International Health Regulation-IHR.pdf

Seminar on International Health Regulations
7/32/2022
Presentation on International Health
Regulations
Presented By:
Govinda Poudel (505)
Aakriti Pandey(501)
MPH 5Th Batch
School of Public Health
Patan Academy of Health Sciences
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Outline of Seminar:
❖ Introduction to International Health Regulation (IHR)
❖ Purpose and Scope
❖ Need for IHR
❖ History of IHR
❖ Comparison between IHR 1969 and 2005
❖ Public Health Emergency of International Concern (PHEIC)
❖ Focal Point for IHR
❖ Point of Entry (POE)
❖ COVID-19 and IHR
❖ Benefit of IHR Implementation
❖ Challenges of IHR implementation
❖ Conclusion
❖ Way Forward
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International Health Regulations (IHR)-Introduction
❏ The International Health Regulations (IHR) are an international
legal instrument that is binding on 196 countries across the globe,
including all member states of the World Health Organization
(WHO) to work together for global health security.
Nepal is one of the member state.
❏ It is a legally- binding agreement.
❏ It significantly contributes to the global public health security.
❏ It improves the capacity of all countries to detect, assess, notify
and response to all public health threats.
Source: IHR 2005
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❏ While disease outbreaks and other acute public health risks are often
unpredictable and require a range of responses, the International
Health Regulations (IHR) provide a complete legal framework that
defines countries’ rights and obligations in handling public health
events and emergencies that have the potential to cross borders.
❏ Providing a new framework for the coordination of the management
of events that may constitute a public health emergency of
international concern.
❏ help prevent the spread of disease across borders.
Contd…..
Source: IHR 2005
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Purpose and scope of IHR
❏ The purpose and scope of IHR is to prevent, protect against, control
and provide a public health response to the international spread of
disease in ways that are commensurate with and restricted to public
health risks, and which avoid unnecessary interference with
international traffic and trade.
❏ Because the IHR are not limited to specific diseases but apply to
new and ever- changing public health risks, they are intended to
have long-lasting relevance in the international response to the
emergence and spread of disease.
❏ The IHR also provide the legal basis for important health documents
applicable to international travel and transport and sanitary
protections for the users of international airports, ports, and ground
crossings.
Source: IHR 2005
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Need for IHR
“A threat anywhere is
a threat everywhere”
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Need for IHR:
❏ According to statistics of the World Tourism Organization,
international tourist arrivals in the year 2005 exceeded 800 million.
❏ International travel can pose various risks to health as travellers may
encounter sudden and significant changes in
➔ altitude
➔ Humidity
➔ microbes and
➔ temperature
❏ Additional health risks arise when:
➔ accommodation is of poor quality
➔ hygiene and sanitation are inadequate
➔ medical services are not well developed
➔ clean water is unavailable
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Need for IHR
❏ It is estimated that 2.1 billion airline passengers travelled in
2004.
❏ The infectious diseases are now spreading faster by emerging and
re-emerging more quickly, than ever before.
❏ There are now more than 40 diseases that were unknown a
generation ago.
❏ During the last five years, WHO has verified more than 1100
epidemic events worldwide.
❏ Consequently the need for international co-operation in order to
safeguard global health has become increasingly important.
❏ About half of the people on Earth live in urban areas ( Wilcox
et al.;2008)
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Need for IHR
❏ Most of the population and projected growth are in low- latitude
urban and many surrounded by vast slum areas that lack clean
water and sanitary facilities.
❏ Animals such as dogs,chickens,cows,rats and many others live in
and near human living quarters,which have been assembled from
whatever materials can be found.
❏ Animals have been the origin of many of the identified emerging
infectious diseases.
❏ HIV/AIDS
❏ H5N1 avian influenza
❏ Severe acute respiratory syndrome (SARS)
❏ Swine -origin H1N1 influenza A
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History of IHR
WHO issued
first set of
legally
binding
international
sanitary
regulation.
1951
WHO adopted
international
sanitary
regulation and
renamed as
international
health
regulation.
1969
Minor
modifications
in IHR,
amended
world wide.
1973,1981
World
health
assembly
adopted
revised IHR
2005
1830,1847
Cholera
epidemics in
Europe were
catalyst for
intense infectious
disease
diplomacy and
multilateral
cooperation.
Came in
to force
revised
IHR.
2007
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History of IHR
❏ The cholera epidemics that overran Europe between 1830 and
1847 were catalysts for intensive infectious disease diplomacy and
multilateral corporation in public health.
❏ This led to the first international sanitary conference in Paris in
1851.
❏ In 1948, the WHO constitution entered into the force.
❏ In 1951 WHO member states adopted the International Sanitary
Regulations.
❏ Replaced and renamed the International Health regulations in 1969,
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History of IHR
❏ The 1969 IHR were primarily intended to monitor and control six
infectious diseases:
❏ Cholera
❏ Plague
❏ Yellow fever
❏ Smallpox
❏ Relapsing fever and typhus
❏ The Regulations were amended in 1973, and then in 1981, to
focus on three diseases: cholera, yellow fever and plague. With the
increase in international travel and trade, and the emergence, re-
emergence and international spread of disease and other threats, the
World Health Assembly called for a substantial revision in 1995.
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History of IHR
❏ In May 2001, the World Health Assembly adopted resolution
WHA 54.14.
❏ Global Health Security: epidemic alert and response, in which
WHO was called upon to support its member states in strengthening
their capacity to detect and respond rapidly to communicable disease
threats and emergencies.
❏ The World Health Assembly adopted the IHR 2005 on May 23
by way of resolution WHA 58.3.
❏ The IHR 2005 entered into force on June 15 2007.
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WHY A NEW IHR?
● IHR (1969)- smallpox, yellow fever, cholera, and plague.
● Eradication of smallpox- requirement for international notification
was reduced to the remaining three diseases.
● Increasing international travel and trade and globalization.
● Early warning is essential and depends on collaboration and
guarantees to notifying member state against misuse of
information.
● Measures should be coordinated internationally - WHO may take
this role.
● Recent experiences -Anthrax attacks (2001) ; SARS (2003) and
Chernobyl disaster
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Why revised International Health
Regulations?
● In today’s world, diseases travel fast and no
single country can protect itself on its own.
● Acknowledging this, the 194 WHO Member
States unanimously adopted a new version
of the International Health Regulations (IHR).
● The revised IHR enter into force in June 2007.
It will now be up to the world to translate the
new code of the Regulations into the reality of
greater international public health security.
Dr Margaret Chan, WHO Director-General-2006
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Our world is changing as never before
Populations grow, age, and move
Diseases travel fast
Microbes adapt
Chemical, radiation, food risks
increase
Health security is at
stake
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cont…
18
● The unique conditions of the 21st century have amplified
the invasive and disruptive power of epidemics and other
public health emergencies.
● The dynamics of disease spread worldwide have changed
greatly.
● We living in a global “village” where diseases can travel at
the speed of jetliners on the wings of international travel and
trade, and can jump from one continent to another in a
matter of hours.
● This has made all nations vulnerable – not just to invasion
of their territories by pathogens, but also to the economic,
political and social shocks of public health
events elsewhere.

