Ebola Risk Communications

 

 

 

# 9046

 

The debate over what is meant by Ebola not being `airborne’ and what constitutes `direct contact’  continues, with a growing chorus of discontent in the media, and online, as to how the CDC describes the risks of transmission to the general public. 

 

Last night, a clearly frustrated Dr. Ian Mackay wrote What words would you use to separate influenza spread from Ebola virus disease spread?    Thoughtful and Highly recommended.

Let me be clear here. Like Dr. Mackay (and most scientists out there), I firmly believe that Ebola is not an airborne virus.  If it were, we’d be digging mass graves all over the world right now.  But there is some risk from large droplet transmission, which can travel a short distance (1 meter or so) through the air. 

 

And therein lies the difficulty.  How to explain the difference to the public.

 

Admittedly, finding a simple, coherent, and accurate way to convey risks to the public – particularly when the topic is likely to alarm – has always been a challenge. The tendency of officials  has generally been to carefully parse these messages in order to deliver a 10 second sound bite that is A) defendably true and B) as non-inflammatory as possible.

 

The problem being, the public knows that you can’t possibly explain a complex set of risks in a 10-second sound byte, and so any attempt to do so is doomed from the beginning.

 

The CDC’s oft repeated message that -  `You can’t get Ebola through air’ -  while technically true, fails to account for the potential for large-droplet-close-quarters transmission.  What I’ve dubbed as being within `spittle range’ from a cough or sneeze. (Note: CDC Interim guidance does acknowledge this possibility).

 

This glaring omission has led to hundreds – if not thousands – of `media voices’ (yes, I use that term very loosely) on TV, in newspapers, on Youtube, Facebook & Twitter to openly question the validity of both the message and the messenger. Add in the growing distrust of governments in general, and any gaps or inconsistencies in the message just add more blood to the water.

 

The public messaging tactics that worked when we had three TV networks, and no internet, are as dead today as film photography.  With Google, all facts are checkable.

 

Which makes both the accuracy and completeness of the messaging coming from the CDC, HHS, WHO, and others on the Ebola outbreak paramount.  A half answer – no matter how true or well intentioned it may be – comes off as being evasive . . .or worse.

 

As it is, with an increasingly skeptical mainstream press and the proliferation of conspiracy sites online, the CDC and the HHS are in serious danger of losing the battle for the hearts and minds of the American public on this Ebola threat – and whatever comes down the pike next. 

 

And while that would be bad for those agencies, it would be even worse for the people they are trying so hard to protect.

 

If I could be bold enough to offer some advice to the CDC, it would be to take a page from the press briefings provided by Dr  Anne Schuchat - director of the National Center for Immunization and Respiratory Diseases, and Assistant Surgeon General of the United States – whom many regarded as being the best communicator at the CDC during the 2009 pandemic.

 

She managed to calmly convey rapidly changing and unscripted information clearly and concisely – while acknowledging the things about the virus that were still unknown – in almost daily briefings during the opening  months of the outbreak.

By ditching the all-too-obvious `talking points’, by being willing to deviate from the `script’  when needed, and by trusting that the vast majority of the American public can handle a certain degree of uncertainty - even when talking about something as scary as Ebola - you can engender far more confidence in your agencies, defuse the critics, and vastly improve the way your messages are received.


And that is the sort of gravitas your agencies are going to need if they are going to deal successfully with Ebola, and whatever else comes next.

The Battle To Control Online MERS Messaging

 

 

# 8471

 

While we’ve a (possibly brief) lull in new MERS reports out of the Middle East one of the fascinating sideshows to the past 72 hours has been watching the attempts to control the MERS message  in newspapers, on twitter, and in other social media outlets.

 

On Saturday, in MERS-CoV: The Twitter Of Their Discontent, I described what appeared to be orchestrated `shout downs’ of MERS rumors, where scores of twitter accounts would tweet word-for-word denials almost simultaneously.

 

For several hours yesterday Arabic language tweets containing the word كورونا (`SK’ or `Corona’) – for reasons I cannot explain - all but disappeared from twitter. Sharon Sanders captured some of this bizarre behavior and posted it on FluTrackers. Tweets eventually resumed, albeit `delayed’ by several minutes at first, but appear to be back to normal today. 

