Joint External Evaluation of IHR Core Capacities of the Kingdom of

Mission report: 12–16 March 2017

WHO/WHE/CPI/2017.25.report

Joint External Evaluation of IHR Core Capacities of the Kingdom of Saudi Arabia

Mission report: 12–16 March 2017 WHO/WHE/CPI/2017.25.report

© 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 Kingdom of Saudi Arabia. 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 ACKNOWLEDGEMENTS

The World Health Organization (WHO) Joint External Evaluation (JEE) Secretariat would like to acknowledge the following, whose support and commitment to the principles of the International Health Regulations (2005) (IHR) has ensured a successful outcome to this JEE mission: • The Government and national experts of the Kingdom of Saudi Arabia for their support and work in preparing for the JEE mission. • The governments of Finland, Morocco, Sweden, the , the United Kingdom, and the United States of America, for providing technical experts for the peer review process. • The Food and Agricultural Organization of the United Nations for contributing experts and expertise. • The Government of the USA for its financial support to this mission. • WHO entities: WHO Country Office of Saudi Arabia, WHO Regional Office for the Eastern Mediterranean, WHO headquarters Department of Country Health Emergencies Preparedness and IHR. • Global Health Security Agenda for its collaboration and support.

Contents

Abbreviations------vi Executive Summary ------1 Introdution------1 Saudi Arabia scores------2 PREVENT—————————————————————————— 4 National legislation, policy and financing------4 IHR coordination, communication and advocacy------6 Antimicrobial resistance------8 Zoonotic diseases------11 Food safety------14 Biosafety and biosecurity------16 Immunization------18 DETECT————————————————————————— 21 National laboratory system------21 Real-time surveillance------24 Reporting------27 Workforce development------29 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—————— 46 Points of entry ------46 Chemical events------49 Radiation Emergencies------52

Appendix 1: Joint External Evaluation Background------55 vi Joint External Evaluation WHO UNICEF SOP SM SFDA PoE PHEIC T OR OIE NPCE NIT NFP MoH MEW MERS-CoV MC JEE IHR IEC HIV HESN HCAI GCMGM GCC FETP FAO EQAS EPI EOC CD CCC CBAHI BSL AMR AFP Abbreviations AG

A World HealthOrganization United NationsChildren’s Fund Standard operating procedures Short (text)messageservice Saudi Food andDrug Authority Point(s) ofentry Public healthemergenciesofinternationalconcern Outbreak responseteam World Organisationfor Animal Health National PlanforChemicalEvents Immunization TechnicalGroup National Advisory National Focal Point Ministry ofHealth Ministry ofEnvironment, Water and Agriculture Middle Eastrespiratory syndromecoronavirus Medical countermeasures Joint ExternalEvaluation oftheIHR International HealthRegulations(2015) Information, educationandcommunication Human immunodeficiencyvirus Health ElectronicSurveillanceNetwork Health care-associatedinfections Global CentreforMassGatheringMedicine Gulf Cooperation Council Field Epidemiology Training Programme Food and Agriculture OrganizationoftheUnitedNations External qualityassessmentscheme Expanded Programme onImmunization Emergency operations centre Saudi CentreforDiseaseControl Command andControlCentre Central Boardfor Accreditation ofHealthcareInstitutions Biosafety level Antimicrobial resistance Acute flaccidparalysis private sectorengagement. and accountability. It alsoincludesbestpractices, financialsustainabilityandanatmosphereconducive to health systembuildsonkey principlesofhealthascentral, integrated andcomprehensive, withefficiency disease burden, qualityand safety, workforce, financialstabilityanddigitization. The concept of thefuture of itscitizens. will focusonsixacutechallengesinthehealthsector,Vision 2030 namelyaccesstocare, hospitals. Saudi Arabia ispresently workingon “Vision 2030” withthegoalofimproving thequalityoflife The traditional health-caresystem includesanetworkofhealth-carecentreswithreferrals totertiarycare 35–45% adultsmokers and24%teenagesmokers). injuries anddisability6 000 deaths), lackofphysicalactivityandsmoking(ranked 23intheworldwith contributing factorstochronicillnessincluderoadtraffic injuries(484 000 accidentsin2009with33 000 Saudi Arabia hasoneofthehighestobesity(33%)anddiabetes(17%)rates intheworld. Additional 29% insmallhospitals(50beds). per 1000population. The hospital bedoccupancyrate ranges from93%inlargehospitals (> 400 beds)to private sector. Basedonstatisticsfrom2010, thereare2.2hospital beds, 2.4physiciansand4.8nurses Approximately 60%ofhealth-careservicesareprovidedbytheMinistryHealth(MoH)and32% by the Government isalsoresponsibleforpublichealthandprovisionofservicestoeverycitizen. right tohealthcareforcitizensandtheirfamiliesincaseofemergency, sickness, disabilityandoldage. The Chapter 5, Articles 27and31ofthebasiclawSaudi Arabia statethattheGovernmentguarantees the Brief summaryofthehealthsysteminSaudi Arabia site oftheprophetMuhammad(Peace beUponHim). Haram inMakkah, destinationoftheannualHajjpilgrimage, andMedina’s Al-Masjid an-Nabawi, burial Saudi Arabia isthebirthplaceofIslamandhometoreligion’s twomostsacredmosques: Masjidal- and infantmortality13.6deathsper1000livebirths. Lifeexpectancyis75.3years. 1000, anddeathrate of3.3per1000population. The maternal mortalityrate is12per100 000 population million. The Saudi Arabian population medianageis27.2yearswithanestimatedbirthrate of18.4per gas, ironore, goldandcopper. The officiallanguageis Arabic. isthecapitalwithapopulationof4.7 with agrossnationalproductpercapitaofUS$13 000 peryear. The majornatural resourcesareoil, natural According to 2013 World Bank figures, the population of Saudi Arabia is 28.83 million (growth rate 1.46%) Persian Gulfcoastlines. The KingdomofSaudi Arabia (Saudi Arabia) encompassesmostofthe Arabian Peninsula, withRedSeaand Introduction each specifictechnicalarea. in Saudi Arabia, notablytheself-assessment, thoroughdocumentation, andsuccinctpresentationscovering The mission was greatly facilitated by the excellentpreparatory work ofthe multisectoral technical experts and competencyinthetechnicalareaswhichcountryexcels. surveillance; workforcedevelopment; andriskcommunication. The challengeisalsotomaintainthequality advocacy; antimicrobialresistance; zoonoticdiseases; biosafetyandbiosecurity; thelaboratory system; need improvementtoachievethehighestlevelofcompetencyare: coordination, communicationand based onitstechnicalandscientificexpertiseaswellthewealthofresourcesavailable. Areasthat Saudi Arabia has made great progress in achieving competencies in the majority of the 19 technical areas Executive summary

1 of IHR Core Capacities of the Kingdom of Saudi Arabia 2 Joint External Evaluation Saudi Arabia scores Arabia Saudi advocacy and communication IHR coordination, andfinancing policy National legislation, Real-time surveillance system National laboratory Immunization biosecurity Biosafety and Food safety Zoonotic diseases resistance Antimicrobial Technical area D.1.2 P.7.2 P.6.2 P.4.3 P.4.2 P.3.4 P.3.3 P.3.2 P.1.2 D.2.4 D.2.3 D.2.2 D.1.4 D.1.3 P.2.1 P.1.1 D.2.1 D.1.1 P.7.1 P.6.1 P.5.1 P.4.1 P.3.1 Specimen referral system andtransport National vaccine access anddelivery training andpractices andbiosecurity Biosafety lished andfunctional Mechanisms forresponding to zoonoses andpotential zoonoses are estab Veterinary oranimalhealthworkforce Antimicrobial stewardship activities Healthcare associated prevention infection andcontrol programmes causedby AMR pathogens ofinfections Surveillance with theIHR(2005) legislation, policiesandadministrative arrangements to enablecompliance The State candemonstrate that ithasadjusted andaligneditsdomestic Syndromic systems surveillance dataAnalysis ofsurveillance Interoperable, interconnected, real-time electronic system reporting system quality Laboratory andlaboratory-based diagnostics Effective modernpoint-of-care of relevant intheimplementation sectors ofIHR mechanismisestablishedforthecoordinationA functional andintegration of IHR other government instruments inplace are sufficient forimplementation Legislation, laws, regulations, administrative requirements, policiesor Indicator- andevent-based systems surveillance diseases testing ofpriority Laboratory fordetection Vaccine coverage ofnational programme (measles)aspart human, animal, andagriculture facilities system isinplace andbiosecurity for biosafety Whole-of-government to foodbornediseaseandfoodcontamination andresponding fordetecting Mechanisms are establishedandfunctioning systems zoonotic inplaceSurveillance forpriority diseases/pathogens Antimicrobial resistance (AMR) detection Indicators - Score 3 4 3 3 3 5 4 4 4 4 3 3 3 3 4 4 4 3 3 4 2 3 3 Radiation emergencies eventsChemical Points ofentry Risk communication personnel deployment countermeasures and Medical authorities and security Linking publichealth operations response Emergency Preparedness development Workforce Reporting D.3.2 R.5.5 R.5.4 R.5.3 R.5.2 R.4.2 R.2.4 R.2.3 R.2.2 R.1.2 D.4.3 D.4.2 RE.2 CE.2 PoE.2 RE.1 CE.1 PoE.1 R.5.1 R.4.1 R.3.1 R.2.1 R.1.1 D.4.1 D.3.1 Reporting network andprotocolsReporting incountry Dynamic listening and rumourmanagementDynamic Communication engagementcommunities withaffected Public communication communication Internal andcoordination andpartner public healthemergency System isinplace forsendingandreceiving healthpersonnelduringa Case management procedures are implemented forIHR-relevant hazards operations Emergency programme operationsEmergency centre operating procedures andplans publichealthrisksandresourcesPriority are mappedandutilized Workforce strategy training programme inplace Field Epidemiology Training Programme orotherappliedepidemiology cies Enabling environment isinplace formanagement ofradiation emergen - CE.2 Enabling environment isinplace formanagement ofchemicalevents Effective publichealth response at points ofentry to radiological andnuclearemergencies andresponding fordetecting Mechanisms are establishedandfunctioning to chemicalevents oremergencies andresponding fordetecting Mechanisms are establishedandfunctioning Routine capacitiesare establishedat points ofentry communicationRisk systems (plans, mechanisms, etc.) during apublichealthemergency System isinplace forsendingandreceiving medicalcountermeasures rol, customs) are linked orconfirmed biologicalevent duringasuspected authorities,Public (e.g. healthandsecurity law enforcement, border cont- Capacity to activate operations emergency se Planisdeveloped andimplemented Multi-hazard National Public Health Preparedness Emergency andRespon- ments Human resources are available to implement IHRcore require capacity System forefficient to reporting WHO, FAO andOIE - 5 5 5 5 4 4 3 4 3 4 4 4 4 4 4 4 4 3 3 3 3 3 5 5 4 3 of IHR Core Capacities of the Kingdom of Saudi Arabia PREVENT 4 Joint External Evaluation Adequate legal framework for States Parties to support and enable the implementation of all their their all of implementation the enable and support to Parties States for framework legal Adequate ministry/sector. the country’s healthsystem. These allarepubliclyavailable and accessiblethroughthewebpageofeach agreements oncross-border collaboration alsoexit. The legalsystemalsodefines the organizationof As theKingdomisamemberofGulfCooperation Council(GCC)andthe Arab Countries Union, inspections andshipsanitationcertificates. health, pesticidesuseandmanagement, nuclearemergency, animalhealthincludingwildanimalsand ship environmental health, importationofanimalmedicalcountermeasures (medications, vaccines), quarantine chemical andbiologicalevents, primaryhealthcare, healthinformationmanagement, healthinsurance, (NFP), publichealthcontrolmeasuresduringHajjand Umrah, plansfornatural disasters, andresponseto Not onlydoesthislegislationaddressalltechnicalareas, itsupportsparticularlytheIHRNationalFocal Point emergencies withinthenationalGovernmentbudgetisupdated annually. considering previous input and in coordination with all concerned sectors. The budget line available for all the CouncilofMinisters. Amendments take placeintheformofdecrees, ordinances andregulations, continual updateandreview, whichiseitherdone bytheconcernedsectororBureauofExpertsat circulars, correspondence, andguidelines. Someofthesehavebeeninplacesince1925andareunder orders, acts, laws, polices, royal decrees, ordinances, ministerialcouncil decrees, ministerialdecrees, issued other instrumentsavailable fortheGovernmenttoimplementIHR. Suchinstruments includeregulations, The termlegislationis used generally in thisdocument to refer the broadrange of legal, administrative or Saudi Target of IHRandoperations withintheStateParty, andfacilitatecoordinationamongtheentitiesinvolved. in amoreeffectivemanner. Implementinglegislationcouldservetoinstitutionalizeandstrengthentherole choose toreviseregulationsorotherinstrumentsinorderfacilitateIHRimplementationandmaintenance of whichimplementationmayrequirenewormodifiedlegislation. Evenifthisisnotrequired, Statesmay The InternationalHealthRegulations(2005)(IHR)outlineobligationsandrightsforStatesParties, insome Introduction andfinancing National legislation, policy PREVENT 1 resources arealsoimportant. Policies thatidentifynationalstructuresandresponsibilities, andtheallocationofadequatefinancial obligations, and rights to comply with and implement the IHR (2005). New or modified legislation in in legislation modified or New (2005). IHR the implement and with comply to rights and obligations, some States Parties for implementation of the IHR (2005). Where new or revised legislation may not be be not may legislation revised or new Where (2005). IHR the of implementation for Parties States some specifically required under the State Party’s legal system, States may revise some legislation, regulations or or regulations legislation, some revise may States system, legal Party’s State the under required specifically other instruments in order to facilitate their implementation and maintenance in a more efficient, effective effective efficient, more a in maintenance and implementation their facilitate to order in instruments other or beneficial manner. States Parties ensure provision of adequate funding for IHR implementation through through implementation IHR for funding adequate of provision ensure Parties States manner. beneficial or the national budget or other mechanism. mechanism. other or budget national the

Detailed guidanceon IHR implementationinnationallegislation, www.who.int/ihr/legal_issues/legislation/en/index.html. Arabia levelofcapabilities 1

