Final Report - Moldova Assessment

Transcription

TECHNICAL ASSESSMENT
REPORT
Moldova
Assessment of the national communicable
disease surveillance and response systems
2014
TECHNICAL ASSESSMENT REPORT
Moldova - Assessment of the national communicable disease
surveillance and response systems
2014
TECHNICAL ASSESSMENT REPORT - MOLDOVA 2014
Page ii of 95
Acknowledgements
The internal and national review team acknowledges with gratitude the full and professional collaboration of
respondents at all levels of the Moldova communicable diseases system. The support of TAIEX and the Romania
National Institute of Public Health, and the WHO Regional Office for Europe WHO Europe and WHO Collaborating Centre
for HIV surveillance in Zagreb, Croatia in enabling the participation of Drs Popovici and Bozicevic, respectively, is
gratefully acknowledged.
Page iii of 95
Contents
Abbreviation ..................................................................................................................v
Executive Summary ....................................................................................................... 1
1
Introduction .......................................................................................................... 6
1.1
1.2
1.3
1.4
2
Background .........................................................................................................................6
Assessment Methodology .................................................................................................6
Country profile ...................................................................................................................7
Health systems profile ....................................................................................................10
Surveillance ......................................................................................................... 16
2.1
Surveillance objectives, legislative framework ............................................................16
2.2
Identification and reporting of diseases under surveillance .....................................17
2.3
Data processing, analysis by the Public Health Centres ............................................18
2.4
Reporting and feedback..................................................................................................19
2.5
Outbreak recognition, management, investigation and reporting ...........................19
2.6
Data protection, data access .........................................................................................21
2.7
Parallel Disease specific surveillance systems .............................................................21
2.8
Other surveillance systems ............................................................................................23
2.9
System sensitivity and specificity ..................................................................................23
2.10 System coordination and integration ............................................................................24
2.11 International reporting and potential for case reporting to EU level.......................26
2.12 System monitoring and evaluation ...............................................................................26
Surveillance and Outbreaks: strengths and weaknesses ......................................................28
Component S1: Legislative and regulatory framework ........................................................28
Component S2: Surveillance information systems ................................................................31
Component S3: Use of surveillance information system .....................................................33
Component S4: Disease specific programmes and surveillance .........................................35
Component S5: Public health workforce ................................................................................38
Component S6: Support to wider health service ..................................................................40
3
Public Health Microbiology System .......................................................................... 41
3.1
System Overview .............................................................................................................41
3.2
Primary diagnostic laboratory services .........................................................................41
3.3
Reference microbiological diagnostic services ............................................................42
3.4
Laboratory activity reporting..........................................................................................44
3.5
Integration with surveillance systems and other sectors ..........................................44
3.6
Integration with alert and response systems ..............................................................45
3.7
Laboratory regulation and standards ...........................................................................46
3.8
Training and continuing education microbiologists and technical staff ..................47
Public health Microbiology: strengths and weaknesses.........................................................48
Component L1: Primary diagnostic laboratory services ......................................................48
Component L2: Reference microbiological diagnostic services ..........................................49
Component L3: Laboratory service quality ............................................................................51
Component L4: Inter-professional and inter-sectoral collaboration ..................................52
4
Page iv of 95
Public Health Emergency Preparedness, Response and Crisis Management ................... 53
4.1
Systems Overview ...........................................................................................................53
4.2
Past crises and potential threats ...................................................................................53
4.3
Management of Public Health emergencies ................................................................54
4.4
Regulatory basis ..............................................................................................................54
4.5
Strategic and Coordinating Bodies ................................................................................55
4.6
Early warning and communications ..............................................................................56
4.7
Training .............................................................................................................................57
4.8
Summary ...........................................................................................................................57
Public health emergency preparedness: strengths and weaknesses ..................................58
Component P1: Regulatory and strategic basis ....................................................................58
Component P2: Emergency preparedness and response organisation .............................59
Component P3: Emergency preparedness planning .............................................................60
Component P4: Preparedness and response operations .....................................................62
Component P5: Monitoring and evaluation ............................................................................64
Annexes ..................................................................................................................... 65
Annex 1.
Annex 2.
Annex 3.
Prevention
Annex 4.
Annex 5.
International and National Review Teams, and National Respondents ..........66
Terms of Reference and Itinerary .........................................................................67
Principal Legislation, Decisions, Orders relating to Communicable Disease
and Control in Republic of Moldova ......................................................................73
List of reportable diseases, syndromes, events. .................................................81
Health Emergency Response Organisations ........................................................85
Maps & figures
Figure
Figure
Figure
Figure
Figure
1
2
3
4
5
-
Republic of Moldova: administrative divisions .....................................................................8
Organisation of the health system, Republic of Moldova. ...............................................11
Organisational chart of the Ministry of Health, Republic of Moldova .............................12
Organisational chart National Centre Public Health ..........................................................13
Public health emergencies organisational structure, Republic of Moldova. ..................56
Tables
Table 1 - List of recommendations ..........................................................................................................4
Table 2 - Economic indicators, Republic of Moldova, 2011 .................................................................9
Table 3 - Health Indicators, Republic of Moldova ...............................................................................10
Table 4 - Reported confirmed disease rates from surveillance systems, for selected diseases,
Republic of Moldova, compared with EU/EEA Member States (mean crude rate), 2012 ..............25
Table 5 - Most significant natural disasters occurring in the Republic of Moldova in terms of
death and population affected, 1990–2014 .........................................................................................53
Page v of 95
Abbreviation
BSL
Biosafety level
CCHF
Crimean-Congo haemorrhagic fever
CLSI
Clinical and Laboratory Standards Institute
CPESS
Civil Protection and Exceptional Situations Service
CPH
Centre for Public Health
CSP
Conferinţa ştiinţifico-practică
DV
Dermato-venereology
ECDC
European Centre for Disease Prevention and Control
EARS
Early Aberration Reporting System
EMAS
Emergency Medical Assistance Service
EU
European Union
EUCAST
European Committee on Antimicrobial Susceptibility Testing
GAVI
Global Alliance for Vaccines and Immunisation
GDP
Gross domestic product
GIS
Geographic information systems
GFATM
Global Fund to Fight AIDS, Tuberculosis and Malaria
HDI
Human Development Index
HIV/AIDS
Human immunodeficiency virus infection and acquired immune deficiency syndrome
IBBS
Bio-behavioural surveillance survey
ICD
International Classification of Disease
IHR
International Health Regulations
MediPIET
Mediterranean Programme for Intervention Epidemiology Training
MoH
Ministry of Health
NCPH
National Centre for Public Health
NIHC
National Health Insurance Company
NIPP
National Tuberculosis Institute
NRL
National reference laboratory
NSPCEM
National Scientific and Practical Centre of Emergency Medicine
PCR
Polymerase chain reaction
PHC
Public Health Centres
PHS
Public Health service
RCDM
Centre for Disaster Medicine
SAE
Electronic surveillance system
SAQ
Self-administered questionnaire
SOP
Standard Operating Procedure
STD
Sexually transmitted diseases
STI
Sexually transmitted infections
TAIEX
Technical Assistance and Information Exchange instrument
TB
Tuberculosis
TESSy
The European Surveillance System
ToR
Terms of Reference
USSR
Union of Soviet Socialist Republics
VETC/STEC
Vero /Shiga toxin- producing Escherichia coli
WHO Europe
World Health Organisation Regional Office for Europe
WNV
West Nile Virus
Page 1 of 95
Executive Summary
Background
Communicable disease surveillance and response systems in the Republic of Moldova have undergone substantial
development from the Shemasko system inherited on independence in 1991, and in the context of repeated reforms of
government administration, healthcare services and public health structures. A major review by WHO in 2001 1 provided
significant impetus and strategic direction to the reform and development of the surveillance system.
Recent years have seen substantial developments in the legislative and strategic frameworks relating to communicable
disease prevention and control, and in technical and design elements of the surveillance and early warning systems. A
major strategic focus over this period has been the decision to align systems as compatible with those of European
Union countries. In 2014 Moldova entered into a Partnership Agreement with the European Union.
The present review was requested by the Ministry, with support from the European Union (TAIEX) and WHO Europe, for
an external system review by an expert team convened by the European Centre for Communicable Disease Control
(ECDC), working in close collaboration with national system leaders and experts. Agreed terms of the review included
particular reference to the effectiveness and efficiency of the communicable disease surveillance and responses systems,
their compatibility with EU requirements and norms, and advice on further strategic and technical development.
The ECDC team, comprising experts from ECDC, the Republic of Romania, and WHO Europe (Zagreb collaborating
centre), undertook preliminary enquiries and carried out a review in Moldova from 31 March – 4 April 2014, working
closely with national leaders and experts, staff and related sector organisations, at both national and rayon/municipal
levels.
System achievements
The international review team recognised a number of particular strengths of the system in Moldova, particularly since
the substantive WHO review of 2001:
Surveillance
Surveillance is based primarily on a national passive system, with a clear and comprehensive legislative and regulatory
framework, which appears generally well accepted by healthcare staff. System development proceeds in the context of
well established strategic planning within overall public health system development.
The surveillance system has a case classification system that is coherent with EU reporting requirements, and applied to
reported cases by epidemiologists at local level. A pilot electronic surveillance system (SAE), is well established
nationally, with good acceptance by data providers and public health staff.
Regular descriptive reporting and analysis, mostly at national level, supports use of surveillance data for ongoing
epidemic intelligence, monitoring of national programme targets, and to support national policy development and
planning. Good use is made of web sites at both local and national level for dissemination of information.
Outbreak recognition and management
Outbreak reporting and management is subject to clear responsibilities and requirements, with local units supported as
necessary by national teams. The SAE has a module for flagging in real time possible disease clusters based on doctor
reporting of individual cases.
Public health laboratories
Primary diagnostic laboratories have benefitted from recent World Bank and European Union investment; facilities and
equipment are generally modern and adequate, with a reasonable range of bacteriology and serology services and well
established patterns of referral to national reference laboratories for selected pathogens. The reporting system provides
a good overview of pathogens diagnosed by the national laboratory system. National reference laboratories carry out all
the core functions expected in a European context. Some are internationally accredited, and participate in external
quality assurance schemes; some are recognised as WHO national centres, and there is involvement in international
surveillance and research projects. There is a good collaboration between microbiologists and epidemiology and clinical
staff, at both local and national levels.
1
WHO (Regional Office for Europe). Assessment of the National Surveillance System for Infectious Diseases. WHO, 2002.
Page 2 of 95
Public health emergency preparedness
Preparedness for response to public health emergencies is a shared responsibility at government level, between civil
protection and public health. There is clear regulation for the authority and line of command in case of emergencies with
potential public health impact. A national, multi-sectorial plan for disaster risk reduction is regularly updated. Districtlevel plans are in place to manage public health emergency situations, and reviewed regularly, with committees
appointed to coordinate activities, and regular multi-sector simulation exercises. Rapid response teams at all levels of
the health system are designated and trained.
There is cross-Ministry planning and management for all crisis situations, including epidemics, and guidelines on
preparedness planning for hospitals and district authorities. For management of major public health events, due to
biological and radiological agents, specific intervention plans and operating procedures are developed and enforced.
Health sector preparedness is monitored and evaluated.
Workforce
There is a dedicated epidemiological and microbiological professional workforce, familiar with the legislative and
regulatory framework for their services. Protocols and standard operating procedures for epidemiologists are in place for
several important service functions, with generally adequate working conditions and infrastructural support. There is
also a well-established programme of guidelines for clinicians that include several communicable diseases of public
health importance. Continuing professional education programmes for doctors are well established.
System Challenges
There are a number of areas where progress since 2001 has been rather muted; implementation of the WHO
assessment findings appear to have been variable. Some system deficiencies could present challenges for effective and
efficient collaboration with the communicable disease surveillance and control network of EU member states 2. The
recommendations of the present review are summarised in Table 1 and set out in more detail in each chapter. A full
listing is also given following the executive summary.
Surveillance
Although there has been considerable technical and legislative work since 2001 on developing priorities for
communicable disease prevention and control, little of this appears reflected in daily work or annual reviews of the
epidemiology services, at either rayon or national levels. Reported diseases are processed by rayon staff in a similar
manner, with little analysis beyond reporting counts to NCPH on standard forms. Skills in the analysis of surveillance
data at rayon level, and the IT infrastructure to support it, both appear very limited. This is only partly compensated for
by a small epidemiological surveillance team at national level, which appears still heavily engaged by the demands of
further development of the electronic surveillance system (SAE).
With the exception of a few diseases (e.g. TB, HIV), there is little tailoring of either information required, or the
investigation approach to the public health importance of the disease, or for understanding of the local epidemiology, or
for the needs of national prevention and control programmes, or policy development. Analytical skills for the
investigation of outbreaks remain limited at rayon level, and analytical methods are infrequently used, even when
supported by national outbreak support teams. Continuing professional education of rayon epidemiologists and their
support staff in these areas must be a priority.
The SAE remains under pilot status, despite clear effectiveness and acceptability. The lack of legislative legitimisation of
case information reported through it hinders its ability to support the implementation of a public health priority based
approach to communicable disease surveillance, prevention and control. The SAE reproduces the traditional forms of
reporting and can generate several different types of report; however it provides for limited data analytical capacities,
especially at local level. Partly for this reason, data analysis even at national level remains limited, even in descriptive
terms.
The presence of a national system of surveillance case definitions, and its implementation by epidemiologists close to
the case at rayon level, is a real strength of the system. However there appear to be no guidelines for, or training in,
their use, and their precision in practice is uncertain.
The sensitivity of surveillance appears quite variable, and there are some diseases of public health importance
essentially unrecognised by the system. While some diseases appear to be subject to reasonable ascertainment (e.g. TB,
salmonellosis, syphilis), others are almost certainly grossly under-reported, or not detected at all (e.g.
campylobacteriosis, legionellosis, listeriosis, Chlamydia, West Nile fever, invasive bacterial diseases). Limited diagnostic
laboratory capacities are an important factor here, although there may also be other underlying healthcare system
2
Decision 2013/1082/EC
Page 3 of 95
issues that require investigation. It is difficult to develop, and have a balanced approach to development of policy,
planning, surveillance and prevention for communicable diseases that are not reasonably recognised and reported.
Some important diseases remain under surveillance through parallel systems (HIV, TB, STIs). There may be benefits in
integrating at least some of these into the main surveillance system, particularly when the SAE is fully operational.
Integration of STI and TB surveillance should have clear benefits. However, the effectiveness and efficiency benefits,
and necessary precautions of such integration, for disease ascertainment and practical prevention and control purposes,
need to be carefully assessed. Improved data protection arrangements may be required. There are clear improvements
needed in HIV surveillance, regardless of the arrangements for its administration.
Liaison with veterinary and food safety authorities’ remains very limited, and needs to be improved, including both more
frequent liaison, and information sharing, of at least defined aggregate data.
Public health laboratory system
The primary diagnostic laboratories have been recently upgraded, and basic primary services and referrals appear to
work well. However there are significant challenges for the ongoing provision and development of national reference
laboratory services, including appropriate modern equipment and diagnostic technologies, consistent procurement (e.g.
of test reagents), and housed in adequate buildings. Recruitment and retention of microbiology specialists is an
increasing problem. There is no national system of biosafety and biosecurity regulation. There is insufficient liaison with
laboratories in other sectors (veterinary, food, and environment). The role of laboratories in supporting communicable
disease outbreak identification and management is unspecified.
Health emergency planning
While civil protection preparedness and response systems are well developed, and regularly exercised, the provision for
public health emergencies, particularly related to major communicable disease outbreaks, or highly contagious cases, is
less clear and secure.
Strategic planning for public health emergencies requires development, with particular reference to compatibility with EU
Decision 2013/1082, and testing through simulation exercises, and training of staff. The lines of command in a public
health (c.f. civil protection) emergency require clarification.
Communicable disease system workforce
As above, formal assessment of the support for communicable disease surveillance, prevention and control through the
training, recruitment and professional education of the workforce is beyond the present review. Incidental assessments
and recommendations are made in the respective chapters.
It is apparent that ongoing maintenance of a skilled workforce related to communicable disease surveillance, prevention
and control is a strategic priority for the Moldova. There are major challenges: recruitment of graduates into the
specialties is falling; retention of skilled staff difficult given better remuneration in other countries; the present workforce
ageing; unfilled vacancies in the rayons. As above, there are important professional skills gaps to be addressed.
While there are good educational facilities for specialist training and continuing education, more needs to be done to
raise the profile of epidemiology and microbiology as careers, for nonmedical as well as medical graduates. The present
medical specialist based model of public health may be unsustainable in the medium to long term; Moldova could
usefully consider leadership in developing a multidisciplinary approach to public health, including communicable
prevention and control, as practised in a number of EU countries.
Page 4 of 95
Table 1 - List of recommendations
[Note: This table includes abbreviated descriptions only: reference should be made to main text for full statement and
rationale]
No
Recommendation (heading)
Priority*:
public
health
impact
Priority**:
Page
Ease of
implementation
Surveillance and outbreak response
S1.1
Surveillance objectives and priorities
1
2
S1.2
Parallel surveillance systems
2
3
S1.3
Liason with veterinary and food safety systems
2
1
S1.4
Personal data protection
3
1
S2.1
Dual paper and electronic reporting systems
1
2
S2.2
Validation of case reports
2
1
S2.3
GIS support to rayon epidemiologists
2
2
S2.4
Early warning and alert system
1
2
S3.1
Use of surveillance data for national level public health functions
1
2
S3.2
Use of surveillance data at rayon level
1
2
S3.3
Gaps in surveillance
1
2
S4.1
HIV surveillance and information issues
2
1, 2
S4.2
STI surveillance
2
1, 2
S4.3
TB surveillance
2
2
S5.1
The epidemiology workforce
1
2
S5.2
Outbreak management lacks analytical investigation
1
2
S5.3
Analytical epidemiology skills of rayon epidemiologists and
support staff
1
2
S5.4
Continuing professional education
1
2
S6.1
Guidelines and training for clinicians
1
2
Public health microbiology
L1.1
Maintenance of diagnostic systems based on classical
technologies
1
2
L2.1
National reference laboratory (NRL) mandate and nomination
2
1
L2.2
Sustainability of good quality NRL services
1
3
L2.3
Biosafety at NRLs
2
2
L2.4
Maintenance of laboratory capabilities with limited resources
1
3
L3.1
Sustainability and development of microbiology expertise
1
2
L3.2
Antimicrobial susceptibility testing
1
1
L4.1
Inter-sectoral collaboration
1
2
L4.2
Business continuity
2
2
55
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L4.3
Laboratory roles in national communicable disease emergencies
1
1
Public health emergency preparedness
P1.1
Complex legislative framework
1
2
P1.2
Alignment to EU acquis
1
2
P2.1
Dispersed and overlapping responsibilities
1
1
P2.2
Biosafety and biosecurity
1
1
P3.1
Public health emergency planning
1
2
P3.2
Operational response planning for health emergencies
1
2
P3.3
Pandemic influenza planning
1
2
P4.1
Operational responsibility in public health emergencies
1
2
P4.2
Public health emergency training
1
2
P4.3
Rapid response teams
1
3
P5.1
Preparedness of local public health sector organisations
1
2
P5.2
Rayon level public health preparedness plans
1
2
P5.3
Links with EU institutions relating to public health emergencies
1
1
*1 = higher public health impact; 3 = lower
** 1= more amenable to implementation, 3 = less
1
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Introduction
1.1 Background
In February 2014 the Ministry of Health of the Republic of Moldova submitted to the European Commission a request for
the organisation of an expert country assessment mission through the TAIEX instrument. The general objective of this
expert mission organized from 31 March to 4 April 2014 was to provide a peer-based assessment of Moldova’s national
communicable diseases surveillance and public health emergency response systems. This mission occurred in a context
of expressed interested by both the EU and Moldova to further develop their cooperation in the field of public health,
with notably a view to raising the level of public health safety and protection of human health and strengthen the public
health system of the Moldova.
The European Union is developing an increasingly close relationship with Moldova, as a partner country within the
European Neighbourhood Policy. In 2014 Moldova and the EU signed an Association Agreement3. This agreement
includes identification of public health as a sector for increased cooperation, including in the area of epidemiological
surveillance and control of communicable diseases.
The specific objectives for this expert mission were to:



Assess Moldova’s communicable diseases national surveillance system components (structure, process,
capacities, effectiveness and coordination) and evaluate its coherence with EU legislation and normative
practice in EU countries;
Assess Moldova’s capacities to respond to public health emergencies;
Provide advice for the development of an action plan setting up priorities for the strengthening of Moldova’s
capacities in disease surveillance.
Such an action plan would be particularly aimed at:




Assessing the existing legal framework in the field of communicable diseases surveillance system with a view to
support harmonization with the EU legislative acquis;
Assessing public health capacities at national and local level;
Revising and updating the list of priority communicable diseases;
Adjusting the list of notifiable diseases and related case definitions.
The conclusions of this expert review are intended to support the development and implementation of a 2-year national
action plan aiming at strengthening Moldova’s surveillance capacities on communicable diseases, including coherence
with EU acquis and professional and service practices compatible with those of EU member states.
1.2 Assessment Methodology
1.2.1 Pre-visit
Objectives of the review, and terms of reference (ToR) were agreed with the Ministry prior to the visit (Annex 2).
Within these parameters for assessment were drawn and adapted from standard ECDC assessment instruments for the
communicable disease surveillance and response systems of enlargement countries. A self-administered questionnaire
(SAQ) comprising key preliminary information requested in advance of the visit was forwarded to the Ministry and
returned to the international review team prior to the visit.
The international review team comprised two epidemiologists specialist in surveillance and outbreak response systems
(one form ECDC, one from Republic of Romania), and a third, specialist in health emergency preparedness (ECDC). The
fourth team member was a specialist in HIV and STD programme assessment and provided courtesy of WHO Europe
(Zagreb collaborating centre). The final team member was a specialist microbiologist (ECDC). Team members from
Romania and WHO Europe were funded by TAIEX and WHO respectively.
The international team reviewed the SAQ response from the Ministry, including associated legislation and reports
provided. Published reports by country authorities were also reviewed, as well as previous reports by international health
authorities.
The scope of the assessment included general review of the legislative and strategic framework pertaining to public
health in general, and communicable disease surveillance and control in particular, and the structure, function,
effectiveness, efficiency, quality and sustainability of the communicable disease surveillance and response, and health
emergency preparedness functions, together with the microbiology services as supporting infrastructure. Human
resource availability, training and continuing education were briefly considered in this context, but not formally assessed.
3
http://eeas.europa.eu/moldova/pdf/eu-md_aa-dcfta_en.pdf
Page 7 of 95
The preliminary and in-country reviews were designed to give a coherent overview of the function of the surveillance
and response system, both regarding performance of individual elements within it, their coordination, and apparent
system effectiveness and efficiency overall. International team reviewers sought to follow the path of patients and
information through the system, from symptomatic presentation to information in the surveillance system, and the uses
of the latter for public health purposes, including policy, disease programme and service planning, routine disease
control service work, and responses to outbreaks and health emergencies.
1.2.2 In-country
For this purpose an itinerary was agreed, as part of the ToR, including site visits in two rayons significantly distant from
the capital, and in Chisinau municipality itself. The team visited institutions and discussed with lead staff, as semistructured interviews, their functions in the surveillance and response system, relationships with other parts of the
system, and other collaborating sectors, reviewed operational data, and facilities and infrastructure. Selected aspects of
function at each institution were examined in detail.
The international team was accompanied on site visits by members of the national review team. The itinerary
commenced with a workshop including presentations by national leaders of key aspects of system legislative, strategic
and functional organisation. Preliminary plenary discussions of findings of the international team were held during the
visit, which concluded with a preliminary debriefing on the final day.
1.2.3 Post visit
Following the in-country review, the findings of the international team relating to system components were reviewed,
identifying key components of system operation, strengths and areas needing development. Interactions between
systems were identified (particularly between surveillance, response, and laboratory systems), and recommendations
identified grouped by their expected public health impact and ease of implementation.
These findings were returned to national team members as a draft report for critical review, and comment, including
correction of factual errors and additional information and observation. The final draft report responding to this input
was returned for final review to Moldova team members in December 2014 and the final report submitted to the Ministry
of Health in March 2015.
A listing of the international and national review teams, and principal country respondents, and detailed itinerary are
given in Annexes 1 and 2.
1.2.4 Assessment limitations
The present assessment was completed by a small international team over five days in-country, supplemented by
documentary review before and after the visit. Only a limited number of organisational entities, leaders and locations
could be visited in that time. In particular it was not possible to formally interview leaders involved in workforce
education, specialist and occupational training, continuing education and workforce planning.
1.3 Country profile
1.3.1 Geographical, Political, Economic background
The Republic of Moldova became independent in 1991 after the break-up of the former USSR. Moldova is divided into
thirty-two districts (rayons) and three municipalities, with 3.5 million habitants4. The autonomous unit of Transnistria, on
the eastern border, is not under direct government control, and was not included in this review.
4
Country Cooperation Strategy at a glance, Moldova, WHO/Europe, 2013
Page 8 of 95
Figure 1 - Republic of Moldova: administrative divisions
With an economy dominated by agriculture and food processing, 58% of its population live in rural areas and 42% in
urban areas5.
5
Sources: Monitoring official development assistance to the health sector in the Republic of Moldova, WHO/Europe 2012 report.
Page 9 of 95
The economic transition that followed the accession to independence caused considerable socioeconomic hardship in the
country and the health status of the population fell, with a steep rise mortality, and negative population growth for
several years4.
Moldova embarked on an ambitious programme of economic reform. Although Moldova is still one of the poorest
countries in the WHO European Region, its recent economic performance has been strong, if volatile: GDP growth has
been solid in recent years5. While the Human Development Index (HDI) is below the European region average, it has
been on an upward trend.
The health status of the Moldovan population has been steadily improving; Moldova regained its pre-independence life
expectancy at birth (69 years) in 2010. The infant mortality rate has been falling steadily since the mid-90’s, reaching 11
per 1000 live births in 20114.
Nevertheless, challenges persist. While increasing, life expectancy remains low compared with other countries of the
WHO European Region. Mortality and morbidity rates are high among the working-age population5, particularly
associated with non-communicable diseases (coronary heart disease, cancer), and lifestyle risk factors, including heavy
alcohol and tobacco consumption4.
Table 2 - Economic indicators, Republic of Moldova, 2011
5
Indicator
Level
GDP growth
6.41%
Population
3 559 000
GDP per capita
$3369
World Bank country classification
Lower middle income
HDI
0.649
1.3.2 Health Reforms
At independence in 1991, Moldova had a health system with numerous facilities and staff but limited resources to
sustain them. Despite some reductions in capacity, Moldova in 1997 had one of the most extensive networks of health
facilities and health staff in either Western Europe or other countries of the former Soviet Union (World Bank 2000) 6.
Economic constraints post-independence led to the dramatic consolidation of the healthcare system, with reductions in
the number of hospital beds, activity levels and personnel.
Moldova inherited the Semashko health care system model from the former Soviet Union. Mandatory health insurance
was introduced in 2004, which has driven the health system towards universal coverage, and greater emphasis on
primary care, which has been reformed on a family doctor model4. Primary and secondary health care have been
reformed and consolidated. Primary care is based on family doctor services, on a general practice model.
Additional challenges include health workforce shortages: emigration, the broadening of alternative career opportunities
and low wages mean that the country is facing recruitment problems for key health workers, particularly in rural areas
and in the primary health care system.
The national sanitary-epidemiology services were reformed as the National Centre of Preventive Medicine, with further
reform as the Public Health Service in 2009. Key policy documents have been developed for the sector: the National
Health Policy 2017-2021 and the Healthcare System Development Strategy 2008-2017 both identify mid- and long-term
reform priorities4.
6
Health systems in transition. Moldova health systems review (2008)
Page 10 of 95
Table 3 - Health Indicators, Republic of Moldova
Indicator
Life expectancy at birth (2010)
Level
4
69.13
Under-5 mortality rate per 10004
19
Maternal mortality rate per 100 000 live births(2010)
Total expenditure on health as % of GDP(2010)
4
44.47
4
11.7
Prevalence of TB burden (2012)7
Estimated MDR-TB among new cases (2012)
249 (per 100 000)
7
Estimates MDR-TB among previously treated cases(2012)
HIV prevalence among TB cases(2012)7
HIV incidence per 100 000 population (2011)
24%
7
62%
6%
5
20.25
1.3.3 Infectious disease challenges
Tuberculosis, HIV and syphilis remain major public health priorities in Moldova. Reported rates of salmonellosis and
EHEC are high compared with those reported in EU countries. At the same time significant emerging diseases in South
East Europe may provide challenges for detection and response (e.g. West Nile virus infection). Some communicable
diseases of public health importance may be under-recognised (see section 2.9).
1.3.4 Development partners
Moldova is benefitting from international support to reform and strengthen the health care system. A number of
international agencies8, in addition to WHO, are active in supporting Moldova through technical assistance, capacity
building, and funds. In 2010, 9.6% of total health expenditure came from external sources4 in the form of project-based
donations and loans from international actors including the EU, the World Bank, GFATM, GAVI and various United
Nations agencies. In 2011, this official development assistance for health reached $59.1 million, across both
communicable and non-communicable diseases.
In 2014 Moldova and the European Union signed an Association Agreement. This Agreement includes identification of
public health as a sector for increased cooperation, including the area of epidemiological surveillance and control of
communicable diseases.
1.4 Health systems profile
1.4.1 Principal health authorities and organisations
(a)
Overview
The healthcare and public health systems of the Republic of Moldova are complex involving a number of state
authorities. Rayons and municipalities are responsible for healthcare services at all levels (emergency, primary,
secondary and tertiary); these are funded primarily through mandatory health insurance, introduced in 2004. The state
Public Health service (PHS) – which includes the national and rayon and municipal centres of public health – addresses
population health issues, and is accountable to and directly financed by the Ministry of Health.
7
8
2012 TB Country work summary, WHO/Europe
UNDP, UNICEF, UNFPA, UNODC, UNAIDS, IAEA the World Bank, European Union, and international NGOs
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Figure 2 - Organisation of the health system, Republic of Moldova
Source: the National Centre Public Health
(b)
Health system financing
Mandatory health insurance funds most of healthcare in the Republic of Moldova, funded through contracts with the
National Health Insurance Company (NIHC). NHIC is funded by employer payroll contributions, transfers from the
national budget to cover the non-working population, direct payments from self-employed workers, state budget
allocations and a small amount from income derived from services.
The Ministry of Health plans and administers the state budget in the health sector. Once the budget is approved by
Parliament, the Ministry of Health can reallocate the resources based on current priorities or emerging needs.
1.4.2 Principal organisations in communicable disease prevention and control
(a)
Ministry of health
The Ministry of Health is responsible for developing and monitoring the implementation of public health policies,
legislation and regulation in the health field, promoting the inclusion of health related action in all public policies, and
supporting their efficient implementation in other sectors.
The Directorates of Public Health, Hospital Care and Emergencies, and Primary Healthcare at the Ministry are headed by
respective Deputy Ministers. The Deputy Minister of Health is also the main state sanitary doctor9.
9
Law No. 10-XVI (3 February 2009) on state surveillance of public health
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Figure 3 - Organisational chart of the Ministry of Health, Republic of Moldova
(b)
Public Health Service (PHS)
The State Public Health Service (PHS), which is seen as an integrated set of entities from the Ministry of Health,
including the Chief State Sanitary Doctor of the Republic, to the National Centre for Public Health and Centres for Public
health at municipal and rayon level.
The PHS is headed directly by a Deputy Minister, and coordinated by the Ministry through the Directorate of Public
Health.
(c)
National Centre for Public Health (NCPH)
The NCPH is directly accountable to the Ministry of Health, and is responsible for most core public health functions at
the national level. The Centre was restructured in 2010.
The Centre monitors and assesses the public health and the healthcare systems, and gives expert health policy advice.
It provides data and reports on principal health indicators; prepares programmes and measures for the prevention of
disease; works on the professional development of public health experts, and performs public health research.
The NCPH also recognizes threats to health and draws up measures for their mitigation; provides technical and
methodological support to rayon and municipal Centres of Public Health; assesses and reports on implementation of
national public health policies, and serves as a training centre.
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Figure 4 - Organisational chart National Centre Public Health
(d)
Rayon/municipal Centres of Public Health
The rayon/municipal centres of public health (CPH) were also restructured in 2010. They are accountable directly to the
Ministry of Health, and rely on NCPH for technical support.
Rayon and municipal Centres of Public Health coordinate the implementation of national public health policies in their
jurisdictions. They undertake core public health functions, including monitoring, prevention, health protection and
promotion, and report periodically to the NCPH regarding the main health indicators and the implementation of national
programmes and ministerial orders.
Rayon CPH structures and organisation vary with size of the population served, but all have divisions or departments for
communicable disease surveillance and control, health promotion and non-communicable disease surveillance, health
protection (including environmental health, occupational health, child and adolescent health) and public health
management. These services are underpinned by microbiology and environmental laboratories, IT and administrative
and logistics support.
(e)
Public health microbiology services
The Public health microbiology system in Moldova is based on microbiology and sanitary-hygiene/environmental
laboratories in each of the 36 rayon or municipal centres for public health (CPH), together with the equivalent
laboratories at NCPH. In addition there are two radiological laboratories, located in Chisinau and at the NCPH Balti.
The core functions of the CPH laboratories are to provide investigations for the detection and confirmation of cases of
infectious disease, and of wider public health threats (biological, chemical, radiological). Clinical and environmental
(food, water, vector) samples are tested in public health microbiological laboratories, at both national and rayon level.
The national level laboratory performs both primary diagnostic and reference laboratory functions.
(f)
Primary care, hospital services
At rayon/municipal levels there are 49 centres of family doctors (35 in districts, one in Balti and 13 in Chişinău
municipality). Depending on the population served, there are family health centres with, typically, 3-4 doctors, single
doctor practices, and health offices without physicians.
In Moldova there are 82 hospitals, almost half of which are in Chişinău municipality, and accounting for over half of all
beds. National hospitals have 36% of all beds, and municipal and rayon hospitals account for 54% of beds. The private
Page 14 of 95
hospital sector is very small (1% of beds). There are continued reforms of the secondary services sector, to reduce
duplication, overlapping of services and oversupply of beds, particularly in Chisinau.
(g)
National Centre of Health Management (NCHM)
The NCHM is an entity accountable to the Ministry of Health, responsible for supporting establishment of the roles,
objectives and procedures of health service providers. In particular, it is responsible for analysis surveys/studies of
disease risk factors; maintaining and managing the national health statistical database; coordinating the collection,
processing and analysis of statistical information on population health and of the medico-sanitary institutions’ activity
results; and developing and implementing assessment systems for national health programmes (for example, HIV/ AIDS
and TB programmes).
(h)
National health insurance Company (NHIC)
The NHIC is an autonomous entity responsible for managing compulsory HIFs. The main tasks of the NHIC include:
establishing and managing the mandatory health insurance system (including applying the appropriate procedures and
mechanisms for creating financial funds to cover the health care costs, in accordance with the unique mandatory health
insurance programme), quality control of the health care provided, and implementing the regulatory framework for
mandatory health insurance.
1.4.3 Other sectors involved in communicable disease control
(a)
Ministry of Agriculture
Ministry of Agriculture’s responsibilities includes responsibility for animal health, zoonotic and vector-borne diseases. At
rayon and municipal level, investigation of zoonotic and foodborne diseases is conducted by epidemiologists in
conjunction with specialists from veterinary services.
(b)
Food Safety Agency (FSA)
The FSA has been recently established as an entity separate from the Ministry of Agriculture, reporting directly to
Government. It is responsible for ensuring safety throughout the food chain, ‘from farm to fork.’ The main
responsibilities of the FSA include animal health, control of zoonoses, and cooperation with the MoH on food safety.
(The MoH is responsible for the prevention of foodborne diseases, and for leading primary and secondary prevention
interventions, and epidemiological investigation of foodborne outbreaks.
(c)
Ministry of Environment
The Ministry of Environment is responsible for developing and promoting state policies in the area of environment
protection and relating to the rational use of natural resources, waste management, biodiversity conservation, geological
research, use and protection of underground sites, water and sanitation supply, and the regulation of nuclear and
radiological activities. The Ministry participates in planning and implementing measures for avoiding occurrence of
natural disasters (floods, droughts) and management of their consequences. Among other duties, the authority
regulates human activities relating to the environment, where these may impact on public health.
1.4.4 Communicable disease system workforce
(a)
Epidemiologists and support staff
Epidemiologists lead both communicable and non-communicable disease divisions or departments at national, municipal
and rayon levels. There are currently 140 epidemiologists including: 32 at the National Center for Public Health, 84 in 34
rayon Centers and two municipal Centers for Public Health (Chisinau, Balti), 11 in 4 departmental Centers for Preventive
Medicine (including ministries of Internal Affairs, and Defense), and 13 in hospitals.
Overall it is estimated that there are 3.2 epidemiologists per 100,000 population. At rayon/municipality level the
epidemiologist: population ratio is approximately 1:42,000.
Epidemiologists are medical graduates with two years specialist training. At present five to ten doctors enter the
specialist training programme each year.
Epidemiologists are responsible for the surveillance and control of communicable diseases in the rayon or municipality,
among other responsibilities (see chapter 2). They also administer and report on childhood immunisation programmes.
Epidemiologists have support staff who assist with administration of infectious disease reports and their investigation
and reporting. Epidemiologist assistants have two years of training after general lyceum study, following a special
curriculum in public health at two municipal colleges (in Chisinau and Balti).
(b)
Page 15 of 95
Public health microbiologists
Microbiologists are medical graduates with five years specialist training. Only laboratories at NCPH and in larger rayons
or municipalities are led by specialist microbiologists; most at rayon level are managed by microbiology technicians,
supported by NCPH microbiologists.
At present NCPH employs 12 microbiologists and 20 technical staff.
2
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Surveillance
2.1 Surveillance objectives, legislative framework
2.1.1 Overview
The objectives and development of the surveillance and control of communicable disease is set out in the principal Act
(below) and further elaborated through Government decisions, Ministerial orders, and the National Strategy on Public
Health for 2014-2020. Healthcare and public health staff are also supported through publications of guidelines and
indications.
2.1.2 Legislation and regulation
In the Republic of Moldova the surveillance of communicable, and non-communicable diseases is carried out and
regulated in accordance with Law No. 10-XVI (3 February 2009) on state surveillance of public health.
This “principal Act” sets out the general citizen rights and obligations of persons in Moldova, to public health in Moldova,
the basic goal and principles of state policy in public health, and principal activities of the state in pursuing these. It sets
out the content of public health surveillance, (as a broad activity also involving health promotion, disease prevention and
control programmes), and the competencies and powers of government, Ministry of Health, other central and local
government authorities.
In particular, the Law established and sets out the responsibilities powers and organisation of the State Public Health
Service (PHS), which is seen as an integrated set of entities from the Ministry of Health, including the Chief State
Sanitary Doctor of the Republic, to the National Centre for Public Health and Centres for Public health at municipal and
rayon level. It also authorises the establishment and principal functions of the state surveillance information system.
Other important primary legislation relating to communicable disease control includes legislation on health services, and
control of HIV/AIDS and tuberculosis (see Annex 3).
In relation to communicable disease prevention and control, the principal Act is supplemented by Government Decisions,
Minister of Health orders and decisions, and Guidelines (see Annex 3). The principal generic legislation includes:

Gov. Decision related to State Surveillance of Public Health nr. 384 (12 May 2010);10

Gov. Decision on approving Regulation related national surveillance and control of communicable diseases and
public health events nr. 951 (25.December 2013);11

Order No. 368 (13 December 2004): submission to the Ministry of Health of urgent and mandatory information
on emergencies and natural disasters;

Order of the Ministry of Health No. 171 (20 June 1990): on improving the record system of certain infectious
and parasitic diseases in the Republic of Moldova;

Order No. 385 (12 October 2007): approving case definitions for surveillance, and reporting of communicable
diseases in the Republic of Moldova;