 

While it carries the government’s statements regarding the MERS virus (at times ad nauseum), twitter is also rife with dubious advice concerning natural cures for, or preventatives against, the MERS virus, unsubstantiated citizen reports of suspected cases being treated in hospitals in the region, `false’ information regarding school closings or other government announcements, and no small amount of criticism of the Ministries of Health,  Education, and Agriculture.

 

All of which makes it very difficult for the reassuring official government stance to be heard . . . or believed.  The following tweet pretty much captures the prevailing sentiment online.

Although the Ministry of Education has repeatedly assured that the schools are `free of corona’, many parents have apparently kept their children out of class the past couple of days. This morning, the following announcement authorizing individual schools to decide when, or if, to curtail public gatherings and assemblies is getting a lot of play of twitter.

 

"Education": for school administrators the power to cancel the morning assembly to prevent the spread of "Corona"

News 24 04/14/2014

Awarded the Ministry of Education, school principals the power to cancel all forms of student groups within schools, so as to avoid the crowds as one of the factors of the spread of the virus, "Corona."

The official spokesman of the ministry, Usaimi Mubarak, according to the "Okaz", that these powers include the queue until the morning and collective activities quarterly.

For its part, said director of one of the girls' schools in Jeddah, said that in connection with the instruction and the reduction of the crowds and gatherings, indicating that they stopped the queue morning as a precautionary measure, and that the students were given sufficient guidance about the disease and its transmission and how to prevent it.

In the same context, said a number of parents of the students, they involuntarily daughters from school out of fear of injury, while others felt it is better to suspend the study until they are safely skip this stage.

The message appearing across the Arabic press this morning from the Saudi MOH seeks to assure that the virus is not easily passed from one person to the next.

 

Rabigh newspaper - rebounds:

Undersecretary of the Ministry of Health Assistant for preventive health, Dr Abdullah al-Asiri, the Scientific Committee of Infectious Diseases confirmed that the virus "Corona" does not move easily between humans, but does not move as associating directly with pneumonic.

He denied Dr. Asiri that there is a relationship between the change in the atmosphere in the Kingdom and to increase the number of HIV infection, indicating that it did not close any hospital in Jeddah due to a virus Corona, but there has been a focal point for directing some cases to other hospitals to give the opportunity to clean-up operations overall emergency teams in Hospital King Fahd.

He pointed out that the development of a vaccine for the virus, "Corona" is difficult in terms of technology, despite ongoing attempts in this regard, so the current efforts are focused on prevention and assessment of therapeutic approaches available, while continuing research to develop a vaccine for humans and animals.

Meanwhile, in the UAE where on Friday the Ministry Of Interior Announced 6 MERS-CoV Cases (1 Fatality), their MOH is doing all that it can to downplay the situation.  This from Al Bayan news.

 

Corona virus is not a concern
Source: Abu Dhabi - Lubna Anwar, WAM

Date: April 14, 2014

The Ministry of Health to the World Health Organization confirmed that the virus, corona virus that causes AIDS Middle East respiratory, not a concern for public health at the moment, and it does not require any action to ban travel to any country in the world, and does not require tests early in the ports of entry, and do not impose any restrictions on trade.

For its part, assured the Health Authority Abu Dhabi audience of citizens and residents in the Emirate of Abu Dhabi on the general situation of the disease. The Commission called on everyone to exercise their daily lives as normal, and not to pay attention to rumors or passed on, and return to reliable official sources for information on the disease.

She stressed that the current situation is not a cause for concern, and that the Commission, in coordination with the Ministry of Health and health authorities and stakeholders in the state, has taken the precautionary measures necessary necessary, in accordance with the recommendations of the scientific and conditions and criteria adopted by the World Health Organization, including the testing necessary for all close contacts of the patients, according to global recommendations in this regard approaches available, while continuing research to develop a vaccine for humans and animals.

( Continue . . . )

 

 

While these and other official statements continue to get wide replay across twitter and the Arabic press, they continue to be met with considerable skepticism.

 

Overreaching assurances, such as the one issued above by the UAE, often have the opposite effect on the public, who would much rather have a realistic appraisal of the risks.

