Handbook for public health

capacity-building at ground
crossings and cross-border
collaboration
©Aurelien Pekezou Tchoffo
Handbook for public health
capacity-building at ground
crossings and cross-border
collaboration
Handbook for public health capacity-building at ground crossings and cross-border
collaboration
ISBN 978-92-4-000029-2 (electronic version)
ISBN 978-92-4-000200-5 (print version)

© World Health Organization 2020

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CONTENTS

ACKNOWLEDGEMENTS v

LIST OF CONTRIBUTORS v

ACRONYMS vii

I ntroduction 1
Rationale 1
Purpose of this handbook 2
Target audience 3
Overview/How to use this guide 3

Part A: Operational considerations for developing public health

emergency preparedness and response capabilities at ground crossings 4
2.1 Strategic risk assessment and planning for risk mitigation 4
2.1.1 Overview 4
2.1.2 Operational guidance 4
2.2 Designation of ground crossings 6
2.2.1 Overview 6
2.2.2 Operational guidance 8
2.2.3 Joint designation or bi/multilateral agreement 8
2.3 Surveillance at a ground crossing 9
2.3.1 Overview 9
2.3.2 Operational guidance 10
2.4 Risk communication 16
2.4.1 Overview 16
2.4.2 Operational considerations 16
2.5 Preparedness for event management and response 19
2.5.1 Overview 19
2.5.2 Operational considerations 20
2.6 Environmental health 24
2.6.1 Overview 24
2.6.2 Operational considerations 25

iii
Part B: Considerations for collaboration at ground crossings 30
3.1 Overview 30
3.2 Opportunities to collaborate – guiding questions 31
3.3 Components of a cross-border collaborative agreement 33

REFERENCES 38

ANNEXES 43
Annex 1. Definitions 43
Annex 2. How to apply the Strategic Risk Assessment Tool 46

iv
ACKNOWLEDGEMENTS
The World Health Organization (WHO) gratefully acknowledges the
contributions of the following individuals to the development of the Handbook
for public health capacity-building at ground crossings and cross-border
collaboration by providing comments and inputs during consultation and field-
testing. WHO also expresses sincere gratitude to the following partners and their
teams who provided technical inputs: United States Centers for Disease Control
and Prevention (US CDC), International Organization for Migration (IOM).

LIST OF CONTRIBUTORS
• Ayed Rashed Alatawi, Ministry of Health, Tabuk, Qatar
• Kholoud Al Hamdan, Ministry of Health, Kuwait
• Sumayah Al Hardan, Ministry of Health, Kuwait
• Khalid Al-Harthi, Ministry of Health, Muscat, Oman
• Ferhad Ali, Ministry of Health, Suliymaniya, Iraq
• Wimmer Alice, International Organization for Migration, Geneva, Switzerland
• Ali Al Maqbali, Ministry of Health, Muscat, Oman
• Atika Berry, Ministry of Public Health, Beirut, Lebanon
• Clive Brown, Centers for Disease Control and Prevention, Atlanta, USA
• Regina Burbiene, EU Healthy Gateways, Joint Action National Public Health
Centre, Vilnius, Lithuania
• Lina Cheito, ESUMOH, Beirut, Lebanon
• Tai-Ho Chen, Centers for Disease Control and Prevention, Atlanta, USA
• Tshewang Dorji, Ministry of Health, Timphu, Bhutan
• Ali El Haj, Lebanese Army, Beirut, Lebanon
• Nada Ghosn, Ministry of Public Health, Beirut, Lebanon
• Nellie Ghusayni, International Organization for Migration, Democratic
Republic of the Congo
• Samir Hadjiabduli, International Organization for Migration, Beirut, Lebanon
• Taufik Hasaba, Ministry of Health, Damascus, Syria
• Maria an der Heiden, Robert Koch-Institute, Germany
• Verica Jovanovic, Institute of Public Health of Serbia, Belgrade, Serbia
• Brigita Kairiene, EU Healthy Gateways, Joint Action, National Public Health
Centre, Klaipeda, Lithuania

v
• Katrin Kohl, Centers for Disease Control and Prevention, Atlanta, USA
• Amalia Kostara, EU Healthy Gateways Joint Action, University of Thessaly,
Greece
• Carlos van der Laat, International Organization for Migration, Geneva,
Switzerland
• Sidi Mohamed Laghdaf, Ministry of Health, Nouakchott, Mauritania
• Assad Mahdi, Ministry of Health, Baghdad, Iraq
• Raphael John Marfo, Kotoka International Airport, Accra, Ghana
• Rebecca D Merrill, Centers for Disease Control and Prevention, Atlanta, USA
• Marcus Aurelio Miranda de Araujo, National Sanitary Control Agency, Brasilia,
Brazil
• Kathleen Moser, Centers for Disease Control and Prevention, Atlanta, USA
• Rodolfo Navarro Nunes, National Sanitary Control Agency, Brasilia, Brazil
• Victor Nyamandi, Ministry of Health and Child Care, Harare, Zimbabwe
• Viviane Nzeusseu, Regional Office for West and Central Africa, International
Organization for Migration Dakar, Senegal
• Jelena Rjabinina, Health Board, Estonia
• Sayed Ataullah Saeedzai, Ministry of Public Health, Kabul, Afghanistan
• Hajar Samaha, Ministry of Public Health, Beirut, Lebanon
• Vladimir Shukhov, Center of Strategic Planning and Medical and Biological
Health Risks Management, Ministry of Health, Russian Federation
• Abeer Sirawan, Ministry of Agriculture, Beirut, Lebanon
• Irfan Tahir, Ministry of National Health Services Regulations and Coordination,
Islamabad, Pakistan
• Amer Teebi, Ministry of Health, Damascus, Syria
• Tegshbayar Tumurbaatar, Ministry of Health, Ulaanbaatar, Mongolia
• Steve Waterman, Centers for Disease Control and Prevention, Atlanta, USA
• Nijuan Xiang, Chinese Centre for Disease Control and Prevention, Beijing,
China
• Moncef Ziani, Ministry of Health, Rabat, Morocco

THE CONTRIBUTIONS OF THE FOLLOWING PERSONNEL OF WHO

HEADQUARTERS ARE ALSO ACKNOWLEDGED
Yolanda Bayugo, David Bennitz, Kevin Carlisle, Luc Bertrand Tsachoua Choupe,
Amaia Artazcoz Glaria, Qudsia Huda, Corinne Beatrice Ponce, Ninglan Wang,
Teresa Zakaria.

vi
SPECIAL THANKS GO TO:
Roberta Andraghetti, Jessica Barry, Nilesh Buddh, Vasily Esenamanov, Haris
Hajrulahovic, Muang Muang Htike, Nicolas Isla, Masaya Kato, Sara Barragan
Montes, Dalia Samhouri, Mary Stephan, Ambrose Talisuna, Ali Ahmed Yahaya
and Weili Zhao for providing inputs and support from WHO regional offices.

SINCERE GRATITUDE IS EXPRESSED TO:

The WHO Eastern Mediterranean Region for providing the testing site, and
to the following WHO personnel for their support during the field-testing in
Lebanon in July 2019.
From the WHO Eastern Mediterranean Regional Office:
Fatima Arifi, Jessica Barry, Khalil Khalil, Habiba Mamlouk, Dalia Samhouri;
And from the WHO Eastern Mediterranean country offices:
Mohamed Sahak (WHO, Afghanistan), Omar Abou Elata and Mahgoub Hamid
(WHO, Egypt), Lora Al Sawalha (WHO, Jordan), Loubna Batlouni and Iman
Shankiti (WHO, Lebanon), Sara Zarti (WHO, Libya), Lydia Voti (WHO, Mauritania),
Yassine Aqachmar (WHO, Morocco), Akiko Takeuchi (WHO, Syria) and Latifa
Assidi (WHO, Tunisia).

ACRONYMS

EBS Event-based surveillance

EWAR Early warning and response
IDSR Integrated Disease Surveillance and Response
IHR International Health Regulations (2005)
IMO International Maritime Organization
NGO Nongovernmental organization
PHEIC Public health emergency of international concern
POE Point(s) of entry
PPE Personal protective equipment
SOP Standard operating procedure
WASH Water supply, sanitation, and hygiene promotion
WHO World Health Organization

vii
Introduction

Rationale
The International Health Regulations 2005 (IHR) stipulate that States Parties should
designate airport(s) and port(s) that will meet the core capacities, as laid out in
Annex 1 of the IHR. However, the regulations only “suggest” that a State Party may
designate ground crossings “where justified for public health reasons” (Articles 19,
20 and 21) and “encourage” neighbouring countries to cooperate by entering into
bilateral or multilateral agreements/arrangements concerning prevention or control
of the international transmission of disease, or by joint designation for developing
IHR ports of entry (POE) capacities.
Ground crossings are predominantly characterized by more complex and varied
environments than settings at other POE such as airports and seaports. Ground
crossings often represent larger cross-border communities with strong family and
commercial ties, where travellers may frequently – even daily – traverse a porous
border. Persons crossing these borders may use a large variety of transport ranging
from trains, trucks (lorries), buses, automobiles, motorcycles or bicycles to animals
or even passing through on foot. Depending on the populations served by ground
crossings, the volume of traffic may fluctuate or vary from tens of thousands to fewer
than 50 persons per day. The infrastructure and resources available to competent
authorities at a ground crossing can differ widely. Some crossings have sustained
electricity and large, modern technologically-equipped facilities with sufficient
staffing, while others may consist of only a simple makeshift gate intermittently
staffed by one or two persons along a rural frontier with no electricity or cell
phone connections, and yet others may be no more than a known location on an
open road or footpath were the land changes from one country to another. Given
extensive terrestrial frontiers and geographical constraints, ground crossings
may be both formal or informal, the latter far outnumbering the former. Finding
sufficient technical staff for such crossings is a significant challenge. The variety of
governmental and nongovernmental stakeholders concerned with ground crossings
includes authorities for border policy and regulations for commerce, immigration,
security, animal health. This range of stakeholders, when coupled with the differing
geographical, sociodemographic, infrastructure and resource factors, often presents
challenges in developing the necessary capacities and collaborative partnerships for
coordination and action within countries and across borders.
Because international travel and traffic occurs at any active ground crossing, even
if non-designated, these unique and varied settings pose substantial challenges to
consistent implementation of the IHR. Consequently, ground crossings present a
potential weak point in global health security and therefore pose greater challenges
for implementing the IHR consistently.
States Parties require guidance on how to implement the IHR core capacity for
prevention, early detection and response to public health events at these often less-
resourced POEs. The guidance must include consideration of how States Parties

1
select ground crossings for designation under the IHR framework and what measures
they can take to achieve and sustain the IHR core capacities in varied contexts.
Given the paucity of available global guidance, this handbook presents a unique
opportunity to address the specific challenges and needs of ground crossings and
their adjacent communities. Drawing upon established guidance, the handbook
seeks not to replicate existing literature on POEs but rather to assemble and frame
the technical knowledge on ground crossings, and to support neighbouring countries
to enter into cross-border collaborative agreements whenever possible.
The handbook presents the key considerations for strengthening IHR capacities at
ground crossings, including considerations for cross-border collaboration.

Purpose of this handbook

This handbook follows a comprehensive approach to health system strengthening
at borders in order to support IHR national focal points and other national agencies
in developing and implementing evidence-based action plans for IHR capacity
development at ground crossings. The approach includes the movement of travellers
and baggage, cargo, containers, conveyances, goods and postal parcels across
ground crossings, as well as the interaction with adjacent border communities. Other
factors can be considered, if needed, throughout the risk assessment.
Specifically, the objectives of the handbook are:
• to introduce principles of strategic risk assessment for prioritizing capacity-
building for preparedness and response at ground crossings;
• to highlight issues to consider when selecting ground crossings for designation
under the IHR;
• to support the establishment and maintenance of cross-border collaboration in
order to improve coordination and communication at ground-crossing settings.
Drawing extensively from previously published guidance documents and reports in
relation to ground crossings, this handbook was developed in collaboration with
public health experts during successive consultative meetings, discussions and field-
testing. Furthermore, experts on the subject from WHO’s six regions were consulted
to provide input and share best practices.
For the purpose of this document, a “ground crossing setting” is considered to be a
structured ground crossing with administrative controls and adjacent communities.
However, the content and principles for strategic risk assessment and the identification
and prioritization of development and maintenance of the core capacities for public
health purposes may be used for diverse ground-crossing settings, including porous
borders.
This document excludes guidance on mass migration across ground crossings.

2
Target audience
Stakeholders with public health roles and responsibilities at ground crossings
are not limited to the public health sector but also include other governmental,
nongovernmental and private sectors and disciplines. This multi-stakeholder
approach is not limited to those who are involved in the response to and management
of public health events but may also include groups and organizations (governmental
and nongovernmental) that can contribute to response measures.
The target audience of this handbook therefore includes:
• the IHR National Focal Point (IHR NFP);
• competent authorities responsible for implementing the IHR at ground
crossings;
• government officials and representatives of nongovernmental organizations
who regularly communicate and coordinate with competent authorities at
ground crossings (e.g. on immigration, security and customs);
• policy-makers who may have the ability to develop new policies and laws to
facilitate the practical implementation of the IHR at ground crossings and in
adjacent border communities;
• public health professionals involved in disease surveillance, health
communication, emergency preparedness and response, animal health,
environmental health etc. at ground crossings and in adjacent border
communities;
• representatives of nongovernmental organizations working in border areas and
adjacent communities.

Overview/How to use this guide

This handbook is divided into two parts.
In Part A, each of the planning and operational chapters represents a stand-alone
technical section which may be consulted separately or in conjunction with related
chapters. The sequence of the chapters in Part A therefore presents operational
modalities to:
• establish and strengthen capacities at ground crossings, beginning with
carrying out a strategic risk assessment to ascertain public health needs and
required resources, and
• guide the work of all relevant stakeholders if a country decides to designate a
particular ground crossing.
The Part B outlines the fundamental tenets for enabling and enhancing cross-border
collaboration, in addition to operational considerations. Each chapter includes
toolboxes presenting complementary resources, technical considerations and
examples of cross-border collaboration.
The annexes contain information which should be used together with the technical
chapters.

