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Emerg Infect Dis
. 2012 Jul;18(7):1041–1046. doi: 10.3201/eid1807.120395
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WORLD HEALTH ORGANIZATION PERSPECTIVE ON IMPLEMENTATION OF INTERNATIONAL HEALTH
REGULATIONS

Maxwell Charles Hardiman


MAXWELL CHARLES HARDIMAN

1World Health Organization, Geneva, Switzerland
Find articles by Maxwell Charles Hardiman
1,✉; World Health Organization Department of Global Capacities, Alert and
Response1
 * Author information
 * Copyright and License information

1World Health Organization, Geneva, Switzerland
✉

Address for correspondence: Maxwell Charles Hardiman, Department of Global
Capacities Alert and Response, World Health Organization, 20 Avenue Appia, 1211
Geneva, Switzerland; email: hardimanm@who.int

✉

Corresponding author.

This is a publication of the U.S. Government. This publication is in the public
domain and is therefore without copyright. All text from this work may be
reprinted freely. Use of these materials should be properly cited.

PMC Copyright notice
PMCID: PMC3376823  PMID: 22709544

--------------------------------------------------------------------------------

The regulations have substantially helped prevent and control the international
spread of diseases, but their full potential has yet to be realized.

Keywords: World Health Organization, international cooperation, regulations,
international health regulations, WHO, implementation, disease, spread,
pandemic, influenza


ABSTRACT

In 2005, the International Health Regulations were adopted at the 58th World
Health Assembly; in June 2007, they were entered into force for most countries.
In 2012, the world is approaching a major 5-year milestone in the global
commitment to ensure national capacities to identify, investigate, assess, and
respond to public health events. In the past 5 years, existing programs have
been boosted and some new activities relating to International Health
Regulations provisions have been successfully established. The lessons and
experience of the past 5 years need to be drawn upon to provide improved
direction for the future.

--------------------------------------------------------------------------------

Throughout the >60 years that the World Health Organization (WHO) has been in
existence, member states have made use of the constitutional provision that
permits the Health Assembly to adopt regulations concerning sanitary and
quarantine requirements and other procedures designed to prevent the
international spread of disease (1). In 1951, the first such regulations, the
International Sanitary Regulations, were adopted and focused on 6 communicable
diseases requiring coordinated international measures to control their
transmission between countries (2). By the 1990s, they had been amended and
renamed the International Health Regulations (IHR); their application was
reduced to only 3 diseases, and they were considered inadequate for addressing
the increasingly globalized nature of health risks. In 1995, the Health Assembly
called on the WHO secretariat to develop revised regulations that were more
relevant to worldwide public health challenges (3–5). A process of intensive and
wide technical consultation was followed by a series of intergovernmental
negotiations in which WHO member states took control of the draft and negotiated
additions and amendments to every aspect before agreeing to a final version in
time for it to be adopted at the 58th Session of the Health Assembly (6).

Since entering into force in 2007, the IHR have provided a legally binding
global framework to support national and international programs and activities
aimed at preventing, protecting against, controlling, and providing a public
health response to the international spread of disease (7). Although the IHR
contain articles directed toward several facets of public health security, they
can be broadly summarized into 2 main areas: urgent actions to be taken with
respect to acutely arising risks to public health and strengthening of national
systems and infrastructure (referred to as core capacities). This article
provides an overview of selected contributions to these areas made during the
past 5 years. It is written from the perspective of the WHO department charged
with coordinating implementation of the IHR at WHO global headquarters in Geneva
and seeks to identify major achievements and continuing challenges.


