all the relevat sectors icludig agriculture ad the Forestry Developmet Agecy. Liberia should establish strategies for food safety. Last but ot least, a budget lie should be created for IHR ad fudig allocated for IHR core capacity buildig from domestic ad iteratioal sources.

11 Republic of Liberia scores Capacities Idicators Score Natioal legislatio, policy ad fiacig IHR coordiatio, commuicatio ad advocacy Atimicrobial resistace Zoootic diseases Food safety Biosafety ad Biosecurity Immuizatio Natioal laboratory system Real-time surveillace Reportig Workforce developmet Preparedess P.1.1 Legislatio, laws, regulatios, admiistrative requiremets, policies or other govermet istrumets i place are sufficiet for implemetatio of IHR (2005) 2 P.1.2 The State ca demostrate that it has adjusted ad aliged its domestic legislatio, policies ad admiistrative arragemets to eable compliace with IHR (2005) 2 P.2.1 A fuctioal mechaism is established for the coordiatio ad itegratio of relevat sectors i the implemetatio of IHR 3 P.3.1 Atimicrobial resistace (AMR) detectio 1 P.3.2 Surveillace of ifectios caused by AMR pathoges 1 P.3.3 Health-care-associated ifectio (HCAI) prevetio ad cotrol programmes 2 P.3.4 Atimicrobial stewardship activities 1 P.4.1 Surveillace systems i place for priority zoootic diseases/pathoges 2 P.4.2 Veteriary or aimal health workforce 2 P.4.3 Mechaisms for respodig to zoooses ad potetial zoooses are established ad fuctioal 2 P.5.1 Mechaisms for multisectoral collaboratio are established to esure rapid respose to food safety emergecies ad outbreaks of foodbore diseases 1 P.6.1 Whole-of-govermet biosafety ad biosecurity system is i place for huma, aimal ad agriculture facilities 2 P.6.2 Biosafety ad biosecurity traiig ad practices 2 P.7.1 Vaccie coverage (measles) as part of atioal programme 3 P.7.2 Natioal vaccie access ad delivery 4 D.1.1 Laboratory testig for detectio of priority diseases 2 D.1.2 Specime referral ad trasport system 3 D.1.3 Effective moder poit-of-care ad laboratory-based diagostics 2 D.1.4 Laboratory quality system 1 D.2.1 Idicator- ad evet-based surveillace systems 4 D.2.2 Iteroperable, itercoected, electroic real-time reportig system 2 D.2.3 Aalysis of surveillace data 4 D.2.4 Sydromic surveillace systems 4 D.3.1 System for efficiet reportig to WHO, FAO ad OIE 2 D.3.2 Reportig etwork ad protocols i coutry 2 D.4.1 Huma resources available to implemet IHR core capacity requiremets 1 D.4.2 FETP 1 or other applied epidemiology traiig programme i place 3 D.4.3 Workforce strategy 2 R.1.1 Natioal multi-hazard public health emergecy preparedess ad respose pla is developed ad implemeted 1 R.1.2 Priority public health risks ad resources are mapped ad utilized. 2 of IHR Core Capacities of the Republic of Liberia 3

12 4Joit Exteral Evaluatio Capacities Idicators Score R.2.1 Capacity to activate emergecy operatios 3 R.2.2 EOC operatig procedures ad plas 4 R.2.3 Emergecy operatios programme 4 R.2.4 Case-maagemet procedures are implemeted for IHR-relevat hazards. 2 Emergecy respose operatios Likig public health ad security authorities Medical coutermeasures ad persoel deploymet Risk commuicatio Poits of etry Chemical evets Radiatio emergecies R.3.1 Public health ad security authorities (e.g. law eforcemet, border cotrol, customs) are liked durig a suspect or cofirmed biological evet 4 R.4.1 System is i place for sedig ad receivig medical coutermeasures durig a public health emergecy 4 R.4.2 System is i place for sedig ad receivig health persoel durig a public health emergecy 4 R.5.1 Risk commuicatio systems (plas, mechaisms, etc.) 3 R.5.2 Iteral ad parter commuicatio ad coordiatio 4 R.5.3 Public commuicatio 4 R.5.4 Commuicatio egagemet with affected commuities 2 R.5.5 Dyamic listeig ad rumour maagemet 3 POE.1 Routie capacities are established at poits of etry 2 POE.2 Effective public health respose at poits of etry 1 CE.1 Mechaisms are established ad fuctioig for detectig ad respodig to chemical evets or emergecies 1 CE.2 Eablig eviromet is i place for maagemet of chemical evets 1 RE.1 Mechaisms are established ad fuctioig for detectig ad respodig to radiological ad uclear emergecies 1 RE.2 Eablig eviromet is i place for maagemet of radiatio emergecies 1 Note o scorig of techical areas of the JEE tool The Joit Exteral Evaluatio process is a peer-to-peer review. As such, it is a collaborative effort betwee host coutry experts ad Exteral Evaluatio Team members. I completig the self-evaluatio, the first step i the JEE process, ad as part of preparig for a exteral evaluatio, host coutries are asked to focus o providig iformatio o their capabilities based o the idicators ad techical questios icluded i the JEE tool. The host coutry may score their self-evaluatio or propose a score durig the o-site cosultatio with the exteral team. The etire exteral evaluatio, icludig the discussios aroud the scores, stregths/best practices, the areas which eed stregtheig/challeges ad the priority actios is doe i a collaborative maer, with exteral evaluatio team members ad host coutry experts seekig agreemet. Should there be sigificat ad irrecocilable disagreemet betwee the exteral team members ad the host coutry experts or amog the exteral or amog the host coutry experts, the Exteral Evaluatio Team Lead will decide o the fial score ad this will be oted i the Fial Report, alog with the justificatio for each party s positio.

