Avian & Human Influenza Facility 78924 Toward a Healthier World: Containing Pandemics Foreword While recent advances bring the eradication of diseases such as polio and malaria within reach, a world free of influenza viruses and animal-borne diseases (zoonoses) is considerably more difficult to achieve. By working together to detect and contain these disease outbreaks, however, countries can minimize their spread and negative impact. With a growing body of scientific knowledge about pathogens and stronger disease control, we can prevent pandemics from becoming global threats. The multi-donor Avian and Human Influenza Facility (AHIF) has supported this international effort. Grants from AHIF have enhanced infectious disease preparation and rapid response, improving management of ongoing and future disease risks. AHIF is making a measurable difference in the ability of developing countries to detect and stop diseases early, reducing their potentially catastrophic effects on public health and livelihoods. Although the nature of influenza viruses and other zoonotic pathogens make future disease outbreaks largely unpredictable, a deeper understanding of how to mitigate risks and reduce the spread of diseases can help. In addition to improving public health, AHIF grants have helped to boost the economic potential of partner countries. Trade opportunities have grown as a result of reduced livestock disease threats and increased adherence to global food safety standards. Farmers and their families have also benefited from lowered disease risks to poultry. Such pandemic preparedness will continue to yield economic returns in the form of reduced economic costs if an outbreak occurs. AHIF has successfully funded projects in 51 countries, leaving an enduring legacy: empowered public health and veterinary services, better equipped hospitals and laboratories, more knowledgeable farmers, and a more informed public. Michael Koch Director Global Partnerships and Trust Fund Operations The World Bank Group ___ 3 The Avian and Human Influenza Facility The Avian and Human Influenza Facility (AHIF) is a multi-donor trust fund administered by the World Bank and supported by the European Commission and nine other donors. It was established in 2006 to respond to global concerns over the rapid spread of avian influenza and the costs associated with it: threats to public health, economic damage, and loss of livelihoods. AHIF funds initiatives that range from short-term emergency responses, to curtail outbreaks, to longer-term investments in preparedness aimed at reducing the risk of future outbreaks of Highly Pathogenic Avian Influenza (HPAI) and other zoonotic diseases. ___ 4 How we help AHIF grants to government agencies in developing countries support country-led efforts to: •   Prevent and control avian influenza and other zoonotic diseases •   Increase preparedness for pandemics and other complex disasters Grants are aligned with other World Bank-financed projects and complement other ongoing programs. Each grant is customized to the needs of the recipient country and comprehensively addresses many of the following focus areas: Awareness, communication, and outreach Public health Capacity building for disease control and prevention Rapid Response Equipment, hospital, and laboratory upgrades Surveillance Preparedness Veterinary systems This strategy addresses the root causes of risks while also preparing government agencies and communities to quickly contain any future outbreaks. ___ 5 AHIF by the numbers: 8-year funding window from 2006-2014 10 donors led by the European Commission 51 developing countries 58 grants US$79 million disbursed ___ 6 Global Reach, Local Impact ___ 7 Handling sick or dying birds without proper precautions can cause avian influenza in humans. ___ 8 Between 2003 and 2011, the H5N1 virus killed or forced the culling of more than 400 million domestic chickens and ducks and caused an estimated US$20 billion in economic damage, according to the Food and Agriculture Organization of the United Nations. ___ 9 Awareness, Communication, and Outreach Making the public aware of the risks of avian flu and other zoonoses and communicating the importance of simple preventative measures can go a long way towards stopping the spread of disease. Similarly, as farmers become aware of the risks, and learn about how disease control yields business benefits, they can be part of the solution. They can work with veterinarians to detect and report diseased poultry promptly and to put in place disease prevention measures. Many of the AHIF grants funded public awareness campaigns and other outreach acticities with targeted messaging for maximum impact. ___ 10 