IHR under WHO guidelines public health instrument of international concern

1. INTERNATIONAL HEALTH
REGULATIONS
JUNIOR RESIDENT: Dr. Tanveer Rehman
FACULTY MODERATOR: Dr. Subitha L

2. CONTENTS
1. Background, Purpose and Scope
2. IHR 2005
3. Determination of a PHEIC
4. Case scenarios
5. GOARN
6. Responsible authorities
7. Public health measures
8. Core capacity requirements
16-07-2018 2Dr Tanveer Rehman PSM JIPMER

3. HISTORY
1. 1830 – 1847: Cholera epidemics in Europe - First International Sanitary
Conference Paris, 1851
2. 1951 - WHO Member States adopted the International Sanitary
Regulations - renamed the International Health Regulations (IHR) in 1969
3. Resurgence of epidemic diseases- The IHR (2005) entered into force on
15 June 2007
16-07-2018 3Dr Tanveer Rehman PSM JIPMER

4. PURPOSE AND SCOPE
“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”
16-07-2018 4Dr Tanveer Rehman PSM JIPMER

5. Why were the IHR revised?
1. Increase in cross-border travel, trade and communication technology
2. Focus on just three diseases (cholera, plague and yellow fever) - not
equipped to address the growing and varied public health risks
3. Reluctance to promptly report outbreaks of these diseases for fear of
unwarranted and damaging travel and trade restrictions
16-07-2018 5Dr Tanveer Rehman PSM JIPMER

6. IHR (2005)
1. From control of borders to containment at source
2. From diseases list to all threats
3. From pre-set measures to adapted and real time response
16-07-2018 6Dr Tanveer Rehman PSM JIPMER

7. Determination of a
Public Health Emergency of International Concern (PHEIC)
1. Director-General (DG) seeks view of “Emergency Committee” (EC)
2. EC formed by IHR Roster of Experts - experts in all relevant fields of expertise
(including from the concerned state party of Emergency) in accordance with the
WHO Regulations for Expert Advisory Panels and Committees
3. DG - invite the State Party in whose territory the event arises to present its
views to the EC
4. Final decision: By DG
16-07-2018 7Dr Tanveer Rehman PSM JIPMER

8. PHEIC DECISION INSTRUMENT
16-07-2018 8Dr Tanveer Rehman PSM JIPMER

9. PHEIC DECISION INSTRUMENT
16-07-2018 9Dr Tanveer Rehman PSM JIPMER

10. CASE SCENARIOS

11. Case 1
1. Municipality with 180,000 inhabitants in the centre of Country A
2. Within last 3 days only: 220 new suspect cases of Cholera
3. Currently: 45 laboratory confirmed Vibrio cholerae cases being treated
4. 4 deaths recorded
5. Rural municipality - poor sanitation services
6. Recent rains setting in with human waste and other materials being washed into
existing water sources leading to widespread contamination
7. Cholera is a recurring problem during rainy season, resulting sometimes into
case fatality rates higher than 2%
16-07-2018 11Dr Tanveer Rehman PSM JIPMER

12. PHEIC DECISION INSTRUMENT
16-07-2018 12Dr Tanveer Rehman PSM JIPMER

13. A. Is the Public Health Impact of the Event Serious?
1. Is the number of cases and/or number of deaths for this type of
event large for the given place, time or population?
OR
2. Has the event the potential to have a high public health impact?
OR
3. Is external assistance needed to detect, investigate, respond and
control the current event, or prevent new cases?
16-07-2018 13Dr Tanveer Rehman PSM JIPMER

14. HIGH PUBLIC HEALTH IMPACT
1. Pathogen with high potential to cause epidemic
2. Indication of treatment failure
3. Cases reported among health staff or vulnerable population
4. Factors delaying public health response (natural catastrophes, armed conflicts)
5. High population density
6. Spread of toxic, infectious or otherwise hazardous materials contaminating a
large geographical area
16-07-2018 14Dr Tanveer Rehman PSM JIPMER

15. B. Is the Event Unusual or Unexpected?
Unusual:
1. An unknown agent or the source, vehicle, route of transmission is
unusual or unknown
2. Evolution of cases more severe than expected or with unusual
symptoms
3. Occurrence of the event itself unusual for the area, season or
population.
Unexpected:
Disease/agent that had already been eliminated or eradicated
16-07-2018 15Dr Tanveer Rehman PSM JIPMER

16. C. Is there a significant risk of international spread?
A. Is there evidence of an epidemiological link to similar events in other States?
OR
B. Is there any factor that should alert us to the potential for cross border
movement of the agent, vehicle or host?
Eg. Index case (or other linked cases) with a history within the previous month:
1. International travel or gathering (pilgrimage, sports event, conference, etc.)
2. Close contact with an international traveller or a highly mobile population
3. Environmental contamination that has the potential to spread across international borders
16-07-2018 16Dr Tanveer Rehman PSM JIPMER

17. D. Is there a significant risk of
International travel or trade restrictions?
1. Similar events in the past resulted in international restriction on
trade and/or travel?
2. Source suspected or known to be a food product/water/other goods
that might be contaminated, that has been exported/imported to/from
other States?
3. In association with an international gathering or in an area of intense
international tourism?
4. Requests for more information by foreign officials or international
media?
16-07-2018 17Dr Tanveer Rehman PSM JIPMER

