The International Health Regulations (2005) (IHR) Emergency Committee met on Thursday, July 21, 2022, from 12:00 to 19:00 CEST to discuss the ongoing multi-country outbreak of monkeypox, and the WHO Director-General is hereby transmitting the Report of that meeting.
The Director-General of WHO extends his deepest appreciation to the Chair, Members, and Advisors for their thoughtful consideration of the issues surrounding this outbreak and for providing invaluable input for his consideration. The members of the Committee could not agree on whether or not this situation constituted a PHEIC (public health emergency of international concern).
The Director-General of the World Health Organization is aware of the difficulties and unknowns surrounding this public health crisis. The Director-General has concluded that the ongoing monkeypox outbreak in multiple countries constitutes a Public Health Emergency of International Concern after hearing the opinions of Committee Members and Advisors and taking into account other factors in accordance with the International Health Regulations.
The recommendations presented below were issued by the Director-General of the WHO after taking into account the views of the Committee.
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Warnings from the World Health Organization's top official about the current monkeypox epidemic in multiple countries
Different categories of States Parties are subject to these Temporary Recommendations depending on their epidemiological situation, transmission patterns, and capacities. At any given time, each State Party is either Group 1 or Group 2 depending on which criteria are met. It's possible that some of the State Parties also belong in Group 3 and/or Group 4.
All interim recommendations must be carried out with due regard for universally recognized human rights, social justice, and the inherent worth and dignity of all people and communities.
Group 1: Parties with no evidence of human monkeypox transmission or no cases detected in the last 21 days
To better prepare for a response to monkeypox and halt its spread from human to human, we must: 1.a. activate or establish health and multi-sectoral coordination mechanisms.
In order to stop the spread of monkeypox undetected, it is important to take the following steps: 1.b. Prepare for and/or carry out interventions to prevent stigmatization and discrimination against any individual or population group that may be affected. Protection of human rights, privacy, and dignity of affected individuals and their contacts in all communities should be at the forefront of these interventions, as well as encouraging voluntary self-reporting and care seeking behavior.
1.c. Include illness that could be caused by monkeypox in established national surveillance systems, and establish and intensify epidemiological disease surveillance, including access to reliable, affordable, and accurate diagnostic tests. Case definitions for suspected, probable, and confirmed cases of monkeypox should be adopted for disease surveillance purposes.
Health care providers in primary care, genitourinary and sexual health clinics, urgent care/emergency departments, dental practices, pediatrics, HIV services, infectious diseases, obstetrics and gynecology, and other acute care settings should be educated and trained to increase the detection capacity (1.d).
Educate communities affected by the multi-country outbreak (including, but not limited to, gay, bisexual, and other men who have sex with men (MSM) or individuals with multiple sexual partners) about the transmission of the monkeypox virus, the importance of taking preventative measures, and the symptoms and signs of monkeypox (e.g., sex workers, transgender people).
To increase the dissemination of accurate and trustworthy data regarding monkeypox and its potential transmission to and within populations or communities at increased risk of infection, it is important to involve key community-based groups, sexual health and civil society networks.
1.g. Target places and spaces where romantic encounters are likely to occur in your efforts to educate the public and rally community support (e.g., gatherings focused on MSM, sex-on-premises venues). This includes collaborating with and providing resources to event organizers of all sizes, as well as the owners and managers of sex on premises venues, in order to raise awareness about the importance of taking precautions and reducing one's own risk of sexual assault.
Probable and confirmed cases of monkeypox must be reported immediately to WHO through channels established under the provisions of the IHR, using the minimum data set contained in the WHO Case Report Form (CRF).
1.i. Do everything that needs to be done to be ready to apply or continue applying the set of Temporary Recommendations listed for Group 2 below in the event that one or more suspected, probable, or confirmed cases of monkeypox are detected for the first time or re-detected.
Group 2: States Parties where imported cases of monkeypox have been confirmed or where there is ongoing human-to-human transmission of monkeypox virus, including in high-risk communities and key population subsets.
