International Health- الصحة الدولية

SBCM-Madinah

International Health
Dr. Ahmed-Refat AG Refat
2013

The World Health Organization (WHO) states, “In the 21st century, health is
a shared responsibility, involving equitable access to essential care and
collective defense against transnational threats.”

1 WWW.SlideShare.net/AhmedRefat 04/2013

Contents
 What is global health? & Global Health Issues
 The International Health Regulations ( IHR -2005 ) .
 Public Health Emergency of International Concern ( PHEIC )
 Decision instrument for PHEIC
 Exercise # 1: Mexican Candy
 Case definitions for the four diseases requiring notification to WHO in all circumstances
under the IHR (2005)
 Health conditions for travellers to Saudi Arabia for the pilgrimage to Mecca (Hajj)
 International Certificate of Vaccination or Prophylaxis
 Exercise #2:Using a dummy " International Certificate of Vaccination or Prophylaxis"
 Cited References & Useful Sources


What is global health?
IOM defines GH as:
Health problems, issues, and concerns that go above
national boundaries, which may be influenced by
circumstances or experiences in other countries, and
which are best addressed by cooperative actions and
solutions (Institute Of Medicine, USA- 1997)


Global Health Issues
Refers to any health issue that concerns many countries or is
affected by transnational determinants such as:
• Climate change
• Urbanisation
• Malnutrition – under or over nutrition
Or solutions such as:
• Polio eradication
• Containment of avian influenza
• Approaches to tobacco control


Historical Development of Term
Public Health: Developed as a discipline in the mid 19th century in
UK, Europe and US. Concerned more with national issues.
• Data and evidence to support action, focus on populations,
social justice and equity, emphasis on preventions vs cure.
International Health: Developed during past decades, came to
be more concerned with
• the diseases (e.g. tropical diseases) and
• conditions (war, natural disasters) of middle and low income
countries.
• Tended to denote a one way flow of ‘good ideas’.


Global Health: More recent in its origin and emphasises a greater
scope of health problems and solutions
• that transcend national boundaries
• requiring greater inter-disciplinary approach

Disciplines involved in Global Health
Social sciences Behavioural sciences
Law Economics
History Engineering
Biomedical sciences Environmental sciences


Global threats: why are we concerned?
_ Epidemics not new, but….took days, weeks/months to reach far
territories
_ Emergence/re-emergence of infectious diseases and increased
pace of spread
_ Threat of deliberate use of biological and chemical agents
_ Impact on health, economy, security
What are IHR (2005)? A global framework
_ Legally-binding global agreement to protect public health
_ The international commitment for shared responsibilities and
collective defense against disease spread.


Why have IHR (2005)?
_ Serious and unusual disease events are increasing and inevitable
_ Globalisation– public health event in one location can be a threat
to others
_ Need for collective effort and agreed rules
– strong national public health system
– international alert & response system


The International Health Regulations (IHR)
are an international legal instrument that is
binding on 194 countries across the globe,
including all the Member States of WHO.
Their aim is to help the international
community prevent and respond to acute
public health risks that have the potential to
cross borders and threaten people
worldwide.

‫اللوائح الصحية الدولية هي صك قانوني دولي ملزم ل 491 ً في جميع أنحاء العالم،ًبما فيها الدول األعضاء في منظمة الصحة العالمية .والغرض من هذه اللوائح‬
‫بلدا‬
ً .‫هو مساعدةًالمجتمع الدولي على منع ومواجهة المخاطر الصحية العمومية القادرة على االنتشار عبرًالحدود وتهديد الناس في شتى أرجاء العالم‬


Scope of IHR (2005)
_ “Disease” under IHR (2005): – “an illness or medical condition,
irrespective of origin or source that presents or could present
significant harm to humans”
_ Notification: All events that may constitute a public health
ً emergency of international concern (PHEIC)

Purpose of IHR (2005)
“To prevent, protect against, control and provide a public health
response to the international spread of disease in ways that are
matching with and restricted to public health risks, and _ which avoid
unnecessary interference with international traffic and trade” –
(Article 2)
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IHR- 1969 IHR- 2005

implement a control of travelers and organize the containment of the risk at
goods when crossing borders and the source, so that risks do not escape
entering countries (e.g., need for control and spread out of the country.
appropriate vaccinations such as YF)
a list of epidemic-prone diseases report any event constituting a threat
to be specially controlled (smallpox, for the international community,
yellow fever, and cholera) whether caused by a disease or other
sources such as chemical spill, or even a
nuclear event.
preset measures, which have to be replaced by a more flexible set of
adopted by all countries adapted responses according to the
nature of the event, that will be
implemented by countries with WHO


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Public Health Emergency of International
Concern ( PHEIC )

Compliance with IHR (2005) implies that all member States must
have implemented at national level the capacity to:
• detect events that may constitute a threat to public health;
• determine if this could be a risk at an international level;
• organize a response in order to contain the event at the source.


