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Public Health Emergency of International Concern

Topic: Social

 From HandWiki - Reading time: 16 min

Short description: Formal declaration by the World Health Organization
Logo of the World Health Organization, the authority that declares PHEICs

A Public Health Emergency of International Concern (PHEIC) is a formal declaration by the World Health Organization (WHO) of "an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response", formulated when a situation arises that is "serious, sudden, unusual, or unexpected", which "carries implications for public health beyond the affected state's national border" and "may require immediate international action".[1] Under the 2005 International Health Regulations (IHR), states have a legal duty to respond promptly to a PHEIC.[2][3] The declaration is publicized by an IHR Emergency Committee (EC) of international experts,[4] which was developed following the 2002–2004 SARS outbreak.[5]

Since 2009, there have been six PHEIC declarations:[6][7] the 2009 H1N1 (or swine flu) pandemic, the 2014 polio declaration, the 2014 outbreak of Ebola in Western Africa, the 2015–16 Zika virus epidemic,[8] the 2018–20 Kivu Ebola epidemic,[9] and the ongoing COVID-19 pandemic.[10][11] The recommendations are temporary and require reviews every three months.[1]

Automatically, SARS, smallpox, wild type poliomyelitis, and any new subtype of human influenza are considered as PHEICs and thus do not require an IHR decision to declare them as such.[12] A PHEIC is not confined to infectious diseases, and may cover an emergency caused by exposure to a chemical agent or radioactive material.[13] It can be seen as an "alarm system", a "call to action" and "last resort" measure.[14][15]

Background

Multiple surveillance and response systems exist worldwide for the early detection and effective response to contain the spread of disease. Time delays still occur for two main reasons, however. The first is the delay between the first case and the confirmation of the outbreak by the healthcare system, allayed by good surveillance via data collection, evaluation, and organisation. The second is when there is a delay between the detection of the outbreak and widespread recognition and declaration of it as an international concern.[5] The declaration is promulgated by an emergency committee (EC) made up of international experts operating under the IHR (2005),[4] which was developed following the SARS outbreak of 2002–2003.[5] Between 2009 and 2016, there were four PHEIC declarations.[7] The fifth was the 2018–20 Kivu Ebola epidemic that was announced on 17 July 2019.[9] The sixth was the 2019–20 COVID-19 pandemic.[10] Under the 2005 International Health Regulations (IHR), States have a legal duty to respond promptly to a PHEIC.[2]

Definition

PHEIC is defined as:

an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response.[16]

This definition designates a public health crisis of potentially global reach and implies a situation that is "serious, sudden, unusual, or unexpected", which may necessitate immediate international action.[16][17]

It can be seen as an "alarm system", a "call to action" and "last resort" measure.[14][15]

Reporting a potential concern

WHO Member States have 24 hours within which to report potential PHEIC events to the WHO.[12] It does not have to be a member state that reports a potential outbreak, hence reports to the WHO may also be received informally, by non-governmental sources.[18][19] Under the IHR (2005), ways to detect, evaluate, notify, and report events were ascertained by all countries in order to avoid PHEICs. The response to public health risks also was decided.[14]

The IHR decision algorithm assists WHO Member States in deciding whether a potential PHEIC exists and whether the WHO should be notified. The WHO should be notified if any two of the four following questions are affirmed:[12]

  • 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?

The PHEIC criteria include a list of diseases that always are notifiable.[18] SARS, smallpox, wild type poliomyelitis, and any new subtype of human influenza are always a PHEIC and do not require an IHR decision to declare them as such.[16]

Large scale health emergencies that attract public attention do not necessarily fulfill the criteria to be a PHEIC.[14] ECs were not convened for the cholera outbreak in Haiti, chemical weapons use in Syria, or the Fukushima nuclear disaster in Japan, for example.[13][20]

Further assessment is required for diseases that are prone to becoming pandemics, including, but not limited to cholera, pneumonic plague, yellow fever, and viral hemorrhagic fevers.[20]

A declaration of a PHEIC may appear as an economic burden to the state facing the epidemic. Incentives to declare an epidemic are lacking and the PHEIC may be seen as placing limitations on trade in countries that already are struggling.[14]

Emergency Committee

In order to declare a PHEIC, the WHO Director-General is required to take into account factors that include the risk to human health and international spread as well as advice from an international committee of experts, the IHR Emergency Committee (EC), one of whom should be an expert nominated by the State within whose region the event arises.[1] Rather than being a standing committee, the EC is created on an ad hoc basis.[21]