18. Case 2
1. 12 tourists: acute gastrointestinal symptoms - prior to departing Country B
2. Staying at the same popular tourist resort hotel
3. Vibrio cholerae in stool: six of them
4. Suspect: source of infection - seafood salad - boat trip
5. Previous years: sporadic cases of cholera
6. Country C reported WHO two likely imported cholera cases just returned
from Country B
16-07-2018 18Dr Tanveer Rehman PSM JIPMER

19. Case 3
1. An area where housing and sanitation conditions are poor
2. 68 clinically suspected and 12 presumptive cases of Bubonic Plague
3. Three patients, of which one died, indicate Septicemic Plague
4. Bacteriologically confirmed or presumptive human cases (300/year) of
bubonic plague occur annually in this enzootic area during the rainy tropical
summer season
5. Local health-care providers started antibiotic treatment with streptomycin
6. Public health education: avoid exposure to fleas
16-07-2018 19Dr Tanveer Rehman PSM JIPMER

20. Case 4
1. 15 days - 23 cases of febrile encephalitis associated with respiratory
illness – 17 deaths
2. Three cases: household members of index case
3. Other cases including one nurse: spread from index - same hospital
4. Specimens from 3 cases tested positive for Nipah virus
5. Over 2000 people in 2 districts were quarantined
6. Investigation: identify the source of human infection (suspected bats)
7. Travel advisory and disease awareness: Mass media
16-07-2018 20Dr Tanveer Rehman PSM JIPMER

21. 16-07-2018 21Dr Tanveer Rehman PSM JIPMER

22. Global Outbreak Alert and Response Network
1. Global technical partnership - World Health Organization (WHO) - to
engage the resources of technical agencies beyond the United Nations for
rapid identification, confirmation and response to PHEIC
2. 200 technical institutions and networks: United Nations organisations, the
Red Cross and Red Crescent Societies, international humanitarian non-
governmental organisations, and national public health institutions
3. Sequence: Formal request for support – Alert - Mission agreed
16-07-2018 22Dr Tanveer Rehman PSM JIPMER

23. 16-07-2018 23
GOARN: 2000 - 2017
Dr Tanveer Rehman PSM JIPMER

24. WHO Levels For Graded Emergencies
16-07-2018 24Dr Tanveer Rehman PSM JIPMER

25. EBOLA OUTBREAK
16-07-2018 25Dr Tanveer Rehman PSM JIPMER

26. 16-07-2018 26Dr Tanveer Rehman PSM JIPMER

27. 16-07-2018 27Dr Tanveer Rehman PSM JIPMER

28. RESPONSIBLE AUTHORITIES
National IHR Focal Point
Dr Ritu Singh Chauhan,
National Professional Officer,
IHR WHO Country Office for India,
RK Khanna Tennis Stadium,
Africa Avenue, New Delhi
IHR Contact Point
Country Health Emergency Preparedness & IHR,
WHO SEARO,
Indraprastha Estate,
Ring Road, New Delhi
16-07-2018 28Dr Tanveer Rehman PSM JIPMER

29. PUBLIC HEALTH MEASURES

30. A. Arrival and
Departure
• Traveller’s itinerary
• Non-invasive medical
examination
• Inspection of baggage
• Vaccination
B. Conveyance
• Free of sources of
infection
• Comply with the health
measures
• Disinfect or isolation
C. Ships and aircraft
• Free pratique by radio or
other communication
means
• If affected: no traveller on
board shall leave
3016-07-2018 Dr Tanveer Rehman PSM JIPMER

31. SURVEILLANCE & NOTIFICATION
1. Develop, strengthen and maintain - capacity to detect, assess, notify
and report events
2. Notify National IHR Focal Point - within 24 hours - public health
emergency of international concern
3. Following a notification - continue to communicate to WHO timely,
accurate and sufficiently detailed information
16-07-2018 31Dr Tanveer Rehman PSM JIPMER

32. Core Capacity requirements for Surveillance & Response
A. Local community level
1. Detect events involving disease
above expected levels
2. Report all available essential
information immediately
3. Implement preliminary control
measures immediately
B. Intermediate level
1. Confirm the status of reported
events
2. Assess reported events
immediately
C. National level
1. Assess all reports of urgent
events within 48 hours
2. Notify WHO immediately
through the National IHR
Focal Point
16-07-2018 32Dr Tanveer Rehman PSM JIPMER

33. Core Capacity
requirements for
Designated Airports,
Ports and Ground
Crossings
Contingency
plan
Care for
affected
travellers
Space:
interview
suspect
Assessment,
quarantine of
suspect
travellers
Disinfect -
baggage
Entry/exit
controls for
travellers
Transfer of
travellers
carrying infection
16-07-2018 33Dr Tanveer Rehman PSM JIPMER

34. Response Global Outbreak Alert
and Response Network
SUMMARY
Event
Intelligence
Verification IHR
Official, State
sources
Risk Assessment
IHRWHO HQ, Regional & Country
Offices, Collaborators
and experts
3416-07-2018 Dr Tanveer Rehman PSM JIPMER

35. THANK YOU
16-07-2018 35Dr Tanveer Rehman PSM JIPMER