1. Contents
Message From The Director Disease Control
Message from Director
Disease Control Division
1 Division, Ministry of Health Malaysia
Ministry of Health Malaysia
The increasing significance of communicable diseases, especially emerging and
From the Desk of Chief Editor 2 reemerging infections is attracting greater attention, not only from the public
health and medical communities but also the lay public. About 65% of the
world’s first news about infectious disease events now comes from informal
Articles : 3 sources, including press reports and the internet which are now easily accessed
by everyone.There is a need to improve surveillance systems in order to recognize
Surveillance System in Malaysia emerging threats, both in the community and in hospitals & health facilities, and
to respond to them in a timely manner.
Developing Critical Appraisal Skill
Surveillance, namely the continuous monitoring of diseases and health
Disease Reports : 8 determinants in populations, has gained much attention over the past fifteen
years. Surveillance can be defined as the ongoing, systematic collection,
verification, analysis, and interpretation of data, and the dissemination of
Towards Measles Elimination information regarding diseases and health events to those who need to know,
for use in public health action to reduce morbidity and mortality and to improve
AGE Outbreak, Tapah, Perak health.
Surveillance Reports: 11 Surveillance data so analysed and interpreted can provide public health
officials and policy-makers with evidence-based information for decision
Notification of Infectious Disease, making. Such reports also enable public health professionals to detect early
May 2005 signals of outbreaks and to take quick remedial measures to control them. If the
surveillance data are not analysed, it is often difficult to detect warning signals
Report of Weekly Infectious Disease on communicable disease outbreaks from raw surveillance data alone. The
Notifications 1990 - 2004 analysed data/information generated should not be filed away but to be used
for timely actions.
Photo Gallery : 12 The impact of communicable diseases has grave implications for the social
and economic well being of the peoples in every nation. Therefore, the Disease
Food for Thought: Control Division has planned and implemented a wide range of programmes
and activities, nation-wide, to reduce the incidences of communicable diseases.
i) Heart - Anywhere & Anytime Strengthening the surveillance of communicable diseases is one of more
ii) Do We Know Our Roles important strategies to keep them at bay. New surveillance systems were
introduced to detect early communicable disease outbreaks, especially newly
emerging & reemerging ones, & to respond rapidly to them. This will also help
Announcement in monitoring them. The establishment of Communicable Disease Surveillance
Section under the Disease Control Division is another step to strengthen
FAO/WHO Consultation on AI & Human Health ; coordination of communicable disease surveillance in our country.
Risk Reduction Measure in Producing, Marketing
& Living with Animals in Asia I hope the publication of this monthly Bulletin of Infectious Diseases will further
4-6 July 2005
Renainsance Hotel, Kuala Lumpur strengthen dissemination of information and also sharing of information for
those in the health & health related agencies in the country.
Fifth Inter - Regional Training Course on
Public Health and Emergency Management
in Asia and the Pacific
4-15 July 2005 DR. HJ. RAMLEE BIN RAHMAT
Bangkok, Thailand Director,
Disease Control Division
Ministry of Health Malaysia

2. Artikel 1
LATAR BELAKANG Notifikasi penyakit berjangkit Sistem survelan mandatori notifikasi penyakit berjangkit
kemungkinan telah dilaksanakan pada zaman jajahan British memerlukan notifikasi mandatori di bawah Akta Pencegahan
dan dikuatkuasakan melalui beberapa ‘enactment’ atau dan Pengawalan Penyakit Berjangkit 1988. Di jadual 1 dan 2
‘ordinance’ seperti ‘Quarantine and Prevention of Disesase Akta tersebut, terdapat 26 penyakit berjangkit yang mesti
Enactment’ untuk negeri-negeri bersekutu, ‘Quarantine and dinotifikasikan. Senarai penyakit yang perlu dinotifikasi
Prevention of Disease Ordinance 1939 untuk negeri Sabah dan sentiasa disemak dari masa ke semasa. Di bawah sistem
Sarawak dan ‘Quarantine and Prevention of Disease Enactment, sekarang, laporan penyakit berjangkit dibuat secara manual
untuk negeri Kelantan, Johor, Terengganu, Kedah dan Perlis. dengan menggunakan borang notifikasi yang terdapat di
Kementerian Kesihatan telah mengkaji semula semua senarai bawah Akta. Walaubagaimana, laporan secara elektronik yang
penyakit-penyakit berjangkit yang telah di panggil Sistem Maklumat Kawalan
dinotifikasi dan menggazetkan senarai Penyakit Berjangkit (CDCIS) telah pun
baru pada tahun 1971 di mana terdapat Sistem Survelan diimplmentasikan sejak tahun 2001.