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cont…
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● They have the power to disrupt the entire global system in
ways that cannot be controlled by one nation acting alone.
● SARS was the first disease of the 21st century to expose the
world’s vulnerabilities. It will not be the last.
● hared vulnerabilities imply shared responsibilities and create
a need for strong collective action to protect lives and
livelihoods from disease spread.
To address these public health risks, the world's
countries, through WHO, initiated an intensive process to
revise the IHR, eventually adopted by the World Health
Assembly in May 2005.

30 years of international health insecurity
● HIV/AIDS
● CHERNOBYL
● PLAGUE
● EBOLA
● NIPAH
● YELLOW FEVER
● …….
● ANTHRAX
● SARS
● MENINGITIS
● CHOLERA
● CHEMICAL
● AVIAN INFLUENZA
● XDR-TB
● ...
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Chernobyl Disaster, 1986
21
The Chernobyl disaster was a nuclear accident that occurred on
26 April 1986 in the Chernobyl Nuclear Power Plant, near the city of
Pripyat in the north of the Ukrainian SSR in the Soviet Union.
The accident results of a flamed reactor design that was operated
with inadequately trained persons. Fire released at 5% of
radioactive materials in many parts.
❖ 2 died on that night and 28 within 1 month later due to acute
radiation syndrome.
❖ 1000 people with highest radiation
❖ 600000 people contaminated.
❖ >5 million exposed
❖ >400 thyroid cancer by 2002.