Order of the Ministry of Health No. 13 (11 January 2011): approving the notification form (emergency
notification data sheet) on reporting case identification of communicable diseases, poisoning, foodborne
diseases, occupational acute poisoning, and/or side-effects after administration of immunobiologic products.
This primary legislation is further enacted through Ministry of Health orders covering mandatory notification of defined
diseases and public health events, including outbreaks (2004), the introduction of national case definitions (2007),
development of the public health laboratory surveillance network (2013) and national surveillance and control of
communicable diseases and public health events (2013)12. Data exchange between the veterinary service and public
health surveillance is also underpinned by regulation (see Annex 3).
10
http://lex.justice.md/index.php?action=view&view=doc&lang=1&id=334620
12
MoH order on approving of case definition for diagnosis, recording and reporting of communicable diseases in the Republic of
Moldova nr. 385 from 12.10.2007
MoH order regarding the implementation of the Programme for development of state surveillance public health Laboratory Network in
RM nr.668 from 10.06.2013
11
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2.1.3 Guidelines and protocols
Below the level of legislation and regulation there is a substantial programme of protocols and guidance developed
directly by NPHC. Protocols and guidance for clinical case management are in place for several notifiable diseases (e.g.
salmonellosis, cryptosporiosis, echinococcus, hepatitis B, rotavirus infection in children, nosocomial infections,
investigation of HIV/AIDS, microbiological investigation of campylobacteriosis, among others). These are often extensive,
although concentrating primarily on clinical management.
Guidelines for epidemiologists have also been developed for specific diseases (e.g. influenza, HIV/AIDS, hepatitis,
rotavirus infection, cholera, tularemia, Annex 3).
2.1.4 National Strategies
The National Strategy on Public Health 2014-2013 sets out the context of public health issues in terms of
population health status, principal causes of morbidity and mortality, and their risk factors. It also outlines the various
organisations responsible for collaborating on implementing the strategy, across health promotion, health protection and
primary and secondary disease prevention. It also sets out key issues relating to public health workforce, and research
Communicable diseases are addressed in the Strategy along with non-communicable diseases and the same key
strategies identified, including; an improved legal framework, sustainable financing, cross-sector collaboration,
strengthening PHS capacities and knowledge and practices of health workers, and promotion of early detection through
strengthened national surveillance systems. Vaccine preventable and nosocomial diseases are specifically identified.
In relation to communicable diseases and public health events, the Action Plan for 2014 -15 includes objectives
related to communicable disease surveillance, epidemic intelligence and early detection and response, preparedness for
public health emergencies (see chapter 4) and strengthening laboratory capacities (see chapter 3).
2.2 Identification and reporting of diseases under surveillance
2.2.1 Diseases, syndromes and health events subject to mandatory reporting
There are presently 72 infectious diseases and syndromes that are mandatory to be reported by healthcare staff in
Moldova. In addition six health problems are reportable (e.g. nosocomial infection, antibiotic resistance) (see Annex 4).
It is also required to report a number of other events, including outbreaks, natural disasters, chemical or radiological
incidents.
2.2.2 Reporters
All health care workers are required to report suspected or confirmed cases of disease or events specified in the
notifiable disease list. Events potentially reportable under the International Health Regulations, 2005 (IHR) must be
reported to the IHR focal point14.
2.2.3 Diagnostic confirmation
Cases are referred for laboratory investigation according to clinical judgement, supported by protocols and guidance
covering several of the commonly occurring and/or important communicable diseases and syndromes (as above)15.
Cases notified initially on suspicion and expected are confirmed through laboratory investigation.
2.2.4 Reporting
Cases of infectious diseases are reported by the primary, emergency, and specialised (infectious diseases doctors)
healthcare, and hospitals (in case of nosocomial infections) to the regional epidemiologists at the territorial Public Health
Centres (PHC).
Doctors report according to one of the notifiable diseases or syndromes, and assign an International Classification of
Disease (ICD-10) code to the case; this applies to both confirmed and unconfirmed (suspected) cases. Paper reports use
form 058/e; a two sided A4 size form which also provides for extensive clinical information through tick boxes on the
reverse side; much of this latter information is optional and often only partially completed (Annex 5).
13
Gov. Decision on approving Strategy on Public Health for period 2014-2020, 20.12.2013, Nr.1032, M.O. nr. 304-310, art nr.1139 din
27.12.2013
14
IHR National Focal Point in accordance with MoH order regarding implementation of Gov. Decision nr. 475 from 26.03.2008 on
approving Action Plan for IHR implementation in the Republic of Moldova nr.268 from 06.08. 2009
15
In accordance with MoH order regarding the implementation of the Programme for development of state surveillance public health
Laboratory Network in RM nr.668 from 10.06.2013 http://www.cnsp.md/down/info1371468083ro.pdf, is mentioned the level of
different public health laboratories core capacities and commences for confirmation
Page 18 of 95
2.2.5 Electronic reporting system
This paper reporting has been supplemented, since 2010, by a dedicated electronic system for communicable disease
reporting (System on Epidemiological Alerts). This system is a dedicated stand-alone reporting system (electronic patient
records are not yet developed in Moldova). The system is however linked to demographic and health care worker
registers. The electronic system appears generally user friendly and well accepted by the healthcare staff sending the
reports – it is understood there was initial resistance from some doctors which has largely settled. Microbiology staff
enters laboratory test data directly into the system.
The system is now entering a second phase of development, supported by World Bank funds, increasing its technical
capabilities and its extension to medical practices is continuing. However, it has not been mandated by regulation as a
sole form of reporting, and even where it is available, doctors must also report using the traditional paper system.
Where medical practices do not have access to the system, or even to the internet, PHC staff may offer services to
support the reporting process.
2.3 Data processing, analysis by the Public Health Centres
2.3.1 Receipt of reports
Reports on communicable cases are received by the rayon (territorial) epidemiologists at the Public Health Centres
(PHC) by two modalities, as above: paper forms and the electronic reporting system (SAE). Some urgent reporting is
also done by telephone.
The electronic system is generally preferred by PHC staff. Epidemiologists and designated staff have access in real time
to cases reported by doctors, and to confirmatory test data entered by laboratories. The national ID number is used as
the common identifier linking the medical and laboratory reports.
Paper reports are also received, checked against the electronic data if applicable, and filed. If there is only a paper
report, PHC staff enters the data into the SAE.
2.3.2 Case classification
Regional Epidemiologists at the rayon centres for Public Health (CPH) review the reported cases on a daily basis, and
make operational decisions re follow-up and further investigation that may be necessary. On a daily basis the
epidemiologists classify the cases (reported by doctors as ICD-10 codes) according to the national system of surveillance
case classification16, as possible, probable and confirmed. Although official reports tabulate data according to reportable
entity and ICD-10 code, only cases that are confirmed through this process by local epidemiologists are included in the
tables.
The national surveillance case classification system was first developed in 2006, following the WHO system review
recommendations in 2001, and revised in 2007, to align more closely with case definitions for reporting to EU level.
There are no written procedures or protocols for PHC epidemiologists covering this process of classification of cases for
surveillance purposes (beyond the end result expressed in the case classification per se), and approaches taken by local
epidemiologists to this process appear to vary. This variation appears more marked for some syndromes, e.g. ILI, SARI.
2.3.3 Data analysis
(a)
Rayon level
At rayon level epidemiologists and staff produce weekly and monthly standard summary reports (Form 2) of the number
of confirmed cases received, together with incidence rates by disease, age group and locality (based on population data
provided by central statistical authorities17).
Standard weekly reports including trend analyses are produced for major groups of diseases and syndromes (e.g. acute
diarrhoeal diseases), and (e.g. diarrhoea disease, acute respiratory disease) and seasonal reports are produced for
influenza monitoring (ILI, ARI, SARI syndromes). Routine reports of immunisation coverage are also produced.
Beyond these standard reports there is little additional or ad hoc analysis by rayon epidemiologists. Data export for
analysis is not well supported by the SAE, and analytical skills of rayon epidemiologists and support staff are not
apparently well developed. Data reported for most cases is limited or variably complete and additional data collection is
not usually undertaken.
16
MoH order on approving of case definition for diagnosis, recording and reporting of communicable diseases in the Republic of
Moldova, 12.10.2007, nr. 385
17
Statistical evidence Form no. 2 “Statistical report on communicable and parasitic diseases”.
Page 19 of 95
Outbreak reporting and investigation are outlined below (see 2.5).
(b)
National level
Epidemiologists and designated analytical staff at the National PHC have access to anonymised individual case reports in
the SAE. Both routine and specific analyses are carried out based primarily on cases validated as confirmed by rayon
epidemiologists – routine statistical reports are based on cases confirmed according to the national case classification
scheme..
The SAE generates standard reports for weekly and monthly reporting of numbers and incidence of confirmed cases of
diseases and syndromes subject to mandatory reporting. These regular analyses are produced by disease, age group
and rayon and locality. Standard denominators are used, derived from census data and projections.
Analyses of incidence trend are carried out for each of the major reportable diseases, on at least a yearly basis, and
published in the Annual Report18. These are usually descriptive trend analyses over recent years, with some breakdown
of demographic data as appears pertinent to the situation; accompanied by a short descriptive text.
Routine descriptive analyses of risk factors are also periodically undertaken, where data is available for particular
diseases (e.g. TB, HIV, Hepatitis B and C, etc). Immunisation uptake standard analyses are completed regularly.
Beyond these routine and annual standard analyses, there is limited analytical analysis or applied research undertaken,
either by NPHC or in association with academic institutions. The NPHC neither publishes frequently in refereed journals,
nor commissions projects from or with academic partners.
The epidemiological analytical team at NPHC is small, and guiding the further development of the electronic reporting
system is a substantial burden.
2.4 Reporting and feedback
2.4.1 Rayon level
At local level the routine surveillance reports on notifiable diseases, diarrhoeal and influenza syndromes are made
available to primary healthcare and hospitals, and other local stakeholders, on a weekly and monthly basis. These are
primarily statistical tables with little or no interpretive text comment. Brief information related to local outbreak(s) are
included if relevant.
An annual report is also produced, which is sent to local hospitals and health centres, and some rayons publish on their
websites22.
2.4.2 National level
The NPHC circulates the weekly and monthly reports on reportable disease frequency and incidence, syndromic
diarrhoeal and sentinel influenza and rotavirus surveillance, as described above, to the Ministry, specialist staff from
PHCs and healthcare workers19.
NHPC also provides reports on epidemic intelligence and national outbreaks to the Ministry on a weekly basis, and more
frequently if required (see below).
An Annual Report is produced, as described above, and published both in hardcopy and on the Ministry website. It is
distributed to data providers and stakeholders as described above.
Other means of communicating with stakeholders include scientific meetings 20, inter-sectoral governmental meetings,
national conferences, and professional fora21.
2.5 Outbreak recognition, management, investigation and
reporting
2.5.1 Overview
Outbreaks are defined in MoH documentation as a situation when diseases or health events occur at a greater frequency
than normally expected in a period of time and place. In practice, at both rayon and local level, two or more linked
cases constitute a potential outbreak, for management and reporting purposes.
18
SUPRAVEGHEREA DE STAT A SĂNĂTĂŢII PUBLICE ÎN REPUBLICA MOLDOVA (RAPORT NAȚIONAL), Minitsry of Health, 2014.
http://cnsp.md/submeniu.php?id1=37&id2=0
20
http://cnsp.md/submeniu.php?id1=50&id2=0
21
http://ms.gov.md/?q=colegiul-ministerului
http://www.gov.md/libview.php?l=ro&id=6459&idc=436
19
Page 20 of 95
Thirty-three outbreaks were reported in 2013, 32 with diarrhoeal disease (503 cases) and one measles outbreak (27
cases).
2.5.2 Outbreak detection
(a)
Local level
At local level primary care and hospital doctors are expected to notify the rayon epidemiologist(s) if they suspect an
outbreak – that they are seeing more cases than expected. Microbiologists also report suspected outbreaks through
changes in pattern of laboratory requests received and identifications made. Finally, managers of institutions such as
(schools, preschools, workplaces, long term care centres) are also expected to report if they suspect an outbreak
(through absenteeism, etc).
Rayon epidemiologists report suspected outbreaks on a prescribed form, or through the outbreak/event reporting facility
on the SAE. In some urgent situations NPHC may be informed directly by healthcare staff regarding an outbreak or case
with a high public health risk.
(b)
National level
At national level, NPHC epidemiologists may also become aware of outbreaks through two additional sources:
(i)
Epidemic intelligence
This is in an early stage of development at NPHC; staff review national and internal media reports, and global
epidemic intelligence websites, on a daily basis. Events within country are followed up for assessment and
verification by rayon epidemiologists on request from NPHC;
(ii)
Early warning system component of SAE
In addition to a general outbreak/event reporting facility, the SAE has a component where the indicator
(individual case based) surveillance reports are reviewed automatically on a daily basis for the presence of
potential clusters of cases. These clusters are identified according to criteria set by the epidemiological system
managers (e.g. x cases of disease X within a given locality within x days).
Aberration detection software is not deployed (e.g. EARS). Flags are reviewed daily by NPHC epidemiologists
and referred as necessary to rayon epidemiologists for follow-up and verification.
2.5.3 Outbreak management, including investigation
(a)
Rayon level
Routine local outbreaks are managed or supervised by rayon epidemiologists, in conjunction with sanitary, veterinary
and/or food safety inspectors as required by the situation, and with active involvement of health care staff as needed.
Most outbreaks are of diarrhoeal disease, and investigation usually includes substantial microbiological investigation of
affected persons, food and environment. Associated epidemiological investigation is usually limited to interviews of
cases, identification of linked cases, and simple descriptive analysis.
The cause of the outbreak is assigned by the epidemiologist, on the basis of microbiological findings (if positive) or of
‘experience.’ Some outbreaks are classified as of source unknown. Analytical epidemiological investigation methods (e.g.
case control or cohort studies) are rarely employed; epidemic curves are not routine.
(b)
Larger outbreaks and events/outbreaks of high public health risk
In these cases, rayon epidemiologists are supported by teams from NPHC, who go out to the rayon to assist with the
investigation and management of the situation. Such teams are multidisciplinary, usually of 4-6 persons, and are
deployed on request of the rayon or NPHC initiative. In 2013 such teams were deployed from Chisinau on twelve
occasions.
2.5.4 Reporting of outbreaks
Rayon epidemiologists file ‘closure’ reports on outbreaks once management and investigation is complete, either on SRE
or prescribed paper forms. Reports on the outbreak occurrence and progress may be included as appropriate in local
and national weekly reports.
NPHC prepares a summary of outbreaks formally reported during the year but this is not formally published as defined
section of the Annual Report; indications of outbreak activity are given in relevant parts of the Report.
2.5.6 Incident reviews
Outbreak report ‘closure forms’ are routinely forwarded to and reviewed at national level. Incident reviews, including
outbreak management, are not routinely conducted at either rayon or national level.
Page 21 of 95
2.6 Data protection, data access
2.6.1 Overview
The protection of personal health data, including information concerning notifiable infectious diseases, is provided for in
national law and regulation. All staff employed in healthcare and rayon and national level PHCs are made aware of their
responsibilities as part of employment.
2.6.2 Access to personally identifiable information
The personal identity of reported notifiable disease cases is (with some exceptions) generally confined to staff at rayon
level. Staff at rayon PHCs is required to protect the identity of cases reported. However few specific organisational
procedures to restrict the number of staff who could see or access reports appear to be in place, particularly for
diseases with potentially stigmatic associations (e.g. STIs, hepatitis, TB).
National level staff generally has access only to anonymised cases (identified by national number, and by
epidemiological (event/episode) number generated by the system). Within the SAE, considerable attention has been
given to the protection of personal data, and the designated staff entitled to use the system has access only to relevant
cases within their jurisdiction or area of reporting responsibility. This system of levels of access is administered and
monitored by SAE epidemiologist administrators at NPHC.
2.6.3 Risk of deductive disclosure
Deductive disclosure remains a significant risk, particularly (but not exclusively) at rayon level. While transparency of
reporting is valued, reporting of individual cases within a locality and restricted time period can make the affected
individuals vulnerable to deductive disclosure.
2.6.4 Special situations
There are some exceptions to this general data protection infrastructure. TB cases are still required to be reported by
name to the Minister of Health. HIV and AIDS cases are reported to a national registry at the Hospital of Dermatology
and Communicable Diseases.
2.7 Parallel Disease specific surveillance systems
2.7.1 Overview
Surveillance of a number of diseases of public health importance is administered in parallel to the main surveillance
system, particularly with respect to initial case reporting and data administration and analysis. These include, in
particular, tuberculosis, HIV and AIDS, and sexually transmitted infections (STI).
2.7.2 Sexually Transmitted Infections
Programme governance, plan/strategy, priorities, and objectives
The national STI programme and STI surveillance is part of the National Program for HIV/AIDS and STIs Prevention and
Control that is co-ordinated as of 2012 by the Hospital of Dermatology and Communicable Diseases. STI screening,
diagnostic testing, treatment and prevention services are provided at various clinical sites, but primarily by dermatovenereology (DV) services.
The surveillance system consists of the disaggregated reporting of cases of syphilis gonorrhoea and chlamydia by DV
services, the monitoring of syphilis prevalence in pregnant women, and STI prevalence assessment through integrated
bio-behavioural surveillance surveys (IBBS) in key populations22.
STI case reporting
The main source of STI case report data is outpatient DV services, which operate in each rayon/municipality as part of
the district hospital, and in Chisinau as a part of the Municipal DV Centre. Patents both self-refer and are referred from
general practitioners. DV services report cases of syphilis, gonorrhoea and chlamydia using individual-level electronic
and paper-based forms, on a monthly basis to both the National Centre of Public Health (NCPH) and the Hospital of
Dermatology and Communicable Diseases.
STI cases are also reported from six departments that operate outside of the health care sector (e.g. the Ministry of
Interior, Justice, Defence, Civil Aviation) and report on an annual basis to NCPH. DV services also carry out regulatory
22
Female sex workers [FSW], people who inject drugs [PWID], men who have sex with men [MSM]), prisoners.
Page 22 of 95
screening programmes of employees involved in various defined occupations involving contact with children (including
doctors). A significant minority of STIs are diagnosed in this way.
Cases of syphilis are largely treated by dermato-venereologists, although an unknown proportion of patients are thought
to consult private physicians. Patients diagnosed with gonococcal infection can also be treated outside of the DV
services, predominantly by gynaecologists and urologists; case notification forms for patients with gonococcal infection
are required to be sent to DV specialists who report them to the National Centre for STIs and NCPH.
Reporting is mainly name-based, though it can also be done anonymously using a system of unified codes. It was stated
during a visit to the Municipal Centre for Dermato-Venereology in Chisinau that approximately 80% of their STI case
report forms are assigned such codes instead of names.
2.7.3 HIV and AIDS
(a)
Overview
HIV surveillance is part of the National Program for HIV/AIDS and STIs Prevention and Control (NAP) that since 2012 is
co-ordinated by the Hospital of Dermatology and Communicable Diseases. Previously, HIV surveillance system was coordinated by NCPH. The National AIDS Programme is implemented through the National Programme on Prevention and
Control of HIV/AIDS and STI for 2011–201523. Implementation of the NAP is coordinated by the National Coordination
Council for HIV and TB, an inter-ministerial and inter-sectoral decision-making body.
(b)
Reporting and surveillance
HIV surveillance in Moldova consists of HIV case reporting, reporting of AIDS deaths, integrated HIV bio-behavioural
surveys (IBBS), population size estimates and HIV testing data.
Reporting of HIV cases is through a system parallel to the main surveillance system. Infectious disease clinicians (since
2012) send completed HIV case report forms from the local level direct to the National AIDS Programme based at the
Hospital for Dermatology and Communicable Diseases (HDCD).
During 2013, data on the mode of HIV transmission were reported for approximately 44% of 706 reported HIV cases. In
the previous years, completeness of mode of transmission data was reportedly much higher. Approximately 70% of
newly diagnosed HIV patients have CD4 count testing; however no data on CD4 counts in newly diagnosed HIV cases
were found in the reports that describe the HIV epidemic in Moldova.
2.7.4 Tuberculosis
TB is a public health priority in Moldova, with a reported incidence of pulmonary TB of 86/100,000 in 2013. The trends
in TB notification rates in the Republic of Moldova have not significantly decreased in the last five years; late diagnosed
cases are frequent. The Republic of Moldova has one of the highest documented levels of multi-drug resistant TB (MDRTB) in the world; around one third of newly diagnosed TB patients two thirds of those returning for treatment have
MDR-TB. Co-infection with HIV is frequent, and cases of nosocomial infection occur, including among hospital staff.
Moldova has a strategic plan for Tuberculosis and is supported by a number of global partners, particularly the Global
Fund. It is supervised by the national Coordination Board for TB and HIV programmes, and the Ministry. The programme
was reviewed by WHO Europe in 2013.
TB surveillance is administered separately from the main communicable disease surveillance system as a parallel system.
Surveillance is based on a combination of passive case finding (symptomatic patients seeking medical care) and active
case finding through extensive fluorography screening programmes. Symptomatic cases are reported by doctors direct
to the National TB programme based at the National Tuberculosis Institute “Chiril Draganiuc” (NIPP). Most notifications
come from district TB services in rayons and municipalities, including the municipal TB hospital in Chisinau.
Most cases are diagnosed or confirmed at the National Reference Laboratory at NIPP. Notifications included more
detailed information than in the general surveillance system; the TB programme maintains a detailed computerised
database of cases, and reports periodically to the Ministry, National Coordination Board, and NCPH (statistics).
2.7.5 Healthcare associated infection, antimicrobial resistance and antimicrobial
usage
Each hospital is required to have an operational plan for the surveillance and control of nosocomial infections developed
in accordance with the national plan approved by the Ministry of Health. National guidelines for surveillance and control
of nosocomial infections – including a section on protecting the health of care workers – have been developed and are in
the process of being implemented. Hospitals have certain facilities for isolation of infectious patients in accordance with
national standards and National Clinical Protocols.
23
Approved by the Government of the Republic of Moldova in 2010
Page 23 of 95
Hospital epidemiologists, where available, are responsible for carrying out investigations, data analysis and reporting of
nosocomial cases and outbreaks according to the standard protocols of the rayon/municipal Centre of Public Health.
Data related to nosocomial and principal surgical infections is reported to the rayon CPH, and aggregated at the
national level.
No community and hospital surveillance systems for antibiotic resistance and antibiotic usage are in place. A monitoring
system for antibiotic resistance was set up in limited number of hospitals. At the national level, for scientific research
purposes, aggregated data regarding drug-resistant pathogens in hospitals are collected. Neither national coordinated
surveillance nor national data are available.
2.8 Other surveillance systems
(a)
Immunisation surveillance
Surveillance of childhood schedule vaccine uptake is undertaken on an ongoing basis, with birth cohorts for resident
children as denominators. There have been no sero-epidemiology surveys in recent years to corroborate apparent
community immunisation levels. Cases of measles are rare, one outbreak was reported in 2012 (see above).
(b)
Sentinel surveillance systems
A number of sentinel systems are in operation, including surveillance of influenza and acute respiratory infection
syndromes, rotavirus infection, and pneumonia in children under 5 years of age24.
(c)
Syndromic surveillance systems
Apart from two of the sentinel systems above, no syndromic surveillance systems 25 are used in the Republic of Moldova.
(d)
Surveillance of special groups
A number of surveillance and screening systems are in operation, which were not specifically assessed during this
review. These include screening procedures for systems for particular occupational groups, returning travellers,
migrants, refugees, prisoners.
(e)
Military, Police
The Military and Police have their own healthcare and infectious disease systems. However aggregate data is submitted
monthly to NCPH. These systems were not assessed during the present review.
2.9 System sensitivity and specificity
2.9.1 Sensitivity
Sensitivity is a critical quality aspect for any surveillance system. Surveillance system sensitivity is defined as the
proportion of actually occurring cases of infection that are known to the surveillance system (WHO 2006). As such, it is a
function of the completeness of both ascertainment and reporting of cases26.
2.9.2 Apparent relative surveillance system sensitivity in Moldova
24
Sentinel surveillance ILI, ARI, SARI (MoH order on the improvement of surveillance system for influenza and acute respiratory
infections nr.824 from 31.10.2011, http://ms.gov.md/legislatie?field_legtip_tid=16&=Caut%C4%83, sentinel surveillance on rotavirus
infection (MoH order nr. 252 from 20.06.2008 on the implementation of sentinel surveillance for rotavirus infection in the Republic of
Moldova, and MoH order 1238 from 07.12.2012 on the assessment of the impact the introduction of rotavirus vaccine, sentinel
surveillance on pneumonia (MoH order regarding epidemiological sentinel surveillance of community acquired pneumonia in children
under 5 years MoH order nr.1190 from 23.10.2013,
http://ms.gov.md/sites/default/files/legislatie/ord._1190_din_23.10.3_supravegherea_epidem._pneumonii_comunitare.pdf
25
E.g. surveillance of defined syndromes in medical emergency care departments, surveillance of relevant ‘over the counter’ pharmacy
drug sales, etc
26
Ascertainment relates to the proportion of actually occurring cases of infection in the country that are actually recognised and
diagnosed by the health care system. There is no expectation for most diseases that ascertainment will approach 100%; for most
diseases the proportion if cases recognised will be much lower, but for surveillance and public health purposes, it is important that the
level of ascertainment be adequate for the public health purposes relevant to that disease (or disease group) and that it be reasonably
consistent over time.
Reporting refers to the communication of the information re a diagnosed case to the country’s surveillance system; there is no reason
in principle why this should not be 100%, and this is the de facto standard.
Page 24 of 95
Table 4 compares the outputs from the Moldova surveillance system - in terms of the annual incidence of cases reported
through it - with the median equivalent outputs from EU member states. Such comparisons do not of themselves
indicate a sensitivity issue for the surveillance system, but, where large differences exist, it poses an apriori question for
consideration by country leaders as to why it should be so.
From the table it appears that the traditionally well recognised public health problems of TB, HIV, salmonellosis and
shigellosis, VTEC/STEC, gonorrhoea and syphilis, are reported by the Moldova system at rates considerably exceeding
the EU median, suggesting both the substantial dimensions of the actual public health problem, and the probable
effectiveness of the systems for their recognition and reporting
However, other diseases, recognised as public health issues in a European context, are reported by the system much
less frequently than in EU member states; e.g. Campylobacteriosis, Yersiniosis, Hepatitis A; legionellosis; Chlamydia;
invasive H.influenzae and S.pneumoniae infections. While it is theoretically possible that the actually incidence of these
diseases is lower than in EU member states, the level of disparity suggests the presence of ascertainment and/or
reporting issues that require further investigation.
A number of diseases, which are required to be reported to EU level by Member States, have not been reported in the
Republic during 2011-2013. These include (in decreasing order of frequency of reporting in the EU): campylobacteriosis,
measles, legionnaires disease, listeriosis, brucellosis, West Nile virus infection, viral haemorrhagic fever (including CCHF)
(see also chapter 3, microbiology). While in some cases this may reflect the true situation, in others failure of
ascertainment and/or reporting is likely. For some diseases, it is noted that laboratory access and capacities is limited.
Some of these relatively uncommon diseases are important from a public health perspective, either because of the
potential severity of the infection (e.g. listeriosis, meningococcal disease), or their epidemic potential (e.g. measles,
legionellosis, WNV infection). Some indicate potentially significant interactions with animal and occupational health (e.g.
yersiniosis, brucellosis); others are emerging diseases in the South-East European region (e.g. WNV infection). Others
are subject to elimination targets (e.g. measles). For these various reasons it is important to establish with reasonable
certainty that these ‘zero reports’ reflect the true epidemiological situation, rather than the failure of health services to
identify cases.
2.10 System coordination and integration
2.10.1 Coordination between national communicable disease systems
As above, TB, HIV/AIDS, STI surveillance systems are administered independently of the main surveillance system.
There is no data linkage between these systems, and each other or the general surveillance system.
There are no or infrequent liaison meetings between epidemiologists administering these different systems. One
consequence of the present arrangement is the effective exclusion of rayon epidemiologists from timely information
about local epidemiology of these diseases (limited to annual high level reports from the respective agencies).
2.10.2 Coordination with other relevant national surveillance and information
systems
There is no data linkage between databases for human and veterinary infectious disease surveillance 27, or with
surveillance of the new Food Safety Authority. In the case of a public health event originated by zoonotic diseases, the
veterinary service reports data through an electronic surveillance system for animal traceability, which was developed to
automatically exchange data with the public health electronic surveillance system; this exchange of information is no
longer working.
There is infrequent liaison, between system leaders at NCPH and at the Ministry of Agriculture (veterinary health), and
the Food Safety Authority.
27
Although this is provided for by regulation
Page 25 of 95
Table 4 - Reported confirmed disease rates from surveillance systems, for selected diseases, Republic of Moldova,
compared with EU/EEA Member States (mean crude rate), 2012
(Diseases reported at less than the 25% percentile reported rate for EU countries are indicated in red).
Disease
Moldova no
reported cases
2012
Moldova rate
confirmed cases
2012
EU Member States
median rate:
reported confirmed
cases /100,000
2012
Tuberculosis
90.6
13.5
Legionellosis
0.0
1.1
Botulism
0.1
0.01
Brucellosis
0.0
0.08
Campylobacteriosis
0.0
68.3
Cryptosporidiosis
1.8
3.1
Giardiasis
6.2
5.4
-
0.2
Hepatitis A
0.1
2.6
Leptospirosis
0.1
0.1
Listeriosis
0.0
0.4
Salmonellosis
34.3
21.9
Shigellosis
13.3
1.6
Toxoplasmosis (congenital)
0.0
1.5
Trichinellosis
0.0
0.1
Tularaemia
0.0
0.2
Typhoid/paratyphoid fever
0.1
0.3
VTEC/STEC
6.4
1.5
Yersiniosis
0.0
2.0
Chlamydia
0.2
177.1
Gonorrhoea
32.6
9.3**
Hepatitis B
1.6
3.3**
Hepatitis C
1.9
7.4**
HIV
13.8
5.7
AIDS
4.4
2.2
Syphilis
63.1
3.6**
Respiratory diseases
Food and waterborne diseases
Echinococcus
Sexually transmitted and blood-borne diseases
Emerging and vector-borne diseases
Page 26 of 95
Dengue
-
0.3
Hantavirus infections
-
1.0
Malaria
0.8
0.9
Q fever
0.1
0.2
Tick-borne encephalitis
0.1
0.5
West Nile Virus infection
0.0
0.1
Invasive haemophilus influenzae
0.0
0.36
Invasive meningococcal disease
0.2
6.40
Invasive pneumococcal disease
0.0
3.63
Measles
0.3
2.2*
Mumps
3.4
2.9*
Pertussis
2.1
10.9*
Rubella
0.1
7.9*
Vaccine preventable diseases
*total reported cases
**2011 data
“0.0” zero reported cases; “-“ no report.
2.11 International reporting and potential for case reporting to
EU level
Communicable disease statistics are supplied annually, on an aggregate basis, to WHO (CISID and EUROFLU). Detailed
anonymised TB case reports are made to WHO on an agreed basis with ECDC. Detailed anonymised case reports for HIV
and AIDS are made direct to ECDC (TESSy).
Reporting to WHO under the International Health regulations are made as required and self-assessment system reports
have been submitted annually according to WHO requirements.
2.12 System monitoring and evaluation
2.12.1 Previous evaluations or reviews
(a)
International organisations
An holistic assessment of the Republic of Moldova surveillance system was completed by WHO in 2001 28. A selfassessment of public health functions in Moldova was completed in association with WHO in 201029.
WHO Europe completed a review of the STD programme, in 2013 (and again, in association with the present review, in
2014). WHO also reviewed the national TB programme in 201330.
(b)
Internal reviews
The Ministry of Health conducted an internal review of legislation compatibility with the EU acquis, in 2013. Otherwise
there have been no internal evaluations of the surveillance and response system in the Republic of Moldova.
28
WHO, Regional Office for Europe. Assessment of the National Surveillance System for Infectious Diseases Republic of Moldova 19-31
March 2001. WHO, 2002
29
WHO, Regional Office forb Europe. Analysis of Public Health Operations, Services and Activities in the Republic of Moldova. WHO,
2012.
30
WHO, Regional Office for Europe. Review of the National Tuberculosis Programme in the Republic of Moldova. WHO, 2013.
Page 27 of 95
2.12.2 System sensitivity and data validity
There have been no internal evaluations or reviews of the sensitivity of the surveillance systems, at a generic level. At a
disease specific level, attempts to estimate true population size and system sensitivity have been undertaken under the
HIV and STI programmes.
2.12.3 Internal data completeness and validity
As described above, there is routine daily activity by rayon epidemiologists and staff checking the accuracy of case data,
referring back to the doctors if necessary, as part of the surveillance case classification process.
There is no regular monitoring of the completeness or timeliness of data supplied, at either rayon or national level,
although this could be built into the operating specifications of the SAE.
2.12.4 Representativeness
There have been no evaluations of the representativeness of the general surveillance system. Studies of reporting
among risk groups are an integral part of the HIV and STI programmes.
Page 28 of 95
SURVEILLANCE AND OUTBREAKS: STRENGTHS AND WEAKNESSES
COMPONENT S1:
LEGISLATIVE AND REGULATORY FRAMEWORK
Strengths
Nationally distributed and regulated passive surveillance system
There is a national distributed passive surveillance system, with a clear and comprehensive legislative and regulatory
framework, generally well accepted by both healthcare staff and public and generally good compliance with reporting.
Strategic planning
There are clear strategic plans for further development of the surveillance system in the context of overall public health
development planning
Outbreak reporting and response
There are clear responsibilities and requirements for outbreak reporting, available 24/7 at local and national levels, with
local PHS responses supported as required by a defined NPHS team
WEAKNESS
RECOMMENDATION
S1.1 Surveillance objectives and priorities
Although there are clear overall objectives for the
effect of the systems for surveillance prevention and
control of communicable diseases, there are no
specific objectives related to the surveillance system
(exceptions include some specific surveillance
requirements for specific programmes, e.g. TB, HIV);
Although prioritisation work has been completed for
communicable diseases, this does not appear to have
been integrated into policy and practice for the
epidemiology services; most diseases are subject to the
same reporting procedures, and there is little particular
attention to the ‘priority diseases’ in the design of or
priorities given to surveillance or control operations at
local level
The notifiable disease list includes diseases and
syndromes of limited public health value:
overwhelming the reporting system, diluting
commitment of primary care doctors to reporting, and
obscuring public health priorities
The prioritisation of communicable diseases should be
reviewed, with a view to integrating attention to priority
diseases at all levels:

national policy development and planning of
preventive programmes and strategies;

(further) development of national strategies
for priority diseases where this is required or
none exist, in collaboration as needed with
veterinary and food safety sectors (e.g. food
and waterborne diseases, vector-borne
diseases, antimicrobial resistance)

design and adjustment of reporting
requirements, and development of analytical
capacities and processes, to meet the needs of
these programmes and strategies;

integration into work processes and practices
at rayon PHC level;

focused training and continuing professional
development on the public health
management of these priority diseases for
public health and healthcare staff
The diseases subject to mandatory reporting should be
critically reviewed, with deletion of diseases and
syndromes which cannot be shown to have sufficient
value for public health purposes to justify mandatory
individual case reporting ;
Consideration should be given specifically to:

the specific surveillance needs and priorities of
the various national disease programmes, and
adapting information to be reported
accordingly
Page 29 of 95

making some diseases/syndromes subject to
reporting only on a periodic aggregate basis;

reducing the amount of clinical information
requested on standard reports
S1.2 Parallel surveillance systems:
Parallel surveillance systems for HIV, STI, TB can
create inefficiencies and/or reduced effectiveness;
through either double reporting, or lack of timely
communication of information (case or aggregate
based as appropriate) to epidemiologists and others
involved in leading or supporting the planning and
implementation of prevention and care programmes, at
both national and rayon level
The integration of these systems into the overall
surveillance system should be actively considered, with
particular reference to:

advantages related to efficiency and quality of
system administration;

improvement in data and communication
linkages between the relevant clinicians and
epidemiologists and staff at both rayon and
national levels, for the purposes of
development of prevention programmes as
well as case and contact management;

particular requirements related to personal
data protection which may be needed for
these disease cases
(For individual diseases, refer component S4)
S1.3 Liaison with veterinary and food safety
systems
There is inadequate liaison and information exchange
between public health and veterinary and food safety
services at both local and national levels - only rabies
cases , or outbreak situations , are subject to adequate
communication with the veterinary services
Formal agreements arrangements should be established
between public health and veterinary and food safety
services covering:

Regular liaison

Regular exchange of surveillance information
and reports

Operating procedures and protocols related to
infectious disease events and outbreaks (see
also ch. 4)

Exploration of potential objectives and content
of potential data linkages
S1.4 Personal data protection
Personal data protection is well regulated, and
understood by individual staff; however there are few
operational processes and procedures at rayon PHC
level to restrict access to case reports to those
handling them or following up the cases;
For some diseases individual named data is transmitted
to national level;
Rayon PHCs should have policies and procedures for
limiting exposure of individual case reports to the
minimum number of staff;
Only anonymised (coded) data should be held at
national level, including personal data related to TB
cases
Publication of statistical reports and maps including
single cases can risk deductive disclosure of the
individuals concerned, particularly for frequent local
level and date specified reports.
Page 30 of 95
Processes should be established for giving avoiding
deductive disclosure of individuals suffering particular
infections, particularly related to regular reports at
district level;
Public health staff (national and rayon level) should
receive training related to deductive disclosure
Page 31 of 95
COMPONENT S2:
SURVEILLANCE INFORMATION SYSTEMS
Strengths
National surveillance case classification system
A well-established31 national case classification system, coherent with EU reporting requirements 32 is applied to cases at
local level by epidemiologists and support staff.
Electronic surveillance information system
An electronic pilot surveillance system is well established nationally, with good levels of acceptance by healthcare data
providers and public health staff.
Information system support for local communicable disease prevention and control
work
Electronic surveillance system offers considerable present and potential assistance to local epidemiologists re the work
case and outbreak detection, validation, analysis, and for monitoring the performance of the surveillance system.
Outbreak and high risk case alert system
An alert system built into the electronic database, routinely flags possible outbreaks identified through indicator
surveillance.
WEAKNESS
RECOMMENDATION
S2.1 Dual paper and electronic reporting
systems; electronic surveillance system still under
‘pilot’ status;
The traditional paper based reporting system is still fully
functional leading to unnecessary double work and
impairing the ability of local public health services to
focus on data validation, control and prevention
activities;
The pilot electronic IT system is currently used primarily
for reproduction of historic33 aggregate reports; its
potential for analysis based on national case definitions is
not yet fully exploited, and it does not support data
export for ad hoc statistical analysis;
Guidelines and operational manuals for rayon/municipal
epidemiologists to work with the electronic system are
not yet available.
Priority should be given to formal establishment of
this pilot system, as soon as practicable, including
necessary legislative and regulatory authority. While it
is recognised that the IT system continues to evolve
technically, the need for parallel paper reporting
should be removed as soon as possible.
Standard reports should also be developed and used
that are explicitly based on the national case
classification system
SOPs for rayon/municipal epidemiologists to work
with the electronic system should be developed.
S2.2 Validation of case reports:
Validation of case reports by local epidemiologists
appears variable in practice: unspecified, manual
processes, in some cases of limited precision (e.g.
influenza related cases)
31
32
33
Operational manuals for rayon/municipal
epidemiologists to work with the case classification
system should be developed.
2007
Essentially identical to the case classification for reporting to EU level (2002), for all relevant diseases and health events.
The present need for this is understood given the pilot status of the system.
Page 32 of 95
S2.3 GIS support to rayon epidemiologists:
While GIS is available as a tool for rayon epidemiologists
as part of the electronic SAE system, the system is
currently unable to support surveillance and outbreak
detection through (confidential) identification of case
locations at village and street level.
The GIS system should be further developed to
identify the distribution of the cases at village and
street level, and available to both national and rayon
level epidemiologists (with appropriate data
protection arrangements)
S2.4 Early warning and alert system:
The early warning and alert module of SAE has
aberration flags based on manually set parameters based
on epidemiological judgement, rather than use of a
statistically based algorithm.
The GIS component of the system is limited to locality
level, and the zone shading of cases numbers; does not
indicate locations of individual cases to street level.
This alert system should continue to be developed, as
a priority; consideration should be given to:

developing a more systematic basis for
defining aberrant levels for ‘flags’ (e.g.
statistically based aberration detection
software)

further enhancing the GIS capabilities down
to individual case and street level (for strictly
confidential internal use by national and
rayon epidemiologists for prevention and
containment purposes, with measures to
avoid deductive disclosure)
Page 33 of 95
COMPONENT S3:
USE OF SURVEILLANCE INFORMATION SYSTEM
Strengths
Feedback of surveillance information
In addition to monthly and annual hard copy reports, there is good use of PH institutions web sites at both local and
national level for dissemination of information about both communicable diseases and their occurrence locally and
nationally
Analysis and use of surveillance information
There is regular basic descriptive analysis and reporting of surveillance data, mostly at national level, with some more
detailed analysis for annual and ad hoc reports, ongoing monitoring of possible disease clusters, and to support national
policy development and planning, and monitoring of some national programme targets.
WEAKNESS
RECOMMENDATION
S3.1 Limited use of surveillance data for national
level public health functions:
At national level analysis of surveillance data is primarily
focused on outbreak detection and the annual report,
with limited use to inform and support policy
development and service planning, programme
monitoring, applied research, national leadership in
communicable disease prevention and control
The capacity (human resources, time, skills) to
analyse surveillance and other relevant (e.g. applied
research) data for these purposes should be
increased to enable sufficient support for these
national public health functions;
S3.2 Limited rayon level analysis and use of
surveillance data:
There is limited ability/expectation on local
epidemiologists to analyse and use surveillance data to
produce information for their intelligence needs and
action;
The analytical capacity and processes at both national
and rayon levels should be improved:
This should be continued and further developed,
including:

greater attention and resource commitment
to data analysis and presentation of data as
useful information that can be understood by
health professionals and the public;

information should be linked with performed
or intended public health actions.
S3.3 Surveillance system sensitivity gaps :
Surveillance sensitivity (level of disease
recognition/ascertainment and reporting) is critically low
for some diseases, e.g. Campylobacter, Chlamydia,
emerging diseases such as West Nile Virus, invasive
meningococcal disease;
For some important diseases, reporting is often late in
the clinical course (TB, HIV).
Other diseases are likely to be considerably underreported cf. comparable systems in some EU member
The healthcare and surveillance pathways of the
diseases identified as comparatively under-reported,
or not reported at all, by the surveillance system,
should be reviewed, to validate whether underascertainment is occurring, identify the healthcare
and laboratory system issues, and plan remedial
action accordingly
states, e.g. parasitic gastrointestinal diseases, yersiniosis,
legionellosis, pertussis34
Some diseases required to be reported at EU level
appear currently not reported at all by the RM system
34
Page 34 of 95
Pathways for identification and reporting of diseases
required for EU level reporting, that have not been
recognised at all by the system over the past three
years, should be reviewed, as above.
These sensitivity issues relate primarily to systemic health service and/or laboratory issues, rather than the surveillance system per se
Page 35 of 95
COMPONENT S4:
DISEASE SPECIFIC PROGRAMMES AND SURVEILLANCE
Strengths
Disease specific surveillance
Well established parallel systems are in place for surveillance of TB, HIV, and sexually transmitted diseases.35
HIV
The current HIV surveillance system provides long-standing data on the number of reported HIV cases and HIV
prevalence data in pregnant women tested for HIV as part of ANC services. HIV prevalence and behavioural data in key
populations have been collected in 2009 and 2013; size estimations of key populations have been done for determining
prevention needs and assessing coverage with different services; system representativeness appears adequate from key
populations;
there is an infrastructure that would support electronic reporting of HIV cases, including CD4 counts at the time of HIV
diagnosis.
Sexually transmitted diseases
Reporting of cases of syphilis and gonorrhoea appears to function well with reasonable sensitivity and
representativeness;
Prevalence estimates for syphilis and hepatitis B are available for several populations at higher risk of STIs;
Two staff have been trained in laboratory diagnostics of STIs at the WHO collaborating centre in Sweden
TB
TB surveillance operates through a well-established web based passive reporting system, from hospital pneumologists to
the national TB centre;
Case information is available in real time, supporting joint control activities at local level between pneumologists, GPs
and epidemiologists;
Surveillance and monitoring at national level is compliant with WHO and ECDC requirements.
Influenza
A sentinel surveillance system is established nationally, looking to detect and identify influenza strains
Immunisation
Vaccine uptake reporting functions routinely and with apparent efficiency nationwide.
WEAKNESS
RECOMMENDATION
S4.1 HIV surveillance and information
The roles and responsibilities among institutions that
participate in HIV surveillance are not well defined,
shared and co-ordinated.
The current fragmentation of HIV surveillance should
be overcome. It is necessary that the National AIDS
Programme of the Ministry of Health establishes a
productive collaboration with key partners from other
governmental institutions, academic institutions and
NGOs.
Capacities of the staff working on HIV surveillance at
the national level (at the National Centre for Public
Health and at the HDCD) need development,
particularly in data use and interpretation.
Staff working on HIV surveillance at the national level
should receive training to develop their capacities in
HIV surveillance and data interpretation.
Improvements should be made to the reporting system:
HIV case reporting system has limited usefulness in
35
HAI and AMR, immunisation surveillance not examined
Page 36 of 95
providing data on the reported mode of HIV
transmission since it severely under-estimates MSM
transmission and probably over-estimates heterosexual
transmission. CD4 count data are not analysed and
presented in the routine surveillance reports.
Some important bridging groups are not yet included in
surveillance, such as sexual partners of PWID, clients
of FSW and migrants, which limits the ability to
interpret increases in sexual transmission from HIV
case reports.
There may be challenges with acceptability of HIV case
reporting by infectious disease clinicians who are, since
the year 2012, requested to report HIV cases to the
National HIV Programme based at the HDCD. Data on
the mode of HIV transmission were available for only
approximately 40% of HIV cases reported in 2013.
There is also unclear responsibility over reporting of
cases of AIDS deaths. Epidemiologists at rayon or
national level have no access to aggregate or
anonymised data related to HIV cases, resulting in lack
of intelligence for action re prevention and early
diagnosis activities at district level.

There is a need to bring in line HIV case
definitions with those recommended by WHO
and ECDC;

HIV case reports need to be entered in an
electronic database that should be based at
the National AIDS Programme;

HIV case reporting should be integrated into
communicable disease case reporting system
and should include data on CD4 counts.

The validity of data on reported modes of HIV
transmission in recently diagnosed HIV cases
should be improved.
Sexual transmission of HIV should be better
understood, by identifying and carrying out surveys in
groups at higher risk of sexually transmitted HIV, such
as pregnant women, sexual partners of PWID, clients of
FSW and migrants.
Clinicians that report HIV cases need training,
supportive supervision and should be given operational
manuals on HIV case reporting in order to ensure
better quality of data.
In order to overcome a legal requirement which
stipulates that electronic HIV case reporting database
cannot be name-based, case reports should be coded
with unique codes;
There is a need to clearly define which institution is
responsible for AIDS deaths reporting and to ensure
greater completeness of data on AIDS deaths;
Since epidemiologists at rayon level are in charge of
developing HIV prevention interventions, HIV case
reporting data should be shared with epidemiologists at
least on a quarterly basis, as well as other HIV
surveillance data.
STI surveillance
STI surveillance is not integrated into communicable
disease surveillance system.
STI surveillance should be integrated into
communicable disease surveillance system.
The case definition for gonorrhoea does not include
asymptomatic infection, cases with infection at extragenital sites, or diagnosis based on nucleic acid
amplifications tests (NAATs).
Case definition of gonorrhoea should be brought in line
with WHO, IUSTI and ECDC case definitions.
Congenital syphilis is not a notifiable disease.
Under-diagnosis and under-reporting of gonorrhoea is
more likely than that for syphilis, since syphilis should
be, diagnosed, treated and reported by dermato-
Congenital syphilis should be a notifiable disease
There is a need to improve the sensitivity of case
reporting of gonorrhoea by collecting information on
diagnosed cases outside of DV clinics.
Page 37 of 95
venereologists.
It is unclear to what extent codes used in STI case
reporting are unique to individual patients.
The functioning and quality of STI case reporting based
on unique codes should be reviewed and assessed.
There is still mandatory STI screening of some
occupational groups.
Mandatory screening of occupational groups for STIs
should be abolished.
With exception of testing for syphilis, symptomatic
male gonococcal urethritis and culture of Trichomonas
vaginalis, the laboratory methods in use for STI
diagnostics are generally not in adherence to
international norms and guidelines.
STI diagnostics should be improved with introduction
of sensitive, validated and quality assured and
controlled laboratory tests.
There are no internationally published studies
regarding gonococcal antimicrobial and no valid
antimicrobial resistance testing or resistance data for
N. gonorrhoeae.
Laboratory diagnosis of Chlamydia trachomatis
infection used antibody detection for diagnosis of
uncomplicated chlamydial infections.
Some level of quality assurance and control system
was available at all visited laboratories where STI
diagnostics is done.
While there appears to be substantial progress made
towards elimination of congenital syphilis, there is no
process established to validate this.
Antimicrobial resistance testing for N. gonorrhoeae
should be established, and studies carried out to
establish the epidemiology of AMR in N. gonorrhoeae in
Moldova.
Antibody detection methods for diagnosing genital
chlamydial infection have highly suboptimal sensitivity
and specificity and should not be used to diagnose
acute uncomplicated C. Trachomatis infection.
A complete quality assurance system should be
established in the key laboratories where STI
diagnostics is done.
The Ministry should request from WHO initiation of the
process for validation of elimination of congenital
syphilis.
TB surveillance
TB surveillance continues to operate in parallel to the
main surveillance system, limiting information to and
involvement of rayon epidemiologists and staff in
disease prevention and control activities at local level;
benefits of the SAE in terms of real time reporting,
analysis and outbreak detection are not available to TB
programme
The present agreement in principle regarding
integrating TB surveillance into the general surveillance
system should be investigated, to identify its benefits in
support of effective Tb control and treatment
compliance at rayon and municipal level, and to identify
additional data protection measured that may be
necessary.
Page 38 of 95
COMPONENT S5:
PUBLIC HEALTH WORKFORCE
Strengths
Workforce
A dedicated and disciplined professional epidemiological and microbiological workforce, familiar with the legislative and
regulatory framework for their service.
Public health procedures and protocols
Protocols and standard operating procedures (SOPs) for epidemiologists and support staff are in place for several
important epidemiology service functions.
Epidemiology unit infrastructure
Generally adequate staff working conditions with good access to computers, information systems, other necessary
equipment, and internet connectivity.
WEAKNESS
RECOMMENDATION
S5.1 The epidemiology workforce:
The epidemiologist workforce is ageing, and it is not
clear that sufficient doctors are being recruited to the
specialty training programme and retained/appointed to
epidemiologist posts related to communicable disease
control to maintain the present workforce over the
medium term;
Attention should be given as a priority to:

forward planning and strategic management
of the impending crisis in the epidemiologist
workforce (through expected retirements);

