Hashim, Ahmed

260 Pages·2017·1.94 MB·English

by  Christine Middleton

Evaluation of how pandemic preparedness activities aided the response to
influenza A (H1N1) pandemic in 2009. A qualitative analysis in seven
countries within the WHO European Region

Dr. Ahmed Hashim

Thesis submitted to The University of Nottingham
For the degree of Doctor of Philosophy
July 2014

Division of Epidemiology and Public Health
School of Medicine
University of Nottingham
Dedication
This thesis is dedicated to
My gorgeous wife Noora,
My beloved son Abdullah,
And my respected parents

i
Abstract
Background: The 2009 influenza A (H1N1) pandemic was the first
pandemic in the era of modern pandemic planning and preparedness.
Although the mortality and morbidity caused by the pandemic was low
compared with the previous pandemics, it gave the first opportunity for
member states to implement an actual pandemic response reflecting on years
of pandemic preparedness and planning. The objective of this study was to
evaluate the usefulness of pandemic preparedness activities as well as to
identify challenges and activities that require further improvement.
Methods: The study was conducted in seven countries within the WHO
regional office for Europe; six of them were identified through a stratified
random sampling in order to get a representative sample across different
levels of preparedness within the WHO European Region. These were
Armenia, Bosnia and Herzegovina, Denmark (pilot country for the study),
Germany, Portugal, Switzerland and Uzbekistan. Research teams visited each
country and interviewed six key stakeholder groups at different administrative
levels. These were Ministry of Health (MOH), National Public Health
Authority (NPHA), Civil Emergency Response (CER) representatives, Sub-
National Government Authority, and primary and secondary healthcare
workers (HCWs). Focus group interviews were conducted using open-ended
questions in semi-structured interview guides.
Results: Six recurring themes were identified as essential aspects of
pandemic planning activities. These were communication, coordination,
ii
capacity building, mutual support, leadership, and flexibility. The following
aspects of pandemic planning activities were found to be inadequate and
should be improved in the future: risk communication with the public and
healthcare workers, coordination of vaccine logistics, flexibility and
adaptability of pandemic plans, and surveillance in the secondary healthcare
setting.
Conclusions: Stakeholders interviewed reported that the pandemic
preparedness activities were worthwhile and appropriate for the response
measures carried out during the pandemic influenza (H1N1) in 2009.
However, the findings identified areas of under planning that were common
to most of the participating countries.

iii
Acknowledgements
Praise is due to almighty GOD for all he has given me, his compassion and
mercifulness to allow me to complete this Ph.D. project.
I would first and foremost like to thank my supervisors, Professor Jonathan
Van-Tam and Professor Ian Shaw for giving me the opportunity to complete
this study. Without their kind supervision, professional guidance, kindness
and mentoring over the years, this thesis would not have been completed.
I owe Professor Van-Tam a special debt of gratitude for his advice provided
to me throughout my Ph.D., M.P.H., and while I was working as an
epidemiologist within his team. His invaluable knowledge, immense technical
support, continual guidance and support over the years have given me great
confidence and have been essential in undertaking this research project. I
learned from him over six years how to communicate with other public health
professionals, work in collaboration, leadership, problem solving, and
supporting and loving others. I really consider him as a father and role model.
Also, I would like to register my gratefulness to Professor Ian Shaw for
introducing me to the social sciences field and the qualitative research
methods His input and feedback were instrumental and helped me to shift my
rational from the deductive-quantitative approach to the inductive-qualitative
methodology. I would also like to thank Dr. Caroline Brown, Dr. Lucie Lucie
Jean-Gilles, and Michala Hegermann-Lindencrone from the World Health
Organization Regional Office for Europe for their professional guidance since
the early start of the project. Their scientific discussions, motivation,
iv
encouragement, constructive criticism and suggestions proved most valuable.
Their faith and belief in me were my motivation, inspiration and strength. I
would also like to thank Dr. Puja Miles from the University of Nottingham
for her help with the sampling of the countries.
I would like to thank the stakeholders in the seven countries for their
participation in the study and for taking the time out of their busy schedules
to interview with me. My thanks also are extended to WHO advisors and
consultants who helped with conducting the interviews: Liana Martirosyan ,
Jo Newstead, Peet Tull, Pasi Penttinen, Emmanuel Robesyn. Christophe
Pierre Bayer, Robb Butler, Ana Paula Coutinho, Irina Papieva, Anna
Pashalishvili, Dmitriy Pereyaslov, Mark Witschi.
I too must register my thankfulness to the WHO Regional Office for Europe
for paying my tuition fees and living expenses throughout my Ph.D. studies.
The office also paid for the travel expenses, accommodation, and
organization of the seven country missions. Moreover, I would like to thank
my colleagues in the Health Protection and Influenza Research Group
(HPRG) who supported me throughout my PhD studies and I would like
particularly to thank Sharon Figgens for her support and encouragement over
the years. Last but not least, I am extremely grateful to my family, parents,
brothers, beloved wife Noora, and wonderful son for their love, patience and
encouragement throughout this study. Lastly, I wish to acknowledge all of
those who are not mentioned, who supported me in any respect during the
completion of my study. Thank you very much to all!
v
List of publications
The following articles and presentations arose from this study:
1. Hashim, A., Jean-Gilles, L., Hegermann-Lindencrone, M., Shaw, I.,
Brown, C., & Nguyen-Van-Tam, J. (2012). Did pandemic preparedness aid
the response to pandemic (H1N1) 2009? A qualitative analysis in seven
countries within the WHO european region. Journal of Infection and Public
Health, 5(4), 286-296.
2. Hashim, A., Shaw, I., Nguyen-Van-Tam, Jean-Gilles, L., Hegermann-
Lindencrone, M., & Brown, C. (2010). Recommendations for good practice
in Pandemic Preparedness: Identified through evaluation of the response to
pandemic (H1N1) 2009.
http://www.euro.who.int/__data/assets/pdf_file/0017/128060/e94534.pdf
3. Oral presentation at the fourth European Scientific Working Group on
Influenza (ESWI) conference in Malta, September 2011. “Evaluation of how
pandemic preparedness helped to deal with H1N1 in the WHO European
Region”.
4. Moderated poster presentation at the fourth European Public Health
conference in Copenhagen, November 2011. Did pandemic preparedness
activities aid the response to influenza (H1N1) pandemic in 2009? A
qualitative analysis.