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H5N1: Avian influenza, a pandemic threat
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H5N1: Avian influenza, a pandemic threat
● In 1997 a high-pathogenicity H5N1 avian influenza virus caused
serious disease in both man and poultry in Hong Kong, China.
● Eighteen human cases of disease were recorded, six of which were
fatal. This unique virus was eliminated through total depopulation
of all poultry markets and chicken farms in December 1997. Other
outbreaks of high-pathogenicity avian influenza (HPAI) caused by
H5N1 viruses occurred in poultry in 2001 and 2002.
● No new cases of infection or disease in man due to these or other
H5N1 viruses have been reported. Prior to the human outbreak, the
H5N1 virus was found to cause extensive death in chickens in three
farms in Hong Kong.
● The significance of this outbreak raised worldwide concern on the
possibilities that such an influenza virus may become the next
influenza pandemic strain.
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0
20000
40000
60000
80000
100000
120000
3/16
3/19
3/22
3/25
3/28
3/31
4/3
4/6
4/9
4/12
4/15
4/18
4/21
4/24
4/27
4/30
5/3
5/6
5/9
5/12
5/15
5/18
5/21
5/24
5/27
5/30
6/2
6/5
6/8
6/11
6/14
6/17
Number
of
passenger
WHO travel recommendations removed
36 116
WHO travel recommendations
2 April
14 670
13 May
102 165
25 May
27 March 23 June
Screening of exit passengers
SARS: an unknown coronavirus
• 8098 cases
• 774 deaths
• 26 countries affected
• trends in airline passenger
movement drop
• economic loss: US$ 60 billion
2003: SARS changes the world
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The 58th World Health Assembly adopts the revised
International Health Regulations, “IHR”
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Comparison between IHR 1969 and 2005
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IHR 1969 VERSUS IHR 2005
From three diseases to all public health threats
From preset measures to tailored response
From control of borders to also include containment at source
From reactive to proactive
PARADIGM SHIFT
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All public health threats
❏ The revised IHR recognize that
international disease threats have
increased
❏ Scope has been expanded from cholera,
plague and yellow fever to all public
health emergencies of international
concern
❏ They include those caused by infectious
diseases, chemical agents, radioactive
materials and contaminated food
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Containment at source
❏ Rapid response at the source is:
❏ the most effective way to secure
maximum protection against
international spread of diseases
❏ key to limiting unnecessary health-
based restrictions on trade and travel
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KEY FEATURES OF IHR 1969
❏ Notification to WHO of cases of cholera,
plague,smallpox and yellow fever
❏ Certain health related rules for international
travel and trade
❏ Prescription of maximum border measures
against cholera, plague and yellow fever
(deratting, disinsection…)
❏ Health documents for people, aircraft and ships.
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LIMITATIONS OF IHR 1969
❏Concerns only cholera, plague and yellow fever
❏The old paradigm of case-based surveillance
❏Difficult to revise disease list
❏Dependent on official notification from the member state
❏No incentives to notification
❏Very few notifications
❏Notifications seemed as a very serious act by states
❏No formal mechanisms for collaboration between member state
and WHO
❏No dynamic in the response for stopping international spread
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What is IHR 2005?
❏ The International Health Regulations are a formal code of conduct
for public health emergencies of international concern.
❏ They're a matter of responsible citizenship and collective
protection.
❏ They involve all 194 World Health Organization member
countries.
❏ They focus on serious public health threats with potential to spread
beyond a country's border to other parts of the world.
❏ Such events are defined as public health emergencies of
international concern, or PHEIC.
❏ The revised International Health Regulations outline the
assessment, the management and the information sharing for
PHEICs.
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● A legal tool: describes procedures, rights
and legal obligations for 195 States Parties
and WHO.
● Legal framework requested, developed
and negotiated by WHO Member States
based on dialogue, transparency and trust.
● State’s commitment - beyond the health
sector.
● 10 Parts, 66 Articles, and 9 Annexes
International public health security is the goal
➔ Ensuring maximum public health security while minimizing interference
with international transport and trade.
➔ Legally binding for WHO and the world’s countries that have agreed to play
by the same rules to secure international health.
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Objectives of IHR 2005
❏ To ensure the appropriate application of routine preventive
measures (e.g. at ports and airports) and the use by all countries of
internationally approved documents (e.g. Vaccination certificate).
❏ To ensure the notification to WHO of all events that may constitute
a public health emergency of international concern.
❏ The implementation of any temporary recommendations should the
WHO Director General have determined that such an emergency is
occurring.
❏ The revised IHR also focus on the provision of support for
affected states and the avoidance of stigma and unnecessary
negative impact on international travel and trade.
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Obligation of the Member States Under IHR 2005
❏ Designating a national IHR focal point
❏ Strengthening core capacity to detect, report and respond rapidly to
public health events
❏ Assessing events that may constitute a PHEIC within 48 hours and
notifying WHO within 24 hours of assessment
❏ Providing routine inspection and control activities at international
airports, ports and some ground crossings
❏ Examining national laws, revising health documents/forms and
certificates, and building a legal and administrative framework in
line with the IHR requirements
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Parts in the IHR (2005)
Part I. Definitions, purpose and scope, principles and responsible
authorities.
Part II. Information and public health response
Part III. Recommendations
Part IV. Points of entry
Part V. Public health measures
Part VI. Health documents
Part VII. Charges
Part VIII. General provisions
Part IX. The IHR Roster of Experts, the Emergency Committee and
the Review Committee
Part X. Final provisions
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Some important definitions under IHR 2005 (Article I)
“affected” means persons, baggage, cargo, containers, goods, postal
parcels or human remains that are infected or contaminated, or carry
sources of infection or contamination, so as to constitute a public
health risk;
“affected area” means a geographical location specifically for
which health measures have been recommended by WHO under
these Regulations;
“decontamination” means a procedure whereby health measures are
taken to eliminate an infectious or toxic agent or matter on a human
or animal body surface, in or on a product prepared for consumption
or on other inanimate objects that may constitute a public health risk;
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“deratting” means the procedure whereby health measures are taken
to control or kill rodent vectors of human disease present in baggage,
cargo, containers, facilities, goods and postal parcels at the point of
entry;
“departure” means, for persons, baggage, cargo or goods, the act of
leaving a territory;
“disinfection” means the procedure whereby health measures are
taken to control or kill infectious agents on a human or animal body
surface or in or on baggage, cargo, containers, goods and postal
parcels by direct exposure to chemical or physical agents;
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“disinsection” means the procedure whereby health measures are
taken to control or kill the insect vectors of human diseases present in
baggage, cargo, containers, goods and postal parcels;
“free pratique” means permission for a ship to enter a port, embark
or disembark, discharge or load cargo or stores; permission for an
aircraft, after landing, discharge or load cargo or stores; and
permission for a ground transport vehicle, upon arrival, to embark or
disembark, discharge or load cargo or stores;
“health measure” means procedures applied to prevent the spread of
disease or contamination; a health measure does not include law
enforcement or security measures;
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“inspection” means the examination, by the competent authority or
under its supervision, of areas, baggage, containers,facilities, goods
or postal parcels, including relevant data and documentation, to
determine if a public health risk exists;
“international traffic” means the movement of persons, baggage,
cargo, containers, goods or postal parcels across an international
border, including international trade;
“point of entry” means a passage for international entry or exit of
travellers, baggage, cargo, containers, conveyances, goods and
postal parcels as well as agencies and areas providing services to
them on entry or exit;
“public health observation” means the monitoring of the health
status of a traveller over time for the purpose of determining the risk
of disease transmission;
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“public health risk” means a likelihood of an event that may affect
adversely the health of human populations, with an emphasis on one
which may spread internationally or may present a serious and direct
danger;
“surveillance” means the systematic ongoing collection, collation
and analysis of data for public health purposes and the timely
dissemination of public health information for assessment and public
health response as necessary;
“verification” means the provision of information by a State Party to
WHO confirming the status of an event within the territory or
territories of that State Party;
“WHO IHR Contact Point” means the unit within WHO which
shall be accessible at all times for communications with the National
IHR Focal Point.
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“National IHR Focal Point” means the national centre, designated
by each State Party, which shall be accessible at all times for
communications with WHO IHR Contact Points under Regulations.
“public health emergency of international concern” A PHEIC is
defined as an: extraordinary event that constitutes a public health risk
to other states through international spread and requires a coordinated
international response:
➢ serious, sudden, unusual or unexpected;
➢ carries implications for public health beyond the
affected State's national border; and
➢ may require immediate international action.
“isolation” means separation of ill or contaminated persons or
affected baggage, containers, conveyances, goods or postal parcels
from others in such a manner as to prevent the spread of infection or
contamination.
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“quarantine” means the restriction of activities and/or separation
from others of suspect persons who are not ill or of suspect baggage,
containers, conveyances or goods in such a manner as to prevent the
possible spread of infection or contamination;
“temporary recommendation” means non-binding advice issued by
WHO pursuant to Article 15 for application on a time-limited, risk-
specific basis, in response to a public health emergency of
international concern, so as to prevent or reduce the international
spread of disease and minimize interference with international traffic.
“standing recommendation” means non-binding advice issued by
WHO for specific ongoing public health risks pursuant to Article 16
regarding appropriate health measures for routine or periodic
application needed to prevent or reduce the international spread of
disease and minimize interference with international traffic.
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Article-2: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.
Article-3: Relates to Principles of the IHR
❖ The implementation of these Regulations shall be with full
respect for the dignity, human rights and fundamental freedoms
of persons.
❖ Guided by the Charter of the UN and the Constitution of the
World Health Organization.
❖ 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, in accordance with the Charter of the UN and the
principles of international law, the sovereign right to legislate and
to implement legislation in pursuance of their health policies
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Article-4:Relates to responsible authorities:
1. All State Parties should establish a National IHR Focal Point
