JOINT EXTERNAL EVALUATION OF IHR CORE CAPACITIES of the REPUBLIC OF ZAMBIA Mission report: 7-11 August 2017
JOINT EXTERNAL EVALUATION OF IHR CORE CAPACITIES of the REPUBLIC OF ZAMBIA Mission report: 7-11 August 2017
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Contents Acknowledgements-------------------------------------------------------------------------------------------------v Abbreviations-------------------------------------------------------------------------------------------------------- vi Executive summary------------------------------------------------------------------------------------------------- 1 Republic of Zambia scores----------------------------------------------------------------------------------------- 3 PREVENT 5 National legislation, policy and financing----------------------------------------------------------------------- 5 IHR coordination, communication and advocacy-------------------------------------------------------------- 7 Antimicrobial resistance------------------------------------------------------------------------------------------- 9 Zoonotic diseases--------------------------------------------------------------------------------------------------12 Food safety----------------------------------------------------------------------------------------------------------15 Biosafety and biosecurity-----------------------------------------------------------------------------------------18 Immunization-------------------------------------------------------------------------------------------------------20 of IHR Core Capacities of the the Republic of Zambia DETECT 22 National laboratory system---------------------------------------------------------------------------------------22 Real-time surveillance---------------------------------------------------------------------------------------------25 Reporting------------------------------------------------------------------------------------------------------------28 Workforce development------------------------------------------------------------------------------------------30 RESPOND 33 Preparedness-------------------------------------------------------------------------------------------------------33 Emergency response operations---------------------------------------------------------------------------------36 Linking public health and security authorities-----------------------------------------------------------------39 Medical countermeasures and personnel deployment-------------------------------------------------------41 Risk communication-----------------------------------------------------------------------------------------------43 OTHER IHR-RELATED HAZARDS AND POINTS OF ENTRY 46 Points of entry------------------------------------------------------------------------------------------------------46 Chemical events----------------------------------------------------------------------------------------------------48 Radiation emergencies--------------------------------------------------------------------------------------------50 Appendix 1: JEE background-------------------------------------------------------------------------------------53 iii
ACKNOWLEDGEMENTS The Joint External Evaluation (JEE) Secretariat of the World Health Organization (WHO) 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 the Republic of Zambia for their support of and work in preparing for the JEE mission. The governments of Japan, Kenya, Nigeria, Sierra Leone, Sweden and Tanzania for providing technical experts for the peer review process. The Nigerian Centre for Disease Control, the Public Health Agency of Sweden, The World Organisation for Animal Health (OIE) and Japan International Corporation Agency for their contribution of experts and expertise. The government of Germany for their financial support to this mission. The following WHO entities: country offices of Ghana, Nigeria, and Zambia, WHO Regional Office for Africa, Country Health Emergencies Preparedness and IHR Department of WHO headquarters. Global Health Security Agenda Initiative for their collaboration and support. of IHR Core Capacities of the the Republic of Zambia v
Joint External Evaluation Abbreviations AEFI Adverse Effects Following Immunization CDC United States Centres for disease control and prevention DMMU Disaster Management Mitigation Unit EPI Expanded Programme for Immunization EPR Emergency Preparedness & Response FETP Field Epidemiology Training Programme GAP Global Action Plan GHS Global Harmonised System GLASS Global Antimicrobial Resistance Surveillance System IAEA International Atomic Energy Agency IDSR Integrated Disease surveillance & Response IHR International Health Regulations (2005) IPC Infection Prevention & Control MCM Medical Counter Measures MOF Ministry of Finance MOFL Ministry of Fisheries & Livestock MOH Ministry of Health MOU Memorandum of Understanding NAP National Action Plan NEPPC&MC National Epidemic Preparedness, Prevention, Control and Management Committees NGO Non-Government Organisation OIE The World Organisation for Animal Health PHA Public Health Act PHC Primary Health Care PHEIC Public Health Emergency of International Concern PHEOC Public Health Emergency Operation Centre RPA Radiation Protection Authority SADC Southern African Development Community SBCC Social & Behaviour Change Communication SOP Standard Operating Procedures TDG Transportation of Dangerous Goods TWG Technical Working Group UNZA University of Zambia UTH University Teaching Hospital VS Veterinary Sector ZEMA Zambia Environmental Management Agency ZNPHI Zambia National Public Health Institute vi
Executive summary Findings from the joint external evaluation The Republic of Zambia is in the southern part of the African continent and is surrounded by 8 other countries; Tanzania, Democratic Republic of Congo, Malawi, Mozambique, Zimbabwe, Botswana, Namibia, and Angola, giving it a vast responsibility for border control. The country is divided into 10 provinces which are predominantly rural and 110 districts. Its population was estimated to be 15 million in the 2010 census. The overall responsibility for the coordination and management of the health sector lies with the Ministry of Health (MOH). The sector is coordinated through the national, provincial, district and community level which facilitates and maintains the link between the various communities and the health system. of IHR Core Capacities of the the Republic of Zambia Technical presentations led by the MoH were given by the multi-sectoral Zambian team focusing on the selfassessment they had conducted, followed by a joint multisectoral discussion. The joint recommendations that followed were the result of this process, supported with various field visits. Overarching issues and priority recommendations: Several overarching themes emerged during the evaluation