Editorial 221
Implementing the Revised International
Health Regulations in India
On 23 May 2005, the World Health Assembly adopted the new
International Health Regulations (IHR).1
The revised IHR came into force on 15 June 2007 in 193 member
countries of the World Health Organization (WHO). The goal of
the IHR is to prevent the international spread of emerging
infections such as severe acute respiratory syndrome (SARS), a
pandemic of human influenza, as well as other public health
emergencies such as chemical and industrial accidents that may
affect populations across borders. The IHR (2005) are an
update of the IHR (1969), which were limited to the reporting
of just 3 infectious diseases—cholera, plague and yellow
fever.2 The IHR (2005) are broader in
scope and require each country to report to the WHO ‘any
public health emergency of international concern (PHEIC)’,
whether nuclear, biological or chemical in nature,
irrespective of the origin. In contrast to the IHR (1969),
which were restricted to the passive reporting of information
by governmental authorities, the IHR (2005) are proactive and
include provisions that empower WHO to initiate an assessment
and response based not only on government reports but also
other relevant information and reports by the media and
non-governmental organizations (NGOs).
Diseases reportable under the IHR (2005)
The infectious diseases reportable under
the IHR (2005) include unusual diseases such as smallpox, wild
poliovirus infection, human influenza (new subtype), SARS;
epidemic-prone diseases such as cholera, pneumonic plague,
yellow fever, viral haemorrhagic fevers, West Nile fever; and
diseases of special regional concern such as dengue fever
(Fig. 1). There are several recent examples of internationally
notifiable infectious diseases that have occurred in India. In
April 2007, in an outbreak of Nipah virus infection in Nadia
District in West Bengal, 5 individuals were infected and all
died.3 A total of 255 cases of
poliomyelitis due to the wild-type virus have been reported in
India up to September 2007.4 Although no
human influenza cases have been reported so far, H5N1
outbreaks among poultry in Maharashtra, Gujarat and Madhya
Pradesh and more recently in Manipur indicate the need for
continued vigilance.5 Outbreaks of
water-borne and vector-borne diseases such as cholera and
dengue fever are also common in India.
Requirements of the IHR (2005)
The requirements that need to be fulfilled by WHO member
countries to comply with the IHR (2005) include (i)
designating a national IHR focal point; (ii) strengthening
core capacity to detect, report and respond rapidly to public
health events; (iii) assessing events that may constitute a
PHEIC within 48 hours and notifying WHO within 24 hours of
assessment; (iv) providing routine inspection and control
activities at international airports, ports and some ground
crossings; and (v) examining national laws, revising health
documents/forms and certificates, and building a legal and
administrative framework in line with the IHR requirements.
Member countries are required to complete the assessment of
existing national structures and resources by June 2009, and
develop the necessary public health infrastructure and human
Fig 1. Simplified decision instrument for assessment and
notification of events that might constitute a public health
emergency of international concern under the International
Health Regulations (IHR) 2005
resources to meet the IHR requirements by
2012. Concerned about the public health risk from human cases
of avian influenza, several countries including India
volunteered to implement in advance some provisions of the IHR
(2005).1
Progress in implementation of the IHR (2005) in India
IHR requirements are being actively
implemented in India. The Government of India has designated
the National Institute of Communicable Diseases (NICD) as the
national focal point for IHR; state-level and district-level
focal points are being identified. Strengthening national
surveillance systems is at the heart of IHR (2005). The
Government of India has allocated Rs 4.08 billion (Rs 408
crores) over 5 years for the Integrated Disease Surveillance
Project (IDSP) to build infrastructural and human capacity at
the district and state levels. Under this project, nearly
20 000 medical officers, 115 000 health workers and more than
4000 laboratory technicians have been trained so far in
procedures for rapid detection and response to disease
outbreaks in 22 states. As envisaged in the National Rural
Health Mission, accredited social health activists (ASHAs) can
play an important role in reporting unusual events to the
local authorities. Improved diagnostic capability through
functional laboratories is a prerequisite for the
identification and surveillance of new pathogens. Towards this
goal, 2 biosafety level (BSL)-3 laboratories have been
established—one at the NICD, Delhi and the other at the
National Institute of Virology, Pune. Networking between
laboratories of different capacities has been planned at
various levels in India.
