Fifth Meeting of the International Health Regulations (2005) (IHR) Emergency Committee on the Multi-Country Outbreak of mpox (monkeypox)

The WHO Director-General transmits the report of the fifth meeting of the International Health Regulations (2005) (IHR) Emergency Committee regarding the multi-country outbreak of mpox (monkeypox), held on Wednesday 10 May from 12:00 to 17:00 CET.

The Emergency Committee acknowledged the progress made in the global response to the multi-country outbreak of mpox and the further decline in the number of reported cases since the last meeting. The Committee noted a significant decline in the number of reported cases compared to the previous reporting period and no changes in the severity and clinical manifestation of the disease. The Committee acknowledged remaining uncertainties about the disease, regarding modes of transmission in some countries, poor quality of some reported data, and continued lack of effective countermeasures in the African countries, where mpox occurs regularly. The Committee considered, however, that these are long-term challenges that would be better addressed through sustained efforts in a transition towards a long-term strategy to manage the public health risks posed by mpox, rather than the emergency measures inherent to a public health emergency of international concern (PHEIC).

The Committee emphasised the necessity for long-term partnerships to mobilize the needed financial and technical support for sustaining surveillance, control measures and research for the long-term elimination of human-to-human transmission, as well as mitigation of zoonotic transmissions, where possible. Integration of mpox prevention, preparedness and response within national surveillance and control programmes, including for HIV and other sexually transmissible infections, was reiterated as an important element of this longer-term transition. In particular, the Committee noted that the gains in control of the multi-country outbreak of mpox have been achieved largely in the absence of outside funding support and that longer-term control and elimination are unlikely unless such support is provided. These sustained investments will, in the long run, save money and lives, and reduce the risk of a global resurgence of mpox, as well as the risk of reverse zoonosis resulting in new areas where the virus may circulate.

The WHO Director-General expresses his gratitude to the Chair, Members, and Advisors for their advice and concurs with this advice that the event no longer constitutes a PHEIC for the reasons detailed in the proceedings of the meeting below and issues revised Temporary Recommendations for the transition period, which are presented at the end of this document.

Proceedings of the fifth meeting of the IHR Emergency Committee

The fifth meeting of the IHR Emergency Committee on the multi-country outbreak of mpox was convened by videoconference, with the Chair and Vice-Chair being present in person at WHO headquarters, in Geneva, Switzerland. Eleven of the fifteen Members and five of the nine Advisors to the Committee participated in the meeting.

In his opening remarks, the WHO Director-General welcomed the Committee, and noted a sustained decline in cases globally, with almost 90% fewer cases reported in the last three months, compared with the previous three months. The Director-General also noted that, while there is a downward trend globally, the virus continues to transmit in certain communities. He further stressed the importance for countries to maintain their surveillance and response capacities, and to continue to integrate mpox prevention and care into existing national health programmes to address future outbreaks.

The Office of Legal Counsel’s representative briefed the Committee Members and Advisors on their roles, responsibilities, and mandate under the relevant articles of the IHR. The Ethics Officer from the Department of Compliance, Risk Management, and Ethics reminded Members and Advisors of their duty of confidentiality as to the meeting discussions and the work of the Committee, as well as their individual responsibility to disclose to WHO in a timely manner any interests of a personal, professional, financial, intellectual or commercial nature that may give rise to a perceived or direct conflict of interest.

The meeting was handed over to the Chair of the Emergency Committee, Dr Jean-Marie Okwo-Bele, who introduced the objectives of the meeting: to provide views to the WHO Director-General as to whether the multi-country outbreak of mpox continues to constitute a PHEIC, and, if so, to review the proposed Temporary Recommendations to States Parties. 

Presentations 

Representatives of Japan, Nigeria and the United Kingdom of Great Britain and Northern Ireland provided updates on the current epidemiological situation in their countries and on the public health measures being implemented.

