By Nirmal Kandel1, Graham Tallis2, Stella Chungong1, Jaouad Mahjour1
1Department of Country Health Emergency Preparedness and IHR, World Health Organisation
2Department of Polio Eradication, World Health Organisation
Continuing outbreaks, disasters and conflict are sufficient evidence that the world remains vulnerable to health emergencies. Emergencies can have significant health, social, economic and political impacts. The International Health Regulations (2005) and other global and regional frameworks guide countries in developing, strengthening and maintaining the national capacities necessary for the prevention, detection, and response to public health events and require a lot of resources. However, there are significant gaps in resources at the national, regional and global level and should capitalise on existing structures, such as polio eradication initiatives to strengthen IHR capacities. In many countries, the polio resources are complementing other disease control efforts during outbreaks, but requires a more systemic approach to leverage its resources for the implementation of IHR. For those with a country perspective, feel free to write a comment in response to this piece.
It has been over a decade since the revised International Health Regulations (2005) came into force on June 2007 requiring countries to detect, assess, notify and respond to any public health events that can constitute potential public health emergencies of international concern (PHEIC). State Parties are strengthening capacities that are required for these functions and regularly reporting their implementation status to the World Health Organization (WHO). During the last ten years, the world has experienced the flu pandemic and multiple PHEICs like poliomyelitis, Ebola virus disease, MERS, Zika outbreak, etc. When events like these occur, many ideas are floated around such as developing a robust mechanism to monitor International Health Regulations (IHR) capacities and addressing resource and capacity gaps. WHO has put together recommendations of the IHR review committees and developed a robust monitoring and evaluation framework. However, there are significant gaps in resource mobilisations at the national, regional and global levels and robust strategies are needed to close these gaps.
Strengthening IHR capacities
Preliminary analysis of findings of the Joint External Evaluation (JEE) and the IHR monitoring questionnaires demonstrate some degree of detection and verification capacities are in place; however, there are significant gaps on preparedness, coordination, workforce, laboratory, analysis, response and resource mobilisation capacities. To address these gaps, many member states have been developing or updating their national action plans for health security (NAPHS) and their implementation requires a lot of resources. Therefore, it is imperative to capitalize on existing structures and capacities like polio eradication initiatives to strengthen IHR capacities. The “Eradication and End Game Strategic Plan 2013-2018” for polio eradication initiative leverage this opportunity to integrate the system for other disease control initiatives.
The example of polio
Since 1988, the Global Polio Eradication Initiative (PEI) has invested $ 9 billion in developing systems and infrastructures for polio surveillance and its eradication. The goal of eradication seems to be closer as the last remaining three endemic countries (Afghanistan, Nigeria and Pakistan) reinforce efforts to stop the transmission of wild polioviruses. Existing polio surveillance systems can collectively provide a robust foundation to prevent, detect, and respond to potential PHEIC. The system is mature, and various countries are increasingly applying them to detect and respond to multiple diseases. A vital element of the Global polio eradication and endgame strategic plan 2013–2018 is to preserve the legacy of the polio eradication initiative to use for other epidemic-prone diseases. A significant effort is being made to transition polio resources to be fit for purpose in the post-eradication era.
Leveraging the polio structures to IHR core capacities
Coordination: The PEI structures can ensure coordination mechanisms are in place and deployment of resources concerning IHR related events. This has been demonstrated in many places not only for the polio program but also for programs like routine immunisation, maternal and child health, and emergency response etc. in some African countries. Thus PEI led coordination mechanism has made a significant contribution to the coordination and delivery of other public health interventions in Africa.
Risk Communication: India is using its polio transition for social mobilisation activities for routine immunisation and sanitation interventions, which are vital elements of the prevention of any potential epidemics. These resources can strengthen risk communication capacities of IHR (2005) for epidemic-prone diseases.
Surveillance: The WHO African region is moving towards applying polio transition to build Integrated Disease Surveillance and Response (IDSR) for disease control and already demonstrated improved data management capacities for IDSR as well as emergency response. Similarly, other countries are using these structures to strengthen the surveillance of vaccine-preventable diseases and during health emergencies such as the 2014 Ebola virus disease outbreak.
Human Resources: The most significant resource of PEI is human resource capacity and their experience, knowledge and skills on disease surveillance. These skilled staff can be instrumental in developing capacities for health security. Good examples include the emergency response to the Nepal Earthquake, the Ebola in Nigeria, the cholera in Yemen, and IDSR in Africa.
Preparedness and Response: The support from the polio program’s infrastructure, particularly the coordination platform (the emergency operation centre), the availability of skilled personnel in the polio program, and lessons learned from managing the polio eradication program significantly contributed to the early containment of the 2014 Ebola virus disease outbreak in Nigeria.
Laboratory: The success of any disease programme is built on a functional laboratory network. The formation of the global polio laboratory network has contributed to supporting countries in their efforts to strengthen laboratory capacity. This has developed a laboratory network and expanded surveillance to other viral priority diseases such as measles, yellow fever, Influenza, MERS-CoV and Ebola. This demonstrates how the polio structures can improve on the disease prevention, detection and control in low- and middle-income countries.
Experience, knowledge and lessons: There are knowledge, skills and lessons learnt on various challenges of eradication initiatives like the impact of the conflict and insecurity, strategies to combat hesitancy to health interventions like vaccination, engaging communities and others. These can be immediately capitalised to strengthen capacities for health security, for instance, the current Ebola outbreak in the conflict-affected region of Democratic Republic of Congo or vaccine aversion in some of the high-income countries.
The polio system is robustly equipped with trained human resources at national and sub-national levels for surveillance, to prevent, detect, and respond to suspected cases. The system has reporting systems from subnational to national levels. Trained staff are well versed, and the system is well equipped with surveillance standards and protocols for diseases. The surveillance system is supported with laboratory facilities either from national, regional or international laboratory networks. In many countries, governments pay for the structure from their national budget, while in some countries the structure is supported by international organisations, partners or donors. Applying the knowledge and lesson learnt from polio and using polio assets and infrastructure is one of the most efficient and effective strategies to strengthen IHR capacities for health security. The governments, WHO, partners, and other agencies should come together on transitioning the polio legacy to IHR streams before the entire structure disappears or is absorbed when the endgame of polio is achieved.
Image credit: World Health Organization