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 May 1, 2006
Tiaji Salaam-Blyther
Analyst in Foreign Affairs
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
There are many strains of avian influenza virus infecting poultry. Influenza
A/H5N1 is a strain of influenza currently spreading throughout the world. Although
it is a bird flu, it has infected a relatively small number of people and killed more
than half of those infected. Some scientists are concerned that H5N1 may cause the
next influenza pandemic. Since 1997, when the first human contracted H5N1 in
Hong Kong, the virus has resurfaced and spread to nearly 50 countries in Asia,
Europe, the Middle East, and Africa — infecting more than 200 people. In February
2006, the virus spread from Asia and central Europe to western Europe. By March
2006, health experts had confirmed new bird flu cases among more than 20 countries
across Europe, Asia, and Africa. Most of the countries were experiencing their first
H5N1 cases. The first human H5N1 fatalities outside of Asia occurred in 2006 when
Turkey and Iraq announced their first human deaths related to H5N1 infection in
January and February, followed by Azerbaijan and Egypt in March.
P.L.109-13, FY2005 emergency supplemental appropriations directed $25
million to USAID for global avian flu efforts. The act also permitted the Secretary
of State to transfer up to $656 million for U.S. avian flu initiatives. Ultimately, $6.3
million was transferred to USAID for those purposes, which enabled the United
States to use $31.3 million of FY2005 emergency appropriations on global avian flu
activities. Emergency funds were directed to global avian flu efforts in FY2006
Defense Department appropriations, which provided $3.8 billion for all U.S. avian
flu initiatives. Although Congress did not specify a total amount that should be spent
on all global initiatives, the U.S. State Department, responsible for coordinating the
international response to avian flu, estimates that some $280 million of the $3.8
billion is being directed to global avian flu initiatives. U.S. agencies and departments
have also used FY2005 and FY2006 non-emergency appropriations to fund global
avian flu and pandemic preparedness efforts. The Senate version of H.R. 4939,
FY2006 Emergency Supplemental Appropriations, provides $3.2 billion to avian flu
efforts. The House version does not include similar language. Relevant FY2007 U.S.
department and agency justifications include some $205 million for global H5N1
initiatives. As in previous fiscal years, additional resources might be directed to
global avian flu efforts through complementary programs not categorized as avian
flu, such as infectious disease programs and international influenza research.
This report provides an up-to-date account of global H5N1-related human
infections and deaths, outlines U.S. government global avian flu programs, and
presents some foreign policy issues for Congress. This report will be updated. For
information on U.S. domestic preparedness efforts, agricultural issues, and anti-avian
flu efforts of overseas governments, please see CRS Report RL33145, Pandemic
Influenza: Domestic Preparedness Efforts, by Sarah A. Lister; CRS Report RS21747,
Avian Influenza: Agricultural Issues, by Jim Monke; and CRS Report RL33349,
International Efforts to Control the Spread of the Avian Influenza (H5N1) Virus:
Affected Countries’ Responses, coordinated by Emma Chanlett-Avery.
Contents
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Global Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Transmission Among Birds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Congressional Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
U.S. Executive Branch Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Department of State . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
U.S. Agency for International Development (USAID) . . . . . . . . . . . . . . . . . 9
U.S. Department of Health and Human Services (HHS) . . . . . . . . . . . . . . . 10
Department of Agriculture (USDA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Department of Defense (DoD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
International Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
United Nations Food and Agriculture Organization . . . . . . . . . . . . . . . . . . 13
The World Organization for Animal Health . . . . . . . . . . . . . . . . . . . . . . . . 14
The World Health Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
International Health Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
The World Bank . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Issues for Congress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Patent Protections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Global Data Sharing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Global Disease Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Global Pandemic Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Combating Bird Flu Among Animals in Affected Countries . . . . . . . . . . . 26
Cost of Culling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Global Economic Impacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Global Biosafety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
List of Tables
Table 1. Human Cases of Avian Influenza A/H5N1 . . . . . . . . . . . . . . . . . . . . . . . 3
Table 2. WHO Pandemic Phases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Table 3. FY2005 and FY2006 Enacted Emergency Supplemental and
FY2007 Request for Global Avian Influenza Initiatives . . . . . . . . . . . . . . . 33
Table 4. International Partnership on Avian and Pandemic Influenza (IPAPI)
Core Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
U.S. and International Responses to the
Global Spread of Avian Flu: Issues for
Congress
Background
There are many strains of avian influenza virus that can cause varying amounts
of clinical illness in poultry. Bird (or avian) flu outbreaks have occurred at various
times around the world.1 Influenza A/H5N1 is a strain of bird flu currently spreading
across the world. Although it is a bird flu, the virus has infected some people and
killed more than half of those infected. Until 1997, there were no known human
H5N1 cases. That year, 18 people in Hong Kong contracted the virus; of whom 6
died. To contain the virus, 1.5 million birds were killed. Since 2003, scientists have
closely monitored resurgent H5N1 outbreaks, which have infected poultry in a
growing number of countries.
According to the World Health Organization (WHO), the hallmarks of a
pandemic are: 1) the emergence of a novel flu virus strain; 2) the strain causes
human disease; and 3) person-to-person transmission is sustained. The pandemic
steps usually occur in six phases. Table 2 shows the phases of a flu pandemic, as
described by WHO. The current global H5N1 outbreak is in pandemic alert phase
three, which means a virus new to humans is causing infections, but not spreading
easily from one person to another.
Humans have no immunity against H5N1 since it is a bird flu and has not
commonly infected people. Some predict that if H5N1 were to become transmissible
among humans, an “influenza pandemic” (worldwide disease outbreak) could begin.
Skeptics argue that such predictions are exaggerated, because if the virus were able
to transform into a strain that is efficiently transmissible among people it would have
already done so. Still some health experts stress that governments should prepare for
some sort of pandemic. During the Spanish flu pandemic of 1918, it is estimated that
between 20 and 50 million people died, and between 200 million and 1 billion were
infected around the world. If a flu pandemic were to occur on the same scale as the
1 For a list of past avian flu outbreaks see CRS Report RS21747, Avian Influenza:
Agricultural Issues, by Jim Monke.
