Final Report Summary - ASIAFLUCAP (Health system analysis to support capacity development to respond to pandemic influenza in Asia)
The emergence of the H1N1/2009 pandemic has led to an increased attention to health system capacity to respond to the threats from the disease. In Asia-Pacific, particularly Southeast Asia, there has been active investment in preparedness strategies and planning in many countries following previous experiences from severe acute respiratory syndrome (SARS) and avian influenza. However, most countries had very limited information on the availability of health system resources to respond to the pandemic. The ASIAFLUCAP project has been implemented since 2008 at a time of uncertain pandemic threat. With funding support from the European Commission (EC) for the study in Thailand, Vietnam, Indonesia and Taiwan and supplementary funding from the Rockefeller Foundation to extend the study to Lao People's Democratic Republic (PDR) and Cambodia, this project provides a framework to evaluate health system capacity and it systematically determines operational capacity gaps in these countries in order to support containment and mitigation of pandemic influenza in the region.
The rapid situational analyses conducted as part of the project prior to the H1N1/2009 pandemic revealed that health system context has very strong influence on the approach adopted towards pandemic preparedness. Investment in pandemic preparedness activities has contributed to the strengthening of health system functions in many countries, specifically in regards to surveillance, laboratory capacity, monitoring and evaluation and public communication. However, the low investment in clinical care and pandemic mitigation preparation was still a major challenge.
Through an extensive review of the literature and guidelines related to influenza and severe respiratory disease infections, we identified a list of key health system resources that are likely to be drawn upon for pandemic responses. The list was reviewed and prioritised to identify essential resources for the region for both containment and mitigation. Extensive fieldwork was conducted to enumerate the quantity of resources at district level from district health offices and hospitals with additional data collected at national levels to capture central stockpiles and core supplies. A training workshop was organised to equip country collaborators with general concepts of geographical information systems (GIS) and necessary policy communications and dissemination skills.
The ASIAFLUCAP project also developed mathematical models as to simulate the transmission dynamics of a pandemic virus in each country under various scenarios. Findings from the latest H1N1/2009 pandemic were used to inform the modelling. By incorporating existing knowledge on patterns of resource usage and resource depletion for severe respiratory cases, the level of key health system resource needs in a given pandemic scenario was estimated. Importantly, the model allows for resource depletion / commitment effects as well as the effects of key public health interventions based on various scenarios. Comparative analyses of resource needs and gaps and the potential impact of inadequate and inefficient distribution of health resources on excess mortality rates were carried out across countries and between provinces within countries. The ASIAFLUCAP simulator, a user-friendly version of the model, was developed as a tool for policy makers and other stakeholders to help inform evidence-based resource allocation.
Pandemic preparation and responses are not merely a technical process. They are political processes involving multiple stakeholders where technical inputs are only one aspect of the decision making process. A stakeholder analysis was also conducted using the actual experience from the response to the H1N1/2009 to identify stakeholder capacity strengths, gaps and constraints and inform the evaluation of governance architecture and processes. Policy linkages and utilisation have been central to the design of the ASIAFLUCAP project, in addition to dissemination via academic publications and presentations.
Project context and objectives:
The ASIAFLUCAP project was conceived and has been implemented since 2008 at a time of uncertain pandemic threat. It was before the emergence of the H1N1/2009 pandemic. At the time, avian influenza acquired world-wide attention when a highly pathogenic strain of the subtype H5N1, which probably arose before 1997 in southern China, gained enzootic status in poultry throughout southeast Asia and 'traversed interclass barriers' when transmitted from birds to mammals (cats, swine, humans). Although not an unprecedented event, the substantial number of documented cases in humans associated with severe disease and several fatalities has raised serious concerns about a pandemic potential of the H5N1 strain. The spread of H5N1 in the southeast Asia region has resulted in considerable public health and political concern. In part this stems from recognition that, should H5N1 undergo re-assortment or mutation, a human pandemic is likely and this was bound to have very substantial global economic and public health consequences. Many experts anticipated that southeast Asia is likely to be the epicentre of the next pandemic of influenza.
The ASIAFLUCAP project was conceived in line with European Union (EU) policy to assist developing countries to combat a potential worldwide influenza epidemic. In 2005 and 2006 activities to combat influenza outbreaks were discussed in several workshops hosted by World Health Organisation (WHO) and the EC. The EC agreed to help providing plans to assist third countries to control and combat the avian influenza virus at its source and it also pledged considerable financial support through the pledging conferences.
One important challenge faced by public health researchers before the launch of the ASIAFLUCAP project was the lack of a universally accepted, organised method for evaluating preparedness. This in part stemmed from uncertainties surrounding likely transmission dynamics of a pandemic. But even when there is broad agreement, or limits can be placed around key parameters (including the impact of interventions), there remains little consensus on the best methodological approach to the evaluation of preparedness. A number of approaches have been taken including assessments of national strategic plans, desk-top simulations, functional exercises, full scale 'wet runs', case studies with site visits to assess health systems and mathematical modelling analyses. All have their strengths and weaknesses but few evaluations have determined specific resource gaps and process frailties.
The ASIAFLUCAP project proposed an innovative approach that had been pilot-tested in the Thailand context to link coherently quantitative analyses of resource gaps with qualitative assessments of governance constraints in utilising those resources determined. Previous reviews of strategic pandemic preparedness plans have shown that many countries have made considerable progress in the past two years. Important resources have already been allocated to the development and/or further strengthening of animal and human disease surveillance and response systems for early detection and prompt containment of avian influenza and other emerging zoonotic diseases. The Beijing pledging conference and subsequent Bamako conference highlighted imperatives in terms of up-scaling capacity to meet resource needs, particularly in Asia and Africa. Considerable efforts have been expended over the past couple of years in developing national strategic pandemic preparedness plans.
However, in southeast Asia whilst considerable progress has been made and substantial domestic and international efforts are being focussed, public health system capacity to respond to pandemic influenza remains a profound challenge. Indeed, it was shown that operational capacity and governance clarity are areas that need to be robust if pandemic influenza responses are to be effective and efficient. Highlighting this issue, a report to the United Nations System Influenza Coordinator (UNSIC) captured a critical gap in preparedness planning, noting: 'Very few countries have succeeded in transforming high-level political plans into a strategic framework and detailed annual operational plans to drive implementation. These operational plans should address both preparedness and response in the event that phase four, five or six is reached.'
The ASIAFLUCAP project proposed to address three critical issues related to pandemic preparation, namely, collaboration with Asian partners, public health research and a focus on containment and mitigation of pandemic influenza. The study has been conducted in four countries namely Thailand, Vietnam, Indonesia and Taiwan. Additional support from the Rockefeller Foundation allowed the project to be carried out in two additional countries, namely Cambodia and Lao PDR. The goal of this project is to provide a strategic framework to evaluate health system operational capacity and to systematically determine operational capacity gaps in order to support containment and mitigate the consequences of pandemic influenza in these countries and elsewhere. There are six specific objectives outlined in the project proposal. These include:
1. to develop a detailed methodological framework to evaluate operational capacity to respond to pandemic influenza.
2. to support evaluation research for pandemic influenza preparedness in Asia and to identify basic principles in determining capacity to ensure a coherent approach to pandemic preparedness in both Asian and European countries.
3. to determine capacity gaps in responding to pandemic influenza in Vietnam, Indonesia, Thailand and Taiwan and strengthen operational response capacity.
4. develop and support a network of expertise, knowledge and shared experience in public health in relation to pandemic influenza preparedness and control across the EU.
5. to build upon and extend a network of EU-funded collaborating operational researchers in a coherent manner, linking projects in a value-added manner.
6. to build upon and extend a network of collaborating operational researchers in EU and Asia, to support sharing of experience, knowledge and skills and to disseminate lessons and best-practice within and across regions.
These objectives are measured by the number of participants, the analytical reports and peer- reviewed journal publications. They are presented later in this report. The success of the network formed under ASIAFLUCAP project can also be measured in terms of joint publications, workshops and briefings. The value-added nature of collaborators working across a number of research projects should ensure a growing body of knowledge, a sustainable research network and operational research capacity in the Asia Pacific region as well as in the EU, in addition to offering added value through cross-learning and sharing of experiences.
Project results:
The EU ASIAFLUCAP project was initiated on 1 May 2008 and carried out over three years, ending on 31 April 2011. The project comprised eight interlinked work packages (WPs):
1. Management and coordination
2. Rapid situational analysis
3. Resource characterisation
4. Stakeholder analysis
5. Scenario development
6. Resource gap analysis
7. Project evaluation
8. Dissemination.
A description of the activities and (where relevant) key findings of each WP is presented below.
