U.S. and International Responses to the Global Spread of Avian Flu: Issues for Congress

Prepared for Members and Committees of Congress

Influenza A/H5N1 is one of many influenza (flu) strains currently spreading throughout the
world. Although it is a bird flu, it has infected some people and killed more than half of those
infected. Since 1997, when the first human contracted H5N1 in Hong Kong, the virus has
resurfaced and spread to more than 50 countries across Asia, Europe, the Middle East, and
Africa—infecting more than 260 people and killing more than 150 of those infected. 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 in more than 20 countries across Europe, Asia, and
Africa. The first human H5N1 fatalities outside of Asia occurred in that year, with Turkey and
Iraq reporting H5N1-related human deaths for the first time in January and February, followed by
Azerbaijan and Egypt in March.
Congress has provided funds for U.S. international avian flu efforts through three appropriations.
P.L. 109-13, FY2005 Emergency Supplemental Appropriations, provided $25 million to combat
the spread of avian influenza. 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, providing a total of $31.3 million for U.S. global avian flu activities from those
appropriations. P.L. 109-148, FY2006 Defense Department appropriations, included $3.8 billion
to address pandemic influenza. P.L. 109-234, FY2006 Emergency Supplemental Appropriations,
provided $2.3 billion for avian and pandemic flu efforts, of which $30 million was appropriated
to USAID for international avian flu efforts and $200 million was appropriated to the Centers for
Disease Control and Prevention (CDC) for global and domestic disease surveillance, laboratory
capacity, research, and other activities. Relevant FY2007 U.S. department and agency budget
justifications included some $205 million for global H5N1 initiatives. As in previous fiscal years,
U.S. agencies and departments might commit additional resources to global avian flu efforts that
were not specifically appropriated for those purposes.
This report provides an up-to-date account of global H5N1-related human infections and deaths,
outlines U.S. global avian flu programs, and presents some foreign policy issues for Congress.
This report will be updated should Congress provides additional funds for global purposes, and
then only if H5N1 becomes effectively transmissible from person-to-person. For information on
U.S. domestic preparedness efforts, agricultural issues, and anti-avian flu efforts of overseas
governments, see CRS Report RL33145, Pandemic Influenza: Domestic Preparedness Efforts, by
Sarah A. Lister; CRS Report RL33795, Avian Influenza in Poultry and Wild Birds, by Jim Monke
and M. Lynne Corn; and CRS Report RL33871, Foreign Countries’ Response to the Avian
Influenza (H5N1) Virus: Current Status, coordinated by Emma Chanlett-Avery.

Backgr ound ..................................................................................................................................... 1
Sources of Transmission...........................................................................................................2
Congressional Response..................................................................................................................3
U.S. Executive Branch Response....................................................................................................4
Department of State (DOS).......................................................................................................5
U.S. Agency for International Development (USAID).............................................................6
U.S. Department of Health and Human Services (HHS)..........................................................7
Department of Agriculture (USDA)..........................................................................................8
Department of Defense (DOD).................................................................................................9
Other U.S. Agencies and Departments....................................................................................10
Department of Homeland Security (DHS)........................................................................10
Department of Transportation...........................................................................................10
Department of the Treasury..............................................................................................10
Department of Commerce (DOC)......................................................................................11
International Response...................................................................................................................11
Allocations of Pledges to Global Avian Flu Activities............................................................12
The World Bank......................................................................................................................13
World Organization for Animal Health (OIE).........................................................................14
United Nations Response........................................................................................................14
Food and Agriculture Organization (FAO).......................................................................15
World Health Organization (WHO)..................................................................................16
Issues for Congress........................................................................................................................18
Providing Additional Funds for Global Avian Influenza Efforts.............................................18
Expanding Access to Drugs and Vaccines...............................................................................18
Improving Health Systems and Disease Surveillance.............................................................19
Combating Bird Flu Among Animals in Affected Countries..................................................19
Planning for Global Economic Impacts..................................................................................20
Appropriations Bills..........................................................................................................23
Other Bills.........................................................................................................................23
Figure A-1. Map of Human and Animal H5N1 Cases...................................................................21
Table 1. Human Cases of Avian Influenza A/H5N1........................................................................2
Table 2. Donor Commitments for Global H5N1 Activities...........................................................12
Table 3. Additional Assistance Needs............................................................................................13
Table A-1. WHO Pandemic Phases...............................................................................................21
Table A-2. U.S. Pledges for Global Avian and Pandemic Influenza.............................................22

Appendix. H5N1 Cases, WHO Pandemic Phases, U.S. Pledges, and Legislative History...........21
Author Contact Information..........................................................................................................24

Influenza A/H5N1 is one of many strains of avian influenza that can cause illness in poultry. Bird 1
(or avian) flu outbreaks have occurred at various times around the world. 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, when the virus resurfaced
and killed 4 people, scientists have closely monitored resurgent H5N1 outbreaks. When analyzing
the viral spread and severity of H5N1, some health experts prefer to consider the average H5N1
human fatality rate since the virus emerged in 2003 (more than 50%). The World Health 2
Organization (WHO), however, considers the annual change of human fatality rates. The overall
human fatality rate was highest in 2004 (73%), followed by 63% to date in 2006, and 43% in

2005 (Table 1).

There has been some debate about whether H5N1 will cause a global pandemic. WHO ranks the
current global H5N1 outbreak in pandemic alert phase three, which means a virus new to humans
is causing infections, but not spreading easily from one person to another (Table A-1). Some
predict that if H5N1 were to become transmissible among humans, the virus could cause an 3
“influenza pandemic” (worldwide disease outbreak). 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. WHO warns that the virus is
continuing to spread and that the threat has not been eliminated. Thus, in the latter view,
governments should continue to prepare for some sort of pandemic and not become complacent
even though H5N1 has not yet become transmissible between people.
At last count, H5N1 has infected birds in more than 50 countries4 and infected 261 people, of 5
whom 157 have died. More than 200 million birds in Europe, the Middle East and Africa have 6
either died from H5N1 or have been culled in containment exercises. From December 2003 to
August 2004, nine Asian countries reported H5N1 outbreaks in poultry. In late July 2005, Russia
identified H5N1 in its poultry for the first time. By October 2005, birds in Croatia, Kazakhstan,
Mongolia, Romania, and Turkey had contracted H5N1. In 2006, human H5N1 cases were being

1 For a list of past avian flu outbreaks, see CRS Report RL33795, Avian Influenza in Poultry and Wild Birds, by Jim
Monke and M. Lynne Corn.
2 WHO,Avian influenza—epidemiology of human H5N1 cases reported to WHO. June 30, 2006. http://www.who.int/
3 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
Spanish flu, estimates of human deaths have ranged between 30 million and 384 million people.
4 The World Organization for Animal Health (OIE) has confirmed H5N1 among birds in the following countries and
territories: Afghanistan, Albania, Austria, Azerbaijan, Bosnia and Herzegovina, Britain, Bulgaria, Burkina Faso,
Burma, Cambodia, Cameroon, China, Côte d’Ivoire, Croatia, Czech Republic, Denmark, Djibouti, 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, Spain, Sudan, Sweden, Switzerland, Thailand, Turkey, Ukraine, and Vietnam.
5 WHO, Cumulative Number of Confirmed Human Cases of Avian Influenza A/H5N1, December 27, 2006.
6 WHO, Address by the Director-General to the 59th World Health Assembly, May 22, 2006. http://www.who.int/gb/

