1. INTERNATIONAL HEALTH REGULATIONS

2. FRAMEWORK:  Introduction  Need for International Health Regulations  History in the formation of International Health regulations  IHR 1969 versus IHR 2005.  Why a new IHR?  Objectives of the revised IHR  Member states and their obligations  Some important definitions and articles under IHR 2005  Health measures at ports and Indian Port Health Rules  Diseases reportable under IHR 2005  Vaccination for travellers  Role of IHR- SARS and H1N1  Progress in the implementation of IHR in India.

3. INTRODUCTION Infectious disease events in one country may be of potential concern throughout the world. How? Tourism or Migration or as a result of disasters Growth in international trade in food Biological, social and environmental changes linked with urbanization Deforestation Alteration in climate Changes in method of food processing, distribution and consumer habits.

4. NEED FOR IHR According to statistics of the World Tourism Organization, international tourist arrivals in the year 2005 exceeded 800 million. International travel can pose various risks to health as travellers may encounter sudden and significant changes in altitude humidity microbes and temperature Additional health risks arise when accommodation is of poor quality hygiene and sanitation are inadequate medical services are not well developed clean water is unavailable

5. It is estimated that 2.1 billion airline passengers travelled in 2006. The infectious diseases are now spreading faster by emerging more quickly, than ever before. There are now 40 diseases that were unknown a generation ago. During the last five years, WHO has verified more than 1100 epidemic events worldwide. Consequently the need for international co-operation in order to safeguard global health has become increasingly important.

7. HISTORY OF INTERNATIONAL HEALTH REGULATIONS 1830, 1847: Cholera epidemics in Europe were catalyst for intense infectious disease diplomacy and multi-lateral co-operation. 1951: WHO issued first set of legally binding international sanitary regulation. 1969: WHO adopted international sanitary regulation and renamed as international health regulation. 1973, 1981: Minor modifications in IHR, amended world wide. 23rd May 2005: World health assembly adopted revised IHR 15th June 2007: Came in to force revised IHR.

8. 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.

9. 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 state No 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

10. WHY A NEW IHR? IHR (1969)- small pox, yellow fever, cholera, and plague. Eradication of small pox- requirement for international notification was reduced to the remaining three diseases. Increasing international travel and trade. Early warning is essential and depends on collaboration and guarantees to notifying member state against misue of information. Measures should be coordinated internationally - WHO may take this role. Recent experiences -Anthrax attacks (2001) ; SARS (2003) and Chernobyl disaster

11. 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

12. WHAT IS IHR 2005? The International Health Regulations are a formal code of conduct for public health emergencies of international concern. They're a matter of responsible citizenship and collective protection. They involve all 193 World Health Organization member countries. They focus on serious public health threats with potential to spread beyond a country's border to other parts of the world. Such events are defined as public health emergencies of international concern, or PHEIC. The revised International Health Regulations outline the assessment, the management and the information sharing for PHEICs.

13. 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.

14. OBLIGATIONS OF THE MEMBER STATES UNDER IHR 2005  Designating a national IHR focal point  Strengthening core capacity to detect, report and respond rapidly to public health events  Assessing events that may constitute a PHEIC within 48 hours and notifying WHO within 24 hours of assessment  Providing routine inspection and control activities at international airports, ports and some ground crossings  Examining national laws, revising health documents/forms and certificates, and building a legal and administrative framework in line with the IHR requirements

15. SOME IMPORTANT DEFINITIONS AND ARTICLES UNDER IHR 2005 ARTICLE 1 “ISOLATION” means separation of ill or contaminated persons or affected baggage, containers, conveyances, goods or postal parcels from others in such a manner as to prevent the spread of infection or contamination. “QUARANTINE” means the restriction of activities and/or separation from others of suspect persons who are not ill or of suspect baggage, containers, conveyances or goods in such a manner as to prevent the possible spread of infection or contamination

16. “STANDING RECOMMENDATION” means non-binding advice issued by WHO for specific ongoing public health risks pursuant to Article 16 regarding appropriate health measures for routine or periodic application needed to prevent or reduce the international spread of disease and minimize interference with international traffic. “TEMPORARY RECOMMENDATION” means non-binding advice issued by WHO pursuant to Article 15 for application on a time- limited, risk-specific basis, in response to a public health emergency of international concern, so as to prevent or reduce the international spread of disease and minimize interference with international traffic.