3
Part A: Operational considerations for developing
public health emergency preparedness and response
capabilities at ground crossings

2.1 Strategic risk assessment and planning for risk mitigation

2.1.1 Overview
Given that ground crossings have diverse contexts, the public health risks are varied.
Consequently, capacities for public health preparedness and response should be
established and strengthened commensurate with the identified risk, presenting a
cost-effective and evidence-based approach to management of national resources
for IHR capacity development at prioritized ground crossings.
A strategic risk assessment is a recommended approach to inform the process
of prioritization and resource allocation at ground crossings. The strategic risk
assessment is a systematic process for gathering, assessing and documenting
information to assign a level of risk. Ultimately, the strategic risk assessment will
help inform decisions by national authorities regarding improvement of capacities to
reduce the risk or impact of identified public health risks such as those associated with
the international movement of persons, baggage, cargo, containers, conveyances,
goods or postal parcels across ground crossings and nearby border communities.
The health impact of a public health emergency can be substantially reduced if
ground crossings, local authorities and adjacent communities are well prepared to
reduce the vulnerabilities and health implications of significant risks that are specific
to a ground crossing. This reduction can be achieved if systematic capacities –
such as emergency preparedness and response plans, institutional capacities and
sustainable budgets, skilled personnel, public awareness, cross-border cooperation/
coordination mechanisms, and procedures for risk-mapping, surveillance and
response to diseases and events – are developed and maintained.

2.1.2 Operational guidance

(Note: This section is not intended to provide guidance on the strategic risk
assessment process during an acute public health event)
2.1.2.1 Strategic risk assessment for ground crossings
The strategic risk assessment should consider not only the context of the physical
ground crossing but also the collaborative frameworks between neighbouring
countries that would address movement across land borders and the interaction with
adjacent border communities.
The strategic risk assessment comprises a set of linked but separate assessments,
namely:
• the hazard assessment to identify prioritized hazards;
• the vulnerability assessment to determine which characteristics or
circumstances of a community or a system make it susceptible to the ongoing
effects of the hazard;

4
 • the severity and coping capacity assessment to identify potential consequences
of the hazard and to assess capabilities to cope with and manage the hazard;
• the likelihood assessment to determine the likelihood that the hazards and
exposures will occur.

How to conduct a strategic assessment of risk at ground crossings

• Establish a risk assessment team: The multisectoral team should consist of
experts in border health strategies and persons with local knowledge about
the targeted environment. These person may include public health experts
from national, regional or local public health authorities; persons from
other government departments such as agriculture, customs, security and
transportation; representatives from the ground-crossing facility; and leaders
from the local community and religious and social groups. This team will use its
collective experience and expertise to provide, gather and interpret qualitative
results from the assessments. Additional members with valuable expertise
(such as veterinarians) can be added to the team at any time as required.
• Perform the assessment: The strategic risk assessment team completes
the separate risk assessments by carrying out desk reviews and facilitated
discussions with key stakeholders.
• Risk characterization (determination of the risk level and ranking): Using the
information gathered during the strategic risk assessment process, the team
assigns a risk characterization level to each hazard identified. The team can
complete the risk characterization process for each hazard by using a risk matrix
tool which combines an estimate of the likelihood of a hazard occurring with the
potential impact if the hazard were to occur. This qualitative process should be
fitted to the national context. General guidance on how to use the matrix and
a formula for determining the impact of the hazard, are detailed in Annex 2.
The value determined by this formula will be factored into the risk matrix along
with the likelihood of exposure to the hazard in order to determine the overall
level of risk.

Risk mitigation and public health emergency planning

Once the risk matrix is produced, the strategic risk assessment team and other national
decision-makers can use this overall assigned level of risk to drive the prioritization of
hazard-specific capacities at ground crossings and to assist States Parties to explore
opportunities for cross-border collaboration, if warranted, at ground crossings and in
border regions. This process takes account of the measures, processes, services and
systems that are already in place, assesses whether they need to be strengthened
and identifies the gaps in risk management. The process also considers how different
ground crossings and adjacent areas interact with the identified risks and how likely
they are to lead to variations of risk across time and locations.
The risk matrix is not a static document or a one-off exercise. It is essential to understand
how changes in the context, trends and variations can affect future developments.
The accuracy and reliability of the strategic risk assessment tool depends to a large
extent on the effectiveness of surveillance, the free-flowing exchange of information,
the quality and the skills of the assessment team and, especially, the ability to identify

5
the key elements to be monitored in order to anticipate developments and address
problems proactively.

Minimum preparedness actions

Minimum preparedness actions for public health emergency planning are required
for ground crossings in accordance with the IHR and should focus on the following
capacity development activities:
è Ground crossing-specific public health preparedness and response measures
should be coordinated across multiple stakeholders and agencies, with clearly
defined roles and responsibilities to identify and prevent the introduction and
transmission of suspected public health events during both routine and response
operations. These measures should include:
• access to medical services including diagnostic services;
• access to equipment and personnel for the transport of ill travellers to an
appropriate medical facility;
• surveillance activities;
• risk communication and social mobilization (i.e. the distribution of public health
information to ensure that travellers meet local vaccination requirements);
• environmental health (i.e. vector control, solid and liquid waste management,
potable water and general sanitation);
• data management and information exchange.
è Additional preparedness actions include:
• development of standard operating procedures and testing for field response;
• implementation of early mitigation measures (e.g. vaccination campaigns);
• implementation of active surveillance (including in communities) in high-risk
regions or districts;
• development of an emergency response contingency plan for scenarios of
identified hazards;
• identification of emergency funds that can be immediately available for
mitigation and preparedness, as well as contingency funds for response;
• cross-border collaboration by harmonizing resources, increasing coordination
and communication, expanding/complementing joint operations/efforts, and
concluding local and national agreements;
• enhanced/emergency waste management services.

2.2 Designation of ground crossings

2.2.1 Overview
Article 21 of the IHR states that States Parties may choose to officially designate a
ground crossing in order to further develop capacities for surveillance and response.
The decision of a State Party to designate a particular ground crossing may be
deemed as strategic for:

6
 • implementing health capacities commensurate with risk and in-country
resource allocations for strengthening preparedness and response, and
• securing in-country economic benefits.
All States Parties intending to designate ground crossings should consider first
completing a strategic risk assessment to better understand and justify their selection.
When prioritizing ground crossings for designation in line with IHR Article 21.1, a
number of factors should be considered (Table 1). It should also be noted that these
factors can be used when prioritizing public health capacity-building at ground
crossings.
Table 1. Factors to consider when designating ground crossings

Volume •C
 onsider not only overall traveller volume but also whether the
volume changes based on time (day/week/season), and what
factors influence those changes (operating hours/accessibility/
security issues).
•T
 he highest volume is not the highest priority factor; rather
consider the level of risk associated with the volume in view of the
collective traveller profiles and other important considerations.
Access to health •A
 ccessibility to health care via the ground crossing influences
care how public health assessment protocols are designed, and how
sufficient infrastructure and resources are provided at the POE (e.g.
lack of/limited access to health care may result in a sick traveller
being isolated at a POE for a longer amount of time).
Connectivity to •H
 ow connected is the POE to other priority populations or
priority populations geographical areas of interest? There may be a lower volume of
and locations travellers at a ground crossing through which people come from
areas that often experience outbreaks or other public health events
or through which travellers pass to seek health care on the other
side of the border.
Strength of the • If the public health surveillance system around the POE is robust, it
surveillance system is likely to identify a potential case associated with travel through
the specific ground crossing. Dedicating limited resources to public
health capacities at that ground crossing might not be the highest
priority for use of resources.
• In contrast, in an area where the surveillance system is poor and
it could take days or weeks before someone is identified and
reported, public health screening of travellers at ground crossings
may be an important way to identify potentially sick travellers.
Coordination with •C
 onsider whether the district or POE has an existing relationship
the neighbouring with the cross-border counterparts. Do they communicate regularly,
country coordinate activities, provide alerts at the local level etc?
•G
 round crossings where this relationship does not exist or is not
strong could be prioritized for designation because there is no
other system in place to identify potentially sick travellers

7
2.2.2 Operational guidance
The designation pyramid (Figure 1) illustrates the process for taking account of
the above factors, country-specific strategies, priorities and other contextual
considerations for States Parties that have decided to designate one or more ground
crossings in accordance with IHR Article 21.
Figure 1. Designation pyramid

High volume of international traffic and one or more of the following;

• High level of dispersal of the traffic inside the country or towards
the other state
Tier 3 • The presence of known disease reservoirs affecting the ground
Ground crossing crossing
characteristics • Community health issues that may spread public health risks
and factors • Animal health issues that may spread public health risks
likely • Environmental health issues that may spread public health risks
to support • Any significant public health risk that exists at travellers’ place of
designation origin, route of transit or destination that may have an impact
on the ground crossing and adjacent areas
• A history of public health events at or near the ground crossing
and adjacent border area

High volume of international traffic or a combination of any

of the following;
• High level of dispersal of the traffic inside the country or
towards the other state
Tier 2 • The presence of known disease reservoirs affecting the
Ground ground crossing
crossing • Community health issues that may spread public health
characteristics risks
and factors • Animal health issues that may spread public health risks
which may • Environmental health issues that may spread public
support health risks
designation • Any significant public health risk that at travellers’
place of origin, route of transit or destination that
may have an impact on the ground crossing and
adjacent border areas

• Low volume of international traffic

• Permanent natural or artificial border barriers that
result in low cross-border interaction
Tier 1 • Reversible or temporary border barriers that
Ground crossing result in limited cross-border interaction
characteristics and because of conflict, political, cultural, economic
factors unlikely to or other reasons
support designation •Informal or porous borders that have no
administrative controls but can be readily
traversed, such as waterways that align with
international borders

8
2.2.3 Joint designation or bi/multilateral agreement
The joint designation of a ground crossing will require the sharing of public health
information and resources across the border in order to benefit all border Member
States and may result in better-adapted risk mitigation systems, reduced financial
costs and administrative burdens, and the opportunity to capitalize on human
resources and sharing of expertise. During a joint designation process, States
Parties may learn that resources in a neighbouring state are situated closer to the
ground crossing, thus allowing for a more cost-effective rapid response during a
public health event. Official cross-border collaborative agreements which allow for
coordinated data-sharing and well-defined communication channels will facilitate, or
may result from, the joint designation process.
Cross-border collaborative agreements are further described in Part B of this
handbook.

Section 2.2 Toolbox

Assessing ground crossing capacities
• The IHR Assessment tool for core capacity requirements at for designated airports, ports
and ground crossings – https://apps.who.int/iris/bitstream/handle/10665/70839/WHO_
HSE_IHR_LYO_2009.9_eng.pdf?sequence=1&isAllowed=y. (NB: This can be used in whole
or in part for non-designated ground crossings in order to assess the required capacities
for compliance with the IHR)
Assessing ground crossing capacities – including border areas
• US Centers for Disease Control and Prevention (CDC) Border health capacity discussion
guide
• Capacity assessment factors, as described in Annex 2
Guidance on the rapid risk assessment of acute public health events can be found at https://
apps.who.int/iris/bitstream/handle/10665/70810/WHO_HSE_GAR_ARO_2012.1_eng.
pdf?sequence=1&isAllowed=y.

2.3 Surveillance at a ground crossing

2.3.1 Overview
Surveillance is 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. Effective surveillance enables
the timely detection of public health events, the coordination and exchange of
epidemiological information, and the ability to apply commensurate and appropriate
public health measures at and around ground crossings.
Given the varied border contexts and the diverse health threats covered by the IHR
all-hazards approach, conducting surveillance at ground crossings presents unique
challenges. States Parties should implement a multi-layered surveillance strategy
along land borders, including integrating their ground crossings into the national
health surveillance system. This can include building on existing disease surveillance
and response mechanisms and enhancing community involvement and capacities
in surveillance activities. A strong national health surveillance system is crucial to
the early detection of cases as travellers may be incubating or may mask signs and
symptoms as they cross an international border.

9
Objectives for surveillance at ground crossings include:
• enabling the early detection of public health events for timely verification and
the application of control measures;
• providing data to public health authorities for risk assessment of events and
hazard mapping;
• informing stakeholders at a ground crossing, in border communities and at
appropriate levels of the health system and other sectors (e.g. customs, animal
health, conveyance operators) of detected events;
• integrating the ground crossing into the local health system, taking into
account its responsiveness as well as its ability to provide essential functions
that meet quality, safety and equity standards;
• assisting stakeholders in initiating preventive and response measures,
investigation and management of events;
• detecting changes in trends of events at a ground crossing and in border
communities, and addressing needs for health-care facilities and services,
laboratories and allocation of resources etc;
• preventing and/or managing the importation and exportation of health hazards
through cross-border movement;
• providing a basis for future programmes, operations research or action-
oriented research and programme improvement.

2.3.2 Operational guidance

2.3.2.1 Reporting and communication
At a ground crossing
Surveillance activities in a ground crossing setting should take place during all hours
of operation. Timely reporting plays an important role in a State Party’s early warning
and response system. Health assessment criteria and formularies at ground crossings
and in border regions should be standardized and should be harmonized with those
developed for community surveillance within the national health surveillance system
in order to achieve consistency in reporting. Importantly, all ground crossings should
be integrated into the national health surveillance system. Information channels –
and the information flow – need to reach decision-makers and should strengthen
coordination between all the functions (Emergency Operations Centre, National
IHR Focal Point), systems and initiatives (e.g. National Event Management System,
rapid response teams, emergency medical teams, early warning systems, Integrated
Disease Surveillance and Response system) within the framework of the IHR.
The information to be reported from a ground crossing is likely to be specified by
the national health surveillance system and may vary between States Parties as the
result of differing local requirements (i.e. documentation required for prophylaxis). In
addition, the type and frequency of information required may vary between routine
operations and emergency response. A minimum data set should be selected on the
basis of a multi-hazard approach and the national health information system, and
this may evolve depending on surveillance needs and the trends of the main (current
or expected) threats. Data security, privacy and interoperability should be taken into
account in computerized information systems.

10
Communication at a ground crossing should include risk communication activities,
including social and mass media communication, to monitor disinformation and
rumours, to promote healthy lifestyles and healthy behaviours.

