As far as an influenza pandemic is concerned, the question is not if but when, not whether millions will die, but how many millions. "The threat of a pandemic influenza is by and large acknowledged as a real threat," says Dr. Amar Bhat, chairman of the APEC Health Task Force and director of the Office of Asia and the Pacific at the U.S. Department of Health and Human Services. "The probability of it happening is greater than zero and the consequences, if and when it happens, are so enormous that we cannot afford to ignore it."

APEC is taking that sobering reality very seriously. In November 2005, APEC Leaders endorsed the APEC Initiative on Preparing for and Mitigating an Influenza Pandemic during the organization's 13th APEC Economic Leaders meeting in Busan, Korea. Under the Initiative economies commit themselves to individual and collective actions, including developing, approving, and implementing multi-sectoral, domestic influenza pandemic preparedness plans consistent with WHO recommendations. Their deadline: November 2006. Member economies are encouraged to work towards testing the plans, beginning with a regional desktop simulation exercise in early 2006 to assess the effectiveness of regional communication networks on avian and pandemic influenza outbreaks.

Avian Influenza is a top concern for Leaders in the Asia-Pacific region. "Given its prominence on the agenda at the Leaders' Meeting in Busan and the potential detrimental impact to the region's economy if an outbreak were to occur, APEC is exploring how to better coordinate its efforts through the collective actions of the Health Task Force," says Ambassador Tran Trong Toan, the APEC Secretariat's Executive Director. The Health Task Force is guiding these discussions in order to seek a quick resolution to the problem. "As the host of APEC 2006, Viet Nam is deeply committed to contributing to this effort by hosting the APEC Health Ministerial Meeting to bring up this issue to the highest-ranking heath officials for timely resolutions".

"If we do not take it seriously, any fruits that we have gained from trade and investment liberalization and facilitation would wither away in a significant way once a pandemic breaks out. Apart from losses and casualties, it is not difficult to imagine how much people would fear traveling, investing and doing business in the affected region"

APEC's Initiative on Preparing for and Mitigating an Influenza Pandemic calls for member economies to collaborate and cooperate in a transparent manner, including the timely sharing of epidemiological data, laboratory samples and viral isolates, with international and human health organizations and surveillance and monitoring of the disease in line with international rules. The Initiative spells out the importance of providing timely reports of suspected and confirmed animal and human cases of avian influenza and to strengthen disease surveillance, particularly by enhancing the capacity to rapidly identify cases and clusters in rural and remote areas.

The Initiative commits economies to respond rapidly to outbreaks in animals and humans; promote transparency in reporting by basing trade and travel restrictions on the science-based recommendations of relevant international organizations; supporting efforts to advance research on avian influenza viruses, vaccine and antiviral development and production. It also calls on member economies to support the development of mechanisms to increase production capacity and enhance the pharmaceutical delivery so that there can be equitable access to vaccines and anti-virals worldwide.

"What APEC is trying to do is part and parcel of what the world is trying to do to better prepare for a worldwide influenza," explains Dr. Bhat. "It involves a number of regional groups, the United Kingdom, the U.S., Japan and so on. They are trying to coordinate between these different groups, not duplicate efforts, and at the same time avoid gaps in planning."

Towards that end, APEC's initiative also calls for economies to develop practical and science-based bio-security guidelines for the poultry sector and veterinary policy guidelines on animal husbandry and strive for, where appropriate, the early implementation of the revised International Health Regulations. Previously the regulations dictated that nations report just three infectious diseases (cholera, plague, and yellow fever) to international health organizations. But the new regulations - effective starting in 2007 - have broadened the list of infectious diseases to include diseases such as avian flu and other public health emergencies of international concern.) "I think most APEC economies are in good shape and can implement the new regulations early on," says Dr. Bhat.

Time is of the essence. Since 2003 more than 60 people have died from the newest strain of avian influenza A/H5N1. Two thirds of the deaths have occurred in Vietnam but the presence of H5N1 in animals has been reported in eight APEC economies and two other Asian countries.

Conservative estimates suggest that predictions of what would be described as an average pandemic could result in five million hospital admissions and as many as seven million deaths. Says Bhat: "We have a potential that is very real but we don't know when and if, and we have a lot to prepare for."

So far the majority of people that have been infected with the H5N1 virus have had close contact with birds; bird to human infection is still very rare and not sustained. But there is the possibility that the deadly H5N1 could mutate into a virus that is easily passed among humans.

Indeed, scientific journals in October reported that a reconstruction of the 1918 influenza virus shows it to be an avian strain that mutated just enough to infect humans directly and easily. The 1918 flu pandemic killed more than 50 million people worldwide.

