From the field side of the binoculars: a different view on global public health surveillance

It is generally assumed by the donor community that the targeted funding of global, regional or cross-border surveillance programmes is an efficient way to support resource-poor countries in developing their own national public health surveillance infrastructure, to encourage national authorities to share outbreak intelligence, and ultimately to ensure compliance of World Health Organization (WHO) Member States with the revised (2005) International Health Regulations. At country level, a number of factors and constraints appear to contradict this view. Global or regional surveillance initiatives, including syndromic surveillance and rumour surveillance projects, have been conceived in neglect of fragile health systems, from which they extract scarce human resources. In contradiction with a rightful stance promoting 'integrated surveillance' by WHO, the nurturing of donor-driven, poorly coordinated and redundant surveillance networks generally adds further fragmentation to national health priorities set up by developing countries. In their current categorical format, ignoring the overwhelming deficits in governance and health care capacity, global surveillance strategies seem bound to benefit mainly the most industrially developed nations through the provision of early warning information or scientific data. In lower-income countries, a focus of resources on strengthening the health system first would ultimately be a more efficient way to achieve proper detection and response to outbreaks at national or sub-national level. As documented in several pilot initiatives at sub-national level (India, South Africa, Tuvalu and Cambodia), the empowerment of frontline health workers and communities is a key element for an efficient surveillance system. Such simple measures centred on human resources and community values appear to be more beneficial than massive and conditional monetary inputs.     

ASM LabCap’s contributions to disease surveillance and the International Health Regulations (2005)

The revised International Health Regulations [IHR(2005)], which requires the Member States of the World Health Organization (WHO) to develop core capacities to detect, assess, report, and respond to public health threats, is bringing new challenges for national and international surveillance systems. As more countries move toward implementation and/or strengthening of their infectious disease surveillance programs, the strengthening of clinical microbiology laboratories becomes increasingly important because they serve as the first line responders to detect new and emerging microbial threats, re-emerging infectious diseases, the spread of antibiotic resistance, and the possibility of bioterrorism. In fact, IHR(2005) Core Capacity #8, "Laboratory", requires that laboratory services be a part of every phase of alert and response.Public health laboratories in many resource-constrained countries require financial and technical assistance to build their capacity. In recognition of this, in 2006, the American Society for Microbiology (ASM) established an International Laboratory Capacity Building Program, LabCap, housed under the ASM International Board. ASM LabCap utilizes ASM's vast resources and its membership's expertise-40,000 microbiologists worldwide-to strengthen clinical and public health laboratory systems in low and low-middle income countries. ASM LabCap's program activities align with HR(2005) by building the capability of resource-constrained countries to develop quality-assured, laboratory-based information which is critical to disease surveillance and the rapid detection of disease outbreaks, whether they stem from natural, deliberate or accidental causes.ASM LabCap helps build laboratory capacity under a cooperative agreement with the U.S. Centers for Disease Control and Prevention (CDC) and under a sub-contract with the Program for Appropriate Technology in Health (PATH) funded by the United States Agency for International Development (USAID). Successful activities of ASM LabCap have occurred throughout Africa, Asia, Central America and the Caribbean. In addition, ASM LabCap coordinates efforts with international agencies such as the WHO in order to maximize resources and ensure a unified response, with the intended goal to help build integrated disease surveillance and response capabilities worldwide in compliance with HR(2005)'s requirements.     

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.

     

Rural health around the world: challenges and solutions

Despite the huge differences between developing and developed countries, access is the major issue in rural health around the world. Even in the countries where the majority of the population lives in rural areas, the resources are concentrated in the cities. All countries have difficulties with transport and communication, and they all face the challenge of shortages of doctors and other health professionals in rural and remote areas. Many rural people are caught in the poverty- ill health-low productivity downward spiral, particularly in developing countries. Since 1992, WONCA, the World Organization of Family Doctors, has developed a specific focus on rural health through the WONCA Working Party on Rural Practice. This Working Party has drawn national and international attention to major rural health issues through World Rural Health Conferences and WONCA Rural Policies. The World Health Organization (WHO) has broadened its focus beyond public health to partnership with family practice, initially through a landmark WHO-WONCA Invitational Conference in Canada. From this has developed the Memorandum of Agreement between WONCA and WHO which emphasizes the important role of family practitioners in primary health care and also includes the Rural Health Initiative. In April 2002, WHO and WONCA held a major WHO-WONCA Invitational Conference on Rural Health. This conference addressed the immense challenges for improving the health of people of rural and remote areas of the world and initiated a specific action plan: The Global Initiative on Rural Health. The "Health for All" vision for rural people is more likely to be achieved through joint concerted efforts of international and national bodies working together with doctors, nurses and other health workers in rural areas around the world.     

