Words carry intent and meaning. Their misuse causes harm. The word “pandemic” has a range of definitions, and it’s used regularly by experts associated with the World Health Organization (WHO). The history of its use is one marked by human messiness. But there is now a new term in town: “Pandemic Emergency”. And it comes with a definition! This will help clarify things in the future. However, that term hasn’t been retroactively applied to COVID-19. If it were to be, we’d be overdue for the WHO to declare an end to the current pandemic. Not that anyone seems to be acting as though we’re still in one.

WHO Member States established the Intergovernmental Negotiating Body (INB) to guide a submission of a draft WHO Pandemic Agreement for the World Health Assembly Committee, 19 May 2025. Within the agreement document is included the latest definition of what they call a “Pandemic Emergency”, a term that first appeared in the June 2024 amendments to a 196-country, legally binding framework (for countries, not corporations) to address global disease, called the International Health Regulations (IHR). The final Pandemic Agreement, a legally-binding deal in which signatory countries agree to an improved more equiatable and collaborative international response to prevent and manage shared pandemic threats, will be open for signature and ratification (by at least 60 countries) after an Intergovernmental Working Group (IGWG) negotiaties the the Annex on Pathogen Access and Benefit Sharing (PABS). So it could yet be a while.

A Pandemic Emergency is now the highest level of alarm contained within the legally-binding IHR and available for use by the WHO Director-General. It also comes with a clear definition, so it is already far superior to what was attached to ‘pandemic’. A new term with a proper definition. That’s actually a big deal.

The COVID-19 pandemic was never defined as a Pandemic Emergency. It still falls under the classical and defined ‘pandemic’ category. Somehow, those associated with the WHO can mentally compartmentalise this new definition from the reality of today’s COVID-19.

This matters because, as I’ll show, one term enables us to exit the current pandemic, while the other does not.

How is a classical pandemic defined?

In many ways! Definitions for the word have been added to, subtracted from, argued about, weaponised and abused over time.

It’s worth highlighting the words of Peter Doshi here: “the simple act of labelling a disease has enormous social, economic and political implications.” It’s always been important to get this definition right and then adhere to it. But we haven’t, and the use of ‘pandemic’ reflects that horrible academic habit of assuming the public understands a word to have the same meaning they do. Hell, it’s not even clear whether ‘pandemic’ was meant to be the description for a limited event or a label that sticks to the causal pathogen for as long as that bug exists, because the path out of a ‘pandemic’ is so badly mapped and rarely trodden.

Variants of ‘pandemic’ define a classical pandemic in various ways. Some are listed below, along with some other concepts.

