Will the avian flu infect Latin America?
The avian influenza virus is on the move and getting stronger. Since 2003, it has been infecting more than just birds; humans, too, have been affected. World Health Organization (WHO) figures show that a total of 152 people have contracted the disease, resulting in 83 deaths, representing 54% of the infected population.
Until last year, the strain of the virus that infects humans was confined to five countries in Asia—Cambodia, China, Indonesia, Thailand and Viet Nam. But this year it has begun to travel westward, migrating to Turkey, a European country. That country reported as many as 21 cases, though just four—and two deaths—have been officially confirmed by WHO laboratories, to date.
Transmission of the virus is from birds to humans, but given the trends in the virus’ behavior, there is a strong risk that human-to-human transmission could occur, creating the possibility of a pandemic situation. Some officials at WHO say that the risk of a pandemic is not a question of “if” but “when.”
But does a virus in Asia and Europe affect people living thousands of miles away in Latin America and the Caribbean? A panel of experts from the IDB, the Pan American Health Organization (PAHO), the World Bank and the United States’ Agency for International Development (USAID) gathered recently at IDB Headquarters to discuss the degree of danger, possible implications for the region and how they can work together to protect and prepare the region for a possible pandemic.
Avian influenza situation today
“Avian influenza is a contagious animal disease caused by viruses that most commonly infect birds, but that have also infected several species of mammals, including humans,” said PAHO’s Dr. Otavio Oliva.
“Most influenza virus strains only infect one animal species, but occasionally a virus will alter itself through genetic mutations, until it becomes capable of infecting other animals, as well,” Dr. Oliva explained. “That’s the problem that we’re facing now with avian influenza, particularly the strain known as H5N1.”
The real danger of flu pandemics comes when genetic mutations occur abruptly. Though it’s rare, it does happen, said Dr. Oliva.
“Pandemics can occur when three conditions are met: there has to be a total lack of immunity to the virus in the world population; the virus must be able to cause disease in humans; and the virus must develop an efficient means of person-to-person transmission,” Dr. Oliva explained. “The third requirement is the only one missing for H5N1 right now.”
So far, all of the infected people have contracted the virus through direct contact with infected birds. There haven’t been any cases where the virus was directly transmitted from one person to another. But influenza experts from WHO, PAHO, and other leading health agencies have warned that viruses are often very good at adapting themselves to their environments.
“In Turkey, we’ve already seen how the virus has mutated at the receptor-binding site; it has begun showing preferential binding to human cell receptors,” warned Dr. Oliva. That type of mutation helps the virus to infect humans more easily.
Given that mutations have already been reported, avian influenza is a very real threat to Latin America and the Caribbean, said PAHO’s Dr. Clarisse Etienne. “Progression of this disease can be very quick—less than 24 hours from one continent to another with the way people travel.” If a global avian influenza pandemic materializes, the disease could arrive in any country on the next flight that lands.
How dangerous is avian influenza to the Americas?
Influenza experts consider the risk of avian flu in Latin America and the Caribbean to be relatively low today, since birds flying south from the US are not believed to intermingle with birds heading to America from Siberia, where one of the latest outbreaks occurred (among birds, not humans).
The current perception of low risk could change, however, given the presence of the H5N1 strain of the virus in Canadian waterfowl, said a report by the IDB’s working group on the avian flu.
But if the virus mutates and person-to-person infection becomes possible, the risk picture changes completely. In that case, pandemic flu could spread in the Americas with or without sick birds. All it would take is one sick person traveling to the region.(1)
“Many countries in the region are vulnerable to global pandemics because their epidemiological surveillance systems are weak, especially for animal surveillance,” said IDB health specialist André Medici.
The British consulting firm Maplecroft developed a Pandemic Risk Index that ranks 161 countries. In that study, seven countries in Central America and the Caribbean are considered at extremely high or high risk, including Haiti, Barbados, Dominican Republic, Grenada, Guatemala, El Salvador and Jamaica.
On a regional level, PAHO’s Dr. Oscar Mujica estimates that if a moderate flu pandemic infected 25 percent of the Latin American and Caribbean population, more than 334,000 people would die over the course of the first eight weeks. If the pandemic were severe, the number of deaths could rise to 2.4 million.
Health is not the only factor to consider, though. An avian influenza pandemic could also have significant economic consequences for the region.
“Over 515 million work days could be lost if a moderate pandemic hit the region; a severe pandemic could increase that number to almost 730 million,” Dr. Mujica said, noting that his estimates are only illustrative and not meant to be taken as absolute predictions. “The direct costs for this lost time could be $15 billion in the former case, or $21 billion in the latter.”
Then there are the risks to the region’s poultry products industry, which produces $18.5 billion in poultry and $5 billion in eggs annually, according to PAHO’s Dr. Cristina Shneider.
“Poultry accounts for 40 percent of the protein consumed in Latin America and the Caribbean; each person in the region consumes 25 kg of poultry and 2.5 kg of eggs annually. If an avian flu pandemic hits the region and a large number of birds die or are culled, we’re going to have a nutrition problem on our hands, as well,” said Dr. Shneider.
Dr. Oliva added, “though the risk of pandemic is real and will persist, and the evolution of the threat cannot be predicted, we have a window of opportunity to intervene by strengthening national and international public health systems now.”
An ounce of prevention
The good news is that health experts from PAHO, the IDB and several other organizations are already hard at work monitoring the situation, implementing preventative measures and planning for a possible pandemic in the region.
On a worldwide scale, a global flu network has been established, led by the US, Australia, the UK and Japan, to work toward avian influenza prevention and monitoring. As part of the global network, 113 National Influenza Centers (NICs) have been established worldwide, of which 25 are located in Latin America and the Caribbean.
