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CDC-INFO National Contact Center H1N1 Response Exercise v. Reality

CDC-INFO National Contact Center H1N1 Response Exercise v. Reality. Susan K. Laird, MSN, RN Clinical Director, CDC-INFO Joint Information Center Team Lead Division of Community Engagement Office of the Associate Director for Communication Centers for Disease Control and Prevention.

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CDC-INFO National Contact Center H1N1 Response Exercise v. Reality

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  1. CDC-INFO National Contact CenterH1N1 ResponseExercise v. Reality Susan K. Laird, MSN, RN Clinical Director, CDC-INFO Joint Information Center Team Lead Division of Community Engagement Office of the Associate Director for Communication Centers for Disease Control and Prevention

  2. Special thanks to Marsha Vanderford, PhD, JIC LeadStephanie A. Dopson, MSW, MPH, ScD. Candidate, Influenza Coordination Unit

  3. Objectives • At the completion of this workshop, attendees will… • have an understanding of how CDC and CDC-INFO respond to emergencies and coordinate during an event • be aware of CDC resources available to AIRS members in support of state and local activities

  4. Public Health Preparedness and Emergency Response:How CDC and CDC-INFO activate and mobilize

  5. National Strategy for Pandemic Influenza 11/05 Homeland Security Council National Strategy for Pandemic Influenza--Implementation Plan 5/06 HHS Pandemic Influenza Plan 11/05 HHS Implementation Plan 11/06 HHS ESF 8 Playbook CDC-INFO Surge and Scalability Plan Planning started years before the H1N1 Pandemic 5

  6. Influenza Pandemic OPLAN AAR AAR AAR DEOC Working Level Workshop4 Oct (8 Hrs) AAR Functional Exercise (Internal/External) 25-27 Apr 07 (48 Hrs) AAR AAR Functional Level Drills(6 Functional Areas)16 Oct – 1 Dec(2-4 Hours Each) Functional Exercise (Surge)14-16 Aug 07 (48 Hrs) AAR Advanced Tabletop: Significant Issue Forum 8 Dec (4 Hours) AAR Functional Exercise – Internal, Full Staff31 Jan – 1 Feb 07(18 Hrs) AAR CDC Exercises (2006-2007) Training/Exercise Methods: Briefings/Seminars Tabletop Discussion Workshops and Functional Drills Functional Exercises Senior/Division Leader OPLAN Seminars 28 Sep & 17 Oct(4 Hrs Each) 2008 Influenza Pandemic Exercise Program CDC Foundation Tabletop 18 Apr (3-4 Hrs) Section Drills 1-30Nov07 AAR Lessons Learned Seminar 15Nov07 Intervals, Actions & Triggers TTX 14Nov07 6

  7. AAR AAR Influenza Pandemic OPLAN AAR CDC Exercises (2008) Training/Exercise Methods: Briefings/Seminars Tabletop Discussion Workshops and Functional Drills Functional Exercises Surgeon General’s Flag Retreat ITA TTX8 Jan 2008(4 Hours) AAR Limited Full Scale Exercise (1 State) Surge/Mitigation 11-13 Mar 2008(48 Hrs) 2009 Exercise Series TTX CDC / PFO / JFO Role and Responsibilities July 10, 2008(4 Hrs) Limited Full Scale Exercise Influenza Pandemic Progression from Acceleration to Peak Transmission(5 State Participation) Sep 16-18, 2008 (48-72 Hrs) DEOC Section Functional DRILLS 3-14 Nov 2008(4-8 Hours) AAR 7

  8. CDC H1N1 Response In late March and early April 2009, cases of human infection with a novel H1N1 influenza virus were first reported in Southern California and near Guadalupe County, Texas. 25 percent of the SNS supplies were deployed to all 62 states or project areas. CDC-developed PCR diagnostic test kits to detect this virus. Test kits have been distributed to all 50 states, the District of Columbia and Puerto and are being distributed internationally.