WP2. Rapid situational analysis
This WP was carried out effectively and has achieved its objective to provide, rapidly, a contextual understanding of the challenges and constraints likely to be faced, the health systems context within which a response must function and identify sources of information, data and stakeholders to inform the remaining WPs. At the beginning of this WP, a toolkit was developed for a rapid systematic analysis of current capacity and capacity development requirements to the threat of pandemic influenza at the country level, or in the case of Indonesia, the provincial level. The toolkit is based on a methodological approach to balance a relatively high degree of accuracy and validity and simplicity, speed and limited cost. A paper describing the underlying methodology has been published in an international peer-review journal.
One workshop was organised in Hanoi, Vietnam, in September 2008 to finalise the toolkit and the report format as well as to coordinate the data collection process and fieldworks in the four countries. Based on the toolkit, literature and document reviews were carried out in each country before fieldwork for key informant interviews and additional data collection. The fieldwork took place between October and December 2008 with researchers from the London School of Hygiene and Tropical Medicine (LSHTM), the Hamburg University of Applied Sciences (HAW-Hamburg) and all four country partners. Important contextual health system structures and processes associated with preparedness were identified and described. Perceived capacity gaps and challenges to preparedness were explored. Our study reveals that health system context has very strong influence on the approach adopted towards pandemic preparedness within a territory. The interfaces and linkages between health system contexts and pandemic preparedness programmes are particularly strong in three areas: governance and stewardship, resources and service provision. Investment in pandemic preparedness activities in the region has contributed to the strengthening of health system functions in many countries, specifically in regards to surveillance, laboratory capacity, monitoring and evaluation and public communication.
However, the low investment in clinical care and pandemic mitigation preparation is still a major challenge. In a number of countries, information on stockpiles of antiviral medicines or other key health system resources is not readily available to policy makers. At service delivery level in several countries, operational plans to respond to later stages of a pandemic are still not in place.
The results from this WP have been documented as four country reports available for download from the ASIAFLUCAP website. Additionally, a comparative analysis was done and published in an open-access journal, BMC Public Health. The findings from this WP have been communicated to policy makers in the countries in time for the spread of the H1N1/2009. At the regional level, they were presented at regional forums such as the Regional UN Pandemic Influenza Donor Coordination Meeting and the Southeast Asia Pandemic Preparedness forum, among others.
WP3. Resource characterisation
The objective of this WP was to determine the scope of resources and characterise those resources used in previous pandemics and public health crises. The activities included a literature review and retrospective analyses of outbreaks in countries of southeast Asia and a systematic review to list resources within the framework of enabling environment, WHO preparedness themes and organisational capacity.
Through an extensive review of literature and guidelines related to influenza and severe respiratory disease infections, this WP identified a list of health system resources that are likely to be drawn upon for surveillance, case investigation, case management, community control and overall management of a pandemic. The review found that 358 health system resource items have been utilised in response to SARS, avian influenza, or pandemic influenza. These resource items can be classified into four main categories, namely materials including drugs, vaccines and personal protective equipments (PPEs); human resource; infrastructure and equipment; management and communication resources.
A panel of experts was formed and a Delphi process was carried out at a workshop in Ubud, Indonesia, to contextualise the resources such that the list can practically inform planners in southeast Asia. The final list contains 57 resource items relating to infrastructure, equipments, materials and human resources. The list was reviewed and prioritised by international and local experts to identify essential resources for the region. A technical report was prepared and the findings from this exercise were documented and submitted for publication (under review) at a regional journal, Southeast Asian Journal of Tropical Medicine and Public Health.
WP4. Stakeholder analysis/institutional mapping
Stakeholders' roles are informed by their relationships with institutions. Many lessons were drawn from the SARS outbreaks and the global governance architecture has been modified as a result. The objective of the stakeholder analysis was to identify stakeholder capacity strengths, gaps and constraints and inform the evaluation of governance architecture and processes. As reported in the Inception Report, this WP was postponed from the earlier planned date in the first year of the project to start in May 2010 instead. The consortium agreed that this new start date fits better with other WPs to ensure smooth progress of and effective coordination between all WPs.
One workshop was organised to identify key areas for stakeholder analysis in all the study countries. A toolkit was developed to collect and analyze important information from key persons inside and outside of the government who might influence the policymaking process with regard to pandemic preparation. In this study, stakeholders refer to individuals, groups, or organisations that have a significant interest in how well a pandemic influenza control and response program functions. It employed key informant interviews as the main data collection method in addition to literature and document review.
Given the emergence of the H1N1/2009 pandemic, we capitalised on this opportunity to draw upon stakeholder's actual experiences from a real pandemic scenario. Thus the stakeholder analysis became, in many ways, a 'post-mortem' of the capacity strengths, challenges and gaps that were exposed or highlighted in each country during the pandemic. Altogether, 132 key informants were interviewed in the four ASIAFLUCAP countries (and 27 more in Lao PDR and Cambodia as part of the Rockefeller Foundation-funded support). They included policy makers, international development partners, academia, private sector and other opinion leaders.
The study found that there were important similarities and differences in two broad aspects of response measures-command and control; and resources and mobilisation-for the H1N1/2009 influenza pandemic. In the aspect of command and control, the pandemic alert announcements declared by the WHO on 27 and 29 April 2009 switched on the pandemic preparedness and response systems from planning to implementation in each of the six countries. A top-down cross-sector command and control model was adopted universally by the participant countries. Moreover, international health organisations seemed to have direct influence over decision-making in some countries. With regard to resources and mobilisation, previous experience in SARS outbreaks and avian influenza epidemics or concerns, together with technical advice and assistance from international health organisations (e.g. the WHO), shaped strategies and action plans profoundly in each of the six countries for the H1N1/2009 pandemic. Three main types of weaknesses or gaps were identified. These were:
1. limited resources (financial, human and material)
2. public compliance to H1N1 vaccination; and
3. risk communication and risk management of governments.
Additionally, three aspects of capacity constraints were identified including regulation enforcement capacity, bureaucratic management capacity and capacity to sustain pandemic preparation and response.
Four key lessons were learned from the stakeholder analysis of the latest pandemic response in the six countries. They are:
1. strengthen information sharing, capacity building and collaboration within and among countries to close the gap between preparedness planning and response implementation
2. improve equitable distribution and timely accessibility of financial, human, technological and material resources, especially at districts and local areas
3. make the governance transparent to enhance public trust and public acceptance of pandemic response measures
4. prepare for the unexpected and speed up research to overcome the unknown.
WP5. Scenario development
The objective of scenario development was to form the basis under which operational capacity can be evaluated and gaps determined. To develop pandemic progression scenarios, the research team comprising of partners from the National Insitute for Public Health and the Environment (RIVM), HAW-Hamburg and LSHTM employed mathematical modelling techniques as a tool to simulate the transmission dynamics of different pandemic influenza scenarios. A compartmental, resource-linked transmission model was developed.
In addition to estimating resource needs for a given pandemic scenario, feedback loops within the model account for the effect of resource depletion on the expected disease burden, in terms of expected mortality rate. The impacts of the available quantities of antiviral drugs, vaccines, hospital beds and medical ventilators are considered in the model. The model can simulate pandemic scenarios for a range of severities, depending on the input parameters values chosen. Two main sets of parameter values were derived from an extensive literature review: one set is based on data from the H1N1/2009 pandemic to simulate a 'mild' scenario, while another set of values was derived from data from the 1918 influenza pandemic and from H5N1, to simulate a more severe hypothetical scenario.
By incorporating existing knowledge on the level of resource use and the rate of resource depletion in severe respiratory cases from earlier studies by local partners, the model can be used to estimate key health system resource needs and gaps in a given pandemic scenario. The assessment of resource requirements takes into account potential reserve (shared) capacity in the health system for scaling up of necessary services. The effects of key interventions (antiviral administration, vaccination, social distancing) based on various scenarios can also be tested and evaluated. To make the model more user-friendly, the 'ASIAFLUCAP simulator' was developed. This comprises of a Microsoft Excel version of the model with a Visual Basic interface that allows researchers and policy makers to easily input data and adjust key parameters to be relevant to their country context. Thus, the ASIAFLUCAP simulator can be used as a tool by policy makers to help inform resource allocation and mobilisation. The ASIAFLUCAP simulator includes both the mild and severe pandemic scenarios and a function to export model outputs into file formats appropriate for GIS mapping software. A workshop was organised to demonstrate the use of this software to all project partners and country users and a demonstration video to show how this software can be utilised for policy decision making was produced and made available on the website (see http://www.asiaflucap.org online). The software has also been demonstrated to regional and country level policy makers and stakeholders at various venues.
WP6. Resource gap analyses
To evaluate the availability and distribution of existing health system resources for pandemic response in the four countries, fieldwork was conducted to enumerate the quantity of essential resources at district level. Data were collected on key resource items based on results from the literature review and Delphi analysis as described in WP3. A number of specifically developed questionnaires were designed and used to collect data from district health offices and hospitals. Additional data were collected from national level to capture the central stockpiles such as antiviral drugs or supplies. These were supplemented by information from routine data sources, literature reviews and interrogation of health system databases.