Advancing Coordination of Response 2.a.
Communities at high risk of exposure, which may vary from context to context but always include gay, bi, and other men who have sex with men, should be the primary focus of response actions with the goal of stopping human-to-human transmission of monkeypox virus (MSM). Targeted risk communication and community engagement, case detection, supported isolation of cases and treatment, contact tracing, and targeted immunization for people at high risk of exposure for monkeypox are all part of the plan.
2.a.ii. Enable and support leadership from affected communities in developing, actively contributing to, and monitoring the response to the health risk being faced by those communities. Extend as many technical, financial, and human resources as you can, and keep mutual accountability for the actions of the affected communities a priority.
2.a.iii Deploy response measures to safeguard those at high risk for severe monkeypox infection (the immunocompromised, children, and pregnant women). Case detection, supported isolation of cases and treatment, contact tracing, and targeted risk communication are all examples of such measures. One such strategy is targeted immunization, which incorporates the patient's values and preferences into the clinical decision.
Protection and community involvement (2.b)
2.b.i. Raise public awareness of the context-dependent nature of the monkeypox virus's transmission, actions to reduce the risk of onward transmission, and clinical presentation in affected communities, and encourage the uptake and appropriate use of preventative measures and the adoption of informed risk mitigation strategies. Limiting skin-to-skin contact or other forms of close contact with others while experiencing symptoms, encouraging a decrease in the number of sexual partners where appropriate (such as at events with sex venues on the premises), and employing other forms of personal protection during and after gatherings of high-risk communities are all examples of this.
Encourage event organizers to take a risk-based approach to the holding of such events and discuss the possibility of postponing events for which risk measures cannot be put in place. 2.b.ii Engage with organizers of gatherings (large and small), including those likely to be conducive for encounters of an intimate sexual nature or that may include venues for sex-on-premises, to promote personal protective measures and behaviors. Infection prevention and control, such as the routine cleaning of event venues, should also be made available, and all relevant information should be communicated to attendees.
2.b.iii) Design and target risk communication and community engagement interventions based on systematic social listening (e.g., via digital platforms) for emerging perceptions, concerns, and misinformation that may impede response actions.
To reduce the risk of spread of monkeypox and ensure that those infected receive timely care, testing, and access to preventative measures and clinical care, it is important to consult with affected communities' representatives, NGOs, elected officials, members of civil society, and behavioral scientists to develop effective interventions that do not stigmatize any individuals or groups.
Security and preventative health measures
2.c.i. Increase monitoring for diseases that may be caused by monkeypox as part of ongoing national surveillance programs, with emphasis on ensuring that people have access to effective, cost-efficient diagnostic tools.
2.c.ii. Weekly reporting to WHO of suspected and confirmed cases of monkeypox, using the WHO Case Report Form's minimum data set (CRF).
Using nucleic acid amplification testing (NAAT), such as real time or conventional polymerase chain reaction, strengthen laboratory capacity and, if necessary, international specimen referral capacities for the diagnosis of monkeypox virus infection and related surveillance (PCR).
Build on existing sequencing capacities around the world to identify circulating virus clades and their evolution, and make genetic sequence data publicly available through databases. 2.c.iv. Strengthen genomic sequencing capacities, and international specimens referral capacities, as needed.
For the duration of the infectious period, 2.c.v., isolate cases. Health, psychological, material, and essential support to adequate living should all be a part of any policies related to isolating cases. Modifying isolation policies late in the isolation period would necessitate minimizing any lingering threat to public health.
2.c.vi. During their time in isolation, patients should be given instructions on how to lessen the likelihood that they will infect others.
To identify (under strict confidentiality), manage, and follow up with contacts for 21 days through health monitoring that can be self-directed or supported by public health officers in the event of a suspected, probable, or confirmed case of monkeypox. The health, mental well-being, material, and essentials needs of contacts should all be addressed by contact management policies.
