Article No. 2 - Vol. 28, No. 4 - December 2009

Progress Report on Technical Matters:
International Health Regulations [2005])

The date 15 June 2007 marks a milestone in global public health. On this date, the new International Health Regulations (IHR [2005]) entered into force. The purpose of the IHR (2005) is “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.”  Indeed, the IHR have become the basic legal instrument for global health security. The IHR (2005) spell out the procedures for early reporting to PAHO/WHO of events that represent global health risks, including those of chemical and nuclear origin, and, if necessary, for mounting a coordinated response to them.

 

Since that date, progress has been reported in the work areas defined for implementation of the IHR (2005), on cooperation with the Member States so that they enhance their capacities in communicable disease surveillance and develop the core alert and response capacities to deal with epidemics and public health emergencies and for PAHO/WHO to coordinate and make available to the Member States the regional capacity necessary for the detection, verification, and assessment of the risks and response to epidemics and other public health emergencies of international concern.

That instrument establishes that the States Parties must have concluded their evaluation of the core capacity requirements for surveillance and response (IHR, Annex 1A) and the core capacity requirements for surveillance in designated ports, airports, and ground crossings (Annex 1B of the IHR) by 15 June 2009 at the latest; moreover, that they should have acquired all the missing capacities by 15 June 2012 at the latest. At the same time, on adopting the IHR (2005) the Member States committed to designating National IHR Focal Points (NFP), which should be operating at all times; to conducting a risk assessment for events, using the decision instrument (IHR, Annex 2); to issuing reports within 24 hours of assessing the information on events that can constitute public health emergencies; to designating the ports and airports that should have the capacities indicated in IHR Annex 1B; and to providing a list of ports authorized to issue ship sanitation control certificates.

This report details the Member States’ progress in meeting the commitments on how the Regulations should be applied.

Activities coordinated with the support of regional integration systems

(a) MERCOSUR working subgroup 11 (SGT-11), which has formed the Intergovernmental Commission for Application of the International Health Regulations for the purpose of harmonizing country activities to train relevant personnel, create forms, interact with other agencies linked with the IHR (2005), improve administrative documentation flows in connection with the IHR (2005), upgrade the information system and the use of tools for core capacity assessment;

(b) Andean Regional Health Agency-Hipólito Unanue Agreement (ORAS/CONHU), which, through Resolution REMSAA XXIX/445-2008 on linking alert and response systems, has spearheaded harmonization of the list of priority reportable diseases with MERCOSUR and adaptation of the epidemiological surveillance instrument of the Hipólito Unanue Agreement (VIGICONHU2) for information exchange among South American countries;

(c) the treaty constituting the Union of South American Nations, which in the UNASUR plan of action gives priority to creation of the epidemiological shield, an effort to which ORAS and MERCOSUR activities will contribute; and

(d) Central America, which, through agreement HON-XXIV-RESSCAD-3 on compliance with the International Health Regulations, commits to disseminating information on the International Health Regulations and making them a priority security issue in the programs of other sectors and the Central American integration processes (trade, tourism, migration, health, social) related to their application; furthermore, the technical cooperation among countries (TCC) project will be executed in a timely manner so that assessments of the core capacities and action plans are completed in 2009 and the National Focal Points are fully functional.

 

Strengthening of National Disease Prevention, Surveillance, Control, and Response Systems