reas that need strengthening and challenges related to the two indicators two the to related • challenges and • strengthening need that reas A • • • • practices best and Strengths - Score 5 policies andadministrative arrangements toenablecompliancewiththeIHR(2005) P.1.2 The statecandemonstrate that ithasadjustedandaligneditsdomesticlegislation, • • • • • practices best and Strengths instruments inplaceare sufficientforimplementationofIHR-Score 4 P.1.1 Legislation, laws, regulations, administrative requirements, policiesorothergovernment Indicators andscores • • • • Recommendations forpriorityactions implementation. Other countriesmay consider emulatingthislegislative framework to improve their IHRcoordinationand Awareness of first-line implementers shouldbe raised on related legislation in the country. sectors. different the among aligned be legislation should of Implementation Saudi Arabia of is international part agreements on public health protection. The systematic review and update mechanism for legislation is effective. A new, comprehensive public health law has been developed and awaits endorsement. Hajj and Umrah legislation is well-established, and complied with all sectors. review and updated regularly as per the requirements of IHR. are instruments governmental other and Relevant requirements legislation, administrative regulations, Legislation is publically available and accessible through websites of the related sectors. and avoids duplication, contradictions in the legislation that governs the different sectors. Theat Bureau the Council of Experts of Ministers with the mandate of review and update of legislation NFP core and expanded functions.. policies and procedures, for exists all technical areas under IHR and implementation, its including the A substantial legal framework, in the form of royal decrees/ordinances, ministerial decrees, regulations, missions took place in the country. Saudi Arabia is fully committed to implementing the IHR; in addition to this JEE, several IHR assessment Establish amechanism to monitor implementation of targeted national legislation. Finalize the electronic system to disseminate legislation to raise awareness of “first-line implementers”. legislation. Establish a mechanism to accelerate the Bureau review of and Experts’ development of IHR-related committees. Finalize pending legislation: National Public Health Law, radiation laws, and terms of reference for 5 of IHR Core Capacities of the Kingdom of Saudi Arabia PREVENT PREVENT 6 Joint External Evaluation Multisectoral/multidisciplinary approaches through national partnerships that allow efficient, alert and and alert efficient, allow that partnerships national through approaches Multisectoral/multidisciplinary Target is akey requisiteforIHRimplementation. including thedesignationofanationalIHRfocalpoint, whichisanationalcentreforIHRcommunications, national partnershipsforefficientandalertresponsesystems. Coordinationofnationwideresources, The effectiveimplementationoftheIHRrequiresmultisectoral/multidisciplinary approachesthrough Introduction IHR andadvocacy coordination, communication • • • practices best and Strengths sectors intheimplementationofIHR-Score 3 P.2.1 Indicators andscores • • • Recommendations forpriorityactions health surveillance. areas underIHR. A numberofcoordinationmechanismsmeetonaregularbasisfor animalandhuman 22 governmentsectors. Sub-committeeshavebeenputinplacetomonitorrepresentationofthevarious A multisectoral, multidisciplinarycoordinationmechanismmeetsatleastannuallywith representationfrom Assistant Ministerlevel. The NFPisamemberofnumberhigh-levelintersectoral coordinationmechanisms. The Kingdomhasestablishedthroughroyal decreeitsIHRNFPfunction, whichisheaded byanofficialat Saudi responsive systems for effective implementation of the IHR (2005). Coordinate nationwide resources, resources, nationwide Coordinate (2005). IHR the of implementation effective for systems responsive including sustainable functioning of a national IHR focal point – a national centre for IHR (2005) (2005) IHR for centre national a – point focal IHR national a of functioning sustainable including communications which is a key requisite for IHR (2005) implementation – that is accessible at all times. times. all at accessible is that – implementation (2005) IHR for requisite key a is which communications States Parties provide WHO with contact details of national IHR focal points, continuously update and and update continuously points, focal IHR national of details contact with WHO provide Parties States annually confirm them. confirm annually Additional coordination also intersectoral exist. forums for health security of the different technical areas. representation from 22 it sectors; is complemented by 19 sub-committees to monitor implementation A multisectoral, multidisciplinary coordination mechanism (National IHR Committee) is in place with The IHR NFP function was established by royal decree and is accessible to all 24/7. sectors, implementation. full its ensure to mechanism evaluation Develop an action plan for IHR implementation based on the JEE outcomes with a monitoring and 2).(Annex events of notification and assessment the for activitiesConduct to increase advocacy awareness on the IHR and particularly decision of its instrument sharing within national the multisectoral IHR committee. information systematic and coordination (SOPs) strengthen to procedures operating standard Develop A functionalmechanismestablishedforthecoordination andintegration ofrelevant Arabia levelofcapabilities • challenges and • strengthening need that reas A There has been no formal evaluation of of the the IHR effectiveness function. not incorporate outside partners of the government sector. Coordination mechanism may not fully facilitate regular/continuous exchange of information and do 7 of IHR Core Capacities of the Kingdom of Saudi Arabia PREVENT PREVENT 8 Joint External Evaluation Support work coordinated by FAO, OIE and WHO to develop an integrated global package of activities to to activities of package global integrated an develop to WHO and OIE FAO, by coordinated work Support Mediterranean Region. However, gapsthatremainareoutlined belowaswellundereachindicator. antimicrobial stewardship, that hasledtooneofthehighestscoresforthistechnicalareainEastern Saudi Arabia hasalsomadegoodprogressinallotherareasrelatedto AMR, including surveillanceand Control; Antimicrobial Stewardship; andDrugsEconomy. accordance with WHO objectives: AMR Awareness; Laboratory Surveillance; InfectionPreventionand stakeholders. The committee includes the following five technical subcommittees that were formed in In ordertocombat AMR, Saudi Arabia formedanationalcommitteethatincludesallrelevant multisectoral various hospitalsaroundtheKingdom, althoughthereisgeneral lackofnationaldataon AMR. in Saudi Arabia overthelastdecadeincomparisonwith rates ofthe1990s. The dataabovearefrom in Gram-negative bacteria(GNB)showsasubstantialincreaseintherate ofcarbapenem-resistantbacteria systems inplace. However, the burdenof AMR remainshigh. The literature reviewofmultidrugresistance has alsomadeprogresstocombat AMR throughaNational Action Plan, enactinglegislation, andputting care-associated cases, community-acquiredcaseshaveessentiallyremainedthesame(Fig. 1). The Kingdom of healthcare-associatedMERS-CoVcasesfrom332in2014to602016. Despitethisdeclineinhealth tremendous progressintheareaofhospitalinfectioncontrol, whichhasresultedinasubstantialdecline As an aftermath of Middle-East Respiratory Syndrome Coronavirus (MERS-CoV), Saudi Arabia has made Saudi Target security andnationalsecurity. in humans. This situationthreatenspatientcare, economicgrowth, publichealth, agriculture, economic alarming rate andisoutpacingthedevelopmentofnewcountermeasurescapablethwarting infections past decade, however, thisproblemhasbecomeacrisis. Antimicrobial resistance(AMR)isevolvingatan of resistancewas slowandthepharmaceuticalindustrycontinuedtocreatenewantibiotics. Overthe resist being killed by antimicrobial agents. For many decades, the problem was manageable as the growth Bacteria andothermicrobesevolveinresponsetotheirenvironmentinevitablydevelopmechanisms Introduction resistanceAntimicrobial combat antimicrobial resistance, spanning human, animal, agricultural, food and environmental aspects (i.e. (i.e. aspects environmental and food agricultural, animal, human, spanning resistance, antimicrobial combat a One Health approach). Each country has: (i) its own national comprehensive plan to combat antimicrobial antimicrobial combat to plan comprehensive national own its (i) has: country Each approach). Health One a resistance; (ii) strengthened surveillance and laboratory capacity at the national and international levels levels international and national the at capacity laboratory and surveillance strengthened (ii) resistance; following international standards developed as per the framework of the Global Action Plan; and (iii) (iii) and Plan; Action Global the of framework the per as developed standards international following improved conservation of existing treatments and collaboration to support the sustainable development of of development sustainable the support to collaboration and treatments existing of conservation improved new antibiotics, alternative treatments, preventive measures and rapid point-of-care diagnostics, including including diagnostics, point-of-care rapid and measures preventive treatments, alternative antibiotics, new systems to preserve new antibiotics. new preserve to systems Arabia levelofcapabilities • practices best and Strengths P.3.2 Surveillanceofinfectionscausedbyantimicrobial-resistant pathogens -Score 3 challenges and • strengthening need that reas A • • practices best and Strengths P.3.1 Indicators andscores • • • • • • Recommendations forpriorityactions Source: acquired MERS-CoVcasesinSaudi Fig. 1. Improved infectioncontrol practices: declineinhealthcare- versus community- Riyadh; Al-Hassa; Al-; ; and Assir; Al-Kharj. There are six designated sentinel sites for surveillance of infections caused pathogens: by AMR priority confirmation (as needed). A Central Public Health should Laboratory designated be as responsible for testing AMR and results. testing reporting AMR for conducting There are regular antibiograms generated within the hospitals and analysed to fulfil quality requirements beds; and the need represent all Saudi regions. of all pathogens. AMR priority These were based selected on their coverage for hospitals with > 150 atotalOf of 150 laboratories nationwide, 30 are designated to detection conduct AMR and reporting the burdenAssess ofin AMR Saudi Arabia and impact on morbidity, its and the economy. mortality Share data AMR with epidemiologists for real-time analysis for reporting, detection and response. Increase the number of sentinel sites for surveillance lab-based AMR by seven sites; needed), including the following: Designate acentral public health laboratory as responsible for testing AMR and confirmation (as interface. Enhance AMR-related activities for all indicators for animal health, including the human–animal Plan. Action National the in timeline Implement antimicrobial stewardship programmes across the Kingdom at all levels, and outline a Antimicrobial resistance detection-Score 3 DeclineinSaudi Arabia MERS-CoV. Arabia, 2014–2016 9 of IHR Core Capacities of the Kingdom of Saudi Arabia PREVENT 10 PREVENT

Joint External Evaluation • • • • practices best and Strengths P.3.3 Healthcare-associated infection(HCAI)prevention andcontrol programmes -Score 4 challenges and • strengthening need that reas A • • challenges and • strengthening need that reas A • • • • • • • • practices best and Strengths P.3.4 challenges and • strengthening need that reas A Comprehensive infection control auditing is carried out in all hospitals three every months. facilities include trained professionals. The infection prevention and control policy, operational plan and SOPs at all health-care tertiary The national plan is for updated HCAI on annual basis, and is operational in 270 hospitals. The designated facilities have all programmes conducted HCAI for at least one year. The number of sentinel sites for lab-basedsurveillance AMR should increased be by seven sites. regions began in 2016. Surveillance for detection of Salmonella, Campylobacter and total bacteria count in in allpoultry animal interface. animal AMR-related activities for all indicators for animal health should enhanced, be including at the human– a timeline outlined in the National Action Plan. Antimicrobial stewardship programmes should implemented be across the Kingdom at all levels, with clinics/pharmacies. private in suboptimal Physician prescription is required for antibiotics. Although implementation is 100% in hospitals, it is Saudi regions to evaluate the infrastructure for the antimicrobial stewardship programme. A onsurvey proper administration of antibiotics was conducted in 20 MoH hospitals selected across all were held in all regions in November 2016, and for health-care workers in care some hospitals. tertiary Antibiotic awareness campaigns for the public, coinciding with the World Antibiotic Awareness Week, The Adult Heath Care-Associated Infections guidelines are being finalized. The Surgical Antibiotic Prophylaxis Guideline has been established with pre-printed order sets. The national guidelines for antibiotic use have been completed and distributed. an annual basis. Saudi Arabia has an approved National Action Plan for Antimicrobial Stewardship, to updated be on The designated centres are conducting some antimicrobial stewardship practices. response. dataAMR should sharedbe with epidemiologists for real-time analysis for reporting, detection and Antimicrobial stewardship activities-Score 3 Adopted measured behaviours, policies and/or practices that minimize the transmission of zoonotic zoonotic of transmission the minimize that practices and/or policies behaviours, measured Adopted • • • Recommendations forpriorityactions the diseases, andanimalhostsareoftenasymptomatic. compatible with dengue and Ebola, animals might notdevelop pathognomonic clinicalsignsfor some of diseases ischallengingsincesomeofthemareviral haemorrhagicdiseaseswithclinicalsignsinhumans priority diseasesrequireimmediateSaudi Arabian notificationandresponse. Controlofpriorityzoonotic rabies, MERS-CoV, brucellosis, avianinfluenza, Rift Valley fever, Alkhurma haemorrhagicfever(AHF). Most There areSOPsforeachoftheninezoonoticdiseases currentlyconsideredanationalpriorityriske.g. the spreadofhighlypathogenicavianinfluenzaduring the 2007outbreak. and MERS-CoVsurveillanceincamels. Coordinationwithotheragencieshasbeensuccessfulinpreventing demonstrated byjointsurveillance of theMoHandMEWA onthetraceback ofhuman exposuretocamels, Saudi Wildlife Authority, SFDA, SaudiCentreforDiseaseControl(CDC), andSaudicustoms). This was of informationanddatawithrelevant stakeholders (MoH, MinistryofMunicipalities, MinistryofInterior, response. A multisectoral approachaddressesmostsignificant zoonoticdiseases, includingthesharing are developedthroughlimitedbuthigh-levelcoordinationamongagenciesforprevention, controland event ofanimaldiseasesthatrequiredepopulation. Nationalpoliciesandstrategies on zoonoticdiseases disease, andsupportthe “One Health” approach. Inaddition, therearecompensationpoliciesinthe Legislation, policiesandcircularsaddressthecontrolofimportantanimaldiseases, includingzoonotic their functions, andprivate veterinarianscanserveassurgecapacityintheeventof anemergency. of Municipalities, andtheSaudiFood andDrug Authority (SFDA). Veterinarians areaccreditedtoperform have veterinariansaspartoftheworkforceincludingMEWA, and(lesscommonly)the MoH, theMinistry with internationalstandardssetbythe World Organisation for Animal Health(OIE). Several ministries approving importsofliveanimals, andimposingquarantine andrestrictionsonanimal movementsinline legislation, addressingsurveillanceforreportableanimaldiseases, issuingcertificatestoexportanimals, (MEWA). MEWA isresponsibleforissuingministerialdecrees andregulationstoenactanimalhealth The veterinaryauthorityisundertheumbrellaofMinistryEnvironment, Water and Agriculture Saudi Target are ofanimalorigin; andapproximately 60%ofallhumanpathogensarezoonotic. that aidinitstransmission. Approximately 75%ofrecentlyemerginginfectious diseases affectinghumans diseases are caused by viruses, bacteria, parasites and fungi carried by animals, insects or inanimate vectors Zoonotic diseasesarecommunicablethatcanspreadbetweenanimalsandhumans. These Introduction Zoonotic diseases diseases from animals into human populations. human into animals from diseases Strengthen the One Health approach by incorporating more veterinarians. Define clear roles and responsibilities to address zoonotic diseases under theOne Health umbrella. (both wild and domestic animals). Amend, expand, and strengthen the interministerial committee, linking the human and animal interface Arabia levelofcapabilities 11 of IHR Core Capacities of the Kingdom of Saudi Arabia PREVENT 12 PREVENT

Joint External Evaluation • • • • practices best and Strengths P.4.1 Surveillancesystemsinplaceforpriorityzoonoticdiseases/pathogens-Score 3 Indicators andscores • • challenges and • strengthening need that reas A • • • • • practices best and Strengths P.4.2 Veterinary oranimalhealthworkforce -Score 3 • • • challenges and • strengthening need that reas A an algorithm in place for the reporting of cases. The veterinary laboratory for tests avian influenza and provides the results in a timely manner.There is the disease priority (e.g. MERS-CoV and avian influenza). The veterinary surveillance system is linked with the human diseases surveillance system for some of for public health.importance The animal health and human health jointly sectors developed the list of zoonotic diseases of priority concern. health There is asurveillance system in place for more than 20% of the zoonotic diseases of greatest public veterinarians. Health One for system accreditation an and FETP) Programme, Provide more capacity-building (e.g. epidemiology/risk assessment training, Field Epidemiology Training than half at subnational levels. subnational at half than While the animal health workforce has within capacity the national public health system, this is less Only afew animal health workers conduct One Health activities. veterinarians. involve Government the within agencies Several such as MERS-CoV and highly pathogenic avian influenza. Veterinarians have successful been very in dealing with demands related to zoonotic priority diseases end of 2017. Saudi authorities have agreed to have an OIE Performance of Veterinary evaluation Services by the The veterinary workforce understands the impactit has on public health. enthusiasticvery about their jobs and the future of the veterinary in services the Saudi Kingdom. The veterinary workforce was transparent during the JEE visit, working vets for the Government are difficult. population animal the in (e.g. Crimean-Congo haemorrhagic fever, Valley Rift fever), making prevention, detection, and control Challenges for the surveillance of some diseases priority exist since animal might hosts asymptotic be tuberculosis, and brucellosis) while other important zoonosis such as rabies are neglected. Some endemic zoonotic diseases do not have a clear surveillance system in place (e.g. Q fever, bovine zoonoses. Surveillance roles and responsibilities are not clearly defined forsome animal diseases including implementation. surveillance wildlife toxoplasmosis), and improved, as well as for follow-up to animal exposures (e.g. rabies), positive surveillance results (e.g. (e.g. Q fever, brucellosis, bovine tuberculosis). Coordination among these agencies should therefore be Saudi Wildlife Authority, disease in animals might not until detected be human of cases zoonosis occur Since there is no routine interaction among focal points at MEWA, MoH, Ministry of Municipalities, and reas that need strengthening and challenges and • strengthening need that reas A • • • • practices best and Strengths and functional-Score 2 P.4.3 Mechanismsforresponding toinfectiousandpotentialzoonoticdiseasesestablished • • • • outbreaks involving public health, livestock, other domestic animals, and wildlife. There is no well-defined mechanism for coordinating response to most priority zoonotic disease 2017. The Kingdom has scheduled an OIE Performance of the Veterinary evaluation Services by the end of manner. There is an algorithm in place for reporting results to relevant stakeholders. The veterinary laboratory provides results of avian influenza passive and active surveillance in a timely selected zoonotic diseases. interactionThere is the effective public between health and the animal health in responding sectors to influenza). as a national (therepriority mechanism is an effective in place to respond to MERS-CoV and avian The surveillance disease system successfully responded to at least 20% of zoonotic diseases recognized defined. more Roles and responsibilities of different agencies working under the One Health umbrella need to be Zoonotic functions require increased human resources to comply with surveillance demands. system for One Health veterinarians, and their integration further into the national public health system. There is aneed for capacity-building (e.g. epidemiology/risk assessment training, FETP), an accreditation and animal interface (both wild and domestic animals). There is aneed to modify, expand, and strengthen the interministerial committee linking the human 13 of IHR Core Capacities of the Kingdom of Saudi Arabia PREVENT 14 PREVENT

