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Pan AmericanHealthOrganization
Disease Surveillance and Response to Disease OutbreaksBWC and the International Health Regulations (IHR)
PAHO/HSD/IR/IHR
Regional Workshop for Latin America and the Caribbeanon the Seventh Review Conference and National Implementation
of the Biological Weapons Convention
Lima, Peru, 9-11 November 2011
Milestones towards the current International Health Regulations
HIV/AIDSChernobyl
Plague Ebola /
Marburg
• Resolution WHA48.7: Revision and updating of theInternational Health Regulations, 1995
• Resolution WHA48.13: New, emerging and re-emerging infectious diseases, 1995
A possible mechanism to support such an initiative is provided by Article VII of the draft Protocol of the Biological and ToxinWeapons Convention of 1972. This draft Protocol is being negotiated by an ad hoc group (established in 1994) of the States Parties to the Biological and Toxin Weapons Convention. Article VII (Scientific and Technological Exchange for Peaceful Purposes and Technical Cooperation) of the draft Protocol aims to enhance international cooperation for the peaceful use of biological materials, equipment, information and technology (e.g. biotechnology).
REQUESTS the Director-General:
(3) to make appropriate arrangements for the development of regional preparedness and response plans
(4) to provide support to Member States for strengthening their capacity to detect and respond rapidly to communicable disease threats and emergencies, especially by developing the laboratory skills needed for diagnosis and providing training in epidemiological methods for use in the field, particularly in the most exposed countries
Milestones towards the current International Health Regulations
HIV/AIDSChernobyl
Plague Ebola /
Marburg
vCJDNipah
Anthrax
4. All activities implemented by WHO on the public health aspects of prevention, preparedness and response to natural, accidental or deliberate releases of biological, chemical and radiological agents involve the closest possible coordination with relevant national and international organizations. A deliberate release of a biological, chemical or radiological agent would likely be considered initially as a natural event, unless the agent had been spread overtly or on a massive scale.
5. WHO focuses on the possible public health consequences of such an incident, regardless of whether it is characterized as a deliberate act or a naturally occurring event. The Organization’s basic activity in this area is to strengthen public health disease alert and response systems at all levels, as such a system will detect and respond to diseases that may be deliberately caused.
10. The United Nations has mandated the Secretary-General “to carry out promptly investigations in response to allegations that may be brought to his attention by any Member State concerning the possible use of chemical and bacteriological (biological) or toxin weapons […] in order to ascertain the facts of the matter …” Initial contacts on the issue of cooperation in the case of investigations have been established with the United Nations.
11. Should the United Nations be called on to respond to a request to investigate, WHO could be asked to provide technical expertise or to make available its existing resources and mechanisms. Nonpublic health issues related to investigations of reports on possible use of chemical and bacteriological (biological) or toxin weapons, however, remain the responsibility of the United Nations.
