Truth may be the first casualty after a bioterrorism incident
Public health communication critical before and after
As is often said of war, truth may be the first casualty of a bioterrorism attack. In a climate in which misinformation could spur panic, clear, effective communication will be the antidote to chaos. In the wake of a bioterrorism attack, for example, effective communication will be critical to secure public confidence and orderly response as the Strategic National Stockpile (SNS) of antibiotics is released and points of dispensing (PODs) are established.
"Dispensing information is just as important as dispensing antibiotics," says Ruth Thornburg, MA, MS, public information and communications specialist in the SNS division at the Centers for Disease Control and Prevention (CDC).
Of course, most communities have communication strategies established as part of their emergency response plans. But deployment of the SNS stockpile ratchets up the response considerably.
"There are two major differences when SNS assets are deployed and PODs are opening," Thornburg said during a recently broadcast CDC satellite public health training session. "These differences are time and patient volume. Remember, our goal is to save lives and prevent illness. To do that, we must be prepared for the worst-case scenario, which is providing prophylaxis to the entire population of your community in 48 hours or less, for an anthrax event."
The CDC program is part of an ongoing training series designed to prepare public health and medical officials for SNS deployment and prevent POD sites from being plunged into confusion.
"A terrorist attack using a biological agent, or a natural occurrence, such as an influenza pandemic, could require that hundreds of thousands of people, maybe millions, receive medication or vaccinations as quickly as possible," said William F. Raub, PhD, principal deputy assistant secretary of public health emergency preparedness at the U.S. Department of Health and Human Services. "This is a formidable challenge, and to meet it, we must find ways to deliver mass prophylaxis more rapidly than ever before.
The CDC faculty and other training participants went through the basics of developing a public information campaign designed to enhance movement of people through the PODs during a public health emergency.
Knowledge is power
"The key to increasing patient flow in the PODs is to provide information that reduces confusion at the dispensing site, guides patients through the dispensing process with minimal questions, and provides a follow-up source of information," Thornburg stressed.
While dispensing information is just as important as dispensing antibiotics and other treatments, there is one key distinction. "Unlike medication, information need not be dispensed only at the POD," Thornburg says. "We realized that we could speed things up at the POD and still make maximum use of our human resources, just by beginning the education process at home. If we anticipate what people will need to know and what questions they will have, we can save time and see more people at the POD."
Of course, when most people think about public information and communication, they immediately think of media relations. "But media relations are only part of the whole public information and communication, or PIC campaign," she said. "A PIC campaign consists of three elements: messages, methods, and materials. The campaign must reach out to all members of the community, and it must be delivered quickly to inform and reassure and educate not only the public, but volunteer staff, medical providers, and other stakeholders, as well."
For example, in the early stages following an anthrax attack, the message should be that safe and effective antibiotics are available at the PODs. "In the early stages of the event, we’re attempting to motivate people with our messages so that they’ll come to the pod for medication, participate in the process at the pod, and complete the prescribed regimen," she said. "Remember, you have a very short period of time to do this, and it will not be an easy task."
Indeed, some evidence suggests that segments of the community will be openly distrustful of the public health message. Others in even greater numbers will not follow instructions because they have compelling conflicts such as protection of their own family members. One telephone survey of 2,545 randomly selected adults in the United States were asked about their response to instructions following smallpox and "dirty bomb" radiation incidents.1 Researchers found that current communications planning won’t work for some bioterror scenarios because "people will not react the way planners want them to. In the smallpox outbreak, only two-fifths of the population would go to the vaccination site. In the dirty bomb explosion, only three-fifths of the population would stay inside the building they are in for as long as officials told them. Contrary to conventional wisdom, the study found that people’s reluctance to follow instructions is not due to ignorance, recalcitrance, or panic. Quite the contrary, most people have solid, common-sense reasons for their behavior."
Therefore, communication planning should promote "adaptive behavior," giving people a sense of purpose and involvement in the reaction, said Dori Reissman, MD, MPH, a behavioral scientist in the CDC national center for injury prevention and control.