Joint External Evaluation Surveillance and response capacity among States Parties for food- and waterborne disease risks or events events or risks disease waterborne and food- for Parties States among capacity response and Surveillance (or furthercases)needtobeputinplace. based onariskassessment, suitableriskmanagementoptionsthatensurethepreventionofhumancases chain continuummustbedeveloped. Ifepidemiologicalanalysisidentifiesfoodasthesourceofanevent, containment iscriticalforcontrol. Riskmanagementcapacitywithregardtocontrolthroughoutthefood international incidentsinvolvingcontaminatedfood. The identificationofthesourceanoutbreakandits developed countries. The rapid globalizationoffoodproductionandtrade hasincreasedthelikelihood of Food- and waterborne diarrhoeal diseases are leading causes of illness and death, particularly in less Introduction Food safety assessment ofthesituation, whichincludesconfirmationofthediagnosis, development ofacasedefinition, response describedinthefoodborne manual. Morespecifically, theORT isresponsibleforthepreliminary In theeventofafoodborne illness, ORT membersprovideinputfollowing theprocedureforoutbreak centres, other government-related sectors, and the private sector, e.g. clinics, hospitals, private practitioners. events canbereportedatdifferent levels, startingfromMoHinstitutionssuch ashospitalsandhealth Foodborne and# 284). investigation whichisdescribedinthefoodbornemanual (Royal decrees# 67 Saudi Arabia hasaneffectivemechanismforrapid reportingandinformationexchange duringan of casesusingastandardizedquestionnaire. investigation, theMoHismainmemberresponsible fortheinvestigationandconductsinterviewing outbreak responseteam(ORT). MostrepresentativesintheORT aretrained regularly. Duringanoutbreak identifies personnelfromtherelevant sectorswhoformpartofanationalcommitteetoparticipateinthe and MinistryofMunicipalRural Affairs fortheinvestigationoffoodborneillness. Eachagency Saudi laws, regulations, andcircularsspecifytheshared responsibilitiesamongtheMoH, SFDA, MEWA, for routinefoodsafety. approach. The private sector and consumers are only marginally involved in the coordination mechanisms Coordination ofoutbreakinvestigation, reporting, testing, andmitigationsuseamultisectoral operational national foodmonitoringprogramme tocheckforfoodcontaminantsinimportedandlocal foodproducts. the monitoringoffoodsafetyforlocalandimportedproducts. Inaddition, SFDAhasimplementeda Directorate isresponsibleforfoodborneillnesssurveillance. Two executivedepartmentswithinSFDAoversee for thecoordinationofroutinefoodsafetyriskmanagement. Within theMoH, the Communicable Disease coordinate eventsrelatedtoacutefoodborneillnessinthehumanpopulation, whiletheSFDAisresponsible authority, throughtheGeneral Directorate ofEnvironmentalandOccupationalHealthProgramme, to implements standardsoflocal, GulfOrganization, andtechnicalregulations. The LawgivestheMoH foodborne illnesses. InadditiontotheFood Law, whichcoversdifferentaspectsoffoodsafety, thecountry Saudi Arabia hasestablishedafoodsafetysystemthatiseffective inpreventingandprotectingagainst Saudi Target by strengthening effective communication and collaboration among the sectors responsible for food safety, safety, food for responsible sectors the among collaboration and communication effective strengthening by and safe water and sanitation. and water safe and Arabia levelofcapabilities • • challenges and • strengthening need that reas A • • • • practices best and Strengths food safetyemergencies andoutbreaks offoodbornediseases-Score 4 P.5.1 Mechanismsformultisectoral collaboration establishedtoensure rapid response to Indicators andscores • • Recommendations forpriorityactions mechanisms targetingspecificfoodsafetystakeholders. MEWA andtheMinistryofMunicipalRural Affairs. This coordinationwillincludecommunication mechanisms byformingacoordinatingcommitteeconsistingofmembersfromrelevant sectorssuchas, government agenciesinvolvedinfoodsafety. Currently, theMoH, andSFDAareimprovingcommunication web-based Rapid Alert SystemforFood andFeed. The systemhasinformationoncontactpointsatother Information relatedtofoodborneillnessesissharedamongfoodsafetystakeholders thoughtheSFDA the laboratory includeaddingtestingforothervirusessuchasnoroviruses. and Bacillus cereus. The laboratory can also detect toxins and chemicals infood and feed. Future plans for Plate Count, coliformandfaecalcoliform, yeastsandmoulds, Enterobacteriaceae, Staphylococcusaureus monocytogenes, Listeriaspp., Salmonellaspp. andCampylobacterjejuni, andenumeration ofthe Aerobic SFDA haslaboratory capacitytodetect Vibrio parahaemolyticus andcholera, EscherichiacoliO517, Listeria involved inthetestingofclinicaland/orfoodsamplescollectedduringaninvestigation. well identifiedincirculars, whichdescribe key stakeholders (e.g. animalhealth, laboratory) thatwouldbe makes recommendations, andproposesremedialactions. Standardprocesses, roles, andproceduresare best communicationstrategies tosharetheinformationwithpatients, colleaguesandinterestedparties, and interpretation of the results. Once the source of the outbreak is identified, the ORT evaluates the collection ofspecimens, formationofhypotheses, dataanalysis, environmentalinvestigation, andanalysis different steps of the food chain. strengthen mitigation the safety “food concept” and consequently reduce risk of human exposure at (including local markets) will contribute to understanding abetter risks, of the affecting factors wholesalers and retailers consumers, managers, employees, government for awareness safety Food investigation. and Continued training and exercises are needed to sustain this in assurance, food capacity safety inspection mitigations or remedial actions that could help to reduce, control, and manage future human exposures. There is aneed to conduct aretrospective evaluation of outbreaks in order to determine possible investigations. illness A coordinating committee consisting of members from relevant shares sectors information on foodborne for Food and Feed. illnesses is shared among stakeholders food safety though the SFDA Rapid web-based System Alert Foodborne outbreak investigations are conducted in real time. Information related to foodborne of and imported local products. There programme is an effective to ensure that food safety product includes testing and surveillance foodborne investigation, prevention, and control of foodborne illness are well defined. There is astrong legal and regulatory framework addressing food safety. Roles and responsibilities for Raise public awareness and about foodborne food safety diseases through public health campaigns. risks. mitigate to riskExpand assessments along for food safety the food supply chain to identifyareas of intervention 15 of IHR Core Capacities of the Kingdom of Saudi Arabia PREVENT 16 PREVENT

Joint External Evaluation A whole-of-government national biosafety and biosecurity system with especially dangerous pathogens pathogens dangerous especially with system biosecurity and biosafety national whole-of-government A plants ortheenvironment. secure infectious agents against those who would deliberately misuse them to harm people, animals, biosafety andbiosecuritytoprotectresearchersthecommunity. Biosecurityisimportantinorderto dedicated toworkwithinfectiousagentshaveraised concernsregardingtheneedtoensureproper of bothnatural anddeliberate origin. At thesametime, theexpansionofinfrastructure andresources tools thatareneededtodetect, diagnose, recognizeandrespondtooutbreaksofinfectiousdiseases Research withinfectiousagentsiscriticalforthedevelopmentandavailability ofpublichealthandmedical diseases. set oftools–suchasdrugs, diagnostics, andvaccines –tocountertheever-evolving threatofinfectious It isvitaltoworkwithpathogensinthelaboratory toensurethattheglobalcommunitypossessesarobust Introduction biosecurity and Biosafety • Recommendations for priorityactions develop asimilaraccreditationmechanism. accreditation assessmentsonceeverytwoyears. Other sectorsthatoperate healthlaboratories haveyetto MoH, including all private medical laboratories; all these laboratories receive safety audits as part of their and includeasectiononbiosafety/biosecurity. This accreditationapplies to laboratories overseenbythe currently administeredbytheSaudiCentral Boardfor Accreditation ofHealthcareInstitutions(CBAHI), Diagnostic Laboratory. Nationalaccreditationstandardsformedicalandpublic healthlaboratories are are mainlystoredinmajorlaboratories suchasregionallaboratories oftheMoHorRiyadh Veterinary receive safetytraining uponappointment andregularlythereafter. Positive infectiousdiseasespecimens biosecurity; however, thereisno unifiedandcomprehensivetraining curriculum. Alllaboratory employees cross-sector coordination. Various governmentagencieshavetheirowntraining programmes forbiosafety/ on Biosafety and Biosecurity, with representatives from relevant governmental sectors, should improve of which(suchashumanhealth)arestrongerthanothers. The recentlyestablished NationalCommittee National GuardHealth Affairs. Differentsectorshavedevelopedbiosafety/biosecurity programmes, some laboratories havegoodsafetymanuals, guidelinesandSOPsundertheministriesof Health, Agriculture, and The Kingdomdoesnotyethavenationalbiosafetyandbiosecuritylegislation, althoughsomeindividual Saudi Target identified, held, secured and monitored in a minimal number of facilities according to best practices; practices; best to according facilities of number minimal a in monitored and secured held, identified, biological risk management training and educational outreach conducted to promote a shared culture of of culture shared a promote to conducted outreach educational and training management risk biological responsibility, reduce dual-use risks, mitigate biological proliferation and deliberate use threats, and ensure ensure and threats, use deliberate and proliferation biological mitigate risks, dual-use reduce responsibility, safe transfer of biological agents; and country-specific biosafety and biosecurity legislation, laboratory laboratory legislation, biosecurity and biosafety country-specific and agents; biological of transfer safe licensing and pathogen control measures in place as appropriate. as place in measures control pathogen and licensing service providers. providers. service to strengthen coordination and ensure unified biosafety and biosecurity across all relevant and sectors Review and clearly define the terms of reference of the National Committee on Biosafety and Biosecurity Arabia levelofcapabilities • • • challenges and • strengthening need that reas A • practices best and Strengths P.6.2 Biosafetyandbiosecuritytraining andpractices -Score 3 • • • challenges and • strengthening need that reas A • • • • • practices best and Strengths agriculture facilities-Score 3 P.6.1 Whole-of-government biosafetyandbiosecuritysysteminplaceforhuman, animaland Indicators andscores • • RRL-CHEMICAL HYGIENE (V3), 2015. PLAN chemicalLaboratory hygiene plan. Riyadh Regional Laboratory, Ministry of Health, doc. reference # RRL-SAFETY MANAGEMENT (V3), PLAN 2015. management safety Laboratory plan. Riyadh Regional Laboratory, Ministry of Health, doc. reference # 2019. continuityService planning. National Guard Health Affairs, doc. reference #7010-05-12-0082, 16 Dec A common training curriculum on biosafety and biosecurity has yet to developed be and implemented. trained. regularly are Capabilities to provide biosafety and biosecurity training are available and workers in different sectors sustainability. ensure to improvement further A mechanism for oversight, enforcement and attribution for biosecurity legislation or guidelines needs health. licensing/accreditationLaboratory mechanisms need to established be other in sectors than human implemented. and National biosafety and biosecurity legislation and guidelines are yet to finalized, be enacted/endorsed are in need of additional strengthening. Cross coordination sector mechanisms, including the National Committee on Biosafety and Biosecurity, Some accredited laboratories use international practices. best workersLaboratory participate in exercises and inspections (CBAHI) years. two every International. Commission some advanced laboratories are also accredited by the College of American Pathologists and Joint All laboratories in the human health sector, both public and private, are accredited by CBAHI; laboratories. SOPs and guidelines have been developed on biosafety and biosecurity for human and animal health and provides amechanism for cross-sector coordination. The National Committee on Biosafety and Biosecurity is represented by different government sectors Develop aunified, comprehensive training programme on biosafety and biosecurity. legislation. guidelinesand biosecurity and biosafety Develop anational strategy identifying prioritized plan of actionfor implementation of the national 17 of IHR Core Capacities of the Kingdom of Saudi Arabia PREVENT 18 PREVENT

Joint External Evaluation A national vaccine delivery system – with nationwide reach, effective distribution, access for marginalized marginalized for access distribution, effective reach, nationwide with – system delivery vaccine national A Target the mostsuccessfulglobalhealthinterventionsandcost-effectiveways tosavelivesandpreventdisease. Immunizations are estimatedto prevent more than 2 million deathsa year globally. Immunization is one of Introduction Immunization about theadvantage ofimmunizationonsocial media. Immunization Week in April toincreasetrustthroughregular transmission ofanimatedfilms andmessages from mandatorytovoluntary vaccination. The planfor2017istolaunchabigcampaign duringtheGlobal in 2009, firstbecauseof the H1N1influenza vaccination campaign, andsecondbecauseoftheswitch an issuebefore2009, when vaccine effectivenesswas notquestioned. The situationchangeddrastically rumours aboutvaccination viasocialmedia. Parent reluctance andpublicdistrustofvaccination werenot Another challengeisvaccine hesitancy, orpopulationgroupsrefusingvaccination andspreadingfalse vaccination statusiscontrolled at thebordercrossing. preventable diseases; thus, measlesandpoliocampaigns areregularlyperformedinbordervillages, and of age. The borderwiththe Republicof Yemen inthesouthisanotherareaofriskfortransmission ofvaccine the nationalmeasles-mumps-rubellacampaignreached98% ofthetargetpopulationbetween6–18years mobile vaccination teams offer vaccinations after gaining trust through contact with local leaders. In 2015, in thewesternpartofcountry. Someoftheillegalsettlersfearcontactwithauthorities, although A challengeforhighcoverage is toaccesshard-to-reachormarginalizedpopulations, andillegalimmigrants SFDA andtheMoH. electronic platformforreportsonvaccine sideeffectswillsoonbeinplacewithcross-notification between are reviewedwithintheMoHincollaboration withSFDAinanationalcommitteeevery fourmonths. An Committee andcausalityassessmentcommitteeinplace. Adverse eventsfollowing immunization(AEFI) has anindependentNationalImmunization Technical Advisory Group(NITAG), NationalCertification on aregularbasisatboththeregionalandnationallevel, andmoreoftenduringoutbreaks. The country coordinators ineveryregion, eachwithateamofat3–5collaborators. Training andsupervisionisdone tetanus, andvaricella. Saudi Arabia hasanEPImanageratnationallevelintheMoHandmorethan20 Haemophilus influenzaetypeB(Hib), measles, mumps, pertussis, pneumococcal, polio, rotavirus, rubella, 95% –forallvaccines intheEPIprogramme: BacillusCalmette–Guérin (BCG), diphtheria, hepatitisB, in private clinicsandhospitals, andnovaccination ismandatory. Vaccination coverage ishigh–atleast Immunization is free at all government health facilities, mainly in the primary health care centres, but also measles caseswerereportedcomparedto252in2013). eliminated, butmeaslesisstillspreadingendemicallyalbeitwithdecreasingincidence(in2016, 125 with theGlobal Vaccine Action Plan. Polio hasbeeneradicated (last casein1995)andneonataltetanus Expanded Programme onImmunization(EPI). Annual, and multi-yearplansaredevelopedforEPI, inline Saudi Arabia hasstrongpoliticalcommitmentandthefinancial sustainabilitytoensureawell-functioning Saudi populations, adequate cold chain and ongoing quality control – that is able to respond to new disease disease new to respond to able is that – control quality ongoing and chain cold adequate populations, threats. Arabia levelofcapabilities • challenges and • strengthening need that reas A • • • • • • • • • • • • practices best and Strengths P.7.1 Vaccine coverage (measles)aspartofnational programme -Score 4 Indicators andscores • • • • • Recommendations forpriorityactions Hajj. offered duringandaroundHajj. NITAG isevaluating vaccination needsandnewrecommendations before Hajj. Close surveillanceof vaccine preventable diseases is carried out andvaccination of internal pilgrimsis for pilgrimsfromendemiccountries. In2017, influenza vaccination willalsoberecommendedforallbefore During Hajj, vaccination againstmeningococcaldiseaseisrequiredforall, andagainstpolioyellowfever officially registered, their exact number is unknown. unknown. is number exact their registered, officially Illegal may settlers hesitant be to approach government facilities for vaccination and, since they are not The reluctance of parents to complete their children’s immunization schedule needs to addressed. be into the HSEN system and will fully be operational within a few years. A national electronic vaccine registry, including messaging short (SMS) services for reminders, is built Compiled and analysed data are used to inform actions and change policies and strategies as needed. years. three every done are surveys Coverage before submission to the national level. A structuredreporting system with exists data flowfrom providersservice to regional level for validation place. in are populations nomadic and illegal marginalized, reach to campaigns Vaccination Vaccination are services provided to troops assigned to work along the southern borders. control outbreaks. arrivals at the single functioning point along of entry the southern border as ameans to prevent and Vaccination (polio, measles-mumps-rubella, meningococcal vaccine) is provided free of charge for all Supplementary immunization years activities in are areas conducted4–5 every at risk of outbreaks. complete their vaccinations at primary health care centres and before school registration. Unvaccinated children, or children with incomplete vaccination, are actively traced and requested to A defaulter registration and retrieval system is in place. Vaccination are services provided free of charge in all government health facilities. years at national level and above 90% in more than 80% of districts. Measles-mumps-rubella vaccination coverage has been steadily above 95% for at least the last five industry. vaccines essential Call for proposals for long-term with vaccine contracts manufacturing companies and localize an platforms. communication Increase communication for behavioural change and impactacross social media and other groups among population. the Map hesitancy Train auxiliary and regional on reporting tools. staff Conduct acoverage administrative to survey verify data. 19 of IHR Core Capacities of the Kingdom of Saudi Arabia PREVENT 20 PREVENT

Joint External Evaluation • • • • practices best and Strengths P.7.2 Nationalvaccineaccessanddelivery-Score 4 • • challenges and • strengthening need that reas A schedules and recommendations are adapted according to needs. Hajj ensures the is country vigilant in international monitoring of vaccine preventable diseases, and campaign). polio subnational influenza, Vaccine delivery has been tested through nationwide vaccine campaigns (measles-mumps-rubella, regional level, and mainly using continuous monitoring level. equipment atlocal fridges on Cold chain temperatures are controlled by an electronic system with alarms in place at national and specifications. standard Vaccine delivery (maintaining the cold chain) is available in all in districts accordance with required areas. reach More mobile vaccination are services needed to reach nomadic groups and those living in hard-to- supervision activities. supervision Rapid turnover staff due to in high part reliance on expatriate requires staff frequent training and occasional at shortages district level. to lead manufacturers, from supply delayed and forecasting, and procurement vaccine Inadequate 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 technical, administrative andreferral linkages. functions andminimalstandards fortests, techniques, equipmentandpersonnel foreachtier, aswellfor will requireathoroughreview andrevisionofthecurrentpublichealthlaboratory networkintermsofits cost. A NationalHealthLaboratory hasnowbeenestablishedandwillsoonbecomefully functional. This and Dammam)playacrucialrole. Manyspecimenshave alsobeenreferredfortestingoverseasatsignificant testing has been distributed among regional laboratories, five of which (Riyadh, Jeddah, Makkah, Madinah, at theRiyadh RegionalLaboratory. Without acentral publichealthlaboratory, confirmatoryandreferral The Kingdomdoesnothavedesignatedreferencelaboratories forprioritydiseases, exceptforpoliolocated services was clearlyandexplicitly definedforeachtierbytheMoH. as thetoptier, followedbyhospital-basedlaboratories andprimary healthcarefacilities. The scopeof human healthsector, a three-tier laboratory network has existed until recently, with regional laboratories play acoordinatingrolebecauseitincludesrepresentatives fromallstakeholders exceptMEWA. Inthe laboratory policy, legislationornationallaboratory strategic plan. The SaudiHealthCouncilcouldpotentially coordination oflaboratory servicesacrosssectorsasthereisnocomprehensivecross-sector national two years. Similar accreditation mechanisms are being finalized in other sectors. A major issue is poor Pathologists andJointCommissionInternational. Accreditation renewal inspectionsareperformedevery and atleastsevenpubliclaboratories areaccreditedtointernationalstandardsbytheCollege of American all laboratories operating undertheMoH and allprivate medical laboratories. Many private laboratories In thehumanhealthsector, adomestic accreditationprogramme, administeredbyCBAHI, ismandatoryfor care testing, andwelltrained andqualifiedstaff. Several BSL-3facilitiesareavailable. a nationallaboratory systemfeaturingexcellentinfrastructure, moderndiagnosticequipmentandpoint-of- There isalsoastrongprivate sector. The countryhasademonstrated abilityforreal-timesurveillanceusing MoH, MEWA, MinistryofNationalGuard, MinistryofDefence, MinistryofInterior, andmajoruniversities. Health laboratory servicesinSaudi Arabia areprovidedbyanumberofgovernmentagencies, includingthe Saudi Target education; andpartnershipscommunication. and specializedtesting; laboratory oversight; emergencyresponse; publichealthresearch; training and food safety, includingdiseaseprevention, controlandsurveillance; integrated datamanagement; reference can serveasafocalpointfornationalsystem, throughtheircorefunctionsforhuman, veterinaryand response, environmentalmonitoringanddiseasesurveillance. Stateandlocalpublichealthlaboratories Public healthlaboratories provideessentialservicessuchasdiseaseandoutbreakdetection, emergency Introduction National system laboratory DETECT laboratory-based diagnostics. laboratory-based Arabia levelofcapabilities 21 of IHR Core Capacities of the Kingdom of Saudi Arabia DETECT 22 DETECT