 

A risk communications lesson that needs to be taken to heart if governments hope to remain relevant and credible in this age of global twitter communications and online media.

 

Cutting Through The Fukushima Fog

 

 

# 5610

Photo credit IAEA

 

As I noted in The Fog Of Disaster Reporting, written less than 48 hours after the earthquake/tsunami combination that devastated northern Japan, my confidence level in the accuracy of many of the stories coming out of the disaster zone was pretty low.

 

So low, that in many cases I opted not to use them in this blog.

 

Since then, we’ve learned that the nuclear accident at the Fukushima Daiichi facility was much worse than first reported. 

 

Despite what we now know was a meltdown of three reactors within hours of the quake, the severity level of the incident was held at a 5 for a full month (the same as Three Mile Island), before being raised to a  Chernobyl-comparable level 7 on April 11th.

 

 

Today, the Yomiuri News Agency is reporting that two of these damaged reactors may have suffered a `Melt Through’ – an even more serious event than a meltdown –where nuclear fuel actually melted through the walls or floors of reactor vessel.

 

Melted Fuel at Fukushima May Have Leaked Through, Yomiuri Says

By Go Onomitsu - Jun 7, 2011 2:02 AM ET

 

 

NHK World News is also reporting that today (Tuesday) a government appointed expert panel met for the first time to investigate the Fukushima nuclear accident (see Govt panel on nuclear accident holds 1st meeting).

 

The panel is expected to produce an interim report by the end of the year, but according to committee's head - Professor Emeritus at the University of Tokyo, Yotaro Hatamura - will not aim to clarify who is responsible for the accident.

 

Meanwhile, just hours before the first meeting of this expert panel was held, it was revealed that the amount of radiation released from the damaged Fukushima facility during the first week of the disaster was likely more than double what had previously been estimated.

 

Japan doubles plant radiation leak estimate

(AFP) – 4 hours ago

TOKYO — Japan has more than doubled its initial estimate of radiation released from the crippled Fukushima nuclear plant in the week after the March 11 tsunami, ahead of the launch of an official probe Tuesday.

 

The nation's watchdog, the Nuclear and Industrial Safety Agency (NISA), now says it believes 770,000 terabecquerels escaped into the atmosphere in the first week -- compared to its earlier estimate of 370,000 terabecquerels.

(Continue . . . )

 

The hits, as they say, just keep on coming.

 

There are now concerns that the environmental contamination surrounding the plant may be worse than previously suspected, and that people beyond the 20 km evacuation radius may have been exposed to more radiation than previously thought.

 

These belated and incrementally worsening status reports from plant operator TEPCO and Japan’s Nuclear Safety Commission probably won’t do a lot to inspire confidence in their future pronouncements.

 

Of course, early reports from the ground during any major disaster are usually fragmentary, often misleading, and occasionally just downright wrong.

 

How much of this `bad information’ is due to attempts to `manage’ the crisis by doling out bad news a piece at a time – and how much comes from a genuine impenetrable `fog’ of disaster – is hard to know.

 

Often it is a mixture of both.

 

But as was noted last month in  Sandman & Lanard On Worst-Case Crisis Communications, it is important for officials to get out in front of any crisis.

 

Playing catch-up, or worse, appearing to intentionally withhold bad news, can make a bad situation worse.

 

Telling the truth and telling it early, are key points to effective crisis communications.

 

Simple advice, yet it is often ignored.

 

In Japan’s nuclear crisis: The need to talk more candidly about worst case scenarios Peter Sandman wrote:

 

The main communication problem results from the public’s inability to know how much of the situation is under how much control, and what might happen if things get worse. Japanese officials have not helped us to understand that.

 

Worse, they have not communicated in ways that encourage us both to trust that they are telling us everything they know and everything they’re worried about, and to trust that they know what they are doing.

 

And earlier, in Cultural differences regarding Fukushima crisis communication Peter wrote about the consensus document on crisis communications from the World Health Organization  entitled “WHO Outbreak Communication Guidelines”.

 

In an excerpt from the section on “Announcing early”, it states:

 

People are more likely to overestimate the risk if information is withheld. And evidence shows that the longer officials withhold worrisome information, the more frightening the information will seem when it is revealed, especially if it is revealed by an outside source….