Until 2011, the names of IHR EC members were not publicly disclosed; in the wake of reforms, now they are. These members are selected according to the disease in question and the nature of the event. Names are taken from the IHR Experts Roster. The director-general takes the advice of the EC, following their technical assessment of the crisis using legal criteria and a predetermined algorithm after a review of all available data on the event. Upon declaration, the EC then makes recommendations on what actions the director-general and member states should take to address the crisis.[21] The recommendations are temporary and require review every three months while in place.[1]

Declarations

Summary of PHEIC declarations <timeline> ImageSize = width:1100 height:auto barincrement:15 PlotArea = left:120 bottom:75 top:0 right:30 Alignbars = justify DateFormat = mm/dd/yyyy Period = from:01/01/2005 till:01/11/2021 TimeAxis = orientation:horizontal format:yyyy

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 id: polio         value: rgb(0,0.42,0.21) legend: Polio
 id: ebola          value: rgb(0.52,0.71,0.25) legend: Ebola_(Western_Africa)
 id: zika          value: rgb(0.43,0.43,0.43) legend: Zika
 id: kebola          value: rgb(0.06,0.16,0.45) legend: Ebola_(Kivu)
 id: covid19          value: rgb(0.06,0.45,0.71) legend: COVID-19

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 bar:polio from:04/29/2014 till:01/11/2021 color:polio
 bar:ebola from:08/07/2014 till:03/29/2016 color:ebola
 bar:zika from:02/01/2016 till:11/18/2016 color:zika
 bar:kebola from:07/17/2019 till:06/26/2020 color:kebola
 bar:covid19 from:01/30/2020 till:01/11/2021 color:covid19

</timeline>

2009 swine flu declaration

H1N1 influenza virus

In the spring of 2009, a novel influenza A (H1N1) virus emerged. It was detected first in Mexico, North America. It spread quickly across the United States and the world.[22] On 26 April 2009,[23] more than one month after its first emergence,[5] the initial PHEIC was declared when the H1N1 (or swine flu) pandemic was still in phase three.[24]Cite error: Closing </ref> missing for <ref> tag The status achieved, as global eradication, was deemed to be at risk by air travel and border crossing overland, with small numbers of cases in Afghanistan, Pakistan, and Nigeria.[20][25]

In October 2019, continuing cases of wild polio in Pakistan and Afghanistan, in addition to new vaccine-derived cases in Africa and Asia, was reviewed and polio continued to be a PHEIC.[26] As of November 2021, taking into account recent events in Afghanistan, a large number of unvaccinated children, increasing mobile people in Pakistan and the risks associated with the COVID-19 pandemic among others, polio remains a PHEIC.[27]

2014 Ebola declaration

Confirmed cases of Ebola were being reported in Guinea and Liberia in March 2014 and Sierra Leone by May 2014. On Friday, 8 August 2014, following the occurrence of Ebola in the United States and Europe and with the already intense transmission ongoing in three other countries for months,[14] the WHO declared its third PHEIC in response to the outbreak of Ebola in Western Africa.[28] Later, one review showed that a direct impact of this epidemic on America escalated a PHEIC declaration.[5] It was the first PHEIC in a resource-poor setting.[14]

2016 Zika virus declaration

On 1 February 2016, the WHO declared its fourth PHEIC in response to clusters of microcephaly and Guillain–Barré syndrome in the Americas, which at the time were suspected to be associated with the ongoing 2015–16 Zika virus epidemic.[29] Later research and evidence bore out these concerns; in April, the WHO stated that "there is scientific consensus that Zika virus is a cause of microcephaly and Guillain–Barré syndrome."[30] This was the first time a PHEIC was declared for a mosquito‐borne disease.[20] This declaration was lifted on 18 November 2016.[31]