13 PREVENT Natioal legislatio, policy ad fiacig Itroductio The Iteratioal Health Regulatios (IHR) (2005) provide obligatios ad rights for States Parties. I some States Parties, implemetatio of the IHR (2005) may require ew or modified legislatio. Eve if a ew or revised legislatio may ot be specifically required, states may still choose to revise some regulatios or other istrumets i order to facilitate IHR implemetatio ad maiteace i a more effective maer. Implemetig legislatio could serve to istitutioalize ad stregthe the role of IHR (2005) ad operatios withi the State Party. It ca also facilitate coordiatio amog the differet etities ivolved i their implemetatio. See detailed guidace o IHR (2005) implemetatio i atioal legislatio at I additio, policies that idetify atioal structures ad resposibilities as well as the allocatio of adequate fiacial resources are also importat. of IHR Core Capacities of the Republic of Liberia PREVENT Target Adequate legal framework for States Parties to support ad eable the implemetatio of all their obligatios, ad rights to comply with ad implemet the IHR (2005). New or modified legislatio i some States Parties for implemetatio of the IHR (2005). Where ew or revised legislatio may ot be specifically required uder the State Party s legal system, States may revise some legislatio, regulatios or other istrumets i order to facilitate their implemetatio ad maiteace i a more efficiet, effective or beeficial maer. States Parties esure provisio of adequate fudig for IHR implemetatio through the atioal budget or other mechaism. Republic of Liberia level of capabilities There is a legal framework to support ad eable the implemetatio of the IHR (2005). However, Liberia has depeded o the Public Health Law eacted i 1976: this Law ad associated legislatio ad policies are beig revised. There are iadequate huma resources to implemet legislatio ad policies: for example, there is a shortage of veteriarias ad epidemiologists. Moreover, fiacial resources are isufficiet to implemet legislatio ad policies so there is a eed to create a budget lie ad allocate resources for IHR i the atioal budget. Recommedatios for Priority Actios Revise the 1976 Public Health Law to icorporate the IHR requiremets to eable eforcemet of the Public Health Law ad other IHR-related legal istrumets. Build capacity for IHR (2005) core competecies ad ehace itersectoral collaboratio. Raise awareess amog all relevat stakeholders about their roles ad resposibilities related to the IHR (2005). Create a budget lie ad allocate fiacial resources to support implemetatio. 5