and responsible authorities for the implementation of health
measures under these Regulations.
1. National IHR Focal Points to be accessible all times for
communications with the WHO IHR Contact Points.
1. WHO should generate IHR Contact Points at headquarters or at
the regional level and accessible at all times with National IHR
Focal Points and send urgent communication on implementation
of the Regulations under Articles 6 to 12 to National IHR Focal
Point.
1. States should provide WHO the details of their National IHR
Focal Point and WHO also provide with details of WHO IHR
Contact Points and it should be updated continuously and
annually.
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Article-5:Surveillance-
develop, strengthen and maintain strong surveillance system not later
than 5 years of IHR Implementation.
Article-6:Notification
shall notify WHO by way of the National IHR Focal Point within 24
hours of assessment of public health information, of all events which
may constitute a public health emergency of international concern within
territory and health measures implemented in response.
Article-7 :Information-sharing during unexpected or unusual public
health events
If a State Party has evidence of an unexpected or unusual public health
event within its territory, irrespective of origin or source, which may
constitute a public health emergency of international concern, it shall
provide to WHO all relevant public health information. In such a case,
the provisions of Article 6 shall apply in full.
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Article-8:Consultation:
The State Party in whose territory the event has occurred may
request WHO assistance to assess any epidemiological evidence
obtained by that State Party.
Article-9: Other reports
● States Parties shall, as far as practicable, inform WHO within 24
hours of receipt of evidence of a public health risk identified
outside their territory that may cause international disease spread,
as manifested by exported or imported:
(a) human cases;
b) vectors which carry infection or contamination; or
(c) goods that are contaminated.
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Article-10 :Verification
(a) within 24 hours, an initial reply to, or acknowledgement of, the
request from WHO;
(b) within 24 hours, available public health information on the status
of events referred to in WHO’s request; and
(c) information to WHO in the context of an assessment under Article
6, including relevant information as described in that Article.
Article-11: Provision of information by WHO
WHO shall send to all States the information as soon as possible that
it has received under Articles 5 to 10 necessary to enable States to
respond to a public health risk.
WHO shall consult with the State Party in whose territory the event is
occurring as to its intent to make information available under this
Article.
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Article-12:Determination of a public health emergency of
international concern on the basis of:
1. information provided by the State Party;
2. the decision instrument contained in Annex 2;
3. the advice of the Emergency Committee;
4. scientific principles and available scientific evidence and information
5. 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.
Article-13: Public health response
Article-14: Cooperation of WHO with intergovernmental
organizations and international bodies.
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Article:15-18 :Recommendations
❖ Temporary recommendations
❖ Standing recommendations
❖ Criteria for recommendations
❖ Recommendations with respect to persons, baggage,
cargo, containers, conveyances, goods and postal parcels
Article:19-22: Point of Entry:
❖ General obligations
❖ Airports and ports
❖ Ground crossings
❖ Role of competent authorities
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Article:23-34: Public Health Measures:
❖ Health measures on arrival and departure
❖ Conveyance operators
❖ Ships and aircraft in transit
❖ Civilian lorries, trains and coaches in transit
❖ Affected conveyances
❖ Ships and aircraft at points of entry
❖ Civilian lorries, trains and coaches at points of entry
❖ Travellers under public health observation
❖ Health measures relating to entry of travellers
❖ Treatment of travellers
❖ Goods in transit
❖ Container and container loading areas
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Article:35-39:Health documents:
❖ General rule (Health Documents)
❖ Certificates of vaccination or other prophylaxis
❖ Maritime Declaration of Health (MDH)
❖ Health Part of the Aircraft General Declaration
❖ Ship sanitation certificates
Article:40-41:Charges:
❖ Charges for health measures regarding travellers
❖ Charges for baggage, cargo, containers, conveyances,
goods or postal parcels
Article:42-46: General provisions:
❖ Implementation of health measures
❖ Additional health measures
❖ Collaboration and assistance
❖ Treatment of personal data
❖ Transport and handling of biological substances, reagents
and materials for diagnostic purposes
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Maritime Declaration of Health (MDH) (Article-37)
★ The MDH according to IHR (2005) is a document containing data
related to the state of health on board a ship during passage and on
arrival at port.
★ It is a useful tool for early detection of public health risks in ships.
★ According to Article 37 ‘the master of a ship, before arrival at its
first port of call in the territory of a State Party, shall ascertain the
state of health on board.
★ The state party may decide whether it requires all arriving ships to
submit a MDH, which should conform to the model provided in
Annex 8 of the IHR.
★ The International Maritime Organization (IMO) is a specialised
agency of the UN that is responsible for measures to improve the
safety and security of international shipping, and to prevent
pollution from ships.
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Collaboration and assistance (Article-44)
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Article:47-53:The IHR Roster of Experts, The Emergency
Committee and The Review Committee:
❖ Composition of IHR Roster of Experts
❖ Terms of reference and composition of Emergency
Committee
❖ Procedure in conducting PHEIC
❖ Terms of reference and composition of Review Committee
❖ Conduct of business (WHA)
❖ Procedures for standing recommendations
Article:54-66: Final Provision:
❖ Reporting and review ( To WHA by State and DG)
❖ Amendments (by WHA)
❖ Settlement of disputes
❖ Relationship with other international agreements
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cont…..
❖ International sanitary agreements and regulations
❖ Entry into force; period for rejection or reservation
❖ New Member States of WHO (Provision)
❖ Rejection
❖ Reservations
❖ Withdrawal of rejection and reservation
❖ States not Members of WHO
❖ Notifications by the Director-General
❖ Authentic texts (language of article)
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Annexes in the IHR:
The IHR (2005) includes provisions for the use of various health
documents that can be presented, if requested, to health authorities.
Annex-1:
A. Core capacity requirements for surveillance and response
B. Core capacity requirements for designated airports, ports and
ground crossings.
Annex-2:
A. Decision instrument for the assessment and notification of events
that may constitute a public health emergency of international
concern
B. Examples for the application of the decision instrument for the
assessment and notification of events that may constitute a public
health emergency of international concern
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Annex-3:Ship Sanitation Control Certificate
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Annex-4:Technical requirements pertaining to conveyances and
conveyance operators
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Annex-5: Specific measures for vector-borne diseases
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ANNEX 6:VACCINATION, PROPHYLAXIS AND RELATED CERTIFICATES
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Annex-7-Requirements concerning vaccination or prophylaxis for specific
diseases
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Annex-8: Model of Maritime Declaration of Health
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Annex-9:Health Part of the Aircraft General Declaration
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Public Health Emergency of International Concern
Defined as “an extraordinary event which is determined to constitute a
public health risk to other states through the international spread of
disease and to potentially require a coordinated international response.
These events of potential international concern, which require states
parties to notify WHO, can extend beyond communicable diseases and
arse from any origin or source.
Example:
Recently on July 23, the WHO Director-General declared the escalating global
monkeypox outbreak a Public Health Emergency of International Concern
(PHEIC). Currently, the vast majority of reported cases are in the WHO
European Region. WHO/Europe remains committed to partnering with
countries and communities to address the outbreak with the required urgency.
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PHEIC
This implies a situation that is:
❖ serious, sudden, unusual or unexpected;
❖ carries implications for public health beyond the affected State's
national border; and
❖ may require immediate international action.
Since 2007, the WHO Director-General has declared public health
emergencies of international concern in response to the following:
● 2009 H1N1 swine flu pandemic
● 2014 Setbacks in global polio eradication efforts
● 2013–2016 Western African Ebola virus epidemic
● 2016 Zika virus outbreak
● 2018–19 Kivu Ebola epidemic
● 2019–21 COVID-19 pandemic
● 2022 Monkeypox outbreak
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DECISION INSTRUMENT (ANNEX 2) OF IHR (2005)
FOR ASSESSMENT AND NOTIFICATION
4 diseases that shall be notified polio
(wild-type polio virus), smallpox, human
influenza new subtype, SARS.
Disease that shall always lead to utilization of
the algorithm: cholera, pneumonic plague,
yellow fever, VHF (Ebola, Lassa, Marburg),
others….
Q1: public health impact serious?
Q2: unusual or unexpected?
Q3: risk of international spread?
Q4: risk of travel/trade restriction?
Insufficient information: reassess
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Events detected by national surveillance system or reported by
media or any non-governmental organization
UNUSUAL DISEASES
⮚Smallpox
⮚Human influenzae
(new subtype)
⮚Wild poliovirus
⮚Severe acute
respiratory syndrome
⮚KNOWN EPIDEMIC
PRONE DISEASES
⮚Cholera
⮚Pneumonic plague
⮚Viral haemorrhagic
fevers
⮚Yellow fever
⮚West nile fever
⮚Other locally or
regionally important
diseases
Any event of
potential
international
public health
concern
▪ Is the public health impact of the event serious?
▪ Is the event unusual or unexpected?
▪ Is there significant risk of international spread?
▪ Is there significant risk of travel or trade restriction?
National IHR focal point to notify WHO
If yes to any two of these questions
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If 2 of the 4 criteria are met, countries are required to notify WHO
within 24 hours.
4 decision criteria are used to assess public health events:
❏ Is the public health impact of this event potentially serious?
❏ Is this event unusual or unexpected?
❏ Is there the potential for international spread?
❏ Is there the potential for travel and trade restrictions?
4 diseases always need to be reported to WHO:
❏ Severe acute respiratory syndrome or SARS
❏ Smallpox
❏ New influenza viruses
❏ Wild-type polio
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Public health emergency of international concern (cont.)
❑ The Director-General of WHO declares if the event is a public
health emergency of international concern from the decision made
by the International Health Regulation Emergency Committee and
circulates the suggestion and recommendation to the WHO and state
parties.
❑ The role of countries is to assess the magnitude and potential risk
involved with an event, and WHO’s role is to make the decision.
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❑ With this design, WHO, as our global public health authority, can
quickly assess the global risk of an event and, if needed, convene
countries to mount a coordinated international response.
❑ Countries don’t need to know what the cause or the source of an
outbreak is to report it to WHO.
❑ The focus is on early detection and reporting to allow for a public
health response before international spread occurs, or at least
minimize the global impact of an outbreak.
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❑ An example of SARS:
▪ The outbreak of SARS started in China in 2002.
▪ Early on, we didn’t know that the illness was caused by a
