The French vaccination campaign 2009: A failed project in Public Health

Luisa Assuncao Sabrina Kunzli

Managing Projects in real Life M. Nicolas Pejout Sciences Po Fall semester 16 October 2012

The French vaccination project a failed project in public health _____________________________________________________________________________________________________

Table of Contents
1.
2. 3. 4. 5. 6. 7. 8. Introduction .......................................................................................................................... 3 The Project: La campagne de vaccination contre la grippe A(H1N1) ..................................... 3 The failure ............................................................................................................................ 4 Why did it fail........................................................................................................................ 4 Recommendations ................................................................................................................ 6 Conclusion ............................................................................................................................ 8 Bibliography.......................................................................................................................... 8 Appendix .............................................................................................................................. 9

Figures
Figure 1: Benchmarking the project Figure 2: Vaccined people per June 2010 Figure 3: The initial costs Figure 4: Timeline Figure 5: The framework of the project 4 9 9 10 10

The French vaccination project a failed project in public health _____________________________________________________________________________________________________

1. Introduction
In 2009, the world was hit by a pandemic influenza popularly known as the swine flu caused by the H1N1 virus, which can only be contracted by person-to-person transmission. Before spreading worldwide the A (H1N1) virus was first detected in Mexico in April 2009 followed by a growing number of cases in the USA. In June 2009, the World Health Organization (WHO) declared this new strain of H1N1 the swine flu a pandemic. By August 2010, the WHO officially announced that the H1N1 influenza pandemic was over. According to them, the A (H1N1) influenza caused 18,000 deaths across 213 countries (World Health Organization website, 2010). Concerned by the speed with which swine flu spread, countries responded to the warning and recommendations posed by the WHO and adopted protective and security measures in order to mitigate transmissions and to prevent deaths. So too did the French government, which initiated a nationwide vaccination campaign with the ultimate goal to vaccinate 75% of the French population. However, this campaign turned out to be a huge failure in public health since only 8.5% of the French people were finally vaccinated. During the swine influenza 312 deaths and over 1,334 severe cases were registered in France (Rapport Assemble National, 2010, p. 147). This paper aims to evaluate the failed project by analysing how and why it failed as well as by giving recommendations. For this purpose, in the first part of this paper we will briefly introduce the 2009 vaccination campaign in France, followed by its failures as well as the reasons for failing will be identified before proceeding to the last part where recommendations will be given.

2. The Project: "La campagne de vaccination contre la grippe A (H1N1)

La campagne de vaccination contre la grippe A (H1N1) was launched on November 12th 2012. Figure 4 in the appendix shows the timeline of the project whose planning phase started with the official declaration by the WHO in June 2009 and ending at the beginning of February 2010. The projects framework consisted of a very centralized structure (see figure 5) involving principal actors such as the Prime Minister, Dominique de Villepin, the ministry of internal affairs and the ministry of health (Rapport Assemble National, 2010, p. 44). Apart from French government authorities, the WHO, international pharmaceutical companies, health care professionals, and of course the French society were involved in the project as well. In order to achieve the ambitious goals of providing two successive vaccine doses to 75% of the entire French population the French government bought 94 millions doses of vaccines as well as 34 millions more in reserve for the upcoming year from the four international operating pharmaceutical companies Sanofi-Pasteur, GlaxoSmithKline, Novartis and Baxter. They ordered 28 millions doses of Panenza, 16 millions doses of Focetria, 50 millions doses of Pandemrix and 50,000 doses of Celvapan. The total amount accounts for approximately 712 million Euros for 94,050,000 doses as shown in figure 3 in the appendix (Rapport Assemble National, 2010, p. 9). For the purpose of carrying out of the vaccine campaign 1,049 special mass vaccination centres were put in place across the country (Rapport National, 2010, p.91). These centres were led by several teams consisting of professionals form the health sector as well as other people working within the that field for instance medical students (Service de presse du ministre de la sant et des sports, 2010, p. 11). Each team was capable of vaccinating 360 people in four hours. The first available vaccines were reserved for and distributed to 1.2 million people working in the health, emergency and security sector at the end of October. On November 12th the official beginning of the project the centres were opened to the public targeting first the priority population: 1.7 million household contacts and caregivers for children younger than 6 months 888,000 additional health care professionals in primary care settings 2.8 million individuals aged 6 months to 64 years at risk for AH1N1 influenza complications

