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January  2004                                                         Volume 5 - Number 4

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Communications...

The Disciplines of Emergency Management – Communications:
Summary of the recently published books and reports on the Anthrax scare of Oct-Nov 2001.

By John S. Rhodes

This research summarizes four of the journal articles/manuscripts written about the anthrax attack of 2001. These articles highlight the issues raises, with regard to risk communication, that occurred during the anthrax response. Additionally, several of the articles contain recommendations for ensuring a better response when the next bioterrorism response is necessary.

The first report reviewed was The General Accounting Office (GAO) assessment titled Bioterrorism: Public Health Response to Anthrax Incidents of 2001. The GAO reported that the major lesson learned was the importance of effective communication, both among responders and with the general public. CDC experienced difficulty in managing the amount of information coming in and communicating with public health officials, the media, and the public. The report also outlined some of these steps take by the CDC to improve the public health response to a bioterrorism event.

The second report reviewed was titled Anthrax 2001: Observations on the Medical and Public Health Response by Gursky, Inglesby, and O’Toole. This report states that the confusion caused by scientific uncertainties was compounded by poor communication among public health officials and the media and the public. The report states it became clear that public health guidance was not being issued fast enough to guide clinical decisions. When no guidance was forthcoming, clinicians relied on their own medical judgment to make diagnoses and initiate treatment and, in some instances, published guidelines based on their experience.

The report also highlighted that some health departments were clear leaders in their ability to develop information for public dissemination more quickly, and were able to share this information broadly with other health departments. The New York City Department of Health officials placed a high priority on communication with the press. They felt that press briefings were an important way to transmit current information and avoid misinformation. One NYC public health official stated, “The mayor had a strong belief that you have to get information out and not keep things from the public.”

The third report reviewed titled An Ounce of Prevention Is a Ton of Work: Mass Antibiotic Prophylaxis for Anthrax, New York City, 2001 by Blank, Moskin, and Zucker. This article outlined the steps the New York City Department of Health (DOH) used for planning and implementing their mass prophylaxis plan during the anthrax attack of 2001. The article stated that careful attention to communication at a variety of levels is critical, from the incident command center to the POD (Point of prophylaxis Distribution sites), and from the health department to the public and the community medical providers.

The fourth report reviewed was Public Health and Bioterrorism: Learning the Lessons of the Anthrax Attacks by Dixon and Sencer. The report outlines the lessons learned as a result of the anthrax attack. The authors reported that public health officials need to communicate better, both to professionals and to the public. The authors’ recommended: 1) The public needs a recognized health spokesperson; 2) There needs to be a clear plan for combating bioterrorism; 3) The infrastructure of the public health system needs to be continuously strengthened; and 4) Modern communication systems and upgraded laboratories are important, but trained personnel are essential.

In October 2001, letters containing anthrax spores were mailed to a Senator Tom Daschle and news media personnel, which signaled the first case of anthrax infection related to an intentional release of anthrax in the United States. Outbreaks of anthrax infection were concentrated in six locations throughout the country. Environmental clean up of contaminated facilities and surveillance for cases of bioterrorism-related anthrax was conducted in Delaware, District of Columbia, Florida, Maryland, New Jersey, New York City, Pennsylvania, Virginia, and other states. Through November 14, 2001 a total of 22 cases of anthrax had met the CDC case definition (1); 10 were confirmed inhalational anthrax, and 12 (seven confirmed and five suspected) were cutaneous anthrax (2). This intentional release of anthrax also resulted in hundreds of persons being placed on prophylactic antibiotic therapy.

Risk communication is defined as “the attempt by science or public health professionals to provide information that allows an individual, stakeholders or an entire community, to make the best possible decisions about their well-being, under nearly impossible time constraints, and to communicate those decisions, while accepting the imperfect nature of their choices.”(3) The 2001 Anthrax attacks provided many opportunities for the government, the U.S. Postal Service and public health officials to communicate with both the public and the employees of the affected agencies. Risk communication by health officials during these anthrax attacks was necessary to mitigate the effects of these attacks. Poor risk communication to the public resulted in distrust by the public it served.

Numerous authors and government agencies have conducted assessments, formulated written reports, and published books/manuscripts on the events. This research summarizes four of the journal articles/manuscripts written about the anthrax attack of 2001. These articles highlight the issues raises, with regard to risk communication, that occurred during the anthrax response. Additionally, several of the articles contain recommendations for ensuring a better response when the next bioterrorism response is necessary.

