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International support during disease outbreaks

By Frank Mahoney and James W. Le Duc

Image credit: "Ebola Isolation Infection Virus" by bhossfeld. CC0 Public Domain via

Since 2009 there have been four declarations of public health emergencies of international concern. 

A public health emergency of international concern is defined as an extraordinary event that might constitute a public health risk to other countries through international spread of disease and require an internationally coordinated response. The International Health Regulations (IHR) agreement forms the basis for international collaboration and coordination on detection and response to outbreaks. As an international agreement, IHR is binding for all 196 World Health Organization (WHO) Member States. IHR focuses on preventing, protecting against, controlling, and responding to the international spread of disease without unnecessary interruptions to traffic and economic trade.

The responsibility for detecting, investigating, and responding to outbreaks resides within the nation’s health authority where the outbreak is occurring. At times, a nation’s capacity for responding might be overwhelmed, necessitating outside technical assistance. Health authorities might be hesitant to request assistance because of economic and political concerns, including the impact outbreaks can have on different sectors.

The roles and responsibilities of different partners for international support during outbreak responses are outlined below.

Ministries of Health: During the recent Ebola virus disease outbreaks, Nigeria, Liberia, Sierra Leone, and Guinea established emergency operations centers (EOCs) and an incident management system (IMS) to coordinate outbreak response and international support. Within the IMS, EOC managers established technical working groups, co- chaired by technical partners, for managing different aspects of the response. During complex outbreaks, most countries coordinate requests for assistance through WHO or might directly request assistance from partners or Member States.

WHO: In the aftermath of the Ebola epidemic, WHO experienced criticism about weak initial response and underwent a reform process for responding to outbreaks of international concern . This reform culminated in a World Health Assembly resolution in 2016 to adopt the Health Emergencies Programme “to deliver rapid, predictable, and comprehensive support to countries and communities as they prepare for, face or recover from emergencies caused by any type of hazard…”.

GOARN: In April 2000, WHO established a formal network of partners to respond to infectious disease outbreaks, natural disasters, and other humanitarian emergencies. GOARN is a collaboration of institutions and networks, constantly alert and ready to respond rapidly to outbreaks. Key partners include academic and scientific institutions, medical and surveillance initiatives, laboratory networks, United Nations (UN) organizations, the Red Cross, and humanitarian nongovernmental organizations (e.g. Médecins sans Frontières, Medical Emergency Relief International, and Epicentre). 

UN Cluster System: Outbreaks of international concern often occur in countries experiencing a humanitarian emergency. In 2005, the UN General Assembly adopted a cluster system to improve capacity for responding to humanitarian emergencies. The system includes organizations (UN and non- UN) working in the main sectors of humanitarian response. On occasion, the cluster system has been involved in managing outbreak response, particularly when outbreaks occur during a humanitarian emergency (e.g. the 2017 outbreak of cholera in Somalia). Historically, outbreaks often lead to humanitarian crises, such as the Ebola outbreaks in West Africa. The cluster system was not activated during the Ebola outbreaks; however, the UN established its Mission for Ebola Emergency Response, which helped coordinate the response.

Considerable progress has been made on coordinating international outbreak response from all the above partners. Nonetheless, the publication and revision of the IHR did not prevent the spread of Ebola in West Africa and highlights the need for continued refinement of global response to international outbreaks. 

This article includes excerpts from the chapter "Multinational outbreak investigations" in The CDC Field Epidemiology Manualpublished on behalf of Centers for Disease Control and Prevention (CDC), edited by Sonja A. Rasmussen, and Richard A. Goodman.