The French vaccination project a failed project in public health _____________________________________________________________________________________________________

In December, the vaccination campaign was extended to other at-risk individuals that were older than 65 years. During that time, the vaccination has also started in schools. The targeted beneficiaries were thoroughly identified by the French Sickness Insurance Fund. Each person had received personalized invitation letter from the Minister of Health. The letter contained some practical information concerning the vaccination as well as the address of the closest vaccination centre. Throughout the campaign 6 million letters were sent (Schwarzinger et al., 2010, pp.1-2). In order to reach the public attention for the vaccination campaign and raise awareness for the critical situation a spot on the radio and a 50 seconds one on television were launched and broadcasted by national channels. In addition, they announced the start of the campaign in the press at the beginning of November. The slogan of the campaign was: La meilleure protection, cest la vaccination (Service de presse du ministre de la sant et des sports, 2010, p. 17).
Country

The French vaccination campaign can be benchmarked to similar projects that had been taken place worldwide. According to the Rapport Assemble National (2010, p. 82), the figure behind clearly shows that the performance of the French vaccination project can be ranked around the middle. Thus, they were not the only country that failed.

Sweden Canada USA Japan France UK Belgium

Percentage of vaccinated population: 64.5% 45% 23.4% 17.9% 8.5% 7.4% 6%

Number of people (approximately) 6 million people 70 million people 22.78 million people 5.36 million people 4.54 million people -

Figure 1: Benchmarking of the project - Own figure

3. The failure
Whereas French authorities and resources were greatly engaged in order to fight swine flu the vaccination campaign ended up as a national public health failed project title was given by the majority of newspapers dealing with the final results of this campaign. The goal was to vaccinate 75% of the population. However, in June 1st 2010 only 8.5% of the population was finally vaccinated. Not even half of those as considered as priority were vaccinated. According to the National Report of the National Assembly (2010) only 25% of pregnant women were vaccinated, 30% of children between 6 and 24 months, 10% of children from 24 months to 11 years old and 30% of health professionals. While we consider this campaign as having failed it is important to distinguish the nature of the different reasons. Some of the factors that led to the failure were based on the uncertainty of the situation. Still many others were management problems that could have been predicted and avoided.

4. Why did it fail

A) Managing uncertainties and squanderings
1. Vaccines overestimation According to French law No. 95-101 of February 2nd 1995, the government response to a risk situation should involve prudence1, prevention2 or precaution when it is a probable risk the scope of which cannot be estimated. Based on this law and on the WHO declaration of a Pandemic of level 6 3, the French government was alarmed and decided to respond under the Precautionary Principle. Therefore, of the three available scenarios i, the French government chose on July 3rd to vaccinate 75% of the population using, for people under 65 years old, two vaccine doses and, for

if it is a known risk and we can calculate its frequency if it is a known risk and we cannot evaluate its frequency 3 http://www.who.int/influenza/preparedness/pandemic/h5n1phase/en/index.html
1 2

The French vaccination project a failed project in public health _____________________________________________________________________________________________________

people over 65, one dose. This decision amounted to the procurement of 119 Million doses. A year later, the National Report registered besides the 50 million doses cancelled a stock of 20.95 million dosesii. According to them, only 64% of the order is explained by the Precautionary Principle; the rest was an overestimation. 2. A high price for a low result At the beginning of the campaign, the expected cost was supposed to be approximately 1.5 billion euros. In the end, only about 668.35 million euros were spent. The costs were reduced because of the annulled vaccines but the indemnity cost was enormous: over 48 million euros for pharmaceutical industries4 and 103.5 million for health professionals. 3. No leeway on contracts Concerning the contracts, the Ministry of Health could not act flexibly because time was pressing but also because they had pre-pandemic contracts to which they were bound. In fact, on July 29th 2005 the Ministry of Health signed a contract with Novartis and on October 27th signed a further one with Sanofi-Pasteur in order to prevent any Pandemic threat. Nevertheless, in 2009, extremely concerned by the abysmal WHO predictions, the Ministry of Health considered that they had not enough doses and hired GlaxoSmithKline and Baxter to make sure they would have the correct amount of vaccines. These last contracts were made in a hurry and pharmaceutical companies had a clear advantage. Firstly because there was a vaccine race between states at the international level and secondly, at the national level, ltablissement de preparation et de rponse aux urgencies sanitaires5 in charge of signing the contracts did not have the expertise to understand the prices and was unable to properly negotiate. In fact, they had to consult M. Nol Renaudin, President of the Economic Committee of Health Products, which ended up costing time and enhancing delays. 4. Delayed decision The Ministry of Health decided its scenario on July 3rd and, only then, established the final amount of needed vaccines, which was already too late. On June 26th, the Haut Conseil de la Sant publique6 said that the implementation of vaccination beyond 30 days after the beginning of the circulation of the influenza A (H1N1) would have a very limited impact on the evolution of the pandemic wave. In fact, the first cases in France were registered at the beginning of May 2006, which means that when the campaign strategy was set, the Ministry of Health should have considered that its impact was going to be small, and furthermore known the delivery delaysiii of the vaccines.