36 jenis penyakit berjangkit yang perlu
di
Malaysia
dinotifikasikan. Pada tahun 1988, Akta Sistem survelan berpandu makmal
Pencegahan dan Pengawalan Penyakit di mana pemantauan agen penyakit
Berjangkit 1988 telah dikuatkuasakan. Oleh berjangkit telah diperkenalkan
Bilangan penyakit berjangkit yang Cawangan Survelan Penyakit pada Ogos 2002. Sistem ini adalah
Berjangkit
Rajah 1 : Mekanisma SistemSurvelan di Malaysia
Survelan Berpandu Survelan Mandatori SurvelanBerpandu Klinikal Survelan Berpandu Survelan Boleh lain-lain
Makmal Notifikasi Penyakit (Sentinel/Sindromik Kebangsaan) Komuniti Agensi
Mikrobiologi Awam: Sentinel Klinik Pilihan Komuniti/ Media/ Jab. Perkhidmatan
Klinik Kesihatan Sindromik Kebangsaan Sumber Haiwan (Penyakit
Hospital (hospital) A&E/Wad/Klinik Antarabangsa Zoonotik
Swasta :
Klinik Swasta FOMEMA Sdn. Bhd.
Hospital
Notifikasi
Mikrooganisma
Notifikasi Pej. Kesihatan Daerah
Mikrooganisma
Pejabat Kesihatan
Negeri
Isolasi dan Notifikasi
Mikrooganisma
IMR/KKM Keputusan
Kebangsaan : Bahagian
Kawalan Penyakit, KKM
perlu dinotifikasikan telah dikurangkan kepada 26 di berkomplemen sistem survelan notifikasi mandatori penyakit
mana penyakit seperti antrax, meningococcal meningitis, berjangkit. Di bawah sistem ini, ia melibatkan laporan
chickenpox, filariasis, leptospiral infections, mumps, opthalmia mikroorganisma yang diisolasi oleh semua makmal awam
neonatorum, puerperal septic abortion, trachoma dan yaws atau swasta di Malaysia kepada pihak berkuasa kesihatan
telah dikeluarkan dari notifikasi penyakit berjangkit. yang relevan. Sekarang ini, terdapat 6 jenis bakteria iaitu V.
cholerae, H. influenzae B, Salmonella spp., S.typhi/paratyhpi, N.
SISTEM SURVELAN PENYAKIT BERJANGKIT meningitides dan Leptospira telah dipilih untuk dipantau oleh
Terdapat beberapa jenis sistem survelan untuk penyakit makmal-makmal mikrobiologi yang telah ditentukan di bawah
berjangkit di Malaysia dan aliran data survelan dan maklumat Kementerian Kesihatan Malaysia.
adalah seperti ditunjukkan pada rajah ‘1’ iaitu:-
• Sistem survelan mandatori notifikasi Sistem survelan berpandu klinikal dihadkan untuk penyakit
• Sistem survelan berpandu makmal berjangkit yang bukan spesifik samaada berasaskan
• Sistem survelan berpandu klinikal kebangsaan (lumpuh flaccid akut, konjuntivitis dan
• Survelan penyakit berjangkit oleh lain-lain agensi gastroenteritis akut) atau sentinel (penyakit tangan, kaki dan
• Sistem survelan berpandu komuniti mulut). Survelan berpandukan makmal juga digunakan untuk
Infectious Disease Bulletin 3

3. notifikasi kes penyakit berjangkit secara ‘syndromes’ (sindrom brucellosis, anthrax, toxoplasmosis dan leptospirosos. Jabatan
jaundice akut, sindrom neurologikal akut, sindrom pernafasan Perkhidmatan Haiwan perlu melaporkan kepada Cawangan
akut, sindrom dermatological akut dan sindrom demam berdarah Survelan Penyakit Berjangkit, KKM seperti dipersetujui oleh
akut) bukan secara penyakit spesifik dan mula diimplementasi di Jawatankuasa Kawalan Penyakit Zoonotik antara Kementerian.
seluruh negara pada tahun 2004.
Survelan berpandu komuniti termasuklah pemantauan rumur
Survelan penyakit berjangkit oleh agensi lain seperti Jabatan atau aduan penyakit berjangkit oleh masyarakat atau orang
Perkhidmatan Haiwan dan FOMEMA Sdn. Bhd. juga membuat awam dan yang disiarkan melalui media cetak dan elektronik.
survelan untuk penyakit berjangkit tertentu. Survelan untuk
penyakit berjangkit di kalangan pekerja asing dibuat oleh NOTIFIKASI PENYAKIT BERJANGKIT
FOMEMA dan dilaporkan kepada Bahagian Kawalan Penyakit, Berikut adalah penyakit-penyakit berjangkit yang terdapat di
KKM. Jabatan Perkhidmatan Haiwan Malaysia pula membuat Jadual 1, Seksyen 2 Akta Pencegahan dan Kawalan Penyakit
survelan untuk penyakit zoonotik. Sekiranya berlaku kejadian Berjangkit 1988 di mana pengamal perubatan perlu memberi
luar biasa penyakit zoonotik pada haiwan seperti rabies, notis kepada Pegawai Kesihatan yang berhampiran seperti
nipah, avian influenza, JE, vancomycin resistant enterococcus, yang ditetapkan di bawah Akta.
