The monkeypox outbreak qualifies as a global health emergency, the World Health Organization’s Director-General Tedros Adhanom Ghebreyesus declared on Saturday, citing a rapid escalation in cases to more than 16,000 reported from 75 nations and territories in recent weeks.
That means the world faces three simultaneous global health emergencies — polio since 2014; COVID-19 since 2020; and monkeypox — that WHO believes deserve a coordinated response, though the U.N. health agency cannot require countries to do anything. Only COVID-19 has been declared a pandemic.
The monkeypox declaration marked the first time a WHO chief issued such a decision despite a lack of consensus among the global public health experts who serve on an advisory International Health Regulations Emergency Committee. As an instrument of international law, the International Health Regulations, or IHR, are legally-binding on 196 countries, including WHO's 194 member nations.
"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 told a virtual press conference. "For all of these reasons, I have decided that the global monkeypox outbreak represents a public health emergency of international concern."
He said six committee members shared his assessment of the public health risk, while nine others did not feel it rises to the level of a Public Health Emergency of International Concern, or PHEIC, the highest level of alert that WHO can issue. Monkeypox, a zoonotic virus that causes flu-like symptoms and rashes across the body, has long been endemic in parts of Africa, but recently began spreading around the globe.
"I know this has not been an easy or straightforward process, and that there are divergent views among the members," he said. "The International Health Regulations remains a vital tool for responding to the international spread of disease. But this process demonstrates once again that this vital tool needs to be sharpened to make it more effective."
A PHEIC is defined as an extraordinary event that poses a public health risk through the international spread of disease, requiring a coordinated international response. Tedros said that "with the tools we have right now, we can stop transmission and bring this outbreak under control." Tedros' declaration is expected to prompt more investment in treatments and scarce vaccines that could ward off a second, dual pandemic.
Battling stigma and discrimination
A vaccine developed for smallpox can be used against monkeypox, but supplies are limited. Smallpox vaccines are thought to be 85% effective against monkeypox, WHO says, while just one vaccine against monkeypox exists but is approved for use only in Canada and the United States.
Until recent months, monkeypox was not known to have caused large outbreaks beyond central and west Africa, where it is endemic in some countries.
In 2003, the first monkeypox outbreak outside of Africa occurred in the United States, where more than 70 cases were reported due to contact with infected pet prairie dogs that were housed with Gambian pouched rats and dormice imported from Ghana.
Since 2018, cases of monkeypox were reported in travelers from Nigeria to Britain, Israel, Singapore and the U.S. Until recently the vast majority of cases originated in Congo and Nigeria, but starting in May multiple cases of monkeypox were identified in non-endemic countries where it wasn't previously detected, prompting urgent studies on the epidemiology, infection sources and transmission patterns.
"The technical and financial resources required to effectively respond to monkeypox in Africa are not yet optimally mobilized," said Africa Centers for Disease Control and Prevention, which called on wealthier countries to share vaccine supplies. "Monkeypox remains a public health emergency in affected African countries and is a high-risk pathogen for other neighboring countries."
The number of cases tripled in Europe in the second half of June as African public health authorities called it an emergency in some nations. By the start of July, WHO officials said Europe was in a race to prevent the virus from becoming entrenched.
WHO's Europe office and the European Center for Disease Prevention and Control have been issuing joint bulletins about the continent's monkeypox outbreak. Their findings come from the 26 nations and areas that submitted detailed information through the European Surveillance System, dubbed TESSy.
Tedros' emergency declaration followed the second meeting of the emergency committee, which overwhelmingly declined to recommend declaring the outbreak a global health emergency a month ago. At the time of that first meeting on June 25, Tedros noted, more than 3,000 cases had been reported from 47 countries and territories, and just three members believed it rose to the level of a PHEIC, while 11 others did not.
When the committee declined to recommend declaring a global health emergency after the first meeting, Tedros described monkeypox as "an evolving health threat" and urged governments to do more surveillance, contact tracing and patient care, and to provide people who are most at risk of contracting the disease with adequate vaccines and antiviral treatments.
Now, Tedros is calling on nations to work closely with communities of men who have sex with men, where the outbreak is concentrated, in sharing information and taking measures that protect the "health, human rights and dignity" of affected communities."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. That means that this is an outbreak that can be stopped with the right strategies in the right groups," he said. "Stigma and discrimination can be as dangerous as any virus."