reported outside of Asia for the first time. While Iraq has reported human H5N1 cases, the strain
has not been detected among its birds.
Table 1. Human Cases of Avian Influenza A/H5N1
COUNTRY 2003 2004 2005 2006 TOTAL
Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths
Azerbaijan 0 0 0 0 0 0 8 5 8 5
Cambodia 0 0 0 0 4 4 2 2 6 6
China 1 1 0 0 8 5 12 8 21 14
Djibouti 0 0 0 0 0 0 1 0 1 0
Egypt 0 0 0 0 0 0 15 7 18 10
Indonesia 0 0 0 0 19 12 55 45 74 57
Iraq 0 0 0 0 0 0 3 2 3 2
Thailand 0 0 17 12 5 2 3 3 25 17
Turkey 0 0 0 0 0 0 12 4 12 4
Vietnam 3 3 29 20 61 19 0 0 93 42
Total 4 4 46 32 97 42 111 76 261 157
Source: WHO, Cumulative Number of Confirmed Human Cases of Avian Influenza A/H5N1.
There is some debate over the primary source of H5N1 transmission. Some experts contend that
wild migratory birds infected with H5N1, notably water fowl, are the main vectors, or media of
transmission. H5N1 has been detected in migratory birds in multiple countries, and in some
instances, its spread has correlated with seasonal migrations of certain wild species. In some
countries, H5N1 has only been found in wild birds. Some veterinarians point out that detecting
H5N1 in wild birds can be difficult, because some of the infected birds are asymptomatic, 7
harboring but not exhibiting disease symptoms or ill effects from the virus.
Other experts, however, maintain that other important modes of transmission should not be
underestimated, such as cross-border trade of infected poultry and transmission through poor
agricultural practices. Indications that may support such assertions include the detection of H5N1
on commercial farms among caged poultry that are unable to mingle with wild fowl; the detection
of H5N1 on farms located far from wetlands where migratory birds seasonally dwell; and the
detection of H5N1 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 8
implicated in the transmission of H5N1.

7 See FAO, Wild birds and Avian Influenza, Sept. 2005, among other sources.
8 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 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

Some epidemiologists contend that the limited human-to-human transmission of H5N1 and other
avian influenza viruses that have occurred should also be closely monitored. WHO asserts that
the limited cases should not cause alarm, because the virus had not spread beyond a first
generation of close contacts or caused illness in the general community. WHO adds that it has not
elevated the pandemic risk of H5N1, because data from the incidents suggest that transmission
requires very close contact with an ill person.

P.L. 109-13, FY2005 Emergency Supplemental Appropriations, provided the first appropriation
for global avian flu efforts, though agencies and departments had already launched initiatives to
combat the virus. The act provided the U.S. Agency for International Development (USAID) $25
million for ongoing efforts to prevent and contain the global spread of H5N1. USAID transferred
$15 million of the funds to the Centers for Disease Control and Prevention (CDC). The
Department of State (DOS) transferred an additional $6.3 million of tsunami relief funds to 9
USAID for international avian influenza activities, as permitted by the law. Including the latter
transfer, FY2005 emergency supplemental appropriations provided $31.3 million for global avian
flu efforts.
In FY2006, the President submitted a $7.1 billion emergency supplemental request for avian and 10
pandemic influenza preparedness. Congress provided $6.1 billion for those efforts in two
supplemental appropriations; appropriating $3.8 billion in P.L. 109-148, FY2006 Defense 11
Appropriations and $2.3 billion in P.L. 109-234, FY2006 Emergency Supplemental
Appropriations. U.S. agencies and departments might contribute additional resources to global
avian flu efforts not specifically provided through these appropriations. Some activities that could
support the control of avian flu include infectious diseases and influenza programs, global
surveillance efforts, and influenza research initiatives.
In FY2007, some appropriations bills included additional funds for global avian and pandemic
influenza preparedness. Congress did not enact any of those measures. Instead, it amended P.L.

109-289 (Division B), which provides funding at the lessor of FY2006 enacted, FY2007 House-

passed, or FY2007 Senate-passed levels until February 15, 2007.

outbreak in Nigeria stirs fresh row over migrant birds, Feb. 8, 2006.
9 FY2007 State Department Function 150 Budget Request, see http://www.state.gov/s/d/rm/rls/iab/2007/. 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.
10 The Administration requested $3.2 billion for obligation in FY2006, $2.3 billion in FY2007, and $1.2 billion for
11 H.Rept. 109-359, the conference report to P.L. 109-148, FY2006 Defense Appropriations, 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 committed to 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.

On November 1, 2005, the President released the National Strategy for Pandemic Influenza.12 The
National Strategy was to provide a framework for future U.S. planning efforts that were
consistent with The National Security Strategy and the National Strategy for Homeland Security.
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.
One day later, on November 2, 2005, the Department of Health and Human Services (HHS)
released its Influenza Plan. The HHS plan provided a detailed explanation of how the department
would implement its part of the National Strategy. Some were disappointed by the relatively small
proportion of funds reserved for international efforts in the National Strategy and in HHS’ Plan.
Advocates of greater spending on global avian flu efforts argued that if more resources were
allocated to containing the virus abroad, Americans would be better protected, domestic pandemic
preparedness efforts would be enhanced, and the likelihood that H5N1 would continue to spread
and become efficiently transmissible between people would be lessened.
Of the $7.1 billion related to international activities, the President requested:
• $200.0 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 (USDA) to undertake
research and development initiatives and to provide avian influenza surveillance
and prevention technical assistance globally;
• $120.0 million for the Department of Defense (DOD) to increase worldwide
surveillance and upgrade related equipment;
• $10.0 million for DOD to assist military partner nations in procuring protective
equipment, portable field assay testing equipment, and related laboratory
• $17.0 million for DOS to implement public diplomacy, training, and international
outreach activities related to avian influenza and pandemic preparedness;
• $1.5 million for DOS International Visitors Program to provide 100 additional
professional exchanges of doctors, health practitioners, and non-governmental
organizations (NGOs);
• $75.2 million to USAID for efforts that encourage behavior change and raise
awareness about avian flu awareness, diagnostic support initiatives, and
pandemic preparedness and planning activities; and

12 Find the National Strategy at https://www.whitehouse.gov/homeland/nspi.pdf. For more on U.S. avian flu and
pandemic preparedness see http://www.pandemicflu.gov.

• $56.3 million for International Disaster and Famine Assistance Funds of USAID
to pre-position supplies and equipment, such as antiviral medication and 13
protective equipment.
In May 2006, the White House released the Implementation Plan for the National Strategy for 14
Pandemic Influenza, which was released in November 2005. The Plan outlined how various
U.S. agencies and departments would integrate the implementation of more than 300 actions that
respond to an influenza pandemic threat. According to a status report on the Plan, released in
December 2006, 92% of those actions have been completed and the United States has invested 15
$434 million in international efforts (Table A-2). The section below summarizes the role of each
agency and department involved in international efforts, as outlined in the Plan, and highlights
appropriations Congress provided to each.
DOS is responsible for coordinating the U.S. international response to H5N1, including the
interagency process to identify countries requiring U.S. assistance, identify priority activities, and
ensure federal government assistance reflects those priorities. The department also informs
American citizens abroad about where they can obtain up-to-date information and pandemic risk
level assessments, enabling them to make informed decisions and take appropriate personal
protective measures. Through its Office of International Health Affairs (OES/IHA), DOS
facilitates policy-making regarding bioterrorism and health security, environmental health,
infectious diseases (e.g., avian and pandemic influenza, SARS, and polio), health in post-conflict
situations, and surveillance and response.
On September 14, 2005, President Bush announced at the United Nations (U.N.) that the United
States would develop an International Partnership on Avian and Pandemic Influenza (IPAPI).
IPAPI utilizes diplomatic initiatives to enhance public health, improve surveillance capacity,
promote transparency, and encourage reporting and rapid sharing of samples. IPAPI 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 16
and the threat of an influenza pandemic. Key activities of IPAPI include
• extending the issue of avian and pandemic influenza preparedness beyond the
health sectors 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.

