CIDRAP Commentary: Sandman & Lanard On Ebola Crisis Communications Lessons

Credit CDC PHIL

 

# 9426

 

When it comes to clear-eyed, coherent risk communications, Dr. Peter Sandman & Dr. Jody Lanard are about as good as it gets – which is why their services have been used by corporations, organizations, and agencies around the globe – often in the midst of a crisis.

I’ve quite happily featured their writings several times since the Ebola crisis began, including:

Sandman & Lanard On Ebola & Failures Of Imagination

NPR: Jody Lanard On Addressing Ebola Fears

Sandman & Lanard: Ebola Risk Communications

 

Today they’ve written a long, and valuable commentary for CIDRAP on the communications lessons (hopefully) learned from America’s brush with Ebola this fall – and lessons that could be applied the next time a `scary’ public health event takes place. 

 

Without further ado, I invite you to follow the link below to read:

 

COMMENTARY: When the next shoe drops — Ebola crisis communication lessons from October

Peter M. Sandman, PhD, and Jody Lanard, MD

Dec 09, 2014

Lessons learned this fall: (1) don't over-reassure, (2) acknowledge uncertainty, (3) don't overemphasize panic, and (4) don't ridicule overreactions.

(Continue . . .)

 

 

For further reading, the Peter Sandman Risk Communications website is an invaluable repository of risk management advice, that quite frankly, should be second home for anyone involved in public relations or risk communications.

Sandman & Lanard On Ebola & Failures Of Imagination

Credit CDC PHIL

 

 

# 9258

 

Yesterday author, blogger, and scary disease girl extraordinaire Maryn McKenna featured a long-read by risk communications experts Dr. Peter Sandman & Dr. Jody Lanard (see her wired blog The Grim Future if Ebola Goes Global) on the conversation that no one in authority seems willing to have right now: 

 

What happens if Ebola is not contained in West Africa?

 

First, a strong recommendation to read the analysis by Sandman & Lanard in its entirety if you haven’t already, after which I’ll have a bit more.

 

Ebola: Failures of Imagination

by Jody Lanard and Peter M. Sandman

The alleged U.S. over-reaction to the first three domestic Ebola cases in the United States – what Maryn McKenna calls Ebolanoia – is matched only by the world’s true under-reaction to the risks posed by Ebola in Liberia, Sierra Leone, and Guinea. We are not referring to the current humanitarian catastrophe there, although the world has long been under-reacting to that.

We will speculate about reasons for this under-reaction in a minute. At first we thought it was mostly a risk communication problem we call “fear of fear,” but now we think it is much more complicated.

(Continue . . . )

 
Highly recommended.

 

Admittedly, I too have found it hard to paint a bleak picture of where this Ebola epidemic could lead – partially, I think as a subconscious pushback against the over-the-top fear mongering that is all too rampant online, and partially due to my deep-seated ex-paramedic mindset of `No matter how bad things get, don’t get rattled, just carry on.’

 

And to be very clear, while my crystal ball is cracked and fogged up badly, my `bleak picture’ isn’t one of massive Ebola epidemics sweeping across the nation, or mass graves in the developed world.  

 

While there are respiratory pathogens out there capable of such carnage, I don’t believe Ebola (in its present incarnation, anyway) to be one of them.

NOTE: The `weasel wording’ in the previous sentence is 100%  intentional, as I think it is important to push back against the absolute assurances constantly being uttered by nervous officials.  

Previously, in An Appropriate Level Of Concern Over Ebola In The US,  I wrote:

 

That is not to say we won’t see impacts from this epidemic.  We already have – in Dallas – and I quite expect we will again.  We could certainly see limited spread here, and even small clusters of cases.  And while it won’t be pretty, and the response may not be perfect,  I have enough faith in our public health infrastructure to believe they would be able to control it.

Now, if Ebola ever finds a way to spread through the mega-cities of Africa, India, Pakistan, or some other high-population, low resource region of the world – the economic, societal, and political destabilization that could occur might change both the nature, and degree, of this epidemic’s threat to the developed world. 

 

A veiled vision, cloaked in ambiguity, that only tentatively hints at what failure to contain the virus in Africa could mean to the rest of the world.  Hindered, no doubt, by my own personal `failure of imagination’, and by the difficulties of accurately projecting the impact of a slow-motion strain wreck. 

 

An epidemic that spreads inexorably – not over weeks or months – but potentially over years.

 

Spreading more like HIV, TB, or Hepatitis than what we might expect from an emerging pandemic virus. Unlike those scourges, however, Ebola kills very quickly – in a matter of days – which increases its immediate impact.

 

How that might play out on the global stage six months or a year from now is very tough to envision, but in a world already roiled in crises, its impact can’t be ignored.