GAO - Bioterrorism: Public Health Response to Anthrax Incidents of 2001 (4)

The General Accounting Office (GAO) performed this assessment at the request of Senate Majority Leader Bill Frist, who has an interest in bioterrorism preparedness. Senator Frist, who is also a physician, asked GAO to review the public health response to the anthrax incidents.

This report is a comprehensive review of the 2001 attacks. The report states that “Local and state public health officials in the epicenters of the anthrax incidents identified strengths in their responses as well as areas for improvement.” It was reported that one of the major lessons learned for public health response was the importance of effective communication, both among responders and with the general public. The experience of responding to the anthrax attacks highlighted many aspects of federal preparedness that could be improved. The Centers for Disease Control and Prevention (CDC) was challenged to both meet resource demands from local and state officials, as well as coordinate the federal public health response in the face of the rapidly unfolding incidents. CDC experienced difficulty in managing the amount of information coming into the agency and in communicating with public health officials, the media, and the public. During November 1-12, CDC received approximately 4,400 calls through the hotline and to the Emergency Operations Center. The Center also received requests for information by email through the Health Alert Network, the Morbidity and Mortality Weekly Review (MMWR), and other public health communications systems (2).

In addition to straining CDC’s resources, the anthrax incidents highlighted shortcomings in the clinical response tools and a lack of training for clinicians in how to recognize and respond to anthrax. CDC has taken steps to improve the public health response to a bioterrorism event. Some of these steps include: creating the Office of Terrorism Preparedness and Emergency Response, creating an emergency operations center, enhancing the agency’s communication infrastructure, developing databases of information and expertise on the biological agents considered likely to be used in a terrorist attack, developing better clinical tools, and increasing training for medical care professionals.

Anthrax 2001: Observations on the Medical and Public Health Response (5)

This report states that the confusion caused by scientific uncertainties was compounded by the poor communication among public health officials and the media and the public. As the investigation first evolved and CDC was learning more about the nature of the anthrax powder, the risk posed by unopened envelopes working their way through post office sorting machines, and other technical issues that determined who was at risk and the nature of the public health response, the public heard little from top federal health officials. Additionally the article states, “It quickly became clear that public health guidance was not being issued fast enough to guide many necessary clinical decisions. When no guidance was forthcoming, clinicians relied on their own medical judgment to make diagnoses and initiate treatment and, in some instances, published guidelines based on their experience. As one physician noted, ‘there were expectations of external support. We were told on October 20th that guidelines from CDC were forthcoming. They were [eventually] posted in the Morbidity and Mortality Weekly Report on the 26th. [Meanwhile] we wrote our own prophylaxis guidelines and created a milieu for clinical decision-making. We created what we needed to create.’”

The difficulties that public health agencies had communicating with the public were particularly serious in the Washington, DC, area, where communication failures led some to speculate that there were racial disparities in the treatment recommendations. When a letter containing anthrax spores was delivered to the office of Senator Daschle, the Capitol physician arranged for Capitol workers to receive nasal swab testing and instituted a course of ciprofloxacin antibiotic prophylaxis. One week later, when it became evident that Brentwood postal workers had been exposed to anthrax, CDC decided not to recommend nasal swabs because they had determined that this test was an unproven and possibly misleading measure of anthrax exposure. CDC had also begun to recommend doxycycline as an alternative antibiotic prophylaxis choice to ciprofloxacin (“Cipro”), because they judged it to be equally efficacious and more readily available. These recommendations led some to believe there was a double standard emerging. As one infectious disease physician in the DC area noted, “There was no printed guidance and a lot of what we did was fly by the seat of our pants. We attempted to be consistent, but CDC’s recommendations and the Capitol physician’s recommendations were different.”

The article didn’t just highlight the deficiencies of the risk communications during the event, it stated that some health departments were clear leaders in their ability to develop information for public dissemination more quickly, and were able to share this information broadly with other health departments. For example, New York City Department of Health officials placed a high priority on communication with the press. They issued timely alerts and updates to clinicians and public health officials in New York City, and these were regularly passed on to others across the country. The department also held regular briefings for the press. They felt that these press briefings were an important way to transmit current information and avoid misinformation. These officials knew they had the authority to speak to the press, because the authority had come from the top. One NYC public health official stated, “The mayor had a strong belief that you have to get information out and not keep things from the public.”