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Table of Contents

Chapter
 1:
 Introduction
 .............................................................................
 1

1.1
 Project
 rationale
 and
 objectives
 ......................................................................
 1

1.2
 How
 did
 influenza
 A
 (H1N1)
 pandemic
 unfold
 in
 2009?
 ...................................
 2

1.3
 Pandemic
 influenza
 preparedness
 ...................................................................
 7

1.4
 How
 did
 the
 researcher
 choose
 pandemic
 influenza
 preparedness
 to
 be
 his

PhD
 research
 project?
 ...........................................................................................
 8

1.5
 Thesis
 overview
 ............................................................................................
 10

1.6
 Summary
 and
 conclusion
 ..............................................................................
 11

Chapter
 2:
 The
 basics
 of
 influenza
 ............................................................
 12

2.1
 Introduction
 ..................................................................................................
 12

2.2
 Inter-­‐pandemic
 Influenza
 (seasonal
 influenza)
 vs.
 Pandemic
 Influenza
 ..........
 12

2.3
 Clinical
 features
 ............................................................................................
 14

2.4
 Influenza
 virology
 .........................................................................................
 17

2.5
 Influenza
 epidemiology
 and
 surveillance
 .......................................................
 19

2.6
 Conclusion
 ....................................................................................................
 22

Chapter
 3:
 Historical
 review
 .....................................................................
 24

3.1
 Introduction
 ..................................................................................................
 24

3.2
 Early
 History
 of
 Infectious
 diseases
 ...............................................................
 25

3.2.1
 The
 plague
 of
 Athens
 .......................................................................................
 25

3.2.2
 The
 Black
 Death
 ...............................................................................................
 26

3.2.3
 Smallpox
 epidemic
 ...........................................................................................
 28

3.2.4
 Syphilis
 outbreak:
 “The
 French
 pox”
 ................................................................
 29

3.3
 Factors
 in
 the
 emergence
 of
 infectious
 disease
 .............................................
 29

3.3.1
 Environmental
 factors
 .....................................................................................
 30

3.3.2
 Human
 behaviours
 and
 demographics
 changes
 ..............................................
 31

3.3.3
 Deficiencies
 in
 public
 health
 infrastructures
 ...................................................
 32

3.4
 Development
 in
 the
 understanding
 of
 infectious
 diseases
 .............................
 33

3.5
 Progress
 in
 infectious
 disease
 planning
 and
 response
 ...................................
 34

3.6
 International
 efforts
 to
 control
 communicable
 and
 infectious
 diseases
 .........
 37

3.7
 Pandemic
 influenza
 preparedness:
 Historical
 review
 .....................................
 41

3.7.1
 Pandemics
 before
 the
 eighteenth
 century
 ......................................................
 41

3.7.2
 Pandemics
 of
 the
 eighteenth
 and
 nineteenth
 centuries
 .................................
 42

3.7.3
 History
 of
 pandemics
 of
 the
 twentieth
 century
 ...............................................
 42

3.8
 Conclusion
 ....................................................................................................
 47

