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Contents                                                          Message From The Director Disease Control            Mes...
Artikel 1LATAR      BELAKANG                         Notifikasi              penyakit           berjangkit             Sist...
notifikasi kes penyakit berjangkit secara ‘syndromes’ (sindrom                   brucellosis, anthrax, toxoplasmosis dan le...
10                                          Surveilance Reports                                                           ...
Surveillance Report                                                                                   Introduction        ...
PERSPECTIVE       Global Public Health Surveillance        under New International Health                 Regulations     ...
Surveillance under International Health Regulationssystem (8). According to these guidelines, evaluating sur-veillance sys...
PERSPECTIVEwhich are usually unexpected and often threaten to spreadinternationally.    In addition to events that may con...
Surveillance under International Health Regulationsattributes, usefulness, sensitivity, timeliness, and stability    and d...
PERSPECTIVEhood, inadequate capacities at the local and intermediate         IHR 2005 includes the core surveillance capac...
Surveillance under International Health Regulationscally advanced and well-resourced countries. The sensitiv-       with t...
PERSPECTIVEsuitable declaration to the WHO Director-General (article              Dr Baker is a public health physician an...
Surveillance under International Health Regulations17. Samaan G, Patel M, Olowokure B, Roces MC, Oshitani H; World        ...
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Disease Surveillance System in Malaysia

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  1. 1. Contents Message From The Director Disease Control Message from Director Disease Control Division 1 Division, Ministry of Health Malaysia Ministry of Health Malaysia The increasing significance of communicable diseases, especially emerging and From the Desk of Chief Editor 2 reemerging infections is attracting greater attention, not only from the public health and medical communities but also the lay public. About 65% of the world’s first news about infectious disease events now comes from informal Articles : 3 sources, including press reports and the internet which are now easily accessed by everyone.There is a need to improve surveillance systems in order to recognize Surveillance System in Malaysia emerging threats, both in the community and in hospitals & health facilities, and to respond to them in a timely manner. Developing Critical Appraisal Skill Surveillance, namely the continuous monitoring of diseases and health Disease Reports : 8 determinants in populations, has gained much attention over the past fifteen years. Surveillance can be defined as the ongoing, systematic collection, verification, analysis, and interpretation of data, and the dissemination of Towards Measles Elimination information regarding diseases and health events to those who need to know, for use in public health action to reduce morbidity and mortality and to improve AGE Outbreak, Tapah, Perak health. Surveillance Reports: 11 Surveillance data so analysed and interpreted can provide public health officials and policy-makers with evidence-based information for decision Notification of Infectious Disease, making. Such reports also enable public health professionals to detect early May 2005 signals of outbreaks and to take quick remedial measures to control them. If the surveillance data are not analysed, it is often difficult to detect warning signals Report of Weekly Infectious Disease on communicable disease outbreaks from raw surveillance data alone. The Notifications 1990 - 2004 analysed data/information generated should not be filed away but to be used for timely actions. Photo Gallery : 12 The impact of communicable diseases has grave implications for the social and economic well being of the peoples in every nation. Therefore, the Disease Food for Thought: Control Division has planned and implemented a wide range of programmes and activities, nation-wide, to reduce the incidences of communicable diseases. i) Heart - Anywhere & Anytime Strengthening the surveillance of communicable diseases is one of more ii) Do We Know Our Roles important strategies to keep them at bay. New surveillance systems were introduced to detect early communicable disease outbreaks, especially newly emerging & reemerging ones, & to respond rapidly to them. This will also help Announcement in monitoring them. The establishment of Communicable Disease Surveillance Section under the Disease Control Division is another step to strengthen FAO/WHO Consultation on AI & Human Health ; coordination of communicable disease surveillance in our country.Risk Reduction Measure in Producing, Marketing & Living with Animals in Asia I hope the publication of this monthly Bulletin of Infectious Diseases will further 4-6 July 2005 Renainsance Hotel, Kuala Lumpur strengthen dissemination of information and also sharing of information for those in the health & health related agencies in the country. Fifth Inter - Regional Training Course on Public Health and Emergency Management in Asia and the Pacific 4-15 July 2005 DR. HJ. RAMLEE BIN RAHMAT Bangkok, Thailand Director, Disease Control Division Ministry of Health Malaysia