Over the years we’ve looked at the real possibility of seeing a Black Swan Event – a  world-changing incident that few, if anyone, had predicted. The phrase was coined by Nassim Nicholas Taleb in his 2004 book Fooled By Randomness, and expanded upon in his 2007 book The Black Swan.

 

Black swan events can arise in a lot of different ways, and various national security documents over the years have analyzed, and warned about, many possible scenarios. 

 

• A Pandemic
• A Cyber Attack
• A Financial Crisis
• A Geomagnetic Storm
• Social Unrest/Revolution

 

It is no coincidence that a severe pandemic ranks at the top of almost every list of highly disruptive national security threats (see 2011 OECD Report: Future Global Shocks,  UK: Civil Threat Risk Assessment, Influenza Pandemic As A National Security Threat).   

Is Ebola a black swan event?   I honestly don’t know. But it could be if it isn’t contained.

 

And right now, despite the upbeat messaging that `we know how to stop Ebola’, there are too many unknowns to be overly confident in the outcome.  Some may say that `failure is not an option’, but the truth is, history is replete with failures.  

 

We just tend to call them something else in the history books.

 

When my wife and I moved aboard our cruising sailboat in 1986, we immediately purchased a combination inflatable dingy/life raft.  We didn’t plan on sinking, but we also knew the ocean might have other plans for us. So with the kind of fatalism only longtime liveaboard sailors can muster, we christened it  `Plan B’.  

 

I’m happy to report it was never used for anything more desperate than rowing ashore to pick up another case of beer.   But it was there, equipped and ready, for any emergency.

 

While I hope we don’t ever need it, we need to be thinking about what our collective Plan B will be, if Ebola isn’t contained in West Africa. And that means thinking about, publicly talking about, and planning for the kind of disruptions that might occur if the virus makes its way to the mega-cities of Africa,  India, China, or South America.

 

Eight years ago the governments of the world urged agencies, organizations, businesses, and individuals to take a good hard look at their daily operations, and plan on how they would cope during a severe influenza pandemic. Since the relatively mild pandemic of 2009, the idea of pandemic planning has largely fallen to neglect.

 

Now might be a very good time to dust off your old pandemic plans, update them as necessary, and encourage others to do so.

 

Because, if Ebola doesn’t turn out to be the next great global public health crisis, there are plenty of other contenders waiting in the wings that could.

Sandman & Lanard: Ebola Risk Communications

 

 

 

# 9159

 

When it comes to risk communications, Dr. Peter Sandman & Dr. Jody Lanard are both highly sought out experts, and over the years I’ve highlighted their work a number of times (you’ll find a small sampling here, here, here & here) . During a crisis, they not only know what needs to be said, they aren’t afraid to say it.

 

Their website is an invaluable repository of risk management advice, that quite frankly, should be second home for anyone involved in public relations or risk communications.

Today (h/t Crof) they’ve posted three long email responses to reporters on Ebola Risk communications that are a `must read’.   Rather than try to pick and choose excerpts, I’ll simply invite you to go to their website to read:

 

Ebola Risk Communication: Talking about Ebola in Dallas, West Africa, and the World

by Peter M. Sandman and Jody Lanard

Sandman & Lanard On The Cochrane Tamiflu Report

 

# 8550

 

Somehow, with all of the MERS news coming out of the Middle East, I managed to miss a terrific piece of analysis by our favorite Risk Communications experts, Dr. Peter Sandman and Dr. Jody Lanard,  published last week on the The Peter M. Sandman Risk Communication Website.

 

Their website is a repository of invaluable risk management advice, that quite frankly should be second home for anyone involved in public relations or risk communications.

 

I’ve highlighted their work often in the past,including Sandman & Lanard: WHO, Pandemic Phases & Public Preparedness, Sandman: A Tale Of Two CDCs, Lanard: China’s Risk Communication On H7N9, and Referral: Sandman On The H5N1 Moratorium.

 

Their latest analysis centers on the  recent release of (and media hype surrounding) a recent Cochrane group analysis that found insufficient evidence to show whether Oseltamivir (Tamiflu ®)  and other NAI antivirals reduces influenza complications and transmission. 

 

I wrote about  this report earlier this month in  Revisiting Tamiflu Efficacy (Again) & The CDC Responds To The Cochrane Tamiflu Study, where I posited the preponderance of evidence supports the use of NAI antivirals for severe influenza.

 

Early last week Declan Butler, writing for the Journal Nature, wrote a piece called Tamiflu report comes under fire, for which Sandman & Lanard have supplied some quotes. Building on their emailed comments to Butler, they penned and posted a longer analysis on their website the following day.

 

Since it would do an injustice to the authors to try to excerpt highlights, I would simply suggest you follow the link below to read it in its entirety. 