Chapter
 4:
 Emergency
 planning
 and
 response
 management
 ....................
 49

4.1
 Introduction
 ..................................................................................................
 49

4.2
 Emergency
 planning
 ......................................................................................
 49

4.3
 Emergency
 planning
 objectives
 .....................................................................
 50

4.4
 Guidelines
 for
 emergency
 planning
 ...............................................................
 52

4.4.1
 Flexibility
 ..........................................................................................................
 52

4.4.2
 Coordination
 ....................................................................................................
 52

4.4.3
 Training
 and
 education
 ....................................................................................
 53

4.4.4
 Dynamicity
 .......................................................................................................
 54

4.5
 Emergency
 response
 management
 ................................................................
 55

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4.5.1
 Collaboration
 ...................................................................................................
 55

4.5.2
 Cognition
 ..........................................................................................................
 56

4.5.3
 Coordination
 ....................................................................................................
 56

4.5.4
 Communication
 ................................................................................................
 57

4.6
 Organizational
 communication
 .....................................................................
 58

4.7
 Basics
 of
 organizational
 communication
 .......................................................
 59

4.7.1
 Organizational
 communication
 as
 a
 process
 ...................................................
 59

4.7.2
 Organizational
 communication
 as
 people
 .......................................................
 59

4.7.3
 Organizational
 communication
 as
 messages
 ...................................................
 59

4.8
 Organizational
 structure
 ...............................................................................
 60

4.9
 Communication
 flows
 ...................................................................................
 60

4.9.1
 Vertical
 communication
 ...................................................................................
 60

4.9.2
 Lateral
 Communication
 ....................................................................................
 61

4.10
 Communication
 network
 .............................................................................
 62

4.11
 Conclusion
 ..................................................................................................
 62

Chapter
 5:
 Pandemic
 preparedness
 activities
 ...........................................
 64

5.1
 Introduction
 ..................................................................................................
 64

5.2
 Background
 on
 emerging
 infectious
 disease
 planning
 ...................................
 64

5.3
 Elements
 of
 pandemic
 influenza
 preparedness
 .............................................
 66

5.3.1
 Pandemic
 planning
 and
 exercising
 ...................................................................
 67

5.3.2
 Surveillance
 ......................................................................................................
 69

5.3.3
 Pharmaceutical
 measures
 ................................................................................
 71

5.3.4
 Non-­‐pharmaceutical
 public
 health
 measures
 ..................................................
 76

5.3.5
 Business
 continuity
 planning
 ...........................................................................
 77

5.3.6
 Communication
 ................................................................................................
 79

5.4
 International
 vs.
 National
 pandemic
 planning
 ...............................................
 81

5.4.1
 International
 Planning
 .....................................................................................
 81

5.4.2
 National
 planning:
 a
 whole-­‐of-­‐society
 approach
 .............................................
 84

5.5
 Conclusion
 ....................................................................................................
 86

Chapter
 6:
 Methods
 .................................................................................
 87

6.1
 Introduction
 ..................................................................................................
 87

6.2
 Qualitative
 evaluation
 methodology
 .............................................................
 88

6.3
 Selection
 of
 countries
 ...................................................................................
 92

6.3.1
 Countries
 stratification
 ....................................................................................
 92

6.3.2
 Sample
 size
 ......................................................................................................
 93

6.3.3
 Stratified
 random
 sampling
 .............................................................................
 94

6.4
 Data
 collection
 ..............................................................................................
 96

6.4.1
 Identifying
 key
 stakeholders
 for
 pandemic
 preparedness
 ...............................
 96

6.4.2
 Interview
 setting:
 Focus
 groups
 .......................................................................
 97

6.4.3
 Structuring
 data
 collection
 instruments
 ..........................................................
 98

6.4.4
 Information
 gathering
 before
 country
 visit
 ...................................................
 100

6.4.5
 The
 pilot
 study
 ...............................................................................................
 101

6.5
 Data
 analysis
 ...............................................................................................
 104

6.5.1
 Data
 transcription
 ..........................................................................................
 104

