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International Health- الصحة الدولية

Global/International health is any health issue that concerns many countries or is affected by transnational determinants

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International Health- الصحة الدولية

  1. 1. SBCM-Madinah International Health Dr. Ahmed-Refat AG Refat 2013The World Health Organization (WHO) states, “In the 21st century, health is a shared responsibility, involving equitable access to essential care and collective defense against transnational threats.”1 04/2013
  2. 2. Contents  What is global health? & Global Health Issues  The International Health Regulations ( IHR -2005 ) .  Public Health Emergency of International Concern ( PHEIC )  Decision instrument for PHEIC  Exercise # 1: Mexican Candy  Case definitions for the four diseases requiring notification to WHO in all circumstances under the IHR (2005)  Health conditions for travellers to Saudi Arabia for the pilgrimage to Mecca (Hajj)  International Certificate of Vaccination or Prophylaxis  Exercise #2:Using a dummy " International Certificate of Vaccination or Prophylaxis"  Cited References & Useful Sources2 04/2013
  3. 3. What is global health? IOM defines GH as: Health problems, issues, and concerns that go above national boundaries, which may be influenced by circumstances or experiences in other countries, and which are best addressed by cooperative actions and solutions (Institute Of Medicine, USA- 1997)3 04/2013
  4. 4. Global Health Issues Refers to any health issue that concerns many countries or is affected by transnational determinants such as: • Climate change • Urbanisation • Malnutrition – under or over nutritionOr solutions such as: • Polio eradication • Containment of avian influenza • Approaches to tobacco control4 04/2013
  5. 5. Historical Development of Term Public Health: Developed as a discipline in the mid 19th century in UK, Europe and US. Concerned more with national issues. • Data and evidence to support action, focus on populations, social justice and equity, emphasis on preventions vs cure. International Health: Developed during past decades, came to be more concerned with • the diseases (e.g. tropical diseases) and • conditions (war, natural disasters) of middle and low income countries. • Tended to denote a one way flow of ‘good ideas’.5 04/2013
  6. 6. Global Health: More recent in its origin and emphasises a greater scope of health problems and solutions • that transcend national boundaries • requiring greater inter-disciplinary approach Disciplines involved in Global Health Social sciences Behavioural sciences Law Economics History Engineering Biomedical sciences Environmental sciences6 04/2013
  7. 7. Global threats: why are we concerned?_ Epidemics not new, but….took days, weeks/months to reach farterritories_ Emergence/re-emergence of infectious diseases and increasedpace of spread_ Threat of deliberate use of biological and chemical agents_ Impact on health, economy, securityWhat are IHR (2005)? A global framework_ Legally-binding global agreement to protect public health_ The international commitment for shared responsibilities andcollective defense against disease spread.7 04/2013
  8. 8. Why have IHR (2005)? _ Serious and unusual disease events are increasing and inevitable _ Globalisation– public health event in one location can be a threat to others _ Need for collective effort and agreed rules – strong national public health system– international alert & response system8 04/2013
  9. 9. The International Health Regulations (IHR)are an international legal instrument that isbinding on 194 countries across the globe,including all the Member States of WHO.Their aim is to help the internationalcommunity prevent and respond to acutepublic health risks that have the potential tocross borders and threaten peopleworldwide.‫اللوائح الصحية الدولية هي صك قانوني دولي ملزم ل 491 ً في جميع أنحاء العالم،ًبما فيها الدول األعضاء في منظمة الصحة العالمية .والغرض من هذه اللوائح‬ ‫بلدا‬ ً .‫هو مساعدةًالمجتمع الدولي على منع ومواجهة المخاطر الصحية العمومية القادرة على االنتشار عبرًالحدود وتهديد الناس في شتى أرجاء العالم‬9 04/2013
  10. 10. Scope of IHR (2005) _ “Disease” under IHR (2005): – “an illness or medical condition, irrespective of origin or source that presents or could present significant harm to humans” _ Notification: All events that may constitute a public healthً emergency of international concern (PHEIC)Purpose of IHR (2005)“To prevent, protect against, control and provide a public healthresponse to the international spread of disease in ways that arematching with and restricted to public health risks, and _ which avoidunnecessary interference with international traffic and trade” –(Article 2) ً10 04/2013
