Joint External Evaluation of IHR Core Capacities of the Republic of Armenia

Mission report: 15–19 August 2016

WHO/WHE/CPI/2017.13

Joint External Evaluation of IHR Core Capacities of the Republic of Armenia

Mission report: 15–19 August 2016 WHO/WHE/CPI/2017.14

© World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules). Suggested citation. Joint External Evaluation of IHR Core Capacities of the Republic of Armenia. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design and layout by Jean-Claude Fattier Printed by the WHO Document Production Services, Geneva, Switzerland ACKNOWLEDGEMENTS

The WHO JEE Secretariat would like to acknowledge the following, whose support and commitment to the principles of the International Health Regulations (2005) have ensured a successful outcome to this JEE mission: • The Government and national experts of the Republic of Armenia for their support of, and work in, preparing for the JEE mission. • The governments of Finland, Germany, Sweden and the United Kingdom for providing technical experts for the peer review process. • The Food and Agriculture Organization of the United Nations (FAO), the World Organisation for Animal Health (OIE), for their contribution of experts and expertise. • The governments of Germany and Finland for their financial support to this mission. • The following WHO entities: WHO Country Office of Armenia, Regional office of Europe, Regional Office for the Eastern Mediterranean. • Global Health Security Agenda for their collaboration and support.

Contents

Executive Summary ------1 The Republic of Armenia Scores------4 PREVENT—————————————————————————— 6 National legislation, policy and financing------6 IHR coordination, communication and advocacy------8 Antimicrobial resistance------10 Zoonotic diseases------13 Food safety------16 Biosafety and biosecurity------18 Immunization------20 DETECT————————————————————————— 23 National laboratory system------23 Real-time surveillance------25 Reporting------28 Workforce development------30 RESPOND ———————————————————————— 32 Preparedness------32 Emergency response operations------34 Linking public health and security authorities------37 Medical countermeasures and personnel deployment------39 Risk communication------41 OTHER IHR-RELATED HAZARDS AND POINTS OF ENTRY—————— 45 Points of entry ------45 Chemical events------48 Radiation Emergencies------50

Appendix 1: Joint External Evaluation Background------52 Abbreviations

AET Applied Epidemiology Training (Cambodia’s version of mFETP) APSED Asia Pacific Strategy for Emerging Diseases AFRIMS Armed Forces Research Institute of Medical Sciences AMR Antimicrobial Resistance CamEWARN Cambodia early warning surveillance system CamLIS Cambodia Laboratory Information System CBRN Combined Joint Chemical, Biological, Radiological, and Nuclear CDC Department of Communicable Diseases Control, Ministry of Health DHS Department of Hospital Service EBS Event-based Surveillance EOC Emergency Operations Centre EQA External Quality Assurance EVD Ebola Virus Disease FAO Food and Agricultural Organization of the United Nations GHSA Global Health Security Agenda IBS Indicator-based Surveillance IHR (2005) International Health Regulations (2005) IPC Infection Prevention and Control IMS Incident Management System JEE Joint External Evaluation OIE World Organisation for Animal Health MERS Middle East respiratory syndrome mFETP modified Field Epidemiology Training NAMRU II Naval Medical Research Unit II NFP National IHR Focal Point PoE Points of Entry RRT Rapid Response Team SNRA Strategic National Risk Assessment SOPs Standard Operation Procedures THIRA Threat and Hazard Identification and Risk Assessment TWG Technical Working Group USAID United States Agency for International Development USCDC United States Centers for Disease Control and Prevention WHO World Health Organization

• • • • • Findings from theJEE Yerevan, Armenia, on19 August 2016. preparedness totheDeputyMinisterofHealth, SergeyKhachatryan attheMinistry ofHealth(MoH)in The entireteampresentedtheresultsofassessmentandobservations ofthe Armenia’s healthsecurity verbally bythenationalteamduringdiscussions. English, andthereforesomeoftheconclusionsassessmentarebasedoninformationprovided to the timescales involved onlyasmallnumber of thesupportingdocumentationwas made available in experts (atshortnotice)whotheJEEteamwishedtointerviewaspartofassessment. However, due sectors forwhichthisexternalevaluation was relevant, aswellotherorganizationsandin-country health securityanditsalliedservicesisveryclear. The Armenian Governmentbroughttogethervarious The authoritiesin Armenia warmly welcomedtheexternalevaluation team. The country’s prioritytowards WHO. recognized technical expertise, as well as advisors representing international organizations including the The teamofexternalexpertsconsistedindividualsselectedfrompeercountriesonthebasistheir Yerevan, Armenia on15–19 August 2016jointlyby Armenian expertsandexternalsubjectmatterexperts. Health Organization(WHO)EuropeanRegionandthetenthglobally. The evaluation was carriedoutin the InternationalHealthRegulations(IHR)(2005). This isthesecondJEEprocesscompletedin World has demonstrated astrongcommitmenttoglobalhealthsecurityandcorenationalcapacitiesrequiredby By requestingajointexternalevaluation (JEE)theRepublicof Armenia (henceforthmentionedas ‘Armenia’) Background Executive summary and Prevention (NCDC)/MoH. Prevention and (SFSS) Service andSecurity public from the experts health National experts Center for Disease Control are investigated by multidisciplinary and multisectoral rapid response teams consisting of State Food Armenia has surveillance and response for foodborne capacity and waterborne diseases. Outbreaks zoonotic diseases in both human and animal health are in sectors place. an intersectoral taskforce for expert zoonotic diseases has been established. Surveillance systems for of Agriculture (MoA), and other relevant partiesinvolved in activities. Within the structure of the MoH The main for partners an integrated approach in the control of zoonotic diseases are the MoH, Ministry Armenia has implemented a number of activities to introduce the One Health approach in the country. practice. However, Armenia needs enhancement further within the animal sector. teaman from and expert WHO published with recommendations a report that have been turned into The human health in Armenia sector had antimicrobial its resistance capability assessed in 2012 by Government, the MoH, and those jointly issued by different line ministries. procedures (SOPs), which in turn are enacted in a number of legally binding decrees by the Armenian Coordination mechanisms the relevant between ministries are outlined in aseries of standard operating the new Public Health Law. expanded functions of the national IHR focal point to strengthen core capacities incorporated within implementation of the IHR (2005) in Armenia. National policies that are in place will facilitate core and There is pronounced political will and extensive national legislation in place tothe support 1 of IHR Core Capacities of the Republic of Armenia 2 Joint External Evaluation • • • • • • • • • • in Armenia. in engagement of communities to strengthen further the already developed risk communication system communication in Armenia is transmitted through amix of channels. There is aneed for more proactive trained spokespersons, and senior every manager has an appointed press person. Public risk included in all available emergency response plans. ministry Every has apublic relations department, Armenia does not have amulti-hazard risk communication plan, but communication procedures are security. law and enforcement the with including sectors different the between investigation of alleged deliberate use events. However, there is need for continuous joint training is in place. Armenia has agreat to link capacity public health and law enforcement, including the A legal framework for sending and receiving medical countermeasures and personnel deployment surge capacities. hours. Armeniatwo has to the activate capacity response operations including those requiring human of timeframe (EOCs)required the centres within operations emergency including operations response administrative mechanism. has The country high-level capability to activate any of the emergency Armenia has developed well avery defined emergency responsesystem involving all tiers of the annual basis, maps resources and ensures that critical stock levels are maintained. of Emergency Situations (MES) risk performs assessments and updates the national risk profile on an of scenarios, and each of these contains specific provisionspertaining to public health.The Ministry country’s implementation of IHR (2005). Emergency response plans have been prepared for avariety Preparedness is an area that receives alot of attention in Armenia, and this is astrong point in the Armenia to other countries have taken place. and multilateral agreements are in place for sending and receiving personnel, and deployments from ensuring that sufficient human resourcecapacities are in place to implement IHR (2005). Bilateral to situation inOwing the part security in the region, Armenia has dedicated to significant efforts established amongst other national ministries and the national IHR focal point. OIE focal point established within Information the MoA. sharing and coordination mechanisms are Armenia has an operational national IHR focal point located within the MoH. There is also an operational through interconnected electronic reporting of zoonotic diseases. data is not yet implemented. The human health needs to sector collaborate with the animal sector however, system; real-time reporting sharing notification of electronic interoperable, interconnected, demonstrated. The information in the human health surveillance system is processed within an indicator-based and event-based surveillance systems) tohuman detect health threats has been for human and animal health. The existence of multiple independent surveillance systems (including Armenia has developed thorough sustainable capabilities for the detection of events of significance quality managementnetwork, system and external quality assurance (EQA) scheme. legislation tothe laboratory support system, as well as introducing acomprehensive laboratory regulated by the MoH. Armenia significantly reformed their laboratoryservices aiming at developing The public health laboratory system in Armenia consists of auniversal which laboratory is network, multiyear plans are developed four every to five years. Armenia has astrong national immunization programme that in was 2005. started Comprehensive compulsory. in Armenia (including veterinary laboratories) and the licensing of laboratories needs to madebe of laboratories international accreditation regarding required is work Further officers. health public usingperformed the established inventory tool. There is abiosafety programme for managers and and transport of pathogens. Annual recording and reporting of particularly dangerous pathogens is Armenia has system agood of biosafety and biosecurity and the Government regulates storage and itsinternationalpartners. implement theidentifiedpriorityactions. This responsibilityliesequallywiththe Governmentof Armenia report shouldbeusedasastronglevertoengagepartnersintodialoguedevelopplanofaction or byacombinationofnationalmeasuresandinvestmentsupportfrominternationalpartners. This to fillsomeoftheidentifiedgapswillbeneeded. Thesecanbedonebytheexisting expertiseinthecountry there is a highwillingnessandcommitment towards meetingtheremainingIHRrequirements. Investments external evaluation teamandthenationalrepresentativesfromallrelevant sectorsitwas evidentthat In summary, Armenia is close to achieving compliance with IHR (2005). In the discussions between the • • • needs to developed be and financial resources are required to maintain current activities in the future. capacity however, laboratory national integrated staff; experienced and equipment facilitieswith care emergency response plan with SOPs, which is exercised regularly. There are some reference health Armenia has astrong history in the radiological protection field.There is a well-developed radiation registration system for chemical sites is needed. a “poisons centre” as a coordination rather than activity build a physical centre. Also, a mandatory chemical incidents and anational coordinating for body chemical safety. Armenia needs to establish aid clarity in both preparedness and response. There is apublic health plan for the management of by alegislative framework. The framework, however, is complex and a“unified chemical law” would Armenia has a developed system for surveillance and response to chemical events that is supported ensure the capacities required under the IHR. Inspectorate. Activities are underway to nominate the rest of the borderline points as entities entry to being implemented through the borderline medical-sanitary inspection points of the State Health that shares border its with Georgia. In the borderline points, the entry capacities of the MoHare IHR (2005) –the Zvartnots International in Yerevan, Airport and the Bagratashen ground crossing havetwo been officially designated for developing public healthcapacities as outlined within the Armenia has one seven rail airports, (two points of entry station and four ground crossings) of which 3 of IHR Core Capacities of the Republic of Armenia 4 Joint External Evaluation Armenia scores advocacy and communication IHR coordination, and financing legislation, policy National development Workforce Reporting surveillance Real-time system National laboratory Immunization biosecurity Biosafety and Food safety Zoonotic disease resistance Antimicrobial

Capacities evant intheimplementation sectors ofIHR(2005) P.2.1 mechanismisestablishedforthecoordination Afunctional andintegration ofrel- ment instruments inplace are sufficient forimplementation ofIHR(2005) P.1.1 Legislation, laws, regulations, administrative requirements, policiesorothergovern- D.4.1 Humanresources are available to implement IHRcore requirements capacity D.3.1 System forefficient to reporting WHO, FAO andOIE D.2.1 Indicator andevent systems basedsurveillance D.1.1 diseases testing ofpriority Laboratory fordetection P.7.1 Vaccine coverage ofnational programme (measles)aspart and agriculture facilities P.6.1 system isinplace andbiosecurity forhuman,animal biosafety Whole-of-government borne diseaseandfoodcontamination. P.5.1 andresponding fordetecting Mechanismsare to establishedandfunctioning food- P.4.1 systems zoonotic inplace Surveillance forpriority diseases/pathogens P.3.1 Antimicrobial resistance (AMR) detection D.2.2 Interoperable, interconnected, real-time electronic system reporting D.1.4 system quality Laboratory D.1.3 Effective modernpoint ofcare baseddiagnostics andlaboratory D.1.2 Specimenreferral system andtransport P.7.2 National vaccine access anddelivery P.6.2 training andpractices andbiosecurity Biosafety functional P.4.3 Mechanismsforresponding to zoonoses andpotential zoonoses are establishedand P.4.2 Veterinary oranimalhealthworkforce P.3.4 Antimicrobial stewardship activities P.3.3 Health care associated prevention infection andcontrol programmes P.3.2 causedby AMR pathogens ofinfections Surveillance policies andadministrative arrangements to enablecompliance withtheIHR(2005) P.1.2 The State candemonstrate that ithasadjusted andaligneditsdomesticlegislation, D.4.3 Workforcestrategy program inplace D.4.2 Field epidemiologytraining programme orotherappliedepidemiology training D.3.2 network andprotocols Reporting incountry D.2.4 Syndromic systems surveillance D.2.3 data Analysisof surveillance Indicators Score 5 5 5 4 4 3 3 5 5 5 5 5 5 3 3 4 5 3 4 4 4 4 4 5 5 4 4 5 emergencies Radiation eventsChemical Points ofentry Risk communication deployment and personnel countermeasures Medical authorities health andsecurity Linking public operations response Emergency Preparedness logical andnuclearemergencies andresponding fordetecting RE.1 Mechanismsare to establishedandfunctioning radio cal events oremergencies. andresponding fordetecting CE.1 Mechanismsare to establishedandfunctioning chemi- PoE.1 Routinecapacitiesare establishedat points ofentry communicationR.5.1 Risk systems (plans, mechanisms, etc.) lic healthemergency R.4.1 System isinplace forsendingandreceiving medicalcountermeasures duringapub toms) are linkedorconfirmed biologicalevent duringasuspect authorities,R.3.1 Public (e.g. healthandsecurity law enforcement, border control,- cus R.2.1 Capacityto activate operations emergency developed andimplemented R.1.1 Multi-hazard national preparedness publichealthemergency andresponse planis RE.2 Enabling environment isinplace formanagement ofradiation emergencies CE.2 Enabling environment isinplace formanagement ofchemicalevents PoE.2 Effective publichealth response at points ofentry listening andrumourmanagementR.5.5 Dynamic R.5.4 Communication engagementcommunities withaffected R.5.3 Public communication communicationR.5.2 Internal andcoordination andpartner emergency R.4.2 System isinplace forsendingandreceiving healthpersonnelduringapublic R.2.4 Case management procedures are implemented forIHRrelevant hazards operationsR.2.3 Emergency programme operationsR.2.2 Emergency center operating procedures andplans publichealthrisksandresourcesR.1.2 Priority are mappedandutilized - - 5 5 4 5 5 5 5 5 5 5 5 5 5 5 4 4 4 3 5 4 5 of IHR Core Capacities of the Republic of Armenia PREVENT 6 Joint External Evaluation States Parties should have an adequate legal framework to support and enable the implementation of of implementation the enable and support to framework legal adequate an have should Parties States well astheallocationofadequatefinancialresourcesarealsoimportant. legislation/en/index.html). Inaddition, policieswhichidentifynationalstructuresandresponsibilitiesas guidance on IHR (2005) implementation in national legislation at (http://www.who.int/ihr/legal_issues/ can alsofacilitate coordination amongthedifferent entitiesinvolvedintheirimplementation. Seedetailed serve toinstitutionalizeandstrengthentheroleofIHR(2005)operations withintheStateParty. It facilitate IHR implementation and maintenance in amore effective manner. Implementing legislation could specifically required, Statesmaystillchoosetorevisesomeregulationsorotherinstrumentsinorder of theIHR(2005)mayrequirenewormodifiedlegislation. Evenifneworrevisedlegislationmaynotbe The IHR(2005)provideobligationsandrightsforStatesParties. InsomeStatesParties, implementation Introduction andfinancing National legislation, policy PREVENT • Recommendations for priorityactions This alsoincludestheapplicationofnewapproaches, suchasthe “One Health” concept. The developmentoffurtherbilateral internationalagreementswithothercountriesneedstobestrengthened. implementation atalllevelsofthecountry. sectors and promotes the integration of legislation of different sectors within the framework of IHR (2005) within thenewPublicHealthLaw. This newPublicHealthLawaimstoharmonize legislationindifferent core andexpandedfunctionsofthenationalIHRfocalpoint andstrengthencorecapacitiesincorporated implementation oftheIHR(2005)betweensectorsin Armenia. Nationalpoliciesareinplacethatfacilitate national IHRfocalpoint, locatedintheMoH, isnowcoordinatinglegalandregulatoryframeworks forthe (2005). Armenia hasextensivenationallegislationinthecontextofIHRimplementation The designated Armenia hasattainedsustainablecapacitiesfornationallegislation, policyandfinancingtoimplementIHR Armenia levelofcapabilities Target all of their obligations and rights to comply with and implement the IHR (2005). In some States Parties, Parties, States some In (2005). IHR the implement and with comply to rights and obligations their of all implementation of the IHR (2005) may require new or modified legislation. Even where new or revised revised or new where Even legislation. modified or new require may (2005) IHR the of implementation legislation may not be specifically required under the State Party’s legal system, States may still choose choose still may States system, legal Party’s State the under required specifically be not may legislation to revise some legislation, regulations or other instruments in order to facilitate their implementation and and implementation their facilitate to order in instruments other or regulations legislation, some revise to States parties should ensure provision of adequate funding for IHR implementation through national national through implementation IHR for funding adequate of provision ensure should parties States maintenance in a more efficient, effective or beneficial manner. manner. beneficial or effective efficient, more a in maintenance budget or other mechanism. other or budget duplications. and legislative gaps identify to implementation IHR legislation for existing of reviews periodic Conduct • strengthening/challenges need that Areas • practices Strengths/best – Score 5 policies andadministrative arrangements toenablecompliancewiththeIHR(2005) P • strengthening/challenges need that Areas • • • practices Strengths/best instruments inplaceare sufficientforimplementationofIHR(2005)–Score 5 P Indicators andscores • • • .1.2 The Statecandemonstrate thatithasadjustedandaligneditsdomesticlegislation, .1.1 Legislation, laws, regulations, administrative requirements, policiesorothergovernment strengthened. This also includes the application of new approaches such as the One Health concept. The development of bilateral further international agreements with other countries needs to be websitesectorial ( jointly different between ministries. Further, all legal documents are available online on one cross- The national legislation is managed with amultidisciplinary approach, i.e. are legal developed texts emergencies. health public during response rapid facilitate informal exchanges the stakeholders. between Such an intensifiedexchange wouldsectors between horizontal formal with and interconnectionestablished different of programmes various of sectors The implementation of the One Health concept needs to developedbe and improved. This includes emergencies. health public of management the into account taking countries, Bilateral with approximately contracts 25 countries facilitate IHR (2005) implementation with these health. environmental health, animal health, human as such sectors, multiple covers (2005) IHR of implementation framework national legislationthe in existing The implementation. Extensive national legislation (with more than legal 400 texts) is in place toIHR (2005) support There is pronounced political will toIHR (2005) support implementation. strengthened. be to needs sectors other of awareness the capacities lies predominantly in the responsibility of other such as sectors, animal health or transport, rights and obligations of Armenia since 2007. the competency for As IHR implementation of some Continue to raise awareness about IHR implementation in all including sectors, in relation to the level. national regional legislation of at implementation the for SOPs Develop adoption of this key legal document in the whole country. of legislation of and different different sectors levels. Therefore, it is recommended to promote the theExpedite adoption of the new Public Health The new Law: Lawshould the integration support www.arlis.am ; however, most of them are in Armenian only). 7 of IHR Core Capacities of the Republic of Armenia PREVENT PREVENT 8 Joint External Evaluation The NFP should be accessible at all times to communicate with the WHO IHR Regional Contact Points and and Points Contact Regional IHR WHO the with communicate to times all at accessible be should NFP The requisite forIHRimplementation. including the designation of an IHR NFP, which is a national center for IHR communications, is a key national partnershipsforeffectivealertandresponsesystems. Coordinationofnation-wideresources, The effectiveimplementationoftheIHRrequiresmultisectoral/multidisciplinary approachesthrough Introduction IHR andadvocacy coordination, communication • • practices Strengths/best sectors intheimplementationofIHR–Score 5. P Indicators andscores No priorityactionswere identifiedinthisarea. Recommendations forpriorityactions though theMoHwebsite. and self-evaluations, whicharesubsequentlysummarizedbythenationalIHRfocal point anddisseminated are implementedinpractice. Multiplesectorscontributetothepreparation ofannualIHRprogressreports response, includingcoordinationmechanisms. Experiencetodateindicatesthattheserecommendations documenting lessonslearntandrecommendingmeasurestobetaken tostrengthenpreparednessand exercises isestablishedbyGovernmentdecree. Majorexercisesarefollowed-upbyafter-action reports exercise” peryear, lastingseveral daysandinvolvingmultiplesectors. The periodicityofthesetraining concern inrecenttimes, exercisesareconductedfourtofivetimesayear, includingonefullscale “live public health emergencies. While Armenia has not experienced an event of national or international Commission isthemultisectoral, multidisciplinarybodythatcoordinatessurveillance and responseduring decrees bytheGovernment, MoH, andjointlyissuedbydifferentlineministries. The NationalEmergency ministries areoutlinedinaseriesofSOPs, whichinturnareenactedanumberoflegallybinding and responsibilitiesofdifferentministriesagencies. Coordinationmechanisms between therelevant A soontobeadoptedPublicHealthLawwillprovideanover-arching framework stipulatingtheroles Armenia: levelofcapabilities Target with all relevant sectors and other stakeholders in the country. States Parties should provide WHO with with WHO provide should Parties States country. the in stakeholders other and sectors relevant all with contact details of NFPs, continuously update and annually confirm them. confirm annually and update continuously NFPs, of details contact .2.1 A functionalmechanism isestablishedforthecoordination andintegration ofrelevant framework outlining the roles and responsibilities of different ministries and agencies. Formalized coordination mechanisms under the new Public Health will Act provide an over-arching implementation.Strong for IHR political support • • strengthening/challenges need that Areas • • informal collaborations across sectors. tradition of working though vertical programmes. There is scope for strengthening the culture to foster Notwithstanding the many formal mechanisms for intersectoral collaboration, there remains astrong synergies across human, animal and environmental health sectors. The One Health concept needs to disseminated further be to create ashared understanding of the practices. improve to implemented subsequently are recommendations and reports after-action Continuous improvement: Periodic are tests conducted, following which lessons learnt are recorded in binding decrees. Multisectoral coordination mechanisms are outlined in aseries of SOPs and enacted in aseries of 9 of IHR Core Capacities of the Republic of Armenia PREVENT 10 PREVENT

