International Health RegulationsInternational Health RegulationsInternational Health RegulationsInternational Health Regulations

A response to global threatsA response to global threatsA response to global threatsA response to global threats

Kamel Senouci, MD, MSc

Pan American Health Organization / World Health Organization

From Guénaël Rodier, Director, IHR Coordination, WHO, Geneva

““““ Fifth annualFifth annualFifth annualFifth annual”””” One Medicine symposiumOne Medicine symposiumOne Medicine symposiumOne Medicine symposium

Globalization and emerging risks:

a one medicine approach to a changing world

Durham, NC, 12th December 2007

• Population growth

• Population ageing

• Population movements

• Urbanization

• Biotechnologies

• Food processing

• Globalized trade

• Access to remote biotopes

• Industrial pollution

• Climate change

• …

A Changing World A Changing World A Changing World A Changing World

A Changing World A Changing World A Changing World A Changing World

l Collapse of public health infrastructure

l Ineffective vector control programmes (WNV, Malaria, Chikungunya…)

l Development of antimicrobial resistance (e.g. XDR-TB)

l Worries about accidental or deliberate release of biological, chemical, or nuclear, agents

l …

Events of potential international public health concern, Events of potential international public health concern, Events of potential international public health concern, Events of potential international public health concern,

January 2001 – June 2007 (n=1976)

Avian Flu, EU$500m

1996 1997 1998 1999 2000 2001 2002 2003

$50bn

$40bn

$30bn

$20bn

$10bn

Estim

ate

dcosts

BSE, UK $10-13bn Foot&Mouth Disease

Taiwan, $5-8bn

1992 1993 1994 1995

Foot-and-Mouth DiseaseUK

$30bn

Avian FluAsia, US, Canada

$10bn

2004

BSE, US $3.5bn

BSE, Canada$1.5bn

Lyme diseaseUS, $2.5bn

SARSChina, Hong Kong,

Singapore, Canada,…$50bn+

Nipah, Malaysia$350-400m

Swine Flu, Netherlands

$2.3bn

BSE, Japan 1.5bn

Economic Impact of Economic Impact of Economic Impact of Economic Impact of

Recent EpidemicsRecent EpidemicsRecent EpidemicsRecent Epidemics

Estimated Economic Impact,

Pandemic Influenza

Source: Oxford EconomicForecasting Group

International Health Regulations (2005)

From control of borders to [also] containment at source

From 3 diseases to all public health threats

From preset measures to adapted responses

IHR(2005) entered into force on

15 June 2007 (or 18 July 2007)

What Countries Must Do: National Focal Point

►OBLIGATIONS

►Remaining accessible 24/7

►Sending urgent communications to WHO IHR Contact Points

►Consolidating inputs and disseminating information to relevant sectors - points of entry, public health services, clinics and hospitals and other government departments

ResponseVerificationAssessmentInvestigation

National SurveillanceSystem

National LaboratorySystem

Detection(Early

Warning)

Veterinarian SurveillanceSystem

Food Surveillance

Notification/Risk

Communication

National Health Emergency Response System

Health Care

Services

Public Health Measures

Health Care

Services

The Role of the

National Epidemic Alert

and Response System

Media, General Public

Authorities/Decision Makers

WHOInternational

Unofficial (Rumors)Sources

What Countries Must Do: National Core Capacities

► Assessment of events

►Using the annex 2

IHR(2005) Decision instrumentIHR(2005) Decision instrumentIHR(2005) Decision instrumentIHR(2005) Decision instrumentIHR(2005) Decision instrumentIHR(2005) Decision instrumentIHR(2005) Decision instrumentIHR(2005) Decision instrumentEvents detected by national surveillance system

Cholera

Pneumonic plague

YF, VHF, WNF,

Diseases with

national/regional

concern

Smallpox

Polio wild-type

HI new subtype

SARS

Any event

potentially

PHEIC

NOTIFICATION TO WHO

4 criteria for risk assessment

IHR(2005) Decision instrumentIHR(2005) Decision instrumentIHR(2005) Decision instrumentIHR(2005) Decision instrumentIHR(2005) Decision instrumentIHR(2005) Decision instrumentIHR(2005) Decision instrumentIHR(2005) Decision instrument4 CRITERIA FOR RISK ASSESSMENT

Is the PH 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 or trade restrictions?