13 FY2006 Emergency Request for Avian and Pandemic Influenza Preparedness. http://www.whitehouse.gov/omb/
14 https://www.whitehouse.gov/homeland/nspi_implementation.pdf
15 http://www.whitehouse.gov/news/releases/2006/12/20061218.html
16 http://www.state.gov/g/oes/c1874.htm

In the FY2006 supplemental request, the President proposed that DOS receive $38.5 million in
FY2006 for international response coordination; diplomatic outreach; exchanges of U.S. and
foreign medical personnel; and protecting U.S. government employees and families at U.S.
missions overseas from avian and pandemic influenza. The Administration proposed that about
$20 million of those funds be reserved for the potential evacuation of U.S. government personnel
and dependents from overseas missions. Though Congress did not appropriate funds to DOS for
avian flu efforts, OMB reports that in FY2006, DOS had spent some $6 million on diplomatic 17
support and international response coordination (Table A-2). The Administration did not request
funds in FY2007 for DOS’ international avian flu activities, and neither chamber proposed
appropriating funds for these efforts.
USAID works with more than 88 foreign governments, international organizations, and other
U.S. government partners to enhance global avian and other influenza pandemic preparedness.
The agency plays a critical role in connecting the response between the human and animal health
sectors to ensure that the efforts are comprehensive and cross-sectoral. With technical guidance
from HHS and USDA, USAID works closely with WHO and FAO to ensure strong coordination
and standardization of efforts to prepare for, identify, and respond to outbreaks of influenza with
pandemic potential in either animal or human populations. In its work with non-governmental
organizations (NGOs) and the private sector, USAID improves outbreak detection capacities and
supports behavior change efforts, including mass communications initiatives. USAID’s key
activities include the following:
• Planning and preparedness initiatives to support the development of national
avian influenza task forces and preparedness plans.
• Surveillance and case detection activities to support animal and human disease-
monitoring efforts.
• Communications projects to support mass media and community-level outreach
to rural populations, which raises public awareness and promotes behaviors that
help reduce risks for disease transmission.
• Commodity stockpiling programs involving training first responders to use
personal protective equipment (PPE), collecting and shipping viral samples,
detecting diseases using improved laboratory equipment, and responding to
infectious disease outbreaks. Since January 2006, USAID has amassed 1.5
million PPE kits, 100 laboratory kits, and 15,000 decontamination kits. Over
200,000 PPE kits have been deployed to 71 countries for use by responders in the
field, including surveillance workers and outbreak response teams. In
anticipation of new avian influenza outbreaks, USAID is pre-positioning PPE 18
kits, decontamination kits, and laboratory kits in 20 countries.
• Emergency outbreak response programs to promote safe culling and disposal
procedures, and demonstrate improved biosecurity practices in poultry-raising

17 OMB reports that DOS committed an additional $25 million to support health activities at embassies and make
evacuation contingency plans at overseas missions. Funding for these activities is not included in Table A-2, because it
is not considered a part of foreign assistance.
18 http://www.usaid.gov/our_work/global_health/home/News/news_items/ai_activities.html

settings. The initiatives also help countries to develop standard procedures for
health facilities at the central and peripheral levels.
P.L. 109-72, FY2005 Emergency Supplemental Appropriations, provided $16.3 million to USAID
for global avian flu efforts, though OMB reports that it spent $21.4 million on the programs in
that fiscal year (Table A-2). Supplemental appropriations attached to P.L. 109-148, FY2006 DOD
Appropriations, provided $131.5 million to USAID for global avian flu efforts. Congress
provided an additional $30 million for the programs in P.L. 109-234, FY2006 Emergency
Supplemental Appropriations. OMB estimates that in FY2005 and FY2006, USAID has
committed $191 million to bilateral avian and pandemic influenza efforts. The Administration
requested $55 million for USAID’s avian and pandemic influenza preparedness efforts in
FY2007. The Senate Foreign Operations subcommittee reported out $25 million for USAID’s
global avian flu efforts, $30 million below requested levels. The House did not include a specific
amount for such efforts.
HHS and its related agencies and institutes lead U.S. influenza surveillance and detection efforts
abroad, which include U.S. participation in collaborative international human influenza research.
In conjunction with WHO and other technical partners, including other U.S. departments and
agencies, HHS also implements a number of other activities related to global avian and pandemic
influenza preparedness, including
• supporting rapid containment of localized outbreaks of novel human influenza
• training foreign health professionals to recognize and treat influenza;
• training and guiding national and local public health authorities in foreign nations
to use, time, and sequence community infection control measures;
• working with USAID to develop local-language campaigns overseas to
communicate information related to pandemic influenza;
• supporting U.S. participation in international efforts to stockpile countermeasures
against possible influenza pandemics;
• supporting the advancement of cell-based influenza vaccines;
• evaluating new H5N1 vaccine candidates;
• developing global capacity to produce large quantities of pre-pandemic vaccine;19
• working with USDA and the Department of the Interior (DOI) to sequence
influenza viruses from wild birds, live bird markets, and pigs in Asia and North
Within HHS, the National Institutes of Health (NIH) fund international research grants related to
avian and pandemic influenza. Research activities include assisting countries to develop and test
vaccines and other drugs; expanding the clinical trials infrastructure and research in southeast

19 Pre-pandemic vaccines are developed with the strain of H5N1 that is currently circulating among poultry.

Asia; and conducting human-animal interface studies, including disease surveillance among 20
animals in the region. CDC officials provide technical assistance in improving governments’
capacity to detect infectious disease outbreaks, preparing and planning for a possible influenza
pandemic, strengthening epidemiology and avian influenza surveillance, enhancing laboratory
safety, developing and training rapid response teams, and supporting stockpiling efforts.
In FY2005 and FY2006, three appropriations specified funding for international avian and
pandemic preparedness at HHS. P.L. 109-72, FY2005 Emergency Supplemental Appropriations,
provided CDC $15 million for international avian flu initiatives. Supplemental appropriations
attached to P.L. 109-148, FY2006 Department of Defense Appropriations, provided $150 million
to CDC for global and domestic disease surveillance, laboratory diagnostics, and rapid response.
P.L. 109-234, FY2006 Emergency Supplemental Appropriations, provided $200 million to CDC
for the same activities indicated in P.L. 109-148. OMB estimates that HHS has allocated $208
million towards international avian and pandemic preparedness efforts in FY2005 and FY2006
(Table A-2).
The Administration requested $145 million for HHS global pandemic influenza and preparedness
initiatives in FY2007. S. 3708, FY2007 Labor, HHS, and Education Appropriations, proposed the
allocation of $40 million for international and domestic surveillance, diagnosis, and epidemic
investigations. The bill also proposes the provision of additional funds for pandemic preparedness
and avian flu, though not specifically for global avian flu efforts. For example, the Committee
suggested that $130 million be appropriated to expand laboratory capacity, research and support
for detecting and characterizing influenza and other pathogens. The House did not suggest a
specific amount for global avian flu efforts, though some funds were reported out for domestic 21
avian flu and pandemic preparedness.
USDA is responsible for collaborating with international organizations, such as the Food and
Agriculture Organization (FAO) and the Organization for Animal Health (OIE) on a range of
activities, including animal health research, risk analyses, and transboundary movement of
animals and animal products. In an effort to strengthen accurate diagnosis of H5N1 among
animals, USDA has developed and applied a real-time diagnostic protocol to analyze influenza in
animal specimens and is assisting countries to adopt and apply this protocol in support of
surveillance and response programs for avian influenza among animals. Other related activities
• encouraging host countries’ compliance with international standards on matters
concerning animal health;
• conducting agricultural research and technical and policy outreach with public
and private stakeholders;
• analyzing short- and long-term economic impacts of influenza outbreaks among
animals, as well as the impact of a potential pandemic on the agricultural sector;

20 HHS FY2007 budget request. http://www.hhs.gov/budget/07budget/2007BudgetInBrief.pdf.
21 For more on the domestic response, see CRS Report RL33145, Pandemic Influenza: Domestic Preparedness Efforts,
by Sarah A. Lister.

