Guidance from Pediatric Stakeholders: A Coordinated Approach to Communicating Pediatric-related Information on Pandemic Influenza at the Community Level

January 27, 2010, 1:30 PM ET

Introduction

Effective communication is a key component of emergency response planning. It can help direct the medical community and the general public to take appropriate action to contain a disease outbreak, limit exposure, and reduce morbidity and mortality. On the other hand, ineffective communication can lead to confusion in both the general public and the emergency response community. It can interfere with the response to an incident. It can lead to public distrust and skepticism, and, once that has happened, it is difficult to regain that trust.

Purpose

The purpose of this document is to provide a suggested approach, based on input from pediatric stakeholders, to communicating pediatric-related information on pandemic influenza at the community level in a step-by-step manner. This is a suggested approach to coordinating communication and disseminating information; it can be adapted or modified to suit most communities as they see fit. The goal is to give community planners "talking points" for discussions on a coordinated approach to communication in their community.

Target Audience

The target audience for this document is community planners who would oversee communication with the medical community and the general public during an influenza pandemic.

Rationale

During an influenza pandemic, a lack of a coordinated approach to communication between the medical community and the general public can result in confusion and actions that interfere with the medical response to the outbreak. To address this issue, pediatric stakeholders, including members of national associations (medical, health, and school related), pediatric primary care providers, and hospitals, met to develop a suggested approach to coordinating the communication of pediatric-related information during the 2009 H1N1 influenza pandemic.

Assumption

It is assumed that the community planners using this document will have experience in developing communication plans for their community. It is beyond the scope of this document to provide a detailed description of the general development process; however, the steps outlined in this document provide a framework for developing such a plan.

Examples of Undesired Actions Taken During the Early Part of the 2009 H1N1 Influenza Pandemic

Medical professionals directing their patients to hospitals for testing or treatment when tests or treatments were not available at their facilities, resulting in a surge in patient volume at the hospital system.

Parents and caregivers:

• Flooding medical provider offices or hospital emergency departments with unnecessary calls or visits for information only or for treatment for minor illnesses that did not require medical care, such as the common cold.
• Demanding influenza testing for their child when such testing was not necessary.
• Sending children to child care or school when ill, thus exposing others to infection.
• Masking an ill child’s fever with medication so that the child could return to school.
• Intentionally exposing their children to persons with 2009 H1N1 influenza so that they would become infected and develop immunity (commonly referred to as "flu parties").
• Refusing vaccination or medical treatment for their children.
• Acquiring and “hoarding” antiviral medications to use in the event that someone in their family became ill.
• "Shopping" for medical professionals who would provide testing or treatment for their child when such testing or treatment was not medically indicated.

Steps to Prevent These Actions

1. Identify trusted sources of information.
2. Identify "The Voice" of the community.
3. Identify those who need the information.
4. Identify the information needed.
5. Condense the information you want to communicate.
6. Identify the methods of communication.

Step 1: Identify Trusted Sources of Information

Public trust is a key component of effective communication. With so many potential sources of information, the public may have difficulty determining which ones to trust. As a result, the first―and perhaps most important―step to developing a coordinated communication approach is to identify your community's trusted sources of information. Possible sources include, but are not limited to:

• The Department of Health and Human Services (HHS)
• The Centers for Disease Control and Prevention (CDC)
• Other federal agencies (e.g., Health Resources and Services Administration [HRSA])
• State and local public health departments
• Professional organizations (e.g., American Academy of Family Physicians [AAFP], American College of Osteopathic Pediatricians [ACOP],  American Academy of Pediatrics [AAP], or National Association of School Nurses [NASN])
• Other state or local agencies
• Hospitals (Infection Control, Emergency Management)

Step 2: Identify "The Voice" of the Community

A key aspect of effective communication is to provide information that is concise, consistent, reliable, and up-to-date. In order to achieve this, the information should be provided from a unified voice within the community. In an influenza pandemic, your community's voice most likely would be its public health department or emergency management agency through a Joint Information Center (JIC) or it may consist of a voice for the medical community and a voice for the general public working together to insure consistency of information flow. These entities would collect information from the trusted sources and then disseminate it to other "voices" within the community (see Step 6).

Step 3: Identify Those Who Need the Information

There are two target audiences for coordinated pediatric-related information: the medical community and the general public. Table 1 shows examples of the makeup of these two entities. Note: These are examples. You may add to these lists as is appropriate for your community makeup.

