Plague - pandemic - panic: information needs and communication strategies for infectious diseases emergencies : lessons learned from anthrax, SARS, pneumonic plague and influenza pandemic

Summary: Information and communication is critical to the successful management of infectious diseases because an effective communication strategy prevents the surge of anxious patients who have not been genuinely exposed to the pathogen ('low risk patients') affecting medical infrastructures (1) and the future transmission of the infectious agent (2). Surge of low risk patients: The arrival of large numbers of low risk patients at hospitals following an infectious diseases emergency would be problematic for three main reasons. First, it would complicate the situation at hospitals receiving exposed patients, delaying the treatment of the acutely ill, creating difficulties of crowd control and tying up medical resources. Second, for the low risk patients themselves, attending hospital following an infectious disease emergency might increase their risk of exposure to the agent in question. Third, the needs of low risk patients may be poorly attended to at hospitals which are already overstretched dealing with medical casualties. Future transmission: Obtaining early information about symptoms and isolating infected patients is the most effective strategy to interrupt the chain of infection in the public in the absence of specific prophylaxis or treatment. Particularly at the beginning of an outbreak, these nonpharmaceutical interventions play an important role in enabling the early detection of signs or symptoms and in encouraging passengers to adopt appropriate preventive behaviour in order to limit the spread of the disease. This thesis includes two papers dealing with this problem: The first part is a systemic literature review of information needs following an infectious disease emergency (Anthrax, SARS, Pneumonic Plague). The key question was: what are the information needs of the public during an infectious disease emergency? The second part is an empirical investigation of information needs and communication strategies at the airport during the early stage of the Influenza Pandemic. The key question here was: what communication strategies help to meet the information needs and to enable the public to behave appropriately and responsibly? Conclusions: Evidence from the anthrax attacks in the United States suggested that a surge of low risk patients is by no means inevitable. Data from the SARS outbreak illustrated that if hospitals are seen as sources of contagion, many patients with non-bioterrorism related health care needs may delay seeking help. Finally, the events surrounding the Pneumonic Plague outbreak of 1994 in Surat, India, highlighted the need for the public to be kept adequately informed about an incident to avoid creating rumours. Clear, consistent and credible information is key to the successful management of infectious disease outbreaks. The results of the empirical investigation suggested that the desire for information is a reflection of current anxiety and does not mirror the objective scientific assessment of exposure. The airport study showed that perceived information needs were directly related to anxiety – the least anxious did not require any further information, the most anxious reported significant information needs concerning medical treatment, public health management and the assessment of the ongoing situation – irrespective of their actual exposure. A communication strategy only focussing on the 'real' exposed individuals neglects the information needs of those worrying about having contracted the virus and seeking medical attendance. Effective communication strategies should enable the general public to detect early signs or symptoms and provide them with behaviour advice to prevent the further transmission of the infectious agent. These include the provision of clear information about the incident, the symptoms and what to do to prevent the further transmission, detailed and regularly updated information in various media formats (telephone, internet, etc.) and rapid triage at hospital entrances to guide patients to the appropriate medical infrastructures. Relevance: These research findings could contribute to a shift in the organisational and communicative approach responding to infectious diseases outbreaks and could be considered relevant for future risk communication and policy decision making.Information und Kommunikation sind die zentralen Momente im Management von Infektionskrankheiten, weil eine effektive Kommunikationsstrategie zum einen den Ansturm auf die medizinischen Infrastrukturen