Public Health Emergency Preparedness

Chapter 4. Analysis

The result of the analysis is a list of requirements for the people, processes, and technology of the HEALTH model. To determine the users' requirements, we conducted research into past public health emergency communications. We also assessed our current capacities.

We conducted research to determine what human resources, processes, and technology would be required to meet our goals and objectives. The research included: review of literature on past responses to public health emergencies, best practices for medical call centers, legal requirements, and direct communication with other public health agencies and medical call centers.

Lessons Learned from Past Public Health Emergencies

Published literature that reported on the lessons learned from emergency or bioterrorist events involving public health or health care agencies was reviewed. Reports were searched for that would provide insight into the resources, processes, and facilities that were used in response and that aided communication with the public during the event. A review of medical libraries was performed using the following databases: Ovid Healthstar (1987-2002), MEDLINE® (1996-2002), and Google.com, the Internet search engine. Articles with the following subject headings were searched for: bioterrorism, disease outbreak, or disaster planning. This group was limited by the terms public health, hotlines, or communication. From this group, articles were considered if they referred to disasters, outbreaks, or mass casualty events, including terrorism. Articles that discussed communications or operational responses or limitations were included. If an article discussed only the identification and, treatment of a causative agent or hospital triage protocols without offering insight into organizational response or aspects of communication, the article was not included. Articles were to be included if the title or abstract discussed one or more of the following questions:

1. How did agencies communicate with the public during response to the emergency?
2. How did recipients perceive the information provided?
3. What information did the public need from government entities during the crisis?
4. What special populations were encountered?
5. What were communication system limitations during the emergency?
6. What were successful communication solutions?
7. What staffing issues were identified during the emergency?
8. What were facility limitations during the emergency?

Several challenges in locating and evaluating information on past responses were encountered. The range of disasters and emergencies that require public health professionals to play a role also include response from several other sectors. In many ways, the field of public health is the newcomer to disaster response. This means that valuable information on past responses may be in the domain of other fields of expertise, including law enforcement, public administration, communications, technology, and so forth. Each of these fields has its own protocols, priorities, and preferred venues for sharing information.

Ultimately, it was useful to expand the search beyond the peer-reviewed journals to include diverse sources, ranging from trade journal reports and commentaries to text from health department or municipal Web sites, conferences, and even congressional testimony. These sources were explored after reviewing articles and doing focused Internet searches through a common search engine (Google.com). The breadth of information and commentary available made it impossible for us to do a comprehensive review. The diversity of evaluation methods, institutional priorities, and even of definitions of success made it appropriate to take a qualitative approach.

Evaluations of the response to past emergency events are not always made available to the public. Sometimes this is due to the sensitivity of the information. For example, the Center for Strategic International Studies arranged a high-level review of the 2001 anthrax attacks. However, due to the sensitivity of the report's content, the Department of Defense has withheld it from the public.^L1

Evaluation methods have been inconsistent. In part this is due to the many different agencies and fields of expertise that are represented in emergency response. In part it is due to the local variation in organizational and operational structures of responding agencies, and in part it is simply due to the diverse and complex nature of disasters.

Development of uniform, objective measures to evaluate emergency response or emergency readiness is an emerging issue.^L2 Maintaining public safety and preventing further injury may be the clear objective, but how is it to be measured? It is difficult to assess how much mortality or morbidity was prevented by actions taken, or how much more could have been prevented if other steps had been taken. Thus, it is difficult to judge the "success" of the response to an event or to make comparisons.

Our interest in the effectiveness of communication during these events is an even more subjective matter. The success of communication will mean different things to different people. For our purposes, we were interested in whether the public health agency was successful in convincing the public to take actions as prescribed by the public health agency, whether they were trusted, and whether their message managed to calm the public. We were also interested in simpler measurements such as, "were they able to answer all their calls in a timely fashion?" or, "was the information shared with the public consistent and accurate?" As it turned out, both qualitative and quantitative information was lacking in the literature.

