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Since the stipulation of IHR revision in 2005, WHO had constituted seven health events as the PHEIC: H1N1 influenza pandemic (2009), Ebola (2013-2015 and 2018-2020), Poliomyelitis (2014-present), Zika (2016), Covid-19 (2020 – present), and Monkeypox (present). Three major PHEICs have still been happening until now and were being recommended an extension although the response and control progress was apparent.
Despite the general reasons why such diseases gathered concern from international power are determined by the seriousness of health impact, nature of events, international risk, travel, and trade; exploring each outbreak event reveals unique rationales:
– The first PHEIC (H1N1 influenza) was facing several levels of pandemic phases before it is verified as a sustained human-to-human transmission whereby the cases had been exponentially high and spread around the world via air travel.
– After the first Ebola outbreak in 2013-2015 in West Africa, the second epidemic occurred in DR Congo which had experienced a delayed PHEIC declaration. However, as the Ebola-affected zones were located in the cross-border area with high travel volume, an exportation case finally happened.
– Vaccine-derived Poliovirus had resulted in exportation events to other countries while the target for Polio eradication is approaching.
– Zika virus epidemic was the first vector-borne disease constituted as PHEIC because of the unusual cluster of unknown complications.
– Covid-19 pandemic with unknown transmittable agents spread massively and caused ‘the death toll’ globally just in the daily count. Travel and trade restrictions led to socioeconomic disruption.
– Once Monkeypox was judged as PHEIC, it was considered as a source of controversy. But WHO has claimed rationales such as not stagnated cases, shortage of vaccine supply, and purpose of preventative measures.PHEIC is an unwanted declaration and predicting the future PHEIC seems like a titanic task whereby all countries are currently planning to not make it happen. However, looking at the side of dynamic transmission and country capacity, the future prediction of PHEIC will likely come from zoonotic diseases contributed by the impact of habitat loss, bushmeat hunting, livestock intensification, antimicrobial resistance, and animal transportation. The largest epidemic risk is shown by zoonotic influenza infection because their transmission mode is massive.
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Thanks for your insightful observation!
You have made a solid point about PHEIC being an undesirable declaration due to several factors that are mostly beyond the consideration of disease control. With the likely emergence of new zoonotic diseases, it would be interesting to see how the international threshold on the declaration will shift in response to the evolving pattern of new outbreaks.
Good job – two thumbs up!!
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The disease outbreak which is potential public health emergency of international concern (PHEIC) should have at least 2 of the following criteria.
1. Serious public health impact of the event
2. Unexpected or unusual event
3. Significant risk of international spread
4. Significant risk of international travel or trade restrictions
After such disease outbreak meets this criteria, the outbreak must be reported to WHO and WHO will make the final decision.Following is list of disease outbreaks with public health emergency of international concern (PHEIC) and the reasons why it is PHEIC.
– Monkeypox. There was unexpected case in some countries, for example, Thailand. In addition, there is a risk of international spread by trevellers.
– Covid-19 infection. The Covid-19 infection is a serious and severe disease that leads to morbidity and mortality. It is a pandemic disease throughout the world. Also, it is high risk of international spread and travel restriction.
– Kivu Ebola. It is a severe disease that leads to morbidity and mortality. Although, there was outbreak in some areas, it has a significant risk of international spread by refugee.
– Zika virus. The virus causes microcephaly of fetus in pregnant women. And it has a significant risk of international spread and travel restriction.
– Ebola. This is a serious and severe disease that causes mortality. Moreover, it is a highly infectious disease that has significant risk of international spread.
– Polio. The polio causes serious neurological sequalae, for example, paralysis. And there were unexpected cases reported in some areas.
– Swine flu. There was unusual incidence of swine flu infection in 2009. In addition, the outbreak was rapidly spread in the US and, later, worldwide.In the future, there will be an outbreak announced as PHEIC by WHO. The truth is the genome of infectious organism is continuously mutated, and emerges as new infectious pathogens. Moreover, people have to travel internationally for their business and recreation which keep the disease potential for international spread.
Thank you.
