Mid-America Regional Public Health Leadership Institute

2007 Kick-Off Conference

Pheasant Run Resort October 16 - 19, 2007

The Internationalizationof Public Health

Judith W. Munson

Executive Director, ICPHEP Adjunct Professor

John Marshall Law School Chicago, Illinois

and Visiting LecturerMasaryk University Faculty of Law

Brno, Czech Republic

Why International? Why Now?

•Are You International?The International Quiz

•The WHO International Health RegulationsNewly Revised

The United States ReservationThe XDR-TB Case

•The ICPHEPThe International Collaborative for Public Health Emergency Preparedness

The First International FellowRadoslav Olejnik, MD, JDSenior Officer for Pandemic PlanningMinistry of Health of the Czech Republic

Why International? Why Now?

Are You International?

(go to the)

The International Quiz

The World Health Organization (WHO)

International Health RegulationsNewly Revised

The United States Reservation and

Understandings

The XDR-TB Case

The WHO

International Health Regulations

Came into Force on June 15, 2007

Keiji FukudaCDC EpidemiologistFlu Hunter

Keiji FukudaCDC EpidemiologistFlu Hunter

Dr. MargaretChan, Director of Health in Hong Kong

Together battled avianinfluenza in Hong Kong in 1997

Then came SARSNov 2002 – July2003

•March 12, 2003 WHO –First alert re: atypical pneumonia•March 15, 2003 WHO First emergency travel advisory•March 27, 2003 WHO recommends screening departing airline travellers from worst affected areas: Q Have you had contact? Q Are you sick?•April 2, 2003 WHO recommends postponement of all non-essential travel to Hong Kong and Guangdong province. •April 23, 2003 WHO recommends postponement of non-essential travel to Toronto (lifted 6 days later—April 29)•May 26, WHO changes Toronto status because of new SARS cases •July 2, 2003 WHO declares Toronto SARS-free, last WHO advisory to be lifted

Time Line for WHO Global Advisories During SARS Epidemic (selected entries)

The WHO was in charge--leading the internationalconfrontation against the1st epidemic of the 21st Century

But who was on duty, and was thereLegal authority to act?

The WHO

The WHO is the United Nations specialized

agency for health. Estab. 1948Governed by World Health Assembly (representing 192 member states)The WHA meets every May in Geneva,Switzerland

WHOThe International Health Regulations --The 1969 Version of the IHRs—were applicable only to 3 diseases:cholera, plague, and yellow feverwhile SARS was circling the globe in 2003

Gro Harlem BrundtlandFormer Director-General

Nominated January 27Elected May 13, 1998, sheAssumed her role on 21 July 1998 and ended her term on 21July 2003

WHO

Approval of new Dir-General Contract onAgenda for WHA actionIn May 2003

Dr. Lee Jong-wook, Former Director GeneralWorld Health Organization

Nominated on January 28, 2003Elected on May 21, 2003

He would leadThe agency Thru the IHRRevision process

The IHRRevision Process wasAlreadyUnderwayWhen SARSHit (avian flu)And the SARSEpidemic wasforging changes in the changes

Add#1

WHO 56 WHA A56/25 Add.1Provisional agenda item 14.16 16 May 2003Concerned that experiences following the emergence and rapid international spread of severe acute respiratory syndrome (SARS) have given concrete expression to the magnitude of these challenges, the inadequacy of the current Regulations, and the urgent need for WHO and its international partners to undertake specific actions not addressed by the Regulations . . . URGES Members States:… (2) to establish immediately a national standing task force or equivalent group and, within it, to designate an official or officials having operational responsibilities and accessible at all times by telephone or electronic communication, to ensure the speed, particularly during emergencies, of both reporting to WHO and consultation with national authorities when urgent decisions must be made;

WHO 56 WHA A56/25 Add.1Provisional agenda item 14.16 16 May 2003

Cont’d

4. REQUESTS the Director-General:

(1) to take into account reports from sources other than official notifications, to validate these reports according to established epidemiological principles and, when necessary and after informing the government concerned, to alert the international community to the presence of a public health threat that may constitute a serious threat to neighboring countries or to international health;

(2)To collaborate with national authorities to assess the severity of the threat and the adequacy of control measures and, when necessary and after informing the government concerned, to conduct on-the-spot studies by a WHO team, with the purpose of ensuring that appropriate control measures are being employed;

WHORevision of the International Health Regulations

(Because of SARS)

--The IHR—The revision process

--12 Regional and Subregional groupsmet to review the revised IHRs in 2004

--Intergovernm’t’l Working Group (IGWG)met in Geneva for 2 weeks in Nov ’04 (over 500

delegates representing more than 150 MS attended)but they did not finish the work, hence

--another meeting re: revisions —Feb 21-25 ‘05 --revisions adopted by the

WORLD HEALTH ASSEMBLY at its May, 2005 meeting

WHORevision of the International Health

Regulations --The IHR—

Revisions adopted in May, 2005

Two years after adoption they wouldcome into force (June 15 2007)

(total of 4 years to accomplish!)

BUT, on May 25, 2006, The World Health Assembly adopted a resolution calling on MS to comply immediately, on a voluntary basis, with provisions of the International Health Regulations relevant to the risk posed by avian influenza and pandemic influenza.

