First Meeting of the International Health Regulations (2005) Emergency Committee About the Spike of Mpox in 2024.
The Director-General of the World Health Organization (WHO), having concurred with the advice offered by the International Health Regulations (2005) (IHR or Regulations) Emergency Committee regarding the upsurge of mpox 2024 during its first meeting, held on 14, 2024, has determined, on the same date, that the ongoing upsurge of mpox in the Democratic Republic of the Congo (DRC) and in a growing number of countries in Africa constitutes a public health emergency The Director-General’s communication regarding the finding of the aforementioned PHEIC on August 14, 2024, is available here.
The Director-General hereby transmits the report of the first meeting of the IHR Emergency Committee on the rise of MPX 2024.
Noting that the Director-General will communicate to States Parties a 12-month extension of the current standing recommendations for mpox, the Director-General’s temporary recommendations for the PHEIC associated with the ongoing mpox outbreak are presented in the final section of this statement and reflect the Committee’s advice.
The Director-General is taking this opportunity to convey his heartfelt appreciation to the Chair, Vice-Chair, and Members of the IHR Emergency Committee, as well as its Advisors.
Meeting Proceedings
The Emergency Committee’s sixteen (16) members and two (2) advisors met by Zoom teleconference on Wednesday, August 14, 2024, from 12:00 to 17:00 CEST. The meeting was attended by fifteen (15) of the Committee’s 16 members, as well as two (2) of its advisors.
The Director-General of the World Health Organization (WHO) attended in person and welcomed the participants. The Director-General’s opening remarks are accessible here.
The Representative of the Office of Legal Counsel addressed the Members and Advisers on their respective roles and obligations, as well as the Emergency Committee’s mandate under the relevant IHR articles. The Ethics Officer from the Department of Compliance, Risk Management, and Ethics gave Members and Advisors an overview of the WHO Declaration of Interests process. Members and Advisors were made aware of their individual responsibility to promptly disclose to WHO any personal, professional, financial, intellectual, or commercial interests that could result in a perceived or actual conflict of interest.
They were also reminded of the need to keep meeting topics and committee work confidential. Each Member and Advisor was surveyed, and no conflicts of interest were detected.
The Representative from the Office of Legal Counsel then facilitated the election of Committee officers in accordance with the Emergency Committee’s norms of procedure and working methods. Professor Dimie Ogoina was elected Chair of the Committee, Professor Inger Damon Vice-Chair, and Professor Lucille Helen Blumberg Rapporteur, all by acclamation.
The meeting was handed over to the Chair, who explained the meeting’s objectives, which were to provide feedback to the Director-General on whether the event constitutes a public health emergency of international concern (PHEIC) and, if so, feedback on potential temporary recommendations.
Session open for representatives of States Parties invited to offer their views
The WHO Secretariat provided an assessment of the global mpox epidemiological situation, stressing that, during the first six months of 2024, the 1854 confirmed mpox cases reported by States Parties in the WHO African Region accounted for 36% (1854/5199) of the cases observed worldwide. Of these confirmed cases in the WHO African region in 2024, 95% (1754/1854) were reported in the Democratic Republic of the Congo (DRC), which is experiencing an increase in mpox cases, with more than 15,000 clinically compatible cases and over 500 deaths reported, already surpassing the number of cases observed in the DRC in 2023.
The increase in mpox cases in the DRC is being driven by outbreaks related with two sub-clades of clade I monkeypox virus (MPXV): clade Ia and clade Ib. Clade I mpox was typically reported in WHO research done in the 1980s as having a fatality rate of around 10%, with the majority of deaths occurring in youngsters.
MPXV clade Ia is endemic in the Democratic Republic of the Congo; the disease primarily affects children; data for 2024 show an aggregated case fatality rate of 3.6%; and the spread is likely sustained through multiple modes of transmission, including person-to-person transmission following zoonotic introduction into a community.