• Pandemic (published 2001): “an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people”
  A dictionary of epidemiology, 4th edition. New York: Oxford University Press; 2001. This is the basic epidemiology definition focused on spread, the only common feature of classical pandemics. It does not specify pathogen novelty, transmission speed or clinical severity components as necessary for the definition.
• An influenza pandemic (published 2003): “An influenza pandemic occurs when a new influenza virus appears against which the human population has no immunity, resulting in several, simultaneous epidemics worldwide with enormous numbers of deaths and illness.”
  An old WHO definition that was revised in a controversial manner in May 2009. The previous definition made no mention of immunity, clinical severity, pathogen novelty (linked to immunity), or virology.
• Pandemic (published 2008, 5th edition): “An epidemic occurring worldwide or over a very wide area, crossing international boundaries, and usually affecting a large number of people”
  Wide spread, but no pathogen novelty, clinical severity or speed components specified.
• Pandemic (published 2009): “simply defining a pandemic as a large epidemic may make ultimate sense in terms of comprehensibility and consistency.”
  Wide spread, but no pathogen novelty, clinical severity or speed components specified by the NIH crew of Morens, Folkers and Fauci.
• Pandemic (published 2009): “basically a new or novel agent emerging with worldwide transmission.”
  Dr Michael Osterholm in the New York Times.
• Pandemic (originally online 24 Feb 2010): “A pandemic is the worldwide spread of a new disease.”
  Many diseases caused by a new pathogen share signs and symptoms but may produce a novel syndrome. True novelty in clinical outcome is rare, so I think this one is too limiting. But maybe a simple misunderstanding about pathogen versus disease. Wide spread, but no pathogen novelty or speed components specified.
• Influenza pandemic (published 2011): “Simultaneous worldwide transmission of influenza is sufficient to define an influenza pandemic and is consistent with the classical definition of ‘an epidemic occurring worldwide'”.
  Heath Kelly noted in this article that “As Doshi has argued, we need to redefine pandemic influenza. We can then describe the potential severity range of future pandemics. Finally, we need to use evidence to assess severity early to anticipate risk.” Spread defines an epidemic, but further work is required to describe its severity.
  The WHO later integrated this thinking. Doshi did not provide his favoured definition.
  Kelly also made another fantastic point: “seasonal epidemics are not considered pandemics. A true influenza pandemic occurs when almost simultaneous transmission takes place worldwide.”
  I believe this should be an essential addition to any definition, as it clearly distinguishes pandemics caused by influenza from seasonal influenza. For an influenza virus to overcome seasonal effects, it must appear sufficiently different to our immune system, and when it does, seasonal factors no longer significantly constrain transmission.
• Pandemic (published 2013): “A novel infection—new and previously unconfronted—that spreads globally and results in a high incidence of morbidity (sickness) and mortality (death)”
  Wide spread and support for pathogen novelty and clinical severity components.
• Pandemic (published 2014, 6th edition): “An epidemic occurring over a very wide area, crossing international boundaries, and usually affecting a large number of people. Only some pandemics cause severe disease in some individuals or at a population level. Characteristics of an infectious agent influencing the causation of a pandemic include: the agent must be able to infect humans, to cause disease in humans, and to spread easily from human to human.”
  Wide spread, but no pathogen novelty or speed components specified. Downplays the clinical severity component.
• Pandemic (published 2017): “Pandemics are, therefore, identified by their geographic scale rather than the severity of illness.”
  A further exploration of the first definition on this list, adhering to spread as the sole factor.
  No mention is made of pathogen novelty, but it denies a role for clinical severity.
• Pandemic (published 2019): “An epidemic that spreads globally”
  Wide spread, but no pathogen novelty or speed components specified.
• Pandemic (published 2020): “a contagious infectious disease that has spread to multiple geographic areas or continents.”
  Wide spread, but no pathogen novelty or speed components specified.
• Pandemic (published 2021): “three criteria generally need to be met (a) it needs to cause disease or death (b) there must be sustained transmission between people and (c) it must be spreading in multiple countries.”
  Wide spread, but no pathogen novelty or speed components specified.
• Pandemic (accessed 21JUL2025): “an infectious disease epidemic that is spreading between people in multiple countries”
  Wide spread, but no pathogen novelty or speed components specified.
• Pandemic (accessed 17JUL2025): “outbreak of infectious disease that occurs over a wide geographical area and that is of high prevalence, generally affecting a significant proportion of the world’s population, usually over the course of several months.”
  Suggests rapid contemporaneous spread with the addition of a time constraint.
• Pandemic (accessed 18JUL2025): “the rapid spread of a new human influenza around the world.”
  From an archived webpage. Pathogen novelty returns and contemporaneous emergence is highlighted.
• Pandemic (accessed 17JUL2025): “a worldwide outbreak of influenza when a new strain of a virus emerges”
  Pathogen novelty is here, and a contemporaneous outbreak is implied.
• Pandemic influenza (accessed 17JUL2025): “An influenza pandemic occurs when a novel influenza virus emerges against which most of the world’s population has little or no immunity”
  Also here.
  This WHO definition focuses on pathogen novelty, specifically the lack of past human exposure and thus immunity.
• Pandemic (accessed 21JUL2025): “outbreak of infectious disease that occurs over a wide geographical area and that is of high prevalence, generally affecting a significant proportion of the world’s population, usually over the course of several months”
  Suggests rapid contemporaneous spread with the addition of a time constraint.
• Pandemic (accessed 21JUL2025): “one thing everyone agrees on is that the word describes the widespread occurrence of disease, in excess of what might normally be expected in a geographical region”
  Wide spread, although not specifying global.
• Pandemic (accessed 25JUL2025): “an outbreak of a disease that occurs over a wide geographic area (such as multiple countries or continents) and typically affects a significant proportion of the population”
  Wide spread but no comment about speed, concurrence or pathogen novelty.
• Pandemic influenza considerations (published 2011): “explicitly establishing a consistent definition is a necessary first step that must be followed by aggressive pre-event education of the global community regarding that definition and its rationale.”

---

• Word root (accessed 21JIUL2025): “First recorded in the 1660s, this word comes from the Latin word pandemus, which itself comes from the Greek pandemos, pan- meaning “all, every, whole,” derived from PIE [Proto Indo European] pant- meaning “all,” and dēmos, meaning “people.”
• Word root (accessed 21JUL2025): pandemic(adj.) of diseases, “incident to a whole people or region,” 1660s, from Late Latin pandemus, from Greek pandemos “pertaining to all people; public, common,” from pan- “all” (see pan-) + dēmos “people” (see demotic). Modeled on epidemic; OED reports that it is “Distinguished from epidemic, which may connote limitation to a smaller area.” The noun, “a pandemic disease,” is recorded by 1853.
• Word roots (accessed 21JUL2025): A series of uses for disease that date back to 1666