“Public Health Emergency of International Concern” means
an extraordinary event which is determined, as provided in
these Regulations:
• to constitute a public health risk to other States through
the international spread of disease, and
• to potentially require a coordinated international
response.


What is a Public Health Emergency of

International Concern (PHEIC)?


The determination if the event constitutes a PHEIC is made
on the basis of four criteria:
1.seriousness of the public health event;
2. unusual or unexpected nature of the event;
3. potential for the event to spread internationally;
4. risk that the event may result in restrictions to travel or trade.
Answering yes to any two of these questions will lead to obligation
for the IHR Focal Point to report the event to WHO as a PHEIC.


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IHR is not a substitute for national
surveillance and response systems
� IHR is about preventing the international spread of
diseases
� IHR is not about a global surveillance system
� But IHR seeks that all Member States be able to timely
detect, assess, notify and report events and respond to
public health risks and public health emergency of
international concern (PHEIC)
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IHR (2005) core capacities requirements
for surveillance and response
Community level and/or primary public health response level
– To detect events involving disease or death above expected levels, report to the
local health personnel and implement preliminary control measures
Intermediate public health response levels
– To confirm the status of reported events and implement control measures
National level (on a 24-hour basis)
– To assess all reports of urgent events within 48 hours and notify the WHO
immediately through the national IHR focal point when required.
– To rapidly determine the control measures required to prevent domestic and
international spread
– To provide direct operational links with senior decision makers and provide liaison
with other sectors
– To establish, operate and maintain a national public health emergency response plan.
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IHR Timeframe
May 2005: World Health Assembly approves the
revised IHR
2007: Entry into force of the revised IHR
2009: All countries have assessed their level of core
capacities
2012: All countries have reached a minimum required level
of core capacities


Decision instrument


Notify to WHO


Is the Public Health Impact of the event SERIOUS?


Is there a significant risk of Is there a significant risk of
international concern ? international concern ?

A positive response to two questions requires a country to notify WHO
4 diseases that always have to be notified polio (wild type virus), smallpox, human
influenza caused by a novel virus, SARS. Diseases that always lead to the use of
the algorithm : cholera, pneumonique plague, yellow fever, VHF (Ebola, Lassa,
Marburg), WNF, meningitis, others


Exercise # 1
Answer the following question by Using the decision tool (annex 2) of IHR-2005

Mexican Candy
California often experiences instances where candy imported from Mexico tests
high for lead that can result in poisonings in children. Would this be reportable
under the IHR (2005)?


Ex. #1 : Mexican Candy
To determine whether an event would be reportable under the IHR (2005), the
circumstances of the event would have to be assessed within the context of the
decision algorithm in Annex 2 of the IHR (2005) document. To be considered a
potential Public Health Emergency of International Concern (PHEIC), the event would
have to meet two of the four criteria (questions) in the decision algorithm.
Question # 1 could be answered with a "Yes" since the scenario involves a toxic
material that has the potential to contaminate a population (in this case, the population
close to the border) or large geographic area.
Question # 3 could be answered with a "Yes" since the contaminated candy is
exported to the U.S. and possibly other countries.
Question #4 could be answered with a "Yes" because the likely response is for the
contaminated candy to be identified as dangerous and subject to regulatory actions by
appropriate U.S. agencies.


Case definitions for the four diseases requiring notification to WHO
in all circumstances under the IHR (2005)
Under the International Health Regulations 2005 (IHR 2005), the World Health
Organization is to establish case definitions for the following four critical diseases
which are deemed always to be unusual or unexpected and may have serious public
health impact, and hence must be notified to WHO in all circumstances:
 smallpox
 poliomyelitis due to wild type poliovirus
 human influenza caused by a new subtype, and
 severe acute respiratory syndrome (SARS).

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Case definitions for
the four diseases requiring
notification in all
circumstances under the
IHR (2005)


A) Human influenza caused by a new subtype
Case definition for notification of human influenza
caused by a new subtype under the IHR (2005)
State Parties to the IHR (2005) are required to immediately notify WHO of any
laboratory confirmed case of a recent human infection caused by an influenza A virus
with the potential to cause a pandemic. Evidence of illness is not required for this
report.