MPXV clade Ib is a novel strain of MPXV that has developed in the Democratic Republic of the Congo and is spreading among humans, most likely through sexual contact, in the country’s east. Although it was initially identified in 2024, estimations suggest it appeared about September 2023. The clade Ib outbreak in the Democratic Republic of the Congo mostly affects adults and is expanding rapidly, owing to transmission connected to sexual contact and amplified in networks associated with commercial sex and sex workers.
Since July 2024, instances of mpox caused by MPXV clade Ib, which is epidemiologically and phylogenetically connected to the outbreak in the DRC’s eastern provinces, have been found in four neighboring countries that had not previously reported occurrences of mpox: Burundi, Kenya, Rwanda, and Uganda.
In 2024, instances of mpox connected to MPXV clade Ia were reported in the Central African Republic and the Republic of Congo, while cases linked to MPXV clade II were documented in Cameroon, Côte d’Ivoire, Liberia, Nigeria, and South Africa.
The clinical presentation of mpox associated with MPXV clade Ia has traditionally been more severe than that associated with MPXV clade II. Clade IIb viruses circulated during the multi-country outbreak that served as a PHEIC from July 2022 to May 2023. There is currently inadequate information available to accurately assess mpox severity related to clade Ib, as data are emerging and few deaths have been recorded, precluding age-stratified analysis.
The secretariat emphasized difficulty in identifying the true level of infection, epidemiologic patterns, and morbidity and death, cautioning against overinterpreting available data to determine crude CFRs by clade/outbreak.
The assessed risk presented by the WHO Secretariat, grouping geographical areas as a result of the assessment of population groups affected, predominant modes of transmission, and MPXV clades involved, was: “high” for eastern DRC and neighbouring countries; “high” for areas of the DRC where mpox is known to be endemic; “moderate” for Nigeria and countries of West, Central, and East Africa where mpox is endemic; and “moderate” for other countries in Africa and around the
The WHO Secretariat also offered an assessment of the activities previously taken to enhance readiness and response initiatives in States Parties experiencing an increase in cases of mpox and at risk. These include, among other things, the release of USD 1.45 million from the WHO Contingency Fund for Emergencies; the start of the process of including two mpox vaccines on the Emergency Use Listing; coordination with partners and stakeholders, including to facilitate equitable access to vaccines, therapeutics, and diagnostics; and the development of a regional response plan, which will cost an initial USD 15 million.
Representatives from Burundi, the Democratic Republic of the Congo, Kenya, Rwanda, South Africa, and Uganda provided the Committee with an update on their respective countries’ mpox epidemic condition, as well as current response efforts, requirements, and problems. Although most countries reported few cases of MPXV-clade Ib-related mpox, Burundi has reported one hundred confirmed cases of mpox connected with clade Ib since July 2024, detected in different districts, with 28% of cases involving children under the age of five years.
The Committee’s members and advisors then engaged in question-and-answer sessions with the presenters. The inquiries and debates centered on the issues and concerns listed below:
The observed complicated and dynamic evolution of the various outbreaks that are driving the upsurge of mpox, as well as its international dissemination, in the DRC and neighboring countries. Elements supporting such observations and suggesting causes for concern include:
Scientific uncertainties and evidence gaps (e.g., role of ecological changes in mpox spread, modes of disease transmission, transmission dynamics, risk factors, disease severity and case fatality rate associated with different MPXV clades, pregnancy outcome in women infected with different MPXV clades);
Adequacy of capacities, recognizing capacities gained during COVID-19 and their heterogeneity across States Parties for surveillance, diagnostic capacities, surveillance modalities at borders, access to clinical care, integration of HIV/STI services in prevention and treatment, risk communication and community engagement, vaccination delivery, and other capacities to support prevention, readiness, and response activities;
Lack of complete understanding of the geographical spread and detailed epidemiology of dynamic mpox outbreaks, including molecular epidemiology, to optimize targeted prevention and control measures, including risk communication and community engagement with local partners to enable appropriate support and behavior modifications, as well as the targeted use of mpox vaccines in at-risk groups;
Availability and availability to laboratory assays that can be performed in demanding situations, as well as methods to identify between circulating MPXV clades. and
