Monkeypox: WHO declares outbreak a public health emergency

The World Health Organization (WHO) on Saturday declared the ongoing worldwide monkeypox outbreak a Public Health Emergency of International Concern (PHEIC), Director-General Tedros Adhanom Ghrebeyesus announced.

Tedros made the declaration despite a lack of consensus among members of the WHO's emergency committee on the monkeypox outbreak. It's the first time a leader of a UN health agency has made such a decision. 

What did Tedros say?

"We have an outbreak that has spread around the world rapidly through new modes of transmission about which we understand too little and which meets the criteria in the international health regulations,'' Tedros said.

"I know this has not been an easy or straightforward process and that there are divergent views among the members" of the committee," he added.

"Although I am declaring a public health emergency of international concern, for the moment this is an outbreak that is concentrated among men who have sex with men, especially those with multiple sexual partners," Tedros went on. "That means that this is an outbreak that can be stopped with the right strategies in the right groups."  

How has the outbreak spread?

The current outbreak started in May, with 20 cases recorded in Britain on May 20, mostly among gay men.

Since then, the outbreak has grown to almost 16,000 cases in 75 countries, Tedros said. Data from the CDC in the US indicate that in one day alone, from July 19 to July 20, confirmed case numbers leaped from 14,511 to 15,378. The current outbreak is centered in Europe.

Since July 14, Bermuda, Thailand, Serbia, Georgia, India and Saudi Arabia have all reported their first cases, adding to the now 73 countries where the current outbreak has been detected.

As the outbreak continues to grow, epidemiologists are split as to whether the WHO's decision was correct. The meeting was the second time the emergency committee convened, after a meeting on June 23 when it decided the outbreak had not met that threshold.

"It is a tricky decision for the committee," said Dr. Jimmy Whitworth, a professor of international public health at the London School of Hygiene & Tropical Medicine.

"In some senses, it meets the definition — it is an unprecedented outbreak widespread in many countries and would benefit from increased international coordination.

"On the other hand, it seems to be an infection for which we have the necessary tools for control; most cases are mild and the mortality rate is extremely low," Whitworth told DW.

What is a PHEIC?

The designation of a Public Health Emergency of International Concern is the WHO's highest alert level. It is based on international health regulations established in 2005, to define countries' rights and obligations in handling cross-border public health occurrences.

The WHO defines a PHEIC as "an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response."

The WHO further explains how this definition implies a situation that is serious, sudden, unusual or unexpected; carries implications for public health beyond an affected country's border and may require immediate international action.

Who decides about a PHEIC?

The WHO's emergency committee on monkeypox provided WHO Director-General Tedros Adhanom Ghebreyesus with advice on the disease but couldn't come to a consensus.

The WHO's emergency committee on monkeypox is composed of 16 members and chaired by Jean-Marie Okwo-Bele from the Democratic Republic of Congo, a former director of vaccines and immunization at the agency.

Other committee members include epidemiologists and disease experts from all around the world.

What are advantages and criticisms of PHEICs?

The purpose of a PHEIC is to focus attention on acute health risks that have the potential to spread internationally and threaten people around the world.

They are intended to help in mobilizing and coordinating information and resources, both nationally and internationally, for the purposes of prevention and response.

In practice, declaring PHEICs may end up causing a financial burden to the country facing the epidemic, particularly if travel and trade are curtailed. Indeed, some countries are reluctant to share public health data in the case of an outbreak for fear of such measures.

Critics of the PHEIC system note that an emergency is only declared when an event has started to spread internationally, indicating it has already reached an acute level. Some have called for various, intermediate stages of alarm.

In the case of COVID-19, for example, a PHEIC was only declared at the end of January 2020, after two meetings earlier in the month had decided against such a move, and several weeks after Beijing had adopted containment measures.

Researchers have found that too many countries take a "wait and see" approach with such declarations, ignoring them until it is too late — as with COVID-19.

"People weren't listening," said WHO emergencies director Michael Ryan on the second anniversary of the COVID-19 pandemic declaration. "We were ringing the bell and people weren't acting."

Such declarations are subject to too much political pressure, argue some. Others offer the criticism that emergency committee rationale has tended to be opaque or contradictory.

What PHEICs have there been in the past?

Until now, the WHO had declared a PHEIC six times, all for viral outbreaks:

• January 2020 for COVID-19, declared when the virus was first detected outside of China. This eventually became a persistent global pandemic
• July 2019 for Ebola, for the second time, relating to the outbreak in eastern DRC
• February 2016 for Zika, which began in Brazil and affected mostly Latin America
• August 2014 for Ebola, for an outbreak in West Africa that also spread to Europe and the US
• May 2014 for polio, following a rise in the spread of "wild polio" and vaccine-derived virus in Afghanistan, Pakistan and Nigeria. Besides the one for COVID-19, this is the only PHEIC still in place.
• 2009 for the H1N1 or "swine flu," which started in Mexico and spread across the world

Three outbreaks have been considered but not declared a PHEIC. These include the deadly MERS outbreak first identified in Saudi Arabia in 2013.

What happens next?

The "WHO will continue to do everything we can to support countries to stop transmission and save lives," Tedros said at a press conference in Geneva on Wednesday.

Testing and vaccination are sharp tools in the fight against monkeypox, although Tedros also said information was key. First and foremost, public health officials need to engage constructively with at-risk communities, experts say.

Some experts have sounded the alarm for a potential pandemic based on the recent large jump in case numbers.

"From what is known, we think it is unlikely to spread far in the general population," said public health professor Whitworth. "For these reasons, I do not think this will become a generalized epidemic."

Edited by: Andreas Illmer, Anne Thomas