A framework was developed to determine resource depletion rates as well as to link this WP with the previous WP on scenario development to allow for the influence of resource depletion on disease progression. The existing gaps of key health system resources were then estimated based on the scenarios developed from pandemic progression modelling. Comparative analyses of resource availability, resource needs and gaps across countries and across provinces within countries, were carried out to identify the types and quantities of critical resources required to respond to pandemic spread. Excess deaths that could be avoided if resources could be deployed effectively were also estimated.
The study found that wide variations exist in resource capacities between and within the six countries. Substantial excess mortalities were predicted as a result of resource gaps, particularly in poorer countries. Severe nationwide shortages of mechanical ventilators were estimated to be a major cause of excess mortalities in all countries except Taiwan. Other resources (oseltamivir, hospital beds and human resources) are inequitably distributed within countries. The findings have important implications for where (both geographically and in which resource types) investment is most needed and the potential impact of resource mobilisation for mitigating the disease burden of an influenza pandemic. Effective mobilisation of resources across administrative boundaries could go some way towards minimising excess deaths. Results from the analyses of resource availability, needs and gaps can help policy makers prioritise their resource allocation plans towards an effective pandemic response given limited resources. In Thailand for example, these results have informed a policy decision by the Ministry of Public Health for increased purchase and distribution of ventilators.
In addition to research activities, a training workshop was organised in July 2009 to equip country collaborators with general concepts of GIS and necessary skills to be able to produce its own resource maps for policy communications and dissemination. Advanced GIS analyses were conducted for specific assessment and comparative analyses of selected key resources.
Furthermore, the ASIAFLUCAP simulator has been disseminated among the partner counties to enable them to conduct further resource gap analyses, for example to explore other scenarios and resources and using updated resource availability data, according to local priorities. A local-level analysis has already been conducted for Bali in Indonesia, which found that the majority of resources were focussed in and around the provincial capital, Denpasar, although gaps in nursing staff, surgical masks and N95 masks were estimated for all districts.
WP7. Evaluation
The objective of the evaluation WP was to provide feedbacks to project collaborators and to ensure the project has met its objectives. The ASIAFLUCAP research consortium conducted a midterm evaluation in addition to an overall project evaluation at the end of the research.
A questionnaire for midterm evaluation was designed by the HAW-Hamburg team to evaluate the perceptions and experiences of all partners about the research project, its progress towards its objectives, lessons learned from research fieldwork and the coordination and management support by LSHTM. It was distributed to all participating partners during the consortium meeting in November 2009. The answers were analysed and the findings were presented to all collaborators. Overall satisfaction towards the project was high but there were recommendations to improve information sharing from different WPs in relation to individual project countries. Internal communication among all project partners was described as good. However, the financial management and reporting process required by the EU was described as difficult. Internal adjustments were made to ensure that activities can be carried out smoother in the second half of the project. Suggestions on how to facilitate dissemination of results and their incorporation into national policies were also asked for.
Before the end of the project, the final project evaluation was prepared and another questionnaire was designed to collect information on the usefulness of a preparedness assessment 'Toolkit' for conducting periodic health care system capacity assessments, based on the instruments used in the ASIAFLUCAP project. In addition the partners were asked how the country benefited from the activities in this project, whether the results are likely to influence ministerial policy making and areas where further research, training and support is needed.
WP8. Dissemination of project lessons
The objective of this WP was to coordinate the dissemination of knowledge and expertise from this project on operational capacity evaluation in support of influenza preparedness planning in Asia. Policy linkages and utilisation are central to the design of the ASIAFLUCAP project. Our research results from all WPs have already been disseminated and used by partners and policy makers. The emergence of the H1N1/2009 epidemic also called for latest findings and knowledge related to pandemic preparation for which the ASIAFLUCAP researchers have contributed both formally and informally. The findings from ASIAFLUCAP have been presented at national, regional and international meetings, including academic conferences and workshops designed specifically for policy makers. A number of research papers and academic publications have been prepared and submitted and published. A number of posters have been prepared and presented at international forums and a number of briefing documents have been produced and disseminated.
All Asian partner countries remarked that the activities in the ASIAFLUCAP project have provided them a valuable new and in-depth insight into their national health systems pandemic management and response capacity as a whole and that of neighbouring southeast Asian project countries. It has enabled an evidence-based estimate of where and to what extent gaps exist and where crucial gaps need to be filled. In general the partners noted the working together with different countries in the region for a common purpose and the methodology of the project master plan as very positive. The regular teleconferences, the face to face meetings with all partners and the workshops were described as being very helpful for understanding and coordinating the project work. The emergence of a common platform for communication among the project countries was noted to be very constructive.
The project has demonstrated new approaches to systematically collect and assess information on the capacity and preparedness of national health system to respond to the threat of an influenza pandemic. The rapid situational analysis, the questionnaire-based resource characterisation, the mathematical simulation model-based resource gap and needs analysis, its graphic visualisation in form of maps and the qualitative interview based stakeholder analysis were the approaches used to provide a very comprehensive picture. A 'toolkit' for the periodic assessment of the national health systems pandemic preparedness and response capacity, based on the instruments used in the project was considered beneficial by all partners.
The project work led to numerous bilateral and multilateral contacts being established not only to institutions dealing with pandemic preparedness activities in the region but also with national institutions in all the ASIAFLUCAP partner countries. At the regional level, cooperations with neighbouring countries, universities, national ministries of health, communicable disease networks, non-governmental organisations (NGOs), research networks, international and regional health organisations and foundations across Asia and Europe developed during the course of this project. At the national level the project facilitated the development of new contacts as well as the strengthening of cooperation and information exchange with national ministries and government institutions, national communicable disease control institutions, policy makers, district health care administrations and hospital administrations.
All project partners remarked that they acquired valuable new research skills. The GIS training workshop showed how to use the program for quick visualisation of resource data on a map, to detect apparent spatial patterns and to visualise geographical clustering of resource needs and gaps. Such graphical illustrations are good tools for informing policy makers and presentation of results. In order to conduct good quality comparable stakeholder interviews for the analysis, local interview teams from each country were trained in the art of conducting objective and impartial interviews and subsequent report writing. The partners also mentioned having gained experience in conducting systematic reviews and writing scientific papers.
Project results including those of the rapid situational analysis and the resource gaps analysis were presented to researchers, government ministries, policy makers and communicable disease networks at high profile international and various national meetings. It was remarked that the WHO, the World Bank, the United States Agency for International Development (USAID) and other international donor agencies were also informed about the project findings as they influence many decision made by policy makers in certain countries. The project countries also remarked that they want to publish the main findings not only in international journals but also in their language in local journals in order to reach the domestic audience.
All Asian project partners mentioned the evaluation of the post A/H1N1 pandemic response as an area requiring further research. The ASIAFLUCAP resource simulation tool although considered to be very useful, was described as difficult to use. Training workshops on how to apply it were suggested. Research on equity of distribution of vaccines and anti-virals and the quality of the anti-viral stockpiles was mentioned as an additional area where information is needed. Both Taiwan and Thailand mentioned that they need to further explore and improve their risk communication skills.
Over the course of the project workshops and briefings have been held with key stakeholders including ministry representatives and observers from multilateral agencies. Knowledge gained from this study has already been shared through researchers' participation at conferences and meetings involving policy makers, academicians, development partners and other interested parties. The project and its initial results have already been highlighted through various forums including the World Economic Forum preparation meeting, disaster management conference, Southeast Asia Pandemic Preparedness Forum and at a number of research centres around the world. In addition, ASIAFLUCAP project coordinators and researchers have been interviewed and quoted in regard to pandemic preparation and responses by various media channels such as the Associated Press, Reuters, Euro Investor, Financial Times, Agence France-Presse, British Broadcasting Corporation (BBC) News, etc. A Conference on Pandemic Preparedness in Asia was held in Bangkok in April 2011, designed specifically to disseminate and discuss the key findings, lessons learned and next steps from the ASIAFLUCAP project.
Potential impact:
A number of activities were conducted and several channels of communication were used to disseminate the findings from the ASIAFLUCAP Project to policy makers, researchers, academia and the public. Specifically, we created the ASIAFLUCAP website (at http://www.asiaflucap.org online) to communicate with collaborators and other partner agencies and to share the findings from this project to the public.
In Thailand the identified resource gaps led to the purchase of additional ventilators for the Ministry of Public Health's hospitals. The identified human resource shortages, non-material infrastructure gaps and the inadequate risk communication will also influence future policy decisions in the country. In Cambodia the identified resource gaps have informed the World Bank avian influenza project which is considering the support of infrastructure and resource improvement processes. In Indonesia the ASIAFLUCAP project results have informed the development of the country wide 'Health Facility Framework Survey', which is to be carried out in all Indonesian districts in 2011. In Vietnam the inadequate logistics of anti-viral distribution, the shortage of isolation rooms and the lack of trained human resources will be the subject of future policy decisions. In Lao PDR the Ministry of Health has been informed about the identified resource gaps and needs which will be the basis of discussion with international donor organisations. In Taiwan inadequate risk communication before and during pandemics was identified as a weakness. Policy decisions to train and improve risk communication skills are planned. In the project Taiwan also learned about the nature and degree of resource gaps in the ASIAFLUCAP project countries, which led to the decisions that it wants to support their efforts towards strengthening the national and regional pandemic management and response capacity.