---

• Pandemic Spread and Severity (published 2009): “WHO, acknowledging that its phasing system needs fine-tuning as it relies only on geographic spread of the novel H1N1 virus, soon plans to institute a severity index to make its warning system” more useful to member countries”, “One possibility he said is to develop a three-point scale for severity that is country specific. So WHO might decide that one country is at phase 6, level 3, while others are at phase 6, level 1”.
  Novelty, global spread and clinical impact come to the fore.
• Pandemic spread (published 2009): “WHO’s own definition requires that the virus shows sustained community spread in countries in at least two of its six regions.”
• Pandemic preparedness (published 2011): “we must remember the purpose of “pandemic preparedness”, which was fundamentally predicated on the assumption that pandemic influenza requires a different policy response than does annual, seasonal influenza. The “pandemic” label must of necessity carry a notion of severity, for otherwise the rationale behind the original policy of having “pandemic plans” distinct from ongoing public health programmes would be called into question.”
• Causal pathogens (published 2022): “While the expected pathogens with pandemic potential tend to be viral, Member States can use the plans more broadly including for bacterial respiratory disease pathogens. As the actions needed to prepare for respiratory pathogens are similar, using an integrated respiratory pathogen preparedness approach offers Member States flexibility to include the range of pathogens that may be of concern in their country”
• Preparedness and Resilience for Emerging Threats (PRET): “PRET includes an organizing framework that allows countries to plan for the different stages of an epidemic or pandemic”.
  The WHO has so far published a checklist for planning a pandemic driven by a respiratory pathogen.
• Endemic: “The constant occurrence of a disease, disorder, or noxious Infectious Agent in a geographic area or population group; it may also refer to the chronic high Prevalence of a disease in such area or group.”

The use of ‘pandemic’ has primarily focused on the widespread geographic spread of disease. But Lawrence Altman’s words in 2009 are a good reminder that “Dictionaries and medical journals offer little guidance. Their definitions can be too vague or too narrow, contradictory and clouded by jargon“.

Disease and pathogen novelty are not consistently present in these definitions, but they are scattered throughout the 25 years of examples. Nonetheless, immunologically speaking, a pathogen doesn’t rip through a human population that is immune to it. I argue that pathogen novelty is inherent to rapid and global transmission. This wasn’t necessarily known, considered or intended to be spelled out, but it’s a biological reality. But implied antigenic novelty alone doesn’t separate pandemic influenza from seasonal influenza. There needs to be some clarity that the spread of a pandemic pathogen is fast enough to occur in both hemispheres within weeks to a few months of human-to-human transmission being identified, as Kelly alluded to above.

The variability of previous ‘pandemic’ definitions means past use doesn’t accurately describe current events, and vice versa. This results in a word that has lost meaning and impact, which in turn can create confusion, anger, loss of trust or apathy among the wider public audience. The human element’s messy role in declaring a pandemic is already well understood among experts.

But what would and would not be declared a pandemic depends on a host of arbitrary factors such as who is doing the declaring and the criteria applied to make such a declaration.

Peter Doshi, The elusive definition of pandemic influenza.
Bull World Health Organ 2011;89:532-538

Without definitions, anyone can apply a preferred meaning to anything. This twisting and inverting of meanings, sometimes using them to the complete opposite of their intended purpose, is a problem we see all the time in the current age of disinformation and rising fascism. With definitions in place, we can point to the intended meaning, and everyone is on the same page. That’s why the new term is a substantial, if ridiculously late, step forward.

The Pandemic Emergency

So, what is this new Pandemic Emergency thing?

The WHO notes on their dedicated webpage, Pandemic prevention, preparedness and response agreement (last updated 17JUN2025), that:

“A Pandemic Emergency aims to trigger a more effective international collaboration in response to events that are at risk of becoming, or have become, a pandemic.

Each and all of the six following criteria must be met for an “event” (which, according to the IHR, means a manifestation of disease or an occurrence that creates a potential for disease) to be determined a “Pandemic Emergency”.

What’s pleasing about this definition is that it finally seems to acknowledge there are more pathogens with pandemic potential than the influenza viruses. Before this, you’d be forgiven for thinking that influenza was the only thing the world’s leading public health advisory body thought about, planned for, or ever expected to be a pandemic threat.

The six WHO criteria defining a Pandemic Emergency

These criteria, which must all be met, are:

A “Pandemic Emergency” means a public health emergency of international concern, that is caused by a communicable disease and:

1. has, or is at high risk of having, wide geographical spread to and within multiple States; and
2. is exceeding, or is at high risk of exceeding, the capacity of health systems to respond in those States; and
3. is causing, or is at high risk of causing, substantial social and/or economic disruption, including disruption to international traffic and trade; and
4. requires rapid, equitable and enhanced coordinated international action, with whole-of-government and whole-of-society approaches;

My thoughts about this.

