CDC-INFO National Contact CenterH1N1 Response

Exercise v. Reality

Susan K. Laird, MSN, RNClinical Director, CDC-INFO

Joint Information Center Team LeadDivision of Community Engagement

Office of the Associate Director for Communication

Centers for Disease Control and Prevention

Special thanks to Marsha Vanderford, PhD, JIC Lead

Stephanie A. Dopson, MSW, MPH, ScD. Candidate, Influenza Coordination Unit

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

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

6

Influenza Pandemic OPLAN

Functional Exercise – Internal, Full Staff31 Jan – 1 Feb 07

(18 Hrs)

AAR

DEOC Working Level Workshop

4 Oct (8 Hrs)AAR

Senior/Division Leader OPLAN

Seminars 28 Sep & 17 Oct

(4 Hrs Each)

AAR

Functional Level Drills

(6 Functional Areas)16 Oct – 1 Dec

(2-4 Hours Each)AAR

Training/Exercise Methods:

Briefings/Seminars

Tabletop Discussion

Workshops and Functional Drills

Functional Exercises

CDC Foundation Tabletop

18 Apr (3-4 Hrs)

AAR

Functional Exercise (Surge)

14-16 Aug 07 (48 Hrs)

AAR

Functional Exercise (Internal/External) 25-27 Apr 07 (48

Hrs)

AAR

Advanced Tabletop: Significant Issue

Forum 8 Dec (4 Hours)

AAR

Section Drills

1-30Nov07 AAR

Intervals, Actions & Triggers TTX

14Nov07

AAR

Lessons Learned Seminar

15Nov07

2008 Influenza Pandemic Exercise Program

CDC Exercises (2006-2007)

7

Influenza Pandemic OPLAN

TTX

CDC / PFO / JFO Role and

Responsibilities July 10, 2008

(4 Hrs) AAR

Limited Full Scale Exercise

(1 State)

Surge/Mitigation

11-13 Mar 2008(48 Hrs)

AAR

Surgeon General’s Flag Retreat

ITA TTX8 Jan 2008(4 Hours) AAR

Limited Full Scale Exercise

Influenza Pandemic Progression from

Acceleration to Peak Transmission

(5 State Participation)

Sep 16-18, 2008

(48-72 Hrs) AAR

2009

Exercise Series

DEOC Section Functional DRILLS

3-14 Nov 2008(4-8 Hours)

AAR

Training/Exercise Methods:

Briefings/Seminars

Tabletop Discussion

Workshops and Functional Drills

Functional Exercises

CDC Exercises (2008)

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.

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

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

1111

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

Response Timeline

Discovery

15 Apr 09to

31 May 09

1 Jun 09to

15 Aug 09

Preparing

S. Hemisphere

16 Aug 09to

4 Oct 09

5 Oct 09to

1 Apr 10

Fall wave

Vaccination

Pre-Pandemic Recovery

Developing Guidance

Sep 8 CDCPosts revised Antiviral drug

guidance

May 6 CDC Posts

Interim guidance

Sep 22 CDC clarificationto reduce burden from

Worried well

13

14

Response—Strategic Goals/ Principles

Reduce illness and death Minimize societal impact Apply greatest effort to interventions with

greatest impact

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

Examples from the H1N1 Response

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

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

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

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

Communicating Prevention Steps

April 24-Aug 31, 2009:

45 Guidance

Documents

Steps for public,

clinicians, state/local

health departments,

businesses, and

Communities to take

Communicating Guidance Information

Key messages

Talking Points for Media

Partners for messagecoordination

Guidance Documents Fact sheetsCDC-INFO ScriptsPSAsPostersPodcasts/VideocastsHealth AlertsTwitter MessagesListserv content

Foreign LanguageTranslations

Situational Awareness

Clinical/Public Health Guidance, Daily Public UpdatesCDC Emergency Website

News MediaPress conferencesNews releasesInterviewsMedia ToursMedia advisories

15 JIC Teams

(Adaptation/Dissemination (fact sheets, PSA’s, “Tweets”, etc) General PublicAffected CommunitiesVulnerable PopulationsCliniciansState/local PH WorkforceLaboratoriansGlobal Communication CounterpartsPolicy MakersCDC Employees