  2. 2. Artikel 1LATAR BELAKANG Notifikasi penyakit berjangkit Sistem survelan mandatori notifikasi penyakit berjangkitkemungkinan telah dilaksanakan pada zaman jajahan British memerlukan notifikasi mandatori di bawah Akta Pencegahandan dikuatkuasakan melalui beberapa ‘enactment’ atau dan Pengawalan Penyakit Berjangkit 1988. Di jadual 1 dan 2‘ordinance’ seperti ‘Quarantine and Prevention of Disesase Akta tersebut, terdapat 26 penyakit berjangkit yang mestiEnactment’ untuk negeri-negeri bersekutu, ‘Quarantine and dinotifikasikan. Senarai penyakit yang perlu dinotifikasiPrevention of Disease Ordinance 1939 untuk negeri Sabah dan sentiasa disemak dari masa ke semasa. Di bawah sistemSarawak dan ‘Quarantine and Prevention of Disease Enactment, sekarang, laporan penyakit berjangkit dibuat secara manualuntuk negeri Kelantan, Johor, Terengganu, Kedah dan Perlis. dengan menggunakan borang notifikasi yang terdapat diKementerian Kesihatan telah mengkaji semula semua senarai bawah Akta. Walaubagaimana, laporan secara elektronik yangpenyakit-penyakit berjangkit yang telah di panggil Sistem Maklumat Kawalandinotifikasi dan menggazetkan senarai Penyakit Berjangkit (CDCIS) telah punbaru pada tahun 1971 di mana terdapat Sistem Survelan diimplmentasikan sejak tahun 2001.36 jenis penyakit berjangkit yang perlu di Malaysiadinotifikasikan. Pada tahun 1988, Akta Sistem survelan berpandu makmalPencegahan dan Pengawalan Penyakit di mana pemantauan agen penyakitBerjangkit 1988 telah dikuatkuasakan. Oleh berjangkit telah diperkenalkanBilangan penyakit berjangkit yang Cawangan Survelan Penyakit pada Ogos 2002. Sistem ini adalah Berjangkit Rajah 1 : Mekanisma SistemSurvelan di Malaysia Survelan Berpandu Survelan Mandatori SurvelanBerpandu Klinikal Survelan Berpandu Survelan Boleh lain-lain Makmal Notifikasi Penyakit (Sentinel/Sindromik Kebangsaan) Komuniti Agensi Mikrobiologi Awam: Sentinel Klinik Pilihan Komuniti/ Media/ Jab. Perkhidmatan Klinik Kesihatan Sindromik Kebangsaan Sumber Haiwan (Penyakit Hospital (hospital) A&E/Wad/Klinik Antarabangsa Zoonotik Swasta : Klinik Swasta FOMEMA Sdn. Bhd. Hospital Notifikasi Mikrooganisma Notifikasi Pej. Kesihatan Daerah Mikrooganisma Pejabat Kesihatan Negeri Isolasi dan Notifikasi Mikrooganisma IMR/KKM Keputusan Kebangsaan : Bahagian Kawalan Penyakit, KKMperlu dinotifikasikan telah dikurangkan kepada 26 di berkomplemen sistem survelan notifikasi mandatori penyakitmana penyakit seperti antrax, meningococcal meningitis, berjangkit. Di bawah sistem ini, ia melibatkan laporanchickenpox, filariasis, leptospiral infections, mumps, opthalmia mikroorganisma yang diisolasi oleh semua makmal awamneonatorum, puerperal septic abortion, trachoma dan yaws atau swasta di Malaysia kepada pihak berkuasa kesihatantelah dikeluarkan dari notifikasi penyakit berjangkit. yang relevan. Sekarang ini, terdapat 6 jenis bakteria iaitu V. cholerae, H. influenzae B, Salmonella spp., S.typhi/paratyhpi, N.SISTEM SURVELAN PENYAKIT BERJANGKIT meningitides dan Leptospira telah dipilih untuk dipantau olehTerdapat beberapa jenis sistem survelan untuk penyakit makmal-makmal mikrobiologi yang telah ditentukan di bawahberjangkit di Malaysia dan aliran data survelan dan maklumat Kementerian Kesihatan Malaysia.adalah seperti ditunjukkan pada rajah ‘1’ iaitu:-• Sistem survelan mandatori notifikasi Sistem survelan berpandu klinikal dihadkan untuk penyakit• Sistem survelan berpandu makmal berjangkit yang bukan spesifik samaada berasaskan• Sistem survelan berpandu klinikal kebangsaan (lumpuh flaccid akut, konjuntivitis dan• Survelan penyakit berjangkit oleh lain-lain agensi gastroenteritis akut) atau sentinel (penyakit tangan, kaki dan• Sistem survelan berpandu komuniti mulut). Survelan berpandukan makmal juga digunakan untuk Infectious Disease Bulletin 3
  3. 3. notifikasi kes penyakit berjangkit secara ‘syndromes’ (sindrom brucellosis, anthrax, toxoplasmosis dan leptospirosos. Jabatan jaundice akut, sindrom neurologikal akut, sindrom pernafasan Perkhidmatan Haiwan perlu melaporkan kepada Cawangan akut, sindrom dermatological akut dan sindrom demam berdarah Survelan Penyakit Berjangkit, KKM seperti dipersetujui oleh akut) bukan secara penyakit spesifik dan mula diimplementasi di Jawatankuasa Kawalan Penyakit Zoonotik antara Kementerian. seluruh negara pada tahun 2004. Survelan berpandu komuniti termasuklah pemantauan rumur Survelan penyakit berjangkit oleh agensi lain seperti Jabatan atau aduan penyakit berjangkit oleh masyarakat atau orang Perkhidmatan Haiwan dan FOMEMA Sdn. Bhd. juga membuat awam dan yang disiarkan melalui media cetak dan elektronik. survelan untuk penyakit berjangkit tertentu. Survelan untuk penyakit berjangkit di kalangan pekerja asing dibuat oleh NOTIFIKASI PENYAKIT BERJANGKIT FOMEMA dan dilaporkan kepada Bahagian Kawalan Penyakit, Berikut adalah penyakit-penyakit berjangkit yang terdapat di KKM. Jabatan Perkhidmatan Haiwan Malaysia pula membuat Jadual 1, Seksyen 2 Akta Pencegahan dan Kawalan Penyakit survelan untuk penyakit zoonotik. Sekiranya berlaku kejadian Berjangkit 1988 di mana pengamal perubatan perlu memberi luar biasa penyakit zoonotik pada haiwan seperti rabies, notis kepada Pegawai Kesihatan yang berhampiran seperti nipah, avian influenza, JE, vancomycin resistant enterococcus, yang ditetapkan di bawah Akta. bovine tuberculosis, bovine spongiform encephalopathy, PENCEGAHAN DAN PENGAWALAN PENYAKIT BERJANGKIT Photo Gallery From Page 12 JADUAL PERTAMA (Seksyen 2) PENYAKIT-PENYAKIT BERJANGKIT OUTBREAK / CRISIS / DISASTER BAHAGIAN 1 1. Batuk Kokol # 2. Campak # 3. Chancroid Incident command center 4. Demam Denggi dan Demam Denggi Berdarah * 5. Demam Kuning * 6. Difteria * 7. Disenteri (Semua jenis) # HEART Hospitals 7A Ebola 8. Jangkitan Gonococcal (Semua jenis) # 9. Keracunan Makanan * 10. Kolera * National Laboratories 11. Kusta # 12. Malaria # State 12A Myocarditis 13. Plague * 14. Poliomielitis (Akut) * District Other Agencies 15. Rabies * 16. Relapsing Fever # Disease Control Division proposed to established an 17. Sifilis (Semua jenis) # 18. Tetanus (Semua jenis) # Emergency Preparedness and Response Center under the 19. Tifoid dan Salmonoloses lain. # CDC Malaysia plan for RM9. 20. Tifus dan Ricketsioses lain. # 21. Tuberkulosis (Semua jenis) # 22. Viral Ensefalitis # 23. Viral Hepatitis # Office of Emergency Preparedness & Response 24. Apa-apa jangkitan microbial lain yang mengancam nyawa # BAHAGIAN II Incidence Command Center Human Immunodeficiency Virus Infection (Semua jenis) # HEART Catitan: (*) - Notifikasi melalui talipon dan diikuti notifikasi In House Training bertulis (dalam masa 24 jam) (#)- Notifikasi bertulis dalam masa 1 minggu Communications selepas diagnosa Intelligence & Documentation Stockpiling & Logistic EIP Malaysia, an in-house training program provides an experiential training environment which incorporate epidemiological knowledge, laboratory & clinical component and emergency response, aims to produce competent and skilled epidemiologist to strengthen our public health workforce. Dr Fadzilah Kamaludin (Director EIP Malaysia)4 Infectious Disease Bulletin