"An effective plan promotes adaptive behavior and brings people to the POD armed with an appropriate set of expectations," she said. "Without such a plan, the POD process is likely to be insensitive to people’s needs — a recipe that can easily lead to fear and mistrust. This can seriously delay or interfere with mass dispensing efforts."
Advance or pre-event planning and communication about PODs well before they are needed could go a long way to allay confusion. Something as simple as professional signage shows that preplanning has occurred. "Do people know that, in the event of an anthrax or smallpox emergency, that PODs would be set up to provide the public with medications?" she said. "We need to let people know about the pods well in advance of needing them. The public will feel more confidence, knowing that pods will be set up and run according to a plan that’s been developed for your area."
Moreover, add an element of "flexibility" to the pre-event message, telling people that changes can be made as warranted by events. "We need to let people know that our planning for the pods is thorough, but also flexible," Reissman says. "If problems come up, there is a mechanism to solve them. We can set expectations without giving out specific locations or activities."
Bring public into the response effort
In addition, empowering the public with specific duties can draw them into the response. "Remember, the event, the agent, the idea of mass prophylaxis, and a government-sponsored POD, will be entirely new for most people," she said. "You will have to convince people of the need to come to a pod, and one way to do that involves giving them specific tasks to complete before they even come to the pod. . . For example, give mothers and fathers something to do, like rounding up their children’s weights or listing grandma’s medications. Tell them to fill out the on-line medical forms if your community has one, or pick up a medical form at the grocery store, the post office, library, or other community area."
While moving along the education process the efforts also inspire action by appealing to our civic-mindedness. "People want to help and do the right thing," she says. "Ask them to check on their elderly neighbors, for example. Ask for their help by not arriving too early before the pod is open. Tell them how easy it will be when they get there. People who are involved and prepared are more likely to come to the pod and cooperate, once they’re there."
The other side of getting people to your medication dispensing site is diplomatically telling those that need not be there to stay away. "We know that not everybody should come to the pod," Thornburg said. "If you have recently become ill you should go to the hospital. The medications in the pods will not help you. By wording it that way, we make it clear that services are not being denied to sick people. The pods just aren’t the place for them to receive the services they need."
Such a message essentially begins a home triage effort, guiding those in need of care to medical facilities and others needing only prophylaxis to the pods. "The fewer sick people go to the pods, [the more] we can increase the overall PPH or patients per hour," Thornburg said.
In that regard, the next challenge is communicating with people to help them move efficiently through the pods, all the while not ignoring their concerns and questions, she added. "We need to minimize confusion and anxiety at the pod. We cannot afford to have serious delays in moving people through the pods."
Even a successfully run POD doesn’t end the response — people may be noncompliant with the medications they have just been administered and supplied with.
"They might get home and start to think it was all a false alarm," Reisman says. "Perhaps they realized they’re just not comfortable taking a bunch of medicine that got handed to them in a government dispensing site in the middle of an emergency. Or maybe they’ve heard an unsubstantiated rumor that the medication will hurt more than it helps."
As the aftermath is played out in the local and national media public health must have a transparent response that inspires confidence.
"Our job includes educating individual members of the public, but also educating the influential people in their lives," she says. "That’s why tapping into cultural networks to disseminate information is also very important. All this is part of an effective method for getting people to take their medicine. Productive back-and-forth communication among leaders, public health, and the general public is essential to delivering the message of medication compliance. At the same time, we want to encourage a two-way communication that allows the public to verbalize their emotions, have their concerns addressed, and have their false beliefs corrected."
(Editor’s note: To view a webcast of the training program go to www.phppo.cdc.gov/PHTN/webcast/antibiotic4/default.asp.)
Reference
- Center for the Advancement of Collaborative Strategies in Health "Redefining Readiness: Terrorism Planning Through the Eyes of the Public." New York Academy of Medicine: September 2004. On the web at www.cacsh.org/index.html.
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