Statement on the twelfth meeting of the International Health Regulations (2005) Emergency Committee regarding the coronavirus disease (COVID-19) pandemic

The WHO Director-General concurs with the advice offered by the Committee regarding the ongoing COVID-19 pandemic and determines that the event continues to constitute a Public Health Emergency of International Concern (PHEIC).

The WHO Director-General considered the advice provided by the Committee regarding the proposed Temporary Recommendations. The set of Temporary Recommendations issued by the WHO Director-General is presented at the end of this statement.

The WHO Director-General is taking the opportunity to express his sincere gratitude to the Chair, and Members of the Committee, as well as to its Advisors.

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Proceedings of the meeting

On behalf of the WHO Director-General, the Executive Director of the WHO Health Emergencies Programme, Dr Michael J. Ryan, welcomed Members and Advisors of the Emergency Committee, all of whom were convened by videoconference.

Dr Ryan expressed concern regarding the current global COVID-19 epidemiological situation. Cases of COVID-19 reported to WHO had increased by 30% in the last two weeks, largely driven by Omicron BA.4, BA.5 and other descendent lineages and the lifting of public health and social measures (PHSM). This increase in cases was translating into pressure on health systems in a number of WHO regions. Dr Ryan highlighted additional challenges to the ongoing COVID-19 response: recent changes in testing policies that hinder the detection of cases and the monitoring of virus evolution; inequities in access to testing, sequencing, vaccines and therapeutics, including new antivirals; waning of natural and vaccine-derived protection; and the global burden of Post COVID-19 condition.

The Ethics Officer from the Department of Compliance, Risk Management, and Ethics briefed Members and Advisers on their roles and responsibilities. Members and Advisors were also reminded of their duty of confidentiality as to the meeting discussions and the work of the Committee, as well as their individual responsibility, to disclose to WHO, in a timely manner, any interests of a personal, professional, financial, intellectual or commercial nature that may give rise to a perceived or direct conflict of interest. Each Member and Advisor who was present was surveyed. No conflicts of interest were identified.

The Representative of the Office of Legal Counsel briefed the Members and Advisors on their roles and responsibilities and the mandate of the Emergency Committee under the relevant articles of the IHR.

The meeting was handed over to the Chair of the Emergency Committee regarding the COVID-19 pandemic, Professor Didier Houssin. The Chair introduced the objectives of the meeting: to provide views to the WHO Director-General on whether the COVID-19 pandemic continues to constitute a PHEIC, and to review temporary recommendations to States Parties.

The WHO Secretariat presented a global overview of the current status of the COVID-19 pandemic and highlighted a number of challenges to the ongoing response. The presentation focused on: the global COVID-19 epidemiological situation; the evolution of the virus and the impact of SARS-CoV-2 variants of concern; an update on international travel-related measures; the current status of COVID-19 vaccination and progress towards WHO vaccination targets; and 2022 WHO Strategic preparedness, readiness and response plan.

Deliberative session

The Committee discussed the following issues: the impact of SARS-CoV-2 virus evolution on the public health response and capacities of health services; progress towards increasing COVID-19 vaccination coverage; changes in testing and surveillance strategies; societal and political risk perception and community engagement; equity and access to countermeasures, vaccines and therapeutics; and maintaining political engagement while balancing the need to respond to other public health priorities and emergencies. The Committee discussed that SARS-CoV-2 virus had not yet established its ecological niche and that the implications of a pandemic caused by a novel respiratory virus may not be fully understood. Consequently, given the current shape and unpredictable dynamics of the COVID-19 pandemic, the Committee emphasized the need to reduce the transmission of SARS-CoV-2 virus. This requires the responsible, consistent, and continued use of individual-level protective measures, to the benefit of communities as a whole; as well as the continued adjustments of community-wide PHSM, to overcome the “all or nothing” binary approaches.

The Committee expressed concern as to the ongoing changes observed in States Parties with respect to steep reductions in testing, resulting in reduced coverage and quality of surveillance as fewer cases are being detected and reported to WHO; and fewer genomic sequences being submitted to open access platforms – resulting in a lack of representativeness of genomic sequences from all WHO regions. This impedes assessments of currently circulating and emerging variants of the virus, including the generation and analysis of phenotypic data. The above is translating into the increasing inability to interpret trends in transmission, and consequently to properly inform the adjustments of PHSM.

