Order Code RL33219
CRS Report for Congress
Received through the CRS Web
U.S. and International Responses to the Global
Spread of Avian Flu: Issues for Congress
Updated January 9, 2006
Tiaji Salaam-Blyther and Emma Chanlett-Avery
Coordinators
Foreign Affairs, Defense, and Trade Division
Congressional Research Service ˜ The Library of Congress

U.S. and International Responses to the Global Spread
of Avian Flu: Issues for Congress
Summary
One strain of avian influenza currently identified in Asia and Europe is known
as Influenza A/H5N1. Although it is a bird flu, it has infected a relatively small
number of people — killing around 50% of those infected. Scientists are unsure if
H5N1 will cause the next influenza pandemic, but there is general consensus that one
is overdue. Flu pandemics have occurred cyclically, roughly between every 30 and
50 years. Since 1997, when the first human contracted H5N1 in Hong Kong, the
virus has resurfaced and spread to more than a dozen countries in Asia and Europe
— infecting more than 140 people and killing approximately half. Britain and
Taiwan both reported avian flu cases of H5N1 in 2005. In the latter cases, the
infected birds were identified as imports, and died in quarantine.
A global influenza pandemic could have a number of consequences. Global
competition for existing vaccines and treatments could ensue. Some governments
might restrict the export of vaccines or other supplies in order to treat their own
population. Some countries might face a shortage of vaccines, antiviral medication,
or other medical equipment, because of limited global supply. Hospitality and airline
industries, and international trade could be negatively impacted. If global travel and
trade were to suddenly drop, there could be productivity losses and service
disruptions. Essential workers might become ill or stay home out of fear of
contracting the virus. Such workers could include law enforcement, medical
personnel, mass transit drivers and engineers, and other crucial emergency personnel.
For FY2006, Congress has provided $25 million for global initiatives to prepare
for pandemic influenza through Foreign Operations appropriations; directed $33.5
million to global disease detection through Labor, HHS, and Education
appropriations; and reserved for international avian flu efforts a portion of $3.8
billion through Defense appropriations.
Bills introduced in the 109th Congress would increase U.S. resources allocated
to the global fight against avian flu; develop a “Pandemic Fund” to augment ongoing
U.S. and international avian flu and pandemic preparedness initiatives; increase
funding for preventing the spread among animals of the H5N1 virus; and strengthen
surveillance capacity within affected countries.
This report will provide an up-to-date account of global H5N1-related human
infections and deaths, outline U.S. government and international responses to the
global spread of H5N1, discuss situations in various countries affected by H5N1, and
present some foreign policy issues for Congress. This report will be periodically
updated.

Contents
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Global Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Congressional Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
U.S. Executive Branch Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
U.S. Department of Health and Human Services (HHS) . . . . . . . . . . . . . . . . 6
U.S. Agency for International Development (USAID) . . . . . . . . . . . . . . . . . 7
Department of State . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Department of Agriculture (USDA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Department of Defense (DoD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
International Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Overview of the Role of the World Health Organization . . . . . . . . . . . . . . 11
WHO’s Global Health Security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
WHO Global Influenza Preparedness Plan . . . . . . . . . . . . . . . . . . . . . . . . . 12
Role of Other International Health Organizations
. . . . . . . . . . . . . . . . . . . 13
International Health Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Affected Countries’ Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Cambodia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
People’s Republic of China, Including Hong Kong . . . . . . . . . . . . . . . . . . . 16
U.S.-PRC Cooperation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Indonesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Laos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Russia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Thailand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Turkey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Vietnam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Issues for Congress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Patent Protections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Global Data Sharing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Global Disease Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Global Pandemic Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Responses by East Asian Regional Groupings . . . . . . . . . . . . . . . . . . 35
Combating Bird Flu Among Animals in Affected Countries . . . . . . . . . . . 36
Cost of Culling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Global Economic Impacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Global Biosafety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

List of Figures
Figure 1. Map of Human and Animal H5N1 Cases . . . . . . . . . . . . . . . . . . . . . . 41
List of Tables
Table 1. Human Cases of Avian Influenza A/H5N1 . . . . . . . . . . . . . . . . . . . . . . . 2
Table 2. WHO Pandemic Phases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Table 3. FY2006 Emergency Supplemental Request . . . . . . . . . . . . . . . . . . . . . 43
Table 4. FY2006 Appropriations Providing Funds for Global Initiatives . . . . . 44
Table 5. Country Allocations for FY2005 Supplemental . . . . . . . . . . . . . . . . . . 45
Table 6. International Partnership on Avian and Pandemic Influenza (IPAPI) Core
Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

U.S. and International Responses to the
Global Spread of Avian Flu: Issues for
Congress
Background
Bird (or avian) flu outbreaks have occurred at various times around the world.1
One strain of avian influenza currently spreading across Asia and Europe is known
as Influenza A/H5N1. Although it is a bird flu, it has also infected a relatively small
number of people — killing around 50% of those infected. Until 1997, there were no
known cases of humans contracting avian influenza. However, that year, 18 people
in Hong Kong contracted the virus; of those 6 died. To stop its spread, 1.5 million
birds were killed. Since 2003, scientists have closely monitored resurgent H5N1
outbreaks, which have infected chickens and ducks in a growing number of countries.
The World Health Organization is particularly alarmed about the rapid spread of
H5N1 in part, because this strain of bird flu has demonstrated the ability to cause
high mortality rates among humans.
According to WHO, the hallmarks of a pandemic are: 1) a novel influenza virus
strain emerges; 2) the strain causes human disease; and 3) person-to-person
transmission is sustained. The pandemic steps usually occur in six phases. Table 1
shows the phases of an influenza pandemic, as described by WHO. The WHO
considers the recent H5N1 outbreak to be in phase three pandemic alert phase, which
means a virus new to humans is causing infections, but does not spread easily from
one person to another.2
Since H5N1 is a bird flu, and has not commonly infected people, humans have
no immunity against it. If H5N1 were to become transmissible among humans, an
“influenza pandemic” (worldwide disease outbreak) could begin, potentially causing
millions of deaths. Skeptics argue that predictions that H5N1 might cause a global
pandemic are exaggerated, because if the virus were able to become efficiently
transmissible among people it would have already transformed.
Still a growing number of health experts underscore that it is critical for
governments to prepare for some form of an influenza pandemic, as the world is
overdue for one. During the influenza pandemic of 1918-1919 (Spanish flu),
estimates are that between 20 and 50 million people died, and between 200 million
1 For a list of past avian flu outbreaks see CRS Report RS21747, Avian Influenza:
Agricultural Issues
, by Jim Monke.
2 WHO, “Avian Influenza — New Areas with Infection in Birds — Update 34,” Disease
Outbreak News
, Oct. 13, 2005, at [http://www.who.int/csr/don/en/].

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and 1 billion were infected around the world. If an influenza pandemic were to occur
on the same scale as the Spanish flu, some estimate that between 30 million and 384
million people could die around the world,3 of which 1.9 million deaths could occur
in the United States.4
Global Prevalence
Since 1997, when the first human contracted H5N1 in Hong Kong, the virus has
resurfaced and spread to birds in fifteen countries, ten in Asia and five in Europe.5
In 2004, nine Asian countries reported H5N1 poultry outbreaks: Cambodia, China,
Indonesia, Japan, Laos, Malaysia, Republic of Korea, Thailand, and Vietnam. By
August 2005, birds in Mongolia had become infected with the virus. Two months
later, in October, domestic birds in Russia and Kazakhstan had contracted H5N1
reportedly through contact with wild waterfowl at shared water sources. By late
October 2005, H5N1 had spread progressively westward to affect six other regions
in Russia, and had infected bird populations in Romania, Croatia, and Turkey.
Although human infection has not been reported outside Asia, health officials are
wary about infection among migratory birds, as the birds are currently acting as
vectors of the virus. Also, infection can potentially be controlled among domestic
birds, but not among wild ones. The chart below shows the latest number of
confirmed human H5N1 cases as reported by WHO as of December 30, 20056. The
map in the Annex (Chart 1) illustrates the human H5N1 cases.
Table 1. Human Cases of Avian Influenza A/H5N1
Indonesia
Vietnam
Thailand
Cambodia
China
Turkey
Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths
16
11
93
42
22
14
4
4
7
3
4
2
Total Cases = 146; Total Deaths = 76
3 Osterholm, Michael, “Pandemic Influenza: A Harbinger of Things to Come.” Presentation
at the Woodrow Wilson International Center for Scholars, September 19, 2005.
[http://www.wilsoncenter.org/index.cfm?fuseaction=news.item&news_id=145329]
4 HHS Pandemic Influenza Plan, November 2005, [http://www.hhs.gov/pandemicflu/plan/].
For more information on issues related to domestic efforts to address H5N1 and pandemic
influenza preparedness, see CRS Report RL33145, Pandemic Influenza: Domestic
Preparedness Efforts
, by Sarah A. Lister.
5 To date, H5N1 has been identified among birds in Cambodia, China, Croatia, Indonesia,
Japan, Kazakhstan, Korea, Laos, Malaysia, Mongolia, Romania, Russia, Thailand, Turkey,
and Vietnam. A bird in Britain was diagnosed with H5N1, however it was an isolated case
found in an imported bird that died in quarantine. World Organization for Animal Health
(OIE), “Update on Avian Influenza in Animals.” December 21, 2005.
[http://www.oie.int/eng/en_index.htm]
6 WHO, Cumulative Number of Confirmed Human Cases of Avian Influenza A/H5N1,
January 9, 2006. [http://www.who.int/csr/disease/avian_influenza/country/en/]

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Congressional Response
Congress provided $25 million to support ongoing U.S. efforts to prevent and
contain the spread of H5N1 through P.L. 109-13, FY2005 Emergency Supplemental
Appropriations
. The act, which passed in May 2005, also provided funds for
domestic pandemic preparedness.7 Additionally, the act directed U.S. agencies to
develop a coordinated response to the global spread of H5N1. Congress provided the
funds to U.S. Agency for International Development (USAID). Pursuant to the
statute, USAID transferred $15 million of the $25 million appropriation to CDC.
The conference report for P.L. 109-102, FY2006 Foreign Operations
Appropriations, urges the United States Executive Director to the World Bank to use
the voice and vote of the United States to increase support for using International
Development Association (IDA) funds to help eligible countries prepare for and
combat a potential avian influenza epidemic. Particularly, the report points out that
funds could be used in Asia for programs to increase surveillance capacity,
compensate small-scale farmers for timely reports of bird die-offs, modernize animal
husbandry practices, and upgrade infectious disease infrastructure. The report also
underscores that the $25 million provided in P.L. 109-13 is the first step in a multi-
year effort to contain, prevent, and prepare for the spread of avian influenza.
H.Rept. 109-337 for H.R. 3010, FY2006 Labor, HHS, and Education
Appropriations, includes $63.58 million for the Public Health and Social Services
Emergency Fund (PHSSEF) to enhance federal, state, and local preparedness to
counter potential biological, disease, chemical, and radiological threats to civilian
populations. Additionally, $33.5 million is directed to global disease detection. The
bill does not include funds to support the President’s FY2006 $7.1 billion emergency
request for avian flu and pandemic influenza preparedness. Instead, appropriators
provided additional funds through FY2006 Defense Appropriations. The FY2006
Defense, Disaster Assistance, and Avian Flu Preparedness Appropriations
conference report, H.Rept. 109-359, reserves a portion of the $3.8 billion directed to
avian flu activities for international avian flu efforts.8 The Senate passed the House
version after removing a controversial provision related to oil drilling in Alaska.
H.R. 3010 and H.R. 2863 were presented to the President on December 28, 2005.
7 For more information on the domestic response to H5N1, see CRS Report RL33145,
Pandemic Influenza: Domestic Preparedness Efforts, by Sarah A. Lister, and CRS Report
RS21747, Avian Influenza: Agricultural Issues, by Jim Monke.
8 The FY2006 Defense, Disaster Assistance, and Avian Flu Preparedness Appropriations
conference report, H.Rept. 109-359, contains $3.8 billion for avian influenza initiatives.
$3.3 billion of the $3.8 billion is directed to the Department of Health and Human Services
(HHS) (of which $267 million is reserved for international initiatives, disease surveillance,
vaccine registries, research, and clinical trials). An additional $500 million is reserved for
international assistance, monitoring and tracking, and research and development, of which
$131.5 million is directed to USAID, $130 million to the Department of Defense, $71.5
million to the Department of Agriculture, $47.3 million to the Department of Homeland
Security, $20 million to FDA, $27 million to the Department of Veterans Affairs, $31
million to the Department of State, and $11.6 million to the Department of the Interior.

