Canada's obligations to global public health security under the revised International Health Regulations.

• Author: McDougall, Christopher W.

Summary

The aim of the World Health Organisation's recently revised International Health Regulations [IHR] is to establish a global alert and response network for outbreaks of infectious disease and other public health threats with the potential for international spread. The rationalized and modernized IHR are a set of obligations and procedures for broad-based domestic and international public health collaboration to contain known risks, respond to unexpected ones, and improve national and international readiness through long-term sustainable capacity building at all levels. However, in the absence of significant changes to existing policies, operations, and capacities both within and among nations, compliance with the requirements of the agreement will remain challenging for many countries. This article briefly surveys the historical origins and the principal requirements of the revised IHR, with a particular focus on four key obligations: (1) to create an integrated national surveillance system; (2) to ensure timely reporting; (3) to prevent the application of excessive restrictive measures; and (4) to contribute to capacity-building in the developing world. Strategies for meeting the challenge of these obligations are proposed, as are recommendations for Canadian policy leadership in laying the foundations for effective global public health security in the 21st century.

Introduction

In May 2005, Member States' delegates to the World Health Assembly [WHA] approved a series of major revisions to the World Health Organisation's [WHO] International Health Regulations [IHR]. (1) The approval of the IHR, the only binding international legal instrument for the control of infectious diseases (2), was a culmination of more than a decade of negotiations that were impelled to conclusion by the SARS experience, the expanding H5N1 crisis, and the threat of another global pandemic of human influenza. This article briefly surveys both the historical origins and some principal requirements of the revised IHR, and it seeks to open a constructive debate on how best to achieve compliance with four particular obligations, each of which raises difficult policy challenges in the Canadian context.

Revision of the IHR

The roots of the IHR stretch back to mid-19th century sanitary conventions among European trading powers devised to reduce the expense of preventing the spread of cholera, yellow fever, and plague. (3) That State Parties to the IHR, as the conventions were renamed in 1961, were still legally obligated to disclose only the incidence of those three diseases a century and a half later provides a good indication of how antiquated the regulations had become by the 1990s. Another was the increasingly wide variation in standards for inspection and hygiene measures, as well as conflicting or discriminatory applications of public health practice. (4) Of greatest concern, however, was that countries had begun, routinely and with impunity, to fail to adhere to the notification regulations and to WHO recommendations with regard to containment protocols. Affected states had become reluctant to give notice of an outbreak, and unaffected states had become increasingly prone to imposing scientifically unjustified (and economically damaging) measures in response to outbreaks. Examples of such non-compliance occurred in the 1990s with apparent outbreaks of plague in India and of cholera in Peru and East Africa, (5) and in 2003 during the SARS crisis. (6)

The 2005 revisions are intended to lift the IHR out of obsolescence and disregard by broadening the scope, enforceability, scientific rigour, and transparency of the regulations, and of the processes through which they will operate. Three specific principles guided the revision process: (1) all public health risks of urgent international concern should be reported to WHO; (2) stigmatisation and unnecessary constraints on international travel and trade should be avoided; and (3) a global system of surveillance and detection, combined with a pro-active response capacity under a WHO-led multilateral framework, should be developed. (7) All State Parties have approved the revisions, set to enter into force in June 2007. Significantly, the United States included in its formal agreement to the regulations a reservation that it will implement them "in line with U.S. principles of federalism." (8)

The primary objective of the regulations remains that of balancing security from the international spread of disease against unnecessary interference with world traffic and trade. Unchanged as well are the four basic state obligations: (1) notification to WHO of cases of certain diseases and transfer of epidemiological evidence thereof; (9) (2) provision of hygienic measures and health services at all ports; (3) issuance of international health and/or vaccination certificates; and (4) application of health measures to international traffic that are not more stringent than the measures described in the Regulations (unless a compelling scientific rationale is assessed as legitimate by WHO authorities).

In tandem or in response to the IHR revision process, numerous plans, goals, and guidelines for improving human and animal health surveillance and pandemic preparedness activities have been developed by public health authorities at all levels of government. (10) Growing awareness of the conflict between the need to boost transparent global detection systems and the substantial economic disincentive to report H5N1 outbreaks recently generated a call, (11) and then a formal recommendation by the WHO Executive Board, (12) to accelerate the process of compliance with key provisions of the revised IHR deemed relevant to pandemic influenza preparedness and response.

Key Changes to the International Health Regulations

The revised IHR contain a number of important changes that distinguish it from its predecessor, three of which are noteworthy here: (1) the requirement that all State Parties meet specific standards and develop minimum capacities for their national surveillance and response systems; (2) the formalization of the WHO's authority to act during potential public health emergencies of international concern; and, (3) the expectation that the State Parties will assist each other, with the assistance of the WHO, in public health capacity-building and implementation of the IHR.

In a departure from the horizontal character of...