• pursuing prevention and control strategies to support international agricultural
systems and commerce.
P.L. 109-148, FY2006 Emergency Supplemental Appropriations, provided $91.3 million to
USDA for avian flu and pandemic preparedness initiatives, of which $19.5 million was
committed to global efforts. OMB estimates that the agency has committed $19.5 million to
global programs, though the agency reports that it has allocated a total of $21 million for 22
international avian flu efforts. The Administration’s FY2007 budget request included $5 million
for USDA’s global avian flu activities. H.R. 5384, FY2007 Agriculture Appropriations, as
reported out of committee, included $4.5 million for U.S. Department of Agriculture’s
international avian flu efforts. The Senate did not include a specific amount for such efforts.
In June 1996, President Clinton issued Presidential Decision Directive NSTC-7, which
established a national policy to address the threat of emerging infectious diseases through 23
improved domestic and international surveillance, prevention, and response measures. The
Department of Defense Global Emerging Infections Surveillance and Response System (DOD-
GEIS), which was developed in response to that directive, facilitates early recognition and control 24
of diseases that threaten national security. The directive expanded DOD’s mission to include
support of global surveillance, training, research, and response to emerging infectious disease
threats. DOD-GEIS are designed to strengthen the prevention of, surveillance of, and response to
infectious diseases that are a threat to military personnel and families, reduce medical readiness,
or present a risk to U.S. national security. The key objectives of DOD-GEIS is to increase DOD’s
emphasis on the prevention of infectious diseases, strengthen and coordinate DOD’s surveillance
and response efforts, and create a centralized coordination and communication hub to help
organize DOD resources and link them with U.S. and international efforts.
The DOD-GEIS network partners with Navy and Army laboratories, and with WHO’s Global
Outbreak Alert and Response Network (GOARN) (described in “International Response” section)
to collect avian influenza isolates from people around the world and share them with CDC and 25
world public health officials for molecular analysis and formulation of influenza vaccines. Key
activities specifically related to avian and pandemic influenza include
• sharing weekly infectious disease surveillance reports;
• developing pandemic influenza emergency response plans for various DOD
• monitoring incidences of influenza among military populations;

22 USDA reports that DOS transferred an additional $1.5 million to the agency for global avian flu efforts, from P.L.
109-13, FY2005 Emergency Supplemental Appropriations. http://www.usda.gov/documents/
23 http://fas.org/irp/offdocs/pdd/index.html
24 GEIS website, http://www.geis.fhp.osd.mil/.
25 DOD-GEIS FY2005 Annual Report.

• training healthcare workers in rapid detection and management of influenza
• implementing cooperative influenza surveillance activities in Asia, the Middle
East, and the Central Asian Republics; and
• evaluating emergency response plans of foreign governments, federal agencies, 26
and international organizations.
Emergency supplemental funds attached to P.L. 109-148, FY2006 Department of Defense
Appropriations, provided $130 million for avian flu activities, of which $120 million were
committed to the Defense Health Program and $10 million to Operation and Maintenance. OMB
estimates that in FY2005 and FY2006, a total of $10 million of DOD avian influenza funds were
committed to global activities (Table A-2). Neither the FY2007 budget request nor P.L. 109-289,
FY2007 Defense Appropriations, included funds for global avian and pandemic preparedness
A number of other U.S. agencies and departments participate in global avian and pandemic
influenza preparedness efforts, including the following:
DHS supports DOS in its coordination of U.S. global avian flu efforts. It also works with the
Department of Transportation (DOT) to encourage international transportation associations and
groups to participate in avian and influenza pandemic preparedness efforts. In the event of a
pandemic, DHS is collaborating with DOS, DOT, and HHS, to encourage foreign entities to share
information on travelers exposed to pandemic influenza, and to screen and limit their entry into
the United States.
In addition to its collaborative efforts with DHS on transportation and border security, DOT
conducts outreach with its public and private stakeholders, provides emergency management and
guidance for civil transportation resources and systems, and leads U.S. international
transportation planning and emergency activities.
The Department of the Treasury assists in analyzing potential economic impacts of an influenza
pandemic, and in monitoring and preparing policy responses to possible pandemic-related
international economic developments. The department also encourages multilateral development
banks and international financial institutions to assist countries impacted by avian influenza.

26 Ibid.

DOC facilitates the expedited interagency review for any export licenses needed for the global
shipment of items related to avian influenza, including test kits and equipment, and technology
that allows rapid identification of strains.

In November 2005, more than 600 delegates from over 100 countries convened in Geneva,
Switzerland, to develop a global action plan to control avian influenza in animals and to limit the
threat of a human influenza pandemic. Participants agreed that capital and other resources were
needed to support countries which had already been affected by avian influenza, to assist
countries bordering those with H5N1 cases, and to boost global capacity to identify and respond
to a human pandemic if one were to occur. At the conference, experts and officials discussed key
financing needs for countries attempting to develop a comprehensive response to H5N1.
The World Bank estimated that countries would need some $1 billion over the next three years to
meet their needs, though the estimate did not include the additional costs of developing human or
animal vaccines, purchasing antiviral medicines, or compensating farmers who lose income when
animals are culled. In January 2006, the World Bank, the European Commission, and the Chinese
government co-sponsored a donor’s conference in Beijing, China, to garner support for global
avian and pandemic influenza action plans. Representatives from approximately 100 countries
and 20 international organizations attended and ultimately pledged about $1.9 billion for avian flu 27
assistance. The top five donors included: the World Bank ($500 million), the United States
($334 million), Japan ($159 million), the EU Member States ($138 million), and the European 28
Commission ($121 million).
In June 2006, members of the international community reconvened in Vienna, Austria, to confirm
the financial resources already pledged at the Beijing conference and to reconsider the financial
needs of those nations contending with H5N1. Since the last conference was held in Beijing, the
virus had spread to Europe and Africa, increasing the amount of funds and other resources that 29
would be needed to contain the virus. At the conference, the newly established ALive Platform 30
estimated that African countries facing H5N1 cases needed an additional $700 million. Health
experts also expressed concern about the continued spread of the animal virus in southeast Asia,
particularly in Indonesia. The United States announced at the conference that it would increase its
pledge by about $28 million.

