Posted: July 16, 2013
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Article SummaryOn July 15, 2013, Canadian Press medical reporter Helen Branswell asked for an interview about how the World Health Organization was setting itself up by convening an “Emergency Committee” to decide whether to recommend declaring the MERS coronavirus a “Public Health Emergency of International Concern” (PHEIC). With MERS infecting only small numbers of people, nearly all of them in Saudi Arabia, wouldn’t such a declaration invite claims that WHO was once again hyping an infectious disease risk? We scheduled an interview for the morning of the 16th. I sent Helen this email beforehand. In both the email and the interview, I stressed that the word “emergency” implies urgency. But a MERS pandemic isn’t imminent, I said; what WHO really needs to do is alert people that a MERS pandemic (someday) could be horrific. Despite the unfortunate nomenclature – including the awkward pronunciation of the “PHEIC” acronym as “fake” – WHO could do a lot more than it’s doing to clarify the distinction.

MERS Isn’t an “Emergency” … Yet

(a July 16, 2013 email to Helen Branswell of the Canadian Press)
Helen Branswell's July 16, 2013 article drew from
this email and a telephone interview that followed.

This is a response to your email about the “communications challenge” facing the World Health Organization and other public health agencies re MERS – especially the “emergency” language they are saddled with.

In hindsight, I’d guess WHO wishes the International Health Regulations had used different terms than “Emergency Committee” and “Public Health Emergency of International Concern” (PHEIC). Everybody thinks of an “emergency” as something that’s already imminent, something that requires people to drop what they’re doing and take urgent action now. By that standard, MERS obviously isn’t an emergency. What worries WHO and other public health agencies is the risk that it could become an emergency with very little warning.

WHO is rightly interested in identifying infectious diseases that might become emergencies before they do so … so it can develop an international response and make appropriate recommendations to national governments.

“Public Health Threat of International Concern” would have been a better label – suggesting seriousness rather than immediacy/urgency. Similarly, it would have helped to label the “Emergency Committee” a “Threat Assessment Committee” instead.

If I were in WHO’s shoes, I’d acknowledge this, straightforwardly and wryly:

Under the International Health Regulations, it’s called an “Emergency Committee.” It’s really a committee to advise us on whether we should ask the world to start preparing for a possible emergency. And what IHR calls a “Public Health Emergency of International Concern” is really a public health threat – a possible emergency – of international concern. A PHEIC declaration is a wake-up call, not an ambulance siren.

We apologize for the wrong impression these terms are giving some people. We’re not predicting a MERS pandemic or a widespread, deadly MERS outbreak. We’re worrying about the possibility of one, and asking the new MERS Emergency Committee to advise us on whether MERS looks threatening enough to merit an international wake-up call.

Wake-up calls are a big part of our job – which inevitably means that sometimes we rightly wake people up about a possible emergency that doesn’t turn into an actual emergency. The danger of doing that too much is something called “warning fatigue.” We warned the world about H5N1 bird flu and so far it has been very deadly but not very widespread – and many people felt we had hyped the risk. We warned people about H1N1 swine flu and it became extremely widespread but not nearly as deadly as we had feared – and many people felt we had hyped the risk. Now we’re looking at MERS, trying to decide whether to issue yet another warning.

What matters most about the International Health Regulations in this regard is the notification requirement. Member states are required to notify WHO immediately (within 24 hours) and directly (not through the rumor grapevine) whenever they become aware of a potential PHEIC. A PHEIC is a potential emergency, so a potential PHEIC is, in essence, a potential potential emergency. WHO only rarely declares a PHEIC (an actual potential emergency) – the 2009 swine flu pandemic was the only time so far since IHR was promulgated in 2005. The importance of a PHEIC declaration is that it gives WHO the right/obligation to make temporary international recommendations on how countries should cope – e.g. on whether there should be Hajj travel restrictions if MERS is declared a PHEIC.