14 PREVENT 6Joit Exteral Evaluatio Idicators ad Scores P.1.1 Legislatio, laws, regulatios, admiistrative requiremets, policies or other govermet istrumets i place are sufficiet for implemetatio of IHR (2005) Score 2 The availability of legislatio such as the Public Health Law ad the Evirometal Protectio Law is a key stregth i esurig that the IHR (2005) core capacities are built up ad sustaied, although some legislatio require revisio. The Public Health Law is curretly beig revised to address emergig issues. There is a very strog political ad parter commitmet to revisig ad implemetig public health laws, as demostrated by Ho. Dr Peter Colema (Chairperso of the Seate Committee o Health) who promised that Committee members, as legislators, are available ad ready to esure the aligmet of the laws with the requiremets of IHR. There is clear evidece of itersectoral collaboratio ad coordiatio to implemet legislatio i the coutry. Esurig the availability of staff, especially at the atioal level, will esure aligmet of the domestic legislatio ad policies with the IHR (2005). There are efforts to adopt ad scale up the Oe Health approach ad to esure that public health laws will icrease relevat capacity for both aimal ad huma health. The existig 1976 Public Health Law eeds to be revised to icorporate all the IHR (2005) requiremets. The framework for itersectoral collaboratio ad partership eeds to be clearly defied, sice it is key to IHR (2005) implemetatio. The Govermet of Liberia eeds to cotiue Capacity-buildig at all levels. The limited fiacial ad huma resources to implemet legislatio at all levels should be addressed. Makig Oe Health a atioal policy will icrease Govermet fiacial iput, stregthe ad speed up IHR implemetatio i all sectors of Liberia society ad icrease collaboratio betwee all stakeholders i the coutry. P.1.2 The State ca demostrate that it has adjusted ad aliged its domestic legislatio, policies ad admiistrative arragemets to eable compliace with the IHR (2005) Score 2 The Govermet of Liberia has developed or adapted or laws ad policies related to aspects of the IHR core capacities. There is a eed to mobilize fiacial ad huma resources. Capacity-buildig eeds to be stregtheed at all levels. Public educatio ad awareess-raisig activities are eeded. Oe Health is a good platform for mobilizig resources locally ad iteratioally to build core capacities i all fields.

15 IHR coordiatio, commuicatio ad advocacy Itroductio The effective implemetatio of the IHR requires multisectoral/multidiscipliary approaches through atioal parterships for efficiet ad alert respose systems. Coordiatio of atiowide resources, icludig the desigatio of a atioal IHR focal poit, which is a atioal cetre for IHR commuicatios, is a key requisite for IHR implemetatio. of IHR Core Capacities of the Republic of Liberia Target Multisectoral/multidiscipliary approaches through atioal parterships that allow efficiet, alert ad resposive systems for effective implemetatio of the IHR (2005). Coordiate atiowide resources, icludig sustaiable fuctioig of a atioal IHR focal poit a atioal cetre for IHR (2005) commuicatios which is a key requisite for IHR (2005) implemetatio that is accessible at all times. States Parties provide WHO with cotact details of atioal IHR focal poits, cotiuously update ad aually cofirm them. Republic of Liberia level of capabilities Prior to the outbreak of Ebola virus disease (EVD), the strategy to ehace parter coordiatio icluded: iformatio systems stregtheig; commo aual plaig; stadard guidelies, orms ad evaluatio. Parter coordiatio mechaisms icluded: the Health Sector Coordiatio Committee, the Natioal Disaster ad Relief Commissio, the Health Sector Coordiatig Committee ad umerous techical committees. I additio, there were special mechaisms icludig the Global Fud to Fight AIDS, Tuberculosis ad Malaria, the Liberia Health Sector Pool Fud, the World Bak, the Fixed Amout Reimbursemet Agreemet, joit plaig ad aual reviews. PREVENT Durig the EVD outbreak, a atioal EVD Task Force was set up, that became the Presidetial Advisory Committee o Ebola. Also set up were the Icidet Maagemet System ad its thematic/techical workig groups, the couty EVD task forces chaired by superitedets, the couty techical committees/icidet maagemet systems chaired by the Couty Health Officer, the district EVD task forces ad the commuity EVD task forces. Sice the EVD outbreak, the followig coordiatio mechaisms have bee istitutioalized: The Natioal Task Force uder the Office of the Presidet; the Health Sector Coordiatio Committee; the Icidet Maagemet System; the Oe Health Coordiatio Committee; the Natioal Surveillace Techical Coordiatio Committee; the Couty Disaster Task Force chaired by the Superitedet; the Couty Surveillace Techical Coordiatio Committee; district disaster task forces; commuity disaster task forces. Key stakeholders have bee idetified ad their roles ad resposibilities defied. They iclude the Office of the Presidet for policy, coordiatio, advocacy ad resource mobilizatio; the Miistry of Fiace ad Developmet Plaig for resource mobilizatio; the Miistry of Iteral Affairs for local leadership ad commuity egagemet durig disaster; the Miistry of Health for plaig, coordiatio, moitorig ad evaluatio; the Miistry of Agriculture for zoootic vaccie-prevetable-disease cotrol; parters for techical ad fiacial support, capacity-buildig ad moitorig ad evaluatio; ad the commuity for mobilizatio ad demad geeratio. Recommedatios for Priority Actios Stregthe ad sustai a multisectoral ad multidiscipliary coordiatio ad commuicatio mechaism with aimal health, wildlife, eviromet ad other relevat sectors, icludig establishig memorada of uderstadig (MoU) for joit actios ad traiig with relevat stakeholders, such as 7

