The Revised International Health Regulations and Their Relevance to Travel Medicine

Max Hardiman MBChB, MRCGP, MFPHM, Annelies Wilder‐Smith MD, PhD, FAMS
DOI: http://dx.doi.org/10.1111/j.1708-8305.2007.00117.x 141-144 First published online: 1 May 2007

Abstract

The revised International Health Regulations 2005 (IHR 2005) will enter into force in June 2007. Here we give an overview of the IHR (2005) and their relevance to the travel medicine practitioner. The two specific applications of the IHR (2005) most likely to be encountered by travelers are the disinsection of aircraft to prevent importation of disease vectors and the yellow fever vaccination requirements imposed by certain countries. A model of the revised international certificate of vaccination or prophylaxis will be shown. The IHR (2005) has moved away from the definition of fixed maximum measures relating to specific diseases and in their place focus on the issuance of context‐specific recommendations, made either on a temporary emergency basis or established for routine application in respect of ongoing risks of disease spread.

The spread of infectious diseases from one country to another and potentially to the entire world is a long‐standing public health concern. Consequently, international cooperation to prevent or minimize the extent of such spread is important. The International Health Regulations (IHR), adopted in 1969, amended in 1973 and 19811 and completely revised in 20052 provide the legal framework for such international cooperation.

The travel medicine practitioner is primarily concerned to provide advice and other services aimed at maintaining and protecting the health of individual travelers who consult with them. Despite the distinction between the role of travel medicine providers and that of the IHR, the internationally binding nature of the regulations and the inclusion within them of specific requirements for certain travelers make it important for clinicians in travel medicine to be familiar with some aspects of the legal provisions.3

History of the IHR

The IHR were originally called International Sanitary Regulations when they entered into force in 1951. The current IHR were adopted by the Twenty‐second World Health Assembly on July 25, 1969, and represent a revised and consolidated version of the previous International Sanitary Regulations.4 The Twenty‐sixth World Health Assembly in 1973 amended the regulations, particularly with regard to the provisions for cholera. The Thirty‐fourth World Health Assembly in 1981 amended the regulations to exclude smallpox, in view of its global eradication. The IHR have recently undergone an extensive revision and renegotiation among World Health Organization’s (WHO) Member States, and the revised regulations—referred to as IHR (2005)—were unanimously adopted on May 23, 2005, by the World Health Assembly. The IHR (2005) will enter into force in international law in June 2007.

The main changes in the revised IHR (2005)

The stated purpose of the IHR (2005) is “to prevent, protect against, control and provide public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.”2

The regulations currently still in force (IHR 1969) have rules that apply to three infectious diseases: cholera, plague and yellow fever. The most significant change to the IHR (2005) has been to broaden their scope of application from three diseases to any event with the potential to be a public health emergency of international concern, including events that do not have an infectious etiology. Following the increasing emphasis on epidemiological surveillance for the detection and control of communicable disease outbreaks, the revised regulations focus on the strengthening of such methods at both the national and the international levels so that the risks from public health emergencies arising within or outside the country can be managed effectively. New or updated provisions are made to reduce or eliminate the sources from which infection spreads, to improve sanitation in and around ports and airports, and to prevent the dissemination of disease vectors. In circumstances where chemical or radiological events pose a serious risk to public health and of spreading internationally, many of the same principles for rapid identification, investigation, public health response, and coordination are applicable.

The main objectives are to ensure (1) the appropriate application of routine preventive measures (eg, at ports and airports) and the use by all countries of certain internationally approved documents (eg, international vaccination certificates) and (2) the notification to WHO of all events that may constitute a public health emergency of international concern and the implementation of any temporary recommendations should the WHO Director‐General determine that such an emergency is occurring. In addition to its new notification and reporting requirements, the IHR (2005) focus on the provision of support for affected states and the avoidance of stigma and unnecessary negative impact on international travel and trade.

The renewed mandate given to Member States and WHO under the IHR (2005) has also increased their respective roles and responsibilities. In particular, States Parties to the IHR (2005) are required to develop, strengthen, and maintain core surveillance and response capacities to detect, assess, notify, and report public health events to WHO and respond to public health risks and public health emergencies. WHO, in turn, is to collaborate with States Parties to evaluate their public health capacities and to facilitate technical cooperation, logistical support, and the mobilization of financial resources for building capacity in surveillance and response.

The text of the revised regulations is divided into 10 parts; part 1 deals with definitions and purpose, parts 2 and 3 deal with the identification and response to public health emergencies, parts 4 to 7 cover public health actions at international ports, airports, and ground crossings including health documentation and charges levied, while the remaining parts deal with procedural and legal aspects of the agreement. Some more technical detail, including model certificates and declarations, are found in a series of nine annexes.

The IHR (2005) are better adapted to the increasing volume and speed of international traffic and trade than were the previous regulations and take into account current trends in the epidemiology of infectious diseases, as well as other emerging and reemerging health risks. They enter into force on June 15, 2007.