  4. 4. 10 Surveilance Reports MONTHLY INFECTIOUS DISEASE REPORT FOR MALAYSIA Number of cases and death notified (mandatory by Act 342) to Ministry of Health, Malaysia MAY 2005 (1 - 28 .5.2005) Cummulative cases (death) until MayInfectious Disease Bulletin 2004 00-04 TOTAL WEEK Median Perlis Kedah P.Pinang Perak Selangor Sembilan Negeri Melaka Johor Pahang Terengganu Kelantan Sabah Sarawak WP KL WP Labuan STATES Same Period 2005 2004 DISEASES Case Death Case Death Case Death Case Death Case Death Case Death Case Death Case Death Case Death Case Death Case Death Case Death Case Death Case Death Case Death Case Death Case Death Case Death Cholera 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12 0 0 0 12 0 1 77 39 0 77 0 Dysentry 1 0 8 0 1 0 3 0 0 0 0 0 0 0 0 0 2 0 4 0 9 0 2 0 6 0 36 0 17 133 174 0 133 0 Food Poisoning 0 0 43 0 7 0 1 0 4 0 56 0 0 0 55 0 96 0 2 0 20 0 13 1 10 0 307 1 622 2838 1717 2 2838 1 Hepatitis A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 2 0 0 0 0 0 3 0 1 102 20 0 44 0 Typhoid & Paratyphoid 0 0 3 1 1 0 0 0 0 0 1 0 0 0 0 0 3 0 7 0 772 0 3 0 0 0 790 1 28 416 1796 2 160 0 Dengue Fever 16 0 81 0 127 0 125 0 80 0 71 0 77 0 36 0 56 0 22 0 64 0 56 0 36 0 847 0 1652 5801 6281 1 7800 3 Dengue Haemorrhagic Fever 2 0 2 0 8 0 3 0 5 0 4 0 7 0 2 0 1 0 0 0 8 0 4 0 1 0 47 0 65 407 497 7 410 6 Malaria 0 0 6 0 0 0 3 0 0 0 0 0 0 0 0 0 15 0 0 0 1 0 21 0 92 0 138 0 396 2140 699 2 2181 9 Relapsing Fever 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Viral Encephalitis 0 0 2 0 3 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 7 1 9 30 41 2 48 0 Yellow Fever 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Diptheria 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 1 2 0 1 1 Measles 0 0 16 0 0 0 5 0 8 0 2 0 3 0 4 0 38 0 1 0 36 0 3 0 8 0 124 0 991 952 699 0 3545 0 Poliomyelitis, Acute 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Tetanus (Others) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 10 4 0 8 0 Tetanus Neonatorum 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 1 5 2 0 4 0 Whooping Cough 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 9 19 1 9 4 Chancroid 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Gonococcal Infection 0 0 5 0 0 0 0 0 1 0 0 0 2 0 5 0 3 0 0 0 1 0 16 0 30 0 63 0 58 408 214 0 334 0 HIV Infection 3 0 13 1 6 0 7 1 0 0 4 1 18 0 23 1 82 6 3 1 83 1 10 2 1 0 253 14 283 1294 1106 58 1294 325 AIDS 1 0 5 4 3 0 2 2 1 0 4 2 0 0 1 1 7 3 0 0 1 0 1 0 0 0 26 12 0 0 125 43 0 0 Syphilis (All Forms) 0 0 2 0 5 0 1 0 3 0 0 0 0 0 5 0 4 0 0 0 0 0 3 0 16 0 39 0 63 476 272 1 341 0 Viral Hepatitis (All Forms) 0 0 4 0 2 0 6 0 5 1 0 0 1 0 32 0 45 2 4 1 20 0 34 0 8 0 161 4 143 1479 897 11 1143 0 Hepatitis B 0 0 2 0 1 0 2 0 4 1 0 0 1 0 10 0 16 0 2 0 3 0 27 0 7 0 75 1 92 1137 538 4 783 0 Hepatitis C 0 0 2 0 1 0 4 0 1 0 0 0 0 0 22 0 28 2 2 1 11 0 7 0 0 0 78 3 47 243 312 7 271 0 Hepatitis Other (Unclassified) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0 1 0 5 0 3 49 27 0 45 0 Leprosy 0 0 0 0 1 0 0 0 0 0 0 0 0 0 3 0 1 0 0 0 0 0 1 0 0 0 6 0 12 56 40 0 69 0 Tuberculosis( All Forms) 11 0 81 3 59 1 55 0 42 0 39 1 26 0 99 1 45 0 19 1 66 0 79 1 54 0 675 8 1003 5077 3492 50 5592 148 Ebola 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Plague 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Rabies 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Typhus & Other Rickettsioses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 13 7 0 12 0 HFMD/Myocarditis 5 0 149 0 95 0 61 0 51 0 36 0 51 0 105 0 114 0 5 0 12 0 12 0 175 0 871 0 23 2094 3054 1 109 0 Total Notification 39 0 420 9 318 2 272 3 200 1 217 4 185 0 370 3 513 11 67 3 1094 1 270 4 439 0 4404 41 5375 Note: Case (death) Data sources: CDCIS 201 No data available for WP Labuan Case notification for WP Kuala Lumpur starting from week 25
  5. 5. Surveillance Report Introduction Under the schedule 1 and 2 of the Prevention and Control of Infectious Disease Act 1988 (PCID), there are 26 infectious diseases which every medical practitioner who treats or become aware of these infectious diseases occurring in any premises shall, with the least practicable delay, gives notice of the existence of the said infectious diseases to the nearest Medical Officer of Health using form 1 of the Act. The notification data were collected and compiled on a In Malaysia - 1990-2004 weekly basis by the District Health Office. A summary report was sent to the State Health Department and Statistic Unit, Disease Control Division, Ministry of Health Malaysia using EPI-203 form.The data contained in this report were based on information recorded on EPI-203 form as at 30 May 2005. Any changesmade to EPI-203 data after this date will not be reflected in this report. This report summarizes the data of weekly mandatoryinfectious disease notifications collected & which were analysed over the period 1990 to 2004.ResultsThe figure 1, below illustrates the total number of infectious diseases notified annually in Malaysia over the period