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The international implications of avian influenza
The International Implications of Avian Influenza
Avian influenza is an ancient virus which lives harmlessly in wild waterfowl, but which
can become extremely virulent in new host species. In the last few years, the
unstable H5N1 strain of the virus has caused hundreds of millions of deaths in
domesticated fowl and over 70 deaths in humans. So far the virus has not become
transmissable between humans, but if it does we could be facing a highly infectious,
The possibility of a human pandemic has low-risk, high-impact characteristics,
making it hard for governments to know where the “minimum readiness threshold”
lies. What proportion of total resources should be devoted to an event which is 90%
unlikely to happen in any given year, but which could be globally devastating if it did?
A virulent pandemic could kill millions of people, cause severe economic damage
and lead to conditions of anarchy in some parts of the world. Developing countries –
particularly in East Asia – are the most likely locations for a human pandemic to
originate due to the conditions under which people and animals live. The effects of a
pandemic would also be much greater in developing countries, particularly for the
Avian influenza is best understood as a transnational threat requiring an
internationally coordinated response. In the age of frequent and rapid international
travel, political borders will provide little protection from the virus – so it is in every
country’s interest to prevent an outbreak occurring anywhere in the world. To do
that we need to share information and pool resources.
International agencies led by the World Health Organisation have responded to the
recent growth in outbreaks of the H5N1 virus among avian populations by updating
guidelines for national pandemic preparedness and identifying priorities for spending
on anti-pandemic resources. Foremost of these are improvements to animal and
human influenza surveillance systems, increased laboratory capacity and
international exchange of information, building a common stockpile of antiviral drugs
for rapid deployment to the scene of an outbreak in humans and integration of
On Monday 7 November 2005 CARE Australia and the Lowy Institute for
International Policy co-hosted a conference looking at the international implications of
avian influenza. The conference was attended by Australians at senior levels in the
government, business, academic, humanitarian and media sectors. Though drawn
from conference outcomes, for the most part this report does not reproduce the
remarks of participants or personally attribute comments or opinions.
The purpose of the conference was to look beyond the short-term, domestically
focused management aspects of the threat and draw out its wider international
implications – political, strategic, economic and humanitarian. It began with an
examination of the epidemiology of the virus and the nature of the risks it poses, and
also looked at how response planning is being coordinated between national
Epidemiology and Risk Factors
Avian influenza is an ancient virus that has lived in the gastrointestinal tracts of some
wild aquatic bird species for centuries, spreading around the world as they migrate
back and forth. These waterfowl have innate immunities which allow them to host
the virus unharmed, and which therefore disfavour the genetic mutations for which
the virus has a natural propensity. But when, through commingling, wild waterfowl
spread the virus to non-immune avian species, new variants can arise which may
become highly pathogenic and highly infectious, causing disease and death in large
Commercial poultry farming in East Asia – particularly China, Cambodia, Vietnam,
Thailand and Indonesia – has been seriously affected by recent outbreaks of the
H5N1 strain of avian influenza, which is the most genetically unstable of the different
classes of influenza and the most likely to be pathogenic in new host species. In
recent months Kazakhstan, Turkey, Romania, Russia, Croatia, Greece and Kuwait
have also detected birds infected with H5N1 within their borders. For the first time
wild birds could be carrying not just the common avian influenza viruses that led to
the emergence of H5N1 in Asia, but also the H5N1 strain itself.
The widespread nature of these outbreaks in both domesticated and wild bird
populations has generated a spike in global concerns that conditions are now ripe for
the H5N1 virus to jump the species barrier and become transmissible between
humans. Other variants of the virus originating in waterfowl have already spread
directly to non-avian species including pigs, horses, cats and various sea mammals,
and indirectly to humans via both poultry and pigs. The transmission within a new
species seems to occur when the avian virus mixes genetically with less pathogenic
influenza viruses common to the new host species.
The main threat from H5N1 in migrating waterfowl is to avian populations, but the risk
of a human-transmissable virus emerging outside East Asia also becomes higher.
No record exists of transmission directly from wild birds to humans, but three strains
have so far become adapted to human hosts, probably via other species. These
three strains equate with the human influenza pandemics of 1918-19, 1957 and
1968, which differ from typical annual human influenza epidemics in their deadliness.
Estimates are that the Spanish Flu of 1918-19 killed between 40 million and 100
million people, although the more recent pandemics killed many fewer. In contrast
with typical annual human influenza, the avian influenza pandemics tended to cause
death among the young and middle-aged with strong immune systems (not just in the
elderly and very young), and by primary viral pneumonia rather than secondary
Animal husbandry practices in parts of many East Asian countries – where several
species of animals, including humans, live in very close proximity with each other –
provide the conditions under which the influenza virus is most likely to jump the
species barrier. Most of the 133 instances of human infection by the H5N1 virus
have occurred in East Asia, and around half have resulted in death. To date there
has been no confirmed case of human-to-human transmission of the virus, and if
such a transmission has occurred it has not continued beyond a second human host.