Joint External Evaluation Support work being coordinated by WHO, FAO, and OIE to develop an integrated and global package of of package global and integrated an develop to OIE and FAO, WHO, by coordinated being work Support agriculture, economicsecurity, andnationalsecurity. of thwarting infectionsinhumans. This situationthreatenspatientcare, economicgrowth, publichealth, (AMR) isoccurringatanalarmingrate andisoutpacingthedevelopmentofnewcountermeasurescapable Over the past decade, however, thisproblem has becomea crisis. The evolutionof antimicrobial resistance of resistancewas slowandthepharmaceuticalindustrycontinuedtocreatenewantibiotics. resist being killed by antimicrobial agents. For many decades, the problem was manageable as the growth Bacteria andothermicrobesevolveinresponsetotheirenvironmentinevitablydevelopmechanisms Introduction resistance Antimicrobial • • • Recommendations forpriorityactions veterinary sectorisnotasadvanced asthehumanhealthsector. and there is a will for further collaboration between the human and animal health sectors. However, the Furthermore, anantimicrobialresistancesurveillance systemisindevelopmenttheveterinarysector ongoing. workers indesignatedhealthfacilities. Monitoringof rational useofdrugsinhospitalsandpharmaciesis health careassociatedinfectioncontrolstrategy isinplaceandtraining isbeingconductedforhealthcare in hospitals. The nextfive-yearstrategy fornosocomial infectionswillbedevelopedtostartin2017. A surveillance studyinhospitalstofurtherassessthesituation Armenia andidentify the useofantibiotics The NetherlandPHIand WHO areplanningaproof-of-principleantimicrobialresistance routinediagnostics antimicrobial resistancestrategy was putintoplacefor2015–2020. assessment havebeenturnedintopractice. A nationalfocal pointwas appointedin2015andanational expert teamfrom WHO RegionalOfficeforEurope. The recommendationsfromthepublishedreportof The humanhealthsectorin Armenia had its antimicrobialresistancecapability assessed in 2012byan Armenia: levelofcapabilities Target activities to combat antimicrobial resistance, spanning human, animal, agricultural, food and environmental environmental and food agricultural, animal, human, spanning resistance, antimicrobial combat to activities aspects (i.e. a one-health approach), including: a) Each country has its own national comprehensive plan plan comprehensive national own its has country Each a) including: approach), one-health a (i.e. aspects to combat antimicrobial resistance; b) Strengthen surveillance and laboratory capacity at the national and and national the at capacity laboratory and surveillance Strengthen b) resistance; antimicrobial combat to international level following agreed international standards developed in the framework of the Global Global the of framework the in developed standards international agreed following level international Action Plan, considering existing standards and; c) Improved conservation of existing treatments and and treatments existing of conservation Improved c) and; standards existing considering Plan, Action collaboration to support the sustainable development of new antibiotics, alternative treatments, preventive preventive treatments, alternative antibiotics, new of development sustainable the support to collaboration measures and rapid, point-of-care diagnostics, including systems to preserve new antibiotics. new preserve to systems including diagnostics, point-of-care rapid, and measures management. Finalize five-year the plan next (2017–2021) for in-hospital nosocomial infections information and Further regulate the agricultural an antimicrobial and start sector resistance surveillance system. system and expand to as many facilities/systems as possible. surveillance epidemiological human sector) national and (agriculture, integrated Establish veterinary • • • • • • • • • strengthening/challenges need that Areas • • • • • • • • • • • • • • practices Strengths/best the veterinarysectorhadbeenmoredeveloped. The two indicatorswere discussed as a single package as they areso closely related. Scoreswould be 4if P P Indicators andscores • .3.2 Surveillanceofinfectionscausedby AMR pathogens–Score 3 .3.1 Antimicrobial resistance (AMR)detection–Score 3 Integration of agriculture and human surveillance is crucial for the system to progress. practice. Antibiotics use in the agriculture needs monitoring, sector perhaps though small animal private levels. local national, at and regional surveillance antimicrobialStrengthen resistance All legal grounds including practices best should in be place. SOPs are in place at regional and local levels. Quality of laboratory testing needs to strengthened. be Agricultural has sector no formal Epi surveillance system –but some plans exist. Animal is not sector included in the planned population study. Sentinel surveillance sites in the animal are sector not yet selected. International training was achieved in EUCAST. A list of antimicrobial-resistant pathogens priority has been created. 2015 guidelines for antimicrobial resistance surveillance are in place. managementTB strategy was approved in 2016. EQA scheme is from active mid- September 2016. testing is in progress. European Committee on Antimicrobial Susceptibility Testing standards (EUCAST) development in blood hospitals. Reference laboratory for antimicrobial resistance surveillance was established in 2013. Sentinel surveillance sites are available: four medical selected facilities; pediatric two adult and two Antimicrobial resistance detection system functions but is not integrated with the animal sector. Indicators exist on antimicrobial resistance and tuberculosis (TB). Interministerial antimicrobial 2016. in held was meeting resistance surveillance resistance antimicrobial in 10 involved provinces Interagency conference was held in 2015 with national training. AMR A permanent task force is in place since 2015. 2012 are in place. PreventionAMR and Control Strategy 2015 and Nosocomial Infection Prevention and Control Strategy antibiotics. of use rational the for required systems improve and Expand 11 of IHR Core Capacities of the Republic of Armenia PREVENT 12 PREVENT

Joint External Evaluation • • • • • • • • • practices Strengths/best P 1 • strengthening/challenges need that Areas • • • • practices Strengths/best P • • strengthening/challenges need that Areas

.3.3 Healthcare associatedinfectionprevention andcontrol programmes –Score 4 .3.4 Antimicrobial stewardship activities–Score 4 http://www.euro.who.int/__data/assets/pdf_file/0006/246471/Lancet-article-Antibiotic-use-in-eastern-Europe-a-cross-national.pdf?ua=1 Health care associated infection of is the clinical part training curriculum. place. in are epidemiologists hospital Funded SOPs are in place for hepatitis B. Staff behaviour is checked regularly. Tertiary hospital for with isolation capacity is in place. Infection control focal points at hospitals have been appointed. All levels of health care are involved in infection control measures. Training implemented. all levels been at has Health care associated infection strategy approved by the Government is in place. No areas are in need of strengthening. No incentive for selling antibiotics without prescription in Armenia from fall 2016 due to the new law. surveyed. countries other than lower Armenia’s consistently was use overall antibiotic In a 2011 study of antibiotic usage in non-European Union southern and Eastern European countries, Survey of pharmacies done in 2014. Monitoring of rational use of drugs in hospitals and pharmacies. Antibiotic use monitoring and antimicrobial resistance drug register need to in be place. There is aneed to expand the number of medical facilities that work on hospital infections. 1 Adopted measured behaviors, policies and/or practices that minimize the transmission of zoonotic diseases diseases zoonotic of transmission the minimize that practices and/or policies behaviors, measured Adopted education ofpublichealthaspects inanimalhealthhasbeendevelopedandimplemented involvingall Veterinarians regularly participateinthe South CaucasusFELTP and MediPIET. A plan for continuous responses havehelpedthecountry tocontroloutbreaksofbrucellosisandanthrax inthepast. to control outbreaks of zoonotic diseases on several occasions. Timely detection followed by rapid joint experts fromtheUnitedStatesandneighbouringGeorgia. Armenia hasalreadydemonstrated itscapacity on brucellosiswereconductedin2015withparticipation ofallrelevant stakeholders andinternational States Cooperative BiologicalEngagement Program (CBEP). For thatpurposeregionaltraining andexercises activities were implementedtointroducetheOneHealthapproachwithinframework oftheUnited in acoordinatedandcollaborative manner(e.g. avianinfluenza, anthrax andbrucellosis). Anumberof human andanimalhealthworkers toinvestigateandrespond tozoonoticeventsasrapid responseteams, of animalsduetoepidemics. Several exerciseshavebeenconductedtopractice andtesttheskillsofboth and respondtotheseprioritydiseases. Stateguaranteed indemnitiesareinplacetocompensateforloss Based onastronglegalframework, guidelinesandSOPshavebeendevelopedtojointlydetect, prevent public health concern: anthrax, avian influenza, brucellosis, glanders, leptospirosis, rabies andtuberculosis. In 2014, ajointdecreeoftheMoHandMoAdefinedlisteightpriorityzoonoticdiseasesgreatest strengthened andexpanded, especiallyintheanimalsector. each year. Laboratory capacitiestosupportastrongsurveillancesystemforzoonoticdiseasescouldbe zoonotic events. LivestockpopulationestimatesaredevelopedbytheNationalStatisticalService(NSS) other activitiesthatareroutinelyperformedandanalyzedusingGISmappingtoassesspotentialriskof surveillance, monitoringofrodentpopulations, andsurveillanceofthebirdpopulationaresome correspondence. The EIDSShasalreadybeendevelopedbutisnotyetfullyoperational. Entomological is likely toenhancetimelyexchangeofinformationbetweensectorsthatarecurrentlybasedonofficial respective humanandanimalcasedefinitions. The electronicintegrated diseasesurveillancesystem(EIDSS) of 85communicablediseasesthataresubjecttoreportingin Armenia includeszoonotic diseaseswith Surveillance systemsforzoonoticdiseasesinbothhumanandanimalhealthsectorsareplace. The list Within thestructureofMoHanintersectoral experttaskforceforzoonoticdiseaseshas beenestablished. stakeholders (such asMinistryofNatureProtectionfor Wildlife Animals) arealsoinvolvedinactivities. partners for an integrated approach in the control of zoonotic diseases are MoH and MoA, other relevant Armenia hasimplementedanumberofactivitiestointroducetheOneHealthapproach. While themain Armenia: levelofcapabilities Target zoonotic. infectious diseasesaffectinghumansisofanimalorigin; approximately 60%ofallhumanpathogensare or inanimatevectorsmaybeneededtotransfer themicrobe. Approximately 75%ofrecentlyemerging These diseasesarecausedbybacteria, viruses, parasites, andfungithatarecarriedbyanimalsinsect Zoonotic diseasesarecommunicableandmicrobesspreadingbetweenanimalshumans. Introduction Zoonotic disease from animals into human populations. human into animals from 13 of IHR Core Capacities of the Republic of Armenia PREVENT 14 PREVENT

