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¹ More information on this can be found at Strengthening health security by implementing the International Health Regulations (2005) (http://www.who.int/ihr/en/).

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Background

The recent outbreaks of Middle East respiratory syndrome coronavirus (MERS-CoV) and Ebola virus disease have underscored the global threats from emerging pathogens and re-emerging outbreak-prone infectious diseases.

The International Health Regulations (IHR) 2005 provides a legal framework for collective responsibility in global health security and requires States to develop and maintain core public health capacities in order to maintain global health security. The core capacities required by IHR are expected to be in place by 2016 and therefore the current implementation status and challenges to implementation need to be evaluated. In addition, countries in the Region have urgently asked for the support of the WHO to assess their preparedness for Ebola virus disease and support in meeting the identified gaps.

In light of these concerns, the WHO Regional Office for the Eastern Mediterranean organized the Third regional stakeholders meeting to review the implementation of the International Health Regulations (2005) with focus on Ebola. The meeting was held in Cairo from 11 to 13 January 2015, with a second session in Tunis on 4–5 February for countries that were not able to participate in the Cairo meeting. The meeting provided an opportunity to the WHO secretariat and Member States to follow up on the progress in implementing IHR capacity requirements

The objectives of the meeting were to:

review key findings and major recommendations based on Ebola preparedness and response readiness assessment missions undertaken in November and December 2014;

identify and agree on specific and pragmatic remedial strategies to overcome challenges and fill gaps highlighted as key factors behind the national, regional and global threats posed by the ongoing MERS-CoV and Ebola outbreaks;

critically review the progress made and reasons behind continuing gaps at country level in implementing the recommendations of the first and second IHR regional meetings;

discuss and identify ways to implement the resolution on global health security of the Sixty-first WHO Regional Committee for the Eastern Mediterranean, and the recommendations from the 2nd IHR Review Committee meeting.

The expected outcomes were to discuss and identify national achievements and gaps in strengthening IHR core capacities in relation to the Ebola preparedness and response readiness assessment missions.

The meeting was attended by IHR focal points from 20 countries of the Region, representatives from UNICEF, FAO/HQ, EMPHNET, the Centers for Disease Control and Prevention (CDC), UNRWA, WHO, Epidemiological Surveillance and IHR, Pandemic and Epidemic Diseases, representatives from public health laboratories, and regional advisers for health risk management.

Country assessments

Although major gaps in the national public health systems for detection of threats have been identified, and there is the capacity to predictably monitor, track and respond to any acute health threats, it is also clear that:

existing coordination structures lack the efficiency of an emergency incident command system;

the absence of a national infection control programme in many countries is a major limitation in planning and implementing effective infection control measures in health facilities;

country surveillance systems lack effective mechanisms to detect threats in a real-time situation, and in addition, no countries have formally established a fully functioning, event-based surveillance system;

the laboratory diagnostic capacity for detection of any emerging pathogen remains significantly weak and compromised;

no States Party has developed an integrated, multi-stakeholder risk communication strategy;

contingency plans at airports do not include public health risk as a contingency.

These findings clearly indicate that, in spite of past experiences with SARS, H5N1 and other pandemics and investments in the IHR and IHR scores, the Region is insufficiently prepared and unready to handle Ebola.

Implementation of IHR

Ebola threat in the context of insufficient implementation of IHR

Ebola virus disease has been recognized for almost 38 years now and we know that the application of certain essential public health measures is critical for controlling outbreaks and preventing transmission.

International travel is the most probable route by which Ebola virus disease can be imported to the countries of the Region. However, as has been seen in the USA, detection of a suspected case arriving from any of the affected countries may be missed at the point of entry (due to the long incubation period: 2 to 21 days) as the case may not present any symptoms. Additionally, after the disease manifests, the case may go unnoticed in the health facilities and that could be a real test of how prepared a health system is to manage and respond to the situation.

Global update on implementation

Globally, there is inadequate implementation of the IHR. This has been highlighted by the Ebola outbreak; insufficient development of core capacities is particularly evident as only a third of countries have met the core capacity. Current methods for accurately monitoring the development and status of countries have been shown to be inadequate for. Many Member States have instituted measures additional to the recommendations of the Emergency Committee without a strong evidence-based rationale.