B) Inappropriate campaign strategy

1. Doctors court-circuited The non-acknowledgement of the most important actors of the health care system is regarded as the biggest error of the vaccination campaign. Not only was the Haut Conseil de la Sant publique ignored but more importantly, the whole body of private practitioners was forgotten. In the project framework iv there was no room for the their opinion. Moreover, it was too centralized which led the project leaders to be overcharged and they ended up forgetting important aspects such as basic provisions for vaccination centers or schools and specific instructions concerning unusual patients and events. They were not even able to ensure the fulfillment of the vaccination training for many of its distributors. According to M. Didier Tabuteau, this campaign brought to light the existing tensions between public authorities and doctors. The campaign built a

[2 million for Sanofi-Pasteur, 10.46 million for Novartis and 35.84 for GlaxoSmithKline]- cf. Annex Etablissement cre le 5 Mars 2007 la demande du ministre charg de la sant, dacqurir, fabriquer, importer, distribuer et exporter des produits et services ncessaires en cas de crise sanitaire 6 Avis du Haut conseil de la sant publique du 26 juin 2009 relatif la pandmie grippale : http://www.sante.gouv.fr/IMG/pdf/Avis_vaccination_vac_sans_adjuvantA_H1N1_080709.pdf
4 5

The French vaccination project a failed project in public health _____________________________________________________________________________________________________

parallel system of vaccination consisting of teams according to healthcare volunteers and left behind 50,000 private practitioners, 60,000 nurses, 3,000 hospitals and 22,000 health officers. Syndicates, health professional organizations and even the National Academy of Medicine made complaints about the fact that this campaign short-circuited the French health system; not only because it was against law7 and but also because it was illogical. They addressed neither existent facilities, nor general practitioners. 2. Citizens avoided the vaccination centers There is no doubt that the missing involvement of private practitioners correlates to the low percentage of vaccinated people. As a result of French societys political distrust, the tradition of blindly trusting private practitioners, the fact that more than 40% of doctors did not get any vaccines and that many even discouraged their patients to do it, each contributed to the overall failure of the campaign. Moreover, as they could not provide the vaccination and could not give enough information to their patients because they were excluded from the project, members of the public considering the vaccination were discouraged and thus, ended up not receiving it. Confused by the unclear information, they preferred to trust their doctors. 3. Communication problems The reluctance of health professionals was the first communication issue. Having been excluded from the system, instead of enhancing the message of the campaign, doctors and nurses led an anti-campaign, both directly with their patients and through the internet. Moreover, the message of the initial campaign had been lost in the media. It was not well-targeted and was identical on both radio and television. Furthermore, advertising for the campaign began a mere three days before vaccinations began on November 12th, leaving an incredibly short time-frame for which the public to become informed. Similarly, too much airtime was given to speakers without medical expertise, giving the campaign less credibility than could otherwise have been achieved. Moreover, the campaign oscillated between trivial and often alarming information, frequently shifting the focus of its message. The anti-propaganda, reached a far greater audience than that of the official campaign. The extent of online rumors discredited the voice of official authorities. A study made by Schwarzinger et al. (2010, p.1) in which 2000 people were interviewed, found that the vast majority of the public thought the vaccine to be more dangerous than the likelihood of being infected with A (H1N1). As such, the messages of the Ministry of Health did not reach their goal.

5. Recommendations
Following the above analysis a few recommendations are now being developed, which might help to improve further vaccination or health-related projects in the future.

