International health regulations

BY: DR.KAVITA YADAVMODERATOR: DR. VIDYA G. S & DR.KAVITHA H .S JSSMCH,MYSORE

Plan of presentation

What is IHRHistory Comparison of 1969 and 2005 IHRPrinciples ,objectives and purpose of IHR IHR implementationHow successful IHR has beenIndian scenarioSummaryReferences

What are International Health Regulations (IHR)?

The International Health Regulations (IHR) are an

international legal instrument that is binding on 194 countries

across the globe, including all member states of the World

Health Organization (WHO). The United States is one of these member states.

IHR are intended to: help prevent the spread of disease across borders

outline the minimum requirements for functional public health system

that allows countries to quickly detect and respond to disease outbreaks in

their communities

History

1830s---New trade patterns allow cholera to spread from South Asia to Europe

and North America, leaving hundreds of thousands dead

1851--France convenes the first International Sanitary Conference to explore

agreement on harmonizing quarantine regulations for cholera, plague, and

yellow fever

1892--Delegates to the seventh conference ratify the first International Sanitary

Convention

1902 -1935--States create intergovernmental institutions [Pan American

Sanitary Bureau (1902), Health Organization of the League of Nations (1920)

Contd.

→ 1948--World Health Organization (and its governing body, the

World Health Assembly, WHA) created

→ 1951--WHA consolidates existing international sanitary

conventions into the singular International Sanitary Regulations

(covering plague, cholera, yellow fever, smallpox, typhus, relapsing

fever)

→ 1969--The renamed International Health Regulations (1969)

replace prior agreements; revisions eliminate but do not add diseases

KEY FEATURES OF IHR 1969

Notification to WHO of cases of cholera, plague smallpox and yellow fever

Certain health related rules for international travel and trade

Prescription of maximum border measures against cholera, plague and yellow fever (deratting, desinsection…)

Health documents for people, aircraft and ships.

LIMITATIONS OF IHR 1969

Concerns only cholera, plague and yellow fever The old paradigm of case-based surveillance Difficult to revise disease list

Dependent on official notification from the member stateNo incentives to notification

Very few notifications Notifications seemed as a very serious act by states

No formal mechanisms for collaboration between member state and WHO

No dynamic in the response for stopping international spread

Why new IHR

→ 1995--Ebola virus outbreak in Central Africa captures global

attention;WHA calls upon WHO Director-General to overhaul

the IHR

The recent increase in trade and tourism.

→ 2003--SARS spreads from China to 25 other countries via air

travel

→ 2005--WHA adopts the revised International Health

Regulations (2005)

IHR 1969 VERSUS IHR 2005

From three diseases to all public health risks

From preset measures to tailored response

From control of borders to also include containment at source

From reactive to proactive

International Health regulations (2005)10 Parts, 66 Articles, 9 Annexes

• PART I DEFINITIONS, PURPOSE AND SCOPE, PRINCIPLES AND RESPONSIBLE AUTHORITIES

• PART II INFORMATION AND PUBLIC HEALTH RESPONSE

• PART III RECOMMENDATIONS

• PART IV POINTS OF ENTRY

• PART V PUBLIC HEALTH MEASURES

• Chapter I General provisions

• Chapter II Special provisions for conveyances and conveyance operators

• Chapter III Special provisions for travellers

• Chapter IV Special provisions for goods, containers and container loading areas

• PART VI HEALTH DOCUMENTS

• PART VII CHARGES

• PART VIII GENERAL PROVISION

• PART IX THE ROSTER OF EXPERTS, THE EMERGENCY COMMITTEE AND THE REVIEW COMMITTEE

• Chapter I The IHR Roster of Experts

• Chapter II The Emergency Committee

• Chapter III The Review Committee

• PART X FINAL PROVISIONS

Purpose and scope

The purpose and scope of these Regulations are to

prevent, protect against, control and provide a public

health response to the international spread of disease in

ways that are commensurate with and restricted to public

health risks, and which avoid unnecessary interference

with international traffic and trade.

Principles

The implementation of these Regulations shall be with full respect for the

dignity, human rights and fundamental freedoms of persons.

The implementation of these Regulations shall be guided by the Charter of the

United Nations and the Constitution of the World Health Organization.

The implementation of these Regulations shall be guided by the goal of their

universal application for the protection of all people of the world from the

international spread of disease.

States have, in accordance with the Charter of the United Nations and the

principles of international law, the sovereign right to legislate and to

implement legislation in pursuance of their health policies. In doing so they

should uphold the purpose of these Regulations

Objectives Of IHR 2005

To ensure the appropriate application of routine preventive measures (e.g. at ports and air ports) and the use by all countries of internationally approved documents (e.g. Vaccination certificate).

