Background
The International Health Regulations (IHR) represents the earliest multilateral initiative by countries to develop an effective framework to prevent cross-border transmission of diseases. The IHR strives to harmonize public health, trade, and traffic, and today remains the only binding set of regulations on global surveillance for infectious diseases by the World Health Organization’s (WHO) Member States.

The current IHR was adopted in 1969, amended in 1973 with additional provisions for cholera, and subsequently revised in 1981 to exclude smallpox. Today, only cholera, plague and yellow fever are notifiable diseases under the IHR. Its fundamental purpose is to ensure maximum security against the international spread of diseases with a minimum interference with world traffic.

Because of extensive globalization in travel and trade, diseases from even remote parts of the world could spread to other areas. Potentially damaging traffic and trade embargoes may be imposed, sometimes based only on the perception of risk for disease importation, and potentially reach global proportions as happened during the cholera epidemic in the Americas in the early 1990’s.

To address the threat posed by substantial increases in international travel and the potential for the rapid spread of infectious diseases, especially by air travel, the World Health Assembly (WHA) requested the revision of the International Health Regulations (IHR) in the 1995 resolution WHA 48.7.

Progress
The current revision is a collaborative process that was initiated in 1995. Its essence is to review the gaps in the present IHR and transform it into an effective regulatory tool for WHO Member States to strengthen global disease surveillance and to be proactive in dealing with international outbreaks. Proposed changes are being developed and fine-tuned to adapt to contemporary global surveillance demands and control of international outbreaks. All of the items introduced are proposals, and as such require extensive consultation before presentation to the WHA and ultimate acceptance by Member States.

The revision approach is based on three specific principles (1):
– Ensuring that all public health risks (mainly of infectious origin) that are of urgent international importance are reported under the Regulations
– Avoiding stigmatization and unnecessary negative impact on international travel and trade and invalid reporting from sources other than Member States, which can have serious economic consequences for countries
– Ensuring that the system is sensitive enough to detect new or re-emerging public health events.

To this end, three key changes are being proposed. First, the scope of reported events will be expanded to include all public health emergencies of international concern. There will be a clear link between reporting and established mechanisms for action.
To define an event as a public health emergency of international concern a set of specific criteria is being proposed:
(1) Severity: The health event produces an abnormal increase of case fatality and/or incidence rates
(2) Unusual or unexpected: An emerging health event or a known health event showing an abnormal behavior
(3) Risk of international propagation
(4) The event will lead, eventually, to international restrictions of travel and trade

Second, a National Focal Point will be designated to facilitate the greater flow of information between the WHO and the different national levels in both directions. Specifically, this focal point should be able to: manage international surveillance and response requirements; advise senior health officials regarding notification to the WHO, and implementation of WHO recommended measures, distribution of information, and coordination of input from several key national areas, such as disease surveillance, ports, airports, and ground crossings’ public health services, as well as other government departments, such as agriculture and customs; and finally, act as the technical resource coordinating body during the revision and implementation processes.

Third, core country capacities required in surveillance and response, including at points of entry will be defined and included in the IHR. In order for urgent national events to be picked up early, each country will require a surveillance system informing on unusual and unexpected events from the periphery into the center in a very short time, including the capacity to analyze rapidly such data. In many countries, this surveillance/analysis capacity may already be in place. Others may need a grace period to fulfill this future IHR requirement, and external assistance and funding may become necessary.

The 43rd Meeting of the Pan American Health Organization (PAHO) Directing Council adopted Resolution CD43.R13 in support of the revision of the International Health Regulations (IHR), urging Member States to participate actively in the review process both nationally and through the regional integration systems.

In the face of the risk posed by the emergence and reemergence of infectious diseases, PAHO has focused its technical cooperation efforts on building a national and subregional capacity to detect, investigate, and control events related to epidemic-prone diseases through emerging disease surveillance networks.

PAHO has also been working with Member States to obtain their comments on the proposed revisions and to keep them informed on the progress made. Moreover, PAHO has taken the opportunity to discuss the IHR revision in working groups on health that were created within the subregional integration systems.

One of these groups has been the Mercado Común del Sur (MERCOSUR), which includes the Southern Cone countries (Argentina, Brazil, Paraguay, and Uruguay, with Bolivia and Chile as observers). This group has provided insight into the proposed changes and has taken concrete steps regarding the IHR, such as: including the Regulations as a priority topic of its Surveillance Working Group; pledging unanimous support to the revision process, especially as it refers to border health and its trade components; conducting four workshops resulting in resolutions and agreements signed by the Ministries of Health; carrying out country activities including the revision of national norms for port-of-entry sanitation and travelers’ health certificates; testing syndromic surveillance at the national level; and testing the algorithm for reporting events of international public health concern.

Another is the Andean subregion comprising Bolivia, Chile, Colombia, Ecuador, Peru and Venezuela; its Organismo Andino de Salud, has included the IHR revision on its health agenda. Through a cooperative agreement with PAHO, it has organized two workshops on the subject to inform the countries of the revision of the IHR, to initiate a national process to bring together interested parties, and to obtain national views regarding the proposed changes. Two ministerial resolutions emerged from this initiative. The first one established national technical task forces and the second urged countries to review and strengthen epidemiological surveillance, especially in border areas.

Next steps
According to the present schedule, the next major milestones in the revision process include:
– Distributing the first draft of the reviewed IHR in all official WHO languages by December 2003
– Convening regional and subregional consultation meetings regarding the proposed changes by June 2004
– Delivering the final draft of the IHR to every country by November 2004
– Discussing the Project Proposal of the new IHR at the World Health Assembly in May 2005

Reference:
(1) World Health Organization. Resolution of the Executive Board of the WHO. Revision of the International Health Regulations. Geneva: WHO; January 2003. (EB111.R13)

Source: Prepared by PAHO’s Area of Disease Prevention and Control, Communicable Diseases Unit (DPC/CD).