1. International Health Regulations (2005)
Third Hemispheric Conference on Port Security of the Inter-American Committee on Ports.
7-10 April 2008
Punta Cana , Dominican Republic
Cooperative Arrangement for Preventing the Spread of Communicable Diseases Through Air Travel (CAPSCA)
Christian Frederickson – PhD, MPH, MPM,
CAREC/PAHO/WHO

2. In May 2005, The 58th World Health Assembly adopted the revised International Health Regulations, “IHR”
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.

3. International Health Regulations 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 193 World Health Organization member countries.

4. International Health Regulations IHR (2005)
They are an international agreement that gives rise to international obligations. 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.

5. International Health Regulations IHR (2005)
IHRs serve a common interest.
First of all, they address serious and unusual disease events that are inevitable in our world today.
They serve a common interest by recognizing that a health threat in one part of the world can threaten health anywhere, or everywhere.
And they are a formal code of conduct that helps contain or prevent serious risks to public health, while discouraging unnecessary or excessive traffic or trade restrictions for, quote, "public health," purposes.

6. Why have IHR? Serious and unusual disease events are inevitable
Globalisation - problem in one location is everybody’s headache
An agreed International Public Health code of conduct for a global approach
Not intended to "interfere" with purely national events
The traffic and trade objective comes AFTER the health objective

11. Some facts and figures:
Over 90% of world trade is transported by the international shipping industry.
Today there are around 50,000 merchant ships that trade internationally and transport all types of cargo.
The world fleet is registered in over 150 nations and manned by over one million seafarers of virtually every nationality. ( ).
From , a WHO review of over 100 outbreaks associated with ships found that more than one-third were related to foodborne transmission ( n/index.html

12. Infectious Disease Concerns in the Caribbean
Dengue virus and Chikungunyavirus
Competent vector in Caribbean and Latin America
Malaria
2007 outbreak Kingston, Jamaica
2006 outbreak Exuma Is. Bahamas
Yellow Fever
Endemic in Guyana, Trinidad & Tobago
Epidemic of Yellow Fever in Paraguay, Brazil
Norovirus
Cruise ships & resort in Dominican Republic (2007)
Poliovirus
21 cases in Hispaniola including 2 fatalities ( )

13. H5N1: Avian influenza, a pandemic threat
The greatest threat to international health security would be an influenza pandemic. It has not receded, but early warnings allow the world a chance to prepare. Implementation of the IHR is the chance to prepare

14. What’s new? From three diseases to all public health risks
From preset measures to tailored response
From control of borders to also include containment at source
The IHR are innovative because
they move from purely a list of diseases to a dynamic process of risk identification, assessment and management
they move from a concept of static defence at borders, airports and ports to the concept of early detection, reporting and containment at source
they built on the concept that international health security is based on strong national public health infrastructure connected a global alert and response system.

15. 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), WNF, others….
Q1: public health impact serious?
Q2: unusual or unexpected?
Q3: risk of international spread?
Q4: risk of travel/trade restriction?
Insufficient information: reassess

16. 1. Health Measures - Recommendations
Temporary recommendations (Art 15)
Standing recommendations (Art. 16)
Examples of health measures for persons (Art. 18)
Review travel history and proof of medical examination, lab analysis, vaccination or other prophylaxis;
require medical examination, vaccination or other prophylaxis;
Public health observation, quarantine, isolation and contact tracing
Entry and exit screening
Refuse entry of suspect and affected persons
Refuse entry of unaffected persons to affected area.
Examples of health measures for baggage, cargo, containers, conveyances, goods and postal parcels (Art. 18)
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.

17. 2. Protections for travellers
Overarching rights (Arts. 3 & 32)
Sanitation and hygiene of transport (Art.s 22 & 24)
Charges (Art. 40)
Data protection (Art. 45)
Unjustified measures (Art.s 23, 30, 31, 35 & 43)

18. 3. Health Measures - General application
Generic
Arrival and departure (Art.s 23 & 31)
Information about travellers itinerary, destination, non-invasive medical examination
Inspection of baggage, cargo, containers, conveyances, goods, postal parcels and human remains
Specific
Yellow fever vaccination (Art. 36, Annexes 6&7)
Vector control - Disinsection of conveyances (Annex 5)