An Ounce of Prevention Is a Ton of Work: Mass Antibiotic Prophylaxis for Anthrax, New York City, 2001 (6)

This article outlined the steps the New York City Department of Health (DOH) used for planning and implementing their mass prophylaxis plan during the anthrax attack of 2001. The article stated that careful attention to communication at a variety of levels is critical, from the incident command center to the POD (Point of prophylaxis Distribution sites), and from the health department to the public and the community medical providers. Also important was the flow of information from public health officials to representatives of the community receiving prophylaxis, and to the community itself. Without such attention, centrally made decisions might not be communicated to POD staff, resulting in mistaken expectations. Reference materials required continuous updating of facts, whether or not new information was available (e.g., “There are no new cases of anthrax as of today.”). These materials needed to be appropriate for use at POD sites, for DOH hotline scripts, and on the DOH website. Information was also disseminated by means of press releases and press conferences. The format for communicating with POD clients included printed materials, live briefings, or both. The medical community was kept abreast of recent developments through multiple broadcast faxes, emails, and website updates from DOH and by quickly establishing a DOH physician hotline staffed by medical professionals. The DOH established three separate hotlines, one each for physicians, those clients directly affected by POD operations, and the general public.

Public Health and Bioterrorism: Learning the Lessons of the Anthrax Attacks (7)

The article outlines the lessons learned as a result of the anthrax attack. The first thing that needs to be done is that public health officials need to communicate better, both to professionals and to the public. Audiences want to hear technical information from persons versed in the subject matter. Health information should come from health authorities, law enforcement information from the enforcers, and political information from the politicians.

Nontraditional methods of communicating amongst the professions must be improved. The delay in publication of traditional journals results in medical personnel formulating their own protocols on the spot. It is a legitimate role of government to provide authoritative information, and CDC and many state and local health departments rose to the occasion. The New York City Department of Health, in particular, conducted an aggressive information dissemination policy.

The authors also discussed what they believe went well regarding the response to the attack. The authors stated, “The system worked. Cases were diagnosed, reported, investigated and the information made available. State and local health departments, while stressed by inadequate resources, coped with the cases and rumors and devoted endless laboratory hours processing materials suspected of being anthrax. The few false positives were environmental samples tested by kits that have not had adequate evaluation.

The authors’ recommendations were as follows: 1) The public needs a recognized health spokesperson; 2) There needs to be a clear plan for combating bioterrorism; 3) The infrastructure of the public health system needs to be continuously strengthened; and 4) Modern communication systems and upgraded laboratories are important, but trained personnel are essential. Additionally, state and local health departments need to continue their efforts to communicate with the health professions on a regular basis, while the health professions need to recognize the value and role of their official health agencies. State and local health officials can be very helpful to practicing physicians -- and vice versa -- but few on either side seem to realize it. Better communication, better planning and better infrastructure add up to better disease prevention.

References

1. CDC. Update: Investigation of anthrax associated with intentional exposure and interim public health guidelines, October 2001. MMWR 2001; 50:889—93.

2. CDC. Update: Update: Investigation of Bioterrorism-Related Anthrax, 2001. MMWR 2001; 50;1008-1010.

3. CDC. Crisis and Emergency Risk Communication Training Module. 2003.

4. United States General Accounting Office, Report to the Honorable Bill Frist, Majority Leader, U.S. Senate. Bioterrorism: Public Health Response to Anthrax Incidents of 2001 October 2003;GAO-04-152. www.gao.gov.

5. Gursky, E., Inglesby, T., O’Toole, T. Anthrax 2001: Observations on the Medical and Public Health Response. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 2003: 1 (2).

6. Blank, S., Moskin, L., Zucker, J. An Ounce of Prevention Is a Ton of Work: Mass Antibiotic Prophylaxis for Anthrax, New York City, 2001. Emerging Infectious Diseases 2003: 9 (6).

7. Dixon, R. Sencer, D. Public Health and Bioterrorism: Learning the Lessons of the Anthrax Attacks. May 2002. http://www.thedoctorwillseeyounow.com/articles/other/bioterr_25/