  9. April 2009 • April 21 – CDC-INFO initiates Log Call for tracking • April 23 – CDC –EOC activated • April 24 – Messaging in place at the front of the IVR redirecting to website • April 30 – highest call volume attempted

  10. 2009 H1N1 Outbreak Response Occurred very late in the season Remarkable heterogeneity across US Affected young people disproportionately Caused widespread illness; some severe or fatal Socially disruptive, especially for schools Tens of thousands of nurses and other health workers responded worldwide

  11. Key Events Novel 2009-H1N1 Declarations: USG: Public Health Emergency declared (26 Apr 2009) Renewed by HHS Secretary Kathleen Sebelius HHS: Downgraded to Phase 1 – Awareness (9 May 2009) WHO: Pandemic Phase 6 (11 JUN 2009 1600 EDT) Outbreaks in at least one country in > two WHO regions USG: National Emergency declared (24 Oct 2009) To allow Section 1135 [42 USC §1320b–5] waivers to be issued 11 11

  12. Response Timeline 15 Apr 09 to 31 May 09 1 Jun 09 to 15 Aug 09 16 Aug 09 to 4 Oct 09 5 Oct 09 to 1 Apr 10 Pre-Pandemic Recovery Discovery Fall wave Preparing S. Hemisphere Vaccination

  13. Developing Guidance Sep 22 CDC clarification to reduce burden from Worried well Sep 8 CDC Posts revised Antiviral drug guidance May 6 CDC Posts Interim guidance 13

  14. Response—Strategic Goals/ Principles Reduce illness and death Minimize societal impact Apply greatest effort to interventions with greatest impact 14

  15. H1N1 Four Pillars of Action Surveillance (Situational awareness) Domestic and Global Health care system Mitigation Vaccination Communication State and Local Support Medical Care and Countermeasures

  16. Examples from the H1N1 Response

  17. Vaccination CDC has isolated the new H1N1 virus and modified the virus so it can be used to make hundreds of millions of doses of vaccine Making vaccine is a multiple step process which takes several months to complete State health departments started ordering Novel H1N1 vaccine on September 30th Novel H1N1 vaccine was widely available to the public by early December and began to be distributed through retail pharmacy chains

  18. Components of a National Voluntary H1N1 Vaccination Program Program planning Engaging partners in government (state, tribal, local) and private sector Financing of program and vaccine administration costs Implementation and vaccine distribution Assessing how many people receive the vaccine Communications General public Health professionals Monitoring vaccine safety Assessing vaccine effectiveness

  19. Communicating Effectively • Continued outreach to: • Parents • Pregnant Women • Child Care Programs • Schools, Colleges and Universities • Travelers, Travel Industry • Clinicians • Laboratorians • Businesses, Employers • Community and Faith-Based Organizations • Correctional facilities • Homeless shelters • Migrant farm workers

  20. CDC’s Communication Response: Guiding Risk Communication Principles Announce early Maintain transparency Do anticipatory guidance Prepare media and public for change Acknowledge uncertainties Involve and empower the public Explain their role in reducing the impact of the outbreak – communicate calls to action Effectively utilize partnerships

  21. Communicating Prevention Steps April 24-Aug 31, 2009: 45 Guidance Documents Steps for public, clinicians, state/local health departments, businesses,and Communities to take

  22. Communicating Guidance Information Talking Points for Media Partners for message coordination Key messages Fact sheets CDC-INFO Scripts PSAs Posters Podcasts/Videocasts Health Alerts Twitter Messages Listserv content Guidance Documents Foreign Language Translations

  23. Situational Awareness Clinical/Public Health Guidance, Daily Public Updates CDC Emergency Website Key Messages 15 JIC Teams (Adaptation/Dissemination (fact sheets, PSA’s, “Tweets”, etc) Media Relations General Public Affected Communities Vulnerable Populations Clinicians State/local PH Workforce Laboratorians Global Communication Counterparts Policy Makers CDC Employees News Media Press conferences News releases Interviews Media Tours Media advisories JIC Channels CDC Emergency Website CDC-INFO (English, Spanish, TTY) Health Alert Network Epi-X Clinician Registry Social Media Partner Distribution Networks

