Chapter Objectives
Describe two types of information that epidemiologists and emergency risk communications cocreate.
Identify three unique information needs of the medical community.
Explain how the information needs of the medical community are different from those of the general public.
List two ways hospital and other medical facilities can leverage the Crisis and Emergency Risk Communication (CERC) framework to communicate with staff and patients.
Cocreating Emergency Risk Communication Messages with Epidemiologists
Collaboration among emergency risk communicators, epidemiologists, clinical experts, and other subject matter experts is critical to the development of scientifically accurate and credible emergency risk communication messages. Being able to create emergency risk communications that demonstrate the Crisis and Emergency Risk Communication (CERC) principles of Be Right, Be Credible, and Promote Action requires the scientific data being gathered and analyzed by epidemiologists and other subject matter experts within the health agency.
“Epidemiology is the branch of medical science that investigates all the factors that determine the presence or absence of diseases and disorders.”[1] Epidemiologists collect and analyze data from people affected by a health emergency to identify the threat and develop a plan to respond to and manage it. Using quantitative and qualitative methods, epidemiologists gather data to understand the context in which a disease exists and progresses, rates of new illness (i.e., incidence rates), and the number of existing cases (i.e., prevalence). Understanding exposure to the infection is key to developing a public health intervention that will protect people’s health. Additionally, epidemiologists seek to understand people’s responses to the illness, including mild or typical symptoms, current immunity, classical clinical features of the illness, and even death.[Reference Brachman, Abrutyn, Brachman and Abrutyn2]
Chapter 2 outlined the key roles to include in a crisis communication team for a health agency and advocated for ensuring subject matter experts serve on the crisis communication team. Subject matter experts such as epidemiologists can be included in the communication team to ensure the development of accurate emergency risk communication messages based on the available science and epidemiological data. While emergency risk communicators understand how to write health messages for a health emergency, the scientific content of the messages will come from the epidemiologists who are collecting the data about the evolving health emergency and its impacts on the community. The following sections outline how epidemiologists and emergency risk communicators cocreate emergency messages that are actionable, understandable, and data-driven.
Message Content: Health Risks and Interventions
Epidemiologists can provide two important types of message content: health risks and interventions. As emergency risk communicators develop messages for the initial, maintenance, and recovery phases of an emergency, the health risk will change as new data become available. Working with epidemiologists ensures emergency risk communicators will have the most accurate and up-to-date information about the health threat, including signs and symptoms, level of risk based upon exposure, level of risk based upon age or underlying health conditions, and what interventions are available to mitigate or prevent the health threat.
Using the 2015–2016 Zika outbreak, let’s review how message content is cocreated between epidemiologists and emergency risk communications. The information gathered by epidemiologists creates a profile of the illness and identifies who is most at risk. Through descriptive and analytic epidemiology, the following information describes the health risks associated with the Zika virus.
Health Risk
In 2016, the World Health Organization (WHO) declared Zika a public health emergency of international concern due to clusters of microcephaly cases and other neurological disorders reported in Brazil and in French Polynesia.[3] Epidemiological information helped health officials understand what the illness is, who is affected, how they are affected, and the location of the outbreak, and in turn develop health interventions to deal with the outbreak. Prior to the recent outbreak, Zika virus was primarily carried by monkeys with little “spillover infections in humans.”[Reference Ibrahim4] However, since 1952, public health officials have had evidence that Zika can infect humans. Early cases were found in Uganda and Nigeria and later in other African countries and Indonesia. By 2007, an epidemic occurred in Yap Island; another then occurred in French Polynesia in 2013, followed by others in Cook Island and New Caledonia in 2014.[Reference Ibrahim4] By 2016, 60 countries were experiencing Zika cases, and by 2017 cities along the US–Mexico border also reported Zika cases. The Zika virus is transmitted to humans by the bite of a female mosquito. Humans spread it to other humans through sexual transmission. Additionally, there is perinatal transmission, meaning the Zika virus can be transmitted in utero to a developing fetus, causing microcephaly – a brain abnormality.[Reference Ibrahim4] Zika can also cause Guillain–Barré syndrome. Symptoms of Zika in adult humans include mild fever, joint pain, headaches, rash, and pink eye.[Reference Ibrahim4] Symptoms can last for up to 7 days and the incubation period is 3–12 days.
All of this information can be used to develop initial, maintenance, and recovery messages for audiences identified through the emergency risk communication plan. Chapters 6, 7, and 9 provide specific steps for writing and creating emergency risk communications during a health emergency. The following is a sample initial emergency risk communication message about Zika. More information about writing and creating initial messages is presented in Chapter 7.
Initial Messages: What They Are and How to Write Them
Communicating early during a health emergency manages the expectations of the public and stakeholders, establishes organizational credibility, establishes trust with those affected by the emergency, and provides actionable health information that people can act upon to protect their health. These first crisis messages are called “initial messages” and they are usually sent within the first 24–48 hours of a health emergency.
Initial message components include:
Addressing uncertainty
Making a commitment
Providing messages of self-efficacy
Expressing empathy
Incorporating these message components into emergency risk communication messages allows spokespeople and health agencies to follow the CERC principles.
Addressing Uncertainty and Making a Commitment
Addressing uncertainty focuses on what is known about the health threat, what is not known, and what public health officials are doing to learn more about the emerging threat. The following example of addressing uncertainty comes from Representative Eliot L. Engel, Ranking Member of the House Committee on Foreign Affairs, on January 28, 2016. Parentheticals are included to emphasize how the message addresses uncertainty (i.e., what is known, what is not known, and what health officials are doing to learn more) and what constitutes a commitment to the community.
We shouldn’t allow the ongoing uncertainty surrounding the Zika virus to spark a panic. (what is unknown) Domestic and international health experts are taking this issue seriously, and I’m committed to working in Congress to ensure that this outbreak is dealt with quickly and competently. (what is known)
President Obama’s recent meeting with top U.S. health officials and today’s announcement by the World Health Organization (WHO) of an emergency meeting on Zika are good steps. (what health officials are doing to learn more) I encourage continued efforts to address the issue head-on. (making a commitment) This challenge will require enhanced research, substantial resources, interagency cooperation, and coordinated efforts to ensure that clear information reaches the public as quickly as possible. I have long called for increased engagement with our partners in the Americas, and at this difficult time, the United States must assist our neighbors as they continue to fight the Zika virus. (making a commitment)[5]
Providing Messages of Self-Efficacy
Providing messages of self-efficacy or promoting action, a CERC principle, means giving people a meaningful action they can take to protect their health and prevent illness. The following example comes from WHO regarding reducing sexual transmission of Zika:
For regions with active transmission of Zika virus, all people with Zika virus infection and their sexual partners (particularly pregnant women) should receive information about the risks of sexual transmission of Zika virus.
WHO recommends that sexually active men and women be counselled and offered a full range of contraceptive methods to be able to make an informed choice about whether and when to become pregnant in order to prevent possible adverse pregnancy and fetal outcomes.
Women who have had unprotected sex and do not wish to become pregnant due to concerns about Zika virus infection should have ready access to emergency contraceptive services and counselling. Pregnant women should practice safer sex (including correct and consistent use of condoms) or abstain from sexual activity for at least the entire duration of pregnancy.
For regions with no active transmission of Zika virus, WHO recommends practicing safer sex or abstinence for a period of three months for men and two months for women who are returning from areas of active Zika virus transmission to prevent infection of their sex partners. Sexual partners of pregnant women living in or returning from areas where local transmission of Zika virus occurs should practice safer sex or abstain from sexual activity throughout pregnancy.[6]
Expressing Empathy
In July 2016, Ashley Young, a pregnant woman living in the United States, wrote then-President Barack Obama a letter about her Zika concerns and potential for getting sick and passing the illness to her child in utero.[Reference Somanader7] President Obama replied to the letter, and his first paragraph is an example using empathy. He acknowledges her concerns and admits his own as a father. The rest of the letter outlines self-efficacy steps Ashley can take and the United States’ commitment to addressing the Zika health threat through research on new vaccines and increased epidemiological surveillance to detect the disease. Parentheticals are included to emphasize how the message addresses empathy and uncertainty (i.e., what is known, what is not known, and what health officials are doing to learn more) and provides a message of self-efficacy.
