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expert reaction to WHO declaring the global monkeypox outbreak a public health emergency of international concern (PHEIC)

At the International Health Regulations Emergency Committee meeting the Director-General determined that the multi-country outbreak of monkeypox constitutes a Public Health Emergency of International Concern (PHEIC).


Dr Hugh Adler, Department of Clinical Sciences, Liverpool School of Tropical Medicine, said:

“I readily admit that I was wrong at the early stages of this outbreak, when I was confident this outbreak would be self-limiting and easily controlled with our available public health tools. The ongoing spread of MPX, facilitated by hitherto unappreciated modes of transmission and scenarios that prevent easy identification of contacts, has taken the global public health community by surprise.  

What is a public health emergency of international concern?

“This declaration does not mean that MPX is a severe illness or causing high rates of mortality, nor does it mean that MPX meets the criteria for a pandemic.  It does mean that this outbreak is extraordinary/unprecedented, that it is affecting multiple countries, and that a coordinated international response is required.  It is interesting that the committee was so closely split regarding whether to declare a PHEIC or not – this reflects how different MPX is to previous PHEICs (for example, COVID-19 or the 2014 W African Ebola outbreak).  Ultimately the third criterion in the PHEIC definition – requires a coordinated international response – is the crucial point here. Naming this a PHEIC adds political weight and urgency to this situation, to ensure that this outbreak can be prioritised when there are multiple competing priorities for governmental attention and funds.  The WHO believes, as I do, that this outbreak is controllable (ie can be stopped from spreading extensively in the wider population) with public health measures including a concerted vaccination campaign, but that this window of opportunity is closing fast.  Hence this declaration.  

Why has it been called? What has changed since the last time it was discussed by the WHO?

“The rate of spread of monkeypox has not slowed, and public health strategies have not shown a high rate of success.  We have more data showing that MPX is presenting in atypical ways, that contact tracing is a massive challenge given the unique circumstances of this outbreak, and that countries are struggling to access vaccine supplies.  

How concerning is this development?

“I think it is a positive development if it succeeds in its intended aim – to raise the political priority of this outbreak, step up the production and supply of vaccines and ensure that vaccines are made available where they are most needed. We have seen how countries can get embroiled in unseemly squabbles over vaccine access, and a key challenge for the WHO will be whether it can moderate such disputes and ensure equitable access. The WHO also noted that MPX continues to circulate in West and Central Africa, with a far higher mortality rate reported in Nigeria than in high-income countries, and these nations need just as much support.  

What changes now it is a public health emergency of international concern?

“As above. This hinges on how relevant and weighty a WHO declaration is perceived by governments, public bodies and vaccine manufacturers/suppliers, as well as people at risk of monkeypox around the world.  Will these words on a page speed up the supply of vaccines and make them available in primary care/sexual health clinics for people at high risk of MPX? Will people at risk of MPX (mainly GBMSM with multiple partners, at this point in time) present for vaccination? Can we devise novel ways to rapidly identify high-risk contacts of MPX cases in time for them to be vaccinated? Will public discourse be free from stigma?”


Prof Piero Olliaro, Professor of Infectious Diseases of Poverty, University of Oxford, said:

“We are in a sort of paradoxical situation with monkeypox.

“On the one hand our knowledge of the clinical presentation and outcomes of monkeypox in the Western world is improving, and we even have potentially one or more treatments and a vaccine, on the other hand we still have little evidence to support which intervention should be used and how to break the chains of transmission and how to effectively manage cases. This because evidence of clinical benefits and public health gains of using these drugs and vaccine has yet to be produced – tecovirimat and vaccine are registered without clinical data.

“Between these uncertainties and the high prices reportedly charged, drug and vaccine supplies are very limited, even in the countries where products are registered.

“So, the hope is that, whether though a PHEIC status or other means, the sense of priority and urgency is raised for governments to not only negotiate procurement with manufacturers, but, importantly, invest into the necessary research to answer those questions and gather evidence of patient-centered and/or public health gains, and cost-effectiveness of using these interventions (drug, vaccine, etc.). These questions can be addressed through a combination of observational studies and randomized controlled trials – which are already at least in part underway, but need funding.” 


Dr Boghuma Kabisen Titanji, Assistant Professor of Medicine, Emory University, Atlanta, said:

“I welcome the decision of the WHO Director to declare the current global monkeypox outbreak a PHEIC.  For several weeks now the criteria for making monkeypox a PHEIC had been met. It is “an extraordinary event which constitutes a public health risk to other states through the international spread of disease and potentially requires a coordinated international response”

“I hope that this will raise the international priority level on monkeypox and galvanize a more coordinated global response which has sadly been lacking so far. It is also an opportunity to get things right on global health equity and access to resources such as testing, vaccination, antiviral medications etc. which are areas in which historically we have seen many failures, resulting in countries with limited resources being left behind.

“Having another zoonotic virus infection firmly establish itself in the human population is not something we can allow and must do everything within our power to prevent this from happening. The PHEIC is just the first step and there is a lot of work that needs to be done here onwards, it is nonetheless and important move which hopefully corrects the course of the response to this emerging pandemic.”


Prof Jimmy Whitworth, Emeritus Professor, London School of Hygiene and Tropical Medicine, said:

“A Public Health Emergency of International Concern is the highest level of alert that WHO can declare.

“This has been declared because the current monkeypox outbreak is unprecedented with widespread cases occurring in many countries, and would benefit from increased attention and co-ordination.   

“Since the last meeting in June the outbreak has continued to expand in terms of number of cases and countries involved, indicating that the control measures that have put in place have not been sufficient to control the spread of the infection.

“This outbreak is concerning for public health practitioners around the world as it has proved very challenging to prevent onward transmission of infection, but it is not a situation that should unduly worry the general public. This is an infection that is transmitted by close contact – touching skin, coughing and sneezing, sharing of utensils, bedding and so on. The vast majority of cases have been in gay, bisexual or other men who have sex with men who have had multiple recent sexual partners. Most people, whatever their sexual orientation, do not have close contact of this sort with many people and so the infection is unlikely to spread easily.

“It is to be hoped that the increased attention to this disease leads to more focus on control within  Africa, the natural home of this virus, where the number of cases has been increasing for the past 20 years.”



Tweets from the WHO

Second meeting of the International Health Regulations (2005) (IHR) Emergency Committee regarding the multi-country outbreak of monkeypox



Declared interests

Dr Hugh Adler: “No conflicts of interest.”

Dr Boghuma Kabisen Titanji: “I have no conflicts of interest to declare.”

Prof Jimmy Whitworth: “No conflicts to declare.”

For all other experts, no reply to our request for DOIs was received.

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