tag:theconversation.com,2011:/us/topics/public-health-emergency-of-international-concern-75240/articlesPublic Health Emergency of International Concern – The Conversation2023-05-09T18:11:40Ztag:theconversation.com,2011:article/2052712023-05-09T18:11:40Z2023-05-09T18:11:40ZPassport bottleneck is holding up international travel by Americans eager to see the world as COVID-19 eases<figure><img src="https://images.theconversation.com/files/524978/original/file-20230508-221323-4jr98o.jpg?ixlib=rb-1.1.0&rect=0%2C333%2C3895%2C1938&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A JetBlue employee poses next to a Boston replica of London's Big Ben before the launch of nonstop flights between Boston and London in 2022.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/jet-blue-employee-gets-her-photograph-taken-standing-next-news-photo/1239787161?adppopup=true">David L. Ryan/The Boston Globe via Getty Images</a></span></figcaption></figure><p>The World Health Organization declared on May 5, 2023, that the COVID-19 pandemic is <a href="https://news.un.org/en/story/2023/05/1136367">no longer a public health emergency</a>. Although the virus is still causing <a href="https://covid.cdc.gov/covid-data-tracker/#trends_weeklydeaths_select_00">hospitalizations and deaths</a>, many travelers who were reluctant to go abroad because of the pandemic now feel freer to travel internationally again.</p>
<p>That’s going to be a whole lot easier to do this summer if <a href="https://travel.state.gov/content/travel/en/passports/how-apply.html">you already have a valid passport</a>. The <a href="https://www.nytimes.com/2023/04/03/travel/passport-processing-wait-times.html">wait times for getting one</a> are soaring. The <a href="https://www.state.gov/update-on-passport-processing-times/">State Department says it can take up to 13 weeks</a> for it to process passport applications, and up to nine weeks for expedited service that requires the payment of extra fees. It’s <a href="https://www.cbsnews.com/news/unprecedented-demand-for-passports-antony-blinken-state-department/">getting about 500,000 passport applications a week</a>, which is at least 30% more than last year, Secretary of State Antony Blinken said in March. And delays in processing were <a href="https://www.thrillist.com/news/nation/passport-application-wait-times-2022">already aggravating in 2021 and 2022</a>.</p>
<p>I’m among the many Americans who have had to <a href="https://abc11.com/us-passport-renewal-status-application/12963897/">cancel or delay trips</a> because of the long wait times. I was hoping to fly to London for a weeklong break between teaching economics courses. Unfortunately, renewing my passport took so long I couldn’t go.</p>
<p>The <a href="https://federalnewsnetwork.com/hiring-retention/2021/07/state-dept-staffing-surge-wont-address-passport-backlog-overnight-union-warns/">government says staffing issues</a> are contributing to the delays. As an economist who <a href="https://blogs.bu.edu/zagorsky/">researches the everyday experiences of consumers</a>, I wondered if there was more to the story, since international travel is a big business. U.S. residents <a href="https://www.trade.gov/data-visualization/monthly-travel-trade-monitor">spent around US$17 billion</a> in just the month of March 2023 going abroad.</p>
<h2>Origin of passports</h2>
<p>Passports <a href="https://www.canada.ca/en/immigration-refugees-citizenship/services/canadians/celebrate-being-canadian/teachers-corner/history-passports.html">have been around a long time</a>. They became more widespread about four centuries ago during the reign of the French King Louis the XIV. The king gave people with <a href="https://www.royal.uk/passports?page=1">royal connections</a> letters asking foreign officials to let the traveler “passe port” – French for pass through – the port or border of <a href="https://www.cbp.gov/about/history/did-you-know/passport-protection">another country safely</a>.</p>
<p>You can find a similar statement in the front of every U.S. passport, which “requests all whom it may concern to permit the citizen/national of the United States named herein to pass without delay or hindrance.”</p>
<p>One reason for the passport bottleneck in the United States is a long-term increase in demand for those official blue booklets. Back in 1989, there were three valid passports for every 100 people in this country. Today there are more than 45 passports for every 100 Americans. More recently, many Americans who let their passports expire because they were avoiding international travel when the pandemic began are <a href="https://thepointsguy.com/news/passport-processing-status/">eager to travel again</a>.</p>
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<h2>Changes after 2000</h2>
<p>The <a href="https://www.census.gov/topics/population.html">U.S. population has increased</a> about 1% each year over the past three decades. During that same period the <a href="https://travel.state.gov/content/travel/en/about-us/reports-and-statistics.html/">number of people holding a valid passport</a> has jumped an average of 10% each year, 10 times faster than population growth.</p>
<p>Part of the rising demand for passports followed a policy change in the early 2000s. <a href="https://1997-2001.state.gov/briefings/statements/971219d.html">Before then no passport was required</a> for U.S. citizens to travel to Canada, Mexico or the Caribbean. A driver’s license or an official document like a birth certificate was suitable documentation to visit countries that shared a common border with the U.S. <a href="https://www.cbc.ca/news/canada/timeline-travel-documents-at-the-canada-u-s-border-1.834929">By 2009, however, a passport was needed</a> to visit those nearby countries by air, land or sea.</p>
<p>But the new rules don’t fully account for the surge in passport issuance. In 2010, about 100 million people had valid U.S. passports. Today, <a href="https://travel.state.gov/content/travel/en/about-us/reports-and-statistics.html/">over 150 million</a> do.</p>
<h2>Lost, stolen and damaged passports</h2>
<p>Another reason for the passport boom is that the State Department is fielding more requests than before for reissued passports to replace lost or stolen documents. </p>
<p>One problem while traveling is <a href="https://www.interpol.int/en/How-we-work/Border-management/Look-after-your-travel-document">keeping your passport safe</a>. While so far <a href="https://theconversation.com/no-americans-shouldnt-fear-traveling-abroad-118305">no one has ever stolen my passport</a>, I have <a href="https://theconversation.com/why-googles-plan-to-blanket-wilderness-with-wi-fi-is-a-bad-idea-49632">spilled food on it while climbing mountains</a>, <a href="https://travel.state.gov/content/travel/en/News/passports/replacing-your-passport-after-the-storm.html">gotten it soaked in a monsoon</a> and crushed it in my luggage <a href="https://theconversation.com/why-would-anyone-want-to-sit-on-a-plane-for-over-18-hours-an-economist-takes-the-worlds-longest-flight-122433">on the world’s longest flight</a>.</p>
<p>If your passport is ever lost, destroyed or stolen, you need to file a <a href="https://eforms.state.gov/Forms/ds64.PDF">DS-64 form</a> with the State Department. Filing this form prevents a thief from using that passport. The data is not just kept in the U.S. but is also sent to <a href="https://www.justice.gov/interpol-washington/pr/interpol-stolenlost-travel-document-database">Interpol’s Stolen/Lost Travel Document database</a>, which prevents worldwide travel by someone posing as you when traveling with your stolen passport.</p>
<p>The government periodically releases the number of DS-64 forms filed. In 2005 <a href="https://www.govinfo.gov/app/details/FR-2005-09-06/05-17636">a bit more than 100,000</a> were submitted. This jumped fivefold to <a href="https://www.federalregister.gov/documents/2021/09/09/2021-18829/30-day-notice-of-proposed-information-collection-statement-regarding-a-lost-or-stolen-us-passport">over 500,000 people who reported losing</a> their passports in 2021.</p>
<h2>Who gets passports?</h2>
<p>Where do passport applications come from? </p>
<p>Not surprisingly, states with more people tend to get more passports. For example, <a href="https://travel.state.gov/content/travel/en/about-us/reports-and-statistics.html/">Californians got the highest number of passports, about 2.7 million, in 2022</a>.</p>
<p>But some states have more wanderlust than others. After adjusting for <a href="https://www.census.gov/data/tables/time-series/demo/popest/2020s-state-total.html">population, over the past few years</a> the top two sources for international travel are the <a href="https://www.census.gov/content/dam/Census/library/publications/2022/acs/acsbr-011.pdf">high-income states</a> of New Jersey and Massachusetts. <a href="https://travel.state.gov/content/travel/en/about-us/reports-and-statistics.html/">Around 1 out every 17 residents</a> in those places applied annually for a passport. </p>
<p>The states where residents are the least likely to apply for a passport are the <a href="https://www.census.gov/content/dam/Census/library/publications/2022/acs/acsbr-011.pdf">low-income states</a> of Mississippi and West Virginia. In those places only about <a href="https://travel.state.gov/content/travel/en/about-us/reports-and-statistics.html/">1 out every 65 residents</a> applied on average each year.</p>
<h2>What can be done?</h2>
<p>One of the reasons passport processing times have gotten so long is that many people are taking trips they put off in the spring of 2020. What can be done? </p>
<p>I suggest two things.</p>
<p>First, the <a href="https://www.trade.gov/press-release/ntto-releases-survey-international-air-travelers-siat-outbound-monitor">Caribbean is one of the most popular U.S. tourist destinations</a>. U.S. travelers today can visit the <a href="https://www.travelchannel.com/destinations/us/photos/no-passport-required">U.S. Virgin Islands and Puerto Rico without a passport</a> because they are U.S. territories. I believe that expanding this access to a small number of Caribbean countries, as was possible before the 2009 policy change, would boost tourism and reduce passport demand.</p>
<p>Second, citizens with a current passport should be able to use it while waiting for a renewal. Right now old passports must be submitted with renewal forms, which blocks international travel. The State Department doesn’t really need the old documents. It recently ran a trial allowing <a href="https://travel.state.gov/content/travel/en/passports/have-passport/renew-online.html">people to renew passports online</a> without asking for their current passport books.</p>
<p>Once a new passport is issued, the old one becomes invalid. This could present a problem for people traveling abroad while their passport renews. There is a simple solution for this. At the beginning of the COVID-19 pandemic the State Department <a href="https://www.state.gov/extension-of-temporary-measure-allowing-return-travel-to-the-united-states-on-expired-u-s-passport-2/">allowed U.S. citizens who were abroad when their passports expired</a> to reenter the country.</p>
<p>Extending this policy would mean people could continue traveling no matter how long it takes to renew their passport.</p><img src="https://counter.theconversation.com/content/205271/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jay L. Zagorsky does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Precautions taken in response to COVID-19 explain some but not all of the recent long delays in getting a passport.Jay L. Zagorsky, Clinical Associate Professor of Markets, Public Policy and Law, Boston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1990602023-02-03T18:10:06Z2023-02-03T18:10:06ZBiden’s plan for ending the emergency declaration for COVID-19 signals a pivotal point in the pandemic – 4 questions answered<figure><img src="https://images.theconversation.com/files/508102/original/file-20230203-8929-i0o9vk.jpg?ixlib=rb-1.1.0&rect=173%2C158%2C4851%2C2779&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">COVID-19 emergency status prompted coordinated vaccination efforts by health care providers, paramedics, volunteers and others.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/sofia-espinoza-tam-daughter-is-held-by-her-father-and-news-photo/1241629409?adppopup=true">Wesley Lapointe / Los Angeles Times via Getty Images</a></span></figcaption></figure><p><em>President Joe Biden announced on Jan. 30, 2023, that <a href="https://www.whitehouse.gov/wp-content/uploads/2023/01/SAP-H.R.-382-H.J.-Res.-7.pdf">he intends to end</a> both the national emergency and the public health emergency declarations related to COVID-19 on May 11, 2023.</em></p>
<p><em>Biden’s announcement came on the same day that the World Health Organization said it still <a href="https://www.who.int/news/item/30-01-2023-statement-on-the-fourteenth-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-coronavirus-disease-(covid-19)-pandemic">considers the COVID-19 pandemic</a> to be a <a href="https://www.who.int/publications/m/item/covid-19-public-health-emergency-of-international-concern-(pheic)-global-research-and-innovation-forum">public health emergency of international concern, or PHEIC</a>, a status that is reassessed every three months. The WHO’s advisory committee noted that although the pandemic is at a turning point, “COVID-19 remains a dangerous infectious disease with the capacity to cause substantial damage to health and health systems.”</em></p>
<p><em>The Conversation asked public health experts <a href="https://cph.osu.edu/people/mjones">Marian Moser Jones</a> and <a href="https://cph.osu.edu/people/afairchild">Amy Lauren Fairchild</a> to put these statements into context and to explain their ramifications for the next stage of the pandemic.</em></p>
<h2>What does ending the emergency phase of the COVID-19 pandemic mean?</h2>
<p>Ending the federal emergency reflects both a scientific and political judgment that the acute phase of the COVID-19 pandemic crisis has ended and that special federal resources are no longer needed to prevent disease transmission across borders. </p>
<p>In practical terms, it means that two declarations – the <a href="https://www.phe.gov/emergency/news/healthactions/phe/Pages/2019-nCoV.aspx">federal Public Health Emergency</a>, first declared on Jan. 31, 2020, and the <a href="https://www.whitehouse.gov/briefing-room/presidential-actions/2022/02/18/notice-on-the-continuation-of-the-national-emergency-concerning-the-coronavirus-disease-2019-covid-19-pandemic-2/">COVID-19 national emergency</a> that President Donald Trump announced on March 13, 2020 – will be allowed to expire in May 2023. </p>
<p>Declaring those emergencies enabled the federal government to cut through a mountain of red tape, with the goal of responding to the pandemic more efficiently. For instance, the declarations allowed <a href="https://aspr.hhs.gov/legal/PHE/Pages/Public-Health-Emergency-Declaration.aspx">funds to be made available</a> so that federal agencies could direct personnel, equipment, supplies and services to state and local governments wherever they were needed. In addition, the declarations made resources available to launch investigations into the “<a href="https://aspr.hhs.gov/legal/PHE/Pages/Public-Health-Emergency-Declaration.aspx">cause, treatment or prevention</a>” of COVID-19 and to enter into contracts with other organizations to meet needs stemming from the emergency. </p>
<p>The emergency status also allowed the federal government to make health care more widely available by <a href="https://aspr.hhs.gov/legal/PHE/Pages/Public-Health-Emergency-Declaration.aspx">suspending many requirements</a> for accessing Medicare, Medicaid and the Children’s Health Program. And they made it possible for people to receive free COVID-19 testing, treatment and vaccines and <a href="https://www.medicaid.gov/medicaid/benefits/downloads/medicaid-telehealth-services.pdf">enabled Medicaid</a> and Medicare to <a href="https://telehealth.hhs.gov/providers/billing-and-reimbursement/">more easily cover telehealth services</a>. </p>