of 1990to 2004. The total number of notifications appeared to be decreasing from 1990 until 1992 and started to increase until1996. From then on, 1997 to 2004, the total number of notifications of infectious diseases appeared to be fluctuating. Thefactors which may contribute to the pattern seen may be more likely due to level of compliance in reporting and outbreakoccurrences in some years. Cholera outbreaks which occurred in 1995 and 1996 may have contributed to the increase inthe total number of notifications and in 1996 there was the added increase in dengue fever notifications when comparedthe preceding years. Graf 1: The number of infectious disease notified annually in Malaysia, 1990-2004 1E+05 90000 Total Notification 60000 30000 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 YearInfectious diseases for which there were no reports (zero notifications) 1990 to 2004 are as follow: yellow fever, plague andebola (Ebola made notifiable under the law in 1995). There was a single report of relapsing fever (1999) and three cases ofacute poliomyelitis in 1992. There were zero notifications for rabies cases except in years 1990 (1 case), 1992 (1 case), 1996(5 cases), 1997 (7 cases), 1998 (1 cases) and 2001 (2 cases).Malaria, tuberculosis, dengue fever, food poisoning and viral hepatitis were the top 5 infectious diseases being reported.Tuberculosis, dengue fever and food poisoning were infectious diseases with increasing number of notifications whilstmalaria notifications have been declining. Infectious Disease Bulletin 11
  6. 6. PERSPECTIVE Global Public Health Surveillance under New International Health Regulations Michael G. Baker* and David P. Fidler† The new International Health Regulations adopted by IHR 1969 restricted surveillance to information providedthe World Health Assembly in May 2005 (IHR 2005) repre- only by governments, lacked mechanisms for swiftlysents a major development in the use of international law assessing and investigating public health risks, containedfor public health purposes. One of the most important no strategies for developing surveillance capacities andaspects of IHR 2005 is the establishment of a global sur- infrastructure, and failed to generate compliance by WHOveillance system for public health emergencies of interna-tional concern. This article assesses the surveillance member states. WHO began revising IHR 1969 in 1995system in IHR 2005 by applying well-established frame- (5), and IHR 2005’s adoption completed the modernizationworks for evaluating public health surveillance. The of this important body of international law on publicassessment shows that IHR 2005 constitutes a major health.advance in global surveillance from what has prevailed in IHR 2005 departs radically from IHR 1969 and repre-the past. Effectively implementing the IHR 2005 surveil- sents a historic development in international law on publiclance objectives requires surmounting technical, resource, health (6). IHR 2005 expands the scope of the regulations’governance, legal, and political obstacles. Although IHR application, strengthens WHO’s authority in surveillance2005 contains some provisions that directly address these and response, contains more demanding surveillance andobstacles, active support by the World Health Organizationand its member states is required to strengthen national response obligations, and applies human rights principlesand global surveillance capabilities. to public health interventions. The most dramatic of these changes involves a new surveillance system that far sur- passes what the IHR 1969 contained. After reviewing key n May 23, 2005, the World Health Assembly adoptedO the new International Health Regulations (IHR 2005)(1) as an international treaty. This step concluded the surveillance concepts and frameworks, this article describes IHR 2005’s surveillance regime and assesses its likely performance. It concludes by discussing obstaclesdecade-long effort led by the World Health Organization that could prevent IHR 2005 from becoming an effective(WHO) to revise the old regulations (IHR 1969) to make global public health surveillance system and addressingthem more effective against global disease threats. how these obstacles might be overcome.Originally adopted in 1951 (2) and last substantiallychanged in 1969 (3), IHR 1969 had lost its effectiveness Key Surveillance Conceptsand relevance by the mid-1990s, if not earlier (4). and Evaluation Framework The resurgence of infectious diseases noted in the first Public health surveillance has been defined as “thehalf of the 1990s showed IHR 1969’s limitations. For ongoing systematic collection, analysis, and interpretationexample, after smallpox was eradicated in the late 1970s, of outcome-specific data for use in the planning, imple-IHR 1969 only applied to the traditionally “quarantinable” mentation, and evaluation of public health practice” (7). Adiseases of cholera, plague, and yellow fever. In addition, surveillance system requires structures and processes to support these ongoing functions (7).*Wellington School of Medicine and Health Sciences, Wellington, The Centers for Disease Control and Prevention (CDC)New Zealand; and †Indiana University School of Law, developed guidelines that identify the essential elementsBloomington, Indiana, USA and attributes for an effective public health surveillance1058 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 12, No. 7, July 2006