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Thanks for sharing your idea! I agree with your thoughts, especially on the genetic factors of microbes. With the latest COVID-19 pandemic, we have witnessed the problematic issue of disease control when we have to deal with the fast mutating organisms that render our preventive measures ineffective. I also hope that we could, someday, develop a countermeasure again such evolving threats or at least have an accurate prediction of such change in time for developing new control strategies.
Good job – keep it up!
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WHO has declared the Public Health Emergency of International Concern (PHEIC) a total of 7 announcements. In each announcement, there were the following reasons:
1. 2009, H1N1 influenza
-Serious? Yes (highly transmission, CFR 0.02%, vaccine unavailable at that time)
-Unusual/Unexpected? Yes (new emerging pathogen)
-International spread? Yes
-Trade/travel restriction? Yes2. 2014, Polio
-Serious? Yes (CFR 2-5% among children/ CFR 15-30% among adolescents and adults)
-Unusual/Unexpected? No
-International spread? Yes (WHO aims to eradicate for preventing a global resurgence of the disease)
-Trade/travel restriction? NO3. 2014, Ebola in Western Africa
-Serious? Yes (CFR 40-50%)
-Unusual/Unexpected? Yes (re-emerging pathogen)
-International spread? Yes
-Trade/travel restriction? Yes (WHO does not recommend general bans on travel or trade, or general quarantine of travelers arriving from Ebola-affected countries. However, 30 countries have instituted restrictions on travel from the three West African countries most affected by Ebola)4. 2015, Zika virus
-Serious? Yes (4-6% of pregnant people infected with the Zika virus have children with microencephaly )
-Unusual/Unexpected? Yes (new emerging disease)
-International spread? Yes (vector-borne disease)
-Trade/travel restriction? NO (If you are pregnant, you should NOT travel to areas with Zika outbreaks.)5. 2018, Ebola epidemic in Kivu region
-Serious? Yes (CFR 67%)
-Unusual/Unexpected? Yes (re-emerging pathogen)
-International spread? Yes
-Trade/travel restriction? Yes6. 2019, COVID-19
-Serious? Maybe Yes (CFR 3% [2017], available vaccine but limited)
-Unusual/Unexpected? Yes (new emerging pathogen)
-International spread? Yes (zoonotic and human-to-human transmission)
-Trade/travel restriction? Yes7. 2022, Monkeypox
-Serious? No (IFR 1.4%, highly spreading)
-Unusual/Unexpected? Yes (re-emerging pathogen)
-International spread? Yes
-Trade/travel restriction? NoIn the future, I really hope that the war between Ukraine and Russia will not use dirty bombs or nuclear weapons. However, if it would be used, it will cause public health emergency of international concern because radioactive substances not only cause serious disease, they can spread far into the air and contaminate water that can reach neighboring countries or go beyond that.
Feel free to correct me, If I’m wrong.
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I like your explanation of how each PHEIC is defined based on the criteria. It helps us confirm that WHO’s stipulation is strongly adequate. Another idea about radioactive substances seems neglected recently but is something needed to be aware of. With the uncertain situation of war, nearest countries are is recommended to structurize a contingency plan in order to mitigate the damaging effect of radioactive substances on human.
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The definition of PHEIC is defined in International Health Regulation (IHR) 2005.
There are many characteristics of PHEIC, however could group into 4 mains domains
1) Is the public health impact of the event serious?
2) Is the event unusual or unexpected?
3) Is there a significant risk of international spread?
4) Is there a significant risk of international travel or trade restrictions?