Joint External Evaluation including reagents. diagnosticdevices,national regulatoryauthorityresponsibleforqualificationandregistration ofin vitro well established in the human health sector, and to a lesser extent in theanimal health sector. SFDA is the An equipmentmaintenanceprogramme, includingmaintenanceandcertificationforbiosafetycabinets, is notifiable diseasesorallIHRhazards. delays. Moreover, theexistingprovisiondoesnotallowtoexpandspecimentransportation servicestoall which havetoarrange specimentransport onacase-by-casebasis, oftenresultingininefficienciesand routine testingspecimens, respectively. However, thesecontracts donotcoverprimaryhealthcarefacilities, has fourcontracts withacouriercompany(SMSA)totransport polio, MERS-CoV, neonatalscreening, and The specimentransportation systemoverall isquitegood, atleastinthehumanhealthsector. The MoH establishing anintegrated publichealthlaboratory informationsysteminthefuture. the currentsystemusedforpublichealthreportingpurposes, isunclearbutwillbeacrucialfactorfor currently usedsystemswitheachotheraswelltheHealthElectronicSurveillanceNetwork(HESN), sector. Somemajorlaboratories havenocomputerizedlaboratory informationsystem. Compatibilityofthe Different systems are being used in different sectors, and even in individual laboratories within the same an alternativeapproachtoEQAS. Laboratory informationsystemsarenotstandardizedorwellintegrated. of whichareoutsourcedandthereforecostly. Somelaboratories exchangesplitsampleswitheachotheras In thehumanhealthsector, alllaboratories arecoveredbyexternalqualityassessmentschemes(EQAS), most reas that need strengthening and challenges and • strengthening need that reas A • practices best and Strengths D Indicators andscores • • • • • Recommendations forpriorityactions .1.1 Laboratory testingfordetectionofprioritydiseases-Score 4 comprehensive coordination. improved with cross-sectoral The national public health laboratory should network reviewed be and upgraded to become more MERS-CoV, plague, tuberculosis, viral and haemorrhagic fever. paralysis (AFP), avian influenza, brucellosis, cholera, HIV, malaria, measles, meningococcal meningitis, Well-developed capabilities are available for many core for tests disease, priority e.g. acute flaccid Ensure participation of all health laboratories in appropriate EQAS. concern. of pathogens Develop and implement national standardized testing algorithms and SOPs for core selected and tests laboratories. high-volume in system information laboratory electronic integrated and standardized a Implement international national regulations. and applicable of biological specimens and other infectious and potentially infectious materials in compliance with referraleffective and reporting mechanisms; and clear procedures for collection and transportation well defined roles and responsibilities(both technical and managerial) at each level of the network; Strengthen atiered and integrated national public health with laboratory clear network, leadership and riskand develop regulations assessmentand risk conduct impact, and legislation.among sectors, concerned ministries and amandate to improve communication and coordination of laboratory services Establish amultidisciplinary regulatory and oversight body, with higher authority functions than the • • challenges and • strengthening need that reas A • • • practices best and Strengths D • • challenges and • strengthening need that reas A • • • practices best and Strengths D • challenges and • strengthening need that reas A • • practices best and Strengths D .1.4 Laboratory qualitysystem-Score 3 .1.3 Effectivemodernpoint-of-care andlaboratory-based diagnostics-Score 3 .1.2 Specimenreferral andtransport system-Score 3 Most EQAS are outsourced and therefore costly. EQAS. proper by covered A significant number of laboratoriesboth within and outside the human health aresector not yet The laboratory accreditation process needs to expanded be beyond the human health sector. EQA programmes are available in most laboratories in the human and animal health sectors. through CBAHI, regular with and audits. inspections A well-established and functioning mandatory accreditation process in exists the human health sector National standards quality for health laboratories are available. informationLaboratory systems are fragmented or lacking within the human health sector. Equipment maintenance programmes beyond the human health need strengthening. sector Standardized and services testing protocols should developed be for other laboratory sectors. used. available are and devices Point-of-care to use them. Modern sophisticated equipment and testing techniques are available trained and staff and qualified The scope for of services laboratory tiers network in the human health is standardized. sector cost. significant at Due to alack of reference laboratories in the country, many specimens are referred for overseas testing hazards. IHR or many diseases notifiable Current specimen transportation with SMSA contracts do not cover primary health care facilities or Established and operational referral different links between tiers, at least in the human health sector. A well-functioning sample transportation system through exists with SMSA contracts courier company. 23 of IHR Core Capacities of the Kingdom of Saudi Arabia DETECT 24 DETECT

Joint External Evaluation 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 Target biological events. leading anintegrated biosurveillanceeffortthatfacilitatesearlywarning andsituationalawareness of The purposeofreal-timesurveillanceistoadvance the safety, securityandresilienceofthenationby Introduction Real-time surveillance be possibleinthenearfuture. continue to be shared traditionally through faxes and emails. In principle, electronic sharing of data should website. Currently, humanandveterinarysectorsdonothaveaccessto each other’s databasesand data system isinitsinfancy, inprincipleitwillproducereal-timesurveillance datatobedisplayedonthe system byregionalfocalpointsoranystakeholder with directrelationtotheanimal. While thiselectronic an electronicnotificationsystemfor13highpriority animal diseases, whichshouldbenotifiedtothe will soonbeabletocollectlaboratory notificationsforalldiseaseselectronically. MEWA hasalsodeveloped Laboratory dataarecurrentlycollected electronicallyinHESNforafewdiseasesonly. However, thesystem makers. when newMERScasesarenotifiedtothesystem, forinstance, anSMSissentto key expertsanddecision- on surveillancedataaregenerated fromthesystem(dashboard). The systemisalsoabletoproducealerts: them witheachregionsotheyhavetheopportunitytolook attheirownsurveillancedata. Weekly reports laboratory results. HESNhas reportingtoolsthatenablevisualizationofdata, forexample, andsharing 2014. HESNnotonlyregistersdiseases, butincludesdetailedcaseinvestigations, outcomesandrepeated diseases arereportedusinganelectronicnotificationsystemcalledHESN, which was establishedin are 47notifiablediseasesofwhich23shouldbereportedimmediatelyand24withinaweek. Allnotifiable Saudi Arabia alsohasafullyoperational indicator-based surveillancesystemforinfectiousdiseases. There health). dedicated hotlinetoreceivereportsofpublichealthevents(937forhumanand800animal surveillance andfieldinvestigationunilaterally ortogetherdependingontheoutbreak. The MoHhasa departments totheMoH)andMoEWA. These ministriesverify thepublichealthproblemandinitiateactive health events, suspectdeathofanimals, etc. arereporteddirectlybyindividuals, municipalitiesandsecurity The country has established an event-based surveillance system inwhich high mortality, any unusual Saudi 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 subnational (local and intermediate), national and international international and national intermediate), and (local subnational between and sectors across collaboration levels of authority regarding surveillance of events of public health significance; improved country and and country improved significance; health public of events of surveillance regarding authority of levels intermediate level regional capacity to analyse and link data from and between strengthened, real-time real-time strengthened, between and from data link and analyse to capacity regional level intermediate surveillance systems, including interoperable, interconnected electronic reporting systems. This would would This systems. reporting electronic interconnected interoperable, including systems, surveillance include epidemiologic, clinical, laboratory, and environmental testing, product safety and quality and and quality and safety product testing, environmental and laboratory, clinical, epidemiologic, include bioinformatics data; and advancement in fulfilling the core capacity requirements for surveillance in in surveillance for requirements capacity core the fulfilling in advancement and data; bioinformatics accordance with the IHR and OIE standards. OIE and IHR the with accordance Arabia levelofcapabilities • challenges and • strengthening need that reas A • • • • practices best and Strengths D challenges and • strengthening need that reas A • practices best and Strengths D Indicators andscores • • • • Recommendations forpriorityactions diseases currentlymanually. in primaryhealthcarecentres. Fever withrash and AFP arenotifiedelectronically, sexuallytransmitted influenza-like illnesssurveillanceisimplementedatsixsentinelsites; andsexuallytransmitted diseases sexually transmitted diseases. AFP andfeverwithrash syndromesarereportedbyallhealth-carefacilities; infection, influenzalike illness, andhaemorrhagicfever. Inaddition, thereissyndromicsurveillancefor Syndromic surveillanceexistsforanumberofsyndromes: AFP, feverwithrash, severeacute respiratory are several publichealthspecialistsatnationallevelabletoanalyzeandinterpretsurveillancedata. are produced, and the data are also reviewed during weekly Command and Control Centre meetings. There functioning electronicsurveillancesystemsarenotyetinterconnected. Weekly reportsofsurveillancedata and localauthorities. Currently, dataaresharedtraditionally betweenhumanandveterinarysectors; the Government. The systemsareableto produce reportsofsurveillancedatathatcanbeaccessedbyregional Electronic surveillancesystemsareinplaceforbothhumanandanimaldiseasessustainedbythe .2.2 Interoperable, interconnected, electronic real-time reporting system-Score 4 .2.1 Indicator- andevent-basedsurveillancesystems-Score 3 Electronic surveillance systems for human and animal diseases should interconnected. be should collected be on all notifiable microbes. Currently laboratory data are collected directly from laboratories for alimited number of diseases; data Data are also used for research. HESN is able to produce of significant alerts findings, e.g. new cases. MERS Regions have access of surveillance to reports data in their ownarea. electronicAn surveillance system is in place for human and animal diseases. standardized. and formalized be should surveillance Event-based municipalities to departments and MoH. However, security few events are notified to the hotline. Event-based surveillance is based on voluntary reporting of unusual health events by individuals, diseases. infectious other of surveillance developing for used also time surveillance for MERS timely collects cases data with almost 100% coverage; this experience is The indicator-based surveillance system for human diseases is well-developed and functioning. Real- planned evaluation the HESN. of Conduct Interconnect the public health and veterinary electronic surveillance systems. Enhance the laboratory surveillance system in HESN. surveillance. event-based standardize and Formalize 25 of IHR Core Capacities of the Kingdom of Saudi Arabia DETECT 26 DETECT

Joint External Evaluation Strengths and best practices best and Strengths D challenges and • strengthening need that reas A • • practices best and Strengths D reas that need strengthening and challenges and • strengthening need that reas A • • .2.4 Syndromic surveillancesystems-Score 4 .2.3 Integration andanalysisofsurveillancedata-Score 4 Notifications of all notifiable microbes should be sent fromdirectly laboratories to HESN. SMS for some alerts diseases (MERS) are sent to decision-makers in real time. Data for some notifiable diseases are received from directly laboratories. Electronic reporting should also be implemented for surveillance of sexually transmitted diseases. Influenza-like illness surveillance is implemented in sentinelsix sites. Data for AFP and fever with rash are collected electronically in HESN. 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 • • • • actions wereidentifiedduringtheevaluation. Although thecountryhaswell-establishedprocedures forreportingaPHEICto WHO, several priority Recommendations forpriorityactions government institutionsparticipatedintheexercise. has also tested its systems to identify and report a PHEIC during the last Hajj. Several ministries and measures definetheproceduresandapprovals forreportingapotentialPHEICto WHO. Saudi Arabia (PHEIC) to WHO. Guidelines for controlof communicable disease and implementation of preventive SOPs areinplaceforapprovingandreportingapotentialpublichealthemergencyofinternationalconcern mechanisms with WHO underarticle8oftheIHR. There arenolimitationsfortheperformanceofIHRNFP, andthecountryhasusedinformalconsultation requirements asamemberoftheGCC, Arab Leagueand OrganizationIslamicConference. with the WHO RegionalOfficefortheEasternMediterranean. Saudi Arabia alsohasregionalreporting The countryhasreceivedtraining fortheseNFProlesin WHO intercountry meetingsandregularconsultations National HajjCommitteeandInfectiousDiseases Technical Group. for makingdecisionsonreporting: theIHRNFPisamemberofCommandandControlCentre(CCC), Committee ofZoonoticDiseases. Publichealth, animalhealthandsecurityauthoritieshaveclearmechanisms Control andCommandCentre(MoH, MEWA, NationalGuardandMilitary); andthe JointInterministerial the CommitteeforDeputyMinistersofHealth, Agriculture andMunicipalities; weekly meetingsofthe the MEWA. The followingmechanismsensurethatinformation betweenthesefocalpointsisexchanged: by awholeteam. The countryhasalsonominatedanoperational OIEfocalpoint, DrMansouralBalaway in Saudi Arabia has nominated an operational IHR NFP – Dr Abdullah M. Assiri at the MoH – who is supported Saudi Target ecosystems reducestheriskofdiseasesatinterfacesbetweenthem. and animal health systems. Collaborative multidisciplinary reporting onthehealth of humans, animals and pathogens continuetoevolveandadaptnewhostsenvironments, imposingaburdenonhuman Health threats at the human–animal–ecosystem interface have increased over the past decades, as Introduction Reporting FAO and OIE. and FAO to through WHO the IHR NFP. Conduct simulation exercises to test and the timely capacity reporting of chemical and radiation events Enhance the awareness and use of Annex 2 of IHR, particularly among non-health sectors. PHEICs. potential of assessments risk multisectoral standardize and improve to SOPs Develop events. these of relevant rapidassessment the national for stakeholders Establish anational electronic platform for the timely reporting of potential PHEIC, with access to all Arabia levelofcapabilities 27 of IHR Core Capacities of the Kingdom of Saudi Arabia DETECT 28 DETECT

Joint External Evaluation D • • challenges and • strengthening need that reas A • • • practices best and Strengths D Indicators andscores • challenges and • strengthening need that reas A • • practices best and Strengths .3.2 Reportingnetworkandprotocols incountry-Score 4 .3.1 Systemforefficient reporting toFAO Training is limited for some relevant sectors. Limited collaboration regarding exists potential PHEIC among some of the relevant stakeholders. increased, including authorities at regional and local level. Awareness of all relevant about events sectors that may of be public health concern should be HESN and is timely an effective system for notifying potential PHEIC to the MoH. Hajj has enhanced the importance of public health and multisectoral reporting. A reporting system for apotential PHEIC to is WHO in place. experience is lacking for chemical and radiationevents. and chemical for islacking experience Despite substantial experience of assessing and reporting potential PHEIC of biological origin, Roles, responsibilities and leadership in assessing apotential PHEIC need clarification and SOPs. In addition to reporting real events, the has country carried out exercises on reporting aPHEIC to WHO. hasThe country substantial experience of reporting PHEIC to WHO. , OIEand O -ScoreWH 4 States Parties with skilled and competent health personnel for sustainable and functional public health health public functional and sustainable for personnel health competent and skilled with Parties States • • • Recommendations forpriorityactions veterinary workforce), andthe Arab Organizationfor Agricultural Development(forimprovedtraining). (EMPHNET), WHO RegionalOffice fortheEasternMediterranean, Food and Agriculture Organization(for with theUSCentersforDiseaseControlandPrevention, EasternMediterranean PublicHealthNetwork the SultanateofOman. Saudi Arabia isprovidingOmaniresidentswithFETPtraining. Partnership alsoexists and internationalpartnershipsexistwithEmoryUniversity, USA, LiverpoolUniversity, UnitedKingdom, and (master’s) degreeinfieldepidemiologyforphysicians. To date, 168studentshavebeentrained. Regional postgraduate training programme in collaboration withKingSaudUniversity, Riyadh, leadingtoadiploma The SaudiFETP, a division ofthe Public HealthDepartment, was established in 1989. It is a2-year public healthworkforce. human resources, thecountryhasidentifiedneedforamulti-organizationalincentivesystem international institutions. Duetoalackofclearcareerpaths, positions, andabilitytoattract andretain health andnursing, aswell4healthinstitutes; Saudiscanalsoobtainadegreethroughnumberof is needed, particularlybeyondpersonneleducatedatthenationallevel. There are 73collegesofmedicine, numbers andtracing ofthepublichealthworkforcebyprofession(epidemiologist, veterinary, nursing, etc.) multisectoral, incorporating human, animal and environmental health on a One Health platform. Updated outbreaks (MERS, avianinfluenzaetc.). Implementationoftheworkforcecapacitystrategy needstobe situations suchastheHajiworkforcestrategy, southernregionfrontlineworkforcestrategy, andforcertain Workforce capacity-buildingstrategies andplansincludenational andinternationaltraining andforspecial 55 000 physicians, 22 000areSaudi(DepartmentofStatistics). which leadstoagreatdealofturnoverandinstabilityinthehealth-caresystem. Ofthe83 000 nursesand Saudi Arabia stillreliesheavilyonanexpatriatepopulation foritshealthworkforce, particularlynurses, Saudi Target scientific skillsandsubject-matterexpertise. developing and maintaining a highly qualified public health workforce with appropriate technical training, Workforce development is important in order to ensure a sustainable public health system over time by Introduction Workforce development surveillance and response at all levels of the health system and the effective implementation of the IHR IHR the of implementation effective the and system health the of levels all at response and surveillance (2005). (2005). for assistant vets. assistant for (physicians and non-physicians) and develop training FETP for veterinarians, including courses short months)Establish (3–6 and short intermediate (1 year) courses FETP for public health workers the actual numberAscertain of health workers in Saudi Arabia through the Department of Statistics. of each of the involved institutions/ministries (stakeholders). Establish anational multisectoral workforce development committee, which includes representatives Arabia levelofcapabilities 29 of IHR Core Capacities of the Kingdom of Saudi Arabia DETECT 30 DETECT

