The Role of Disease Surveillance in Achieving IHR Compliance by 2012

Abstract

The World Health Organization's revised International Health Regulations (IHR (2005)) call for member state compliance by mid-2012. Variation in disease surveillance and core public health capacities will affect each member state's ability to meet this deadline. We report on topics presented at the preconference workshop, “The Interaction of Disease Surveillance and the International Health Regulations,” held at the 2010 International Society for Disease Surveillance conference in Park City, Utah. Presenters were from the Pan American Health Organization (PAHO), the U.S. Department of Health and Human Services (HHS), the Centers for Disease Control and Prevention (CDC), the Armed Forces Health Surveillance Center, U.S. Naval Research Unit Six, the Philippines' National Epidemiologic Center, and the French armed forces. The topics addressed were: an overview of the revised IHRs; disease surveillance systems implemented in Peru, the Philippines, and by the French armed forces; the capacity building efforts of the CDC; partnerships and contributions to IHR compliance from HHS; and the application of the IHRs to special populations. Results from the meeting evaluation indicate that many participants found the information useful in better understanding current efforts of the U.S. government and international organizations, areas for collaboration, and how the IHRs apply to their countries' public health systems. Topics to address at future workshops include progress and challenges to IHR implementation across all member states and additional examples of how disease surveillance supports the IHRs in resource-constrained countries. The preconference workshop provided the opportunity to convene public health experts from all regions of the world. Stronger collaborations and support to better detect and respond to public health events through building sustainable disease surveillance systems will not only help member states to meet IHR compliance by 2012, but will also improve pandemic preparedness and global health security.

Increases in international travel and trade have ushered in a new era of globalization. As countries and people become more intertwined, the spread of emerging and reemerging diseases in the setting of health risks, like poverty, will have a strong impact on the world's population. In recognition of these new health threats and the need for efficient coordination and response, the revised International Health Regulations (IHRs) were adopted by the World Health Organization (WHO) member states during the 58th World Health Assembly in 2005 and entered into force in June 2007.¹ They constitute a legally binding framework, and their scope is “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.”¹

Hence, the IHRs adopted a multisectoral approach and encompassed a broad range of public health hazards (biological, chemical, radionuclear, and of unknown etiology). Among other provisions, the IHRs mandate states parties to establish, by June 2012, core capacities to detect, assess, report, and respond to public health events of potential international concern across all levels of the public health system.¹ Guidance on how to reach 8 core capacities (national legislation, policy, and financing; coordination and national focal point (NFP) communications; surveillance; response; preparedness; risk communication; human resources; and laboratory) for surveillance and response, including points of entry and 5 additional technical areas, has been provided by WHO to its member states.² Despite the commitment of states parties to establish core capacities by June 2012, it can be anticipated that not every country will meet the deadline.^3,4 This deadline should be regarded as a target set to maintain the momentum and a step in the sustainable and ongoing preparedness process, where countries adapt lessons learned and evidence-based best practices.

To further the agenda going forward, a preconference workshop, “The Interaction of Disease Surveillance and the International Health Regulations (2005),” was held at the International Society for Disease Surveillance Conference in Park City, Utah, in November 2010 to discuss the revised IHRs, establishing surveillance systems in resource-limited countries, and how specific contributions help countries to comply by 2012.⁵ The workshop was organized and sponsored by the Armed Forces Health Surveillance Center's Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) and hosted presenters from the Philippines' Department of Health; Naval Medical Research Unit Six (NAMRU-6) in Lima, Peru; the French military; the Centers for Disease Control and Prevention (CDC); the U.S. Department of Health and Human Services (HHS); and the Pan American Health Organization (PAHO) of WHO. Attendees were public health professionals from local departments of health, national and international government agencies, and ministries of health. Below are the topics related to IHRs that were covered in the workshop.

