For reference purposes and to facilitate implementation, this section at times summarizes or paraphrases the official text of the IHR. The official text of the IHR, including the authentic texts in the six official languages of WHO (Arabic, Chinese, English, French, Russian and Spanish) may be found at www.who.int/ihr.
Basic provisions of the IHR
Purpose and scope
The International Health Regulations 2005 (IHR) were adopted by the World Health Assembly in May 20051 and entered into force in June 2007. They are legally binding upon 194 IHR States Parties, including all WHO Member States. The IHR establish fundamental global legal requirements for all countries on international coordination in the detection and investigation of, and response to, public health risks (and related subjects), including some arising in the context of transmission of TB on aircraft.
The purpose and scope of the IHR (Article 2) are to prevent, control and respond to risks of international disease spread “in ways that are commensurate with … public health risks, and which avoid unnecessary interference with international traffic and trade”. The disease-related scope of the IHR is extremely broad (essentially an “all risks” approach), covering not only communicable diseases but also risks arising from chemical or radionuclear sources as well as other biological public health risks.
Key rights, obligations and other provisions
To address public health risks, the IHR include several basic rights and obligations for States Parties, many of which may apply in the context of TB, including:
- Reporting/notification/verification by States Parties to WHO. Notification to WHO is required for all cases of: (i) certain specified diseases; and (ii) all events involving at least two of the following four criteria, regardless of the particular disease or risk: seriousness of public health impact; unusual or unexpected nature; risk of international spread; and risk of interference with international trade. Notification of TB-related events would fall under the second category. Other provisions require additional reporting to WHO or verification of public health events upon request to WHO.
- Public health capacity. Obligations of States Parties to develop national core public health capacities for detection, assessment, control and reporting of public health events, and at some international ports, airports and ground crossings.
- Travellers. Obligations to provide proper treatment of international travellers by States Parties, including some human rights and other protections, such as protection of personal health data, prior informed consent for examinations and procedures, and other provisions.
- Measures. Authorizations and limits on health/sanitary measures that may be applied by States Parties to international travellers, conveyances (e.g. aircraft, ships), cargo and goods.
- Certificate/document requirements on sanitary requirements for international air and sea traffic.
The IHR also provide for determination by the WHO Director-General, in extraordinary public health situations, of public health emergencies of international concern (PHEIC) under the IHR, according to specified criteria and procedures. While such predictions of the future are necessarily speculative, even within the broadened scope of the revised IHR, such PHEICs are currently expected to be relatively rare. The likelihood that an event involving TB in international air travel may at some point be determined to be a PHEIC by the Director-General is difficult to predict; the possibility cannot be excluded.
In some situations, cases of TB relating to international travel may be notifiable to WHO, depending on factors such as infectiousness, duration and proximity of contact with others, and involvement of MDR or XDR-TB, in accordance with Annex 2 of the IHR. In addition, cases relating to international travel may be otherwise reportable to WHO or verifiable under other IHR provisions.
Applicability of the IHR – No PHEIC required
The IHR do not require an event to have occurred which has been determined to constitute a PHEIC (or which is a potential PHEIC or notifiable) for many provisions in the Regulations to be applicable. Events that will be assessed under the IHR and determined to be PHEICs are expected to be relatively rare, but certain provisions of the IHR will still apply. For example, international travellers (with certain stipulated exceptions) are entitled to most of the relevant protections for them in the IHR when measures (e.g. medical examinations, quarantine, isolation, etc.) are applied for public health purposes – whether a serious public health risk has been identified or not.
The States Parties’ obligations to develop and/or maintain key public health capacities for surveillance or response apply, regardless of whether a specific event is occurring. Similarly, the option for States Parties to request information from airline pilots or companies (see below) is also generally available as indicated under the IHR (although some may require particular public health justification). Additional procedures will be involved in the context of a PHEIC, such as the issuance by the Director-General of WHO of official IHR “temporary recommendations”.
Provisions relevant to transmission of tuberculosis on aircraft
TB cases or events involving air travel may come within a number of different subjects addressed by the IHR, including: (1) State obligations to notify, report to WHO or verify TB cases or events; (2) State and WHO activities involving assessment of and response to TB cases or events; (3) provisions specifying health measures that States may (or may not) apply relating to international travellers (e.g. examinations, contact investigation, isolation/quarantine, protection of personal health information) and aircraft/airlines (e.g. provision of contact and other public health information).
Informational requirements from travellers, and aircraft pilots and operators
States Parties may require, for public health purposes:
- on arrival or on departure that travellers provide information on their itinerary for potential contacts with infection/contamination, and their destination so that they may be contacted (Article 23.1.a.i–ii); and
- that conveyance operators facilitate the provision of available relevant public health information to national authorities. Depending on the circumstances, such information may potentially include passenger manifests and seating plans, which may be needed for contact-tracing and follow-up after an infectious person has travelled by air (Annex 4.A.1.d).
Pilots in command of aircraft or their agents are obliged to report to airport control any cases of illness indicative of infectious disease or a public health risk on board as early as possible (if known) before arrival at the airport of destination. This information must be relayed immediately to the authorities competent for the airport (Article 28.4).