Is the event unusual

or unexpected?

Is there a significant risk

of international spread

NOTIFICATION TO WHO

REASSESS

no

yes

no

no

no

no

no

yes

yes

yes

yes

yes

The Role of NFP and The Role of NFP and

PAHO/WHOPAHO/WHO

IHR NATIONAL FOCAL POINT

IHR ReportsDisseminatePublic Health Information

Assistance Response

WHOWHO

Event Risk Assessment

•NOTIFICATION OF POTENTIAL

PUBLIC EMERGENCY OF INTERNATIONAL

CONCERN (PHEIC)

•CONSULTATION

Verification

OTHER SOURCES

INFORMAL / UNOFFICIAL INFORMATION

Initial screen

Initial screen

The Role of PAHO/WHOThe Role of PAHO/WHO

Epidemic Intelligence

Epidemic Intelligence

INFORMAL SOURCESGlobal Public Health Intelligence

Network (media), NGOs

FORMAL SOURCESWHO laboratory networks, (sub-)regional networks,

WROs & MoH, UNOs, OIE…

VerificationVerification

ResponseResponse Global Outbreak Alert and Response Network

COORDINATIONOPERATIONAL

SUPPORTRISK COMMUNICATIONPUBLIC HEALTH

SERVICES

Risk AssessmentRisk Assessment

HQREGIONAL OFFICESCOUNTRY OFFICES

• Epidemiology • Laboratory• Clinical

• Logistics • Communications• Security

• Social Mobilization• Behaviour Change

OFFICIALSOURCES

e.g. WRO, MoH, OIE, FAO

UNOFFICIAL SOURCES

E.g. NGOs, WHO CCs

►Activity from January 2007 to September 2007

0

5

10

15

20

25

30

35

40

45

50

WHO & NFP assessment

concluded

WHO & NFP assessment

ongoing

Information only

From Jan to Sept 2007, PAHO

identified 57 events of potential

importance for international public

health

43 (75%)

9 (16%)

5 (9%)

What Countries Must Do: National Focal Point

What Countries Must Do: National Core Capacities

► Core capacities for surveillance and response

►3 levels: National, Intermediate, Local

►Detection, verification, evaluation,

►All type of events

►Report to WHO

►Response

► Core capacities at Points of Entry

►Detection, verification, evaluation,

►Ports, airports, ground crossings

Areas of work for IHR implementation

► Other Intergovernmental organizations

e.g. FAO, OIE, ICAO, IMO, UNWTO …

► Development agencies

e.g. AFD, CIDA, DFID, JAICA, USAID, ADB, ASEAN, EC, MERCOSUR, WB …

► WHO Collaborating Centres and Technical partners

International Networks / National agencies / NGOs: e.g. GOARN, IANPHI, Pasteur IN, MSF, TEPHINET, GEISS, CDC, ECDC, HPA, InVS …

► Industry associations e.g. ACI, IATA, ISF, ISO …

• Health system

• Epidemiology

• Laboratory

• Preparedness

• Case management

• Infection control

• Social mobilisation

• Communication

• …

• Ports

• Airports

• Ground crossings

23 of 66 articles and 8 of 9 annexes

directly address travel, trade, and

transport.

► A commitment of countries (e.g. National budget line)

► Build on existing national and WHO regional strategies for

surveillance and response

e.g. National Pandemic Preparedness Plans

► Direct support from WHO Regional Offices

► Technical guidance from WHO Offices

and WHO Collaborating Centres e.g. CDC, NIH, Universities …

June 2007 – June 2009

Assessing Public Health Resources

Surveillance and response capacity

– Early warning and detection systems (information, communications etc)

– Human resources (rapid investigation teams, surveillance officers, …)

– Equipment and drugs (PPEs, sampling materials, drugs, stockpiles)

– Who's doing what and where(NGOs, government, private )

June 2009 – June 2012

Implementing national action plans

Surveillance and response system

– Investigation/response team

– Safe transport of specimens

– Reference laboratory

– Laboratory EQA programme

– Epidemiology & data analysis

– Risk assessment

– Case management

– Communication

– Social mobilization

– Inter-sectoral collaboration

► At all times

• Access to medical service

• Transport of ill travellers

• Inspection of conveyances

(e.g. Ship Sanitation Control Certificate)