 

Overstated Attack Hiding Behind Scientific Assessment: An April 2014 Cochrane Review Trashes the Usefulness of Influenza Antiviral Drugs

by Peter M. Sandman and Jody Lanard

(an April 15, 2014 email responding to Declan Butler of Nature)

Declan Butler’s April 22, 2014 article drew from this email.

Introductory Note

In early April 2014, the Cochrane Collective published two journal articles and a news release that went out of their way to understate the value of Tamiflu and Relenza, the two antiviral drugs used against influenza. When Nature reporter Declan Butler asked for our comment, we quickly sent back the short email posted below.

 

(Continue . . . )

 

The Sandman site is a treasure trove of risk communications information, and you could literally spend days just hitting the highlights. 

 

Highly recommended.

Sandman & Lanard On China’s H7N9 Risk Communications

Credit FAO

 

 

# 8278

 

After the debacle of the SARS cover up in 2002-2003, and a decade of less-than-forthcoming admissions regarding their H5N1 problems, Chinese health officials have earned a good deal of rare, but well-deserved praise for their apparent openness on the emerging H7N9 virus. 

 

Over the past week, however, we’ve seen disturbing reports that the Chinese MOA (Ministry of Agriculture) and poultry industry leaders – tired of the stigma and declining poultry sales – are down playing the dangers (see China’s MOA Disputes Poultry As Source Of H7N9 Infections) and are seeking to curb public disclosure of cases, while demanding a name change  from `bird flu’ to simply `flu’.

 

Over the past 24 hours China’s official news agency –  Xinhua - has also begun publishing a series of reassuring `forward-looking’ articles heralding the creation of an H7N9 vaccine,  without mentioning the long road still ahead to test, produce, and (perhaps someday) distribute the vaccine in any useful quantity.

 

H7N9 vaccine to undergo clinical testing Xinhuanet 2014-02-09 18:39

H7N9 vaccine proves effective on lab mice Xinhuanet 2014-02-09 10:05

Vaccine development progresses as China reports more H7N9 ca... Xinhuanet 2014-02-08 22:50

Vaccine developed as China reports more H7N9 cases Xinhuanet 2014-02-08 20:42

 

While we continue to see case reports coming out of affected provinces – with this apparent move to try to downplay the threat – one has to wonder just how accurate these daily counts are going to be going forward. China’s MOA carries great sway, perhaps even more than the Ministry of Health, and as we’ve discussed in the past (see Food Insecurity, Economics, And The Control Of H7N9), their agendas don’t always mesh.

 

All of which serves as prelude to a brilliant piece by our favorite Risk Communications experts,  Dr. Peter Sandman and Dr. Jody Lanard,  published on the The Peter M. Sandman Risk Communication Website, a repository of invaluable risk management advice, that quite frankly should be second home for anyone involved in public relations or risk communications.

 

I’ve highlighted their work often in the past,including Sandman & Lanard: WHO, Pandemic Phases & Public Preparedness,  Sandman: A Tale Of Two CDCs, Lanard: China’s Risk Communication On H7N9, and Referral: Sandman On The H5N1 Moratorium.

 

Follow the link below to read:

 

Forgoing Trust, China’s Poultry Industry Lobbies for an H7N9 Cover-Up

by Jody Lanard and Peter M. Sandman

(a February 6, 2014 email to Lisa Schnirring of CIDRAP News)
Lisa Schnirring’s February 6, 2014 article drew from this email.

According to the South China Morning Post and other sources, China’s poultry industry wants China’s public health agencies to stop reporting individual cases of H7N9, to “avoid excessively detailed reports” of H7N9 infections, and to call this novel bird flu virus “H7N9 flu” or “H7N9 virus” rather than “H7N9 bird flu.” The industry’s goal is to reduce consumer concern about shopping for, purchasing, cooking, and eating poultry.

This has two main problems.

First, the industry’s goal is inappropriate. Consumer concern is justified, at least about contact with live poultry, and particularly about environmental exposure at live animal markets. (There isn’t any evidence that eating well-cooked or even poorly-cooked poultry is dangerous; the H7N9 virus is mostly found in the respiratory tract of infected poultry, unlike the more systemic distribution of the H5N1 virus in infected poultry.) The number of human cases of H7N9 in China, though not huge, is growing faster than last year and far faster than H5N1. And the available evidence strongly suggests that most victims are catching the virus from poultry or poultry environments (such as live animal markets), and at most only occasionally from other people. The U.S. government, among others, advises visitors to China to avoid contact with live poultry and live animal markets. It is not foolish for Chinese consumers to try to be as cautious as their food-purchasing and food-consumption patterns permit. This is especially true in the face of massive expert uncertainty about how this new virus behaves.

