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Homeland Security

REPORT TO THE PRESIDENT ON U.S. PREPARATIONS FOR 2009-H1N1 INFLUENZA



VII. Improving Communications


CHAPTER SUMMARY

Communication will be one of the most formidable challenges in managing the anticipated resurgence of 2009-H1N1 this fall, due to the rapidly evolving nature of the outbreak, the number and complexity of the messages, and the myriad channels through which the public will be receiving information.

CDC is the lead Federal agency for communication with state and local health departments, health care providers, and the general public. CDC’s communications plans for the first two groups appear to be proceeding well, although we offer some suggestions.

Concerning communications with the general public, the Working Group believes it would be desirable to have well-developed communications plans that cover a variety of contingencies and is concerned that the planning for such communications may be somewhat behind schedule.

We recommend that CDC expand its efforts to develop a full range of communication plans for various
contingencies. In view of the fact that 2009-H1N1 particularly affects young people, these plans would ideally include outreach not only to traditional media but also new media and social networking channels.

Introduction

One of the lessons of prior influenza epidemics is the importance of timely, clear, and effective commu­ nication among government officials, medical professionals, and the public. In spring 2009, CDC reacted well in terms of communications with both professionals and the public. CDC maintained a steady flow of up-to-date information and admitted the limitations of its knowledge as the situation evolved.

During the expected fall resurgence of 2009-H1N1, communication will again pose a formidable chal­ lenge for officials and others trying to manage the pandemic. But the communications challenge will be fundamentally different than in the spring, when the epidemic arrived unexpectedly and CDC’s stance was necessarily reactive. For the anticipated fall resurgence, CDC’s approach must be pro-active. The fundamental difficulties are that (i) the messages will be more numerous and more complex and (ii) the precise content of the messages is uncertain for now and will depend on the specifics of how the public health situation unfolds. Nonetheless, the existing data give planners enough knowledge to envision different scenarios of how events could play out (see Chapter 3). This makes it possible—and we believe imperative—to have carefully considered communication plans prepared in advance, ready for many contingencies.

For instance, if only limited supplies of vaccine are available initially, it is likely that diverse groups at particularly high risk of severe disease will be prioritized for vaccination and potentially for antiviral medications, as described in Chapter 5. Communication plans need to be developed to reach individuals

who belong to the designated high-risk groups and their health care providers—for example, through patient advocacy groups, provider organizations, radio and TV spots, and social networking. The content and format of the outreach materials should be considered in advance. Contacts should be made in advance with leaders of relevant media or patient organizations so they can prime their networks for rapid delivery of the relevant messages.

CDC clearly is the lead Federal agency for communication with three constituencies: (1) state and local health departments, (2) health care providers, and (3) the general public. The Working Group reviewed CDC’s communications plans in these areas for the anticipated epidemic this fall.

The Working Group expressed confidence in CDC’s communications plans with the public health departments and health care providers; the Group’s primary suggestion for communication with these groups is that CDC work to harmonize recommendations with relevant medical societies. In contrast, the Working Group expressed some concern that CDC’s plans for public communications appear to be inadequately developed at present and somewhat behind schedule. In addition, the Group was con­cerned that CDC had not adequately planned to engage the full range of communications channels. Because 2009-H1N1 will particularly affect young people, there is an opportunity and need to engage new media and social networking channels.


MAIN RECOMMENDATION (CHAPTER 7)

We recommend that CDC accelerate its planning efforts for public communications. Given the limited time frame and the wide range of uncertainties, we recommend that CDC systematically identify the full range of messages that may need to be communicated, particularly messages about actions that may be required of the public under various scenarios; prepare well-developed plans for these communications; and begin outreach to relevant communications channels as soon as possible.

We also recommend that CDC engage not only traditional media, with which CDC has deep experi­ ence, but also new media and social networking channels, especially given the propensity of the 2009-H1N1 virus to infect young people. For this purpose we recommend that CDC draw heavily on the expertise of the office of the Federal Chief Technology Officer.

Communication with State and Local Health Departments

CDC deserves high marks for its coordination of information flow to and from state and local health departments during the spring 2009-H1N1 outbreak. It clearly articulated what was known and unknown, provided useful updates in real time, and assimilated large amounts of regional data to pro­ vide an evolving picture of what was happening on the national level.