2018–20 Kivu Ebola declaration

In October 2018 and then later in April 2019, the WHO did not consider the 2018–20 Kivu Ebola epidemic to be a PHEIC.[32][33] The decision was controversial, with Michael Osterholm, director of the Center for Infectious Disease Research and Policy (CIDRAP) responding with disappointment and describing the situation as "an Ebola gas can sitting in DRC that's just waiting for a match to hit it",[34] while the WHO panel were unanimous in their decision that declaring it a PHEIC would not give any added benefit.[34] The advice against declaring a PHEIC in October 2018 and April 2019, despite the criteria for doing so appearing to be met on both occasions, has led to the transparency of the IHR EC coming into question. The language used in the statements for the Kivu Ebola epidemic has been noted to be different. In October 2018, the EC stated "a PHEIC should not be declared at this time". However, in the 13 previously declined proposals for declaring a PHEIC, the resultant statements quoted "the conditions for a PHEIC are not currently met" and "does not constitute a PHEIC". In April 2019, they stated that "there is no added benefit to declaring a PHEIC at this stage", a notion that is not part of the PHEIC criteria laid down in the IHR.[21][35]

After confirmed cases of Ebola in neighbouring Uganda in June 2019, Tedros Adhanom, the director-general of the WHO, announced that the third meeting of a group of experts would be held on 14 June 2019 to assess whether the Ebola spread had become a PHEIC.[36][37] The conclusion was that while the outbreak was a health emergency in the Democratic Republic of the Congo (DRC) and the region, it did not meet all the three criteria for a PHEIC.[38] Despite the number of deaths reaching 1,405 by 11 June 2019 and 1,440 by 17 June 2019, the reason for not declaring a PHEIC was that the overall risk of international spread was deemed to be low, and the risk of damaging the economy of the DRC high.[39] Adhanom also stated that declaring a PHEIC would be an inappropriate way to raise money for the epidemic.[40] Following a visit to the DRC in July 2019, Rory Stewart, the UK's DfID minister, called for the WHO to declare it an emergency.[41]

Acknowledging a high risk of spread to the capital of North Kivu, Goma, a call for a PHEIC declaration was published on 10 July 2019 in the Washington Post by Daniel Lucey and Ron Klain (the former United States Ebola response coordinator). Their declaration stated that "in the absence of a trajectory toward extinguishing the outbreak, the opposite path—severe escalation—remains possible. The risk of the disease moving into nearby Goma, Congo—a city of 1 million residents with an international airport—or crossing into the massive refugee camps in South Sudan is mounting. With a limited number of vaccine doses remaining, either would be a catastrophe".[42][43] Four days later, on 14 July 2019, a case of Ebola was confirmed in Goma, which has an international airport and a highly mobile population. Subsequently, the WHO announced a reconvening of a fourth EC meeting on 17 July 2019, when they officially announced it "a regional emergency, and by no means a global threat" and declared it as a PHEIC, without restrictions on trade or travel.[44][45] In response to the declaration, the president of the DRC, together with an expert committee led by a virologist, took responsibility for directly supervising action, while in protest of the declaration, health minister, Oly Ilunga Kalenga resigned.[46] A review of the PHEIC had been planned at a fifth meeting of the EC on 10 October 2019 [47] and on 18 October 2019 it remained a PHEIC[9] until 26 June 2020 when it was decided that the situation no longer constituted a PHEIC, as the outbreak was considered over.[48]

2019–22 COVID-19 declaration

Morphology of SARS-CoV-2

On 30 January 2020, the WHO declared the outbreak of COVID-19, centered on Wuhan in central China, a PHEIC.[10][49]

Map of WHO regional offices and their respective operating regions.
  Africa; HQ: Brazzaville, Republic of the Congo
  Americas; HQ: Washington, D.C., United States
  Eastern Mediterranean; HQ: Cairo, Egypt
  Europe; HQ: Copenhagen, Denmark
  South East Asia; HQ: New Delhi, India
  Western Pacific; HQ: Manila, Philippines

On the date of the declaration there were 7,818 cases confirmed globally, affecting 19 countries in five of the six WHO regions.[50][51] Previously, the WHO had held EC meetings on 22 and 23 January 2020 regarding the coronavirus pandemic,[52][53][54] but it was determined at that time that it was too early to declare a PHEIC, given the lack of necessary data and the (then) scale of global impact.[55][56]

The WHO recognized the spread of COVID-19 as a pandemic on 11 March 2020.[57] The third meeting of the emergency committee convened on 30 April 2020,[58] fourth on 31 July,[59] fifth on 29 October,[60] sixth on 14 January 2021,[61] seventh on 15 April 2021,[62] ninth in October 2021,[63] and tenth in January 2022.[64] As of April 2022, following the eleventh meeting it continues a PHEIC.[11]