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Table 3 reflects FY2006 appropriations that include funding for global avian flu
activities.
Press reports quote a number of Members expressing concern about funding the
President’s $7.1 billion avian flu and pandemic preparedness request. The Chairman
of the House Energy and Commerce Committee, Joe Barton, reportedly stated that
he would not support funding for the bill if the President did not provide offsets for
avian flu and pandemic preparedness spending.9 Others proposed that Congress
spread out funding the request over a few years.
Some congressional Members argued that the Administration has allocated
insufficient resources to the global fight against H5N1 and pandemic planning. Of
the $7.1 billion requested, approximately $388 million would be reserved for global
efforts. A number of Members have introduced legislation to increase U.S. resources
allocated to the global fight against avian flu. Some bills, such as H.R. 4062,
Pandemic Preparedness and Responsibility Act and its Senate companion, S. 1821,
propose developing a “Pandemic Fund”to augment ongoing U.S. and international
avian flu and pandemic preparedness initiatives. Other bills, such as H.R. 4476,
Global Network for Avian Influenza Surveillance Act, and its Senate companion, S.
1912, advocate greater support for initiatives that prevent the spread of H5N1 among
animals. A number of bills, such as H.R. 3369, Attacking Viral Influenza Across
Nations Act
, and its Senate companion, S. 969, suggest the U.S. strengthen
surveillance capacity within affected countries. Bills, such as H.R. 813, Flu
Protection Act
, and its Senate companion, S. 375, aim to boost influenza vaccine
supply. Additionally, other legislation, such as H.R. 4245, Influenza Preparedness
and Prevention Act
encourage greater international cooperation.
Some Members of Congress have also expressed support for greater spending
on global initiatives during congressional hearings. For example, during the House
International Relations Committee hearing on pandemic flu in December 2005,
Chairman Henry Hyde questioned whether the amount the President requested for
international pandemic flu preparedness was sufficient. A number of other
committees have also held hearings on avian flu and pandemic preparedness,
including the Senate Foreign Relations and Appropriations Committees, House
Agriculture Committee and a joint hearing by the House Homeland Security and
Armed Services Committees.
U.S. Executive Branch Response
On November 1, 2005, the President released the National Strategy for
Pandemic Influenza. One day later, on November 2, 2005, the Administration
released the U.S. Department of Health and Human Services (HHS) Influenza Plan.
The HHS plan provided a detailed explanation of how the national strategy would be
implemented. Some were disappointed by the relatively small proportion of funds
reserved for international efforts. It has been argued that greater investment in
9 CQ Today, “Bush Flu Spending Request Meets Resistance from House Republicans.
November 8, 2005. [http://www.cq.com]

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pandemic influenza preparedness abroad could enhance domestic pandemic
preparedness efforts. Of the $7.1 billion requested, approximately $388 million is
reserved for global initiatives. Of the $388 million, $200 million is made available
for HHS to bolster international surveillance capacity; $131.5 million for USAID to
implement avian influenza containment efforts globally; an additional $18.5 million
for the State Department for avian flu and pandemic preparedness activities in
diplomatic arenas, $20 million for the potential evacuation of U.S. government
personnel and their dependents in the event of a pandemic; and $18.3 million for the
Department of Agriculture to provide technical assistance in international animal
surveillance.10 Table 2 summarizes the FY2006 emergency request.
HHS (and its relevant agencies), USAID, the Department of Agriculture, and
the Department of Defense are the key U.S. departments and agency involved in
containing the global spread of H5N1 and preparing for pandemic influenza. The
Department of State plays a complementary role by raising the issue in diplomatic
arenas. The unique role that each agency plays is described in order of presence on
the ground.
Prior to 2005 — when Congress provided $25 million for preventing the global
spread of avian influenza and preparing for pandemic influenza — U.S. agencies had
been enhancing laboratory capabilities, training health care providers, strengthening
surveillance systems, and developing influenza pandemic plans. Through the
FY2005 emergency appropriations, Congress directed U.S. agencies to revisit
international influenza initiatives and ensure that there was a coordinated response
to the global spread of H5N1. USAID and HHS (including its relevant agencies)
undertook country planning visits to Vietnam, Cambodia, and Laos. After the trip,
the team outlined in a report11 a number of factors that have complicated efforts to
contain the spread of H5N1 in Vietnam, Cambodia, and Laos, which included:
! Between 70% and 80% of poultry in the three countries are raised in
small backyard farms, hindering national governments’ ability to
ensure health standards.
! Between 50% and 80% of poultry die from other avian infections,
complicating efforts to identify unusual die-offs, and limiting
farmers’ likelihood of reporting bird deaths to authorities.
! Although culling is an essential element of controlling the spread of
H5N1, poorer countries can not afford to systematically compensate
farmers for lost stock, which also increases reluctance to report signs
of infection.
! Wild birds and domesticated ducks are H5N1 reservoirs.
10 FY2006 Emergency Request for Avian and Pandemic Influenza Preparedness.
[http://www.whitehouse.gov/omb/budget/amendments/supplemental_11_01_05.pdf]
11 Report from Country Planning Visits, “U.S. Government Emergency Response to Avian
Influenza: A Plan of Action for Vietnam, Laos, and Cambodia.” July 11-24, 2005. This
report was provided to CRS by USAID.

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! Low levels of awareness exist among local farmers.
! There is little pandemic preparedness activity in the countries toured.
! The capacity to monitor and respond effectively to animal outbreaks
is limited. Veterinary services are inadequate to deal with the scope,
severity, and rapid spread of H5N1 epidemics, which has resulted in
the disease becoming increasingly endemic among animal
populations in the region. The lack of human resources for disease
surveillance, diagnostics, and response also severely limits the
capacity of human health systems, and continued human infections
of avian influenza threaten to overburden already fragile public
health infrastructures.
The report also included an action plan, which outlined the activities that each
agency would implement. The agency-specific strategies are briefly described below.
Table 4 provides a country-specific illustration of Department of Health and Human
Services (HHS) and USAID spending for the FY2005 Emergency Supplemental
Appropriations.
U.S. Department of Health and Human Services (HHS)
CDC is the key agency at HHS responsible for implementing U.S. anti-influenza
activities around the world. The Coordinating Center for Infectious Diseases and the
Field Epidemiology Training Program — a CDC-sponsored activity — are also
critical components of HHS global pandemic preparedness initiatives. Activities
with foreign governments or populations include pandemic preparedness and
planning; training in avian influenza surveillance; laboratory safety and skills
instruction; epidemiology training; developing and training rapid response teams;
stockpiling support; and deployment of expert disease control teams.
It is not possible to disaggregate H5N1-specific funding, because H5N1,
seasonal flu, and pandemic preparedness initiatives are interlocked. A significant
part of H5N1 and pandemic influenza planning is funded through the Global Disease
Detection (GDD) Initiative at CDC. GDD aims to recognize infectious disease
outbreaks faster, improve the ability to control and prevent outbreaks, and detect
emerging microbial threats. CDC estimates that in FY2004, it spent approximately
$5 million on activities related to international influenza through both its Infectious
Diseases Control and GDD programs. In FY2005, CDC spent approximately $6
million through these activities, in addition to the $15 million emergency
appropriations. In 2005, CDC expanded its GDD activities by creating new sites,
improving early warning systems, researching new viral strains, and supporting
international organizations. Congress provided $21.4 million for GDD in
FY2005.The HHS FY2006 budget request suggests increasing GDD funding by
$12.1 million to $33.5 million, of which a portion would be used for international

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bird flu initiatives.12 H. Rept.109-337, FY2006 Labor, HHS, and Education
Appropriations
directed $33.5 million to GDD.
U.S. Agency for International Development (USAID)
USAID coordinates its global H5N1 and influenza response with other U.S.
agencies. It also works closely with the WHO, the Food and Agriculture Organization
of the United Nations (FAO), and other international governments and organizations
to support national influenza and H5N1 prevention efforts. To date, the agency has
spent $13.7 million on avian influenza prevention and containment ($10 million of
which was funded through the FY2005 emergency appropriations).13 Specifically,
the agency has:
! dedicated $7.5 million to Cambodia, China, Indonesia, Laos, and
Vietnam for strengthening disease surveillance, laboratory diagnosis,
and rapid containment of animal outbreaks;
! provided $2.85 million for communication campaigns in Laos,
Cambodia, Vietnam, and Indonesia aimed at reducing animal
handling practices that place humans at risk;
! committed over $1.6 million to enhance national planning efforts,
strengthen avian influenza control and outbreak response, and
augment human disease surveillance systems and laboratories;
! granted WHO $300,000 for international coordination efforts and for
improving disease control and surveillance measures;
! provided WHO an additional$250,000 for personal protective
equipment (PPE) used in handling and disposing of infected poultry;
and
! distributed some 10,000 sets of PPEs, which include manual
sprayers to assist in decontaminating hospital rooms and equipment,
Tyvek suits (protective coveralls used in hazardous situations),
gloves, boots, masks, and eye protection in Cambodia, Thailand,
Laos, Vietnam, and Indonesia.
The Administration’s FY2006 emergency supplemental request allocates $131.5
million to USAID for avian flu and pandemic preparedness initiatives abroad. The
funds would be used to pre-position supplies and equipment that prevent and control
the spread of avian influenza; launch awareness raising campaigns; and accelerate
international planning and preparedness. The request proposes that $2 million of the
USAID funds be reserved for initiatives in Russia and Eastern Europe.
12 Interviews with CDC staff, October 13, 2005 and November 1, 2005.
13 USAID Fact Sheet “Avian Influenza Preparedness, Response, and Containment.” October
27, 2005. [http://www.usaid.gov].

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Department of State
On September 14, 2005, President Bush announced the International Partnership
on Avian and Pandemic Influenza (IPAPI) at the U.N. General Assembly High-Level
Plenary Session. IPAPI seeks to generate and coordinate political momentum and
action for addressing the threats of avian and pandemic influenza based on a set of
core principles. The principles are focused on enhancing preparedness, prevention,
response, and containment activities (see Table 5). The Partnership brings key
nations and international organizations together to improve global readiness by:
! elevating the issue of avian and pandemic influenza preparedness to
the national level;
! coordinating efforts among donor and affected nations;
! mobilizing and leveraging resources;
! increasing transparency in disease reporting and surveillance; and
! building capacity to identify, contain, and respond to pandemic
influenza.
The State Department works closely with regional organizations, including the
Association of Southeast Asian Nations (ASEAN) and the Asia Pacific Economic
Cooperation (APEC) forum, to address avian influenza and the threat of an influenza
pandemic. The work includes efforts to encourage comprehensive national pandemic
preparedness plans that address the multi-sectoral impacts of an influenza
pandemic.14
In the FY2006 supplemental request, the President proposed that the State
Department receive $38.5 million in FY2006 for international response coordination;
diplomatic outreach; exchanges of U.S. and foreign medical personnel; and for avian
and pandemic influenza health support and protection of U.S. government employees
and families at U.S. missions overseas. About $20 million of those funds would be
reserved for the potential evacuation of U.S. government personnel and dependents
from overseas missions.
14 The State Department also implements influenza pandemic preparedness initiatives
through the Office of International Health Affairs (OES/IHA), which works with agencies
throughout the U.S. government to facilitate policy-making regarding bioterrorism and
health security, environmental health, infectious diseases (e.g., SARS, Avian Influenza,
Pandemic Influenza, Polio), health in post-conflict situations, and surveillance and response.
[http://www.state.gov/g/oes/c1874.htm].

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Department of Agriculture (USDA)
U.S. Department of Agriculture (and its related agencies)works closely with
other U.S. agencies on the ground, as well as other international organizations to help
nations take steps to address and control the spread of avian influenza. Dr. Ron
DeHaven, Administrator, Animal and Plant Health Inspection Service (APHIS) of
USDA stated that addressing avian flu at its source — in affected poultry abroad —
and participating in international eradication efforts provide the best opportunity to
reduce or eliminate the risk of an H5N1 pandemic.15 In that view, USDA and other
analysts consider the department’s efforts a critical element in the global fight against
the spread of H5N1.

Through $4 million in FY2003 emergency funding, APHIS launched an
outreach campaign called “Biosecurity for the Birds,” which provides poultry farmers
with the latest information on biosecurity to prevent the spread of avian infections
on farms. USDA is translating the brochures for use in southeast Asia.
Additionally, in the FY2006 emergency supplemental, the President requests
$91.3 million for USDA, of which $18.3 million is reserved for international
initiatives. The would be allocated as follows:
! $8.0 million for wildlife, poultry and swine surveillance and
diagnostics;
! $1.75 million for biosecurity enhancement through education and
information;
! $1.05 million for technical assistance through training and avian
movement control;
! $3.8 million for training and education related to industry changes
and food safety planning;
! $1.05 million for training and education regarding poultry
destruction and disposal methods;
! $0.6 million for testing and evaluation of vaccine formulations; and
! $2.1 million for in country expertise for longer term assistance.
Department of Defense (DoD)
The Department of Defense Global Emerging Infections System (GEIS) delivers
health care to American armed forces around the globe.16 GEIS has a network of
overseas medical research laboratories that track, prevent, and treat infectious
diseases around the world. The objective is to protect the U.S. military and
strengthen its ability to address the challenges related to a potential pandemic
influenza, including compromised military force health and readiness. GEIS is also
a critical partner in the WHO’s Global Outbreak Alert and Response Network
15 USDA, Transcript of Technical Briefing regarding Avian Influenza. October 26, 2005.
[http://www.usda.gov/birdflu]
16 GEIS website, [http://www.geis.fhp.osd.mil/].

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(GOARN) (described below). Key DoD-GEIS activities to combat the spread of
H5N1 and prepare for an influenza pandemic have included:
! providing a DoD staff veterinarian to serve as a member of the
WHO GOARN Team in Laos, and to conduct training workshops in
detecting and diagnosing avian flu cases;
! placing a U.S. Navy microbiologist at the Institute Pasteur in Ho Chi
Minh City, Vietnam, to hold training sessions on rapid diagnostic
test methodology;
! monitoring and preventing infectious disease emergence in southeast
Asia through its Armed Forces Research Institute of Medical
Sciences (AFRIMS).17
The Naval Medical Research Unit-2 (NAMRU-2) is another critical part of
DoD’s effort to prevent H5N1 from becoming a human pandemic and prepare for an
influenza pandemic. NAMRU-2 supports the GEIS mission through four programs:
emerging diseases, enteric diseases, parasitic diseases, and virology. NAMRU-2 is
an overseas research laboratory based in Jakarta, Indonesia with related activities in
Southeast Asia and the Pacific Islands. NAMRU-2 also supports a satellite
laboratory in Phnom Penh, Cambodia, in collaboration with the Cambodian National
Institute of Public Health. Key activities include:
! bolstering local, national, and regional diagnostic and
epidemiological capacity;
! assisting in the development of new surveillance strategies, such as
the novel syndromic surveillance initiative Early Warning Outbreak
Recognition System (EWORS);
! implementing a comprehensive influenza surveillance project in
Indonesia, which provides prevalence data and temporal, genotype
data of circulating strains;
! collaborating with CDC in its FY2005 and FY2006 global influenza
activities; and
! facilitating the transformation of outbreak response structures into
more effective, multidisciplinary, centrally directed ones.18
The FY2006 emergency supplemental request would reserve $10 million of the
$130 million allocated to the Department of Defense for procuring protective
17 DoD, Global Emerging Infections System Annual Report Fiscal Year 2004.
[http://www.geis.fhp.osd.mil/GEIS/aboutGEIS/annualReports/GEIS_AR_04.pdf].
18 DoD, Global Emerging Infections System Annual Report Fiscal Year 2004.
[http://www.geis.fhp.osd.mil/GEIS/aboutGEIS/annualReports/GEIS_AR_04.pdf].

