15 February 2023 — The WHO Director-General transmits the report of the fourth meeting of the International Health Regulations (2005) (IHR) Emergency Committee regarding the multi-country outbreak of monkeypox (mpox), held on Thursday, 9 February 2023 from 12:00 to 17:00 CET.
Following a series of consultations with global experts, WHO recommends a new preferred term “mpox” as a synonym for monkeypox. Both names will be used simultaneously for one year while the term “monkeypox” is phased out. This report uses the term “mpox” (for more information see here).
The Emergency Committee acknowledged the progress made in the global response to the multi-country outbreak of mpox and the further decline in the number of reported cases since the last meeting. The Committee observed that a few countries continued to see a sustained incidence of illness; the Committee is also of the view that underreported detection and under-reporting of confirmed cases of illness in other regions is likely. Therefore, the Committee considered various options to sustain attention and resources to control the outbreak and advised maintaining the Public Health Emergency of International Concern (PHEIC), while beginning to consider plans to integrate mpox prevention, preparedness and response within national surveillance and control programmes, including for HIV and other sexually transmissible infections.
The WHO Director-General expresses his gratitude to the Chair, Members, and Advisers for their advice and concurs with this advice that the event continues to constitute a PHEIC for the reasons detailed in the proceedings of the meeting below and issues revised Temporary Recommendations in relation to this PHEIC, which are presented at the end of this document.
Proceedings of the fourth meeting of the IHR Emergency Committee
The fourth meeting of the IHR Emergency Committee on the multi-country outbreak of mpox was convened by videoconference, with the Chair and Vice-Chair being present in person on the premises of WHO headquarters, Geneva, Switzerland. Thirteen of the fifteen Members and four of the nine Advisors to the Committee participated in the meeting.
In his opening remarks, the WHO Director-General welcomed the Committee, and noted a sustained decline in cases globally, with the majority of cases being reported from the Regions of the Americas. The Director-General also noted the need to sustain efforts for surveillance, prevention and care; vaccinate high-risk populations; improve equitable access to diagnostics, vaccines and treatment for all who need them; and continue to fight stigma and discrimination and ensure respect for human rights. While noting that the continued human-to-human transmission could lead to a resurgence of cases, he concluded that over the longer-term, mpox programmes and services should be integrated into national surveillance and control programmes, including for HIV and other sexually transmitted infections.
The Office of Legal Counsel’s representative briefed the Committee Members and Advisors on their roles, responsibilities, and mandate under the relevant articles of the IHR. The Ethics Officer from the Department of Compliance, Risk Management, and Ethics reminded Members and Advisers of their duty of confidentiality as to the meeting discussions and the work of the Committee, as well as their individual responsibility to disclose to WHO in a timely manner any interests of a personal, professional, financial, intellectual or commercial nature that may give rise to a perceived or direct conflict of interest.
The meeting was handed over to the Chair of the Emergency Committee, Dr Jean-Marie Okwo-Bele, who introduced the objectives of the meeting: to provide views to the WHO Director-General as to whether the multi-country outbreak of mpox continues to constitute a PHEIC, and, if so, to review the proposed Temporary Recommendations to States Parties.
Presentations
Representatives of Brazil updated the Committee on the epidemiological situation in their country and their current response efforts.
The Secretariat provided an update on the epidemiological situation and the current response efforts, with the WHO Regions of Europe and the Americas providing additional regional updates.
The Secretariat informed that the current global risk of the mpox multi-country outbreak is assessed as remaining moderate globally and in four of the WHO regions, reduced from moderate to low in the Region of South-East Asia and remaining low in the Western Pacific Region. Further details can be found in the 15th External situation report. All data are available, and case counts are updated weekly at this link - 2022 Monkeypox Outbreak: Global Trends.
The Secretariat further informed the Committee that its Strategic preparedness, readiness and response plan for monkeypox, and appeal, launched in July 2022 to help guide coordinated public health action to stop the outbreak will come to an end in June 2023, while additional resources are being sought through the WHO’s Health Emergency Appeal in 2023.
The WHO European Region reported that as of 3 February, 43 countries and territories have not detected any new cases in the past three months. While 18 countries and territories continue to report recent local human-to-human transmission, case numbers have decreased significantly. Future risks of outbreaks relate to the ongoing importation, forthcoming mass gatherings, potential reduced vaccination and surveillance, limited access to testing and behaviour change/. To tackle this, the Region is working towards a five-year plan to achieve and sustain the elimination of mpox in all Member States through engagement with affected communities and integrating intervention into the sexual health programs, to be discussed at the Regional Committee in autumn 2023.
The Region of the Americas reported a stable number of cases in the last six weeks, with 200-250 cases per week, and 4% of cases occurring in women. In addition, while the vaccine supply is limited, seven countries have started vaccination. Risk communication and community engagement interventions are being delivered through HIV community-based networks.
After the presentations, Committee Members and Advisors proceeded to engage the Secretariat and the presenting country in a question-and-answer session.
Deliberative session
The Committee reconvened in a closed meeting to examine the questions in relation to whether the event continues to constitute a PHEIC, and if so, to consider the proposed Temporary Recommendations, drafted by the WHO Secretariat in accordance with IHR provisions. The Secretariat provided a presentation on the legal provisions under the IHR in relation to the determination of a PHEIC, and the issuance of Temporary Recommendations.
The Committee acknowledged that further progress was made in reducing the number of cases as well as international transmission, but several concerns persist. These include: ongoing transmission in some regions, such as Central America; insufficient evidence regarding vaccine effectiveness on the individual and population levels and duration of immunity, either disease or vaccination-induced; a potential shift in some countries towards the most marginalized populations who have the least access to prevention measures and treatments; the possibility that behaviour change is not sustained in the long run; and reduced surveillance and lack of reporting of cases to WHO, particularly in countries where the disease is endemic.