<h2>What policy changes will occur once the emergency is declared over?</h2>
<p>The end to the federal emergency <a href="https://theconversation.com/medicaid-coverage-is-expiring-for-millions-of-americans-but-theres-a-proven-way-to-keep-many-of-them-insured-197847">could substantially reduce</a> the number of people insured under Medicaid. Before the pandemic, states required people to prove every year that they met income and other eligibility requirements. </p>
<p>In March 2020, Congress enacted a continuous enrollment provision in Medicaid that prevented states from removing anyone from their rolls during the pandemic. In a December 2022 appropriations bill, Congress passed a provision that will end continuous enrollment on March 31, 2023. </p>
<p>The Biden administration has <a href="https://www.whitehouse.gov/wp-content/uploads/2023/01/SAP-H.R.-382-H.J.-Res.-7.pdf">defended this time frame as sufficient</a> to ensure that “patients do not lose access to care unpredictably” and that state Medicaid budgets – which have been infused with emergency funds since 2020 – “don’t face a radical cliff.” But many people with Medicaid may be unaware of these changes until they actually lose their benefits.</p>
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<p>Some states have already indicated that they will <a href="https://medicaid.ohio.gov/stakeholders-and-partners/covidunwinding/covidunwinding">begin disenrolling members in April 2023</a> or require members to <a href="https://www.hhs.texas.gov/services/health/coronavirus-covid-19/coronavirus-covid-19-information-people-receiving-services/end-continuous-medicaid-coverage">apply to be considered for renewal</a>. This could result in between <a href="https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision/">5 million and 14 million people</a> losing coverage.</p>
<p>People with Medicare do not have to worry about losing their benefits, since this program is age-based, not income-based. The array of telehealth services that Medicare began <a href="https://telehealth.hhs.gov/providers/billing-and-reimbursement/billing-and-coding-medicare-fee-for-service-claims/?">covering during the pandemic</a> will continue to be covered through December 2023. Medicare coverage for many telehealth services could also <a href="https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-final-rule">be made permanent</a> after this year. </p>
<p>The end of the emergency could additionally curb access to COVID-19 drugs, tests and vaccines. Federal emergency funding for free treatment or vaccination will end when the emergency status is lifted on May 11. If such programs are to continue, <a href="https://www.kff.org/coronavirus-covid-19/issue-brief/how-much-could-covid-19-vaccines-cost-the-u-s-after-commercialization/">the cost will fall</a> to state and local health agencies or insurance companies. </p>
<p>We are concerned that the withdrawal of federal emergency funds for vaccination may further slow the already sluggish uptake of boosters. As of Jan. 25, 2023, <a href="https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html">about 20% of the population ages 5 and up</a> and <a href="https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-people-booster-percent-pop5">only 40.1%</a> of those 65 and older – who are <a href="https://doi.org/10.1002%2Fhsr2.657">at the highest risk of death from COVID-19</a> – had received an <a href="https://theconversation.com/will-omicron-specific-booster-shots-be-more-effective-at-combating-covid-19-5-questions-answered-189610">updated bivalent booster</a> dose. Once the emergency ends, <a href="https://doi.org/10.1377/forefront.20210303.890600">measures that allowed</a> a broad array of health providers – from pharmacist interns to retired nurses and even veterinarians – to administer vaccines will expire, which could lead to decreased access to vaccination in many parts of the U.S. </p>
<h2>What does this mean for the status of the pandemic?</h2>
<p><a href="https://www.ncbi.nlm.nih.gov/books/NBK143061">A pandemic declaration</a> represents an assessment that human transmission of a disease, whether well known or novel, is “extraordinary,” that it constitutes a public health risk to two or more states and that controlling it requires an international response. </p>
<p>At some point the WHO will end its pandemic declaration. On Jan. 30, 2023, World Health Organization Director-General Tedros Adhanom Ghebreyesus described the pandemic as being “<a href="https://www.cnn.com/2023/01/30/health/who-covid-public-health-emergency/index.html">at a transition point</a>.” But the WHO’s assessment is that the risks are still considerable. Ghebreyesus noted that COVID-19 continues to strain health care systems, exacerbate health care workforce shortages and exceed surveillance system capacities. </p>
<p>The U.S. remains one of the <a href="https://covid19.who.int">global COVID-19 hot spots</a>. With more than <a href="https://covid.cdc.gov/covid-data-tracker/#trends_weeklydeaths_select_00">3,500 hospitalizations per week on average</a> in January 2023, and 3,452 deaths per week as of early February 2023, the U.S. has <a href="https://www.nytimes.com/interactive/2021/world/covid-cases.html">among the highest deaths per capita in the world</a>.</p>
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<h2>How does the Biden administration’s stance differ from the WHO’s position?</h2>
<p>In some ways they are very similar. The WHO is looking at the pandemic from a global perspective while the Biden administration is examining it from a national perspective. The WHO’s stance reflects the assessment that the world is not sufficiently vaccinated, that health care systems remain vulnerable and that unchecked disease transmission in some parts of the world should remain a source of international concern and attention. </p>
<p>China’s massive outbreak after the <a href="https://www.npr.org/2022/12/20/1143413739/confusion-and-falsehoods-spread-as-china-reverses-its-zero-covid-policy">lifting of its zero-COVID policy</a> in early December 2022 has <a href="https://www.bbc.com/news/world-asia-china-64449226">received a great deal of media attention</a>. But less noted is the fact that <a href="https://ourworldindata.org/covid-vaccinations?country=OWID_WRL#what-share-of-the-population-has-received-at-least-one-dose-and-completed-the-initial-vaccination-protocol">vaccination rates across</a> African nations average 40%, and that vaccination rates are very low in countries that are experiencing conflict, such as Syria, where only 15% of the population has received any COVID-19 vaccine.</p>
<p>The WHO’s continuation of the global pandemic status signals that there is more international coordination and work to be done. In contrast, the Biden administration is making a social and political judgment that it is time to wind down the federal role.</p>
<p>Biden’s order will not affect state-level or local-level emergency declarations. These declarations have allowed states to allocate resources to meet pandemic needs and have <a href="https://telehealth.hhs.gov/providers/policy-changes-during-the-covid-19-public-health-emergency/telehealth-licensing-requirements-and-interstate-compacts/">included provisions</a> allowing them to respond to surges in COVID-19 cases by allowing out-of-state physicians and other health care providers to practice in person and through telehealth. </p>
<p>Almost all U.S. states, however, have <a href="https://nashp.org/states-covid-19-public-health-emergency-declarations-and-mask-requirements/">ended their own public health emergency</a> declarations. Eight states – California, Colorado, Delaware, Georgia, Illinois, New Mexico, Rhode Island and Texas – still have emergency declarations in effect, but all of them will expire by the end of February 2023 unless renewed. </p>
<p>While some states may choose to make permanent some COVID-era emergency standards, such as looser restrictions on telemedicine or out-of-state health providers, it could be a long time before either politicians or the public regain an appetite for any emergency orders directly related to COVID-19.</p><img src="https://counter.theconversation.com/content/199060/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>President Joe Biden’s intention to end the national COVID-19 emergency will have long-lasting ripple effects on federal programs such as Medicare, Medicaid and the Children’s Health Insurance Program.Amy Lauren Fairchild, Dean and Professor of Public Health, The Ohio State UniversityMarian Moser Jones, Associate Professor and Graduate Director of Family Science, The Ohio State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1978062023-01-18T23:30:36Z2023-01-18T23:30:36ZThe costly lesson from COVID: why elimination should be the default global strategy for future pandemics<figure><img src="https://images.theconversation.com/files/505025/original/file-20230117-25-pmbqda.jpg?ixlib=rb-1.1.0&rect=8%2C76%2C5682%2C3626&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Getty Images</span></span></figcaption></figure><p>Imagine it is 2030. Doctors in a regional hospital in country X note an expanding cluster of individuals with severe respiratory disease. Rapid whole-genome sequencing identifies the disease-causing agent as a novel coronavirus.</p>
<p>Epidemiological investigations suggest the virus is highly infectious, with most initial cases requiring hospitalisation. The episode bears a striking resemblance to the COVID outbreak <a href="https://doi.org/10.1016/S0140-6736(20)30211-7">first detected in December 2019</a>.</p>
<p>Regional and national health authorities are notified quickly. The national contact point for the International Health Regulations 2024 (a major revision to the <a href="https://www.who.int/publications/i/item/9789241580496">current IHR 2005</a>) sends a description to the World Health Organization (<a href="https://www.who.int/">WHO</a>). After an intense exchange of information and risk assessment, it declares a public health emergency of international concern. </p>
<p>The outbreak is assigned a response strategy of “elimination”. This designation initiates a well-rehearsed procedure, including mobilising expertise and resource stockpiles. </p>
<p>The elimination response results in localised quarantine measures at the epicentre and its surrounds and a travel freeze across a wide radius within country X and at its borders. It also prompts intensified local and international surveillance. Case numbers rise rapidly but plateau after three weeks, and then fall until no new cases are detected in the community. </p>
<p>After eight weeks of intensive efforts the outbreak is over – similar to the experience of New Zealand, which terminated its initial COVID outbreak in eight weeks using an <a href="https://www.nejm.org/doi/10.1056/NEJMc2025203">elimination strategy</a>. The outbreak had spread regionally within country X, but not internationally.</p>
<p>This is how we propose, in <a href="https://doi.org/10.1016/S0140-6736(22)02489-8">The Lancet</a>, the world should respond to future pandemic threats.</p>
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Read more:
<a href="https://theconversation.com/chinas-covid-cases-may-have-hit-900-million-whats-headed-our-way-197896">China's COVID cases may have hit 900 million. What's headed our way?</a>
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<h2>An upgraded pandemic response to eliminate at source</h2>
<p>The process by which the WHO currently decides whether to declare a public health emergency of international concern (under the International Health Regulations 2005) has <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30401-1/fulltext">drawn criticism</a> for being too slow. </p>
<p>The upgraded response framework we propose would enhance the existing risk assessment by routinely requiring WHO to assign a high-level response strategy for managing this risk. For potential pandemics, we consider this strategy should be elimination rather than suppression or mitigation, which have been the usual default options in the past. In simple terms, “if in doubt, stamp it out”.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-suppressed-our-scientific-imagination-four-experts-examine-the-big-successes-and-failures-of-the-covid-response-so-far-178705">'We suppressed our scientific imagination': four experts examine the big successes and failures of the COVID response so far</a>
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</em>
</p>
<hr>
<p>The idea of eliminating novel emerging infectious diseases at the earliest possible stage is intuitively appealing and not new. It has been proposed for eliminating <a href="https://www.nature.com/articles/nature04017">novel pandemic influenza outbreaks</a>. </p>
<p>This approach successfully <a href="https://doi.org/10.1016/S1473-3099(20)30129-8">eliminated and then eradicated</a> the SARS pandemic in 2003 (caused by SARS-CoV). It also proved successful in China during <a href="https://www.who.int/publications/i/item/report-of-the-who-china-joint-mission-on-coronavirus-disease-2019-(covid-19)">early containment of COVID</a> in Wuhan. </p>
<p>We have described this concept <a href="https://www.bmj.com/content/371/bmj.m4907">previously</a>. Whether this approach could have eliminated and ultimately eradicated COVID, if pursued early and in a co-ordinated way globally, remains a topic of speculation.</p>
<h2>An elimination strategy also slows the spread of infection</h2>
<p>There is a second broad reason for the WHO assigning an explicit strategic goal of elimination to pandemic diseases with sufficient severity. It can also slow or interrupt the global spread of a new infectious disease. This action buys time for interventions to be developed, building on rapidly accumulating scientific knowledge. </p>
<p>Some countries in the Asia-Pacific region adopted elimination and strong suppression strategies. This approach largely prevented widespread COVID circulation for the first one to two years of the pandemic, keeping <a href="https://doi.org/10.1016/S0140-6736(22)01585-9">mortality rates low</a>. </p>
<p>It allowed time for vaccine development and roll-out and for jurisdictions to prepare their health systems for managing large numbers of infected people. Notable examples are New Zealand, Australia and Singapore. They have been able to keep their <a href="https://ourworldindata.org/coronavirus">cumulative mortality low</a> by international standards. </p>
<figure class="align-center ">
<img alt="This world map shows that cumulative numbers of deaths in countries." src="https://images.theconversation.com/files/505011/original/file-20230117-11910-vgmyqo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/505011/original/file-20230117-11910-vgmyqo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=424&fit=crop&dpr=1 600w, https://images.theconversation.com/files/505011/original/file-20230117-11910-vgmyqo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=424&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/505011/original/file-20230117-11910-vgmyqo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=424&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/505011/original/file-20230117-11910-vgmyqo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=532&fit=crop&dpr=1 754w, https://images.theconversation.com/files/505011/original/file-20230117-11910-vgmyqo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=532&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/505011/original/file-20230117-11910-vgmyqo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=532&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">New Zealand, Australia and Singapore have lower cumulative numbers of deaths than other countries.</span>