Between bordering countries

Effective coordination and communication for the exchange of health information
is particularly important along porous borders. The timely exchange of information
should be strengthened at local level through multisectoral collaboration between
neighbouring countries (e.g. commerce, trade, customs, animal health, environment,
health). The information to be shared at a ground crossing should accurately reflect
the readiness of the neighbour countries to deal with ground crossing threats. The
minimum data set should cover both the national needs and the neighbouring
country’s needs.
The best available information is needed for an evidence-based decision-making
process at the highest political levels (and not only at the local level), in accordance
with established agreements.
The decision-making process must comply with the purpose of the IHR “in ways
that are commensurate with and restricted to public health risks, and which avoid
unnecessary interference with international traffic and trade”, with full respect for
openness and transparency and for people’s dignity, human rights and fundamental
freedoms.
Additional information can be found in Part B.
2.3.2.2 Alert systems for a ground crossing
Alerts of travel-related cases at a ground crossing
When there are suspected or confirmed cases of a communicable disease during
travel, health staff at the ground crossing should assist surveillance teams in
completing investigations and applying response measures. Additionally, fellow
travellers might be investigated and – as appropriate on the basis of the results of
investigations – either may be subject to further evaluation, quarantine or isolation,
or medical care, or may be advised to contact their health-care provider should they
become ill during a specified period following the travel. They should always refer to
their recent travel history during their health assessment so that the national health
surveillance system can be informed as required.

Alerts from medical facilities around a ground crossing

The health facilities in the area of a ground crossing should establish both routine and
emergency procedures for timely reporting of travel-related cases of public health
concern to the appropriate health authority, including those at a ground crossing
and in adjacent district health authorities.
In all health facilities, the clinical evaluation of cases of communicable diseases of
public health concern should contain a detailed history of recent travels (i.e. within
the past 3 months) including means of travel, origin, transit points, destination(s),
routes taken, purpose of travel and duration of travel. Investigation may take
place retrospectively and public health measures may need to be applied after the
travellers have left the ground crossing.

11
Travel information collected as above will make it possible to:
• link the case with travel and consequently inform the health authority at the
ground crossing, who may then implement the necessary health measures;
• inform, as needed, the counterpart authorities in neighbouring countries ;
• identify all travel-related cases and analyse the surveillance data based on that
parameter.
The diseases listed in Annex 2 of the IHR should be considered, according to the
country context, for the systematic recording of travel information. Diseases to
be recorded include, for instance, anthrax, diphtheria, viral haemorrhagic fevers
(e.g. Ebola, Lassa, Marburg, Yellow fever), pulmonary tuberculosis, meningococcal
disease, measles, severe acute respiratory syndrome (SARS), Middle East respiratory
syndrome - coronavirus (MERS-CoV), human influenza caused by a new subtype,
pneumonic plague and Legionnaires’ disease.

Alerts from adjacent border community surveillance

Communities near ground crossings that receive cross-border travellers, animals or
goods (e.g. villages with a market that receives travellers, animals or goods from
across a border), and communities along a porous border, or some distance away
from the border along a transit route (e.g. a major city located on a roadway or
railway line), should be aware of the need to alert surveillance teams when an event
may be associated with recent international travel. Sources of community event-
based surveillance vary widely and may include traditional and alternative healers,
educational establishments, labour and industry sources, community or religious
leaders, local media, and cross-border initiatives.

Alerts from zoonotic disease surveillance using the One Health approach
The movement of humans, animals, and agricultural products may have an
international impact on public health. Border health measures should include
surveillance for animal diseases and controls on the movements of animal and
agricultural products.
Given the trans-boundary incidence of zoonotic diseases and associated human
and animal movement, health officials should coordinate disease surveillance and
control efforts with officials responsible for animal health, agriculture, wildlife and
natural resources. Public health and border officials should work towards developing
a single disease surveillance platform (i.e. the “One Health” approach) that includes
alerts for outbreaks in humans, domestic animals and wildlife.
In countries where veterinary facilities might not have existing links to the national
health surveillance system, public health surveillance should account for unusual
events, such as clusters of animal illnesses or deaths of animals which may have
crossed land borders.

Alerts from food and water safety surveillance

Considering the amount and types of goods that may pass through a ground
crossing, and the time spent transiting, certain risks should be taken into account
when considering surveillance needs. Plants, water, food, animal products and
commercial goods which may contain potential public health threats should be
considered on the basis of a risk assessment approach.

12
Surveillance of the ground crossing premises, vendors of water and food safety
compliance is also highly recommended to ensure there is a safe environment
for those using the ground crossing. Routine checks by trained staff should be
implemented, and methods for verifying possible contamination with laboratory
diagnostics should be considered.
2.3.2.3 Surveillance activities during public health emergencies
In emergency settings (e.g. enhanced exit controls for an Ebola outbreak or a
chemical spill in a river that traverses an international border), additional capacity
may be added to ground crossings to provide enhanced health screening (e.g. exit
screening, including temperature screening, health declarations, focused medical
examination etc.) and measures to report directly to the national health surveillance
system.
Additionally, travellers, animals and goods that pass through a ground crossing may
travel long distances across the country. Consequently, the links with travel history,
zoonotic disease surveillance and environmental data/information should be always
considered in order to avoid the further spread of public health risks, particularly in
the context of a public health emergency.

Exit screening
The following guidance should be considered if a State Party deems exit screening
necessary to prevent the exportation of a communicable disease, or if WHO
recommends exit screening:
• Prioritize ground crossings for exit screening activities on the basis of risk.
• Ensure sustainably of resources to conduct exit screening.
• Standardize communications (questionnaires, declarations, case definitions,
information sheets, etc).
• Primary screening should be carried out by designated staff, using established
procedures and appropriate personal protective equipment, to visually
observe travellers for signs of illness, take temperature measurements and
have travellers complete questionnaires and/or declarations.
• For travellers identified during primary screening as requiring further evaluation,
there should be secondary screening which:
– should be conducted by trained medical staff and may involve in-depth
interviews, additional temperature measurements and completion of
additional screening forms;
– may also include a focused medical evaluation;
– may result in travel restrictions or referral to a health facility for further
evaluation and treatment should the traveller be exhibiting clinical signs and
symptoms consistent with the disease of concern.
• During a public health emergency, a list should be established of any persons
with travel restrictions and should updated regularly. The list should be shared
with all relevant health authorities, while respecting the principles of data
privacy and security, for the adoption of public health measures as appropriate.
Public health authorities should take into account that a symptomatic individual
may be permitted to travel under special arrangements (i.e. continued medical
supervision while travelling).

13
Entry screening
WHO does not recommend entry screening. However, for the purposes of
preparedness planning, countries may wish to develop plans and procedures for
entry screening according to their own risk assessment and cost-benefit analysis.
Entry screening may be introduced if there is suboptimal exit screening from affected
areas, or where there is limited accessibility or where internal surveillance capacity
is limited. However, entry screening must not interfere with international travel and
trade. Planning for entry screening should consider the resource implications and
the potential effectiveness. The technical considerations can be found in WHO’s
Technical note for Ebola preparedness planning for entry screening at airports, ports
and land crossings.1

2.3.2.4 Porous borders and community-level surveillance

Porous and informal border crossing points are characterized by the uncontrolled and
often undocumented nature of movement. These crossings therefore require special
consideration when applying surveillance measures that not only take account of the
risks at points of origin, transit points and destinations, but also elucidate motivations
for travel and estimate the volume of travel (including seasonal differences) and the
characteristics of travellers at such ground crossings.
Establishing surveillance zones along porous border areas that extend into
communities can be an effective strategy when determining where and how to apply
public health measures. Within these zones, strategic gathering places (e.g. markets,
schools, places of worship) can receive selected public health measures such as
screening activities, isolation and quarantine, infection prevention and control,
communication strategies, public health declarations, education, outreach and
awareness activities. Mapping information and technologies which show nationally
established health regions, human and animal mobility factors, geographical
features, disease and vector patterns, and various other local and regional data can
provide strategic oversight to inform surveillance strategies.

2.3.2.5 Surveillance training

Needs: Some ground crossings may be regularly staffed by dedicated health or non-
health personnel who are able examine sick travellers or animals and goods, facilitate
referrals and report cases directly to the appropriate health authority. However, in
many cases, ground crossing staff will not have public health, medical, veterinary or
environmental training. In these cases, targeted POE staff can be trained to make
initial health assessments and health referrals based on signs and symptoms of
priority diseases. Targeted training can be supplemented by awareness sessions that
are tailored to health and non-health staff accordingly.
Objective: To enhance capacity-building of human resources involved in surveillance,
preparedness and response at ground crossings and adjacent border communities.
Plan: A sustainable training plan should be developed and implemented for all
parties, across all categories of personnel involved in public health surveillance.

See: https://apps.who.int/iris/bitstream/handle/10665/144819/WHO_EVD_Guidance_PoE_14.3_eng.pdf?sequence=1&isAllowed=y
1

accessed 8 October 2019.

14
Training according to a regular schedule or as needed is of particular importance
to ensure that surveillance staff are able to apply the most recent techniques and
technologies properly and that updated protocols/guidelines are being used.
Audience: In addition to the public health workers required at a ground crossing,
training should be provided for conveyance operators, customs staff, key actors
of adjacent border communities and other personnel who have initial contact with
travellers.
Contents: Training programmes should address roles and responsibilities, standard
operating procedures, means of communications, case definitions and other
applicable elements in order to enable the trainees to recognize key symptoms and
signs of events among (primarily) travellers.
Regular meetings between the various authorities involved will also contribute
to harmonizing training practices and improving the overall surveillance system.
An information card or other readily accessible reference material summarizing
surveillance training elements – such as signs and symptoms of priority diseases as
well as key contact numbers –may be helpful for both health and non-health public
health staff at ground crossings.

Chapter # Toolbox
Surveillance activities in an emergency setting
• Rapid risk assessments for acute public health events (https://apps.who.int/iris/bitstream/
handle/10665/70810/WHO_HSE_GAR_ARO_2012.1_eng.pdf?sequence=1&isAllowed=y,
accessed 10 October 2019).
• International Health Regulations (2005) and chemical spills (http://apps.who.int/iris/
bitstream/handle/10665/249532/9789241509589-eng.pdf?sequence=1, accessed 10
October 2019).
One Health
• WHO-OIE Operational framework for good governance at the human-animal interface:
bridging WHO and OIE tools for the assessment of national capacities (www.oie.int/
fileadmin/Home/fr/Media_Center/docs/pdf/WHO-OIE_Operational_Framework_final.pdf,
accessed 10 October 2019).
• OIE Tool for the Evaluation of Performance of Veterinary Services – OIE PVS Tool (https://
www.oie.int/en/solidarity/, accessed 10 October 2019).
• Arriola CS, Rubin C. Prioritizing zoonoses: a proposed One Health tool for collaborative
decision-making. PLoS ONE. 2014;9(10) e109986. doi:10.1371/journal.pone.0109986
Exit screening
• Exit screening at airports, ports and land crossings: interim guidance for Ebola virus
disease (https://apps.who.int/iris/bitstream/handle/10665/139691/WHO_EVD_Guidance_
PoE_14.2_eng.pdf?sequence=1&isAllowed=y, accessed 10 October 2019).
Entry screening
• Technical note for Ebola preparedness planning for entry screening at airports, ports and
land crossings (https://apps.who.int/iris/bitstream/handle/10665/144819/WHO_EVD_
Guidance_PoE_14.3_eng.pdf?sequence=1&isAllowed=y, accessed 10 October 2019).

15
2.4 Risk communication
2.4.1 Overview
Risk communication planning and training are essential for comprehensive public
health preparedness and response, as well as for determining the resources that need
to be allocated for risk communication activities. At a ground crossing, authorities
may be requested by public health officials or others to communicate certain risks
to the public at the crossing itself or within the adjacent border communities – for
instance, distributing current public health information or ensuring that travellers
meet local vaccination requirements. Considering the international nature of ground
crossings, certain factors such as differences in language, culture and health-care
practices need to be taken into consideration when designing and implementing
risk communication plans that respect the need for transparency and trust. Ground
crossings may additionally reflect geographical contexts with diverse socioeconomic,
political and other complexities, including those associated with bordering countries.
Nevertheless, ground crossings and nearby communities provide unique
opportunities to educate travellers and commuters about public health events
and sound public health advice (signs and symptoms, where to seek care etc.).
Community engagement should therefore include coordinated strategies and
messaging by officials between neighbouring countries to ensure harmonized and
consistent approaches to public health threats.

2.4.2 Operational considerations

Risk communication should be incorporated into preparedness planning for major
events and in all aspects of an outbreak response. The principles and steps shown in
Table 2 are particularly critical to risk communication strategies at ground crossings
and in nearby communities.
Table 2. Principles and steps for risk communication strategies at ground crossings

How? •A
 ssess the cultural context of the border region and priority
audiences (e.g. political tensions, cultural or religious
Assessing the
practices, misperceptions, unfounded beliefs, risky behaviours,
needs and
misinformation).
knowledge gaps
•A
 ssess the languages spoken by priority audiences, literacy
levels (both the ability to read and health literacy) and access to
technology.
•A
 ssess risks of the spread of the public health event through cross-
border movement.
•M
 ap out coverage of potential media channels, including binational
communication channels (e.g. cell phone coverage by carriers and
radio station range in border areas) to identify gaps. Social media
and traditional media should be part of an integrated strategy with
other forms of communication to achieve convergence of verified,
accurate information.

16
Who? • Identify and locate priority audiences, such as commercial traders,
transportation workers, traditional healers, commuters, students,
Identifying the
mobile populations and others who are most likely to cross the
intended audience
border or to interact with cross-border travellers.
•M
 aintain a list of relevant points of contact and update this list as
necessary.
What? •M
 essage content should be consistent with national messaging and
should be tailored for cultural relevancy and the evolution of the
Developing
public health events (e.g. adapt national messages to the context
message content
of the border region and the border crossing). Agreements or
and appropriate
memorandums of understanding between bordering States Parties
forms/channels for
and/or other stakeholders may be beneficial when harmonizing risk
message delivery
communications. Content should be specific, realistic and designed
by local experts familiar with the preferences of the priority
audiences.
• Include community leaders in the development of messaging.
•U
 se the most effective and trusted forms of message delivery for
each priority audience (e.g. targeted SMS messaging, radio public
service announcements or dramas, meetings with community
leaders, social mobilizers, print material, educational materials used
by social mobilizers as teaching tools). Use appropriate channels for
message distribution to fill information and message gaps.
•F
 or print materials, content should be mostly visual, with images
that are culturally relevant and easy to understand for audiences
with low literacy levels.
•M
 aterial should be used cautiously because of potential
socioeconomic impact.
•T
 ranslate messages and materials into languages understood by
border crossers on both sides of the border, adjusting for cultural
and linguistic appropriateness.
Where? •A
 t ground crossings place print materials (e.g. posters, banners,
pamphlets, advisory material), including low-literacy and no-literacy
Determining
items, at highly visible places in high-volume locations.
delivery,
geographical • In a border region, place print materials in high-volume places (e.g.
location and bus terminals/stops, transportation junctions, markets, mosques,
coverage churches).
•C
 oordinate with partners and companies to address coverage gaps.
When? • Identify peak travel routes or other hotspots where people gather
along the border (e.g. marketplaces, official and informal border
Identifying timing
crossings, transportation hubs).
•P
 rioritize key areas and times for dissemination of messages based
on busy travel and gathering times
•D
 isseminate the key messages following communication timelines,
as set out by the national risk communication strategy, to cover all
phases of a public health event until recovery.
With what • Identify staffing, platforms, financial resources or other factors that
resources? can improve communications with the public and partners during
emergencies.