  11. 11. ً11 04/2013
  12. 12. IHR- 1969 IHR- 2005implement a control of travelers and organize the containment of the risk atgoods when crossing borders and the source, so that risks do not escapeentering countries (e.g., need for control and spread out of the country.appropriate vaccinations such as YF)a list of epidemic-prone diseases report any event constituting a threatto be specially controlled (smallpox, for the international community,yellow fever, and cholera) whether caused by a disease or other sources such as chemical spill, or even a nuclear event.preset measures, which have to be replaced by a more flexible set ofadopted by all countries adapted responses according to the nature of the event, that will be implemented by countries with WHO12 04/2013
  13. 13. ً13 04/2013
  14. 14. Public Health Emergency of International Concern ( PHEIC )Compliance with IHR (2005) implies that all member States musthave implemented at national level the capacity to:• detect events that may constitute a threat to public health;• determine if this could be a risk at an international level;• organize a response in order to contain the event at the source.14 04/2013
  15. 15. “Public Health Emergency of International Concern” meansan extraordinary event which is determined, as provided inthese Regulations:• to constitute a public health risk to other States throughthe international spread of disease, and• to potentially require a coordinated internationalresponse.15 04/2013
  16. 16. What is a Public Health Emergency of International Concern (PHEIC)?16 04/2013
  17. 17. The determination if the event constitutes a PHEIC is madeon the basis of four criteria:1.seriousness of the public health event;2. unusual or unexpected nature of the event;3. potential for the event to spread internationally;4. risk that the event may result in restrictions to travel or trade. Answering yes to any two of these questions will lead to obligation for the IHR Focal Point to report the event to WHO as a PHEIC.17 04/2013
  18. 18. ًIHR is not a substitute for nationalsurveillance and response systems� IHR is about preventing the international spread ofdiseases� IHR is not about a global surveillance system� But IHR seeks that all Member States be able to timelydetect, assess, notify and report events and respond topublic health risks and public health emergency ofinternational concern (PHEIC) ً ً18 04/2013
  19. 19. IHR (2005) core capacities requirements for surveillance and responseCommunity level and/or primary public health response level– To detect events involving disease or death above expected levels, report to thelocal health personnel and implement preliminary control measuresIntermediate public health response levels– To confirm the status of reported events and implement control measuresNational level (on a 24-hour basis)– To assess all reports of urgent events within 48 hours and notify the WHOimmediately through the national IHR focal point when required.– To rapidly determine the control measures required to prevent domestic andinternational spread– To provide direct operational links with senior decision makers and provide liaisonwith other sectors– To establish, operate and maintain a national public health emergency response plan. ً19 04/2013
  20. 20. IHR TimeframeMay 2005: World Health Assembly approves therevised IHR2007: Entry into force of the revised IHR2009: All countries have assessed their level of core capacities2012: All countries have reached a minimum required level of core capacities20 04/2013
  21. 21. Decision instrument21 04/2013
  22. 22. 22 04/2013
  23. 23. Notify to WHO23 04/2013
  24. 24. Is the Public Health Impact of the event SERIOUS?24 04/2013
  25. 25. Is there a significant risk of Is there a significant risk of international concern ? international concern ?A positive response to two questions requires a country to notify WHO4 diseases that always have to be notified polio (wild type virus), smallpox, humaninfluenza caused by a novel virus, SARS. Diseases that always lead to the use ofthe algorithm : cholera, pneumonique plague, yellow fever, VHF (Ebola, Lassa,Marburg), WNF, meningitis, others25 04/2013
  26. 26. Exercise # 1Answer the following question by Using the decision tool (annex 2) of IHR-2005 Mexican CandyCalifornia often experiences instances where candy imported from Mexico testshigh for lead that can result in poisonings in children. Would this be reportableunder the IHR (2005)?26 04/2013
