Fifth meeting of the International Health Regulations (2005) Emergency Committee regarding the upsurge of mpox 2024

The Director-General of the World Health Organization (WHO) is hereby transmitting the report of the fifth meeting of the International Health Regulations (2005) (IHR) Emergency Committee (Committee) regarding the upsurge of mpox 2024, held on Thursday, 4 September 2025, from 12:00 to 17:00 CEST.

Concurring with the advice and considerations expressed by the Committee during the meeting, the WHO Director-General, on 5 September 2025, determined that the upsurge of mpox 2024 no longer constitutes a public health emergency of international concern (PHEIC). The WHO Director-General, following further thorough consideration of the advice by the Committee to issue temporary recommendations, considers that the current standing recommendations for mpox, extended until 20 August 2026, are adequate to inform actions by all States Parties to control the spread of mpox.

The WHO Director-General expresses his most sincere gratitude to the Chair, Members, and Advisors of the Committee for the thoughtful advice they provided and their tireless commitment.

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Proceedings of the meeting

Sixteen (16) Members of, and two Advisors to, the International Health Regulations (2005) (IHR or Regulations) Emergency Committee regarding the upsurge of mpox 2024 (Committee) were convened by teleconference, via Zoom, on Thursday, 4 September 2025, from 12:00 to 17:00 CEST. Eleven (11) of the 16 Committee Members, and the two Advisors to the Committee participated in the meeting.

The Director-General of the World Health Organization (WHO) joined in person and welcomed the participants, including Government Officials designated to present their views to the Committee on behalf of the two invited States Parties - the Democratic Republic of the Congo (DRC), Sierra Leone, Uganda, and the United Kingdom. The opening remarks by the Director-General are available here.

The Representative of the Office of Legal Counsel then briefed the Members and Advisors on their roles and responsibilities and identified the mandate of the Committee under the relevant articles of the IHR. The Ethics Officer from the Department of Compliance, Risk Management, and Ethics proceeded with the rollcall and provided the Members and Advisors with an overview of the WHO Declaration of Interests process. The Members and Advisors were made aware of 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 actual conflict of interest. They were additionally reminded of their duty to maintain the confidentiality of the meeting discussions and the work of the Committee. Each Member and Advisor was surveyed, with no conflicts of interest identified.

The meeting was handed over to the Chair who introduced the objectives of the meeting, which were to provide views to the WHO Director-General on whether the event continues to constitute a public health emergency of international concern (PHEIC), and to provide views on the proposed temporary recommendations.

Session open to representatives of States Parties invited to present their views

The WHO Secretariat presented the comparative assessment (August 2024 vs September 2025) of the indicators - categorized under five domains -, each associated with one or more of the three criteria defining a PHEIC, as per Article 1 - Definitions of the IHR.

Those domains, with related indicators, were discussed by the Committee and the WHO Secretariat during their informal meeting, agreed upon at the fourth meeting of the Committee, which was held on 25 July 2025, and they were subsequently refined further by the WHO Secretariat. The criteria defining a PHEIC, and the related domains and indicators are presented below, with that order reflected by the level of the indents.

Extraordinary

Growth rate and incidence
Evidence of recent higher than previously observed effective reproduction number (Rt)/growth rate and incidence for mpox given clade and geography beyond what a country can respond to.

Over the past 12 months, mpox cases reported in the WHO African Region accounted for over 80% of those reported globally, with the highest incidence reported from Burundi, the DRC, Sierra Leone, and Uganda, all of which showed sustained declining trends, with occasional flare ups in other countries as reported from Guinea and Liberia at the time of the meeting. Travel-related clusters of mpox cases, within and beyond the WHO African Region, continued to be observed and controlled (e.g., United Kingdom), their frequency mostly reflecting the incidence trends in countries of origin. MPXV clade IIb activity has been declining globally since August 2024 and stabilizing at lower levels in recent months. In August 2024, the risk related to this domain was assessed as "high", with "moderate" confidence. By September 2025, the assessment improved to "low", with confidence remaining "moderate", indicating a sustained reduction of MPXV transmission over the period considered.

Demographics affected and transmission risk
Evidence of newly affected population groups or high incidence in certain population groups (high-risk groups, internally displaced people, children, etc.) or evidence of transmission by routes not currently understood.

Over the past 12 months, a clearer picture has emerged of the population groups affected by mpox clade Ib and MPXV routes of transmission, with close, intimate contact driving transmission and the highest secondary attack rate being associated with sexual contact. As such, the vast majority of settings are seeing the highest incidence among young male and female adults - mostly reflecting heterosexual sexual contact transmission - while the incidence among children is lower and largely reflects household transmission. The secretariat noted however that in the provinces of North Kivu and South Kivu in the DRC, a higher proportion of paediatric mpox cases has been reported than what has been seen in other settings as the outbreak continued to decline - a situation that warrants further investigation. MPXV clade IIb outbreaks in West Africa predominantly involve young adults of both sexes. Outside the African continent, travel-related introductions of MPXV clade I have all been linked to adults travelling back from countries with community transmission, while the reports of MPXV clade IIb continue to be associated with transmission among men who have sex with men. In August 2024, the risk related to this domain was assessed as "high", with "moderate" confidence. By September 2025, the assessment improved to "low", with confidence remaining "moderate", allowing for targeted risk communication and community engagement (RCCE) interventions.