Response

In 2018, an examination of the first four declarations (2009–2016) showed that the WHO was noted to be more effective in responding to international health emergencies, and that the international system in dealing with these emergencies was "robust".[8]

Another review of the first four declarations, with the exception of wild polio, demonstrated that responses were varied. Severe outbreaks, or those that threatened larger numbers of people, did not receive a swift PHEIC declaration, and the study hypothesized that responses were quicker when American citizens were infected and when the emergencies did not coincide with holidays.[5]

Non-declarations

2013 MERS

World MERS outbreak[65]

PHEIC was not invoked with the Middle Eastern Respiratory Syndrome (MERS) outbreak in 2013.[66][67] Originating in Saudi Arabia, MERS reached more than 24 countries and resulted in more than 580 deaths by 2015, although most cases were in hospital settings rather than sustained community spread. As a result, what constitutes a PHEIC has been unclear.[13][6] As of May 2020, there had been 876 deaths.[6][68]

Non-infectious events

PHEIC are not confined to only infectious diseases. It may cover events caused by chemical agents or radioactive materials.[13]

Debate exists regarding whether the emergence and spread of antimicrobial resistance may constitute a PHEIC.[69][70][71]

See also

References

  1. ↑ 1.0 1.1 1.2 1.3 WHO Q&A (19 June 2019). "International Health Regulations and Emergency Committees". https://www.who.int/features/qa/emergency-committees/en/. 
  2. ↑ 2.0 2.1 Eccleston-Turner, Mark; McArdle, Scarlett (2020). "The law of responsibility and the World Health Organisation: a case study on the West African ebola outbreak". in Eccleston-Turner, Mark; Brassington, Iain (in en). Infectious Diseases in the New Millennium: Legal and Ethical Challenges. Switzerland: Springer. pp. 89–110. ISBN 978-3-030-39818-7. https://books.google.com/books?id=79TkDwAAQBAJ&q=states+have+a+legal+duty+to+respond+promptly+to+a+PHEIC. 
  3. ↑ Collins, E. (2010). "13. Communication with the public". in Van-Tam, Jonathan (in en). Introduction to Pandemic Influenza. Wallingford, Oxford: CAB International. pp. 192. ISBN 978-1-84593-578-8. https://books.google.com/books?id=_IYYr9cjE30C&pg=PA195. 
  4. ↑ 4.0 4.1 "Strengthening health security by implementing the International Health Regulations (2005); About IHR". WHO. https://www.who.int/ihr/about/en/. 
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Hoffman, Steven J.; Silverberg, Sarah L. (18 January 2018). "Delays in Global Disease Outbreak Responses: Lessons from H1N1, Ebola, and Zika". American Journal of Public Health 108 (3): 329–333. doi:10.2105/AJPH.2017.304245. ISSN 0090-0036. PMID 29345996. 
  6. ↑ 6.0 6.1 6.2 Mullen, Lucia; Potter, Christina; Gostin, Lawrence O.; Cicero, Anita; Nuzzo, Jennifer B. (1 June 2020). "An analysis of International Health Regulations Emergency Committees and Public Health Emergency of International Concern Designations" (in en). BMJ Global Health 5 (6): e002502. doi:10.1136/bmjgh-2020-002502. ISSN 2059-7908. PMID 32546587. PMC 7299007. https://gh.bmj.com/content/bmjgh/5/6/e002502.full.pdf. 
  7. ↑ 7.0 7.1 Pillinger, Mara (2 February 2016). "WHO declared a public health emergency about Zika's effects. Here are three takeaways". Washington Post. https://www.washingtonpost.com/news/monkey-cage/wp/2016/02/02/who-declared-a-public-health-emergency-about-zikas-effects-here-are-three-takeaways/. (Subscription content?)
  8. ↑ 8.0 8.1 Hunger, Iris (2018) (in en-US). Coping with Public Health Emergencies of International Concern. 1. Oxford University Press. doi:10.1093/oso/9780198828945.003.0004. ISBN 978-0191867422. https://www.oxfordscholarship.com/view/10.1093/oso/9780198828945.001.0001/oso-9780198828945-chapter-4. (Subscription content?)