Joint External Evaluation • • • • • • • • Recommendations forpriorityactions engaged inresponsetozoonoticevents. SFSS oftheMoAorganizesshort-termtraining andupdatingofinformationforveterinaryspecialists levels. Currentlyaround650veterinariansareoperating inthecommunitiesonacontractual basis. The • • • • strengthening/challenges need that Areas • • • • practices Strengths/best P Indicators andscores .4.1 Surveillancesystemsinplaceforpriorityzoonoticdiseases/pathogens–Score 5 Laboratory capacitiesLaboratory exist in animal and human health sectors. assessments. Surveillance of relevant (wild vectors birds, rodent populations, etc.) are in place and used for risk approach to zoonotic events of public health concern. Several decrees, guidelines and SOPs developed to facilitate the implementation of the One Health Joint decree by MoHand MoA has defined a list of eight priority zoonotic diseases. early detection, and timely and rapid response to these events. acomprehensivePerform retrospective review of multisectoral response to zoonotic events to evaluate through implementation of the existing plan for continuous training of staff. Ensure professional further development of veterinarians with afocus on the local (community) level, (such as analysis of research questions, geographic information system (GIS) mapping and research). Further enhance the use of surveillance data in order to facilitate risk assessment of zoonotic diseases through full operationalization of the already existing EIDSS. Further strengthen the One-Health concept by integrating human and animal surveillance systems strengthened and expanded especially in the animal sector. capacitiesLaboratory toastrong support surveillance system for zoonotic diseases could be purposes). Existing information put canbe to use better if it is in acommon database (such as for research mayOwners/farmers only animal report diseases for which indemnities are paid. EIDSS is in place but not yet fully operational. Integrated approach with timely sharing of relevant information. Surveillance systems for zoonotic diseases are in place for both animal and human sectors. Intersectoral taskforce expert has been established. 2015. in started was concept Health One the of Implementation m

be directly linked. EIDSS will enhance further data exchange, and laboratories from animal and human will sectors • strengthening/challenges need that Areas • • • practices Strengths/best based moreonassumptionsthanevidence. As nosystemisinplacetosystematicallymonitorandevaluate responsetozoonoticevents, thisscoreis functional –Score 5 P • strengthening/challenges need that Areas • • • • practices Strengths/best animal health. clear what proportion of them have been trained in the One Health approach and public health aspects of Although thenumberofveterinariansoperating atthelocallevelismorethansufficient(>600), it was not P .4.3 Mechanismsforresponding tozoonosesandpotentialare establishedand .4.2 Veterinary oranimalhealthworkforce –Score 5 established. Routine system for monitoring and evaluation of response activities to zoonotic events needs to be concern. international and national potential of events zoonotic Several exercises as well as real events have shown proof that the is country able to respond in time to have been developed. Guidelines with SOPs for joint approach in the detection and control of all zoonotic priority diseases zoonoses and potential zoonoses. One Health approach with strong intersectoral cooperation and collaboration for responding to level. community the at needs the One Health approach and public healthin animal aspects health may not yet sufficient be to cover all Proportion of veterinary and field communitystaff animal healthcare providers already trained in the Health activities at the local level. More than veterinarians 600 operating in the communities is a sound foundation for conducting One A plan for continuous education of public healthin animal aspects health is in place. in the near future. Veterinarians regularly participate in the South Caucasus FELTP and will also enrolled be in the MediPIET regions. Sufficient animal workforcecapacities theOne to Healthsupport approach at national level and in all 15 of IHR Core Capacities of the Republic of Armenia PREVENT 16 PREVENT

Joint External Evaluation States parties should have surveillance and response capacity for food and water borne diseases’ risk or or risk diseases’ borne water and food for capacity response and surveillance have should parties States cases) needtobeputinplace. assessment, suitableriskmanagementoptionsthatensurethepreventionofhumancases(orfurther must be developed. If epidemiological analysis identifies food as the source of an event, based on a risk critical forcontrol. Riskmanagementcapacitywithregardtocontrolthroughoutthefoodchaincontinuum incidents involving contaminated food. The identification of the source of an outbreak and its containment is The rapid globalizationoffoodproductionandtrade hasincreasedthepotentiallikelihood ofinternational Introduction Food safety • Recommendations forpriorityactions Public awareness offoodsafety remainsanissuein Armenia thatwarrants furtheraction. food safetycontrolcapacitiesatbordercontrolsareneeded. of problemsandrecommendedsolutions. Furtherimprovements intheavailability oflaboratory testsand information notonlyondangerousfoodstuffs, butalso implementationofresponseactivities, discussion detected, theinformationisexchangedwithmultisectoral stakeholders. Cooperation includesexchangeof investigations areplanned, conductedandreportedusingstandardizedforms. When eventsofconcernare workshops andpractical exercisesorganizedbyinternationalpartnersduringrecentyears. Epidemiological To developprofessionalknowledgeandskills, rapid responseteammembershave received training through defined. or instructions of the Head of Service, where all aspects of response, activities and responsibilities are public healthexpertsfromtheNCDC/MoH. The SFSSrapid responseteamoperations areguidedbydecrees investigated bymultidisciplinaryandmultisectoral rapid response teamsconsistingofSFSSexpertsand Armenia hassurveillanceandresponsecapacityforfoodbornewaterborne diseases. Outbreaksare safety activitiesareregulatedbybilateral agreementsandcooperation withthirdpartycountries. legislative acts. In2015, Armenia becameafullmemberoftheEurasian EconomicUnionandtherebyfood Service carriesoutitsactivitiesinaccordancewiththelegislationofRepublic Armenia andother regulation offoodsafety; itcarriesoutsupervision, andinsomecasesmaytake disciplinaryaction. The The SFSSoftheMoAisfoodsafetyauthorityin Armenia. The SFSSisresponsibleforthelegislative Armenia: levelofcapabilities Target events. It requires effective communication and collaboration among the sectors responsible for food safety safety food for responsible sectors the among collaboration and communication effective requires It events. and safe water and sanitation. and water safe and and food contamination by: contamination food and Further enhance the national for early capacity detection and rapid response to foodborne diseases m m

Ensuring that the hotline call managed service by the SFSS is known to the public. Raising public awareness through of food safety public campaigns. • • • • • • strengthening/challenges need that Areas • • • practices Strengths/best disease andfoodcontamination–Score 5 P Indicators andscores .5.1 Mechanismsare establishedandfunctioningfordetectingresponding tofoodborne Introduction of Hazard Analysis and Critical Control Points (HACCP) plan in the food industry. security. threatening are food that diseases infectious emerging of track Keeping Improvement control of food safety capacities at border controls. Further improvements in the availability of laboratory tests. Government funding systems for food safety should increased. be personnel working in food safety. Inclusion training of food safety in educational programmes and provision of continuous training for (ISO 17025 international accreditation with exists accreditation). capacity Laboratory National legislation in the field safety of is food in compliancewith international requirements. policies safety Food and functions exist under asingle authority. 17 of IHR Core Capacities of the Republic of Armenia PREVENT 18 PREVENT

Joint External Evaluation A whole-of-government national biosafety and biosecurity system is in place, ensuring that especially especially that ensuring place, in is system biosecurity and biosafety national whole-of-government A plants, ortheenvironment. to secureinfectiousagentsagainstthosewhowoulddeliberately misusethemtoharmpeople, animals, biosafety andbiosecuritytoprotectresearchersthecommunity. Biosecurityisimportantinorder dedicated toworkwithinfectiousagentshaveraised concernsregardingtheneedtoensureproper of bothnatural anddeliberate origin. At thesametime, theexpansionofinfrastructure andresources tools thatareneededtodetect, diagnose, recognize, andrespondtooutbreaksofinfectiousdisease Research withinfectiousagentsiscriticalforthedevelopmentandavailability ofpublichealthandmedical diseases. set oftools—suchasdrugs, diagnostics, andvaccines—to countertheeverevolvingthreatofinfectious Working withpathogensinthelaboratory isvitaltoensuringthattheglobalcommunitypossessarobust Introduction biosecurity and Biosafety • • Recommendations for priorityactions biosafety andbiosecuritytrainings inthefuture. Scientific-Educational CenteroftheNCDC. The ArmenianGovernmenthasshowncommitmenttofunding under theCBEP; fromlate2016thetraining willbeincorporated intothecurriculumofInternational – aglobalengineeringconsultancyservice-currentlyprovides biosecuritytraining oflaboratory personnel public healthofficers, whichhasbeencreatedwiththe collaboration oftheEuropeanUnion(EU). CH2MHILL biosafety andbiosecuritycapabilitiesinSouthCaucasus andinCentral Asian countries)formanagersand phase training programme accompaniedbyguidingvisits. There isabiosafetyprogramme (Strengthening There isajointtraining andmonitoring systemforMoHandMoA, establishedundertheCBEP–athree- performed againassoonthenewlaboratory isavailable. (questionnaire). This was lastdonein2014, asthemain laboratory was beingrenovated in2015. Itwillbe and reportingofparticularlydangerouspathogensisperformedusinganestablishedinventorytool Threat Reduction Agency (DTRA)CBEP and an external assessmenthasbeenperformed. Annual recording transport ofpathogens. This processisundertheUnited StatesDepartmentofDefense(DoD) Armenia hasagoodsystemofbiosafetyandbiosecurity, withtheGovernmentregulatingstorage and Armenia: levelofcapabilities Target dangerous pathogens are identified, held, secured and monitored in a minimal number of facilities facilities of number minimal a in monitored and secured held, identified, are pathogens dangerous according to best practices; biological risk management training and educational outreach are conducted conducted are outreach educational and training management risk biological practices; best to according to promote a shared culture of responsibility, reduce dual use risks, mitigate biological proliferation and and proliferation biological mitigate risks, use dual reduce responsibility, of culture shared a promote to deliberate use threats, and ensure safe transfer of biological agents; and country-specific biosafety and and biosafety country-specific and agents; biological of transfer safe ensure and threats, use deliberate biosecurity legislation, laboratory licensing, and pathogen control measures are in place as appropriate. as place in are measures control pathogen and licensing, laboratory legislation, biosecurity identification of possible gaps. possible of identification Develop an action plan for the coordination of the biosafety and biosecurity training system and Armenia. in laboratories of biosecurity and biosafety for international accreditation the Further • • strengthening/challenges need that Areas • practices Strengths/best P • • strengthening/challenges need that Areas • • practices Strengths/best and agriculture facilities–Score 4 P scores and ndicators I • .6.2 Biosafetyandbiosecuritytraining andpractices –Score 4 .6.1 Whole-of-government biosafetyandbiosecuritysystemisinplaceforhuman, animal, Ensure funding streams cancover all appropriate training needs in the future. ensure it is audited/evaluated and for coverage. effectiveness toNeed embed the training system of the International Scientific-Educational Center of the NCDC and Good training systems developed with international support. Licensing laboratories of made compulsory. to be needs (including laboratories). veterinary Further work needs to done be regarding international accreditation of laboratories in Armenia Secure legal basis for biosecurity and biosafety systems. All high containment specimens are in one place. licensing of arrangements. component quality the developing licensingImplement compulsory for all laboratories (including laboratories) veterinary including 19 of IHR Core Capacities of the Republic of Armenia PREVENT 20 PREVENT

Joint External Evaluation A functioning national vaccine delivery system—with nationwide reach, effective distribution, access for for access distribution, effective reach, nationwide system—with delivery vaccine national functioning A Target deaths ayearglobally. ways tosavelivesandpreventdisease. Immunizationsareestimatedtopreventmorethantwo-million Immunization isoneofthemostsuccessfulglobalhealthinterventionsandcost-effective Introduction Immunization estimates from 2010 and 2015). Administrative estimates of MCV 1 coverage have constantly been at a Overall, vaccination coverage foralltargetgroupsisatastable levelof92%(inlinewithDHScoverage aspects oftheimmunization programme. if vaccinations arerejected. A monitoringsystemisinplacetocollectinformationonall theimportant (hepatitis B, influenzaand rabies). Vaccines areadministeredonavoluntarybasisbutparentshavetosign also offeredtoyoungmaleadults(meningococcaldisease, hepatitis A andtularemia)toriskgroups from trivalent tobivalent oral poliovaccine hasalsobeenimplemented. Inaddition, vaccinations are was introducedin2012, pneumococcal vaccine in2013, andinactivated poliovaccine in2016. A shift The routineimmunizationscheduleforchildrencovers 13 diseases, usingeightvaccines. Rotavirusvaccine international market. national and30%atregionallevelsarekept inorder to preventstockouts evenifshortagesoccurinthe seems to be guaranteed from central level downtohealthfacilitylevel. Reserve bufferstocks of 50%at and private) offervaccinations to the target groups free of charge. Highqualitycold chainmaintenance where healthfacilitiescollecttheirvaccines everymonth. Currently371healthinstitutions (bothpublic for quarterlydistributionofvaccines andvaccination equipment fromnationaltoregionalstores procured throughUnitedNationsInternationalChildren’s Fund(UNICEF)onceayear. NCDCisresponsible Only rotavirusvaccination activitiesarestillbeingco-fundedbyGAVI until2018. Vaccines arecentrally The Government has gradually increased its share of funding for routine vaccinations up to nearly 100%. are incorporated incurriculaofacademictraining institutions. Initiative. Written guidelinesareupdatedeachyear. Training manualsforphysicians, nursesandvaccinators evaluated bytheSupportingIndependentImmunizationand Vaccine Advisory Committees(SIVAC) has also established a strongNational Immunization Technical Advisory Group(NITAG), supported and organizations, coordinatethesupportofallagenciesinvolvedinProgramme. Since2013, Armenia several nationalministries, internationalorganizations(suchasGAVI, UNICEF, WHO) andnongovernmental regulating theProgramme. An Interagency CoordinatingCommittee(ICC), composedofrepresentatives and providingsustainablefinancingofimmunizationservices. Several decreesand lawsareinplacefor measles andrubellaelimination, hepatitisBcontrol, ensuringhighcoverage rates, introducingnewvaccines, Programme 2016–2020arefullyinlinewith WHO strategies intheGVAP, i.e. focusingonpolioeradication, plans are developed every four to five years. The targets of the recently approved National Immunization Armenia has a strong national immunization programme in place since2005. Comprehensive multiyear Armenia: levelofcapabilities marginalized populations, adequate cold chain, and ongoing quality control—that is able to respond to to respond to able is control—that quality ongoing and chain, cold adequate populations, marginalized new disease threats. disease new • • • • • • strengthening/challenges need that Areas • • • • • • practices Strengths/best P Indicators andscores • • • Recommendations forpriorityactions trends forallvaccine preventablediseasesundersurveillanceisobserved. computerized systemforvaccine managementisnotyetoperational. Ingeneral, decreasingincidence number ofparentsarehesitanttovaccinate theirchildren, andthisrequiresspecialattention. Also, a followed by local transmission. The monitoring system is still based on several paper forms. An increasing outbreaks inneighbouringcountries, anydetectedmeaslescaseswereduetoimportationandnot high levelof97%since2010. As aresultthelastdiphtheriacasewas reportedin2000, anddespitemeasles .7.1 Vaccine coverage (measles)aspartofnationalprogramme –Score 5 Marginalized groups have been successfully addressed. successfully been have groups Marginalized surveillance. under diseases allpreventable in vaccine incidence Decreasing Comprehensive monitoring is in place. system Increasing numbers of parents are hesitant to vaccinate their children, which requires special attention. Monitoring system is still based on several paper forms. sustained. be to has vaccination coverage High-level rates: vaccinationcoverage High NITAG is operational since 2013 and evaluated with ahigh score by SIVAC. Strong partnership within the and country with global (i.e. partners GAVI, UNICEF and WHO). (2016–2020) Program Immunization National 2016. in approved was Strong legal framework with updates five years every Strong political will is highlighted in the joint assessment GAVI–UNICEF–WHO in 2015. Improve quality of monitoring using electronic and registry vaccine management. Address vaccine hesitant groups adapted with communication methodologies. introductions. vaccine Sustained for financial advocacy resource mobilization of the national vaccination programme and new m m m m m

No indigenousNo in neighbouring despite measles outbreaks countries. cases No of cases diphtheria since 2000. regions. between coverage variationin Low 97%. of level constant at coverage MCV1 92%. rate coverage Overall 21 of IHR Core Capacities of the Republic of Armenia PREVENT 22 PREVENT

Joint External Evaluation • • • • • practices Strengths/best P • • strengthening/challenges need that Areas .7.2 Nationalvaccineaccessanddelivery–Score 5 vaccinations in all regions. all in vaccinations Well-organized vaccine delivery system and maintaining cold chain guarantees free access to Strong collaboration with and from support international such partners as GAVI, UNICEF and WHO. vaccines expires in 2018. Immunization programme will fully be funded by the Government GAVI after for support rotavirus vaccines. quality high to access sustainable UNICEF guarantees through Procurement Strong legal framework. Secured funding for introduction of new vaccines is needed in the future. operational. yet isnot management vaccine for Computerized system Real-time biosurveillance with a national laboratory system and effective modern point-of-care and and point-of-care modern effective and system laboratory national a with biosurveillance Real-time • • • Recommendations for priorityactions long-term development. the already achievedpositivecapacityimprovements, sustainablenationalfundingshouldbe secured for been bothfinanciallyandtechnicallysupportedbythe United StatesDTRA. Inordertostayoncoursewith Strengthening ofthe Armenian laboratory capacitytomeettheIHRandOIErequirementshaspredominantly are accreditedtotheISO17025standard. The EQAschemeiscurrentlyunderdevelopment. Laboratories areaccreditedbya designatedagencyundertheMinistryofEconomics, and46laboratories populations thathavenotyetbeenreached. parts ofthecountry. An increaseinmobilelaboratory capacityisneededtoprovideaccesstestingfor for specimenreferral andtransport (fundedbytheGovernment) areinplaceandabletoreachalmostall are onlyavailable atthenationallevel. The othercoretests canbedoneatallthreelevels. The systems (polymerase chain reaction) is done at the national level and in two regional laboratories. Tests for polio staff have undergone training. All the 10 core tests can be conducted in Armenia. Testing for influenza Armenia hasmodernizedseveral laboratories, whicharenow equippedwithstate-of-the-arttoolsand Laboratory Center(RLC)oftheNCDC. local, regionalandnational. There areseveral referencelaboratories inthecountryincludingReference a universallaboratory network, whichisregulatedbytheMoH. The laboratories operate onthreelevels; quality managementsystemandEQAscheme. The publichealthlaboratory systemin Armenia consistsof legislation forsupportingthelaboratory system, and(ii)introducingacomprehensive laboratory network, During recent years Armenia significantly reformedtheir laboratory services aiming at(i)developing Armenia: levelofcapabilities Target education; andpartnershipscommunication. and specializedtesting; laboratory oversight; emergencyresponse; publichealthresearch; training and food safety including disease prevention, control, and surveillance; integrated data management; reference can serveasafocalpointfornationalsystem, throughtheircorefunctionsforhuman, veterinaryand response, environmentalmonitoring, anddiseasesurveillance. Stateandlocalpublichealthlaboratories Public healthlaboratories provideessentialservicesincludingdiseaseandoutbreakdetection, emergency Introduction National system laboratory DETECT laboratory-based diagnostics. laboratory-based Obtain additional reference strains of pathogens to improve validation of diagnostic methods. fundingSecure for national coordination network. laboratory expanding of the theExpand universal laboratory to network cover all public health laboratories in Armenia. 23 of IHR Core Capacities of the Republic of Armenia DETECT 24 DETECT

