1. IHR implementation Preben Aavitsland
Department of Infectious Disease Epidemiology
Norwegian Institute of Public Health at
EpiTrain V, Vilnius, October

2. Contents Contents of IHR Main challenges for countries Conclusion
Background and purpose
IHR suveillance system
WHO’s many sources of epidemic intelligence
National IHR Focal Point
Member states’ obligations to build capacities
Main challenges for countries
WHO’s power to define an event
No political interference
Build capacities worldwide
No withholding of information
No excessive response
Conclusion

3. Background
Increased need for international public health security and cooperation
New diseases (SARS!)
More international travel
More people
Old IHR almost useless
Only cholera, plague and yellow fever
Dependent on official notification
No incetives for notifications
No formal cooperation mechanisms
No dynamics in international response

4. Outline of the IHR Part I Definitions and purpose
Part II Surveillance and response (annex 1+2)
Part III WHO recommendations concerning specific threats
Part IV –
VIII Routine measures
Part IX Procedures
Part X Reservations, disputes, etc

5. Key contents of the IHR
A new international system for epidemic intelligence
A procedure for WHO’s recommendations to guide the response to public health emergencies of international concern
A set of international rules on routine measures against international disease spread

6. Purpose of IHR (Art 2)
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.

7. The IHR surveillance system
Local level
National IHR Focal Point
WHO
notify, inform, consult in confidence
do surveillance
assess national events

8. Event based surveillance
From disease list to event definition
A difficult, but rational change
The disease + the circumstances
Undiagnosed diseases
New diseases

9. Decision instrument (annex 2) to determine whether an event may be a public health emergency of international concern (pheic)
Simlified by Baker & Fidler, 2006

10. Two or more yes  notify WHO.
Any event of potential international public health concern, including those of unknown causes or sources
A case of the following diseases is unusual or unexpected and may have serious public health impact, and thus shall be notified: Smallpox, Poliomyelitis due to wild-type poliovirus, Human influenza caused by a new subtype, Severe acute respiratory syndrome (SARS).
Yes No
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 travel and trade restrictions?
Events detected by national surveillance system
Two or more yes  notify WHO.

11. Notification is a start of a dialogue (i.e. ”not a big deal”)
Potential pheic notified by country
High sensitivity, low positive predictive value
Dialogue
Pheic declared by WHO

12. The IHR surveillance system
Mass media, GPHIN, MediSYS, Google, NGOs, ProMED etc + other countries
do surveillance
verify
Local level
National IHR Focal Point
WHO
notify, inform, consult in confidence
do surveillance
assess national events

13. WHO’s use of other information
The country no longer has monopoly on informing WHO
A reform worth fighting for!
WHO must verify information with country
WHO can keep source confidential
 All of us are now event-detectives for WHO
 An important role for e.g. the ProMED network
If you think your Government is delaying notification  write in ProMED

14. National IHR Focal Point (Art. 4)
An office (not individual) designated by the country
Accessible at all times for communications with the WHO
Direct telephone, fax and generic institutional address
Communicate contact details to WHO
Through Ministry to Director General of WHO

15. Communications Surveillance responsible Public health services
National IHR Focal Point
WHO EURO IHR Focal Point
Points of entry
Clinics and hospitals

16. National IHR Focal Point tasks I
Article 6: Notification of all events which may constitute a pheic
Article 7: Information-sharing during unexpected or unusual public health events
Article 8: Voluntary information to WHO of other events and consult on health measures
Article 9: Information to WHO of public health risk identified outside the country evidenced by imported/exported human cases, or contaminated vectors or products
Article 10: Responding to WHO requests for verification of reports from other sources
Article 11: Receiving information from WHO on events in other countries
Article 12: Consulting with the WHO Director-General on determination and termination of a pheic

17. National IHR Focal Point tasks II
Forward information from WHO
on public health risks
on potential pheic
on temporary and standing recommendations
other information
to the relevant sectors of administration
those responsible for surveillance
points of entry
public health services
clinics and hospitals
other

18. National IHR Focal Point tasks III
Consolidating input from relevant sectors of administration
those responsible for surveillance
points of entry
public health services
clinics and hospitals
Other
Establish efficient and functional channels of communication
Input which is necessary for the analysis of national public health events and risks

19. Obligations to build capacities
Article 5+13 and Annex 1A: Epidemic intelligence
Detect events
Report events
Assess events
Notify events to WHO
Respond to events
Article 20 and Annex 1B: Airports, ports, ground crossings capacities
Access to medical service
Safe environment
Access to rooms for interview, quarantine, isolation
Ability to disinsect, disinfect etc.