bovine tuberculosis, bovine spongiform encephalopathy,
PENCEGAHAN DAN PENGAWALAN PENYAKIT BERJANGKIT Photo Gallery From Page 12
JADUAL PERTAMA
(Seksyen 2)
PENYAKIT-PENYAKIT BERJANGKIT
OUTBREAK / CRISIS / DISASTER
BAHAGIAN 1
1. Batuk Kokol #
2. Campak #
3. Chancroid Incident command center
4. Demam Denggi dan Demam Denggi Berdarah *
5. Demam Kuning *
6. Difteria *
7. Disenteri (Semua jenis) #
HEART Hospitals
7A Ebola
8. Jangkitan Gonococcal (Semua jenis) #
9. Keracunan Makanan *
10. Kolera * National Laboratories
11. Kusta #
12. Malaria # State
12A Myocarditis
13. Plague *
14. Poliomielitis (Akut) * District Other Agencies
15. Rabies *
16. Relapsing Fever # Disease Control Division proposed to established an
17. Sifilis (Semua jenis) #
18. Tetanus (Semua jenis) # Emergency Preparedness and Response Center under the
19. Tifoid dan Salmonoloses lain. # CDC Malaysia plan for RM9.
20. Tifus dan Ricketsioses lain. #
21. Tuberkulosis (Semua jenis) #
22. Viral Ensefalitis #
23. Viral Hepatitis # Office of Emergency Preparedness & Response
24. Apa-apa jangkitan microbial lain yang mengancam nyawa #
BAHAGIAN II Incidence Command Center
Human Immunodeficiency Virus Infection (Semua jenis) # HEART
Catitan: (*) - Notifikasi melalui talipon dan diikuti notifikasi In House Training
bertulis (dalam masa 24 jam)
(#)- Notifikasi bertulis dalam masa 1 minggu Communications
selepas diagnosa
Intelligence & Documentation
Stockpiling & Logistic
EIP Malaysia, an in-house training program provides an experiential training environment
which incorporate epidemiological knowledge, laboratory & clinical component and
emergency response, aims to produce competent and skilled epidemiologist to strengthen
our public health workforce.
Dr Fadzilah Kamaludin (Director EIP Malaysia)
4 Infectious Disease Bulletin

4. 10
Surveilance Reports
MONTHLY INFECTIOUS DISEASE REPORT FOR MALAYSIA
Number of cases and death notified (mandatory by Act 342) to Ministry of Health, Malaysia
MAY 2005 (1 - 28 .5.2005)
Cummulative cases
(death)
until May
Infectious Disease Bulletin
2004
00-04
TOTAL
WEEK
Median
Perlis
Kedah
P.Pinang
Perak
Selangor
Sembilan
Negeri
Melaka
Johor
Pahang
Terengganu
Kelantan
Sabah
Sarawak
WP KL
WP Labuan
STATES
Same Period
2005 2004
DISEASES
Case
Death
Case
Death
Case
Death
Case
Death
Case
Death
Case
Death
Case
Death
Case
Death
Case
Death
Case
Death
Case
Death
Case
Death
Case
Death
Case
Death
Case
Death
Case
Death
Case
Death
Case
Death
Cholera 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12 0 0 0 12 0 1 77 39 0 77 0
Dysentry 1 0 8 0 1 0 3 0 0 0 0 0 0 0 0 0 2 0 4 0 9 0 2 0 6 0 36 0 17 133 174 0 133 0
Food Poisoning 0 0 43 0 7 0 1 0 4 0 56 0 0 0 55 0 96 0 2 0 20 0 13 1 10 0 307 1 622 2838 1717 2 2838 1
Hepatitis A 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 2 0 0 0 0 0 3 0 1 102 20 0 44 0
Typhoid & Paratyphoid 0 0 3 1 1 0 0 0 0 0 1 0 0 0 0 0 3 0 7 0 772 0 3 0 0 0 790 1 28 416 1796 2 160 0
Dengue Fever 16 0 81 0 127 0 125 0 80 0 71 0 77 0 36 0 56 0 22 0 64 0 56 0 36 0 847 0 1652 5801 6281 1 7800 3
Dengue Haemorrhagic Fever 2 0 2 0 8 0 3 0 5 0 4 0 7 0 2 0 1 0 0 0 8 0 4 0 1 0 47 0 65 407 497 7 410 6
Malaria 0 0 6 0 0 0 3 0 0 0 0 0 0 0 0 0 15 0 0 0 1 0 21 0 92 0 138 0 396 2140 699 2 2181 9
Relapsing Fever 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Viral Encephalitis 0 0 2 0 3 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 7 1 9 30 41 2 48 0
Yellow Fever 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Diptheria 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0 1 2 0 1 1
Measles 0 0 16 0 0 0 5 0 8 0 2 0 3 0 4 0 38 0 1 0 36 0 3 0 8 0 124 0 991 952 699 0 3545 0
Poliomyelitis, Acute 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Tetanus (Others) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 10 4 0 8 0
Tetanus Neonatorum 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 1 5 2 0 4 0
Whooping Cough 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 9 19 1 9 4
Chancroid 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gonococcal Infection 0 0 5 0 0 0 0 0 1 0 0 0 2 0 5 0 3 0 0 0 1 0 16 0 30 0 63 0 58 408 214 0 334 0
HIV Infection 3 0 13 1 6 0 7 1 0 0 4 1 18 0 23 1 82 6 3 1 83 1 10 2 1 0 253 14 283 1294 1106 58 1294 325
AIDS 1 0 5 4 3 0 2 2 1 0 4 2 0 0 1 1 7 3 0 0 1 0 1 0 0 0 26 12 0 0 125 43 0 0
Syphilis (All Forms) 0 0 2 0 5 0 1 0 3 0 0 0 0 0 5 0 4 0 0 0 0 0 3 0 16 0 39 0 63 476 272 1 341 0
Viral Hepatitis (All Forms) 0 0 4 0 2 0 6 0 5 1 0 0 1 0 32 0 45 2 4 1 20 0 34 0 8 0 161 4 143 1479 897 11 1143 0
Hepatitis B 0 0 2 0 1 0 2 0 4 1 0 0 1 0 10 0 16 0 2 0 3 0 27 0 7 0 75 1 92 1137 538 4 783 0
Hepatitis C 0 0 2 0 1 0 4 0 1 0 0 0 0 0 22 0 28 2 2 1 11 0 7 0 0 0 78 3 47 243 312 7 271 0
Hepatitis Other (Unclassified) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0 1 0 5 0 3 49 27 0 45 0