The epidemiology of SARS-CoV-2 virus infection remains unpredictable as the virus continues to evolve, through sustained transmission in the human population and in domestic, farmed, and wild animals in which the virus was newly introduced.

The Committee noted that both the trajectory of viral evolution and the characteristics of emerging variants of the virus remain uncertain and unpredictable, and, in the absence of the adoption of PHSM aiming at reducing transmission, the resulting selective pressure on the virus increases the probability of new, fitter variants emerging, with different degrees of virulence, transmissibility, and immune escape potential.

For these reasons, the Committee highlighted the need for all States Parties to continue to apply PHSM proportionate to their epidemiological situation, stressing the continued use of effective, individual-level protective measures to reduce transmission. The Committee acknowledged the ongoing challenges faced by States Parties in adjusting and implementing PHSM. The Committee acknowledged WHO’s advice to States Parties to regularly assess the epidemiological situation at sub-national levels and adjust PHSM proportionately. PHSM should be adjusted based on estimates of disease prevalence and population protection from infection and vaccination, as well as the capacities of the local health system (already challenged, inter alia, by staff shortages due to COVID-19 related burn-out).

The Committee highlighted the need to improve surveillance, by broadening and developing an array of approaches and tools aiming at achieving global situational population- based and geographic representativeness. These include, but are not limited to, the integration of self-testing results and sentinel surveillance approaches into national and global surveillance schemes, and aggregate sampling strategies with Nucleic Acid Amplification Test-based tools and detailed deep genome sequence probing. Novel surveillance approaches would enhance better assessment of trends in epidemiology of infection, disease, and viral evolution, as well as trends in health system capacity, and support agility and timely adjustments of PHSM. The Committee acknowledged the need to expedite integration of COVID-19 surveillance into routine systems, for instance by integrating COVID-19 surveillance with the surveillance of other respiratory pathogens; and recognized the potential value of supplementing surveillance with wastewater surveillance. In addition, access to timely and accurate testing, with linkage to clinical care and therapeutics, needs to be maintained.

The Committee recognised the continued work of WHO and partners in increasing vaccination coverage in all six WHO regions, with focus in achieving the highest possible vaccination coverage among persons at highest risk of severe disease outcomes and among persons at highest risk of exposure; as well as assessing and addressing barriers to vaccine uptake. However, given the persistent vaccine inequities, the Committee reinforced the need for ensuring that the highest priority groups are vaccinated in every country, with a primary series and booster dose, in accordance with WHO global vaccination strategy and the updated WHO SAGE Roadmap for prioritizing uses of COVID-19 vaccines. The Committee expressed concern over the lack of data shared with WHO on vaccination coverage in the high priority groups for 30% of the countries. The Committee acknowledged the disruption the pandemic continues to have on routine immunization activities, which is resulting in outbreaks of vaccine-preventable diseases in areas of low coverage.

The Committee highlighted that immediate efforts are warranted to promote access for Low and Middle Income Countries to therapeutics that reduce disease severity in both ambulant and hospitalised patients. The Committee warned that the lack of equitable access that occurred with vaccines should not be repeated with therapeutics. The Committee also highlighted the continued need for further research and development for COVID-19 in the areas of epidemiology and variants, diagnostics, clinical care including care for Post COVID-19 condition, and additional COVID-19 vaccines.

Given the general public’s perception that the pandemic may be over, the Committee also highlighted the ongoing challenges in communicating, particularly to communities that continue to experience high levels of transmission, that the mitigation of the impact of the ongoing COVID-19 pandemic, in the immediate and longer terms, depends on the use of PHSM. The Committee emphasised the importance of using learning from the last two and a half years to nuance the implementation of PHSM in individual communities. The Committee acknowledged that any risk communication and community engagement effort should hinge on consistent and synchronized political will, policies, and a concert of community influencers to shift the course of risk perception.

Status of the Public Health Emergency of International Concern

The Committee recognized an overall decoupling of incident cases from severe disease, deaths, and pressure on health systems in the context of increased population immunity.

However, the Committee unanimously agreed that the COVID-19 pandemic still meets the criteria of an extraordinary event that continues to adversely impact the health of the world’s population, and that the emergence and international spread of new SARS-CoV-2 variants may present an even greater health impact.

The Committee explicitly indicated the following reasons underpinning their advice to the WHO Director-General as to the event continuing to constitute a PHEIC.

Firstly, the recent increase in the growth rate of cases in many States Parties in different WHO regions.