<span class="attribution"><a class="source" href="https://ourworldindata.org/excess-mortality-covid">Our World in Data</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>If elimination is ultimately not successful or justifiable, an organised transition to another strategy (suppression or mitigation) should be considered. Processes for managing these transitions can <a href="https://doi.org/10.1016/S2214-109X(21)00494-0">draw on experience</a> from the current pandemic.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-should-new-zealand-manage-covid-from-now-limit-all-infections-or-focus-on-preventing-severe-disease-189461">How should New Zealand manage COVID from now – limit all infections or focus on preventing severe disease?</a>
</strong>
</em>
</p>
<hr>
<h2>Elimination makes sense for other potential pandemics</h2>
<p>The most recently declared public health emergency of international concern is <a href="https://jamanetwork.com/journals/jama/fullarticle/2794922#:%7E:text=7:%7E:text=7">mpox</a> (formerly known as monkeypox). Under our proposed change to the International Health Regulations, the WHO would have been required to assign a response strategy to this disease. </p>
<p>Elimination again makes sense as a default approach. That is what countries around the world have effectively been doing. And this approach appears to be <a href="https://ourworldindata.org/monkeypox">working</a>.</p>
<p>The other current public health emergency of international concern is <a href="https://doi.org/10.1016/S2666-5247(22)00253-1">poliomyelitis</a>. Unlike COVID and mpox, this disease is already subject to <a href="https://www.who.int/publications/i/item/9789240031937">a global eradication</a> goal. </p>
<p>A further benefit of the elimination strategy is that it supports strengthening of health system infrastructure in low and middle-income countries. This capacity building has contributed to the elimination of periodic Ebola outbreaks in Africa, which have been designated as public health emergencies of international concern in <a href="https://www.who.int/emergencies/situations/ebola-outbreak-2014-2016-West-Africa">2014-16</a> and <a href="https://www.who.int/emergencies/situations/Ebola-2019-drc-">2019-20</a>. It could also support elimination of mpox, an <a href="https://doi.org/10.1371/journal.pntd.0010141">increasing threat in Africa</a>.</p>
<p>Upgraded International Health Regulations could stimulate a huge global investment in <a href="https://doi.org/10.1016/S0140-6736(23)00015-6">infrastructure to stop epidemics at source</a> and improve <a href="https://doi.org/10.3201%2Feid1207.051497">surveillance capacity</a>. These capacities are critical given the range of <a href="https://doi.org/10.1111/1753-6405.12991">future pandemic scenarios</a>, including the threat from <a href="https://sciencepolicyreview.org/wp-content/uploads/securepdfs/2022/08/MITSPR-v3-191618003014.pdf">bioweapons with advances in synthetic biology</a>.</p>
<p>Let us hope that when the world is next confronted by the spark of a new emerging infectious disease with pandemic potential, the WHO rapidly declares a public health emergency of international concern and assigns an elimination strategy. And the international community reacts vigorously to extinguish the spark before it becomes an inferno.</p><img src="https://counter.theconversation.com/content/197806/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Baker's employer, the University of Otago, receives funding for his research on Covid-19 and other infectious diseases from the Health Research Council of New Zealand and the New Zealand Ministry of Health.</span></em></p><p class="fine-print"><em><span>David Durrheim, Li Yang HSU, and Nick Wilson do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>An upgraded global response to future potential pandemic threats would give the best chance of eliminating new infectious diseases at source before they spread globally.Michael Baker, Professor of Public Health, University of OtagoDavid Durrheim, Professor of Public Health Medicine, University of NewcastleLi Yang HSU, Vice Dean of Global Health, Saw Swee Hock School of Public Health, National University of SingaporeNick Wilson, Professor of Public Health, University of OtagoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1882802022-08-11T20:05:09Z2022-08-11T20:05:09ZWhy doesn’t monkeypox have a new name yet?<p>As monkeypox vaccination programs roll out and health authorities release information about how to reduce the spread of the virus, progress on another aspect of the outbreak is lagging: its name.</p>
<p>On June 14, the Director-General of the World Health Organization (WHO), Tedros Adhanom Ghebreyesus, <a href="https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-covid-19-media-briefing--14-june-2022">said</a> the agency was:</p>
<blockquote>
<p>working with partners and experts from around the world on changing the name of monkeypox virus, its clades and the disease it causes.</p>
</blockquote>
<p>This followed a <a href="https://virological.org/t/urgent-need-for-a-non-discriminatory-and-non-stigmatizing-nomenclature-for-monkeypox-virus/853">letter</a> signed by 29 scientists around the world calling for a non-discriminatory and non-stigmatising name for the virus.</p>
<p>More than eight weeks later, nothing has changed yet.</p>
<p>Since mid-May 2022, as of August 10, 31,425 cases of monkeypox have <a href="https://www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.html">been reported</a> in 82 countries – including 66 in <a href="https://www.health.gov.au/health-alerts/monkeypox-mpx/about">Australia</a> – which historically haven’t reported cases of the virus. </p>
<p>During the same period, 375 cases have been reported in seven countries that have historically reported monkeypox. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/478629/original/file-20220811-4746-26kwy4.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/478629/original/file-20220811-4746-26kwy4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/478629/original/file-20220811-4746-26kwy4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=322&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478629/original/file-20220811-4746-26kwy4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=322&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478629/original/file-20220811-4746-26kwy4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=322&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478629/original/file-20220811-4746-26kwy4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=404&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478629/original/file-20220811-4746-26kwy4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=404&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478629/original/file-20220811-4746-26kwy4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=404&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Confirmed monkeypox cases globally. Orange = has not historically reported monkeypox; blue = has historically reported monkeypox.</span>
<span class="attribution"><a class="source" href="https://www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.html">CDC</a></span>
</figcaption>
</figure>
<p>While the focus has been on changing the name of monkeypox, it’s the names of the two main clades (organisms derived from a common ancestor) that are most geographically <a href="https://www.statnews.com/2022/06/11/monkeypox-virus-name-stigma/#:%7E:text=In%20a%20position%20paper%20published,the%20current%20names%20are%20discriminatory">discriminatory</a>. They are currently named the Congo Basin (or Central Africa) clade and the West Africa clade.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/monkeypox-in-australia-should-you-be-worried-and-who-can-get-the-vaccine-187917">Monkeypox in Australia: should you be worried? And who can get the vaccine?</a>
</strong>
</em>
</p>
<hr>
<h2>How is the name of a disease created?</h2>
<p>In 2015, the WHO, in consultation and collaboration with the World Organization for Animal Health and the Food and Agriculture Organization of the United Nations, <a href="https://www.who.int/publications/i/item/WHO-HSE-FOS-15.1">identified</a> best practices for the naming of new human diseases. These conclude:</p>
<ul>
<li><p>if the causative pathogen is known, it should be used as part of the disease name with additional descriptors; for example, <em>novel</em> coronavirus respiratory syndrome</p></li>
<li><p>names should be short (minimum number of characters) and easy to pronounce; for example, H7N9 </p></li>
<li><p>potential acronyms should be evaluated to ensure they also comply with these best practices </p></li>
<li><p>geographic locations, such as cities, countries, regions, and continents should be avoided; poor earlier examples include Murray Valley encephalitis and Spanish flu </p></li>
<li><p>people’s names (such as <a href="https://www.cdc.gov/parasites/chagas/gen_info/detailed.html#:%7E:text=Chagas%20disease%20is%20caused%20by,referred%20to%20as%20American%20trypanosomiasis.">Chagas disease</a>) and the names of species (such as swine flu and bird flu) should be avoided.</p></li>
</ul>
<p>Naming of the disease caused by SARS-CoV-2, COVID-19, did not include the name of the pathogen. But it did comply with the other criteria and, fortunately, was not called Wuhan disease or China virus.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/todays-disease-names-are-less-catchy-but-also-less-likely-to-cause-stigma-131465">Today's disease names are less catchy, but also less likely to cause stigma</a>
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<h2>How is the name of a virus created?</h2>
<p>The WHO is not directly responsible for naming or renaming viruses, clades of viruses and the diseases those viruses cause. Naming virus species is the responsibility of the <a href="https://ictv.global/">International Committee on Taxonomy of Viruses</a>.</p>
<p>Monkeypox is a member of the <a href="https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/smallpox-and-other-orthopoxvirus-associated-infections">orthopoxvirus family</a> and related to smallpox, which was eradicated in 1979. Unlike other bugs, such as parasites like malaria (<em>Plasmodium falciparum</em>) and bacteria like “golden staph” (<em>Staphylococcus aureus)</em>, there is still <a href="https://link.springer.com/article/10.1007/s00705-019-04477-6">not a consistent system</a> of assigning binomial (two words) Latinised names to viruses. </p>
<p>A subcommittee of the International Committee on Taxonomy of Viruses is in the process of finalising a proposal for new binomial names for all the poxviruses, including monkeypox.</p>
<figure class="align-center ">
<img alt="3D visualisation of a monkeypox cell" src="https://images.theconversation.com/files/478657/original/file-20220811-26-wdm2i8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/478657/original/file-20220811-26-wdm2i8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=311&fit=crop&dpr=1 600w, https://images.theconversation.com/files/478657/original/file-20220811-26-wdm2i8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=311&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/478657/original/file-20220811-26-wdm2i8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=311&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/478657/original/file-20220811-26-wdm2i8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=391&fit=crop&dpr=1 754w, https://images.theconversation.com/files/478657/original/file-20220811-26-wdm2i8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=391&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/478657/original/file-20220811-26-wdm2i8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=391&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">We’re still waiting for the new binomial name for monkeypox.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/monkeypox-cell-infectious-disease-molecules-blood-2160385559">Shutterstock</a></span>
</figcaption>
</figure>
<p>Most viral conditions have <a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it">different names</a> for the disease it causes and the virus itself. </p>
<p>In the case of the novel coronavirus causing the current pandemic, the short name of the disease is COVID-19, while the virus is named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). </p>
<h2>Why is it so hard to change the name of monkeypox virus?</h2>
<p>Monkeypox is not a <a href="https://www.smh.com.au/national/should-we-be-worried-about-the-spread-of-monkeypox-20220729-p5b5lu.html">new</a> virus; it was discovered in 1958. </p>
<p>While on the face of it, the name monkeypox does not seem stigmatising (other than to monkeys) some have <a href="https://theconversation.com/whats-in-a-name-why-giving-monkeypox-a-new-one-is-a-good-idea-185307">pointed out</a> that monkeys are rarely associated with the Western world, and this association with the global South could be seen as problematic. The word monkey has also been employed in racist slurs against people of colour.</p>
<p>Monkeypox is also a misnomer because monkeys <a href="https://theconversation.com/australia-secures-450-000-new-monkeypox-vaccines-what-are-they-and-who-can-have-them-187691">are not</a> its natural host, which is probably in rodents. The name of the virus was given because it was first identified in laboratory monkeys in Copenhagen.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australia-secures-450-000-new-monkeypox-vaccines-what-are-they-and-who-can-have-them-187691">Australia secures 450,000 new monkeypox vaccines. What are they and who can have them?</a>
</strong>
</em>
</p>
<hr>
<p>However, there is a problem with the names of the virus’s clades. The two main clades are named after West Africa and the Congo Basin, the latter causing <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">more severe illness</a>. This contravenes the WHO’s efforts to avoid naming viral diseases after countries or continents. </p>
<p>Unfortunately, many media outlets use photos of Africans, often children, with the tell-tale rash. This heightens perceptions that this is an “African disease” that has escaped to the Western world.</p>
<p>Despite the WHO naming criteria announced in 2015, the agency has been unable to change the name of the Middle East Respiratory Syndrome (MERS), caused by a camel coronavirus. In fact, one of the largest outbreaks of MERS was in <a href="https://www.who.int/westernpacific/emergencies/2015-mers-outbreak">South Korea</a>.</p>
<p>One of the main reasons given for not changing the name is that it could disconnect future researchers from research papers written over more than five decades. This seems a weak argument because it’s almost certain that future researchers will be aware of the original name.</p>
<p>Another challenge is that the name would need to be changed in the International Classification of Diseases (ICD) which is used around the world for medical billing and clinical epidemiology studies. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1557481401947127810"}"></div></p>
<p>There is an apparent consensus among virologists that the new name will be something like Orthopoxvirus monkeypox. “That’s certainly the majority proposal at this stage,” according to the chair of the poxvirus <a href="https://www.statnews.com/2022/08/01/the-campaign-to-rename-monkeypox-gets-complicated/">subcommittee</a> of the International Committee on Taxonomy of Viruses. </p>
<p>This is not much of a change and is inconsistent with WHO’s naming criteria. </p>
<p>There is, however, <a href="https://www.science.org/content/article/rename-monkeypox-remove-geographic-stigma-researchers-say">more optimism</a> the two clades could shed their geographic names to something like clades 1 and 2.</p>
<h2>Focus on prevention and control</h2>
<p>During the long process of changing its name, the prevention and control of monkeypox <a href="https://theconversation.com/monkeypox-in-australia-should-you-be-worried-and-who-can-get-the-vaccine-187917">remain the same</a>:</p>