16 PREVENT 8Joit Exteral Evaluatio security agecies ad the Miistry of Natioal Defece. I additio establish a focal poit for veteriary public health withi the Miistry of Health to drive the Oe Health efforts. Revise the terms of referece (TOR) for the atioal IHR cetre withi the Miistry of Health ad Miistry of Agriculture to make them more resposive ad accoutable to all relevat sectors. Icrease advocacy, awareess-raisig amog the local populatio o the importace of IHR, promote multidiscipliary ad multi-stakeholder participatio i the cotext of the Oe Health approach ad esure that the IHR cetres have the ecessary capacity ad logistics (office, trasport, iformatio ad commuicatio) to make them more fuctioal. Stregthe cross-border coordiatio, commuicatio ad advocacy with all eighbourig coutries ad other coutries i the wester Africa regio. Establish a sigle iformatio platform ad regularly produce ad dissemiate iformatio products (dashboards, bulletis, daily alert, weekly/mothly/quarterly/aual updates) ad share them promptly with all stakeholders. Coduct aual IHR review meetigs ad facilitate a regioal review. I additio, coduct quarterly multisectoral meetigs i each couty. Idicators ad Scores P.2.1 A fuctioal mechaism is established for the coordiatio ad itegratio of relevat sectors i the implemetatio of IHR Score 3 There is very high political commitmet, as show by the creatio of a high-level coordiatio mechaism uder the leadership of the Presidet the Presidetial Advisory Committee o Ebola. There are efforts to formulate a Oe Health strategy, ad a atioal Oe Health Committee has bee established. A Natioal Disaster Relief Commissio has bee established uder the Miistry of Iteral Affairs. There is a Natioal Disease Surveillace Techical Coordiatio Committee withi the Miistry of Health with techical workig groups (Commuity Evet-Based Surveillace (CEBS), Border Coordiatio Group, epidemic preparedess ad respose (EPR), etc.) Emergecy operatios cetres established at cetral level ad i all the 15 couties ad icidece maagemet systems established at atioal ad couty levels. Coordiatio roles ad resposibilities have bee defied for the relevat stakeholders. There are major challeges with coordiatio with the Miistry of Agriculture ad veteriary services. There are o SOPs to streamlie coordiatio mechaisms, yet there are umerous committees ad task forces. There is limited iformatio maagemet ad sharig with other sectors: veteriary services, port health authorities, abattoirs ad slaughterhouses, defece ad evirometal health. A sigle iformatio platform should be set up. Sustaied fudig for coordiatio, multidiscipliary ad multisectoral egagemet is required, alog with capacity-buildig for coordiatio at atioal ad couty levels; icreased advocacy with all stakeholders icludig lie miistries, the private sector, faith-based istitutios, parters ad the commuity; proactive ivolvemet of all stakeholders (multidiscipliary ad multisectoral); ad support for commuicatio to facilitate iformatio maagemet. There is a eed for sustaied fudig for coordiatio, iformatio maagemet ad advocacy for Oe Health through developmet of a Oe Health strategy.

17 Atimicrobial resistace Itroductio Bacteria ad other microbes evolve i respose to their eviromet ad ievitably develop mechaisms to resist beig killed by atimicrobial agets. For may decades, the problem was maageable as the growth of resistace was slow ad the pharmaceutical idustry cotiued to create ew atibiotics. of IHR Core Capacities of the Republic of Liberia Over the past decade, however, this problem has become a crisis. Atimicrobial resistace is evolvig at a alarmig rate ad is outpacig the developmet of ew coutermeasures capable of thwartig ifectios i humas. This situatio threates patiet care, ecoomic growth, public health, agriculture, ecoomic security ad atioal security. Target Support work coordiated by FAO, OIE ad WHO to develop a itegrated global package of activities to combat atimicrobial resistace, spaig huma, aimal, agricultural, food ad evirometal aspects (i.e. a Oe Health approach). Each coutry has: (i) its ow atioal comprehesive pla to combat atimicrobial resistace; (ii) stregtheed surveillace ad laboratory capacity at the atioal ad iteratioal levels followig iteratioal stadards developed as per the framework of the Global Actio Pla; ad (iii) improved coservatio of existig treatmets ad collaboratio to support the sustaiable developmet of ew atibiotics, alterative treatmets, prevetive measures ad rapid poit-of-care diagostics, icludig systems to preserve ew atibiotics. PREVENT Republic of Liberia level of capabilities The coutry has ot developed ay capabilities to address AMR. There is o plaed activity to develop a atioal actio pla to combat AMR, ad there is iadequate kowledge about the Global Actio Pla o AMR. There are o AMR detectio, surveillace ad stewardship programmes i place. Liberia has a atioal IPC programme that covers aspects of the HCAI cotrol programme, but the coutry does ot have a stipulated HCAI cotrol programme. A atioal programme o health care associated ifectio prevetio ad cotrol was lauched after the Ebola outbreak ad has bee established i all health-care settigs. There is a draft Laboratory Strategic Pla , but it does ot iclude AMR testig or surveillace. The Natioal Drug Formulary, Natioal Drug Policy, Natioal Therapeutic Guidelies for Liberia ad the atioal IPC pla ad guidelies eed to be reviewed ad updated to reflect the curret situatio of the coutry. Recommedatios for Priority Actios Establish a atioal committee to address the Global Actio Pla o AMR, ivolvig the differet sectors (huma, aimal, agriculture, eviromet, scietific ad research commuity, public ad civil society) to develop the Liberia atioal actio pla o AMR usig a Oe Health approach. Develop a atioal AMR surveillace system based o the existig laboratory capacity i health-care settigs ad hospitals supported by a atioal referece laboratory ad a atioal surveillace system i the aimal ad agriculture sectors. Stregthe implemetatio of HCAI prevetio ad cotrol programme i health-care settigs, icludig surveillace of HCAI ad the core compoets of the HCAI programmes. Formulate clear policies ad guidelies for atimicrobial stewardship. 9