  9. ↑ 9.0 9.1 9.2 WHO Statement (18 October 2019). "Statement on the meeting of the International Health Regulations (2005) Emergency Committee for Ebola virus disease in the Democratic Republic of the Congo on 18 October 2019" (in en). https://www.who.int/news-room/detail/18-10-2019-statement-on-the-meeting-of-the-international-health-regulations-(2005)-emergency-committee-for-ebola-virus-disease-in-the-democratic-republic-of-the-congo. 
  10. ↑ 10.0 10.1 10.2 WHO Statement (31 January 2020). "Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV)" (in en). 31 January 2020. https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov). 
  11. ↑ 11.0 11.1 "Statement on the eleventh meeting of the International Health Regulations (2005) Emergency Committee regarding the coronavirus disease (COVID-19) pandemic" (in en). https://www.who.int/news/item/13-04-2022-statement-on-the-eleventh-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-coronavirus-disease-(covid-19)-pandemic. 
  12. ↑ 12.0 12.1 12.2 Mark A. Hall; David Orentlicher; Mary Anne Bobinski; Nicholas Bagley; I. Glenn Cohen (2018). "8. Public Health Law". Health Care Law and Ethics (9th ed.). New York: Wolters Kluwer. p. 908. ISBN 978-1-4548-8180-3. https://books.google.com/books?id=mwJODwAAQBAJ&pg=PA908. 
  13. ↑ 13.0 13.1 13.2 13.3 Halabi, Sam F.; Crowley, Jeffrey S.; Gostin, Lawrence Ogalthorpe (2017) (in en). Global Management of Infectious Disease After Ebola. Oxford University Press. pp. 110. ISBN 978-0190604882. https://books.google.com/books?id=nvzmDAAAQBAJ&pg=PA110. 
  14. ↑ 14.0 14.1 14.2 14.3 14.4 14.5 14.6 Rull, Monica; Kickbusch, Ilona; Lauer, Helen (8 December 2015). "Policy Debate | International Responses to Global Epidemics: Ebola and Beyond" (in en). International Development Policy 6 (2). doi:10.4000/poldev.2178. ISSN 1663-9375. 
  15. ↑ 15.0 15.1 Maxmen, Amy (23 January 2021). "Why did the world's pandemic warning system fail when COVID hit?" (in en). Nature 589 (7843): 499–500. doi:10.1038/d41586-021-00162-4. https://www.nature.com/articles/d41586-021-00162-4. Retrieved 29 April 2021. 
  16. ↑ 16.0 16.1 16.2 WHO Regulations (2005). "Annex 2 of the International Health Regulations (2005)". https://www.who.int/ihr/annex_2/en/. 
  17. ↑ Exter, André den (2015). "Part VI Public Health; Chapter 1.1 International Health Regulations (2005)" (in en). International Health Law and Ethics: Basic Documents (3rd ed.). Maklu. pp. 540. ISBN 978-9046607923. https://books.google.com/books?id=FhMACwAAQBAJ&pg=PA540. 
  18. ↑ 18.0 18.1 Davies, Sara E.; Kamradt-Scott, Adam; Rushton, Simon (2015) (in en). Disease Diplomacy: International Norms and Global Health Security. Johns Hopkins University Press. ISBN 978-1421416489. https://books.google.com/books?id=kvvVBgAAQBAJ&pg=PA61. 
  19. ↑ Lencucha, Raphael; Bandara, Shashika (18 February 2021). "Trust, risk, and the challenge of information sharing during a health emergency". Globalization and Health 17 (1): 21. doi:10.1186/s12992-021-00673-9. ISSN 1744-8603. PMID 33602281. 
  20. ↑ 20.0 20.1 20.2 20.3 Cite error: Invalid <ref> tag; no text was provided for refs named Gostin2016
  21. ↑ 21.0 21.1 21.2 Kamradt-Scott, Adam; Eccleston-Turner, Mark (1 April 2019). "Transparency in IHR emergency committee decision making: the case for reform" (in en). British Medical Journal Global Health 4 (2): e001618. doi:10.1136/bmjgh-2019-001618. ISSN 2059-7908. PMID 31139463. 
  22. ↑ Sara E. Davies; Adam Kamradt-Scott; Simon Rushton (2015). Disease Diplomacy: International Norms and Global Health Security. JHU Press. p. 95. ISBN 978-1-4214-1648-9. https://books.google.com/books?id=kvvVBgAAQBAJ&pg=PA95. 
  23. ↑ Director-General (2009). Implementation of the International Health Regulations (2005), Report of the Review Committee on the Functioning of the International Health Regulations (2005) in relation to Pandemic (H1N1) 2009. WHO. pp. 118. http://apps.who.int/gb/ebwha/pdf_files/WHA64/A64_10-en.pdf. 