<ul>
<li>surveillance</li>
<li>finding cases, isolation and contact tracing</li>
<li>behaviour change communication to reduce the number of sexual partners</li>
<li>vaccination of close contacts and treatment of severe illness with antiviral drugs.</li>
</ul>
<p>This needs close engagement with communities most affected by the virus – men who have sex with men. It’s crucial to <a href="https://theconversation.com/monkeypox-isnt-like-hiv-but-gay-and-bisexual-men-are-at-risk-of-unfair-stigma-183571">prevent stigma</a> and discrimination, not because of the name of the virus itself but those who are most vulnerable to infection.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/monkeypox-isnt-like-hiv-but-gay-and-bisexual-men-are-at-risk-of-unfair-stigma-183571">Monkeypox isn’t like HIV, but gay and bisexual men are at risk of unfair stigma</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/188280/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Toole receives funding from the National Health and Medical Research Council.</span></em></p>As monkeypox vaccination programs roll out and health authorities work to reduce the spread of the virus, progress is lagging on renaming it.Michael Toole, Associate Principal Research Fellow, Burnet InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1876692022-07-26T16:05:08Z2022-07-26T16:05:08ZWhy declaring monkeypox a global health emergency is a preventative step – not a reason for panic<figure><img src="https://images.theconversation.com/files/475942/original/file-20220725-15-q3633s.jpg?ixlib=rb-1.1.0&rect=26%2C44%2C5802%2C3305&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The monkeypox virus, shown in this illustration, can be transmitted through close contact between people.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/monkeypox-virus-illustration-royalty-free-illustration/1402267440?adppopup=true">Thom Leach/Science Photos Library via Getty Images</a></span></figcaption></figure><p>Countries that are members of the United Nations are obligated to report cases of unusual diseases that have the potential to become global health threats. In May 2022, more than a dozen countries in Europe, the Americas and other regions of the world that had never before had cases of monkeypox <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON385">started to report cases occurring within their borders</a>.</p>
<p>In response, the director-general of the World Health Organization, Tedros Adhanom Ghebreyesus, convened a <a href="https://www.who.int/groups/monkeypox-ihr-emergency-committee">monkeypox emergency committee</a> to track the evolving situation. At the committee’s first meeting on June 23, 2022, the members observed that the “<a href="https://www.who.int/news/item/25-06-2022-meeting-of-the-international-health-regulations-(2005)-emergency-committee--regarding-the-multi-country-monkeypox-outbreak">multi-country outbreak</a>” might be stabilizing as case counts had plateaued in several countries. </p>
<p>However, after thousands more cases of monkeypox were diagnosed in dozens of countries in July, it became clear that the outbreak had not stagnated. On July 23, 2022, Tedros <a href="https://www.who.int/director-general/speeches/detail/who-director-general-s-statement-on-the-press-conference-following-IHR-emergency-committee-regarding-the-multi--country-outbreak-of-monkeypox--23-july-2022">declared monkeypox a public health emergency of international concern</a>. </p>
<p>As a <a href="https://scholar.google.com/citations?user=IhG7428AAAAJ&hl=en&oi=ao">global health expert who specializes in infectious disease epidemiology</a> I do not think that most people need to be worried about monkeypox. This decision by the WHO, though it may sound ominous, is not a sign of bad things to come. Rather, it is a way to prevent monkeypox from becoming a global crisis.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/475943/original/file-20220725-10610-gzehbx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="The logo of the World Health Organization on the groups headquarters in Geneva, Switzerland." src="https://images.theconversation.com/files/475943/original/file-20220725-10610-gzehbx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/475943/original/file-20220725-10610-gzehbx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/475943/original/file-20220725-10610-gzehbx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/475943/original/file-20220725-10610-gzehbx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/475943/original/file-20220725-10610-gzehbx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/475943/original/file-20220725-10610-gzehbx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/475943/original/file-20220725-10610-gzehbx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The director-general of the World Health Organization has the power to declare an event a public health emergency of international concern.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Logo_@_World_Health_Organization_@_Pregny-Chamb%C3%A9sy_(50637498101).jpg#/media/File:Logo_@_World_Health_Organization_@_Pregny-Chamb%C3%A9sy_(50637498101).jpg">Guilhem Vellut/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>What is a public health emergency of international concern (PHEIC)?</h2>
<p>The <a href="https://www.who.int/publications/i/item/9789241580496">International Health Regulations</a> are a set of rules that guide how the WHO and United Nations member states respond to emerging health threats.</p>
<p>Under the current regulations, a “public health emergency of international concern” – often abbreviated as a PHEIC – can be declared by the WHO director-general when <a href="http://dx.doi.org/10.1136/bmjgh-2020-002502">three criteria are met</a>: the situation is an “extraordinary event,” there is a risk of spread to other countries, and the situation might “potentially require a coordinated international response.” </p>
<p>Before monkeypox, only five diseases had been designated as PHEICs since the WHO started using the term in 2005: the H1N1 influenza pandemic in 2009; polio resurgences in Afghanistan, Nigeria and Pakistan in 2014; the Ebola epidemic in Guinea, Liberia and Sierra Leone in 2014 and an Ebola outbreak in the Democratic Republic of Congo 2019; the spread of Zika virus in the Americas in 2016; and the coronavirus pandemic in 2020. While all of these events were noteworthy, only the coronavirus pandemic became a worldwide catastrophe. </p>
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<h2>Why is monkeypox a public health emergency of international concern?</h2>
<p>The director-general of the WHO is the only person who can declare a PHEIC, but the decision is based on advice from the designated emergency committee. After the monkeypox emergency committee met for the second time, on July 21, 2022, it released a report stating that “the multi-country outbreak of monkeypox <a href="https://www.who.int/news/item/23-07-2022-second-meeting-of-the-international-health-regulations-(2005)-(ihr)-emergency-committee-regarding-the-multi-country-outbreak-of-monkeypox">meets all the three criteria defining a PHEIC</a>.”</p>
<p>The rapid spread of the virus to more than 70 countries was evidence of the risk of further international spread. The committee expressed concerns about whether vaccines would be priced reasonably and distributed equitably in the absence of a coordinated international response. And it agreed that there were aspects of the situation that were “extraordinary” – a vague term that is not defined in the International Health Regulations.</p>
<p>However, the committee did not express unanimous agreement that a public health emergency of international concern should be declared. Some members questioned whether a disease that has a low case fatality rate should be a PHEIC. Others worried that a PHEIC designation could further stigmatize LGBTQ communities since most cases thus far have been diagnosed among men who have sex with men. </p>
<p>The <a href="https://doi.org/10.1126/science.ade0761">vote from the emergency committee was split</a> – nine against and six for PHEIC status. But Director-General Tedros opted to go ahead and declare monkeypox a PHEIC. </p>
<h2>What happens now?</h2>
<p>The <a href="https://doi.org/10.1093/jtm/taaa227">goal of a PHEIC designation</a> is to prevent an emerging disease from becoming a global health crisis. The WHO has two initial goals for monkeypox. First, to try to stop the virus from beginning to circulate in susceptible populations where it is not currently present. And second, to distribute vaccines and antiviral medications to the countries and communities that need them most. </p>
<p>After the PHEIC declaration, the WHO released a <a href="https://www.who.int/news/item/23-07-2022-second-meeting-of-the-international-health-regulations-(2005)-(ihr)-emergency-committee-regarding-the-multi-country-outbreak-of-monkeypox">set of temporary recommendations</a> that asks countries to work harder on preventing cases in affected and at-risk communities, to improve clinical care for people with monkeypox and to contribute to research on vaccines and treatments for monkeypox. The recommendations also ask countries to advise infected individuals and their direct contacts not to travel except in urgent situations, but they do not impose any restrictions on international travel or trade. </p>
<p>Finally, the WHO has advised that individuals who are members of at-risk communities take steps to protect themselves from the virus, but has not called for changed behavior in the general public.</p>
<p>A public health emergency of international concern is the highest level of alert in the International Health Regulations, but it is not a synonym for a pandemic. The status is a tool for protecting global population health and not a declaration that a global crisis is already happening.</p><img src="https://counter.theconversation.com/content/187669/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathryn H. Jacobsen does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>By late July 2022, monkeypox was present in more than 70 countries with significant spread in certain communities. As a result, the World Health Organization began taking steps to fight the virus.Kathryn H. Jacobsen, William E. Cooper Distinguished University Chair, Professor of Health Studies, University of RichmondLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1868722022-07-15T12:19:03Z2022-07-15T12:19:03ZIs monkeypox a pandemic? An epidemiologist explains why it isn’t likely to become as widespread as COVID-19, but is worth watching<figure><img src="https://images.theconversation.com/files/474184/original/file-20220714-32258-jxqdeg.jpg?ixlib=rb-1.1.0&rect=30%2C69%2C2871%2C1705&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Monkeypox is caused by the monkeypox virus, which are the ovals and circles seen in this electron microscope image of the skin of a person infected with monkeypox.</span> <span class="attribution"><a class="source" href="https://phil.cdc.gov/Details.aspx?pid=22664">Cynthia S. Goldsmith, Russell Regnery/CDC</a></span></figcaption></figure><p>Monkeypox is the latest global public health threat to make headlines. Most people who contract the monkeypox virus experience flu-like symptoms and a <a href="https://www.cdc.gov/poxvirus/monkeypox/symptoms.html">blistery rash</a> that lasts two to four weeks, but a small percentage of infected people develop sepsis or other severe and <a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">potentially fatal complications</a>.</p>
<p>It is not uncommon for there to be <a href="https://doi.org/10.1371/journal.pntd.0007791">small outbreaks of monkeypox</a> in Central and West Africa, but in the last few weeks, dozens of countries from other world regions have reported <a href="https://ourworldindata.org/monkeypox">thousands of cases of monkeypox</a>. </p>
<p>As an infectious disease epidemiologist, I’ve received many inquiries from colleagues and friends about whether a monkeypox pandemic will be the next big disruption to our lives. A disease is considered to be <a href="https://doi.org/10.1093/oso/9780192897855.003.0002">pandemic</a> when two separate conditions are met: cases are occurring globally and the number of cases being diagnosed is large enough to qualify as <a href="https://theconversation.com/whats-the-difference-between-pandemic-epidemic-and-outbreak-133048">epidemic</a>. An epidemic is characterized by new cases of a disease occurring at a <a href="https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section11.html">higher than typical rate in at least several communities</a>.</p>
<p>While the monkeypox situation is certainly newsworthy, as of mid-July 2022, it did not clearly meet both of the requirements for pandemic status. More importantly, the current evidence suggests that <a href="https://theconversation.com/what-is-monkeypox-a-microbiologist-explains-whats-known-about-this-smallpox-cousin-183499">monkeypox</a> is very unlikely to become a global health catastrophe even if the virus spreads and becomes pandemic.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/474185/original/file-20220714-32290-5vz2ce.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A map showing much of the world in red." src="https://images.theconversation.com/files/474185/original/file-20220714-32290-5vz2ce.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/474185/original/file-20220714-32290-5vz2ce.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=305&fit=crop&dpr=1 600w, https://images.theconversation.com/files/474185/original/file-20220714-32290-5vz2ce.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=305&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/474185/original/file-20220714-32290-5vz2ce.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=305&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/474185/original/file-20220714-32290-5vz2ce.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=383&fit=crop&dpr=1 754w, https://images.theconversation.com/files/474185/original/file-20220714-32290-5vz2ce.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=383&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/474185/original/file-20220714-32290-5vz2ce.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=383&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">As of mid-July 2022, monkeypox cases associated with the current outbreak (shown in red on the map, with previous outbreaks in other colors) were occurring mostly in Europe and the Americas, and few cases were being reported from Africa and Asia.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Monkeypox_By_Country.svg#/media/File:Monkeypox_By_Country.svg">ArcMachaon/Wikimedia Commons</a></span>
</figcaption>
</figure>
<h2>Is monkeypox global?</h2>
<p>Both the 2009 <a href="https://www.who.int/emergencies/situations/influenza-a-(h1n1)-outbreak">H1N1 influenza</a> virus and the <a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019">SARS-CoV-2 coronavirus</a> that emerged in 2019 quickly spread to every region of the world. Global health experts were in full agreement that those were pandemic events. By contrast, the <a href="https://www.who.int/groups/ebola-virus-disease-in-west-africa-(2014-2015)-ihr-emergency-committee">Ebola virus</a> epidemic in West Africa from 2014 to 2016 was mostly contained to just that one region of the world and never spread globally. </p>
<p>The <a href="https://www.who.int/emergencies/situations/monkeypox-oubreak-2022">current distribution</a> of monkeypox cases is somewhere between those two scenarios. As of mid-July 2022, about <a href="https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-covid-19-media-briefing--12-july-2022">9,200 total cases</a> of monkeypox had been reported by 63 countries. For reasons that are not yet fully understood, almost all of those cases happened in <a href="https://cdn.who.int/media/docs/default-source/2021-dha-docs/20220706_monkeypox_external_sitrep_final.pdf">Europe and the Americas</a>, and only a few cases were reported by <a href="https://ourworldindata.org/monkeypox">African, Asian and Middle Eastern</a> countries.</p>
