Revising the International Health Regulations

Canadian Stakeholder Comments on the January 12, 2004 Working Paper on the revised International Health Regulations

PDF Version (114 KB)

January 2005

For further information or to obtain additional copies, please contact:

International Affairs Directorate
Health Canada
Address Locator: 1903B
3rd Floor Jeanne Mance Building
Tunney's Pasture
Ottawa, Ontario K1A 0K9

Table of Contents

• Introduction
• Overview
• Feedback from Interested Organizations: A Review
• Annex A: List of Contributors
• Annex B: Notice of Consultation

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Introduction

On January 12, 2004, the World Health Organization (WHO) issued a Working Paper on the revision of the International Health Regulations (IHR), the central legal framework to control to international spread of infectious diseases. The current IHR date back to 1969 and only address three specific diseases - yellow fever, cholera and the plague. The revisions process aims to broaden the scope of the regulations and establish an internationally agreed upon framework for countries to report possible public health emergencies of international concern (PHEIC) to the World Health Organization. Along with other Member States, Canada supports the need to update the Regulations and is actively involved in the negotiation process.

In November 2004, Canada participated in an initial intergovernmental meeting of the 192 WHO Member States on the revisions to the IHR. In preparation for this meeting, Health Canada, the federal department leading the formulation of Canada's position in the negotiations, in partnership with the Public Health Agency of Canada (PHAC), invited the views of external stakeholders on the revisions process. Within the provisions of the proposed revised IHR, key processes relate to countries' capacity to report and respond to possible public health emergencies of international concern. These include disease surveillance; provisions for routine and emergency measures at points of entry to a country; provisions for conveyances, conveyance operators, containers and container loading areas as possible sources of infection; and health measures related to admission of international travellers. Recognizing that organizations working in public health, transport, shipping, trade and border monitoring, would have potential interest in the revisions process, Health Canada and PHAC invited the submission of views and perspectives of stakeholders in these fields. In addition, stakeholder groups in the travel industry, non-governmental organizations, professional associations and consumer groups were also consulted.

In July 2004, the WHO's Working Paper of January 12, 2004 was sent to 65 stakeholder groups across Canada, along with a notice explaining the purpose of the IHR revisions for Canada (see Annex B), and a questionnaire to guide feedback. These documents were also posted on the Health Canada Population and Public Health Branch website (now part of PHAC) and stakeholders had the option of submitting comments via this web link. A total of 12 organizations (see Annex A), answered the call for comments. Those responding included health professional associations; unions; port authorities, shipping and transport associations. This document is a summary of the main points raised in the submissions.

Health Canada and PHAC would like to thank all those who took the time to submit their comments on the IHR revisions process. The next intergovernmental meeting will be held in February 21-26, 2005, with the intention to have the final revisions adopted when the World Health Assembly meets in May 2005.

Additional information on the IHR can be found on the following web sites:

• Public Health Agency of Canada
• The World Health Organization
• Intergovernmental Working Group (Nov. 1-12, 2004; Feb. 21-26, 2005) on the IHR

Overview

The comments from stakeholders were generally supportive of the effort to revise the IHR. There was broad recognition of the need to update this international framework, and of the revisions process as an opportunity for Canada to share with the world lessons learned in its experience of dealing with infectious disease spread, particularly through the 2003 SARS outbreak. Stakeholders also, for the most part, recognized that a revised IHR would actually enhance the ability of state authorities around the world to work with the WHO in reporting, responding to, and managing infectious disease threats, and thereby strengthen global health security.

Questions and concerns raised in the stakeholder responses most often addressed the broad nature of the provisions in the IHR. Stakeholders commented that they could not determine exactly how a provision might be carried out given the non-specific nature of wording in the articles. Other stakeholder comments recognized and emphasized the need for policy coherence between the revised IHR and existing Canadian legislation and regulations.

Stakeholders comments are based on the IHR revisions text in the January 12, 2004 Working Paper, which the WHO developed for consultation at regional level. These regional consultations took place over the Spring and Summer of 2004, including three meetings held in the region of the Americas in which Canada participated. A summary report on the consultations in all six regions of the WHO is available at http://www.who.int/gb/ghs/pdf/IHR_IGWG_2-en.pdf . Based on input given by Member States through these regional consultations, the WHO issued an updated version of the text. This version, released on September 30, 2004, became the basis for discussion at the November intergovernmental meeting. Following this meeting, a revised version was released on January 24, 2005 for discussion at the upcoming February 2005 meeting. This version of the document addresses many of the concerns that stakeholders raised in their review of the draft January 12, 2004 Working Paper and can be found at

• http://www.who.int/gb/ghs/pdf/IHR_IGWG2_2-en.pdf and
• http://www.who.int/gb/ghs/pdf/IHR_IGWG2_2Corr.1-en.pdf

Feedback from Interested Organizations: A Review

Three main stakeholder groups offered feedback on the revised IHR January 12, 2004 Working Paper: transport associations from shipping and air-related industry, port authorities, and organizations representing health care workers and professionals. Common themes among the stakeholder comments were: the scope and purpose of the IHR; specifics of implementation and compliance; compatibility with existing agreements and practices; and methods for determining a public health emergency of international concern (PHEIC).