  24. ↑ Renee Dopplick (29 April 2009). "Inside Justice | Swine Flu: Legal Obligations and Consequences When the World Health Organization Declares a 'Public Health Emergency of International Concern'". http://www.insidejustice.com/intl/2009/04/30/swine_flu_who_pheic/. 
  25. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named Wild2020
  26. ↑ "News Scan: Polio in Pakistan" (in en). 4 October 2019. http://www.cidrap.umn.edu/news-perspective/2019/10/news-scan-oct-04-2019. 
  27. ↑ "Statement of the Thirtieth Polio IHR Emergency Committee" (in en). https://www.who.int/news/item/23-11-2021-statement-of-the-thirtieth-polio-ihr-emergency-committee. 
  28. ↑ "Ebola outbreak in West Africa declared a public health emergency of international concern" (in en). 8 August 2014. http://www.euro.who.int/en/health-topics/emergencies/pages/news/news/2014/08/ebola-outbreak-in-west-africa-declared-a-public-health-emergency-of-international-concern. 
  29. ↑ WHO (1 February 2016). WHO Director-General summarizes the outcome of the Emergency Committee on Zika
  30. ↑ "Zika Virus Microcephaly And Guillain–Barré Syndrome Situation Report". World Health Organization. 7 April 2016. http://apps.who.int/iris/bitstream/10665/204961/1/zikasitrep_7Apr2016_eng.pdf?ua=1. 
  31. ↑ "Fifth meeting of the Emergency Committee under the International Health Regulations (2005) regarding microcephaly, other neurological disorders and Zika virus". WHO. https://www.who.int/mediacentre/news/statements/2016/zika-fifth-ec/en/. 
  32. ↑ Green, Andrew (20 April 2019). "DR Congo Ebola outbreak not given PHEIC designation". The Lancet 393 (10181): 1586. doi:10.1016/S0140-6736(19)30893-1. PMID 31007190. 
  33. ↑ "Statement on the meeting of the International Health Regulations (2005) Emergency Committee for Ebola virus disease in the Democratic Republic of the Congo on 12th April 2019". World Health Organization. 12 April 2019. https://www.who.int/news-room/detail/12-04-2019-statement-on-the-meeting-of-the-international-health-regulations-(2005)-emergency-committee-for-ebola-virus-disease-in-the-democratic-republic-of-the-congo-on-12th-april-2019. 
  34. ↑ 34.0 34.1 Cohen, Jon (12 April 2019). "Ebola outbreak in Congo still not an international crisis, WHO decides" (in en). https://www.science.org/content/article/ebola-outbreak-congo-still-not-international-crisis-who-decides. 
  35. ↑ Lancet, The (25 May 2019). "Acknowledging the limits of public health solutions" (in en). The Lancet 393 (10186): 2100. doi:10.1016/S0140-6736(19)31183-3. ISSN 0140-6736. PMID 31226033. 
  36. ↑ Hunt, Katie. "Ebola outbreak enters 'truly frightening phase' as it turns deadly in Uganda" (in en). https://edition.cnn.com/2019/06/12/health/ebola-outbreak-death-uganda-africa-intl-bn/index.html. 
  37. ↑ Gladstone, Rick (12 June 2019). "Boy, 5, and Grandmother Die in Uganda as More Ebola Cases Emerge" (in en-US). The New York Times. ISSN 0362-4331. https://www.nytimes.com/2019/06/12/world/africa/ebola-uganda-congo.html. 
  38. ↑ "Statement on the meeting of the International Health Regulations (2005) Emergency Committee for Ebola virus disease in the Democratic Republic of the Congo on 14 June 2019" (in en). https://www.who.int/news-room/detail/14-06-2019-statement-on-the-meeting-of-the-international-health-regulations-(2005)-emergency-committee-for-ebola-virus-disease-in-the-democratic-republic-of-the-congo. 
  39. ↑ Souchary, Stephanie (17 June 2019). "Ebola case counts spike again in DRC" (in en). http://www.cidrap.umn.edu/news-perspective/2019/06/ebola-case-counts-spike-again-drc. 
  40. ↑ Soucheray, Stephanie (16 July 2019). "WHO will take up Ebola emergency declaration question for a fourth time" (in en). http://www.cidrap.umn.edu/news-perspective/2019/07/who-will-take-ebola-emergency-declaration-question-fourth-time. 
  41. ↑ Wintour, Patrick (7 July 2019). "Declare Ebola outbreak in DRC an emergency, says UK's Rory Stewart" (in en-GB). The Guardian. ISSN 0261-3077. https://www.theguardian.com/world/2019/jul/07/declare-ebola-outbreak-in-drc-an-emergency-says-uks-rory-stewart. 
