What is the global architecture around epidemic preparedness and response?

SPEAKER: The global architecture around epidemic preparedness and response aims to minimise vulnerabilities to acute public health risks and events that endanger the collective health of populations living across national, regional, and international borders. Many disease outbreaks such as SARS in 2003, the H1N1 influenza pandemic in 2009, and more recently the Ebola viral disease (EVD) outbreaks in West Africa and in the Democratic Republic of Congo highlight the toll of outbreaks on the health of populations on public health systems and on the economy. Even when the morbidity and mortality are globally relatively low, the socioeconomic impact could be quite high.

One such example is the 2003 SARS outbreak where less than 9,000 people were affected globally with less than 800 deaths, but the economic repercussions were huge with an estimated loss of $30 to $50 billion US. The avian influenza outbreak cost $30 billion. The EVD outbreaks since 2014 cost over $50 billion, and the Zika outbreak was estimated to cost between $7 and $18 billion.

Many frameworks guide the work done in preparedness including the Sendai Framework, the Universal Health Coverage 2030 as well as other regional strategies such as the Integrated Disease Surveillance and Response Strategy in the African region, IDSR, and the Asia-Pacific Strategy for Emerging Diseases, APSED, in the Western Pacific and Southeast Asian regions. One of the most critical frameworks is the International Health Regulations, which we will discuss in more details in the next slides.

The implementation of these frameworks are facilitated through mechanisms such as the WHO contingency fund for emergencies to finance immediate response, the World Bank Pandemic Emergency Financing Facility, PEFF, which is a quick disbursing financing mechanism to enable large-scale response and monitored through mechanisms such as the global preparedness monitoring board co-led by the World Health Organisation and the World Bank. There are other member states driven initiatives such as the Global Health Security Agenda, which supports the acceleration of the implementation of the international health regulations for health security.

The International Health Regulations, a legally binding instrument for the 196 States Parties to the regulations and were adopted in June 2005, hence the name IHR 2005. They entered into force in June 2007. The purpose and scope are 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. The IHRs are about risks, vulnerabilities, and a global commitment to mitigate these. They have a number of rights and obligations for WHO and States Parties including the development of national capacities to detect, assess, notify, and respond to public health emergencies.

Under the International Health Regulations, capacities should be in place at the local, intermediate, and national public health levels but also at the international levels. The identification and control of events at source is critical and resilient communities are central to this effort. The local level should have the capacities to detect the event early to report them and institute preliminary control measures. The intermediate level should support the local level to confirm, assess, and respond. In addition, the national level should be able to assess, notify, and provide a public health response.

During the 2014 EVD outbreaks in West Africa, for example, Nigeria was able to early detect the outbreak, investigate, conduct timely laboratory confirmation, comprehensive contact tracing, and leverage in country resources, and provide strong leadership in the control of the outbreak. The details of the capacities required under the IHR can be found in Annex 1 of the IHR 2005. In cases where the event spreads beyond national borders, the capacities to verify, assess, and support should be available at regional and international levels. WHO provides a coordinated response to public health events through various mechanisms including through the Global Outbreak Alert and Response Network, GOARN.

The decision instrument in Annex 2 of the IHR 2005 should be used to carry out a risk assessment and notification of events that may constitute a Public Health Emergency of International Concern or a PHEIC. A PHEIC is declared by the Director General of WHO based on the views and advice of an emergency committee. Temporary recommendations are issued when a PHEIC is declared.

Whilst the role of the local and national levels are critical in the prevention, detection, and response to public health events and emergencies, the global level is equally important in providing global norms, standards, and guidance in documenting and disseminating best practises, in monitoring progress and evaluating outcomes and impact, in building strategic partnerships, and in mobilising and providing coordinated international response. Since 2008, six parties to the International Health Regulations have used an annual reporting tool to inform WHO of their progress in implementing core capacities. Although progress has been made in many areas, the IHR review committee noted that countries still face significant challenges in implementing the IHR. The graphic represents the 13 core capacities for 167 countries that reported in 2007.

It shows that countries report doing well in zoonosis, laboratories, surveillance, and much less so in chemical, radiological, human resources, and capacities at the points of entry. These data are available on the WHO Global Health Observatory. Strategies for measuring capacities include the IHR five-year strategic plan, which has three major pillars, notably country capacity building, event management, and monitoring and accountability pillars. The status of implementation of the IHR core capacity is measured both in a qualitative and quantitative manner that ensures not only the availability of the capacities but also their functionality.

The IHR monitoring and evaluation framework is composed of the mandatory States Parties annual report, the voluntary Joint External Evaluations, or JEEs, the simulation exercises which allow the validation of procedures, plans and systems, and after action reviews that allow the incorporation of lessons learned following a real-life event. These increase transparency, mutual accountability, trust building between states as well as promoting dialogue and sustainability of interventions. The framework also takes into account assessments carried out at the human, animal and environmental interface from whence most emerging infectious diseases arise.

Using the findings of IHR monitoring and evaluation framework as well as the IHR performance of veterinary services or previous assessments at the human animal interface, using the risk profiling, and taking into account other relevant assessments, WHO and partners work with countries to develop operational plans and five-year national action plans for health security. They work with countries to build strategic partnerships to finance and implement these plans. This multi-sectoral agency plan development is laid and owned by the country with the full engagement of all relevant sectors. Strong multi-sectoral collaboration networks and strategic partnerships including at the human and animal health sectors is important for effective implementation of IHR for global health security. Taking a multi-sectoral approach for preparedness is key.

Leveraging knowledge, expertise, and resources and adopting a whole of government perspective is crucial given that health security is everybody’s business.

The preparedness and response to public health events need to be anchored in resilient health systems that can search to meet the requirements needed to manage health emergencies. This goes beyond the health sector to include other key sectors such as agriculture, trade, transport, finance, parliamentarians, etc. As the world strives towards universal health coverage and attaining the sustainable development goals, a whole of government approach is critical to accelerate the implementation of the International Health Regulations and build an even more robust architecture around epidemic preparedness and response.

In conclusion, outbreaks could have a high impact on health and socioeconomic development. Strong collaboration, partnerships, and coordination between sectors at all levels are essential for effective epidemic preparedness and response. The local levels and communities are central to this effort and must be informed, involved, and engaged.

The IHR’s are a key element of the global architecture for epidemic preparedness and response and improving capacities at all levels to prevent, detect, and respond and building resilient health systems will lead to more sustainable preparedness.