 

Early announcements are often based on incomplete and sometimes erroneous information. It is critical to publicly acknowledge that early information may change as further information is developed or verified.

 

 

 

For anyone even remotely involved as a spokesperson for an agency, organization, or company during a crisis, their site should be viewed as essential reading. 

 

Unfortunately, the stream of continually revised information coming out of Japan over the past three months appears more akin to the hoary old tale of the wealthy Englishman who, after traveling the world for many months, called home and spoke to his butler.

 

 

"Well James, has anything happened in my absence?"

 

"Yes, sir.  Your dog died."

 

"He died? Whatever from?  He was a young pup."

 

"Probably from eating burned horse flesh, sir."

 

"Burned horseflesh?  Where on earth did he get burned horseflesh?"

 

"From the stables, Sir. They burned to the ground two weeks ago."

 

"How did the stables catch fire?"

 

"Probably flames from the house, sir."

 

"The house burned down too!  How did that happen?

 

"We suspect the drapes caught fire from the candles, sir."

 

"Candles!  We have electricity. Why on earth were you using candles?"

 

"They were around your mother's coffin in the parlor, sir."

 

"Mum is dead!  My God James, what happened!"

 

"Well Sir, we suspect it was from the shock of your wife running off with the gardener . . ."

 

You get the idea.

 

While the exchange above may make for good comedy, any semblance of it in the real world makes for lousy crisis communications.

Sandman On Flu Risks For Seniors

 

# 4235

 

 

“This next week, or beginning this weekend, we're going to kick off the national influenza vaccination week. This is a concerted effort that the CDC, health and human services and all of our partners to encourage vaccination.

 

It includes a focus on people at high risk for complications, adults with emphysema, pregnant women, seniors, children, really encouraging vaccination for anyone who hasn't yet been vaccinated and wants to be.” – Dr. Anne Schuchat, CDC News conference Jan 8th, 2010

 

 

Yesterday, the CDC basically stated that it was time for seniors to get in line for the novel H1N1 vaccine.   Until now, with vaccine in short supply, the focus has been on vaccinating children, teenagers, and adults under the age of 64.

 

While this change was anticipated, many seniors – after hearing for months that they are at low risk of catching the virus – may not be very quick to embrace the vaccine.   And that is something that Dr. Peter Sandman worries will backfire on public health officials.

 

Dr. Peter Sandman is an expert on effective crisis communications, and he along with his wife and colleague  Dr. Jody Lanard produce a wealth of invaluable risk management advice on their website:

 

 

I’ve highlighted their work on numerous occasions, including:

 

Peter Sandman: Swine Flu For Grownups

Experts: `Mild’ Is A Misleading Term For This Pandemic

Peter Sandman On Pandemic Risk Communication

 

Yesterday Newsweek ran a story entitled Why Seniors Really Should Fear Swine Flu which was based largely on an analysis created by Dr. Sandman back in December, looking at the relative risks that various age groups face with the H1N1 swine flu.

 

Dr. Sandman used data from CDC Estimates of 2009 H1N1 Influenza Cases, Hospitalizations and Deaths in the United States, April – November 14, 2009  which is pretty much summarized in the chart below.

 

 

 

First we’ll look at the opening paragraphs of the Newsweek article, then we’ll go to the original analysis by Dr. Sandman, and end with a few brief comments of my own.

 

 

Why Seniors Really Should Fear Swine Flu

The CDC's vaccination advice for the over-65 set has been misleading.

By Sharon Begley 

Jan 8, 2010

In the federal government's explanations of swine flu, through its Web site and public-service announcements, one message has come through loud and clear: seniors can rest easy. Children face a much greater risk from this disease, and they are dying from it in numbers never seen with regular, seasonal flu. Maybe seniors even have some special immunity to H1N1.

 

There's only one problem: according to a new analysis, the CDC's own numbers show clearly and unequivocally that H1N1 is more than twice as deadly to seniors as to children. As a result, "many older adults undoubtedly underestimate their own risk and the importance of getting vaccinated," says Peter Sandman, a longtime scholar of risk communication. "Older adults have been told they don't have to worry, and that's not true. If the virus comes back, people will die."

