CDC-INFO National Contact Center
H1N1 Response
Exercise v. Reality
Susan K. Laird, MSN, RN
Clinical Director, CDC-INFO
Joint Information Center Team Lead
Division 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
Planning started years before
the H1N1 Pandemic




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
5
CDC Exercises (2006-2007)
Training/Exercise Methods:
Senior/Division
Leader OPLAN
Seminars
28 Sep & 17 Oct
(4 Hrs Each)
AAR
Influenza Pandemic
OPLAN
AAR
Briefings/Seminars
AAR
Tabletop Discussion
Workshops and Functional Drills
DEOC Working
Level Workshop
4 Oct (8 Hrs)
Functional Level
Drills
(6 Functional Areas)
16 Oct – 1 Dec
(2-4 Hours Each)
AAR
Advanced Tabletop:
Significant Issue
Forum
8 Dec (4 Hours)
AAR
Functional Exercise
– Internal, Full Staff
31 Jan – 1 Feb 07
(18 Hrs)
Functional Exercises
2008 Influenza
Pandemic
Exercise
Program
Functional Exercise AAR
(Internal/External)
AAR
25-27 Apr 07 (48
Functional Exercise
Hrs)
(Surge)
14-16 Aug 07
(48 Hrs)
CDC Foundation
Tabletop
18 Apr (3-4 Hrs)
Section Drills
AAR
1-30Nov07
AAR
Lessons
Learned
Seminar
Intervals,
Actions &
Triggers TTX
14Nov07
15Nov07
AAR
6
CDC Exercises (2008)
Surgeon General’s
Flag Retreat
ITA TTX
8 Jan 2008
(4 Hours)
Training/Exercise Methods:
Briefings/Seminars
Tabletop Discussion
AAR
Workshops and Functional Drills
Functional Exercises
Influenza Pandemic
OPLAN
Limited Full Scale
Exercise
(1 State)
Surge/Mitigation
2009
AAR
Exercise Series
11-13 Mar 2008
(48 Hrs)
TTX
CDC / PFO / JFO
Role and
Responsibilities
July 10, 2008
(4 Hrs)
AAR
Limited Full Scale
Exercise
Influenza Pandemic
Progression from
Acceleration to Peak
Transmission
(5 State Participation)
DEOC Section
Functional DRILLS
AAR
Sep 16-18, 2008
(48-72 Hrs)
AAR
3-14 Nov 2008
(4-8 Hours)
7
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



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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
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
11
Response Timeline
15 Apr 09
to
31 May 09
1 Jun 09
to
15 Aug 09
16 Aug 09
to
4 Oct 09
5 Oct 09
to
1 Apr 10
Pre-Pandemic
Recovery
Discovery
Fall wave
Preparing
S. Hemisphere
Vaccination
Developing Guidance
Sep 22 CDC clarification
to reduce burden from
Worried well
May 6 CDC
Posts
Interim guidance
Sep 8 CDC
Posts revised
Antiviral drug
guidance
13
Response—Strategic Goals/ Principles



Reduce illness and death
Minimize societal impact
Apply greatest effort to interventions with
greatest impact
14
H1N1 Four Pillars of Action

Surveillance (Situational awareness)



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
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
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
Talking Points for Media
Key messages
Guidance Documents
Foreign Language
Translations
Partners for
message
coordination
Fact sheets
CDC-INFO Scripts
PSAs
Posters
Podcasts/Videocasts
Health Alerts
Twitter Messages
Listserv content
Situational Awareness
Clinical/Public Health Guidance, Daily Public Updates
CDC Emergency Website
Key Messages
15 JIC Teams
Media Relations
(Adaptation/Dissemination (fact sheets, PSA’s, “Tweets”, etc)
General Public
Affected Communities
Vulnerable Populations
Clinicians
State/local PH
Workforce
Laboratorians
Global Communication
Counterparts
Policy Makers
CDC Employees
JIC Channels
CDC Emergency Website
CDC-INFO (English, Spanish, TTY)
Health Alert Network
Epi-X
Clinician Registry
Social Media
Partner Distribution Networks
News Media
Press conferences
News releases
Interviews
Media Tours
Media advisories
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 Media
4/21-6/12 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)
Targeted Communication to Vulnerable
Populations
Deaf and Hard of Hearing
CDC-INFO scripts always in TTY
PSA’s in American Sign Language
•H1N1 General messages
•Hand hygiene
• Collaboration with Partners: ASL
PSAs Courtesy of the University of
Rochester
•http://www.cde.gov/h1n1flu/deaf.htm
Communicating through Partners
Government, NGO, faith-based organizations, and other
partners who serve vulnerable populations distribute CDC’s
messages.
Example of CDC partners who serve disabled populations:

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
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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
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



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20% (8) changed once
12% (5) changed twice
10% (40) removed and not replaced
Most frequently changed/major changes



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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



However, it was still difficult to tell what was new


Labeled revisions as updates and date stamped them
Pushed them to partners through distribution channels
as “updates”
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
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
Facemask/Respirator Use
Posted May 27, 2009
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
Talking Points for Media
Key messages
Guidance Documents
Foreign Language
Translations
►Lessons Learned:
Automated
Tracking/Update Systems
Partners for
message
coordination
Fact sheets
CDC-INFO scripts
PSAs
Posters
Podcasts/Videocasts
Health Alerts
Twitter Messages
Listserv content
Situational Awareness
Clinical/Public Health Guidance, Daily Public Updates
CDC Emergency Website
Key Messages
15 JIC Teams
Media Relations
(Adaptation/Dissemination (fact sheets, PSA’s, “Tweets”, etc)
General Public
Affected Communities
Vulnerable Populations
Clinicians
State/local PH
Workforce
Laboratorians
Global Communication
Counterparts
Policy Makers
CDC Employees
JIC Channels
CDC Emergency Website
CDC-INFO (English, Spanish, TTY)
Health Alert Network
Epi-X
Clinician Registry
Social Media
Partner Distribution Networks
News Media
Press conferences
News releases
Interviews
Media Tours
Media advisories
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


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Threaten internal consistency
Surprise and conflict with external partners
Recommendations:

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Increased collaboration and notification with partners
Automated change/content management systems
Guiding Principles

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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 Response
Major Challenges

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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

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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
up – funding??
 Should have initiated the PAT call (Process
Action Team)
 Putting content in place when there aren’t any
answers yet
 Staffing
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

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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)

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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
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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
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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
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
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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-INFO
MAY 2010

H1N1 Inquiries as of 5/18/2010:

General Public
 Calls
 Emails
Clinicians
 Postal & TTY

TOTAL
142,248
47,483
23,408
16
INQUIRIES 213,155
THANK YOU!
QUESTIONS?
slaird@cdc.gov
404-498-6310