Regional update on implementation

By 2013, the Region had made significant progress in implementation of the IHR, with important achievements in each of the core capacities. Highlights included the establishment of surveillance units in all Member States, the development of necessary legislation in 16 Member States, the establishment of public health emergency response mechanisms in 18, indicator-based surveillance which included an early warning function in 19 and effective mechanisms for risk communication during a public health emergency in 14.

Nevertheless, a number of gaps have been identified. The 2014 deadline to ensure that certain functional capacities required by the Regulations are in place has now passed. Out of the 21 IHR States Parties in the Region, 13 have requested a second extension, despite the expectation that the majority of countries would be able to meet the deadline. The recent MERS-CoV and Ebola virus disease outbreaks highlighted the main challenges in IHR implementation.

Key impediments to implementation

insufficient authority/capacity of IHR national focal points

implementation of IHR considered the sole responsibility of ministries of health

limited national investment in financial and human resources

insufficient awareness of other sectors

ongoing complex emergencies/conflicts

focus on extension of timelines rather than expansion of capacities.

Challenges in implementation are also associated with political and geopolitical transition, insufficient understanding of the regulations, insufficient coordination between neighbouring countries to enhance cross-border collaboration, and the high turnover among professionals.

Early detection of emerging infectious diseases

The CAPSCA initiative

The purpose of CAPSCA (Collaborative Arrangement for the Prevention and Management of Public Health Events in Civil Aviation) is to assist Member States with the implementation of the IHR in the aviation sector by promoting intersectoral communication and collaboration, ensuring the aviation sector is ready to respond to a public health event and the provision of core capacities at airports designated as points of entry.

The International Civil Aviation Organization, in collaboration with WHO, amended the documentation on operations (carriage of Universal Precaution Kit for cabin crew to manage a public health event on board) and facilitation (communication procedures/identification of an infectious traveller when on board). So far 11 Member States have joined the CAPSCA-MID regional project: Bahrain, Egypt, Islamic Republic of Iran, Iraq, Jordan, Lebanon, Kuwait, Oman, Qatar, Saudi Arabia and Sudan.

Actions taken on Ebola include the September 2014 agreement between the International Civil Aviation Organization and UNDP under the mandate of the “Operational aspects of Ebola response multi-partner trust fund”. The fund will support the relief operation in West Africa with the ultimate goal of reducing the risks from the gaps between the public health sector and the aviation sector in preparedness planning.

Regional progress on early detection

According to the recent country assessments in 18 Member States, the core capacities for early detection are not yet fully operational. The current surveillance systems have important gaps in alert function and EBS need substantial strengthening. The prevailing gaps in most health laboratories may preclude the safe testing of specimens and this would impair the capacity for detection, assessment and response to suspected cases of Ebola virus disease at point of entry.

Next steps

Focus of implementation

Over the coming period, the focus of implementation should be on:

conducting advocacy and outreach activities,

establishing a committee of legal advisers representing the different sectors to review national legislation,

properly equipping national focal points,

establishing an IHR intersectoral committee with high-level representation,

establishing a mechanism of information sharing with clear terms of reference,

allocating the necessary budget to implement the national IHR plan of action,

developing retention plans for human resources, with both short-term and long-term solutions,

starting dialogue between neighbouring countries and finding a mechanism to enhance cross-border collaboration,

establishing a mechanism to provide financial, technical and logistic support to countries.

The way forward

The theoretical construct of the IHR has now been tested against the realities of public health threats (e.g. polio, MERS-CoV, Ebola virus disease). The diversity and increasing frequency of events involving infectious diseases (and other hazards) are reminders that the IHR remains the foundation of global health security – the principles and themes provide the foundation for a long-term approach: interdependence between countries with respect to threats, risk-based framework, proportionality in capacity-building and response measures. Thus, the work to develop, strengthen and maintain core capacities under the IHR should be viewed as a continuing process for all countries.

Recommendations

After discussion and deliberation on the information provided in the context of Ebola virus disease, the following recommendations were made (Box 1).