How the IHR (2005) Shaped the COVID-19 Pandemic Response in the Eastern Mediterranean Region: What Went Well and What Did Not

Abstract

The COVID-19 pandemic has underscored the importance of the International Health Regulations (IHR) (2005) in addressing global health emergencies. This review aims to improve healthcare system capabilities, future preparedness, and actions in the Eastern Mediterranean Region, particularly in low-resource areas. The IHR, established in 1969, initially focused on 6 diseases but has since expanded to include a wider range of public health threats. These regulations establish a globally recognized legal framework that is applicable to all 196 states parties, including all 194 World Health Organization member states. The IHR prioritize the prevention, protection, and control of global disease transmission while minimizing unwarranted disruptions to international travel and commerce. Nonetheless, the response to COVID-19 in the Eastern Mediterranean Region revealed a range of deficiencies despite the regulatory strengths. Some countries encountered challenges in fully complying with their IHR obligations, particularly in terms of preparedness, and occasional geopolitical tensions obstructed international collaboration. The pandemic experience underscores the need for improved trust, resource allocation, and regulatory revisions to address upcoming global health challenges. This case study highlights positive aspects of the pandemic response, including the swift exchange of information and global cooperation, while also recognizing shortcomings, such as delays in reporting and unequal vaccine access. In summary, the COVID-19 pandemic underscores the urgency of subsequent updates to the IHR or comparable accords, such as the IHR amendments and the pandemic treaty, to rectify these deficiencies. Updates should place a greater emphasis on transparency, cultivating trust, enhancing preparedness, and establishing mechanisms that incentivize comprehensive compliance among all participating nations.

Introduction

Disease outbreaks and other unusual public health threats are typically unpredictable and necessitate a variety of responses. The International Health Regulations (IHR) (2005),¹ however, provide a comprehensive legal framework outlining countries’ rights and responsibilities in managing public health events and emergencies that have the potential to spread across borders. This case study examines the role played by the IHR during the COVID-19 pandemic. We highlight the effective measures taken and the opportunities that were missed, with the aim of enhancing future preparedness and action, and bolstering healthcare system capacity, particularly in resource-constrained countries.

The Eastern Mediterranean Region (EMR) encompasses a variety of member states with diverse cultural and structural contexts influencing their health infrastructure and governance. These differences are also reflected in the way countries manage and respond to public health emergencies. Some countries have robust health systems with well-established protocols for disease surveillance and emergency response, while others may lack the necessary infrastructure and resources, leading to various levels of IHR implementation. Governance structures also differ, with some countries having centralized health governance systems that can quickly mobilize resources, whereas others rely on decentralized systems that may face challenges in coordination and rapid response.

International Health Regulations

As global trade and travel expand, so does the possibility of the spread of disease. The public health and economic impact of infectious diseases can cause significant harm to humans while also severely affecting a country’s economy. The IHR were first adopted by the World Health Assembly in 1969 to cover 6 diseases: yellow fever, cholera, malaria, smallpox, relapsing fever, and typhus. It should be noted that the IHR have been revised several times over the years to include a wider range of public health risks and events beyond just these specific diseases and to remove relapsing fever and typhus.² The IHR are a comprehensive legal framework that defines countries’ rights and obligations in managing public health emergencies and crises that have the potential to cross national borders. These regulations are an internationally binding legal authority instrument that apply to all 196 states parties, including the 194 WHO member states. The IHR (2005) went into effect on June 15, 2007.¹

The IHR are designed to prevent, protect, and control the global spread of diseases in a manner that is proportionate to the public health risks at hand, while minimizing unwarranted disruptions to international travel and trade (IHR Articles 23 to 34).^1,3 The IHR incorporate several innovative features, including a comprehensive scope that encompasses not only specific diseases or modes of transmission but also any diseases or medical conditions that could significantly harm human health, regardless of its origin or source. Furthermore, they include requirements for the states parties to establish a minimum set of core public health capabilities, obligations for the states parties to notify WHO of events that might result in a public health emergency of international concern (IHR Article 6 and Annex 2), provisions granting WHO the authority to consider unofficial reports of public health incidents and seek verification from the states parties regarding these events, procedures for the WHO director-general to determine a public health emergency of international concern (PHEIC) and issue temporary recommendations, taking into account the opinions of an emergency committee, safeguards protecting the human rights of individuals and travelers, and the establishment of national IHR focal points and WHO IHR contact points to facilitate urgent communication between states parties and WHO (IHR Article 4).⁴