  24. Role of Businesses/Employers in Pandemic Planning and Response Protect the workforce Encourage ill staff to stay home Do not punish staying home Plan for/support telework Encourage vaccination, especially of high-risk workers Keep businesses operational (esp. Critical Infrastructure) Ensure communities continue to function

  25. Communicating through News Media4/21-6/12 2009 • CDC News Media Inquiries • 100 per day (range 10-250) • News Briefing Telebriefing Participants (31 briefings) • 700 avg. participants per briefing (range 450-2450) • Stories by National Print Media featuring CDC • 2,582 (represents actual stories not repeated stories) • CDC Media Web Site Section Views 1,050,342 • (25,000 per day) • CDC In-studio interviews • 70 national/local interviews (CBS, Fox, CNN, NBC, ABC, MSNBC, Univision, C-SPAN)

  26. Targeted Communication to Vulnerable Populations Deaf and Hard of Hearing CDC-INFO scripts always in TTY PSA’s in American Sign Language •H1N1 General messages •Hand hygiene • Collaboration with Partners: ASL PSAs Courtesy of the University of Rochester • http://www.cde.gov/h1n1flu/deaf.htm

  27. AIRS! American Association on Intellectual and Developmental Disabilities Brain Injury Association of America Florida Association for the Deaf GA Council for the Hearing Impaired National Institute on Disability and Rehabilitation Research March of Dimes Foundation Helen Keller Foundation Lighthouse for the Blind National Council on Disability National Organization on Disabilities Independent Living Centers Association of University Centers on Disabilities March of Dimes Communicating through Partners Government, NGO, faith-based organizations, and other partners who serve vulnerable populations distribute CDC’s messages. Example of CDC partners who serve disabled populations:

  28. April 22, 2009 One fact sheet on H1N1 (swine flu) 6,000 page views July 12, 2009 300 + pages on H1N1 95 million page views Social Media Connections Widgets Buttons E- cards Twitter Feeds Pulling Traffic to CDC’s Website

  29. Sample of 2009 H1N1 Social Media

  30. Challenges in sharing guidance Guidance Changed 4/24-7/16 • 41% (17/41) guidance documents changed • 20% (8) changed once • 12% (5) changed twice • 10% (40) removed and not replaced • Most frequently changed/major changes • Case definition • Identification of and caring for patients • Antiviral guidance • School Guidance

  31. Communicating Change: In Practice Practices for setting expectations for change: • Label guidelines “interim” • Forecast changes to come in talking points and print materials Example: Interim Guidance for Clinicians on the Prevention and Treatment of Novel Influenza A (H1N1) Influenza Virus Infection in Infants and Children May 13, 2009 3:30 PM ET This document provides interim guidance for clinicians who are caring for young children with novel influenza A (H1N1) virus infection. As additional information becomes available, the guidance in this document may be updated.

  32. Communicating Change: Challenges Rapidly changing guidance • 44% of all guidance documents (18/41) changed between initial release and 7/16/09 • 17% (3/18) of first week’s guidance changed in the first week of the response • 73% of guidance documents (30/41) first 2-weeks of response • 37% (11/30) of guidance changed once within 2 weeks • 10% (3/30) documents changed twice within 2 weeks • On a single day (May 1) 4 guidance documents were revised and reposted.

  33. Implications of Changes • Many revisions— • CDC tried to help audiences negotiate changes • Labeled revisions as updates and date stamped them • Pushed them to partners through distribution channels as “updates” • However, it was still difficult to tell what was new • One partner—dedicated one full-time person to culling through CDC’s revised guidance and key points daily to figure out what was new. • Lesson Learned: highlight new sections at the top of revisions.