Secondly, the continuing and substantial evolution of SARS-CoV-2 virus, which, while inherent to all viruses, is expected to continue in an unpredictable manner. Yet the ability to assess the impact of variants on transmission, disease characteristics, or countermeasures, including diagnostics, therapeutics and vaccines, is becoming increasingly difficult as a result of the inadequacy of current surveillance, including the reductions in testing and genomic sequencing. Additionally, there are uncertainties surrounding the level of readiness of already overburdened health systems, across all WHO regions, to respond to future COVID-19 pandemic waves.

Thirdly, public health and health planning tools to reduce transmission and disease burden (including hospitalisations and admissions to intensive care units of severe cases, and the impact of post COVID-19 condition) are not being implemented in proportion to local transmission levels or health system capacities.

Finally, there are inadequacies in risk communication and community engagement related to the need for the implementation or adjustment of PHSM, as well as a disconnect in the perception of risk posed by COVID-19 between scientific communities, political leaders and the general public.

For these reasons, continued coordination of the international response is necessary to reconsider approaches allowing for the accurate and reliable monitoring of the evolution of the COVID-19 pandemic and triggering of adjustments to PHSM. Coordination is also still necessary to intensify and sustain development and research efforts related to effective and equitably available countermeasures and to develop further risk communication and community engagement approaches.

The Committee considered the Temporary Recommendations proposed by the WHO Secretariat and provided its advice.

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Temporary Recommendations issued by the WHO Director-General to all States Parties

1. 1. MODIFIED: Strengthen national response to the COVID-19 pandemic by updating national preparedness and response plans in line with the priorities and potential scenarios outlined in the 2022 WHO Strategic Preparedness, Readiness and Response Plan. States Parties should regularly conduct assessments (including e.g. intra action and after action reviews) to inform current and future response, readiness and preparedness efforts, so that future challenges are rapidly identified and managed, including with tools and approaches different from those adopted in the context of the current shape of the pandemic. (WHO Strategic preparedness, readiness and response plan to end the global COVID-19 emergency in 2022)

1. 1. MODIFIED: Address risk communications and community engagement challenges and the need to address divergent perceptions in risk between scientific communities, political leaders and the general public. Proactively counter misinformation and disinformation, and include communities in decision-making. To rebuild trust and to address pandemic fatigue and risk perceptions, States Parties should explain clearly and transparently changes in the implementation of PHSM, as well as the uncertainties related to the evolution of the virus and related potential scenarios. Risk communication and community engagement efforts can only be effective in altering the course of current individual behaviours if underpinned by consistent strategies, policies and the political will to manage the COVID-19 pandemic, and concurrent public health risks, within and among States Parties. (WHO risk communications resources)

1. 1. MODIFIED: Achieve national COVID-19 vaccination targets in accordance with global WHO vaccination targets and the updated WHO SAGE Roadmap for prioritizing uses of COVID-19 vaccines. States Parties should determine and close the vaccination gap among high-risk populations to achieve the highest possible vaccination coverage among persons at highest risk of severe disease outcomes and among persons at highest risk of exposure, health workers, the elderly and other priority groups. This includes a primary series and booster dose as per WHO SAGE recommendations. In addition, States Parties must continue to support global equitable access to vaccines to achieve national coverage targets on the way to the WHO global COVID-19 vaccination targets, which includes 70% population coverage in every State Party for further disease reduction and protection against future risks. States Parties with less than 20% vaccination coverage should develop strategies and/or receive assistance to improve their status. States Parties need to ensure that routine immunization activities continue and may consider integrating COVID-19 vaccination into routine immunization services, such as the co-administration of COVID-19 vaccine and an inactivated seasonal influenza vaccine, as warranted. (WHO SAGE Prioritization Roadmap; Interim statement on the use of additional booster doses of Emergency Use Listed mRNA vaccines against COVID-19; Coadministration of seasonal inactivated influenza and COVID-19 vaccines)

1. 1. MODIFIED:. Continue to promote the use of effective, individual-level protective measures to reduce transmission (e.g. wearing of well-fitted masks, distancing, staying home when sick, frequent hand washing, avoiding closed spaces with poor ventilation, crowded places, improving and investing in ventilation of indoor spaces) in order to reduce transmission and slow down viral evolution. States Parties should be prepared to scale up PHSM rapidly in response to changes in the virus and the population immunity, as COVID-19 continues to have the potential to stretch the capacity of public health and health services, with hospitalizations, intensive care admissions, fatalities, management of the Post COVID-19 condition, and thus compromise the health system’s capacity not only to deliver COVID-19 related care, but also the care for other acute and chronic conditions (Considerations for implementing and adjusting PHSM in the context of COVID-19)