Joint External Evaluation • • practices Strengths/best D.1.1 Laboratory testingfordetectionofprioritydiseases–Score 4 Indicators andscores • • • strengthening/challenges need that Areas • • practices Strengths/best D.1.4 Laboratory qualitysystem–Score 4 • • • strengthening/challenges need that Areas • practices Strengths/best D.1.3 Effectivemodernpointofcare andlaboratory baseddiagnostics–Score 4 • strengthening/challenges need that Areas • • practices Strengths/best D.1.2 Specimenreferral andtransport system–Score 4 • strengthening/challenges need that Areas network is capable of continuous capacity development. continuous capacity of is capable network All the 10 core and theperformed canbe tests three-level organizational structure of the laboratory Legal foundation for the universal laboratory is network in place. Safety Inspectorate. Fully operationalize the recently established reference laboratories of the NCDC and the State Food Implement anational EQA scheme including the required administrative organization. Sustainable national funding is needed for administration of the national EQA scheme. Continuous training staff requirement is in place. mandatory. is management Quality The collection of in vitro diagnostic devices is currently too diverse and needs to standardized. be Ensure sustainable national funding for modernization of laboratory equipment and training of staff. referenceExpand strain collection for validation of diagnostic methods. suchlaboratory as MediLabSecure) networks facilitate modernization of laboratory-based diagnostics. international(including in collaboration participation and laboratories reference of availability The Increase mobile laboratory to provide capacity access to testing for populations currently not reached. freeoffered of charge. 96% of the population has access to advance diagnostics (including 10 core tests) and testing is Referral and transport of samples are standardized and procedures are as defined by MoH orders. forNeed expansion of the universal laboratory and network financial for theexpansion.support Strengthened foundational indicator- and event-based surveillance systems that are able to detect detect to able are that systems surveillance event-based and indicator- foundational Strengthened • • • Recommendations forpriorityactions uremic syndromeandhaemorrhagicfeversyndrome. of publichealthemergencies, i.e. acuteflaccidparalysis, severeacuterespiratory infections, haemorrhagic- A syndromicsurveillancesystemisinplace, whichassiststhedetectionoffourcoresyndromesindicative data andriskassessmentareperformedsystematicallyatalllevelsbydedicatedteamsofqualifiedstaff. however, real-timesharingofnotification dataisnotyetimplemented. Analysisandreportingofsurveillance surveillance system is processed within an interoperable, interconnected, electronic reporting system; and event-basedsurveillancesystems, todetectpublichealththreats. Informationinthepublichealth human andanimalhealth. There aremultipleindependentsurveillancesystems, includingindicator-based Armenia hasdevelopedthoroughsustainablecapabilitiesforthedetectionofeventssignificance Armenia: levelofcapabilities Target biological events. leading an integrated bio-surveillance effort that facilitates early warning and situational awareness of The purposeofreal-timesurveillanceistoadvance thesafety, security, andresilienceoftheNationby Introduction Real-time surveillance events of significance for public health, animal health and health security; improved communication and and communication improved security; health and health animal health, public for significance of events collaboration across sectors and between sub-national, national and international levels of authority authority of levels international and national sub-national, between and sectors across collaboration regarding surveillance of events of public health significance; improved country and regional capacity capacity regional and country improved significance; health public of events of surveillance regarding to analyze and link data from and between strengthened, real-time surveillance systems, including including systems, surveillance real-time strengthened, between and from data link and analyze to interoperable, interconnected electronic reporting systems. This can include epidemiologic, clinical, clinical, epidemiologic, include can This systems. reporting electronic interconnected interoperable, laboratory, environmental testing, product safety and quality, and bioinformatics data; and advancement in in advancement and data; bioinformatics and quality, and safety product testing, environmental laboratory, fulfilling the core capacity requirements for surveillance in accordance with the IHR and the OIE standards. OIE the and IHR the with accordance in surveillance for requirements capacity core the fulfilling event-based and syndromic surveillance. syndromic and event-based of the notificationsystem strengthento the present surveillancesystems, including indicator-based, Enhance training of peripheral level in disease staff surveillance: Educate and train at all staff levels ensure rapid detection of relevant infections of public health importance. diarrhoea with dehydration) should integrated be into the existing syndromic surveillance system, to currently allows the surveillance of four core syndromes. Further syndromes (such as acute watery Include syndromes further in the already established syndromic surveillance system: The system is not available in real-time mode. system is in place, notification data arestill processed manually at the local level (data entry), i.e. data interconnected and in real time (starting at the level of laboratories and physicians): While such a Integrate reporting mechanisms using an electronic secure reporting system that is interoperable and Develop and implement electronic notification,which allows real-time access to surveillance data. 25 of IHR Core Capacities of the Republic of Armenia DETECT 26 DETECT

Joint External Evaluation • • • • practices Strengths/best D.2.1 Indicatorandeventbasedsurveillancesystems–Score 4 Indicators andscores • • • practices Strengths/best D.2.3 Analysis ofsurveillancedata–Score 5 • • • • strengthening/challenges need that Areas • • • • practices Strengths/best D.2.2 Interoperable, interconnected, electronic real-time reporting system–Score 3 • • • strengthening/challenges need that Areas events and syndrome reports. syndrome and events Trained and experienced public health professionals systematically screen for media relevant reports filtering, confirmation and analysisof information. collection, systematic the includes evaluated. This regularly are systems surveillance various The surveillance). event-based and indicator-based (including Information from official and nonofficial sources is beingused in the various surveillancesystems Comprehensive legislation place. is in according to IHR (2005)), and extendable to currently relevant syndromes. (2005)), currently to IHR to according extendable and The reporting system is flexible (i.e. not only restricted to diseases that are mandatorily notifiable Nosocomial diseases are included in the reporting forms. A standardized notification format is used, that is harmonized according to ICD-10 codes. High turnover in the ofpublic staff health is achallenge. sector strengthened. further be Collaboration the human between and animal health in the area sectors of zoonotic diseases should Skills of professionals in electronic reporting system should improved be at the subregional level. the national to level. notification level of the from starting intoData entry the electronic reporting system should conducted be without interruption of media, methods. Public health professionals, particularly at the national level, are continuously trained in data analysis onwards. service health public Data is transmitted within the electronic reporting system in real-time mode from the level of regional All data is integrated in one electronic reporting system, i.e. the EIDSS. Classification Diseasesof (ICD)-10 codes. A standardized notification format is used, that is harmonized according to the International environment. Infrastructures and functions need to adapted be according to the rapidly changing (technical) New methodological approaches, e.g. surveillance methods, should considered be and applied. Data quality needs to improved. be • • • strengthening/challenges need that Areas • • practices Strengths/best D.2.4 Syndromic surveillancesystems–Score 4 • strengthening/challenges need that Areas status. A sustainable surveillance system for acute flaccid paralysis is a key element to show proof polio-freeof Investment in laboratory capacities should also considered be for the regional level. information other from sectors. The syndromic surveillance system database should continuously be improved, such as by including from the local level. is available all starting levels, at system this surveillance through gathered information Epidemiological The syndromic surveillance system for the four core syndromes is highly sensitive. The skills of public health professionals regarding analysis of surveillance data should improved. be 27 of IHR Core Capacities of the Republic of Armenia DETECT 28 DETECT

Joint External Evaluation Timely and accurate disease reporting according to WHO requirements and consistent coordination with with coordination consistent and requirements WHO to according reporting disease accurate and Timely ecosystems reducestheriskofdiseasesatinterfacesbetweenthem. and animalhealthsystems. Collaborative multidisciplinaryreportingonthehealthofhumans, animals, and pathogens continuetoevolveandadaptnewhostsenvironments, imposingaburdenonhuman Health threats at the human–animal–ecosystem interface have increased over the past decades, as Introduction Reporting • • • Recommendations forpriorityactions points toensuretimelyreportingandinformationexchange, needsimprovement. regulations. Also, cooperation withothercountries, inparticularbetweennationswithcommonborder communications with WHO werehowevernotperformedinatimelyfashionaccordance withIHR(2005) public health emergency of international concern(PHEIC) and file a timely report to WHO. Existing Thus far, Armenia hasnotexperiencedaneventwithdemonstrated abilitytobeidentifiedasapotential that facilitatesresponsetonationalpublichealtheventsinacoordinatedmanner. instrument isutilizedwhenassessingpublichealthevents, and Armenia additionally hasasysteminplace network ofIHRresponsiblecontactpointswithineachministry. The IHR(2005) Annex IIdecision-making IHR focalpoint, aspervarious SOPsandGovernmentDecreeN1138-N(26 August 2010). There isa Information sharingandcoordinationmechanismsareestablishedamongotherministriesthenational for OneHealthrelatedtopics. these twoentities(suchasinazoonoticevent). Jointtrainings inreportingareheld with MoHandMoA established withintheMoA, andsupportivelegislationexiststofacilitateinformationexchangebetween 809-N (19July2009)and913-N(6 August 2009). Inaddition, thereisalsoanoperational OIEfocalpoint national coordinatingbodyandtheofficialcommunicationhubwith WHO, asperGovernmentalDecrees Armenia hasanoperational nationalIHRfocalpointlocatedwithintheMoH, whichserves asthedesignated Armenia: levelofcapabilities Target FAO and OIE. and FAO Conduct simulation exercises to test 24-hour timely notification potentialof PHEIC WHO.to designating these ground crossings for the implementation of IHR (2005) capacities. Enhance reporting of public health events atdetected ground crossings with other countries by jointly national IHR focal points of neighbouring countries with the facilitation of WHO. Enhance communication and collaboration the national between IHR focal point of Armenia and the • • strengthening/challenges need that Areas • • • practices Strengths/best D.4.2 Reportingnetworkandprotocols incountry–Score 3 • • strengthening/challenges need that Areas • • • • • practices Strengths/best D.4.1 Systemforefficient reporting to WHO Indicators andscores Coordination and cooperation agreements with other countries regarding mutual training are required. reporting. in gaps capacity Ensuring the continuity human of high-capacity resources, turnover high staff and consequential Regular and systematic training occurs for related including sectors, non-health sectors. Efficient vertical informationexchange from subnational levels to national levelwithin sectors. mechanisms among theof at different network the national sectors level. Multisectoral coordination is in place to respond to potential and real PHEICs, and information exchange to ensure timely reporting and information exchange. Improving cooperation with other countries, in particular among nations with common border points reporting. in gaps capacity Ensuring the continuity human of high-capacity resources, turnover high staff and consequential threats. health national IHR focal point bilateral mechanisms have been previously used to exchange information on Bilateral agreements exist to facilitate monthly reporting for infectious diseases with 25 countries; and and informationreporting exchange requirements. Systematic training and exercising occurs with diverse national including sectors, training segments on Standardized and protocols formats to streamline exist reporting coordination and communication. events. safety food and zoonotic Coordination mechanisms exist across national in particular sectors, with the OIE focal point for and mandate for reporting aPHEIC to as the WHO national coordinating body. The national IHR focal point is established with clear terms of reference (ToRs), and has the authority , F A O andOIE–Score 3 29 of IHR Core Capacities of the Republic of Armenia DETECT 30 DETECT

Joint External Evaluation States parties should have skilled and competent health personnel for sustainable and functional public public functional and sustainable for personnel health competent and skilled have should parties States Target training, scientificskills, andsubject-matterexpertise. by developingandmaintainingthehighlyqualifiedpublichealthworkforcewithappropriatetechnical Workforce developmentisimportantinordertodevelopasustainablepublichealthsystemovertime Introduction Workforce development • Recommendations for priorityactions required spectrumofpublichealthservices. health workforce. Therefore, Armenia shouldbeginplanningandmonitoringhumanresourcelevelsforthe very few systematic efforts to conduct workforce planning activities focusing specifically onthe public support fromtheUnitedStatesCentersforDiseaseControl andPrevention(CDC). There arecurrently A long-termstrategy wouldbe requiredtoreducethedependencyofSouthCaucasusFELTP on the general healthworkforce. planning, suchasmonitoringofretentionandimplementing measurestoimproveretention, allfocuson is nostrategy focusingspecifically onthepublichealthworkforce. Similarly, activitiesrelatedtoworkforce development strategy thatcoverstheentirehealthworkforceisinplaceforperiod 2014–2018, there by the International Scientific-Educational Centerofthe NCDC. While ahealthcarehumanresource international programmes, theNCDCisonvergeoflaunchinganationalFETP, whichwillbeprovided A mentorshipprogramme isinplaceforboththeFELTP andMediPIET. Inadditiontoparticipatinginthese EU MediPIET. trained onthetwo-yearSouthCaucasusFELTP, andaround10%havegraduated theninemodulesof trained fieldepidemiologistsper200,000population. Nearly20%of Armenianepidemiologistshavebeen authorities, thecountryhas161trained epidemiologistsinservice, morethanten timesthetargetofone from Armenia to other countrieshave taken place. According to the datapresentedby Armenian Bilateral andmultilateral agreementsareinplaceforsending andreceivingpersonnel, anddeployments hygienists, entomologists, veterinarians, clinicians, paramedical personnel andlaboratory technicians. multidisciplinary capacity in place at the national, regional and local levels, including epidemiologists, ensuring thatsufficienthumanresourcecapacitiesareinplacetoimplementIHR(2005). The countryhas Owing inparttothesecuritysituationregion, Armenia hasdedicated significanteffortsto Armenia: levelofcapabilities health surveillance and response at all levels of the health system and the effective implementation of the the of implementation effective the and system health the of levels all at response and surveillance health IHR (2005). A workforce includes physicians, animal health or veterinarians, biostatisticians, laboratory laboratory biostatisticians, veterinarians, or health animal physicians, includes workforce A (2005). IHR scientists, farming/livestock professionals, with an optimal target of one trained field epidemiologist (or (or epidemiologist field trained one of target optimal an with professionals, farming/livestock scientists, equivalent) per 200,000 population, who can systematically cooperate to meet relevant IHR and PVS core core PVS and IHR relevant meet to cooperate systematically can who population, 200,000 per equivalent) competencies. human resources across the full of public spectrum health services. Initiate planning, workforce public focusingthe on specifically health workforce; plan monitorand • strengthening/challenges need that Areas • • practices Strengths/best D.5.3 Workforce strategy –Score 5 • • strengthening/challenges need that Areas • • • practices Strengths/best programme inplace–Score 5 D.5.2 Fieldepidemiologytraining programme orotherappliedepidemiologytraining • strengthening/challenges need that Areas • practices Strengths/best D.5.1 Humanresources are availabletoimplementIHRcore capacityrequirements –Score 5 Indicators andscores • • • resources for public health services. the needs of the public health workforce. Armenia should begin planning and monitoring of human the number of public health professionals, amore focused approach is required to adequately address specifically on the public health workforce.As the number of healthcare professionals greatlyexceeds There are currently to few conduct workforce systematic very planning efforts activities focusing Retention is monitored and measures are being taken to improve retention. implemented. Workforce planning is taking place and ahuman resource development strategy is currently being South Caucasus FELTP. A long-term strategy would required be to reduce the dependency on the United States CDC for the The national currently FETP being piloted needs to firmly be established. Armenia has alarge number of trained epidemiologists. national. piloting the is currently A mentorship programme is in place and the International Scientific-Educational Center of the NCDC the EU MediPIET. Armenia regularly participates in the South Caucasus FELTP run by the United States CDC, as well in remuneration is perceived as low, and there is arelatively high rate turnover. of staff Public health professions are perceived as being than less attractive health care professions; level of internationally.deploying workforce is multidisciplinary, functions at both national and subnational levels, and is capable of Armenia has ahigh level of human resource to implement capacity IHR (2005). The public health of the South Caucasus FELTP, as so to reduce dependency from United States CDC. along-termIdentify strategy, in dialogue with other countries in the region, for taking over responsibility Allocate funding to increase thepackage benefits of public health professionals to ensure retention. NCDC. the of Center International Scientific-Educational the by piloted being currently national FETP the Rollout 31 of IHR Core Capacities of the Republic of Armenia DETECT 32 RESPOND