Bhutan: Heightened Influenza Awareness In remote, landlocked Bhutan, outbreaks have been contained swiftly due to an intensive public awareness campaign and bio-security training for government supervisors, poultry businesses, and farmers. A US$2.5 million AHIF grant supported communications on the importance of prevention to the general public and to poultry farmers. Essential diagnostic equipment was purchased for more systematic surveillance of both avian and human influenzas. “Fluview,� a widely- circulated monthly newsletter, brings vital information to the public. Communications efforts also include government agencies; officials from various ministries are coordinating on surveillance, preparedness, and response in the event of an influenza outbreak. Results and impact •   Awareness campaigns aimed at poultry handlers, meat vendors, and commercial farmers have increased their understanding of avian influenza and reduced risky behaviors. •   Veterinary Village Teams spread the word when outbreaks occur across the border in India. •   Extensive training and capacity building has enabled expansion of clinical avian influenza surveillance, more rapid diagnosis, and better containment. •   The new Serbithang hospital has acquired polymerase chain reaction and immunofluorescence assay capacity among other state-of-the-art facilities critical to enhanced diagnostic capabilities. ___ 11 Capacity Building for Disease Control and Prevention Stop disease before it starts Prevention is obviously essential, but success requires complex efforts to keep poultry healthy and uninfected along the entire poultry-handling chain: from family farmers and commercial poultry enterprises to marketing, public supervisory agencies, and border control teams. A lack of skills, knowledge, or resources at any point along the chain increases the risk of unsafe practices or of potential threats going undetected, creating an opening for the spread of disease. In response, all AHIF-funded projects focus on increasing the knowledge and skills of veterinary and human public health workers. These efforts reduce risks and build capacity for rapid response when disease strikes. ___ 12 H5N1 Outbreaks in Mongolia (2006 - 2013) Mongolia: Building Skills for Improved Disease Control With an abundance of migratory water birds and a comparatively small domestic poultry sector, Mongolia faced challenges in detecting potential sources of zoonotic disease and preventing disease spread. Results and impact The country’s veterinary and human public health services lacked skills, knowledge, personnel, and •   Better diagnostic capacity and enhanced equipment to respond quickly. Public animal and surveillance have improved avian flu outbreak human health services each operated separate, detection and improved global knowledge about non-integrated emergency response command and the influence of wild bird migrations on the control structures, causing confusion, overlaps, and spread of avian influenza. inefficiencies. As global concerns over the H5N1 •   A zoonotic disease risk assessment manual avian flu reached a peak in 2006, the Mongolian supports veterinary and public health staff learning. government requested assistance in implementing a •   22 skilled joint rapid response teams, comprised of comprehensive and coordinated strategy and action public health, agriculture, emergency management plan for Avian and Human Pandemic Influenza. and inspection staff, are deployed throughout the country to prevent disease spread. A US$4.7 million AHIF grant addressed skills gaps •   7 hospitals are better prepared to treat severe and other issues to enable integrated approaches and respiratory infectious diseases, following more comprehensive infectious disease detection, specialized training on infection surveillance, response, and preparedness. intensive care, ventilator operation, and virus genetic sequencing. ___ 13 To diagnose avian flu in humans, samples of fluids from the nose or throat are tested for evidence of the virus. These samples must be taken within the first few days after symptoms appear. According to doctors at the Mayo Clinic, results can take weeks or just a few hours depending on the type of test used. ___ 14 Equipment, Hospital, and Laboratory Upgrades If laboratories lack proper equipment—or if there are not enough labs available in a high-risk region — even skilled technicians will find it difficult to correctly diagnose a disease. Similarly, if veterinary and public health officials lack the means to reach remote farms or poultry markets, surveillance will is likely to be limited and ineffective. Animal health labs are a key part of the picture. Hospitals, human health