18 Joit Exteral Evaluatio Idicators ad Scores P.3.1 Atimicrobial resistace (AMR) detectio Score 1 Address regular AMR testig ad laboratory AMR detectio ad surveillace i the laboratory strategic pla. Coduct a eeds assessmet i all laboratories to idetify the mai gaps to support the idetificatio of AMR pathoges. Improve laboratory capacity at atioal level through the establishmet of a laboratory etwork with a apex atioal referece laboratory to establish ad maitai stadards. PREVENT Coduct risk assessmets for both huma ad aimal pathoges ad establish a database of all the atimicrobials used i the coutry. Establish a atioal actio pla for AMR i a Oe Health cotext. P.3.2 Surveillace of ifectios caused by AMR pathoges Score 1 The draft five-year laboratory strategic pla will be updated to address regular AMR testig, detectio ad surveillace. The coutry has the Natioal Therapeutics Guidelies for Liberia ad Essetial Medicies List to guide the use of the most commo drugs ad medicies. A drug policy ad a law o the Liberia Medicies ad Health Products Regulatory Authority (LMHRA) have bee formulated to guide ad reiforce the ratioal use of medicies. Establish a surveillace system for ifectios caused by AMR pathoges, icludig desigatio of selected setiel sites as part of the atioal actio pla o AMR. Review ad update the Natioal Drug Policy of P.3.3 Health-care-associated ifectio (HCAI) prevetio ad cotrol programmes Score 2 There is a draft atioal IPC pla ad guidelies. Frot-lie health workers have bee traied i IPC practices. IPC guidelies ad material have bee distributed to health facilities which have desigated IPC focal poits. Implemetatio of the HCAI guidelies at atioal level, icludig regular traiig, moitorig ad evaluatio. P.3.4 Atimicrobial stewardship activities - Score 1 Stregths/ best practices Establishmet of a prescriptio-based access to atimicrobials i the Agriculture sector. 10

19 There exist some documets for AMR stewardship such as: IDSR guidelies 2016, Therapeutic guidelies Admiistratio of drugs is based o prescriptio by qualified persoel i Agriculture sector. Establish a robust AMR stewardship programme for the coutry. of IHR Core Capacities of the Republic of Liberia PREVENT 11