Table 1 Persons and Groups Who Need Pediatric-related Information during an Influenza Pandemic
Medical Community	General Public
Primary care providers Public health Hospitals Urgent care centers Home health Pharmacies School-based health entities Federally qualified health centers and their federal entities (e.g., HRSA) Retail-based clinics Payers Local and national trade entities (e.g., AAP, ACOP, AAFP)	Media Family Pre-schools Elementary schools High schools Colleges Faith-based organizations Community-based organizations (e.g., Red Cross, Rescue Missions, YMCA, YWCA) Advocacy groups (e.g., homeless) Government officials

Step 4: Identify the Information Needed

Pediatric stakeholders identified many areas where information is needed by both the medical community and the general public. These areas and the specific information needed are shown in Tables 2 and 3. Based on the experiences with influenza or other disease outbreaks in your community, you may have other items to add to this list.

There may be several sources of information you should consider consulting, including information obtained at the local, state or federal level.  CDC has provided information, guidance, and messages for specific audiences on its H1N1 web site.

 

Table 2 Pediatric-related Information Needed by the Medical Community
Topic Area	Information Needed
Information Access	Where can I get current information? Who can I call? Where can I go? Who is my community's trusted source(s) of information?
Roles and Responsibilities	What are my roles and responsibilities? What are the roles and responsibilities of each member of the medical community?
General Awareness	Who are considered high-risk pediatric patients? How transmissible is the 2009 H1N1 influenza virus? How is 2009 H1N1 influenza different from seasonal flu?
Communication	How can I get early notification of changes in guidelines, regulations, protocols, recommendations, and the disease virulence/pathology? How can I get up-to-date information on pandemic status and surveillance information? What do I tell my patients and their caregivers? What messages should I be disseminating? How do I counter anti-vaccine rhetoric? How can I correct inconsistent messaging? What is the process/mechanism?
Infection Control	How can healthcare facilities eliminate sources of infection and transmission within their facilities? How long should ill healthcare personnel stay home? How can I limit exposure and contamination in my waiting areas? What personal protective equipment (PPE) should be worn by healthcare personnel caring for patients with influenza-like illness? Where can I get more PPE (e.g., masks, gloves, and gowns) when my supplies are exhausted?
Management of Ill/Infected Children	When should parents take their children to their primary care physician? When should parents take their children to the hospital Emergency Department? What is the care protocol when caregivers or parents become too ill to provide care to a child? When are children sick enough to be kept home/sent home from school? When should he/she return to school?
Testing	When should I test for flu? If I need to refer a patient for testing, where do I send them? How are test results reported, and what do the different results (e.g., “positive”, “negative”) mean? Where do I send tests? How do I obtain test results? When will results be available?
Surge	Where do I send my pediatric patients when my facility is over capacity? What alternate care sites are in the community?
Vaccine	When will it be available? Where will it be available? To whom will the vaccine be sent? How much will be available? Who gets vaccinated? What are the priorities? What are the costs of the vaccine and its administration? What are the reimbursement protocols? What is the efficacy and safety of the vaccine? What legal/liability protection is in place for me and my staff? Can the vaccine be given with the seasonal flu vaccine? What are the side effects? To whom do I report them? If a child had 2009 H1N1 influenza in the spring, does he/she still need a vaccine? What do I do with left over vaccine?
Antivirals	When will antivirals be available? Where will they be available? How many doses will be available? Where can I get more if I run out? What are the recommendations for antiviral treatment and prophylaxis of both pediatric patients and their caregivers? What legal/liability protection is in place for me and my staff? What are the recommendations or options if antivirals prove to be ineffective?

 

Table 3 Pediatric-related Information Needed by the General Public
Topic Area	Information Needed
Information Access	Who can I call to get information or answers to my questions? Who can I trust to provide reliable information/answers? If I hear inconsistent messages or get inconsistent information, who should I believe?
General Information	What are the symptoms of 2009 H1N1 influenza? How is 2009 H1N1 influenza different from seasonal flu? Is my child at risk? Should my child be tested for flu? Am I at risk if I was exposed to someone with the flu? What should I do?
Treatment	When should I call a doctor or hospital about my child's illness? When should I take my child to a doctor or hospital? When should I keep my child out of school or away from others? For how long? If I do not have a doctor or insurance, where do I take my child? If my doctor's office is closed, where do I take my child?
Prevention	How can I protect myself and my children from getting sick? Should we avoid public places? Are there additional steps we can take?
Vaccine	Does my child need to get vaccinated? What are the priorities for vaccination? Where can I get the vaccine for my child? When should I get my child vaccinated? How many shots does my child need? What are the risks? Is the vaccine safe? What do I do if my child has an egg allergy? How much does it cost? Do I have to pay for it? Why should my child get vaccinated? Are there any side effects? If my child had 2009 H1N1 influenza, does he/she need a vaccine?
Antivirals	Is there a medicine my child can take if he/she is ill? Can I get antivirals ahead of time? Does my child need antivirals? What do I do if I have a prescription for an antiviral but it's not available? Why not treat everyone with symptoms?