For example, we were interested to find out the volume of telephone calls to agencies or emergency hotlines during emergency events; we found this information was rarely reported. Even when volume was reported, the authors either did not offer an assessment of this information, or reported that they simply did not know the volume of calls that went unanswered due to staffing or system limitations.^L3 It appeared that most agencies did not have systems in place to conduct even this simple level of evaluation of telephone communications, a level of evaluation that is standard in the medical call center industry.

This sort of problem may stem from the perception that health departments are not communications centers and, therefore, that tracking the volume of calls, type of calls, length of call, number of hang-ups, wait time, etc. is not their role—this despite the fact that during emergencies many local and national public health departments set up impromptu call centers because of overwhelming public demand for direct communication.^L3-L6

Valuable information was available from sources that are unconventional as far as most public health topics are concerned. Hospital administrators, public policy makers, information technology specialists, law enforcement, and emergency response departments are less likely to publish their experiences in peer reviewed journals and are more likely to post information on their Web sites—or to share it at conferences or in editorials or articles submitted to trade journals. Contributions also came from business, telecommunications and technology journals, Web sites, and newsletters.

Fifty-seven articles relayed experiences from actual events (disease outbreaks, the World Trade Centers attack, the 2001 anthrax attacks, mass casualty incidents, and natural disasters) or training exercises. These articles included reports on epidemiological investigations, national surveys, personal accounts and editorial commentary, or recommendations. In addition, we included six bioterrorism preparedness guidelines that were produced by State or national agencies. Although they did not assess past events, we thought it appropriate to consider the recommendations of these documents. Except for the guidelines and manuals that were included, articles were left out of the final selection if they did not include some reference to lessons learned from past events or training exercises.

The table below attempts to describe these sources, however the categories are subjective, and therefore the table should be used only as a general orientation to the sources we used.

Editorials, case studies, and evaluations were used as ways of describing the continuum of reporting, with editorials being the most subjective and evaluations the most objective and comprehensive. The surveys were directed either at public attitudes surrounding communications and disasters or were directed at health departments or hospitals to assess current state of readiness. Several evaluation articles used more qualitative survey methods as a tool for conducting the evaluation; these were not included with the surveys. It should be kept in mind that most of the sources focused on only one or a few aspects of the events being described. Articles about general preparedness included a range of recommendations with examples from multiple past experiences.

The 63 sources that we ultimately used to inform our model development cannot be considered as a definitive collection. However, they did offer valuable insights. The patchwork nature of the sources that we found lent itself to a qualitative approach. We looked for issues that have emerged from these sources to establish some consensus between the articles and the questions we had posed.

How did agencies communicate with the public during the emergency?

Events that generated high public concern, whether localized or national in scope, were usually responded to with information posted on Web sites and in press releases and brochures. However, the higher the concern about the event, the greater the demand for one-on-one communication. In many cases, public agencies responded to this demand by setting up ad hoc hotlines.

Seven such hotlines were mentioned in 11 of our sources, including:

1. New York City LifeNet (mental health hotline responding to September 11, 2001)^L5
2. New York City West Nile virus (WNV) hotline (during the 1999 outbreak)^L6
3. Greater New York Hospital Association (GNYHA) phone bank (located hospitalized friends and family after September 11, 2001)^L7
4. New Jersey Emergency Operations Center (hotline for surveillance of anthrax cases in 2001)^L8
5. Center for Disease Control and Prevention (CDC) Emergency Operations Center (put into operation in response to the anthrax letters)^L3,L9
6. Idaho StateComm (coordinated response to anthrax investigations)^L10
7. Florida Health Department meningitis vaccination hotline (following a meningitis outbreak)^L4

How did recipients perceive the information provided?