Joint External Evaluation Development and maintenance of national, intermediate (district) and local/primary level public health health public level local/primary and (district) intermediate national, of maintenance and Development emergency. support operations attheintermediateandcommunity/primaryresponselevelsduringapublichealth identification andmaintenancesofavailable resources, includingnationalstockpilesandthecapacityto and nuclear hazards. Other components of preparedness include mapping of potentialhazards, the response levelpublichealthemergencyplansforrelevant biological, chemical, radiological Preparedness includesthedevelopmentandmaintenanceofnational, intermediateandcommunity/primary Introduction Preparedness RESPOND • strengthening/challenges need that Areas • practices Strengths/best developed andimplemented–Score 5 R.1.1 Multi-hazard nationalpublichealthemergency preparedness andresponse planis Indicators andscores • Recommendations forpriorityactions resources andensuresthatcriticalstocklevelsaremaintained. levels. The MESperformsriskassessmentsandupdatesthenationalprofile on anannualbasis, maps times ayear, includinganannual nation-wide testinvolvingthefullspectrumofpublicinstitutions, atall there areplansformobilizingresourcestosupportresponseatthelocallevel. Tests areconductedseveral health, inlinewiththerequirementsof Annex 1A, Article 2oftheIHR(2005). Surgecapacityisinplaceand been preparedforavariety ofscenarios, andeachofthesecontainsspecificprovisions pertainingtopublic Preparedness isastrongpointin Armenia’s implementation ofIHR(2005). Emergencyresponseplanshave Armenia: levelofcapabilities Target emergency response plans for relevant biological, chemical, radiological and nuclear hazards. This covers covers This hazards. nuclear and radiological chemical, biological, relevant for plans response emergency mapping of potential hazards, identification and maintenance of available resources, including national national including resources, available of maintenance and identification hazards, potential of mapping stockpiles and the capacity to support operations at the intermediate and local/primary levels during a a during levels local/primary and intermediate the at operations support to capacity the and stockpiles public health emergency. emergency. health public No areas are in need of strengthening. response plans are in place and regular simulation exercises are conducted. The MES and MoHform astrong institutional framework for emergency preparedness. Comprehensive Prioritize rolling out of the Disaster Resilient Community Programme to national scale. • strengthening/challenges need that Areas • • practices Strengths/best R.1.2 Prioritypublichealthrisksandresources are mappedandutilized–Score 5 preparedness and response plans appropriate. as emergency health public update and risks, emerging of assessment Continuously the improve aligned to the needs dictated by the national risk profile. The MES and MoHmonitor different stockpiles and resources, and ensure that they are up-to-date and Risk assessments are annually performed and the national risk profile is updated accordingly. 33 of IHR Core Capacities of the Republic of Armenia RESPOND 34 RESPOND

Joint External Evaluation Countries will have a public health Emergency Operation Center (EOC) functioning according to minimum minimum to according functioning (EOC) Center Operation Emergency health public a have will Countries support decision-makingandimplementation, coordination, andcollaboration. during aresponsetoanemergencyorexercise. They alsoprovideotheressentialfunctionsto exercises. EOCsprovidecommunicationandinformationtoolsservicesamanagementsystem information andresourcesforstrategic managementofpublichealthemergenciesandemergency A publichealthemergencyoperations center(EOC)isacentral locationforcoordinatingoperational Introduction operations response Emergency • • • • Recommendations forpriorityactions regularly withtheinvolvementofrelevant sectors. Simulation exercisestotestthecapacityofcountry respondtothedifferenthazardsareconducted place fromtheperipheral tothecentral levelwiththeneeded procedures. are available atdifferentlevelsforcaseinvestigationandmanagement. A casereferral systemisalsoin Case managementproceduresandguidelinesareavailable forallIHR-relevant hazards. Trained personnel procedures arereviewedregularlyandsharedwiththedifferentstakeholders. These plansareflexibletoaddresscomplexhealthemergencyissuesincludingatpointsofentry. These Plans andproceduresexistintheEOCs, aswellMoUsbetweenagenciestoformalizecollaborations. through formalandinformalexchangeofinformationbetweenthedifferentsectors. a widerange ofscenarios, triggersandactivation levelsare inplace. Situationalawareness ismaintained A nationalframework, i.e. theNationalIncidentManagementSystem, andspecific activation planswith operations requiringsurgehumancapacities. including theEOCswithinrequiredtimeframe oftwohours. Armenia canalsoactivate response mechanism. The country has a high-level of capability to activate any of the emergency response operations Armenia hasaverywelldefinedemergencyresponsesysteminvolvingallthetiersofadministrative Armenia: levelofcapabilities Target common standards; maintaining trained, functioning, multi-sectoral rapid response teams and “real-time” “real-time” and teams response rapid multi-sectoral functioning, trained, maintaining standards; common biosurveillance laboratory networks and information systems; and trained EOC staff capable of activating activating of capable staff EOC trained and systems; information and networks laboratory biosurveillance a coordinated emergency response within 120 minutes of the identification of a public health emergency. health public a of identification the of minutes 120 within response emergency coordinated a Further enhance of the the on disaster capacity country risk reduction. origins. Raise the awareness of the population regarding response to public health emergencies of different Enhance of the risk capacity assessment of potential PHEICs at the different administrative levels. PHEIC. potential to response rapid and detection Enhance the early warning system by linking to indicator-based and event-based surveillance for early • strengthening/challenges need that Areas • • practices Strengths/best R.2.3 Emergency operations programme –Score 5 • • • strengthening/challenges need that Areas • • • • • practices Strengths/best R.2.2 Emergency operations centre operating procedures andplans–Score 5 • strengthening/challenges need that Areas • • • • practices Strengths/best R.2.1 Capacitytoactivateemergency operations –Score 5 Indicators andscores EOC should of any apart be simulation exercise for testing response. sectors. all concerned cover Training and place in are programmes Simulation exercises are conducted regularly and the needed improvement is carried out. week. A roster should developed be toand support ensure that EOC functions 24 hours aday, seven days a Training needs to continued be for all relevant ministries, including EOC members. activation. response There should amore be systematic evaluation of the resources needed at each level to ensure consistent Trainings have been conducted tothe activation support process of EOCs. Triggers to activate the EOC are available. place. isin system Risk-based communication Plans and procedures are in place. The EOC has to the function capacity 24 hours aday, seven days aweek with designated personnel. identified. were challenges major No availability. staff Surge Strong communication the differentthrough between sectors senior officials. needed. when operations, in SOPs to activate emergency operations are in place and Armenia has to the maintain capacity continuity sectors. National plan for emergency preparedness and response to all hazards is in place and accessible to all 35 of IHR Core Capacities of the Republic of Armenia RESPOND 36 RESPOND

Joint External Evaluation • strengthening/challenges need that Areas • • • practices Strengths/best R.2.4 Casemanagementprocedures are implementedforIHRrelevant hazards –Score 5 The capacity of riskThe capacity assessment needs strengthening. further Protocols and procedures are accessible to ground personnel. Referral system is in place from peripheral level to central level. all hazards. for developed have been protocols management Case In the event of a biological event of suspected or confirmed deliberate origin, a country will be able to to able be will country a origin, deliberate confirmed or suspected of event biological a of event the In • • • • practices Strengths/best are linked during asuspectorconfirmedbiologicalevent–Score 5 R.3.1 Publichealthandsecurityauthorities, (e.g. lawenforcement, border control, customs) Indicators andscores • • • Recommendations forpriorityactions preparedness andresponseplans, arenotanintegral partofthenationalplan. annual basisandthenationalplanisreviewedaccordingly. Sectoral plansthatexist, includingpublichealth laboratory systemsandnetworksarecapableofidentifyingunknownagents. Drills areconductedonan including thoseatpointsofentryfortheearlydetectionsourcespublichealthevents. Existing authorities thatensurestimelyandcoordinatedresponseoperations. Enforcement systemsareinplace, There isregularreal-timeinformationsharingbetweennationalpublichealthagenciesandlawenforcement and securitysectorstosupporttheimplementationofanypublichealthprogramme. plan ofthecountry. The Armenian systemallowsthepublichealthsectortocalluponlawenforcement alleged deliberate useevents. This isaddressedinthepublic healthemergencypreparednessandresponse Armenia hasgreatcapacitytolinkpublichealthandlawenforcement, includingtheinvestigationof Armenia: levelofcapabilities Target law enforcementwillneedtoquicklycoordinateitsresponsewithpublichealthandmedicalofficials. (e.g., theanthrax terroristattacks)ornaturally occurring(e.g., flupandemics). Inapublichealthemergency, Public healthemergenciesposespecialchallengesforlawenforcement, whetherthethreatismanmade Introduction authorities security and health public Linking conduct a rapid, multi-sectoral response, including the capacity to link public health and law enforcement, enforcement, law and health public link to capacity the including response, multi-sectoral rapid, a conduct and to provide and/or request effective and timely international assistance, including to investigate alleged alleged investigate to including assistance, international timely and effective request and/or provide to and use events. use There is strong coordination and collaboration with the media. There is joint risk assessment, investigation and response. place. in is sharing information regular Timely There are formal agreements in place among all of the relevant sectors. SOPs. Review existing SOPs for joint investigation and response to public health events and develop necessary response. Improve bilateral information sharing related to public health events detection, investigations and Ensure accessibility of all existing plans to the relevant stakeholders of public health and security. 37 of IHR Core Capacities of the Republic of Armenia RESPOND 38 RESPOND

Joint External Evaluation Areas that need strengthening/challenges • strengthening/challenges need that Areas • • enforcement and security sectors. security and enforcement There is need for continuous joint training the including different between sectors with the law place. in are emergencies health public including emergencies SOPs to guide the actions of different stakeholders in ahighly coordinated multisectoral response to event. hazardous major or disaster The public health has sector clear protocols that engage forces the security to assist when there is a A national framework for transferring (sending and receiving) medical countermeasures and public health health public and countermeasures medical receiving) and (sending transferring for framework national A • • • Recommendations forpriorityactions assets internationally. Group (INSARAG) andhasatrained NationalUrbanSearchandRescue Team andcandoesdeploy Security Treaty Organization. Armenia isalsoamemberoftheInternationalSearchandRescue Advisory and mutualaid. Armenia is amemberoftheEurasian EconomicCommunity(EurAsEC)andCollective Armenia hassignedbilateral andmultilateral agreementsconcerning sharingsituationalerts, information emergency situations. been signedwithfivemajorpharmaceuticalimportersfortheproductionandimportofmedicinesduring pharmaceutical companies producing several types of antibiotics within the country. Written contracts have in thecountryarealsoobligedbylawtohavea30-daystockpileofmedicalsupplies. There arefour mobilize thestockpileinanemergency, upon agreementwiththePrimeMinister. All medicalfacilities medicines, medicalandsanitaryequipment. The MinisterofEmergencySituations hastheauthorityto There isanationalstockpileofsuppliesforemergencysituationsintheStateReserve Agency, including plans. After thatmajorsimulationseveral tabletopexercises havealsobeencarriedout. were simulated. The lessonsidentifiedinthisexerciseledtotheadaptationsof various proceduresand International Airport. Duringtheexerciseprocessesofhumanitarianassistance receipt anddistribution the system. In2014amultisectoral simulatedearthquake exercisewas conductedattheZvartnots countermeasures and deploying personnel. There are regular drills and simulation exercises to improve Armenia hasthelegalframework inplacefortransferring (sending, receivinganddistributing)medical Armenia: levelofcapabilities Target emergency forresponse. health. Inaddition, itisimportanttohavetrained personnelwhocandeployincaseofapublichealth catastrophic infectiousdiseasethreats. InvestmentsinMCMcreateopportunitiestoimproveoverall public Medical Countermeasures(MCM)arevitaltonationalsecurityandprotectnationsfrompotentially Introduction deployment countermeasuresMedical andpersonnel and medical personnel among international partners during public health emergencies. health public during partners international among personnel medical and improve radio communication services. communication radio improve Modernize emergency response equipment, such as ambulances for transporting multiple victims and material reserves. state the in stockpiles increase to order in funding additional Secure Provide training further to regional-level distribution staff.

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Joint External Evaluation • • • • • • • practices Strengths/best health emergency –Score 5 R.4.1 Systemisinplaceforsendingandreceiving medicalcountermeasures duringapublic Indicators andscores • • • • strengthening/challenges need that Areas • • • • • • • • • practices Strengths/best emergency –Score 5 R.4.2 Systemisinplaceforsendingandreceiving healthpersonnel duringapublichealth • • • • strengthening/challenges need that Areas Regular drills that increase preparedness and feed into the updating of plans are conducted. place. isin facility health each at stockpile 30-day notified. National stockpile is in place and warehouse are ready staff to deploy within hours of being two Multisectoral subteams are operating at all points. entry isExperience in of place. staff Single system. management is inLegal place. framework in case of an emergency. an of case in ofLack specialists (such as anesthesiologists, resuscitation specialists, surgeons) who would needed be Legal framework needs constant review. Infrastructure for receiving relief workers from abroad needs to brought be up to international standards. training. regional in Improvement standards. National Urban Search and Rescue team is in place with qualifications up to international INSARAG Regular drills that increase preparedness and adjust plans are conducted. Local level committees are responsible for overseeing deployment of both supplies and health personnel. Transportation are costs covered by the Armenian Government on the basis of mutual agreements. Plans exist for accommodating them in special secure camps. Certificates of licensed professionals comingfrom abroad are recognized. and later in Indonesia. Past experience country of international deployment of health personnel in earthquake in Iran 2003 health40 personnel on ateam list are ready for deployment within 24 hours. is inLegal place. framework Being an earthquake prone is country achallenge. training. regional in Improvement Provision additional of financial resources the above for recommendations. material of reserves. development Further States parties should have risk communication capacity which is multi-level and multi-faced real time time real multi-faced and multi-level is which capacity communication risk have should parties States is overloaded(suchasduring blizzardsinwinterduetostuckcars), callsarere-directed tonationalcentre regionally distributedandcalls aredirectedtoregionalcrisismanagementcentres. Iftheregionalcallline need acommunicationoroperative response. The 911lineattheNationalCrisisCentre oftheMESisalso daily activemedia, socialmedia andInternetmonitoringreportingonevents andrumoursthatmay ministries couldbeimproved. NCDCattheMoHandmostotherpublicrelations departmentsconduct and communicate via social media, Facebook and Instagram, but formal and informal contacts with other has anappointedpressperson. The publicrelationspersonnelintheMoH, MoAandMEScollaborate well Every ministryhasapublicrelationsdepartmentwithtrained spokespersons, andeveryseniormanager organizations. were tested, includingmultistakeholder collaboration withinternationalandlocalnongovernmental During emergencydrills, suchasthesimulatedearthquake attheairportin2014, alllevelsofcommunication sociologist and psychologist) responsible for coordinating public communication during an emergency. established attheMESwithmultiprofessionalcompetencies (journalists, communication, photographers, communication atnational, regionalandlocallevels. At thenationallevelaJoint InformationCentreis and responsibilitiesofstaffinchargeriskcommunication. There areappointed focalpointsforrisk are includedinallavailable emergencyresponseplans. These nationalplansarticulateprocedures, roles then. Armenia doesnothaveamulti-hazardriskcommunicationplan, butcommunication procedures Risk communicationisregulatedby two decreessignedin2003and2005, andrevisedseveral timessince Armenia: levelofcapabilities Target communications plansneedtobetestedandupdatedasneeded. decision makingareessentialforbuildingtrustbetweenauthorities, populationsandpartners. Emergency mechanisms shouldbeestablished. Inaddition, thetimelyreleaseofinformationandtransparency in and stakeholders inthecountryneedtobeidentified, andfunctionalcoordinationcommunication levels. Disseminatingtheinformationthroughappropriatechannelsisessential. Communicationpartners prevention andcontrolactionthroughcommunity-basedinterventionsatindividual, familyandcommunity voice oftheaffectedpopulation. Communicationsofthiskindpromotetheestablishmentappropriate political andeconomicaspectsassociatedwiththeeventshouldbetaken intoaccount, aswellthe For any communication about risk caused by a specificeventto be effective, thesocial, religious, cultural, the disseminationofinformationtopublicabouthealthrisksandevents, suchasoutbreaksofdiseases. the capacitytocopewithanunfoldingpublichealthemergency. An essentialpartofriskcommunicationis define risks, identifyhazards, assessvulnerabilities andpromotecommunityresilience, therebypromoting Risk communicationsshouldbeamulti-levelandmulti-facetedprocesswhichaimsathelpingstakeholders Introduction Risk communication exchange of information, advice and opinion between experts and officials or people who face a threat or or threat a face who people or officials and experts between opinion and advice information, of exchange hazard to their survival, health or economic or social well-being so that they can take informed decisions to to decisions informed take can they that so well-being social or economic or health survival, their to hazard mitigate the effects of the threat or hazard and take protective and preventive action. It includes a mix of of mix a includes It action. preventive and protective take and hazard or threat the of effects the mitigate communication and engagement strategies like media and social media communication, mass awareness awareness mass communication, media social and media like strategies engagement and communication campaigns, health promotion, social mobilization, stakeholder engagement and community engagement. community and engagement stakeholder mobilization, social promotion, health campaigns, 41 of IHR Core Capacities of the Republic of Armenia RESPOND 42 RESPOND

