Exploring the international arena of global public health surveillance

Threats posed by new, emerging or re-emerging communicable diseases are taking a global dimension, to which the World Health Organization (WHO) Secretariat has been responding with determination since 1995. Key to the global strategy for tackling epidemics across borders is the concept of global public health surveillance, which has been expanded and formalized by WHO and its technical partners through a number of recently developed instruments and initiatives. The adoption by the 58th World Health Assembly of the revised (2005) International Health Regulations provides the legal framework for mandating countries to link and coordinate their action through a universal network of surveillance networks. While novel environmental threats and outbreak-prone diseases have been increasingly identified during the past three decades, new processes of influence have appeared more recently, driven by the real or perceived threats of bio-terrorism and disruption of the global economy. Accordingly, the global surveillance agenda is being endorsed, and to some extent seized upon by new actors representing security and economic interests. This paper explores external factors influencing political commitment to comply with international health regulations and it illustrates adverse effects generated by: perceived threats to sovereignty, blurred international health agendas, lack of internationally recognized codes of conduct for outbreak investigations, and erosion of the impartiality and independence of international agencies. A companion paper (published in this issue) addresses the intrinsic difficulties that health systems of low-income countries are facing when submitted to the ever-increasing pressure to upgrade their public health surveillance capacity.     

Global public health surveillance under new international health regulations

The new International Health Regulations adopted by the World Health Assembly in May 2005 (IHR 2005) represents a major development in the use of international law for public health purposes. One of the most important aspects of IHR 2005 is the establishment of a global surveillance system for public health emergencies of international concern. This article assesses the surveillance system in IHR 2005 by applying well-established frameworks for evaluating public health surveillance. The assessment shows that IHR 2005 constitutes a major advance in global surveillance from what has prevailed in the past. Effectively implementing the IHR 2005 surveillance objectives requires surmounting technical, resource, governance, legal, and political obstacles. Although IHR 2005 contains some provisions that directly address these obstacles, active support by the World Health Organization and its member states is required to strengthen national and global surveillance capabilities.     

Disease surveillance system: a mandatory conduit for effective control of infectious diseases in pakistan

In Pakistan, absence of a nationwide surveillance mechanism and strategy is the main reason for the failure in effectively controlling communicable diseases. The seasonal outbreaks of various infectious diseases every year call for an integrated surveillance system on a national level for planning effective preventive strategies. Opportunity to adopt a tested and tried model exists at this time in terms of the "Disease Early Warning System" set up by World Health Organization in conflict-affected districts. Replicating this system in other districts is both practical and feasible as technical support is readily available through the World Health Organization. Such a system once put in place has potential to not only decrease morbidity and mortality through early detection and prompt control of outbreaks but also to facilitate effective financial, human resource, and materials management at the district level. This would be a step toward a more responsive health system at the local level.     

Globalization, international law, and emerging infectious diseases.

The global nature of the threat posed by new and reemerging infectious diseases will require international cooperation in identifying, controlling, and preventing these diseases. Because of this need for international cooperation, international law will certainly play a role in the global strategy for the control of emerging diseases. Recognizing this fact, the World Health Organization has already proposed revising the International Health Regulations. This article examines some basic problems that the global campaign against emerging infectious diseases might face in applying international law to facilitate international cooperation. The international legal component of the global control strategy for these diseases needs careful attention because of problems inherent in international law, especially as it applies to emerging infections issues.     

Polio Eradication Initiative: Contribution to improved communicable diseases surveillance in WHO African region

IntroductionSince the launch of the Global Polio Eradication Initiative (GPEI) in 1988, there has been a tremendous progress in the reduction of cases of poliomyelitis. The world is on the verge of achieving global polio eradication and in May 2013, the 66th World Health Assembly endorsed the Polio Eradication and Endgame Strategic Plan (PEESP) 2013–2018. The plan provides a timeline for the completion of the GPEI by eliminating all paralytic polio due to both wild and vaccine-related polioviruses.MethodsWe reviewed how GPEI supported communicable disease surveillance in seven of the eight countries that were documented as part of World Health Organization African Region best practices documentation. Data from WHO African region was also reviewed to analyze the performance of measles cases based surveillance.ResultsAll 7 countries (100%) which responded had integrated communicable diseases surveillance core functions with AFP surveillance. The difference is on the number of diseases included based on epidemiology of diseases in a particular country. The results showed that the polio eradication infrastructure has supported and improved the implementation of surveillance of other priority communicable diseases under integrated diseases surveillance and response strategy.ConclusionAs we approach polio eradication, polio-eradication initiative staff, financial resources, and infrastructure can be used as one strategy to build IDSR in Africa. As we are now focusing on measles and rubella elimination by the year 2020, other disease-specific programs having similar goals of eradicating and eliminating diseases like malaria, might consider investing in general infectious disease surveillance following the polio example.     