• Control of vectors / reservoirs

► For responding to events

• Emergency contingency plan

• Arrangement for isolation (human, animal)

• Space for interview / quarantine

• Apply specific control measures

(Annex 1B)

• Intelligence

• Verification

• Risk assessment

• Response (GOARN)

• Logistics

• …

• Influenza

• polio• SARS• smallpox• cholera• meningitis• yellow fever• food safety• chemical safety• radionuclear safety• …

Risk AssessmentRisk Assessment

Verification with Member States

Verification with Member States

Initial ScreeningInitial Screening

Response Strategy and OperationsResponse Strategy and Operations

► Notification

► Consultation

► Verification

IHR National IHR National IHR National IHR National

Focal PointFocal PointFocal PointFocal Point

WHO IHR Contact WHO IHR Contact WHO IHR Contact WHO IHR Contact

PointPointPointPoint

"Shall be accessible at all times" (Art. 4)

IHR Communications

WHO Regional

Office

Designated national

institutionEvent Management System

Event Management System

PAHOPAHO

AFROAFRO

WPROWPRO

HQHQ

SEAROSEARO

EMROEMRO

EUROEURO

PAHOPAHO

AFROAFRO

WPROWPRO

EMROEMRO

SEAROSEARO

Event Management System

WHO Portal

Operations

Member States

IHR Event Information Site for IHR Event Information Site for IHR Event Information Site for IHR Event Information Site for IHR Event Information Site for IHR Event Information Site for IHR Event Information Site for IHR Event Information Site for NFPsNFPsNFPsNFPsNFPsNFPsNFPsNFPs

GOARN: Institutions and Partner NetworkGOARN: Institutions and Partner NetworkGOARN: Institutions and Partner NetworkGOARN: Institutions and Partner Network

GOARN SiteGOARN SiteGOARN SiteGOARN Site

Operational Support Team

GOARN management

Field epidemiology unit

Logistics unit

Field logistics

Stockpiles

Logistics mobility unit (Dubai)

Electronic tools

Event Management System (EMS)

Field Information Management System (FIMS)

Early Warning Alert and Response System (EWARN)

Strategic Health Operations Centre (SHOC)

GOARN WHO Support SystemGOARN WHO Support SystemGOARN WHO Support SystemGOARN WHO Support System

1 laboratory

�1 laboratory

national network

Annual output

175-200,000 samples

15-40,000 isolates

2-6000 viruses characterized

WHO Human Influenza Collaborating Centers

115 National Influenza Centers (NIC) in 84 countries

Seasonal Vaccine

Composition

Seasonal Vaccine

Composition

e.g. Global Influenza

Surveillance Network

Strengthen threatStrengthen threatStrengthen threatStrengthen threat----specific control programmesspecific control programmesspecific control programmesspecific control programmes

• Anthrax

• Anti-microbial resistance

• Arboviruses (e.g. Rift valley fever, West Nile fever)

• Chemical Safety

• Cholera and other epidemic diarrhoeal diseases

• Dengue

• Food safety

• HIV/AIDS

• Influenza (seasonal, avian, and pandemic threat)

• Malaria

• Measles and other vaccine-preventable diseases

• Meningococcal meningitis

• Poliomyelitis eradication initiative

• Radiation and environmental health

• Smallpox

• SARS and other severe acute respiratory infections

• Tuberculosis

• Yellow Fever

• Viral haemorrhagic fevers (e.g. Ebola, Marburg, Lassa)

• Zoonoses

►> 95% of

day-to-day

threats to

international

health

security !

►> 95% of

day-to-day

threats to

international

health

security !

… / …

► IHR Roster of Experts

► Emergency Committee

► Review Committee

► Progress report to the World Health Assembly

► National and international awareness

►Playing “the game” or not…

► Intersectoral collaboration

• Health, Agriculture, Education, Defence, Transport, Trade

► Resource mobilization

• Countries (national budget) with initial support from bilateral

donors, WHO, foundations, private sector, …

• “Rich” countries supporting the “poor” countries…

Main Challenges

Kamel Senouci, MD, MScHealth surveillance and disease management, Communicable diseases

Epidemic Alert and Response Team, IHR regional focal pointPan American Health Organization / World Health Organization

Thank you

www.who.int/ihrwww.paho.org