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Comment
Abstract
The revised International Health Regulations (IHR) 1 entered into force on June 15, 2007, obligating (now) 196 States Parties to detect, assess, report, and respond to potential public health emergencies of international concern (PHEIC) at all levels of government, and to report such events rapidly to the WHO to determine whether a coordinated, global response is required. In the 8 years since its entry into force, there have been three declared PHEIC, including pandemic infl uenza H1N1 in 2009, re-emerging wild-type poliovirus in April, 2014, Ebola virus disease in west Africa in August, 2014, and the emergence of new diseases such as Middle East respiratory syndrome coronavirus and infl uenza H7N9, with still uncertain risks to global population health.
Implementation of the IHR has been tested under real world conditions. The regulations have served as a valuable guidepost for national and international capacity building, coordination, and collaborations for global health security. Other international fora have also recognised the importance of the IHR as a global framework, and have focused discussions among nations on IHR-related core capacities in meetings of the Biological and Toxin Weapons Convention, the Global Health Security Initiative, the North American Plan for Pandemic and Avian Infl uenza, the Convention on Biological Diversity, and United Nations Security Council Resolution 1540, in addition to debate at the World Health Assembly.
Other new partnerships have formed to strengthen the global response to public health threats. In February, 2014, the USA, along with almost 30 nations and the Directors-General of the WHO, Food and Agriculture Organization, and Organization for Animal Health, launched the Global Health Security Agenda to address several high-priority, global infectious disease threats. Foundations have become increasingly engaged in global health security, becoming primary funders for capacity building around the world, and the World Bank is playing an increasingly more prominent role in global health preparedness and response.
Yet by 2012, only 42 nations (21%) reported that they had fully implemented the IHR and built appropriate core capacities to detect, assess, report, and respond to public health emergencies. With follow-up reporting in 2014, only 64 nations reported that they had fully implemented the IHR-an increase of only 10% over 2 years. The other 67% of nations either requested another 2-year extension (81) or reported nothing at all (48). 2 National compliance statistics are themselves an indicator of the challenges associated with IHR implement ation, particularly the paucity of mandated funding to support capacity building. Additionally, it has become clear that the methods for assessing health security preparedness leave substantial room for interpretation, and there are ongoing disagreements over the mandate for the airport or port health certifi cation programme outlined in Article 20.
Failure of the global community to respond rapidly and eff ectively to the Ebola virus disease outbreak in west Africa demonstrates that there remain major implementation challenges, even beyond funding and political will. It is time to consider whether or not aspects of the foundation for global health security embodied in the IHR (2005) are too vague, missing, or need to be strengthened in order for IHR to stay relevant and useful.
With the 10-year anniversary of the IHR's entry into force on June 15, 2017, a full and formal IHR review conference could address the following issues (among others): • Metrics: assessing national capacity, including objective independent assessments of compliance • Sample sharing: linking IHR and the Pandemic Infl uenza Preparedness Framework, with approaches for sample sharing beyond infl uenza • International contact tracing: improved systems for identifying and coordinating public health measures for high-risk travellers • Response: responsibilities for coordination in a multinational emergency response • Capacity building: funded structures within WHO and the regional offi ces to assist nations with building required capacities • Zoonotic disease: application of IHR to animal diseases and development of one health systems.
www.thelancet.com/lancetgh Vol 3 July 2015
The WHO and designated committees of experts have been reviewing these ideas and are committed to strengthening the IHR, including examining performance after public health events. 2, 3 We argue that, although this is a necessary step, it is now time to open the debate to all Member States of the World Health Assembly, so that all nations, with varying experiences, can provide input into how the regulations are strengthened.
States Parties should take the opportunity at the May, 2015, World Health Assembly to begin to discuss the need for a review conference to consider amendments to the IHR. Stakeholder meetings and regional consultations in 2015 and 2016, with formal discussion at the WHO Executive Board meeting in 2016, could lead to formal resolutions at the 2016 World Health Assembly calling for a 2017 review conference. This process would be consistent with Articles 2(k), 21(a), and 22 of the WHO Constitution, and previous iterations of the regulations as amended. 4 A formal review conference in the spring of 2017 would produce amendments that could be adopted at the 2017 World Health Assembly-on the 10th anniversary of the IHR's entry into force.
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