Dear Ashley:
Thank you for writing me. Your email reached my desk, and as President and as a father, I want you to know I take your concerns very seriously. My foremost priority is the health and safety of Americans and my Administration is working around the clock to protect you and families across our country. (express empathy)
Most people who become infected with Zika will not even know it because the symptoms are usually nonexistent or mild. However, as you noted, scientists have established a link between Zika infections during pregnancy and poor birth outcomes. Our primary goal is to minimize these outcomes, and early in the year I instructed my staff to do all we can to respond to the Zika threat. (address uncertainty – what is known)
While we are still learning about Zika, we do know there are ways to minimize your risk if it does appear in your community, including protecting yourself from mosquito bites by wearing long sleeves and pants, staying in places with air conditioning and window and door screens, and wearing EPA-registered insect repellants. You can find more information and steps you can take to protect yourself and your family from Zika at www.CDC.gov/Zika. CDC regularly updates this information as we learn more, so I encourage you to check back often. (address uncertainty – what is known; provide messages of self-efficacy)
In the meantime, I have directed my team to accelerate research on new vaccines and methods of detecting the disease. Additionally, I’ve formed a coalition of experts and Federal, State, and local leaders to combat the spread of Zika so that we can identify any outbreaks in the continental United States early and contain them. To make sure our public health officials have the resources needed to prepare and respond to Zika, I’ve asked Congress to approve $1.9 billion in emergency funding to support and advance these efforts as quickly as possible. (make a commitment) Again, thank you for writing. Your message will remain on my mind. (express empathy)
Sincerely,
Barack Obama[Reference Somanader7]
Interventions
The second message content area where emergency risk communicators and epidemiologists cocreate emergency risk communications is communicating health interventions, or the actions people can take to protect their health during a health emergency. Chapters 7 and 8 provide in-depth information about promoting health interventions during short- and long-term health emergencies. Let us continue reviewing the 2015–2016 Zika health emergency to understand how epidemiologists and emergency risk communications cocreate emergency risk communication messages about health interventions.
Since the Zika virus is transmitted by mosquitoes, looking at the physical environment would be a key intervention in stopping mosquito breeding. This intervention of addressing the environment is critical in reducing the spread of Zika because there is no vaccine available to prevent Zika. Strategies to address mosquito breeding include:
Elimination of standing water containers
Use of larvicides (biological or chemical) to disrupt mosquito development
Chemical control: spraying or toxic baits of adult mosquitoes
Physical control: trapping female mosquitoes to prevent egg-laying or capturing eggs
There are no specific treatments for Zika; nonpharmaceutical intervention, such as providing supportive care in the form of resting, increasing fluids, and taking medication to reduce fever and pain, are key action steps that can be taken. Additionally, to reduce sexual transmission, wearing condoms is recommended.
All of this information can be used to develop initial, maintenance, and recovery messages for audiences identified through the emergency risk communication plan. Chapters 6, 7, and 9 provide specific steps for writing and creating emergency risk communications during a health emergency. The following is a sample maintenance emergency risk communication message about Zika. More information about writing and creating maintenance messages is provided in Chapter 7.
Maintenance Messages: What They Are and How to Write Them
Maintenance messages are usually sent about 7 days into a health emergency, and this phase can last for weeks, months, or even years. There are four key message components of a maintenance message that will support the CERC principles of Be Right, Be Credible, Promote Action, and Show Respect. Incorporating these message components into emergency risk communication messages allows spokespeople and health agencies to follow the CERC principles.
Maintenance message components include:
Interventions
Making a commitment to the community
Continuing with the Zika virus outbreak, the following sections provide examples of the maintenance message components listed above. In April 2016, CDC released a statement scientifically confirming the link between the Zika virus and microcephaly.[Reference Akpan8] This confirming affirmed many of the health interventions the CDC was promoting for pregnant women. The following paragraphs outline maintenance messages used by the CDC to deepen the knowledge regarding the risks to pregnant women by the Zika virus.
Deeper Risk Explanations
The following text is taken from the CDC website “Zika during Pregnancy.”[9] The intended audience is pregnant women in the United States.
Zika During Pregnancy
CDC recommends you take special precautions if you are pregnant to protect yourself from Zika virus infection.
Because Zika during pregnancy can cause severe birth defects, if you are pregnant, you should not travel to areas with Zika outbreaks (as indicated by red areas on the Zika map). Before traveling to other areas with risk of Zika (as indicated by purple areas on the Zika map), you should talk to a healthcare provider and carefully consider the potential risks of Zika and other infectious diseases.
The only way to completely prevent Zika infection during pregnancy is to not travel to areas with risk of Zika and to use precautions or avoid sex with someone who has recently traveled to a risk area.
We do not have accurate information on the current level of risk in specific areas. The large outbreak in the Americas is over, but Zika is and will continue to be a potential risk in many countries in the Americas and around the world. No local spread of Zika virus has been reported in the continental United States since 2017.
There is no vaccine to prevent or medicine to treat Zika. If you are considering travel to an area with risk of Zika, talk to your health care provider first. It is important to understand the risks of Zika infection during pregnancy, ways to protect yourself, signs of Zika, and the limitations of Zika testing upon your return.[9]
The CDC website content continued to deepen the risk explanation by including information about travel to and from an area with a Zika outbreak, risk of Zika to future pregnancies, and Zika test results. This information was given in English and Spanish.
Interventions
As discussed earlier, there are no vaccines or treatments for Zika. Instead, prevention activities are key. CDC outlines the following key nonpharmaceutical interventions in an infographic (see Figure 4.1):
1 Increasing awareness about sexual transmission.
2 Steps to take to prevent transmission: wearing insect repellant; wearing long sleeves and pants; staying indoors with air conditioning or using window screens; removing standing water around the home.
3 Increasing awareness about Zika and birth defects and encouraging condom use.
4 Encouraging pregnant women to not travel to areas with Zika.
5 Monitoring return travelers and using safe-sex practices.
Figure 4.1 CDC infographic: Top 5 things everyone needs to know about Zika
CDC created this infographic to explain nonpharmaceutical interventions that the public can take to protect themselves from Zika. Providing information on interventions is a key message component of a CERC maintenance message.
Making a Commitment to the Community
The following example message was sent out after the outbreak of Zika and shows how the Obama administration communicated a commitment to the community during the health emergency. This example demonstrates how the President make a commitment to the community to monitor the situation and mitigate the health threat to the public.
The Zika virus is a disease spread primarily through the bite of an infected mosquito – the same type of mosquito that spreads other viruses like dengue and chikungunya.
While most people have no symptoms at all, Zika causes mild illness in some. However, the Centers for Disease Control and Prevention (CDC) has established a link between Zika infection during pregnancy and serious birth defects and other poor pregnancy outcomes. We also know that there can be other serious neurological impacts in some people who are infected with Zika.
We are closely tracking and responding to outbreaks of this virus across the Americas. We have seen transmission in Puerto Rico, the U.S. Virgin Islands, and American Samoa, in addition to cases reported in Mexico, Central and South America, the Caribbean, and the Pacific Islands. The Florida Department of Health is tracking cases of non-travel related Zika in one small area in South Florida and is closely coordinating with the CDC as they further investigate this ongoing situation.
And we know that this particular mosquito lives in certain parts of the southern United States, and we now know that Zika can also spread in another type of mosquito that is present throughout much of the United States. So now is the time to prepare as the seasons change and weather gets warmer.
As President Obama said, we all have to remain vigilant when it comes to combating the spread of diseases like Zika. That’s why the President has called on Congress to provide emergency funding to combat this disease, including to
a. speed the development of a vaccine;
b. allow people – especially pregnant women – to more easily get tested and get a prompt result; and
c. ensure that states and communities – particularly those in the South that have experienced local outbreaks of dengue and chikungunya in the past – have the resources they need to fight the mosquito that carries this virus.
Congress needs to act now to ensure that we have the resources we need to take every step necessary to protect the American people from the Zika virus.[10]
Addressing Rumors and Misinformation
In February 2016, The New York Times wrote an article outlining rumors associated with Zika and providing accurate information.[Reference McNeil11] One of the rumors and information correcting this misinformation are provided in the following as an example of how to address rumors that emerge during a health emergency.