process. Legislation, Guidelines, and Formalised Systems: Although there are several laws in operation such as the Public Health Act 1995 and the Food and Drug Act 2007, they do not effectively accommodate the requirement of the International Health Regulations (2005) (IHR) or the standards of the World Organisation for Animal Health (OIE). In Food Safety, there was a requirement for the new law to bring the food processing functions from farm to fork in line with the IHR (2005) and to include the veterinary services and all other relevant ministries to ensure a multisectoral approach. Similar observations were made in other technical areas. They included the need for Zambia to finalize its multi-hazard health emergency preparedness and response plan and other plans that were still in draft form. Also recommended was the legalisation of the neighbourhood health committees to boost health education at the community level and formalized relevant agreements regarding public health emergencies with neighbouring countries. The finalization of the national nuclear and Radiological Emergency Preparedness Response Plan and the National Nuclear Policy was also recommended. In other areas, it was suggested by the experts that Zambia creates plans and strategies, for example, for the control and prevention of zoonotic diseases, and the uncontrolled use of antimicrobials in both human and animal health. Other recommendations from the team of experts was for the inclusion of some of the current structures such as the National Epidemic Preparedness, Prevention, Control and Management Committee (NEPPC&MC) to be formally adopted in the Public Health Act currently being reviewed and National Action Plans for designated Points of Entries. However, Zambia is making steady progress in the legislative process to pass the Public Health Act and the Food and Drug Act. It is expected that these new pieces of legislation will bring about the coordination, strengthening, and the clarification of the roles and responsibilities of the various agencies under the banner of a One Health approach. Collaboration and Information Sharing The need for collaboration and sharing of information with other stake holders and Ministries was emphasized during the evaluation. The absence of linkages created missed opportunities for joint working and systems that would assist in bringing about a One Health approach to encourage, extend, and facilitate interaction. Although guidelines and systems existed in some areas, these were not shared with the relevant stakeholders and dialogue between the different sectors was sub-optimal. Some of the areas highlighted included: 1
2Joint External Evaluation 1) Strengthening multisectoral coordination to enhance information sharing among stakeholders involved in Emergency Response. 2) A One Health approach in the testing of diseases and their surveillance that will incorporate private laboratories. 3) Coordination for chemical safety between different relevant government agencies. 4) The establishment of protocols and Standard Operating Procedures (SOPs) between the various entities including health, defence, security, law enforcement and international organisations in Public Health and Security including the National IHR Focal Point (NFP). 5) Creation of an All Hazard Public Risk Communication Plan to be shared with all sectors for effective synchronization and collaboration. It is important not only to create these systems but to ensure that they are shared and effectively operated in order for them not to become fragmented and uncoordinated. Closely aligned to this will be the missed opportunities for joint training exercises which facilitate the sharing of knowledge and expertise within the various sectors. Here, the experts stressed the importance of an inclusive One Health approach that must fully embrace the animal and environmental health sectors and strengthen the NFP to enable proper coordination and reporting to all relevant stakeholders. The Directors and Ministries Response: The way forward for Zambia In looking forward however, Zambia should be extremely proud of its workforce. The total commitment and dedication of the national experts to the evaluation process was evident in the clear and informative presentations and the discussions that ensured with the external team. The staff on the ground who were encountered during the field visits were also noted to be passionate in carrying out their various duties. The MOH and the various Directors in their closing summaries were open and accommodating and fully embraced the results of the JEE; seeing it as a process that can only aid Zambia s progress in fully meeting its IHR (2005) responsibilities. It is an exciting time for Zambia as it embarks on major changes which include the revision and finalization of the Public Health Act and the Animal Health Act and the amendment to the Disaster Management Act and the Food and Drug Act 2007. The experts, through the joint evaluation process and in collaboration with the presenters have provided some direction in terms of the gaps that should be filled. Another arm of change is the current overhaul of the health sector, focusing on health promotion, disease prevention and rehabilitative services. The Zambian National Public Health Institute (ZNPHI) performs all functions pertaining to disease surveillance, intelligence, and epidemic preparedness. With a national budget, it is well placed to improve the surveillance capacity and is committed to a timelier and better documented data that will facilitate the sharing of information and good channels of communication. The Director of Health acknowledged that this channel of communication needs to be widely extended to be all-encompassing and it was stated that the imminent Public Health Act will bring together all the different ministries and coordinate roles and responsibilities. The limited resources of those on the ground will be appraised and issues around inadequate facilities will be addressed and working environments improved. The animal sector was equally aware of the gaps in collaboration with the human sector and the director very much hoped that the priority actions jointly agreed will assist Zambia to focus on working more collaboratively with other sectors. In summary, Zambia is rising to the challenges it faces with the current developments in the country. A multihazard National Action Plan for Health Security building on the JEE and other past assessments will help to channel resources from the government and partners to address gaps identified. This, in addition with adequate and relevant training of the workforce, essential guidelines and procedures and the realization of plans and legislation currently in the draft stage will set the scene for delivering the requirements of the IHR (2005) in a One Health perspective.