If 2 or more criteria are met, this would consider the potential PHEIC
So far, there is only small number of PHEIC declared by WHO including1) H1N1 pandemic, 2009
It’s observed unusual number of cases by Mexico firstly. After investigation, it was found that the strain is different the past. Due to limited immunization, it led to significant increase in the number of hospitalization and death.2) Polio eradication, 2014
Due to the nature of disease, it could lead to serious complication including that meningitis, paralysis and subsequently led to disability and death, The polio itself is very contagious. At that time there are many countries affected by polio epidemic and at risk of international spreading.3) Outbreak of Ebola in Western Africa, 2014
The index case is in small village in Guinea (Dec 2013) and spread to capital city of Guinea and subsequently spread to international level in the short time due to the Weak surveillance systems and poor public health infrastructure contributed to the difficulty surrounding the containment of this outbreak (may considered need of external support/assessment)4) Zika virus, 2015-2016
The health concern of Zika virus is the linkage to the microencephaly and other neurological complications. The decision of declared this event as PHEIC is due to the clusters of microencephaly. Apart from that, there is the risk of international spreading requiring the public attention from other country.5) Kivu Ebola Epidemic, 2019
The index case was found in Democratic Republic of the Congo (DRC) in the Goma, a city of almost two million people on the border with Rwanda, and the gateway to the rest of DRC and the world which may considered the risk of international spreading. At that time not only the international spreading is concerned. The high fatality rate (67%) is also the public health concern.6) SAR-CoV, 2019
As we all went through this situation, the SAR-CoV2 index was found in China and spread to other countries in very short timeline. The strain of the virus is new at that time. The travel and trade restriction were implemented.In term of the future PHEIC, the SAR-CoV2 in the country limited in vaccination including North Korea and others could led to the strain mutation and subsequently led to the outbreak in the future.
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1) The 2009 H1N1 pandemic
Mexico was the first country to report an unusually high number of cases. Following the completion of the investigation, it was discovered that the strain is distinct from those seen in the past. Because to the lack of vaccination, there was a huge rise in the number of people who ended up in the hospital or died.2) Polio eradication in 2014
As a result of the characteristics of the infection, it had the potential to cause catastrophic complications, such as meningitis and paralysis, which might ultimately result in death or disability. During that time period, an outbreak of polio has struck a number of countries, putting those nations at danger for its spread to other nations.3) Outbreak of Ebola in Western Africa, 2014
This epidemic was difficult to manage because it quickly spread to neighboring nations owing to inadequate monitoring systems and inadequate public health infrastructure, both of which added to the difficulties of the situation.4) Zika virus outbreak in 2015-2016
The Zika virus has been linked to a variety of neurological problems, including microencephaly. The clusters of microencephaly were the primary factor that led to the conclusion to classify this occurrence as PHEIC. Aside from that, there is the possibility that the disease would spread internationally, which would need the attention of the public in other countries.5) Kivu Ebola Epidemic, 2019
Since the Democratic Republic of the Congo (DRC) is a neighboring country of Rawanda and the Ebola outbreak in Kivu originated in DRC, there is a potential for the disease to move internationally . The high case fatality rate is also another reason that WHO consider the PHEIC.6) SAR-CoV in 2019
The SAR-CoV2 virus was originally discovered in China, and within a relatively short period of time, it spread to other nations. During that time period, the viral strain in question is novel. The restrictions on travel and commerce have been put into effect. It’s impact on social, political and economic factors are still be observed.Regarding future PHEIC, it will depend of the collective investment from high-income countries towards LMICs, strengthening public health emergency management is essential. Even with data from the COVID-19 pandemic, inequities still exist and paradoxical investment of health resources in high-income countries still exist. So, the question should not be will the next pandemic happen. It should be when the next pandemic happen, will the LMICs be prepared enough to prevent it.
From this lesson, I believe that the next pandemic will be mostly air-borne as it’s spread can be hard to contain without proper investments.
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The disease outbreaks that were declared as PHEIC are monkeypox, COVID-19, Kivu Ebola, Zika virus, Ebola, Polio, and H1N1 (swine flu). The outbreaks raised concerns because they met >/= 2 criteria of the following:
1. Is the public health impact of the event serious?
2. Is the event unusual or unexpected?
3. Is there a significant risk of international spread?
4. Is there a significant risk of international travel or trade restrictions?In my opinion, I think a disease that potentially led to PHEIC, in the future, is an infectious disease caused by mutated strain of viruses. Because people can move from one country to another within a day or an hour, this can increase overall risk of international spread very fast and deemed to be high. In addition, to be declared as PHEIC, a condition of disease potentially escalates the threat level which it possibly has no definitive treatment and causes life threatening.
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Thanks for sharing! I agree that most of the attention has been on viral disease in terms of the new PHEIC. It would be interesting to see how we could predict the probability of PHEIC from each potential mutated strain. Maybe, bioinformatics and statistical genetics could be able to help us with these predictions!
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There were seven diseases declared by WHO as Public Health Emergency of International Concern because these diseases reached at least two of the four criteria below.