labs, and clinics with the capacity to diagnose, treat, and quarantine patients also play an important role. For maximum effectiveness, these animal and human health labs and other public health services must work together in a “One Health� approach to coordinate disease response and control. AHIF funded capital and other upgrades in diagnostic human and animal health labs and related services. These improvements allow the labs to perform their critical early disease detection and diagnosis roles and coordinate more effectively. Financing for transport helped rapid response teams deploy to outbreak sites and extended surveillance to potential disease hotspots in the poultry-handling chain from out-of-the- way family farms to commercial enterprises, backyard poultry set-ups, and markets in villages and cities. ___ 15 H5N1 Outbreaks in Cameroon (2006 - 2013) Cameroon: Bringing the Lab to the Farm Transportation in rural Cameroon can be a challenge. The roads are dirt paths that lead past many small farms where families raise poultry to feed themselves and to sell at local open-air marketplaces. With no poultry surveillance in the country, let alone in such remote locations, government officials became concerned about the country’s vulnerability to HPAI Results and impact and other zoonotic diseases and asked for help with surveillance. Their aim was effective oversight of the •   The purchase of 24 motorcycles and two country’s poultry operations—including family farms— rugged all-terrain vehicles enables traveling regardless of where they were located. veterinary teams to reach remote farms. •   Mobile veterinary labs allow for comprehensive The AHIF grant, together with support from other monitoring of poultry health as veterinary teams sources, funded development of a comprehensive bring the lab to the farms. surveillance system that monitors both commercial •   Education and outreach has increased public poultry enterprises and small family farms. awareness and medical knowledge. ___ 16 The World Health Organization reports that only one of the prerequisites for the start of a global human pandemic is missing: the establishment of efficient human-to-human transmission. ___ 17 Preparedness activities such as drafting and rehearsing response plans, developing a pandemic vaccine, and securing supplies of antiviral drugs are costly. Countries where H5N1 is endemic – and where a pandemic virus is most likely to emerge – lack the financial resources for these activities, leaving them even more vulnerable. Preparedness Since the first confirmation of a large-scale outbreak of H5N1 avian flu in 2003, the virus has affected 63 countries throughout Asia, Europe, the Middle East, and Africa. As of 2013, the virus continued to circulate in birds and poultry in a dozen countries, posing a persistent risk to public health and livelihoods. Although future geographic distribution is unknown, it is certain that new outbreaks of this or other pathogens will continue to occur. If not contained quickly at their animal source, the contagion can spread within the country and beyond. If the pathogens transmit readily from human to human, the outcome can be a devastating pandemic. As countries learn from previous outbreaks, they can better prepare for future threats and reduce the risk that disease will spread. Preparedness has benefits beyond a specific strain of virus because it gives countries the tools they need to handle other kinds of public health risks promptly and effectively. AHIF grants have funded numerous efforts to improve preparedness in countries that already have faced outbreaks and in countries that are at risk. ___ 18 The program has helped the country become better Armenia: prepared for other diseases, as demonstrated by rapid containment of a 2008 African Swine Fever Better Preparedness, outbreak. To date, Armenia has remained free from HPAI outbreaks. Effective Prevention Results and impact In 2006, Armenia was in a difficult situation. Neighbors Azerbaijan, Georgia, Russia, and Turkey were dealing •   The new National Animal Disease Information with avian influenza outbreaks. In Azerbaijan and System tracks and monitors diseases more Turkey, people died after contracting HPAI. Some effectively, enabling improved public health factors mitigated the country’s risks—it is not a coordination. destination for migratory birds, and long cold winters •   Laboratory upgrades and purchases of mean that poultry are kept inside where they have essential field equipment have enhanced limited contact with wild birds. Nevertheless, the preparedness; the government can now government moved quickly to address the potential access remote areas for