Severity
Evidence of (i) increasing severity and mortality over time, (ii) significantly higher-than-expected mortality in a given setting and/or (iii) large proportion of mortality not associated with risk factors (suppressed immunity).

Uncertainties and unknowns present at the time the PHEIC was determined in August 2024, have been progressively elucidated. While there was uncertainly around the severity and case fatality rate (CFR) for MPXV clade Ib at the time of the PHEIC declaration, more data has since shown that the mortality remains low, in line with the CFR documented for clade IIb, and is linked to known vulnerabilities, mainly immunodeficiency - often associated with uncontrolled HIV in the context of mpox. The secretariat also highlighted that a higher CFR continues to be observed in endemic provinces of the DRC where MPXV clade Ia is circulating, although with a trend from >3% at the time of the PHEIC declaration, to ~1.6% in 2025, and ~1% in August 2025. The main documented complications are ophthalmic and dermatological (e.g., scarring after extensive lesions). In August 2024, the risk related to this domain was assessed as "moderate", with "low" confidence. By September 2025, the assessment improved to "low", together with level confidence regarded as "high", indicating that risk factors for severe or fatal outcome are better characterized.

International spread

Geographical spread
Evidence of rapid geographical expansion of community transmission in the last 3 months and/or high numbers of importations that suggest undetected/uncontrolled community transmission in origin countries.

In late 2024 and early 2025, the expansion of MPVX clade Ib activity across countries in East and Southern Africa was observed along trucking corridors, followed by within-country spread. In 2025, MPXV clade II activity has intensified or emerged in countries in West Africa. Noting that the number of travel-related cases has declined in recent months, the observed exportation patterns from countries in the African continent broadly match modelled expectations, supporting the view that surveillance is detecting cases where probability is highest. Travel-related case counts have fallen in recent months, likely reflecting reduced transmission at source, though transmission may persist in select locations. In August 2024, the risk related to this domain was assessed as "high", with "moderate" confidence. By September 2025, the assessment improved to "low", together with the level confidence regarded as "high", signalling advances in surveillance capacity and transparency in international reporting and information sharing.

International cooperation / Extraordinary

Response capacity and access to countermeasures
Evidence of case incidence beyond what a country has capacity to respond to, including access to and capacity to deploy testing, vaccines, clinical management, community engagement, etc.

Advances in surveillance in countries in the African continent observed since August 2024 are underpinned by expanded diagnostics capacity, including through decentralization of testing (e.g., in the DRC, the number of testing sites has increased from nine to 28). Six in vitro diagnostic products for MPXV are approved for emergency use (i.e., are included in the WHO Emergency Use List (EUL)), and eight are under assessment for prospective inclusion in the EUL, including antigen rapid diagnostic tests (RDT). RCCE interventions scaled up significantly, with nine countries implementing community feedback and social listening, and 13 countries having conducted social and/or behavioural studies. Vaccine access has grown with ~1.6 million doses of MVA-BN vaccine delivered to 13 countries in the African continent, and approximately 1 million doses administered in ten of those countries. Through bilateral arrangements, the DRC accessed LC16m8 vaccine, with approximately 40 000 doses administered. While mathematic modelling suggests that vaccination in the early phases of fast-growing outbreaks has the greatest impact, in the context of the observed declining trends in number of mpox cases, vaccine needs are expected to decrease. Despite progress, funding constraints and competing health emergencies and priorities continue to limit scale and pace of the response. In August 2024, the risk related to this domain was assessed as "moderate", with "moderate" confidence, with no changes assessed by September 2025, reflecting persisting challenges in maintaining the desired level of intensity of mpox control interventions.

The WHO Secretariat signalled to the Committee that, considering the assessment of the aforementioned five domains; as well as the WHO Strategic framework for enhancing prevention and control of mpox: 2024-2027; the standing recommendations for mpox, valid until 20 August 2026; and the Mpox Transition Roadmap: From Emergency Response to Integration into Routine Health Systems (being finalised), a strategic transition for mpox control would be warranted - from an emergency response posture to programmatic, health system-integrated sustained efforts, also preserving the readiness capacity. Such strategic transition would focus high-level advocacy and resource mobilization; maintaining a vaccine stockpile to respond to localized upsurges of mpox; continuous efforts to counter stigma and misinformation, as well as to promote timely care-seeking behaviour; and integrating mpox prevention and control services within existing HIV/STI platforms. The WHO Secretariat also offered to the Committee some considerations concerning the following regulatory aspects in case the WHO Director-General decide to terminate the PHEIC: no impact on MVA-BN vaccine as it is prequalified; mpox-related products currently in the EUL would remain unchanged until further notice; new mpox-related products may be ineligible for inclusion in the EUL unless the WHO Director-General authorises the continued use of the EUL assessment in the public-health interest.