Look at it stepwise:

  1. Right now, MERS is a potential PHEIC, a “potential potential emergency” – which is why KSA was obligated under IHR to report it to WHO, and why KSA is under continuing pressure to do better reporting. It’s also why other countries are being asked to watch for cases.
  2. The MERS Emergency Committee may or may not advise WHO Director-General Margaret Chan to declare MERS a PHEIC, “a potential emergency” – depending on whether it feels she needs to start telling member countries what she thinks they should do to prepare and respond (e.g. Hajj travel restrictions).
  3. MERS will be an emergency (nothing potential about it) if it starts spreading human-to-human more widely and more broadly (not just to close contacts, family members, and healthcare workers), looking like it’s about to go pandemic.
  4. It’ll be a dire emergency if it does that while remaining anywhere near as deadly as it is right now, especially if we still have no vaccine and no effective treatment.

In other words, a WHO PHEIC declaration really means, “Yes, this is an event that could turn into an international emergency. Countries should do X and Y now to try to prevent the emergency and prepare for it if it comes. Right now it’s a potential emergency.”

A notifiable event is a potential PHEIC, a potential potential emergency: It means, “Yes, the country that found it should tell WHO, so WHO can figure out whether to declare a PHEIC, and whether to tell other governments to take precautions.”

What matters most in all this is the obligation of Saudi Arabia – an obligation that has yet to be entirely honored – to tell WHO what’s going on, quickly and directly, so WHO can help assess the threat, advise KSA on what to do, and consider whether it needs to declare a PHEIC. Under IHR, WHO can declare a PHEIC and then convene an Emergency Committee; or, especially if there’s some controversy over whether it’s serious enough, it can convene an Emergency Committee to advise it on whether to declare a PHEIC. It chose the latter course this time. Importantly, the Emergency Committee is also charged with advising WHO on when a pathogen is no longer a PHEIC … clearly implying that there will be false alarms! (A pathogen can become no longer a PHEIC because the pandemic is over or because the virus is disappearing or becoming endemic without ever causing a pandemic.)

Bottom line: MERS is NOT an emergency, and nomenclature to the contrary is an unnecessary risk communication burden. But MERS genuinely is a new pathogen that could turn into an emergency with little warning. It’s more alarming than H5N1 or H7N9 for a number of reasons:

  • It’s the newest of the three, the latest to earn our attention.
  • It appears to be the most active, currently, in terms of human cases.
  • It’s the most mysterious, partly because of Saudi Arabia’s stunning opacity. We don’t even know what the animal reservoir is.
  • It has the worst prospects for even a minimally protective vaccine or drug. There is no existing vaccine or drug for any human coronavirus.
  • It has killed the highest percentage of known cases (though all three viruses have terrifyingly high case fatality rates).
  • It passes most readily from human to human. Unlike the other two, it has infected large clusters of health care workers.
  • It poses the most immediate international policy conundrum: whether to promulgate Hajj travel recommendations.

In my judgment, WHO has been too hesitant to tell the world how worrisome MERS really is. It has been admirably candid about the possibility that MERS might start spreading more widely. But it has focused more on the possibility of a SARS-like event than the possibility of a pandemic. And it has said very little about the possibility of a horrific pandemic with a case fatality rate far worse than any flu pandemic ever and, unlike flu, with no vaccine or antiviral deus-ex-machina in the works. WHO has not been forthcoming about the scariest scenario: an incredibly deadly pandemic that must be fought without meds, solely with non-pharmaceutical interventions. At that point doctors and public health professionals would matter less than experts in things like infrastructure maintenance, crowd control, and other aspects of disaster response.

But there is nothing to suggest that that scary scenario is about to emerge. It may not even be possible.

The problem with the word “emergency” is that it focuses too much on the urgency of the threat, and too little on its possible magnitude. Creating the misimpression that it thinks an international outbreak is about to happen won’t help WHO warn that a horrifically serious international outbreak might someday happen.

The main dilemma posed by MERS isn’t how to get ready this week for another SARS-like outbreak (MERS this time) that’s almost surely upon us. The main dilemma is how (and whether) to get ready for something much, much worse that MERS may someday launch … or may never come at all.

With all this language of “emergency,” WHO sounds like it’s warning about a risk that’s imminent but almost certainly not horrific. It is doing nothing to launch a dialogue about a risk that’s horrific but almost certainly not imminent.

Copyright © 2013 by Peter M. Sandman

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