Workshop: The State of National Governance Relative to the
International Health Regulations (2005)
Ottawa, Canada, 20-21 September 2006
Overview: United States of America
Anthony A. Marfin
Centers for Disease Control and Prevention
Goal
Describe the extent to which United States
has a system of governance that will enable
effective implementation of the revised
International Health Regulations 2005
Background: Political Structure
• Federal system of government
• States independent sovereign governments
• States retain powers not expressly
delegated to Federal government
• Full presidential system
Who does public health?
•
Concurrent jurisdiction
•
•
U.S. Constitution division of jurisdiction:
“[P]owers not delegated to the United States by
the Constitution, nor prohibited by it to the
States, are reserved to the States, respectively,
or to the people.”
Federal government given power “to regulate
commerce with foreign nations, among the
several States (interstate)” Movement of
disease affects commerce
•
Who does public health?
• Responsibility for public health is shared but most
functions are decentralized
• Within a single state: All aspects of
surveillance, reporting, & public health clearly
belong to state/local HDs
• International and interstate events: Jurisdiction
of federal government
• Federal public health entities DO NOT have direct
authority over state/local public health entities
National Core Capacities
Where public health activities are performed
Activity
National
State
Case detection/notification No
Yes
Collection of case data
No
Yes
Analysis & interpretation
Yes
Yes
Investigation of cases & confirmation of diagnosis:
• Epidemiologist
*
Yes
• Clinician
No
*
• Laboratory
*
*
Dissemination
Yes
Yes
Response/Intervention
*
Yes
* Upon request
Local
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Notifiable Diseases
• “Notifiable diseases” vary between counties & states
• Federal government, only 9 quarantinable diseases
• Harmonization through consensus with professional
organizations of state/local public health officers
• Example (CSTE): “…by supporting the use of effective
public health surveillance and good epidemiologic
practice through training, capacity development, and
peer consultation, developing standards for practice
…”
IHR negotiation & approval
USG will implement IHRs in a manner consistent with our
fundamental principles of federalism
IHRs will be implemented by the Federal Government to the
extent that the implementation of the Regulations comes
under the legal jurisdiction of the Federal Government
To the extent that IHR obligations come under the legal
jurisdiction of the state/local governments, the USG will
bring these obligations with a favorable recommendation to
the notice of the appropriate state authorities
Development of
surveillance systems
• Work with professional groups representing state
and local health officers and epidemiologists to
adopt the IHR 2005 requirements as a standard
• As necessary, provide financial and technical
support to states to adopt a new standard
Surveillance: Detection,
notification, verification & reporting
• Performed by state/local government; technical / lab
assistance from federal government (upon request)
• Federal government has constitutional authority to
ensure that these processes meet IHR 2005
requirements in interstate or international settings
• No authority over events that occur within a state
(without an interstate or commerce connection)
• Mechanisms to ensure that these processes meet
IHR 2005 requirements are being discussed
• Currently, USG works with professional groups
representing state/local government to adopt
requirements as their standard
Surveillance: Detection, notification,
verification & reporting
• Communication:
• CDC’s Epi-X – Rapid, firewall-protected privileged
information sharing system between federal, state, and
local health officials
• Health Alert Networks
• CDC forward-deployed field stations (Quarantine
Stations)
Jurisdictional authority for PHEICs
• Federal government will express authority over
PHEICs within specific jurisdictions (i.e.,
international and interstate events)
• Otherwise, U.S. state/local governments will have
such authority (intrastate events involving nonFederal assets or resources)
• Regarding PHEICs in intrastate settings, USG will
take appropriate measures to facilitate the
implementation of IHRs at the local level
Potential Obstacles
• Potential obstacles to communication/collaboration
• Dual reporting system
• Variation in technologic capacity amongst
states/counties
• Need for rapid movement of information
• Establishing and using a National IHR Focal
Point for all international communications
Overcoming these obstacles
• How to overcome these obstacles
• Standardize data collection based on scientific principles
• Simplify data transfer (“NECESSARY not desirable”)
• Web-based data systems (“workspaces”) that are jointly
accessible and maintained by 3 levels of government
• XML file transfers between data systems
• Dedicated communication system for public health
practitioners
• Communication protocols between 3 levels of government
• Communication protocols within federal government for
sending/receiving international communications
• Methods to overcome obstacles will require:
• Agreements regarding data sharing
• Development and access to secured electronic
communication systems
Summary & conclusions
• Obstacles to implementation include:
• Decentralized public health delivery system
• Implementing in a manner consistent with
fundamental U.S. principles of federalism.
• Full implementation relies cooperation from state and
local governments
• Rapid communication between 3 levels of
government
• Technical support for state/local HDs
• No expectations of outside agencies for any assistance
with implementation