The truth about PHEICs

The recent decision by the WHO Director-General that the Ebola virus outbreak in DR Congo does not constitute a Public Health Emergency of International Concern (PHEIC)¹ has generated controversy, as articulated by the Editors² of The Lancet. Members of the WHO Strategic and Technical Advisory Group for Infectious Hazards (STAG-IH) have discussed this Editorial and would like to clarify the role of the International Health Regulations (IHR) and the designation of a PHEIC.

The predecessor to the IHR, the International Sanitary Regulations (ISR), were agreed upon in 1851 by diplomats from 12 European countries to protect against cross-border transmission of disease (mainly cholera) in a way that minimised interference with international trade and travel. In 1969, the World Health Assembly (WHA) adapted and renamed the ISR as the IHR.³ Until its most recent revision in 2005, the IHR considered only cholera, plague, and yellow fever, with smallpox—after its eradication—having been removed from the original IHR by a minor revision in the 1980s.

In 2003, the emergence of severe acute respiratory syndrome, followed shortly thereafter by the avian influenza (H5N1) outbreak, underlined the need for rapidly concluding the IHR revision that had been requested by the WHA in a 1995 resolution. IHR (2005) represents a consensus among all WHO Member States to cooperate for global health security. It shifts the focus from quarantine and embargoes at borders to containment at source, increases the emphasis on preparedness by requiring all countries to maintain necessary core capacities in surveillance and response, and widens the scope from reporting of a predefined disease list to reporting of a public health event based on a decision tree analysis.

Through its legal framework, IHR (2005) ensures rapid collection of information, availability of international support to affected countries, and a common understanding of what constitutes a PHEIC: “an extraordinary event which is determined…to constitute a public health risk to other States through the international spread of disease”. Trade and traffic remain as important to the IHR as they did in 1969—the regulations are meant to prevent unwarranted restrictions on travel and trade that do not rest on a science-based risk analysis.

The decision to declare a PHEIC lies with the WHO Director-General and requires the input of a committee of experts—the IHR emergency committee. By declaring a PHEIC, the Director-General requires state parties to share critical information for risk assessment, adjust response plans if deemed necessary, and implement temporary recommendations formulated by the emergency committee. As the Acting Chair of the emergency committee for Ebola stated on June 14, 2019,¹ the declaration of a PHEIC for the current Ebola outbreak would add no clear benefit in any of these three areas. Both DR Congo and Uganda are providing information in a timely manner, and 10 months into the outbreak (with innumerable daily border crossings of inhabitants in the area), the recent event in Uganda is confined to close family members. Members of the emergency committee cited potential disadvantages of a PHEIC declaration (effects on travel and trade that could impede support to affected regions and hinder outbreak control) and provided technical advice that the STAG-IH supports fully.

Since 2005, WHO has declared four PHEICs: the H1N1 influenza virus pandemic (2009), the resurgence of wild poliovirus (2014), the west Africa Ebola virus outbreak (2014), and the Zika virus outbreak (2018). As international public health emergencies evolve into more complex forms, it becomes necessary to identify gaps in the alarm and response mechanisms, and the WHA has called for two reviews of IHR (2005): one in 2010, after the H1N1 influenza virus pandemic, and a second in 2015, to examine the response to the west Africa Ebola virus outbreak. Citing the difficulties and potential risks in opening an accepted international agreement to revision, Member States requested a mechanism to independently monitor WHO's ongoing risk assessment. STAG-IH has its origin in this request, and has since its first meeting in 2018 reviewed WHO's risk assessments and responses before and between the emergency committee's three meetings about the current Ebola virus outbreak.

The public health community must recognise the close link between disease and trade inherent in IHR (2005) and the risks and benefits of using this strong instrument of international law to raise awareness and resources—a policy that could jeopardise the future effectiveness of these regulations in sectors of society other than health.

© 2019 James Akena/Reuters