SIXTY-SECOND WORLD HEALTH ASSEMBLY Provisional agenda item 12.2
A62/6 9 April 2009
Implementation of the International Health Regulations (2005) Report by the Director-General 1. In resolution WHA61.2, the Health Assembly decided that States Parties to the International Health Regulations (2005) and the Director-General would report annually to the Health Assembly on the implementation of the Regulations. It further decided that the first review and evaluation of the functioning of the decision instrument described in Annex 2 of the Regulations would be submitted to the Sixty-second World Health Assembly. 2. This report describes activities undertaken since the report submitted to the Health Assembly in May 2008,1 and is structured in line with the “areas of work for implementation” established in 2007.2 It also summarizes information received by WHO regarding implementation activities carried out by States Parties for the period 15 June 2007 to March 2009. The Executive Board took note of an earlier version of this report at its 124th session in January 2009.3 3. In order to facilitate States Parties’ reporting to the Health Assembly, in accordance with Article 54.1 of the Regulations, the Secretariat prepared a questionnaire, which was circulated in February 2008, requesting information on progress achieved in implementation of the Regulations since their entry into force on 15 June 2007. The Secretariat summarized the information received from the 144 States Parties that responded and sent that report to National IHR Focal Points in October 2008. Nearly all respondents (97%) provided full contact details of the national focal point, and most (89%) reported establishment of a means to provide continuous coverage for urgent communications with WHO. The responses indicated that communication channels between the national focal points and other relevant national authorities had been established by 83% of reporting Parties, with the agriculture ministry being the most frequently cited as collaborators. The competent authorities for the application of health measures at points of entry had been identified by 80% of respondents. Nearly three quarters (73%) of Parties reported having taken action to promote the awareness and understanding of the Regulations. At the time of reporting, 21% of Parties’ countries indicated that they had examined the possible need for additional financial resources in order to implement adequately the requirements of the Regulations. Some 68% of respondents expressed an intention to adapt existing national legislation to meet their obligations, and 58% reported their participation in regional arrangements that explicitly covered implementation of the Regulations.
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Document A61/7. Document WHO/CDS/EPR/IHR/2007.1. Document EB124/2009/REC/2, summary record of the first meeting, section 7.
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4. In order to update this information for the Sixty-second World Health Assembly a further questionnaire was sent to National IHR Focal Points in early February 2009 for completion online, by e-mail or in hard copy. Preliminary analysis based on the responses from 82 States Parties in all WHO regions that were received by the submission deadline shows that National IHR Focal Points continue to establish cross-sectoral links (100%) and that, in addition to the health sector, the food safety (91%) and agriculture, fisheries and animal health (82%) sectors are the most frequently cited collaborators. All 82 States Parties indicated that activities had been undertaken to promote awareness of the requirements of the Regulations with policy- and decision-makers being the most frequently identified target of such activity (83%) after health sector personnel (91%). Other primary targets for these activities are personnel in the food safety sector (80%) and those involved in emergency preparedness (76%). The limited number of responses available at the time of submitting this report, however, renders any detailed comparison between the 2008 results and this latest update uncertain. The Secretariat will continue to solicit additional responses and provide a fuller analysis on that basis. In 2009 the Secretariat plans to establish a new web-based system for States Parties to report progress in implementation. Such a system will also facilitate the Secretariat's annual reporting to the Health Assembly by allowing the extraction of key indicators status in a timely way, without having to rely on repeated completion of questionnaires.
GLOBAL PARTNERSHIP 5. The Secretariat continues to produce multilingual online training packages for all staff and national health authorities. These packages contain, inter alia, general knowledge about the Regulations and a more specific training module on event assessment and notification using the decision instrument. Another is being developed on adjustments of national legislation appropriate for full and efficient implementation. The second edition of the Regulations, published in English in 2008, includes Annex 9 as revised by ICAO1 in 2007, and appendices containing a list of States Parties and their reservations and other communications to WHO. The other five language versions were published in January 2009 and all are available on the WHO web site. 6. WHO maintains close working relationships with other organizations of the United Nations system and international agencies and other entities, including the Cruise Lines International Association, the International Association of Independent Tanker Owners and European Centre for Disease Prevention and Control. WHO also continues to rely heavily on its technical partners1 including those in the Global Outbreak Alert and Response Network. Efforts to encourage the donor community and development agencies to support implementation are being made with regard to the strengthening of national surveillance and response capacities, as set out in Annex 1 of the Regulations. Regional organizations such as the Asian Development Bank, the European Union and MERCOSUR (the Common Market of the South) have been powerful allies in this endeavour. Roles for finance and commerce ministries and for central banks in support of implementation continue to be explored.
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Document A61/7.
