Table.
Comparison of IHR time periods with the COVID-19 chronology by phase and action criteria
| Relevant IHR article | Applicable intervenient | Response required by IHR | IHR-stipulated timeline | Timeline of COVID-19 actions | COVID-19 event | |
|---|---|---|---|---|---|---|
| Pre-detection (assess capacities) | Article 59 and Annex 1 | State | Assess capacity to meet minimum surveillance requirements | No later than June, 2009 | NA | NA |
| Pre-detection (meet capacities) | Article 5 and Annex 1 | State | Ensure capacity to detect, assess, notify, and report events | June, 2012 | Self-reported full compliance with surveillance core capacity | China reported 100% surveillance capacity in 2019, but no Joint External Evaluation has been done and published for China |
| Event detected by local surveillance system (t1) | Article 4 and Annex 1 | State (local community level, primary public health response level, or both) | Detect events involving disease or death above expected rates and report essential information immediately to the subnational or national public health authority | Dec 27, 2019 (ie, immediately upon detection at local level) | Dec 30, 2019 (t1 + 72 h) | The Wuhan CDC received reported cases of pneumonia of unknown origin from the Hubei Provincial Hospital, Wuhan on Dec 27, 2019; China's internal timeline indicates that the National Health Commission did not receive reports until the WMHC released an urgent notice on treatment of patients on Dec 30 |
| Event reported to the subnational surveillance system | Article 5 and Annex 1 | Subnational level (eg, state or province) | Confirm and assess urgent events and report immediately; in case of an urgent event, report all essential information to national level public health authority (eg, China Center for Disease Control and Prevention) | Dec 27, 2019 (ie, immediately upon detection at the subnational level [Hubei province]) | Unclear | Unclear if this action occurred, but direct national reporting from local to national levels, bypassing subnational level, is permitted; unclear when and if the Hubei Provincial CDC reported to the Chinese National Government |
| Event reported to national level (t2) | Article 6 and Annex 1 | State | Assess all reports of urgent events within 48 h; China NFP to notify WHO (per Articles 6 or 7) if conditions are met | Jan 1, 2020 (t2 + 48 h at most) | Jan 3, 2020 (t1 + 168 h, or t2 + 96 h) | Upon learning of the cases (Dec 30, 2019), the NHC commenced investigation; cases probably satisfied the IHR definition of urgent,4 requiring assessment within 48 h, but it is not necessarily evident during the early stages of an outbreak whether an event meets this definition; no action appears to have been taken by Jan 1, 2020 (no statements exist that Annex 2 was used by national authorities to assess if an Article 6 notification was required) |
| Event is a potential PHEIC | Article 6.1 and Annex 2 | State | Notify WHO of potential PHEIC within 24 h of assessment, via NFP | Dec 31, 2019 (t2 + 24 h at most) | Jan 3, 2020 (t1 + 168 h, or t2 + 96 h), or Jan 4, 2020 (t1 + 192 h, or t2 + 144 h) | No statements exist that the Annex 2 assessment process was followed, or of a clear Article 6 notification; a potential PHEIC includes a serious public health impact and an unusual or unexpected event (these were probably already met at this stage; however, whether a novel pathogen meets the criteria for constituting a potential PHEIC requires a degree of subjective assessment); China NFP confirmed information on Jan 3, 2020; although States must confirm if Article 6 is triggered following an Article 10 request, whether China's response included this is unclear; on Jan 4, WPRO stated “China has reported to WHO regarding a cluster of pneumonia cases“42 |
| Event is a potential PHEIC | Article 6.2 and Annex 2 | State | Provide accurate and sufficiently detailed public health information | Ongoing (ie, in a “timely” manner, as stated in Article 6.2) | Information actively sought by WHO | WPRO requested further information (Jan 4, 2020); WHO awaiting further information (Jan 5);similar statements about the provision of information from WHO's Director-General in January; viral genetic sequence first shared |
