Implementation of IHR
Roles & Responsibilities of
State
Dr. Sujeet Singh
Broad Areas
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IHR requirements
Key areas
Activities for effective implementation
Core capacities
Roles & responsibilities
What are IHRs?
An international legal instrument, legally binding
on all WHO Member States who have not rejected
them
• IHR (1969):
 Objective: Maximum security
against international spread of
diseases with minimum interference
to world traffic
 Scope: Only 3 diseases (Cholera,
plague, yellow fever)
 Limitations:
 Dependence on affected country to
notify;
 Lack of mechanisms for collaboration
between WHO and affected country
Emerging Pathogens and IHR
• Smallpox,
cholera,
plague
subject
to
regulations till 1970s- Now eradicated/
controlled.
• IHR were not fulfilling purpose as evident from
plague outbreak (1994), SARS outbreak (
2003) and Influenza A H1N1 (2009)
• Emergence and re- emergence of diseases of
International concern in last decade
Recent Outbreaks
• In other countries
– SARS
– Avian Influenza
– Influenza A H1N1
• In India
– Plague
– DHF
– PHEIC related to disasters, Chemical accident,
radiological
SARS Outbreak (2003)
• IHR 1969 with provision for reporting for 3
diseases only
• No IHR provisions for SARS – China
• Delay in cause detection, mode of spread etc.
• Surveillance & response in each country were
different ( Mostly Reactive response)
– Entry screening (1.20 lac pax. screened per week)
– Isolation and quarantine
– Lab. Testing & prophylaxis/treatment for cases and
contacts
– Reporting & documentation
• Highlighted the importance and need for
revision of IHR 1969
Influenza A H1N1
• IHR (2005) in place (better planned)
– Guidelines on surveillance & response
– Uniform procedures - entry screening, contact
tracing, chemoprophylaxis, PPEs etc.
– Isolation and sample for Laboratory tests
– Guidelines for management of case &
suspects, disinsection & use of PPEs
– Periodic review of strategy by daily reporting
IHR (2005) Document
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66 Articles organized in X Parts
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9 Annexes
Annex 1 – Core Capacity
Requirements for Surveillance &
Response, and for Designated
Airports, Ports and Ground
Crossings
Annex 2 – Decision Instrument for
Assessment & Notification of
Events that may constitute a Public
Health Emergency of International
Concern
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Available on Website:
http://www.who.int/csr/ihr/en/
What is New in IHR (2005)
• Concept of National focal point
• Covers all dangerous diseases both new and
existing PHEIC
• WHO has the mandate to verify rumors, news
from print/electronic media of disease / outbreaks
• Obligation to develop core capacity both at
country level as well as ports/ airports
• Provision for WHO assistance for early diagnosis
• Provision of dispute solving through court of
arbitration
• Covers notification for chemical & radio-nuclear
events as well
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Major Obligations for Member States
Designation of
National IHR
Focal Point
Legal &
administrative
framework
Response
Major
Obligations
Assess
events
& notify
potential
PHEIC
Core
capacities to
detect, report
and respond
Responsibility of National Focal Point
(NCDC)
• To notify PHEIC to WHO
• To respond to requests for verification of
information of such events.
• Support field investigations, provide early
diagnosis and provide technical guidance
to states for timely and effective response
to PHEIC
• Co-ordination with state units and WHO
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Public Health Emergency of International
Concern (PHEIC)
• An extraordinary public
health event which
constitutes a public health
risk to other countries
through international
spread of disease
potentially requires a
coordinated international
response
“Disease means an illness or medical condition, irrespective of origin or
source that presents or could present significant harm to humans”
Determination of PHEIC – 4 criteria
 Unusual or Unexpected Event
 Event resulting in Serious Public Health
Impact
 Event with significant risk of international
spread
 Event with significant risk of international
travel or trade restriction
Any event irrespective of origin & source meeting
any 2/more criteria shall be considered as PHEIC
& notified to WHO under IHR (2005)
Notification
The IHR(2005) requires notification of all
events which may constitute PHEIC
within 24 - 48 hours
To respond to requests for verification of
rumors / news received from print media
or other sources
No specified list of diseases (algorithm
provided)
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Key Areas for effective
implementation
• Legal provision – IHR (legal & technical)
» National - Epidemic Disease Act -1987
» Disaster Management Act 2005
» Draft Public Health (prevention, control
and management of epidemics,
bioterrorism and disasters) Bill provides
for prevention, control & management of
epidemics and public health
consequenses of disasters
» Indian Aircraft (public Health) Rules, 1954
& Indian Port Health rules, 1955
Key Areas (contd.)