NICs monitor the influenza situation at a national level in the countries where they are located, isolating and characterizing viruses and sending samples to the Centers for Disease Control in the US for final characterization.
“The first line of prevention is early detection of viral circulation in poultry and the adoption of immediate control measures to eradicate viral circulation,” said Dr. Oliva.
Pan American Health Organization officials have trained all countries in the region—including those that do not have NICs—in influenza virus surveillance and diagnosis.
Countries have a key role
But even with a global network in place, countries need to step up to the plate if they want to stop avian flu from becoming a pandemic, health experts said.
PAHO, the IDB and other organizations are working with the countries in the region to develop National Influenza Pandemic Preparedness Plans (NIPPP) based on guidelines put out by the World Health Organization. The plans include measures for emergency preparedness, surveillance, case investigation and treatment, preventing the spread of disease, and managing essential services. USAID experts are helping countries develop self-assessments of their NIPPPs as well as action plans to fill any gaps.
To date, eight countries in the region—Argentina, Brazil, Costa Rica, Honduras, Panama, Chile, Ecuador and Mexico—either have completed NIPPPs or written drafts, plus the English-speaking Caribbean countries have drafted a subregional plan. Eleven others are currently developing their plans, including Bolivia, Colombia, the Dominican Republic, El Salvador, Guatemala, Haiti, Nicaragua, Paraguay, Peru, Uruguay and Venezuela.
But most of the plans have yet to be evaluated on their readiness to be implemented. For example, do the countries have financing available to strengthen animal and human health surveillance and laboratory networks, stockpile vaccines and antiviral drugs, compensate poultry product producers and small farmers for economic losses, and strengthen social communication and warning systems?
“Countries need to let the World Health Organization know about new flu cases in their territory; they need to make sure entry points such as airports, ports and border zones have adequate training in detection and surveillance; and they need to get involved at the local level in their public health systems and make sure people are informed,” said PAHO’s Dr. Mario Libel.
Some countries in the region have already begun efforts to contain the disease. For example, Brazil has set aside $440 million for this purpose, and has checkpoints in place at ports and airports to examine birds shipped into the country.
The Mexican government has designated $55 million to develop a bird flu vaccine, stockpile existing anti-viral drugs, buy protective gear for health personnel, and monitor the disease.
IDB versus avian influenza
“The IDB is involved in efforts to prevent and monitor avian flu on three fronts,” said the IDB’s César Falconi. “It provides financing to fund programs that address the flu, it supports PAHO in technical training initiatives, and it provides technical cooperation and support, again in collaboration with PAHO.”
The Bank is currently funding a regional technical cooperation project to support PAHO in evaluating and implementing countries’ NIPPPs. The project will also produce a study the determine countries’ degree of preparedness for avian influenza and develop a model for NIPPPs, or country action plans.
“Countries with skilled personnel and institutions can transfer their know-how to others that are less well-endowed,” said the IDB’s André Medici. “But that may not happen unless incentives are created to intensify cooperation.”
In addition to addressing health factors that may arise from an avian flu pandemic, the Bank is looking at economic and social considerations, as well.
“In some countries in the region, poultry products are so important to the economy that when prices rise, people actually call it ‘inflación del pollo’ (or chicken inflation),” said Falconi. “In order to protect the economies of such countries, the IDB is financing technical cooperation activities to evaluate financial compensation mechanisms, in case culling or other emergency measures are required.”
Finally, the Bank is actively coordinating with international institutions, governments, the private sector, research centers, and civil society, through participation in conferences, working groups and international initiatives, including the Global Framework for the Progressive Control of Trans-border Animal Diseases (GF-TADs).
GF-TADs is working to develop a coordinated regional action plan taking into account issues that are difficult to address at the national level, such as bird migration standards updating, and international communications and cooperation.
Getting the region’s attention…
Health experts stressed that what’s been done so far is just a fraction of what needs to be done to really prepare for a pandemic; and that the need to prepare is more urgent than it may seem.
“Latin America and the Caribbean are seen as low-risk regions for avian influenza,” said the IDB’s Marco Ferroni, “and people tend to ignore low risks.”
The way to get countries to pay more attention to the risks is to produce a study showing the expected impacts of an avian flu pandemic, both in health and economic terms, health experts said.
“Even if there are zero cases of the flu in the Americas, Latin America, and especially Brazil, will suffer because exports of chicken will plummet due to fear of the disease. The economic impacts on the region could be huge,” said the World Bank’s Mark Cackler.
Latin America and the Caribbean produce 16 million tons of poultry annually, representing 26 percent of the total worldwide poultry production, as well as 5 million tons of eggs per year. Brazil is the third largest poultry producer in the world; poultry products account for 23 percent of that country’s exports, according to PAHO.
…and moving forward
PAHO's Dr. Etienne emphasized the need to coordinate efforts across sectors and agencies. “We urgently need to put together a joint initiative,” she said. “We need to jointly develop the information to give to countries to communicate with their people, for example. We also need to work jointly on assessing country plans, doing gap analyses and economic modeling, and information knowledge management.”
Fundraising is another area for collaboration, said the IDB’s Wanda Engel. “We need to coordinate on financing country plans; piecemeal financing isn’t going to get us anywhere,” she said.
The international community committed $1.9 billion to the anti-avian flu effort at a conference in Beijing, China, earlier this month. But World Bank estimates put the total cost of a pandemic to the world’s economy at $800 billion in the first year, alone.
Dr. Margaret Chan, a pandemic expert at WHO, said in Beijing that the cost of acting now is “peanuts,” compared to the potential losses in the event of a pandemic.
(1) Note: See Avian vs. Pandemic Flu on PAHO's website.