27 Pledges include the amounts that donors anticipate providing directly to countries through bilateral assistance,
contributions to international organizations, and loans provided by international lending institutions. The pledges that
the United States makes at these conferences include funds previously outlined in this report.
28 World Bank, “Avian and Human Influenza: Update on Financing Needs and Framework. November 30, 2006.
29 The ALive Platform, a multi-partner program initiated by the World Bank, focuses on livestock in Africa and their
relationship to economies and public health. ALive coordinates and fills gaps in existing livestock programs,
strengthens veterinary services, and initiates programs focused on poverty reduction, economic growth, research, and
regional and international market access. For more information on the ALive Program, see http://www.oie.int/eng/
press/en_040720.htm and http://www.fao.org/docs/eims/upload//217651/hpai_strategy_africa_en.pdf.
30 OIE press release, “SOM meeting on Avian Influenza and Human Pandemic Preparedness concludes its work in
Vienna.” July 7, 2006. http://www.oie.int/eng/press/en_060607.htm

Between December 6 and December 8, 2006, the international community met in Bamako, Mali,
to assess progress made in controlling the spread of H5N1 avian flu since the previous
conferences held in Geneva, Beijing, and Vienna. At the conference, donors pledged an additional 31
$475 million to fighting H5N1. The United States again increased its pledge to reach a total of
$434 million (Table A-2). Details were not provided on how the additional funds would be
In preparation for the Bamako conference, the World Bank released a report which highlighted
how much the international community had pledged to global avian flu activities, and how those 32
pledges were committed as of October 31, 2006 (Table 2). By then, donors had committed $1.4 33
billion of the $1.9 billion pledged at the Beijing conference. Donors preferred to target their
assistance to country programs, reserving about 36% of committed funds for bilateral efforts.
Nearly half of all funds committed for bilateral programs were provided by multilateral banks in
the form of loans and credits (low-interest loans); bilateral funds provided by donor government 34
are usually given in the form of grants. Donors targeted about 17% of committed funds to
international organizations like WHO, FAO, OIE, and UNICEF; and 14% to regional
organizations, such as the Association of Southeast Asian Nations (ASEAN), Inter-African
Bureau for Animal Resources (IBAR), and South Asian Association for Regional Cooperation
Table 2. Donor Commitments for Global H5N1 Activities
($ in millions)
Donor Country Program AHI Facility International Organizations Regional Organizations Other Total % of Commitments
Bilateral $218 $17 $216 $155 $330 $936 67%
European $48 $58 $0 $38 $41 $185 13%
Multilateral $242 $0 $20 $0 $19 $281 20%
Total $508 $75 $236 $193 $390 $1,402 100%
% of 36% 5% 17% 14% 28% 100%
Source: World Bank, “Avian and Human Influenza: Update on Financing Needs and Framework.”

31 FAO press release,International donors up funding to fight H5N1 avian flu.” http://www.fao.org/newsroom/en/
32 The World Bank defines a commitment as a finalized agreement between the donor and recipient for the designated
purposes, and a firm decision that prevents the use of the allocated amount for other purposes.
33 World Bank, “Avian and Human Influenza: Update on Financing Needs and Framework. November 30, 2006.
34 Key multilateral banks include the World Bank, the African Development Bank (AfDB), the Asian Development
Bank (ADB), and Inter-American Development Bank (IDB).

Due to the continued spread of H5N1, the World Bank estimated that countries would need
between an additional $1.2 billion and $1.5 billion over the next few years. The Bank estimated
that Africa needed the largest amount of additional support because of the spread of H5N1 to the
region, and the relatively poor conditions of veterinary and public health services in most
countries throughout the area (Table 3). As of October 31, 2006, 18% of total commitments for
bilateral assistance were targeted at Africa, of which less than half were in the form of grants. A
loan from the World Bank to Nigeria comprised more than half of all commitments to Africa, 35
leaving $44.2 million for 8 additional countries contending with the H5N1 threat.
Table 3. Additional Assistance Needs
($ in millions)
Regions and Additional Commitments for % of Commitments for
Organizations Financing Need Country Programs Country Programs
Sub-Saharan Africa $466 $94.2 18.3%
East Asia and the $221—$404 $232.9 45.4%
Europe and Central $33—$52 $151.5 29.5%
Latin America & the $2—$3 $9.6 1.9%
Middle East and North $70—$113 $17.6 3.4%
South Asia $85—$113 $7.7 1.5%
U.N. Agenciesa $300 $0.0
OIEa $25 $0.0
Total $1,202—$1,476 $513.5b 100.0%
Source: World Bank, “Avian and Human Influenza: Update on Financing Needs and Framework.”
a. Reflects financial needs for 2007 only.
b. CRS recognizes the difference between the figure provided for committed funds targeted at country
programs in Column 2 of Table 3 and Column 1 of Table 2.
The World Bank is responsible for reviewing country preparedness plans, estimating the costs of
implementing those plans, and managing and tracking international pledges for the plans. In
addition, it is providing $500 million in low-interest loans to countries heavily affected by H5N1.
The funds will be used to supplement government resources, strengthen veterinary systems, and
assist in culling and animal vaccination programs. The World Bank funds global avian and
pandemic flu preparedness efforts through two mechanisms: the Global Program for Avian
Influenza (GPAI) and the Avian and Human Influenza Facility (AHIF). The Bank anticipates
providing some $500 million in loans, credits (low-interest loans), or grants to about 25 countries
through GPAI. GPAI funds are provided through the International Development Association

35 The World Bank has since increased funding to Nigeria to $65 million.

(IDA). Nearly half of the funds have already been committed ($244.2 million).36 AHIF grants are
intended to supplement loans, credits and other grant assistance provided from other sources.
AHIF funds are flexible and are not earmarked. International donors have contributed about $75
million to this fund to date.
OIE, FAO, and WHO are the three lead international organizations responsible for coordinating 37
the global response to H5N1. OIE promotes and coordinates surveillance and control of animal
diseases throughout the world. The organization also establishes guidelines to help countries
improve animal disease control and eradication methods. In 1995, the Agreement on the
Application of Sanitary and Phytosanitary Measures (the “SPS Agreement”) of the World Trade
Organization (WTO) came into force. The SPS Agreement established basic rules for food safety
and animal and plant health standards. WTO Members created the SPS Agreement, because of the
risks posed by trade in animals and animal products. The standards, guidelines, and
recommendations issued by OIE were designated as the international reference in the field of 38
animal diseases and zoonoses.
Utilizing funds raised at the three international conferences on avian flu (see the World Bank
subsection), OIE has begun evaluating veterinary services in 15 pilot countries on all five
continents. The evaluations identified issues that needed to be resolved in order to comply with
international veterinary services standards. OIE reports that the countries used feedback from the
evaluations to make political and budgetary reforms, and where necessary, prepare their
applications for international funding. The World Bank refers to the evaluations when setting
funding levels for countries seeking to improve their animal health infrastructure. OIE aims to 39
evaluate 105 countries over a three-year period.
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 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, which outlines WHO’s goals and actions, as well as recommended actions for 40
individual nations at each pandemic phase. FAO and WHO are the two key U.N. agencies