Leprosy 0 0 0 0 1 0 0 0 0 0 0 0 0 0 3 0 1 0 0 0 0 0 1 0 0 0 6 0 12 56 40 0 69 0
Tuberculosis( All Forms) 11 0 81 3 59 1 55 0 42 0 39 1 26 0 99 1 45 0 19 1 66 0 79 1 54 0 675 8 1003 5077 3492 50 5592 148
Ebola 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Plague 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Rabies 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Typhus & Other Rickettsioses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 13 7 0 12 0
HFMD/Myocarditis 5 0 149 0 95 0 61 0 51 0 36 0 51 0 105 0 114 0 5 0 12 0 12 0 175 0 871 0 23 2094 3054 1 109 0
Total Notification 39 0 420 9 318 2 272 3 200 1 217 4 185 0 370 3 513 11 67 3 1094 1 270 4 439 0 4404 41 5375
Note: Case (death)
Data sources: CDCIS 201
No data available for WP Labuan
Case notification for WP Kuala Lumpur starting from week 25

5. Surveillance Report
Introduction
Under the schedule 1 and 2 of the Prevention and Control
of Infectious Disease Act 1988 (PCID), there are 26 infectious
diseases which every medical practitioner who treats or
become aware of these infectious diseases occurring in
any premises shall, with the least practicable delay, gives
notice of the existence of the said infectious diseases to
the nearest Medical Officer of Health using form 1 of the
Act.
The notification data were collected and compiled on a
In Malaysia - 1990-2004 weekly basis by the District Health Office. A summary report
was sent to the State Health Department and Statistic Unit,
Disease Control Division, Ministry of Health Malaysia using
EPI-203 form.
The data contained in this report were based on information recorded on EPI-203 form as at 30 May 2005. Any changes
made to EPI-203 data after this date will not be reflected in this report. This report summarizes the data of weekly mandatory
infectious disease notifications collected & which were analysed over the period 1990 to 2004.
Results
The figure 1, below illustrates the total number of infectious diseases notified annually in Malaysia over the period of 1990
to 2004. The total number of notifications appeared to be decreasing from 1990 until 1992 and started to increase until
1996. From then on, 1997 to 2004, the total number of notifications of infectious diseases appeared to be fluctuating. The
factors which may contribute to the pattern seen may be more likely due to level of compliance in reporting and outbreak
occurrences in some years. Cholera outbreaks which occurred in 1995 and 1996 may have contributed to the increase in
the total number of notifications and in 1996 there was the added increase in dengue fever notifications when compared
the preceding years.
Graf 1: The number of infectious disease notified annually in Malaysia, 1990-2004
1E+05
90000
Total Notification
60000
30000
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Year
Infectious diseases for which there were no reports (zero notifications) 1990 to 2004 are as follow: yellow fever, plague and
ebola (Ebola made notifiable under the law in 1995). There was a single report of relapsing fever (1999) and three cases of
acute poliomyelitis in 1992. There were zero notifications for rabies cases except in years 1990 (1 case), 1992 (1 case), 1996
(5 cases), 1997 (7 cases), 1998 (1 cases) and 2001 (2 cases).
Malaria, tuberculosis, dengue fever, food poisoning and viral hepatitis were the top 5 infectious diseases being reported.
Tuberculosis, dengue fever and food poisoning were infectious diseases with increasing number of notifications whilst
malaria notifications have been declining.
Infectious Disease Bulletin 11

6. PERSPECTIVE
Global Public Health Surveillance
under New International Health
Regulations
Michael G. Baker* and David P. Fidler†
The new International Health Regulations adopted by IHR 1969 restricted surveillance to information provided
the World Health Assembly in May 2005 (IHR 2005) repre- only by governments, lacked mechanisms for swiftly
sents a major development in the use of international law assessing and investigating public health risks, contained
for public health purposes. One of the most important no strategies for developing surveillance capacities and
aspects of IHR 2005 is the establishment of a global sur-
infrastructure, and failed to generate compliance by WHO
veillance system for public health emergencies of interna-
tional concern. This article assesses the surveillance member states. WHO began revising IHR 1969 in 1995
system in IHR 2005 by applying well-established frame- (5), and IHR 2005’s adoption completed the modernization
works for evaluating public health surveillance. The of this important body of international law on public
assessment shows that IHR 2005 constitutes a major health.