Joint External Evaluation guaranteed. to befurtherdeveloped. Sustainablefundingforcommunicationparticularlyatthelocallevelneedstobe communication linksbetweencertainregionsandpublicrelationdepartmentsatnationallevelmayneed than buildingcommunicationincollaboration withthelocalcommunityasequalpartners. Also, horizontal developed riskcommunicationsystemin Armenia. The tendencyisfortop-downcommunication, rather However, thereisaneedformore proactiveengagementofcommunitiestofurtherstrengthenthealready delegated fundingforresponseandcommunicationactivities, consultationandfeedback. the ChiefofCivilProtection(apersonelectedbycommunity(from10000–150000persons)with current healthrisktopics to the MoH. Newactionandrisk communication plans are disseminatedthrough goal ofthiscommissionistobeadiscussionforumfortheparticipantsprovidetheirperspectiveon national andinternationalnongovernmentalorganizations, cliniciansandtwopublicopinionleaders. The A newlyestablishedpubliccommissionon “public opinion” attheMoH, includesrepresentativesfrom contacted fordisseminatinginformation. national list of community members with telephone numbers in certainhard-to-reach areas, who canbe to crisiszonescreateahotspotofradio broadcasting. Ifallothermediatransmissions fail, thereisa special carforradio transmission aswellforrelayingmessagesthroughaloudspeaker canbedeployed emergency, broadcastingonallchannelscanbeinterruptedtobroadcastriskcommunicationmessages. A communication messages. The national television channel reaches all parts of Armenia and in case of which iswidelydisseminated. Agreements aresignedwiththreemobilecellularcompaniestotextrisk MES also produces a newspaper called Emergency Gazette with 10,000 private and public subscribers, risk communication is transmitted through texts or videos, updated regularly, and every hour during a crisis. web, socialmediaandnewspaperstothegeneral population. The MEShasawebsite(www.mes.am) where education andcommunication(IEC)materialsdistributedinschoolsaswellthroughtelevision, radio, Public riskcommunicationin Armenia istransmitted throughamixofchannelsincludinginformation, and arealsoskilledinfirefighting. in Yerevan. Four specialrescuesquadsareonduty24hourseverydaytorespondcalls • • • practices Strengths/best R.5.1 Riskcommunicationsystems(plans, mechanisms, etc.) –Score 4 Indicators andscores • • • • Recommendations forpriorityactions Hotlines function in all government agencies. all in government function Hotlines emergencies. National platform for risk reduction system at MES (Joint Information Centre) is established for focal points at national, regional and local levels. responsible plan with response emergency each in included risk communication of Regulated system Ensure sustainable funding for risk communications activities, especially at the local level. role of communities as “equal partners”. Strengthen partnerships local communities between and authorities, and mechanisms tothe support than health, agriculture and emergencies. Strengthen informal communications, relationships and key trust between in actors ministries other working in the different ministries. various the public relations between media and rumour monitoringand communications reports teams Strengthen communication and knowledge management mechanisms, to enable daily sharing of • • • • practices Strengths/best R.5.3 Publiccommunication–Score 5 • • • strengthening/challenges need that Areas • • • • • • practices Strengths/best R.5.2 Internalandpartnercommunicationcoordination –Score 5 • • • • strengthening/challenges need that Areas • • endemic in Armenia. in endemic Training for mass media journalists is conducted on diseases that have high outbreak risk or are programme. trainers the training NCDC Head of Public Relations underwenttraining WHO on risk communication, which turned into a MES. of Academy Training of specialists involved in risk communications is conducted by the Crises Management State speaking to the public. The crisis management centre, including the Joint Information Centre at the MES, is atrusted asset for Improve communication skills at local and regional levels. Sustained funding for local communication work is required. improve of risk the efficiency communications. Regular training in risk communications is carried but out, an increased budget for training would plan and have their own(limited) budget. feedback on new emergency actionplans. They develop a local version of the national communication Chief of Civil Protection and associated local volunteers are in dialogue with local stakeholders and give participation of stakeholders and updates information on the MES website. In emergency situations, the public relations department regular of MES conducts media briefingswith MoH and the Ministry of Territorial Administration (under which health facilities are organized). Communication is coordinated among crisis management centres and public relations units of MES, MES is equipped with communication consisting network of Internet, cable, and fax radio. organizations, are in partners the active exercise as well as in adapting plans from lessons learned. During drills, and healthnational workers, care media actors and international nongovernmental All risk communication planning that includes multistakeholders’ roles and responsibilities are in place. Constant challenge to maintain trust in information transmitted by MoH. some ministriesbetween may achallenge be for rapid communication. All messages from each ministry need to clearedbe by the highest level of management; coordination capacities. communication local of Development developed. less are regions between communications horizontal that shown Vertical communication from national, regional to local level well, works but simulation exercises have participationwith of representatives fromgovernment agencies. and functioning of an intersectoral joint information center in of case an emergency (major earthquake) Regular exercises are conducted. The latest drill by MES on 19–20 July 2016 was on the establishment Well-functioning 911 call-line at both regional and national levels. 43 of IHR Core Capacities of the Republic of Armenia RESPOND 44 RESPOND

Joint External Evaluation Strengths/best practices Strengths/best R.5.4 Communicationengagementwithaffectedcommunities–Score 4 • strengthening/challenges need that Areas • • • • • • strengthening/challenges need that Areas • • • practices Strengths/best R.5.5 Dynamiclisteningandrumourmanagement–Score 5 • • strengthening/challenges need that Areas • • • • • • Develop local capacity for risk communication. for capacity local Develop are used on the MES website. Armenian language is spoken by >95% of the population and understood by all, but three languages Visual public communication materials are audience testedtarget among a prior to publication. fromstarting pre-school level. Risk communication on how to behave in an emergency is taught in the basic school curriculum however this may hinder adaptation of communication with the help of local communities. local help of the however this communicationwith may of hinder adaptation response, of dissemination efficient more enable to emergencies during force is in management Vertical significant negative behaviour.on impact at-risk population. There are, however, few examples very of rumours gettingout of control with pandemic, despite the rumours and mistrust, they achieved 98% coverage of vaccination among the There are examples of occasions that showed mistrust towards the MoH. For example in the influenza Rumours spread quickly in Armenia and need to managed be during crises. governmentbetween bodies if required. them, if necessary, are cleared in the management of each government department and shared counterbalance to strategies communication and rumours/information double-checked on Reports systematic way. Information is double-checked and risk communication is adapted accordingly. Dynamic listening through exists many channels (hotlines, media, social media, local actors) in a of the ministries. different A system for daily monitoring and reporting on rumours is in place in the public relations department Exercises and simulations should focus more on local community engagements. partnership with the community. Currently there is more risk of a top-down communication tradition rather than building equal plans. communication risk better build to help will that channels communication preferred A recent of survey more than 10,000 participants was conducted on trusted information resources and Public commission for shaping public communication is in place at the national level. Health promotion is implemented by regional and local MoHhealth facilities. was used to identifyissues in need of improvement. populationsFeedback system from affected during the earthquake drills flood emergency and Artik and/or at-risk affected between population and the response teams. Crisis management centres are operating on a24-hour schedule. This enables communication two-way plans, roles and responsibilities and is outlined in the locally developed response plans. Involvement of local government bodies and volunteer groups is envisioned in all emergency response States Parties should designate and maintain the core capacities at the international airports and ports (and (and ports and airports international the at capacities core the maintain and designate should Parties States bioterrorism. country needstofurtherenhance preparednessforpublichealthresponserelatedto massmigration and A functioningvectorcontrol programme atalldesignated pointsofentryneedstobeestablished. The activities requiredcontinuous effortandinvestmentfromallstaffatthepointsofentry. and significant collaboration was noted among the sectors, however streamlining and coordination of hand, andexamplesofpublichealthresponsestoexercises anddrillswereshared. Overall, highcapacity routine andemergencysituations. The stateofthefacility’s capacityandequipmentwas observedfirst- Zvartnots International Airport was conductedtodiscusspointsofentrycapacitiesspecific toIHR, forboth Development Programme (UNDP) andtheEurasian EconomicCommunity. Duringthemission, asitevisitto at Armenia’s borderpointsthroughsupportfromvarious technicalpartners, suchasUnitedNations Significant physicalinvestmentsandcapacitybuilding training/projects havebeenrecentlyimplemented multisectoral coordinationamongst sectors. well as other national health regulatory guidelines at Armenia’s points ofentry. Numerous policies support The StateHealthInspectorate onbehalfoftheMoHisresponsibleforimplementationIHR(2005)as through various exercisesanddrills. and collaborate withwell-definedstakeholders forbothroutineandemergencycapacities, asdemonstrated decree N1418 (10 June 2011). Competent authorities have been clearly identified at the points of entry Armenia hasadoptedspecificprovisionsunderIHRforthetwodesignatedpointsofentryGovernment diplomatic relationshipswithitsneighboringcountries. Georgia. Armenia sharesterrestrialborderswith Azerbaijan, Georgia, Iran and Turkey yetholdsnoofficial Zvartnots International Airport in Yerevan, andtheBagratashen groundcrossingthatsharesitsborderwith have beenofficiallydesignatedfordevelopingpublichealthcapacitiesasoutlinedwithintheIHR– Armenia hassevenpointsofentry(twoairports, onerail stationandfourgroundcrossings), ofwhichtwo Armenia: levelofcapabilities Target measures requiredtomanageavariety ofpublichealthrisks. health reasons, aStateParty maydesignategroundcrossings)whichwillimplementspecificpublichealth the corecapacitiesatdesignatedinternationalairportsandports(andwherejustifiedforpublic of healthmeasurestopreventinternationalspreaddiseases. StatesParties arerequiredtomaintain All corecapacitiesandpotentialhazardsapplytoPoints ofentryandthusenabletheeffectiveapplication Introduction Points of entry ENTRY OF POINTS AND HAZARDS IHR-RELATED OTHER where justified for public health reasons, a State Party may designate ground crossings) which implement implement which crossings) ground designate may Party State a reasons, health public for justified where specific public health measures required to manage a variety of public health risks. health public of variety a manage to required measures health public specific 45 of IHR Core Capacities of the Republic of Armenia OTHER 46 OTHER

Joint External Evaluation resulted inaScore3forthisindicator. conveyances available at points of entry) were existent, the lack of a functioning vector control programme (Inspection programme toensuresafeenvironment)andScore5(Trained personnelfortheinspectionof The external assessment team and their Armenian counterparts concluded that while elements of Score 4 P Indicators andscores • • • Recommendations forpriorityactions • practices Strengths/best P • • • strengthening/challenges need that Areas • • • • • • • practices Strengths/best oE.1 Routinecapacitiesare establishedatpointsofentry–Score 3 oE.2 ffectivepublichealthresponse atpointsofentry–Score 4 and plans with the exiting legal base. Establish a formal working group representing relevant stakeholders for streamlining activities, SOPs ensure asafe environment at points of entry. to control, vector particular in programmes, health public of implementing Enhance planningand points of entry. Review and update existing SOPs for the early detection and management of public health events at different potential threats. Contact points for all relevant are regularly sectors maintained and posted. sanctioned within N-777, binding on all relevant stakeholders with clearly defined roles concerning A national emergency public health response plan for exists both designated points of entry, and is jointThe draft decree control on vector at is points of currently entry pending. Establishment of afunctioning control vector programme at all designated points of entry initiation isolation, applicable. of if Development of a“one-stop single window” system for the identification travelers of affected and English.Russian and Health sensitization for pertinent public health matters is displayed in multiple languages –Armenian, contractors. party third Disinfection and deratting are done in the Zvartnots International premises Airport ayear twice via water, potable establishments. eating washrooms, clean Safe environment for traveling passengers was ensured at with points facilities of entry such as hygienic Availability of trained to control staff conveyances at the designated points of entry. measures). (e.g.measures noncontact Rapid threat detection and management capabilities are in place, including the existence of preventive cases. suspected of management Points have of entry established links with local health centres and veterinary for services the patients. infectious highly for place in is facility Quarantine equipment and transport of suspected to cases appropriate medical centres via ambulance services. Points to possessthe provide capacity of entry access to medical and services staff, diagnostic • • strengthening/challenges need that Areas • • • patients. Securing specialized transport (capsules, special ambulances) for the safe transfer of highly infectious Preparedness for public health response related to mass migration and bioterrorism. cases. Ebola suspected of management for equipment Emergency training and exercises occur periodically, such as proper utilization of personal protective travelers, also exists. Provision of appropriate space to persons, interview separate suspected or affected from other to cargo/conveyances exist. Specific areas and protocols for reserved quarantine, as well as for the application of control measures 47 of IHR Core Capacities of the Republic of Armenia OTHER 48 OTHER

Joint External Evaluation States parties should have surveillance and response capacity for chemical risk or events. It requires requires It events. or risk chemical for capacity response and surveillance have should parties States Target transportation andsafedisposal effective communication and collaboration among the sectors responsible for chemical safety, industries, States partiesshouldhavesurveillanceandresponsecapacityforchemicalriskorevents. Itrequires Introduction eventsChemical • • practices Strengths/best events oremergencies –Score 4 CE.1 Mechanismsare established and functioningfordetectingresponding tochemical Indicators andscores • • • Recommendations forpriorityactions dispose ofhazardouswastes; howeverthereislimitedabilitytoundertake soiltesting. mandatory. There is legal provisionforcontaminatedlandandthecontrolofsitesthatareusedto for chemicalsafety. There issomeregistration ofhazardouschemicalsites, butthisneedstobemade There isapublichealthplanforthemanagementofchemicalincidentsandnationalcoordinatingbody is publishedonamonthlybasisandinvestigationreportsofincidentsarereportedannually. chemical testingfacilities, althoughclinicaltreatment facilities are limited insize. Chemicalmonitoringdata which was apparentduringthejointpresentation. There islegislationrelatingtofoodcontaminationand liaison betweenenvironmentalandchemicalauthorities(andotherrelevant government authorities), chemical conventions, suchasthoseofStockholmandMinamata. There is verygoodcooperation and response. There arealsolegalframeworks forchemical transportation and Armenia isasignatoryto but theframework iscomplexanda “unified chemicallaw” wouldaidclarityinboth preparednessand at nationallevel), whichreportstotheNCDCforeachevent. A legislativeframework supportsthesystem; chemical surveillancesystemhasbeenoperating atlocal, regionalandnationallevels (monthlyanalysis Armenia has a well-developed system for surveillance and response to chemical events. Since 2015, a Armenia: levelofcapabilities effective communication and collaboration among the sectors responsible for chemical safety, industries, industries, safety, chemical for responsible sectors the among collaboration and communication effective transportation and safe disposal. safe and transportation Satisfactory human and financial human and resources. Satisfactory Surveillance system is now embedded at local, regional and national levels. Participate in international chemical/toxicological networks, such as INTOX and CHEMNET. for hazardous sites. Develop and endorse a“unified” law governing chemical matters and a mandatory registrationsystem Set up acoordinating “poisons centre” to enhance the functioning of chemical expertise. • • strengthening/challenges need that Areas • • • practices Strengths/best CE.2 Enablingenvironment isinplaceformanagementofchemicalevents–Score 4 • • • strengthening/challenges need that Areas Develop a“unified law” for covering all pertaining matters to chemicals. forNeed amandatory registration system for hazardous chemical sites. Regular exercises conducted to observe responses. Good legislative framework in place, but somewhat complex. Established national coordinating body. isrequired. international in chemical/toxicological networks Participation Communication systems for publication of monitoring data need to streamlined. be Poisons centre is needed, more as acoordination rather than activity as aphysical centre. 49 of IHR Core Capacities of the Republic of Armenia OTHER 50 OTHER

Joint External Evaluation States parties should have surveillance and response capacity for radio-nuclear hazards/events/emergencies. hazards/events/emergencies. radio-nuclear for capacity response and surveillance have should parties States Target management. It requireseffectivecommunicationandcollaboration amongthesectorsresponsibleforradio-nuclear States partiesshouldhavesurveillanceandresponsecapacityforradio-nuclear hazards/events/emergencies. Introduction Radiation emergencies • • strengthening/challenges need that Areas • practices Strengths/best and nuclearemergencies –Score 5 RE.1 Mechanismsare establishedandfunctioningfordetectingresponding toradiological Indicators andscores • • • Recommendations forpriorityactions requested byotherjurisdictionsduetoitsexpertiseandisusedasanexemplarinthisfield. experience fromtheChernobylresponse)totreatradiological injuries. Armenia hasahistoryofbeing regularly. There arealso reference health care facilities with equipment and experienced staff (some with There isawell-developedradiation emergencyresponseplanwithSOPsinplace; andthisisexercised radiological incident. also is a set of risk assessment and surveillance-monitoring procedures, to trigger/mount a response to a laboratory capacityforenvironmentalmonitoringandsurveillanceofbothpeople materials. There waste storage facilitieswherenuclearandradioactive facility, materialsareused. andof other There is storage facility,power plant, dryspentnuclear fuel ionizingradiation sources, RADONtyperadioactive andradiation safetyofthe Nuclear Regulatory regulatesthe nuclear Armenian nuclear Authority (ANRA) for a few decades, and has developed strong strategic plans for nuclear and radiation safety. The Armenian Armenia hasastronghistoryintheradiological protectionfield. Ithasoperated anuclearpowerstation Armenia: levelofcapabilities It requires effective communication and collaboration among the sectors responsible for radio-nuclear radio-nuclear for responsible sectors the among collaboration and communication effective requires It management. Develop national integrated laboratory capacity. laboratory national integrated Develop toNeed increase the number of trained staff. plans. response and system surveillance Well-developed Develop amobile decontamination facility that used canbe at border crossings. system. laboratory national radiological integrated an Develop as are experienced retiring staff (not aunique situation to Armenia). Establish aformal training scheme to increase radiological in younger expertise generation specialists • strengthening/challenges need that Areas • • practices Strengths/best RE.2 nablingenvironment isinplaceformanagementofradiation emergencies –Score 5 Financial resources will needed to be maintain current activities in the future. Very integration good with authorities partner and government departments. planningframework. and legislation Well-developed 51 of IHR Core Capacities of the Republic of Armenia OTHER 52

