Central Asia Regional Health Security Workshop
George C. Marshall European Center for Security Studies
17-19 April 2012, Garmisch-Partenkirchen, Germany
International Health Regulations - IHR
(2005)
Dr Hashim Elzein Elmousaad
Public Health Specialist
19 April 2012
Contents
• Introduction: What is IHR? Purpose and scope
• Historical Background
• Public Health emergency of international concern
(PHEIC) and reporting
• Infectious Diseases of Concern & events
• IHR Implementation and approaches
• IHR Challenges
• Core Capacity Requirements
• Partners
• Implementation Progress
What is IHR?
The International Health Regulations (2005) IHR - are
an international agreement that is legally binding on
194 countries (States Parties), including all WHO
Member States.
Entry into force on 15 June 2007
Health Security Response:
International Health Regulation
Contain the
international
spread of
diseases
Maintain the
sovereignty of
states and
cause minimal
disruption to
international
flow of people
and goods
The purpose and scope of
these Regulations are to
prevent, protect, and
provide a public health
response to the
international threat and
spread of diseases.
Also, avoid unnecessary
disruption of
international travel and
trade
Efforts to control Infectious Diseases
• 1838 – Superior Council of Health of Constantinople is established to supervise
the sanitary regulation of the Turkish port in order to prevent the spread of
cholera from Asia to Europe.
• 1851 – The first International Sanitary Conference held in Paris to draft uniform
quarantine measures for all Mediterranean ports.
• 1902 – The International Sanitary Bureau of the Americas, the precursor of PAHO
was formed
• 1907 – The Office International D'Hygiène Publique is established to administer
the international sanitary conventions and provide epidemiological intelligence
• 1923 – The Health Organization of the League of Nations is formed.
• 1948 – The World Health Organization (WHO) is founded.
• 1951 – The World Health Assembly (WHA) adopts the International Sanitary
Regulations.
• 1969 – The WHA adopts the International Health Regulations.
• 1981 – The IHR are amended to include only 3 diseases.
• 2005 – The WHA adopts the IHR (2005).
• 2007 – The IHR (2005) enter into force.
IHR(2005)
- From control of borders to containment at source
- From diseases list to all threats
- From preset measures to adapted and real time
response
6
Public Health emergency of international concern
(PHEIC)
PHEIC is an extraordinary event which is determined, as provided
in these Regulations:
i.
to constitute a public health risk to other States through the
international spread of disease and
ii. to potentially require a coordinated international response.

IHR require procedural steps by the DG/WHO in determining
that a PHEIC exists
Notify, report, consult and inform WHO
• Notification – States Parties are required to notify WHO of all
events that are assessed as possibly constituting a PHEIC
• Within 24 hours of assessment (decision instrument provided in
Annex 2 of the Regulations).
• Four criteria that States Parties must follow in their assessment
of events within their territories and their decision as to
whether an event is notifiable to WHO:
• 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 restriction(s) to
travel and trade?
Notify, report, consult and inform WHO
• Consultation - In cases
where the SP is unable to
complete a definitive
assessment with the
decision instrument in
Annex 2, (confidential
consultations with WHO)
• Other Reports - State
Parties must inform
WHO on receipt of
evidence of a public
health risk identified
outside their territory
that may cause
international disease
spread.
Notify
Consult
Decision instrument (Annex 2) of IHR (2005)
for Assessment and Notification
4 diseases that shall be notified polio
(wild-type polio virus), smallpox,
human influenza new subtype, SARS.
Disease that shall always lead to
utilization of the algorithm: cholera,
pneumonic plague, yellow fever, VHF
(Ebola, Lassa, Marburg), WNF,
others….
Q1: public health impact serious?
Q2: unusual or unexpected?
Q3: risk of international spread?
Q4: risk of travel/trade restriction?