<p>Is that distribution sufficiently global to meet the definition of a pandemic? Maybe. </p>
<h2>Is monkeypox an epidemic?</h2>
<p>The next condition to meet the pandemic threshold is whether places where monkeypox is present are experiencing epidemics.</p>
<p>Europe and the Americas typically have <a href="https://doi.org/10.1371/journal.pntd.0010141">zero cases</a> of monkeypox per year, so the current case counts in these regions are much higher than normal. </p>
<p>But it is also important to look at how much community transmission is happening. If hundreds of people get sick after attending a single event – like a concert or festival – that would typically be classified as an outbreak. The situation would only become an epidemic if infections started occurring among many people who were not close contacts of event attendees. Once widespread and sustained community transmission begins occurring, it is much harder to control a virus. </p>
<p>Most of the people diagnosed with monkeypox in May and June 2022 were 20- to 50-year-old men who identify as members of the <a href="https://doi.org/10.1126/science.add5497">LGBT+ community</a>. In July 2022, cases were not yet occurring at significant levels in multiple age and sociodemographic groups. </p>
<p>Is the current pattern of spread sufficient to classify monkeypox as an epidemic rather than an outbreak? Maybe, but only in some of the countries that have reported monkeypox cases this year.</p>
<p>Since the answers to whether monkeypox is global and an epidemic are both “maybe” rather than “yes,” this suggests that monkeypox is not a pandemic – at least not yet. But it could become one soon.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/474186/original/file-20220714-9428-a0lb0l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A photo of a man's torso with many small lesions" src="https://images.theconversation.com/files/474186/original/file-20220714-9428-a0lb0l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/474186/original/file-20220714-9428-a0lb0l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=391&fit=crop&dpr=1 600w, https://images.theconversation.com/files/474186/original/file-20220714-9428-a0lb0l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=391&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/474186/original/file-20220714-9428-a0lb0l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=391&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/474186/original/file-20220714-9428-a0lb0l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=491&fit=crop&dpr=1 754w, https://images.theconversation.com/files/474186/original/file-20220714-9428-a0lb0l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=491&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/474186/original/file-20220714-9428-a0lb0l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=491&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Monkeypox produces blistery skin lesions, as shown in this photo from the Centers for Disease Control and Prevention taken in the Democratic Republic of Congo in 1997.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/Monkeypox/3a2240b22aff43aab5eb20d5f5793149/photo?Query=monkeypox&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=33&currentItemNo=1">Associated Press/CDC</a></span>
</figcaption>
</figure>
<h2>How worried should you be about monkeypox?</h2>
<p>Pathogens like <a href="https://doi.org/10.3389/fpubh.2018.00241">monkeypox</a> are usually spread through touch and other types of <a href="https://www.cdc.gov/poxvirus/monkeypox/transmission.html">close contact</a> with an infected person. Epidemiologists worry much less about pathogens with “person-to-person” transmission than they do about respiratory viruses like influenza and the coronavirus that can spread easily through the air.</p>
<p>Over the course of just a few months, COVID-19 transitioned from a local concern in Wuhan, China, into the worst pandemic in a century. That is <a href="https://doi.org/10.1093/cid/cit703">not going to happen with monkeypox</a>.</p>
<p>Why? First, the monkeypox virus is <a href="https://doi.org/10.2471%2FBLT.19.242347">much less contagious</a> than the circulating strains of coronavirus. Second, monkeypox is less deadly than COVID-19. The <a href="https://cdn.who.int/media/docs/default-source/2021-dha-docs/20220706_monkeypox_external_sitrep_final.pdf">case fatality rate</a> during the current international outbreak is less than one death for every 1,000 adult cases, which is lower than the percentage of unvaccinated people who die after getting <a href="https://doi.org/10.1016/S1473-3099(20)30244-9">COVID-19</a>. And, third, <a href="https://apps.who.int/iris/rest/bitstreams/1433527/retrieve">existing vaccines</a> will be able to help slow the spread of monkeypox in high-risk populations if <a href="https://www.msn.com/en-us/news/us/public-health-clinics-running-out-of-monkeypox-vaccine-as-lines-form-and-systems-crash/ar-AAZxMuv">problems with limited supplies</a> can be resolved.</p>
<p>The World Health Organization follows a set of rules called the <a href="https://www.who.int/publications/i/item/9789241580496">International Health Regulations</a> that guide global public health responses to emerging threats. Under these regulations, the WHO has the authority to declare a “public health emergency of international concern” – commonly shortened to the acronym <a href="https://doi.org/10.1093%2Fjtm%2Ftaaa227">PHEIC</a> – when an infectious disease is spreading internationally and might “potentially require a coordinated international response.” The goal is to detect and respond to potential global health crises and prevent them from becoming pandemics.</p>
<p>An <a href="https://www.who.int/emergencies/situations/monkeypox-oubreak-2022">expert panel convened by the World Health Organization on June 23</a> determined that monkeypox was a “multi-country outbreak” but did not meet the criteria to be a public health emergency of international concern. The panel will meet again on July 21 to examine the distribution and frequency of new case reports. If the rate of new cases continues to increase and there is evidence of transmission within more diverse populations, monkeypox may be declared a public health emergency. </p>
<p>But even if monkeypox is declared to be a public health emergency of international concern, it is not going to become a devastating pandemic like COVID-19.</p><img src="https://counter.theconversation.com/content/186872/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathryn H. Jacobsen does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The monkeypox virus, which is commonly found in West and Central Africa, is now causing many infections in the U.S., Europe and Latin America.Kathryn H. Jacobsen, William E. Cooper Distinguished University Chair, Professor of Health Studies, University of RichmondLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1852972022-06-26T00:11:02Z2022-06-26T00:11:02ZMonkeypox is not a global emergency for now, says WHO. 3 things we need to know next about how it’s mutating and spreading<figure><img src="https://images.theconversation.com/files/470411/original/file-20220623-52182-eny4r6.jpg?ixlib=rb-1.1.0&rect=1%2C0%2C997%2C666&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/monkeypox-virus-3d-illustration-zoonotic-poxviridae-2159713933">Shutterstock</a></span></figcaption></figure><p>The World Health Organization (WHO) has <a href="https://twitter.com/DrTedros/status/1540791694236344321">decided not</a> to declare monkeypox a public health emergency of international concern. <a href="https://theconversation.com/at-what-point-is-a-disease-deemed-to-be-a-global-threat-heres-the-answer-185547">This may change</a> in the future.</p>
<p>However, WHO Director-General Tedros Adhanom Ghebreyesus <a href="https://www.who.int/news-room/speeches/item/who-director-general-s-statement-on-the-report-of-the-meeting-of-the-international-health-regulations-(2005)-emergency-committee--regarding-the-multi-country-monkeypox-outbreak">said</a> he was “deeply concerned” about the evolving threat of monkeypox, which he said had reached more than 50 countries.</p>
<p>There have been <a href="https://map.monkeypox.global.health/country">more than</a> 4,100 confirmed cases globally, including at least 13 in Australia.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1540818908927729665"}"></div></p>
<p>The WHO also acknowledged there were many unknowns about the outbreak.</p>
<p>Here are three things we know about monkeypox and three things we want to find out.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/at-what-point-is-a-disease-deemed-to-be-a-global-threat-heres-the-answer-185547">At what point is a disease deemed to be a global threat? Here's the answer</a>
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<h2>3 things we know</h2>
<p><strong>1. Monkeypox is caused by a virus</strong></p>
<p>Monkeypox is a large DNA virus belonging to the orthopoxvirus family. Unlike the related smallpox virus, variola, which only affected humans, monkeypox virus is found in rodents and other animals in parts of Africa. </p>
<p>We know of two clades (virus groupings), and it is the less severe of the two currently <a href="https://theconversation.com/monkeypox-in-australia-what-is-it-and-how-can-we-prevent-the-spread-183526">circulating</a> outside Africa.</p>
<p>Orthopoxviruses are stable viruses that do not mutate much. Multiple mutations, however, <a href="https://www.statnews.com/2022/06/02/mutations-in-monkeypox-virus-explainer/">have been described</a> in the virus causing the current outbreak. </p>
<p>In the United States, at least two separate strains have been circulating, suggesting <a href="https://www.statnews.com/2022/06/03/genetic-data-indicate-at-least-two-separate-monkeypox-outbreaks-underway-suggesting-wider-spread/">multiple introductions</a> into the country. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/monkeypox-in-australia-what-is-it-and-how-can-we-prevent-the-spread-183526">Monkeypox in Australia: what is it and how can we prevent the spread?</a>
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<hr>
<p><strong>2. You can be infected for more than a week and not know</strong></p>
<p>It takes an <a href="https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2022.27.24.2200448">average 8.5 days</a> from infection to showing symptoms, such as enlarged lymph nodes, fever and a rash, which usually looks like fluid-filled blisters that erupt. People are infectious while they have the rash, and are usually infectious for about two weeks.</p>
<p>Children are most severely affected and have a higher risk of dying from the disease. Historically, in the endemic countries of Africa, <a href="https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0010141#sec016">almost all deaths</a> have been in children.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/470419/original/file-20220623-52323-3o78bp.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Child with monkeypox lesions on limbs" src="https://images.theconversation.com/files/470419/original/file-20220623-52323-3o78bp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/470419/original/file-20220623-52323-3o78bp.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=393&fit=crop&dpr=1 600w, https://images.theconversation.com/files/470419/original/file-20220623-52323-3o78bp.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=393&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/470419/original/file-20220623-52323-3o78bp.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=393&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/470419/original/file-20220623-52323-3o78bp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=493&fit=crop&dpr=1 754w, https://images.theconversation.com/files/470419/original/file-20220623-52323-3o78bp.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=493&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/470419/original/file-20220623-52323-3o78bp.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=493&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Children with monkeypox, such as this four-year-old girl, are at increased risk of severe disease.</span>
<span class="attribution"><a class="source" href="https://phil.cdc.gov/Details.aspx?pid=2329">CDC</a></span>
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<p>The European epidemic is <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON392">mostly in adult males</a>, so this, together with better access to care, may explain the low rate of deaths in these countries.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/whats-in-a-name-why-giving-monkeypox-a-new-one-is-a-good-idea-185307">What's in a name? Why giving monkeypox a new one is a good idea</a>
</strong>
</em>
</p>
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<p><strong>3. We have vaccines and treatments</strong></p>
<p>Vaccines work. Past vaccination against smallpox provides <a href="https://doi.org/10.1093/ije/17.3.643">85% protection</a> against monkeypox. Smallpox was declared <a href="https://www.cdc.gov/smallpox/index.html">eradicated in 1980</a>, so most mass vaccination programs ceased in the 1970s. </p>
<p>Australia never had mass smallpox vaccination. However, an <a href="https://wwwnc.cdc.gov/eid/article/24/4/17-1233_article">estimated 10%</a> of Australians have been vaccinated in the past, mostly migrants.</p>
<p>Vaccines protect for many years but immunity wanes. So <a href="https://wwwnc.cdc.gov/eid/article/27/4/20-3569_article">declining population-level protection</a> is likely responsible for the resurgence of monkeypox seen since 2017 in Nigeria, one of seven endemic hot spots in Africa.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/470421/original/file-20220623-52339-3o78bp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Man showing smallpox vaccine scar on upper arm" src="https://images.theconversation.com/files/470421/original/file-20220623-52339-3o78bp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/470421/original/file-20220623-52339-3o78bp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/470421/original/file-20220623-52339-3o78bp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/470421/original/file-20220623-52339-3o78bp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/470421/original/file-20220623-52339-3o78bp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/470421/original/file-20220623-52339-3o78bp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/470421/original/file-20220623-52339-3o78bp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Even if you have been vaccinated against smallpox, protection wanes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/monkeypox-smallpox-vaccine-scar-on-young-2158715369">Shutterstock</a></span>
</figcaption>
</figure>
<p>Mass vaccination is not recommended. But vaccines <a href="https://www.who.int/publications/i/item/who-mpx-immunization-2022.1">can be given</a> to contacts of confirmed cases (known as post-exposure prophylaxis) and people at high risk of contracting the virus, such as some lab or health workers (pre-exposure prophylaxis).</p>
<p>There are also <a href="https://jglobalbiosecurity.com/articles/10.31646/gbio.12/">treatments</a>, such as vaccinia immune globulin and antivirals. These were developed against smallpox.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/monkeypox-we-have-vaccines-and-drugs-to-treat-it-183686">Monkeypox: we have vaccines and drugs to treat it</a>
</strong>
</em>
</p>
<hr>
<h2>3 things we want to find out</h2>
<p><strong>1. How much do these new mutations matter?</strong></p>
