Intended for healthcare professionals


WHO keeps covid-19 a public health emergency of international concern

BMJ 2023; 380 doi: (Published 06 March 2023) Cite this as: BMJ 2023;380:p504

Linked Editorial

The World Health Organization’s pandemic treaty

Linked Opinion

Lack of preparedness for the next pandemic is an emergency

  1. Jodie McVernon, director of Doherty epidemiology1 2,
  2. Jonathan Liberman, associate professor in law and global health2
  1. 1Department of Infectious Diseases, University of Melbourne at Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
  2. 2University of Melbourne, Parkville, Australia
  1. Correspondence to: J McVernon j.mcvernon{at}

A sensible decision—the defining criteria still apply

On 30 January 2023 the director general of the World Health Organization, Tedros Adhanom Ghebreyesus, announced his decision that covid-19 remains a public health emergency of international concern (PHEIC),1 three years after the emergency was first declared.2 In doing so, Tedros acknowledged the advice of the covid-19 emergency committee that “the covid-19 pandemic is probably at a transition point.” There is considerable speculation about when the PHEIC will be terminated.3

PHEICs are determined by the director general under the International Health Regulations,4 the legal framework governing international disease spread. PHEICs are events that are deemed to be extraordinary, constitute a public health risk to other states through international spread of disease, and potentially require a coordinated international response.4 The subjectivity of the decision making is inescapable.

PHEICs are the highest and only alarm under the International Health Regulations.5 Whether they function effectively as such an alarm remains debatable.6 They also activate certain powers, including the ability of the WHO director general to issue “temporary recommendations.” These include health measures that affected and unaffected states may implement to prevent or reduce international spread of disease and avoid unnecessary interference with international traffic. While not legally binding, temporary recommendations are intended to guide state practice—both in measures that should be taken and in measures that should not be exceeded without adequate justification, particularly restrictions on international travel and trade.

Continuing risk

The director general’s recent determination that covid-19 still meets the PHEIC criteria is correct. Globally, SARS-CoV-2 remains an “extraordinary” risk to health based on reported rates of infection and disease.7 Moreover, transmission from humans to multiple mammalian species has been observed with minimal adaptation,8 and the size of these reservoirs is unknown. Against this backdrop, it remains highly likely that variants of concern will emerge that are more transmissible, more pathogenic, or otherwise able to evade public health and medical countermeasures.9

Variants of concern arise in one subpopulation or location but potentially constitute a public health risk to other states. Both rapid genomic identification and epidemiological characterisation are needed to assess new variants, a task becoming more challenging as surveillance efforts decline globally.1 Integration of covid-19 into existing infectious disease reporting systems remains a priority to enable ongoing risk assessment, including estimation of delayed health effects. WHO’s technical advisory group on virus evolution10 has recently been paying close attention to China’s omicron wave and the rapid rise to dominance of the XBB1.5 variant in the US as potential global threats.

But determining the risk of variants to settings other than their source requires efforts to understand transmission and pathogenicity in populations with different infection and vaccination histories.11 Global vaccine inequity contributes to ongoing disparity of health outcomes12 and perpetuates the risk of further variants of concern.13 Understanding of the effectiveness of covid-19 vaccines against transmission and severity of disease has shifted substantially over the past two years, but longer term data are needed to help assess the likely effect of new variants in different countries and to inform immunisation programmes to support resilience.14

Finally, a coordinated international response clearly remains essential to identify and mitigate ongoing risks from covid-19 and to support effective, evidence based communication. Current and emerging recommendations on public health and social measures, vaccines, and therapeutics are based on evidence that will continue to evolve. The current transition to endemicity assumes that risk of severe outcomes will continue to increase predictably with age, but a shift in pathogenicity to younger age groups would require a substantial review of prevention, control, and treatment strategies.15 Development of improved countermeasures16 agnostic to variant characteristics remains an important, internationally shared research and development priority.

These ongoing risks and uncertainties are challenging for decision making. The WHO emergency committee and the director general are clearly grappling with the potential risks of terminating the PHEIC designation and aiming for a careful transition when the time comes.1 These deliberations are occurring in parallel with substantial changes to global emergency governance arrangements. WHO member states are negotiating amendments to the International Health Regulations as well as a new legally binding agreement (most likely a treaty) on pandemic prevention, preparedness, and response.17 Proposals include the possibility of issuing intermediate public health alerts (short of PHEICs) and determining public health emergencies of regional concern.18 Notably, although covid-19 is routinely referred to as a pandemic, this word is not used in the International Health Regulations.

The early draft of the pandemic treaty contemplates a much broader agreement than the current International Health Regulations, including integrated human and animal surveillance systems for pathogens and variants with pandemic potential and equitable access to diagnostics, therapeutics, and vaccines.19 The definition of “pandemic” in the treaty, and the declaration or termination of such an event, will have far wider ramifications than those related to a PHEIC. It remains to be seen whether member states will be prepared to give WHO’s director general the authority to determine and terminate future pandemic events, and, if so, the criteria they will set for such decisions.


  • Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. JMcV receives research funding from the Australian government through the National Health and Medical Research Council and contracts with the Departments of Health and Aged Care and Foreign Affairs and Trade and WHO. JL holds research contracts with WHO.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

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