March 22, 2023

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What is the practical significance when WHO declares monkeypox as a public health event of international concern?

What is the practical significance when WHO declares monkeypox as a public health event of international concern?


What is the practical significance when WHO declares monkeypox as a public health event of international concern?

WHO makes an exception to declare monkeypox as a public health event of international concern, what is the practical significance?


All current efforts and efforts to combat monkeypox are aimed at preventing it from becoming a chronic infectious disease in the global community – possibly akin to a sexually transmitted disease. WHO’s PHEIC discussions are also based on this background.


· Monkeypox mainly affects people who are gay or bisexual. This group has been on the fringes of society for a long time, and has suffered severe discrimination in the HIV epidemic.

Announcing PHEIC may trigger another round of discrimination and misunderstanding, and it is not conducive to encouraging them to cooperate with public health related investigations.


Following the World Health Organization (WHO) Director-General Tedros Adhanom Ghebreyesus declaring the monkeypox outbreak a Public Health Event of International Concern (PHEIC) on July 23, the United States also declared monkeypox a public health emergency on August 4.

The number of cases and the attention of international organizations and governments have made monkeypox, an infectious disease that is extremely unfamiliar to most people, frequently reported in the newspapers.

On the other hand, we also need to see that Tedros announced that PHEIC was an “exception” when the international expert group meeting did not reach a consensus, which was questioned by some people as an overreaction.

Why is the PHEIC of monkeypox controversial? What does PHEIC mean? What impact will it have on the future spread of monkeypox?



What is the practical significance when WHO declares monkeypox as a public health event of international concern?

What is the practical significance when WHO declares monkeypox as a public health event of international concern?



Monkeypox will be different in 2022

Regardless of whether they agree with the WHO’s decision to designate monkeypox as PHEIC, and no matter how different the actual threat posed by monkeypox is, the vast majority of public health experts and scientists have to admit that this monkeypox epidemic is different from previous ones. a little different.

Monkeypox is not a new pathogen, since its discovery in 1958, humans have been dealing with it for more than half a century. But if you compare past monkeypox outbreaks, there are still many different manifestations of this round of monkeypox transmission in 2022.

Past cases of monkeypox have been concentrated in sporadic outbreaks in some parts of Central and West Africa. Some local rodents may be natural hosts of monkeypox virus, and human-wildlife contact has led to repeated monkeypox infections in these places.

Monkeypox belongs to the pox virus and is a close relative to smallpox, which is why the current academic consensus believes that the smallpox vaccine also has a certain protective effect on monkeypox.

However, monkeypox is known to be far less infectious and virulent than smallpox. Outside of Africa, community transmission of monkeypox cases is rare until 2022.

In 2003, the United States experienced the worst monkeypox outbreak before, with 47 confirmed and suspected cases of monkeypox infection in 6 states.

Post-mortem investigations found that the source was that imported animals from Africa were mixed with pets sold, causing consumers who bought pets to be infected.

From this case, it is not difficult to find that the monkeypox epidemic before 2022 is characterized by, first, few infected cases, and second, there is a clear import link with Africa.

For comparison, as of August 3, 2022, the US Centers for Disease Control and Prevention (CDC) has accumulated more than 6,600 infected cases in this round of monkeypox outbreaks, affecting 48 states across the United States.

Moreover, unlike those infected in the past epidemics who have a clear history of travel and contact in Africa, according to WHO statistics, 99% of the infected persons of monkeypox cases outside Africa in 2022 will be men, and more than 95% of them will be gay men.

This means that this round of monkeypox has a clear phenomenon of intra-population spread, and the spread mode and scope are significantly different from those in the past.

This is reminiscent of the early days of the AIDS (HIV) outbreak in the 1980s—and it was the first time that gay men in Europe and America were hit.

Although monkeypox does not allow infected people to carry the virus for a long time like HIV, and it is not as deadly as HIV, public health experts have to worry about whether monkeypox will take hold in human society and become another long-term infectious disease.

Therefore, the threat of transition from an occasional and sporadic tropical disease to a long-term infectious disease among people can explain why the WHO and public health departments in Europe and the United States have paid great attention to monkeypox.