If it had, the world could already be suffering a highly infectious, highly pathogenic
Judging the likelihood of an avian influenza outbreak in humans is an extremely
complex technical task because it requires input from a disparate range of academic
disciplines and government functions, as well as sustained international information
exchange. It is not possible to quantify accurately the likelihood of a pandemic
occurring – all we can do is take note of changes in the risk environment and try to
respond accordingly. But if one commonly-cited assessment is accurate – that an
avian influenza pandemic in humans is 10% likely to happen in the next couple of
years – we have a serious problem on our hands.
Based on past experience we know that the effects of a pandemic as widespread
and deadly as avian influenza will have far-reaching consequences in humanitarian,
economic and security terms. So the challenge for risk managers in government
and business is to judge correctly the amount of resources that should be spent on
preparing for a pandemic that is, by the common estimate, 90% unlikely
to happen in
any given year. Defining this “minimum readiness threshold” is in many ways the
underlying task for rich nations preparing for a pandemic event.
For the poorer nations of Asia – which are also the most likely locations from which a
human-transmissable strain could emerge – the equation is rather different. With
less state capacity, they are more constrained in the action they can take to prevent
a pandemic from occurring, or once a pandemic has occurred. The involvement of
the international community is essential if developing countries are to mitigate the
risks of a pandemic – both for their sakes and for ours. In contrast with the previous
instances of virulent influenza in humans, the frequency and speed with which
international journeys are undertaken nowadays makes containing a highly infectious
virus within the region of its outbreak virtually impossible.
International Implications of an Outbreak
Infectious disease is usually framed as a public health issue. Some might think that
by promoting infectious disease to the security agenda we make the mistake of
confusing its effects with those of international politics, but in practice those effects
can be remarkably similar. An event which kills tens of thousands of people,
frightens millions more into inactivity, slices billions of dollars from the economy and
seriously threatens provision of basic services could equally be the result of a nuclear
explosion, large-scale conventional warfare or a highly pathogenic infectious disease
pandemic. Of those three scenarios, an infectious disease pandemic is the most
A high rate of infection, disease and death can destroy the veneer of society very
quickly. When a government can no longer protect its citizens from harm the social
contract lapses, collective action breaks down and the potential for chaos multiplies.
Because weak states are particularly vulnerable, developing regions can destabilise
very quickly and even undermine global order. Acknowledging the security
implications of a pandemic is an important step to take because it can motivate
governments and other actors to mobilise anti-pandemic resources of an order higher
than would otherwise be available. While care must be taken that raising the profile
of the risk does not lead to counter-productive public hysteria, it is also true that a
common threat – understood widely and well in advance – can unite us.
The SARS experience of 2003 had serious social and economic consequences well
beyond the deaths it caused, even though governments acted rapidly, cooperated
effectively and managed to limit the spread of disease. They were aided in this by
the nature of the SARS infection itself, which becomes symptomatic before it is
infectious and is therefore much easier to isolate along with its human hosts.
Influenza, by contrast, does not become evident in its host until a couple of days after
the person becomes infectious, making effective quarantine extremely difficult. That
characteristic alone amplifies the importance of preventing an initial infection from
Pandemics of H5N1 influenza in domestic fowl have caused huge economic losses
to the chicken farming and egg production industries. Nearly 200 million birds have
been killed by the virus or culled to halt its propagation. In rich countries the effects
do not spread noticeably beyond those industries, but in poorer countries they can be
devastating. In East Asia, many millions of chickens have been destroyed over the
last couple of years – at the cost of tens of billions of dollars – in an effort to control
H5N1 outbreaks, with significant negative impacts on food security and growth.
Beside the economic impacts that would be caused by a human pandemic, however,
the damage to chicken farming industries is merely trifling. To begin with, tens of
thousands of people would likely die from the disease in Australia alone. Many more
would become sick and unable to work for a period, and would, in turn, remove
healthy people from the workforce to care for them. Most people would be unwilling
to interact more than was absolutely necessary in the hope of avoiding the infection.
Businesses based on public gathering or personal services (for example in transport,
retailing, hospitality and tourism) would grind to a halt. A crucial question would be
whether basic services such as utilities maintenance and distribution of food could be
Substantial secondary effects would flow from damage to economic confidence.
Markets could fail and much domestic and international trade could break down.
Financial markets would factor in higher risk assessments very quickly, further
damaging investor confidence. Direct costs to government would be substantial,
including the provision of vaccines to key workers, running quarantine operations,
monitoring the spread of disease and bearing associated medical costs. But it is
also true that while some sectors would suffer gravely, others could benefit in time
Significant difficulties arise in trying to quantify the economic effects of a pandemic,
because of the large number of variables and the wide spread of their likely values.