Republic of Zambia scores Technical areas Indicators Score National legislation, policy and financing IHR coordination, communication and advocacy Antimicrobial resistance Zoonotic diseases Food safety Biosafety and biosecurity Immunization National laboratory system Real-time surveillance Reporting Workforce development P.1.1 Legislation, laws, regulations, administrative requirements, policies, or other government instruments in place are sufficient for implementation of IHR (2005) 2 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) 2 P.2.1 A functional mechanism is established for the coordination and integration of relevant sectors in the implementation of IHR 1 P.3.1 Antimicrobial resistance detection 4 P.3.2 Surveillance of infections caused by antimicrobial-resistant pathogens 4 P.3.3 Health care-associated infection (HCAI) prevention and control programmes 3 P.3.4 Antimicrobial stewardship activities 3 P.4.1 Surveillance systems in place for priority zoonotic diseases/pathogens 3 P.4.2 Veterinary or animal health workforce 4 P.4.3 Mechanisms for responding to infectious and potential zoonotic diseases are established and functional 1 P.5.1 Mechanisms for multisectoral collaboration are established to ensure rapid response to food safety emergencies and outbreaks of foodborne diseases 2 P.6.1 Whole-of-government biosafety and biosecurity system is in place for human, animal and agriculture facilities 2 P.6.2 Biosafety and biosecurity training and practices 1 P.7.1 Vaccine coverage (measles) as part of national programme 4 P.7.2 National vaccine access and delivery 4 D.1.1 Laboratory testing for detection of priority diseases 4 D.1.2 Specimen referral and transport system 2 D.1.3 Effective modern point-of-care and laboratory-based diagnostics 3 D.1.4 Laboratory quality system 3 D.2.1 Indicator- and event-based surveillance systems 3 D.2.2 Interoperable, interconnected, electronic real-time reporting system 2 D.2.3 Integration and analysis of surveillance data 3 D.2.4 Syndromic surveillance systems 3 D.3.1 System for efficient reporting to FAO, OIE and WHO 2 D.3.2 Reporting network and protocols in country 2 D.4.1 Human resources available to implement IHR core capacity requirements 3 D.4.2 FETP 1 or other applied epidemiology training programme in place 3 D.4.3 Workforce strategy 2 of IHR Core Capacities of the the Republic of Zambia 1 FETP: Field epidemiology training programme 3
4Joint External Evaluation Technical areas Indicators Score Preparedness Emergency response operations Linking public health and security authorities Medical countermeasures and personnel deployment Risk communication Points of entry Chemical events Radiation emergencies R.1.1 National multi-hazard public health emergency preparedness and response plan is developed and implemented 1 R.1.2 Priority public health risks and resources are mapped and utilized 1 R.2.1 Capacity to activate emergency operations 2 R.2.2 EOC operating procedures and plans 1 R.2.3 Emergency operations programme 1 R.2.4 Case management procedures implemented for IHR relevant hazards. 2 R.3.1 Public health and security authorities (e.g. law enforcement, border control, customs) are linked during a suspect or confirmed biological event 1 R.4.1 System in place for sending and receiving medical countermeasures during a public health emergency 1 R.4.2 System in place for sending and receiving health personnel during a public health emergency 1 R.5.1 Risk communication systems (plans, mechanisms, etc.) 2 R.5.2 Internal and partner communication and coordination 3 R.5.3 Public communication 4 R.5.4 Communication engagement with affected communities 3 R.5.5 Dynamic listening and rumour management 4 PoE.1 Routine capacities established at points of entry 1 PoE.2 Effective public health response at points of entry 1 CE.1 Mechanisms established and functioning for detecting and responding to chemical events or emergencies 2 CE.2 Enabling environment in place for management of chemical events 3 RE.1 Mechanisms established and functioning for detecting and responding to radiological and nuclear emergencies 2 RE.2 Enabling environment in place for management of radiation emergencies 2 Scores: 1=No capacity; 2=Limited capacity; 3=Developed capacity; 4=Demonstrated capacity; 5=Sustainable capacity.