The Secretariat provided a comprehensive update on the epidemiological situation and the current response efforts, with the WHO Region of Africa providing an additional regional update. The WHO Region of Africa reported that more than 1500 cases were confirmed since January 2022 in 13 countries, with the majority of these cases being reported from Nigeria and the Democratic Republic of the Congo. There was little information on modes of transmission and the quality of reported data through the surveillance systems was uneven in the African Region. 

The Secretariat informed that the current global risk of the mpox multi-country outbreak is assessed as remaining moderate globally and in four of the WHO regions and remaining low in South-East Asia and the Western Pacific Regions. Further details can be found in the 22nd External situation report. All data are available, and case counts are updated weekly at this link - 2022 Monkeypox Outbreak: Global Trends.

The Secretariat further informed the Committee that the WHO Monkeypox Strategic preparedness, readiness and response plan will come to an end in June 2023, and that there are plans to develop a long-term strategy for the control and eventual elimination of human-to-human transmission, and mitigating the zoonotic transmission where it occurs, along with a country planning guide to support the implementation of this strategy.

After the presentations, Committee Members and Advisors proceeded to engage the Secretariat and the presenting countries in a question-and-answer session.

Deliberative session

The Committee reconvened in a closed meeting to examine the questions in relation to whether the event continues to constitute a PHEIC, and to advise on the proposed Temporary Recommendations, in accordance with IHR provisions.

The Committee acknowledged the continued progress since the last meeting in reducing the number of cases and deaths, and the lack of significant changes in the demographics and severity of clinical manifestations, with the major factors contributing to deaths and severity continuing to be related to untreated HIV infections and immunosuppression. The Committee, however, recognized some remaining concerns, including duration of immunity following infection or vaccination, with breakthrough infections in fully vaccinated persons and cases of reinfection; insufficient evidence about vaccine effectiveness; and the poor quality of data and inconsistency in reporting of cases to WHO, particularly in countries where the disease occurs regulalry.

The Committee also noted no changes in the risk assessment since the last meeting. Some uncertainties were raised regarding the potential impact of upcoming large social gatherings among high-risk groups, although it was noted that such gatherings held in some countries during the last year and recently did not lead to spikes in the number of cases. In addition, it was noted that some regions have started to develop post-emergency plans and have begun integration of the response into sexually transmissible infection programs.

The Committee expressed concerns about the persisting knowledge gaps related to mpox in Africa, the lack of access to vaccines, medicines, and diagnostic testing capacities in many low-income countries; the recurring zoonotic transmission in Africa; and the fact that not all countries are receiving the support they need or have structures or systems to respond to mpox, including inadequate support for marginalized groups.

In conclusion, having considered the significant decline in the global spread of mpox and the gains achieved in the control of the outbreak in many countries, the Committee advised that the event requires a transition from a PHEIC to a robust, proactive and sustainable mpox response and control program, that prevents resurgence of global spread, aims to eliminate person-to-person transmission, and mitigates the impact of local spill-over effects. The Committee emphasized the need for long-term attention and support, including financial support, particularly for countries where mpox occurs regularly, and advised that Standing Recommendations under the IHR would now be a more appropriate tool to manage the immediate, short and long-term public health risks posed by mpox.

The Committee emphasized the need to rally partners and resources for a sustained WHO-led strategy to improve surveillance, research and control measures, and to prioritize and invest in African countries and other underserved communities where mpox readiness and response efforts still remain inadequate. These investments should target surveillance, laboratory testing, data quality, access to vaccines and therapeutics, risk communication and community engagement, and research, among other identified gaps

 The Committee provided advice on the draft Temporary recommendations, with the understanding that such Temporary recommendations may continue to be issued by the WHO Director-General if needed after the termination of the PHEIC. The Committee also emphasized the need for IHR States Parties to strengthen their commitments and accountability in the implementation of the temporary recommendations. Further, the Committee recommended vigilance about any new, significant event or the emergence of new knowledge that might require reconsidering mpox as a PHEIC.