It’s good. It introduces a new term allowing us to step out from under the shade of past human indecisiveness and inconsistency. It uses the standard epidemiology definition of wide spread (No. 1) but includes the need to define clinical severity in terms of healthcare capacity overload (No. 2), societal overload (No. 3) and the need for global response and intervention (No. 4). It doesn’t specify pathogen novelty but, again, ‘wide spread’ implies that. And I would have liked to discuss contemporaneous spread in both hemispheres. Still, the No. 2 and No. 3 probably preclude a novel seasonal influenza (these are A(H1N1), A(H3N2), and B/Victoria) subtype from causing a Pandemic Emergency because of pre-existing immunity.

Sadly, this new term fails to address the trail of current classical pandemics that, in my opinion, need to be clarified and decisively classified by the body that oversees this – the WHO.

Thought exercise: are we in a Pandemic Emergency right now?

If we imagine that the new Pandemic Emergency term does apply to COVID-19 – and there’s no evidence it does – would COVID-19 meet all of those criteria and thus deserve to be called a Pandemic Emergency? To me, it does not. However, perhaps that’s because COVID-19 was labelled a pandemic before this new definition existed. It’s probably ‘just’ a classical pandemic.

Why do I say COVID-19 wouldn’t meet the criteria for a Pandemic Emergency? Let’s step through those criteria.

Firstly, the COVID-19 event was determined on 5th May 2023, to be “an established and ongoing health issue which no longer constitutes a public health emergency of international concern (PHEIC).”

Secondly, SARS-CoV-2 remains the pathogen causing COVID-19, so it is a communicable disease.

Next, let’s step through that four-point list with what we know today:

1. COVID-19 is already present worldwide.
   It can now only spread to new worlds!
2. COVID-19 is no longer overwhelming the health systems of high-income countries.
   Certainly, no more than a very large influenza season does, and nothing like what it was doing during the first wave. COVID-19 unquestionably imposes an extra annual burden that has had to be staffed and funded on top of the burden of harm being borne by those suffering from its different impacts.
   NOTE: There is no distinction made between high-income and low- and middle-income countries. There probably should be.
3. COVID-19 no longer poses a risk to travel or trade.
   The days of the early response to SARS-CoV-2 as an impactful emerging pathogen are behind us, even with new SARS-CoV-2 variants emerging regularly and rare zombie emergences of past variants popping up on occasion. That doesn’t rule out a new SARS-CoV-2 strain emerging, but the same is also true for RSV, MPV, or HCoV-OC43, among many other viruses. One could argue we should have named some SARS-CoV-2 variants as new strains, but we didn’t. Travel and trade have resumed, but are now threatened by politics.
4. There is no longer ongoing, coordinated international whole-of-government/society action to respond to recurring COVID-19 epidemics.
   SARS-CoV-2 is treated as if it were a standard endemic respiratory virus, occurring in most, if not all, jurisdictions worldwide, with a periodicity that appears relatively stable. Its role in chronic disease is barely discussed, and data collection has been scaled back, no longer being coordinated and provided to the public or the WHO in the same manner as it once was. The impact of nonpharmaceutical interventions upon other respiratory virus seasons has also shown solid signs of receding.

Therefore, Nos. 1, 2, 3, and 4 are no longer ongoing or yet to happen; we’re not in a PHEIC, but COVID-19 remains a communicable disease. Mild, moderate and severe disease outcomes and harms, including death, still occur, but less frequently now, and they remain the minority of outcomes.

If we were to undertake a thought exercise and apply the WHO definition of a Pandemic Emergency, COVID-19 is no longer one. Would standing down the pandemic change anything about our current post-PHEIC scaled-back response to COVID-19? Not that I can see. However, COVID-19 has not been redefined as a Pandemic Emergency so it remains a classical pandemic.

The WHO has convened experts on numerous previous occasions to develop tools to assist the organisation in determining the timing of classical pandemics and to guide States in creating their own alert and response systems and management tools. This is all part of the WHO being the directing and coordinating authority for health within the United Nations system, having a mandate for global pandemic influenza risk management, which is reflected at all levels of the organisation.

Influenza has heavily influenced pandemic planning

These tools were developed for influenza because no one expected a shrewd coronavirus to outmaneuver the many H-something-N-something influenza viruses present in animals and become the next pandemic pathogen. I wonder if one reason the WHO hasn’t already called an end to the COVID-19 pandemic is that it hadn’t prepared for a novel, but non-influenza respiratory pathogen.

