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‘It’s still killing and it’s still changing.’ Ending COVID-19 states of emergency sparks debate

Kai Kupferschmidt, Meredith Wadman

May 5, 2023

The World Health Organization (WHO) today declared an end to the emergency phase of the COVID-19 pandemic, days ahead of when a similar emergency in the United States is also set to expire. Both moves are likely to usher the world into a new phase of disease monitoring with a scaling back of surveillance and available resources to fight COVID-19.

WHO’s director-general, Tedros Adhanom Ghebreyesus, said at a press conference today in Geneva that WHO’s emergency committee met yesterday and recommended ending the Public Health Emergency of International Concern (PHEIC), the highest alert level WHO can declare, that has been in effect since 30 January 2020. “It’s therefore with great hope that I declare COVID-19 over as a global health emergency,” Tedros said.

The pandemic had been on a downward trajectory for a year, Tedros said, allowing most countries to return to life as it was before COVID-19. “What this news means is that it is time for countries to transition from emergency mode to managing COVID-19 alongside other infectious diseases,” he said. Tedros emphasized that this declaration does not mean COVID-19 is no longer a threat. “The worst thing any country could do now is to use this news as a reason to let down its guard, to dismantle the systems it has built, or to send the message to its people that COVID-19 is nothing to worry about,” he said.

Ending the PHEIC is the right move, says Lawrence Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University. “The world has moved on from the emergency phase of the pandemic and it is wise of WHO to do the same.”

Since the start of the pandemic 3 years ago, WHO has recorded close to 7 million deaths from COVID-19, though the real death toll from the pandemic may be three times that. A few thousand deaths are still being reported to the agency every week, and some models estimate that excess mortality is still at about 10,000 deaths a day worldwide.

In his statement, Tedros highlighted COVID-19’s ongoing impact. “Last week, COVID-19 claimed a life every 3 minutes and that’s just the deaths we know about,” he said, emphasizing that thousands of people around the world are still being treated for the disease in intensive care units and millions of others are dealing with the prolonged aftereffects of COVID-19 infections. “This virus is here to stay,” he added. “It’s still killing and it’s still changing. The risk remains of new variants emerging that cause new surges in cases.”

The WHO news comes just ahead of the end of the United States’s public health emergency (PHE) on 11 May, and on the same day that Rochelle Walensky, director of the U.S. Centers for Disease Control and Prevention (CDC), which has weathered stiff criticism for its handling of the pandemic, announced her resignation and intent to leave agency at the end of June.

The end of the U.S. PHE next week will impact policies as wide-ranging as the flow of migrants at the southern border, which the emergency has allowed the government to stifle on public health grounds—and the federal government’s provision of free rapid antigen tests, which will end.

In a press conference explaining some of the changes, which were also outlined in two articles published Friday in the Morbidity and Mortality Weekly Report, CDC officials conceded they will lose some insight into the pandemic as their data collection powers are dialed back.

The changes in CDC’s capabilities come as roughly 1100 people in the U.S. are dying weekly of COVID-19, the lowest number since March 2020. Most deaths are occurring in people 65 and older.

When the PHE ends, the agency will no longer be able to compel testing laboratories to report their COVID-19 test results, or states to report numbers of vaccinations, although many are expected to continue to report the latter voluntarily. The agency’s collection and publication of aggregate data—the total number of cases in a jurisdiction—will also end. Case numbers and test positivity levels—the percentage of positive tests among all tests taken—will no longer appear on its popular data tracker.

Still, senior CDC officials insist the remaining data will be adequate. “We have the right data for this phase of COVID-19,” said Nirav Shah, CDC’s principal deputy director. “Though our data going forward will be different, they will continue to provide timely insights for CDC, for local health officials as well as for the public to understand COVID-19 dynamics.”

Shah said the agency’s primary surveillance metric in the new regime will be hospitalization data, which will continue to be reported from all hospitals weekly, rather than daily. In an era in which people don’t test or don’t report test results, “Hospitalizations provide the best national level view of COVID trends,” Shah said. 

