Influenza A/H5N1 is one of many strains of avian influenza that can cause illness in poultry. Bird (or avian) flu outbreaks have occurred at various times around the world. Until 1997, there were no known human H5N1 cases. That year, 18 people in Hong Kong contracted the virus; of whom 6 died. To contain the virus, 1.5 million birds were killed. Since 2003, when the virus resurfaced and killed 4 people, scientists have closely monitored resurgent H5N1 outbreaks. When analyzing the viral spread and severity of H5N1, some health experts prefer to consider the average H5N1 human fatality rate since the virus emerged in 2003 (more than 50%). The World Health Organization (WHO), however, considers the annual change of human fatality rates. The overall human fatality rate was highest in 2004 (73%), followed by 63% to date in 2006, and 43% in 2005 ( Table 1 ). There has been some debate about whether H5N1 will cause a global pandemic. WHO ranks the current global H5N1 outbreak in pandemic alert phase three, which means a virus new to humans is causing infections, but not spreading easily from one person to another ( Table A-1 ). Some predict that if H5N1 were to become transmissible among humans, the virus could cause an "influenza pandemic" (worldwide disease outbreak). Skeptics argue that such predictions are exaggerated, because if the virus were able to transform into a strain that is efficiently transmissible among people it would have already done so. WHO warns that the virus is continuing to spread and that the threat has not been eliminated. Thus, in the latter view, governments should continue to prepare for some sort of pandemic and not become complacent even though H5N1 has not yet become transmissible between people. At last count, H5N1 has infected birds in more than 50 countries and infected 261 people, of whom 157 have died. More than 200 million birds in Europe, the Middle East and Africa have either died from H5N1 or have been culled in containment exercises. From December 2003 to August 2004, nine Asian countries reported H5N1 outbreaks in poultry. In late July 2005, Russia identified H5N1 in its poultry for the first time. By October 2005, birds in Croatia, Kazakhstan, Mongolia, Romania, and Turkey had contracted H5N1. In 2006, human H5N1 cases were being reported outside of Asia for the first time. While Iraq has reported human H5N1 cases, the strain has not been detected among its birds. There is some debate over the primary source of H5N1 transmission. Some experts contend that wild migratory birds infected with H5N1, notably water fowl, are the main vectors, or media of transmission. H5N1 has been detected in migratory birds in multiple countries, and in some instances, its spread has correlated with seasonal migrations of certain wild species. In some countries, H5N1 has only been found in wild birds. Some veterinarians point out that detecting H5N1 in wild birds can be difficult, because some of the infected birds are asymptomatic, harboring but not exhibiting disease symptoms or ill effects from the virus. Other experts, however, maintain that other important modes of transmission should not be underestimated, such as cross-border trade of infected poultry and transmission through poor agricultural practices. Indications that may support such assertions include the detection of H5N1 on commercial farms among caged poultry that are unable to mingle with wild fowl; the detection of H5N1 on farms located far from wetlands where migratory birds seasonally dwell; and the detection of H5N1 in regions where H5N1-linked wild fowl die-offs have not been reported. In some countries, such as in Nigeria, there are some indications that wild fowl may not be implicated in the transmission of H5N1. Some epidemiologists contend that the limited human-to-human transmission of H5N1 and other avian influenza viruses that have occurred should also be closely monitored. WHO asserts that the limited cases should not cause alarm, because the virus had not spread beyond a first generation of close contacts or caused illness in the general community. WHO adds that it has not elevated the pandemic risk of H5N1, because data from the incidents suggest that transmission requires very close contact with an ill person. P.L. 109-13 , FY2005 Emergency Supplemental Appropriations, provided the first appropriation for global avian flu efforts, though agencies and departments had already launched initiatives to combat the virus. The act provided the U.S. Agency for International Development (USAID) $25 million for ongoing efforts to prevent and contain the global spread of H5N1. USAID transferred $15 million of the funds to the Centers for Disease Control and Prevention (CDC). The Department of State (DOS) transferred an additional $6.3 million of tsunami relief funds to USAID for international avian influenza activities, as permitted by the law. Including the latter transfer, FY2005 emergency supplemental