Third International Health Regulations Emergency Committee meeting addresses mpox upsurge

The Director-General of the World Health Organization (WHO) is hereby transmitting the report of the third meeting of the International Health Regulations (2005) (IHR) Emergency Committee (Committee) regarding the upsurge of mpox 2024, held on Tuesday, 25 February 2025, from 12:00 to 17:00 CET.

Concurring with the advice unanimously expressed by the Committee during the meeting, the WHO Director-General determined that the upsurge of mpox 2024 continues to meet the criteria of a public health emergency of international concern (PHEIC) and, accordingly, on 27 February 2025, issued temporary recommendations to States Parties.

The WHO Director-General expresses his most sincere gratitude to the Chair, Members, and Advisors of the Committee.

Proceedings of the meeting

Sixteen (16) Members of, and two Advisors to, the International Health Regulations (2005) (IHR) Emergency Committee (Committee) were convened by teleconference, via Zoom, on Tuesday, 25 February 2025, from 12:00 to 17:00 CET. Fourteen (14) of the 16 Committee Members, and one of the two Advisors to the Committee participated in the meeting.

On behalf of the Director-General of the World Health Organization (WHO), the Deputy Director-General welcomed Members of and Advisors to the Committee, as well as Government Officials designated to present their views to the Committee on behalf of the ten invited States Parties – Burundi, Canada, China, the Democratic Republic of the Congo (DRC), Nepal, Nigeria, Rwanda, Sierra Leone, Uganda, United Arab Emirates and United Kingdom of Great Britain and Northern Ireland (United Kingdom).

In his opening remarks, the WHO Deputy Director-General recalled that, on 14 August 2024, the upsurge of mpox was determined to constitute a public health emergency of international concern (PHEIC). He noted that, over the three years from 1 January 2022 through 31 January 2025, almost 130 000 confirmed cases of mpox, including over 280 deaths, were reported to WHO from 130 countries and territories in all six WHO Regions, including seven countries and territories that had reported their first mpox cases since the previous meeting of the Committee on 22 November 2024. The WHO African Region, where some States Parties are continuing to experience sustained community transmission, accounts for 61% of the cases and 72% of the deaths reported globally over the past 12 months.

The WHO Deputy Director-General highlighted that, since the last meeting of the Committee, the epidemiological situation continues to be volatile. Despite observed improvements pertaining to several aspects of the response – emergency coordination, surveillance, laboratory diagnostics, empowerment of communities, furthering equitable access to medical countermeasures and tools – several critical challenges had emerged, including: (a) rising geopolitical instability in the DRC due to escalating conflict affecting mpox response operations resulting in temporary pauses in operation, relocation of staff and restricted access to affected populations; (b) concurrent health emergencies requiring States Parties and partners to respond (e.g. Sudan virus disease outbreak in Uganda); and (c) uncertainties related to the pause in financial support from the United States of America (United States) occurring in the broader landscape of declining foreign assistance. To date, globally, one-third of the funds supporting the response to mpox had been pledged by the United States. Without sufficient funds, the ability of States Parties, WHO and partners to maintain, sustain, and expand the response to mpox would be compromised.

The Representative of the Office of Legal Counsel then briefed the Members and Advisors on their roles and responsibilities and identified the mandate of the Committee under the relevant articles of the IHR. The Ethics Officer from the Department of Compliance, Risk Management, and Ethics provided the Members and Advisors with an overview of the WHO Declaration of Interests process. The Members and Advisors were made aware of 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 actual conflict of interest. They were additionally reminded of their duty to maintain the confidentiality of the meeting discussions and the work of the Committee. Each Member and Advisor was surveyed, with no conflicts of interest identified.

The meeting was handed over to the Chair who introduced the objectives of the meeting, which were to provide views to the WHO Director-General on whether the event continues to constitute a PHEIC, and if so, to provide views on the potential proposed temporary recommendations.

Session open to representatives of States Parties invited to present their views

The WHO Secretariat presented an overview of the global epidemiological situation of mpox, including all circulating clades of monkeypox virus (MPXV). Outside the WHO African Region, cases of mpox reported to WHO are associated with the spread of MPXV clade IIb, with a decline in the number of cases reported in recent months. In the WHO African Region, amid the circulation of multiple MPXV clades, the still growing number of cases reported monthly is driven by the spread of MPXV clade Ib. Since the Committee last met, on 22 November 2024, exported travel-related cases of confirmed MPXV clade Ib infection have been detected in eight additional countries outside the WHO African Region.

