The international health regulations (IHR) is an agreement among 194 countries, including all WHO member countries ,to work together for healthy security of the world. Under the IHR, all countries need to report all events of international public health impact

1. International health
regulations
DR. NISHANT MISHRA

2. Contents
1. Introduction
2. History
3. IHR mandates
4. Principles of IHR
5. PHEIC
6. Travel Notice

3. Introduction :-
The international health regulations (IHR) is an agreement among 194
countries, including all WHO member countries ,to work together for
healthy security of the world. Under the IHR, all countries need to
report all events of international public health impact.

4. 14th
century
• Quarantine was implemented in Europe to protect
against plague epidemic. So ,ships arriving in Venice
from infected ports was restricted for 40 days.
1851
• International sanitary conference at Paris for
standardization of quarantine against cholera, plague
and yellow fever.
1907
• Office ,International D’ Hygiene Publique (OIHP)
,dissolved in 1946.
1948
• World Health Organization was established.
HISTORY :-

5. 1969
• International health regulations (“ the IHR” or “
regulations” were adopted by world health assembly
.(revised in 1973 and 1981)
1995
• Revision of IHR to address the progress of the
international travel and trade , emergence or re-
emergence of the disease and pubic health risks of
international concern.
2005
• The revised IHR was implemented since 15th june
2007

6. The goal of the IHR is “to prevent, protect against , control and respond to the
international spread of disease while avoiding unnecessary interference with
international traffic and trade”.
The purpose and scope of the IHR (2005):
 To prevent, protect and control the international spread of disease.
 To provide a public health response appropriate to public health risks.
 To avoid interference in international traffic and trade unnecessarily.

7. DETECT ASSESS
RESPOND REPORT
IHR
MANDATES
Make sure
that
surveillance
system detect
potential
harms
Work together
with other
countries to
make decisions
in public health
emergencies.
Respond to public
health events
Report specific
diseases and
PHEIC Respond

8. Principles of international health regulations
The regulations shall be implemented-
 With full respect for dignity , human rights and fundamental freedom of
persons.
 Guided by the charter of united nations and the constitution of the WHO .
 Guided by the goal of their universal application for the protection of all
people of the world from the international spread of disease.
 States have right to legislate and to implement legislation in pursuance of
their health policies.

9. Major changes were seen in IHR (2005) version which led to the broadening of
the scope of these regulations:
a) Not limited to any specific disease or manner of transmission, but covering illness
or medical condition, irrespective of origin or source, that presents or could present
significant harm to humans .
b) State Party obligations to develop certain minimum core public health capacities.
c) Obligations on States Parties to notify WHO of events that may constitute a public
health emergency of international concern according to defined criteria .

10. d) Provisions authorizing WHO to take into consideration unofficial reports of public
health events and to obtain verification from states parties concerning such events .
e) Procedures for the determination by the director-general of a “public health
emergency of international concern” and issuance of corresponding temporary
recommendations, after considering the views of an emergency committee.
f) Protection of the human rights of persons and travelers .
g) The establishment of national IHR focal points and WHO IHR contact points for
urgent communications between states parties and WHO.

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12. National Centre for Disease Control (NCDC), Delhi was designated the NFP for IHR
implementation by Govt. of India in 2007.
The functions of NFP include:
• Coordination and communication with WHO and states/districts
• Designation of nodal officers at state level
• Enhanced disease surveillance through Integrated Disease Surveillance
Programme (IDSP)
• Strengthening laboratory network across the country.
Implementation of IHR in India

13. • Stakeholder meetings to review the progress of IHR implementation at all levels
• Interaction with nodal agencies for a coordinated response to public health
event(s).
• Core capacity building in IHR through state surveillance officers
• Increased awareness about IHR among health administrators and professionals
• Surveillance & response capacity (rapid response teams)
• Entry screening at designated airports followed by community surveillance through
IDSP.

14.  NFP-IHR India has been instrumental in regular day to day surveillance,
coordination with various stakeholders of IHR and regular strengthening of
various core capacities for effective health security during emergencies. It
requires multisectoral co-ordination involving various nodal ministries /
departments.

16. CORE CAPACITY REQUIREMENTS FOR SURVEILLANCEAND
RESPONSE
1. States Parties shall utilize existing national structures and resources to meet their
core capacity requirements under these Regulations, including their surveillance,
reporting, notification, verification, response and collaboration activities .

