Numerous infectious disease outbreaks and emergencies are reported to the World Health Organization (WHO) on almost a daily basis, with many dealt with by national health systems and posing no major threat.
There are localized outbreaks that transit from an endemic status to epidemic in a single country, and go on to spread to adjacent countries, then a region, and beyond. WHO is responsible for overseeing the 2005 International Health Regulations (IHR) an international agreement approved by its 194 member countries.
Its IHR Emergency Committee is tasked with determining if a specific outbreak warrants a declaration of a “Public Health Emergency of International Concern” (PHIEC), thereby triggering the call for a coordinated international response which may entail streamlined funding, acceleration of vaccines and therapeutics, as well as significant restrictions on travel and trade.
Because this process has proven less than fully effective for multiple reasons, there are discussions underway to reform the IHR, the basis for the PHEIC declarations; at the same time, Africa is contemplating taking such a determination in their own regional institutional hands.
Africa’s growing institutional capacity
In 2017 the African Union established the African Center for Disease Control and Prevention (Africa CDC) which has grown in size and reputation. There are those who firmly think it could act more quickly in designating an infectious disease as a continental threat and taking action.
Consideration of this option is timely now because we are in the midst of a major Monkeypox global outbreak, and there have been two cases of the deadly Marburg Virus reported in Ghana which has not been known yet to have crossed a border, both originating in Africa.
The thought is that while our world is globalized, earlier regional engagement may be useful for the rest of the world.
Whether this will happen in having a regional instrument to declare major outbreaks is yet to be decided. In the meantime, a brief look at these two current very different infectious disease examples provides some insight into the dilemma and challenges.
Monkeypox was first discovered in a monkey in 1958 with the first infection in a human in 1970 in a small child in the Democratic Republic of the Congo.
Since that time, there has been a number of cases but relatively few outside West and Central Africa, where the disease is endemic, and typically only affects a few people before transmission stops. This time, this is significantly different since the first case was reported in the United Kingdom in May 2022, and there have been more than 2,500 cases confirmed worldwide.
A new study of the virus’s genetic makeup has shed fresh light on how the outbreak began, and how the virus is evolving as it spreads. A paper in Nature Medicine found that the viruses responsible for the current monkeypox outbreak may be related to ones responsible for causing a handful of human cases in the United Kingdom, Israel, and Singapore during 2018 and 2019. These earlier cases were all linked to travel from Nigeria.
Furthermore, the ongoing outbreak most likely arose from a single human case, with signs of ongoing evolution as the virus passes from person to person.
African cases have been traced to contact with wild animals or the use of animal products for medicinal or cultural practices. As deforestation and urbanization drive people and animals into closer quarters, more viruses may make the jump to human hosts and global warming accelerates this process.
The message is clear that possibilities of new infectious diseases may come from human incursions to natural habitats with opportunistic infections taking advantage of the denser environment. It argues for more proactive surveillance of wildlife, especially, at known possible hotspots, and a One Health approach.
It has been known since 1967 when there were two outbreaks in Europe, namely in Frankfurt, Germany and Belgrade, Serbia. For only the second time this virus has been found in West Africa, specifically in a corner of Ghana. And like Ebola, it is a highly infectious viral hemorrhagic fever for which there is no vaccine. It is deadly, with high rates of mortality.
Ghana’s health service and the World Health Organization (WHO) have responded swiftly to identify close contacts of the cases identified and are taking precautionary steps to get ahead of any possible new outbreak. (98 contacts, including health workers and others in the community, are being monitored.) It will take time to determine if these containment efforts have been successful. For now, two deaths are reported:
As Jimmy Whitworth of the London School of Hygiene and Tropical Medicine put it, “It is important to try and understand how the virus got into the human population to cause this outbreak and to stop further cases.”
What, when, and where were there interactions between animals and humans, and any changes in the environment, which led to this outbreak will be crucial to preventing future outbreaks.
Deciding on when to sound the alarm
The International Health Regulations (2005) Emergency Committee met on 23 June 2022 regarding the multi-country monkeypox outbreak to advise the WHO Director-General on whether monkeypox constituted a Public Health Emergency of International Concern (PHEIC). The committee advised the WHO Director-General that the outbreak should not constitute a PHEIC at this stage.
“I think they made a big mistake,” says Yale School of Public Health epidemiologist Gregg Gonsalves, who advised the committee. “They punted.”
Here we see on the one hand WHO’s global emergency committee evaluating the evidence and concluding it was not, at least not yet, a PHEIC; others looking at the same facts, felt strongly otherwise. A month later, as this article came out (July 23), the news broke that WHO has now taken the decision to declare monkeypox a PHEIC – by now it has affected nearly 17,000 people in 74 countries.
Add to the mix past WHO delays in acting quickly with Ebola and COVID, and the inability of the World Health Assembly to reform the IHR and authorize greater proactivity. As a result, it has led to disappointment and looking for other alternatives and for one region, specifically empowering the Africa CDC to declare a “Public Health Emergency of Continental Security”.
Has WHO been supportive of this approach? For now, the World Health Organization African Regional Office (WHO AFRO) has expressed disapproval of the Africa CDC’s quest for such a mandate during a meeting of African Union health ministers which discussed revisions to the statutes under which Africa CDC operates.
In principle, the Africa CDC could be given more authority, including the power to declare regional or continent-wide health emergencies.
WHO AFRO eventually issued a statement calling for an assessment of the proposed policy’s benefits and risks to member States. It noted that while the policy change could reduce Africa’s dependence on others, it could also trigger more travel and trade restrictions and isolate the continent as occurred with the travel bans imposed by many countries in southern Africa after scientists there identified the emergence of the Omicron variant of the SARS CoV2 virus.
The matter is still outstanding with the health ministers to make recommendations which would eventually be placed before the AU Executive Council for a decision.
What of the Future?
If monkeypox cases level off or decline, then the WHO IHR Emergency Committee’s decision not to trigger a declaration of a PHEIC will have proven right. But of course, the opposite is also true.
Certainly, if Marburg is not contained and breaks out of Ghana, it will generate similar questions, essentially whether earlier and swifter action by a regional authority to declare a “Public Health Emergency of Continental Security” would make a difference.
It is worth noting that discussions have begun concerning a new WHO pandemic treaty or international agreement. As we know, however, infectious diseases wait for no one and the negotiation processes are likely to be prolonged. (should there be measurable progress, it would be a worthy subject of future commentary.)
The fact that questions are raised around deciding which institution should make decisions on infectious declarations of public health emergencies and whether they have the capacity to act to respond to common health threats, is symptomatic of some level of growing mistrust of globalization and in the ability of global institutions to adequately address regional problems. Solutions will be needed to accommodate both global and regional institutions, to everyone’s benefit.
Editor’s Note: The opinions expressed here by Impakter.com columnists are their own, not those of Impakter.com – In the Featured Photo: World Health Organization (WHO) deploys the first protection and medical kits in Likati (Bas-Uele province) to respond to the Ebola Epidemics. Source: MONUSCO Photos.