For post-exposure prophylaxis in contacts, including household, sexual, and other contacts of community cases and health workers where there may have been a breach of personal protective equipment, 2.c.viii. consider the targeted use of second- or third-generation smallpox or monkeypox vaccines (hereinafter referred to as vaccine(s)) (PPE).
Health care workers, laboratory workers with orthopoxviruses, clinical laboratory personnel performing diagnostic testing for monkeypox, and members of communities at high risk of exposure or engaging in high-risk behaviors, such as having multiple sexual partners, are all candidates for pre-exposure prophylaxis with vaccines.
2.c.x. For vaccine and immunization policy decisions, the National Immunization Technical Advisory Group (NITAG) should be consulted. A cost-benefit analysis needs to guide these. Vaccine recipients should always be made aware of the duration of time needed for a vaccine to provide any promised immunity protection.
2.c.xi Involve populations most likely to be affected by a vaccine rollout in the decision-making process.
Infection prevention and clinical management
2.d.i. Create and use clinical care pathways and protocols for suspected cases of monkeypox, including screening, triage, isolation, testing, and clinical assessment; train healthcare providers on these procedures; and track their use.
Infection prevention and control (IPC) measures include engineering and administrative practices as well as personal protective equipment (PPE), and they must be established, implemented, trained on, and monitored by healthcare providers.
2.d.iii Equip all personnel with proper PPE and instruct them in its proper use, as appropriate for the workplace environment, in healthcare facilities and laboratories.
Clinical care protocols for patients with uncomplicated monkeypox disease (such as keeping lesions clean, controlling pain, and maintaining adequate hydration and nutrition), severe symptoms, acute complications, and for monitoring and managing mid- or long-term sequelae should be developed, updated, and implemented.
2.d.v. Use the WHO Global Clinical Platform for Monkeypox to standardize data collection and report on clinical outcomes.
Science of Preventative Medicine
To rapidly increase evidence generation on efficacy and safety, to collect data on the effectiveness of vaccines (e.g., the comparison of one or two dose vaccine regimens), and to conduct vaccine effectiveness studies, all efforts should be made to use existing or new vaccines against monkeypox within a framework of collaborative clinical efficacy studies, using standardized design methods and data collection tools for clinical and outcome data.
To swiftly increase evidence generation on efficacy and safety, it is imperative that we (as a community) 2.e.ii. make every effort to use existing or new therapeutics and antiviral agents for the treatment of monkeypox cases within a framework of collaborative clinical efficacy studies, employing standardized design methods and data collection tools for clinical and outcome data.
Vaccines and antivirals for monkeypox can be used under expanded access protocols like the Monitored Emergency Use of Unregistered and Investigational Interventions (MEURI), with harmonized data collection for clinical outcomes, when use within a collaborative research framework is not feasible (such as the WHO Global Clinical Platform for Monkeypox).
Two-Fourths: Overseas Vacations
Take the following steps as part of 2.f.i.
Anyone exhibiting symptoms consistent with monkeypox virus infection; anyone who is suspected, probable, or confirmed to have monkeypox by health authorities with jurisdiction; anyone who has been exposed to an infected monkey.
Until it is determined that the contact of a monkeypox case is no longer a public health risk, they should not travel at all (even internationally). There are a few exceptions to this rule, including: patients who need to leave immediately for medical care or those evacuating from dangerous situations (such as war or natural disasters); contacts for whom pre-departure arrangements to ensure the continuity of health monitoring are agreed upon by the relevant sub-national health authorities or, in the case of international travel, by the relevant national health authorities;
If the health monitoring of cross-border workers who have been identified as contacts of a monkeypox case is coordinated by the competent authorities on both sides of the border, the workers can go about their normal business as usual.