The WHO Secretariat then focused on the three countries reporting most cases of MPXV clade Ib since January 2024 – the DRC (over 15 000 cases, including cases in areas where MPXV clade Ia is circulating); Burundi (over 3000 cases, with a sustained decrease reported weekly and a geographic shift to the administrative capital Gitega since the Committee last met); and Uganda (nearly 3000 cases, with an exponential increase in and around the capital Kampala since the Committee last met). Notwithstanding changes in the case definition of mpox cases, uneven surveillance coverage (including due to the conflict in the eastern provinces of the country), and limited laboratory testing capacity in the DRC introducing some challenges in the interpretation of data , the number of mpox cases reported weekly is plateauing and the geographic distribution of cases, in all provinces in the country, remained very similar to the situation presented at the previous meeting of the Committee. Mathematical modelling work suggests that, since the PHEIC was determined in mid-August 2024 in the DRC, the transmission rate has decreased in certain health zones of the North Kivu and South Kivu Provinces, as well as in some health zones of the capital Kinshasa where vaccination efforts are underway.

The spread of MPXV clade Ia and Ib, in North Kivu, South Kivu, and Kinshasa Provinces of the DRC, as well as in Burundi and Uganda, appears to have started among adults, including through sexual networks involving commercial sex workers and their clients, disproportionately affecting the 20–39 years age group. Since then, in North Kivu and South Kivu Provinces of the DRC, more age group became affected reflecting community transmission through close contact, including household, whereas, in the capital Kinshasa, the spread has remained within the adult population. In Burundi and Uganda, the age distribution of mpox cases shows a bimodal pattern, with high incidence observed among young adults and younger children. This pattern reflects both ongoing sexual transmission and close contact transmission in household settings. The strikingly high proportion of cases among younger children (0-9 age group) observed in Burundi is possibly attributable to transmission occurring within health care facilities settings.

In addition to the three aforementioned countries, community transmission of MPXV clade Ib is also observed in Kenya, Rwanda, and Zambia, while travel-related imported cases have been reported both, by countries in the WHO African Region (Angola, Zimbabwe, with cases in Tanzania being under investigation), and by 14 countries in the five remaining WHO Regions. Most travel-related imported cases are male and, in instances where limited secondary transmission in the country of importation has occurred, a few children have been infected through household contact, including child-to-child transmission on one occasion. The five imported cases with sole travel history to the United Arab Emirates may signal wider mpox transmission in that country.

Mortality associated with the different MPXV clades in the WHO African Region, and notwithstanding the limitation of surveillance and laboratory diagnostics in the DRC, clade Ia accounts for the majority of fatal cases (1345), corresponding to an average case fatality rate (CFR%) of 2.5-3%, being highest in children under 1 year of age (4–5%). The CFR attributed with clade Ib infection remains very low at around 0.2%, and similar to the that attributed to clade IIb, with recorded deaths associated with specific risk factors such as uncontrolled HIV and other comorbidities.

The WHO Secretariat also noted an increase in mpox cases reported in West African countries since the PHEIC was determined in mid-August 2024, including the first cases of mpox, due to MPXV clade IIa, reported by Sierra Leone.

The WHO Secretariat presented the assessed risk by MPXV clades and further expressed in terms of overall public health risk where any given clade/s is/are circulating, as: Clade Ib – high public health risk in the DRC and neighbouring countries; Clade Ia – moderate public health risk in the DRC; Clade II – moderate public health risk in Nigeria and countries of West and Central Africa where mpox is endemic; and lade IIb – moderate public health risk globally.

The WHO Secretariat subsequently provided an update on response actions taken together with States Parties and partners since the Committee last met. In addition to the overview provided by the WHO Deputy Director-General, and in the epidemiological overview, the WHO Secretariat provided details on progress and challenges focusing on the aspects of the response outlined below.

The coordination of emergency operations by the WHO Secretariat was readjusted – including based on action reviews and leveraging the comparative advantages of WHO, State Parties, and partners –prioritizing a flexible, agile, and delivery-focused response. However, while decentralized field operations have intensified, such shifts take time, particularly in specific settings in the DRC and amid changes in geopolitical partnerships. The operational decentralization continues to emphasize increased laboratory diagnostic support, increased dissemination of standards and guidance to deliver safe clinical care, and empowering communities to enhance their efforts to protect themselves from risks associated with mpox.

Additionally, through the Access and Allocation Mechanism (AAM), WHO and partners (Africa Centres for Disease Control and Prevention (Africa CDC), the Coalition for Epidemic Preparedness Innovations (CEPI), Gavi, The Vaccine Alliance (Gavi), and the United Nations Children’s Fund (UNICEF)) are continuing coordinated and multifaceted efforts to prioritize access to and roll out mpox vaccines in an equitable manner.