We found no reports of focus groups, opinion surveys, or other attempts to collect information on the public's perception of the information given. This may mean that this information wasn't collected in these events or simply that it wasn't deemed important to the objective of the publication. In evaluating the public education campaign waged by the New York City Department of Health during the West Nile virus outbreak of 1999, Vincent Covello, of the Centers for Risk Communication, concluded that this was the one major shortcoming of the campaign.^L5,L6

Public perception of the trustworthiness and reliability of information sources was assessed in surveys conducted by the Harvard School of Public Health and the Robert Wood Johnson Foundation Survey Project on American's Response to Biological Terrorism. In these surveys (conducted nationally in the last months of 2001), about 60 percent of Americans reported confidence in the CDC; 38 percent reportedly had confidence in the secretary of Health and Human Services, Tommy Thompson; 33 percent reported that they would trust the secretary for Homeland Security, Tom Ridge. Forty eight percent reported they trusted their State governor; 52 percent said they trusted the director of their State health department; 61 percent reported they would trust the head of the local fire department, and 77 percent said they trusted their own doctor for reliable information.^L11,L12

The articles describing the implementation of emergency hotlines focused on aspects of epidemiological investigation; as a result, they did not attempt to assess public satisfaction with the information shared. In fact, the only indication of the potential for satisfaction or dissatisfaction was reflected in the frequent reports of agencies and hospitals being overwhelmed by surges in call volume (14 articles reported such surges). None of the reports included quantification of calls lost, dropped, hang-ups, or wait times that would indicate whether or not the systems in place were adequate to meet the demand.

Many health agencies reported confusion over who was in charge and what messages should be released to the public. Information and communication vacuums caused surges of concerned citizens to present at public health and medical facilities looking for information or even to volunteer; this severely impacted the activities of those agencies.^L13,L14

A few articles alluded to the inconsistency of information being disseminated by the media, public agencies, or community leaders as having exacerbated the public's anxiety and distrust of authorities, leading to an increase in demand for information and poorer compliance with health recommendations.^L1,L4,L7

In the case of the response to an outbreak of meningococcal disease in Florida, local politicians publicly challenged the health department's decision to vaccinate only those younger than age 18; this resulted in anxiety and many calls to the hotline set up by the health department (5,000 calls in 1 week in an affected population of 33,000).^L4

Following the anthrax attacks, the New Jersey Department of Health went against the recommendations of the CDC and offered prophylaxis to all postal workers at the two affected offices in New Jersey.^L1,L7,L9 The contrast in treatment given to occupants of Senator Daschle's office and workers at the Washington, DC area postal center that had processed a suspect piece of mail resulted in widespread allegations of racism and severely undermined the trust the public had in CDC and other officials.^L1

What information did the public need from government entities during the crisis?

High-stress situations evoke strong emotions, such as fear, anxiety, distrust, anger, outrage, helplessness, and frustration that form barriers to effective communication.^L6 "By definition, terrorism is an assault on the mental health and well-being of the public. Its goals are to create panic, fear, and anxiety."^L15 Especially if an infectious agent is released, it is vital that the public's trust and cooperation is engaged immediately to ensure that announced disease containment measures are followed. During the tabletop exercise "Dark Winter," former Senator Sam Nunn was quoted as saying, "The Federal government has to have the cooperation from the American people. There is no Federal force out there that can require 300,000,000 people to take steps they don't want to take."^L16

Several of the articles found through our research reported that during emergencies, many people contacted hospitals to obtain assistance, information, to locate missing loved ones, or to volunteer.

Following a school shooting with mass casualties, a hospital in Eugene, Oregon, set up a special room for parents of victims who arrived at the hospital trying to locate their relatives.^L17 The Greater New York Hospital Association and the Office of the Mayor of New York City worked together to set up a phone bank and a Web site to aid the public in locating missing family and friends immediately following September 11, 2001.^L7

The 2001 anthrax attacks and WNV outbreak in 1999 created high demand for medical diagnostic and treatment information for patients, "worried well," and health care providers.^L1,L6,L18 Several sources described how health care providers came to rely on television news programs for information on the development of the anthrax investigation and latest recommendations because of the failure in communication from the CDC and State public health officials.^L1,L19