Step 5: Condense the Information You Want to Communicate

Step 4 provided a long list of examples of the information needed by the medical community and the general public, but this information needs to be condensed to a more manageable size for public consumption. Looking at the information in Step 4, here are some suggested topic areas into which the information can be condensed.

Table 4 Suggested Information Topics
Medical Community	General Public
Who to Call For Information Where to Go for Resources Testing Protocols Medical Fact Sheet on 2009 H1N1 influenza Medical Fact Sheet on the 2009 H1N1 influenza Vaccine	10 Things Parents Want to Know about 2009 H1N1 influenza 10 Things Parents Should Ask Their Doctor Fact Sheet on 2009 H1N1 influenza Fact Sheet on the 2009 H1N1 influenza Vaccine
* CDC has provided information, guidance, and messages for specific audiences on its H1N1 web site.

Step 6: Identify the Methods of Communication

Developing plans or protocols for disseminating information within a community is not a new science. More than likely, there are many communication experts within your community that can assist you with determining the best method for disseminating information or messages to the medical community and to the general public. For your benefit, suggested methods of communication that were identified by pediatric stakeholders are shown in Table 5.

Table 5 Suggested Methods of Communication
Medical Community	General Public
Hotlines Web sites E-mail Listservs Newsletters Informed (i.e., trusted) journalists	Controlled media (e.g., television, radio, newspaper, social networks [Facebook, Twitter, MySpace, YouTube], blogs, podcasts, Web sites), billboards Schools Trusted agents (e.g., faith-based organizations, block units, celebrities, recognized professionals, community advocates) Mail, e-mail, pamphlets, flyers, brochures, "backpack mail"

Issues That May Need to Be Addressed

During the course of the pediatric stakeholder meeting, several issues arose that may need to be addressed individually at the community level either through direct communication or public messaging. These issues were common themes that posed challenges for communicators in the first half of 2009 and may continue to be concerns for planners and communicators.

• Risk Communication Concerns: Some parents may send their children to school when they are sick. Some parents may ignore public health alerts and intentionally expose their children to the infection. Older children (teenagers and college students) may ignore symptoms and go out in public. The general public needs to be alerted to the risks and consequences of their behavior.
• Surge Concerns: Doctors offices, emergency departments, school health offices, and other medical facilities may be flooded with parents or caregivers seeking information or demanding treatment for their child when such treatment is not necessary. Such actions will decrease these facilities' ability to treat patients truly in need of medical care.
• Unintended consequences of recommendations or public messages. Sometimes recommendations or public messages have unintended consequences. For example, at the start of the 2009 H1N1 influenza pandemic, one recommendation was for parents to have a child ill with flu-like symptoms tested for 2009 H1N1 influenza. As a result, parents flocked to their doctors' offices seeking tests. Some of these doctors did not have the capability to test for flu; some ran out of testing supplies; and some referred their patients to hospitals for testing. The end result was some parents were upset with their doctors for not testing their children plus the healthcare community was overwhelmed by parents seeking tests for their children.
• Changes in recommendations:  As more information becomes available, communicators should anticipate that recommendations may change, be prepared to explain these changes to the public, and develop messages to minimize confusion regarding current recommendations.

The key point that came out of the pediatric stakeholders' meeting was that, to facilitate an efficient and effective response to an influenza pandemic, the communication of information to the medical community and the general public needs to be achieved through a coordinated approach. The key points of this approach are:

• People need to know where to go to get the information they need.
• The information needs to come from a trusted source.
• The information needs to be up-to-date and reliable.
• The information needs to be accessible.

 

The Oak Ridge Institute for Science and Education (ORISE) is a U.S. Department of Energy (DOE) institute focusing on scientific initiatives to research health risks from occupational hazards, assess environmental cleanup, respond to radiation medical emergencies, support national security and emergency preparedness, and educate the next generation of scientists.

This document was prepared for the Centers for Disease Control and Prevention (CDC) Division of Healthcare Quality Promotion (DHQP) by ORISE through an interagency agreement with DOE. ORISE is managed by Oak Ridge Associated Universities under DOE contract number DE-AC05-06OR23100.

The findings and conclusions in this document are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.