In Chapters 3 and 4, the Working Group recommends that CDC (i) define and disseminate specific sce­ narios concerning the pandemic and (ii) improve various surveillance systems. These steps should feed into and enhance communications with state and local health departments. In addition, the Working Group urges CDC to prepare materials to help Federal, state, and local health officials deal with potential misunderstandings relating to adverse events. It is certain that, by chance, some adverse events will occur following vaccination (e.g., on any given day, some elderly individuals will die and pregnant women will miscarry). It is important that CDC has well-developed materials completed in advance to set such events in context, as well as to help experts recognize truly unexpected occurrences.

Communication with Health Care Providers

Medical professionals rightly regard CDC as the authoritative source for public health information, especially during emerging epidemics. In general, CDC has discharged this function well during the present crisis. However, there have been several instances in which its recommendations have been controversial—particularly those regarding hospital infection control, which have sometimes been based on hypothetical concerns rather than epidemiological data. Some of these recommendations generated controversy and even outright opposition from caregivers. For example, CDC’s recommenda­ tion for use of N95 respirators by those caring for hospitalized 2009-H1N1 patients is at variance with the views of several other expert bodies. Such conflicts can generate confusion and anxiety at many levels in the hospital workplace, impair effective compliance with proper infection control, and undermine physician confidence in CDC and public confidence in local infection control measures at a time when confidence levels need to be maximized.


RECOMMENDATION 7-1: HARMONIZE RECOMMENDATIONS

We recommend that CDC work to harmonize its recommendations with those of relevant profes­ sional societies prior to their public release. As discussed in Chapter 5, relevant societies include the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America ( IDSA ), and, where recommendations concern children, the American Academy of Pediatrics (AAP).

Communication with the General Public

CDC and other Federal agencies must communicate with the public in two broad areas: (1) medical interventions (vaccines and antiviral medications); and (2) non-medical, community-based interven­ tions (e.g., social distancing and isolation of sick individuals). The Working Group has some concerns with the communications plans in both areas. Since they have different origins, the two sets of concerns are considered separately.

Medical Interventions: CDC has a long history educating the public about seasonal influenza and the vaccine that provides protection against it. Despite this experience, efforts to prepare the influenza public information campaign for fall 2009 have been hampered by several factors, including:

  • the need to divert staff to communicate urgently with the public regarding the spring 2009- H1N1 outbreak

  • uncertainties about the 2009-H1N1 vaccine (including how much will be available, on what schedule it will arrive, how many doses may be needed, and who should receive vaccination); and

  • the inherent complexity of a public health message that encompasses two vaccines for two different types of influenza (2009-H1N1 and a seasonal strain), especially if two doses of 2009- H1N1 vaccine are required.

For these and other reasons there is much communications work ahead, and very little time to complete it. CDC’s information campaign will need to:

  • refocus the public’s attention on 2009-H1N1 influenza, which has largely receded from public consciousness (due in part to the media’s sporadic attention to the topic), and its relationship to seasonal influenza;

  • keep the public updated about the severity of the epidemic;

  • educate the public about when to seek medical attention and where to do so;

  • inform the public about personal and community-wide action that may be necessary this fall, and steps people can take to be prepared;

  • reach groups at particularly high risk; and

  • respond effectively to unexpected events, such as reports of adverse events that occur following (but not necessarily because of) vaccination.

To accomplish these missions, it is critical that CDC have well-developed public communications plans that can be launched rapidly. The planning for various contingencies should be completed now, before all the relevant information is available. Contacts with various media should be established soon, and messages and materials should be developed and tested.

We particularly encourage CDC to work with new media and social networking channels. Beyond simply transmitting CDC’s own messages, we believe there are opportunities to engage and encourage the creativity of the social networking community to create content and collect information. Members of the Working Group were impressed by a recent paper by researchers at Google and CDC demonstrating that an analysis of Google searches related to influenza-like symptoms was able to identify outbreaks earlier than conventional surveillance systems. Examples could include: 1) websites with information about initial self-diagnosis and treatment, up-to-date information about the epidemic, and perhaps even ways to share personal information that could help inform national surveillance; 2) mobile phone “apps” with similar content; 3) videos that convey messages in unusual ways; and 4) Facebook quizzes on influenza, shared among friends. In support of efforts to fight the influenza virus, we advise the use of communications tools designed to facilitate their “going viral.” Such tools are more likely to be created by members of the public than by the government. However, it may be possible to encourage such efforts through contests and other mechanisms.