Overview of the IHRs

Dr. Roberta Andraghetti from PAHO/WHO provided the keynote address, speaking of the importance of the IHRs and providing an overview of the core capacities needed to achieve compliance by 2012. The 8 core surveillance and response capacities are central to enhancing national and global health security and capabilities of member states to detect, assess, report, and respond to public health events of potential international concern.⁶ States parties with the ability to assist others are expected to do so and to provide necessary technical and financial support for capacity building through detecting and responding to outbreaks. Technical support and dialogue was encouraged not only on the local and national levels, but also on multilateral and United Nations–coordinated levels.⁶ The Global Outbreak Alert and Response Network (GOARN) is the international collaborative group, under WHO's auspices, from which countries may request assistance with disease control efforts, investigation of events, and support for national outbreak preparedness measures.⁷

IHRs and Disease Surveillance

The following talks presented examples of how electronic disease surveillance has been used to support IHR implementation and compliance in the field.

An overview of the Integrated Disease Surveillance and Response System (PIDSR), the electronic surveillance system of the Philippines, was presented by Dr. Vito G. Roque, Jr., of the Philippines' National Epidemiology Center (NEC). The framework for both local and national response systems incorporates case data collected from hospitals, clinics, laboratories, ports, and airports as well as from the communities.⁸ Additionally, short message service (SMS) texting and the internet are used where available. Data are reported weekly, and immediate notification of a reportable event or disease is required within 24 hours. The flow of outbreak and event notification is built to feed data collected from clinical, laboratory, and community sources to the appropriate local and regional surveillance unit, which then directs the information to the necessary public health office for response and support.⁸ Flow of information is separate for weekly and immediate reporting to allow for rapid dissemination when necessary, with notifications of public health events of potential international concern sent to WHO from the NEC. Immediate reportable diseases, syndromes, and events are framed around those outlined in the IHRs.¹ PIDSR is an integrated response system that actively involves the community in disease surveillance and strengthens local capacity.

From U.S. NAMRU-6 in Peru, Dr. Ricardo Hora addressed influenza surveillance in the Peruvian military. The disease surveillance system, called Alerta, is used by the Peruvian armed forces to collect case information from central and remote locations in Peru and uses standards established by the ministry of health (MoH).⁹ Reported data are stored on an internet-hosted database and are analyzed by epidemiologists at the Peruvian military headquarters and also by Peruvian military liaisons detailed to NAMRU-6. Official analytical reports and outbreak alerts are sent to the Peruvian armed forces to assist with training, allocation of resources, and outbreak response decisions.⁹ Modeling a system established in the U.S. Navy by the Naval Health Research Center in San Diego, California, and to support the Alerta system, Peruvian naval healthcare personnel were trained to collect throat and nasal specimens, run laboratory diagnostics, and implement control measures for respiratory pathogens on ships. In July 2009, the healthcare personnel aboard the BAP Mollendo, a Peruvian naval ship, detected an outbreak of novel influenza A (H1N1) through use of passive surveillance and laboratory diagnostics, and they implemented infection control measures while en route to Peru from San Francisco.¹⁰ The outbreak provided an example of the benefits of laboratory diagnostics to augment syndromic surveillance systems in settings at high risk for disease transmission.⁹

Jean-Baptiste Meynard, MD, PhD, from the French armed forces discussed the electronic surveillance efforts used in France and in foreign lands. Their surveillance system uses traditional and real-time reporting to generate early warnings. Alarms and alerts initiate evaluations, investigations, and the appropriate countermeasures.¹¹ Using PDAs and laptops, epidemiologic information obtained even in the most remote areas can be transmitted to a remote server via satellite phone connections. Declaration networks, made up of local health headquarters, collect data from patient records and transmit the data to the analysis network comprised of the Military Public Health Department, the National Health Services headquarters, and the National Command and Control Center.¹¹ In collaboration with Institut Pasteur, 2 of the countries participating in the French military's early warning system are French Guiana and Djibouti. Use of the system assisted in the rapid response to outbreaks of malaria and dengue in both countries. During the 2009-10 H1N1 pandemic in France, the French military surveillance system contributed to the mapping of near real-time data of military and civilian populations, allowing French health officials to track the geographic distribution of influenza and compare differences of incidence rates for the 2 populations.¹¹

Dr. Joel Montgomery spoke about the U.S. CDC's Global Disease Detection program (GDD) and its support of the IHRs. Created in 2004, it serves as a WHO Collaborating Center for implementation of IHR surveillance and response capacity to assist resource-limited countries in developing detection and control capabilities.¹² With a primary emphasis on capacity building and surveillance, 7 regional GDD centers work with local public health offices to strengthen their ability to detect and respond to diseases and events.¹ These regional centers partner with WHO in Guatemala, Kenya, Egypt, India, Thailand, China, and Kazakhstan to implement the core capacities of the IHRs. Specifically, the GDD program focuses on enhancing outbreak response and preparedness, pathogen discovery, training and surveillance, and networking, all aligning with Article 44 of the IHRs.¹² Through assessing these activities and gaps, both regionally and nationally, a plan to meet IHR compliance is established and implemented through the respective GDD regional centers.