With the WHO Mpox global strategic preparedness and response plan, September 2024-February 2025 (SPRP) reaching the end of its initial timeframe, and considering the response strategy it outlines as still fit for purpose, the WHO Secretariat is planning to release an extension of the plan in the coming weeks.

In September 2024, the WHO Secretariat launched an appeal for US$ 87.4 million to support mpox response efforts WHO appeal: mpox public health emergency 2024 with US$ 65.5 million raised by the time of this meeting. The contribution from the United States had accounted for 33% of the funds raised, of which US$ 7.5 million is currently inaccessible due to the freeze of funds from the United States. As part of planning for the extension of the SPRP, the WHO Secretariat is conducting a review of available resources to address priority needs and mitigate potential future gaps in the delivery of the response. While the above-mentioned freeze is expected to primarily impact operations in Burundi, the Central African Republic, the DRC, the Republic of the Congo, and Rwanda, broader challenges are anticipated for the second and third quarters of 2025. Given the evolving epidemiological situation and challenges noted above, the reduction in predictable and flexible funding throughout 2025 will put at risk the progress of the mpox response to date.

Representatives of Burundi, the DRC, Nigeria, Sierra Leone, and Uganda updated the Committee on the mpox epidemiological situation in their countries and their current control and response efforts, needs and challenges, including those related to the freeze of the funds from the United States. The use of mpox vaccine is contemplated in the response plans of the DRC, Nigeria, Sierra Leone, and Uganda. In Burundi, following action review, community-based interventions that are being strengthened in areas experiencing high incident of mpox include risk communication and awareness raising.

Members of, and the Advisor to, the Committee then engaged in questions and answers, revolving around the issues and challenges enumerated below, with the presenters from States Parties and the WHO Secretariat, as well as with representatives of States Parties invited to submit a written statement to the Committee ahead of the meeting – Canada, China, Nepal, the United Arab Emirates, and the United Kingdom.

Funding – The Committee reiterated the importance of efforts to mobilize domestic financial resources to support mpox response activities. Burundi and the DRC indicated the funds allocated to the response by their respective Governments, also providing details of specific activities supported. The DRC indicated that, at present, the freeze of the funds from the United States is impacting the transportation of clinical specimens and laboratory diagnostics, with a decline in the testing rate, and that the Government is exploring solutions with other partners. The WHO Secretariat added that alternative funding sources are being explored with non-traditional donors.

Age distribution of mpox cases – The WHO Secretariat indicated that (a) there are studies ongoing to determine the secondary attack rate by age group and type of exposure; (b) at least in Burundi, there is no evidence of large outbreaks in settings where children are congregating and, hence, supporting evidence of child-to-child transmission; and (c) in the South Kivu Proving of the DRC, it remains unknown the extent to which transmission to children is occurring beyond the household setting.

Impact of vaccination on transmission – The DRC indicated that, at present, there is no information about whether the use of the limited amount of mpox vaccine available is being effective in interrupting mpox transmission.

The DRC – The DRC indicated that, due to insecurity and to decrease in laboratory testing rate, any apparent decrease of the number of reported mpox cases may represent an artifact and should be interpreted with caution. The WHO Secretariat highlighted that, being mpox a relatively mild illness, the rate of underreporting is unknown and that the trends of mpox surveillance data are critical to monitor the evolution of the situation. With respect to detection of a new MPXV clade Ia lineage in Kinshasa, the WHO Secretariat indicated that the strain, similarly to clade Ib, has increased human-to-human transmission potential.

Uganda – Uganda elaborated on the shift of the dynamics of mpox transmission from lower to higher income groups. The initial spread of MPXV clade Ib initiated long-distance truck drivers, it continued in fishing communities, and then within commercial sex networks in the capital Kampala. The fact that more affluent individuals are now affected poses a public health risk both, nationally and internationally. Therefore, the use of mpox vaccine is focused among sex workers in Kampala.

Nigeria – Nigeria indicated that, in the context of the mpox response, the human health and animal health sectors are working very closely and that, despite the numerous research initiatives, to date, there is no evidence of animal involvement in sustaining the mpox outbreak in the human population. Nigeria, with a population of 200 million persons, indicated that 20 000 doses of mpox vaccine have been used in the country, targeting health care workers, female sex workers, and men who have sex with men.