Scope and purpose
Shipping organizations raised concerns about the scope of certain provisions of the revised IHR, for example, those regarding public health measures for containers and container loading areas, conveyances and cargo, especially with respect to vector control. They recommended that such public health measures, including the issuance of Maritime Declarations of Health, only be applied to conveyances and containers arriving from areas affected by a public health emergency of international concern. They also commented that the requirement for ships or agents to report cases of illnesses on board should be limited to dangerous and communicable types of illness. There was also concern that the carrying out of provisions for the IHR should not interfere with the commercial activities of ships or ports.

In contrast, other stakeholders suggested broadening the scope of the revised IHR, for example, to include injuries in the definition of disease, and physical sources of injuries in addition to biological, chemical or radio-nuclear sources of diseases. Other comments suggested provisions on infection control should be part of the revised regulations.

Implementation and compliance
Submissions from shipping associations and port authorities raised concerns regarding their potential role in the implementation of the IHR. They questioned, for example, who would be responsible for surveillance at Canadian ports and which criteria would be used to designate 'points of entry' (i.e. ports, ground crossings, airports) that would have to develop the surveillance capacities outlined in the document. Stakeholders also commented on the extent of core capacity requirements the would be required under the revised IHR (for example in Annex 1). There was some concern that the one-year time line provided to put such capacities in place might be too short. An additional question was whether there might be penalties or fines in case of deliberate or repeated non-compliance to certain provisions of the IHR.

Comments from health professionals associations on implementation included support for the new Public Health Agency of Canada to be the National IHR 'Focal Point'. There was also support for the development and/or adjustment of federal, provincial and territorial response plans to be in harmony with the processes in the revised IHR. Further comments emphasized the need to protect the safety of health care workers in the response to health emergencies, and the need to treat health care professionals as partners in these processes. Concerns were raised on the particular obligations of health care workers and physicians in the reporting of health emergencies, and potential privacy issues in light of the need to treat notifications of public health threats anonymously unless the risks of such confidentiality clearly outweighed the benefits.

Compatibility with other agreements/practices
Various transportation industry stakeholders had concerns about the potential of the revised IHR to overlap with international agreements of other organizations, such as the International Maritime Organization. Air-transport associations raised concerns about the potential for conflict between public health considerations in emergency situations and possible aircraft safety and operational concerns. They recommended that due consideration be given to the judgement of the captain of the aircraft with respect to the nature of aviation emergencies and the danger that any passenger(s) may pose to the health of others. Some also raised the question of whether the Maritime Declaration of Health (Annex 8) and Aircraft General Declaration (Annex 9) could create liability issues for individual masters or captains of ships and aircraft.

Methods for determining a public health emergency of international concern (PHEIC)
Organizations representing health care workers and professionals expressed their support for the IHR revisions, and stressed that decision-making in relation to the IHR should be evidence-based, and that the WHO process of reviewing public health risks be independent and unbiased. The approach to determining a public health emergency of international concern in the revised IHR by use of a decision-instrument (Annex 2) was found favourable. They expressed the need for the term "public health emergency of international concern" to be defined. These organizations, among others, also expressed support for a disease list to work in concert with the decision-instrument. Such a 'hybrid approach" to assessing public health emergencies, which combines the decision-instrument and the disease list, was felt to be most effective. Stakeholders suggested the disease list be reviewed and updated on a regular basis.

Post-script

Many of the comments offered by Canadian stakeholders were similar to comments the WHO received in regional consultations on the January 12, 2004 Working Paper. Consequently, the changes incorporated in the September 30, 2004 version, and subsequently the January 24, 2005 version, of the proposed text in many cases respond to concerns raised by stakeholders. Certain areas of this latest version of the proposed revisions are especially relevant in this regard including:

• Definitions (Article 1); i.e. includes new for 'disinfection', 'invasive', 'quarantine', and 'public health emergency of international concern'
• Purpose and scope (Article 2)
• Responsible authorities (Article 3)
• Other reports (Article 7)
• Cooperation of WHO with international organization and bodies (Article 12)
• Collaboration and assistance (Article 41)
• Decision instrument and disease list (Annex 2)

With respect to specific comments on the compatibility of the revised IHR with other international agreements, the WHO undertook a separate extensive review of this issue and published the results in a separate document entitled, "Review and approval of proposed amendments to the International Health Regulations: relations with other international instruments" . As a result of this review, the WHO made adjustments to the September 30, 2004 draft text, which are also reflected in the January 24, 2005 version, to ensure compatibility, and where possible create synergy, between the IHR and other international instruments.