PREVENT National legislation, policy and financing Introduction The International Health Regulations (IHR) (2005) provide obligations and rights for States Parties. In some States Parties, implementation of the IHR (2005) may require new or modified legislation. Even if a new or revised legislation may not be specifically required, states may still choose to revise some regulations or other instruments in order to facilitate IHR implementation and maintenance in a more effective manner. Implementing legislation could serve to institutionalize and strengthen the role of IHR (2005) and operations within the State Party. It can also facilitate coordination among the different entities involved in their implementation. See detailed guidance on IHR (2005) implementation in national legislation at http://www.who.int/ihr/legal_issues/legislation/en/index.html. In addition, policies that identify national structures and responsibilities as well as the allocation of adequate financial resources are also important. of IHR Core Capacities of the Republic of Zambia PREVENT Target Adequate legal framework for States Parties to support and enable the implementation of all their obligations, and rights to comply with and implement the IHR (2005). New or modified legislation in some States Parties for implementation of the IHR (2005). Where new or revised legislation may not be specifically required under the State Party s legal system, States may revise some legislation, regulations or other instruments in order to facilitate their implementation and maintenance in a more efficient, effective or beneficial manner. States Parties ensure provision of adequate funding for IHR implementation through the national budget or other mechanism. Zambia level of capabilities Zambia has a Public Health Act (PHA) of 1995 which has the objective of addressing disease prevention and public health surveillance and response. The Food and Drugs Act 2007, addresses consumer protection against hazards and frauds in the sale of food. The Disaster Management Act outlines the implementation of multisector disaster and emergency responses coordinated by the Office of the Vice President. The country is implementing the Integrated Disease Surveillance and response (IDSR) strategy in the identification of diseases, reporting, assessment, response, monitoring and evaluation of priority diseases, conditions, and events. Other relevant legislation includes Environmental Management Act of 2011, the Animal Health Act of 2010 and the Zambia Wildlife Act of 1998. Under the strong coordination mechanisms under the Southern African Development Community (SADC) Regional Collaborative Centre, a Memorandum of Understanding (MoU) for communicable diseases was signed in May 2011 with neighbouring countries namely Angola, Namibia, the Democratic Republic of Congo (DRC), Congo and Zambia. There is also an arrangement between DRC and Zambia to exchange information on public health emergencies for the prevention and control of Public Health Emergencies of International Concern (PHEICs). An assessment of both the Public Health Act and the Food and Drugs Act was undertaken with a key recommendation being the need to review the PHA to incorporate IHR (2005). The review process is underway with issues of IHR co-ordination, the NFP and capacity strengthening in areas such as points of entry being incorporated in the revised PHA which is currently in draft form. 5
PREVENT 6Joint External Evaluation Recommendations for priority actions Finalize the revision of the Public Health Act and Food and Drug Act to take into consideration the provision of the IHR. Finalize agreements/protocols on IHR coordination among various government ministries and partners. Document and finalize agreements, protocols, or MOUs with neighbouring countries regarding public health emergencies. Develop SOPs to support implementation of IHR (2005) including provisions for resources. Indicators and scores P.1.1 Legislation, laws, regulations, administrative requirements, policies or other government instruments in place are sufficient for implementation of IHR (2005) Score 2 Zambia is a signatory to IHR (2005) and is implementing the IDSR strategy down to the lower levels of the health care system. Various forms of legislation related to public health are in existence. There is strong political will to address gaps in the existing PHA including the inadequate legislation covering IHR (2005). This is obvious in the ongoing revision of the PHA which has been multisectoral, drawing participants from Human and Animal Health, Environment, and Food Safety. The proposed establishment of the ZNPHI which will have the legal mandate to coordinate disease prevention, control and response activities also shows commitment to strengthen public health structures. There is a need to complete the legal processes involved in the passing of the revised PHA to incorporate IHR 2005 as soon as possible since the process has been protracted. Current collaborations between government agencies are largely informal and are not backed by formal institutionalized arrangements and memorandum of understanding. Formal agreements with neighbouring countries on public health emergencies are still inadequate for collaborative approach for disease prevention and control across the region. P.1.2 The State can demonstrate that it has adjusted and aligned its domestic legislation, policies and administrative arrangements to enable compliance with the IHR (2005) Score 2 The National Focal Point (NFP) for IHR has been identified within the MOH to communicate notifications and information to WHO and other stakeholders. Plans are underway to address human resource gaps such as the institutionalization of port health staff at Points of Entry. A clear structure outlining the roles and responsibilities for IHR coordination and consistent resources to enable adequate functioning of the IHR national focal point (NFP) to adequately discharge expected duties are outstanding. Modalities to incorporate staff such as those for port health in the human resource structure in compliance with IHR (2005) are not yet in place. MoH (2015) IHR (2005) Implementation Plan, Lusaka.