  7. 7. Surveillance under International Health Regulationssystem (8). According to these guidelines, evaluating sur-veillance systems involves 2 main steps: 1) describing thepurpose, operation, and elements of the system and 2)assessing its performance according to key attributes. Thisarticle uses this 2-step approach to evaluate the global pub-lic health surveillance system prescribed by IHR 2005.Surveillance System Specified in IHR 2005 In the CDC framework, describing a surveillance sys-tem includes 4 main elements: 1) health-related eventsunder surveillance and their public health importance, 2)purpose and objectives of the system, 3) components andprocesses of the system, and 4) resources needed to oper-ate it (8).Health-related Events under Surveillance IHR 2005 identifies health-related events that eachcountry that agrees to be bound by the regulations (a “stateparty”) must report to WHO. In terms of health-relatedevents that occur in its territory, a state party must notifyWHO of “all events which may constitute a public healthemergency of international concern” (article 6.1). Theseevents include any unexpected or unusual public healthevent regardless of its origin or source (article 7). IHR2005 also requires state parties, as far as is practicable, toinform WHO of public health risks identified outside their Figure 1. International Health Regulations (IHR) 2005 decisionterritories that may cause international disease spread, as instrument (simplified from annex 2 of IHR).manifested by exported or imported human cases, vectorsthat may carry infection or contamination, or contaminat-ed goods (article 9.2). IHR 2005 provides guidance to assist state parties’ Third, IHR 2005 includes a list of diseases for which acompliance with these obligations in 4 ways. First, IHR single case may constitute a PHEIC and must be reported2005 defines a “public health emergency of international to WHO immediately. This list consists of smallpox,concern” (PHEIC) as “an extraordinary event which is poliomyelitis, human influenza caused by new subtypes,determined [by the WHO Director-General]… (i) to con- and severe acute respiratory syndrome (SARS). A secondstitute a public health risk to other States through the inter- list of diseases exists (Figure 1) for which a single casenational spread of disease and (ii) to potentially require a requires the decision instrument to be used to assess thecoordinated international response” (article 1.1). Unlike event, but notification is determined by the assessment andIHR 1969’s limited scope of application to just 3 commu- is not automatic. Finally, IHR 2005 also encourages statenicable diseases (3), IHR 2005 defines disease as an illness parties to consult with WHO over events that do not meetor medical condition that does or could threaten human the criteria for formal notification but may still be of pub-health regardless of its source or origin (article 1.1). This lic health relevance (article 8).scope therefore encompasses communicable and noncom- IHR 2005’s expansion of the range of public healthmunicable disease events, whether naturally occurring, events under surveillance and the use of risk assessmentaccidentally caused, or intentionally created. criteria in deciding what is reportable is possibly the single Second, IHR 2005 contains a “decision instrument” most important surveillance advance in IHR 2005. This(annex 2) that helps state parties identify whether a health- change greatly enhances effective surveillance of emerg-related event may constitute a PHEIC and therefore ing infectious diseases, which are “infections that haverequires formal notification to WHO (Figure 1). The deci- newly appeared in a population or have existed but are rap-sion instrument focuses on risk assessment criteria of pub- idly increasing in incidence or geographic range” (9). IHRlic health importance, including the seriousness of the 2005’s surveillance strategy, especially the decision instru-public health impact and the likelihood of international ment, has been specifically designed to make IHR 2005spread. directly applicable to emerging infectious disease events, Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 12, No. 7, July 2006 1059
  8. 8. PERSPECTIVEwhich are usually unexpected and often threaten to spreadinternationally. In addition to events that may constitute a PHEIC, IHR2005 also requires state parties to report the health meas-ures (e.g., border screening, quarantine) that they imple-ment in response to such events (article 6). State partiesare also specifically required to inform WHO within 48hours of implementing additional health measures thatinterfere with international trade and travel, unless theWHO Director-General has recommended such measures(article 43).Purpose and Objectives of Surveillanceunder IHR 2005 IHR 2005’s purpose is to prevent, protect against, con-trol, and facilitate public health responses to the interna-tional spread of disease (article 2), and IHR 2005 makessurveillance central to guiding effective public healthaction against cross-border disease threats. The regulations Figure 2. Public health surveillance structures and processes specified in International Health Regulations (IHR) 2005.define surveillance as “the systematic ongoing collection,collation and analysis of data for public health purposesand the timely dissemination of public health informationfor assessment and public health response as necessary” national IHR focal points through WHO, IHR 2005 estab-(article 1.1). Surveillance is central to IHR 2005’s public lishes a global network that improves the real-time flow ofhealth objectives, which explains why IHR 2005 requires surveillance information from the local to the global levelall state parties to develop, strengthen, and maintain core and also between state parties (article 4.4).surveillance capacities (article 5.1). This obligation goesbeyond anything concerning surveillance in IHR 1969, Resources Needed to Operate IHR 2005’swhich did not address surveillance infrastructure and capa- Surveillance Systembilities beyond a general requirement for a state party to Building and maintaining the surveillance system envi-notify WHO of any outbreak of a disease subject to