IHR implementation

Preben Aavitsland

Department of Infectious Disease Epidemiology

Norwegian Institute of Public Health

at

EpiTrain V, Vilnius, October 22 2007

Contents

Contents of IHR1. Background and purpose2. IHR suveillance system3. WHO’s many sources of epidemic intelligence4. National IHR Focal Point5. Member states’ obligations to build capacities

Main challenges for countries1. WHO’s power to define an event2. No political interference3. Build capacities worldwide4. No withholding of information5. No excessive response

Conclusion

Background

• Increased need for international public health security and cooperation– New diseases (SARS!)

– More international travel

– More people

• Old IHR almost useless– Only cholera, plague and yellow fever

– Dependent on official notification

– No incetives for notifications

– No formal cooperation mechanisms

– No dynamics in international response

Outline of the IHR

Part I Definitions and purpose

Part II Surveillance and response (annex 1+2)

Part III WHO recommendationsconcerning specific threats

Part IV –

VIII Routine measures

Part IX Procedures

Part X Reservations, disputes, etc

Key contents of the IHR

• A new international system for epidemic intelligence

• A procedure for WHO’s recommendations to guide the response to public health emergencies of international concern

• A set of international rules on routine measures against international disease spread

Purpose of IHR (Art 2)

The purpose and scope of these Regulations are to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.

The IHR surveillance system

National IHR Focal Point

WHOLocal level

assess

national

eventsdo surveillance

notify,

inform,

consult in

confidence

Event based surveillance

• From disease list to event definition

• A difficult, but rational change– The disease + the circumstances

– Undiagnosed diseases

– New diseases

Decision instrument(annex 2) to determine whether an event may be a public health emergency of international concern (pheic)

Simlified by Baker & Fidler, 2006

Any event of potential international public health concern, including those of unknown causes or sources

A case of the following diseases is unusual or unexpected and may have serious public health impact, and thus shall be notified: Smallpox, Poliomyelitis due to wild-type poliovirus, Human influenza caused by a new subtype, Severe acute respiratory syndrome (SARS).

Yes No Yes No

Is the public health impact of the event serious?

Is the event unusual or unexpected?

Is there a significant risk of international spread?

Is there a significant risk of international travel and trade restrictions?

Two or more yes notify WHO.

Events detected by national surveillance system

Notification is a start of a dialogue(i.e. ”not a big deal”)

Potential pheic notified by country

Pheic declared by WHO

Dia

log

ue

High sensitivity, low positive predictive value

The IHR surveillance system

National IHR Focal Point

WHOLocal level

Mass media, GPHIN, MediSYS, Google, NGOs, ProMED etc + other countries

assess

national

eventsdo surveillance

notify,

inform,

consult in

confidence

verify

do surveillance

WHO’s use of other information

• The country no longer has monopoly on informing WHO

• A reform worth fighting for!

• WHO must verify information with country

• WHO can keep source confidential

All of us are now event-detectives for WHO An important role for e.g. the ProMED network

If you think your Government is delaying notification write in ProMED

National IHR Focal Point (Art. 4)

• An office (not individual) designated by the country

• Accessible at all times for communications with the WHO– Direct telephone, fax and generic institutional

e-mail address

• Communicate contact details to WHO– Through Ministry to Director General of WHO

Communications

National IHR Focal Point

WHO EURO IHR Focal Point

Surveillance responsible

Points of entry

Public health services

Clinics and hospitals

National IHR Focal Point tasks I• Article 6: Notification of all events which may constitute a

pheic• Article 7: Information-sharing during unexpected or unusual

public health events• Article 8: Voluntary information to WHO of other events and

consult on health measures• Article 9: Information to WHO of public health risk identified

outside the country evidenced by imported/exported human cases, or contaminated vectors or products

• Article 10: Responding to WHO requests for verification of reports from other sources

• Article 11: Receiving information from WHO on events in other countries

• Article 12: Consulting with the WHO Director-General on determination and termination of a pheic

National IHR Focal Point tasks II

• Forward information from WHO– on public health risks

– on potential pheic

– on temporary and standing recommendations

– other information

• to the relevant sectors of administration– those responsible for surveillance

– points of entry

– public health services

– clinics and hospitals

– other

National IHR Focal Point tasks III

• Consolidating input from relevant sectors of administration– those responsible for surveillance

