International Health Regulation.pptx

IHR is an International documents which guide and bound the nations through defined guidelines .

1. International Health Regulations By : Saroj Rimal (HA,BPH,MPA,MPH) 1

2. 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 2

3. 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 3

4. 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 4

5. 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 i nternational travel and transport and sanitary protections for the users of international airports, ports, and ground crossings. Source: IHR 2005 5

6. Need for IHR “A threat anywhere is a threat everywhere ” 6

7. 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 H umidity 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 7

8. Need for IHR It is estimated that 2.1 billion airline passengers travelled in 200 4 . 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) 8

9. 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 9

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11. 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 1 830,1847 Cholera epidemics in Europe were catalyst for intense infectious disease diplomacy and multilateral cooperation. Came in to force revised IHR . 2007 11

12. 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, 12

13. 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. 13

14. 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. 14

15. 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 15

16. 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 19 4 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 16

17. 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 17

18. 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.

19. cont… 19 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.

20. 30 years of international health insecurity HIV/AIDS CHERNOBYL PLAGUE EBOLA NIPAH YELLOW FEVER ……. ANTHRAX SARS MENINGITIS CHOLERA CHEMICAL AVIAN INFLUENZA XDR-TB ... 20

21. 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.

22. H5N1: Avian influenza, a pandemic threat 22

23. 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. 23

24. 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 24

25. The 58th World Health Assembly adopts the revised International Health Regulations , “IHR” 25

26. Comparison between IHR 1969 and 2005 26

27. 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 27

28. 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 28

29. 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 29

30. 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. 30

31. 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 31

32. 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 19 4 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 . 32

33. 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. 33

34. 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. 34

35. 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 35

36. 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 36

37. 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; 37

38. “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; 38

39. “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; 39

40. “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; 40

41. “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. 41

42. “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 . 42

43. “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.   43

44. 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 U N 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 U N and the principles of international law, the sovereign right to legislate and to implement legislation in pursuance of their health policies 44

45. Article-4 : Relates to responsible authorities: All State Parties should establish a National IHR Focal Point a nd responsible author ities for the implementation of health measures under these Regulations. National IHR Focal Points to be accessible all times for communications with the WHO IHR Contact Points . 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. 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. 45

46. 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. 46

47. 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. 47

48. 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. 48

49. Article-12 : Determination of a public health emergency of international concern on the basis of: information provided by the State Party; 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. 49

50. 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 50

51. 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 51

52. 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 52

53. 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. 53

54. Collaboration and assistance (Article-44) 54

55. 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 55

56. 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) 56

57. 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: Core capacity requirements for surveillance and response B. Core capacity requirements for designated airports, ports and ground crossings. Annex-2: Decision instrument for the assessment and notification of events that may constitute a public health emergency of international concern 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 57

58. Annex-3:Ship Sanitation Control Certificate 58

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60. Annex-4:Technical requirements pertaining to conveyances and conveyance operators 60

61. Annex-5: Specific measures for vector-borne diseases 61

62. ANNEX 6:VACCINATION, PROPHYLAXIS AND RELATED CERTIFICATES 62

63. Annex-7-Requirements concerning vaccination or prophylaxis for specific diseases 63

64. Annex-8: Model of Maritime Declaration of Health 64

65. Annex-9:Health Part of the Aircraft General Declaration 65

66. 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. 66

67. 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 M onkeypox outbreak 67

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69. 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 69

70. 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 70

71. 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 71

72. 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. 72

73. Public health emergency of international concern (cont.) 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. 73

74. Public health emergency of international concern (cont.) 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. 74

75. 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. 75

76. 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 76

77. 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. 77

78. 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. 78

79. 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. R adio 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 79

80. 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 80

81. I HR Capacities required at each level 81

82. 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 . 82

83. 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 83

84. 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. 84

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86. 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) A ssist - ( 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. 86

87. 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" 87

88. IHR Core Capacities 88

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91. 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. 91

92. 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. 92

93. EDCD-National Focal Point of IHR 93

94. 94

95. 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. 95

96. 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. 96

97. 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. 97

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99. 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. 99

100. 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 100

101. 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. 101

102. 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 102

103. 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 Malangwa PoE, Sarlahi Province No. 2 Kunauli PoE, Saptari Province No. 2 Gaur PoE, Rautahat Province No. 2 103

104. 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 Darchula PoE, Darchula Sudurpashchim Province Jhulaghat PoE, Baitadi Sudurpashchim Province Rasuwaghadi, Rasuwa Bagmati Province Kodari/Tatopani, Sindupalchowk Bagmati Province 104

105. 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 105

106. 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 106

107. POINT OF ENTRY : CORE CAPACITY REQUIREMENTS (ROUTINE) 107

108. 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 P rovide 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) 108

109. 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) 109

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116. 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 116

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119. 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. 119

120. 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. 120

121. 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. 121

122. Major activities in Nepal 122

123. 123 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

124. Before COVID 124

125. After COVID 125

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131. 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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135. 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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137. 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 137

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140. 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 140

141. Screening at POE 141

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143. 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.

144. Example of IHR Violation: 144

145. 145 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.

146. 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.

147. 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.

148. 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 148

149. Lives saved Good international image No unilateral travel and trade restrictions Public trust No political and social turmoil Benefit from IHR implementation 149

150. 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

151. 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

152. 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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154. 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

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

156. 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   156

157. https://www.who.int/docs/default-source/nepal-documents/novel-coronavirus/health-sector-emergency-response-plan-covid-19-endorsed-may-2020.pdf https://www.who.int/docs/default-source/nepal-documents/novel-coronavirus/covid-19-nepal-preparedness-and-response-plan-(nprp)-draft-april-9.pdf?sfvrsn=808a970a_2 https://covid19.mohp.gov.np/ 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. Health emergency Operation center Network of Nepal Implementation of International Health Regulations (2005)Report of the First Regional Workshop Male, Republic of Maldives, 23-25 April 2007 Assessing the Ground Crossing Points of Nepal and Their Compliance with the International Health Regulations (2005) to Prepare and Inform the Public Health Response to COVID-19 Ministry of Health and Population NEpal Ministry of foreign affairs and general administration, Nepal Epidemiology and disease control division, Nepal Ninth Meeting of the Inter-American Committee on Ports (CIP) Assessment of Public Health Events through International Health Regulations, United States, 2007–2011 157

158. 158 https://www.macleans.ca/opinion/china-was-in-violation-of-international-health-regulations-what-do-we-do-now/ https://www.who.int/westernpacific/activities/implementing-the-international-health-regulations https://pubmed.ncbi.nlm.nih.gov/14575073/#:~:text=In%201997%2C%20a%20high%2Dpathogenicity,chicken%20farms%20in%20December%201997 . https://world-nuclear.org/information-library/safety-and-security/safety-of-plants/chernobyl-accident.aspx https://www.researchgate.net/publication/31088492_From_International_Sanitary_Conventions_to_Global_Health_Security_The_New_ International_Health_Regulations www.cdc.gov/globalhealth/healthprotection/ghs/ihr/index.html https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8217593/ Impact of COVID-19 on health services utilization in Province-2 of Nepal: a qualitative study among community members and stakeholders https://www.business-standard.com/about/what-is-bhopal-gas-tragedy New variant Creutzfeldt-Jakob disease and bovine spongiform encephalopathy https://mohp.gov.np/attachments/article/703/Responding%20to%20COVID-19,%20Health%20sector%20preparedness,%20response%20and%20lessons%20learnt.pdf

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