Clairmont Heights Civic Association

By Sherline Lee

Even for an epidemiologist who works in public health preparedness and response, being asked to explain to the public what we do at CDC can be difficult.  

That said, sometimes opportunities to talk about public health drop into your lap.   A few months ago I was catching up with my friend Austin, an engineer for a large corporation.  It turned out that while on long-term assignments he and his team had recently taken to playing the board game, “Pandemic.”   One might think that an infectious disease would make for a strange game premise, but to my surprise it’s been gaining a loyal fan base. Of note, the game has recently profiled by Wil Wheaton on his “Geeks and Sundry” tabletop videocast seen by more than 350,000 viewers and positively reviewed on many board game sites.

What? You Think Public Health is Fun?

When I asked Austin about why his teammates enjoyed Pandemic, he pointed out that the game differed from many others in that it was designed to make players collaborate, not compete.  In addition, players had to learn not only their own roles but the roles of other players in order to attempt to outsmart the disease as it tried to spread city to city across the globe. 

Finding out that your job is the premise of a game your friend likes to play is amusing.  However this conversation provided me with an opportunity to reflect further.  As it turns out, I had played this game several years ago with a fellow CDC epidemiologist who had a connection to one of the developers.  She asked my team, who was also working on developing educational activities, to play the game with her to provide feedback on potential new roles for a planned expansion to the game and the gameplay itself.  

I remember our team talking to her about how well the game reflected the reality and values of public health.  We also discussed how the game forced players to think beyond themselves and about the other people around their game table.  Public health response, after all, is all about the collaboration of multiple disciplines that function best when they do it together.  Public health professionals know that containing a pandemic requires practitioners all over the world to be well equipped and to be able to communicate just as well as game players around the same table.

Something’s Missing…

If there was one thing that did bother me, it was that among the five roles which players could pick from (i.e., archivist, medic, operations expert, scientist, and researcher), there was no epidemiologist.  However, as I looked at the new version my friend Austin was playing, I was relieved to see an epidemiologist had finally joined the ranks in the expanded form of the game.  That role, alongside seven new ones, became part of the “Pandemic” game world. 

While I’m sure these additions were made to change the gameplay and offer new things for fans to play, I also think it reflects a subtle message about public health. We continue to plan with many specialists inside the agency along with local, state, national and international partners on a daily basis, getting ready to respond and “beat disease at its game.” 

On a more personal note, I keep hoping to run into other friends and acquaintances that have played the game.  After all, each fan of “Pandemic” I encounter represents another opportunity to talk about what we do in public health preparedness.  And every game player might someday also become a fan of public health.

Sherline Lee is a CDC epidemiologist works in the Healthcare Preparedness Activity program (http://www.cdc.gov/phpr/healthcare) in the Division of Strategic National Stockpile and collaborates on developing tools with public health, healthcare, and emergency management partners.

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Are you a fan of Pandemic? Do you have other public health related games you love playing with your friends? Tell us!

By Cate Shockey

This blog is part of a series, covering a preparedness topic each month from the Do 1 Thing Program. Join us this month as we discuss preparedness at work, school, and in your community.

No matter where you are, you need to know how to make sure you and your loved ones are safe in an emergency. If you’re not at home during an emergency, do you know what the plan is for your work, child’s school, or community?

In our office, we practice shelter-in-place and building evacuations quite often. We have signs posted in the hallways and have mandatory safety training every year. What we do not practice, however, is earthquake drills. To make it fun and engaging, we held an earthquake drill in our break room and called it the Harlem ShakeOut. In just a few minutes, everyone learned what to do in an earthquake in a room surrounded by glass.

My mom’s second graders really got into the earthquake drills back in March, and jumped on the chance to practice another drill this month! With storm season in full swing, the class practiced tornado drills in the hallway. The students lined up along the interior wall, huddled on the ground with their knees up under them, and used their hands to cover the back of their heads.

Here are a few things you can do this month to make sure the people who count on you are prepared for an emergency:

• Make sure emergency procedures are in place at your workplace or child’s school. Are evacuation routes and tornado shelter locations clearly marked? How will you be provided emergency and warning information?
• Hold emergency training and drills for different situations (earthquake, tornado, fire drill, etc.).
• Know where fire extinguishers and automatic external defibrillators (AEDs) are located in the building.
• Give emergency kits to people who count on you (elderly parents and neighbors, college students, etc.)
• Find out if your community has designated evacuation routes or shelter locations.