On the positive side, the Committee notes that the global risk is assessed as moderate, with two regions having a low risk; that no significant changes in the demographics occurred, although a small number of cases were reported in women in the region of the Americas; that the predominant mode of transmission remains through direct and sexual contact; and that transmission declined in a number of countries prior to the escalation of vaccination programs, concurrently with community engagement activities, acquired immunity after infection amongst those who were at highest risk, and a growing understanding of transmission dynamics. In addition, some regions have started to develop post-emergency plans and began the integration of the response into sexually transmissible disease programs.
Nevertheless, the Committee expressed concerns about the possible resurgence of cases in some regions, due to both the potential seasonal differences in the occurrence of infection and particularly in the context of the resumption of LGBTQ social events and other mass gathering events in the coming months; the lack of access to vaccines and testing capacities; the recurring zoonotic transmission in Africa; the fact that not all countries are receiving the support they need or have structures or systems to respond to mpox, including inadequate support for marginalized groups; and general fatigue among supporting agencies in view of competing priorities and emergencies.
The Committee acknowledged one WHO region’s proposal to develop a five-year elimination strategy and stressed the need for all countries to rapidly develop and continue to implement existing short-term responses to mpox and begin the development of national and regional plans aimed at long-term elimination of human-to-human transmission or control, as appropriate and feasible, with gradual integration into HIV and other sexually transmissible disease programs.
Lastly, noting that mpox transmission still persists in some countries and that there remain important research gaps to optimize the knowledge needed to tame the outbreaks, the Committee advised maintaining PHEIC and provided advice on the draft Temporary recommendations prepared by the Secretariat, with the understanding that such Temporary recommendations may continue to be issued by the WHO Director-General if needed after the future termination of the PHEIC.
Temporary Recommendations issued by the WHO Director-General in relation to the multi-country outbreak of mpox
These proposed Temporary Recommendations continue to support the goal of the Strategic Preparedness, Readiness and Response Plan for Monkeypox 2022–2023 with the aim of stopping the ongoing mpox outbreak and its objectives to interrupt human-to-human transmission, protect the vulnerable, and minimize zoonotic transmission of the virus.
Significant progress has been achieved in ending the ongoing multi-country mpox outbreak with a decline in cases globally. While the previously issued Temporary Recommendations continue to hold, recommendations for areas that continue to represent challenges and emerging areas of work due to lessons learned are emphasized in this document.
These Temporary Recommendations apply to States Parties according to their epidemiological situation, patterns of transmission, and capacities with respect to mpox; they refer to the reality that any State Party may experience importation or local transmission of mpox and some States Parties may also be experiencing zoonotic transmission.
Thus, each State Party should develop a strategy to maintain surveillance and response capacity in the medium to long term while States Parties in a position to support scaling up access to medical countermeasures, including through technology transfer, should continue efforts. With cases in some countries increasingly occurring within communities/individuals experiencing racism and other stigma and discrimination, strategies to reach these groups through risk communication, prevention and treatment are critical. In implementing these Temporary recommendations, States Parties should ensure full respect for the dignity, human rights and fundamental freedoms of persons, in line with the principles set out in Article 3 of the IHR.
The WHO advises States Parties to prepare short and medium to long-term plans for the control of mpox, and to maintain vigilance and response capacity as well as engagement with local communities and key stakeholders, following the WHO relevant guidelines.
States Parties should strengthen action in the following key areas:
- Develop and implement operational plans, including monitoring and evaluation, to set clear targets for stopping human-to-human transmission of mpox in countries currently affected by the outbreak, or mpox control in countries with known animal-to-human transmission. In that regard, State Parties should also consider developing surveillance and control plans that apply to situations where intimate sexual contact is not necessarily the predominant mode of transmission.
- Maintain laboratory-based epidemiological surveillance, including reporting of the minimum dataset of variables defined in the WHO Case Reporting Form. States Parties should continue to share confirmed and probable mpox case reports with WHO through IHR communications in a timely manner. Countries should work towards the elimination of mpox (i.e. interrupting local or community transmission, and taking measures to promptly detect and contain imported outbreaks) where feasible and maintain high-quality indicator-based and event-based surveillance to underpin all such efforts.
- Integrate mpox surveillance, detection, prevention, care and research into innovative HIV and STI prevention and control programmes and services, in order to understand risks of resurgence, detect outbreaks early, reduce barriers to health services, communicate risk, strengthen detection of undiagnosed HIV infection and early and continued antiretroviral treatment, advance clinical care for HIV-mpox co-infection, and address fear, stigma and discrimination in at-risk populations.
- Continue to enhance access to diagnostics, vaccines and therapeutics, including through allocation mechanisms and technology transfer, and subsidy of regional manufacturing to advance global health equity in areas where people may experience barriers to care, including minorities and those in the global south.
- Strengthen and support capacity in resource-limited settings where mpox continues to occur, including for but not limited to One Health and animal health, to better understand and characterize all modes of transmission and respond to outbreaks wherever they occur.
- Implement a strategic and coordinated research agenda to ensure ongoing evidence generation including but not limited to a better understanding of mpox clinical virology, modes of transmission, social determinants for affected groups and clinical disease, particularly in immune-suppressed individuals, and development of countermeasures, including effective behaviour change, rapid diagnostics and next-generation therapeutics and vaccines.
The recommendations below extend or modify those issued on 1 November 2022. In line with the WHO announcement on 28 November 2022, the term monkeypox in reference to the disease has been replaced with mpox throughout this document. WHO documents referenced are current as of 7 February 2023.
For remarks of WHO Director-General at today's briefing, see: WHO Director-General's opening remarks at the media briefing – 15 February 2023