  34. Implications of Change:Potential for Internal Inconsistency is High Guidance for Novel H1N1 Flu: Taking Care of a Sick Person in Your Home Guidance for Infection Control for Care of Patients with Confirmed or Suspected Novel Influenza A (H1N1): Virus Infection in a Healthcare Setting Facemask/Respirator Use Posted May 27, 2009 Guidance for Non Pharmaceutical Community Mitigation in Response to Human Infections with Swine Influenza (H1N1) Virus

  35. Implications of Change:Sometimes public versions/translations were delayed Talking Points for Media Partners for message coordination Key messages Fact sheets CDC-INFO scripts PSAs Posters Podcasts/Videocasts Health Alerts Twitter Messages Listserv content Guidance Documents Foreign Language Translations ►Lessons Learned: Automated Tracking/Update Systems

  36. Situational Awareness Clinical/Public Health Guidance, Daily Public Updates CDC Emergency Website Key Messages 15 JIC Teams (Adaptation/Dissemination (fact sheets, PSA’s, “Tweets”, etc) Media Relations General Public Affected Communities Vulnerable Populations Clinicians State/local PH Workforce Laboratorians Global Communication Counterparts Policy Makers CDC Employees News Media Press conferences News releases Interviews Media Tours Media advisories JIC Channels CDC Emergency Website CDC-INFO (English, Spanish, TTY) Health Alert Network Epi-X Clinician Registry Social Media Partner Distribution Networks

  37. Implications of Change:External Inconsistency • Rapid changes in guidance caught some partners by surprise • For example, schools complied with closing, following release of May 1 School Dismissal Guidance • On May 4, CDC issued changed guidance focused on isolation of ill children, rather than school closings • Lessons learned: Increased collaboration with partners in the development and revision of guidance.

  38. LESSONS LEARNED(AND STILL LEARNING)

  39. Lessons Learned • Possible to rapidly issue and disseminate broad public health guidance • Changes in guidance can be rapidly achieved to meet evolving circumstances • Rapid changes have potential to • Threaten internal consistency • Surprise and conflict with external partners • Recommendations: • Increased collaboration and notification with partners • Automated change/content management systems

  40. Guiding Principles • Build and maintain trust and credibility • Provide the public with timely, accurate, and consistent information – and tell them what they can do to help keep themselves and their families safe • Provide partners with information to support their response efforts

  41. Mitigation Strategy • Identify and acknowledge uncertainties • Recognize the amount of uncertainty is more than everyone would like • Trust the public to tolerate incomplete and potentially upsetting information

  42. More Guiding Principles • Anticipate and prepare media and public for changes • Put responses in place rapidly – the phone is going to ring! • Involve and empower the public • Explain their role in reducing the impact of the outbreak – communicate calls to action • Share dilemmas and challenges • Effectively use partnerships

  43. CDC’s Communication ResponseMajor Challenges • Instant, immense, and ongoing demands for information • Frequent and rapid change • Coordination • Clearance – assuring scientific accuracy and consistency • Pre-prepared pandemic flu messages and materials were not easily adapted

  44. Vaccine Issues • Overpromised and underdelivered • Concerns about safety – “H1N1 vaccine was made too fast and too new to be safe” • CDC recommendations for priority vaccination - people didn’t understand reasons • Risk v. benefit perception • Characterization of the pandemic H1N1 virus as “moderate” severity

  45. HOTWASHES AND AFTER ACTIONS • Hotwashes • Daily for Exercises • Focus on how to we communicate internally • Fix on the fly during events • Staffing up – funding?? • Should have initiated the PAT call (Process Action Team) • Putting content in place when there aren’t any answers yet

  46. AFTER ACTION REVIEW • PURPOSE • Conduct a structured, discovery learning review of critical topics relevant to activities during the H1N1 response and capture lessons learned which will be used to develop a Corrective Action Plan and assign responsibility to individuals or groups with a timeline for completion

  47. AFTER ACTION PROCESS • The AAR is a structured review process that provides immediate feedback for all training/response events and allows participants to discover: • What Happened? • Why it Happened? • How it can be fixed, refined or improved?

  48. AAR RULES OF ENGAGEMENT • Must be a professional discussion – not a critique • Everyone’s opinion is important and everyone participates • We need to be hard on the process, but respectful of each other • Focus on how to do it better next time • Take ownership for fixes

  49. AFTER ACTION(HINDSIGHTS ON THE BAD STUFF) • No substantive content in the first few days to couple of weeks while guidance was being developed • CDC-INFO agents were frustrated with not having information to share, especially sensing caller anxiety • Should have instituted PAT calls immediately • Insufficient team depth to support sustained event 24/7/365

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