Indonesia Conducts 3-Day Drill of Pandemic Influenza National Response Plan
By Luciana Borio, MD, May 1, 2008
A small rural village in Bali spent months preparing to participate in what the Jakarta Post described as Indonesia’s first massive pandemic influenza exercise, held this past weekend.1 Indonesia has good reason to drill on a large scale: 107 people have died from H5N1 avian influenza avian flu there, a number that represents close to 50% of the world's total human deaths from H5N1, and the virus is endemic in bird populations in most of the country.2
Indonesia’s scripted exercise, which cost $500,000 and was funded by the U.S. Centers for Disease Control and Prevention (CDC), began the morning of Friday, April 25, and ran through Sunday, April 27.3 With 1,000 participants, this drill involved local village residents, 20 institutions–ranging from the armed forces, to healthcare organizations, to foreign and trade ministries–and more than 50 foreigners, including many diplomats; it was covered by more than 50 local and international journalists.4,5 The purpose was to test the Indonesian government’s readiness and response to a pandemic, as outlined in its National Strategic Plan for Avian Influenza Control and Pandemic Influenza Preparedness.1,6 The Jakarta Post reported that at least 2 other much smaller drills were held earlier this year, and that Singapore and South Korea have conducted computer-simulated drills, but this was the first in the region that involved real-life conditions. The paper also reported that 8 more simulations will be conducted throughout the year.6
The drill began in Dangin Tukadaya village, on the resort island of Bali, when a man presented himself to a clinic with symptoms of avian influenza. Health workers, who initially assumed he had been in contact with infected chickens, soon learned that the man had no such contact, and they realized that he had contracted the illness from another villager, indicating that the H5N1 virus was being spread from person to person.5
In response, access to the village was shut down, chickens were slaughtered, and health officials raced to identify and isolate other ill people and quarantine their houses and families.3 Local officials distributed supplies to those under quarantine. Antiviral prophylaxis was dispensed to prevent disease spread. Schools were closed. Healthcare workers donned full body protective suits and “moved like ghostly astronauts around the field hospital tents set up outside the main building.”4 Travelers at the Bali airport were screened with thermal scanners to detect fever prior to leaving or entering. Vehicles from the village arriving at the airport were sprayed with disinfectant, and passengers underwent “health checks.” Those who had visited the affected village underwent additional screens.7
This drill was fully scripted and limited to a small rural community. While analysis and final reports on the drill will take some time, first impressions suggest that some of the public health actions that were taken in the drill, such as imposition of quarantine, are difficult to implement and sustain and are of limited value in a pandemic situation. News reports did not cover hospital response, so it is not possible to learn how the main hospital managed to deliver care to the ill patients.
Two commendable features of the exercise were the involvement of the full range of sectors (health, safety, transportation, etc.) and the extent to which local villagers participated in this exercise. Pandemic influenza drills typically test formal response institutions, casting the population at-large as mere bystanders to the crisis. In contrast, rural villagers played key roles in this exercise, learning first hand the challenges of disease containment as well as the difficulties of cross-sector coordination.
The comments of one villager suggest the value of incorporating citizens into preparedness activities. Villager I Wayan Nerken, 51, whose role in the drill was to report the sudden "death" of one of his chickens, said the exercise was "very useful . . . So far the information that we've got about bird flu has been limited to what we've seen on television. We don't really understand [how to act] when an infection happens," he told the press. "Before this I didn't know that we're not supposed to handle the carcasses when chickens die suddenly."5
Monica Schoch-Spana, PhD, contributed to this article.
Fitri E. Bird flu drill gives residents golden lessons. Jakarta Post April 27, 2008. http://www.thejakartapost.com/news/
2008/04/27/bird-flu-drill-gives-residents-golden-lesson.html. Accessed April 30, 2008.
World Health Organization. Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO. http://www.who.int/csr/disease/avian_influenza/country/ cases_table_2008_04_02/en/index.html. Updated April 2, 2008. Accessed April 30, 2008.
Fitri E. Drills to test pandemic preparedness. Jakarta Post April 26, 2008. http://www.thejakartapost.com/node/167307. Accessed April 30, 2008.
Williamson L. Bird flu: Indonesia's trial run. BBC News April 29, 2008. http://news.bbc.co.uk/go/pr/fr/-/2/hi/asia-pacific/7371658.stm. Accessed April 30, 2008.
Indonesia runs massive bird flu drill. Agence France-Presse April 25, 2008. http://afp.google.com/article/ALeqM5iB2SZX9N0iuouw
3Mp8r6SIEdUjAQ. Accessed April 30, 2008.
Fitri E. Why bird flu? Why a pandemic simulation? Jakarta Post April 27, 2008. http://www.thejakartapost.com/news/
2008/04/27/why-bird-flu-why-a-pandemic-simulation.html. Accessed April 30, 2008.
Friti E. Bali airport in ‘chaos’ as flu pandemic drill ends. Jakarta Post April 28, 2008. http://www.thejakartapost.com/news/
2008/04/28/bali-airport-039chaos039-flu-pandemic-drill-ends.html. Accessed April 30, 2008.
Schoch-Spana M, Franco C, Nuzzo JB, Usenza C; on behalf of the Working Group on Community Engagement in Health Emergency Planning. Community engagement: leadership tool for catastrophic health events. Biosec Bioterror 2007;5:8-25.
Wray RJ, Becker SM, Henderson N, et al. Communicating with the public about emerging health threats: lessons from the Pre-Event Message Development Project. Am J Public Health 2008 Apr 1 [Epub ahead of print] http://www.ajph.org/cgi/content/abstract/AJPH.2006.107102v1. Accessed April 30, 2008.