Bloomberg Reports:

The deadly swine flu outbreak that’s spread across Mexico and infected people in California and Texas may be declared an international health emergency.

The World Health Organization will hold a teleconference with flu experts at 4 p.m. Geneva time to decide whether the situation is “a public health event of international concern,” said Gregory Hartl, a WHO spokesman.

At least 68 have died and more than 1,000 have fallen ill with flu-like symptoms in the Mexico City region in the past month, Jose Cordova, Mexico’s Health Minister, told reporters yesterday. The country’s government has shut schools and distributed face masks.

Human-to-human spread of the previously unseen H1N1 swine influenza in Mexico and the U.S. is heightening concern that the virus may spark a pandemic. WHO Director-General Margaret Chan may raise the level of pandemic alert if today’s meeting recommends that it is globally significant, Hartl said.

“We do not know whether this swine flu virus or some other influenza virus will lead to the next pandemic,” Richard Besser, acting director of the U.S. Centers of Disease Control and Prevention, told reporters yesterday on a teleconference. “Scientists around the world continue to monitor the virus and take its threat seriously.”

****

For those who are interested:  this category of “Public Health Event of International Concern” is a relatively new one, created with the enactment of the 2005 Revised International Health Regulations (IHR).  These regulations sought to provide WHO with increased powers to monitor and intervene in outbreaks of novel pathogens.  I’m appending below a section from a paper I recently wrote that focuses in part on the history of IHR.

Epidemic Intelligence

Beginning in the 1990s, DA Henderson and others connected the interest in emerging diseases among life scientists with national security officials’ concern about the rise of bioterrorism, suggesting that a global disease surveillance network could serve to address both problems. Henderson’s model of disease surveillance came out of his background at the Epidemic Intelligence Service (EIS) located at the Centers for Disease Control. The EIS was founded in 1952 by Alexander Langmuir. As Lyle Fearnley has described, Langmuir pioneered a method of epidemiological surveillance designed to track each instance of a disease within a given territory – one that would serve the needs both of disease epidemiology and biodefense.  Langmuir defined this form of surveillance as “continued watchfulness over the distribution and trends of incidence through systematic consolidation and evaluation of morbidity and mortality data and other relevant data.”  Henderson had used this method in tracking the global incidence of smallpox as part of the eradication program. His proposed global network of surveillance centers and reference laboratories extended this approach to as yet unknown diseases, providing early warning for response to outbreaks of any kind – whether natural or man-made.

Through Langmuir’s successors at CDC, expertise in epidemic intelligence diffused to the World Health Organization, which by the late 1990s became increasingly focused on the problematic of emerging infections. The career of epidemiologist David Heymann is instructive. Heymann began his career in the CDC’s Epidemic Intelligence Service, and in the 1970s worked with CDC on disease outbreak containment in Africa and with WHO on the smallpox eradication program. In the early years of the AIDS pandemic, he helped establish a WHO office to track the epidemiology of the disease in developing countries. He then returned to Africa in 1996 to lead the response to a widely publicized Ebola outbreak in Congo. After this he was asked by the Director of WHO to develop an emerging disease program. Heymann set up a global funding mechanism that broadened WHO’s emerging disease surveillance and response capacities along the CDC model.

After the Ebola outbreak, as well as catastrophic outbreaks of cholera in Latin America and plague in India in the early 1990s, he later reflected, a “need was identified” for stronger international coordination of response. A key problem for outbreak investigators was that national governments often did not want to report the incidence of a disease that could harm tourism and international trade.  The existing International Health Regulations – which required nations to report on only three diseases, cholera, plague and yellow fever – were ineffectual in forcing disease notification for at least two reasons. For one, the limited list of reportable conditions was of no relevance for “emerging diseases”; second, there was no way of enforcing compliance with reporting requirements. While, as Heymann put it, “in our emerging diseases program our idea was to change the culture so that countries could see the advantage of reporting,” a means of enforcing compliance was needed. The proposed revision of IHR became a vehicle for outbreak investigators to construct the functioning global surveillance system that had been envisioned by Henderson and others.
Planners of the revised IHR proposed three key innovations that would make the new regulations useful for governing a range of potential disease emergencies. The first focused on the scope of the regulations’ application.  Through the invention of the concept of the “public health emergency of international concern” (PHEIC), IHR developers tremendously expanded the kinds of events to which the regulations might apply. Naturally occurring infectious diseases such as influenza and Ebola, intentional releases of deadly pathogens such as smallpox, or even environmental accidents – such as those that occurred at Bhopal in 1984 and Chernobyl in 1986 – were examples of events that could provoke the declaration of a PHEIC. The IHR “decision instrument” was a critical tool for guiding states in determining what constitutes a public health emergency that required the notification of WHO. However, the pathway defined as “any event of international public health concern” left considerable room for interpretation of the scope of the regulations.