Realised and potential impacts from the ASIAFLUCAP Project as well as dissemination activities are described in more detail in the following four sections namely: skills and expertise developed in the ASIAFLUCAP project; new cooperations developed through the ASIAFLUCAP project; use of ASIAFLUCAP project results for policy decision making; publications, conference presentations, meeting presentations and other media outlets.
Skills and expertise developed in the ASIAFLUCAP project
All Asian partner countries remarked that the activities in the ASIAFLUCAP project have provided valuable new insights into their national health systems pandemic management and response capacity as a whole and enabled an estimate of where and to what extent gaps exist and where crucial gaps need to be filled. The project has shown new ways of how to systematically collect and assess detailed health system resource data related to pandemic influenza preparedness using the rapid situational analysis and the questionnaire based resource characterisation. This project has also helped the partner countries to develop human resource capacity by acquiring new research skills.
The GIS two-day short training course held in July 2009 by the LSHTM/Mahidol University in Bangkok showed the participants from all ASIAFLUCAP partner countries how to use the program for quick visualisation of data (e.g. number and spread of cases, number and geographic distribution of ventilators) on a map, to detect apparent spatial patterns e.g. resource excess or gap clusters and to visualise resource needs and gaps.
The Taiwan team responsible for conducting the stakeholder interviews received comprehensive interview training. They went to all ASIAFLUCAP partner countries introduced the aims of the stakeholder analysis and trained the local interview teams in the art of conducting objective and impartial interviews and subsequent report writing. They also accompanied them as observers during the first few interviews and discussed problems that arose. This improved the interview and research skills of the local staff and ensured good quality and comparable results.
New cooperations developed through the ASIAFLUCAP project
Cambodia
The Cambodian team, in collaboration with ASIAFLUCAP project partners and the support of policy makers in Cambodia developed a proposal based on the results of the ASIAFLUCAP project to conduct economic evaluations. The proposal has been accepted by the German Society for International Cooperation (GIZ) for support.
Lao PDR
Lao PDR has remarked that this project has helped to strengthen cooperation with different ministries at the national level (Ministry of Agriculture and Forestry, Ministry of information and Culture). In addition contacts with international were either established or strengthened. The project also helped to develop new contacts with countries in the region and with research and teaching institutions in Europe, such as the LSHTM and the HAW-Hamburg.
Vietnam
Vietnam established new contacts and shared experiences with other Asian countries in the project. The project has fostered the interaction and information exchange among authorities responsible for pandemic preparedness and response to the H1N1 and H5N1 pandemics in Vietnam namely Ministry of Health (MoH), MOST and Ministry of Agriculture and Rural Development (MoARD). The weaknesses identified through the health system analysis and the data on the health care resource gaps, have and will be the subject of presentations and discussions by the MoH and MOST at international meetings.
Indonesia
Indonesia has developed networks, at the local and national government level within the country, in Southeast Asia and internationally. We are now linked to international and regional organisations such as WHO, Food and Agricultural Organisation (FAO), the Canadian International Development Agency (CIDA), the Itnernational Development Research Centre (IDRC), Rockefeller, AusAID, the Asian Partnership of Emerging Infectious Disease Research (APEIR) network, the German Technical Cooperation (GTZ), USAID, United States (US) Government, Australian government and the Association of Southeast Asian Nations (ASEAN) who are concerned with pandemic preparedness management.
Thailand
Thailand benefited from working together with other partner countries in the region. In Thailand, the project team established close contact with the Department of Disease Control and collaborated with the researcher Mr Porntip, who was one of members in the war room during the A/H1N1 2009 pandemic. We also consulted the Bureau of Epidemiology who provided us the national data set on influenza cases and the guidelines.
Taiwan
Taiwan established many contacts with institutions in Asia and Europe:
National Institutions: Academia Sinica, Taiwan and Yang Ming University, Taiwan
1. Regional institutions: National EID Coordination Office, Ministry of Health, Laos PDR, other ASIAFLUCAP partner countries, Japan.
2. European institutions:
1. Influenza National Reference Laboratory, Medical University of Vienna
2. AGES in Austria
3. Ministry of Health, Austria
4. Ministry of Health, Welfare and Sport, Netherlands
5. RIVM in Netherlands
6. Netherlands Institute for Health Services Research
7. Bernhard Nocht Institute for Tropical Medicine in Germany
8. the National Institute for Infectious Diseases 'L. Spallanzani' in Italy
9. Health Protection Agency in the United Kingdom (UK)
10. InVs in France.
UK - London (LSHTM)
As a result of this EU project numerous contacts were established, specially with universities, national ministries of health, communicable disease networks, NGOs, research networks and foundations across Asia and Internationally. The institutions include MBDS, National Ministries of Health, UNSIC, WHO SEARO and WPRO, USAID, 'Predict', 'Respond', National University of Singapore, Duke-NUS, University of Udayana - Bali, Burnet Institute - Australia, RSIS - Singapore, Chinese University of Hong Kong, Hong Kong University, CelAgrid - Cambodia NGO, GIZ - Germany, Cabinet Office - UK, US CDC, CDC Thailand, APEIR, IDRC, ASEF.
In addition the new collaborations resulted in the application and initiation of new projects as listed below:
1. Research proposal on: evidence based investment options to improve pandemic preparedness in Cambodia and Laos. Proposal submitted to GIZ - Germany. Involved ASIAFLUCAP partners (HAW, LSHTM, MoH -NAEICO)
2. Surge capacity proposal for Indonesia. Involved institutions: (University of Indonesia and LSHTM with Indonesia's MoH -NIHRD)
3. Biomedical surveillance project in Bali. Involved institutions: (University of Indonesia and LSHTM with Duke-NUS)
4. Contact patterns in Asia: Study funded by WHO. Involved institutions: (University of Indonesia, IHPP- Thailand, LSHTM, Oxford Clinical Research Unit in Hanoi-Vietnam and International Vaccine Institute in Seoul Korea).
Use of ASIAFLUCAP project results for policy decision making
The findings of the health system, the resource gap and the stakeholder analysis revealed different degrees of weaknesses and shortages in the national pandemic management and response capacities which have and will hopefully continue to trigger policy decisions to improve pandemic preparedness. The countries mentioned the following areas where policy decisions were or are likely to be influenced.
Lao PDR
The outcomes of the ASIAFLUCAP Project were presented to the National Emerging Infectious Disease Coordination Office - Laos (NEIDCO), who in turn informed the MoH in Laos about the identified pandemic preparedness resource gaps and needs in the country. This will form the basis of discussions for further assistance through international donor organisations.
Vietnam
A sufficient quantity of 30 million doses of anti-viral drugs like Tamiflu/Oseltamivir, have been stockpiled by Vietnam as an important pandemic preparedness measure. The logistics of the rapid and adequate distribution has however be identified as a problem which will be addressed. The identified shortage of isolation rooms at most levels of the health system and the lack of trained human resources specially at district level significantly influence national pandemic preparedness and will be the subject of future policy decisions.
Indonesia
The results of the health system resource needs and gaps analysis and the model simulation are contributing to the development of the new Healthcare Facility Framework Survey which will be conducted by the Ministry of Health to cover all districts in Indonesia, in 2011.
Cambodia
As the project objectively identified the resource gaps and needs in Cambodia, the World Bank AI project is now considering the renovation of isolation wards in the provincial hospitals, procurement of pick up cars, motorbikes and laptops with modems for rapid response team (RRT) members, thermo-scanners for major points of entry and ventilators for designated hospitals in the country.
Thailand
In Thailand policy makers were informed about the findings on the shortage of ventilators which led to acquirement of additional ventilators for the Ministry of Public Health's hospitals. Resource shortages in particular the improvement of human resources and infrastructure resources (rather than material resources) will be subject to future policy decisions. The stakeholder analysis revealed public risk communication during the A/H1N1 2009 pandemic as one of the weaknesses which we intend to improve.
Taiwan
The findings of the rapid situational analysis informed the pandemic planning and response activities during the A/H1N1 2009 pandemic. Policy makers in Taiwan learned about the nature and degree of resource gaps in the ASIAFLUCAP project countries, they want to collaborate with these countries and support their national and regional pandemic management and response capacity. The project work also identified risk communication during the A/H1N1 2009 pandemic, as a weakness, policy decisions to improve risk communication will be made in the near future.