appropriations provided $31.3 million for global avian flu efforts. In FY2006, the President submitted a $7.1 billion emergency supplemental request for avian and pandemic influenza preparedness. Congress provided $6.1 billion for those efforts in two supplemental appropriations; appropriating $3.8 billion in P.L. 109-148 , FY2006 Defense Appropriations and $2.3 billion in P.L. 109-234 , FY2006 Emergency Supplemental Appropriations. U.S. agencies and departments might contribute additional resources to global avian flu efforts not specifically provided through these appropriations. Some activities that could support the control of avian flu include infectious diseases and influenza programs, global surveillance efforts, and influenza research initiatives. In FY2007, some appropriations bills included additional funds for global avian and pandemic influenza preparedness. Congress did not enact any of those measures. Instead, it amended P.L. 109-289 (Division B), which provides funding at the lessor of FY2006 enacted, FY2007 House-passed, or FY2007 Senate-passed levels until February 15, 2007. On November 1, 2005, the President released the National Strategy for Pandemic Influenza. The National Strategy was to provide a framework for future U.S. planning efforts that were consistent with The National Security Strategy and the National Strategy for Homeland Security. The President requested $7.1 billion to fund the National Strategy for Pandemic Influenza, some of which he suggested be set aside for international activities. The majority of the funds, $6.7 billion, were requested for HHS. One day later, on November 2, 2005, the Department of Health and Human Services (HHS) released its Influenza Plan. The HHS plan provided a detailed explanation of how the department would implement its part of the National Strategy. Some were disappointed by the relatively small proportion of funds reserved for international efforts in the National Strategy and in HHS' Plan. Advocates of greater spending on global avian flu efforts argued that if more resources were allocated to containing the virus abroad, Americans would be better protected, domestic pandemic preparedness efforts would be enhanced, and the likelihood that H5N1 would continue to spread and become efficiently transmissible between people would be lessened. Of the $7.1 billion related to international activities, the President requested: $200.0 million for HHS to undertake a number of activities, including international pandemic preparedness planning initiatives and pandemic influenza disease surveillance; $18.3 million for the U.S. Department of Agriculture (USDA) to undertake research and development initiatives and to provide avian influenza surveillance and prevention technical assistance globally; $120.0 million for the Department of Defense (DOD) to increase worldwide surveillance and upgrade related equipment; $10.0 million for DOD to assist military partner nations in procuring protective equipment, portable field assay testing equipment, and related laboratory equipment; $17.0 million for DOS to implement public diplomacy, training, and international outreach activities related to avian influenza and pandemic preparedness; $1.5 million for DOS International Visitors Program to provide 100 additional professional exchanges of doctors, health practitioners, and non-governmental organizations (NGOs); $75.2 million to USAID for efforts that encourage behavior change and raise awareness about avian flu awareness, diagnostic support initiatives, and pandemic preparedness and planning activities; and $56.3 million for International Disaster and Famine Assistance Funds of USAID to pre-position supplies and equipment, such as antiviral medication and protective equipment. In May 2006, the White House released the Implementation Plan for the National Strategy for Pandemic Influenza, which was released in November 2005. The Plan outlined how various U.S. agencies and departments would integrate the implementation of more than 300 actions that respond to an influenza pandemic threat. According to a status report on the Plan, released in December 2006, 92% of those actions have been completed and the United States has invested $434 million in international efforts ( Table A-2 ). The section below summarizes the role of each agency and department involved in international efforts, as outlined in the Plan, and highlights appropriations Congress provided to each. DOS is responsible for coordinating the U.S. international response to H5N1, including the interagency process to identify countries requiring U.S. assistance, identify priority activities, and ensure federal government assistance reflects those priorities. The department also informs American citizens abroad about where they can obtain up-to-date information and pandemic risk level assessments, enabling them to make informed decisions and take appropriate personal protective measures.