Yesterday, 1st February 2016, the World Health Organisation (WHO) declared a Public Health Emergency of International Concern. A PHEIC is an ‘extraordinary event’ which constitutes a public health risk to other communities through the international spread of disease and would potentially require an international response to bring it under control. This declaration was made following increasing concern about the spread of the Zika virus disease and its link to cases of babies born with microcephaly and other neurological disorders in Brazil. This declaration has a purpose – it will spur into action an international response.
So how exactly is a PHEIC declared?
A PHEIC declaration is made under the International Health Regulations (IHR) 2005. These regulations provide a legal framework, agreed between 196 countries, to prevent and control the international spread of disease and to provide a public health response to qualifying events. They also strive to prevent unnecessary restrictions on travel and trade as a consequence of global health events.
As part of the IHR, states are obliged to notify the WHO of any kind of ‘event’ which may constitute a PHEIC, where an event is any manifestation of disease or any occurrence that creates a potential for disease which could spread internationally or require an international response to bring it under control. So before a PHEIC is declared, there is a lot of work behind the scenes to make sense of emergent and actual events and to classify them one way or another.
Making sense of events: the Decision Instrument
There are some disease events that are notifiable regardless of the circumstances of their emergence. These are smallpox, poliomyelitis, new types of human influenza, and SARS. But there are other events that are not obviously notifiable. To help states do this work, there is the Decision Instrument. This is an algorithm contained within the IHR which sets the parameters for acting on an event detection. States are required to investigate reports of urgent events that could be a notifable event within 48 hours of it being reported.
The decision instrument asks four main questions:
- Is the public health impact of the event serious?
- Is the event unusual or unexpected?
- Is there a significant risk of international spread?
- Is there a significant risk of international travel or trade restrictions?
Events that meet one or more of the decision instrument criteria qualify for further assessment and events that meet more than two criteria must be notified. Events like cases of disease reported among health staff, treatment failure such as antibiotic resistance and vaccine failure or cases reported in highly populated areas would qualify under the decision instrument.
There are of course some cases where there is great uncertainty over whether or event is notifiable or not. In these cases, states are encouraged to keep WHO informed.
Once an event has been diagnosed as being notifiable, the notification must be immediately made to WHO via a chain of command, usually through an appointed national IHR Focal Point (a national centre set up to liaise with WHO) in communication with a WHO IHR Contact Point (which is a dedicated unit within WHO). The notification should contain as much information known about the event as possible – such as case definitions, laboratory results, number of cases identified and number of deaths and details of any health measure so far put in place in response to the event. This then triggers assessment by the WHO, which is typically done through consultation with a specialist Emergency Committee. Once a declaration has been made, the WHO will then make a number of recommendations to states to help prevent and control the spread of disease.
How a PHEIC is declared: Ebola outbreak in December 2013
Before the escalation of international response to the Zika virus disease, the last time a PHEIC was declared was on 8th August 2014 during the Ebola outbreak in Western Africa, which affected Guinea, Liberia and Sierra Leone. The timing of the Ebola PHEIC declaration has been subjected to debate and criticism, most notably from humanitarian organisations on the ground that claim the international community was slow to respond to their calls for action. See MSF’s response here http://www.msf.org/article/ebola-failures-international-outbreak-response
The UK Government’s International Development Committee undertook a review into the global response to Ebola. Oral and written evidence was recorded in 2015. Some of the discussion gives us an insight into the problematics of detecting, diagnosing and declaring a PHEIC in practice. I’ll mention a few here.
One of the challenges described by Dr Aylward, a Special Representative for the Ebola Response from the WHO, is making sense of events that appear to be ‘normal’ health events. Normal in the sense that they are somewhat familiar and, because of their familiarity, it is assumed that they will be managed in normal ways, utilising already existing capacity. In the case of Ebola, there had been outbreaks before, all of which were managed and brought under control without the need for an international response.
“The challenge was that it was such a new thing. Ebola had occurred so many times up until then. We had the two dozen outbreaks in DR Congo and Uganda and various other places. They had all been managed within a number of weeks or months at most, and they had all led to relatively small flares. So there was a certain sense of, “This is Ebola. We know Ebola. This will be manageable.” Those proved wrong assumptions, but they proved to be the wrong assumptions by everybody.” (Dr Aylward, oral evidence, 25th November 2015, pg15)
There is also the challenge of processing and sorting multiple alerts, where habitual processing methods like filtering might mistakenly overlook or disregard some alerts, again, because of their familiarity or repetition. Dr Nabarro, representative of the United Nations Secretary-General’s Special Envoy on Ebola, talks about the difficultly experienced in digesting multiple alerts from one source:
“All of us who deal with rumour and who respond to alerts have a habit sometimes of tuning out information that comes from a particular source. I do not want, in any way, to suggest that this was the case but… I believe that sometimes the open mind is not maintained when information comes from sources that tend to be the providers of alerts on a lot of occasions. You get a kind of discounting capacity in your head. It is the same in other forms of intelligence, and so the maintenance of an open mind is absolutely critical and all of us need, as a result of this, to be much more ruthless in purging ourselves of any discount factors when information comes from one or other source” (oral evidence, 25th November 2015).
There is talk of a turning point. Something happened that made it unavoidably obvious that this was a notable event that required an international response. Dr Aylward talks about this key decision point in the process of making the Ebola PHEIC declaration:
“If you look first at the trigger for the PHEIC, what happened was, you will remember, that a person with Ebola boarded an aeroplane and flew into Nigeria, and then we had the case there and the outbreak there, which clearly demonstrated the international risk and led to that declaration” (oral evidence, 25th November 2015).
Maybe the systems in place to help decision making are flawed or fail to provide an anticipated outcome. For Dr Aylward, there is a mismatch between the purpose of the International Health Regulations and the act of declaring the PHEIC which makes the work of making a declaration problematic.
“I feel that because a PHEIC is something that is grounded in a treaty whose purpose is to prevent inappropriate restrictions on travel and trade, there is almost by definition a reticence to declare until absolutely necessary that something is a public health emergency of international concern. Maintaining travel and trade is the purpose. In the emergency management world I work, in we work differently. When something escalates, you go with a no-regrets approach and you declare early, based on the complexity, severity, scale, et cetera, of a crisis. The IHR and PHEIC are not well designed” (oral evidence, 25th November 2015).
This leads to questions about the appropriateness of decision making procedure, relating specifically to the temporal character of some emergency events (e.g. emergent, slow-burning health events that have the potential to become something else) and the point at which a declaration is made (without ‘delay’):
“As we look going forward, what we need to do is ensure that there is international consensus around the grading of infectious pathogens as they evolve from an outbreak to a health emergency to a health crisis to truly a destabilising security crisis, as this one did. That should be what triggers the involvement, because a PHEIC may be too late; it is not designed to grade an escalating crisis.” (25th November, IDC).