IHR coordination, communication and advocacy Introduction The effective implementation of the IHR requires multisectoral/multidisciplinary approaches through national partnerships for efficient and alert response systems. Coordination of nationwide resources, including the designation of a national IHR focal point, which is a national centre for IHR communications, is a key requisite for IHR implementation. of IHR Core Capacities of the Republic of Zambia Target Multisectoral/multidisciplinary approaches through national partnerships that allow efficient, alert and responsive systems for effective implementation of the IHR (2005). Coordinate nationwide resources, including sustainable functioning of a national IHR focal point a national centre for IHR (2005) communications which is a key requisite for IHR (2005) implementation that is accessible at all times. States Parties provide WHO with contact details of national IHR focal points, continuously update and annually confirm them. PREVENT Zambia level of capabilities The National IHR Focal Point (NFP) is designated at Ministry of Health in the Department of Health Promotion, Environment, and Social Determinants. Stakeholders have been identified but not formally appointed. The general terms of reference for the IHR coordination committee (technical working group (TWG)) have been developed but SOPs for the coordination, communication, and advocacy for smooth operation of the NFP are yet to be put in place. An IHR plan (2013-2015) was developed and implemented. There is a multi-sectoral, multidisciplinary body, epidemic and response committee, the NEPPC&MC addressing IHR requirements on surveillance and response for public health emergencies of national and international concern. This Committee participated in the response to the cholera outbreak in 2016 and 2017. Some members are ad hoc and participate in meetings as and when relevant. The frequency of NEPPC&MC meetings depends on whether there is an ongoing public health event. Outside these meetings, there is no formal mechanism for systematic information sharing / communication between relevant sectors. Recommendations for priority actions Develop terms of reference that define the roles and responsibilities of NFP and IHR TWG. Develop relevant SOPs for communication and coordination between the NFP and identified sectors, WHO and OIE. Establish a One Health platform where all stakeholders are represented for proper coordination of IHR activities. Conduct simulation exercises to test the coordination and communication mechanism between the NFP and stakeholders including WHO, and OIE. Build capacity of IHR NFP and focal persons of identified sectors to facilitate IHR implementation. 7
PREVENT 8Joint External Evaluation Indicators and scores P.2.1 A functional mechanism established for the coordination and integration of relevant sectors in the implementation of IHR Score 1 Note: While the NEPPC&MC is in place, it does not serve as the formal mechanism for IHR coordination, communication and advocacy with consistent participation of all relevant ministries. Technical committee for IHR is established although not formalized; and ministries have been requested to submit their focal people. Some focal people from stakeholders are appointed. The process is on-going. Even though not formalized, the NFP is linked to other stakeholders. Availability of IHR plan which was implemented (2013-2015). Coordination and communication between NFP and other sectors (One Health Platform) including IHR contact point and Headquarters. Institutionalization of IHR TWG / Coordinating Committee. Defining roles and responsibilities of each sector in the IHR TWG / Coordinating Committee. SOPs for communication and coordination between NFP and identified sectors.