17. 2. At the local community level and/or primary public health response level
The capacities :
a. To detect events involving disease or death above expected levels for the time
and place in all areas within the territory of the state party.
b. To report all available essential information immediately to the appropriate level
of healthcare response. Essential information includes : clinical descriptions,
laboratory results, sources and type of risk, numbers of human cases and deaths,
conditions affecting the spread of the disease and the health measures employed.
c. To implement preliminary control measures immediately.

18. 3. At the intermediate public health response levels
The capacities:
a. To confirm the status of reported events and to support or implement additional
Control measures.
b. To assess reported events immediately and, if found urgent, to report all essential
Information to the national level. The criteria for urgent events include serious public
health impact and/or unusual or unexpected nature with high potential for spread.

19. 4. At the national level:
Assessment and notification.
The capacities:
a. To assess all reports of urgent events within 48 hours
b. To notify WHO immediately through the national IHR focal point when the assessment
indicates the event is notifiable.
Public health response.
The capacities:
a. To determine rapidly the control measures required to prevent domestic and international
spread.

20. b. To provide support through specialized staff, laboratory analysis of samples
(domestically or through collaborating centres) and logistical assistance
(e.g.Equipment, supplies and transport)
c. To provide on-site assistance as required to supplement local investigations.
d. To provide a direct operational link with senior health and other officials to approve
Rapidly and implement containment and control measures.
e. To provide direct link with other relevant government ministries.

21. f. To provide, by the most efficient means of communication available, links with
hospitals, clinics, airports, ports, ground crossings, laboratories and other key operational
areas for the dissemination of information and recommendations received from WHO
regarding events in the state party’s own territory and in the territories of other states
parties;
g. To establish, operate and maintain a national public health emergency response plan,
including the creation of multidisciplinary/ multisectoral teams to respond to events that
may constitute a public health emergency of international concern.
h. To provide the precedings on a 24-hour basis.

22. PUBLIC HEALTH EMERGENCIES OF INTERNATIONAL
CONCERN
An extraordinary public health event :-
• A public health risk to other countries through the international spread of disease.
• Potentially requires a coordinated international reponse.
• Determined by WHO after consultation with emergency committee.
 The revised regulations introduced the concept of a “public health
emergency of international concern (PHEIC).”

23. Notification
Each state party shall notify WHO , within 24 hours about assessment of public
health information of all events accurately and in detail which constitutes a PHEIC.
Four decision criteria to assess public health events:
1) Is the public health impact of this event potentially serious ?
2) Is this event unusual or unexpected ?
3) Is there the potential for international spread?
4) Is there the potential for travel and trade restrictions?
If 2 of the 4 criteria are met , countries are required to notify WHO within 24 hours.

24. DECISION INSTRUMENT FOR THE
ASSESSMENT AND NOTIFICATION OF
EVENTS THAT MAY CONSTITUTE A PUBLIC
HEALTH EMERGENCY OF INTERNATIONAL
CONCERN
The decision instrument is mainly based on
four questions which are as follows:
• Is the public health impact of the event
serious?
• Is the event unusual or unexpected?
• Is there a significant risk of international
spread?
• Is there a risk for international trade
restrictions?
A yes to any of the two questions leads to the
classification of the event into public health
emergency of international concern.

25. Consultation
In need , countries can request WHO assistance to assess any epidemiological
evidence obtained by that country.
Verification
WHO verifies reports from state parties. Each state party shall verify and provide
information , requested by WHO within 24 hours . WHO will assess the potential for
international spread and possible effect on international traffic and the adequacy of
control measures.

26. Determination of a public health emergency of international concern
The Director-General shall determine, on the basis of the information received, in
particular from the State Party within whose territory an event is occurring, whether an
event constitutes a public health emergency of international concern in accordance with the
criteria and the procedure set out in the regulations.

27. In determining whether an event constitutes a public health emergency of international
concern, the Director-General shall consider:
(a) information provided by the State Party.
(b) the decision instrument contained in Annex 2.
(c) the advice of the Emergency Committee.
(d) scientific principles as well as the available scientific evidence and other relevant
Information.
(e) an assessment of the risk to human health, of the risk of international spread of
disease and of the risk of interference with international traffic.