Pilots or their agents must supply any information required by the State Party concerning health conditions on board during an international voyage and any health measures applied to the aircraft (Article 38.2). They must also complete and deliver the Health part of the Aircraft General Declaration to the authority competent for the airport (unless not required by the State Party) which requires the name and seat number (or function) of persons on board who may be suffering from a communicable disease1 (Article 38.1; Annex 9).
Notification/reporting/verification of disease
As noted, States Parties may have an obligation to notify or otherwise report to WHO or verify cases or events involving TB and air travel depending on the context. These obligations apply whether or not the event constitutes a PHEIC, as a key purpose of the provisions is early detection and international assessment of all events that may potentially develop to the level of a PHEIC (articles 6; 9.2; 10.1–2).
Treatment of personal data
States Parties are obliged to collect and handle health information containing personal identifiers in a confidential manner. However, States Parties may disclose and process personal data when it is essential for the purposes of assessing and managing a public health risk, subject to particular requirements (Article 45.1–2).
Health measures applied to travellers
Subject to the other provisions in the IHR and any relevant international treaties to which the State may also be a party, States Parties may require, for public health purposes, travellers on arrival or on departure to undergo a non-invasive medical examination, as defined in the IHR (Article 23.1.a.iii). This may include a sputum test (collected externally). Specific requirements must be fulfilled to justify any invasive examination. See below concerning prior informed consent.
Suspect or affected travellers
A State Party may apply “additional” health measures on the basis of evidence of a public health risk, in particular with regard to suspect or affected travellers, including the least invasive and intrusive examination that would achieve the particular public health objective. Any such additional measures (which would include quarantine or isolation) must be based on scientific principles, the available scientific evidence of a risk to human health, and any specific guidance or advice from WHO (articles 23.2; 43.2). In the context of the IHR, an “affected” traveller is a traveller who is infected or contaminated or who carries sources of infection or contamination, so as to constitute a public health risk. A “suspect” traveller is a traveller considered to have been exposed, or possibly exposed, to a public health risk and who could be a possible source of spread of disease (Article 1).
Travellers seeking temporary or permanent residence
Subject to certain requirements, the Regulations do not preclude States Parties from requiring medical examination, vaccination or other prophylaxis, or proof of vaccination or other prophylaxis, as a condition of entry for travellers seeking temporary or permanent residence (Article 31.1.b).
Subject to certain exceptions and requirements, no medical examination, vaccination, prophylaxis or other health measures may be carried out without the traveller’s prior express informed consent (Article 23.3–4). However, if the traveller fails to consent to medical examination, vaccination or other prophylaxis which is permitted under the IHR, or refuses to provide the specific information or documents authorized under the IHR (noted below), the State Party may deny entry to the traveller provided certain additional requirements are fulfilled (e.g. transparency, nondiscrimination, appropriate treatment of travellers). If there is evidence of an imminent public health risk, a State Party may, in accordance with its law and other requirements in the IHR, and to the extent necessary to control the risk, advise or compel the traveller to undergo the least intrusive and invasive medical examination that would achieve the public health objective, or vaccination or other prophylaxis, or additional established health measures that prevent or control the spread of disease, including isolation, quarantine or public health observation (Article 31.2).
Treatment of travellers
States Parties shall treat travellers with courtesy, and with respect for their dignity, human rights and fundamental freedoms, and minimize any discomfort or distress associated with health measures implemented under the IHR. This includes taking into consideration gender, sociocultural, ethnic or religious concerns. In addition, for travellers who are quarantined, isolated or subject to medical examination or other procedures for public health purposes, the State must provide adequate food, water, accommodation, clothing, medical treatment and other requirements (Article 32).
Charges for health measures regarding travellers
With some limited exceptions, the IHR either restrict or prohibit charging travellers for most health measures applied to them on public health grounds, including a ban on charges for medical examinations, isolation and quarantine expenses, certificates specifying measures applied or measures applied to baggage; vaccinations and prophylaxis on arrival may be charged for under certain circumstances. However, States Parties may charge for other health measures including those that are primarily for the benefit of the traveller according to certain rules established in the IHR. Charges that are permitted may not exceed the actual cost of providing them and may not discriminate based on nationality, domicile or residence of the traveller (Article 40).
Timeliness, transparency and nondiscrimination
Whether health or sanitary measures under the IHR are applied to persons, conveyances or goods, they must be “initiated and completed without delay, and applied in a transparent and nondiscriminatory manner” (Article 42).
WHO recommendations under the IHR
In addition to providing relevant public health advice in the course of its activities generally, the Director-General will make a formal temporary recommendation under the IHR if the Director-General determines that a PHEIC is occurring, or in other circumstances potentially a standing recommendation for ongoing public health risks for routine or periodic application, including at international points of entry, for the application of appropriate health measures by States Parties, including measures applicable to international transport and risks of disease transmission in air travel. These IHR recommendations may include, for example, implementation of tracing of contacts of suspects or affected persons, isolation and treatment where necessary of affected persons; quarantine or other measures for suspects; placing suspects under public health observation. Prior to issuance of both temporary and standing recommendations, specific procedures must be followed (articles 15–18).
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World Health Organization, Geneva
Tuberculosis and Air Travel: Guidelines for Prevention and Control. 3rd edition. Geneva: World Health Organization; 2008. Annex 1, International Health Regulations (2005): Selected provisions.