17
 Coordination and • Identify roles and responsibilities of the risk communication
consistency personnel.
•P
 rovide training to risk communication personnel for responding to
local hazards.
•C
 oordinate content, timing and delivery methods with
neighbouring countries to ensure consistency or messaging for
audiences in these countries and to optimize resources.
•A
 lign communications content and materials for the border region
with national messaging.
•C
 oordinate any adaptations and revisions to communications
material with neighbouring countries based on evaluation or
evolution of understanding of the outbreak.
•F
 ollow up with partners to ensure that they are discussing a unified
set of messages coordinated with social mobilization efforts and
community outreach.
Monitoring and •M
 onitor the risk communication to ensure its continuing
evaluation implementation before during and after public health events. It is
also important during this process to monitor rumours and social
media and to adjust the communication message plan when
necessary.
•E
 valuate the impact and consistency of messages at border
crossings and in border communities through formal and informal
dialogue with the community to monitor what they need and want.
•E
 valuate jointly with the participation of all relevant stakeholders
and local communities the forms of message delivery for each key
population.
•R
 evise messages as necessary to further enhance desired
understanding or behavioural change.
•D
 ocument lessons learned in order to incorporate them into future
operational research and to enhance/develop standard operating
procedures for risk communication.

Chapter # Toolbox
Communicating risk in public health emergencies
(https://apps.who.int/iris/bitstream/handle/10665/259807/9789241550208-eng.
pdf?sequence=2&isAllowed=y, accessed 10 October 2019).

18
2.5 Preparedness for event management and response
2.5.1 Overview
Preparedness and response: Activities and measures for preparedness and response
should be enabled and reinforced at ground crossings via established public health
response plans and accompanying standard operating procedures. Plan development
should take account of the types of potential emergencies a ground crossing may
experience, as well as relevant legal authorities, surveillance mechanisms, response
triggers, notification pathways, resources necessary to implement a response,
mechanisms to obtain additional resources (surge capacity), and communications
needs. The process should ensure the training of all responders and event managers
in the relevant sections of the plan – standard operating procedures, simulation
exercises (table-top, drills or full-scale exercises) to test plans, with updates to the
plans as needed, based on lessons learned or changes following responses, exercises
or periodic reviews.
Given the complexity of institutions and stakeholders, a ground crossing-specific
public health preparedness and response plan should:
• reflect coordination across multiple agencies and describe specific procedures
to identify and prevent the introduction and transmission of suspected public
health events during both routine and response operations;
• align with relevant national, intermediate and local public health emergency
response plans;
• clearly identify roles and responsibilities in a response to a public health event
to avoid obstructions or obstacles;
• be tested and exercised during preparedness planning;
• pre-position anticipated essential resources at or in proximity to ground
crossings, and have tested mechanisms to enhance and replenish resources
during an emergency situation:
• be flexible, adjustable to different scenarios and scalable to adapt to the size
and scope of the emergency (from a single sick traveller to an outbreak in a
border community).
For ground crossings that lack a consistent agency presence or other resources
to create and maintain a public health emergency response plan, States Parties
can tailor the ground crossing-specific preparedness planning to needs identified
through the strategic risk assessment process. At the same time, States Parties
should incorporate ground crossings in national preparedness and response plans.

19
2.5.2 Operational considerations
2.5.2.1 Recommended steps for the development of a ground crossing response
plan 2 include:
1. Establish a planning team that includes subject matter experts from applicable
agencies/stakeholders.
2. Prepare for the planning phase:
a. Take into account international, regional, national and local considerations.
b. Gather background information and lessons learned from the past.
c. Create situational awareness.
d. Understand the ground crossing risk profile.
e. Understand the current core capacity at the point of entry.
f. Identify competent authorities and a committee for implementation of the plan.
3. Initiate the planning phase:
a. Create a template.
b. Ensure the plan is realistic and achievable.
4. Write the plan.
5. Review the plan.
6. Test the plan.
7. Obtain stakeholder sign-off (obtain approval for the plan from the relevant
ministerial level).
8. Conclude the planning phase.
9. Publish and communicate the plan.
10. Brief and train required personnel.
11. Schedule regular exercises.
12. Review, update and maintain the plan as required.

2.5.2.2. Public health response measures

The public health response to individual travellers, baggage, cargo, containers,
conveyances, goods and postal parcels with known or suspected exposure to a
chemical contaminant, radiological event or communicable disease largely depends
on the type of exposure and whether detection occurred before, during or after
travel. While air and marine travel often have distinct points of departure and arrival,
the public health response at ground crossings can be very challenging given the
nature of the movement at a ground crossing coupled with the variability or absence
of administrative controls at many crossings. It is this variability in administrative
controls and structure that highlights the importance of integrating the ground
crossing into the national surveillance and response structure.
Table 3 illustrates some response capacities that could be in place to address
sick travellers – as well as baggage, cargo, containers, conveyances, goods and
postal parcels – before, during and after travel. Public health measures at borders
should be conducted in a way that protects the rights and dignity of travellers and
minimizes disruption of travel and trade, including avoidance of border closures in
almost all cases.

2
International health regulations (2005): a guide for public health emergency contingency planning at designated points of
entry. Geneva: World Health Organization; 2012 (https://apps.who.int/iris/bitstream/handle/10665/206918/9789290615668_eng.
pdf?sequence=1&isAllowed=y, accessed 10 October 2019).

20
Table 3. Response capacities before, during and after travel

Response capacity Before travel During travel After travel

Contact-tracing A serious illness Conduct contact-
on a conveyance tracing for those
(i.e. bus or train) persons who may
may prompt the have been exposed
collection of contact on the conveyance.
information from
Determine the
fellow travellers.
traveller’s point of
Determine the origin and other
traveller’s point of locations along
origin and other the journey where
locations along exposures might
the journey where have occurred.
exposures might
have occurred.
Communications Inform travellers of Conduct risk Find a mechanism to
disease information, communication on provide feedback on
precautionary specific disease sick travellers to the
advice, health information, country of origin.
measures adopted precautionary
at a ground crossing, advice, and where
risk communication to seek help if signs
etc. and symptoms
develop.
Education Educate or counsel Provide public Provide public
travellers about health information health information
delaying travel or to ill travellers and to ill travellers and
other measures (e.g. potential contacts. potential contacts.
isolation).
Health declaration Detect signs of Have trained staff Have trained staff
and medical symptoms and available to conduct available to conduct
evaluation history of exposure assessments of assessments of
manifested through overtly ill travellers overtly ill travellers.
health declaration, identified at the
plus vigilant ground crossing.
observation of overt
illness.
Isolation Provide temporary N/A Provide temporary
facilities or nearby facilities or nearby
hospitals/clinics hospitals/clinics
to isolate the sick to isolate the sick
traveller. traveller.
Medical facilities Provide reasonably Provide reasonably Provide reasonably
timely transportation timely transportation timely transportation
and access to and access to and access to
medical facilities for medical facilities for medical facilities for
further evaluation further evaluation further evaluation
and laboratory and laboratory and laboratory
testing if required. testing if required. testing if required.

21
 Response capacity Before travel During travel After travel
Quarantine Implement N/A Follow up with
community-level communities on
controls such as quarantine of
quarantine to restrict travellers exposed to
the movement public health risks.
of travellers with
exposure history.
Review of relevant Determine whether N/A Determine if a
health documents a traveller is to be traveller poses
(e.g. vaccination exposed to a public public health risks.
certificate) health risk.
Screening Prevent the travel of N/A Increase health
an affected traveller awareness, active
through a ground case-finding through
crossing or other reviewing the health
POE. declaration, and
focused medical
evaluation.
Travel restrictions Prevent the travel of Prevent the further Prevent the further
an affected traveller travel of an affected travel of an affected
through a ground traveller through a traveller through a
crossing or other ground crossing or ground crossing or
POE. other POE. other POE.
Watch lists Monitor available N/A Monitor available
national and national and
international international
“watch lists” to “watch lists” to
detect ill travellers detect ill travellers
who intend to who intend to
cross borders. This cross borders. This
capacity requires capacity requires
well developed alert well developed alert
and communication and communication
systems between systems between
countries. countries.
Border closure and While border closure may seem an attractive political option to
control prevent the spread of a communicable disease across international
land borders, evidence that closing a border is an effective disease
prevention measure is scant-to-nonexistent, and the negative
economic and social consequences can be significant. Closing
land borders can have the opposite effect of increasing the risk of
spread by encouraging travellers to take uncontrolled routes across
the border. In addition, as per Article 43 of the IHR, restrictive
measures such as closing a border should be avoided when
reasonable alternative measures are available and would achieve a
similar level of health protection.
Similarly, implementation of border health measures that slow
and impede travel, such as extensive health-screening processes,
may discourage travel through official ground crossings, causing
travellers to bypass the public health intervention.

22
2.5.2.3 Challenges to implementing an effective response at ground crossings, espe-
cially in remote border areas, include:
• ill or exposed travellers purposely avoiding crossing borders at supervised
ground crossings (public health measures implemented at POE may therefore
need to be extended at travellers’ transit and congregation points beyond the
border areas);
• staff turnover or limited staffing, with difficulties in maintaining trained staff;
• little or no advance warning of the arrival of an ill or exposed traveller at a
border post;
• lack of basic supplies;
• lack of safe and reliable medical transport;
• large distances from the nearest health-care facility;
• unreliable communications infrastructure and mechanisms.
Thus, an effective event management strategy at land borders is to strengthen
disease surveillance in high-risk border regions. Health officials in these regions
should put in place enhanced surveillance systems which can involve community
leaders in reporting events of potential public health significance, mapping of
known travellers’ transit and congregation points through participatory population
movement, establishing clear cross-border communication pathways for notifiable
events and linking ground crossing officials to such systems.

2.5.2.4 Event management

Response officials should tailor the interventions to the event, including through
(additional) event-specific risk assessments, and should have predefined triggers
for implementation, escalation or de-escalation, and return to steady state. The
volume, frequency and type of cross-border movement of travellers, animals, cargo,
conveyances etc. should be subject to a risk analysis in order to put in place an
adequate plan of inspection and adoption of public health measures as required.
Event management preparedness and response activities should include a number
of important measures, namely:
• Population movements across and along the border should be mapped to
assess the pathways and the congregation points of cross-border population
movements.
• The likelihood of transmission (accounting for clinical and environmental
factors) and the feasibility of carrying out the measures (based on information
and resources) should also be considered as part of the risk analysis process.
• Control measures (i.e. disinsection, deratting, disinfection, decontamination
and treatment) are critical factors in an effective response. The necessary
equipment, resources, trained staff, adequate infrastructure and areas for
applying the control measures must be identified.
• In order to prepare properly for and respond to a public health event,
trained staff should understand the epidemiological situation at the ground
crossings, as well as the applicable sampling and testing protocols, vector

23
 control measures, and all other relevant standard operating procedures and
protocols that may apply.
Based on the nature of the emergency, some additional factors may play a
significant role in the spread of diseases and could be taken into consideration
if applicable. These factors include the movement of animals through known
areas or at specific periods (e.g. seasonal migratory routes for birds and/or
mammals) and climate threats (e.g. rainfall, temperature, wind movements,
global radiation, air humidity).
Management of a public health event with a risk of cross-border spread or in
border communities should be aligned with local, regional or national response
plans. Special considerations include the potential implementation of public health
interventions at designated and nondesignated ground crossings, transit routes and
congregation points, and the need to coordinate response efforts with national,
intermediate and local authorities on both sides of the border. In larger responses
requiring multisectoral participation, coordination of response through a command
and control structure involving one or more emergency operation centres is likely to
apply. In such situations, ground crossings and border district public health authorities
should be part of the established incident management structure with clearly defined
roles and responsibilities. Domestic and cross-border up-to-date contact lists should
be maintained by all stakeholders for both routine and emergency operations.
Clearly identified lines of cross-border communications and decision-making to
facilitate timely notification of cross-border partners are critical for effective response
and resource utilization. Stakeholders should understand how the established
standard operating procedures and national emergency response plans are linked
to regional plans and what threshold or event would trigger the notification of
international organizations such as WHO.

Chapter # Toolbox
Public health preparedness at points of entry (https://apps.who.int/iris/bitstream/hand
le/10665/206918/9789290615668_eng.pdf?sequence=1&isAllowed=y, accessed 10 October 2019).

2.6 Environmental health

2.6.1 Overview
Environmental health capacities serve as fundamental preventative measures to
maintain ground-crossing facilities in a sanitary condition and thereby to reduce factors
that may have an adverse impact on health. The development of these capacities
may present a particular challenge to resource-poor States Parties; consequently,
opportunities to collaborate across borders to maximize resources for the mutual
development of capacities at the ground crossing should be explored. Additionally,
collaboration both within and between neighbouring countries promotes effective
and timely information-sharing and data management with the relevant stakeholders
in order to address environmental health concerns.

24
Performing a risk assessment is the best way to show which capacities should be
developed commensurate with the risk profile of a ground crossing, and therefore
additional considerations may need to be taken beyond the essential capacities.
Essential environmental capacities such as vector control, solid and liquid waste
management, potable water and general sanitation are outlined in this guidance
as crucial for all ground-crossing settings. The resources required to achieve these
capacities should be planned both for routine operations and for responding to a
public health event.
This section provides an overview of selected environmental health capacities. Risk-
based assessments and resource availability will guide the necessity and extent to
which each of these capacities are to be developed within a country-specific context.