An incomplete mapping of mpox-related research and development efforts underway, including many initiatives underway, including a WHO and Africa Centers for Disease Control and Prevention (Africa CDC) consultation scheduled for August 2024;
Unpredictability and a lack of financial resources at both national and international levels to scale up and sustain actions to prevent and control the spread of mpox, despite the preparation of costed global, regional, and national response plans;
need-based access to mpox vaccines, given the current global shortage; the vaccine’s current limited production, contingent on orders placed with the manufacturer; and the lengthy time required to develop legal agreements for mpox vaccine donation rather than direct procurement. Regarding access to vaccinations, the WHO Secretariat informed the Committee of its continued engagement with multiple partners under the interim coordination framework for medical countermeasures. (i-MCM-Net), including Gavi and the United Nations Children’s Fund, on coordinating the donation and allocation process in an equitable, needs-based manner;
Access to the antiviral medicine tecovirimat, given that both the minimum amount required to make an order with the manufacturer and the product’s price pose significant hurdles for many States Parties,. While data is being gathered on its usage in the treatment of cases of mpox, it can be accessible under the procedure for Monitored Emergency usage of Unregistered and
Experimental Interventions (MEURI);
The need for reporting on how States Parties are implementing the standing recommendation for mpox released on August 21, 2023.
Deliberative session
Following the open session for invited States Parties, the Committee reconvened in a closed session to consider the questions of whether the event is a PHEIC or not, and if so, to consider the temporary recommendations drafted by the WHO Secretariat in accordance with IHR provisions.
The Chair reminded the Committee Members of their duty and recalled that a PHEIC is described in the IHR as “an extraordinary event, which constitutes a public health risk to other States through the international spread of disease, and potentially requires a coordinated international response.”
The Committee unanimously agreed that the ongoing outbreak of mpox fits the criteria for a PHEIC and that the Director-General be notified appropriately.
The Committee’s unanimous views were supported by further observations on concerns and challenges raised during the question and answer session.
The Committee considered the event to be “extraordinary” because of
(a) the increase in mpox clade I disease occurrence in the DRC and the emergence of the new MPXV clade Ib, the human-to-human transmission context in which it is occurring, its rapid spread in some settings, and available evidence suggesting that MPXV clade I is associated with a more severe clinical presentation than MPXV clade II;
(b) the diverse The complex, dynamic, and rapidly evolving epidemiology observed across States Parties in the WHO African Region in terms of: overall rapid increase of the number of cases reported in some settings, differences in population age-groups affected, routes and modes sustaining transmissions in different contexts;
(c) the severity of the clinical presentation in children and immunocompromised individuals, including people living with uncontrolled HIV infection or advanced HIV
Furthermore, the Committee emphasized that its level of concern is further heightened by
(a) uncertainties and gaps in knowledge and evidence related to
(i) multiple epidemiological aspects, including drivers of transmission, morbidity, and mortality associated with infections with different MPXV sub-clades;
(ii) the incompleteness and uncertainties of available epidemiological data and considered by the Committee, due to the limitations of current surveillance.DRC is experiencing an increase in mpox, which impedes the implementation of control measures;
(iii) the impact of control measures, including the targeted use of vaccines and their overall effectiveness;
(b) the risk of the emergence and spread of additional MPXV clade I and clade II mutations in the context of limited capacity to implement control measures.
The Committee considered that the event “constitutes a public health risk to other States through the international spread of disease” because of
(a) the documented recent spread of MPXV clade Ib from eastern DRC to Burundi, Kenya, Rwanda, and Uganda;
(b) the limited capacity to control transmission in endemic situations and in areas of upsurge through enhanced surveillance enabling the implementation of targeted response interventions that are eventually subordinated to The i-MCM-Net has also been activated for mpox. In light of the Africa CDC’s declaration of the event as a Public Health Emergency of Continental Security on August 13, 2024, the Committee concluded that international cooperation must be strengthened and coordinated, particularly in terms of
(a) facilitating equitable access to vaccines, therapeutics, and diagnostics,
(b) mobilizing financial resources.
