1. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 1 |1 | International Health Regulations (2005) and EWARS Dr Nirmal Kandel, MBBS, MA, MPH Disease Surveillance and Epidemiology WHO - Indonesia

2. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 2 |2 | Objectives The IHR history and principles Define EWAR as a component of IHR and as such the need of EWAR components in the surveillance systems of countries

3. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 3 |3 | What is IHR? Definition History Functions Principles EWAR and IHR Conclusions A binding legal document between WHO and Member States with:  rights  obligations  standardized procedures

4. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 4 |4 | IHR 2005 Definition History Functions Principles EWAR and IHR Conclusions Established by negotiation between States Adopted at the World Health Assembly (2005) & legally binding on WHO’s Member States Entry into force on 15 June 2007 Five years to develop country core capacities

5. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 5 |5 | Definition History Functions Principles EWAR and IHR Conclusions International Health Security IHR(2005), a paradigm shift From control of borders to containment at source From diseases list to all threats From preset measures to adapted response

6. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 6 |6 | Health system Epidemiology Laboratory Preparedness Case management Infection control Social mobilisation Communication … Health system Epidemiology Laboratory Preparedness Case management Infection control Social mobilisation Communication … National disease surveillance and response system IHR Annex 1A

7. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 7 |7 | Ports Airports Ground crossings Intersectoral collaboration Aviation sector (ICAO, ACI, IATA) Shipping (IMO, ISF, CLIA) Railways (UIC) IHR Annex 1B, (also 3, 4, 5, 8, and 9)

8. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 8 |8 | Intelligence Verification Risk assessment Response (GOARN) Logistics Surveillance and response at global level IHR Annex 2 (notification instrument)

9. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 9 |9 | Aim of IHR Definition History Functions Principles EWAR and IHR Conclusions « 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 unecessary interference with international traffic and trade »

10. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 10 | IHR 2005 innovations Definition History Functions Principles EWAR and IHR Conclusions WHO authorized to: – consider unofficial reports or disease events and obtain verification, – declare a PHEIC and issue temporary recommendations, Establishment of IHR National Focal Points and WHO Contact Points for urgent communications (24/7 availability), Update and revise many technical and regulatory functions, including points of entry.

11. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 11 | IHR 2005 innovations Definition History Functions Principles EWAR and IHR Conclusions Not limited to specific diseases, but to any threat, Country obligations to: – develop minimum core public health capacities, – Notify WHO of any potential PHEIC according to defined criteria,

12. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 12 | Core Capacities (Annex 1a) Surveillance and Response Definition History Functions Principles EWAR and IHR Conclusions – Detection (EWAR) – Verification – Investigation – Notification – Response

13. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 13 | Function of a surveillance system aiming to detect any abnormal phenomenon that will trigger prompt public health interventions Early Warning

14. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 14 | Early warning and response

15. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 15 | Indicator-based surveillance Event-based surveillance Signal Initial assessment Monitor Discard or close Investigate Daily Round Table Report Daily Internal Response Team External Response Team Action plan Support Coordinate Update assessment Prepare Sit rep Monitor Early Warning and Response Loop Early Warning Response

16. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 16 | PHEIC Definition History Functions Principles EWAR and IHR Conclusions “an extraordinary event which constitutes a public health risk to other States through the international spread of disease and potentially require a coordinated international response” Member States need to report any potential PHEIC DG of WHO declares PHEIC

17. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 17 | Notification Definition History Functions Principles EWAR and IHR Conclusions Countries have the obligation to: Notify WHO of any potential PHEIC Within 24 hours of assessment, using a specifically designed decision instrument Continue to provide WHO with detailed information “Notification” process itself does not mean a real “PHEIC”

18. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 18 | IHR - Event notification and determination Community concern Media Private/public clinicians concern Public services, agencies Health care system Lab Pharmacies HOT LINE Informal system Event-based Surveillance Health system based Signal Yes ALERT Public health risk identified Unusual disease pattern ? Event verified ? Public health Significance? International Concern? PHEIC Investigation & control Notification to WHO Yes Early Warning Response Source Status Decision Action IHR National Focal Point IHR WHO Focal Point

19. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 19 | Decision instrument to identify a potential PHEIC Definition History Functions Principles EWAR and IHR Conclusions – All cases of: new subtype human influenza, wild-type polio, SARS, smallpox – Events involving certain other diseases (cholera, pneumonic plague, yellow fever, viral haemorragic fevers, West Nile Fever, meningococcal disease) – All events involving at least 2 of 4 criteria: 1.Potentially severe public health impact 2.Unusual or unexpected nature 3.Significant risk of international spread 4.Significant risk of restrictions on international travel or trade

20. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 20 | Risk of spread internationally? Reassess when more information available NoNo Yes NoNo Is the event unexpected? Notify the event under the International Health Regulations Yes Is the event unexpected? NoNo Risk of spread internationally? NoNo Yes Risk for international sanctions? NoNo Is the event serious? Yes NoNo IHR Decision intrument

21. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 21 | Conclusions (1) Definition History Functions Principles EWAR and IHR Conclusions IHR is a legally binding international instrument developed through negotiation between States Purpose of IHR is to prevent and respond to the international spread of disease while avoiding unnecessary interference with international traffic and trade

22. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 22 | Conclusions (2) Definition History Functions Principles EWAR and IHR Conclusions IHR represents a huge opportunity to develop needed core capacities in every country To establish and maintain an effective national early warning system (EWAR) is an obligation for all member States.

23. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 23 | Question Time 1.Do you think IHR is a useful instrument at national and international level? 2.If you were nominated National IHR Focal Point tomorrow how would you proceed to ensure that the obligations of your country in terms of surveillance and response were met?

24. Disease Surveillance and Epidemiology (DSE) – WHO Indonesia 24 | Thank you