ESTABLISHMENT OF NATIONAL IHR FOCAL POINTS

One of the early demonstrations of global commitment to implementation of the
IHR has been the successful establishment of National Focal Points (NFPs) in all
but 1 of the states parties to the IHR. (States parties to the IHR include all
WHO member states, the Holy See [an observer to the World Health Assembly], and
Liechtenstein.) NFPs are national centers, not individual persons, that occupy a
critical role in conducting the communications aspects of the IHR, within their
countries and internationally (8). They are responsible for proactively
notifying WHO of relevant health events, responding to WHO secretariat requests
for event-related information, and ensuring that messages and advice from WHO
are disseminated to the relevant actors within the country. Since 2007, NFPs
have been increasingly diligent in updating and confirming their contact details
to WHO on an annual basis as required by the regulations. NFPs are officially
sanctioned to work with WHO on IHR implementation and provide feedback to WHO on
country needs and concerns for this task. Staff members who work in NFPs are a
major audience for WHO training materials. The engagement of NFPs in the
scientific evaluation of the IHR notification procedures has indicated that a
high proportion of NFPs had a good understanding of the notification procedures
and had accessed WHO training materials on this issue and has indicated that
agreement was high in terms of events that must be notified when applying the
procedures (9). NFPs have access to the contact details of all other NFPs
through a password-protected website that enables direct communication among
countries at the NFP level. For events that do not require WHO coordination
(such as routine tracing of contacts for an infectious disease associated with
international travel), such direct communications have been useful.

Not all NFPs are able to function as expected. For example, some contact details
fail to work for urgent communications, some NFPs indicate that procedures for
round-the-clock communications are not yet established, and delays in responding
to requests for event information often occur. Studies have indicated that NFPs
know how to assess events under the IHR. Their participation in event-related
communications is increasing; however, their role has been primarily providing
official and accurate information on events that first gain WHO attention
through informal sources such as media reports. Among the reasons identified for
such less-than-optimal performance is that some NFPs lack authority or access to
the necessary authority, resulting in delays in obtaining clearance for
communications. Such lack of authority is also identified as a barrier to the
effective intersectoral collaboration that is envisioned as critical to the NFP
role within their national situation. Although NFPs generally recognize the
value of engaging with government sectors outside the health ministry, they lack
the convening power needed to establish solid and reliable linkages.


PILOT TESTING OF IHR-IMPLEMENTATION COURSE

A key WHO objective is to strengthen the human resources available to countries
to set up and manage systems for securing global public health under the IHR
framework. In partnership with established educational institutions, the WHO
secretariat has been pilot testing an IHR-implementation course, which promotes
a global harmonized understanding and application of the IHR framework.

The IHR-implementation course is for public health professionals, mainly those
belonging to NFPs but also those from other related sectors from national or
international organizations in public and private sectors. The course is
delivered over 5 months as on-the-job training. The 210 total learning hours
consist of 12 weeks of distance learning with tutoring and a 6-week break used
to finalize assignments and prepare for the 2-week face-to-face session.

The first 3 pilot IHR-implementation courses have been operated by the WHO
Department of Global Capacities, Alert and Response in collaboration with the
University of Pretoria, South Africa; Georgetown University Law Center, USA; the
University of Geneva, Switzerland; and Institut Bioforce Développement, France.
Implementation of the courses involved the contributions of several WHO
departments: Food Safety, Zoonoses and Foodborne Diseases; Protection of the
Human Environment; Health Action in Crises; and Health Systems and Services. WHO
Regional Offices have been mobilized to identify and sponsor participants.

The IHR-implementation courses have been delivered in English to 89 participants
from 57 countries in all 6 WHO regions. Post-training evaluation of the first 2
courses conducted in 2011 indicated that the course content was relevant to
participants’ work, improved their understanding of IHR, and increased their
confidence when dealing with the topic. Competencies developed have been put
into practice, and material from the course has been re-used at the national
level. The opportunity to engage with peers from other countries during and
after the course was considered especially valuable.

In light of the positive evaluation and continuing need, organization of
additional courses at the national level is planned. A need to provide the
course in languages other than English requires new institutional partners and
additional resources. Some of the IHR-implementation course contents are being
developed into stand-alone modules for potential integration into other
established training opportunities such as field epidemiology training and
Masters of Public Health programs.