More importantly, the industry’s recommendations are bound to backfire. It is a fundamental principle of risk communication that mistrust arouses outrage. In other words, people become much more concerned about a health risk when they discover that they are not being told the whole truth about that risk. When sources cannot be trusted, small risks look big and big risks look bigger.

(Continue . . . )

 

As long as the information coming out of China has been perceived as being reasonably reliable, it has been fairly easy to accept their assurances that there are no signs of sustained human-to-human transmission of the virus. 

Should that flow of information stop (or appear manipulated) – due to political or economic interests trumping those of public health – those assurances will quickly ring hollow, regardless of the actual situation on the ground.

 

Sandman & Lanard: WHO, Pandemic Phases & Public Preparedness

The current WHO phase of pandemic alert for avian influenza A(H5N1) is: ALERT

 

# 7484

 

Last May the internationally known, and highly regarded risk communications team of Dr. Peter Sandman and Dr. Jody Lanard wrote about the CDC’s  messaging on the H7N9 virus threat (see Sandman On H7N9 Risk Communications: Candor, but No Push to Prepare).

 

The Peter M. Sandman Risk Communication Website contains a wealth of invaluable risk management advice, which quite frankly should be second home for anyone involved in public relations or risk communications.

 

Yesterday they posted a letter from pandemic preparedness expert Eric S. Starbuck, DrPH, MPH, (see Paper: Are We Prepared For A Pandemic In Low Resource Communities?) asking (among other things) about the absence of any definitive pandemic phasing information on MERS-CoV and the H7N9 virus on the World Health Organization’s website.

 

As you can see by the graphic at the top of this blog, the H5N1 falls clearly in the `Alert Phase’, but a similar graphic for MERS-CoV or H7N9 are not currently posted on the WHO website.  

 

The closest thing I’ve found is this twitter  statement by Gregory Hartl – spokesperson for WHO – on the H7N9 virus back in April.

 

 

In response Peter & Jody take a detailed look at the World Health Organization’s new (Interim) Guidance on Pandemic Influenza Risk Management (see WHO Unveils New Pandemic Guidance) and how it presumably relates to MERS-CoV and H7N9, and their overall pandemic preparedness messaging.

 

I won’t even attempt to excerpt from this thoughtful 5000+ word analysis, and will instead simply make my strongest possible recommendation that you follow the link below and read it in its entirety.

 

Pandemic preparedness and pandemic stages re H5N1, H7N9, and MERS

 

 

Pandemic preparedness messaging is something I struggle with nearly every day in this blog, and so I know how difficult it can be to find the right `tone’; one that informs without turning people off to the message.

Agencies and organizations like WHO, CDC, ECDC and others also face the inevitable hyping of anything they say by the `tabloid press’. Then, if the worst doesn’t happen (and on the media’s time table), they can expect public excoriation.

 

It may not be `fair’, but it does sell papers. 

 

So their reluctance to come out too strongly before there is evidence of a clear and present danger is understandable. 

 

The suggestion by Sandman and Lanard that `other sorts of agencies – national security agencies, public works agencies, disaster response agencies, etc.’ – who are more used to dealing with the public and disaster response - get involved in the pandemic preparedness messaging makes sense to me.

 

Although you have to dig to find it (and already know it exists), you can find some pandemic preparedness information provided by FEMA, Ready.gov, and Flu.gov.

 

http://www.ready.gov/pandemic

http://www.flu.gov/pandemic/#

 

But I’ve seen no discernable push by either of these websites since the emergence of H7N9 or MERS-CoV to promote enhanced pandemic preparedness for the public.

 

The proactive pandemic preparedness messaging from federal agencies that we saw prior to the 2009 H1N1 pandemic has largely disappeared.

 

I suspect that the prolonged economic downturn has something to do with this, but I fear this may turn out to be penny wise and pound foolish.

 

For my part, I’ll continue to promote pandemic and `all hazards’ preparedness in this blog. 

 

Not because I’m convinced that a pandemic is on the horizon, but because I know that bad things (tornadoes, floods, hurricanes, earthquakes,  and yes . . . pandemics) will happen, often with little warning.

 

And the advantage always goes to those who are best prepared.

 

 

 

And finally, my thanks to Peter & Jody for the very kind mention of this blog in their comment.

Sandman On H7N9 Risk Communications: Candor, but No Push to Prepare

A CDC scientist uses a pipette to transfer H7N9 virus into vials for sharing with partner laboratories for public health research purposes.

 

 

# 7283

 

Dr. Peter Sandman, and his wife and colleague Dr. Jody Lanard, together run The Peter M. Sandman Risk Communication Website. They provide consulting services to individuals, organizations, companies, and even governments – often during their worst public relations nightmares.

