Chapter 1 summary
Evolution of public health security
Chapter 1 begins by tracing some of the first steps, historically, that led to the introduction of IHR (1969) – landmarks in public health starting with quarantine, a term coined in the 14th century and employed as a protection against “foreign” diseases such as plague; improvements in sanitation that were effective in controlling cholera outbreaks in the 19th century; and the advent of vaccination which led to the eradication of smallpox and the control of many other infectious diseases in the 20th century. Understanding the history of international health cooperation – its successes and its failures – is essential in appreciating its new relevance and potential.
Numerous international conferences on disease control in the late 19th and early 20th centuries led to the foundation of WHO in 1948. In 1951, WHO Member States adopted the International Sanitary Regulations, which were replaced and renamed the International Health Regulations in 1969. Starting in 1995, the Regulations were revised through an intergovernmental process which took into account new epidemiological understanding and accumulated experience, and which responded to the changing world and the related increased threats to global public health security. It was agreed that a code of conduct was required that could not only prevent and control such threats, but could also provide a public health response to them while avoiding unnecessary interference with international trade and traffic. The revision process was completed in 2005 and the Regulations are now referred to as IHR (2005).
Chapter 1 describes how the basis of an effective global system of epidemic alert and response was initiated by WHO in 1996 and how it has been widely expanded since then. It was built essentially on a concept of international partnership with many other agencies and technical institutions. Called the Global Outbreak Alert and Response Network (GOARN), this partnership provides an operational and coordination framework to access expertise and skill, and to keep the international community constantly alert to the threat of outbreaks and ready to respond. Coordinated by WHO, the network is made up of over 140 technical partners from more than 60 countries.
In addition, the unique, large-scale active surveillance network developed by the Global Polio Eradication Initiative is being used to support surveillance of many other vaccine-preventable diseases, such as measles, meningitis, neonatal tetanus and yellow fever. This network is also regularly supporting outbreak surveillance and response activities for other health emergencies and outbreaks described in the report. In 2002, WHO established the Chemical Incident Alert and Response System to operate along similar lines to GOARN. This was extended in 2006 to cover other environmental health emergencies, including those related to the disruption of environmental health services, such as water supply and sanitation, as well as radiological events and emergencies.
The revised Regulations define an emergency as an “extraordinary event” that could spread internationally or might require a coordinated international response. Events that may constitute a public health emergency of international concern are assessed by State Parties using a decision instrument and, if particular criteria are met, WHO must be notified. Mandatory notification is called for in a single case of a disease that could threaten global public health security: human influenza caused by a new virus subtype, poliomyelitis caused by a wild-type poliovirus, SARS and smallpox.
The broad definitions of “public health emergency of international concern” and “disease” allow for the inclusion in IHR (2005) of threats beyond infectious diseases, including those caused by the accidental or intentional release of pathogens, or chemical or radionuclear materials. This extends the scope of the Regulations to protect global public health security in a comprehensive way.
The IHR (2005) redirect the focus from an almost exclusive concentration on measures at airports and seaports aimed at blocking the importation of cases, as required in IHR (1969), towards a rapid response at the source of an outbreak. They introduce a set of “core capacity requirements” that all countries must meet in order to detect, assess, notify and report the events covered by IHR (2005) and aim to strengthen collaboration on a global scale by seeking to improve capacity and demonstrate to countries that compliance is in their best interests. Thus, compliance has three compelling incentives: to reduce the disruptive consequences of an outbreak, to speed its containment, and to maintain good standing in the eyes of the international community.
A revolutionary departure from previous international conventions and regulations is the fact that IHR (2005) explicitly acknowledges that non-state sources of information about outbreaks will often pre-empt official notifications. This includes situations where countries may be reluctant to reveal an event in their territories. WHO is now authorized through IHR (2005) to take into account information sources other than official notifications. WHO will always seek official verification of such information from the country involved before taking any action based on the information received. This reflects a new reality in a world of instant communications: the concealment of disease outbreaks is no longer a viable option for governments.