A) Managing uncertainties
1. More realistic estimations based on reliable information and data As described in the previous part one of the problems was related to the overestimation of the vaccines. Alarmed by the recommendation of the WHO the French government rashly ordered a too big share of doses acting according to the Precautionary Principle. Even though, the French government was not wrong in his reactions, they should have tried to step into a dialogue with the WHO first in order to get more information and data regarding the situation. This would have avoided an overreaction that had lead to an overestimation of the vaccines doses needed. For this purpose we suggest a creation of a special task force at the European Union level, involving several EU countries, to put pressure on the WHO for receiving clear facts, numbers and information. For a realistic calculation these kind of information are evident.

Law n 2009-879, July 21st 2009, stipulates that general medicine should be the first engaged in risky situations.

The French vaccination project a failed project in public health _____________________________________________________________________________________________________

With regard to the targeted number of people the project leaders should have been more realistic and less ambitious. Being faced with a huge time pressure the vaccination campaign aimed at mitigating the spread of the swine flu it was a very ambitious goal to vaccine 75% of the population in a very short time of period. Especially when considering the fact that in normal cases they only target 50% of the population. Therefore, the projects goal to vaccine 75% of the population was too ambitious and led to unnecessary high costs. 2. Better and more flexible co-operation with companies One further problem of the vaccination campaign was related to the mismanagement of contracts with the pharmaceutical companies as shown in the previous part. Due to pre-pandemic contracts the French government was bound to the already set conditions and could not change them anymore when facing the pandemic threat. For this reason, having more flexible contracts with pharmaceutical companies would have enabled the French government to react more flexible and better manage any uncertainties regarding number of vaccine doses needed. 3. Consider time frame Considering the time frame there are two recommendations. As the time frame was extremely restrictive and could not be changed the focus lies on two major facts that were responsible for a loss of time. First, they did not listen to the "Haut Conseil de la Sant Publique" that said that any actions were already too late. If they had they would have saved money and maybe consider another way of fighting the virus. Thus, the first recommendation refers to thoroughly take into account experts' knowledge. The second element that cost the time was the delays between creating the vaccines and having them on the market. There were three ways of getting authorization to trade vaccines (the mock-up authorization or prototype authorization, the decentralized authorization and the American authorization) but they were slow. Therefore, it is recommended for a further pandemic to have a policy that short-cuts normal market authorizations in critic periods.

B) Wrong campaign strategy?

1. Build up a more coherent framework One of the biggest problems of the project is related to its framework. First of all, the framework has not foreseen to include any private practitioners. This led to the circumstance that a very important and active stakeholder in the public health sector was not part of the vaccination project. Since they are the direct connection between public health and the citizens their involvement in the project would have significantly contributed to the success of the project. It is, therefore, recommended to integrate all possible and relevant stakeholders in the project that could be useful in achieving the goals. In addition, the organisation was very centralized structured. This structure has led to a high exposure of single units and derived from that to a poor fulfilment of their tasks as described above. A more decentralized structure where regions and zones have bigger responsibilities would have enabled the French government not only to allocate the responsibilities more efficiently but also to reach more citizens. Especially for a governmental project that targets the whole population the involvement of all governmental levels is essential. Of course, this would also require a proper report system that is necessary for transparency so that all involved officials know what the other side is doing. 2. Take into consideration the needs of the target groups According to the project was only possible to get the vaccination at the centres that have been put in place for that purpose. Since the project failed to attract enough people the provision of the vaccination at different places would have helped to attract more people. Therefore, they should have better considered the different needs of the target groups and thus offer the vaccination at different locations. It would have been effective letting private practitioners vaccine their patients in their offices since patients have a much closer relationship to them than some medical staff working in the vaccination centres.

The French vaccination project a failed project in public health _____________________________________________________________________________________________________

3. Use diverse communication tools The low number of vaccine people has further shown that the communication tools that were used during the project were not sufficient enough to reach a wider audience possible and to raise the awareness of the benefits of vaccination. Alongside a 50 seconds spot on the television as well as one on the radio they should have also used other kind of communication tools in order to create attention for the vaccination campaign. First, it is recommended to take into consideration the use of social media tools not only to reach a diverse group of people but also to make all information about the pandemic swine flu easily accessible to everyone. Tools such as Facebook and Twitter would have enabled the project team to regularly give updates on the campaign and to inform people about the newest developments with regard to the spread of the swine flu. With these kind of tools they could have involved the society within the project and make it a societal project in which everyone wants to be part of rather than only a government one. Moreover, marketing of the campaign should have commenced earlier in order to provide a more thorough sweep of information and hence, convinced more members of the public to participate. In addition, the involvement of private practitioners into the campaign would also have helped to get peoples attention and interest since people usually get first hand information in health care issues from them. Similarly, the organization of informal information sessions at a local level could have been utilized in order to communicate information more personally and allowed for questions to be answered.

