After 2003, outbreaks of H5N1 avian flu surged in several Asian countries. In Vietnam, which shares a long border with Lao PDR, nearly a fifth of the entire poultry stock died or was culled in 2003 in disease control efforts. Lao poultry, which is a staple for most of the population as well as an important source of income, was clearly at risk. However, the veterinary services could not carry out adequate surveillance and control of the disease because they lacked people, equipment, training, and other resources. The country had only a few veterinarians. If avian flu was allowed to spread in poultry, it would have more opportunities to mutate.
A mutation making the virus transmissible among humans would have potentially catastrophic consequences for Lao PDR and the rest of the world. Controlling the virus at the source in poultry was therefore an imperative. Most of the country’s 20 million poultry are raised in small units: an average village has some 350 chickens and other poultry, raised by 78 families, while about 25 percent of the country’s poultry production is on commercial farms near cities.
Detecting and controlling H5N1 avian flu would only be possible with farmers’ cooperation. The authorities, concerned that a pandemic (affecting people in all countries) should not start in Lao PDR, asked for help from the international community. As one of the poorest countries in the region, Lao PDR lacked the financial resources to respond adequately to a highly probable outbreak in poultry, putting at risk not only farmers’ livelihoods but, should a mutation occur, also human health, the country’s economy, and the populations and economies of the rest of the world.
The program was multisectoral: it was jointly prepared and implemented by the veterinary services, public health departments, communications department, disaster risk management unit and other organizations, under the overall coordination from the office of the prime minister. The project was part of the “Global Program for Avian Influenza Control and Human Pandemic Preparedness and Response,” which the World Bank used to support avian flu control and pandemic preparedness in 60 countries. The essence of the Bank’s approach was to emphasize pandemic prevention and to work with partners at the country, regional, and global levels. Extinguishing the source of a potential human disease in animals could prevent human illness, deaths, and the severe economic disruption that a pandemic would bring. Prevention in turn required that human public health be concerned with the source of the risk, which was in poultry, outside the health sector.
In Lao PDR, as in many developing countries, this was the first time that external assistance was provided to animal health services since this had not been a donor priority. These services still require substantial strengthening. Communications was also a key component, to increase farmers’ awareness of disease risks and to encourage their cooperation with prompt reporting of disease and culling (compensation was provided for animals destroyed in the interest of public health). While the project was an emergency one, training and other capacity building were included, since the risks of animal-borne diseases are rising in developing countries, including Lao PDR. The project took advantage of the high international attention and additional resources to make progress in animal disease detection and control. The project also supported pandemic preparedness.
Key outcomes from September 2006 to June 2011:
- All 17 provinces have established multisectoral avian influenza teams (surpassing the end-of project target of 85 percent of provinces having established such teams). These teams mobilize in case of an outbreak and are an essential component of preparedness for rapid and appropriate reaction to outbreaks. The effectiveness of the teams was reviewed as well as tested in actual avian flu outbreaks.
- All provinces have elaborated and adopted avian influenza and pandemic preparedness plans (surpassing the end-of-project target of 85 percent of provinces having such plans). These plans were tested in the 2009 H1N1 flu pandemic; in part thanks to the plans and related preparedness, the impact of the pandemic was very small.
- By 2010, biosecurity and biosafety training for: 73 percent of backyard farmers in the three most populous provinces (starting from a baseline of 0 in 2006), 12 percent of farmers in the 14 other provinces (reaching the target), 100 percent of commercial producers of chickens, and 100 percent of commercial producers of ducks. Surveys of Knowledge, Attitudes, and Practices showed increased knowledge, which is essential for disease prevention, detection, and control.
- Biosecurity training delivered to 305 slaughterhouses (compared to a target of 181), 733 poultry traders, and 1,556 fighting cock owners.
- Active disease surveillance established in 156 markets, entailing inspection at least twice a month (surpassing the target of 150 markets).
- One hundred percent of diagnostic tests were carried out within 48 hours of reaching a laboratory and 100 percent of samples reached a laboratory within 48 hours of the disease outbreak. Rapid diagnosis is a crucial step in disease control. Delayed diagnostics lead to delayed control measures, increasing the risk that a disease outbreak will spiral out of control. An animal health laboratory is nearing completion, augmenting Lao capacity to identify pathogens that threaten people, livestock, and/or wildlife.
- At least two village veterinary workers were trained on avian influenza prevention, symptoms and response in 73 percent of villages. Avian flu prevention training was delivered to 5.5 percent of markets (compared to a target of 2.3 percent) and 16 percent of villages (compared to a target of 25 percent of villages).
- Health workers received training on disease surveillance, infection control and case management. The trainees were tested, including through role-play, showing that training was effective.
- Health departments in 94 percent of provinces now send weekly surveillance reports (compared to an end-of-project target of 75 percent and baseline of 0).
Four avian flu outbreaks were successfully contained in Lao PDR, so that the disease did not spread. The risk of emergence of a pandemic, which would have affected the whole world, was lowered because Lao PDR did not allow the H5N1 virus an opportunity to mutate. It is impossible to know whether the virus would have mutated had these outbreaks not been contained.
As an intermediate output, the project put a spotlight on the acute weaknesses of public veterinary health services. However, with more robust support in the years to come, these weaknesses can be remedied to the benefit of the people in Lao PDR, the region, and the rest of the world. The policy dialogue with IDA and evaluation of the performance of Lao veterinary services, carried out during the project period with OIE assistance, are essential contributions to a future program to ensure prevention of animal-origin diseases, including those with pandemic potential.
The project was supported by an International Development Association (IDA) grant of US$4 million. Co-financing was from the Avian and Human Influenza Facility (AHIF) grant of US$6.4 million, and the Japan Policy and Human Resources Development (PHRD) Fund grant of US$2 million. Both the AHIF and the PHRD grants are Bank-administered trust funds. The AHIF is a multi-donor facility with contributions from ten donors, of which the European Commission is the largest.
IDA worked with in-country donors, the World Organisation for Animal Health (OIE), and the United Nations (UN) agencies and organized annual joint implementation reviews to identify gaps and overlaps. This coordination was appreciated by government and partners and established a good model for joint work across sectors. IDA provided regular reports to donors to the AHIF, and some donors participated in scheduled in-country reviews. The Food and Agriculture Organization of the UN (FAO), the Australian Agency for International Development (AusAID), the United States Agency for International Development (USAID), the World Health Organization (WHO), CARE, the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP), the United States Centers for Disease Control and Prevention, the European Commission, the Asian Development Bank, OIE, the International Organization for Migration (IOM), and the UN System Influenza Coordination are among the partners who worked with the government to implement the program, which benefited from total external support of US$35 million. These partnerships and engagement at ministerial conferences on animal and pandemic influenzas helped Lao officials improve their knowledge of disease prevention and control in other countries and globally.
Toward the Future
The project-supported improvements in capacity and equipment/facilities will serve well to contain future disease outbreaks, which are unfortunately likely to recur. Improved knowledge among people about the ways to protect themselves and their poultry will continue to be relevant. However, substantial additional resources are needed to establish and operate a fully effective disease prevention and control capacity. The Lao authorities have decided to adopt a One Health approach, focusing on containing infectious diseases at their animal source in order to protect humans. The government is currently seeking support for strengthening the country’s animal health services and related human health systems and the way they work together.
The response to avian and pandemic influenza was an example of international community mobilization to deliver a global public good. The two major shortcomings are that governments and donors pay little attention to sustainability and that they grossly underestimate the pandemic threat. As a result, pandemic prevention and preparedness are not being financed, so the modest capacities created during the international response will degrade and ultimately disappear.