  42. ↑ Soucheray, Stephanie (11 July 2019). "Three more health workers infected in Ebola outbreak" (in en). http://www.cidrap.umn.edu/news-perspective/2019/07/three-more-health-workers-infected-ebola-outbreak. 
  43. ↑ Klain, Ronald A.; Lucey, Daniel (10 July 2019). "Opinion | It's time to declare a public health emergency on Ebola" (in en). Washington Post. https://www.washingtonpost.com/opinions/its-time-to-declare-a-public-health-emergency-on-ebola/2019/07/10/c77641fc-a327-11e9-b732-41a79c2551bf_story.html. 
  44. ↑ "Ebola outbreak in the Democratic Republic of the Congo declared a Public Health Emergency of International Concern" (in en). 17 July 2019. https://www.who.int/news-room/detail/17-07-2019-ebola-outbreak-in-the-democratic-republic-of-the-congo-declared-a-public-health-emergency-of-international-concern. 
  45. ↑ "Ebola outbreak declared public health emergency" (in en-GB). BBC News. 17 July 2019. https://www.bbc.com/news/health-49025298. 
  46. ↑ Schnirring, Lisa (22 July 2019). "DRC health minister resigns after government takes Ebola reins" (in en). http://www.cidrap.umn.edu/news-perspective/2019/07/drc-health-minister-resigns-after-government-takes-ebola-reins. 
  47. ↑ Schnirring, Lisa; 9 October 2019. "Response resumes following security problems in DRC Ebola hot spot" (in en). http://www.cidrap.umn.edu/news-perspective/2019/10/response-resumes-following-security-problems-drc-ebola-hot-spot. 
  48. ↑ "Final Statement on the 8th meeting of the International Health Regulations (2005)" (in en). 26 June 2020. https://www.who.int/news-room/detail/26-06-2020-final-statement-on-the-8th-meeting-of-the-international-health-regulations. 
  49. ↑ Ramzy, Austin; Jr, Donald G. McNeil (30 January 2020). "W.H.O. Declares Global Emergency as the new Coronavirus Spreads" (in en-US). The New York Times. ISSN 0362-4331. https://www.nytimes.com/2020/01/30/health/coronavirus-world-health-organization.html. 
  50. ↑ WHO Report (30 January 2020). "Novel Coronavirus(2019-nCoV): Situation Report-10". WHO. 30 January 2020. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200130-sitrep-10-ncov.pdf?sfvrsn=d0b2e480_2. 
  51. ↑ "Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV)". WHO. 30 January 2020. https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov). 
  52. ↑ Fifield, Anna; Sun, Lena H. (23 January 2020). "Nine dead as Chinese coronavirus spreads, despite efforts to contain it". The Washington Post. https://www.washingtonpost.com/world/asia_pacific/nine-dead-as-chinese-coronavirus-spreads-despite-efforts-to-contain-it/2020/01/22/1eaade72-3c6d-11ea-afe2-090eb37b60b1_story.html. 
  53. ↑ Schnirring, Lisa (22 January 2020). "WHO decision on nCoV emergency delayed as cases spike" (in en). http://www.cidrap.umn.edu/news-perspective/2020/01/who-decision-ncov-emergency-delayed-cases-spike. 
  54. ↑ WHO Statement (22 January 2020). "WHO Director-General's statement on IHR Emergency Committee on Novel Coronavirus" (in en). 22 January 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-statement-on-ihr-emergency-committee-on-novel-coronavirus. 
  55. ↑ Joseph, Andrew (23 January 2020). "WHO declines to declare China virus outbreak a global health emergency" (in en-US). https://www.statnews.com/2020/01/23/who-declines-to-declare-china-virus-outbreak-a-global-health-emergency/. 
  56. ↑ WHO Statement (23 January 2020). "Statement on the meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus 2019 (n-CoV) on 23 January 2020" (in en). https://www.who.int/news-room/detail/23-01-2020-statement-on-the-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov). 
  57. ↑ "WHO Director-General's opening remarks at the media briefing on COVID-19 – 11 March 2020". World Health Organization. 20 March 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020. 