Check out Do 1 Thing for more tips and information, and start putting your plans in place for unexpected events. Are YOU ready?

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Tell us how your work place stays prepared for the unexpected or what your child’s school does to keep parents informed. If you are part of a community group that would help in a disaster, we want to hear about it!

Taking on the role of interim CDC director can be an intimidating task, but an impending pandemic can make the position exponentially more daunting. This is the situation Dr. Richard Besser faced in 2009 when he stepped into his new job. But Besser took the task head on and guided the country’s premier health agency through the H1N1 outbreak with skill and confidence. Through this experience Besser saw first hand how important communication is to building the publics’ trust and improving health behaviors.

When it was time for Besser to hand over the reins, his next career choice made perfect sense, Chief Health and Medical Editor for ABC News. He would be able to continue his work communicating important health information to the public, and hopefully help improve the lives of his viewers.

Of course, Besser often calls upon his past experiences when covering stories and the ongoing outbreak of H7N9 is no exception. Just like during H1N1 Besser realizes there is a fine line between reporting on a story and unnecessarily raising the publics’ fear. In the beginning, ABC News was the only network covering the story, which raised concern in Besser.  Were they overhyping?  Or was this threat real?  

Understanding that there are usually many nuances any outbreak, he connected with CDC for a reality check on H7N9.  After confirmation from the CDC Influenza Division and WHO that the emergence of the new H7N9 virus was a legitimate cause for concern, Besser’s team started to strategize the best way to cover the story.  One of their first decisions: get on the ground in China.

Getting in to mainland China proved to be more difficult than Besser had imagined, as gettings visas for journalists can be challenge.  Instead, Besser headed to Hong Kong to cover the story from there.  Hong Kong was familiar territory for Besser, being the hotbed of activity for the 2003 SARS outbreak, and it was a great place to do preparedness reporting for H7N9.

What Besser found was a part of China that was very aware of the threat posed by H7N9 and incredibly prepared.  They were taking this new strain seriously.  Hospital wards were full of empty beds, ready to receive sick patients and markets and ports of entry were under tight scrutiny.

Because this is a bird flu virus and most cases of bird flu generally happen after contact with infected poultry or surfaces contaminated with the virus, the biggest concern was live poultry. China is a country where the cultural practice is to buy live chickens at the market and have them killed on the spot in order to have the freshest chicken possible.  After SARS, China reduced the markets and started testing every chicken shipment at every border.  If a chicken tests positive, all chicken shipments stop immediately.

In addition to testing chickens for bird flu, China has enacted an interesting way of screening people for H7N9.  Besser reports that in Hong Kong they are using infrared sensors to spot a person with an elevated body temperature out of a crowd.  If a person is spotted, they are brought in for testing.  This screening is being done at all ports of entry, including train stations and airports.

With the preparedness measures in place, the people of Hong Kong were clearly aware of the threat through the media, but there was no real fear of an outbreak. The newspaper headlines kept people informed about H7N9 cases, and the government dispelled fears through preparedness efforts.  They are ready to respond quickly and minimize the impact to the public’s health.

For Besser, the trip to Hong Kong served to tell the story back home. “The people I met in Hong Kong were reassured that I was there to illuminate the issue and not hype it.  My background with public health certainly opened doors, but my purpose was to share a message.”  Besser says that the same emphasis on preparedness seen in Hong is also the approach being taken in in the United States. By getting the preparedness and response message out there, CDC has been very clear about the steps the agency is taking to prepare for H7N9 and urging travelers returning from China to report flu-like symptoms to a doctor. 

For more information on H7N9, visit CDC’s Flu website.

One of the many roles of public health is to protect consumers from threats like foodborne outbreaks. Much of this hinges on quickly getting out clear messages to the public that provide simple steps to help stem the spread of disease. This is something public health professionals have been doing for over a hundred years, but a recent outbreak of Salmonella Heidelberg got us wondering, “Are we doing enough to keep the public safe? Are we too slow? And, How can we improve?”

That’s not to say there weren’t triumphs in this outbreak, but like most responses we had a moment of self-reflection when the crisis was over and we were able to take a step back and consider our methods. What we found was a need for stronger policies and faster messaging to the public.