Insufficient information: reassess
Implications of non-compliance to IHR
 WHO will know from other
sources
 Position of the State Party will
change from article 6
(notification) to article 10
(verification)
 WHO will request verification
 WHO will embark on
investigation based on risk
assessment
 IHR allow WHO to use
whatever available information
to alert other partners
 Compliant SP will receive
timely international support
when needed
Core Capacity Requirements


8 Core capacities
◦ Legislation and Policy
◦ Coordination
◦ Surveillance
◦ Response
◦ Preparedness
◦ Risk Communications
◦ Human Resources
◦ Laboratory
3 levels
◦ National
◦ Intermediate
◦ Peripheral/Community
Potential Hazards
 Infectious
 Zoonosis
 Food safety
 Chemical
 Radio nuclear
Events at
Points of Entry
Infectious Diseases of Concern in
Central Asia
• In 2010, the first WPV importation into the European Region
resulted in 476 confirmed cases: 458 in Tajikistan, 14 in Russia,
three in Turkmenistan, and one in Kazakhstan.
• Foot Mouth Disease: Kazakhstan May – August 2011(More than
2,7 thousand cattle had to be destroyed)
• Multidrug-resistant (MDR) TB (serious problem)
• Hepatitis A & E
• Typhoid
1
Public health risks and emergencies
1 October 2010 - 9 February 2011
• 137 events were recorded in the Event
Management System and tracked
–European Region: chemical events, food
safety-related events, earthquake, dengue
fever, West Nile fever, poliomyelitis, measles,
malaria, acute hepatitis, cryptosporidiosis and
influenza
Globalization of food
Rapid globalization of food
production and trade has increased.
From 1970 – 2000:
• Over 100 outbreaks associated with ships 1/3rd were
related to food borne transmission (WHO review).
• Rapid exchange of food safety information at both
national and international level.
Chemical incident “types”
 Technological
 Complex
 Deliberate
An estimated 8.3% of all deaths and 5.7%
of all disease burden were attributable to
exposure to selected chemicals in 2004.
Source: Knowns and unkowns on burden of
disease due to chemicals, Prüss-Uestun et al.,
Environmental Health, 2011
 Natural
 Others
Accident, Bhopal, India
As, Bangladesh
Sarin attack, Tokyo
Radio-nuclear Events
Responsibility Of IHR Implementation
Jointly with States Parties and WHO
• States Parties capacity:
Well established national surveillance and response
infrastructure.
Collaborate actively with each other, together & with WHO,
Mobilize the financial resources
Facilitate the implementation of their obligations under the
IHR.
• WHO:
(Upon request) WHO assists developing countries in
mobilizing financial resources and provides technical
support to build, strengthen and maintain the capacities set
out in Annex 1 of the Regulations.
New implementation approach
–
–
–
–
–
–
–
–
–
–
–
National Focal Points, WHO Contact Points in ROs, IHR in HQ,
Annual reporting to WHA,
Capacity building,
Event information system, Site: Efficient mechanism for
information sharing, 182 countries accessed EIS
Major global events,
Coordination with other sister organization such as FAO, OIE and
regional focal points in food and chemical safety, radiation and
nuclear fields.
Event based surveillance, national guidelines and SoPs for
multisectoral coordinated response
Hazard analysis activities based on “All Hazards” approach
Biorisk management plans
Risk communication
Points of entry
IHR Challenges
 IHR 2005 is not for ministries of health only
 Empowerment of the NFP
 Development of core capacities at country level
 Maintain disease surveillance, early warning and response system:
Human resources
 Ensure effective involvement of the private sector
 Adequate funding
 The importance of transparency
 Maintenance and expansion of existing partnerships and
sustaining commitment of stakeholders
 Advocacy and awareness-raising

What Member States need to do?