monitoring and threat. surveillance. •   A new, state-of-the-art disease control facility A US$2 million AHIF grant supported a strong and is the first line of defense in stopping zoonotic effective preparedness and emergency response diseases such as anthrax, tuberculosis and program, steered by a cross-ministerial government brucellosis, which can easily spread from task force. The program received complementary animals to humans. support from other donors as well. ___ 19 Public Health As of March 2013, the World Health Organization reported 622 laboratory-documented cases of human infection from the H5N1 avian flu strain. Of these cases, 322 proved fatal—a 60 percent fatality rate. While the number of new H5N1 cases has declined in recent years, indicating progress in disease control at the animal source, new threats continue to emerge. A novel coronavirus (nCov) infected humans in several countries in the Middle East and the United Kingdom in 2012-13, probably after infecting goats and camels; another avian flu outbreak in humans, caused by the H7N9 virus, appeared in China in the spring of 2013. AHIF grants contribute to improved public health and safety by building government capacity to monitor disease patterns and respond rapidly when outbreaks occur. Reducing human exposure to infected poultry and other animals is vital. Strong public health communications play a key role in increasing public confidence and minimizing panic, which can have high economic costs. ___ 20 H5N1 Outbreaks in Lao PDR (2006 - 2013) Lao PDR: Coordinated Response for Reduced Public Health Risks Nearly 45 percent of the population in Lao PDR lives on less than one dollar a day, and more than 80 percent raise backyard poultry. The potential for disastrous impacts from an uncontrolled H5N1 outbreak is high, with a 2004 outbreak leading commercial farmers to lose more than 150,000 birds through culling. Results and impact The situation has been further complicated by the country’s porous borders with neighboring countries •   A compensation program to offset poultry losses already facing severe H5N1 flu outbreaks. has helped to increase reporting of disease by farmers, keep commercial producers in business, Against this backdrop, the government initiated a and change behaviors to reduce future risks. strategic and coordinated communicable disease •   Large-scale training efforts on biosecurity control plan and sought support from the World Bank measures to reduce risks targeted provincial and and other donors. AHIF provided US$4.4 million district officials, village chiefs, and teachers, who that leveraged additional funding and supported shared their knowledge with other local residents. a coordinated approach among the 27 partner •   Lab upgrades to enable 24-hour turnaround on organizations and the government to enhance the sample analysis have improved the country’s effectiveness of the response. diagnostic capabilities. •   Provincial- and district-level rapid response teams Significant progress has been made since the plan’s are in place, assisted by telephone hotlines for implementation, including swift containment of H5N1 quick reporting on suspected outbreaks. avian flu outbreaks: by project’s end, 100 percent of •   Prevention and early, effective control of the country’s 141 provinces were free of avian flu. contagion have yielded high economic returns, ranging from 38 percent on an expected value basis to 129 percent on a disease risk basis. ___ 21 Responding to the outbreak of the new H7N9 influenza virus requires strong biosecurity measures. The novel virus is hard to detect in poultry because it causes little to no signs of disease in animals. Rapid Response When an outbreak of avian influenza strikes, untold damage can result. Livelihoods are destroyed. Humans may become infected, and the economic, social, and political impacts are potentially severe. Mitigating these impacts depends on a government’s ability to respond quickly and appropriately with both veterinary and human public health expertise. AHIF assisted such rapid response efforts, including funding to compensate small poultry farmers for culling diseased or at-risk poultry. When complemented by communications, compensation programs can change behaviors to improve poultry safety and reduce the risks of human and poultry infection. ___ 22 Vietnam: From H5N1 Outbreaks in Vietnam (2006 - 2013) Emergency Response to Integrated Disease Control and Prevention In 2003 and 2004, H5N1 avian flu spread to 57 of 64 provinces in Vietnam, and 44 million poultry—17 percent of the nation’s stock—died from the disease or were culled to prevent further outbreaks. Veterinary health and disease surveillance