19. 4. Affected conveyances and imported cases
Affected or diverted conveyances and emergencies (Art.s 25,26,27 & 28)
Imported cases (Art. 9)

20. 4. Health Measures - additional
Additional (National and International Law) health measures (Art 43)

21. Learning from experience: the example of SARS
Identification of the problem
Linking events in different countries
Co-ordinating international response
Field Teams
Laboratory
Epidemiology
Clinical
Travel advice, entry and exit screening at PoE
Timely information & recommendations for control
Provision of direct support and assistance
SARS demonstrates the limitations of current IHR
What WHO & MSs did to collaborate
What needed to be included in a legal framework for working in this manner

22. What do the IHR call for?
Strengthened national capacity for surveillance and control, including in travel and transport
Prevention, alert and response to public health emergencies of international concern
Rights, obligations and procedures, and progress monitoring
Global partnership and international collaboration

23. Strengthen national disease surveillance, prevention, control and response system
Requires a commitment of States Parties
Mobilization of national resources: e.g. staff, infrastructure, budget
Development of national action plans, integrated and coordinated with
intermediate and local levels and points of entry (ports, airports, ground crossings)
Builds on existing national and regional strategies
Requires sustained multisectorial approach and international collaboration

24. IHR Strategic Implementation Plan
if IHR was a lighthouse …
National Capacity Strengthening
International initiatives and networking
NATIONAL SURVEILLANCE AND RESPONSE
WHO GLOBAL ALERT AND RESPONSE SYSTEM
THREAT-SPECIFIC CONTROL PROGRAMMES
INTERNATIONAL TRAVELS AND TRANSPORTS
LEGAL PROCEDURES
AND MONITORING
GLOBAL PARTNERSHIP

25. IHR Implementation Plan
GLOBAL PARTNERSHIP
Foster global partnerships (example CAPSCA PROJECT)
STRENGTHEN NATIONAL CAPACITY
2. Strengthen national disease surveillance, prevention, control and response systems
3. Strengthen public health capacities in travel and transport, including routine measures and emergency preparedness at points of entry
PREVENT AND RESPOND TO INTERNATIONAL PUBLIC HEALTH EMERGENCIES
4. Strengthen WHO global alert and response system
5. Strengthen threat-specific international control programmes
LEGAL ISSUES AND MONITORING
6. Sustain rights, obligations and procedures
7. Conduct studies and monitor progress

26. The IHR foster global partnership
Other intergovernmental organizations:
UN system (e.g. FAO, IAEA, ICAO, IMO, UNWTO)
others: regional (e.g. EU, ASEAN, MERCOSUR), technical (e.g. OIE)
Development agencies:
governments, banks
WHO Collaborating centres
Academics & professional associations
Industry associations (e.g. IATA, ISF)
NGOs and Foundations
The IHR provide for cooperation between WHO and other competent intergovernmental organizations or international bodies in the implementation of the Regulations.
WHO will therefore continue to foster its longstanding working relationships with a number of organizations such as the International Atomic Energy Agency, the International Air Transport Association, the International Civil Aviation Organization, the International Maritime Organization, the World Tourism Organization, Food and Agriculture Organization of the United Nations, the Office International d'Epizooties (World Organisation for Animal Health) and the World Trade Organization.
In addition to these specialized organizations, WHO will work with regional economic integration organizations such as the European Union and the Mercado Común del Sur (MERCOSUR) in implementing the Regulations in the countries of their respective regions.

27. STRENGTHEN NATIONAL CAPACITY FOR PUBLIC HEALTH RESPONSE
2. Strengthen national disease surveillance, prevention, control and response systems
3. Strengthen public health capacities in travel and transport – points of entry
Timeline
2007
2009
2012
2014
2016
Assessing Planning
Implementation
2 years (2) + (up to 2)
extensions
"As soon as possible but no later than five years from entry into force …" (Articles 5, 13)

28. 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
The extent of international travels is an extraordinary opportunity for disease transmission.