coronavirus or that it had likely jumped from animals to human.
▪ The event met 2 of assessment criteria of a public health
emergency of international concern:
• Serious impact of public health: the disease could kill people,
but we didn’t know what it was, how it was transmitted, how
we could prevent or treat it, and who could get sick from it.
• Potential for international spread: we knew that the disease
affected travelers, who could ‘export’ the disease to other
countries.
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❑ An example of SARS (cont.):
▪ This event would have been a prime event to report to WHO under
the IHR and to benefit from a coordinated international response.
▪ If we had had the current IHR already in place during the SARS
outbreak, it is possible that WHO would have learned sooner about
the event.
• This could have enabled scientists to potentially identify the
cause of this illness sooner.
• Some of the significant economic impact on China because of
travel warnings by many countries against travel to China
might have been prevented through modified global
recommendations.
▪ It is because of SARS that the global public health community got
together to revise an older set of the international health
regulations and adopt the current set.
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DISEASES REPORTABLE UNDER IHR 2005
● New diseases are emerging at the historically unprecedented rate of
one per year.
● The infectious diseases reportable under the IHR (2005) include:
UNUSUAL
DISEASES
⮚Smallpox
⮚Human
influenzae (new
subtype)
⮚Wild poliovirus
⮚Severe acute
respiratory
syndrome
KNOWN EPIDEMIC
PRONE DISEASES
⮚Cholera
⮚Pneumonic plague
⮚Viral haemorrhagic
fevers
⮚Yellow fever
⮚West nile fever
OTHER
LOCALLY OR
REGIONALLY
IMPORTANT
DISEASES
⮚Dengue fever
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❏ Once a WHO member country identifies an event of concern, the
country must assess the public health risk of the event within 48 hours.
❏ If the event is determined to be notifiable under IHR the country must
report the information to WHO within 24 hours.
❏ Some diseases always require reporting under the IHR, no matter when
or where they occur, while others become notifiable when they represent
an unusual risk or situation.
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CATEGORIES OF THESE REPORTABLE DISEASES
❑ Epidemic prone diseases
Cholera, yellow fever, meningococcal disease, SARS, avian
influenza, ebola, marburg haemorrhagic fever, nipah virus
infection, drug resistant diarrhoeal diseases, hospital acquired
infections, malaria, meningitis, respiratory tract infections and
sexually transmitted infections and HIV infections.
❑ Food borne diseases
Microbial contamination chemicals and toxins. The emergence of
new food borne diseases i.e. new variant of Creutzfeldt Jakob
disease associated with bovine spongiform encephalopathy (BSE).
❑ Accidental and deliberate outbreaks
Breaches in biosafety measures are often responsible for
outbreaks associated with the accidental release of infectious
agents for example anthrax in USA in 2001.
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❑ Toxic chemical accidents
Dumping of 500 tons of petrochemical waste in at least 15 sites
led to the deaths of 8 people, and 90000 were seeking medical help
in West Africa in the year 2006.
❑ Radio nuclear Accidents
Chernobyl disaster in 1986 resulted in the evacuation and
resettlement of over 3,36,000 people.
❑ Environmental disasters
■ Heatwave in Europe 2003, the lives of 35,000 persons were
linked to extremes in weather.
■ Bhopal gas tragedy in December 1984
■ 1700 people died in Carbon dioxide poisoning in Central
Africa in 1986
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What do the IHR call for?
❏ Strengthened national capacity for surveillance
and control, including in travel and transport
❏ Prevention, alert and response to international
public health emergencies
❏ Global partnership and international
collaboration
❏ Rights, obligations and procedures,
and progress monitoring
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IHR Capacities required at each level
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Why should countries implement the IHR?
Countries will receive:
❏ WHO assistance in building core
capacities
❏ WHO’s guidance during outbreak
investigation, risk assessment, and
response
❏ WHO’s advice and logistical support
❏ information gathered by WHO about
public health risks worldwide
❏ assistance to mobilize funding
support
To detect and contain public health threats faster, to contribute to
international public health security, and to enjoy the benefits of
being a respected partner.
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WHO to help countries managing events
❏ New WHO global Event Management
System
❏ WHO Regional Alert and Response
teams
❏ Train countries’ NFPs and WHO
contact points for event management
❏ Expand GOARN and other
specialized and regional support
networks
❏ Develop new tools and standard
operating procedures
❏ Carry out IHR exercises
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Adapted response
❏ International public health security is
based on strong national public
health infrastructure connected to a
global alert and response system.
❏ This is at the core of the IHR.
❏ It interlinks in real time 120 networks
and institutes.
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Acute public health threats are collectively managed
The key functions of this global system, for
States and WHO, are to:
❏ detect-(has to be time bound)
❏ verify-(definition of cases and fulfillment of criteria
-if exists-)
❏ assess-(assessment of conditions, situations,
process, and surveillance)
❏ inform-(local and international authorities)
❏ Assist-(for development of national and
international plans)
The IHR define a risk management process where States Parties work
together, coordinated by WHO, to collectively manage acute public
health risks.
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As each country builds its capacity, the entire world
wins
The greatest assurance of public health security will come when all
countries have in place the capacities for effective surveillance and
response, for:
● infectious diseases ● radiological-related diseases
● chemical-related diseases ● food-related diseases
Timeline
15 June 2007 2009 2012 2014 2016
Planning Implementation
2 years + 3 + (2) + (up to 2)
"As soon as possible but no later than five years from entry into force"
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IHR Core Capacities
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National IHR Focal Point
Each State Party will designate or establish a National Focal Point
(NFP), accessible at all times to communicate with WHO IHR contact
points (Article 4)
❏ The designation of National IHR Focal Points has made an
important contribution to the process of developing the IHR (2005).
❏ Under the Regulations National IHR Focal Points are to play an
equally important role in implementing the Regulations at the
national level.
❏ The National IHR Focal Point is charged with maintaining a
continuous official communication channel between WHO and
States Parties.
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In addition to this legal requirement, the National IHR Focal Point will
need
❏ to ensure the analysis of national public health risks in terms of
international impact,
❏ participate in collaborative risk assessment with WHO,
❏ advise senior health and other government officials regarding
notification to WHO and implementation of WHO
recommendations,
❏ and distribute information to and coordinate input from several
national sectors and government departments.
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EDCD-National Focal Point of IHR
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❏ Epidemiology and Disease Control Division was established as a
Division of Statistics in 2030 BS and reorganized as Epidemiology
and Statistical Division in 2035.
❏ According to new organizational structure developed in 2050 BS,
this Division is named as Epidemiology and Disease Control
Division.
❏ With the guidance of Ministry of Health, DoHS and co-ordination of
central level organizations, hospitals, regional health directorate and
medical colleges, along with technical assistance of WHO activities
are being performed.
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❏ Technical as well as financial support is provided by WHO, USAID,
DFID, NHSSP, UNFPA, UNICEF, RTI, CNTD, Save The Children
and Global Fund for EDCD to achieve the objective of this division.
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This division is responsible for following areas:
❏ Epidemic/outbreak preparedness and control programme,
❏ Malaria pre-elimination programme,
❏ Kalazar elimination programme,
❏ Lymphatic filaria elimination programme,
❏ Dengue control programme,
❏ Disaster management programme,
❏ Control of zoonotic disease specially snake bites and dog
bites, avian influenza control programme and
❏ Surveillance and communicable disease research programme.
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Importance of national capacity
The best way to prevent international spread of diseases is to detect
public health events early and implement effective response actions
when the problem is small.
❏ Early detection of unusual disease events by effective national
surveillance (both disease and event based)
❏ Systems to ensure response (investigation, control measures) at all
levels (local, regional, and national)
❏ Routine measures and emergency response at ports, airports and
ground crossings.
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Point of Entry (POE):
PART IV – POINTS OF ENTRY-“point of entry” means a passage for
international entry or exit of travellers, baggage, cargo, containers,
conveyances, goods and postal parcels as well as agencies and areas
providing services to them on entry or exit;
❏ Article 19 General obligations
❏ Article 20 Airports and ports
❏ Article 21 Ground crossings
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POE
❏ Protect the health of travellers and population and avoid/reduce
spread of disease.
❏ Keep airports, ports and ground crossings terminals running and
aircrafts, ships and ground vehicles operating in a sanitary condition
and free of sources of infection and contamination, as far as
practicable.
❏ Capacity in place for detection, containment at source and to
respond to emergency and implement public health
recommendations, limiting unnecessary health-based restrictions on
trade and travel.
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POE
Designation of points of entry –
❏ States Parties shall designate Airports, seaports, landports and Ports
for developing capacities.
❏ States Parties where justified for PH reasons, may designate ground
crossings for developing capacities, taking into consideration
volume and frequency of international traffic and public health risks
of the areas in which international traffic originates.
❏ States Parties sharing common borders should consider: Bilateral
and multilateral agreements Joint designation of adjacent ground
crossing for capacities
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Point of Entry:
Name of PoE
Province
By Air:
TIA POE Kathmandu Bagmati
Province
GBIA POE Rupendehi Lumbini
Province
By Land
Rani PoE, Morang
Province No. 1
Kakadbhitta PoE, Jhapa Province No. 1
Pashupatinagar PoE, Ilam Province No. 1
Maadar PoE, Siraha Province No. 2
Thadi PoE, Siraha
Province No. 2
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Bhittamode PoE, Mohattari
Province No. 2
Birgunj PoE, Parsa
Province No. 2
Maheshpur PoE, Nawalparasi West Lumbini
Province
Belahiya PoE, Rupandehi
Lumbini Province Taulihawa PoE, Kapilvastu
Lumbini Province Krishnanagar PoE,
Kapilvastu Lumbini Province
Gulariya PoE, Bardiya
Lumbini Province
Jamunaha PoE, Banke
Lumbini Province Gaddachauki PoE, Kanchanpur
Sudurpashchim Province Gauriphanta PoE,
Kailali Sudurpashchim Province
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SCREENING OF PERSONS AT ENTRY AND EXIT
❏ No specific health measures are advised
❏ Review travel history in affected areas
❏ Review proof of medical examination
and any laboratory analysis
❏ Require medical examinations
❏ Review proof of vaccination or other
prophylaxis
❏ Require vaccination or other prophylaxis
❏ Place suspect persons under public health
observation
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❏ Implement quarantine or other health measures for suspect persons
❏ Implement isolation and treatment where necessary of affected
persons
❏ Implement tracing of contacts of suspect or affected persons
❏ Refuse entry of suspect and affected persons
❏ Refuse entry of unaffected persons to affected areas
❏ Implement exit screening and/or restrictions on persons from
affected areas
Contd
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POINT OF ENTRY : CORE CAPACITY REQUIREMENTS (ROUTINE)
107