36 Albania ($6.1 million), Armenia ($9.3million), Azerbaijan ($5.1 million), Georgia ($10.3 million), the Kyrgyz
Republic ($6.4 million), Laos ($13.6 million), Moldova ($10.6 million), Nigeria ($65.0 million), Romania ($47.7
million)Tajikistan ($6.8 million), Turkey ($55.2 million), and Vietnam ($6.2 million), and West Bank and Gaza
Territories ($10.0 million).
37 OIE is not a U.N. agency. http://www.oie.int/eng/avian_influenza/
38 For more information on the SPS Agreement see http://www.wto.org/english/tratop_e/sps_e/spsund_e.htm.
39 OIE press release, “Support for governance relating to the prevention and control of animal diseases: the OIE takes
another step forward.” November 24, 2006. http://www.oie.int/eng/press/en_061124.htm
40 Find the WHO Global Influenza Preparedness Plan at http://www.who.int/csr/resources/publications/influenza/

implementing global avian influenza and pandemic preparedness initiatives, though other U.N. 41
agencies are involved in the global response.
FAO, OIE, and WHO have each developed early warning and response systems that collect,
verify, analyze and respond to information gathered from a variety of sources. OIE and WHO are
the official sources of disease notification or infection outbreaks for the international community,
with OIE reporting on animal cases and WHO on human ones. In July 2006, the three
organizations launched a joint Global Early Warning and Response System for Major Animal 42
Diseases (GLEWS). In October 2006, OIE and FAO launched a Crisis Management Center,
which houses health experts ready to be rapidly dispersed to countries contending with plant and 43
animal disease outbreaks. The United States provided $5.1 million and three veterinarians to the
In conjunction with OIE, FAO coordinates the global surveillance and response to H5N1 among
livestock. Specific activities include technical assistance in developing national avian influenza
prevention and control plans; advice on contingency planning; training of veterinarians; and
provision of equipment and supplies, such as laboratory equipment and vaccines. In January
2006, at the Beijing donor conference, FAO presented a plan that it developed with OIE to control
and eradicate H5N1 in animals. Key components of the program to be implemented by FAO and
OIE included: coordinating and managing the global response to H5N1; supporting countries with
H5N1 cases to control and eradicate the disease; and assisting countries without H5N1 cases to
develop preparedness plans. The plan, which was accepted at the Beijing conference, included a
budget of $476 million for a three-year cycle. FAO estimated that it would need $130 million to
fulfill its part of this global effort.
As H5N1 continued to spread, requests for assistance simultaneously rose. In response, FAO and 44
OIE revised their plan, particularly to expand assistance to Africa, Latin America, and the
Caribbean. The revised plan anticipated that $882 million would be required to address H5N1 in
the animal health field, excluding farmer compensation costs. FAO would need $308 million of
the funds to undertake its part of the global effort. As of September 30, 2006, donors had pledged 45
$94.4 million to FAO and an additional $39.5 million had been promised to the organization. At

41 Other U.N. agencies that participate in the global response include U.N. Children’s Fund (UNICEF), U.N.
Development Program (UNDP), U.N. Office for the Coordination of Humanitarian Affairs (OCHA), and World Food
Program (WFP).
42 OIE press release, “Launch of global early warning system for animal diseases transmissible to humans. July 24,
FAO also released a report on the initiative entitled,”The Global Early Warning and Response System for Major
Animal Diseases including Zoonoses (GLEWS)”
43 FAO press release,New Crisis Management Center launched by FAO. October 12, 2006. http://www.fao.org/
44 For more on FAOs proposal on responding to H5N1 in Africa, seeHighly Pathogenic Avian Influenza in Africa: A
Strategy and Proposed Program to Limit Spread and Build Capacity for Epizootic Disease Control.”
45 FAO,Interim Report on the Global Programme for Control and Eradication of Highly Pathogenic Avian Influenza
(H5N1).” September 2006. http://www.fao.org/docs/eims/upload//217280/rep_hpai_sfera_en.pdf

last count, the United States was the largest donor to FAO; providing more than 20% of pledged 46
FAO has established a flexible spending account, Special Fund for Emergency and Rehabilitation
Activities (SFERA), which is used to respond to geographical and thematic areas of greatest need.
FAO encourages donors to pledge funds to this account since the funds are not earmarked.
SFERA funds are allocated irrespective of the region, project, or disease. Although FAO prefers
that donors channel more of their contributions to SFERA, as of September 30, 2006, donors have 47
committed $24.9 million to the account. The United States is not a contributor to this account.
WHO is the U.N. agency responsible for coordinating the global response to human cases of
H5N1, monitoring the spread of the virus among humans, and determining when a virus has
caused a global pandemic. It also provides the international community with guidelines, 48
procedures, and recommendations on addressing infectious disease outbreaks, including H5N1.
In an effort to respond to the global spread of diseases, such as H5N1, and to minimize their
interference with international traffic and trade, the World Health Assembly revised the
International Health Regulations (IHR) in May 2005. The revised international legal instrument,
which is to come into force in June 2007, outlines the roles of WHO and its Member States in
identifying and responding to infectious disease threats, and compels Member States to share
information about infectious disease outbreaks and other public health emergencies of 49
international concern.
Under the revised IHR, Member States are required to develop and strengthen surveillance and
response capacities, respond to public health risks and public health emergencies, and report
public health events, such as infectious disease outbreaks, to WHO. The revised IHR mandates
the WHO to evaluate governments’ public health capacities, provide technical assistance, offer
logistical support, and mobilize financial resources for building capacity in surveillance and
response. Although the revised IHR do not include an enforcement mechanism, all WHO
Member States are bound to them, except those that have objected to them. WHO and a number
of countries, including the United States, have already taken steps towards implementing the
revised IHR and improving countries’ capacities to respond to international health risks and
One of the first steps taken was to develop the Global Outbreak Alert and Response Network
(GOARN); a system that manages critical information about outbreaks and ensures accurate and
timely communications among key international public health professionals. Another critical step
was to establish a global stockpile of influenza treatments. In August 2005, WHO estimated that 50,51
it would need about 3 million doses of antiviral treatments to avert a global pandemic.

46 http://www.fao.org/newsroom/en/focus/2006/1000348/index.html
47 FAO,Interim Report on the Global Programme for Control and Eradication of Highly Pathogenic Avian Influenza
(H5N1).” September 2006. http://www.fao.org/docs/eims/upload//217280/rep_Hpai_sfera_en.pdf
48 http://www.who.int/csr/disease/avian_influenza/guidelines/en/
49 http://www.who.int/csr/ihr/en/
50 http://www.searo.who.int/LinkFiles/Avian_Flu_Stockpile_Oseltamivir.pdf
51 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.

Tamiflu is an antiviral treatment that has been effective in treating people infected with H5N1.
Many health experts hope that Tamiflu remains effective if H5N1 becomes effectively
transmissible among people.
On April 19, 2006, Roche officials handed over 3 million Tamiflu courses52 to WHO.53 Half of
the treatments are being held in Switzerland and the other 1.5 million courses are being stored in
the United States. Under a separate agreement, Roche has donated an additional two million
courses to WHO. The courses are to be used to treat people in those developing countries which 54
are most likely to be affected by avian influenza and least likely to be able to purchase the drug.
According to WHO, it has made significant progress in implementing the goals and strategies
outlined in its Global Influenza Preparedness Plan. In the Plan, all activities and goals were
grouped into five key strategies (which are bolded). At the end of May 2006, key 55
accomplishments in the five areas included:
• reduced human exposure to the H5N1 virus—distributed 4,920 PPE; provided
biopacking for international shipment of infectious substances, viral transport
media, and other laboratory supplies; conducted assessment missions in 30
countries to determine the capacity and effectiveness of health infrastructures and
resources; and provided technical support in 8 countries and the West Bank and
Gaza territories;
• strengthened the early warning system—developed guidelines on collecting, 56
preserving and shipping specimens for the diagnosis of H5N1 virus infection;
supported the strengthening of field epidemiology in southeast Asia; supported
the improvement of surveillance and early warning systems in Burkina Faso,
Cameroon, Côte d’Ivoire, Niger, and Nigeria; aided countries to diagnose H5N1;
strengthened laboratory diagnostic capacity for H5 diagnosis in Nigeria,
Cameroon, and Côte d’Ivoire;
• intensified rapid containment operations—co-sponsored meetings and 57
conferences to develop an early containment protocol; developed guidelines on
managing a stockpile of antivirals; and drafted operating procedures on the
deployment of antivirals, including those stockpiled by WHO (explained below);
• built capacity to cope with a pandemic—worked with governments to
strengthen national preparedness plans; held a meeting with technical experts and
potential pharmaceutical manufacturers to assess antiviral drug capacity in