Earlier pandemic-determining criteria also presumed that a pandemic would be of high severity; however, this wasn’t the case with the 2009 influenza A(H1N1pdm09) pandemic. Adaptation of subsequent definitions aimed to address this misunderstanding.

WHO makes guides, States implement plans

It’s worth noting that all these extra tools (the legally binding IHR is not one of these tools) were intended as guides. The WHO cannot dictate or forcefully impose its will on States using these tools or via IHR amendments. Whether a State succeeded or failed in its response to COVID-19 was entirely up to it, not the WHO. The history, advice and guides existed, but each created their response. How well those worked depended on the State-specific response and whether it used the guide’s collective expertise and accounted for local issues, pain points, financial situations, cultural needs, and quirks. Or, whether a framework was considered and adhered to at all.

The example of Australia’s response and plans

Before the 2009 pandemic, Australia used a differently structured phased plan for pandemic response, from the one produced by the WHO, with further local modifications. Its phases were called ALERT, DELAY, CONTAIN, SUSTAIN, CONTROL, and RECOVER. However, “on the day”, the nitty-gritty of any response should always be flexible enough to evolve with information that only becomes available in real-time and the help of local expertise.

For COVID-19, a big portion of the Australian expert response was rolled out upon the WHO declaration of a PHEIC. Australia’s Emergency Response Plan for Communicable Disease Incidents of National Significance (CDINS) was enacted upon the WHO declaration of a pandemic.

These are local plans, and none were forced by or under WHO control.

It’s noteworthy that the CDINS, following the advice of the local expert committee, was withdrawn after the WHO’s IHR Emergency Committee for COVID-19 determined that COVID-19 no longer constituted a PHEIC.

The Australian Health Protection Principal Committee (AHPPC) stated that “Australia has shifted to managing COVID-19 consistent with other common communicable diseases, focusing on prevention, reducing transmission and management of serious illness, hospitalisations and death.” This made sense as the AHPPC noted that in Australia, “Most national coordination and response measures that were implemented as part of the CDINS (e.g. international border restrictions, universal isolation and quarantine requirements, and enhanced infection prevention and control) have already been stood down in Australia, in alignment with WHO advice.”

In other words, Australia rolled back its response to pre-pandemic levels, even though the WHO has yet to declare the COVID-19 pandemic over.

What then is the point of continuing to call COVID-19 ‘pandemic’? I doubt Australia is the only country to have acted this way.

The guides are for State reference but aren’t forcefully imposed by the WHO

While researching this, it has become clear to me that many WHO-collected expert brains dedicated their good intentions and a significant amount of their time to thinking about how to prepare for and keep others safe from the harms caused by the rapid spread of a pandemic pathogen. It’s been a thankless job. The job, in fact, appears to act like a constant beacon attracting the ire of moths haunted by their failures to heed decades of warnings, literature, and messaging. Unfortunately, the thought processes behind decisions are often unavailable, likely buried in the minutes of decades of committee meetings or lost with the departure of experts. When the COVID-19 pandemic struck, many State decision-makers either lacked a rulebook, ignored all this work, or binned it, succumbing to the worst of all influences — those driven by politics, profit, culture wars or unsupported feelz.

An overview of the WHO’s “Pandemic Phases”

Before the Pandemic Emergency was defined in the IHR amendment, the WHO used a series of Phases to indicate the world’s position on a path that leads into and around a pandemic. It was not often that these defined a clear path out. These are my best efforts at reconstructing the order of appearance of these WHO tools. For a more academic exploration, try this, this or this publication.

1999

This guide wasn’t summarised in a graphical format as later ones were—at least not in this document—but instead used a large table with many words! Avian influenza A(H5N1) (also referred to as “avian flu,” in the news) was a particular driver for this, which, yes, has been scaring humans for nearly three decades. This definition noted “serious morbidity” and included pathogen novelty. The following two updates would drop clinical severity. Still, it would return in 2013, when the guide would outline the need to assess severity to inform decisions such as vaccine and antiviral production and use, healthcare resource allocation, and the strength of measures like school closures and social distancing.

From the outset, it was clear that the WHO would report the end of a classical pandemic, which would follow the second and subsequent waves of infections.

Waves and COVID-19

After the initial wave, our epidemics of symptomatic SARS-CoV-2 infections have been driven by the emergence of new immune-escape variants, which seem to occur in the traditional respiratory virus temperate season, around both winter and summer. Despite summer not being a conventional “flu season”, sufficient pathogen novelty overcomes climate and schooling-related influences in the world of respiratory virus infections. The influenza A(H1N1pdm09 pandemic in the United States was a good example of that.