28. RECOMMENDATIONS
Temporary recommendations
1. If it has been determined in accordance with Article 12 that a public health
emergency of international concern is occurring, the Director-General shall issue
temporary recommendations in accordance with the procedure set out in Article 49.
Such temporary recommendations may be modified or extended as appropriate,
including -after it has been determined that a public health emergency of
international concern has ended, at which time other temporary recommendations
may be issued as necessary for the purpose of preventing or promptly detecting its
recurrence.

29. 2. Temporary recommendations may include health measures to be implemented by the
State Party experiencing the public health emergency of international concern, or by
other States Parties, regarding persons, baggage, cargo, containers, conveyances, goods
and/or postal parcels to prevent or reduce the international spread of disease and avoid
unnecessary interference with international traffic.
3. Temporary recommendations may be terminated in accordance with the procedure
set out in Article 49 at any time and shall automatically expire three months after their
issuance. They may be modified or extended for additional periods of up to three
months.

30. Criteria for recommendations
When issuing, modifying or terminating temporary or standing recommendations,
the Director General shall consider:
(a) the views of the States Parties directly concerned;
(b) the advice of the Emergency Committee or the Review Committee, as the case
may be;
(c) scientific principles as well as available scientific evidence and information;

31. d) health measures that, on the basis of a risk assessment appropriate to the
circumstances,are not more restrictive of international traffic and trade and are not
more intrusive to persons than reasonably available alternatives that would achieve the
appropriate level of health protection;
(e) relevant international standards and instruments;
(f) activities undertaken by other relevant intergovernmental organizations and
international bodies; and
(g) other appropriate and specific information relevant to the event.

32. Emergency committee
1. The Director-General shall establish an Emergency Committee that at the request of
the Director-General shall provide its views on:
(a) whether an event constitutes a public health emergency of international concern;
(b) the termination of a public health emergency of international concern; and
(c) the proposed issuance, modification, extension or termination of temporary
recommendations.
2. The Emergency Committee shall be composed of experts selected by the Director-
General from the IHR Expert Roster .

33. COVID-19 as a Public Health Emergency of International
Concern (PHEIC) under the IHR
On 31 December 2019, China
was the first state to report to the
WHO that a pneumonia of
unknown cause was detected in
Wuhan City, Hubei Province of
China.
On 13 January 2020, Thailand reported a
similar case. On 16 January 2020, Japan
informed the WHO of a confirmed case of
the novel coronavirus, referred to as 2019-
nCoV. On 20 January 2020, the Republic of
Korea
The WHO Director-General first convened this Emergency Committee for COVID-19 on
22 January and again on 23 January 2020. During these meetings, the four states (China,
Thailand, Japan and the Republic of Korea) briefed the Emergency Committee in line with
Article 49 of the IHR

34. The Emergency Committee reconvened within a week, on 30 January 2020. By then 18 states had
reported COVID-19 cases to the WHO. The Emergency Committee agreed that the outbreak now met the
criteria for a PHEIC and proposed advice that could be issued as “temporary recommendations”.
The WHO made the assessment on 11 March 2020 that COVID-19 can be
characterised as a pandemic
In line with Article 15(3), these recommendations were reviewed three months later, on 30 April 2020.
The ninth meeting of the Emergency Committee convened by the WHO Director-General under the
International Health Regulations (2005) (IHR) regarding the coronavirus disease (COVID-19)
pandemic took place on 22 October 2021

35. TRAVEL NOTICE
CENTRES OF DISEASE CONTROL has issued different types of notices for international travelers
on 5th April 2013.they describe both levels of risk for traveler and recommended preventive measures
to take at each level.
Notice level Traveler action Risk to traveler
Level 1:-Watch Usual precautions Usual baseline risk or slightly above
baseline risk for destination and limited
impact on traveler.
Level 2:- Alert Enhanced precautions Increased risk in defined settings or
associated with specific risk factors ,
certain high risk populations may wish to
delay travel to these destinations.
Level 3 :-Warning Avoid all non-essential
travel to this destinations
High risk to travelers.

36. Reference :-
1) International Health Regulations (2005) Third Edition by WHO.
2) IAPSM’s textbook of community medicine.
3) Textbook of community medicine by Sunder Lal , Adarsh , Pankaj .
4) Tot manual IDSP –NCDC, revised 2020.