The International Health Regulations (IHR), first adopted by the World Health Assembly in 1969 and last revised in 2024, are legally binding rules that only apply to the WHO that is an instrument that aims for international collaboration "to prevent, protect against, control, and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks and that avoid unnecessary interference with international traffic and trade". The IHR is the only international legal treaty with the responsibility of empowering the World Health Organization (WHO) to act as the main global surveillance system.
In 2005, following the 2002–2004 SARS outbreak, several changes were made to the previous revised IHRs originating from 1969. The 2005 IHR came into force in June 2007, with 196 binding countries that recognised that certain public health incidents, extending beyond disease, ought to be designated as a Public Health Emergency of International Concern (PHEIC), as they pose a significant global threat. Its first full application was in response to the swine flu pandemic of 2009.
In 2024, the regulations were amended further due to COVID-19 pandemic.
History
Origins The original International Health Regulations (IHR) were adopted in 1969. However, its underpinnings can be traced to the mid-19th century, when measures to tackle the spread of plague, yellow fever, smallpox and particularly cholera across borders, with as little interference to global trade and commerce, were debated.Howard-Jone, Norman (1975) "The scientific background of the International Sanitary Conferences". World Health Organization; Geneva, p. 13. To address the realisation that countries varied with regards to their sanitary regulations and quarantine measures, the first of these series of early international sanitary conferences was convened in Paris in 1851. This was in the same year that telegraphic communications became established between London and Paris. 12 nations attended this conference, of which 11 were European states and three would sign the resulting convention. In the 19th century. there were 10 of these conferences.
1948: the World Health Organization Constitution was founded.
1951: the WHO issued its first infectious disease prevention regulations, the International Sanitary Regulations (ISR 1951), which focussed on six quarantinable diseases; cholera, plague, relapsing fever, smallpox, typhoid and yellow fever.
1969: the ISR were revised and renamed the 'International Health Regulations'.
Early history 1973: the Twenty-Sixth World Health Assembly amended the IHR (1969) in relation to provisions on cholera.World Health Assembly (1981). "WHA34.13 Amendment of the International Health Regulations (1969)". Thirty-fourth World Health Assembly, Geneva, 4–22 May 1981: part I: resolutions and decisions: annexes. World Health Organization. p. 10
1981: in view of the global eradication of smallpox, the Thirty-fourth World Health Assembly amended the IHR (1969) to exclude smallpox in the list of notifiable diseases subject to the IHR (1969).
1995: during the Forty-Eighth World Health Assembly, the WHO and Member States agreed on the need to revise the IHR (1969). Several challenges were placed against the backdrop of the increased travel and trade characteristic of the 20th century. The revision of IHR (1969) came about because of its inherent limitations, most notably: narrow scope of notifiable diseases (cholera, plague, yellow fever). The past few decades had seen the emergence and re-emergence of infectious diseases. The emergence of "new" infectious agents Ebola Hemorrhagic Fever in Zaire (modern-day Democratic Republic of Congo) and the re-emergence of cholera and plague in South America and India, respectively; dependence on official country notification; and lack of a formal internationally coordinated mechanism to prevent the international spread of disease.
21st century developments In 2005, a values statement document entitled "The Principles Embodying the IHR" was published and said inter alia:Art. 3, IHR (2005) With full respect for the dignity, human rights and fundamental freedom of persons; Guided by the Charter of the United Nations and the Constitution of the World Health Organization; Guided by the goal of their universal application for the protection of all people of the world from the international spread of disease; States have, in accordance with the Charter of the United Nations and the principles of international law, the sovereign right to legislate and to implement legislation in pursuance of their health policies. In doing so, they should uphold the purpose of these Regulations.
On 15 June 2007, the IHR (2005) entered into force, and were binding as of June 2020 on 196 States Parties, including all 194 Member States (countries) of WHO.
In 2010, at the Meeting of the States Parties to the Convention on the Prohibition of the Development, Production and Stockpiling of Bacteriological (Biological) and Toxin Weapons and Their Destruction in Geneva, the sanitary epidemiological reconnaissance was suggested as a well-tested means for enhancing the monitoring of infections and parasitic agents. The aim of this recommendation was to prevent and minimize the consequences of natural outbreaks of dangerous infectious diseases, as well as the threat of alleged use of biological weapons against BTWC States Parties. The conference also noted the significance of the sanitary epidemiological reconnaissance in assessing the sanitary-epidemiological situation, organizing and conducting preventive activities, indicating and identifying pathogenic biological agents in the environmental sites, conducting laboratory analysis of biological materials, suppressing hotbeds of infectious diseases, and providing advisory and practical assistance to local health authorities.