a
Public Health
Emergency
Contingency plan:
coordinator, contact
points for relevant
PoE, PH & other
agencies
Provide assessment &
care for affected
travellers, animals:
arrangements with
medical, veterinary
facilities for isolation,
treatment & other
services
b c
Provide space,
separate from other
travellers to
interview suspect
or affected persons
d
Provide for
assessment,
quarantine of
suspect or affected
travellers
e
To apply
recommended
measures,
disinsect, disinfect,
decontaminate,
baggage, cargo,
containers,
conveyances,
goods, postal
parcels etc
f
To apply entry/exit
control for departing &
arriving passengers
g
Provide access to
required
equipment,
personnel with
protection gear for
transfer of
travellers with
infection/
contamination
POINT OF ENTRY : CAPACITY REQUIREMENTS DURING PHEIC (EMERGENCY)
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VACCINATION FOR TRAVELLERS
CATEGORY VACCINES
ROUTINE
IMMUNIZATION
Diphtheria, Tetanus, and Pertussis
Hepatitis B
Haemophilus influenzae type b
Human papillomavirus
Influenza
Measles, mumps and rubella
Pneumococcal disease
Poliomyelitis
Rotavirus
Tuberculosis (BCG)
Varicella
SELECTIVE USE FOR
TRAVELLERS
Cholera
Hepatitis A
Japanese encephalitis
Meningococcal disease
Rabies
Tick- borne encephalitis
Typhoid fever
Yellow fever
MANDATORY
VACCINATION
Yellow fever (according to
vaccination country list)
Meningococcal disease and polio
(required by Saudi Arabia for pilgrims)
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EWARS and International Health Regulation (IHR)
❏ One of the most important aspects of IHR 2005 is the establishment
of a global surveillance system for public health emergencies of
international concern.
❏ The IHR requires the rapid detection of public health risks, as well
as the prompt risk assessment, notification, and response to these
risks.
❏ EWARS in Nepal works as an indicator-based surveillance in line
with the requirement of IHR 2005.
❏ The data received by EWARS are assessed at EDCD by the National
Focal point for IHR. The identified public health risks and events are
communicated within the country, with WHO and with other
countries as needed
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COVID 19 and IHR
COVID-19 IHR Emergency Committee
The IHR Emergency Committee for COVID-19 held its first meeting on
22 and 23 January 2020. On 30 January 2020, following its second
meeting, the Director-General declared that the outbreak constituted a
Public Health Emergency of International Concern, accepted the
Committee’s advice and issued it as IHR Temporary Recommendations.
The Committee continues to meet on a regular basis.
Temporary recommendations to State Parties
❏ Share best practices, including from intra-action reviews, with
WHO; apply lessons learned from countries that are successfully re-
opening their societies (including businesses, schools, and other
services) and mitigating resurgence of COVID-19.
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❏ Support multilateral regional and global organizations and
encourage global solidarity in COVID-19 response.
❏ Enhance and sustain political commitment and leadership for
national strategies and localized response activities driven by
science, data, and experience; engage all sectors in addressing the
impacts of the pandemic.
❏ Continue to enhance capacity for public health surveillance, testing,
and contact tracing.
❏ Share timely information and data with WHO on COVID-19
epidemiology and severity, response measures, and on concurrent
disease outbreaks through platforms such as the Global Influenza
Surveillance and Response System.
❏ Strengthen community engagement, empower individuals, and build
trust by addressing mis/disinformation and providing clear guidance,
rationales, and resources for public health and social measures to be
accepted and implemented.
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❏ Engage in the Access to COVID-19 Tools (ACT) Accelerator,
participate in relevant trials, and prepare for safe and effective
therapeutic and vaccine introduction.
❏ Implement, regularly update, and share information with WHO on
appropriate and proportionate travel measures and advice, based on
risk assessments; implement necessary capacities, including at points
of entry, to mitigate the potential risks of international transmission
of COVID-19 and to facilitate international contact tracing.
❏ Maintain essential health services with sufficient funding, supplies,
and human resources; prepare health systems to cope with seasonal
influenza, other concurrent disease outbreaks, and natural disasters.
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Major activities in Nepal
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❏ Nepal announced a nationwide lockdown after second case of
COVID-19
❏ Suspension of public transport
❏ Suspension of international flights
❏ Closure of schools, colleges and universities
❏ Closure of government services and private institutions
❏ No gathering of more than 25 people
❏ Nepal established health desks at Tribhuvan International Airport
as well as on other border checkpoints with India.
❏ Quarantine centers and temporary hospitals being set up
❏ Designated COVID-19 hospitals
❏ Setting up of ICU units and isolation at hospitals
❏ Expanding and upgrading laboratory services