List of websites:
1. ASIAFLUCAP project website: http://www.asiaflucap.org/
2. The ASIAFLUCAP simulator. Innovative and user-friendly tool built in MS Exceland#174; for assessing health system capacity for responding to various pandemic influenza scenarios. The ASIAFLUCAP simulator video guide is available publicly at http://www.youtube.com/watch?v=2VX_eQpT4tM
3. Video about the ASIAFLUCAP project, the ASIAFLUCAP simulator and GIS is available at http://www.youtube.com/watch?v=W9BNHot1eLg
4. The ASIAFLUCAP project related information can be accessed via the Taiwan centre for disease control (CDC) intranet: http://intranet.cdc.gov.tw/ASIAFLUCAP/
The rapid situational analyses conducted as part of the project prior to the H1N1/2009 pandemic revealed that health system context has very strong influence on the approach adopted towards pandemic preparedness. Investment in pandemic preparedness activities has contributed to the strengthening of health system functions in many countries, specifically in regards to surveillance, laboratory capacity, monitoring and evaluation and public communication. However, the low investment in clinical care and pandemic mitigation preparation was still a major challenge.
Through an extensive review of the literature and guidelines related to influenza and severe respiratory disease infections, we identified a list of key health system resources that are likely to be drawn upon for pandemic responses. The list was reviewed and prioritised to identify essential resources for the region for both containment and mitigation. Extensive fieldwork was conducted to enumerate the quantity of resources at district level from district health offices and hospitals with additional data collected at national levels to capture central stockpiles and core supplies. A training workshop was organised to equip country collaborators with general concepts of geographical information systems (GIS) and necessary policy communications and dissemination skills.
The ASIAFLUCAP project also developed mathematical models as to simulate the transmission dynamics of a pandemic virus in each country under various scenarios. Findings from the latest H1N1/2009 pandemic were used to inform the modelling. By incorporating existing knowledge on patterns of resource usage and resource depletion for severe respiratory cases, the level of key health system resource needs in a given pandemic scenario was estimated. Importantly, the model allows for resource depletion / commitment effects as well as the effects of key public health interventions based on various scenarios. Comparative analyses of resource needs and gaps and the potential impact of inadequate and inefficient distribution of health resources on excess mortality rates were carried out across countries and between provinces within countries. The ASIAFLUCAP simulator, a user-friendly version of the model, was developed as a tool for policy makers and other stakeholders to help inform evidence-based resource allocation.
Pandemic preparation and responses are not merely a technical process. They are political processes involving multiple stakeholders where technical inputs are only one aspect of the decision making process. A stakeholder analysis was also conducted using the actual experience from the response to the H1N1/2009 to identify stakeholder capacity strengths, gaps and constraints and inform the evaluation of governance architecture and processes. Policy linkages and utilisation have been central to the design of the ASIAFLUCAP project, in addition to dissemination via academic publications and presentations.
Project context and objectives:
The ASIAFLUCAP project was conceived and has been implemented since 2008 at a time of uncertain pandemic threat. It was before the emergence of the H1N1/2009 pandemic. At the time, avian influenza acquired world-wide attention when a highly pathogenic strain of the subtype H5N1, which probably arose before 1997 in southern China, gained enzootic status in poultry throughout southeast Asia and 'traversed interclass barriers' when transmitted from birds to mammals (cats, swine, humans). Although not an unprecedented event, the substantial number of documented cases in humans associated with severe disease and several fatalities has raised serious concerns about a pandemic potential of the H5N1 strain. The spread of H5N1 in the southeast Asia region has resulted in considerable public health and political concern. In part this stems from recognition that, should H5N1 undergo re-assortment or mutation, a human pandemic is likely and this was bound to have very substantial global economic and public health consequences. Many experts anticipated that southeast Asia is likely to be the epicentre of the next pandemic of influenza.
The ASIAFLUCAP project was conceived in line with European Union (EU) policy to assist developing countries to combat a potential worldwide influenza epidemic. In 2005 and 2006 activities to combat influenza outbreaks were discussed in several workshops hosted by World Health Organisation (WHO) and the EC. The EC agreed to help providing plans to assist third countries to control and combat the avian influenza virus at its source and it also pledged considerable financial support through the pledging conferences.
One important challenge faced by public health researchers before the launch of the ASIAFLUCAP project was the lack of a universally accepted, organised method for evaluating preparedness. This in part stemmed from uncertainties surrounding likely transmission dynamics of a pandemic. But even when there is broad agreement, or limits can be placed around key parameters (including the impact of interventions), there remains little consensus on the best methodological approach to the evaluation of preparedness. A number of approaches have been taken including assessments of national strategic plans, desk-top simulations, functional exercises, full scale 'wet runs', case studies with site visits to assess health systems and mathematical modelling analyses. All have their strengths and weaknesses but few evaluations have determined specific resource gaps and process frailties.
The ASIAFLUCAP project proposed an innovative approach that had been pilot-tested in the Thailand context to link coherently quantitative analyses of resource gaps with qualitative assessments of governance constraints in utilising those resources determined. Previous reviews of strategic pandemic preparedness plans have shown that many countries have made considerable progress in the past two years. Important resources have already been allocated to the development and/or further strengthening of animal and human disease surveillance and response systems for early detection and prompt containment of avian influenza and other emerging zoonotic diseases. The Beijing pledging conference and subsequent Bamako conference highlighted imperatives in terms of up-scaling capacity to meet resource needs, particularly in Asia and Africa. Considerable efforts have been expended over the past couple of years in developing national strategic pandemic preparedness plans.
However, in southeast Asia whilst considerable progress has been made and substantial domestic and international efforts are being focussed, public health system capacity to respond to pandemic influenza remains a profound challenge. Indeed, it was shown that operational capacity and governance clarity are areas that need to be robust if pandemic influenza responses are to be effective and efficient. Highlighting this issue, a report to the United Nations System Influenza Coordinator (UNSIC) captured a critical gap in preparedness planning, noting: 'Very few countries have succeeded in transforming high-level political plans into a strategic framework and detailed annual operational plans to drive implementation. These operational plans should address both preparedness and response in the event that phase four, five or six is reached.'
The ASIAFLUCAP project proposed to address three critical issues related to pandemic preparation, namely, collaboration with Asian partners, public health research and a focus on containment and mitigation of pandemic influenza. The study has been conducted in four countries namely Thailand, Vietnam, Indonesia and Taiwan. Additional support from the Rockefeller Foundation allowed the project to be carried out in two additional countries, namely Cambodia and Lao PDR. The goal of this project is to provide a strategic framework to evaluate health system operational capacity and to systematically determine operational capacity gaps in order to support containment and mitigate the consequences of pandemic influenza in these countries and elsewhere. There are six specific objectives outlined in the project proposal. These include:
1. to develop a detailed methodological framework to evaluate operational capacity to respond to pandemic influenza.
2. to support evaluation research for pandemic influenza preparedness in Asia and to identify basic principles in determining capacity to ensure a coherent approach to pandemic preparedness in both Asian and European countries.
3. to determine capacity gaps in responding to pandemic influenza in Vietnam, Indonesia, Thailand and Taiwan and strengthen operational response capacity.
4. develop and support a network of expertise, knowledge and shared experience in public health in relation to pandemic influenza preparedness and control across the EU.
5. to build upon and extend a network of EU-funded collaborating operational researchers in a coherent manner, linking projects in a value-added manner.
6. to build upon and extend a network of collaborating operational researchers in EU and Asia, to support sharing of experience, knowledge and skills and to disseminate lessons and best-practice within and across regions.
These objectives are measured by the number of participants, the analytical reports and peer- reviewed journal publications. They are presented later in this report. The success of the network formed under ASIAFLUCAP project can also be measured in terms of joint publications, workshops and briefings. The value-added nature of collaborators working across a number of research projects should ensure a growing body of knowledge, a sustainable research network and operational research capacity in the Asia Pacific region as well as in the EU, in addition to offering added value through cross-learning and sharing of experiences.
Project results:
The EU ASIAFLUCAP project was initiated on 1 May 2008 and carried out over three years, ending on 31 April 2011. The project comprised eight interlinked work packages (WPs):
1. Management and coordination
2. Rapid situational analysis
3. Resource characterisation
4. Stakeholder analysis
5. Scenario development
6. Resource gap analysis
7. Project evaluation
8. Dissemination.
A description of the activities and (where relevant) key findings of each WP is presented below.
WP2. Rapid situational analysis
This WP was carried out effectively and has achieved its objective to provide, rapidly, a contextual understanding of the challenges and constraints likely to be faced, the health systems context within which a response must function and identify sources of information, data and stakeholders to inform the remaining WPs. At the beginning of this WP, a toolkit was developed for a rapid systematic analysis of current capacity and capacity development requirements to the threat of pandemic influenza at the country level, or in the case of Indonesia, the provincial level. The toolkit is based on a methodological approach to balance a relatively high degree of accuracy and validity and simplicity, speed and limited cost. A paper describing the underlying methodology has been published in an international peer-review journal.