• Monitor and report on IHR implementation progress
• Notify, report, consult and inform WHO
• Understand WHO’s role in international event detection,
joint assessment and response
• Participate in the PHEIC determination and WHO
recommendations - making processes
• Strengthen national surveillance and response capacities
• Increase public health security at ports airports and
ground crossings
• Use and disseminate IHR health documents at points of
entry
STRENGTHENING NATIONAL CAPACITY
• Timeline
2 years + 3 + (2) + (up to 2)
2007
Planning
2009
2012
2014
2016
Implementation
"As soon as possible but no later than five years from entry into force …"
(Articles 5, 13)
IHR partners: Article 14
• Intergovernmental organizations or international bodies:
•
•
United Nations (e.g. FAO, IAEA, ICAO, IMO, UNWTO)
International Labor Organization (ILO)
• Development agencies: governments, banks
• WHO Collaborating centres
•
Academics & professional associations
•
Industry associations (e.g. IATA, ISF)
•
NGOs and Foundations
•
International Committee of the Red Cross (ICRC)
•
International Federation of Red Cross and Red Crescent Societies
(IFRCS)
•
International Organization for Epizootics governments, banks
• Regulations do not limit the provision by WHO of advice, support or
technical or other assistance for public health purposes
Monitoring Progress: Current situation
(Article 54)
• In resolution WHA61.2, States Parties and the DG would
report annually to the WHA
• Self-assessment questionnaire Mid-February 2010
• 126 responses, representing 65% of the 194 States
Parties
• Tracking implementation on Eight types of core capacity
and five relevant hazard types
• Four-point scale: Level <1(foundational); Level 1 (inputs
and processes in place); Level 2 (outputs and some
outcome demonstrated); and Level 3 (capacities beyond
the State’s borders)
Main Results of Monitoring the IHR
Implementation 1
• Eight core capacities: (132 SP)
– 58% have developed national plans
– 30% have Good progress in national legislation
– About 50% the reporting States at the foundational level (Level <1)
for two types of core capacity preparedness and human resources;
– 90% of reporting SP are using the decision instrument in Annex 2 of
the Regulations to notify WHO.
– 50% of reporting SP have developed national public health
emergency response plans for discharging their obligations under
IHR with regard to hazards and points of entry.
Results of Monitoring Implementation 2
Progress on hazard types:
– More attributes being achieved for zoonotic and food safety-related events,
and fewer being achieved for chemical and radio-nuclear events
– For chemical and radio-nuclear events, nearly 50% of reporting SP are still
in the foundational level (Level <1) in terms of overall capacity.
Progress on points of entry:
– 62% of reporting SP have reached Level 1
– 28% of reporting SP achieved Level 2, with 41% at Level 1.
– Response capacities are weaker; 46% of the reporting SP at Level <1.
Conclusions of the Monitoring Report
• SPs have made progress in implementing the IHR (2005)
with the support of the WHO regional offices {response to
pandemic (H1N1) 2009}
• Governments’ awareness raised regarding the
importance and uniqueness of IHR.
• The implementation of the IHR in countries continues to
present serious challenges, a number of countries may
not meet the core capacity requirements for surveillance
and response described in Annex 1A of the Regulations
by the deadline of 15 June 2012.
Questions?
Dr Hashim A. Elzein Elmousaad
Public Health Specialist
Cairo – Egypt
elmousaadh@gmail.com
Tel: 00201120400733
References
• INTERNATIONAL HEALTH REGULATIONS (2005) -SECOND EDITION - World
Health Organization 2008.
• http://www.who.int/archives/fonds_collections/bytitle/fonds_1/en/index.htm
• WHO/CDS/EPR/IHR/2007.1, “International Health Regulations (2005): areas of
work for implementation” at http://www.who.int/ihr/area_of_work/en/index.html
• http://www.who.int/water_sanitation_health/diseases/shipsancompendium/en/ind
ex.html
• Implementation of the International Health Regulations (2005) - Report by the
Director-General 64th WHA. A64/9; 17 March 2011.
• Implementation framework at http://www.who.int/ihr/checklist/en/index.html
• http://www.who.int/csr/don/archive/year/2010/en/