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Before COVID
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After COVID
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❏ To support the Government
of Nepal in preparing and
responding to an outbreak of
COVID-19 of a scale that
necessitates an international
humanitarian response
(including mitigation of
social and economic
impacts).
❏ To ensure that affected
people are protected and have
equal access to assistance and
services without
discrimination, in line with
humanitarian principles and
best practise.
131
COVID-19 Response Plan

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❏ This plan intends to prepare and
strengthen the health system
response that is capable to
minimise the adverse impact of
COVID-19 pandemic.
❏ Provide clear policy guidance for
timely health system preparedness
and readiness to respond to the
pandemic.
❏ Provide a guiding framework for
timely, efficient and effective
response to the pandemic. Provide
official guidance
135
Health Sector Emergency Response Plan

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Activities undertaken by government were guided by this plan.
It includes:
❏ Public health and social measures
❏ Quarantine management
❏ Community engagement and risk communication
❏ Case investigation and contact tracing
❏ Surveillance
❏ Screening at Point of Entries(POE)
❏ Community level screening and testing
❏ Emergency response teams
❏ Other Socio-administrative measure
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❏ Hospital Based Interventions:
❏ Hospital care and referral
❏ Laboratory services and other areas of hospital intervention
❏ Management and Oversight
❏ Safety and security of the frontline staff
❏ Human resource management and capacity building
❏ Logistics and supply chain management
❏ Collaboration and partnership
❏ Monitoring, evaluation and reporting
❏ Research
❏ Budget and financial arrangements
❏ Budget estimation
❏ Financing mechanism and funding
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Screening at POE
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What happens When state do not want to follow IHR?
143
❏ If a State notifies the Director-General of its rejection of these
Regulations or of an amendment thereto within the period
provided in paragraph 1 of Article 59 (The period provided in
execution of Article 22 of the Constitution of WHO for rejection
of, or reservation to, these Regulations or an amendment thereto,
shall be 18 months from the date of the notification by the
Director-General of the adoption of these Regulations or of an
amendment to these Regulations by the Health Assembly.
❏ Any rejection or reservation received by the Director-General
after the expiry of that period shall have no effect), these
Regulations or the amendment concerned shall not enter into
force with respect to that State.
❏ Any international sanitary agreement or regulations listed in
Article 58 to which such State is already a party shall remain in
force as far as such State is concerned.