  • The strategic objective of improving surveillance, alert, and response systems for epidemics and public health emergencies in the Member States within the framework of the IHR (2005) grew out of the assessment of existing core competencies. The Pan American Sanitary Bureau (PASB), in collaboration with the MERCOSUR Intergovernmental Commission for Application of the International Health Regulations provided countries with the necessary tools to undertake this assessment, which should be completed by 15 June 2009 at the latest. As of the date of this document, the available information shows that 27 countries, 17 of them in Latin America and 10 in the English-speaking Caribbean, have already completed the assessment of their surveillance and response capacities. Concerning assessment of the necessary capacities at points of entry, the available information indicates that the assessment has been conducted in 12 Latin American and 5 English-speaking Caribbean countries.
  • Use of the four criteria of the decision instrument for the assessment and reporting of events that can constitute a public health emergency of international concern, namely 1) those that have serious implications for public health, 2) are unusual or unexpected, 3) pose a significant risk of spreading internationally and 4) a significant risk of prompting international travel or trade restrictions. That has created a new paradigm in the dialogue between National Focal Points and the Pan American Sanitary Bureau (PASB), making it possible to focus on the need for good information obtained from field investigation to offer timely support to contain the events at their source and at the same time, to alert territories and populations exposed to the potential risk of their spread. Simulation exercises conducted in the subregional workshops held by the surveillance networks have enabled participants to discuss application of the criteria in real situations.
  • Subregional meetings. Three meetings were held (South America, Central America, and the Caribbean) with the heads of the national surveillance services to review and update the functions of the National Focal Points, evaluating the core capacities necessary for surveillance and response, and analyze public health emergency response operations.
  • Training. In coordination with pandemic influenza preparedness initiatives, some 60 national health officials and 15 PAHO professionals received training to hone their skills as leaders of rapid response teams. Some of the areas addressed were: coordination, management, communication, logistics, social mobilization, and biosafety. This activity was carried out in collaboration with the Project of Communicable Disease Prevention and Control (HSD/CD) of the Area of Health Surveillance and Disease Prevention and Control (HSD) and the Area of Emergency Preparedness and Disaster Relief (PED) for a regional team from PAHO and national experts from Bolivia, Costa Rica, Ecuador, Honduras, Jamaica, Paraguay, and Uruguay.
  • Event Management System (EMS). Through collaboration with WHO headquarters, the Ministry of Health of Brazil, and the Ministry of Health of Chile, the event management system (EMS) has been adapted for use in the National Focal Points; operating guidelines were prepared to promote full operation of the National Focal Points.

Health Security for Travelers and Conveyances

Four regional activities were devoted to updating professionals charged with application of the sanitary surveillance and control measures at points of entry. The first of these was held in Mexico and Barbados for the Spanish- and English-speaking countries, respectively. The activities focused on the following points:

a) the obligations of countries and the timetable for developing core capacities at points of entry in compliance with the IHR (2005);
b) validation of the tool to facilitate assessment of core capacities at points of entry and its instructions;
c) discussion of the methodology to be used; and
d) preparation of the action plan to close the gaps and the surveillance plan; and updating on the new certificates for ships and aircraft.

Further, two workshops were later held in Miami, USA, and Santos, Brazil that offered extensive hands-on sessions on cargo and cruise ships to review inspection procedures and the issuance of ship sanitation control certificates and to speed up creation of the network of officials responsible for port health.

As part of the initiatives to address problems at points of entry, collaboration has been under way with the Organization of American States (OAS)’ Technical Advisory Group on Port Security to address the issue of the necessary core capacities in the designated ports in routine activities as well as activities in response to events that can constitute a public health emergency of international concern.

Strengthening of PAHO Alert and Response Systems

The designated regional Point of Contact for the IHR (2005), which is the Communicable Disease Prevention and Control Project of the Health Surveillance and Disease Prevention and Control Area, supported the work of the professionals from the Alert and Response Team of this Project for activities in epidemic intelligence, verification of events identified by unofficial sources, risk assessment, and response coordination. These activities are supported by advisers from other PASB units from Headquarters (Immunization, Emergencies and Disasters, Health Technologies, etc.) and the decentralized entities and offices in the countries and are carried out in coordination with WHO Headquarters and the five WHO Regional Offices. The Regional Focal Point operates in epidemiological shifts and is accessible 24 hours a day, seven days a week. Communication takes place by e-mail ( This e-mail address is being protected from spam bots, you need JavaScript enabled to view it '; document.write( '' ); document.write( addy_text48462 ); document.write( '<\/a>' ); //-->\n This e-mail address is being protected from spam bots, you need JavaScript enabled to view it ) and telephone (001-202-368-8929) or fax (001-202-351-0548).

PAHO uses the Event Management System (EMS) created by WHO Headquarters in Geneva to facilitate the management of information on events and outbreaks. In May 2009, the computer platform was updated and now uses a Web application; this will speed up implementation of the unified system at the three levels of the Organization, facilitating systematic entry of information, risk assessment; the decisions of the Organization, and the interventions carried out.

The Alert and Response Team holds a daily a session to review and assess the risk of recently identified events and those in the monitoring phase to determine whether immediate steps should be taken to request verification, issue alerts, and identify technical cooperation needs.

