Now let's talk about an important advancement in surveillance data reporting, the International Health Regulations (2005). Let's start by going back in time to November, 2002 when atypical pneumonia cases were reported from Guangdong Province in China. We know now that that atypical pneumonia was caused by what's known as SARS, Severe Acute Respiratory Syndrome, that's caused by a coronavirus. Now, that initial report was laid in 2002, but by March, 2003, less than six months later, there was already a global alert that had been issued by the WHO for respiratory disease of unknown origin, from people coming from China, Vietnam, and Hong Kong. So, within just five months of that first case report, SARS had spread to numerous countries throughout Asia, and the WHO was putting the entire global community on alert for cases. As you know, our world is highly connected through airline traffic, people can move from one continent to another within hours. So, SARS represented a real threat for a global pandemic. By April, 2003, they had finally identified the SARS coronavirus, and cases in countries affected continued to grow. There was a big concern again that this could become a pandemic. In the US, CDC actually began some initial pandemic planning, although ultimately no pandemic was declared. By the end of that year, in 2003, SARS cases have been reported from 29 countries. There had been more than 8,000 probable cases detected, with 774 deaths. If any of you hearing this lecture were in public health in 2003, you'll remember the panic associated with SARS. SARS took a tremendous toll not only in terms of human lives, but in commercial productivity. There were travel bans. Airlines stopped flights. Healthcare workers were scared. Of course, many healthcare workers were part of those who became infected and died. It really was a global public health crisis, even if it didn't reach pandemic proportions. We're lucky it didn't reach pandemic proportions. That's due in part to the ability of countries that showcases to contain them and to improve infection control sufficiently to stop transmission chains. It was a stark reminder that public health threats, even in one locality, can quickly become global. Pathogens do not respect national boundaries. We needed a way to be able to communicate with each other more effectively about these emerging threats because if they were not contained quickly, they can become global threats. This isn't limited to only emerging infections. It also includes environmental threats. What about a nuclear leak that could quickly cross boundaries as well? What about an oil spill in a major river way that forms the border between two countries? Any kind of public health threat should be reported if we are to respond as a global public health community in an effective way, and we're all safer if we share information about these types of events and risks to our health. So, following this emergency, the global community came up with the International Health Regulations (2005). They went into effect ultimately in 2007, and they represent a major step forward in a collective agreement to share surveillance data on these emerging public health threats. The IHR (2005) defines a PHEIC or a Public Health Emergency of International Concern 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. So, the IHR says that member states are legally required to report these PHEICs to the WHO, and they're required to report within 24 hours of confirmation of the event. WHO has a mandate then to coordinate the international response and control efforts that should be undertaken to control the threats that are reported through the IHR. A central theme to the IHR is capacity building. So, think about it this way, what countries are able to report to the WHO depends entirely on their national ability to detect. So, if they don't have the laboratory capacity to test for diseases that could be a public health emergency, then how are they supposed to report them? So, without bolstering, the capacity of countries to surveil for these threats, to test for them, to identify them, the requirements for them to report them are completely useless. So, this global mandate for countries to report disease threats under the IHR brought additional resources to countries to develop their surveillance programs. So, there's been a direct link between this mandate and global agreement to report threats with investments, substantial investments and surveillance programs, and laboratory capacity around the world. Of course, detecting emerging infections requires the ability to do two things. It may require new lab methods or diagnostics for those emerging infections, but it also requires the ability to detect endemic pathogens. So, if you see an outbreak of diarrhea, of respiratory disease, a country needs to be able to determine if this is just an endemic pathogen or something new that they need to report to the WHO under IHR. So, a really nice benefit of capacity building with IHR is that we've also built surveillance systems in places that didn't exist before to detect endemic pathogens, things that would never be reported under the IHR but make real substantive differences to surveillance programs at the country level. So, we went twice with capacity building for IHR. It's clear that IHR (2005) was an important improvement for global health security, but the system is still imperfect. There's a mandate, a legal requirement for countries to report, but if you don't report a public health event in your country, there's really no action that can be taken. They had strong disincentives for reporting an outbreak of a scary emerging infection. Recall what happened with SARS. There can be traveled bans. There can be economic hardships. Recently, there was an outbreak of Nipah virus in India in a rumor spread once the outbreak was reported in the media, that the outbreak was being spread by fruit bats. So, the mango producers lost a lot of money because known would buy mangoes. Think about the political consequences for public health officials who report outbreaks. Many, the health minister or local health authority, has been fired because either they were seen as incompetent in preventing the outbreak or incompetent because they did not stop it fast enough. Again, there are many disincentives for reporting these outbreaks to the WHO. What's important to remember, however, is that although they're difficult, they're vitally important. Many threats will not lead to an international incident, right? Just because there's a small outbreak that you identify in your country, if you're able to contain it there, it won't spread anywhere else. So, there's probably some allure in a wait and see approach within national governments. If they don't have to declare the outbreak, may be they wait and see, and the outbreak will go away on its own. But there are real inherent risks to that strategy because often, the best time to contain an outbreak is when it first starts. Once it's already spread beyond a country's borders, it becomes increasingly difficult to control, and that's why the wait and see approach just doesn't work well for public health. Ultimately, as a global community, we need to be able to increase the benefits for countries for reporting. They need to receive assistance. They need to receive congratulations for reporting because there are real risks to them for reporting as well. But as a global community, it's in all of our best interests for that reporting to occur.