 

Sandman's analysis of the latest estimates of cases, hospitalizations, and deaths by the U.S. Centers for Disease Control and Prevention is here, but let me summarize the basics. Children 0 to 17 are likeliest to catch swine flu. But adults (18 to 64) and seniors (65 and older) are much more likely to die of the disease. Kids are least likely to die if they catch swine flu.

 

(Continue . . .)

 

 

The analysis from the Sandman website follows.  You’ll want to follow the links to read this in its entirety.

 

 

What the CDC Is Saying about Swine Flu Severity

• How deadly is the pandemic so far?
• What age groups is it hitting hardest?
• What age groups does the government say it is hitting hardest?

by Peter M. Sandman

This update draws some inescapable tentative conclusions from the most recent (December 10) tentative estimates of U.S. pandemic flu cases, hospitalizations, and deaths provided by the U.S. Centers for Disease Control and Prevention (CDC).

 

The update also contrasts the CDC’s estimates with CDC communication about them, and with the Department of Health and Human Services’ new H1N1 vaccination campaign, “Together we can all fight the flu,” launched on December 7.

 

I don’t have any opinion on whether the estimates the CDC reported on December 10 are reliable, valid, and useful. But I am certain that the arithmetic I have performed on those estimates to show what they mean is solid. And I am certain that what the CDC’s estimates mean diverges significantly from what the U.S. government is telling people about the pandemic.

(Continue . . . )

 

 

It is important to note that  Dr. Sandman is not criticizing the CDC’s decision to target children, teenagers, and younger adults for vaccination.  That is, as he points out, not his field of expertise.

 

He cautions, however, that the messaging from the CDC needs to accurately convey the facts, and not just support their policy decisions.  Something he feels hasn’t always happened with their vaccine messaging.

 

Otherwise, he warns, they risk losing credibility.

 

Last summer, when the Advisory Committee On Immunization Practices decided to target children, teenagers and young adults (see The ACIP Committee Recommendations) for vaccination, the data was showing mostly children and teenagers being hit by this virus.

 

The downsizing of the estimated volume of vaccine to be available by mid-October, from 120 million doses to about 45 million (a target that was not met), further complicated matters.

 

Between the early demographic data, and the scarcity of vaccine supplies, one can understand the focus by the CDC on vaccinating pregnant women, children and teenagers.  

 

Since kids are walking Petri dishes, targeting them first appeared to provide the most bang for the buck. 

 

Although it was only 3 weeks ago that I was able to get the H1N1 vaccine (I’m 55 and not in a risk group), we now find ourselves awash in vaccine.  To the point where there is talk of giving away millions of doses lest they go unused.

 

Admittedly, all of this has been a precarious balancing act for the CDC, with shifting demographics and vaccine supplies. Trying to convey a simple `sound byte’ message about vaccination, without it becoming too convoluted, has been a challenge.

 

And perhaps, that’s the problem.   Trying to deal in `sound bytes’.

 

Designing an information campaign that relies on 10 second, or even 30 second PSAs, is the equivalent of my giving up this blog and only posting 140 character `microblogs’ on Twitter.  

 

It makes it difficult to `flesh out’ a message.

 

I’m not an expert on crisis communications, but following the ACIP recommendations, a better message early on might have been:

 

“Pandemic flu is a risk to everyone, although some in our older population may be lucky enough to have developed limited immunity to this virus.

 

Eventually we hope to see everyone vaccinated against H1N1, as vaccination is our best protection against influenza.

 

Right now, however, vaccine supplies are limited. More is on the way.

 

But for now we need to target those who are the biggest spreaders of the flu – children and young adults – and those we currently believe to be at highest risk – pregnant women and those with chronic health problems.

 

We ask for your patience.  When more vaccine becomes available, we will expand coverage to all ages.”

 

Too complicated?    I don’t think so.

 

But it requires more than 10 seconds. 

 

And it requires trusting the public to understand that there are physical limits as to what the government can do.   Something that  many in government are loath to admit.

 

As we face an increasingly complicated world, with threats that are not always well defined and solutions that are not always clear cut, we should be moving towards better risk communication . . .not shorter risk communication.

 

And for that, I can think of no better resource than the Sandman website.   Something that should be required reading for anyone charged with communicating with the public.