advance in global surveillance from what has prevailed in IHR 2005 departs radically from IHR 1969 and repre-
the past. Effectively implementing the IHR 2005 surveil- sents a historic development in international law on public
lance objectives requires surmounting technical, resource, health (6). IHR 2005 expands the scope of the regulations’
governance, legal, and political obstacles. Although IHR application, strengthens WHO’s authority in surveillance
2005 contains some provisions that directly address these
and response, contains more demanding surveillance and
obstacles, active support by the World Health Organization
and its member states is required to strengthen national response obligations, and applies human rights principles
and global surveillance capabilities. to public health interventions. The most dramatic of these
changes involves a new surveillance system that far sur-
passes what the IHR 1969 contained. After reviewing key
n May 23, 2005, the World Health Assembly adopted
O the new International Health Regulations (IHR 2005)
(1) as an international treaty. This step concluded the
surveillance concepts and frameworks, this article
describes IHR 2005’s surveillance regime and assesses its
likely performance. It concludes by discussing obstacles
decade-long effort led by the World Health Organization that could prevent IHR 2005 from becoming an effective
(WHO) to revise the old regulations (IHR 1969) to make global public health surveillance system and addressing
them more effective against global disease threats. how these obstacles might be overcome.
Originally adopted in 1951 (2) and last substantially
changed in 1969 (3), IHR 1969 had lost its effectiveness Key Surveillance Concepts
and relevance by the mid-1990s, if not earlier (4). and Evaluation Framework
The resurgence of infectious diseases noted in the first Public health surveillance has been defined as “the
half of the 1990s showed IHR 1969’s limitations. For ongoing systematic collection, analysis, and interpretation
example, after smallpox was eradicated in the late 1970s, of outcome-specific data for use in the planning, imple-
IHR 1969 only applied to the traditionally “quarantinable” mentation, and evaluation of public health practice” (7). A
diseases of cholera, plague, and yellow fever. In addition, surveillance system requires structures and processes to
support these ongoing functions (7).
*Wellington School of Medicine and Health Sciences, Wellington, The Centers for Disease Control and Prevention (CDC)
New Zealand; and †Indiana University School of Law, developed guidelines that identify the essential elements
Bloomington, Indiana, USA and attributes for an effective public health surveillance
1058 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 12, No. 7, July 2006

7. Surveillance under International Health Regulations
system (8). According to these guidelines, evaluating sur-
veillance systems involves 2 main steps: 1) describing the
purpose, operation, and elements of the system and 2)
assessing its performance according to key attributes. This
article uses this 2-step approach to evaluate the global pub-
lic health surveillance system prescribed by IHR 2005.
Surveillance System Specified in IHR 2005
In the CDC framework, describing a surveillance sys-
tem includes 4 main elements: 1) health-related events
under surveillance and their public health importance, 2)
purpose and objectives of the system, 3) components and
processes of the system, and 4) resources needed to oper-
ate it (8).
Health-related Events under Surveillance
IHR 2005 identifies health-related events that each
country that agrees to be bound by the regulations (a “state
party”) must report to WHO. In terms of health-related
events that occur in its territory, a state party must notify
WHO of “all events which may constitute a public health
emergency of international concern” (article 6.1). These
events include any unexpected or unusual public health
event regardless of its origin or source (article 7). IHR
2005 also requires state parties, as far as is practicable, to
inform WHO of public health risks identified outside their
Figure 1. International Health Regulations (IHR) 2005 decision
territories that may cause international disease spread, as
instrument (simplified from annex 2 of IHR).
manifested by exported or imported human cases, vectors
that may carry infection or contamination, or contaminat-
ed goods (article 9.2).
IHR 2005 provides guidance to assist state parties’ Third, IHR 2005 includes a list of diseases for which a
compliance with these obligations in 4 ways. First, IHR single case may constitute a PHEIC and must be reported
2005 defines a “public health emergency of international to WHO immediately. This list consists of smallpox,
concern” (PHEIC) as “an extraordinary event which is poliomyelitis, human influenza caused by new subtypes,
determined [by the WHO Director-General]… (i) to con- and severe acute respiratory syndrome (SARS). A second
stitute a public health risk to other States through the inter- list of diseases exists (Figure 1) for which a single case
national spread of disease and (ii) to potentially require a requires the decision instrument to be used to assess the
coordinated international response” (article 1.1). Unlike event, but notification is determined by the assessment and
IHR 1969’s limited scope of application to just 3 commu- is not automatic. Finally, IHR 2005 also encourages state
nicable diseases (3), IHR 2005 defines disease as an illness parties to consult with WHO over events that do not meet
or medical condition that does or could threaten human the criteria for formal notification but may still be of pub-
health regardless of its source or origin (article 1.1). This lic health relevance (article 8).
scope therefore encompasses communicable and noncom- IHR 2005’s expansion of the range of public health
municable disease events, whether naturally occurring, events under surveillance and the use of risk assessment
accidentally caused, or intentionally created. criteria in deciding what is reportable is possibly the single
Second, IHR 2005 contains a “decision instrument” most important surveillance advance in IHR 2005. This
(annex 2) that helps state parties identify whether a health- change greatly enhances effective surveillance of emerg-
related event may constitute a PHEIC and therefore ing infectious diseases, which are “infections that have
requires formal notification to WHO (Figure 1). The deci- newly appeared in a population or have existed but are rap-
sion instrument focuses on risk assessment criteria of pub- idly increasing in incidence or geographic range” (9). IHR
lic health importance, including the seriousness of the 2005’s surveillance strategy, especially the decision instru-
public health impact and the likelihood of international ment, has been specifically designed to make IHR 2005
spread. directly applicable to emerging infectious disease events,
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 12, No. 7, July 2006 1059

8. PERSPECTIVE
which are usually unexpected and often threaten to spread
internationally.