In order to deal with an overwhelming demand for current information following the anthrax mailings, the District of Columbia Hospital Association commenced daily conference calls for all their local hospitals; they report that the number of participants grew to over 500 on each call.^L19

Unfortunately, there is a general dearth of information on what the public actually wanted to know during any of these emergencies. None reported having systematically or routinely processed information on the causes for public concern. This may mean that this information was not collected and two-way communication was lacking, or it may only indicate that the information did not seem relevant to include in public documents. Although there is a wealth of literature on risk communication, little empirical data have been collected on the public's communication needs during particular events. A few articles discussed this problem in retrospect. Suggested ways to collect this information in future events included focus groups, surveys, or community meetings with an opportunity for community members to exchange ideas and concerns with officials.^L6,L21

What special populations were encountered?

The populations of greatest concern to the public, as judged from the nature of the hotlines that were set up by various agencies, were children, hospitalized or missing victims of mass casualties, "worried well" or people with perceived exposures, and people suffering emotional trauma following an event. However, none of the articles evaluating response to actual events identified any other at-risk groups such as the elderly, tourists, or homeless, disabled, mentally ill, or minority populations. Again, this seems to be a function of the failure of respondents to have identified special populations or their needs during the event, and a failure to attempt post-event evaluation of this aspect of public service.

In Chapter 5, we further address special populations when we review the findings of a recent study on special populations in Colorado and their needs for risk communication in a public health emergency.

What were communication system limitations?

Emergency events, whether localized outbreaks or national terrorist events, resulted in a large demand for one-on-one communication, implying that press releases and media events do not satisfy all of the public's needs.

At least 14 articles described surges in call volume that surpassed the agency's capacity even though there was no technical failure. The events discussed ranged from a blackout to a high school shooting with mass casualties to the WTC attack and the anthrax attacks; the affected agencies included hospitals and public health departments. During the West Nile virus outbreak of 1999, the New York City Department of Health received more than 150,000 telephone calls in the first month of operation of their hotline.^L6,L21 During the anthrax investigations, the CDC telephone lines were overwhelmed, resulting in doctors and hospitals complaining that they were getting their information from news media reports.^L1,L19

The CDC Web site crashed twice during the anthrax crisis due to heavy demand and lack of redundancy.^L1 In a test of the Health Alert Network conducted in 1999, only 35 percent of E-mails sent from the CDC to local health departments reached their targets, in part because so many agencies are still not equipped with adequate technology.^L19

Although many healthcare facilities reported that they were able to use their disaster recovery plans and benefited greatly from past experience and training,^L17,L22 most agencies resorted to ad hoc processes or fell back on established relationships more than formal incident command structure to manage the situation.^L23,L24

Telephone communication, whether landlines or cell phones, were unreliable, especially during the first hours of the events because of lines going down or channels being flooded with calls; yet most communication systems relied on telephone. It did not require an event the size of the World Trade Center (WTC) attack to jam cell phone frequencies. During the Columbine tragedy in Colorado, the cell phone network was overloaded by hundreds of journalists, citizens and responders trying to make calls; during the first hour of the response, the County dispatch center couldn't get through to the local command center because radio frequencies were also jammed.^L25

Other communication modes including the Internet, Web-chat, fax, or E-mail, were not as widely used during the emergencies, although when they were used they were effective. On 9-11, approximately 4-5 million citizens across the country resorted to E-mail in order to locate friends and relatives because of their inability to get through on the telephone.^L26 The director of Medical Informatics at St. Vincent's Medical Center in New York City reports that their Web site received double the usual traffic in the 2 weeks following the WTC attacks.^L27 Impromptu call centers struggled to assure appropriate response to high priority calls amidst high call volumes due to inadequate staff or systems capacity.^L3 In at least two cases, forms were completed manually because computers or software programs were lacking; this resulted in errors and missing information.^L3,L28