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equipment; laboratory diagnostic equipment; portable field assay testing equipment;
and surveillance and communication equipment.
International Response19
Overview of the Role of the World Health Organization
The World Health Organization, established in 1948, is the U.N. system’s
authority on international public health issues. It assists governments to improve
national health services and establish worldwide standards for foods, chemicals, and
biological and pharmaceutical products. WHO concentrates on preventive rather
than curative programs, including efforts to eradicate endemic and other widespread
diseases, stabilize population growth, and improve nutrition, sanitation, and maternal
and child care. WHO works through contracts with other agencies and private
voluntary organizations. The United States has been a member of WHO since its
inception.
WHO is a central actor in the global response to the outbreak of H5N1 avian
influenza. As in the case of SARS in 2003, WHO seeks to mitigate the risks avian
influenza and infectious diseases pose to international public health, and to assure the
availability of appropriate containment mechanisms, particularly since global travel
has become the primary means of spreading disease around the world. With the
exception of SARS and HIV/AIDS, H5N1 is viewed as the most serious challenge
the WHO has faced in the last few decades.
WHO’s Global Health Security
The Epidemic and Pandemic Alert and Response system is a critical part of
WHO’s global health security plan. Key aspects of the program include:
! The Alert and Response Operations: systematically track the
development of diseases, share and disseminate information, and
coordinate rapid outbreak response and logistics.
! The Global Outbreak Alert and Response Network (GOARN):
provides an operational framework and aims to create a standardized
international outbreak response system through 112 institutions and
networks of people and technical resources.20
! The Global Public Health Intelligence Network (GPHIN): tracks
Internet communications through a customized search engine, which
effectively picked up telecommunicated alerts in China during the
19 This section prepared by Rhoda Margesson, Analyst in Foreign Affairs.
20 For more information on the Global Outbreak Alert and Response Network, see
[http://www.who.int/csr/outbreaknetwork].

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SARS outbreak. WHO also uses the system to clarify or refute
information that may create disruption or panic.
WHO Global Influenza Preparedness Plan21
In September 2005, U.N. Secretary-General Kofi Annan appointed Dr. David
Nabarro as the Senior U.N. System Coordinator for Human and Avian influenza. Dr.
Nabarro, seconded from the WHO, is responsible for coordinating the avian
influenza containment efforts of the various U.N. agencies. Dr. Nabarro is also
tasked with encouraging global support and implementation of the WHO Global
Influenza Preparedness Plan. The plan outlines WHO goals and actions, as well as
recommended actions for individual nations, at each pandemic phase (see Table 1).
The plan contains an annex of recommendations to nations for “non-pharmaceutical
public health interventions,” such as isolation, quarantine and travel restrictions. The
annex stresses the use of voluntary rather than compulsory measures. Additionally,
it stresses that nations implement infection-specific responses, noting the lack of
demonstrated utility of certain practices. For example, certain SARS control
measures, such as temperature screening at airports, would not be expected to
effectively control influenza spread.22

WHO has requested $150 million to establish a global stockpile of influenza
vaccines and treatments. WHO officials underscore that wealthy and poor countries
must develop pandemic preparedness plans collectively to reduce national and
international viral transmission. The organization envisions using the stockpile to
arrest a potential pandemic by containing the virus at the first sign of an outbreak. In
the event of an outbreak, WHO asserts that a pandemic could potentially be averted
if antiviral drugs were quickly distributed in a poor country without access to them.23
To date, countries have pledged between $20 million and $30 million to fund the
stockpile. Roche, the patent holder of Tamiflu, announced that it would donate three
million courses of the drug to WHO24. The company estimates that the three million
courses would be ready before mid-2006.
Similarly, the U.N. General Assembly has established an emergency fund —
Central Emergency Response Fund (CERF) — to provide quick initial funding
during the early stages of emergencies and to minimize extra costs related to funding
delays. The U.N. aims to have a $500 million revolving budget that could be used
within three to four days of the start of an emergency. To date, the United Nations
2 1 The WHO influenza pandemic preparedness Home Page is at
[http://www.who.int/csr/disease/influenza/pandemic/en/index.html].
22 See WHO, Department of Communicable Disease Surveillance and Response Global
Influenza Programme, “Responding to the Avian Influenza Pandemic Threat: Recommended
Strategic Actions,” WHO/CDS/CSR/GIP2005.8.
23 WHO, “Donation of three million treatments of oseltamivir to WHO will help early
response to an emerging influenza pandemic.” August 24, 2005.
[http://www.who.int/mediacentre/news/releases/2005/pr36/en/index.html].
24 Roche, “Roche donates 3 million treatments of antiviral Tamiflu to the WHO for use in
an influenza pandemic.” August 24, 2005. [http://www.roche.com/med-cor-2005-08-24]

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has received more than $200 million for the fund, which will be launched in mid-
January and should be operational by March.25
Role of Other International Health Organizations
The U.N. Food and Agriculture Organization coordinates global surveillance
and response activities for animal influenza strains with pandemic potential, such as
H5N1.26 To accomplish its mission, FAO works closely with the World Organization
for Animal Health, known by its French acronym, OIE.27 Rapid detection of avian
influenza outbreaks is key to controlling the disease both in poultry and in people,
and is therefore key to preventing and controlling a potential influenza pandemic.
FAO, OIE, and WHO work closely to prevent and respond to the threat of an avian
influenza pandemic. FAO has spent $7.5 million on H5N1 initiatives since 2004.
USAID is granting the UN organization $6 million, and the German government has
pledged $20 million for 2005 and 2006 activities.28 FAO is requesting an additional
$175 million from the international community, due to the rapid global spread of
H5N1.
The World Bank provides low-interest loans to countries heavily affected by
H5N1. Additionally, the Bank coordinates efforts between countries, and encourages
them to develop pandemic plans that connect sectors, such as health and rural
development. In September 2005, representatives from the WHO, FAO, OIE and the
World Bank met with health experts from the United Nations, European Commission
and H5N1-affected countries to discuss the global spread of H5N1, to emphasize the
importance of pandemic planning, and to prepare a coordinated response. On
November 4, 2005, the World Bank announced that it would provide $500 million
in loans to poor southeast Asian countries that are struggling to combat avian
influenza. The funds will be used to supplement government resources, strengthen
veterinary systems, and assist in culling and animal vaccination programs.29
Although the World Bank has agreed to provide $500 million in loans to affected
countries, the Bank estimates that $1 billion could be needed over the next three
years.30 The $1 billion does not include the cost of financing human or animal
vaccine development, purchasing antiviral medicine, or compensating farmers for
loss of income.
25 United Nations, “U.N. Establishes New Emergency Fund,” December 16, 2005.
[http://www.irinnews.org]
26 See FAO avian influenza home page at [http://www.fao.org/ag/againfo/subjects/en/
health/diseases-cards/special_avian.html].
27 See OIE avian flu home page at [http://www.oie.int/eng/AVIAN_INFLUENZA/
home.htm]
28 Interview with FAO official, October 31, 2005.
29 World Bank Press Release, “New Global Program to Deal with Avian Flu.” November
4, 2005. [http://www.worldbank.org]
30 UN News Service, “Bird flu: UN-sponsored conference draws up six-point action plan.”
November 9, 2005. [http://www.un.org/apps/news/]

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The WHO, FAO, OIE, and the World Bank co-sponsored a meeting on avian
influenza and human pandemic influenza on November 7-9, 2005, in Geneva,
Switzerland, to develop an integrated global plan and to focus on funding
initiatives.31 Participants agreed to a six-point global plan which called for:
! Controlling the virus at its source in birds;
! Strengthening surveillance, early detection, rapid response systems,
and laboratory capacity;
! Training national staff in investigating animal and human cases, and
planning and testing rapid containment activities;
! Building and testing national pandemic preparedness plans,
conducting a global pandemic response exercise, and enhancing
health systems;
! Developing integrated country plans that encompass all sectors; and
! Ensuring factual and transparent communications.32
International Health Regulations
An outbreak of infectious diseases raises many public health questions including
the application of international law, particularly as it affects three main areas —
International Health Regulations (IHR); public health measures and civil and political
rights; and principles of state responsibility.33 This section will focus on the IHR
because of its relevance to WHO.
On May 23, 2005, the World Health Assembly revised the IHR, adding novel
influenza strains (those with pandemic potential) and SARS to the list of “notifiable
diseases” that WHO urges countries to report. In addition, the revised IHR include
a provision requiring notification of “events of international concern.” This
mechanism could strengthen WHO’s ability to address emerging diseases, because
it requires member States to report unusual health events whether or not they are
attributable to a known pathogen. The updated IHR also include expanded
requirements for disease surveillance and control activities at points of international
travel (airports, border crossings, etc.), and urge developed countries to assist
developing countries to gain the capacities needed to meet the new disease control
guidelines.34
The revised IHR are to replace the existing IHR (adopted in 1969) on June 15,
2007, when the revised regulations come into force. Considered an international
legal instrument, the revised IHR will be binding on all WHO member States who
31 The World Bank Group, “Partners Meeting on Avian Influenza and Human Pandemic
Influenza.” [http://www.worldbank.org]
32 UN News Service, “Bird flu: UN-sponsored conference draws up six-point action plan.”
November 9, 2005. [http://www.un.org/apps/news/]
33 The American Society of International Law, SARS and International Law, April 2003, see
[http://www.asil.org/insights].
34 The revised International Health Regulations, approved by the World Health Assembly
on May 23, 2005, are available at [http://www.who.int/csr/ihr/en/].

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have not stated a reservation or rejected them altogether, and on non-member States
that have notified the Director-General of WHO that they agree to be bound by the
revised IHR.35 Between now and June 2007, WHO and Member States may take
concrete steps towards implementation of the revised IHR and to improve their
capacity to respond to international health risks and emergencies.36 The revised IHR
do not include an enforcement mechanism. However, for states to respond
appropriately and avoid potentially harmful consequences, much of the
encouragement to comply will likely come from international pressure, as the SARS
outbreak demonstrated.
Affected Countries’ Response
Degree and sophistication of preparation for avian influenza vary widely among
the affected countries. The more affluent governments have undertaken more
extensive measures as well as committed national resources to hedge against the risk
of a pandemic. Japan and Taiwan have reportedly both accumulated stockpiles of
Tamiflu and are preparing to manufacture their own supply. Singapore has
reportedly stockpiled antivirals for 10% of its population, enhanced surveillance, and
put a detailed contingency plan in place. WHO officials praised an exercise run by
South Korea which simulated how the government would respond to an outbreak.37
On the other hand, the closed governments of Burma (Myanmar) and North Korea
offer little reliable information about the presence of bird flu within their borders.
Although both Yangon and Pyongyang have provided limited cooperation with the
FAO, their officially rosy outlooks are treated with skepticism by international health
experts and could constitute a weak link in the event of a pandemic.
The profiles below focus on countries that have had cases of human infection.
Although Russia has had no human cases to date, an analysis of H5N1 cases has been
included, because H5N1 has spread to other parts of Europe from there. H5N1 cases
in birds have been confirmed in Romania, Turkey, Kazakhstan, the Ukraine, and
Croatia,38 and Turkey confirmed two deaths from the virus in early 2006. Britain and
Taiwan both reported cases of H5N1 in 2005. However, the incidences are not
discussed here, as experts concluded that the imported birds were identified and died
in quarantine, and are believed unlikely to have spread the disease.
35 If a State makes a reservation that is compatible with the “object and purpose of IHR
(2005)” and at least one-third of other States have not objected to the reservation within six
months of notification, the revised IHR will enter into force for that State, subject to its
reservation. See WHO, “Frequently Asked Questions About IHR,” at
[http://www.who.int/csr/ihr/howtheywork/faq].
3 6 S e e W H O , “ F r e q u e n t l y A s k e d Q u e s t i o n s A b o u t I H R , ” a t
[http://www.who.int/csr/ihr/howtheywork/faq].
37 “The Front Lines in the Battle Against Avian Flu Are Running Short of Money,” New
York Times
. October 9, 2005.
38 OIE, Update on Avian Influenza in Animals, January 9, 2006. [http://www.oie.int/]

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Cambodia39
Between February and April 2005, four Cambodians were confirmed to have
died from the H5N1 avian flu virus. All four victims lived in Kampot province, an
area where 600 poultry reportedly had fallen ill and died in March 2005. Despite
warnings, many villagers ate birds that had been sick because food is not plentiful.
Health experts predict that more cases in Cambodia are likely, though the WHO has
not reported any additional human cases. Health officials in Kampot are being taught
how to identify symptoms of avian influenza and instructed to notify the provincial
health department. In September 2005, more than 1,000 water birds were reportedly
found dead in poultry farms in Batambang and several other provinces. None of the
birds tested have been confirmed to have the H5N1 virus. The Cambodian
government has cooperated fully with the WHO, but the government has limited
capacity to contain outbreaks of the disease. Compared to Thailand, in Cambodia,
poultry farms are smaller but more numerous, and many chickens roam freely, while
transportation and communications links are far less developed; hence monitoring
the nation’s poultry stocks is more difficult. The U.S. government assessment team
that visited Laos, Cambodia, and Vietnam in July 2005 reported that the U.S.
government, FAO, and WHO have strong working relationships with relevant
ministries in the Cambodian government, while over 200 international donors and
NGOs operating in the country could play an effective role in mobilizing an effective
response to an outbreak of avian flu. On October 12, 2005, U.S. Secretary of Health
and Human Services Michael Leavitt, on a visit to Southeast Asia, signed a
cooperation agreement with Cambodian officials pledging $1.8 million to Cambodia
to help the country guard against the spread of H5N1.40 United Nations experts
estimated that Cambodia needs $18 million to develop programs to stem the spread
of the virus. In December 2005, Germany announced that it would provide $3
million to the kingdom to help fight the disease.41
People’s Republic of China, Including Hong Kong42
The November 2005 confirmation of the first human cases and deaths from
H5N1 in China in 2005 renewed fears that the spread of H5N1 could accelerate
within China.43 The close proximity of millions of people, birds, and animals in
southern China has made it a common breeding ground for deadly types of influenza
viruses, including the H5N1 avian flu virus, that jump the species barrier to humans.
Added to this, the PRC’s poor public health infrastructure and the traditionally
secretive, un-transparent policy approach of its communist government have made
international health specialists particularly concerned about the PRC as a possible
contributor to an H5N1 flu global pandemic. Health care specialists have cited the
39 This section prepared by Thomas Lum, Specialist in Asian Affairs, 7-7616.
40 “U.S., Cambodian Health Ministers Sign Deal on Bird Flu Cooperation,” Agence France
Press
. October 11, 2005.
41 “Cambodia Needs $18 Million for Bird Flu Fight — UN,” Reuters, December 16, 2005.
42 This section was prepared by Kerry Dumbaugh, Specialist in Asian Affairs, 7-7683.
43 As of January 1, 2006, there were 7 confirmed cases of avian flu and 3 deaths in China.

