The World Health Organization (WHO) may have lofty aspirations – “the attainment by all peoples of the highest attainable standard of health” – but when a new human disease begins to spread or hen a known disease behaves in an unusual and threatening way, it has few levers to pull. One important decision it can make, however, is to declare a public health emergency of international concern (USPPI), a designation that gives the WHO additional powers and serves as a global wake-up call.
After a closed-door meeting, a panel of WHO experts announced on June 25 that the rapidly growing monkeypox epidemic did not yet justify the status – a verdict the agency accepted. The panel’s finding was widely criticized by virologists, epidemiologists and public health experts, and it sparked 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 Gregg Gonsalves, a Yale School of Public Health epidemiologist who advised the committee. “They kicked.”
The WHO has previously been criticized for waiting too long to declare a USPPI for the COVID-19 and Ebola outbreaks in West Africa and the Democratic Republic of Congo. “The agency track record is that they tend to be later,” says Jeremy Youde, a global health researcher at the University of Minnesota, Duluth. “Right now, USPPI is sending the message that the 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 have already closed on stopping the establishment of a new sexually transmitted disease in the world, but a USPI has not even been declared.”
The panel did not fully explain why the monkeypox outbreak does not merit PHEIC status. The International Health Regulations, a global treaty updated in 2005, defines a USPPI – pronounced as “false” – as an “extraordinary event that is determined to pose a risk to the public health of other states through the spread of a disease and that it may potentially require a coordinated international response. With more than 4,000 cases of monkeypox 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 only one criterion in doubt, says Alexandra Phelan, a Georgetown University lawyer who specializes in global health policy: whether the surge is an “extraordinary event.” This determination is tricky because monkeypox is an endemic, though neglected, disease in some African countries. “It is unfair and unethical to determine that an event is only extraordinary if it is happening now in high-income countries,” Phelan said. Rather than delay a USPPI, however, the WHO should re-examine the fairness of the criteria, she says.
Boghuma Titanji, a virologist at Emory University, notes that the question is not just where monkeypox spreads, but also how. The vast majority of recent cases have involved men who have sex with men, a trend not seen before. The panel report suggests its authors declined to recommend a PHEIC even though all the criteria were met, says Clare Wenham, a global health expert at the London School of Economics. “We’ve seen this inconsistent application of a USPPI’s criteria 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.”
The real usefulness of a USPPI also remains a subject of debate. The statement obliges member countries to follow WHO recommendations, such as sharing case data, and allows the agency to issue travel advice. “To date, there is no scientific evidence on the effect of a PHEIC,” Wenham said.
But declaring a PHEIC highlights a pathogen, says Phelan: “I worry what waiting a few weeks before getting enough political attention will mean for community transmission.” A delay can also let an outbreak grow so large that countries are more likely to stockpile vaccines and other resources. “As more and more countries are affected, they are less able to help affected countries early on,” says Phelan. And there’s no evidence that calling a PHEIC early has any downsides, Youde says.
The panel acknowledged that some of its own members disagreed with the decision and said it would revisit the matter if there was new evidence that monkeypox was spreading to other countries or to other countries. new groups, or the severity of the disease increases. Signs that the virus is establishing new animal reservoirs outside of Africa may also warrant reconsideration.
“I think some of those criteria will be met almost immediately,” Gonsalves says. The list of affected countries is growing almost daily and cases of illness in children have already been reported. The panel report mentions a potential reassessment in 21 days, Gonsalves notes, “but I hope [WHO’s] the general manager is smart enough to summon people again in a much more timely manner.