kanalisiert (1) und zum anderen durch die Informationen zum angemessenen Verhalten die weitere Übertragung des Krankheitserregers vermeidet (2). Ansturm auf medizinische Infrastrukturen: Ein großer Ansturm von nicht direkt exponierten Patienten (sogenannte „Low Risk Patients“) auf medizinische Infrastrukturen während Infektionsausbrüchen ist aus drei Gründen problematisch: Erstens verschärft dieser Ansturm die ohnehin schon schwierige Lage in den Krankenhäusern und führt dazu, dass Schwerkranke aus Kapazitätsgründen nicht angemessen versorgt werden können. Zweitens erhöht der Aufenthalt in der Notaufnahme eines Krankenhauses während eines Infektionsgeschehens die Infektionsgefährdung. Drittens ist durch die Kapazitätsausschöpfung nicht gewährleistet, dass „Low Risk Patients“ entsprechend ihrer medizinischen Indikation adäquat versorgt werden. Weitere Übertragung des Krankheitserregers: Die frühzeitige Information über Symptome, Übertragungswege und angemessenes Verhalten führt dazu, dass symptomatische Patienten isoliert und die weitere Verbreitung des Krankheitserregers durch ein adäquates Infektionsschutzverhalten gestoppt wird. Diese nichtpharmazeutischen Maßnahmen sind insbesondere in der Frühphase von Infektionsausbrüchen, in denen noch keine Impfungen oder Therapien zur Verfügung stehen, von hoher Relevanz und helfen sowohl die symptomatischen Patienten zu identifizieren als auch die Bevölkerung mit einem angemessenen Verhalten zu schützen. In dieser Dissertation werden zwei Arbeiten zusammengefasst, die dieser Problematik nachgehen: den ersten Teil bildet eine systematische Literaturübersicht über die publizierten Daten zu den Informationsbedürfnissen und zum adäquaten Verhalten während Infektionsausbrüchen am Beispiel von Anthrax, SARS und der Lungenpest. Leitfrage dieser Studie ist: Was sind die Informationsbedürfnisse der Öffentlichkeit während eines Infektionsgeschehens? Den zweiten Teil bildet eine empirische Erhebung am Flughafen zu den Informationsbedürfnissen und Kommunikationsstrategien zu Beginn der Influenza Pandemie. Leitend bei dieser Studie ist die Frage, welche Kommunikationsstrategien den Informationsbedürfnissen adäquat sind und gleichzeitig die Öffentlichkeit in die Lage versetzt, sich angemessen zu verhalten? Ergebnisse: Die Anthrax Anschläge in den USA haben gezeigt, dass es nicht unbedingt zu einem Massenansturm von „Low Risk Patients“ kommen muss, wenn die Informationen über Diagnostik und therapeutische Maßnahmen adäquat kommuniziert werden. Aus den Erfahrungen von SARS konnte man sehen, dass auch die umgekehrte Situation Probleme schafft: wenn Patienten, die medizinische Behandlung benötigen, nicht die medizinischen Infrastrukturen aufsuchen, weil diese selbst zum Ort der Ansteckung geworden sind, kann das dramatische medizinische Folgen haben. Der Ausbruch der Lungenpest in Indien, verknüpft in ein Netz von Gerüchten, hat deutlich gemacht, wie wichtig die umfassend und aktuell korrekt informierte Öffentlichkeit ist. Die Ergebnisse aus der empirischen Arbeit am Flughaben belegen, dass das Informationsbedürfnis nicht an die wissenschaftlich-medizinische Einschätzung der Exposition und des objektiven Ansteckungsrisikos geknüpft ist, sondern vielmehr die eigene Wahrnehmung und das Gefühl einer möglichen Ansteckung reflektiert. Diejenigen, die am meisten Angst vor Ansteckung hatten, artikulierten auch den größten Informationsbedarf, während diejenigen, die sich ausreichend informiert fühlten, auch nur eine geringe Besorgnis zum Ausdruck brachten. Diese Relation wurde unabhängig der objektiven Exposition beobachtet. Eine Kommunikationsstrategie, die nur die objektiv Exponierten adressiert, zielt also an denjenigen vorbei, die – exponiert oder nicht – besorgt sind und aufgrund dieser Sorge zu einem Problem der medizinischen Infrastrukturen werden können. Eine effektive Kommunikation sollte die Öffentlichkeit in die Lage versetzen, die entsprechenden Symptome frühzeitig zu erkennen und sich sowohl bei Erkrankung, als auch bei der Unterbrechung der Infektionskette adäquat zu verhalten. Dazu braucht es klare, aktuelle und glaubwürdige Informationen über das Ausbruchsgeschehen, die Symptome und das Schutzverhalten, kontinuierliche Kommunikation über verschiedene mediale Formate (Telefon, Internet, etc.), schnelle Triage in den Krankenhäusern und eine kompetente Führung, um festlegen zu können, welcher Patient in den spezifischen medizinischen Infrastrukturen am besten aufgehoben ist. Relevanz: Die Ergebnisse dieser Arbeit können dazu betragen, dass eine verbesserte Risiko- und Krisenkommunikation das Management von Infektionskrankheiten der politischen Entscheidungsträger erleichtert