Web-based surveillance and global Salmonella distribution, 2000-2002

Salmonellae are a common cause of foodborne disease worldwide. The World Health Organization (WHO) supports international foodborne disease surveillance through WHO Global Salm-Surv and other activities. WHO Global Salm-Surv members annually report the 15 most frequently isolated Salmonella serotypes to a Web-based country databank. We describe the global distribution of reported Salmonella serotypes from human and nonhuman sources from 2000 to 2002. Among human isolates, S. Enteritidis was the most common serotype, accounting for 65% of all isolates. Among nonhuman isolates, although no serotype predominated, Salmonella enterica serovar Typhimurium was reported most frequently. Several serotypes were reported from only 1 region of the world. The WHO Global Salm-Surv country databank is a valuable public health resource; it is a publicly accessible, Web-based tool that can be used by health professionals to explore hypotheses related to the sources and distribution of salmonellae worldwide.     

Global public health security

The framework of the newly revised International Health Regulations is a key driver in the effort to strengthen global public health security. Unanimously agreed upon by the World Health Assembly on May 23, 2005, the regulations are the result of experience gained and lessons learned during the past 30 years. This global legal framework includes a commitment from the World Health Organization (WHO) and from each WHO member state to improve capacity for disease prevention, detection, and response. It provides standards for addressing national public health threats that have the potential to become global emergencies. Its success will rely on the capacity and performance of national public health systems, anchored by strong national public health institutes (NPHIs). The new International Association of National Public Health Institutes aims to strengthen and invigorate existing NPHIs, to create new NPHIs where none exist, and to provide funded grants to support NPHI development priorities.     

International Health Regulations--what gets measured gets done

The global spread of severe acute respiratory syndrome highlighted the need to detect and control disease outbreaks at their source, as envisioned by the 2005 revised International Health Regulations (IHR). June 2012 marked the initial deadline by which all 194 World Health Organization (WHO) member states agreed to have IHR core capacities fully implemented for limiting the spread of public health emergencies of international concern. Many countries fell short of these implementation goals and requested a 2-year extension. The degree to which achieving IHR compliance will result in global health security is not clear, but what is clear is that progress against the threat of epidemic disease requires a focused approach that can be monitored and measured efficiently. We developed concrete goals and metrics for 4 of the 8 core capacities with other US government partners in consultation with WHO and national collaborators worldwide. The intent is to offer an example of an approach to implementing and monitoring IHR for consideration or adaptation by countries that complements other frameworks and goals of IHR. Without concrete metrics, IHR may waste its considerable promise as an instrument for global health security against public health emergencies.     

International law and communicable diseases

Historically, international law has played a key role in global communicable disease surveillance. Throughout the nineteenth century, international law played a dominant role in harmonizing the inconsistent national quarantine regulations of European nation-states; facilitating the exchange of epidemiological information on infectious diseases; establishing international health organizations; and standardization of surveillance. Today, communicable diseases have continued to re-shape the boundaries of global health governance through legally binding and "soft-law" regimes negotiated and adopted within the mandate of multilateral institutions - the World Health Organization, the World Trade Organization, the Food and Agriculture Organization, and the Office International des Epizooties. The globalization of public health has employed international law as an indispensable tool in global health governance aimed at diminishing human vulnerability to the mortality and morbidity burdens of communicable diseases.     

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.     

