International Health- الصحة الدولية

1 WWW.SlideShare.net/AhmedRefat 04/2013

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.”


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 هذه من والغرض .العالمية الصحة منظمة في األعضاء الدول فيها بماالعالم، أنحاء جميع في بلدا 194ل ملزم دولي قانوني صك هي الدولية الصحية اللوائح

.العالم أرجاء شتى في ناسال وتهديد الحدودعبر االنتشار على القادرة العمومية الصحية المخاطر ومواجهة منع على الدولي المجتمعمساعدة هو


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)



IHR- 1969 IHR- 2005

implement a control of travelers and goods when crossing borders and entering countries (e.g., need for

appropriate vaccinations such as YF)

organize the containment of the risk at the source, so that risks do not escape control and spread out of the country.

a list of epidemic-prone diseases to be specially controlled (smallpox, yellow fever, and cholera)

report any event constituting a threat for the international community, whether caused by a disease or other sources such as chemical spill, or even a

nuclear event.

preset measures, which have to be adopted by all countries

replaced by a more flexible set of adapted responses according to the nature of the event, that will be implemented by countries with WHO



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.


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)


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.


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?


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

Is there a significant risk of

international concern ?

Is there a significant risk of

international concern ?


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).


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,

rreeggaarrddlleessss ooff aaggee aanndd vvaacccciinnaattiioonn ssttaattuuss,, 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





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

http://wwwnc.cdc.gov/travel/

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

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

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.


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.

http://www.cdc.gov/quarantine/


Health & Medicine

International Health- الصحة الدولية