Coincident polio and Ebola crises expose similar fault lines in the current global health regime

Background

In 2014, the World Health Organization (WHO) declared two "public health emergencies of international concern", in response to the worldwide polio situation and the Ebola epidemic in West Africa respectively. Both emergencies can be seen as testing moments, challenging the current model of epidemic governance, where two worldviews co-exist: global health security and humanitarian biomedicine.

Discussion

The resurgence of polio and the spread of Ebola in 2014 have not only exposed the weaknesses of national health systems, but also the shortcomings of the current global health regime in dealing with transnational epidemic threats. These shortcomings are of three sorts. Firstly, the global health regime is fragmented and dominated by the domestic security priorities of industrialised nations. Secondly, the WHO has been constrained by constitutional country allegiances, crippling reforms and the limited impact of the (2005) International Health Regulations (IHR) framework. Thirdly, the securitization of infectious diseases and the militarization of humanitarian aid undermine the establishment of credible public health surveillance networks and the capacity to control epidemic threats.

Summary

The securitization of communicable diseases has so far led foreign aid policies to sideline health systems. It has also been the source of ongoing misperceptions over the aims of global health initiatives. With its strict allegiance to Member States, the WHO mandate is problematic, particularly when it comes to controlling epidemic diseases. In this context, humanitarian medical organizations are expected to palliate the absence of public health services in the most destitute areas, particularly in conflict zones. The militarization of humanitarian aid itself threatens this fragile and imperfect equilibrium. None of the reforms announced by the WHO in the wake of the 68^th World Health Assembly address these fundamental issues.

     

Communicable diseases in the South-East Asia Region of the World Health Organization: towards a more effective response

This article looks at the current burden of communicable diseases in the South-East Asia Region of the World Health Organization and analyses whether the current levels and trends in funding are adequate to meet the needs of control, prevention and treatment. Our analysis considers the Millennium Development Goals (MDGs) for health and indicators of economic progress in each country, as well as the impact of the global financial crisis on progress towards MDGs for communicable diseases in the region. The analysis indicates that the current focus of funding may need to be expanded to include less-discussed but high-burden diseases often related to inadequacies in the health sector and the particular development paths that countries pursue. Scarce funding during times of global economic recession could be used more effectively if informed by a careful analysis of the complex set of factors, including behavioural, environmental and health systems factors, that determine the burden of communicable diseases. Significant gaps in funding as well as varying regional needs warrant a more diverse set of national and international aid measures. Although regional and global collaboration is critical, the effectiveness of future policies to deal with the burden of communicable diseases in the region will only be assured if these policies are based on evidence and developed by policy-makers familiar with each country’s needs and priorities.     

Surveillance of smallpox.

An intensified global smallpox eradication programme was started by the World Health Organization in 1967. This paper describes the basic techniques employed and the experiences involved in implementing the procedures. Surveillance schemes have varied considerably in detail from country to country according to different health structures, and the emphasis is therefore placed on the more generally used approaches. Finally, important principles in the implementation of the smallpox surveillance programme are considered in relation to the development of such programmes for other communicable diseases.     

The Scottish Centre for Infection and Environmental Health (SCIEH)

The Scottish Centre for Infection and Environmental Health has four core functions: the monitoring and surveillance of communicable diseases and environmental hazards in Scotland; operational advice and support at national and local level; research; and education and training. Its work is determined by a specification drawn up by the Public Health Policy Unit of the Scottish Office Department of Health. To fulfill its remit it works closely with a wide range of professionals, including those in the Scottish Office Department of Health, the health service, local government, and in organisations concerned with the environment. It also has close relationships with the Communicable Disease Surveillance Centre, Public Health Laboratory Service, London, the World Health Organization and other international bodies.     