Tools such as wastewater testing and genomic sequencing will still be used to give CDC greater visibility into SARS-CoV-2’s distribution and evolution than it has for other respiratory pathogens such as influenza and respiratory syncytial virus, Shah stressed. In addition, COVID-19–associated deaths—a hard if lagging metric that is reported on death certificates nationally—will be published weekly by CDC, cast as a percentage of all U.S. deaths.

But public health experts disagree that the new data landscape will be adequate. “I think it is a mistake to unwind the data collection and reporting infrastructure too aggressively,” says David O’Connor, a virologist at the University of Wisconsin-Madison who has tracked the pandemic locally through wastewater studies. “I worry that dismantling data collection and visualization tools now will leave us more vulnerable the next time there is a new viral disease threat.”

“CDC is making the best of a very difficult situation,” adds Tom Frieden, a former CDC director who is the president and CEO of Resolve to Save Lives, a nonprofit that works on epidemic preparedness. “When the public health emergency goes away, some of the emergency authorities that allowed CDC to collect more granular information go away.”

The dialing back of data collection has already happened elsewhere, including in Israel, which during the first years of the pandemic was a paragon of providing quick and comprehensive data on the pandemic. In March, the country closed its national command and control emergency infrastructure. And for the most recent 12 months, “There is no good data to allow accurate estimates of morbidity and mortality … as testing recommendations changed and are no longer systematic,” Ran Balicer, deputy director general of Clalit Health Services, Israel’s largest health maintenance organization, said in an email. Balicer chaired Israel’s National Expert Advisory Team on COVID-19 throughout the pandemic.

WHO’s decision to end the PHEIC has fewer clear consequences, says Clare Wenham, a global health expert at the London School of Economics. “Because we don’t know what impact a PHEIC does or doesn’t have, then it’s hard to say what impact something being redetermined a PHEIC or the emergency ending will have.”

Still, the transition could carry risks, Didier Houssin, chair of WHO’s emergency committee, said, comparing the situation to a hermit crab transitioning from one shell to another. The risks the committee debated included that a new variant could take the world by surprise, that ending the PHEIC could be misinterpreted by countries and lead them to lower their guard, and that access to vaccines could be hampered. But those risks had to be balanced with a realistic picture of the pandemic, Houssin said, as the number of weekly reported deaths for each of the past 10 weeks has been the lowest since March 2020.

Keeping a PHEIC in place too long also carries risks, Gostin says. “The public loses trust in WHO and other public health agencies.” Moreover, if emergencies go on too long, “They dilute the power of an emergency declaration, and the public will not readily support declaring an emergency for future crises,” he says.

In announcing the end of the PHEIC, Tedros said WHO will establish a review committee tasked with developing “long-term, standing recommendations for countries on how to manage COVID-19 on an ongoing basis.” Alexandra Phelan, a global health expert at the John Hopkins Bloomberg School of Public Health, welcomes the review. “We have an opportunity to provide greater clarity about the end of PHEICs: How do we transition out of an emergency without losing political, financial, and technical commitment to addressing the structural and long-term impacts to public health?” she says.

Gregg Gonsalves, a public health expert at the Yale School of Public Health, says he is less concerned about what to call the pandemic than what is done to address it. Regardless of whether it is called a PHEIC, COVID-19 continues to cause death and suffering across the globe, he says. “Yet, almost everywhere we’ve declared mission accomplished and we have no appetite for doing anything more to fight this disease,” Gonsalves says. “We’re willing to bake in a huge amount of morbidity and mortality to get back to normal [and] it doesn’t bode well for facing our future.”

In the end, both the end of the PHEIC and the upcoming expiration of the U.S. PHE reflect that, in the views of governments and organizations, “the emergency and acuity part is in the rear view mirror,” says Beth Blauer, a data and public policy expert at Johns Hopkins University who helped develop that institution’s widely used Coronavirus Resource Center. “The systems themselves have indicated that this need to have [COVID-19] at the fore as a dedicated declared emergency is no longer the best use of collective resources.”

In his press conference, Tedros also urged all countries to do more to prepare for future pandemics. “One of the greatest tragedies of COVID-19 is that it didn’t have to be this way,” he said. The tools to detect and respond to pandemics better are available, “But globally, a lack of coordination, a lack of equity, and a lack of solidarity meant that those tools were not used as effectively as they could have been. Lives were lost that should not have been.”

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