Joint External Evaluation • WHO USCDC USAID TWG THIRA SOPs SNRA T RR PoE NFP NAMRU II mFETP MERS OIE JEE IMS IPC IHR (2005) IBS GHSA FAO EVD EQA EOC EBS DHS CD • CBRN • CamLIS CamEW AMR • practices best AFRIMS and Strengths APSED D AET Indicators andscores Abbreviations • • • challenges and • strengthening need that reas A • • • practices best and Strengths D • • • • challenges and • strengthening need that reas A .4.1 Humanresources availabletoimplementIHRcore capacityrequirements -Score 3 .4.2 FETPorotherappliedepidemiologytraining programme inplace-Score 4

professional incentives as well as recognition of national training programmes. Establish career paths for public health workers (including graduates), FETP with financial and a good healtha good system and to work within the IHR framework. managedThe country expatriate to attract health where Saudi staff health were lacking staff to ensure districts. Each region has apublic health division with an epidemiologist, and MEWA representation in most than MERS. and aspecific rapid response team,which it plans to generalize to cover public health threats other The Public Health Department formed amultidisciplinary team (CCC) in response to the MERS outbreak be established. Partnerships with countries in the region to share graduates FETP during emergency events needs to development. further needs Field epidemiology tracking capacity of human resources, mainly educated abroad, has but started communication. and formation team multidisciplinary regarding needed is Improvement approach needs to established. be Advanced training FETP for veterinarians and other professionals that contribute to the One Health bodies to provide public health and epidemiology training. available within the for country health-care workers. Also, there are agreements with international Other long-term public health training programmes (Master of Public Health, Master of Science) are capacities. Trained field epidemiologists are available throughout the forboth country human and animal health (veterinarians, nurses, etc.). Plans are national to start basic and intermediate training. Advanced is FETP in place with plans to expand to other professionals in the One Health network health. Specialized human in some capacity areas of IHR is scarce, such as risk communication and animal review. under Incentives to maintain and efforts the existing public health workforce are needed, and are currently Tracing, and attracting retaining qualifiedwithin staff the public health shouldsector be improved. in the field during thesame event. Coordination and multisectoral collaboration is lacking, and multiple investigation teams deployed can Reliance on expatriate health staff, in particular nurses, needs to addressed. be ARN World HealthOrganization United StatesCentersforDisease ControlandPrevention United States Agency forInternationalDevelopment TechnicalGroup Working Threat andHazardIdentificationRisk Assessment Standard Operation Procedures Strategic NationalRisk Assessment Rapid Response Team Points ofEntry National IHRFocal Point Naval MedicalResearchUnitII modified FieldEpidemiology Training Middle Eastrespiratory syndrome World Organisationfor Animal Health Joint ExternalEvaluation Incident ManagementSystem Infection PreventionandControl International HealthRegulations(2005) Indicator-based Surveillance Global HealthSecurity Agenda Food and Agricultural OrganizationoftheUnitedNations Disease Ebola Virus External Quality Assurance Emergency Operations Centre Event-based Surveillance Department ofHospitalService Department ofCommunicableDiseasesControl, MinistryofHealth Combined JointChemical, Biological, Radiological, andNuclear Cambodia Laboratory InformationSystem Cambodia earlywarning surveillancesystem Antimicrobial Resistance Armed Forces ResearchInstituteofMedicalSciences Asia Pacific Strategy forEmergingDiseases Applied Epidemiology Training (Cambodia’s versionofmFETP) • • challenges and • strengthening need that reas A • • practices best and Strengths D .4.3 Workforce strategy -Score 3 A plan for amulti-organization incentive system for the public health workforce is required. Multisectoral collaboration on the One Health platform should strengthened. be Work is ongoing to improve the public health workforce strategy and tracking system. flu). avian and Other health workforce strategies and plans exist for certain situations like Hajj and outbreaks (MERS A health-care strategy is available for the labour workforce, although it needs multisectoral collaboration. 31 of IHR Core Capacities of the Kingdom of Saudi Arabia 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 confirm them. States Parties should provide WHO with contact details of IHR NFP, continuously update and annually the WHO IHR regional contact points andwithallrelevant sectors andotherstakeholders in the country. a key requisite for IHR implementation. The IHR NFP should be accessible at all times to communicate with including thesustainablefunctioningofanIHRNFP, whichisanationalcentreforIHRcommunications, is national partnershipsforeffectivealertandresponsesystems. Coordinationofnationwideresources, The effectiveimplementationoftheIHR(2005)requiresmultisectoral/multidisciplinary approachesthrough Introduction Preparedness RESPOND • Recommendations forpriorityactions – andothercountriestoemulate. hazard plan. The Saudiemergency responseaccomplishmentscanbeusedasaregionalstandardforGCC trained andfullyfunctionalstaff, haveledtothedevelopment andimplementationofaneffectivemulti- levels. Meticulousplanning, multisectoral collaboration, decisiveleadership, appropriateresourcesand preparedness andresponsecapabilitythatcanrespond to, manageandmitigatemulti-hazardsonall crisis events. Consequently, Saudi Arabia’s investmentshaveledtoaneffectiveandrobustpublichealth civilian hospitalscommunicateandcoordinateeffectivelytoquicklyresolvepublichealthemergencies utilized toconveyhowtheEasternProvinceCivilDefence, subnationalresponsedecontaminationunitand performing asimulationexercisefortheJEEteaminDammamregion. A multisectoral approachwas response. Additionally, Saudi Arabia hasdemonstrated itsabilitytorespondall-hazardseventsby priority publichealthrisksandmappedresourcestomitigatetheseforaneffectiveemergency across thenation. Saudi Arabia, incollaboration withseveral sectorsoftheGovernment, hasidentified Multi-hazard publichealthnationalandsubnationalresponseplanshavebeendevelopedimplemented which includesaholisticandintegrated approachtopreventingandmitigatingpublichealth emergencies. The Kingdomhasmadesignificantinvestmentsinitspublichealthpreparednessandresponseinfrastructure, Saudi 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. health public linkage with the Civil Defence Council. approach for health within the national preparedness structure; the committee should have formal Establish ahigh-level steering committee within the Saudi CDC to ensure an all-hazard and multisectoral Arabia levelofcapabilities reas that need strengthening and challenges and • strengthening need that reas A • • • practices best and Strengths R.1.2 Prioritypublichealthrisksandresources mappedandutilized-Score 4 • challenges and • strengthening need that reas A • • • • • practices best and Strengths developed andimplemented-Score 4 R.1.1 Nationalmulti-hazard publichealthemergency preparedness andresponse plan Indicators andscores The risks and resource mapping should beyond extend communicable diseases and Hajj/Umrah season. (critical stock levels) for responding to events priority and other emergency risk are accessible. National profiles on risks and resources are developed and reviewed regularlystockpiles andsector National resources have been mapped, including the needs for each sector. A risk assessment has been conducted to identifypotential urgent national and subnational risks. response capacity are procured. anticipate public health impactand ensure that resources necessary beyond local and subnational A high-level overarching steering committee that has a360° field visionof could to serve analyse and diseases and all other hazards are not seamlessly managed in aholistic manner. The existing plans are not comprehensive and should fully a multi-hazard reflect approach; communicable accordingly. updated and subnational endemics, and The national public health emergency response plan has been tested in an actual emergency for Hajj response). intermediate levels toactionat local support response level (including to scale capacity up the level of Procedures, plans and astrategy is in place to reallocate or mobilize resources from national and is available. international concern and Coverage for pointsand of surge entry to respond capacity to public health emergencies of national National response plan(s) incorporates Global Health Agenda Security IHR-related hazards. developed. been has requirements capacity A multi-hazard national public health emergency preparedness and response plan that covers IHR core 33 of IHR Core Capacities of the Kingdom of Saudi Arabia RESPOND 34 RESPOND

Joint External Evaluation Country with public health emergency operations centre functioning according to minimum common common minimum to according functioning centre operations emergency health public with Country 2 support decision-makingandimplementation, coordinationandcollaboration. during aresponsetoanemergencyorexercise. They alsoprovideotheressentialfunctionsto exercises. EOCsprovidecommunicationandinformationtoolsservices, andamanagementsystem information andresourcesforstrategic managementofpublichealthemergenciesandemergency A publichealthemergencyoperations centre(EOC)isacentral locationforcoordinatingoperational Introduction operations response Emergency • • Recommendations forpriorityactions during atimeofcrisisorpublichealthemergency. up anddemonstration showcased thehighlevelofprofessionalcompetencewhichunitiscapable sustaining training, drills and plannedexercises for theorganization. The hospitaldecontamination drillset- right purpose. The entireoperation reflectedahighlyefficient training programme thatfrequentlyconducts expedites thefunctionalcapabilityofteamsandensuresthathaverightchecklistfor developed colourcodedJob Action Sheetsforeachstaffmemberwitharesponsefunction. This technique triggers forresponse. As ademonstration ofexcellencein emergencyoperations management, thehospital including theDharan MilitaryComplex, allarefullyaware of emergencymanagementoperations andthe From individualmedicalstaffathospitalstomanagersandleaderstheEasternProvinceCivilDefence, appropriate emergencyresponselevel. support to the situation. Detailed plans and activation protocols are available to facilitate activation at the facilities areseamlesslyintegrated andlayeredtomatchtheappropriatelevelofcoordinated response resource procurement. State-of-theartEOC facilities existatthenational, subnationalandlocallevel. These standards, andsignificantinvestmentshavebeenmadeininfrastructure development, stafftraining and subnational level. The organizational construct complies with WHO’s Framework for Public Health EOC Saudi Arabia hasdevelopedemergencyresponseprocedures andestablishedEOCsatnational Saudi Target standards; maintaining trained, functioning, multisectoral rapid response teams and “real-time” “real-time” and teams response rapid multisectoral functioning, trained, maintaining standards; biosurveillance laboratory networks and information systems; as well as trained EOC staff capable of of capable staff EOC trained as well as systems; information and networks laboratory biosurveillance activating a coordinated emergency response within 120 minutes of the identification of a public health health public a of identification the of minutes 120 within response emergency coordinated a activating emergency.

describing howplans and emergencyresponseactionssupported thelargernationalresponsestructure. It shouldbehighlighted thateach of theSaudi presenters for each function of preparedness/response and emergency operations performedbrilliantly in integration with other systems (including surveillance information to Saudi CDC). Saudi to information surveillance (including systems other with integration 911 of implementation for momentum Maintain the ensure number) and telephone (unified emergency threat. health public MERS-CoV in order to maintain to the activate capacity acoordinated emergency response to any Sustain levels of investment, infrastructure developed and capacity in relation to Hajj/Umrah and Arabia levelofcapabilities 2 • • practices best and Strengths R.2.4 Casemanagementprocedures implementedforIHRrelevant hazards -Score 5 challenges and • strengthening need that reas A • • practices best and Strengths R.2.3 Emergency operations programme -Score 5 challenges and • strengthening need that reas A • • • practices best and Strengths R.2.2 EOCoperating procedures andplans-Score 5 • • • challenges and • strengthening need that reas A • • • practices best and Strengths R.2.1 Capacitytoactivateemergency operations -Score 5 Indicators andscores levels. levels. available system are relevant health hazards at IHR-relevant other guidelinesfor management Case diseases. epidemic-prone available guidelines are management priority for Case information management system (IMS) operations within and outside the health sector. coordinate one health response, such coordination needs to strengthened be to include standardized Despite that the fact the functions and operations were tested with demonstrated capability to 120 within response minutes. emergency health one coordinate to capability EOC activated aresponse system for communicable diseases and epidemics and demonstrated making. Multiple EOC exercises have been completed to test systems, operational capabilities and decision- hazards. disease-related noncommunicable to expanded be should Capacity level and procedures for acquiring additional resources. Response plans are in place that describe scaled levels of response with resource requirements for each subject-matter expertise) with an expanded set of functions. EOC plans are in place for functions including public health science (epidemiology, medical and other Several functioning EOCs are in place connecting the whole country. Legislative guidance or regulations should also developed be as appropriate. deployment. personnel and countermeasures medical A guidance document should strategically be planned and developed to strengthen and expand Testing should expanded be to hazards beyond health and not exclusively specific to Hajj/Umrah. and infrastructureEOC staff may capacity not adequate be to cover an all-hazard response. Staff use actual responses to hone further their skills and improve response times. The system is tested at least ayear twice to test EOC activation. hours. response within two Dedicated are EOC trained staff in emergency management, SOPs for PHEIC, and canactivate a 35 of IHR Core Capacities of the Kingdom of Saudi Arabia RESPOND 36 RESPOND

Joint External Evaluation reas that need strengthening and challenges and • strengthening need that reas A • Case management SOPs should expanded be beyond transport of potentially infectious patients. and resources. including staff potentially infectious patients in the community and at with points the of appropriate entry capacity Case management SOPs are available and implemented for the management and transport of Country conducts a rapid, multisectoral response in case of a biological event of suspected or confirmed confirmed or suspected of event biological a of case in response multisectoral rapid, a conducts Country • Recommendations for priorityactions health andwidersecurityservices. instrumental toprovideoperational andinstitutionaloversightofallrelevant aspectsoflinkagesbetween (accidental, incidental, deliberate andinfectiousevents). The newlyestablishedSaudiCDCcanbe legislative framework andrefined SOPstoconcretizejointworkingduringandbetweenallhazards A reviewoflegalandpolicyinstrumentsisnecessary, whichcouldleadtothedevelopmentofafocused There areclearaspirations and expectationsofallstakeholders toinstitutionalizetheexistinglinkages. platform for all relevant authorities, includingtheMoH, intheirroutineoperations andduringmajor events. incident that couldaffecttheholy city. Although the facility is undertheMinistryofInterior, itprovidesa full functionalityofamajorincidentmanagementsystem, andallowstheKingdomtomanageanymajor for riskreduction, publichealthandsafetyintheregion. Ithasbeeninoperation for sevenmonthswith The 911 hotline under the Ministry of Interior in Makkah is a well-resourced set-up with the mandate available fromstand-byserviceprovidersbutnotembeddedwithinfrontlinecapacities. have accesstomobileandfixedlabfacilitiesinadditionsitudetectionkits. Toxicology expertiseis chemical orradiation contaminatedpatients. SitevisitstoMakkahindicatedthatthe frontlinefacilities Facilities oftheCivilDefenceanddesignatedhospitalshavedecontaminationcapacitiestomanage accidental/incidental healthsecurityevents. from othercountries. The NationalSecurityCouncilandCivilDefenceleadinvestigations ofdeliberate or the GCC. Ifneeded, theIHRNFPcancommunicatewithauthoritiestosharemedicaldataofpilgrims of chemical, biological, radiological andnuclear events isinplace, whichextends to include countries under confirmed casesofSaudinationalsandthosecomingfromoverseas. Sharingofinformationinthecontext Guard. Integrated withsecuritysectors, thehealthauthoritiescanundertake contact tracing forsuspected/ linkages betweenthehealthandsecuritysectorsunderMinistryofInteriorNational event ofemergenciesandexercises. The Royal Decree andtheCivilDefence Act facilitatethecurrent In Saudi Arabia, cooperation between publicandsecuritysectorshasgrownbeentestedinthe Saudi Target law enforcementwillneedtoquicklycoordinateitsresponsewithpublichealthandmedicalofficials. (e.g. ananthrax terroristattack)ornaturally occurring(e.g. aflupandemic). Inapublichealthemergency, Public healthemergenciesposespecialchallengesforlawenforcement, whetherthethreatismanmade Introduction authorities security and health public Linking deliberate origin, including the capacity to link public health and law enforcement, and to provide and/or and/or provide to and enforcement, law and health public link to capacity the including origin, deliberate request effective and timely international assistance, such as to investigate alleged use events. use alleged investigate to as such assistance, international timely and effective request public health and security sectors to ensure multisectoral health response and preparedness. sectors public health and security Develop aregulatory framework to harmonize and strengthen further the existing linkage between Arabia levelofcapabilities 37 of IHR Core Capacities of the Kingdom of Saudi Arabia RESPOND 38 RESPOND