29. 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.
Increasing recognition that WHO cannot replace or make up for weak or missing capacity at national level

30. Core capacity requirements for designated points of entry PoE Art
DESIGNATION OF POINTS OF ENTRY
States Parties shall designate Airports and Ports for developing capacities – Annex 1b
States Parties where justified for PH reasons, may designate ground crossings for developing capacities – Annex 1b, 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 – Annex 1b
Identify competent authority for each designated point of entry
WHO CERTIFICATION FOR AIRPORTS AND PORTS
Under request of State Party WHO may arrange to certify it
Need to develop procedures and guidelines by WHO

31. Capacity Strengthening at Points of Entry
PoE Core capacity requirements at all times (routine)
(b) Equipment & personnel for transport ill travellers
(a) Assessment and Medical care, staff & equipment
(c) Trained personnel for inspection of conveyances
(e) Trained staff and programme for vector control
(d) ensure save environment: water, food, waste, wash rooms & other potential risk areas - inspection programmes

32. PoE Capacity requirements for responding to potential PHEIC (emergency)
Provide assessment & care for affected travellers, animals: arrangements with medical, veterinary facilities for isolation, treatment & other services b
Provide space, separate from other travellers to interview suspect or affected persons c
Public Health Emergency Contingency plan: coordinator, contact points for relevant PoE, PH & other agencies a
Provide for assessment, quarantine of suspect or affected travellers d
Provide access to required equipment, personnel with protection gear for transfer of travellers with infection/ contamination
To apply recommended measures, disinsect, disinfect, decontaminate, baggage, cargo, containers, conveyances, goods, postal parcels etc g e f
To apply entry/exit control for departing & arriving passengers

33. Some principle approaches
Continuous risks
Routine measures in place
"sanitary conditions" at points of entry and conveyances
travellers, goods etc.
Specific measures for certain known risks in place
Vector control, vaccination
Standing recommendations
Sudden increase in risk
Detection
information & verification
notification
risk assessment
Response
Support to investigation and control
Information and recommendations
IHR have always dealt with both "preventive", routine measures and "reactive" event related measures. This approach has been maintained.
In IHR(2005) the possibility of amending or adding to the routine measures is foreseen through "Standing Recommendations".
The Reglations encompass the detection and response to urgent events at both the national and international levels.

34. Points of entry Key public health functions
PREVENTION EARLY WARNING RESPONSE
RISK MANAGEMENT INSPECTION CONTINGENCY
ROUTINE CONTROL SCREENING PLANS
CONTROLING EVENTS
& RESPONDING
TO EMERGENCIES
DETECTING PUBLIC
HEALTH EVENTS
OF INTERNATIONAL
CONCERN
CONTROLING KNOWN
PUBLIC HEALTH RISKS
At PORTS, AIRPORTS,
GROUND CROSSING

35. What does WHO do under the IHR?
Designate WHO IHR contact points
Support States Parties in assessing their public health risks, through the notification, consultation, and verification processes
Inform State Parties of relevant international public health risks
Recommend public health measures
Assist States Parties in their efforts to investigate outbreaks and meet the IHR national core capacities requirements for surveillance and response and points of entry

36. 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 Global Outbreak and Alert Response Network GOARN and other specialized and regional support networks
Develop new tools and standard operating procedures
Carry out IHR exercises
WHO wide-exercise tests the global system for international health security
On, 15 June 2007, the day of the IHR’s entry into force, WHO will hold the first exercise to test its preparedness to successfully manage and support States during public health emergencies of international concern. As part of WHO's increased responsibilities under the revised IHR, considerable effort has been made to establish procedures, technological and human resource infrastructures to ensure WHO is ready to receive, analyse and disseminate information and make recommendations for dealing with public health emergencies of international concern.
The exercise on 15 June is the first of a series meant to test the mechanisms in place, their compliance with the IHR and opportunities for improvement. It consists of notifying a public health event involving multiple regions. This is an occasion to validate policy direction and coordination, information management and risk assessment capacity as well as the ability to utilize communications methods to report events from the country level through the Regional Offices to Headquarters.
Participants will span many levels of WHO across the globe, including selected country office staff, WHO IHR contact points, Regional Directors, Regional Advisors, WHO Emergency and Preparedness and Response group at Headquarters, and the office of the Director-General.