The Committee then evaluated the text of temporary recommendations offered by the WHO Secretariat, which was briefly presented during the meeting. The committee stated that it would continue to review the proposed temporary recommendations while finalizing the meeting report.
The Committee noted that, in his opening remarks, the Director-General announced a 12-month extension of the current standing recommendations for mpox, which were slated to expire on August 20, 2024. The Committee also noted that, if the Director-General determines that the mpox outbreak constitutes a PHEIC, it would be the first time since the Regulations went into effect that temporary and standing recommendations to States Parties on the same public health risk would coexist.
As a result, the Committee emphasized that any temporary proposal given by the Director-General should be very particular and targeted and thus not duplicate the standing recommendations.
Although both temporary and standing recommendations are non-binding advice to States Parties, the Committee recommended that mechanisms for monitoring the uptake, implementation, and impact of such recommendations be included in the set of temporary recommendations to States Parties that the Director-General may issue in relation to the event under consideration.
Conclusions
The Committee reiterated its concern about the evolution of the multifaceted mpox outbreak, including the many uncertainties surrounding it and the capacities in place to control the spread of mpox in States Parties experiencing outbreaks or in States Parties that may be forced to do so as a result of additional international spread.
The Committee recognized the importance of coordinated international cooperation in assisting States Parties’ efforts to control the spread of mpox in the WHO African Region, including facilitating access to and use of vaccines, therapeutics, and diagnostics; mobilizing financial resources for States Parties experiencing disease outbreaks; and synergistic initiatives by WHO and partners, including Africa CDC.
Nonetheless, the Committee stated that the development of strategic ways to help States Parties become more self-sufficient in preventing the spread of mumps is necessary. To that end, the Committee believes that the Director-General’s finding that the mpox outbreak is a PHEIC will encourage States Parties confronting outbreaks to more effectively commit and deploy domestic resources.
Temporary recommendations given by the Director-General of the World Health Organization (WHO) to States Parties regarding the public health emergency of international concern associated with the outbreak of mpox.
These temporary recommendations are offered to States Parties suffering an increase in mpox, including but not limited to the Democratic Republic of the Congo and Burundi, Kenya, Rwanda, and Uganda.
They are meant to be implemented by those States Parties in addition to the current standing recommendations for mpox, which will be extended until August 20, 2025 and are included at the end of this paper for easy reference.
The aforementioned standing guidelines apply to all States Parties in the context of global efforts to prevent and control the spread of mpox illness, as stated in the WHO Strategic Framework for strengthening mpox prevention and control 2024–2027.
All current WHO interim technical guidance is available on this page of the WHO website. WHO evidence-based guidance has been and will continue to be revised to reflect the changing situation, new scientific evidence, and WHO risk assessment to assist States Parties in implementing the WHO Strategic Framework for improving mpox prevention and control.
According to Article 3 Principle of the International Health Regulations (2005) (IHR), States Parties must implement these temporary recommendations, as well as the standing recommendations for mpox, with full respect for the dignity, human rights, and fundamental freedoms of individuals, in accordance with the principles outlined in Article 3 of the IHR.
Emergency Coordination
Establish or improve national and local emergency response coordination arrangements.
Establish or improve the coordination of all partners and stakeholders involved in or supporting response actions through cooperation, including the introduction of accountability systems.
Engage partner groups for collaboration and support, including humanitarian players in contexts of insecurity, locations with internal or refugee population displacements, and hosting communities vulnerable areas.
Collaborative Surveillance and Lab Diagnostics
Improve surveillance by enhancing the sensitivity of methodologies used and ensuring wide geographical coverage.
Increase access to accurate, inexpensive, and available diagnostics to discriminate monkeypox viral clades, especially by increasing arrangements for sample transit, decentralization of diagnostics, and arrangements for genomic sequencing;
Identify, monitor, and support the contacts of people with mpox to avoid further transmission;
Increase efforts to thoroughly examine instances and outbreaks of mpox illness in order to clarify the ways of transmission and prevent its spread to household members and communities.
