international health regulations and their implementation.success of IHR in SEAR region and implementation in India.

1. International health
regulations
BY: DR.KAVITA YADAV
MODERATOR: DR. VIDYA G. S &
DR.KAVITHA H .S
JSSMCH,MYSORE

2. Plan of presentation
 What is IHR
 History
 Comparison of 1969 and 2005 IHR
 Principles ,objectives and purpose of IHR
 IHR implementation
 How successful IHR has been
 Indian scenario
 Summary
 References

3. What are International Health Regulations
(IHR)?
 The International Health Regulations (IHR) are an
international legal instrument that is binding on 194 countries
across the globe, including all member states of the World
Health Organization (WHO).
 The United States is one of these member states.
 IHR are intended to:
 help prevent the spread of disease across borders
 outline the minimum requirements for functional public health system that
allows countries to quickly detect and respond to disease outbreaks in their
communities

4. History
 1830s---New trade patterns allow cholera to spread from South Asia to
Europe and North America, leaving hundreds of thousands dead
 1851--France convenes the first International Sanitary Conference to explore
agreement on harmonizing quarantine regulations for cholera, plague, and
yellow fever
 1892--Delegates to the seventh conference ratify the first International
Sanitary Convention
 1902 -1935--States create intergovernmental institutions [Pan American
Sanitary Bureau (1902), Health Organization of the League of Nations
(1920)

5. Contd.
 → 1948--World Health Organization (and its governing body, the
World Health Assembly, WHA) created
 → 1951--WHA consolidates existing international sanitary
conventions into the singular International Sanitary Regulations
(covering plague, cholera, yellow fever, smallpox, typhus, relapsing
fever)
 → 1969--The renamed International Health Regulations (1969)
replace prior agreements; revisions eliminate but do not add diseases

6. 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, desinsection…)
 Health documents for people, aircraft and ships.

7. 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

8. Why new IHR
 → 1995--Ebola virus outbreak in Central Africa captures global
attention;WHA calls upon WHO Director-General to overhaul the
IHR
 The recent increase in trade and tourism.
 → 2003--SARS spreads from China to 25 other countries via air
travel
 → 2005--WHA adopts the revised International Health
Regulations (2005)

9. IHR 1969 VERSUS IHR 2005
From three diseases to all public health risks
From preset measures to tailored response
From control of borders to also include containment at source
From reactive to proactive

11. International Health regulations (2005)
10 Parts, 66 Articles, 9 Annexes
• 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
• Chapter I General provisions
• Chapter II Special provisions for conveyances and conveyance operators
• Chapter III Special provisions for travellers
• Chapter IV Special provisions for goods, containers and container loading areas
• PART VI HEALTH DOCUMENTS
• PART VII CHARGES
• PART VIII GENERAL PROVISION
• PART IX THE ROSTER OF EXPERTS, THE EMERGENCY COMMITTEE AND THE REVIEW COMMITTEE
• Chapter I The IHR Roster of Experts
• Chapter II The Emergency Committee
• Chapter III The Review Committee
• PART X FINAL PROVISIONS

12. Purpose and scope
 The purpose and scope of these Regulations are 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.

13. Principles
 The implementation of these Regulations shall be with full respect for the
dignity, human rights and fundamental freedoms of persons.
 The implementation of these Regulations shall be guided by the Charter of the
United Nations and the Constitution of the World Health Organization.
 The implementation of these Regulations shall be 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 United Nations and the
principles of international law, the sovereign right to legislate and to
implement legislation in pursuance of their health policies. In doing so they
should uphold the purpose of these Regulations

14. Objectives Of IHR 2005
 To ensure the appropriate application of routine preventive measures
(e.g. at ports and air ports) 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.

16. IHR implementation
 Strengthening national capacity for surveillance and
control at port , airport, ground crossing and travel
&transport.
 Prevention ,alert and response to public health
emergencies.
 Global partnership.
 Rights, obligations ,procedure and progress monitoring.