17. ARTICLE 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. ARTICLE 3 Relates to principles of the IHR 1. The implementation of these Regulations shall be with full respect for the dignity, human rights and fundamental freedoms of persons. 2. Guided by the Charter of the United Nations and the Constitution of the World Health Organization. 3. Guided by the goal of their universal application for the protection of all people of the world from the international spread of disease. 4. 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

18. ARTICLE 4 Relates to responsible authorities PUBLIC HEALTH RESPONSE (ARTICLE 5-14) ARTICLE 5 surveillance ARTICLE 6 notification ARTICLE 7 Information-sharing during unexpected or unusual public health events ARTICLE 8 consultation

19. ARTICLE 9 Other reports ARTICLE 10 Verification ARTICLE 11 Provision of information by WHO ARTICLE 12 Determination of a public health emergency of international concern ARTICLE 13 Public health response ARTICLE 14 Cooperation of WHO with intergovernmental organizationsand international bodies

20. DECISION INSTRUMENT (ANNEX 2) OF IHR (2005) FOR ASSESSMENT AND NOTIFICATION 4 diseases that shall be notified polio (wild-type polio virus), smallpox, human influenza new subtype, SARS. Disease that shall always lead to utilization of the algorithm: cholera, pneumonic plague, yellow fever, VHF (Ebola, Lassa, Marburg), WNF, others…. Q1: public health impact serious? Q2: unusual or unexpected? Q3: risk of international spread? Q4: risk of travel/trade restriction? Insufficient information: reassess

21. Events detected by national surveillance system or reported by media or any non-governmental organization UNUSUAL DISEASES  Smallpox  Human influenzae (new subtype)  Wild poliovirus  Severe acute respiratory syndrome UNUSUAL DISEASES  Smallpox  Human influenzae (new subtype)  Wild poliovirus  Severe acute respiratory syndrome  KNOWN EPIDEMIC PRONE DISEASES  Cholera  Pneumonic plague  Viral haemorrhagic fevers  Yellow fever  West nile fever  Other locally or regionally important diseases  KNOWN EPIDEMIC PRONE DISEASES  Cholera  Pneumonic plague  Viral haemorrhagic fevers  Yellow fever  West nile fever  Other 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?  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

22. HEALTH MEASURES AT PORTS ON ARRIVAL  All sanitary operations shall be carried out so as not to cause discomfort to any person or injury to health not to cause damage to the structure of the ship to avoid risk of fire or damage of goods on board.  The Health Authority shall issue : 1) A certificate free of charge, of the sanitary measures applied, the methods and reasons of applying the measures ; 2) Shall issue a certificate to any traveler of the date of arrival or departure and measures applied to him and his baggage.  Allow a person under surveillance to move freely and carry out medical examination or investigations if necessary.  A ship shall not be denied of free pratique on account of any other epidemic diseases other than specified in IHR.

23. It shall not be prevented from discharging or loading of cargo or taking of fuel or water. The health authority may tackle all practicable measures to prevent discharge of sewage and effuse which may contaminate the waters of the port. Vessels arriving at Indian ports shall be subjected to Health Inspection b y the Health Officer to ascertain the following of sewage and effuse which may contaminate the waters of the port. Whether general hygiene and sanitation on vessel are satisfactory. Whether there exists rodent, vermin or insect infestation Whether potable drinking water is supplied according to the prescribed code of sanitary practices for supply of safe drinking water.

24. The following documents must be checked and/or issued by the Health Officer on visiting every vessel that is granted radio free pratique. 1. Maritime declaration of health according to IHR if the last port of call is a foreign port. 2. Crew list. 3. Yellow Fever Vaccination certificates of the crewmembers wherever necessary. 4. Deratting or Deratting exemption certificate. 5. Medicine chest certificate. 6. Certificate of health and sanitary inspection. 7. Certificate showing date and time of granting of radio pratique.

25. HEALTH MEASURES AT PORT ON DEPARTURE: The health authority of the port (the frontier port) shall take all practicable measures: To prevent the departure of an infected person or suspect To prevent introduction of possible agent of infection or vectors If the area is declared as infected the crew of the ship requires a valid certificate to that effect. The health authority, if considers necessary, may examine any person before his departure on an international voyage. A crew on an international voyage if on arrival is placed under surveillance; he may be allowed to continue on the voyage. However, the health authority must be notified of the place to which he is proceeding.

26. SCREENING OF PERSONS AT ENTRY AND EXIT No specific health measures are advised Review travel history in affected areas Review proof of medical examination and any laboratory analysis Require medical examinations Review proof of vaccination or other prophylaxis Require vaccination or other prophylaxis Place suspect persons under public health observation

27. Implement quarantine or other health measures for suspect persons Implement isolation and treatment where necessary of affected persons Implement tracing of contacts of suspect or affected persons Refuse entry of suspect and affected persons Refuse entry of unaffected persons to affected areas Implement exit screening and/or restrictions on persons from affected areas

28. DISEASES REPORTABLE UNDER IHR 2005 New diseases are emerging at the historically unprecedented rate of one per year. The infectious diseases reportable under the IHR (2005) include: UNUSUAL DISEASES  Smallpox  Human influenzae (new subtype)  Wild poliovirus  Severe acute respiratory syndrome UNUSUAL DISEASES  Smallpox  Human influenzae (new subtype)  Wild poliovirus  Severe acute respiratory syndrome KNOWN EPIDEMIC PRONE DISEASES  Cholera  Pneumonic plague  Viral haemorrhagic fevers  Yellow fever  West nile fever KNOWN EPIDEMIC PRONE DISEASES  Cholera  Pneumonic plague  Viral haemorrhagic fevers  Yellow fever  West nile fever OTHER LOCALLY OR REGIONALLY IMPORTANT DISEASES  Dengue fever OTHER LOCALLY OR REGIONALLY IMPORTANT DISEASES  Dengue fever