| Event is unexpected or unusual and is a potential PHEIC | Article 7 | State | Provide all relevant public health information | Ongoing (ie, in a “timely” manner”, as stated in Article 7) | Information actively sought by WHO | As above |
| Event is not a potential PHEIC, including if information to assess is insufficient | Article 8 | State | Advise and consult WHO on event and appropriate control measures, via NFP | Ongoing | NA | Article 8 consultation request does not appear to have occurred |
| Event is not a potential PHEIC, and more information becomes available | Annex 2 | State | Reassess when more information becomes available to determine if a notification under Article 6 is required | Ongoing | None | No indications Annex 2 assessments occurred; might have justified Article 6 notification delays |
| Reports of an event from other sources (on receipt of t3) | Article 9.1 | WHO | Assess reports from other sources, communicate to the State where the event is allegedly occurring | Ongoing (t3) | WHO obligation | First media report (Dec 31, 2019); Taiwan contacts the WHO headquarters (Dec 31); New York Times contacts WHO Country Office with a news request; WHO headquarters detects ProMED reports; WHO Country Office sees local bulletin from WMHC |
| In case of evidence of a public health risk to another State from exported or imported cases (t4) | Article 9.2 | Other States | Inform WHO within 24 h of receipt of evidence | t4 + 24 h at most | NA | NA |
| Reports of an event from other sources (verification) | Article 10.1 | WHO | Request verification from State of other reports | Ongoing | Jan 3, 2020 (0415 h CET; t3 + 72 h) | WHO Country Office seeks information from the Chinese Government (Dec 31, 2019); WPRO IHR Focal Point requests information from China's NFP (Jan 1, 2020); WHO headquarters requests WPRO to use Article 10 (Jan 1); WPRO sends formal verification request under Article 10 (Jan 3; this action appears to have been the only one meeting Article 10 verification steps) |
| If WHO seeks verification of reports from other sources (t5) | Article 10.2 | State | Upon request, verify and provide, within 24 h, acknowledgment of request and available public health information on the events and assessment of events under Article 6 (and relevant public health information) | t5 + 24 h at most | Jan 3, 2020 (0915 h CET; t5 + 5 h) | China NFP acknowledges verification request received and verifies information within 5 h; no detail on whether China then made an official Article 6 notification, or if Annex 2 was used; no further public health information appears to have been provided (WPRO requests more info on Jan 4, 2020) |
| WHO can share information with other States | Articles 10.4, 11.1, and 11.3 | WHO | If State doesn't accept offer of collaboration (Article 10.3), WHO may share information with other states if justified by the magnitude of the public health risk (Article 10.4); similarly, WHO must share information it receives that is necessary to enable a public health response to the risk with other states, if there is evidence confirming international spread, if control measures are unlikely to succeed, or if international measures are immediately needed (Articles 11.1 and 11.2); in such cases, WHO must consult with the affected State (Article 11.3) | No stipulated time for notifying other states; decision based on whether there is a public health risk to other states | Jan 4, 2020 (0422 h CET) | WHO informed China it would notify all IHR Focal Points; unclear which provision WHO was sharing information under; if China did not reject assistance under Article 10.3, Article 11 might apply to the disclosure of information (which would allow public sharing of information, consistent with WPRO's tweet and DONS on Jan 4, 2020) |
Time markers under the IHR are t1 for cases first detected, t2 for event assessed by State, t3 for WHO receiving report from other sources, t4 for the timepoint at which other states must report if they receive evidence of event in another state (not relevant in this scenario), and t5 for verification requested. CDC=Center for Disease Control. CET=Central European Time. DONS=Disease Outbreak News. IHR=International Health Regulations. NA=not applicable. NFP=National Focal Point. NHC=China's National Health Commission. PHEIC=Public Health Emergency of International Concern. WMHC=Wuhan Municipal Health Commission. WPRO=WHO's Western Pacific Regional Office.