Dr Alexandra Phelan Profile picture
Nov 8, 2021 8 tweets 5 min read Read on X
📰New Study🔬 out in @TheLancet!

By building a moment by moment chronology, we analyze how an outbreak became a pandemic & priorities for international reform.

So excited to share this huge team effort led by the amazing @sudhvir!

Link: thelancet.com/journals/lance…

Explainer🧵1/8 Image
2/8
In this paper, we:
1⃣ build a 50pg moment by moment chronology from outbreak to pandemic
2⃣ identify & analyze 5 key phases of events
3⃣map actions against IHR obligations under international law
4⃣propose 5 key areas for #GlobalHealthLaw reform, inc. IHR & #PandemicTreaty
3/8
1⃣ the chronology was built using:
💠systematic review of peer-reviewed articles & public reports w author follow up for preprints & additional lit
💠systematic review of internal WHO correspondence & documents
💠validation from experts inc. at WHO
It's incredibly detailed:
4/8
2⃣ we identified the below five key phases of events, and detail and evidence each stage where available, from likely spillover to clinical detection, domestic assessment, reporting to WHO, WHO assessment, and international response. Image
5/8
3⃣we mapped actions of States, WHO & other actors against their international legal obligations under the International Health Regulations.

Despite the "fog of an outbreak", the time from clinical detection to international reports was a matter of days: ie relatively fast
6/8

For the IHR wonks out there, the role of "other reports" (Art 9) and WHO's power to verify information (Art 10) was useful. Given how quickly everything progressed, if comparing to Art 6, we're talking days to hours, not days to weeks. This means a rethink of "rapid".
7/8
4⃣We propose five key areas for reform, which involve:
🌏 amend IHR to bring into the 2020s, eg immediate notify high impact respiratory pathogens (like novel influenzas now)
🌍adopt #PandemicTreaty for many critical matters that go beyond IHR legal scope, w equity at centre Image
8/8
There are a lot of assumptions about the early days of the pandemic, inc. what actually needs to be reformed to stop an outbreak from becoming a pandemic.

I encourage you to read the whole paper @TheLancet & explore our interactive chronology at: …commendations.theindependentpanel.org/public-chronol…

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More from @alexandraphelan

Apr 29
One area of contention for this week's #PandemicAgreement negotiations is the phrase "Mutually Agreed Terms" (MAT). This phrase is common in international biodiversity law.

🧵Here's a short thread on why MAT may be suitable for biodiversity but not for intellectual property.
The draft #PandemicAgreement contains 7 references to MAT:
Art 9 - Research & Development
Art 10 - Sustainable & Diversified Production
Art 11 - Tech Transfer & Know-How
Art 19 - International Cooperation
MAT is a phrase used in international biodiversity law, in particular, the Nagoya Protocol: a treaty establishing Access and Benefits Sharing (ABS).

For example, Nagoya's provisions on equitable benefits sharing include several references to MAT: Image
Read 9 tweets
Apr 28
There are reports out of Ranchi, India of 8 human H5N1 cases: 6 poultry farm workers & 2 doctors (which is of particular concern if accurate as canaries of H2H spread)

Clusters of limited H2H H5N1 spread are not unheard of: v. different to sustained H2H.
timesofindia.indiatimes.com/city/ranchi/bi…
WHO has reportedly been informed and a local rapid response team activated. Those infected have been isolated (articles incorrectly use the term quarantine) & contact tracing is underway.

Reports of impending lockdown in this article:
thailandmedical.news/news/breaking-…
At this stage, news reports are somewhat sensationalist but there’s clearly some concerning features indicating possible *limited* H2H transmission to health care workers and scale of government response.

It would be good to also know more about the condition of the cases.
Read 5 tweets
Sep 19, 2022
There's no formal process under international law or governance for declaring a pandemic over.

For influenza, the post-pandemic phase is defined by a return to seasonal levels, but we don't know (1) if that will occur for COVID19 (albeit likely) & (2) what those levels will be. Image
With the continued transmission of COVID19 and emergence of new variants, we are clearly not in the "pandemic's over" phase. There's clear guidance (again, that can be modified from flu) with what we should be doing Image
Finally, we cannot detach guidance like this from the fact that decisions about stages masks the disproportionate burden carried by vulnerable populations. There is a particular ethical duty on governments to act to protect these populations that persists regardless of stage.
Read 6 tweets
Jul 23, 2022
As we wait to hear if the WHO Director-General will declare #monkeypox a Public Health Emergency of International Concern, it’s a good time to reflect:

What happens when a PHEIC is declared?

tldr: 🚨💰🧾🌎⚖️

🧵 1/7
First: 🚨

A PHEIC is a global alert and call to action.

Health matters aren’t necessarily on country leaders’ radars: PHEICs are intended to address this.

2/7
Second: 💰

A PHEIC does not open up any new funds or financing. As the DG has said in past PHEICs:

3/7
Read 7 tweets
Nov 30, 2021
WHO has issued advice to countries on 🌍international traffic🌍 in relation to the omicron variant. It is nuanced and well considered.

Full text here: who.int/news-room/arti…

Key points in 🧵below:
WHO commends South Africa🇿🇦 & Botswana🇧🇼 for surveillance and genetic sequencing capacities, transparency, and rapid reporting under the IHR.

WHO calls on all countries to show solidarity w 🇿🇦 & 🇧🇼, & rapid & transparent info sharing, noting omicron likely in more countries🗺️
Omicron has a number of mutations, some of which are concerning, particularly potential increased reinfection risk.

Countries should apply "evidence-informed and risk-based approach" when implementing travel measures (per IHR).
Read 6 tweets
Nov 30, 2021
As Dante wrote in Paradiso, “Fate’s arrow, when expected, travels slow”.
The emergence of concerning variants, arbitrary rather than risk based travel restrictions, global vaccine injustice, ableism in endemicity, are not only our present, but our future w/o political action.
Early in the pandemic, those of us in global public health would entreaty “this will be a marathon, not a sprint”.

Some days, it feels as though we’ve entered an ultramarathon with no conditioning.
I know so many of my colleagues and friends - epis, virologists, journos, civil servants, advocates, HCWs - are beyond exhausted. There is no respite, and no matter how hard you work, success (the mere KPI of stopping death & illness) is dependent on political leadership.
Read 11 tweets

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