Is the public health impact of the event serious? Is the event unusual or unexpected? Is there a significant risk for international spread? Is there a significant risk for international travel or trade restrictions?H1N1 influenza A (2009) H1N1 influenza was the novel influenza A which was not previously identified in animals and humans. Moreover, after the first emerged, it spread across the United States and the world.
Polio (2014) Polio virus could cause mobility issues after people become infected, paralytic polio followed by muscle weakness and extreme fatigue could happen. Fecal to Oral or Oral to Oral route transmission causes the risk of international spread among migrants where there is poor hygiene and a high number of non-vaccinated groups.
Ebola (2014) Ebola virus had a high rate of mortality from fluid loss and bleeding, and at that time it happened in the countries where health systems were weak. This outbreak caused the highest number of cases compared to previous outbreaks. There was an occurrence of cases outside the initial country, Guinea, including neighboring countries and other continents. Travel restrictions were recommended from unaffected countries.
Zika virus (2016) Even though Zika virus infections had shown mild symptom and asymptomatic cases, the occurrence of microcephaly, Guillain-Barré syndrome, and possibly other neurological defects linked to zika virus were unknown. Initially, there was international spread from French Polynesia to The Americas. Travel warnings had been announced from many countries especially for those pregnant who wanted to travel to infected areas.
Kivu Ebola (2018) This Ebola outbreak was the biggest outbreak in Democratic Republic of the Congo and military conflict had affected the ability of outbreak control with an unexpected number of infections and an impact on Public Health. Moreover, the transmission had internationally spread to neighboring countries.
COVID-19 (2020) COVID-19 could fit into every criterion: First, it potentially caused mortality, spreading areas were large and impacted health care workers. Second, the pathogen was unknown initially. Third, there were events found outside the initial country of outbreak caused by travel. Last, Because of airborne transmission and ability to stay in the air for a long period, Travel and Trade had to be halted.
Monkeypox (2022) Monkeypox had emerged in the area outside of West and Central Africa, and especially with MSM group. This was an unusual event and it spread internationally to many countries.
I would like to mention the infectious diseases which could possibly emerge by climate changes. Increasing of the temperature is one of the main changes which could cause temperature increase in areas where it used to be cold. These could lead to unusual growing of disease vectors such as mosquitoes or ticks in areas where it hasn’t been abundant before. These could create an unusual health event which harms people. Moreover, rising of water and floods could bring people exposure to water, possibly followed by water-borne diseases after the disaster. Finally, Bacteria or Viruses might adjust to the high temperature environment which would be harder to control.
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Thanks for sharing your idea and good job mentioning climate change as a factor that influences infectious diseases. This is one of the issues in planetary health that is likely to play a bigger role in these recent years!
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1)H1N1 Pandemic (Swine Flu) 2009
It was an unusual event of infection with a new strain of H1N1 at that time, starting from Mexico then spread quickly across the United States and the world. Some studies estimated that the real number of cases could be 11 -21% of global population at that time. The risk of serious illness was no higher than the previous flu, however, the report in late 2020 showed that this pandemic resulted in a large increase in the number of new cases of narcolepsy.
2)Polio eradication 2014
Poliovirus infection can cause permanent serious neurological condition. It spreads from person to person. There are unexpected cases in some areas and it has a risk of international spread by border crossing overland.
3)Ebola in Western Africa 2014
This was the most widespread outbreak of the disease before COVID19. It causes significantly mortality, with a considerate case fatality rate and socioeconomic disruption in the region.
4)Zika Virus Pandemic 2015-2016
This Zika virus is a cause of microcephaly and Guillain-Barre’ syndrome and it was the first time a PHEIC was declared for a mosquito-borne disease. This pandemic has started from Brazil and affected other countries.
5)Kivu Ebola Epidemic 2018-2019
This is a re-emerging of pathogen epidemic in the area that has risk of international spread into nearby country which has international airport or crossing into the massive refugee camps nearby area which has limited number of vaccines.
6)COVID-19 Outbreak 2019-present
This event is an unexpected massive spread globally outbreak and still ongoing. The airborne transmission mode makes it spread exponentially worldwide. The pandemic is one of the deadliest in history (as Nov2022) and triggered severe social and economic disruption around the world.