2.f.ii. Create working lines of communication among health authorities, transportation authorities, and operators of transportation and entry points to:
Support international contact tracing for people who have developed symptoms of monkeypox virus infection while traveling or after returning home;
Distribute informational materials at entry points about monkeypox symptoms, infection control measures, and how to access medical care once there;
The World Health Organization recommends against taking any precautions for international travel beyond those outlined in sections 2.f.i and 2.f.ii.
Group 3: States Parties where zoonotic transmission of monkeypox is known to occur or has been reported, where monkeypoxvirus presence has been documented in any animal species, and where infection of animal species in countries may be suspected, including newly affected countries.
3.a. Establish or activate collaborative One Health coordination or other mechanisms between public health, veterinary, and wildlife authorities at the federal, national, subnational, and/or local level, as appropriate, to understand, monitor, and manage the risk of animal-to-human and human-to-animal transmission in natural habitats, forested and other wild or managed environments, wildlife reserves, domestic and peri-domestic settings, zoos, pet shops, animal shelters, and other similar settings.
3.b. Conduct in-depth case studies and investigations to characterize transmission patterns, taking into account any documented or suspected spillovers from or back to animals. Case investigation forms should be revised and adapted in all settings to inquire about potential zoonotic and human-to-human exposures and transmission routes. Spread the word to WHO about the results of your efforts, which should include regular case reporting.
Class 4: Member States that Produce Medicines for Countermeasure Use
States 4.a Increased production and availability of medical countermeasures against smallpox and monkeypox should be made by parties with manufacturing capacity for such items.
the 4.b. States To help stop the spread of monkeypox, parties and manufacturers should collaborate with WHO to ensure that diagnostics, vaccines, therapeutics, and other necessary supplies are made available to countries where they are most needed based on public health needs, solidarity, and reasonable cost.
The Meeting Minutes
On the premises of WHO headquarters in Geneva, Switzerland, Zoom hosted the second meeting of the IHR Emergency Committee to discuss the global outbreak of monkeypox, with the Chair and Vice-Chair present in person.
The meeting was held virtually, with members and advisors participating via videoconference. Fifteen of the Committee's sixteen Members and all ten of the Committee's Advisors were present.
The Director-General of the World Health Organization (WHO) greeted the Committee, noting that he had reconvened them to evaluate the short- and long-term public health implications of the development of the multi-country monkeypox outbreak.
The Director-General of WHO voiced concern over the rising number of reported cases from an increasing number of countries and emphasized the difficulties posed by the variability in transmission patterns across WHO's Regions. He also emphasized his understanding that many factors must be taken into account when deciding whether or not to declare a PHEIC in order to ensure the public's safety.
After reviewing the relevant articles of the IHR, the Representative of the Office of Legal Counsel briefed the Members and Advisors on their duties and the scope of the Emergency Committee's authority.
Members and Advisors were given a briefing on their responsibilities by the Ethics Officer from the Department of Compliance, Risk Management, and Ethics. Members and Advisors were also reminded of their obligation to maintain the confidentiality of Committee deliberations and activities, and of their individual responsibility to disclose to WHO, in a timely manner, any interests of a personal, professional, financial, intellectual, or commercial nature that might give rise to a perceived or direct conflict of interest. There was a poll taken of all present Members and Advisors. There were no apparent conflicts of interest.
Dr. Jean-Marie Okwo-Bele, Chair of the Emergency Committee, took the floor and outlined the meeting's purpose: to advise the WHO Director-General on whether or not the current monkeypox outbreak across multiple countries constitutes a PHEIC and, if so, to review the proposed temporary recommendations to States Parties.
Presentations
After only 3,040 cases were reported in 47 countries at the beginning of May 2022, the WHO Secretariat gave a presentation on the global epidemiological situation, highlighting the 14,533 probable and laboratory-confirmed cases (including 3 deaths in Nigeria and 2 in the Central African Republic) reported to WHO from 72 countries across all six WHO Regions between 1 January 2022 and 20 July 2022.
There are now cases of monkeypox being reported from countries all over the world, including those in the WHO European Region and the Region of the Americas, where it had never been seen before.
