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Overview International Health
Regulations (IHR 2005)
LtCol. Sam Barringer, DVM
United States Air Force Academy
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Overview
"As we have seen recently with
SARS and H5N1 avian
influenza, diseases respect no
boundaries. In today's world, a
threat anywhere means danger
everywhere.“
(December 13, 2006)
--HHS Secretary Michael O. Leavitt, on
occasion of official United States
acceptance of revised IHR
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Background
Purpose of the WHO International Health
Regulations 2005
…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
(IHR 2005, Article 2).
Homeland Security Presidential Directive
HSPD-21
Calls on HHS to "establish a national
biosurveillance system for human health, with
international connectivity where appropriate, that
is predicated on State, regional, and communitylevel capabilities and creates a networked system
to allow for two-way information flow between
and among Federal, State, and local public health
authorities and clinical health care providers."
Strategy submitted to
Homeland Security Council
October 31, 2008
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IHRs History
• During the Forty-Eighth World Health Assembly in 1995, WHO and Member
States agreed on the need to revise the IHR (1969). The revision of IHR
(1969) came about because of its inherent limitations, most notably:
• Narrow scope of notifiable diseases (cholera, plague, yellow fever). The past few
decades have seen the emergence and re-emergence of infectious diseases. The
emergence of “new” infectious agents Ebola Hemorrhagic Fever and the reemergence of cholera and plague in South America and India, respectively;
• Dependence on official country notification; and
• Lack of a formal internationally coordinated mechanism to prevent the international
spread of disease.
• These challenges were placed against the backdrop of the increased travel and trade
characteristic of the 20th century.
• The IHR (2005) entered into force, generally, on 15 June 2007, and are
currently binding on 194 countries (States Parties) across the globe,
including all 193 Member States of WHO.
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Recent Outbreaks
From WHO World Health Report 2007
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IHRs: Key Changes from 1969
• Notify WHO of events
meeting defined criteria –
beyond prescribed list
• Enhance their events
management – especially
alert and response actions
• Meet minimum core
capacities – notably in
surveillance, response, and
at points of entry
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IHR Purpose
The World Health
Organization’s IHRs are
legally binding regulations
that form international law
which aim to:
a) assist countries to work
together to save lives and
livelihoods endangered by
the spread of diseases and
other health risks, and
b) avoid unnecessary
interference with
international trade and
travel.
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IHRs: Serves a Common Interest
• Serious and unusual disease
events are inevitable.
• A health threat in one part of
the world can threaten health
anywhere or everywhere.
• Provides a formal code of
conduct:
– helps contain or prevent
serious risks to public
health
– discourages unnecessary
or excessive traffic or trade
restrictions, for "public
health purposes"
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IHRs: Serves a Common Interest
• International agreement giving
rise to international
obligations
• Focuses on serious public
health threats with potential
to spread beyond a country′s
borders, to other parts of the
world
• Such events are defined as a
Public Health Emergency of
International Concern (PHEIC)
• Outlines assessment,
management, and information
sharing for PHEICs
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IHRs: In Brief
• ARE
– Written in legal language
– Supported by guidelines to aid compliance
– Intended to contain public health threats and minimize economic
disruption
• ARE NOT
– Self—explanatory
– Recommendations for safe travel
– A scientific consensus on everything possible to prevent disease
spread
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IHRs: Notifiable Diseases
ALWAYS Notifiable:
– Smallpox
– Poliomyelitis, wild—type
– Human influenza, new
sub—type
– Severe Acute Respiratory
Syndrome (SARS)
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IHRs: Notifiable Diseases
Other Potentially
Notifiable Events:
– Examples: cholera,
pneumonic plague,
yellow fever, viral
hemorrhagic fever, and
West Nile fever
– Other biological,
radiological, or
chemical events may fit
the decision algorithm
and be reportable
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WHO Pandemic Phases
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Making the Determination
•
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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 or
trade restrictions?
WHO makes the final determination that a Public
Health Emergency International Concern exists
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Serious Implication on
Public Health?
• There is potentially high morbidity and/or mortality
• The geographic scope is large or spreading over a large area
(e.g. multi—state or regional); is in area of high population
density
• The agent is highly transmissible/pathogenic
• The event has compromised containment or control efforts
• Therapeutic/prophylactic agents are unavailable, absent, or
ineffective
• Cases occurring among health care staff
• Assistance for investigation & response required
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Unusual or Unexpected?
• The disease—causing agent is yet unknown or a new
(emergent) pathogen
• The population affected is highly susceptible
• The affected country’s Government is encouraging
local and state Governments to aid compliance
• The event is unusual for the season, locality or host
• There is a suspicion that this may have been an
intentional act
• Agent had been eliminated or never reported in this
country before.
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Significant Risk for
International Spread?
• Epidemiologic link to a similar
event outside the affected
country
– International travel or
gathering
– Contact with traveler or
mobile population
• Potential cross—border
movement of
pathogen/agent/host
• Conducive transmission
vehicles: air, water, food or
environmental
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Risk for Trade or
Travel Restrictions?
• There is a history of similar events in the past that
have resulted in restrictions
• The event is associated with an international
gathering or a tourist area
• The event is or has gained significant government or
media attention
• There is a zoonotic disease or the potential for an
epizootic event, or exported/imported food/water—
related
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Making the Determination
In summary …
• Local situational
assessment required
– Decision instrument
available
• WHO will also assess
before any publication
or formal response
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Reporting Timeline
48—hour Time Requirement
• After a Governmental Agency
learns of a potential PHEIC
within its state or territory, it
must assess the event within
48 hours.
24—hour Time Requirement
• The Government Agency has
24 hours to notify WHO after
it believes that a potential
PHEIC may exist.
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Global Health and IHRs
Shared responsibility –
to establish core capacities:
• Surveillance and response
• Points of entry
• Country—specific
procedures—key element of
WHO′s strategy for global
health security
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Global Health and IHRs
Robust National Response
Effort is Expected:
• Context—specific
• Flexible
• Interventional health
measures permitted
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Global Health and IHRs
Entrance Screening
Permissible
• Medical exams and
interviews
• Vaccination and other
measures by consent
• Quarantine/isolation –
respect for human rights
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IHR References
• WHO IHR website: http://www.who.int/csr/ihr/en/
• HHS Global Health website: http://www.globalhealth.gov/ihr/
• HHS Announcement the U.S. accepted the IHR (2005):
http://www.hhs.gov/news/press/2006pres/20061213.html
• CDC IHR website: http://www.cdc.gov/cogh/ihregulations.htm
• Baker MG, Fidler DP. Global public health surveillance under the new
International Health Regulations. EID; July 2006, Vol. 12.
http://www.cdc.gov/ncidod/eid/vol12no07/05-1497.htm
• The CDC’s National Notifiable Diseases Surveillance System (NNDSS)
notifiable diseases website: http://www.cdc.gov/epo/dphsi/nndsshis.htm
• McNabb, Scott J.N., PhD, MS, Kohl, Katrin S., MD, PhD, MPH, International
Health Regulations: Revised for Today‘s World, U.S. Centers for Disease
Control and Prevention, Coordinating Office for Global Health. Available at
http://www.cdc.gov/cogh/ihrMaterial/powerpoint.htm
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Any Questions?
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