17. 1 Strengthening national
capacity

18. Country’s liabilities
 At point of entry: Under normal conditions
At the time of emergency
 Establishment of national focal point
 Strengthening of surveillance and reporting system

19. For ships
 Sanitary operation without harming ship and passenger
 Certificate is given free of charge
 Free pratique
 Subjected to health inspection for hygiene and
sanitation,rodents/vermin infestation,drinking water
availability and quality

20. Documents checked
 Maritime declaration of health,
 Crew list and vaccination certificate of members
 Deratting or deratting exemption certificate
 Certificate of health and sanitary inspection
 Certificate showing date and time of pratique
 Ship sanitation control certificate
 Ship sanitation control exemption certificate

21. For people
 Certificate of date of arrival or departure
 Certificate of health measures applied to him or his
baggage
 May examin person before voyage if needed
 Person under surveillance may be allowed to continue his
voyage but health authorities must be kept informed
 Review travel history in affected area
 Review proof of medical examination,vaccination and lab
analysis

22. Contd.
 Place a suspected person under observation.
 Implement quarantine or isolation or treatment as needed.
 May refuse entry of affected person.
 May refuse entry of unaffected person in affected area.
 Implement exit screening.
 Medical facilities for ill travellers.

23. Health measures for baggage, cargo, containers,
conveyances, goods and postal parcels
• Review manifest, Proof of measures taken on
departure or in transit, Routing and implement
inspections
• Implement treatment to remove infection and
contamination, vectors and reservoirs.
• Isolation and quarantine, seizure and destruction
• Refuse departure or entry.

24. Ground Crossing
 States Parties sharing common borders should consider:
 (a) entering into bilateral or multilateral agreements or
arrangements concerning prevention or control of
international transmission of disease at ground crossings
in accordance with IHR
 (b) joint designation of adjacent ground crossings for the
capacities .

25. Categories Of These Reportable Diseases
• Epidemic prone diseases
• Food borne diseases
• Accidental and deliberate outbreaks
• Toxic chemical accidents
• Radio nuclear Accidents
• Environmental disasters

26. 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)

28. National IHR Focal Points (NFPs)
 Important role in implementation of IHR
 The national centre for communications with WHO:
 On a 24/7 basis (by telephone, fax, email)
 NOT an individual person
 To notify PHEIC to WHO
 To respond to requests for verification of information of such
events.
 Support field investigations, provide early diagnosis and provide
technical guidance to states for timely and effective response to
PHEIC
 Co-ordination with state units and WHO

29. Strengthening of surveillance system
 Each country is suppose to enhance its surveillance and
reporting system so that diseases of international concern
can be picked up at the earliest and hence controlled in a
better way.

30. 2 Prevention alert and
response to PHEIC

31. Public Health Emergency of International
Concern (PHEIC)
 An extraordinary public
health event which
 constitutes a public health
risk to other countries
through international spread
of disease
 potentially requires a
coordinated international
response

32. 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(ebola,lasaa)
Yellow fever
West Nile fever
Other locally or
regionally important
diseases
Any event
of potential
internation
al 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

39. 3 GLOBAL PARTNERSHIP
AND INTERNATIONAL
COLLABORATION

40. The IHR foster global partnership
 Other intergovernmental organizations:
 UN system (e.g. FAO, IAEA, ICAO, IMO)
 others: regional (e.g. EU, ASEAN), technical (e.g. OIE)
 Development agencies:
 governments, banks
 WHO Collaborating centres
 Academics & professional associations
 Industry associations
 NGOs and Foundations

42. Global distribution of GOARN institutions and
partners
A network of more than 150 technical institutions,
WHO manages secretariat and logistic support

43. GOARN
 Global Outbreak Alert and Response Network (GOARN)
provides a framework for the technical coordination of
international alert and response activities with institutions
and countries around the world.
 They lay out new obligations devised to collectively
respond to international public health challenges of the
21st century, taking advantage of new developments in
biotechnology, surveillance systems, and information
technology, such as rapid data sharing.

44. 4 RIGHTS,OBLIG-
ATIONS AND
PROCEDURES,PR
OGRESS
MONITORING

45. According to the IHR (2005), what are
the key obligations for WHO?
 Laying down the rules for global public health security
 Monitoring the implementation of IHR (2005) and
updating guidelines so that they remain scientifically valid
and consistent with changing requirements.