Currently, males account for the vast majority of reported monkeypox cases; these cases tend to cluster in urban areas and among gay, bi, and other MSM who have sex with men (MSM), as well as in their respective social and sexual networks. An unknown number of isolated cases among children were reported early on.
There has also been an increase in the number of reported cases in countries in West and Central Africa, where the demographic profile appears to differ from that observed in Europe and the Americas, where a disproportionate number of female and juvenile cases have been reported.
The basic reproduction number (R0) is predicted by mathematical models to be greater than 1 in MSM populations and lower than 1 in all other environments. Example countries with estimated R0 values include Spain (1.8), the United Kingdom (1.6), and Portugal (1.4).
Monkeypox outside of Africa typically presents as a self-limiting disease, with rash lesions localized to the genital, perineal/perianal, or peri-oral area, that often do not spread further, and appears before the development of lymphadenopathy, fever, malaise, pain, and associated lesions.
Data from the surveillance systems in the Netherlands, the United Kingdom of Great Britain and Northern Ireland (UK), and the United States suggest an average incubation period of 7.6 to 9.2 days for reported cases (United States). According to calculations, the average time between serial events is 9.8 days (95 percent CI 5.9-21.4 day, based on 17 case-contact pairs in the United Kingdom).
There have only been a handful of reported cases among medical professionals. Even though no occupational transmission cases have been found through the ongoing investigations, it is important to note that this does not mean that no cases exist.
The Secretariat reported that the WHO risk assessment has not changed since the Committee's first meeting on 23 June 2022, and that the risk is still rated as "moderate" globally and in all six WHO Regions, with the exception of the European Region, where it is rated as "high."
The European Center for Disease Prevention and Control (ECDC) and the European Commission's Health Emergency Preparedness and Response Authority (HERA) have conducted modeling work that suggests case isolation and contact tracing could be effective in bringing the outbreak under control. The operational experience gained so far in responding to this event, however, indicates that putting such interventions into practice is extremely challenging due to factors such as the difficulty in identifying cases due to barriers to access diagnostic testing, the difficulty in isolating cases for 21 days due to the current post-lockdown context caused by the COVID-19 pandemic, and the difficulty in tracing contacts due to the fact that contacts are often multiple and may be anonymous. Pre-exposure prophylaxis of high-risk individuals seems to be the most effective strategy to use vaccines when contact tracing is less effective, or impractical, according to the modeling by ECDC and HERA, which suggests that this can increase the chances of controlling the outbreak. However, one of the limitations of the modeling work is the lack of information on how well monkeypox vaccines work. Moreover, there are difficulties associated with vaccine accessibility in the operationalization of such a vaccination strategy.
There is genetic variation between the West African clade and the virus strains that have been isolated from other countries. There is ongoing research to determine if the observed genomic changes result in phenotypic changes such as increased transmissibility, virulence, immune escape, resistance to antivirals, or reduced impact of countermeasures.
Spillback of the monkeypox virus from humans to other animal species is possible, despite the fact that many animal species (including rope squirrels, tree squirrels, Gambian pouched rats, dormice, and non-human primates) are known to be susceptible to the virus in the natural setting. The World Health Organization (WHO) Secretariat and its One Health partners, the Food and Agriculture Organization (FAO) and the World Organisation for Animal Health (OIE), do not have any evidence of anthropozoonotic transmission at this time (WOAH).
The WHO Secretariat detailed the organization's current response to the outbreak and its ongoing efforts to develop a Strategic Readiness and Response Plan for monkeypox, the ultimate goal of which is to halt the disease's spread from person to person.
The Committee was given an update (in order) on the epidemiological situation in Spain, the United Kingdom, the United States, Canada, and Nigeria. Nigeria was the only country where a single partner was not involved in the transmission of the virus; reports from the other four countries all indicated that MSM constituted 99 percent of the transmission.