All the current measures and efforts against monkeypox are really aimed at preventing it from becoming a long-term infectious disease in the global community – possibly akin to a sexually transmitted disease. The WHO’s PHEIC discussion is based on this background.




What does it mean for monkeypox to be a PHEIC?

After the WHO declared monkeypox a PHEIC, some readers may feel that the monkeypox epidemic has become serious, but the more worthy question is: what does it mean to become a PHEIC?

A Public Health Event of International Concern – PHEIC, is a WHO class statement that refers to “unusual events that pose a public health risk to other countries through the international spread of disease and may require a coordinated international response”.

PHEIC actually stands for WHO’s series of assessments, detections, and coordinated responses to international public health threats.

As we all know, promoting the prevention and control of global epidemics is one of the main functions of the WHO.

However, in the context of highly unbalanced global development, it is not easy for the WHO to improve the global public health prevention and control capabilities.

Especially when it comes to assessing and responding to a public health problem with a potential international threat, the WHO often faces two diametrically opposed criticisms of “making a fuss” and “moving slowly” at the same time.

The declaration mechanism of PHEIC was established in 2005. One of the backgrounds is the SARS epidemic in 2002-2003, that is, when a new virus spreads, public health problems can quickly break through national borders, and the problem of a certain country evolves into an international crisis , timely response requires more reasonable international risk assessment and coordination.

What PHEIC wants to solve is the delay in the discovery and confirmation of major public health risks by the international community.

One of the reasons for these delays is that in the places where the public health problem first appeared, it will be accompanied by the local problem of collecting data and judging the seriousness of the problem in a timely manner.

Taking monkeypox as an example, the natural occurrence area of ​​this disease is in Central Africa and West Africa, which are areas with relatively poor sanitation conditions.

It is very likely that tracking the dynamic changes of an infectious disease in a timely manner is beyond the actual capacity of the local area.

In this regard, PHEIC provides a mechanism for regions to report to WHO, which is conducive to quickly passing potential public health crises to WHO, who will then make further assessments.

The declaration includes not only WHO member states, but also NGOs, which reduces the risk of missing sources.

More importantly, PHEIC declaration also provides a judgment standard, that is, what kind of situation should be declared according to PHEIC.

Four criteria:

  • Is the impact on public health serious?
  • Is the event unusual or unexpected?
  • Are there significant risks to international spread?
  • Are there significant risks associated with international travel or trade restrictions?


According to the regulations, if any two of the above are met, member states should declare potential PHEICs to WHO.

In addition to infectious diseases, nuclear leakage and chemical pollution can be declared, but the PHEIC declarations announced so far are all in the field of infectious diseases.

Still taking monkeypox as an example, the speed and scope of the epidemic in 2022 will be significantly different from those in the past.

The risk of international transmission is serious, and the threat to public health is clearly in line with the PHEIC standard.

In addition, in order to further reduce the risk of underreporting, the potential PHEIC declaration also lists a list of diseases that can be declared immediately after discovery, including SARS, smallpox, poliomyelitis, new influenza viruses, etc.

Once a potential PHEIC report is received by WHO, discussions are held to confirm the need to declare a PHEIC.

This step is actually another delay in resolving the international public health crisis – when an epidemic occurs in one place, the entire international community often delays the recognition of potential risks.

Under the PHEIC mechanism, the WHO’s Emergency Committee can conduct a comprehensive analysis of specific potential reported data to assess whether it meets the PHEIC criteria.

Finally, the Director-General of WHO decides whether to declare PHEIC based on the committee’s opinion and other evidence.

It is not difficult to see from the PHEIC declaration and declaration process that the WHO hopes to accelerate the international community’s judgment on public health crises with more scientific and unified standards. The reason is that in any public health crisis, intervention at an earlier time is more likely to be successful and less costly.

Since its establishment in 2005, there have been six PHEIC declarations including monkeypox: swine flu in 2009, polio in 2014 (still not resolved), Eboa virus in 2014, Zika virus in 2016, Ebola virus in 2018 and 2020 COVID-19 (still unresolved).