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Spanish flu, some estimate that between 30 million and 384 million people could die
around the world,2 of which 1.9 million deaths could occur in the United States.3
Global Prevalence
Since 1997, when the first human contracted H5N1 in Hong Kong, the virus has
resurfaced and spread to birds in nearly 50 countries.4 Figure 1 in the Appendix
maps H5N1 cases among animals and people. In 2004, nine Asian countries reported
H5N1 poultry outbreaks. By August 2005, birds in Mongolia had become infected
with the virus. Two months later, birds in Russia and Kazakhstan had contracted
H5N1 reportedly through contact with wild birds at shared water sources. By late
October 2005, H5N1 had spread westward, affecting six other regions in Russia and
infecting birds in Romania, Croatia, and Turkey. In 2006, countries in western
Europe, the Middle East, and Africa reported H5N1 infection among their poultry
stocks. Also, Azerbaijan, Egypt, Iraq, and Turkey reported the first H5N1 human
cases outside of Asia. Although Iraq has reported human H5N1 cases, no birds have
been diagnosed with the virus. Table 1 below shows the number of confirmed
human H5N1 cases as reported by WHO as of April 27, 2006.5
2 Osterholm, Michael, “Pandemic Influenza: A Harbinger of Things to Come.” Presentation
at the Woodrow Wilson International Center for Scholars, Sept. 19, 2005.
[http://www.wilsoncenter.org/index.cfm?fuseaction=news.item&news_id=145329]
3 HHS Pandemic Influenza Plan. [http://www.hhs.gov/pandemicflu/plan/].
4 The World Organization for Animal Health (OIE) has confirmed H5N1 among birds in the
following countries: Afghanistan, Albania, Austria, Azerbaijan, Bosnia and Herzegovina,
Britain, Bulgaria, Burkina Faso, Burma, Cambodia, Cameroon, China, Croatia, Czech
Republic, Denmark, Egypt, France, Georgia, Germany, Greece, Hungary, India, Indonesia,
Iran, Israel, Italy, Japan, Jordan, Kazakhstan, Korea, Malaysia, Mongolia, Niger, Nigeria,
Palestinian Autonomous Territories, Pakistan, Poland, Romania, Russia, Serbia and
Montenegro, Slovakia, Slovenia, Sweden, Switzerland, Thailand, Turkey, Ukraine, and
Vietnam.
5 WHO, Cumulative Number of Confirmed Human Cases of Avian Influenza A/H5N1, April
27, 2006. [http://www.who.int/csr/disease/avian_influenza/country/en/].
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Table 1. Human Cases of Avian Influenza A/H5N1
COUNTRY
HUMAN CASES
DEATHS
Azerbaijan
8
5
Cambodia
6
6
China
18
12
Egypt
12
4
Indonesia
32
24
Iraq
2
2
Thailand
22
14
Turkey
12
4
Vietnam
93
42
Total
205
113
Source: WHO: Cumulative Number of Confirmed Human Cases of Avian Influenza A/H5N1.
Transmission Among Birds
There is some debate over how H5N1 is spread. Some experts contend that
migratory virus-carrying wild bird species, notably water fowl, are a key H5N1
vector, or medium of transmission. H5N1 has been detected in migratory birds in
multiple countries, and in some instances, its spread has been temporally correlated
with seasonal migrations of certain wild species. In some countries, wild birds
comprise the sole known H5N1-positive animal population. Some wild species may
also be passive carriers of H5N1, harboring but not exhibiting disease symptoms or
ill effects from the virus.6
Other experts, however, maintain that cross-border trade in infected poultry and
poor agricultural practices, including the use of infected bird feces in fertilizer and
animal feed, may comprise equally or more important vectors. Indications that may
support such assertions include the initial detection of H5N1 on commercial farms
in caged poultry that are unable to mingle with wild fowl, and the detection of H5N1
on farms located far from wetlands where migratory birds seasonally dwell, or in
regions where H5N1-linked wild fowl die-offs have not been reported. In some
countries, such as in Nigeria, there are some indications that wild fowl may not be
implicated in the transmission of H5N1.7
6 See FAO, Wild birds and Avian Influenza, Sept. 2005, among other sources.
7 See Ellen Paul [Exec. Dir., Ornithological Council], “What We Don’t Know About Bird
Flu,” Washington Post, Dec. 27, 2005; BirdLife Int., “Are High Risk Farming Practices
Spreading Avian Flu?,” Jan. 18, 2006; and BirdLife Int., “Autumn Waterbird Migration
(continued...)
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There has also been some debate about the role of cats in transmission of the
virus, particularly since the virus has been detected among cats in a number of
countries, including Germany. On April 14, 2006, the World Organization for
Animal Health (OIE) and the United Nations Food and Agricultural Organization
(FAO) confirmed that domestic and wild birds were essentially the animal species
transmitting and spreading the H5N1 virus. Furthermore, the two organizations
found that while some 50 non-domestic bird species have proved susceptible to
infection with the virus, aquatic birds seemed to play a major role in the international
spread of the virus. Concurrently, OIE and FAO confirmed the statement issued by
the World Health Organization (WHO) in February 2006 that “there is no present
evidence that domestic cats can play a role in the transmission cycle of H5N1
viruses.” Nonetheless, the OIE advised that domestic cats be kept indoors in infected
zones and surveillance zones due to their susceptibility to the virus.8
Congressional Response
Congress provided $31.3 million to support ongoing U.S. efforts to prevent and
contain the global 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.9 Congress directed $25 million to the
U.S. Agency for International Development (USAID). Pursuant to the statute,
USAID transferred $15 million of the $25 million appropriation to CDC. The act also
permitted the Secretary of State to transfer part of the tsunami relief funds to federal
agencies for avian flu activities. Ultimately, an additional $6.3 million was
transferred to USAID for international avian influenza activities,10 bringing the total
for FY2005 emergency supplemental spending on international avian influenza
activities to $31.3 million.
