Intended for healthcare professionals


We need a universally endorsed definition of a pandemic for the Pandemic Accord to be effective

BMJ 2023; 382 doi: (Published 23 August 2023) Cite this as: BMJ 2023;382:p1946
  1. Noor Shakfeh, policy and health strategist1,
  2. Fifa A Rahman, civil society representative2,
  3. Katri Bertram, founding partner3
  1. 1Washington, DC, USA
  2. 2ACT-Accelerator
  3. 3Partners for Impact (PFI)
  1. Twitter: @NShakfeh @FifaRahman @KatriBertram

For the Pandemic Accord to be effective, member states must urgently focus negotiations to define its scope, including its definition of “pandemic,” and ensure the definition avoids the pitfalls of past mistakes, argue Noor Shakfeh, Fifa Rahman, and Katri Bertram

Member states of the Intergovernmental Negotiation Body (INB)1 have roughly nine months left before they need to present a draft outcome to the World Health Assembly in May 2024. While their negotiations to date have understandably focused on provisions related to access and benefit-sharing, and distribution of countermeasures, the implementation of these as well as all other provisions will ultimately depend on whether an outbreak meets member states’ negotiated definition of “pandemic.”

At a joint meeting in July 2023 with the working group to amend the International Health Regulations (WGIHR),2 member states met to discuss the scope of the accord, including the definition of a “pandemic.” Though formal negotiations on the term have yet to begin, member states’ interventions and a presentation by Mike Ryan, executive director of WHO’s Health Emergencies Programme, reflected the decisive impact the definition will have on the application of the accord in future outbreaks, including surge financing, access to, and distribution of pandemic-related products, and research and development.

Since the covid-19 pandemic began, the multilateral pandemic preparedness and response landscape has undergone transformation with the creation of the Pandemic Fund3; early development of a medical countermeasures platform for future pandemics4; governmental negotiations on a Pandemic Accord, revisions of the International Health Regulations (IHR 2005), and a UN political declaration on pandemic prevention, preparedness, and response.5 However, there is still no universally endorsed definition of “pandemic.” The INB Bureau text attempts to offer a definition for pandemic, which references a global outbreak of a pathogen with sustained human transmission, little immunity, high mortality, and causing social and economic disruptions that would require global collaboration to control.6

While the draft definition broadly references socio-economic impacts and the need for global collaboration, its specific references to morbidity, mortality, and immunity overemphasises technical criteria, which has historically failed to marshal quick political action needed from leaders during a major outbreak. In the early stages of other outbreaks where technical data were overly relied upon, such as Zika and covid-19, these data were not always readily ascertained, nor could they garner the necessary urgency to marshal a globally coordinated response. In the case of Zika, a public health emergency of international concern (PHEIC) was not declared until 1 February 2016,7 four months after the Pan American Health Organisation (PAHO) issued its first epidemiological update on the virus,8 and two months after PAHO recognised the link between Zika and microcephaly and 21 countries had already been affected.9 On the other end of the spectrum where morbidity was readily observed, the novel SARS-CoV-2 virus failed to trigger payout from the World Bank’s Pandemic Emergency Financing Facility (PEF) until it killed nearly 150 000 people globally and its casualty rates met the “exponential growth” requirement outlined in the bond prospectus.10

Repeating the mistake of over-relying on technical considerations and failing to give due consideration to socio-economic implications could hinder the accord’s ability to deliver member states’ ambitions to avoid the major disruptions that led them to embark on negotiating an accord and amendments processes in the first place. Critically, it could also undermine member states’ established aim to ensure equity in prevention and response—especially for those countries and regions with lesser international influence, limited surveillance and reporting capacity, and greater socio-economic vulnerability. Member states need to establish a definition with balanced and well calibrated technical and socio-economic considerations that can provide holistic situational awareness, especially during the early stages of an outbreak, to avoid repeating past mistakes and to ensure that the accord can achieve the ambition needed.

For ongoing pandemic reforms to be effective and sufficient, the definition of a “pandemic” cannot be left an afterthought—especially as an outbreak of Disease X becomes all but certain as the climate emergency continues to worsen.11 Member states will face challenging negotiations on this definition. There is no time to lose for member states to get this definition right, as it will determine the scope and effectiveness of the entire accord. We therefore call on member states to:

1) Urgently prioritise defining “pandemic,” ensuring alignment with all other pandemic-related agreements and processes being negotiated in parallel.

2) Ensure that technical data, such as mortality and immunity data, are not the sole or overemphasised metrics for defining a pandemic. The risk of an outbreak must be calibrated with socio-economic context.

3) Agree on a clear definition and resulting triggers, to ensure that past mistakes are not repeated, and utilise the expertise and experience of civil society, including communities and academia, to develop an effective definition conducive to a “no-regrets” approach.

4) Prioritise language that ensures solidarity and garners political mobilization, and overcomes narrow, national self-interests of a few countries at the cost of billions of people around the world.


  • Competing interests: NS is a global health consultant, 2022 Emerging Leader in Biosecurity Initiative Fellow, and holds patent US11615473B2: Resilience Measurement System; FAR is a Special Advisor for Health Poverty Action and Principal Consultant at Matahari Global Solutions; KB is a senior global health consultant. None further declared.

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