This annual and biannual (twice-yearly) epidemic pattern may change over time. It may settle into a yearly pattern, similar to influenza, RSV or MPV in temperate zones, or develop into a biennial (every second year) pattern, like other human coronaviruses. Or it may not. Do we need to wait around for that to happen before calling an end to the current pandemic, though? Nope.

2005

The next iteration of the Phases involved a significant update and revision, with a greater focus on earlier stages to highlight the benefits of rapid intervention in containing or delaying the spread of a new influenza virus, integrating lessons learned from the emergence and containment of SARS (2003). It did not address clinical severity or non-influenza pathogens, but it retained pathogen novelty.

This concept was effectively applied in New Zealand and Australia, which contained SARS-CoV-2 at their borders until more than 80% of the population was vaccinated, resulting in the saving of thousands of lives.

The 2005 revision also took into account the enzootic presence of influenza viruses in animals, a better understanding of influenza evolution, new vaccine creation methods and laboratory diagnostic techniques, improved antiviral developments, and revisions to the legally binding IHR.

2009

In 2009, the Phases were revised again to make them easier to understand and based on what could be observed. This did not include details about clinical severity but still retained the aspect of pathogen novelty.

There are still six phases in 2009, plus a couple of post-pandemic periods, referred to as “post-peak” and “post-pandemic.” CIDRAP wrote a great side-by-side comparison of the 2005-revised 1999 phases versus the 2009 phases for those who crave more detail.

You can see the groupings below presented in an illustration, along with the WHO definitions of when we could have been in each period. The post-peak period is characterised by levels of the new influenza virus dropping below the peak. The path to a post-pandemic period is defined here as the pathogen’s levels returning to those seen for a seasonal influenza virus. In Australia, examining surveillance data from the same sources for SARS-CoV-2 and influenza viruses over the same period reveals that SARS-CoV-2 levels rhythmically fall below their peak.

What about even more bolted-on definitions?

Influenza and other respiratory virus pandemics, although that’s not specified here, diverge from bacterial pandemics and less transmissible viral pandemics. Very transmissible and constantly evolving pathogens can persist successfully among human populations and, without extraordinary effort, cannot be put back in their box.

SARS-CoV (the 2003 version) wasn’t as efficient at transmission as influenza, SARS-CoV-2 or other endemic respiratory viruses because it was less likely to shed before symptoms emerged. With this and because of a great deal of effort in several countries, it was contained.

In his book, PANDEMICS A Very Short Introduction, Christian McMillen adds a subdefinition to the mix before stepping through the pandemics of plague, smallpox, malaria, cholera, tuberculosis, influenza and HIV/AIDS. Others include dengue and syphilis. McMillen classifies pandemics as either discrete or persistent events. He includes Tuberculosis, malaria and HIV/AIDS as persistent pandemics. But perhaps more importantly, he ties these to poverty. To digress for a moment, a discrete pandemic caused by a rapid transmitter, such as influenza, still leaves behind a persistent pathogen among humans, each providing “genes” for offspring viruses that continue to cause harm today. An influenza pandemic may end in name, but the pathogen usually remains. Therefore, this subdefinition may not be applicable to influenza pandemics, at least until we have better vaccines and drugs that can eradicate or eliminate the pathogen, or at least its associated disease.

McMillen noted that most places with persistent pandemics are located in the “global south”.

HIV/AIDS, a persistent pandemic example, fits this picture (the WHO refer to HIV/AIDS as a global epidemic, not a pandemic). While there are drugs available to increase the number of people living with HIV/AIDS rather than dying from it, progress is most off track in the global south, where fewer funds are available to implement all that is needed to provide this care.

Another example is cholera, an antibiotic-treatable bacterial disease for which there are also vaccines. The Vibrio cholerae bacteria thrive in areas where clean water is absent and have long been associated with social inequality. Parts of the world have been in the seventh cholera pandemic for over 60 years, with 51 countries listed as hosting endemic cholera. For a disease to be both endemic and pandemic is a good example of a word that has lost its meaning.

Perhaps pandemic pathogens could also be subcategorised based on the relative speed of their transmission. My blog-level thoughts on that idea are:

• Fast transmitters. Novel subtypes or strains of a known pathogen that will reach a pandemic level of global spread and initial levels of overwhelming harm but eventually settle into a “normal” level of spread, producing less harm if we a) develop very effective vaccines, and b) maintain a source of care and willpower. An example is the influenza A(H1N1pdm09) virus.
  In the case of an entirely novel emerging pathogen, it may revert to a recurring low level—a trough between seasonal epidemic peaks—after several waves. An example is SARS-CoV-2 and probably viruses like HCoV-OC43 and RSV at some point in the past.
• Slow transmitters. New subtypes, strains or completely novel pathogens as above that reach a pandemic level of global spread and initial levels of overwhelming harm, may also eventually become endemic in some or all jurisdictions and may be managed with vaccines or drugs, but which require closer or more prolonged contact (e.g. HIV, SARS, MPOX) or a vector (e.g. malaria) to spread so take more time.

