WHO monkeypox decision renews debate about global alarm system for outbreaks

The World Health Organization (WHO) may have very high aspirations—“the attainment by all peoples of the highest possible level of health”—but when a new human disease begins to spread, or a known one behaves in unusual, threatening ways, it has few levers to pull. One important decision it can make, however, is declaring a Public Health Emergency of International Concern (PHEIC), a designation that gives WHO some additional powers and serves as a global wake-up call.

After a meeting behind closed doors, a WHO expert panel announced on 25 June that the rapidly growing monkeypox epidemic does not yet warrant that status—a verdict the agency has accepted. The panel’s conclusion was widely criticized by virologists, epidemiologists, and public health experts, and it has triggered a new debate about the purpose of the PHEIC, an instrument created to help improve the response to international health threats. “I think they made a big mistake,” says Yale School of Public Health epidemiologist Gregg Gonsalves, who advised the committee. “They punted.”

WHO has previously come under fire for waiting too long to declare a PHEIC for COVID-19 and Ebola epidemics in West Africa and the Democratic Republic of the Congo. The agency’s “track record is that they tend to be on the later side of things,” says Jeremy Youde, a global health researcher at the University of Minnesota, Duluth. “Right now PHEICs send the message that WHO is the last institution to grasp that a newly identified outbreak is indeed a public health emergency of international concern,” adds biologist Michael Worobey of the University of Arizona. “The window may already have closed on stopping the establishment of a new sexually transmitted disease worldwide, but a PHEIC has not even been declared.”

The panel didn’t fully explain why the monkeypox outbreak doesn’t deserve PHEIC status. The International Health Regulations, a global treaty updated in 2005, define a PHEIC—pronounced as “fake”—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.” With more than 4000 monkeypox cases since May in more than 40 countries where it is not normally seen, global spread is clearly a concern, and the panel says the outbreak requires “collaborative international efforts.”

That leaves just one criterion in doubt, says Alexandra Phelan, a lawyer at Georgetown University who specializes in global health policy: whether the surge is an “extraordinary event.” That determination is tricky because monkeypox is an endemic, if neglected, disease in some African countries. “It is unjust and unethical to determine an event is only extraordinary if it is now occurring in high-income countries,” Phelan says. Rather than holding off on a PHEIC, however, WHO should re-examine how equitable the criteria are, she says.

Emory University virologist Boghuma Titanji notes that the question isn’t just where monkeypox is spreading, but also how. The vast majority of recent cases have been in men who have sex with men, a pattern not seen before. The panel’s report suggests its authors declined to recommend a PHEIC even though all criteria were met, says Clare Wenham, a global health expert at the London School of Economics. “We have seen this inconsistent application of the criteria of a PHEIC throughout its history,” she says. The yes-or-no nature of the decision probably leads experts to be cautious, Youde says: “It’s tricky, because it’s such a blunt instrument.”

How helpful a PHEIC truly is remains a matter of debate as well. The declaration obligates member countries to follow WHO’s recommendations, such as sharing data on cases, and allows the agency to issue travel advice. “To date there is no scientific evidence on the effect a PHEIC has,” Wenham says.

But declaring a PHEIC puts the spotlight on a pathogen, Phelan says: “I worry what waiting a few weeks before sufficiently grabbing political attention will mean for community transmission.” A delay can also let an outbreak grow so big that countries are more likely to hoard vaccines and other resources. “As more countries become affected, they’re less able to help countries affected early on,” Phelan says. And there is no evidence that calling a PHEIC early has downsides, Youde says.

The panel acknowledged that some of its own members disagreed with the decision and said it will reconsider the issue if there is new evidence that monkeypox is spreading to other countries or new groups, or that the severity of the disease is increasing. Signs the virus is establishing new animal reservoirs outside Africa might also warrant a reconsideration.

“I think some of these criteria will be met almost immediately,” Gonsalves says. The list of affected countries is growing almost daily and there have already been reports of the disease in children. The panel’s report mentions a potential re-evaluation in 21 days, Gonsalves notes, “but I hope [WHO’s] director-general is smart enough to convene people again in a much more timely manner.”

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