In addition to events that may constitute a PHEIC, IHR
2005 also requires state parties to report the health meas-
ures (e.g., border screening, quarantine) that they imple-
ment in response to such events (article 6). State parties
are also specifically required to inform WHO within 48
hours of implementing additional health measures that
interfere with international trade and travel, unless the
WHO Director-General has recommended such measures
(article 43).
Purpose and Objectives of Surveillance
under IHR 2005
IHR 2005’s purpose is to prevent, protect against, con-
trol, and facilitate public health responses to the interna-
tional spread of disease (article 2), and IHR 2005 makes
surveillance central to guiding effective public health
action against cross-border disease threats. The regulations Figure 2. Public health surveillance structures and processes
specified in International Health Regulations (IHR) 2005.
define surveillance as “the systematic ongoing collection,
collation and analysis of data for public health purposes
and the timely dissemination of public health information
for assessment and public health response as necessary” national IHR focal points through WHO, IHR 2005 estab-
(article 1.1). Surveillance is central to IHR 2005’s public lishes a global network that improves the real-time flow of
health objectives, which explains why IHR 2005 requires surveillance information from the local to the global level
all state parties to develop, strengthen, and maintain core and also between state parties (article 4.4).
surveillance capacities (article 5.1). This obligation goes
beyond anything concerning surveillance in IHR 1969, Resources Needed to Operate IHR 2005’s
which did not address surveillance infrastructure and capa- Surveillance System
bilities beyond a general requirement for a state party to Building and maintaining the surveillance system envi-
notify WHO of any outbreak of a disease subject to the sioned in IHR 2005 will require substantial financial and
regulations. technical resources. State parties will be primarily respon-
sible for providing resources needed to develop their core
Components and Processes of IHR 2005 Surveillance surveillance capacities. Each state party has to assess its
IHR 2005 describes key aspects of the surveillance ability to meet the core surveillance requirements by June
process from the local to the global level. As part of IHR 2009. In addition, each state party has to develop and
2005’s core surveillance and response capacity require- implement a plan for ensuring compliance with core sur-
ments, each state party has to develop and maintain capa- veillance obligations (articles 5.1 and 5.2, annex 1).
bilities to detect, assess, and report disease events at the WHO is obliged to assist state parties in meeting their
local, intermediate, and national levels (article 5.1, annex surveillance system obligations (article 5.3), but this provi-
1). Officials at the national level must be able to report sion does not allocate any WHO funds for this purpose.
through the national IHR focal point to WHO when State parties are required to collaborate with each other in
required under IHR 2005 (articles 4.2 and 6). The regula- providing technical cooperation and logistical support for
tions also mandate that WHO establish IHR contact points surveillance capabilities and in mobilizing financial
that are always accessible to state parties (article 4.3). resources to facilitate implementation of IHR 2005 (article
Connecting these levels produces the surveillance archi- 44.1).
tecture illustrated in Figure 2.
Requiring that a national IHR focal point be established Evaluating the IHR 2005 Surveillance System’s
is another surveillance initiative in IHR 2005. The focal Attributes and Potential Performance
point is designed to facilitate rapid sharing of surveillance Key attributes of effective surveillance systems identi-
information because it is responsible for communicating fied by CDC are usefulness, sensitivity, timeliness, stabil-
with the WHO IHR contact points and disseminating infor- ity, simplicity, flexibility, acceptability, data quality,
mation within the state party (article 4.2). By linking positive predictive value, and representativeness. Of these
1060 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 12, No. 7, July 2006

9. Surveillance under International Health Regulations
attributes, usefulness, sensitivity, timeliness, and stability and document its contribution to prevention and control of
will be most critical to the success of the IHR 2005 sur- adverse health events. IHR includes mechanisms to review
veillance system. Simplicity, acceptability, and flexibility and, if necessary, amend its provisions and in particular
will affect the establishment and sustainability of the sur- requires periodic evaluation of the functioning of the deci-
veillance system. Data quality, positive predictive value, sion instrument (article 54).