1. 1. MODIFIED: Take a risk-based approach to mass gathering events by evaluating, mitigating, and communicating risks. Recognizing that there are different drivers and risk tolerance for mass gatherings, it is critical to consider the epidemiological context (including the prevalence of variants of concern and the intensity of transmission), surveillance, contact tracing and testing capacity, as well as adherence to PHSM to reduce transmission risk of SARS-CoV-2 (e.g. request attendees wear well-fitted masks, provide outdoor spaces where attendees can eat and drink, reduce crowding, improve indoor ventilation) when conducting this risk assessment and planning events, in line with WHO guidance. (WHO mass gathering COVID-19 risk assessment tool: generic events)

1. 1. MODIFIED: Adjust COVID-19 surveillance to focus on the burden of COVID-19, its impact on health and public health services; and prepare for sustainable integration with other surveillance systems. States Parties should collect and publicly share indicators to monitor the burden of COVID-19 (e.g. new hospitalizations, admissions to intensive care units, deaths, and Post COVID-19 condition). States Parties should integrate respiratory disease surveillance, for instance by leveraging and enhancing the Global Influenza Surveillance and Response System (GISRS). States Parties should be encouraged to 1) maintain representative testing strategies; 2) focus on early warning and trend monitoring, including through the progressive development and introduction of environmental surveillance schemes (e.g., wastewater surveillance); 3) monitor severity in vulnerable groups; and 4) enhance laboratory surveillance to detect, track and characterize potential new variants and monitor the evolution of SARS-COV-2. (Guidance for surveillance of SARS-CoV-2 variants; WHO global genomic surveillance strategy for pathogens with pandemic and epidemic potential 2022–2032)

1. 1. MODIFIED: Make available essential health, social, and education services. States Parties should enhance access to health, including through the restoration of health services at all levels and strengthening of social systems to cope with the impacts of the pandemic, especially on children, young adults, and individuals with Post COVID-19 condition. Within this context, States Parties should maintain educational services by keeping schools fully open with in-person learning. In addition, essential health services, including COVID-19 vaccination, should be provided to migrants and other vulnerable populations as a priority. (Building health systems resilience for universal health coverage and health security during the COVID-19 pandemic and beyond: WHO position paper; The State of the Global Education Crisis | UNICEF; Clinical management of COVID-19: Living guideline)

1. 1. MODIFIED: Continue to adjust international travel-related measures, based on risk assessments. The implementation of travel measures (such as vaccination, screening, including via testing, isolation/quarantine of travelers) should be proportionate (based on risk assessments) and should avoid placing the financial burden on international travelers, in accordance with Article 40 of the IHR. (Policy considerations for implementing a risk-based approach to international travel in the context of COVID-19)

1. 1. EXTENDED: Do NOT require proof of vaccination against COVID-19 for international travel as the only pathway or condition permitting international travel. States Parties should consider a risk-based approach to the facilitation of international travel. (Interim position paper: considerations regarding proof of COVID-19 vaccination for international travelers; Policy considerations for implementing a risk-based approach to international travel in the context of COVID-19)

1. 1. MODIFIED: Support timely uptake of accurate and timely SARS-CoV-2 testing, linked to WHO recommended therapeutics. States Parties should provide access to COVID-19 treatments for vulnerable populations, particularly immunosuppressed people, and improve access to specific early treatments for patients at higher risk for severe disease outcomes. Local production and technology transfer related to vaccines, other therapeutics and diagnostics should be encouraged and supported as increased production capacity can contribute to global equitable access to therapeutics. (Therapeutics and COVID-19: living guideline; COVID-19 Clinical Care Pathway)

1. EXTENDED: Conduct epidemiological investigations of SARS-CoV-2 transmission at the human-animal interface and targeted surveillance on potential animal hosts and reservoirs. Investigations at the human animal interface should use a One Health approach and involve all relevant stakeholders, including national veterinary services, wildlife authorities, public health services, and the environment sector. To facilitate international transparency, and in line with international reporting obligations, findings from joint investigations should be reported publicly. (Statement from the Advisory Group on SARS-CoV-2 Evolution in Animals; Joint statement on the prioritization of monitoring SARS-CoV-2 infection in wildlife and preventing the formation of animal reservoirs)