South Asia Region
Avian Influenza and Pandemic Preparedness
A Briefing Note
Background Information:
A human pandemic can start when three conditions have been met: a new influenza virus subtype
emerges; it infects humans, causing serious illness; and it spreads easily and sustainably among humans.
The H5N1 virus 1now infecting domestic poultry flocks in East Asia and ECA amply meets the first two
conditions, but not yet the third: it is a new virus for humans (H5N1 viruses have never circulated widely
among people), and it has infected more than 100 humans, killing over half of them. No one will have
immunity should an H5N1-like virus emerge which is easily transmitted among humans. In comparison to
anti-bacterial drugs, anti-viral drugs tend to be less effective and more toxic. The effectiveness of an antiviral drug such as Tamiflu against a variant of H5N1 will only be known after it emerges and would
likely need to be administered within 48 hours of symptoms being detected. Hence, even in the most
advanced health care settings with the best of treatment and supportive care, this type of influenza could
be a very dangerous disease. Even if the disease were “mild” WHO estimates, based on the 1957
pandemic, indicate that between 2 million and 7.5 million people could die from a pandemic of H5N1.
The influenza pandemics of 1957 and 1968 arrived with little warning and vaccines arrived too late to
have an impact. The amount of any grace period if/when the next pandemic occurs is unknown. The virus
could change through “re-assortment” which might lead to very rapid spread of a virus transmitted from
human to human. Alternatively, the virus could change through “adaptive mutation” in which case the
grace period will be significantly longer.
No vaccine for H5N1 yet exists although considerable work is ongoing in a number of countries to
develop one. Generally, production of large amounts of a vaccine would have to wait until the antigenic
composition of the pandemic virus became clear.
Early detection of cases, and more importantly clusters of cases, will be a significant challenge. Influenza
caused by H5N1 presents with symptoms, primarily respiratory, that are common to many other diseases.
Most cases have been detected in hospitals. Proper diagnosis requires sophisticated laboratories able to
contain and handle highly pathological micro-organisms. Ensuring that samples, often in large numbers,
can quickly get to such laboratories will be important.
Containment of clusters of cases through the use of anti-viral drugs is potentially important and will be
seen publicly as necessary. However, mathematical modeling suggests that doing this effectively will
require 80% coverage of the affected population within two weeks of the index case.
The continuing spread of the H5N1 Avian flu from East Asia via migratory birds to other countries in
Central Asia and Eastern Europe calls attention to the imminent threat of the disease spreading to the
South Asia Region also. While the highly pathogenic avian flu has not appeared (or has not been
reported) in the Region as yet,2 its significant potential human and economic costs point to the urgency of
The evidence suggests that Avian Flu is spread by migrating wild bird populations and is therefore virtually
unstoppable at source.
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A less virulent strain of avian flu (H9, H7 and H3) has been found in Pakistan. However, there is no cause for any
complacency. South Asia lies on the migratory route for birds from SE Asia. Many people live in close proximity to
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formulating national human and animal health strategies for dealing with avian flu and other zoonotic
diseases (animal diseases which can be transmitted to humans) that may arise. The recent outbreak of
Japanese encephalitis in Uttar Pradesh, India which originated from pigs and killed hundreds of people-mostly children, illustrate the costs in terms of loss of human life from a zoonotic disease outbreak. Other
direct costs can be significant, such as the health cost of treating ill people, economic losses in livestock
output (through death from the disease or mandatory slaughtering to prevent its spread), and losses in
livestock export revenues. There will also be significant indirect economic costs arising from losses in
labor productivity due to illnesses or worker absenteeism, and declines in tourism revenues and business
travel.3
In addition to the human dimension, an important consideration in developing animal health strategies in
SAR countries for dealing with zoonotic diseases, is that livestock plays several important roles.
Livestock is a major source of livelihood, especially for a large share of the poor. It is also an important
source of protein for the poorest, draft power for farming, organic fertilizer and household fuel (manure),
store of wealth, and insurance substitute during times of crisis. Economy-wise, the livestock sector is also
a major contributor to GDP. The large number of rural households and especially the very poor who are
dependent on livestock for their livelihoods complicates the challenge of controlling zoonotic diseases
such as Avian flu. Control measures, such as mandatory vaccinations and slaughtering of birds without
any compensatory measures, can have an adverse impact on household incomes and discourage reporting
by affected households. There is therefore a need to develop an effective coordinated animal health
strategy that will address the public safety and livelihood objectives in dealing with the disease.
Controlling the animal outbreaks is an essential prerequisite for controlling the human outbreaks.
On human health, weak epidemiological, laboratory and clinical capacity in the region, are challenges in
addressing a pandemic. India is probably the only country with institutional capacity to address a
pandemic. GOI has drawn up an emergency preparedness plan and is on alert for the threat of the H5N
virus coming into India. There is a national laboratory in Bhopal which is equipped to handle the testing
of birds and the Government has laid down a protocol for handling and transport of possible infected wild
birds. The Indian authorities seem to be alert to the threat and are in touch with FAO on upgrading their
testing facilities. They are on alert for the arrival of migratory birds this winter. State systems are
probably much less well prepared. GOI believes that the main threat comes from the huge numbers of
small scale chicken producers (contract rearers of chicks and those who keep free range chickens) as it
would be difficult to extend surveillance to these categories of producers. The larger commercial
producers are better equipped to prevent and/or detect the presence of avian flu in their businesses. Most
other SA countries have weak or almost nonexistent public health surveillance systems and limited
laboratory capacity as well. Bangladesh can benefit from ICDDRB laboratory capacity. Country
assessments will provide further and detailed information on these matters.
Main issues in addressing the Avian Influenza:

Avian influenza involves many players, including health, agriculture, economics, finance, and
planning among others. At the country level, in particular, an integrated, multi-sectoral response is
needed based on clear shared objectives. This needs to incorporate appropriate responses to both the
animal health and human health dimensions but also appropriate social measures (transport
domestic birds and come into contact with live poultry, and the dense urban conurbations make for a likely rapid
spread of the pandemic, should it come.
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In East Asia, the economic cost of the severe acute respiratory syndrome (SARS) outbreak was estimated at 2% of
East Asian GDP in one quarter, mostly from indirect costs such as reduced labor productivity and lost export and
tourism revenues.
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restrictions, mass communication strategies, etc.). Furthermore, country, regional, and global
strategies should clarify the linkages between animal and human health and integrate the objectives,
approaches, and timeframes of the responses on both fronts. The ability to convene a wide range of
country donors and partners to collaborate across sectors will be critical.

Individual countries are central to any coordinated response. Country strategies developed and
owned by the governments facing the threat of avian influenza should be the foundation of a global
response. Capacities to plan and execute appropriate responses vary considerably among countries.

The geographic coverage of a response should be determined by both immediate and anticipated
needs. Indeed, a minimum level of preparedness is needed in all countries. However our response
should first focus on countries at higher risk - Pakistan, India, Bangladesh and Afghanistan.

Short-term and long-term actions need to be taken and an appropriate balance struck between the
two. Immediate action is needed in a number of areas, but there is also a longer-term agenda given
systemic shortcomings with respect to core public health functions and animal health systems. It is
critical that attention be given urgently to putting in place those animal and public health measures
that can contain or delay the spread of the epidemic at the source. However, work on both the shortand long-term fronts needs to proceed in parallel, and efforts should be made to ensure that short-term
responses are consistent with and contribute to proposed longer-term interventions. Setting priorities
in both cases will be essential.

Regional aspects of the response also need to be addressed and coordinated. Actions to secure
borders and control international trade/travel in the event of a pandemic, and measures to limit the
effects of disease transmission by migratory birds are trans-boundary issues requiring regional and/or
international coordination. Regional efforts should build on existing mechanisms such as the Global
Framework for Progressive Control of Transboundary Diseases (GF-TADs) a joint FAO/OIE
initiative whose Regional Steering Committee is managed from the OIE Regional Representation
Office in Tokyo and regional organizations such as ASEAN, SAARC.

Addressing economic and social impacts must be an integral part of the response. A pandemic could
have devastating economic and social consequences, including large-scale loss of livelihoods as well
as lives. Even if a pandemic does not occur, there could be important socioeconomic effects resulting
from the response to the perceived risks. Countries will confront choices in balancing preparation
versus action since both imply economic costs. At least four classes of economic costs or impacts
should be considered under a human and animal pandemic scenario: (i) Effects of sickness and
mortality on potential output; (ii) private preventive responses to an epidemic; (iii) public policy
responses to epidemic threats; and (iv) cost of lost livelihoods due to animal death or animal health
control measures (mandatory slaughter).

