The International Health Regulations 2005 and their implications for local Port Health

This guidance provides an explanation of the key implications of the International Health Regulations (IHRs) for local Port Health planning and service delivery.

The IHRs 2005 are a legally binding international instrument whose purpose is 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 and trade".
The full IHR are available http://www.who.int/gb/ebwha/pdf_files/WHA58/A58_55-en.pdf

There are some key concepts within them:

National Focal Point (NFP)
Article 4 of the IHR 2005 requires a State Party to "designate or establish a National IHR Focal Point" (NFP) which "shall be accessible at all times for communications with the WHO IHR Contact Points".  The NFP has a duty to both assess events that may be PHEICs (see below) and to notify them to WHO.  The UK Government has decided to designate the HPA as the UK's NFP.  The duty doctor system at CfI is generally the initial point of contact for the NFP and the Director (or deputy) of CfI is the individual with overall responsibility for the NFP function.

Designated Points of Entry
Designated Points of Entry are those ports and airports which meet the standards set out in Annex 1B of the IHRs.  These will be designated by the UK Government, with the IHRNFP holding a list of them.  This list will be posted on the HPA website and the current list for England is included in annex 1.

Public Health Emergencies of International Concern (PHEIC)
Under the new IHR, state parties have a duty to notify WHO of any case of a list of specified diseases; smallpox, poliomyelitis due to wild-type virus, human influenza caused by a new sub-type and SARS.  These diseases must always be notified to WHO.  In addition the new IHR make provision for notification of other events that may constitute a Public Health Emergency of International Concern (PHEIC), and an algorithm has been developed to assist with this (available at Annex 2 of the IHR(2005)).  Note that events may be biological, chemical or radiological in nature.
Competent Authority
A competent authority is the local authority or port health authority responsible for the implementation and application of health measures at designated points of entry under the IHR 2005.

As a signatory to the IHRs, the UK has many responsibilities. These include:

Notification of Public Health Emergencies of International Concern to the International Health Regulations National Focal Point (IHRNFP).  

There is an obligation on signatories to the IHRs to assess all events which may constitute a PHEIC and to report these to WHO along with any health measures implemented in response.  For the UK this obligation is to be undertaken by the HPA in its role as IHR National Focal Point. 

A joint protocol has been developed between the Department of Health and the HPA for the assessment and reporting of PHEICs by the NFP.  For cases of diseases on the specified list that must always be reported to WHO the HPA will assess and notify directly to WHO.  Declaring a PHEIC is, however, a major step, with significant consequences nationally and internationally.  Where the event is not one of the diseases on the specified list the decision-making involves the appropriate HPA expert team, the CfI Director and the CMO before WHO is informed.  The timescales are tight, as a State must notify WHO of a PHEIC within 24 hours of assessment.

The key implication is that Health Protection Units handling suspected cases of any of the list of specified diseases, or any other event that may constitute a PHEIC should inform CfI immediately as per the protocol (note that this applies even where the event is chemical or radiological).  When communicating with CfI in the context of notification of disease or events to IHR, this should be clearly stated so that the appropriate response is triggered.  The relevant HPA expert team (most usually within CfI) will initiate the PHEIC assessment in conjunction with the local team.

Article 22.2 of IHRs 2005 – competent authorities communicating with IHRNFP on public health measures taken under IHR 2005

This article includes the day to day activities carried out by competent authorities at designated points of entry, such as de-ratting, disinfecting, decontaminating or disinsecting, rather than any additional measure taken, to which article 27(below) relates.  It is envisaged that there will be some form of periodic, regular return from the competent authority to the IHRNFP, but these arrangements have yet to be clarified.  It is not expected that this will require any specific action by HPUs.

Article 27.1 of IHRs 2005 –  the reporting of "additional health measures "

This article requires a competent authority at a designated point of entry to have the power to "disinfect, decontaminate, disinsect or derat a conveyance".  It goes on to say that "the competent authority may implement additional measures (e.g. isolating the conveyance) as necessary to prevent the spread of disease".  If "additional measures" are implemented, the competent authority is required to notify the IHRNFP.  The rationale behind this requirement is that such an exceptional measure may indicate the possibility of a PHEIC.

Article 43.2 describes "additional health measures" in more detail. They are any measure "which significantly interferes with international traffic", i.e. refusal of entry or departure or delay for more than 24 hours. If this occurs, the IHR requires a State which is implementing such additional measures to notify WHO within 48 hours of such measures and their rationale.
It is expected that implementing such additional measures will be a rare event.  As such, if a competent authority feels it needs to exercise this power, it should inform the local Health Protection Unit immediately, if it is not already in consultation with them anyway.  The HPU will then notify the IHR National Focal Point immediately, by contacting the Duty doctor at CfI, making sure that attention is drawn to this as an Article 27 issue.

All Port Health Authorities/Local Authorities which are "competent authorities" under the IHRs are requested by the HPA to ensure that the responsibility to notify the local Health Protection Unit  in these circumstances is included within their code of operating practice.

Last reviewed: 23 April 2009