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Example of IHR Violation:
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❏ The Chinese government was responsible for collecting data
about its spread and promptly informing the World Health
Organization (WHO), governments and scientists around the
world.
❏ Instead, China suppressed, falsified and obfuscated data and
repressed advanced warnings about the contagion as early as
December, well before the start of the global pandemic.
❏ The Chinese government also joined Moscow in exploiting
confusion around the pandemic by engaging in information
warfare through blatant disinformation on the origins of the virus,
suggesting it was developed as a tool for U.S. biological warfare.
❏ Last week, the Canadian government announced that one million
face masks recently purchased from China failed to meet
standards and would be returned.

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IHR and NCDs
146
In 2005, the World Health Organization introduced the International
Health Regulations (IHR) 2005 a diverse set of approaches to reduce the
impact of international public health emergencies through improved
country capacity to detect, assess, report, and respond to health security
threats. In 2014, the Global Health Security Agenda (GHSA) emerged
as a joint initiative among multiple countries to further support
implementation of the IHR.However, despite the syndemic relationship
between communicable and noncommunicable conditions worldwide
and despite growing recognition that integrated health systems are
important to health security objectives, NCD aspects of health
security are not part of IHR- or GHSA-related preparedness
approaches.
In a world of overlapping disease risks, where NCDs can no longer be
siloed away as an independent circumstance from pandemic outcomes,
pandemic prevention strategies might benefit from incorporating select
NCD elements as part of an integrated approach to health systems.

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IHR implementation and effects on routine services
147
Example from Nepal at the time of COVID-19 Pandemic
A qualitative study among community members and stakeholders at
Province-2 on impact of COVID-19 on health service utilization presented
that:
❏ Maternity services, immunization, and supply of essential medicine
were found to be the most affected areas of healthcare delivery during
the lockdown.
❏ Participants reported that the interruptions in health services were
mostly due to the closure of health services at local health care facilities,
limited affordability, and involvement of private health sectors during
the pandemic, fears of COVID-19 transmission among health care
workers and within health centers, and disruption of transportation
services.
❏ In addition, the participants expressed frustrations on poor testing,
isolation, and quarantine services related to COVID-19, and poor
accountability from the government at all levels towards health services
continuation/management during the COVID-19 pandemic.

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Major Achievements
❏ IHR national focal points
❏ Assessment and plans
❏ Training and capacity buildings
❏ IHR 2005 advocacy and provincial distribution
❏ Surveillance and response
❏ Laboratory support
❏ Collaboration with international community
❏ Reporting to WHO
❏ Asking for extension
❏ Still long way to go
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❏ Lives saved
❏ Good international image
❏ No unilateral travel and trade restrictions
❏ Public trust
❏ No political and social turmoil
Benefit from IHR implementation
149

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Challenges for IHR implementation in Nepal
150
❏ Lack of infrastructure to respond at the time of emergencies.
❏ Difficult to mobilize resources
❏ Difficult to develop and implement national action plans
❏ Lack of skilled manpower
❏ Challenges to strengthen capacity at airports, and ground
crossings
❏ No proper reporting mechanisms
❏ Lack of supervision and monitoring

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Countries’ challenges for IHR implementation
❏ Mobilize resources and develop national action plans
❏ Strengthen national capacities in alert and response
❏ Strengthen capacity at ports, airports, and ground crossings
❏ Maintaining strong threat-specific readiness for known
diseases/risks
❏ Rapidly notify WHO of acute public health risks
❏ Sustain international and intersectoral collaboration
❏ Monitor progress of IHR implementation
151

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Conclusion
❏ IHR implementation is the responsibility of all sectors of the
government.
❏ Coordination is the must
❏ Capacities should be established
❏ Proper implementation ensure saving lives and resources
❏ Good international image
❏ Capacity building and human resources
❏ National and global health security
❏ Collaboration across countries
152

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Way Forward
❏ Capacity development
❏ Contingency planning
❏ Cross-border coordination
❏ Disease surveillance
❏ Infrastructure, equipment, and supplies (including ICT)
❏ Immigration and visa consular process
❏ IPC including WASH services
❏ Protection
❏ Risk communication
154

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This is all for health security.
Are we prepared for the next pandemic?
155

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● WHO, International Travel and Health. World Health Organization; January 2007. annex 2,
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