Risk communication in public health and health security

Risk communication is a core capacity under the World Health Organisation’s (WHO) International Health Regulations (2005) and an important part of modern public health practice. However, while international legislative frameworks set the scope of risk communication, there is a demand for increasing and improving evidence and skills in risk communication research, policy and strategy development, evaluation of practice and sustainable capacity building. This cumulative habilitation describes the major contributions to the field of risk communication in public health and health security both at a thematic, content level of risk communication research policy and practice and at a broader methodological level. It introduces the new conceptual paradigm of risk communication that moves risk communication from being a technical capacity to convey health risk information to a targeted audience to a governance approach with three strategic axes of information (gathering, assessing and sharing), communication (strategies, key messages and means of communication) and coordination (at various administrative levels). It introduces a new system to understand risk communication practice by providing a matrix of risk communication activities, such as information (listening), communication (relationship-building) and coordination (supportive environments) across the lifecycle of an event, e.g. outbreak, before, during and after. Adopting this new perspective can generate innovative insights, as demonstrated in the field of antimicrobial resistance. The new paradigm and its methodology can also support strategy development at health policy level and facilitate the assessment of public health security. The Marburg Biosafety and Biosecurity Scale (MBBS) is a framework for rational risk assessment and risk communication and offers a new metric to assess biosafety and biosecurity that can also guide capacity building in these areas. Evaluation of public health interventions is essential to monitor progress, identify and assess areas for improvements and demonstrate useful outcomes and overall impact. The Earlier – Faster – Smoother – Smarter approach is an original framework to monitor, evaluate and guide risk communication activities for earlier detection, faster response, smoother coordination and smarter legacy that were applied in two case studies (Ebola, earlier detection). Risk communication in public health and health security has important thematic outputs with significant outcomes and impact. The applied, new methodology is a social laboratory format that is social, experimental and systematic and has the potential to become a genuine methodological category. Both, content and methodological approaches, contribute to a framework for a sustainable implementation of the new risk communication paradigm in public health research, policy and practice.Risikokommunikation ist eine Kernkompetenz im Rahmen der Internationalen Gesundheitsvorschriften (IGV 2005) der Weltgesundheitsorganisation (WHO) und ein wichtiger Teil moderner Gesundheitssysteme und öffentlicher Gesundheitspraxis. Während die internationale Gesetzgebung den Geltungsbereich der Risikokommunikation festlegt, besteht die Forderung nach mehr und besserer Evidenz und Kompetenz in der Risikokommunikationsforschung, ihren gesundheits- und sicherheitspolitischen Implikationen, der Strategieentwicklung, der Evaluation der Praxis und dem nachhaltigen Kapazitätenaufbau. Diese kumulative Habilitation beschreibt die wichtigsten Beiträge zur Risikokommunikation in der öffentlichen Gesundheit und Gesundheitssicherstellung sowohl auf einer thematischen, inhaltlichen Ebene und auf einer breiteren methodischen Ebene. Diese Arbeit stellt das neue Paradigma der Risikokommunikation vor, das Risikokommunikation von einer technischen Fähigkeit zur Vermittlung von Gesundheitsrisikoinformationen an ein Zielpublikum zu einem Governance-Ansatz mit drei strategischen Achsen der Information (Erfassung, Bewertung und gemeinsame Nutzung), Kommunikation (Strategien, Kernbotschaften, mediale Formate) und Koordination (auf verschiedenen Administrationsebenen) entwickelt. Sie stellt ein neues System vor, um die Risikokommunikationspraxis besser zu verstehen, indem es eine Matrix von Risikokommunikationsaktivitäten wie Information (Zuhören), Kommunikation (Beziehungsaufbau) und Koordination (supportive Umgebungen) über den gesamten Zeitraum eines Ereignisses, z.B. ein Infektionsausbruch, beschreibt (vorher, währenddessen, danach). Diese Perspektive kann innovative Erkenntnisse erzeugen, wie auf dem Gebiet der antimikrobiellen Resistenz gezeigt wird. Das neue Paradigma und seine Methodik können auch die Strategieentwicklung auf gesundheitspolitischer Ebene unterstützen und die Bewertung der Gesundheitssicherheit erleichtern. Die Marburg Biosafety and Biosecurity Scale (MBBS) ist ein konzeptioneller Rahmen für eine rationale Risikobewertung und Risikokommunikation und bietet eine neue Metrik zur Bewertung von Biosafety und Biosecurity, die auch den Kapazitätenaufbau in diesen Bereichen leiten kann. Für die Evaluierung von Interventionen im Bereich der öffentlichen Gesundheit ist von wesentlicher Bedeutung, die Fortschritte adäquat beurteilen zu können, sowie Bereiche für Verbesserungen zu identifizieren. Der Earlier-Faster-Smoother-Smarter Ansatz ist ein neuer Rahmen für die Evaluierung von Risikokommunikation, der zu früheren Detektion, einer schnelleren Reaktion, einer besseren Koordination und wirksameren Policy führen kann, der in zwei Fallstudien angewendet wurden (Ebola, frühere Detektion). Die Risikokommunikation im Bereich der öffentlichen Gesundheit und der Gesundheitssicherheit liefert wichtige thematische Ergebnisse. Die angewandte, neue Methodik ist ein soziales Laborformat („Social Laboratory“), das sozial, experimentell und systematisch ist und das Potential hat, eine eigene methodische Kategorie zu werden. Sowohl Inhalt als auch die methodischen Ansätze können zu einer nachhaltigen Umsetzung des neuen Risikokommunikations-Paradigmas in Gesundheitssystemen und öffentlicher Gesundheitspraxis beitragen