As part of the professional development of the staff working in the PAHO Representative Offices, a technical meeting was held in Bogotá, Colombia, under the framework of the application of the IHR (2005) to discuss epidemic intelligence, coordinated management of outbreaks, support for the NFP, and updating of the roster of regional experts for mobilizing the response to public health emergencies.

Public Health Events of potential international concern – Region of the Americas

From January to December 2007, 78 public health events of potential international concern were reported in the Region, while 56 events were reported for the same period in 2008.  Table 1 presents the sources of information of the events for the same periods in 2007 and 2008, respectively.

Table 1. Oficial source of information for Public Health Events of potential international concern, January to December 2007, Region of the Americas

January to December

Source of information

Source of information

Source of information

Source of information

Year

Captured by the PAHO alert system % (No.)

Reported by the NFP % (No.) Total of registered Public Health events

Information reported by assorted government institutions other than the NFP % (No.) 

Total of registered Public Health events

2007

58% (45)

10% (8)

32% (25)

78

2008

28% (30)

28% (16)

10% (8)

56

Source: Communicable Diseases Prevention and Control (CD), Health Surveillance and Disease Prevention and Control (HSD). PAHO. 2009.

 

Concerning the response, the Organization provided some type of cooperation for 58 (51%) out of 113 events recorded through application of the IHR (2005) since June 2007 through the Representative Office or Headquarters. During that same period, the National Focal Points reported 24 events with potential implications for international public health. In 66% (16) of these events, the Organization provided support for their local control.

A substantial improvement has been observed in the coverage and quality of event risk assessment and in the activities of the NFP in furnishing initial information on events in their territory. One hundred percent of the events that can constitute a public health emergency of international concern captured by the PAHO alert system were verified by the PAHO Epidemic Alert and Response Team at PAHO/WHO Headquarters, in close coordination with the Representative Offices, technical units, and National Focal Points.

Since the IHR (2005) entered into force, semiannual tests have been conducted to evaluate the systems for communication between PAHO and the designated NFP, for which messages are sent via e-mail, telephone, or fax. The results for telephone communication indicate a positive response from 29 of the 33 countries to which messages were sent; however, responses were received from only nine countries within 48 hours of sending the e-mail. On the other hand, information on coverage of care 24 hours a day, seven days a week was obtained from the NFP of 28 countries; of these, 26 have this service. The shortage of human resources, high management turnover, and restrictions on international calls are mentioned as factors responsible for the lack of coverage.

The Pan American Sanitary Bureau (PASB) made progress in preparing the floor plans for the Emergency Operating Center (EOC) in the Headquarters building to ensure access to timely, reliable information on events that pose a threat to public health, enable the Organization to assess health risks, and respond when the countries require it. The professional team that will work in this space will consist of advisers in IHR epidemic alert and response and emergency preparedness and disaster relief, who will follow standard operating procedures.

Monitoring and Legal Affairs

In order to determine whether the legal framework of the Member States was adequate to facilitate full compliance with the IHR (2005), technical meetings were held with the PAHO staff in charge of health legislation, the IHR (2005) coordinator at WHO Headquarters, and experts from Georgetown University (PAHO/WHO Collaborating Center for ethics and health) and the George Washington University to determine areas of collaboration to assist the countries in their review of national health legislation during application of the IHR (2005).

In 2009, a workshop with the legal advisers from the English-speaking Caribbean countries was held in Barbados to facilitate an exchange of ideas on the processes under way to review current legislation and to familiarize them with WHO guidelines and the reference materials prepared for this purpose. The participants determined the priority areas in which to start or accelerate the amendment process, with the assistance of regional advisers from PAHO, WHO headquarters, and the Government of Canada. A similar workshop will be held for the countries of Latin America in 2009.

Despite the countries’ progress in setting up National Focal Points and assessing and strengthening the core capacities necessary for early detection and control of events that can constitute international public health emergencies, full application of the IHR (2005) as a political commitment by the States requires a sustained effort under the leadership of the ministries of health.

Source: Taken from the document presented during PAHO’s Executive Committee (CD49/INF/2, Rev. 1 (Eng.)), 17 September 2009, Washington, DC


 

 

 

 

Ten things you need to know about the IHR (2005), WHO
 http://www.who.int/ihr/about/10things/en/index.html, accessed on 31 March 2009.