  27. 27. Ex. #1 : Mexican CandyTo determine whether an event would be reportable under the IHR (2005), thecircumstances of the event would have to be assessed within the context of thedecision algorithm in Annex 2 of the IHR (2005) document. To be considered apotential Public Health Emergency of International Concern (PHEIC), the event wouldhave to meet two of the four criteria (questions) in the decision algorithm.Question # 1 could be answered with a "Yes" since the scenario involves a toxicmaterial that has the potential to contaminate a population (in this case, the populationclose to the border) or large geographic area.Question # 3 could be answered with a "Yes" since the contaminated candy isexported to the U.S. and possibly other countries.Question #4 could be answered with a "Yes" because the likely response is for thecontaminated candy to be identified as dangerous and subject to regulatory actions byappropriate U.S. agencies.27 04/2013
  28. 28. Case definitions for the four diseases requiring notification to WHOin all circumstances under the IHR (2005)Under the International Health Regulations 2005 (IHR 2005), the World HealthOrganization is to establish case definitions for the following four critical diseaseswhich are deemed always to be unusual or unexpected and may have serious publichealth impact, and hence must be notified to WHO in all circumstances:  smallpox  poliomyelitis due to wild type poliovirus  human influenza caused by a new subtype, and  severe acute respiratory syndrome (SARS). ً ً28 04/2013
  29. 29. Case definitions for the four diseases requiring notification in all circumstances under the IHR (2005)29 04/2013
  30. 30. A) Human influenza caused by a new subtypeCase definition for notification of human influenzacaused by a new subtype under the IHR (2005)State Parties to the IHR (2005) are required to immediately notify WHO of anylaboratory confirmed case of a recent human infection caused by an influenza A viruswith the potential to cause a pandemic. Evidence of illness is not required for thisreport.An influenza A virus is considered to have the potential to cause a pandemic if thevirus has demonstrated the capacity to infect a human and if the heamagglutinin gene(or protein) is not a variant or mutated form of those, i.e. A/H1 or A/H3, circulatingwidely in the human population.An infection is considered recent if it has been confirmed by positive results frompolymerase chain reaction (PCR), virus isolation, or paired acute and convalescentserologic tests. An antibody titre in a single serum is often not enough to confirm arecent infection, and should be assessed by reference to valid WHO case definitions forhuman infections with specific influenza A subtypes.30 04/2013
  31. 31. B) Poliomyelitis due to wild-type poliovirusUnder the IHR (2005), a notifiable case of poliomyelitis due to wild-typepoliovirus is defined as a suspected case* with isolation of wild poliovirus instool specimens collected from the suspected case or from a close contact ofthe suspected case.C) SARS Case definitionIn the SARS post-outbreak period, a notifiable case of SARS is defined as anindividual with laboratory confirmation of infection with SARS coronavirus(SARS-CoV) who either fulfils the clinical case definition of SARS or hasworked in a laboratory working with live SARS-CoV or storing clinicalspecimens infected with SARS-CoV.31 04/2013
  32. 32. Clinical case definition of SARS:1. A history of fever, or documented feverAND2. One or more symptoms of lower respiratory tract illness (cough, difficultybreathing, shortness of breath)AND: 3. Radiographic evidence of lung infiltrates consistent with pneumoniaor acute respiratory distress syndrome (ARDS) or autopsy findings consistentwith the pathology of pneumonia or ARDS without an identifiable causeAND4. No alternative diagnosis can fully explain the illness.Diagnostic tests required for laboratory confirmation of SARS:A) Conventional reverse transcriptase polymerase chain reaction(RT-PCR) and real-time reverse transcriptase PCR (real-time RT-PCR) assay detecting viral RNA present in:1. At least two different clinical specimens (e.g. nasopharyngeal and stool)32 04/2013