Information technology is being harnessed to facilitate
rapid communication from the districts upwards. In
collaboration with the Indian Space Research Organization, the National Informatics Centre and Bharat
Sanchar Nigam Limited, districts are being connected
electronically through satellite and the terrestrial network
for transmission of surveillance data, videoconferencing and
distance learning.
Another important obligation of the IHR
(2005) is to provide routine inspection and control activities
at international airports, ports and ground crossings. Each
year, more than 25 million international passengers pass
through India via 21 international airports, 12 ports and 3
major land border crossings. The Public Health Act of India
has been drafted and the Indian Port Health Rules and Indian
Aircraft (Public Health) Rules are currently being examined
for their compliance with IHR (2005).
Challenges to implementation in India
While implementation of the IHR (2005) is
being systematically planned, several challenges are
anticipated in its operationalization in a country as large
and diverse as India. A strong public health infrastructure
and participation of all governmental organizations and NGOs
are important prerequisites for successful implementation of
the IHR (2005). Reporting of and responding to public health
emergencies in a timely manner requires the full participation
of and commitment from every health professional, whether in
the public or private sector, or from civil society or the
media. Moreover, as many emerging infectious diseases are
zoonotic in origin, there is a need for close collaboration
between the veterinary and human health sectors. As health is
a state subject in India, the local and district
administration, and state governments will have to be fully
involved and committed to operationalizing the IHR (2005) in
their areas of jurisdiction. Failure to share information in a
timely manner by local public health authorities undermines
the IHR and can be detrimental to the national economy.
Another important challenge is that huge financial resources
will be required to fully comply with the IHR (2005)
requirements. Unless the level of government investment in
public health infrastructure is enhanced substantially, the
essential capacity required to detect and contain infectious
diseases and other public health emergencies will remain
limited.
Opportunities provided by the IHR (2005)
The many challenges in implementing the IHR
(2005) can also be seen as opportunities for strengthening
public health systems in India. Working within a multilateral
framework based on partnership and collaboration, India stands
to benefit from the IHR (2005) by improving national
surveillance capacity, building on current systems to quickly
respond to public health emergencies, encouraging the use of
modern communication tools, and increasing commitment to
public health. The IHR (2005) also present an important
opportunity for the international donor community to make a
long term investment in India’s public health infrastructure.
Strengthening core capacity for surveillance so that public
health emergencies are detected rapidly, verified and reported
can help in ensuring national and international health
security.6
Conclusion
The IHR (2005) is a historical development
in public health. The Regulations offer an expanded scope to
prevent and contain the international spread of infectious
diseases and other emergencies. Turning the vision of IHR
(2005) into a reality in India may be a challenge but brings
unparalleled opportunities to work together to further fortify
the foundations of public health systems in India.
REFERENCES
-
World Health Organization. Fifty-eighth
World Health Assembly Resolution WHA 58.3: Revisions of the
International Health Regulations, 23 May 2005. Available at
http://www.who.int/ebwha/pdf_files/WHA58/WHA58_3-en.pdf
(accessed on 28 September 2007).
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World Health Organization. International
health regulations (1969). 3rd ed. Geneva:World Health
Organization; 1983. Available at http://whqlibdoc.who.int/publications/1983/9241580070.pdf
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World Health Organization. Nipah virus
outbreak in India and Bangladesh. Communicable Disease
Newsletter 2007;4:3. Available at http://www.searo.who.int/
(accessed on 29 September 2007).
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World Health Organization. Polio update:
Report for week 39. Vaccine Preventable Disease
Surveillance Bulletin, 1 October 2007;11:1.
Available at http://searo.who.int/EN/Section1226/showfiles.asp
(accessed on 4 October 2007).
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Government of India, Ministry of
Agriculture. Brief to media on containment of avian
influenza in Imphal, Manipur, 27 July 2007. Available at
http://dahd.nic.in/birdflue.htm (accessed on 4 October
2007).
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Guenael R, Greenspan AL, Hughes JM, Heymann
DL. Global public health security. Emerg Infect Dis
2007;13:1447–52.
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