International Health Regulations

The International Health Regulations originated with the International Sanitary Regulations adapted at the International Sanitary Conference in Paris in 1851. The cholera epidemics that hit Europe in 1830 and 1847 made apparent the need for international cooperation in public health.

In 1948, the World Health Organization Constitution came about. The Twenty-Second World Health Assembly (1969) adopted, revised and consolidated the International Sanitary Regulations, which were renamed (in the English language only) the International Health Regulations (1969). The Twenty-Sixth World Health Assembly in 1973 amended the IHR (1969) in relation to provisions on cholera. In view of the global eradication of smallpox, the Thirty-fourth World Health Assembly amended the IHR (1969) to exclude smallpox in the list of notifiable diseases.

During the Forty-Eighth World Health Assembly in 1995, WHO and Member States agreed on the need to revise the IHR (1969). The revision of IHR (1969) came about because of its inherent limitations, most notably:

• narrow scope of notifiable diseases (cholera, plague, yellow fever). The past few decades have seen the emergence and re-emergence of infectious diseases. The emergence of “new” infectious agents Ebola Hemorrhagic Fever in Zaire (modern- day Democratic Republic of Congo) and the re-emergence of cholera and plague in South America and India, respectively;
• dependence on official country notification; and
• lack of a formal internationally coordinated mechanism to prevent the international spread of disease.

These challenges were placed against the backdrop of the increased travel and trade characteristic of the 20th century.

The IHR (2005) entered into force, generally, on 15 June 2007, and are currently binding on 196 States Parties, including all 194 Member States (countries) of WHO.

The implementation of IHR (2005) shall be:

1. With full respect for the dignity, human rights and fundamental freedom of persons;
2. Guided by the Charter of the United Nations and the Constitution of the World Health Organization;
3. Guided by the goal of their universal application for the protection of all people of the world from the international spread of disease;
4. States have, in accordance with the Charter of the United Nations and the principles of international law, the sovereign right to legislate and to implement legislation in pursuance of their health policies. In doing so, they should uphold the purpose of these Regulations. (Art 3. IHR (2005))

In 2010 at The Meeting of the States Parties to the Convention on the Prohibition of the Development, Production and Stockpiling of Bacteriological (Biological) and Toxin Weapons and Their Destruction in Geneva [1] the sanitary epidemiological reconnaissance was suggested as well-tested means for enhancing the monitoring of infections and parasitic agents, for practical implementation of the IHR (2005) with the aim was to prevent and minimize the consequences of natural outbreaks of dangerous infectious diseases as well as the threat of alleged use of biological weapons against BTWC States Parties. The significance of the sanitary epidemiological reconnaissance is pointed out in assessing the sanitary-epidemiological situation, organizing and conducting preventive activities, indicating and identifying pathogenic biological agents in the environmental sites, conducting laboratory analysis of biological materials, suppressing hotbeds of infectious diseases, providing advisory and practical assistance to local health authorities.

A PHEIC is defined in the IHR (2005) as, “an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response”. [1] This definition implies a situation that is:

• serious, sudden, unusual or unexpected;
• carries implications for public health beyond the affected State’s national border; and
• may require immediate international action.

Since 2007, the WHO Director-General has declared public health emergencies of international concern in response to the following: [2]

1) 2009 H1N1 influenza pandemic

2) 2014 setbacks in polio global eradication efforts

3) 2014 west Africa Ebola epidemic

4) 2016 Zika virus outbreak

5) 2018–19 Kivu Ebola epidemic

Criticism of International Health Regulations

Revisions to the International Health Regulations in 2005 were meant to lead to improved global health security and cooperation. However, the WHO’s perceived delayed and inadequate response to the west African Ebola Epidemic brought renewed international scrutiny to the International Health Regulations. Numerous published reports by high-level panels have assessed the International Health Regulations for inadequacies and proposed actions that can be taken to improve future responses to outbreaks. [3]

One publication reviewed seven of these major reports and identified areas of consensus on action. [4] The seven reports noted inadequate compliance with WHO’s International Health Regulations as a major contributor to the slow response to Ebola. They found three major obstacles that contributed to poor compliance: 1) countries’ core capacities, 2) unjustified trade and travel restrictions, and 3) inability to ensure that governments report outbreaks quickly.

· Core Capacity

The IHR requires countries to assess their disease surveillance and response capacities and to identify if they can adequately meet their requirements. The seven Ebola reports universally agree that the country’s self-assessment capabilities are insufficient and that verification measures need to be improved upon. A significant problem is the inadequate level of core capacities in some countries, and the question of how to build upon them has been frequently raised. The reports make several recommendations to encourage governments to increase investment in outbreak identification and response programs. These include technical help from external sources conditional on mobilizing domestic resources, external financing for low income countries, pressure from the international community to increase investment, and considering outbreak preparedness as a factor in the International Monetary Fund’s country economic assessments, which influence governments’ budget priorities and access to capital markets.

· Trade and Travel

The second issue frequently raised is ensuring that restrictions on trade and travel during outbreaks are justified. Because of increased attention and concern from the public and the media, many governments and private companies restricted trade and travel during the Ebola outbreak, though many of these measures were not necessary from a public health standpoint. These restrictions worsened financial repercussions and made the work of aid organizations sending support to affected regions more difficult.

There was broad consensus across the reports that bringing such restrictions to a minimum is critical to avoid further harm to countries experiencing outbreaks. Moreover, if governments assume that reporting will lead to inappropriate travel and trade restrictions, they may be hesitant to notify the international community about the outbreak. Potential solutions raised included the WHO and the UN more assertively “naming and shaming” countries and private companies that impose unjustified restrictions on WHO working with the World Trade Organization, International Civil Aviation Organization, and International Maritime Organization to develop standards and enforcement mechanisms for trade and travel restrictions.

· Outbreak Reporting

The third compliance issue relates to countries’ obligation to rapidly report outbreaks. The reports recommend strengthening this obligation by WHO publicizing when countries delay reporting suspected outbreaks. In contrast, mechanisms ensuring that countries rapidly receive operational and financial support as soon as they do report were also recommended. A novel approach to encourage early notification is the World Bank’s Pandemic Emergency Financing Facility. This was created to provide rapid financing for the control of outbreaks and to protect countries from the devastating economic effects of outbreaks via an insurance program.