In FY2006, the President submitted a $7.1 billion emergency supplemental
request for avian flu and pandemic influenza preparedness. Appropriators attached
$3.8 billion in emergency supplemental funds for avian flu initiatives (reserving a
portion for international efforts) to P.L.109-148, FY2006 Defense Appropriations.11
7 (...continued)
Ends Without Spread of H5N1 Bird Flu,” Aug. 12, 2005; David Brown, “Poultry, Not Wild
Birds, Most Often Carries Deadly Avian Flu to Africa,” Washington Post, Feb. 16, 2006;
and AFP, “Bird flu outbreak in Nigeria stirs fresh row over migrant birds,” Feb. 8, 2006.
8 OIE, “Susceptibility of animal species to the H5N1 Asian strain.” April 14, 2006.
[http://www.oie.int/eng/press/en_060413.htm]
9 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.
10 FY2007 State Department Function 150 Budget Request. Of the $6.3 million, $1.8
million went to Asia and the Near East region, $3.0 million to Europe and Eurasia, and $1.5
million to sub-Saharan Africa.
11 The conference report for P.L.109-148, FY2006 Defense Appropriations, H.Rept. 109-
(continued...)
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The State Department, responsible for coordinating U.S. international avian flu
efforts, estimates that some $280 million of the $3.8 billion is being directed to
global avian flu initiatives. It is important to note that additional global avian flu
efforts might be supported through other activities not specified in this report, such
as avian flu related activities (e.g., infectious disease programs), ongoing influenza
programs without “avian flu” requested funding, or international influenza research
initiatives. Appropriators will be debating the appropriate level of funding for H.R.
4939, FY2006 Emergency Supplemental Appropriations. The Senate version
includes $3.2 billion for avian flu efforts, of which at least $200 million is set aside
for the Centers for Disease Control and Prevention (CDC) to implement global and
domestic disease surveillance, laboratory capacity and research, risk communication,
laboratory diagnostics, rapid response initiatives, and quarantine efforts. The House
version does not specify additional funding for avian flu efforts.
The President requests about $205 million specifically for international avian
flu activities in FY2007. However, as in previous fiscal years, additional resources
might be directed to global avian flu efforts through complementary programs or
initiatives not specified as avian flu. The Senate Budget Committee passed
S.Con.Res. 83 on March 16, 2006, which directs appropriators to provide up to $2.3
billion in FY2007 appropriations for pandemic influenza preparedness. S.Con.Res.
83 also includes an additional $352 million for pandemic influenza preparedness
activities. The House version, H.Con.Res. 376, passed on March 31, 2006, exempts
up to $2.3 billion reserved for avian flu spending from budgetary controls. Table 3
in the appendix outlines the amounts the Administration specifically requests for
international avian flu initiatives in FY2007, and enacted spending for those activities
through FY2005 and FY2006 emergency supplementals. Additional funds that an
agency or department might have spent through regular FY2005 and FY2006
appropriations are not included in the table. Instead, reported figures are footnoted
below the table.
Some Members have argued that the Administration had proposed allocating
insufficient resources to the global fight against H5N1 and pandemic planning,
particularly in Africa. For example, during the House Foreign Operations
Subcommittee hearing on pandemic flu in March 2006, Chairman Jim Kolbe
suggested that the $55 million that USAID was requesting for FY2007 global avian
flu initiatives might not be sufficient, and encouraged the agency to request
additional funds if necessary. The Chairman also questioned why such a small
proportion of the FY2007 requested funds were allocated to Africa (less than $10
million). A number of Members have introduced legislation to increase U.S.
11 (...continued)
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, $91.4 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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resources allocated to the global fight against avian flu. Some bills, such as H.R.
4062, Pandemic Preparedness and Response 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.
U.S. Executive Branch Response
On November 1, 2005, the President released the National Strategy for
Pandemic Influenza.12 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
pandemic influenza preparedness abroad could enhance domestic pandemic
preparedness efforts.
The President requested $7.1 billion to fund the National Strategy for Pandemic
Influenza, some of which he suggested be set aside for international activities. The
majority of the funds, $6.7 billion, were requested for HHS. The President requested
that the $6.7 billion be funded as such: $3.2 billion in FY2006, $2.3 billion in
FY2007, and $1.2 billion in FY2008. The President requested that the rest of the
funds be funded through FY2006 emergency appropriations.
Of the $7.1 billion related to international activities, the President requested:
! $200 million for HHS to undertake a number of activities, including
international pandemic preparedness planning initiatives and
pandemic influenza disease surveillance;
! $18.3 million for the U.S. Department of Agriculture to undertake
research and development initiatives and to implement international
programs that provide avian influenza surveillance and prevention
technical assistance;
! $120 million for the Department of Defense (DoD) to increase
worldwide surveillance and upgrade related equipment;
! $10 million for DoD to assist military partner nations in procuring
protective equipment, portable field assay testing equipment, and
related laboratory equipment;
12 For more information on U.S. government avian flu and pandemic preparedness see
[http://www.pandemicflu.gov]
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! $17 million for the Department of State to implement public
diplomacy, training, and international outreach activities related to
avian influenza and pandemic preparedness;
! $1.5 million for the Department of State International Visitors
Program to provide 100 additional professional exchanges of
doctors, health practitioners, and non-governmental organizations
(NGOs);
! $75.2 million for Child Survival and Health Programs (CSH) of
USAID to implement behavior change and avian flu awareness
campaigns, diagnostic support initiatives, and pandemic
preparedness and planning activities; and
! $56.3 million for International Disaster and Famine Assistance
Funds of USAID to pre-position supplies and equipment, such as
antiviral medication and protective equipment.13
As indicated in the previous section, Congress ultimately provided $3.8 billion
through FY2006 emergency appropriations to fund the first phase of the National
Strategy for Pandemic Influenza.