<p>The virus causing the current outbreak has <a href="https://www.statnews.com/2022/06/02/mutations-in-monkeypox-virus-explainer/">several mutations</a> compared with versions of the virus circulating in Africa. However, we don’t know if these mutations affect clinical disease and how the virus spreads.</p>
<p>The monkeypox virus has a <a href="https://nextstrain.org/monkeypox/hmpxv1">very large genome</a>, so is more complex to study than smaller RNA viruses, such as influenza and SARS-CoV-2 (the virus that causes COVID).</p>
<p>Experts wonder if the mutations have made it more contagious or changed the clinical pattern to be more like a sexually transmitted infection. A <a href="https://www.cidrap.umn.edu/news-perspective/2022/06/virus-causing-monkeypox-outbreak-has-mutated-spread-easier">study</a> from Portugal shows the mutations likely make the virus more transmissible.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/monkeypox-is-a-dna-virus-unlike-coronavirus-heres-what-that-means-for-the-virus-and-us-184708">Monkeypox is a DNA virus unlike coronavirus – here's what that means for the virus and us</a>
</strong>
</em>
</p>
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<p><strong>2. How is it spread? Is that changing?</strong></p>
<p>Monkeypox has not been described as a sexually transmitted infection in the past. However, the current transmission pattern is unusual. There <a href="https://www.journalofinfection.com/article/S0163-4453(22)00335-8/fulltext">seems to be</a> a very short incubation period (of 24 hours) following sexual contact in some, but not all, cases. </p>
<p>It is a respiratory virus, so aerosol transmission is possible. But historically <a href="https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0010141#sec016">most transmission</a> has been from animal to human. When there was transmission between humans, this usually involved close contacts.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1536532197397565440"}"></div></p>
<p>The rapid growth of the epidemic in non-endemic countries in 2022, however, has been all due to spread between humans. There may be <a href="https://www.npr.org/sections/health-shots/2022/06/25/1107416457/monkeypox-outbreak-in-us">many more cases</a> than officially reported.</p>
<p>We do not know why the pattern has changed, whether it is sexually transmitted or simply transmitted due to intimate contact in specific and globally connected social networks, or whether the virus has become more contagious. </p>
<p>The virus is found in the skin rash, mouth and semen, but this <a href="https://www.science.org/content/article/monkeypox-outbreak-mostly-affecting-men-sex-men">does not prove</a> it is sexually transmitted.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/monkeypox-this-is-an-entirely-new-spread-of-the-disease-184085">Monkeypox: ‘This is an entirely new spread of the disease’</a>
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</em>
</p>
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<p><strong>3. How far will it spread? Does COVID make a difference?</strong></p>
<p>Will this spread more widely in the community? Does the COVID pandemic increase the risk? <a href="https://theconversation.com/how-monkeypox-epidemic-is-likely-to-play-out-in-four-graphs-184578">Possibly, yes</a>.</p>
<p>We must also not drop the ball on surveillance in the wider community or <a href="https://www.acpjournals.org/doi/10.7326/M22-1748">stigmatise the LGBTQI community</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1528888390027984896"}"></div></p>
<p>Due to waning immunity from the smallpox vaccine globally and the spread of monkeypox to many countries already, we may see the epidemic spreading more widely. </p>
<p>If it does so and starts infecting large numbers of children, we could see more deaths because children get more severe infection. </p>
<p>So we should monitor globally for clusters of fever and rash, and <a href="https://www.epiwatch.org/media/EPISCOPE_JUNE_14_2022.pdf">misdiagnosis</a> as chickenpox, <a href="https://www.rch.org.au/kidsinfo/fact_sheets/Hand_foot_and_mouth_disease/">hand foot and mouth disease</a>, herpes simplex or other diseases with a rash.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-monkeypox-epidemic-is-likely-to-play-out-in-four-graphs-184578">How monkeypox epidemic is likely to play out – in four graphs</a>
</strong>
</em>
</p>
<hr>
<p>Another factor is COVID. As people recover from COVID, their immune system <a href="https://www.nature.com/articles/s41392-021-00749-3#citeas">is impaired</a>. So people who have had COVID may be more susceptible to other infections.</p>
<p>We see the same with measles infection. This weakens the immune system and increases the risk of other infections for <a href="https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-020-05469-7">two to three years</a> afterwards.</p>
<p>If the epidemic becomes established in countries outside the endemic areas, it may infect animals and create new endemic zones in the world. </p>
<p>It is important we do everything possible to stop this epidemic.</p><img src="https://counter.theconversation.com/content/185297/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>C Raina MacIntyre receives funding from NHMRC and MRFF. She has been on advisory boards for Bavarian Nordic and received funding for a smallpox workshop she conducted in 2019 from Emergent Biosolutions, Bavarian Nordic, Siga technologies and Meridien Medical. She is on the WHO SAGE Smallpox and Monkey Pox Ad Hoc Advisory Group.</span></em></p>Monkeypox has spread to more than 50 countries and will continue to be monitored. Here’s what we know about monkeypox so far and what researchers want to find out.C Raina MacIntyre, Professor of Global Biosecurity, NHMRC Principal Research Fellow, Head, Biosecurity Program, Kirby Institute, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1315712020-02-13T08:59:32Z2020-02-13T08:59:32ZLassa fever: why there’s a call to declare a health emergency in Nigeria<figure><img src="https://images.theconversation.com/files/315042/original/file-20200212-61935-6wbvv3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Alarmed by a rapid spread of Lassa fever, the Nigerian Academy of Science is calling on government to declare a health emergency. </span> <span class="attribution"><span class="source">Pius Utomi Ekpei/AFP via Getty Images</span></span></figcaption></figure><p><em>The Nigerian Academy of Science <a href="https://guardian.ng/news/declare-lassa-fever-national-emergency-says-academy-of-science/">has called</a> for the current outbreak of Lassa fever in Africa’s most populous nation to be declared a national health emergency because of its severity. Adejuwon Soyinka asked Dr Doyin Odubanjo to unpack the background.</em></p>
<p><strong>How serious is the current Lassa fever outbreak in Nigeria?</strong></p>
<p>It is serious enough given the worsening trend. It has spread from just two states when it was first diagnosed in 1969 to <a href="http://www.xinhuanet.com/english/2020-02/10/c_138769873.htm">23 states in 2019</a>. The situation has increasingly got worse over the years. In 2018, the Nigerian Centre for Disease Control <a href="https://ncdc.gov.ng/diseases/info/L">reported</a> the largest ever number of cases in Nigeria, with over 600 confirmed cases and over 170 deaths. </p>
<p>And the numbers have continued to rise. An alarm was raised over the tripling of the number of suspected cases between 2017 and 2018 only for the reported number of suspected cases <a href="http://www.xinhuanet.com/english/2020-02/10/c_138769873.htm">to rise in 2019</a>. </p>
<p>Outbreaks have historically occurred during the dry season – November to April. But in recent years there have also been cases during the rainy season. Fatality rates are also <a href="https://ncdc.gov.ng/diseases/info/L">unacceptably high</a>. Over the last few years they have remained between 20% and 25%. This is particularly bad given that there is an effective treatment for the disease if it’s detected early and patients are presented at the hospital.</p>
<p><strong>How do people get infected and why has it been persistent?</strong></p>
<p>Lassa fever <a href="https://theconversation.com/lassa-fever-will-keep-ravaging-nigeria-unless-better-surveillance-is-put-in-place-83847">is a viral haemorrhagic disease</a> caused by the Lassa virus which naturally infects the widely distributed house rat. It’s transmitted through the urine and droppings of infected rats found in most tropical and subtropical countries in Africa. They are able to contaminate anything they come in contact with. The Lassa virus spreads through human to human contact with tissue, blood, body fluids, secretions or excretions. This includes coughing, sneezing, kissing, sexual intercourse and breastfeeding. In hospitals the disease is spread through contaminated equipment.</p>
<p>People become ill six to 21 days after they are infected. A fever is usually the first symptom followed by headaches and coughing, nausea and vomiting, diarrhoea, mouth ulcers and swollen lymph glands. Some patients also complain of muscle, abdomen and chest pains. And later, patients’ necks and faces swell and they bleed from their orifices and into their internal organs. Lassa fever can be fatal, but it can be treated if diagnosed early.</p>
<p><a href="https://www.cdc.gov/vhf/lassa/treatment/index.html">A drug</a> does exist for the treatment of the disease. But its efficacy is affected by the fact that Nigeria has inefficient laboratory diagnosis and patients are admitted late to hospital. </p>
<p>The spread of the disease throughout the country may also have resulted from increased contact between humans and rodents. This has happened as populations of rodents have grown, encouraged by a pervasively poor environmental sanitation. </p>
<p>Another factor is that inadequate attention has been paid to the disease. This has led to poor funding for research into drugs, including vaccination, and compounded by a weak disease surveillance and response system and a relatively weak health system.</p>
<p><strong>What needs to be done?</strong></p>
<p>To successfully turn the tide, governments at state and federal level need to mount an extensive and sustained public Lassa fever prevention and control awareness programme.</p>
<p>States of the federation also need to establish functional isolation wards for the treatment of Lassa fever patients. </p>
<p>It is also important to set up a mechanism for improving environmental sanitation in a sustained way throughout the country to reduce rodent population as well as rodent – human contact.</p>
<p>Funds should also be provided for research into finding new drugs for Lassa fever treatment and the development of a Lassa fever vaccine.</p>
<p><strong>What difference would a public health emergency make?</strong></p>
<p>A recent, and good example, of the difference this can make was the <a href="https://www.bbc.com/news/world-africa-28715939">announcement</a> of a public health emergency in 2014 to tackle the Ebola virus outbreak.</p>
<p>The announcement led to an emergency mode being activated with the attendant political will and funding which <a href="https://theconversation.com/how-nigeria-beat-the-ebola-virus-in-three-months-41372">ultimately stopped</a> the spread of the disease within 93 days.</p>
<p>This is why the Nigerian Academy of Science is calling for more action. In particular, we are recommending that an interdisciplinary committee be set up comprising medical and veterinary specialists, epidemiologists, social scientists, media practitioners, community representatives. This would be along the lines of an approach known as One Health. This is rooted in the understanding that human health is affected by interactions between people, the environment and animals. </p>
<p>Equally important is the need for the government to enhance the capacity of the national laboratory network for reliable and efficient diagnosis of suspected cases. This is because only about 20% of suspected Lassa fever cases are usually <a href="https://www.frontiersin.org/articles/10.3389/fpubh.2019.00170/full">diagnosed</a>.</p>
<p>Government should also provide adequate funds for a sensitive disease surveillance and response system. This is a system that ensures disease outbreaks (not just Lassa fever) are quickly noticed, diagnosed, and appropriate responses or containment measures are started in the shortest possible time.</p><img src="https://counter.theconversation.com/content/131571/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Doyin Odubanjo does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Concerned about rising cases and spread of Lassa fever, the Nigerian Academy of Science has called on government to declare it a national health emergency.Doyin Odubanjo, Executive Secretary, Nigerian Academy of ScienceLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1311282020-02-05T13:12:15Z2020-02-05T13:12:15ZIs the coronavirus a pandemic, and does that matter? 4 questions answered<figure><img src="https://images.theconversation.com/files/313534/original/file-20200204-41532-f3wy0v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Flight attendants check temperatures of passengers aboard an Air China flight from Melbourne to Beijing on Feb. 4, 2020. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/APTOPIX-China-Outbreak/50184f4d18db47c7933892aa1b538c24/2/0">AP Photo/Andy Wong</a></span></figcaption></figure><p><em>Editor’s note: The new coronavirus has now <a href="https://www.nytimes.com/2020/02/04/world/asia/coronavirus-china.html?action=click&module=Top%20Stories&pgtype=Homepage">affected more than 20,000 people</a> in China and claimed more lives as of Feb. 4 than the SARS epidemic from 2002 to 2004. Hong Kong has reported its <a href="https://www.wsj.com/articles/coronavirus-cases-rise-above-20-000-in-china-as-hong-kong-reports-first-death-11580799736">first death</a>. Some public health officials have said the outbreak is <a href="https://www.nytimes.com/2020/02/02/health/coronavirus-pandemic-china.html">likely to soon be a pandemic</a>, but the <a href="https://www.bbc.com/news/world-asia-china-51368873">World Health Organization</a> said Feb. 4 that it isn’t, yet. Just what is a pandemic anyway? An epidemiologist and public health researcher explains.</em></p>
<h2>1. What is a pandemic?</h2>
<p>When a disease outbreak, or epidemic, crosses international boarders and spreads across a wide region, we public health professionals typically call it a <a href="https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section11.html">pandemic</a>. The term “pandemic” tells us that the outbreak is occurring in many places but says nothing about its severity. </p>
<p>Because of their wide geographic distribution, pandemics usually affect a large number of people. While we usually think of pandemics in relation to <a href="https://www.who.int/csr/disease/swineflu/en/">serious</a>, life-threatening diseases, even outbreaks of mild diseases could cross borders and become pandemics.</p>
<h2>2. Does it matter if it is or isn’t called a pandemic?</h2>
<p>Calling an outbreak a pandemic is simply a reflection of where the disease is spreading. The terminology doesn’t change anything about the severity of the disease or how we are responding. </p>
<p>Since the day the outbreak was identified, health officials worldwide have been taking steps to <a href="https://emergency.cdc.gov/han/han00424.asp">isolate ill people to try and prevent any spread</a> and <a href="https://www.whitehouse.gov/briefings-statements/press-briefing-members-presidents-coronavirus-task-force/">quarantine people who have traveled to certain areas of China</a>. The World Health Organization <a href="https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)">declared it to be a Public Health Emergency of International Concern</a> Jan. 30, which improves information sharing and coordination throughout the world.</p>
