CDC officials share key pandemic communications lessons

Jan 27, 2011 (CIDRAP News) – Two federal officials who frequently appeared on television as top sources during the 2009 H1N1 pandemic provided a rare glimpse behind the curtain at some of the event's pivotal moments today during a panel discussion at an infectious disease conference in Washington, DC.

Dr Richard Besser, senior health and medical editor at ABC News, served as acting director at the US Centers for Disease Control and Prevention (CDC) during the first few months of the outbreak. And Dr Anne Schuchat was one of the CDC's top influenza experts who frequently led press conferences and fielded questions from worried lawmakers.

Both were part of a panel to discuss communications lessons during the pandemic at the Infectious Diseases Society of America (IDSA) pandemic and seasonal influenza conference. The IDSA is streaming the 2-day conference live on its Web site.

Besser said that in the first few days of the novel H1N1 outbreak, CDC officials implemented a strategy of being freely available to the media in order to cement its role as the main source of information and to build the public's trust. "We wanted people to know what we were doing," he said.

Early on in public forums, other federal departments such as Homeland Security and the State Department turned to the CDC when science and public health questions arose, which set a helpful and clear tone for the response, he said. "This is an important point that guided the response in a very healthy way—the response was guided by the best science possible."

Schuchat said the central science-based theme also helped her navigate what she said was one of the toughest questions she received, which came up in a Capitol Hill homeland security hearing: What would it take to trigger a border closure? She said by then, the CDC already knew the virus had been detected in three states and was likely to be circulating in several more. And studies have shown border closures do little to block the spread of flu and can hurt the flow of commerce and crucial supplies.

Lauran Neergaard, a health reporter for the Associated Press, said the most difficult communications issues that arose was trying to explain what was known about the severity of the new flu in the face of much uncertainty. She added that writers are always grasping for case and death numbers to help flesh out the impact of the disease.

"The numbers were difficult, and then how the numbers were generated changed halfway through. It was surreal, almost," she said, alluding to new modeling techniques that were designed to portray a more accurate range of illnesses and deaths.

Then about 5 months into the pandemic, an expert group appointed by the Obama administration released a risk assessment listing a range of possible scenarios, one of which speculated that as many as 90,000 people could die. Some media outlets didn't explain that such a large death projection was only one of several possibilities, and the 90,000 deaths fit well into a "sound bite."

Schuchat described the focus on the death projection in the President's Council of Advisors on Science and Technology (PCAST) report as one of her many "Pepto-Bismol" moments during the pandemic, but she said she understands why the media singled out that number. "They were filling a gap, because no one was telling them [the numbers]."

One of the other major communications challenges, according to panel members, was how to portray disease severity. Besser and Schuchat both said health officials need more clarity on severity definitions, which are notoriously difficult to spell out, even when talking about flu to other experts.

Dr. Daniel Jernigan of the CDC said in another presentation at the meeting that his agency and others have been working on a new way to assess and describe the severity of a flu pandemic.

During the first wave of 2009 H1N1 cases in the spring of 2009, officials from a number of countries urged the World Health Organization (WHO) to delay declaring a full-fledged pandemic, on grounds that it would frighten the public into thinking the virus was a much greater threat than it actually was. The WHO's pandemic phases were based on the geographic extent of the virus rather than the clinical severity of disease. The agency declared a phase 6 or full pandemic on Jun 11, when the virus had been spreading in multiple countries for about 6 weeks.

Jernigan noted that the CDC before the 2009 pandemic had a pandemic severity index that was patterned after the system for classifying hurricanes. "It was geared toward the very severe, high-fatality pandemics, and was based on case-fatality rate and excess mortality. It didn't work very well for something that didn't have high mortality," he said.

He said what's needed is a severity scale or description that considers many factors, such as attack rate, hospitalization rate, ICU admission rates, and virus characteristics, and that reflects the different levels of confidence officials would have in the early and later stages of a pandemic. CDC experts have worked with officials from the WHO, the European Centre for Disease Prevention and Control, and other experts to come up with such a tool, he added.

Jernigan showed slides of a graph that depicted transmission or incidence on a vertical axis and clinical severity of illness on the horizontal axis. CDC experts have been working to figure out where previous pandemics would fit into such a framework, he added.

"You can get a little more nuance and can use this to help explain where the current problem is in relation to past pandemics, and also tailor community mitigation efforts," he said.

Just how to use the experimental tool has not been determined yet, but the CDC is planning to test it in an exercise in March and will do further testing after that, Jernigan said.

"We're trying to find better ways to explain just how bad it [a pandemic] is," he said.

During the communications roundtable, experts said distilling complex messages about pandemic flu was a tough challenge, especially in short media sound bites. Besser revealed that a broadcast media sound bite is roughly 14 seconds long.

Though many experts have given the CDC high marks for its communications efforts, which early in the pandemic included daily press conferences, some of the CDC's top officials say the agency could do more to address vaccine delivery and connect better with doctors.

Schuchat said the CDC learned that it needed more concrete information for local health officials responsible for lining people up for the vaccine and more general information for the public. "There were so many different voices, and we all didn't say the same thing," she said.

Before the virus emerged, pandemic planning scenarios always included scarce vaccine supplies. However, some officials were surprised when that turned out to be the case in the fall of 2009. "There was inadvertent messaging that we were going to have a lot," Schuchat said.

Besser praised his colleagues for how they handled vaccine safety issues, especially getting the word out early about the prevalence of background events such as Guillain-Barre syndrome and miscarriages. Schuchat said that inviting the media to flu "boot camps" and pandemic exercises not only helped inform reporters, the events also helped federal officials anticipate possible vaccine safety messaging problems.

Another lesson the CDC learned during the pandemic is that extra efforts are needed to communicate with policymakers and politicians. Schuchat said health experts shouldn't assume that such officials have more background information about flu than the general public.

For example, Besser said that, the day after the CDC issued travel precautions about traveling to Mexico early in the pandemic, Vice President Joe Biden told a news reporter that he didn't think it was safe for his family to fly. Besser said that, as one of the main CDC spokespeople, he turned Biden's quote into a teachable moment about staying home when sick while reinforcing the message that it was safe to fly.

"It's not just public health that needs to be on message; political leadership needs to stay on message," he said.

See also:

Jun 11, 2009, CIDRAP News story on WHO's declaration of the H1N1 pandemic

May 18, 2009, CIDRAP News story on officials urging WHO to delay pandemic declaration

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