the sioned in IHR 2005 will require substantial financial andregulations. technical resources. State parties will be primarily respon- sible for providing resources needed to develop their coreComponents and Processes of IHR 2005 Surveillance surveillance capacities. Each state party has to assess its IHR 2005 describes key aspects of the surveillance ability to meet the core surveillance requirements by Juneprocess from the local to the global level. As part of IHR 2009. In addition, each state party has to develop and2005’s core surveillance and response capacity require- implement a plan for ensuring compliance with core sur-ments, each state party has to develop and maintain capa- veillance obligations (articles 5.1 and 5.2, annex 1).bilities to detect, assess, and report disease events at the WHO is obliged to assist state parties in meeting theirlocal, intermediate, and national levels (article 5.1, annex surveillance system obligations (article 5.3), but this provi-1). Officials at the national level must be able to report sion does not allocate any WHO funds for this purpose.through the national IHR focal point to WHO when State parties are required to collaborate with each other inrequired under IHR 2005 (articles 4.2 and 6). The regula- providing technical cooperation and logistical support fortions also mandate that WHO establish IHR contact points surveillance capabilities and in mobilizing financialthat are always accessible to state parties (article 4.3). resources to facilitate implementation of IHR 2005 (articleConnecting these levels produces the surveillance archi- 44.1).tecture illustrated in Figure 2. Requiring that a national IHR focal point be established Evaluating the IHR 2005 Surveillance System’sis another surveillance initiative in IHR 2005. The focal Attributes and Potential Performancepoint is designed to facilitate rapid sharing of surveillance Key attributes of effective surveillance systems identi-information because it is responsible for communicating fied by CDC are usefulness, sensitivity, timeliness, stabil-with the WHO IHR contact points and disseminating infor- ity, simplicity, flexibility, acceptability, data quality,mation within the state party (article 4.2). By linking positive predictive value, and representativeness. Of these1060 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 12, No. 7, July 2006
  9. 9. Surveillance under International Health Regulationsattributes, usefulness, sensitivity, timeliness, and stability and document its contribution to prevention and control ofwill be most critical to the success of the IHR 2005 sur- adverse health events. IHR includes mechanisms to reviewveillance system. Simplicity, acceptability, and flexibility and, if necessary, amend its provisions and in particularwill affect the establishment and sustainability of the sur- requires periodic evaluation of the functioning of the deci-veillance system. Data quality, positive predictive value, sion instrument (article 54).and representativeness are central to accurately character-izing health-related events under surveillance. Table 1 Sensitivity of the Surveillance Systemsummarizes these attributes, provides commentary on The IHR 2005 surveillance provisions imply 100% sen-their relevance to effective surveillance under IHR 2005, sitivity as a standard, namely the reporting of all eventsand assesses the likely performance of the IHR 2005 sur- that meet notification requirements. The use of risk assess-veillance system for each attribute. The following para- ment criteria (Figure 1) also allows for higher sensitivitygraphs concentrate on assessing IHR 2005 with respect to for PHEIC than would be possible with a list of predeter-the key attributes of usefulness, sensitivity, timeliness, mined disease threats (as in IHR 1969). To test the poten-and stability. tial sensitivity of the decision instrument proposed in drafts of the revised IHR in 2004, investigators in theUsefulness of the Surveillance System United Kingdom applied the then-proposed decision The central premise of IHR 2005 is that rapidly detect- instrument to all events (N = 30) that were importanting PHEIC will support improved disease prevention and enough to have been published in the national surveillancecontrol both within and between state parties. Ample evi- bulletin for England and Wales during 2003 (11).dence shows that delayed recognition and response to According to this method, 12 of the 30 events would haveemerging diseases may result in adverse consequences in been reportable under the decision instrument. Theseterms of illness and death, spread to other countries, and events included all those that were considered potentialdisruption of trade and travel (10). The usefulness of sur- PHEIC. Investigators concluded that the decision instru-veillance under IHR 2005 represents the sum of all the crit- ment was highly sensitive for selecting outbreaks and inci-ical system attributes and can only be assessed after the dents that require reporting under the proposed IHRsystem is in operation, so this attribute is not discussed revision.here. However, for the future sustainability and develop- The sensitivity of the IHR 2005 surveillance systemment of IHR 2005, we must evaluate its overall usefulness will probably be affected by 2 factors. First, in all likeli- Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 12, No. 7, July 2006 1061