29. CATEGORIES OF THESE REPORTABLE DISEASES  Epidemic prone diseases Cholera, yellow fever, meningococcal disease, SARS, avian influenza, ebola, marburg haemorrhagic fever, nipah virus infection, drug resistant diarrhoeal diseases, hospital acquired infections, malaria, meningitis, respiratory tract infections and sexually transmitted infections and HIV infections.  Food borne diseases Microbial contamination chemicals and toxins. The emergence of new food borne diseases i.e. new variant of Creutzfeldt Jakob disease associated with bovine spongiform encephalopathy (BSE).  Accidental and deliberate outbreaks Breaches in biosafety measures are often responsible for outbreaks associated with the accidental release of infectious agents for example anthrax in USA in 2001.

30.  Toxic chemical accidents Dumping of 500 tons of petrochemical waste in at least 15 sites led to the deaths of 8 people, and 90000 were seeking medical help in West Africa in the year 2006.  Radio nuclear Accidents Chernobyl disaster in 1986 resulted in the evacuation and resettlement of over 3,36,000 people.  Environmental disasters  Heatwave in Europe 2003, the lives of 35,000 persons were linked to extremes in weather.  Bhopal gas tragedy in December 1984  1700 people died in Carbon dioxide poisoning in Central Africa in 1986

31. VACCINATION FOR TRAVELLERS

32. SEVERE ACUTE RESPIRATORY SYNDROME The 2003 outbreak of SARS. This newly discovered pathogen was quickly spread by an infected traveler who left Guangdong Province, China. Arrived in Hong Kong, where he infected 10 other people staying in a hotel, leading directly or indirectly to cases in 8 countries. The combined influence of World Health Organization (WHO) travel advisories and media attention to SARS affected traveler behavior. Tourist arrivals in East Asian airports dropped 41% from April 1 to April 21, 2003.

33. FIGURE 2. Pandemic (H1N1) 2009. Countries, territories and areas with laboratory-confirmed cases and number of deaths as reported to WHO. Status as of 1 August 2010

34. 2009 INFLUENZA A(H1N1)  In March 2009, a new strain of influenza A (H1N1) began spreading in Mexico.  Within 30 days, cases occurred in US states bordering Mexico.  Within 90 days, WHO declared that a pandemic, or global outbreak of H1N1 influenza, was occurring.  Analysis of preliminary passenger volume data for the largest airline carriers between Mexico and the United States indicated that during April 27 through May 17, 2010, northbound volume dropped 42%, and southbound volume dropped 57%, as compared to the previous year.

35. (a) Assessment and Medical care, staff & equipment (b) Equipment & personnel for transport ill travellers ( c) Trained personnel for inspection of conveyances ( d) ensure save environment: water, food, waste, wash rooms & other potential risk areas - inspection programmes (e) Trained staff and programme for vector control Capacity Strengthening at Points of Entry POINT OF ENTRY : CORE CAPACITY REQUIREMENTS (ROUTINE)

36. a Public Health Emergency Contingency plan: coordinator, contact points for relevant PoE, PH & other agencies Provide assessment & care for affected travellers, animals: arrangements with medical, veterinary facilities for isolation, treatment & other services b c Provide space, separate from other travellers to interview suspect or affected persons d Provide for assessment, quarantine of suspect or affected travellers e To apply recommended measures, disinsect, disinfect, decontaminate, baggage, cargo, containers, conveyances, goods, postal parcels etc f To apply entry/exit control for departing & arriving passengers g Provide access to required equipment, personnel with protection gear for transfer of travellers with infection/ contamination POINT OF ENTRY : CAPACITY REQUIREMENTS DURING PHEIC (EMERGENCY)

37. RECENT EXAMPLES OF NOTIFIABLE DISEASES IN INDIA In April 2007, in an outbreak of Nipah virus infection in Nadia District in West Bengal, 5 individuals were infected and all died. A total of 255 cases of poliomyelitis due to the wild-type virus have been reported in India up to September 2007. Although no human influenza cases have been reported so far, H5N1 outbreaks among poultry in Maharashtra, Gujarat and Madhya Pradesh and more recently in Manipur indicate the need for continued vigilance. First case of human-to-human transmission of the deadly virus of swine flu (H1N1) in India was reported in Hyderabad, tolls of lives. Outbreaks of water-borne and vector-borne diseases such as cholera and dengue fever are also common in India.

38. IMPLEMENTATION OF IHR IN INDIA The Government of India has designated the National Institute of Communicable Diseases (NICD) as the national focal point for IHR Strengthening national surveillance system is at the heart of IHR (2005). The Government of India has allocated Rs 4.08 billion (Rs 408 crores) over 5 years for the integrated disease surveillance project (IDSP) to build infrastructural and human capacity at the district and state levels To facilitate rapid communication from the district onwards, districts are being connected electronically, through satellite and the terrestrial network for transmission of surveillance data.

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