An influenza A virus is considered to have the potential to cause a pandemic if the
virus has demonstrated the capacity to infect a human and if the heamagglutinin gene
(or protein) is not a variant or mutated form of those, i.e. A/H1 or A/H3, circulating
widely in the human population.
An infection is considered recent if it has been confirmed by positive results from
polymerase chain reaction (PCR), virus isolation, or paired acute and convalescent
serologic tests. An antibody titre in a single serum is often not enough to confirm a
recent infection, and should be assessed by reference to valid WHO case definitions for
human infections with specific influenza A subtypes.


B) Poliomyelitis due to wild-type poliovirus
Under the IHR (2005), a notifiable case of poliomyelitis due to wild-type
poliovirus is defined as a suspected case* with isolation of wild poliovirus in
stool specimens collected from the suspected case or from a close contact of
the suspected case.

C) SARS Case definition
In the SARS post-outbreak period, a notifiable case of SARS is defined as an
individual with laboratory confirmation of infection with SARS coronavirus
(SARS-CoV) who either fulfils the clinical case definition of SARS or has
worked in a laboratory working with live SARS-CoV or storing clinical
specimens infected with SARS-CoV.


Clinical case definition of SARS:
1. A history of fever, or documented fever
AND
2. One or more symptoms of lower respiratory tract illness (cough, difficulty
breathing, shortness of breath)
AND: 3. Radiographic evidence of lung infiltrates consistent with pneumonia
or acute respiratory distress syndrome (ARDS) or autopsy findings consistent
with the pathology of pneumonia or ARDS without an identifiable cause
AND
4. No alternative diagnosis can fully explain the illness.

Diagnostic tests required for laboratory confirmation of SARS:
A) Conventional reverse transcriptase polymerase chain reaction
(RT-PCR) and real-time reverse transcriptase PCR (real-time RT-
PCR) assay detecting viral RNA present in:
1. At least two different clinical specimens (e.g. nasopharyngeal and stool)


OR
2. The same clinical specimen collected on two or more occasions during the
course of the illness (e.g. sequential nasopharyngeal aspirates)
OR
3. In a new extract from the original clinical sample tested positive by two
different assays or repeat RT-PCR/real-time RT-PCR on each occasion of
testing
OR
4. In virus culture from any clinical specimen.
B) Enzyme Linked Immunosorbent Assay (ELISA) and
immunofluorescent assay (IFA)
1. Negative antibody test on serum collected during the acute phase of illness
followed by
positive antibody test on convalescent phase serum, tested simultaneously
OR


2. Fourfold or greater rise in antibody titre against SARS-CoV between an
acute serum
specimen and a convalescent serum specimen (paired sera), tested
simultaneously.

D) Smallpox- Case definition .
States Parties to the IHR (2005) are required to immediately notify to WHO of
any confirmed case of smallpox. The case definition for a confirmed smallpox
case includes the following:
Confirmed case of smallpox:
An individual of any age presenting with acute onset of fever (≥38.3°C/101°F),
malaise, and severe prostration with headache and backache occurring 2 to 4
days before rash onset
AND


Subsequent development of a maculopapular rash starting on the face and
forearms, then spreading to the trunk and legs, and evolving within 48 hours to
deep-seated, firm/hard and round well-circumscribed vesicles and latern
pustules, which may become umbilicated or confluent
AND
Lesions that appear in the same stage of development (i.e. all are vesicles or
all are pustules) on any given part of the body (e.g. the face or arm)
AND
No alternative diagnosis explaining the illness
AND
Laboratory confirmation.

*A suspected case is defined as a child under 15 years of age presenting with
acute flaccidparalysis (AFP2), or as any person at any age with paralytic
illness if poliomyelitis is suspected.


Health conditions for
travellers to Saudi Arabia
for the pilgrimage to Mecca
(Hajj)


The Ministry of Health of Saudi Arabia has issued the following requirements and
recommendations for entry visas for the Hajj and Umra seasons in 2012.

I. Yellow fever
(A) In accordance with the International
Health Regulations 2005,1 all travellers arriving
from countries or areas at risk of yellow fever (see
list below) must present a valid yellow fever
vaccination certificate showing that the person was


vaccinated at least 10 days previously and not more
than 10 years before arrival at the border.
In the absence of such a certificate, the individual
will be placed under strict surveillance for 6 days
from the date of vaccination or the last date of
potential exposure to infection, whichever is earlier.
Health offices at entry points will be responsible
for notifying the appropriate


Director General of Health Affairs in the region or governorate about the
temporary place of residence of the visitor.

Countries/areas are at risk of yellow fever transmission
(as defined by the International travel and health 2012):
Africa: Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Côte d’Ivoire,
Democratic Republic of the Congo, Equatorial Guinea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea Bissau, Kenya,
Liberia, Mali, Mauritania, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, Sudan, South Soudan, Togo and Uganda.