In January 2018, a group of WHO bureaucrats published an article in BMJ Global Health entitled "Strengthening global health security by embedding the International Health Regulations requirements into national health systems", in which the authors argued that "the 2014 Ebola and 2016 Zika outbreaks, and the findings of a number of high-level assessments of the global response to these crises, [clarified] that there is a need for more joined-up thinking between health system strengthening activities and health security efforts for prevention, alert and response."
In 2022 the World Health Organisation in a decision WHA75 proposed amendments which amongst other things change the principles in Article 3 removing: "full respect for the dignity, human rights and fundamental freedoms of persons"
In 2024, WHO members adopted further amendments at the 77th World Health Assembly in Geneva amid deficiencies in response to COVID-19 pandemic. The amendments introduced a new level of global alert – a "pandemic emergency" – for stronger international cooperation beyond a public health emergency of international concern (PHEIC). The amendments also established the National IHR Authorities run by governments to coordinate IHR implementation. They include provisions for better access to medical products and financing. The amendments entered into force in September 2025.
Public Health Emergency of International Concern (PHEIC)
A Public Health Emergency of International Concern, or PHEIC, is defined in the IHR (2005) as, "an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response". This definition implies a situation that is: serious, sudden, unusual or unexpected; carries implications for public health beyond the affected State's national border; and may require immediate international action.
Since 2007, the WHO Director-General has declared public health emergencies of international concern in response to the following: 2009 H1N1 swine flu pandemic 2014 setbacks in global polio eradication efforts 2013–2016 Western African Ebola virus epidemic 2016 Zika virus outbreak 2018–19 Kivu Ebola epidemic 2019–23 COVID-19 pandemic 2022 Clade II mpox outbreak 2024 Clade I mpox outbreak 2026 Ituri Ebola outbreak
IHR Experts Roster The IHR Experts Roster, which is regulated by Article 47 of the IHR, is tended by DGWHO, who "shall establish a roster composed of experts in all relevant fields of expertise... In addition, [s/he] shall appoint one member at the request of each State Party."
Pro-tem structure IHR Emergency Committee
In order to declare a PHEIC, the WHO director-general is required to take into account factors which include the risk to human health and international spread as well as advice from an internationally made up committee of experts, the IHR Emergency Committee (EC), one of which should be an expert nominated by the State within whose region the event arises. Rather than being a standing committee, the EC is created ad hoc.
Until 2011, the names of IHR EC members were not publicly disclosed; in the wake of reforms now they are. These members are selected according to the disease in question and the nature of the event. Names are taken from the IHR Experts Roster. The director-general takes the EC's advice following their technical assessment of the crisis using legal criteria and a predetermined algorithm after a review of all available data on the event. Upon declaration of the PHEIC, the EC then makes recommendations on what actions the director-general and member states should take to address the crisis. The recommendations are temporary and require three-monthly reviews.
IHR Review Committee The formation of an IHR Review Committee is the responsibility of the DGWHO. They are selected from the IHR Experts Committee, and "when appropriate, other expert advisory panels of the Organization." Furthermore, the DGWHO "shall establish the number of members to be invited to a meeting, determine its date and duration, and convene the Committee."
"The DGWHO shall select the members of the Review Committee on the basis of the principles of equitable geographical representation, gender balance, a balance of experts from developed and developing countries, representation of a diversity of scientific opinion, approaches and practical experience in various parts of the world, and an appropriate interdisciplinary balance."
Criticism of international health regulations
Revisions to the International Health Regulations in 2005 were meant to lead to improved global health security and cooperation. However, the WHO's perceived delayed and inadequate response to the West African Ebola epidemic brought renewed international scrutiny to the International Health Regulations. By 2015, 127 of the 196 countries were unable to meet the eight core public health capacities and report public health events as outlined.Solomon, Danielle. (9 January 2019). "Brexit and health security: why we need to protect our global networks". Journal of Public Health Policy. National Library of Medicine (US) website 40(1): 1–4. doi: 10.1057/s41271-018-00160-3. Retrieved 6 April 2020. Numerous published reports by high-level panels have assessed the International Health Regulations for inadequacies and proposed actions that can be taken to improve future responses to outbreaks.L. Gostin et al. "The International Health Regulations 10 years on: the governing framework for global health security," Lancet, vol. 386, pp. 2222–2226, 2015.