Transcript IHR implementation Preben Aavitsland Department of Infectious Disease Epidemiology Norwegian Institute of Public Health at EpiTrain V, Vilnius, October 22 2007

IHR implementation
Preben Aavitsland
Department of Infectious Disease Epidemiology
Norwegian Institute of Public Health
at
EpiTrain V, Vilnius, October 22 2007
Contents
Contents of IHR
1.
2.
3.
4.
5.
Background and purpose
IHR suveillance system
WHO’s many sources of epidemic intelligence
National IHR Focal Point
Member states’ obligations to build capacities
Main challenges for countries
1.
2.
3.
4.
5.
WHO’s power to define an event
No political interference
Build capacities worldwide
No withholding of information
No excessive response
Conclusion
Background
• Increased need for international public health
security and cooperation
– New diseases (SARS!)
– More international travel
– More people
• Old IHR almost useless
–
–
–
–
–
Only cholera, plague and yellow fever
Dependent on official notification
No incetives for notifications
No formal cooperation mechanisms
No dynamics in international response
Outline of the IHR
Part I
Part II
Part III
Definitions and purpose
Surveillance and response (annex 1+2)
WHO recommendations
concerning specific threats
Part IV –
VIII
Routine measures
Part IX
Procedures
Part X
Reservations, disputes, etc
Key contents of the IHR
• A new international system for epidemic
intelligence
• A procedure for WHO’s
recommendations to guide the response
to public health emergencies of
international concern
• A set of international rules on routine
measures against international disease
spread
Purpose of IHR (Art 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.
The IHR surveillance system
Local
level
National
IHR Focal
Point
WHO
Event based surveillance
• From disease list to event definition
• A difficult, but rational change
– The disease + the circumstances
– Undiagnosed diseases
– New diseases
Decision
instrument
(annex 2) to
determine
whether an
event may be a
public health
emergency of
international
concern (pheic)
Simlified by Baker & Fidler, 2006
Events detected
by national
surveillance
system
Any event of
potential
international
public health
concern,
including those of
unknown causes
or sources
Yes
A case of the following
diseases is unusual or
unexpected and may
have serious public
health impact, and thus
shall be notified:
Smallpox, Poliomyelitis
due to wild-type
poliovirus, Human
influenza caused by a
new subtype, Severe
acute respiratory
syndrome (SARS).
No
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 and trade
restrictions?
Two or more yes  notify WHO.
Yes
No
Notification is a start of a dialogue
(i.e. ”not a big deal”)
Dialogue
High sensitivity,
low positive
predictive value
Potential pheic
notified by country
Pheic declared by
WHO
The IHR surveillance system
Mass media,
GPHIN, MediSYS,
Google, NGOs,
ProMED etc + other
countries
Local
level
National
IHR Focal
Point
WHO
WHO’s use of other information
• The country no longer has monopoly on
informing WHO
• A reform worth fighting for!
• WHO must verify information with country
• WHO can keep source confidential
•  All of us are now event-detectives for WHO
•  An important role for e.g. the ProMED network
If you think your Government is delaying
notification  write in ProMED
National IHR Focal Point (Art. 4)
• An office (not individual) designated by the
country
• Accessible at all times for communications
with the WHO
– Direct telephone, fax and generic institutional
e-mail address
• Communicate contact details to WHO
– Through Ministry to Director General of WHO
Communications
Surveillance
responsible
Public health
services
Points of entry
Clinics and
hospitals
National IHR
Focal Point
WHO EURO
IHR Focal Point
National IHR Focal Point tasks I
• Article 6: Notification of all events which may constitute a
pheic
• Article 7: Information-sharing during unexpected or unusual
public health events
• Article 8: Voluntary information to WHO of other events and
consult on health measures
• Article 9: Information to WHO of public health risk identified
outside the country evidenced by imported/exported human
cases, or contaminated vectors or products
• Article 10: Responding to WHO requests for verification of
reports from other sources
• Article 11: Receiving information from WHO on events in
other countries
• Article 12: Consulting with the WHO Director-General on
determination and termination of a pheic
National IHR Focal Point tasks II
• Forward information from WHO
–
–
–
–
on public health risks
on potential pheic
on temporary and standing recommendations
other information
• to the relevant sectors of administration
–
–
–
–
–
those responsible for surveillance
points of entry
public health services
clinics and hospitals
other
National IHR Focal Point tasks III
• Consolidating input from relevant sectors of
administration
–
–
–
–
–
those responsible for surveillance
points of entry
public health services
clinics and hospitals
Other
• Establish efficient and functional channels of
communication
• Input which is necessary for the analysis of
national public health events and risks
Obligations to build capacities
Article 5+13 and Annex
1A: Epidemic
intelligence
• Detect events
• Report events
• Assess events
• Notify events to WHO
• Respond to events
Article 20 and Annex 1B:
Airports, ports,
ground crossings
capacities
• Access to medical
service
• Safe environment
• Access to rooms for
interview, quarantine,
isolation
• Ability to disinsect,
disinfect etc.