– Assessment & strengthening of core capacities at
national/state/districts – nodal officers/RRTs
(multidisciplinary)
– Trained manpower development – contingency
plan
– SOPs for procedures – case management,
screening, contact tracing, chemoprophylaxis,
PPEs etc.
– Facilities for isolation, quarantine and case
management – laboratory/hospital back-up
support
– Risk assessment and Communication network
– Periodic review, data processing and reporting
Activities undertaken for Effective
Implementation of IHR (2005)
• Activities at National level
• Activities by State
Governments/ UTs and
District Authorities
• Activities related to the
Airports/ Ports/ Ground
Crossings
Activities at National Level
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National IHR focal point designated - NCDC
Coordination with WHO & states/districts
Designation of Nodal officers
Core capacity building
Increased awareness about IHR among
health administrators and professionals
• Surveillance & response capacity (RRT)
• Enhanced Satellite based disease
surveillance
• Strengthening laboratory network
National Level Activities
• Develop RRT guidelines, laboratory &
computer manuals, and training materials
• Train State Rapid Response Teams
• Strengthen & network National & Regional
laboratories
• Establish rapid communication network
• Technical review, co-ordination, monitoring
& evaluation
Activities – State/UT Govts & District Authorities
• State & District IHR focal
points designated
• Reporting by State/District to
National Focal Point as per
IHR
• IHR in IDSP trainings
• Surveillance & response
capacity enhanced – Influenza
A H1N1
IDSP Objectives
• Establish early warning mechanism
• Laboratory strengthening & networking
for surveillance & rapid confirmation of
diagnosis
• Effective use of surveillance data using
rapid means for communication
• Institute appropriate & timely response
for prevention & control of outbreaks
Events that may
constitute PHEIC
Alert &
Response
Operations
Detection
Verification
Risk assessment
Response
Surveillance & response:
capacities required at each level
- Event
Regional & International level
National level
Intermediate level
Local level
alert
- verification
- Assessment
- Intl. response
- Assessment
- Notification
- P.H. response
- Confirmation
- Response
- Assessment
- Detection
of event
- Reporting
- Controlling
At the National Level
• Assessment and notification. The capacities:
• To assess all reports of urgent events within 48
hours; and
• To notify WHO immediately
• To confirm the status of reported events and to
support or implement additional control measures;
and
• To assess reported events immediately and, if
found urgent, to report all essential information to
the national level. For the purposes of this Annex,
the criteria for urgent events include serious public
health impact and/or unusual or unexpected
nature with high potential for spread.
Activities on the part of State Governments/UTs
and District Authorities
• Designation of IHR focal points – 24x7
accessibility
• Assessment and strengthening of disease
surveillance & response capacity as per IHR
• Evaluation & strengthening of laboratory
capacities (inventory of regional /national labs)
• Evaluation & strengthening of isolation
facilities & infection control practices
• Mechanism for rumour verification
• Awareness reg. information to be reported to
NFP
Activities on the part of State Governments/ UTs and
District Authorities contd...