Prior to 2005, 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 report14 a number of factors that have
complicated efforts to contain the spread of H5N1 in those countries, 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.
13 FY2006 Emergency Request for Avian and Pandemic Influenza Preparedness.
[http://www.whitehouse.gov/omb/budget/amendments/supplemental_11_01_05.pdf]
14 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. Since then the agency-specific strategies have been
augmented and are briefly described below.
Department of State
The U.S. Department of State is responsible for coordinating the U.S.
international response to the global spread of H5N1. Ambassador John Lange
replaced Ambassador Nancy Powell as the Senior Coordinator for Avian Influenza
and Infectious Diseases in March 2006. Ambassador Lange is responsible for
overseeing the work of the technical implementing agencies: HHS (and its relevant
agencies), USAID, the Department of Agriculture, and the Department of Defense.
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. Through IPAPI, the U.S. government seeks to enhance public health
and surveillance capacity through diplomatic initiatives that promote transparency
and encourage reporting and rapid sharing of samples. 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
4). 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
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preparedness plans that address the multi-sectoral impacts of an influenza
pandemic.15 The next IPAPI meeting is scheduled for June 2006.
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. OMB reports that in FY2006, $6 million of the funds were
allocated to diplomatic support and international response coordination and $25
million were directed to health support for embassy and evacuation contingency for
overseas missions. The Administration did not request additional funds in FY2007
for State Department international avian flu activities.
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 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. USAID reports that it has
allocated $22.1 million to global avian flu prevention and containment during
FY2005 ($16.3 million of which was funded through the FY2005 emergency
appropriations).16 USAID has received $131.5 million from FY2006 emergency
supplemental appropriations for global avian flu efforts. The FY2007 budget
requests $55 million to USAID for continued avian flu and pandemic preparedness
initiatives abroad. Specifically, the agency has:
! strengthened disease surveillance, laboratory diagnosis, and rapid
containment of animal outbreaks in Cambodia, China, Indonesia,
Laos, and Vietnam;
! supported communication campaigns in Laos, Cambodia, Vietnam,
and Indonesia aimed at reducing animal handling practices that place
humans at risk;
! distributed more than 30,000 personal protective equipment (PPE)
sets, which include manual sprayers to assist in decontaminating
hospital rooms and equipment, Tyvek suits (protective coveralls
15 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].
16 USAID Avian Flu Update #29, February 9-March 13, 2006.
[http://www.usaid.gov/our_work/global_health/home/News/news_items/actions.html].
CRS-10
used in hazardous situations), gloves, boots, masks, and eye
protection in Asia, Europe, and Africa;
! deployed infectious disease and animal health experts to Iraq,
Turkey, Ukraine, Romania, Armenia, Azerbaijan, Georgia, Moldova,
and Nigeria to provide short-term technical assistance, assisted in the
rapid collection of animal samples and helped implement procedures
to strengthen surveillance and containment efforts in the countries;
! provided Ukraine PPE kits that two veterinary laboratories and
cullers and first responders from the Ministry of Emergencies are
using in their response and containment activities;
! granted WHO $300,000 for international coordination efforts and for
improving disease control and surveillance measures; and
! provided WHO an additional $250,000 for PPE.17
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.
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. In FY2006, HHS enhanced its
international pandemic research activities. Research activities included assisting in
the development and testing of candidate vaccines and drugs produced by Vietnam
and other countries with endemic avian influenza; expanding the clinical trials
infrastructure and research in southeast Asia; conducting human-animal interface
studies, including disease surveillance among animals in the region; and expanding
other research to accelerate the development of pandemic influenza vaccines, drugs,
and diagnostics.18
HHS budget officials estimate that CDC spent $15 million on international
avian flu initiatives through FY2005 emergency appropriations. OMB estimates that
17 USAID, Avian Influenza Updates 29 and 32, March 13, 2006 and April 14, 2006.
[http://www.usaid.gov/our_work/global_health/home/News/news_items/actions.html]
1 8 HHS FY2007 budget request. [http://www.hhs.gov/budget/07budget/
2007BudgetInBrief.pdf]
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HHS will spend $114 million on global avian flu initiatives through FY2006
emergency supplemental funds included in FY2006 DoD appropriations. However,
these figures might be adjusted as the fiscal year progresses and additional funds
might be provided through FY2006 Emergency Supplemental Appropriations. The
Administration requests $145 million for HHS global pandemic influenza and
preparedness initiatives in FY2007.
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.19 In that view, USDA and other
analysts consider the department’s efforts a critical element in the global fight against
the spread of H5N1.
USDA works closely with OIE, FAO, and WHO to assist HPAI-affected
countries and other neighboring countries, including Europe, with disease prevention,
management, and eradication activities. USDA also implements training activities
for scientists in those countries.
Through FY2006 emergency supplemental appropriations, Congress directed
$91.3 million to USDA for avian flu and pandemic preparedness initiatives, of which
approximately $18 million was reserved for international efforts. The Administration
request $5 million for USDA international avian flu activities in FY2007.
Department of Defense (DoD)
The Department of Defense Global Emerging Infections Surveillance and
Response System (DoD-GEIS) supports and coordinates DoD global surveillance,
training, public health research and outbreak response capabilities.20 Specifically,
DoD-GEIS projects support outbreak response preparation, detection, clinical
investigation, microbial agent identification, and communicable disease control and
prevention. GEIS has a network of overseas medical research laboratories that track,
prevent, and treat infectious diseases around the world. The objective is to ensure
national security, 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 (GOARN) (described below). In FY2005, the GEIS global
19 USDA, Transcript of Technical Briefing regarding Avian Influenza. October 26, 2005.
[http://www.usda.gov/birdflu]