MONITORING OF PROGRESS OF IHR NATIONAL CORE CAPACITIES

One of the most substantial obligations introduced by the IHR is the commitment
of states parties to develop, strengthen, and maintain national capacities to
identify, investigate, assess, and respond to public health events in their
territories and to develop, strengthen, and maintain routine and emergency
public health capacities at certain designated points of entry. These
obligations were introduced in acknowledgment that effective national systems
are the essential underpinning to any global health security and that such
systems are the mechanisms needed to prevent many public health events from
reaching the level of international significance. The IHR capacities are
described in functional terms in Annex 1, and a major milestone toward
implementation has been to reach a consensus on the scope and technical
components that can be expected to contribute to the required functionality.

For surveillance and response, the capacities are grouped under the following 8
main headings:

 * National legislation, policy and financing

 * Coordination and NFP communications

 * Surveillance

 * Response

 * Preparedness

 * Risk communication

 * Human resources

 * Laboratory

A range of potential health hazards can fall under the IHR capacity
requirements. These hazards have been identified as infectious, zoonotic, food
safety, chemical, and radiologic/nuclear.

To help states parties assess their capacity, a monitoring framework was
developed. The framework represents a consensus of technical expert views drawn
globally from WHO member states, technical institutions, partners, and from
within WHO. The framework incorporates current knowledge and concepts that have
been successfully used to monitor capacity-development activities. It builds on
the experts’ knowledge of current capacities of states parties, existing
regional and country strategies for capacity development, and other available
resources and tools, particularly other tools used for IHR core capacity
assessment by states parties. Using a checklist of 20 indicators, the IHR
monitoring process assesses status of implementation in 8 areas of core
capacity, development of capacities at points of entry, and development of
capacities for the IHR-relevant hazards.

An annual questionnaire is used to collect data on the core capacities; country
responses are stored in a secure database at WHO, accessible only to IHR NFPs
and the secretariat through use of tools that ensure country confidentiality.
The questionnaire is made available in several formats, including through the
Internet. To ensure that the full spectrum of relevant hazards is covered, NFPs
are advised to lead the process of completing the questionnaire, in close
collaboration with officials responsible for the various capacity areas and
including other sectors.

Outputs of the monitoring framework include country profiles for all reporting
countries and detailed NFP reports on strengths, weakness, and gaps; profiles
for the 6 WHO regions; and aggregated global reports for the World Health
Assembly. This information has enabled states parties to measure progress and
identify where improvements are needed, thereby providing evidence for program
planning, recommendations, and decision making. At the global level, this
monitoring information is used by the secretariat to comply with the Health
Assembly request for an annual report on IHR implementation from WHO, including
information provided by states parties and on the secretariat’s activities.
Thus, WHO governing bodies can take account of the progress when directing
secretariat activities. The analysis also enables better identification of the
priority areas toward which the secretariat and other development partners can
focus their support to countries.

From a total of 194 states parties, the questionnaire elicited 128 and 156
responses for 2010 and 2011, respectively. Because not all states parties
responded to the questionnaire, the reports produced might not completely
reflect IHR core capacity development strengths and weaknesses at the regional
and global levels. Evaluating implementation status in nonresponding countries
is challenging, especially because some of these countries face the greatest
implementation difficulties. With the goal of improving the validity and
consistency of self-reported data, several multicountry workshops and trainings
have been held and standardized data collection and analysis tools have been
promoted. Such challenges are also being addressed by identifying several
supplementary information sources that might partially reflect national IHR
capacities and including such information in an additional report to the 2012
Health Assembly.

The biggest challenge involved in implementing the IHR is ensuring that the IHR
core capacities are present in all countries of the world. Ensuring IHR core
capacities is also the area in which the IHR have the greatest potential to make
a major contribution to world health; as the process approaches a key 5-year
milestone on June 15, 2012, all efforts are being refocused on this issue.