• Preparation and periodical updating of public health
contingency plans
• Involvement of private sector and professional
organizations (e.g. IMA) for disease surveillance
activities
• APHOs/ PHOs/ Ground crossings be included in
state surveillance committees
• Identification of high-risk areas near international
borders and programme for cross-border control of
diseases
Activities (contd.) State Governments/ District
• Linkages of IDSP/NFP with all state/ district HQs
• Nodal officers to be identified in:
– Designated hospitals, laboratories and various
pest/ vector control agencies
– State Health Directorates, District Health
Authorities
– Local municipality, cantonment board, other
relevant agencies
– Ministries of Civil Aviation, Shipping, Surface
transport, Agriculture (veterinary dept.), Home
Affairs, Tourism, Railways
– Customs, Immigration, AAI
– AOC, Association of shipping agents
– CISF
Activities related to the Airports/ Ports/ Ground
Crossings
• Designation of Airports/ Ports/ Ground Crossings
IHR Focal Points
• Training of technical staff on IHR
• Assessment & strengthening of capacities at
designated entry/ exit points
• Awareness about information to be reported to NFP
• Referral system for medical care services
• Creation of new public health units
• Improve infrastructure of quarantine centers
• District IDSP lab be designated for each APHO/ PHO
• Provision of entomologist for vector surveillance &
control activities
District Responsibilities
• Identify district RRT members – multidisciplinary
• Train Medical Officers & PMWs – event reporting
– numbers of human cases and deaths, conditions
affecting the spread of the disease and the health
measures employed and Clinical descriptions
• Modernize & computerize District Epid. Cell
• Identify & strengthen District Labs
– SOPs for sample collection/transportation, media
• Reporting of events / PHEIC from district/state
• Response plan
National level response
• To determine rapidly the control measures required to prevent
domestic and international spread;
• To provide support through specialized staff, laboratory analysis of
samples (domestically /regional collaborating centres) and logistical
assistance (e.g. equipment, supplies and transport);
• To provide on-site assistance to supplement local investigations;
• Coordination / liaison with other relevant
ministries/departments/NGOs
• Coordination with senior health officials to approve rapidly and
implement containment and control measures
• To establish links with hospitals, clinics, airports, ports, ground
crossings, laboratories etc.for the dissemination of information and
recommendations received from WHO regarding events
• To establish, operate and maintain a national public health
emergency response plan, including the creation of multidisciplinary/
multisectoral teams to respond to PHEIC
State Level Capacities
• To detect events involving disease or death above expected
levels for the particular time and place in all areas within the
territory of the State Party; and
• To report all available essential information immediately to the
appropriate level of healthcare response.
• At the community level, reporting shall be to PHC/CHCor the
appropriate health personnel. At the primary public health
response level, reporting shall be to the district/State or national
response level,
Essential information includes :
• Clinical descriptions, laboratory results, sources and type of
risk, numbers of human cases and deaths, conditions affecting
the spread of the disease and the health measures employed;
and
• To implement preliminary control measures immediately.
Laboratory strengthening
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Identify and strengthen labs at National, Regional,State and
district
Intrasectoral, intersectoral and international networking
SOPS & facilities for sample collection/storage/transportation
Outbreak Investigation Kits
Inventory of Biosafety levels labs:BSL-2/BSL-3/ BSL-4
Focus on Epidemic-prone and EIDs
Arrangements for diagnostic kits and reagents
Mechanism of release of reports & documentation
Define role of private labs
Laboratory Roles
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Focus labs for neglected areas: TSS,Food Posionings
Labs - Diseases in Animals
Environmental sampling :Air,food, water
Water quality monitoring
Mobile labs/ Portable labs / Temporary labs
Lab-based surveillance before, during and after the disasters
Plan for processing of non-conclusive samples-newer pathogens?
Where to send?
• Ensure availability PPEs, disinfectants, chemo/immunoprophylaxis
Networking & Web-based
surveillance
- Interactive website www.nicd.org, is
operational for online data entry
– Directory of NSPCD official at centre,
state and districts is available
Web-based Surveillance
SUMMARY
• Action plan for (Proactive Response)
– Core capacity development - IHR module for PHEIC
– Training of manpower including field staff on
Surveillance, response & case reporting
– Resource planning –drugs, reagents, PPEs
– Intersectoral coordination
– Laboratory support
– Real time exercises
– Retrospective Epidemiological study of disasters in the
area
• Collaboration of plan with allied agencies, areas
and states
THANKS