2.6.2 Operational considerations

Vector and reservoir control
Vector surveillance and control at ground crossings is an effective method to reduce
the risk of transmission of pathogens imported with vectors and reservoirs, as well as
prevent the dispersal of local vectors to other countries (Table 4).
Table 4. Considerations when implementing a vector control programme

An integrated vector and reservoir control programme in place

Development of an integrated vector and reservoir control programme includes
identification of risk, establishment of threshold levels, inspection, employment
of control measures and evaluation of effectiveness. The programme should
include special arrangements or agreements/contracts with all service providers.
The programme should also focus on the coordination between neighbouring
countries to address gaps in vector and reservoir control and to synchronize the
preventive and response measures. The programme needs to be developed and
implemented with the involvement of local communities in order to increase the
acceptance of the planned health measures.
Trained personnel for control of vectors and reservoirs
An adequate number of personnel must be available with appropriate training
and knowledge to detect and control the public health risks of vectors and
reservoirs, as well as to oversee and audit services and facilities of the ground
crossing and surrounding areas.
Monitoring of vectors at the ground crossing facility and in the surrounding area
Monitoring should be maintained and updated for routine operations and
emergencies. The monitoring should include baseline information on vectors and
reservoirs, detection and identification, testing for pathogens, and effectiveness
of control measures such as disinsection and deratting. Results of the latest audit
of services and facilities should be available and accessible.

25
 Dedicated space, equipment and supplies for use by vector and reservoir
control staff
A dedicated and secure space/room should be available for use by vector
and reservoir control staff and for the storage of public health equipment
and supplies, including: insecticides, rodenticides, traps and application
equipment, equipment for inspection, and a workplace and supplies for staff
to prepare inspections, complete reports and prepare, calibrate and store
sampling equipment.
Demonstrating knowledge
Ground-crossing facility staff should be able to demonstrate knowledge of the
use of correct control methods for relevant vector-borne diseases and for hosts
and vectors.

Waste management
A safe environment for travellers using ground-crossing facilities requires a proper
waste management system to be in place. The competent authorities are therefore
responsible for the management/supervision of the removal and safe disposal of any
contaminated water or food, human or animal dejects, wastewater and any other
contaminated matter (Table 5).
Table 5. Considerations when implementing a waste management programme

Develop a waste management plan

A documented, tested and updated solid and liquid waste management
programme, including for medical wastes, should be in place. The plan should
include actions for both routine operation and emergencies, with standard
operating procedures for safe transport and final destination of the solid and
liquid waste generated and/or treated at the point of entry. The plan should be
developed and signed off with both health and non-health sectors responsible
for waste management at a specific ground crossing.
Trained personnel
An adequate number of personnel with appropriate training and knowledge
should be available to manage and oversee waste management practices and
facilities at ground crossings.
Monitoring of waste management
All present and potential public health risks from solid and liquid waste are
detected and assessed, and recommended control measures are implemented.
Records are maintained and testing results are documented and available,
covering: public collection within the boundaries of the ground crossing,
cargo and container terminals, infrastructure and courtyards, transport and
waste service providers for conveyances, and waste services for dangerous
waste (medical/infectious, chemical, cutting instruments and sharps etc.).
Contamination of potable water may result from inadequate waste management.
Health concerns must be addressed in the waste management monitoring
system.

26
 Designated facilities, equipment and supplies
Access to appropriate disposal facilities/systems should be in place. Waste
management containers must be leakproof, identified as to their contents,
constructed of material that can be cleaned easily and covered when not in use.
Waste management containers must be sufficient in number, accessible and
emptied on a regular basis. Containers must not be stored or maintained in a
manner that would attract or harbour vectors.
Demonstrating knowledge
Staff should be able to demonstrate knowledge of solid and liquid waste
treatment and control methods, systems for detection and assessment, and
recommended control measures for present and potential risks from solid and
liquid waste.

Potable water
Assuring the safety and quality of the potable water supply additionally contributes
to the safe environment for travellers and others using ground crossings (Table 6).
Table 6. Considerations for ensuring the safety and quality of potable water

Develop a management plan for potable water

A water safety programme should address all water safety risks, including
suppliers, water storage tanks, water vehicles, drinking-water fountains, and
potential cross-connection and backflow hazards. The plan should be developed
and signed off with both health and non-health sectors responsible for the
potable water supply chain.
Trained personnel
An adequate number of personnel should have the training and knowledge to
manage, maintain and monitor potable water, plus water management practices
and facilities at ground crossings.
Monitoring potable water
A documented, tested and updated water safety programme should be in
place for both routine operation and emergencies. The programme should be
conducted by, or under the supervision of, a competent authority, ensuring that
records are maintained and testing results are documented and available.
Water quality, including the effect of disinfection, should be monitored regularly
to ensure that all present and potential public health risks from water supply
are detected and assessed, and that recommended control measures are
implemented. The programme’s agenda, plus dates and results of testing
and inspection, should be recorded and communicated, as appropriate, to
neighbouring countries that share the same water source.
Potable water sources should be kept under surveillance and supervision in
secure places, far away from sources of pollution, and approved by the relevant
health authority. Potable water quality should conform to the standards outlined
in local and/or national standards/legislation.

27
 Designated facilities, equipment and supplies
Potable water facilities and equipment should be maintained in good operating
order and should be serviced regularly.
An adequate supply of potable water should be available. This supply should
be sufficient to meet the peak demand of the ground crossing facility. In
the event of contamination of the water source, a plan should be in place to
ensure an alternative supply of sufficient and safe potable water, especially for
emergencies.
Demonstrating knowledge
Staff should demonstrate a knowledge of water safety management – i.e.
knowledge of correct practices, especially with regard to the source, storage,
distribution, treatment and control methods.

General sanitation
The competent authorities at a point of entry are obliged to ensure that the premises,
and the conveyances and goods passing through, are kept free from sources of
infection and contamination in order to mitigate the international spread of public
health risks (Table 7).
Table 7. Considerations regarding general sanitation

Develop a management plan for sanitation

The sanitation management plan should include details of roles and
responsibilities, cleaning schedules and standard operating procedures for both
routine operation and emergencies.
Trained personnel
There must be an adequate number of personnel with training and knowledge
in cleaning and sanitation practices to carry out these activities effectively at a
ground crossing.
General sanitation monitoring
The frequency of cleaning should be documented and records made available.
During public health emergencies, enhanced measures should be implemented
and documented. Additionally, the solid and liquid wastes generated should
be treated according to the emergency waste management plan and standard
operating procedures.
Designated facilities, equipment and supplies
Buildings and structures should be designed and constructed in a way that
facilitates the maintenance of a hygienic environment.
Public washroom premises should be consistent with the volume of travellers and
frequency of travel and should be in good operational condition. The washroom
premises should be cleaned regularly and hygienically, with consideration for the
volume of passengers and personnel using the terminal and other facilities at the
point of entry.
Demonstrating knowledge
Staff should be able to demonstrate knowledge of the use of correct
methods and an understanding of techniques for cleaning, disinfection and
decontamination.

28
Chapter # Toolbox
• Assessment tool for core capacity requirements at designated airports, ports and ground
crossings (https://apps.who.int/iris/bitstream/handle/10665/70839/WHO_HSE_IHR_
LYO_2009.9_eng.pdf?sequence=1&isAllowed=y, accessed 10 October 2019).
• Guidelines for drinking-water quality (http://apps.who.int/iris/bitstream/hand
le/10665/254637/9789241549950-eng.pdf?sequence, accessed 10 October 2019).
• Handbook for vector surveillance and control at ports, airports, and ground crossings
(https://apps.who.int/iris/bitstream/handle/10665/204660/9789241549592_eng.
pdf?sequence=1&isAllowed=y, accessed 10 October 2019).
• Water, sanitation and hygiene in health care facilities (https://apps.who.int/iris/bitstream/
handle/10665/154588/9789241508476_eng.pdf?sequence=1&isAllowed=y, accessed 10
October 2019).

29
Part B: Considerations for collaboration at ground
crossings

3.1 Overview
The IHR articles 21.2, 44 and 57.2 address the value of cross-border collaboration
and provide a legal framework for it. Cross-border collaboration reinforces and
augments existing capacities in a ground-crossing setting by harmonizing resources,
strengthening coordination and communication, and expanding/complementing
joint operations/efforts. Effective collaborative agreements can have a significant
impact on border health capacities.
In many cases, the development of effective national-level collaborative agreements
has evolved from the development of small, local cross-border pilot projects to
enhance public health communication and collaboration. Smaller-scale pilot or
disease-specific or event-specific collaborative projects across borders may help to
establish the conditions and lessons learned for successful longer-term binational
collaboration. Similarly, collaborative arrangements at ground crossings are likely to
be driven by and carried out in accordance with binational collaborative agreements.
Encouraging local and national agreements that support cross-border collaboration
on local prevention or control of diseases which threaten to spread internationally
strengthens IHR implementation and increases collective health security. These
collaborative agreements may include:
• harmonizing public health surveillance and control measures, including timely
identification of cases associated with ground crossings or other international
travel;
• establishing cross-border communication/coordination protocols or mecha-
nisms to enable timely information-sharing at the local level (e.g. local/bina-
tional committees);
• ensuring proper environmental and health-care conditions for the populations
sharing the border;
• coordinating available resources to maximize the efficiency of the response
(e.g. by referring sick travellers to a health-care facility on the other side of the
border if that will facilitate more timely medical evaluation and treatment);
• considering binational surge capacity if the impact of a public health emergency
affecting a border region is likely to be greater on one side of the border than
the other, or if one country has more resources available in the region than the
other.
The handbook encourages opportunities and considerations for joint/cross-border
synergies. Part A provides overall operational guidance while Part B outlines planning
elements for formalized cross-border collaboration.

30
3.2 Opportunities to collaborate – guiding questions
A series of guiding questions has been provided in the five-part Table 8 below and
should be considered as part of an overall strategy when exploring opportunities to
collaborate binationally or within a region.
Table 8. Guiding questions when defining a strategy on cross-border collaboration

Table 8a. Cross-border considerations – Joint Designation

Binational and regional information-sharing capacities
1. Has information on the disease burden been communicated? For instance:
• areas with diseases of international concern, and
• seasonal changes in disease patterns.
2. Is information on population movements shared between States Parties? For instance:
• cross-border movement that may have an impact on the international spread of disease,
• higher volumes of cross-border movement, and
• seasonal changes in movement patterns.
3. Are there opportunities to collaborate on current or planned interventions? For instance:
• additional training for community surveillance volunteers,
• increased laboratory capacity,
• immunization campaigns,
• engaging community leaders (e.g. healers, religious leaders), and
• establishing sentinel sites in health centres
4. Do the means exist to coordinate with cross-border counterparts to share information
about public health events such as outbreaks, intervention strategies, case definitions etc?
5. What legal frameworks, legal agreements, memorandums of understanding, other
agreements or joint technical committees are in place that may have an impact on cross-
border collaboration?

Table 8b. Cross-border considerations – Surveillance, building on existing integrated

disease surveillance and response (IDSR), community-based surveillance activities
1. Would entering into a collaborative arrangement for sharing information, data or
protocols be beneficial bilaterally or regionally?
2. Are there any opportunities to harmonize the capacities of surveillance systems by
entering into binational or regional collaborative arrangements?
3. Is there an opportunity or need to collaborate on the following reporting threshold
factors, namely:
• differences in case definitions,
• differences in priority diseases,
• differences in detection capacity, and
• differences in reporting frequency?
4. Is there an opportunity or need to collaborate on the following reporting format factors,
namely:
• differences in language, and
• differences in laboratory capacities, methods, reagents or sampling methods?
5. Are mechanisms in place for neighbouring countries to advise each other about travel-
related cases?

31
 Table 8c. Cross-border considerations – Communications
1. Have cross-border points of contact been identified for reporting and receiving
notification of public health events?
2. Have different sectors/stakeholders been considered in communication plans? Strategies
to collaborate and coordinate by using a multisectoral approach should be considered.
3. Are there opportunities to collaborate on social mobilization efforts?
4. Are there procedures at the central level to collaborate on drafting press releases?
5. Can communications strategies be coordinated and/or harmonized? For instance:
• message content, and
• timing of communication campaigns.
6. Are there opportunities to collaborate on communication between border health
authorities, referral clinics/hospitals and transportation services?
7. Is there an opportunity to exchange maps of livestock migration routes and border
livestock markets?

Table 8d. Cross-border considerations – Preparedness and response

Medical and public health service capacities
1. Is there a need to collaborate on the collection of information on cross-border cases and
community connectivity? For instance:
• incorporate travel history and travel intent in initial investigations,
• register, follow up and monitor/control case movement, and
• when mass cross-border movement is identified, immediately coordinate (i.e. surge
capacity).
2. Would additional collaboration and coordination with nearby health facilities or referral
health facilities be beneficial?
Response plans and training capacities
3. Is there an opportunity to collaborate regarding resources for public health event
management at ground crossings (i.e. provision of isolation, quarantine, referral
hospitals/clinics, stocks of medicines/vaccines)?
4. Is there an opportunity to collaborate on laboratory services such as sample collection,
storing, packaging and transport?
5. Is there a need to collaborate on the coordination of control strategies (i.e. vector
control, vaccination)?
6. Is there an opportunity to conduct joint training exercises, or cross-border table-top and/
or simulation exercises?
7. Are there opportunities to collaborate on cross border public health response
challenges? For instance:
• differences in rapid response team design,
• differences in emergency operation centre design, and
• differences in screening measures at borders.

32
 Table 8e. Cross-border considerations – One Health
1. Is there a need to exchange maps of livestock migration routes and border livestock
markets?
2. Are there needs and opportunities to collaborate on capacity-building in diagnosis and
response of emerging and re-emerging zoonosis diseases for both human and animal
sectors?
3. Is there an opportunity to collaborate on control of cross-border livestock movement
through joint animal health inspection and certification?
4. Is there a need to collaborate in animal quarantine measurement at the ground crossing?

3.3 Components of a cross-border collaborative agreement

The strategic risk assessment process may lead to opportunities to enter into cross-
border collaborative arrangements. The following elements should be taken into
consideration when developing a cross-border collaborative agreement:
• political commitment,
• identification of key stakeholders,
• clearly identified objectives and desired outcomes,
• identification of hazard(s),
• the scope and level of cooperation,
• operational considerations,
• complementary communication and technical mechanisms,
• leveraging existing agreements, and
• financial resources.