<p>These actions will continue no matter what it is called.</p>
<h2>3. Would it being a pandemic put me at greater risk?</h2>
<p>Your risk wouldn’t changed simply because of a change in terminology. Though the virus has been identified in <a href="https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200204-sitrep-15-ncov.pdf">23 countries</a> as of Feb. 4, over 99% of the cases have occurred in China. </p>
<p>Local transmission outside of China has generally been limited to people who had direct contact with ill travelers from China. In a <a href="https://www.nytimes.com/reuters/2020/02/03/business/31reuters-china-health-germany.html">cluster reported from Germany</a>, several employees of a company were infected by a co-worker who returned from travel to China, and one of the employees infected one of their children. This clearly shows that person-to-person spread is possible, but it doesn’t mean that the disease is spreading extensively in the community.</p>
<p>Even if an outbreak is spreading worldwide, how it is spreading locally and how people respond is what determines your risk.</p>
<h2>4. So what happens next?</h2>
<p>Public and global health experts and health care workers will continue to respond to this outbreak as they have for the last month. Doctors and nurses in the community will continue to quickly identify ill people and test them for the coronavirus. Sick people will be isolated so that they don’t spread their illness to their family, friends or co-workers. Public health officials will track the spread of this outbreak and will use that information to prevent the spread of the disease in the community. </p>
<p>The next move is up to the virus.</p>
<p>[ <em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://theconversation.com/us/newsletters/weekly-highlights-61?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=weeklysmart">You can get our highlights each weekend</a>. ]</p><img src="https://counter.theconversation.com/content/131128/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Brian Labus received past funding from the Centers for Disease Control and Prevention for disease surveillance activities while working at the local health department.</span></em></p>The World Health Organization has said the coronavirus is not yet a pandemic. That raises a question: just what is a pandemic? An expert explains.Brian Labus, Assistant Professor of Epidemiology and Biostatistics, University of Nevada, Las VegasLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1309502020-01-31T20:18:25Z2020-01-31T20:18:25ZWhat the coronavirus emergency declaration means for Canada<figure><img src="https://images.theconversation.com/files/313136/original/file-20200131-41476-1jtrzdm.jpg?ixlib=rb-1.1.0&rect=86%2C80%2C3416%2C2279&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People wait at Toronto Pearson International Airport on Jan. 25, 2020. </span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span></figcaption></figure><p>The director general of the World Health Organization (WHO) has <a href="https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)">decided the outbreak of 2019-nCoV constitutes a public health emergency of international concern (PHEIC)</a> as more countries reported confirmed cases of the coronavirus. The move updates the organization’s decisions from last week, when it said it lacked enough scientific evidence to declare the emergency.</p>
<p>The WHO has declared only five other PHEICs in the past decade: the H1N1 influenza pandemic (2009-10), setbacks in fighting polio (2014), West Africa’s Ebola outbreak (2014), Zika virus (2015-2016) and the recent and ongoing Ebola outbreak in the Democratic Republic of the Congo. </p>
<p>Although the WHO responded to <a href="https://www.who.int/news-room/photo-story/photo-story-detail/urgent-health-challenges-for-the-next-decade">58 health emergencies in 50 countries last year</a>, PHEICs are a unique category of emergencies: they are defined under the <a href="https://www.who.int/ihr/publications/9789241596664/en/">International Health Regulations</a> as extraordinary public health events that endanger global public health through the international spread of disease, and that potentially require a coordinated international response.</p>
<p>There have been three confirmed cases of 2019-nCoV Ontario, and one in British Columbia. Public health officials continue to stress that the risk of infection in Canada is low. So what does the emergency declaration mean for Canadians and Canada’s role internationally?</p>
<h2>Enhanced actions</h2>
<p>The International Health Regulations aim to “prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.” </p>
<p>The PHEIC declaration gives the WHO more power to muster an international response to the outbreak to prevent or reduce the spread of disease. Its recommendations are not binding on member countries, but they are expected to follow them. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1222973217435987970"}"></div></p>
<p>In this case, <a href="https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)">the WHO recommendations ask China</a> to enhance its actions to contain the outbreak, share relevant data on cases and conduct exit screening at international airports and ports. It also recommends other countries share information with the WHO, focus on reducing human infections and inform the WHO of any travel restrictions. </p>
<p>The WHO has recommended nations support those with weaker health systems and accelerate the development of vaccines and treatments. Canadian scientists are already working to develop a new vaccine against the novel virus, although it <a href="https://globalnews.ca/news/6481486/canada-vaccine-theresa-tam-coronavirus/">likely won’t be ready for at least a year</a>.</p>
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Read more:
<a href="https://theconversation.com/how-social-media-is-changing-research-and-reactions-to-coronavirus-outbreak-130748">How social media is changing research and reactions to coronavirus outbreak</a>
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<p>The IHR Emergencies Committee, which advises the WHO director general, said the recommendations should be interpreted in the spirit of solidarity and in support of China, to enhance preparedness in other regions of the world that may need additional support. </p>
<p>The committee has warned against any travel or trade restrictions, even as the United States has placed <a href="https://www.cnn.com/2020/01/30/politics/coronavirus-alert/index.html">travel restrictions</a> on travel to China. Canada <a href="https://doi.org/10.1017/cyl.2017.18">closed its borders to people from Ebola-affected countries during the 2014-16 outbreak</a> even though there was no scientific evidence supporting the decision, and was was criticized by the WHO for doing so. </p>
<h2>Why now?</h2>
<p>The declaration of a global public health emergency can have serious repercussions. If it is called too early, it can interfere with international traffic and trade. But if it is called too late, the WHO may be viewed as failing to adequately protect the public’s health. </p>
<p>The WHO has been <a href="https://www.sfchronicle.com/news/article/World-health-agency-opts-against-global-alarm-on-14998851.php">criticized in the past for both premature</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5803810/">delayed declarations of PHEICs</a>. Some experts have said <a href="https://www.nytimes.com/2020/01/30/health/coronavirus-world-health-organization.html">WHO was too slow</a> in its declaration on 2019-nCoV.</p>
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Read more:
<a href="https://theconversation.com/coronavirus-in-wuhan-residents-shout-stay-strong-from-windows-130851">Coronavirus in Wuhan: Residents shout 'stay strong' from windows</a>
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<p>The declaration is both a <a href="https://www.washingtonpost.com/politics/2020/01/26/who-held-off-declaring-wuhan-coronavirus-global-health-emergency-heres-why/">political</a> and ethical decision made in a time of immense uncertainty. It must strike a careful balance between the need to curb the spread of disease and prevent unnecessary fear and interference. </p>
<h2>What does it mean?</h2>
<p>It does not necessarily mean the risk of infection has increased in Canada. </p>
<p>The WHO declared the emergency to coordinate an international response to protect countries with health-care systems that are otherwise ill-prepared to deal with this novel virus. </p>
<p>Despite its weaknesses, the Canadian health-care system is relatively well-equipped and prepared to address infectious disease outbreaks, particularly as a result of <a href="https://www.ncbi.nlm.nih.gov/books/NBK92467/">its experience</a> with the outbreak of Severe Acute Respiratory Syndrome (SARS). Multiple systems exist in Canada <a href="https://news.gov.bc.ca/releases/2020HLTH0015-000151">to prevent the spread of serious infectious diseases</a>.</p>
<p>Canadians should not fear 2019-nCoV simply as a result of the WHO’s declaration. Rather Canada and Canadians have an important, collective role to play in curbing the spread of this novel virus — and avoid the mistakes made in the past.</p>
<p>Instead, Canada can offer scientific expertise to help ill-equipped countries with surveillance and detection, and Canadians can do their part to help curb the spread of the disease by adopting common sense hygiene practices.</p><img src="https://counter.theconversation.com/content/130950/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maxwell J. Smith consults with the World Health Organization.</span></em></p><p class="fine-print"><em><span>Jacob Shelley does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The declaration does not mean the risk to Canadians has changed, but it does mean Canada must step up to help those countries with weaker heath-care systems.Maxwell J. Smith, Assistant Professor & Co-Director, Health Ethics, Law, & Policy (HELP) Lab, Western UniversityJacob Shelley, Assistant Professor & Co-Director, Health Ethics, Law, & Policy (HELP) Lab, Western UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1304882020-01-28T12:27:28Z2020-01-28T12:27:28ZPerspectives from Kenya and Ghana on coronavirus preparations<figure><img src="https://images.theconversation.com/files/311605/original/file-20200123-162232-1gij0ys.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Kenyan health workers from port health services screen inbound travelers for temperatures at Nairobi's Jomo Kenyatta International Airport.
</span> <span class="attribution"><span class="source">EPA/Daniel Irungu</span></span></figcaption></figure><p><em>Chinese officials have <a href="https://www.who.int/health-topics/coronavirus">identified</a> a novel coronavirus which belongs <a href="https://theconversation.com/what-the-latest-coronavirus-tells-us-about-emerging-new-infections-130623">to a family of viruses</a> that cause illnesses ranging from the common cold to more severe diseases. Countries across the world have heightened their disease surveillance systems and, in some cases, issued travel advisories. The Conversation Africa asked experts from Ghana and Kenya about their preparedness.</em> </p>
<hr>
<p><strong>What measures need to be put in place to contain the virus?</strong></p>
<p><strong><em>Abdhalah Ziraba, Kenya:</em></strong> Public health education, particularly for travellers and airport public health staff, is critical. National newspapers and broadcast channels, as well as various social media outlets, should be used. People in all countries, not just Kenya, need to be made aware of the symptoms which include fever, cough, difficulty breathing, sneezing, and body aches.</p>
<p>The other important intervention is to maintain vigilance at entry ports to screen for fever and vet travel histories, particularly incoming flights from China and the region. Kenya has <a href="https://mobile.nation.co.ke/news/Kenya-issues-alert-on-Coronavirus/1950946-5427668-1597ihgz/index.html">announced</a> that it will screen all passengers arriving from China and increased the levels of vigilance at all entry points. </p>
<p>All suspected cases need to be assessed further. A major consideration will be whether someone has a history of travelling from Wuhan, the Chinese epicentre of the outbreak, and other cities that have reported cases or being in contact with a person suspected of having the disease. </p>
<p>After being assessed, any suspected cases should be reported to the country’s health authorities immediately, and the subjects isolated and managed as per protocol.</p>
<p><strong><em>Peter Kojo Quashie, Ghana</em>:</strong> A number of measures need to be put in place. Due of the previous and ongoing response to Ebola, some measures are already in place.</p>
<ul>
<li><p>Arriving passengers need to be screened for elevated temperatures. Those with high ones need to be quarantined</p></li>
<li><p>travel history needs to be established</p></li>
<li><p>Secure quarantine areas at airports and selected hospitals</p></li>
<li><p>Rapid testing protocols must be put in place</p></li>
<li><p>Port and airport health officials and everyone who will get in contact with travellers should be properly educated on how to behave and what personal protective equipment (PPE) is required. </p></li>
</ul>
<p>On top of these, additional steps should include:</p>
<ul>
<li><p>Routing passengers arriving from China and other South East Asian countries to another terminal or section, and screening them individually. </p></li>
<li><p>Continuous monitoring of passengers from China and South East Asia for at least a month as was done in some countries for people who returned from Ebola endemic regions. These travellers should be counselled on the need to avoid large crowds and non-essential contact with people.</p></li>
</ul>
<p>It is important to establish health support for Ghanaians in China, especially in Wuhan. It is also imperative to keep track of Ghanaians in China, providing them support as well as knowing when they return.</p>
<p><strong>What systems, already in place to deal with Ebola, will come in handy? What more needs to be done?</strong></p>
<p><strong><em>Abdhalah Ziraba, Kenya:</em></strong> Airport public health officials have got better at screening at ports of entry, especially for international arrivals. Basic screening is done using thermal cameras to detect fever. Kenyan officials have the equipment in hand and the trained personnel to swing into action fast.</p>
<p>Public health officials need to vigilant and have a high index of suspicion to be able to identify potential cases. They will then be able to flag travellers who seem unwell, more so if they have a matching travel history. </p>
<p>To support their work, public health authorities also need to mobilise a rapid surveillance and response team so that they can manage any suspected cases- including taking samples, isolation and reporting on developments.</p>
<p><strong><em>Peter Kojo Quashie, Ghana</em>:</strong> <a href="https://www.newsghana.com.gh/ghanas-main-airport-on-high-alert-over-coronavirus-outbreak/">Temperature</a> screening protocols have been in place since the onset of the 2014 Ebola crisis. I believe they need to be revisited to screen at a lower threshold (for example temperature > 37.5C) to avoid missing patients who are just beginning to show signs of the disease. </p>
<p>Scientists in the national influenza control lab at the University of Ghana have written standard operating procedures and testing protocols to allow for rapid laboratory detection of this new virus. This effort, in collaboration with Ghana Health Service, the <a href="http://www.africacdc.org/">Africa Centres for Disease Control and Prevention</a> and the West African Health Organisation, has been ongoing since the virus was first detected. </p>