Engagement of various stakeholders will be key. Agencies will need to coordinate on strategies and
messages to communicate effectively and to mitigate impacts. Efforts are urgently needed to build the
political commitment necessary to ensure swift action at the country level using existing channels and
working effectively with other coordinating bodies. This will need to be combined with appropriate
information and engagement starting at the grassroots levels in affected areas and also with the larger
population. Regionally and globally, coordinated efforts will be critical to ensure integrated, clear and
accurate information is available on the scope of the problem as well as on the short-term and longerterm responses.
South Asia short term response for the next 3 months:
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At this time, we do not have full information on what our technical and financial partners in SAR
propose to do. However, many actions/ideas are being considered. (India is considering allowing generic
production of Tamiflu etc). There are also many multilateral and bilateral responses, including WHO,
FAO, USA, EU, Canada etc. India has undertaken its country assessment in collaboration with WHO,
Department of animal husbandry and a few technical institutes and in Pakistan, the MOH, Agriculture,
FAO and WHO have had several meetings to discuss the country preparedness plan. ADB has offered
assistance. The EU is anxious to collaborate with the Bank. We will therefore need to work closely with
the relevant Development Partners. We will also look at our existing projects, mainly in the health
portfolio to gear up for a fast response. In India, the Disease Surveillance, and Food and Drugs projects
can be used to further strengthen the surveillance and early warning systems and laboratory and outbreak
investigation capacity as well. In Bangladesh we should do the same under the HNPSP II operation. In
Pakistan, we recently concluded an assessment of the current Public Health Surveillance System, which is
practically nonexistent, except for polio surveillance. The weak capacity in Pakistan is a major of
concern. (USAID wants to collaborate with the Bank in supporting Pakistan in strengthening their
outbreak investigation capacity). In this context, we should explore the possibility of an operation that
will strengthen the overall epidemiological and laboratory capacity. If compensation issues arise (poultry
culling) we would need to put together an emergency financing package.
The Bank is also preparing a global program for use by all regions, using the horizontal adaptable
program loan instrument (APL), similar to the instrument already used to support the HIV/AIDS’ efforts
in Africa and the Caribbean. The APL would provide an overall framework for coordinated action and
co-financing with other multilateral organizations and donor agencies, by establishing a US$500 million
facility to provide financial and technical assistance to individual countries. The global APL instrument,
by visibly committing substantial resources and complementing activities supported by other international
organizations and donor agencies, would help ensure the availability of adequate resources to fund
priority investments and technical assistance for the rapid scaling-up of individual countries’ responses.
This global program would be based on integrated national plans, including short-and medium-term
development plans, based on the global strategies agreed by the international community. It would
support individual countries to adapt, according to local realities, the provisions of global strategic
preparedness and response plans. Each country that decides to participate would be able to present its
proposals for consideration and support under the framework of the global program, using a combination
of the tools and mechanisms available. The individual country project would have to be designed in
agreement with the overall guidelines of the GPAI program, but taking into account the particular country
situation, existing capacity and resources available, as well as other ongoing efforts being implemented
simultaneously in relation to Avian Influenza.
Actions Needed Within Next 3 Months:
1. Assist SAR countries prepare national plans including:
a. Assessment of technical, infrastructure, organizational and human resource capacity of
animal health departments to monitor and control disease outbreaks,
b. Institutional arrangements including Coordination mechanisms
c. Surveillance and Control Measures for animal and human health
d. Assessment of Effectiveness of Activities ( animal and human health)
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e. Review of government policies linked to disease management (e.g. disease prevention,
slaughter and compensation policy, communication linkages between Ministry of
Livestock and Ministry of Health),
f. Examination of existing production systems and their vulnerabilities to disease
transmission, preventive and corrective measures in place, etc.
g. Resource Implications of Getting Prepared
h. Potential Economic Impact Analysis
2. National workshops as a means to build awareness and understanding of the issues and foster
agreement on necessary actions.
3. Identify possible courses of action at the national and regional level, including initiatives to
formulate national preparedness strategies and detailed implementation plans, and possible areas
where the Bank could provide support to national governments and other agencies (FAO, OIE,
SAARC, etc)
The countries in SAR have different levels of preparedness and the areas of support needed will vary by
country.
Organizational Arrangements
1. We have set up an SAR response team and will allocate appropriate administrative budget. The
team includes staff from SASAR, SASHD reporting to Connie and Julian, and a SAREX focal
point. We will add additional staff as necessary to ensure linkages between Ministries responsible
for animal health services and public health and Ministries of Finance and Trade.
On the animal health issues the overall team would be led by Gajanand
Pathmanathan/Robert Epworth, with SASAR field based staff (Martien van Niewkoop in
India, Mohinder Mudahar in Bangladesh, Tekola Dejene in Pakistan, Norman Piccioni in
Afghanistan and Terrence Abeysekera in Sri Lanka ) taking the lead on the respective
country initiatives. The team will be assisted by consultants.
On human health issues the overall team will be led by Ana Abreu with the support of
Kees Kostermans, and Benjamin Loevinshon). The country focal points (Pakistan –
Inaam Haq, India - GV Ramana, Afghanistan – Kayhan Natiq, Bangladesh- Dinesh Nair),
will take the lead on the respective countries and they will be assisted by consultants.
2. Establish formal linkages with WHO/FAO counterparts and other financial partners working in
SAR and identify focal points in each agency.
3. Based on above discussions with partners finalize in-country activities, institutional
responsibilities and funding sources.
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