The second major innovation was an expansion of the potential sources of reports of outbreaks: whereas the prior IHR restricted reporting to national governments, the revisions allowed reports from non-state sources such as media. In this way, state parties’ refusal to report outbreaks could not block the functioning of the system. Indeed, the official recognition of media reports would encourage compliance on the part of states. Critical to making this possible was the emergence of internet-based reporting systems such as ProMED in the US and GPHIN in Canada that scoured international media for stories about possible outbreaks. As Weir and Mykhalovskiy (2007) note, these information networks liberated global public health surveillance from exclusive reliance on traditional epidemiological methods – such as the case report. In 1997, WHO established GOARN (Global Outbreak Alert and Response Network), a system linking individual surveillance and response networks, which eventually had 120 partners.

Finally, the third key innovation of the revised IHR was to require that states build national capacity for infectious disease surveillance and response. The construction of these “national public health institutes” on the model of CDC would make possible a distributed global network that relied on the functioning of nodes in each country. As one document suggested: “It is proposed that the revised IHR define the capacities that a national disease surveillance system will require in order for such emergencies to be detected, evaluated and responded to in a timely manner” (Fidler 2005: 353). However, it was unclear where the resources would come from to make this possible in poor countries that lacked functioning health systems. WHO gave countries until 2016 to fulfill this obligation.

Rolling out the system: SARS

While the revised IHR were not officially approved by the World Health Assembly until 2005, and did not go into effect until June 2007, the SARS outbreak of early 2003 gave Heymann and his colleagues in WHO’s emerging infections branch a chance to roll out elements of its new outbreak and surveillance response system well in advance. As an outbreak of an unknown and unexpected, but potentially catastrophic viral disease, SARS fit well into the existing category of “emerging infections” (Hooker 2007). The Chinese government’s initial failure to fully report the outbreak led WHO to rely on its new technique of using non-state sources of information: SARS was the first time GOARN identified an epidemic that was rapidly spreading internationally. As opposed to nation-states, Heymann noted, international scientists “are really willing to share information for the better public good” (Ashraf 2004: 787). GOARN made it possible to electronically link leading laboratory scientists, clinicians and epidemiologists around the world in a “virtual network” that rapidly generated knowledge about the disease. WHO tracked the spread of the illness closely and issued a series of recommendations on international travel restrictions. According to Heymann, who led the agency’s response, this rapid reaction was key to the containment of the epidemic by July 2003 – though he also acknowledged the good fortune that SARS had turned out not to be easily transmissible.

The lesson of SARS, from the vantage of the new regime of global health security, was that, in a closely interconnected and interdependent world, “inadequate surveillance and response capacity in a single country can endanger the public health security of national populations and the rest of the world” (Heymann 2004). Processes of globalization – including migration, ecological transformations, and massive international travel – had led to new biological, social and political risks. Only a global system of rapidly shared epidemiological information could provide adequate warning in order to mitigate these risks.  National sovereignty must accede to the demands of global health security. This lesson was then applied to the next potential disease emergency, avian influenza. As Garrett and Holbrooke argued (2008), in calling for Indonesia to comply with WHO’s virus-sharing network, SARS had proven that “globally shared health risk demands absolute global transparency.”

Whether the revised IHR would live up to its billing as a radical transformation of international public health would depend at least in part on its capacity to force sovereign states to comply with the requirements of global health surveillance. The case of Indonesian flu viruses indicated that an alternative regime of global health – one focused on the problem of access to essential medicines – could well complicate such efforts. As Fidler acknowledged, IHR did not address the major existing infectious disease problems of the developing world:

“The strategy of global health security is essentially a defensive, reactive strategy because it seeks to ensure that States are prepared to detect and respond to public health threats and emergencies of international concern. The strategy does not require States go on the offensive against the factors that lead to disease emergence and spread. The new IHR are rules for global triage rather than global disease prevention” (Fidler 2005: 389).

The program of global health security did not have any means to address, for example, the HIV/AIDS pandemic – and thus did not attract the interest of global health advocates focused on the AIDS crisis. It contained no provisions regarding medication access, prevention programs, or vaccine research and development (ibid: 391).