Joint External Evaluation • • • • practices best and Strengths linked duringasuspectorconfirmedbiologicalevent-Score 4 R.3.1 Publichealthand security authorities (e.g. lawenforcement, border control, customs) Indicators andscores • • • challenges and • strengthening need that reas A Experience is available on joint exercises and emergency responses. responses. emergency and isavailable exercises joint on Experience SOPs are in place that enable integrated response. A Royal Decreeand Civil Defence provide Act the legal framework for ongoing linkages. Triggers for notification and information sharing in the context of emergencies are in place. sectors. public health and security between Review the outcome and lessons learnt from joint activities and exercises to strengthen the linkages exercises to ensure linkages effective to respond to all hazards. and training joint and SOPs guidelines, joint including development, capacity Enhance integrated health. Saudi CDC canprovide this institutional home. to facilitate sectors security the cross-benefit of joint collaboration that couldbeyond extend public overarchingAn institutional home is needed to maintain and promote linkages the health between and for all hazards. IHR sectors/services including security sectors A specific legal instrument shouldbe developed to enable routine and proactive engagement between National framework for transferring (sending and receiving) medical countermeasures, and public health health public and countermeasures, medical receiving) and (sending transferring for framework National health emergency -Score 5 R.4.1 Systeminplaceforsendingandreceiving medicalcountermeasures duringapublic reas that need strengthening and challenges and • strengthening need that reas A • • • • practices best and Strengths Indicators andscores • • • Recommendations forpriorityactions its plansandprocedures. Ithasanestablishednationalframework andinstitution to managetheseneeds.. The countryhasintegrated thereceiptandsendingofmedicalcountermeasurespersonnel aspartof Saudi Target emergency forresponse. health. Inaddition, itisimportanttohavetrained personnelwhocanbedeployedincaseofapublichealth catastrophic infectiousdiseasethreats. InvestmentsinMCMcreateopportunitiestoimproveoverall public Medical countermeasures(MCM)arevitaltonationalsecurityandprotectnationsfrompotentially Introduction deployment countermeasuresMedical andpersonnel and medical personnel from international partners during public health emergencies. health public during partners international from personnel medical and The deployment of MCM should expanded. be hasThe country joined anumber of regional partnerships covering medical countermeasures. during the Hajj/Umrah season and in relation to the MERS-CoV response. There have been at least annual opportunities to demonstrate functionality of the deployment systems Plans and procedures have incorporated both receiving and sending MCM. A coordination has entity been established for sending MCM. Explore additional partnerships for sending and receiving both MCM and personnel deployment. Ensure availability of fast-track mechanisms for incoming personnel. reactive. than Strengthen and expand MCM and personnel deployment regulatory framework to proactive be rather Arabia levelofcapabilities

39 of IHR Core Capacities of the Kingdom of Saudi Arabia RESPOND 40 RESPOND

Joint External Evaluation • challenges and • strengthening need that reas A • • • practices best and Strengths emergency -Score 5 R.4.2 Systeminplaceforsendingandreceiving healthpersonnel duringapublichealth Cooperation). Partnerships are mainly limited to regional entities (GCC, Arab League, Organization of Islamic deployment. personnel Fast-track processes (particularly facilitated requirements) entry need to developed be for incoming hasThe country joined anumber of regional partnerships covering personnel deployment during the Hajj/Umrah season and in relation to the MERS-CoV response. There have been at least annual opportunities to demonstrate functionality of the deployment systems Plans and procedures incorporate receiving both and sending personnel. State Parties use multilevel and multifaceted risk communication capacity. Real-time exchange of of exchange Real-time capacity. communication risk multifaceted and multilevel use Parties State strategies andSOPs weredeveloped, implemented andtested. expanding healthmessages in several languagesacross social mediachannels. Hajj-specificcommunication and evaluating socialmedia, improvinginternalcoordination amongdifferentsectorsandpartners, and measures. Nationalemergency riskcommunicationcapacitywas strengthened, particularlyinmonitoring During the2016Hajj, the MoHseizedtheopportunitytoimprovepublicpreparedness andresponse of pilgrimsduringtheHajjpresents tremendouspublichealthpreparednesschallenges forSaudi Arabia. were formallyestablishedwithstronglinkstoEOCsin Riyadh, JeddahandMakkah. The massmigration emergencies duringtheHajj, andabroaderworkinggroup inMoH, activated intheeventofanemergency, A riskcommunicationsunitwithintheGlobalCentreforMass GatheringMedicine(GCMGM)torespond and capacitieswithintheMinistryacrosssectorsto better managepublichealthemergencies. on boardmanyoftherecommendationsandaccelerated itsinvestmentinriskcommunicationcoordination experiences to improve the five IHR indicators for risk communication discussed below. The MoH has taken recommendations toformalizeariskcommunicationsystem byexpandingtheuseofexperts, MoHunitsand by theMoHand WHO Regional OfficefortheEasternMediterranean in August2015, provides detailed capacities andactivitiesinSaudi Arabia. A jointRiskCommunicationCapacity Assessment, organized are some of the recent challenges that have reinforced the needfor strengthened risk communication MERS-CoV outbreaks, declining public trust in immunization and a large, unregistered migrant population Saudi Target populations andpartners. Emergencycommunicationsplansshouldbetestedandupdatedasneeded. release ofinformationandtransparency indecision-makingareessentialtobuildtrustbetween authorities, identified, andfunctionalcoordinationcommunicationmechanismsestablished. Inaddition, thetimely appropriate channelsis essential. Communicationpartnersandstakeholders inthecountryneedtobe based interventionsatindividual, familyandcommunitylevels. Disseminatingtheinformationthrough Communications ofthiskindpromoteappropriatepreventionandcontrolactionthroughcommunity- of theaffectedpopulation. political andeconomicaspectsassociatedwiththeeventshouldbetaken intoaccount, includingthevoice For any communication about risk caused by a specificeventto be effective, thesocial, religious, cultural, the disseminationofinformationtopublicabouthealthrisksandevents, suchasdiseaseoutbreaks. capacity tocopewithanunfoldingpublichealthemergency. An essentialpartofriskcommunicationis risks, identifyhazards, assessvulnerabilities andpromotecommunityresilience, therebypromotingthe Risk communicationsshouldbeamultilevelandmultifacetedprocessthataimstohelpstakeholders define Introduction Risk communication information, advice and opinions between experts and officials or people who face a hazard or threat to to threat or hazard a face who people or officials and experts between opinions and advice information, their survival (health, economic or social well-being), so that informed decisions can be made to mitigate mitigate to made be can decisions informed that so well-being), social or economic (health, survival their the effects of the threat or hazard and protective and preventive action can be taken. This includes a mix mix a includes This taken. be can action preventive and protective and hazard or threat the of effects the of communication and engagement strategies, such as media and social media communications, mass mass communications, media social and media as such strategies, engagement and communication of awareness campaigns, health promotion, social mobilization, stakeholder engagement and community community and engagement stakeholder mobilization, social promotion, health campaigns, awareness engagement. Arabia levelofcapabilities 41 of IHR Core Capacities of the Kingdom of Saudi Arabia RESPOND 42 RESPOND

Joint External Evaluation • • practices best and Strengths R.5.1 iskcommunicationsystems(plans, mechanisms, etc.) -Score 3 Indicators andscores • • • • • Recommendations forpriorityactions of smartphoneownership. Morethan40%ofthepopulationregularlyaccess Twitter and YouTube. Saudi Arabia alsohasoneofthefastestgrowingsocialmediamarkets intheMiddleEastduetohighrates enhanced 937callcentrefordataanalysis, dynamiclisteningandrumourmanagementareinplace. is regularlydisseminatedtostrictlycontrolledmedia(TV, radio, newspapers). Mediamonitoringandan of MediaandPublicRelationswhoreportsdirectlytothe Vice-Minister ofHealth. Healthinformation The MoHhasalsoscaleduppubliccommunicationeffortswithacoreteam, ledbytheDirectorGeneral to standardizeriskcommunicationwithintheEOCstructure. coordination betweensectors, andacrosssubnationaldirectorate levels. Effortsarealreadyunderway and proceduresthataddresspublichealthemergencies, ensurebetterinformationsharingandregular The MoHplanstoexpandthesestrategies andSOPsintostrongoperational communicationstructures 3 cross-cutting responsestopublichealthemergencies. lessons, experiencesandsuccessfulmodelstobuildaformalriskcommunicationssystemthatcanprovide proactive riskcommunicationactivitiesduringtheHajjoverpast18monthshaveproducedample Saudi Arabia hasgoodcapacityacrossallfivedomainsofrisk communication. Additionalinvestmentsfor mobilization, andgenerate engagementandfeedbackwithpilgrims. teams madeupofmedicalstudents, localcharitymembers, andRedCrescentvolunteerstoimprovesocial not beenevaluated. However, aspartofthe2016Hajjpreparations, theMoHtrained rapid response information educationandcommunication(IEC)materials. Ingeneral, theefficacyoftheseactivitieshas Community engagementeffortsarelimitedtospecific, health-daycampaignsanddisseminationof platforms. MoH hasstartedtocapitalizeontheinformationsharingandfeedbackpotentialofthesesocialmedia

BBC news, Arabia profile–media(www.bbc.com/news/world-middle-east-14703480). sector when managingsector zoonotic diseases. health promotion, other internal units and some external particularly partners, from the animal health A broad risk communication working group within the MoHincludes coordination with public relations, cross-sectoral, national capacities in this area of work. There is strong MoHcommitment and investment to improve skills staff and develop sustainable, decision-making. Integrate feedback and lessons learnt from the listening and rumour system into high-level MoH theExpand volunteer to network reach local communities across the country. levels. directorate and subnational national, publicExpand communication and health education capacity-building to relevant across MoHstaff civil and the society private with standardized sector roles and responsibilities. Formalize a national coordination mechanism for risk communication that includes relevant ministries, levels. directorate Scale up risk the communication structure and functions across the MoH, and at subnational and 3 The • practices best and Strengths R.5.3 Publiccommunication-Score 3 • challenges and • strengthening need that reas A • • • • practices best and Strengths R.5.2 Internalandpartnercommunicationcoordination -Score 3 • challenges and • strengthening need that reas A • • • social media platforms and mobile phone applications. The Media and Public Relations Unit engages in weekly media briefings and public outreach through consistent flow of two-way information andbetter planning for emergencies. hampers times non-emergency during ministries between meetings regularcoordination of lack The ranks. management lower lower levels of government. This jeopardizes information flow and compromises decision-making at Coordination of resources and information within the MoHis weak. Top-level decisions do not reach by an operational communications plan for the Hajj period. Internal and coordination partner and collaboration were scaled up during the 2016 Hajj and supported Agriculture, Red Crescent groups. and charity with academic and government institutions and more formal linkages with Civil Defence, Ministry of partnershipsExternal with the MoHare expanding through recent memoranda of understanding disease outbreaks or public health crises. integrated within EOC structures. These processes transferred canbe and altered for use during and tested being are procedures risk communication response, emergency For emergencies. during Increased investment in EOC contributes scale-up to improved internal communication and coordination alerts. mandate to lead internal and communication partner for disease outbreaks and other public health external The new partners. working group for risk communications within the MoHis building its risk communication plan that includes clear roles and responsibilities for MoH, other ministries, and Main stakeholders have been identified and the MoH is in the process of developing a multi-hazard response. emergency health public of the MoH canincrease awareness and acceptance of this IHR domain as acritical component of understanding across all Risk sectors. communication orientation workshops provided across all levels The concept of risk communication has negative connotations in the Arabic language and lacks common information for information loop sharing two-way a and decision-making. The risk communication function at the subnational and directorate levels are weak and do not provide decisions. all times and in-depth data analysis which used canbe to inform better MoHpublic communication The 973 hotline has been significantlyexpanded to include surge of capacity operators150 call on at leadership. Media plans and SOPs for risk communication have been but drafted require endorsement by MoH Hajj. the during response emergency National Emergency Plan. operational An communication plan and SOPs have been developed for The roles and responsibilities of the risk communication unit within the GCMGM are outlined in the 43 of IHR Core Capacities of the Kingdom of Saudi Arabia RESPOND 44 RESPOND

Joint External Evaluation reas that need strengthening and challenges and strengthening need that reas A • • • • • • • practices best and Strengths R.5.5 Dynamiclisteningandrumourmanagement-Score 3 • challenges and • strengthening need that reas A • • • practices best and Strengths R.5.4 Communicationengagementwithaffectedcommunities-Score 3 • • • and Instagram were the most popular platforms used by the pilgrims. the MoHneeded to use expand of its social media beyond Twitter and Facebook. YouTube, Snapchat, A social media listening launched project, during the 2016 Hajj for target audience analysis, found that Hajj. the during languages seven in produced materials systematically Public communication now are Since 2015, there has been an increase in communication materials and messages in several languages. expanded and endorsed by MoH leadership. forSOPS public communication during emergencies have been developed but need to revised, be the media on local public health issues. spokespersonsOfficial are designated at the subnational and directorate levels canand engagewith A routine media and social media monitoring system is in place at national and subnational levels. Hajj. the during operational only Rapid response teams for community engagement are trained to provide community feedback but are public health concerns. a real-time, multi-channel, feedback system to two-way address rumours and misunderstandings of The 937 call centre has increased for multi-level capacity its response and data analysis: it now provides WhatsApp. as particular, to counter the growing spread of anti-vaccine information through mobile applications such in mothers reaching parents, vaccine-averse on focus also must Communication engagement populations such as unregistered migrants and Bedouin tribes. regions, and outside the Hajj season. Targeted communication and resources are needed for vulnerable Proactive communication need to engagement expanded be to local communities, efforts other Promotion Unit and other teams to develop public health messages and IEC materials. The recently established MoHinternal working groups have improved coordination the Health between centre, and training of community volunteers and primary health care workers. Hajj. Community feedback and consultations have also increased through the of scale-up the 937 call The MoH conducted and surveys focus group discussions for community feedback during the 2016 plan. national emergency trained in 2017. Health promotion and community engagement procedures are now outlined in the response and community engagement during the 2016 Hajj. additional An 1200 volunteers will be The MoHtrained more than 520 Red Crescent volunteers and medical/nursing students for rapid engagement. media local international islow and There reportingbetter on scientific information related to public health. In-depth media briefings on public health threats combinedwith journalist training are needed for 2017. by A MoHpublic communication strategy with SOPs and trained should staff finalized be and endorsed • • challenges and • strengthening need that reas A • shared for high-level decision-making. decision-making. high-level for shared A process should established be to enable data analysis from dynamic listening mechanisms to be all regions and vulnerable populations in Saudi Arabia. Audience analyses and primary health care community outreach programmes should expandedbe to year-round. regular focus groups, intercept interviews, test messages with communities, across all regions, and To improve local knowledge, attitudes and behaviour ofpopulation, underserved there should more be public health concerns across the country. different languages and social media platforms that are being applied to improve MoH’s response to of MoH’s communication The results highlighted efforts. of messages, use lessonsof on the efficacy A social media listening project launched during the 2016 Hajj produced athorough audience analysis 45 of IHR Core Capacities of the Kingdom of Saudi Arabia RESPOND 46 OTHER

Joint External Evaluation States Parties designate and maintain core capacities at international airports and ports (and where where (and ports and airports international at capacities core maintain and designate Parties States Introduction Points of entry ENTRY OF POINTS AND HAZARDS IHR-RELATED OTHER • • • Recommendations forpriorityactions compliance withIHRarticle21, whichdealswiththejoint designationofadjacentgroundcrossings. ground crossingontheSaudisideanditsneighbouring counterpartontheJordanianside, exemplifies On theotherhand, thecooperation andthecommunicationbetweencompetentauthority at Tabouk with thePoE intermsofevidence-basedresearch, performance assessmentandriskcommunication. for Mass Gathering Medicine (GCMGM). This is a WHO collaborating centreand can collaborate closely events. Moreover, the Kingdom houses the institution in charge of the pilgrimages, i.e. the Global Centre on decadesofplanning, managing, monitoringandprovidinghealthcareduringthesetwomassgathering religious massgatheringsworldwide. The PoE inSaudi Arabia haveaccumulatedextensiveexperiencebuilt Indeed, besideUmrah, whichisashorterpilgrimagetoMakkah, theHajjisone of thelargestyearly assigned forHajjandUmrah. In linewiththeprovisionsofIHR Annex 1, 13PoE havebeen “designated” duetothefactthattheyare Aviation except Al Madinah airport, which is operated by TAV. Saudi Ports Authority regulates the ports. seaports and13groundcrossings. The airportsareregulatedandoperated bytheGeneral Authority ofCivil The Kingdomencompasses28pointsofentry(PoE) including7internationalairports, 8international Saudi Target required tomanageavariety ofpublichealthrisks. a StateParty maydesignategroundcrossings), whichwillimplementspecificpublichealthmeasures capacities atdesignatedinternationalairportsandports(andwherejustifiedforpublichealthreasons, of healthmeasurestopreventinternationalspreaddiseases. StatesParties arerequiredtomaintaincore All core capacities and potential hazards apply to points of entry and thus enable the effective application justified for public health reasons, a State Party may designate ground crossings) that implement specific specific implement that crossings) ground designate may Party State a reasons, health public for justified public health measures required to manage a variety of public health risks. health public of variety a manage to required measures health public coordination the competent between authority and the Saudi Customs, the SFDA and MEWA. Enhance and formalize and at at freight seaport airport areas, in compliance with IHR article 22, to the issue capacity Extend Ship Sanitation Certificates to other majorseaports. plans. emergency Review, test and update public health emergency contingency plans at PoE and their integration in the Arabia levelofcapabilities • • • • • • practices best and Strengths PoE.2 Effectivepublichealthresponse atpointsofentry-Score 4 • • • challenges and • strengthening need that reas A • • • • • • • practices best and Strengths PoE.1 Routinecapacitiesestablishedatpointsofentry-Score 4 Indicators andscores • Personal protective equipment and hand held infrared thermometers are available. are thermometers infrared held hand and equipment protective Personal Adequate isolation rooms are available at points of entry. Appropriate spaces are available, on site, to interview travellers. and assess suspected or affected animals. and/or travellers suspect quarantine and assess to facilities with place in are Pre-arrangements The competent authority has full membership, at points of entry, in the EOCs. documented and tested at the designated points of entry. available, plans,are emergency local within plans,incorporated contingency emergency Public health PoE (food safety, potable water and liquid and solid waste management). environment at the designated PoE, and the process accelerated for their duplication at non-designated The functioning system activities should supervisory reinforced be and completed to ensure asafe Declaration, even out of Hajj season. Conveyance inspection needs to at generalizedbe airports to include the check of the Aircraft General Certificates, in addition to theextension certificates which they alreadyissue onaregular basis. should enabled be to issue Ship Sanitation Control Certificates and ShipSanitation ControlExemption from JeddahApart Islamic which Port, issues three Ship Sanitation Certificates, the other seven seaports designated points of entry. should expanded, be including the entomological surveillance of mosquito and adult larvae, to non- The surveillance, and the control vector programmes carried out by the Directorate of Health Affairs The competent authority has full membership in the facilitation committees at points of entry. Conveyances are systematically inspected, complemented by the check of disinfection certificates. Health through promotion out sensitization is and education carried anddistribution the pamphlets. of follow-up is carried out for unvaccinated pilgrims. and yellow fever vaccination is verified for the pilgrims or endemicfrom affected countries. Medical recommendations; WHO to according countries certain unvaccinated from to pilgrims isgiven vaccine chemoprophylaxis is provided to unvaccinated pilgrims and those from meningitis belt countries; polio A,C,W135,Y); serogroups against vaccine meningococcal vaccinationisverified (quadrivalent Meningitis Civil Aviation, Saudi Red Crescent, MoHand private companies. Ambulances are available, provided by the Fire and Rescue under Services the General Authority of Cutting-edge equipped medical are services endowed with large premises and skilled, trained staff. Hajj season, 1700 are assigned to points of entry. A huge number have of staff been appointed at PoE. Indeed, of the 26 000 personnel hired during the hazards. all to Enhance of thehuman capacity resources at PoE for the early detection, investigation and response 47 of IHR Core Capacities of the Kingdom of Saudi Arabia OTHER 48 OTHER