Are genetically modified mosquitoes the real cause of the birth defects?
That buzzing sound you hear is a “no.”
A British company, Oxitec, released genetically engineered mosquitoes in Brazil in an attempt to control dengue fever. But the later microcephaly outbreaks were far away. For example, the largest mosquito release was in Piracicaba, which is 1,700 miles from Recife, where microcephaly was most common. The mosquitoes have also been released in the Cayman Islands, Malaysia and Panama without causing problems.
Mosquitoes fly less than a mile in their lifetimes. Also, only male mosquitoes were released. They do not bite humans or spread disease and were genetically programmed to die quickly.[Reference McNeil11]
Data Graphics
Another important way for epidemiologists and emergency risk communicators to cocreate emergency risk communication messaging is through data graphics that are used on websites, social media channels, handouts, slide decks, or media briefings. As outlined in Chapter 5, multiple communication channels can be used to disseminate key emergency public health messaging. Each communication channel will have a corresponding communication product that can be created and tailored for that particular channel. For example, when engaging in a media briefing, incorporating data graphs and charts may help enhance messaging and further explain the health risk to the public.
Engaging the crisis communication team, including graphic designer, social media manager, and website administrator, will help ensure the usability of the graphics for multiple communication channels. For example, CDC created a data graphic that visually depicts the percentage of babies that are born to people infected with the Zika virus while pregnant (see Figure 4.2). The graphic shows that 5% of babies are Zika-associated birth defects if the mother was infected with Zika while pregnant. Using contrasting colors and icons of infants, the visual depicts the low percentage of babies born with Zika-associated birth defects.
Figure 4.2 CDC graphic: Babies born to people infected with Zika virus while pregnant
CDC created this figure – a data graphic – that visually depicts the percentage of babies that are born to people infected with the Zika virus while pregnant. Data graphics are often cocreated by risk communicators and epidemiologists and are a visual way to explain the risk associated with a health threat.
During the COVID-19 pandemic, CDC created a community-level map that would track data by county and provide a way for people to interpret the risk of getting COVID-19 in their own community (see Figure 4.3). Available epidemiological data about the number of cases and hospitalizations in the area were used to create the data graphic. The map included an image of the United States and incorporated assorted colors that corresponded to particular levels of risk: black was low level, light gray was medium level, and dark gray was high level.
Figure 4.3 CDC Instagram post of United States COVID-19 community-level map
CDC created this figure – a data graphic – that visually depicts the risk of contracting COVID-19 in different communities across the United States. Data graphics are often cocreated by risk communicators and epidemiologists and are a visual way to explain the risk associated with a health threat.
The key for emergency risk communicators is to ensure that the health risk message can be succinctly explained and does not leave interpretation of the graphic up to the end user. A recent study revealed two common problems with public health graphics and data dashboards related to COVID-19.[Reference Momenipour, Rojas-Murillo, Murphy, Pennathur and Pennathur12] First, in charts or graphs that focused on conveying risk, the color graduations were not prominent enough to indicate increased levels of risk. Interpretation of these data and risks was thus left up to the reader. Second, the data dashboards included case counts, interactive charts, and maps with filters, but there were limited to no explanations of what the data meant for people trying to understand their personal risk level within their community.[Reference Momenipour, Rojas-Murillo, Murphy, Pennathur and Pennathur12]
Again, by working together, emergency risk communicators and epidemiologists can design website graphics and data dashboards that convey accurate risk information to the public through the use of trend lines, warning signs, and different colors and icons signaling increased or decreased threat. Create interactive features that allow people to select location information in order to understand the health risk by geographical area. Use “conventional urgency colors instead of non-standard color schemes (i.e., red, yellow, green, for high, moderate, and no urgency levels, respectively) so that the colors directly correspond to user mental models representing danger, moderate danger, and no danger. In addition to using colors, including patterned or texture areas could address accessibility concerns for color-blind users.”[Reference Momenipour, Rojas-Murillo, Murphy, Pennathur and Pennathur12]
Identifying Unique Information Needs of the Medical Community
So far, this chapter has examined how to communicate with the general public by cocreating emergency risk communication messages with epidemiologists. Another equally important set of people need to receive communications during an outbreak, and this group has different informational needs, requiring messages to be tailored to this unique audience. This unique audience is the medical community.
As outlined in Chapter 3, audiences and audience segmentation are important for emergency risk communicators to identify in order to tailor messages that will resonate with each audience. This section will highlight the medical community as a particular audience segment with a unique set of information needs during a health emergency. The first part of this section looks at how the public health community can better understand the needs of the medical community when developing emergency risk communication messages and materials for them. The second part of this section looks at how the medical community can use the CERC framework within its own health care system to communicate with its audiences.
Early coordination between public health, hospitals, urgent care clinics, skilled nursing facilities, and other organizations that provide health care is critical: “Improving response during this window requires acquiring the capability to execute three fundamental elements of early epidemic response: finding cases and identifying where infections are spreading, stopping or slowing community transmission, and supporting those infected or at risk for infection so that hospitals are not overwhelmed and mortality is reduced.”[Reference Bourdeaux, Sasdi, Oza and Kerry13]
Medical Community as Audience Segment
To understand how the medical community is integrated into public health emergency preparedness, it is helpful to look at the Administration for Strategic Preparedness and Readiness’s (ASPR) Hospital Preparedness Program (HPP). The HPP is designed to support health care delivery system preparedness in the event of a large-scale health emergency and build collaborations between health care delivery and public health agencies.[14] Within the HPP, Health Care Coalitions (HCCs) are designed to bring together individual health care and response organizations such as acute care hospitals, emergency medical service (EMS) providers, emergency management agencies, and local and state public health agencies to prepare health care delivery systems to respond to health emergencies.
Similar to the Public Health Emergency Preparedness (PHEP) cooperative grants discussed in Chapter 2, HPP cooperative agreements require a particular set of reporting requirements to prepare the health care system for public health emergencies. These requirements include the following:
Multiyear training and exercise plans
Infectious disease preparedness surge annexes
Infectious disease preparedness surge tabletop discussions/exercises
Financial reporting, including budgets and spend plans
Annual HCC work plans
Annual HCC training plans
Templates
Annual joint HPP–PHEP vulnerable populations exercises
Pandemic influenza planning requirements
Joint exercises between HPP–PHEP partners
After-action reports and improvement plans
Crisis standards of care documents
Hazard vulnerability assessments
Attending particular public health preparedness conferences[15]
Since the HPP and HCC represent critical investments into a system’s approach to preparing public and private health care organizations for health emergencies, it is equally critical for emergency risk communicators to consider the information needs of the medical community during a health emergency. As HPP requirements focus extensively on planning, exercising, and coordination between hospital preparedness and public health preparedness, emergency risk communicators also need to understand what to communicate with this particular audience. Additionally, it is important for emergency risk communicators to consider the information needs of the entire medical community. For example, there are health care providers who provide services outside of hospitals. While hospitals are an important partner in public health emergencies, primary and urgent care clinics often get overwhelmed with questions from their patients, and so they need the most up-to-date information. Including all medical providers on Health Alert Network (HAN) messages ensures the entire medical community will receive important emergency risk communication about a health emergency.
In contrast to the general public, the medical community has particular knowledge, skills, and job responsibilities that are technical, advanced, and treatment-focused. While public health is focused on preventing community health harms and carrying out government legislation to support the health of the community, the medical community is generally focused on treating and curing disease at the individual level.
Common Information Needs of the Medical Community during a Health Emergency
The following six information needs of the medical community are based upon systematic literature reviews of scientific research and personal interviews with members of the medical community.
Scientific Guidance
The medical community needs scientific, evidence-based guidance regarding the identification, collection, and reporting of disease data and data on the treatment of patients. Scientific guidance includes the following key information:
Testing and testing priorities for suspected cases
Handling, collecting, testing, and submitting requirements of clinical specimens
Risk factors and symptoms of the illness
How to prepare for receiving patients with the illness or disease[16]
Kattaryna Stiles, Oregon Health Authority Healthcare Preparedness Program liaison, explained that often scientific guidance documents can be written more abstractly to allow multiple types of health care organizations (urban health care systems, rural health care systems, small health care providers, etc.) to apply the guidance according to the size, scope, and resources available within the organization.[Reference Stiles17] Further, Stiles suggested two challenges of providing scientific guidance during health emergencies: changing guidance and conflicting guidance between CDC and Oregon Health Authority.