It appears that the number of reported cases in Spain has been decreasing over the past few weeks, but this may be due to reporting delays. There have been relatively few reports of cases among females and children with epidemiological links to MSM, and the vast majority of cases have been reported in major urban areas. Health care providers, contacts, and HIV-positive individuals are encouraged to get vaccinated as a form of preexposure prophylaxis, but there is a shortage of vaccines.
Few severe cases of monkeypox (including encephalitis) were reported in the United Kingdom, and the country plans to update its case definition to account for newly recognized conditions like proctitis. Monkeypox virus DNA (assumed to be infectious due to moderate Ct values) has been detected on surfaces in healthcare facilities and private homes. The vaccine strategy is directed at high-risk MSM in an effort to prevent further spread of the disease through post-exposure and prophylactic measures before potential exposure.
Although monkeypox is widespread in the United States, the majority of reported cases are centered in just three major cities. Of the known cases, only one involved a pregnant woman and one involved a child. The remaining 99 percent all involve males having sexual contact with other men.
Given the difficulties in contact tracing, Canada is taking a comprehensive approach to pre-exposure prophylaxis and is putting a strong emphasis on engagement with community-led organizations supporting key affected populations groups.
Approximately 800 cases of monkeypox were reported in Nigeria between September 2017 and July 10, 2022, with a case fatality rate of 3% among confirmed cases. There is no evidence of sexual transmission, and most of the cases have been found in men between the ages of 31 and 40. Year 2022 saw the highest annual total of reported cases since 2017's.
A Q&A session with the Secretariat and the presenting countries was held after the presentations by the Committee Members and Advisers.
The Committee is still worried about many different things, such as the following: the need for more research into transmission dynamics; the effect of stigma on health-seeking behavior among MSM; the potential impact on rights-based care delivery by Ministries of Health and other authorities; and the difficulties associated with the use of public health and social measures to halt transmission, such as isolation, access to testing, and other similar measures.
Fears were voiced about the fairness of future pricing and distribution of antivirals and vaccines.
Talking it over
The Committee reconvened in closed session to discuss the Temporary Recommendations, developed by the WHO Secretariat in line with IHR provisions, and whether or not the incident in question constitutes a PHEIC.
A reminder of the Committee's charge and the definition of a PHEIC under the IHR were provided by the WHO Secretariat at the request of the Chair: an extraordinary event that constitutes a public health risk to other States through international spread and which potentially requires a coordinated international response.
Evidence collected by the Secretariat was compared to the factors proposed by the Committee at its first meeting in order to reevaluate the outbreak. The Committee took note of the generally moderate level of confidence in the available data to make any informed determination on these factors.
The number of countries reporting their first case(s) of monkeypox and the number of cases in some West and Central African countries are just two of the nine factors that have changed significantly since the last meeting, based on the most recent data. As a result of the epidemic, there was a slight acceleration in the overall growth rate. In spite of the fact that cases have been reported among health workers, most reported exposure in the community. Case reports and social media monitoring have only uncovered a small fraction of the actual number of cases among sex workers. Some women and children contracted the virus through secondary exposure. A small number of children were reported to have no epidemiological link to another case, but limited transmission was observed among vulnerable groups (immunosuppressed individuals, pregnant women, or children). Although there has been no significant change in the overall clinical severity of cases since the last meeting, there have been a small number of extremely severe cases, two intensive care unit admissions, and five deaths reported. No information about the possibility of spillover from humans to animals is currently available. According to reports, there may have been alterations to the virus's genome, which could have an effect on the virus's characteristics. The virus clade typically found in Central Africa has not been reported to spread outside of these regions.
Conclusions
A variety of opinions were voiced by committee members regarding the issues at hand. In the end, they couldn't agree on what to tell the World Health Organization's director-general about the ongoing monkeypox outbreak in multiple countries: that it is or isn't a Public Health Emergency of International Concern (PHEIC). The following is a summary of the arguments for and against this conclusion made by the Committee members. These thoughts represented:
Perspectives of Committee Participants in Favor of Future PHEIC Determination
A PHEIC is defined as "[...] an extraordinary event [...] I constitut[ing] a public health risk to other States through the international spread of disease and (ii) which may potentially require a coordinated international response," and the current monkeypox outbreak across multiple countries meets all three of these criteria.
