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IHR COORDINATION PROGRAMME

Christian Frederickson PhD, MPH, MPM,CAREC/PAHO/WHO

International Health Regulations (2005)

Third Hemispheric Conference on Port Securityof the Inter-American Committee on Ports.

7-10 April 2008

Punta Cana , Dominican Republic


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In May 2005, The 58th World Health Assembly adopted

the revised International Health Regulations, IHR

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


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International Health Regulations IHR (2005)

The International Health Regulations are a formal code ofconduct 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.


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They are an international agreement that gives rise tointernational obligations. 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 ofinternational concern, or PHEIC. The revised International

Health Regulations outline the assessment, the management

and the information sharing for PHEICs.


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IHRs serve a common interest.

First of all, they address serious and unusual disease events that

are inevitable in our world today.

They serve a common interest by recognizing that a health threat

in one part of the world can threaten health anywhere, or

everywhere.

And they are a formal code of conduct that helps contain or

prevent serious risks to public health, while discouraging

unnecessary or excessive traffic or trade restrictions for, quote,

"public health," purposes.


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Why have IHR?

Serious and unusual diseaseevents are inevitable

Globalisation - problem in onelocation is everybodys headache

An agreed International Public Healthcode of conduct for a global approach


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Some facts and figures:

Over 90% of world trade is transported by the international shippingindustry.

Today there are around 50,000 merchant ships that trade internationally and

transport all types of cargo.

The world fleet is registered in over 150 nations and manned by over onemillion seafarers of virtually every nationality. (www.shippingfacts.com ).

From 1970-2000, a WHO review of over 100 outbreaks associated with

ships found that more than one-third were related to foodborne transmission

(http://www.who.int/water_sanitation_health/diseases/shipsancompendium/

en/index.html


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Infectious Disease Concerns in the Caribbean

Dengue virusandChikungunyavirus

Competent vector in Caribbean and Latin America

Malaria 2007 outbreak Kingston, Jamaica 2006 outbreak Exuma Is. Bahamas

Yellow Fever

Endemic in Guyana, Trinidad & Tobago Epidemic of Yellow Fever in Paraguay, Brazil

Norovirus Cruise ships & resort in Dominican Republic (2007)

Poliovirus 21 cases in Hispaniola including 2 fatalities (2000-2001)


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H5N1: Avian influenza, a pandemic threat


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Whats new?

From three diseases to all public health risks

From preset measures to tailored response

From control of borders to also include containmen

at source

Decision instrument (Annex 2) of IHR (2005)


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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


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1. Health Measures - Recommendations

Temporary recommendations (Art 15)

Standing recommendations(Art. 16)

Examples of health measures for persons(Art. 18)

Review travel history and proof ofmedical examination, lab analysis,vaccination or other prophylaxis;

require medical examination,vaccination or other prophylaxis; Public health observation, quarantine,

isolation and contact tracing Entry and exit screening Refuse entry of suspect and affected

persons Refuse entry of unaffected persons to

affected area.

Examples of health measures for baggagcargo, containers, conveyances, goodsand postal parcels (Art. 18)

-Review manifest, Proof of measures

taken on departure or in transit, Routingand implement inspections

-Implement treatment to remove infectioand contamination, vectors andreservoirs.

-Isolation and quarantine, seizure anddestruction

-Refuse departure or entry.


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2. Protections for travellers

Overarching rights (Arts. 3 & 32)

Sanitation and hygiene of transport (Art.s 22 & 24)

Charges (Art. 40)

Data protection

(Art. 45)

Unjustified measures

(Art.s 23, 30, 31, 35 & 43)


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3. Health Measures - General application

Generic

Arrival and departure (Art.s 23 & 31)

Information about travellers itinerary, destination, non-invasive medical examination

Inspection of baggage, cargo, containers, conveyances,goods, postal parcels and human remains

Specific Yellow fever vaccination

(Art. 36, Annexes 6&7)

Vector control - Disinsection of conveyances(Annex 5)


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4. Affected conveyances and imported cases

Affected or diverted conveyances andemergencies (Art.s 25,26,27 & 28)

Imported cases (Art. 9)


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4. Health Measures - additional

Additional (National and International Law) health measures(Art 43)


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Learning from experience: the example of SAR

Identification of the problem

Linking events in different countries

Co-ordinating international response

Field Teams

Laboratory

Epidemiology

Clinical

Travel advice, entry and exit screening at PoE

Timely information & recommendations for control

Provision of direct support and assistance


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What do the IHR call for?