Antimicrobial resistance Introduction Bacteria and other microbes evolve in response to their environment and inevitably develop mechanisms to resist being killed by antimicrobial agents. For many decades, the problem was manageable as the growth of resistance was slow and the pharmaceutical industry continued to create new antibiotics. of IHR Core Capacities of the Republic of Zambia Over the past decade, however, this problem has become a crisis. Antimicrobial resistance is evolving at an alarming rate and is outpacing the development of new countermeasures capable of thwarting infections in humans. This situation threatens patient care, economic growth, public health, agriculture, economic security and national security. Target Support work coordinated by FAO, OIE and WHO to develop an integrated global package of activities to combat antimicrobial resistance, spanning human, animal, agricultural, food and environmental aspects (i.e. a One Health approach). Each country has: (i) its own national comprehensive plan to combat antimicrobial resistance; (ii) strengthened surveillance and laboratory capacity at the national and international levels following international standards developed as per the framework of the Global Action Plan; and (iii) improved conservation of existing treatments and collaboration to support the sustainable development of new antibiotics, alternative treatments, preventive measures and rapid point-of-care diagnostics, including systems to preserve new antibiotics. PREVENT Zambia level of capabilities In 2017 Zambia produced a Multisectoral National Action Plan (NAP) on antimicrobial resistance. The plan was developed by a multidisciplinary team with representatives from human health, agriculture, the environmental sector, academia, regulatory bodies, civil society, planning and finance authorities. The NAP follows the five strategic objectives outlined in the WHO Global Action Plan. Zambia enrolled in the WHO Global Antimicrobial Resistance Surveillance System (GLASS) in 2016. GLASS encourages countries to enrol even if they have only a single surveillance site that can provide good quality data. All the priority pathogens recommended by the GLASS can be tested in a single surveillance site, the University Teaching Hospital (UTH). This site participates in a proficiency testing programme organized by WHO (AFRO). In addition to UTH, the Chest Diseases Laboratory also performs susceptibility testing on isolates from cases of tuberculosis. GLASS will initially collect data from isolates from humans but will later expand to collect data from isolates from animals. In the animal health sector, antimicrobial susceptibility testing is done at the University of Zambia School of Veterinary Medicine and Central Veterinary Research Institute. The Ministry of Health/ National Public Health Institute is currently assessing laboratory capacity to perform antibacterial susceptibility testing. This assessment is expected to be completed by September 2017. The plan is to use the findings of the assessment to increase the number of sites conducting AMR surveillance with the goal of having at least one site in each of the 10 provinces. The current version of the national Infection Prevention and Control Guidelines was produced in 2016. Topics related to antimicrobial stewardship are addressed in the NAP. There are national treatment guidelines which encourage the use of appropriate agents. Although there are laws regulating access to 9
Joint External Evaluation antimicrobials these are not always enforced and unregulated access to antimicrobials in human health and animal health sectors remains a problem. Recommendations for priority actions Improve human resources and infrastructure to boost laboratory capacity for AMR testing for both human and animal health. Strengthen quality management systems in the laboratories performing antibacterial susceptibility testing in the human and animal health sectors. Set up more surveillance sites for AMR and strengthen the AMR surveillance system for human and animal health. Improve awareness of the importance of appropriate use of antimicrobials among health care workers, veterinary workforce, and the public. PREVENT Promote the implementation of Infection Prevention and Control (IPC) guidelines in healthcare facilities. Indicators and scores P.3.1 Antimicrobial resistance detection Score 4 There is strong political commitment to address the challenge of antimicrobial resistance. The multisectoral National Action Plan has been produced. There is capacity at the University Teaching Hospital to test all the pathogens identified in the GLASS. National laboratories performing susceptibility testing are participating in external quality assessment schemes. The ability to perform antibacterial susceptibility testing is not widespread. Reagent shortages can limit the availability of testing. There is a lack of appropriately trained staff to perform susceptibility testing at subnational level. P.3.2 Surveillance of infections caused by antimicrobial-resistant pathogens Score 4 Zambia has enrolled in the WHO GLASS and will be reporting susceptibility data for the full range of pathogens requested by GLASS. The surveillance site has already been collecting data on resistance rates for many years. The Ministry of Health is already planning to enroll additional surveillance sites as capability improves. Lack of human resources, equipment and reagents is limiting the number of surveillance sites. There is limited data availability on antimicrobial consumption. 10
P.3.3 Health care-associated infection (HCAI) prevention and control programmes Score 3 Revised National Infection Prevention and Control (IPC) guidelines have been produced. A national IPC policy, operational plan, and SOPs are available. Most health facilities have a functional IPC committee. Enforcement of IPC policies are not universal. of IHR Core Capacities of the Republic of Zambia Increase in awareness of the importance of IPC among health care workers and the community. Strengthening the system for monitoring health care associated infections. P.3.4 Antimicrobial stewardship activities Score 3 Relevant topics are addressed in the multisectoral NAP. There is national guidance on appropriate use of antibiotics. PREVENT Antimicrobial stewardship assessments of patterns of antibiotic use are conducted in some facilities. There is insufficient awareness in the country on the appropriate use of antimicrobials. Laws regulating access to antimicrobials are not effectively enforced. There is a need for more research to better inform treatment guidelines. 11