<p>Steps that were effective during the Ebola crisis and helped reduce the spread of the virus included hand washing, as well as educating the public about what precautions they have to take for their personal and public health. </p>
<p><strong>What lessons can African countries bring to bear given their experience of handling outbreaks like Ebola?</strong></p>
<p><strong><em>Abdhalah Ziraba, Kenya</em>:</strong> Many countries are now readying themselves to mount a response bringing together specialists and other players from different sectors with centralised coordinating. Several countries also have epidemic outbreak response plans in place, as well as resources and facilities to deal with situations like this. But the comprehensiveness of these varies greatly. </p>
<p>Finally, with lessons from the Ebola, SAR and MERS outbreaks, there is a greater ability to coordinate a response and to keep the public accurately informed. This prevents a panic situation that often fuels the spread of outbreaks. Public health authorities are now more likely to avoid knee jerk interventions not supported by evidence. These can often be counterproductive, as was the case with the <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61412-4/fulltext">Ebola outbreak in West Africa</a>.</p>
<p><strong><em>Peter Kojo Quashie, Ghana</em>:</strong> There are significant differences between the Ebola virus and this coronavirus. First, the spread of Ebola was limited to villagers who crossed border freely, health workers, and a few immigrants who visited their villages and then returned. Second, it is transmissible by bodily fluids, and requires direct contact with an infected individual or surface.</p>
<p>If the latest coronavirus virus is transmitted like MERS or SARS, then it transmits like a <a href="https://foreignpolicy.com/2020/01/26/2019-ncov-china-epidemic-pandemic-the-wuhan-coronavirus-a-tentative-clinical-profile/">the common cold</a>. It is therefore likely to be much more <a href="https://foreignpolicy.com/2020/01/26/2019-ncov-china-epidemic-pandemic-the-wuhan-coronavirus-a-tentative-clinical-profile/a">infectious than Ebola</a>. </p>
<p>Fortunately, the preparedness of most African countries were not tested during the West African Ebola epidemic. Unfortunately, that means infection control protocols were never challenged. </p>
<p>In terms of a rapid laboratory diagnosis, we have protocols in place and skilled laboratory personnel. But we have to effectively isolate the risk. That’s the part that must continuously be worked on and reworked. </p>
<p>We should look at how countries like Canada managed to <a href="https://www.ncbi.nlm.nih.gov/books/NBK92467/">track down infected people</a> and keep the SARS epidemic in check in 2003. In addition, the WHO protocols published <a href="https://www.who.int/csr/resources/publications/WHO_CDS_CSR_ARO_2004_1/en/">in 2004 for SARS</a> will be more effective than protocols for Ebola. Lessons learned from the still ongoing <a href="https://www.who.int/emergencies/mers-cov/en/">MERS epidemic</a> would be useful, as well as understanding the issues of stigma and cultural issues that are the main challenges of the response to Ebola in Africa.</p>
<p>Other things to consider are the fact that, unlike SARS and unlike Ebola, there are <a href="https://www.sciencemediacentre.org/expert-reaction-to-news-reports-that-the-china-coronavirus-may-spread-before-symptoms-show/">reports</a> that patients infected with 2019-nCoV are infectious even during the incubation period, before they get a fever. This would mean that temperature screening won’t work. What would be required is stronger, and different, terminal and individualised screening.</p>
<p>But there are a few recommendations for personal safety that were effective during the SARS and Ebola outbreak. These included avoiding large crowds and stuffy areas as well as not shaking hands. Health sector workers should used enhanced personal protective equipment and change gloves regularly. Finally, masks can help. But they should be changed regularly and disposed of safely.</p>
<p>Lastly, if you have cold or flu-like symptoms and have been in contact with travellers from China, alert public health officials and avoid non-essential contact with others.</p><img src="https://counter.theconversation.com/content/130488/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Airport public health officials have got better at screening at ports of entry especially for international arrivals.Abdhalah Ziraba, Research Scientist, African Population and Health Research CenterPeter Kojo Quashie, Senior Research Fellow, West African Institute for Cell Biology of Infectious Pathogens, University of GhanaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1219912019-08-21T12:57:07Z2019-08-21T12:57:07ZWhy the DRC Ebola outbreak was declared a global emergency and why it matters<figure><img src="https://images.theconversation.com/files/288869/original/file-20190821-170946-fmp18c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> </figcaption></figure><p>In mid-July the WHO declared the Ebola epidemic in the Democratic Republic of Congo (DRC) a <a href="https://www.who.int/news-room/detail/17-07-2019-ebola-outbreak-in-the-democratic-republic-of-the-congo-declared-a-public-health-emergency-of-international-concern">Public Health Emergency of International Concern</a>. At the time over 2000 cases had been reported. A factor that <a href="https://www.who.int/ihr/procedures/statement-emergency-committee-ebola-drc-july-2019.pdf">is likely to have influenced the decision</a> was that a new case had been noted near Goma near the border with Rwanda. The fear was that the disease would spread through Goma, a city of 2 million people, and that it would rapidly cross into Rwanda, Uganda and Burundi.</p>
<p>The decision was taken by the International Health Regulations Emergency Committee. It made its decision at the fourth meeting it had held since the DRC epidemic began a year ago. </p>
<p>Global efforts to manage epidemics are documented as far back as <a href="https://www.historytoday.com/archive/black-death-greatest-catastrophe-ever">the black plague in Europe in the 14th century</a>, where borders were monitored for infections. Since that time, rules have been developed and honed to keep up with the emergence of new diseases as well as with the growing complexities of a world that’s increasingly connected through travel and trade.</p>
<p>An epidemic refers to a specific pattern of exponential growth in infections – above the usual expected occurrence – over a short time frame, usually days or weeks. Epidemics have an acutely disruptive and immediate impact that requires urgent attention. </p>
<p>Ebola is an example. Any delay in response can be critical because of the exponential growth in case numbers. This was seen during the outbreak in West Africa in 2014. In March there were only hundreds of cases. Within months the number had spiked to over <a href="https://jglobalbiosecurity.com/articles/36/">28,000</a>. Most could have been prevented if there had been a more immediate response. </p>
<p>Other diseases such as malaria or HIV can affect large numbers of people too, but are not epidemic diseases. Changes to these endemic infections occur more slowly, typically over years.</p>
<p>Measles is another epidemic disease. Even though there’s a cheap and effective vaccine and vaccination rates are high in many countries, it remains a leading killer in the world. <a href="https://www.sciencedirect.com/science/article/pii/S0264410X18308387?via%3Dihub">Outbreaks</a> continue to occur in low and high income settings. So why hasn’t it been declared a public health emergency of international concern? </p>
<p>The seriousness of an epidemic is a function of several factors. These <a href="https://www.sciencedirect.com/science/article/pii/S002074891400234X">include</a> the degree of contagiousness and potential for rapid spread, severity of infection, case fatality rate (the number of infected people who die), availability of vaccines or treatment, impact on travel and trade, and the socioeconomic context. </p>
<p>Measles is in fact much more contagious than Ebola. But the case fatality rate is much lower – 0.2% compared to 50%-90% for Ebola. </p>
<p>The context of the epidemic also matters. For example the risk from Ebola <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/risa.12876">was much higher in West Africa</a> in 2014 where the case fatality rate was over <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61706-2/fulltext">70%</a>, compared to only 20% in the US where high quality healthcare was available. </p>
<p>So, the combination of a serious epidemic disease such as Ebola, with a high case fatality rate, occurring in a low income setting beset by conflict, as well as the risk of spread to other countries, would have influenced the WHO decision on Ebola in the DRC. Perhaps the delay in making the decision in the 2014 in West Africa – now recognised <a href="https://jglobalbiosecurity.com/articles/36/">as a missed opportunity</a> – may also have been a consideration.</p>
<h2>What it triggers</h2>
<p>Declaration of a “public health emergency of international concern” by the WHO triggers a number of things. </p>
<p>The first is that it signals a commitment to provide international resources for the response. </p>
<p>The second is that it enables other provisions of the <a href="https://www.who.int/features/qa/emergency-committees/en/">International Health Regulations</a>. These originated from the International Sanitary Regulations of <a href="https://apps.who.int/iris/handle/10665/85636">the mid 1900s</a>, which were used to control cholera epidemics. At this time, there was increasing awareness of the social and economic affects of epidemic diseases across borders, as well as concern about undue interference with trade. </p>
<p>In 1969 the regulations were <a href="https://www.who.int/ihr/current/en/">renamed</a> the “International Health Regulations” by the World Health Organisation. They were then modified in 1973 and 1981. But even then they provided a framework for only 3 diseases – cholera, yellow fever and plague. The principles behind them was </p>
<blockquote>
<p>maximum security against the international spread of diseases with a <a href="https://www.who.int/trade/distance_learning/gpgh/gpgh8/en/index7.html">minimum interference with world traffic</a>. </p>
</blockquote>
<p>In 1995, formal revision commenced to expand the scope of the regulations with six proposed categories of <a href="https://www.asil.org/insights/volume/8/issue/8/revision-world-health-organizations-international-health-regulations">reportable syndromes</a>: </p>
<ul>
<li><p>acute haemorrhagic fever syndrome,</p></li>
<li><p>acute respiratory syndrome, </p></li>
<li><p>acute diarrhoeal syndrome, </p></li>
<li><p>acute jaundice syndrome, </p></li>
<li><p>acute neurological syndrome, and </p></li>
<li><p>other notifiable syndromes. </p></li>
</ul>
<p>In addition, five factors were proposed to determine if a cluster of syndromes was urgent and of international importance. These were rapid transmission in the community, unexpectedly high case fatality ratio, a newly recognised syndrome, high political and media profile, and trade or travel restrictions. </p>
<p>The last revision to the regulations was done in 2005 following the <a href="https://www.asil.org/insights/volume/8/issue/7/sars-and-international-law">SARS epidemic of 2003</a>.</p>
<p>The five substantive changes from the prior version were: </p>
<ul>
<li><p>a dramatic expansion of the scope of the regulations,</p></li>
<li><p>the creation of obligations on states to develop minimum core surveillance and response capacities,</p></li>
<li><p>granting WHO the authority to access and use non-governmental sources of surveillance information,</p></li>
<li><p>granting WHO the power to declare a public health emergency of international concern and to issue recommendations on how states-parties deal with it; and </p></li>
<li><p>the <a href="https://www.repository.law.indiana.edu/cgi/viewcontent.cgi?article=1399&context=facpub">incorporation of human rights</a> concepts into the implementation of the regulations.</p></li>
</ul>
<p>The regulations set down how an emergency will be managed. This includes setting up a roster of experts appointed by the Director General of WHO in all relevant fields of expertise. Then an emergency committee is drawn from this roster for advice. The committee has to decide on a range of issues to do with managing the epidemic. This includes whether an event constitutes a global emergency and when it should be ended.</p>
<p>But the regulations can only go so far. Many countries cannot comply with them due to lack of resources. And their contribution to controlling the 2014 Ebola outbreak is unclear, as it was invoked <a href="https://www.who.int/mediacentre/news/statements/2014/ebola-20140808/en/">late in the epidemic</a>. </p>
<p>Since the Ebola epidemic of 2014 the regulations have only been invoked twice, for the <a href="https://www.who.int/ihr/emergency-committee-zika/en/">Zika virus epidemic</a> in 2016 and for the Ebola epidemic in DRC in 2019. </p>
<p>In the case of Zika virus, case fatality was low. But the decision to declare a global emergency was <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00320-2/fulltext">because there was so much that wasn’t known</a> about birth defects and neurological illness caused by the virus.</p>
<h2>More than a health issue</h2>
<p>Many of the problems of global emergencies are not specific health problems, but relate to civil society, community engagement, law and order and border control. In the 2014 Ebola epidemic, for example, a health promotion team <a href="https://www.washingtonpost.com/news/to-your-health/wp/2014/09/18/missing-health-workers-in-guinea-were-educating-villagers-about-ebola-when-they-were-attacked/">was massacred in Guinea</a> because local people were fearful of outsiders coming to their village. </p>
<p>Similar issues have arisen in the DRC, including <a href="https://www.theguardian.com/global-development/2019/feb/28/arsonists-attack-ebola-clinics-in-drc-as-climate-of-distrust-grows">burning down</a> of treatment centres in Katwa and Butembo. </p>
<p>This highlights the importance of grassroots community empowerment and mobilisation, engagement of local leaders, cultural sensitivity and risk communication in epidemic response. </p>
<p>The environment of violence, conflict and lack of trust surrounding the current epidemic would no doubt have been part of the deliberations of the WHO expert committee. The decision to declare a public health emergency of international concern in July 2019 when there were around 2000 cases was prudent given the lessons learned after delaying the declaration of the 2014 epidemic.</p><img src="https://counter.theconversation.com/content/121991/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>C Raina MacIntyre currently receives funding from NHMRC, including a Centre for Research Excellence and a Principal Research Fellowship. She has received funding or in-kind support for investigator driven research from Sanofi, Seqirus, Pfizer and Merck. She has received sponsorship for workshops from Emergent Biosolutions, Bavarian Nordic, Siga Technologies and Meridien Medical Technologies. </span></em></p><p class="fine-print"><em><span>Obijiofor Aginam was a recipient of the Social Sciences and Humanities Research Council (SSHRC) of Canada grant (2005-2008); Social Science Research Council (SSRC) of New York grant (2004-2005).</span></em></p>Timing is everything when it comes to making a decision about declaring a disease outbreak a public health emergency of international concern.C Raina MacIntyre, Professor of Global Biosecurity, NHMRC Principal Research Fellow, Head, Biosecurity Program, UNSW SydneyObijiofor Aginam, Deputy-Director & Head of Governance for Global Health, International Institute for Global Health (UNU-IIGH), United Nations UniversityLicensed as Creative Commons – attribution, no derivatives.