Joint External Evaluation • • Preparation andimplementationofthemission each party’s position. Team Leadwilldecidetheoutcome; thiswillbenotedintheFinalReportalongwithjustificationfor host countryexpertsoramongtheexternal the hostcountryexperts, theExternalEvaluation Should therebesignificantandirreconcilabledisagreement betweentheexternalteammembersand experts seekingfullagreementonallaspectsofthefinal reportfindingsandrecommendations. and thepriorityactionsshouldbecollaborative, withexternalevaluation teammembersandhostcountry discussions aroundthescores, thestrengths, theareaswhichneedstrengthening, bestpractices, challenges host countryexpertsandExternalEvaluation TeamThe members. entireexternalevaluation, including The JointExternalEvaluation processisapeertoreview. As such, itisacollaborative effortbetween The JEEProcess: • • • • Objectives • • • • • • • • Mission teammembers Yerevan,2016 15-19 August Armenia Mission placeanddates Appendix Appendix 1: Joint Evaluation External Background reporting requirements and responsibilitiesreporting forJEE the process. resources to successfully necessary participate in the JEE process; and provide guidance on self- National training was conducted in July 2016 to provide national stakeholders with information and Armenia to review the agenda, responsibilities and logistics. Prior to the visit, several communications took place the Regional WHO between for Europe Office and (2005) for global capacities health security. Recommend actions priority to update and finalize the national plan to achieve and maintain IHR Develop describing areport the progress and gaps in implementing IHR (2005) capacities. documents. related all Review entry. of points at including events the implementationAssess of IHR (2005) capacities for surveillance and response to public health Ann Lindstrand, National Public Health Institute, Sweden Barry, WorldJessica Health Organisation/EURO Jussi Sane, National Public Health Institute, Finland Andreas Reich, Germany, Koch Robert Institute Organisation/EURO Health World Krauss, von Krayer Martin Milde-Busch,Astrid Germany, Koch Robert Institute John Simpson, United Public Kingdom, Health England Team Co-Lead TeamDalia WHO/EMRO Samhouri, Lead Ministry ofHealth, Environmental HygieneUnit Ministry ofHealth, National ReferenceLaboratory Ministry ofHealth, Emergency SituationsandMilitaryRecruitmentPreparednessUnit Ministry ofHealth, StateHealthInspectorate Ministry ofHealth, NationalCenterforDiseasesControl andPrevention Ministry ofHealth, PublicHealthDepartment P Sergey Khachatryan, DeputyMinister ofHealth, MinistryofHealth, Republicof Armenia Armenia leadrepresentative Key participantsandinstitutionsfrom Armenia • • • • • • Limitations andassumptions • • • • • articipating institutions known to nationals through their internal discussion. internal their through nationals to known to meet with and peers, opportunity identifygaps. These may not all be in but reflected the is report The team felt that the process useful itselfwas very for since Armenian it provided experts the inbe the main focus), actions and that priory the has country to work on should the be main concern. team, however, emphasized that scoring is not the main objective of aJEE (and should therefore not policies and SOPs, which the team could not validate due to language barrier and time constraints. The The majority of the indicators were scored 5based on confirmation of national availability of plans, the mission arrival. information. Only afew background documents were translated to English and shared one day before mission arrival to the country. Therefore, there was not enough for the team to read and process the The completed self-evaluation tool was shared with the external evaluation team one day before the verified. This peer-to-peeris a review. The evaluation is not an audit and information provided by Armenia will not independently be It is assumed that the results of this evaluation will made be publically available. managed.could be The evaluation was conducted in one week; which limited the amount and depth of information that actions. and priority technical teams involved in the evaluation, to present the outcomes of the JEE, as well as practices best A debriefing meeting was heldwith senior officials, including the ministerdeputy of health and national actions. and to reach consensus a scoresand the priority on Meetings with relevant stakeholders and fieldvisits were conducted to validate the collected information mission. outcomesobjectives and expected of the evaluation, and to discuss and finalize the agenda of the A one-day orientation was conducted with the JEE team to orient them on the JEE process and tool, and logistics arrangements to facilitate the deployment to the country. of external experts Armenia of CountryThe WHO Office alongwith Armenia MoH, put in place administrative the necessary the complete JEE tool for review one day before the external evaluation. Background documents were identified and a few of them were sharedwith the JEE team alongwith 53 of IHR Core Capacities of the Republic of Armenia 54

Joint External Evaluation • IHR coordination, communicationandadvocacy • • • • • • • • • • • • National legislation, policyandfinancing Supporting documentationprovided by Armenia State CommitteeonNuclearSafetyRegulationRadiationSecurityDepartment Ministry ofEnvironmentalProtectionHazardousSubstancesad Waste Policy Division Ministry ofEmergencySituationsRescueService Ministry of Agriculture Food SafetyStateService and radiological factors. radiological and point on detection of an event that may constitute apublic health event due to biological, chemical MoH DecreeN26-N of 29.11.2010: on approving model procedure of reporting to national IHR focal prevention. and epidemiology,brucellosis diagnosis, prevention, treatment, Joint Decreeof MoHand MoA No. 2925–A of 12.12.2014: on approving methodology/guidelines for treatment, prevention, infection control. MoH DecreeNo. 1975–A of 19.08.2014: on Ebola Virus Disease epidemiology, standard definition, case animals. and humans for common approving the methodology of risk assessment of communicable diseases humans, affecting and those Joint MoHNo. Decreebetween 1302-A of 26.05.2015 and MoA No. 144-A of 08.06.2015: on Epidemic. AvianPathogenic Influenza Government of 19.01.2006: Decision N 480-N on approving the National Plan on Response to Highly foci. contamination biological in activities Government Decision N967-N of 18.08.2015: on approving the order of organization of rescue activities in chemical contamination foci. Government Decision N942-N of 18.08.2015: on approving the order of organization of rescue activities in radioactive contamination foci. Government Decision N943-N of 18.08.2015: on approval of the order of organization of rescue means. civil Defense areas, and neutralization and disinfection of radiological, chemical and microbiological Government Decision N1297-N of 04.10.2012: on defining the order of identification of dangerous diseases. communicable of surveillance electronic realtime for MoH DecreeNo. 35-N of 17.12.2010: on approval of and sanitary epidemiological norms and regulations health carefacilities. for these diseases of the MoHstructural divisions, free-standing units, entities under the MoH, and prevention and control program, and the 2016-2020 Action Plan as well as the notification schemes Agriculture No. 3-A of 13.01.2016: on approval of the plague, tularemia, smallpox and influenza Joint Decreeof the Ministers of TAES No. 19-A of 15.01.2016, MoHNo. 3676-A of 22.12.2015, MoH DecreeNo. 3205-A of 13.11.2015: on approval of the guidelines on risk assessment methodology. National (No Service 41-A Security of 10.12.2015). of Territorial Administration and Emergency Situations (No. 1245-A of 01.12.2015) and the Government diseases, approved by the MoH(No. 3250-A of 18.11.2015), MoA (No. 246-A of 24.11.2015), Ministry Joint Decree: on organization of the implementation of integrated electronic system for control of • • • • • • • • • • • • • • • Government DecreeNo. 22 of 07.06.2012: on approving the timetable of multidisciplinary exercises. national IHR focal point and the MES, MEP and MA. Agriculture No. 120-N of 01.07.2013: on approving standard procedures for cooperation the between 670-N of 05.08.2013, Minister of Environmental Protection No. 132-N of 09.07.2013, Minister of Joint Decreeof the Minister of Health No. 32 of 20.06.2013, Minister of Emergency Situations No. sector. the Ministry of Territorial Administration in of case emergence of public health problems in the water cooperation mechanisms the national between IHR focal point and the State Water Committee of Committee of the MTA No. 163-N of 12.12.2011: on approving the standard procedures ensuring Joint Decreeof the Minister of Health No. 24-N of 06.12.2011 and the Chairman of the State Water mechanisms the national between IHR focal point and the General Department of Civil Aviation. of Civil Aviation N171-N of 03.10.2011: on approving the standard procedures ensuring cooperation Joint Decreeof the Minister of Health of 27.09.2011 No. 09-N and the Head of General Department national IHR focal point and the State of the Service Ministry Security of Food Agriculture. of 07.11.2011: on approving the standard procedures ensuring cooperation mechanisms the between Joint Decree of the Minister of Health No. 14-N of 02.11.2011 and the Minister of Agriculture N 47-N national IHR focal point and the Ministry of Economy. of 16.11.2011: on approving the standard procedures ensuring cooperation mechanisms the between Joint Decreeof the Minister of Health No 12-N of 18.10.2011 and the Minister of Economy N935-N national IHR focal point and the Ministry of Economy. of 16.11.2011: on approving the standard procedures ensuring cooperation mechanisms the between Joint Decreeof the Minister of Health No. 11-N of 18.10.2011 and the Minister of Economy N934-N national IHR focal point and the Ministry of Economy. of 16.11.2011: on approving the standard procedures ensuring cooperation mechanisms the between Joint Decree of the Minister of Health No. 10-N of 18.10.2011 and the Minister of Economy N 933-N of cooperation of the national IHR focal point and the Ministry of Education and Science. topics in curricula of medical educational institutions of the Republic of Armenia, within the framework N 1180-N of 25.10.2011: on approving the standard procedures of introduction of new public health Joint Decreeof the Minister of Health No. 13-N of 25.10.2011 and Minister of Education and Science agriculture,of territorial administration situations, and emergency environmental protection. standard procedures defining cooperation mechanisms nationalbetween IHR pointfocal and ministries Minister of Agriculture 198-N of 08.09.2015. Minister of EP 274-N of 25.09.2015 ‘On approving the Joint Decreeof Minister of Health of 19.08.2015, No. 46-N Minister of MTAES No. 943-N of 17.09.2015, as wellnetwork; as approval of the commission membership and procedures. activities related to IHR,prevention and control of communicable diseases, and integrated laboratory Government DecreeN22-A of 17.01.2013: on creation of amulti-disciplinary commission coordinating chemical facilities or chemical hazards.. Government DecreeN861-N of 08.07.2010: on plan for population protection during accidents at care system for emergency situations due to communicable diseases (for all levels and structures). MoH DecreeN3102-A of 28.12.2012: on approving the preparedness and response plan in the health earthquakes.strong Government DecreeNo. 919-N of 10.06.2011: on plan for organization of population protection during procedures of the national IHR focal point and stakeholders. Government DecreeN1138-N of 26.08.2010: on approving cooperation mechanisms and coordination 55 of IHR Core Capacities of the Republic of Armenia 56

Joint External Evaluation • • • • • • • • F • • • • • • • • Zoonotic disease • • • • • • • • Antimicrobial resistance ood safety epidemics, issued (document translated in English in advance). Decree of the Minister of Health 2115 – Aof 23.12.10: on approving the guidelines on management of NCDC, the membership thereof and procedures. Decree of the NCDC General Director of 30.12.2014: on creation of rapid response teams of the MoH 1888-N (21.11.2002) and 1915-N http://www.arlis.am/DocumentView.aspx?DocID=84843 amendments to Government Decree 1032-N (24.07.2004) and (iv) annulling Government Decrees and additions to Government Decrees 1516-N (02.09.2002) and 1316-N (15.08.2002), (iii) making Ministry of Agriculture;the RA approving the SFSS Charter and structure, (ii) making amendments Government Decree1730-N of 30.12.2010: on (i) creation of the State under Service Security Food http://snund.am/en/legal-acts/food-safety/the-laws/ http://www.arlis.am/DocumentView.aspx?DocID=104105 Republic of Armenia Law on food safety. Instructions of the head of SFSS and the RVSPCLS, www.snund.am. Charters of SFSS structural units and filed job descriptionsoffices, of theinspectors, RVSPCLS RRT. animals. and humans for common diseases infectious Guidelines on indicators for assessment of the system for epidemiological and veterinary control of animals. and humans Government Decree of50 13.12.2012: on programme on control of infectious diseases common for Government Decree 82-N of 31.01.2008. Government Decree 1477-N of 11.12.2008. programmes. training Government protocol decision No. 22 of 07.06.2012: on approval of the timetable of multidisciplinary Decree of Minister of Health 1433-A of 12.05.2016. 2016. 27.07. Decree of the Minister of Health of 14.07.2016 and Decreeof the Minister of Agriculture N188-A, 01.12.2014. of Joint Decreeof the Minister of Health of 13.11.2014 No. 66-N and the Minister of Agriculture 247-N http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(14)70071-4/abstract Government DecreeNo. 3337-A of 23.12.2013. Government DecreeNo. 11-A of 24.03.2016. Decree No. of the 59-N Minister of Health Decreeof 14.10.2013. WHO. Response letter No. /09/14965-15 dated 24.12.2015 Minister of the Deputy of Health addressed to letter ofWHO 4December 2015. MoH DecreeNo. 2427-A of 02.08.2016. MoH DecreeNo. 3671-A of 22.12.2015. . . . . • • • • • • • • • • • • • • • • Biosafety andbiosecurity • classification of the laboratories” and the biological risk assessment tools. diseases and risk-based infectious diagnosticsof biological in laboratories laboratory risks performing MoH Order No. 3788-A of 25.12.2015: on approving the methodological guideline on “Assessment of transportation of hazardous cargo and on declaring void the MoHOrder No. 1409-N of 06.12.2006. MoH Order No. of 23.06.2014: 38-N on approving the and sanitary hygienic requirements for Group Iand II pathogenicity. MoH Order No. 1408-N of 06.12.2016: on approving the procedure of handling microorganisms of laboratories. 2016 radiological and chemical biological, of operation “Requirements for on MoH Order of 19.02.2016: No. 04-N on approving the rules sanitary and hygiene norms N 3.1.1-032- “Requirements for storage and use of chemical substances in chemical and biological laboratories”. which deal with biological, chemical and radiological agents”, and the methological guideline on first medical aidequipment, the list and the instructions for the use of suchequipment in laboratories biosecurity, chemical and radiological safety, the methodological instructions on “Requirements for the MoH Order No. 475-A of 19.02.2016: on approving the model manuals and SOPs on laboratory diseases”. infectious diagnosticsof laboratories laboratory performing MoH Order No. 3786-A of 25.12.2015: on approving the manual on “Ensuring laboratory biosafety in systems. safety radiological and chemical biosecurity, biosafety, Government Decree No. 108-N of 12.02.2015: on approving the general requirements for laboratory “Requirements for storage and use of chemical substances in chemical and biological laboratories”. which deal with biological, chemical and radiological agents”, and the methological guideline on first medical aidequipment, the list and the instructions for the use of suchequipment in laboratories biosecurity, chemical and radiological safety, the methodological instructions on “Requirements for the MoH Order No. 475-A of 19.02.2016: on approving the model manuals and SOPs on laboratory transportation of hazardous cargo and on declaring void the MoHOrder No. 1409-N of 06.12.2006. MoH Order No. of 23.06.2014: 38-N on approving the and sanitary hygienic requirements for Group I and II pathogenicity. MoH Order No. 1408-N of 06.12.2016: on approving the procedure of handling microorganisms of 3.1.1-032-2016:N laboratories. radiological and chemical biological, of operation for requirements on of 19.02.2016:MoH Order No 04-N on approving the rules sanitary and hygiene norms diseases. infectious diagnosticsof laboratories laboratory performing MoH Order No 3786-A of 25.12.2015: on approving the manual on ensuring laboratory biosafety in systems. safety radiological and chemical biosecurity, biosafety, Government DecreeNo. 108-N of 12.02.2015: on approving the general requirements for laboratory guidance (adapted). biosecurity laboratory WHO “Requirements for storage and use of chemical substances in chemical and biological laboratories”. which deal with biological, chemical and radiological agents”, and the methodological guideline on first medical aidequipment, the list and the instructions for the use of suchequipment in laboratories biosecurity, chemical and radiological safety, the methodological instructions on “Requirements for the MoH Order No 475-A of 19.02.2016: on approving the model manuals and SOPs on laboratory investigation of foodborne poisonings. Decree of the Minister of Health N2014 –A of 31.08.12: on approving guidelines on epidemiological 57 of IHR Core Capacities of the Republic of Armenia 58