Influenza, COVID-19, and perhaps past respiratory virus pandemics are highly effective at transmitting, and their pandemic pathogens are constantly and relatively rapidly evolving. Because of this, they can very successfully persist among human populations. For example, we still live with the descendants of past influenza pandemic pathogens, even though we are no longer amid those pandemics. Without effective vaccines, such as those seen with smallpox, history has shown that containing fast-transmitting pandemic pathogens is a struggle.

2013 (2017)

In 2013, a streamlined risk-based, less rigid continuum of revised pandemic (still influenza-focused) phases was published in the Pandemic Influenza Risk Management guidance document, updating and replacing the 2009 Pandemic Influenza Preparedness and Response: WHO Guidance Document.

The 2013 guidance aimed to allow more flexibility in dealing with influenza pandemics since the previous formats hadn’t imagined an unexpectedly less severe, more “moderate” event such as the 2009 influenza A(H1N1pdm09). The revised pandemic phases described the global spread (epidemiology) of the new influenza subtype (virology and pathogen novelty), taking into account the disease (clinical severity) it causes, and introduced a risk-based approach. They also uncoupled global pandemic phases from local management decision-making.

The 2013 revision noted that “The pandemic influenza phases reflect WHO’s risk assessment of the global situation regarding each influenza virus with pandemic potential infecting humans. These assessments are initially made when such viruses are identified and are updated based on evolving virological, epidemiological, and clinical data. The phases provide a high-level, global view of the evolving picture.“

The addition of an Interpandemic period highlighted that vigilance should not disappear between pandemics. Vigilance needs to be endemic!

The update also noted: “This guidance is designed to help Member States to implement pandemic influenza surveillance immediately before and during an influenza pandemic.” The WHO doesn’t hold a gun to any State’s head. Leaders make their own sovereign plans and decisions, and if they’re adults, they own their successes and failures.

There was also a document called the WHO guidance for surveillance during an influenza pandemic, 2017 Update, which had a slightly different version of the graphic above. This figure is also accompanied by a somewhat more descriptive footnote: “WHO’s determination of the global pandemic phase will be based on risk assessments that will use surveillance data and will take into account severity, transmission, virological characteristics and population immunity.”

So the continuum approach still accounts for clinical severity, notes that the speed of phase change may be fast or slow, and again, mentions pathogen novelty. All good things.

However, there is no specific detail about what defines the end of a pandemic in this continuum, just a transition phase based on the State’s risk assessments. The WHO manage this part, but it would have been better to be clearer.

Reporting to WHO should continue on a weekly basis until the WHO Director-General declares that the pandemic has ended, even if the Member State is no longer detecting new cases (i.e. there should be reporting of zero cases).

WHO guidance for surveillance during an influenza pandemic, 2017 Update

A recent pandemic: influenza A(H1N1pdm09)

On the 10th of August 2010, the WHO Director General declared that “The world is no longer in phase 6 of influenza pandemic alert. We are now moving into the post-pandemic period. The new H1N1 virus has largely run its course.”

The WHO can and has done this before. They can end a pandemic even if the pathogen remains in place for an unknown period. ‘Pandemic’ is just a poorly defined word subject to the mercy of human decision-making.

We still live with the offspring of that pathogen, influenza A(H1N1pdm09), today. It’s the primary driver of Australia’s 2025 winter flu season. It returns each year as a seasonal virus, and while it still causes severe disease and death, it mostly doesn’t, just like SARS-CoV-2. It still produces new immune escape variants and retains the potential to create significant pathogen novelty in the form of shifted influenza virus variants after genetic recombination with a different subtype. But this pandemic was still declared over.

Today and the Pandemic Emergency…

Which brings us back to today, where we started this piece.

While it seems like we could apply influenza A(H1N1)pdm09-thinking to the COVID-19 event we’re living in, it’s not that simple. As I’ve hopefully shown, we lack the definition for a classical pandemic that’s required. Despite my really wanting the word to have a nice, simple, and precise definition, it clearly doesn’t. You can’t change that. “Pandemic” is a word that’s as subject to human decision and whim as any other word. It’s just too heavily burdened with baggage to be salvageable for use in a public health or global disease context.

Other classical pandemics, which could be argued to be re-emerging or rolling isolated epidemics if pathogen novelty were a fixed element of the classical pandemic term, have continued and been ongoing for years.