  33. 33. OR2. The same clinical specimen collected on two or more occasions during thecourse of the illness (e.g. sequential nasopharyngeal aspirates)OR3. In a new extract from the original clinical sample tested positive by twodifferent assays or repeat RT-PCR/real-time RT-PCR on each occasion oftestingOR4. In virus culture from any clinical specimen.B) Enzyme Linked Immunosorbent Assay (ELISA) andimmunofluorescent assay (IFA)1. Negative antibody test on serum collected during the acute phase of illnessfollowed bypositive antibody test on convalescent phase serum, tested simultaneouslyOR33 04/2013
  34. 34. 2. Fourfold or greater rise in antibody titre against SARS-CoV between anacute serumspecimen and a convalescent serum specimen (paired sera), testedsimultaneously.D) Smallpox- Case definition .States Parties to the IHR (2005) are required to immediately notify to WHO ofany confirmed case of smallpox. The case definition for a confirmed smallpoxcase includes the following:Confirmed case of smallpox:An individual of any age presenting with acute onset of fever (≥38.3°C/101°F),malaise, and severe prostration with headache and backache occurring 2 to 4days before rash onsetAND34 04/2013
  35. 35. Subsequent development of a maculopapular rash starting on the face andforearms, then spreading to the trunk and legs, and evolving within 48 hours todeep-seated, firm/hard and round well-circumscribed vesicles and laternpustules, which may become umbilicated or confluentANDLesions that appear in the same stage of development (i.e. all are vesicles orall are pustules) on any given part of the body (e.g. the face or arm)ANDNo alternative diagnosis explaining the illnessANDLaboratory confirmation.*A suspected case is defined as a child under 15 years of age presenting withacute flaccidparalysis (AFP2), or as any person at any age with paralyticillness if poliomyelitis is suspected.35 04/2013
  36. 36. Health conditions for travellers to Saudi Arabia for the pilgrimage to Mecca (Hajj)36 04/2013
  37. 37. The Ministry of Health of Saudi Arabia has issued the following requirements and recommendations for entry visas for the Hajj and Umra seasons in 2012.I. Yellow fever(A) In accordance with the InternationalHealth Regulations 2005,1 all travellers arrivingfrom countries or areas at risk of yellow fever (seelist below) must present a valid yellow fevervaccination certificate showing that the person was37 04/2013
  38. 38. vaccinated at least 10 days previously and not morethan 10 years before arrival at the border.In the absence of such a certificate, the individualwill be placed under strict surveillance for 6 daysfrom the date of vaccination or the last date ofpotential exposure to infection, whichever is earlier.Health offices at entry points will be responsiblefor notifying the appropriate38 04/2013
  39. 39. Director General of Health Affairs in the region or governorate about thetemporary place of residence of the visitor.Countries/areas are at risk of yellow fever transmission(as defined by the International travel and health 2012):Africa: Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Côte d’Ivoire,Democratic Republic of the Congo, Equatorial Guinea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea Bissau, Kenya,Liberia, Mali, Mauritania, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, Sudan, South Soudan, Togo and Uganda.Americas: Argentina, Bolivarian Republic of Venezuela, Brazil, Colombia, Ecuador, French Guiana, Guyana,Panama, Paraguay, Peru, Plurinational State of Bolivia, Suriname and Trinidad and Tobago .39 04/2013
  40. 40. (B) Aircrafts, ships and other means of transportation coming fromcountries affected by yellow fever are requested to submit a certificateindicating that it applied disinsection in accordance with methodsrecommended by WHO.40 04/2013
  41. 41. In accordance with the International Health Regulations 2005, all arrivingships will be requested to provide to the competent authority a valid ShipSanitation Certificate.Ships arriving from areas at risk for yellow fevertransmission may also be required to submit to inspection to ensurethey are free of yellow fever vectors, or disinsected, as a condition ofgranting free pratique (including permission to enter a port, to embark ordisembark and to discharge or load cargo or stores).41 04/2013
  42. 42. 42 04/2013
  43. 43. II. M eningococcal meningitis(A) For all arrivalsVisitors from all over the world arriving for thepurpose of Umra or pilgrimage or for seasonal workare required to produce a certificate of vaccinationwith the quadrivalent (ACYW135) vaccine againstmeningitis issued not more than 3 years previouslyand not less than 10 days before arrival in KSA.The responsible authorities in the visitor’s countryof origin should ensure that adults and children43 04/2013