6. Conclusion
This paper has highlighted the failure of the vaccination project that took place in France in 2009. Derived from the failure this paper has further developed recommendations that could be considered for any future projects in public health. After all, it is important to underline that the goal of the project was very ambitious considering the short time of period that was available to carry out the campaign. The communication tools and the framework of the project were not adequate enough to address the issue and convince the French public to be vaccinated. Nevertheless, it has to be emphasized that in France only 312 people have died compared to the overall registered deaths rate of 18,138 people. Although the French government was able to distribute over 5 million vaccinations and far fewer people were affected by swine flu than had previously been predicted, the project was still largely unsuccessful in achieving its goals.

7. Bibliography
BBC website (2012): Health causes of swine flu. http://www.bbc.co.uk/health/physical_health/conditions/swineflumulti1.shtml [accessed 13 October 2012] Retrieved from

Service de presse du ministre de la sant et des sports (2009): Lancement de la campagne vaccinalecontre la grippe A(H1N1) dans les centres de vaccination. Retrieved from http://www.sante.gouv.fr/IMG/pdf/Lancement_de_la_campagne_vaccinale_contre_la_grip pe_A_H1N1_dans_les_centres_de_vaccination.pdf [accessed 5 October 2012] Schwarzinger, M. et al. (2010): Low Acceptability of A/H1N1 Pandemic Vaccination in French Adult Population: Did Public Health Policy Fuel Public Dissonance? PLoS One 5(4): e10199. Doi:10.1371/journal.pone.0010199

The French vaccination project a failed project in public health _____________________________________________________________________________________________________

World Health Organization website (2010): Situation updates Pandemic (H1N1) 2009. Retrieved from http://www.who.int/csr/disease/swineflu/updates/en/ [accessed 6 October 2012] Assemble National (2010): Rapport denqute sur la manire dont a t progr amme, explique et gre la campagne de vaccination contre la grippe A(H1N1). Retrieved from http://www.assembleenationale.fr/13/rap-enq/r2698.asp#P1551_252939 [accessed 25 September 2012] Commission d'enqute sur la manire dont a t programme, explique et gre la campagne de vaccination contre la grippe A (H1N1) http://www.assemblee-nationale.fr/13/dossiers/enquete_campagne_vaccination_grippeA.asp [accessed 7 October 2012] Dossier de presse : Droulement de la campagne de vaccination contre la grippe A(H1N1) jeudi 3 dcembre 2009 http://www.sante.gouv.fr/dossier-de-presse-deroulement-de-la-campagne-de-vaccination-contre-lagrippe-a-h1n1-jeudi-3-decembre-2009.html [accessed 7 October 2012] Dossier de presse : Lancement de la campagne vaccinale contre la grippe A(H1N1) dans les centres de vaccination http://www.sante.gouv.fr/dossier-de-presse-lancement-de-la-campagne-vaccinale-contre-la-grippea-h1n1-dans-les-centres-de-vaccination.html [accessed 7 October 2012] Moatti Schwarzinger, Grippe A : pourquoi les Franais nont-ils pas mieux adhr la campagne de vaccination ? http://www.inserm.fr/espace-journalistes/grippe-a-pourquoi-les-francais-n-ont-ils-pasmieux-adhere-a-la-campagne-de-vaccination [accessed 12 October 2012]

8. Appendix
Vaccined people per June 2010
Nombre de personnes vaccines Centres de vaccination quipes mobiles de vaccination en milieu scolaire et hors scolaire (notamment tablissements mdico-sociaux) tablissements de sant (1) Mdecine librale 4 168 021 553 937

520 753 16 385

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Centres de secours (personnels de secours) Centres de rtention Grandes administrations et grandes entreprises (vaccination autonome) Franais rsidant ltranger Total
Figure 2: Rapport (2010), p.5