A strategic plan based on careful monitoring
of human resources and assignment of
responsibilities should be developed by the
Ministry in conjunction with education and
training authorities;

Consideration should be given to the
increased use of nonmedical staff in
epidemiology services, and to the adjusting
the present required activities of specialist
epidemiologists.
There are unfilled vacancies for epidemiologists,
particularly at rayon level;
Epidemiologists perform some routine activities that
could be performed by staff with less specialist training
(both clinical, e.g. nurses, and nonclinical, e.g. MPH or IT
graduates). Epidemiologists carry out many reporting
activities for statistical purposes with little apparent
public health use.
S5.2 Outbreak management lacks analytical
investigation:
Outbreak investigations are still patient oriented, offering
few elements on descriptive and little in terms of
analytical investigation;
Reporting of outbreaks is mandatory, but the quality of
outbreak investigations and response is not adequately
monitored.
Training and continuing education programmes
should be provided to strengthen the continuing
professional development of epidemiologists
particularly related to use of analytical methods in
outbreak investigation, surveillance and development
of prevention programmes.
Professional guidelines and Standard Operating
Procedures (SOPs) for outbreak investigation should
be further updated and developed.
Incident reviews of (at least a sample of) outbreaks,
including their management, should be regularly
undertaken, for benefit of learning of epidemiologists
and staff nationwide.
Page 39 of 95
S5.3 Analytical epidemiology skills of rayon
epidemiologists and support staff:
Rayon epidemiologists and support staff appear to lack,
and/or do not have time or resources to apply modern
skills in both descriptive and analytical epidemiology,, to
support both surveillance and investigation of outbreaks;
In-service training and continuing professional
education programmes should be provided for
epidemiologists and support staff;
The programme of developing and updating protocols
and SOPs for public health staff should continue, and
be extended to cover all important aspects of public
health practice at district and national levels;
Particular attention should be given at rayon level to
protocols/SOPs relating to:

outbreak investigation

analysis and use of surveillance data

validation of surveillance case classification
procedures
S5.4 Continuing professional development
Few of the continuing professional development (CPD)
activities/events presently available to medical
specialists, including epidemiologists and microbiologists,
(as well as general practitioners and hospital doctors,
who need to keep up to date), appear to relate to
communicable disease prevention and control (apart
from vaccination);
CPD programmes for epidemiologist support staff appear
to be limited.
CPD programmes should recognise the need for
continuing professional development in the field of
communicable diseases prevention and control, and
provide training opportunities accordingly, for both
public health and healthcare staff;
Epidemiologists should be expected, and supported to
have, CPD activities related to communicable disease
prevention and control, and relevant skills (eg
statistical analysis).
CPD programmes should be developed for public
health support staff;
Where CPD programmes for both epidemiologists and
support staff, are deficient related to needed skills for
the epidemiology service (e.g. in surveillance and
outbreak investigation), they should be
complemented by in-service training.
Use international opportunities to support further
training of epidemiologists (e.g. MediPIET) and
develop national capacities for training public health
specialists in the field of intervention epidemiology.
Page 40 of 95
COMPONENT S6:
SUPPORT TO WIDER HEALTH SERVICE
Strengths
Guidelines and training for clinicians
A well-developed programme of clinical and public health guidelines is in place, for most diseases of public health
significance, below the level of (but supported by) ministerial regulation, available to doctors and other health service
staff. Training programmes, particularly for family doctors, are well established
WEAKNESS
RECOMMENDATION
Guidelines and training for clinicians:
The guidelines programme does not cover all
infectious diseases of public health relevance, public
health management aspects are sometimes underdeveloped, and some guidelines need updating
Training programmes, particularly for family doctors,
are well established, but with little attention to public
health management of infectious diseases considered
This important programme of work should be maintained,
supported and extended; particular attention should be
given to:

further increasing the technical areas where
healthcare staff can be supported through
guidance without requirement for ministerial
regulation or decision;

consideration should be given to extracting,
consolidating and promulgating public health
management guidelines as a national
Communicable Disease Public Health
Handbook;
Training of clinicians should be ensured, at both national
and rayon level, that includes public health and
communicable disease public health management
competencies (in addition to existing continuing
professional, education on clinical subjects).
3
Page 41 of 95
Public Health Microbiology System
3.1 System Overview
Laboratory services for both diagnostic and reference purposes are provided primarily by a network of laboratories
under Centres for Public Health, at rayon, municipal and national level.
The primary legal framework underpinning laboratory surveillance is the 2013 MoH order regarding the implementation
of the programme for development of the state surveillance public health laboratory network in the Republic of
Moldova36.
3.2 Primary diagnostic laboratory services
3.2.1 Diagnostic services
Moldova has the laboratory diagnostic capacity to confirm cases according to the EU case definitions for all diseases
under EU surveillance except for those indicated in chapter 2.
Primary diagnostic services are provided by:

Laboratories of the Centres for Public health (CPH) in rayons and municipalities: these laboratories are
authorised by the Minister of Health to carry out laboratory investigations on causative agents of communicable
diseases under national surveillance.

National reference laboratory (NRL): the NRL at Chisinau also provides primary diagnostic services, e.g. for
virological testing and “dangerous pathogens”.

Private laboratories: there are also a small number of private laboratories in Moldova, located mainly at private
clinics. Such laboratories are reported to perform diagnostic testing for sexually transmitted diseases including
HIV/AIDS. However, it is not clear if and how they are reporting (see chapter 2, HIV, STD surveillance).
3.2.2 Range and scope of diagnostic tests
The majority of primary diagnostic services, for both family doctors and hospitals, are provided by CPH laboratories,
making them also the prime source of microbiological data for surveillance. They include mainly basic bacteriology and
parasitology investigations (light microscopy for Giardia lamblia and helminths), and ELISA (screening tests) for HIV.
There is very limited capability in the field of virology (serological testing is 99% performed for HIV screening, the
remaining 1% is mainly performed for research purposes). Real-time PCR machines are few, and often dedicated to an
individual disease (e.g. influenza). There is no capacity to sequence/perform full genome typing.
3.2.3 Antimicrobial resistance testing
There is no community and hospital surveillance system for antimicrobial resistance (AMR) and antibiotic usage are in
place. A monitoring system for antibiotic resistance was set up in a limited number of hospitals. For example,
antimicrobial susceptibility testing is performed for Salmonella only at the national level.
Clinical breakpoints as described by the Clinical and Laboratory Standards Institute (CLSI) are used for antimicrobial
susceptibility testing, data interpretation and reporting37.
3.2.4 Referral systems
Should the laboratory located at the rayon/municipal CPH be unable to diagnose a suspected case, or be in the need of
confirmatory diagnostics, it may refer patient samples to the respective national reference laboratory. No charge is
levied for referral of samples. For some pathogens, referral is required by regulation.
3.2.5 Capacity and infrastructure
Operational conditions of clinical microbiology laboratories, including provision of adequate staffing, space and
equipment, are regulated by national ordinance.38 There appears to be limited capacity for timely sample transportation
from clinicians to the laboratory, particularly outside the rayon centre. CPH laboratories have capacity for pre-analytical
preparation of samples for serological testing and sample storage.
36
37
38
http://www.cnsp.md/down/info1371468083ro.pdf
http://clsi.org/blog/2012/01/13/clsi-publishes-2012-antimicrobial-susceptibility-testing-standards/
Ordinul Ministerului Sănătăţii nr. 668 din 10 June 2013; http://www.cnsp.md/down/info1371468083ro.pdf
(a)
Page 42 of 95
Human resources
Public health laboratories at rayon/municipal level are led by microbiology technicians who are university graduates, with
continuous professional education in microbiology, and supported by microbiologists from NCPH. Staff appear dedicated
and well-motivated, with a good knowledge of diagnostic tests available.
(b)
Buildings and equipment
The laboratory space within the public health centres appears generally sufficient: an average microbiological laboratory
space of 275m2 and Sanitary Hygienic Laboratory space of 183m2 is regulated39.
The microbiological laboratories of municipal centres visited (Chisinau, Cahul, Ungheni), are generally well equipped for
the range of tests that they perform. Rayon microbiology facilities have been recently upgraded via World Bank funding.
Modern equipment has been provided by several international donors (e.g. World Bank, EC, WHO, CDC) including
MicroScan Walk Away automated microbiology systems for bacterial pathogens, Phoenix 100 ID/AST system for
identification of Enterobacteriaceae and commonly isolated glucose non-fermenting gram negative bacilli (automated
system for identification and antimicrobial resistance testing), as well as class 2 biosafety cabinets, refrigerators,
ultracentrifuges, and autoclaves. The sanitary hygiene laboratories have more basic, rather out-dated equipment.
(c)
Supplies and procurement
Laboratories at both local and national level frequently lack reagents to perform requested diagnostic tests –
procurement is intermittent. The modern equipment requires specific consumables.
(d)
Laboratory information system
While laboratories in public health services are connected to SAE with test results immediately available on SAE, some
clinicians are not connected to the internet so there is still paper based reporting of laboratory test results done in
parallel. Private laboratories are not connected to the laboratory information system.
3.3 Reference microbiological diagnostic services
3.3.1 Formal recognition
No formal procedure for nomination of national reference laboratories is in place.
3.3.2 Primary diagnostic services
The reference laboratory at NCPH performs primary diagnostics for rare, difficult to culture, and dangerous pathogens,
as well as other common pathogens. Diagnostic services are provided for both hospital inpatients and outpatients, as
well as for family doctors.
Serologic and molecular diagnostic methods are used for:

Viral infections: hepatitis, HIV / AIDS, rotavirus, herpes virus (ELISA and PCR).

Respiratory infections: influenza, SARS, parainfluenza, adenovirus, RS virus (ELISA and PCR).

Parasitic infections: Cysticercosis, Echinococcosis, Trichinellosis, Toxocara, Toxoplasmosis (ELISA)

Bacterial infections: Mycoplasma, Chlamydia, bacterial meningitis, Salmonellosis, Shigellosis, Yersiniosis,
Escherichia coli, Campylobacter, Listeriosis (ELISA and PCR).

Vaccine preventable diseases: Rubella, Rubeola, Measles, Diphtheria, Tetanus (ELISA).

Dangerous pathogens: Brucellosis, Tularaemia, Anthrax, Leptospirosis, Q-fever, West Nile fever (ELISA and
PCR).
Virological diagnostic capacity is very limited. There are few real-time PCR machines available, and these are usually
exclusively dedicated to individual diseases (e.g. influenza).
There is extremely limited capacity to perform molecular typing, and no capacity to perform gene sequencing.
39
Decision Nr. 668
Page 43 of 95
3.3.3 Characterisation and reference services
Reference diagnostics provide confirmatory diagnosis of samples sent from primary laboratories across the country.
These include isolation and characterisation of human pathogens, including determination of virulence factors. There is
capacity (methods not specified) to perform molecular typing of Salmonella, VTEC and Listeria.
Scientific advice provided includes guidance on diagnostic methods/practices, disease/pathogen specific guidance;
national guidelines for clinical laboratory practice.
3.3.4 Referral systems (national and international)
A national referral system exists for referral of certain samples from public health laboratories to Chisinau (e.g. primary
testing (ELISA) for HIV is performed in the public health laboratories and then referred for molecular
testing/confirmation).
Although there are much international collaboration established within surveillance and research networks, there are no
formal international referral arrangements in place.
Examples of international collaboration include:



CDC
o
Rotavirus vaccine effectiveness
o
Norovirus, and hepatitis viruses
WHO
o
Influenza - WHO reference laboratory for influenza, exchange of information, sentinel site, sending of
isolates to the WHO collaborating center in London
o
Polio - WHO reference laboratory for polio
o
Rubella and measles (WHO reference laboratory, Moscow)
EU Networks
o
Danish veterinarian institute (SalmSurv)
o
Romanian institute

Twining project

Black sea network;
o
o
Laboratories in Moscow and in the Saratov university (e.g. arboviruses)
Pact for stability for public health problems (AMR, TB, HIV working groups).
3.3.5 Other reference services
(a)
Training
Training is regularly conducted both for staff of the reference laboratory and for staff of the public health centre
laboratories on the routine tests performed. There is limited training of laboratory personnel on new test methods.
(b)
Scientific advice
Scientific advice provided by the NRLs includes guidance on diagnostic methods/practices (e.g. disease/pathogen
specific guidance; national guidelines for clinical laboratory practice).
(c)
Information to the public
Information to the public is provided both at both rayon national level in collaboration with the epidemiologists (e.g. on
preventive measures and recommendations for implementation of specific control measures).
3.3.6 Capacity and infrastructure
(a)
Human resources
The NRLs at NCPH are led by specialist medical microbiologists, supported by microbiology technicians (see chapter 1).
(b)
Buildings and equipment
Both the Laboratory for Dangerous Pathogens and the Reference Laboratory for Microbiology within the NCPH at
Chisinau are located in a rather run down building with old, partially obsolete equipment.
The Laboratory for Dangerous Pathogens includes a biosafety 3 facility (glovebox). It has capacity to work with small
animals (rodents, mosquitoes etc), and maintains its own animal facility.
Page 44 of 95
There are some extant security problems, e.g. the access to the dangerous pathogen laboratory is not secured (normal
door/lock). Access to the rooms at higher biosafety level/BSL3 glove box is restricted and under video surveillance.
The Center for Virology (for respiratory and gastrointestinal infections) is located in a new building with new equipment
(real time PCR, serological testing, and isolation).
The Influenza, measles and Polio laboratories are WHO accredited and participates in regular international
EQAs/proficiency testing. They have all necessary equipment and a dedicated room for egg inoculation, but (as yet) no
eggs.
(c)
Supplies and procurement
Laboratories frequently lack reagents to perform requested diagnostic tests, due to intermittent procurement.
(d)
Laboratory information system
The reference laboratories have all access to computer/ internet.
3.4 Laboratory activity reporting
Annually extensive activity reports (“passports”) are produced by all the 36 public health laboratories. These are
aggregated into the Annual Laboratory Activity Report by the National Reference Laboratory.
The microbiology data in the report are primarily descriptive showing the number and type of tests performed by
region/municipality. Analytical data (e.g. resistance trends) are shown for selected pathogens or health issues, such as
HIV/AIDS, Tuberculosis and antibiotic resistance.
3.5 Integration with surveillance systems and other sectors
3.5.1 Reporting of infectious disease cases
Reporting of microbiological test results as part of the national case reporting is outlined in chapter 2. Public health
laboratories performing microbiological testing have access to the real-time electronic reporting system in place and
report according to the national regulations.
The system provides a good link between clinical, epidemiological and laboratory data. The feedback of results to
clinicians is appreciated for diagnosis and therapy, and the system is well accepted. Some reporting is done in parallel
on paper as still some clinicians have no access to the internet.
3.5.2 Liaison with epidemiologists and public health units
In the Centres for Public Health, both on the municipal and the national level there is a good liaison between
microbiologists and the epidemiologists. A consensus workshop was held in 2007 consolidating the links between
clinicians, laboratories and the epidemiology services.
3.5.3 Liaison with other sector laboratories
Collaboration between human pathogen laboratories mostly occurs on ad hoc basis with most laboratories not being
integrated into national laboratory networks. There are only national networks on TB and HIV. Collaboration with private
laboratories both for research and health emergencies appears limited.
(a)
Veterinary
Veterinary services have one national and three regional laboratories. There is no data linkage with human surveillance
systems.
Collaboration with the laboratories of the Ministry of Agriculture are limited, both for research and health emergencies.
Good collaboration appears to be established relating to suspected rabies cases. Collaboration relating to e.g. anthrax,
brucellosis, tularaemia takes place only at national level. At the municipal level, staff appear unfamiliar with diseases
such as West Nile virus.
(b)
Food
Liaison with the newly established National Food Safety Agency as well as with the Consumer Protection Agency under
the Ministry of Economy appears limited roles and responsibilities need to be clearly outlined and procedures agreed
upon.
There is the capacity to detect the following bacteria in food (ELISA): E.coli (O157), Listeria monocytogenes, enterotoxin
producing Staphylococci.
(c)
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Environment
The control of environmental hazards is divided between different authorities which lack coordination and cooperation.
Each authority has its own laboratory network doing analysis of environmental health hazards. The Public health
laboratory carries out investigations for the detection and confirmation of public health threats, however, lacking up-to
date equipment and qualified personnel.
The Ministry of Health is responsible for developing the legislation on air quality and environment protection. The testing
of environmental samples collected with the purpose of monitoring risk factors is carried out mainly by three
laboratories: the NCPH lab, and those of the Centres of Public Health in Chisinau and Balti municipalities.
(d)
Potable water
The Minster of Health is responsible for developing national legislation in relation to drinking water and in collaboration
with the Ministry of Environment for developing the legislation on sewage and discharge of waste and residues.
There is capacity for the detection of the following bacteria in drinking water: E. coli, E. faecalis, Clostridium perfringens,
P. aeruginosa, S. aureus.
3.6 Integration with alert and response systems
3.6.1 Overview
Authorised laboratories of the public health institutes should perform the laboratory examinations in the event of an
epidemic of infectious diseases. If laboratories identify any unusual event of potential public health impact as of their
routine work, they are obliged to promptly report this to the national centre of public health. At the national level trends
of microbiological findings are analysed. Monitoring for detecting new and/or emerging pathogen strain characteristics is
done by some of the NRLs (e.g. influenza, measles, polio).
There is a system in place to allow reporting of unusual events of potential public health impact (as detected by analysis
of laboratory results) such as:

Cases of pathogens with new profile/determinants of antimicrobial drug resistance;

Cases of pathogens with new or unusual virulence profile;

Clusters in time/area of isolates/case of common genotype;

Increased occurrence of pathogens or increase in antigenic type distribution;

However, there is very limited capacity to detect rare and/or emerging strains/pathogens as they will escape
testing with standard methods applied.
The capacity of the public health laboratory network to investigate health threats is especially weak in terms of detection
and confirmation of toxic and radiologic agents.
3.6.2 Role in outbreaks
The role of the laboratories in potential epidemics is outlined in the national legislation and is covered during the
training/specialisation in microbiology.
Reference microbiology laboratories may participate in outbreak investigations. Assistance from national level is given to
regional level laboratories if needed. In most cases however, the outbreak control team at regional level is considered
competent enough to perform investigation on differential diagnoses using its own public health laboratories; however,
this can only be the case for bacteriological agents.
Inter-sectoral table-top exercises and drills for rapid response teams involving the national laboratory network are
provided annually by the CPESS and MoH.
3.6.3 Sentinel surveillance
Laboratories participate in sentinel surveillance systems for ILI, ARI, SARI, rotavirus infection40 and childhood
pneumonia41 (see chapter 2).
40
(MoH order nr.252 from 20.06.2008 on the implementation of sentinel surveillance for rotavirus infection in the Republic of Moldova,
and MoH order nr.1238 from 07.12.2012 on the assessment of the impact the introduction of rotavirus vaccine)
41
(MoH order regarding epidemiological sentinel surveillance of community acquired pneumonia in children under 5 years MoH order
nr.1190 from 23.10.2013
http://ms.gov.md/sites/default/files/legislatie/ord._1190_din_23.10.3_supravegherea_epidem._pneumonii_comunitare.pdf)
Page 46 of 95
3.7 Laboratory regulation and standards
3.7.1 Regulatory mandate
Public health laboratories operate under the mandate of the MoH order regarding the implementation of the Programme
for development of state surveillance public health Laboratory Network in RM42.
3.7.2 Quality systems
(a)
Internal quality assessment systems
All public health laboratories have internal quality assurance programs. The performance of results is assessed through
inter-laboratory comparison of results.
Guidelines, SOPs/quality manuals are developed by each laboratory to address handling, analysis and evaluation of the
samples.
(b)
External quality assessment systems
The NCPH organises annually national external quality control programmes for microbiological, sanitary-hygiene and
radiological laboratories.
The NRLs on influenza, polio and enteric pathogens, measles and rubella regularly participate in international quality
assessment schemes for diagnosis and pathogen characterization. The Reference Laboratory for Microbiology has
excellent results in international panels for measles and rubella.
(c)
Accreditation
All public health laboratories are accredited every five years by the National Council for Evaluation and Accreditation in
Health (CNEAS) in accordance with standards developed by the International Organization for Standardisation (ISO)43.
Three laboratories (NCPH laboratory, CSP Chisinau and CSP Ceadar Lunga) are accredited by the Accreditation Centre
Product Conformity Assessment (CAECP)44. CAECP performs annual external quality control accreditation of laboratories
for surveillance. Quality management systems are in place in accredited laboratories.
NCPH laboratories have accreditation by WHO e.g. for the diagnosis of polio, rubella, measles and influenza.
3.7.3 Biosafety
(a)
Biosafety levels
Most human microbiology laboratories are at biosafety level 2 (BSL2). BSL3 facilities operate at the National Centre for
Public Health in Chisinau (Dangerous Pathogens Laboratory).
(b)
National administration of biosafety
There appears to be no national system for the regulation of biosafety in primary and secondary microbiology
laboratories.
The National Commission for biologic security established through the law nr 755-XV from 21st of December 2001 on
biological security executes only authorisation and control duties of activities involved in process of obtaining, testing,
producing, using and marketing of genetically modified microorganisms, plants and animals through modern
biotechnology45. No national authority is responsible for developing and monitoring the implementation of biosecurityand biosafety standards.
The existing guidance on laboratory biosafety is essentially the translated version of the WHO laboratory biosafety
manual, 3rd edition) 201146 . Guidance on “Regulations for the Transport of Infectious Substances and Biosafety” was
42
MoH order nr.668 from 10.06.2013, http://www.cnsp.md/down/info1371468083ro.pdf
ISO 17025 and ISO 15189
44
ISO 17025
45
According to the Regulation of organization and functioning of the nominated Commission approved by the Government decision nr.
603 from 20th May 2003.
46
43
Page 47 of 95
approved in 2011, and is applied, and training given47. There are international sample shipment providers/couriers,
which can ship highly infectious substances in accordance to the international biosafety regulations (but at high costs).
3.8 Training and continuing education microbiologists and
technical staff
Specialist training and continuing education for microbiologists was not assessed during this country visit. It was noted
that international training (e.g. seminars, courses, workshops, twinning programs) is rarely available for laboratory staff
other than for national laboratory heads (due to lack of dedicated funds).
47
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PUBLIC HEALTH MICROBIOLOGY: STRENGTHS AND WEAKNESSES
COMPONENT L1:
PRIMARY DIAGNOSTIC LABORATORY SERVICES
Strengths
Diagnostic services of rayon and municipal laboratories:
An adequate range of basic bacteriology services is provided for both primary care and hospital clinicians.
Equipment and estate infrastructure of municipal level laboratories
Facilities and equipment are modern and adequate for the range of tests performed.
Problem
Recommendation
L1.1 Sustainability of diagnostic services
Maintenance of current laboratory investigation
capabilities with limited human resources is a
continuing difficulty.
Many currently used diagnostic tests rely on
classical, laborious, time consuming technologies.
Consideration should be given to progressively
increasing the use of other test systems (e.g.
rapid diagnostic test systems) and processes
(automatisation).
Validated rapid test kits could be used for rapid
laboratory diagnosis in field investigations.
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COMPONENT L2:
REFERENCE MICROBIOLOGICAL DIAGNOSTIC SERVICES
Strengths
National Reference public health functions
NRLs provide a range of services consistent with the core functions of NRLs outlined in the ECDC technical guidance;48
Legal mandate for confirmatory testing for surveillance
For a selected number of diseases, national legislation obliges primary testing laboratories to forward clinical samples to
the national level for confirmation;
Microbiology reporting system
The current laboratory reporting system provides a real-time overview of most of the pathogens diagnosed by the
national laboratory system, including the possibility to monitor trends in pathogen characteristics.
Problem
Recommendation
L2.1 National reference laboratory (NRL)
mandate and nomination
Mandate and core functions of NRLs are not
formally defined. There is no selection or review
process of candidate providers based on objective
proficiency and performance criteria (evidence
based nomination);
NRLs should be nominated:

Based on demonstrated capabilities and
performance (by e.g. successful
completion of external quality
assessment rounds and/or accreditation
using national/international standards),

Under defined terms of reference (such
as these promoted by ECDC in the Core
functions of microbiology reference
laboratories for communicable diseases”,
June 2010

For a defined period of time, implying
revision of capabilities and quality of
services before possible re-nomination.
L2.2 Sustainability of good quality NRL
services
Sustainable good quality laboratory services
depend on continuous financial support,
compliance with confirmatory testing, and a
critical throughput of appropriate primary and
referral test requests.
The financing of NRLs should be sufficient to
ensure uninterrupted provision of requested
laboratory services (e.g. logistics of reagents
supply);
The use of joint diagnostic and reference
microbiology applied research projects could be
promoted as a funding source for increasing
referral of samples and clinical isolates.
NRL facilities appear outdated and the equipment
is partially obsolete.
Funding for test reagents is neither sufficient nor
consistent to enable continuing procurement
without gaps.
48
NRLs should be appropriately re-equipped and
renovated to meet current generally accepted
standards;
Measures should be investigated to maintain and
increase the referral of samples isolates to NRLs
for confirmatory testing;
ECDC technical report “Core functions of microbiology reference laboratories for communicable diseases”, June 2010.
Page 50 of 95
L2.3 Biosafety at NRLs
There is no obligatory certification for biosafety
compliance.
Laboratory staff should be trained regularly to
increase biosafety awareness and compliance;
There is no regular auditing, exercises and
training of staff in biosafety (both expert and
support personnel, including cleaning and
maintenance staff).
A national system for certification of laboratory
biosafety compliance should be considered. Such
a system could include provision for auditing and
training. A bio-safety officer at national level could
be appointed to oversee this activity;
Access to the BSL3 laboratory should be
continuously monitored.
L2.4 Maintain laboratory testing
capabilities with limited human resources
Many current diagnostic tests rely on classical
laborious time consuming technologies.
Consider to progressively increase use of other,
including automated, test systems (e.g. rapid
diagnostic test systems) and processes.
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COMPONENT L3:
LABORATORY SERVICE QUALITY
Strengths
Competent and dedicated workforce
Staff at the public health laboratories is dedicated and highly motivated. At both municipal and national levels, staff has
a good knowledge of diagnostic tests available.
The heads of the public health laboratories visited are university graduates, continuous professional education in
microbiology. Some of the staff in the NRLs is involved in international surveillance and research projects.
Quality of NRLs
Some of the NRLs are internationally accredited (Influenza, polio, measles and rubella) and participate regularly in
external quality assurance, with very good results. Some serve as WHO national reference centres.
Problem
Recommendation
L3.1 Sustainability and development of
microbiology expertise
There is a decline in medical graduates
specialising in Medical Microbiology and little
evidence of involvement of other scientifically
trained experts (e.g. molecular biology,
biotechnology, bioinformatics) in NRL functions
(e.g. data analysis, research and method
development).
Recruitment into the specialty should be
developed, and the attractiveness of a relatively
long specialisation should be enhanced. Possible
contributions could include:

increased involvement of medical
microbiologists in epidemiological
investigations and preparedness and
response activities;

opportunities offered by the ECDC
supported EUPHEM training scheme;

education activities of learned societies
in clinical microbiology;
Non-medical microbiology staff could be more
involved in applied research at the NRLs (e.g. new
method development and validation).
L3.2 Antimicrobial susceptibility testing
EUCAST breakpoints are not used for
antimicrobial susceptibility testing as required by
case definitions for reporting to EU level.
Antimicrobial susceptibility testing should be
aligned with the EUCAST methodology and
interpretation criteria, including breakpoints..
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COMPONENT L4:
INTER-PROFESSIONAL AND INTER-SECTORAL COLLABORATION
Strengths
Good public health collaboration
There is a good collaboration/ communication between epidemiologist and public health microbiology staff within the
Public Health Centres. Microbiologists are involved in outbreak investigations as members of multidisciplinary outbreak
teams. Technical advice is provided on appropriate microbiological sampling, sample transportation and sample testing
procedures as well as interpretation of specialized test results.
Good international collaboration
There are active international public health and research collaborations on a variety of agents with many international
partners.
Problem
Recommendation
L4.1 Inter-sectorial collaboration
There are limited collaborations with
environmental testing laboratories and veterinary
laboratories both on public health and research.
Improve inter-sectoral collaboration between
services and laboratories at national level, (e.g.
regarding sharing of data, information, and
reports; explore potential for data linkage of
surveillance systems);
Increase knowledge of veterinary epidemiologists
and microbiologists regarding emerging infectious
diseases (e.g. West-Nile virus).
L4.2 Business continuity
There are no generators ensuring continuous
function of microbiological equipment
Procure back up power sources for national
reference laboratories.
L4.3 Clarity of laboratory role in national
communicable disease emergencies
The national emergency plan does not mention
laboratories (see chapter 4).
The role of laboratories in communicable disease
outbreaks should be integrated into national
health emergency plans.
Simulation exercises could be conducted to test
roles and responsibilities of NRLs and other public
health microbiology laboratories, including surge
testing capacity in the case of a major outbreak of
a communicable disease.
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4 Public Health Emergency Preparedness,
Response and Crisis Management
4.1 Systems Overview
The Republic of Moldova has in recent years developed a substantial body of legislation and capacities for a solid public
health preparedness and response system, with shared responsibilities between civil protection and public health. The
system, and particularly the public health component, has taken good advantage of international support in modernising
a structure inherited from past administrations and built on a wide multi-sectorial network from central down to local
level to prepare and respond to emergencies and disasters to which the country is prone.
The Public Health system (at both national and rayon levels) were significantly re-organised in 2010, and is now being
adapted to reflect the new Public Health Strategy 2014 -2020.
4.2 Past crises and potential threats
The database of the Centre for Research on the Epidemiology of Disasters (CRED) lists epidemics, floods, extreme
temperatures, windstorms and drought as the natural disasters that are responsible for the highest mortality rates and
have the greatest adverse effect on large numbers of the population in the Republic of Moldova.
Table 5 - Most significant natural disasters occurring in the Republic of Moldova in terms of death and population
affected, 1990–2014
Category
Event
# of
Events
Killed
Total
Affected
Damage (000
US$)
Drought
Drought
3
2
216194
406000
0.7
72064.7
135333.3
-
1647
-
-
1647
-
10
7374
-
10
7374
-
13
-
-
13
-
-
10
4457
54832
3.3
1485.7
18277.3
51
47500
307752
12.8
11875
76938
-
2600000
31600
-
2600000
31600
3
25580
-
3
25580
-
ave. per event
Epidemic
Bacterial Infectious
Diseases
1
ave. per event
Extreme
temperature
Cold wave
1
ave. per event
Extreme winter conditions
1
ave. per event
Flood
Unspecified
3
ave. per event
General flood
4
ave. per event
Storm
Unspecified
1
ave. per event
Local storm
ave. per event
1
Created on: Apr-2-2014. - Data version: v12.07;
Source: "EM-DAT: The OFDA/CRED International Disaster Database;
www.em-dat.net - Université Catholique de Louvain - Brussels - Belgium"
Page 54 of 95
4.3 Management of Public Health emergencies
The National Public Health Strategy 2014-202049 outlines a new approach in public health in Moldova (see chapter 1).
In particular, the legal framework in the area of public health emergencies is to address priorities, gaps and outcomes
for the development of an integrated, all-hazard public health emergency preparedness framework.
The Strategy is accompanied by a detailed Plan of Actions with specific objectives and tasks related to the strengthening
of preparedness and response to public health emergencies. Of particular relevance are:

Task 2.1.6: Adjustment of the legal framework (regulations, standards, guides, indications and methodological
recommendations) on public health emergencies of chemical, biological, radiological origin to the international
standards;

Task 2.1.8: Establishment and implementation of the National Integrated System of health sector preparedness
and response to public health emergencies;

Task 2.1.12: Periodical training of the intervention teams on planning, preparing, estimating the needs and
vulnerabilities, evaluating, managing and communicating the risks, and post-intervention evaluation.
Cross-cutting activities include responsibilities for inspection, monitoring, and enforcement, shared between the newlyestablished National Food Safety Agency (NFSA), under the Government authority, the SPHSS under the Ministry of
Health and the Consumer Protection Agency (CPA) under the Ministry of Economy. The existing legislation and related
regulations appear to be in line with the EU legislation.
4.4 Regulatory basis
The preparedness for, response to, and recovery from public health emergencies is a shared responsibility at
government level, between civil protection and public health. There is a large body of legal provisions that regulates the
authority and line of command in case of emergencies with potential public health impact.
4.4.1 Civil protection
The implementation of policy and plans is mainly achieved through the Civil Protection and Emergency Situations
Services, which come under the authority of the Ministry of Interior, and are regulated mainly by the following
legislation:

Law No 271 on Civil Protection of 9 November 1994: establishes the fundamental principles of civil protection
and the legal framework according to which all public authorities, enterprises, institutions, organizations, and
citizens are required to act.

Decision No. 347 of 25 March 2003: includes a definition and classification of the different types (e.g. natural,
technological, biological-social) and levels (local, territorial, national, trans boundary) of an emergency. The
Decision also includes the provisions for collecting and exchanging information on prevention and response.

Decision No. 961 of 21 August 2006: establishes a national laboratory network for the surveillance and control
of radioactive, poisonous and highly toxic substances, and biologic agents in the environment.

Law No. 93 on Civil Protection and Emergency Situations Service of 5 April 2007: establishes the Civil Protection
and Emergency Situations Services, defines its roles and responsibilities at national and sub-national levels, as
well as the conditions of service. The Civil Protection and Emergency Situations Services are responsible for
coordinating the activities of all authorities involved in response to disasters, including the health authorities.
4.4.2 Health services
In the health sector, crisis preparedness, mitigation and response is covered by three overarching laws:
49
50

Law No. 411 of 28 March 1995, which establishes the fundamental requirements for providing health care to
the population, also in crisis situations (Article 24), aimed at strengthening crisis preparedness and response in
the health sector.

Law No. 10-XVI of 3 February 2009 which defines responsibilities of PHS on surveillance and control of
communicable diseases and public health events, including investigation of outbreaks of infectious diseases. A
dedicated chapter (IX) relates to approach, responsibilities and management of public health emergencies. In
the context of the International Health Regulations (2005 50), the law sets out special “empowerment” clauses
Government Decision No. 1032 of 20.12.2013)
WHO, 2005
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concerning persons and goods, for specific actions that can be required to be taken during public health
emergencies (articles 60 and 61).

Government Decision No. 1076/2010 provides definitions, classifications and evaluation criteria for emergency
situations, as well as methodology for data collection and information flow
The Ministry of Health unified plan for emergency situations takes into consideration country-specific risks and sets out
the basic measures to be followed, including health care for the population facing certain threats and triggers; for
example, situations such as earthquakes, outbreaks of communicable disease, epidemics, radioactive contamination,
transport accidents, and accidents and incidents caused by chemical agents.
This plan is published the Ministry of Health website. Rayon/ municipal and institutional plans for prevention,
preparedness and management of public health emergencies are annually adjusted and approved.
At operational level some specific plans exist for preparedness and response to certain public health events (i.e.
avian/pandemic influenza, cholera and outbreaks of acute diarrhoeal diseases).
4.5 Strategic and Coordinating Bodies
Health emergency planning and response involves organisations at governmental, Ministry and local levels (see Annex
5)
4.5.1 Governmental level
(a) Government Commission for Emergency Situations
The Commission is the main body responsible for implementing preventive measures, verifying emergency preparedness
and managing emergency situations, generated by all hazards. The Commission is chaired by the Prime Minister and
includes representatives from all ministries and departments. The Commission has executive functions for prevention
and response in all-hazard emergencies.
(b) Civil Protection and Exceptional Situations Service (CPESS)
CPESS is a national multi-sectorial agency and working body of the Government Commission for Emergency Situations,
under the authority of the Ministry for Internal Affairs, and acting as the secretariat (implementing body) of the
Government Commission. It is responsible for development of the National Multi-sectoral Plan for Civil Protection that
includes components from the sector plans of the ministries and government agencies.
(c) National Extraordinary Commission for Public Health
The Commission is responsible for an integrated approach on prevention and management measures, multi-sectorial
mobilization and coordination of response to public health threats and emergencies. It ensures an adequate degree of
preparedness for public health emergencies and their management.
4.5.2 Coordinating bodies subordinated to the Ministry of Health
(a)
MoH Commission for Emergency Situations
The Commission is responsible for ensuring an adequate degree of the Health System preparedness for public health
emergencies, as well as providing management of measures on prevention, mitigation, response and recovery in case of
their occurrence.
(b)
National Centre of Public Health (NCPH)
NCPH is the scientific, technical and coordinating institution of the MoH Service of State Surveillance, and the
Implementing body of the National Extraordinary Public Health Commission (see chapter 1). NCPH functions include
emergency preparedness and interventions in public health emergencies, in collaboration with the relevant services of
other ministries and central authorities.
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Figure 5 - Public health emergencies organisational structure, Republic of Moldova
Source: Moldova Ministry of Health
In case of emergency situations such as outbreaks, the NCPH (and CPH at rayon/municipal levels), carry out antiepidemic and sanitary-hygienic measures
(c)
National Scientific and Practical Centre of Emergency Medicine (NSPCEM)
Tertiary level medical institution, providing emergency medical care, including for mass casualty situations. NSPCEM is a
coordinating body of the Medical Emergency Service and Disaster Medicine Service.
(d)
Centre for Disaster Medicine (RCDM)
RCDM is a specialized subdivision within NSPCEM, responsible for planning and coordinating the work of all components
of the Disaster Medicine Service.
4.5.3 Rayon/municipal level
At local level, emergency pre-hospital care is provided by a system comprising the Emergency Medical Assistance
Service (EMAS), and Emergency Medicine Zonal Stations, supported by Medical units, Paramedical and medical teams, ,
and Civil Protection first aid teams, drawn for different organisations (see Annex 4.1).Hospitals provide emergency inpatient and out-patient care, as well as specialized medical teams.
As above the Centres for Public health carry out local epidemic control and hygiene measures in disease outbreak
situations, supported as needed by teams from NCPH (see section 2.5).
4.6 Early warning and communications
All major emergencies are reported to the Civil Protection and Emergency Situations Services and the governor of the
respective district. Communication channels are maintained via the telephone (including mobile telephones) and the
Internet, and there are separate communication lines with the Civil Protection and Emergency Situations Services, the
Hydro- meteorological services (Hydromet) and the police.
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The warning and communication system is based on the Emergency Medical Assistance Service despatch services and
transmission networks, through which information regarding the emergency is sent and medical care activities for the
population are conducted and coordinated. To achieve this task in all EMAS substations, special points for the reception
and distribution of urgent information have been established by Minister of Health order51.
The Operative Service of the Ministry of Health for 24 hour communication is located in the Ministry, but is part of the
Disaster Management Centre, under the authority of the National Emergency Medicine Centre (NCPH). It is responsible
for taking telephone calls on a 24-hour basis from a variety of sources, through the public number (721010). The main
role of the Operative Service is two-fold: (1) to deal with general enquiries from the public on health-related issues and
problems in accessing health services (but not calls for emergency ambulance services; these are directed through the
903 number); and (2) to act as focal point for the communication of important information between the Ministry of
Health and other ministries, subordinate institutions, hospitals and district authorities, on request.
The staff of the Operative Service has no service provision authority: in the event of a serious event, it is responsible
only for ensuring that information reaches the relevant people within in the Ministry of Health, functioning basically as
the Ministry's hot line. The Service is well organized and has well-documented standard operating procedures, with lists
of contact numbers for hospitals and key personnel and a system of logging calls and action taken.
In accordance with IHR requirements that call upon countries to strengthen their capacities on early detection,
assessment and communication on public health threats, a unit monitoring public health threats at regional, national and
international level was created in 2009 in the NCPH.
4.7 Training
The Epidemiology Department of the State University of Medicine and Pharmacy “Nicolae Testemitanu” provides a small
training program on public health emergencies management, risk management and risk communication. The training
curricula on Public health emergencies preparedness and response is underdeveloped.
The Faculty of Post Graduate Medicine offers a number of obligatory short courses and postgraduate training in public
health, including a module on climate change and health. However, training in disaster management is not available.
Training in emergency medicine is provided in medical colleges and training centres, and there is now a medical
specialty training programme in emergency medicine.
4.8 Summary
In summary the Moldova health emergency preparedness system has a number of strengths:
51

The Civil Protection and Emergency Situation Service maintains a national, multi-sectorial plan for the
protection of citizens. It includes components of all plans prepared by the various ministries and government
agencies, including the health sector.

The intersectorial Extraordinary Committee on Public Health (national and rayon level) ensures an integrated
approach, applying prevention and management measures, multi-sectoral mobilisation and coordination
response in public health threats and emergencies.

A national multi-hazard sector plan is available which appears to cover the main components necessary to
initiate a crisis response, with components of mass casualty and health care management.

Similar generic plans exist for each district and detailed plans specific to avian influenza and influenza pandemic
have also been developed.

National multi-sectoral and sectoral/district-level plans are in place to manage emergency situations, and
committees are appointed at all jurisdictions to coordinate activities.

Rapid response teams at all health system levels are designated and trained in first response to disasters.

The communicable disease surveillance system is well equipped to monitor occurrence of infectious diseases
and identify unusual and unexpected health events clustering by place, time and population groups, allowing
early detection, risk assessment and response actions.

For management of public health events caused by biological and radiological agents, specific intervention
plans and operation procedures are developed and approved.

IHR (2005) is in the process of being implemented, and the National Focal Point for IHR is the contact for
national and international partners during an emergency of international concern.
MoH order nr.382 from 11.08.2009.
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PUBLIC HEALTH EMERGENCY PREPAREDNESS: STRENGTHS AND WEAKNESSES
COMPONENT P1:
REGULATORY AND STRATEGIC BASIS
Strengths
Regulatory framework
The preparedness for, response to, and recovery from public health emergencies is a shared responsibility at
government level, between civil protection and public health. Legal basis exists that regulates the authority and line of
command in case of emergencies with potential public health impact.
Well maintained cross sector plans
The Civil Protection and Emergency Situation Service maintains and regularly updates a national, multi-sectorial plan for
disaster risk reduction. It includes components of all plans prepared by the various ministries and government agencies,
including the health sector.
Problem
Recommendation
P1.1 Complex legislative framework
The existing legal framework applicable to public health
preparedness and response system is diluted in multiple
primary and secondary legal acts.
Operational responsibilities and associated regulations
are similarly reflected in numerous provisions and
guidelines which make it difficult (at field level) to
clearly understand the links and chain of command.
The Ministry of Health Commission for Emergency
Situations, in collaboration with the Civil Protection
and Emergency Situation Service should develop a
simple, integrated strategic framework (and roadmap)
to identify shortcomings and to align the national
legislation to the requirements of the EU Decision
1082/2013, especially as it concerns the national allhazard plans for cross-border threat to health.
P1.2 Alignment to EU acquis
The legal framework in the area of public health
emergency preparedness and response is not fully
adjusted to the provisions of EU acquis (eg. Decision
1082/2013).
Coordination of key activities among the authorities
concerned is not regulated by clear terms of reference
(e.g. sharing of data on food-borne outbreaks).
Standard operating procedures for intervention on
specific hazards and emergencies, as well as business
continuity plans for essential services within the health
sector (though appears that some hospital maintain an
emergency plan for acute crises) are not in place.
There is a need (MoH) to develop a public health
strategic preparedness plan, defining requirements
(upsurge capacity) and responsibilities of all services,
and a detailed plan of specific and cross-sectorial
simulation exercises aimed at testing operational
procedures and training of emergency personnel.
Priority sectors should be identified with which joint
SOPs and TORs need to be developed, tested and
enforced.
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COMPONENT P2:
EMERGENCY PREPAREDNESS AND RESPONSE ORGANISATION
Strengths
Traditional organisational frameworks
A well-structured organisation, at all level of the government and territorial jurisdictions, based on a framework inherited
from previous administrations.
Response plans and structures in place at all levels
National multi-sectorial and district-level plans for disaster risk reduction are in place to manage emergency situations,
and committees are appointed to coordinate activities. Rapid response teams at all levels of the health system are
designated and trained.
National level expert and cross sector planning
The Commission for Exceptional Situations, represented by different ministries and departments, is responsible for
planning and management in all crises situations, including epidemics. The Civil Protection is the national authority
responsible for implementing policies in the area of crisis situations and the National Multi-sectorial Plan for Civil
Protection includes components from the sector plans of the ministries and governmental agencies.
Hospital and local health emergency planning
The Ministry of Health develops guidelines on preparedness planning to hospitals and district authorities. Plans
developed by the district are approved in coordination with the Disaster Medicine Centre.
Problem
Recommendation
P2.1 Dispersed and overlapping responsibilities
The organisational structure at national and local level
has developed over recent years by the way of adding
entities with overlapping responsibilities.
The dispersed capacities to identify, assess, and
manage public health risks and emergencies, as well as
the insufficient cross-sector collaboration at the local
and national levels, are of concern for clarity of the line
of command from central to local level, in planning and
responding to public health emergencies.
Clear responsibilities, and necessary resources, should
be assigned to the NCPH for:

Public health risk assessment;

Developing an integrated PH emergency
plan, with guidelines and operating
procedures;

Developing and maintaining exercise and
training programmes for targeted PH
personnel for preparedness and response to
PH emergencies of both short and long
duration (outbreaks and pandemics).
P2.2 Biosafety and biosecurity
There is no specific strategic framework in the area of
biosafety and biosecurity addressing laboratory capacity
for identifying, assessing, monitoring, and minimizing
health risks of biologic origin, including assessing
events due to deliberate release of agents
(bioterrorism).
The institutional framework for preparedness and
response should clearly identify links and
responsibilities between relevant authorities (across
sectors such as public health laboratories and law
enforcement) and develop specific guidelines and
terms of reference addressing biosafety and response
to deliberate release of agents.
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COMPONENT P3:
EMERGENCY PREPAREDNESS PLANNING
Strengths
Maintained and updated cross-sector planning
The CPESS is responsible for preparing and regularly updating a national, multi-sectorial plan for the protection of
citizens, including components of all plans prepared by the various ministries and government agencies, including the
health sector.
A national multi-hazard preparedness plan (under the strategic coordination of Civil Protection) is available covering the
main components necessary to initiate a crisis response. Similar generic plans exist for each district and detailed plans
for specific health threats (avian influenza and influenza pandemic) were developed.
Pandemic preparedness planning
The current national Pandemic Influenza preparedness plan was published in December 2009. MoH intended to update
the plan in 2013, addressing all potential pandemic strains not just H1N1.
Communication plans
The MoH has a "General Communication Plan in Public Health" which includes a communication plan for the public
covering communication for all extraordinary health events including pandemic influenza.
Communication material was produced and tested during the 2009 H1N1 pandemic, based on WHO guidelines and
translated into Moldovan and Russian. Posters were also distributed at the airport.
Problem
Recommendation
P3.1 Public health emergency planning
Health sector preparedness planning focuses mainly on
emergency care services and the emergency response
phase.
The disaster management plan seems not to be geared
to respond to crisis of long duration such as pandemic
flu.
There is a need (MoH) to develop a public health
strategic plan, defining requirements (upsurge
capacity) and responsibilities of all services, and a
detailed plan of specific and cross-sectorial simulation
exercises aimed at testing operational procedures and
training of emergency personnel.
The strategic plan should give considerations to a
multi-hazard approach, defining common managerial
responsibilities concerning dissemination of
information, crisis coordination and definition of roles.
Risk assessment is not formally and systematically
performed for emergencies in the public sector
involving communicable diseases, using modern
methods of risk ranking, to identify vulnerability in the
PH sector and to define the necessary flexibility,
efficiency and resource to respond to PH emergencies
A systematic risk profile on communicable diseases
(vulnerability, impact) should be developed using risk
ranking methodology (cf. ECDC project proposal) as a
basis to inform PH emergency planning for priority
events. A working group could be appointed under
the authority of the NCPH to perform this task in a
timely manner and develop a review programme to
regularly update the ranking (re. P3.2 for operational
plans).
P3.2 Operational response planning for health
emergencies
Specific preparedness and response (operational) plans
are lacking (or outdated) for major public health
emergencies, including templates and guidelines for
assessment of risks, needs, and vulnerabilities planning,
testing, response, risk/crisis communication (including
for deliberate release of biologic agents).
The all-hazard generic plan should be accompanied
by more detailed specific plans, based on a robust risk
assessment (impacts and vulnerabilities), each with
guidelines on hazard-specific issues, such as:

Distancing measures for populations and
rationale for access to services;

Preparedness for mass gathering
management;
Page 61 of 95

Communicable diseases with epidemic
potential (e.g. dengue, cholera, avian
influenza or influenza pandemic) and
zoonoses; consideration to be given to
prolonged crises.

Incidents due to deliberate release
(biological, chemical, radio-nuclear).

