The challenge to know and control: Disease outbreak surveillance and alerts in China and India

Abstract

Since the revisions to the International Health Regulations (IHR) in 2005, much attention has been turned to how states, particularly developing states, will address core capacity requirements. The question often examined is how states with poor health systems can strengthen their capacity to identify and verify public health emergencies of international concern. A core capacity requirement is that by 2012 states will have a surveillance and response network that operates from the local community to the national level. Much emphasis has turned to the health system capacity required for this task. In this article, I seek to understand the political capacity to perform this task. This article considers how the world's two most populous states,1 China and India, have sought to communicate outbreak events in times of crisis and calm. I consider what this reporting performance tells us of their capacity to meet their IHR obligations given the two countries differing political institutions.

Keywords:

• risk communication
• surveillance
• infectious diseases
• political regime
• transparency

Notes

1. For the purposes of this paper, I use the word ‘state’ as a shorthand for the nation-state of China and India, or member state as used by the United Nations.

2. A PHEIC is defined in Article 2, IHR (2005) as involving the ‘international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade’. Annex 2 provides the criteria states are to use for assessing whether an outbreak is a potential PHEIC (WHO 2008a, WHA 58.3 2005, Annex 2).

3. Public health assessment under the IHR requires states to determine whether an outbreak should be notified to the international community under the following criteria:

Is the public health impact of the event serious? (yes/no)

Is the event unusual or unexpected? (yes/no)

Is there any significant risk of international spread? (yes/no)

Is there any significant risk of international travel or trade restrictions? (yes/no)

(WHO 2008b, p. 14).

4. But there is evidence of little incident reporting on the SEARO site in spite of its large outbreak cases per year. http://www.searo.who.int/en/Section10/Section392_1382.htm

5. With the only exception of some SARS reports from China in 2003 where WHO referred to the fact that there was evidence that the case load was higher than what the government was reporting.

6. Additional measures that I took to control for identifying an outbreak as ‘new’ versus ‘ongoing’ outbreaks in the case of cholera, dengue and JE proved to be quite difficult. To control for this problem, I imposed a geographical and time limit before identifying the outbreak as ‘new’. Time lag for disease outbreaks followed a fourteen day rule. If there was a fourteen day lag in reporting a disease outbreak (i.e. no new reports or reports of disease spread) the next outbreak of same disease was classified as ‘new’. The goal here was not always to trace the progression of an actual case, but the progression of state reporting in contrast to informal reporting behaviour.