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PRC government’s early lack of cooperation during the outbreak of Severe Acute
Respiratory Syndrome, or SARS — a previously unknown virus that surfaced in
southern China in 2003 — as a principal cause for that virus’ quick global spread
before it was contained.44 As of January 1, 2006, there have been 31 outbreaks of the
H5N1 strain in Chinese poultry since late October 2005, heightening international
health concerns.
Hong Kong in late 1997 is where the H5N1 avian flu virus for the first time was
recorded as jumping directly from its traditional animal species to humans, infecting
18 people in Hong Kong and killing six. Although the Hong Kong government
responded aggressively at that time, in three days exterminating its entire poultry
population of 1.5 million birds, the 1997 outbreak marked the beginning of the cycle
of H5N1 outbreaks that expanded on a much wider scale throughout Asia in late
2003 and early 2004. On January 27, 2004, a WHO official stated that a “staggering”
number of birds, both migratory and domestic, were infected with the virus in at least
ten Asian countries. That same day in 2004, the PRC became the tenth country to
acknowledge ongoing outbreaks of avian flu within its borders. According to WHO,
H5N1 is now considered endemic in parts of China. In addition to afflicting
domestic poultry and migratory birds in isolated parts of China, H5N1 also has been
documented in parts of China’s pig population.45
The 2003 SARS experience appears to have made PRC leaders more sensitive
to potential catastrophic health issues. Consequently, Beijing has been far more
assertive in enacting measures to combat the H5N1 virus. But even with the positive
steps that have been taken, PRC officials face enormous problems in implementation.
The PRC Ministry of Health reports it has established 63 influenza monitoring labs
throughout most of China46 and has crafted and published an emergency plan for an
influenza pandemic, including a four-color-coded notification system.47 On
November 21, 2005, PRC agricultural officials at a press conference further
announced the adoption and immediate implementation of contingency regulations
to combat the spread of the disease and to punish government officials that delay or
obfuscate medical and scientific reports about the virus. The regulations include
requirements that provincial and municipal level officials notify the central
government within four hours after a new flu outbreak.
By November 2005, PRC officials confirmed that they had either destroyed or
vaccinated millions of healthy domestic poultry and that they were planning to
inoculate the entire Chinese poultry population, a massive effort which would include
44 For more on SARS — Severe Acute Respiratory Syndrome — see CRS Report RL32227,
SARS, Avian Flu, and other Challenges for China’s Political, Social, and Economic
Transformation.
45 According to the U.S. Centers for Disease Control and Prevention. See website at
[http://www.cdc.gov/flu/avian/outbreaks/asia.htm].
46 Beijing Liaowang in Chinese. Translated on September 26, 2005, in FBIS,
CPP20051018050001.
47 PRC Ministry of Health, “Preparations and Plan for an Influenza Pandemic Emergency,”
September 28, 2005, translated in FBIS, CPP20051012335002 (October 12, 2005).

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as many as 14 billion chickens, geese, and ducks.48 As a logistical effort, the
initiative faces daunting difficulties — first among them the sheer size of China’s
poultry population and the fact that the poultry industry is widely scattered, including
millions of rural households with a dozen or fewer chickens that roam free. Second,
according to medical experts, the poultry vaccine to be fully effective must be given
in two separate doses about a month apart, meaning the entire undertaking has to be
performed twice for a single inoculation to be effective.49 In addition, some health
officials have expressed concern that such a broad campaign could backfire and
actually contribute to spreading the disease further. Potential problems include the
use of unlicensed or substandard vaccines (a problem announced in Liaoning
Province in 2005) which could mask flu symptoms in birds but leave them still
contagious;50 and the possibility that vaccinators themselves could spread the virus
on their clothing or shoes unless rigid decontamination procedures are followed.51
In another anti-flu initiative, on November 2, 2005, the Chinese government
announced an earmark of 2 billion yuan ($420 million) from China’s current budget
to fight avian flu and the banning of poultry imports from 14 countries affected by
avian flu. The Swiss manufacturer of Tamiflu, Roche, also announced it had reached
an agreement with China on developing a generic version of Tamiflu.52
Despite these preparations, some international health experts quietly continue
to question the PRC’s transparency on avian flu issues. In late April and June 2005,
for instance, PRC officials reported an unknown cause for the suspicious sudden
deaths of thousands of migratory birds in western China’s Qinghai Lake. In July
2005, a virology team from Hong Kong reported in a scientific journal that their
research showed the Qinghai bird deaths were from an H5N1 strain genetically
similar to that originating in south China. The Hong Kong report was vigorously
criticized as inaccurate by Jia Youling, an official with the PRC Ministry of
Agriculture charged with coordinating avian-flu eradication.53 On June 18, 2005, the
Washington Post reported that Chinese farmers had been using one of two types of
anti-influenza drugs (amantadine, a drug meant for humans) to treat poultry for the
48 Cody, Edward, “China to vaccinate billions of birds; campaign aims to stem avian flu,”
Washington Post, November 16, 2005, p. A15.
49 Fountain, Henry, “How to vaccinate 14 billion birds,” The New York Times, November
20, 2005, p. 2.
50 Sipress, Alan, bird flu experts warn against bad vaccines; improper poultry inoculation
may spread virus,” Washington Post, November 22, 2005, p. A24.
51 McNeil, Donald Jr., “Health experts fear Chinese flu vaccination plan could backfire,”
The New York Times, November 20, 2005, p. 12.
52 Wright, Tom, “Roche to Let Chinese Producer Make Flu Drug.” New York Times,
December 13, 2005.
53 The independent virology team was from the University of Hong Kong and included Dr.
Guan Yi, a co-author of the scientific report published in Nature magazine on July 7, 2005.
For reference to PRC official Jia Youling’s comments, see Sipress, Alan, “China has not
shared crucial data on bird flu outbreaks, officials say,” in the Washington Post, July 19,
2005, p. A15.

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H5N1 bird flu virus, potentially rendering the drug ineffective against the virus strain
in humans — a story that PRC officials also have denied.54
In its anti-flu efforts, China also remains burdened by perennial problems
involving local and regional compliance with central government directives. This
takes on new dimensions when potential remedies — such as the mandatory
destruction of infected poultry flocks — may rob indigent farming families of their
principal source of food or cash.
U.S.-PRC Cooperation. President George Bush and PRC President Hu
Jintao have discussed greater avian flu coordination on several occasions — during
a meeting at the U.N. summit in September 2005 and during Bush’s visit to Beijing
in November 2005.55 During the latter visit, the two sides initialed a joint initiative
on avian flu, promising to participate in joint research on human and animal virus
samples, establish a mechanism to share influenza strains for research purposes, and
cooperate actively on a number of regional and international levels, including the
WHO, the U.N. Food and Agriculture Organization, and the World Organization of
Animal Health. In spite of this Sino-U.S. agreement, WHO officials on December
30, 2005 announced that as of that date, China still had not shared with international
health officials flu virus samples from its infected poultry — a key step in tracking
the virus’ mutation and devising an effective vaccine.
A this point, the level of cooperation also appears uncertain in another key area
of the bilateral agreement — that involving cooperation on “influenza vaccine
development.” China appears to have advanced on vaccine development — the
PRC’s State Food and Drug Administration approved clinical trials for a Chinese-
developed human avian flu vaccine in November 2005 — and the United States is
separately working on a vaccine of its own.
Indonesia56
Indonesia is viewed, along with Cambodia, Laos, and Vietnam, as a weak link
in the effort to curb an outbreak of avian flu. A lack of resources, expertise, and a
slow recognition of the problem has hindered Indonesia’s response. Indonesia has
a population of some 1.3 billion chickens with as many as 400 million of those in
informal settings. Indonesia has resisted mass culling of bird populations. In 2003,
when H5N1 was first seen in the bird population, there was not much alarm in
Indonesia as the virus was not generally viewed as a significant threat to humans. The
virus is now considered endemic in the bird population of Indonesia and outbreaks
54 Washington Post, June 18, 2005, p. A01. Some sources also have suggested that the virus’
apparent new resistance to known drugs may be the result of renegade pharmaceutical labs
in China dispensing the wrong anti-viral medications, raising additional questions about the
PRC government’s ability to exert control over a potential pandemic. International Herald
Tribune
, July 5, 2005, p. 3.
55 King Jr., Neil, “Hu pledges efforts to ease U.S. strains — ,” Asian Wall St. Journal,
September 15, 2005, p. A1.
56 This section prepared by Bruce Vaughn, Analyst in Asian Affairs, 7-3144.

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in birds have so far been reported in 25 out of Indonesia’s 33 cities and provinces.57
Concern grew in June 2005, when Indonesia saw its first human H5N1 fatality. WHO
later confirmed H5N1 as the cause of death in July 2005. In October 2005, when a
38-year-old man and two of his children died of the disease in an affluent section of
Jakarta, some began to speculate that the virus could spread from person to person,
but to date this has not been verified.
There have been a number of questionable reports regarding the number of
human cases of H5N1 infection. One report claimed that 85 people had been
admitted to hospitals in Indonesia with suspected or confirmed cases of avian flu
since the first case in June 2005 (though the man died in June 2005, the cause of
death was not attributed to H5N1 until July, as indicated above).58 However, WHO
has only confirmed 16 human cases of H5N1 infection, of whom 11 have died.59
While Indonesia was viewed as initially trying to cover up the outbreak, it has
more recently moved to address the problem. Plans to stem the spread of the disease,
should it mutate and spread more widely among human populations, involve rapid
reaction and vaccine distribution. Such an approach is dependent on early detection
and reporting by local health officials, and the availability of the resources necessary
to treat an outbreak. On December 19, 2005, Indonesia announced a three-year
national strategic plan to contain the avian flu virus. The plan will use such measures
as culling, vaccination, and community-based surveillance of bird populations.
Critics of the plan have pointed out that it does not address birds kept in informal
settings.60 In addition, the government plans to establish a national commission for
bird flu control that includes all ministries, private and non-governmental agencies,
and the Red Cross.61

The Indonesian government appears to be making limited progress in
acknowledging and dealing with a large scale outbreak. Foreign Ministry Spokesman
Yuri Thamrin has stated “we need international cooperation to fight the virus.”62
Agriculture Minister Anton Apriyanto has indicated that the government will
slaughter poultry to stem serious outbreaks. The minister had reportedly earlier
stated that the government did not have enough money to compensate farmers for
their slaughtered animals. The government reportedly spent $13 million in 2005 to
57 “Indonesia Set to Form National Commission for Bird Flu Control,” Thai News Service.
January 10, 2006.
58 “Indonesia Reduces Confirmed Bird Flu Death Toll to 3 from 6,” AFX Asia. October 6,
2005.
59 WHO, Confirmed Human Cases of Avian Influenza A (H5N1). Accessed on December
30, 2005. [http://www.who.int/csr/disease/avian_influenza/country/en/]
60 “Toll UP but Indonesia Ready for Bird Flu,” ISI Emerging Markets. January 2, 2006.
61 “Indonesia Set to Form National Commission for Bird Flu Control,” Thai News Service.
January 10, 2006.
62 “Indonesia Calls for Intl Cooperation to Combat Bird Flu,” Dow Jones Newswire. Sept.
30, 2005.

CRS-21
cull infected livestock.63 According to WHO expert Gina Samaan, Indonesian
hospitals are increasingly prepared and “the surveillance system has been enhanced,
in the sense that there has been lots of training undertaken to ensure that surveillance
of the health department in the provincial and district levels can respond and can
initiate an investigation.”64 Eleven companies in Indonesia account for 60% of
Indonesian poultry and are reportedly reluctant to allow government monitoring of
their birds for fear that they will not be compensated for birds killed to stem an
outbreak of the H5N1 avian influenza. Indonesia’s poultry industry generated $3.75
billion in revenue in 2004.65
Health experts believe Indonesia does not have a sufficient supply of antiviral
treatments for a country with more than 200 million people, and where H5N1 is
endemic among the bird population. In September, Indonesia’s Minister of Health
asked for international assistance and expressed concern that her country is not
capable of containing the spread of H5N1.66 Since then, the international community
has pledged $140 million in assistance, and the Indonesian Government has allotted
just over $60 million for bird flu prevention.67 WHO officials have also called for
countries to donate antiviral drugs to Indonesia. Additionally, Australian Foreign
Minister Alexander Downer has warned that Indonesia is not prepared to respond to
an avian flu outbreak amongst its human population. Australia has planned a meeting
with Indonesian and WHO officials in Indonesia to strengthen Indonesia’s capacity
to deal with avian flu. Australia has also pledged funding to Indonesia for the
purchase of Tamiflu tablets to treat about 40,000 people.68 India has also reportedly
agreed to provide 1,000 doses, adding to Indonesia’s own supply of 10,000 doses.69
Reporting indicates that Indonesian officials were aware of bird flu in the bird
populations for two years but suppressed the information until humans began to
become infected. It has been asserted that “the Indonesian government failed to take
measures that could have broken the chain, [of the spread of bird flu] while
discouraging research into the outbreak.” The outbreak was evidently suppressed due
to lobbying by the poultry industry in Indonesia. There are also allegations that the
63 Alan Sipress, “Indonesia Warns of Possible Bird Flu Epidemic,” Washington Post.
September 21, 2005.
64 “Indonesia Making Progress in Fight Against Bird Flu - WHO,” AFX Asia. September 30,
2005.
65 Phelim Kyne and Fitri Wulandari, “Indonesian Poultry Cos Hobble Avian Flu Control
Ops,” Dow Jones Newswires. October 5, 2005.
66 Reuters, “Indonesia says bird flu outbreak may become epidemic.” September 21, 2005.
[http://www.alertnet.org].
67 “Indonesia Set to Form National Commission for Bird Flu Control,” Thai News Service.
January 10, 2006.
68 Nicholas Zaminska, “Asian Nations Start Critical Bird Flu Preparations,” The Wall Street
Journal
. October 3, 2005.
69 Eaton, Dan and Telly Nathalia, “Indonesia says bird flu outbreak may become epidemic.”
Reuters. September 21, 2005. [http://www.alertnet.org/thenews/newsdesk/JAK58836.htm].