20. Local level capacities
Surveillance
Detect outbreaks of disease or death
Report immediately to higher level
Response
To implement preliminary control measures immediately

21. Regional level capacities
Surveillance
Confirm status of events
Assess events immediately
Report to national level
Response
Support or implement additional control measures

22. National level capacities
Surveillance
Assess all events within 48 hours
Notify WHO
Response (24 h per day)
Determine control measures
Provide lab support
Provide on-site assistance
Provide operational links with officials, ministries, hospitals, entry points
Have emergency plan

23. Two phases Phase 1: 15 June 2007 – 15 June 2009
Assess surveillance and response capacity requirements described in Annex 1A of the IHR (2005)
Develop national action plans to ensure that these core capacities are present and functioning throughout the country
Phase 2: 15 June 2007 – 15 June 2012
Surveillance and response capacities set out in Annex 1A must be implemented
(An additional 2-year period until 15 June 2014 may be granted)

24. Main challenges for countries
WHO’s power to define an event
No political interference
Build capacities worldwide
No withholding of information
No excessive response

25. ”Acute watery diarrhoeal syndrome”

26. Determining whether event is pheic
Old IHR
New IHR
Country
Detect
Detect
Determine
Notify
Notify
Publication + measures
Determine
WHO
Publication +measures

27. The ramification of notification has changed
Notification does not imply that an event is a pheic
Notification is just “telling WHO about an event”
Notification has no immediate consequences for your country
WHO can know about the event from other sources
WHO can start assessing the event without country’s official notification
It is the event itself - not the official notificiation of it - that is the basis of WHO’s determination of pheic

28. This is the revolution of the new IHR!
Countries have given WHO the power to determine events that can invoke IHR measures
WHO is working on behalf of us all in
doing epidemic intelligence
determining pheic
recommending measures

29. Non-political surveillance
Old IHR: Political interference in public health surveillance, because of fear of travel/trade sanctions
Deciding to notify WHO of a possible pheic is a professional public health decision, not a political one
Avoid elaborate decision systems for WHO notification

30. Build capacities worldwide
Global surveillance not stronger than the weakest link
Annex 1 is a powerful capacity list
Build multipurpose capacities
Use annex 1 to get resources
Your government signed up to it
Assist other countries
Annex 1 as a checklist for your international development agency

31. Notify WHO early Incentive 1: Confidential dialogue
Incentive 2: IHR protection against unjustified measures
Incentive 3: Assistance by WHO and other countries
Incentive 4: WHO will know sooner or later anyway

32. The Kon-fu-tse principle of surveillance
”Notify to WHO the events that you would like to know about if they occured in your neighbour country.”

33. National laws on communicable diseases
Protect the rights of the individuals with disease and cause minimal harm
Stop the national spread of the disease

34. International law on communicable diseases (=IHR)
Protect the sovereignty of states and cause minimal harm (restrictions)
Stop the international spread of the disease

35. Additional measures
Measures beyond WHO recommendations possible (art 43)
But need public health rationale and scientific information
Should be avoided
May undermine the whole IHR
Especially if poorly justified measures against poorer countries

36. Conclusions
IHR are a major step forward in global epidemic intelligence
Not perfect, but as good as was possible
Shifting power from countries to WHO (which works on behalf of all countries)
Multilateral solutions
Actual use more important that wording
We can all make the IHR work by respecting the spirit of IHR: early sharing of information + the right and non-excessive health measures
National capacity building is important