  58. ↑ "Statement on the third meeting of the IHR (2005) Emergency Committee regarding the outbreak of coronavirus disease (COVID-19)" (in en). 1 May 2020. https://www.who.int/news-room/detail/01-05-2020-statement-on-the-third-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-coronavirus-disease-(covid-19). 
  59. ↑ "Statement on the fourth meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of coronavirus disease (COVID-19)" (in en). https://www.who.int/news/item/01-08-2020-statement-on-the-fourth-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-coronavirus-disease-(covid-19). 
  60. ↑ "Statement on the fifth meeting of the International Health Regulations (2005) Emergency Committee regarding the coronavirus disease (COVID-19) pandemic" (in en). https://www.who.int/news/item/30-10-2020-statement-on-the-fifth-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-coronavirus-disease-(covid-19)-pandemic. 
  61. ↑ "Statement on the sixth meeting of the International Health Regulations (2005) Emergency Committee regarding the coronavirus disease (COVID-19) pandemic" (in en). https://www.who.int/news/item/15-01-2021-statement-on-the-sixth-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-coronavirus-disease-(covid-19)-pandemic. 
  62. ↑ "Statement on the seventh meeting of the International Health Regulations (2005) Emergency Committee regarding the coronavirus disease (COVID-19) pandemic" (in en). https://www.who.int/news/item/19-04-2021-statement-on-the-seventh-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-coronavirus-disease-(covid-19)-pandemic. 
  63. ↑ "Statement on the ninth meeting of the International Health Regulations (2005) Emergency Committee regarding the coronavirus disease (COVID-19) pandemic" (in en). https://www.who.int/news/item/26-10-2021-statement-on-the-ninth-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-coronavirus-disease-(covid-19)-pandemic. 
  64. ↑ "Statement on the tenth meeting of the International Health Regulations (2005) Emergency Committee regarding the coronavirus disease (COVID-19) pandemic". 19 January 2022. https://www.who.int/news/item/19-01-2022-statement-on-the-tenth-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-coronavirus-disease-(covid-19)-pandemic. 
  65. ↑ "WHO | MERS-CoV". http://www.who.int/csr/don/archive/disease/coronavirus_infections/en/. 
  66. ↑ Robert Herriman (17 July 2013). "MERS does not constitute a Public Health Emergency of International Concern (PHEIC): Emergency committee". The Global Dispatch. http://www.theglobaldispatch.com/mers-does-not-constitute-a-public-health-emergency-of-international-concern-pheic-emergency-committee-32451/. 
  67. ↑ David R Curry (20 July 2013). "WHO Statement: Second Meeting of the IHR Emergency Committee concerning MERS-CoV – PHEIC Conditions Not Met | global vaccine ethics and policy". Center for Vaccine Ethics and Policy. http://centerforvaccineethicsandpolicy.net/2013/07/20/who-statement-second-meeting-of-the-ihr-emergency-committee-concerning-mers-cov-pheic-conditions-not-met/. 
  68. ↑ "WHO | Middle East respiratory syndrome coronavirus (MERS-CoV) – Saudi Arabia". http://www.who.int/csr/don/05-may-2020-mers-saudi-arabia/en/. 
  69. ↑ "Can the International Health Regulations apply to antimicrobial resistance?" (in en-us). https://medicalxpress.com/news/2011-04-international-health-antimicrobial-resistance.html. 
  70. ↑ Wernli, Didier; Haustein, Thomas; Conly, John; Carmeli, Yehuda; Kickbusch, Ilona; Harbarth, Stephan (April 2011). "A call for action: the application of The International Health Regulations to the global threat of antimicrobial resistance". PLOS Medicine 8 (4): e1001022. doi:10.1371/journal.pmed.1001022. ISSN 1549-1676. PMID 21526227. 
  71. ↑ Kamradt-Scott, Adam (19 April 2011). "A Public Health Emergency of International Concern? Response to a Proposal to Apply the International Health Regulations to Antimicrobial Resistance" (in en). PLOS Medicine 8 (4): e1001021. doi:10.1371/journal.pmed.1001021. ISSN 1549-1676. PMID 21526165. 

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