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Indonesian government has not funded its announced policy to vaccinate poultry
against the virus.70
Laos71
An outbreak of H5N1 avian flu in poultry was confirmed early 2004, but Laos
has had no known cases in humans, according to the WHO. There have been no
reports of avian influenza in birds or humans in Laos in 2005.72 As of June 2005, the
Lao government estimated that 60,000 birds had been lost to the infection and
another 98,000 to culling. However, this number reflects only documentation from
commercial farms; the vast majority of poultry-rearing in Laos takes place in smaller,
family-run farms.
Some experts argue that there is an urgent need for foreign health organizations
to focus upon and assist Laos, given its proximity to other countries with the disease
and the lack of government capacity, particularly its weakness in surveillance. The
central and local governments have limited capabilities for collecting and
disseminating information, monitoring avian populations, and conducting laboratory
analysis to confirm cases of the virus. In addition, according to a U.S. government
assessment team that visited Laos, Cambodia, and Vietnam, the country’s health care
system faces “severe limitations” and would be “quickly overwhelmed” in the event
of a large-scale human outbreak.73 The FAO and the WHO reportedly have strong
working relationships with the Lao government.74 On October 13, 2005, U.S.
Secretary of Health and Human Services Michael Leavitt, on a visit to Southeast
Asia, signed a cooperation agreement with Lao officials pledging $3.4 million to
Laos for controlling outbreaks of avian flu.75
Russia76
The H5N1 strain spread into Central Asia in 2005 and was first diagnosed in
southern Russia (in the Novosibirsk region) as well as in northern Kazakhstan in July
2005. Outbreaks in both countries were attributed to contact between domestic birds
and waterfowl migrating from Southeast Asia. There have been no confirmed human
70 Alan Sipress, “Indonesia Neglected Bird Flu Until Too Late,” The Washington Post,
October 20, 2005.
71 This section prepared by Thomas Lum, Specialist in Asian Affairs, 7-7616.
72 “WHO Urges Laos to Prepare for Deadly Human Version of Bird Flu,” Agence France
Presse
, August 27, 2005.
73 “U.S. Government Emergency Response to Avian Influenza: A Plan for Vietnam, Laos
and Cambodia: Report from Country Planning Visits,” July 2005.
74 “WHO Urges Laos to Prepare for Deadly Human Version of Bird Flu,” Agence France
Presse
. August 27, 2005
75 “Intl Donors Pledge More Than $17M to Help Southeast Asia Combat Bird Flu,”
Forbes.com. October 13, 2005.
76 This section prepared by Jim Nichol, Specialist in Russian and Central Asian Affairs, 7-
2289.

CRS-23
cases in Russia. The avian flu spread to eight southern regions of Russia, including
two regions bordering the Caspian Sea,77 but did not spread north toward Moscow..
Besides Russia, avian flu was reported in 2005 in other countries bordering the Black
Sea, including Romania, Turkey, and Ukraine, and human cases were reported in
Turkey in early 2006. The WHO is concerned about the widening geographical
spread of the avian flu into Russia and neighboring countries, because it increases
opportunities for humans to catch the virus and for the virus to improve its
transmissibility through mutation or reassortment.78 The WHO’s National Flu Center
in St. Petersburg announced in August 2005 that it would work more closely with the
Vektor Virology Center in southern Russia, which had been monitoring flu viruses
among wild migratory birds for several years.
In response to the reports of outbreaks in Russia, the EU in late August raised
“serious concerns” that the virus could spread to Western Europe and called on
member-states to step up surveillance efforts. It also banned the import of poultry
from Russia. Responding to rumors that the avian influenza had spread into western
Russia, Germany in October temporarily ordered free-range poultry to be kept
indoors, as did the Netherlands in August. Iran, in September 2005, banned the
import of Russian wheat as feedstock.79
Most observers judged Russia as fairly efficient in identifying avian influenza
cases and working with international health organizations, at least at the outset. The
areas where the outbreaks occurred were quarantined. No poultry or products were
permitted to be exported beyond the areas, poultry in these areas exposed to H5N1
were slaughtered, and many people were examined and immunized. Russia’s Deputy
Foreign Minister Alexander Yakovenko asserted in early October 2005 that Russia
had made a major contribution to countering the spread of avian flu and pandemic
flu worldwide.80 Other observers raised concerns about Russia’s ultimate capacity
to respond to the spreading virus, or to deal with human cases. They warned that
since Russia has devoted few budgetary resources in recent years to improving
healthcare, it has not adopted many newer disease-control measures, such as
employing fewer and more highly trained staff, using advanced disease-detection
equipment, and relying more on primary healthcare. According to one commentator,
“pandemic control requires prompt detection of cases and targeted interventions for
the first clusters. But it remains doubtful whether Russia has the necessary capacity....
The country’s huge size [also] is an obstacle to those services that do function
well.”81
77 The eight administrative areas are the Astrakhan, Chelyabinsk, Kurgan, Novosibirsk,
Omsk, and Tyumen oblasts (regions), the Kalmyk republic, and the Altay kray (territory).
78 World Health Organization. Geographical Spread of H5N1 Avian Influenza in Birds:
Situation Assessment and Implications for Human Health
, Update 28, August 18, 2005.
79 Agence France Presse, August 22, 2005; Foreign Broadcast Information Service (FBIS),
September 3, 2005, Doc. No. IAP-11012.
80 The Lancet, August 27-September 2, 2005, p. 689; Interfax, October 4, 2005.
81 The Lancet, August 27-September 2, 2005, p. 689.

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Among measures taken by Russian federal and local officials, Chief Health
Inspector Gennadiy Onishchenko issued a directive in August 2005 to implement the
May 2005 recommendations of WHO on controlling a possible influenza pandemic.
According to WHO criteria, Onishchenko stated, Russia is in the second stage of the
avian flu epidemic, when the virus is spreading among fowl and can cause human
illness, although it has not become easily transmissible among humans (see Table 1).
He called for regional officials to “introduce the necessary corrections into regional
plans to prepare for a [human] flu pandemic,” including the “allocation of additional
funds” for prevention and treatment, and to coordinate these plans with the federal
government. In October 2005, he issued instructions to regional and health officials
regarding the clinical pattern, differential diagnosis, and prevention and treatment of
H5N1 influenza in humans. Regional officials complained that the regions had
strained to shoulder the financial burden of compensating owners for the destruction
of birds and of other containment measures. Consequently, regional representatives
have called on the federal government to provide more funds for responding to
possible new outbreaks among poultry, as well as humans. Some observers have also
noted that the federal government could have played a greater role in coordinating
regional outbreak responses. Analysts have noted that responses in each region were
often divergent and not coordinated.82
Some Russian doctors and officials have argued that the risk of a pandemic is
low, but that the best methods to hedge against such a possibility are better medical
care to boost the health of at-risk Russians, flu immunizations for these Russians, and
reserve supplies of flu vaccine.83 They suggest that existing human flu vaccines may
help protect the population if H5N1 becomes readily transmissible among humans.
In early September 2005, Vladimir Fisinin, the Vice President of the Russian
Academy of Agricultural Sciences, called for the Russian government to allocate
funds to produce 40 million doses of existing human flu vaccines, as well as 20
million reserve doses. At the same time, the St. Petersburg Institute of Influenza is
working with WHO on the development of a human vaccine targeting the H5N1
influenza virus. The Institute in late 2005 reported promising tests in animals, and
plans human clinical trials in 2006. The Moscow newspaper Nezavisimaya gazeta
in late October 2005 urged the Russian government to also consider buying Tamiflu
to treat humans in case of a pandemic.84
Russian President Vladimir Putin called in November 2005 for the legislature
to approve Russian membership in the U.N.’s FAO, in order to facilitate cooperation
with member countries in combating epidemics, including avian influenza. Russia’s
Federal Service for Veterinary and Plant Control (VPC) in September 2005 proposed
that OIE, the European Commission’s Health and Consumer Protection Directorate,
and U.S. veterinary officials launch a joint program in early 2006 to monitor avian
influenza in water fowl as they migrate from places where they spend the winter —
Southeast Asia, Africa, northern Australia and Oceania — to Europe, Asia and North
82 FBIS, August 18, 2005, Doc. No. CEP-19027.
83 FBIS, September 13, 2005, Doc. No. CEP-346004.
84 ITAR-TASS, October 23, 2005; ITAR-TASS, October 27, 2005; FBIS, October 24, 2005,
Doc. No. CEP-346001; December 6, 2005, Doc. No. CEP-346002.

CRS-25
and South America. The VPC warned that the H5N1 virus is likely to reappear in
southern Russia in Spring 2006 and possibly infect birds migrating towards Central
and Eastern Europe.85
Thailand86
Thailand, among the earliest and hardest hit by the avian flu, has emerged as a
leader in fighting the spread of the virus. From the initial 2003 outbreak, 8 of
Thailand’s 12 reported human cases were fatal.87 Fourteen of the 22 reported human
cases have been fatal to date. As a major poultry exporter, Thailand’s economy has
suffered significantly from the impact on the industry. After an initially sluggish
response, including allegations by the press that government officials covered up
evidence of an outbreak88, the Thai authorities have led the effort to respond to the
problem and particularly to facilitate regional cooperation. During a meeting with
Prime Minister Thaksin in September 2005, President Bush praised Thailand as a
leader in fighting the disease and pledged further U.S. cooperation.
Considerable economic damage from the news of the influenza has spurred
Bangkok to address the problem. Thailand’s poultry exports, the fourth-largest in the
world, bring in over $1 billion annually; the loss this year contributed to a 4.4% year-
on-year contraction of the agricultural sector in mid-2005.89 Both domestic and
international demand for chicken fell due to fears of infection. Thailand needs 90
days without outbreaks in order to receive certification from the World Organization
for Animal Health (OIE) to resume exporting fresh poultry.90
Thai authorities have taken several steps to contain the spread of avian
influenza. The Department of Livestock Development, Ministry of Agriculture and
Cooperatives is the focal point for combating the virus, while Department of Disease
Control, Ministry of Public Health is also a key player. The National Committee on
Avian Influenza Control, under the supervision of a Deputy Prime Minister, was
established in 2004 to map out national strategy. As part of the plan, over 40 million
birds have been exterminated, and surveillance teams have been deployed throughout
the country. In December 2005, the Ministry of Public Health announced that
Oseltamivir, an antiviral treatment for influenza, would be produced and distributed
85 FBIS, September 7, 2005, Doc. No. CEP-27067.
86 This section prepared by Emma Chanlett-Avery, Analyst in Asian Affairs, 7-7748.
87 WHO, Cumulative Number of Confirmed Human Cases of Avian Influenza A/H5N1
Reported to WHO
, December 7, 2005.
[http://www.who.int/csr/disease/avian_influenza/country/en/].
88 “Thai Authorities Should Take Strong Action Against Bird Flu,” Bangkok Post editorial.
October 4, 2005.
89 “Bird Flu: Asian Contagion?” Economist Intelligence Unit. July 25, 2005.
90 “Thailand Has First Avian Flu Outbreaks in 3 Months,” CIDRAP News at
[http://www.cidrap.umn.edu]. July 11, 2005.

CRS-26
to the public at subsidized prices.91 Bird smuggling from Cambodia was targeted by
border authorities.92 By mid-2005, over 11,000 poultry farms reportedly met the
government’s biosecurity standards. Thai officials acknowledge, however, that small
farms with open-air facilities, which increase the risk of contamination, remain less
regulated. Unlike China, Thailand bans the use of H5N1 vaccines in its poultry
population. Law enforcement authorities cracked down on illegally imported bird flu
vaccines from China; the H5N1 vaccine is prohibited because the government
believes that its use in poultry could lead to further mutation of the virus.93
After the re-surfacing of the flu in July 2005, the Agriculture and Cooperatives
Ministry established guidelines for poultry farmers to get permission from local
leaders before moving their flocks. The movement of fowl is considered to be a key
concern of livestock officials. Mobile checkpoints were set up in the provinces most
affected to enhance scrutiny of such movements.94 Fighting cocks have been
implicated as one of the main transmitters to humans. The sport is intensely popular
in Thailand, with up to 30 million spectators annually.95 The industry, resistant to
any form of government control, eventually struck a compromise with the Thai
government which allows for the registration of the birds and the stadiums, as well
as measures to control their movement. 96
Thailand has promoted regional cooperation on containing the flu, proposing an
ASEAN animal hygienic fund and pledging $300,000 to start the project. The
resulting center would enhance cross-border surveillance and control measures, as
well as serve as an information distribution center for all ASEAN countries on the
spread of the virus97. Public Health Minister Suchai Charoenratanakul pledged that
Thailand would contribute a minimum of 5% of its own supply to a proposed
regional stockpile of antiviral drugs.98 Thailand and Indonesia pledged to exchange
information on influenza prevention and vaccine development. Thailand received
one million baht ($25,000) from FAO to set up laboratories and serve as a
coordinating center for avian experts, and has received technical assistance from the
European Union to improve networking between laboratories working on the avian
influenza. Thailand also hosts platforms that are cited as key to the U.S. government
91 “Thai Public Health Minister Announced that Thailand Can Produce Oseltamivir,” Thai
News Service
. December 8, 2005.
92 “Squawking at the Bird Flu Warning,” Los Angeles Times. September 1, 2005.
93 “Thailand Cracks Bird Flu Vaccine Smuggling Syndicate,” BBC Monitoring Asia Pacific.
September 20, 2005.
94 “Avian Flu - Fresh Outbreak,” Bangkok Post. July 14, 2005.
95 “Squawking at the Bird Flu Warning,” Los Angeles Times. September 1, 2005.
96 “Ministry cuts Deal of Fighting Cock Zoning,” Bangkok Post. July 15, 2005.
97 “Thailand Proposes Regional Bird Flu Control Center,” Thai News Service. September
27, 2005.
98 “Bird Flu Pandemic Risk ‘Very High’,” CNN.com. October 11, 2005.

CRS-27
response; USAID lists two Bangkok-based organizations as crucial implementing
partners.99
Turkey100
In early January 2006, the WHO confirmed four cases of H5N1 virus in humans;
two of them, young siblings, were fatal.101 The deaths were the first from the virus
outside of China and Southeast Asia. Other press reports, citing Turkish officials,
claimed up to 15 suspected human cases, most of them children in the eastern rural
district of Dogubayazit. WHO officials sent a team to the region for further
investigation, and praised the initial response of the Turkish Health Ministry.102
Vietnam103

WHO reports that there have been 93 confirmed cases — including 42 deaths
— of avian influenza in Vietnam since late December 2003. According to USAID,
the H5N1 virus is believed to be endemic in Vietnam’s waterfowl population. The
Vietnamese government estimates the country’s total poultry population to be around
250 million birds, including 20 million to 60 million ducks and geese. Between 60%
and 70% of the poultry population is raised in “backyard farms,” in close proximity
to other birds, and the government estimates that 65 per cent of farm households
nationwide raise poultry. Poultry generally is sold live in local markets and is
slaughtered at home. U.N. agencies have estimated that disease containment,
including culling of poultry, have cost the Vietnamese economy an estimated $200
million.104 The wartime and tsunami supplemental (P.L. 109-13), which the House
passed on May 5, 2005 and the Senate on May 10, 2005, provides $25 million to help
combat the disease, including approximately $7 million to be used in Vietnam.
In 2005, the Vietnamese government began intensifying its response to the
disease by establishing an interagency working group that includes the FAO and
WHO. At the local level, inter-ministerial steering committees have been established
within the Vietnamese Communist Party’s people’s committees, which operate
throughout the country. However, the quality of inter-ministerial coordination, in
addition to the capacity of Vietnam’s local institutions to monitor, report, and handle
disease outbreaks, have been called into question. The central government in Hanoi
is developing a national pandemic preparedness plan, and as of mid-October 2005
99 “U.S. Government Emergency Response to Avian Influenza: A Plan of Action for
Vietnam, Laos, and Cambodia - Report from Country Planning Visits July 11-24, 2005. “
United States Agency for International Development.
100 This section prepared by Emma Chanlett-Avery, Analyst in Asian Affairs, 7-7748.
101 WHO, Cumulative Number of Confirmed Human Cases of Avian Influenza A/H5N1
January 7, 2006. [http://www.who.int/csr/don/2006_01_07/en/index.html]
102 “Bird Flu Spreads Across Turkey,” CNN News Online. January 9, 2006.
103 This section prepared by Mark Manyin, Specialist in Asian Affairs, 7-7653.
104 USAID, “U.S. Government Emergency Response to Avian Influenza: A Plan of Action
for Vietnam, Laos and Cambodia. Report from Country Planning Visits,” July 11-24, 2005.