Political commitment
Political will on both sides of the border is a fundamental element of any cross-
border collaborative agreement. Agreements are often complex undertakings that
require both political and public will to align for an agreement to be successful.
The basic elements of any agreement are likely to require the government to invest
financial, human, material and other resources. Without the necessary political
commitment and influence, any potential agreement is at great risk of not being
realized. The political commitment becomes even more significant if it is reflected in
and endorsed by national legislation.

An example of political commitment

It is important to acknowledge the countries and authorities which have reached
understandings and have entered into agreements for cross-border collaboration.

Key stakeholders
The first step in the cross-border collaborative process is to identify key stakeholders,
followed by identification of their existing cross-border collaborative mechanisms,

33
including non-health ones, that could host or facilitate health ones. For instance,
taking a One Health approach, non-traditional public health counterparts such
as ministries of agriculture, environment or livestock could be integrated into a
stakeholder analysis to facilitate operational considerations on animal health,
environmental health or related commercial trade.
This multi-stakeholder process will assist in identifying critical gaps as well as
collaborative actions to address the gaps in terms of technical and resource
mobilization. A comprehensive and up-to-date stakeholder contact list is essential
to the successful implementation of this component.

Examples of key stakeholders

Examples include areas such as agriculture, environment, finance, intergovernmental
organizations, livestock, plants, transport, trade etc.

Objectives
The objectives outlined in a collaborative agreement should be specific to the
disease or to the public health issue of concern. Governmental and nongovernmental
stakeholders should endeavour to articulate a common understanding of the issue
and should link the objectives of the collaborative agreement to larger national
agendas. It is imperative to document achievable and measurable objectives within
an agreement in order to reach the desired outcomes. Any outcomes identified in
collaborative agreements should also have mutually agreed timelines or milestones
in order to be successful.

An example of a statement of objectives

The agreement aims to strengthen public health capabilities in cross-border disease
surveillance, risk assessment, preparedness and coordinated response to public
health events that have potential to cause international spread through cross-border
movement at a specific ground crossing.

Prioritized hazard(s)
Hazards may be biological, zoonotic, chemical or radiological. The strategic risk
assessment process supports the assessment of public health hazards that are
significant for a specific ground crossing and the adjacent border communities.
Sources of information that may assist in the identification of hazards include previous
disease information in the region, epidemiological studies, data on the health-
care system, clinical data, surveillance data and trends, and academic/research
information. The agreement should state the priority diseases, including zoonotic
diseases, and public health events that are associated with a specific ground crossing.

An example of a statement of prioritized hazard(s)

The priority diseases are cholera, Ebola, plague, vector borne diseases, vaccine-
preventable diseases, and outbreaks of emerging/re-emerging infectious diseases
– including zoonotic diseases and chemical or radiological incidents affecting
neighbouring countries.

34
The scope and form of cooperation
The scope and form of cooperation with counterparts across borders are important
for public heath collaboration. Counterparts should agree a communications plan,
the type and frequency of meetings, training events, financial commitments and, if
applicable, the application of public health measures. When determining activity
schedules, resource considerations such as funds required for travel, meetings,
training, translation and other activities should be factored into any agreement.

Examples of the scope and form of cooperation:

These include:
• a coordination committee comprised of national coordinators assigned by
participating countries/districts;
• information and data exchange on diseases and public health events;
• experience and best practice shared through defined means/platforms;
• health care networking and sharing of resources;
• laboratory capacity-strengthening and networking;
• joint human resource development through exchange of experts, training and
site visits;
• coordinated response, including active case-finding through screening.

Operational considerations
Available resources, both human and operational, should be taken into consideration
when developing a collaborative agreement because one State Party’s capacities –
as such as laboratory capacities – may be more developed or better situated than
those in neighbouring countries. Other operational considerations such as potential
differences in case definitions, outbreak notification thresholds and laboratory
methods should be harmonized whenever possible.
An additional cross-border requirement is for free and open, systematic and routine
cross-border exchange of important public health information at the local/district
level. This information exchange must respect the sovereignty of each country and
the national public health surveillance system procedures of each State Party.

Examples of operational considerations

• Cross-border partners should consider harmonizing case definitions and
unique identifiers to use for binational case identification in border districts.
• Travel history data may include:
– contact with persons who lived or travelled in the neighbouring country
since the contagious period began;
– contact with persons who lived or travelled in the neighbouring country
since the incubation period began;
– travel history since the initial epidemiological link and/or incubation period
began.

35
 • Incident cases or communicable disease contacts that occur in non-border
jurisdictions may be included in cross-border surveillance reports if the travel
history suggests possible border region or cross-border travel.
• Information-sharing agreements should be developed between laboratories
where possible.

Complementary communication and public health measures

Complementary communication and public health measures are necessary to
achieve the desired outcomes of a collaborative agreement. Complementary
communication and collaboration protocols should be established to enable near-
simultaneous cross-border notification to appropriate public health authorities in
order to avoid delays in response. These cross-border communication protocols
should include criteria for notification similar to those recommended for national
notification, designated points of contact and alternates, and emergency contact
information. When clear and timely, cross-border communication can be critical to
minimize the international risk and impact of public health threats.
Information-sharing can facilitate strengthened preparedness by collating public
health surveillance data in a binational or multinational geographical region to enable
population-based analysis of, for instance, disease incidence and spread. This type
of collaboration can be initiated and sustained through joint designation of shared
ground crossings (IHR Article 21.2), formal agreements for cross-border information-
sharing, collaboration in response at the local, intermediate and national levels, and
for disease- or event-specific collaborative projects.
The application of public health measures that may cross borders – such as mass
vaccination plans, social mobilization activities or vector control programmes
– should be coordinated across borders whenever possible in order to maximize
impact.

Example of complementary communication and public health measures

• Jointly conduct risk-mapping at ground crossings and adjacent border regions
in order to identify border areas of high risk due to cross-border movement.
• Jointly define criteria for notification of public health events.
• Exchange knowledge and information relating to diseases or other public
health risks, health promotion and risk communication, hygiene and sanitation,
and human resource development for ground crossings and nearby border
communities.
• Identify health measures (e.g. early detection, investigation, quarantine,
isolation, contact tracing, etc.) as a joint disease defence mechanism that
prevents or controls the spread of the disease nationally and internationally
among the participating countries.

36
Leveraging existing agreements
States Parties are encouraged to establish formal agreements and standard operating
procedures at the local level for timely sharing of information necessary for a public
health response. These agreements may be binational or multinational in scope.
Leveraging existing agreements between countries on a binational or district basis
may be necessary in order to develop and strengthen critical partnerships across
national land borders at the district and ground-crossing levels. These agreements
should be communicated to the national, provincial and local governments in order
to ensure that all stakeholders are aware of the agreements and the impact they may
have at the various levels of government.

An example of leveraging existing agreements

The cross-border agreement is subject to the legislation in each country that is
party to the agreement. Therefore, participating countries are encouraged to
leverage their existing cooperation with regard to direct and rapid exchange of
public health information between the neighbouring territories of different states.
Such information should include public health measures to be applied in adjacent
territories of different states at their common frontier, arrangements for carrying
affected persons or affected human remains by means of transport specially adapted
for the purpose, and the deratting, disinsection, disinfection, decontamination or
other action designed to render goods free from disease-causing agents.

Financial resources
Establishing collaborative agreements between neighbouring countries and
supporting such initiatives financially can be a challenge for both developed and
less-developed countries. The scope of cross-border collaborative activities will need
to be prioritized within existing funding resources. Engaging multiple stakeholders
– which may include government ministries, traditional community leaders, the
leadership of nongovernmental organizations, business leaders and other civil
society partners, including conveyance operators – may help in securing funding to
realize these collaborative agreements.

An example of financial resources

Participating countries will consider and establish a joint mechanism to mobilize
financial resources in order to support implementation of identified activities in each
country.

37
REFERENCES

(1) Ajalla MEA, Andrade SM, Tamaki EM, Waissmann W, Diettrich SH, Silva
BA. The context of leprosy in Brazil-Paraguay border. Ciênc Saúde Colet.
2015;21(1):225-32.
(2) An introduction to risk communication. Geneva: World Health Organization;
2014 (https://www.who.int/risk-communication/introduction-to-risk-
communication.pdf, accessed 18 October 2019).
(3) Arsuaga M, de la Calle-Prieto F, Negredo Antón A, Vázquez González A.
Emerging viral infections and hepatotropic virus]. Enferm Infecc Microbiol
Clin. 2016;34(8): 508-15.
(4) Balajee SA., Arthur R, Mounts AW. Global health security: building capacities
for early event detection, epidemiologic workforce, and laboratory response.
Health Secur. 2016;14(6):424-32.
(5) Bharati K, Ganguly NK. Tackling the malaria problem in the South-East Asia
Region: need for a change in policy? Indian J Med Res. 2013;137(1):36-47.
(6) Bhatnagar N, Grover M, Kotwal A, Chauhan H. Study of recent Ebola virus
outbreak and lessons learned: a scoping study. Ann Trop Med Public Health.
2016;9(3):145-51.
(7) Bond KC, Macfarlane S, Burke C, Ungchusak K, Wibulpolprasert S. The
evolution and expansion of regional disease surveillance networks and their
role in mitigating the threat of infectious disease outbreaks. Emerg Health
Threats. 2013;6.
(8) Border health capacity discussion guide. Atlanta (GA): US Centers for Disease
Control and Prevention; 2017.
(9) Strengthening public health leadership in Central America and the Dominican
Republic. Atlanta (GA): US Centers for Disease Control and Prevention;
2018 (https://www.cdc.gov/globalhealth/stories/comisca.htm, accessed 18
October 2019).
(10) Traveler’s health (online). Atlanta (GA): US Centers for Disease Control and
Prevention (http://wwwnc.cdc.gov/travel, accessed 18 October 2019).
(11) Cetron M. The changing patterns of global migration and the impact on
infectious diseases. Int J Infect Dis. 2010;14:e18-e19.
(12) Cohen D, Gargouri N, Ramlawi A, Abdeen Z, Belbesi A, Al Hijawi B et al.
A Middle East subregional laboratory-based surveillance network on
foodborne diseases established by Jordan, Israel, and the Palestinian
Authority. Epidemiol Infect. 2010;138(10):1443-8.

38
(13) Cohen NJ, Brown CM, Alvarado-Ramy F, Bair-Brake H, Benenson GA, Chen
TH et al. Travel and border health measures to prevent the international
spread of Ebola. MMWR Suppl. 2016;65(3):57-67.
(14) Communicable disease control in emergencies. A field manual. Geneva:
World Health Organization; 2005 (http://apps.who.int/iris/bitstre
am/10665/96340/1/9241546166_eng.pdf, accessed 18 October 2019).
(15) Coordinated public health surveillance between ground crossing and
national health surveillance systems: advising principles. Geneva: World
Health Organization; 2018 (Document WHO/HSE/GCR/LYO/2018.41).
(16) Cui L, Yan G, Sattabongkot J, Cao Y, Chen B, Chen X et al. Malaria in the
Greater Mekong subregion: heterogeneity and complexity. Acta Trop.
2012;121(3):227-39.
(17) International health regulations (2005): a guide for public health
emergency contingency planning at designated points of entry. Geneva:
World Health Organization; 2012 (https://apps.who.int/iris/bitstream/ha
ndle/10665/206918/9789290615668_eng.pdf?sequence=1&isAllowed=y,
accessed 18 October 2019).
(18) Edelson PJ, Phypers M. TB transmission on public transportation: a review of
published studies and recommendations for contact tracing. Travel Med Infect
Dis. 2011;9(1):27-31. doi: 10.1016/j.tmaid.2010.11.001. Epub 2010 Dec 17.
(19) Gao S, Mioc D, Anton F, Yi X, Coleman DJ. Online GIS services for mapping
and sharing disease information. Int J Health Geogr. 2008;7:8.
(20) Gateway to health communication and social marketing practice. Atlanta
(GA): Centers for Disease Control and Prevention; 29 April 2013 (http://www.
cdc.gov/healthcommunication/, accessed 18 October 2019).
(21) Generic public health preparedness in Europe. Brussels: European Commission;
2011 (https://ec.europa.eu/health/sites/health/files/preparedness_response/
docs/gpp_technical_guidance_document_april2011_en.pdf, accessed 18
October 2019).
(22) Greece: assessing health-system capacity to manage sudden, large influxes
of migrants. Geneva: World Health Organization; 2015 (http://www.euro.
who.int/en/health-topics/health-determinants/migration-and-health/
publications/2015/greece-assessing-health-system-capacity-to-manage-
sudden,-large-influxes-of-migrants-2015, accessed 18 October 2019.
(23) Gresham LS, Smolinski M, Suphunchaimat R, Kimball AM, Wibulpolprasert
S. Creating a global dialogue on infectious disease surveillance: connecting
organizations for regional disease surveillance (CORDS). Emerg Health
Threats. 2013;6.
(24) Gustavsen K, Sodahlon Y, Bush S. Cross-border collaboration for neglected
tropical disease efforts: lessons learned from onchocerciasis control
and elimination in the Mano River Union (West Africa). Global Health.
2016;12(1):44.

39
(25) Information to States Parties regarding determination of fulfilment of IHR
national Core Capacity requirements and potential extensions. Geneva:
World Health Organization; 2014 (Document WHO/HSE/GCR/2014.9).
(26) International health regulations (2005). Assessment tool for core capacity
requirements at designated airports, ports, and ground crossings. Geneva:
World Health Organization; 2009 (Document WHO/HSE/IHR/LYO/2009.9).
(27) International Health Regulations (2005) and chemical spills. Geneva:
World Health Organization; 2015 (http://apps.who.int/iris/bitstream/ha
ndle/10665/249532/9789241509589-eng.pdf?sequence=1, accessed 18
October 2019).
(28) IOM supports cross border campaign to eliminate malaria in Southern
Africa [online]. Geneva: International Organization for Migration; 2014. Press
release, 4 November 2014 (https://www.iom.int/news/iom-supports-cross-
border-campaign-eliminate-malaria-southern-africa, accessed 31 May 2018).
(29) Health, border and mobility management. Geneva: International Organization
for Migration; 2016 (https://www.iom.int/sites/default/files/our_work/
DMM/IBM/updated/Health_and_Humanitarian_Border_Management.pdf,
accessed 31 May 2018).
(30) Jalloh MF, Bunnell R, Robinson S, Jalloh MB, Barry AM, Corker J et al.
Assessments of Ebola knowledge, attitudes and practices in Foröcariah,
Guinea and Kambia, Sierra Leone, July-August 2015. Philos Trans R Soc Lond
B Biol Sci. 2017;372(1721).
(31) Migration and health: key issues (online). Copenhagen: World Health
Organization Regional Office for Europe; 2016 (http://www.euro.who.int/
en/health-topics/health-determinants/migration-and-health/migrant-
health-in-the-european-region/migration-and-health-key-issues, accessed
18 October 2019).
(32) Mohr O, Hermes J, Schink SB, Askar M, Menucci D, Swaan C et al.
Development of a risk assessment tool for contact tracing people after
contact with infectious patients while travelling by bus or other public ground
transport: a Delphi consensus approach. BMJ Open. 2013;3(10):e002939. doi:
10.1136/bmjopen-2013-002939.
(33) Munier A, Njanpop-Lafourcade BM, Sauvageot D, Mhlanga RB, Heyerdahl L,
Nadri J et al. The African cholera surveillance network (Africhol) consortium
meeting, 10-11 June 2015, Lomé, Togo. BMC Proc. 2017; 11(Suppl 1):2.
(34) Natural ventilation for infection control in health-care settings. Geneva:
World Health Organization; 2009 (https://apps.who.int/iris/bitstream/ha
ndle/10665/44167/9789241547857_eng.pdf?sequence=1&isAllowed=y,
accessed 18 October 2019).
(35) Operational guidelines on cross-border control of priority communicable
diseases. New Delhi: World Health Organization Regional Office for South-
East Asia; 2001 (Document SEA-CD-124).

