18 March 2008
Updated Rules Offer New Framework for Health Security
Novel disease surveillance and response approaches shaped revisions
Atlanta -- A new human case of highly pathogenic H5N1 avian influenza announced by the Ministry of Health and Population in Egypt March 11 and confirmed by the World Health Organization (WHO) brings the total number of cases around the world since 2003 to 372, with 235 deaths.
Many of the tracking systems and processes that allow WHO to monitor and rapidly issue such infectious disease alerts and proactively respond to disease outbreaks that could affect other countries are a result of the International Health Regulations (IHR) that were revised in 2005 and went into effect in June 2007.
The revisions updated the 1969 regulations, which asked countries voluntarily to report only cholera, plague and yellow fever. Under the 1969 version, if countries reported the diseases at all, WHO published the information once a week in an epidemiological record. Measures for dealing with the diseases were outlined in the regulations, and only member countries were allowed to report disease outbreaks.
In 2007, the regulations, Dr. David Heymann, WHO assistant director-general for health security and environment, told attendees March 16 during the 2008 International Conference on Emerging Infectious Diseases in Atlanta, “went from a set of guidelines that asked us to report three diseases, to a reporting of all public health events.”
“They went from a passive system where the information was printed in a weekly bulletin to a proactive system using real-time surveillance and evidence that within 24 hours arrives on the desk of a [WHO member state representative] in every country in the world,” he added.
All 193 members of WHO are signatories to the treaty, which, Heymann added, “if used properly provide for us a framework under which we can all work together to ensure the world’s public health security.”
SARS EMERGING
In 1996, WHO decided the regulations needed updating. The vision, Heymann said, “was for a world on the alert, able to detect and respond to international infectious disease threats within 24 hours using the most up-to-date means of global communication and collaboration.”
The revision process began with a series of novel approaches to disease surveillance and response. In 1998, Canada established the Global Public Health Intelligence Network (GPHIN), an Internet-based early warning system that gathers reports of public health significance in seven languages by monitoring global media sources like news service wires and Web sites.
In 2000, WHO established the Global Outbreak Alert and Response Network (GOARN), a technical collaboration that now has 120 institutions and networks that pool resources for rapid identification, confirmation and response to outbreaks of international importance.
GPHIN and GOARN, Heymann said, helped WHO begin to determine how the regulations best could be modified.
Then, in February 2003, one case of an emerging infection now known as severe acute respiratory syndrome (SARS) in China’s Guangdong province turned into an outbreak that affected 27 countries. Between November 2002 and July 2003, the outbreak infected 8,096 people and killed 774.
“SARS,” Heymann said, “was the first global outbreak that could be dealt with on a day-to-day basis, changing policies, changing strategies as necessary based on real-time evidence coming in from [GPHIN and] GOARN.”
Three months later, when the WHO World Health Assembly met to consider the IHR revisions, the SARS outbreak convinced member country representatives to pass the enabling resolution and allow WHO to accept disease reporting information from any source, not just member states.
ON THE ALERT
During the SARS outbreak, just five years ago, WHO had no way to contact its 193 member countries, so it released a press statement about the disease that, Heymann said, “caught every minister of health and every institution in the world off guard because we were unable to notify them prior to putting this out.”
In February 2008, WHO was able quickly to notify ministers of health in all member countries about an outbreak of yellow fever occurring in Paraguay.
“It only took a click on an icon and everyone in the world on February 22 was notified,” Heymann said. “One hundred ninety-three member countries have electronic communication with WHO through an International Health Regulation focal point that is required in all countries under this treaty.”
The revised regulations include smallpox, polio, SARS and new strains of human influenza, whose occurrences member states must report immediately to WHO. (See “Avian Flu Vaccine Stockpile Being Planned for Developing Nations.”)
“In influenza, like in many other diseases,”Heymann said, “we haven’t advanced very much further than [the pandemic in] 1918, except that now we have the International Health Regulations, which call for collective action for our global public health security. We must make these regulations work.”
Additional information about the International Health Regulations and GOARN is available on the WHO Web site.
More information about GPHIN is available on the Canadian Public Health Service Web site.
