Geneva: The World Health Organisation has said that monkeypox outbreak in more than 70 countries is now a global emergency.
WHO Director-General Tedros Adhanom Ghebreyesus made the decision to issue the declaration despite a lack of consensus among members of WHO's emergency committee. It was the first time the chief of the UN health agency has taken such an action.
"In short, 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 said.
"I know this has not been an easy or straightforward process and that there are divergent views among the members" of the committee, he added.
Although monkeypox has been established in parts of central and west Africa for decades, it was not known to spark large outbreaks beyond the continent or to spread widely among people until May, when authorities detected dozens of epidemics in Europe, North America and elsewhere.
Declaring a global emergency means the monkeypox outbreak is an "extraordinary event" that could spill over into more countries and requires a coordinated global response. WHO previously declared emergencies for public health crises such as the COVID-19 pandemic, the 2014 West African Ebola outbreak, the Zika virus in Latin America in 2016 and the ongoing effort to eradicate polio.
The emergency declaration mostly serves as a plea to draw more global resources and attention to an outbreak. Past announcements had mixed impact, given that the UN health agency is largely powerless in getting countries to act.
It’s usually a mild viral infection. The virus belongs to the same family as the smallpox (Orthopoxvirus genus in the family Poxviridae). This genus also includes variola virus (which causes smallpox), vaccinia virus (used in the smallpox vaccine), and cowpox virus.
Last month, WHO's expert committee said the worldwide monkeypox outbreak did not yet amount to an international emergency, but the panel convened this week to reevaluate the situation.
According to the US Centres for Disease Control and Prevention, more than 16,000 cases of monkeypox have been reported in 74 countries since about May. To date, monkeypox deaths have only been reported in Africa, where a more dangerous version of the virus is spreading, mainly in Nigeria and Congo.
In Africa, monkeypox mainly spreads to people from infected wild animals like rodents, in limited outbreaks that typically have not crossed borders. In Europe, North America and elsewhere, however, monkeypox is spreading among people with no links to animals or recent travel to Africa.
WHO's top monkeypox expert, Dr. Rosamund Lewis, said this week that 99% of all the monkeypox cases beyond Africa were in men and that of those, 98% involved men who have sex with men. Experts suspect the monkeypox outbreaks in Europe and North America were spread via sex at two raves in Belgium and Spain.
Michael Head, a senior research fellow in global health at Southampton University, said it was surprising WHO hadn't already declared monkeypox a global emergency, explaining that the conditions were arguably met weeks ago.
The definition implies that the situation is serious, sudden, unusual or unexpected; carries implications for public health beyond an affected country's border; and may require immediate international action.
Some experts have questioned whether such a declaration would help, arguing the disease isn't severe enough to warrant the attention and that rich countries battling monkeypox already have the funds to do so" most people recover without needing medical attention, although the lesions may be painful.
"I think it would be better to be proactive and overreact to the problem instead of waiting to react when it's too late," Head said. He added that WHO's emergency declaration could help donors like the World Bank make funds available to stop the outbreaks both in the West and in Africa, where animals are the likely natural reservoir of monkeypox.
In the US, some experts have speculated whether monkeypox might be on the verge of becoming an entrenched sexually transmitted disease in the country, like gonorrhea, herpes and HIV.
"The bottom line is we've seen a shift in the epidemiology of monkeypox where there's now widespread, unexpected transmission,'' said Dr. Albert Ko, a professor of public health and epidemiology at Yale University. "There are some genetic mutations in the virus that suggest why that may be happening, but we do need a globally-coordinated response to get it under control,'' he said.
Monkeypox: From beginnings in Africa to global spread
As monkeypox infections jump around the world, prompting a scramble for vaccines, here’s a look at how the disease has spread since first appearing in Africa in the 1970s.
Monkeypox, so called because it was first discovered in a monkey, is related to the deadly smallpox virus, which was eradicated in 1980, but is far less severe.
The strain currently circulating outside Africa is the milder of two known versions.
1970: First case in humans
Human monkeypox is first identified in 1970 in Zaire (now the Democratic Republic of Congo) in a nine-year-old boy.
It becomes endemic in the tropical rainforests of central and west Africa, where 11 countries report cases.
The virus is transmitted through close contact with infected animals, mostly rodents, or humans.
2003: First outbreak outside Africa
In June 2003, the disease surfaces in the United States - the first time it had been detected outside Africa.
The illness is believed to have spread after rodents, imported into the US from Ghana, infected prairie dogs.
The US Centres for Disease Control and Prevention (CDC) reports 87 cases but no fatalities.
2017: Epidemic in Nigeria
2017 brings a major outbreak in Nigeria, with more than 200 confirmed cases and a fatality rate of around three percent, according to the WHO.
Over the next five years, sporadic cases are reported around the world in travellers arriving from Nigeria, notably in Britain, Israel, Singapore and the United States.
May 2022: Surge outside Africa
In May 2022, a flurry of cases is detected in countries outside Africa, in people with no travel links to the region. Most of those affected are gay men.