So far the best course of action is to prevent avian flu from becoming a human disease and preparing for a potential pandemic. Disease awareness, early detection and notification are prerequisites for effective control programs. APEC and its APEC Health Task Force have taken on a series of collaborative projects and proposals addressing emerging infectious diseases, preparedness and prevention. Efforts include the APEC Symposium on Response to Outbreaks of Avian Influenza and Preparedness for a Human Health Emergency, which was held at the end of July in San Francisco. The symposium put forward a wide range of suggestions in response to the threat of avian flu. Comprehensive joint proposals also have been put forward by a number of economies to strengthen cooperation to respond to avian flu outbreaks and meetings such as the one held in Brisbane in late October on Avian and Influenza Pandemic Preparedness and Response continue to add value. Most recently China is proposing to host a three-day event in April 2006 to address cooperation and coordination on emerging infectious diseases, focusing on prevention and containment.

Earlier this year, APEC's Budget and Management Committee approved for funding a project on pandemic preparedness. The project will establish general protocols and systems to help APEC member economies keep functioning in the event of a pandemic. This would not only involve international trade and transport sectors but also essential services within economies. Views put forward during consultation with health, trade and business sectors in the region will be brought together at a multi-sectoral symposium to be held in Vietnam in 2006. Following that symposium, recommendations will be finalized and will be launched in Australia in 2007.

Ultimately a key element of APEC's Influenza Pandemic Initiative is to urge all economies in APEC to work together and share information as quickly and widely as possible so that the group can prepare and respond as quickly as possible should an outbreak occur. "We want to be helpful to other economies and we can only do that when we have information to work from," explains Dr. Bhat. "If economies keep quiet about what is happening in their country, we aren't able to help them."

But it won't be easy. "By and large it's happening," says Bhat. "But it is difficult. Part of the problem is capacity and infrastructure. A lot of countries and not just APEC economies have weak public health infrastructure and the ability to report disease back to the capital is not there in many countries." Bhat notes that this is particularly true in countries where public hospitals are not the only vehicle for receiving health care and where a lot of people go to private practitioners or simply to a local pharmacist and never make it into the central health system. What's more, the number of economies that have actually completed pandemic preparedness plans is discouraging. In a recent presentation to APEC's Health Task Force, Dr. Ben Schwartz of the National Vaccine Program Office in the U.S. Department of Health and Human Services, noted that at the time of the survey, only five of APEC's 21 member economies had completed and approved national pandemic plans. Since the time of his survey, additional economies have completed their surveys. Barriers to preparing national pandemic plans according to Schwartz ranged from lack of interest on the part of ministries of health, to lack of guidance, lack of interest by government leaders to a lack of funding.

Meanwhile, a number of countries around the world are trying to stockpile Tamiflu, an anti-viral drug that has shown promise in the laboratory to treat avian flu in humans. Asian governments have announced that they want to start producing Tamiflu and are seeking licenses and technical assistance from Swiss-based Roche Holding AG to produce the medicine on their own. Associated Press recently reported that Indonesia and Vietnam have secured permission from Roche to produce the medicine on their own. Other economies, like Chinese Taipei and Thailand, are in talks with the company. But Bhat and others warn that anti-virals, and Tamiflu specifically, are not magic bullets.

For one thing, Tamiflu is a fairly complex product to make and a core ingredient - which is primarily obtained from star anise grown in China - is in short supply. "It's not a simple thing to manufacture and economies should not rely on it, they have to be prepared in other ways," says Bhat. "We don't even know how effective the drug would be during a pandemic. We can't afford to put all our eggs in one basket with Tamiflu. We need to continue with research on vaccines and anti-virals."

Indeed challenges remain on many fronts. Speakers at the APEC symposium on avian flu held in San Francisco urged governments to provide adequate compensation for poultry farmers and cautioned that countries should attempt reform of poultry production systems with low to minimal bio-security, most often characterized by the birds being sold in live bird markets, and of village and backyard systems with minimal bio-security. Reforms should follow international guidelines, addressing improvement in hygiene, introduction of market rest days for cleaning and disinfection, the segregation of different animal species, practices of storing and stacking animal cages, training and education of producers and market workers and the use of personal protective equipment. But while cities like Hanoi and Beijing have taken strong measures such as closing down wet markets, economies overall face an uphill battle.

APEC's role is to ensure the leaders at the top level are aware and are focusing on this issue and are doing all that they can within their economies, explains Bhat. "We have sent a consistent message that there is a real threat. It's really up to the individual economies working with their local and provincial authorities, as well as with international organizations such as WHO and the Food and Agriculture Organization to do what is necessary.

"While APEC can't do it for them, we can raise the alarm and try to help out with specific projects and share information"

"From a larger perspective, APEC's solution to Avian Influenza will be seen as a test case for how APEC will deal swiftly and effectively with an emerging threat that may have enormous consequences for people and business in APEC. APEC's reaction will show that APEC is dynamic in responding to the changing environment and new challenges, and that APEC really cares for its people in a practical way", concluded Ambassador Toan.