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The World Health Organization on Saturday declined to declare the unprecedented monkeypox outbreak that has spread around the world a public health emergency as of now.

A public health emergency of international concern, or PHEIC, grants the WHO director-general certain powers, such as the ability to recommend how countries should respond. While it’s a legal lever the agency can use, it’s also a tool that can grab public attention and steer it to try to address burgeoning health threats. Such a declaration could further rally donors and member countries to increase funding.

The WHO can revisit its decision. In January 2020, for example, the WHO didn’t declare the emerging coronavirus crisis a PHEIC, only to do so a week later.

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The announcement came after a WHO emergency committee met Thursday to discuss the outbreak. Some 3,000 cases have been documented since mid-May, largely in Europe and the Americas — outside the regions in West and Central Africa where the virus is endemic and has animal reservoirs. Most of the cases have been in gay, bisexual, and other men who have sex with men, with many occurring in men who have had multiple recent sex partners. One death has been reported, in an immunocompromised person.

Despite the PHEIC decision, WHO Director-General Tedros Adhanom Ghebreyesus sought to underscore the seriousness of the threat, noting the convening an emergency committee in the first place was a sign of that. In a statement, Tedros noted that the outbreak “is clearly an evolving health threat” that “requires our collective attention and coordinated action now.” But he said that the committee that advised him on the issue decided that the outbreak did not yet constitute a PHEIC, and he agreed.

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“What makes the current outbreak especially concerning is the rapid, continuing spread into new countries and regions and the risk of further, sustained transmission into vulnerable populations including people that are immunocompromised, pregnant women, and children,” Tedros said in the statement. “That is why it is urgent that all member states, communities and individuals take the recommendations of the committee for stepped-up surveillance, improved diagnostics community engagement and risk communication, and the appropriate use of therapeutics, vaccines, and public health measures including contact tracing and isolation.”

In a summary of the committee’s discussion, the WHO said the group acknowledged that facets of the outbreak are unusual and that the response clearly necessitated international efforts, but that “while a few members expressed differing views,” the committee reached a consensus that the outbreak did not amount to a PHEIC. The committee said it should reconsider the decision depending on whether cases accelerate in the next few weeks; more countries start reporting cases; if there are upticks in cases in other groups of people, including sex workers; and if there are any signs the virus is becoming more transmissible or starts causing more severe illness.

A PHEIC (pronounced like “fake”) describes an extraordinary or unusual health threat that poses risks to other places through international spread and requires a coordinated response. PHEICs are typically declared when urgent international action is needed.

A PHEIC is not the same thing as a pandemic. The former is a technical mechanism the WHO can employ, while the latter is a rhetorical acknowledgement of vast global spread of a disease. When the WHO started referring to Covid-19 as a pandemic, for example, it was a reflection of the scale of the crisis, not a move that granted the agency any more powers.

The WHO has been working to try to ensure the fair distribution of vaccines and drugs that can prevent and treat monkeypox. Those vaccines and treatments are in limited supply and countries in Europe and the Americas have been trying to purchase more of them.

In the past, monkeypox infections seen outside the countries where the virus is endemic have typically been imported cases or have involved limited household transmission. This is the first time the virus has started circulating more widely in other countries.

Gregg Gonsalves, an associate professor of epidemiology at Yale School of Public Health, disagreed with WHO’s decision, which he called a “punt.” He said he felt that the criteria had been met and that a PHEIC declaration could have pushed public health authorities to step up their response and coordinate better across countries.

Gonsalves served as an adviser to the emergency committee, but did not have a say in whether to recommend a PHEIC be declared.

“An expanding outbreak of this disease is not good for anyone,” he said, noting that African public health officials have been saying for years that monkeypox needs more global attention. “Right now, we are not on top of our game with monkeypox, at least in the United States,” he added, pointing to the patchy surveillance system and limited vaccine deployment.

Monkeypox infections can lead to painful lesions and rashes, including vesicles forming on the palms. Some of the cases in the current outbreak have been mild and diverged from textbook cases of the infection, with people having just a few genital or anal lesions instead of broader rashes. Many of the cases in the current outbreak have been comparatively mild, though some patients have been hospitalized for pain management as the infection runs its course.

The virus is spread through close contact, mainly through respiratory droplets or direct exposure to lesions or to contaminated clothing or linens.

Some countries have begun vaccinating contacts of people with infections, and some have recently expanded eligibility criteria, with health officials in the United Kingdom, parts of Canada, and New York City offering vaccines for broader groups of men who have sex with men.

Though documented case counts have recently surged, genetic analyses suggest that the virus could have been circulating among people at low levels for several years before taking off.

In the current outbreak, the United States has reported 200 monkeypox cases, though public health experts are concerned that number doesn’t reflect the true breadth of the virus’s spread. Germany has identified more than 675 cases, Portugal more than 300, and the United Kingdom more than 900.

South Africa on Thursday also reported a case in a person who had no recent travel history.

Separately, the United States announced Wednesday it had started shipping monkeypox tests to five commercial laboratory companies to expand testing. The nation’s raw testing capacity wasn’t the key issue, but clinicians and advocates had reported the process to get a test — which involved contacting local health departments and a two-step testing regimen — was too complicated and made it difficult for individuals to find clinics willing to provide tests.

The PHEIC designation was created in an update to the International Health Regulations following the 2002-2003 SARS outbreak. The regulations, which are agreed to by WHO member states, are designed to help the world respond to public health threats while avoiding “unnecessary interference with international traffic and trade,” according to the WHO.

The first PHEIC was declared for the 2009 H1N1 flu pandemic, and others have included Ebola outbreaks and the Zika epidemic. The two active PHEICs are for Covid-19 and the continued transmission of polio.

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