Stakeholders who submitted comments on sanitary guidelines for workers in the air industry can also note that the WHO's Guide to Ship Sanitation and Guide to Hygiene and Sanitation in Aviation are both presently in revision. Information, and a call for submission of comments on these revisions.

Annex A: List of Contributors

1. Port de Québec
2. Hamilton Port Authority
3. Canadian Shipowners Association
4. Chamber of Shipping of British Columbia
5. . North West Cruise Ship Association
6. Shipping Federation of Canada
7. International Air Transport Association (IATA)
8. Air Transport Association of Canada (ATAC)
9. Canadian Air Transport Security Authority
10. Canadian Airports Council (CAC)
11. Canadian Medical Association (CMA)
12. Canadian Union of Public Employees (CUPE)

Annex B: Notice of consultation

Revising the International Health Regulations
Give your input on the negotiation process

In the past few decades, infectious diseases have reemerged as a growing threat to global health security. Both "new"diseases such as SARS and BSE, and "old" ones such as tuberculosis, and influenza, have had serious impacts for Canada and the world. Increases in antimicrobial resistance, in diseases transmitted from animals to humans, and in international trade and travel all compound the public health threat posed by infectious diseases.

In response, the World Health Organization is revamping the International Health Regulations, the central legal framework addressing the international spread and control of infectious diseases. The current Regulations date back to 1969 and only address three specific diseases - yellow fever, cholera and the plague. Along with other Member States, Canada supports the need to update the Regulations and is actively participating in the negotiating process. An intergovernmental meeting of all WHO Member States on the revisions is to be held in Geneva in November 2004. A "Working paper" with an initial draft of the revised Regulations is the document under discussion in the run up to this negotiation.

The goal of the Regulations remains to ensure the maximum security against the international spread of disease with minimum interference with world traffic. The revised regulations (55 articles and 10 annexes) will constitute a legally binding international agreement governing key elements in the prevention and control of infectious disease spread, including:

• disease surveillance;
• determination of public health emergencies of international concern (PHEIC)
• notification, verification and response to a PHEIC;
• provisions for routine and emergency health measures at airports, ports, ground crossings;
• provisions for conveyances and conveyance operators, goods, containers and container loading areas, as possible sources of infection or contamination; and
• surveillance of travellers and other migrant populations.

Send us your comments

The revised International Health Regulations should reflect the current reality of new and re-emerging infectious diseases. In an increasingly globalized world, journey times are often shorter than the incubation period of disease, placing Canadian cities and citizens at risk of being affected by outbreaks which begin in other parts of the world. Canada believes that the WHO has both the mandate and the expertise to lead international co-operation in this area. Completion of negotiations and adoption of the revised Regulations by the World Health Assembly is scheduled for May 2005.

As Canada prepares for the upcoming negotiations, we invite your organization to submit comments on any aspect of the proposed negotiating text, especially those articles which would affect your business both directly and indirectly. Views from stakeholders in the fields of public health, transport, shipping, trade, and border monitoring are of particular interest. We want to know the issues and operational effects that your organization sees arising from an agreement of this nature. Please use the feedback questionnaire to guide your input. General comments are also welcome.

Questionnaires and written submissions should be sent to
IHR-RSIconsultation@hc-sc.gc.ca at Health Canada no later than Friday September 10th, 2004.

More information on the IHR revisions process can be found through the following web links of the World Health Organization:

• General information on IHR 

• Other countries views on IHR revisions

• WHO Frequently Asked Questions on IHR revisions

• WHO Regional Offices' press releases on the IHR revision process:
  http://www.paho.org/English/DD/AIS/be_v24n4-IHR.htm
  http://www.euro.who.int/surveillance/cooperation/20040611_1
  http://www.wpro.who.int/public/press_release/press_view.asp?id=388

• Access to the draft regulations in English, French, Arabic, Chinese, Russian

• Access to background document "Global crises, global solutions - Managing public health emergencies of international concern through the revised International Health Regulations"

Your suggestions and comments will be summarized in a report to be made available to the public.

The Government of Canada welcomes the opportunity to receive the views of interested Canadians on the revision of the International Health Regulations.