One workshop was organised in Hanoi, Vietnam, in September 2008 to finalise the toolkit and the report format as well as to coordinate the data collection process and fieldworks in the four countries. Based on the toolkit, literature and document reviews were carried out in each country before fieldwork for key informant interviews and additional data collection. The fieldwork took place between October and December 2008 with researchers from the London School of Hygiene and Tropical Medicine (LSHTM), the Hamburg University of Applied Sciences (HAW-Hamburg) and all four country partners. Important contextual health system structures and processes associated with preparedness were identified and described. Perceived capacity gaps and challenges to preparedness were explored. Our study reveals that health system context has very strong influence on the approach adopted towards pandemic preparedness within a territory. The interfaces and linkages between health system contexts and pandemic preparedness programmes are particularly strong in three areas: governance and stewardship, resources and service provision. Investment in pandemic preparedness activities in the region has contributed to the strengthening of health system functions in many countries, specifically in regards to surveillance, laboratory capacity, monitoring and evaluation and public communication.
However, the low investment in clinical care and pandemic mitigation preparation is still a major challenge. In a number of countries, information on stockpiles of antiviral medicines or other key health system resources is not readily available to policy makers. At service delivery level in several countries, operational plans to respond to later stages of a pandemic are still not in place.
The results from this WP have been documented as four country reports available for download from the ASIAFLUCAP website. Additionally, a comparative analysis was done and published in an open-access journal, BMC Public Health. The findings from this WP have been communicated to policy makers in the countries in time for the spread of the H1N1/2009. At the regional level, they were presented at regional forums such as the Regional UN Pandemic Influenza Donor Coordination Meeting and the Southeast Asia Pandemic Preparedness forum, among others.
WP3. Resource characterisation
The objective of this WP was to determine the scope of resources and characterise those resources used in previous pandemics and public health crises. The activities included a literature review and retrospective analyses of outbreaks in countries of southeast Asia and a systematic review to list resources within the framework of enabling environment, WHO preparedness themes and organisational capacity.
Through an extensive review of literature and guidelines related to influenza and severe respiratory disease infections, this WP identified a list of health system resources that are likely to be drawn upon for surveillance, case investigation, case management, community control and overall management of a pandemic. The review found that 358 health system resource items have been utilised in response to SARS, avian influenza, or pandemic influenza. These resource items can be classified into four main categories, namely materials including drugs, vaccines and personal protective equipments (PPEs); human resource; infrastructure and equipment; management and communication resources.
A panel of experts was formed and a Delphi process was carried out at a workshop in Ubud, Indonesia, to contextualise the resources such that the list can practically inform planners in southeast Asia. The final list contains 57 resource items relating to infrastructure, equipments, materials and human resources. The list was reviewed and prioritised by international and local experts to identify essential resources for the region. A technical report was prepared and the findings from this exercise were documented and submitted for publication (under review) at a regional journal, Southeast Asian Journal of Tropical Medicine and Public Health.
WP4. Stakeholder analysis/institutional mapping
Stakeholders' roles are informed by their relationships with institutions. Many lessons were drawn from the SARS outbreaks and the global governance architecture has been modified as a result. The objective of the stakeholder analysis was to identify stakeholder capacity strengths, gaps and constraints and inform the evaluation of governance architecture and processes. As reported in the Inception Report, this WP was postponed from the earlier planned date in the first year of the project to start in May 2010 instead. The consortium agreed that this new start date fits better with other WPs to ensure smooth progress of and effective coordination between all WPs.
One workshop was organised to identify key areas for stakeholder analysis in all the study countries. A toolkit was developed to collect and analyze important information from key persons inside and outside of the government who might influence the policymaking process with regard to pandemic preparation. In this study, stakeholders refer to individuals, groups, or organisations that have a significant interest in how well a pandemic influenza control and response program functions. It employed key informant interviews as the main data collection method in addition to literature and document review.
Given the emergence of the H1N1/2009 pandemic, we capitalised on this opportunity to draw upon stakeholder's actual experiences from a real pandemic scenario. Thus the stakeholder analysis became, in many ways, a 'post-mortem' of the capacity strengths, challenges and gaps that were exposed or highlighted in each country during the pandemic. Altogether, 132 key informants were interviewed in the four ASIAFLUCAP countries (and 27 more in Lao PDR and Cambodia as part of the Rockefeller Foundation-funded support). They included policy makers, international development partners, academia, private sector and other opinion leaders.
The study found that there were important similarities and differences in two broad aspects of response measures-command and control; and resources and mobilisation-for the H1N1/2009 influenza pandemic. In the aspect of command and control, the pandemic alert announcements declared by the WHO on 27 and 29 April 2009 switched on the pandemic preparedness and response systems from planning to implementation in each of the six countries. A top-down cross-sector command and control model was adopted universally by the participant countries. Moreover, international health organisations seemed to have direct influence over decision-making in some countries. With regard to resources and mobilisation, previous experience in SARS outbreaks and avian influenza epidemics or concerns, together with technical advice and assistance from international health organisations (e.g. the WHO), shaped strategies and action plans profoundly in each of the six countries for the H1N1/2009 pandemic. Three main types of weaknesses or gaps were identified. These were:
1. limited resources (financial, human and material)
2. public compliance to H1N1 vaccination; and
3. risk communication and risk management of governments.
Additionally, three aspects of capacity constraints were identified including regulation enforcement capacity, bureaucratic management capacity and capacity to sustain pandemic preparation and response.
Four key lessons were learned from the stakeholder analysis of the latest pandemic response in the six countries. They are:
1. strengthen information sharing, capacity building and collaboration within and among countries to close the gap between preparedness planning and response implementation
2. improve equitable distribution and timely accessibility of financial, human, technological and material resources, especially at districts and local areas
3. make the governance transparent to enhance public trust and public acceptance of pandemic response measures
4. prepare for the unexpected and speed up research to overcome the unknown.
WP5. Scenario development
The objective of scenario development was to form the basis under which operational capacity can be evaluated and gaps determined. To develop pandemic progression scenarios, the research team comprising of partners from the National Insitute for Public Health and the Environment (RIVM), HAW-Hamburg and LSHTM employed mathematical modelling techniques as a tool to simulate the transmission dynamics of different pandemic influenza scenarios. A compartmental, resource-linked transmission model was developed.
In addition to estimating resource needs for a given pandemic scenario, feedback loops within the model account for the effect of resource depletion on the expected disease burden, in terms of expected mortality rate. The impacts of the available quantities of antiviral drugs, vaccines, hospital beds and medical ventilators are considered in the model. The model can simulate pandemic scenarios for a range of severities, depending on the input parameters values chosen. Two main sets of parameter values were derived from an extensive literature review: one set is based on data from the H1N1/2009 pandemic to simulate a 'mild' scenario, while another set of values was derived from data from the 1918 influenza pandemic and from H5N1, to simulate a more severe hypothetical scenario.
By incorporating existing knowledge on the level of resource use and the rate of resource depletion in severe respiratory cases from earlier studies by local partners, the model can be used to estimate key health system resource needs and gaps in a given pandemic scenario. The assessment of resource requirements takes into account potential reserve (shared) capacity in the health system for scaling up of necessary services. The effects of key interventions (antiviral administration, vaccination, social distancing) based on various scenarios can also be tested and evaluated. To make the model more user-friendly, the 'ASIAFLUCAP simulator' was developed. This comprises of a Microsoft Excel version of the model with a Visual Basic interface that allows researchers and policy makers to easily input data and adjust key parameters to be relevant to their country context. Thus, the ASIAFLUCAP simulator can be used as a tool by policy makers to help inform resource allocation and mobilisation. The ASIAFLUCAP simulator includes both the mild and severe pandemic scenarios and a function to export model outputs into file formats appropriate for GIS mapping software. A workshop was organised to demonstrate the use of this software to all project partners and country users and a demonstration video to show how this software can be utilised for policy decision making was produced and made available on the website (see http://www.asiaflucap.org online). The software has also been demonstrated to regional and country level policy makers and stakeholders at various venues.
WP6. Resource gap analyses
To evaluate the availability and distribution of existing health system resources for pandemic response in the four countries, fieldwork was conducted to enumerate the quantity of essential resources at district level. Data were collected on key resource items based on results from the literature review and Delphi analysis as described in WP3. A number of specifically developed questionnaires were designed and used to collect data from district health offices and hospitals. Additional data were collected from national level to capture the central stockpiles such as antiviral drugs or supplies. These were supplemented by information from routine data sources, literature reviews and interrogation of health system databases.
A framework was developed to determine resource depletion rates as well as to link this WP with the previous WP on scenario development to allow for the influence of resource depletion on disease progression. The existing gaps of key health system resources were then estimated based on the scenarios developed from pandemic progression modelling. Comparative analyses of resource availability, resource needs and gaps across countries and across provinces within countries, were carried out to identify the types and quantities of critical resources required to respond to pandemic spread. Excess deaths that could be avoided if resources could be deployed effectively were also estimated.
