Why declaring monkeypox a global health emergency is a preventative step, not a cause for panic

United Nations member countries are required to report cases of unusual diseases that may become threats to global health. In May 2022, more than a dozen countries in Europe, the Americas, and other regions of the world that had never previously had cases of monkeypox began reporting cases occurring within their borders.

In response, the director-general of the World Health Organization, Tedros Adhanom Ghebreyesus, convened an emergency monkeypox committee to monitor the development of the situation. At the committee’s first meeting on June 23, 2022, members noted that the “multi-country outbreak” may be stabilizing as the number of cases has stabilized in several countries.

However, after thousands more cases of monkeypox were diagnosed in dozens of countries in July, it became clear that the outbreak had not stopped. On 23 July 2022, Tedros declared monkeypox a public health emergency of international concern.

As a global health expert specializing in infectious disease epidemiology, I don’t think most people need to worry about monkey pox. This decision by the WHO, while it may seem ominous, is not a sign of bad things to come. Rather, it is a way to prevent monkeypox from becoming a global crisis.

The Director-General of the World Health Organization has the power to declare an event a public health emergency of international concern. Guilhem Vellut/Wikimedia Commons, CC BY

What is a Public Health Emergency of International Concern (PHEI)?

The International Health Regulations are a set of rules that guide how WHO and United Nations member states respond to emerging health threats.

Under current regulations, the Director-General of the WHO can declare a “public health emergency of international concern” – often abbreviated as PHEIC – when three criteria are met: the situation is an “extraordinary event”, there is a risk of spread to other countries, and the situation could “potentially require a coordinated international response”.

Before monkeypox, only five diseases had been designated as PHEICs since the WHO began using the term in 2005: the H1N1 influenza pandemic in 2009; polio resurgences in Afghanistan, Nigeria and Pakistan in 2014; the Ebola epidemic in Guinea, Liberia and Sierra Leone in 2014 and an Ebola outbreak in the Democratic Republic of Congo in 2019; the spread of the Zika virus in the Americas in 2016; and the coronavirus pandemic in 2020. While all of these events were noteworthy, only the coronavirus pandemic became a global catastrophe.

Why is monkeypox a public health emergency of international concern?

The WHO Director-General is the only person who can declare a PHEIC, but the decision is based on the advice of the designated emergency committee. After the monkeypox emergency committee met for the second time on July 21, 2022, it issued a report stating that “the multinational smallpox outbreak meets all three criteria that define a PHEIC.”

The rapid spread of the virus to more than 70 countries was evidence of the risk of further international spread. The committee expressed concern about whether vaccines would be reasonably priced and distributed equitably in the absence of a coordinated international response. And he agreed that there were aspects of the situation that were “extraordinary,” a vague term that is not defined in the International Health Regulations.

However, the committee did not express unanimous agreement that a public health emergency of international concern should be declared. Some members questioned whether a disease that has a low mortality rate should be a PHEIC. Others worried that a PHEIC designation could further stigmatize LGBTQ communities, since most cases so far have been diagnosed among men who have sex with men.

The emergency committee vote was split: nine against and six in favor of PHEIC status. But Director General Tedros chose to go ahead and declare monkeypox a PHEIC.

what happens now

The goal of a PHEIC designation is to prevent an emerging disease from becoming a global health crisis. WHO has two initial targets for monkeypox. First, to try to stop the virus from starting to circulate in susceptible populations where it is not currently present. And second, to distribute vaccines and antiviral drugs to the countries and communities that need them most.

Following the PHEIC statement, WHO published a set of interim recommendations calling on countries to do more to prevent cases in affected and at-risk communities, to improve clinical care for people with smallpox, and to contribute to smallpox vaccine and treatment research. The recommendations also call on countries to advise infected people and their direct contacts not to travel except in urgent situations, but do not impose any restrictions on travel or international trade.

Finally, the WHO has advised that people who are members of at-risk communities take steps to protect themselves from the virus, but has not called for a change in behavior from the general public.

A public health emergency of international concern is the highest level of alert in the International Health Regulations, but is not synonymous with a pandemic. The status is a tool to protect the health of the world’s population and not a declaration that a global crisis is already underway.

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