The best approach begins with a series of possible infection scenarios, each of which
yields a range of cost estimates. But despite the difficulties in generating accurate
numbers, modeling the economic effects of a pandemic is still important for planning
policy responses and intervention strategies. A series of models can give rise to a
series of flexible responses quickly adaptable to the detailed characteristics of a
The effects of pandemic avian influenza in humans would be much greater in
developing countries, where the probability of death from communicable diseases is
much higher. Poorer states have less capacity to plan for and respond to disease
pandemics and also exhibit demographic, social and commercial traits less resistant
to the spread of infectious disease. These include areas of high population density,
rapid population growth, close-quarters animal husbandry and a propensity for public
disruption and in some cases civil war. The timing of an outbreak would regulate its
effects because consumption is still directly linked to seasonal production cycles.
Perhaps the most serious general impact of a pandemic in developing countries
would be the number of people driven into poverty. In cases where one bread-
winner supports a great many family members, a single death can be catastrophic.
Negative economic impacts would take hold very quickly, curtailing the provision of
social services and leading to rapid de-urbanisation. Whereas internal migrants
might normally expect to earn their keep in the informal economy, there would be few
opportunities to do so in a pandemic situation. Rural areas would then be playing
host to critical masses of internally displaced people, which in turn could help spread
the infection and severely reduce basic medical, sanitation, and sustenance
It would be extremely difficult for the international humanitarian community to
operate in regions caught in the grip of a pandemic because of the lack of personal
security for their staff and because access to many areas would be curtailed by
quarantine restrictions. Capacity would also be reduced because of the many
competing calls on national and international resources. Rich governments that
could otherwise be relied upon to provide support in times of emergency would be
busy responding to the pandemic in their own backyards.
International Coordination and Response Planning
The central lesson from SARS and previous pandemics of virulent influenza is that
transnational threats require transnational responses. In the face of avian influenza,
countries will stand or fall together because once a pandemic takes hold in one
country it is virtually certain to spread across the world. In the case of avian
influenza, prevention is vastly better than the cure. It is in every country’s interest to
do whatever it can to prevent an outbreak in humans wherever it might occur.
For the global community, the best chance of preventing an outbreak – or dealing
successfully with one that does occur – will come with effective international
coordination. Rich and poor countries alike must pool their resources and share
information, recognising that in our globalised world political borders cannot prevent
the spread of highly infectious disease. The imperative for rich countries in
particular is to concentrate more on assisting developing countries to reduce the
likelihood of an outbreak. More broadly, rich countries should continue to pursue the
development agenda as the conditions of poverty make a human-transmissable
strain of the virus more likely to appear.
Science is advanced enough to deal effectively with a pandemic if its resources can
be adequately marshalled. Vaccine development infrastructure is already in place
for tackling annual human influenzas, and given time should be able to mitigate the
effects of an avian strain. In the meantime the judicious international deployment of
antiviral drugs such as Tamiflu and Relenza – widely stock-piled by developed
countries in particular – could prevent a breakout epidemic of avian influenza
becoming pandemic. The success of that tactic will depend on how rapidly the
antivirals can be made available where needed, but also presupposes that the virus
has not developed a resistance to the drugs, which could happen if they are
deployed unnecessarily or in a piece-meal fashion. Ultimately, it is political and
economic factors that will determine the nature of our response.
Fortunately, the recent spike in global concern has already improved networks of
international exchange. In the last month there has been a series of multinational
meetings at senior bureaucratic and ministerial level. The World Health
Organization – the lead international agency in fighting avian influenza – held a major
planning conference at its Geneva headquarters in November in conjunction with the
Food and Agriculture Organization, the World Organisation for Animal Health and the
World Bank. Some of the larger international humanitarian non-government
organisations have also turned their attention to the problem, although there is still a
considerable lack of engagement in the NGO sector generally.
An element common to the outcome of many of these meetings is the recognition
that more should be done to tackle the virus at source, in avian and other animal
populations, rather than exclusively planning for its emergence. China, which is
suffering repeated outbreaks of the virus in domestic fowl, announced recently that it
was in the process of vaccinating all 14 billion of its chickens. If equally drastic and
costly measures are to be avoided elsewhere, a considerable and rapid investment is
needed from the international community. The WHO has called for US$35 million
over the next six months alone to fund its strategic recommendations, and many
governments – including Australia’s – have made unilateral pledges of support to
The WHO and its partner organisations will direct resources to controlling the source
of the virus in birds, improving systems of surveillance for animal and human
influenza, building laboratory capacity, developing rapid containment plans, helping
countries to develop integrated national plans, and encouraging them to share
information freely. They have moved to create a stockpile of antiviral drugs, pledged
by national governments and drug manufacturers, which can be rapidly deployed to
the location of an outbreak. In January 2006, financial donors will meet in Beijing to
discuss the deployment of anti-pandemic resources in more detail.
Australian Council for International Dev.
Australian Agency for International Dev.
January 1999 Pharmacokinetic Considerations in Obesity Contribution from Division of Pharmaceutical Sciences, College of Pharmacy and Graduate Center for Toxicology, University ofKentucky, Lexington, Kentucky 40536-0082. Final revised manuscript received October 26, 1998. Accepted for publication October 28, 1998. Introduction There have been several references reviewing the causesan
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