First, during a health emergency, the evolving situation creates challenges when new information becomes available, especially when that new information directly impacts the scientific guidance that is currently available. By using dates, different colored fonts, and subheadings, health agencies can alert the medical community to new additions to the scientific guidance documents. Second, timing the release of scientific guidance can be challenging when state health departments are unaware of when CDC will release new scientific guidance. For example, a state health department may adapt CDC’s scientific guidance to be more explicit regarding state and local statues. After releasing the adapted guidance, CDC may release a new document with new information. This can create challenges for the medical community as to which guidance ought to be followed.[Reference Stiles17] Although issuing multiple editions of scientific guidance may feel redundant, medical providers agree that releasing scientific information early and often during a health emergency is important to enabling hospitals to manage response operations within their organizations.[Reference Aslam18, Reference Duchesne19]
Data Reporting
The reporting of disease data is an important function hospitals and health care systems carry out because the more disease data public health epidemiologists have, the better they can identify the disease, its health effects, and who is at risk and so develop health interventions to mitigate impacts on the health care system responsible for treating the disease. Typically, the state government designates what diseases must be reported to the state health departments. A notifiable disease is a disease that “requires health providers (usually by law) to report to state or local public health officials. Notifiable diseases are of public interest by reason of their contagiousness, severity, or frequency.”[20]
During COVID-19, hospitals had to report more than just cases of COVID-19; they also provided data on numbers of cases, deaths, new hospital admissions, numbers of hospitalized patients, and hospitalized patients in intensive care units. Some state and local health departments also tracked the number of available beds and ventilators within the health care system. Kattaryna Stiles suggested that during COVID-19 systems were used to track the data trends of hospitals regarding bed capacity. If beds were available, public health organizations could help coordinate information-sharing between hospitals, and patients were diverted to different hospitals as needed. These types of information-sharing and coordination were possible because hospitals reported key data regarding resource availability.[Reference Stiles17] Juan Duchesne, Tulane School of Medicine Division Chief of Acute Care Surgery and Medical Director of the Trauma Center at University Medical Center New Orleans, agreed that data regarding resources (i.e., hospital beds, available ventilators, personal protective equipment [PPE]) were helpful, and he suggested that sharing data and models regarding viral replication rates and spread and hospital bed saturation would also help hospitals better manage their health care systems during a health emergency.[Reference Duchesne19]
Health Risk
Like the public, health care providers want to understand the health risk from a disease, including its signs, symptoms, incubation period, and treatment options. Providing more specific epidemiological information to determine risk and protective health actions is extremely helpful for medical providers. Genevieve Buser of Pediatric Infectious Disease for a large medical facility in Portland, Oregon, offered this insight: Alerting hospitals that “one case of measles was reported in Oregon” is unhelpful for understanding health risk or for taking action. In contrast, a better emergency risk message would say:
One case of measles was identified in Portland Metro area (or county if can provide by law) in an unvaccinated adult with recent international travel. We suspect the infection was acquired internationally. Ongoing investigations are underway to determine exposures during the contagious period. General public risk is at baseline, and no action is needed at this time. Measles infection is spread through infectious droplets and aerosols. Two vaccinations or birth before 1957 are considered to give life-long protection against measles infection. More information to follow.[Reference Buser21]
Providing more information about the case, a descriptive epidemiology, and prevention and treatment information helps clinicians to determine whether their community is at risk or not.[Reference Buser21]
For medical providers, understanding the health risk, exposure risk, and symptomology is critical to determining the diagnosis, testing, and treatment of patients. In contrast, communicating health risks to the public gives them an opportunity to engage in behavior to prevent the threat from harming their health. If a person arrives at a hospital with illness or disease, it is often too late to prevent health harm, and the hospital or treatment facility must now contend with treating infectious exposures. In addition to conveying information on risks to the general public, health care providers also need to understand how to treat and determine possible exposures to other patients and clinical staff. It is critical that health care providers know how the disease spreads so that health care facilities can take proactive measures to protect patients and staff from getting ill.
Information Relevant by Hospital Department or Medical Facility
In the United States, the private health care industry provides treatment in a variety of ways, including trauma care, hospital care including obstetrics and gynecology (OBGYN), cancer treatment and intensive care units, inpatient and outpatient surgeries, physical rehabilitation, assisted care living, nursing homes, and hospices. Each of these departments within a hospital or standalone health care facility requires specific information based upon its role and function in providing care. For health departments developing emergency risk communication, it is critical to understand the broad messages each health care facility needs (i.e., general prevention messages regarding nonpharmaceutical interventions) and more unique and tailored information regarding processes, procedures, and treatment.[Reference Stiles17, Reference Aslam18, Reference Duchesne19, Reference Buser21]
Personal Protective Equipment
The clinical community needs information about PPE and how to keep staff safe when handling specimens and when treating patients.[Reference Aslam18, Reference Duchesne19] PPE keeps people safe from radiological and biological hazards.[22] Infection control practices like hand hygiene and PPE use are critical steps that support the prevention of illness spread.[22] PPE characteristics include design features, material performance, and use desirability. Design features include protection of mucous membranes, provision of a wide range of vision, and ability to communicate, and they are designed for the size of the person. Material performance includes durability over long shifts, ability to withstand repeated disinfection processes, and, in some cases, the ability to withstand tropical climate exposure. Desirability of use includes simple steps and procedures to don and doff the PPE and the ability to dispose of the PPE in an environmentally friendly manner.[22]
Interventions and Treatments
During a health emergency, interventions play a vital role in mitigating and preventing new cases of the illness through nonpharmaceutical and pharmaceutical activities and behaviors. Communicating health intervention information to the medical community is important so that health care providers can answer questions when asked by patients and work colleagues. Health care providers are often the first sources patients go to when seeking information about health risks. Additionally, when individuals become ill, they will seek out medical care, and the medical community needs to be prepared with clinical guidelines for treatment. During the COVID-19 health emergency, the US National Institutes of Health (NIH) developed COVID-19 treatment guidelines to provide clinicians with guidance for caring for patients with COVID-19.[23] To create the treatment guidelines, NIH convened a panel of medical experts to identify relevant information and published scientific literature related to COVID-19 and to create a systematic and comprehensive review of the literature. After synthesizing the information and discussing it, the panel recommended treatment guidelines based upon scientific evidence and expert opinion.[23] The guidelines created by NIH were also shared with the medical community on CDC’s website, which provided specific information for health care workers.[24]
Understanding How Medical Community Audience Segments Are Different than the General Public
Chapter 3 of this book took an in-depth look at audiences and audience segmentation. It is important for emergency risk communicators to understand the information needs of the medical community and how they differ from the needs of the general public. This section outlines audience segments, key messages, channels, and communication products for the medical community.
Audience Segments
The medical community is made up of many distinct types of medical professional. These include primary care clinicians (i.e., medical doctors, nurse practitioners, physician assistants), pediatricians, osteopathy doctors, naturopaths, dentists, ophthalmologists, nurses, laboratorians, medical imaging technicians, anesthesiologists. There are also many different types of medical facility, including trauma care and hospital care, including pediatricians, neonatal, OBGYN, cancer treatment and intensive care units, inpatient and outpatient surgeries, physical rehabilitation, primary care, pediatrics, assisted care living, nursing homes, and hospices. It is important to outline the information needed by the various health care facilities.
Key Messages
As outlined earlier, there are six key information needs of the health care community. Ensure key messages to this audience include scientific guidance, data-reporting requirements to public health, epidemiological data, health risks, PPE, and health care interventions and treatments. In comparison, messages for the general public provide general overviews of the health emergency, including health risks and simple actions the public can do to protect their health.
Channels
Key channels to reach the medical community include Epi-X and the HAN. Specific webinars or conference calls can be hosted to share key medical information with the medical community. Additionally, leverage HCCs to share and amplify messaging for the medical community. For example, CDC hosts the Clinician Outreach and Communication Activity (COCA) call during health emergencies to share key information with the medical community.[25] In comparison with the general public, health departments are likely to use many channels, including news media and social media, to communicate with a broad audience. Specific channels for the medical community or secure channels like HAN and Epi-X may be used to communicate clinical information.