While in some cases incident command functioned very well due to prior training,^L29 in other cases a lack of clear command structure resulted in slow decision making, garbled communications within and between responding agencies, and lack of control of information being provided to the public and media.^L30 During the Top Officials (TOPOFF) exercise in 2000, consensus-making conference calls included between 50 and 100 participants.^L30,L31 During the WNV outbreak in 1999, up to 18 agencies were participating in the investigation and response, and communicating through lengthy conference calls.^L32

Julie Casani and her colleagues at the Maryland Department of Health and Mental Hygiene describe how their agency struggled with the role as "consultant" to health care providers. The challenge was both in providing the right information amidst the changing understanding of the etiology and treatment of inhalational anthrax, and also simply in handling the demand for direct communication 24 hours a day, 7 days a week.^L24

During the 1995 heat wave in Chicago, poor communications and decision-making within government led to a failure to recognize the growing disaster and to implement disaster management activities. This may have contributed to some of the 500- 700 lives lost.^L33

What were successful communications solutions?

• Interhospital communications systems.^{L7,L17,L20,L22,L34-36}
• Fax machines hooked up to run on emergency power for backup communications and use of broadcast faxes.^L22,L34
• Emergency management mobile command vehicles.^L34,L37
• Physical runners to communicate needs between hospitals.^L34
• Accessing office functions from off-site via secure Web technology.^L34
• Setting up mass dial-up Internet Service Provider accounts for local health agencies having trouble accessing Internet.^L34
• High-speed wireless Internet networks.^L34
• Wireless Local Area Network (LAN).^L34,L35
• Satellite reach-back communications.^L34,L35
• "BlackBerry," handheld wireless devices providing mobile, continuous E-mail access.^L34,L35,L38
• Web sites set up to communicate with employees ^L34,L36
• Health Information Network, a Web-based system for infectious disease reporting and for syndromic surveillance or other centralized information sources for health care providers, by fax, E-mail, Web site, or hotline.^L28,L34,L36
• Amateur radio.^L34,L39
• Integrated Services Digital Network (ISDN), a dial-up connection that can be used for video conferencing.^L34,L35
• Community-wide, centralized patient locator systems (such as the Greater New York Hospital Association established following the WTC attacks). ^L20,L27,L34
• Nextel "dispatch" function that allows responders to contact pre-programmed groups instantly and simultaneously, saving the time required to contact individuals separately.^L34
• 800 MHz radios so responders can monitor emergency operations.^{L22,L34,L40,L41}
• Videoconferencing.^L35,L42
• Developing forums for two-way communications with the public.^L6,L35,L41
• Pre-event joint planning, training and practice, not only to establish roles, but to create relationships between stakeholders, responders, and media to facilitate communication during the emergency.^{L23,L29,L34,L43-L45}
• Offering mental health services to the public, including responders, as soon as possible following a tragic event.^L5,L20,L46
• Triaging telephone calls.^L3,L22,L47
• Redundancy in everything from cable lines to having pagers from multiple companies.^L34,L41,L44
• Involving the news media early and consistently in the communication process.^{L17,L27,L34,L41}
• Developing "dual uses" for emergency response systems so that systems with rare emergency use are exercised through some alternative, routine use. This also protects capacity through boom and bust funding cycles.^{L21,L26,L32,L34,L42}
• Pre-event development of an "information stockpile" in multiple formats.^L34
• Developing a responsibility checklist for each role within your agency's incident command system.^L29
• Developing a procedure for processing potential volunteers and staff from other agencies or departments.^L37
• Having an emergency transportation plan for staff and supplies.^L37
• Organizing regional (events in surrounding States that will have impact) planning, decision-making, mutual aid agreements, and response committees.^{L20,L29,L30,L38,L39}

What were staffing issues during emergencies?

Many agencies reported that sustained response strained the agency and staff.^{L1,L4,L9,L10,L24,L28,L48,L49} Staff in many agencies were exhausted following the anthrax attacks because of the need to collect samples, conduct investigations, trace contacts, dispatch surveillance teams, and follow up on cases.