and representativeness are central to accurately character-
izing health-related events under surveillance. Table 1 Sensitivity of the Surveillance System
summarizes these attributes, provides commentary on The IHR 2005 surveillance provisions imply 100% sen-
their relevance to effective surveillance under IHR 2005, sitivity as a standard, namely the reporting of all events
and assesses the likely performance of the IHR 2005 sur- that meet notification requirements. The use of risk assess-
veillance system for each attribute. The following para- ment criteria (Figure 1) also allows for higher sensitivity
graphs concentrate on assessing IHR 2005 with respect to for PHEIC than would be possible with a list of predeter-
the key attributes of usefulness, sensitivity, timeliness, mined disease threats (as in IHR 1969). To test the poten-
and stability. tial sensitivity of the decision instrument proposed in
drafts of the revised IHR in 2004, investigators in the
Usefulness of the Surveillance System United Kingdom applied the then-proposed decision
The central premise of IHR 2005 is that rapidly detect- instrument to all events (N = 30) that were important
ing PHEIC will support improved disease prevention and enough to have been published in the national surveillance
control both within and between state parties. Ample evi- bulletin for England and Wales during 2003 (11).
dence shows that delayed recognition and response to According to this method, 12 of the 30 events would have
emerging diseases may result in adverse consequences in been reportable under the decision instrument. These
terms of illness and death, spread to other countries, and events included all those that were considered potential
disruption of trade and travel (10). The usefulness of sur- PHEIC. Investigators concluded that the decision instru-
veillance under IHR 2005 represents the sum of all the crit- ment was highly sensitive for selecting outbreaks and inci-
ical system attributes and can only be assessed after the dents that require reporting under the proposed IHR
system is in operation, so this attribute is not discussed revision.
here. However, for the future sustainability and develop- The sensitivity of the IHR 2005 surveillance system
ment of IHR 2005, we must evaluate its overall usefulness will probably be affected by 2 factors. First, in all likeli-
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 12, No. 7, July 2006 1061

10. PERSPECTIVE
hood, inadequate capacities at the local and intermediate IHR 2005 includes the core surveillance capacity that
levels within state parties will limit the system’s sensitivi- local and intermediate public health entities must be able
ty more than capacities at the national level. Second, state to carry out their reporting responsibilities immediately
parties may not always be willing to comply with their (annex 1).
reporting obligations in the face of possible adverse polit- WHO’s ability to draw on a wide array of sources of
ical and economic consequences that may result from information, including the Internet and nongovernmental
alerting the world to a disease event in their territories. organizations and actors, may enhance the timeliness of
Fear of such adverse consequences undermined reporting the IHR 2005 surveillance system (13,17). In countries that
obligations in IHR 1969. have less well-developed local, intermediate, and national
IHR 2005 incorporates strategies to address these surveillance systems, nongovernmental sources of infor-
potential limitations. First, as noted above, IHR 2005 mation can often provide information faster than govern-
requires state parties to build and maintain core local, ments. Accessing this type of information early and often
intermediate, and national surveillance capabilities (article helps WHO contact countries sooner, which increases the
5.1, annex 1). Fulfillment of this obligation will improve chances of more effective interventions.
surveillance capacity vertically, from local to national lev-
els, which should support higher sensitivity. Stability of the Surveillance System
Second, IHR 2005 permits WHO to improve sensitivi- The obligations each state party has to build and main-
ty by collecting and using information from multiple tain core capacities in surveillance at the local, intermedi-
sources. IHR 1969 only allowed WHO to use information ary, and national levels, combined with the responsibilities
provided by state parties (3), and failure of state parties to for surveillance WHO has globally, should construct a
abide by their reporting obligations adversely affected global surveillance system that will be stable and reliable
WHO surveillance activities (5). Under IHR 2005, WHO over time. Recognizing that core capacities at the national
can collect, analyze, and use information gathered from level and below will not develop overnight, IHR 2005
governments, other intergovernmental organizations, and gives state parties until June 2012 to develop these capac-
nongovernmental organizations and actors (article 9.1). By ities (article 5.1). State parties can obtain a 2-year exten-
permitting WHO to cast its surveillance network beyond sion on this deadline by submitting a justified need and an
information it receives from governments, IHR 2005 cre- implementation plan and can request an additional 2-year
ates opportunities for WHO to improve the sensitivity of extension, which the WHO Director-General has the dis-
the surveillance system and avoid being blocked by gov- cretion to approve or deny (article 5.2).
ernmental failure to comply with reporting requirements. The 5-year grace period, and the possibility of 2-year
extensions, was a necessary compromise and reflects the
Timeliness of the Surveillance System difficulties many developing states will have in improving
Public health practitioners understand how timely noti- their surveillance systems. The stability and reliability of
fication of public health risks is necessary for effective the IHR 2005 surveillance system are designed to increase
intervention strategies (12,13), lessons reiterated in the steadily as the grace period and any extensions come to an
SARS pandemic (14). Timely surveillance is also stressed end.
in connection with strategies to deal with pandemic influen-
za (15,16). Timeliness may be the most important attribute Potential Obstacles to Achieving IHR 2005
that IHR 2005 will have to demonstrate to be effective. Surveillance System Objectives
IHR 2005 contains several provisions that relate to time- Continued lamentations about the weaknesses of public
liness. National-level assessments with the decision instru- health surveillance nationally and globally (18) illustrate
ment must be completed within 48 hours (annex 1, part A, that achieving useful, sensitive, timely, and stable surveil-
6[a]). State parties must then notify WHO within 24 hours lance through IHR 2005 will be a challenge for states and
of assessing any event that may constitute a PHEIC or that the international community. Several potential obstacles,
is unexpected or unusual (articles 6.1 and 7). The same 24- including technical, resource, governance, legal, and polit-
hour requirement applies to reporting public health risk out- ical concerns, will complicate and frustrate efforts to
side a state party’s territory that may constitute a PHEIC improve national and global surveillance capabilities.