Europe is the epicentre of the new outbreak.
By May 20, Britain has recorded 20 cases, mostly among gay men.
On the same date, the WHO counts 80 confirmed cases around the world, including in Australia, Belgium, Canada, France, Germany, Italy, Portugal, Spain and Sweden.
Late May: Vaccinations start
On May 23, the United States says it is preparing to administer smallpox vaccines, which are effective against monkeypox, to people who have been in close contact with monkeypox patients.
Three days later, the European Union says it is working on centralising purchases of vaccines, as it did for Covid-19.
June: More than 1,000 cases
In early June, WHO chief Tedros Adhanom Ghebreyesus says that more than 1,000 confirmed cases of monkeypox have been reported to WHO from 29 countries where the virus is not usually present.
On June 21, Britain announces plans to offer vaccines to gay and bisexual men with multiple sexual partners.
WHO experts meet on June 23 to discuss the threat but decide that monkeypox does not constitute a global public health emergency.
July: 14,000 cases, 70 countries
On July 8, health authorities in France also launches pre-emptive jabs for people considered at risk, including gay men, trans people and sex workers.
On July 14, the US CDC reports more than 11,000 confirmed cases in some 60 countries where monkeypox is not usually found. Most of the cases are in Europe, the United States and Canada.
The number of infections in New York doubles in under a week to several hundred. People stand in line for vaccines, which are in short supply.
On July 20, Tedros announces that almost 14,000 confirmed cases have been reported to the WHO this year, from more than 70 countries, with five deaths, all in Africa.
He says six countries reported their first cases in the previous week, while some states have limited access to diagnostics and vaccines, making the outbreak harder to track and to stop.
The WHO calls a new expert meeting for July 21 to decide whether to declare a health emergency.
On July 23, WHO declares monkeypox a global emergency.
Monkeypox: how a global health emergency is decided
Here is a look at how the decision is made and previous PHEIC declarations:
What is a PHEIC?
The conditions which must be met are set out under the 2005 International Health Regulations (IHR) - the legal framework defining countries' rights and obligations in handling public health events that could cross borders.
A PHEIC is defined in the regulations as "an extraordinary event which is determined to constitute a public health risk to other states through the international spread of disease and to potentially require a coordinated international response".
The definition implies that the situation is serious, sudden, unusual or unexpected, carries implications for public health beyond an affected country's border, and may require immediate international action.
The WHO's 16-member emergency committee on monkeypox is chaired by Jean-Marie Okwo-Bele from the Democratic Republic of Congo, who is a former director of the WHO's Vaccines and Immunisation Department.
The committee brings together virologists, vaccinologists, epidemiologists and experts in the fight against major diseases.
It is co-chaired by Nicola Low, an associate professor of epidemiology and public health medicine from Bern University.
The other 14 members are from institutions in Brazil, Britain, Japan, Morocco, Nigeria, Russia, Senegal, Switzerland, Thailand and the United States.
Eight advisers from Canada, the DRC, South Africa, Sweden, Switzerland and the United States also take part in the meetings.
The emergency committee provided WHO chief Tedros Adhanom Ghebreyesus with an assessment of the risk to human health, the risk of international spread and the risk of interference with international traffic.
But it was unable to reach a consensus on whether or not to trigger the highest alert, Tedros said Saturday, so the WHO chief then had to decide himself.
Six previous PHEICS
The WHO has previously declared a PHEIC six times:
- 2009: H1N1 swine flu
The pandemic was first detected in Mexico and then quickly spread across the United States and the rest of the world.
- May 2014: Poliovirus
Declared following a rise in cases of wild polio and circulating vaccine-derived poliovirus. Besides Covid, it is the only PHEIC still in place.
- August 2014: Ebola
Outbreak in western Africa which spread to Europe and the United States.
- February 2016: Zika virus
The epidemic began in Brazil and heavily affected the Americas. The only PHEIC declared over a mosquito-borne virus.
- July 2019: Ebola
The second Ebola PHEIC was over the outbreak in Kivu in eastern DRC.
- January 2020: Covid-19
Declared when - outside of China where the virus first emerged - there were fewer than 100 cases and no deaths.
The Covid-19 PHEIC declaration came after a third meeting of the emergency committee on the spreading virus. Meetings on January 22 and 23, 2020 decided that the outbreak did not constitute a PHEIC.
Despite the declaration, it was only after March 11, that Tedros described the rapidly worsening situation as a pandemic, leading many countries to wake up to the danger.
The sluggish global response still rankles at the WHO's headquarters and raised questions about whether the PHEIC system under IHR was fit for purpose.
By March 11, the number of cases outside China had soared, with more than 118,000 people having caught the disease in 114 countries, and 4,291 people having lost their lives, following a jump in deaths in Italy and Iran.
"The warning in January was way more important than the announcement in March," WHO emergencies director Michael Ryan said on the second anniversary of the pandemic declaration.
"People weren't listening. We were ringing the bell and people weren't acting.