Tenazität: Die „natürliche Dekontamination“ von Bakterien und Toxinen

Das Wissen von der Überlebensfähigkeit humanpathogener Erreger und Toxine ist im Kontext bioterroristischer Gefahrenlagen in einer besonderen Weise relevant: Ein profundes und detailliertes Wissen über die Rahmenbedingungen pathogener Wirkungsmechanismen ermöglicht eine adäquate und präzise Risikobewertung und ist eine Voraussetzung für die Abschätzung der Notwendigkeit weiterer Maßnahmen. Andererseits ermöglicht das Wissen über die Widerstandsfähigkeit von Erregern auch neue Ausbringungsmöglichkeiten als erweiterte Option bioterroristischer Gefährdungen – so wurde eine Veröffentlichung kontrovers diskutiert (und von der Publikation zeitweise zurückgezogen), die die Ausbringungsmöglichkeiten von Botulinumtoxin in Frischmilch untersucht hat. Dieser Beitrag gibt eine kurze Übersicht zur Problematik der Fragestellung und zu Forschungen zur Tenazität von Bakterien und Toxinen. Er verdeutlicht außerdem die methodischen Schwierigkeiten, mit denen dieser Forschungsbereich konfrontiert ist. Abschließend wird das Spannungsfeld zwischen effektiver und effizienter Dekontamination einerseits und einer Verhinderung der Proliferation von sensitivem Wissen andererseits zur Diskussion gestellt

Biosafety and biosecurity: a relative risk-based framework for safer, more secure, and sustainable laboratory capacity building