20 GEIS website, [http://www.geis.fhp.osd.mil/].
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professional network isolated influenza viruses from approximately 1,800 individuals
from about 20 countries; these influenza isolates were made available to CDC and
world public health officials for molecular analysis and for consideration in the
formulation of vaccination preparations.21 Key DoD-GEIS activities to combat the
spread of H5N1 and prepare for an influenza pandemic have included:
! the provision of influenza data analyses, surveillance information,
and influenza isolates for WHO, DoD, and CDC through
cooperative relationships that included sharing weekly surveillance
reports;
! the development of pandemic influenza emergency response plans
for various DoD branches;
! surveillance for incidence of influenza among military populations;
! training and education sessions for healthcare workers that would
aid in rapid detection and management of influenza illnesses;
! implementation of cooperative influenza surveillance activities in
seven countries in the Middle East and in the Central Asian
Republics, notably providing laboratory and epidemiological support
in the identification of the avian influenza A H5N1 virus from
wildfowl specimens in Kazakhstan;
! implementation of cooperative projects with the government of
Indonesia, WHO and CDC, including providing diagnostic support
for avian influenza (H5N1); and
! the evaluation of 29 emergency response plans from foreign
governments, federal agencies, and international organizations.22
The DoD overseas medical research laboratories are another critical part of
DoD’s avian flu containment and pandemic preparedness efforts. These Navy and
Army laboratories support the GEIS mission through four programs: emerging
diseases, enteric diseases, parasitic diseases, and virology. The overseas laboratories,
based in Egypt, Indonesia, Kenya, Peru, and Thailand, collect and analyze biological
samples. The overseas laboratories have been critical in U.S. government H5N1
surveillance efforts. DoD also maintains related research activities in Southeast Asia
and the Pacific Islands, and supports a satellite laboratory in Phnom Penh, Cambodia,
in collaboration with the DoD overseas laboratory in Indonesia (Navy Medical
Research Unit 2) and 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);
21 DoD-GEIS FY2005 Annual Report.
[http://www.geis.fhp.osd.mil/GEIS/DoDGEISNews/GEIS_AR_05.pdf]
22 Ibid.
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! 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.23
According to the FY2007 DoD Budget Justification, the department received
$130 million from FY2006 emergency supplemental appropriations for avian flu
activities, of which $120 million has been allocated to the Defense Health Program
and $10 million to Operation and Maintenance. The FY2007 budget request did not
include a specific amount for avian flu.
International Response
The United Nations Food and Agriculture Organization (FAO), the World
Organization for Animal Health (OIE), and the World Health Organization (WHO)
have been working closely to prevent and respond to the threat of an avian influenza
pandemic. The FAO and OIE coordinate global surveillance and response activities
related to animals transmission of H5N1. WHO focuses on coordinating the
international response to H5N1 infection in humans. This section describes the roles
of these three organizations in responding to and containing the global spread of
H5N1. An analysis of the World Bank and its work in this area is also explored.
United Nations Food and Agriculture Organization
FAO coordinates global surveillance and response activities for animal
influenza strains with pandemic potential, such as H5N1.24 To accomplish its
mission, FAO works closely with OIE.25 Specifically, FAO and OIE work with other
agencies to assist regional and national authorities in developing appropriate avian
influenza prevention and control plans and strategies. 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.
On March 17, 2006, FAO released a proposal for a global avian influenza
control and eradication plan.26 The plan outlined what activities FAO would
23 DoD, Global Emerging Infections System Annual Report Fiscal Year 2004.
[http://www.geis.fhp.osd.mil/GEIS/aboutGEIS/annualReports/GEIS_AR_04.pdf].
24 See FAO avian influenza home page at [http://www.fao.org/ag/againfo/subjects/en/
health/diseases-cards/special_avian.html].
25 See OIE avian flu home page at [http://www.oie.int/eng/AVIAN_INFLUENZA/
home.htm].
26 FAO, “Avian Influenza Control and Eradication: FAO’S Proposal for a Global Program.”
March 17, 2006. [http://www.fao.org/ag/againfo/subjects/documents/ai/
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implement and how much funds would be needed to support the program. The report
emphasized that as the virus spreads needs change, making it increasingly difficult
to predict sufficient levels of logistical and budgetary resources. FAO pointed out
that in November 2005, it was estimated that FAO would need $494 million over
three years to implement a global program. However, after the rapid spread of the
virus to Europe and Africa, the three-year budget estimate jumped to $882 million.27
FAO anticipates involvement in implementing 25% of donor-assisted projects in
infected countries, and 50% of assistance to non-infected countries in preparedness
outbreaks.
The World Organization for Animal Health
OIE, an intergovernmental organization established in 1924 and based in
France, seeks to collect, analyze, and disseminate the latest scientific information on
animal disease control. There are 167 member countries in OIE, one of which is the
United States. The organization establishes guidelines to help countries improve
disease control and eradication methods. OIE also provides technical support to
member countries requesting assistance with animal disease control and eradication
operations. According to the OIE website, one of its most critical functions is to
establish international standards for adequate veterinary services and to assist
member countries to implement the standards.28
In December 2005, the OIE Director General Dr. Bernard Vallat released a
statement arguing that globalization facilitates the appearance of emerging and
reemerging diseases and greatly increases their impact. Furthermore, it was argued
that national veterinary services are the “very core body for the prevention, detection,
and control of animal diseases, including those transmissible to humans. Veterinary
services play a major role in every country as guarantors of animal health and
associated public health issues.”29 Furthermore, OIE presses for greater public
investment in veterinary services, deeming it a global public good of great
importance.
In April 2006, OIE launched “Safe Supply of Affordable Food for Everyone
Everywhere.” The initiative seeks to facilitate and strengthen the global food safety
system, enhance animal disease prevention and control efforts worldwide; and
leverage resources from public-private partnerships. OIE argues that this initiative
is critical to countering the affects avian influenza has had on the animal kingdom,
which if not addressed could have significant global consequences for agricultural
26 (...continued)
Global_Programme_March06.pdf]
27 Ibid.
28 OIE, “OIE at a Glance.” Accessed on April 28, 2006.
[http://www.oie.int/eng/OIE/en_oie.htm]
29 OIE, “Prevention, detection, and control of animal diseases, including zoonoses:
Veterinary Services, the core of the global system.” December 2005. [http://www.oie.int/
eng/edito/en_lastedito.htm]
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economies, food security, and public health.30 Dr. Vallat asserts that the initiative
is crucial, because many governments in developing countries are incapable of
raising their animal health and public health infrastructures to international standards,
which outline how to address avian influenza and other emerging animal diseases,
without cooperation with the private sector.31
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. 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 by some as the most serious challenge facing WHO.