Special Populations and Event Reporting

The application of IHRs to special populations, such as combat forces in war zones and security forces in noncombat roles, was the topic presented by Lieutenant Matthew Johns, MPH, from the U.S. Armed Forces Health Surveillance Center. Understanding disease dynamics among special populations varies greatly, as migration, remote settings, and lack of infrastructure are factors that must be taken into consideration.¹³ Additionally, surveillance and clinical care may not always be tied together, and reporting requirements and tracking may differ between these special populations and the host country governments.¹³ For example, domestic and international partners of the AFHSC-GEIS network report surveillance findings to GEIS and also communicate findings to host country officials.¹³ The Department of Defense Global Influenza Surveillance Program incorporates sentinel, population-based, electronic, lab-specific, and regional surveillance systems and allowed for the close tracking and reporting of pandemic A/H1N1 influenza in 2009-10.¹³ In part because of the 2009 pandemic, reporting mechanisms were established between GEIS partners and their host country counterparts, further supporting Articles 9 and 44 of the IHRs.

U.S. Partnerships for IHR Compliance

Dr. Jose Fernandez of the U.S. Department of Health and Human Services described partnerships that support member state IHR compliance by 2012. The public health infrastructure and capacity of the member states varies greatly and, as a result, so does their ability to meet the requirements under the IHRs.¹⁴ IHR Article 44 focuses on collaboration and assistance for capacity building and outlines a number of partnerships that member states and WHO can undertake to support states in meeting compliance.¹ The U.S. has defined its role as a member state that supports and collaborates with other states to assist with compliance requirements by the 2012 deadline. For example, the U.S. government's Biosecurity Engagement Program is working with numerous countries to conduct training sessions in biosafety and pathogen security, infectious disease surveillance, and molecular diagnostics, and it is also working with countries to build surveillance, human resources, and laboratory capacities.¹⁴ The assistance provided focuses on identifying the public health needs and gaps of the country, creating an action plan, coordinating with the WHO regional and country offices, and identifying outside partners already assisting with IHR-relevant capacity building. All of these steps are taken to ensure a long-term sustainability plan for the host-country.¹⁴

Assessment of Workshop Effectiveness

At the conclusion of the workshop, all participants were provided with a workshop evaluation form. Attendees had the opportunity to answer several questions regarding the usefulness of the workshop, its objectives, baseline understanding of the topics addressed, and suggestions for how to improve future meetings. Of the 25 attendees at the meeting, 10 provided responses to the evaluation form (40%). Prior to the workshop, 80% of the attendees reported having none to moderate familiarity with the IHRs. The IHRs and public health events of potential international concern were reported to be not at all or a very little part of daily work activities. The workshop was reported by 70% of responding attendees to have enhanced their understanding of the IHRs, as well as compliance and reporting responsibilities. In terms of how the workshop would affect strategies for conducting surveillance, 20% of attendees responded moderately, 40% considerably, and 40% completely. Sixty percent of respondents had a considerable increase in their understanding of how electronic surveillance and outbreak response systems were used in developing settings.

The majority of participants reported an enhanced understanding of CDC's GDD program and its efforts to develop and strengthen global health capacity. The variety of examples were reported to have better explained how various countries are working to meet IHR surveillance requirements. In terms of their countries, 80% of attendees reported the workshop considerably to completely provided potential solutions for achieving IHR compliance. Lastly, the presentation “Partnerships for Supporting Compliance by 2012” was reported to be helpful in identifying partnerships for attendees' countries.