Background: Laboratory capacity building is characterized by a paradox between endemicity and resources: countries with high endemicity of pathogenic agents often have low and intermittent resources (water, electricity) and capacities (laboratories, trained staff, adequate regulations). Meanwhile, countries with low endemicity of pathogenic agents often have high-containment facilities with costly infrastructure and maintenance governed by regulations. The common practice of exporting high biocontainment facilities and standards is not sustainable and concerns about biosafety and biosecurity require careful consideration. Methods: A group at Chatham House developed a draft conceptual framework for safer, more secure, and sustainable laboratory capacity building. Results: The draft generic framework is guided by the phrase “LOCAL – PEOPLE – MAKE SENSE” that represents three major principles: capacity building according to local needs (local) with an emphasis on relationship and trust building (people) and continuous outcome and impact measurement (make sense). Conclusion: This draft generic framework can serve as a blueprint for international policy decision-making on improving biosafety and biosecurity in laboratory capacity building, but requires more testing and detailing development

Ein neues Verständnis von Risikokommunikation in Public-Health-Notlagen

Risk communication of public institutions should support the population in the decision-making process in the event of existing risks. It plays a particularly important role in health emergencies such as the SARS-CoV‑2 pandemic. After the SARS outbreak in 2003, the World Health Organization (WHO) revised its International Health Regulations (IHR 2005) and called for risk communication to be established as a core area of health policy in all member countries. While the emphasis on health policy was welcomed, the potential for risk communication in this area has not yet been fully exploited. Reasons include discrepancies in the understanding of risk communication and the large number of available methods. This discussion article is intended to help establish a new understanding of risk communication in public health emergencies (emergency risk communication – ERC). It is suggested that, in addition to the risks, the opportunities of the crisis should be included more and that risk communication should be understood more as a continuous process that can be optimized at various points. The “Earlier-Faster-Smoother-Smarter” approach and in particular the earlier detection of health risks (“Earlier”) could support the management of public health emergencies in the future

Re-thinking risk communication: information needs of patients, health professionals and the public regarding MRSA – the communicative behaviour of a public health network in Germany responding to the demand for information

Objectives: Multidrug resistant organisms (MDRO), including Meticillin-resistant Staphylococcus aureus (MRSA), and health care associated infections (HCAIs) are pressing issues for health care systems across the world. Information and communication are considered key tools for the prevention and management of infectious diseases. Public Health Authorities (PHA) are in a unique position to communicate with health care professionals, patients and the public regarding the health risks. Study design: We used PHA helpdesk interaction data to first ascertain the information requirements of those getting in contact with the service, and secondly to examine the communicative behaviour of the PHA, with a view to improving the quality of communication strategies. Methods: Data on helpdesk interactions between 2010 and 2012 were obtained from a MDRO network of nine German PHAs. 501 recordings were coded and descriptive statistics generated for further qualitative thematic analysis. Results: Our analysis revealed a similar pattern of questions among different groups. Key areas of need for information were around eradication, cleaning and isolation measures. Reported problems were a lack of expert knowledge and continuity of treatment. The helpdesk response was mainly a conversation offering scientific advice, but also included other communication services that went beyond the provision of scientific facts, such as follow-up calls, referral suggestions and consultations on behalf of the caller. These social communication activities seem to have an important impact on the acceptability of public health recommendations and use of the helpdesk

Re-thinking risk communication: information needs of patients, health professionals and the public regarding MRSA – the communicative behaviour of a public health network in Germany responding to the demand for information

Objectives: Multidrug resistant organisms (MDRO), including Meticillin-resistant Staphylococcus aureus (MRSA), and health care associated infections (HCAIs) are pressing issues for health care systems across the world. Information and communication are considered key tools for the prevention and management of infectious diseases. Public Health Authorities (PHA) are in a unique position to communicate with health care professionals, patients and the public regarding the health risks. Study design: We used PHA helpdesk interaction data to first ascertain the information requirements of those getting in contact with the service, and secondly to examine the communicative behaviour of the PHA, with a view to improving the quality of communication strategies. Methods: Data on helpdesk interactions between 2010 and 2012 were obtained from a MDRO network of nine German PHAs. 501 recordings were coded and descriptive statistics generated for further qualitative thematic analysis. Results: Our analysis revealed a similar pattern of questions among different groups. Key areas of need for information were around eradication, cleaning and isolation measures. Reported problems were a lack of expert knowledge and continuity of treatment. The helpdesk response was mainly a conversation offering scientific advice, but also included other communication services that went beyond the provision of scientific facts, such as follow-up calls, referral suggestions and consultations on behalf of the caller. These social communication activities seem to have an important impact on the acceptability of public health recommendations and use of the helpdesk