The Outbreak

Between June 2012 and January 2013 epidemiologists with Oregon Public Health, along with the Washington State Department of Health, CDC, and the US Department of Agriculture independent of each other, began noting increases in the number of Salmonella infections. Thanks to surveillance systems like CDC’s Pulsenet and National Retail Monitoring System (NARMS), epidemiologists were able to narrow down the specific genetic make-up of the Salmonella in question (Salmonella Heidelberg) and link it to raw or undercooked Foster Farms brand chicken.

The Pros and Cons

For decision-making and public information, we did several things right. Including:

1. Communicating with the company responsible for the tainted chicken, which helped provide critical information needed to confirm the source.
2. Developing simple messages that explained the outbreak and how individuals could prevent Salmonella were developed. These messages followed the Crisis & Emergency Risk Communication  framework, which encourages the use of transparent messaging that provides the public with meaningful actions to protect themselves from harm.
3. Growing a strong partnership between our epidemiologists, leadership, and risk communication officer over the course of the investigation provided a basis for mutual trust and respect. This rapport led to faster message development.
4.  Finally, by following Incident Command System principles we were able to better coordinate communication activities across the several agencies involved.

Although we were successful in getting the message out, there were several factors that we felt slowed this outbreak response down:

1. Despite having several state and federal agencies collecting clues, we weren’t doing it together, which meant more time was spent on the backend to get everyone on the same page.
2. Not all staff had been trained on the laws and policies related to release of information, which was needed for rapid decision-making during the outbreak.
3. Oregon Public Health (as we suspect is the case with many state health departments) has no risk communication policy, which meant not everyone was on the same page about how and when we would share information and release information to our partners and the public.
4. Political happenings unrelated to the outbreak ended up blocking the release of important health messages by two days—another all too common experience for many risk communicators.

How Can We Improve?

Given these pros and cons, we still think much can be done to improve decision-making and risk communication during an outbreak. The federal Food Safety and Modernization Act of 2010 was an important step toward improving the safety of our nation’s food supply.  However, our experience responding to Salmonella Heidelberg outbreak in Oregon also suggests that additional state and federal policies are needed not only to prevent outbreaks, but also to help public health authorities implement best practices in risk communications and public health responses when outbreaks do occur.

No state health department funded with federal dollars—CDC or otherwise—should be without a well-developed risk communications plan that can be operationalized at a moment’s notice. Similarly, states should be held accountable to ensure information about emerging outbreaks is shared between epidemiologists, other partners, and response staff, and to identify the triggers for public warning and messaging about health risks. Depending on the risk, even a one day delay in response could mean more sick people, and in turn more health care and social costs.

We do know from our own experience that state and local public health agencies sometimes face unique challenges in balancing the need to be right and credible with the public’s need to know about potential health threats. In many states, there are laws that—very appropriately–prevent public health agencies from releasing certain types of identifiable or highly sensitive information. However, there are almost no laws that ensure public health officials with information about a health risk be allowed or even required to warn the public, free from interference by political forces or threats of litigation by the food industry.

Policies that encourage health departments to share what they know, possibly by providing immunity from lawsuits when warning the public about risky food products, are needed. Policies that ensure that all parties work together as early as possible in a suspected outbreak are needed, along with policies that ensure that health care technologies can capture and send essential data from the health care setting to public health officials.

Our Responsibility

The public health system is under more pressure than ever to be relevant, timely, and right. While important progress has been made over the past decade, identifying outbreaks, analyzing them, and disseminating information to the public requires the expertise of highly trained professionals with the tools and policies that enable them to do their jobs.

Health officials too must sometimes strike the difficult balance between the political realities of our work and the public’s health and safety. As Dr. Martin Luther King, Jr. said “[T]here comes a time when one must take a position that is neither safe, nor politic, nor popular, but he must do it because Conscience tells him it is right.” As public health professionals, we have a responsibility to our colleagues, constituents, friends, families and ourselves to improve the quality and performance of our public health systems and services.

More Information

For more on this topic check out the Pew Charitable Trust report, “Too Slow” analyzing the detection and response to a 2011 outbreak linked to ground turkey.

Disclaimer: This blog post does not represent the official views of the Oregon Public Health Division or the Oregon Health Authority

Thanks to contributing authors:

Jean O’Connor, JD, DrPH, Former Oregon State Public Health Deputy Director (July 2011-April 2013) and Adjunct Associate Professor of Health Policy at Emory University.

Kathleen Vidoloff, PhD, Emergency Risk Communication Officer, Oregon Public Health Division and Adjunct Professor University of Oregon.