  44. 44. over the age of 2 years are given 1 dose of thequadrivalent polysaccharide (ACYW135) vaccine.(B) For arrivals from countries in the Africanmeningitis belt, namely Benin, Burkina Faso, Cameroon, Chad, Central AfricanRepublic, Côte d’Ivoire, Eritrea, Ethiopia, Gambia, Guinea, Guinea-Bissau, Mali, Niger,Nigeria, Senegal and Sudan.In addition to the above stated requirements,chemoprophylaxis will be administered at port ofentry to all arrivals from these countries to lowerthe carriers rate among them. Adults will receiveciprofloxacin tablets (500 mg), children will receiverifampicin, and pregnant women will receiveceftriaxone injections.44 04/2013
  45. 45. 45 04/2013
  46. 46. Vaccination with quadrivalent (ACYW135) vaccine is required for:– all citizens and residents of Medina and Meccawho have not been vaccinated during the past 3 years;– all citizens and residents undertaking the Hajj;– all Hajj workers who have not been vaccinated inthe past 3 years;– any individual working at entry points or in directcontact with pilgrims in Saudi Arabia.46 04/2013
  47. 47. 47 04/2013
  48. 48. III. Poliomyelitis(A) All travellers arriving from polio-endemiccountries and re-established transmissioncountries, namely: Afghanistan, Angola, Chad, theDemocratic Republic of Congo, Nigeria and Pakistan,regardless of age and vaccination status, shouldreceive 1 dose of oral poliovirus vaccine (OPV).Proof of OPV vaccination at least 6 weeks priordeparture is required to apply for entry visa forSaudi Arabia.48 04/2013
  49. 49. These travellers will also receive:1 dose of OPV at borders points on arrival in SaudiArabia. The same requirements are valid fortravelers from recently endemic countries at highrisk of reimportation of poliovirus, i.e. India.(B) All visitors aged under 15 years travelling toSaudi Arabia from countries with imported cases ofpoliomyelitis or circulating vaccine-derivedpolioviruses (see list below) in the past 12 months (asof mid-February 2012) should be vaccinated againstpoliomyelitis with the OPV or inactivated poliovirusvaccine (IPV).49 04/2013
  50. 50. Proof of OPV or IPV vaccination is required 6 weeksprior the application for entry visa.Irrespective of previous immunization history, allvisitors under 15 years arriving in Saudi Arabia will alsoreceive 1 dose of OPV at border points.Polio cases related to wild poliovirus importation or tocirculating vaccine-derived poliovirus have beenregistered during the past 12 months in the followingcountries:China, Central African Republic, Côte d’Ivoire, Kenya, Mali,Niger, Somalia and Yemen.50 04/2013
  51. 51. 51 04/2013
  52. 52. 52 04/2013
  53. 53. IV. Seasonal influenza The MOH-KSA recommends that international pilgrims be vaccinated against seasonal influenza before arrival into the kingdom of Saudi Arabia, particularly those at increased risk of severe complications (e.g. the elderly over 65 years of age, people with pre-existing medical conditions such as people with chronic respiratory or heart diseases, hepatic or renal failure, neuromuscular or metabolic diseases including53 04/2013
  54. 54. diabetes or immunocompromised conditions due to various reasons such as HIV infection or immune suppressive therapy). Pregnant women can also be considered for vaccination. In Saudi Arabia, seasonal influenza vaccine is recommended for internal pilgrims, particularly those with pre-existing health conditions, and all health staff working in the Hajj premises.54 04/2013
  55. 55. 55 04/2013
  56. 56. V. Health educationHealth authorities in countries of origin are required to provideinformation to pilgrims on infectious diseases symptoms,methods of transmission, complications and means of prevention.VI. FoodHajj and Umrah performers are not allowed to bringfresh food in Saudi Arabia. Only properly canned orsealed food or food stored in containers with easy access forinspection is allowed in small quantities, sufficient for one personfor the duration of his or her trip.VII. International outbreaks responseUpdating immunization against vaccine-preventablediseases in all travellers is strongly recommended. With therecent resurgence of measles and rubella cases, special attentionis needed for both of these vaccines to avoid widespreadoutbreaks with this virus during this year Hajj and Umra.56 04/2013