46. Major Obligations for Member States
Assess
events
& notify
potential
PHEIC
Response
Core
capacities to
detect, report
and respond
Legal &
administrative
framework
Designation of
National IHR
Focal Point
Major
Obligations

47. Benefits to Member States
• Being a partner in the international effort to maintain global
health security.
 Core capacities will be strengthened to report and respond to
public health risks and a PHEIC in the country.
 Clear guidelines on outbreak verification process, technical
and logistical support will be provided by WHO upon request
in the case of a PHEIC.
 Be eligible for support from Global Outbreak Alert and
Response Network (GOARN).
 WHO emphasizes an amicable settlement of differences
through, negotiation, mediation, conciliation and arbitration.

48. Implications of non-compliance to IHR
• WHO will know from other sources
 Position of the State Party will change from article 6
(notification) to article 10 (verification)
 WHO will request verification
 WHO will embark on investigation based on risk
assessment
 IHR allow WHO to use whatever available information
to alert other partners

49. Barriers to implementation
 Technical
 Resources
 Governance
 Legal
 Political

50. How successful has the IHR system been?
 The system has been very successful when we consider
the number of events notified to WHO under regulations.
 >220 events worldwide were formally notified to WHO and posted
on the secure IHR website as meeting at least 2 of the 4 risk
assessment criteria.
 Hundreds of more postings on a secure IHR website for information
exchange on events between countries, which could include
information about event response measures taken.

52. Indian scenario

53. The Stakeholders for IHR Implementation
Airports,
Ports &
Ground
Crossings
States, UTs
&
District
Authorities
National Focal Point
NICD, Delhi
Other
Ministries,
&
Deptts.
MOHFW
DGHS

54. India and IHR
 National Focal Point: NICD
 Surveillance:IDSP (Rs.408 CRORE)
 Legal:
The Public Health Act of India has been drafted
 Indian Port Health Rules and Indian Aircraft (Public
Health) Rules are currently being examined for their
compliance with IHR (2005).
 National - Epidemic Disease Act -1987 .
 Disaster Management Act 2005

55. Contd.
 Lab: 2 bio safety level (BSL) —one at the NICD, Delhi
and second at National Institute of Virology, Pune.
 Connectivity: In collaboration with the ISRO, the
National Informatics Centre and BSNL, districts are
being connected electronically through satellite and the
terrestrial network for transmission of surveillance data,
videoconferencing and distance learning
 PoE: 25 million international passengers pass through
India via 21 international airports, 12 ports and 3 major
land border crossings yearly.

56. Summary
 What is IHR.
 What are its principles , objectives and scope.
 How it is implemented.
 What are the responsibilities of WHO and the state
parties.
 Where India stands.

57. REFERENCES
 World Health Organization. International health regulations (1969). 3rd ed. Geneva:World Health
Organization; 1983. Available at http://whqlibdoc.who.int/publications/1983/9241580070.pd
 WHO, International Health Regulation (2005): Geneva, World Health Organization; 2006.
 The World Health Organization, fifty – eight World Health Assembly Resolution WHA 58.3: Revision
of the International Health Regulation, 23 may 2005. Available at http: // www.who.int/
ebwho/pdf.files/WHA 58 /WHA58.3-en pdf.
 WHO, International Travel and Health. World Health Organization; January 2007. annex 2, 213.
 WHO, International Travel and Health. World Health Organization; January 2011. Chapter 6, 82-142.
 Narain Jai P, Lal S, Garg R. Implementing the Revised International Health Regulations in India. The
National Medical J India 2007; 20 (5) : 221- 23.
 David P. Fidler. From International Sanitary Conventions to Global Health Security: The New
International Health Regulations. Chinese Journal of International Law (2005), Vol. 4, No. 2, 325–
392. Downloaded from oxfordjournals.org.
 URL: http://www.port-health.org/sanitation/index
 Implementation of the International Health Regulations (2005). Report of the Review Committee on
the Functioning of the International Health Regulations (2005) in relation to Pandemic (H1N1) 2009.
Report by the Director-General.
 Mankar M, Pinto V. International Health Regulation. Bombay Hospital Journal,2009; 51; 2:222-28.