systems were Results and impact overwhelmed. With 15 human deaths recorded in 2004, the potential for a global influenza pandemic •   Strengthened veterinary services to improve seemed substantial. disease surveillance and epidemiological investigations. To address the situation, the World Bank partnered with •   Market-based disease controls, ring other donors to finance the world’s first comprehensive vaccination of poultry, and border animal avian flu emergency response. National disease quarantines helped break chains of infection. surveillance and diagnostic capacity mechanisms in •   Construction of a poultry destruction and the poultry sector to contain serious outbreaks were disposal site in Lang Son province enabled enhanced. Public health improved due to heightened increased control over poultry coming from knowledge on how to mitigate risks. other countries. •   Early warning and rapid response mechanisms With support from a US$10 million AHIF grant, a enhanced the effectiveness of human health second-generation program was set up in 2007. surveillance and response systems. The program helped the country transition from •   Hospital upgrades, medical staff training, and emergency response to integrated surveillance and coordinated preparedness planning have disease control, with a focus on early detection and enabled better infection control and reduced medical preparedness for a pandemic in 11 high-risk the risk of severe impacts from a pandemic. provinces. ___ 23 Domestic poultry are now free from the H5N1 virus in most of the 63 countries infected in 2006. However, large reservoirs of the H5N1 virus still exist in some regions of the world. Without adequate controls and surveillance, the FAO says that disease could quickly spread once again. Surveillance Effective monitoring and surveillance are essential to preventing the spread of disease. This is not just an inside- national-borders issue, however. The rise of global and regional trade in livestock and livestock products, the prevalence of cross-border poultry smuggling in some regions, and the potential for disease transmission by migratory birds that move across national borders all point to a need for international surveillance and disease control systems. Many AHIF-funded projects have featured components focused on enhancing disease surveillance capabilities and reducing border vulnerability. These efforts included measures to encourage neighboring countries to work together on implementing stronger surveillance systems. ___ 24 Such regional cooperation is critical, as inadequate Middle East: Cross- surveillance and response capacity in one country endangers not just that nation but also poses a public Border Collaboration health threat to neighboring countries and the entire world. for Infectious Disease Surveillance Results and impact A remarkable coalition of public health, agriculture, •   Neighboring countries in a conflict-prone region and emergency management authorities has quietly have found common ground as they work created coordinated regional disease preparedness together to face infectious disease threats, plans and outbreak response systems with support with positive spillovers for regional stability and from a US$1 million AHIF grant. The Middle East cooperation. Consortium on Infectious Disease Surveillance •   The regional network approach has helped to (MECIDS) includes Israel, the Palestinian Authority and leverage additional funding and expert support Jordan, with participation from Egypt. for surveillance, preparedness, and emergency response. MECIDS has mobilized for emergency action several •   The cooperative approach, featuring frequent times in recent years. Preparedness and planning have communication, coordinated planning and enabled swift, cross-border coordinated deployment sharing of experiences and best practices, has of resources and containment of disease outbreaks. helped reduce the risk of widespread infectious disease outbreaks. ___ 25 Veterinary Systems Veterinary public health systems are essential for monitoring poultry populations and detecting animal diseases such as avian flu. While demand for public veterinary services continues to grow, limited human and financial resources constrain government capacity to respond, particularly in low- and middle-income countries. AHIF addressed these limitations by funding public veterinary systems, building human resources capacity through disease surveillance training, and facilitating partnerships with private veterinarians for surveillance. These efforts bring broad-based benefits by strengthening the first line of defense against the spread of zoonotic diseases. HPAI virus infection