52 A course of medication is a period of continuous treatment with a drug, sometimes with variable dosage.
53 WHO press release,Handover of Rapid Response Stockpile for pandemic influenza containment.” April 19, 2006.
54 Roche press release,Roche reaches agreement with Aspen to provide influenza medicine for Africa.. May 16,
2006. http://www.roche.com/med-cor-2006-05-16
55 WHO, “WHO Activities in Avian Influenza and Pandemic Influenza Preparedness.” http://www.who.int/csr/disease/
56 http://www.who.int/csr/resources/publications/surveillance/WHO_CDS_EPR_ARO_2006_1/en/index.html
57 WHO in conjunction with other governments developed a global protocol on how to contain the transmission of a
pandemic virus at its source. For a draft of the protocol see http://www.who.int/csr/disease/avian_influenza/guidelines/

southeast Asia; and developed recommendations for the pharmacological 58
management of patients with H5N1 infection; and
• coordinated global scientific research and development—held a number of 59,60
meetings on developing and increasing pandemic influenza vaccines; made
available several new recombinant H5N1 prototype vaccine strains; and
published a bibliography of research on avian influenza.

Some Members have suggested that a greater portion of influenza pandemic preparedness funding
be spent on global efforts. During a House Foreign Operations Subcommittee hearing on
pandemic flu in March 2006, Representative Kolbe stated that the $55 million that USAID
requested for FY2007 global avian flu initiatives were insufficient, and encouraged the agency to
request additional funds if necessary. Representative Kolbe also questioned why such a small
proportion of the FY2007 requested funds were allocated to Africa (less than $10 million).
Appropriators did not enact any of the FY2007 appropriations that included specific funding for
global avian flu activities. Instead, Congress amended P.L. 109-289 (Division B), which provides
funding at the lessor of FY2006 enacted, FY2007 House-passed, or FY2007 Senate-passed levels
until February 15, 2007. Supporters of greater spending on global avian flu efforts urge Congress th
to provide additional funds for international efforts and to enact legislation in the 110 Congress th
similar to those bills introduced in the 109 Congress which sought to increase resources to
global avian and pandemic influenza preparedness (for a list of the bills see Appendix).
Intellectual property rights has become an increasingly contentious issue in global health,
particularly since companies began threatening to produce generic versions of HIV/AIDS
treatments without the patent holders’ permission. Some drug manufacturers in developing
countries have argued that Tamiflu and other patented antivirals are too expensive for most poor 61
countries. In October 2005, a representative from an Indian drug manufacturer threatened that
the company would develop and sell a generic version of Tamiflu “at a humanitarian price” in 62
developing nations, and not in the United States or Europe. Since then, Roche has granted 63
sublicenses to manufacturers in China, India, South Africa, and the United States. In the event

58 http://www.who.int/medicines/publications/WHO_PSM_PAR_2006.6.pdf
59 http://www.who.int/csr/disease/influenza/WHO_OIE_FAOMeetingreport.pdf
60 http://www.who.int/vaccine_research/diseases/influenza/Working_Paper_2.pdf
61 For more information on this issue, see CRS Report RL33159, Influenza Antiviral Drugs and Patent Law Issues, by
Brian T. Yeh.
62 McNeil Jr., Donald,Indian Company to Make Generic Version of Flu Drug Tamiflu.” New York Times. October 14,
2005. http://www.nytimes.com.
63 Roche press release,Roche donates a further 2 million treatment courses of antiviral Tamiflu to the WHO for
regional stockpiling.” January 17, 2006. http://www.roche.com/med-cor-2006-01-17 Also see http://www.roche.com/
med-cor-2005-12-23, http://www.roche.com/med-cor-2005-10-18, and http://www.roche.com/med-cor-2006-05-16.

of a pandemic, some assert that the United States will not export the antivirals that it is
stockpiling. In that light, some observers are advocating that Congress provide funds to support
countries in developing the capacity to develop and purchase antivirals. Still others contend that
the United States could help to contain the spread of H5N1 by exporting generic antivirals to non-
producing countries that can not afford to purchase the drugs (see H.R. 3369, S. 969, and H.R.


Some epidemiologists have expressed similar concerns related to H5N1 vaccine availability. If
H5N1 vaccines are developed, they would be a primary mechanism for controlling the spread of
the virus and reducing associated mortality and morbidity. Due to a number of uncertainties,
including unpredictable market demand and pricing, liability and intellectual property
considerations, and regulatory and tax issues, global and domestic vaccine research and
manufacturing capacity is limited. Global health experts contend that some of the most affected
countries do not have the capacity to produce vaccines, nor will they have the ability to purchase
sufficient quantities of the vaccine in the event of a pandemic. One article in the Journal of Public
Health Policy pointed out that “almost 40% of the world’s supply of interpandemic influenza 64
vaccines is used in countries that do not produce their own vaccines.” Some health experts
would like Congress to increase funding for HHS’ activities related to improving global vaccine
research and development capacity.
A number of health experts advocate greater U.S. investment in the strengthening of foreign
health systems overall. Proponents argue that the spread of H5N1 and the inability of countries
like Indonesia to contain the virus demonstrates the need to increase support for public health
systems. Supporters also argue that increased spending might encourage state openness and
responsibility, and enhance global cooperation and containment efforts.
Due to the poor state of health infrastructures in a number of countries, key sectors that are
critical in identifying and containing the spread of H5N1—such as disease surveillance and
veterinary services—are ill-equipped. Many health experts are concerned that a pandemic might
progress before it is discovered in a country where H5N1 is endemic. Supporters of this idea
argue that 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. Some health experts th
would like Congress to enact legislation in the 110 Congress, similar to measures introduced in th
the 109 Congress, that would strengthen health systems and veterinary health services in
developing countries (see H.R. 4476, S. 1912, S. 2170, H.R. 4245, and H.R. 4603).
Mass culling of infected poultry and in regions surrounding infected animals is the most widely
used containment measure. WHO has expressed concern that some farmers in poorer countries
might not cull their poultry, because they depend on poultry farming and their governments might
not be able to compensate them. Some scientists propose researching the effectiveness of

64 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.

alternative containment strategies, such as implementing cleaning days (when all live markets are
simultaneously emptied and cleaned) and separating ducks and chickens in live poultry markets
to decrease viral transmission. Others advocate the development of a global fund to support
countries in their farmer compensation efforts. Some encourage Members to enact legislation in thth
the 110 Congress similar to bills introduced in the 109 Congress (see H.R. 4062, S. 1821 and
H.R. 4603).
In connection with the Bamako Conference on avian and pandemic influenza, the World Bank
released a report that predicted the economic impacts of a global influenza pandemic. If the
pandemic was mild, killing about 1.4 million people (seasonal flu kills between 0.2 million and
1.5 million people annually), the World Bank estimated global output would decline by less than
1%. A more moderate pandemic, killing 14.2 million people, could cause global GDP to fall more
than 2%, representing about $200 billion in one quarter or $800 billion over a year. A severe
pandemic, modeled after the 1918 Spanish flu, could cut global GDP by almost 5%, constituting a 65
major global recession. The World Bank predicts that developing countries would be hardest hit.
Many economists assert that health and non-health related sectors could be severely affected by a 66
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 67
the SARS outbreak. In 2002 and 2003, SARS cost the Asia-Pacific region about $40 billion.
Additionally, flights to the region fell by about 45%, crippling the airline and hotel industries.
Canada estimated that it lost approximately $1.2 billion, with about $763 million spent on the 68
health-care system.
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. In th
the 109 Congress, some Members introduced legislation to establish a National Pandemic
Influenza Economic Advisory Committee that would 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 (see H.R. 4062, S. 969, and H.R. 3369). Supporters of this idea th
suggest that Congress enact similar legislation in the 110 Congress.