REQUESTS the Director-General:(1) to continue, in consultation with relevant intergovernmental agencies and other international organizations, to strengthen global surveillance of infectious diseases, water quality, and food safety, and related activities such as revision of the International Health Regulations and development of WHO’s food safety strategy, by coordinating information gathering on potential health risks and disease outbreaks, data verification, analysis and dissemination, by providing support to laboratory networks, and by making a strong contribution to any international humanitarian response, as required;
(3) to continue to issue international guidance and technical information on recommended public health measures to deal with the deliberate use of biological and chemical agents to cause harm, and to make this information available on WHO’s web site;
Milestones towards the current International Health Regulations
HIV/AIDSChernobyl
Plague Ebola /
Marburg
vCJDNipah
AnthraxSARS
International Health Regulations
• WHO Member States recognized need to collectively respond to public health emergencies of international concern
• An Intergovernmental Working Group tasked with the revision of the IHR(1969) in 2004
• WHO Member States adopted the current IHR during the 58th World Health Assembly in 2005 with Resolution WHA58.3• Resolution WHA58.29: Enhancement of laboratory biosafety
• Current IHR entered into force in June 2007• A legal tool: describes procedures, rights and legal obligations for
States Parties and WHO• 10 Parts, 66 Articles, and 9 Annexes
The World Health Report 2007A safer future: global public health security in the 21st century
• Links between health, foreign policy and security increasingly clear over past decade and subject of widespread discussion in high level fora
• The core surveillance and response capacities under IHR are central to national, regional, and global public health security
• Recognition of a collective responsibility towards internationalpublic health, based on dialogue, transparency and trust - nothing new at technical level (Annex 1 – “existing”)
Purpose and scope of the IHR
• From three diseases to all public health hazards, irrespective of origin or source• From control of borders to containment at source• From preset measures to adapted response
“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 2)
PART I – DEFINITIONS, PURPOSE AND SCOPE, PRINCIPLES AND RESPONSIBLE AUTHORITIES
Article 1 - Definitions“disease” means an illness or medical condition, irrespective of origin or source, that presents or could present significant harm to humans
PART II – INFORMATION AND PUBLIC HEALTH RESPONSE
Article 7 - Information-sharing during unexpected or unusual public health eventsIf a State Party has evidence of an unexpected or unusual public health event within its territory, irrespective of origin or source, which may constitute a public health emergency of international concern, it shall provide to WHO all relevant public health information
WHO strategic frameworkIHR Areas of Work, 2007
1. Foster global partnerships 2. Strengthen national disease prevention,
surveillance, control and response systems 3. Strengthen public health security in travel and
transport 4. Strengthen WHO global alert and response
systems 5. Strengthen the management of specific risks 6. Sustain rights, obligations and procedures 7. Conduct studies and monitor progress
Accessibility at all timesPrimary channel for WHO-NFP event-related communicationsDisseminate information within WHO"Activate" the WHO assessment and response system
DetectAssessReportRespond
Accessibility at all timesCommunication with WHODissemination of information nationallyConsolidating input nationally
National surveillance and response systemsIncluding at Points of Entry
National IHRFocal Points (NFP)
WHO IHR Contact Points
EmergencyCommittee
Other competent organizations(IAEA etc.)
Ministries and sectors concerned
Determine Public Health Emergency of International Concern (PHEIC)Make temporary and standing recommendations
ReviewCommittee
ExpertRoster
WHO Director-General
NotificationConsultationReportVerification
Unusual healthevents
IHR operational framework
PART I – DEFINITIONS, PURPOSE AND SCOPE, PRINCIPLES AND RESPONSIBLE AUTHORITIES Article 4 - Responsible authorities
1. Each State Party shall designate or establish a National IHR Focal Point and the authorities responsible within its respective jurisdiction for the implementation of health measures under these Regulations.
2. National IHR Focal Points shall be accessible at all times for communications with the WHO IHR Contact Points provided for in paragraph 3 of this Article. The functions of National IHR Focal Points shall include:(a) sending to WHO IHR Contact Points, on behalf of the State Party concerned, urgent communications concerning the implementation of these Regulations, in particular under Articles 6 to 12; and(b) disseminating information to, and consolidating input from, relevant sectors of the administration of the State Party concerned, including those responsible for surveillance and reporting, points of entry, public health services, clinics and hospitals and other government departments.
3. WHO shall designate IHR Contact Points, which shall be accessible at all times for communications with National IHR Focal Points. WHO IHR Contact Points shall send urgent communications concerning the implementation of these Regulations, in particular under Articles 6 to 12, to the National IHR Focal Point of the States Parties concerned. WHO IHR Contact Points may be designated by WHO at the headquarters or at the regional level of the Organization.
4. States Parties shall provide WHO with contact details of their National IHR Focal Point and WHO shall provide States Parties with contact details of WHO IHR Contact Points. These contact details shall be continuously updated and annually confirmed. WHO shall make available to all States Parties the contact details of National IHR Focal Points it receives pursuant to this Article.