But after the PHEIC statement, a more realistic problem arose-although WHO has recommendations for response strategies, there are actually no mandatory measures and no fixed resource allocation.

The above dilemma has become the focus of questioning the practical significance and role of PHEIC.

It is also important to note that the PHEIC highlights the threat of international proliferation, in contrast to recommendations often accompanied by international travel restrictions.

This has become a disguised punishment for many outbreak areas – once PHEIC is declared, the place where it occurs is likely to be economically hit by travel and trade restrictions.

On the contrary, the response measures recommended by the WHO, such as international resource allocation, are not mandatory, and it is difficult to ensure that the actual support for the outbreak occurs.



Monkeypox PHEIC for and against

The debate over the meaning of PHEIC also extends to this monkeypox. The difference is that the past five PHEIC declarations were all implemented under the unanimous recommendation of the Emergency Committee, while monkeypox in the two WHO emergency meetings in June and July this year, the Emergency Committee failed to recommend PHEIC. Agree.

Among them, the June meeting did not recommend the PHEIC statement, and in the July meeting, there were 6 experts in favor and 9 against it.

Although the WHO Director-General has the final jurisdiction of PHEIC, this kind of practice that is different from past practice is naturally more concerning.

Whether for or against declaring monkeypox a PHEIC, some basic facts are not in dispute. But it is precisely some of the facts that support PHEIC, while other basic facts become reasons to oppose PHEIC.

First, monkeypox cases are really growing. According to the data listed in the two WHO emergency monkeypox meetings, the epidemic affected 47 countries in June, and by July 20, the number had risen to 72 countries.

As of July 20, global monkeypox cases rose to 14,533, and by August 4, there were more than 26,000 cases. These figures fully meet the PHEIC criteria for a significant risk of international spread and a serious impact on public health.

Second, infections are still largely concentrated among gay men—99% of cases are among gay men.

A small number of cases in women and children can basically be traced back to close contact with gay men.

As we mentioned in the previous article, the characteristics of such an infected population are very different from those of monkeypox in the past, and also meet the abnormal epidemic standards in PHEIC.

But there are other basic facts that make monkeypox’s need to be classified as PHEIC debatable. For example, the vast majority of cases are concentrated in male same-sex or bisexual people with multiple sexual partners, which means that monkeypox has not spread to other groups.

Even from the modeling of European countries most affected by monkeypox, the R0 (basic infection number) of monkeypox is higher than 1 only in gay men, less than 1 in other populations, and less than 2 even in gay men .

This means that the actual transmission ability of monkeypox is still relatively weak. PHEIC must not only consider the spread of a certain infectious disease in the past, but also consider the threat in the future. Judging from the spread of monkeypox and the limitations of the population, it seems difficult to say that its threat will increase significantly.

In addition, the pathogenicity of monkeypox was not enhanced. When the WHO declared monkeypox a PHEIC, there were only 5 deaths worldwide, all in Africa.

As of August 4, the number of deaths had risen to 10, including 6 in Africa, 2 in Spain, and 1 each in Brazil and India.

Death cases outside the natural occurrence area are of course worthy of attention, but technically, the mortality rate of monkeypox is still not high with more than 25,000 infected cases worldwide.

To sum up, the abnormal manifestations of monkeypox now seen are mostly different from the past in terms of infection mode. The concentrated transmission in the male homosexual population cannot rule out the trend of STD transmission, but the pathogenicity is maintained at a low level. The urgency and importance of declaring monkeypox a PHEIC is questionable.

Another reason that makes the need for PHEIC even more puzzling is that many people have to ask: How can announcing a monkeypox PHEIC actually help?

The view that most people agree with is that once the PHEIC is announced, it can increase the global attention to a public health event, that is, announcing PHEIC can increase the public’s attention to monkeypox, and thus to trace the infected and the close ones. Safeguarding measures play a supporting role.

But opponents of the monkeypox PHEIC decision will point out that monkeypox is already under global concern, and that announcing the PHEIC will not raise it further.

In addition, monkeypox mainly affects people who are gay or bisexual. This group has been on the fringes of society for a long time, and has suffered severe discrimination in the HIV epidemic.

