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International Health
Regulation
Dr. Riris Andono Ahmad MPH PhD

Courtesy of dr. Yodi Mahendradhata

Presentation structure
p International

health security
p The international health regulation (2005)
and implied mandates and obligations

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Part 1.
International health security

Security threat in the 21st century?

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Probable SARS transmission on

flight CA112 in March 2003

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Direct economic impact of selected

infectious disease outbreaks, 19902003a

Threats to public health security

p Decisions

and actions taken (by

governments or individuals) in
investments or surveillance measures
p Conflict, displacement, lack of
commitment, misinformation.
p Microbial evolution andantibiotic
resistance.

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Inadequate investment
p Reduced

vigilance of prevention
programmes can result in outbreaks.
p Vector-born diseases re-emerged in subSaharan Africa after widespread use of
insecticides ended.
p Real global threats of HIV/AIDS was only
recognized after first cases in the United
States.

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Unexpected policy changes

p Oral

polio vaccine was claimed to be

unsafe in Nigeria in 2003.
p Government reduced immunization.
p A large outbreak of polio resulted;
previously polio-free areas were infected.
p Thousands of children paralysed.
p The disease spread to polio-free countries.

Conflict
p Civil

war in Angola hampered efforts to

contain an outbreak of Marburg
haemorrhagic fever in 2005. (200 people
affected, 90% died).
p Rwanda crisis up to 800 000 people fled to
the Democratic Republic of the Congo. In
the absence of adequate sanitation, about
50 000 died from cholera and dysentery.

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Microbial evolution and antibiotic

resistance
p Evolution

of resistance to anti-infective
drugs contributes to the emergence and
re-emergence of infectious diseases.
p Bacteria develop resistance to antibiotics
through spontaneous mutation and
through the exchange of genes between
bacterial strains and species.

Health and global security

p

Most cities in the US are within 36-hour

commercial flight of any area of the world less
time than incubation period of many diseases
Bill Clinton
Forms of threats:
n
n
n
n
n

More casualties than wars, e.g. vietnam

More military hospitals admisson than injuries
International peacekeeping efforts
Impact on socioeconomic of developing world
Challenge development in former communists

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Evolution of public health security

p Plague:

In 1348, plague killed up to twothirds of the population in Europe.

p Cholera: In 1855, cholera killed an
estimated 500 people in a 10-day period
in London.
p Smallpox: Smallpox ravaged populations
until it was finally eradicated in 1979.

International cooperation origins

p Traditional

control measures quarantine,

sanitation and immunizationbecame
inadequate.
p International cooperation needed to
control the spread of infectious diseases.
p International conventions on sanitation
and health of the 1850s evolved into the
International Health Regulations (1969).
p Revised IHR (2005) came into force in
June 2007.

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Milestones in international public health security

Part 2.
The international health
regulation

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IHR (2005) in brief (1)

p An

international law to prevent the spread

of public health emergencies.
p WHO Member States bound to cooperation
and transparency.
p Compliance will reduce outbreaks' impact.
p All countries must detect, assess, notify
and report events covered by IHR.

IHR (2005) in brief (2)

p Mandatory

notification of a single case of

some rare disease e.g. smallpox, polio.
p The IHR include emergencies caused by
releases of chemical or radionuclear
materials.
p WHO can use early unofficial sources of
information, but will verify with countries
before taking any action.

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From IHR (1969) to IHR (2005):

a major paradigm shift
p From

control at borders to [also]

containment at source
p From a list of diseases to all public health
threats
p From preset measures to adapted
response

IHR (2005) Main legal requirements (1)

p

Core capacity requirements for countries to

"detect, assess, notify and report events in
accordance with the regulations" and to "respond
promptly and effectively to public health risks"
Obligation, permission or prohibition of certain
public health actions in respect of international
travellers, goods, cargo and conveyances and the
ports, airports and border crossings that they
utilize
Administration of IHR such as the nomination in
each country of a National IHR Focal point and,
for WHO, the nomination of WHO IHR Contact
Points

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IHR (2005) Main legal requirements (2)

p Management

of information and public

health response for events which may
constitute a "public health emergency of
international concern"
p Full respect of human rights and the
guidance provided by the Charter of the
United Nations and the Constitution of the
World Health Organization

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4 assessment criteria of events

p Is

the public health impact of the event

serious?
p Is the event unusual or unexpected?
p Is there a significant risk of international
spread?
p Is there a significant risk of international
restriction(s) to travel and trade?

Areas of work for implementation (1)

p Foster

global partnerships
p Strengthen national disease
surveillance, prevention, control and
response systems
p Strengthen public health security in
travel and transport
p Strengthen WHO global alert and response
systems

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Areas of work for implementation (2)

p Strengthen

the management of specific

risks
p Sustain rights, obligations and procedures
p Conduct studies and monitor progress

Strengthen national disease surveillance,

prevention, control and response systems (1)
p
p
p

Ensure that relevant public health functions for

alert and response are in place and operational
Conduct exercises to identify operational gaps in
the national surveillance and response systems.
Ensure that the national surveillance and
response system uses internationally recognized
quality standards
Consider strengthening human resources through
training in intervention epidemiology, outbreak
investigation, laboratory diagnostics, case
management, infection control, social
mobilization, and risk communication.

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Strengthen national disease surveillance,

prevention, control and response systems (2)
p Assess

and plan operational links between

national surveillance and response
systems and points of entry
p Use standard WHO indicators to carry out
regular assessments of core public health
capacities to monitor progress and assess
future needs.
p Where appropriate, develop proposals for
international partnerships and the
mobilization of external resources.

Strengthen national disease surveillance,

prevention, control and response systems (3)
p Ensure

that all national action plans are

implemented within the set timeframe.
p Mobilize the necessary resources from the
national budget and, where proposals
have been developed, from international
partners.
p Conduct drills on a regular basis to test
the continuous operational capacity of the
national surveillance and response
systems.

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Strengthen public health security in

travel and transport (1)
p Develop,

strengthen and maintain core

capacities on a routine and emergency
basis.
p Identify designated PoE that must have
core capacities in place, and notify these
to WHO.
p Identify the competent authority for each
designated PoE in its territory.

Strengthen public health security in

travel and transport (2)
p Put

in place enhanced contingency and

emergency planning mechanisms for all
new IHR provisions at all designated PoE:
operational capacities are tested on a regular
basis with drills and exercises.
n requirements under the IHR are integrated into
existing emergency, facilitation and security
plans at PoE.
n

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Strengthen public health security in

travel and transport (3)
n

States Parties are able to provide WHO with

relevant data regarding any potential public
health risk.

p Integrate

drills into the contingency and

emergency mechanisms to test
operational capacity.

Three top priorities for ministries of health

p Establishing

a national IHR focal point

p Ensure adherence to reporting
requirements and verification of public
health events
p Assess and strengthen national capacities

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Timeline
p The

IHR (2005) come into force on 15

June 2007.
p States Parties shall meet the core capacity
requirements
from 15 June 2007, States Parties have 2
years to assess their national structures and
resources and develop national action plans
n from 15 June 2009, States Parties have 3
years to meet the core capacity requirements.
n

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