Health imperatives in foreign policy: the case of Malaysia

Malaysia's global, regional and bilateral international health relations are surveyed against the historical backdrop of the country's foreign policy. Malaysia has always participated in multilateral agencies, most notably the World Health Organization, as such agencies are part of the longstanding fabric of "good international citizenship". The threats of infectious diseases to human health and economic activity have caused an intensification and an organizational formalization of Malaysian health diplomacy, both regionally and bilaterally. Such diplomacy has also established a basis for developing a wider set of cooperative relationships that go beyond responding to the threat of pandemics. As Malaysia approaches "developed" status, its health sector is becoming increasingly integrated into the global economy through joint research and development ventures and transnational investment. At the same time, it will have the technological, financial and human resources to play an expanded altruistic role in global and regional health.     

Surveillance for dracunculiasis, 1981-1991.

In 1986 the World Health Organization (WHO) designated dracunculiasis (guinea worm disease) as the next disease scheduled to be eradicated (by 1995) after smallpox. Dramatic improvement in national and international surveillance has played a key role in the global eradication campaign, which was initiated at CDC in 1980. About 3 million persons are still affected by the disease annually, with adverse effects on their health as well as on agricultural production and education. Over 100 million persons are at risk of having the disease in more than 20,000 villages in India, Pakistan, and 17 African countries. At least one nationwide, village-by-village search to detect all villages with endemic dracunculiasis and count cases is recommended at the outset of each national campaign, followed by monthly reporting by village-based health workers in the targeted villages during the implementation phase. Rapid dissemination of the results of the surveillance is critical. Intensive case detection and containment--with rewards for reporting of cases--are most appropriate near the end of each campaign. Cameroon, Ghana, India, Nigeria, and Pakistan have pioneered the various surveillance methods for this disease in recent years. Methods for conducting surveillance of dracunculiasis and other important diseases must continue to be developed and improved as countries now believed to be free of dracunculiasis prepare to apply to WHO for certification of elimination of dracunculiasis.     

The impact of globalization on vaccine development and availability

Globalization is likely to affect many aspects of public health, one of which is vaccine-preventable communicable diseases. Important forces include increased funding initiatives supporting immunization at the global level; regulatory harmonization; widespread intellectual property rights provisions through the World Trade Organization agreements; the emergence of developing-country manufacturers as major players in vaccine supply; and the appearance of new communicable disease threats, including those potentially linked to bioterrorism. All of these forces can affect, either positively and negatively, the development and availability of vaccines. Harnessing these will be a challenge for policymakers and immunization stakeholders.     

加强监测传染病的口岸控制

目的探讨在新形势下如何加强监测传染病的口岸控制。方法从目前监测传染病的流行简况、监测传染病口岸控制的措施及应注意三方面问题进行阐述。结果加强监测传染病的口岸控制应科学确定监测传染病名录、完善疫情管理信息系统、完善口岸旅检通道和公共场所的设施设备和疫情公告制度、专业队伍建设和加强与地方的协作关系。结论加强监测传染病的口岸控制对防止传染病的传入传出意义重大。     

The World Health Organization and the transition from "international" to "global" public health

The term "global health" is rapidly replacing the older terminology of "international health." We describe the role of the World Health Organization (WHO) in both international and global health and in the transition from one to the other. We suggest that the term "global health" emerged as part of larger political and historical processes, in which WHO found its dominant role challenged and began to reposition itself within a shifting set of power alliances.Between 1948 and 1998, WHO moved from being the unquestioned leader of international health to being an organization in crisis, facing budget shortfalls and diminished status, especially given the growing influence of new and powerful players. We argue that WHO began to refashion itself as the coordinator, strategic planner, and leader of global health initiatives as a strategy of survival in response to this transformed international political context.     

