IHR implementation Preben Aavitsland Department of Infectious Disease Epidemiology Norwegian Institute of Public Health at EpiTrain V, Vilnius, October 22 2007

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

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

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

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

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.

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

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

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

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.

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

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

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

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 e-mail address Communicate contact details to WHO Through Ministry to Director General of WHO

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

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

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

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

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.

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

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

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

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)

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

”Acute watery diarrhoeal syndrome”

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

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

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

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

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

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

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.”

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

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

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

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