 

Their website contains a wealth of invaluable risk management advice, which quite frankly should be second home for anyone involved in public relations or risk communications.

 

 

I’ve highlighted their work often in the past, most recently in Sandman: A Tale Of Two CDCs, Lanard: China’s Risk Communication On H7N9, and Referral: Sandman On The H5N1 Moratorium.

 

Today Peter takes a long, and detailed look at the messaging coming out of the CDC and the World Health Organization on the emerging H7N9 virus (and MERS-CoV).  

 

While he finds their candor over the threat posed by these emerging pathogens praiseworthy, he finds their preparedness messaging to the public to be seriously lacking. 

 

There is simply too much good stuff here to even begin to excerpt it here. Instead, I will strongly urge you to read this exceptional opinion piece in its entirety.

 

When you return, I’ll have a bit more.

 

H7N9 Risk Communication: Candor but No Push to Prepare

by Peter M. Sandman

 

 

The lack of individual (or even corporate) preparedness messaging coming from the CDC and FEMA on these potential pandemic threats is a mystery to me, although I suspect it has much to do with the hammering they took after the worst case scenarios failed to materialize with the 2009 pandemic.

 

Many pundits and critics, most with the benefit of perfect hindsight, accused them of `crying wolf’.

 

But as any epidemiologist will tell you.  If you’ve seen one flu pandemic . . . you’ve seen one flu pandemic.

 

There’s simply no way to know, in advance, how severe any influenza (or MERS) pandemic might be. In many respects, the world got off very easy the last time.

 

Later today I’ll be posting a follow up blog on pandemic preparedness resources.

Sandman: A Tale Of Two CDCs

 

 

# 7203

 

 

Regular readers (and anyone familiar with the world of risk communication issues) already know of Dr. Peter Sandman, and his wife and colleague Dr. Jody Lanard, who together run The Peter M. Sandman Risk Communication Website.

 

 

Over the years they’ve provided many corporations, agencies, and governments invaluable assistance on handling media relations during a crisis. I’ve highlighted Peter and Jody’s work often in the past, including:

 

Peter Sandman On the CCIVI Vaccine Report

Peter Sandman: Swine Flu For Grownups

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

Peter Sandman On Pandemic Risk Communication

Today they have a lengthy analysis on the messaging and communication strategies being employed by China’s CDC and our own CDC on the emerging H7N9 virus that builds upon an earlier post I linked to on Saturday (see Lanard: China’s Risk Communication On H7N9).

 

The post (wherein Peter very kindly mentions this blog), is called:

 

Posted: April 8, 2013

H7N9: A Tale of Two CDCs

 

This post, along with the rest of their website, is a treasure trove of great advice and information of interest to anyone who is, or may someday become, a spokesperson during a crisis.

Highly recommended.

Peter Sandman On the CCIVI Vaccine Report

 

# 6638

 

Two days ago Michael Osterholm and his group at CIDRAP released their 160-page Comprehensive Influenza Vaccine Initiative (CCIVI) report, that among other things, cited longstanding overstatement of the effectiveness of the seasonal flu vaccine as a barrier to creating new, and more efficient vaccine technology.

 

Up until about a year ago the CDC’s mantra has been for healthy adults under the age of 65, in years when the vaccine is a good match to circulating strains, effectiveness ranges from 70%-90%.

 

A statement that at times was interpreted as `up to 90% effective’  by officials and the media. A quick Google this morning found the following statement on a major company’s website (link) from 2006.

 

Get a seasonal flu shot every year. The Centers for Disease Control and Prevention (CDC) report that getting a seasonal flu shot the best way to prevent the seasonal flu. In fact it's up to 90% effective in preventing the seasonal flu and even if you catch the seasonal flu, the immunity provided by the vaccine can make your case milder.

 

Not only does this site overstate the effectiveness of the seasonal flu jab, it fails to mention the CDC’s  disclaimer of `in healthy adults under the age of 65’. I can find plenty of instances of this 90% effectiveness meme being used, some as recently as August of this year (link)

 

A little more than a year ago the CDC updated their FAQ on Flu Vaccine effectiveness, and as part of a much longer detailed posting, lowered their estimate of the inactivated flu shot’s effectiveness to read:

 

. . . recent RCTs of inactivated influenza vaccine among adults under 65 years of age have estimated 50-70% vaccine efficacy during seasons in which the vaccines' influenza A components were well matched to circulating influenza A viruses.

 

A number that pretty much matched CIDRAP’s finding (see A Comprehensive Flu Vaccine Effectiveness Meta-Analysis) which would be released a couple of weeks later. That analysis showed the trivalent inactivated vaccine (TIV) had a combined efficacy of 59% among healthy adults (aged 18–65 years).