Joint External Evaluation • • • challenges and • strengthening need that reas A 4

CAPSCA: Collaborative Arrangements forthePreventionandManagement ofPublicHealthEventsinCivil Aviation. Voluntary requests for the certification WHO of PoE, as wellCAPSCA as Passenger Locator Form and the PANS-ATM doc4444. Association procedure regarding the detection of suspected on-board, cases as well as the use of the Awareness needs to made be among airlines crews by promoting the International Air Transport considered. be facilitiesshould health designated The development and testing of SOPs for the safe transfer of infected/contaminated travellers to pre- consider any update. necessary general PoE emergency plans. Additionally, exercises/drills should conducted be to test these plans and Emergency contingency plans need to validated be at non-designated PoE and incorporated within the 4 visits, should be considered. be should visits, States Parties with surveillance and response capacity for chemical risks or events. This requires effective effective requires This events. or risks chemical for capacity response and surveillance with Parties States • Recommendations for priorityactions International ChemicalsManagement. Arabia isinvolvedwithinternational chemical/toxicological networks, e.g. theStrategic Approach to Key government sectors involved in chemical events participate in multisectoral collaborations and Saudi monitoring aresecurelycarriedoutbygovernmentsectors involvedinchemicalevents. monitoring, andpersonalprotectiveequipment. In addition, samplinganddetection, identificationand Key governmentsectorsinvolvedinchemicaleventsare wellequippedwithdetection, identificationand hazard sitesandfacilitiessuchas ARAMCO andSABIC, wherecomprehensiveinventoriesarerequired. Standard planning, environmentalpermitsandspecific regulationsareinplaceforthecontrolofmajor chemical eventsandpotentialriskstheirresponse. information exchangebetweenchemicalandsurveillanceunitsotherrelevant sectors onurgent sectors involvedinchemicaleventshavetheirowndatabasesplacetopromotetimelyandsystematic place andareaccreditedwithfulllaboratory capacitytoconfirmprioritychemicalevents. Key government There areninepoisoncentreslocatedindifferentregionsofSaudi Arabia, allofwhichhavesurveillancein their ownguidelinesormanuals, whicharealsodevelopedbasedontheNPCE. roles andresponsibilitiesclearlydefined. Majorchemicalandoilcompanies, e.g. ARAMCOandSABIC, have on intoxication andpoisoningaredevelopedbasedontheNationalPlanforChemicalEvents(NPCE) with Guidelines ormanualsforkey governmentsectorsinvolvedinchemicaleventsandanyassociatedSOPs • • • towards establishinganationalchemicalsafetybodytoconsolidateandstreamlinethe followingareas: Saudi Arabia hashighcapabilitiesandcapacitiestodeal with chemicalevents, andisslowlymoving Saudi Target communication andcollaboration amongthesectorsresponsibleforsafety. State Parties tohavesurveillance and responsecapacitytomanagechemical risks or events and effective with othersectorsresponsibleforchemicalsafety, industry, transportation andsafedisposal. This requires Timely detectionof, and effectiveresponsetopotentialchemicalrisksand/oreventsrequirescollaboration Introduction eventsChemical communication and collaboration among the sectors responsible for chemical safety, industries, industries, safety, chemical for responsible sectors the among collaboration and communication transportation and safe disposal. disposal. safe and transportation transparency and progress towards the One Health goal. Continue to improve multisectoral collaborations and promote data and information exchange with collaboration. multisectoral for mechanisms Functional Information exchange key between government involved sectors in chemical events. poisonings. and intoxication events, chemical for response and Surveillance Arabia levelofcapabilities 49 of IHR Core Capacities of the Kingdom of Saudi Arabia OTHER 50 OTHER

Joint External Evaluation • • • • • • practices best and Strengths events oremergencies -Score 4 CE.1 Mechanismsestablishedandfunctioningfordetectingresponding tochemical Indicators andscores • • • • • • practices best and Strengths CE.2 Enablingenvironment inplaceformanagementofchemicalevents-Score 4 • challenges and • strengthening need that reas A data sheets, safety data sheets, and contact details and contact data sheets, of manufacturers. safety data sheets, Saudi Arabia is developing ownnational its database to include data and information, such as material reporting. incident and monitoring environmental surveillance, chemical for held regularly meetings multisectoral and information exchange in atimely and systematic manner. Early summaries alert are produced and Key government involved sectors in chemical events have their owndatabases to promote secure data is network inA support place to promote more systematic analysis by the SFDA. exposure to some chemicals. These protocols will continue to developed. be addition, online resources are available to hospital and medical staff, including treatment protocols for accredited with full laboratory to deal capacity with chemical events, intoxication and poisonings. In All nine poison centres located in different regions of the have country surveillance in place and are chemical and oil companies have their ownguidelines, these are also based on the NPCE. management of chemical events, intoxication and poisoning, all based on the NPCE. Although major Guidelines or manuals are available for key government on surveillance, sectors assessment and theirsectors, functions in detecting and responding to chemical events, and business continuity. The NPCE has light atraffic system that indicatesstrategic triggerswith descriptions of key government sectors. through occurrence of real event or simulation exercises on anational level involving key government Test and update national policies and guidelines or manuals and associated SOPs on chemical events place. in already system accreditation Achieve internationally recognized accreditation for government laboratories, in addition to the national inventories are produced. are inventories for the control of major hazard sites and facilities, e.g. and ARAMCO SABIC, for which comprehensive In addition to standard planning and environmental permit regulations, specific regulations are in place incidents. chemical dealing with sectors government Roles and responsibilities are clearly defined in the NPCE, guidelines, manuals and SOPs for key poisonings. and intoxication events, chemical of management in guidelines or manuals developed for key government on the surveillance, sectors assessment and Elements e.g. of alerts, SOPs for coverage, criteria of when and rosters, how to duty are alert, included keybetween government involved sectors in chemical events. Regulations are in place to ensure and promote data and information exchange and collaboration place. in system national accreditation Internationally recognized accreditation for is government necessary laboratories, in addition to the with transparency in order to achieve the One Health goal. Multisectoral collaboration should improved be data and information and secured exchange promoted • challenges and • strengthening need that reas A • • • sectors. updated through real events or simulation exercises at anational level involving key government National policies, guidelines, manuals and associated SOPs on chemical events should tested be and streamlined. and consolidated National policies, plans and legislation for chemical event surveillance and alert response need to be community. documents, assisting with training and making available and knowledge expertise to the international to International Chemicals Management, and in establishing focal points, writing and peer-reviewing Saudi Arabia participates in international chemical/toxicological e.g. networks, the Strategic Approach development. and research and training, and development professional participation, external to open conferences scale, local a on exercises joint Functional, multisectoral mechanisms are in place for collaboration on chemical events, e.g. regular sampling. out carry and securely monitoring, equipment, and can protective and personal Key government involved sectors in chemical events are well equipped with detection, identification 51 of IHR Core Capacities of the Kingdom of Saudi Arabia OTHER 52 OTHER

Joint External Evaluation States Parties with surveillance and response capacity for radiological and nuclear hazards/events/ nuclear and radiological for capacity response and surveillance with Parties States Target responsible forradiation emergencymanagement. potential radiological and nuclear hazards/events/emergencies are required in collaboration with sectors To counterradiological andnuclearemergencies, timelydetectionandaneffectiveresponsetowards Introduction Radiation emergencies • • • • Recommendations forpriorityactions participates inthatagency’s training andexercises. Atomic Energy Agency conventionsforearlynotificationandrequestassistance andcontinuously Management CentreinKuwait, whichmanagesthePlan. Saudi Arabia isalsoamemberoftheInternational regional radiological andnuclearemergencypreparednessresponseplan, ledby the GCCEmergency define roles and responsibilities of all concerned entities. Moreover, Saudi Arabia is a party on the GCC both anationalplanandmedicalto respond toradiological andnuclearemergencies. The plans Defence as IncidentCommander, and the MoH as the health responseentity. The country has approved emergencies; theCommitteeconsistsofallmainresponseandsupportorganizations, includingCivil Saudi Arabia hasformedapermanentNationalCommittee torespondradiological andnuclear emergency responseplan. policy, proceduresandauthorities; capacity-building; monitoringradiation exposure; anddevelopinga and security of public, workers and other tasks including, but not limited to: setting radiation protection from King Abdulaziz CityforScienceand Technology toKA CARE includingnuclearandradiological safety for Atomic andRenewable Energy(KA CARE). Articles 4and5transferred the rolesandresponsibilities In theareaofradiation emergencies, Saudi Arabia establishedthroughRoyal DecreetheKing Abdullah City Saudi emergencies. This requires effective communication and collaboration among the sectors responsible for for responsible sectors the among collaboration and communication effective requires This emergencies. radiological and nuclear emergency management. management. emergency nuclear and radiological identify areas of improvement. of areas identify Improve participation of the medical in national sector and international exercises and training, to facilities. health and equipment capabilities, workforce relatedradiationemergencies, to sector medical the of assessment an Conduct the national public health plan. including emergencies, nuclear and radiological for procedures organization response Harmonize the emergencies. nuclear and radiological to respond Communicate requirements medical the and priorities through permanent the national to committee Arabia levelofcapabilities • practices best and Strengths RE.2 Enablingenvironment inplaceformanagementofradiation emergencies -Score 4 • • • • • challenges and • strengthening need that reas A • • • • • • • • practices best and Strengths and nuclearemergencies -Score 4 RE.1 Mechanismsestablishedandfunctioningfordetectingresponding toradiological Indicators andscores structure for coordinating responses among the main stakeholders. a has and implemented, isup-to-date, emergencies nuclear and radiological national plan for The updated. and tools,Laboratory techniques, and procedures for systematic analyses need to revised, be enhanced accident. nuclear or radiological a to response emergency managing an and Guidelines are needed to assist public health authorities todecision-making support during planning Assistance through Network the focal point at the MoH(which needs to updated). be Coordination needs to developed be with WHO’s Radiation Emergency Medical Preparedness and drillsconducted. regularly response radiation emergency and enhanced be should radiation emergencies of patients manage can facilitiesthat health to Access improvement. further need emergency, radiological or accident nuclear a of case the in assistance on and accident, a nuclear of notification international e.g. of conventions, early on Implementation stakeholders. other with coordination and cooperation NuclearThe draft Law for an independent nuclear regulatory should body considered,be with Monitoring radiation stations are able to detect in areas surrounding Kingdom. the coordination and communication with the MoH and IHR NFP. for point focal a designated has emergencies nuclear and radiological plan for national medical The manages and regulates the at industry present. Minister in 2008, the SFDA is responsible still CARE for monitoring importedfood. However, KA In the National Response Plan for Radiological and Nuclear Emergencies, approved by the Prime interventions. emergency nuclear or radiological during authorities health public by hasA survey also been conducted in the provinces the to need for verify additional guidelines for use Japan. in accident Fukushima nuclear public. Calculations are based on official data on in radioactivity air,soil, water and food suppliespost The Government assessments has safety on radiation performed dose estimates for the general and responsible be phase for the of next emergency preparedness, response and recovery. emergencies nuclear and radiological to respond to formed been has National Committee permanent A agriculture. and food, shelter, as such thyroid-blocking, countermeasures return, and evacuation long-term and early level interventional for followed planning closely are emergency related to International standards risks. potential and events radiological hospitals) for designated for MoH and command Incident Systematic information exchange is in place the response between organizations (Civil Defence as is linked CARE with international and national organizationsKA as the national warning point. 53 of IHR Core Capacities of the Kingdom of Saudi Arabia OTHER 54 OTHER

Joint External Evaluation • • • • challenges and • strengthening need that reas A • • • nuclear power plant in Saudi Arabia. Saudi plant in power nuclear Human resources will have to increase significantly to meet radiation needs safety of the planned plan. medical national detailed the including organizations, response the among harmonized be should emergencies nuclear and radiological for Procedures plans. emergency increased, and areas for improvement identified. In addition, more drills are needed to test the Participation of the medical in national sector and international exercises and training should be facilities. health and equipment training, capabilities, workforce related radiation emergencies, to A self-assessment should conducted be with aview to prioritizing the needs of the medical sector industry. nuclear regulateto the Kingdom. Meanwhile, is responsible KA CARE for the ad hoc coordination of the different stakeholders the in way under projects energy nuclear peaceful regulate to the development isunder Law Nuclear A samples. radiation emergency of analysis systematic isavailable the for capacity Laboratory materials. waste and Policies and regulations are in place concerning the transportation of radioactive materials, samples and coordinates including multisectoral functions, information sharing, and assessments. updating SOPs, facilitates Emergencies Nuclear and Radiological to Response for National Permanent Committee The in Saudi Arabia to reviewtheagenda, responsibilities, andlogistics. A nationaltraining was conducted Prior tothevisit, several communicationstookplacebetween assessmentteammembersandexperts Preparation andimplementationofthe mission • • • • • • • • • • • • • Mission teammembers • • • • Objectives Riyadh, KingdomofSaudi Arabia, 12–16March2017. Mission placeanddates Annex 1: Evaluation Joint background External Laura Ngo-Fontaine, Communications specialist, Ngo-Fontaine, Laura Geneva, Switzerland and Advocacy Morocco Mohammed Moussif, Public Health Mohammed Department, VInternational Casablanca, Airport, Emirates Arab United , Fahad Bloushi, Al Emergency Preparedness and Response, Federal AuthorityFor Nuclear Regulation, States Health Preparedness and Response, Centres for Disease Control and Prevention, Atlanta United GA, Public of Office Operations, Emergency of Division Management, Emergency Global Chuck Menchion, Hazards, Public Health England, London, United Kingdom Lau, ChemicalsGary and Poisons Centre Department, For Radiation, Chemical and Environmental Silvia Kreindel, and Food Agriculture Organization, Rome, Italy Ann Linstrand, Vaccination Programs, Public Health of Sweden, Agency Solna, Sweden Markku Kuusi, Infectious Disease Control Unit, National Institute of Health, Helsinki, Finland for the EasternOffice Mediterranean, Cairo, Egypt Karen Nahapetyan, Public Health Laboratory, Department of Communicable Diseases, Regional WHO Sohail Saikat, Universal Health Coverage and Quality, headquarters, WHO Geneva, Switzerland RegionalWHO for the Eastern Office Mediterranean, Cairo, Egypt Program, Emergency Health WHO Risk Assessment, and Francis Grenier, Information Emergency Health Program, Regional WHO for the Eastern Office Mediterranean, Cairo, Egypt Emergency Health IHR, and Preparedness Emergency Health Country Dalia (Co-Lead) Samhouri, Control and Prevention, Atlanta United GA, States of America Kashef Ijaz, (Lead) Centre for Global Health, Division of Global Health Protection, Centres for Disease for globalcapacities 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 capacities. documents. related all Review entry. of points at including events, health the implementationAssess of IHR public health capacities for surveillance and response to public 55 of IHR Core Capacities of the Kingdom of Saudi Arabia 56