  57. 57. Preparation for international travel provides opportunity to reviewthe immunization status of travellers. Incompletely immunizedtravellers can be offered routine vaccinations recommended innational immunization schedules (these usually includediphtheria, tetanus, pertussis, polio, measles and mumps), inaddition to those needed for the specific travel (e.g.meningococcal vaccination for Hajj). In International Travel andHealth 2012, WHO recommends that travelers ensure immunityagainst measles by having at least 2 doses of vaccine and againstrubella by 1 dose of vaccine.In the event of a public health emergency of international healthconcern, or in the case of any disease outbreak subject tonotification under the IHR-2005, the health authorities in SaudiArabia, following consultation with WHO, will undertake additionalpreventive precautions necessary to avoid the spread of infectionduring the pilgrimage or on return to their country of origin.57 04/2013
  58. 58. International Certificate of Vaccination or Prophylaxis58 04/2013
  59. 59. 59 04/2013
  60. 60. Requirements for validityThis certificate is valid only if the vaccine or prophylaxis used hasbeen approved by the World Health Organization.This certificate must be signed in the hand of the clinician, whoshall be a medical practitioner or other authorized health worker,supervising the administration of the vaccine or prophylaxis. Thecertificate must also bear the official stamp of the administeringcentre; however, this shall not be an accepted substitute for thesignature.Any amendment of this certificate, or erasure, or failure to60 04/2013
  61. 61. complete any part of it, may render it invalid.The validity of this certificate shall extend until the date indicatedfor the particular vaccination or prophylaxis. The certificate shallbe fully completed in English or in French. The certificate mayalso be completed in another language on the same document, inaddition to either English or French.NotesThe only disease specifically designated in the International HealthRegulations (2005) for which proof of vaccination or prophylaxismay be required as a condition of entry to a State Party, is yellowfever. When administering this vaccine, the clinician must write“Yellow Fever” in the space provided on this certificate.61 04/2013
  62. 62. This same certificate will also be used in the event that these Regulations areamended or a recommendation is made under these Regulations by the WorldHealth Organization to designate another disease.62 04/2013
  63. 63. 63 04/2013
  64. 64. 64 04/2013
  65. 65. 65 04/2013
  66. 66. INFORMATION FOR PHYSICIANS1. The dates for vaccination on each certificate are to be recorded inthe following sequence: day, month, year – the month in letters.Example: January 1, 2001 is written 1 January 2001.2. If vaccination is contraindicated on medical grounds, the physicianshould provide the traveller with a written opinion, which healthauthorities should take into account.3. Vaccination certificate requirements of countries are publishedby WHO in International travel and health. Information ondesignated yellow fever vaccinating centres is available from localor national health offices.4. The physician should always consider that his/her patient mayhave a travel-associated illness.66 04/2013
  67. 67. Exercise #2 Use a dummy " International Certificate of Vaccination or Prophylaxis" and fill the required data of a hypothesized traveler67 04/2013
  68. 68. 68 04/2013
  69. 69. Cited References & Useful Sources69 04/2013
  70. 70. 70 04/2013
  71. 71. 71 04/2013
  72. 72. ً ً ً72 04/2013
  73. 73. CDC – Travel yellow book KSA : Hajj Health Regulations (2005) travel and health (ITH) – 2012: Publication on health risks forinternational travellers, vaccination requirements and precautions to take. 04/2013
  74. 74. Dr Yoga Nathan .Introduction to Global Health .. GEMS ULWHO/EPR .International Health Regulations (2005).Update onimplementation Monitoring & Evaluation System.WHO. International Health Regulations in the context of PandemicInfluenzaAl-Tawfiq JA, Memish ZA. The Hajj: updated health hazards andcurrent recommendations for 2012. Euro Surveill.2012;17(41):pii=20295. ً ً ً ً ً74 04/2013
  75. 75. Quarantine and Isolation Isolation and quarantine are public health practices used to stop or limit the spread of disease.  Isolation is used to separate ill persons who have a communicable disease from those who are healthy.  Quarantine is used to separate and restrict the movement of well persons who may have been exposed to a communicable disease to see if they become ill. Words quaranta giorni which mean 40 days. ً ً75 04/2013
  76. 76. ً ً ً ً76 04/2013

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Global/International health is any health issue that concerns many countries or is affected by transnational determinants


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