Communication Products
Based upon the key messages and channel identification, the following communication products will be needed to communicate with the medical community: (1) scientific guidance documents; (2) slide decks for webinars; and (3) handouts or videos as supplemental information for training or educational purposes. In comparison to the general public, communication products for the medical community need to include tailored and specific information. Often, emergency risk communicators develop educational materials like posters and infographics for the public and share those with the medical community. It is important for emergency risk communicators to realize that the medical community is looking for specific information from the health department about the health emergency. Often, HCCs will create public education materials that are of no use to the medical community. Instead, leverage preexisting materials from federal or state government agencies for public education and create and tailor communication materials that include key information that the medical community needs on:
Mini Case Study: CDC COCA Call, COVID-19 Vaccines, December 30, 2020
This mini case study looks at information provided to the clinical and medical community from the CDC’s COCA team. Read the following excerpt from the December 30, 2020, COCA call and answer the questions provided to further understand the importance of segmenting the clinical community as a specific audience with specific information needs.
Good afternoon. I’m Commander Ibad Khan and I’m representing the COCA with the Emergency Risk Communication Branch at the Centers for Disease Control and Prevention. I’d like to welcome you to today’s COCA call. COVID-19 vaccines: Update on allergic reactions, contraindications, and Precautions. Continuing education is not offered for this COCA call. All participants joining us today are in listen-only mode. After the presentations, there will be a Q&A session. Using the webinar system, you may submit a question at any time by clicking the Q&A button at the bottom of your screen, typing your question in the Q&A box, and submitting your question. The video recording of this COCA will be posted on COCA’s webpage and available to view on demand a few hours after the call ends. If you are a patient, please refer your questions to your health care provider. For those who may have media questions, please contact CDC Media Relations at 4046393286 or send an email to media at CDC.gov. I would now like to introduce our presenters for today’s COCA call.
Our first presenter is Captain Tom Shimabukuro. Captain Shimabukuro is a medical officer and currently serves as the Veteran’s Vaccine Safety Team lead for CDC COVID-19 response. Our second presenter is Commander Sara Mbaeyi. Commander Mbaeyi is a medical officer in the clinical guidelines team for CDC COVID-19 response. Captain Shimabukuro, please proceed.
Thank you. I just want to make sure you can hear me before I start. (Yes, Captain.) Great. Good afternoon. And thanks for having me today. It’s a pleasure to present to the group. I’m going to be talking about anaphylaxis following messenger RNA COVID-19 vaccination. I just want to note that some of the slides we’ll be presenting today are adapted from a presentation at ACIP [Advisory Committee on Immunization Practices] on December 19th by Dr. Tom Clark. Next slide. So the first concern for anaphylaxis following COVID-19 vaccination occurred in the United Kingdom, which initiated their vaccination program just prior to the US initiating its vaccination program. And on December 8 the UK started vaccinating with the Pfizer–BioNTech COVID-19 vaccine. On December 9, the UK authorities confirmed two cases of anaphylaxis after vaccination and promptly issued this press release from the MHRA [Medicines and Healthcare products Regulatory Agency]-based confirmation of guidance to vaccination centers on managing allergic reactions following COVID-19 vaccination with the Pfizer–BioNTech vaccine. Next slide. So as far as the US program, ACIP considered anaphylaxis risk during deliberations on the Pfizer–BioNTech COVID-19 vaccine during its December 11th and 12th meeting, it issued interim recommendations for the use of the Pfizer–BioNTech COVID-19 vaccine, and shortly thereafter, CDC issued interim considerations preparing for the potential management of anaphylaxis at COVID-19 vaccination sites. Next slide. So at an ACIP meeting on December 19th and 20th, CDC gave an update on anaphylaxis in the US following COVID-19 vaccination. And in this presentation, CDC had identified six case reports of anaphylaxis following the Pfizer–BioNTech vaccine that met the Britain collaboration criteria for anaphylaxis. All the cases occurred within the recommended observation window and were promptly treated, and all these suspected cases were notified through a CDC notification processes. And at that time, December 19, 272,000 doses of the Pfizer–BioNTech COVID-19 vaccine had been administered. Currently, there’s over 2 million doses of the Pfizer vaccine that have been administered. Next slide. So seek actions to address. These reports of anaphylaxis include courses, close coordination with FDA on safety monitoring, and continued enhanced monitoring for anaphylaxis cases through the Vaccine Adverse Event Reporting System. This involves rapid identification and follow-up on suspected anaphylaxis cases and also case reviews and consultation with allergy immunology experts to provide guidance on evaluation of persons following anaphylaxis to COVID-19 vaccine. And I will say since the December 19th presentation, CDC and FDA through monitoring and various have continued to identify additional cases of anaphylaxis occurring following the Pfizer–BioNTech vaccination. Next slide. So I want to emphasize the role of health care providers in safety monitoring, specifically for monitoring for anaphylaxis.
And that primarily involves recognizing, responding, and reporting anaphylaxis cases following COVID-19 vaccination to VAERS [Vaccine Adverse Event Reporting System] and reporting adverse events to VAERS in accordance with the FDA Emergency Use Authorization reporting requirements and CDC guidance. I’ll also mention participation in CDC’s V-safe program, both for yourself when you get vaccinated and encouraging patients to participate in V-safe and finally communicating with patients on vaccine safety. Next slide. So VAERS is the nation’s early-warning system for vaccine safety provides the quickest information on adverse events and the quickest information to allow us to characterize the safety profile of newly authorized vaccines when recommended in the population. It’s comanaged by CDC and FDA. It’s a spontaneous reporting or passive surveillance system, and it depends on individuals to send reports to viewers. So anyone can send a report to theirs. But health care provider reports are particularly valuable because we believe that the level of detail in the clinical information provided from health care providers in these reports is particularly useful for CDC and FDA. Next slide. The process for reporting adverse events to viewers is an online process. You go to the various websites at Verizon.gov and on the landing page you see here there is a link in the left-hand corner. You click on that link and it takes you to the electronic or the online reporting form and you can fill out a report.
Click “Submit” and then you get a notification that you have successfully completed a report for help. There’s a 1-800 number and there’s also an information email. And if you want to watch video instructions on submitting various reports, you can go to that YouTube link and view a video that’s been created by CDC and FDA. Next slide. And I had mentioned previously – I just want to mention it again – V-safe is an active monitoring system that was stood up by CDC just for COVID-19 vaccination. And these are some resources on the program. Next slide. Right now, V-safe involves a manual registration process. Patients have to self-register. What I’ve shown you here on the on the right-hand side is a screenshot of the of the V-safe information sheet. The full sheet has a URL code and – I’m sorry – a URL and a QR code that you can scan to take you to the registration site. Patients have to enter a few data elements and register, and once you’re in the system, then CDC begins sending text messages that involve health check-ins. And these messages have links to web surveys where individuals can report on their postvaccination experience.
And we are asking that health care providers help us get as many people to use V-safe as possible. And that primarily involves giving a one-page information sheet to patients at the time of vaccination or posting information in the clinic area or the area where individuals are getting vaccination posting so that individuals have access to the URL and the scannable QR code and also counseling patients on the importance of enrolling in V-safe. This just can be very quick and saying this is what the program is and we encourage you to participate. So we’ve created this electronic version of the V-safe information sheet as well, some promotional materials for distribution to public health and health care partners. Next slide. And I just want to wrap up with a reference slide here on information on how to report to viewers. The most important thing that health care providers can do, both to help us monitor for anaphylaxis and allergic reactions and to help us monitor vaccine safety in general, is to report adverse events to viewers and report them as quickly after they happen as possible and to be as complete on the report as possible. And then it has some safe resources and some general CDC vaccine safety information. Next slide. Thank you.[26]
Reflection Questions
Answer the questions provided to gain further understanding of the importance of segmenting the clinical community as a specific audience with specific information needs.
Provide three examples of how these messages are designed for a clinical or medical audience based upon the common information needs of the medical community during a health emergency.
How does the communication channel (e.g., webinar) support the intention of this being designed for a clinical or medical audience?
How does the COCA call host and spokesperson support the intention of this being designed for a clinical or medical audience?