40
(36) O’Shannassy TO. Greater Mekong subregion (GMS): context. Southeast
Asian J Trop Med Public Health. 2013;44 Suppl 1:1-45 (discussion 306-7).
(37) Phommasack B, Jiraphongsa C, Oo MK, Bond KC, Phaholyothin N,
Suphanchaimat R et al. Mekong Basin Disease Surveillance (MBDS): a trust-
based network. Emerg Health Threats. 2013;6.
(38) PIP’s win-win in Moldova: leveraging national capacity-building for
neighbouring countries. Geneva: World Health Organization; 2015 (http://
www.who.int/risk-communication/country-stories/moldova-training/en/,
accessed 18 October 2019).
(39) Responding to communicable diseases in internationally mobile populations
at points of entry and along porous borders, Nigeria, Benin, and Togo. EID
Journal. 2017;23(13) (https://wwwnc.cdc.gov/eid/article/23/13/17-0520_
article, accessed 18 October 2019).
(40) SPHERE Handbook: humanitarian charter and minimum standards in
humanitarian response. Geneva: Sphere Project; 2018 (https://www.
spherestandards.org/handbook-2018/, accessed 18 October 2018).
(41) Varan AK, et al. Multinational disease surveillance programs for cross-border
epidemiologic information exchange. Am J Trop Med Hyg. 2014;91(5):219-20.
(42) Varan AK, Bruniera-Oliveira R, Peter CR, Fonseca-Ford M, Waterman SH.
Multinational disease surveillance programs: promoting global information
exchange for infectious diseases. Am J Trop Med Hyg. 2015;93(3):668-71.
(43) Vector surveillance and control at ports, airports, and ground crossings.
Geneva: World Health Organization; 2016 (https://apps.who.int/iris/bitstream/
handle/10665/204660/9789241549592_eng.pdf?sequence=1&isAllowed=y,
accessed 18 October 2019).
(44) Waterman SH, Escobedo M, Wilson T, Edelson PJ, Bethel JW, Fishbein DB.
A new paradigm for quarantine and public health activities at land borders:
opportunities and challenges. Public Health Rep. 2009;124:203-11.
(45) Weinberg M, Waterman S, Lucas CA, Falcon VC, Morales PK, Lopez LA et al.
The U.S.-Mexico Border Infectious Disease Surveillance Project: establishing
binational border surveillance. EID Journal. 2003;9(1) (https://wwwnc.cdc.
gov/eid/article/9/1/02-0047_article, accessed 18 October 2019).
(46) Weinberg M, Waterman S, Lucas CA, Falcon VC, Morales PK, Lopez LA et al.
The U.S.-Mexico Border Infectious Disease Surveillance project: establishing
binational border surveillance. Emerg Infect Dis. 2003;9(1):97-102.
(47) Whittaker M. Update from the Asia Pacific Malaria Elimination Network
(APMEN). Malaria J. 2012;11:S18.
(48) WHO guidance for the use of Annex 2 of the International Health Regulations
(2005): decision instrument for the assessment and notification of events that
may constitute a public health emergency of international concern Geneva:
World Health Organization; 2008 (Document WHO/HSE/IHR/2010.4).

41
(49) WHO interim guidance for Ebola virus disease: exit screening at airports,
ports, and land crossings. Geneva: World Health Organization; 2014 (http://
apps.who.int/iris/bitstream/handle/10665/139691/WHO_EVD_Guidance_
PoE_14.2_eng.pdf?sequence=1&isAllowed=y), accessed 18 October 2019).
(50) WHO outbreak communication guidelines. Geneva: World Health
Organization; 2005 (Document WHO/CDS/2005.28) (http://apps.who.int/iris/
bitstream/10665/69369/1/WHO_CDS_2005_28_eng.pdf?ua=1,accessed 18
October 2019).
(51) WHO outbreak communication planning guide. Geneva: World Health
Organizaton; 2008 edition (https://apps.who.int/iris/bitstream/hand
le/10665/44014/9789241597449_eng.pdf?sequence=1&isAllowed=y,
accessed 18 October 2019).
(52) Rapid risk assessment of acute public health events. Geneva: World Health
Organization; 2012 (https://apps.who.int/iris/bitstream/handle/10665/70810/
WHO_HSE_GAR_ARO_2012.1_eng.pdf?sequence=1&isAllowed=y,
accessed 18 October 2019).
(53) WHO Namibia and Angola welcomes historical cross border agreement
to close the net on malaria (online). Brazzaville: World Health Organization
Regional Office for Africa; 2018 (http://www.afro.who.int/news/who-namibia-
and-angola-welcomes-historical-cross-border-agreement-close-net-malaria,
accessed 31 May 2018).
(54) World Health Organization and Singapore hold fourth Asia-Pacific dengue
workshop (online). Manila: World Health Organization Western Pacific Region;
2018 (http://www.wpro.who.int/mediacentre/releases/2014/20140826/en/,
accessed 31 May 2018.
(55) International Health Regulations. Geneva: World Health Organization; 2005.
(56) World - travel advice on MERS-CoV for pilgrimages. Geneva: World Health
Organization; 2013.
(57) Handbook for the management of public health events in air transport.
Geneva: World Health Organization; 2015.
(58) Xu L, Stige LC, Kausrud KL, Ben Ari T, Wang S, Fang X et al. Wet climate
and transportation routes accelerate spread of human plague. Proc Biol Sci.
2014;281(1780). doi: 1098/rspb.2013.3159.
(59) Zhang J, Dong JQ, Li JY, Zhang Y, Tian YH, Sun XY et al. Effectiveness and
impact of the cross-border healthcare model as implemented by non-
governmental organizations: case study of the malaria control programs
by health poverty action on the China-Myanmar border. Infect Dis Poverty.
2016;5(1):80.

42
ANNEXES
Annex 1. Definitions
“Affected” means persons, baggage, cargo, containers, conveyances, goods,
postal parcels, or human remains that are infected or contaminated, or carry sources
of infection or contamination such as to constitute a public health risk.

“Contact-tracing” means the identification of persons who may have been exposed
to an infectious disease. It aims to identify new cases and respond to them in a timely
way, hence preventing the further spread of the disease.

“Contamination” means the presence of an infectious or toxic agent or matter on a

human or animal body surface, in or on a product prepared for consumption or on
other inanimate objects, including conveyances, that may constitute a public health
risk.

“Competent authority” means an authority responsible for the implementation and

application of health measures under the International Health Regulations (2005).

“Communicable disease” means a disease that is caused by a microorganism such

as bacteria, virus, parasite or fungi that can be spread, directly or indirectly, from one
person to another.

“Conveyance” means an aircraft, ship, train, road vehicle or other means of transport
on an international voyage.

“Conveyance operator” means a natural or legal person, in charge of a conveyance

or their agent.

“Designated point of entry” means airports, ports and certain ground crossings
designated by States Parties to develop the capacities set forth in Annex 1 of the
International Health Regulations (2005). These capacities include: an access to
appropriate medical services (with diagnostic facilities); services for the transport
of ill persons; trained personnel to inspect ships, aircraft and other conveyances;
maintenance of a safe environment; a programme and trained personnel for the
control of vectors and reservoirs; a public health emergency contingency plan; and
capacities for responding to events that may constitute a public health emergency
of international concern.

“Early warning and response” means the organized mechanism for the earliest
possible detection of any public health event requiring rapid investigation and
response.

“Event” means a manifestation of disease or an occurrence that creates a potential

for disease.

43
“Event-based surveillance” means the organized collection, monitoring, assessment
and interpretation of mainly unstructured ad hoc information regarding health events
or risks, which may represent an acute risk to human health. Event-based surveillance
is a functional component of early warning and response.

“Ground crossing” means a point of land entry in a State Party, including one
utilized by road vehicles and trains.

“Indicator-based surveillance” means the systematic (regular) collection,

monitoring, analysis and interpretation of structured data – i.e. of indicators produced
by a number of well-identified, mostly health care-based formal sources.

“International Health Regulations (2005)” is the international legal instrument that

is binding in 196 countries across the globe, including all WHO Member States. The
regulations aim to help the international community prevent and respond to acute
public health risks that have the potential to cross borders and threaten people
worldwide. The IHR, which were adopted by the Fifty-Eighth World Health Assembly
on 23 May 2005 and entered into force on 15 June 2007, require countries to report
certain health events to WHO. Building on WHO’s unique experience in global
disease surveillance, alert and response, the IHR define the rights and obligations
of countries to report events and establish a number of procedures that WHO must
follow in its work to uphold global public health security.

“National IHR Focal Point” means the national centre, designated by each State
Party, which shall be accessible at all times for communications with WHO IHR
Contact Points under the International Health Regulations (2005).

“Notification” is the mandatory or advised communication of information by a State

Party to WHO, as stated in article 6 of the International Health Regulations (2005).

“Point of entry” means a passage for international entry or exit of travellers,

baggage, cargo, containers, conveyances, goods and postal parcels, as well as
agencies and areas providing services to them on entry or exit.

“Public health emergency of international concern” is an extraordinary event

which is determined, as provided in the IHR (i) to constitute a public health risk to
other States Parties through the international spread of disease, and (ii) to potentially
require a coordinated international response.

“Public health risk” is the likelihood of an event that may affect adversely the health
of human populations, with an emphasis on one which may spread internationally or
may present a serious and direct danger.

“Reporting” is the process by which health events and health risks are brought to
the knowledge of the health authorities.

44
“Reservoir” means an animal, plant or substance in which an infectious agent
normally lives and whose presence may constitute a public health risk.

“Sentinel surveillance” means that a limited network of carefully selected reporting

sites, with a high probability of seeing cases of disease, is used as a source of case
reporting in order to signal trends, identify outbreaks and monitor the burden of
disease in a community as a rapid, economical alternative to other surveillance
methods.

“Surveillance” or “public health surveillance” means 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.

“Traveller” means a natural person undertaking an international voyage.

“Vector” means an insect or other animal which normally transports an infectious

agent that constitutes a public health risk.

“WHO IHR Contact Point” means the unit within WHO which shall be accessible at
all times for communications with the National IHR Focal Point.

45
Annex 2. How to apply the Strategic Risk
Assessment Tool

2.1 How to use this tool:

• Step 1. Assemble a strategic risk assessment team. The knowledge and
expertise of the team will greatly influence the quality of the strategic risk
assessment process. Additional expertise can be brought in at any time.
• Step 2. Identify suspect hazards, known hazards or public health concerns
associated with prioritized ground crossings. Much information on hazards
may already exist at the country or ground-crossing level, including general
risk, hazard analysis and mapping (Table A1). Additional public health and
related information can be collected from surveillance data. Country-specific
information can be combined with neighbouring country information if
available. Furthermore, this baseline information may contain key descriptions
of vulnerability, severity, coping capacity and likelihood.
• Step 3. Use tables A2, A3 and A4 as guides for the team to evaluate
vulnerability, severity and coping capacity assessments. The team needs to
evaluate only the factors relevant to the identified hazards. It should also be
noted that each question does not have to be asked for each identified
hazard as many capacities are cross-cutting and can be grouped into
broader categories (e.g. the capacity to have staff trained on personal
protective equipment in a laboratory setting will be cross-cutting for
many agents that requires laboratory diagnostic capabilities).
• Step 4. For each individual hazard identified through the hazard assessment
process, the strategic risk assessment team will use Figure A1 (the risk matrix
tool) to assign a level of risk (risk characterization process). In order to populate
the risk matrix, the team should complete the following steps:
– Step 4.a The strategic risk assessment team will use the information from
the hazard assessment to assign a qualitative descriptive value (between
very unlikely and almost certain) to the risk matrix tool to describe the
likelihood of the hazard occurring (Table A5).
– Step 4.b The strategic risk assessment team will use the information from
the vulnerability, severity and coping capacity assessments to assign a
qualitative descriptive value of minimal-to-severe to the impact of the
hazard occurring to the risk matrix tool.
o G
 uidance on how to assign a value to the impact of the hazard occurring
can be found in the formula presented in Table A6.
o G
 uidance on how to read the values generated by the impact formula risk
can be found in Table A7.

46
 • Step 5. Risk mitigation: the team will prioritize the capacity-development
activities driven by the overall level of risk (likelihood x impact), as determined
by the risk characterization process (Table A8). The team will also decide on
the risk mitigation actions required, as well as the minimum and additional
preparedness actions.
Note: A companion Strategic Risk Assessment Tool spreadsheet has been
developed to support the assessment.

2.2. Assessment factors

Table A1. Hazard assessment

A listing of all existing or emerging hazards with the potential to cause a health
emergency and that may have an impact on the ground crossing, based on public health
event data. Hazards may be biological, zoonotic, chemical or radiological.
1. Assess burden of diseases factors. Review records such as:
epidemiological studies
health-care system data
clinical data
existing mapping data on the distribution of high consequence communicable
disease, and
surveillance data and trends.
2. Evaluate data and linkages between available public health data, literature reviews,
studies and academic/research information.
3. Review immunization registries, vital statistics and any disparities.
4. Identify the type of hazard.