The United Arab Emirates – Considering that, in five instances, travel-related imported cases of MPXV clade Ib infection had sole travel history to the United Arab Emirates, the representative of the country (a) indicated that the National IHR Focal Point reported to WHO the first case of MPXV clade Ib infection; (b) briefly described the surveillance, laboratory diagnostic, case management, and risk communication approaches in place; (c) indicated that mpox vaccine is available to health care workers and as a post-exposure measure; and (d) recalled that the country is bilaterally supporting the response efforts of some African countries.

The United Kingdom – The United Kingdom (a) described the detection, investigation, and clinical and public health management of the travel-related imported mpox cases; and (b) highlighted that the countries of origin of the imported cases are systematically informed about the occurrences.

Deliberative session

Following the session open to invited States Parties, the Committee reconvened in a closed session to examine the questions in relation to whether the event constitutes 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 mandate and recalled that a PHEIC is defined 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 was unanimous in expressing the views that the ongoing upsurge of mpox still meets the criteria of a PHEIC and that the Director-General be advised accordingly

The overarching considerations underpinning the advice of the Committee are (a) the insecurity in the eastern provinces and in the capital of the DRC – the State Party epicenter of the MPXV clade Ib outbreak –, hampering mpox response field operations and with the potential to morph into a larger scale humanitarian response; (b) the freeze of funding by the United States both, of specific mpox response activities as well as of other, directly or indirectly related, aid interventions; and (c) the continuing detection of travel-related imported mpox cases in States Parties within and outside the WHO African Region.

On that basis, the Committee considered that:

The event is “extraordinary” because of (a) the persistent, if not increasing, challenges in gauging the actual magnitude and trend of the MPXV clade Ib outbreak, especially in the DRC. This is thwarting the ability to assess progress, if any, towards controlling the spread of mpox and to adjust response interventions. The Committee’s reading is that, overall, the epidemiological situation is worryingly similar to that observed in November 2024; (b) the unfolding dynamics of MPXV clade Ib transmission, resulting in the shift in age groups affected and, hence, posing challenges in timely targeting response interventions; (c) the co-circulation and the risk of mutations of MPXV clades in the context of sustained community transmission; and (d) the possibility of change in the severity of disease resulting from food insecurity and interruption in the delivery of HIV-related care due to the freeze of aid.

The event “constitutes a public health risk to other States through the international spread of disease” because of (a) the doubling of the number of States Parties having detected travel-related imported cases of MPXV clade Ib infection since the Committee last met, both in the WHO African Region and in all five other WHO Regions; (b) the possible influx of refugees from the eastern provinces of the DRC into neighbouring countries.

The event “requires a coordinated international response” because of the needs (a) to mobilize, and optimize the use, of financial and other resources to sustain response efforts, at the required level, in the medium term, following the freeze of funding by the United States; and (b) to continue facilitating and increasing equitable access to mpox vaccines and diagnostics.

The Committee subsequently considered the draft of the temporary recommendations proposed by the WHO Secretariat

Anticipating the possibility that the WHO Director-General may determine that the event continues to constitute a PHEIC, the Committee had received a proposed set of revised temporary recommendations ahead of the meeting. This reflected the proposal to extend most of the temporary recommendations issued on 27 November 2024. The Committee indicated that it would be giving them further consideration with a view to share its advice in that regard with the WHO Director-General as soon as possible. In such a way, should the WHO Director-General determine that the event continues to constitute a PHEIC, he could proceed, without delay, with issuing such communication together with a prospective revised set of temporary recommendations.

The Committee agreed to finalize the report of its third meeting during the week of 3 March 2025.

Conclusions

The Committee reiterated its concern regarding the continuing spread of MPXV in and beyond Africa, considering global geopolitical developments, the humanitarian situation in the DRC, as well as the foreseeable options and opportunities to secure sustainable funding to support response efforts. The Committee considered that the determination by the WHO Director-General that the upsurge of mpox still constitutes a PHEIC would be warranted. However, the Committee cautioned about the possible unintended consequences of determining an event to constitute a PHEIC for extended periods of time, since this could undermine the global public health alert function intrinsic to such a determination and reduce the leverage of a PHEIC in boosting domestic and international response efforts for future events. To that effect, the Committee reiterated the need to elaborate on considerations, related to the three criteria defining a PHEIC, that would inform its future advice to the WHO Director-General as to the termination of this PHEIC.

The Incident Manager for mpox at WHO headquarters, on behalf of the WHO Deputy Director-General, expressed his gratitude to the Committee’s Officers, its Members and Advisor and closed the meeting.