 

While these numbers are much lower than we would would like to see, 50%-60% protection is far superior to no protection at all.

 

Which is why I continue to get, and support getting, the seasonal flu vaccine.

 

All of which serves as prelude to some extended comments released yesterday by Dr. Peter Sandman on the CCIVI report and public health’s long-standing inclination to overstate the effectiveness of the flu vaccine.

 

For those unfamiliar with Dr. Sandman, he is a world renown expert on crisis communications, who along with his wife and colleague Dr. Jody Lanard, provide consulting services to individuals, organizations, and companies – often during their worst public relations nightmares.

 

Together they also produce a wealth of invaluable risk management advice on their website, which quite frankly should be second home for anyone involved in public relations or risk communications.

 

In the interests of full disclosure Dr. Sandman served on the CCIVI Expert Advisory Group and has worked with CIDRAP in various capacities in the past, points that he makes abundantly clear in his preface. 

 

What follows are excerpts from a lengthy email he sent to Lisa Schnirring of CIDRAP NEWS, in advance of the report’s release, for use in her news articles.

There is so much good content here, I find it difficult to pick and choose excerpts.  As you’ll see, from the title onward, Dr. Sandman does not mince words - so please - follow the link to read it in its entirety.

 

 

We’d Be Likelier to Develop a Better Flu Vaccine If Public Health Officials Didn’t Keep Misleading Everyone about the Flu Vaccine We Have

 

by Peter M. Sandman

(an October 14, 2012 email to Lisa Schnirring of CIDRAP News)

On October 15, 2012, CCIVI released its report, entitled “The Compelling Need for Game-Changing Influenza Vaccines.” The report argued that the current flu vaccine is sorely inadequate; that a key barrier to developing a better vaccine is the widespread judgment that the current one is fine; and that the main reason the vaccine’s effectiveness is so consistently overestimated is that public health officials keep saying it is better than it is.

<SNIP>

Chapter 7 does a fine job of documenting how public health – especially ACIP – overestimates and overstates the efficacy of the flu vaccine. There are really three criticisms here:

• ACIP recommendations for ever-wider flu vaccination have been grounded in claims, assumptions, and judgments that the vaccine was more effective than it actually is.
• Early on that was because good data weren’t available, but long after there were ever-better data showing that the flu vaccine wasn’t very effective, ACIP continued to speak and act as if it were – ignoring some studies, misinterpreting others, leaning too heavily on studies with big methodological flaws, relying on plausibility and expert judgment while claiming to be relying on sound science, etc.
• In their zeal to encourage vaccination, ACIP, CDC, and the rest of the public health leadership kept telling the public (often via state and local public health officials and people’s personal doctors) that the flu vaccine worked better than it works.

<SNIP>

2. How do you think the report will be received? (Some of Chapter 7 sure reads like a GAO report. Lots of investigation work went into the analysis of ACIP’s recommendations.) What areas might see some early impact from the findings?

The central claim in the report is of course its claim that the flu vaccine is a lot less effective than most vaccines and a better one is badly needed.

 

Many in public health will find that claim difficult to embrace. But however reluctantly, I think they will embrace it. The Lancet I.D. study paved the way; in anticipation of that study’s publication, CDC stopped claiming 70–90% effectiveness in healthy adults under 65 and retreated to the much more supportable 50–70% estimate.

 

Now, sadly, CDC and many lower-level public health officials often provide no flu vaccine effectiveness estimate at all in their public communications, having learned that 70–90% is scientifically unsound but fearful that the more accurate 50–70% might undermine public acceptance. This is a small example of officials not trusting the public, which is a very large risk communication problem in public health. (See “Trust the Public with More of the Truth: What I Learned in 40 Years in Risk Communication.”)

 

(Continue . . .)

 

 

The CCIVI report and Dr. Sandman’s comments will undoubtedly discomfit many in the public health field, even if they privately accept their findings. 

 

There is, after all, legitimate concern that anti-vaccine activists will use this report as fodder for their propaganda machine.

 

But in reality, public health faces an even bigger challenge.

 

As I wrote earlier this year in in Science At The Crossroads, the public’s faith in science and technology is eroding. And during a public health emergency, that could prove disastrous.

 

One only has to look at the deep divisions over climate change, evolution, vaccine safety, nuclear power, and genetically modified food crops to realize just how wide this rift between the public and scientists has become.

 

Recent revelations regarding deceit and fraud in scientific research (see PNAS study Misconduct accounts for the majority of retracted scientific publications) have only served to intensify this mistrust.

 

Rekindling the public’s trust is paramount, and the first step in that direction is trusting the public with the truth (or at least, our best estimation of the truth at the time).

