The World Health Organization (WHO) has ended the global health emergency for mpox, marking the end of a 10-month juggling act by the UN health agency as it scrambled to deal with concurrent global pandemics. 

The announcement arrives just days after WHO declared the end of the global health emergency for COVID-19 last Friday, three years and 6.9 million lives after the virus was elevated to a global pandemic in January 2020. 

At a press briefing at WHO’s Geneva headquarters on Thursday, Director-General Dr Tedros Adhanom Ghebreyesus said that despite the change in designation, both viruses still pose “significant health challenges”. 

“While the emergencies of mpox and COVID-19 are both over, the threat of resurgent waves remains for both,” Tedros said. “Both viruses continue to circulate, and both continue to kill. This does not mean the work is over.”

What now?

Tedros’ announcement follows a recommendation by WHO’s emergency committee on mpox hashed out at a prolonged closed-door meeting on Wednesday. The committee assessed that the virus no longer represented a public health emergency of international concern, and recommended an end to the emergency. 

Leaders of the emergency committee stressed that the end of the emergency is not the end of the fight against the virus – but the beginning of a policy shift. 

“Lifting the public health emergency of international concern in no way means that mpox is no longer an infectious disease threat,” said Dr Nicola Low, vice-chair of the mpox committee that issued the recommendation. “[It] means moving towards a strategy that is going to manage the long-term health risks posed by mpox rather than the emergency measures that are inherent in public health emergencies.”

The committee’s recommendations include integrating mpox into national pandemic prevention, preparedness and surveillance programmes, as well as sexual health services already in place for diseases like HIV. 

“It is critically important that we continue the efforts that have been initiated already,” said Dr Rosamund Lewis, technical lead for mpox at WHO’s health emergencies programme. “As long as the virus is given an opportunity to continue to transmit from person to person, it also has the opportunity to evolve.”

Affected communities are key to sustained success

Central to the WHO mpox committee’s policy recommendations is an emphasis on continued engagement with affected communities like men who have sex with men. 

Outside of the endemic African countries, men who have sex with men account for nearly all mpox cases, including 99% in the United States. Meanwhile, around half of all mpox infections have been in people living with HIV. 

Immunocompromised patients with HIV are not only at higher risk of severe disease from mpox, but also present an ideal environment for the virus to mutate and evolve to become more transmissible. 

Including mpox as standard in monitoring, detection and prevention programmes for sexually transmitted diseases will allow men who are already connected to sexual health services to be checked for mpox at the same time as other STIs – streamlining surveillance and treatment for both patients and health authorities, experts said. 

“Typically, around half of the cases have been among people who are living with HIV. Gay and bisexual men who have sex with men are the most affected population group here,” said Andy Seale, senior advisor at WHO on global HIV, hepatitis and sexually transmitted infections programmes. “Outbreaks like this start and end in communities and it is these communities that will help us be on top of the surveillance, the intelligence and the dynamics as the outbreak continues to evolve.” 

WHO experts also credited community organisations for their key role in helping to contain the outbreak of the virus through education, awareness, treatment and vaccination campaigns. 

“We now see steady progress in controlling the outbreak based on the lessons of HIV and working closely with the most affected communities,” Tedros said. “The work of community organisations together with public health authorities has been critical.” 

Endemic African countries are another story

Lost in the shuffle of the celebrations over the end of the mpox emergency is the reality that countries where the disease is endemic – such as the Democratic Republic of Congo and Nigeria – still have a steep hill to climb. 

While a vaccine intended for smallpox made by Danish company Bavarian Nordic was quickly deployed under emergency authorizations in the United States and Europe at the start of the mpox emergency, the manufacturer’s monopoly over the vaccine patent and limited stock prior to the global outbreak made access difficult, even for rich countries. 

“[We] recognize that there has been less than expected or less than desired commitments to vaccine equity and distribution, particularly to Africa,” Lowe said. “But it’s also recognized that we still have insufficient evidence about vaccine effectiveness from randomized control trials.”

Currently, WHO recommends the use of Bavarian Nordic’s vaccine primarily for post-exposure prophylaxis, and only for use in prevention under specific circumstances. Randomised control trials to improve data on the efficacy of the vaccine are being planned in endemic countries, Lowe said. 

Another obstacle to eradicating mpox is the mystery around how the strain of the virus that spread globally evolved to sustain prolonged human-to-human transmission. Until that question can be solved, the road to ridding the world of the virus remains a long one.

“How it went from a possible zoonotic source to the human population with amplification of transmission is something we don’t yet have information on,” Lewis said. “We need to continue to support countries and regions where this research on the origins of the virus that will be instrumental to our understanding going forward is ongoing.

“Countries in Africa were dealing with mpox long before this outbreak began, and will continue to deal with it for some time to come,” Lewis said.