The study found that wide variations exist in resource capacities between and within the six countries. Substantial excess mortalities were predicted as a result of resource gaps, particularly in poorer countries. Severe nationwide shortages of mechanical ventilators were estimated to be a major cause of excess mortalities in all countries except Taiwan. Other resources (oseltamivir, hospital beds and human resources) are inequitably distributed within countries. The findings have important implications for where (both geographically and in which resource types) investment is most needed and the potential impact of resource mobilisation for mitigating the disease burden of an influenza pandemic. Effective mobilisation of resources across administrative boundaries could go some way towards minimising excess deaths. Results from the analyses of resource availability, needs and gaps can help policy makers prioritise their resource allocation plans towards an effective pandemic response given limited resources. In Thailand for example, these results have informed a policy decision by the Ministry of Public Health for increased purchase and distribution of ventilators.
In addition to research activities, a training workshop was organised in July 2009 to equip country collaborators with general concepts of GIS and necessary skills to be able to produce its own resource maps for policy communications and dissemination. Advanced GIS analyses were conducted for specific assessment and comparative analyses of selected key resources.
Furthermore, the ASIAFLUCAP simulator has been disseminated among the partner counties to enable them to conduct further resource gap analyses, for example to explore other scenarios and resources and using updated resource availability data, according to local priorities. A local-level analysis has already been conducted for Bali in Indonesia, which found that the majority of resources were focussed in and around the provincial capital, Denpasar, although gaps in nursing staff, surgical masks and N95 masks were estimated for all districts.
WP7. Evaluation
The objective of the evaluation WP was to provide feedbacks to project collaborators and to ensure the project has met its objectives. The ASIAFLUCAP research consortium conducted a midterm evaluation in addition to an overall project evaluation at the end of the research.
A questionnaire for midterm evaluation was designed by the HAW-Hamburg team to evaluate the perceptions and experiences of all partners about the research project, its progress towards its objectives, lessons learned from research fieldwork and the coordination and management support by LSHTM. It was distributed to all participating partners during the consortium meeting in November 2009. The answers were analysed and the findings were presented to all collaborators. Overall satisfaction towards the project was high but there were recommendations to improve information sharing from different WPs in relation to individual project countries. Internal communication among all project partners was described as good. However, the financial management and reporting process required by the EU was described as difficult. Internal adjustments were made to ensure that activities can be carried out smoother in the second half of the project. Suggestions on how to facilitate dissemination of results and their incorporation into national policies were also asked for.
Before the end of the project, the final project evaluation was prepared and another questionnaire was designed to collect information on the usefulness of a preparedness assessment 'Toolkit' for conducting periodic health care system capacity assessments, based on the instruments used in the ASIAFLUCAP project. In addition the partners were asked how the country benefited from the activities in this project, whether the results are likely to influence ministerial policy making and areas where further research, training and support is needed.
WP8. Dissemination of project lessons
The objective of this WP was to coordinate the dissemination of knowledge and expertise from this project on operational capacity evaluation in support of influenza preparedness planning in Asia. Policy linkages and utilisation are central to the design of the ASIAFLUCAP project. Our research results from all WPs have already been disseminated and used by partners and policy makers. The emergence of the H1N1/2009 epidemic also called for latest findings and knowledge related to pandemic preparation for which the ASIAFLUCAP researchers have contributed both formally and informally. The findings from ASIAFLUCAP have been presented at national, regional and international meetings, including academic conferences and workshops designed specifically for policy makers. A number of research papers and academic publications have been prepared and submitted and published. A number of posters have been prepared and presented at international forums and a number of briefing documents have been produced and disseminated.
All Asian partner countries remarked that the activities in the ASIAFLUCAP project have provided them a valuable new and in-depth insight into their national health systems pandemic management and response capacity as a whole and that of neighbouring southeast Asian project countries. It has enabled an evidence-based estimate of where and to what extent gaps exist and where crucial gaps need to be filled. In general the partners noted the working together with different countries in the region for a common purpose and the methodology of the project master plan as very positive. The regular teleconferences, the face to face meetings with all partners and the workshops were described as being very helpful for understanding and coordinating the project work. The emergence of a common platform for communication among the project countries was noted to be very constructive.
The project has demonstrated new approaches to systematically collect and assess information on the capacity and preparedness of national health system to respond to the threat of an influenza pandemic. The rapid situational analysis, the questionnaire-based resource characterisation, the mathematical simulation model-based resource gap and needs analysis, its graphic visualisation in form of maps and the qualitative interview based stakeholder analysis were the approaches used to provide a very comprehensive picture. A 'toolkit' for the periodic assessment of the national health systems pandemic preparedness and response capacity, based on the instruments used in the project was considered beneficial by all partners.
The project work led to numerous bilateral and multilateral contacts being established not only to institutions dealing with pandemic preparedness activities in the region but also with national institutions in all the ASIAFLUCAP partner countries. At the regional level, cooperations with neighbouring countries, universities, national ministries of health, communicable disease networks, non-governmental organisations (NGOs), research networks, international and regional health organisations and foundations across Asia and Europe developed during the course of this project. At the national level the project facilitated the development of new contacts as well as the strengthening of cooperation and information exchange with national ministries and government institutions, national communicable disease control institutions, policy makers, district health care administrations and hospital administrations.
All project partners remarked that they acquired valuable new research skills. The GIS training workshop showed how to use the program for quick visualisation of resource data on a map, to detect apparent spatial patterns and to visualise geographical clustering of resource needs and gaps. Such graphical illustrations are good tools for informing policy makers and presentation of results. In order to conduct good quality comparable stakeholder interviews for the analysis, local interview teams from each country were trained in the art of conducting objective and impartial interviews and subsequent report writing. The partners also mentioned having gained experience in conducting systematic reviews and writing scientific papers.
Project results including those of the rapid situational analysis and the resource gaps analysis were presented to researchers, government ministries, policy makers and communicable disease networks at high profile international and various national meetings. It was remarked that the WHO, the World Bank, the United States Agency for International Development (USAID) and other international donor agencies were also informed about the project findings as they influence many decision made by policy makers in certain countries. The project countries also remarked that they want to publish the main findings not only in international journals but also in their language in local journals in order to reach the domestic audience.
All Asian project partners mentioned the evaluation of the post A/H1N1 pandemic response as an area requiring further research. The ASIAFLUCAP resource simulation tool although considered to be very useful, was described as difficult to use. Training workshops on how to apply it were suggested. Research on equity of distribution of vaccines and anti-virals and the quality of the anti-viral stockpiles was mentioned as an additional area where information is needed. Both Taiwan and Thailand mentioned that they need to further explore and improve their risk communication skills.
Over the course of the project workshops and briefings have been held with key stakeholders including ministry representatives and observers from multilateral agencies. Knowledge gained from this study has already been shared through researchers' participation at conferences and meetings involving policy makers, academicians, development partners and other interested parties. The project and its initial results have already been highlighted through various forums including the World Economic Forum preparation meeting, disaster management conference, Southeast Asia Pandemic Preparedness Forum and at a number of research centres around the world. In addition, ASIAFLUCAP project coordinators and researchers have been interviewed and quoted in regard to pandemic preparation and responses by various media channels such as the Associated Press, Reuters, Euro Investor, Financial Times, Agence France-Presse, British Broadcasting Corporation (BBC) News, etc. A Conference on Pandemic Preparedness in Asia was held in Bangkok in April 2011, designed specifically to disseminate and discuss the key findings, lessons learned and next steps from the ASIAFLUCAP project.
Potential impact:
A number of activities were conducted and several channels of communication were used to disseminate the findings from the ASIAFLUCAP Project to policy makers, researchers, academia and the public. Specifically, we created the ASIAFLUCAP website (at http://www.asiaflucap.org online) to communicate with collaborators and other partner agencies and to share the findings from this project to the public.
In Thailand the identified resource gaps led to the purchase of additional ventilators for the Ministry of Public Health's hospitals. The identified human resource shortages, non-material infrastructure gaps and the inadequate risk communication will also influence future policy decisions in the country. In Cambodia the identified resource gaps have informed the World Bank avian influenza project which is considering the support of infrastructure and resource improvement processes. In Indonesia the ASIAFLUCAP project results have informed the development of the country wide 'Health Facility Framework Survey', which is to be carried out in all Indonesian districts in 2011. In Vietnam the inadequate logistics of anti-viral distribution, the shortage of isolation rooms and the lack of trained human resources will be the subject of future policy decisions. In Lao PDR the Ministry of Health has been informed about the identified resource gaps and needs which will be the basis of discussion with international donor organisations. In Taiwan inadequate risk communication before and during pandemics was identified as a weakness. Policy decisions to train and improve risk communication skills are planned. In the project Taiwan also learned about the nature and degree of resource gaps in the ASIAFLUCAP project countries, which led to the decisions that it wants to support their efforts towards strengthening the national and regional pandemic management and response capacity.
