Following the International Health Regulations (2005) (IHR) on disease outbreaks, the World Health Organization (WHO) has declared monkeypox a global health concern, thus giving temporary recommendations to curtail the spread.

WHO Director-General Tedros Adhanom made the declaration at the second Emergency Committee meeting on the multi-country outbreak held on Thursday, 21 July 2022.

Tedros said the multi-country outbreak of monkeypox constitutes a Public Health Emergency of International Concern noting that adequate implementation of the recommended Temporary measures will enhance member countries’ commitment to deal with the menace.

“The multi-country outbreak of monkeypox meets all the three criteria defining a PHEIC contained in Article 1 of the Regulations (1. an extraordinary event […] 2. constitut[ing] a public health risk to other States through the international spread of disease 3. which may potentially require a coordinated international response);

• The moral duty to deploy all means and tools available to respond to the event, as highlighted by leaders of the LGBTI+ communities from several countries, bearing in mind that the community currently most affected outside Africa is the same initially reported to be affected in the early stages of HIV/AIDS pandemic;

• The observed rising trends in the number of cases reported globally, in an increasing number of countries, and, yet, likely to reflect an underestimation of the actual magnitude of the outbreak(s);

• The cases of monkeypox reported in children and pregnant women, are reminiscent of the initial phases of the HIV pandemic;

• Future waves of monkeypox cases are expected as the monkeypox virus is introduced in additional susceptible populations;

• The modes of transmission sustaining the current outbreak are not fully understood;

• The changes in the clinical presentation of cases of monkeypox currently observed with respect to the clinical picture known to date;

• The need to generate further evidence related to the effectiveness of the use of both, pharmaceutical and non-pharmaceutical measures in controlling the outbreak;

• The significant morbidity associated with the monkeypox outbreak(s);

• The potential future implications on public health and health services if the disease were to establish itself in the human population across the world, particularly for an orthopoxvirus causing human disease, as global immunity has greatly declined after smallpox was eradicated;

The perceived benefits associated with the prospective determination of a PHEIC include:

• Maintaining a heightened level of awareness and alert, which would increase the probability of stopping human-to-human transmission of monkeypox virus;

• Boosting political commitment towards response efforts; Increasing opportunities for funds to be released for the response, and research purposes, as well as for the mitigation of the socioeconomic impact of the disease;

• Boosting international coordination of response efforts, in particular, to secure equitable access to vaccines and antivirals;

• The possible stigmatization, marginalization, and discrimination that may result from the prospective determination of a PHEIC should not be regarded as a deterrent to doing so and would need to be addressed.

Committee Members’ views NOT in support of the prospective determination of a PHEIC

• The overall global risk assessment presented by the WHO Secretariat remained unchanged with respect to that presented to the Committee on 23 June 2022;

• The greatest burden of the outbreak is currently reported in 12 countries in Europe and in the Americas, with no indications, based on currently available data, of an exponential increase in the number of cases in any of those countries, and early signs of stabilization or declining trends observed in some countries;

• The vast majority of cases are observed among MSM with multiple partners, and, despite the operational challenges, there is the opportunity to stop ongoing transmission with interventions targeted to this segment of the population. Cases observed beyond this population group, including among health workers are, to date, limited;

• The severity of the disease is perceived to be low;

• The epidemic is gaining maturity, with future waves expected, and clearer indications about the effectiveness of policies and interventions are being generated;

The potential risks of hampering response efforts through the prospective determination of a PHEIC are perceived as outweighing the benefits of the latter for the following reasons:

• The stigma, marginalization, and discrimination that a determination of a PHEIC may generate against the currently affected communities, especially in countries where homosexuality is criminalized, LGBTI+ communities are not well established and engaged in a dialogue with governments. Communities in some countries have reportedly indicated that minimizing stigma associated with monkeypox – which unlike HIV infection may be a visible condition– requires developing novel approaches, which could be challenging in the context of a PHEIC;”

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