Table A2. Vulnerability assessment

Evaluate the potential vulnerabilities of the population to the hazards Comments
identified in the hazard assessment.
In consultation with local experts, stakeholders and local sources of
information, the strategic risk assessment team should use a series of
guiding factors and any other relevant local information about the hazard
to assign an vulnerability score to the hazard on a scale of 1 to 5. The score
will be subjective in nature and should be based on the best available,
accurate and recent information.
The vulnerability score will then be entered into the companion strategic
risk assessment tool spreadsheet to determine the hazard’s level of impact.
The assigned score from 1 to 5 would be as follows:

Exposure
1 Very low vulnerability
2 Low vulnerability
3 Moderate vulnerability
4 High vulnerability
5 Very high vulnerability

47
 Guiding factors to take into consideration when determining vulnerability:
• Identify geographical areas that are likely to be affected by the health consequences
and distribution factors (e.g. the number and location of chemical plants and the
chemicals they use).
• Identify and estimate the number of exposed persons at a ground crossing who may
contract a disease or who could become infected because of their lack of immunity (i.e.
the susceptible population at risk) in the case of a biological hazard.
• Identify and estimate the size and density of communities near ground crossings or
along associated transit routes.
• Identify and estimate the number of persons living in the high-risk area of the ground
crossing and adjacent border communities. In the case of a chemical or radiological
hazards, estimate:
o the duration of exposure;
o the risk of exposure to chemical or radiological substances, or vulnerability to natural
disasters.
• Identify the modality of interactions between communities on either side of a ground
crossing with travellers, cargoes and conveyances moving across borders.
• Assess social determinants of health (e.g. access to food, water, housing).
• Determine whether potentially impacted populations have access to health-care
services.

Table A3. Severity

For each identified hazard, the strategic risk assessment team shall assign a severity
score on a scale of 1 to 5.
A series of guiding factors are provided below and can be taken into consideration in
conjunction with other available data to determine the severity score.
The severity score will then be entered into the companion strategic risk assessment
spreadsheet tool to determine the hazard’s level of impact.
The assigned severity score from 1 to 5 would be as follows:

Severity
1 Very low severity
2 Low severity
3 Moderate severity
4 High severity
5 Very high severity

Guiding factors to take into consideration when determining severity are:

• seriousness of consequences (morbidity and mortality);
• exposed population immune status factors;
• vector-borne disease factors (e.g. distribution, density, infectivity, seasonal variations)
and/or animal hosts (density, prevalence, existing control programmes) along/across
borders and travel routes having an impact on borders.

48
Table A4. Coping capacity assessment
Coping capacities refer to the capabilities of the ground crossing and border region to
cope with and manage the potential hazards.
A series of guiding questions have been provided in this table to assist in the evaluation
of existing coping capacities that may be used to manage potential hazards.
These questions have also been provided in the companion strategic risk assessment
tool. All applicable questions are to be answered as yes or no in the companion
strategic risk assessment tool.
A value of 1-5 is to be assigned to the level of each coping capacity required,
commensurate with the hazards, with 1 being very high (the necessary capacities
commensurate to the hazard are in place) and 5 being very low (no capacities
commensurate to the hazard are in place).
The companion strategic risk assessment tool will calculate the average value of all
coping capacities evaluated and this number (1-5) will be the overall coping capacity
value that will be used to populate the risk assessment formula.
Based on the overall coping capacity value, the following scales can be used for rating
existing capacities to the hazard.

Coping capacity
1 Very high
2 High
3 Partial

4 Low
5 Very low

Communication and coordination Yes No

• Have any staff members at the ground crossing been identified as focal
points for communication with stakeholders within the ground crossing
(e.g. service providers, stakeholders, medical facilities that provide public
health services to the ground crossing)?
• Are there means of communication to receive and/or report available
public health surveillance information?
• Has public health information been provided by the ground crossing to
travellers?
• Has public health information been provided by the ground crossing to
local communities adjacent to the ground crossing?
• Has public health information been provided to the surveillance system by
local communities adjacent to ground crossing?
• Have communication mechanisms been established to communicate
health-related information from the ground crossing to neighbouring
countries or to regional disease surveillance networks?
• Have communication mechanisms to communicate to all levels of
government and policy makers and stakeholders been established?
• Has an up-to-date emergency contact list been established of stakeholders
for public health events management?

49
 Surveillance Yes No
• Are standard case definitions for public health events under surveillance
(e.g. diseases, symptoms) used at the ground crossing?
• Are standard operating procedures in place to identify suspect cases at
the ground crossing?
• Are standard operating procedures in place to identify suspect cases
within neighbouring communities?
• Does the surveillance system receive public health information from
ground crossings, including the presence of ill or deceased travellers?
• Does the surveillance system receive environmental health information
from ground crossings in relation to infection and contamination of food/
water?
• Does the surveillance system receive information in relation to vectors and
reservoirs associated with vector-borne diseases?
• Does the surveillance system receive information in relation to chemical or
radiological hazards?
• Have the reporting sites been established at the ground crossing and
along the border region?
• Have the reporting mechanisms from the ground crossing to the national
level been identified?
• Have the reporting mechanisms from the border community to the
national level been identified?
• Is information standardized when a public health event is reported by
the ground crossing to the national surveillance system (i.e. is there a
predefined list and standardized format for the variables to be reported)?
• Have the staff of the ground crossing been trained in how to identify a
potentially ill traveller?
• Has a system been established between the national surveillance system
and the ground crossing for management of case-related data (including
contact-tracing)?
• Have roles and responsibilities of all stakeholders been identified,
documented and shared, including in adjacent border communities?
Mapping cross-border movements (travellers, goods, cargo) Yes No
Structured border with administrative controls
• Have travel routes (e.g. origin, destination and transit pathways) and the
potential for international traffic dispersal through links to major roadways,
railways, airports and ports of entry been assessed?
An open/porous border
• Have the critical access points from one country to another along the
border been identified in order that one can understand the movement
dynamics of travellers, goods and cargo?
• Have the critical points of congregation where cross-border travellers may
interact with other travellers, and/or adjacent border communities, been
identified?
• Are the points of access and of congregation prioritized on the basis of
estimates of traveller volume?

50
Assessment and care of travellers Yes No
• Has adequate space to conduct private interviews with ill travellers been
identified at a ground crossing?
• Have isolation and quarantine facilities been identified?
• Are there language barriers or cultural differences that may hinder the
assessment of travellers?
• Are translation services available?
• Have the following factors been taken into account when undertaking
observation or isolation of suspected or affected travellers at ground
crossings? Is there:
- shelter
- sanitation
- water
- waste disposal
- food
- privacy and safety
- communications
- transportation?
• Has access to qualified laboratories been identified and established?
Health-care facilities Yes No
• Has the type and proximity of the health-care facilities providing services
to the ground crossing been determined?
• Do travellers and ground-crossing staff have access to medical
professionals?
• Are accessible health-care resources able to respond to a communicable
disease event?
Transportation Yes No
• Have procedures been established for transporting samples to
laboratories (cross-border transport)?
• Are there means of transport available to convey travellers who are (or are
suspected of being) ill from a ground crossing to a health-care facility?
Trained staff Yes No
• Are sufficient numbers of trained staff available for routine functions at
ground crossings?
• Have surge capacities been taken into consideration in order to respond
to a public health emergency at a ground crossing and in a border region?
• Are ground crossing table-top exercises and/or field and/or full-scale drills
conducted?
• Are trained staff available to inspect conveyances at or near the ground
crossing?
• Are after-action reports available?
• Has a gap analysis been conducted to address human resource capacities
in the after-action review?
• Does regular on-the-job training take place for IHR health functions?

51
 Technical and logistical issues Yes No
• Are the necessary instruments (chemicals and equipment) available to
manage an event of public health concern at a ground crossing or in a
border region?
• Has the location for storing equipment and supplies (e.g. PPE, disinfectant,
etc) been identified?
• Has the access to equipment and supplies (e.g. PPE, disinfectant, etc.) for
the ground crossing been identified?
Environmental health programmes Yes No
• Are environmental health programmes established near or at the
ground crossing and in communities linked to the ground crossing by
transportation routes? Do the programmes include:
- potable water safety
- vector control
- solid waste and sewage management
- food safety?
• Is the general level of sanitation at the ground crossing facility and
in surrounding areas conducive to the transmission of communicable
diseases?
• Are there any factors that may have an impact on the application of
possible recommended measures such as disinsection, disinfection,
decontamination or other treatment of contaminated conveyances,
baggage and goods (e.g. human resources, equipment, supplies)?
Vectors Yes No
• Have vectors of public health significance been identified?
• Do data exist on the epidemiological context and the local entomological
situation at the ground crossing and in the border region?
• Is a vector control programme in place at the ground crossing?
• Is a vector control programme in place in the border region?
• Has information on the vector control programme in one country been
shared with the neighbouring country?
One Health Yes No
• Has a communication mechanism been established for exchanging
information and maps of livestock migration routes and border livestock
markets at ground crossings that have importation or exportation of
livestock?
• Is there access to diagnosis of emerging and re-emerging zoonotic
diseases for both human and animal sectors?
• Is there access to veterinary services for conducting quarantine and
isolation of affected animals detected among imported/exported
animals at ground crossings (e.g. are there services for decontamination,
disinfection and treatment of affected animals)?

52
 Emergency preparedness plans Yes No
• Have ground crossings been incorporated into community/national public
health emergency plans?
• Have emergency planning exercises for ground crossings been conducted?
• Are exercises conducted on traveller screening activities for early detection
of cases?
• Are there any cross-border communication protocols for sharing disease
information?
• Do up-to-date emergency contact lists exist within the country?
• Do up-to-date emergency contact lists exist of countries on both sides of the
ground crossing?
• Have ground crossings been integrated into the community/national
communication protocol?
• Have standard operating procedures been established for the detection,
investigation and management of cases and affected conveyances (e.g. exit
screening)?
Vaccination and prophylaxis Yes No
• Are the vaccination requirements of the country published?
• Have these requirements been communicated to the bordering countries?
• Are records of vaccination required at POE?
• Are there any vaccination or prophylaxis services for travellers at the ground
crossing?
• Are there any vaccination or prophylaxis services for the border region?
• Do contingency plans for mass vaccination exist?
• Has the general health status of the communities near the ground crossing
or along transit routes that are linked to the ground crossing been
considered (i.e. malnutrition, vaccination rates)?
Community engagement Yes No
• Could any local cultural practices along the border region (i.e. burial
practices) increase the hazard?
• Have health-seeking practices been identified among the border
communities?
• Are there social or behavioural considerations?
• Have any ethical concerns of note been identified?
• Has the community’s general level of acceptance of potential control
measures been considered?
Overall score

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2.3 Risk characterization (determination of risk level and hazard ranking)

2.3.1 Determination of likelihood

Table A5. Likelihood of occurrence
For each possible hazard (biological, chemical, physical or radiological), determine the
likelihood of occurrence.
Determine the likelihood of occurrence of a hazard by evaluating its frequency
and seasonality, and by identifying the possible negative health consequences for
populations at ground crossings and in adjacent border communities.

Likelihood
1 Very unlikely
2 Unlikely
3 Likely
4 Very likely
5 Almost certain

Examples of questions that can assist in assessing the likelihood of a specific hazard:
• Are there any interactions at ground crossings and in the border region that
facilitate the introduction/spread of diseases to the bordering countries?
• Is the hazard highly infectious?
• Is there any past evidence of local spread within the border region? Is there an
index case that is associated with a history of travelling to bordering countries
within the previous month, or of close contact with a traveller/mobile population
at the ground crossing, or participation in an international gathering in the
bordering countries?
• Is there any past evidence of an event caused by an environmental
contamination associated with this specific hazard (biological, zoonotic,
chemical or radiological) that has the potential to spread across borders?
• Is the event at a ground crossing or in a border region with intense international
traffic and limited capacity for sanitary control or environmental disinfection
and decontamination?

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2.3.2 Determination of the level of impact
The formula in Table A6 is intended to assist the user to determine the scale of the
impact of an individual hazard on an aggregation of the scores given for vulnerability,
severity and coping capacity.

Table A6. Determination of level of impact

Impact = (vulnerability + severity
Level of impact
+ coping capacity)/3
Very low 1
Low 2
Moderate 3
High 4
Very high 5

Table A7. Impact value definitions

Level Impact
1 Very low • Limited impact on the affected population.
• Little disruption to normal activities and services.
• Routine responses are adequate and there is no need
to implement additional control measures.
• Few extra costs for authorities and stakeholders.
2 Low • Minor impact for a small population or at-risk group.
• Limited disruption to normal activities and services.
• A small number of additional control measures will be
needed that require minimal resources.
• Some increased costs for authorities and
stakeholders.
3 Moderate • Moderate impact because a large population or at-
risk group is affected.
• Moderate disruption to normal activities and services.
• Some additional control measures will be needed
and some of these require moderate resources for
implementation.
• Moderate increase in costs for authorities and
stakeholders.
4 High • Major impact for a small population or at-risk group.
• Major disruption to normal activities and services.
• A large number of additional control measures will
be needed and some of these require moderate
resources for implementation.
• Significant increase in extra costs for authorities and
stakeholders.
5 Very high • Severe impact on the affected population.
• Severe disruption to normal activities and services.
• A large number of additional control measures will
be needed and most of these require moderate
resources for implementation.
• Serious extra costs for authorities and stakeholders.

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2.4 Figure A1. Risk matrix tool

Almost
certain

Highly
likely
Likelihood
of hazard Likely
occurring

Unlikely

Very
unlikely
Very low Low Moderate High Very high
Consequences of hazard occurring (impact)

2.5 Table A8. Risk mitigation and level of risk and preparedness & res-
ponse capacity development

Likelihood Risk mitigation actions Capacities/examples

and impact
of each
individual
hazard
Minimum preparedness Ongoing monitoring of the hazards to determine
actions (Ground that the impact or likelihood doesn’t increase.
crossing capacity
development activities)
Additional Provision for adequate capacities should be
preparedness actions: prioritized due to the high impact of occurrence
Minimum preparedness and/or likelihood. Refer to previous assessment of
actions, plus coping capacities to assist with this prioritization.
Risk mitigation Hazards that are characterised both as high
actions: any additional impact and high likelihood should receive the
preparedness actions, highest priority for capacity development and be
plus identified specifically in contingency plans. Refer
to previous assessment of coping capacities to
assist with this prioritization.

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