Strengthened national capacityfor

surveillance and control, including in traveland transport

Prevention, alert and response to public

health emergencies of international concer Rights, obligations and procedures,

and progress monitoring

Global partnership and international

collaboration

St th ti l di ill


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Requires a commitment of States Parties

Mobilization of national resources: e.g. staff, infrastructure, budget

Development of national action plans, integrated and coordinated with

intermediate and local levels and points of entry (ports, airports, ground crossi

Builds on existing national and regional strategies

Requires sustained multisectorial approach and international collaboratio

Strengthen national disease surveillance,

prevention, control and response system

IHR Strategic Implementation Plan


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NATIONAL

SURVEILLANCE

AND RESPONSE

WHO GLOBAL

ALERT AND

RESPONSE SYSTEM

THREAT-SPECIFIC

CONTROL

PROGRAMMESINTERNATIONAL

TRAVELS AND

TRANSPORTS

GLOBAL PARTNERSHIP

International

initiatives andnetworking

National Capacity

Strengthening

IHR Strategic Implementation Plan

if IHR was a lighthouse

LEGAL PROCEDURES

AND MONITORING


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GLOBAL PARTNERSHIP

1. Foster global partnerships (example CAPSCA PROJECT)

STRENGTHEN NATIONAL CAPACITY

2. Strengthen national disease surveillance, prevention, control and response systems

3. Strengthen public health capacities in travel and transport, including routine measuresand emergency preparedness at points of entry

PREVENT AND RESPOND TO INTERNATIONAL PUBLIC HEALTH EMERGENCIES

4. Strengthen WHO global alert and response system

5. Strengthen threat-specific international control programmes

LEGAL ISSUES AND MONITORING

6. Sustain rights, obligations and procedures

7. Conduct studies and monitor progress

IHR Implementation Plan


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The IHR foster global partnership

Other intergovernmental organizations:

UN system (e.g. FAO, IAEA, ICAO, IMO, UNWTO)

others: regional (e.g. EU, ASEAN, MERCOSUR), technical (e.g. OIE)

Development agencies:

governments, banks

WHO Collaborating centres

Academics & professional associations

Industry associations (e.g. IATA, ISF)

NGOs and Foundations


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STRENGTHEN NATIONAL CAPACITY FOR PUBLICHEALTH RESPONSE

2. Strengthen national disease surveillance, prevention, control and response system

3. Strengthen public health capacities in travel and transport points of entry

Timeline

2007 2009 2012 2014 2016

Assessing

Planning

Implementation

2 years + 3 + (2) + (up to 2)

"As soon as possible but no later than five years from entry into force " (Articles 5, 13

extensions


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Containment at source

Rapid response at the sourceis:

the most effective way to securemaximum protection againstinternational spread of diseases

key to limiting unnecessaryhealth-based restrictions ontrade and travel


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Importance of national capacity

The best way to prevent international

spread of diseases is to detect public health

events early and implement effective

response actions when the problem is small

Early detection of unusual disease events by

effective national surveillance (both disease and

event based) Systems to ensure response (investigation,

control measures) at all levels (local, regional,

and national)

Routine measures and emergency response at

ports, airports and ground crossings.

Core capacity requirements


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Core capacity requirements

for designated points of entry PoEArt.19, 20 & 21

DESIGNATION OF POINTS OF ENTRY States Parties shalldesignate Airports and Ports for developing capacities

Annex 1b

States Parties where justified for PH reasons, maydesignate ground crossingfor developing capacities Annex 1b, taking into consideration volume andfrequency of international traffic and public health risks of the areas in whichinternational traffic originates.