  10. 10. PERSPECTIVEhood, inadequate capacities at the local and intermediate IHR 2005 includes the core surveillance capacity thatlevels within state parties will limit the system’s sensitivi- local and intermediate public health entities must be ablety more than capacities at the national level. Second, state to carry out their reporting responsibilities immediatelyparties may not always be willing to comply with their (annex 1).reporting obligations in the face of possible adverse polit- WHO’s ability to draw on a wide array of sources ofical and economic consequences that may result from information, including the Internet and nongovernmentalalerting the world to a disease event in their territories. organizations and actors, may enhance the timeliness ofFear of such adverse consequences undermined reporting the IHR 2005 surveillance system (13,17). In countries thatobligations in IHR 1969. have less well-developed local, intermediate, and national IHR 2005 incorporates strategies to address these surveillance systems, nongovernmental sources of infor-potential limitations. First, as noted above, IHR 2005 mation can often provide information faster than govern-requires state parties to build and maintain core local, ments. Accessing this type of information early and oftenintermediate, and national surveillance capabilities (article helps WHO contact countries sooner, which increases the5.1, annex 1). Fulfillment of this obligation will improve chances of more effective interventions.surveillance capacity vertically, from local to national lev-els, which should support higher sensitivity. Stability of the Surveillance System Second, IHR 2005 permits WHO to improve sensitivi- The obligations each state party has to build and main-ty by collecting and using information from multiple tain core capacities in surveillance at the local, intermedi-sources. IHR 1969 only allowed WHO to use information ary, and national levels, combined with the responsibilitiesprovided by state parties (3), and failure of state parties to for surveillance WHO has globally, should construct aabide by their reporting obligations adversely affected global surveillance system that will be stable and reliableWHO surveillance activities (5). Under IHR 2005, WHO over time. Recognizing that core capacities at the nationalcan collect, analyze, and use information gathered from level and below will not develop overnight, IHR 2005governments, other intergovernmental organizations, and gives state parties until June 2012 to develop these capac-nongovernmental organizations and actors (article 9.1). By ities (article 5.1). State parties can obtain a 2-year exten-permitting WHO to cast its surveillance network beyond sion on this deadline by submitting a justified need and aninformation it receives from governments, IHR 2005 cre- implementation plan and can request an additional 2-yearates opportunities for WHO to improve the sensitivity of extension, which the WHO Director-General has the dis-the surveillance system and avoid being blocked by gov- cretion to approve or deny (article 5.2).ernmental failure to comply with reporting requirements. The 5-year grace period, and the possibility of 2-year extensions, was a necessary compromise and reflects theTimeliness of the Surveillance System difficulties many developing states will have in improving Public health practitioners understand how timely noti- their surveillance systems. The stability and reliability offication of public health risks is necessary for effective the IHR 2005 surveillance system are designed to increaseintervention strategies (12,13), lessons reiterated in the steadily as the grace period and any extensions come to anSARS pandemic (14). Timely surveillance is also stressed end.in connection with strategies to deal with pandemic influen-za (15,16). Timeliness may be the most important attribute Potential Obstacles to Achieving IHR 2005that IHR 2005 will have to demonstrate to be effective. Surveillance System Objectives IHR 2005 contains several provisions that relate to time- Continued lamentations about the weaknesses of publicliness. National-level assessments with the decision instru- health surveillance nationally and globally (18) illustratement must be completed within 48 hours (annex 1, part A, that achieving useful, sensitive, timely, and stable surveil-6[a]). State parties must then notify WHO within 24 hours lance through IHR 2005 will be a challenge for states andof assessing any event that may constitute a PHEIC or that the international community. Several potential obstacles,is unexpected or unusual (articles 6.1 and 7). The same 24- including technical, resource, governance, legal, and polit-hour requirement applies to reporting public health risk out- ical concerns, will complicate and frustrate efforts toside a state party’s territory that may constitute a PHEIC improve national and global surveillance capabilities.(article 9). State parties must also respond within 24 hours Table 2 summarizes these potential barriers and possibleto all requests that WHO makes for verification of health- responses.related events in their territories (article 10.2). Timeliness of reporting is likely to be affected more by Technical Issuesactions taken at local and intermediate levels than national- Emerging infectious diseases often create technicallevel provision of information to WHO. In this regard, challenges for surveillance, even for the most technologi-1062 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 12, No. 7, July 2006