65 World Bank, “Evaluating the Economic Consequences of Avian Influenza. http://siteresources.worldbank.org/
66 For more on the economic impacts of avian influenza, see CRS Report RS22453, Avian Flu Pandemic: Potential
Impact of Trade Disruptions, by Danielle Langton.
67 Osterholm, Michael, “Preparing for the Next Pandemic.” Foreign Affairs, July/August 2005.
68 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

Figure A-1. Map of Human and Animal H5N1 Cases
Source: Information based on the World Health Organization (WHO) website, and the World Organization for
Animal Health (OIE) website. Adapted by CRS (5/2/07).
Table A-1. WHO Pandemic Phases
Phase Description Overarching Public Health Goals
Interpandemic Period
Phase 1 No new influenza virus strains have been detected in Strengthen global influenza pandemic
humans. A virus strain that has caused human infection preparedness at the global, regional and
may be present in animals. If so, the risk of human national levels.
infection is considered to be low.
Phase 2 No new influenza virus strains have been detected in Minimize the risk of transmission to humans;
humans. However, a circulating animal influenza virus detect and report such transmission rapidly
strain poses a substantial risk of human disease. if it occurs.
Pandemic Alert Period
Phase 3 Human infection(s) with a new strain, but no human-to-Ensure rapid characterization of the new
human spread, or at most rare instances of spread to a virus strain, and early detection, notification
close contact. and response to additional cases.

Phase Description Overarching Public Health Goals
Phase 4 Small cluster(s) with limited human-to-human Contain the new virus within limited foci or
transmission, but spread is highly localized, suggesting delay spread to gain time to implement
that the virus is not well adapted to humans. preparedness measures, including vaccine
Phase 5 Larger cluster(s), but human to human spread still Maximize efforts to contain or delay spread,
localized, suggesting that the virus is becoming to possibly avert a pandemic, and to gain
increasingly better adapted to humans, but may not yet time to implement pandemic response
be fully transmissible (substantial pandemic risk). measures.
Pandemic Period
Phase 6 Pandemic: increased and sustained transmission in the Minimize the impact of the pandemic.
general population
Source: World Health Organization.
Table A-2. U.S. Pledges for Global Avian and Pandemic Influenza
($ in millions)
Amount Pledged
FY2005 Funding Source
Beijing Vienna Bamako Total
Reprogrammed Funds from USAID Missions 5.14 1.75 0.0 6.89
P.L. 109-13, FY2005 Emergency Supplemental 31.30 0.00 0.00 31.30
- HHS (15.00) (0.00) (0.00) (15.0)
- USAID (16.30) (0.00) (0.00) (16.3)
HHS Base Funding 17.70 25.30 0.00 43.00
- OPHEP (4.20) (0.00) (0.00) (4.20)
- CDC (3.50) (0.00) (0.00) (3.50)
- NIH (10.00) (0.00) (0.00) (10.00)
TOTAL FY2005 54.14 27.05 0.00 81.19
Amount Pledged FY2006 Funding Source
Beijing Vienna Bamako Total
P.L. 109-148, FY2006 Defense Appropriations 279.50 1.57 0.00 281.07
- USAID (131.50) (0.00) (0.00) (131.50)
- HHS Research Programs (31.00) (0.00) (0.00) (31.00)
- Other HHS Programs (83.00) (0.00) (0.00) (83.00)
- USDA (18.00) (1.57) (0.00) (19.57)
- DOD (10.00) (0.00) (0.00) (10.00)
- Department of State (6.00) (0.00) (0.00) (6.00)
P.L. 109-234, FY2006 Emergency Supplemental 0.00 0.00 66.00 66.00
- HHS (0.00) (0.00) (36.00) (36.00)
- USAID (0.00) (0.00) (30.00) (30.00)
Reprogrammed Funds from USAID Missions 0.00 0.00 6.50 6.50

Amount Pledged
FY2005 Funding Source
Beijing Vienna Bamako Total
TOTAL FY2006 279.50 1.57 72.50 353.57
TOTAL FY2005 AND FY2006 333.64 28.62 72.50 434.76
Source: OMB, December 11, 2006.
Note: The figures in this table reflect funds pledged to global avian influenza activities. Some of the funds that
OMB reports agencies and departments committed to global activities were not specifically appropriated for
those purposes.

H.Rept. 109-463 to H.R. 5384, FY2007 Agriculture Appropriations, would have provided $4.5
million for U.S. Department of Agriculture’s international avian flu efforts. The Senate did not
include a specific amount for such efforts.
S.Rept. 109-277 to H.R. 5522, FY2007 Foreign Operations Appropriations, would have provided
$25 million for USAID’s global avian flu efforts, $30 million below requested levels. The House
did not include a specific amount for such efforts.
S. 3708, FY2007 Labor, HHS, and Education Appropriations, proposed $40 million for
international and domestic surveillance, diagnosis, and epidemic investigations. Additional funds
would have been provided in the bill for pandemic preparedness and avian flu, though not
specifically for global avian flu efforts. For example, the Committee proposed $130 million to
expand laboratory capacity, research and support for detecting and characterizing influenza and
other pathogens. The House did not propose a specific amount for global avian flu efforts, though
some funds would have been appropriated to avian flu and pandemic preparedness.
H.R. 4062 and S. 1821, Pandemic Preparedness and Response Acts proposed developing a
“Pandemic Fund”to augment ongoing U.S. and international avian flu and pandemic preparedness
H.R. 4476 and S. 1912, Global Network for Avian Influenza Surveillance Acts, would have
increased support for initiatives that prevent the spread of H5N1 among animals.
H.R. 3369 and S. 969, Attacking Viral Influenza Across Nations Acts, would have provided funds
to support U.S. efforts to strengthen surveillance capacity within affected countries.
H.R. 4245, Influenza Preparedness and Prevention Act, would have increased the number of
international public health sites and staff abroad in countries impacted by pandemic influenza.

S. 2170, Global Pathogen Surveillance Act of 2005, would have provided $1 billion for a real-
time international threat detection system, offers training and education for epidemiologists in
developing countries, offered training and consultation on disease and syndrome surveillance, and
provided assistance to developing countries for the purchase and maintenance of public health
laboratory equipment and supplies.
H.R. 4603, Pandemic and Seasonal Influenza Act of 2005, would have provided funds to
establish a global network for avian influenza surveillance, offer technical assistance to countries
for disease detection, strengthen veterinary systems, and institute a Coordinator of U.S.
Assistance to Combat Avian Influenza.
H.R. 4392, To provide for the importation of pharmaceutical products under a compulsory
license as provided for under the World Trade Organization, would have permitted the United
States to export generic antivirals to non-producing countries.
Tiaji Salaam-Blyther
Specialist in Global Health
tsalaam@crs.loc.gov, 7-7677