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CHAPTER END CASE: FIGHT AGAINST GLOBAL PANDEMICS EMERGENCE OF HIGHLY PATHOGENIC AVIAN INFLUENZA In 1997, the avian influenza virus or bird flu first surfaced in Hong Kong. Since then, it has remained largely a disease affecting birds with sporadic infections of humans who have had contact with infected fowl Hundreds of millions of birds have died or been culled because of the virus since 2003. Until January 2007, 163 people were reported to have been killed by the virus, mostly in Indonesia, Vietnam, Thailand, and China. In 2006, the virus became deadlier: 70 per cent of infected persons died from it. Between 2003 and 2005, avian influenza was reported in 15 countries, mainly in South-East and Central Asia. By May 2006, the highly pathogenic avian influenza (HPAI), also called H5N1, had spread to 45 countries. In some countries it was only found in wild fowl, in other countries and regions, like India, Africa, the Middle East, and Europe, the virus was identified in domestic and commercial poultry populations. Between 2003 and early 2007, the virus had caused estimated economic losses to the Asian poultry sector of around 10 billion US$. It has destroyed the livelihoods of hundreds of thousands of poor livestock farmers. It jeopardizes commercial poultry production, and is an increasing obstacle to regional and international trade. RISK OF A PANDEMIC? The fact that there has been a recent continual increase in the number of known cases of avian influenza transmission has raised concerns over the potential appearance of a human pandemic which could have extremely harmful effects on the health and livelihood of all human beings. However, it is extremely uncertain whether or when a pandemic will emerge. Since the sixteenth century, three pandemics on average have been recorded per century. In the last 100 years, pandemics have occurred in 1918, 1957, and 1968. The most severe was in 1918, the so-called Spanish influenza, with an estimated rate of 50 million deaths within 18 months. A pandemic today would travel faster, given the improvements in transportation. Experts forecast a death toll of between 2 to 50 million for an avian influenza pandemic. This would not only put high requirements on countries' health systems, but would also result in an unprecedented social and economic impact. According to World Bank estimates, the cost of a pandemic could amount to 1.5-2 trillion US$ in a severe pandemic scenario GLOBAL PROGRAM FOR AVIAN INFLUENZA MAIN PLAYERS In light of the unprecedented potential harm incurred by an avian influenza pandemic, the World Bank, along with other agencies of the UN system (Food and Agriculture Organization (FAO). World Health Organization (WHO), together with the World Organization for Animal Health (OIE), a globally operating intergovernmental organization), started to design a Global Program for Avian Influenza (GPAI) in 2005. Why those organizations? The World Bank has the infrastructure and ability to work across sectors, to raise funds, and to mobilize technical assistance and knowledge- sharing activities at regional and global levels. The World Health Organization specializes in public health on a global level. The Food and Agricultural Organization and the Organization for Animal Health are the experts in agricultural issues and animal health. The program is scheduled to be implemented over three time-frames: immediate to short (1-3 years), short to medium (4-6 years) and medium to long-term (7-10 years). It involves numerous players, namely in the areas of health, agriculture, economics, finance, and planning. Apart from the international organizations mentioned above, the world's governments, together with many non-governmental bodies, private entities and international scientific, developmental, humanitarian and security organizations are involved in the program. Some 25 countries received financing under this program by the end of 2006, including Vietnam, Bangladesh, India, Nigeria, Ethiopia, Turkey, and Romania. In the infected countries and the non-infected at-risk countries, governmental agencies committed to controlling trans-boundary animal diseases are part of an integrated, multi-sector response to the threat posed by the deadly disease. In some countries, the military have also to be considered because they play a major role in emergencies. OBJECTIVES The long-term objectives of the program are: diminishing the global threat of a human pandemic stabilizing poultry production supporting a robust regional and international trade in poultry and poultry products increasing human and food safety improving the livelihoods of the rural poor. What concrete activities can lead to the accomplishment of these objectives? Simply put, it is a careful adherence to basic public health and infection control measures, for instance contact investigation, and infection control at healthcare facilities. Given the uncertainty and the lack of knowledge regarding the spread and persistence of H5N1, the program also supports further research and investigations into avian influenza. Yet, it will not be easy to achieve the goals due to the complex interface between farming systems, the livestock trade, food safety and public health. The activities described need to be embedded in a strong common vision. It is also important to adapt the global measures to local contexts, tailoring the various activities to local needs. The countries have a great variation in their capacity to deal with the outbreak of a serious disease. The global program consists of many single projects which are dedicated to realizing the above mentioned obiectives with measures that are adapted to local conditions. ISSUES There are different sources of financial resources: the internal resources of the infected and at-risk countries, funding provided by international organizations, but also funding through a so-called multi-donor trust fund which mainly supports countries that lack financial resources, for example in Africa. By April 2006, the economic heavyweights like China, the EU countries, Japan, Russia, and the USA, but also smaller countries like Saudi Arabia, Singapore, South Korea and Thailand, together with the European Commission, the Asian Development Bank and the World Bank, had provided an overall sum of almost 1.9 billion US$ for the program. Yet, too few financial resources are available for the program as of the end of 2006. Another issue is the lack of support for communications. People need clearer and more comprehensive information regarding the risk and outbreak of the disease. Recently, more difficulties have emerged as reflected in the following example of Indonesia. Indonesia is the country worst affected by bird flu. It has recorded 85 cases, of which 64 have been fatal. To protect the world's population from a pandemic, the WHO wants to develop a vaccine against the virus. Consequently, it needs samples of the virus. In February 2007, the director-general of the WHO gave a written guarantee to the Indonesian health minister stating that no avian influenza samples were to be passed on to companies for commercial use. However, Indonesia wants a legally binding agreement before it will share samples with the WHO. The Indonesian government is afraid samples will be used for commercial purposes without its permission. The deputy health minister for research feels that Indonesia has been cheated by the WHO before, as it had allegedly passed on samples to companies. He says that good relationships can be restored quickly, but only if the WHO respects Indonesia. International avian influenza experts consider the withholding of samples as a great risk to global health because Indonesia is viewed as not having the expertise to determine whether the virus is mutating into a form which could trigger a global pandemic. Other experts understand the tough stance of the Indonesian government as it would have to pay millions of dollars for vaccines to pharmaceutical companies which would have obtained the samples for free. They feel that it is only ethical to share the risks and benefits. As of May 2008, Indonesia and other countries reluctant to share information about their viruses have started to exchange information using a freely accessible global database. Until then, the WHO had kept crucial information in a private database at a US government laboratory in Los Alamos, USA, with limited access for 15 other laboratories only. Cpic WITY scope and relate the scope you formulated to the SMART rule. 2. Explain the project organization and if possible sketch out how the different parts of the organization relate to each other. TI