36 080 360 2 687 62 763 5 360 986

Initial calculation
Fabricants Spcialits Commande initiale (en nombre de doses) Caractristiques du vaccin Prix unitaire en euros hors taxes Cot total en millions deuros hors taxes Cot total en millions deuros toutes taxes comprises 369,25 184,63 157,659

GlaxoSmit hKline SanofiPasteur Novartis

Pandemrix Panenza Focetria

50 000 000 28 000 000 16 000 000

Multidoses 300 000 monodoses 5,8 millions de monodoses (avenant notifi le 13 octobre 2009) Multidoses

7 6,25 9,34

350 175 149,44

Baxter Total

Celvapan

50 000 94 000 000

10

0,5 674,94

0,528 712,06

Figure 3: Rapport, (2010), p. 8

Timeline

10

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Figure 4: Rapport, 2010, p. 42

The framework of the project

Figure 5. Rapport (2010), p. 45

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The French vaccination project a failed project in public health _____________________________________________________________________________________________________

Scenarios
1 2 la vaccination de la totalit de la population, qui ncessitait la commande de 130 millions de doses de vaccins la vaccination de la totalit de la population de moins de soixante-cinq ans et linjection dune seule dose pour les plus de soixante-cinq ans, dans la mesure o ces derniers bnficient dj dune certaine immunit grce la vaccination contre la grippe saisonnire, hypothse qui supposait lacquisition de 119 millions de doses ; et enfin, la vaccination dune population plus restreinte, se limitant notamment aux jeunes, aux personnes fragiles et aux personnes rle critique en cas de pandmie (PARCEP), pour laquelle 60 millions de doses savraient indispensables. Figure 6. Rapport (2010), p.26

ii

tat du stock de vaccins au 5 mai 2010

(En nombre de doses)

Doses de vaccins livres par les laboratoires Sorties des sites de stockage de lPRUS tablissements de sant Sorties dpartements doutre-mer Sorties centres de vaccination Dons lOrganisation mondiale de la sant Sorties officines Ministre des affaires trangres, collectivits et pays doutre-mer Vente au Qatar Campagne interne des ministres Total Stock disponible total au 5 mai 2010 Dpositaire PRUS Rpartiteurs pharmaceutiques Total Stock physique au 05 mai 2010 Dpositaires PRUS Rpartiteurs pharmaceutiques Don lorganisation mondiale de la sant en attente denlvement Total

44 052 200 1 565 700 459 600 9 160 000 9 400 000 1 277 000 858 000 300 000 83 500 23 103 800 18 464 700 2 483 700 20 948 400 18 464 700 2 483 700 3 365 000 24 313 400

volution des rsultats des sondages dopinion raliss par le service dinformation du Gouvernement
Date du sondage 22 et 23 juillet 2009 24 et 25 aot 2009 31 aot et 1er septembre 2009 14 et 15 septembre 2009 14 et 15 octobre 2009 4 et 5 novembre 2009 27 et 30 novembre 2009
iii

Intention de se faire vacciner certainement et probablement 67 % 65 % 56 % 39 % 19 % 14 % 26 %

Delays
Vaccins
Total des commandes (nombre de doses) Hypothses de rendement de la souche Aot Septe mbre / Octobr e Octobr e/ Novem bre Novemb re / Dcembr e Dcembre / Janvier Janvier / Fvrier Fvrier / Mars Mars / Avril

Celvapan (Baxter) Pandemrix (GlaxoSmithKi ne)

50 000 50 000 000 22,5 g 34 g 45 g

12 000

38 000 4 934 000 5 434 000 7 651 000 8 151 000 10 368 00010 868 000
Septembre Octobre

5 434 000 8 151 000 10 868 000

Novembre

5 434 000 8 151 000 17 896 000

Dcembre

5 434 000 17 896 000

Janvier

5 434 000

17 896 000

Focetria (Novartis)

Tranche ferme : 16 000 000

Hypothse 1 : 30 % Hypothse 2 : 60 % Hypothse 3 : 100 %

1 500 000

2 500 000

4 500 000

1 000 000 2 000 000 par mois 2 000 000 3 000 000 par mois

3 000 000 5 000 000

6 000 0 00 10 000 000

10 000 0 00 16 000 0 00

12