Americas: Argentina, Bolivarian Republic of Venezuela, Brazil, Colombia, Ecuador, French Guiana, Guyana,
Panama, Paraguay, Peru, Plurinational State of Bolivia, Suriname and Trinidad and Tobago .


(B) Aircrafts, ships and other means of transportation coming from
countries affected by yellow fever are requested to submit a certificate
indicating that it applied disinsection in accordance with methods
recommended by WHO.


In accordance with the International Health Regulations 2005, all arriving
ships will be requested to provide to the competent authority a valid Ship
Sanitation Certificate.

Ships arriving from areas at risk for yellow fever
transmission may also be required to submit to inspection to ensure
they are free of yellow fever vectors, or disinsected, as a condition of
granting free pratique (including permission to enter a port, to embark or
disembark and to discharge or load cargo or stores).


II. M eningococcal meningitis
(A) For all arrivals
Visitors from all over the world arriving for the
purpose of Umra or pilgrimage or for seasonal work
are required to produce a certificate of vaccination
with the quadrivalent (ACYW135) vaccine against
meningitis issued not more than 3 years previously
and not less than 10 days before arrival in KSA.
The responsible authorities in the visitor’s country
of origin should ensure that adults and children


over the age of 2 years are given 1 dose of the
quadrivalent polysaccharide (ACYW135) vaccine.
(B) For arrivals from countries in the African
meningitis belt, namely Benin, Burkina Faso, Cameroon, Chad, Central African
Republic, Côte d’Ivoire, Eritrea, Ethiopia, Gambia, Guinea, Guinea-Bissau, Mali, Niger,
Nigeria, Senegal and Sudan.
In addition to the above stated requirements,
chemoprophylaxis will be administered at port of
entry to all arrivals from these countries to lower
the carriers rate among them. Adults will receive
ciprofloxacin tablets (500 mg), children will receive
rifampicin, and pregnant women will receive
ceftriaxone injections.


Vaccination with quadrivalent (ACYW135) vaccine is
required for:
– all citizens and residents of Medina and Mecca
who have not been vaccinated during the past 3 years;
– all citizens and residents undertaking the Hajj;
– all Hajj workers who have not been vaccinated in
the past 3 years;
– any individual working at entry points or in direct
contact with pilgrims in Saudi Arabia.

III. Poliomyelitis
(A) All travellers arriving from polio-endemic
countries and re-established transmission
countries, namely: Afghanistan, Angola, Chad, the
Democratic Republic of Congo, Nigeria and Pakistan,
regardless of age and vaccination status, should
receive 1 dose of oral poliovirus vaccine (OPV).
Proof of OPV vaccination at least 6 weeks prior
departure is required to apply for entry visa for
Saudi Arabia.


These travellers will also receive:
1 dose of OPV at borders points on arrival in Saudi
Arabia. The same requirements are valid for
travelers from recently endemic countries at high
risk of reimportation of poliovirus, i.e. India.
(B) All visitors aged under 15 years travelling to
Saudi Arabia from countries with imported cases of
poliomyelitis or circulating vaccine-derived
polioviruses (see list below) in the past 12 months (as
of mid-February 2012) should be vaccinated against
poliomyelitis with the OPV or inactivated poliovirus
vaccine (IPV).


Proof of OPV or IPV vaccination is required 6 weeks
prior the application for entry visa.

Irrespective of previous immunization history, all
visitors under 15 years arriving in Saudi Arabia will also
receive 1 dose of OPV at border points.
Polio cases related to wild poliovirus importation or to
circulating vaccine-derived poliovirus have been
registered during the past 12 months in the following
countries:
China, Central African Republic, Côte d’Ivoire, Kenya, Mali,
Niger, Somalia and Yemen.


IV. Seasonal influenza

The MOH-KSA recommends that international
pilgrims be vaccinated against seasonal
influenza before arrival into the kingdom of Saudi
Arabia, particularly those at increased risk of
severe complications (e.g. the elderly over 65
years of age, people with pre-existing medical
conditions such as people with chronic respiratory
or heart diseases, hepatic or renal failure,
neuromuscular or metabolic diseases including


diabetes or immunocompromised conditions due to
various reasons such as HIV infection or immune
suppressive therapy). Pregnant women can also
be considered for vaccination.
In Saudi Arabia, seasonal influenza vaccine is
recommended for internal pilgrims, particularly
those with pre-existing health conditions, and all
health staff working in the Hajj premises.