Other specific major hazards (environmental,
technological and social) to which the
country is vulnerable.
P3.3 Pandemic influenza planning
An updated national Pandemic Influenza Preparedness
plan (post 2009 pandemic) has not been completed.
not finalized.
A new national preparedness plan for Pandemic
Influenza addressing issues identified during H1N1
2009 pandemic should be developed with reference to
the new WHO guidelines on pandemic influenza
(2013).
Page 62 of 95
COMPONENT P4:
PREPAREDNESS AND RESPONSE OPERATIONS
Strengths
Clarity of operational response planning
The civil protection service has developed a classification of emergency situations based on resources needed for first
response.
The multi-sectorial organisation of the strategic level is reflected at the operational level in response to an emergency,
where the responsibility for coordinating health-related support in a crisis situation is shared between the Ministry of
Health and their Commission for Emergency Situations, the State Agency for Material Reserves, Public Acquisitions and
Humanitarian Aid, the Government’s Interdepartmental Commission for Humanitarian Aid and possible other central,
regional and local authorities.
Specific response plans for major public health events
For management of major public health events caused by biological and radiological agents, specific intervention plans
and operating procedures are developed and enforced.
Cross border agreements
A cross-border agreement (with Romania and Ukraine) exists for deployment of response capacities in case of major
emergencies. This includes provisions for earthquakes and floods.
Moldova has sufficient emergency medical services (rapid response teams) nationwide.
Outbreak detection and response
The communicable disease surveillance system is able to detect unusual and unexpected health events, allowing early
detection, risk assessment and rapid response. Local staff carries out investigations of outbreaks, and national staff are
often involved in support to local epidemiologists for events of major importance.
Problem
Recommendation
P4.1 Clarity of operational responsibility in
public health emergencies
The dispersed capacities to identify, assess, and
manage public health risks and emergencies, as well as
the insufficient cross-sector collaboration at the local
and national levels, make difficult the effective
coordination of response to minimise the impact of
public health emergencies
It would be useful to clearly define the lines of
command and control in public health emergencies,
preferably having the Ministry of Health and their
crisis coordinator as the highest authority.
The NCPH could be delegated by the MoH to develop
an operational preparedness and response plan,
based on the national all-hazard strategic plan. Local
public authorities, could be involved in developing
generic and specific plans (including training and
exercising) beginning from regional and municipal risk
assessment
P4.2 Public health emergency training
There are limited trained human resources in the
primary healthcare and public health systems, to be
able to assess the public health risks, to plan and
evaluate, as well as to report data to the surveillance
system.
An inventory of essential resources and trained
personnel should be developed and maintained,
including the acquisition of modern equipment for
rapid identification and confirmation of threats
(mobile labs and rapid intervention teams)
At the national level refresher training is provided
regularly for epidemiologists involved in response
teams, but at the sub-national level Moldova lacks the
finances for this regular training.
Training programmes need to include not only
emergency medicine and mass casualty management
but also a broad range of topics related to disaster
management and public health.
A programme of regular training of the intervention
Page 63 of 95
teams should be developed on planning, preparing,
estimating the needs and vulnerabilities, evaluating,
managing and communicating the risks, and postintervention evaluation.
P4.3 Rapid response teams
Rapid response teams appear to lack equipment (i.e.
transport, mobile labs) and training in public health
emergencies (planning, risk assessment, risk
management and crisis communication) in line with
international standards and best practice.
A long-term, cost-effective business plan should be
developed for modernising mobile and PPE
equipment, and submitted to relevant authorities
(including donor community) for project funding.
Page 64 of 95
COMPONENT P5:
MONITORING AND EVALUATION
Strengths
Exercising and monitoring of plans at national and rayon level
The Civil protection and Emergency Situations service (CPESS) is responsible for conducting multi-sectorial simulation
exercises in six or seven districts a year, and for reporting on the status of the health sector to the Prime Minister. The
Disaster Medicine Centre has been delegated by the Ministry of Health to be responsible for monitoring and evaluation in
the health sector and takes an active role in this process.
The generic, all-hazard health sector plans at the rayon/municipal level, which are based on a national template, are
reviewed and coordinated by the Disaster Medicine Centre on a yearly basis and approved by the governor of the rayon.
Problem
Recommendation
P5.1 Preparedness of local public health sector
Apart from that which is implemented in cooperation
with the Civil Protection and Emergency Situations
Service, the Public Health sector does not have a
strategy for monitoring and testing the effectiveness of
Rayon health sector plans or the crisis plans of
individual medical services (laboratories, epidemiology
services, PHC).
L5.2 Rayon level public health preparedness
plans
Insufficient human resources in the rayon and
municipal Centres of Public Health to provide complete
and prompt reporting on events with public health
impact and monitor the effectiveness of local plans.
L5.3 Links with EU institutions relating to public
health emergencies
Although international collaboration exists in civil
protection (including links with EU MIC), and the
system has been tested with international inputs, the
links with EU are still to be established, especially in
consideration to the monitoring and evaluation of public
health capacities and capabilities to respond to crossborder health threats.
The preparedness and response plan should contain
a programme of simulation exercises for different
scenarios at national and rayon/municipal levels,
including in individual medical facilities, for example
dealing with an unidentified infectious disease with
a high mortality rate.
The simulation exercises should be extended to
involve the national reference laboratories (see
recommendation L4.3). The exercises should aim at
identifying gaps and procedures to be addressed by
revision of respective plans and establishment of
specific training curricula for personnel.
Lessons learned from the pandemic influenza
response (2009) could be used as case study to
identify gaps of an all-hazard public health
preparedness plan, and to build upon.
Strengthening operational links with the European
Centre for Disease Prevention and Control and
participating actively in relevant disease-specific
networks and training and evaluation projects
(including international simulation exercises, and
system assessments in other countries) would
provide opportunities to review and improve some
of the gaps and give access to EU financial
mechanisms.
Annexes
1
International and National Review Teams, and National Respondents
2
Terms of Reference
3
Legislation, Decisions, Orders relating to Communicable Disease Prevention and Control
4
List of reportable diseases, syndromes, events.
5
Organisational Responders: Public Health Emergencies
Page 65 of 95
Page 66 of 95
Annex 1. International and National Review Teams, and
National Respondents
International team:
Massimo Ciotti, senior expert, public health emergency preparedness, , ECDC (international team leader)
Ivana Bozicevic, epidemiologist, WHO Collaborating Centre, Zagreb.
Graham Fraser, epidemiologist, ECDC.
Katrin Leitmeyer, public health microbiologist, ECDC.
Florin Popovici, medical chief, Romania National Institute of Public Health, Bucharest.
Nabil Safrany, international liaison support, ECDC (Stockholm).
National team:
Stela Gheorghita, epidemiologist, NCPH, Chisinau (national team leader).
Ion Apostol, specialist, NCPH, Chisinau.
Natalia Caterinciuc, epidemiologist, Center for diarrheic and zoonotic diseases, NCPH, Chisinau.
Valeriu Chicu, associate professor, State University of Medicine and Pharmacy, Chisinau.
Radu Cojocaru, public health microbiologist, NCPH, Chisinau.
Anatolie Melnic, epidemiologist, Center for Vaccine Preventable diseases, NCPH, Chisinau.
Constantine Rimis, public health microbiologist, NCPH, Chisinau.
Principal System Respondents in Moldova:
(a) National:
Stela Gheorghita, epidemiologist, NCPH, Chisinau (national team leader).
Valeriu Chicu, associate professor, State University of Medicine and Pharmacy, Chisinau.
Anatolie Melnic, epidemiologist, Center for Vaccine Preventable diseases, NCPH, Chisinau.
Radu Cojocaru, public health microbiologist, NCPH, Chisinau.
Natalia Caterinciuc, epidemiologist, Center for diarrheic and zoonotic diseases, NCPH, Chisinau.
Constantine Rimis, public health microbiologist, NCPH, Chisinau.
Ion Apostol, specialist, NCPH, Chisinau.
(b) Rayon and municipalities:
Luminita Suveica, manager, Center of Public Health, mun. Chisinau.
Nicolai Furtuna, epidemiologist, Center of Public Health mun. Chisinau.
Liliana Domenti – manager, Institute of Phthysiopneumology, Chisinau.
Lucia Pirtina, coordinator of HIV/AIDS program, Dermatovenerology and communicable diseases hospital, Chisinau.
Vorel Bradu, head of the Center of Public Health Ungheni.
Vladimir Lisenco, head of the Center of Public Health Cahul.
Page 67 of 95
Annex 2. Terms of Reference and Itinerary
Expert Mission on Assessment of National Surveillance System for Communicable Diseases
INT MARKT IND/EXP
54525
organised in co-operation with ECDC
Venue: 30.03.2014
Chisinau, Republic of Moldova
31 March - 04 April 2014
For more information on TAIEX assistance and to download presentations of
this event, please go to : http://ec.europa.eu/enlargement/taiex.
Aim of the Expert Mission: Assessment of National Surveillance System for
Communicable Diseases
The objectives of the Assessment of National Surveillance System for
Communicable Diseases include:
1. Assessment of Communicable Diseases national surveillance system components (structure,
process, capacities, effectiveness, coordination) to evaluate the compliance with EU disease
networks;
2. Assessment of the status of preparedness planning to respond to emergencies with
particular reference to intra and intersectoral collaboration with sectors essential for the
functioning of the public health sector;
3. Draw the proposal/plan of action on base of standard tools (strengths, weaknesses,
opportunities, threats) for setting priorities, planning, integration of parallel surveillance
system and the preparedness activities, mobilizing and distribution of available resources.
Page 68 of 95
Expert Mission Agenda
Day 1: Monday 31 March 2014
Time
09:0010.00
Activity
Briefing at the National
Center of Public Health, MoH
10.1511.15
Briefing of the mission
Presentation on the purpose
questionnaire, procedure
expectation from the
evaluation
Ministry of Health
11.3512.35
Visit to the European Union
Delegation to the Republic
of Moldova
EU Delegation to the
Republic of Moldova
Address: 12, Kogălniceanu
str., Chișinau, Tel : 22
505210
12.3513.30
Lunch
13.3017.00
Workshop with national
experts.
- Preparation activities for
evaluation,
- Selection of territories for
evaluation,
- Procedure and Data
Collection Tools,
- Field Testing of
Questionnaire
- Exercises on Field
Assessment
Facility / Venue
National Center of Public
Health
Health
Participants
Experts
Mihail Pisla; NCPH
Ion Bahnarel, NCPH
Stela Gheorghita, NCPH
Anatolie Melnic, NCPH
Radu Cojocaru, NCPH
Natalia Caterinciuc, NCPH
Experts
Svetlana Cotelea, deputy minister
MoH
Carolina Cerniciuc, MoH
Eugenia Berzan, MoH
Mihail Pisla; NCPH
Stela Gheorghița, NCPH
Experts
EU Delegation representatives
Mihail Pisla; NCPH
Experts
Mihail Pisla; NCPH
Radu Cojocaru, NCPH
Valeriu Chicu, Nicolae
Testemitsanu State University of
Medicine and Pharmacy (SUMF)
Ghenadie Curochin, Nicolae
Medicine and Pharmacy
Ludmila Birca, mun. hospital of
contagious diseases in children
Constantin Rimis, NCPH
Nicolae Furtuna, Center of Public
Health mun. Chisinau
Nicolae Gaisan, Center of Public
Health Cahul
Veaceslav Cislari, Center of Public
Health mun. Balti
Viorel Bradu, Center of Public
Health Ungheni
Vasile Bejenaru, Center of Public
Health Edinet
Veronica Lefter, Center of Public
Health Calarași
Anatolie Talmazan, Center of
Public Health Causeni
Page 69 of 95
Day 2 : Tuesday 01 April 2014
Time
07.00
Activity
Departure to the districts
Facility / Venue
Health
10:0013.00
Visits to districts/rayons:
2 groups working in parallel:
I group - Ungheni
II group - Cahul :
Center of Public Health
Ungheni
Center of Public Health Cahul
Interested authorities
13.0013.30
13.3017.00
19.30
Each group will be split in 2
small subgroups (one
international expert and one
national expert):
I subgroup:
- primary health service
- hospital (infectologist,
pulmonologist, dermatovenerealogist etc)
II subgroup:
- veterinary and food safety
service
- rayon level civil emergency
coordinator
Lunch
Field visit in selected
territories: territorial CPH
Both subgroups
- laboratory
- public health service
(epidemiologist and staff;
sanitary inspector)
- other relevant services
Arrival in Chisinau
Ungheni
Center of Public Health Cahul
Participants
Experts
Radu Cojocaru, NCPH
Valeriu Chicu, SUMF
Experts
Valeriu Chicu, SUMF
Radu Cojocaru, NCPH
Vorel Bradu, Center of Public
Health Ungheni
Vladimir Lisenco, Center of Public
Health Cahul
Specialists from the Center of
Public Health Ungheni and Cahul
Experts
Valeriu Chicu, SUMF
Radu Cojocaru, NCPH
Vorel Bradu, Center of Public
Health Ungheni
Vladimir Lisenco, Center of Public
Health Cahul
Public Health Ungheni and Cahul
Page 70 of 95
Day 3 : Wednesday 02 April 2014
Time
08.00
Activity
Coordination meeting
Facility / Venue
Health
10:0013.00
Visits to intermediar and
national level
services/leaders mun.
Chisinau:
2 groups working in
parallel:
I group will work with
national level and will be
split in 2 subgroups: health
and non-health sectors
I subgroup
National CD
surveillance and
control leader
and team (NCPH)
National reference
lab
National
programme
leaders: TB, HIV,
STI
National leader CD
emergency (MoH)
II subgroup
National civil
emergency
programme
leaders (Ministry
of Interior)
Others
II group will be split in 2
subgroups (one international
expert and one national
expert) to visit:
I subgroup
- primary health services
(municipal and rural area)
- hospital
II subgroup
- laboratory
- public health service
(epidemiologist and staff;
sanitary inspector)
- other special relevant
services
Lunch
Health
Chisinau,
Visits to intermediar and
national level
Health
13.0013.30
13.30-
Participants
Experts
Valeriu Chicu, SUMF
Radu Cojocaru, NCPH
Experts
Valeriu Chicu, SUMF
Radu Cojocaru, NCPH
Luminita Suveica, Center of Public
Health Chisinau,
Public Health mun. Chisinau
Liliana Domenti – Institut of
Pneumology;
Lucia Pirtina, coordinator of
HIV/AIDS program , etc
Experts
Page 71 of 95
17.00
services/leaders mun.
Chisinau
mun. Chisinau
Valeriu Chicu, SUMF
Radu Cojocaru, NCPH
Luminita Suveica, Center of Public
Health mun. Chisinau,
Public Health mun. Chisinau
Liliana Domenti – Institute of
Pneumology;
Lucia Pirtina, coordinator of
HIV/AIDS program , etc
Day 4 : Thursday 03 April 2014
Time
09:0013.00
Activity
Preliminary conclusions and
additional visits to
intermediar and national
level health and non-health
services, mun. Chisinau
Facility / Venue
Health
mun. Chisinau
13.0013.30
13.3017.00
Participants
Experts
Radu Cojocaru, NCPH
Nicolai Furtuna, Center of Public
Public Health mun. Chisinau, etc.
Lunch
Feedback workshop with
national experts
Health
Experts
Mihail Pisla, NCPH, Ion Bahnarel,
NCPH
Radu Cojocaru, NCPH
Ghenadie Curochin, Nicolae
Page 72 of 95
Day 5 : Friday 04 April 2014
Time
09.0012.30
12.3013.30
13.3015.00
15.3017.00
Activity
Preparation meeting for
debriefing at the MoH
Facility / Venue
Health
Participants
Experts
Radu Cojocaru, NCPH
Valeriu Chicu, Nicolae Testemitsanu
State University of Medicine and
Pharmacy
Lunch
Debriefing at the Ministry of
Health
Discussions, outcomes,
collaboration perspectives
Ministry of Health
Health
Experts
Svetlana Cotelea, deputy minister
MoH
Carolina Cerniciuc, MoH
Eugenia Berzan, MoH
Mihail Pisla, NCPH
Ion Bahnarel, NCPH
Pharmacy
Radu Cojocaru, NCPH
Experts
Mihail Pisla, NCPH
Ion Bahnarel, NCPH
Pharmacy
Radu Cojocaru, NCPH
Page 73 of 95
Annex 3. Principal Legislation, Decisions, Orders relating to
Communicable Disease Prevention and Control in Republic of
Moldova
Nr.
d/o
Name
Data of
approving
Nr.
Published
Laws
1. Law on State Surveillance of Public
Health
03.02.2009
nr.10-XVI
2. Law on health service
28.03.1995
nr.411-XIII
3. Law on prophylaxis of HIV/AIDS
16.02.2007
nr. 23-XVI
4.
04.07.2008
Nr. 153
Law on control and prophylaxis of
tuberculosis
M.O.nr.67/183
din 03.04.2009
http://lex.justice.md/index.php?acti
on=view&view=doc&lang=1&id=33
1169
M.O. nr. 34, art nr.373 din
22.06.1995
2823
M.O.nr. 54-56/250 din 20.04.07
3271
M.O.nr.143-144, art nr.583 din
05.08.2008
8770
Governmental Decree / Decision
5. Gov. Decision on approving law on
health service
06.08.2007
Nr 886
6. Gov. Decision on approving Strategy of
health system development for period
2008-2017
7. Gov. Decision related to State
Surveillance of Public Health
24.12.2007
Nr. 1471
8. Gov. Decision related to the National
Extraordinary Commission of Public
Health
14.12.2009
Nr.820
9. Gov. Decision on approving Action Plan
for IHR implementation in the Republic
of Moldova
26.03.2008
Nr.475
10. Gov. Decision on approving Strategy on
Public Health for period 2014-2020
20.12.2013
Nr.1032
12.05.2010
nr.
384
MO nr. 127-130/931 din 2007
http://lex.justice.md/md/324940/
M.O nr. 8-10, art nr. 43 din
15.01.2008
http://lex.justice.md/md/326615/
M.O., nr.78-80/455 din 21.05.2010
4620
MO nr 187-188 din 18.12.2009
3111
MO nr 16-17/88 din 26.01.2008
7526
M.O. nr. 304-310, art nr.1139 din
27.12.2013
0833
Page 74 of 95
11. Gov. Decision on approving of gradual
sectoral
framework
for
combating the effects of new pandemic
influenza
A
(H1N1)
in
Republic of Moldova
15.12.2009
Nr.824
12.
Gov. Decision on approving National
Immunization Program for period 20112015
23.12.2010
Nr.1192
13. Gov. Decision on approving National
Program on prevention and control of
HIV/AIDS and STI for period 2011-2015
16.12.2010
nr.1143
14. Gov. Decision on approving National
Program on combating viral hepatitis B,
C and D for period 2012-2016
13.02.2012
Nr.90
15.
Gov. Decision on approving National
Program on control of tuberculosis for
period 2011-2015
21.12.2010
16. Gov. Decision on approving Regulation
related national surveillance and control
of communicable diseases and public
health events
25.11.2013
17. Gov. Decision related to the combating
and prophylactic measures of rabies
06.05.1998
Nr.494
18. Gov. Decision on Sanitary Regulation on
hygiene for health care institutions
23.07.2010
Nr.663
Nr.1171
Nr.951
M.O. nr. 191-192, art nr.927 din
25.12.2009
3177
M.O. nr. 259-263, art nr.1319 din
31.12.2010
7207
M.O. nr. 254-256, art nr.1286 din
24.12.2010
7100
M.O. nr. 34-37
din 17.02.2012,
art Nr : 115
2219
M.O. nr. 259-263, art nr.1316 din
31.12.2010
7204
M.O. nr.284-289 (4602-4607) din
06.12.2013
0538
M.O. nr. 62-65/1998 din 09.07.1998
2497
5428
19.
MoH order/decision
20. MoH order on State Surveillance of
Public Health
21. MoH order on approving of case
definition for diagnosis, recording and
reporting of communicable diseases in
the Republic of Moldova
22. MoH
order
regarding
the
implementation of the Programme for
development of state surveillance public
health Laboratory Network in RM
03.06.2010
12.10.2007
10.06.2013
nr.369
http://www.cnsp.md/info.php?id1=
34&id2=4&page=7
nr. 385
Nr.668
http://www.cnsp.md/down/info137
1468083ro.pdf
Page 75 of 95
23. MoH decision available on
commissioning experimental electronic
surveillance system for communicable
diseases
24. MoH on approving reporting form about
detection of communicable disease,
intoxication, toxi-infection caused by
food and/or occupation site, adverse
effect after vaccination
25. MoH order on the improvement of
surveillance system for influenza and
acute respiratory infections
26. MoH order on enhancing activities on
combating viral hepatitis B,C and D in
RM
31.07.2009
nr.477-d
11.01.2011
Nr.13
http://ms.gov.md/sites/default/files/
legislatie/ordinul_nr._13_din_11.01.
2011.pdf
31.10.2011
Nr.824
http://ms.gov.md/legislatie?field_le
gtip_tid=16&=Caut%C4%83, MoH
order 824
21.09.1998
nr. 264
27. MoH order regarding organization
prevention and combating measures for
cholera and other acute diarrheal
diseases in RM
28. MoH order regarding epidemiological
sentinel surveillance of communityacquired pneumonia in children under 5
years
29. MoH order regarding implementation of
Gov. Decision nr. 475 from 26.03.2008
on approving Action Plan for IHR
implementation in the Republic of
Moldova
30. MoH order Related to prophylactic
measures and combating viral hepatitis
B in RM
03.06.2010
nr.371
legislatie/ordin_no_371_din_03.06.2
010.pdf
23.10.2013
Nr.1190
legislatie/ord._1190_din_23.10.3_su
pravegherea_epidem._pneumonii_c
omunitare.pdf
06.08. 2009
nr.268
14.07. 2004
nr. 211
31. MoH order on implementation of
National Program on combating viral
hepatitis B, C and D for period 20122016
32. MoH order on implementation of
National Immunization Program for
period 2011-2015
30.03.2011
Nr.301
legislatie/ordinul_nr._104_din_16.02
.2011.pdf
33. MoH order on implementation National
Program on prevention and control of
HIV/AIDS and STI for period 2011-2015
34. MoH order on the surveillance and
.2012.pdf
legislatie/ordinul_nr._69_din_03.02.
2011.pdf
16.02.2009
nr.51
http://cnsp.md/down/info13893705
31ro.pdf
35. MoH order on approving forms for
health care
31.10.2011
Nr.828
.2011.pdf
36. MoH order on strategies to eliminate
measles and rubella and surveillance of
these infections
23.01.2006
nr. 37
control of nosocomial infections" that
approved "Guidelines for the surveillance
and control of nosocomial infections"
Page 76 of 95
37. MoH order on changes of the
"Instruction on conducting laboratory
investigation to HIV/ AIDS in blood
donor samples, people from high risk
groups and other contingents of the
population in diagnostic laboratories for
AIDS, hepatitis and other viral
infections"
38. MoH order about testing of blood
donors for HIV / AIDS in blood
transfusion centers in RM
02.04.2002
nr. 64
11.12.2003
nr. 354
39. Epidemiological surveillance on
HIV/AIDA. Standard protocol.
19.01.2007
nr.20
40. MoH order on approving the regulation
for examination and medical
surveillance to detect contamination
with human immunodeficiency virus
(AIDS)
41. MoH order on the implementation of
Gov. Decision nr.1075 from 16.11.2010.
Joint Action Plan of the countries NIS
on combating HIV/AIDS
42. MoH decision on carrying out
surveillance of HIV/AIDS second
generation
31.07.2007
nr. 314
27.12.2011
nr. 842
14.05.2009
nr. 300
43. MoH decision on optimizing the
collection, transportation and release
the results for blood samples for HIV
testing.
44. MoH Order on the optimization of
epidemiological surveillance and
increase the effectiveness of measures
to prevent and combating helmintiasis
in RM"
45.MoH order on the Rules of examination
and medical surveillance to detect
contamination with human
immunodeficiency virus (AIDS)
46. MoH and MoA order on surveillance,
monitoring, prophylactic and combating
of salmonellosis
15.07.2009
nr. 420
23.01.2006
nr. 36
76ro.pdf
08.08.2012
nr.790
M.O. nr.234-236/1329 din 09.11.12
5329
30.09.2004
nr.285
47. MoH order on improving of prophylactic
measures on rabies
12.03.99
nr.74
48. MoH order on improving measures for
diagnostic, prophylaxis and
epidemiological surveillance of
zooantroponosis
49. MoH order on prophylaxis and
combating Bovine spongiform
encephalopathy (Creutzfeldt-Jacob).
10.08.02
nr.218
28.11.01
nr.274
50. MoH order on improving the control and
prevention of yersiniosis
21.05.97
nr.108
Page 77 of 95
51. MoH on epidemiological surveillance of
typhus, the control and prevention of
pediculosis
21.02.2013
Nr.164
legislatie/ord_164_din_21.02.2013.p
df
52. MoH order on achievement
Gov.Decision nr. 663 of 23.07.2010
approving the Regulation on the
hygiene health medical institutions
14.09.2010
Nr.632
http://www.ms.gov.md/sites/default
/files/legislatie/ordin_no_632_din_1
4.09.2010.pdf
53.MoH order on implementation of
measures for prevention morbidity of
diphtheria
18.09.1986
nr. 380
54.MoH order on improving measures for
enhancing activities in prophylaxis
meningococcal infection and
implementation of epidemiological
surveillance
55.MoH order for unification bacteriological
investigations used in clinical-diagnostic
laboratories
01.12.1988
nr.858
22.04.1985
nr.535
56. MoH decision on improving activities of
bacteriological laboratories of CPH
30.12.1997
nr.314
57. MoH decision on implementation of
measures for minimizing of effect of
bioterrorist act in the Republic of
Moldova
58. MoH
decision
on
implementing
biosecurity measures
14.04.2003
nr.105-d
15.04.03
nr.108-d
Guideline
59.“National guidelines and
Operational
Manual
on
second
generation
epidemiological surveillance on HIV/AIDS
in Republic of Moldova”
60.National guidelines and quality
management in laboratory investigation
on HIV/AIDS in RM
61. Toxocarosis
26.12.2013
MoH ord.
nr. 1551
19.01.2007
Ord. MS
nr. 20
62.Standard on epidemiological
surveillance on HIV/AIDS
25.11.2013
63.
16.02.2009
Guidelines for the surveillance and
control of nosocomial infections
09.09.13
64. Ghidelines. Intestinal dismicrobism in
children.
16.05.01
65.Criptosporidasis: ethiopathogenesis,
clinical manifestation, laboratory
diagnostics, epidemiology, combating
28.02.2005
Ghide,
aproved by
MoH order
nr. 0114/16-91
Nr. 951
25ro.pdf
Approved
by MoH
order nr.
51
http://www.cnsp.md/down/info138
9370531ro.pdf
Nr.12
RM nr.
01.10.32.23
Page 78 of 95
and prevention measures
66.Etiology, epidemiology, pathogenicity,
clinical manifestation, laboratory
diagnostics, treatment, combating and
prevention measures strongiloidosis.
67.Echinococcoses (hidatidozis):
etiology, pathogenicity, clinical
manifestation, laboratory diagnostics,
treatment, epidemiology and
prophylactic measures
68.Methods for sanitary – parasitology
investigation in environment objects
28.02.2005
RM nr.
01.10.32.24
15.05. 2012
IM nr.3
20.07. 2011
ord. MS
nr.585
69. Guidance on laboratory biosafety,
(WHO Laboratory biosafety manual, 3th
edition)
2011
88ro.pdf
70. Guidance on regulations for
the Transport of Infectious
Substances
2011
63ro.pdf
Indications, recommendations
71. Methodical indications. Epidemiology of
salmonellosis in humans and animals,
prevention and control measures
23.12.2005
Nr.08c1/2573
72. Recommendation. Rotavirus infection in
children - etiology, epidemiology,
clinical diagnosis, treatment, prevention
24.10.2013
73. Recommendation. Supplementary
measures on prophylaxis and
combating diarrheic diseases in
children.
74. Methodical indications. Epidemiology,
diagnosis
and prophylaxis of Lyme
borreliosis
28.02.2005
Nr.01.10.3
2.2-2
23.03.2006
08a-1/557
75. Methodical indications. Microbiologic
diagnostics of diarrheic diseases
24.08.2012
Nr.7
76. Methodical indications. Determination of
bacterial sensitivity to antimicrobial
preparations by diffusion method.
24.08.2012
Nr.8
77. Indications.
Epidemiology,
clinical
manifestation,
and
epidemiological
surveillance for tularemia
14.01.97
Nr.7-d
78. Indications.
Epidemiology,
clinical
manifestation,
and
epidemiological
surveillance for leptospirosis
14.01.97
Nr.8-d
79. Indications.
Epidemiology,
clinical
manifestation,
and
lab.diagnostic,
16.06.1999
06.3.9.27
Page 79 of 95
epidemiological surveillance for anthrax
80. Indications.
Epidemiology,
clinical
manifestation,
lab.diagnostic,
epidemiological
surveillance
and
prophylaxis for Q fever
22.12.1999
Nr.06.3.9.3
1
81. Indications.
Epidemiology,
clinical
manifestation,
and
epidemiological
surveillance for brucelosis
17.12.2001
Nr.06.9.3.4
7
82. Indications. Clinical manifestation, and
epidemiological surveillance for
spongiform encephalopathy
07.03.2003
Nr.06.9.3.4
8
83. Indications. Microbiologic diagnostic of
campilobacteriosis
22.06.2006
84. Indications. Collecting, evidence and
prognosis
of
number
of
small
micromammals
12.10.2012
Nr.9
Food safety
85. Law regarding food
18.03.2004
nr. 78
86. Gov. Decision on approving Regulation
regarding microbiological criteria for
food
16.03.09
nr.221
08.11.07
(anex nr.4)
nr.120
9
88. Government Decision approving
sanitary regulations on food
supplements
02.09.09
nr.538
89. Government Decision on approving
Sanitary Regulations on new food
products
31.12.09
nr.925
Sanitary Regulations for contaminants
in food
22.06.10
nr.520
91. Government Decision on approving of
General Regulations on food hygiene
25.05.10
Nr.412
87. Gov. Decision on catering services
M.O., nr.83-87/431 din 28.05.2004
3238
M.O. nr.59-61/272 din 24.03.09
1096
M.O., nr.180-183/1281 din 23.11.07
5940
M.O, nr.138-139/603 din
08.09.2009
2200
M.O., nr.2-4/16 din 15.01.2010
3395
M.O., nr.108-109/607 din
29.06.2010
5039
M.O., nr.83-84 din 28.05.10
4708
Page 80 of 95
Sanitary Regulations on infant formulas
and formulas of preparations for infants
and toddlers
Sanitary Regulations on food additives
11.05.11
Nr.338
29.03.13
nr.229
M.O., nr.82 din 17.05.11
8552
M.O. nr.69-74 din 05.04.13
7280
Page 81 of 95
Annex 4. List of reportable diseases, syndromes, events.
Infectious diseases and special health events reportable in the Republic of Moldova
(with indication of diseases and health events reportable to EU level)
Anexa nr. 1 la ordinul MS nr. 385 din 12.10.2007
Denumirea
Boli aflate în
supraveghere în
UE*
2
3
Nr.d/r
1
I.
Boli transmisibile
1.
Amibiaza
2.
Antraxul
3.
Ascaridioza
4.
Boala (infecţia) meningococică
5.
Borrelioza Lyme (Boala Lyme)
6.
Botulismul
*
7.
Bruceloza
*
8.
Criptosporidioza
*
9.
Dermatomicozele
10.
Difteria
*
11.
Echinococoza
*
12.
Enterobioza (oxiuriaza)
13.
Febra Galbenă
*
14.
Febra hemoragică de Crimeea-Congo
*
15.
Febra hemoragică Lassa
*
16.
Febra hemoragică Marburg/Ebola
*
17.
Febra Q
*
18.
Febra tifoidă şi paratifoidă
*
*
*
Page 82 of 95
19.
Gonorea
*
20.
Gripa aviară
*
21.
Gripa umană
*
22.
Hepatita virală A
*
23.
Hepatita virală B
*
24.
Hepatita virală C
*
25.
Hepatita virală D
26.
Hepatita virală E
27.
Himenolepidoza
28.
Holera
*
29.
Infecţia cu Campylobacter
*
30.
Infecţia cu Citomegalovirus
31.
Infecţia cu Escherichia coli Entero- Hemoragică (EHEC)
32.
Infecţia enterovirală
33.
Infecţia genitală cu Chlamidia trachomatis
*
34.
Infecţia cu Haemophilus influenzae tip b, invazivă
*
35.
Infecţia rotavirală
1
2
*
3
36.
Infecţia cu Streptococcus pneumoniae, invazivă
*
37.
Infecţia cu virusul West Nile
*
38.
Infecţia cu virusurile Herpes simplex
39.
Lambliaza (Giardiaza)
*
Legioneloza
*
41.
Leptospirozele
*
42.
Listerioza
*
43.
Malaria (paludismul)
*
44.
Mononucleoza infecţioasă
45.
Oreionul (parotidita epidemică)
40.
*
46.
47.
Page 83 of 95
Ornitoza
Pertussis (tusea convulsivă)
*
48.
Pesta
*
49.
Poliomielita paralitică
*
50.
Rabia umană (turbarea)
*
51.
Rubeola şi rubeola congenitală
*
Rujeola
*
53.
Salmonelozele (non-typhi, non-paratyphi)
*
54.
Scabia
55.
Scarlatina
56.
Shigellozele
*
57.
Sifilisul
*
58.
Sindromul acut respirator sever (SARS)
*
59.
Sindromul Imunodeficienţei Dobândite (SIDA)
*
60.
Infectarea cu HIV
*
61.
Tetanosul neonatal
62.
Tetanosul şi tetanosul obstetrical
63.
Tifosul exantematic şi boala Brill
64.
Toxoplasmoza
*
65.
Trichineloza (Trichinoza)
*
66.
Trichocefaloza (Trichuriaza)
67.
Tuberculoza
*
68.
Tularemia
*
69.
Variantă nouă a maladiei Creutzfeldt-Jakob
*
70.
Varicela
71.
Variola
*
72.
Yersinioza
*
52.
II.
Probleme speciale de sănătate
*
Page 84 of 95
73.
Boli diareice acute
74.
Infecţii acute ale căilor respiratorii superioare
75.
Infecţii nosocomiale
*
76.
Reacţii adverse şi complicaţii postvaccinale
*
77.
Rezistenţa antimicrobiană
*
78.
Toxiinfecţii alimentare
*
Page 85 of 95
Annex 5. Health Emergency Response Organisations
Governmental Level
Civil
Protec
Public
Health
Legal
draft
Exec
Plan
Oper
Evid
base
Info
Mgnt
Train
Eval
Responsibilities
x
Main body responsible for implementing
preventive measures, verifying emergency
preparedness and managing emergency
situations, generated by all hazards. The
Commission is chaired by the Prime
Minister and includes representatives from
all ministries and departments.
Government Commission for Emergency Situations
x
The Commission has executive functions
for prevention and response in all-hazard
emergencies. The Commission is chaired
by the Prime Minister. The Deputy-Prime
Ministers, the Minister of Internal Affairs
and the Head of Civil Protection and
Emergency Situations Service of the MIA
are Vice-Chairmen. The Commission’s
composition includes the heads of relevant
Central Public Authorities.
Civil Protection and Exceptional Situations Service (CPESS)
x
x
x
x
x
National multi-sectorial agency and
working body of the Government
Commission for Emergency Situations,
under the authority of the Ministry for
Internal Affairs, and acting as the
secretariat (implementing body) of the
Government Commission.
Responsible for development of the
National Multisectoral Plan for Civil
Protection that includes components from
the sector plans of the ministries and
government agencies.
National Extraordinary Commission for Public Health
x
x
x
x
Responsible for an integrated approach on
prevention and management measures,
multi-sectorial mobilization and
coordination of response to public health
threats and emergencies.
Ensures an adequate degree of
preparedness for public health
emergencies and their management. One
of the Deputy-Prime Ministers is appointed
as Commission's Chairman and Minister of
Health is appointed as Vice-Chairman. The
Commission’s composition includes heads
(or deputies) of relevant Central Public
Page 86 of 95
Authorities, as well the chiefs of central
level health structures. The Commission
has the right to declare/cancel the state of
emergency in Public Health.
Coordinating bodies subordinated to the Ministry of Health
MoH Commission for Emergency Situations
x
x
Under the authority of the MoH.
Ensuring an adequate degree of the
Health System preparedness for public
health emergencies, as well as providing
management of measures on prevention,
mitigation, response and recovery in case
of their occurrence.
State Public Health Surveillance Service
x
Includes the National Center for Public
Health, Public Health Centers of Chisinau
and Balti municipalities and 34 public
health centers at district level. In case of
emergency situations such as outbreaks
the public health centers perform antiepidemic and sanitary-hygienic measures.
The public health centers are part of the
National laboratory Network.
National Scientific and Practical Centre of Emergency Medicine (NSPCEM)
x
x
Tertiary level medical institution, providing
emergency medical care, including for
mass casualty. NSPCEM is a coordinating
body of the Medical Emergency Service
and Disaster Medicine Service.
Centre for Disaster Medicine (RCDM)
x
x
x
x
x
x
(A specialized subdivision within NSPCEM)
is responsible for planning and
coordinating the work of all components
of the Disaster Medicine Service. RCDM
gathers and analyzes information on
potential risks triggering emergency
situations, plans the organisation of
medical care in cases of mass casualty,
performs training of medical personnel of
the health institutions in preparedness and
response to public health emergencies,
and evaluates the level of preparedness of
medical institutions. In case of threat or
outbreak of large-scale RCDM’s staff is
deployed to the MoH and provides
operational guidance to the Commission’s
Page 87 of 95
Operative Command Center.
National Centre of Public Health (NCPH)
x
x
x
x
x
Implementing body of the National
Extraordinary Public Health Commission.
Scientific, technical and coordinating
institution of the MoH Service of State
Surveillance. NCPH provides evidence
basis for public health policies and
strategies, develops drafts for sanitary
regulations, methodologies and other acts
on public health, ensures research and
development of expertise, provides
support to rayon and municipal Centres of
Public Health and performs other activities
on Public Health Surveillance. NCPH’s
functions include emergency preparedness
and interventions in public health
emergencies, in collaboration with the
relevant services of other ministries and
central authorities. NCPH is the
designated National Focal Point for
International Health Regulations (IHR). At
this end the Section of public health alerts
monitoring and disease notification,
performs early warning functions.
LocaL Level
Emergency Medicine Zonal Stations
x
x
Functional and structural components of
the Medical Emergency Service at the prehospital stage. They are accountable to
the Ministry of Health and provide
emergency medical care in their
jurisdictions (zone). They include district
Emergency Medicine Substations and
Emergency Medicine Points, located in the
served area. Currently there are 4
Emergency Medicine Zonal Stations in the
country: North, Central, South and
Autonomous Territory of Gagauzia.
x
Provides emergency medical assistance to
population in pre-hospital stage (including
in cases of mass casualty events) and
assisted medical transportation of patients
from the accident or illness area to
designated health facilities.
Structurally the Service consists of
NSPCEM, which is both a specialized
Emergency Medical Assistance Service
x
Page 88 of 95
hospital and coordination body of the
Service, 4 Emergency Medicine Zonal
Stations with 41 Emergency Medicine
Substations and 88 Emergency Medicine
Points. Distributed in the country there are
about 250 ambulance team on duty, as
first response for emergency medical
assistance of population in case of mass
casualty events.
Hospital system
x
x
Consists of:
a) 62 public hospitals, including:
- 34 district hospitals;
- 10 municipal hospitals;
- 18 republican hospitals;
b) 10 departmental hospitals;
c) 10 private hospitals.
The total number of public hospital beds is
tallying up to 20,021 (561.0 hospital beds
per 100,000 people). Over 50 per cent of
hospitals (16 national hospitals, 9
municipal hospitals, 8 public departmental
hospitals and 8 private hospitals) with
9,369 beds overall, or 46.8 per cent of the
total number of hospital beds, are in the
municipality of Chisinau. The remaining
hospitals, most of which are district-level
inpatient facilities, are located all over the
country.
Medical units
x
x
In addition to their basic functions, most
medical institutions are required to create
and maintain units with different
healthcare profiles. According to the
national Plan of health care in the event of
Emergency Situations health care
institutions in the country are responsible
to maintain the following number of units:
- paramedical teams – 620; - medical
teams – 488 - specialized medical teams –
90 - preventive medicine teams – 42 medical detachments - 3
x
Based at family doctors' centers, health
centers, district and municipal hospitals to
be mobilized in case of emergency,
together with ambulance teams, prehospital medical and emergency care.
x
Usually created by republican and
municipal hospitals in order to strengthen
the capacity of medical institutions,
directly involved in providing medical
assistance in emergency situations, by
providing specialized medical care.
Paramedical and medical teams
x
Specialized medical teams
x
Page 89 of 95
Civil Protection’s first aid teams
x
x
Teams created on voluntary principle by
private companies, enterprises,
educational institutions, local authorities,
etc. to provide first aid to injured people
in emergency situations, their evacuations
outside the outbreak zone and their
concentration in gathering points.
The responsibility for the aid teams’
preparedness lies on the directors of
facilities to which they belong. In the
event of a public health threat or outbreak
the teams go under the responsibility of
the health authority of the respective
emergency situation’s commission.

Final Report - Moldova Assessment

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