– points of entry

– public health services

– clinics and hospitals

– Other

• Establish efficient and functional channels of communication

• Input which is necessary for the analysis of national public health events and risks

Obligations to build capacities

Article 5+13 and Annex 1A: Epidemic intelligence

• Detect events• Report events• Assess events• Notify events to WHO• Respond to events

Article 20 and Annex 1B: Airports, ports, ground crossings capacities

• Access to medical service

• Safe environment• Access to rooms for

interview, quarantine, isolation

• Ability to disinsect, disinfect etc.

Local level capacities

Surveillance

• Detect outbreaks of disease or death

• Report immediately to higher level

Response

• To implement preliminary control measures immediately

Regional level capacities

Surveillance

• Confirm status of events

• Assess events immediately

• Report to national level

Response

• Support or implement additional control measures

National level capacities

Surveillance

• Assess all events within 48 hours

• Notify WHO

Response (24 h per day)

• Determine control measures

• Provide lab support

• Provide on-site assistance

• Provide operational links with officials, ministries, hospitals, entry points

• Have emergency plan

Two phases

Phase 1:15 June 2007 –15 June 2009

• Assess surveillance and response capacity requirements described in Annex 1A of the IHR (2005)

• Develop national action plans to ensure that these core capacities are present and functioning throughout the country

Phase 2:15 June 2007 –15 June 2012

• Surveillance and response capacities set out in Annex 1A must be implemented

• (An additional 2-year period until 15 June 2014 may be granted)

Main challenges for countries

1. WHO’s power to define an event

2. No political interference

3. Build capacities worldwide

4. No withholding of information

5. No excessive response

”Acute watery diarrhoeal syndrome”

Determining whether event is pheic

Detect

Determine

Notify

Publication + measures

Old IHR

Detect

Determine

Notify

Publication +measures

New IHR

WH

OC

ountr

y

The ramification of notificationhas changed

• Notification does not imply that an event is a pheic• Notification is just “telling WHO about an event”• Notification has no immediate consequences for

your country

• WHO can know about the event from other sources• WHO can start assessing the event without

country’s official notification• It is the event itself - not the official notificiation of

it - that is the basis of WHO’s determination of pheic

This is the revolution of the new IHR!

• Countries have given WHO the power to determine events that can invoke IHR measures

• WHO is working on behalf of us all in– doing epidemic intelligence

– determining pheic

– recommending measures

Non-political surveillance

• Old IHR: Political interference in public health surveillance, because of fear of travel/trade sanctions

• Deciding to notify WHO of a possible pheic is a professional public health decision, not a political one

• Avoid elaborate decision systems for WHO notification

Build capacities worldwide

• Global surveillance not stronger than the weakest link

• Annex 1 is a powerful capacity list– Build multipurpose capacities

• Use annex 1 to get resources– Your government signed up to it

• Assist other countries– Annex 1 as a checklist for your international

development agency

Notify WHO early

• Incentive 1: Confidential dialogue

• Incentive 2: IHR protection against unjustified measures

• Incentive 3: Assistance by WHO and other countries

• Incentive 4: WHO will know sooner or later anyway

The Kon-fu-tse principle of surveillance

”Notify to WHO the events that you would like to know about if they occured in your neighbour country.”

National laws on communicable diseases

Stop the national spread of the disease

Protect the rights of the

individuals with disease

and cause minimal harm

International lawon communicable diseases (=IHR)

Stop the international spread of the disease

Protect the sovereignty of

states and cause minimal

harm (restrictions)

Additional measures

• Measures beyond WHO recommendations possible (art 43)– But need public health rationale and scientific

information

• Should be avoided

• May undermine the whole IHR– Especially if poorly justified measures against

poorer countries

Conclusions

• IHR are a major step forward in global epidemic intelligence– Not perfect, but as good as was possible

• Shifting power from countries to WHO (which works on behalf of all countries)– Multilateral solutions

• Actual use more important that wording– We can all make the IHR work by respecting the spirit

of IHR: early sharing of information + the right and non-excessive health measures

• National capacity building is important