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Health


IS WHO READY TO END THE GLOBAL HEALTH EMERGENCY OVER COVID? MAYBE NOT JUST YET

 * 

By Helen Branswell Jan. 25, 2023

Reprints
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From left, Michael Ryan, Tedros Adhanom Ghebreyesus, and Maria Van Kerkhove of
the WHO attend a daily Covid-19 press briefing at the organization's Geneva
headquarters in March 2020, just weeks after the WHO declared a PHEIC. FABRICE
COFFRINI/AFP via Getty Images
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Three years ago, the World Health Organization declared that the mushrooming
outbreak of a new coronavirus — later named SARS-CoV-2, the cause of Covid-19 —
posed such a threat to global health that it merited designation as a public
health emergency of international concern.

On Friday, an emergency committee will meet again to deliberate whether the time
has come to recommend to WHO Director-General Tedros Adhanom Ghebreyesus that he
declare the global health emergency is over. The final decision rests with
Tedros, who generally — though not always — follows the advice of WHO emergency
committees.

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This gathering, the committee’s 14th, comes as Covid rips for the first time
through the world’s most populous nation, after China lifted the draconian “zero
Covid” policy that kept the virus at bay for nearly three years. That factor
alone could persuade the committee that this is not the time to advise Tedros to
call an end to the PHEIC, a designation that grants the WHO director-general
certain powers, including the ability to issue recommendations for how countries
should respond.

On Tuesday Tedros hinted he doesn’t feel the time is right, noting that Covid
deaths are on the rise again globally. Over the past eight weeks, more than
170,000 such deaths have been reported, he said, adding that figure is certainly
an underestimate.

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“While I will not preempt the advice of the emergency committee, I remain very
concerned by the situation in many countries and the rising number of deaths,”
the director-general said during the WHO’s weekly press briefing. “While we’re
clearly in better shape than three years ago when this pandemic first hit, the
global collective response is once again under strain.”

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Whatever the decision Friday — which likely won’t be revealed until Monday —
outside experts acknowledge the Covid pandemic may no longer strictly meet the
criteria for a PHEIC (pronounced “fake”).

Under the International Health Regulations (IHR), a binding international
treaty, a public health emergency of international concern can be declared in
the face of a health event that meets three criteria: it is serious, sudden,
unusual, or unexpected; it has the potential to spread across borders; and it
may require a coordinated international response.

Covid is still serious, but sudden, unusual, or unexpected? Not any more.
Borders have been crossed; the virus has spread planet-wide. At this point in
the pandemic, international responses are being wound down.

Still, Tom Bollyky, director of the global health program at the Council on
Foreign Relations, doesn’t expect quick action on terminating the PHEIC. He
suspects the WHO may end the Covid PHEIC in 2023 — but not now.

“I think they will be particularly slow here, given a still quite high death
toll, given what’s happening in China,” Bollyky said, noting that in the past,
the WHO hasn’t been quick to end PHEICs.


RELATED: FDA SCIENTISTS PROPOSE AN ANNUAL COVID SHOT MATCHED TO CURRENT STRAINS

The emergency committee itself has indicated, though, that it is thinking about
how to land the plane. The committee has met a dozen times since the Covid-19
PHEIC was declared on Jan. 30, 2020; the reports of 11 of those meetings
stressed there was unanimous agreement among committee members of the ongoing
need for a PHEIC. In the report of its most recent meeting in October, there was
no mention of “unanimous” agreement that the pandemic still constituted a PHEIC.

At the October meeting, the expert panel asked the WHO staffers who assist it to
set up a session at which it could discuss how a PHEIC could be terminated
safely. In particular, it asked for advice on potential negative consequences of
ending the PHEIC, and whether WHO could still issue temporary recommendations to
countries on how to respond to Covid once the PHEIC was over. The IHR gives WHO
the power to issue temporary recommendations to countries while a PHEIC is
underway, for example, recommending countries not put cross-border travel
restrictions in place. In theory those recommendations are binding, but in
reality the treaty has no enforcement mechanism and countries can and do ignore
the recommendations, as the United States did recently when it instituted a
requirement that travelers from China produce a negative Covid test to enter the
country.

The discussion on how to safely end a PHEIC will take place Friday, in
conjunction with the meeting of the emergency committee, WHO spokesperson Tarik
Jašarević told STAT. “It is an informal technical discussion of the committee
with the secretariat on the criteria for terminating the PHEIC.”

One of the problems for this committee, and for the WHO, is that while there are
guidelines for when a PHEIC may be declared, there are none for when one should
be ended.

“There is certainly no defined pathway for when a PHEIC is no more a PHEIC,”
said Preben Aavitsland, state epidemiologist at the Norwegian Institute of
Public Health.

Since the tool was created, seven PHEICs have been declared: for the H1N1 flu
pandemic in 2009; the large West African and North Kivu Ebola outbreaks; the
Zika outbreak; the international mpox outbreak; and the Covid pandemic. In 2014,
when rising case counts appeared to threaten the decades-old effort to eradicate
polio, a PHEIC was declared for polio, which remains in place to this day.


