DevExplains: How will the COVID-19 health emergency end?

With COVID-19 cases and deaths on a decline globally, the world could be closer to ending its emergency phase in 2023.

“We're hopeful that at some point next year, we will be able to say that COVID-19 is no longer a global health emergency,” World Health Organization’s Director-General Tedros Adhanom Ghebreyesus said during a press briefing last week.

It has been almost three years since WHO declared the COVID-19 outbreak as a public health emergency of international concern, or PHEIC, considered the highest form of alarm the agency can declare in the hopes of moving the world into action in response to a global threat. But many countries have already moved on from treating it as an emergency, easing movement restrictions, changing testing guidelines, and dropping masks mandates that were put in place at the height of the crisis to reduce infections.

How COVID-19 plays out in countries in the Northern Hemisphere this winter could help pave the way in determining if it still constitutes a global emergency, although WHO officials said the expert committee and Tedros himself — who makes the final decision on the matter — will have a lot more to consider when they meet in January.

“It's not just the virus issues that matter. It's the response and the coordination and the need for that coordinated response,”  Dr. Michael Ryan, executive director of WHO’s Health Emergencies Programme, said in the same briefing. “So Dr. Tedros has a balance to strike here, between the virus, its impact, its unpredictability, and whether or not we have dealt with the vulnerabilities and the resilience issues in our health systems so we can cope.”

But what is the criteria for determining that a global health “emergency” is no longer one, and what happens if the classification is lifted for COVID-19?

How to end a PHEIC

The criteria to declare an end to the COVID-19 emergency will be up for discussion at the emergency committee in January, Tedros said.

The International Health Regulations, a binding treaty outlining WHO’s and member states’ obligations in a public health emergency, defines what constitutes a PHEIC. And the same criteria are usually used to determine when to call it off.

“[I]t’s logical that the emergency should end when the criteria for calling a PHEIC are no longer present. Yet there’s no political pressure to end a PHEIC and WHO has been haphazard and inconsistent in ending emergencies,” said Lawrence Gostin, a professor at Georgetown University and member of the committee in charge of reviewing the IHR.

Gostin said the IHR “should specify a clear process and criteria for ending PHEICs” — something that experts said should be done for determining a PHEIC — and WHO member states can do that as they discuss reforms to the regulations.

The consequences

Given that many countries have long moved on from dealing with COVID-19 as an emergency, some experts think ending COVID-19 as a PHEIC may not have much impact in the way countries are currently dealing with the outbreak.

“The international categorization is something for WHO to decide based on the data they have seen, based on the resources that are required, based on whether there are countries that are under threat or not,” Dr. Githinji Gitahi, CEO of Amref Health Africa and board member of the Coalition for Epidemic Preparedness Innovations, told Devex. “ It doesn't change how countries make their own decision to move forward.”

He said some countries in Africa such as Kenya are still maintaining their emergency operating centers, but countries are no longer just focusing their emergency response on COVID-19.

There are multiple reasons why the experts under the IHR emergency committee determined COVID-19 remain a global emergency back in October. At that time, they said weekly COVID-19 deaths remain higher compared to other diseases caused by a respiratory virus, and the virus continues to evolve and may pose challenges to the effectiveness of current vaccines and treatments. In addition, inequities persist between and within countries in accessing vaccines and treatments. Declaring that COVID-19 is not a global emergency anymore might only aggravate these inequities, and “demobilise” pandemic preparedness efforts.

But much of this is already happening even with a PHEIC declaration in place. Ryan said many countries have already “disinvested” in genomic and surveillance capacities because of fiscal pressures on their economy. This could affect efforts to track the evolution of the virus, and in ensuring the effectiveness of vaccines.

In Europe, for example, funding to maintain virus sequencing activities has decreased, affecting WHO’s ability to say “with very good precision” what’s happening with the virus and where it’s spreading, according to Dr. Catherine Smallwood, COVID-19 incident manager for WHO Europe.

Similarly, inequities in access to vaccines and treatments aren’t new. This was happening even at the height of the COVID-19 emergency, said Amref’s Dr. Gitahi.

“When the COVID emergency was at its height, Africa did not get vaccines at all, when it was actually a real emergency that people were dying,” he said.

One consequence of ending a PHEIC is the resumption of royalties in some licensing deals, such as Pfizer's licensing deal with the Medicines Patent Pool for its COVID-19 antiviral, Paxlovid.

“[O]nce the PHEIC is over[,] royalties will become payable to Pfizer on countries in the licence that aren’t classified as low-income. Although the royalty rates are not that high so there won’t be a lot of difference,” MPP Executive Director Charles Gore wrote in an email to Devex.

But it might have an impact on demand, which could lead to manufacturers terminating their licenses.

“[P]resumably once it stops being a PHEIC that means the number of cases is relatively low so decreased demand will definitely have an impact. For example some of our licensees might terminate their licences or if they haven’t finished development they might simply stop development,” Gore said.

That may not bode well for many low- and middle-income countries that still don’t have access to COVID-19 treatments like Paxlovid.

Much closer, but with some caveats

It’s not the first time that Tedros has made hopeful remarks regarding COVID-19. In September, he said the world has “never been in a better position to end the pandemic.” And in early December, he said the world is “much closer to being able to say the emergency phase is over.”

Those remarks however came with the same caveats — “we’re not there yet”. And during last week’s briefing, he and other WHO officials said a lot of uncertainties and challenges still remain in 2023.

“I think that's why Tedros has said sometime next year, because I believe he's a man who's not going to try and … predict the future in the heart of the winter season where this virus is really, in many countries, still spreading pretty much out of control,” Ryan said.

COVID-19 deaths remain in the thousands weekly, with close to 10,000 deaths reported in the past week globally. China, for one, is experiencing a surge in cases, with some researchers predicting a huge death toll. Only one in five people in low-income countries have been vaccinated, and there remains poor access to diagnostics and treatments in these countries. There also remains many people at high risk of developing severe disease, such as the elderly, who have not been vaccinated.

The virus also continues to evolve, but genomic sequencing in countries is declining. There’s also a question as to how prepared health systems are in addressing COVID-19 along with other respiratory diseases.

In Europe, Smallwood said they’re seeing an increase in COVID-19 hospitalizations, and there’s been an increase in intensive care unit admissions in some countries like France. But the increased circulation of other respiratory viruses, such as influenza and respiratory syncytial virus infection, including among children, together are putting some strain on hospitals.

So while the world may be moving away from a “constant state of emergency,” there remains a lot of “unpredictability”, and many factors need to be taken into account in lifting the global emergency classification on COVID-19, she said.

Having been a COVID-19 incident manager over the past three years, Smallwood said she’s wary of declaring victory against the virus too soon. “And so something that I always will be cautious in doing is saying, ‘Oh, we're done’.”