With the COVID-19 PHEIC over, what next?

With the formal declaration of a public health emergency of international concern ending, what are the implications for international response efforts? John Zarocostas reports from Geneva. “It is time for countries to transition from emergency mode to managing COVID-19 alongside other infectious diseases”, declared WHO Director-General Tedros Adhanom Ghebreyesus on May 5, 2023, shortly after he had accepted the advice of the Emergency Committee to end the COVID-19 public health emergency of international concern (PHEIC). Tedros had declared COVID-19 a PHEIC on Jan 30, 2020. The decision to end the emergency was welcomed by global health leaders. “I think it was a very smart move. Tedros was right to end the PHEIC. No disease should be in a chronic state of emergency that goes on for years and years, because that dilutes the power of calling an emergency in the first place. Its saps public trust in governments or WHO in calling an emergency”, Lawrence Gostin, Professor of Global Health Law at Georgetown University (Washington, DC, USA), told The Lancet. “The world has moved on from COVID-19, and so, there would have been social and political costs for WHO if it dragged the COVID PHEIC out too long.” With the PHEIC now over, what happens next? When the PHEIC was declared in 2020, recommendations were included to support countries with weaker health systems; accelerate the development of vaccines, therapeutics, and diagnostics; review preparedness plans; identify gaps and evaluate the resources needed to identify, isolate, and care for people with COVID-19; and prevent transmission. Foremost, the PHEIC also required enhanced surveillance by WHO members and, as stipulated by the International Health Regulations (IHR), to report to WHO the outbreak and the evolution of the disease in their countries. Actions undertaken also included the procurement and distribution of scarce supplies of personal protective equipment, COVID-19 test kits, vaccines, medicines, and other medical equipment. WHO says that it is switching its focus towards the management of the disease as an established and ongoing health issue, and it has unveiled a roadmap to integrate COVID-19 surveillance and response activities into routine health programmes. On May 5, WHO said that state parties to the IHR should maintain reporting of mortality and morbidity data, as well as variant surveillance information to WHO. The Access to COVID-19 Tools Accelerator (ACT-A), first established in April, 2020, to accelerate the development and production of, and equitable access to, COVID-19 tests, treatments, and vaccines, will continue. COVID-19 Vaccines Global Access (COVAX)—the vaccines pillar of ACT-A that has so far delivered almost 2 billion vaccine doses to 146 countries—will continue to provide funded doses and delivery support throughout 2023, in line with demand. A spokesperson of Gavi, the Vaccine Alliance told The Lancet that COVAX does not expect any changes in the prices it pays for its procured doses for 2023, which are fixed as per the Advance Purchase Agreement contract. Partners in ACT-A are evaluating ways to ensure countries have access to COVID-19 tools until the end of 2025, and to maintain the ability to relaunch and collaborate on a large scale if COVID-19 surges again. The main thing, as one senior WHO health diplomat says, “is not to make the error of shutting down quickly”. Some of the partners, including The Global Fund to Fight AIDS, Tuberculosis and Malaria and UNICEF have resources, or long-term contracts in place, to continue until the end of 2025. As for the role of ACT-A in the longer term, some experts are of the view that there is no need to set up a new mechanism similar to the ACT-A for pandemic preparedness. Mohga Kamal-Yanni, Policy Co-Lead for the People's Vaccine Alliance, told The Lancet: “the moral of the story is that you don’t need a new body. Rather, the changes that need to happen to ensure equitable assess are the governments themselves have to commit to sharing doses of vaccines, medicines, or whatever.” The WHO Director-General will continue to authorise the use of the emergency use listing (EUL) procedure, a risk-based mechanism for assessing and listing unlicensed vaccines, therapeutics, and diagnostics with the aim of expediting the availability of these products to people affected by a public health emergency. The procedure has been often used during the pandemic, for example to make available mRNA vaccines and the first two in-vitro diagnostic tests for SARS-CoV-2. The termination of PHEIC, WHO officials said, should not affect access to vaccines and diagnostics that have already received an EUL, and state parties will be able to access these vaccines and diagnostics, provided the manufacturers continue production. In terms of vaccination policy, WHO has recommended that countries integrate COVID-19 vaccination into other immunisation programmes and maintain efforts to increase COVID-19 vaccination coverage for all people in the high-priority groups. Tedros has cautioned that the worst thing any country could do now is to use the news of the end of PHEIC “as a reason to let down its guard, to dismantle the systems it has built”. He has decided for the first time to use a provision of the IHR to develop long-term standing recommendations for countries on how to manage COVID-19. Didier Houssin, Chair of the Emergency Committee, told a news conference on May 5, that standing recommendations will allow “to better integrate risk assessment and risk management concerning COVID-19 in the broader framework of pandemic preparedness and response”. David Heymann, Professor of Infectious Disease Epidemiology at the London School of Hygiene & Tropical Medicine (London, UK), told The Lancet: “If standing recommendations are added to the IHR, it would seem they could be aimed at highly transmissible respiratory infections in general as preparedness for a future epidemic or pandemic of respiratory disease, and that excerpts from some of the excellent WHO guidelines for high transmission respiratory infections would be more useful as standing recommendations than specific guidelines for COVID-19, which are already available from WHO advisory groups.” “There might also be consideration about more equitable distribution of vaccines, therapeutics, and diagnostics when they become available during, and/or as preparedness, for future outbreaks, but this may not be within the scope of the IHR, and may, in fact, be covered in an eventual [pandemic] treaty.” The decision to invoke this IHR provision, Gostin and others noted, was highly appropriate and helps underscore that although the PHEIC is over, the global threat remains. “This virus will continue to cause waves. What we are hopeful of is that we have the tools in place to ensure that the future waves do not result in more severe disease, do not result in waves of death”, said Maria Van Kerkhove, WHO Technical Lead on COVID-19. Tedros is well placed to use the upcoming 2023 World Health Assembly (starting on May 21) and other major upcoming global gatherings to muster the necessary political and diplomatic support to finalise talks on a global pandemic accord and to revise the IHR—both viewed as necessary for strengthening global health security against future threats. Tedros believes the first-hand experience of the unprecedented pandemic “will be enough to drive the negotiations forward and have a good outcome by May, 2024”. Suerie Moon, Co-Director of the Global Health Centre at the Graduate Institute Geneva (Geneva, Switzerland), told The Lancet that it is difficult to predict how long it will take to conclude the IHR amendments and the pandemic instrument process. “In my view, they’re politically interlinked, so if one drags on, the other may very well drag on.” Moon and other health experts tracking the talks point out that some issues, such as diversification of production for vaccines, therapeutics, and diagnostics, have already marshalled substantial support. “I think the political commitment to diversification of production remains very high. I think people feel shocked. What's happened has not been forgotten in the countries that are left the furthest behind, and by that I mean sub-Saharan Africa in particular, and some other parts of the world.” Ellen ‘t Hoen, Director of Medicines Law & Policy, told The Lancet that the political processes to address more equity and diversification of production are in full motion and will not stop because of the end of the PHEIC. “A lot of the issues of expanding production, the transfer of technology, and the creation of mRNA hubs in sub-Saharan Africa, all of that is part of the talks”, she noted. But Hoen said what she is worried about the language in a final pandemic accord. In the area of questions on intellectual property rights, she noted: “The language is very weak. All the core themes are there, but the actual duties and obligations are very weak.”