Representatives of the DRC, Sierra Leone, Uganda, and the United Kingdom updated the Committee on the mpox epidemiological situation in their countries, their current control and response efforts, needs, challenges, and plans in the medium term.

Members of, and Advisors to, the Committee then engaged in questions and answers with the presenters from States Parties and the WHO Secretariat.

Deliberative session

Following the session open to invited States Parties, the Committee reconvened in a closed session to examine the questions in relation to whether the event constitutes a PHEIC and to consider the temporary recommendations drafted by the WHO Secretariat in accordance with IHR provisions.

The Chair reminded the Committee Members of their mandate and recalled that a PHEIC is defined in the IHR as an "extraordinary event, which constitutes a public health risk to other States through the international spread of disease, and potentially requires a coordinated international response".

Except for one Member, who expressed concerns regarding future access to vaccine, the Committee expressed the views that the upsurge of mpox no longer meets the criteria of a PHEIC and that the Director-General be advised accordingly. The Committee advised that, while the issuance of temporary recommendations would be warranted, the temporary recommendations drafted by the WHO Secretariat would require to be revised, so that these specifically focus on actions for States Parties to transition from an emergency response posture to programmatic, health system-integrated efforts for mpox control.

The overarching consideration underpinning the advice of the Committee regarding the termination of the PHEIC is that, amid no major shifts in the global trajectory of the event and no anticipated ones in the coming months, the marginal benefits of continuing managing the event as a PHEIC over an extended period are limited. Additionally, the protracted PHEIC status of an event may undermine, in the future, the global public health early warning function, and related call for urgent action, intrinsic to the determination of a PHEIC.

On that basis, the Committee considered that:

The event is no longer regarded as "extraordinary" because of (i) the sustained and consistent decline in the number of cases observed in the African continent, and, while flare-ups are expected, in some contexts the pattern of spread has become analogous to endemic; (ii) the clearer understanding and predictability of MPXV transmission dynamics, as well as of the risk factors associated with severe or fatal outcome; and (iii) States Parties' progress in implementing mpox control interventions, in an integrated manner, with a consolidated view that capacities developed and know-how acquired need to be sustained.

The event no longer "constitutes a [significant] public health risk to other States through the international spread of disease" because (i) such risk has decreased since the determination of the PHEIC, as substantiated by patterns of exported cases matching modelled expectations, hence indicating a reduced number of pockets of undetected transmission; and (ii) imported cases, particularly in States Parties beyond the African continent, have not resulted in significant onward transmission, indicating the health systems' resilience and capacities to detect and manage introductions through targeted interventions.

The "require[ment for] a coordinated international response" to manage the event have decreased in light of (i) the improved States Parties' capacities; (ii) the decreased risk of international spread; (iii) the establishment of international coordination mechanisms, and the level of coordination achieved since the determination of the PHEIC, making them adequate for addressing mpox-specific related needs in an effective manner; and (iv) the establishment of MPVX transmission in certain contexts in the African continent warranting pivoting from a response posture to a long-term programmatic, health system-integrated, approach. This implies the delivery of international support through routine cooperation channels to cater for multiple public health priorities in a more sustainable and effective manner.

The Committee subsequently considered the draft of the temporary recommendations to States Parties proposed by the WHO Secretariat.

The Committee, ahead of its meeting, had received proposed temporary recommendations drafted by the WHO Secretariat in accordance with the provisions of the Regulations. The proposed temporary recommendations mostly reflected the extension of the temporary recommendations issued by the WHO Director-General on 9 June 2025.

The Committee advised that, while the issuance of temporary recommendations would be warranted, the proposed set would require to be revised, by specifically focusing on actions for States Parties to transition from an emergency response posture to programmatic, health system-integrated, efforts for mpox control, including: (a) sustaining domestic resource mobilization and pursue flexible funding arrangements to (i) maintain surveillance (e.g., targeted testing); (ii) integrated care delivery services (within HIV/STI platforms in particular); and (iii) operational readiness (e.g., rapid investigation of mpox-related events in urban areas and high-risk networks; (b) decentralizing testing capacity and logistics in States Parties experiencing access constraints (e.g., conflict-affected areas); (c) prioritizing RCCE activities to counter stigma and misinformation, promote timely care-seeking behaviour, and address vaccine hesitancy; and (d) defining target and eligible populations for vaccination; applying dose-sparing strategies; and pairing any stockpiling with demand-generation to minimize wastage.

Conclusions

The Committee recognized that the prospective termination of the PHEIC may inadvertently signal that mpox control efforts are no longer a priority and, hence, dent political will, as well as the commitment of donors and vaccine manufacturers. Therefore, continued high-level advocacy and international collaboration remains critical, particularly to secure equitable access to vaccine.

The Executive Director of the WHO Health Emergency Preparedness and Response Programme, on behalf of the WHO Director-General, expressed his gratitude to the Committee's Officers, its Members and Advisors and closed the meeting.