RECOMMENDATION 7-2: CDC COMMUNICATION EXPANSION

We recommend that CDC expand its efforts to develop a robust communications plan covering the full range of potential public messages about medical and non-medical interventions. We strongly suggest that communications efforts be launched prior to September 1.

    A. With respect to traditional media, we suggest that CDC reach out to major communication channels (e.g., editorial boards and medical reporters at newspapers, TV and radio stations, and magazines) to inform them about issues, to interest them in running stories to promote awareness, and to maintain connections that will facilitate communication when unfolding events demand rapid responses.

    B. With respect to new media and social networking, we suggest that CDC reach out to key companies (e.g., Facebook, Twitter, Google, Apple) and other innovative entities and indi­ viduals (those who maintain prominent websites and blogs related to health in general and influenza in particular). In this outreach, CDC could benefit by working closely with the Federal Chief Technology Officer.

    C. In addition, we urge CDC to expand its capacity to develop rapid responses to misinformation appearing in traditional media and on the Internet

Non-medical Interventions : Compared to communications about medical interventions, communica­ tions about social actions to mitigate spread of the influenza virus can be crafted in relatively finished form despite uncertainties about details of the epidemic. Public understanding about such personal measures and their public health value are particularly important given the likelihood that vaccine will not be available as rapidly as desirable. The Working Group expressed some concern that public com­ munications plans for such measures appear to be incompletely developed.

Fundamentally, there are two main categories of personal actions to mitigate viral spread, hand hygiene awareness and individual efforts at social distancing, which can be summarized in two simple messages: “Keep your hands clean” and “Stay home when you’re sick.” Although these messages are simple, the educational campaign is difficult because it involves persuading people to change established pat­ terns of behavior and requires broad adoption to be successful. Campaigns to encourage these actions should strive for clarity and simplicity; use diverse and complementary channels of communication; and incorporate thoughtful policies to mitigate barriers to compliance (see Chapter 7). Importantly, such campaigns will need to educate the public about why the measures are needed as well as how to comply with them.

Hand hygiene awareness is more than just hand washing. It includes minimizing contact of hands with respiratory secretions—by coughing into a sleeve rather than a hand, for example. Communication channels that can transmit graphic visual images (e.g., television and Internet) are likely to be the most effective. The public already has accepted media ads involving more sensitive bodily functions, and major advertising agencies know how to craft effective and acceptable messages in this regard. New media and social networking expertise may also be effective here.

Social distancing campaigns, especially those that go well beyond the simple notion of remaining isolated, generally at home, when ill, must enlist the participation of the general public to be effective. Workers and students will need to know when to stay home and for how long; they will also need guid­ ance about proper infection control in the home. When asking the public to eschew activities that involve crowds at sporting events, concerts, transportation centers, shopping areas, and other gathering places, the messages will need to explain the rationale for such changes in behavior and provide an estimate of the length of time the recommendations will be in place. All channels are useful and efforts should be made to enlist the most effective communicators (e.g., celebrities) to deliver the relevant messages.

Such campaigns also need to enlist the support of those responsible for the venues in which suscep­ tible and infected people are likely to congregate (e.g., employers, school and university administrators, church leaders, sports leagues, and rock concert promoters). Now is the time for the CDC to establish communication channels with corporate human resource professionals, school officials, and others to inform them about the public health issues surrounding 2009-H1N1 and to help them understand that allowing sick individuals to stay home is in their organizations’ best interest, as it will minimize large-scale absenteeism. Universities may require special guidance about infection control in dormitory settings.


RECOMMENDATION 7-3: CDC COMMUNICATION QUICK LAUNCH

We recommend that CDC rapidly develop and launch its communications plan concerning personal non-medical interventions.

In particular, we suggest that CDC: a) immediately hire a major advertising organization to help craft ads for non-medical interventions, targeted at various audiences (e.g., employers, the general public, school administrators) and b) work with the Federal Chief Technology Officer to engage new media and social networking channels in support of these goals.



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