2. Strengthen national disease prevention, surveillance, controland response systems3. Strengthen public health security in travel and transport
Implementation of National IHR Action Plan
Entry into force
Core capacities present
Assessment of public health core capacities
June 2007 June 2009 June 2012
National IHR Action Plan
20142016
IHR Core Capacity - Articles 5, 13, and Annex 1
However…preparedness is forever
International Health Regulations
• Legal framework requested, negotiated, and developed by WHO Member States
• Tool that serves public health according to good, evidence-based, practice and adapted to the context
• Opportunity to establish / maintain a public health system robust enough to ensure the flexibility needed to institutionalise lessons learned from real life in a continuous and dynamic manner
1.APublic Health Surveillanceand Response
1.BPoints of Entry
Chemical
Biological
Radionuclear
Community/primary level
Intermediate level
National level
Art. 7
Art. 5Art. 13
Art. 19Art. 20Art. 21
At all times
Potential PHEIC
IHR Core Capacity - Annex 1
Art. 4National IHR Focal Point (NFP)
IHR Core CapacityWHO, 2011
1. National legislation, policy and financing2. Coordination and NFP communications3. Surveillance4. Response5. Preparedness6. Risk communication7. Human resource capacity8. Laboratory
• Points of Entry• IHR Potential hazards 1: zoonotic events• IHR Potential hazards 2: food safety• IHR Potential hazards 3: chemical event• IHR Potential hazards 4: radiation emergencies
IHR National Core Capacity Status, 15 October 2011Preliminary data
IHR National Core Capacity Status, 15 October 2011Preliminary data
http://www.who.int/ihr/legal_issues/legislation/en/index.htmlhttp://www.who.int/ihr/legal_issues/legislation/es/index.html
Core Capacity: 1. National legislation, policy and financing
Subject areas affected by IHR implementation
• environment• public health• international ports, airports, ground crossings (including
quarantine)• customs• food safety• agriculture (including animal health)• radiation safety• chemical safety• transportation (including dangerous goods)• collection, use and disclosure of public health information• public health activities of authorities or other relevant entities at
the intermediate (e.g. state, provincial or regional) and local levels
WHO - International Digest of Health Legislationhttp://apps.who.int/idhl-rils/
Argentina, Brazil, Colombia, Costa Rica, Ecuador, Peru
Core Capacity: 2. Surveillance and 3. Response
SignalUnusual health event
Response
ComplementaryEvent-based surveillance(unstructured information)- Media reports- Hotlines (community, professionals, etc.)
- NGOs- Diplomatic channels- Military channels- Etc.
Indicator-based surveillance(discrete variables)- Case based (aggregated, individual)- Laboratory results- Environmental measurements- Drug sales- Absenteeism - Etc.
VerificationTriangulationdes sources
Deliberate events (DE) indicators• Determining whether a disease outbreak is caused deliberately may not be easy • Likelihood of occurring low, but potentially catastrophic consequences
• Alert signals: An announcement of deliberate release, or the observation of unusual or unexpected clinical and/or epidemiological characteristics of individual cases or clusters of disease
• Clinical and epidemiological findings: Unusual or unexpected clinical manifestations of an illness in patients and unusual epidemiological findings during an outbreak investigation
• Laboratory findings: Laboratory results identifying specific biological agents, including the identification of pathogens that are rarely seen in a given population and/or geographical area
• Specific high-risk diseases: The presence of specified diseases that should always be investigated and managed as possible DEs unless an alternative cause is positively established
• Evidence of biological agent dissemination: Observed on-site findings of dissemination materials, equipment or other forensic evidence
Decision instrument - Annex 2
Notifiable diseases:- Poliomyelitis, wild-type virus- Human influenza, new subtype- SARS- Smallpox
Any event of potential international public health concern
Diseases that shall always lead to utilization of the algorithm: Cholera, pneumonic plague, yellow fever, viral haemorrhagic fevers (Ebola, Lassa, Marburg), West Nile fever, other diseases of special national or regional concern (e.g. dengue fever, Rift Valley fever and meningococcal disease)
• 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?
