On July 5, WHO announced that the organization is appointing an Emergency Committee under the International Health Regulations (IHR) for the Middle East Respiratory Syndrome (MERS). This is the first such committee to be appointed since the committee for Swine Flu in April 2009.
Procedures and legal framework
The Emergency Committee will meet by telephone on July 9 and on July 17. The membership list was announced on July 8. (After 2009, WHO was criticised for keeping the membership list secret until after the committee had ended its function.)
According to the IHR (Article 12), the Director-General of WHO may, based on inter alia the advice of an Emergency Committee, determine that an event, such as an outbreak of an infectious disease, constitutes a public health emergency of international concern (PHEIC).
A PHEIC is defined in the IHR (Article 1) as «an extraordinary event which is determined, as provided in these Regulations: (i) to constitute a public health risk to other States through the international spread of disease and (ii) to potentially require a coordinated international response».
An Emergency Committee is by definition temporary, and is made up of technical experts that are drawn from the IHR Expert Roster (Article 47) and from advisory panels to WHO. WHO Member States and intergovernmental organizations have since 2007 proposed members to this roster.
The tasks of the Emergency Committee (Article 48) are to advise the Director-General on whether an event constitutes a PHEIC, when this PHEIC can be considered over, and proposals for temporary recommendations (Article 15) to member states on health measures to «prevent or reduce the international spread of disease and minimize interference with international traffic» (Article 1), including modification and termination of these recommendations. These measures may concern travel advice, surveillance, clinical management, infection control and other areas (Article 18).
Member states are expected to follow the recommendations. If member states want to implement additional health measures, they must justify this according to a certain procedure (Article 43).
The main effect of a PHEIC declaration, is thus that WHO is given the power to issue temporary recommendations.
Will WHO declare MERS a PHEIC?
Since the IHR went into force on June 15, 2007 there have been several events that fits the definition of a PHEIC. Regardless of this, only the 2009 swine influenza pandemic has been declared a PHEIC (lasting from April 25, 2009 till 10 august, 2010). This probably means that WHO considers that not all such events need to be declared a PHEIC. The WHO probably will make such a determination only when it sees an actual need now or in the near future.
There are some costs of declaring a PHEIC:
Firstly, the administrative burden of convening an Emergency Committee, communicating with member states and so on may be substantial.
Secondly, the actual determination in itself may cause worries, influence people’s risk perception and lead to unnecessary measures, such as screening in airports or quarantining travellers. Labelling MERS as a PHEIC may lead to false beliefs in the dangers of this outbreak. (And this tendency is worsened by the fact that the only previous PHEIC was the 2009 influenza pandemic.) Thus, any declaration of a PHEIC needs to be accompanied by clear risk assessment and risk communication.
Still, the fact that WHO is convening an Emergency Committee, in my view, means that WHO is seriously considering declaring MERS a PHEIC. I see two reasons why WHO may consider this:
Firstly, the WHO may see a need for giving their advice to member states on this situation more weight by labelling the advice «temporary recommendations» under the IHR (Article 15). The current advice is that:
- member states «continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns», and «promptly assess and notify WHO of any new case of infection with MERS-CoV»,
- member states promptly investigate the source and mode of exposure for cases,
- doctors «maintain vigilance» and consider testing for MERS-CoV in travellers returning from the Middle East with severe acute respiratory infections, and that
- health care facilities «take appropriate measures to decrease the risk of transmission of the virus to other patients, health care workers and visitors».
WHO does not recommend screening at points of entry, travel restrictions or trade restrictions.
The WHO may not be satisfied with the pace of new information about the features of this new disease. The reservoir of the virus is still unknown, as is the source of infection for most cases.
Perhaps the WHO want to be prepared if the situation escalates, and member states are tempted to institute border measures to alleviate fears in their population. The WHO may then give temporary recommendations actively advising against screening, travel restrictions and trade restrictions.
Also, the WHO may want to be prepared if there is a need for temporary recommendations during the upcoming Hajj pilgrimage season (Mid-October).