Report suspected, probable, and confirmed mpox cases to WHO in a timely and weekly basis;
Safe and Scalable Clinical Care
Provide clinical, nutritional, and psychosocial support for patients with mpox, including, when warranted and possible, isolation in care facilities and guidance for home-based care.
Develop and implement a strategy to increase access to optimal supportive clinical treatment for all mpox patients, particularly children, HIV patients, and pregnant women. This includes offering HIV tests to adult patients who do not know their HIV status and to children as appropriate, with links to HIV treatment and care services when indicated; the prompt identification and effective management of endemic co-infections, such as malaria, varicella zoster, and measles viruses, as well as other sexually transmitted infections (STIs) among cases linked to sexual contact;
Strengthen health and care workers’ capacity, knowledge, and abilities in the clinical and infection prevention and control pathways, from diagnosis to discharge of patients with suspected and confirmed mpox, and provide them with personal protective equipment;
Promote and implement infection prevention and control measures, as well as basic water and sanitation services, in health care institutions, households, congregate settings (e.g., prisons, internally displaced persons and refugee camps, schools, etc.), and cross-border transit zones.
International traffic
Establish or strengthen cross-border collaboration arrangements for surveillance and management of suspected mpox cases, as well as the provision of information to travelers and conveyance operators, without resorting to general travel and trade restrictions that unnecessarily impact local, regional, or national economies;
Vaccination
Prepare for the introduction of the mpox vaccine for emergency response by assembling national immunization technical advisory groups, briefing national regulatory authorities, and developing national policy frameworks to apply for vaccines through existing mechanisms.
Initiate plans to advance mpox vaccination activities in areas with incident cases (i.e., disease onset within the previous 2-4 weeks), focusing on people at high risk of infection (e.g., contacts of cases, including sexual contacts, children, and health and health-care workers). This requires the rapid adaptation of immunization strategies and plans to concerned locations, the availability of vaccines and supplies, and proactive community engagement to develop and sustain demand for and trust in vaccination. and data gathering during immunization in accordance with implementable study methods.
Risk communication and community involvement
Improve risk communication and community engagement systems with affected communities and local workforces to support outbreak prevention, response, and vaccination strategies, such as through training, mapping high-risk and vulnerable populations, social listening and community feedback, and managing misinformation. This entails, among other things, effectively communicating the uncertainties regarding the natural history of mpox, updating information about mpox, including information from ongoing clinical trials, the efficacy of mpox vaccines, and the uncertainties regarding the duration of protection following vaccination;
Address stigma and discrimination in any form through meaningful community engagement, particularly in health care and risk communication programs;
Governance and Finance
Galvanize and scale up national funding, and investigate external opportunities for targeted support of prevention, readiness, and response efforts.
Integrate mpox prevention and response measures into existing programs aimed at preventing, controlling, and treating other endemic diseases—especially HIV, as well as STIs, malaria, tuberculosis, and COVID-19, as well as noncommunicable diseases—with the goal of not negatively impacting their delivery.
Addressing Research Gaps
Invest in addressing knowledge gaps and generating evidence, during and after outbreaks, regarding the dynamics of mpox transmission, risk factors, the social and behavioral drivers of transmission, the natural history of disease, through trials for novel therapeutics and vaccines against mpox, the effectiveness of public health interventions, with a One Health approach.
Report on the implementation of temporary suggestions.
Report to WHO quarterly on the status and obstacles associated with the implementation of these temporary guidelines, using a standardized tool and channels made available by WHO.
The Director-General of the World Health Organization (WHO) has issued standing recommendations for mpox in accordance with the International Health Regulations (2005) (IHR). States Parties should develop and implement national mpox plans based on WHO strategic and technical guidance, outlining critical actions to sustain control and eliminate human-to-human transmission in all contexts through coordinated and integrated policies. Actions are advised for:
Incorporate lessons learnt from response evaluations (such as intra- or after-action assessments) into relevant plans and policies to sustain, adapt, and promote essential components of the response, as well as educate public health policies and programs.