Describe the role data play in this webinar and why this information about data is important for the clinical and medical audience to hear?
How is this webinar different than a webinar planned for a general public audience?
Medical Community Using the CERC Framework for Its Audiences
In addition to the medical community being a message receiver of CERC messages, the medical community can also follow the CERC framework in communicating with its staff and patients. Specifically, the principles of Be First, Be Right, Be Credible, Provide Empathy, Show Respect, and Promote Action can help guide emergency risk communications with hospital and health care settings. A recent study developed a 13-question survey based on the CERC framework to analyze how hospital leaders in Singapore communicated emergency risk information to their staff members during the February 2020 COVID-19 response.[Reference Ow Yong, Xin, Wee, Poopalalingam, Chiang Kwek and Thumboo27] The research identified one key area where hospital leadership excelled in emergency risk communication and highlighted areas where improvements are needed.
The one area of strength of hospital emergency risk communication messaging was demonstrated by senior leadership. Senior leadership provided daily instructions that hospital staff felt were instructive and timely. Hospital staff also felt they were given enough information to stay safe. The following sections discuss the five areas for improvement discovered in the hospital study and how using CERC principles could have enhanced hospital emergency risk communication.
Middle Management
Although senior leadership demonstrated the CERC principles, hospital staff reported that middle management seemed to lack understanding of how to implement guidance from senior leadership within their teams. The inability to implement the guidance from senior leadership within teams left hospital staff feeling frustrated and unseen by their managers, and many hospital staff reported a lack of empathy from their immediate supervisor. By using the CERC principles of providing empathy and showing respect, middle managers could have better connected with their staff regarding the uncertainty of the emerging COVID-19 outbreak.
Resource Allocation and Logistics
Hospital staff reported a lack of clarity regarding new and emergent procedures regarding patient screening. The patient screening procedures and locations of patient screening would often change without staff being notified or receiving explanations as to why these changes had occurred. By engaging in the CERC principles of being right and credible and showing respect, hospital staff could have engaged in clear communication and information-sharing and established a communication protocol regarding the patient screening process. By establishing a communication protocol, the staff in charge of patient screening would be able to know how, when, and who to notify when changes were made to the screening process. This type of communication demonstrates the CERC principles by ensuring all staff have the most accurate information about patient screening, and it shows respect by ensuring that no one is left out of the communication loop, ensuring everyone is able to fully engage in their work and understand what is expected of them when carrying out their job responsibilities.
Human Resources and Staff Welfare
One of the biggest challenges staff within public health and the medical community faced regarding COVID-19 was the ability to personally process the evolving situation while simultaneously engaging in their professional work. Further, due to the workload increases, staff had to switch roles or take on other people’s work throughout the outbreak. In the Singapore hospital study, staff reported a lack of empathy regarding their welfare during the outbreak. Further, staff felt that some of the human resources policies were communicated in an authoritarian and rule-based manner rather than with empathy and concern given the evolving health emergency. Engaging in empathy and showing respect to all staff are key CERC principles that can enhance internal human resource policy communications during health emergencies.
Information Overload
During health emergencies, in which uncertainty, stress, and anxiety are high, receiving information is helpful, but there also needs to be a balance in how and when information is shared. Sharing information too often or frequently changing processes or procedures can be hard for people to cognitively process. A balance must be struck regarding higher-priority and lower-priority communications. For example, hospital staff suggested that secure text messaging be used to communicate higher-priority alerts, while emails could be used to share lower-priority alerts. By sending secure text messages for higher-priority alerts, hospital staff could come to understand that a text message meant immediate action was required, while an email indicated action could be instigated later in time.
Audience Segmentation
The Singapore hospital study revealed that emergency communication within hospitals also requires audience segmentation. Specifically in this study, health care professionals who had worked more than 5 years at the hospital responded well to the senior leadership messages, while those who has worked less than 1 year at the hospital were often unsure of what actions to take during the health emergency. Other demographics, including age and job position, also affected how individuals processed information from senior leadership regarding the health emergency. Conducting audience segmentation and tailoring information within a hospital will ensure key health emergency messages are received and acted upon by all staff regardless of demographic differences.
Katrina Hurley, MD, chief of an urban emergency department in Canada, remembers wanting to receive transparent, frequent, and highly specific information about the emerging COVID-19 health threat.[Reference Hurley28] For example, when guidance was being issued about PPE for hospital staff, she recalls wanting to receive specific evidence-based information that the recommended PPE would protect her and her staff from getting ill. She felt that evidence-based information would have enhanced her trust in these messages. Dr. Hurley also remembers receiving many questions from patients regarding information they had seen on social media or news media. While she didn’t always know the social media post or news story to which the patient was referring, Dr. Hurley did her best to address patients’ fears and combat misinformation. She even engaged in her own information-seeking, and she would share what she learned with colleagues and staff. A key takeaway here for hospital emergency risk communicators is to engage in news and social media monitoring to identify potential questions that patients might have based on trending news and social media posts. By reviewing these daily media reports, doctors can become more prepared to handle patient questions that arise from news and social media. See Chapter 10 for more information on news and social media monitoring.
Theory Callout: The Elaboration Likelihood Model
The Elaboration Likelihood Model (ELM) offers insights for emergency risk communicators on how to tailor messages for a specific audience and why tailoring messages can result in people taking a specific action.[Reference Schmid, Rivers, Latimer and Salovey29] The ELM, developed by researchers Richard Petty and John Cacioppo, explains how attitude change can persist over time or be relatively short-lived based on how messages are received and processed.[Reference Petty, Brino, Kruglanski, Higgins and Van Lange30] Using the lens of cognitive processing, Petty and Cacioppo suggested how people can be persuaded to change their mind or act through a continuum of thought processing. At one end of the continuum is low thought processing, and at the other is high thought processing. For those engaged in high thought processing about a message, such as considering the message sender, message content, and previous knowledge about the topic, it is possible that the individual may change their mind or be persuaded to look at the content differently.[31] Additionally, one’s motivation and ability to process the information also play roles in how the information is received and processed. When motivation and ability are high, people engage a central route of processing and are likely to have their mind changed. In contrast, low thought processing may result in a short-term but not a permanent change of mind. For example, if motivation and ability are low or there is a lot of noise in the environment, the processing goes through a peripheral route and is not likely to result in a permanent change of mind. A temporary change of mind might occur, but not a permanent one.
Within the context of the Singapore hospital study and by applying the CERC framework within the hospital, the ELM can provide emergency risk communicators with additional understanding as to why it is important to tailor messages to the audiences. First, as discussed in Chapter 3, audience segmentation is important for understanding who the audience is and what characteristics and values are represented in each audience segment. Next, by considering the message sender, message content, channel, amount of noise or distraction in the media environment, and the audience’s previous knowledge about the content, these messages can be tailored to resonate with each audience segment. Finally, infusing the tailored content with the CERC principles of being right, credible, empathetic, and respectful, the health emergency information is more likely to be received, processed, and acted upon by the audience segment receiving the tailored messaging.
Introduction
On September 30, 2014, CDC Director Dr. Tom Frieden officially announced that the first case of Ebola virus disease (Ebola) to be diagnosed in the United States was being treated at Texas Health Presbyterian Hospital in Dallas, Texas.[32] Standing alongside Dr. Frieden was the Commissioner of the Texas Department of State Health Services, a hospital epidemiologist with the Texas Health Presbyterian Hospital in Dallas, and the Dallas County Health and Human Services Director.[32] This was the initial message of CDC’s stateside response to the Ebola epidemic of 2014–2016. Ebola is an infectious disease, originating in Central Africa, which typically causes a severe – and often fatal – hemorrhagic fever, in which symptoms include malaise, vomiting, diarrhea, and internal as well as external bleeding.[Reference Bell, Damon, Jernigan, Kenyon, Nichol and O’Connor33] Ebola virus is primarily spread via person-to-person transmission through direct contact with blood or bodily fluids of a symptomatic individual, such that a person is only able to spread the disease if they are also displaying symptoms.[Reference Bell, Damon, Jernigan, Kenyon, Nichol and O’Connor33] Prior to 2014, there had been at least 20 outbreaks of Ebola, primarily occurring in West Africa, though none were as large as what was encountered in 2014.[Reference Bell, Damon, Jernigan, Kenyon, Nichol and O’Connor33] During the 2014–2016 epidemic, Ebola was introduced to the United States for first time when a patient, who was likely exposed to Ebola in Liberia, traveled to Dallas, where he eventually developed symptoms and was diagnosed with Ebola.[Reference Bedrosian, Young, Smith, Cox, Manning and Pechta34] A total of four cases of Ebola were eventually reported in the United States, three of which occurred in Dallas, and of those three, the second and third were nurses who had cared for the first case. The following analysis will outline the general timing of these cases and the three phases of disaster communications, and it will provide examples of how CDC positively or negatively highlighted the principles outlined in their own CERC manual.