Dr. Lee Jong-wook, Former Director General, WHO

Nominated on January 28, 2003Elected on May 21, 2003Died suddenly on May 22, 2006, dramatically falling to the floor as the World Health Assembly convened

What are the IHRs

Binding International Agreement – these are the global rules to protect health – also referred to as a treaty(previous versions had been in place since 1951)

– which addresses

•Global health security•Epidemic alert and response•Global public health response to natural occurrence, accidental release,

or deliberate use of biological and chemical agents or radio-nuclear material that affect health, and

•Assess and report events which constitute a “Public health emergency of international concern”

TO REPEAT:TO REPEAT:

Assess and report events

which constitute a

“Public health emergency of international concern”

MOST IMPORTANT PROVISIONS OF THE IHR*

No longer limited in scope to 3 diseases—now, encompasses any event which may constitute a “public health emergency of international concern”

Such events must be reported in accordance with Annex 2.

Jwm opinion only

ANNEX 2

The Director-General of WHO determines whether an event constitutes a

“PUBLIC HEALTH EMERGENCY OF

INTERNATIONAL CONCERN”

But Note:

Establishes a global public health communication network (Article 4)

--a National IHR focal Point for each State Party to be designated

--WHO IHR Contact Points to be identified

MOST IMPORTANT PROVISIONS OF THE IHR (cont’d):

Establishes an IHR Roster of Experts and makes provisions for the selection of experts from the Roster for the Emergency Committee “according to the fields of expertise and experience most relevant to the specific event that is occurring.”

(This assists in the highest level of expertise being brought to bear upon any threat to the public’s health on a moments notice.)

MOST IMPORTANT PROVISIONS OF THE IHR (cont’d):

CNN rule: WHO will maintain confidentiality of member state information UNLESS “information about the same event has already become publicly available”—in which case WHO may make the information available to the public.(Article 11)

MOST IMPORTANT PROVISIONS OF THE IHR (cont’d):

The United States has accepted the IHRs with the reservation that it will implement them in line with U.S. principles of federalism.

US Reservation and three understandings

THE RESERVATION STATES:

The United States has accepted the IHRs with the reservation that it will implement them in line with U.S. principles of federalism.

US Reservation and three understandings

In addition, the U.S. Government has also submitted three understandings, setting forth its views that

(1)incidents that involve the natural, accidental or deliberate release of chemical, biological or radiological materials are notifiable under the IHRs;

(2)countries that accept the IHRs are obligated to report potential public health emergencies that occur outside their borders to the extent possible; and

(3)the IHRs do not create any separate private right to legal action against the federal government.

… and three understandings

The U.S. statement also expresses several concerns about interpretations of provisions of the IHRs relating to releases of chemical, biological and radiological materials; the protection of national security; and federalism.

According to the statement, the United States will submit a later reservation to the IHRs to clarify that U.S. implementation will be consistent with the federalist system, which reserves many powers and responsibilities to state governments.

For additional information, see a May 23 WHO press release on the new International Health Regulations.

The text of the U.S. statement follows:[The U.S. Mission to the United Nations]

[Geneva, Switzerland]A 58/4

May 23, 2005STATEMENT FOR THE RECORD BY THE

GOVERNMENT OF THE UNITED STATES OF AMERICACONCERNING THE WORLD HEALTH ORGANIZATION’SREVISED INTERNATIONAL HEALTH REGULATIONS

This reservation and the understandings had been made knownOn the day the Revised IHRs were announced by the WHO on May 23, 2005. usinfo.state.gov/usinfo/Archive/2005/May/23-321998.html

Twenty-eight states, including Florida, Massachusetts and New York, allow parents to opt out for medical or religious reasons only. Twenty other states, among them California, Pennsylvania, Texas

and Ohio, also allow parents to cite personal or philosophical reasons. Mississippi and West Virginia allow exemptions for

medical reasons only.

From 2003 to 2007, religious exemptions for kindergartners increased, in some cases doubled or tripled, in 20 of the 28 states

that allow only medical or religious exemptions, the AP. . . . Religious exemptions decreased in three of these states —

Nebraska, Wyoming, South Carolina — and were unchanged in five others.

Example of public health laws and actions under the U.S. federal system

Parents use religion to avoid vaccines http://news.yahoo.com/s/ap/20071017/ap_on_re_us/vaccine_skeptics

But Back to the IHRs

And the answer to these Questions:

What do the IHRs have to Do with me, my job, my agency?

They came into force on June 15, 2007But,One month earlier, a “publichealth emergency of international concern” riveted the world

It was the case of the Extensively Drug-Resistant TBXDR-TB

It involved many of the public health agencies at the local and state and national levels:•Fulton County HD•Georgia Division of PH•Georgia State PH Laboratory•CDC•Atlanta Airport CBP

There are 327 ports of entry into theUnited States

Everyone in this room works in a border stateAnd O’Hare Airport is in the center of us all

http://homeland.house.gov/SiteDocuments/tbreport.pdf.

This report is an excellent, EXCELLENT,Case study for all of us in public health.It was not written by one of us. It was writtenBy the Majority Staff of the U.S. House of RepresentativesCommittee on Homeland Security, Rep. Bennie G. Thompson,Chairman

It documents, in detail, how the public health Professionals failed to comply with the IHRs

But back to the present threat…

Avian Influenza Update

Cumulative Confirmed Human Cases Of H5N1 Reported to WHOAs of October 17, 2007

12 Countries331 Cases203 Deaths

The WHOHeadquarters: Geneva, SwitzerlandDirector-General: Margaret Chan

Elected November 6 – 9, 2006 Assumed duties: January 4, 2007

We have come full circle, as themajor threat to the public’s health on the international platform is an avian influenza pandemic

…and the doctor who made the decisions that eradicated AI H5N1 in 1997 is now the Director-General of theWorld Health Organization

Dr. Margaret Chan

The End

Thank You Very Much