JIC ChannelsCDC Emergency WebsiteCDC-INFO (English, Spanish, TTY)Health Alert NetworkEpi-XClinician RegistrySocial MediaPartner Distribution Networks

Media Relations

Key Messages

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

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)

CDC-INFO scripts always in TTY PSA’s in American Sign Language

•H1N1 General messages•Hand hygiene

Targeted Communication to Vulnerable Populations

Deaf and Hard of Hearing

• Collaboration with Partners: ASL PSAs Courtesy of the University of Rochester

• http://www.cde.gov/h1n1flu/deaf.htm

Communicating through Partners

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

Government, NGO, faith-based organizations, and other partners who serve vulnerable populations distribute CDC’s messages.

Example of CDC partners who serve disabled populations:

Pulling Traffic to CDC’s Website 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

Sample of 2009 H1N1 Social Media

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

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.

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.

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.

Implications of Change:Potential for Internal Inconsistency is High

Facemask/Respirator Use Posted May 27, 2009

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

Guidance for Non Pharmaceutical Community Mitigation in Response to Human Infections

with Swine Influenza (H1N1) Virus

Implications of Change: Sometimes public versions/translations were delayed

Key messages

Talking Points for Media

Partners for messagecoordination

Guidance Documents Fact sheetsCDC-INFO scriptsPSAsPostersPodcasts/VideocastsHealth AlertsTwitter MessagesListserv content

Foreign LanguageTranslations

►Lessons Learned: Automated Tracking/Update Systems

Situational Awareness

Clinical/Public Health Guidance, Daily Public UpdatesCDC Emergency Website

News MediaPress conferencesNews releasesInterviewsMedia ToursMedia advisories

15 JIC Teams

(Adaptation/Dissemination (fact sheets, PSA’s, “Tweets”, etc) General PublicAffected CommunitiesVulnerable PopulationsCliniciansState/local PH WorkforceLaboratoriansGlobal Communication CounterpartsPolicy MakersCDC Employees

JIC ChannelsCDC Emergency WebsiteCDC-INFO (English, Spanish, TTY)Health Alert NetworkEpi-XClinician RegistrySocial MediaPartner Distribution Networks

Media Relations

Key Messages

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.

LESSONS LEARNED(AND STILL LEARNING)

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

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

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

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

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

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

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

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

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?

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

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

HINDSIGHTS - 2

Normal escalation process didn’t work due to program overload

Difficult to decide how to surge up for staffing – volume not predictable in the beginning

Normal process for evaluation difficult to continue as designed for steady state

WHAT WORKED WELL

The CDC-INFO Surge and Scalability Plan and process was practiced and known

CDC.gov website was updated frequently – more than daily

New call flows and escalations were set up to coincide with special teams within EOC

Communication between all CDC-INFO teams was good

Once approval was given from CDC, contact center surge staff was on the floor quickly

WHAT WORKED WELL-2

Podding of surge staff – simplified training processes

Development of email templates to facilitate rapid response to high email volume

Applying Hotwash input/Lessons Learned on a daily basis – identify what isn’t working right away and fix it!

Good tracking and reporting mechanisms in place promptly

WHAT WORKED WELL - 3

CDC-INFO supported several state and local contact centers Provided current, updated scientifically

accurate content on a weekly basis (version control)

Provided several states with detailed reporting with geographic detail

UPDATE

January 12, 2010 – Activated for Haiti Earthquake

May 10, 2010 – Activated for Deepwater Horizon

H1N1 Activation continues

CDC-INFOMAY 2010

H1N1 Inquiries as of 5/18/2010: General Public

Calls 142,248Emails 47,483

Clinicians 23,408 Postal & TTY 16

TOTAL INQUIRIES 213,155

THANK YOU!

QUESTIONS?

slaird@cdc.gov

404-498-6310