CRS-28
had presented a draft to international health agencies and foreign aid donors. Since
the first outbreak of avian influenza was reported, over 40 million birds have been
culled, though low compensation for farmers appears to have acted as a disincentive
for farmers to report signs of infection. In August 2005, Vietnam began a mass
poultry vaccination program. In early January 2006, the Ministry of Agriculture and
Rural Development (MARD) declared that under the program, all provinces and
cities had completed two phases of vaccinations for over 240 million birds. Critics
have called Vietnam’s previous poultry vaccination programs ineffective. In October
2005, the government signed a bilateral health cooperation agreement with the
United States and agreed with a number of U.N. agencies to conduct a joint
prevention program.
There are conflicting reports on the willingness of the Vietnamese government
to cooperate with international health workers. Many accounts praise the government
for responding quickly and cooperatively, particularly in the winter and spring of
2005, when two sets of initial blood tests by Vietnamese and WHO officials
indicated that dozens, and perhaps scores, of Vietnamese might have been infected
with the virus. Subsequent testing revealed that the initial test results had been false
positives.105 Other accounts, which appear to be in the minority, have charged that
the Vietnamese government has been uncooperative with international health
agencies, particularly in the first months of the outbreak in 2004.106
Issues for Congress
Some experts point out that in order to effectively contain the spread of H5N1
and prepare for pandemic influenza, the U.S. government would need to develop a
plan that integrates domestic and international policy. Some of the policy responses
may originate domestically, but resonate globally. For example, issues related to
U.S. drug policy, such as vaccine technology and intellectual property rights could
impact access to antiviral drugs and vaccines in countries where H5N1 is endemic
— particularly since some of the most affected countries do not have the capacity
to produce or purchase sufficient quantities of the drugs.107 One article in the Journal
of Public Health Policy pointed out that “almost 40% of the world’s supply of
interpandemic influenza vaccines is used in countries that do not produce their own
vaccines.”108
105 See, for instance, Nicholas Zamiska, “Pandemic Watch: Inside U.N. Agency, Flu Data
Sparked A Tense Debate,” The Wall Street Journal, October 18, 2005.
106 See, for instance, Adrian Levy and Cathy Scott-Clark, “Flu on the Wing,” The Guardian,
October 15, 2005.
107 For more information on these issues see CRS Report RL31145, Pandemic Influenza:
Domestic Preparedness Efforts
, by Mark Gurevitz.
108 Fedson, David, “Preparing for Pandemic Vaccination: An International Policy Agenda
for Vaccine Development.” Journal of Public Health Policy 2005, Volume 26, Issue 1,
April 2005. p.11.

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Concurrently, some domestic issues are impacted by international
developments. For example, some are concerned that the United States might not
have enough antiviral medication if an influenza pandemic were to occur within the
next year since it belatedly ordered Tamiflu (a drug effective in mitigating the course
of illness caused by H5N1 infection in most cases). Senator Barack Obama is quoted
as expressing concern in an interview that the United States would have to wait for
its Tamiflu shipments after Britain, France, and Japan.109 Some countries in Europe
have reportedly ordered enough antiviral medication to treat 20% to 40% of their
populations. For example, the Dutch Health Ministry has reportedly ordered enough
Tamiflu to treat one-third of the population (5 million doses), and Britain is believed
to have ordered enough Tamiflu to treat about 25% of its population (15 million
people). Canada reportedly has stocks for just over 5% of its citizens.110 Current
reported U.S. stocks are sufficient to treat slightly more than 1% of all Americans.
However, in November 2005, the President announced through the National Strategy
for Pandemic Influenza that the United States would procure enough medicine by the
end of 2006 to treat 25% of the U.S. population. Below are some issues that
particularly impact the most affected countries in Asia, and other parts of the world.
Patent Protections
Intellectual property rights has become an increasingly contentious issue in
global health, particularly since companies began threatening to ignore patents for
HIV/AIDS treatments. In an effort to expand global access to flu drugs, the United
Nations had been encouraging Roche — the patent holder of Tamiflu — to license
other companies to produce generic versions of the drug. Roche announced on
October 21, 2005 that U.S. pharmaceutical companies could manufacture a generic
version of Tamiflu.111 Legislation introduced in the first session of the 109th
Congress aims to permit the United States to invoke a compulsory license and export
generic versions of the drug to non-producing countries.112 Some speculate that
Roche has been increasing efforts to license its products in other countries, in part
because an Indian pharmaceutical company, Cipla, has threatened to manufacture a
generic version of the drug — in spite of Roche’s patent rights. Underscoring that
Tamiflu is too expensive for many of the least developed countries, a Cipla
representative said that the company would sell the generic version of Tamiflu “at a
humanitarian price” in developing nations, and not in the United States or Europe.113
Two Indian pharmaceutical companies are reportedly negotiating with Roche to
109 Harris, Gardiner, “Officials May Spend Billions to Stockpile Influenza Drug.” New York
Times, October 7, 2005.
110 Ibid.
111 Alonso-Zaldivar, Ricardo, “Roche agrees to generic version of Tamiflu drug.” Baltimore
Sun
, October 21, 2005. [http://www.baltimoresun.com].
112 H.R. 4392, To provide for the importation of pharmaceutical products under a
compulsory license as provided for under the World Trade Organization.

113 McNeil Jr., Donald, “Indian Company to Make Generic Version of Flu Drug Tamiflu.”
New York Times. October 14, 2005. [http://www.nytimes.com].

CRS-30
produce generic versions of Tamiflu.114 Roche also reached an agreement with a
Chinese pharmaceutical company to make the drug.115
Health experts predict that patent protections will continue to be a contentious
issue as poorer countries seek to protect themselves against virulent diseases. Some
analysts contend that Congress faces an issue of whether to help countries where
H5N1 is endemic gain greater access to generic versions of Tamiflu and other
antivirals if licensed drugs are not accessible. Supporters assert that the precedent
for greater access to generics by poorer countries had already been established on
December 6, 2005, when World Trade Organization (WTO) members approved
changes to the intellectual property agreement making permanent a decision on
patents and public health116. The General Council decision means that for the first
time a core WTO agreement will be amended. The decision directly transforms the
August 30, 2003 waiver to Section 31(f) of the Trade-Related Aspects of Intellectual
Property Rights (TRIPS)117. The waiver permits a country without manufacturing
capacity to obtain cheaper generic versions of patented medicines from countries
under compulsory licenses. The waiver enables the country to receive generic
versions of drugs in situations of “national emergency or other circumstances of
extreme urgency.”118 A separate statement describes members’ “shared
understanding” on how the decision is interpreted and implemented. Particularly, the
statement points out that the decision will be used in good faith in order to deal with
public health problems and not for industrial or commercial policy objectives.119
Although the waiver was seen as a tool to enable largely poorer countries to import
generic versions of licensed drugs, one piece of legislation proposes that the U.S.
Trade Representative inform WTO that the United States declares itself an “eligible
importing member” to import pharmaceutical products, largely because Roche is
unable to meet the “public health needs” of the United States.120
WTO members voted against delineating which drugs should be included in the
waiver agreement. Consequently, there is not consensus on which drugs are
considered critical in protecting public health. Advocates argue that in the event of
114 Jack, Andrew, “India drugs groups in Tamiflu talks.” Financial Times. December 12,
2005. [http://news.ft.com/home/us/]
115 Wright, Tom, “Roche to Let Chinese Producer Make Flu Drug.” New York Times.
December 13, 2005. [http://nytimes.com]
116 WTO, “Members OK amendment to make health flexibility permanent.” December 6,
2005. [http://www.wto.org/english/news_e/pres05_e/pr426_e.htm]
117 Article 31(f) of the TRIPS Agreement says that production under compulsory licensing
must be predominantly for the domestic market. The concern was that this could limit the
ability of countries that cannot make pharmaceutical products from importing cheaper
generics from countries where pharmaceuticals are patented.
118 For more information on this issue see CRS Report RS21609, The WTO, Intellectual
Property Rights, and the Access to Medicines of Controversy
, by Ian F. Fergusson.
119 WTO, “Members OK amendment to make health flexibility permanent.” December 6,
2005. [http://www.wto.org/english/news_e/pres05_e/pr426_e.htm]
120 H.R. 4392, To provide for the importation of pharmaceutical products under a
compulsory license as provided for under the World Trade Organization.


CRS-31
a pandemic, the new WTO amendment should apply to antiviral drugs and H5N1
vaccines for use in animals. Opponents are concerned that some might abuse and
undermine the agreement by reselling the drugs and vaccines for profit. In the event
of a pandemic, Congress might be faced with the decision on whether to support or
oppose the export of generic antivirals. Additionally, increased pressure might be
placed on Congress to encourage USDA to share with other countries some of its
H5N1 vaccine for use in animals.
Global Data Sharing
In spite of Tamiflu stockpiling efforts, it is unknown if the medicine will be
broadly useful in treating human H5N1 victims in a pandemic scenario. Some health
experts were reportedly alarmed when two patients in Vietnam who were infected
with H5N1 and aggressively treated with Tamiflu later died. Some are beginning to
question if the recommended dosage should be changed, as doctors reportedly
adhered to the recommended regimen when treating the two patients.121 Health
experts point out that more information is needed on patients who have already been
treated for H5N1 with Tamiflu. Data from the subjects would help in determining
if the drug remains effective in fighting H5N1 and if changes to dosage regimens are
required.
Those pressing for greater international data sharing point to new research that
might counter previous findings on the limited effectiveness of amantadine. The
New York Times reported in September 2005 that researchers found that amantadine
was no longer effective against H5N1. WHO reportedly spent $1.3 million to
stockpile the drug when it was used during the 1997 H5N1 outbreak. The Times
article asserted that in 2005, laboratory research found that all human viral samples
of H5N1 were resistant.122 Before 2000, almost no influenza virus was resistant to the
drug. Some experts speculated that viral resistence occurred in part, because China
reportedly used amantadine, intended solely for humans, on animals. (See “Affected
Countries’ Response” section). However, the Wall Street Journal quoted Dr. Shu
Yuelong, the Director of China’s national influenza laboratory, as stating that
preliminary evidence indicates that amantadine might be effective in treating avian
influenza in people.123 Dr. Shu reported that all of the viral samples that have been
isolated from patients in China were sensitive to amantadine. Those findings
conflicted with previous research on virus samples that were taken from patients in
Indonesia and found to be resistant to the drug. The new research has reportedly
prompted WHO and other officials to consider whether amantadine might eventually
play a role in fighting H5N1. The article underscores that there are currently too few
samples to draw any firm conclusions.
121 Chang, Alicia, “Bird Flu Victims Die After Drug Resistence.” Washington Post.
December 21, 2005. [http://www.washingtonpost.com]
122 Rosenthal, Elisabeth, “Two Studies Find Flu Treatments Fall Far Short.” September 22,
2005. [http://www.nytimes.com].
123 Zamiska, Nicholas, “Scientists Says Bird-Flu Virus Appears to Be Stable in China; No
Signs that Avian Strain Is Easily passed by People; Old Drug Shows Promise.” December
12, 2005.

CRS-32
Some believe that some countries are intentionally withholding viral samples
of H5N1 cases. One article stated that countries with human H5N1 cases do not want
to send viral samples to the WHO or other industrialized countries, because they fear
the samples will be used to develop up-to-date vaccines which they will not have
access to.124 Others have speculated that China is withholding its samples, because
it is trying to produce an H5N1 vaccine.125
Some analysts propose that the United States and other countries should vote
to provide WHO with enforcement mechanisms. Supporters argue that WHO should
be able to force countries to share viral samples. Others contend that Congress
should provide greater support and resources to WHO, particularly for strengthening
global laboratory and testing capabilities. Skeptics point out that WHO has not
provided transparent, detailed data on the adequacy of funds or how funds are spent.
Global Disease Surveillance
A number of analysts have argued that due to insufficient investment in disease
surveillance and health care in many of the countries where H5N1 is endemic, a
pandemic may progress before it is discovered. In this view, ill-equipped
surveillance systems will be slow to determine the source of a pandemic, evaluate the
rate of viral transmission, ascertain whether H5N1 has become efficiently
transmissible among humans, or rate the effectiveness of anti-flu initiatives. Senate
Majority Leader Bill Frist has proposed $1 billion for a real-time international threat
detection system.126
USAID and other U.S. government officials suspect that the lack of documented
human cases of H5N1 in Laos has more to do with inadequate surveillance and
reporting systems than an absence of infection.127 Some health experts believe that
H5N1transmission could already be underway in Laos, since surrounding countries
have already had human and animal outbreaks. Key U.S. agencies and international
organizations have determined that Laos is a country that needs critical prevention,
monitoring, and surveillance support in order to prevent full-blown human-to-human
transmission of H5N1 that could emerge and sweep across the region without
warning.128
Some experts have expressed increasing concern about the capacity of poorer
countries that have not yet had H5N1 cases to effectively contain the spread of the
virus and plan for pandemic influenza, particularly in sub-Saharan Africa. FAO has
124 Globe and Mail, “Chinese officials haven’t shared samples of H5N1: experts.”
November 18, 2005. [http://www.theglobeandmail.com].
125 China Daily, “China: Bird flu vaccine for human use developed.” November 15, 2005.
[http://www.chinadaily.com.cn/english/doc/2005-11/15/content_494593_3.htm].
126 Honorable Bill Frist website, “First Addresses National Press Club on Avian Flu —
Pandemic: The Economy Killer.” December 8, 2005. The Senate passed S. 2170 on
December 22, 2005.
127 Interview with USAID official, October 11, 2005.
128 Ibid.