The CDC ultimately followed up on 10,000 individuals who received antibiotic prophylaxis for possible anthrax exposure.^L18 The New Jersey and CDC Operations Centers took over 6,000 telephone calls while conducting passive surveillance for anthrax.^L8 Connecticut estimated that surveillance for anthrax took up 1,500 hours of Federal and State staff time.^L50 Calls to New York City's mental health hotline, LifeNet, increased by 98 percent from October 2001 to March 2002, following September 11.2001.^L45 Staffing New York City's WNV hotline took from 25 to75 people per shift for 1 month.^L51 Although only 22 cases of anthrax were confirmed following the anthrax mailings, the Laboratory Response Network (LRN) processed more than 125,000 clinical specimens and almost 1 million environmental samples.^L52

With the possibility of telephones lines being down and cellular lines jammed, communicating with staff during the emergency was a common problem. Alternatives to telephone communications are necessary for activating extra resources, whether staffing or supplies. Alternative systems suggested were Internet, E-mail, television and radio broadcasts, staff emergency call-up lists, and disaster plans dictating where staff and volunteers should report and to whom they should report when an emergency strikes.^{L34,L35,L39,L41} As mentioned above, some agencies set up Web sites to inform employees of changing situations and direct them as to where and when to report.^L34,L36 It was also important to communicate to staff any changes in decision-making or other procedures as events unfolded.^L53

As was noted previously, several articles mentioned the difficulty that health services and public health staff had in switching gears from consensus decision-making to an incident-command structure.^{L1,L24,L30,L31} In both real and training events, actors had difficulty contacting their counterparts at other agencies, either because those people had moved to an emergency operations center, were on conference calls, or because they did not know whom, specifically, to contact.^L31,L52

The need to pre-identify and train volunteers was a frequent topic of concern, along with community level disaster preparedness training.^L35,L48,L54 The inability of hospitals or other agencies to verify the skills, qualifications, licenses, or security clearance for volunteers was often discussed.^L24,L34,L55 When volunteers or staff from other departments had been cleared, training was a problem. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has called for funding of the Public Health Security Act. This act would create a national credentialing system to give planners before an event and Incident Commanders during an event access to information on credentialed volunteers.^L7

Mass casualty incidents and sustained events also tax staff emotionally as well as physically. Several articles discussed the need to set up means for staff to communicate with family during a disaster without jamming telephone lines, or to set up rooms with television or radio to allow staff to follow unfolding events when their time permits.^{L17,L40,L41,L53}

How to protect health care workers or first responders from unnecessary exposure to risk, whether from infectious or toxic agents or from other physical dangers, came up in a few papers.^L56

In several cases employees, whether hospital workers or other first responders, arrived at work to help even when not called, potentially putting themselves at risk unnecessarily.^L36 The same concern exists for volunteers who are likely to risk their own health and safety in trying to help others.^L57

What were facility limitations during the emergency?

None of the sources that we found attempted to comprehensively assess facility limitations. However, some limitations were mentioned. Often, equipment stocks were inadequate to support volunteers or additional staff; for example, there often were not enough telephones, computers, or safety hood cabinets.^L10

Emergency procurement was a problem for hospitals and health agencies, sometimes because telephones were not working or because knowledge of procedures were lacking (such as how to access the National Pharmaceutical Stockpile).^{L1,L5,L10,L25}

At the Pentagon, a makeshift pharmacy was set up on Pentagon grounds to aid the wounded and emergency responders on 9-11. The pharmacy chief reported that the most important lesson that she learned was to have a large emergency sign to indicate the mobile pharmacy's location to people needing assistance or bringing in supplies.^L25

Space for mass vaccination, triage, sheltering stranded citizens, decontamination, mortuary facilities, parking, mental health counseling, blood donation centers, volunteer coordination centers, meeting rooms, and press conferences were all mentioned as issues.^{L2,L17,L29,L38,L405}

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L55. Denlinger RF, Gonzenbach K. The 'Two-Hat Syndrome': determining response capabilities and mutual aid limitations. Perspectives on Preparedness 11. Cambridge, MA: John F. Kennedy School of Government, Harvard University, August 2002.

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