Because the community currently most affected outside of Africa is the same as the one initially reported to be affected in the early stages of the HIV/AIDS pandemic, there is a moral obligation to deploy all available means and tools to respond to the event, as highlighted by leaders of the LGBTI+ communities from several countries.
the increasing rates at which new cases are being reported across an ever-widening range of countries, which are likely to be underreporting the true scope of the outbreak(s);
Similar to the early stages of the HIV pandemic, monkeypox has been reported in children and pregnant women.
As the monkeypox virus is introduced to more susceptible populations, new waves of cases are anticipated;
It is unclear what kinds of transmission are keeping the current epidemic going;
Differences between the current clinical picture of monkeypox and the previously established picture;
It is essential to collect more data on the efficacy of pharmaceutical and non-pharmaceutical measures in containing the outbreak.
The serious illness caused by the monkeypox epidemic;
Given that global immunity has greatly declined since smallpox was eradicated, the potential future implications on public health and health services if the disease were to establish itself in the human population worldwide;
Potentially increasing the likelihood of halting human-to-human transmission of the monkeypox virus through heightened awareness and alert, as well as other benefits, a PHEIC determination is seen as having.
improving political will to support relief efforts; facilitating more opportunities for the release of funds for response, research, and reducing the disease's societal and economic impact;
Increasing cooperation between countries in their response, especially to ensure that everyone can get the vaccines and drugs they need;
Prospective determination of a PHEIC should not be seen as discouraging because of the potential stigmatization, marginalization, and discrimination that may result.
opinions of committee members who are opposed to the possibility of a PHEIC being determined
The WHO Secretariat's global risk assessment presented to the Committee on June 23, 2022, has not changed since then.
There is no evidence, based on the current data, that the number of cases will increase exponentially in any of the 12 countries where it is being reported that they are suffering the most from the outbreak, and there are even early signs of stabilization or declining trends in some of these countries;
Most infections are found in MSM who have had multiple partners, and despite logistical hurdles, there is an opportunity to halt further transmission by focusing on this population. Limited data exists outside of this population, even among healthcare professionals.
The disease is thought to be mild;
Clearer indications about the efficacy of policies and interventions are being generated, and new waves of the epidemic are expected.
In the eyes of many, the pros of determining a PHEIC in advance don't balance out the risks of stymieing response efforts in the future.
LGBTI+ communities are not well established and engaged in a dialogue with governments because of the stigma, marginalization, and discrimination that a determination of a PHEIC may generate against the currently affected communities, especially in countries where homosexuality is criminalized. Communities in some countries are rumored to have said that, unlike HIV infection, monkeypox may be a visible condition, making it difficult to minimize stigma using standard methods, which could be the case in the context of a PHEIC.
Since May 2022, the WHO Secretariat has taken action to raise the alert regarding the unfolding monkeypox outbreak, including convening the Committee. These measures appear to have been successful, as they have triggered immediate response efforts in many countries in the northern hemisphere.
There are no known obstacles to the global implementation of the Secretariat's technical guidance issued to inform national response efforts, so it is widely regarded as adequate and comprehensive.
The identification of a PHEIC may not be seen as a tool for either triggering or boosting efforts to improve West and Central African countries' surveillance, laboratory, and response capacities;
Public health emergency infectious case definition (PHEIC) determination would unnecessarily and artificially increase public perception of disease risk, leading to increased demand for vaccines that should be used prudently;
There would be no return to "business as usual" if a PHEIC was not identified. Beyond a simple high-visibility determination, the communication of the WHO Director-decision General's would still be an opportunity to convey the required continuity of the full range of necessary public health actions.