The IHR core capacity index⁴ is a proxy indicator of a country’s readiness and ability to effectively prevent, identify, and respond to public health events and emergencies. This index assesses a country’s ability to meet the IHR essential requirements for managing and mitigating the consequences of public health risks. It essentially calculates the average percentage of accomplishments related to 13 fundamental capacities: (1) national legislative, policy, and normative instruments and financing; (2) IHR coordination and national IHR focal point communications; (3) surveillance; (4) health emergency management/response, including infection prevention and control; (5) public health preparedness; (6) risk communication and community engagement (RCCE); (7) human resources; (8) laboratory; (9) points of entry and border health; (10) zoonotic disease events; (11) food safety; (12) chemical events; (13) radiation emergencies.⁴

WHO has declared a PHEIC on several occasions. WHO determines whether an event is considered a PHEIC after carefully evaluating whether the reported event (1) has a serious public health impact, (2) is unusual or unexpected, (3) has a high risk of international spread, and (4) has a high risk of international travel or trade restrictions. Previous declarations were made for the 2009 novel influenza A (H1N1) pandemic, the 2014 wild poliovirus outbreak, the 2014-2016 Ebola outbreak in West Africa, the 2015-2016 Zika virus epidemic, and the 2018 Ebola outbreak. Recently, 2 diseases were declared to be PHEICs, namely, COVID-19 in 2020 and mpox (monkey pox) in 2022. These declarations highlight the gravity and global implications of these public health crises, prompting coordinated international responses to address them.⁵

COVID-19

In the first 6 weeks of 2020, the novel coronavirus, identified as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), rapidly extended from the People’s Republic of China to an additional 25 countries within a month.^6-8 On October 12, 2023, WHO had received reports of a total of 771.2 million confirmed cases of COVID-19. Among these cases, 23.4 million were reported in the EMR, representing 3% of global cases. The number of COVID-19-related deaths had reached almost 7 million, with 351,518 of these fatalities reported in the EMR, representing 5% of global deaths. Furthermore, a cumulative total of 13.5 vaccine doses had been administered by October 4, 2023, as part of ongoing efforts to manage the pandemic.⁹

On January 30, 2020, in response to the recommendations of the International Health Regulations and Emergency Committee, the WHO director-general declared the outbreak to be a PHEIC.¹⁰ As part of this declaration, WHO issued temporary recommendations advising against the adoption of “any travel or trade restriction” beyond exit screening at China’s international transit points.¹¹ It also aimed to heighten global awareness and prompt a coordinated international response to the emerging threat. While the IHR allow states parties to apply “additional health measures” that differ from WHO’s recommendations, any significant interference with international traffic, measures that refuse or delay entry/departure of people or goods for more than 24 hours, must be based on available scientific evidence and principles, temporary in their use, reported with their rationale to WHO, and adhere to human rights standards.¹¹

In accordance with World Health Assembly resolution WHA73.1,¹² the WHO director-general initiated an IHR review committee.¹³ This committee has been tasked with 2 primary goals: assessing the effectiveness of the IHR in the context of the COVID-19 response and assessing the status of previous IHR Review Committee recommendations. Commencing its work in September 2020, the committee convened regularly and reported its progress to WHO governing bodies through the director-general.

The WHO director-general delivered the report of the 15th meeting of the IHR Emergency Committee on the COVID-19 pandemic on May 4, 2023.¹⁴ The director-general agreed with the committee’s recommendations, which was based on an assessment of 3 fundamental PHEIC criteria: COVID-19’s continued extraordinary nature, its status as a public health risk to other countries due to international transmission, and the need for a coordinated international response.

The Review Committee on the Functioning of the International Health Regulations During the COVID-19 Response, convened by the WHO director-general, conducted a comprehensive review from September 2020 to April 2021.¹⁵ The committee emphasized 8 key messages in critical areas, addressing compliance, early alert and response, and financing. Lack of compliance with IHR obligations, particularly on preparedness, contributed to the prolonged global health emergency. Recommendations included elevating responsibility for IHR implementation to the highest government level, establishing robust accountability mechanisms, and ensuring predictable financing for effective IHR implementation. The committee formulated 40 practical recommendations covering areas such as the role of national IHR focal points, core capacity requirements, legal preparedness, and risk assessment. Key proposals include integrating core capacities into broader health systems, enhancing legal frameworks, and promoting transparency in information sharing.

