Christian Frederickson – PhD, MPH, MPM, CAREC/PAHO/WHO

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 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

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. (www.shippingfacts.com ). • From 1970-2000, a WHO review of over 100 outbreaks associated with ships found that more than one-third were related to foodborne transmission (http://www.who.int/water_sanitation_health/diseases/shipsancompendium/en/index.html

12. Infectious Disease Concerns in the Caribbean • Dengue virusandChikungunyavirus • 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 (2000-2001)

13. H5N1: Avian influenza, a pandemic threat

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

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

22. What do the IHR call for? • Strengthened national capacityfor 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 … International initiatives and networking National Capacity Strengthening WHO GLOBAL ALERT AND RESPONSE SYSTEM NATIONAL SURVEILLANCE AND RESPONSE 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

27. Timeline 2 years + 3 + (2) + (up to 2) 2007 2009 2012 2014 2016 Assessing Planning Implementation 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 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

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.

30. Core capacity requirementsfor designated points of entry PoEArt.19, 20 & 21 • DESIGNATION OF POINTS OF ENTRY • States Parties shalldesignate Airports and Ports for developing capacities – Annex 1b • States Parties where justified for PH reasons, maydesignate 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 Provide space, separate from other travellers to interview suspect or affected persons b 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 entryand 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

34. Points of entry Key public health functions • PREVENTION EARLY WARNINGRESPONSE • 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

37. Event Intelligence Official, State sources Verification Risk Assessment WHO HQ, Regional & Country Offices, Collaborators and experts Response Global Outbreak Alert and Response Network WHO system of Global Outbreak Alert and Response Network GOARN Operations

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) • IHR text: • http://www.who.int/csr/ihr/WHA58_3-en.pdf • More information, FAQs on IHR: http://www.who.int/csr/ihr/en/ • For more queries on IHR • international travel and transport: • ihrtransport@who.int

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 issuanceof 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 issuanceof 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 issuanceof Ship Sanitation Certificates SSC • ShipSanitation 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.

47. http://www.who.int/csr/ihr/ssc/en/index.html

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 http://www.who.int/csr/ihr/ • 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.

50. http://www.who.int/csr/ihr/portslanding/en/index.html