Aim to eliminate human-to-human transmission of mpox by anticipating, detecting, planning for, and responding to outbreaks, as well as taking appropriate steps to limit zoonotic transmission.
Build and maintain capacity in resource-constrained contexts and among marginalized people where mpox transmission persists to better understand transmission patterns, quantify resource requirements, and detect and respond to outbreaks and community transmissions.
States As a fundamental foundation for the actions listed in A to support the eradication target, parties are advised to create and maintain laboratory-based surveillance and diagnostic capacities to improve epidemic detection and risk assessment. Actions are advised for:
4. Make mumps a notifiable disease in the national epidemiological monitoring system.
5. Improve diagnostic capacity across the healthcare system for laboratory and point-of-care confirmation of cases.
6. Follow WHO guidelines and use the Case Reporting Form to report confirmed cases with a recent international travel history.
7. Collaborate with other countries to make genome sequencing available or accessible to all countries. Share genetic sequencing data and metadata in public databases.
8. Notify WHO of significant MPOC-related events via IHR channels.
C. States Parties are advised to improve community protection by increasing capacity for risk communication and community engagement, tailoring public health and social measures to local contexts, and continuing to strive for equity and building trust with communities through the following actions, particularly for those most vulnerable. Actions are advised for:
9. Work with health authorities and civil society to communicate danger, raise awareness, and engage affected communities and at-risk groups.
10. Implement initiatives to reduce stigma and discrimination against any persons or groups who may be impacted by mpox.
D. States. Parties are encouraged to initiate, maintain, support, and collaborate on research to provide evidence for mpox prevention and control, with the goal of eliminating human-to-human transmission of mpox. Actions are advised for:
11. Contribute to the global research agenda by generating and disseminating knowledge on essential scientific, social, clinical, and public health aspects of polio transmission, prevention, and control.
12. Conduct clinical studies for medical countermeasures, such as diagnostics, vaccinations, and medicines, in various populations to assess safety, efficacy, and duration of protection.
13. States Parties in West, Central, and East Africa shall further investigate the risk, vulnerability, and impact of polio, taking into account various modes of transmission in different demographics.
E. States Parties are advised to implement the following precautions regarding international travel:. Actions are advised for:
14. Encourage authorities, health care providers, and community groups to equip travelers with important information about how to protect themselves and others before, during, and after attending activities or gatherings when mpox is a danger.
15. Advise anyone suspected or known to have mpox, or who may be a contact in a case, to take precautions to avoid exposing others, including when traveling internationally.
16. Avoid establishing mpox-specific travel health measures such as entry or exit screening, as well as testing or vaccine restrictions.
States Parties are encouraged to provide guidance and coordinate resources to ensure optimally integrated clinical care for mpox, including access to specific treatment and protective measures for health workers and caregivers as needed. States Parties are encouraged to take initiatives like:
17. Provide optimal clinical care, including infection prevention and control strategies, for suspected and confirmed mumps in all clinical settings. Ensure that health care providers receive appropriate training and personal protective equipment.
18. Integrate mpox detection, prevention, care, and research into HIV and sexually transmitted illness prevention and control programs, as well as other health services, as needed.
States Parties are encouraged to cooperate together to provide equitable access to safe, effective, and quality-assured mpox countermeasures, including resource mobilization methods. States Parties are encouraged to take action towards:
19. Improve access to diagnostics, genomic sequencing, vaccines, and therapeutics for affected communities, particularly in resource-constrained settings where mpox occurs frequently. This includes men who have sex with men and groups at risk of heterosexual transmission, with a focus on marginalized groups.
20. Make mpox vaccines available for primary prevention (pre-exposure) and post-exposure immunization for mpox-prone individuals and communities, in accordance with WHO Strategic Advisory Group of Experts on Immunization (SAGE) recommendations.