To ensure the notification to WHO of all events that may constitute a public health emergency of international concern.

The implementation of any temporary recommendations should the WHO Director General have determined that such an emergency is occurring.

The revised IHR also focus on the provision of support for affected states and the avoidance of stigma and unnecessary negative impact on international travel and trade.

IHR implementation

Strengthening national capacity for surveillance and control at port , airport, ground crossing and travel &transport.

Prevention ,alert and response to public health emergencies.

Global partnership.Rights, obligations ,procedure and progress monitoring.

1 Strengthening

national

capacity

Country’s liabilities

At point of entry: Under normal conditions At the time of

emergency

Establishment of national focal pointStrengthening of surveillance and reporting

system

For ships

Sanitary operation without harming ship and passengerCertificate is given free of chargeFree pratiqueSubjected to health inspection for hygiene and

sanitation,rodents/vermin infestation,drinking water availability and quality

Documents checked

Maritime declaration of health,Crew list and vaccination certificate of membersDeratting or deratting exemption certificateCertificate of health and sanitary inspectionCertificate showing date and time of pratiqueShip sanitation control certificateShip sanitation control exemption certificate

For people

Certificate of date of arrival or departureCertificate of health measures applied to him or his

baggageMay examin person before voyage if neededPerson under surveillance may be allowed to continue his

voyage but health authorities must be kept informedReview travel history in affected areaReview proof of medical examination,vaccination and lab

analysis

Contd.

Place a suspected person under observation.Implement quarantine or isolation or treatment as needed.May refuse entry of affected person.May refuse entry of unaffected person in affected area.Implement exit screening.Medical facilities for ill travellers.

Health measures for baggage, cargo, containers, conveyances, goods and postal parcels

• Review manifest, Proof of measures taken on departure or in transit, Routing and implement inspections

• Implement treatment to remove infection and contamination, vectors and reservoirs.

• Isolation and quarantine, seizure and destruction

• Refuse departure or entry.

Ground Crossing

States Parties sharing common borders should consider:(a) entering into bilateral or multilateral agreements or

arrangements concerning prevention or control of international transmission of disease at ground crossings in accordance with IHR

(b) joint designation of adjacent ground crossings for the capacities .

Categories Of These Reportable Diseases

• Epidemic prone diseases• Food borne diseases

• Accidental and deliberate outbreaks• Toxic chemical accidents• Radio nuclear Accidents• Environmental disasters

VACCINATION FOR TRAVELLERSCATEGORY VACCINES

ROUTINE IMMUNIZATION

Diphtheria, Tetanus, and Pertussis Hepatitis BHaemophilus influenzae type bHuman papillomavirus InfluenzaMeasles, mumps and rubellaPneumococcal diseasePoliomyelitisRotavirus Tuberculosis (BCG)Varicella

SELECTIVE USE FOR TRAVELLERS

CholeraHepatitis AJapanese encephalitisMeningococcal diseaseRabiesTick- borne encephalitisTyphoid feverYellow fever

MANDATORY VACCINATION

Yellow fever (according tovaccination country list)Meningococcal disease and polio(required by Saudi Arabia for pilgrims)

National IHR Focal Points (NFPs)

Important role in implementation of IHRThe national centre for communications with WHO:

On a 24/7 basis (by telephone, fax, email) NOT an individual person

To notify PHEIC to WHOTo 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

Strengthening of surveillance system

Each country is suppose to enhance its surveillance and reporting system so that diseases of international concern can be picked up at the earliest and hence controlled in a better way.

2 Prevention alert and response to PHEIC

Public Health Emergency of International Concern (PHEIC)

An extraordinary public health event whichconstitutes a public health

risk to other countries through international spread of disease

potentially requires a coordinated international response

Events detected by national surveillance system or reported by media or any non-governmental organization

UNUSUAL DISEASESSmallpoxHuman influenzae (new subtype)Wild poliovirusSevere acute respiratory syndrome

KNOWN EPIDEMIC PRONE DISEASESCholeraPneumonic plagueViral haemorrhagic fevers(ebola,lasaa)Yellow feverWest Nile feverOther locally or regionally important diseases

Any event of potential internation

al public health

concern

Is the public health impact of the event serious?Is the event unusual or unexpected?Is there significant risk of international spread?Is there significant risk of travel or trade restriction?