20 Joit Exteral Evaluatio Zoootic diseases Itroductio Zoootic diseases are commuicable diseases that ca spread betwee aimals ad humas. These diseases are caused by viruses, bacteria, parasites ad fugi carried by aimals, isects or iaimate vectors that aid i its trasmissio. Approximately 75% of recetly emergig ifectious diseases affectig humas is of aimal origi; ad approximately 60% of all huma pathoges are zoootic. PREVENT Target Adopted measured behaviors, policies ad/or practices that miimize the trasmissio of zoootic diseases from aimals ito huma populatios. Republic of Liberia level of capabilities Liberia s zoootic disease detectio ad respose capabilities were tested durig the EVD outbreak i 2014/2015 ad three subsequet flare-ups i Liberia implemets a CEBS programme, icludig commuity triggers for aimal-health evets, that otifies ad egages the commuity ad health sectors. I additio, the Govermet has worked to improve commuicatio about zoootic diseases by desigatig a represetative from various sectors, icludig the Miistry of Health, Miistry of Agriculture, Forestry Developmet Authority ad Evirometal Protectio Agecy, to atted Oe Health Coordiatio Committee meetigs. Recommedatios for Priority Actios Idetify priority zoootic diseases of domestic aimals ad wildlife i the commuity. Educate ad raise awareess i commuities about zoootic disease cotrol, good aimal husbadry practices ad aimal welfare. Prioritize resources i order to esure the reductio of potetial spill over of zoootic diseases ito the huma populatio. Ehace veteriary services ad icrease research ito livestock diseases. Develop the iitial ad cotiuous traiig of veteriary persoel. Fialize draft legislatio: agriculture law ad proposed aimal disease law. Develop a multisectoral approach to zoootic diseases at the atioal, couty ad local levels. Idicators ad Scores P.4.1 Surveillace systems i place for priority zoootic diseases/pathoges Score 2 The Govermet has established relatioships with committed potetial implemetig parters, icludig the USAID Emergig Pademic Threats programme phase 2, cosistig of the FAO compoet, the PREDICT project ad preparedess ad respose; ad with ogovermetal orgaizatios to stregthe veteriary services, icludig zoootic disease surveillace, diagostic capacity ad improvemet of the veteriary laboratory ifrastructure. 12

21 Stadard operatig procedures have bee developed for field samplig for zoootic diseases. Some surveillace has bee iitiated ad additioal field traiig will be coducted. There is curretly o formal lik (i terms of iformatio sharig) betwee the aimal health ad huma public health sectors. Curret surveillace for aimal bites (suspected rabies) uder IDSR has established a lik betwee huma ad aimal health through collaboratio betwee the MOH ad the MOA. However the practice of iformatio sharig is icosistet, o-systematic or iadequate. of IHR Core Capacities of the Republic of Liberia There is a eed to stregthe screeig of livestock at border crossig poits ad ispectio at poits of etry, where testig ca be performed o aimals quaratied, as ecessary. P.4.2 Veteriary or Aimal Health Workforce Score 2 The Govermet has idetified the eed for additioal veteriary ad aimal health workers ad has assiged livestock officers to each of the 15 couties. Liberia curretly does ot have a field etwork or established procedures to coduct fully fuctioal zoootic disease surveillace because of iadequate staffig ad techical capacity. PREVENT Workforce developmet should iclude the resources to trai ad compesate persoel, icludig veteriarias, aimal scietists ad laboratory techicias, i order to provide a robust aimal health ifrastructure withi the coutry. The curret educatioal system i Liberia does ot iclude the optio of a veteriary degree. Capacity amog huma resources i good agricultural practices ad empowermet of farmers i food security ad healthy productio of food of aimal origi, icludig zoootic disease cotrol, would reduce the risk of trasmissio of zoootic diseases. Establishmet of public health ad food safety sectios uder the Livestock Departmet at the Miistry of Agriculture would also limit the risk of zoootic diseases. P.4.3 Mechaisms for respodig to zoooses ad potetial zoooses are established ad fuctioal Score 2 The aimal health ad wildlife sectors have led aimal surveillace ad performed research i domestic aimals ad wildlife. Capacity-buildig i field veteriary service ad disease surveillace is critical for a adequate respose. There is a eed to restore the veteriary laboratory to full fuctioality i order to respod to potetial zoootic disease evets. It would be beeficial to have a desigated IHR focal poit at the Miistry of Agriculture. 13