Additionally, the committee urged WHO to adopt a more formal approach to convey information about emergency committee meetings, develop standards for digital vaccination certificates, and strengthen communication through digital technology.¹⁵ The committee emphasized collaboration, coordination, and financing, and called for a global convention on pandemic preparedness and response. It underscored the need for compliance and accountability, recommending the establishment of national competent authorities and the development of a universal periodic review mechanism. Finally, the committee highlighted the slow pace of implementing previous recommendations and recommended a comprehensive assessment after the COVID-19 pandemic to evaluate their impact at national, regional, and WHO levels.

Role of IHRDuring the COVID-19 Pandemic

In any public health emergency, the IHR are well considered, appropriate, and meaningful. However, many countries only applied the IHR partially because they were not aware of the regulations or deliberately ignored them.^16,17 Member states’ inadequate compliance with their obligations under the IHR, particularly in terms of preparedness, has contributed to the prolonged global health crisis of the COVID-19 pandemic. To enhance compliance, it is imperative to prioritize the implementation of the IHR at the highest levels of government and incorporate it into the broader framework of establishing a robust healthcare system through a whole-of-government approach. This could involve measures such as ensuring that national focal points for IHR are effectively organized, adequately resourced, and positioned within government structures that have the necessary seniority and authority to engage meaningfully with all relevant sectors during crisis response.¹⁸

Eastern Mediterranean Region Situational Analysis

The EMR faced unique challenges in controlling the spread of SARS-CoV-2 due to protracted conflicts, limited resources, weak health systems, and geopolitical issues. More than half of the countries in the EMR are fragile conflict zones, hindering regional solidarity and global cooperation on vaccine access. The region, representing 9% of the global population, bears 43% of the world’s humanitarian needs, with 64% of global refugees originating from there.¹⁸ The pandemic has exposed weaknesses in health systems, delayed progress toward Sustainable Development Goals, and highlighted the urgency of addressing emergency preparedness. The EMR’s response has been largely effective but diverse, considering the region’s multiple protracted emergencies, vulnerable economies, and fragile health systems.^19,20

Our evaluation of the EMR’s response to the COVID-19 pandemic involved assessing the region’s adherence to IHR obligations. This included an examination of early alert and response mechanisms, public health infrastructure, coordination and communication, and risk management strategies. We then analyzed the effectiveness and diversity of the response by comparing the actions taken by countries in the EMR with the core capacities outlined by the IHR. This systematic evaluation highlights how different countries in the region managed the pandemic, taking into consideration their unique challenges, such as protracted conflicts, limited resources, and geopolitical issues.

The WHO Eastern Mediterranean Regional Office (EMRO) initiated a comprehensive response to the COVID-19 pandemic in early 2020, emphasizing a “whole-of-government, whole-of-society approach.” Efforts included a regional incident management system, a blueprint for future responses, and a ministerial group for guidance. The response involved expanding testing and laboratory capacity, creating over 600 new laboratories, and instituting quality control measures. Despite progress, challenges persist, such as limited vaccine access, infodemics, and vaccine hesitancy. As of December 6, 2023, 23.4 million cases and 351,821 deaths were reported, with a case fatality ratio of 1.5%.²¹ The region faces difficulties in information sharing, early warning systems, protection of health workers, vaccine equity, critical care capacities, and maintaining essential health services.²²

In 2021, EMRO proposed an action plan for health emergency preparedness in EMR that outlined short-term and medium- to longer-term priorities.²³ The plan aimed to expedite efforts to conclude the COVID-19 pandemic, strengthen health security as an integral part of overall health system enhancement, and establish a resilient health system capable of anticipating and preventing future health emergencies. Additionally, the plan sought to align and expedite the achievement of the Sustainable Development Goals, fostering a better, safer, and healthier region. It includes a monitoring and evaluation mechanism. The Regional Committee for the EMR endorsed the proposed plan of action along with the associated resolution.

Volunteers, health workers, and community-based groups were crucial during the COVID-19 pandemic and will remain so in future disasters. Community engagement in EMR is influenced by several factors, including trust in public health institutions, cultural beliefs and previous practices, levels of health literacy, and effectiveness of communication strategies.²⁴ Between December 2020 and May 2021, EMRO carried out an extensive mapping initiative on community engagement in the EMR. The primary objective was to identify the methods used for community engagement, including success stories, drivers, facilitators, challenges, and obstacles. The analytical framework used was a socioecological model, and evidence was gathered through a review of articles, research papers, government directives, WHO program documentation, and interviews with key stakeholders, such as WHO and United Nations agency personnel, civil society representatives, and officials from various countries. The results of the mapping exercise indicated that while some factors influencing community engagement were universally applicable, others were highly contingent on specific contexts. Additionally, there might be other factors that were not documented or shared during the interviews.

