From Outbreak to World War Z, Hollywood has repeatedly forced us to consider the international community’s preparedness for the outbreak of disease. The International Health Regulations (IHR) are international agreements that set the overall framework for infectious disease surveillance. They were created to prevent, protect against, and provide a public health response to the international spread of disease.
The first International Sanitary Convention came into force in 1892. These attempted to prevent the spread of cholera through inspections of ships passing through the Suez Canal. In 1948, the WHO(World Health Organization) organized the world’s international sanitary conventions and treaties. This allowed the WHO to act as a central authority requiring disease surveillance information, and eventually establishing the legal obligations of states to report disease outbreaks to the rest of the world.
The International Sanitary Regulations, the precursor to the IHR, required states to report the presence of six designated diseases: smallpox, cholera, yellow fever, typhus, relapsing fever and plague. Also, it required WHO member states to take necessary hygiene measures for cargo and personnel crossing their borders, and allowed for states to require travelers to present vaccination information.
When the WHO emerged as the central receptacle of information about the outbreak of SARS in 2003, the inability of international obligations to provide a framework for global action against the spread of SARs provided the motivation for the draft of the IHR that held specified legal obligations. The current revisions of the IHR were created in 2005, and came into force June 15, 2007 as a legally binding agreement under international law.
The Scope of the IHR was expanded to encompass all events that may lead to a public health emergency of international concern, whether naturally occurring or man made. Some diseases (smallpox, wild-type polio, SARS, and new sub-types of influenza) must automatically be reported to the WHO upon discovery. Other cases must be assessed using a decision-making instrument created by the WHO. Urgent public health events are considered under these provided criteria, and must be assessed with 48 hours of discovery.
Will the event cause trade or travel restrictions? Is it an unusual or unexpected event? Can the event be considered to have the potential for serious public health impact? Is there significant risk of international spread? Answering yes to two of these four questions will trigger that nation’s responsibility to report the event to the WHO within 24 hours of confirmation. Endemic diseases therefore, are not required to be reported to the WHO, unless there is a risk that it will cross the border.
The IHR requires national surveillance structures to take a role in monitoring the public health situation, detect unusual public health events, and report epidemiological information to authorities to come up with control measures. Implementing this requires federal governments to harmonize public health policy and practice with regional governments, a challenge for many governments.
Canada, for instance, has been confronted with the issue that much of the relevant surveillance and primary care infrastructure is spread across regional governments, as health care is primarily a responsibility of the province. This has lead to consideration of Memorandams of Understanding between the federal government and provincial governments, pertaining to data transfer for public health emergencies of international concern.
Problems expand beyond federalism and regional jurisdiction for lower-income countries in implementing the IHR. Costs associated with the IHR are a problem in some states, as investment in surveillance to meet core requirements directly competes with primary care funding in some cases. Also, compliance can be an issue as many states fear the impact that reporting these public health events could have on their nation’s economy in the form of lost trade and tourism revenue. Attempts to mediate problems with disease reporting compliance has lead to non-governmental sources being allowed to provide information to the WHO based on the IHR criteria. The WHO can act upon these non-governmental sources as it sees fit.
Recent debates surrounding global health security have questioned whether the benefits of agreements such as the IHR are being distributed equitably. There are concerns that the promotion of Global Health Security and international agreements like the IHR are concealing an underlying agenda that is aimed towards protecting high-income countries from diseases emerging in the lower to middle income countries. Most of the naturally occurring pathogens that are recognized as security threats are recognized as such by high-income nations. These security threats are usually focused on re-emerging infectious diseases such as pandemic influenza, SARS, and HIV/AIDS. This focus has been criticized as they include a small proportion of the actual health issues worldwide.
Despite several concerns about its effectiveness and bias towards protecting wealthier nations, surveillance of public health events of international concern remains a major issue. The IHR, therefore, could be an important factor in facilitating international cooperation to avoid international pandemics.