Timeline of Key Events
In early 2014, Ebola was spreading rapidly around Liberia, Guinea, and Sierra Leone, and it was officially classified as a Public Health Emergency of International Concern on August 8.[Reference Bedrosian, Young, Smith, Cox, Manning and Pechta34] On September 19 a man left Liberia, arrived in Dallas on September 20, and presented to the emergency room on September 26 with 2 days of symptoms, though was not admitted until September 28 when he returned to the emergency room a second time.[32] Two days later, on September 30, an initial message from CDC was given to the people of Dallas – and the United States as a whole – that the patient had been officially diagnosed with Ebola.[32] After over a week of caring for this patient, multiple press conferences, countless tweets, and quite a bit of discussion by local and national media and politicians, it was on October 8 that the first patient diagnosed in the United States with Ebola died.[Reference Fernandez and Philipps35] On October 10, one of the nurses who had cared for that first patient was diagnosed with Ebola.[36] On October 14, a second nurse was diagnosed with Ebola, and it was reported that she had traveled on a commercial flight the night before.[37] The CDC Director told the public that she should not have traveled; however, it came out that she was unaware of this restriction, and she had at no point had a fever (temperature over 100.4°F). Even though she was under surveillance for symptoms, she had never been advised not to travel.[Reference Schnirring38]
These two cases led CDC to increase the personnel and equipment support it was sending to Dallas.[37] After these two cases in Dallas, which this analysis focuses on, there were no further diagnosed cases of Ebola in that region; however, there was another patient who was diagnosed in New York City after returning from serving as a volunteer health care worker in West Africa.[Reference Bell, Damon, Jernigan, Kenyon, Nichol and O’Connor33] There were eventually seven other patients treated for Ebola in the United States; however, these patients were all diagnosed and underwent initial work-up outside of the country.[Reference Bell, Damon, Jernigan, Kenyon, Nichol and O’Connor33] In mid-November, a press release from CDC stated that all patients and their contacts who were being monitored for possible exposures in Dallas and Ohio, where the third case had traveled, had all cleared the incubation period and these communities had no more active – or at the time potential – Ebola virus disease, and so the threat had been mitigated.
Initial Message
On September 30, the CDC Director, standing alongside representatives of local agencies, put out an initial message addressing the first patient to test positive for Ebola virus in the United States. This message came out soon after the results of the official CDC-sanctioned Ebola test.[32] The message was delivered in an even tone by the CDC Director. Everyone on stage was given an opportunity to share their experience in patient care or implementation of public health measures to mitigate the spread of Ebola, as well as to respond to specific media questions at the end. The press briefing began with an overview of the severity, route of transmission, incubation period, and symptoms of Ebola. Along with confirming that there was a patient with Ebola in Dallas, the patient’s journey through the symptoms of Ebola was explained. It was also detailed how he had been to the emergency room, been given antibiotics, and been discharged, returning to the hospital a few days later, before now testing positive.
The CDC Director was sure to remind everyone that patient care was the primary focus, and that CDC was supporting the hospital with this. He stressed that contact tracing was the second large focus, which CDC was supporting the city leadership with. There was reference to the Ebola treatment and contact tracing being done in West Africa and how the skills developed from that response could improve the care and strategies in the United States; however, it was stressed that the current case represented a very different situation and so required a different form of response. A message was directed at health care workers locally and nationwide to question patients as to whether they had been to endemic areas or had been exposed to anyone who may have themselves been exposed to Ebola. He stressed the necessity of adhering to proper PPE and hygiene practices and pointed out that nearly every hospital in the country had the capacity to properly treat and isolate Ebola patients. Following the CDC Director’s message, the local epidemiologist clarified again how Ebola is spread and specifically acknowledged and addressed frequently misinterpreted science in this area. Before closing the press conference, the CDC Director reminded people that contact tracing and quarantine represented “core public health work” that CDC does well. He mentioned where and how to get more info, and he stated, “We will stop this in its tracks.”[32]
Maintenance Message
Maintenance messaging by CDC was implemented over multiple platforms, including traditional as well as social media and, importantly, frequent in-person press conferences. Press conferences included updates on how the individual case (or cases) were progressing.[39] Another important element that was stressed in these press conferences was the frequently repeated concept that Ebola can only be spread by infected individuals who are symptomatic. There was also an online presence, with Twitter (now X) being utilized to share small pieces of information and with accessible educational materials being made available on the CDC website.[40] These online resources included information on the specifics of Ebola virus, reminders on handwashing, health care provider-specific instructions, frequently asked questions, and much more.[40]
When two of nurses, both of whom had treated the first case of Ebola, were eventually found to have the virus, CDC addressed their status and how they may have gotten Ebola. The messaging around the exposure focused on how poor adherence to proper donning and doffing of PPE by the poorly trained staff likely led to their exposure and eventual transmission.[37] They later rephrased this, as CDC received criticisms that this message put too much blame on the patients dealing with Ebola instead of CDC being accountable for not properly supporting these nurses dealing with the treatment of Ebola for the first time. More specifically regarding the third case, CDC reported that the nurse was diagnosed immediately after traveling from Dallas to Cleveland. Though the CDC Director stated the nurse should not have traveled, as she was considered an exposed contact, CDC later clarified that she had not been restricted from travel.[Reference Schnirring38]
Resolution Message
Though there was a fourth case of Ebola to be diagnosed in the United States during this crisis, the scope of this case study is on the situation in Dallas. The first resolution message from CDC came on November 14 after all the cases and contact tracing were resolved in Dallas. A press release was sent out in which CDC provided a quick synopsis of the four cases, highlighted the work done by all health care and public health professionals, and confirmed that no individuals under 21-day quarantine had developed Ebola, which indicated that at that time Ebola had been contained.[41] A more robust official resolution message came in the form of a supplement, of over 100 pages, added to CDC’s Morbidity and Mortality Weekly Report (MMWR) summarizing the outbreak.[Reference Bell, Damon, Jernigan, Kenyon, Nichol and O’Connor33]
At this time, a digital and in-person exhibit on Ebola was established for a year, and it is still available online.[42] Both the MMWR supplement and the exhibit provided opportunities for CDC to provide the public with more information, to share lessons learned from the response, to acknowledge the lives lost, and to recognize the efforts put in by hundreds of people to combat the 2014–2016 Ebola epidemic.
CERC Principles
CDC created the CERC manual as a guide that they recommend using to direct communications in times of crisis.[43] The basis of the manual is six guiding principles that illustrate how to craft and deliver messages in emergencies. These are to be applied to messaging at every stage of a disaster response. In analyzing the messages delivered by CDC surrounding the cases of Ebola diagnosed in Dallas, six examples are identified and applied to each of the CERC principles. Each of these highlights how well or poorly the principles were followed at various stages of the messaging.
Be First
Being first sets the tone for the response messaging. It demonstrates that an agency is capable of putting together a message promptly, which in the eyes of the public may indicate that they can respond quickly as well. In this case, CDC, alongside local officials in Dallas, was able to host a press conference where it was stated: “We received in our laboratory today specimens from the individual, tested them and they tested positive for Ebola.”[32] CDC was able to address the big-picture questions surrounding what Ebola is, how it arrived in Dallas, and what CDC and the city will be doing about it. CDC also addressed as many details as it legally could regarding the individual who was battling the virus. There was space for questions, which were all answered in the moment. Setting up a press conference rapidly, being sure to include local officials, and sharing all possible information up front are strong examples of how to be first in crisis communications. This approach showed the city and country that a response was underway, and it indicated how CDC would be conduct messaging regarding future positive cases in a prompt manner.