Watching the Games: public health surveillance for the Sydney 2000 Olympic Games

STUDY OBJECTIVE: To describe the development of the public health surveillance system for the Sydney 2000 Olympic Games; document its major findings; and discuss the implications for public health surveillance for future events. DESIGN: Planning for the system took almost three years. Its major components included increased surveillance of communicable diseases; presentations to sentinel emergency departments; medical encounters at Olympic venues; cruise ship surveillance; environmental and food safety inspections; surveillance for bioterrorism; and global epidemic intelligence. A daily report integrated data from all sources. SETTING: Sydney, Australia. Surveillance spanned the period 28 August to 4 October 2000. PARTICIPANTS: Residents of Sydney, athletes and officials, Australian and international visitors. MAIN RESULTS: No outbreaks of communicable diseases were detected. There were around 5% more presentations to Sydney emergency departments than in comparable periods in other years. Several incidents detected through surveillance, including injuries caused by broken glass, and a cluster of presentations related to the use of the drug ecstasy, prompted further action. CONCLUSIONS: Key elements in the success of public health surveillance for the Games included its careful planning, its comprehensive coverage of public health issues, and its timely reporting and communication processes. Future systems need to be flexible enough to detect the unexpected.     

全球卫生治理面临的挑战及其应对策略

人人享有健康是一项基本人权。全球卫生治理的使命就是要在全世界范围内促进“人人享有健康”。目前,全球卫生治理面临诸多重大挑战,如治理主体众多但目标不一致导致领导权威难以确立,以国家为中心的国际体制使跨国集体行动的达成存在一定困难,各国对公共卫生事项设置的优先顺序存在分歧,全球卫生资金投入不足且分配不均,全球卫生治理严重缺乏国际协调,全球卫生治理基本框架尚未完全形成等。为了应对挑战,建议深化全球卫生改革,提高全球卫生治理的能力与效率;国际社会与各国政府必须审思与重构自身卫生法律与政策,把重点放在促进卫生公平而非提高经济竞争力上;各国政府必须重点关注民生和民权,重视非卫生领域政策与卫生政策的协调,从根本上改善健康的决定因素;增加全球卫生治理的透明度、建立新型问责制,增强世界卫生组织的权威性;在全球层面构建全球卫生治理基本框架,增强全球卫生治理的有序性。     

Influenza virus samples, international law, and global health diplomacy

Indonesia's decision to withhold samples of avian influenza virus A (H5N1) from the World Health Organization for much of 2007 caused a crisis in global health. The World Health Assembly produced a resolution to try to address the crisis at its May 2007 meeting. I examine how the parties to this controversy used international law in framing and negotiating the dispute. Specifically, I analyze Indonesia's use of the international legal principle of sovereignty and its appeal to rules on the protection of biological and genetic resources found in the Convention on Biological Diversity. In addition, I consider how the International Health Regulations 2005 applied to the controversy. The incident involving Indonesia's actions with virus samples illustrates both the importance and the limitations of international law in global health diplomacy.     

全球卫生治理机制及中国参与的建议

随着全球化的纵深发展,全球卫生逐渐取代国际卫生,成为学界关注热点.全球卫生领域存在诸多亟需解决的问题,而这些问题的解决需要良好的全球卫生治理,实现全球卫生治理的五大功能,即达成价值观念的共识、制定相应的规则、实现治理的多元化、动员和分配资金、提供领导和协调等.针对全球卫生领域的不同趋势,建议确立以世界卫生组织为中心的全球卫生治理体系、在世界卫生组织框架内实现治理的多元化以及加强全球卫生立法等.中国作为新兴经济力量,在全球卫生治理中占有重要地位,应更为活跃地参与全球卫生治理.首先,建议中国制定国家层面的全球卫生战略;其次,积极参与全球行动网络和治理平台;最后,培养全球卫生研究和实践人才.     

Impediments to global surveillance of infectious diseases: consequences of open reporting in a global economy

Globalization has led to an increase in the spread of emerging and re-emerging infectious diseases. International efforts are being launched to control their dissemination through global surveillance, a major hindrance to which is the failure of some countries to report outbreaks. Current guidelines and regulations on emerging and re-emerging infectious diseases do not sufficiently take into account the fact that when developing countries report outbreaks they often derive few benefits and suffer disproportionately heavy social and economic consequences. In order to facilitate full participation in global surveillance by developing countries there should be: better and more affordable diagnostic capabilities to allow for timely and accurate information to be delivered in an open and transparent fashion; accurate, less sensationalist news reporting of outbreaks of diseases; adherence by countries to international regulations, including those of the World Trade Organization and the International Health Regulations; financial support for countries that are economically damaged by the diseases in question. The article presents two cases--plague in India and cholera in Peru--that illuminate some of the limitations of current practices. Recommendations are made on measures that could be taken by WHO and the world community to make global surveillance acceptable.