Local level capacities
Surveillance
• Detect outbreaks of
disease or death
• Report immediately to
higher level
Response
• To implement
preliminary control
measures
immediately
Regional level capacities
Surveillance
• Confirm status of
events
• Assess events
immediately
• Report to national
level
Response
• Support or implement
additional control
measures
National level capacities
Surveillance
• Assess all events within
48 hours
• Notify WHO
Response (24 h per day)
• Determine control
measures
• Provide lab support
• Provide on-site assistance
• Provide operational links
with officials, ministries,
hospitals, entry points
• Have emergency plan
Two phases
Phase 1:
15 June 2007 –
15 June 2009
• Assess surveillance and
response capacity
requirements described in
Annex 1A of the IHR
(2005)
• Develop national action
plans to ensure that these
core capacities are
present and functioning
throughout the country
Phase 2:
15 June 2007 –
15 June 2012
• Surveillance and
response capacities set
out in Annex 1A must be
implemented
• (An additional 2-year
period until 15 June 2014
may be granted)
Main challenges for countries
1.
2.
3.
4.
5.
WHO’s power to define an event
No political interference
Build capacities worldwide
No withholding of information
No excessive response
”Acute watery diarrhoeal syndrome”
Determining whether event is pheic
Old IHR
New IHR
Detect
Detect
Determine
Notify
Notify
Publication
+ measures
Determine
Publication
+measures
The ramification of notification
has changed
• Notification does not imply that an event is a pheic
• Notification is just “telling WHO about an event”
• Notification has no immediate consequences for
your country
• WHO can know about the event from other sources
• WHO can start assessing the event without
country’s official notification
• It is the event itself - not the official notificiation of
it - that is the basis of WHO’s determination of
pheic
This is the revolution of the new IHR!
• Countries have given WHO the power to
determine events that can invoke IHR
measures
• WHO is working on behalf of us all in
– doing epidemic intelligence
– determining pheic
– recommending measures
Non-political surveillance
• Old IHR: Political interference in public
health surveillance, because of fear of
travel/trade sanctions
• Deciding to notify WHO of a possible pheic
is a professional public health decision, not
a political one
• Avoid elaborate decision systems for WHO
notification
Build capacities worldwide
• Global surveillance not stronger than the
weakest link
• Annex 1 is a powerful capacity list
– Build multipurpose capacities
• Use annex 1 to get resources
– Your government signed up to it
• Assist other countries
– Annex 1 as a checklist for your international
development agency
Notify WHO early
• Incentive 1: Confidential dialogue
• Incentive 2: IHR protection against
unjustified measures
• Incentive 3: Assistance by WHO and other
countries
• Incentive 4: WHO will know sooner or later
anyway
The Kon-fu-tse principle of
surveillance
”Notify to WHO
the events that
you would like to
know about if
they occured in
your neighbour
country.”
National laws on communicable
diseases
Stop the
national
spread of
the disease
Protect the
rights of the
individuals
with disease
and cause
minimal harm
International law
on communicable diseases (=IHR)
Stop the
international
spread of
the disease
Protect the
sovereignty of
states and
cause minimal
harm
(restrictions)
Additional measures
• Measures beyond WHO recommendations
possible (art 43)
– But need public health rationale and scientific
information
• Should be avoided
• May undermine the whole IHR
– Especially if poorly justified measures against
poorer countries
Conclusions
• IHR are a major step forward in global epidemic
intelligence
– Not perfect, but as good as was possible
• Shifting power from countries to WHO (which
works on behalf of all countries)
– Multilateral solutions
• Actual use more important that wording
– We can all make the IHR work by respecting the spirit
of IHR: early sharing of information + the right and nonexcessive health measures
• National capacity building is important