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• Modernisation of the International Health Regulations - WHO European Region consultation
  

Modernisation of the International Health Regulations - WHO European Region consultation

Attempts to use legal measures to prevent the international spread of infections have taken place since the cholera epidemics that spread from the far east into Europe in the 19th Century. This culminated in regulations devised at the International Sanitary Conference in Paris in 1851.  The current legislation is that in the International Health Regulations (IHR) (1) which were developed by the World Health Organization (WHO) in 1969 (2).  The current Regulations, which were originally intended to help monitor and control six serious infectious diseases, only require countries to report to WHO and apply control measures for just three infections: cholera, plague, and yellow fever.

Since the 1980s a series of developments and events have made it apparent that the current Regulations are inadequate as a legal response to global outbreaks, and rising levels of infectious diseases. The impetus for this has come from increased international travel and trade, emerging infections, the threat of bioterrorism, and a series of inadequately controlled international outbreaks, epidemics, and events, such as HIV, multidrug resistant tuberculosis, variant Creutzfeldt Jakob disease, the viral haemorrhagic fevers, SARS, and avian influenza.  WHO and its member states have been responding to such events and have developed good capacity in WHO Communicable Disease Surveillance and Response Division (WHO- CSR) (details can be found at <http://www.who.int/csr/about/en/>) and the Global Outbreak Alert and Response Network (GOARN) (details at <http://www.who.int/csr/outbreaknetwork/en/>).  There is, however, no adequate legal underpinning for this work.  For example, when concern was expressed that national authorities in China had been slow in reporting the outbreak of what became SARS in late 2002, it turned out that there was neither a legal reason for them to make such a report, nor any legal justification for WHO being able to insist on investigating when it became aware of rumours of severe outbreaks of pneumonia in Guangdong Province late in 2002.  In contrast, Chinese authorities would be legally obliged to report even a single case of cholera.

WHO and its ruling body, the World Health Assembly, have been developing new regulations since 1995. Following a series of resolutions passed by the World Health Assembly between 2001 and 2003, a draft set of radically improved Regulations was issued in January 2004 (3).  These regulations, which comprise 55 articles and ten Annexes, are now being considered in WHO regional consultations with a view to a final text being approved by the World Health Assembly in the spring of 2005. The regulations would come into force in January 2006.  The Regional Consultation for WHO's European Region is taking place in Copenhagen from 9 to 11 June.

Much of the regulations reflect what has become good practice by WHO and member states in the past years in response to threats such as SARS and viral haemorrhagic infections, and outbreaks of unknown diseases. The regulations are complex and a longer article describing them can be found on the HPA website at  <http://www.hpa.org.uk/hpa/international/IHR.htm>.

There are six major developments proposed in the new Regulations.

• They would require member states to notify to WHO of any events or disease that potentially constitutes a public health event or emergency of international concern ie a prescriptive list of diseases is not being used.  Member States would also be obliged to respond to WHO's requests for verification of information regarding national risks when WHO becomes aware of other reports or even rumours. This would enable WHO to ensure appropriate technical assistance for effective protection and management of such events.
• The scope of the Regulations will also be extended beyond infections to include chemical and radiation threats as well as events where the cause is as yet unclear.
• Each WHO member state will be required to have one or more national IHR focal points and corresponding contact individuals. These will form the operational link between states and WHO, and provide and receive official information to and from WHO on a continuous basis.  This is so that recommendations for response actions and measures to protect the state can be communicated effectively.
• Each state will be required to have core public health capacities in order to detect, report, and respond to public health risks and potential or actual public health events of international concern. In addition to this, specific capacities will be required for the implementation of routine measures at points of entry (airports, seaports and land borders). 
• WHO's response to an event may include temporary or standing recommendations for measures for application by the state affected by a public health issue of international concern, other states, and operators of international transport. Temporary recommendations would be made by WHO on an ad hoc, time-limited, risk-specific basis, as a result of a public health event of international concern.  Standing recommendations, made by WHO under the draft revised IHR, would indicate the appropriate measures for routine application for specific on-going public health risks. 
• Finally, the proposed Regulations include procedures for member states and WHO obtaining independent advice concerning implementation of the Regulations. First is the establishment of a committee to be used during public health emergencies to provide advice on temporary recommendations. The second is the establishment of an IHR review committee which will consider disputes, the development of standing recommendations and evaluate how the Regulations are functioning.

The Department of Health in London is leading the response to the proposals, which are also being considered at a European Union level prior to the European meeting. The HPA has been asked to provide technical support to the Department in considering how the new Regulations would work operationally, and it has developed an interim position which is broadly supportive, but with some suggestions for detail improvement  <http://www.hpa.org.uk/hpa/international/IHR_statement.htm>. The Department of Health (England) is consulting with other government departments and the Departments of Health in the devolved administrations (Northern Ireland, Scotland, and Wales), while the Health Protection Agency is consulting with its technical counterparts in the devolved administrations and equivalent agencies throughout the United Kingdom.  Comments are sought on the HPA technical view <http://www.hpa.org.uk/hpa/international/IHR_statement.htm> and these should be sent by email before7 June 2004 to <cdscdirector@hpa.org.uk>, marked International Health Regulations.

The process of consultation will not finish with the Copenhagen meeting as WHO regional views will subsequently be combined and a revised set of Regulations will probably be issued later in 2004.   A further UK view will be needed at that point.

References

1.WHO.  Current International Health Regulations (IHR) [online] [cited 12 May 2004]. Geneva: World Health Organization, page undated.  Available at <http://www.who.int/csr/ihr/current/en/>.

2.WHO.  Frequently asked questions on the proposed revision of the International Health Regulations [online] [cited 12 May 2004].  Geneva: WHO, 2004.  Available at <http://www.who.int/csr/ihr/howtheywork/faq/en/>.

3.WHO.  International health regulations.  Working paper for regional consultations.  Geneva: WHO, 2004. Available at <http://www.who.int/csr/ihr/revisionprocess/working_paper/en/>.