Joint External Evaluation • • National laboratory system • • • • • • • • • • • • • Immunization • • • • • • • MoH Order No. 2019-A of 24.07.2013: on establishment of working groups to coordinate activities advance). in English universal laboratory creation network and the 2013-2014 actionplan thereof (document translated in Government Protocol DecreeNo. 20 of 23.05.2013: on approving the strategic programme for the http://www.armstat.am/am/?nid=81 https://web.facebook.com/groups/kksenyak.am/ https://web.facebook.com/groups/apcmembersmail/ https://web.facebook.com/groups/693854794063217/ https://web.facebook.com/1455050464736078/photo http://moh.am/?section=news%2Fopen&id=143&nid=39 the-%20executive-secretary-of-the-armenian-nitag http://www.nitag-resource.org/news-and-events/news/73-voices-from-the-field-gayane-sahakyan- http://armeniasputnik.am/radio/20160710/4233691.html https://www.youtube.com/watch?v=Yq7rJRlXhXY http://moh.am/?section=news/open&id=143&nid=2091 http://moh.am/?section=news/open&id=143&nid=117 http://moh.am/?section=news/open&id=143&nid=3288 for-2011-2015/ http://www.gavi.org/country/armenia/documents/cmyps/comprehensive-multi-year-plan- No. 13-A of 06.10.2015 and MoA Chief of State Order Service No. Safety Food 1006-A of 02.10.2015. Administration and Emergency Situations (MoTA &ES) Order No. 1064-A of 08.10.2015, MoDOrder MoH Order No. 2647-A of 29.09.2015, MoA Order No. of 204-A 02.10.2015, Minister of Territorial personal and collective protection equipment used in chemical and biological laboratories”, by: Joint Order on approving the methodological guideline on “Requirements for conformance of the coordination board (biosafety) and security commission for the universal laboratory network. MoH Order No. 203-A of 07.02.2014: on approving the working procedures of the professional management and on approving the nominal list of members thereof. coordination board (biosafety) and security commission for the universal laboratory network Republic of Armenia Government DecreeNo. 43-A of 31.01.2014: on establishing aprofessional handling PDP based on the level of danger in accordance with international requirements. MoH Order No. 3132-A of 27.12.2014: on approving the lists for classification of PDP and laboratories services. laboratory dangerous waste management and biological, chemical and radiological hazards response in the MoH Order No. 1405-A of 17.06.2014: approving On the standard operational procedures for international requirements. with accordance in agents infectious of processing and MoH Order No. 1411-A of 17.06.2014: approvingOn the standard operational procedures for storage 2011. governments, USA and Republic of Armenia Government System for protection against PDP: Agreement the Armenia between • • • • • • • • • • • • • Real-time surveillance • • Site visitstotwolaboratories: • • International programmes: • • • nosocomial for health infections workers. MoH Decree845-A of 11.04.2015: on approving the training programme on prevention and control of surveillance. radiation exposure MoH Decree No. of 24.12.2014: 3088-A on approving the guidelines on chemical poisonings and 2014 on chemical poisonings and radiation exposure surveillance. MoH DecreeNo. 74-N of 27.12.2014: on approving and sanitary epidemiological norms N 3.1.1–028– system. surveillance cancer breast and diabetes MoH Decree No. 2965-A of 15.12.2014: on approving the guidelines for acute cardiac infarction, investigation. epidemiological - MoH Decree No. 3205-A of 13.11.2015: on approval of the guidelines on risk assessment methodology plan-timetable.and MoH DecreeNo. of 24.12.2014: 3089-A on approving the procedure for data validation, the checklist levels. the to according indicators MoH DecreeNo. 2597-A of 28.09.2013: on approval of guidelines on surveillance and evaluation systems at all levels of NCDC. Decree of General Director of the NCDC No. 3919-A of 15.12.2014: on implementation of analytical within the NCDC, and approving the RRT membership and procedures. Decree of General Director of the NCDC No. 22-L of 30.12.2014: onrapid setting response teams (RRT) MTAES (01.12.2015, No 1245-A) and National (10.12.2015, Service Security No 41-A). System (IEDSS) approved by MoHDecrees (18.11.2015 No 3250-A), (24.11.2015, MA No 246-A), Joint Decree: on organization of implementation of the Integrated Electronic Disease Surveillance MoH Decree3385-N of 27.11.2015: on approval of the administrative statistical form. report approval of the latter’s operational procedures and the model shifts. form of duty Decree of General Director of the NCDC No. of 29.12.2014: 20-L on creation of NCDC hotline service, diseases’. communicable of surveillance electronic time real of rules and norms epidemiological Government Decree No. 35-N of the Minister of Health dated 17.12.2010 ‘On approval ofand sanitary Regional laboratory in Gyumri (Shirak Branch of the NCDC). Reference laboratory of the National Center for Disease Control and Prevention in Yerevan. http://www.medilabsecure.com/project_objectives.html http://www.iqls.net/?Pn=Article_View&Article_Id=101. Accreditation and list of accredited laboratories, http://www.mineconomy.am/arm/570/free.html site).on Several MoH orders: laboratories and the procedure of their acknowledgement (checked with translation on site). Government of DecreeNo. 03.03.2016: 206-N on approving the requirements set for reference advance). related to implementation of the universal laboratory (document network translated in English in http://www.moh.am/ (in Armenian, most relevant orders checked with translation . . 59 of IHR Core Capacities of the Republic of Armenia 60

Joint External Evaluation • Reporting • • • • Workforce strategy • • • • • • • • • • • Government Decrees: Government http://www.moh.am/?lang=en response plan in the healthcare system (for all levels and agencies). MoH order No. 3102-A of 28.12.2012: on approving infectious disease emergency preparedness and populationRA in of case strong earthquakes. Government DecreeNo. 919-N of 10.06.2011: on approving the plan of protection organization of the protection. andbody the ministries of agriculture, territorial administration and emergency situations, and nature ensuring collaboration mechanisms and establishing the processes national between coordination and Minister of Nature Protection (No. 274-N of 25.09.2015): on approving the standard procedure and Emergency Situations (No. 943-N of 17.09.2015), Minister of Agriculture (N 198-N of 08.08.2015) Joint order of the Minister of Health of (No. 19.08.2015), 46-N Minister of Territorial Administration factors. radiological and chemical biological, to due emergency publichealth a of notification MoH Decree # 26 of 29.11.2010: on approval of the standard procedure of national IHR focal point Terms point. reference, focal of national IHR http://www.armstat.am/en/?nid=82 15.08.2012.of system in Yerevan, Kapan, Vanadzor, Nairi and Ijevan cities and deeming void MoHDecreeNo. 1881 of 15.03.2015:MoH Decree No. 886-A on continuing implementation of influenzasentinel surveillance ofMoH DecreeNo. 08.12.2010: 29-N on polio surveillance in Republic of Armenia. uremic - syndrome. hemolytic hemolytic -uremic syndrome; and guidelines on management of patients with E. coli and resulting its MoH DecreeNo. 2587-A of 22.12.2011: on approving the guidelines on E. coli and resulting its 29.10.2009. of reporting forms and Instructions on their population, as well as deeming void MoHDecreeNo. 19-N MoH DecreeNo. 19-N of 09.11.2012: on approving the immunization-related administrative statistical the Republic of Armenia of 18.07.2015. MoH DecreeNo. 1941-A: on administration of preventive vaccination in pre-conscription age males in 27.05.2015.of and prevention activities and MoH Decree(24.07.2015) on amendments to the MoHDecree1315-A on amendmentsMoH Decrees 2008-A: to the MoHDecree1315-A (27.05.2015) on measles control for health workers. care and workshops inactivated vaccines in the National Immunization Calendar, and organization and conduct of trainings MoH DecreeNo. 3402-A of 27.11.2015: on approval of the training manuals on introduction of pathological andwith anatomical abnormalities’. MoH Decree1403-A of 17.06.2015: on approving the SOP on sampling organs from rodents and corps m m m m

N 1138-N (26.08.2010). (04.09.2014) 957-N 913-N (06.08.2009) (19.07.2009)809-N . . • • • • • • • authorities Preparedness, Emergency response operations andLinkingpublichealthsecurity • • • • • • • • • • • • Government DecreeNo. 1064-N of 29.07.2004. Government DecreeNo. 1064-N of 29.07.2004. Government DecreeNo. 919-N of 06.07.2010. Government DecreeNo. 861-N of 08.07.2010. Government DecreeNo. 2328-N of 22.12.2005. Government DecreeNo. 1532-N of 13.11.2003. Government of 10.04.2003. DecreeNo. 384-N strategy and the list of activities. Government Decree No. 5of 06.02.2014: on approving the healthcare human resource development healthcare. of field the in MoH order No. 3713-A of 24.12.2015: on approving qualification specifications ofmedical professions hospitals. (specialty) and women’s consultations, posts, nursing centers, health rural – adults and children’s), individual specialized family offices, medical doctors’ offices, ambulatories, equipment qualifications and staff for provision of healthcare and medical polyclinicsservices by (joint Government Decree No 1936-N of 05.10.2002: on approving the conditions and requirements for the pharmaceutical, public health professions and narrow specialties healthcare of the RA sector. Government decree No 952-N of 04.09.2014: on approving the lists of medical, stomatological, levels” guideline”.by methodological MoH order No 2597-A of 28.09.2013: on approving “Epidemiological analysis and evaluation indicators all levels of the National Center of Disease Control and Prevention state non-commercial organization. MoH NCDC General Director’s order No 3919-A of 15.12.2014: on introduction of analysis system on realtime. in diseases infectious of surveillance epidemiological MoH order No 35-N of 17.12.2010: on approving sanitary-epidemiological norms and rules of electronic committee and the staff professional development and national focal point, establishment and adapt of MediPIET national Minister’s order 02.10. 2015No 2702-A- the On appointment of MediPIET national center for 25.11.2004, and Government DecreeNo. 1316-N of 15.08.2002. 29.07.2004, Government Decree No. 1893-N of 06.10.2005, Government Decree No. 1724-N of No. 1319-N of 30.09.2010, as well as on declaring void the Government DecreeNo. 1146-N of No. 1300-N of 15.08.2002, Government DecreeNo. 1821-N of 14.11.2002, and Government Decree Government Decree No. 857-N of 25.07.2013: on amendments and addenda to Government Decree and Prevention non-commercial state organization. organizations and close joint stock companies and establishment of National Center of Decease Control Government DecreeNo. 1134-N of 17.10. 2013: on reorganization of anumber of state non-commercial teams. response rapid Prevention non-commercial state organization, and the composition and operation procedure the of of rapid response teams of the Republic of Armenia MoH National Center of Disease Control and NCDC General director’s order No. 22-L of 30.12.2014: on approving the procedure of establishment Republic of Armenia chemical facilities or achemical danger. Government DecreeNo. 861-N of 08.07.2010: on population protection plan in of case accidents in 61 of IHR Core Capacities of the Republic of Armenia 62

Joint External Evaluation • • • • Risk communications • • • • • • Medical countermeasures andpersonnel deployment • • • • • • • • • • • government bodies and organizations for public and civil protection in emergency situations, as well as Government decision of 22.01.2015: No 46-N on preparedness of state government and local self- situations. non-emergency in well as as emergencies, (epidemics), radiological and/or chemical outbreaks during lifestyle healthy of increase of population awareness (certain groups), dissemination of health knowledge and promotion Government decision No 15-N of 19.04.2012: on endorsement of “Procedures and plan of actions on Law on “Population protection in emergency situations”, 1998. Situation [website] Emergency www.mes.am. of Ministry international-organisations/EurAzES/ Agreement of the Republic of Armenia on joining EurAsEc on May 29, 2014. http://mfa.am/en/ CSTO/ http://mfa.am/en/international-organisations/ States Cooperation. Treaty Independent of Security Decree of the Higher Council of the Republic of Armenia of 28.07.1992: on ratification of the Collective protection of the Republic of Armenia during severe earthquake. Government Decree N919-P of 10.06.2011: on approval the plan for organization of population of materials stocks reserve for rapid response. Government Decree N52-P of 29.01.2016: on defining the list and accumulation norms forstate response. rapid for reserve state the of provision Government Decree N923-P of 13.08.2015: on defining the order for formation, preservation and assistance. humanitarian as Health and distribution of medicines and medical countermeasures, received on behalf of the Ministry of Government Decree N1431-P of 14.10.2004: on regulation process for formation, receipt, accounting investigation. epidemiological MoH No. 3205-N of 13.11.2015: on methodological guideline, risk assessment methodology. 08.06.2015). of 144-A common for humans, humans and animals (Republic of Armenia MoHNo. 1302-A of 26.05.2015, No. Joint order: on methodology of assessment, management and reduction of risks of infectious diseases and Minister of Nature Protection (No. 274-N of 25.09.2015). and Emergency Situations (No. 943-N of 17.09.2015), Minister of Agriculture (N 198-N of 08.09.2015) Joint order of the Minister of Health of (No. 19.08.2015), 46-N Minister of Territorial Administration Government DecreeNo. 281-N of 07.03.2012. material reserve. state on Law: Government DecreeNo. 8of 03.03.2016. Government DecreeNo. 777-N of 22.06.2012. Government DecreeNo. 1138-N of 26.08.2010. Government of 19.01.2006. DecreeNo. 480-A Government DecreeNo. 8of 03.03.2016. Government DecreeNo. 943-N of 18.08.2015. • • • • • • • • • • • Chemical events • • • • P • • oints ofentry cadaster. cadaster. Government Decree #144-N, 18.01.2007: on defining the procedure for waste managementstate products. ofsome and import peculiarities for export approval and license import of the on the RA, export and application forms and defining licensing 15.03.2007 and approval of the lists of prohibited orfor restricted transition products through customs ofGovernment 05.02.2015: Decree #90-N on making amendments in Government decree #327-N of Government Decree#1739-N of 07.12.2006: on defining thestate procedure for waste registration. extraction. substance useful and locating) (elimination, disinfection, removal accumulation, Government Decree#1343-N of 14.09.2006: on defining the procedure for waste registration: waste locating) and useful substance extraction. Government Decree#1343-N of 14.09.2006: on waste accumulation, removal (elimination, disinfection, Government Decree#1180-N of 13.07.2006. accumulation, processing and useful substance extraction. Government of 20.04.2006: Decree #500-N on defining the procedure for register on waste description. Government Decree #47-N of 19.01.2006: on defining the procedure for waste identification/ waste normatives and the locating benchmark volumes. Government Decree #2291-N of 09.12.2005: on approval of the procedure for approval on of projects waste processing, activities. disinfection, and locating transportation, protection, Government Decree #121-N of 30.01.2003: on approval of the procedure for licensing hazardous Law on Waste (2004). MoH Decree#629A of 12.04.2011: on attaching healthcare facilities to quarantine sanitary points. 11.12.2014) of N1404-N National Action Plan for a‘Single Window’ approach at border points (2015-2017) entry within programmes concerning biological risks for staff. points of entry from differentestablishing sectors Joint joint Decrees 320-A/34-A/4095-A/2390-A training Government Decrees: Government earthquake) on July 19-20, 2016. (major emergency of case in center information joint intersectoral of functioning and establishment Decision of the Minister of Emergency Situations No 416-A of 10.07.2016: to conduct adrill on organization; Charter structure of MES, and amendments staff in anumber of Government decisions. Government decision No 259-N of 03.03.2016: on establishment of “Staff of the MES” state m m m m the Government decision No 134-N. regulations for emergency preparedness training of the general population and revoking article 30 of

N 1138-N (26.08.2010) N-777 (2011) N 702 (12.05.2011) (10.06.2011) N1418 63 of IHR Core Capacities of the Republic of Armenia 64

Joint External Evaluation • • • • • Radiation emergencies • • • • isolation of orphan radio-active materials. radio-active orphan of isolation Government Decree No. 553-N as of 03.05.2007: the legal on the approval act of the detection and the procedure for safe transport of nuclear and radioactive materials. ST-R-1 revised based on SSR-6) and Government DecreeNo. 931-N as of 27.06.2002: on approval of and radioactive materials (development of this document were transportation fully based on rules IAEA Government Decree No. 1263 as of 24.12. 2001: on approval of special rules on transportation of nuclear Statute.The ANRAs emergencies. radiological and Government protocol decision as of 18 March 2016: on approval of national response plan for nuclear radiationemergencies. and plant nuclear authorities and other relevant organizations of preparedness and response to Armenian nuclear power plan of the Armenian nuclear power plant), clearly establishes responsibilities of the governmental Government DecreeNo. 2328-N: on approval of the national population protection plan (off-site level. danger to according classified Order of the Minister of Nature Protection of 430-N 25.12.2006: on approval of the list of waste industrial and consumer waste (including mining) on the territory of the RA. Order of the Minister of Nature Protection #342-N of 26.10.2006: on approval of the list of accumulated processes. accumulated industrial and consumer waste and the list of accumulated due to various technological Government protocol resolution of 19.10.2009: #48 on approval of the indicators of the of main types construction and dismantled waste. Government protocol resolution #30, 23.07.2009: on approval on conditions use for of safety Joint External Evaluation of IHR Core Capacities of the Republic of Armenia

Mission report: 15–19 August 2016

WHO/WHE/CPI/2017.14