RISK COMMUNICATION AS A CORE PUBLIC HEALTH COMPETENCE IN INFECTIOUS DISEASE MANAGEMENT: DEVELOPMENT OF THE ECDC TRAINING CURRICULUM AND PROGRAMME

Risk communication has been identified as a core competence for guiding public health responses to infectious disease threats. The International Health Regulations (2005) call for all countries to build capacity and a comprehensive understanding of health risks before a public health emergency to allow systematic and coherent communication, response and management. Research studies indicate that while outbreak and crisis communication concepts and tools have long been on the agenda of public health officials, there is still a need to clarify and integrate risk communication concepts into more standardised practices and improve risk communication and health, particularly among disadvantaged populations. To address these challenges, the European Centre for Disease Prevention and Control (ECDC) convened a group of risk communication experts to review and integrate existing approaches and emerging concepts in the development of a training curriculum. This curriculum articulates a new approach in risk communication moving beyond information conveyance to knowledge- and relationship-building. In a pilot training this approach was reflected both in the topics addressed and in the methods applied. This article introduces the new conceptual approach to risk communication capacity building that emerged from this process, presents the pilot training approach developed, and shares the results of the course evaluation.published_or_final_versio

Communicating the risk of MRSA: the role of clinical practice, regulation and other policies in five European countries

Background: The threat posed by Meticillin-resistant Staphylococcus aureus (MRSA) has taken on an increasingly pan-European dimension. This article aims to provide an overview of the different approaches to the control of MRSA adopted in five European countries (Austria, Germany, Netherlands, Spain, and the UK) and discusses data and reporting mechanisms, regulations, guidelines, and health policy approaches with a focus on risk communication. Our hypothesis is that current infection control practices in different European countries are implicit messages that contribute to the health-related risk communication and subsequently to the public perception of risk posed by MRSA. A reporting template was used to systematically collect information from each country. Discussion: Large variation in approaches was observed between countries. However, there were a number of consistent themes relevant to the communication of key information regarding MRSA, including misleading messages, inconsistencies in content and application of published guidelines, and frictions between the official communication and their adoption on provider level. Summary: The variability of recommendations within, and across, countries could be contributing to the perception of inconsistency. Having inconsistent guidelines and practices in place may also be affecting the level at which recommended behaviors are adopted. The discrepancy between the official, explicit health messages around MRSA and the implicit messages stemming from the performance of infection control measures should, therefore, be a key target for those wishing to improve risk communication

Decision-making criteria among European patients: exploring patient preferences for primary care services

Background: Health economics preference-based techniques, such as discrete choice experiments (DCEs), are often used to inform public health policy on patients’ priorities when choosing health care. Although there is general evidence about patients’ satisfaction with general-practice (GP) care in Europe, to our knowledge no comparisons are available that measure patients’ preferences in different European countries, and use patients’ priorities to propose policy changes. Methods: A DCE was designed and used to capture patients’ preferences for GP care in Germany, England and Slovenia. In the three countries, 841 eligible patients were identified across nine GP practices. The DCE questions compared multiple health-care practices (including their ‘current GP practice’), described by the following attributes: ‘information’ received from the GP, ‘booking time’, ‘waiting time’ in the GP practice, ‘listened to’, as well as being able to receive the ‘best care’ available for their condition. Results were compared across countries looking at the attributes’ importance and rankings, patients’ willingness-to-wait for unit changes to the attributes’ levels and changes in policy. Results: A total of 692 respondents (75% response rate) returned questionnaires suitable for analysis. In England and Slovenia, patients were satisfied with their ‘current practice’, but they valued changes to alternative practices. All attributes influenced decision-making, and ‘best care’ or ‘information’ were more valued than others. In Germany, almost all respondents constantly preferred their ‘current practice’, and other factors did not change their preference. Conclusion: European patients have strong preference for their ‘status quo’, but alternative GP practices could compensate for it and offer more valued care