States Parties sharing common borders should consider: Bilateral and multilateral agreements

Joint designation of adjacent ground crossing for capacities Annex 1b

Identify competent authority for each designated point of entry

WHO CERTIFICATION FOR AIRPORTS AND PORTS

Under request of State Party WHO may arrange to certify it

Need to develop procedures and guidelines by WHO

Capacity Strengthening at

PoE Core capacity requirements at all times (routine)


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(a) Assessment

and Medical care,

staff & equipment

(b) Equipment &personnel for

transport ill travellers

(c) Trained personnelfor inspection of

conveyances

(d)ensure save environment:water, food, waste, wash rooms

& other potential risk areas -

inspection programmes

(e) Trained staff andprogramme for vector

control

Capacity Strengthening at

Points of EntryPoE Core capacity requirements at all times (routine)

PoE Capacity requirements for responding to potential PHEIC


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a

Public Health

EmergencyContingency plan:

coordinator, contact

points for relevant

PoE, PH & other

agencies

Provide assessment &

care for affected

travellers, animals:

arrangements with

medical, veterinaryfacilities for isolation,

treatment & other

services

bc

Provide space,separate from other

travellers tointerview suspect or

affected persons

d

Provide for

assessment,

quarantine of

suspect or affected

travellers

e

To apply

recommendedmeasures, disinsect,

disinfect,

decontaminate,

baggage, cargo,

containers,

conveyances, goods,

postal parcels etc

fTo 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

p y q p g p

(emergency)

S i i l h


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Some principle approaches

Continuous risks

Routine measures in place

"sanitary conditions" at points of entry

and conveyances

travellers, goods etc.

Specific measures for certainknown risks in place

Vector control, vaccination

Standing recommendations

Sudden increase in risk

Detection

information & verification

notification

risk assessment

Response

Support to investigation and control

Information and recommendations

Points of entryK bli h lth f ti


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Key public health functions

PREVENTION EARLY WARNING RESPONSE

RISK MANAGEMENT INSPECTION CONTINGENCY

ROUTINE CONTROL SCREENING PLANS

CONTROLING KNOWN

PUBLIC HEALTH RISKS

At PORTS, AIRPORTS,

GROUND CROSSING

CONTROLING EVENTS

& RESPONDING

TO EMERGENCIES

DETECTING PUBLIC

HEALTH EVENTS

OF INTERNATIONAL

CONCERN

What does WHO do under the IHR?


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What does WHO do under the IHR?

Designate WHO IHR contact points

Support States Parties in assessing their public health risks,

through the notification, consultation, and verification processes

Inform State Parties of relevant international public health risks

Recommend public health measures

Assist States Parties in their efforts to investigate outbreaks

and meet the IHR national core capacities requirements for

surveillance and response and points of entry

WHO to help countries managing events


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WHO to help countries managing events

New WHO global Event Management System

WHO Regional Alert and Response teams

Train countries NFPs and WHO contact points for event manageme

Expand Global Outbreak and Alert

Response Network GOARN andother specialized and regionalsupport networks

Develop new tools and standardoperating procedures

Carry out IHR exercises


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ResponseResponse Global Outbreak Alertand Response Network

WHO system of Global Outbreak Alert andResponse Network GOARN OperationsEvent

Intelligence

Event

Intelligence

VerificationVerification

Official, State

sources

Risk AssessmentRisk AssessmentWHO HQ, Regional & Country

Offices, Collaborators

and experts

Global distribution of GOARN institutions and partne

A t k f th 130 t h i l i tit ti


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A network of more than 130 technical institutions,

WHO manages secretariat and logistic support

Global partnership and international collaboratio


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Global partnership and international collaboratio

Countries challenges for IHR implementation
http://www.ilo.org/public/english/index.htmhttp://www.wto.org/english/thewto_e/10anniv_e/10anniv_e.htmhttp://www.icao.int/index.htmlhttp://www.iata.org/index.htm


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Countries challenges for IHR implementation

Mobilize resources and develop national action plans

Strengthen national capacities in alert and responseStrengthen capacity at ports, airports, and ground crossings

Maintaining strong threat-specific readiness for known

diseases/risks

Rapidly notify WHO of acute public health risksSustain international and intersectoral collaboration

Monitor progress of IHR implementation

PHE- Multi-sectoral Approach


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Public health services

Health care system Veterinary services Agriculture Education Communication

Transport Trade Security Army, air force,defense

Prime Ministers

Office/Presidential Cabinet

Scientific committee, Turkey

Avian Flu 2006

PHE- Multi-sectoral Approach

Coordination with safety,

security and facilitation localand national plans and

operational procedures and

committees on implementing

public health emergency plans

Integration of local public health

emergency plan with a nationalsurveillance and response plan

Coordinating airport operations

with national and international

public health response plans

Information on IHR(2005)


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Information on IHR(2005)

IHR text: http://www.who.int/csr/ihr/WHA58_3-en.pdf

More information, FAQs on IHR:http://www.who.int/csr/ihr/en/

For more queries on IHR international travel and transport:

[email protected]

Note on arrangements for the issuance of Shi
http://www.who.int/csr/ihr/WHA58_3-en.pdfhttp://www.who.int/csr/ihr/en/mailto:[email protected]:[email protected]://www.who.int/csr/ihr/en/http://www.who.int/csr/ihr/WHA58_3-en.pdf


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Sanitation Certificates SSC

As of 15 June 2007 the International Health Regulations (2005)

("IHR (2005)") have introduced new certification procedures for

ships. The new certificates are entitled Ship Sanitation Control

Exemption Certificate/Ship Sanitation Control Certificate ("Ship

Sanitation Certificates" or "SSC"). These SSC replace the

previous Deratting/Deratting Exemption certificates ("DC/DEC")provided for under the 1969 Regulations.

After 15 December 2007, no Deratting Certificate will be

valid.

Interim technical advice for inspection and issuan


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of Ship Sanitation Certificates SSC

Valid for six month period

Used to identify and record all areas of ship-borne public health risks (notlimited to rodents), together with any required control measures to beapplied.

The SSC may be required from all ships, whether seagoing or inlandnavigation vessels, on an international voyage calling at the port of a

State Party. It may be renewed at any port authorized to issue such renewals by a State

Party.

Authorized ports must have the capability to inspect, issue and implement(or supervise implementation of) necessary measures for the Ship

Sanitation Control Certificate.

Interim technical advice for inspection and issuance

f Shi S it ti C tifi t SSC


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Ship Sanitation Control Exemption Certificate issued when

no evidence of a public health risk is found on board and

the competent authority is satisfied that the ship is free ofinfection and contamination, including vectors and reservoirs.

This certificate shall normally be issued only if the inspectionhas been carried out when the ship and holds are empty orwhen they contain only ballast or other material, of such natureor so disposed as to make a thorough inspection of the holdspossible.

Interim technical advice for inspection and issuance

f Shi S it ti C tifi t SSC


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ShipSanitation Control Certificate: issued when

evidence of a public health risk, including sources of infection

and contamination, is detected on board and

after required control measures have been satisfactorily

completed;

the SSC must record the evidence found and the control

measures taken.


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IHR COORDINATION PROGRAMME http://www.who.int/csr/ihr/ssc/en/index.html


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Ports Listing for issuing SSC


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g g

WHO is requesting information from States Parties regarding which ports

each State Party is authorizing to issue these certificates and theirextensions. As it becomes available, this information will be made

accessible through the "SSC Ports List" which will be published on the IHR

website http://www.who.int/csr/ihr/

It should be noted that the listing of ports authorized by States Parties for

the purpose of issuing SSC is not the same as the separate designation bythem of points of entry PoE for development of core public health capacities

as specified under Annex 1B of the IHR (2005).

PoE include international ports but also airports and ground crossings, and

the capacities required extend beyond inspection and certification1.


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IHR COORDINATION PROGRAMME http://www.who.int/csr/ihr/portslanding/en/index.html

Port authorized to issue SSCby WHO Regions and States Parties

Port authorized to issue SSCby WHO Regions and States Parties


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by WHO Regions and States Partiesby WHO Regions and States Parties

49 / 184 States Parties(SP) Total: 1338 ports

as of 20/03/2008

33%

(72)

WPRO

12 / 28 SP

AFRO

03 / 46 SP

AMRO

08 / 36 SP

EMRO

06 / 21 SP

EURO

17 / 53 SP

SEARO

03 / 11 SP

TRAVEL AND TRANSPORT IHR(2005)Challenges


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Challenges

Designation of authorized ports to issue SSC

Designation of PoE to develop, maintain and strength core capacities

Assessment of core capacities for designated points of entry

Implementation of WHO Certification for IHR core capacities requirements for portsand airports

Integration of points of entry activities to national surveillance system

Development of Intersectorial approach of Public Health concerns at PoE(e.g.;facilitation, security, safety and trade)

Development of integrated emergency contingency plans for PoE

Development of strategic approach for international communication and cooperationfor response to events involving points of entry, travel and transport

Thank you. Any questions?


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Thank you. Any questions?

[email protected]

Or

Daniel MENUCCI IHR Technical Officer Lyon

FR.

[email protected]
mailto:[email protected]:[email protected]

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