Realised and potential impacts from the ASIAFLUCAP Project as well as dissemination activities are described in more detail in the following four sections namely: skills and expertise developed in the ASIAFLUCAP project; new cooperations developed through the ASIAFLUCAP project; use of ASIAFLUCAP project results for policy decision making; publications, conference presentations, meeting presentations and other media outlets.
Skills and expertise developed in the ASIAFLUCAP project
All Asian partner countries remarked that the activities in the ASIAFLUCAP project have provided valuable new insights into their national health systems pandemic management and response capacity as a whole and enabled an estimate of where and to what extent gaps exist and where crucial gaps need to be filled. The project has shown new ways of how to systematically collect and assess detailed health system resource data related to pandemic influenza preparedness using the rapid situational analysis and the questionnaire based resource characterisation. This project has also helped the partner countries to develop human resource capacity by acquiring new research skills.
The GIS two-day short training course held in July 2009 by the LSHTM/Mahidol University in Bangkok showed the participants from all ASIAFLUCAP partner countries how to use the program for quick visualisation of data (e.g. number and spread of cases, number and geographic distribution of ventilators) on a map, to detect apparent spatial patterns e.g. resource excess or gap clusters and to visualise resource needs and gaps.
The Taiwan team responsible for conducting the stakeholder interviews received comprehensive interview training. They went to all ASIAFLUCAP partner countries introduced the aims of the stakeholder analysis and trained the local interview teams in the art of conducting objective and impartial interviews and subsequent report writing. They also accompanied them as observers during the first few interviews and discussed problems that arose. This improved the interview and research skills of the local staff and ensured good quality and comparable results.
New cooperations developed through the ASIAFLUCAP project
Cambodia
The Cambodian team, in collaboration with ASIAFLUCAP project partners and the support of policy makers in Cambodia developed a proposal based on the results of the ASIAFLUCAP project to conduct economic evaluations. The proposal has been accepted by the German Society for International Cooperation (GIZ) for support.
Lao PDR
Lao PDR has remarked that this project has helped to strengthen cooperation with different ministries at the national level (Ministry of Agriculture and Forestry, Ministry of information and Culture). In addition contacts with international were either established or strengthened. The project also helped to develop new contacts with countries in the region and with research and teaching institutions in Europe, such as the LSHTM and the HAW-Hamburg.
Vietnam
Vietnam established new contacts and shared experiences with other Asian countries in the project. The project has fostered the interaction and information exchange among authorities responsible for pandemic preparedness and response to the H1N1 and H5N1 pandemics in Vietnam namely Ministry of Health (MoH), MOST and Ministry of Agriculture and Rural Development (MoARD). The weaknesses identified through the health system analysis and the data on the health care resource gaps, have and will be the subject of presentations and discussions by the MoH and MOST at international meetings.
Indonesia
Indonesia has developed networks, at the local and national government level within the country, in Southeast Asia and internationally. We are now linked to international and regional organisations such as WHO, Food and Agricultural Organisation (FAO), the Canadian International Development Agency (CIDA), the Itnernational Development Research Centre (IDRC), Rockefeller, AusAID, the Asian Partnership of Emerging Infectious Disease Research (APEIR) network, the German Technical Cooperation (GTZ), USAID, United States (US) Government, Australian government and the Association of Southeast Asian Nations (ASEAN) who are concerned with pandemic preparedness management.
Thailand
Thailand benefited from working together with other partner countries in the region. In Thailand, the project team established close contact with the Department of Disease Control and collaborated with the researcher Mr Porntip, who was one of members in the war room during the A/H1N1 2009 pandemic. We also consulted the Bureau of Epidemiology who provided us the national data set on influenza cases and the guidelines.
Taiwan
Taiwan established many contacts with institutions in Asia and Europe:
National Institutions: Academia Sinica, Taiwan and Yang Ming University, Taiwan
1. Regional institutions: National EID Coordination Office, Ministry of Health, Laos PDR, other ASIAFLUCAP partner countries, Japan.
2. European institutions:
1. Influenza National Reference Laboratory, Medical University of Vienna
2. AGES in Austria
3. Ministry of Health, Austria
4. Ministry of Health, Welfare and Sport, Netherlands
5. RIVM in Netherlands
6. Netherlands Institute for Health Services Research
7. Bernhard Nocht Institute for Tropical Medicine in Germany
8. the National Institute for Infectious Diseases 'L. Spallanzani' in Italy
9. Health Protection Agency in the United Kingdom (UK)
10. InVs in France.
UK - London (LSHTM)
As a result of this EU project numerous contacts were established, specially with universities, national ministries of health, communicable disease networks, NGOs, research networks and foundations across Asia and Internationally. The institutions include MBDS, National Ministries of Health, UNSIC, WHO SEARO and WPRO, USAID, 'Predict', 'Respond', National University of Singapore, Duke-NUS, University of Udayana - Bali, Burnet Institute - Australia, RSIS - Singapore, Chinese University of Hong Kong, Hong Kong University, CelAgrid - Cambodia NGO, GIZ - Germany, Cabinet Office - UK, US CDC, CDC Thailand, APEIR, IDRC, ASEF.
In addition the new collaborations resulted in the application and initiation of new projects as listed below:
1. Research proposal on: evidence based investment options to improve pandemic preparedness in Cambodia and Laos. Proposal submitted to GIZ - Germany. Involved ASIAFLUCAP partners (HAW, LSHTM, MoH -NAEICO)
2. Surge capacity proposal for Indonesia. Involved institutions: (University of Indonesia and LSHTM with Indonesia's MoH -NIHRD)
3. Biomedical surveillance project in Bali. Involved institutions: (University of Indonesia and LSHTM with Duke-NUS)
4. Contact patterns in Asia: Study funded by WHO. Involved institutions: (University of Indonesia, IHPP- Thailand, LSHTM, Oxford Clinical Research Unit in Hanoi-Vietnam and International Vaccine Institute in Seoul Korea).
Use of ASIAFLUCAP project results for policy decision making
The findings of the health system, the resource gap and the stakeholder analysis revealed different degrees of weaknesses and shortages in the national pandemic management and response capacities which have and will hopefully continue to trigger policy decisions to improve pandemic preparedness. The countries mentioned the following areas where policy decisions were or are likely to be influenced.
Lao PDR
The outcomes of the ASIAFLUCAP Project were presented to the National Emerging Infectious Disease Coordination Office - Laos (NEIDCO), who in turn informed the MoH in Laos about the identified pandemic preparedness resource gaps and needs in the country. This will form the basis of discussions for further assistance through international donor organisations.
Vietnam
A sufficient quantity of 30 million doses of anti-viral drugs like Tamiflu/Oseltamivir, have been stockpiled by Vietnam as an important pandemic preparedness measure. The logistics of the rapid and adequate distribution has however be identified as a problem which will be addressed. The identified shortage of isolation rooms at most levels of the health system and the lack of trained human resources specially at district level significantly influence national pandemic preparedness and will be the subject of future policy decisions.
Indonesia
The results of the health system resource needs and gaps analysis and the model simulation are contributing to the development of the new Healthcare Facility Framework Survey which will be conducted by the Ministry of Health to cover all districts in Indonesia, in 2011.
Cambodia
As the project objectively identified the resource gaps and needs in Cambodia, the World Bank AI project is now considering the renovation of isolation wards in the provincial hospitals, procurement of pick up cars, motorbikes and laptops with modems for rapid response team (RRT) members, thermo-scanners for major points of entry and ventilators for designated hospitals in the country.
Thailand
In Thailand policy makers were informed about the findings on the shortage of ventilators which led to acquirement of additional ventilators for the Ministry of Public Health's hospitals. Resource shortages in particular the improvement of human resources and infrastructure resources (rather than material resources) will be subject to future policy decisions. The stakeholder analysis revealed public risk communication during the A/H1N1 2009 pandemic as one of the weaknesses which we intend to improve.
Taiwan
The findings of the rapid situational analysis informed the pandemic planning and response activities during the A/H1N1 2009 pandemic. Policy makers in Taiwan learned about the nature and degree of resource gaps in the ASIAFLUCAP project countries, they want to collaborate with these countries and support their national and regional pandemic management and response capacity. The project work also identified risk communication during the A/H1N1 2009 pandemic, as a weakness, policy decisions to improve risk communication will be made in the near future.
List of websites:
1. ASIAFLUCAP project website: http://www.asiaflucap.org/
2. The ASIAFLUCAP simulator. Innovative and user-friendly tool built in MS Exceland#174; for assessing health system capacity for responding to various pandemic influenza scenarios. The ASIAFLUCAP simulator video guide is available publicly at http://www.youtube.com/watch?v=2VX_eQpT4tM
3. Video about the ASIAFLUCAP project, the ASIAFLUCAP simulator and GIS is available at http://www.youtube.com/watch?v=W9BNHot1eLg
4. The ASIAFLUCAP project related information can be accessed via the Taiwan centre for disease control (CDC) intranet: http://intranet.cdc.gov.tw/ASIAFLUCAP/