Temporary Recommendations issued by the WHO Director-General in relation to the multi-country outbreak of mpox

These Temporary Recommendations continue to support the goal of the WHO Strategic Preparedness, Readiness and Response Plan for Monkeypox 2022–2023 and WHO operational guidelines to stop the outbreak and meet the objectives to interrupt human-to-human transmission, protect the vulnerable, and minimize zoonotic transmission of the virus.

Any State Parties may experience importation or local transmission of mpox and some States Parties may also be experiencing zoonotic transmission. These Temporary Recommendations apply to all States Parties in all stages of mpox readiness or response, as outlined in previous sets of Temporary Recommendations, in order to further support mpox control and eventual elimination of human-to-human transmission. States Parties in a position to support scaling up access to medical countermeasures in low- and middle-income countries should continue to do so.

In implementing these Temporary Recommendations, States Parties should ensure full respect for the dignity, human rights and fundamental freedoms of persons, in line with the principles set out in Article 3 of the IHR. The WHO advises States Parties to maintain readiness and response capacity in collaboration with key communities, partners and other stakeholders through a One Health approach. 

To meet the objectives above, States Parties should:

1. Sustain and promote key elements of the mpox response strategy and review their experience to inform public health policies, programmes and actions.
2. Develop and implement integrated mpox control plans and an elimination strategy with the aim of preventing and stopping human-to-human transmission and/or mitigating zoonotic transmissions, as appropriate.
3. Maintain epidemiological surveillance of mpox, making every effort to ensure laboratory confirmation of suspected cases and reporting to WHO of confirmed and probable cases, according to variables defined in the WHO Case Reporting Form.  
4. Report immediately all confirmed travel-related mpox cases to WHO through channels established under IHR provisions.
5. Integrate mpox detection, prevention, care and research with existing and innovative HIV and sexually transmitted disease prevention and control programmes, and other health services as appropriate. 
6. Sustain and invest in risk communication and community support and engagement for affected communities and at-risk groups, including through health authorities and civil society.
7. Continue to implement interventions to avoid stigma and discrimination against any individuals or group that may be affected by mpox.
8. Support and enhance access to diagnostics, vaccines and therapeutics to advance global health equity, in particular for most affected communities worldwide, including gay, bisexual and other men who sex with men, with special attention to those most marginalized within those groups, and in resource-constrained countries where mpox is endemic.
9. Continue to strengthen diagnostic capacity, decentralized access to testing, and genomic sequencing, including sharing of genetic sequence data through public databases.
10. Continue to make vaccines available for primary preventive (pre-exposure) and post-exposure vaccination for persons and communities at high risk of mpox.  
11. Ensure provision of optimal clinical care with infection prevention and control measures in place for suspected or confirmed mpox in all clinical settings. Ensure training of health care providers accordingly.
12. Strengthen capacity in resource-limited and rural settings where mpox continues to occur, to better understand modes of transmission, quantify resource needs, and respond to outbreaks and sustained chains of transmission.
13. Implement a coordinated research agenda to generate and promptly disseminate evidence for key scientific, social, clinical and public health aspects of mpox prevention and control. Continue clinical trials of medical countermeasures, including vaccines, therapeutics, and diagnostics, in different populations, in addition to monitoring of vaccine safety, effectiveness and duration of protection from infection and vaccination. 
14. Countries in West, Central and East Africa where mpox is endemic should make additional efforts to elucidate mpox-related risk, vulnerability and impact and to investigate, understand and control mpox in their respective settings, including the consideration of zoonotic, sexual and other modes of transmission in different demographic groups.

Detailed Temporary Recommendations issued on 15 February 2023 following the 4^th IHR Emergency Committee meeting remain technically valid for all States Parties. All current WHO interim technical guidance and WHO operational guidance can be found on the WHO website. To follow on from the existing Strategic Preparedness, Readiness and Response Plan, WHO will release an overarching global strategy and new country planning guide for mpox elimination and control.