Hopefully, it’s now more apparent why the WHO and its experts, in defining the criteria for a brand-new term, are taking a clever and useful approach. This provides a clear alternative path around the past’s blather. And, of course, every country can and will still make its own plans and adhere to them or ignore them (and the WHO) as it sees fit at the time. So long as they address the IHR’s framework or course.

For today’s pandemic, it’s clear that the conditions are not met for it to be called a Pandemic Emergency. In other words, we’d be overdue to call this pandemic to a close if the new criteria were to be applied. But they haven’t been. The WHO is likely sticking with the classical pandemic-free-for-all approach— which, sadly, makes the most bureaucratic sense. So we might be living under the shadow of the COVID-19 pandemic forever. Or it might end tomorrow, as the old label is that uncertain.

What if the COVID-19 pandemic were to end tomorrow?

If the COVID-19 pandemic were to end tomorrow, SARS-CoV-2 and its immune-moderated outcomes would remain, just as for influenza A(H1N1) virus.

Drawing the pandemic to a close would not change the following facts about SARS-CoV-2…

• The majority of infection outcomes are asymptomatic, mild, or moderate.
• Infection can cause respiratory, systemic, gastrointestinal, cardiac and neurological symptoms
• In a portion of cases, chronic physical and mental health impacts remain after one or more infections, with more risk attached to being non-immune at first infection or having a severe outcome.
• Immunity can reduce the likelihood of developing long COVID.
• Disease outcomes after infection of the immune are less severe than in the non-immune.
• Hybrid immunity (vaccination + infection) means that new or ‘breakthrough’ infections occur less often.
• A new variant can infect a person with past immunity.
• Even mild (non-hospitalised) infection outcomes can result in more GP or primary care visits up to six months later than in controls, worsening with severe initial illness.
• SARS-CoV-2 evolves to escape past immunity, but remains ‘SARS-CoV-2’.

While vaccination and infection have provided many with disease-moderating immunity, acute and chronic infection and disease outcomes from SARS-CoV-2 will persist, whether we refer to COVID-19 as a pandemic or an endemic disease.

The reality is that society, industry and executive leadership have all decided, through a lack of planning and action and after the WHO ended the PHEIC, to allow SARS-CoV-2 to become a constant presence among humanity. That ship has sailed. Where this respiratory virus exists, disease exists. There are no longer fast-tracked vaccine and drug improvements. Promotion of non-pharmaceutical interventions is minimal to non-existent, and only those suffering from long COVID are talking about it.

What does this mean?

‘Pandemic’, a worldwide epidemic, is a word that now requires its own definition each and every time it’s used, due to a long, shambolic history of tunnel vision, assumptions, and bolted-on upgrades to make it a more contemporaneously meaningful term. When that wasn’t working, the WHO devoted 20 years to creating and then updating pandemic preparedness guidelines in 1999, 2005, 2009, and 2013 to help States develop better plans tailored to their local context.

Then, in 2024, the WHO overcame decades of increasing confusion and created a shiny new term to better define future pandemics: the Pandemic Emergency. This was the update we really needed. It accounts for any novel communicable pathogen—not just influenza—that requires creation of a PHEIC and can spread globally, overwhelm health system capacity, disrupt society, economies, travel, and trade, and demands careful and considered international collaborative response.

Apart from conveying information, words can also cause distress. Why continue the ongoing use of a word that can drive anxiety among the public if it’s neither needed nor being responded to?

Because COVID-19 was classified during the classical pandemic era, and due to bureaucratic constraints, ‘Pandemic Emergency’ likely won’t see use until the next pandemic. If we applied its definitions today, it could provide a path out of the COVID-19 pandemic as quickly as the WHO eventually navigated us out of the influenza A(H1N1pdm09) pandemic; however, it would require the WHO to demonstrate courageous global leadership in applying the new to the old.

Thanks for reading. Please sign up for the blog notifications – just put your email in the pop-up window – to be notified of future blogs as soon as they come out.

UPDATES

• 25JUL2025.
  • Title changed from “Is COVID-19 a Pandemic or a Pandemic Emergency? Does it even matter?”
  • Feature graphic changed “or” to “and”
  • Added definition stating that the IHR are an instrument of international law, legally-binding in 196 countries.
  • Clarified that ‘Pandemic Emergency’ has never been retroactively applied to COVID-19. But left several instances of “what if it were” as that is part of this blog’s purpose in making us think about why there is an improved definition for something. However, we are still currently living with an active example of that something, but under an outdated definition.
  • Added some more background to the Pandemic Agreement’s creation, need for ratification, and that it is legally binding amonfg those who are signatories
  • Posed the question of why continue using a word that can cause anxiety among the public when the term is no longer needed.
• Some egeneral grammatical updates.