Be Right
Being first with initial and maintenance messages set the tone for how CDC was going to present information during this response, yet being sure that such information was right was important for continued community trust in the organization. Accurate information, especially in the case of an emerging virus that people are unfamiliar with, is important to eliminate confusion and keep people returning to CDC for guidance and assurance. CDC did a good job of sharing all it knew from the beginning, and to the fullest extent possible as each case was identified and treated within the legal and ethical bounds allowed with regards to patient privacy. The following quote from Dr. Frieden during his initial conference demonstrates how CDC is knowledgeable and a leader in the field by referring to the work that had already been done in West Africa, as well as the many organizations who work alongside CDC:
While we do not currently know how this individual became infected, they undoubtedly had close contact with someone who was sick with Ebola or who had died from it. In West Africa, we are surging the response not only of CDC where we have more than 130 people in the field, but also throughout the U.S. government. The president has leaned forward to make sure we are acting proactively there and the defense department is on the ground, already strengthening the response. We are working with USAID and other parts of the government as well as with a broad global coalition to confront the epidemic there. Ultimately, we are all connected by the air we breathe. And we are invested in ensuring that the disease is controlled in Africa, but also in ensuring that where there are patients in this country who become ill, they are isolated. We do the tried-and-true core public health interventions that stop the spread of Ebola.[32]
Be Credible
Being correct and accurate with information can help establish the credibility of an organization. However, that credibility, which takes so much effort to build, can begin to crack with only a few poor comments. When declaring the third case of Ebola to be confirmed in Dallas, CDC detailed where that individual had recently traveled in order to educate the public on who may or may not need to be concerned regarding possible exposure. This individual was one of the many nurses who had cared for the initial case of Ebola in Dallas. All of those who cared for the patient were considered possible exposures and told to monitor themselves for symptoms.[44] After caring for the first case, this nurse went to a family wedding in Ohio via plane, and though she was not symptomatic at the time of travel, all passengers on the plane were publicly asked to contact CDC and monitor themselves for symptoms.[44] In the initial messaging of the third case, the CDC Director saying that the nurse should not have traveled made it seem as if she had gone against the advice and authority of CDC.[Reference Schnirring38] When challenged further, it was revealed that the nurse had not been informed that her colleague had tested positive for Ebola, nor did she report a fever; therefore, she had been cleared to fly.[Reference Schnirring38]
This moment in the maintenance phase of messaging illustrated a lack of credibility. CDC thus lost some of the trust it had built up on multiple fronts. The initial fear that someone with Ebola had traveled when CDC was claiming to be tracking possible exposures and containing the spread demonstrated that it did not have as strong a grasp on the situation as it was letting on. This may have reduced CDC’s credibility in the public eye; however, the primary loss of credibility occurred with the revelation that CDC had not been honest in what they had initially communicated to both the patient and the public. The message from CDC can be perceived as placing blame on the patient for traveling against advice, which will be addressed in the later subsection on the CERC principle Show Respect. By appearing to lie and place blame on the victim when CDC’s efforts were being questioned and also appearing to have failed to contain the virus, this message from the CDC represents a poor example of being credible.
Express Empathy
When sharing the initial message, one of the first things said by the CDC Director was a great example of expressing empathy. After briefly explaining the background information on Ebola virus, Dr. Frieden revealed that there was a person who had tested positive in Dallas. Immediately after this he said, “First, to care for the patient. We’ll be hearing from the hospital shortly, to provide the most effective care possible as safely as possible to keep to an absolute minimum the likelihood of the possibility that anyone would become infected.”[32] This message shows a commitment to patient care and to protecting individuals in the community. Demonstrating this primary goal CDC’s initial message expresses empathy through its dedication to those individuals affected by Ebola instead of just focusing on population-level operations.
Promote Action
Throughout its messaging, CDC sought to promote action within the health care sector. This was done in maintenance messaging via its online platform as well as in press conferences. In one of the early press conferences, a week after the initial message, CDC directed a message at health care workers to “be on high alert and to identify individuals who have a travel history to the areas that are affected and that come in with any symptoms that could be associated with Ebola …”[39] This is an example of the phrasing directed specifically at hospitals and health care workers that was used in many of CDC’s messages. There were many of these targeted directions to health care workers advising them to question symptomatic patients as to whether they had been in a region where there was Ebola or had had contact with someone who may have been exposed. This messaging provided actions to those who were at the highest risk of being exposed to Ebola. It provided some sense of focus to the medical community and demonstrated this CERC principle well. The only criticism to be levelled in this area of health care-directed messaging is that there was not a lot messaging directed to the public on actions they could take.
Show Respect
As mentioned earlier, there were moments when the messaging took on a tone of blaming those who were exposed to and diagnosed with Ebola. The earlier example demonstrated how the message in question led to a loss of credibility. This message also failed to follow the sixth CERC principle of Show Respect. This message placed the burden of responsibility for exposure on the shoulders of nurses. These were nurses who had never cared for Ebola patients before and were not properly trained to do so. The following is the first thing the CDC Director said when announcing the first nurse to be diagnosed with Ebola:
Good morning, everyone. And thank you for joining us. We’re deeply concerned by the news that a health care worker in Texas has tested preliminarily positive for infection with Ebola virus. Confirmatory testing is underway at CDC and will be completed later today. We don’t know what occurred in the care of the index patient, the original patient in Dallas, but at some point there was a breach in protocol and that breach in protocol resulted in this infection.[36]
This message begins not by acknowledging the challenges that this nurse has faced, but rather that there was a breach of protocol. Later, the CDC Director does demonstrate respect for what the nurse had gone through; however, beginning the message in this way came off as if the exposure had been the fault of those providing care. Respecting the communities at risk is important for maintaining their full participation and trust, and failing to do so at the beginning of the message may have caused people to dismiss the remainder of the message. This specific message demonstrates how CDC can inadvertently deliver messages that frighten the public by not embodying the principle of respect.
Lessons Learned
Based on this analysis, there are a few important lessons to be learned regarding disaster messaging. One of the clearest lessons from this case relates to the ways in which accountability and blame can be perceived. When sharing its messages about the two nurses who had been infected with Ebola, the CDC messaging could have been perceived as being paternalistic to the point of blaming the victims. As mentioned earlier, this both damages the credibility of the messenger and fails to show respect to the local response. When describing the way in which the two nurses were exposed, CDC should have acknowledged that adapting to a new threat can be challenging and provided a supportive message. Addressing poor training represents an opportunity to be respectful and to state what could be improved.
The way CDC handled the situation of the nurse traveling was an extension of this paternalistic tone and could have been improved with more honesty up front. From the beginning, CDC should have acknowledged how it is challenging to adhere to quarantine policies. It is important also not to place blame before fully understanding what was told to whom.
Another lesson to be learned is that, when promoting action, it is important to address specific communities; however, specific actions need to be provided for the general public as well. CDC demonstrated good promotion of action in their online and in-person maintenance messaging to health care professionals. Much of the maintenance messaging was focused on how Ebola is only transmissible when an individual is infectious. Though this was meant to reassure the public, it did not provide any actions that people could implement to take some ownership in the campaign to prevent Ebola transmission. This was an opportunity to enlist the support of the public and decrease the amount of fear the public might feel and the unnecessary use of hospital resources by the public in anxious times.
Conclusion
Many lessons learned from the Ebola epidemic are still applicable. All organizations must continue to remember to provide less paternalistic messaging, to stress the importance of action in all communities, and to do everything possible to be honest and show respect to everyone. In the response to Ebola in Dallas in late 2014, CDC demonstrated three phases of disaster communication, and though positive and negative examples of each of the six CERC principles could be found in the messaging during each phase, this messaging was conducted at the high level that is expected of the federal agency responsible for infectious disease control in the United States.
End-of-Chapter Reflection Questions
2 Identify your health and medical partners for an infectious disease outbreak.
3 How do you communicate with these partners? What are the challenges with communicating with health and medical partners? Are you able to notify them of information prior to releasing information to the media?
4 Field trip: Relationships are vital before and during health emergencies. Set up an in-person meeting with a community-based organization or a medical professional you haven’t met yet or haven’t seen in a while to discuss the current status of emergency risk communication in your agencies.
