WHO Declares the Second PHEIC
During the past six months, wild poliovirus has spread internationally from three States: Pakistan to Afghanistan, Syria to Iraq, and Cameroon to Equatorial Guinea. The World Health Organization (WHO) acknowledges that this is a stark contrast from 2012-2013, a period in which there was near-cessation of any cross-border spread of the disease. This alarming spread of polio, which has occurred during the virus’s low transmission season, culminated this week in WHO’s Director-General declaring a Public Health Event of International Concern (PHEIC) – an event that (1) constitutes a public health risk to other States through international spread of disease, (2) could threaten trade and travel, and (3) will potentially require a coordinated international response – based on the advice of an Emergency Committee. This is only the second time since the revised International Health Regulations (IHR) were adopted in 2005 and entered into force in 2007 that WHO has designated a serious public health event a PHEIC.
Before this new eruption, the world had never been closer to the goal of eradicating wild poliovirus. Over the past 25 years, billions of dollars have been dedicated to polio control initiatives and vaccination campaigns; the number of annual cases has plummeted from roughly 350,000 in 1988 to just over 200. Still, coordinated efforts to eradicate polio have fallen short of deadlines repeatedly. In 2013, Rotary International and the Gates Foundation catalyzed a renewal of resources, committing hundreds of millions of dollars to carry the Global Polio Eradication Initiative through its 2018 “endgame.”
For the past several years, polio has been relatively contained (the number of cases as of April 2014 was 68, compared to 24 at the same time last year). However, given the location and status of States where polio is currently present, the risk of international spread is high. WHO identified Pakistan, Cameroon, and Syria as the countries posing the greatest risk of exporting the virus. While their neighbors may currently be polio-free, many of these countries are in the midst of internal conflict or remain fragile, creating a higher risk of reinfection due to weakened health systems. Syria is a prime example: vaccination rates dropped from 95% in 2010 to just 45% in 2013, and now the disease is spreading. In Pakistan, vaccination campaigns have come under consistent attack by militants who view the campaigns as a cover for espionage.
The IHR (2005) is functionally a global agreement among countries that have committed to meeting minimal obligations: to build national capacities to be able to detect, report, and respond to public health emergencies so that outbreaks can be contained before they spread across borders.
WHO stated in its press release that it expects polio-infected countries tointerrupt wild poliovirus transmission within their borders as rapidly as possiblethrough polio eradication strategies. In response, governments once hesitant to enforce national vaccination campaigns are raising their levels of activity.
The meeting of the WHO IHR Emergency Committee and the declaration of a PHEIC have brought global attention to the crisis. The declaration on a PHEIC and its endorsement by the WHO-Secretariat impose travel restrictions on Pakistan, Cameroon, and Syria. Most notably, the declaration has led to special measures including mandatory immunizations for all travelers. While these actions may have some benefit, at least one Pakistani health official has stated publicly that these restrictions came too soon and were unexpected.
While the declaration of a PHEIC and the WHO’s actions may have some benefits, one must ask: is this how the IHR (2005) should be used? Polio is a vaccine-preventable disease, and its occurrence is not new. An eradication campaign has been underway since 1988. The declaration of a PHEIC in this case may weaken the power and meaning of the IHR (2005) such that in future (and potentially more serious) situations, States may devote fewer resources and less attention to PHEICs.
WHO has identified Afghanistan, Equatorial Guinea, Ethiopia, Iraq, Israel, Somalia, and Nigeria as States that are infected with wild poliovirus but do not currently export the virus. These countries pose an ongoing risk for new wild poliovirus exportations in 2014. It should be noted, however, that even though Israel is listed as an infected State, no actual cases of polio have been confirmed in the country; the virus has only been isolated in sewage. The fact that WHO identified Israel as an “infected” country begs the question: is this is how Annex 2 of the IHR – the algorithm for countries to help determine when an event could be a PHEIC – should be utilized? While wild-type poliovirus is designated in Annex 2 as a disease that is always notifiable to WHO, and therefore the isolation of the virus from human or non-human (e.g., environmental samples) requires notification to WHO, technically, infection is defined in the IHR as meaning “the entry and development or multiplication of an infectious agent in the body of humans and animals that may constitute a public health risk”. Israel appears to have been singled out for having the laboratory diagnostic capacity to find polio in environmental samples.
Nevertheless, for now, the question is whether those States with polio cases have the resources to contain the disease. The WHO sets forth various actions to take, e.g., ensuring all travelers have the vaccination, but for countries like Syria where travelers may also be refugees, international collaboration may be required. WHO and others will continue to support efforts on the ground to ensure this recent spread of the virus is contained.
The Global Health Security Program is a research effort managed by the Department of Health Policy at The George Washington University’s Milken Institute of Public Health. It is co-directed by Drs. Rebecca Katz (a Truman Security Fellow) and Julie Fischer. This article was originally posted on the “From the Global to the Local” project’s blog, managed by the Milken Institute.