in poultry can cause disease that affects multiple internal organs. Death often occurs within 48 hours. The mortality rate is 90-100 percent. ___ 26 Honduras: Stronger Veterinary Services In Honduras, one of the poorest countries in Latin America, poultry production employs more than 12,000 Hondurans directly and an additional 150,000 indirectly. The country could not afford a disease outbreak that devastated the poultry population or curtailed cross- border trade. But risks abounded, including liberal and sometimes illegal trade of poultry and poultry products, live bird markets, and poor biosecurity on poultry farms. Migratory wild birds also posed additional risks. The country’s veterinary services faced severe constraints, including insufficient knowledge of general animal health, disease prevention and detection, and what to do with affected birds. There was also not enough skilled personnel to implement a program that could reach all points along the poultry market chain. A US$300,000 AHIF grant provided in 2008 contributed to a broad improvement in the nation’s veterinary services capacity. The response focused on building technical animal health skills, purchasing needed equipment, developing national surveillance and preparedness plans, and creating a compensation program for poultry producers if outbreaks occur and culling is needed. Results and impact •   To date, there have been no documented H5N1 outbreaks in Honduras. •   Geographic information systems, early warning mechanisms, and a national intervention plan have improved monitoring and effective emergency response preparedness. •   Animal health professionals know more about how to detect and diagnose zoonotic diseases, and lab upgrades have given them greater diagnostic capabilities. ___ 27 AHIF at Mission End Established to fill financing gaps in the action plans of developing countries to cope with H5N1 outbreaks, AHIF has largely accomplished its goals. Through the years, AHIF support has strengthened systems and built capacity, making countries more knowledgeable and better prepared even in the face of unknown future risks. The World Bank gratefully acknowledges the support of the Facility’s donors. Now, as the Facility begins its operational wind down—with close-out slated for June 2014—the work begun through AHIF funding is being continued by the countries themselves. The governments of partner countries are demonstrating their commitment to building on the gains in disease preparedness and risk reduction as part of a global partnership to contain pandemics for a healthier world. ___ 28 Photo Credits: Cover Photo: Schoolchildren laughing and waving hands. Maxim Zolotukhin / World Bank. Pg. 4, Chicken/bird wet-market near Hanoi. Ducks are transported to be resold in the capital city. EC Mid-Term Evaluation Team / World Bank. Pg. 5, AHI drill (triage and dummy patient) - China AHI Project. Shiyong Wang / World Bank. Pg. 8, Taking delivery of young chicks at the Ba Vi wholesale live bird market near Hanoi. The Vietnam AHI Project / World Bank. Pg. 10, Influenza awareness campaign in Sri Lanka. David Gray / World Bank. Pg. 11, Local villager in the resettlement village. Meriem Gray / World Bank. Pg. 12, Avian Influenza Control Project / World Bank. Pg. 13, Animal and human influenza capacity building drill in Mongolia. Shiyong Wang / World Bank. Pg. 14,15, 23, Laboratory in Hanoi where tests on Avian Flu are being conducted. Simone D. McCourtie / World Bank. Pg. 16, Feeding time at a poultry farm. Charlotte Kesl / World Bank. Pg. 18, AHI drill with dummy patient - China AHI Project. Shiyong Wang / World Bank. Pg. 19, Lab specialist working on avian influenza. The World Bank Pg. 20, Air disinfection drill - China AHI Project. Shiyong Wang / World Bank. Pg. 21, Wild bird avian influenza surveillance. Shiyong Wang / World Bank. Pg. 22, Animal and human influenza capacity building drill in Mongolia. Shiyong Wang / World Bank. Pg. 24, Luzdary Viveros, a poultry farmer. Charlotte Kesl / World Bank. Pg. 25, Middle East Consortium on Infectious Disease Surveillance (MECIDS). David Gray / World Bank. Pg. 26, Dr. Shamar Gul, responsible for the laboratory. Avian Influenza Control Project / World Bank. Pg. 27, Man working in the cooperative farm in Siguatepeque Honduras. Alfredo Srur / World Bank. Pg. 28, A youth holds a white pigeon. Yuri Mechitov / World Bank. Program Management Global Partnerships and Trust Fund Operations Department Concessional Finance and Global Partnerships Vice Presidency The World Bank 1818 H Street, NW Washington DC 20433 USA AHIF Donors: Australia India China Korea Estonia Russian Federation The European Slovenia Commission Iceland United Kingdom