22 Joit Exteral Evaluatio Food safety Itroductio Food- ad water-bore diarrhoeal diseases are leadig causes of illess ad death, particularly i less developed coutries. The rapid globalizatio of food productio ad trade has icreased the potetial likelihood of iteratioal icidets ivolvig cotamiated food. The idetificatio of the source of a outbreak ad its cotaimet is critical for cotrol. Risk maagemet capacity with regard to cotrol throughout the food chai cotiuum must be developed. If epidemiological aalysis idetifies food as the source of a evet, based o a risk assessmet, suitable risk maagemet optios that esure the prevetio of huma cases (or further cases) eed to be put i place. PREVENT Target Surveillace ad respose capacity amog States Parties for food- ad water-bore disease risks or evets by stregtheig effective commuicatio ad collaboratio amog the sectors resposible for food safety, ad safe water ad saitatio. Republic of Liberia level of capabilities The Liberia authorities state that food safety moitorig is ogoig, although it is ot well coordiated i a structured, itegrated surveillace system. Curretly, the Miistry of Health issues oly food safety permits, ot food safety certificates, to food establishmets. Liberia authorities have oted that there are ogoig efforts amog the Mao River Uio coutries to stregthe ispectio ad quaratie measures for the cross-border live food aimal trade to cotrol aimal diseases of ecoomic ad public health importace. There are sector guidelies for food safety stadards withi the Miistry of Agriculture ad Miistry of Health. However, there is o established surveillace system for foodbore diseases to assist i implemetig these stadards. Recommedatios for Priority Actios I view of Liberia s curret lack of capabilities for detectig ad respodig to foodbore disease ad food cotamiatio, it is recommeded that the followig priority areas should be addressed. Establish a comprehesive foodbore disease surveillace system. Build ad sustai the capacity i huma resource, logistics, ifrastructure ad techical support at all levels, icludig laboratories, to promote the eforcemet of the 1976 Public Health Law. Stregthe itersectoral collaboratio accordig to istitutioal madates to implemet the 1976 Public Health Law. Idicators ad Scores P.5.1 Mechaisms are established ad fuctioig for detectig ad respodig to foodbore disease ad food cotamiatio Score 1 Liberia has atioal food safety guidelies, although they are ot eforced. The coutry is a member of the Iteratioal Food Safety Network (INFOSAN), the Codex Alimetarius Commissio ad the West Africa Trade Orgaizatio. 14

23 A Natioal Stadards Laboratory has bee established with limited but icreasig capability. It s curretly ivolved i the testig of the various bottled water brads ad a umber of locally available food items circulatig i Liberia markets. There are focal persos i relevat govermet miistries but there is limited coordiatio or commuicatio amog them. Despite the costraits that Liberia faces, the authorities have bee able to coduct periodic ispectio of food establishmets ad to issue permits ad clearaces before opeig food establishmets. of IHR Core Capacities of the Republic of Liberia Liberia requires capacity-buildig i huma resources, logistics, ifrastructure ad techical expertise. The ewly established Natioal Stadards Laboratory has limited capacity for microbiology ad focuses oly o detectio. The Laboratory is i the process of achievig compliace with Iteratioal Orgaizatio for Stadardizatio rules, so it caot curretly assist other atioal laboratories to develop quality systems. It is apparet that there is limited itersectoral collaboratio i eforcig the 1976 Public Health Law. There are clear roles ad resposibilities amog stakeholders, but limited coordiatio. PREVENT Lastly, Liberia shares its borders with other developig coutries, but these borders have bee observed to be porous due to poor border cotrols. As a result, there is urestricted iformal cross-border trade i live food aimals ad other commodities. 15

24 Joit Exteral Evaluatio Biosafety ad biosecurity Itroductio It is vital to work with pathoges i the laboratory to esure that the global commuity possesses a robust set of tools such as drugs, diagostics, ad vaccies to couter the ever-evolvig threat of ifectious diseases. PREVENT Research with ifectious agets is critical for the developmet ad availability of public health ad medical tools that are eeded to detect, diagose, recogize ad respod to outbreaks of ifectious diseases of both atural ad deliberate origi. At the same time, the expasio of ifrastructure ad resources dedicated to work with ifectious agets have raised cocers regardig the eed to esure proper biosafety ad biosecurity to protect researchers ad the commuity. Biosecurity is importat i order to secure ifectious agets agaist those who would deliberately misuse them to harm people, aimals, plats or the eviromet. Target A whole-of-govermet atioal biosafety ad biosecurity system with especially dagerous pathoges idetified, held, secured ad moitored i a miimal umber of facilities accordig to best practices; biological risk maagemet traiig ad educatioal outreach coducted to promote a shared culture of resposibility, reduce dual-use risks, mitigate biological proliferatio ad deliberate use threats, ad esure safe trasfer of biological agets; ad coutry-specific biosafety ad biosecurity legislatio, laboratory licesig ad pathoge cotrol measures i place as appropriate. Republic of Liberia level of capabilities Liberia is workig to improve biosafety ad biosecurity followig the EVD outbreak. Issues were idetified durig the outbreak, relatig to laboratory capacity, ifectio cotrol, persoal protective equipmet ad biosafety ad biosecurity traiig. Liberia is workig with iteratioal parters to improve may areas of biosafety ad biosecurity. Curretly, there are a umber of draft regulatory documets relatig to biosafety ad biosecurity which eed to be fialized. I additio, there is cosiderable goodwill amog several stakeholders who are kee to shape the regulatory eviromet i the future, icludig: laboratory authorities, aimal health persoel, border security ad the Liberia Natioal Police. Most of these stakeholders were actively ivolved i the respose to the EVD outbreak. The Evirometal Protectio Agecy provides overall legislatio ad regulatios for compliace with biosafety ad biosecurity. Although a draft atioal evirometal health policy exists, it is ot comprehesive ad eeds to be updated. I additio, there are o atioal biosecurity or biosafety legislatio, regulatios or frameworks ad o official biosafety or biosecurity moitorig. However, parters have supported traiig for umber of staff from the Miistry of Agriculture, the Miistry of Commerce ad Idustry, the Miistry of Health, the Miistry of Justice, the Liberia Natioal Police, the Bureau of Immigratio ad Naturalizatio (BIN) 1 ad the Armed Forces of Liberia. This has cotributed to the curret stregths of the coutry s biosafety ad biosecurity capabilities. Further, Liberia has existig documetatio although much of it is i draft form icludig the Natioal Evirometal ad Occupatioal Health Policy (2010), the five-year Laboratory Strategic Pla (2016), the Natioal Laboratory 1 Editor s Note: ow the Liberia Immigratio Service. 16