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 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. 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.32
30 OIE, “World Organization for Animal Health (OIE) launches a global alliance against
animal diseases, including zoonoses. April 21, 2006.
[http://www.oie.int/eng/press/en_060420.htm]
31 Ibid.
32 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.
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WHO is establishing a global stockpile of influenza vaccines and treatments.33
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.34 Roche, the
patent holder of Tamiflu, announced that it would donate 3 million courses of the
drug to WHO.35 On January 17, 2006, WHO announced that Roche would donate
an additional 2 million treatment courses of Tamiflu for use in developing countries
— bringing the total of donated courses to 5 million.36 Roche officials announced
on April 19, 2006, that 3 million Tamiflu courses were ready to be shipped to an
influenza outbreak site at WHO’s request.37
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.38 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
33 For more information on the global stockpile see WHO, “Responding to the avian
influenza pandemic threat: recommended strategic actions.” [http://www.who.int/csr/
resources/publications/influenza/WHO_CDS_CSR_GIP_05_8-EN.pdf]
34 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].
35 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]
36 WHO, “Additional two million treatment courses of oseltamivir donated to WHO to help
countries which cannot afford the treatment.” January 17, 2006. [http://www.who.int/
mediacentre/news/notes/2006/np01/en/index.html]
37 Roche press release, “Rapid response stockpile of Tamiflu now ready and available to the
World Health Organisation (WHO). April 19, 2006. [http://www.roche.com/
med-cor-2006-04-19]
38 The American Society of International Law, SARS and International Law, April 2003, see
[http://www.asil.org/insights].
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developing countries to gain the capacities needed to meet the new disease control
guidelines.39
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
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.40 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.41 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.
At the Executive Board’s semi-annual session, from January 23-28, 2006, the
Board discussed a number of issues, including how to reduce the risk of a global
influenza pandemic. During the 117th Session, the Board discussed strategies to
encourage countries to immediately voluntarily comply with provisions of the revised
IHR related to a possible flu pandemic. Member countries, such as Canada, are
reportedly among those who advocate for the revised IHR to be adopted earlier than
2007.42 During the session, the 32 Board Members backed and released WHO
Pandemic Influenza Draft Protocol for Rapid Response and Containment. The draft
protocol must be ratified by the General Assembly in May 2006. The protocol seeks
to “facilitate rapid detection and assessment of potential ‘signals’ that the virus is
improving its transmissibility, and to guide implementation of effective response
interventions before an emerging pandemic virus has spread beyond an initial
outbreak zone.”43 Former Ambassador Nancy Powell stated at a House Foreign
Operations subcommittee hearing that the U.S. is working with countries to help
them comply with the IHR. Ambassador Powell pointed out that in the Caucuses
there is a lack of boxes used for sending viral samples to WHO, and a lack of
information on how to adhere to the IHR. Various U.S. government agencies are
39 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/].
40 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. WHO, “Frequently Asked Questions About IHR.”
[http://www.who.int/csr/ihr/howtheywork/faq].
41 WHO, “Frequently Asked Questions About IHR.” [http://www.who.int/csr/ihr/
howtheywork/faq].
42 Nebehay, Stephanie, “WHO backs early adoption of bird flu rules.” Reuters, January 26,
2006. [http://www.alertnet.org/thenews/newsdesk/L26248393.htm]
43 WHO, “WHO Pandemic Influenza Draft Protocol for Rapid Response and Containment.”
January 27, 2006. [http://www.who.int/csr/disease/avian_influenza/guidelines/
RapidResponse_27%2001.pdf]
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reportedly working with countries to demonstrate how to safely handle and transport
viral samples to WHO.
The World Bank
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.44
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.45 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.
On January 17-18, 2006, the World Bank, the European Commission, and the
Chinese government co-hosted the “International Pledging Conference on Avian and
Human Influenza.” The conference’s stated goal was to raise between $1.2-$1.4
billion from the global community to combat avian flu in developing and middle-
income countries.46 Representatives from approximately 100 countries and 20
international organizations attended, ultimately pledging $1.9 billion in avian flu
assistance.
Details on how the money will be spent are scant; however, David Nabarro, the
U.N. bird flu coordinator, stressed that “there will be very clear procedures for the
monies being applied to particular programs.” Among the donors, the World Bank
reportedly promised $500 million, the U.S. pledged $334 million, Japan offered $159
million, EU member states donated $138 million, and the European Commission, the
EU’s executive body, pledged $121 million. Although China is struggling to contain
the spread of H5N1, it pledged $10 million.47 It is anticipated that $635.2 million
44 World Bank Press Release, “New Global Program to Deal with Avian Flu.” November
4, 2005. [http://www.worldbank.org]
45 UN News Service, “Bird flu: UN-sponsored conference draws up six-point action plan.”
November 9, 2005. [http://www.un.org/apps/news/]
46 “Avian and Human Influenza: Financing Needs and Gaps,” World Bank, January 12,
2006, pp. 10-11. [http://siteresources.worldbank.org/PROJECTS/Resources/40940-
1136754783560/AHIFinancingGAPSFINAL.pdf]
47 Information in this paragraph was compiled from the Wall Street Journal, “Donors Pledge
$1.9 billion to Fight Avian Flu in Developing Nations.” January 19, 2006.
(continued...)
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would go to East Asia and the Pacific, $224.6 million to Eastern Europe and Central
Asia, $147.1 million to Africa, $110.1 million to the Middle East and Africa, $76.0
million to South Asia, and $9.2 million to Latin America and the Caribbean.48
The World Bank has already begun plans for distributing the $1.9 billion raised.