EMR countries have developed various strategies to enhance community engagement, such as strengthening capacities of local leaders and influencers, adapting messages to cultural contexts, and using social media to reach broader audiences. Additionally, historical experiences with health interventions and existing social dynamics played a significant role in shaping community responses.

Countries with the largest populations in the region faced distinct challenges and demonstrated notable strategies in their pandemic response efforts. One country struggled initially with vaccine rollout and was among the last to undergo a Joint External Evaluation assessment,²⁵ which reflects the varying levels of preparedness and response capacities across the region. In contrast, another country was an early adopter of the Joint External Evaluation and developed a costed national action plan for health security with provincial task forces, which provided significant advantages in coordinating and executing response efforts. These examples reflects the importance of tailored strategies that consider each country’s unique context and the critical role of early assessment and planning in enhancing health emergency responses.

Lessons Learned From the COVID-19 Pandemic in EMR

Individuals, communities, and governments all over the world have learned valuable lessons from the COVID-19 pandemic. Some of these lessons from the EMR member states include:

Efficient early alert and response mechanisms necessitate enhanced collaboration, coordination, and the establishment of trust between countries and with WHO. This trust can be cultivated through regular, meaningful, and frequent interactions that extend beyond crisis situations. Participation in networks like the Global Outbreak Alert and Response Network or the International Association of National Public Health Institutes represents a crucial step in this direction.

In general, EMR countries that swiftly implemented early travel restrictions, coupled with comprehensive public health measures, managed to delay the onset of the pandemic within their borders. While implementing precautionary travel restrictions can be effective in the initial stages of health crises, policymakers should carefully consider the longer-term consequences of maintaining such restrictions within the broader context of their economic and social impacts. Furthermore, the implementation of strict travel measures with inadequate notice or over extended periods raises significant human rights concerns that warrant attention and consideration.^26-28

Successful implementation of the IHR is dependent on both national and international political commitment and long-term funding. Unfortunately, the level of political will and financial resources dedicated to IHR implementation remains insufficient and inconsistent. This underinvestment threatens the IHR’s goals and our collective ability to respond effectively to global health threats. It emphasizes the importance of a more stable and substantial commitment to IHR enforcement, both within and across national borders.

The IHR primarily rely on cooperation but lack robust enforcement mechanisms, potentially allowing countries to not consistently fulfill their obligations without penalties. Despite the emphasis of the IHR on capacity building, many countries still faced resource constraints that hindered their ability to detect, assess, and respond effectively to the pandemic.

Additionally, the global response to COVID-19 encountered occasional hindrances stemming from geopolitical tensions and nationalistic agendas, leading to periods of public distrust in international organizations and initiatives. The pandemic underscored that, despite the IHR focus on preparedness, many nations were ill prepared for such a significant PHEIC.

What Went Well During the COVID-19 Response in EMR

The IHR were quickly activated in response to the COVID-19 pandemic, allowing for the rapid exchange of information and fostering global collaboration. Member states participated in risk assessment, readiness, and coordinated response efforts within the IHR framework, and global collaboration resulted in the rapid development and distribution of COVID-19 vaccines. The pandemic highlighted the importance of regulatory guidelines in managing global health crises and established mechanisms for accountability.

EMR member states have improved their laboratory capabilities by leveraging COVID-19 response efforts in the short term to improve long-term readiness for managing epidemic-prone diseases and high-threat pathogens. This includes providing technical assistance to national public health laboratory networks through workshops, training, and mentoring. Furthermore, international and national agencies, as well as partners in the public health and humanitarian sectors, have collaborated to provide technical assistance in strengthening core risk communication capacities.²⁹ This initiative relies heavily on the RCCE Collective Service, a coordination mechanism comprised of WHO, United Nations Children’s Fund, the International Federation of Red Cross and Red Crescent Societies, and the Global Outbreak Alert and Response Network.

During the COVID-19 pandemic, the RCCE Collective Service was established to centralize efforts in managing social and behavioral information, resulting in a comprehensive data repository and a global dashboard derived from over 200 social and behavioral surveys.²⁹ The RCCE Collective Service also created interim guidance, COVID-19 materials, and products, as well as 2 online training courses that are now available on the OpenWHO platform.