CRS-33
recently warned that the risk of H5N1 spreading to the Middle East and Africa has
markedly increased. FAO is particularly wary of the virus reaching Eastern Africa,
as the surveillance capacities and veterinary services in those countries are limited.
According to Reuters, a WHO representative declared that an H5N1 outbreak would
likely be missed in Africa, as bird nutrition is poor and high mortality among poultry
is common. Concurrently, human cluster cases are likely to be missed due to poor
surveillance systems. South Africa is reportedly the only country in sub-Saharan
Africa to have drawn up a pandemic preparedness plan.129 Some experts fear that an
unabated H5N1 outbreak in East Africa could make the bird flu endemic there. “If
the virus were to become endemic in eastern Africa, it could increase the risk that the
virus would evolve through mutation or reassortment into a strain that could be
transmitted to and between humans.”130
The press reported on December 20, 2005 that a bird suspected of having
contracted H5N1 in Ethiopia, tested negative of the virus.131 Experts are concerned
that birds in Ethiopia and other countries in the Rift Valley, including Kenya,
Tanzania, and Uganda, are at particular risk of avian flu infection due to the large
numbers of migratory birds that fly to the region during the European winter. Those
concerned about insufficient surveillance and diagnostic equipment and expertise,
point out that Ethiopia had to use health experts and equipment from Egypt to
determine what caused a rash of bird deaths in December 2005. USAID with support
from the U.S. Navy Medical Research Unit (NAMRU) in Cairo reportedly provided
$15,000 in emergency funding to analyze the viral samples of dead pigeons found in
Addis Ababa and the Eastern Somali region for H5N1 infection. Additionally,
USAID has reportedly reprogrammed $600,000 from existing surveillance funds for
bird flu initiatives in Ethiopia.132 The funds are to help provide technical assistance
to the Ministries of Agriculture and Health, develop laboratory and communications
capacity, and procure Personal Protective Equipment for first responders.
Many of the countries in which H5N1 is endemic have complained that they can
not afford to implement the strategies recommended by the international community.
Furthermore they are hesitant to divert their limited budgets — already struggling to
contend with AIDS, child and maternal health, tuberculosis, and other health
challenges — to something that might not occur. Advocates of greater assistance to
the region, point out that countries with more resources for pandemic planning than
neighboring poorer countries have also acknowledged difficulties in responding to
the H5N1 threat. A news report cited a South Korean health worker who stated that
129 Reuters, “Bird Flu in Africa Could Swamp Health Systems: WHO.” November 27, 2005.
[http://www.nlm.nih.gov/medlineplus/news/fullstory_27731.html]
130 “UN agency says risk of bird flu spreading to Middle East, Africa rises markedly.” U.N.
News Center, October 19, 2005.
[http://www0.un.org/apps/news/story.asp?NewsID=16037&Cr=bird&Cr1=flu]
131 Reuters Foundation, “ETHIOPIA: Birds Test Negative for avian flu.” December 20,
2005. [http://www.alertnet.org]
132 USAID, H5N1 Avian Influenza (AI) Most Recent Developments and Actions. November
26 - December 19, 2005.

CRS-34
his country is ill-equipped to respond to a pandemic citing insufficient supplies of
medication, hospital beds, and ventilators.133
On December 22, 2005, the Senate passed S. 2170, which would help
developing countries bolster their disease surveillance programs, and establish
fellowships for citizens of those countries to study epidemiology and public health
in the United States. Additionally, some in Congress have advocated for greater U.S.
spending on fighting the global spread of H5N1 avian flu. Press reports quoted
Representatives Henry Hyde and Tom Lantos, Chairman and Ranking Member of the
House International Relations Committee respectively, stating concern about the
level of funding the Administration proposes to provide for global efforts in
FY2006134. Advocates assert that the $388 million the Administration requests for
international H5N1 initiatives will not be enough to fund the significant amount of
assistance needed by countries with H5N1-endemic stocks. Particularly, experts add
that the threat of an H5N1 or other influenza pandemic illuminates the neglect that
health care systems in many southeast Asian countries have faced over the last couple
of decades. Proponents argue that if the United States would increase its funding to
support global health care systems the global community could benefit from efficient
outbreak reporting and control measures, accurate diagnoses, enhanced case
management, and improved disease surveillance and monitoring.
Global Pandemic Planning
Some experts caution that pandemic preparedness plans must extend beyond
procuring and stockpiling antiviral drugs and vaccines. In this view, governments
must also develop detailed vaccine and treatment distribution plans. Particular
attention has been paid to H5N1-affected countries that have communication and
infrastructure barriers, especially between urban and rural areas (where many of the
backyard poultry farms exist). Many Asian countries have significant income and
infrastructure gaps between rural and urban areas. In the rural areas, there are often
few hospitals and treatment centers. Equipment can be outdated or lacking.
Veterinary and animal health services can be limited. Additionally, in many cases
rural governments operate independently from urban governments, which tend to
receive larger portions of national resources. Farmers in rural areas may not adhere
to government H5N1 initiatives, exacerbating the problem. One infectious disease
expert in Hong Kong asserted that the communication problem is particularly acute
in China. “I trust and believe the central government has very good intentions, but
unfortunately, it is a very big country. At the district, regional levels, the failure to
communicate continues.”135
133 Grudgings, Stuart, “Rich-poor divide hoblles Asia’s bird flu plans.” Reuters, September
13, 2005. [http://www.reuters.com]
134 GovEXEC.com, “House panel calls plan for tracking avian influenza ‘inadequate’.”
December 7, 2005. [http://govexec.com/dailyfed/1205/120705cdpm2.htm]
135 Grudgings, Stuart, “Rich-poor divide hobbles Asia’s bird flu plans.” Reuters. September
13, 2005. [http://www.reuters.com]

CRS-35
Responses by East Asian Regional Groupings. As Southeast Asia’s
major multinational fora, the Association of southeast Asian Nations (ASEAN) has
taken some steps to improve transnational coordination in combating the spread of
a potential pandemic, and limiting the spread of the H5N1 virus. To this end,
ASEAN members have created a number of institutional arrangements, including a
Highly Pathogenic Avian Influenza (HPAI) Taskforce, an ASEAN Expert Group on
Communicable Diseases, the ASEAN Animal Health Trust Fund, and the ASEAN
Plus Three136 Emerging Infectious Diseases Programme. At the eleventh ASEAN
summit in Kuala Lumpur, Malaysia, in December 2005, ASEAN leaders discussed
establishing a regional network of stockpiles of antiviral drugs.
Drafting an avian influenza declaration was the single tangible achievement of
the inaugural meeting of East Asia’s newest regional grouping, the East Asia Summit
(EAS), which met in Kuala Lumpur in December 2005 immediately following the
ASEAN summit.137 In their Summit Declaration on Avian Influenza Prevention,
Control and Response, EAS leaders committed to “ensure rapid, transparent and
accurate ...communications,” establish information sharing protocols among member
countries and multilateral organizations, create a regional network of stockpiles of
antiviral, and to establish regional avian influenza and pandemic preparedness
strategies backed by supporting national legislation.
Pandemic planners are warning that no country has the surge capacity to meet
national demands for consumer products and medical services for the full term of an
influenza pandemic (an estimated six months to a year). The United States, and other
industrialized nations, rely on a range of critical products from H5N1-affected
countries, such as medical supplies, military parts, and sanitation equipment. These
supply chains are replenished “just-in-time” to minimize costs. If an outbreak were
to occur, hospitals, food and water systems, and the military could all be vulnerable
to interrupted supply due to absenteeism, border closures, and other supply chain
disruptions. Therefore, the private sector, as well as national and international trade
organizations have been urged to participate in pandemic planning.
Some analysts argue that resources allocated to containing the spread of H5N1
have been insufficient in part, because many countries have funded the response
primarily through the Ministries of Agriculture and Health. Some experts point out
that an influenza pandemic will likely impact the animal and health sectors, as well
as trade, security, hospitality, and labor. Consequently, they say, governments should
develop pandemic plans that utilize the resources of other ministries that are often
better funded, such as Ministries of Trade, Tourism, and Commerce. Some analysts
note that U.S. officials, such as the U.S. Trade Representative and the Secretary of
Commerce should be engaged in U.S. international pandemic influenza planning
136 ASEAN Plus Three consists of the ASEAN countries plus China, Japan, and South
Korea.
137 Participants in the first EAS included the ten ASEAN members (Brunei, Burma,
Cambodia, Indonesia, Laos, Malaysia, Philippines, Singapore, Thailand, and Vietnam), the
“plus three” states (China, South Korea, and Japan), as well as Australia, New Zealand, and
India. For more on the summit, see CRS Report RS22346, East Asian Summit: Issues for
Congress
, by Bruce Vaughn.

CRS-36
efforts. Others would like Congress to encourage public-private partnerships that
augment U.S. international avian flu and pandemic preparedness efforts.
Combating Bird Flu Among Animals in Affected Countries
Most countries have used mass culling to prevent viral spread when avian
influenza outbreaks are detected. However, some countries have not been able to
rely on this process as a primary containment measure, because the governments
might not have been able to compensate farmers for slaughtering their stocks.
Scientists have also found that mass culling is sometimes not feasible when wild
birds are involved in transmission. Some health experts assert that there should be
more research on more affordable methods of preventing pandemics at their source
— in the animals that carry the virus. Strategies such as implementing cleaning days
(when all live markets are simultaneously emptied and cleaned), and separating ducks
and chickens in live poultry markets may decrease viral transmission among animals.
Some countries (including China) propose using vaccination to control avian
influenza in poultry. Skeptics warn that animal vaccination is a risky strategy, as it
is often difficult to distinguish infected from vaccinated animals, complicating efforts
to track the disease. Additionally, vaccination campaigns, if not carried out properly,
could result in entrenchment of the disease rather than eradication, further threatening
public health. 138
Cost of Culling. It has been suggested that a global fund should be
established to compensate farmers for culling their poultry in countries whose
governments can not afford to compensate the farmers. The WHO has already
expressed concern that some farmers in poorer countries may not cull their poultry,
because their livelihoods depend on poultry farming. For example, Indonesia has
carried out only a limited culling drive, because it lacks the funds to compensate
farmers.139 Farmers in some parts of Romania reportedly failed to cull their birds
despite government orders to do so. In some affected countries, public and animal
health authorities are reluctant to destroy their population’s dominant protein source
and income. A number of bills, such as H.R. 4062 and its counterpart S. 1821, have
been introduced that support the concept of a “Pandemic Fund”, which could include
funds for farmer compensation.
The World Bank announced that it would provide $500 million in loans to poor
countries struggling to fund national avian flu and pandemic preparedness plans —
a portion of which could be used to support poor farmers.140 However, the Bank
noted that $1 billion could be needed over the next three years to help countries
contain the spread of H5N1. The Asia Development Bank (ADB) also announced
138 Ilaria Capua and Stafano Manganon, “Vaccination for Avian Influenza in Asia,” Vaccine,
Vol. 22, 2004, pp. 4137-4138.
139 Perry, Michael, “Poor Asian farmers are weak link in bird flu fight.” Reuters. September
19, 2005. [http://www.alertnet.org/thenews/newsdesk/SYD28137.htm]
140 World Bank, “New Global Program to Deal with Avian Flu.” November 4, 2005.
[http://www.worldbank.org]

CRS-37
that it is prepared to provide at least $470 million to support Asian anti-H5N1 and
pandemic preparedness efforts.141
Some have suggested that the United States target some foreign aid funds to
help the affected governments — including Vietnam, Indonesia, Cambodia, and Laos
— cover the cost of compensating individuals and companies for the destruction of
their birds. In this view, such assistance could help the image of the United States in
the region by demonstrating American concern and could minimize reluctance to
slaughter infected flocks. Others would like to see increased assistance to prevent the
spread of H5N1 among animals.
Global Economic Impacts
The health and non-health related costs of a global influenza pandemic could be
very high, though difficult to estimate. For example, Canadian and Asian hospitality
and tourism sectors were considerably impacted during the SARS outbreak. In 2002
and 2003, SARS cost the Asia-Pacific region about $40 billion.142 Additionally,
flights to the region fell by about 45%, crippling the airline and hotel industries.
Canada estimated that it lost approximately $1.2 billion, with about $763 million
spent on the health-care system.143 In the event of a flu pandemic, researchers expect
Britain, Greece, Spain, Italy, and other countries that rely heavily on tourism, to be
most affected economically. One economist estimated that a flu pandemic could
force Britain’s GDP to fall by 8% or $168 billion (about 95 billion pounds), and
result in the loss of almost 1 million jobs (about 3% of all employment). 144
The World Bank estimates that a global influenza pandemic could cost the
global economy about $200 billion in one quarter or $800 billion over a year (about
2% of the global GDP). The Bank based its estimate on the economic losses induced
by the SARS pandemic, which caused GDP to fall by 2% in Asia over a three month
period in 2003. However, the Bank underscored that it is virtually impossible to
accurately determine how much a global influenza pandemic would cost the world,
because experts assume that the immediate shock during a flu epidemic could be
larger and last longer than SARS. The 1918 pandemic, for example, came in three
waves, and spread over two years.145 Some economists have advised the United
141 ADB, “ADB Support for Asia’s Fight Against Avian Flu Could Reach $470 Million.”
November 9, 2005. [http://www.adb.org/Documents/News/2005/nr2005173.asp]
142 Osterholm, Michael, “Preparing for the Next Pandemic.” Foreign Affairs, July/August
2005. [http://www.foreignaffairs.org].
143 Ibid. Country-specific SARS-related information, including costs and fatalities can be
found in CRS Report RL32072, Severe Acute Respiratory Syndrome (SARS): The
International Response
, by Rhoda Margesson and Tiaji Salaam.
144 Nordland, Rod and George Wehrfritz, “A Costly Disease: Europe and the rest of the
world braces for the economic fallout of a possible bird-flu pandemic.” October 24, 2005.
[http://msnbc.msn.com/id/9711926/site/newsweek/]
145 World Bank East Asia and Pacific Region, “Spread of Avian Flu Could Affect Next
Year’s Economic Outlook.” November 2005.
(continued...)