6.5.2
 Organizing
 data
 ..............................................................................................
 104

6.5.3
 Data
 coding
 ....................................................................................................
 105

6.6
 Credibility
 of
 the
 findings
 ............................................................................
 106

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6.7
 Ethics
 ..........................................................................................................
 107

6.8
 Summary
 and
 conclusion
 ............................................................................
 107

Chapter
 7:
 Findings
 .................................................................................
 109

7.1
 Introduction
 ................................................................................................
 109

7.1.1
 Characteristics
 of
 study
 participants
 ..............................................................
 109

7.1.2
 Country
 visits
 .................................................................................................
 111

7.2
 Theme
 one:
 Communication:
 ......................................................................
 113

7.2.1
 Multi-­‐sectoral
 participatory
 planning
 ............................................................
 113

7.2.2
 Plan
 dissemination
 channels
 and
 target
 groups
 ............................................
 116

7.2.3
 Useful
 actions
 for
 effective
 communication
 ..................................................
 119

7.2.4
 Areas
 of
 under
 planning
 and
 communication
 difficulties
 encountered
 ........
 122

7.3
 Theme
 two:
 Coordination
 ...........................................................................
 126

7.3.1
 Timelines
 of
 coordinated
 pandemic
 planning
 activities
 ................................
 126

7.3.2
 Useful
 coordination
 activities
 ........................................................................
 129

7.3.3
 Exercises
 related
 to
 pandemic
 preparedness
 ................................................
 131

7.3.4
 Areas
 of
 under
 planning
 in
 terms
 of
 coordination
 .........................................
 134

7.4
 Theme
 three:
 Capacity
 Building
 ...................................................................
 136

7.4.1
 Training
 as
 a
 useful
 activity
 before
 pandemic
 ...............................................
 137

7.4.2
 Useful
 activities
 implemented
 before
 the
 pandemic
 .....................................
 139

7.4.3
 Useful
 actions
 for
 enhancing
 capacity
 building
 .............................................
 142

7.4.4
 Under
 planning
 of
 certain
 capacity
 building
 activities
 ...................................
 144

7.5
 Theme
 four:

 Mutual
 Support
 ......................................................................
 145

7.5.1.
 Guidance
 documents
 were
 useful
 pandemic
 activities
 before
 and
 after
 the

pandemic
 ................................................................................................................
 145

7.5.2
 Under
 planning
 financial
 support
 for
 pandemic
 preparedness
 activities
 ......
 149

7.5.3
 Under
 planning
 for
 support
 in
 certain
 areas:
 .................................................
 150

7.6
 Theme
 five:
 Leadership
 ...............................................................................
 151

7.6.1
 Sectoral
 lead
 roles
 during
 pandemic
 preparedness
 planning
 ........................
 152

7.6.2
 Actions
 considered
 useful
 by
 countries
 for
 effective
 pandemic
 preparedness

planning
 through
 leadership
 ...................................................................................
 155

7.6.3
 Expectation
 from
 WHO
 as
 a
 leader
 on
 pandemic
 preparedness
 ...................
 157

7.7
 Theme
 six:

 Adaptation
 and
 flexibility
 in
 pandemic
 planning
 .......................
 158

7.7.1
 Revision
 of
 pandemic
 plans
 before
 the
 pandemic
 .........................................
 159

7.7.2
 Planning
 scenarios
 .........................................................................................
 160

7.7.3
 Useful
 actions
 for
 flexible
 planning
 and
 response
 .........................................
 160

7.7.4
 Under
 planning
 in
 certain
 areas
 .....................................................................
 162

7.8
 Conclusion
 ..................................................................................................
 164

Chapter
 8:
 Discussion
 .............................................................................
 166

8.1
 Introduction
 ................................................................................................
 166

8.2
 Development
 of
 public
 health
 management
 of
 communicable
 diseases
 ......
 167

8.3
 Core
 principles
 for
 pandemic
 preparedness
 ................................................
 171

8.3.1
 Leadership
 and
 national
 pandemic
 planning
 committee
 ..............................
 175

8.3.2
 Participatory
 planning
 ....................................................................................
 176

8.3.3
 Financial
 support
 to
 preparedness
 and
 planning
 activities
 ...........................
 178

8.3.4
 Communication
 and
 coordination
 .................................................................
 178

8.3.5
 Command
 and
 control
 structure
 ...................................................................
 180

8.3.6
 Communication
 with
 the
 public
 .....................................................................
 181

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