Joint External Evaluation Key hostcountryparticipantsandinstitutions • • • Limitations andassumptions practices andpriorityactions. officials andnationaltechnicalteamsinvolvedintheevaluation topresenttheoutcomesofJEE, best and toreachaconsensusonthescorespriorityactions. A debriefingmeeting was heldwithsenior Meetings withtherelevant stakeholders andfieldvisitswereconductedto validate thecollectedinformation expected outcomes, andtodiscussfinalizetheagendaofmission. One-day orientationwas providedtotheJEEexternalexpertsonprocessandtool, objectivesand complete JEEtoolforreview. and responsibilities. BackgrounddocumentswerecollectedandsharedwiththeJEEteamalong to participate successfully in the JEE process; and to provide guidance on self-reporting requirements on 23–24February 2017toprovidenationalstakeholders withtheinformationandresourcesnecessary Dr. HamadA.Alkanhal Dr. ShamsuEldin Faisal Fagbo Dr. Ibrahim Qasim Dr. HalaRushdy Dr. HailAlAbdely Dr. NaifRaihan Dr. MohamedBelawi Dr. HamoudAlGharni Dr. AbdallahIbrahim Arbab Dr. AliAlghamdi Dr. NailaAbualjadayel Ms. Nouf Alghamdi Dr. TagreedAlgaith Ms. Rowena Costes Mr. Jamal Yousuf Aboissa Dr. NaifMohdAlraihan Dr. AbdallaIbrahim MohamedSalih Dr. Alghamdi Sultan Dr.Abdullah Assiri HaniJokhdar Dr Name assessment rating mutually agreed by the external assessment team and the Saudi counterparts. Information provided by the Kingdom is not independently verified, but was jointly discussed and an The results of this evaluation will made be publicly available. entry. There was insufficient time visitto other cities Kingdom.in the managed. Field visits were conducted to Jeddah, Dhahran and Madinah to look at EOCs and points of The evaluation lasted one which week, limited the amount and depth of information that could be Executive Director ofMonitoring andCrisis Management Centres forPreventiveAssistant Deputyship Health Director General, AnimalResources Management ofHealth FacilitiesGeneral Department control Infection Director ofHealth General, Facilities General Department control, Infection Specialist Public Health, Control Diseases ofInfectious General Department forPreventiveAssistant Deputyship Health Resident Control, Physician/ Infection CDC,MOH Saudi Consultant MedicalOfficer NTPMOH,Senior Public Health Specialist/Health Care Strategy General Directory General Director forHealth Care Strategy General Directory forPreventiveAssistant Deputyship Health ofPublic Health Deputyship Coordinator inCDC package ofGHSAaction forPreventiveAssistant Deputyship Health forPreventiveAssistant Deputyship Health Minister forPreventiveAssistant Deputy Health, MOH,IHR/NFP Minister ofHealth forPublicDeputy Health, MOH Affiliation Ms. AmaniAbdullaAlOtaibi Ms. Tahani AliAlKhalifah Ms. MashailAlQhuwaie Ms. HissahAbdulrahman AlMutairi Ms. HananAbuHaimed Ms. Fatimah Al Thyab Mr. NasserAbu Talb Dr. AlHassan Sami Dr. AlJuhani Khalid Dr. MohammedAlHeliel Dr. Asiri Saad Dr. Emad Altaf Dr. Anwar Al.Mosa Dr. AlShehri Saud Dr. AlMohamadi Khalid Dr. AlAsiri Serri Dr. AlQahtani AbdulRahman Dr. AbuHaimed Khalid Dr. NaifMohammedAlRaihan Dr. AlMudarraa Saeed Sami Dr.Randa MohamedNouh Dr. MohamedAblowi Dr. Rafaat AlHakeem Dr. Al-Raddadi Rajaa Dr. AbdullahAlzahrani Mr. KinanMohdAlkabbani Dr. MohamedAblowi Dr. AliMohamedKheyami Dr. HassanAlhababi Raed Dr.Muslim Yonus AboHassan Dr.Abdel wahab Zaid BinJumma Dr. binAliAlShehri Soad Dr. HaniAliAlmadan Dr. AliAldowerij Dr. El Rasha Araby Dr. MahmoudLubbad Dr. TamaderKurdi Unit Head, NSD Unit Head, NSD Unit Head, NSD Unit Head, NSD Unit Head, NSD (DoNSD) Departments Director ofNursingServices Head ofEOCand937 Consultant Medicine Emergency Consultant Medicine Emergency Consultant Department, Director ofEmergency Medicineand ofEmergency Toxicology Consultant Department, Director ofEmergency Medicine Emergency Executive Director ofChemical&Nuclear Warfare Weapons Protection Consultant Medicine Emergency Consultant, Radiation &Chemical Warfare Services Director Emergency Consultant Public Health, Head ofCCC Consultant Medicine Emergency Team leader, Consultant Medicine Emergency Specialist Public Health, Consultant Epidemiologist, Field Saudi Epidemiology Training Program Field Epidemiology Training Programme Control Diseases Director ofInfectious General, General Department Consultant Preventive Medicine Epidemiologist, Network Health Electronic (HESN) Surveillance National Health Laboratory National Health Laboratory Regional Laboratory, Riyadh forPreventiveAssistant Deputyship Health andBloodBank Regional laboratory Veterinarian ofMunicipalandRural Affairs intheMinistry ofHealth and at theDepartment Doctor Veterinary Control Coordinator oftheFood Program Safety Health Director General oftheGeneral Directorate ofEnvironmental Health andOccupational Health andFoodprograms andchemicalsafety safety supervisor Assistant Director General, General Directorate ofEnvironmental Health andOccupational 57 of IHR Core Capacities of the Kingdom of Saudi Arabia 58

Joint External Evaluation • • • • • • • IHR coordination, communicationandadvocacy Supporting documentationprovided byhostcountry Mr. Turki AlHamid Dr.Zahir MohamedAlAmin Dr.Inas Ibrahim AbdulAziz Dr.Osman MohamedEl Neel Dr. AlMadhi AbdulAziz Dr. Alghamdi AliSaeed Dr.Yasir MunirBakhsh Dr.Rasha AlSayed AlArabi Dr.Abdullah AliAlgarni Dr. HaniAliAlMoazin Dr.Aamir HassanMohamed Colonel /Ibrahim AhmedAlghamdi Hoqail Mr.Abdullah BinAbdulmohsenAl Mr. ArshadAliSdiqi Mrs. Tagreed MosahAlqorashi Mr. MusaedAlMalki Dr. Abdelrahman Alarfaj Engr. Ibrahim Al-ghamdi Engr. Ibrahim Al-ghamdi Dr. AliAsiri Eng. AlZibn Suliman Dr. HamoudAlGharni Mr. MeshalAlrabian MahmoudAlNahas Dr FahadDr Alamari Ms. AmnahAwam AhmedAlGanainy Dr Alotaibi Badriah Dr AlShehri Ms. Badryah Mr. Ibrahim AlMughaib External assessmentExternal for points of reports entry, food safety, EPI. Health condition for pilgrims. Executive regulations for health surveillance system at points of entry. Health surveillance system at points of entry. Nominations letter for the IHR focal points in different sectors. Arabia. Saudi in system Notification Royal Decreefor the establishment of the IHR National Focal Point function. General Department of Infectious Diseases Control, Diseases ofInfectious General Department Control, Diseases ofInfectious General Department Control, Diseases ofInfectious General Department FDASaudi ofEnvironment,Ministry Water andAgriculture Control Diseases ofInfectious General Department ofEnvironmentalGeneral Department andOccupation Health RedCrescentSaudi Authority ofMunicipalandRural Affairs Ministry ofEnvironmentalGeneral Department andOccupation Health General Directorate ofCivil Defence ofEmergency General Department ofEnvironmentalGeneral Department andOccupation Health forPreventiveAssistant Deputyship Health ofHealth FacilitiesGeneral Department control Infection ofEnvironmentalGeneral Department andOccupation Health ofEnvironmentalGeneral Department andOccupation Health Control Diseases ofInfectious General Department Director General Adviser Director General Assistant Director General, The GlobalCentre forMassGatherings Medicine ManagementHead Department, ofRisk The GlobalCentre forMassGatherings Medicine Director General, The GlobalCentre forMassGatherings Medicine Training &Disaster Management Coordination Office andSecurity Head ofSafety Director ofEMS • • • • • • Biosafety andbiosecurity • • • F • • • • • • • • • • • • • Antimicrobial resistance • • ood safety SAFETY MANUAL (V3), 2015. manual. safety Laboratory Riyadh Regional Laboratory, Ministry of Health, doc. reference #RRL- RRL-LAB- INFECTION CONTROL MANUAL (V3), 2015. infectionLaboratory control manual. Riyadh Regional Laboratory, Ministry of Health, doc. reference # BAC-0051 (V4), 02 May 2017. Bioterrorism agents policy. Riyadh Regional Laboratory, Ministry of Health, doc. reference #DPP- 05-12-0041, 01 March 2010. 7010- # reference doc. Affairs, National Guard Health safety. specimen and hazards Microbiological reference #7010-05-12-0004, 01 March 2010. Implementation, maintenance, inspection of safe working practice. National Guard Health Affairs, doc. 12-0003, 01 March 2010. management safety Laboratory programme. National Guard Health Affairs, doc. reference # 7010-05- JEE national self-assessment for the technical area “Food Safety”. visit to the SFDA laboratory. National Monitoring Contaminants, during the Food presentations Microbiology Section Laboratory on plenary. during presentation National verbal GDIPC document on isolation rooms in hospitals. GDIPC document in care tertiary hospitals. on IPC staff MEWA document on number of farms and sentinel site for surveillance. AMR Ministry of Environment Water and Agriculture lab policies and procedures. procedures. and lab policies Microbiology control audit tool.Infection manual. Control and Prevention Infection National PreventionCore in Infection and components Control. Meeting minutes of committees. leader. AMR of Appointment All technical committee actionplans. Plan. Action National National Committee RFP. AMR cases. syndrome of Ministry ofReports Environment Water and Agriculture on animal to human Middle East respiratory Drill documents. 59 of IHR Core Capacities of the Kingdom of Saudi Arabia 60

Joint External Evaluation • • • • • • • • • • Immunization • • • • • • • • • • • • • • • Real-time surveillance • • • • National laboratory system WHO MR report. MR WHO Monthly statistical from regions. reports report. joint WHO/UNICEF Annual Schedule. Immunization up Catch National Schedule. Immunization proposal. survey Coverage report. review Desk plans. annual and multi-year Comprehensive Circulars MoHand medical between supply directorate and other stakeholders as needed. NITAG meeting agenda and minutes. Letter from SFDA showing intersectoral collaboration in health matters. Ministerial decree to form an infectious diseases committee; MoH. progress. The system of practicing health profession; MoH, www.nazaha.gov.sa/mwg-internal/de5fs23hu73ds/ Circular of mandatory reporting all over the through country electronic system (HESN); MoH. Circular of mandatory reporting all over theMoH. country; OIE World Animal Health Information System (reports); MEWA. UCM_071583 www.moa.gov.sa/webcenter/faces/systemRegulations/UCM_conn_u23_dDocName_u3a_ www.boe.gov.sa/printsystem.aspx?lang=ar&systemid=350&versionid=326 Animal protection law for the Gulf Countries Council; MEWA blog/2016/05/----2. The law of veterinary medicine practice in the Gulf countries; MEWA, www.irshadvetsu.com/ Veterinary brochures; MEWA. www.irshadvetsu.com/mwg-internal/. MEWA, clinics; and hospitals veterinary of Guidelines Guidelines of infectious diseases and policy procedures 12 (p reporting to WHO); MoH. www.moh.gov.sa/Portal/Whatsnew/Pages/default.aspx. Guidelines notification of infectious diseases ed. (sixth 2016); MoH, Health. of Ministry laboratories, reference manual mycobacteriology for procedures and policy General Scope for of services different tiers of Ministry laboratory of Health. network, Royal decree No. on National M/3 System, Laboratory issued on 8/2/1423. CBAHI standards quality for health laboratories. • • • • • • • Workforce development • • • • • • • • • • • • • • • • Reporting • • list and placements, www.fetp.edu.sa/DFECourse_Layout.php. placements, list and Documents for curriculum, FETP rules and regulations, faculty, courses, short graduates FETP contact Document for establishment of Saudi FETP; Saudi Arabia and MoH. Documents for establishing the CCC: centrally and regionally. system. reporting national MEWA MoH infectious disease reporting system Health Electronic Surveillance (HESN). Network MEWA. of Statistics 6%D9%88%D9%8A%20%D9%84%D8%B9%D8%A7%D9%85%201436%D9%87%D9%80.pdf. 8%A5%D8%AD%D8%B5%D8%A7%D8%A6%D9%8A%20%D8%A7%D9%84%D8%B3%D9%8 Documents/%D8%A7%D9%84%D9%83%D8%AA%D8%A7%D8%A8%20%D8%A7%D9%84%D Statistics of the MoH; Healthcare Strategy in the Kingdom www.moh.gov.sa/Ministry/Statistics/book/ meetings. of Minutes Exercise of Ebola in case Jeddah MoH. airport, Print of outbreak news; MoH. Preventive medicine Hajj committee objectives; MoH. of Finance, Municipality); MoH Royal order on forming an intersectoral committee (MoH, MEWA, Ministry of Interior, SFDA, Ministry Letter from SFDA on intersectoral collaboration in health matters; SFDA. Ministerial decree of forming an infectious diseases committee; MoH. progress. The system of practicing health profession; MoH, www.nazaha.gov.sa/mwg-internal/de5fs23hu73ds/ Circular of mandatory reporting all over the through country electronic system (HESN); MoH. Circular of mandatory reporting all over theMoH. country; OIE Animal Health Information System (reports): MEWA. dDocName_u3a_UCM_071583. emid=350&versionid=326, www.moa.gov.sa/webcenter/faces/systemRegulations/UCM_conn_u23_ www.boe.gov.sa/printsystem.aspx?lang=ar&syst GCC law for MEWA, countries; protection Animal blog/2016/05/----2. The law of veterinary medicine practice in the Gulf countries; MEWA, www.irshadvetsu.com/ Veterinary brochures; MEWA. www.irshadvetsu.com/mwg-internal/. MEWA, clinics, and hospitals veterinary of Guidelines Guidelines of infectious diseases and policy procedure 12 (p reporting to WHO); MoH. Preventive medicine Hajj committee objectives; MoH. Ministry of Finance, Municipality); MoH. Royal order of forming an intersectoral committee (MoH, MEWA, Ministry of Interior affairs, SFDA, 61 of IHR Core Capacities of the Kingdom of Saudi Arabia 62

Joint External Evaluation • • • Preparedness • • • • • Points ofentry • • • • • • • • • • • Risk communication • Linking publichealthandsecurityauthorities • • • • Emergency response operations Site visit at Dharan Military Complex and Eastern Province Civil Defence facilities. staff. Hospital General Dammam Interviews with officialsfrom the Ministry of Health, Ministry of Interior, Ministry Defenceof and Presentation from MoH. University. Liverpool Agreements with International bodies for providing training in public health, e.g. CDC, University, Emory programmes. training workforce veterinary MEWA for Documents programmes. training national long-term other for Documents Procedure of application of the above-mentioned Royal Decree, 2012. Royal Decree, above-mentioned the of application of Procedure according to the IHR,at the points of entry. Royal Decree, N° M/47 on 07/08/1433 of the Hegira, regarding the implementation of health control, Memorandum of Understanding with University Um Al-Qura (training of rapid response teams). (Risk Mosque the Prophets Assessments). Memorandum of Understanding with the General Presidency for the Affairs of the Grand Mosque and Risk Communication. for Recommendations and Risk Assessment Risk Communication Training Concept Paper. Course versions). (English Arabic Stroke and Heat Infographic Social Intelligence Project for Hajj: Concept Paper and Results Report. 2016Hajj Plan. Emergency Hajj 2016 SOPs for Communications. Hajj 2016 Media Preparation Plan. Hajj 2016 Operational Plan for Public Communications. 2015. Assessment, Risk Communication Capacity Civil Defence Act. guidesStaff for facilities. facilities. Province Eastern Site at visit Hospital staff. Interviews with officialsfrom MoH, Ministry of Interior, Ministry Defenceof and Damman General Presentation from MoH. • • • • • • • • • • • • • Radiation emergencies • • • • • • • Chemical events • • • • • • • Samples of licensing applications for the industrial and medical sectors. emergency. radiological or accident nuclear a of case the in assistance on convention IAEA accident. a nuclear of notification early on convention IAEA International Atomic Energy Agency related documents: related documents: International AtomicAgency Energy Waste Management. Radioactive Regulations for Regulations for Safe Transport of Radioactive Materials. Radiation. Ionizing against Protection Radiation for Regulation Basic materials, Civil Defence; Ministry of Interior. hazardous preventive for requirements IV: Part supervision, preventive and requirements Safety Arabia. Saudi in transportation materials radioactive including evaluationDraft for the report current practices of the management of chemical and hazardous Royal Decree establishing King Abdullah for City Atomic and Renewable Energy. (RNEPR) plan. response and preparedness GCC, emergency nuclear and radiological regional emergencies. nuclear and radiological plan for National medical emergencies. nuclear and radiological to National respond plan to SFDA. from Documents SABIC. and ARAMCO from Management Chemical MoH System of Surveillance and Monitoring for Chemical Incidents. MoH Public Health Plan for Chemical Emergencies. Chemical Management. of Assessment PME National Plan for Chemical Events (Civil Defence). Law of Chemicals and Management. Import 2–7 September 2015. regarding report WHO the assessment of the IHR core capacities at points of entry, Saudi Arabia, Islamic Jeddah Port. drill documents, plan and contingency emergency Public health Madinah International Airport. Al drill documents, plan and contingency emergency Public health International Airport. plan, Jeddah contingency emergency Public health International Airport. Control, Jeddah Health Border emergency. or disaster of case Evacuation plan in Communicable Diseases, Department of Public Health, Ministry of Health, 2012. Manual of procedures of the border health control at points of entry. General Directorate of Health care and preventive measures during Hajj, at . m m m

the environment No. TS-R-1 Safety Requirements. TS-R-1 No. environment the Safety Regulations for the Safe Transport of Radioactive Material; 2009Edition for protecting people and Safe Transport No. TS-R-1 (2000) BSS Series Safety No. 115 (1996) 63 of IHR Core Capacities of the Kingdom of Saudi Arabia Joint External Evaluation of IHR Core Capacities of the Kingdom of Saudi Arabia

Mission report: 12–16 March 2017

WHO/WHE/CPI/2017.25.report