25 Policy (2011), the Biosafety Maual (2012) ad the Natioal Ifectio Protectio ad Cotrol Guidelies (2016). Furthermore, there exists a catalogue of the specimes collected durig the 2014/2015 Ebola outbreak i the coutry, ad storage of ifectious specimes is cosolidated at the Natioal Referece Laboratory, although there is limited screeig for biological weapos at poits of etry. As with most techical areas of this report, the major challege for implemetig measures for biosecurity ad biosafety is the limited fudig from the Govermet ad the depedece o parters for the fudig of biosecurity ad biosafety activities. There also exists a lack of a explicit atioal policy addressig biosafety ad biosecurity: the latest available documet, geerated i 2012, was ever fialized ad was largely focused o the laboratory. Other guidelies for biosecurity ad biosafety were draw up with the assistace of the World Bak i 2009 to supplemet the Evirometal Protectio Agecy regulatios, but these are i draft form ad are ot curretly implemeted. To date, there remais o biosafety-level-3 laboratory i the coutry, although this is recommeded for the hadlig of highly ifectious pathoges. As a result of the Ebola outbreak of 2014/2015, there has bee ivestmet i the developmet of medical waste maagemet facilities at hospital level, IPC stadard operatig procedures, a safe ad quality services strategy, ad safe specime hadlig ad trasportatio practices have bee stregtheed. From the laboratory perspective, there has bee a move towards molecular methods of testig, such as polymerase chai reactio ad serology, to limit the eed to culture dagerous pathoges. Although traiig i biosecurity ad biosafety is coducted, it is parter-drive ad there is o official traiig programme or pla. Cosequetly, the traiig is ot well coordiated ad ofte excludes relevat sectors. There is also a lack of risk assessmets or safety audit plas for biohazard procedures i all sectors, ad o framework exists to documet, report, ivestigate or address icidets ad accidets related to biological hazards. I additio, there are limited occupatioal health services, icludig provisio of immuizatio agaist pathoges that staff may ecouter. There is a eed for itegratio of biosafety ad biosecurity traiig for all relevat stakeholders. Liberia eeds to develop ad implemet occupatioal health ad safety ad vacciatio policies. Furthermore, there is a eed for moitorig through coordiated biosafety ad biosecurity surveillace ad implemetatio of a solid maagemet pla. This ca be achieved through a comprehesive atioal policy o biosafety ad biosecurity; desigatio of focal poits i all relevat sectors, with well-defied roles ad resposibilities; a clear moitorig pla for regular safety audits of facilities ad istitutios dealig i biological hazards; ad regular risk assessmet of processes ad procedures. of IHR Core Capacities of the Republic of Liberia PREVENT Recommedatios for Priority Actios To address the challeges Liberia faces i biosafety ad biosecurity, it is recommeded that the coutry works towards addressig the followig priority areas. Develop ad implemet a comprehesive atioal policy o biosafety ad biosecurity that icludes all relevat sectors. Establish likages betwee the huma, aimal ad evirometal health sectors to address biosafety/ biosecurity cocers i lie with the Oe Health approach, build capacity ad implemet strategic actio. Idicators ad Scores P.6.1 Whole-of-govermet biosafety ad biosecurity system is i place for huma, aimal, ad agriculture facilities Score 2 Followig the coutry presetatio ad subsequet discussios with iput from relevat sectors, there was a cosesus that Liberia s self-assessmet of biosafety ad biosecurity had bee lower tha was justified. It was agreed that, sice evidece had bee provided that other sectors of govermet had coducted 17