7)Monkeypox 2022
An ongoing outbreak of Monkeypox, unexpected initial cluster of cases traveled across the country from Nigeria endemic area) to UK. The number of cases outside endemic area has been increasing and its close skin-to-skin contact transmission has raise concerned in sexual transmission disease among particular groups.The spread of antimicrobial resistance might be one of the PHEIC in the future.
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(1) Could you list the disease outbreaks that have been declared as the Public Health Emergency of International Concern (PHEIC) and (2) Why do these outbreaks raise such concerns??
1. 2009 H1N1 pandemic – First index case was observed in Mexico, presented with symptoms resembling influenza. After further investigation, a new strain of influenza virus was identified in the US. It is more likely to raise concern as it has travelled across the states with a high morbidity and mortality.
2. 2014 Polio virus – no wonder why this is one of the most disabling outbreak and results in PHEIC declaration. This virus is highly contagious via faecal-oral route. A large number of people has been affected, causing severe disability across multiple countries before the vaccine become available.
3. 2014 Ebola outbreak in Western Africa and 2018-2019 Ebola, Kivu epidemic – This disease has a high mortality rate and difficult to detect in the first stage of infection. A lockdown has taken place throughout the affected states .
4. 2015-2016 Zika virus – This zoonotic disease is transmitted through the bite of Aedes mosquito family, which could potentially transmit across the country. A series of infant cases born with microcephaly and neurological disease was associated with this disease.
5. 2019 nCoV (COVID-19) – A pandemic with active cases to-date. With its rapid contagiousness and risks of complications in specific population, it has raised a red flag and public lockdown including travel restriction, place lockdown were taken into action.
6. 2022 Monkeypox – transmitted through close contact and cases were identified in many countries, including Thailand.(3) In your opinion, is there a disease or condition that may potentially lead to PHEIC in the future? Why?
I think the possibility of new emerging disease, especially a zoonotic disease can potentially lead to PHEIC declaration. As there is a group of people who are at risk of being exposed to unknown pathogens by going to places like a cave or even seek exotic animals for food. Also, historic diseases may be re-emerge again from climate change or inadequate control and elimination.
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Public Health Emergency of International Concern (PHEIC) is a formal declaration by WHO of an event that constitutes a public health risk to other countries through international spread or impact of disease and potentially requires a coordinated international response. The following list of disease outbreaks has been declared as PHEIC as it met at least 2 criteria to report as potential PHEIC.
Is the public health impact of the event serious?
Is the event unusual or unexpected?
Is there a significant risk of international spread?
Is there a significant risk of international travel or trade restrictions?2009 H1N1 pandemic – a virus is widespread globally (originated in Mexico and rapidly spread around the world via air travel), virus containment was unfeasibility at that stage, high pandemic mortality burden, and the vaccine was unavailable at that time
2014 Poliomyelitis – Poliovirus were infected among children and adults, spread internationally by travellers (on land and air). WHO aims to eradicate polio and requests more internationally coordinated efforts.
2014 Ebola (in Western Africa) – causing major loss of life and socioeconomic disruption in the region (high case-fatality rate), internationally spread of Ebola in West Africa.
2015-2016 Zika virus epidemic – There were clusters of microcephaly, Guillain-Barré syndrome and other neurological disorders reported in Brazil. Zika can cause severe complications such as haemorrhagic shock and death. Zika spread to other countries around the world via travellers.
2018-2019 Kivu Ebola epidemic – It is re-emerging pathogen epidemic and the disease potentially spread from Goma (as the city is a provincial capital with an airport with international flights.)
2019 COVID-19 Outbreak – An ongoing pandemic disease widely spread in many countries around the world with potential mortality. The disease is an airborne transmission. International travel and trade were restricted.
2022 Monkeypox – closed-contact transmission, predominantly occurring among MSM. The disease is widespread in many other countries outside of West and Central Africa.
In my opinion, the disease that originated from animals, mutation, and animal-to-human that causes respiratory conditions might potentially lead to PHEIC in the future. Most of the diseases declared as PHEIC are from where animals and humans are in close contact. The disease could spread widely and easily with respiratory symptoms (air-borne transmission) with travellers worldwide because the infected people often create aerosols when they cough or sneeze.
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