WHO received regular reports on new variants, such as the epidemiology of new variants of concern, including the Delta and Omicron variants, and their impact on clinical aspects of the disease. Furthermore, EMRO diligently monitored and reported on states parties’ compliance with their obligations under the IHR regulations, particularly regarding event notification and verification.³⁰

Efforts have been directed toward promoting implementation of the IHR regulations at points of entry for travel and transport. EMRO has launched a number of initiatives, including the development and regular updating of policy and technical guidance, as well as operational tools. These efforts aim to assist countries in implementing a risk-based approach to international traffic management during health emergencies, and strengthening public health measures and capacities at entry points, particularly in the context of the COVID-19 pandemic.³¹

Regular systematic reviews are conducted by EMRO to assess the effectiveness of various public health and social measures, including travel-related measures, in minimizing the exportation, importation, and transmission of SARS-CoV-2, while considering the broader impact of such measures on international travelers. Additionally, WHO has consistently updated its interim guidance to align with the evolving dynamics of COVID-19.³² These updates incorporate the risk-based approach to international travel and address new variants, as well as the role of COVID-19 vaccination in the overall risk management process.

Furthermore, EMRO has played an important role in helping countries strengthen their IHR capacities and implement public health measures for the pandemic response. For example, EMRO has facilitated online consultations with member states and conducted assessments and training for the IHR national focal points in multiple countries, all with the goal of strengthening global health security and ensuring public health system resilience.

What Did Not Go Well During the COVID-19 Response in EMR

The COVID-19 response revealed several weaknesses in IHR implementation, including delays in reporting and transparency, variations in IHR implementation, unequal vaccine access, hesitancy in information sharing, and gaps in public health emergency preparedness. The zoonotic origins of COVID-19 highlighted the need for improved surveillance and prevention measures for such diseases, emphasizing the importance of strengthening the One Health approach in the region. These issues highlight the importance of reforming and improving the IHR, as well as fostering greater international collaboration to ensure a more effective response to future global health threats.

A limitation of IHR implementation is that while every country in the region is expected to have the capability to detect and promptly report new infections to WHO, the reality is that not all regional countries can consistently detect emerging infections at an early stage, devise effective responses, and promptly notify WHO. Furthermore, even after WHO declared COVID-19 a PHEIC on January 30, 2020, some EMR countries refrained from implementing travel restrictions or quarantine measures. They opted for a “wait and see” approach, deeming it less economically disruptive than immediate public health measures, particularly when the severity of the new pathogen’s impact remained uncertain.^33-35 Later, other countries in the EMR started to make decisions about closing points of entry and restricting travel that were not recommended by WHO and did not conform with the IHR.

Therefore, revisions to the International Health Regulations Monitoring and Evaluation Framework³⁶ tools was necessary because it was clear that they did not adequately address crucial areas that received little attention before the COVID-19 pandemic, such as leadership and governance, infection prevention and control, risk communication, and community engagement.²²

The IHR expects that every country possesses the capacity to address public health crises and it mandates an annual competency evaluation through the States Parties Self-Assessment Annual Report (SPAR) as a mandatory tool of the IHR Monitoring and Evaluation Framework.³⁷ However, the 2020 SPAR evaluation of IHR implementation in 174 countries revealed an implementation rate of about 70%.³³ In previous PHEICs, such as influenza A (H1N1) in 2009 and Ebola in 2014, approximately one-quarter of states parties implemented additional health measures that deviated from the recommendations set forth by WHO.³⁸

Additionally, the inconsistent and unclear rationales behind the announced recommendations created challenges in comprehending the basis for published guidance. Outbreaks vary from one another, and as a result, different temporary recommendations regarding international travel and trade measures may be warranted. Moreover, as we learn more during the course of an outbreak, it is natural for recommendations to evolve and be updated to reflect our increasing understanding of the situation.³⁹

Conclusion

The COVID-19 pandemic has shed light on the complexities of global health governance and security. The IHR are crucial in shaping global responses to health emergencies, but their reliance on cooperation rather than strict enforcement mechanisms emphasizes the importance of trust and mutual support among countries. The varying levels of IHR compliance highlight the need for standardized implementation and shared responsibilities in times of crisis.

The resource shortages that many countries experienced during pandemic response efforts serve as a stark reminder of the need to address global health disparities and guarantee that countries have access to the tools and capabilities required to successfully manage public health threats. While nationalistic agendas and geopolitical tensions are not entirely unexpected in a global context, they have nonetheless complicated the response to the pandemic, emphasizing the need for nations to put aside their differences and cooperate.

In summary, the COVID-19 pandemic underscores the urgency of making subsequent updates to the IHR or comparable accords, such as the IHR amendments and the pandemic treaty, to rectify these deficiencies. Updates should place a greater emphasis on increasing transparency, cultivating trust, enhancing preparedness, and establishing mechanisms that incentivize comprehensive compliance among all participating member states.

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