COVID 19: International Health Regulations and World Health

Organization
Introduction
The World Health Organization (WHO), since its constitutional establishment in 1946, has a
central and historic role in the coordination and management of global health and diseases.
During the last Century, the technological & industrial revolution substantially increased
travel and trade between nations in the world, escalating the emergence (or re-emergence)
of communicable infectious diseases threats. The growing concern of transborder contagion
transmission led to the adoption in 1969 by WHO member states of the first legally-binding
International Health Regulations (IHR) (1). The International Health Regulations or "IHR" are
an international law which helps countries work together to save lives and livelihoods caused
by the international spread of diseases and other health risks. At the turn of the 21st Century,
the 2002-03 global outbreak of SARS-COV (Severe Acute Respiratory Syndrome caused by
SARS Coronavirus) became the first public health emergency of international concern (PHEIC)
of newly webwide globalized century. The lessons learnt by SARS-COV, in particular by the
transborder epidemic surge due to information delays on reporting and lack of border
containment, triggered the spread of SARS worldwide and led to the thorough revision of the
“IHR 2005”, adopted during the 58th World Health Assembly in 2005 by 194 member states
across 6 regions (2). International Health Regulations (IHR) 2005 was designed to be practical
and useful with detailed yet culturally adapted measures and rules: new criteria for early
reporting, four typologies included in PHEIC events and potential pandemic: (i) infectious
(human + zoonoses), (ii) foodborne, (iii) chemical and (iv) radio-nuclear. New tools and
protocols/certifications are included for control and inspection at borders (entry points: land,
ports, airports), quarantines and isolation measure and risk communication tools. On 15th
June 2007, the IHR (2005) entered into force [6]. The IHR (2005) establish a set of rules to
support the global outbreak alert and response system and to require countries to improve
international surveillance and reporting mechanisms for public health events and to
strengthen their national surveillance and response capacities. Under the IHR (2005), all cases
of these four diseases must be automatically notified to WHO: smallpox, poliomyelitis due to
wild-type poliovirus, SARS and cases of human influenza caused by a new subtype. These
countries are required to notify and report events and other information through their
National IHR Focal Points to a regional WHO IHR Contact Points Focal points and Contact
points must be available on a 24 hour-a-day basis, seven days a week (3).
IHR define requirements for core capacities at various levels (4):
• Event detection
o Local, regional, national level
• Event assessment and notification
o National level
• Public health response to events 24/7
o Support, including on-site assistance
o Communication links
o Public health emergency plan
A Public Health Emergency of International Concern, or PHEIC, is defined in the IHR (2005)
as, “an extraordinary event which is determined to constitute a public health risk to other
States through the international spread of disease and to potentially require a coordinated
international response”.[2] This definition implies a situation that is:
• serious, sudden, unusual or unexpected;
• carries implications for public health beyond the affected State's national border; and
• may require immediate international action (4).
Uncertainties of Coronaviruses
Human coronaviruses were first characterized in the 1960s and were found out to be
responsible for high prevalence of upper respiratory tract infections in children; the SARS-
COV epidemic highlighted the zoonosis and challenge of the animal-human transmission (5).
According to IHR 2005, four epidemic diseases require immediate notification irrespective of
context: smallpox, poliomyelitis, human Influenza new subtypes and SARS. Despite the fact
that the WHO IHR is an important instrument based precisely on the coronavirus family, the
reality shows that new unknown agents can remain unknown for an extended time and
remain unpredictable with high contagious rates. Many experts have expressed concern
about it and asked for a revision of IHR to adapt it to experiences and lessons learnt (6).
COVID-19: a global pandemic
COVID-19 is a novel disease with incompletely described clinical course and uncertain risk
factors and risk transmission. A lack of global and local scientific consensus on COVID-19
outbreak remains to this date on a wide range of issues: origin of the virus (i.e. case 0),
different mutations of the virus, dynamics and lifetime of the virus (i.e. mutation, elements
of HIV), characteristics and determinants of transmission rate of contagion (R0 scale), multi-
epidemiological approach, inconsistent clinical manifestations, standard treatment vs
differential symptomatology, socio-environmental factors, post-exposure and reliability of
immunity solutions with a mutating virus (i.e. antibody tests, vaccines for a given strain) etc.
The current uncertainty and unpredictability of COVID-19 calls for the emergence of a new
scientific consortium of expertise in all those domains to proceed to a large data and case
mapping, which will serve in the construct a new preparedness paradigm based on multilevel
expertise (7). Many of the travel restrictions implemented by dozens of countries during the
COVID-19 outbreak are therefore violations of the IHR and at least two-thirds of these
countries have not reported their additional health measures to WHO, which is a further
violation of IHR Articles. Travel restrictions prevent supplies from getting into affected areas,
slow down the international public health response, stigmatize entire populations, and
disproportionately harm the most vulnerable among us. Effective global governance is not
possible when countries cannot depend on each other to comply with international
agreements. The IHR only governs countries, not corporations and other non-governmental
actors. Thus, some countries are finding themselves with de-facto travel restrictions when
airlines stop flying to places affected by COVID-19. Additionally, the IHR does not have robust
accountability mechanisms for compliance, enforcement, oversight, and transparency. But
the IHR is the legally binding system for protecting people worldwide from the global spread
of disease (8). Here, the role of the WHO is uncertain, however, given that the WHO did not
recommend any restrictions in the first place, and also its recommendations were widely
ignored by member states. More generally, criticisms of the WHO’s role in the COVID-19
pandemic, regardless of their merits, make it more challenging for the WHO to lead.
Global response towards WHO during COVID-19
Distrust of the WHO and global approaches to managing pandemics amongst some nations
have been highlighted in the response to COVID-19. Issues related to the transparency of
States Parties and their willingness to report have emerged, particularly with respect to
disclosure surrounding the original outbreak in Wuhan, China (9). The WHO has also been
accused of delaying the declaration of a PHEIC and not calling for needed travel restrictions.
Further evidence of the impact of populist sentiment is the reluctance of countries with
purportedly populist governments, such as the United States, Brazil and the United Kingdom,
to follow WHO guidance. In the UK this was manifest by the initial “herd immunity’ as
opposed to “lockdown” strategy. In the United States and Brazil there have been efforts to
downplay the impact of the pandemic and question international guidance. (10). At the same
time, it needs to be acknowledged that the WHO guidance on both not imposing travel
restrictions and questioning the value of masks at the outset of the pandemic may not have
been supported by subsequent evidence.
Conclusion
Highly transparent and positive local, national and global responses to international health
threats through the IHR can help assure global health security and do so in ways that are
visible and valued by local populations. Although some variation between regions is to be
expected but the IHR (2005) remain the source of legal obligations applicable to all the WHO
member states, enabling a balance of consistency and flexibility. Lessons learned during this
pandemic period can inform ongoing discussions about how to reform the WHO and the IHR
(2005) to make them more effective.
References:
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