(article 9). State parties must also respond within 24 hours Table 2 summarizes these potential barriers and possible
to all requests that WHO makes for verification of health- responses.
related events in their territories (article 10.2).
Timeliness of reporting is likely to be affected more by Technical Issues
actions taken at local and intermediate levels than national- Emerging infectious diseases often create technical
level provision of information to WHO. In this regard, challenges for surveillance, even for the most technologi-
1062 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 12, No. 7, July 2006

11. Surveillance under International Health Regulations
cally advanced and well-resourced countries. The sensitiv- with the United Nations and the World Bank, could consid-
ity of surveillance systems for new pathogens has histori- er developing a global strategy to support the development
cally been limited, particularly if such pathogens presented and maintenance of core surveillance capacities.
themselves in unusual or unexpected ways. Recent model-
ing has shown that the ability to control the spread of a Governance Issues
new pathogen is influenced by the proportion of transmis- Governance obstacles include managerial and adminis-
sion that occurs before the onset of overt symptoms or trative weaknesses in countries from the local to the
through asymptomatic infection (19). This property national level. Few countries have conducted a systematic
explains why diseases such as influenza and HIV may be review of their surveillance systems, and thus most lack
more difficult to control than smallpox or SARS. detailed knowledge of gaps and limitations in their surveil-
Consequently, surveillance needs to be sufficiently sen- lance infrastructures and how to address these problems
sitive to detect infectious agents that have not yet resulted (26). Only a few states have assessed their ability to detect
in large numbers of diagnosed cases. One approach to this and respond to emerging disease threats, such as those
challenge is syndromic surveillance (20), but such surveil- posed by bioterrorism agents (27). The IHR 2005 require-
lance has not been effective in detecting emerging infec- ment that each state party assess the condition of its public
tious diseases early (21). In fact, WHO abandoned health surveillance within 2 years of the regulations’ entry
syndromic surveillance as a strategy for the revised IHR into force should help countries improve their national
after pilot studies demonstrated that it was not effective governance for surveillance purposes. Again, many states
(22). Improved diagnostic technologies may also help pub- will need external assistance with such work.
lic health authorities identify new pathogenic threats (23).
Strategies for enhancing reporting processes have been Legal Issues
well described (24). State parties may face legal complications in imple-
menting IHR 2005 within their national legal and constitu-
Resource Issues tional systems. For example, the United States has
The demands of IHR 2005 surveillance obligations will indicated that requirements of US federalism may affect its
confront many countries, particularly developing coun- compliance with IHR 2005 (28). The US position suggests
tries, with resource challenges. IHR 2005 does not include that other countries may also wish to formulate reserva-
financing mechanisms, which leaves each state party to tions to IHR 2005 to account for the demands of their
bear the financial costs of improving its own local, inter- national constitutional structures and systems of law (29).
mediate, and national level surveillance capabilities. The Whether such reservations will undermine the IHR 2005
obligation on state parties and WHO to collaborate in surveillance system cannot be assessed, but this concern
mobilizing financial resources (article 44) is a weak obli- has to be monitored closely as countries determine whether
gation at best. The lack of economic resources will, if not reservations are required under their national constitution-
more vigorously addressed as recommended by the UN al systems. IHR 2005 also specifies that domestic legisla-
Secretary-General (25), retard progress on all aspects of tion and administrative arrangements be adjusted fully
the upgraded surveillance system. WHO, in conjunction with IHR 2005 by June 2007, or by June 2008 after a
Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 12, No. 7, July 2006 1063

12. PERSPECTIVE
suitable declaration to the WHO Director-General (article Dr Baker is a public health physician and senior lecturer at
59.3). Helping state parties update their public health law the Wellington School of Medicine and Health Sciences. He has
may be technical assistance that industrialized countries worked as a short-term consultant to WHO during development
can provide. and implementation of IHR 2005. His research interests include
emerging infectious diseases, surveillance and outbreak investi-
Political Issues gation, and the role of housing conditions as health determinants.
Questions remain about the level of political commit-
Mr Fidler is an international lawyer and professor of law at
ment countries will demonstrate in implementing IHR
the Indiana University School of Law, Bloomington, Indiana. In
2005. IHR 1969 suffered because state parties frequently
conjunction with the Center for Law and the Public’s Health of
failed to report notifiable diseases and routinely applied
Georgetown and Johns Hopkins Universities, he provided analy-
excessive trade and travel restrictions (4). The relevance of
sis to WHO of potential conflicts between IHR 2005 and other
such trade and travel concerns was most recently illustrat-
international legal regimes. His research interests include global
ed during the SARS pandemic through China’s initial fears
health governance, biosecurity, and the role of international law
that disclosing the pandemic would harm its economy and
in global public health.
foreign trade (30,31). WHO’s access to nongovernmental
sources of surveillance information reduces the incentives
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Search
past issues
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