INTERAGENCY COLLABORATION FOR PUBLIC HEALTH AT POINTS OF ENTRY

Although many IHR provisions address international travel and transport and
public health activities at points of entry (ports, airports, and ground
crossings), these have not been areas in which WHO or many member states had
strong preexisting programs. Attention has therefore been focused on leveraging
interagency and multisectoral collaboration at all levels to achieve the public
health objectives. For example, the Cooperative Arrangement for the Prevention
of Spread of Communicable Disease through Air Travel project (10) is an
initiative of the WHO sister agency the International Civil Aviation
Organization, through which countries can receive support for realizing IHR
objectives relating to air travel. Other collaborations include the
International Tourism Response Network (11), regional networks such as the Risk
Assessment Guidance for Infectious Diseases Transmitted on Aircraft project
(initiated by the European Centre for Disease Prevention and Control) (12), and
the European Commission ship sanitation training network project (13). To
facilitate information sharing and coordination among authorities responsible
for health measures and development of IHR core capacities at points of entry,
WHO supports a specialized network for ports, airports, and ground crossings:
the PAGnet (14). During the 2011 nuclear accident in Japan, the 2010–11 cholera
epidemic in Haiti, and the 2009 influenza A (H1N1) pandemic, PAGnet offered a
communication platform to public health officials at points of entry around the
world, facilitating timely information sharing on response measures that helped
avoid overreaction and unnecessary barriers to international travel and trade.

Although assessments have shown many IHR capacities at certain points of entry
in several countries, countries differ widely in the levels of capacity, the
allocation of responsibilities, and the priority given to this area of public
health. This heterogeneity makes it more difficult to provide guidance and
advice that is relevant to the national and local contexts of all ports,
airports, and ground crossings around the world. Private industry and commercial
organizations, which involve a variety of governmental sectors in addition to
health, are key actors for the implementation of IHR provisions affecting travel
and transportation. WHO must use its convening power, its neutrality, and its
focus on public health objectives to help the disparate actors reach consensus.


PANDEMIC INFLUENZA AND CONVENING OF THE EMERGENCY COMMITTEE

Around the world, many IHR provisions are used daily. Thus far, however, the
full range of provisions relating to global emergencies have been applied to
only 1 event: the 2009–2010 influenza pandemic. The IHR define a category of
events with the term “public health emergency of international concern.” The WHO
director-general follows defined procedures to determine which events are so
characterized. The key practical outcomes of such a determination are the
provision of relevant information to all states parties, the convening of an IHR
Emergency Committee to advise the director-general regarding the event, and the
issuance of IHR temporary recommendations.

The first IHR Emergency Committee was convened on April 25, 2009, to advise the
WHO director-general about the determination of the first public health
emergency of international concern under the IHR. That this first meeting of the
Emergency Committee took place by teleconference within 48 hours of the decision
to convene it demonstrated that the procedures established by the IHR could work
in practice. The continued work of this committee, providing advice to the
director-general for more than a year, demonstrates the commitment of its
members to support the governments of the world and WHO in their responses to
the emergency. During the influenza pandemic, the NFP network developed
much-needed momentum and provided early information and situation updates as the
virus was identified around the world. The WHO secretariat was able to provide
updates, announcements, and advice to countries through the event information
site for NFPs with timing that was coordinated with its provision of public
information.

The duration of the public health emergency of international concern posed
several challenges for the procedures established for IHR implementation. For
example, the decision to protect the impartiality of the advice given by members
of the IHR Emergency Committee (by not publishing their names until after their
work was completed) was not helpful when their work went on for more than a year
and was under intense media speculation. Also, the rules adopted for temporary
recommendations were designed to allow them for only a limited amount of time,
which was just barely compatible with the pandemic experience. The IHR did not
prevent several countries from applying restrictive travel- and trade-associated
measures not recommended by WHO, although several such measures were
discontinued or modified after communication with the WHO secretariat. The IHR
Review Committee was concerned by the restrictive measures and provided
recommendations on how they can be more effectively addressed (15).