Ways Forward

Informing public health professionals on the importance and relevance of the IHRs to their country and the development of partnerships were the main goals of the meeting; knowledge is one of the first steps toward supporting compliance in all states parties to the regulations. The majority of the audience had some familiarity with the revised IHRs but felt the meeting enhanced their understanding of the scope of the revised IHRs, compliance by 2012, and reporting responsibilities. Furthermore, the workshop encouraged participants to consider strategies for conducting surveillance within the framework of the IHRs and provided a clearer understanding of how electronic surveillance and outbreak response systems were used in developing settings and how they contribute to capacity building efforts. Future topics for discussion suggested by participants included additional examples from resource-limited settings, the domestic context of implementing and strengthening capacity, progress updates from member states in meeting 2012 compliance, challenges faced by WHO regarding implementation, and how events are detected and decisions are made for the notification of public health events of potential international concern to WHO.

Conclusion

Compliance with the IHRs by 2012 is a universal goal supported by the global public health community. Early warning systems and the flow of actionable information to public health centers provide professionals with the tools to effectively respond to health-related events. The evolution of technology has allowed the public health community to adopt these new tools for conducting surveillance. Many resource-limited countries still lack access to appropriate electronic surveillance systems, which may limit their ability to rapidly detect outbreaks and other health events that affect resource-poor countries and the international community. Supporting countries in building sustainable surveillance systems not only helps these countries in meeting IHR compliance, but also improves global health security and, ultimately, stability.

Footnotes

Acknowledgments

The authors gratefully acknowledge the contributions of all presenters and participants at the preconference workshop and thank the Oak Ridge Institute of Education and Science for their assistance with the workshop's organization. This work was supported by the U.S. Department of Defense, Armed Forces Health Surveillance Center's Division of Global Emerging Infections Surveillance and Response System. This report was supported in part by an appointment to the Postgraduate Research Participation Program at the U.S. Army Public Health Command (Provisional), administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the U.S. Department of Energy and USAPHC (Prov). The opinions stated in this article are those of the authors and do not represent the official position of the U.S. Department of Defense.

References

World Health Organization. International Health Regulations (2005), 2nd. Geneva: World Health Organization, 2008.

World Health Organization. IHR Core Capacity Monitoring Framework: Checklist and Indicators for Monitoring Progress in the Development of IHR Core Capacities in States Parties. Geneva, Switzerland: World Health Organization, 2011.

World Health Organization. Implementation of the International Health Regulations (2005) Geneva, Switzerland: World Health Organization, 2011.

World Health Organization. Report of the Review Committee on the Functioning of the International Health Regulations (2005) in Relation to Pandemic (H1N1) 2009. Geneva: World Health Organization, 2011.

International Society for Disease Surveillance 9th Annual Conference of the International Society for Disease Surveillance, 2010. http://www.syndromic.org/annual-conference/2010. 2011 September 8.

Andraghetti

. The interaction of disease surveillance and the International Health Regulations (IHR) Presentation at the 9th Annual Conference of the International Society of Disease Surveillance, Park City, Utah, 2010.

World Health Organization. Global Outbreak Alert & Response Network. Global Alert and Response (GAR), 2011. http://www.who.int/csr/outbreaknetwork/en/. 2011 September 8.

Roque

. Overview of the Philippine Integrated Disease Surveillance and Response System (PIDSR) Presentation at the 9th Annual Conference of the International Society of Disease Surveillance, Park City, Utah, 2010.

Hora

. Influenza in Peru: disease surveillance in the Peruvian military. Presentation at the 9th Annual Conference of the International Society of Disease Surveillance, Park City, Utah, 2010.

10.

Outbreak of 2009 pandemic influenza A (H1N1) on a Peruvian Navy ship—June-July 2009. MMWR Morb Mortal Wkly Rep, 2010 Feb 19 59,6:162–165.

11.

Meynard

. Efforts from overseas. Presentation at the 9th Annual Conference of the International Society of Disease Surveillance, Park City, Utah, 2010.

12.

Montgomery

. Global disease detection and the revised International Health Regulations (IHR 2005) Presentation at the 9th Annual Conference of the International Society of Disease Surveillance, Park City, Utah, 2010.

13.

Johns

. International Health Regulations (2005): surveillance and reporting challenges for special populations. Presentation at the 9th Annual Conference of the International Society of Disease Surveillance, Park City, Utah, 2010.

14.

Fernandez

. International Health Regulations (2005): partnerships for supporting compliance by 2012. Presentation at the 9th Annual Conference of the International Society of Disease Surveillance, Park City, Utah, 2010.