The worst outcome of the two World Health Organization (WHO) pandemic negotiations currently underway would be the adoption of contradictory definitions and processes, warned Dr Mike Ryan, the head of health emergencies at the World Health Organization (WHO) on Friday.

“At the very minimum, the two instruments will need to be very aligned on the definitions they use,” stressed Ryan at a joint meeting of the Intergovernmental Negotiating Body (INB) negotiating a pandemic accord, and the Working Group on the International Health Regulations (WGIHR), which is amending the globally binding regulations relating to public health emergencies.

Twisted road from emergency to pandemic

The primary determination of the IHR is whether a  public health emergency of international concern (PHEIC) exists that requires the collective response of the member states, Ryan explained at Friday’s meeting.

“The binary nature of the PHEIC is sometimes difficult to deal with because, at one level you either have a PHEIC or you don’t, [but] the events don’t sit that easily,” said Ryan. 

Ryan suggested that member states could introduce a third category to indicate an “intermediate stage” that would enable WHO to say: “We’re very worried, but it’s not yet a PHEIC”. 

Surprisingly, the International Health Regulations (IHR) do not include a definition of a pandemic, whereas the INB has a draft definition in its compilation draft of a pandemic accord.

The textbook definition of a pandemic is “a public health emergency that represents a fully global threat that we expect to affect everyone in the population”, according to Ryan.

But declaring a pandemic is tricky as it usually had to be made before all countries have been affected and often when there isn’t yet enough data to determine the trajectory of a disease outbreak.

“So the question is, are you defining a pandemic that will occur are you defining a pandemic that has occurred? And when you still have a fighting chance of containing a disease, does a pandemic definition assist or not assist in that process?” he asked.

“You could argue that polio was a pandemic although it was never declared as a pandemic. You could also argue that Mpox was a pandemic because it affected people all over the world, but it affected a particular population segment all over the world. So you can get yourself into a lot of twisted discussions,” he warned.

“Do the member states want to introduce the concept of ‘pandemic’ formally into the process, or do you want to have that characterization built in as part of the declaration of PHEIC? They’re not exactly the same thing.”

Already, the process of getting as far as identifying a potential health risk is detailed and complicated.

“There is a very complex intelligence workflow, and this is going on 24 hours a day, 365 days a year, and being carried out by all of our regional and country offices with yourselves,” Ryan told member states.

“Around 60,000 different pieces of information are scanned a month, and at least 1000 signals of relevance are detected,” he added. Around 35 new health threats were considered for a formal rapid risk assessment by the Secretariat each month, with around five requiring assessment.

Country responses

In response to the challenges Ryan posed, the US suggested: “a tiered alert system under the IHR to better define stages of public health threats, enable better reporting incentives and to prevent local or regional outbreaks from becoming large-scale global health emergencies, including pandemic emergencies”. 

The US said that it viewed the “current PHEIC or binary approach as insufficient to trigger international coordinated action at earlier stages of outbreaks”. This was needed to “mobilise resources, facilitate early assistance and allow countries and regions to ramp up response measures in a more tailored and timely way”.

“Our proposal under the IHR also includes the pandemic emergency declaration within this tiered alert system to maintain consistency with the well-established framework to evaluate risks and to galvanise a coordinated global response to declared emergencies,” added the US representative.

“This IHR pandemic emergency declaration would be linked to the pandemic accord because of its ability to trigger activation of emergency response provisions within the accord.”

Brunei proposed “a simple definition of a pandemic as a PHEIC resulting from an emerging infectious disease with potential to overwhelm health systems”, and said its declaration should lie within the provisions of the IHR.

“While the IHR has its emphasis on the early spread of disease, it doesn’t say very much about what happens when the global spread is already well established. It is in this gap that we see a pandemic accord can be of most value by providing for a multilateral system for ensuring global health security in the event of sustained and prolonged disease spread,” added Brunei. 

The Brunei representative made a rather neat distinction between the two instruments, characterising the IHR as “emphasising the obligations of member states to the WHO, particularly in terms of reporting, surveillance and domestic implementation of standing recommendations of the Director General”, and the pandemic accord, which “could serve as an instrument that outlines the obligation of member states to each other”. 

Australia also supported strengthening the process to declare a PHEIC and new IHR provisions “to introduce criteria for declaration of a pandemic or pandemic emergency”.

“The criteria must be unambiguous and meaningfully differentiate between a pandemic and a PHEIC, and the definition of a pandemic should avoid restrictive criteria that might delay effective public health responses,” it stressed.

The joint WGIHR and INB meeting continues on Monday.

INB informal meetings to continue

Meanwhile, the public report back at the end of the sixth INB meeting on Friday yielded very little information other than that there will be more informal meetings to assist with its negotiations on the controversial Chapter Two on equity. 

The informal meetings will continue on research and development (Article 9), on access and benefit sharing (Article 12) and supply chain logistics (Article 13).

Three new informal meeting processes have been added to the already overloaded agenda. Informal meetings on the “co-development and transfer of technology and know-how” (Article 11) will be co-facilitated by Colombia, the Philippines and Saudi Arabia.

India, Tanzania, and the United Kingdom will co-facilitate informal talks on pandemic prevention and public health surveillance (Article 4) and “Strengthening pandemic prevention and preparedness through a One Health approach” (Article 5).