ESTABLISHMENT OF EXTERNAL IHR REVIEW

The potential to learn lessons from the 2009–2010 pandemic influenza experience
and the need to address public concerns regarding the WHO response led to the
establishment of the first IHR Review Committee. The remit of this committee was
expanded (by the WHO Executive Board from a periodic review of the functioning
of the IHR, as required under IHR Article 54) to include an independent,
external review of the international response to pandemic influenza. Although
the secretariat provided administrative and logistic support, the committee,
under the chairmanship of Harvey Fineberg, enjoyed complete autonomy in
interpreting their mandate, defining their methods of work, and identifying
their evidence. In doing so, they followed the requirements of the IHR in
ensuring states parties the opportunity to observe and engage in formal
committee meetings. After more than a year, the committee delivered its final
report to the 64th Health Assembly, at which the approach taken was commended
and the recommendations were endorsed by the member states. Despite findings
that WHO faced systemic difficulties and some shortcomings in addressing the
influenza pandemic, the committee concluded that the actions taken were
motivated by public health concerns and found no evidence of misconduct. The 15
recommendations in this report have gone on to form a major component of the
biennial work plans of the relevant WHO departments.

The exhaustive work of the IHR Review Committee made heavy demands on the time
of its expert members and on WHO resources. WHO should take advantage of the
exceptional opportunity to learn from this analysis of the pandemic experience.

The IHR allow review committees to give advice broadly on the functioning of the
regulations, and it can be foreseen that in future years, committees will need
to be convened with markedly different tasks, for example, advising on the
granting of a second round of extensions to the core capacity time frame. At
such time, the working methods of such a future review committee will need to be
reassessed to fit with its mandated task.


CONCLUSIONS

The IHR are a legal tool designed to contribute to the achievement of public
health goals, in which success is seen and measured in improvements to public
health rather than adherence to any particular article of the document. At the
same time, given the large number of initiatives for and influences on public
health outcomes, it will always be hard to tease out and identify the specific
contributions of such an instrument to global health. This article indicates
some of the direct effects that IHR implementation is having on public health
practice. Where states and WHO are building on preexisting programs, the IHR
have boosted continuing commitment and momentum. An example at the international
level is the WHO program for management of acute public health events; an
example at the country level is the program to strengthen capacity in public
health laboratories. In addition to boosting existing programs, some new
activities relating to IHR provisions have been successfully established, such
as the NFP network and the Emergency Committee.

The lessons and experience of the past 5 years need to be drawn upon to provide
improved direction for the future. The member state–driven negotiations provide
a legacy of ownership and commitment from countries, which continues to be
evident in the nature and number of interventions concerning IHR during meetings
of WHO governing bodies. As we approach the 5-year target date of June 2012, the
immediate challenge is for WHO and the states parties to live up to the
intention of the IHR national core capacity requirements and to make the best
use of the opportunity for countries to continue their efforts beyond that date
as anticipated under the extension procedure provided by the IHR.


BIOGRAPHY

Dr Hardiman is team leader within the WHO Department of Global Capacities, Alert
and Response, which focuses on the legal and procedural aspects of IHR
implementation. His research interests are detection and response to disease
outbreaks and protection against the international spread of disease.


FOOTNOTES

Suggested citation for this article: Hardiman MC; World Health Organization
Department of Global Capacities, Alert and Response. World Health Organization
perspective on implementation of International Health Regulations. Emerg Infect
Dis [serial on the Internet]. 2012 Jul [date cited].
http://dx.doi.org/10.3201/eid1807.120395

1

Members who contributed to this article: Anouk Berger, Stella Chungong, Sophia
Desillas, Paula Gomez, Fernando Gonzalez-Martin, Daniel Menucci, Varvara
Mouchtouri, Isabelle Nuttall, Bruce Plotkin, Rajesh Sreedharan, and Jun Xing.


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Articles from Emerging Infectious Diseases are provided here courtesy of Centers
for Disease Control and Prevention


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 * Abstract
 * Establishment of National IHR Focal Points
 * Pilot Testing of IHR-Implementation Course
 * Monitoring of Progress of IHR National Core Capacities
 * Interagency Collaboration for Public Health at Points of Entry
 * Pandemic Influenza and Convening of the Emergency Committee
 * Establishment of External IHR Review
 * Conclusions
 * Biography
 * Footnotes
 * References


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