V. Health education
Health authorities in countries of origin are required to provide
information to pilgrims on infectious diseases symptoms,
methods of transmission, complications and means of prevention.
VI. Food
Hajj and Umrah performers are not allowed to bring
fresh food in Saudi Arabia. Only properly canned or
sealed food or food stored in containers with easy access for
inspection is allowed in small quantities, sufficient for one person
for the duration of his or her trip.
VII. International outbreaks response
Updating immunization against vaccine-preventable
diseases in all travellers is strongly recommended. With the
recent resurgence of measles and rubella cases, special attention
is needed for both of these vaccines to avoid widespread
outbreaks with this virus during this year Hajj and Umra.


Preparation for international travel provides opportunity to review
the immunization status of travellers. Incompletely immunized
travellers can be offered routine vaccinations recommended in
national immunization schedules (these usually include
diphtheria, tetanus, pertussis, polio, measles and mumps), in
addition to those needed for the specific travel (e.g.
meningococcal vaccination for Hajj). In International Travel and
Health 2012, WHO recommends that travelers ensure immunity
against measles by having at least 2 doses of vaccine and against
rubella by 1 dose of vaccine.
In the event of a public health emergency of international health
concern, or in the case of any disease outbreak subject to
notification under the IHR-2005, the health authorities in Saudi
Arabia, following consultation with WHO, will undertake additional
preventive precautions necessary to avoid the spread of infection
during the pilgrimage or on return to their country of origin.


International Certificate
of Vaccination or
Prophylaxis

Requirements for validity
This certificate is valid only if the vaccine or prophylaxis used has
been approved by the World Health Organization.
This certificate must be signed in the hand of the clinician, who
shall be a medical practitioner or other authorized health worker,
supervising the administration of the vaccine or prophylaxis. The
certificate must also bear the official stamp of the administering
centre; however, this shall not be an accepted substitute for the
signature.
Any amendment of this certificate, or erasure, or failure to


complete any part of it, may render it invalid.
The validity of this certificate shall extend until the date indicated
for the particular vaccination or prophylaxis. The certificate shall
be fully completed in English or in French. The certificate may
also be completed in another language on the same document, in
addition to either English or French.
Notes
The only disease specifically designated in the International Health
Regulations (2005) for which proof of vaccination or prophylaxis
may be required as a condition of entry to a State Party, is yellow
fever. When administering this vaccine, the clinician must write
“Yellow Fever” in the space provided on this certificate.


This same certificate will also be used in the event that these Regulations are
amended or a recommendation is made under these Regulations by the World
Health Organization to designate another disease.


INFORMATION FOR PHYSICIANS
1. The dates for vaccination on each certificate are to be recorded in
the following sequence: day, month, year – the month in letters.
Example: January 1, 2001 is written 1 January 2001.
2. If vaccination is contraindicated on medical grounds, the physician
should provide the traveller with a written opinion, which health
authorities should take into account.
3. Vaccination certificate requirements of countries are published
by WHO in International travel and health. Information on
designated yellow fever vaccinating centres is available from local
or national health offices.
4. The physician should always consider that his/her patient may
have a travel-associated illness.

Exercise #2

Use a dummy " International Certificate
of Vaccination or Prophylaxis"
and fill the required data of a
hypothesized traveler


Cited References
&
Useful Sources

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CDC – Travel
http://wwwnc.cdc.gov/travel/

Online yellow book
http://wwwnc.cdc.gov/travel/yellowbook/2012/table-of-contents.htm

MOH- KSA : Hajj
http://www.moh.gov.sa/HealthAwareness/Hajj/Pages/default.aspx

International Health Regulations (2005)
http://www.who.int/ihr/en/index.html

International travel and health (ITH) – 2012: Publication on health risks for
international travellers, vaccination requirements and precautions to take.
http://www.who.int/ith/chapters/en/index.html


Dr Yoga Nathan .Introduction to Global Health .. GEMS UL
WHO/EPR .International Health Regulations (2005).Update on
implementation Monitoring & Evaluation System.
WHO. International Health Regulations in the context of Pandemic
Influenza
Al-Tawfiq JA, Memish ZA. The Hajj: updated health hazards and
current recommendations for 2012. Euro Surveill.
2012;17(41):pii=20295.

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Quarantine and Isolation
http://www.cdc.gov/quarantine/

Isolation and quarantine are public health practices used to stop or limit the
spread of disease.
 Isolation is used to separate ill persons who have a communicable disease from
those who are healthy.
 Quarantine is used to separate and restrict the movement of well persons who
may have been exposed to a communicable disease to see if they become ill.
Words quaranta giorni which mean 40 days.
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