In February 2006, the World Bank announced that it would provide the Kyrgyz
Republic $4 million, the first of the $500 million in avian flu assistance grants. The
grant is intended to support national efforts to strengthen veterinary services, enhance
information dissemination, and improve disease surveillance.49 The World Bank also
announced in February that it is planning to provide $50 million in emergency funds
to Nigeria for culling and farmer compensation, as well as vaccination assistance.50
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.51 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.”52 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
47 (...continued)
[http://www.wsj.com]
48 BBC, “$1.9bn pledged for bird flu fight.” January 18, 2006. [http://news.bbc.co.uk/go/pr/
fr/-/1/hi/world/asia-pacific/4622982.stm]
49 World Bank press release, “First World Bank Avian Flu Grant to Kyrgyz Republic.”
February 9, 2006. [http://www.worldbank.org]
50 World Bank press release, “Emergency Aid for Nigeria to Combat Avian Flu.” February
24, 2006. [http://www.worldbank.org]
51 For more information on these issues see CRS Report RL33145, Pandemic Influenza:
Domestic Preparedness Efforts, by Sarah Lister.
52 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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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.53 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.54 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.55 Two Indian
pharmaceutical companies are reportedly negotiating with Roche to produce generic
versions of Tamiflu.56 Roche also reached an agreement with a Chinese
pharmaceutical company to make the drug.57
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.58 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 health.59 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).60 The waiver permits a country without manufacturing
53 Alonso-Zaldivar, Ricardo, “Roche agrees to generic version of Tamiflu drug.” Baltimore
Sun, October 21, 2005. [http://www.baltimoresun.com].
54 H.R. 4392, To provide for the importation of pharmaceutical products under a
compulsory license as provided for under the World Trade Organization.
55 McNeil Jr., Donald, “Indian Company to Make Generic Version of Flu Drug Tamiflu.”
New York Times. October 14, 2005. [http://www.nytimes.com].
56 Jack, Andrew, “India drugs groups in Tamiflu talks.” Financial Times. December 12,
2005. [http://news.ft.com/home/us/]
57 Wright, Tom, “Roche to Let Chinese Producer Make Flu Drug.” New York Times.
December 13, 2005. [http://nytimes.com]
58 For more information on influenza and patent issues, see CRS Report RL33159, Influenza
Antiviral Drugs and Patent Law Issues.
59 WTO, “Members OK amendment to make health flexibility permanent.” December 6,
2005. [http://www.wto.org/english/news_e/pres05_e/pr426_e.htm]
60 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
(continued...)
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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.”61 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.62
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.63
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
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.64 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.
60 (...continued)
generics from countries where pharmaceuticals are patented.
61 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.
62 WTO, “Members OK amendment to make health flexibility permanent.” December 6,
2005. [http://www.wto.org/english/news_e/pres05_e/pr426_e.htm]
63 H.R. 4392, To provide for the importation of pharmaceutical products under a
compulsory license as provided for under the World Trade Organization.
64 Chang, Alicia, “Bird Flu Victims Die After Drug Resistence.” Washington Post.
December 21, 2005. [http://www.washingtonpost.com]
CRS-22
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.65 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.66 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.
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.67 Others have speculated that China is withholding its samples, because
it is trying to produce an H5N1 vaccine.68
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
65 Rosenthal, Elisabeth, “Two Studies Find Flu Treatments Fall Far Short.” September 22,
2005. [http://www.nytimes.com].
66 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.
67 Globe and Mail, “Chinese officials haven’t shared samples of H5N1: experts.” November
18, 2005. [http://www.theglobeandmail.com].
68 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].
CRS-23
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.69
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.70 The New York Times reported that
Laos has 69 veterinarians in the entire country, and all but two of them were trained
in other Communist countries before the collapse of the former Soviet Union.
Additionally, Laos reportedly has no veterinary school.71 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.72 U.N. officials argue that Laos exemplifies the sort of long-
term assistance that other poorer countries will require, such as training in veterinary
services and surveillance systems, provision of surveillance and testing equipment,
and support for farmer compensation.73
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 is
particularly wary of the virus spreading across 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 initially 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.74 Some experts fear that an unabated H5N1
outbreak in Africa could make the bird flu endemic there. “If the virus were to
become endemic in Africa, it could increase the risk that the virus would evolve
69 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.
70 Interview with USAID official, October 11, 2005.
71 Bradsher, Keith, “Health Officials Call for Long-Term Spending on Bird Flu.” January
17, 2006. [http://www.nytimes.com]
72 Ibid.
73 Bradsher, Keith, “Health Officials Call for Long-Term Spending on Bird Flu.” January
17, 2006. [http://www.nytimes.com]
74 Reuters, “Bird Flu in Africa Could Swamp Health Systems: WHO.” November 27, 2005.
[http://www.nlm.nih.gov/medlineplus/news/fullstory_27731.html]
CRS-24
through mutation or reassortment into a strain that could be transmitted to and
between humans.”75
The press reported on December 20, 2005 that a bird suspected of having
contracted H5N1 in Ethiopia, tested negative of the virus.76 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.77 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
his country is ill-equipped to respond to a pandemic citing insufficient supplies of
medication, hospital beds, and ventilators.78
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
75 “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]
76 Reuters Foundation, “ETHIOPIA: Birds Test Negative for avian flu.” December 20,
2005. [http://www.alertnet.org]
77 USAID, H5N1 Avian Influenza (AI) Most Recent Developments and Actions. November
26 - December 19, 2005.
78 Grudgings, Stuart, “Rich-poor divide hobbles Asia’s bird flu plans.” Reuters, September
13, 2005. [http://www.reuters.com]
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FY200679. Advocates assert that the Administration requests for international H5N1
initiatives will not sufficiently address the significant needs of 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.”80
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
79 GovEXEC.com, “House panel calls plan for tracking avian influenza ‘inadequate’.”
December 7, 2005. [http://govexec.com/dailyfed/1205/120705cdpm2.htm]
80 Grudgings, Stuart, “Rich-poor divide hobbles Asia’s bird flu plans.” Reuters. September
13, 2005. [http://www.reuters.com]
CRS-26
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
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. 81
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.82 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 —
81 Ilaria Capua and Stafano Manganon, “Vaccination for Avian Influenza in Asia,” Vaccine,
Vol. 22, 2004, pp. 4137-4138.