  11. 11. Surveillance under International Health Regulationscally advanced and well-resourced countries. The sensitiv- with the United Nations and the World Bank, could consid-ity of surveillance systems for new pathogens has histori- er developing a global strategy to support the developmentcally been limited, particularly if such pathogens presented and maintenance of core surveillance capacities.themselves in unusual or unexpected ways. Recent model-ing has shown that the ability to control the spread of a Governance Issuesnew pathogen is influenced by the proportion of transmis- Governance obstacles include managerial and adminis-sion that occurs before the onset of overt symptoms or trative weaknesses in countries from the local to thethrough asymptomatic infection (19). This property national level. Few countries have conducted a systematicexplains why diseases such as influenza and HIV may be review of their surveillance systems, and thus most lackmore difficult to control than smallpox or SARS. detailed knowledge of gaps and limitations in their surveil- Consequently, surveillance needs to be sufficiently sen- lance infrastructures and how to address these problemssitive to detect infectious agents that have not yet resulted (26). Only a few states have assessed their ability to detectin large numbers of diagnosed cases. One approach to this and respond to emerging disease threats, such as thosechallenge is syndromic surveillance (20), but such surveil- posed by bioterrorism agents (27). The IHR 2005 require-lance has not been effective in detecting emerging infec- ment that each state party assess the condition of its publictious diseases early (21). In fact, WHO abandoned health surveillance within 2 years of the regulations’ entrysyndromic surveillance as a strategy for the revised IHR into force should help countries improve their nationalafter pilot studies demonstrated that it was not effective governance for surveillance purposes. Again, many states(22). Improved diagnostic technologies may also help pub- will need external assistance with such work.lic health authorities identify new pathogenic threats (23).Strategies for enhancing reporting processes have been Legal Issueswell described (24). State parties may face legal complications in imple- menting IHR 2005 within their national legal and constitu-Resource Issues tional systems. For example, the United States has The demands of IHR 2005 surveillance obligations will indicated that requirements of US federalism may affect itsconfront many countries, particularly developing coun- compliance with IHR 2005 (28). The US position suggeststries, with resource challenges. IHR 2005 does not include that other countries may also wish to formulate reserva-financing mechanisms, which leaves each state party to tions to IHR 2005 to account for the demands of theirbear the financial costs of improving its own local, inter- national constitutional structures and systems of law (29).mediate, and national level surveillance capabilities. The Whether such reservations will undermine the IHR 2005obligation on state parties and WHO to collaborate in surveillance system cannot be assessed, but this concernmobilizing financial resources (article 44) is a weak obli- has to be monitored closely as countries determine whethergation at best. The lack of economic resources will, if not reservations are required under their national constitution-more vigorously addressed as recommended by the UN al systems. IHR 2005 also specifies that domestic legisla-Secretary-General (25), retard progress on all aspects of tion and administrative arrangements be adjusted fullythe upgraded surveillance system. WHO, in conjunction with IHR 2005 by June 2007, or by June 2008 after a Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 12, No. 7, July 2006 1063
  12. 12. PERSPECTIVEsuitable declaration to the WHO Director-General (article Dr Baker is a public health physician and senior lecturer at59.3). Helping state parties update their public health law the Wellington School of Medicine and Health Sciences. He hasmay be technical assistance that industrialized countries worked as a short-term consultant to WHO during developmentcan provide. and implementation of IHR 2005. His research interests include emerging infectious diseases, surveillance and outbreak investi-Political Issues gation, and the role of housing conditions as health determinants. Questions remain about the level of political commit- Mr Fidler is an international lawyer and professor of law atment countries will demonstrate in implementing IHR the Indiana University School of Law, Bloomington, Indiana. In2005. IHR 1969 suffered because state parties frequently conjunction with the Center for Law and the Public’s Health offailed to report notifiable diseases and routinely applied Georgetown and Johns Hopkins Universities, he provided analy-excessive trade and travel restrictions (4). The relevance of sis to WHO of potential conflicts between IHR 2005 and othersuch trade and travel concerns was most recently illustrat- international legal regimes. His research interests include globaled during the SARS pandemic through China’s initial fears health governance, biosecurity, and the role of international lawthat disclosing the pandemic would harm its economy and in global public health.foreign trade (30,31). WHO’s access to nongovernmentalsources of surveillance information reduces the incentives Referencesthat state parties once had to hide disease events, as wasdemonstrated during the SARS pandemic (32). In addition, 1. World Health Assembly. Revision of the International HealthIHR 2005 includes provisions that require WHO to recom- Regulations, WHA58.3. 2005 [cited 2006 May 2]. Available from h t t p : / / w w w. w h o . i n t / g b / e b w h a / p d f _ f i l e s / W H A 5 8 - R E C 1 /mend, and state parties to use, control measures that are no english/Resolutions.pdfmore restrictive than necessary to achieve the desired level 2. United Nations. International Sanitary Regulations, 175 UN Treatyof health protection (articles 17, 43). Uncertainty lingers, Series 214. 1951.however, as to whether these obligations will fare better in 3. World Health Organization. International Health Regulations (1969). 3rd ed. Geneva: The Organization; 1983.terms of state party compliance than similar ones in IHR 4. Fidler D. International law and infectious diseases. Oxford:1969. Clarendon Press; 1999. 5. World Health Organization. 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