Relevance to the travel medicine practitioner

The two specific applications of the IHR (2005) most likely to be encountered by travelers (and therefore of importance to the travel medicine practitioner) are the disinsection of aircraft to prevent importation of disease vectors5 and the yellow fever vaccination requirements imposed by certain countries.6,7

Disinsection of aircraft

“Disinsection” means the procedure whereby health measures are taken to control or kill the insect vectors of human diseases present in baggage, cargo, containers, conveyances, goods, and postal parcels. Every conveyance leaving a point of entry situated in an area where vector control is recommended should be disinsected and kept free of vectors. The IHR (2005) also specify that States Parties shall establish programs to control vectors that may transport a public health risk in the immediate vicinity of international ports, airports, and ground crossings.

Yellow fever

Mandatory vaccination against yellow fever is carried out to prevent the importation of yellow fever virus into vulnerable countries. These are countries where yellow fever does not occur but where the mosquito vector and non‐human primate hosts are present. Importation of the virus by an infected traveler could potentially lead to the establishment of infection in mosquitoes and primates, with a consequent risk of infection for the local population. In such cases, vaccination is an entry requirement for all travelers arriving from countries, including airport transit, where there is an existing risk of yellow fever transmission. If yellow fever vaccination is contraindicated for medical reasons, a medical certificate is required for exemption. Such a certificate of exemption does not preclude a state from quarantining the traveler without a valid vaccination certificate for 7 days. The international yellow fever vaccination certificate becomes valid 10 days after vaccination and remains valid for a period of 10 years. For information on countries that require proof of yellow fever vaccination as a condition of entry, see reference country list.

Travelers should be aware that the absence of a requirement for vaccination does not imply that there is no risk of exposure to yellow fever in the country and that yellow fever vaccination may be recommended.6

As of June 2007, the current “international certificate of vaccination or revaccination against yellow fever” will be replaced by the “international certificate of vaccination or prophylaxis.” Clinicians who will issue the certificate should note that the main difference to the current certificate is that they have to specify in writing in the space provided that the disease for which the certificate is issued is “yellow fever.”Figure 1 shows the model international certificate of vaccination of prophylaxis.

Figure 1

As of June 15, 2007, the “international certificate of vaccination or prophylaxis,” is as above.

The 1969 regulations contain a provision that only vaccinating centers designated by the national authority can issue a valid international certificate of vaccination against yellow fever (article 66).1 It is not the application of the vaccination that was so far restricted to such centers but the issuance of valid certificates. This provision is no longer maintained in the IHR (2005). However, the following should be noted:

  1. The requirement to use a vaccine approved by WHO is maintained [annex 7.2 (e) and annex 6.1].

  2. The requirement that national authorities designate vaccination centers is maintained [annex 7.2 (f)].

Consequently, there is no longer an international requirement for valid certificates to be issued solely by the designated national centers, but States Parties must continue to designate such centers. Thus, they can use national instruments to restrict the issuance of certificates within their own territories to such designated centers to achieve the quality and safety objectives of annex 7.2 (f). An international certificate can only be issued by the center administering the vaccination.

Apart from the measures for yellow fever discussed, the IHR (2005) have moved away from the definition of fixed maximum measures relating to specific diseases and in their place focus on the issuance of context‐specific recommendations, made either on a temporary emergency basis or established for routine application in respect of ongoing risks of disease spread. Although states will not have a legal obligation to follow these recommendations, experience has shown that there is a high degree of compliance with timely and relevant guidance issued by WHO in respect to preventing international disease spread. The indicative list of health measures that may be considered in such recommendations includes many that would impact significantly upon international travelers, such as health screening on arrival or departure, certification requirements, and restrictions on travel. It will therefore be important for those giving health advice to travelers to ensure they are kept informed of any new recommendations that may be issued under the IHR.

A number of provisions are included to protect the international traveler from unjustified health measures. While states are permitted to apply measures in addition to those provided for under the regulations, there are a series of requirements in relation to such measures aimed at ensuring that they are scientifically valid and that information about their application is available. Specific articles seek to restrict unjustified medical examination, interruption of voyages, denial of entry, forced vaccination, documentation requirements, and unreasonable charges. In addition, there is reference to the dignity, human rights, and fundamental freedom of persons and specifically to the treatment of international travelers during the application of health measures including quarantine or isolation.

It is the responsibility of the individual governments to notify WHO of events that qualify as potential public health emergencies of international concern; however, travel medicine practitioners will be interested in the provision that requires states to report concerns regarding emergencies that may be developing elsewhere in the world on the basis of imported cases of disease as it may well be in travel clinics where such imported cases are first detected.

Declaration of Interests

Both authors are employees of the WHO. Otherwise the authors state they have no conflicts of interest.

References

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