82 Perry, Michael, “Poor Asian farmers are weak link in bird flu fight.” Reuters. September
19, 2005. [http://www.alertnet.org/thenews/newsdesk/SYD28137.htm]
CRS-27
a portion of which could be used to support poor farmers.83 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 that it is
prepared to provide at least $470 million to support Asian anti-H5N1 and pandemic
preparedness efforts.84
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 International Monetary Fund recently released a report which outlined the
potential global economic and financial impact of an avian flu pandemic. The report
outlines some possible effects of a severe pandemic. According to the report,
government finances might sharply deteriorate due to increased expenditure on health
and public safety. Concurrently, IMF asserts that governments could experience a
decrease in revenues as businesses and consumers avoid purchases, firms scale back
production as employee attendance drops, and borders close. There could also be
disruptions in payment systems leading to less revenue flow to national treasuries,
the report predicts. Governments might also be indirectly affected if poultry
businesses demand compensation, or if tourism, transport, retail, and insurance
industries become bankrupt. Ultimately, the IMF document predicts that a severe
avian flu pandemic could trigger a “sharp but short-lived impact” on the global
economy. However, the report asserts that financially stable economies might be
better equipped to contend with sharp fluctuations in GDP from quarter to quarter.
The IMF document reported that countries previously affected by SARS, some
countries that had recently dealt with avian flu outbreaks, and several countries with
large, complex financial systems generally had more advanced preparations.85
Many economists assert that health and non-health related sectors could be
severely affected by a global influenza pandemic, though it would be difficult to
predict the costs of those effects. 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.86 Additionally, flights
83 World Bank, “New Global Program to Deal with Avian Flu.” November 4, 2005.
[http://www.worldbank.org]
84 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]
85 IMF, The Global Economic Impact of an Avian Flu Pandemic and the Role of the IMF.
February 28, 2006. [http://www.imf.org/external/pubs/ft/afp/2006/eng/022806.htm]
86 Osterholm, Michael, “Preparing for the Next Pandemic.” Foreign Affairs, July/August
(continued...)
CRS-28
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.87 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). 88
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.89 Some economists have advised the United 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.90 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 2003.91 In 2004, U.S. exports to China grew to $33 billion, more than double the
86 (...continued)
2005. [http://www.foreignaffairs.org].
87 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.
88 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/]
89 World Bank East Asia and Pacific Region, “Spread of Avian Flu Could Affect Next
Year’s Economic Outlook.” November 2005.
[http://siteresources.worldbank.org/INTEAPHALFYEARLYUPDATE/Resources/EAP-
Brief-avian-flu.pdf]
90 U.S. Trade Representative Robert Portman discussion at the US-ASEAN Business
Council Second Annual Asia Forum, November 1, 2005.
91 USTR website, “America’s Trade with China.” April 21, 2004. [http://www.ustr.gov]
CRS-29
level in 2001.92 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.93
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
if an H5N1 pandemic were to reach the United States.94 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.95 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
92 USTR website, “Real Results in U.S. Trade with China.” September 9, 2004.
[http://www.ustr.gov]
93 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]
94 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]
95 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.
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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.96 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.”97
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,
2005.98 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.99
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.100 Japan,
.already accomplished in viral research, is reportedly helping Vietnam build a
biosafety lab to work with the influenza virus.101 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.102
96 Kolata, Gina, “Experts Unlock Clues to Spread of 1918 Flu Virus.” New York Times,
October 6, 2005. [http://www.nytimes.com]
97 Ibid.
98 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.
99 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.
100 Altman, Lawrence and Keith Bradsher, “Vaccine Alone Won’t Stem Avian Flu, Experts
Warn.” New York Times. August 8, 2005. [http://www.nytimes.com]
101 Interview with State Department staff, October 18, 2005.
102 Abbott, Alison, “The flu HQ.” Nature, Volume 414, November 1, 2001.
[http://www.nature.com]
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Appendix
Figure 1. Map of Human and Animal H5N1 Cases
CRS-32
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
transmission rapidly if it occurs.
strain 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
notification and response to additional
close contact.
cases.
Phase 4
Small cluster(s) with limited human-
Contain the new virus within limited foci
to-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-33
Table 3. FY2005 and FY2006 Enacted Emergency Supplemental
and FY2007 Request for Global Avian Influenza Initiatives
($ millions)
FY2005
FY2006
Emergency
Emergency
AGENCY
FY2007 Request
Appropriations
Appropriations
Enacted
Enacted
Department of Health and
15.0a
114.0
145.0b
Human Services
Department of Agriculture
18.0
5.0b
Department of Defense
10.0
Not availablec
Department of State
6.0
0.0
USAID
16.3d
132.0
55.0b
Source: Prepared by CRS from FY2005 and FY2006 Emergency Supplemental appropriations,
FY2007 budget requests were compiled from agency or department justifications, and interviews with
CDC Washington officials.
a. CDC Washington officials indicate that it spent $6 million on international avian flu activities
through FY2005 appropriations. This figure is in addition to the $15 million provided through
the FY2005 emergency supplemental.
b. U.S. Office of Management and Budget (OMB).
c. The FY2007 DoD Budget Justification did not specify a request for avian flu efforts.
d. The FY2005 emergency supplemental permits the Secretary of State to transfer up to $656 million
to various U.S. agencies for avian flu activities. USAID received $31.3 million of those funds,
of which $15 million was transferred to HHS. See Congressional Response section and
Department of State 2007 Budget Request at [http://www.state.gov/s/d/rm/rls/iab/2007/pdf/].
CRS-34
Table 4. 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]