National IHR focal point to notify WHO

If yes to any two of these questions

3 GLOBAL

PARTNERSHIP AND INTERNATIONAL COLLABORATION

The IHR foster global partnership

Other intergovernmental organizations: UN system (e.g. FAO, IAEA, ICAO, IMO) others: regional (e.g. EU, ASEAN), technical (e.g. OIE)

Development agencies: governments, banks

WHO Collaborating centresAcademics & professional associationsIndustry associationsNGOs and Foundations

Global distribution of GOARN institutions and partners

A network of more than 150 technical institutions, WHO manages secretariat and logistic support

GOARN

Global Outbreak Alert and Response Network (GOARN) provides a framework for the technical coordination of international alert and response activities with institutions and countries around the world.

They lay out new obligations devised to collectively respond to international public health challenges of the 21st century, taking advantage of new developments in biotechnology, surveillance systems, and information technology, such as rapid data sharing.

4 RIGHTS,OBLI

G-ATIONS AND PROCEDURES,PROGRESS MONITORING

According to the IHR (2005), what arethe key obligations for WHO?

Laying down the rules for global public health security

Monitoring the implementation of IHR (2005) and

updating guidelines so that they remain scientifically

valid and consistent with changing requirements.

Major Obligations for Member States

Assess events

& notify potentialPHEIC

Response

Core capacities to detect, report and respond

Legal & administrative

framework

Designation ofNational IHRFocal Point

Major Obligations

Benefits to Member States

• Being a partner in the international effort to maintain global health security.

Core capacities will be strengthened to report and respond to public health risks and a PHEIC in the country.

Clear guidelines on outbreak verification process, technical and logistical support will be provided by WHO upon request in the case of a PHEIC.

Be eligible for support from Global Outbreak Alert and Response Network (GOARN).

WHO emphasizes an amicable settlement of differences through, negotiation, mediation, conciliation and arbitration.

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

Barriers to implementation

TechnicalResourcesGovernanceLegalPolitical

How successful has the IHR system been?

The system has been very successful when we consider

the number of events notified to WHO under regulations.

>220 events worldwide were formally notified to WHO and posted

on the secure IHR website as meeting at least 2 of the 4 risk

assessment criteria.

Hundreds of more postings on a secure IHR website for information

exchange on events between countries, which could include

information about event response measures taken.

Indian scenario

The Stakeholders for IHR Implementation

Airports,Ports & Ground

Crossings

States, UTs &

DistrictAuthorities

National Focal PointNICD, Delhi

Other Ministries,

& Deptts.

MOHFW

DGHS

India and IHR

National Focal Point: NICDSurveillance:IDSP (Rs.408 CRORE)Legal: The Public Health Act of India has been drafted Indian Port Health Rules and Indian Aircraft (Public

Health) Rules are currently being examined for their compliance with IHR (2005).

National - Epidemic Disease Act -1987 . Disaster Management Act 2005

Contd.

Lab: 2 bio safety level (BSL) —one at the NICD, Delhi and second at National Institute of Virology, Pune.

Connectivity: In collaboration with the ISRO, the National Informatics Centre and BSNL, districts are being connected electronically through satellite and the terrestrial network for transmission of surveillance data, videoconferencing and distance learning

PoE: 25 million international passengers pass through India via 21 international airports, 12 ports and 3 major land border crossings yearly.

Summary

What is IHR.What are its principles , objectives and scope.How it is implemented.What are the responsibilities of WHO and the

state parties.Where India stands.

REFERENCES

World Health Organization. International health regulations (1969). 3rd ed. Geneva:World Health Organization; 1983. Available at http://whqlibdoc.who.int/publications/1983/9241580070.pd

WHO, International Health Regulation (2005): Geneva, World Health Organization; 2006. The World Health Organization, fifty – eight World Health Assembly Resolution WHA 58.3: Revision

of the International Health Regulation, 23 may 2005. Available at http: // www.who.int/ ebwho/pdf.files/WHA 58 /WHA58.3-en pdf.

WHO, International Travel and Health. World Health Organization; January 2007. annex 2, 213. WHO, International Travel and Health. World Health Organization; January 2011. Chapter 6, 82-142. Narain Jai P, Lal S, Garg R. Implementing the Revised International Health Regulations in India. The

National Medical J India 2007; 20 (5) : 221- 23. David P. Fidler. From International Sanitary Conventions to Global Health Security: The New

International Health Regulations. Chinese Journal of International Law (2005), Vol. 4, No. 2, 325–392. Downloaded from oxfordjournals.org.

URL: http://www.port-health.org/sanitation/index Implementation of the International Health Regulations (2005). Report of the Review Committee on

the Functioning of the International Health Regulations (2005) in relation to Pandemic (H1N1) 2009. Report by the Director-General.

Mankar M, Pinto V. International Health Regulation. Bombay Hospital Journal,2009; 51; 2:222-28.