Secondly, the WHO may simply want to underscore the seriousness of the MERS outbreak, put pressure on member states to contribute data, information and resources, and to put the organisation clearly in the coordinating seat and be ready for any developments.
Outcome of the two first meetings of the Emergency Committee
Following the second meeting of the Committee on July 17, WHO stated that the Director-General agreed with the Committee’s assessment «that the current MERS-CoV situation is serious and of great concern, but does not constitute a PHEIC at this time». The Committee will reconvene in September, at the latest.
The Committee underscored the need for «improved data Collection» and «full and timely reporting of all confirmed and probable cases» of MERS to WHO in accordance with the IHR.
Outcome of the third meeting of the Emergency Committee
Following the third meeting of the Committee on September 25, WHO stated that the Director-General «accepted the Committee’s assessment and thanked its Members for their advice» not to declare the MERS outbreak a PHEIC, and she followed this advice. The Committee will reconvene in November, at the latest.
The Committee underscored the need for «strengthening surveillance, especially in countries with pilgrims participating in Umrah and the Hajj».
Outcome of the fourth meeting of the Emergency Committee
Following the fourth Meeting of the Committee on December 4, 2013, WHO stated that the Director General «accepted the Committee’s assessment».
The Committee reiterated its previous advice and especially emphasized the need for «investigative studies, including international case-control, serological, environmental, and animal-human Interface studies, to better understand risk factors and the epidemiology».
Outcome of the fifth Meeting of the Emergency Committee
Following the fifth Meeting of the Committee on May 13, 2014, WHO stated that the Director General «accepted the Committee’s assessment».
The Committee «emphasized that its concern about the situation had significantly increased. Their concerns centred on the recent sharp rise in cases; systemic weaknesses in infection prevention and control, as well as gaps in critical information; and possible exportation of cases to especially vulnerable countries».
The Committee reiterated its previous advice and strongly urged WHO and Member States to, inter alia, «initiate and accelerate critical investigations, including case-control, serological, environmental, and animal studies, to better understand the epidemiology, especially risk factors and assess the effectiveness of control measures».
How dangerous is MERS?
The main factors in a risk assessment is virulence («severity»), transmissibility and population immunity. Information may come from studies of the virus, the reservoirs, the patients, the population, animal experiments, and epidemiological investigations around cases.
Virulence: The MERS-CoV is highly virulent and seems to be causing severe disease or even death in most patients (as of July 18, 45 of 88 known patients have died). However, we do not yet know the full clinical spectrum of this disease. There may be several milder cases that remain undiagnosed, and there are also examples of confirmed, mild cases.
Transmissibility: The reservoir of MERS-CoV is unknown and so is the source of infection for most known cases. The virus has been detected in dromedary camels, and some patients may have been infected by direct contact with camels. There have been a few instances of transmission between humans, especially in hospital and family care settings. Probably, the route of transmission between humans is droplet spread and direct contact with body fluids. Still, the transmission seems to be not very effective, and thus occur mostly in hospitals when infection control measures are not strictly adhered to.
Population immunity: It is likely that very few people have protective immunity against this virus.
In conclusion, MERS is currently not a great danger to global health. However, the case-fatality risk seems very high, much is still unknown about the origin of the virus, and cases are still occurring in the Middle East with occasional leakage to other countries by returning travellers. Pilgrimage to Saudi-Arabia may increase exportation of the virus by pilgrims.
This post will be updated as new information becomes available. See also Our MERS page.
- First version posted July 5 at 16:41 CET
- A few English language corrections on July 6 at 21:35 CET
- A link to the membership list was added on July 8 at 20:18 CET
- Dates for the Committee’s meetings were updated on July 10 at 09:05 CET
- Section on Outcome of the Committee’s two first Meetings added on July 20 at 09:20 CET
- Comment about Hajj in the last paragraph and added and case numbers updated on July 20 at 09:20 CET
- Outcome of the third meeting of the Emergency Committe added on September 25 at 10:40 CET.
- Outcome of the fourth meeting of the Emergency Committee plus some changes in risk assessment added on May 9, 20014 at 14:40 CET.
- Outcome of the fifth meeting of the Emergency Committee added on May 15, 2014 at 14:30 CET.