 

If the vaccine is only 60% effective, we need to embrace that number and promote it the same way we do seatbelts.

 

Seatbelts don’t guarantee you’ll walk away from a wreck, but they sure improve your odds.

 

Most people understand that, and buckle up.

 

I honestly believe that those who are inclined to get a flu shot will accept those limitations, while those who are vehemently against vaccines  . . .  well, they weren’t going to be persuaded by VE numbers, no matter how high they were.

 

I can’t help but remember what a terrific job the CDC’s Admiral Anne Schuchat - Director of the National Center For immunization and Respiratory Diseases - did during the summer and fall of 2009 briefing the press and the public day after day on the emerging H1N1 pandemic.

 

Her candor, ability to work `off script’ and willingness to concede the things they did not know about the virus were equal parts effective, comforting, and refreshing - and in my mind, anyway – constituted the CDC’s finest hour during that crisis.

 

I believe this type of straight talk should be the model for all public health messaging, even if inconvenient facts (like a VE rate of 60%) are less than comforting.

 

That it is only if you trust the public with the truth that you can win, and hold, their confidence. 

 

Anything less just deepens the rift of public distrust and plays into the hands of the critics.

Peter Sandman: Outrage On Both Sides

 

 

# 6335

 

 

Dr. Peter Sandman is a world renown expert on crisis communications, and along with his wife and colleague Dr. Jody Lanard, provide consulting services to individuals, organizations, and companies – often during their worst public relations nightmares.

Together they also produce a wealth of invaluable risk management advice on their website, which quite frankly should be second home for anyone involved in public relations or risk communications.

 

 

I’ve highlighted Peter and Jody’s work often in the past, including:

 

Peter Sandman: Swine Flu For Grownups

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

Peter Sandman On Pandemic Risk Communication

 

 

When you think about `risk communications’ and `flu’, very little comes close to the often unseemly debate of the past few months over the publication of the Kawaoka and Fouchier H5N1 transmissibility papers.

 

 

For those that need a refresher:

 

Last September, Ron Fouchier from the Netherlands (and almost simultaneously Professor Yoshihiro Kawaoka from Wisconsin) announced success in creating enhanced strains of the H5N1 avian flu virus in the laboratory that can transmit efficiently among ferrets, which quickly sparked biosecurity concerns.

 

For some background, see Katherine Harmon’s Sci-Am article , New Scientist: Five Easy Mutations, & NPR: Bio-Terrorism Concerns Over Bird Flu Research.

 

 

The fate of these two papers has now been decided; Kawaoka’s was published earlier this month (see Nature Publishes The Kawaoka H5N1 Study), and a revised version of Fouchier’s paper is due out anytime.

 

While the original focus of this debate has been settled, we are left with nagging questions regarding the way this debate was handled, and concerns over what happens when this sort of situation inevitably occurs again.

 

Which brings us to a long, detailed, and very informative analysis of the risk communication missteps made by both sides of this debate, posted by Dr. Sandman on his website in response to a reader’s comment.

 

It is called:

 

Risk communication aspects of the debate over H5N1 transmission studies

 

 

I’ll not try to summarize this well reasoned and detailed examination of the events of the past few months, as to do so would be a disservice.

 

This article deserves to be read in its entirety. 

 

Highly recommended.

Jody Lanard: Risk Communication & Flu Vaccine Effectiveness

 

 

# 5923

 

My thanks to Crof for picking up on a short posting by Dr. Jody Lanard on the CDC’s recent unveiling of flu vaccine efficacy numbers.

 

As most of my readers know, flu vaccine effectiveness studies have been all over the map in recent years, with some showing remarkably high levels of protection while others have returned less encouraging numbers. 

 

For years the CDC’s mantra has been for healthy adults under the age of 65, in years when the vaccine is a good match to circulating strains, effectiveness ranges from 70%-90%.

Of course, if you don’t fall into this `ideal’ cohort, or if the virus drifts away from the vaccine strain, your mileage may vary. 

 

Sometimes, considerably.

 

Which is something we’ve addressed numerous times in this space, including:

 

Study: Obesity, Influenza & Immunity

Study: Flu Vaccines And The Elderly

Flu Shots For The Elderly May Have Limited Benefits

 

Recently the CDC updated their FAQ on Flu Vaccine effectiveness, and as part of a much longer detailed posting, lowered the estimate of the inactivated flu shot’s effectiveness to read:

 

. . . recent RCTs of inactivated influenza vaccine among adults under 65 years of age have estimated 50-70% vaccine efficacy during seasons in which the vaccines' influenza A components were well matched to circulating influenza A viruses.

 

 

Dr. Jody Lanard, who along with her husband Peter Sandman, are considered among the most authoritative in the world on the subject of risk communications, has posted a brief commentary on the way this revised information has been rolled out by the CDC.