Decision instrument - Annex 2Two of the following criteria…but
• Not a risk assessment framework per se• Guidance to inform the decision to communicate with WHO• When in doubt• Potential benefits• Anything that you would want to know from others
WHO Event Management ProcessInformation and Public Health Response
States Parties
WHO
Others sources
Event’sRisk assessment
AssistRespond
Disseminate information
Initial screening
Verification
Informal/Unofficial information`
Formal reports
4. Strengthen WHO global alert and response systems
Public health events of potential international concern considered by WHOJan 2001-14 June 2011
(n=3,763; 858 (25%) in AMRO)
Number %
Substantiated 2,448 65
No outbreak 619 16
Discarded 290 8
Unverifiable 289 8
Undetermined 117 3
Total 3,763 100
Substantiated public health events of potential international concernby source of initial information
Jan 2001-14 June 2011(n=2,448; 477 (19%) in AMRO)
Substantiated public health events of potential international concernby hazard
Jan 2001-14 June 2011 (n=2,448)
85%
Substantiated public health events of potential international concernby hazard
AMRO, Jan 2001-14 June 2011 (n=477)
Substantiated public health events of potential international concernTop diseases / conditions
AMRO, Jan 2001-14 June 2011 (n=477)
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total%
Grand totalInfluenza due to identified avian or animal influenza virus 2 1 63 8 1 75 16Dengue Fever 1 6 5 1 23 6 6 48 10Measles 1 1 1 4 12 6 5 4 7 41 9Yellow Fever 2 1 3 3 2 2 4 4 1 22 5Salmonella infections, other 1 3 1 2 5 1 3 16 3Malaria 1 1 2 2 1 2 5 14 3Rabies 1 2 6 1 10 2Cholera 1 1 2 4 8 2Influenza due to identified human influenza virus 2 1 1 1 3 8 2Trypanosomiasis - Chagas' disease 1 1 1 2 3 8 2
CholeraMexico
Bolivia
El SalvadorNicaraguaGuatemala
Argentina
PeruPanama
Ecuador
ParaguayUruguay
Chile
Philippines
Switzerland
JamaicaCaribbean Malaysia
Egypt
Laos
2009 - 20112009 - 2011
Philippines
Switzerland
MalaysiaLaos
Mongolia
LeptospirosisCholera
Dengue
Suriname
Cholera
PakistanHaitiHaiti Egypt
CCHF
Cholera
Dengue
10 August 2010
Conclusions - 1
• The IHR a legal tool, serving national and international public health• The IHR present a mechanism to ensure commitment of States Parties and
relevant sectors to provide necessary technical and financial support –National IHR Action Plans
• Legal structures must be adapted to meet IHR commitments within the context of multiple national and multilateral obligations, and considering overlapping mandates of partners institutions
• Development of capacities must build on existing resources, initiatives and structures to minimize unnecessary duplication and optimize cost-effectiveness
Conclusions - 2
• Implementation of IHR must be done in the context of regional diversity in resources, capacities, and legal frameworks – role of sub-regional integration mechanisms
• Lessons learnt from practice, particularly from pandemic (H1N1) 2009 are important to harmonize the interpretation of the IHR and further improve the application of the IHR and maximize their anticipated benefits
Summary conclusion 1The IHR helped make the world better prepared to cope with public-health emergencies. The core national and local capacities called for in the IHR are not yet fully operational and are not now on a path to timely implementation worldwide.
Recommendation 1Accelerate implementation of core capacities required by the IHR
Recommendation 4Ensure necessary authority and resources for all National IHR Focal PointsStates Parties should ensure that designated National IHR Focal Points have the authority, resources, procedures, knowledge and training to communicate with all levels of their governments and on behalf of their governments as necessary.
http://apps.who.int/gb/ebwha/pdf_files/WHA64/A64_10-en.pdf
