International Health Regulations: WHO Framework to Combat Epidemics

WHO International Working Group on the Revision of the International Health Regulations (WHO/Jean-Marc Ferré)

Global Need for Coordination of Efforts

The International Health Regulations (IHR) is a structural body created to increase Global Health Security and prevent national public health emergencies from becoming global crises. The IHR were first implemented in 1969 focusing on plague, cholera, yellow fever and small pox. Several years later in 1995, the reemergence of plague in India and Ebola in Democratic Republic of Congo (DRC) created the need to revise and update the IHR. This led to the creation of a network of technical collaborations among existing institutions and networks, which would pool human and technical resources for the rapid identification, confirmation and response to outbreaks of international importance: the Global Outbreak Alert and Response Network (GOARN). Most recently, the GOARN has focused on the Middle East Respiratory Syndrome Coronavirus (MERS-CoV). Alert and response operations functions include:

  • Event-based surveillance, multi-hazard rapid risk assessment and event-based risk communications
  • Critical information and communications platforms for decision support
  • Operations and logistics platforms for any WHO response to international public health risks.

As the revision of IHR continued, the Severe Acute Respiratory Syndrome (SARS) epidemic in 2003 further evolved the process, giving birth to the revised IHR, the IHR 2005, which was adopted at the 58th world health assembly in 2005. Within two years of adoption, the entry into force for most countries was a significant public health landmark for the WHO and its member states. Not limited to any specific disease, the IHR 2005 urged the member countries to notify


the WHO of events that can potentially constitute a public health emergency of international concern. The IHR 2005 also urged the countries to develop core public health capacities by the year 2012, with a possible 2-year extension. All the Member States have abided by the IHR principles, and the countries were left to self-report their progress on core capacity development, such as surveillance, diagnostic and containment demands.

Intergovernmental Working Group on the Revision of the International Health Regulations (WHO/Jean-Marc Ferré)

Over the past few years, the programs initiated as per the IHR have been boosted, and new activities regarding the provision of these health regulations have been successfully established.

However, the 2014 Ebola outbreak in west Africa has shattered the economics and the dynamics of the west African countries and has left the world with a setback that reflects the lack of adherence and implementation of the IHR. The lack of financing in the initial vision of the IHs has become a huge missed opportunity that has affected developing economies further more. Although the framework for the development and implementation of IHR is available with high-income countries, the low-income and middle-income economies have faced tough challenges in adherence to these regulations.

Acknowledging the gaps in the global governance and with distinctive interests in the global security, the United States has launched the “Global Health Security Agenda” in order to accelerate progress towards a world safe and secure from infectious disease threats and to promote global health security as an international security priority.

IHR 2005 and Ebola

Looking at the financial perspective in retrospect, the current Ebola outbreak, which is not yet completely controlled, has already cost west Africa more than $32 billion.

The Emergency Committee regarding the 2014 Ebola outbreak in West Africa convened by the WHO Director-General under the IHR 2005 held its 3rd meeting of members and advisers on Wednesday, 22 October 2014. The Committee held the unanimous position that the epidemic continues to constitute a Public Health Emergency of International Concern (PHEIC).

The Emergency Committee’s current situation update included:

  • Cases continue to increase exponentially in Guinea, Liberia, and Sierra Leone.
  • The key lessons learned to control the outbreak include the importance of leadership, community engagement, bringing in more partners, paying staff on time, and accountability. WHO, UN partners and the international community have increased their support in these countries.
  • The outbreaks in Nigeria and Senegal were declared over as of October 20th and October 17th, respectively. The Committee applauded this development and commended those involved in this achievement.
  • Cases have recently occurred in Spain and USA with the index cases in both countries coming from West Africa.

The Emergency Committee’s recommendations for countries with “Intense Transmission” (Liberia, Sierra Leone, Guinea):

  • Exit screening in Guinea, Liberia and Sierra Leone remains critical for reducing the exportation of Ebola cases.
  • States should maintain and reinforce high-quality exit screening of all persons at international airports, seaport, and major land crossings, for unexplained febrile illness consistent with potential Ebola infection.
  • The exit screening should consist of, at a minimum, a questionnaire, a temperature measurement and, if fever is discovered, an assessment of the risk that the fever is caused by Ebola virus disease (EVD).
  • States should collect data from their exit screening processes, monitor their results, and share these with WHO on a regular basis and in a timely fashion to increase public confidence and provide important information to other States.

The Emergency Committee’s recommendations for all other countries:

  • No general ban on international travel or trade.
  • A general travel ban is likely to cause worsening economic turmoil and may increase the uncontrolled migration of people from affected countries raise the risk of international spread of Ebola.
  • The Committee emphasized the importance of normalizing air travel and the movement of ships, including the handling of cargo and goods, to and from the affected areas, to reduce the isolation and economic hardship of the affected countries.
  • Entry screening may have a limited impact in reducing international spread when added to exit screening, and its advantages and disadvantages should be carefully considered.
  • If entry screening is implemented, countries should consider the following issues:
    • It offers an opportunity for individual evaluation, but the resource demands may be significant, even if screening is targeted.
    • Management systems must be in place to care for travelers and suspected cases in compliance with IHR requirements.
  • Countries should use a risk-based approach to make decisions about cancelling international meetings and mass gatherings.
  • There should not be a general ban on participation of competitors or delegations from countries with transmission of Ebola wishing to attend international events and mass gatherings but that the decision of participation must be made on a case by case basis by the hosting country.

The Emergency Committee’s final recommendation is very poignant:

All countries should strengthen education and communication efforts to combat stigma, disproportionate fear, and inappropriate measures and reactions associated with Ebola. Such efforts may also encourage self-reporting and early presentation for diagnosis and care.


Report written by Sarathi Kalra, MD, MPH and Bobby Kapur MD, MPH.

One comment

  1. Prof OP Kalra Principal University College of Medical Sciences, University of Delhi

    Needs urgent attention of international health policy makers. Wonderful and practical suggestions.

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