Assessment of public health events through International Health Regulations, United States, 2007-2011

Under the current International Health Regulations, 194 states parties are obligated to report potential public health emergencies of international concern to the World Health Organization (WHO) within 72 hours of becoming aware of an event. During July 2007-December 2011, WHO assessed and posted on a secure web portal 222 events from 105 states parties, including 24 events from the United States. Twelve US events involved human influenza caused by a new virus subtype, including the first report of influenza A(H1N1)pdm09 virus, which constitutes the only public health emergency of international concern determined by the WHO director-general to date. Additional US events involved 5 Salmonella spp. outbreaks, botulism, Escherichia coli O157:H7 infections, Guillain-Barré syndrome, contaminated heparin, Lassa fever, an oil spill, and typhoid fever. Rapid information exchange among WHO and member states facilitated by the International Health Regulations leads to better situation awareness of emerging threats and enables a more coordinated and transparent global response.     

Capacity for a global vaccine safety system: the perspective of national regulatory authorities

Confidence in vaccine safety is critical to national immunization strategies and to global public health. To meet the Millenium Development Goals, and buoyed by the success of new vaccines produced in developing countries, the World Health Organization has been developing a strategy to establish a global system for effective vaccine pharmacovigilance in all countries. This paper reports the findings of a qualitative survey, conducted for the WHO Global Vaccine Safety Blueprint project, on the perspectives of national regulatory authorities responsible for vaccine safety in manufacturing and procuring countries. Capacity and capabilities of detecting, reporting and responding to adverse events following immunization (AEFI), and expectations of minimum capacity necessary for vaccine pharmacovigilance were explored. Key barriers to establishing a functional national vaccine safety system in developing countries were identified. The lack of infrastructure, information technology for stable communications and data exchange, and human resources affect vaccine safety monitoring in developing countries. A persistent "fear of reporting" in several low and middle income countries due to insufficient training and insecure employment underlies a perceived lack of political will in many governments for vaccine pharmacovigilance. Regulators recommended standardized and internationally harmonized safety reporting forms, improved surveillance mechanisms, and a global network for access and exchange of safety data independent of industry.     

Health threats and health system crises. An approach to early warning and response. 2008 SESPAS Report

The world is changing more and faster than ever before. New diseases are coming to light each year, controlled diseases are reemerging as potential threats, and natural or man-made disasters are increasingly affecting human health. The "International Health Regulations (2005)" reflect the changes in the response of public health to this new situation. Surveillance of specific diseases and predefined control measures have been replaced by surveillance of public health events of international concern and control measures adapted to each situation. The public health events of international interest are characterized by their seriousness, predictability, the risk of international spread and potential for travel or trade restrictions. The development of the European Early Warning and Response System in 1998 and the creation of the European Center for Disease Prevention and Control in 2005 demonstrate political commitment in Europe, with early detection of and response to public health threats. However, timely risk evaluation and response at a national level requires improved data digitalization and accessibility, automatic notification processes, data analysis and dissemination of information, the combination of information from multiple sources and adaptation of public health services. The autonomous regions in Spain are initiating this adaptation process, but interoperability between systems and the development of guidelines for a coordinated response should be steered by the National Interregional Health Council and coordinated by the Ministry of Health. Efficient early warning systems of health threats that allow for a timely response and reduce uncertainty about information would help to minimize the risk of public health crises. The profile of public health threats is nonspecific. Early detection of threats requires access to information from multiple sources and efficient risk assessment. Key factors for improving the response to public health threats are the development of surveillance methods and operational research in public health.     

A growing global network's role in outbreak response: AFHSC-GEIS 2008-2009

A cornerstone of effective disease surveillance programs comprises the early identification of infectious threats and the subsequent rapid response to prevent further spread. Effectively identifying, tracking and responding to these threats is often difficult and requires international cooperation due to the rapidity with which diseases cross national borders and spread throughout the global community as a result of travel and migration by humans and animals. From Oct.1, 2008 to Sept. 30, 2009, the United States Department of Defense's (DoD) Armed Forces Health Surveillance Center Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) identified 76 outbreaks in 53 countries. Emerging infectious disease outbreaks were identified by the global network and included a wide spectrum of support activities in collaboration with host country partners, several of which were in direct support of the World Health Organization's (WHO) International Health Regulations (IHR) (2005). The network also supported military forces around the world affected by the novel influenza A/H1N1 pandemic of 2009. With IHR (2005) as the guiding framework for action, the AFHSC-GEIS network of international partners and overseas research laboratories continues to develop into a far-reaching system for identifying, analyzing and responding to emerging disease threats.     