RELATED: COVID’S WINTER SURGE IS POISED TO EXCEED SUMMER PEAK

Most of the earlier PHEICs were called in response to disease events where
transmission was eventually stopped, making it easier to know when to declare an
ending, Aavitsland said. (Even though the 2009 flu pandemic virus did not
disappear, it settled into a seasonal circulation pattern within about 15 months
of its initial detection. The H1N1 pandemic was declared a PHEIC on April 25,
2009; the PHEIC was ended on Aug. 10, 2010.)

The Covid situation is markedly different, with the virus still causing high
numbers of deaths — averaging about 600 a day in the U.S. alone at this point.
The rapid-fire evolution of the virus, with a succession of variants and
subvariants that have eroded the protection against infection created by
vaccine-derived and infection-induced immunity, also gives pause to people
trying to assess where we stand with this new virus.

“With major Ebola outbreaks it’s easy. The PHEIC ends when the outbreak is over.
This outbreak, however, does not disappear. The virus is here to stay,”
Aavitsland said.

Still, he believes it is past time to end the Covid PHEIC.

“What will change between now and the next [emergency committee] meeting in
April? And the meeting after? Several hundred millions Chinese will be infected
for the first time. Several hundred millions Americans, Europeans, Africans, and
Asians will be infected for the second or third time. And so on. There’s no need
to wait,” Aavitsland said.

David Heymann, a professor of infectious diseases epidemiology at the London
School of Hygiene and Tropical Medicine, also believes the need for a PHEIC for
Covid may have passed.

Heymann, who spent two decades at the WHO, was the chair of the emergency
committee that was set up to advise the global health agency on the Zika
outbreak of 2015-2016. That PHEIC is the shortest on record, having been wound
down in just under 10 months.

“When we understood that WHO had a control mechanism in place for Zika, and when
they had an advisory group that could handle Zika recommendations for them, we
felt that the public health emergency of international concern was over,”
Heymann said.


RELATED: DEATH CERTIFICATE RECORDS OF LONG COVID ARE A ‘FLOOR OF AN ESTIMATE,’
EXPERTS SAY

Is there any rationale for prolonging the Covid PHEIC? “Based on the criteria
that the committee that I chaired used, no,” he said. “I cannot see the reason
to continue it.”

Ending the PHEIC would not be a declaration that Covid no longer poses a threat
to the world, nor would it constitute a declaration by the WHO that the pandemic
is over.

In fact, there is unlikely to be a declaration of the end of the pandemic — not
now, not later. The International Health Regulations do not include provisions
for a formal declaration of a pandemic and they don’t have a mechanism for
declaring that one has ended. Though many experts and news outlets around the
world — including STAT — interpreted a March 11, 2020, acknowledgement by Tedros
that a pandemic was underway as a formal declaration, in reality the WHO does
not declare that a pandemic has started nor does it signal when one has ended,
Maria Van Kerkhove, the agency’s leading coronavirus expert, told STAT. “We
don’t declare pandemics,” she said.

The PHEIC also does not confer on the WHO powers that are similar to those that
the U.S. federal government acquired when it declared the new virus a national
public health emergency in January 2020.

(Health and Human Services Secretary Xavier Becerra renewed the public health
emergency declaration on Jan. 11, the 13th extension of the provision. It is
widely expected the latest extension will be the last, and that Becerra will
announce in early February that the federal government will allow the emergency
status to lapse on April 11.)

“What the PHEIC is largely meant to do is to prompt and empower nation states to
act. It’s meant to raise an alarm, to inspire action,” Bollyky said. “What the
public health emergency designation is meant to do in the U.S. is empower the
federal government to act. … So they’re just fundamentally different in that
regard. Having a PHEIC does not empower WHO to do much.”

Why keep it in place then? “It gives them political coverage that they’re taking
this seriously,” he said.

Amanda Glassman, executive vice president of the Center for Global Development,
said in her view, the decision of the emergency committee on Friday could go
either way. But regardless of what the group decides, she said, one thing has
been made clear by the Covid pandemic — the PHEIC mechanism needs an overhaul.

“The whole binary nature of the PHEIC, yes or no, is fundamentally unsuited to
the evolution of these diseases and these events,” she said, noting that the
tool doesn’t appear to be doing what it was designed to do.

“The PHEIC did not help us coordinate policy,” Glassman said. “I think later, we
should reflect on this mechanism, and whether it’s doing what it’s supposed to
do in the first place.”

Get your daily dose of health and medicine every weekday with STAT’s free
newsletter Morning Rounds. Sign up here.

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ABOUT THE AUTHOR REPRINTS


HELEN BRANSWELL

Senior Writer, Infectious Diseases

Helen Branswell covers issues broadly related to infectious diseases, including
outbreaks, preparedness, research, and vaccine development. Follow her on
Mastodon and Bluesky.


@HelenBranswell

linkedin.com/in/helen-branswell-22ab936/


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public health

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