Joint External Evaluation Zoonotic diseases Introduction Zoonotic diseases are communicable diseases that can spread between animals and humans. These diseases are caused by viruses, bacteria, parasites and fungi carried by animals, insects or inanimate vectors that aid in its transmission. Approximately 75% of recently emerging infectious diseases affecting humans is of animal origin; and approximately 60% of all human pathogens are zoonotic. PREVENT Target Adopted measured behaviors, policies and/or practices that minimize the transmission of zoonotic diseases from animals into human populations. Zambia level of capabilities Studies have estimated that at least six out of every ten emerging diseases are zoonotic in nature with the majority of these pathogens originating from wildlife hosts. Drivers of infectious disease emergence include abundance of wildlife, population growth, change in land use and climate change. Most, if not all of these drivers are present in Zambia. The country has a significant population of livestock, keeping communities that live in close proximity to wildlife, facilitating a human-livestock-wildlife interface that predisposes humans and livestock to zoonotic infections. Zambia has in the recent past experienced a number of zoonotic disease outbreaks. These include anthrax in Western and Eastern provinces, zoonotic plague in Eastern and Southern provinces, Lujo virus disease, salmonella, rabies and human trypanosomiasis. The country also bears a significant endemic zoonotic disease burden from neglected zoonotic diseases like brucellosis and cysticercosis. The true burden and socio-economic impact of zoonotic diseases is however unknown. This is because of weak surveillance of zoonotic diseases characterised by underreporting and inadequate laboratory capacity especially in the animal health sector. The animal health sector reports zoonotic diseases on immediate and monthly basis through a Ministry of Livestock and Fisheries system while public health system reports zoonotic diseases on immediate and weekly basis through the Integrated Disease Surveillance and Response (IDSR) platform. In addition to indicator-based surveillance, the public health system has a syndromic surveillance system (based on the IDSR platform). The animal health system does not have syndromic surveillance in place. Both structures do not have an event based surveillance system. Anthrax, Plague, Lujo virus disease, Salmonella, Rabies, trypanosomiasis and Bovine tuberculosis are identified as the priority zoonotic diseases. However, the priority list was not developed through a collaborative decisionmaking process. The country does not have a formal One Health coordinating structure or guidelines on One Health implementation but there is a pilot One-Health initiative at national level. Recommendations for priority actions Develop a strategic plan for zoonotic disease control and prevention which should include a priority zoonotic disease list developed using a multisectoral decision-making process. Carry out laboratory capacity assessment to guide the strengthening of diagnostic capacity for prioritized zoonotic diseases at national and sub-national levels. 12
Evaluate and strengthen the existing surveillance system attributes to improve surveillance for priority zoonotic diseases. Carry out a human resource needs assessment for the veterinary workforce to identify human resource gaps. Establish a formal One Health platform to coordinate implementation of One Health including the prevention and control of zoonotic disease. Indicators and scores of IHR Core Capacities of the Republic of Zambia P.4.1 Surveillance systems in place for priority zoonotic diseases/pathogens Score 3 Both public and veterinary health sectors have an indicator based surveillance system that collects zoonotic disease data. Some of the priority zoonotic diseases are under surveillance in IDSR platform in the Ministry of Health and under the Ministry of Livestock and Fisheries system for the veterinary sector. Existence of a National Epidemic, Preparedness, Prevention, Control, and Management Committee that provides a platform for data sharing. There is a provisional list of priority zoonotic diseases that guides resource allocation in the animal health sector. PREVENT There is a need to establish a formal zoonotic data sharing mechanism. The mechanism will lay out guidelines for sharing of surveillance and laboratory data. Data quality, timeliness and reporting rates are some of the surveillance attributes that were reported to perform sub-optimally. There is immediate need to evaluate the existing public health and veterinary sector zoonotic disease surveillance system to identify gaps and weaknesses in zoonotic disease surveillance. Improve laboratory diagnosis for zoonotic diseases both in human and animal health sectors. P.4.2 Veterinary or animal health workforce Score 4 The country has a graduate veterinary school and a number of diploma level animal health worker training institutions. Deployment of veterinarians to at-least 70% of all camps (smallest administrative units). University of Zambia is offering a OH graduate course. Zambia has a Field Epidemiology and Training Programme. There is a need to map the animal health human resource in Zambia to identify any possible gaps in deployment of animal health workers. An urgent need exists to include veterinarians in the Field Epidemiology training Programme (FETP) programme. Develop structured on-job training programme on IHR and OIE PVS (Performance of Veterinary Services) for the animal health workforce. 13