Announcing the PHEIC may trigger another round of discrimination and misunderstanding, and it is not conducive to encouraging them to cooperate with public health-related investigations.

It is from different perspectives that diametrically opposite conclusions can be drawn.

The WHO emergency meeting on monkeypox failed to make a unanimous recommendation for PHEIC, and even more negative votes than yes votes from participating experts.

However, WHO Director-General Tedros Adhanom Ghebreyesus, who has the decision-making power, believes that it is more beneficial to make a PHEIC declaration for monkeypox after further weighing.

One of the possible guesses that influenced this decision is that the WHO, while declaring monkeypox as PHEIC, also proposed a differentiated prevention strategy based on the differences in the epidemic situation in different countries.

It can be said that PHEIC is an opportunity for WHO to recommend its own epidemic prevention advice to countries and seek global coordination and cooperation.



Can PHEIC change the development of monkeypox epidemic?

The next question is, can the epidemic prevention suggestions brought by PHEIC really work?

Specifically, WHO has proposed epidemic prevention recommendations for countries under the monkeypox PHEIC:

The first category is countries with no cases (such as China), which need to strengthen relevant monitoring to help prevent the further spread of the epidemic;

The second category is the country with the spread of the epidemic, and it is necessary to prevent the spread from intensifying. In addition to isolating infected people and contacting close contacts, it is also necessary to use a smallpox vaccine that is also effective against monkeypox—for example, as a therapeutic use for infected people, and preventive vaccination for close contacts and medical staff;

The third category is the countries and regions where there are cases of animal-to-human transmission of monkeypox (such as some African countries), and it is also necessary to pay attention to the transmission between animals and humans, and whether there is any return from humans to animals.

In addition to the above three categories, there is another category of countries that have the ability to develop and produce related medical materials, such as countries with smallpox vaccine production capacity. The recommendation given by the WHO is that these countries should coordinate the global supply of medical resources.

The statement and recommendations are very clear, but whether the WHO’s work can have a positive impact on the development of the monkeypox epidemic will depend on the actual implementation of countries, especially whether there are practical actions in cooperation and coordination of resource allocation.

It can be seen that for those countries with vaccine and testing reagent resources, they have been strengthening surveillance and taking measures to reduce the spread of monkeypox long before WHO’s recommendation or PHEIC statement.

But the problem today is that there are only a limited number of vaccines, therapeutics or testing reagents available globally.

Taking vaccines as an example, from a safety point of view, only the non-replicative third-generation smallpox vaccine is currently suitable for monkeypox.

The global stock of this vaccine is currently limited, and most of them are supplied to European and American countries, but the supply is still in short supply.

Under such circumstances, how to make the resources of drugs and treatment more in line with the actual epidemic situation, rather than the economic development of each country, will be the challenge that WHO has to face.

In theory, the PHEIC announcement could prompt organizations such as the World Bank to provide support to under-resourced countries hit by the pandemic.

However, the resource gap of the monkeypox epidemic is due to the lack of related drugs, testing and other physical objects.

It remains to be seen whether providing more economic assistance opportunities can be converted into medical resources.

In addition, monkeypox research remains scientifically uncertain. More and more evidence points to its manifestations close to a sexually transmitted disease.

For example, the infected population is concentrated in male homosexual or bisexual people with multiple sexual partners. For example, some studies have shown that there is viral DNA in semen.

This results in a huge difference in the pattern and scope of monkeypox transmission from the past.

But whether monkeypox is sexually transmitted or not, human-to-human transmission of the virus still relies heavily on prolonged close contact.

If the public can have more awareness of the virus, especially in high-risk groups to increase vigilance through knowledge education, and cooperate with epidemiological investigations such as case tracking, then the further spread of monkeypox can be controlled and prevented from becoming a long-term existence.

There is still hope for new sexually transmitted diseases globally.

But this requires WHO’s PHEIC to raise public awareness without intensifying prejudice and discrimination against men of the same sex or bisexuality.

And this may be the variable that has the greatest impact on the trend of the monkeypox epidemic.






References: What is the practical significance when WHO declares monkeypox as a public health event of international concern?
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What is the practical significance when WHO declares monkeypox as a public health event of international concern?

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