Intended for healthcare professionals


Why the monkeypox outbreak constitutes a public health emergency of international concern

BMJ 2022; 378 doi: (Published 09 August 2022) Cite this as: BMJ 2022;378:o1978
  1. Tedros Adhanom Ghebreyesus, Director, General,
  2. World Health Organization

On 23 July, I declared the global monkeypox outbreak a public health emergency of international concern (PHEIC) and issued recommendations to all countries, with the objective of stopping transmission and controlling the outbreak.

Monkeypox has been known to infect humans for more than 50 years, but until this year, was little known or understood outside Africa, and received scant attention or investment.

On 13 May, the United Kingdom reported a case of monkeypox in an individual with recent travel history to Nigeria, one of several African countries where the virus is known to be endemic. Since then, the outbreak has expanded rapidly. At the time of writing, more than 26 000 cases have been reported from 85 countries and territories, with 12 deaths, and the outbreak shows no sign of slowing down.

The majority of reported cases—over 97%—are among men who have sex with men (MSM), especially those with multiple sexual partners, underscoring the need for all countries to work closely with affected communities to design and deliver effective information and services, to guard against stigma and discrimination, and to adopt measures that protect their health, human rights, and dignity.

In most cases the disease is self-limiting; however, symptoms can be severe and about 10% of cases are admitted to hospital to manage the excruciating pain caused by the disease or secondary infections.

Two smallpox vaccines have been approved for use against monkeypox and a third is under consideration. However, data are lacking on the efficacy of these vaccines for monkeypox, and an effective immune response can take several weeks to develop, meaning vaccination will not provide instant protection against infection or disease. WHO is working with manufacturers to accelerate equitable access to vaccines, and with affected countries to generate data on their efficacy.

The primary focus for all countries, therefore, must be to stop transmission using effective public health tools, including enhanced disease surveillance, careful contact tracing, tailored risk communication and community engagement, and risk reduction measures. It is also critical to ensure all affected communities have equitable access to other tools needed to stop transmission, including testing, antivirals, and supportive care.

Under the International Health Regulations (IHR), the decision to declare a PHEIC rests with the WHO Director-General, taking into consideration the information provided by countries; the risk to human health, international spread, and the potential for interference with international traffic; scientific principles, evidence, and other relevant information; and the advice of the Emergency Committee, a panel of external experts convened by the Director-General to advise her or him on whether the public health event in question constitutes a PHEIC. On this occasion, the Emergency Committee was, for the first time since the IHR entered into force in 2007, unable to reach consensus.

The rapid international spread of the virus, the risk of further spread with unknown impact, the potential for the virus to become entrenched in previously unaffected regions, and the fact that the outbreak clearly met the definition of a PHEIC outlined in the IHR, all led me to the decision that the outbreak constitutes a public health emergency of international concern.

A PHEIC is the highest level of alarm under the IHR, and the only one. It’s clear that although the IHR remains a vital tool for controlling the international spread of disease, it is a tool that must be sharpened to make it more effective. In particular, the binary nature of the determination of a PHEIC is too blunt for evaluating the spectrum of risk posed by emergencies of different kinds.

Alongside the process of negotiating a new international accord on pandemic preparedness and response, WHO’s Member States are also considering targeted amendments to the IHR, including ways to improve the process for declaring a PHEIC.

More importantly, this outbreak is another demonstration that breaking the cycle of “panic and neglect” that for decades has been the hallmark of the global response to epidemics and pandemics requires a paradigm shift in global health. The world ignores at its peril pathogens that spread “only” in low-income countries; most are one flight away from sparking a global public health emergency. Protecting the health of any population relies ultimately on protecting the health of every population, through stronger public health functions and health systems, based on robust primary health care and a commitment to universal health coverage. Global health security depends on local health security in every country.


  • Competing interests: none declared.

  • Provenance and peer review: commissioned, not peer reviewed.