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STRENGTHENING NATIONAL CAPACITY 7. Regarding national capacities in disease surveillance and response, the Secretariat, through its regional and country offices, continues to adapt WHO’s regional strategies for national disease surveillance and response systems to the requirements of the Regulations. The WHO Lyon Office for National Epidemic Preparedness and Response continues to provide technical assistance for the assessment of existing national structure and resources, the development of regional surveillance networks, and the promotion of laboratory quality systems. It also supports training in field epidemiology and risk communication. 8. Special attention has been given to the importance of good laboratory practices and quality management for the most vulnerable health systems. Microbiology External Quality Assessment programmes for epidemic-prone diseases were continued for 76 reference laboratories in 46 countries in the African Region and 21 countries in the Eastern Mediterranean Region. Thirteen twinning projects were established between resource-limited laboratories and specialized institutions throughout WHO’s six regions. Laboratory biosafety training programmes and laboratory certification for transport of infectious substances also form part of WHO’s efforts to bring the laboratory back to the core of national surveillance systems. Programmes in this area have been set up in the African, South-East Asia and Western Pacific Regions. 9. For further improvement of global influenza preparedness, WHO has continued to strengthen national and regional capacities in influenza laboratory diagnosis, surveillance, preparedness and response by working with three countries on the formal designation of new WHO Influenza Collaborating Centres, by supporting the designation and setting-up of seven new national influenza centres since November 2007, and by supporting stronger quality assurance and training activities. The continuation of the WHO External Quality Assessment project for the detection of influenza subtype A viruses using the polymerase chain reaction was followed by distribution of two proficiency testing panels every year to all National Influenza Centres and other national influenza laboratories with capacity to use the polymerase chain reaction test. Tailored training as follow-up to the WHO External Quality Assessment project was organized for national influenza centres in Africa, Asia and the Middle East. In addition further training sessions to increase influenza laboratory capacity will be organized for African countries later in 2009. In the past two years, training workshops for safe handling of infectious substances under ICAO regulations were held in all six WHO regions. For the past several years, WHO Collaborating Centres for reference and research on influenza have been updating and distributing influenza diagnostic reagents for surveillance to national influenza centres at no cost. 10. The Secretariat has supported States Parties in assessing and strengthening capacities at designated international airports, ports and ground crossings, in accordance with Annex 1 of the Regulations, and has also been supporting the implementation of the requirements of the Regulations concerning ship inspection and the issuance of Ship Sanitation Certificates. As of 1 March 2009, more than 1640 ports have been listed as authorized to issue Ship Sanitation Certificates by 69 countries in all WHO regions. Joint initiatives were prepared as part of the Cooperative Agreement for Preventing the Spread of Communicable Diseases through Air Travel, under the leadership of ICAO. Following a series of expert consultations and workshops, with over 500 participants from 87 countries in all WHO regions, several technical documents were developed, existing guidelines were updated, and new technical guidelines are in preparation for the certification of ports, airports and ground crossings. The workshops provided the opportunity to validate and introduce new tools for implementation of the Regulations at global level.
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PREVENTION AND RESPONSE TO INTERNATIONAL PUBLIC HEALTH EMERGENCIES 11. The networks of National IHR Focal Points and WHO IHR Contact Points continue to be used effectively for rapid communication of public health information between WHO and States Parties. WHO has maintained and tested the accessibility and effectiveness of its Regulations Contact Points in all six regional offices. The number of users with access to the IHR Event Information Site has continued to grow; the current number of accounts is 638, representing 157 States Parties. 12. On 11 and 12 June 2008, WHO tested its alert and response procedures worldwide through the Public Health Security Exercise, which helped to identify opportunities for improvement in detecting and responding to potential or real international public health emergencies. Although the processing and consolidation of information proved to be challenging, a flow of crucial public health information was quickly established and sustained between the Secretariat (headquarters, regional offices and country offices) and participating Member States. Case definitions for the four notifiable diseases in the Regulations were posted on the WHO web site together with the WHO Interim Guidance for the use of the decision instrument. This guidance document builds on input from experts and WHO staff members experienced in the development and application of the decision instrument in Annex 2 of the Regulations. The document is designed primarily for National IHR Focal Points and for others responsible for assessing the need to notify WHO of events under the Regulations and includes case scenarios illustrating the application of the assessment criteria. An expert consultation (Geneva, 20–22 October 2008), which was attended by experts from 13 States Parties and all six regional offices, provided advice on further refining the interim guidance (which is due to be made available later in 2009) and recommended methodologies for the review and evaluation of the functioning of Annex 2. In addition to two quantitative and one qualitative analyses, a study of WHO databases was recommended as a first step. 13. In line with a recommendation from the expert consultation, the Secretariat reviewed communications, assessments and outcomes of public health events that were reported to, or identified for follow-up by, the Organization. The main source of data used was the Event Management System which has been implemented at WHO headquarters for several years and more recently introduced into some regional offices. All events entered into the System between the entry into force of Regulations on 15 June 2007 and 31 December 2008 were reviewed and the regional offices validated the data, through for example identification of additional events and filling in gaps where information in the System was missing. Of the 684 events included in the study the National IHR Focal Point was positively identified as the initial information source in 133 (19%) and official government sources in a further 64 (9%). Of the 133 events whose initial report was from a National IHR Focal Point there was evidence that Annex 2 of the Regulations had been used in the assessment of the event on 44 occasions (33%). In 95 of the reports from National IHR Focal Points (71%) the nature of the report under the Regulations (i.e. notification, information-sharing, consultation or other report) was not specified, and only 14 (11%) were identified specifically as notifications under the Regulations. These results indicate that the National IHR Focal Points are not yet a major source of early information to WHO on events and there is no evidence to confirm that Annex 2 of the Regulations is being frequently or routinely used in the assessment of events. This analysis throws a limited amount of light on the use being made of Annex 2 by States Parties; the Event Management System is an operational tool and not intended to collect information of the type needed to understand the extent of current use, and any barriers to more extensive use, of the decision instrument. The findings emphasize the importance of the further studies recommended by the expert consultation, so that actions to improve the use of Annex 2 can be designed and targeted appropriately and the early flow of information to WHO on events facilitated.