37. WHO system of Global Outbreak Alert and Response Network GOARN Operations
Event
Intelligence
Verification
Official, State
sources
Risk Assessment
WHO HQ, Regional & Country Offices, Collaborators and experts
Response
Global Outbreak Alert
and Response Network
An international system has been established at WHO
Key elements of this system are enshrined in obligations under IHR(2005)

38. Global distribution of GOARN institutions and partners
A network of more than 130 technical institutions,
WHO manages secretariat and logistic support

39. Global partnership and international collaboration

40. 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

41. PHE- Multi-sectoral Approach
Coordination with safety, security and facilitation local and national plans and operational procedures and committees on implementing public health emergency plans
Integration of local public health emergency plan with a national surveillance and response plan
Coordinating airport operations with national and international public health response plans
Public health services
Health care system
Veterinary services
Agriculture
Education
Communication
Transport
Trade
Security
Army, air force, defense…
Prime Minister’s Office/Presidential Cabinet
Scientific committee, Turkey , Avian Flu 2006

42. Information on IHR(2005) http://www.who.int/csr/ihr/WHA58_3-en.pdf
IHR text:
More information, FAQs on IHR:
For more queries on IHR
international travel and transport:
If anyone asks how to get more information

43. Note on arrangements for the issuance of Ship Sanitation Certificates SSC
As of 15 June 2007 the International Health Regulations (2005) ("IHR (2005)") have introduced new certification procedures for ships. The new certificates are entitled Ship Sanitation Control Exemption Certificate/Ship Sanitation Control Certificate ("Ship Sanitation Certificates" or "SSC"). These SSC replace the previous Deratting/Deratting Exemption certificates ("DC/DEC") provided for under the 1969 Regulations.
After 15 December 2007, no Deratting Certificate will be valid.

44. Interim technical advice for inspection and issuance of Ship Sanitation Certificates SSC
Valid for six month period
Used to identify and record all areas of ship-borne public health risks (not limited to rodents), together with any required control measures to be applied.
The SSC may be required from all ships, whether seagoing or inland navigation vessels, on an international voyage calling at the port of a State Party.
It may be renewed at any port authorized to issue such renewals by a State Party.
Authorized ports must have the capability to inspect, issue and implement (or supervise implementation of) necessary measures for the Ship Sanitation Control Certificate.

45. Interim technical advice for inspection and issuance of Ship Sanitation Certificates SSC
Ship Sanitation Control Exemption Certificate issued when
no evidence of a public health risk is found on board and
the competent authority is satisfied that the ship is free of infection and contamination, including vectors and reservoirs.
This certificate shall normally be issued only if the inspection has been carried out when the ship and holds are empty or when they contain only ballast or other material, of such nature or so disposed as to make a thorough inspection of the holds possible.

46. Interim technical advice for inspection and issuance of Ship Sanitation Certificates SSC
Ship Sanitation Control Certificate: issued when
evidence of a public health risk, including sources of infection and contamination, is detected on board and
after required control measures have been satisfactorily completed;
the SSC must record the evidence found and the control measures taken.

49. Ports Listing for issuing SSC
WHO is requesting information from States Parties regarding which ports each State Party is authorizing to issue these certificates and their extensions. As it becomes available, this information will be made accessible through the "SSC Ports List" which will be published on the IHR website
It should be noted that the listing of ports authorized by States Parties for the purpose of issuing SSC is not the same as the separate designation by them of points of entry PoE for development of core public health capacities as specified under Annex 1B of the IHR (2005).
PoE include international ports but also airports and ground crossings, and the capacities required extend beyond inspection and certification1.

51. Port authorized to issue SSC by WHO Regions and States Parties
AFRO
03 / 46 SP
AMRO
08 / 36 SP
WPRO
12 / 28 SP
33%
EMRO
06 / 21 SP
SEARO
03 / 11 SP
(72)
49 / 184 States Parties (SP) Total: 1338 ports as of 20/03/2008
EURO
17 / 53 SP

52. TRAVEL AND TRANSPORT IHR(2005) Challenges
Designation of authorized ports to issue SSC
Designation of PoE to develop, maintain and strength core capacities
Assessment of core capacities for designated points of entry
Implementation of WHO Certification for IHR core capacities requirements for ports and airports
Integration of points of entry activities to national surveillance system
Development of Intersectorial approach of Public Health concerns at PoE (e.g.;facilitation, security, safety and trade)
Development of integrated emergency contingency plans for PoE
Development of strategic approach for international communication and cooperation for response to events involving points of entry, travel and transport

53. Thank you. Any questions? Or
Daniel MENUCCI IHR Technical Officer Lyon FR.