Joint External Evaluation P.4.3 Mechanisms for responding to infectious and potential zoonotic diseases established and functional Score 1 There has been joint response for a number of zoonotic disease outbreaks in the recent past. However, there are no formal guidelines or protocols for joint response. National Epidemic, Preparedness, Prevention, Control, and Management Committee provides a platform for multisectoral coordination. There is a need to establish a formal legal platform to coordinate agencies and the different levels of government involved in zoonotic event response. There is need to immediately develop zoonotic data sharing SOPs at national and sub-national level. PREVENT Establish a continuous education programme on surveillance and zoonotic event outbreak response for public health and veterinary sector staff at all levels. There are no joint contingency plans for any zoonotic disease. Development of joint animal and human health contingency plans for at-least 4 top zoonotic diseases is a priority. 14
Food safety Introduction Food- and water-borne diarrhoeal diseases are leading causes of illness and death, particularly in less developed countries. The rapid globalization of food production and trade has increased the potential likelihood of international incidents involving contaminated food. The identification of the source of an outbreak and its containment is critical for control. Risk management capacity with regard to control throughout the food chain continuum must be developed. If epidemiological analysis identifies food as the source of an event, based on a risk assessment, suitable risk management options that ensure the prevention of human cases (or further cases) need to be put in place. of IHR Core Capacities of the Republic of Zambia Target Surveillance and response capacity among States Parties for food- and water-borne disease risks or events by strengthening effective communication and collaboration among the sectors responsible for food safety, and safe water and sanitation. PREVENT Zambia level of capabilities Several internal and external assessments of the food control system have been conducted in Zambia over the past years, including one by the Food and Agriculture Organization (FAO) in 2012 and the OIE PVS Evaluation in 2008. This JEE process also provided the opportunity to make a rapid assessment of the situation through information sharing with agencies in charge and through site visits in Livingstone and Kuzungula districts. Food safety is mainly under the mandate of the MoH. However, food safety controls are delegated to Local Government Authorities staffed with health inspectors. The Ministry of Fisheries and Livestock (MOFL) and the Ministry of Agriculture (MOA) are responsible for food safety related to primary production and the import of food. The field visit conducted in Livingstone and Kuzungula districts found that: The unlimited access by farmers to all veterinary medicines at pharmacies implies that most local food of animal origin (egg, milk, and meat) are likely to contain chemical residues at levels higher than the Maximal Residue Limits set by the Codex Alimentarius Commission. There is weak collaboration between district veterinary officers and counci food inspectors. There is limited ante and post-mortem inspection of animals slaughtered (apart from one small-scale cattle slaughterhouse for which inspection was conducted by an experienced veterinary assistant). There was limited on-farm inspection in relation to primary production food safety, and an absence of procedures for the control of imported food. The country is facing challenges to reach the main objectives of national food control systems, i.e. protecting public health by reducing the risk of foodborne illness and contributing to economic development by maintaining consumer confidence in the food system (both for domestic and international trade). Introducing reforms aimed at modifying the systems from a top-down manner and to cover the entire country may be faced with challenges because of the current complex situation. It is therefore proposed that a reform be designed and implemented in a pilot territory (e.g. one province or one district). Such a reform 15
Joint External Evaluation will need to be very carefully designed with involvement of all concerned parties (both public agencies and private stakeholders) and with some short-term international expertise. The selected province(s) for this pilot could be those where the demand for higher standards exists (e.g. areas with international tourism). Recommendations for priority actions Establish or strengthen a food safety platform comprising of the veterinary sector and other food safety stakeholders. Design, implement, monitor, and evaluate a National Food Control System as per international guidelines. Finalize the Food Safety Act and the Food Safety Strategy and develop implementing rules and SOPs according to the new strategy. Obtain validation for the Food Safety Strategy from the concerned ministries. PREVENT Produce, implement, and evaluate action plans, related to specific food safety aspects (e.g. residue, meat, hygiene). Include food borne events into the Health Management Information System (HMIS). Indicators and scores P.5.1 Mechanisms for multisectoral collaboration established to ensure rapid response to food safety emergencies and outbreaks of foodborne diseases Score 2 Availability of legislation, some guidelines, and standards. Availability of laboratories and competences (FDL, Central Veterinary Research Institute, National Institute for Scientific & Industrial Research, University of Zambia, Zambia Bureau of Standards). Availability of Food Safety Focal Points and committees (INFOSAN, Codex, OIE, International Plant Protection Convention). Some collaboration through established committees at central level. Availability of some skilled human resources at all levels. Availability of a local training programme in Food Safety MSc One Health Food Safety. Adoption of the One Health concept. Application of Good Manufacturing Practices ( GMP) (Hazard analysis and critical control points (HACCP) and Good Agricultural practices) by some food industries. Certification for conformity of Food Business Operators. Food safety audits through qualified auditors. Inter and intra laboratory testing. Proficiency testing. Inspections and monitoring of foods. Export of honey to Europe and preparation to export of goat meat to Saudi Arabia. 16