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14. The application of the Regulations to the management of specific health risks continues to be analysed in relation to the undiminished threat posed by current outbreaks of avian influenza in poultry, human infections with avian influenza viruses and the preparations for a possible influenza pandemic. WHO has convened a series of global consultations to update guidance on pandemic influenza preparedness and response. This new advice will be disseminated to Member States and other stakeholders shortly. 15. During the period under review, WHO has responded to significant public health events in accordance with the Regulations, including cases of lead intoxication in children and the new and widespread global resistance to the antiviral agent oseltamivir among seasonal influenza viruses A (H1N1). In the related area of chemical and radiological public health risks, WHO has ensured that its threat-specific networks, such as the Radiation Emergency Medical Preparedness and Assistance Network, ChemiNet (WHO Global Chemical Incident Alert and Response Network), the poisons centre network and BioDoseNet (the Global Biodosimetry Network), are fully aware of both the requirements of the Regulations and their roles in improving national surveillance capacities and in assisting in international alert, assessment and response. WHO has conducted surveillance and assessment of chemical-related outbreaks, provided technical support to countries facing chemical emergencies, and organized emergency response missions, for example to deal with an outbreak of illness of unknown etiology (later identified as being due to ingestion of sodium bromide) and mass lead poisoning in children. WHO has used its recently developed common platform for alert and response to potential public health emergencies to participate in the international nuclear emergency exercise held in 2008 (one of several such exercises periodically organized and coordinated by IAEA), named “ConvEx-3”. An expert consultation on yellow fever and international travel was organized (Geneva, 4 and 5 September 2008) to review the criteria for inclusion of countries and/or areas in, or their removal from, the list of those with yellow fever transmission, in accordance with Annex 7 of the Regulations. Participants also reviewed the criteria for determining the list of countries or areas with yellow fever transmission for which WHO might recommend vector-control measures for departing conveyances, as set out in Annex 5 of the Regulations. On the recommendation of the consultation, an informal working group of experts on country-specific mapping of yellow fever risk has been set up. Finally, a separate report on food safety has been submitted to the Health Assembly.1
LEGAL ISSUES AND MONITORING 16. In accordance with requirements of the Regulations, the Director-General has appointed 56 experts nominated by States Parties to serve on the Roster of Experts in 21 subject areas, and she has proposed an additional 117 experts. Administrative procedures have been developed so that the Secretariat can meet requirements during a public health emergency of international concern. Advice and information on the Regulations and other implementation issues are continuously provided within WHO, to States Parties and to competent intergovernmental organizations or international bodies. 17. The Secretariat monitors the progress of States Parties in establishing National IHR Focal Points, their communications and their access to the Event Information Site. The preparation of specific indicators to monitor national progress in strengthening core capacities set out in Annex 1 of the Regulations has reached its final stages.
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Document A62/21.
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REGIONAL ACTIVITIES 18. Provision of support to States Parties by WHO’s regional and country offices has increased. Activities to raise awareness in health and other governmental sectors in countries have been carried out. Relying heavily on existing regional strategies and technical partners, workshops on the Regulations, meetings and field visits, including in the area of capacity strengthening at points of entry (international ports, airports and ground crossings), have been organized in all WHO regions. 19. In addition to WHO’s IHR Contact Points being available on a continuous basis at regional level for urgent communications with National IHR Focal Points, all WHO regional offices have set up emergency operation rooms with greatly improved communication facilities. All were tested during the Public Health Security Exercise. 20. Key issues in implementation include the need to continue to increase awareness by national and regional stakeholders. Regional offices have identified a need for greater focus in the mobilization of resources and the role of disease-specific programmes in contributing to generic capacity strengthening.
ACTION BY THE HEALTH ASSEMBLY 21. The Health Assembly is invited to take note of this report.
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