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States to identify source countries for key imports and develop a detailed plan that
would ensure continuity.
Economists point out that an Asian economy crippled by an influenza pandemic
could impact the U.S. economy, even if a significant number of Americans was not
sickened or killed by H5N1. According to U.S. Trade Representative (USTR) Robert
Portman, South Korea and Malaysia are the 7th and 10th largest trading partners for
the United States, respectively. The United States earned $72 billion and $40 billion
from South Korea and Malaysia, respectively, in 2004. Both countries have had
H5N1 cases among their flocks.146 Additionally, U.S. exports to China, one of the
most threatened countries, grew 76 percent between 2000 and 2003, while sales to
the rest of the world declined by 9 percent. China is now the sixth largest market for
U.S. exports and America’s third largest trading partner overall — surpassing Japan
in 2003.147 In 2004, U.S. exports to China grew to $33 billion, more than double the
level in 2001.148 Therefore, any pandemic related disruption of bilateral trade could
have a large impact. Alternatively, some economists predict that U.S. poultry exports
could increase as countries move to ban imported birds from countries with H5N1-
endemic stocks.
CLSA Asia-Pacific Markets, the Asian investment banking arm of Crédit
Agricole of France, estimates that H5N1 has already cost the region between $8
billion and $12 billion, citing the prolonged poultry ban by the European Union from
eight Asian countries and the death or destruction of some 140 million chickens and
other poultry. The Prime Minister of Thailand stated that the avian flu has already
cost his country some $1.09 billion, in addition to the $55.78 million the government
paid to farmers for a mass chicken cull.149
Some analysts caution that Congress should be prepared to respond to the impact
that potential fluctuations in supply and demand from key Asian markets might have
on the U.S. economy. Particularly, some would like Congress to direct the U.S. Trade
Representative to prepare a report that comprehensively analyzes the potential
economic gains and losses to the U.S. economy in a pandemic scenario due to
changes in Asia’s economy. Experts point out that the Congressional Budget Office
(CBO) report A Potential Influenza Pandemic: Possible Macroeconomic Effects and
Policy Issues
focuses on possible supply and demand changes in the U.S. economy
145 (...continued)
[http://siteresources.worldbank.org/INTEAPHALFYEARLYUPDATE/Resources/EAP-
Brief-avian-flu.pdf]
146 U.S. Trade Representative Robert Portman discussion at the US-ASEAN Business
Council Second Annual Asia Forum, November 1, 2005.
147 USTR website, “America’s Trade with China.” April 21, 2004. [http://www.ustr.gov]
148 USTR website, “Real Results in U.S. Trade with China.” September 9, 2004.
[http://www.ustr.gov]
149 Bullion, Alan, “Threats on the Wing.” The World Today, August/September 2005. Also
see, Bradsher, Keith, “Some Asian Bankers Worry About the Economic Toll From Bird
Flu.” New York Times. April 5, 2005. [http://www.nytimes.com]

CRS-39
if an H5N1 pandemic were to reach the United States.150 The Wall Street Journal
reported that the U.S. poultry industry currently exports about 15% of its chicken
meat annually, earning $2.2 billion in 2004. The article asserted that some poultry-
industry executives are concerned that importing countries might reject poultry from
states that have vaccinated the animals.151 Consequently, many executives in the
poultry industry are opposed to vaccinating chickens intended for export. Some
would like Congress to require USDA to present clear guidelines on how and when
poultry would have to be vaccinated.
Global Biosafety
In October 2005, scientists reported that the 1918 influenza pandemic that had
killed between 20 million and 50 million people worldwide may have emerged from
an avian flu strain. Health experts have debated whether the genetic sequence of the
1918 influenza should be published. Some were concerned that the information
could be used to construct a biological weapon. However, other scientists argued that
sharing such important findings is critical to efficiently identifying dangerous viruses,
and to finding ways to disable them. Ultimately, the genetic sequence was
published.152 Dr. Anthony Fauci, Director of the National Institute of Allergy and
Infectious Diseases, and Dr. Julie Gerberding, Director of the CDC, said in a joint
statement, “The new studies could have an immediate impact by helping scientists
focus on detecting changes in the evolving H5N1 virus that might make widespread
transmission among humans more likely.” Furthermore, the HHS National Science
Advisory Board for Biosecurity “voted unanimously that the benefits [to making the
results public] outweighed the risk that it would be used in a nefarious manner.”153
However, the Administration acknowledged that the influenza virus could be used
as a biological weapon and added the virus to the Select Agent list on October 20,
2005.154 Congress authorized the Select Agent program in the late 1990s to track the
movement of certain bacteria and viruses that could potentially be used as bioterrorist
weapons.155
150 CBO, A Potential Influenza Pandemic: Possible Macroeconomic Effects and Policy
Issues.
December 8, 2005. [http://www.cbo.gov/ftpdocs/69xx/doc6946/12-08-BirdFlu.pdf]
151 Kilman, Scott, “Vaccine Remains Sticking Point in U.S. Defense Against Bird Flu.”
December 12, 2005. [http://www.wsj.com]. Basic screening tests for bird flu used by many
importing countries leave ambiguous whether a bird testing positive is infected with H5N1
or has been vaccinated against it.
152 Kolata, Gina, “Experts Unlock Clues to Spread of 1918 Flu Virus.” New York Times,
October 6, 2005. [http://www.nytimes.com]
153 Ibid.
154 CDC, “Possession, Use, and Transfer of Select Agents and Toxins — Reconstructed
Replication Competent Forms of the 1918 Pandemic Influenza Virus Containing Any
Portion of the Coding Regions of All Eight Gene Segments.” 70 Federal Register 61407,
October 20, 2005.
155 For more information, see the CDC Select Agent Program page at
[http://www.cdc.gov/od/sap] and CRS Report RL31719, An Overview of the U.S. Public
Health System in the Context of Emergency Preparedness
, by Sarah A. Lister.

CRS-40
Health specialists caution that lab safety must be a top priority as other countries
begin to develop their own research and vaccine capacities. Some are closely
watching Taiwan in its effort to build its own influenza vaccine factory.156 Japan,
already accomplished in viral research, is reportedly helping Vietnam build a
biosafety lab to work with the influenza virus.157 If global influenza vaccine
production is to increase, disease experts caution that some form of oversight must
first be established. Some scientists advocate the development of an international
influenza research facility. Supporters envision a global laboratory that could rapidly
identify influenza threats, and produce appropriate vaccines. It also could, they say,
streamline existing flu monitoring systems. Opponents of this idea believe that
current technology, such as the WHO’s Internet-based FluNet, is fully capable of
obtaining the same goal. Furthermore, critics believe that scientists might lose
interest in sharing viral samples, if they believe their analytical and research
capacities will be taken away.158
S. 1873, The Biodefense and Pandemic Vaccine and Drug Development Act,
would address production of pandemic products. The bill would authorize funding
for surge capacity of manufacturing vaccines. It would also authorize funding for
research and development of flu vaccines, counter measures, and pandemic products.
156 Altman, Lawrence and Keith Bradsher, “Vaccine Alone Won’t Stem Avian Flu, Experts
Warn.” New York Times. August 8, 2005. [http://www.nytimes.com]
157 Interview with State Department staff, October 18, 2005.
158 Abbott, Alison, “The flu HQ.” Nature, Volume 414, November 1, 2001.
[http://www.nature.com]


CRS-41
Appendix
Figure 1. Map of Human and Animal H5N1 Cases

CRS-42
Table 2. WHO Pandemic Phases
Phase
Description
Overarching Public Health Goals
Interpandemic Period
Phase 1
No new influenza virus strains have
Strengthen global influenza pandemic
been detected in humans. A virus
preparedness at the global, regional and
strain that has caused human infection
national levels.
may be present in animals. If so, the
risk of human infection is considered to
be low.
Phase 2
No new influenza virus strains have
Minimize the risk of transmission to
been detected in humans. However, a
humans; detect and report such
circulating animal influenza virus strain
transmission rapidly if it occurs.
poses a substantial risk of human
disease.
Pandemic Alert Period
Phase 3
Human infection(s) with a new strain,
Ensure rapid characterization of the new
but no human-to-human spread, or at
virus strain, and early detection,
most rare instances of spread to a close
notification and response to additional
contact.
cases.
Phase 4
Small cluster(s) with limited human-to-
Contain the new virus within limited foci
human transmission, but spread is
or delay spread to gain time to
highly localized, suggesting that the
implement preparedness measures,
virus is not well adapted to humans.
including vaccine development.
Phase 5
Larger cluster(s), but human to human
Maximize efforts to contain or delay
spread still localized, suggesting that
spread, to possibly avert a pandemic,
the virus is becoming increasingly
and to gain time to implement pandemic
better adapted to humans, but may not
response measures.
yet be fully transmissible (substantial
pandemic risk).
Pandemic Period
Phase 6
Pandemic: increased and sustained
Minimize the impact of the pandemic.
transmission in the general population
Source: World Health Organization.

CRS-43
Table 3. FY2006 Emergency Supplemental Request
($ millions)
AGENCY
ACTIVITIES
AMOUNT
Department
Increase vaccine manufacturing capacity so that 25% of
6,700.0
of Health and
Americans would have access to antiviral medication,
Human
and the entire U.S. population would have access to
Services
pandemic influenza vaccines within a six-month period.
Department
Research and development, domestic surveillance and
91.4
of
diagnosis of live bird markets, wildlife and bird
Agriculture
flyways, smuggling and waterfowl, planning and
preparedness training and modeling of scenarios, and
the production of 40 million doses of animal vaccine.
Department
Purchasing avian influenza vaccines, increasing world
130.0
of Defense
wide surveillance of the virus, and upgrading
surveillance, laboratory, information management
equipment. Additionally, $10 million of the $130
million is intended to assist military partner nations in
procuring protective equipment, laboratory diagnostic
equipment, portable field assay testing equipment
surveillance, and essential communication equipment.
Department
Pandemic scenario modeling, personal protective
47.3
of Homeland
equipment, private sector pandemic assistance planning,
Security
and exercises and training for DHS frontline staff.
Department
For the U.S. Geological Survey (USGS), the U.S. Fish
11.6
of the Interior
and Wildlife Service, the National Park Service, and
other Federal agencies to begin an interagency effort to
detect avian influenza in wild birds, with an initial focus
on early detection activities in Alaska and coastal areas.
Department
International response coordination, including foreign
38.5
of State
governments and non-governmental organizations,
diplomatic outreach, exchanges of U.S. and foreign
medical personnel, and for avian and pandemic
influenza health support and protection of U.S.
government employees and families at U.S. missions
overseas. $20 million of the funds would be reserved for
the potential evacuation of U.S. government personnel
and dependents from overseas missions.
Department
Increasing avian influenza surveillance programs and
27.0
of Veterans
establishing real-time surveillance data links with CDC.
Affairs
USAID
Pre-position supplies and equipment to prevent and
131.5
control the spread of avian influenza(within one year of
receiving funds); increase awareness of risks and
appropriate behaviors to reduce transmission among
humans and animals; improve surveillance and
response; and accelerate international planning and
preparedness. $2 million of the funds are reserved for
Russia and Eastern Europe.
GRAND TOTAL
7,177.3
Source: Prepared by CRS from FY2006 Emergency Request.

CRS-44
Table 4. FY2006 Appropriations Providing Funds for Global
Initiatives
Legislation
FY2006 Senate
FY2006 House
Appropriations
Appropriations
H.R. 3010,
$60 million for global
$36.5 million to combat the
Labor, HHS, Education
surveillance.
spread of the avian flu in
Asia, and to enhance global
surveillance and response
network for infectious
diseases.
H.Rept. 109-337 provides $183.5 million for the Public Health and Social Services
Emergency Fund (PHSSEF), of which $120 million would be available until expended.
Presented to the President for signature on December 28, 2005.
P.L. 109-102,
$10 million, control the
No similar language.
Foreign Operations
spread of the avian flu.
P.L. 109-102 provides $25 million for strengthening international surveillance, reporting,
and response capacity.
H.R. 2863,
$33 million, avian flu
No similar language.
Department of Defense
global surveillance;
H.Rept. 109-359 provides $3.8 billion for avian flu initiatives, of which $3.3 billion is
directed to the Public Health and Social Services Emergency Fund. $267 million of the
$3.3 billion is reserved for international initiatives, disease surveillance, vaccine
registries, research, and clinical trials. An additional $500 million is reserved for
international assistance, monitoring and tracking, and research and development. The
conference report, H.Rept. 109-359, Emergency Supplemental Appropriations to Address
Hurricanes in the Gulf of Mexico and Pandemic Influenza
, provides $3.8 billion for avian
influenza initiatives. Specifically, the bill directs $3.3 billion to PHSSEF, $131.5 million
to USAID, $130 million to the Department of Defense, $71.5 million to APHIS, $47.3
million to the Department of Homeland Security, $20 million to FDA, $27 million to the
Department of Veterans Affairs, $31 million to the Department of State, and $11.6
million to the Department of the Interior. Presented to the President for signature on
December 28, 2005.
Source: Prepared by CRS from FY2006 appropriations legislation.

CRS-45
Table 5. Country Allocations for FY2005 Supplemental
COUNTRY
CDC FUNDING
USAID FUNDING
Vietnam
$2.634 million
$ 3.45 million
Indonesia
$0.25 million
$ 3.15 million
Cambodia
$1.858 million
$ 2.25 million
Laos
$1.858 million
$ 1.60 million
China
$0.00
$ 0.50 million
Regional
$3.35 million
$ 2.75 million
TOTAL
$9.95 million
$13.7 million
Sources: USAID Press Release, October 27, 2005 and CDC Washington Office, November 8, 2005.
CDC Funding reflects spending from FY2005 Emergency Supplemental. USAID Funding includes
reallocated funds from other programs.

CRS-46
Table 6. International Partnership on Avian and Pandemic
Influenza (IPAPI) Core Principles
1. International
cooperation to protect the lives and health of our people;
2.
Timely and sustained high-level global political leadership to combat avian and
pandemic influenza;
3. Transparency in reporting of influenza cases in humans and in animals caused
by strains that have pandemic potential, to increase understanding, preparedness
and, especially to ensure rapid and timely response to potential outbreaks;
4.
Immediate sharing of epidemiological data and samples with the World Health
Organization (WHO) and the international community to detect and characterize
the nature and evolution of any outbreaks as quickly as possible, by utilizing,
where appropriate, existing networks and mechanisms;
5.
Rapid reaction to address the first signs of accelerated transmission of H5N1 and
other highly pathogenic influenza strains so that appropriate international and
national resources can be brought to bear;
6. Prevent and contain an incipient epidemic through capacity building and in-
country collaboration with international partners;
7. Work in a manner complementary to and supportive of expanded cooperation
with and appropriate support of key multilateral organizations (WHO, Food and
Agriculture Organization, World Organization for Animal Health);
8.
Timely coordination of bilateral and multilateral resource allocations; dedication
of domestic resources (human and financial); improvements in public
awareness; and development of economic and trade contingency plans;
9.
Increased coordination and harmonization of preparedness, prevention, response
and containment activities among nations, complementing domestic and
regional preparedness initiatives and encouraging where appropriate the
development of strategic regional initiatives;
10. Actions based on the best available science.
Source: State Department Press Release, “U.S. Launches International Partnership on Avian and
Pandemic Influenza.” September 22, 2005. [http://www.state.gov/r/pa/prs/ps/2005/53865.htm]