 

Highly recommended.

 

Follow the link to read:

 

Brief analysis of a risk communication error:

The CDC reports its newest estimate of influenza vaccine efficacy: 50-70% in healthy adults under 65

By Jody Lanard M.D. (posted on October 25 2011, 1:30 pm EDT)

 

 

 

Between Sandman and Lanard, they produce a wealth of invaluable risk management advice freely available on their website:

 

 

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

 

Over the years I’ve been happy to feature their writings a number of times, including here, here, and here.  

 

For more, simply do a blog search on `Sandman’.

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 & Lanard On Worst-Case Crisis Communications

 

 

# 5411

 

 

When it comes to risk communications during a crisis, you’d have to go a long way to beat the advice of Dr. Peter Sandman and his wife Dr. Jody Lanard. 

 

Both are highly regarded consultants in the field, and have been called upon by entities both public and private during times of crisis. Between the two of them, they produce a wealth of invaluable risk management advice freely available on their website:

 

 

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

 

Over the years I’ve featured their writings a number of times, including here, here, and here.   For more, simply do a blog search on `Sandman’.

 

Last night Sandman and Lanard responded to an anonymous journalist’s question regarding the open discussion of `worst-case’ scenarios in Japan. 

 

You’ll find an excerpt below, but follow the link to read it in its entirety (and follow the links as well!).

 

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

name:Anonymous

field:Newspaper reporter

date: March 16, 2011

location:Canada

comment:

I’m a reporter working on a story that takes a look at the rhetoric/fear-mongering surrounding the disaster in Japan. I figured you’d have some awesome insights based on your field of work.

The story is pegged to these comments, from Europe’s Energy Commissioner Guenther Oettinger, on Tuesday:

• “There is talk of an apocalypse and I think the word is particularly well chosen. Practically everything is out of control. I cannot exclude the worst in the hours and days to come.” [from: www.telegraph.co.uk]
• “The site is effectively out of control. In the coming hours there could be further catastrophic events which could pose a threat to the lives of people on the island.” [from: msnbc.tumblr.com]

Do you have any reactions?

peter responds:

Note: My wife and colleague Jody Lanard collaborated on this response.

Oettinger’s statements are at the upper end of dramatic. “Practically everything” isn’t out of control.

 

Statements like his result from the failure of officials to follow two crucial precepts of crisis communication.

• Be incredibly respectful of and empathic about normal people’s fears and fantasies.
• Get out in front of worst-case-scenario speculation by sharing the worst case scenarios that officials consider possible and worth planning for.

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.

 

What are the worst cases their experts are worried about and working to prevent? The world has a right to know that, and the world has a right to judge them harshly for not revealing that. More importantly, the world has no choice but to try to figure out on its own what the worst case scenarios might be that officials are either too irresponsible to consider or too cowardly to reveal.

 

Under such conditions, outside speculation about worst case scenarios justifiably gains traction – especially since the trajectory of the story has been to keep getting worse in the face of official assurances that things were not likely to get worse.

 

Ideally, officials would have preempted much outside speculation by sharing their worst fears publicly. Our crisis communication advice is always that officials should try to recreate in the public the same level of concern that they themselves are experiencing, and should focus about equally on the two most important questions about the short-term future:

1. What do you think is most likely to happen?
2. What’s the worst outcome that you haven’t dismissed as too unlikely to be worth worrying about?

Since officials have avoided answering the second question, speculation has taken off.

(Continue . . . )

 

 

Great stuff, so go read it all.

Sandman And Lanard On Pandemic Credibility and Communication

 

 

# 4688

 

 

My thanks and a big hat tip to Crof at Crofsblog  for posting a link to what he rightfully calls the ` absolute must read’ of the day; an in-depth analysis of the World Health Organization’s pandemic communications and the charges of a `fake pandemic’.

 

The “Fake Pandemic” Charge Goes Mainstream and WHO’s Credibility Nosedives

by Peter M. Sandman and Jody Lanard

The extremely long assessment that follows advances an argument we can summarize in a single sentence:

The absurd charge that the World Health Organization (WHO) hyped a fake pandemic in order to enrich Big Pharma has gained undeserved mainstream credibility mostly because WHO has badly mishandled its risk communication about three issues: (a) the mildness of the pandemic (so far); (b) the debatable meaning of the term “influenza pandemic”; and (c) the inevitable – but not culpable – structural conflicts of interest of WHO advisors.

 

(Continue reading . . . )

 

Dr. Peter Sandman is an internationally recognized 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:

 

Referral: Risk Communication and Disasters

Peter Sandman: Swine Flu For Grownups

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

Peter Sandman On Pandemic Risk Communication

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.