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.     

Strategies for implementing the new International Health Regulations in federal countries

The International Health Regulations (IHR), the principal legal instrument guiding the international management of public health emergencies, have recently undergone an extensive revision process. The revised regulations, referred to as the IHR (2005), were unanimously approved in May 2005 by all Member States of the World Health Assembly (WHA) and came into effect on 15 June 2007. The IHR (2005) reflect a modernization of the international community's approach to public health and an acknowledgement of the importance of establishing an effective international strategy to manage emergencies that threaten global health security. The success of the IHR as a new approach to combating such threats will ultimately be determined by the ability of countries to live up to the obligations they assumed in approving the new international strategy. However, doing so may be particularly challenging for decentralized countries, specifically those with federal systems of government. Although the IHR (2005) are the product of an agreement among national governments, they cover a wide range of matters, some of which may not fall fully under the constitutional jurisdiction of the national government within many federations. This tension between the separation of powers within federal systems of government and the requirements of an evolving global public health governance regime may undermine national efforts towards compliance and could ultimately jeopardize the regime's success. We hosted a workshop to examine how federal countries could address some of the challenges they may face in implementing the IHR (2005). We present here a series of recommendations, synthesized from the workshop proceedings, on strategies that these countries might pursue to improve their ability to comply with the revised IHR.     

Global health security and the International Health Regulations

Global nuclear proliferation, bioterrorism, and emerging infections have challenged national capacities to achieve and maintain global security. Over the last century, emerging infectious disease threats resulted in the development of the preliminary versions of the International Health Regulations (IHR) of the World Health Organization (WHO). The current HR(2005) contain major differences compared to earlier versions, including: substantial shifts from containment at the border to containment at the source of the event; shifts from a rather small disease list (smallpox, plague, cholera, and yellow fever) required to be reported, to all public health threats; and shifts from preset measures to tailored responses with more flexibility to deal with the local situations on the ground. The new IHR(2005) call for accountability. They also call for strengthened national capacity for surveillance and control; prevention, alert, and response to international public health emergencies beyond the traditional short list of required reporting; global partnership and collaboration; and human rights, obligations, accountability, and procedures of monitoring. Under these evolved regulations, as well as other measures, such as the Revolving Fund for vaccine procurement of the Pan American Health Organization (PAHO), global health security could be maintained in the response to urban yellow fever in Paraguay in 2008 and the influenza (H1N1) pandemic of 2009-2010.     

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。     

Emergent pathogens, international surveillance and international health regulations (2005)

In order to address the vitality of the microbial world, to detect emerging infectious diseases, to determine their potential threat to public health, and to establish effective interventions, the World Health Organization (WHO) has developed and coordinates the Global Outbreak Alert and Response Network (GOARN) which connects several surveillance networks. Some of these networks are specific to epidemic-prone diseases, such as influenza, dengue, yellow fever or meningitis. Others were especially designed to track unusual events--such as the emergence of SARS--that are naturally-occurring, accidental, or deliberately created (biological weapons, bio-terrorism). Lastly, a special effort is being made at the international level to modernize the International Health Regulations, now obsolete, and to support all the countries in the reinforcement of their outbreak alert and response capacity.     

The public versus the World Health Organization on health system performance

The World Health Organization (WHO) ranked health systems in 191 countries based on measures developed by public health experts. This paper compares the WHO rankings for seventeen industrialized countries with the perceptions of their citizens. The results show little relationship between WHO rankings and the satisfaction of the citizens who experience these health systems. The health systems of some top WHO performers are rated poorly by their citizens, including the low-income and elderly. The two rated most highly by the public rank at the bottom of the WHO ratings. These findings suggest that both public and expert views should be considered in international rankings.