Crossing Borders: One World, Global Health

International Health Regulations (2005) Fifth Anniversary: Shifting Focus From Surveillance to Accelerating Implementation of Core Capacities

David Scales, Martin S. Cetron, and John S. Brownstein

On 15 June 2012, the World Health Organization (WHO) marked the fifth anniversary of the implementation of the International Health Regulations 2005 (IHR). The IHR (2005) have successfully solidified the recent shift from disease- to event-based surveillance, thereby improving event detection and rapid response. The success of the IHR in the next half-decade will depend on States Parties consistently meeting their core capacities requirements for surveillance and response. Unfortunately, these integrated, systems-based capacities risk a lessened impact due to complacency.

The IHR (2005) were born out of concern for the dangers posed by emerging and reemerging pathogens and bioterrorism post-9/11. Negotiators agreed that disease-oriented surveillance alone seemed obsolete in light of such broad public health threats and that event-based and syndromic surveillance systems offered greater potential for early detection (Figure 1). Practically, this paradigm shift was made possible through use of unofficial sources for initial epidemic detection and official sources for confirmation and ongoing surveillance. This approach proved important to containing severe acute respiratory syndrome (SARS) [1, 2]. The revised IHR, specifically Annex 2, codified in a legally binding framework the event-based approach to early epidemic detection and surveillance [3].

Figure 1.

Time from outbreak start to case detection and outbreak report before and after the coming into force of the International Health Regulations (IHR) 2005. The average time difference in days between the estimated outbreak start date and the estimated date of outbreak detection (Pre: 42.6 [95% confidence interval {CI}, 36.1–49.2]; Post: 17.9 [95% CI, 9.0–26.9]) and between the estimated outbreak start date and the date of the earliest public report (Pre: 51.0 [95% CI, 44.4–57.6]; Post: 36.9 [95% CI, 25.2–48.6]). The graph also shows time differences for outbreaks reported in the World Health Organization's Disease Outbreak News before and after 15 June 2007, when the IHR 2005 officially went into effect. Although both time differences were reduced after the IHR 2005 came into effect, only the time difference between outbreak start and outbreak detection was statistically significant (see Chan et al [6] for data and methods). Abbreviation: IHR, International Health Regulations.

WHO's use of unofficial sources in epidemic surveillance has had 2 major effects. First, the role of the state has quietly shifted. Previously, governments controlled the flow of outbreak information to WHO, from epidemic detection and verification to systematic reporting; post-SARS, the idea that States Parties are exclusively sovereign over disease reporting within their territories has become blurred [4]. Second, the IHR have allowed the WHO to adapt to new technologies that enable crowd-sourcing and participatory epidemiology [5]. Although signal-to-noise issues persist, the officially sanctioned use of informal sources has helped propel faster epidemic detection and response [6, 7].

Table 1.

Core Capacities to Be Assessed by Member States

In consultation with Member States, technical institutions and partners, the World Health Organization identified the following global indicators for monitoring the development of International Health Regulations (IHR) core capacities [10]:

National legislation, policy, and financing Coordination and National IHR focal point communications Surveillance Response Preparedness Risk communication Human resources Laboratory

Ports of Entry

Potential Hazards 1. Zoonotic events

Potential Hazards 2. Food safety events

Potential Hazards 3. Chemical events

Potential Hazards 4. Radiological and nuclear events

To continue to reduce the time between epidemic detection, verification, and reporting, countries must meet the core capacities requirements described in IHR Annex 1. By 15 June 2012, States Parties agreed to develop, strengthen, and maintain systems for the detection, verification, and reporting of public health emergencies at local and country levels, as well as detection and control mechanisms at ports of entry. Emphasizing event rather than disease detection, these capacities are a systems-wide approach to public health emergency management, requiring communication and coordination across frequently “siloed” governmental departments. As an example, some countries, such as the United States, Finland, and China, have each sought to combine public health expertise into a unified National Public Health Institute [8, 9].

However, governments risk growing complacent, while attention on the IHR (2005) has faded and funding has diminished due to the global financial crisis. Traditional shoe-leather epidemiology requires human resources, education, and expertise. Increased laboratory capacity requires financial investment for equipment and a sustained commitment to education and capacity building to maintain consistent, high-quality results. Detection and response capacity at ports of entry requires collaboration across multiple sectors, as does building effective risk communication procedures.

While meeting core capacity requirements was expected to be an evolving process requiring a multiyear commitment, 2 trends have become apparent 5 years after the IHR (2005) have gone into effect. First, core capacities implementation is behind schedule; second, implementation has been most rapid in traditional public health sectors but has lagged in areas requiring cross-sector collaboration and coordination.

In technical consultation with Member States, WHO developed metrics by which governments can measure core capacities implementation, including incorporation into domestic law and investments to expand human resources, laboratory, and surveillance capacities (see Table 1) [10]. Much work remains to be done. Some 2-year extensions beyond the original 2012 deadline have already been given. Region-specific metrics on core capacities implementation show that even those extensions will not be sufficient for States Parties to meet all core capacity requirements [11, 12]. The IHR Review Committee's recommendation that implementation needs to be accelerated is even more salient [7].

Moreover, WHO reports show that implementation is happening most rapidly in sectors traditionally associated with public health: epidemic preparedness, laboratory capacity, and surveillance and response. Average capacity scores in these sectors are consistently the highest, although there is interregion variability. However, implementation is lagging in areas most indicative of the cross-sector coordination key to ensuring long-term impact of the IHR (2005), such as event detection and response capacities for radiation or chemical emergencies, preparedness at ports of entry, and coordinated, effective risk communication. Fewer than 50% of reporting countries have a capacity score >75% [11, 12].

The focus on the IHR (2005) has been on surveillance and reporting. Five years after the IHR came into force, the focus now should be on accelerating the implementation of core capacities, particularly in areas that require cross-sector coordination. If fully implemented in a manner commensurate with the event-based framework of the IHR (2005), the core capacities have the potential to reduce even further the time from event detection to reporting and response.

Editorial comment. Advancements in surveillance have significantly reduced the time from outbreak start to detection and response. The IHR (2005) have contributed by ensuring that WHO can use unofficial sources for event detection. Further reductions in time from outbreak start to detection are likely to come from more rapid and widespread implementation of the “core capacities” for surveillance and response and for designated ports of entry outlined in Annex 1 of the IHR. State Party reporting to the WHO shows that implementation of core capacities requirements lags behind the original deadline of 15 July 2012. Some least developed countries will require further extensions. While implementation of all core capacities should be accelerated, emphasis should be placed on those that require cross-sector collaboration. Implementation of these requirements lags behind that of other core capacities. (M. C.)